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S O M ATO M
S E S S I O N S

Case Reports
from
multislice CT
SOMATOM Plus 4
Volume Zoom

S P E C I A L

I S S U E

From the editor


This is the first special issue of Siemens SOMATOM
Sessions with case reports from the early users of our new
multislice CT: SOMATOM Plus 4 Volume Zoom. These
special issues will focus on presenting the clinical results
of both routine and advanced applications. This special
issue provides you with the excitement of multislice CT
We are now seeing things which have never been seen
before e. g. CT imaging of the coronary arteries with
Quarter Second CT, the CT Angio run-offs of the extremities
and the functional imaging of the larynx, etc. On the other
hand, the improvement of the routine applications is
also dramatic, e. g. the diagnostic imaging of oncology and
acute pulmonary embolisms, etc.
As always we would appreciate your suggestions and
comments.
Special thanks to Dr. Roman Fishbach for his valuable
assistance.

Xiaoyan Chen, M.D.


Editor of SOMATOM Sessions

The drugs and doses mentioned herein are consistent with the approval
labeling for uses and/or indications of the drug. The treating physician bears
the sole responsibility for the diagnosis and treatment of patients, including
but not limited to the parameters selected during image acquisition and
postprocessing and any drugs and doses prescribed in connection with such
use.

Contents
Letter from the Editor

Page 2

High Grade Post Stent Stenosis Detected by Retrospectively


ECG gated Multislice CT
Christoph Becker, MD, Andreas Knez, MD, Bernd Ohnesorge, PhD
Klinikum Grosshadern, University of Munich

Page 4

Lower Extremity Run-off with Multislice CT


U. Joseph Schoepf, MD
Klinikum Grosshadern, University of Munich

Page 6

An Anomalous Right Subclavian Artery


U. Joseph Schoepf, MD
Klinikum Grosshadern, University of Munich

Page 8

Right Renal Artery Aneurysm with Bilateral Renal Infarctions


Mark E. Baker, MD
The Cleveland Clinic Foundation

Page 10

Acute Central Pulmonary Embolism


U. Joseph Schoepf, MD
Klinikum Grosshadern, University of Munich

Page 12

Pancreatic Carcinoma
Ulrich Baum, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg

Page 14

Liver Metastases with Vena Cava Thrombus


Cheng Hong, MD, Roland Bruening, MD
Klinikum Grosshadern, University of Munich

Page 16

Rectal Carcinoma
Anton Nmayr, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg

Page 18

Rectourethral Fistula
Ulrich Baum, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg

Page 20

Functional Imaging of the Larynx and Hypopharynx


Micheal Lell, MD
Institute of Diagnostic Radiology, University of Erlangen-Nuremberg

Page 22
3

High Grade Post Stent Stenosis Detected by


Retrospectively ECG gated Multislice CT
History:
A 54-year-old man with coronary artery disease had
received four stents in all major coronary vessels. After
intervention, he still complained about chest pain under
exercise and underwent ECG stress testing with patho-

Conventional angiography, performed the next day,


confirmed the situation of 80 % left anterior descending
coronary artery reduction behind the stent (Fig. 2). The
patient was then successfully treated with balloon angioplasty of the stenotic segment.

logic results. CT angiography of the coronary arteries


was planned to control the patency of the coronary stents.
To follow the course of the coronary vessels through the
axial images, Volume Rendering Technique (3DVirtuoso,
Siemens Medical Engineering, Forchheim, Germany) was
performed. The 3D model clearly demonstrates the location
of the coronary stents (Fig. 1). The lumen of the left anterior
descending coronary artery behind the stent is significantly
reduced. All other coronary arteries show regular vessel
lumen and contrast enhancement.

Fig. 2: Conventional angiography, performed the


next day, confirmed the high grade stenosis of the left
anterior descending coronary artery. The patients
underwent successful treatment by balloon angioplasty.

Fig. 1: Volume rendering technique visualizes the


course of the coronary vessels and the location of the
stent (white). Note that the curved left anterior
descending artery shows significant lumen reduction
compared to the right coronary artery.

Technical data:

Clinical comments and summary:

Spiral CT acquisition was performed with a multislice

Conventional coronary angiography would be the method

spiral CT scanner (SOMATOM Plus 4 Volume Zoom,

of choice to demonstrate the patency of coronary stents.

