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Pacha TO, Mommsen P, Brauckmann V, Aktas G, Krempec M, Wilhelmi B, Clausen JD, März V, Krezdorn N, Vogt PM, Sehmisch S, Hinrichs JB, Ernst J. [Interdisciplinary extremity board in the treatment of complex injuries]. Unfallchirurgie (Heidelb) 2023; 126:175-183. [PMID: 36746799 DOI: 10.1007/s00113-023-01290-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Interdisciplinary case conferences are well-established in the field of oncology in order to provide the best possible treatment for patients with complex disease patterns which overlap several disciplines. METHODS After studying the available literature the aims, indications, frequency, patient enrolment and documentation modalities, disciplines necessary to create the reconstruction plan and evaluation parameters of the board, were agreed in an interdisciplinary discussion among colleagues. The utilization of the extremity board and demographic features of the cases presented in the extremity board within the first 6 months were subsequently descriptively analyzed. RESULTS The agreed primary aim of an extremity board is the timely and transparent preparation of a high-quality holistic reconstruction plan for optimized treatment of a challenging patient collective with complex injuries of the extremities. Decisive interfaces of an extremity board are the participation of interdisciplinary disciplines, established enrolment and documentation modalities and a longitudinal analysis of parameters of the acute medical treatment, the long-term function and quality of life of those affected. The patient collective so far mostly includes men under 40 years old with traumatic soft tissue defects and combined injuries. On average, reconstruction plans for 1-2 patients were approved in an interdisciplinary team per session. CONCLUSION The extremity board serves as a platform for coordinated planning of treatment for patients with complex injuries. The limited personnel and time resources represent the greatest challenge for the successful implementation. The extremity board enables a high degree of interdisciplinary networking. The digital registration and documentation modality within the internal hospital documentation system is of utmost relevance. The preparation of the reconstruction plan is of decisive importance for the qualitative success of treatment and the restoration of function. The longitudinal analysis of appropriate parameters is imperative to measure the quality of treatment.
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Affiliation(s)
- T Omar Pacha
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - P Mommsen
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - V Brauckmann
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - G Aktas
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - M Krempec
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - B Wilhelmi
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - J-D Clausen
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - V März
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - N Krezdorn
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - P M Vogt
- Klinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - S Sehmisch
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - J B Hinrichs
- Klinik für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - J Ernst
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
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Becker LS, Becker ER, Stuebig T, Hinrichs JB. Preoperative Coil-Embolization of a Large, Myelon-Compressing Vertebral Metastasis Involving the Artery of Adamkiewicz. Journal of Clinical Interventional Radiology ISVIR 2023. [DOI: 10.1055/s-0043-1761623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
Abstract
Background Metastatic spinal cord compression causes neurologic impairment and pain, potentially improved by decompression surgery at the risk of heavy intraoperative bleeding. Preoperative embolization carries the risk of nontarget embolization, potentially causing spinal ischemia. Current evidence indicates that knowledge of artery of Adamkiewicz (AKA) location and the amount of collateralization may help estimate the risk of postinterventional spinal cord injury.
Case Presentation In this case of a 73-year-old female patient with progression of a large, myelon-compressing vertebral metastasis of L1, protective, blood-flow-controlling occlusion of the proximal-most points of the AKA and segmental spinal arteries was safely performed prior to tumor embolization, surgical decompression, and tumor debulking.
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Affiliation(s)
- LS Becker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hanover, Germany
| | - ER Becker
- Private Neurological Practice, Braunschweig, Germany
| | - T. Stuebig
- Department of Traumatology, Hannover Medical School, Hanover, Germany
| | - JB Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hanover, Germany
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Meine TC, Becker LS, Dewald CLA, Maschke SK, Maasoumy B, Jaeckel E, Wedemeyer H, Wacker FK, Meyer BC, Hinrichs JB. Percutaneous Transsplenic Balloon-Assisted Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Portal Vein Obliteration for Portal Vein Recanalization: Feasibility, Safety and Effectiveness. Cardiovasc Intervent Radiol 2022; 45:696-702. [PMID: 35018502 PMCID: PMC9018628 DOI: 10.1007/s00270-021-03054-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/30/2021] [Indexed: 02/07/2023]
Abstract
Purpose To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)–transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique. Materials and Methods In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR–TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose–area product (DAP) and air kerma (AK) were evaluated. Results Transsplenic PVR–TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy. Conclusions Transsplenic PVR–TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-021-03054-2.
