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A life-threatening lower gastrointestinal bleeding is a rare complication due to coloscopic polypectomy. The following case report deals with a severe bleeding that was caused by polypectomy of a villous adenoma in a patient with chronic pancreatitis causing a huge pseudoaneurysm of the splenic artery. After polypectomy a wide iatrogenic communication between the pseudoaneurysm and the colon existed causing massive arterial intraluminal bleeding. Although this was successfully managed by transcatheter arterial embolization via splenic artery, the patient died a few days later caused by disseminated intravasal anticoagulation and multi organ failure.

Iatrogen hinterlassene chirurgische Fremdkorper sind selten. Sie konnen zu einer aseptischen Fremdkorperreaktion ohne signifikante Symptome fuhren oder eine exsudative Fremdkorperreaktion verursachen, welche fruhe, aber unspezifische Symptome hervorruft. Am haufigsten handelt es sich bei den hinterlassenen Fremdkorpern um Tupfer oder Bauchtucher (Gossypibom). Auch wenn es keine vergleichenden Studien bezuglich der diagnostischen Genauigkeit der unterschiedlichen bildgebenden Modalitaten gibt, so scheint die CT die am besten geeignete Methode zu sein, um Fremdkoper zu diagnostizieren. Bis auf rontgendichte Marker gibt es jedoch auch in der CT keine spezifischen Zeichen fur das Vorhandensein eines Gossypibom, sodass es eines erfahrenen Radiologen bedarf, um Fremdkorper von anderen morphologisch sehr ahnlichen Differenzialdiagnosen wie Abszessen und Hamatomen abgrenzen zu konnen.

A life-threatening lower gastrointestinal bleeding is a rare complication due to coloscopic polypectomy. The following case report deals with a severe bleeding that was caused by polypectomy of a villous adenoma in a patient with chronic pancreatitis causing a huge pseudoaneurysm of the splenic artery. After polypectomy a wide iatrogenic communication between the pseudoaneurysm and the colon existed causing massive arterial intraluminal bleeding. Although this was successfully managed by transcatheter arterial embolization via splenic artery, the patient died a few days later caused by disseminated intravasal anticoagulation and multi organ failure.

The aim of this study was to compare conventional 2D FLAIR and single-slab 3D FLAIR sequences in the detection of lesions in patients with multiple sclerosis. Eight patients with MS were examined at 3.0 T by using a 2D FLAIR sequence and a single-slab 3D FLAIR sequence. A comparison of lesion detectability was performed for the following regions: periventricular, nonperiventricular/juxtacortical and infratentorial. The contrast-to-noise ratios (CNRs) between lesions and brain tissue and CSF were calculated for each sequence. A total of 424 lesions were found using the 2D FLAIR sequence, while with the 3D FLAIR sequence 719 lesions were found. With the 2D FLAIR sequence, 41% fewer lesions were detected than with the 3D FLAIR sequence. Further, 40% fewer supratentorial and 62.5% fewer infratentorial lesions were found with the 2D FLAIR sequence. In images acquired with the 3D FLAIR sequence, the lesions had significantly higher CNRs than in images acquired with the 2D FLAIR sequence. These are the first results using a single-slab 3D FLAIR sequence at 3.0 T for detection of lesions in patients with MS. With the 3D FLAIR sequence significantly higher CNRs were achieved and significantly more lesions in patients with MS were detected.

OBJECTIVE: It is often difficult to decide whether a cystic brain lesion is a tumor or an abscess by means of conventional MRI techniques. The immediate diagnosis of a brain abscess is important for the patient's outcome. Our goal was to study the ability of diffusion-weighted imaging and calculation of the apparent diffusion coefficient (ADC) to differentiate between these two pathologies. PATIENTS AND METHODS: Ten patients (five men, five women) with cystic brain lesions were examined with MRI. The ADC maps were calculated for each subject and the ADC value of each lesion was measured. Histology revealed glioblastoma multiforme in six patients and abscess in four patients. RESULTS: All brain abscesses showed markedly hyperintense signal changes on diffusion-weighted imaging, whereas the appearance of glioblastoma varied from slightly hyperintense to hypointense signal conversion. The mean ADC value calculated in the six patients with cystic brain tumor was: 2.05 x 10 (-3) mm(2)/s (1.38-2.88 x 10 (-3) mm(2)/s). The mean ADC value of the four patients with brain abscess was: 0.57 x 10 (-3) mm(2)/s (0.38-0.77 x 10 (-3) mm(2)/s). CONCLUSION: Diffusion-weighted imaging and calculation of ADC maps constitute a helpful tool to differentiate between cystic brain tumors and brain abscesses.

