Hyperechoic Pattern Research Articles

Pancreatic Ultrasound in High-risk Neonates

Pancreatic ultrasound is employed to assess the structure of the organ and diagnose various conditions. However, analyses of pancreatic images of high-risk newborn infants are scarce.Aim of the study: to investigate pancreatic echogenicity in high-risk neonates and evaluate the association between pancreatic echogenicity and clinical diagnosis.Materials and methods. This prospective observational case-control ultrasound study included 105 neonates admitted to the neonatal intensive care unit or outpatient. The patients were divided into two groups: group 1 (high-risk), which included 55 high-risk neonates, and group 2 (control), which included 50 neonates of comparable age with no history of high-risk pregnancy or delivery who were presented for medical consultation. Abdominal ultrasound examinations were performed, with a focus on the pancreas. Pancreatic echogenicity was classified as hyperechoic, isoechoic, or hypoechoic, relative to the liver.Results. No significant difference in pancreatic size was observed between the high-risk and control groups. A significant predominance of hyperechogenicity over hypoechogenicity or isoechogenicity was found in the high-risk group. A significant difference in echogenicity was found between the high-risk and control groups (P=0.0001). Neonates in the control group were more likely to have pancreatic isoechogenicity (60%) compared to hyperechogenicity (34%) or hypoechogenicity (6%). In the high-risk group, neonates had a higher frequency of pancreatic hyperechogenicity (72.72%) compared to hypoechogenicity (10.9%) or isoechogenicity (16.36%). Notably, 83.3% of infants born to diabetic mothers had a hypoechogenic pattern. Certain high-risk infants, such as preterm infants and those with perinatal asphyxia, had a higher frequency of hyperechogenicity (83.3%). The percentage of hypoechoic pattern was comparable in male and female newborns (50%); isoechoic pattern was more prevalent in females (77.3%) than in males (22.2%), while males had a more frequent hyperechoic pattern (57.5%).Conclusion. Evaluation of the pancreas in high-risk neonates and monitoring of long-term outcomes are of critical importance, especially in the infants of diabetic mothers.

Prospective study of quantitative liver MRI in cystic fibrosis: feasibility and comparison to PUSH cohort ultrasound.

Pediatric radiologists can identify a liver ultrasound (US) pattern predictive of progression to advanced liver disease. However, reliably discriminating these US patterns remains difficult. Quantitative magnetic resonance imaging (MRI) may provide an objective measure of liver disease in cystic fibrosis (CF). The purpose of this study was to determine if quantitative MRI, including MR elastography, is feasible in children with CF and to determine how quantitative MRI-derived metrics compared to a research US. A prospective, multi-institutional trial was performed evaluating CF participants who underwent a standardized MRI. At central review, liver stiffness, fat fraction, liver volume, and spleen volume were obtained. Participants whose MRI was performed within 1 year of US were classified by US pattern as normal, homogeneous hyperechoic, heterogeneous, or nodular. Each MRI measure was compared among US grade groups using the Kruskal-Wallis test. Ninety-three participants (51 females [54.8%]; mean 15.6 years [range 8.1-21.7 years]) underwent MRI. MRelastography was feasible in 87 participants (93.5%). Fifty-eight participants had an US within 1 year of MRI. In these participants, a nodular liver had significantly higher stiffness (P<0.01) than normal or homogeneous hyperechoic livers. Participants with a homogeneous hyperechoic liver had a higher fat fraction (P<0.005) than others. MRelastography is feasible in children with CF. Participants with a nodular pattern had higher liver stiffness supporting the US determination of advanced liver disease. Participants with a homogeneous hyperechoic pattern had higher fat fractions supporting the diagnosis of steatosis.

Mixed and Purely Hyperechoic Breast Masses: A Radiologic-Pathologic Review.

Breast US is a mainstay of modern-day breast imaging, especially in the diagnostic and interventional realm. The BI-RADS atlas described six echo patterns relative to the subcutaneous mammary fat: anechoic, hypoechoic, complex cystic and solid, isoechoic, heterogeneous, and hyperechoic. Hyperechoic breast masses demonstrate increased echogenicity relative to subcutaneous mammary fat or equal to fibroglandular tissue. Pathologically, the hyperechoic pattern at breast US results from the intermingling of different components: adipose tissue, fibrous tissue or stroma, secretions, blood or vascularity, and calcifications. Most hyperechoic masses are benign, especially homogeneously hyperechoic masses. However, hyperechogenicity does not exclude malignancy. Two echo patterns have been identified in hyperechoic malignant lesions, including those with a hypoechoic center and hyperechoic rim known as the rim pattern and a mass with hyperechoic areas distributed through the mass known as a dispersed pattern. This article aims to illustrate the echogenic patterns of breast lesions and various benign and malignant hyperechoic breast lesions with radiologic-pathologic correlation and to increase awareness of heterogeneously hyperechoic breast lesions as a manifestation of malignancy.

Specific imaging features indicate the clinical features of patients with hepatic perivascular epithelioid cell tumor by comparative analysis of CT and ultrasound imaging.

