Quantitative analysis of MRI signal intensity as a tool for evaluating tooth pulp vitality

OBJECTIVES

To assess whether it is possible to measure tooth vitality using magnetic resonance imaging (MRI).

METHODS

Signal intensity measurements were conducted using T(1) and T(2) sequences at the region of interest in 211 teeth (35 patients).

RESULTS

Clinical findings showed that 17.3% of the teeth were avital, whereas 82.7% were found to be vital. Neither the T(2) sequence nor the non-contrast-enhanced T(1) sequence showed significant differences between vital and avital teeth. However, the contrast-enhanced sequence and, in particular, a comparison of signal intensities between the non-contrast-enhanced T(1) sequence and the contrast-enhanced sequence showed a significant difference between vital and avital teeth.

CONCLUSION

Contrast-enhanced MRI enables us to draw conclusions on pulpal perfusion in vivo.

High-resolution dental magnetic resonance imaging of inferior alveolar nerve responses to the extraction of third molars

The objective of this study was to assess whether signal changes can be detected in the neurovascular bundle of the mandibular canal after the extraction of a third molar. We retrospectively analyzed MRI scans of 30 test subjects with healthy mandibles and 41 patients who had had a wisdom tooth extracted. Signal intensities were measured at particular sites in the neurovascular bundle, which were defined as regions of interest (ROI) in the sagittal T1-weighted images before and after intravenous administration of a paramagnetic contrast agent. On the basis of the signal intensity increases that were measured after contrast agent administration, we compared the signal increases obtained for the patients who had received surgical treatment with the results obtained for the population of test subjects with unremarkable mandibles ( t-test, P<0.05). Compared with the healthy test subjects, patients who had received surgical treatment showed significantly higher signal intensity increases at two measurement sites, i.e., the second molar and the second premolar ( P<0.05). We found no significant differences when the measurements were performed at the first molar ( P=0.06), the third molar ( P=0.47) and in the area of the ascending mandibular ramus ( P=0.79). Compared with a population of healthy test subjects, patients who had their third molars surgically removed show higher signal intensity increases in the neurovascular bundle after intravenous contrast agent administration. The underlying cause may be the higher blood flow in the arteries and veins and the perineural plexus, which may give evidence of the pathophysiological mechanism of nerve damage in the narrow canal as a result of osteotomy.

Quantitative Analyse der MR-Signal-Intensit�t des N.�petrosus major bei Patienten mit idiopathischer Fazialisparese

The objective of this study was to evaluate signal intensity increases in the greater petrosal nerve after contrast agent administration to gather information on the etiology of idiopathic peripheral facial paralysis. Magnetic resonance images were obtained from 18 patients who received inpatient medical treatment for acute peripheral facial nerve palsy. Images of intratemporal segments of the facial nerve were taken with a slice thickness of 0.75 mm. After multiplanar reconstruction, regions of interest (ROI) were defined in the proximal segment of the greater petrosal nerve. After multiplanar reconstruction, it was possible to visualize the greater petrosal nerves of all 18 patients. The nerve's average diameter was found to be 0.68 mm (range 0.5-0.9). Signal intensity increased by an average of 50.3% (range -10-146%) after contrast agent administration. Whereas this intensity was slightly reduced in two patients, it was increased in 16. No correlation could be established between greater signal intensity and medical history, clinical condition, laboratory findings, or electrophysiological data. In contrast to quantitative measurements in the facial nerve, ROI measurements in the greater petrosal nerve do not correlate with medical history, clinical condition, or laboratory findings. For this reason, MRI of this nerve does not enable us to draw conclusions on the etiology of idiopathic peripheral facial paralysis.

Diagnosis of chondral lesions of the knee joint: can MRI replace arthroscopy? A prospective study

The role of magnetic resonance tomography (MRI) for the diagnosis of chondral lesions of the knee joint is still unclear. The sensitivity of the method ranges from 15% to 96%. The scope of our daily experiences showed that there were considerable deviations between the tomographical and arthroscopical results, which vary from the results of experimental studies. Therefore we have conducted a prospective study to investigate the question of how MRI can replace arthroscopy (ASC) in the diagnosis of cartilage damages in the scope of daily routine. All 195 patients included in this study received a magnetic resonance tomography followed by an arthroscopy. A clear diagnosis of supposition had to be determined before the magnetic resonance tomography. The patients were divided into 3 Groups. Group A (n=86) received a standard Military Hospital Ulm (MH) MRI--sagittal STIR TSE and PD TSE, coronal and transversal T2 FFE (TR=660 ms, TE=18 ms, FA=30 degrees, 512 matrix). In addition, one sub-Group, AK (n=21) was examined with a special cartilage sequence of the cartilage fs T1 W FFE. Neither patients in Group AK nor in Group A as a whole received any contrast medium. Group B (n=88) was examined with an alternate MRI protocol (Radiological Joint Practice, Neu-Ulm--sagittal T1 SE, T2 SE and T2 FLASH (TR=608 ms, TE=18 ms, FA=20 degrees, 256 matrix), coronal PD fs), employing gadolinium as a contrast medium. 156 cartilage lesions were found arthroscopically. In Group A the sensitivity was 33%, the specificity 99%, and the positive and negative prediction values 75% and 98% respectively. Group B reached a sensitivity of 53% and a specificity of 98%. The positive prediction value was 48% and the negative was 98%. Group AK showed a sensitivity of 38% and specificity of 98%; the positive and negative prediction values came to 50% and 97% respectively. In conclusion, our results indicate that the MRI examination techniques recommended in the literature at present are not able to replace the ASC for the diagnosis of cartilage damages of the knee joint. In view of the high specificity (97%-99%) and the high negative prediction value (97%-98%), MRI is suitable for the exclusion of cartilage lesions. For a negative MRI associated with a cartilage injury, a cautious attitude towards an operative cartilage treatment is therefore justified. Because the MRI can not replace the ASC for diagnostic of cartilage damage, the ASC still has to be seen as the method of choice for the evaluation of cartilage damage.