Cross-sectional imaging modalities such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and Positron emission tomography (PET)/CT have benefited from rapid technical advances in recent years. In patients with colorectal tumors, multislice CT is the standard technique for preoperative evaluation and follow-up. It is faster than single-slice helical CT and allows for excellent 3D imaging of liver anatomy and tumor volumetry. The most accurate technique for detecting and characterizing focal liver lesions is MRI using state-of-the-art scanners and liver-specific contrast agents and should be used for preoperative evaluation of all possible surgical candidates. Whole-body FDG-PET and PET/CT are most useful in the detection of extrahepatic disease and may alter clinical management in up to 20% of patients by detecting extrahepatic spread of disease.

Purpose: To evaluate the performance of four 3D‐ToF magnetic resonance angiography (MRA) sequences with and without integrated parallel acquisition techniques (iPAT) at 1.5T and 3.0T in imaging intracranial vessels. Material and Methods: Seven volunteers and 5 patients (4 aneurysms, 1 AVM) underwent 3D‐ToF‐MRA at 1.5T (Magnetom Sonata) and 3.0T (Magnetom Trio) with and without parallel acquisition techniques (iPAT) using similarly designed 8‐channel phased‐array head coils. Imaging time of the pulse sequences was set to 7.15 and 7.35 min, respectively. Images were analyzed quantitatively by calculating signal‐to‐noise (SNR) and contrast‐to‐noise (CNR) ratios of proximal M2 segments and qualitatively by using a 5‐point scale. Results: SNR and CNR were significantly higher for both 3D‐ToF sequences at 3.0T compared with both pulse sequences at 1.5T. The highest SNR and CNR were obtained at 3.0T without iPAT. However, because of a higher spatial resolution (matrix 512×640) visualization of small vessel details was best at 3.0T with iPAT. Conclusion: Intracranial 3D‐ToF‐MRA at 3.0T offers superior image quality compared with 1.5T, particular in the delineation of smaller vessels. In contrast to 1.5T, implementation of iPAT at 3.0T is of additional benefit since the high SNR available at 3.0T allows for higher spatial resolution without prolongation of measurement time.

Small cell carcinoma (SCC) of the pancreas is a rare malignancy with an extremely poor prognosis. We present the case of a 74-year-old man with a 2-month history of upper abdominal discomfort who was diagnosed with SCC of the pancreas tail, involvement of peripancreatic and mesenteric lymph nodes and multiple liver metastases (extended disease). A CT scan and a positive somatostatin receptor scintigraphy showed no evidence of a primary lung tumour. The diagnosis of a SCC was confirmed by biopsy. Local tumour control could be achieved by gemcitabine once a week and a long-acting somatostatin analogue once a month, but liver metastasis showed progress. Thus, 5-fluorouracil on a weekly basis was started. The patient died 8 months after diagnosis and had not been hospitalised in the meantime.

Magnetic resonance imaging (MRI) of diffusion and magnetization transfer was combined with 1H-spectroscopic imaging (CSI) to evaluate the clinical potential of in-vivo profiles of various brain pathologies. Ten patients (multiple sclerosis, cerebrovascular disease, leukodystrophy, Alzheimer dementia) and five healthy volunteers were investigated with diffusion-weighted MRI, magnetization transfer imaging, and CSI. Proton spectra were analyzed as ratios of NAA/Cr and Cho/Cr calculated from the peak areas of N-acetylaspartate (NAA), (phospho)-creatine (Cr) and choline (Cho). The apparent diffusion coefficient (ADC) and the magnetization transfer ratio (MTR) were determined in identical voxels to ensure identical partial volume effects compared to CSI. Compared to MTR and ADC assessments, the lower spatial resolution of CSI clearly indicates a hindrance at 1.5 T. In most demyelinating lesions, NAA/Cr reduction paralleled attenuated MTRs and elevated ADCs. By contrast, in acute stroke and some acute MS lesions the ADC was reduced, while MTR and NAA/Cr were also decreased. In Alzheimer's dementia, ADC was increased, MTR unchanged and Cho/Cr increased. In a case of leukodystrophy, ADC was pronouncedly increased, MTR and NAA/Cr both reduced, and Cho/Cr normal. Combined measurements of ADC, MTR and CSI are feasible and provide differential in-vivo information on various brain pathologies.

