09. May 2020

When a stroke happens …

May 10th is the “Day against the Stroke”. We think this is an important day, because when a stroke occurs, time is an important factor and the right treatment is necessary. If you have a stroke, you also have to have radiology imaging support and that’s why we at Team Fair Imaging took a close look at the topic and asked what relatives can do and clarified why it is so important even in times of the coronavirus to go to the hospital go.

With Priv.-Doz. Dr. med. We conducted an interview with Eberhard Siebert, senior physician at the Institute of Neuroradiology at Charité, to take a closer look at the topic of stroke.

Priv.-Doz. Dr. med. Eberhard Siebert

Attending, Head of Service

at CCM Institut of Neuroradiology

Charité –Universitätsmedizin Berlin

Please introduce yourself briefly.
As a neuroradiologist, I have specialized in imaging diagnostics and minimally invasive treatment of neurological diseases, a fascinating area. One of my focal points is the treatment of acute stroke. Treatment options in this area have improved tremendously in recent years. Being part of this great progress means a lot to me. As an interventionalist, it is always very nice to see patients recover practically completely on the treatment table after a successful procedure.

What is a stroke?
In the event of a stroke, a blood clot blocks a vein in the brain. The area blocked in this way does not get enough blood and can therefore no longer function normally. It usually dies within hours. The neurological symptoms that arise in this way are therefore still capable of regressing at the beginning if the occlusion is removed in short time. Once the brain part behind the blockade has died, permanent disabilities likely occur.

How can I recognize a stroke?
A stroke usually manifests itself through “sudden”, i.e. suddenly occurring neurological deficits. Typical characters are e.g. a weakness on one side of the body, problems with speaking, not feeling everything, visual disturbances or coordination disorders.

What should be done in this case?
It is of utmost importance to act quickly in this situation. Any hesitation carries the great risk of deterioration. The principle is: Time is brain!, because the brain cannot survive this condition permanently. Calling emergency services at any time of the day or night is therefore urgently required. Patients affected are then brought to a hospital by ambulance, which includes a so-called stroke unit and can treat strokes around the clock.

What is going to be done in the hospital?
First of all, you will undergo an emergency neurological examination and the neurologist will ask you some important questions. Immediately afterwards, a (neuro)radiological imaging of the head is carried out. This can be a CT or an MRI (see Figure 1). These two medical imaging methods can be used to decide on a so-called “revascularization therapy”, that is, a treatment aiming to dissolve or mechanically remove the clot in the brain vessels (Figure 2). In the further course of the hospital stay, the causes of the clot formation are searched for and these are also treated in a targeted manner. The first rehabilitation measures are also being initiated while in the hospital.

Figure 1 Acute stroke can be identified very reliably by means of MRI (arrow). This infarction, which is only as small as a pinhead, lies in the brain supply area of the hand and the patienthad fine motor disorder that suddenly appeared three hours ago with weakness in the left hand.

Figure 2 In the case of severe stroke with large clots that are stuck far down in the vascular tree (left picture, arrow = location of the blockage due to a stuck clot), the clot can be removed with a so-called thrombectomy using a neuroradiological catheter procedure (2nd picture from left: the clot was passed and a so-called stentretriever was released, bridging the clot, recognizable by the punctiform markings). Together with a manual suction on the catheter, the stentretriever with the clot hooked into it was pulled out. The vascular tree is again completely open to all branches (2nd from right, right: catheter and stentretriever with the clot trapped and removed). The patient had sudden and complete paralysis of the left side of the body three hours ago together with feeling weak and having a speech disorder. Minutes after the clot was removed, the patient’s symptoms improved significantly.

Does the new corona virus infection cause strokes?
There is no reliable data on this yet. However, there is increasing evidence that coagulation disorders occur more frequently in people with Covid-19, which then can lead to strokes.

I am very afraid of Corona. Should I avoid hospitals at the moment?
These concerns are quite understandable in the current situation. However, it is of utmost importance that you immediately contact emergency services or the fire department if you suspect a stroke, as this is the only way to obtain the effective therapies described in Figure 2 in the time frame in which the disease can still be treated. Otherwise there is a high risk of permanent severe disabilities that could have been avoided.

We are often asked whether patients should come to the hospital for planned neurological therapies …
Many patients with chronic neurological diseases are permanently followed by neurological consultation services. Our Department of Neurology at Charité has recently started video consultation hours, during which many concerns can be discussed and the medical approach can be defined together with the patients for the next weeks and months. There is also a lot that can be discussed over the phone. For regularly required therapies, e.g. certain infusions, however, a short stay in the hospital is still necessary and recommended in many cases. This is because the current situation is likely to continue for several months and thus treatments should not be delayed.

