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Background. External impingement tests are considered as being particularly reliable for identifying subacromial and coracoid shoulder impingement mechanisms. The purpose of the present study was to evaluate if these tests are likely to provoke an internal shoulder impingement mechanism which, in cases of a pathologic condition, can lead to a positive test result.Method. In 37 subjects, the mechanical contact between the glenoid rim and the rotator cuff (RC) was measured quantitatively and qualitatively in external impingement test positions using an open MRI system.Results. Mechanical contact of the supraspinatus with the posterosuperior glenoid was present in 30 subjects in the Neer test. In the Hawkins test, the subscapularis was in contact with the anterosuperior glenoid in 33 subjects and the supraspinatus in 18. In the horizontal impingement test, anterosuperior contact of the supraspinatus with the glenoid was identified in 35 subjects.Conclusion. The Neer, Hawkins, and horizontal impingement tests are likely to provoke the mechanism of an internal shoulder impingement. A posterosuperior internal impingement mechanism is being provoked predominately in the Neer test. The Hawkins test narrows the distance between the insertions of the subscapularis and supraspinatus and the anterosuperior labrum, which leads to an anterosuperior impingement mechanism.

Understanding the mechanisms of shoulder impingement created by clinical tests is crucial to accurately evaluate the condition. The objective of this study was to relate mechanisms of subacromial and coracoid impingement occurring in positions of the shoulder during clinical examination, in quantitative and qualitative terms. A 1.0T open magnetic resonance imaging system was used in 18 female and 19 male subjects, to determine the distances between the humeral head and the acromion or coracoid, and contact with the rotator cuff (RC). Measurements were taken with the shoulder in neutral, “Hawkins”, “Neer”, and 90° abduction/15° internal rotation (horizontal impingement test) positions. Additionally, impingement was classified based on the grade of RC contact with the acromion or coracoid. In the Hawkins position, distance between the supraspinatus and the coracoid was closest (14.5 ± 4.5 mm), while the coracohumeral distance (CHD) narrowed (p

Background Cell therapy (CTx) is a strategy to support cardiac regeneration after myocardial infarction (MI). Thus far, clinical studies provided mixed results. Here, we investigated whether transmurality of the infarct may play a relevant role. Methods 18 patients (63±3years, 15 male) undergoing elective coronary artery bypass graft (CABG) surgery 2.2±0.7months post MI participated. 10 had transmural and 8 non-transmural infarct scars assessed by Tc-99m-MIBI Single-Photon Emission Computed Tomography (SPECT) and F18-FDG-Positron-Emission-Tomography (PET). During surgery, 10ml of sternal bone marrow were obtained, mononuclear cells (MNC) were isolated. At the end of surgery MNC were injected into the infarctions' center and border zones (10 injections, 2ml total, 6.6±1.3×10 7 MNC). Results No major complications attributable to cell therapy were observed. The sizes of non-transmural scars were reduced at 3 and 24months after treatment (7.7±1.1% and 5.5±1.8 vs. 17.5±4.9%, P=0.05 and P=0.04), while transmural scars remained unchanged (23.5±2.6% and 23.8±3.2 vs. 23.5±2.6%, P>0.99 and P=0.95). A trend towards improved LVEF was seen in patients with non-transmural scars (MRI: 48.8±5.1% vs. 30.6±8.7%, P=0.3; SPECT: 54.1±3.1 vs. 41.0±4.0, P=0.086), but not in patients with transmural scars (MRI: 36.7±3.9 vs. 34.3±5.0, P=0.63, SPECT: 37.8±3.1 vs. 37.9±2.3%, P=0.96). Conclusions A single hybrid intervention of MNC recovery, purification and injection with CABG-surgery (MNC/CABG) may be an attractive modality for cell therapy. However, no regeneration of avital transmural scar tissue seems to occur, while the contribution of MNC to improved perfusion in non-transmural myocardial infarct scars remains to be determined.