Hintergrund: Die posteriore Enzephalopathie (PE) ist klinisch durch rasch progrediente Visusstorungen bis hin zur kortikalen Blindheit, psychopathologische Auffalligkeiten mit im Vordergrund stehender Desorientierung, epileptische Anfalle und Kopfschmerzen charakterisiert. Kernspintomographisch zeigen sich bilaterale subkortikale, aber auch kortikale Lasionen betont parietookzipital. Ziel der Untersuchung sind die Darstellung und Analyse neuroradiologischer und klinischer Befunde bei der PE. Patienten und Methodik: Die klinischen und neuroradiologischen Untersuchungsergebnisse von neun stationar im Zeitraum von 2000 bis 2002 behandelten Patienten wurden ausgewertet. Neben der initialen Kernspintomographie zwischen dem 1. und 4. Tag nach Beginn der klinischen Symptomatik erfuhren vier Patienten eine MRT-Verlaufsuntersuchung und eine MR-Angiographie. Bei acht Kranken wurden erganzend diffusionsgewichtete Sequenzen (DWI) akquiriert. Ergebnisse: Mogliche Ursachen der PE waren Praeklampsie (2), postpartale Angiopathie (2), Cyclosporin-A-Gabe (1), Cisplatintherapie (1), hypertone Krise (1); bei zwei intensivpflichtigen Patienten blieb die Ursache unklar. Kernspintomographisch zeigten sich parietale (9), parietookzipitale (8), frontodorsale (5) und zerebellare (3) hyperintense bilaterale Lasionen in den T2-gewichteten und Fluid-Attenuated-Inversion-Recovery-(FLAIR-)Sequenzen, wobei neben dem Marklager immer auch angrenzende kortikale Strukturen mitbetroffen waren. Bei drei Patienten trat zusatzlich eine Hamorrhagie uberwiegend im Kortex auf. MR-angiographisch hatten vier Patienten diffuse Vasospasmen. Im Verlauf erfuhren funf Patienten eine vollstandige Ruckbildung, zwei Patienten eine deutliche und zwei Patienten nur eine moderate Besserung der neurologischen Ausfalle. Schlussfolgerungen: Entgegen der initialen Beschreibung als posteriore reversible Leukenzephalopathie liegt bei der PE oft auch eine kortikale Beteiligung vor. Zerebellare Lasionen sprechen nicht gegen die Diagnose einer PE. Die Signalveranderungen in den DWI sind sowohl Ausdruck eines vasogenen als auch zytotoxischen Odems, da sich bei Verlaufsuntersuchungen betont kortikale Nekrosen zeigen konnen. Ein generalisierter Vasospasmus wie auch das weibliche Geschlecht scheinen begunstigende Faktoren fur eine PE zu sein.

Noninvasive tumor ablation can be achieved by extracorporeally induced high intensity focused ultrasound. Clinical high intensity focused ultrasound performed to date for renal tumors have only been experimental in nature. We present specific details on a patient with renal cell carcinoma who underwent high intensity focused ultrasound with curative intent and long-term followup examinations.Ultrasound waves were generated by a cylindrical piezoelectric element focused by a paraboloid reflector. High intensity focused ultrasound was applied to 3 tumors in 3 sessions with the patient under general anesthesia or sedation analgesia, followed by magnetic resonance imaging for 6 months.After treatment magnetic resonance imaging showed necrosis in the 2 tumors in the lower kidney pole within 17 and 48 days, respectively. The necrotic tumor area shrank thereafter within 6 months. The tumor in the upper pole was not affected by treatment due to absorption of the ultrasound energy by the interposed ribs. General anesthesia was required to apply high energy levels of focused ultrasound. Absorption of high intensity focused ultrasound in the tissue induced sharply demarcated thermonecrosis. For 50 years patients have been treated with high intensity focused ultrasound for different indications, focusing on the brain, eyes, prostate, liver and bladder. For the kidney experimental but only few clinical studies indicate sufficient tissue ablation.In our case contactless noninvasive application of high intensity focused ultrasound to 2 renal carcinomas achieved thermal ablation. When high intensity focused ultrasound energy was coupled correctly, no lesions occurred outside of the target area. Successful high intensity focused ultrasound application depended on optimum energy coupling, a sufficiently high ultrasound energy level and general anesthesia.

Autoimmune pancreatitis (AIP) was first classified as a defined disease entity in 1995. It accounts for approximately 2 % of cases of chronic pancreatitis (western world prevalence 36-41/100,000 inhabitants) and AIP is diagnosed in 2.4 % of pancreas resection specimens.Presentation of strategies for diagnosis and treatment with focus on differentiation of AIP and pancreatic carcinoma.Selective literature research in PubMed regarding pathogenesis, diagnosis and treatment of AIP.Key characteristics of AIP are recurrent jaundice due to obstructed bile ducts, histological evidence of fibrosis, a lymphoplasmocytic or granulocytic infiltrate and the response to steroid therapy. There are two distinctive forms of AIP: type I or lymphoplasmocytic sclerosing pancreatitis and type II or idiopathic duct centric pancreatitis. The IgG4 positive AIP type I belongs to the group of IgG4-related systemic diseases. Diagnosis of AIP is established according to the international consensus diagnostic criteria (ICDC) or HISORt (mnemonic standing for histology, imaging, serology, other organ involvement and response to therapy) criteria. Differentiation from pancreatic adenocarcinoma can be challenging. The standard treatment consists of corticosteroids and in some cases azathioprine can be added. In refractory disease rituximab is a further option. Treatment is indicated in patients with jaundice, systemic manifestation or persistent pain.Although AIP is increasingly being identified, the differentiation from pancreatic adenocarcinoma still remains difficult and in cases of a suspicion of neoplasia, resection should be favored. It can successfully be treated conservatively with steroids and rituximab.

