The acute abdomen is one of the most frequent, most dangerous and most difficult problems that the diagnostic radiologist has to deal with. This comprehensive manual presents a clinico-radiologic approach to the use of diagnostic imaging techniques for acute abdominal conditions. Imaging techniques, radiologic symptoms and clinical conditions are treated separately. This lucid format, together with a detailed subject index, offer the reader a quick and reliable reference aid in daily practice. The text is clearly structured and concise in style, and provides helpful practical hints, including discussion of diagnostic pitfalls. It is supported by a wealth of illustrations covering native diagnosis, ultrasonography, computer tomography and angiography.

Since the beginnings of diagnostic ultrasound in the 1950s, each decade has seen significant advances in this technology. Commer cialization of ultrasound occurred during the 1960s with the introduction of many of the clinical uses that are in existence today. The 1970s showed the most dramatic changes with the commercial introduction of gray-scale and real-time ultrasound. In the 1980s many new advances were introduced, including color Doppler, as well as a wide variety of endoluminal approaches, including endorectal, endovaginal and transesophageal. The decade of the 1990s promises even more significant advances with further transducer miniaturization, three-dimensional ultra sound, and the introduction of a variety of ultrasound contrast agents. With such rapid changes occurring, it becomes important to disseminate knowledge in as rapid a fashion as possible, thus it was quite appropriate that a meeting such as this be held to provide an in-depth review of the many new areas of ultrasound imaging that show promise for the future. Emphasis was on the new uses of ultrasound in gastrointestinal diseases. Many of these advances will, of course, also have applications in many other areas of the body. It is hoped that those in attendance will acquire a much broader understanding of where ultrasound is now and where it is headed in the not too distant future.

Over a mere 5 years, neonatal cranial sonography has evolved from an obscure and largely experimental imaging possibility to the modality of preference in the examination of the young brain. The almost immediate acceptance of the ultrasound examination of the neonatal brain was based on a number of coinci dent factors, the most important of which was the emergence of a burgeoning population of premature neonates who were, for the first time, surviving be yond infancy. These delicate patients were beginning to withstand the rigors of extrauterine life when not fully prepared for it; pulmonary, cardiac, and infec tious diseases no longer claimed most of them. With survival, a new specter reared its head: Would the eventual mental and neurologic status of these same children be worth the expense and time needed to bring them through their first months? This issue became increasingly pressing as evidence mounted through the 1970s that very premature neonates were at a high risk for intracranial hemor rhage and posthemorrhagic complications. An imaging modality that could evaluate the premature brain was sorely needed. The CT scanner with its proven ability to diagnose intracranial hemorrhage was of little value in this regard. So too were static gray-scale or waterpath ultrasound units. These modalities all had the same limitation, lack of portability. As neonatal intensive care units proliferated, so did the technology that would soon allow cribside neonatal neuroimaging, the real-time sector scanner."

Very thorough knowledge of breast pathology is a sine qua non for interpretation of breast films ... progress in X-ray diagnosis could only be made by careful comparison of the film with the actual specimen. H.INGLEBY Multiplication of the same e"oneous diagnosis does not make that diagnosis co"ect. J.G.AzZOPARDI Paradoxically enough, our specialty considers the radiologist who mis takes a skin fibroma or the calcifications in a sponge kidney for a kid ney stone to lack basic knowledge, while the radiologist who imme diately calls for the surgeon because of a few white spots on a mammogram is thought to be acting according to the rules of medical practice. Misunderstandings and confusion with regard to breast pathology as well as the comfortable philosophy that superfluous biopsies are the price we have to pay for the early detection of carcinomas have in many places led to a loss of confidence in mammography. Yet this is a meth od with which carcinomas can be detected earlier than with any other imaging technique.

