Echodense Areas Research Articles

Myocardial fat overgrowth in Proteus syndrome.

Proteus syndrome (PS) is a rare, mosaic disorder with asymmetric and distorting overgrowth of the skeletal system, skin, and adipose tissues. Cardiac abnormalities are rare in this syndrome and only two prior cases have been reported. Many patients with PS followed at our institution underwent transthoracic echocardiograms for preoperative evaluation or as work-up for associated pulmonary disease. Some were noted to have prominent, focal echodense areas in the myocardium. We further investigated cardiac findings in a cohort of children and adult patients with PS. Patients with abnormal echocardiograms were referred for cardiac magnetic resonance imaging, Holter monitoring, and exercise treadmill testing. Twenty children and adults with PS, age 24 months to 50 years old, underwent transthoracic echocardiograms. Seven patients (35%) had focal bright echodense areas within the myocardium suggesting fatty infiltration. The majority of patients had significant involvement of the interventricular septum. The cardiac characteristics of all patients with fatty infiltration on transthoracic echocardiograms were compared to Proteus patients without these findings. There were no significant differences in chamber sizes, mass, systolic or diastolic function. No increased risk of conduction defects or arrhythmias was found. This study shows that abnormal fat overgrowth is a common finding in the myocardium in patients with Proteus syndrome; however, it is not associated with functional derangements or arrhythmias. Further evaluation of a larger number of Proteus patients is needed in order to determine the frequency and prognosis of cardiac involvement. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

Rectus-abdominis-Syndrom

Three athletes (one female, two males), aged 18-21 years, developed acute abdominal pain, two of them immediately after exercise including abdominal muscle training. The female patient had a pulmonary infection of uncertain cause at the time. The second patient obviously suffered from an allergic or parasitic disease (eosinophilia of 26%). The third patient, a swimmer, had the symptoms in the course of a flu-like infection after drinking about 100 g alcohol. Serum creatinine kinase activity was 7,800-17,500 U/l, making acute muscle damage likely, probably rhabdomyolysis. Ultrasound examination revealed echo-dense areas of the rectus abdominis muscle in two of the patients, in one of them associated with marked muscle swelling. In the third patient ultrasound was unremarkable during a symptom-free interval 8 days after the onset of symptoms. These observations indicate that even during banal infections sport exercise involving special strain on the abdominal musculature should not be undertaken because of the risk of rhabdomyolysis.

Collagen Fiber Morphology Determines Echogenicity of Myocardial Scar: Implications for Image Interpretation

Fibrous tissue appears as echo dense areas on conventional ultrasound images; however, the determinants of such echo brightness have not been assessed. We demonstrated previously, using 600-MHz ultrasound images, that collagen fiber morphology determines echo brightness. In the current study, we tested the hypothesis that collagen fiber morphology also determines echogenicity of myocardial scar at the lower transducer frequencies used in conventional ultrasound. We examined both the infarcted and noninfarcted regions of rat hearts 1 and 3 weeks after permanent coronary artery occlusion. Ultrasound images obtained from excised hearts were digitized to quantify echocardiographic brightness. The hearts were then sectioned, stained with picrosirius red, and examined with polarized light microscopy. We found that myocardial scar tissue appeared either hyperechoic or normoechoic depending on collagen fiber morphology. Specifically, the hyperechoic areas corresponded to the 3-week-old infarcted regions containing thick collagen fibers that appeared predominantly orange when viewed with polarized light. In contrast, normoechoic areas corresponded to the 1-week-old infarcted regions containing thin collagen fibers that appeared predominantly green and also to noninfarcted myocardium. We conclude that the echogenicity of tissue early after infarction is similar to that found in normal, noninfarcted myocardium, thus compromising the ability of echocardiography to distinguish between these two states based on echotexture.