[Quantitative analysis of contrast enhanced MRI of the inferior alveolar nerve in inflammatory changes of the mandible]

PURPOSE

To evaluate the role of contrast enhanced MRI in quantifying signal changes of the inferior alveolar nerve following inflammatory changes of the mandible.

MATERIAL AND METHODS

30 patients with inflammatory changes of the mandible underwent MRI of the face. Both sides of the mandible, the affected as well as the unaffected healthy side were evaluated retrospectively. Regions of interest were placed at 5 defined places on both sides to assess signal intensity before and after intravenous application of paramagnetic contrast agent. The results of the measurements were compared between the healthy and the affected side (t-test, p < 0.05) and correlated with clinical findings (t-test, p < 0.05).

RESULTS

All patients with hypesthesia of the inferior alveolar nerve in areas of the lips or chin (n = 4) showed a marked increase in signal intensity from 35 % to 83 % distal to the inflammatory process. Patients without sensitivity disorders showed less increase in signal intensity with a maximum of 51 % distal to the inflammatory process. In nearly all patients no contrast enhancement was observed distal to the first molar on the unaffected side.

CONCLUSIONS

Quantitative analysis of contrast enhanced MRI of the neurovascular bundle is able to show pathologic mandibular lesions. In case of inflammatory changes of the mandible the neurovascular bundle is able to show pathologic mandibular lesions. In case of inflammatory changes of the mandible, the neurovascular bundle shows a significant increase in signal intensity distal to the lesion compared to the unaffected healthy side of the mandible.

MR imaging of traumatic lesions of the inferior alveolar nerve in patients with fractures of the mandible

BACKGROUND AND PURPOSE

The objective of this study was to assess whether MR imaging can image the neurovascular bundle in patients with fractures of the mandible. In addition, an attempt was made to evaluate whether MR images provide information regarding the continuity of the inferior alveolar nerve before surgery and regarding signal intensity changes after trauma.

METHODS

We analyzed preoperative MR images of 23 patients with mandibular fractures. Object-oriented sagittal view proton density- and T1-weighted sequences (before and after the administration of contrast agent) were used not only in an attempt to obtain purely qualitative information regarding nerve continuity in the neurovascular bundle (inferior alveolar nerve, artery, vein) but also to perform quantitative region-of-interest measurements of signal intensities at four defined measurement sites. The measurements were compared with those obtained for a patient population with healthy mandibles.

RESULTS

It was possible to interpret MR images in 21 cases. MR imaging findings showed that the neurovascular bundle had been cut in two patients and was intact in the remaining 19 patients. These MR imaging findings were confirmed intraoperatively in all cases. Although we found no significant signal intensity differences between patients with intact nerves and patients with cut nerves, we found significant differences between patients with mandibular fractures and patients with unremarkable mandibles.

CONCLUSION

It is possible to diagnose the interruption of nerve continuity by using MR imaging. Signal intensity measurements in the neurovascular bundle provide no information regarding nerve continuity.

High-resolution MR technique allowing visualization of the course of the inferior alveolar nerve along cystic processes

Magnetic resonance imaging is not established in the preoperative diagnosis of mandibular cystic lesions; therefore, no attempts have been made thus far to evaluate the course of the mandibular neurovascular bundle along the process. However, the radiologist can detect the neurovascular bundle along the cystic lesion by high-resolution MR imaging and convey this information to the maxillofacial surgeon. This reduces the risk of intraoperative damage of the nerve. The examination of the neurovascular bundle can easily be integrated in a tumor MRI protocol of the jaw if the slice orientation is adapted to the course of the mandibular canal.

[Comparison of the reliability of subjective evaluation and quantitative measurements of MR signal intensity in inflammations of the intratemporal facial nerve]

PURPOSE

To compare in a single-blind study the reliability of quantitative measurements and subjective evaluations of contrast enhancement of the facial nerve in patients with idiopathic facial paralysis.

