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Purpose: To evaluate the clinical results of percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease.Methods: Rotational atherectomy was performed in 39 patients aged 39-87 years (mean 66.6 years). A total of 71 lesions (43 stenoses and 28 occlusions) were treated in 40 limbs. Additional balloon angioplasty was required in 54% of lesions. Fifteen patients (37.5%) presented in Fontaine stage II, 10 patients (25%) in Fontaine stage III and 15 patients (37.5%) in Fontaine stage IV. Rotational atherectomy at 750 rpm was carried out over a 0.014-inch guidewire with continuous aspiration into a vacuum bottle. Follow-up angiography and color flow Doppler examinations were performed in 22 patients (23 limbs) after a mean period of 6 months (range 2-14 months).Results: There was one primary technical failure. In 36 of 40 lesions there was a good angiographic result with residual stenoses in less than 30%. In 70 lesions treated by rotational atherectomy, however, 54% showed residual stenoses of 30%-50% and these cases required additional balloon angioplasty. The mean ankle-brachial index improved significantly (p << 0.001) from 0.49 before the procedure to 1.01 after the procedure. A single distal embolus, related to primary recanalization, occurred and there were two large inguinal hematomas. Cumulative clinical patency after 6 months was 83.8% and cumulative angiographic patency after 6 months was 79.1%.Conclusion: Percutaneous rotational atherectomy is a promising approach for the treatment of chronic peripheral vascular disease. Further prospective, randomized studies are necessary to compare percutaneous transluminal angioplasty with this new technical approach. [ABSTRACT FROM AUTHOR]

Polymer-ceramic materials were placed in the in-needle device. Polymer-ceramic Monolithic In-Needle Extraction (MINE) device is an extraction device used in sample preparation step but, on the other hand, it can be a tool for examination of interactions between potential antiresorptive drugs and bones. MINE device was used as tool for determination of bisphosphonate affinity to hydroxyapatite. Spectra of prepared materials containing different proportion of the ceramic part were performed with the use of Fourier transform infrared spectroscopy. The extraction of sodium risedronate as standard compound from simulated body fluids was carried out by pumping liquid samples through the MINE device. The amount of sodium risedronate in solutions was examined using UV-VIS spectroscopy. The sorption results of sodium risedronate obtained for monolithic materials containing different amount of hydroxyapatite were compared to the values determined for pure (bulk) hydroxyapatite. Sorption capacity for polymer-ceramic materials placed in the in-needle extraction device was about 0.39mg of sodium risedronate. The complete desorption process was carried out at the level over 95% using various eluents. The results of sorption-desorption experiments allow to deduce on the affinity of sodium risedronate to the ceramic part of sorbent (hydroxyapatite)., (Copyright © 2016 Elsevier B.V. All rights reserved.)

A method based on experimental and in silico evaluations for investigating interactions of organic phosphates and phosphonates with hydroxyapatite was developed. This quick and easy method is used for determination of differences among organophosphorus compounds of various structures in their mineral binding affinities. Empirical sorption evaluation was carried out using liquid chromatography with tandem mass spectrometry or UV-VIS spectroscopy. Raman spectroscopy was used to confirm sorption of organic phosphates and phosphonates on hydroxyapatite. Polymer-ceramic monolithic material and bulk hydroxyapatite were applied as sorbent materials. Furthermore, a Polymer-ceramic Monolithic In-Needle Extraction device was used to investigate both sorption and desorption steps. Binding energies were computed from the fully optimised structures utilising Density Functional Theory (DFT) at B3LYP/6-31+G(d,p) level. Potential pharmacologic and toxic effects of the tested compounds were estimated by the Prediction of the Activity Spectra of Substances using GeneXplain software., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: The extract of oak bark (QRB7) has been used for years as a topical medication with success. QRB7 is the proprietary oak bark extract in Bensal HP. It is indicated as an external treatment for the inflammation and irritation associated with many common forms of dermatitis, including certain eczematoid conditions. These conditions include complications associated with pyodermas, and in the treatment of insect bites, burns, and fungal infections., Objective: To quantitatively measure the difference in diabetic ulcer size reduction when using Bensal HP versus silver sulfadiazine cream (SSC) for topical treatment as an adjunct to conventional treatment., Setting: Private office of the primary author., Methods: Forty diabetic patients with noncellulitic plantar Wagner grade 1 or 2 ulcers and a minimal ankle brachial index of 0.75 were randomly assigned to either the Bensal HP (QRB7) treatment group or SSC control group for 6 weeks of treatment. In addition to either Bensal HP or SSC, all wounds were cultured and treated with debridement at time 0, 2, 4, and 6 weeks and with off-loading., Results: The combined wound diameter of the Bensal HP group decreased 72.5% compared to 54.7% for the SSC group. There was a statistical significance between the decreases in wound sizes after 6 weeks of treatment (P = .016). The Cohen effect size for the Bensal HP group was 2.06 compared with 1.03 for the SSC group., Conclusion: In this tightly controlled 6-week study in which no patients were lost to follow-up, Bensal HP seems to be an effective treatment for properly treated diabetic ulcers, outperforming an identical control group whose only difference was SSC as a medication.