Siemens Medical Engineering, Forchheim, Germany).The

For the first time, however, virtually motion-free visualization

digital ECG signal was simultaneously recorded during

of the coronary arteries is feasible with a conventional

the spiral scan.

rotation CT scanner. The spatial resolution, the low image


noise and the high contrast in the images can be superior

For contrast enhancement 140 ml non-ionic contrast media

to any other modality currently used for non-invasive

(Ultravist 300, Schering, Berlin, Germany) was administered

coronary angiography. Therefore, prospective ECG gated

with a flow rate of 3 ml/s through a peripheral vein.

multislice CT is a new non-invasive modality, which

The spiral scan delay was 25 s after the start of contrast

provides diagnostic information for follow-up of patients

injection.

after coronary intervention either balloon angioplasty


or coronary stenting.

Slice Collimation

4 x 1 mm

Slice Width

1.25 mm

Recon Increment

0.5 mm

KV

140

mA (mAs/slice)

300 (75)

Pitch

1.5

Kernel

B30

Scan Range

10.5 cm

Scan Time

35 s

Rotation Time

0.5 s

Temporal Resolution

0.25 s

FOV

200 mm

CT angiography of the coronary arteries, combined with


unenhanced imaging/scanning of the coronary arteries
for calcifications will also help the physician to rule out
coronary artery disease and to detect high grade stenosis
in the proximal part of the coronary tree in asymptomatic
patients (with coronary risk factors) or patients with unatypical chest pain.

Image reconstruction was performed with retrospective


ECG gating at 450 ms before the next R wave.

Lower Extremity Run-off with Multislice CT


History:

Clinical comments and summary:

A 67-year-old male patient presented with lower extremity

The unparalleled speed of multislice CT allows the poten-

pain and numbness, which required frequent stops when

tial for expanded applications of CT imaging. The ability to

walking more than 600 feet. Peripheral vascular disease was

cover the entire lower extremity with high spatial resolution

suspected and lower extremity angiography was scheduled.

is certainly an outstanding example of the increased capa-

However, the patient, who had already undergone multiple

bilities offered by multislice technology. In this case, despite

cardiac catheterizations for coronary disease, declined

of the patient declining invasive angiography, an evaluation

this invasive procedure. Multislice CT was suggested as an

of the lower extremity vessels was feasible by performing a

alternative modality, to non-invasively evaluate the lower

40 s scan with a mere 150 cc of contrast material.

extremity vessels, which the patient agreed to.


The MIP reconstruction reveals severe calcifications in the

Technical data:

distal aorta and common iliac arteries. The heavily calcified


superficial femoral artery is bilaterally occluded over the

CT angiographhy of the lower extremity arteries was

entire range of the vessel. Blood flow to the lower extremity

performed using a multislice spiral CT scanner (SOMATOM

is maintained by bilateral collateralization to the popliteal

Plus 4 Volume Zoom, Siemens Medical Engineering,

artery. In the calves, the anterior tibial arteries are occluded

Forchheim, Germany). The patient was scanned crano-

in both legs. The posterior tibial artery on the left shows

caudally with breath-holding during the first 10 seconds of

multiple, severe stenoses. Surgical clips are seen in both

the scan. A range from the aortic bifurcation to the ankles

calves after harvesting of veins for CABG surgery.

was included in the scan range. 2.5 mm collimation was


used at a table feed of 15 mm per 0.5 s scanner rotation

Thus, multislice CT can be considered as a non-invasive

(30 mm/s). These parameters result in a pitch (table feed

and cost-effective diagnostic imaging modality for lower

per scanner rotation/collimation) of 6, equivalent to a pitch

extremity vascular disease.

of 1.5 in conventional single slice spiral CT. Scanning was


performed at 120 kV and 150 mAs. The scan was contrast
enhanced with 150 cc of a non-ionic contrast agent
(Imagopaque 300, Nycomed, Oslo, Norway), injected at
3.5 cc/s with a scan delay of 30 seconds using an automated injector (Liebel-Flarsheim, Cincinnati, OH). From the
raw data, 3 mm sections were reconstructed with 2 mm
increment using a soft body kernel. MIP reconstruction
was performed on the Volume Wizard (the second console
of SOMATOM Plus 4 Volume Zoom).