Case report: CT appearance of capillary and cavernous lymphangiomatosis of the spleen in an adult

A 70-year-old woman underwent a routine US examination at which the spleen was found to be enlarged with diffuse, irregular inhomogeneifies. The patient was transferred to our hospital for further investigation. On physical examination she presented with a palpable, slightly enlarged spleen. There were no other pathological findings. Red and white blood counts were normal with normal differential counts and the platelet count was 248 x 106/1. Tumour markers (~-fetoprotein, carcinoembyronic antigen) and echinococcus serology were negative, as were all other blood tests. At US (Sonoline SI-400, Siemens, Erlangen, Germany) the spleen was enlarged with irregular, echodense areas of inhomogeneous echotexture. These lesions were predominantly located at the hilum and the poles of the spleen (Fig. 1). The US examination of all the other abdominal organs was normal and plain X-rays of the chest and abdomen were normal as well. The unenhanced conventional CT (Somatom HiQ, Siemens, Erlangen, Germany) of the abdomen (Fig. 2) showed a markedly enlarged spleen (13x 10x 15cm), where mainly the medial and lower two-thirds of the organ were enlarged. The density of the parenchyma was predominantly inhomogeneous with an homogeneous part of normal density in the lateral third. Centrally in the spleen there was a geographically shaped area measuring approximately 3.5 cm in diameter with irregular, poorly defined borders. The measurement in this area revealed decreased density (31 HU) compared to the normal looking lateral part of the spleen (49 HU). Smaller similar areas of decreased density were found in the medial and anterior part of the spleen. Streaky, partly patchy structures of increased density (72 HU) were found surrounding the hypodense areas and underneath the capsule. There was no calcification or cyst-like structure. The stomach and tall of the pancreas were slightly displaced mediocranially and the left kidney was displaced caudally. Two small calculi were detected in the right kidney. All other organs of the abdomen were normal. After injection of 100ml contrast agent (Ultravist | 300, Schering, Berlin, Germany) (flow = 3 ml/s, delay = 35 s) most of the splenic parenchyma showed slight homogeneous enhancement (Fig. 3)i The hyperdense structures described above showed minimal contrast agent uptake and the hypodense areas showed no enhancement. A nuclear scan with technetium Tc99m-labelled erythroyctes revealed splenomegaly with normal uptake only in the lateral part of the spleen. The

Subacute Left Ventricular Free Wall Rupture: Surgical Repair Prompted by Echocardiographic Diagnosis

Subacute cardiac rupture may occur in patients with electrocardiographic and enzyme evidence of transmural myocardial infarction. In the unusual case we encountered, these changes were absent. The echocardiographic observation of an echo-dense area within the pericardial space, due to an organized thrombus, provided early diagnosis of cardiac rupture and prompted surgery.

Prenatal Stroke Suggested by Intrauterine Ultrasound and Confirmed by Magnetic Resonance Imaging

Cerebral infarction is rare in premature newborns and is most commonly the result of arterial embolization from the placenta. A focal echodense area was identified on prenatal cranial ultrasonography (US) in a premature infant (34 weeks of gestation). After birth, cerebral infarction was confirmed by magnetic resonance imaging (MRI). The clinical findings, imaging findings and pathogenesis are discussed. New diagnostic methods such as MRI show to be a useful approach in the neonatal period facilitating recognition of cerebrovascular accidents also in low-birth-weight infants.

In vitro and in vivo evaluation of intraluminal ultrasound in normal and atherosclerotic arteries

This study evaluated the dimensional and morphologic precision of arterial images obtained using intraluminal rotating A-scan ultrasound catheters [5.0F (30 mHz) and 8.0F (20 mHz)]. Dimensions of in vitro ultrasound images from human arteries (eight normal and nine arteriosclerotic) were compared with those from histologic sections of the vessels. In addition, in vivo ultrasound studies (23 normal and 22 arteriosclerotic) of canine femoral arteries were compared with luminal dimensions obtained from angiograms of the vessels. The correlation of in vitro ultrasound images to luminal diameters (n = 22, r = 0.96), adventitial diameters (n = 19, r = 0.83), and wall thickness (n = 19, r = 0.68) in normal human vessels was significant (p less than 0.05). In vitro measurements of images and histologic specimens from human atherosclerotic arteries also correlated significantly (p less than 0.05) with luminal diameters (n = 27, r = 0.91), adventitial diameters (n = 24, r = 0.60), and wall thickness (n = 24, r = 0.62). Morphologically, in vitro images of the wall of normal human arteries had a concentric laminated appearance and atherosclerotic vessels had patchy echodense and echolucent areas. In vivo studies showed significant correlation of diameters for both normal (n = 16, r = 0.91, p less than 0.05) and arteriosclerotic (n = 16, r = 0.57, p less than 0.05) canine arteries compared with luminal dimensions measured from uniplanar angiograms. We conclude that rotating A-scan intraluminal ultrasound accurately defines both normal and atherosclerotic arterial wall morphology and dimensions. This technology may be valuable for intravascular guidance of angioplasty devices by identifying the location and consistency of lesions.