Hintergrund: Durch die Einfuhrung der ultraschnellen Kernspintomographie (MRT), einschlieslich der Darstellung des hepato-pankreatischen Gangsystems (MRCP) und der 3D-Gefasdarstellung (MR-Angio) haben sich neue diagnostische Moglichkeiten in der Diagnostik von Pankreasveranderungen ergeben. Material und Methode: Wir berichten uber 143 operierte Patienten mit benignen und malignen Pankreaserkrankungen, die ausschlieslich eine MR-Diagnostik praoperativ erhalten haben. Alle radiologischen Befunde wurden intraoperativ uberpruft. Ergebnisse: Es konnte fur die Frage nach der Resektabilitat eine Sensitivitat von 96,0 % bei einer Spezifitat von 89,5 % und bei der Festlegung der Dignitat eine Sensitivitat von 99,1 %, bei einer Spezifitat von 95,2 % mit der MR-Pankreasdiagnostik erreicht werden. Schlussfolgerung: Nach unseren Erfahrungen mit der MR-Pankreasdiagnostik wird sich dieses sichere und komplikationslose diagnostische Verfahren als Standard durchsetzen.

Accurate imaging is essential for correct operative planning and successful surgical intervention in renal cell carcinoma (RCC). Our objective was the comparison of color duplex sonography with spiral computed tomography (CT) and surgical-pathological findings in the evaluation of renal masses to determine tumor localization, size, tumor thrombus extent and lymph node metastases.We evaluated 60 patients with a renal mass in a prospective study. Both color duplex sonography and CT were performed by different investigators without knowledge of the supposed diagnosis. The color Doppler findings were compared to CT and surgical pathological findings.The sensitivity of color duplex sonography in the detection of RCC and lymph node metastases is comparable to that of CT (100%). Color duplex sonography was superior in the detection of renal vein involvement. Color duplex sonography alone allowed correct planning of the surgical procedure without intraoperative changes in all patients.Duplex sonography provides exactly the same information as CT. Although duplex sonography is less expensive with lower exposure to radiation, most surgeons will still probably demand CT for diagnosis, especially as this method is unerring and duplex sonography highly depends on the expertise of the person using it.

Aim We demonstrate a technique for examining the hip joint sonographically in a standardised way using sectional planes corresponding to the guidelines provided by the work group "Sonography of the Musculo-Skeletal System" of the German Society of Ultrasound (DEGUM). MRT-scans were used as a comparative standard. Method The ultrasound examination was performed in the following standardised way: a transversal and longitudinal scan were done in the ventral region and additionally a longitudinal scan in the lateral region. In cases without pathological findings two standardised planes should be documented. In the case of pathological findings the picture should be documented in two standardised planes and compared to the corresponding contralateral site. An ultrasound examination standardised in this way facilitates a precise assessment of the ventral joint capsule, the bone structures, the ventral and lateral aspects of the glenoid cavity and the peri-articular soft tissue structures of the hip joint. Results An examination technique is presented which offers additional pictorial information, saves costs and is not harmful to the patient. Conclusion The ultrasound examination of the hip joint can supply additional information about diseases and traumatic changes in this region. In paediatric hip disorders such as transient synovitis, septic arthritis, juvenile arthritis, Leg-Calve-Perthes disease and slipped femoral epiphysis, the ultrasound examination can provide important additional information for the initial differential diagnosis and during follow-up.

Background Malignant tumours of the duodenum are rare and often difficult to diagnose. Due to the small clinical experience with duodenal malignancies their prognosis is unknown and resection is the treatment of choice.Case report Adding to a small series of incidental tumours, we report the case of a 65-year-old patient with primary extranodal (MALT-) lymphoma of the duodenum infiltrating the pancreatic head. The patient was admitted because of anaemia and epigastric discomfort with a history of Helicobacter- pylori associated gastric ulceration. Physical examination and bloodchemical values were otherwise normal. Endoscopy revealed duodenal ulceration but the biopsies taken from the ulceration did not give any evidence of malignancy or residual Helicobacter pylori infection. But MRT showed a circular intramural tumour of the duodenum. On laparotomy a large duodenal tumour adherent to the pancreatic head was found and a Whipple procedure was performed.Conclusion Apart from describing the case of a rare lymphoproliferative disorder of the duodenum, this report illustrates the diagnostic difficulties with uncommon neoplasm's of the duodenopancreatic region and the value of MRT prior to resection of a duodenopancreatic mass.

