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This retrospective, observer blinded case-control study aims to compare the prevalence of neurovascular conflicts (NVCs) of the vestibulocochlear nerve and the anterior inferior cerebellar artery (AICA) in patients presenting with clinical signs of acute vestibular neuritis with and without subsequent objective vestibular function loss (VFL). 58 acute cases of clinically suspected acute vestibular neuritis were investigated with same day cranial MRI at a tertiary referral centre and compared to 61 asymptomatic controls. The prevalence of NVCs in cases with objective VFL were also compared to cases without VFL. Radiologists described the NVC as "no contact" (Grade 0), "contact < 2 mm" (Grade 1), "contact > 2 mm" (Grade 2) and "vascular loop presence" (Grade 3) without knowledge of neurotological data. Neurotological data was collected without knowledge of MRI findings. Vestibular function was tested by bithermic caloric irrigation. 26 cases (45%) showed caloric VFL (Group A), whereas 32 (55%) exhibited no VFL (Group B). Group A included 13 cases with NVCs (50%), Group B included 26 NVC cases (82%) (p = 0.012) and the control group included 16 individuals (26%) (p < 0.001 for comparison of all 3 groups). Group B had a significantly higher NVC-Grading than Group A (p = 0.009). There was no statistically significant association between NVCs and either SNHL or tinnitus (p > 0.05). Our results suggest that patients presenting with clinical signs of acute vestibular neuritis who show symmetrical caloric vestibular function test results have a significantly higher NVC prevalence in the cerebellopontine angle.

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Laparoscopic adjustable gastric banding is a surgical procedure that is increasingly being performed for the treatment of morbid obesity. As with any intervention, gastric banding is not free from complications. Complications after gastric banding can be divided into early and late complications. Early complications include band malposition and perforation of the stomach. Late complications comprise pouch dilatation, intraluminal band penetration and oesophageal dilatation. Understanding the principles of the intervention is essential for both the interpretation of the resulting radiographical findings and the diagnosis of potential complications. We report on the normal anatomy and the most frequent complications seen after gastric banding.

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PURPOSE: To evaluate retrospectively the results of consensus double reading of mammograms in a private practice for a period of 1.5 years (November 2001 to March 2003). MATERIALS AND METHOD: Two independent experts with dedicated training read all mammograms on a weekly basis. All mammograms including sonographic examinations were evaluated independently and categorized using the BI-RADS classification. The achieved consensus included a possible recommendation for recall or therapy. A total of 3936 mammograms and 1912 sonography studies were evaluated. All cases with BI-RADS 4 and 5 categories were compared with the histologic results. For a period of three months, the acceptance of double reading including a delay of the final report by one week was tested with a questionnaire and informed consent sheet. RESULTS: BI-RADS categories 4 and 5 were found in 57 cases, with 41 consensus results by two independent readers and 26 carcinomas verified by histology. No consensus could be reached in 16 patients, of which 10 had a final histologic result, with 5 benign lesions and 5 carcinomas of less than 1 cm in diameter. Clinical symptoms or alterations were absent in all patients. The 5 carcinomas were discovered by the double reading procedure. The result of the questionnaire (695 questionnaires) showed a refusal rate of 0.7 %, with only 5 women refusing the opportunity of double reading their mammograms. CONCLUSION: Double reading of mammograms by independent experts is feasible, shows a measurable increase in quality and is accepted by almost all women.

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The present trial focused on the exact role of colour and power Doppler sonography in Achilles tendinopathy and correlated these techniques with the clinical severity of the disease and with findings on grey-scale sonography. Twenty patients with in total 28 symptomatic Achilles tendons were included in this prospective trial. Additionally included were the asymptomatic tendons (n = 12) of patients and both tendons (n = 30) of fifteen controls. The pain score of Robinson - which ranges from 0 (strong severe pain) to 100 (asymptomatic) - was used to assess clinical severity of the disease. Both tendons of patients and controls were examined by a GE LOGIQ 9 trade mark scanner with a small-parts 14 MHz transducer. Grey-scale sonography detected in total 31 focal hypoechoic areas in 19 (68 %) of the 28 symptomatic tendons. Colour as well as power Doppler sonography detected blood flow in 14 (74 %) of the 19 tendons with focal hypoechoic areas. No blood flow was detected in the remaining symptomatic tendons (n = 14) and in the asymptomatic tendons of patients or in both tendons of controls. Colour and power Doppler sonography resulted in a specificity of 100 % and a sensitivity of 50 % for symptomatic Achilles tendinopathy. Patients with blood flow within the tendon had a significantly lower score according to Robinson than symptomatic patients without flow (P = 0.009). It is concluded that colour and/or power Doppler sonography are useful as an adjunct to grey-scale sonography in the examination of Achilles tendinosis, especially because the presence of blood flow is associated with stronger pain, discomfort and physical restriction.

