Objectives: Focal therapy with high-intensity focused ultrasound (HIFU) is an emerging option for the treatment of prostate cancer and often followed up by MRI. Image assessment of treatment failure, however, requires proper knowledge about typical procedure-related changes in prostate MRI, which is sparse, in particular for unilateral HIFU treatment and late follow up (beyond 6 months). The goal of this study was therefore to compile the type and frequency of such MRI findings in selected patients without recurrent cancer 12 months after prostate hemiablation. Methods: Data from a prospective multicenter trial on HIFU hemiablation were reviewed retrospectively. Trial patients have had a late follow-up by MRI (at around 12 months) and either MRI/transrectal ultrasound (TRUS) fusion or standard TRUS-guided biopsy. This work deliberately included patients with non-recurrent cancer in the treated prostate lobe in per-protocol biopsy leaving 30 men with initial International Society of Urological Pathology (ISUP) Grade Group of 1 or 2. Six categories of potential HIFU-related MRI features were assessed by an expert committee and then evaluated by two readers in consensus: 1. shrinkage of the treated lobe, 2. residual prostate tissue, 3. fluid-filled cavity, 4. fibrosis, 5. hematoma residuals (in the prostate or seminal vesicles) and 6. contrast enhancement of the ablated area. Results: Shrinkage of the ablated lobe was seen in 93% of the cases with an average percent volume change of-37% (range:-70% to +108%). In the contralateral lobe, the volume remained practically the same (-2% on average, p = 0.804). In the ablated lobe, the frequency of fibrosis was 97%. Residual prostate tissue was seen in 93% of the cases. The frequency for fluid-filled cavities was 97%, with the wide majority (90%) contiguous with the urethra. Hematoma residuals in the prostate and in seminal vesicles were found in 47% and 10% of the patients, respectively. Contrast enhancement was both rim-like (50%) as well as diffuse (33%) within the ablated area. Conclusion: In our case series of HIFU hemiablation in the prostate, shrinkage, residual prostate tissue, fluid-filled cavities contiguous with the urethra and fibrosis were very common late MRI findings of the ablated lobe in non-recurrent patients. Rim-like contrast enhancement or diffuse one within the ablated area were less frequent.

Pneumatosis beschreibt ganz allgemein den Zustand von extraluminaler Luft im Körper. Sie kann dabei in ganz unterschiedlichen Lokalisationen auftauchen. Am bekanntesten ist die Pneumatosis intestinalis als intramurale Lufteinschlüsse des Gastrointestinaltraktes. Sie kann jedoch auch im Mesenterium und Mediastinum vorkommen und wird dann als Pneumatosis mesenterialis bzw. Pneumatosis mediastinalis bezeichnet. Sie tritt in jedem Alter ohne Geschlechtspräferenz auf (Takase et al. BMC Res Notes 2017; 10: 319). Sie tritt häufig, jedoch nicht ausschließlich bei Patienten unter Immunsuppression auf.

One of the main concerns in planning a vaginal birth after previous cesarean section is the risk for uterine rupture which is considered to be associated with the wall thickness in the scar area. Assuming the uterine scar to be located within the lower uterine segment (LUS), ultrasound diagnostic with LUS thickness measurement is widely used for prenatal risk assessment. Although intensively investigated there is a strong inhomogeneity of study results and reliable examination protocols and reference values are still missing 1,2 .

BACKGROUND/AIMS:The position of the tip of tunnelled haemodialysis (HD) catheters (THC) might influence flow characteristics during HD. In chest X-ray (CXR), carina-related landmarks may be practicable to verify the THC position, and tip-carina distance (TCD) might be useful to predict early-flow dysfunctions. METHODS:In this single-centre, retrospective study, the TCD and the angle between the distal catheter and the body vertical axis (tip-body vertical-angle [TVA]) was measured in 115 THC by post-procedure CXR with 2 investigators. The parameters were proved to be feasible by interrater-reliability and correlated with the incidence of flow-dysfunction within 10 days after insertion. RESULTS:Steep-aligned (TVA <40°, p < 0.01) and deep-ending catheters (TCD: right-sighted >1.5 cm or left-sighted >4.5 cm below the carina; p < 0.01) showed a significantly less dysfunction with a good interrater-reliability (R[TVA] = 0.8, R[TCD] = 0.9). CONCLUSIONS:Carina-related landmarks in CXR might be helpful to predict early-flow dysfunctions. However, randomized studies will be necessary to confirm this in fluoroscopic-guided placement during the insertion of THC.