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Affiliation(s)
- T C Meine
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - L S Becker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - C L A Dewald
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - S K Maschke
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - B Maasoumy
- Department of Hepatology, Gastroenterology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - E Jaeckel
- Department of Hepatology, Gastroenterology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - H Wedemeyer
- Department of Hepatology, Gastroenterology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - F K Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - B C Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - J B Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220 Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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Becker LS, Hinrichs MH, Werncke T, Dewald CLA, Maschke SK, Limbourg FP, Ringe KI, Hinrichs JB, Wacker F, Meyer BC. Adrenal venous sampling in primary hyperaldosteronism: correlation of hormone indices and collimated C-arm CT findings. Abdom Radiol (NY) 2021; 46:3471-3481. [PMID: 33674958 PMCID: PMC8215038 DOI: 10.1007/s00261-021-03003-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the feasibility and effect of an approach to adrenal venous sampling (AVS) analysis by combining established selective cortisol and aldosterone indices with the acquisition of a collimated C-arm CT(CACTColl). METHODS Overall, 107 consecutive patients (45f,62 m; 54 ± 10 years) undergoing 111 AVS procedures without hormonal stimulation from 7/13 to 2/20 in a single institution were retrospectively analysed. Hormone levels were measured in sequential samples of the suspected adrenal veins and right iliac vein, and selectivity indices (SI) computed. Stand-alone SICortisol and/or SIAldosterone ≥ 2.0 as well as SICortisol and/or SIAldosterone ≥ 1.1 combined with positive right-sided CACTColl of the adrenals (n = 80; opacified right adrenal vein) were defined as a successful AVS procedure. Radiation exposure of CACT was measured via dose area product (DAP) and weighed against an age-/weight-matched cohort (n = 66). RESULTS Preliminary success rates (SICortisol and/or SIAldosterone ≥ 2.0) were 99.1% (left) and 72.1% (right). These could be significantly increased to a 90.1% success rate on the right, by combining an adjusted SI of 1.1 with a positive CACTColl proving the correct sampling position. Sensitivity for stand-alone collimated CACT (CACTColl) was 0.93, with 74/80 acquired CACTColl confirming selective cannulation by adrenal vein enhancement. Mean DAPColl_CACT measured 2414 ± 958 μGyxm2, while mean DAPFull-FOV_CACT in the matched cohort measured 8766 ± 1956 μGyxm2 (p < 0.001). CONCLUSION Collimated CACT in AVS procedures is feasible and leads to a significant increase in success rates of (right-sided) selective cannulation and may in combination with adapted hormone indices, offer a successful alternative to previously published AVS analysis algorithms with lower radiation exposure compared to a full-FOV CACT.
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Affiliation(s)
- L S Becker
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - M H Hinrichs
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - T Werncke
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - C L A Dewald
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - S K Maschke
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - F P Limbourg
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - K I Ringe
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - J B Hinrichs
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - F Wacker
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - B C Meyer
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, OE8220, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Ringe KI, Hinrichs JB. [Erratum to: State of the art in the diagnostics of hepatocellular carcinoma and current treatment options]. Radiologe 2021; 61:385. [PMID: 33765172 DOI: 10.1007/s00117-021-00837-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- K I Ringe
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Carl-Neuberg Str. 1, 30625, Hannover, Deutschland.
| | - J B Hinrichs
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Carl-Neuberg Str. 1, 30625, Hannover, Deutschland
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Dewald CLA, Becker LS, Maschke SK, Meine TC, Alten TA, Kirstein MM, Vogel A, Wacker FK, Meyer BC, Hinrichs JB. Percutaneous isolated hepatic perfusion (chemosaturation) with melphalan following right hemihepatectomy in patients with cholangiocarcinoma and metastatic uveal melanoma: peri- and post-interventional adverse events and therapy response compared to a matched group without prior liver surgery. Clin Exp Metastasis 2020; 37:683-692. [PMID: 33034815 PMCID: PMC7666275 DOI: 10.1007/s10585-020-10057-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/25/2020] [Indexed: 01/15/2023]
Abstract
To evaluate feasibility, frequency and severity of peri-procedural complications and post-procedural adverse events (AEs) in patients with advanced cholangiocarcinoma or liver metastasis of uveal melanoma and prior hemihepatectomy undergoing chemosaturation percutaneous hepatic perfusion (CS-PHP) and to analyze therapy response and overall survival compared to a matched group without prior surgery. CS-PHP performed between 10/2014 and 02/2018 were retrospectively assessed. To determine peri-procedural safety and post-procedural adverse events, hospital records and hematological, hepatic and biliary function were categorized using Common Terminology Criteria for Adverse Events (CTCAE) v5.0 (1–5; mild-death). Significance was tested using Wilcoxon signed-rank and Mann–Whitney U test. Kaplan–Meier estimation and log-rank test assessed survival. Overall 21 CS-PHP in seven patients (4/7 males; 52 ± 10 years) with hemihepatectomy (grouphemihep) and 22 CS-PHP in seven patients (3/7 males; 63 ± 12 years) without prior surgery (groupnoresection) were included. No complications occurred during the CS-PHP procedures. Transient changes (CTCAE grade 1–2) of liver enzymes and blood cells followed all procedures. In comparison, grouphemihep presented slightly more AEs grade 3–4 (e.g. thrombocytopenia in 57% (12/21) vs. 41% (9/22; p = 0.37)) 5–7 days after CS-PHP. These AEs were self-limiting or responsive to treatment (insignificant difference of pre-interventional to 21–45 days post-interventional values (p > 0.05)). One patient in grouphemihep with high tumor burden died eight days following CS-PHP. No deaths occurred in groupnoresection. In comparison, overall survival after first diagnosis was insignificantly shorter in groupnoresection (44.7(32–56.1) months) than in grouphemihep (48.3(34.6–72.8) months; p = 0.48). The severity of adverse events following CS-PHP in patients after hemihepatectomy was comparable to a matched group without prior liver surgery. Thus, the performance of CS-PHP is not substantially compromised by a prior hemihepatectomy.