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PURPOSE: To evaluate the role of real-time extended field-of-view sonography (EFOVS) in symptomatic Achilles tendon disease in comparison with MR imaging (MRI). MATERIALS AND METHODS: Twenty-three symptomatic tendons were examined by conventional grayscale sonography, EFOVS and MRI, which served as the gold standard. RESULTS: The median tendon thickness in MRI was 7.8 mm (IQR 3.1) and correlated significantly to the results of EFOVS (7.0 mm, IQR 2; r = 0.74, P < 0.01). In total, MRI detected 24 lesions in 18 tendons and EFOVS 21 hypoechoic lesions in 15 tendons, corresponding to a sensitivity of 87.5 % and specificity of 100 %. The additional usage of conventional grayscale sonography improved sensitivity to 95.8 %. The median distance of the largest lesion to the calcaneal tuberosity was 10.4 mm (IQR 3.4) in MRI and 8.5 mm (IQR 5.1) in EFOVS (r = 0.64; P < 0.05). The sensitivity and specificity of EFOVS for the detection of a peritendinitis were 63.6 % and 66.7 %, respectively. Corresponding values for the detection of a bursitis were 68.8 % and 28.6 %. The additional usage of conventional grayscale sonography improved the specificity to 85.7 %. CONCLUSION: The combination of EFOVS and grayscale sonography has the potential to challenge MRI as the preferred imaging method in diagnosing symptomatic Achilles tendon disease, especially with respect to saving time and cost and the absence of any contraindications.

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OBJECTIVE: To evaluate the role of routine chest radiographs in the diagnosis of thoracic aortic aneurysms (TAA). METHODS: An electronic full-text search was performed in our radiological information system for all patients who underwent chest radiograph under standard conditions between 1998 and 2000 and who had suspected widening or aneurysm of the thoracic aorta as a diagnosis. Computed tomography (CT) of the thorax was used as the gold standard and had to be performed within a period of 30 days. Two independent and blinded observers evaluated different morphologic and morphometric parameters in the diagnosis and correlated the results with those of CT. RESULTS: 28 patients were included in the present trial. With almost perfect interobserver correlation (r = 0.95) both investigated morphometric parameters correlated well (r = 0.85 and 0.83) with the diameter of the aorta as evaluated with CT. While a low subjective over-all probability for TAA had a negative predictive value of 100 %, we found that, despite an almost perfect interobserver variability (Kappa > 0.8), none of the investigated morphologic parameters (discrepancy between the ascending and descending aorta, displacement of the trachea to the right and caudal displacement of the left main bronchus) was significantly correlated with the final diagnosis. CONCLUSION: The investigated morphometric parameters help to estimate the diameter of the aorta in the arch and in the descending section, but none of the morphologic criteria can be used for the diagnosis of TAA.

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BACKGROUND/AIMS: The pathogenesis of thrombocytopenia associated with advanced liver disease is still controversial. To study the impact of portal decompression on this hematologic complication, we conducted a prospective, controlled study to compare the course of platelet counts in patients after implantation of a transjugular intrahepatic portosystemic shunt (TIPS) with matched controls without shunts. METHODS: Fifty-five TIPS patients and 110 controls matched for age, sex, Child-Pugh class, etiology of liver disease and baseline platelet count were included, and followed for 1 year. Follow-up visits were scheduled after 1 month, after 3 months, and at 3-month intervals thereafter. RESULTS: Nonparametric Mann-Whitney U-tests revealed significantly higher platelet counts for TIPS patients as compared to controls from the 1st through the 12th month (p<0.01). During the study period, the median platelet count of TIPS patients increased by 19.7%, from 104.0/nl (IR: 68.0) to 124.5/nl (IR: 41.0). In contrast, during the same period the median platelet count of controls decreased by 17.1%, from 102.5/nl (IR: 66.0) to 85.0/nl (IR: 67.5). In the group of cases with baseline platelet counts < or =100/nl, platelet counts had increased by at least 25% at month 12 in 65% of TIPS patients, but in only 5% of controls (p<0.001). However, normalization of platelet counts, i.e. > or =150/nl, was not achieved in any case. Neither the portosystemic pressure gradient after TIPS implantation, nor the percentage of portosystemic pressure gradient reduction during the procedure was predictive of platelet response. CONCLUSIONS: TIPS implantation increases platelet counts significantly. However, portal hypertension is clearly not the only mechanism contributing to thrombocytopenia in advanced liver disease.