In January 1995, 300 participants from Asia, USA, and Europe lively discussed the "State of the Art and Future Aspects of CT" in Peking, China. The workshop was designed to cover all essential aspects of modern CT imaging including the historical development, different techniques, contrast agents, organ systems, and indications. The comparative evaluation of CT versus MRI and ultrasound was a central topic. Additionally, a special session was dedicated to "Angiography Tomorrow." This book summarizes the state of the art in both conventional and spiral CT imaging and provides some suggestions as for the future role of the method.

by Dr. Donald L. King The past decade has seen the ascent of ultrasonography to a preeminent position as a diagnostic imaging modality for obstetrics and gynecology. It can be stated without qualification that modern obstetrics and gynecology cannot be practiced without the use of diagnostic ultrasound, and in particular, the use of ultrasonogra phy. Ultrasonography quickly and safely provides detailed, high resolution images of the pelvic organs and gravid uterus. The quality and quantity of diagnostic information obtained by ultra sonography far exceeds anything previously available and has had a revolutionary impact on the management of patients. High resolution static images permit the intrauterine diagnosis of fetal growth retardation and fetal abnormalities. In addition to tradi tional images, newer dynamic imaging techniques allow observa tion of fetal motion, cardiac pulsation, and respiratory efforts. The use of ultrasonography for guidance has greatly augmented the safety and utility of amniocentesis. One of the great virtues of diagnostic ultrasound has been its apparent safety. At present energy levels, diagnostic ultrasound appears to be without any injurious effect. Although all the availa ble evidence suggests that it is a very safe modality and that the benefit to risk ratio is very high, the actual safety margin for its use Vll as yet remains unknown. As a consequence, practitioners are urged to limit its use only to those situations in which genuine clinical indica tions exist and real benefit to the patient is likely to result."

Owing to the anatomic complexity of the neck and the diver sity of pathologic entities affecting it, the cervical region has long been of great semiological interest. Physical examination is an easy means of evaluating the size and origin of a solitary cervical mass, yet valid interpretation can prove difficult when the normal morphology of the neck has been altered; excellent examples are patients with extensive fibrosis or scarring secondary to previous irradiation or surgery. Like wise, physical examination cannot assess the relations of a pathologic process to adjacent structures - e. g., invasion can not be distinguished from simple displacement -and it is un suitable for monitoring therapeutic efficacy, such as the re sponse of metastatic nodes to medical management. Between physical examination, which remains fundamental, and exploratory surgical procedures, which are often the only means of obtaining indispensable anatomic proof for diagno sis, lie a number of recent imaging techniques including com puted tomography and magnetic resonance imaging using surface coils that provide invaluable information for the in vestigation of cervical pathologies. Real-time ultrasonogra phy occupies a privileged position because of its noninvasive ness, rapidity, and reliability, especially when performed by a specially trained examiner."

Diagnostic ultrasound is changing dramatically because of the development of a variety of high resolution real-time scanning instruments. Until recently the standard instrument was the articulated arm contact scanner. Real-time scanners were viewed as adjunct instruments for specific and limited pur poses. The roles are reversing with real-time instruments more frequently accepted as the primary diagnostic tool and the contact scanner becoming the ancillary instrument for use mainly for viewing a large field that cannot be scanned with real-time instruments. Two recent editorials stated that real-time instruments were used as the sole diagnostic instrument for between 80% [Cooperberg (2)] and 98% [Bartrum and Crow (1)] of their abdominal examinations. This book introduces the reader to the field of real-time scanning in the abdomen. It presupposes an understanding of basic physical concepts of ultrasound, the appearance of both normal and pathologic conditions as produced by static articulated arm contact scanning, and a familiarity with the techniques of contact scanning. It is designed to acquaint the reader with the spectrum of real-time instrumentation, provide a basic understanding of the physics of ultrasound as related to these instruments, emphasize the special skills required in the use of this equipment, and describe applications of real-time scanning for various parts of the abdomen. While numerous illustrations of both normal and pathologic anatomy are shown, the book is an all-inclusive study of abdominal pathology as demonstrated by real-time imaging.

This is a unique book in that it brings together the two key investigative techniques in Gynaecology and Obstetrics, namely ultrasound and endoscopy. So often in the past they were regarded by their exponents as rival techniques but it is now recognised that they are complementary to each other. Consequently future trainees in endoscopy should become efficient in transvaginal sonography and vice versa. Ultrasound can be used to study the morphology of the pelvic organs such as the endometrium, myometrium and ovaries, and being non-invasive, safe and convenient can be repeated as often as is deemed necessary to monitor changes over time; for example in the investigation of the infertile woman the development of the dominant follicle, the maturation of the endometrium and the formation of the corpus luteum can be documented throughout the menstrual cycle while growth of ovarian cysts can be precisely measured to determine the need for surgery. A seldom-mentioned strength of the ultrasound examination is its interactive quality, for example by performing abdominal palpation during the scan, the mobility of the uterus and ovaries can be assessed. Also the images as they appear can be shown to the patient to aid understanding. Ultrasound can also determine function and the use of Doppler has been used for example to access endometrial receptivity, follicular maturity and the likelihood of malignancy in the endometrium or ovary.