The objective of the study was to explore the CT and ultrasound features and clinical significance of perivascular epithelioid cell tumor (PEComa) of the liver. Eleven hepatic PEComa patients treated in our hospital were retrospectively analyzed based on the characteristics of the imaging results of the patients, including conventional ultrasound, CDFI, contrast-enhanced ultrasound (CEUS), and contrast-enhanced CT (CECT). CT scans showed that all lesions were hypodense. Ultrasonography showed that lesions were either hyperechoic (4/11, 36.36%), hypoechoic (4/11, 36.36%), isoechoic (1/11, 9.09%), or heterogeneously echoic (2/11, 18.18%). CDFI showed that most of the lesions had an abundant blood supply (9/11, 81.82%). Whether on CT scan or ultrasonography, the margins of the lesions were dominated by clear margins. Ultrasonography revealed more features: hyperechoic patterns around lesions (3/11, 27.27%) and lateral shadow (5/11, 45.45%). The CDFI showed that large blood vessels were observed around the lesions (9/11, 81.82%). CECT shows two enhancement patterns: "fast in and fast out (FIFO)" (8/11, 72.72%) and "fast in and slow out (FISO)" (3/11, 27.27%). CEUS shows that all lesions had the enhancement pattern of "FISO," which was different from CECT. All lesions displayed rapid enhancement during HAP in CEUS during 7-20 s. Four patients (36.36%) washed out at 60-180 s, another four (36.36%) washed out at 180-300 s, and the remaining three patients (27.27%) showed no signs of washout even at 360 s. Some imaging features, such as clear margins, peripheral hyperechoic around the lesion, lateral shadow, the large blood vessels around lesions, and the "FISO" enhancement pattern, may indicate expansive growth of the tumor and be helpful in the diagnosis of PEComa. Ultrasound images may provide more details for clinical reference.

Ultrasound location of ground-glass opacity during thoracoscopic surgery.

Application of video-assisted thoracoscopy brought lung surgery into the minimally invasive era; the lack of tactile feedback using VATS, remains a disadvantage because surgeons are unable to locate lesions with a finger or device. This study aimed to investigate the effectiveness, the applicability and the utility of intraoperative ultrasound (IU), for the localization of small ground-glass opacity (GGO) lesions in the parenchyma, as a guide in finding their margins in a deflated lung. We included 15 consecutive patients undergoing diagnostic resection of GGOs via VATS in the Thoracic Surgery Unit of the University of 'Luigi Vanvitelli' of Naples from November 2019 to December 2021. They were under general anaesthesia, when the lung had been collapsed, the probe was placed in the region where the target lesion was thought to reside on the basis of low-dose computed tomography scanning. GGO could be identified their sizes, echo levels and posterior echo was recorded by IU when the lung was completely deflated. We conducted a retrospective single-centre study. All GGOs were identified by IU. The mean size and depth were 14.1 ± 0.5 and 4.8 ± 0.3 mm, respectively. Six (40%) lesions had hyperechoic patterns, 9 (60%) had mixed echogenicity where the hyperechoic patterns were irregularly mixed with hypoechoic patterns. The final diagnoses included 2 (15%) atypical adenomatous hyperplasia; 2 (15%) adenocarcinomas in situ; 3 (23%) minimally invasive adenocarcinomas and 6 (46%) invasive adenocarcinomas. The results of our study showed that IU could safely and effectively detect GGOs.

Unexpected hyperechoic lesions of the breast and their correlations with pathology: a pictorial essay.

Hyperechoic lesions of the breast encompass a wide range of conditions that are occasionally encountered during breast ultrasonography. Although typical hyperechoic lesions with a distinct fat component on imaging are well known, some hyperechoic lesions are diagnosed as unexpected pathology, making the radiology-pathology correlation difficult. Therefore, understanding the pathology of these lesions and how it correlates with imaging findings can help radiologists accurately diagnose and properly manage a range of related conditions. This article presents a pictorial review of unexpected hyperechoic benign and malignant breast lesions, with a focus on the pathological conditions that give rise to the hyperechoic pattern.

A cross-sectional study of 502 patients found a diffuse hyperechoic kidney medulla pattern in patients with severe gout

We have previously shown that ultrasonography can detect hyperechogenic crystal deposits in the kidney medulla of patients with gout. In this cross-sectional study we investigated the frequency and clinical correlates of hyperechogenic kidney medulla in 502 consecutive primary consultants for gout (ACR/EULAR criteria) at the Vien Gut medical center in Ho Chi Minh City, Vietnam. None of these patients received urate-lowering drugs. Kidney medulla echogenicity on B-mode ultrasonography was compared to that of the kidney cortex. Overall, 36% patients showed a hyperechoic pattern of Malpighi pyramids. On univariate analysis, the pattern was significantly associated with age, estimated gout duration, steroid-dependency, clinical tophi, urate arthropathy, double contour thickness at the scanned joints, coronary heart disease, arterial hypertension, hyperuricemia, proteinuria, leukocyturia, and decreased estimated glomerular filtration rate. On multivariable analysis, the hyperechoic pattern was associated with estimated disease duration, clinical tophi, urate arthropathy, double contour thickness and decreased estimated glomerular filtration rate. No hyperechoic pattern was observed in 515 consecutive consultants without gout. Thus, hyperechoic kidney medulla was frequently demonstrated in Vietnamese patients with tophaceous gout and associated with features of tubulointerstitial nephritis. This finding revives the hypothesis of microcrystalline nephropathy of gout, predominantly seen in untreated gouty patients, which could be an important target for urate-lowering therapy.