Imaging of cerebral arterio-venous malformations by transcranial colour-coded real-time sonography

Transcranial color-coded real-time sonography (TCCS) is a new diagnostic method allowing the non-invasive imaging of parenchymal and vascular structures of the adult brain through the intact skull. A description of the sonographic findings in two patients presenting with a radiologically ascertained arterio-venous malformation is provided. The AVM's can be depicted in the two-dimensional B-mode image as echodense areas interspersed with zones of lower echodensity. Their extension correlated with corresponding MRI images. The color-coded illustration of intravascular flow phenomena allowed the distinct identification of the major afferent feeding vessels, the venous drainage and of the vascular convolution of both AVM's. Information on hemodynamics, as e.g. the blood supply of the angioma by the contralateral internal carotid artery, are obtained by color-coded identification of intravascular flow direction including analysis of the Doppler frequency spectrum. All findings obtained by TCCS complied with those established by angiography. We conclude, that TCCS is a suitable method for early diagnosis and long term follow up of cerebral AVM's.

An echocardiographic study of the association of ventricular septal defect and right ventricular muscle bundles with a fixed subaortic abnormality

Since 1983, 36 patients with the combination of right ventricular muscle bundles and a perimembranous ventricular septal defect have been studied in our institution to address the incidence of an associated subaortic abnormality. Of that total 32 (88%) had echocardiographic evidence of such an abnormality (29 had a typical subaortic ridge protruding from the crest of the interventricular septum and the remaining 3 had an echodense area in the same location). Surgical confirmation of the presence or absence of a subaortic abnormality was available in 26. There was correlation between the surgical and echocardiographic findings in all patients. A resting Doppler gradient of ≥10 mm Hg was present in only 10. During the study period, 6 patients had Doppler evidence of progression of their gradient. The incidence of subaortic abnormalities in right ventricular muscle bundles and ventricular septal defects appears to be far greater than previously suspected. The exact significance of this finding in the absence of a pressure gradient is still unclear.

Interobserver variability in neonatal cranial ultrasonography.

The reliability of cranial ultrasound diagnosis in the premature neonate was examined using data from an ongoing multicentre study of the epidemiology and long-term consequences of neonatal brain haemorrhage. First week ultrasound films (obtained at 4 hours, 24 hours and 7 days) from 60 study subjects were randomly selected for independent review by two groups of experienced interpreters, and results were recorded separately for observations (i.e. presence or absence of an abnormal echodense area on a film) and interpretations (i.e. presence or absence of haemorrhage or ventricular dilatation) in each hemisphere. Because of deaths in the first week of life, the total number of films examined was 138. Concordance on the presence or absence of an abnormal echodensity was examined for each individual film for three areas of interest: the germinal matrix, the ventricles and the parenchyma. Concordance on the presence or absence of haemorrhage or ventricular dilatation was examined only for the seventh-day film, or the final film prior to death. Finally, concordance was analysed with the diagnostic interpretations grouped into categories thought to differ prognostically for long-term outcome. In general, concordance was poorest for germinal matrix lesions and best for parenchymal lesions. Concordance was lower for observations made on each individual film than it was for interpretation of the final film in each case. Fifty-five of 60 cases (92%) were assigned to the same major prognostic category by both readers. Ultrasound review conferences were held periodically and there was evidence that concordance in ultrasound reading and interpretation improved during the course of the study.

Early evaluation of cardiac injury by two-dimensional echocardiography in patients suffering blunt chest trauma

The availability of two-dimensional echocardiography as a clinical tool has led to an interest in its applicability, usefulness, and reliability in the evaluation of blunt cardiac trauma. Forty patients who sustained objective evidence of blunt chest trauma were evaluated at our institution using serial ECGs, creatine phosphokinase (CPK) isoenzyme determinations, and two-dimensional echocardiography. Twenty patients (50%) manifested evidence of cardiac injury as demonstrated by abnormal ECGs, elevated CPK isoenzymes, or abnormal echocardiograms. Nine (23%) patients had abnormal echocardiograms with findings of pericardial effusions in four, chamber enlargement in three, and echodense areas of the right ventricle in two. There was no correlation with ECG changes or the presence of CPK isoenzymes. Based on these observations we believe echocardiography can be used as a noninvasive modality to complement other clinical tools in the detection of blunt cardiac injury.