The MIP reconstruction reveals severe calcifications in the


aortic bifurcation and common iliac arteries. The heavily
calcified superficial femoral artery is bilaterally occluded over
the entire range of the vessel. Blood flow to the lower extremity
is maintained by bilateral collateralization to the popliteal
artery. In the calves, the anterior tibial arteries are occluded
in both legs.The posterior tibial artery on the left shows multiple,
severe stenoses. Surgical clips are seen in both calves after
harvesting of veins for CABG surgery.

An Anomalous Right Subclavian Artery


History:

Technical data:

A 42-year-old female patient presented to the gastro-

CT angiography of the thoracic aorta was performed using

intestinal service of our institution with a long-standing

a multislice spiral CT scanner (SOMATOM Plus 4 Volume

history of dysphagia. An esophageal study was ordered,

Zoom, Siemens Medical Engineering, Forchheim, Germany).

which revealed scalloping of the esophageal wall (Fig. 1)

The patient was scanned cranio-caudally within one breath-

suggestive of an anomalous right subclavian artery.

hold. The entire thoracic aorta and supra-aortic branches

Subsequently, CT angiography of the thoracic aorta was

were included in the scan range. 2.5 mm collimation was

ordered.

used at a table feed of 15 mm per 0.5 s scanner rotation


(30 mm/s).These parameters result in a pitch (table feed
per scanner rotation/collimation) of 6, equivalent to a
pitch of 1.5 in conventional single slice spiral CT. Scanning
was performed at 120 kV and 120 mAs. The scan was
contrast enhanced with 70 cc of a non-ionic contrast agent
(Imagopaque 300, Nycomed, Oslo, Norway), injected at
4 cc/s with a scan delay of 25 seconds using an automated
injector (Liebel-Flarsheim, Cincinnati, OH).

Results and comments:


Any kind of vascular imaging greatly benefits from the
unparalleled speed of multislice CT. In the case presented
here, excellent contrast enhancement of the full length
of the thoracic aorta could be achieved with only 70 cc of
contrast material (Fig. 2 a-d). This is made possible by the
500 msec gantry-rotation, which allows covering the
entire chest (e. g. 30 cm) in 10 sec. In this case, which was
subsequently confirmed by digital subtraction angiography
(Fig. 3), multislice scanning enables a comprehensive,
Fig. 1: Esophageal study demonstrating scalloping
next to the thoracic aorta typical for an anomalous
right subclavian artery.

non-invasive diagnosis of the vascular anomaly and the


surrounding thoracic anatomy, thus facilitating surgical
planning (Fig. 4). The high spatial resolution, which can be
achieved by using thin collimation also, allowed performing
lumenal views of the vessel prior to surgery (Fig. 5).
After successful surgical reinsertion of the right subclavian
artery, the symptoms in this patient completely resolved.

Fig. 2a-d: Axial sections of a multislice CTA show


excellent contrast enhancement with as little as 70 cc
of a non-ionic contrast medium.

Fig. 3: Digital subtraction angiography confirms the


anomalous origin of the right subclavian artery.

Fig. 4: Volume rendering of the CTA data set facilitates


anatomic visualization and helps in surgical planning.

Fig. 5: Lumenal views enable identification of


the orifices of the supra-aortic branches and of the
anomalous right subclavian artery.

Right Renal Artery Aneurysm with


Bilateral Renal Infarctions
History:
The patient is a 29-year-old woman transferred from another
hospital for management of a perinephric hematoma
and renal infarcts. Three weeks prior to transfer, the patient
developed right flank pain, and an outside CT scan showed
a right renal artery aneurysm associated with a large perinephric hematoma. The patient remained stable and it was
determined that the large hematoma should be allowed to
resolve prior to the repair of the aneurysm. On the evening
prior to transfer, the patient developed left flank pain and
gross hematuria. An outside CT scan demonstrated new
left renal infarcts. The right renal artery aneurysm and large
perinephric hematoma remained.
At transfer, the patient underwent emergent renal arteriography (Fig. 1) showing right renal artery dissection, an
aneurysm as well as multiple infarcts involving both kidneys.
A transesophageal echocardiogram was performed and
no atrial thrombus was present. There was however severe

Fig. 1: Digital arteriogram shows a right renal artery


aneurysm (arrow) and a beaded appearing main renal
artery. Note the hypoperfused upper pole.

tricuspid regurgitation, mild to moderate aortic regurgitation,


and moderate mitral regurgitation. There is a significant
family history. Both grandfathers as well as a granduncle
died of ruptured abdominal aortic aneurysms. A provisional
diagnosis of type IV Ehlers-Danlos disease was entertained.