Bei Patientinnen mit Z.n. Sectio steht die Vermeidung einer Uterusruptur und auch unnötiger weiterer Kaiserschnitte im Fokus der Geburtsplanung. Die sonografische Dickenmessung des unteren Uterinsegmentes (LUS) soll hierbei zur Abschätzung von Risiken und Chancen dienen. Der Wert einer zusätzlichen MRT-Untersuchung ist für die LUS Diagnostik nicht hinreichend untersucht. Ziel der Studie ist die Evaluation der Machbarkeit einer MRT-Bildgebung und Dickenmessung des LUS bei Z.n. Sectio sowie die Erhebung typischer MRT-Befunde und der Vergleich zum Ultraschall.

ZusammenfassungKnochenmarködeme (KMÖ) am Kniegelenk werden aufgrund der breiten Verfügbarkeit der MRT zunehmend häufiger diagnostiziert und können Ausdruck einer Stressfraktur (SF) sein. SF umfassen sowohl Ermüdungs- als auch Insuffizienzfrakturen. Meist treten zunächst lokalisierte Schmerzen unter Belastung auf. Später kann ein Progress bis hin zu immobilisierenden Schmerzen stattfinden. Bis zu 95 % der Stressfrakturen finden sich an der unteren Extremität. Die proximale Tibia ist selten betroffen, meist liegt eine einseitige Manifestation vor. Ursächlich für ein KMÖ am Knie sollten differentialdiagnostisch eine spontane Osteonekrose (M. Ahlbäck), sekundäre Osteonekrosen wie auch das transiente Knochenmarködem-Syndrom in Betracht gezogen werden. Diese können mit sekundären Schäden der Gelenkoberflächen einhergehen. Die MRT stellt den Goldstandard in der Diagnose und Differenzialdiagnostik von Stressfrakturen dar.Wir berichten über eine 24-jährige Patientin mit zum Teil immobilisierenden, atraumatischen Schmerzen der Hüft- und Kniegelenke. Die laborchemische Diagnostik zeigte keine Hinweise auf eine Erkrankung des rheumatologischen Formenkreises, eine reaktive Arthritis oder Osteomyelitis. Die MRT der Kniegelenke ergab den seltenen Fall einer beidseitigen Stressfraktur in der medialen proximalen Tibia. Unter konservativer Therapie mit Belastungsreduktion und Analgesie nach Schmerzniveau wurde die Patientin schmerzfrei. In den Verlaufs- MRT 8 Wochen später konnte eine Restitutio ad integrum der SF bestätigt werden.Für Stressfrakturen der proximalen Tibia liegen wenige Arbeiten bezüglich der besten Therapiemöglichkeit vor. Als „first line” Therapie steht die konservative Therapie mit Belastungsreduktion oder ggf. vollständiger Entlastung sowie Analgesie mit nichtsteroidalen Antirheumatika zur Verfügung. Alternativ kann bei fehlendem Ansprechen ein Off-Label-Use Therapieversuch mit Bisphosphonaten, Iloprost oder Denosumab in Betracht gezogen werden. Daten zur operativen Therapie von Stressfrakturen der proximalen Tibia liegen nicht vor. Dementsprechend sollte die Indikation zurückhaltend gestellt werden.

Aufgrund des erhöhten Uterusrupturrisikos wird bei der Planung einer vaginalen Geburt nach Sectio häufig die Dicke des unteren Uterinsegments (uUS) sonografisch bestimmt. Ein geeignetes Untersuchungsprotokoll und ein zuverlässiger Referenzwert können wegen der inhomogenen Datenlage bisher nicht empfohlen werden. Da Limitationen der Ultraschalldiagnostik denkbare Gründe hierfür sind, haben wir die MRT als alternatives, nichtinvasives bildgebendes Verfahren genutzt, um die pränatale Diagnostik des uUS weiter zu erörtern.