Abstract No. 475 Radiologic-pathologic correlation of the echogenic patterns of hepatic lesions undergoing ultrasound-guided biopsy

To examine sonographic radiologic-pathologic correlation of primary and metastatic liver tumors. This may aid the interventional and diagnostic radiologist in procedural guidance and lesion characterization. Between 2010 and 2018, 913 ultrasound-guided biopsies of liver masses were performed at our institution. The echogenicity of a random sampling of 577 of these lesions (mean patient age, 61.5 years; 53% male) were reviewed from the procedural sonographic images of the biopsied lesions and correlated to the biopsy pathology diagnosis. Lesion echogenicity was characterized in reference to the hepatic background parenchyma as either hypoechoic, hyperechoic, or iso/hyperechoic with hypoechoic halo, or isoechoic. This was recorded from biopsy procedural dictation or jointly reviewed by a senior/junior radiology resident. Radiologic-pathologic correlation was confirmed with 2-year follow-up for benign results and repeat imaging/biopsy to amend false negative results. Upon final radiologic-pathologic correlation, 89% (510 of 572, reported in Table 1) were true positive for malignancy, 8% true negative (46) and 3% (16) false negative. Primary tumor class was associated with tumor echogenicity (Table 1). Melanoma, lymphoma and breast cancer were most associated with hypoechoic pattern and neuroendocrine tumors, gastrointestinal adenocarcinomas and hepatocellular carcinoma more associated with hyperechoic pattern (Table 1, P = 0.0002). Smaller lesion size was associated with hypoechoic compared to hyperechoic lesions (Table 1, P = 0.001). 69% of lesions less than 3 cm diameter (140/204) were hypoechoic compared to 50% if larger (162/322) (P <0.001). Histologic tumor differentiation was reported on a subset of cases with hypoechogenicity associated with tumor de-differentiation (P = 0.01) Tumor echogenicity immediately prior to biopsy was associated with the type of primary or metastatic hepatic tumor, tumor size and histologic differentiation. This small pilot study may guide the interventional radiologist in performing a biopsy and expected pathologic results.Table 1Malignant lesionsHypoechoic %(n)Hyperechoic %(n)Hypoechoic halo %(n)Isoechoic %(n)P valueN57% (302)29% (152)10% (50)4% (22)Tumor PrimaryMelanoma82% (31)5% (2)11% (3)4% (1).0002Lymphoma82% (18)9% (2)9% (2)0Breast77% (26)15% (5)6% (2)3% (1)Pancreatic adenocarcinoma70% (56)16% (13)6% (5)8% (6)cholangiocarcinoma66% (21)22% (7)6% (2)6% (2)Genitourinary59% (13)32% (7)5% (1)5% (1)Carcinoma of unknown primary55% (28)28% (14)12% (6)6% (3)Lung54% (14)31% (8)12% (3)4% (1)Hepatocellular carcinoma50% (38)40% (30)11% (8)0Other tumors50% (10)30% (6)12% (3)4% (1)Gastrointestinal carcinoma39% (31)44% (35)14% (11)3% (2)Neuroendocrine35% (16)50% (23)9% (4)7% (3)Biopsied lesion sizelesion size (cm)3.7, SD 2.14.5, SD 2.84.4, SD 1.94.7, SD 2.4.001Tumor histologic differentiationWell37% (18)51% (25)8% (4)4% (2).01Moderate52% (44)30% (25)14% (12)4% (3)Poorly63% (113)24% (44)8% (15)4% (8) Open table in a new tab

Natural Poisoning by Tephrosia cinerea in Sheep from Western Region of Rio Grande do Norte State, Northeastern Brazil