MATERIALS AND METHODS

Magnetic resonance images with a 0.7 mm slice thickness (surface coil) were obtained in patients with idiopathic facial paralysis before and after administration of Gd-DTPA, 0.1 mmol/kg. The five intratemporal segments of the facial nerve were quantitatively measured and subjectively assessed by five radiologists as to the degree of enhancement. The results were compared as to the reliability of both methods.

RESULTS

Using the quantitative measuring method, 175 measurements were calculated from a total of 350 regions of interest. At all 35 measured sites, the five quantitative measurements produced identical results. In contrast, the subjective assessment of the five radiologists arrived at a majority consensus in only 16 sites. A complete agreement was not reached for any measured site.

CONCLUSION

The measured quantitative increase in signal intensity after administration of contrast medium is more reliable than subjective assessment. The quantitative method enables reproducible signal intensity measurements even for different window settings and can be easily and swiftly performed at the workstation.

[Topography of the inferior alveolar nerve in relation to cystic processes of the mandible in dental MRI]

PURPOSE

Cystic processes are changing the course of the inferior alveolar nerve in the mandible. This study evaluates the possibility of demonstrating the relationship between space-occupying processes and the course of the neurovascular bundle.

MATERIALS AND METHODS

Thirteen patients with cystic processes in the mandible (9 keratocystic lesions, 1 eosinophilic granuloma, 1 plasmocytoma, 2 adamantinomas) were examined by MRI (1.5-T magnet, 8-cm surface coil, PD-gradient-echo-sequences in sagittal and coronal orientation, without enhancement) and the results retrospectively evaluated.

RESULTS

The entire course of the nerve could be delineated in all patients. In six patients with minor cystic processes, the nerve was identified in both sagittal and coronal orientation. In seven patients with major cystic lesions, only parts of the nerve were detected in either image orientation, but the nerve could be visualized in its entire length by evaluating coronal and sagittal images side by side.

CONCLUSION

It is possible to delineate the inferior alveolar nerve in its entirety along pathologic mandibular lesions. For large cystic lesions, this requires the evaluation of both coronal and sagittal sections of multidirectional MRI.

[MRI vs. arthroscopy in the diagnosis of cartilage lesions in the knee. Can MRI take place of arthroscopy?]

INTRODUCTION

The accuracy of magnet resonance imaging in diagnosing cartilage lesions is discussed controversially. The sensitivity of this examination ranges from 15 % to 96 %. Clinical evidence demonstrates that cartilage lesions, diagnosed by MRI, were not confirmed in arthroscopy. The purpose of this prospective study was to analyse the practicability of replacing arthroscopy by MRI in diagnosis of cartilage lesions.

PATIENTS AND METHODS

195 patients with acute or chronic knee pain were examined by reason of a pathological clinic result by MRI preoperatively. In group A (n = 86), a standard program was performed in the radiological department of German Army Hospital (sagittal STIR TSE und PD TSE, coronary und transversal T2 FFE [TR = 660 ms, TE = 18 ms, FA = 30 degrees, 512er-Matrix]), in 21 patients (subgroup AK) a cartilage specific sequence (fs T1 W FFE) without gadolinium was added. Patients in group B (n = 88) were examined in a private outpatient clinic (sagittal T1 SE, T2 SE and T2 FLASH [TR = 608 ms, TE = 18 ms, FA = 20 degrees, 256er-Matrix]) with the use of gadolinium. A clear clinical diagnosis had to be performed before MRI examination.

RESULTS

156 lesions of the cartilage were detected arthroscopically. The sensitivity of the examination was in group A 33 %; group B 53 %; group AK 38 %, specificity in group A 99 %; group B 98 % and group AK 98 %. The positive and negative predictive values were in group A 75 %/98 %; group B 48 %/98 % and in group AK 50 %/97 %.

CONCLUSION

MRI was not able to detect reliable cartilage lesions. Until now, arthroscopy is the golden standard to detect cartilage lesions.

Bell's palsy: what is the prognostic value of measurements of signal intensity increases with contrast enhancement on MRI?

Our objective was to assess the prognostic value of measurements of the degree of contrast enhancement of the intratemporal segments of the facial nerve. We prospectively obtained MRI, slice thickness <1 mm of 20 patients with a facial palsy on the first day of inpatient treatment, and measured contrast enhancement of the nerve. The data were compared with compound muscle action potential (CMAP) measurements and the clinical course. Analysis of the initial enabled differentiation of three patients whose palsy was to show no improvement from 17 whose palsy was to resolve as expected. No patient with a poor outcome showed lesser increase in signal in the internal auditory canal, pars tympanica and pars mastoidea than patients who fully recovered. In no patient who had been diagnosed on the basis of the initial MRI as having a "normal" palsy was the amplitude of the (CMAP) reduced to less than 20% that of the normal side. Measurement of contrast enhancement was thus shown to be a prognostic indicator and may provide a basis for a differential treatment of facial palsy.

