T. Zontsich

Lung manifestation in asymptomatic patients with primary Sjögren syndrome : Assessment with high resolution CT and pulmonary function tests

The authors studied 37 consecutive patients with primary Sjögren syndrome and normal chest radiographs. Thin-section CT images were analyzed using a semiquantitative grading system. The presence, distribution, and severity of 9 morphologic parameters were assessed. In 34 patients, CT findings were correlated to pulmonary function tests (PFTs). Abnormal high resolution CT (HRCT) findings were seen in 24 of 37 patients (65%): interlobular septal thickening, n = 9; micronodules, n = 9; ground glass attenuation n = 4; parenchymal cysts, n = 5. Intralobular opacities, honey combing, bronchial wall thickening, bronchiectasis, and pleural irregularities were less frequent. Both HRCT and PFTs were normal in 10 patients. Computed tomography was normal in four patients with PFTs that indicated the presence of small airway disease. High resolution CT abnormalities were found in seven patients with normal PFT. The overall correlation between HRCT and PFTs was poor. High resolution CT and PFTs appear to be sensitive for both the early detection of parenchymal abnormalities and a decreases in lung function in asymptomatic patients with primary Sjögren syndrome. However, abnormal HRCT findings do not necessarily indicate a substantial alteration in PFTs.

Double Inversion Recovery Imaging of the Brain: Initial Experience and Comparison with Fluid Attenuated Inversion Recovery Imaging

The purpose of this study was to evaluate the diagnostic efficacy of the double inversion recovery fast spin echo (DIR-FSE) sequence for brain imaging compared to the fluid-attenuated inversion recovery (FLAIR) sequence. DIR-FSE and FLAIR-FSE sequences were obtained and compared side by side. Image assessment criteria included lesion conspicuity, contrast between different types of normal tissue, image quality, and artifacts. In addition, contrast ratios and contrast-to-noise ratios were determined. Scan time of DIR-FSE was 33% longer than scan time of FLAIR-FSE. Overall lesion conspicuity was equal on DIR-FSE and FLAIR-FSE; however, DIR-FSE showed particular advantages for infratentorial lesions and lesions with only poor contrast on T2-weighted images, whereas FLAIR was slightly superior for small superficial cerebral abnormalities. Gray-white differentiation was better with DIR-FSE. Cerebrospinal fluid suppression was equal on both sequences; cerebrospinal fluid pulsation artifacts were more pronounced on DIR-FSE but did not cause diagnostic difficulties on these images. We conclude that DIR-FSE might be obtained if infratentorial lesions and abnormalities with only slightly prolonged T2 relaxation times are suspected. Otherwise, FLAIR-FSE seems preferable.

Preoperative imaging of lower extremity varicose veins : Color coded duplex sonography or venography ?

We prospectively examined 137 limbs in 112 consecutive patients with clinical evidence of severe varicosis by color coded duplex sonography and ascending venography (including varicography in 48 limbs) to evaluate the diagnostic capabilities of color coded duplex sonography in the assessment of venous anatomy, variant varicosis, postthrombotic changes, and incompetence of the superficial and perforating venous system. Additionally, descending venography was performed in the first 52 limbs and compared to color coded duplex sonography in the diagnosis of deep and superficial venous reflux. Variant venous anatomy (21 cases) was missed in two limbs and misinterpreted in one limb by ascending venography compared to surgery. Color coded duplex sonography was inconclusive in two cases. Variant varicosis (59 cases) was missed in seven surgically proved cases by venography and in one case by color coded duplex sonography. Color coded duplex sonography was inconclusive in five cases. Ascending venography was slightly superior to color coded duplex sonography in the detection of postphlebitic changes. Good agreement was found between color coded duplex sonography and descending venography in the grading of superficial (k = 0.75) and deep venous reflux (k = 0.79). Excellent agreement was found between ascending venography in the grading of long (k = 0.96) and short (k = 0.94) saphenous vein reflux. More incompetent perforating veins were detected by ascending venography, (and varicography) than by color coded duplex sonography, but the latter technique allows direct preoperative marking of the skin, which is beneficial for the surgeon. We conclude that color coded duplex sonography is a valuable imaging tool before venous stripping and is capable of replacing invasive ascending and descending venography. Only patients with inconclusive color coded duplex sonographic results (e.g., complex variant venous anatomy) should proceed to venography.