We report the results of a longitudinal study involving MRI and clinical follow-up in nine siblings from four families with Miyoshi myopathy (MM). All individuals carried pathogenic dysferlin gene (DYSF) mutations with six of them suffering from symptomatic disease and three being presymptomatic. In presymptomatic subjects, MRI was sensitive to detect alterations in muscle tissue years before disease onset. The first MRI alteration to disclose was evidence for myoedema in dorsal compartment muscles of the legs followed by fatty degeneration. Moreover, MRI changes anticipated the topography of subsequent clinical muscle involvement and progressed from distal to proximal dorsal leg muscles. In symptomatic subjects, MRI changes reflected the pattern and severity of clinical muscle involvement. MRI evidence, however, suggests that muscle involvement is much more prominent in early disease stages than clinically seen. Clinical follow-up up to 8 years made evident that MM onset occurs at a mean age of 18.4 years. The most prominent initial deficit was impaired tiptoe gait due to muscle plantarflexor dysfunction followed by impaired dorsiflexor function. Dorsal compartments were predominantly affected not only in distal but also in proximal leg muscles, and a more rapid progression was noticed during the early phase of the disease. Our data suggest that MRI is a helpful diagnostic tool for an early diagnosis of MM and other distal myopathies since it provides sensitive and topographic information about initial and even preclinical muscle involvement. This is of particular relevance in Miyoshi myopathy because distinct CK elevation is present long before its clinical onset and often misdiagnosed as "idiopathic".

Neuroimaging studies in humans have shown that different working memory (WM) tasks recruit a common bilateral fronto-parietal cortical network. Animal studies as well as neuroimaging studies in humans have suggested that this network, in particular the prefrontal cortex, is preferentially recruited when material from different domains (e.g. spatial information or verbal/object information) has to be memorized. Early imaging studies have suggested qualitative dissociations in the prefrontal cortex for spatial and object/verbal WM, either in a left-right or a ventral-dorsal dimension. However, results from different studies are inconsistent. Moreover, recent fMRI studies have failed to find evidence for domain dependent dissociations of WM-related activity in prefrontal cortex. Here we present evidence from two independent fMRI studies using physically identical stimuli in a verbal and spatial WM task showing that domain dominance for WM does indeed exist, although only in the form of quantitative differences in activation and not in the form of a dissociation with different prefrontal regions showing mutually exclusive activation in different domains. Our results support a mixed dimension model of domain dominance for WM within the prefrontal cortex, with left ventral prefrontal cortex (PFC) supporting preferentially verbal WM and right dorsal PFC supporting preferentially spatial WM. The concept of domain dominance is discussed in the light of recent theories of prefrontal cortex function.

Hypofrontality and decreased lateralization have been two major, albeit controversial, results from functional neuroimaging studies of schizophrenia. We used fMRI to study cortical activation during a verbal and spatial working memory (WM) task (2-back) in 15 inpatients acutely ill with schizophrenia and 15 matched control subjects. We hypothesized (i) hypofrontality in patients in both tasks and (ii) decreased lateralization of prefrontal activation in patients under the assumption that, in controls, left prefrontal cortex (PFC) is engaged preferentially in the verbal task (verbal domain dominance) and the right prefrontal cortex is engaged preferentially in the spatial task (spatial domain dominance). Our results showed no significant differences in frontal activation between controls and patients, i.e. no hypofrontality in patients, even at a very liberal threshold (p<0.01). This may be explained by the fact that nearly all patients studied received atypical neuroleptics. Nonetheless, we found evidence for more subtle, domain-related prefrontal dysfunction. Whereas controls showed verbal WM domain dominance in left inferior frontal cortex and spatial WM domain dominance in right prefrontal cortex, these domain dominance effects were absent in the patient group, i.e. there were no lateralization effects. Finally, only patients showed an inverse correlation between performance and right prefrontal activation in verbal WM. We conclude that the finding of hypofrontality may depend on the medication of the patients and that there is prefrontal dysfunction even in the absence of hypofrontality.

Episodic memory performance varies in older subjects but underlying biological correlates remain as yet ambiguous. We investigated episodic memory in healthy older individuals (n=24; mean age: 64.4+/-6.7 years) without subjective memory complaints or objective cognitive impairment. Episodic memory was assessed with repetitive learning and recall of abstract geometric patterns during fMRI. Group analysis of brain activity during initial learning and maximum recall revealed hippocampal activation. Correlation analysis of brain activation and task performance demonstrated significant hippocampal activity during initial learning and maximum recall in a success-dependent manner. Neither age nor gray matter densities correlated with hippocampal activation. Functional imaging of episodic memory thus permits to detect objectively variability in hippocampal recruitment in healthy aged individuals without subjective memory complaints. Correlation analysis of brain activation and performance during an episodic memory task may be used to determine and follow-up hippocampal malfunction in a very sensitive manner.