[The prognostic value of quantified MRI at an early stage of Bell's palsy]

OBJECTIVE

The aim of the study was to assess whether MRI has a prognostic value at an early stage of Bell's palsy.

MATERIAL AND METHODS

Prospective, blinded study on 30 patients suffering from Bell's palsy, who came to hospital until the sixth day of illness, to receive high doses steroid therapy. MRI was done on the first day of inpatient treatment as a gradient-echo-sequence with a slice thickness of 0.7 mm before and after i. v. administration of 0.1 mmol GdDTPA/kg weight. The signal intensity increase was evaluated quantitatively by region on interest (ROI). The results were compared to the clinical outcome and the results of electrophysiology.

RESULTS

The examinations of all patients could be evaluated. The 3 patients who developed a chronic facial paralysis were detected by MRI on the first day of inpatient treatment. The patients, who showed MR signs for an unfavorable course, had a highly significant pathologic compound muscle action potential (CMAP) as a result of the electrophysiologic measurement. Rather than using complex measurement procedures it is possible to obtain reliable prognostic information from just one measurement within the Internal auditory canal before and after i. v. administration of contrast.

CONCLUSION

MRI has a prognostic value at an early stage of the illness. In the clinical setting this measurement is easy to perform, so that it is possible to obtain prognostic information at a stage when causal treatment is still possible.

Interferon-gamma in 5 patients with cutaneous radiation syndrome after radiation therapy

BACKGROUND

Irradiation can cause acute inflammatory responses as well as chronic fibrotic alterations of the skin. Cutaneous radiation fibrosis evokes a complex of therapeutic problems. However, therapeutic options, apart from surgical approaches, are limited.

PATIENTS AND METHODS

Five female patients suffering from severe cutaneous fibrosis were treated with interferon-gamma on a low-dose regimen, 3 x 100 microg/week subcutaneously for 6 months, then once per week for another 6 months. In 4 patients, skin thickness was measured with high-frequency (20 MHz) ultrasound in a clinically well-defined target skin lesion. In 1 patient, nuclear magnetic resonance imaging was performed to quantify the extent of cutaneous radiation fibrosis and to monitor the therapeutic outcome.

RESULTS

All patients suffered from radiation-induced cutaneous fibrosis. Additionally, in 1 patient, a fistula, as assessed by lymph vessel scintigraphy, and in another patient a radiation ulcer was diagnosed. In all patients, reduction of radiation-induced fibrosis could be documented. Both fistula and radiation ulcer regressed completely under interferon-gamma therapy.

CONCLUSION

Low-dose interferon-gamma therapy is a new and effective treatment modality for cutaneous radiation fibrosis caused by radiation therapy. The positive impact of interferon-gamma on our patients warrants randomized double-blind trials on therapy of radiation fibrosis.

The radiation accident in Georgia: clinical appearance and diagnosis of cutaneous radiation syndrome

BACKGROUND

Eleven male Georgian soldiers were accidentally exposed to radiation by cesium 137 during their training in a military exercise camp in Lilo, Georgia between November 1996 and May 1997.

OBJECTIVE

The characteristic sequelae of accidental cutaneous irradiation and available diagnostic methods are described.

METHODS

Magnetic resonance imaging (MRI) of radiation ulcers was performed in all patients; thermography was performed in 2. In 7 patients ulcers and white macules were examined with high-frequency 20 MHz sonography; histologic results were obtained from all patients.

RESULTS

Predominant lesions were radiation ulcers in 11 patients and white hairless macules in 7. MRI showed ulcers down to the muscles and an increase of signal intensity in the musculature in 9 cases. The corresponding muscle histology demonstrated vasculitis in 7 patients and necrosis in 2. In 2 patients, MRI signal intensity of the musculature was normal. In 3 patients, 20 MHz sonography showed dermal defects; 1 patient had cutaneous fibrosis. Thermography demonstrated hypothermic zones with extended inflammatory zones adjacent to the radiation ulcers in both patients examined.

CONCLUSION

High-frequency 20 MHz sonography, MRI, and thermography are useful noninvasive methods for diagnosis of the extent of cutaneous radiation syndrome and for therapy planning.

[Recurrent pneumothorax after surgical resection treatment]

Between 1984 and 1994, 27 men and 4 women with primary spontaneous pneumothorax were treated surgically by excision of the bullae, without pleurectomy. The purpose of the present study was to establish by computed tomography (CT) of the lung whether the excision permanently eliminated the cause of pneumothorax. The median follow-up was 72 (21-127) months. There were two patients with recurrences (6.4%) who were operated on again. Sixteen of 31 patients had new blebs in the apex of the lung as documented by postoperative CT. The study indicates that simple excision of the bullous area cannot prevent the recurrence of blebs.

[Acute diagnosis of thoracic injuries of therapeutic relevance in severely injured and polytraumatized patients]

PURPOSE

To determine the value of supine chest radiography in comparison to orientating chest CT in the initial diagnostic evaluation of severely polytraumatised patients.