Purpose The objective of this study was to describe contrast-enhanced magnetic resonance angiography (MRA) of the lower extremities at 3.0 T system for assessment of high resolution images in patients with peripheral arterial occlusive disease (PAOD). Material and methods 21 Patients with suspected PAOD were examined with four-station MRA at a 3.0 T MR system. The MRA protocol consisted of a hybrid technique with two contrast media injections, the first one for visualization of the calf and foot vasculature (non-moving-table technique), the second one for imaging the aortoiliacal and femoral arteries (moving-table technique). For the femoropopliteal and calf station a randomly segmented central k-space ordering (contrast-enhanced timing-robust angiography [CENTRA]) was used. MR-images were analyzed independently by two radiologists with regard to image quality, venous overlap and grade of stenosis. In 6 patients digital subtraction angiography was performed within the following 7 days and evaluated by two radiologists in consensus with regard to the grade of stenosis. The vasculature-tree of each leg was divided in 12 segments, and 3 anatomical regions (iliacal, femoropopliteal, calf/foot). Results 490 and 488 of 495 arterial segments were visualized with diagnostic image quality by observer 1 and observer 2, respectively. Image quality was excellent in 470 and 457 arterial segments, respectively. Only 4 segments were rendered as non-diagnostic due to venous overlap. Relevant arterial stenoses (50–99%) were detected in 43 and 47 segments by observer 1 and observer 2, 66 and 65 arterial segments, respectively, were interpreted as occluded. Conclusion The hybrid MRA protocol at 3.0 T offers high diagnostic quality for the whole peripheral arterial tree without venous contamination at high spatial resolution.

Stage IV colorectal cancer is usually an incurable disease. However, patients with resectable metastases have 5-year disease-free survival rates of up to 30%. Even with primarily irresectable disease, cure can be achieved in patients who become operable after neoadjuvant treatment. To improve the prognosis of these patients, highly effective neoadjuvant regimens need to be developed.Here, we report the case of a 62-year-old male patient who had been diagnosed with International Union against Cancer (UICC) stage III colon cancer 7 years previously and now presented with a large, irresectable liver metastasis and enlarged perihepatic lymph nodes. After neoadjuvant treatment with cetuximab, bevacizumab and XELOX, the patient showed a complete remission and underwent surgery. Histopathologically, the resected tissue and lymph nodes were free of residual tumor.To our knowledge, this is the first report of a complete pathological response in a patient with irresectable colorectal cancer after intensive chemotherapy/anti-EGFR/ VEGF antibody therapy. This combination regimen may help to improve the survival rates for patients with irresectable disease.

Evaluation of complications, patient satisfaction and clinical benefit of port systems with authorization for high pressure injection of contrast agent during CT/MR examinations.Ultrasound-guided insertions of central venous port catheters were performed through the lateral subclavian vein at a university teaching hospital. The radiological information system (HIS/RIS) was used to evaluate technical success and complication rates. Assessment of patient satisfaction and clinical benefit was carried out by a questionnaire during a telephone call 6 months after implantation of the port system.A total of 195 port systems in 193 patients were implanted. The catheter remained in place for a mean duration of 169 days (overall 29,210 catheter days). The technical success rate was 99.5 % and the overall complication rate was 17.4 % (24/138; 0.82 per 1000 catheter days). Follow-up revealed 13 early port explantations (9 %). Most of the patients reported high satisfaction in general (satisfied/very satisfied: 94 %). 34/209 contrast-enhanced CT/MRT scans (16 %) were performed using the port for contrast media injection. There were no complications during or after administration of contrast agent via the port system.The Powerport system is a safe alternative for peripheral i. v. contrast media injection during CT/MR scans, but has been infrequently used. Most patients reported high overall satisfaction with the port system.