Background: Tephrosia cinerea is a toxic plant responsible for liver fibrosis, which results in ascites and weight loss in sheep and probably goats. Although T. cinerea is widespread in Brazil, reports of poisoning are described in a few regions, named Eastern “Seridó” region of Rio Grande do Norte state, Central “Sertão” region of Ceará state, and “Sertão” of Paraíba state. Thus, this paper aimed to report the clinical-epidemiological, laboratorial, pathological and ultrasonographic findings of sheep spontaneously poisoned by T. cinerea in the Western region of Rio Grande do Norte state, Northeastern Brazil.Cases: The evaluated cases occurred in sheep raised on properties located in the municipalities of Areia Branca and Tibau, Western region of Rio Grande do Norte state, Northeastern Brazil. In all visited farms, the pasture had a marked predominance of the T. cinerea. Clinical signs included progressive weight loss, dehydration, bilateral abdominal distension, and respiratory dyspnea probably due to diaphragmatic compression. Other less frequent clinical signs were hyporexia, pale mucosae, rough hair coat and polyuria. Hematology revealed leukocytosis by neutrophilia, while serum biochemical analysis revealed increased activities of GGT (mean 96.3 U/L, reference: 20-52 U/L) and ALT (mean 55.0 U/L, reference: 22-38 U/L) and reduced levels of total proteins (mean 5.3 g/dL, reference 6.0-7.9 g/dL), albumin (mean 2.0 g/dL, reference 2.4-3.0 g/dL), and globulins (mean 3.2 g/dL, reference 3.5-7.0 g/dL). Abdominal ultrasonography was performed in one sheep, revealing a large amount of anechoic peritoneal effusion without floating echogenic debris or spots, and distention of hepatic vessels and portal veins. On the other hand, the ultrasonographic examination did not reveal changes in gallbladder, in right kidney and in the size of the liver. Gross pathological findings included severe ascites, moderate hydrothorax and hydropericardium, and liver showing irregular nodular surface, whitish areas and hardened consistency. The ascetic fluid was clear and is volume ranged from 8 to 13.5 liters. Microscopic evaluation of liver revealed hepatocyte necrosis, diffuse deposition of collagen fibers, and ductular proliferation.Discussion: Definitive diagnosis of poisoning by T. cinerea was made by the association of epidemiological, clinical, laboratory and pathological findings. It is known that the plant is part of the botanical composition of the diet of sheep all year long, but the poisoning becomes important mainly during the dry season. Affected sheep showed a typical ascitic condition due to diffuse liver fibrosis. Main ultrasonographic findings corresponded to hyperechoic diffuse diseases patterns, such as lipidoses and toxic liver diseases. The alterations observed in the biochemical panel are consistent with hepatic damage caused by the plant. The hematological findings are suggestive of immune system interference of poisoned sheep, but it is not possible to infer if it were the direct action of some component(s) of the plant or if it would be secondary to the severe nutritional deficiency induced by the poisoning. The toxic principle of T. cinerea remains undetermined, but it is already known that it is not pyrrolizidine alkaloids. The probable pathophysiological mechanism of ascites is the increased blood pressure on the portal vein walls due to the greater resistance of the liver parenchyma, but there should also be some contribution of hypoalbuminemia, which reduces plasmatic colloid osmotic pressure.

High-frequency ultrasound, computed tomography and computed tomography arthrography of the cranial cruciate ligament, menisci and cranial meniscotibial ligaments in 10 radiographically normal canine cadaver stifles

BackgroundBilateral non-traumatic cranial cruciate disease is frequently seen in originally unilateral cruciate pathology. Untreated cranial cruciate ligament disease and concurrent meniscal lesions cause progressive osteoarthritis and pain of the stifle joint. Early presurgical diagnosis is important, but remains difficult.The purpose of this ex vivo study was (1) to describe the ultrasonographic appearance of the canine cranial cruciate ligament (CrCrL), menisci and meniscal ligaments using a high-frequency linear transducer, (2) to determine the length of the CrCrL seen on ultrasonography (US) and (3) to describe and compare the appearance of the CrCrL, menisci and meniscal ligaments on US, computed tomography (CT) and computed tomography arthrography (CTA).ResultsUS and CT examinations were performed on 10 radiographically normal cadaveric stifles of adult dogs weighing more than 15 kg, followed by macroscopic and histologic evaluations. The CrCrL had a parallel hyperechoic fibrillar pattern at the insertion on the tibia and a hypoechoic structure more proximally in all stifles. This pattern was visible over 35% (median) of the total length of the ligament, with 50% (median) of the total length CrCrL that could be outlined. All medial menisci and 8 out of 10 of the lateral menisci showed hypoechoic lines within their bodies oriented obliquely to the direction of the ultrasound beam. Fifteen of the 20 cranial meniscotibial ligaments were detected, showing a hyperechoic fibrillar pattern. Normal macro- and microscopic appearance was observed in all menisci, with the radial bundles of collagen fibers at the level of and with similar orientation as the intrameniscal hypoechoic lines on US.The CrCrL, menisci and meniscal ligaments were of intermediate density on CT, but marked improvement of the border detection was obtained using CTA. Contrast within the CrCrL was observed in 4/10 stifles using CT and confirmed in 3/4 stifles on histology. One of these ligaments had a partial tear (5–10%) on macroscopic evaluation. None of the menisci showed any abnormalities on CTA.ConclusionsNormal canine menisci are heterogeneous on high-frequency US and a fibrillar pattern may be observed in the cranial meniscotibial ligaments and the distal portion of the CrCrL. Linear areas of contrast may be detected within the cranial cruciate ligament of radiographically normal stifles.

Intrathyroidal ectopic thymus tissue: a diagnostic challenge.

