To identify imaging algorithms and indications, CT protocols, and radiation doses in polytrauma patients in Swiss trauma centres.

Es werden 4 ältere Patientinnen mit therapieresistenter Periarthropathie des Hüftgelenks und MR-tomographisch nachgewiesener Ruptur der Gluteus-medius- und/oder -minimus-Sehne vorgestellt. Eine Traumaanamnese fehlte bei allen Patientinnen. Ein positives Trendelenburg-Zeichen zeigten 3 der 4 Patientinnen. Die Magnetresonanztomographie (MRT)-Untersuchung stellt in der Diagnose der Gluteusruptur die Methode der Wahl dar. Der MRT-Befund ist entweder eine offensichtliche Diskontinuität der betroffenen Sehne oder ein erhöhtes T2-Signal oberhalb, weniger spezifisch auch lateral des Trochanter major. Eine elongiert erscheinende Sehne entspricht in der Regel einer Partialruptur. Schmerzen und lokale Druckdolenz über dem Trochanter major werden häufig einer Bursitis trochanterica oder Periarthropathia coxae zugeordnet. Differenzialdiagnostisch sollte an partielle oder komplette Rupturen der Gluteus-medius- oder -minimus-Sehne gedacht werden. Solche Rupturen stellen vermutlich bei Patienten mit lateralem Hüftschmerz und neu aufgetretenem Hinken einen häufiger als bisher angenommenen Befund dar. Die tatsächliche Inzidenz ist jedoch ebenso wenig untersucht wie die klinische Relevanz. Es fehlen insbesondere Studien über die Prävalenz bei asymptomatischen Probanden und prospektive Untersuchungen zum Risiko einer Arthroseentwicklung (welche zumindest theoretisch aufgrund verminderter Schutzreflexe via Propriozeptoren der Muskelspindeln möglich erscheint) sowie zum Sturzrisiko als Folge der verminderten Abduktionsleistung. Zur Therapie existieren nur chirurgische Arbeiten. Die Erfolgsaussichten konservativer Behandlungsansätze sind nicht untersucht.

The cases of four elderly patients with persistent trochanteric pain and tears of the gluteus medius and/ or gluteus minimus tendons detected in magnetic resonance imaging (MRI) are presented. There was no history of local trauma in any patient but three patients had a positive Trendelenburg sign. Magnetic resonance imaging showed either an obvious discontinuity of the affected tendon or an increased T2 signal above, or less specifically lateral to the greater trochanter. The presence of an elongated tendon on MRI is most likely indicative of a partial rupture of the tendon. Pain and local tenderness over the lateral aspect of the hip in clinical examination is commonly attributed to trochanteric bursitis or trochanteric pain syndrome. Partial or complete tears of the gluteus medius and/ or gluteus minimus tendons are thought to represent an unusual finding. However, the true incidence and the clinical significance of hip abductor degeneration and rupture remain to be determined. More studies are needed to examine the prevalence of ruptures in as- ymptomatic patients, to evaluate the subsequent risk for developing osteoarthritis of the hip (caused by impaired protective reflexes originating from proprioceptive nerve endings in muscle spindles) and to determine the risk for falls related to weakness of hip abduction. Furthermore, no data exist regarding the success rate of conservative treatment. Tears of the gluteus medius and minimus tendons in the elderly population are likely to be a more common cause of pain in the greater trochanteric region than previously thought. In patients who do not respond to conservative treatment, weakness of hip abduction (positive Trendelenburg sign) and new limping should point to the possibility of hip abductor ruptures. The most useful examination technique for diagnosis is MRI.

Ziele: To evaluate the prognostic value of different CT-measurement for response assessment after initiation of chemotherapy in patients with synchronous colorectal cancer liver metastases at initial staging. Methode: 35 patients with colorectal carcinoma and synchronous hepatic metastases at initial staging

Aseptic pachymeningitis is a rare and serious complication of rheumatoid arthritis (RA). Herein, we describe a patient with rheumatoid factor-positive and anti-cyclic citrullinated peptide-positive RA who experienced a focal seizure, with aphasia and convulsions of the right side of the body. The findings of magnetic resonance imaging and histologic analysis led to a diagnosis of rheumatoid pachymeningitis. Because the patient had a large number of CD20-expressing B lymphocytes, therapy with rituximab was started and has resulted in complete and sustained remission of both the pachymeningitis and the RA for >2 years. Despite a decrease in immunoglobulins, the patient has remained free of infections, which illustrates the favorable outcome that can result from therapeutic B cell depletion in this potentially lethal manifestation of RA.