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Affiliation(s)
- C L A Dewald
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - L S Becker
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - S K Maschke
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - T C Meine
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - T A Alten
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - M M Kirstein
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - A Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - F K Wacker
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - B C Meyer
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - J B Hinrichs
- Department of Diagnostic and Interventional Radiology, Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Becker LS, Maschke SK, Dewald CLA, Meine TC, Winther HBM, Kirstein MM, Kloeckner R, Meyer BC, Wacker F, Hinrichs JB. Two-dimensional parametric parenchymal blood flow in transarterial chemoembolisation for hepatocellular carcinoma: perfusion change quantification and tumour response prediction at 3 months post-intervention. Clin Radiol 2020; 76:160.e27-160.e33. [PMID: 33028487 DOI: 10.1016/j.crad.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/09/2020] [Indexed: 11/19/2022]
Abstract
AIM To evaluate the feasibility and potential value of two-dimensional (2D) parametric parenchymal blood flow (2D-PPBF) for the assessment of perfusion changes during transarterial chemoembolisation with drug-eluting beads (DEB-TACE) and to analyse correlations of 2D-PPBF parameters and tumour response. MATERIALS AND METHODS Thirty-two patients (six women, 26 men, mean age: 67±8.9 years) with unresectable hepatocellular carcinoma (HCC) who underwent their first DEB-TACE were included in this study. To quantify perfusion changes using 2D-PPBF, the acquired digital subtraction angiography (DSA) series were post-processed. Ratios were calculated between the reference region of interest (ROI) and the wash-in rate (WIR), the arrival to peak (AP) and the area under the curve (AUC) of the generated time-density curves. Comparisons between pre- and post-embolisation data were made using the Wilcoxon signed-rank test. Tumour response was assessed at 3 months using the modified Response Evaluation Criteria in Solid Tumours (mRECIST) and correlated to changes of 2D-PPBF parameters. RESULTS All 2D-PPBF parameters derived from the ROI-based time-attenuation curves were significantly different pre-versus post-DEB-TACE. Although the AUC, the WIR and target lesion size measured in accordance with mRECIST decreased (p≤0.0001) significantly, AP values showed a significant increase (p = 0.0033). Tumour response after DEB-TACE correlated with changes in the AUC (p = 0.01, r = -0.45). CONCLUSION 2D-PPBF offers an objective approach to analyse perfusion changes of embolised tumour tissue following DEB-TACE and can therefore be used to predict tumour response.
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Affiliation(s)
- L S Becker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - S K Maschke
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - C L A Dewald
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - T C Meine
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - H B M Winther
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - M M Kirstein
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - R Kloeckner
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg-University Medical Centre, Mainz, Germany
| | - B C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - F Wacker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - J B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany.