Purpose: To evaluate the frequency and significance of thromboembolic complications following endovascular treatment of aortic aneurysms., Methods: One hundred seventy-four patients (153 men; mean 71.4 years, range 26-90) underwent endovascular repair of aneurysms of the thoracic (n = 38) or abdominal (n = 136) aorta using a variety of endografts. All patients were examined preprocedurally using 3-phase helical computed tomography (CT) to determine appropriate endograft size. To exclude the occurrence of infarction in parenchymal organs, the first postprocedural CT scan was compared with preoperative findings. Newly recognized perfusion deficits were taken as evidence of procedure-related infarction., Results: Infarctions were detected in 16 (9.2%) patients: 13 in the kidneys, 2 in the spleen, with 1 in the mesentery; only the mesenteric infarction was clinically symptomatic. Both splenic infarctions were associated with deployment of stent-grafts in the thoracic aorta (5.3% of the 38 patients), while the mesenteric and 13 renal infarctions were seen in patients with infrarenal abdominal aortic aneurysms (0.7% and 9.6%, respectively, of 136 patients). One patient experienced complete thromboembolic occlusion of a renal artery, which was partially recanalized with intraoperative lysis., Conclusions: Thromboembolic complications of endovascular aortic aneurysm repairs are not uncommon, and although usually asymptomatic, these sequelae have the potential to be life threatening. Perfusion abnormalities may respond to immediate lytic therapy with complete dissolution of the thrombus in certain isolated cases.

Background: Pancreatic injury is a dangerous complication in multiple injury, and experience with its diagnosis and treatment is usually limited., Method: Retrospective analysis of 3,840 patients admitted after multiple trauma from January 1, 1982, until May 31, 2000., Results: A laparotomy was performed in 121 cases (3.15%) due to suspected intra-abdominal lesion. 32% of the patients (39/121) had a pancreatic lesion; 23% (9/39) had a rupture of the major pancreatic duct. Primary laparotomy was performed in 72% of the patients (28/39). Superficial lesions were treated by explorative laparotomy alone (n = 7), debridement and external drainage (n = 20), or necrosectomy and lavage (n = 3). Complex pancreatic lesions were treated by pancreatojejunostomies (n = 5), pancreatic left resections (n = 2), or exploration alone (n = 2). 8 of 39 patients died (20%), 4 intraoperatively. Of the surviving 35 patients, a pancreas-associated complication developed in 8 patients (23%): pancreatic abscesses (n = 4), traumatic pancreatitis (n = 3), pancreatic fistulas (n = 2), and pseudocysts (n = 2)., Conclusions: Pancreatic injury is an infrequent but dangerous complication in severe trauma. Superficial lesions not affecting the major pancreatic duct can be managed by debridement and external drainage. If the major pancreatic duct is ruptured, organ-preserving, complex reconstructive procedures are necessary. When diagnosed timely and treated according to severity and overall situation, pancreatic injuries have an acceptable morbidity, but usually a high mortality., (Copyright 2002 S. Karger AG, Basel)

Purpose: To report our experience with interventional procedures used to treat complete and incomplete persistent sciatic arteries (PSA)., Case Reports: Three female patients with PSAs displayed varying symptoms referable to this rare anatomical variant. In the first woman, a 1-year history of intermittent lower limb ischemia and an acute event prompted angiography, which demonstrated proximal occlusion of 2 crural vessels and a partially thrombosed sciatic artery aneurysm. To prevent further embolism, the aneurysm was excluded with a stent-graft. Endograft patency and aneurysm exclusion have been maintained up to 22 months. In a 41-year-old diabetic with chronic limb ischemia and digital gangrene, a flow-limiting stenosis of the sciatic artery was stented, restoring adequate pedal perfusion. The stent remained patent at the 18-month follow-up. The third patient suffered from a tumor-related pelvic hemorrhage originating from retrograde perfusion through the PSA, which had been ligated during previous surgery. Attempted embolization via a collateral connection between the incomplete PSA and the popliteal artery failed, and the patient died., Conclusions: Vasculopathies involving the sciatic artery are uncommon but may be amenable to interventional techniques, such as coil embolization and stent implantation. PSA aneurysm exclusion with a stent-graft may represent a new therapeutic alternative to standard surgery that obviates potential sciatic nerve damage, but the durability of the repair remains to be determined.

Hippocampal activation is required for episodic memory. Encoding and retrieval of novel and memorable items have been related to different locations in the hippocampus; however, the data remain ambiguous. The application of a newly designed keyboard allowed investigation of brain activation during encoding and free immediate and delayed recall with functional magnetic resonance imaging (fMRI) in young healthy controls (n = 12). Because of the repetitive learning and recall conditions, an individual learning gradient was used to contrast neural activity at different individual levels of novelty. During learning, subjects were asked to memorize 10 geometric patterns requiring the establishment of intra-item associations for memorization. After learning, subjects were asked to recall the items actively via the keyboard. Learning and recall were alternated five times. Delayed recall was scanned about 15 min after the fifth immediate recall condition without subjects having seen the items again. Left-sided anterior hippocampal activity was observed during conditions of initial learning as well as maximum recall. Neural activity during delayed recall did not reveal hippocampal responses and was characterized by a transition of neural activity from occipitoparietal regions to bilateral temporal cortices. We conclude that both lateralization and segregation depend on the specific relational characteristics of the stimuli requiring establishment of intra-item associations for encoding as well as retrieval. The absence of hippocampal activation during delayed recall together with the increase of lateral temporal involvement possibly corresponds with an emerging transition from episodic to long-term memory.

