SIEMENS Research Articles

Anaplastic large cell lymphoma of the vertebra masquerading as tuberculous spondylitis: potential pitfalls of conventional imaging

A 26-year-old woman presented with a 6-month history of progressive neck pain associated with a 1-month history of fever, cough, and weight loss. Physical examination revealed a febrile patient with a temperature of 39.1 C. There were localized tenderness and reduced range of motion at the cervicothoracic region of the spine. There was no neurological deficit. Laboratory findings revealed a raised white blood cell count of 21.6 9 10/L. There was elevation of inflammatory markers such as erythrocyte sedimentation rate (79 mm/hr) and C-reactive protein (137 mg/L). Serum lactate dehydrogenase and tumor markers such as alpha-fetoprotein, beta-human chorionic gonadotropin, carcinoembryonic antigen, and CA-125 levels were normal. Radiographs of the cervical spine and chest revealed bony erosions in the C7 and T1 vertebrae (Fig. 1, arrowhead), and right upper lobe consolidation with air bronchograms (Fig. 1, arrow). Contrast-enhanced computed tomography (CT) scan showed bony erosions with pathological fractures involving the C7 to T3 vertebrae (Fig. 2a, b, arrows). An adjacent large paravertebral thick-walled rim-enhancing lesion was seen (Fig. 2c, arrow). There was lung consolidation in the posterior segment of the right upper lobe (Fig. 2d, arrow) as well as prominent mediastinal and retroperitoneal (Fig. 2e, arrow) lymph nodes. Gadolinium-enhanced magnetic resonance imaging (MRI) of the spine was performed to evaluate the soft tissues and spinal cord. MRI revealed altered marrow signal and abnormal enhancement in the C7 to T4 vertebrae with adjacent enhancing subligamentous and epidural masses as well as mild kyphosis (Fig. 3, arrows). There was relative sparing of most of the intervertebral disks. The radiographic, CT, and MRI findings were typical of pulmonary tuberculosis (TB) with tuberculosis spondylitis. The clinical findings further corroborated this presumptive diagnosis. However, multiple induced sputum specimens were negative for acid-fast bacilli smears and molecular TB tests. Moreover, the vertebral destruction seemed more extensive than expected for TB that had been symptomatic for only 6 months. Hence the possibility of an alternative diagnosis was entertained. [F]fluorodeoxyglucose positron emission tomography/ computed tomography (FDG-PET/CT) scan (Biograph mCT 64-slice, Siemens AG, Erlangen, Germany) was subsequently performed to assess the extent and pattern of disease, and to determine the most suitable site for biopsy. The PET/CT scan showed FDG-avid vertebral and paravertebral masses (standardized uptake value, SUVmax 28.3) extending from the C7 to T4 vertebrae (Fig. 4a, arrow), FDG-avid lung consolidation with air bronchograms (SUVmax 7.9) in the right upper lobe (Fig. 4b, arrows), FDG-avid lesions in both kidneys (SUVmax 11.1) (Fig. 4c, arrows), and FDG-avid retroperitoneal (SUVmax 7.6) lymphadenopathy (Fig. 4d, arrows). In addition, the spleen (SUVmax 8.3) and bone marrow (SUVmax 5) showed diffusely increased FDG uptake (Fig. 4a, e, arrowheads). The pattern of disease demonstrated on L. K. Khor (&) S.-J. Lu Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore e-mail: superkhor@hotmail.com

Different changes in slope between the medial and lateral tibial plateau after open-wedge high tibial osteotomy

In contrast to radiographic measurements, MRI provides multiple slices of the knee joint in the sagittal plane, making it possible to assess the medial and lateral tibial slope separately. The purpose of this study is to investigate the effect of medial open-wedge high tibial osteotomy (MOWHTO) on bony and meniscal slope in the medial and lateral tibiofemoral compartments. It was hypothesised that greater changes on the medial tibial plateau would be observed compared with the lateral one. A retrospective analysis of prospectively collected data was performed on pre- and post-operative MRIs from 21 patients (17 men and 4 women; age 52±9years). Inclusion criteria were varus alignment, medial compartment osteoarthritis and election for a primary MOWHTO. Each patient had a preoperative and a post-operative high-resolution MRI (3Tesla, Magnetom Trio, Siemens AG) at an average follow-up of 2.1years. A previously published method was used to measure bony and meniscal slope for each compartment. The difference between pre- and post-operative tibial slope for both compartments was calculated and associated with the amount of frontal correction. There was a significant increase in bony tibial slope in both compartments following MOWHTO. When a change in bony tibial slope was detected in an individual patient, the change was larger in the medial compartment, with the average change also significantly greater (p<0.01) in the medial compartment (2.4°±1.3°) compared with the lateral compartment (0.9°±1.1°). There was also a significant increase (p<0.01) in the lateral tibial meniscal slope of 0.9°±1.4°, which was equivalent to the change in the bony lateral slope. The amount of frontal correction was not significantly associated with the amount of change in slope. The results suggest that the modification of the bony slope is larger in the medial compartment after MOWHTO, which is likely related to the location of the hinge on the lateral tibial cortex. These findings suggest that consideration of the medial and lateral tibial slope intra-operatively could be important to identify the optimal location of the hinge. However, further studies are required before recommending any modification to the surgical technique, as the potential clinical consequences of tibial slope alterations remain unknown. IV.