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Kamp JC, Suhling H, Ramthor M, Hinrichs JB, Soudah B, Adel J, Welte T, Ringshausen FC. [Eosinophilic Granulomatosis with Polyangiitis with Pulmonary and Cardiac Involvement]. Pneumologie 2020; 75:33-38. [PMID: 32707588 DOI: 10.1055/a-1209-4292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A 62-year-old patient with bronchial asthma and chronic rhinosinusitis underwent inguinal hernia surgery. After the operation, sudden circulatory arrest occurred, requiring cardiopulmonary resuscitation. Coronary angiography revealed a 99 % proximal stenosis of right coronary artery (RCA) with unsuspicious and smooth coronary vessel walls. In the further course, several similar events occurred, but without pathological findings in the coronary angiography. Initially, echocardiography showed slightly reduced left ventricular ejection fraction of 45 %. Chest radiography revealed bilateral pulmonary infiltrates, and white blood cell count showed severe eosinophilia (37 %). Serological antibody testing including ANA, ENA and c-/p-ANCA was negative. Myeloproliferative pathologies were excluded by bone marrow puncture. The patient suffered from emerging dyspnea, weakness, and ongoing weight loss. A methylprednisolone pulse of 250 mg/d for 3 days remained without significant effect, so that the patient was eventually referred to our university hospital due to ongoing clinical deterioration. On admission, the patient suffered from weakness, progressive muscular atrophy, and dyspnea on exertion. Physical examination revealed a right-sided peroneal paralysis. Bronchial lavage detected severe eosinophil alveolitis (37 %), and laboratory findings showed elevated cardiac enzymes and NT-proBNP (Troponin-T > 700 ng/l, NT-proBNP > 10.000 ng/l). Echocardiography revealed a dramatic deterioration of cardiac function (LVEF 16 %). Interdisciplinary discussion between pulmonologists and cardiologists lead to the diagnosis of ANCA-negative eosinophilic granulomatosis with polyangiitis (EGPA) with pulmonary and cardiac involvement. Initiation of immunosuppressive therapy with methylprednisolone 1000 mg/d for 3 days followed by cyclophosphamide therapy (6 pulses, administered every 4 weeks) led to substantial symptomatic improvement, complete regression of pulmonary infiltrates and marked recovery of cardiac function (LVEF 47 %). CONCLUSION: Serological detection of elevated ANCAs is not necessary for diagnosis of EGPA. Only 30 - 70 % of patients are positive for these, particularly if neurological and/or renal rather than cardiac and/or pulmonary involvement is present. This may be a pitfall in establishing the correct diagnosis. Induction therapy with cyclophosphamide is the preferred treatment for steroid-refractory EGPA with life-threatening organ involvement.
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Affiliation(s)
- J C Kamp
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Deutsches Zentrum für Lungenforschung (DZL), Hannover
| | - H Suhling
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Deutsches Zentrum für Lungenforschung (DZL), Hannover
| | - M Ramthor
- Klinik für Kardiologie und konservative Intensivmedizin, Vivantes Humboldt-Klinikum, Berlin
| | - J B Hinrichs
- Institut für diagnostische und interventionelle Radiologie, Medizinische Hochschule Hannover, Hannover
| | - B Soudah
- Institut für Pathologie, Medizinische Hochschule Hannover, Hannover
| | - J Adel
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover
| | - T Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Deutsches Zentrum für Lungenforschung (DZL), Hannover
| | - F C Ringshausen
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Deutsches Zentrum für Lungenforschung (DZL), Hannover
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Maschke SK, Winther HMB, Meine T, Werncke T, Olsson KM, Hoeper MM, Baumgart J, Wacker FK, Meyer BC, Renne J, Hinrichs JB. Evaluation of a newly developed 2D parametric parenchymal blood flow technique with an automated vessel suppression algorithm in patients with chronic thromboembolic pulmonary hypertension undergoing balloon pulmonary angioplasty. Clin Radiol 2019; 74:437-444. [PMID: 30890260 DOI: 10.1016/j.crad.2018.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/03/2018] [Indexed: 12/21/2022]
Abstract
AIM To evaluate the feasibility of two-dimensional parametric parenchymal blood flow (2D-PPBF) to quantify perfusion changes in the lung parenchyma following balloon pulmonary angioplasty (BPA) for treatment of chronic thromboembolic pulmonary hypertension. MATERIALS AND METHODS Overall, 35 consecutive interventions in 18 patients with 98 treated pulmonary arteries were included. To quantify changes in pulmonary blood flow using 2D-PPBF, the acquired digital subtraction angiography (DSA) series were post-processed using dedicated software. A reference region of interest (ROI; arterial inflow) in the treated pulmonary artery and a distal target ROI, including the whole lung parenchyma distal to the targeted stenosis, were placed in corresponding areas on DSA pre- and post-BPA. Half-peak density (HPD), wash-in rate (WIR), arrival to peak (AP), area under the curve (AUC), and mean transit time (MTT) were assessed. The ratios of the reference ROI to the target ROI (HPDparenchyma/HPDinflow, WIRparenchyma/WIRinflow; APparenchyma/APinflow, AUCparenchyma/AUCinflow, MTTparenchyma/MTTinflow) were calculated. The relative differences of the 2D-PPBF parameters were correlated to changes in the pulmonary flow grade score. RESULTS The pulmonary flow grade score improved significantly after BPA (1 versus 3; p<0.0001). Likewise, the mean HPDparenchyma/HPDinflow (-10.2%; p<0.0001), APparenchyma/APinflow (-24.4%; p=0.0007), and MTTparenchyma/MTTinflow (-3.5%; p=0.0449) decreased significantly, whereas WIRparenchyma/WIRinflow (+82.4%) and AUCparenchyma/AUCinflow (+58.6%) showed a significant increase (p<0.0001). Furthermore, a significant correlation between changes of the pulmonary flow grade score and changes of HPDparenchyma/HPDinflow (ρ=-0.21, p=0.04), WIRparenchyma/WIRinflow (ρ=0.43, p<0.0001), APparenchyma/APinflow (ρ=-0.22, p=0.03), AUCparenchyma/AUCinflow (ρ=0.48, p<0.0001), and MTTparenchyma/MTTinflow (ρ=-0.39, p<0.0001) could be observed. CONCLUSION The 2D-PPBF technique is feasible for the quantification of perfusion changes following BPA and has the potential to improve monitoring of BPA.
