Color Doppler Appearance Research Articles

Assessment of scrotal disorders using ultrasonography and Color Doppler Imaging

Background and Aim: An acute scrotum is defined as acute pain with or without scrotal swelling, may be accompanied by local signs or general symptoms. Ultrasound is an ideal imaging modality for the evaluation of scrotum in pediatric patients. Scrotal ultrasound can differentiate between solid and cystic masses and localize the mass as either testicular or Para testicular. The present study was aimed to know role of ultrasound and color Doppler imaging in the diagnosis of scrotal disorders. Material and Methods: It was prospective study conducted at Tertiary care teaching Hospital. We observed total 200 patients referred to the department of Radiodiagnosis for scrotal ultrasonography and Doppler study by the department of Surgery. Clinical history was obtained along with thorough physical examination before subjecting the patients for ultrasound examination. The Grey scale & color Doppler ultrasound routinely performed in all these patients. Results: Majority of cases had inflammatory lesion (32%) followed by hydrocele (28%), hernia (9%), undescended testis (8%) and scrotal tumors (3%). In majority of cases left side involved (36%) followed by right side (32%) while 64 cases bilateral side involved. With color doppler appearance of inflammatory scrotal pathology we found that there were 19 cases of acute epididymo orchitis, 10 cases with diffuse increase in vascularity. Among 5 cases of chronic epididymo-orchitis, 4 cases showed increase in vascularity. Conclusion: High-frequency ultrasonography enables in clear demonstration of morphological alterations associated with acute scrotal inflammatory diseases, and color Doppler sonography is highly sensitive in diagnosing acute scrotal pathology. In addition, Color Doppler sonography accurately differentiates between testicular ischemia and torsion from acute inflammatory diseases in acute painful scrotal conditions.

English

Hematocele with blunt scrotal trauma is an uncommon cause of the testicular pain. Elastography is the new recent advance in the field of ultrasound. USG and elastography findings of the acute hematocele is described in this aricle. Testicular trauma is the third most common cause of acute scrotal pain,1 and high-frequency ultrasonography (USG) with a linear array transducer is the first preferred modality for testicular trauma evaluation. Extra testicular haematoceles or blood collections inside the tunica vaginalis are the most common findings in the scrotum after blunt injury.2 On clinical assessment, haematocele appears as a hard mass like swelling and causes pain in the scrotum. In the majority of cases, spontaneous resolution occurs with the support of conservative therapy,3 even if treated conservatively, may result in infection, discomfort, or atrophy in undiagnosed broad hematoceles and testicular hematomas over time.4 A testis with its coverings, epididymis, and spermatic cord are all contained in each hemiscrotum. A typical testis is 5 x 3 x 2 cm in diameter and has an intermediate echogenicity. The tunica albuginea is a fibrous covering that protects the testis from damage from the external injuries. It is located on top of the tunica vasculosa, which is made up of capsular arteries. A testis with its coverings, epididymis, and spermatic cord are all contained in each hemiscrotum. With its high tensile strength, the tunica albuginea plays an important role in shielding the testis from trauma. It can withstand a force of up to 50 kg without bursting. The testicular parenchyma is made up of several lobules, each of which is made up of several seminiferous tubules that lead to dilated spaces inside the mediastinum called the rete testis through the tubuli recti. The epididymis is made up of a head, neck, and tail that protects the superolateral part of the testis. The epididymis' tail ends in the spermatic cord as the vas deferens. The epididymal head is a 5 – 12 mm pyramidal structure that sits atop the testis' superior pole. The head is almost isoechoic to the testis. The epididymis has a 2 – 4 mm thick body.5 The patient lies in a supine position with the scrotum covered by a towel positioned between the thighs during scrotal ultrasound. A high-frequency lineararray transducer with a frequency range of 7 – 14 MHz is preferred. The scrotum is always soft to the touch after trauma, making scanning difficult. It should be attempted to examine both the testes and the epididymis in their entirety, as well as any extra testicular lesions. The testes are assessed in two planes: longitudinal and transverse. Each testis and epididymis should be compared to the contralateral testis and epididymis in terms of size and echogenicity. Transverse scrotal imaging is important for depicting both testes and comparing their gray-scale and colour Doppler appearances.

What every radiologist should know about adnexal torsion.

