Typical Sonographic Features Research Articles

Contrast-enhanced ultrasound in abdominal trauma

Increasing evidence supports a role for contrast-enhanced ultrasound in the assessment of blunt abdominal trauma. Accurate definition of organ injury can be demonstrated, as well as extension to solid organ capsule and even vascular injury. Low-dose contrast is needed for renal imaging, to avoid obscuration of deeper structures from intense cortical enhancement. The liver should be evaluated in the arterial phase for active bleeding and in the late phase for lacerations. The spleen is best assessed in the delayed phase, thereby limiting misinterpretation of early heterogeneous contrast uptake. Typical sonographic features of traumatic injuries of the solid abdominal organs are described. Although contrast-enhanced computed tomography is the gold standard modality for imaging abdominal organ traumatic injury, contrast-enhanced ultrasound has developed a role in the emergency setting, particularly in low-energy injuries and in follow-up of traumatic injuries.

Menetrier’s disease associated withHelicobacter pylori: three cases with sonographic findings and a literature review

Menetrier's disease is a rare cause of protein-losing gastropathy characterised by hypertrophy of the gastric folds. Three cases are reported. Helicobacter pylori was detected by culture and CLO test in two cases and on follow-up gastroscopy in the other. The first two patients were given eradication therapy and hypertrophic gastropathy resolved whereas in the third the disease remitted prior to the eradication treatment. Typical sonographic features were thickened gastric wall with preservation of the wall stratification. A review of the literature found eight cases of Menetrier's disease associated with H. pylori in children and these cases are briefly reviewed. H. pylori infection should be considered in all children with Menetrier's disease and, if isolated, eradication treatment should be administered.

Cystic Parathyroid Adenoma: Sonographic Features and Correlation With 99mTc-Sestamibi SPECT Findings

The purpose of this study was to describe the typical ultrasound features of cystic parathyroid adenoma. A review of a surgical database and electronic medical records from 2006 to 2009 identified the cases of 15 patients who underwent preoperative cervical sonography for primary hyperparathyroidism with subsequent resection of pathologically proven parathyroid adenoma with predominantly cystic components. Two radiologists retrospectively evaluated the preoperative ultrasound images and assessed for cyst complexity, size, location, and color Doppler vascularity. Technetium-99m-sestamibi SPECT findings, surgical and pathologic reports, and the results of parathyroid hormone assay of the cyst fluid also were reviewed. Most of the cystic adenomas (14/15, 93%) were deep or inferolateral to the adjacent thyroid. The same percentage were elongated and had peripheral nodular components. An echogenic border separating the adenoma from the overlying thyroid was identified in 9 of 15 patients (60%). Color Doppler examination of 14 patients showed feeding vessels with internal color flow to the solid components in 10 patients (71%). Six of 14 patients underwent preoperative or intraoperative sampling of cyst fluid, and the assay showed the parathyroid hormone levels ranged from 1,198 to greater than 5,000 pg/mL. Fourteen of 15 patients underwent preoperative sestamibi SPECT, and the adenoma was definitively localized in four patients (29%). The accuracy of preoperative localization improved to 79% (11/14) when sestamibi SPECT scans were interpreted in correlation with cervical ultrasound images. Awareness of typical sonographic features (location, color Doppler vascularity) may aid radiologists in preoperative localization of parathyroid adenomas, even when cystic degeneration occurs. In cases in which imaging or clinical features are equivocal, the results of cyst fluid sampling and parathyroid hormone assay are confirmatory.

Case report of a testicular epidermoid cyst and review of its typical sonographic features

A case of testicular epidermoid cyst, demonstrating multiple characteristic sonographic patterns in a single lesion, is presented with a brief review of the distinctive ultrasound features. It is important to remember that the sonographic patterns describing testicular epidermoids represent the varied amounts and arrangements of keratin of a particular lesion. A given lesion may demonstrate subtle variability or more than one characteristic pattern at any given time. With this in mind, preoperative characterization of testicular epidermoids should allow for increasing utilization of testicular sparring surgery in the management of this benign lesion.

Giant cell arteritis with eye involvement - color doppler imaging (cdi) of retrobulbar vessels findings

Background. Giant cell arteritis is a primary vasculitis, that affects medium-sized arteries, especially branches of the ECA. Purpose. The main objective was to assess the role of CDI of retrobulbar vessels in the study of two patients with Horton’s disease with eye involvement. Methods. We have used a sonographer with 8-15 MHz linear probe for CDI of orbital vessels. Results. Both patients presented malaise, temporal headache, tender temporal arteries and laboratory signs of inflammation. The first patient had a left central retinal artery obstruction, and the second one had a left ischaemic optic neuropathy. They presented a painless, severe loss of vision of the left eye. Temporal artery histology was positive in both cases. Ultrasound investigation was performed before corticosteroid treatment. CDI of retrobulbar vessels detected low blood velocities, especially end-diastolic velocities and high resistance index in all retrobulbar vessels, in both orbits, for both patients (especially on the affected side). Typical sonographic features in temporal arteritis were ”dark halo sign” (vessel wall thickening), associated with stenoses or occlusions of branches of ECA. Interestingly, in both cases, the CCA and the ICA were, also, affected. Conclusions. Ultrasound technique is a valuable diagnostic tool to investigate giant cell arteritis.