Object: Failed-back syndrome is still an unsolved problem. Use of ADCON-L gel, already commercially available, has been proven to reduce postoperative scarring in animal experiments. The authors of two controlled clinical studies have also shown positive results when applying the gel. They did not, however, establish patient-oriented endpoints. The authors report a study of ADCON-L in which they focus on patient-oriented endpoints., Methods: Patients with lumbar disc herniation were randomized to an ADCON-L-treated or control group. Therapeutic success was evaluated using the validated Hannover Questionnaire on Activities of Daily Living (FFbH) 6 months after surgery. The study took place between November 14. 1996, and April 20, 1998, in eight neurosurgical centers in Germany. A total of 398 patients was recruited; 41 patients dropped out during follow up. The mean functional FFbH score (100 points = all activities are possible without problem; 0 points = no activity is possible) was 78.5 points in the ADCON-L-treated group compared with 80 points in the control group. Furthermore, in terms of secondary outcome variables, the ADCON-L group did not have an advantage over the control group. Only the mean magnetic resonance imaging score showed a slight advantage of ADCON-L over the control group., Conclusions: The authors found no positive effect of treatment with ADCON-L gel in patients in whom one-level lumbar microdiscectomy was performed. Because of its rather large sample size and its homogeneity, the study had sufficient power to detect even small differences between the two groups.

Purpose: To examine the incidence of intraprosthetic thrombotic deposits in aortic endografts., Methods: Transfemoral implantation of tube or bifurcated stent-grafts was performed in 82 patients (75 men; average age 67.7 years, range 25-88) for treatment of aneurysms of the abdominal (n = 73) or thoracic (n = 9) aorta in a 3.5-year period. Patients underwent 3-phase helical computed tomographic (CT) examinations at 3-month intervals. The length and cross-sectional area of any thrombotic deposits were measured from axial and 3-dimensional CT images., Results: Over a 12.1-month mean follow-up, intraluminal deposits of thrombotic material were observed in 19 (23.2%) patients, all with infrarenal endografts that were predominately of a bifurcated design. The first signs of thrombus formation occurred on average 7 months postoperatively (range 1 week to 20 months). In 16 patients, nonocclusive deposits of thrombotic material were seen in the aortic segment of the endograft; a graft limb was involved in 5 patients. Three graft limbs occluded owing to kinking; no thrombus was seen on CT scans taken prior to occlusion. In 3 cases the thrombotic deposits disappeared completely from the prosthesis lumen during follow-up., Conclusions: Based on this small experience, nearly 1 in 5 patients may experience some degree of intraluminal thrombus following endovascular treatment of aortic aneurysms. Whether the deposition of thrombus is influenced by the geometry of the aortic stent-graft or by flow conditions within the prosthetic lumen must be determined in future studies.

Purpose: To report our experience in the percutaneous management of dislocated endovascular stents., Methods: During a 6-year period, 28 (2.7%) patients with a maldeployed or migrated endovascular stent (20 Palmaz, 5 Wallstent, 2 Memotherm, and 1 AVE) were recognized among 1021 patients undergoing noncardiac vascular stent procedures. Percutaneous stent management was performed using balloon catheters, gooseneck snares, grasping forceps, or additional stent implantation on the basis of the stent type, degree of expansion, mechanical characteristics, and location of the stent., Results: Three stents that embolized into the pulmonary artery were left in situ, but percutaneous management was successful in 23 (92%) of the remaining 25 dislocated stents (12 venous and 13 arterial stents). Twelve stents were repositioned in an alternate, stable position or the primarily intended location; 4 stents were anchored by a second stent, and 7 stents were removed percutaneously. In the 2 failed cases, the stents were retrieved using a minor surgical procedure. There were 2 minor groin hematomas but no secondary complications during a median follow-up of 26.2 months (range 1-62)., Conclusions: Percutaneous management of migrated or maldeployed endovascular stents is highly effective with few complications. On the basis of our findings, these techniques should be considered the therapy of choice.

