Sebastian Harth

Pulmonary artery pulse wave velocity derived from phase-resolved functional lung MRI was higher in pulmonary hypertension and independently associated with right ventricular function and 12-month mortality.

Background/Objectives: The assessment of endometriosis (EMS)-associated pain is important, but only very few studies address the potential use of questionnaires for non-invasive prediction of the disease. Methods: In a prospective observational study from 2016 to 2024 with patients (n = 228) using hormonal contraception, all women with suspected EMS answered two questionnaires and were examined physically and with transvaginal ultrasound (TVUS). If deep infiltrating EMS (DIE) was suspected, magnetic resonance imaging (MRI) was performed. EMS diagnosis was confirmed by histological examination. Statistical analysis was mainly performed using 2 × 2 contingency tables. The decision tree was created manually. Results: The mean numerical rating scales (NRSs) of EMS-positive compared to EMS-negative patients were ~4-fold higher (4.45 and 1.15, respectively). Patients with EMS have, significantly, ~3 times more significant parameters compared to patients without EMS (18.5 and 5.9, respectively). In combination with dysuria and lightning-like pain, this resulted in very good prediction. A decision tree yielded a sensitivity of 0.924, a specificity of 0.917, a positive predictive value (PPV) of 0.924, a negative predictive value (NPV) of 0.917, and a positive likelihood ratio of 11.2, indicating a very good diagnostic test. There is no typical endometriosis pain, but various pain patterns are predictive of EMS. Conclusions: Thus, a reliable non-invasive EMS diagnosis by questionnaires is possible and could reduce the delay in the detection of EMS.

Uterine fibroids, or leiomyomas, are benign uterine tumors with a lifetime prevalence of approximately 75%. While only a minority become symptomatic, their impact on quality of life remains profound owing to heavy menstrual bleeding, bulk symptoms, and reproductive dysfunction. Interestingly, fibroids are not reliably diagnosed on physical examination, nor can their impact be predicted through palpation. Consequently, the diagnosis and phenotypic categorization of uterine fibroids relies primarily on imaging to guide subsequent clinical management. Ultrasound should be the first‐line diagnostic modality, and magnetic resonance imaging should be reserved for complex cases and/or surgical planning. Adherence to standardized structured reporting across imaging modalities is critical to improve diagnostic accuracy, differentiate fibroids from conditions such as adenomyosis or malignancies, predict therapeutic responses, and plan surgical interventions. Imaging reports should follow the FIGO classification system for uterine fibroids, to enable a standardized description of their relationship to the endometrium, myometrium, and uterine serosa.

Anogenital distance (AGD) is regarded as a potential biomarker for endometriosis, and a measurement on MRI images has been found to be promising. This study aimed to evaluate the measurement of AGD on MRI to predict the surgical diagnosis of endometriosis. We included 127 patients who received an MRI for endometriosis between October 2018 and February 2023. AGD was measured on MRI by two readers (MRI-AGD-AC: clitoris to anus; MRI-AGD-AF: posterior fourchette to anus). The feasibility and interobserver reliability of AGD measurements were evaluated. Differences in AGD between patient groups were analyzed. The intraclass correlation coefficient estimates indicated a good to excellent reliability of MRI-AGD-AC (0.92; 95% CI: 0.83–0.95) and a poor to good reliability of MRI-AGD-AF (0.68; 95% CI: 0.27–0.83). No statistically significant differences in the mean MRI-AGD-AC and MRI-AGD-AF in patients with and without surgical diagnosis of DIE (p = 0.413; p = 0.110), peritoneal endometriosis with and without DIE (p = 0.641; p = 0.323), and ovarian endometriosis (p = 0.155; p = 0.150) were found. The AUC ranged from 0.475 (95% CI: 0.365–0.584) to 0.586 (95% CI: 0.454–0.718). Thus, AGD does not constitute a valuable biomarker for patients with clinically suspected endometriosis.

Objectives: This study aimed to analyze the prevalence and clinical significance of incidental findings on MRI for endometriosis. Differences between patients with and without evidence of deep infiltrating endometriosis on MRI were to be examined.Methods: This was a retrospective, descriptive cross-sectional single-center study. All patients who received a pelvic MRI for endometriosis between April 2021 and February 2023 were included. The presence and frequency of incidental findings were noted after review of all MR images and radiology reports. The potential clinical significance of the findings was analyzed. Differences in the frequency of incidental findings between patients with and without evidence of deep infiltrating endometriosis on MRI were evaluated, utilizing the Chi-square test, Fisher's exact test and Mann–Whitney U-test.Results: 303 consecutive patients (mean age, 33.4 years ± 8.3) were evaluated. Incidental findings were noted in 299/303 (98.7%) patients. Most frequently, ossification of the hip acetabular rim and degenerative changes of the lumbar spine were noted. In 25/303 (8.3%) patients, incidental findings had high clinical significance. For specific incidental findings, significantly higher prevalences were found in patients with than in patients without evidence of deep infiltrating endometriosis on MRI (hip acetabular rim ossification, p = 0.041; annulus fibrosus fissures, p = 0.006; gallstones, p = 0.042).Conclusions: Incidental findings are very common on pelvic MRI for endometriosis. The detection of incidental findings can lead to the diagnosis of relevant diseases and thus enable early treatment. On the other hand, many incidental findings have no, only minor, or uncertain consequences.