Adnexal torsion is the fifth most common gynecologic surgical emergency, requiring clinician and radiologist awareness. It involves the rotation of the ovarian tissue on its vascular pedicle leading to stromal edema, hemorrhagic infarction, and necrosis of the adnexal structures with the subsequent sequelae. Expedient diagnosis poses a difficult challenge because the clinical presentation is variable and often misleading. Adnexal torsion can mimic malignancy as it can take a subacute, intermittent, or chronic course, and thereby can be complicated to diagnose. The torsion may occur in the normal ovary but is usually secondary to a preexisting adnexal mass. Early surgery is necessary to avoid irreversible adnexal damage and to preserve ovarian function especially in children and young women. Pelvic ultrasound forms the foundation of diagnostic evaluation due to its ability to directly and rapidly evaluate both ovarian anatomy and perfusion. Moreover, it is a noninvasive and accessible technique. However, the color Doppler appearance of the ovary should not be relied upon to rule out torsion because a torsed ovary or adnexa may still have preserved arterial flow due to the dual blood supply. MR and CT may be used as problem-solving tools needed after the ultrasound examination but should not be the first-line imaging modalities in this setting due to ionizing radiation and potential time delay in diagnosis. The goal of this article is to review the adnexal anatomy, to familiarize radiologists with the main imaging features, and to discuss the main mimickers and the most common pitfalls of adnexal torsion. Main points Adnexal torsion is an uncommon gynecological disorder caused by partial or complete rotation of the ovary and/or the Fallopian tube about the infundibulopelvic ligament. The ovaries receive a dual blood supply from the ovarian artery and uterine artery. The lack of pathognomonic symptoms and specific findings on physical examination makes this entity difficult to diagnose. Since the right adnexa are most commonly involved, symptoms may mimic acute appendicitis. Persistence of adnexal vascularization does not exclude torsion. In the pediatric age group, gray-scale ultrasound is the best modality of choice. Obtaining CT and/or MR images should not delay treatment in order to preserve ovarian viability.

Flaming portal vein as a new color Doppler sign of portal gas: report of two cases.

Portal gas is relatively rare, and the majority of reported cases have shown it to have a close relation to bowel diseases. At present, portal exploration usually begins with color Doppler sonography, and clinicians now possess a good understanding of color Doppler findings of a wide spectrum of portal abnormalities. However, the color Doppler sign we present in this article has not been reported before. We report two cases of ischemic bowel disease in which B-mode ultrasound showed multiple hyperechoic spots moving in the portal vein; the color Doppler appearance was as if the portal vein was on fire (flaming portal vein sign). Knowledge of this simple color Doppler sign helps to improve the diagnostic strategies in patients with portal gas.

Color doppler appearance of penile cavernosal-spongiosal communications in patients with high-flow priapism

Superselective embolization of the torn artery is currently considered the treatment of choice for patients with high-flow priapism. After embolization, however, the arterial-sinusoidal fistula is still patent in a significant percentage of patients, despite arteriographic evidence of occlusion. To investigate the prevalence and flow characteristics of penile cavernosal-spongiosal communications (CSCs) in patients with high-flow priapism, and to establish whether the recognition of these vessels before and after angiographic embolization has a role in predicting the outcome of therapy. Twelve consecutive patients with high-flow priapism underwent penile color Doppler ultrasound before and after angiographic embolization of the arterial-sinusoidal fistula. The prevalence of CSCs feeding the fistula was evaluated before and after embolization. Before angiographic embolization, color Doppler ultrasound identified five CSCs in 3/12 patients. One CSC was proximal to the fistula, and 4/5 were distal. After angiographic embolization, the fistula was not completely closed in these patients, fed by the distal CSCs. However, spontaneous closure occurred within 1 month. The fistula was also fed by CSCs in another two patients in whom these vessels were not evident before embolization. In one case, the fistula closed spontaneously within 1 week, while in the other case the fistula remained patent, fed by other collateral vessels. The type of vessels that are involved in refilling the fistula after embolization is of concern for the outcome of the patients. In our series, the fistulas supplied only by CSCs closed spontaneously within 1 month. Watchful waiting should be preferred to repeated embolization to avoid the risk of unnecessary procedures.

Prostate Cancer Associated with Hemorrhagic Cyst: Findings on Transrectal Doppler Sonography

Cysts in the region of the prostate are common and may present as either intraprostatic or periprostatic. However, a hemorrhagic cyst in this area is unusual. A 62-year-old man was transferred to our hospital for elevated serum prostate-specific antigen (502 ng/mL). A digital rectal examination revealed a non-tendered fluctuation over the prostate, masquerading as an abscess-like lesion. The urine was sterile. Transrectal sonography revealed a cystic lesion over the apical portion of the prostate. On color and power Doppler appearance, mildly increased vascularity but asymmetric distribution was found. With the patient's consent, about 20 mL of sterile, non-coagulant, dark, bloody fluid was aspirated under sonographic guidance. After aspiration, the prostate outline returned to a near normal but existed as an echo-heterogeneous entity. Bilateral sextant biopsy was simply performed thereafter and pathology showed adenocarcinoma from each core (Gleason score, 4 + 5/10). Hormonal therapy was administered because of multiple bony metastases. However a cyst in this area is unusual. We herein report a newly diagnosed prostrate cancer associated with a hemorrhagic cyst which was masquerading as a abscess-like lesion. The Doppler transrectal sonographic appearance of this particular case of prostate cancer is also described.