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BACKGROUND: Isolated left ventricular abnormal trabeculation (ILVAT) is defined as > 3 coarse trabeculations of the left ventricular wall, apically to the papillary muscles, in hearts without congenital malformations. HYPOTHESIS: The aims of the study were to assess by echocardiography the prevalence of ILVAT, to confirm the diagnosis by cardiac magnetic resonance imaging (CMRI), to look for cardiac findings in ILVAT, and to determine whether ILVAT is familial and associated with neurological disorders. METHODS: During a 1-year period (July 1995 to July 1996) all patients in whom transthoracic echocardiography visualized ILVAT, were included in the study. The examination and measurements were performed according to established guidelines. RESULTS: During 1 year, ILVAT was found in 6 of 3,397 patients (0.2%). When applied, CMRI confirmed ILVAT. Four patients had heart failure, all had electrocardiographic (ECG) abnormalities. None of the investigated relatives showed ILVAT. One patient had Becker's muscular dystrophy, three had mitochondrial myopathy, one had polyneuropathy, and one had muscle wasting of unknown origin. CONCLUSIONS: Isolated left ventricular abnormal trabeculation is rare, visible on echocardiography and CMRI, associated with ECG abnormalities, sometimes with heart failure, and always with neuromuscular disorders. Thus, when ILVAT is found, the cardiologist should consider a neurology referral.

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PURPOSE: Evaluation of MR imaging in patients with acute subarachnoid hemorrhage (SAH) at 0.5 Tesla using the FLAIR (Fluid Attenuated Inversion Recovery) sequence. Additionally, the value of MR angiography (MRA) in the diagnosis of intracranial aneurysms was assessed. MATERIALS AND METHODS: 19 patients with suspected acute SAH were included in this study. MR imaging was performed using an axial FLAIR sequence and axial T1, T2 and PD weighted sequences. In 16 patients an additional MRA (3D-TOF) was performed. 10 patients without SAH were examined as a control group. At the end of the study the 29 MR examinations were randomised and the images were read by two experienced radiologists; subsequently a consensus interpretation was made. RESULTS: In 16 patients an acute SAH was verified with the FLAIR sequence, in 13 cases the origin of hemorrhage was found during surgery. In the consensus interpretation of the MR images all cases were diagnosed properly. 12 of the 16 MRA studies were of diagnostic quality, but only 6 cases were interpreted correctly. CONCLUSION: The FLAIR sequence at 0.5 Tesla proved effective in the diagnosis of acute SAH. MRA at 0.5 Tesla failed in the detection of intracranial aneurysms.

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Evaluation of the pericardium using the capabilities of computed tomography (CT) and magnetic resonance imaging (MRI) remains one of the last requests to the radiologists within the spectrum of cardiac diagnostics. New technical developments in CT and MRI improve diagnostic accuracy in diagnosing pericardial disease and help to define adequate therapeutic management. The purpose of this article is to review the diagnostic possibilities of the radiologist in pericardial diseases with emphasis on CT and MRI. The anatomy of the normal pericardium including pericardial recessus and sinuses is reviewed followed by a brief discussion of congenital abnormalities. Particular attention is paid to acquired pericardial diseases including the potential characterization of pericardial effusions. Pericardial thickening and pericardial constrictions are discussed and the differentiation between pericardial constriction and restrictive cardiomyopathy is highlighted because of the therapeutic implications. Finally a brief review of primary and metastatic pericardial tumours is given.