Chronic traumatic aneurysm of the distal radial artery is rare. The literature offers only 20 cases of chronic traumatic vascular lesions of the thenar region. We present the case of a 58-year-old cheese maker who had done manual work for years and who experienced swelling at the thenar eminence, pain, cold and warm paresthesia and circulatory disturbance in his index finger. Duplex ultrasound and CT angiography revealed an aneurysm of the superficial branch of the radial artery indicating a thenar hammer syndrome. He was subjected to a microsurgical end-to-end repair after resection of the aneurysm. This is the first closely documented case of a true aneurysm of the superficial branch of the radial artery. We also present a comprehensive survey of published studies of chronic vascular lesions of the thenar region related to thenar hammer syndrome and patient occupation, symptoms, diagnostis and therapy.

We evaluated the impact of stereo-visualisation of three-dimensional volume-rendering CT datasets on the inter- and intraobserver reliability assessed by kappa values on the AO/OTA and Neer classifications in the assessment of proximal humeral fractures. Four independent observers classified 40 fractures according to the AO/OTA and Neer classifications using plain radiographs, two-dimensional CT scans and with stereo-visualised three-dimensional volume-rendering reconstructions. Both classification systems showed moderate interobserver reliability with plain radiographs and two-dimensional CT scans. Three-dimensional volume-rendered CT scans improved the interobserver reliability of both systems to good. Intraobserver reliability was moderate for both classifications when assessed by plain radiographs. Stereo visualisation of three-dimensional volume rendering improved intraobserver reliability to good for the AO/OTA method and to excellent for the Neer classification.These data support our opinion that stereo visualisation of three-dimensional volume-rendering datasets is of value when analysing and classifying complex fractures of the proximal humerus.

Bei Patienten mit Otosklerose sind die Stapedektomie und heute die Stapedotomie die Therapie der Wahl. Misserfolge sind selten, können aber eine Revisions-Op. notwendig machen. Wir haben die Bedeutung der Computertomographie (CT) nach nicht erfolgreicher Stapes-Op. analysiert.

Background. Stapedectomy and, more recently, stapedotomy have been widely accepted as the primary surgical techniques to improve conductive hearing in patients suffering from otosclerosis. Unsuccessful outcomes are infrequent, but revision surgery may become necessary. We have analyzed the value of computed tomography (CT) scanning following unsuccessful stapes surgery.Patients and methods. In a total of 37 CT scans, the depth of insertion, angle between prosthesis and footplate, location of prosthesis within the oval niche, visibility of the prosthesis, dehiscence of the superior semicircular canal, and extent of otospongiotic foci were evaluated and compared with the audiometric results.Results. There was no significant correlation between CT parameters and audiologic results, except for patients with cochlear otosclerosis or lateral dislocation of the piston. One previously unknown dehiscence of the superior semicircular canal was diagnosed. Otospongiotic foci were seen in 13 ears (35%).Conclusion. Displacements of the stapes piston and rare causes for an insufficient result, such as a dehiscence of the superior semicircular canal, can be diagnosed accurately by CT. However, correlation between the audiologic results and the findings on CT scans was possible in only a few cases. Nevertheless, CT scans provide additional information for surgical planning in revision stapes surgery and may become increasingly important to reduce unanticipated intraoperative risks; they may even guide the surgeon not to perform unnecessary revision surgeries.