Purpose Uterine rupture during labor is a rare but life-threatening complication after previous cesarean section (CS). Prenatal risk is assessed using ultrasound thickness measurement of the lower uterine segment (LUS). Due to inhomogeneous study results, however, clinical obstetrics still lacks for standard protocols and reliable reference values. As 3 T magnetic resonance imaging (MRI) has not yet been sufficiently studied regarding LUS diagnostics after previous CS, we sought to evaluate its feasibility focusing on thickness measurements and typical characteristics of the CS-scar region in comparison to ultrasound and the intraoperative status. Methods In this prospective study, 25 asymptomatic patients with one previous CS and inconspicuous ultrasound findings were included. An additional 3 T MRI with either a T2-weighted Turbo-Spin-Echo or a Half Fourier-Acquired-Single-shot-Turbo-spin-Echo sequence in a sagittal orientation was performed. We analyzed categorical image quality, inter- and intra-rater reliability as well as anatomy, morphology and thickness of the LUS. Results were compared to ultrasound and intraoperative findings. Results MRI provided good to excellent image quality in all patients. The imaged structures presented with a high variability in anatomy and morphology. Image characteristics indicating the uterine scar were only found in 11/25 (44%) patients. LUS thickness measurements with MRI showed good inter- and intra-rater reliability but poor agreement with ultrasound. Conclusions MRI is appropriate for additional LUS diagnostics in patients with previous CS. The strong individual variability of LUS-anatomy and morphology might explain the difficulties in establishing uniform diagnostic standards after CS.

Bone marrow edemas at the knee joint are diagnosed with increasing frequency due to the broad availability of MRI. These can be an expression of stress fracture. SF comprise both, fatigue and insufficiency fractures. In most cases, localized pain first occurs under load-bearing activities. Later on, there may be a progression to immobilizing pain. Up to 95 % of stress fractures are found in the lower extremity. The proximal tibia is rarely affected and usually there is a one-sided manifestation. As a differential diagnosis a transient bone marrow edema syndrome, secondary osteonecrosis as well as a spontaneous osteonecrosis of the knee (M. Ahlback) should be considered. These can be accompanied by secondary damage to the joint surfaces. MRI represents the gold standard in the diagnosis and assessment of stress fractures.We report about a 24-year old female patient with partially immobilizing, atraumatic pain of the hip and knee joints. Laboratory diagnostics showed no evidence of rheumatoid arthritis, a reactive arthritis or osteomyelitis. MRI of the knee joints showed bilateral bone marrow edema of the proximal tibia with signs of stress fractures. After conservative therapy with stress reduction and analgesia according to pain level, MRI showed complete regression of signs of the stress fracture eight weeks later. The load-bearing capacity

Aufgrund des erhöhten Uterusrupturrisikos wird bei der Planung einer vaginalen Geburt nach Sectio häufig die Dicke des unteren Uterinsegments (uUS) sonografisch gemessen. Wegen der inhomogenen Datenlage wird dieses Vorgehen bisher nicht in den deutschen Leitlinien empfohlen. Es fehlen ein geeignetes Untersuchungsprotokoll und ein zuverlässiger Referenzwert. Die MRT ist ein alternatives, nichtinvasives bildgebendes Verfahren, das für die Erörterung von Problemen der pränatalen Ultraschalldiagnostik des uUS vielversprechend aber bisher wenig genutzt ist.

Ziel war die vorläufige technische und klinische Evaluation eines MR-kompatiblen, pneumatisch gesteuerten Assistenzsystems für In-Bore-Prostatabiopsien (PBx) bei 1,5 T.