PURPOSE: Evaluation of high-resolution 2D-RARE MRCP in the diagnosis of pancreaticobiliary diseases. MATERIALS AND METHODS: 23 patients with various pancreaticobiliary diseases were evaluated using conventional and high-resolution 2D-RARE sequences. RESULTS: High-resolution RARE MRCP allowed for improved delineation of biliary and pancreatic ducts at the expense of reduced signal-to-noise ratio. Pathological findings were significantly (p < 0.001) better demonstrated with high resolution RARE MRCP (score 1.65 +/- 0.54) as compared to the conventional RARE sequence (score 2.58 +/- 0.62). CONCLUSIONS: High-resolution 2D-RARE-MRCP improves the delineation of biliary and pancreatic ducts. This sequence should replace the conventional 2D-RARE sequence.

In den ersten Stunden nach zerebraler Ischamie ist eine exakte Diagnosestellung haufig schwierig. Die diffusionsgewichtete (DW) Magnetresonanztomographie (MRT) ermoglicht die bildliche Darstellung betroffener Parenchymanteile und quantitative Erfassung der Gewebeveranderungen, noch bevor eindeutige Auffalligkeiten im T2-gewichteten Bild nachweisbar sind. Wir analysierten 105 MRT-Untersuchungen akuter Schlaganfalle (

PURPOSE To prospectively evaluate the role of MRI including MR cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic cancer. MATERIAL AND METHODS ERCP and MRI including MRCP were performed in 52 patients with suspected pancreatic cancer. MRCP was obtained using a single-shot RARE technique. The results of axial images and MRCP were compared to concurrently performed ERCP examinations. The standards of reference were the surgical and pathological findings, respectively. Image quality of MRCP was assessed using a three-step-score (1 = good, 2 = fair, 3 = nondiagnostic). RESULTS In 88% of the cases the MRCP was of good quality. Only in 4% was MRCP non-diagnostic. The combination of MRI and MRCP showed an overall accuracy of 88%, whereas the overall accuracies of MRCP alone and ERCP were 80%, and 85%, respectively. The positive predictive values of MRI/MRCP, MRCP alone, and ERCP were 91%, 85%, and 88%, respectively. CONCLUSION For the detection of pancreatic cancer MRI including MRCP is comparable to ERCP and can be regarded as the method of choice in patients with suspected pancreatic cancer. ERCP is the procedure of choice in patients with contraindications to MRI and in patients in whom additional therapeutic procedures are performed.

PURPOSE To evaluate the accuracy of 3D-MRA in preoperative staging in correlation to intraoperative and histological results. METHODS In 30 patients with focal liver lesions axial and coronal MR sequences (T1w-Flash 2D, T2w-TSE unenhanced. T1w-Flash 2D, TRUE FISP contrast-enhanced) as well as coronal breath-hold MRA were performed. The technical parameters of the MRA were as follows; TR/TE 5/2 ms, flip angle 40 degrees, 32-40 partitions with an effective slice thickness of 2-3 mm, acquisition time 26 s, matrix 128 x 256, FOV 320 x 320 to 400 x 400. RESULTS In 23/30 patients liver resection was performed. Correct prediction of segmental localization was achieved in preoperative MRI of 22 patients (98%). The presumed histology was correct in 20/23 cases (87%). The evaluation of the hepatic vascular structures was correctly predicted in all cases. By use of multiplanar reconstructions and single image view of the 3D data base of MRA, additional information could be obtained in 13 patients. CONCLUSIONS Breath-hold 3D-MRA gives certain information on localization and relation of vascular structures to focal hepatic lesions. In presentation of portal venous structures MRA is superior to conventional angiography.

PURPOSE To assess the utility of breath-hold abdominal ultrafast three-dimensional (3D) gadolinium-enhanced dual-phase magnetic resonance angiography (MRA). MATERIAL AND METHODS 125 patients with various abdominal pathologies were imaged using a breath-hold ultrafast gadolinium-enhanced dual-phase 3D-MRA technique. RESULTS 119 (95%) of 125 MRA's were of good or excellent quality. The sensitivity in the detection of renal artery stenoses as well as stenoses of the celiac trunk and the superior mesenteric artery was 100%. Accessory renal arteries (n = 9) and replaced hepatic arteries (n = 4) were reliably detected by MRA. In 24 (71%) of 34 cases MR-angiographic delineation of the spleno-portal system and hepatic veins was superior compared to conventional angiography. CONCLUSION Breath-hold gadolinium-enhanced dual-phase 3D-MRA has the potential to replace conventional angiography in the abdomen.

