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Radiology

Diagnostic Radiology

Radiology deals with diagnostics of different diseases using ionised radiancy (x-Ray), magnet fields (Nuclear Spin Tomography), Supersonic examinations and contrast medium illustrations of inner organs (Ill. 1) as well as vessels (Ill. 2).

Methods:

  • Conventional Radiology (e.g. Stomach illustrations (Ill. 1), skeletal x-ray radiography, lung x-ray radiograph, mammography), nowadays mostly digital
  • Computer Tomography (CT)
  • Magnetic Resonance Tomography (MRT)
  • Sonography (Supersonic examination)

 

Computertomographie – CT

The CT is a special x-ray procedure which has been introduced into diagnostics in the late 70ties. This CT-machine consists of a circular x-ray detector that catches the x-rays produced by a circular x-ray tube turning around the patient. Supported by a computer, image elements that have been created through the absorption of different x-rays in the body are then converted into tomograms. Thus slice-like, anatomically correct tomograms through the body areas examined can be obtained. This method has a high diagnostic significance considering many diseases, particularly for diagnostics of the abdominal cavity (abdomen) and lung considering pulmonary diseases (Ill. 3).

ill. 3a
ill. 3b
Ill. 3: In the left lung, near the thoracic wall, a lung nodule (Lung metastasis; arrow) with a size of 8 mm has been detected (Ill. 3a). It cannot be seen in a conventional radiograph (Ill. 3b)

In addition to this, computer tomography is the method to choose considering the clarification of diseases or injuries of bones and the remaining skeletal system. We work e.g. with a modern Spiral-CT that also allows a volume determination of the organs examined. Through this technique organs, such as the liver can be examined in different blood circulation phases (Arterial phase, portal-venous phase). Thus a higher diagnostic safety is achieved (Ill. 4).

 

Ill. 4a
Ill. 4b
Ill. 4: CT-examinations of the liver in the early phase (Arterial phase; ill. 4a) and in the phase (Portal-venous phase; ill. 4b) after an intravenous contrast medium application. In the right liver lobe there are two “dark”-appearing (Hypodense) metastases (Arrows) across from the healthy liver tissue.

Furthermore, three-dimensional reconstructions (3D-Illustrations) of bony structures and – after intravenous injections of contrast mediums – also of arteries can be created that have a great significance for the planning of surgical interventions (Ill. 5b).

Ill. 5a
Ill. 5b
3D-reconstruction of the pelvis during an intravenous CM-injection to illustrate the pelvis arteries (so-called Angio-CT). The left pelvis artery is closed below the abdominal aorta partition point (arrow head). The right pelvis path line is illustrated inconspicuously (arrow).

Under CT-sight control, also analgesic therapeutic treatments considering dorsal diseases, tissue collection for pathologic examinations, Abscess drainages and other interventions can be performed. These are further described in the chapter “Interventional Radiology”.

Coronary-CT

With a special technique (WCG-Triggering) coronary blood vessels are examined to clarify coronary heart diseases (Ill. 6); by doing this, an early diagnosis of a coronary heart disease without straining (e.g. cardiac catheter examination).

Ill. 6: CT of the coronary blood vessels (Coro-CT): Distinct wall calcification of the left coronary vessels (arrow), which can be detected up to the vessel origin of the aorta.

Nuclear Spin Resonance Tomography

The Nuclear Spin Resonance Tomography (MRT) that manages without ionising radiancy plays an increasing role in general radiology. In this procedure protons are used for imaging, although images generated in this way are not produced through x-rays but through irradiation of radio frequency waves that interplay with protons bonded to water (So-called “Nuclear Magnetic Resonance”).

As MRT is carried out without x-rays, it can be repeated discretionary often and used on, for instance, small children without any risk. In general radiology the imaging diagnostic of joints, the spinal column and soft tissues made great progress through MRT; thus ruptures of the meniscus that previously could only be diagnosed operatively (through arthroscopy) can be illustrated fast and without any straining of the patient, nowadays (Ill. 7).

Ill. 7a
Ill. 7b
Ill. 7a,b: Horizontal rupture in the medial meniscus posterior horn (Arrows). In contrast to this, notice the physiologic signal-free illustration of the medial meniscus posterior horn.