As a second-line imaging modality for leiomyomas (syn. fibroids) to sonography in clinical routine, MRI offers the advantages of a large field-of-view, multiplanarity and excellent soft-tissue contrast. MRI can accurately aid therapeutical planning (surgical and interventional) and helps in the detection of differential diagnoses (e.g. malignancy, inflammation). The basic MRI imaging protocol for leiomyomas, recommended by the European Society of Urogenital Radiology (ESUR), includes an axial T1W sequence as well as sagittal and axial T2W sequences; if necessary, supplemented by dynamic contrast sequences and optional diffusion-weighted images (DWI) in the case of indeterminate adnexal masses, rapidly growing uterine masses or T2W-hyperintense leiomyomas (Kubik-Huch RA et al. Eur Radiol 2018; 28: 3125–3137). Whereas leiomyomas without degeneration or variant histologic subtype can be diagnosed with confidence on MRI, the various types of degeneration (hyaline, cystic, myxoid, red/carneous, calcific, post-embolization) can significantly alter imaging appearance with overlapping features of malignant or infectious disease. We report a case of extrahepatic, pelvic cystic echinococcosis in contact with the uterus, mimicking degenerated leiomyomas. Received: 11 May 2023 Accepted after revision: 13 November 2023 Article published online: 05 December 2023 © 2023. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Mitral annular disjunction (MAD) refers to a structural abnormality of the mitral annulus in which a section of the mitral valve leaflets attaches to the atrial wall at a location away from the junction of the left atrial and left ventricular myocardium. Although first described in 1981 [Bharati S et al. Am Heart J 1981; 101 (5): 667], MAD has recently attracted more attention because of the growing body of evidence suggesting a potential relationship between MAD and ventricular arrhythmias and sudden cardiac death (SCD). It is most commonly diagnosed by transthoracic echocardiography, but findings may be subtle, and further cardiac imaging such as MRI may be necessary. Although not a very recent entity, it is possible that MAD may not be a well-known diagnostic consideration among the radiology community. To increase awareness for this abnormality, we present a previously asymptomatic young patient who needed cardiopulmonary resuscitation due to ventricular fibrillation. After a comprehensive evaluation, mitral valve prolapse (MVP) and MAD were found as the only culprits that may explain her malignant arrhythmia. A 27-year-old woman with no previous medical history had a cardiac arrest at home. She was found to have ventricular fibrillation. After cardioversion, she was intubated. Blood tests were normal other than slightly increased cardiac enzymes that could be due to resuscitation. Transthoracic echocardiography performed in the emergency setting had shown slightly reduced left ventricular function. Subsequently, the patient underwent contrast-enhanced cardiac MRI. On MRI, there was late systolic mitral valve prolapse and regurgitation. It was also noted that the patient had MAD with a distance up to 15 mm between the left atrial insertion of the posterior mitral leaflet and the posterior/posterolateral left ventricular myocardium ([Fig. 1], [Fig. 2]). Left ventricular function was normal. Along with a small pericardial effusion, cardiac MRI also showed mild hypertrophy of the basal myocardium on the inferolateral, inferior, and inferoseptal wall. No late gadolinium enhancement (LGE) was found. Left ventricular global T1 relaxation times were found to be slightly increased (990–1080 ms) that could be attributed to minimal edema due to resuscitation. Later, an implantable cardioverter-defibrillator was placed for secondary prevention of malignant arrhythmias and SCD. The mitral annulus is a D-shaped structure with a straight anterior component and a curved posterior part. The posterior mitral annulus consists of four structures which are held together by a fibrous cord: the left atrial wall, the leaflet hinge line, the LV free wall, and the epicardial adipose tissue [Wu S et al. Front Cardiovasc Med 2022; 9 DOI: 10.3389/fcvm.2022.976066]. In MAD, the leaflet hinge line is located more superiorly toward the atrial wall, resulting in a gap between the valve-atrium junction and the left ventricular myocardium. This separation of the annulus from the ventricular myocardium results in a paradoxical motion of the annulus where instead of contraction, it expands with ventricular systole and causes the mitral annular diameter to increase. Depending on the patient population, imaging modalities used, and the definition of MAD, varying prevalences have been reported in the literature. Konda et al. reported a prevalence of 8.6% in a cohort of 1439 patients who underwent transthoracic echocardiography [Konda T et al. J Echocardiogr 2017; 15: 176]. In a systematic review, the pooled prevalence of MAD in patients with mitral valve prolapse and/or Barlow’s disease was found to be 30.1%. [Bennett et al. Echocardiography 2022; 39 (3): 514]. The exact relationship between MAD and MVP is not clear. It has been shown that MAD is associated with malignant arrhythmia in patients with or without MVP [Dejgaard LA et al. J Am Coll Cardiol 2018; 72 (14): 1600]. The exact mechanism of arrhythmia in MAD is also not elucidated but it is thought that aberrant dynamics of the annulus and papillary muscles seen in MAD may cause myocardial fibrosis and arrhythmia [Drescher CS et al. Circ Cardiovasc Imaging 2022; 15 (9) DOI: 10.1161/circimaging.122.014243]. The diagnosis can be made by echocardiography, CT, or MRI. However, it was shown that MRI is more sensitive compared to both transthoracic and transesophageal echocardiography (with sensitivities of 42.0%, 17.3%, and 25.5%, respectively) [Mantegazza V et al. Heart 2021; 107: 25]. For the MRI evaluation of patients with MAD, in addition to standard two-chamber, three-chamber, four-chamber, and short-axis steady-state free precession images, obtaining mitral valve images perpendicular to the coaptation line and parallel to the valve plane is suggested [Musella F et al. Clin Radiol 2022; 77 (2) DOI: 10.1016/j.crad.2021.11.004]. Volumetric analysis of the left ventricular function and aortic phase-contrast sequences are useful for the quantitative evaluation of mitral regurgitation. Myocardial fibrosis, which can be seen in patients with MAD, can be assessed with LGE imaging. The MAD distance, which is the gap between the valve-atrium junction and the left ventricular myocardium, is more prominent and usually measured at end-systole. Although there is not a clear cut-off value for the diagnosis and distances ranging from more than 1 millimeter to more than 10 millimeters have been reported, it has been shown that increasing length of the MAD gap is associated with an increased rate of arrhythmic events. Papillary muscle fibrosis seen on LGE imaging on MRI is also found to be related to arrhythmia [Dejgaard LA et al. J Am Coll Cardiol 2018; 72 (14): 1600]. Currently, there is not a clear strategy for the management of patients with MAD. Implications of MAD in terms of follow-up care, preventing sudden cardiac death, and determining the need for mitral valve intervention are presently uncertain. In summary, the significance of mitral valve prolapse and...

