Purpose: The Department of Radiology at the University Hospital Innenstadt Munich provides all clinical departments of a large university hospital with several radiology units at different locations. During the last four years all units have been fully digitalized with a stepwise installation of a PACS. The PACS also processes images from the Nuclear Medicine Department. Methods: As image modalities, archive systems and review workstations, we use devices from multiple vendors, which are integrated into a consistent system using the DICOM standard. The hospital has developed its own RIS and an intranet information system, which provides access to all reports and images from radiology for all clinical departments inside the hospital Additionally, other clinical information such as laboratory results or ECC examinations are available through the system. Results: After one year of operation, the system succeeded in the clinical routine work as the primary source for radiological reports and images as well as for laboratory values. Conclusion: The advantages of digitalization were, besides reduction of film cost, especially optimizations of work flow with access to digital images from everywhere at any time.

Intestinal ischemia is still a challenge for clinicians and requires a close interdisciplinary cooperation between internist, surgeon and radiologist. In the East years the diagnosis and therapy, classically invasive and surgical, was supplemented by duplex ultrasound and percutaneous techniques like angioplasty and stenting.A 56 year-old man from Greece presented with epigastric pain, which was intensified by food ingestion. These symptoms were caused by a stenosis of the superior mesenteric artery, which was diagnosed by duplexsonography and angiography. No bloodflow was detected in the inferior mesenteric and the celiac artery Occlusion of one internal carotid artery made the patient a poor candidate for surgery. Therefore an interventional approach was chosen. A good result was achieved by angioplasty and stent implantation. On the day after the intervention oral food intake was possible without any pain. 18 months after the intervention the patient was free of abdominal symptoms.Therapy of mesenteric ischemia by percutaneous angioplasty and stenting is published only in case-reports and small series. Therefore the indication is mainly restricted to patients with a high risk for a surgical intervention.

PURPOSE:The Department of Radiology at the University Hospital Innenstadt Munich provides all clinical departments of a large university hospital with several radiology units at different locations. During the last four years all units have been fully digitalized with a stepwise installation of a PACS. The PACS also processes images from the Nuclear Medicine Department.METHODS:As image modalities, archive systems and review workstations, we use devices from multiple vendors, which are integrated into a consistent system using the DICOM standard. The hospital has developed its own RIS and an Internet information system, which provides access to all reports and images from radiology for all clinical departments inside the hospital. Additionally, other clinical information such as laboratory results or ECG examinations are available through the system.RESULTS:After one year of operation, the system succeeded in the clinical routine work as the primary source for radiological reports and images as well as for laboratory values.CONCLUSION:The advantages of digitalization were, besides reduction of film cost, especially optimizations of work flow with access to digital images from everywhere at any time.

Intestinal ischemia is still a challenge for clinicians and requires a close interdisciplinary cooperation between internist, surgeon and radiologist. In the last years the diagnosis and therapy, classically invasive and surgical, was supplemented by duplex ultrasound and percutaneous techniques like angioplasty and stenting. A 56 year-old man from Greece presented with epigastric pain, which was intensified by food ingestion. These symptoms were caused by a stenosis of the superior mesenteric artery, which was diagnosed by duplex sonography and angiography. No blood flow was detected in the inferior mesenteric and the celiac artery. Occlusion of one internal carotid artery made the patient a poor candidate for surgery. Therefore an interventional approach was chosen. A good result was achieved by angioplasty and stent implantation. On the day after the intervention oral food intake was possible without any pain. 18 months after the intervention the patient was free of abdominal symptoms. Therapy of mesenteric ischemia by percutaneous angioplasty and stenting is published only in case-reports and small series. Therefore the indication is mainly restricted to patients with a high risk for a surgical intervention.