Spiral CT evaluation of deep venous thrombosis

Spiral CT venography is a technical innovation in vascular imaging that can optimize vessel contrast in the deep venous system and, therefore, is an accurate diagnostic tool to detect deep venous thrombosis. Compared with conventional venography, the amount of contrast material can be reduced by 80%. While using spiral CT as the primary imaging technique for the detection of pulmonary embolism, the cause of embolism can be evaluated within a short period of additional imaging time without further patient mobilization. This review outlines fundamental techniques in spiral CT venography and summarizes our clinical experience at Vienna University Medical Center.

Trauma des Gesichtsschädels und der Schädelkalotte

ZusammenfassungGesichtsschädeltraumata sind häufig und werden überwiegend durch Verkehrsunfälle (VU) verursacht. Sogenannte „high velocities injuries” (VU und Geschoße) bedingen komplexe Frakturen, die sich den klassischen Frakturmustern nicht zuordnen lassen und (bedingt durch die Pathogenese) sich meist auch mit anderen oft lebensbedrohlichen und daher primär zu versorgenden Verletzungen präsentieren. Die primäre Abklärung eines Patienten mit einem Gesichtsschädeltrauma beginnt mit einer systematischen klinisch-physikalischen Untersuchung, da bereits eine Vielzahl aller Frakturen durch Inspektion und Palpation diagnostiziert werden kann. Die komplette und detailierte Evaluierung vieler Frakturen wird jedoch durch begleitende Weichteilschwellungen erschwert, sodaß meist eine weiterführende Bildgebung in Form konventioneller Röntgenaufnahmen bzw. eines Schichtbildverfahrens notwendig ist. Die Computertomographie (CT) gilt heute als die Methode der Wahl, da sie sowohl Weichteilverletzungen, als auch kleinste knöcherne Details mit hoher Auflösung darstellen kann. Die komplette Charakterisierung eines Frakturtyps sowie der Nachweis aller potentiell vorliegenden Komplikationen stellen die Basis für eine optimale Therapie dar und können erst nach einer kompletten radiologischen (bevorzugt CT-) Abklärung getroffen werden.SummaryFacial trauma is frequent and mainly caused by motor vehicle accidents. Due to this main etiologic factor, trauma to the facial skeleton is often associated with serious injuries, commonly involving the brain, chest or abdomen. As a consequence, the initial clinical management of these patients includes control of hemorrhage and immediate assessment of life-threatening injuries, including the maintenance of the airways. Patients presenting with facial trauma are initially evaluated with a systematic clinical examination because many fractures can be accurately diagnosed by inspection and palpation alone. In these cases plain film radiographs serve only for confirmation and documentation of the diagnosis. In many other cases accompanying and extensive soft tissue swelling may clinically obscure fractures. A complete and accurate evaluation of these patients requires additional radiological imaging methods. A series of plain films may be generally sufficient but in most of the cases they can be regarded as initial screening methods for more thorough diagnosis with computed tomography (CT). In trauma patients CT is the imaging method of choice because it shows more fracture lines and displaced fragments than any other imaging modality. CT delineates soft tissue and bony structures and can localize and even characterize foreign bodies. A complete and accurate characterization of the fracture type and potentially associated complications is mandatory for the appropriate treatment and can only be achieved by careful radiological (CT) evaluation.

Pulmonary alveolar proteinosis in a child: HRCT findings before and after bronchoalveolar lavage

Abstract. We demonstrate the high-resolution computed tomography (HRCT) findings of pulmonary alveolar proteinosis in a child before and after bronchoalveolar lavage. The CT pattern in our case differs from the pattern described in previous reports. We found a more homogeneous distribution of the pulmonary changes and a “crazy paving” pattern. High-resolution CT may be helpful in the differential diagnosis of this rare disease and in the follow-up of the pulmonary changes after bronchoalveolar lavage.