Risk‐Informed Regulation and Safety Management of Nuclear Power Plants—On the Prevention of Severe Accidents

There are four operating nuclear power plant (NPP) units in Finland. The Teollisuuden Voima (TVO) power company has two 840 MWe BWR units supplied by Asea-Atom at the Olkiluoto site. The Fortum corporation (formerly IVO) has two 500 MWe VVER 440/213 units at the Loviisa site. In addition, a 1600 MWe European Pressurized Water Reactor supplied by AREVA NP (formerly the Framatome ANP--Siemens AG Consortium) is under construction at the Olkiluoto site. Recently, the Finnish Parliament ratified the government Decision in Principle that the utilities' applications to build two new NPP units are in line with the total good of the society. The Finnish utilities, Fenno power company, and TVO company are in progress of qualifying the type of the new nuclear builds. In Finland, risk-informed applications are formally integrated in the regulatory process of NPPs that are already in the early design phase and these are to run through the construction and operation phases all through the entire plant service time. A plant-specific full-scope probabilistic risk assessment (PRA) is required for each NPP. PRAs shall cover internal events, area events (fires, floods), and external events such as harsh weather conditions and seismic events in all operating modes. Special attention is devoted to the use of various risk-informed PRA applications in the licensing of Olkiluoto 3 NPP.

Integrated operation systems and voice recognition in minimally invasive surgery: comparison of two systems

Integrated operation systems were developed for centralization and easy control of all components within the operating room (OR). These systems represent central units that use communication technology to connect and control various components of the OR. Voice control that is independent of the speaker has been a pioneering innovation in the central control of different OR components. The aim of the present study was to evaluate the utility of two voice-activated control systems, the Siemens Integrated OR System (SIOS, Siemens Medical Solutions, Siemens AG) and the OR1 (Karl Storz GmbH & Co. KG), for delivery of commands to specific OR equipment. To compare the two systems, actions such as adjusting the operating table, increasing gas pressure, switching on the video recorder, and controlling the endolight source were defined according to a study protocol. These actions were to be executed by test persons through speech and manual control after a suitable training period. The parameters evaluated were training time, time to execute each action, number of repeated commands, and number of functional errors. Seventy-four test persons from five nations were selected to participate. The numbers of repeated commands and functional errors differed significantly between systems in all user groups in favor of the SIOS (mean repeated commands for surgeons: SIOS, 2.4; OR1, 14.7, p < 0.0001). The SIOS voice control was more effective and more reliable than that of the OR1. Importantly, unlike the OR1, the SIOS produced no functional errors. The appropriate conditions for greater acceptance of these systems must be considered, together with additional technical improvements and possible combinations of advantages of the available systems.

Transcatheter Aortic Valve Replacement using DynaCT

We report a successful transcatheter aortic valve replacement (TAVR) using syngo DynaCT (Siemens AG, Forchheim, Germany) in an 86-year-old man who had severe aortic valve stenosis. Syngo DynaCT is a cross-sectional radiological imaging system that facilitates intraoperative imaging via interventional angiographic systems; this navigation system is useful during TAVR, especially in cases of poor calcification at the annulus.

E-005 Accuracy of software for intracranial aneurysm geometry quantification

Introduction/purposeEndovascular treatment planning for intracranial aneurysms requires accurate quantification of aneurysm geometry. Today, aneurysm geometry is typically measured manually on an angiographic workstation based on three-dimensional (3D) Digital Subtraction Angiography...

P-041 Enhanced procedural guidance during deployment of flow-diverters using 3D land marking and overlay technique

PurposeEndoluminal parent vessel reconstruction using flow-diverting device has emerged as a viable alternative to stent-assisted coiling/surgical clipping in wide necked intracranial aneurysms.1 Accurate device positioning in parent vessel and deployment...

O-031 Metal artifact reduction for C-arm flat panel CT: preliminary results in neurointerventional applications

PurposeWith the advent of latest generation flat panel detectors, C-arm angiographic systems have the ability to provide high-resolution CT-like images of brain parenchyma, vasculature and deployed devices while the patient...