OBJECTIVE:The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest X-ray (CXR) in the diagnostic work-up of blunt thoracic trauma and whether the additional information obtained influences subsequent decisions on therapy in the early management of severely injured patients.PATIENTS AND METHODS:In a prospective study of 103 consecutive patients with clinical or radiological signs of chest trauma (94 multiply injured patients with chest trauma, 9 patients with isolated chest trauma) who had an average ISS of 30 and an average AIS thorax of 3, initial CXR and TCT were compared after the first assessment in our emergency department (a level I trauma center). Mortality in this group was 10% (n = 10).RESULTS:In 67 patients (65%) TCT revealed major complications of chest trauma that had been missed on CXR: lung contusion (n = 33), pneumothorax (n = 27), residual pneumothorax after chest tube placement (n = 7), hemothorax ((n = 21), displaced chest tube (n = 5), diaphragmatic rupture (n = 2), myocardial rupture (n = 1); in 11 patients only minor additional pathologic findings (dystelectasis, small pleural effusion) were visualized on TCT; and in 14 patients CXR and TCT showed identical pathologic results. In 11 patients neither CXR nor TCT revealed pathologic findings. The TCT scan was significantly more effective than routine CXR in detecting lung contusions (P < 0.001), pneumothorax (P < 0.005) and hemothorax (P < 0.05). In 42 patients (41%) the additional TCT findings did affect, the therapy selected: chest tube placement or chest tube correction in mostly anteriorly located pneumothoraces or large hemothoraces (n = 31), influence on ventilation mode and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12), laparotomy in cases of diaphragmatic lacerations (n = 2), bronchoscopy for atelectasis (n = 2), exclusion of aortic rupture (n = 2), endotracheal intubation (n = 1), pericardiocentesis (n = 1).CONCLUSIONS:TCT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions and pneumo- and hemothorax. Early TCT influences therapeutic management in a considerable subset of patients. We therefore recommend TCT in the primary diagnostic work-up of multiple injured patients with suspected chest trauma, because early and accurate diagnosis of all thoracic injuries along with acceptance of the implications for therapy may reduce complications and improve the outcome in polytraumatized patients with blunt chest trauma.

To enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed, comparing two prospectively recorded collectives of polytraumatized patients 4/1988-12/1993 (A; n = 126) and 1/1994-6/1996 (B; n = 74). Nine specifically defined parameters were used to assess the therapeutic process of early clinical trauma management. All parameters showed an improvement after implementation of the algorithm (group B): (1) Complete radiological and sonographic basic diagnostics in 97% vs. 92% of patients; (2) time interval of 38 min vs. 55 min until cranial CT was done after severe head injury (GCS < 10); (3) reduction of delayed diagnosis of lesions to 5% vs. 24%; (4) duration of 16 min vs. 20 min until intubation; (5) period of 23 min to 30 min to pleural drainage; (6) duration of 18 min vs. 32 min until transfusion in shock; (7) period of 79 min vs. 98 min until emergency operation in shock; (8) duration of 95 min vs. 124 min until trepanation, and (9) operation rate within 24 h after admission to ICU in 3% vs. 12%. The lethality rates of each collective were assessed after subdivision in three groups (I-III) with middle (ISS: 18-24), high (ISS: 25-49) and extreme (ISS: 50-75) injury severity. In all groups of both collectives ISS values, age, initial loss of consciousness (GCS) and shock were comparable (except the higher injury severity of collective B in group I). In all groups a reduction of lethality could be shown for collective B: Group I, 0% vs. 20% (P < 0.05); group II, 8% vs. 24% (P < 0.05); and group III, 40% vs. 71%, not significant because of the small group in B (n = 5). The implementation of therapeutic management guidelines led to an improvement of both treatment processes and outcome. In order to regularly reassess validity and practicability of such guidelines as well as further enhance therapeutic quality, a continuous evaluation programme representing a quality management system should be inaugurated.