The prevalence of thyroid nodules in pediatric population is 0.2-2%, which is lower than adults. However, the probability of the nodule to be malignant is higher than adults (20-73%). Differential diagnosis of thyroid lesions in children includes intrathyroidal ectopic thymus tissue (ITT). ITT can present as a thyroid nodule, and be confused with malignancy with its hyperechoic pattern; this might cause unnecessary fine-needle aspiration biopsies and/or surgical interventions. In the current study, we mainly aim to define both US and color Doppler ultrasonography (CDUS) characteristics of ITT. We also aim to describe the most sensitive and most specific diagnostic parameters of ITT. We have evaluated US examination reports of 56 children for whom differential diagnosis included ITT between February 2015 and August 2018. We have recorded sonographic characteristics of the lesions, CDUS data, and thyroid hormone levels. Study population consists of 56 patients (22 ITT, 34 other diagnoses). Median age of the population is 10years. Age, sex, laboratory results, and follow-up change in lesion diameters do not show any significant difference between ITT and other diagnosis groups. Typical US appearance, fusiform lesion shape, and isovascular CDUS characteristics are higher in ITT group. The median value of the lesion's highest diameter is smaller in ITT group. The most valuable criteria to predict ITT presence were the fusiform shape and the longest diameter of the lesion. Fusiform shape and a maximum diameter of ≤ 9mm are the most selective criteria to predict ITT diagnosis.

Diagnostic approach to subcutaneous nodules in patients with neuroendocrine tumours treated with depot somatostatin analogs: a cross-sectional study.

The presence of cutaneous nodules in patients with gastroenteropancreatic neuroendocrine tumours (GEP-NETs) receiving depot somatostatin analogs (SSAs) is a diagnostic challenge as differential diagnosis between injection site reactions and metastases is essential. To characterize the clinical, radiological, cytological and histopathological features of subcutaneous nodules in patients with GEP-NETs treated with SSAs. Retrospective, cross-sectional study of patients with GEP-NETs treated with SSAs in whom subcutaneous nodules were detected on routine abdominal computed tomography (CT) scans. High resolution and colour Doppler ultrasonography was performed. Those patients with inconclusive radiological studies went through fine-needle aspiration cytology (FNAC) and/or biopsy. Twelve patients (five males, seven females) were included (six midgut carcinoid NETs, six pancreatic NETs). Three patients received intramuscular depot octreotide, seven subcutaneous lanreotide, and two both treatments. CT scan findings were nonspecific. Sonography revealed a hyperechoic pattern in recent injections, and a hypoechoic pattern with a characteristic hyperechoic peripheral rim in long-term injections (more than 3 months after injection). On colour Doppler sonography, nodules showed no signs of intralesional vascularity. Fine-needle aspiration cytology (FNAC) was performed in five patients, revealing a characteristic acellular proteinaceous material. Biopsy in four patients showed different reactional infiltrates around the acellular material. High resolution and colour Doppler ultrasonography may be very useful for the differential diagnosis of subcutaneous nodules in patients with GEP-NETs treated with SSAs. FNAC and a biopsy are useful tests for confirmation of the diagnosis in patients with inconclusive findings. We propose a management algorithm.

Does Pretrigger Echogenic Endometrium in Assisted Reproductive Technology Cycles Reflect Raised Serum Progesterone Level?

Background:Serum progesterone is the main hormone of the luteal phase. The hyperechoic pattern of the endometrium in the luteal phase is believed to be induced by raised serum progesterone. Serum progesterone is found to be raised cases of controlled ovarian stimulation (COS) cycle on the day of ovulation trigger.Aim:This study aims to find the association between echogenicity of endometrium and raised serum progesteroneObjective:The objective of this study is to determine whether raised pretrigger serum progesterone influences the echogenicity of the endometriumMaterials and Methods:In this prospective observational study, we evaluated 221 patients who underwent COS. Echogenic patterns of the endometrium on transvaginal sonography were described as hypoechoic/trilaminar endometrium (Type A), isoechoic (Type B), and hyperechoic (Type C). The endometrial pattern and serum progesterone levels were evaluated on the day of ovulation trigger and value of ≥1 ng/ml was considered as elevated.Results:A total of 168 patients out of 221 patients (76.01%) had elevated serum progesterone levels on the day of ovulation trigger. Type A endometrium was found in a total of 174 patients, of these 132 patients (75.86%) had raised serum progesterone. Type B endometrium was found in 35 patients, of these 27 patients (77.14%) had raised serum progesterone. Type C endometrium was seen in 12 patients, out of these 9 patients (75.00%) had raised serum progesterone level. There was no statistically significant difference in the echogenic patterns of endometrium in patients with raised progesterone (≥1 ng/ml). On intergroup comparison, the difference in the progesterone levels between type A and type C was statistically significant (P = 0.02), and on receiver operating characteristic curve analysis, echogenic endometrium was found to predict progesterone level of 1.57 ng/ml with a sensitivity of 58.3% and specificity of 58.4% only.Conclusion:Echogenicity of the endometrium does not reliably predict raised serum progesterone on the day of ovulation trigger.

Evaluation of sonographic endometrial patterns and endometrial thickness as predictors of ectopic pregnancy.

