Pulsed Doppler Ultrasonography Research Articles

Increased blood flow in the anterior humeral circumflex artery correlates with night pain in patients with rotator cuff tear

Background Night pain is a particularly vexing symptom in patients with rotator cuff tear. It disturbs sleep and decreases quality of life, and there is no consensus regarding its etiology. Based on arthroscopic surgical observations of synovitis around the rotator interval or capsule surface in rotator cuff tear, we hypothesized that blood flow from the artery feeding the capsule increases blood supply to the synovium. This study aimed to investigate the relationship between blood flow and night pain using pulse Doppler ultrasonography.Methods A series of 47 consecutive patients with rotator cuff tear was evaluated. The peak systolic velocity and resistance index of blood flow in the ascending branch of the anterior humeral circumflex artery were evaluated using pulse Doppler ultrasonography. We also investigated 20 normal shoulders in healthy volunteers. The peak systolic velocity and resistance index were compared between affected and unaffected sides in patients and between dominant and nondominant sides in controls.Results Anterior humeral circumflex artery peak systolic velocity and resistance index did not differ between sides in control subjects or in patients with rotator cuff tear without night pain. However, anterior humeral circumflex artery peak systolic velocity and resistance index did differ significantly between sides in patients with rotator cuff tear with night pain.Conclusions This study revealed anterior humeral circumflex artery hemodynamics in patients with rotator cuff tear and normal subjects using Doppler ultrasonography. Night pain, particularly involving aching, appears to be related to the hemodynamics. These findings suggest that investigating the hemodynamics of patients with rotator cuff tear with night pain may lead to greater understanding of the etiology of this symptom.

P22.01: Novel technique to detect fetal heart rate automatically using two‐dimensional speckle‐tracking echocardiography

Although it is ideal to avoid using pulsed Doppler in the first trimester for the safety, it is inevitable to use current available ultrasound technique, pulsed Doppler or M-mode echocardiography, to measure fetal heart rate. We developed novel technique to assess fetal heart motion by using two-dimensional speckle-tracking method and validated the feasibility of automated fetal heart rate (FHR) calculation using this technique. Normal singleton fetuses were selected for the study. Feral heart was visualized and then the heart motion was recorded by conventional two-dimensional ultrasonography for the analysis. Square-shaped region-of-interest (ROI) was placed on the fetal heart. The outer squares of 3x3 grid within ROI were used for tracing the heart itself and the central square of ROI was analyzed to calculate FHR. Cyclic changing pattern of central square was calculated automatically and used for counting FHR (AutoFHR). Furthermore, AutoFHR was compared with FHR derived from conventional M-mode echocardiography. Total 48 singleton fetuses were eligible for the study and single analysis was done in each fetus. Mean gestational age at analysis was 30.0 ± 6.8 weeks of gestation. The tracing of fetal heart during fetal gross movement was possible and AutoFHR could be calculated. AutoFHR was significantly correlated with FHR by M-mode echocardiography (R = 0.880, P < 0.05). Inter-observer and intra-observer variability (%CV) were 1.2 and 2.2, respectively. AutoFHR was possible even in early first trimester (7 weeks of gestation). AutoFHR was novel technique to calculate FHR by not using Doppler ultrasound or M-mode echocardiography. This novel technique would make it easier and safer to detect fetal heart rate than conventional pulsed Doppler technique.

The successful detection of postpartum unruptured vaginal pseudoaneurysm using ultrasonography: a case report.