Objective: This is the first report of the direct integration of functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) data into cranial neuronavigation., Methods: In a patient with a left precentral oligodendroglioma (World Health Organization Grade III), the Zeiss MKM system (Carl Zeiss Co., Oberkochen, Germany) was used for navigation based on thin-slice, T1-weighted, contrast-enhanced magnetic resonance imaging (MRI) scans. fMRI and methionine PET data were integrated by landmark matching, with reference to skin fiducials., Results: The inaccuracy of the image fusion between fMRI and T1-weighted MRI data was 1.7 mm, that between PET and T1-weighted MRI data was 4.3 mm, and that for the subsequent registration of the navigation was 1.2 mm. The correct fMRI localization of the precentral gyrus was intraoperatively verified by cortical somatosensory evoked potential (phase-reversal) monitoring. Although the tumor was not clearly defined in the MRI scans, [11C]methionine PET demonstrated a clear tumor border, enabling us to achieve gross total tumor removal without postoperative functional deficits., Conclusion: Functional neuronavigation permits observation and preservation of relevant brain areas. Other functional areas (such as short-term memory areas) that can be detected only by fMRI might also warrant future monitoring. The simultaneous integration of fMRI and PET data adds a new dimension to cranial neuronavigation, enabling the observation of tumors in relation to functional cortical areas (in our case, the motor strip).

Evaluation and treatment recommendations for a painful knee in a runner can be accomplished with a good knowledge of knee pathology, careful physical exam, and appropriate use of imaging tests. Most knee problems in a runner fall into one of the entities listed above. Fortunately, almost all can expect significant improvement with appropriate treatment.

Without question, injury to the Achilles' tendon is one of the commonest running injuries involving the lower extremity. Repair of acute and delayed ruptures is discussed. Tendonitis is by far commoner than ruptures. The pathology and conservative and surgical treatments are discussed.

Purpose: Conventional postoperative evaluation of patients following carotid thromboendarterectomy (TEA) consists of a clinical neurologic examination to assess neurologic deficits, color duplex ultrasound to document the surgically reestablished patency of the carotid artery, and CT for exclusion of postoperative ischemic infarctions. Recent studies prove that diffusion-weighted MRI is more sensitive in the detection of fresh insults than conventional MRI and CT. The objective of the study was to ascertain the incidence of clinically asymptomatic peri-and postoperative ischemic infarctions visualized at MRI., Method: We included 52 patients in the study. Fifty-one patients (31 men, 20 women; average age 68 years) underwent cranial MR examination including a diffusion-weighted sequence at 24 h prior to carotid TEA and again 24 h following the procedure. One patient did not agree to participate., Results: In 29 of 51 patients (56%), neither the pre-nor the postoperative MR scans showed any diffusion abnormalities. In 16 patients (31%), however, preoperative MRI detected fresh ischemic insults. In nine patients (17.6%), the size of the insult resulted in surgery being postponed for 4 weeks. In six patients (11.8%), postoperative MRI returned findings of fresh disturbances of diffusion suggestive of ischemia that were not visualized on preoperative scans. Discrete neurologic deficits were observed in only two (3.9%) of these patients. Deficits were transient and disappeared within 72 h., Conclusion: Our findings underscore MRI's capacity for visualizing perioperative ischemic events. Moreover, MRI provides evidence of clinically asymptomatic embolisms that occur perioperatively.

Purpose: To determine whether embolization of endoleaks after endovascular repair of aortic aneurysms is associated with a decrease in the diameter of the aneurysm., Methods: Fifteen patients (13 men; median age 76 years) demonstrated primary endoleaks persisting > or =3 months after endovascular abdominal aortic aneurysm repair with a variety of commercial endografts. In 8 patients, coil embolization failed to completely obliterate the leak, whereas embolotherapy proved successful in the remaining 7 patients. Surveillance of endoleaks and the effect of their embolization on aneurysm size were followed with serial computed tomographic (CT) scans. Follow-up after embolization extended for at least 12 months., Results: Patients with persistent leak exhibited a slight increase in mean aneurysm area from 21.41+/-4.25 to 22.47+/-6.70 cm2. Medians differed from 20.03 (range 16.59-28.73) to 23.03 (range 14.14-33.69) cm2 (p = 0.0078, 95% confidence interval [CI] = 0.0075 to 0.0081). Successfully treated patients, however, showed a mean decrease from 20.58+/-3.63 (median 19.87) to 16.36+/-6.46 cm2 (median 18.10) at 1 year (p = 0.0156, 95% CI = 0.0151 to 0.0160). The medians differed significantly between groups (p < 0.05)., Conclusions: Persistent endoleaks after endovascular aortic aneurysm treatment led to an increase in the diameter of the aneurysm, whereas complete occlusion was associated with a significant decrease in aneurysm diameter.

The aim was to compare spiral CT and MRI enhanced with mangafodipir trisodium (Mn-DPDP) in the detection and staging of pancreatic lesions. 20 patients with suspected pancreatic cancer were included in a phase III study. Triphasic spiral CT (4 ml s-1) and MRI (axial T1 weighted turbo spin echo with and without fat suppression, T1 weighted gradient echo and T2 weighted turbo spin echo at 1.5 T) were performed. All sequences were repeated following contrast medium using the same instrument settings as in the unenhanced sequences. Mn-DPDP was administered by slow injection of 5 mumol kg-1 body weight. Imaging results were correlated with surgery, laparoscopy, biopsy and/or follow-up. Eight pancreatic adenocarcinomas were present. Ten patients had chronic pancreatitis, and two showed a stenosing papillitis. CT detected eight malignant lesions and MRI detected seven. One pancreatic cancer was not detected with MRI. CT and MRI excluded malignancy in nine patients. MRI and CT returned three false positive results. Mn-DPDP improved delineation of the lesion, resulting in a higher level of diagnostic confidence. Differentiation between pseudotumorous lesions in chronic pancreatitis and pancreatic carcinoma was difficult due to similar slight contrast enhancement. Owing to better delineation of the lesion and the higher confidence in diagnosis, MRI with Mn-DPDP may have the potential to improve the detection rate and the staging accuracy of focal pancreatic lesions. These results need to be confirmed in a larger patient trial.