Examining the use of imaging during T-AVI: focus on online 3D DynaCT

Transcatheter aortic valve implantation (T-AVI) is a closed heart procedure with lack of direct vision to the native valve. This makes precise imaging important before and during T-AVI. Aortic annulus diameter, distance between coronary ostia and aortic annulus, as well as conditions of the femoral and coronary arteries has to be preoperatively evaluated by echocardiography, computed tomography and angiography. During T-AVI, echocardiography and fluoroscopy/angiography play important roles for precise implantation of the prosthesis, for functional assessment after implantation and for detecting/excluding any potential complications. Syngo DynaCT (Siemens AG, Forchheim, Germany) is an intraprocedural imaging tool for T-AVI allowing for 3D visualization of the aortic root and for delineating some important landmarks, such as the coronary ostia and the nadirs. DynaCT eases the T-AVI procedure, and together with further integration of echo and preoperative computed tomography data by means of fusion imaging, ...

WE‐A‐218‐10: The Tradeoff between Diagnostic Performance and Radiation Dose for CT Imaging in the Diagnosis of Appendicitis Across Observers with Various Levels of Experience

Purpose: To investigate the tradeoffs between radiation dose and diagnostic performance in CT for a challenging clinical task (diagnosis of appendicitis). Methods: This IRB approved study utilized data for 20 patients undergoing clinical CT exams for indications of appendicitis. Medical records were reviewed to establish true diagnosis and identified 10 positive and 10 negative cases. Original (100%) and simulated reduced dose levels (70%, 50%, 30%, 20% of original) were created with a validated software tool using raw projection data from each scan. An observer study was performed with 6 radiologists (of different training and cross‐sectional reading experience) reviewing each case at each dose level in stratified random order over several sessions. Readers assessed image quality and provided confidence in their diagnosis of appendicitis, each on a 5 point scale. Receiver Operating Characteristics (ROC) curves were generated for each dose level using all rating levels and from the resulting ROC curves, the AUC (Area under curve) was calculated for each dose level. This analysis was repeated for groups of readers with different experience levels. Results: The ROC curves averaged over all 6 observers and corresponding AUC values showed indifferent performances for all the dose levels. For the 2 non‐abdominal trained, occasional CT readers, the performance did not decrease until 30% dose level. For the 2 non‐abdominal trained, routine CT readers, the performance did not decrease until 20% dose level. For the 2 abdominal trained, routine CT readers, the performance is consistent across all the dose levels. Conclusions: This preliminary study demonstrated the tradeoffs between radiation dose and diagnostic performance and indicated that: (a) There is essentially no difference between diagnostic performance of 100%, 70%, and 50% dose level for all 6 observers. (b) For abdominal CT specialists, the diagnostic difference is not substantially compromised even at 20% dose levels. (c) For non‐abdominal trained CT readers, the performance declines at 30% and 20% dose levels. For Michael McNitt‐ Gray: Institutional research agreement, Siemens AG Recipient research support Siemens AG

SU-E-I-114: Clinical Ultrasound Transducer Degradation Effects on the Accuracy of Spectral Doppler Velocity Measurements.

Ultrasound Doppler velocity measurements are routinely used to determine the severity of a stenosis in the carotid, renal or peripheral arteries. The objective of this study is to investigate and demonstrate the relationship between Doppler velocity measurements and transducer degradation conditions encountered in a clinical environment. Assessing transducer performance was accomplished using the First Call aPerio Test System transducer analyzer (Sonora Medical Systems, Longmont, CO). This system was used to conduct 1,145 semi-annual transducer assessments at 7 clinical sites from September 2007 to February 2012 as part of a comprehensive quality control program. The results were evaluated to determine the degree of transducer degradation encountered in the clinical environment. A Siemens Acuson S2000 (Siemens AG, Erlangen, Germany) ultrasound system was employed with the 1425A LE Doppler Flow System (Gammex, Middleton, WI) to determine Doppler velocity measurements. A transducer fixation device was fabricated to provide accurate, repeatable velocity measurements. Transducers with the most severe degradation were evaluated by comparing velocity measurements to those without defects. Using several matched transducer pairs, simulated failure modes were tested. The Doppler measured time-average mean (TAMn) and time-average maximum (TAMx) velocities were obtained and reported. This investigation found that 4.5% of the transducers surveyed during this 5-year period of time failed at least one acceptance criteria. Many (346 or 30%) had at least one defect. Typical findings include dead elements, lens delamination, wire cuts, and capacitance shorts. Only the most severe transducer defects and degradation conditions resulted in a noticeable deviation in the velocity measurements. Simulated transducer degradation testing confirmed this finding. The relationship between Doppler velocity measurements and transducer degradation conditions is limited, becoming significant for only the most severe degradation conditions. Based on our experience, this level of transducer degradation is rarely encountered in the clinical environment.

WE-G-217BCD-05: Fiducial Marker-Based Motion Compensation for the Acquisition of 3D Knee Geometry Under Weight-Bearing Conditions Using a C-Arm CT Scanner.