IntroductionWe report the first case of the successful detection of postpartum unruptured vaginal pseudoaneurysm using power- and pulsed-Doppler ultrasonography after delivery.Case descriptionA 38-year-old primiparous Japanese woman had a vaginal laceration with pulsatile bleeding after delivering by vacuum extraction. Transvaginal ultrasonography of the repaired vaginal wall showed an 18 × 20 mm hematoma within which a 6 × 7 mm pulsating anechoic mass was detected. Power-Doppler ultrasonography showed blood flow signals in the anechoic mass. Arterial waveforms detected in pulsed-Doppler mode were suggestive of unruptured pseudoaneurysm. Careful monitoring with contrast-enhanced computed tomography showed an increase in the size of the pseudoaneurysm on the fourth postpartum day. On the sixth postpartum day, massive vaginal bleeding occurred. Emergency angiography revealed strong staining with extravasation from the left vaginal artery, confirming the diagnosis of pseudoaneurysm. Embolization for hemostasis was successfully performed.Discussion and evaluationAs far as we know, our case is the first in which an unruptured vaginal pseudoaneurysm was diagnosed using ultrasonography. The differential diagnoses of pseudoaneurysm are arteriovenous malformations including arteriovenous fistula. This case had the typical ultrasonographic patterns of pseudoaneurysm in which the presence of one or two cystic masses in B-mode and color- and/or power-Doppler flow signals was demonstrated along with high-resistance arterial flow waveforms in pulsed-Doppler mode. Sequential examinations of contrast-enhanced CT showed ongoing development of the pseudoaneurysm. In retrospect, we could have performed angiography for embolization when the unruptured pseudoaneurysm was diagnosed, or at the latest when ongoing development of the pseudo-aneurysm was recognized, irrespective of whether symptoms were present.ConclusionsUltrasonography is a non-invasive and clinically useful modality in the differential diagnosis of pseudoaneurysm. Contrast-enhanced computed tomography with or without ultrasonography can be useful for sequential monitoring of the size of unruptured pseudoaneurysms.

Safety of Diagnostic Ultrasound No. 6. The Safety of Pulsed Doppler Ultrasound

There are two pulsed Doppler ultrasound including continuous wave (CW) Doppler and pulsed Doppler, where the safety is discussed in the pulsed Doppler, because of its higher ultrasound intensity, due to longer pulse and higher pulse repetition frequency than simple B-mode ultrasound, and obstetrical setting of ultrasound devices determines the thermal and mechanical indices below one in pulsed Doppler. Ultrasound user is responsible to ultrasound safety, where the user lowers the ultrasound thermal and mechanical indices below one, when indices are higher than one. The use of pulsed Doppler in the first trimester is regulated by ISUOG committee.

General principles of carotid Doppler ultrasonography.

Carotid Doppler ultrasonography is a popular tool for evaluating atherosclerosis of the carotid artery. Its two-dimensional gray scale can be used for measuring the intima-media thickness, which is very good biomarker for atherosclerosis and can aid in plaque characterization. The plaque morphology is related to the risk of stroke. The ulceration of plaque is also known as one of the strong predictors of future embolic event risk. Color Doppler ultrasonography and pulse Doppler ultrasonography have been used for detecting carotid artery stenosis. Doppler ultrasonography has unique physical properties. The operator should be familiar with the physics and other parameters of Doppler ultrasonography to perform optimal Doppler ultrasonography studies.

ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics

<scp>ISUOG</scp> Practice Guidelines: use of Doppler ultrasonography in obstetrics

Update on ultrasound imaging of liver fibrosis

Update on ultrasound imaging of liver fibrosis

Eye vessels doppler sonography and optical coherence tomography in assessing the effectiveness of treatment of patients with diabetic retinopathy

Aim. To study the properties of eye vessels Doppler sonography and retinal optical coherence tomography in assessing the treatment effectiveness in patients with diabetic retinopathy. Methods. 122 patients (244 eyes) with type 2 diabetes mellitus and nonproliferative diabetic retinopathy aged 41 to 55 years were examined. The disease duration ranged from 2 to 15 years. All patients were treated with glibenclamide and supportive therapy: eye drops of 1% methylethylpiridinol - 1 drop 3 times a day, 20% pyracetam solution - 5 ml intravenously for 14 days. Patients were divided into 4 groups: 1st group included 30 patients who were administered with Hirudo powder, 2nd group consisted of 32 patients treated with Hirudo powder in combination with laser photocoagulation, 3rd group included 30 patients treated by laser photocoagulation and 4th group consisted of 30 patients who were treated with glibenclamide and supportive therapy only. All patients were examined before and 4 days after treatment, examination included standard ophthalmic examination, retinal optical coherence tomography and eye vessels pulsed color Doppler sonography. Results. Improvement of circulation parameters resulting in increased blood flow speed and decrease of vascular resistance index, as well as visual acuity improvement, reduction of macular edema were registered in the first group after the treatment. In the 2nd group, significant improvement of circulation parameters as increased blood flow speed and decrease of vascular resistance index, visual acuity increase, reducing of the area and height of macular edema were observed. In the 3rd group, deterioration of circulation parameters as decreased blood flow speed and increase of vascular resistance index, slight visual acuity increase and reducing of the area and macular edema height were observed. In the 4th group improvement of circulation parameters was non-significant as well as visual acuity change and retinal condition. Thus, combination of Hirudo powder and retinal laser photocoagulation was the most effective method, leading to improvement of circulation parameters, visual acuity increase, reduction of macular edema. Conclusion. Quantitative analysis of retinal optical coherence tomography and eye vessels Doppler sonography parameters and their link to visual acuity testing allows to assess completely the effectiveness of conducted treatment.