Purpose To assess the interrater agreement and reliability of experienced abdominal radiologists in the characterization and grading of arterial phase gadoxetate disodium-related respiratory motion artifact on liver MRI. Materials and Methods This prospective multicenter study was initiated by the working group for abdominal imaging within the German Roentgen Society (DRG), and approved by the local IRB of each participating center. 11 board-certified radiologists independently reviewed 40 gadoxetate disodium-enhanced liver MRI datasets. Motion artifacts in the arterial phase were assessed on a 5-point scale. Interrater agreement and reliability were calculated using the intraclass correlation coefficient (ICC) and Kendall coefficient of concordance (W), with p < 0.05 deemed significant. Results The ICC for interrater agreement and reliability were 0.983 (CI 0.973 – 0.990) and 0.985 (CI 0.978 – 0.991), respectively (both p < 0.0001), indicating excellent agreement and reliability. Kendall’s W for interrater agreement was 0.865. A severe motion artifact, defined as a mean motion score ≥ 4 in the arterial phase was observed in 12 patients. In these specific cases, a motion score ≥ 4 was assigned by all readers in 75% (n = 9/12 cases). Conclusion Differentiation and grading of arterial phase respiratory motion artifact is possible with a high level of inter-/intrarater agreement and interrater reliability, which is crucial for assessing the incidence of this phenomenon in larger multicenter studies. Key Points ▪ Interand intrarater agreement for motion artifact scoring is excellent among experienced readers. ▪ Interrater reliability for motion artifact scoring is excellent among experienced readers. ▪ Characterization of severe motion artifacts proved feasible in this multicenter study. Citation Format ▪ Ringe KI, Luetkens JA, Fimmers R et al. Characterization of Severe Arterial Phase Respiratory Motion Artifact on Gadoxetate Disodium-Enhanced MRI – Assessment of Interrater Agreement and Reliability. Fortschr Röntgenstr 2018; 190: 341–347

Purpose To assess the interrater agreement and reliability of experienced abdominal radiologists in the characterization and grading of arterial phase gadoxetate disodium-related respiratory motion artifact on liver MRI. Materials and Methods This prospective multicenter study was initiated by the working group for abdominal imaging within the German Roentgen Society (DRG), and approved by the local IRB of each participating center. 11 board-certified radiologists independently reviewed 40 gadoxetate disodium-enhanced liver MRI datasets. Motion artifacts in the arterial phase were assessed on a 5-point scale. Interrater agreement and reliability were calculated using the intraclass correlation coefficient (ICC) and Kendall coefficient of concordance (W), with p < 0.05 deemed significant. Results The ICC for interrater agreement and reliability were 0.983 (CI 0.973 – 0.990) and 0.985 (CI 0.978 – 0.991), respectively (both p < 0.0001), indicating excellent agreement and reliability. Kendall’s W for interrater agreement was 0.865. A severe motion artifact, defined as a mean motion score ≥ 4 in the arterial phase was observed in 12 patients. In these specific cases, a motion score ≥ 4 was assigned by all readers in 75 % (n = 9/12 cases). Conclusion Differentiation and grading of arterial phase respiratory motion artifact is possible with a high level of inter-/intrarater agreement and interrater reliability, which is crucial for assessing the incidence of this phenomenon in larger multicenter studies. Key Points Citation Format

Purpose Evaluation of trauma patients with chest tube malposition using initial emergency computed tomography (CT) and assessment of outcomes and the need for chest tube replacement. Methods Patients with an injury severity score > 15, admitted directly from the scene, and requiring chest tube insertion prior to initial emergency CT were retrospectively reviewed. Injury severity, outcomes, and the positions of chest tubes were analyzed with respect to the need for replacement after CT. Results One hundred seven chest tubes of 78 patients met the inclusion criteria. Chest tubes were in the pleural space in 58% of cases. Malposition included intrafissural positions (27%), intraparenchymal positions (11%) and extrapleural positions (4%). Injury severity and outcomes were comparable in patients with and without malposition. Replacement due to malfunction was required at similar rates when comparing intrapleural positions with both intrafissural or intraparenchymal positions (11 vs. 23%, p = 0.072). Chest tubes not reaching the target position (e.g., pneumothorax) required replacement more often than targeted tubes (75 vs. 45%, p = 0.027). Out-of-hospital insertions required higher replacement rates than resuscitation room insertions (29 vs. 10%, p = 0.016). Body mass index, chest wall thickness, injury severity, insertion side and intercostal space did not predict the need for replacement. Conclusions Patients with malposition of emergency chest tubes according to CT were not associated with worse outcomes compared to patients with correctly positioned tubes. Early emergency chest CT in the initial evaluation of severely injured patients allows precise detection of possible malposition of chest tubes that may require immediate intervention.