3.2 Technique ............. '. . . . . . . 123 3.3 Drainage Catheters: Materials and Selection . 139 3.4 The Loop Catheter . . . . . . . . . . 141 4 Aspiration of Pancreatic Pseudocysts 145 E. Concluding Remarks 149 151 References " Subject Index . 158 VII List of Contributors BURGER, H. R, Dr. med., Oberarzt, Institut fur Pathologie, Univer sitiit Zurich, SchmelzbergstraBe 12, CH-8091 Zurich EINIGHAMMER, H.J., Dipl. Phys., Dr. rer. nat., Neurologische Uni versitatsklinik, MoorenstraBe 5, 0-4000 Dusseldorf HAUKE, R, Dipl., Phys., Dr. rer. nat., Gesellschaft fur Medizin. Techn. Informationssysteme, MarienstraBe 2,0-7910 Neu-Ulm PEmo, G., Professor Dr. med., Leitender Arzt, Abteilung fUr Zytolo gie, Institut fur Pathologie, Universitatsspital, CH-8091 Zurich " ... so it is not good for men to fear all that is not already known and settled, and thus feel that it is bad and harmful to strive for a greater perfection than already exists." Holderlin to his mother, 16. November 1799 A. Introduction 1 General The modem cross-sectional imaging methods of sonography and computed to mography, developed in the early 1970s, have contributed greatly to noninva sive studies of the parenchymatous organs and permit the evaluation of patho logic changes in areas that were previously accessible only to invasive, indirect, or inadequate examination."

Just a very few years after Edler and Hertz had described the clinical use of M-mode echocardiographyl Satomura reported the application of Dop 2 pler ultrasound to the study of cardiac function. Yet Doppler ultrasound has been integrated into diagnostic practice in cardiology much more slowly than conventional (M-mode and two-dimensional) echocardiogra phy. Now, however, tremendous growth in the interest of clinicians in the diagnostic use of Doppler ultrasound can be observed and may in fact be due to the recent advent of color flow imaging. The reason for this growth may be that this method makes it possible to directly visualize the blood flow in the cardiovascular system in cross-sectional views. Moreover, the results are reproducible and much easier to understand than the older mapping techniques using a single-gate Doppler. In its short existence many different names have been used to describe this method, for instance, color Doppler, color flow imaging, real-time two-dimen sional Doppler echocardiography, and Doppler flow imaging. This diver sity reflects the large interest that many researchers have shown in this method. The technical development of color blood flow imaging (CBFI) - as this method will be called in this book - has not yet reached a universally accepted standard of performance in cardiology. Despite this state of flux and the uncertainty about future developments, I think it is justified to dedicate an entire book to this fascinating method."

Any book with the words percutaneous and interventional is immediately identified as one that brings to its readers a distillation of a number of new and exciting techniques. Percutaneous is not exactly a new word but it has come to take on an entirely new meaning in recent years. Interventional is a recent acquisition to medical language indicating an entirely new approach to many aspects of medical management. Exactly when is the right time to make a distillation of new thoughts and expertise requires something of the art of a master brewer. First the ingredients must be prepared, the recipe must be just right, there must be excellent quality control as well as the master brewer's touch to produce the product when the time is right. Dr. Lang has assembled just the right ingredients in the form of a very impressive team of experts in these new fields of uroradiology and urological management. Ventures into percutaneous urology may date back 30 years but the main growth in the range of procedures and the development of the technology has occurred only in the last 10 years. Relieving upper tract obstruction seemed a natural sequel to renal biopsy but the imagination to develop an effective treatment for stones was an impressive extension of the concept of minimally invasive surgery.