Imaging the knee under realistic load-bearing conditions can be carried out in a horizontal plane using a C-arm CT scanner. Human subjects can be scanned in a standing position and acquired data successfully reconstructed. However, reconstructing this data is a challenge due to significant artifacts that are induced due to involuntary motion. Here, we propose motion correction methods in 2D and 3D. Four volunteers were scanned for 8 seconds while squatting with ∼30 degree flexion. Eight tantalum fiducial markers suitably attached around the knee were used to track motion. The marker position in each projection was semi- automatically detected. Each marker's static 3D position, which served as a reference to correct temporal motion, was estimated by triangulating each marker's 2D position from 248 projections using known projection matrices. Motion was corrected in 3 ways: 1) 2D projection shifting based on the mean position of markers, 2) 2D projection warping using approximate thin- plate splines, 3) 3D rigid body warping. The original reconstruction was severely motion-corrupted which made it impossible to distinguish the boundaries of bones. Reconstruction with projection shifting and warping in 2D improved visualization of edges of soft tissue as well as bone. A simple numerical metric of residual bead deviation from static position was reduced from 3.2mm to 0.4mm. The 2D-based methods are inherently limited in that they cannot fully accommodate different 3D movements at different depths from the X-ray source. Reconstruction with 3D warping shows clearer edges and less streak artifact than the 2D methods. The proposed three motion correction methods effectively reduced motion-induced artifacts in the reconstruction and are therefore suitable for weight-bearing scanning. Future work includes scanning patients in standing position after contrast injection for evaluating the soft tissue structure and constructing 3D finite element models for the estimation of joint cartilage stress. This study was supported by Center for Biomedical Imaging at Stanford, by Siemens AG, Healthcare Sector, and by the Lucas Foundation at Stanford. The concepts and contents proposed here are based on research and are not commercially available.

TU‐G‐217BCD‐08: The Relationship of Image Noise and Organ Dose as a Function of Patient Size for Abdominal CT Exams at 5 Different Dose Levels When Tube Current Modulation Is Used

Purpose: To investigate the relationship of image noise and organ dose as a function of patient size for abdominal CT exams at a 5 different dose levels when tube current modulation is used. Methods: This IRB approved study selected 20 patients scanned by a Siemens Sensation64 CT scanner with CareDose4D turned on. Images at lower dose levels (20%, 30%, 50%, and 70%) were simulated for each patient. Noise for each image set was obtained by drawing an ROI in a homogeneous region in the liver. Radiation dose to liver was obtained using a previously validated Monte Carlo simulation package. The perimeter of the patient at the liver level was also obtained. Results: Noise and liver dose were plotted as a function of patient size for the 100% dose level image sets. Noise behaves roughly as a linearly function of patient perimeter. This is consistent to the principle of CareDose4D: higher noise is acceptable in larger patients due to the intrinsic better contrast from extra fat tissue. As patient size increase, liver dose also increases in a nearly linear fashion, except for two extra large patients. In addition, noise was plotted as function of liver dose for all the image sets (including all 5 dose levels). For each patient, the noise approximately decreases in an inverse square root relationship as the dose increases, as expected. Larger patients' images have higher noise at the same liver dose. Therefore higher organ dose is required to achieve a similar noise level. Conclusions: This study investigated the relationship between image noise, organ dose and patient size. The results showed that with CareDose4D: (a) both noise and liver dose increases as patient size increases; (b) larger patients require a higher organ dose in order to have a similar noise level as a smaller patient. For Michael McNitt‐Gray: Institutional research agreement, Siemens AG Recipient research support Siemens AG

Micro-Structural Alterations in the Brain of Well-Treated HIV+ Patients with Mild Neurocognitive Disorders: A Multi-Contrast MRI Study at High Field (S37.001)