04. May 2020

If the heart is not beating properly from birth on – congenital heart defects

When a child is born with a congenital heart defect, both parents and doctors are concerned. Although congenital heart defects are by far the most common congenital disease in newborns, there are many questions.

May 5th is the day of the heart-sick child. That was why the Team Fair Imaging talked to Univ.- Professor Dr. med. Felix Berger, the director of the Clinic for Pediatric Cardiology at Charité – University Medicine Berlin and director of the clinic for congenital heart defects – pediatric cardiology at the German Heart Center Berlin.

Univ.- Professor Dr. med. Felix Berger

Felix Berger has been director of the pediatric cardiology clinic at Charité – University Medicine Berlin and director of the clinic for congenital heart defects – pediatric cardiology at the German Heart Center Berlin since 2004.

Born in the Palatinate and formerly an ice hockey player, is a specialist in the treatment of congenital heart defects and heads several international consortia dedicated to the research of therapies for congenital heart defects.

How often are children born with congenital heart defects?

Every 100th newborn is born with a congenital heart defect. With 700,000 to 800,000 live births in Germany, this means that around 7000 to 8000 children are born with a congenital heart defect each year.

When exactly does the congenital heart defect appear and how does it get recognized?

The congenital heart defect occurs in the first weeks of embryonic development at different times during the development of the heart and can be very complex.

Basically, one can expect that about 1/3 of the heart defects are simple heart defects and show a frequent tendency to heal spontaneously or require treatment only in later childhood or adolescence.

Another third are moderate heart defects that need to be treated; treatment can take place until school age.

The last third is very complex and urgent, so treatment for severe congenital heart disease must be done in the newborn or early infant period.

What about the prognosis and the importance of early detection?

The child’s prognosis depends on the timing and accuracy of the diagnosis. This is why prenatal diagnosis is crucial. In experienced hands, it enables the detection and classification of almost all heart defects at an early stage, which then allows pregnancy advice and birth planning in a congenital heart disease center.

The decisive factor is the detection and timely and specific treatment of the heart defect in order to enable survival without irreversible organ damage and a good quality of life.

The successes in the treatment of congenital heart diseases already allow more than 90% of all children with congenital heart diseases to live in good quality of life up to middle to old adult age. The prerequisite for this is permanent support from specialists for congenital heart defects in order to ensure optimal care and therapy control at all times.

How are children with cardiac diseases supported by imaging in pediatric cardiology and radiology?

The most important aspect is the timely and exact diagnosis. It defines the choice and control of therapy. This makes imaging in pediatric cardiology one of the most important tools for diagnosing. The most important working tool is echocardiography (echo) as a non-invasive imaging method, which in almost all cases allows the diagnosis and exact description of the congenital heart defects. Echo also allows control of treatment and outpatient controls visits at any time.

In order to answer specific questions, “sectional imaging” by means of an MRI (X-ray-free) or CT (X-ray-based) is advised (Fig. 1 and 2).

With these examination methods, for example, spatial relationships of vascular connections in the different parts of the heart can be defined. In addition, the positional relationships of the vessels to the chambers, but also the dimensions of the chambers, the spatial relationship of defects and the assignment to the vessel structures can be described pretty well. This additional information alone often makes it possible to decide to what extent a heart defect can be completely corrected or whether preparatory or partially corrective operations are necessary. In addition, there is invasive cardiac catheterization, which has moved away from the diagnostic to the therapeutic aspect in recent years. Cardiac catheterization can be used, for example, to measure the pressure in different heart and vessel sections. Today, however, cardiac catheterization is used to optimally carry out minimally invasive treatments for mild to moderate heart defects without surgery for the individual patient.

What are the challenges in treating these children in pediatric cardiology?

In addition to timely diagnosis, the initiation of specific therapy for heart defects is crucial. The primary goal is not only to treat the heart defect as correctively as possible, but also to achieve the best life prospects with maximum quality of life. Avoiding accompanying organ damage (lung / kidney / brain) has highest priority and the interaction of experts in a multidisciplinary team is an important prerequisite.

Here, the contribution of the respective specialist expertise in radiology, pneumology, nephrology and neurology plays a central role in addition to cardiological and cardiosurgical care. Risks such as radiation exposure are particularly important in order to avoid long-term consequences or other illnesses in later life. It is always about finding the most gentle form of therapy and diagnosis without having to accept a deficit of information.

Which family aspects are considered in the treatment in pediatric cardiology?

A congenital heart defect affects not only the individual patient, but also the whole family. Be it the clarification of a possible inheritance of the heart defect or the explicit information of the parents and later of course also of the patient him- or herself about the heart defect and the resulting consequences such as resilience or restrictions in daily life or special features relating to school or training .

All of this influences the social structure of the family. Special care by psychosocial staff and psychologists is therefore important during treatment.