To evaluate whether endometrial patterns and thickness could be used for the prediction of ectopic pregnancy (EP). A prospective study was conducted in a center in India between October 2007 and December 2008. It included 100 women with an early pregnancy confirmed by urine pregnancy testing but for whom an intrauterine gestational sac was not visualized on transvaginal ultrasonography (TVS). The women were divided into an EP group and an intrauterine pregnancy (IUP) group depending on the final diagnosis. The endometrial pattern and endometrial thickness were determined by TVS. Sensitivity and receiver operating characteristic curve analyses were performed to determine the predictive value. A heterogenous hyperechoic or trilaminar endometrial pattern was noted in 53 (77%) of 69 women in the EP group and 12 (39%) of 31 in the IUP group, and a homogenous hyperechoic pattern in 3 (4%) women in the EP group and 13 (42%) in the IUP group. An endometrial thickness of less than 9.8mm was predictive of EP (P<0.001), and an endometrial pattern other than homogenous hyperechoic had a sensitivity and a negative predictive value of 81.3% for the diagnosis of EP. Evaluation of endometrial thickness and pattern by TVS helps to identify women with a pregnancy of unknown location for close supervision.

Is ultrasonographic evaluation essential for diagnosis of retained products of conception after surgical abortion?

The aim of this study was to evaluate the predictive value of symptomatic evaluation with transvaginal ultrasonographic findings for diagnosis of retained products of conception (RPOC) after voluntary pregnancy termination via manual vacuum aspiration (MVA). A total of 466 patients with a gestational age < 10 weeks were followed up at the 7th day after MVA of unwanted pregnancies. The patients who had intense or moderate bleeding and other symptoms related to RPOC had a re-evacuation and all the patients were followed up until the next menstruation. Ultrasonographic evaluation was repeated weekly in asymptomatic patients with abnormal ultrasonographic findings (increased endometrial thickness, presence of hyperechogenic, mixed and hypoechogenic material) until a normal endometrial cavity was visualized. Out of the 466 patients, 15 (3.2%) had symptoms of RPOC at day 7 while the remaining 451 (96.8%) were asymptomatic and 20 (57.9%) had normal ultrasonographic findings. The 15 symptomatic patients (3.2%) had a repeated MVA. Nine of these 15 patients (60%) had endometrial echogenicity with mixed patterns, two (13.3%) had endometrial echogenicity with hyperechoic patterns, and the remaining four (26.7%) had normal endometrial echogenicity at day 7. Histopathologic examination of 12 of these 15 patients (80%) showed chorionic villi while no gestational tissue was noted in the remaining three of these patients. Endometrial thickness ≥ 10 mm on day 7 had 75% sensitivity and 100% specificity for diagnosis of RPOC in symptomatic women. None of the 451 asymptomatic patients developed any symptoms or needed any further intervention. As abnormal ultrasonographic findings return to normal over time in asymptomatic patients, the diagnosis of RPOC should not be based on ultrasonographic findings.

Systemic sclerosis - a multi-purpose use of ultrasound: Editorial comment on: G. Pracoń, M. Płaza, M. Walentowska-Janowicz, I. Sudoł-Szopińska The value of ultrasound in the diagnosis of limited scleroderma - a case report.