Fragestellung: Material und Methode: Ergebnisse: Schlussfolgerung: Purpose Materials and Methods: Result: Conclusion:

METHODS:We assessed the staging accuracy of endorectal magnetic resonance imaging (eMRI) and transrectal ultrasonography (TRUS) for localized prostate cancer. 54 patients with biopsy proven prostate cancer underwent TRUS and eMRI prior to radical retropubic prostatectomy. The MR images were prospectively interpreted by two radiologists. These findings were compared with the histopathological results.RESULTS:Overall accuracy of eMRI in defining local tumor stage was 93% by radiologist A and 56% by radiologist B. Overall accuracy by TRUS was 63%. Analysis of interobserver agreement showed a poor correlation regarding MRI studies. Endorectal MRI was more sensitive than TRUS for detecting capsular penetration and seminal vesicle involvement. TRUS revealed a relatively high specificity and was superior to eMRI in this regard.CONCLUSION:This series shows the current limited value of TRUS and eMRI for planning treatment in patients with clinically localized prostate cancer.

Objective: Changes in biochemical markers of bone formation and resorption were followed over the course of 1 year in premenopausal, perimenopausal and early postmenopausal women. Methods: Sixty-four subjects were analyzed, grouped according to their menstrual pattern, menopausal complaints and endocrinological parameters to be premenopausal (n=20), perimenopausal (n=24) or early postmenopausal (n=20). The parameters studied at four visits during the 12-month study period were the urinary pyridinium cross-links pyridinoline (PYD) and deoxypyridinoline (DPD), and N-terminal telopeptide (NTX) as bone resorption markers, as well as osteocalcin (OC) and bone-specific alkaline phosphatase (BAP) in serum, representing bone formation. The longitudinal changes over time as well as intergroup differences were analyzed using generalized estimating equations (GEE) in connection with Wald statistics. Results: Over the course of 1 year BAP levels decreased in the late premenopausal group (P<0.05). The perimenopausal group exhibited significant changes of PYD, DPD and OC (P<0.01), NTX levels were higher than in premenopause. Postmenopausal subjects had elevated NTX values, while PYD and DPD levels remained close to the perimenopausal range. Only for OC a time effect was seen during postmenopause. Conclusions: Changes in bone turnover already begin in late premenopause, when decreased bone formation may precede increased bone resorption. The rise of NTX from late premenopause through early postmenopause indicates diagnostic sensitivity of this parameter to changes in bone metabolism induced by estrogen withdrawal. PYD and DPD do not follow this pattern, but change significantly with time during perimenopause to then remain largely unchanged in early postmenopause.

Methodik. Um die Bedeutung von endorektaler MRT (eMRT) und transrektalem Ultraschall (TRUS) für Therapieentscheidungen beim lokalisierten Prostatakarzinom zu beurteilen, führten wir beide Untersuchungen bei 54 Patienten vor radikaler Prostatektomie durch und verglichen die Befunde mit den histologischen Ergebnissen. Die eMRT wurde doppelblind von 2 in der MRT-Diagnostik der Prostata erfahrenen Radiologen ausgewertet.

Previously, vascular imaging was done exclusively using angiography (X-ray projectional imaging of vessels opacified by iodinated contrast media). Recently angiography especially is used in combination with angioplasty (percutaneous enlargement of a closed or stenotic vessel). There has been a change from invasive to non invasive procedures. New developments in computed tomography (CT), magnetic resonance imaging (MR) and ultrasound have reduced the indications for the invasive digital subtraction angiography (DSA). Further improvement especially im MR-angiography and colour-coded dopplersonography will cover all primary diagnostic vascular examinations.

OBJECTIVE:To examine the role of endorectal magnetic resonance imaging (eMRI) and transrectal ultrasonography (TRUS) for clinically localized prostate cancer and to assess interobserver agreement in interpreting MRI studies. PATIENTS AND METHODS:Fifty-four patients with biopsy-confirmed prostate cancer underwent TRUS and eMRI before radical retropubic prostatectomy. The MR images were prospectively interpreted by two radiologists with special expertise in this field. The criteria evaluated prospectively in each patient were extracapsular extension (ECE) and seminal vesicle invasion (SVI). The results were correlated with the histopathological findings after radical prostatectomy. RESULTS:At pathology, 27 patients had stage pT2, 15 had stage pT3a and 12 had stage pT3b lesions. The overall accuracy of eMRI in defining local tumour stage was 93% by radiologist A and 56% by radiologist B; the overall accuracy by TRUS was 63%. There was a poor correlation for the MRI studies between observers. The eMRI was more sensitive than TRUS for detecting ECE and SVI in organ-confined prostate cancer. TRUS had a relatively high specificity for ECE and SVI, and was better than eMRI in this regard. CONCLUSION:Whereas MRI tended to over-stage, TRUS under-staged prostate cancer. This series shows the current limited value of TRUS and eMRI for planning treatment in patients with clinically localized prostate cancer. Treatment decisions should not be altered based on TRUS or eMRI findings alone.