Three-dimensional HDlive rendering images of the TRAP sequence in the first trimester: reverse end-diastolic umbilical artery velocity in a pump twin with an adverse pregnancy outcome.

The twin reversed arterial perfusion (TRAP) sequence, also known as fetus acardius, occurs in 0.3 % of monozygotic twin gestations, which amounts to a frequency of about 1 per 35,000 deliveries [1, 2]. There have been only two reports on antenatal three-dimensional (3D) sonographic diagnosis of the TRAP sequence during pregnancy [3, 4]. The HDlive is a new surface render mode involving the use of skin-like colors, and ‘‘its system uses an adjustable light source, giving the operator the opportunity to create lighting and shadowing effects and thereby increasing depth perception’’ [5]. There have been four reports on fetal, placental, and umbilical cord ultrasound images using the 3D HDlive rendering mode [5–8]. Employing 3D HDlive with new skin-like colors, we can achieve a natural and anatomically realistic appearance of the embryo and fetus in utero. However, there has been no reports on 3D HDlive rendering displays of the TRAP sequence in the first trimester of pregnancy. There have been five reports on reverse end-diastolic velocity in umbilical artery velocimetry with an adverse pregnancy outcome at less than 14 weeks of gestation, which suggested that reverse end-diastolic umbilical artery velocity waveforms might be an ominous sign in early pregnancy [9–13]. However, there are no sonographic findings in the first trimester that can help to distinguish between pregnancies resulting in death of the pump twin from those that will survive until prophylactic intervention at 16–18 weeks in TRAP sequence cases [14]. In this report, we present our experience of a TRAP sequence reconstructed employing the 3D HDlive rendering mode, and discuss the reverse end-diastolic blood flow velocity waveform in the umbilical artery of a pump twin with an adverse pregnancy outcome in the first trimester. A 33-year-old pregnant Japanese woman, gravida 1, para 0, was referred to our ultrasound clinic because of a suspected TRAP sequence at 11 weeks and 6 days of gestation. The 2D sonography and the 3D surface rendering mode (Voluson E8, GE Healthcare, Milwaukee, WI, USA) showed a normal pump twin and small acardiac twin with acrania and absence of the heart and upper limbs (Fig. 1). The crown-rump length of the pump twin was 43.3 mm (consistent with the corresponding age), and no gross fetal anomaly was noted. The longitudinal distance between the upper pole and rump of the acardiac fetus was 27.6 mm. The 3D HDlive rendering mode provided anatomically realistic images for TRAP sequence diagnosis (Fig. 2). Color and pulsed Doppler sonography revealed a reverse end-diastolic umbilical artery velocity in the pump twin at 13 weeks and 1 day of gestation (Fig. 3a). There was a single-artery umbilical cord between the placenta and acardiac fetus, and a reversed tiny absent diastolic umbilical artery velocity was noted (Fig. 3b). Fetal demise of the pump twin was confirmed at 14 weeks’ gestation. Delivery C. Tenkumo H. Tanaka M. Ito E. Uketa N. Mori U. Hanaoka K. Kanenishi T. Hata (&) Department of Perinatology and Gynecology, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan e-mail: toshi28@med.kagawa-u.ac.jp

Evaluation of the relationship between salivation ability and blood flow velocity in the submandibular gland using pulsed Doppler ultrasonography