Purpose To provide methods for stereoscopic visual demonstration from 3D reconstructed MR angiographic images. Methods Stereoscopic viewing can be obtained with pairs of images that are displayed at angles of 15 degrees. Optical devices as stereoscopic binoculars or minor stereoscopes facilitate stereoscopic viewing. The possibility of stereoscopic projections for a larger auditorium is mentioned. Results Using three clinical examples the advantages of stereoscopic display of MR angiograms are demonstrated. Conclusions MR angiography allows stereoscopic viewing with simple methods, like CT- and conventional rotation angiography. This principle, which has been known for 100 years, may thus acquire a new significance.

OBJECTIVE: This prospective study was undertaken to evaluate the accuracy of a noninvasive "all-in-one" staging method in predicting surgical resectability in patients with pancreatic or periampullary tumors. SUMMARY BACKGROUND DATA: Despite progress in imaging techniques, accurate staging and correct prediction of resectability remains one of the chief problems in the management of pancreatic tumors. Staging algorithms designed to separate operable from inoperable patients to save the latter an unnecessary laparotomy are becoming increasingly complex, expensive, time-consuming, invasive, and not without risks for the patient. METHODS: Between August 1996 and February 1997, 58 consecutive patients referred for operation of a pancreatic or periampullary tumor were examined clinically and by 5 staging methods: 1) percutaneous ultrasonography (US); 2) ultrafast magnetic resonance imaging (UMRI); 3) dual-phase helical computed tomography (CT); 4) selective visceral angiography; and 5) endoscopic cholangiopancreatography (ERCP). The assessment of resectability by each procedure was verified by surgical exploration and histologic examination. RESULTS: The study comprised 40 male and 18 female patients with a median age of 63 years. Thirty-five lesions were located in the pancreatic head (60%), 11 in the body (19%), and 1 in the tail of the gland (2%); there were 9 tumors of the ampulla (16%) and 2 of the distal common duct (3%). All five staging methods were completed in 36 patients. For reasons ranging from metallic implants to contrast medium allergy or because investigations already had been performed elsewhere, US was completed in 57 (98%), UMRI in 54 (93%), CT in 49 (84%), angiography in 48 (83%), and ERCP in 49 (84%) of these 58 patients. Signs of unresectability found were vascular involvement in 22 (38%), extrapancreatic tumor spread in 16 (26%), liver metastases in 10 (17%), lymph node involvement in 6 (10%), and peritoneal nodules in only 2 patients (3%). These findings were collated with those of surgical exploration in 47 patients (81 %) and percutaneous biopsy in 5 (9%); such invasive verification was deemed unnecessary and therefore unethical in 6 clearly inoperable patients (10%). In assessing the four main signs of unresectability (extrapancreatic tumor spread, liver metastases, lymph node involvement, and vascular invasion), the overall accuracy of UMRI was 95.7%, 93.5%, 80.4%, as compared to 85.1%, 87.2%, 76.6% for US and 74.4%, 87.2%, 69.2% for CT. In assessing vascular invasion, the sensitivity, specificity, and overall accuracy of angiography were 42.9%, 100%, and 68.8%, respectively. There were 3 complications (12.5%) after 24 resections, 5 in 17 palliative procedures, and none after 6 explorations only. The hospital stay was 14 days after resection, 13 after palliative bypass, and 6 after exploration alone. There was no operative or hospital mortality in these 58 cases. CONCLUSIONS: Although it is by no means 100% accurate, UMRI is equal or even superior to all other staging methods. It probably will replace most of these, because it provides an "all-in-one" investigation avoiding endoscopy, vascular cannulation, allergic reactions, and x-radiation. But because even UMRI is not perfect, the final verdict on resectability of a tumor still will depend on surgical exploration in some cases.

We present the methodology and data indicating the feasibility of a five-study collaborative stroke trial. The core study, the Warfarin-Aspirin Recurrent Stroke Study (WARSS), is a prospective, random

The concept of critical care in stroke is a controversial issue. The question of whether full-scale critical care management of stroke improves patient outcome is still open and probably depends on th

The authors report serial MRI of a patient with Bickerstaff's brainstem encephalitis (BBE), disclosing caudal migration of an initial upper midbrain lesion. High apparent diffusion coefficient values imply a vasogenic rather than cytotoxic edema as the cause of the hyperintense signal changes on T2-weighted images.

Pseudomembranous colitis (PMC) is an infectious colitis usually occurring as a complication of antibiotic therapy. The computed tomography (CT) findings of 10 patients with PMC are reviewed. All patients demonstrated an abnormal large bowel wall with an average thickness of 13 mm (range 7-31 mm). Additional, but less frequent findings included mesenteric inflammation, ascites, pleural effusions, and dilatation of the large or small bowel. Pancolonic involvement was seen in 7 cases, while three patients had focal colitis. Although the CT appearance of PMC is not specific, the diagnosis may be suggested in the proper clinical setting.

