[CT of the upper ankle joint. Anatomy--pathology]

Diagnosis of ligament ruptures via the possibilities of conventional radiology is often insufficient. To verify CT efficiency, postmortem specimens were scanned in axial, coronal and sagittal planes and compared with anatomical findings of sections in identical planes. After the preliminary examinations we conducted a study on 32 patients. The examinations of the anterior talofibular ligament showed a correlation between CT and operative findings in 30 of 32 cases.

[MR tomography of the elbow joint]

MR examinations of the elbow joint of three healthy subjects and a comparison with corresponding sections of anatomical preparations show that MR tomography enables not only an excellent differentiation of muscles, tendons and of the articular capsule, but will also visualise vessels and nerve tracts. MR tomography proved superior to the conventional methods in demonstration of separate fragments and inflammatory changes in the bone on examining 11 pathological elbow joints: congenital malformation, osteochondritis dissecans, ostitis, ulnar and radial nerve lesions, completely healed radius fracture and epicondylitis of the radial and ulnar humerus. Epicondylitis could not be demonstrated by MR. Magnetic resonance tomography seems to be the only method that enables direct visualisation of the nerve paths at the elbow joint.

[Percutaneous embolization with spirals in bleeding uterine cancer]

Percutaneous transcatheter embolization (PTE) in patients with life threatening bleeding carcinomas of the uterine cervix using stainless steel coils, proves to be an effective treating method. There is a low incidence of complications concerning the local cutis, nerves or arteries. PTE does not allow a causal therapy of the malignant disease, but in half of our patients (n = 13) embolization was the precondition for initial or further adequate therapeutic management.

[Plasma histamine liberation after the application of nonionic contrast media]

In 94 patients the levels of plasma histamine have been measured after application of three nonionic contrast media (iopromide, iopamidol, iohexol) and after application of blood-isotonic saline solution. A significant liberation of histamine could be observed after administration of contrast media and also after administration of saline solution. Neither between the three nonionic contrast media nor between the contrast media and the saline solution significant differences could be measured. Administering contrast media after subsequently saline solution the levels of histamine were lower than in case of pure contrast media application. Psychogenically induced histamine liberation is discussed.

Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonus

We studied the effect of seizures and myoclonus following cardiopulmonary resuscitation (CPR) on the outcome of all comatose adult survivors of CPR over an 8-year period. Either seizures or myoclonus occurred in 50 of 114 patients (44%): seizures in 41 patients (36%) and myoclonus in 40 (35%). Status epilepticus or status myoclonus occurred in 36 patients (32%), and 19 (17%) had myoclonic status epilepticus (MSE). Seizures and myoclonus per se were not significantly related to outcome, but status epilepticus, status myoclonus, and, particularly, MSE were predictive of poor outcome as judged by survival and recovery of consciousness.

[Digital subtraction dacryocystography and sialography]

Fourteen examinations of the tear ducts and 21 sialograms were performed using digital subtraction and conventional techniques. In nine of the former and 15 of the latter, digital subtraction produced better results, in the remainder conventional technique was equally good. The advantages of digital subtraction are due to the removal of superimposed structures of the skull. Dose measurements at the level of the lens of the eye showed a greatly reduced radiation dose when using digital subtraction, as compared with conventional dacryocystography. Digital subtraction techniques with pulsed radiation and the ability to perform pixel shift is an optimal method for performing radiological examinations of the tear ducts and salivary glands.

[Risk of tuberculosis infection among hospital personnel]

The decrease in morbidity due to tuberculosis and the increasing number on non-infected persons strongly suggest a review of the conventional tuberculosis monitoring procedures in hospital staff. A study at Luebeck university on the risk of tuberculosis infection among medical personnel showed that tuberculin tests in non-infected persons and chest x-rays only if exposed to patients in the infectious stage of tuberculosis will suffice and comply with the Federal regulations governing health protection of medical and paramedical staff.

Utility of DSA in the evaluation of haemodialysis access fistulas

Results of 39 intravenous and intraarterial DSA studies of haemodialysis access fistula are presented. Advantages of DSA versus conventional fistulography and xeroangiography are discussed. Digital subtraction angiography represents an accurate, time-saving and low complication approach to the evaluation of failing dialysis access fistulas.

Cardiac gating in intravenous DSA

ECG-gating of a pulsed radiation exposure during end-diastole using digital subtraction angiography shows significantly better results in the examination of the aortic arch vessels and pulmonary arteries and may be expected to decrease the rate of false positive diagnosis of stenosis when examining renal arteries. Different types of misregistration artifacts due to a smear effect by integrating several television frames using non-gated DSA are described and schematically explained. Furthermore, a short description of the difficulties which may be encountered with ecg-gated DSA--mainly rapid changes of heart frequency--is given.