To investigate the possibility of predicting salivation ability using pulsed Doppler ultrasonography. Thirty healthy volunteers were enrolled in this study. The blood flow velocity in the submandibular gland before and during acid stimulation was recorded by pulsed Doppler ultrasonography. The changes in the maximum blood flow velocity (V max) and minimum blood flow velocity (V min) were analyzed and compared with the salivation abilities. Strong linear correlations between before and during acid stimulation were observed in the amount of salivation (R = 0.879, p < 0.05) and the V max (R = 0.938, p < 0.05). The mean change rate in the stimulated V max was 1.58 (range 1.10–4.58), and the mean (range) change rates in the V max after 1, 3, and 5 min of acid stimulation were 0.96 (0.47–1.47), 0.97 (0.79–1.40), and 0.98 (0.70–1.23), respectively. No strong linear correlation was observed between the amount of salivation and the blood flow velocity. Although it is known that an increase in the amount of salivation is closely related to an increase in the blood flow velocity in the salivary glands, our findings did not show a linear correlation between the amount of salivation and the blood flow velocity.

Idiopathic Constriction of the Fetal Ductus Arteriosus

Premature constriction or closure of the ductus arteriosus can occur during fetal life. It is a rare phenomenon and has been described secondary to medication or structural lesions or as idiopathic constriction. Premature closure of the ductus arteriosus can lead to progressive right heart dysfunction with tricuspid regurgitation, congestive heart failure, fetal hydrops, and intrauterine death. This series describes diagnosis of fetal ductus arteriosus constriction of unknown etiology in 3 cases, prenatal management, and outcomes. Constriction of the ductus arteriosus can be diagnosed prenatally with careful interrogation of the ductal arch using pulsed Doppler sonography and complete fetal echocardiography. Close monitoring is mandatory to rule out development of right heart failure and to determine the intervention time.

Evaluation of testicular perfusion with color and pulsed Doppler ultrasonography after “standing laparoscopic peritoneal flap hernioplasty technique”

Evaluation of testicular perfusion with color and pulsed Doppler ultrasonography after “standing laparoscopic peritoneal flap hernioplasty technique”

Differences in Sonographic Features of Papillary Thyroid Carcinoma Between Neck Lymph Node Metastatic and Nonmetastatic Groups

The purpose of this study was to assess the differences in sonographic features of papillary thyroid carcinoma between neck lymph node metastatic and non-metastatic groups. A total of 155 patients with 155 papillary thyroid carcinoma nodules were included and divided into two groups: with neck lymph node metastases (52 cases) and without neck lymph node metastases (103 cases). The size, shape, border, margin, halo, internal architecture, echogenicity, echo homogeneity, calcifications, and contact extent between the nodule border and thyroid capsule were evaluated by gray scale sonography, and color Doppler sonography was applied to assess the vascularization distribution and vascularization degree in the nodules. The peak systolic velocity, pulsatility index, resistive index, peak systolic velocity difference, pulsatility index difference, and resistive index difference were measured by pulsed Doppler sonography in 80 lesions. The differences in the sonographic features of papillary thyroid carcinoma between the metastatic and nonmetastatic groups were investigated. The differences in the size, percentage of the nodule border that contacted the thyroid capsule, calcifications, vascularization degree, and resistive index difference of the lesions were statistically significant between the metastatic and nonmetastatic groups (P < .05). Our findings suggest that a larger size, a greater contact percentage, combined microcalcifications and macrocalcifications, a higher blood supply, and a higher resistive index difference were significantly more common in the metastatic group compared to the nonmetastatic group.

Are increased carotid artery pulsatility and resistance indexes early signs of vascular abnormalities in young obese males?

To provide insight into the factors by which obesity in itself may directly lead to early arterial damage, we aimed to determine early sonographic markers of obesity-related vascular dysfunction in young obese males. Thirty-five young obese males and 23 age-matched healthy male volunteers were recruited into the study. Common carotid artery pulsatility index and resistance index were calculated from blood flow velocities curves obtained by pulsed Doppler ultrasonography. The mean pulsatility index, resistance index, body mass index, waist circumference, systolic and diastolic blood pressure, homeostasis model assessment for insulin resistance, plasma fasting glucose, insulin, C-peptide, triglycerides, low-density lipoprotein cholesterol, and high-sensitivity C-reactive protein were statistically higher in obese subjects than in healthy controls. Our results suggest that depressed vessel compliance and increased vascular resistance are features of young, obese, normotensive subjects independently of and in addition to cardiovascular risk factors. As changes in arterial wall properties may be incipient in young obese subjects, future studies will be required to demonstrate whether early intervention such as diet and exercise in this population can improve vascular functions.