Technical data:
The CT examination was performed on SOMATOM Plus 4
Volume Zoom as a follow-up approximately two months
after the initial episode.The arterial phase of the examination
was performed using 1 mm collimation, 500 ms gantry
rotation, pitch 4.5 with slice reconstruction at 1.5 mm thickness every 1.5 mm along the Z-axis.

Results:
The scan shows a right renal artery aneurysm, bilateral
renal infarcts which decreased in size when compared to
the outside examination as well as resolution of the right
perinephric hematoma.

10

Fig. 2: Axial image (arterial phase, 1.5 mm) shows a


right renal artery aneurysm as well as a hypoperfused
portion of the right kidney.

Fig. 3: Curved MPR image shows the right renal artery


aneurysm as well as bilateral renal infarcts.

Fig. 4: MIP image shows the right renal artery


aneurysm as well as bilateral renal infarcts.

Fig. 5: Front view of a Volume Rendering image shows


the aneurysm and the relationship of the aneurysm to
the kidney in 3-dimension.

Fig. 6: Top view of a Volume Rendering image shows


the aneurysm and the relationship of the aneurysm to
the kidney in 3-dimension.

11

Acute Central Pulmonary Embolism


History:

Results and comments:

After traveling in a car for several hours, a 54-year-old

When acute pulmonary embolism is suspected, scanner

male patient collapsed in the parking lot. He arrived in the

speed is of paramount importance for a quick and compre-

emergency department in a cardiorespiratorily unstable

hensive diagnosis in dyspnoeic, critically ill patients. The

state. His ECG showed a typical SI.-QIII configuration.

scan protocol, which was used in this case, allowed cover-

Acute pulmonary embolism was suspected and the patient

ing the entire chest of a patient with very thin collimation

was referred to the CT department for an emergency scan.

within an 8 s breath-hold. Despite this unparalleled speed,


the image quality that obtained in this case was extra-

Technical data:

ordinary and allowed us to clearly delineate the embolus,


which extends across the pulmonary bifurcation (Fig. 1, 2).

CT angiographhy of the pulmonary arteries was performed

The acquisition of very thin slices facilitates the detection

using a multislice spiral CT scanner (SOMATOM Plus 4

of small peripheral emboli and improves the image quality

Volume Zoom, Siemens Medical Systems, Forchheim,

of any kind of three-dimensional post-processing (Fig. 3).

Germany). The patient was scanned caudo-cranially within

Judging from the shape of the embolus, the likeliest source

one breath-hold. The entire lung parenchyma was included

is the deep veins of the lower extremities. In this case,

in the scan range. 2.5 mm collimation was used at a table

the high speed of multislice scanning allowed including the

feed of 15 mm per 0.5 s scanner rotation (30 mm/s). These

entire venous system of the abdomen and legs in the

parameters result in a pitch (table feed per scanner rotation/

examination (Fig. 4), without administering any additional

collimation) of 6, equivalent to a pitch of 1.5 in conventional

contrast material. Owing to the speed of our multislice

single slice spiral CT. Scanning was performed at 120 kV

CT system, this second scan took a mere 16 s. This way,

and an effective tube current of 120 mAs. The scan was

extensive residual thrombosis in pelvic veins could be

contrast enhanced with 120 cc of a non-ionic contrast agent

diagnosed in the same session (Fig. 5), thus sparing this

(Imagopaque 300, Nycomed, Oslo, Norway), injected at

critically ill, ICU bound patient any further investigations.