MATERIAL AND METHODS

303 patients with primary indication for a cranial CT following trauma were investigated between 1988 and 1993. After performing the cranial CT all patients underwent a chest CT with an average of 6 CT slices without changing the position of the patient and with a median scan time of 4 minutes. The results of the chest CT were correlated with the findings of the supine chest radiography in regard to therapeutically relevant pathological changes.

RESULTS

The sensitivity in detection of pneumothorax in supine chest radiography was 53% versus 97% in CT, atelectasis 20% versus 94%, lung contusion 79% versus 99%, haemotothorax 62% versus 97%. More fractures were found conventionally (sensitivity 94%) than by chest CT (sensitivity 44%).

CONCLUSION

Supine chest radiography of polytraumatised patients is clearly inferior to orientating chest CT in demonstrating posttraumatic lesions; obtaining therapeutically relevant information justifies the additionally needed small amount of time.

[Radiographically demonstrable spinal changes in asymptomatic young men]

PURPOSE

To find reliable data of the incidence of different variations of the spine.

MATERIAL AND METHODS

Standardised radiographic examinations of 10,922 young, healthy pilot aspirants of the German air force were made. Radiographic examination included the whole spine in a.p. and lateral projection, the cervical spine in oblique projection and in a subunit of 5781 men the lumbar spine in oblique projection.

RESULTS

The following incidences were found: mild habit scoliosis: 80.4%, structural scoliosis: 9%, severe thoracal kyphosis without severe lumbar lordosis: 5.1% and together with severe lumbar lordosis: 30.8%, mild forms of kyphosis of adolescence: 23.3%, severe forms: 2.1% and cuneiform deformation of vertebral body: 4.9%, sacralization: 7.8%, lumbarization: 5.9%, spondylolysis: 6.2%, spondylolisthesis: 4.3% and lumbar chondrosis: 2.1%. Chondrosis of the thoracal and cervical spine, osteochondrosis and coalescent vertebral bodies were found in less than 0.8% each.

CONCLUSION

In only 2.6% were there no pathological findings. This shows importance of radiological spine examinations especially for industrial and preventive medicine.

[Bilateral ureteroiliac fistula coincident with radiotherapy and ureteral splint]

Fistulas between the iliac artery and the ureter are uncommon. Overall, fewer than 20 cases have been described in the literature. We report the first bilateral case, in which there was an association with indwelling bilateral ureteral stents and a history of radiation therapy following hysterectomy performed because of malignancy. The patient presented with massive gross haematuria.

[Failed sclerotherapy trials with the V. spermatica interna. A retrospective analysis in 1141 patients with idiopathic varicocele]

From July 1988 until December 1990 1141 patients with left-sided idiopathic varicocele underwent phlebography of the spermatic internal vein, and percutaneous sclerotherapy with sodium morruate (Varicocid) was intended to be performed. In 125 of these patients sclerotherapy was not feasible. The reasons for this were analysed in a retrospective study. According to the anatomical situation of the spermatic vein, there were significant differences in technical success. In case of incompetent valve of the spermatic vein at the renal origin (type I, 2A, 3, 4A), selective probing and following sclerotherapy was possible in 97%. Anatomic variations with competent valve of the spermatic vein (type 0, 2B, 4B) led to difficulties in selectively probing the vessel, and sclerotherapy was feasible in only 72.7%. In these angiographically difficult cases, spasm of the spermatic vein and/or perforation prevented sclerotherapy in 29 of 125 patients.

Long-term results of corpus cavernosum autoinjection therapy for chronic erectile dysfunction

Between May 1985 and March 1992, 172 patients suffering from chronic erectile dysfunction (21-70 years old) underwent constant corpus cavernosum autoinjection therapy (CAT) with a standardized papaverine phentolamine mixture (16385 injections). Thereafter 41 patients continued CAT with the single agent papaverine (1257 injections). On the basis of both these 17642 protocol auto-injections, and over 6 years of experience with intracavernosal autoinjection therapy we conclude that, especially with the papaverine-phentolamine mixture, CAT constitutes an effective therapy (full rigidity in 95.8%) with tolerable side-effects for chronic erectile dysfunction when preceded by careful patient selection and thorough multi-disciplinary evaluation. This is especially so in the case of arterial and/or neurogenic aetiology of the erectile dysfunction. In addition, the contraindications must be strictly observed, the treatment and technique fully explained, and a regular follow-up instituted. CAT is generally well accepted by the patients and their partners (98.8%/97.6%) and has distinct positive effects on self-esteem (77.8%), performance anxiety (84.4%), and partnership (79.5%). The most serious side-effect was prolonged erection (25 out of 17642 injections). In 6 patients reversible fibrotic changes near the tunica albuginea were observed.