Influence of elastic tube deformation on flow behavior of a shear thinning fluid

The non-Newtonian fluid flow characteristics in collapsible elastic tubes are useful to understand biofluid mechanics in human body. We investigated the flow behavior of a shear thinning carboxymethyl-cellulose aqueous solution in a collapsible elastic tube immersed in water filled chamber under compressive transmural (internal minus external) pressure. The collapsed elastic tube shape is determined by computer tomography based image analysis and velocity profiles are monitored using pulsed ultrasound Doppler velocimetry technique. As external pressure increases at a steady volume flow rate, the elastic tube collapses from elliptical to line or area contacted two lobes shape. Since the outlet pressure in collapsed tube with reduced cross sectional area is lower, the compressive transmural pressure is more negative at downstream than that at upstream. When the downstream transmural pressure is −18mbar, the collapsed tube cross sectional area A reduces to one-sixth of the undeformed tube. The corresponding maximum flow velocity in the collapsed tube is about twice than that in undeformed tube. The similarity tube law represents well the experimental variation in A with the transmural pressure. The tube shape and velocity profile are measured along the tube length, the velocity profiles being bi-modal in the two lobes (no line or area contact) shape over the tube length of about 8cm starting from 5cm near the downstream. The velocity profiles gradually turned into uni-modal as the tube deformed into elliptical shape after 13cm length. Consequently, the average shear rate near the tube wall increased from 79 to 243s−1 thereby reducing the viscosity from 0.11 to 0.087Pas at the most collapsed region along the tube length 5–9cm from downstream. The shear thinning solution viscosity decreases as the cross sectional area reduces. The periodic flow characteristics during ramp-up and ramp-down are governed by the volume flow rate and applied external chamber pressure. The maximum velocity at the undeformed elastic tube center increases an order of magnitude as time elapses in a periodic flow cycle.

Influence of bitches sex pheromones on the heart rate and other chosen parameters of blood flow in stud dogs (Canis familiaris)

The aim of this study was to verify the usefulness of the measurement of chosen cardiovascular activity parameters for examination of sex pheromones effects in male dogs. We evaluated the influence of the bitches’ sexual pheromones (BSP) on heart rate (HR) with the use of a Holter monitor, and chosen parameters of blood flow in vessels of penis, testes and kidney, with color-coded and pulsed Doppler ultrasonography. We found that the BSP increased HR in all examined males even without showing any other signs of arousal. There were no changes in the RI (resistant index) and PI (pulsative index) in any trials during the pheromone presentation. The increase in blood flow intensity was noted in penile vessels but not in the testes and kidney. We concluded that measurement of flow intensity in the penis as well as the changes in heart rate as the male’s reaction to the BSP can be useful in research concerning sex pheromones in dogs.

Respiratory variations in pulmonary and systemic blood flow in healthy humans

Cardiovascular oscillations are tightly coupled to respiration. Respiratory sinus arrhythmia (RSA) is an important part of heart rate variability with unknown function. Stroke volumes from the right (r-SV) and left (l-SV) side of the heart are assumed to vary differently with respiration, but have not previously been recorded non-invasively and simultaneously in humans. The present study introduces an improved technique for capturing respiratory variations in r-SV. Six young volunteers were investigated during spontaneous and metronome-paced breathing in the left lateral decubitus position. Heart rate (HR, from ECG), l-SV (from finger blood arterial pressure curve) and r-SV (pulsed ultrasound Doppler) were recorded. Left and right cardiac outputs (l-CO and r-CO) were calculated beat by beat from HR, l-SV and r-SV. Respiratory variations in cardiovascular variables and phase angles were estimated by spectral analysis at respiratory frequency (0.15-0.40 Hz). The amplitude of respiratory variations in l-CO was 17% of r-CO (94% CI (6%, 35%), P=0.03). The amplitude of the respiratory variations in l-SV was not different from r-SV (74%, 94% CI (50%, 127%) non-significant). Increases in HR and r-SV were in phase with inspiration, while l-SV decreased during inspiration. The amplitude of respiratory variations in l-CO is significantly smaller than in r-CO. Respiratory variations in HR and in l-SV are in inverse phase; thus, RSA buffers respiratory variations in l-SV. RSA plays an important role in reducing oscillations in systemic blood flow resulting from respiratory changes in venous return.