Intratesticular varicocele: evaluation using grey scale and color Doppler ultrasound

Intratesticular varicocele is a rare condition with a variable clinical and ultrasound presentation. The purpose of this study was to evaluate the grey scale and color Doppler appearances of intratesticular varicocele (ITV). Herein we present seven new cases of intratesticular varicocele. From 2003 to 2005 we evaluated 342 patients referred to our department for routine andrological evaluation by scrotal color Doppler ultrasound. We detected seven entirely asymptomatic cases of ITV by use of grey scale ultrasound. In color Doppler sonography the patients showed retrograde blood flow, either spontaneously or during Valsalva manoeuvre. In all seven cases left side ITV with testicular volume disproportion between the right and left testis (2 ml) was found. Five patients had an extratesticular varicocele. In all patients the diameters of intratesticular vein were less than 2 mm. Intratesticular varicocele is a clinically occult lesion that may occur in association with extratesticular varicocele. Further investigations are needed to clarify its clinical significance, however, considering the temperature mediated damage on the affected testis, it is our opinion that all ITV must be considered for treatment even if an extratesticular varicocele is not present.

Sonography of the Acute Scrotum: The Four T’s of Testicular Imaging

The scrotum is frequently imaged on an emergent basis. The differential diagnosis of the acute scrotum can be divided into four categories-torsion, trauma, tumor, and "testiculitis" (epididymo-orchitis). Although testicular neoplasms are not imaged emergently, 15% are detected incidentally when performing an emergent scrotal ultrasound. Therefore, the emergent sonographic examination of the testicles should include a thorough search for malignancy. Images demonstrating the sonographic and color Doppler appearances of each of the "four T's" will be reviewed. The radiographic review will focus on the imaging features, which are the keys to arriving at the correct diagnosis.

Intratesticular Varicocele

The purpose of this study was to evaluate the gray scale and color Doppler appearances of intratesticular varicocele (ITV) in a relatively large series of men and to compare the findings with those previously reported. Fifteen ITVs found in 12 men referred for sonographic examination of a variety of scrotal conditions were retrospectively evaluated. Review of the side, location, shape, and diameter of the dilated veins, the presence of an extratesticular varicocele (ETV), and the color Doppler appearance of the ITV before and during the Valsalva maneuver was performed. Seven (47%) of 15 ITVs were located in the left testis, 2 (13%) in the right, and 3 (20%) bilateral. Eighty-six percent of the ITVs were associated with an ipsilateral ETV. The locations of the ITVs were subcapsular in 60% of the cases and within or near the mediastinum of the testis in 40%. The shapes of the ITVs were tubular in 46%, oval in 27%, and both tubular and oval in the remaining 27%. Color Doppler imaging showed spontaneous flow in 60% of cases, whereas in the remaining 40%, the blood flow could be seen only after the Valsalva maneuver. Intratesticular varicocele is a rare condition with a variable clinical and sonographic appearance. It is usually associated with ETV. It occurs in the left, right, or both testes and may be subcapsular or mediastinal in location. The prevalence of a subcapsular location of ITVs in this series was by far higher than previously mentioned in the literature. The Valsalva maneuver plays a very important role in the diagnosis of ITV because in almost half of cases, the flow will not show up spontaneously.

Intratesticular varicocele

Extratesticular varicocele is a common clinical condition, occurring in up to 20% of the normal adult male population. It is characterized by dilatation of the veins of the spermatic cord and has well-described sonographic appearances. Intratesticular varicocele is characterized by dilated intratesticular veins and is extremely rare. It usually, but not always, occurs in association with an ipsilateral extratesticular varicocele. We describe the sonographic and colour Doppler appearances of this poorly described entity in a middle-aged man referred for evaluation of a painful left testicular swelling.