[Long-term results of corpus cavernosum auto-injection therapy in treatment of patients with chronic erectile dysfunction]

From May 1985 to July 1989, 143 patients suffering from chronic erectile dysfunction (21-70 years old) underwent constant corpus cavernosum auto-injection therapy (CCAT) with papaverine alone (1257 injections) or with a standardized papaverine-phentolamine mixture (11035 injections). On the basis of these 12,292 protocol auto-injections and over 4 years' experience with intracavernosal auto-injection therapy we conclude: CCAT, especially with the papaverine-phentolamine mixture, constitutes an effective therapy (full rigidity in 95.9%) with tolerable side-effects for chronic erectile dysfunction when preceded by careful patient selection and thorough multidisciplinary evaluation, especially in the case of arterial and/or neurogenic aetiology of the erectile dysfunction; in addition, the contraindications must be strictly observed, the treatment and technique fully explained, and a regular system instituted. CCAT is generally well accepted by the patients and their partners (100%/98.3%) and has distinct positive effects on self-esteem (77.8%), performance anxiety (84.4%) and partnership (79.5%). The most serious side-effect was prolonged erection (25 out of 12,292 injections). In 3 patients reversible fibrotic changes near the tunica albuginea were observed.

[Nitroglycerin test for the diagnosis of erectile dysfunction]

In 33 patients with erectile dysfunction arterial inflow was measured by Doppler-sonography over the superficial dorsal and deep cavernous arteries in the proximal section after local application of 1.6 mg glycerol trinitrate (nitroglycerin) to the glans penis. With this test we were able to reveal a minimal increases in maximal systolic flow over both arteries at 29/66 measurement sites. This is thus an easier way of localizing penile vessels in the flaccid state. In no case did we see tumescence or rigidity.

Erectile response to intracavernous injection of vasoactive drugs after penile prosthesis removal

Two patients with a history of penile prosthesis removal presented for non-prosthetic treatment of their erectile dysfunction. The first patient had a penile implant for two years before it was removed and showed extensive cavernosal fibrosis. He did not respond to intracavernosal injection of vasoactive drugs. The second patient had the prosthesis for four weeks. He showed no evidence of cavernosal fibrosis and responded well to the intracavernous injection. He has been in an intracavernous autoinjection program for more than one year without complications.

[Results of multidisciplinary assessment of patients with erectile dysfunction]

A total of 326 patients with chronic erectile dysfunction were investigated by a multidisciplinary approach. It was found that several causes combined (multifactorial genesis) in 77.1%. Organic causes alone were found quite frequently, viz. in 43.6%, while primarily psychogenic causes alone were found in only 5.5%; in contrast, combined organic and psychogenic causes were found in 46.0%. There were pathologic organic findings in 89.6%: vascular in 74.5% (arterial 64.1%, cavernous/venous 30.4%), neurogenic in 42.0%; side effects of drugs in (10.1%); endocrine (7.7%) and local penile causes (4.3%) are not so important in erectile dysfunction. Treatment suited to the pathogenesis was instituted (psychotherapy, vein ligation, self-injection of vasoactive drugs into the corpus cavernosum).

Diagnosis of venous incompetence in erectile dysfunction. Comparative study of cavernosography and Doppler ultrasound

In 26 of 214 patients with erectile dysfunction and proved venous incompetence by cavernosography, an additional bidirectional Doppler ultrasound was performed also to demonstrate venous outflow disturbances. All except one leakage in the superficial and deep dorsal veins could be demonstrated as well as 4 of 6 cavernosum-glandular shunts. Bidirectional Doppler ultrasound visualized a continuous retrograde blood flow from the sulcus coronarius to the root of the penis in superficial and deep dorsal penile veins as well as in ectopic penile veins, an orthograde blood flow in the sulcus coronarius in cavernosum-glandular shunt.

[Diagnostic value of sonography and double contrast arthrography in meniscus lesions]

Using a real time scanner and a 7.5 mHz transducer, the meniscus can bei visualised as a homogeneous triangle. It is clearly distinguishable from the tibial plane und the condyle of the femur. Tears in the meniscus show up as a double contour rich in echoes with an intervening low-echo area, or as a contour rich in echoes with an adjacent low-echo area. The posterior horn area can be visualised most clearly. Assessment of the interior part of the meniscus is somewhat easier than visualising the exterior part. In a clinical study with 107 menisci examined by sonography and controlled by arthroscopy or arthrotomy the rate of accurate diagnoses by sonography of the meniscus is 82%. 42 of these menisci were additionally examined by double contrast arthrography besides sonography. This yielded an accuracy rate of 74% for double contrast arthrography; the latter is superior to sonography only in the anterior horn area. Problems in respect of meniscus sonography occur only in case of transverse ruptures, scars and longitudinal meniscus ruptures presenting as bucket handle tears near the base. The typical longitudinal tear in the area of the posterior horn can be visualised most clearly. Analysis of the results shows that sonography of the meniscus is a noninvasive, painless and randomly reproducible and risk-free examination method which has a diagnostic value especially in the area of the posterior horn that can be compared with double contrast arthrography. Further studies must show whether with an increasing spread of the method it would be possible to replace double contrast arthrography by sonography in diagnosis of menisceal trouble.