4 cc/s with an empiric scan delay of 16 seconds using an


automated injector (Liebel-Flarsheim, Cincinnati, OH).
Judging from the history of the patient, the likeliest source
of emboli in this case was deep venous thrombosis of the
leg veins. Therefore, the contrast bolus, which had been
injected to examine the pulmonary arteries, was used for
detection of residual thrombi in the lower extremity. With a
total delay of 150 s after the start of contrast administration,
the entire abdomen and lower extremity were covered
with 4 x 5 mm collimation at a table feed of 30 mm per 0.5 s
scanner rotation (60 mm/s, pitch 6). Scanning was also
performed at 120 kV and 120 mAs in order to reduce radiation dose to the patient.

12

Fig. 1, 2: Acute central pulmonary embolism with


embolic material extending across the pulmonary
bifurcation.

Fig. 3: Volume rendering of the same data set


demonstrates the anatomic distribution and the extent
of the embolus within the pulmonary vessels.

Fig. 5: Axial section through the pelvis of the patient


demonstrates significant residual thrombus in the iliac
veins.

Fig. 4: Volume rendering of the lower extremity scan


of the same patient. This scan is not diagnostic for
detecting deep venous thrombosis, but serves the
purpose to illustrate the impressive range which can be
covered within few seconds using multislice technology.

13

Pancreatic Carcinoma
History:

Patient preparation:

60-year-old male patient with painless jaundice and back

Oral contrast medium: 1600 ml water over 30 minutes.

pain since eight days. Ultrasound revealed an extra- and

Right side position for 5 minutes before scanning;

beginning intrahepatic cholestasis and an enlarged head of

Spasmolysant immediately before scanning;

the pancreas with suspected cyst formation in the uncinate

Supine position during scanning.

process. Lab works: normal levels of amylase and lipase,


elevated phosphatase and bilirubin and CA 19-9.
ERCP: Filiform stenosis of the common bile duct in the

Results:

head of the pancreas indicates carcinoma of pancreatic head.

Enlargement of the pancreatic head. Hypodense lesions


consisting of solid and cystic parts are depicted in the
pancreatic head. Dilated common bile duct, normal calibre

Technical data:

of the pancreatic duct. The mass in the pancreatic head


lies in close vicinity of the superior mesenteric vein and the

Scan

confluens of the portal vein. The multiplanar reformations

Region

upper abdomen

Scan length

156 mm

Slice collimation

4 x 1 mm

Table feed/rotation

3.5 mm

Pitch

3.5

Scan direction

caudocranial

Rotation time

0.5 s

kV

120

mAs

165

Kernel

B30

Scan time

23 s

delineate a thin layer of fatty tissue between the mass and


the SMV. Infiltration of the portal vein can be excluded.

Comments:
One of the major advantages of multislice Spiral CT is
that you can acquire an anatomical range with thin slice
(4 x 1 mm) in a reasonable scan time. This provides you
with the possibility of excellent multiplanar reformations
that demonstrate the exact delineation of the tumor
extension in all directions. I. e. the exact determination of
the tumor extension, the differentiation from neighbouring

Contrast Injection

vessels (celiac trunk, hepatic artery, splenic artery, left

Volume

150 ml (non-ionic
contrast medium)

Concentration

300 mg iodine/ml

Flow rate

3 ml/s

Start delay

40 s

Image reconstruction
Reconstructed slice width

1.25 mm/4 mm

Reconstruction increment

1 mm/3 mm

Postprocessing
Multiplanar reformations

14

gastric artery, portal vein, superior mesenteric vein, splenic


vein) and organs (duodenum, stomach, liver, spleen) can
be shown clearly.

Fig. 1: Axial image


This image shows a slightly dilated bile duct and the
normal calibre of the pancreatic duct.

Fig. 2: Axial image


Enlargement of the pancreatic head with a hypodense
lesion consisting of a solid part and a small cyst with
a diameter of 10 mm. The tumor is adjacent to superior
mesenteric vein.

Fig. 3: MPR
Vascular infiltration is excluded by curved coronal
MPRs. This images shows normal calibre of the great
peripancreatic veins (portal vein, superior mesenteric
vein, splenic vein). Pay attention to the small line of
fatty tissue between the superior mesenteric vein and
the carcinoma.