Objective: To investigate MRI markers of subtle HIV effects on the brain. Background Mild neurocognitive disorders (MND) affect a subset of HIV+ patients under effective highly active antiretroviral therapies (HAART). The physiopathology of MND is however not clear, as well as the reasons why some well-treated patients suffer from MND while other not. Here, we used a multi-contrast MRI based approach at high field to test the hypothesis that well-treated aviremic MND+ patients present different brain micro-structural characteristics compared to MND- HIV patients and healthy controls (HC). Design/Methods: We enrolled 17 MND+ and 19 MND- patients with undetectable viremia and 14 age-matched HC. MRI acquisitions at 3T included: MP2RAGE for T1 relaxation times as well as Magnetization Transfer (MT), T2* and Susceptibility Weighted Imaging (SWI) to probe micro-structural integrity and iron deposition. Regions of interest were automatically extracted for white and gray matter (WM, GM), thalamus, basal ganglia and hippocampus. Statistical analysis used multivariate permutation-based Hotelling tests and correction for family-wise error rate. A linear discriminant analysis between MND+ and MND- patients was performed using multi-parametric MRI data (T1, MT ratio, SWI) and cross-validated with a leave-one-out test. Results: Multivariate analysis showed significant differences between MND+ and MND- patients in WM and GM (p=0.02 respectively), and between MND+ and HC in the caudate (p=0.02). Univariate analysis revealed that MND+ patients had lower MT ratio than MND- and HC, reaching significance in WM and caudate (p=0.01). The linear discriminant analysis distinguished MND+ and MND- patients with a classification quality of 0.73% after cross-validation. Conclusions: Our findings show the presence of micro-structural brain alterations in MND+ patients as compared to MND- and HC, suggesting loss of structural integrity. In addition, they suggest that multi-contrast MRI at high field may be a powerful approach to understand the physiopathology of MND and to discriminate between patients9 sub-groups. Supported by: Centre d9Imagerie BioMedicale of the University of Lausanne, the Swiss Federal Institute of Technology Lausanne, the University of Geneve, the Centre Hospitalier Universitaire Vaudois, the Hopitaux Universitaires de Geneve, the Leenaards, the Jeantet and the Stoicescu foundations and the Swiss National Science Foundation Grant PZ00P3_131914/1. Disclosure: Dr. Granziera has nothing to disclose. Dr. Daducci has nothing to disclose. Dr. Simioni has received personal compensation for activities with Gilead and Boehringer Ingelheim as a speaker. Dr. Cavassini has nothing to disclose. Dr. Roche has received personal compensation for activities with Siemens AG as an employee. Dr. Meskaldji has nothing to disclose. Dr. Michel has nothing to disclose. Dr. Calmy has nothing to disclose. Dr. Hirschel has nothing to disclose. Dr. Krueger has received personal compensation for activities with Siemens AG as an employee. Dr. Krueger has received research support from Siemens AG. Dr. Du Pasquier has received personal compensation for activities with Merck Serono, Biogen Idec, Abbott, and ViiV.

Modic changes: prevalence, distribution patterns, and association with age in white men

Suspected as a cause of back pain, Modic changes (MCs) have received increasing attention in spine research and care. Yet, epidemiologic knowledge of MCs based on the general population, which may provide an important clinical reference, is limited. To investigate the prevalence and distribution patterns of MCs in the lumbosacral spine and their associations with age in a large population-based sample of men. An epidemiologic investigation of lumbar magnetic resonance images (MRIs). This study was based on the Twin Spine Study database, comprising a sample of male twins shown to be largely representative of the base Finnish population. Lumbar spine MRIs (1.5 Tesla Magnetom; Siemens AG, Erlangen, Germany) of 561 subjects (mean age, 49.8 years; range, 35-70 years) were included in the present study. For each spine, all 11 end plates (L1-S1) in the lumbar region were evaluated using both T1- and T2-weighted images to identify MCs, which were classified into Type 1, 2, 3, and mixed types. Furthermore, the number and location of MCs were recorded, as well as the anteroposterior (AP) and transverse sizes, to explore the prevalence and distribution pattern of MCs in the lumbar region and associations with age. Modic changes were identified in 55.6% (312) of individuals and 13.5% (830) of end plates studied. Among these MCs, 64.2% (533) were Type 2, 16.0% (133) were Type 1, 18.1% (150) were Mixed Type 1/2, and the remaining 1.6% (13) were noted as Type 3 or Mixed Type 2/3. Modic changes were more common in the lower (74.5%) than in the upper lumbar region (25.5%), and 77.9% (642) of MCs presented in pairs at opposing end plates of a disc. Moreover, the specific type of MCs on opposing end plates was usually concordant. The presence of MCs in the lumbar region was associated with age (odds ratio=1.05-1.08 for each additional year of age, depending on type of MCs, p<.001). In addition, greater age was associated with a greater number of end plates affected and MCs of larger size (p<.001). Modic changes are common MRI findings in the lumbar spines of middle-aged white men, with Type 2 MCs predominating. Mainly present in the lower lumbar region, MCs tend to affect both end plates adjacent to a disc simultaneously, and they commonly involve the entire AP diameter of the vertebral end plate. The presence and size of MCs are clearly related to age, suggesting that aging or associated factors may play an essential role in the pathogenesis of MCs.