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Affiliation(s)
- S K Maschke
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - H M B Winther
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - T Meine
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - T Werncke
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - K M Olsson
- Clinic for Pneumology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - M M Hoeper
- Clinic for Pneumology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - J Baumgart
- Siemens Medical Solutions USA, Inc., Angiography, Fluoroscopic and Radiographic Systems, Hoffman Estates, IL, USA
| | - F K Wacker
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - B C Meyer
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - J Renne
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - J B Hinrichs
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany.
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Werncke T, Hinrichs JB, Alikhani B, Maschke S, Wacker FK, Meyer BC. Virtual single source CT using dual source acquisition: Clinical applicability in run-off CT-angiography for intra-individual comparison of different scan protocols. Eur J Radiol 2018; 101:149-156. [PMID: 29571789 DOI: 10.1016/j.ejrad.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/06/2018] [Accepted: 02/11/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE Virtual single source computed tomography (VSS-CT) acquisition on a dual source CT (DSCT) has been demonstrated to allow for dose-neutral intra-individual comparison of three acquisition protocols at different radiation dose levels (RDL) within one acquisition in a phantom. The purpose of this study was twofold: first to evaluate the applicability of VSS-CT in patients and second to optimize the task-dependent trade-off between radiation dose and image quality of lower extremity CT angiography (run-off CTA). MATERIAL AND METHODS In this IRB-approved prospective study 52 patients underwent run-off CTA between 06/2012 and 06/2013. VSS-CT acquisition was conducted using a first generation DSCT applying equal X-ray tube settings (120 kVp), collimation (2 × 32 × 0.6 mm), and slice thickness (1.0 mm) but different effective tube current-time products (tube A: 80 mAs, tube B: 40 mAs). Three different image datasets representing three different radiation dose levels (RDL40, RDL80, RDL120) were reconstructed using a soft kernel from the raw data of tube B, tube A or both tubes combined. Dose length products (DLP) of each raw data set were documented. Quantitative image quality (IQ) was assessed for five anatomical levels using image noise and contrast-to-noise ratio (CNR). To investigate dose efficiency of each acquisition, the dose-weighted CNR (CNRD) was determined. Qualitative IQ was evaluated by two blinded readers in consensus using a 5-point Likert scale and compared with a Friedman- and posthoc Wilcoxon test. RESULTS Mean DLP was 200 ± 40, 400 ± 90 and 600 ± 130 mGy·cm for the RDL40, RDL80 and RDL120, respectively. Image noise and CNR were best for RDL120 and decreased significantly for RDL80 and RDL40, independent of the anatomic level (p < 0.001). CNRD showed no significant differences at the abdominal and pelvic level between the investigated radiation dose levels. However, for thigh to foot level a significant increase of CNRD was noted between RDL120, RDL80 and RDL40. Significant differences of qualitative IQ were observed between RDL120 and RDL40 from the abdominal to the foot level, whereas no difference was seen for the other dose levels. CONCLUSION Radiation dose splitting with VSS-CT can be applied to run-off CTA facilitating intra-individual comparison of different acquisition protocols without additional radiation exposure. Furthermore, a radiation dose reduction potential for run-off CTA of approximately 1/3 as compared to the acquisition protocol recommended by the manufacturer could be identified in this study.
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Affiliation(s)
- T Werncke
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
| | - J B Hinrichs
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - B Alikhani
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - S Maschke
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - F K Wacker
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - B C Meyer
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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