Problemstellung: In einer prospektiven Studie sollte untersucht werden, ob bei polytraumatisierten Patienten durch die initiale Computertomographie des Thorax (CTT) die diagnostische Genauigkeit für ein begleitendes Thoraxtrauma erhöht werden kann und ob aus evtl. gewonnenen Mehrinformationen wesentliche klinische Konsequenzen für das frühe Polytraumamanagement gezogen werden können. Patienten und Methodik: In einer prospektiven Untersuchung wurde bei 103 Patienten mit Verdacht auf Thoraxtrauma (94 Polytraumatisierte mit Thoraxtrauma, 9 Patienten mit isoliertem Thoraxtrauma) mit einem mittleren ISS von 30 (12 – 66), sowie einem mittleren AIS-Thorax von 3 (1 – 5), im Rahmen der primären Schockraumdiagnostik eine CTT angefertigt und mit der initialen routinemäßig im Liegen angefertigten Röntgenaufnahme des Thorax (RT) verglichen. Ergebnisse: Bei 65% der Patienten ( n = 67) wurden durch die CTT wesentliche zusätzliche Informationen gewonnen (Lungenkontusionsherde ( n = 33), ventraler oder nicht vollständig entlasteter Pneumothorax ( n = 34), Hämatothorax ( n = 21), Thoraxdrainagenfehlplazierung ( n = 5), u. a. (z. B. Zwerchfell – bzw. Myokardruptur); bei weiteren 11 Patienten wurden geringfügige zusätzliche Informationen (z. B. Dystelektase, kleiner nicht drainagepflichtiger Pleuraerguß) in der CTT erzielt, bei 14 Patienten waren pathologische Befunde in RT und CTT identisch, bei 11 Patienten waren beide Untersuchungen ohne pathologischen Befund. Insgesamt erwies sich die CTT in der Diagnostik der Lungenkontusion ( p <0.001), sowie des Pneumo- ( p <0.005) und des Hämatothorax ( p <0.05) der RT signifikant überlegen. Aufgrund der Zusatzinformationen der CTT wurden bei 42 Patienten (41%) z. T. wesentliche therapeutische Konsequenzen gezogen: Thoraxdrainageanlagen bzw. -korrekturen ( n = 31), druckkontrollierte Beatmung bzw. Drehbettbehandlung bei Lungenkontusion ( n = 14), Einfluß auf den Operationszeitpunkt bzw. die primäre Verfahrenswahl begleitender Verletzungen des Bewegungsapparats (z. B. Femur) ( n = 12), Intubation ( n = 1), Bronchoskopie ( n = 2), Operationsindikation bei Zwerchfellruptur ( n = 2), Ausschluß einer Aortenruptur ( n = 2), Perikardpunktion bei Myokardruptur ( n = 1). Schlußfolgerung: Die CTT in der Primärdiagnostik des polytraumatisierten Patienten erlaubt eine wesentlich genauere Diagnostik thorakaler Verletzungen (insbesondere Pneumothorax, Hämatothorax und Lungenkontusionen) mit z. T. wesentlichen therapeutischen Konsequenzen für das weitere Management. Möglicherweise kann dadurch die bekanntermaßen hohe Komplikationsrate nach Thoraxtrauma gesenkt und die durch das Thoraxtrauma negativ beeinflußte Prognose des Polytraumatisierten verbessert werden.

Summary To enhance the quality of treatment of patients with multiple injuries (blunt trauma), guidelines for the acute clinical management (trauma-algorithm) were implemented at our clinic in 1994. The impact of these guidelines was analysed, comparing two prospectively recorded collectives of polytraumatized patients 4/1988–12/1993 (A; n = 126) and 1/1994–6/1996 (B; n = 74). Nine specifically defined parameters were used to assess the therapeutic process of early clinical trauma management. All parameters showed an improvement after implementation of the algorithm (group B): (1) Complete radiological and sonographic basic diagnostics in 97 % vs. 92 % of patients; (2) time interval of 38 min vs. 55 min until cranial CT was done after severe head injury (GCS < 10); (3) reduction of delayed diagnosis of lesions to 5 % vs. 24 %; (4) duration of 16 min vs. 20 min until intubation; (5) period of 23 min to 30 min to pleural drainage; (6) duration of 18 min vs. 32 min until transfusion in shock; (7) period of 79 min vs. 98 min until emergency operation in shock; (8) duration of 95 min vs. 124 min until trepanation, and (9) operation rate within 24 h after admission to ICU in 3 % vs. 12 %. The lethality rates of each collective were assessed after subdivision in three groups (I–III) with middle (ISS: 18–24), high (ISS: 25–49) and extreme (ISS: 50–75) injury severity. In all groups of both collectives ISS values, age, initial loss of consciousness (GCS) and shock were comparable (except the higher injury severity of collective B in group I). In all groups a reduction of lethality could be shown for collective B: Group I, 0 % vs. 20 % ( P < 0.05); group II, 8 % vs. 24 % ( P < 0.05); and group III, 40 % vs. 71 %, not significant because of the small group in B ( n = 5). The implementation of therapeutic management guidelines led to an improvement of both treatment processes and outcome. In order to regularly reassess validity and practicability of such guidelines as well as further enhance therapeutic quality, a continuous evaluation programme representing a quality management system should be inaugurated.