Sarcoidal granulomas in tattoos

A case of sarcoidal granuloma in tattoos, occurring in the setting of systemic sarcoidosis, is presented. The differential diagnosis of granulomatous reactions in tattoos is reported.

[Intravenous DSA following kidney transplantation]

Intravenous DSA is a simple angiographic technique in the follow-up of patients with renal transplants. It is of value in the post-operative anuric phase, for investigating renal function which is deteriorating and for demonstrating, or excluding, stenosis of the renal artery at the anastomosis during the development of hypertension. Changes in the peripheral arteries are not usually demonstrable. Reduced opacification of the parenchyma is observed during rejection and if there has been damage to the transplant, but is not seen if the transplant is functioning normally.

[Comparison of Doppler ultrasound, intravenous DSA and conventional film angiography in diagnosing stenosing changes in the area of the carotid bifurcation]

The findings on Doppler ultrasound, intravenous DSA and conventional film angiography were compared in 66 examinations of the carotids with regard to their specificity, sensitivity and accuracy. Comparisons with the literature show that intravenous DSA equals Doppler ultrasound only if good or excellent results of the latter are considered. If poorer DSA results are included, diagnostic precision of this method is 5 to 10% less than that of Doppler ultrasound. Mural ulceration can be diagnosed by means of intravenous DSA in only about 50% of cases, whereas Doppler ultrasound is unable to diagnose this. Improved image quality of intravenous DSA, with better diagnostic precision, could be achieved by using ECG gating.

[Intra-arterial digital subtraction angiography of the femoral bifurcation as a supplement to conventional pelvic-leg arteriography]

In view of the fact that in prognosis and treatment of arterial occlusion, particular importance must be attached to the profunda femoris artery, and especially to the region of origin of this artery, it is imperative to achieve angiographic representation of the descent of the profunda femoris artery without any masking. The intra-arterial injection method employing digital subtraction angiography is the method of choice, since it requires a low amount of contrast agent, time, and film. In 90 per cent of the cases, ipsilateral anterior oblique projection will be most suitable to represent the femoral bifurcation, which depends on the course of the profunda femoris artery in anterior-posterior projection, the angle varying between 30 degrees 40 degrees. 50 to 70 per cent of the stenoses occurring in the descending part of the profunda femoris artery, can be recognised via oblique projection only.

[The so-called inflammatory aneurysm of the abdominal aorta]

The computer tomographic appearances of four patients with the rare inflammatory aneurysm of the abdominal aorta are described. The condition, whose aetiology is not known, affects mostly men in the fifth, sixth and seventh decade. Computed tomography shows, in addition to the typical changes due to an aortic aneurysm, horse-shoe shaped, circular, homogeneous peri-aneurysmal masses, which enhance after intravenous contrast. Bolus injection of contrast is necessary in order to differentiate these from a dissection or retroperitoneal lymphoma. Distinction between these conditions is possible as a result of the various types of enhancement which occur in the aortic lumen, in fibrosis and in lymphoma.

Evaluation of brainstem stroke using brainstem auditory evoked responses

Brainstem stroke syndromes are primarily determined by clinical criteria. There are few diagnostic procedures which are of benefit for the evaluation of brainstem ischemic events. Brainstem auditory evoked responses (BAERs) are a new electrophysiologic technique for assessing brainstem function. To evaluate the use of BAERs in patients with brainstem ischemic events, 35 individuals with recent brainstem strokes, selected by strict clinical criteria, were evaluated with BAERs. The initial BAER was abnormal in 22 of 35 patients (63%). When the clinical course and site of the lesion are correlated with the BAER results, several trends emerge. An unstable course, characterized by progression or remission and relapse, was present in 19/35 (54%) of patients, and 15/19 (79%) of these individuals had an initially abnormal BAER. The other 16 brainstem stroke patients with a stable clinical course had an initially abnormal BAER in 7 instances (44%). This difference is statistically significant at the p = 0.04 level. The principal sites of ischemia were mesencephalic in 11/35, pontine in 13/35, and medullary in 11/35. The association of an abnormal BAER with an unstable clinical course seemed independent of the site of the lesion, However, of the 9 deaths that occurred, all were in patients with mesencephalic or pontine lesions, and 8 of these individuals had an initially abnormal BAER. Abnormal BAERs in patients with brainstem ischemic lesions correlate with an unstable clinical course. Furthermore, individuals with pontomesencephalic infarction and abnormal BAERs have an especially poor prognosis. The BAER may be of prognostic value in the early evaluation of patients with brainstem ischemic strokes.