Percutaneous sclerotherapy of idiopathic varicocele in childhood: a preliminary report

Of 31 boys 10 to 16 years old referred for treatment of a left grade II or III varicocele 28 underwent percutaneous sclerotherapy. Due to anatomical and technical obstacles sclerotherapy was not possible in 3 boys. At follow-up 1 of 16 boys (6.2 per cent) had a mild recurrence detected by Doppler sonography of the spermatic cord. Percutaneous sclerotherapy had no serious side effects, and proved to be an efficient and convenient treatment of left varicocele in childhood.

Primary erectile dysfunction

We evaluated 67 patients 18 to 60 years old (mean age 28.5 years) with primary erectile dysfunction (absence of full sustained erections since early childhood or puberty) using a multidisciplinary approach. Organic causes of the erectile dysfunction were found in 57 of the 67 patients (85 per cent): 12 (18 per cent) had neurological, 35 (52 per cent) arteriogenic and 35 (52 per cent) venogenic abnormalities. Psychogenic factors were diagnosed in 11 patients (16 per cent), while in 4 (6 per cent) a classification was not possible. Concomitant psychogenic abnormalities were found in 39 of the 57 patients (68 per cent) with organic primary erectile dysfunction. Our results suggest that primary erectile dysfunction is caused mainly by organic factors. However, for successful therapy the frequent secondary psychogenic abnormalities must be considered.

Effects of intracavernosal pharmacotherapy on self-esteem, performance anxiety and partnership in patients with chronic erectile dysfunction

156 patients undergoing intracavernosal autoinjection pharmacotherapy for periods of 2-36 months were studied for the effect of treatment on self-esteem, performance anxiety, partnership and acceptance using a semi-structured questionnaire. Replies were received from 86.3% of the patients. 93% gave a very good, good or satisfactory rating of intracavernosal pharmacotherapy. 78.2% indicated that their self-esteem had grown. 79.4% said that performance anxiety diminished in the course of therapy (25.6%) or disappeared entirely (53.8%). 71.8% of the replies confirm the positive effect of treatment on marital relations or partnership. 61.9% of the patients used intracavernosal pharmacotherapy permanently. 28.3% needed therapy intermittently or at large intervals only, and 4.5% (7 patients) were cured of their chronic sexual dysfunction. When preceded by thorough multidisciplinary diagnostics and careful patient selection, intracavernosal pharmacotherapy constitutes an efficient mode of treatment for chronic erectile dysfunction.

[Diagnosis of venous insufficiency in erectile dysfunction: comparative studies of cavernosonography and Doppler sonography]

In 26 out of 214 patients with erectile dysfunction and venous insufficiency proven by cavernosography, bidirectional Doppler ultrasound was also performed to demonstrate venous leakage in addition. Except for one, all 25 cases of leakage in the superficial and deep dorsal veins could be demonstrated, as could four of six cases of cavernosoglandular shunts. Using bidirectional Doppler ultrasound, it was possible to visualize a continuous orthograde blood flow from the sulcus coronarius to the root of the penis in superficial and deep dorsal penile veins, as well as in ectopic penile veins, and a retrograde blood flow in the sulcus coronarius in cavernosoglandular shunts.

Arterial anatomy and arteriographic diagnosis of arteriogenic impotence

One hundred twenty-six bilateral selective arteriographic examinations of the iliopudendal vascular tree were performed after comprehensive multidisciplinary evaluation in patients with chronic erectile dysfunction. Best imaging results were obtained by performing the arteriography under epidural anesthesia after intracavernous injection of a vasoactive drug combination. The arteriography is mandatory prior to revascularization procedures. It is further indicated in primary erectile dysfunction and posttraumatic erectile failure. The importance of cavernosography and selective arteriography in primary erectile dysfunction is stressed. Increasing knowledge about the influence of vasoactive drugs on penile hemodynamics has led to its application in diagnosis and therapy of erectile dysfunction. Pharmacocavernosography, Doppler-ultrasound of penile arteries after intracavernous injection of a vasoactive drug combination, and pharmacoarteriography are refined techniques to prove a vascular etiology of erectile dysfunction. The results of the morphologic studies of the vascular system are correlated with functional testing of erectile capacity by intracavernous application of a papaverine-phentolamine drug combination.

Mid-term results of autoinjection therapy for erectile dysfunction

Of over 300 patients with erectile dysfunction, 186 were selected for intracavernosal autoinjection therapy with a standardized papaverine-phentolamine mixture. A total of 156 patients performed 4,813 protocol autoinjections with a minimum of 10 and a maximum of 230 per patient. The dose that induced a full erection at the hospital could be reduced under home conditions by a mean of 35 per cent. Systemic side effects were not observed. The most inconvenient local side effects were prolonged erections in 24 patients in diagnostic use and in 3 patients in therapeutic use. There were treated easily without further consequences.