Fig. 4: MPR
The MPR allows the exact assessment of anatomic
details of the upper abdomen. Please note the excellent
visualization of the vessels and the gastrointestinal
wall.

15

Liver Metastases with Vena Cava Thrombus


History:

Image reconstruction

A 73-year-old women presented with a 4-week history

Reconstructed slice width

1.25 mm

3 mm

of nausea, vomiting, and generalized abdominal pain, which

Reconstruction increment

0.8 mm

3 mm

had worsened over the preceding 3 days. She had undergone chemotherapy for Sigmoid carcinoma 3 years previously.
An ultrasound scan examination 4 days prior to presentation

Postprocessing
Multiplanar reformations

had shown multiple hepatic lesions. An enhanced CT of


the abdomen was subsequently performed.

Technical data:

Results and comments:

Bi-phasic spiral scanning with a multislice spiral CT scanner

The scanning protocol chosen for the arterial phase pos-

(SOMATOM Plus 4 Volume Zoom, Siemens, Forchheim,

sessed elements to ensure that such metastases are clearly

Germany), and multiplanar reformations (MPR).

identified with high reliability using thin slice collimation.


The slice width of 1.25 mm provides high spatial resolution

Scan

and the overlapping image reconstruction helps to increase

Region

upper abdomen
(Arterial phase)

upper abdomen
(Venous phase)

Scan length

200 mm

200 mm

Slice collimation

4 x 1 mm

4 x 2.5 mm

Table feed/rotation 6 mm

15 mm

Pitch

Scan direction

craniocaudal

caudocranial

Rotation time

0.5 s

0.5 s

kV

120

120

mAs

110

110

Kernel

B30

B30

Scan time

17.57 s

7.47 s

the quality of image postprocessing. Obtaining the coverage desired with the technical factors and collimation
necessary to attain excellent image quality that can only be
achieved with the multislice technology.
A helpful follow-up with careful imaging procedures was
used to evaluate the clinical situation and pathologic changes,
which might critically affect management. For this reason
imaging must be performed to determine the number
of metastases present and their segmental location and
extent, and the relationship of the lesions to the major
venous structures (Fig. 1). Compared with the axial image
(Fig. 2), the MPR image was of paramount importance in

Contrast Injection
Volume

the visualization of the thrombus in this case. The throm-

100 ml (non-ionic
contrast medium)

bus was clearly visualized in the coronal reconstruction

Concentration

300 mg iodine/ml

(Fig. 3). By providing imaging along planes that more closely

Flow rate

3 ml/s

demonstrate the segments of the liver, we are able to

Start delay

25 s

50 s

accurately detect and define tumor involvement in this region


accurately.

16

Fig. 1: Coronal MPR shows the possibility to delineate


liver lesions with reconstructed views.

Fig. 2: Axial image during arterial phase shows a


contrast free segment of the inferiour vena cava
however the reason is not obvious. It may be caused
by inflow effects or by a thrombus.

Fig. 3: Coronal reformatted image during venous


phase shows clearly an oval hypodense defect of inferior
vena cava at the hepatic level, which indicates a
thrombus.
17

Rectal Carcinoma
History:

Image reconstruction

This is a 76-year-old male patient presented with rectal

Reconstructed slice width

1.25 mm/3 mm

5 mm

bleeding. The patient reported that 30 minutes after

Reconstruction increment

1 mm/3 mm

2.5 mm

defecation he felt again the need for defecation. He had


produced a significant amount of light red blood. Since
the bleeding did not stop he went to the hospital. In the

Postprocessing
Multiplanar reformations

Department of Surgery digital examination revealed a large


mass in the distal rectum. The endosonographic examination confirmed the suspected rectal carcinoma with
probable infiltration of the left-sided levator ani muscle.
The presacral space could not be assessed. Staging was
completed by CT.