To evaluate the feasibility of retrieval of misplaced central venous catheters in the subclavian artery with a percutaneous closure device (AngioSeal).According to the radiologic information system of a university hospital, 7 patients (6 women, 1 child) underwent removal of a misplaced central venous catheter (4 × 7 F, 1 × 8 F, 2 × 13 F) in the subclavian artery between January 2008 and June 2012 with the 8 F percutaneous closure device AngioSeal. The body mass index (BMI) of 7 patients was available, 3 of whom were obese (BMI 2 × 35.7 and 1 × 33.0). Both 13 F catheters were removed in a balloon-supported manner as described elsewhere. The Broviak catheter of a 21-month-old boy was removed by surgical support with preparation of the catheter to its vessel entry. Success control was done by a transfemoral DSA in 5 of the 7 patients. 2 patients received clinical follow-up.In all cases the misplaced catheter could be removed successfully. In all 7 patients, there was no arterial bleeding after catheter removal. Complications were not observed.Removal of misplaced central venous catheters in the subclavian artery by the percutaneous closure device AngioSeal is safe. Percutaneous catheter removal should be regarded as the method of choice, even in obese patients.

A retrospective analysis of the long-term success rates of endoluminal therapy of renal artery stenosis in a university hospital was carried out.Preinterventional and postinterventional data contained in the clinical records of all 104 patients who underwent percutaneous transluminal angioplasty (PTA, 25 patients) or stent PTA (79 patients) from 01 January 1994 to 31 December 2007, were documented using an electronically structured questionnaire and a time period classification. Subgroup analyses and statistical calculations were done using t-tests for joint random samples.At day 1 postintervention all patients showed a statistically significant decrease in mean systolic blood pressure (all patients: p=0.002, stent PTA group: p=0.023, PTA group: p=0.022). The significant decrease in mean systolic blood pressure persisted in years 1 and 2 postintervention (all patients: p=0.009 and 0.007, stent PTA group: p=0.039 and 0.015, respectively). Mean blood pressure values remained constant during the other time periods analyzed. In patients with a stent PTA carried out between 2001 and 2007 there was no significant reduction of prescribed antihypertonic drugs (p=0.023 and p=0.046, respectively). Mean serum creatinine concentrations decreased during years 1 and 2 postintervention and increased starting in year 3. In patients with elevated serum creatinine levels prior to the intervention the increase in mean serum creatinine level started in year 5.Endoluminal therapy of arteriosclerotic renal artery stenosis delays further deterioration of renal function and stabilizes blood pressure as well as the number of prescribed antihypertonic drugs. This can be considered a response to treatment in view of the mostly chronic progressive course of the disease.

A 57-year-old immunocompromised man (OKT3 therapy following rejection reaction after renal transplantation) was presented to the ENT clinic because of progredient dysphagia and pain in the neck region. Twelve hours before, a esophagogastroduodenoscopy had been performed in an external clinic.There was palpable crepitation over the area of the larynx. Laboratory tests showed an increase of CRP and leucocytosis. Computed tomography with contrast agent showed a pronounced emphysema of the neck and extravasation on the level of the larynx. An x-ray with esophagramm showed a leakage of contrast agent at the hypopharynx.The patient received 1 × 2 g Ceftriaxon and 3 × 400 mg Metronidazol intravenously. Endoscopy with rigid instruments showed a 0.5 cm slit-like lesion of the left sinus piriformis with putrid secretion. Via a trans-cervical approach a parapharngeal abszess of 2 cm was explored and treated with drainage and lavage. The upper esophageal sphincter was slitted and the pharynx perforation multilayered closed from outside. A CT scan after 24 hours showed decreasing emphysema with signs of an absczess. The further clinical course was uneventful. After 3 months a bland cervical scar and normal ENT status could be observed at a patient free of symptoms.Perforation of the upper aerodigestive tract is a rare complication of a flexible esophagogastroduodenoscopy. Early diagnosis and treatment is needed to prevent the development of sepsis, an abscess or a mediastinitis as potential life threatening effects with a poor prognosis. Depending on the defect size and the overall situation a conservative or surgical management should be followed. Special attention should be paid to immunocompromised patients after a esophagogastroduodenoscopy as clinical signs of a perforated aerodigestive tract may be reduced or missing.