EA further important application area of the MRT in orthopaedic diagnostics is spinal cord examinations; through the possibility of multi-planar illustration this method succeeds more in illustrating herniated vertebral discs than with computer tomography (Ill. 8)

Ill. 8a
Ill. 8b
Ill. 8c
Ill. 8: A big, down turning herniated vertebral disc between the fourth and fifth lumbar vertebra body. Through the illustration of the spinal column in two spatial directions (sagittal, Ill. 8a; axial, Ill. 8b) it is possible to determine the exact dimension and direction of the herniated vertebral disc tissue (Arrows). Through a special technique spinal cord fluid (liquor) in the spinal canal can be illustrated. Thus narrowing through a herniated disc can be detected (MR-Myelography; Ill. 8c; Arrow head)

Also for the remaining clinical subjects, such as internal medicine or cardiology (cardiac diagnostics) the nuclear spin resonance tomography becomes increasingly important; thus this method has gained more significance for the detection of tumours set in the cardiac chamber (Ill. 9), valvular defects and cardiac muscle function disorders.

Ill. 9: Atrium myxoma (Histologically saved; arrow) in the left atrium

Also vessel diagnostics was revolutionised by the nuclear spin angiography (MR-Angiography; without the use of invasive and thus patient straining angiography, it is possible, nowadays, to concisely illustrate pelvis arteries, renal arteries (Ill. 10) or other vessel territories, in a short examination time.

Ill. 10: Contrast agent – supported MR-angiography of the celiac aorta and renal arteries: The celiac aorta shows significant wall anomalies as result of an arteriosclerosis; beneath the renal arteries’ outlet (Arrows) the celiac aorta is widened (infrarenal aorta aneurysm; arrow head). The renal arteries are inconsoicious, renal artery stenosis does not occur not occur on both sides.

While the MRT is used in the abdomen and in the pelvis more frequently for urologic and gynaecologic problems, it plays no significant role in the routine diagnostic of lung diseases, as the aeriferous lung only has only a few protons bonded to water that can contribute to imaging.

Angiography

The intra-arterial angiography has been a very important procedure for decades up to now. Nowadays, it is proceeded through DSA-technique (Digital subtraction angiography). Angiography still is the most important diagnostic method for a direct illustration of vessels in most different body regions. This method has great diagnostic importance, considering in the diagnostic (and therapy, see below) of arterial peripheral occlusion disease (“Intermittent claudication”) or renal artery diseases, if it is about an exact illustration of vessels narrowing and closure in the Beckenbeinstrombahn (Ill. 2) or renal arteries (Ill. 11). Diagnostic angiographies are performed ambulant. As the vessel region examined is checked through an angiography catheter, mostly passed through a leg artery (so-called “trans-femoral approach”), the patient must rest three to four hours after the examination to avoid a hematoma in the ridge; after this, he is allowed to go home. Only in the last year, about 400 arterial angiographies were performed in our institute, thereof about 150 micro-therapeutic interventions (so-called “vascular interventions”).

Ill. 11: Vessel illustration through a catheter brought into the ventral aorta: High-grade renal artery stenosis on the right hand (arrow), moderate-graded renal artery stenosis on the left hand (arrow head).

 

Therapeutic (interventional) Radiology

Besides mere diagnostic measures, in computer tomography (CT) and angiography we mainly perform micro-therapeutic interventions and tissue collections.

Interventional computer tomography:

  • CT-controlled biopsy (Tissue sampling)
  • CT-controlled pain treatment
    • Facette blockades with backache (so-called lumbalgy) as result of degenerative changes of the small vertebral joints
    • CT-controlled PERIRADIKULÄRE WURZELINFILTRATION coming up with backache that moves down to the legs (so-called Lumboischialgie) as result of herniated vertebral discs

In the last 12 months, in our institute there have been more than 70 CT-controlled samples intakes, 90 PERIRADIKULÄRE WURZELINFILTRATIONEN and about 230 CT-controlled facette blockades without complications, but with very good results.

CT-controlled biopsy

In case of certain illnesses, it is necessary to take tissue samples that can be used to specifically plan and perform treatments. Such tissue samples can be taken CT-controlled from lymphatic knobs, lung processes, liver focuses and from bony structures, e.g. the spinal column (Ill. 12a-c).

Ill. 12a
Ill. 12b
Ill. 12c
Ill. 12: CT-controlled sample collections from a osteoclerotic focus in the 2nd LWK (Ill. 12a, thin long arrow). Under CT-control a biopsy needle is brought next to a bone (Ill. 12a), through the cortical bone substance in a suspicious bone focus (Ill. 12b, arrow head) so that a biopsy can be taken. Ill. 12c shows a bone defect (short arrow) after the withdrawal of a press cast.

As these punctures are performed very preserved with thin puncture needles, an intervention can be accomplished ambulant.