Erectile dysfunction due to ectopic penile vein

A total of 86/260 patients with erectile dysfunction had venous leakage as (joint) etiology. In 5 of 86 patients cavernosography showed pathologic cavernosal drainage only via an ectopic penile vein into the femoral vein. After ligation of this pathologic draining vessel, 4 of 5 patients regained spontaneous erectability. One patient with pathologic bulbocavernosus reflex latencies needed intracavernosal injection of vasoactive drugs for full rigidity.

Functional evaluation of penile hemodynamics

A multidisciplinary study was performed on 200 consecutive patients with erectile dysfunction more than 1 year in duration, which included a standardized intracavernous injection of a vasoactive substance mixture (15 mg. per ml. papaverine plus 0.5 mg. per ml. phentolamine). The multidisciplinary findings correlated well with the intracavernous dose needed for full erection. The group without pathological hemodynamic findings (36 patients) needed an average of 0.67 ml. and the group with pathological inflow (107) needed an average of 1.07 ml. In the venous insufficiency group (57 patients) only 18 achieved full erections with an average of 2.1 ml. (39 achieved tumescence only to 3 ml.). The results show that standardized intracavernous injection of a vasoactive substance mixture is a useful method to evaluate penile hemodynamics. This pharmacological test appears to be effective in the differential diagnosis of nonvascular and vascular erectile dysfunction.

[Open multicenter study of the differential diagnosis of erectile dysfunction with a papaverine-phentolamine combination (BY023)]

We report the results of an open multicenter clinical trial with 115 patients. The results of a pharmacological test using intracavernously applied mixture of papaverine and phentolamine were compared with the results of a multidisciplinary evaluation of erectile dysfunction. Sensitivity and specificity of our test were determined. The injection of our drug solution caused an increase in tumescence and/or rigidity in all patients. The evaluation of the dose dependent erectile response makes it possible to distinguish between the three main pathogenetic principles: non-vascular, arterial and venous etiology of erectile dysfunction. The pharmacological test requires one to four intracavernous injections of 0.5-3.0 ml of the drug solution (7.5-45 mg papaverine hydrochloride, 0.25-1.5 mg phentolamine mesylate).

Late results after sclerotherapy of varicocele

Percutaneous sclerotherapy is technically feasible in about 80% of patients with idiopathic varicocele. Persistence must be reckoned with in 3-5% of the cases. Sclerotherapy is a low-risk technique which can be applied on an outpatient basis in the vast majority of cases. In about 40% of the cases, an improvement of the fertility can be attained by raising the spermatozoal density; the total motility and morphology of the spermatozoa can only be slightly improved by this therapy. Percutaneous sclerotherapy is to be recommended as an alternative to surgery since it provides equally good results, is cheaper and causes hardly any complications.

[Diagnosis of vascular impotence: comparison of Doppler sonography and arteriography]

The use of Doppler ultrasonography to examine penile arteries represents an important step in the multidisciplinary evaluation of erectile dysfunction. This noninvasive method for demonstrating the presence of arterial lesions was found to have a sensitivity of 92.6% and an accuracy of 90% when compared with selective arteriography. The necessity of performing selective arteriography can be markedly reduced in cases of erectile dysfunction by investigations using Doppler ultrasonography.

[Intravascular pressure measurements and phlebography of the renal vein: a contribution to the etiology of varicocele]

Phlebography of the left renal vein was performed in 80 patients with left-sided varicocele demonstrating the nutcracker phenomenon. In 39 cases we could prove a compression of the left renal vein. In 10 varicocele patients additional intravascular pressure measurements were studied in both renal veins in the supine and erect position. We found no significant difference between the pressure in the left and right renal vein in the supine position: values varied with respiration. Changing from the supine to the erect position one can note a significantly elevated pressure, higher on the left side than on the right side due to the longer excursion of the left kidney. Urine investigations were done in 153 patients before and in 191 after sclerotherapy to detect protein or blood. Only in 4 patients we found proteinuria but no microhematuria. The results suggest that the aetiology of the varicocele formation is not the nutcracker phenomenon or renal vein hypertension; the predominant cause is a congenital incompetence of the valves in the left testicular vein. The driving force for the retrograde blood flow from the left renal vein into the testicular vein was the increase in pressure: in the supine position caused by respiration, the continuous reflux in the erect position caused by the hydrostatic pressure. The varicocele does not cause a congested kidney with hematuria and proteinuria.

[2 years' experiences with cavernosal autoinjection therapy]

Between February 1985 and January 1987, 186 patients with erectile dysfunction were selected for cavernosal autoinjection therapy (CAT). After more than 4800 protocolled autoinjections and 10-230 CAT/pt., no cavernous fibrosis, penile deviation or cavernitis occurred. The only serious side effects were prolonged erections in about 10% during diagnostic and less than 1% during therapeutic use. These prolonged erections could be easily treated by puncture and aspiration of corpora cavernosa or intracavernosal injection of Metaraminol.