This study aimes to determine the complication rates, possible risk factors and outcomes of emergency procedures performed during resuscitation of severely injured patients. The medical records of patients with an injury severity score (ISS) >15 admitted to the University Hospital Leipzig from 2010 to 2015 were reviewed. Within the first 24 hours of treatment, 526 patients had an overall mechanical complication rate of 26.2%. Multivariate analysis revealed out-of-hospital airway management (OR 3.140; 95% CI 1.963–5.023; p < 0.001) and ISS (per ISS point: OR 1.024; 95% CI 1.003–1.045; p = 0.027) as independent predictors of any mechanical complications. Airway management complications (13.2%) and central venous catheter complications (11.4%) were associated with ISS >32.5 (p < 0.001) and ISS >33.5 (p = 0.005), respectively. Chest tube complications (15.8%) were associated with out-of-hospital insertion (p = 0.002) and out-of-hospital tracheal intubation (p = 0.033). Arterial line complications (9.4%) were associated with admission serum lactate >4.95 mmol/L (p = 0.001) and base excess <−4.05 mmol/L (p = 0.008). In multivariate analysis, complications were associated with an increased length of stay in the intensive care unit (p = 0.019) but not with 24 hour mortality (p = 0.930). Increasing injury severity may contribute to higher complexity of the individual emergency treatment and is thus associated with higher mechanical complication rates providing potential for further harm.

Für die differenzialdiagnostische Einordnung von Hüftschmerzen ist die klinische Untersuchung nur bedingt hilfreich. Wertvoll ist neben dem Patientenalter auch die Anamnese. Zudem kann die Bildgebung wichtige Hinweise für die korrekte Diagnose liefern. Heutzutage wird in Deutschland häufig als primäre Bildgebung eine Magnetresonanztomographie durchgeführt, die bei vielen verschiedenen Pathologien ein Knochenmarködem (KMÖ) zeigen kann. Das KMÖ tritt beim transitorischen Knochenmarködem und außerhalb der atraumatischen Hüftkopfnekrose auf, u. a. begleitend bei Koxarthrose, Arthritis, „herniation pit“ und Osteoidosteom. Der vorliegende Beitrag beschreibt einige häufige Differenzialdiagnosen und gibt Hinweise, wie die korrekte Zuordnung zu den jeweiligen Diagnosen gelingen kann.

Purpose: Central venous catheter insertion for acute trauma resuscitation may be associated with mechanical complications, but studies on the exact central venous catheter tip positions are not available. The goal of the study was to analyze central venous catheter tip positions using routine emergency computed tomography. Methods: Consecutive acute multiple trauma patients requiring large-bore thoracocervical central venous catheters in the resuscitation room of a university hospital were enrolled retrospectively from 2010 to 2015. Patients who received a routine emergency chest computed tomography were analyzed regarding central venous catheter tip position. The central venous catheter tip position was defined as correct if the catheter tip was placed less than 1 cm inside the right atrium relative to the cavoatrial junction, and the simultaneous angle of the central venous catheter tip compared with the lateral border of the superior vena cava was below 40°. Results: During the 6-year study period, 97 patients were analyzed for the central venous catheter tip position in computed tomography. Malpositions were observed in 29 patients (29.9%). Patients with malpositioned central venous catheters presented with a higher rate of shock (systolic blood pressure <90 mmHg) at admission (58.6% vs 33.8%, p = 0.023) and a higher mean injury severity score (38.5 ± 15.7 vs 31.6 ± 11.8, p = 0.041) compared with patients with correctly positioned central venous catheter tips. Logistic regression revealed injury severity score as a significant predictor for central venous catheter malposition (odds ratio = 1.039, 95% confidence interval = 1.005–1.074, p = 0.024). Conclusion: Multiple trauma patients who underwent emergency central venous catheter placement by experienced anesthetists presented with considerable tip malposition in computed tomography, which was significantly associated with a higher injury severity.

Ziel der Studie war die Analyse typsicher MR-Bildbefunde der Prostata nach Hemiablation durch High-intensity focused ultrasound (HIFU).