Purpose: Identification of the precentral gyrus can be difficult in patients with brain tumors. The purpose of the current study was to evaluate the clinical usefulness of functional MRI (fMRI) in identifying motor cortex and speech areas as a part of preoperative neurosurgical planning., Method: fMRI was performed using a 1.5 T MR unit in 41 patients with brain tumors. The motor paradigm was finger tapping and foot movement, whereas the language paradigm consisted of a two word semantic test. Statistical analysis of the data was done using the Kolmogorow-Smirnow test. Plots of signal intensities over time were created., Results: The precentral gyrus was identified in 38 of 41 patients. In two patients, fMRI was not of acceptable quality due to motion artifacts. Speech areas were localized in 33 patients. In a typical clinical setting, the value of the method was graded "high.", Conclusion: fMRI's efficacy in the preoperative localization of language and motor areas is high. The method should become a routine adjunct for preoperative evaluation of brain tumors in the near future.

Neuroprotective strategies are currently being developed for stroke patients. Although the focus is on the development of early treatment the importance of late pathogenetic events is increasingly recognized. To investigate the microglial reaction in stroke we used a marker for activated microglia, [11C]PK11195, and PET in five patients with ischemic stroke 5-53 days after infarction. In one patient serial measurements were made. We demonstrated in each individual and at each point in time that a microglial reaction takes place in the area where T1 weighted MRI (magnetic resonance imaging) shows intensity changes. We consider this PET method as a promising tool to study the late pathogenetic consequences of cerebral infarction and to evaluate neuroprotective strategies with respect to the consequences of the microglial activation.

Objective: We report our first experiences with the direct integration of fMRI data into cranial neuronavigation., Method: For navigation we used the MKM system and thin-sliced T1 contrast enhanced images. As a first step 21 patients had fMRI for localization of the precentral gyrus, 2 patients for Broca area detection. By anatomical correlation, these functional data were indirectly compared to the intraoperative findings using cortical SSEP (n=20) or cortical stimulation (n=3). Encouraged by these preliminary results, we started the direct integration of fMRI into neuronavigation in June 1999, followed by PET in January 2000, enabling us to compare functional images with intraoperative findings directly. fMRI and PET data were integrated by landmark matching referring on skin fiducials. Meanwhile, fMRI data of 8 patients (6 motorcortex, 2 Broca) and PET images of 1 patient were directly integrated into neuronavigation. Six out of 8 patients had additional cortical monitoring, 2/8 were exclusively operated on by functional neuronavigation., Results: Using indirect comparison between fMRI and intraoperative findings we observed a good correlation in every case for the motorcortex, but only in 1/2 for the speech area. In all 6 direct integrated fMRI cases, these findings corresponded well to the conventional ones. Both patients with sole functional navigation did not have any postoperative neurological deficit. The inaccuracy of the fMRI ifT1 matching was 2. 7 mm (sigma=0.9 mm) and 1.3 mm (sigma=0.4 mm) of the subsequent referenciation of the navigation. The tumor delinement shown by 11C-methionine PET could be proven by intraoperative biopsy outside its indicated tumor margin. The inaccuracy of the PET matching was 0. 8 mm., Conclusion: Functional neuronavigation enables to visualize and preserve relevant brain areas. Other functional areas like short-term memory, which solely can be detected by fMRI might also be monitored in the future. The integration of PET data expect to gain a better differentiation of tumor and edema.

This paper, along with a review of osteoporosis, examines 21 patients (15 women and 6 men) who presented to the senior author between May 1997 and January 1999 with unexplained metatarsal fractures. All 21 patients agreed to bone density testing. Twenty of the 21 had bone densities significantly below the mean for corresponding age, gender, and race. The average bone density for the 21 patients was 2.1 standard deviations below the expected mean for the corresponding 30-year-old reference population and 1.7 standard deviations below the mean for an age, gender, weight, and ethnicity matched population. Distribution and location of the fractures were also investigated. The Body Mass Indices were calculated for all 21 patients, but did not seem to play a role in the fractures. Pertinent medical histories and possible factors for comorbidity are also presented. In all cases successful treatment consisted of guarded weightbearing in a padded boot. The authors conclude that there is a previously unreported correlation between metatarsal insufficiency fractures and low bone mass in both genders, confirmed by the abnormal bone mineral density testing. They also point out that men should be made aware that they can suffer from this disease.