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PURPOSE: The aim of the study was to assess the value of a scoring system for the diagnosis of acalculous cholecystitis (AC) on ultrasound (US) follow-up examinations and to discuss the merits of scoring system compared to clinical outcome and pathohistologic findings. MATERIAL AND METHODS: In this prospective study, 21 patients at the intensive care unit (ICU) of a medical department were examined by follow-up US. Sonographic parameters of the gallbladder (GB) were obtained (longitudinal and transversal diameter, wall thickening, contents, and pericholecystic fluid) and scored (2 points: distension of GB, thickening of GB wall; 1 point: striated thickening of GB wall, sludge, and pericholecystic fluid; range (0-8). The US findings were correlated with clinical findings and histology at cholecystectomy or autopsy. RESULTS: Of a total of 77 follow-up examinations in these 21 patients, US demonstrated GB distension in 19 patients, wall thickening in 18, sludge in 15, striated thickening of the GB wall in 13, and pericholecystic fluid in 12 patients. Of these, 41 (53%) examinations were scored > or = 6, and 36 (47%) examinations < or = 5. None of the patients with a maximum score during follow-up of < or = 5 (n = 8) had pathohistologic proof of AC or died due to GB complications. Patients with maximum scores of > or = 6: had pathohistologic proof of AC (n = 4); survived with normalization of GB morphology (n = 4); had a normal GB at autopsy (n = 1); or were lost for pathohistologic proof at autopsy (n = 2). CONCLUSION: Our results indicate that regular, short-term follow-up allows early diagnosis and immediate therapy for AC. The scoring system could be helpful in differentiating between patients with an abnormal GB without AC (score < or = 5) and those with an abnormal GB (score > or = 6) with a suspicion of AC. In the latter group, more aggressive diagnostic and therapeutic procedures may be indicated.

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OBJECTIVE: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a relatively new therapy for variceal bleeding. The aim of this study was to assess clinical course 2 years after TIPS procedure. DESIGN: The study was designed as a prospective, uncontrolled cohort study. METHODS: Forty-six patients who underwent successful TIPS implantation were followed prospectively by clinical examinations, duplex sonography and portal venography. Mean follow-up in surviving patients was 24.1 +/- 9.0 months. RESULTS: The cumulative rate of survival was 80.4% at 1 year and 70.2% at 2 years. The cumulative rebleeding rate was 12.4% at 1 year and 21.3% at 2 years. The mortality rate of episodes of variceal rebleeding was 22.2%. Variceal rebleeding was associated with shunt abnormalities, and successful shunt revision resulted in control of the bleeding. The cumulative incidence of shunt stenosis or occlusion was 41.2% at 1 year and 54.9% at 2 years. Of those patients without shunt abnormalities after 1 year, 23.3% developed shunt stenosis or occlusion during the second year after TIPS procedure. Shunt revision was successful in 96.6% of cases. Secondary patency rate was 88.1% after 2 years. CONCLUSION: Successful TIPS implantation results in a low rate of morbidity and mortality from variceal rebleeding over 2 years. TIPS creation in combination with careful follow-up examinations represents an effective long-term treatment of recurrent variceal bleeding. Even in patients in whom no shunt abnormality is detected during the first year, routine duplex follow-up examinations should be continued at 3-month intervals.

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Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is associated with a broad spectrum of acute and chronic complications. Data concerning incidence and prognosis of these complications are conflicting but of great importance toward defining the role of TIPS relative to other therapeutic options. We conducted a prospective, uncontrolled cohort study in 53 patients to assess incidence, management and clinical outcome of complications occurring after TIPS procedure. Mean follow-up was 21.1 +/- 9.0 months. Technique-related mortality was 2%; 9% of patients died within 30 days after TIPS procedure. The overall survival rate after 18 months was 74%. The overall incidence of primary hepatic encephalopathy (HE) within the first year was 25%, and 77% of episodes could be managed successfully by medical treatment or implantation of a reducing stent. The rate of patients without rebleeding after 18 months was 84%. Rebleeding was associated with shunt abnormalities, and the bleeding was controlled by revision of the stent. Two patients died of variceal hemorrhage. The cumulative incidence of shunt stenosis or occlusion was 47% after 18 months. The technical success rate of shunt revision was 97%. TIPS implantation is associated with a considerable risk of HE and shunt stenosis or occlusion. Nevertheless most episodes of HE can be managed by medical treatment or implantation of a reducing stent. Angiographic revision of the stent is successful in nearly all cases of stenosis or occlusion. We therefore conclude that TIPS implantation in combination with careful follow-up examinations constitutes effective medium-term treatment of portal hypertension in a considerable proportion of patients.