We studied 32 consecutive patients with known or suspected cerebrovascular abnormalities studied with spiral CT following a intravenous bolus injection of iodinated contrast medium with a power injector. Flow was 3 or 4 ml/s. In an attempt to define the appropriate delay time and scan duration a cranial angio-CT without table increment was performed on 10 patients. Enhancement was measured by manually placed regions of interest within the left middle cerebral artery and the inferior sagittal sinus. All patients except one had intraarterial angiography (DSA) for comparison. In 6 patients with an arteriovenous malformation (AVM) follow-up was possible after one and/or two embolisation procedures. These patients had plain and contrast-enhanced spiral CT. The diagnosis was aneurysm in 9 (8 berry aneurysms, one giant fusiform aneurysm), AVM in 13 (all supratentorial) and traumatic arteriovenous fistula in one. In 9 patients there were no detectable pathological vascular findings. After 3D reconstruction the size (between 5 and 28 mm), location and the relationship to the parent vessel of the aneurysms, the extent of the AVMs and the distribution of the embolisation material could be demonstrated clearly. The main feeding vessel(s), nidus and draining veins were reliably shown. The decreased extent of the AVMs after embolisation was clearly demonstrated. There was no difference in diagnosis when DSA and 3D-CT were compared by two independent radiologists. We consider arterial spiral CT with 3D reconstruction to have the potential of offering important diagnostic information for the treatment of intracranial AVMs and aneurysms.

Retrospektive und prospektive Auswertungen polytraumatisierter Patienten unseres Krankengutes hatten aufgezeigt, daß die Abdominalbeteiligung bei rascher und sicherer Diagnostik und frühest-möglicher adäquater Therapie zu keiner Verschlechterung der Prognose führte. Dagegen waren verzögert diagnostizierte bzw. übersehene Abdominalverletzungen mit einer erhöhten lokalen und systemischen Komplikationsrate behaftet [1]. Im folgenden wird diesbezüglich der Stellenwert und die Bedeutung der Diagnostik von Hohlorgan- und Zwerchfellverletzungen untersucht.

In 20 patients with known or suspected supratentorial arteriovenous malformations, an attempt was made to see how far CT angiography with 3-dimensional reconstructions is able to make a diagnosis and to differentiate the various components of the angioma. Spiral CT was performed following an intravenous bolus injection of 60-80 ml of iodine containing contrast medium. In all patients the diagnosis was confirmed by intra-arterial DSA of the vertebral vessels. In 13 patients, av malformations could be diagnosed following multiplanar 3-D reconstructions which agreed with the findings on DSA. The large supplying vessels, the nidus and the large draining veins could be defined with certainty. In 6 patients follow-up examination after embolisation was performed. The results could be demonstrated in three dimensions and the success of treatment could be documented unequivocally. CT angiography with 3-D reconstruction is able to supply important information in the majority of intracranial av malformations, both during initial investigation and following treatment.

Balloon angioplasty and bypass graft surgery are common procedures for treating vascular occlusive disease. The purpose of this preliminary investigation was to evaluate the effectiveness and the safety of a new catheter system, first introduced by KR Kensey. The system involves a flexible catheter with a high speed rotating tip, driven by an electrical motor. The tip is cooled by a continuous flow of sterile saline containing dextran 40, heparin and urokinase. Radiopaque contrast medium may be infused through the catheter to allow the device to be guided and to detect lesions and to evaluate the efficacy of treatment. The system was applied in three patients with occlusive vascular disease (Stage IIb) and segmental or total occlusion of the superficial femoral artery (SFA). The milling catheter was introduced percutaneously into the common femoral artery and guided to the area of occlusion under DSA control. In two patients total recanalisation was achieved after passage of the milling catheter. In one patient the totally occluded SFA could not be cannulated and a femoro-popliteal bypass was performed one week later. Complications such as perforation of the vessel or peripheral embolisation were not observed. Pedal pulses were improved significantly in one patient. Further investigations will be necessary to demonstrate whether the milling catheter can be safely used to revascularise patients with limb threatening peripheral vascular disease.