Visuospatial navigation in animals and human subjects is generally studied using maze exploration. We used functional MRI to observe brain activation in male and female subjects as they searched for the way out of a complex, three-dimensional, virtual-reality maze. Navigation activated the medial occipital gyri, lateral and medial parietal regions, posterior cingulate and parahippocampal gyri as well as the right hippocampus proper. Gender-specific group analysis revealed distinct activation of the left hippocampus in males, whereas females consistently recruited right parietal and right prefrontal cortex. Thus we demonstrate a neural substrate of well established human gender differences in spatial-cognition performance.

Purpose: The purpose of this work was to determine potential causes of foot pain in patients who have had a surgical release of the plantar fascia for treatment of fasciitis., Method: We studied 17 patients (15 women, 2 men; age range 22-59 years, mean 40 years) with foot pain after undergoing a fasciotomy. Fourteen unilateral and three bilateral procedures accounted for the 20 ankles evaluated. Mean duration after surgery was 22 months (range 3-53 months). Each patient was instructed to localize the pain to a region of the foot; classify the pain as new onset, persistent, or recurrent; and characterize it as to the action that produced the greatest pain. T1-weighted sagittal and dual-echo T2-weighted images in the sagittal, coronal, and axial planes were obtained in a 1.5 T magnet. The MR studies were evaluated for abnormalities of the plantar fascia, perifascial soft tissues, tendons, and osseous structures., Results: The plantar fascia appeared thick in all ankles (mean 8.0 mm, range 6-12 mm). A total of 25 symptomatic sites were assessed. An acute plantar fascia rupture explained plantar symptoms in two feet. In another 16 feet (12 with plantar heel pain and 4 with nonspecific heel pain), 6 had documentation of acute plantar fasciitis and 9 demonstrated perifascial edema. Of the latter nine feet, five demonstrated abnormalities of the posterior tibialis, peroneus longus, and peroneus brevis tendons. The pain localized to the medial arch in six feet; five feet had abnormalities of the posterior tibialis tendon and one foot demonstrated edema in the flexor digitorum brevis muscle. The pain localized to the lateral midfoot in one foot, which had a cuboid stress fracture., Conclusion: The cause of foot pain in patients who had a plantar fasciotomy appeared to be multifactorial. Three likely causes of pain were identified: persistent or recurrent acute plantar fasciitis, pathology related to arch instability, and structural failure from overload.

Background & Aims: Arterioportal fistulas (APFs) are rare vascular disorders of the mesenteric circulation. The aim of this study was to determine the etiology, anatomical location, and main symptom at presentation of APFs, and analyze the various modes of treatment., Methods: The etiology, clinical presentation, radiographs, and treatment of 12 patients with APFs are reported in detail, and another 76 cases published since 1980 are reviewed., Results: APFs result from trauma (n = 25, 28%), iatrogenic procedures (n = 14, 16%), congenital vascular malformations (n = 13, 15%), tumor (n = 13, 15%), aneurysm (n = 12, 14%), and other causes (n = 11, 12%). The origin of APFs is the hepatic artery in the majority of patients (n = 56, 65%). The main symptoms at presentation are lower or upper gastrointestinal bleeding (n = 29, 33%), ascites (n = 23, 26%), heart failure (n = 4.5%), or diarrhea (n = 4.5%). Radiological intervention provides definitive treatment in 42% (n = 33) of patients, whereas the remainder are treated by surgery alone (n = 27, 31%) or a combination of radiological intervention and surgery (n = 8, 9%)., Conclusions: APFs result in a protean syndrome variously combining portal hypertension and other hemodynamic imbalances (heart failure, intestinal ischemia). Single or multiple interventional radiological procedures using arterial and/or venous approaches allow definitive treatment of most APFs. With increasing technological advances, it is anticipated that surgery will only be indicated in rare instances after failure of radiological intervention(s).

Purpose: MR mammography (MRM) is a sensitive diagnostic method for the detection of mammary carcinomas. The present study evaluates whether MRM can yield additional relevant data in cases of histologically confirmed mammary carcinoma., Method: Thirty-four patients with histologically confirmed mammary carcinoma were examined at MRM using a T1-weighted GE sequence and a T2-weighted SE sequence. Morphologic criteria and the dynamic contrast medium behavior of the tumors were evaluated., Results: MRM showed a 100% sensitivity and diagnostic accuracy in the detection of mammary carcinomas. Additionally, three unexpected contralateral carcinomas were discovered. In 26 patients, there was a multifocal or multicentric tumor process. In 24 patients, peritumoral edema was visualized, which corresponded histologically in 21 patients with lymphangiosis and in 3 with an inflammatory peritumoral reaction., Conclusion: Because of its high sensitivity in the diagnosis of multifocal disease and of contralateral carcinomas, MRM would seem to represent a useful addition to preoperative diagnostic procedures. The potential benefit to the patient and its cost efficiency, however, remain to be clarified.