Background Our rationale was to evaluate whether a 64-slice CT scanner allows accurate measurement of computed tomographic (CT) changes in coronary artery flow profiles and whether CT flow measurements are suitable for classifying the significance and hemodynamic relevance of a stenosis and thereby supplement as a functional parameter for morphological stenosis analysis. Methods A total of 50 patients prospectively underwent computed tomography coronary angiography (coronary CTA) in a multidetector CT scanner (Brilliance 64, Philips)±1 day before or after invasive coronary angiography (ICA). Immediately thereafter, 2 radiologists reviewed the imaging data to detect any vessel segments with morphology poorly evaluable by coronary CTA. A locally constant cyclical measurement was acquired in these coronary arteries in breath-hold technique during the passage of a 50ml bolus of contrast media. For analysis, time–density curves of the bolus passage were registered in the coronary artery and the aorta (internal reference), the up-slopes were determined and correlated with each other. The results were compared with the ICA findings. Results 47 of 50 CT flow measurements were evaluable. A good correlation was found between the degrees of stenosis and slope ratios in aorta and coronary artery ( R 2 =0.92). The threshold corridor was 0.55–0.77 for distinguishing hemodynamically (≥70%) from non-hemodynamically relevant stenoses. Conclusions CT-based coronary artery flow measurements (CTFM) correlate well with the angiographically determined degree of stenosis and can elevate by non-invasive means the diagnostic accuracy of coronary CTA. From both a clinically diagnostic and scientific standpoint, CTFM proves a suitable method for quantifying coronary blood flow.

PURPOSE In this study we examined the feasibility of portal vein embolization (PVE) by using the Amplatzer Vascular Plug (AVP-II). We measured the time of vessel occlusion after plug deployment and changes in plug length and diameter within 4 weeks of PVE. MATERIALS AND METHODS In 10 consecutive patients (4 women, age 64 +/- 10 yrs, 48 - 82 yrs) an ipsilateral PVE of the right portal vein was performed prior to intended hemihepatectomy. After embolization with microparticles, the right portal vein was occluded using an AVP-II. We measured the time of complete vessel occlusion by angiography. Follow-up with computed tomography (CT) was performed within 72 h and after 4 weeks. RESULTS PVE was performed in all 10 patients without acute complications. Complete vessel occlusion was achieved in 9.7 +/- 5.1 min (range 1 - 21 min). On follow-up CT we found enhanced arterial vascularization of the embolized liver segments in 5 / 5 patients within 72 hours and in 6 / 10 patients after 4 weeks. The plug showed a contraction of 20 +/- 9 % and a dilatation of 23 +/- 13 %. Thus, the AVP-II dilated to 94 +/- 8 % (78 - 100 %) of its nominal diameter. The plug diameter was significantly larger in men compared to women (17 +/- 1.7 mm vs. 14 +/- 1.4 mm, p < 0.02). We did not observe any recanalization or migration of the device. The volume of the left liver lobe increased significantly by 27 % (p < 0.001) after 4 weeks. CONCLUSION PVE with the AVP-II is a feasible and effective method. The AVP-II can dilate within 4 weeks up to its nominal diameter dependent on the grade of oversizing. Dilatation of the diameter is associated with a shortening in length.

Multidetector computed tomography (MDCT) is especially suited for emergency diagnostics in multiple trauma patients. The objectives of this study were to investigate the types and frequencies of injuries associated with tram accidents in pedestrians. Eighteen consecutive pedestrian patients with multiple traumas after tram accidents were evaluated with MDCT in our Level I Trauma Center. The mean age in our patient cohort was 36.9 years with a range from 14-92 years. There was a trend for accident events occurring more commonly during the winter months in middle-aged men, often under the influence of alcohol. Patients were divided into two groups with unilateral or complex injury patterns. In both groups, leading diagnoses were head (83.3%) and thorax injuries (66.6%). Abdominal injuries (44.4%) were less common and mainly found in the complex injuries group. The most serious injuries occurred in the complex injuries group when the victim was caught under or between tramcars. A wide range of injuries is associated with tram accidents in pedestrians, which can be classified into two main injury patterns, unilateral and complex. The life-limiting injuries in this setting involved the head with a mortality rate of 22.2% (four patients) in our cohort.