Objectives: The purpose of this investigation was to evaluate the inter- and intraobserver variability of the updated #Enzian classification of endometriosis on MRI and to evaluate the influence of reader experience on interobserver concordance.Methods: This was a prospective single-center study. All patients were included who received an MRI of the pelvis for evaluation of endometriosis between March and July 2023 and who have provided written informed consent. Images were reviewed independently for endometriosis by three radiologists, utilizing the MRI-applicable categories of the #Enzian classification. Two radiologists had experience in pelvic MRI and endometriosis imaging. One radiologist had no specific experience in pelvic MRI and received a one-hour briefing beforehand.Results: Fifty consecutive patients (mean age, 34.9 years ±8.6 [standard deviation]) were prospectively evaluated. Interobserver agreement was excellent for diagnosis of deep infiltrating endometriosis (Fleiss’ kappa: 0.89; 95% CI 0.73–1.00; p < 0.001) and endometriomas (Fleiss’ kappa: 0.93; 95% CI 0.77–1.00; p < 0.001). For the experienced readers, interobserver agreement in the assessment of compartments A, B and C was excellent (κ_w ranging from 0.84; 95% CI 0.71–0.97; p < 0.001 to 0.89; 95% CI 0.82–0.97; p < 0.001). For the pairings of the experienced readers to the reader without specific experience in pelvic MRI, agreement was substantial to excellent (κ_w ranging from 0.64; 95% CI 0.44–0.85; p < 0.001 to 0.91; 95% CI 0.84–0.98; p < 0.001). Intraobserver variability was excellent for compartments A, B and C (κ_w ranging from 0.85; 95% CI 0.73–0.96; p < 0.001 to 0.95; 95% CI 0.89–1.00; p < 0.001).Conclusion: With sufficient experience, the #Enzian classification enables the achievement of excellent inter- and intraobserver agreement in MRI-based diagnosis of deep infiltrating endometriosis and endometriomas.