Enthesiopathy of the flexor carpi ulnaris at the pisiform: Findings of high-frequency sonography

Objectives Acute or chronic pain at the pisiform may be due to tendinopathy of the flexor carpi ulnaris tendon (FCU) insertion, mechanical overuse, bony fractures, and osteoarthritis of the pisiform-triquetral joint. Enthesiopathy of the FCU at the pisiform might exhibit abnormalities assessable for sonographic characterization. This study aimed to determine the most relevant sonographic features of tendinopathy of the FCU insertion at the pisiform. Materials and methods We retrospectively analyzed radiological findings of 9 patients admitted for high-frequency sonographic evaluation of a painful pisiform FCU insertion. The FCU insertion was assessed for active enthesiopathy in terms of tendon thickening and hyperemia, peritendinous effusion, peritendinous hyperemia, peritendinous soft tissue thickening, cystic fluid collections, erosive cortical irregularities, and osteoproliferative alterations at the pisiform. Results Of all patients, 5 had inflammatory rheumatic disorders and the remainder had a painful pisiform FCU insertion related to overuse. While peritendinous effusion, pisiform erosive cortical irregularities, and peritendinous soft tissue thickening at the FCU insertion were exclusively found in rheumatic patients, active enthesiopathy of the FCU tendon, pisiform osteoproliferative alterations, and hyperemia of the peritendinous soft tissue were inconsistent and found in both groups. Cystic fluid collections from the pisiform-triquetral joint were only seen in patients with overuse. Conclusions In this small case series of patients with pain at the pisiform FCU insertion, we could reveal several typical sonographic features for insertion tendinopathy. Further studies should prove if these sonographic features could impact on the management of patients with pain at the pisiform.

Sonographische Diagnostik von Trophoblasterkrankungen in der Frühschwangerschaft

Gestational trophoblastic disease (GTD) is classified as a metastatic or non-metastatic lesion, furthermore, villous GTD is distinguished from non-villous GTD. Because of their higher incidence and their risk of persistent gestational trophoblastic neoplasia (pGTN), early diagnosis of molar pregnancies is of clinical importance. Advances in ultrasound (US) technology and frequent application of transvaginal sonography in early pregnancy have changed the clinical and pathological presentation of molar pregnancies. Based on US imaging and histopathological examination of products of conception, the majority of cases are diagnosed in early pregnancy, either as incidental findings or in women presenting with symptoms of miscarriage. Molar pregnancies have characteristic sonographic features which are more pronounced as pregnancy advances. In early pregnancy, overall US detection rates for molar pregnancies range between 34-56% depending on gestational age, sonographic features, histologic morphology, apparative equipment, and operator expertise. There also seems to be an intrinsic limit to US detection rates based on histomorphometric features of the hydropic villi. Thus, in early pregnancy, lack of typical sonographic features does not exclude molar pregnancy. If a condition predisposing for pGTN is not recognized at the time of evacuation, prognosis is worse. With increasing demand for medical management of miscarriages and abortions, when products of conception are usually not submitted for histological examination, sonographic assessment of the chorion is mandatory. In the case of suspicious findings, surgical management and histological examination are indicated.

Ultrasound diagnosis of pseudomembranous colitis

The diagnosis of pseudomembranous colitis (PMC) is based on the history of exposure to antibiotics, characteristic endoscopic findings and on demonstrating the presence of Clostridium difficile toxins in the faeces. This report presents typical sonographic features of PMC. The sonograms of 13 patients with PMC (7 males, 6 females, median age 70 years, range 55-84 years), were retrospectively analyzed. Patients' histories, clinical findings, the results of colonoscopy including histological findings and microbiological tests were related to the sonographic features of inflammation of the colon. At sonography the wall of the colon was thickened (6-17 mm) in each of the patients, different types of changed wall-architecture were seen. In 85% sonographic signs of colitis were restricted to the left colon, whereas in 15% a pancolitis was diagnosed. Ascites was detected in 38%, the colon contents were visible in 85%, in 77% the lumen was narrowed. Colonoscopy confirmed the diagnosis in six patients, in two patients endoscopy was performed only to control the effect of therapy and in five patients endoscopy was thought to be unnecessary. Sonography can supplement history and clinical findings if PMC is suspected. Potentially life-saving therapy can be initiated even if colonoscopy has not been performed and results of microbiological assessment are not yet available. However, the diagnosis of PMC remains to be based on the gold standard of colonoscopy and histological findings.