To prospectively determine feasibility and diagnostic accuracy of 3D contrast-enhanced MR-angiography (CE-MRA) at 3.0 tesla (T) in patients with peripheral arterial occlusive disease. Digital subtraction angiography (DSA) was used as reference standard.Thirty consecutive patients with suspected peripheral arterial occlusive disease were examined on a 3.0 T MR system by using the integrated whole body coil. A 4-station examination protocol in hybrid technique was chosen, containing 2 gadodiamide injections, the first one for imaging the calf and foot arteries (single-step technique) and the second injection for the visualization of the aortoiliacal and femoral arteries (bolus-chase MRA). All patients underwent DSA within the following 48 hours. The arterial tree of each leg was divided in 15 segments and 4 anatomic regions (iliacal, femoral, popliteal/proximal calf, distal calf/foot). Two radiologists analyzed the MR-images with regard to image quality, grade of stenosis, and venous overlap. DSA-images were analyzed by 2 radiologists in consensus with regard to the stenosis grade.Eight hundred eighty-five and 884 of 889 arterial segments at CE-MRA were rated with excellent or good diagnostic image quality by observer 1 and observer 2, respectively. In only 3 segments image quality was affected by venous contamination. Sensitivity of CE-MRA for determination of relevant arterial stenoses (50%-99%) and occlusions--as compared with DSA--was 95.3% (both observer) and specificity was 98.5% and 97.8% for observer 1 and observer 2, respectively.Peripheral hybrid CE-MRA at 3.0 T is feasible and proved to be reliable at depiction of stenoses and occlusions of the whole pelvic and lower leg arterial system.

A case of perforating injury to the hypopharynx following uneventful intubation is reported. As symptoms are relatively unspecific, perforating trauma of the pharynx, larynx, esophagus or trachea may temporarily remain undetected. Consecutive development of an abscess or mediastinitis can cause a potential vital threat to the patient. Depending on the defect size and the overall situation a conservative or surgical management should be followed. Persistent complaints of neck or thorax pain after endotracheal intubation should always raise suspicion of injury to the upper aerodigestive tract, even after uncomplicated intubation.

Permanent prostate implants are widely used as therapy for localized prostate cancer. Transperineal placement of (125)I seeds can be directed safely by transrectal ultrasound imaging. Misplaced seeds can produce serious damage in various organs, especially in the rectal mucosa. The rescue of misplaced seeds can be performed with open surgery or with minimally invasive percutaneous intervention. We report a case of percutaneous fluoroscopically guided salvage of misplaced perirectal (125)I prostate customized stranded seeds using an interventional angiographic catheter.

The classic methods for surveilling the efficacy of radiotherapy in prostate cancer are not accurate enough. The objective of this analysis was to determine whether prostate-specific antigen could perform this task.From 1/95 to 10/95, 16 patients were treated at our clinic. 7 of these underwent primary irradiation, 4 treatment for local recurrence, and 5 had adjuvant radiotherapy. Radiotherapy was carried out with a total dose of 60 Gy in 30 fractions, 10 fractions per week, to the prostate bed plus 2 cm safety margin.PSA levels usually start to decline between the 3rd and the 4th week of radiotherapy with a half-life of 2.5 months. Five patients had equal or rising PSA levels, including all three patients with recurrent tumor.In most cases, PSA declined continuously from the 3rd week of therapy. Our median half-life was similar to other reported results. Persisting or rising PSA levels are an indicator for local or distant recurrence; all our patients who developed a recurrence showed a corresponding PSA increase.