The parents’ fears and insecurities about the present heart defect and the prospects often pose major problems that can only be addressed comprehensively through the transparent handling of all information and the sensitive integration of all psychosocial support services.

Fig. 1: CT diagnosis of an infant (1 month) with a complex early childhood heart defect. Precise knowledge of the anatomy is essential for precise diagnosis of the therapy. The examination was carried out on a state-of-the-art CT, which enables a quick examination with very low radiation dose. A-D shows a clearly changed anatomy of the heart, which is on the patient’s right side (B-D). In addition to other anatomical changes, it is also noticeable that the second main cavity of the heart (C *) is reduced in size. There is also a pathological connection between the two atria and the large cardiac cavities (à). The flow of blood to the heart is also different in this patient than usual, the lower vena cava is not created. Instead, the blood from the legs is passing through a continued vein from the abdominal cavity (azygos vein) to the right heart, which runs parallel to the main artery (A, B *).
© Dr. Thula Walter-Rittel
Fig. 2: Emergency CT diagnosis in a young girl after surgical replacement of the main artery.
Young patient who received a surgical replacement of the aorta due to a congenital dilation. The patient came to the clinic in an emergency with severe chest pain. The CT diagnostics were started immediately to rule out rupture of the aorta and occlusion of the coronary arteries. With modern CT technology, a quick and accurate diagnosis is possible. The CT shows the aortic replacement without rupture signs (A, B à), as well as the open coronary arteries (C *).
© Dr. Thula Walter-Rittel

Interdisciplinary Team members contributing to this blog post in addition to Prof. Berger:

Dr. Thula Walter-Rittel, Dr. Sven-Christian Weber-Bärenbrinker, Bernd Opgen-Rhein, Priv.-Doz. Thomas Elgeti, Prof. Marc Dewey

04. March 2020

Fair Imaging: Patient Perspective

by @BirgitPower on #FairImaging

Honestly: when I had my first MRI, which was in 2005, I was in a very emotional situation. I, the panic in person, second name claustrophobia, should enter this rattling and loud device. I was alone. Nobody explained anything to me, there was only one assistant who was stressed and who just managed to hand me the emergency button, which was good and I also used it.

In short, we did it. Somehow. We both were stressed and I was intimidated at that time. Today, I would respond and explain to her that I have a right to proper information if I have to sign consent. But that is today and I am well informed and I can respond accordingly if necessary.

Something that lasted, and there are still many people who need examinations, for example in radiology, who just can’t stand up for themselves. Factors include language problems with a migrant background or a lack of health literacy and knowledge of their own patient rights. Many little things can play a role. Sometimes you are intimidated and lack the courage to speak up or ask questions. Understandable, such situations are often perceived as threatening. You are afraid. In addition there are endless waiting times and sometimes you think you will be put in the back. Is that so? Who knows.

How do you know if everything medical is going the way it should be if you are fighting emotionally anyway?

Time to take a closer look. When Prof. Marc Dewey, radiologist at Charité in Berlin, invited me to participate in a study on “social cohesion” and in the #FairImaging project as a patient advocate, I was happy to agree. Because I’m interested and with MS we also have to undergo MRI regularly (or not) to monitor the progress of the MS. To say it in this way: it is very interesting! 

Prof. Dr. Marc Dewey
Prof. Dr. Marc Dewey, Charité Radiology Department

But to explain you more, I invited Prof. Dewey to tell us more about the Initiative #FairImaging:

Why do we do #FairImaging?

An illness is suspected and you get admitted to a hospital: Tests such as medical imaging is often carried out to identify the disease you may have. Will you get the right imaging? Will it be at the right time? Do all patients get what they need medically? Can patient safety be further improved?

What do we do in #FairImaging?

We analyze whether socio-economic factors are associated with medical imaging. In other words: do all patients get the imaging they need in a short time?

How do we do #FairImaging?

FairImaging is a transdisciplinary project. That means working with representatives from society and not just science on these issues. In particular, the experiences and knowledge of patients are essential in order to better understand relationships.

Which scientists are in #FairImaging?

Professors from all three universities in Berlin and Charité from different fields. In this way, we ensure the necessary competence and work in an interdisciplinary manner.

Was could be the result of #FairImaging?

Medical care could be improved by adapting imaging, individually and live, to the background of patients and medical requirements.

#FairImaging is a consortium of more than 20 experts from different scientific areas. We are working in small working groups on different aspects of the project and will come together next on March 6, 2020 to exchange our results and also discuss about the report in May. 

You want to know more? 

On Prof. Dewey`s website you can find more under “Fair Imaging”: https://marcdewey.de/fairimaging/

You can follow Prof. Dewey on twitter: https://twitter.com/ProfDewey

We established already the #FairImaging and send tweets out. 

At the moment we are working on a strategy to deliver more content on twitter to inform you better in the future. 

So: More to come!