CT-Phlebographie Eine neue Methde zur Diagnostik von Venenthrombosen an der oberen und unteren Extremität

ZusammenfassungDie Spiral-CT-Phlebographie ist eine neue bildgebende Methode, die aufgrund des hohen Gefäßkontrastes im Venensystem ein wertvolles Hilfsmittel für die Diagnostik der Thrombose im Venensystem der unteren und oberen Extremität darstellt. Seit 1994 untersuchten wir 114 Extremitäten mit der CT-Phlebographie. Dieses Kollektiv schließt 102 CT-Phlebographien der unteren Extremität und 12 CT-Phlebographien der oberen Extremität sowie des oberen Einflußtraktes ein. Die Wertigkeit der Methode im Vergleich zur konventionellen Phlebographie und Farbdopplersonographie werden analysiert. Im Bereich der unteren Extremität zeigte die CT-Phlebographie eine Sensitivität von 100% und Spezifität von 96%. Ähnlich gute Ergebnisse liegen auch bei Patienten mit postthrombotischen Veränderungen vor. Die Kontrastierung der einzelnen Venenabschnitte war signifikant besser als in der konventionellen Phlebographie. Besonders im Bereich der unteren Hohlvene, den Beckenvenen und der Vena femoralis profunda war eine deutlich bessere Gefäßkontrastierung zu beobachten. Die CT-Phlebographie ist eine vielversprechende Methode zur Thrombosediagnostik der unteren und oberen Extremität. Vorteile sind die Reduktion der Kontrastmittelmenge und die Darstellung perivaskulärer Strukturen. Nachteilig sind die erhöhte Strahlenbelastung und die höheren Kosten der Methode.SummarySpiral CT venography is a new method in vascular imaging, which is an accurate tool for the evaluation of deep venous thrombosis in the lower and upper extremity. Materials and methods: 102 lower extremities and 12 upper extremities were evaluated for deep vein thrombosis using spiral-CT-venography. The results were compared with findings of ascending venography, color coded duplex sonography and clinical follow up. Results: Spiral CT venography of the lower extremity showed a sensitivity of 100% and a specifity of 96%. The quality of venous opacification with CT venography compared with ascending venography was superior in all venous segments. Discussion: Spiral CT venography is a valuable tool for the detection of deep venous thrombosis. Advantages of the method are the reduction of the amount of contrast material necessary for opacification and the detection of perivascular soft tissue alterations. The application of CT venography is limited due to higher costs and radiation dosage.

Präoperative Bildgebung bei primärer Varikose und Rezidivvarikose: Phlebographie vs. farbkodierte Duplexsonographie