Metastatic Choriocarcinoma to the Breast: Appearance on Mammography and Doppler Sonography

Kalra N, Ojili V, Gulati, M, Prasad GRV, Vaiphei K, Suri S etastases to the breast are uncommon, and there are few reports of the radiologic features of metastatic malignant tumors of the breast [1]. Choriocarcinoma is a rare extramammary source of breast metastases [2, 3]. In this case report, we describe the mammographic and color Doppler appearances of metastatic choriocarcinoma to the breast that have not been previously described, to our knowledge, in the literature.

Can color Doppler sonography aid in the prediction of malignancy of thyroid nodules?

To determine whether color Doppler interrogation of a thyroid nodule can aid in the prediction of malignancy. We obtained color Doppler images of thyroid nodules undergoing sonographically guided fine-needle aspiration. The color Doppler appearance of each nodule was graded from 0 for no visible flow through 4 for extensive internal flow. The size, sonographic appearance, results of fine-needle aspiration, and surgical pathologic findings, if available, were recorded for each nodule. There were 254 nodules sampled, of which 32 were malignant (all confirmed at surgery) and 177 were benign. Fourteen (43.8%) of the 32 malignant nodules were color type 4, compared with only 26 (14.7%) of the 177 benign nodules (P = .0004, Fisher exact test). Thirteen (40.1%) of the 32 malignant nodules were solid, as were 18 (10.2%) of the 177 benign nodules (P = .006, Fisher exact test). Among solid nodules, the prevalence of malignancy was greater when the nodule was hypervascular (13 [41.9%] of 31) than when the color type was less than 4 (11 [14.7%] of 77; P = .004, Fisher exact test). Solid hypervascular thyroid nodules have a high likelihood of malignancy (nearly 42% in our series). The color characteristics of a thyroid nodule, however, cannot be used to exclude malignancy, because 14% of solid nonhypervascular nodules were malignant.

Color Doppler appearance of penile cavernosal-spongiosal communications in patients with severe Peyronie's disease.

Our objective was to investigate the prevalence and Doppler characteristics of penile cavernosal-spongiosal communications (CSC) in patients with severe Peyronie's disease. These vessels are either anastomoses connecting the cavernosal arteries with the urethral arterial network or afferent vessels to the corpus spongiosum. Twenty patients with severe Peyronie's disease underwent penile color Doppler US after intracavernous injection of prostaglandin E(1). Study inclusion criteria were penile curvature or shortening which made intercourse difficult or impossible. The quality of erectile response was subjectively scored. The spectral characteristics of CSC were evaluated in comparison with waveform changes in cavernosal artery. There were 4 patients with normal erectile response, 10 with discrepancy in rigidity of the penile base and tip, 4 with veno-occlusive dysfunction and 2 with arteriogenic dysfunction. The CSC just proximal to the plaques had peak systolic velocity (PSV) significantly higher and resistance index (RI) significantly lower than the other CSC. The PSV in CSC near the plaques of patients with base-tip discrepancy and with veno-occlusive dysfunction were significantly higher than in the other patients. In patients with severe Peyronie's disease CSC near the plaques remain patent with low-resistance flow supporting the hypothesis that blood leakage can occur through these vessels.

Color Doppler appearance of penile cavernosal-spongiosal communications in patients with normal and impaired erection.

Our objective was to investigate prevalence and Doppler characteristics of penile cavernosal-spongiosal communications (CSC). These vessels are either anastomoses connecting the cavernosal arteries with the urethral arterial network or afferent vessels to the corpus spongiosum. Sixty-one consecutive patients underwent penile color Doppler US. Waveform changes in CSC were evaluated in comparison with changes in the cavernosal artery. Eighteen of 61 patients had normal erection, 17 of 61 had arterial insufficiency, and 26 of 61 had veno-occlusive dysfunction. Resistance index (RI) in CSC was significantly lower than in cavernosal arteries in all patients and increased during phases 1-2 (positive diastolic flow). Peak systolic velocity (PSV) in CSC was significantly higher in the patients with veno-occlusive dysfunction. During cavernosal phase 4 (diastolic flow reversal) CSC of patients with normal erection or with arterial insufficiency disappeared, underwent markedly reduced diastolic flow, or had systolic flow inversion. Conversely, low resistance flow was appreciable in CSC of patients with veno-occlusive dysfunction who reached phase 4. During phase 5 (systolic peak reduction) all CSC disappeared. Color Doppler US allows evaluation of CSC both in patients with normal and impaired erection.