For the fourth English edition, this highly popular book has been thoroughly revised and updated to include such new sections as endoscopic digestive US and abnormalities related to AIDS. It is the only work available covering the diagnostic US of the whole abdomen, and its superb treatment of elementary symptoms enables beginners to become familiar with more complicated features. After an extensive technical introduction, the book covers the sonoanatomy and ultrasonic symptomatology of the diseases of the digestive system and the abdominal vessels. Numerous tips on avoiding pitfalls, as well as indications for other procedures, and backed by some 1000 illustrations, this is well on its way to becoming a standard text for practitioners and clinicians in the field.

Sonography is an ideal real-time imaging technique for the evaluation of muscles and tendons of the extremities, and this book is a useful reference for both the technique of examination and normal ultrasound anatomy. The first part considers technical aspects of the examination such as sonographic equipment, water-path systems, and dynamic maneuvers. The basic sonographic patterns of normal muscles, tendons, and other components of the extremities are then presented. Emphasis has been placed on pitfalls and artifacts. The other available imaging techniques for muscles and tendons are also discussed. The second part comprises an atlas of normal ultrasound scans of shoulder, arm, elbow, forearm, wrist, hand, thigh, knee, leg, ankle, and foot, with accompanying explanatory line drawings.

by Dr. Jan. J. Smulewicz Ultrasound imaging has reached a stage of sophistication where by diagnostic information can be gained without discomfort to the patient and with complete absence of morbidity and mortality. The procedure is quick, safe, noninvasive and in many instances can supersede and obviate more time-consuming procedures requiring catheterization, injection of a contrast material, and radiographic imaging. In obstetrical problems the danger of ionizing radiation to the fetus is eliminated. In debilitated and very ill patients this simple and painless method becomes the procedure of choice. Unique features of ultrasound equipment allow for pinpoint local ization oflesions and direct visual guidance of percutaneous puncture techniques for aspiration and biopsy. The accuracy of ultrasound guided punctures and the absence of side effects make this modality far superior to percutaneous invasive techniques performed with other imaging systems. Renal cyst puncture and amniocentesis are but two of the procedures in which ultrasonic guidance is the method of choice. v Dr. Hassani has throughly explained and carefully explored the wide variety of exam inations available with ultrasound. The large volume of material and the clear interpre- tion makes this book of great interest to all of the medical profession. In addition to the existing methods available for diagnostic in terpretations, this method of noninvasive diagnosis should find its way into every hospital or center where good medical care is provided. JanJ. Smulewicz, M.D."

Cardiac ultrasound has rapidly developed into one of the most important clinical methods for diagnosis and follow-up of patients with heart disease and has changed the practice of cardiology permanently. In addition to improving image quality, most of the progress relies on digital image acquisition, storage, and quantitative analysis equipment. Automatic endocardial detection and three- dimensional reconstruction are now being developed. The progress with contrast echocardiography for myocardial perfusion imaging and results with tissue characterization is slow, but ever increasing, illustrating that the full potential of the method has not yet been explored. All of these digital techniques are extensively dealt with in this volume. Computerized tools will help the clinical cardiologists in their daily practice and stimulate further development to gen- uinely improve patient care in the coming years. We wish to thank the authors to this volume for their excellent contribution and Mrs. T. van der Kolk for secretarial assistance. IX Contributors F. J. ten Cate Thorax Center, Erasmus University, P. O. Box 1738, 3000 DR Rotterdam, The Netherlands R. Erbel II Medical Clinic, Johannes Gutenberg University, Langenbeckstr. 1, P. O. Box 3960, D-6500 Mainz, FRG Co-authors: R. Zotz, B. Henkel, G. Schreiner, C. Steuernagel, R. Zahn, H. Kopp, W. Clas, R. Brennecke, P. Schweizer, J. Meyer S. B. Feinstein Division of Cardiology, Box 44, University of Chicago, 950 East 59th Street, Chicago, IL 60637, USA D. G. Gibson Department of Cardiology, Brompton Hospital, Fulham Road, London SW3 6HP, UK Co-author: R. B. Logan Sinclair E.