Results:

Technical data:

The examination was biphasic: (1) arterial phase for


Scan

demonstration of the tumor and (2) portal venous phase for

Regions

(1) Pelvis

(2) Abdomen

Scan length

200 mm

450 mm

Slice collimation

4 x 1 mm

4 x 2.5 mm

Table feed/rotation 3.5 mm

10 mm

Pitch

3.5

Scan direction

craniocaudal

craniocaudal

Rotation time

0.5 s

0.5 s

kV

120

120

mAs

150

175

Kernel

B30

B30

Scan time

30 s

23 s

Contrast Injection
Volume

120 ml (non-ionic
contrast medium)

Concentration

300 mg iodine/ml

Flow rate

3 ml/s

Start delay

30 s

18

70 s

further abdominal staging. 800 ml of a diluted water


soluble iodine contrast medium were given p. o. 20 minutes
prior to the examination for demarcation of the small
bowel. The rectum was filled with water (Hydro-CT) to outline the positive tumor enhancement in the arterial phase.
The post processing was made with the images of the
arterial phase. CT morphology supported the diagnosis of a
rectal carcinoma. The tumor invaded the caudal perirectal
fatty tissue and the levator ani muscle on the left side.
Distant metastases were not identified. The CT results
were confirmed by surgery.

Fig. 1: Axial plane


The tumor has a pronounced enhancement in the
arterial phase. Main tumor mass dorsally on the left,
almost circular growth.

Fig. 2: Axial plane


The tumor invades the levator ani muscle.

Fig. 3: Sagital MPR


Good delineation of the tumor, the presacral space
is not invaded.

Fig. 4: Coronal MPR


Enhanced rectal carcinoma. But there is no sign of
a transmural growth in the cranial part. And caudally
the tumor is not well differentiated from the perirectal
fatty tissue (suspected infiltration).

19

Rectourethral Fistula
History:

Image reconstruction

79-year-old male patient complaining of air passing through

Reconstructed slice width

1.25 mm/3 mm

his urethra. The patient had sustained a pelvic gunshot

Reconstruction increment

1 mm/3 mm

wound during the war associated with recurrent abscess


formations. After years without complaints the patient

Postprocessing

noticed air passing through his urethra last year. Endoscopic

Multiplanar reformations

examination resulted in suspicion of a small recto-urethral


fistula. Preoperative demonstration of the exact course
of the fistula was required. Endoscopic filling of the fistula
was not successful, MRI was not performed due to his
pacemaker.

Technical data:

Results:
The examination was performed without oral, rectal or

Scan

intravenous contrast medium first. Several metallic foreign

Region

Pelvis

Scan length

200 mm

Slice collimation

4 x 1 mm

Table feed/rotation

3.5 mm

Pitch

3.5

Scan direction

craniocaudal

Rotation time

0.5 s

kV

120

mAs

150

Kernel

B30

Scan time

30 s

bodies up to 5 mm in diameter and scar tissue in the area


of the former gunshot canal were seen. The former canal
runs from the right ventro-laterally to the left dorso-laterally
and has a close association with the urethra and rectum.
Air within the scar tissue or a fluid accumulation in the small
pelvis was not found.
After rectal and intravenous contrast medium administration
a tiny fistula between rectum and urethra is identified. The
orientation of the fistula is well depicted in the parasagittal
reformations and during interactive cine-mode.

Contrast Injection
Volume

120 ml (non-ionic contrast medium)

Concentration

300 mg iodine/ml

Flow rate

3 ml/s

Start delay

30 s

Comments:
If MRI is contra-indicated, multislice Spiral CT can be used
for diagnosis of small pelvic fistulas due to its almost
isotropic resolution. The 500 ms rotation time and 4-slice
acquisition per rotation allow thin slice scanning within a
reasonable scan time. Therefore a large anatomical section
can be covered within single breath-hold, and even very
small structures can be depicted with excellent image quality in all planes, i. e. axial and multiplanar reformations.

20

Fig. 1: Axial image without rectal contrast medium.


Collapsed rectum. Soft tissue (scar) between the
infundibulum of the bladder and the rectum and
perirectal on the left side.

Fig. 2: Axial image with rectal contrast medium.


After rectal filling a tiny fistula is identified between
rectum und urethra.

Fig. 3: Axial image without rectal contrast medium.


Scar tissue and a metallic foreign body between the
urinary bladder and the rectum.

Fig. 4: Axial image with rectal contrast medium.


Air and contrast medium filled rectum. No contrast
medium is seen inside the bladder.