An unusual finding after resuscitation: contusio cordis

Sirs: Contusio cordis is characterized by hemorrhage and patchy fibrosis as a result of strong kinetic forces. Contusio cordis most commonly develops after blunt chest traumas [1, 2]. Cardiac magnetic resonance (CMR) imaging can be a useful tool to visualize the underlying pathological process in such patients. Here, we report on a highly unusual case of cardiac contusion caused by chest compressions during resuscitation that was detected by CMR. A 53-year-old male collapsed as a spectator watching a football game. The onsite emergency services found a pulseless patient and initiated immediate onsite cardiopulmonary resuscitation. The initial onsite ECG showed asystole that in the course of resuscitation converted into a stable sinus rhythm. The patient received epinephrine. No defibrillation was used. The patient was admitted to our Emergency Department. The past medical history of the patient was unremarkable. A thorough examination of the patient, including chest X-ray, pulmonary CT scans and a cardiac evaluation including coronary angiography, echocardiography and an EP study did not show any relevant findings except for unspecific pulmonary nodules. There was no family history for hereditary diseases. ECG gave no evidence for channelopathies. 24-h holter ECG and exercise testing were also normal. There was also no history of prior or recent chest trauma. Blood tests showed signs of myocardial injury with an elevated cTroponin T level [0.75 (normal: 0–0.03) lg/dl] and an elevated CK level [683 (normal: 190 or less) U/l] that were associated with unspecific ECG changes in V2 und V3 (Fig. 1a, b). Coronary artery disease could be ruled out (Fig. 1c, d). For further evaluation, 2 days after the initial event, a cardiac MRI in short axis and 4-chamber view was performed (MAGNETOM Avanto 1.5T, Siemens AG Sector Healthcare, Erlangen, Germany). Late gadolinium enhancement (LGE) imaging with PSIR–SSFP revealed a hyperintense area in the right ventricular wall with a hypointense core zone (Fig. 2a) and a regional wall motion abnormality. Contrast enhanced computed tomography (ceCT) was performed (SOMATOM Sensation 64, Siemens AG Sector Healthcare, Erlangen, Germany) to rule out a thrombus as eligible differential diagnosis for the cardiac alteration. ceCT of the heart revealed a regional wall thickness (Fig. 2b) without circumscribed myocardial or endothelial alteration. On the follow-up cardiac MRI, 1 week later, both the size of the suspicious area and the regional wall motion abnormality were declining (Fig. 2c). On day 9 after the initial event, the blood markers were back in normal range. A 2D transthoracic echocardiographic examination showed a completely normal cardiac function without any abnormalities in regional cardiac wall motion (Fig. 1c, d). After surviving sudden cardiac arrest, the patient received an ICD. It was for this reason that further cardiac MRI studies especially with regard to detection of myocardial fibrosis could not be undertaken. The patient was regularly examined for ICD follow-ups with no further events over 2 years. Long-term follow-up ceCT was performed 2 years later, confirming a complete resolution of wall thickness in CT (Fig. 2d). We here describe a patient with no evident cause for cardiac arrest. However, we were able to describe a set of findings that was highly suggestive of a cardiac contusion caused by forced CPR [3, 4]. The laboratory findings of T. Reiter (&) O. Ritter M. Beer B. Petritsch University Hospital Wuerzburg, Wuerzburg, Germany e-mail: reiter.theresa@googlemail.com; Reiter_T@medizin.uni-wuerzburg.de

Ictal focal hyperperfusion demonstrated by arterial spin-labeling perfusion MRI in partial epilepsy status

Dear Sir, Pulsed arterial spin-labeling (PASL) perfusion magnetic resonance imaging (MRI) is a noninvasive method of measuring regional cerebral blood flow (rCBF) without contrast medium and has been routinely applied in cerebrovascular diseases as a cerebral perfusion measurement [1]. In partial epilepsy, ictal cortical hyperperfusion is believed to be a useful marker for identifying epileptogenic zone, and singlephoton emission computed tomography (SPECT) is commonly used for evaluating differences between interictal and ictal cerebral perfusions. Few reports have described hemodynamic changes detected by PASL in interictal [2–4] and peri-ictal states [5, 6]. Recently, we had a rare opportunity to conduct PASL imaging and also diffusion-weighted imaging (DWI) of a patient both in partial epilepsy status (PES) and during the interictal state. Our patient, a 25-year-old man with normal development and no neurological deficits, had sometimes experienced a short-term feeling of visual distortion in the left half of his visual field since age 20 years. He had his first generalized convulsion and was admitted to our hospital. One week later, he complained of frequent occurrences of blurred vision or elementary visual hallucinations like flickering lights in the left half of his visual field, sometimes accompanied by rotating his head to the left. An electroencephalogram (EEG) recorded three ictal events during 30 min. The ictal pattern showed rhythmic bursting epileptic activities arising from the right occipital region, gradually reaching high amplitude and spreading to surrounding areas within approximately 2 min and then finished without generalizing (Fig. 1a). He presented with seizures at a frequency of five to six times per hour in the daytime, so-called PES. After starting carbamazepine administration, the seizures gradually decreased and had disappeared 3 days later. He experienced left visual field loss for a few days even after the seizures had disappeared but ultimately recovered from this deficit. MRI scans were performed on a 3 T MRI system (MAGNETOM Verio; Siemens AG, Munich, Germany) on the first day that frequent seizures occurred (Fig. 1b–d) and 1 week after the seizures had completely disappeared (Fig. 2). Cortical evaluation by reversed Short T1 inversion recovery (STIR) imaging indicated an anomaly consistent with a cortical malformation in the right medial occipital region (Fig. 1b). PASL was performed with a pulsed sequence, using QUIPSII perfusion mode [7] and the following parameters: nine slices; FOV read, 300.0 mm; FOV phase, 206.0; slice thickness, 10.0 mm; TE/TR/ Tl1/Tl2020/3,500/800/2,200 ms. PASL results were coregistered with FLAIR images. While focal hyperintense signals on DWI were observed in the limited area of the M. Oishi :Y. Fujii Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata, Japan