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In laryngectomized patients a tracheo-esophageal artificial fistula can be used to achieve air flow from the trachea to the esophagus during speech. A one-way plastic valve is often used for the fistula. A free jejunal graft between the trachea and the esophagus can also be used. To avoid aspiration the transplant is attached to the submental area giving the graft a siphon-like shape. We performed 23 videoradiographic examinations using high-density barium in 14 such patients. The aim was to evaluate the protective function of these grafts against aspiration. Penetration of the bolus and a small amount of residual contrast material in the ascending limb of the graft was a normal finding. If the standard barium bolus reached the descending limb at any time during the examination, this was a sign of aspiration hazard. To avoid aspiration, the vertex of the speech siphon should be higher than the level of the hypopharyngeal anastomosis.

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We present two patients with an extremely rare condition: abnormal cardiac levoposition. Alterations in the ECG caused by this congenital abnormality and additional chest symptoms led to the false diagnosis of previous myocardial infarction. Chest X-ray and echocardiography suggested cardiac malformation. Correct diagnosis of cardiac levoposition was established by magnetic resonance imaging.

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Several reports on the occurrence of pancreatic dysfunction complicating Crohn's disease have been published during the past few years. Nevertheless, the pathogenesis of these disorders remains controversial. In this report, we describe a patient presenting with extrahepatic cholestasis and a mass in the head of the pancreas. Histological examination showed a granulomatous inflammation caused by Crohn's disease involving the stomach, the duodenum, and the head of the pancreas, clearly showing that the pancreas can also be a localization of Crohn's disease. Granulomatous inflammation could be an important factor in the pathogenesis of pancreatic dysfunction occurring in association with Crohn's disease.

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Successful allogeneic bone marrow transplantation (BMT) for hematologic disorders may be complicated by graft-versus-host-disease (GVHD). Chronic GVHD is a systemic disease, involving, among other organs, the skin, mouth, liver, and esophagus. Esophageal involvement results in mucosal inflammation, leading to submucosal fibrosis and, occasionally, formation of webs and strictures. We investigated 25 allogeneic BMT recipients (17 with and eight without chronic GVHD). All patients had a videofluoroscopic study of the pharynx and esophagus to determine the radiographic abnormalities characteristic of chronic GVHD. Oropharyngeal abnormalities (poor bolus control, pharyngeal retention, or excessive mucous secretions) were found in five patients with and three patients without GVHD. Only one patient with GVHD had a pharyngo-esophageal stricture. There was no significant difference between the two groups with regard to pharyngo-esophageal radiographic abnormalities and esophageal symptoms. Radiographic evidence of esophageal motility disorder is not specific for GVHD involvement. In the absence of specific radiographic features, endoscopy is the most accurate method for the diagnosis of esophageal involvement by GVHD.

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The purpose of this study was to evaluate the efficacy of a new automatic biopsy device (Autovac, Angiomed, Karlsruhe, Germany) in ultrasound (US) guided biopsies of focal abdominal lesions. 50 consecutive patients with focal abdominal lesions underwent US guided biopsies. In the first 24 patients, needle passes were performed with the Autovac system (outer diameter 0.95 mm) as well as with the Biopty gun (outer diameter 0.9 mm) (Bard Covington, USA). The size and the quality of the histologic and the cytologic material obtained by both systems were evaluated by histopathologists blinded to the system used. Autovac yielded significantly more material (defined as the area of the obtained tissue cores) and a significantly higher quality score than did the Biopty system. 96% of the histologic specimen and 100% of the cytologic smears obtained with Autovac were diagnostic, compared to 70 and 81% with Biopty, respectively. With the exception of a short-time elevation of the blood pressure in one patient, no complications occurred. The results indicate an advantage of the automatic full-cut type system Autovac over the tru-cut type Biopty gun in US-guided biopsies of focal abdominal lesions.

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