Sysyemic sclerosis (SSc) is a chronic connective tissue disease characterized by multi-organ involvement. In its variants, SSc may affect the skin, vessels, the heart, joints and the lungs. As such, it is potentially available for ultrasound examination in a wide field of applications. With the most modern linear high-frequency transducers, it has become feasible to examine the skin in patients with SSc. US makes it possible to measure the thickness of the skin and subcutaneous tissue thereby helping determine the potential skin involvement and its range, and differentiate the localized from diffuse forms of SSc(1). Moreover, the examination of dermal thickness and echogenicity may be helpful in stratifying SSc into the edematous, fibrotic and atrophic phases of skin involvement(2). Elastosonography, a method combining the assessment of ultrasound and elastic properties of the tissue, is also shown to be a promising technique in SSc(3). Raynaud phenomenon and vascular involvement in SSc may be the primary events, even preceding skin affection. The assessment of the vessels is therefore of cardinal significance in SSc. A Doppler analysis of flow in patients suspected of SSc may reveal if Raynaud phenomenon is of primary or secondary character(4). The anatomical features of vessels may also help in the analysis of Raynaud phenomenon(5). Furthermore, as atherosclerosis is more prevalent in patients with SSc, the assessment of carotid plaques with US(6) may induce earlier prophylaxis in this group of patients. This assumption is strengthened by more frequent subclinical heart involvement in patients with SSc compared with healthy controls, as assessed with echocardiography(7), yet another application of US in this disease. In the rheumatologic world, it is obviously the musculoskeletal system that receives the most attention. And it is also like that in rheumatology-related US. Pain in the musculoskeletal system is frequently reported in patients with SSc. Until recently, it has been considered neither to be inflammatory nor leading to erosive joint disease. US supports though that the reason for pain can be detected and visualized. In studies comparing patients with SSc, rheumatoid arthritis (RA) and healthy controls, it has been shown that inflammatory joint changes occur as often as in joints of patients with RA(8). Synovial proliferation, joint effusion and tendinitis were reported, and only Doppler signal and erosive joint disease were more frequent in patients with RA. In a study by Chitale et al., US findings in the hands of patients with SSc were compared with magnetic resonance imaging (MRI)(9). The latter showed both more inflammatory changes than US and bone erosions, which were not detected with US. Tendon involvement was assessed in a study by Elhai et al. and signs of tendinitis were more frequent in patients with SSc in comparison with RA patients(10). Another study by Cuomo et al. also presented characteristic features of tendon and retinaculum involvement showing a hyperechoic pattern(11). In many SSc patients, interstitial pulmonary fibrosis (IPF) is a significant manifestation of the disease and a frequent cause of death. The method of choice for assessment and follow-up of IPF is high-resolution computed tomography (HRCT). The need for frequent assessments and the increasing radiation dose of SSc patients with lung affection makes the use of US, with a potential support of HRCT, particularly attractive in long-term monitoring as a non-radiation method. A significant correlation of findings in US, HRCT score and diffusion capacity of the lungs to carbon monoxide test in a study by Tardella et al.(12), as well as other authors(13, 14), makes the possibility feasible. The elementary lesions in US assessment of patients with IPF are B-lines, i.e. vertical reverberation artifacts, also called comet tails, generated by the reflection of the US beam from thickened subpleural interlobular septa detectable in the lung intercostal spaces. But still, the skin is the most dominant and frequently affected organ in SSc. The authors of the paper in “Journal of Ultrasonography” deal with an aspect of SSc that is seldom investigated(15). Grzegorz Pracon et al. report on characteristic ultrasound features of hydroxyapatite deposits in a finger of a patient with limited SSc. It is an original finding which, when applied in practice, may lead to a quick surgical intervention and alleviation of the patient's symptoms. The present study, seen in relation to the available research results, stresses the need for further and more detailed assessment of patients with SSc in the hope of quicker diagnosis, detecting complications and potential monitoring of the disease and its treatment.

The Role of Ultrasonography for Differentiating and Management of Malignant Cervical Lymph Nodes

Objective:To investigate the value of grey scale and Doppler ultrasonography in the assessment of metastatic and lymphomatous cervical lymph nodes.Methods:One hundred and nineteen malignant cervical lymph nodes in 119 patients diagnosed as malignant according to grey scale, color Doppler and spectral Doppler ultrasonography features were included in this study. The sizes, shape, echo pattern, echogenic hilus, nodal border, cystic necrosis and coagulation necrosis, vascular distribution pattern, resistivity and pulsatility index values of lymph nodes were noted. All patients had histopathological diagnosis.Results:The final diagnosis of the 42 lymph nodes was lymphoma, and of the 77 lymph nodes was carcinoma metastasis (33 thyroid carcinoma metastasis and 44 squamous cell carcinoma metastasis). While a hyperechoic pattern and calcification were detected in the lymph nodes originating from thyroid carcinoma as 39% and 33%, respectively, a reticular pattern (26%) and low resistive and pulsatility indices were detected in lymph nodes originating from lymphoma. These criteria were statistically significant for the differential diagnosis (p<0.05). Size, shape, hypoechoic echo pattern, absence of echogenic hilus, nodal border, cystic necrosis, coagulation necrosis and vascular distribution pattern were not found to be significant for the detection of a primary tumour.Conclusion:Hyperechoic echo pattern, reticular pattern, calcification, low resistivity and pulsatility indices are useful parameters for the differential diagnosis of malignant cervical lymph nodes. These ultrasonography critaria can be used for assesment and management of unknown primary malign neck nodes.