Bribery and Corruption in Telecommunications – Best Practice in Prevention and Remedies

This paper analyses a collection of cases of corruption in telecommunications to identify failings and best practice in legislation, regulation and practice, plus measures to reduce occurrences. The Washington Consensus as applied to telecommunications creating efficient and competitive markets that would better meet the needs of consumers and businesses, while supporting economic development and avoiding being a burden on the taxpayer. The recipe contained significant but, apparently, unanticipated risks of and opportunities for holders of public office to make private and illegal gains. No measures were put in place to contain or to detect the corruption, with the result that individual cases came to light only slowly. The current trials in India concerning the “2G spectrum scam” and the settlement by Siemens AG with prosecutors in Germany and the USA are the most conspicuous examples. Work to bolster anti-corruption efforts in developing countries has been separate from support for reform in telecommunications, with no special attention given to the sector. The traditional form of corruption was in procurement, with payments for contracts for network equipment. Purchasing shifted to private-sector operators, supposedly disciplined by investors and markets against corrupt practices. The risks of corruption were raised by all three telecommunications pillars of the Washington Consensus. Liberalisation required the issuance of new licences which were assigned in whole or in part to family members, cronies and to bribe payers. Licence conditions could be varied by bribes – buying lower levels of competition or exclusivity. Privatisation has seen the sale to cronies and bribe payers. Often the price was raised and with it the bribes by sweetening the terms (e.g., adding a wireless licence). Policy and regulation have both been controlled by operators, by bribes and regulatory capture. Action within the sector is now essential first to identify and then implement best practice in the avoidance and elimination of corruption. Transparency in ownership requires disclosure of the beneficial owners of operators, avoiding the anonymity of holding companies in tax havens, to reduce the problems of stakes being assigned to the family and cronies of politicians. Major multi-national groups should identify their minority “business partners”, which they have avoided by terms such as “local investors”. Registers of the financial interests of heads of state, ministers, members of parliament, and senior officials are essential, with penalties for errors and criminal sanctions for unexplained accumulation of assets. Key individuals, such as heads of state, ministers of communications and regulators should be precluded from holding financial interests in the sector. A further area where transparency is required is in payments made for privatisation and for licences. All payments should be fully declared so that records can be checked against expenditure. Systems of governance for telecommunications must reflect the risks of corruption. Any remaining public procurement contracts need to be subject to strict rules, with a high level of transparency. Similar practices are required for development aid, to ensure that any money is identified and the terms made clear. The success of the US Foreign Corrupt Practices Act combined with the Securities Exchange Act point to the need for detailed accounting rules, with published audited reports – country by country – and strict obligations to investigate malfeasance. Provision must also be made to protect whistleblowers. Ministries and regulators need to adopt integrity policies including explicit anti-bribery rules, with training, signed annual declarations by key individuals and robust protection for whistleblowing. They also need to ensure transparency of their own accounts, to show payments received from operators and its disbursement or retention (e.g., in universal service or rural subsidy funds), this includes remuneration and benefits paid to senior officials. A range of practices in better regulation can be adopted to reduce the risks of corruption, including annual work plans, key performance indicators, annual reports to parliament, impact assessments for proposed measures, consultations on those measures and a robust appellate system.