A gravida 5, para 4 presented with generalized tonic-clonic seizures in the 37th week of gestation. The previous course of the pregnancy had been uneventful. Blood pressure was normal and there was no proteinuria or edema. A magnetic resonance scan of the brain was obtained to rule out intracranial bleeding, sinus vein thrombosis and encephalitis. The scan showed the characteristic findings of eclampsia. Seven hours after the seizure the patient was delivered vaginally of a slightly growth retarded male newborn. The further course was uneventful and the cerebral changes resolved without specific treatment. Eclamptic seizures are generally considered due to the failure of autoregulatory mechanisms and subsequent endothelial damage and vasogenic, cerebral edema. Without systemic hypertension this hypothesis is unsatisfactory. Endothelial dysfunction with increased vascular sensitivity to vasopressors is a more likely mechanism.

Often, equivocal pancreatic cystic masses in a patient cannot be clearly identified. We report on a 74-year-old patient who consulted us with size-gaining multi-cystic lesions located at the pancreatic head and tail as well as with an increased CA 19-9 level. By using diagnostic methods as ultrasound, radiological images and innovative endoscopic techniques an intraductal papillary mucinous neoplasm (IPMN) was diagnosed. Evaluation of equivocal cystic lesions requires developing of further strategies as well as integration of new concepts: We present a diagnostic algorithm based on endoscopy that enables us to perform an adapted therapy by having a more accurate evaluation and the opportunity to gain samples where unclear lesions are given.

Despite numerous publications on the epidemiology of inflammatory bowel diseases (IBD) there is a lack of systematic investigations on live-threatening complications of IBD and their causes. This study evaluates risk factors, course and outcome in intensive-care patients which were related to complications of IBD.Among 6071 admissions to the intensive-care unit (ICU) of a gastroenterological department (university hospital with IBD-outpatient unit) between 1.1.1991 and 31.1.2008 36 ICU admissions of 28 patients with IBD were documented and prospectively analysed from 1996 onwards, using a structured questionnaire on causes for ICU admission as well as risk factors regarding death, organ failure and length of ICU stay.ICU admissions of IBD patients mainly resulted from three causes: complications specific to IBD (44 %), including acute flare-up, perforation and electrolyte imbalance, septic complications (22 %) and thromboembolic complications (17 %). Five patients died, all from septic complications related to immunosuppression including candida sepsis, varicella pneumonia during treatment with infliximab, and pneumocystis pneumonia related to treatment with azathioprine. The most important risk factors according to uni- and multivariate analyses were old age on ICU-admission and first diagnosis of IBD, previous surgery related to IBD and Crohn's disease.Complications of both IBD and immunosuppressive therapy may be live-threatening in patients with IBD. Better characterization of patients with a high probability of improved outcome by immunosuppressive and/or antibody-therapy seems to be preferable to noncritical early use of these drugs.

In contrast to the intramedullary (80%) and intracortical (14%) subtypes, the subperiostal subtype of aneurysmatic bone cysts (sABC) is relatively rare (6%). Females are affected more frequently than males, whereby the diaphysis is predominantly affected and less frequently the metaphysis of long bones as well as the vertebral column. Especially in conventional radiography sABCs can mimic aggressive lesions. Cross-sectional imaging can potentially reduce the wide range of differential diagnoses. Due to typical imaging features magnetic resonance imaging (MRI) is the most valuable modality to reduce the range of possible differential diagnoses. MRI usually presents a multicystic appearance with a hypointense rim of the lesion, contrast-enhancing cyst walls, fluid levels and edema-like changes in the adjacent tissue. In sABCs with solid components the diagnosis cannot be made with confidence and the suspicion must be confirmed by biopsy. The therapy of primary lesions consists of curettage or the complete excision of the sABC and the defects are subsequently filled with spongiosa or bone cement depending on the size of the lesion.

Gastric outlet obstructions can be of benign or malignant origin. In the case of the female patient described in this article, the extended diagnostic procedure with computed tomography and bone marrow biopsy was the key to a definite diagnosis and treatment planning.