Purpose: This is a study of 140 patients undergoing MR mammography (MRM) for evaluation of possible local recurrent disease following breast-conserving surgical treatment of mammary carcinoma. MRI was performed 1-228 months (mean 28.3 months) postoperatively., Method: MRM and interpretation of the dynamic measurements were performed in a standardized manner after positioning the patient in a double breast coil. A GRE sequence (Flash 3D, TE 5 ms, TR 12 ms, FA 25 degrees) was acquired before and 1, 2, 3, and 8 min after intravenous injection of Gd-DTPA in a dose of 0.15 mmol/kg body wt., Results: Recurrent disease was excluded in 82.8% of cases with MRM. In another 13.6% of patients, MRM was able to reliably detect recurrence of malignancy. In five cases (3.6%), MRM returned false-positive results., Conclusion: MRM is a sensitive method for detecting or excluding recurrence of malignant disease. It remains to be determined whether early detection of recurrent disease can contribute significantly to improving the prognosis in these patients.

Objective: Our purpose was to describe the morphologic appearance of musculoskeletal lesions in patients with cystic echinococcosis shown by CT and MR imaging., Conclusion: Patients with musculoskeletal lesions of cystic echinococcosis typically have cystic structures in adjacent soft tissues. These cysts morphologically resemble abscesses, with peripheral uptake of contrast medium and variable signal intensities on T1-weighted MR images. The absence of calcifications or endovesicular daughter cysts does not exclude the diagnosis of cystic echinococcosis.

Purpose: To evaluate the clinical efficacy of the Amplatz device for the treatment of acute occlusions of the lower limb arteries., Materials and Methods: Forty patients with acute occlusion of the lower limb arteries (3 hours to 8 days; mean, 2 days) were treated using the Amplatz clot macerator. Acute thrombotic lower limb occlusion was due to an embolic event in 32 patients and to atherosclerotic disease in eight patients., Results: Complete success, with complete clearing of thrombotic material without an adjunctive procedure, was achieved in 75% (30 of 40) of the patients. Mean thrombectomy time in these patients was 75 seconds. Partial success, with incomplete clearing of the thrombus, requiring additional procedures such as local thrombolysis, angioplasty, or atherectomy, was achieved in 20% (eight of 40) of the patients. The Doppler index increased significantly (P < .001) from .45 before intervention to .96 after intervention. There were two failures (5%). No major complications occurred., Conclusion: Mechanical thrombectomy with use of the Amplatz device is a promising approach for quick recanalization of acute peripheral thromboembolic occlusions. Further studies are needed to prove the long-term patency after mechanical thrombectomy with use of this device.

MR mammography (MRM) seems to be a sensitive method for detection of breast cancer. The effect of cytotoxic agents on the dynamics of contrast medium uptake in primary breast carcinoma or recurrent disease is not known. This study addresses this question and evaluates MRM as a method of monitoring therapeutic success. A total of 13 patients (age range 34-62 years) with histologically confirmed breast cancer were investigated. The patients received neoadjuvant intravenous (iv) chemotherapy. MRM and interpretation of the dynamic measurements were performed in a standardized manner after positioning the patient in a double breast coil. A gradient echo sequence (Flash 3D, TE 5 ms, TR 12 ms, flip angle 25 degrees) was acquired before and 1, 2, 3 and 8 min after intravenous injection of Gd-DTPA 0.15 mmol kg-1 body weight. A T2 weighted SE sequence (TE 103 ms, TR 6900 ms, 4 mm, field of view 350 mm) was also obtained. MRM was performed prior to histological evaluation and after chemotherapy. All cases of malignancy were correctly diagnosed with MRM. Based on MR findings, eight patients were classified as "responders" and the remaining as "non-responders". In the "responders" a flattening of the Gd-DTPA uptake curve after the first cycle of chemotherapy of complete absence of Gd-DTPA uptake after the fourth cycle was observed. The change in Gd-DTPA uptake behaviour led to an underestimation of the extent of tumour in two patients and false negative findings in four patients. MRM provides information regarding response to therapy following the first cycle. MRM does not provide information regarding invasive tumour tissue in "responders".

Objective: Our objective was to determine the accuracy, precision, and reliability of MR imaging as a technique for measurement of the femoral antetorsional angle., Subjects and Methods: We used MR imaging to measure anteversion of the femoral neck in 44 patients: 19 children (range, 3-17 years old; mean, 11 years old) and 25 adults (range, 18-83 years old; mean, 29 years old)., Results: We found a high correlation between MR imaging and CT measurements (r = 77). On CT, the mean angle for children was 34 degrees and for adults it was 22.2 degrees. On MR imaging, the mean angle for children was 23.22 degrees and for adults it was 15.71 degrees. The mean anteversion angles obtained by CT exceeded those obtained by MR imaging. Mean interobserver and intraobserver agreements were high for MR imaging (r = .97 and r = .97, respectively) and for CT (r = .99 and r = .96, respectively)., Conclusion: Compared with CT as the gold standard, MR imaging measurement of femoral anteversion allows precise anatomic measurements and produces reliable, reproducible results. MR imaging is recommended for preoperative planning in pediatric patients with femoral rotation osteotomies.