Dens fracture in a patient with extensive craniocervical bone pneumatization

Craniocervical bone pneumatization in humans is very rare: only a handful of cases have been reported, predominantly in males (1). The characteristic air-filled bones are prone to fracture, even following minor trauma. Our case report (2) recently published in the December 2011 issue of Diagnostic and Interventional Radiology described abnormal extensive craniocervical bone pneumatization in a 47-year-old man; the same patient again presented to our hospital 10 months later with cervical pain after minor trauma (collapse). The patient complained of neck pain. No evidence of a neurological deficit was found. Initially performed plain radiographs of the upper cervical spine showed no evidence of a fracture. Because clinical symptoms persisted, we performed multislice computed tomography (MSCT) of the skull base and upper cervical spine using a 64-detector-row computed tomography (CT) scanner (Siemens Sensation 64, Siemens AG Sector Healthcare, Erlangen, Germany). Axial, coronal, and sagittal reconstructions were made using 0.75-mm slices. In addition to pre-existing extensive pneumatization of the skull base and atlas (Fig. a), submillimeter-scale axial images showed two thin lines at the dens at 7 and 9 o’clock (Fig. b), suspicious for thin fractures. In contrast to the previous CT findings (Fig. a), ambient soft-tissue emphysema could be observed on axial reconstructions (Fig. b, arrow). Although pre-trauma coronal reconstructions (Fig. c) showed pneumatization of the right hemicorpus of the axis, post-trauma MSCT depicted an Anderson and D’Alonzo Type III dens fracture (3) extending through the vertebral body of the axis (Fig. d, arrows). Patients who have been diagnosed with extensive craniocervical bone pneumatization need to be aware of the fragility of that anatomic region, and treating physicians should consider that even minor head or neck trauma may have serious consequences, such as fractures of the craniocervical region, in these patients. As reported earlier, the complex anatomy of the craniocervical region aggravates

Technique of Multi-Planar CT Image Reconstruction for the Evaluation of Superior Semicircular Canal Dehiscence Syndrome

Superior semicircular canal dehiscence (SSCD) syndrome is an unusual cause of vertigo that was first identified by Minor in 1998. The patients initially described by Minor presented with vertigo, oscillopsia, and/or dysequilibrium related to sound, changes in middle ear pressure, and/or changes in intracranial pressure due to an absence of the bony layer that normally covers the superior semicircular canal.1 Subsequent clinical studies have shown that the condition may lead to a variety of vestibular and/or auditory symptoms that mimic other otologic disorders. These symptoms include autophony, ear blockage or fullness, conductive hearing loss, pulsatile tinnitus, dizziness or vertigo with head movements, and general disequilibrium.2&#x0D; &#x0D; In a patient with the appropriate symptoms, the diagnosis of superior semicircular canal dehiscence syndrome rests on the identification of a dehiscence in the bone overlying the semicircular canal on coronal high-resolution temporal bone computed tomographic scans (white arrowhead, Figure 1).&#x0D; It must be emphasized that due to the low specificity of images taken at 1.0- and 1.5-mm collimation, current radiologic literature advocates the use of coronal reformatted images based on submillimeter (0.4 – 0.6-mm) collimated axial scans. It must also be stressed that although reformatted coronal images are sufficient for the radiologic evaluation of SSCD in most cases, oblique reformatted images in the Stenver and Pöschl planes are necessary in equivocal cases.3 When operative management becomes necessary, these views are indispensable for proper surgical planning.&#x0D; &#x0D; The images in oblique planes of reconstruction can be created on radiologic imaging software that allows multiplanar reconstruction (MPR) of the raw axial CT image data set. This software allows the original data set to be simultaneously viewed in the standard sagittal, coronal and axial orthogonal planes of orientation (Figure 2) and manipulated into non-orthogonal or arbitary planes of orientation (oblique and double-oblique).&#x0D; The images in this article were made using syngo CT (version 2010B) software (Siemens AG, Berlin and München). This software has a set of toggle buttons in the 3D task window that allow manipulation of the primary image data set (Figure 3).&#x0D; The orthogonal axial image at the level of the superior semicircular canal is used as the primary reference image (Figure 4). The image has been zoomed in and panned using the Zoom/Pan function to center the image on the superior semicircular canal to be viewed. With the Free View Mode activated, aligning the first reference line in the primary reference image to the long axis of the petrous bone and centered between the arms of the superior semicircular canal (white bar, Figure 4) creates a secondary reference image in the Stenver plane (Figure 5). Aligning the second reference line in the primary reference image to the short axis of the petrous bone and running through both arms of the superior semicircular canal (black arrow, Figure 4) creates the tertiary image in the Pöschl plane that allows visualization of the superior semicircular canal as a complete ring (Figure 6). As the superior semicircular canal may not be perfectly vertically oriented in the orthogonal axial reference image, adjustments in the vertical reference line of the secondary reference image in the Stenver plane to run along the long vertical axis of the superior semicircular canal are made (white bar, Figure 5). This will allow perfect visualization of the ring of the superior semicircular canal and any dehiscences of the overlying bone in the Pöschl plane (white arrowhead, Figure 6).&#x0D; Imaging of the inner ear structures in non-orthogonal planes of orientation are not usually provided to the clinician by radiology centers in the Philippines. With a small investment in time and effort at the radiology workstation, it is possible for the clinician to view the inner ear structures, especially the semicircular canals, in their actual anatomic planes. This will allow for the accurate diagnosis and managment of less common, but treatable causes of otologic symptoms.