Dual-head gamma cameras operated in coincidence mode are a new approach for tumour imaging using fluorine-18 fluorodeoxyglucose (FDG). The aim of this study was to assess the diagnostic accuracy of such a camera system in comparison with a full-ring positron emission tomography (PET) system in patients with lung cancer. Twenty-seven patients (1 female, 26 males, age 62±9 years) with lung cancer or indeterminate pulmonary nodules were studied on the same day with a full-ring PET scanner (Siemens ECAT EXACT) and a coincidence gamma camera system (ADAC Vertex MCD). Sixty minutes after injection of 185–370 MBq FDG, a scan of the chest was performed with the full-ring system. Approximately 2 h p.i., the coincidence camera study was performed. Coincidence gamma camera (CGC) and PET images with (PETac) and without attenuation correction (PETnac) were analysed independently by two blinded observers. In addition, FDG uptake in primary tumours and involved lymph nodes was quantified relative to normal contralateral lung (T/L ratios). All primary tumours were histologically proven. The lymph node status was histologically determined in 23 patients. In four patients, no lymph node sampling was performed because of extensive disease or concurrent illnesses. In the 27 patients, 25 primary lung cancers and two metastatic lesions were histologically diagnosed. The number of coincidences per centimetre axial field of view was 3.33±0.93×105 for the CGC and 1.09±0.36×106 for the dedicated PET system. All primary tumours (size: 4.6±2.6 cm) were correctly identified in the CGC and dedicated PET studies. T/L ratios were 4.7±2.5 for CGC and 6.9±2.8 for PETnac (P <0.001). Histopathological evaluation revealed lymph node metastases in 11 of 88 sampled lymph node stations (size: 2.3±1.0 cm). All lymph node metastases were identified in the PETac studies, while PETnac detected 10/11 and CGC 8/11. For positive lymph nodes that were visible in CGC and PETnac studies, T/L ratios were 3.7±2.3 for CGC and 6.6±3.1 for PETnac (P=0.02). The diameters of false-negative lymph nodes in the CGC studies were 0.75, 1.5 and 2 cm. False-positive FDG uptake in lymph nodes was found in two patients with all three imaging methods. For all lesions combined, T/L ratios in CGC relative to PETnac studies decreased significantly with decreasing lesion size (r=0.62; P<0.001). In conclusion, compared with a full-ring PET system the sensitivity of CGC imaging for detection of lung cancer is limited by a lower image contrast which deteriorates with decreasing lesion size. Nevertheless, the ability of CGC imaging to detect pulmonary lesions with a diameter of at least 2 cm appears to be similar to that of a full-ring system. Both systems provide a similar specificity for the evaluation of lymph node involvement.

This study evaluated the functional outcome of operatively treated high condylar and diacapitular fractures of the temporomandibular joint (TMJ) by electronic axiographic recordings of condylar movements and magnetic resonance imaging (MRI), displacement of the disc and lesions of TMJ soft tissues being frequent in this type of mandibular fractures 28 patients with 35 condylar fractures, who underwent surgery over a preauricular approach were imaged postoperatively (mean 24 months) with a 1.5 Tesla MRI system to determine, a) the position of the disc, b) the range of mobility of the disc and c) condylar mobility in closed and open mouth position, comparing fractured sides (FS) vs non fractured sides (NFS). Linear movements between the two jaw positions in the sagittal plane were measured by transparency foil superimposition. The results indicate: 1) 71% of the discs (FS) were found to be in normal position, no disc was displaced without reduction. However, these data stood in contrast to severe limitations (75% or more) of axiographic tracings as presented by 25% of the subjects. 2) Significant correlations were found between fused (proportional to=0.05) or highly immobilized (proportional to=0.01) discs and axiographic limitations, suggesting disc mobility to be a valuable parameter for assessment of postoperative functional outcome.