This book constitutes the Proceedings of the 26th Symposium on Acoustical Imaging held inWindsor, Ontario, Canada during September 9-12, 2001. This traditional scientific event is recognized as a premier forum for the presentation of advanced research results in both theoretical and experimental development. The lAIS was conceived at a 1967Acoustical Holography meeting in the USA. Since then, these traditional symposia provide an opportunity for specialists who are working in this area to make new acquaintances, renew old friendships and present recent results of their research. Our Symposium has grown significantly in size due to a broad interest in various topics and to the quality of the presentations. For the firsttime in 40 years, the IAIS was held in the province of Ontario in Windsor, Canada's Automotive Capital and City of Roses. The 26th IAIS attracted over 100specialists from 13countries representing this interdisciplinary field in physical acoustics, image processing, applied mathematics, solid-state physics, biology and medicine, industrial applications and quality control technologies. The 26th lAIS was organized in the traditional way with only one addition-a Special Session "History of Acoustical Imaging" with the involvement of such well known scientists as Andrew Briggs, Noriyoshi Chubachi, Robert Green Jr., Joie Jones, Kenneth Erikson, and Bernhard Tittmann. Many of these speakers are well known scientists in their fields and we would like to thank them for making this session extremely successful.

Avascular Necrosis (AVN) is a disease resulting from temporary or permanent loss of blood supply. It frequently affects the femoral head and in this area, if left untreated, routinely causes premature joint destruction.

In the USA, 5 to 10% of cases of hip osteoarthritis requiring total hip replacement are primarily caused by AVN. In 33 to 72% of patients, the disease is bilateral. The peak incidence is between 30 and 60 years of age, and the social costs of this pathology are remarkable. There is therefore increasing interest in hip joint preserving techniques such as conservative treatment through electromagnetic fields and shockwaves as well as joint preserving surgical techniques. This volume aims to present a complete overview of the current knowledge on AVN including therapeutic options.

The aim of this work was not an exhaustive review of all pediatric echo graphic problems but a presentation of our daily experience with ultrasonography in pediatric practice. Several teams of pediatric radiologists from France and Belgium have combined their experiences to produce a practical book. The different authors have been chosen for their specific experience and their special area of work. The different chapters express therefore personal opinions. Unresolved questions are posed and ultrasonographic examinations are used in the diagnosis of different diseases, while the discoveries and ideas of the individual authors are described. Some fields are not included, such as echocardiography. Gabriel Kalifa Contents Chapter 1. Antenatal Diagnosis by Ultrasonography . . . . . . . . . . . . . . 1 . . . Introduction ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 Ultrasonography of a Normal Pregnancy ...................... 1 2.1 Timing of Successive Examinations. . . . . . . . . . . . . . . . . . . . . . . 1 2.2 Normal Fetal Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2.2.1 Central Nervous System .......................... 3 2.2.2 Chest........................................... 3 2.2.3 Abdomen....................................... 3 2.2.4 Skeletal System . . . . . . . . . . . . . . . . . . . . . . . . 3 . . . . . . . . . .

The history of the use of ultrasound in medicine has been one of evolution of technology and innovative methods of applying this technology to imaging body structures. Many scientists and clinicians have contributed to this evolution. Ophthalmic ultrasound has become an indispensible tool in ophthalmic practice, with its own instrumentation and techniques. Ultrasound frequencies used in ophthalmology have generally been higher than those used in general medicine because of a requirement for higher resolution and a lesser need for deep penetration. Most ophthalmic diagnostic equipment uses frequencies in the 10 MHz range. The use of ultrasound frequencies in the 50-100 MHz range is a relatively new development in ultrasound imaging of the eye. This technique has been developed in our laboratories over the past several years. We have progressed from the theoretical description of the basic science required, past the first in-vitro experiments in eye bank eyes, to the construction of an instrument capable of clinical application. We have gained broad clinical experience with this instrument in normal patients and patients with ocular disease. A commercial instrument based on our original clinical scanner has recently become available, allowing other clinicians to apply this tool to ophthalmic research and clinical practice. We have applied the term ultrasound biomicroscopy to this new imaging technique because of similarities to optical biomicroscopy, i. e. , the observation of living tissue at microscopic resolution.