Solitary intracranial plasmacytoma: two patients with extended follow-up

Solitary neoplastic proliferation of plasma cells (plasmacytoma) rarely occurs in the central nervous system. The longest follow-Up in nine previously reported patients was 5 years. We have followed two patients with solitary intracranial plasmacytoma for 8 and 13 years, respectively. At the time of biopsy diagnosis, neither showed involvement of the adjacent calvarium or evidence of a systemic plasma cell dyscrasia. The first patient underwent partial excision of a mass in the right occipital lobe that showed no gross or microscopic involvement of the dura. The second patient had partial resection of a mass arising from dura and invading the left temporal lobe. Postoperative irradiation was given to both patients. No clinical or radiological sign of recurrent brain tumor has developed in either patient during the extended follow-up period. Neither patient has had laboratory or clinical evidence of a systemic plasma cell dyscrasia. Solitary intracranial plasmacytoma may be a "curable" brain tumor.

Tumours in the region of the papilla of Vater. Diagnosis via endoscopy, biopsy, brush cytology, ERPC and CT-scan

Thirty-two cases of tumour in the region of papilla of Vater are reported including five benign lesions (papillitis, polyp, duodenitis) and 27 periampullary carcinomas. Duodenoscopy has a key position in the diagnosis of these lesions, since by judging the endoscopic appearance of the papilla a forceps biopsy and brush cytology can be performed. Accuracy of forceps biopsy is up to 66%, whereas diagnostic accuracy of brush cytology only reaches about 44%. Because of the possible false positive results, brush cytology should be regarded with reserve in the diagnosis of periampullary carcinomas. Retrograde filling of contrast medium of bile and/or pancreatic ducts mainly serves for delineation of tumour size and allows fine needle aspiration under fluoroscopy. Success rate of retrograde cannulation is rather low. CT-scans are of great importance in detecting metastases of liver and/or regional lymphnodes but are of little value in diagnosing the primary lesion.

Evoked responses in vitamin B12 deficiency

Abnormalities of visual, brainstem auditory, and somatosensory evoked responses were demonstrated in two of seven individuals with vitamin B12 deficiency. The evoked response delays correlated directly with the degree of neurological dysfunction. Abnormalities were present in sensory systems without clinical evidence of involvement and were similar to those found in individuals with multiple sclerosis.

[Accuracy of endoscopic retrograde pancreatico-cholangiography in the diagnosis of pancreatic disease: an analysis of three thousand investigations (author's transl)]

Endoscopic retrograde pancreatico-cholangiography (ERPC) gave the correct diagnosis in 83% of 269 cases of pancreatitis confirmed by operation, clinical features, laboratory findings and course. It provided the correct diagnosis in 85% of 82 cases of necrosis of the pancreas and pseudocysts confirmed at operation. ERPC is one of the most important methods of investigation in papillary stenosis, because it can demonstrate both ducts and can reveal functional changes, especially delayed emptying. The correct diagnosis of carcinoma of the pancreas, confirmed at operation or histologically, was made in 88% of 107 cases. Endoscopy correctly diagnosed 26 of 27 cases of papillary carcinoma. Biopsy with subsequent histological study and cytological analysis of pancreatic secretion further served to confirm the diagnoses established by ERPC.

[A comparison of the diagnostic accuracy of ultrasound, computer tomography and ERPC in chronic pancreatitis and carcinoma of the pancreas (author's transl)]

A comparison of the diagnostic accuracy of ultrasound, computer tomography and ERPC in chronic or recurrent pancreatitis and pancreatic carcinoma has shown that ERPC is the most precise of the three methods. This was particularly important in the demonstration of the small, still operable, carcinomas of the pancreas. Sonography is most useful for serial observations of pancreatic pseudocysts due to chronic recurrent pancreatitis. In this situation, ERPC should only be used if sonography and computer tomography cannot localise the lesion. Where the computer tomogram has shown evidence of enlargement of the pancreas, sonography may show an area devoid of echos within the enlarged organ, suggesting the presence of a carcinoma. Computer tomography superior to ultrasonography in delineating the extent of extensive pancreatic disease and in showing the anatomical structures surrounding the pancreas.

[Endoscopic retrograde cholangiography (ERC) in congenital cystic biliary anomalies (author's transl)]

Cystic anomalies of the bile duct are rare conditions found mostly in the younger age groups and four times more frequently in women than in men. The introduction of retrograde contrast filling of the bile ducts has led to a marked improvement in the pre-operative diagnosis. Precise demonstration of the anatomical relationships is of the utmost importance for surgical intervention. A number of variants of cystic bile duct anomalies must be differentiated from double gall bladders, bile duct fistulas, pancreatic cysts and pseudocysts; small cysts (type IV) must be distinguished from the autoimmune form of cholangitis-pericholangitis and from acquired generalised bile duct dilatation. The prognosis of cystic biliary anomalies is determined by the complications of these conditions. These include ascending cholangitis, stone formation and malignant change.