The Role of Colour Flow Doppler in the Investigation of the Salivary Gland Tumour

AIMS: Ultrasound is a highly effective imaging technique to determine salivary gland tumours and may help to identify many benign lesions. The aim of this study is to evaluate whether colour Doppler is able to further differentiate the malignant tumour.METHODS: Fifty-six patients with salivary gland lesions were prospectively assessed using ultrasound imaging with colour flow and power Doppler. The peak systolic velocity (PSV) was measured and the pulsatility index (PI) and resistive index (RI) calculations were performed on the pulsed wave traces. The real time ultrasound morphology and the Doppler information were correlated with the histology.RESULTS: In 18 of the 56 patients, no internal colour flow or power Doppler changes could be detected. The real time ultrasound morphology diagnosed benign disease with sensitivity of 89.7% with specificity of 57.1%. The positive predictive value was 93.6%. There were no significant differences in the colour Doppler appearances in terms of vessel type or intratumour distribution which could separate benign from malignant conditions. However, there was statistical discrimination for PI and RI values (P=0.0006, P=0.0002, respectively). No malignant lesions were seen when the PI was less than 1.8 and RI was less than 0.8. The PSV was elevated in several cases (>50cm per s) but there was no statistical correlation with malignancy.CONCLUSION: The risk of malignancy increases by a third when the colour Doppler demonstrates increased intratumour vascular resistance (RI>0.8 and PI>1.8), with positive predictive value of 97.3% (sensitivity 75.5%, specificity 85.7%).Bradley, M. J. (2000). Clinical Radiology55, 759–762.

Sonographic spectrum of the corpus luteum in early pregnancy: gray-scale, color, and pulsed Doppler appearance.

We describe the gray-scale and Doppler sonographic features of the corpus luteum during the first trimester of pregnancy. Using transvaginal sonography, we prospectively evaluated the ovaries of 160 patients with spontaneous singleton intrauterine gestations between 5 and 8 weeks' menstrual age. Size, sonographic appearance, resistance index, and peak systolic velocity were recorded. The corpus luteum was identified in 157 (98%) of 160 patients. The mean diameter was 1.9 +/- 0.6 cm. The most common appearance was a round hypoechoic structure, found in 54 patients (34%). Other appearances included a cyst with a thick wall and anechoic center (43 patients, 27%), a cyst containing internal debris (36 patients, 23%), and a thin-walled simple cyst (24 patients, 15%). Corpus luteal blood flow was visualized with color Doppler imaging in 92% (145/157) of patients in whom the corpus luteum was found. Color Doppler imaging typically revealed a circumferential rim surrounding part or all of the corpus luteum. Low-resistance blood flow was seen with pulsed Doppler interrogation, with a mean resistance index of 0.49 +/- 0.08 and mean peak systolic velocity of 17 +/- 10 cm/second. The corpus luteum in early pregnancy is routinely identified with transvaginal sonography and has a wide range of sonographic appearances. Recognizing the various appearances of the corpus luteum is important to avoid confusing them with true ovarian abnormalities.

The role of colour and duplex Doppler ultrasound in the assessment of thyroid nodules

The role of colour and duplex Doppler ultrasound in investigating nodular thyroid disease was evaluated. Fifty patients with solitary or dominant nodules were studied. All nodules were examined with colour Doppler with spectral analysis performed on vascular lesions. Pathological correlation was available for all nodules. The majority of thyroid nodules could be accurately categorized by their colour Doppler appearances. This was true for both solitary and dominant nodules. All neoplastic nodules (adenomas, carcinomas) contained intra-nodular flow signals. The majority of the colloid nodules were either avascular or had halo flow signals only. A minority of colloid nodules were vascular. These nodules were large (> 2 cm), had dominant halo vessels and cytological evidence of follicular cell hyperplasia. Although colour Doppler lacks absolute specificity in discriminating neoplastic and non-neoplastic thyroid nodules, the data suggests the modality has considerable use in clinical practice. The spectral analysis data was time-consuming to obtain and had less obvious clinical application.

Case report: Paratesticular rhabdomyosarcoma — Colour Doppler appearances

Paratesticular rhabdomyosarcoma is a rare tumour of childhood and early adult life. We report a case in which the paratesticular location and colour Doppler appearances led to confusion with epididymitis.

Case report: Grey scale and colour Doppler ultrasound appearance of acute sarcoidosis of the parotid gland

Sarcoidosis is a relatively common disease with protean clinical manifestations. Involvement of the parotid glands in the acute presentation is well recognized but the grey scale and colour Doppler appearances are less well so. These are described in a case where imaging and biopsy proved valuable in the diagnosis of acute sarcoid presenting as sicca syndrome.

Variable Color Doppler Appearance of Pseudoaneurysm in Pancreatitis

Variable Color Doppler Appearance of Pseudoaneurysm in Pancreatitis