Endoscopic Resection of a Bleeding Brunnerʼs Glands Hamartoma

Brunner's glands hamartoma is a rare and benign lesion arising from the brunner's glands of the duodenum. This proliferation can be symptomatic with bleeding or obstruction, rarely with chronic pancreatitis. Around 200 cases have been reported and tumors are rarely more than 5 cm. A 81 years-old lady known for gastroeosophageal reflux on proton pump inhibitor and a 28x18 mm pedunculated submucosal lesion (hyper echoic with small hypo echoic foci) of the duodenum which was stable in appearance and size in 2009 presented with a 5 days history of melena with abdominal discomfort. Her blood work was remarkable for haemoglobin of 64 g/L (127 g/L previously).Figure 1The upper endoscopy showed a more than 5 cm duodenal polyp with multiples ulcerations and friability without active bleeding. Placement of a ligating device to prevent the rebleeding, polyloop 30mm (Olympus: HX-400U-30), was impossible due to the size and position of the lesion. A CT-scan confirmed a polypoïd lesion anchored in the duodenal bulb without extra digestive extension of suspicious ganglion. An endoscopic ultrasonography showed a more than 4x3 cm lesion of the duodenal bulb with a relatively short and thick peduncle originating from the mucosa with complete sub mucosa infiltration. This lesion was diffusely homogenous with a hyper echoic pattern. There was no muscular layer infiltration. Considering the advanced age of the patient an endoscopic resection was considered acceptable. A second endoscopy was performed. An « en bloc » resection with a 3x6 cm Acusnare polypectomy snare (Cook Medical: ASJ-1-S: G22630) at the base of the peduncle. The polyp was displaced in the stomach with some resistance and an arterial bleeding from the base of the polypectomy was control with a Resolution Clip (Boston Scientific: 2261). Two other clips were installed and a polyloop 30 mm surrounding the clips closed the mucosal defect. The polyp was then grabbed with the snare but was too big to pass the gastro oesophageal junction. We unsuccessfully tried to cut the polyp in two pieces. A 16.7 mm inner diameter 50 cm length Guardus gastric overtube (USEndoscopy: BX00711149) was placed in the stomach. The polyp was grabbed again with the snare and impacted 50% of its length in the distal portion of the overtube. All items (polyp, scope, overtube) were removed « en bloc » without much resistance. Pathology showed a 5.5x4x2.2 cm lesion with a 1.2x2 cm insertion site considered a brunner's glands hamartoma without dysplasia with multiple superficial ulcers. The resection was incomplete with lesion at the insertion site. The patient had no complication or further bleeding and was discharged home. A six months follow-up upper endoscopy is pending.

A new assessment tool for Parkinson disease: the nigral lesion load obtained by transcranial sonography.

A sonographic method that provides for the measurement of a single frozen image and ignores the remaining portions of the midbrain has been used recently as a biological marker of Parkinson disease. We propose a new approach to evaluating the midbrain: obtaining the nigral lesion load, with which it is possible to acquire an estimate of the real damage to the substantia nigra. We studied 60 patients with Parkinson disease and classified them according to the Hoehn and Yahr scale (Neurology 1967; 17:427-442). Magnetic resonance imaging of the brain, ioflupane-labeled single-photon emission computed tomography, and technetium Tc 99m-labeled single-photon emission computed tomography were performed. Assessment of the midbrain parenchyma was performed with transcranial sonography to quantify the extent of hyperechoic signals on 2 different scans (upper and lower substantia nigra). In 90% of patients (54), we found pathologic hyperechoic substantia nigra signals (>0.25 cm(2)). These data were similar to those described previously by other authors. However, the sum of the values obtained from each measurement (total of 4 per patient) showed that patients with severe disease had larger nigral lesion loads. In most cases, the study showed impairment of the nigrostriatal dopaminergic system when the hyperechoic pattern was more pronounced. Transcranial sonography is a useful tool for Parkinson disease workup. A single measurement of substantia nigra echogenicity may be insufficient for an optimal definition of the stage of the disease. A study of the entire midbrain may deliver more information than a single measurement.

Sonography only in emergency? The black and the white

The ultrasound transducer generates ultrasounds. It emits them, collects the return echo and allows the ultrasound system to re-create an image that (few people) know how to interpret. The probe and the ultrasound system work together by measuring the liquid component of a tissue, as ultrasounds propagate easily trough the water. On sonography imaging liquids appear black because they are “anechoic”. It means that the ultrasound wave goes through them without emitting any return echo . Tissues containing a lot of water appear dark , or “hypoechoic” , because the larger part of the ultrasound waves go through them while a small part of them is reflected by the tissues and returns to transducer. Otherwise less hydrated tissues appear lighter, or “hyperechoic”, because they reflect the largest amount of ultrasound. On sonography, a solid tissue appears white with a black shadow below, as it reflects all the ultrasounds. The air does not reflect ultrasound but scatters them back toward the probe. The return echo signals are interpreted as dispersion artifacts. With these simple concepts, it is easier to interpret many ultrasound images. The search of liquid effusions, anechoic, in the context of serous cavities after a trauma, in well known as FAST sequence and its evolution EFAST . This sequence is a versatile and valuable tool, also available for those physicians inexperienced in sonography . The FAST sequence is feasible anywhere (point of care) and without mobilizing the inpatient (bedside) or during CPR . The versatility of this sequence has allowed many physicians without specific training or background to approach clinical sonography. Ultrasound focused lung sequence (LUS) was proposed for respiratory disease, very frequent in pediatrics. The presence of tipical artifacts allow to detect a regular air intake in lung parenchyma near next to the chest wall. Their absence is a sure sign of respiratory disease. A question naturally arises: why should we use ultrasound just in urgency? There is no unambiguous answer, but after the last decade, the US scanner is becoming a valuable tool to further investigate the physical examination, especially in emergency department. In Table ​Table11 it summarizes that a basic sonography could be the chest examination in order to evaluate the air intake Simultaneously, a further application could be addressed to the research of anechoic areas and/or hyperechoic pathological patterns of abdomen, not just after trauma. Table 1 During the last year an interesting application was referred to the detection of skull fractures. This easy and bedside procedure presents good sensitivity (88%) and high specificity (97%). All of these procedures appear useful tools for the optimization of waiting times of diagnostic imaging in emergency (golden hour!) and for reduction of ionizing radiations use in pediatric patients.