CT-controlled pain treatment

A further important therapy modality is the CT-controlled pain treatment of backaches, which (with herniated vertebral discs) are performed as so-called “periradikuläre Nervenwurzelinfiltration” (Ill. 13) and with degenerative changes of the small vertebral joint – spondylarthrosis – as “CT-controlled facette blockade” (Ill. 14); the principle of treatment is the local application of long effecting pain killers (Local anesthetic) and cortisone preparation that have a inflammation-inhibiting effect. In case of a herniated vertebral disc, a resorption of the prolapsed intervertebral disc tissue through an induction of body-own granulation tissue. In the area of small vertebral joints often pure alcohol is injected to denervieren joints analocially to facette coagulations and to guarantee long-time analgesia. These pain-therapeutic interventionsare not only performed at the lumbar spine, but also at the breast and neck spinal column.

Ill. 13: CT-controlled periradikuläre Nervenwurzelinfiltration on the left side in neuroforamen LWK 4/5. Control of the needle position before medicament injection (arrow).
Ill. 14:CT-controlled ambilateral facette joint blockade with bilateral spondylarthrosis, with dumcumentations of needle position in joint cavum of the small vertebral joints (arrows).

Vascular interventions in angiography – balloon dilatation and lysis therapy

In the last years the minimal invasive therapy of vessel stenoses and vessel closures in most different body areas have spread very much. The principle of vessel narrowing treatment on a radiologic way is the PTA (Percutanic Transluminal Angioplasty) using a balloon catheter. Using this method, balloons installed on vessel catheters are brought into the area of the narrowed artery sector and stretched, afterwards; the atherothrombotic wall deposits, leading to vessel narrowing, are therby pushed into the vessel wall. The vessel narrowing is removed on this way (Ill. 15a-c).

Ill. 15a
Ill. 15b
Ill. 15c
Ill. 15:High grade narrowing of a leg artery (A. femoralis superficialis) above the knee joint (Ill. 15a, arrow). After balloon dilatations (Ill. 15b, arrow head) this vessel gets a normal width again, a significant stenosis (vessel narrowing) cannot be detected anymore (Ill. 15c).

In the areas of the leg arteries (femoropopliteales Stromgebiet Ill. 15a-c) the success rate in angioplasty is at about 75%, in the pelvis etage (Ill. 16a-d) it is even higher with 90%. Also the long-time results (Offenheitsrate after 5 years) in the Beckenstromgebiet are 84% higher than in the area of leg and lower leg arteries, where a long time success rate can be calculated at around 65-70%. If there is a rupture of the vessel wall during treatment (so-called dissection),the damaged vessel can be repaired through an implantation of a vessel orpthesis (stent) in the same session. IN the pelvis etage the better long time results result in a tendence to treat diseased vessel sections with stents directly (Ill 16a-d).

Ill. 16a
Ill. 16b
Ill. 16c
Ill. 16d
Ill. 16: High grade stensis in the right pelvis aretery (A. iliaca communis; 16a, arrow). After a balloon dilatation (16b, arrow head) and implantation of a vessel prothesis (stent; 16c, small arrow heads) a complete removal of the vessel narrowing is achieved (16d).

Furthermore, there is a possibility to reopen closed leg arteries through locally in the vein applicated medicaments dissolving clots in a biochemical reaction (Ill. 17); in our institute we practise a so-called “short time lysis” at which the medicament rtPA /synthetic created tissue-plasminogen-activator) is infused locally into the throbus over a time span of 1-5 hours with adose of 10 mg/h. Through this therapy it often succeeds to avoid an otherwise impending loss of an extremity (amputation).

Ill. 17: Fresh embolic closing of the left shank artery (A. poplitea; Ill. 17a, arrow) and the downstram shank arteries (Comp. with the healthy opposite site). After a breakup of the closure with overall 50 mg rtPA over a tome period of 5 hours a complete reopening of the shank arteries (lll. 17 b).

If the lysis therapy of a vessel closure in the Beckenbeinstrombahn is planned, it must be known that it is definitely worthwhile – in dependence on the cross section of the lysed vessek – to open also older closures. As rule of thumb it generally counts that

  • In the Beckenstrombahn (A. iliaca) a lysis therapy up to one year
  • In the Beckenstrombahn (A. femoralis) a lysis therapy up to six months
  • And in the shank vessels (Aa. Poplitea, tibialis and fibularis) up to 3 months

The vessel closure can successfully be treated, afterwards.

The balloon dilatation treatment of Beckenbeinarterien (Ill. 15; Ill. 16), but also of renal artery stenosis (Ill 18a-c) is performed in our institute; thus the patient does not need to stay in hospital after complex vascular interventions.

 

Ill. 18a
Ill. 18b
Ill. 18c
Ill.18:.High grade renal outlet stenosis on the right side (Ill. 18a, arrow). After a balloon dilatation of the stenosis (Ill. 18b, arrow head)the renal artery appears unconsciously again.