Retinonoblastoma: A Clinical, Immunohistochemical, and Electron Microscopic Case Report

A 4-year, 9-month-old boy had a history of leukocoria of the right eye for approximately six months prior to admission. The other eye was normal. There was no family history of retinoblastoma. Funduscopy disclosed a large white mass extending from the nasal pars plana to the mid-pupillary zone and the posterior pole with a near total retinal detachment in the superior temporal quadrant. A B-scan ultrasound showed an echo dense area of the anterior portion of the mass. A CT scan showed intraocular tissue densities with no evidence of optic nerve involvement or extraocular extension. Immunohistochemistry of a fresh frozen portion of tumor revealed reactivity with antibodies directed against interphotoreceptor retinoid-binding-protein (IRBP), neuron-specific enolase, glial fibrillary acidic protein, S-antigen, focal reactivity with opsin, and scattered cytoplasmic staining for cyclic GMP and cyclic GMP phosphodiesterase. Biochemical analysis of fresh frozen tissue samples confirmed the presence of IRBP. Transmission electron microscopy disclosed occasional Flexner-Wintersteiner rosettes connected by zonula adherens-like junctions. These showed inner segment-like structures containing prominent mitochondria, portions of cilia and fragments of outer segment material. These data, along with the immunocytochemistry indicates a predominant neuronal nature of the tumor cells with significant photoreceptor-like differentiation.

Diagnosis and evolution of periventricular leukomalacia: a study with real-time ultrasound

Periventricular leukomalacia is an ischemic lesion in periventricular white matter of premature infants. Hemorrhage into the ischemic area occurs in up to 25% of cases. We report two cases in which the diagnosis of periventricular leukomalacia was made during life with real-time ultrasound scanning. In one case, serial scans demonstrated the evolution of echodense regions, observed in the first 3 days of life, to cystic echolucent areas at 4 weeks. In the second case, periventricular echodense areas did not precede the occurrence of cystic echolucent lesions. This may reflect a more chronic ischemic cerebral insult (consistent with recurrent apnea and bradycardia) rather than a presumed acute episode of cerebral ischemia (with or without secondary hemorrhage) sustained by the first case. Real-time ultrasound scanning is a simple, non-invasive technique with which to document the evolution of periventricular leukomalacia, and thus to define the clinical neurological correlates in the neonatal period.

Focal Ischemic Cerebral Injury in the Newborn: Diagnosis by Ultrasound and Correlation with Computed Tomographic Scan

Ischemic brain injury in the newborn is a common cause of subsequent neurologic deficits seen in older children. Clearly, determination of severity and location of such injury is important for management and prognosis. Although ultrasound scanning of the brain has been used extensively in the premature infant for diagnosis of hemorrhagic lesions, its use in the term infant for recognition of ischemic cerebral lesions has not been reported. Four cases are described in which focal echodense areas were identified on ultrasound scan of the brain. These echodense areas on ultrasound corresponded to the appearance on computed tomographic (CT) scan of areas of decreased density which are known to represent ischemic cerebral injury. In three of the four cases there were focal neurologic findings and/or focal abnormalities on EEG. In two cases, real-time ultrasound scanning demonstrated changes in arterial pulsations in cerebral vessels in the area of the lesions. Thus in both, there was diminution in pulsations within the echodense areas and in one case, an increase in pulsations was observed at the periphery of the echodense lesion. Our data demonstrate the value of ultrasound scanning for assessment of the extent and location of focal cerebral ischemic lesions in the newborn. Such assessment permits assessment of prognosis.

Ultrasonic Diagnosis of Intrahepatic Biliary Stones

To the Editor.— The ultrasound characteristics of stones in the gallbladder are well known.1Ultrasound has also been reported to be useful in showing renal calculi.2In both locations stones typically show dense echoes with acoustic shadowing. We report a case of intrahepatic stones in a patient with primary intrahepatic calculus disease and discuss the clinical and ultrasonic features. Report of a Case.— Six years after undergoing a cholecystectomy, a 32-year-old Oriental woman had a chief complaint of sudden onset of nausea, vomiting, and right upper quadrant pain radiating to the back. She was not jaundiced, but her urine was dark. Results of a roentgenographic examination of the chest and abdomen were normal. The total bilirubin value was 1.5 mg/dL, and an intravenous cholangiogram was performed, but the biliary system was not visualized. An ultrasound examination uncovered multiple echodense areas within the liver parenchyma that produced acoustic shadowing