Fig. 5: Parasagittal MPR, without rectal and i.v. contrast


medium.
Before the rectal filling the rectosigmoideum is
collapsed. A differentation of the anterior and posterior
rectal wall is not possible. No assessment of air or fluid
between rectum, urethra or bladder. Therfore a fistula
between rectum and urethra can not be identified.

Fig. 6: Parasagittal MPR, with rectal and i.v. contrast


medium.
Multiplanar reconstruction show the whole course of
the tiny fistula from the rectum to the urethra.

21

Functional Imaging of the Larynx and Hypopharynx


History:

Image reconstruction

Healthy volunteer, examination was performed to

Reconstructed slice width

4 mm/1.25 mm

demonstrate improved possibilities for diagnosis of laryngeal

Reconstruction increment

2 mm/1.2 mm

pathology.
Postprocessing
Multiplanar reformations

Technical data:
Results:

Scan
Region

quiet breathing: base of skull to


aortic arch
Valsalvas manoeuvre: epiglottis to
cricoid cartilage
e-phonation: epiglottis to cricoid
cartilage

Examination during quiet breathing is the routine technique.

Scan length

quiet breathing: 200 mm


Valsalvas manoeuvre: 100 mm
e-phonation: 100 mm

the piriform sinus.

Slice collimation

4 x 1 mm

Table feed/rotation

6 mm

Pitch

Scan direction

craniocaudal

Rotation time

0.5 s

kV

140

mAs

130

Kernel

B30

Scan time

quiet breathing: 17 s
Valsalvas manoeuvre: 8 s
e-phonation: 8 s

Contrast Injection
Volume

150 ml (non-ionic contrast medium)

Concentration

300 mg iodine/ml

Flow rate

2.5 ml/s

Start delay

80 s

22

The short scan time without apnoea minimizes motion


artifacts. Coronal image reformations improve assessment
of the laryngeal structures like the true and the false cord,
the laryngeal sinus and the paralaryngeal space as well as

Complete distension of the piriform sinuses during


e-phonation allows differentiation between tumor and
mucus retention. The Valsalvas manoeuvre is used for
patients which are not able to phonate long enough, but the
close alignment of true and false vocal cords may obscure
small tumors in this region. Valsalvas manoeuvre can
lead to better expansion of the laryngeal sinus (Morgagni),
improving accuracy in staging laryngeal tumors.

Fig. 1a: Quiet breathing.


Mucus retention in the left piriform recess especially
in combination with the neighboring enlarged lymph
node can lead to misdiagnosis of malignancy.

Fig. 1b: Quiet breathing.


Coronal MPR demonstrating normal piriform sinus
on the right side, obliterated sinus on the left side due
to mucus retention.

Fig. 2a: E-Phonation.


Expansion of both piriform sinuses during e-phonation
excluding hypopharyngeal tumor.

Fig. 2b: E-Phonation.


Clear delineation of laryngeal structures, normal
piriform sinuses.

Fig. 3a: Valsalva-manoeuvre.

Fig. 3b: Valsalva-manoeuvre.

23

This Issues Authors


Christoph R Becker, MD

Cheng Hong, MD, Roland Bruening, MD

Micheal Lell, MD

Department of Diagnostic Radiology


Klinikum of the
Ludwig-Maximilians-University
Marchioninistr. 15, D-81377 Munich
Germany

Department of Diagnostic Radiology


Klinikum of the
Ludwig-Maximilians-University
Marchioninistr. 15, D-81377 Munich
Germany

Institute of Diagnostic Radiology


University of Erlangen-Nuremberg
Maximiliansplatz 1, D-91054 Erlangen
Germany

U. Joseph Schoepf, MD

Mark E. Baker, MD

Department of Diagnostic Radiology


Klinikum of the
Ludwig-Maximilians-University
Marchioninistr. 15, D-81377 Munich
Germany

Division of Radiology/Hb6
9500 Euclid Avenue
Cleveland, Ohio 44195
USA

Anton Nmayr, MD
Institute of Diagnostic Radiology
University of Erlangen-Nuremberg
Maximiliansplatz 1, D-91054 Erlangen
Germany

Ulrich Baum, MD
Institute of Diagnostic Radiology
University of Erlangen-Nuremberg
Maximiliansplatz 1, D-91054 Erlangen
Germany

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