ZusammenfassungGrundlagen: Die Evaluation der diagnostischen Möglichkeiten von aszendierender Preßphlebographie (APP) und farbkodierter Duplexsonographie (FKDS) bei primärer Varikose bzw. Rezidivvarikose. Methodik: 155 Beine von 130 konsekutiven Patienten wurden mittels APP (inklusive Varikographie in 48 Fällen) und FKDS untersucht, die Resultate mit den Operationsergebnissen korreliert. Ergebnisse: Bei primärer Varikose (n=131) wurden venöse Normvarianten (n=21) 2mal von der APP übersehen und 4mal als inkonklusiv von der FKDS beurteilt. Inkomplette Stammvarikosen (n=49) wurden in 3 Fällen phlebographisch und in 7 Fällen mittels FKDS falsch interpretiert, die FKDS war zusätzlich bei 2 komplexen Normvarianten inkonklusiv. Bei Rezidivvarikose (n=24) war die FKDS in 8 Fällen inkonklusiv, die APP einmal. Die APP war überlegen in der Beurteilung postthrombotischer Veränderungen. Es fand sich eine exzellente Übereinstimmung in der Beurteilung des Varikose-Schweregrades. Die APP entdeckte mehr inkompetente Perforansvenen als die FKDS verglichen mit dem chirurgischen Situs, die FKDS erlaubt hingegen das präoperative Markieren der Perforantes. Schlußfolgerungen: Die FKDS ist eine zur präoperativen Varizendiagnostik taugliche Methode und kann die APP partiell ersetzen. Patienten mit Rezidivvarikosen, inkompletten Stammvarikosen bzw. unklaren FKDS-Ergebnissen sollten einer APP zugeführt werden.SummaryBackground: Purpose of this study was the evaluation of the diagnostic possibilities of ascending venography (AVG) compared to color coded duplex sonography (CCDS) in primary and recurrent varicosis. Methods: We prospectively examined 155 limbs in 130 consecutive patients with clinical evidence of severe varicosis by CCDS and AVG (including varicography in 48 limbs). Results: In 131 limbs of primary varicosis variant venous anatomy (n=21) was missed in two limbs by AVG compared to surgery. CCDS was inconclusive in 4 cases. Variant varicosis (n=49) was inconclusive in 3 cases by AVG and in 7 cases by CCDS. CCDS was inconclusive in 8/24 cases of recurrent varicosis, AVG once. AVG was slightly superior to CCDS in the detection of postphlebitic changes. Excellent agreement was found between AVG and CCDS in the grading of saphenous vein reflux. There were more incompetent perforating veins detected by AVG (and varicography) than by CCDS, but CCDS allows direct preoperative marking of the skin, which is beneficial for the surgeon. Conclusions: We conclude that CCDS is a valuable imaging tool before venous stripping which is partially capable of replacing AVG. Patients with recurrent varicosis, variant venous anatomy or inconclusive CCDS results should proceed to AVG.

Bildgebung zur präoperativen Abklärung bei Varikose der unteren Extremität Klassische Insuffizienzmuster und klinische Wertigkeit

ZusammenfassungDie Varikose der unteren Extremität ist eine häufige Erkrankung mit großer volkswirtschaftlicher Bedeutung. Neue, gezielt auf das individuelle Befallsmuster ausgerichtete Operationsmethoden, wie die endoskopische Perforansligatur, verlangen eine präzise präoperative bildgebende Diagnostik. In diesem Beitrag werden die zur Verfügung stehenden Methoden, wie aszendierende Phlebographie (AP), farbkodierte Duplex-Sonographie (FCDS) und deszendierende Phlebographie dargestellt und hinsichtlich ihrer Wertigkeit analysiert. Darüberhinaus werden mögliche Varianten des oberflächlichen Venensystem und die radiologischen Befunde erläutert. Das oberflächliche Venensystem zeichnet sich durch eine ausgeprägte Variabilität aus. Auch aus diesem Grund ist es wichtig, die individuelle Situation bei jedem Patienten genau zu erfassen, damit ein geeignetes operatives Vorgehen geplant werden kann. Durch die kombinierte Anwendung von AP und FCDS können bei Patienten mit Varikose suffiziente und insuffiziente Venenabschnitte präzise identifiziert werden.SummaryVenous varicose are one of the most common diseases in industrial countries today. New surgical strategies, tailored to a patient’s specific pattern of venous incompetence require more detailed preoperative imaging. Methods: In this review of current literature we analyzed the value of ascending venography, color coded duplex sonography and descending venography for preoperative planning of varicose surgery. On the other hand, we describe variant anatomy of the superficial venous system like the different levels of escape points and perforating veins. Results: Ascending venography and color coded duplex sonography are both excellent modalities for detection of reflux in the saphenofemoral and saphenopopliteal junction. The results of current literature indicate, that ascending venography is superior to color coded duplex sonography in the detection of incompetent perforators. Conclusion: Ascending venography and color coded duplex sonography provide improved information, that may be crucial for surgical planning. The high heterogeneity and broad distribution of valvular incompetence confirmes the importance of detailed preoperative imaging.

Spiral-CT-Venography of the Lower Extremity in Deep Venous Thrombosis: First Results

To compare the diagnostic capability of spiral CT Venography (CTV) and conventional phlebography (CPH) in patients with deep venous thrombosis (DVT).