Surgery an essentially manual exercise in its early days, has progressively grown richer in complementary techniques helping the surgeon to perfect his movements and increase efficiency. This is particularly the case with digestive surgery, which has been thoroughly transformed by radiology, endoscopy and extemporaneous examinations effected during surgical intervention. Such methods make it possible for surgeons to develop subtle nuances in operative techniques and to specify indi cations more and more precisely. Ultrasonography must now be included among such techniques. It supplements them and can sometimes even replace them. For these reasons, this work devoted to the use of ultrasound by the surgeon during surgical intervention is of great interest. Two general conditions had to be met before ultrasonography could be em ployed in abdominal surgery: the method and apparatus had to be adapted to its surgical utilization, and the surgeon had to adapt to a nonsurgical technique. The first condition has been fulfilled for all purposes. Intraoperative sonograms can be generated at a very high rate and are proving to be more and more useful. The miniaturization of probes permits their application almost everywhere with opti mal results. Of course, the costs are still high, but one can expect them to decrease.

For doctors and students who wish to learn ultrasonography concisely yet comprehensively. The authors present the subject both systematically and practically, and with the facility of quick reference in mind, making generous use of flow-charts, tables and teaching-points. All general aspects of diagnostic ultrasound are covered, concentrating on those disorders encountered in the daily routine of scanning, but also referring to rarer conditions which need to be considered in differential diagnosis.

Sonography is a noninvasive diagnostic method that has gained an established place in many branches of medicine. Although the inability of ultrasound to penetrate bone delayed its application in the orthopedic field, the successful work of R. Graf in the early detection of pediatric hip disorders with ultra sound has served as an impetus for the increasing use of sonogra phy to detect and evaluate abnormalities of the musculoskeletal system. It is certain that further advances in this modality will be forth coming, and that sonography will be applied to new lines of inves tigation in orthopedic diagnosis. In Arthrosonography the authors use concise text and copious illustrations to demonstrate the potential applications of articular ultrasound, its diagnostic capabilities, and technical aspects of the ultrasound examination. Potential pitfalls are also explained. This book is the logical outcome of the application of diagnos tic ultrasound in orthopedics and rheumatology. It covers all basic practical aspects of arthrosonography and will be a valued re source for those concerned with the evaluation of the musculo skeletal system. HANS RETTIG Contents Introduction . . . . . . . . . . . . . 1 The Piezoelectric Effect - The Basis of Modem Sonography . . . . . . 1 Ultrasound Techniques. . . . . . . . . . . 1 General Principles of Diagnostic Ultrasound 2 Landmarks for Arthrosonography 6 Artifacts ........ . 6 Reverberations . . . . . 7 Hyperbolic Artifacts . . 7 Acoustic Mirror Image . 8 Special Phenomena in Arthrosonography 8 "Wandering Echo" Phenomenon . ."

Twenty years ago, the enzyme superoxide dismutase which uses the superoxide radical anion as its specific substrate was reported. With this discovery was born a new scientific field, in which oxygen, necessary for aerobi c 1 ife on thi s planet, had to be cons i dered also in terms of its toxicity and stresses. This stimulated the search for knowledge of active oxygen species in biology and medicine. Superoxide and other reactive oxygen species are now implicated in many disease processes. Major advances have been achieved during these past years with respect to free radical generation and mechanisms of free radical action in causing tissue injury. In parallel, the possibil ity of influencing free radical related disease processes by antioxidant treatment was studied in various in vitro and in vivo systems. This was the unique theme of a conference organized in Paris by the Society for Free Radical Research (December 9-10, 1988) which brought together experts from basic sciences and clinicians in order to evaluate the current status of antioxidant therapy. The conference emphasized fundamental processes in antioxidant action. Among the major topics were superoxide dismutase (SOD) and low molecular weight substances with such activity, called SOD mimics. Other antioxidant enzymes were also considered. Antioxidant vitamins, in particular vitamins E and C, other naturally occurri ng antioxidants and vari ous synthet i c antioxidants were included in the presentations as there is now a rapidly developing series of compounds with potentially interesting clinical applications.

Das Buch enth{lt eine Auswahl der Vortr{ge, die auf dem 15. Dreil{ndertreffen der deutschsprachigen Ultraschallgesellschaften gehalten wurden. Damit informiert es }ber neue technische Entwicklungen und den praktischen Einsatz in den verschiedenen medizinischen Fachgebieten.