Background and Purpose —There is uncertainty concerning the etiology of transient global amnesia (TGA). Previous CT and MRI studies have indicated that permanent structural abnormality is rare in TGA. Diffusion-weighted (DW) MRI is very sensitive to early ischemic parenchymal changes and has recently demonstrated embolic infarction in the posterior cerebral artery territory in 2 TGA patients. We report the findings of DW MRI in 8 patients in acute stages of TGA. Methods —Conventional and echo-planar DW MRI was performed in 2 patients in the active phase and 6 patients in the recovery phase (1 to 8 hours after cessation of anterograde memory dysfunction) of spontaneously occurring TGA. Results —None of the patients showed signs of hyperintensity on DW images or hypointensity on quantitative apparent diffusion coefficient (ADC) maps to suggest regional decreases of water mobility or acute T2 changes on transverse or coronal slices. Conclusions —We were unable to detect ADC or acute T2 changes with echo-planar DW MRI in patients with TGA, which suggests that mechanisms other than ischemic infarction may cause TGA. We did not identify spreading depression–associated changes of the ADC. Further refinement of MRI sequences may be necessary to detect subtle or transient signal change in brain parenchyma.

With approximately 150 reported cases, fistulas between the abdominal aorta and inferior vena cava are rare. Preoperative clinical diagnosis of aortocaval fistula is difficult because the classical triad of abdominal pain, pulsatile abdominal mass, and abdominal machinery-like bruit may be absent in up to 50 % of patients. We report a case of aortocaval fistula complicating abdominal aortic aneurysm which was diagnosed preoperatively using breath-hold gadolinium-enhanced three-dimensional MR angiography.

In recent years continuous advancements in software and hardware technology of modern MRI systems have contributed to substantial progress in the field of pancreatic tumor imaging. Despite technical advances in abdominal MRI, multislice CT still remains the preferential diagnostic tool for pancreatic lesions. In the majority of cases the essential clinical questions can thereby be answered with a high degree of accuracy. However, in dilemma cases state-of-the-art MR imaging can provide relevant information for the diagnosis allowing an optimal therapeutic concept. This report gives an overview on possible applications for MRI in the diagnostic evaluation of malignant pancreatic tumors.

Objective. To assess the therapeutic benefit of mycophenolate mofetil (MMF) in retroperitoneal fibrosis (RF). Methods. MMF 2 g/day and prednisone 1 mg/kg were initiated in nine patients with radiological (9/9) and histological verification (2/9) of idiopathic RF. Out of nine patients, seven needed bilateral ureteral stenting due to extensive hydronephrosis. Results. All patients experienced regression of radiological extension. Out of seven patients, five were free of ureteral catheters after a mean of 5.6 months and two remained on stenting due to secondary stenosis. Within 6 months mean creatinine and CRP fell from 2.5 to 1.2 mg/dl and from 4.0 to 1.4 mg/dl, respectively. MMF was discontinued after a mean of 27 months. Prednisone was tapered to zero after a mean of 7 months. Side-effects were urinary tract infections in 7/9 patients and impaired glucose tolerance in 3/9. No recurrence occurred after withdrawal of glucocorticoids and MMF in 7/9 patients after a mean overall follow-up of 55 months (range 12-120). Conclusions. Treatment with MMF and glucocorticoids was successful in inducing partial or complete and lasting remission in RF. The results suggest the use of MMF as additional immunosuppressive option

Magnetic resonance cholangiopancreaticography (MRCP) with heavily T2-weighted RARE and HASTE sequences has become an important imaging modality for the morphologic evaluation of intra- and extrahepatic bile ducts. However, for the diagnosis of functional biliary disorders, cholangiopancreaticography (ERCP) and endoscopic manometry, two invasive techniques with considerable morbidity and mortality, remain the standard. Biliary scintigraphy, secretin-stimulated MRCP, and secretin-stimulated endoscopic ultrasound have not proven to be sufficient to replace these techniques as they lack diagnostic accuracy and correlate poorly with manometry results. Contrast-enhanced magnetic resonance cholangiography (CE-MRC) uses hepatocyte-selective contrast agents that are eliminated by the biliary system. Therefore, these substances can serve as biliary contrast agents in T1-weighted MR imaging. This method makes a noninvasive functional evaluation of the hepatobiliary system possible. In the present article, our preliminary experience with Gd-EOB-DTPA-enhanced MRC is summarized and potential clinical applications of this method are discussed. Additionally, the article reviews publications evaluating a possible benefit of CE-MRC with other hepatobiliary contrast agents such as mangafodipir trisodium.

The Abernethy malformation is a rare anomaly with partial or complete congenital absence of the portal vein and subsequent development of extrahepatic portocaval shunts. Diagnosis is usually made in childhood following the finding of liver neoplasms combined with slightly increased liver enzymes. There is a female predominance. Further findings are malformations of the heart, skeletal system and kidneys. Short-term follow-up of the liver lesions is recommended. Progressive disease can be treated by partial liver resection or transplantation. Diagnosis of the Abernethy malformation is based on various imaging modalities. We report the MRI and MRA findings of an Abernethy malformation in a 35-year-old woman with multiple liver cell adenomas and review the 32 previously published cases.