Progress in diagnosis and treatment of acute kidney injury post neonatal asphyxia

Acute kidney injury(AKI) is a common consequence of perinatal asphyxia,occurring in up to 56％ of these infants,which can cause multiply organ dysfunction and neonatal death.This review summaries the development of early detection indexes in laboratory and clinic such as novel biomarker,urinary protein,urinary enzyme,renal blood flow velocity by pulse Doppler ultrasonography,and treatment in AKI post neonatal asphyxia.It provides more positive meanings on early detection,early management and eventually mortality reduction. Key words: Asphyxia; Neonate; Acute kidney injury; Biomarker; Diuretics; Dopamine

Measurement of the exercising blood flow during rhythmical muscle contractions assessed by Doppler ultrasound: Methodological considerations

Given the recent technological developments, ultra-sound Doppler can provide valuable measurements of arterial blood flow with high temporal resolution. In a clinical setting, measurements of hemodynamics is used to monitor, diagnose and manage changes in blood velocity profile for cardiac valve disease, relatively large vessel stenosis and other cardiovascular diseases. In health science and preventive medicine for cardiovascular disease with exercise therapy, evaluation of cardiac and vascular function is a useful indicator not only at rest but also during exercise, leading to improved exercise tolerance as well as physical activity. During exercise, the increase in oxygen uptake (calculated as product of arterial blood flow to the exercising limb and the arteriovenous oxygen difference) is directly proportional to the work performed. The increased oxygen demand is met through a central mechanism, an increase in cardiac output and blood pressure, as well as a peripheral mechanism, an increase in vascular conductance and oxygen extraction (major part in the whole exercising muscles) from the blood. Therefore, the determination of the local blood flow dynamics (potential oxygen supply) feeding to rhythmic muscle contractions can contribute to the understanding of the factors limiting the work capacity including, for instance the muscle metabolism, substance utilization and vasodilatation in the exercising muscle. Using non-invasive measures of pulsed Doppler ultrasound the validity of evaluating blood velocity/flow in the fore- arm or lower limb conduit artery feeding to the mus- cle is demonstrated during rhythmic muscle exercise; however the exercising blood velocity profile (fast Fourier transformation) due to muscle contractions is always seen as a physiological variability or fluctuations in the magnitude in blood velocity due to the spontaneous muscle contraction and relaxation induced changes in force curve intensity. Considering the above mentioned variation in blood velocity in relation to muscle contractions may provide valuable information for evaluating the blood flow dynamics during exercise. This review presents the methodological concept that underlines the methodological considerations for determining the exercising blood velocity/flow in the limb conduit artery in relation the exercise model of dynamic leg exercise assessed by pulsed Doppler ultrasonography.

The value of Doppler sonography in differential diagnosis of cervical lymphadenopathy

In this prospective study we evaluate Doppler spectral parameters in lymphomatous, reactive, metastatic and acute inflammatory lymph nodes &amp; evaluated the pulsed Doppler sonography as a technique to distinguish between different causes of cervical lymphadenopathy. Spectral Doppler analysis with measurement of resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV) &amp;End diastolic velocity (EDV) was performed in 100 patients with cervical lymphadenopathy. The results of Doppler analysis were compared with findings of cytology &amp; histology or with clinical presentation &amp; follow up. T-test was used to assess statistical significance of differences in Doppler parameters between groups of patients. Significant differences in RI &amp; PI were shown between all groups of patients except between lymphomatous &amp; reactive lymph nodes. Specificity of 100% for metastatic nodal involvement was shown for cutoff values RI&gt;0.80 &amp; PI &gt; 1.80 . A positive predictive value (PPV) of 100% for acute lymphadenitis was shown for cutoff values RI &lt; 0.50 &amp; PI &lt; 0.60. An EDV &gt; 10 cm/s has 100% negative predictive value for nodal metastasis, &amp; EDV &lt; 2cm/s has 100% specificity &amp; PPV for metastases . Although there exist differences in RI, PI, PSV &amp; EDV between different nodal diseases, unfortunately, only extreme cutoff values may occasionally be helpful in differential diagnosis. Doppler spectral analysis is a valuable noninvasive adjunct which can help in differentiation between metastatic, lymphomatous, acute inflammatory &amp; reactive lymphadenopathy, but cannot eliminate the need for biopsy in the majority of cases.