Impact of sonography in gouty arthritis: Comparison with conventional radiography, clinical examination, and laboratory findings

Objective To explore the typical sonographic features of gray-scale and Power Doppler of acute and chronic gouty arthritis in conjunction with radiographic, clinical, and laboratory findings. Materials and methods All hand, finger, and toe joints of 19 patients with acute and chronic gout were examined with gray-scale and Power Doppler sonography. The number and size of bone changes detected with sonography was compared to radiographic findings. Vascularization of the synovial tissue was scored on Power Doppler (grades 0–3), and was compared with clinical appearance, including swelling, tenderness, and redness (grades 0–3). Results In acute gout, mild to moderate echogenic periarticular nodules with sonotransmission and hypervascularization of the edematous surrounding soft tissue were found. In chronic gout, tophaceous nodules completely blocked transmission of US wave, leading to strong reflexion and dorsal shadowing in a minority of cases. No significant difference in the detection of large bone changes (>2 mm) was found between sonography and radiography. However, gray-scale sonography was significantly more sensitive in the detection of small bone changes ( p < 0.001). Power Doppler scores were statistically significantly higher than clinical examination scores ( p < 0.001). Discussion Sonography is superior to radiographs in evaluating small bone changes. The inflammatory process in joints can be better detected with Power Doppler sonography than with clinical examination. Typical sonographic appearance of acute and in particular of chronic gout might provide clues on gouty arthritis that adds to the information available from conventional radiography, clinical, and laboratory findings.

Evaluation of Arteriovenous Malformations (AVMs) With Transcranial Color-Coded Duplex Sonography

The clinical value of transcranial color-coded duplex sonography (TCCS) in the evaluation of arteriovenous malformations (AVMs) has not yet been fully investigated. In this study, 54 intracranial AVMs confirmed by angiography were prospectively examined over 6 years. The purpose of the study was to describe their typical sonographic features and to define sensitivity for diagnosis with regard to the location of an AVM. Transcranial color-coded duplex sonographic findings for 54 patients with intracranial AVMs are presented. The vessels of the circle of Willis were identified by location, course, and direction of flow on color flow images. In accordance with digital subtraction angiography, the intracranial AVMs could be visualized in 42 cases (sensitivity, 77.8%). The pathologic vessels were coded in different shades of blue and red, corresponding to varying blood flow directions in the AVM. The major feeding vessels could be easily identified. Hemodynamic parameters showing increased systolic and diastolic flow velocities and a decreased pulsatility index were better attainable with TCCS than with conventional transcranial Doppler sonography. Arteriovenus malformations located near the cortex, that is, in the parietal, frontal, occipital, and cerebellar regions of the brain, could not be visualized. In contrast, AVMs located in the basal regions were very easy to image (sensitivity, 88.9%). Additionally, TCCS proved useful for follow-up examinations postoperatively or after embolization. Transcranial color-coded duplex sonography is a valuable noninvasive method for the diagnosis and long-term follow-up of intracranial AVMs. Arteriovenous malformations located in the axial imaging plane can be more easily detected. Nevertheless, TCCS should not be used as a screening method.

Sonographic findings in stress fractures of the lower limb: preliminary findings

Stress fractures are common injuries frequently overlooked on first radiographs, especially in the early course. The gold standard for accurate diagnosis is MRI and scintigraphy. We report six cases of stress fractures of the lower limb diagnosed with sonography and describe typical sonographic features.

P10.05: Increased nuchal translucency as a sole clue of prenatal diagnosis in a fetus with trisomy 13

Trisomy 13 is a fatal chromosomal abnormality. The average length of survival of an infant with trisomy 13 is approximately 4 days. A body of literature supports the use of second trimester ultrasound as a capable adjunct in the prenatal diagnosis of trisomy 13. Over 90% of affected fetuses are present typical sonographic features include holoprosencephaly, facial anomalies, renal anomalies, cardiac defects, and polydactyly. However, there is no consensus about the trisomy 13 showing normal second trimester sonographic findings. We report an unusual case of trisomy 13, demonstrating the increased nuchal translucency as an apparently isolated prenatal finding. A 31-year-old gravida 2 para 1 was referred at 14 weeks of gestation for increased nuchal translucency. Amniocentesis was performed and chromosome analysis showed the karyotype 46, XX, + 13, der (14; 21) (q10: q10). Detailed ultrasound was performed at 18 weeks of gestation, and showed no additional ultrasonographic abnormalities. On postmortem examination, no external abnormalities were noted, with the exception of low set ears. All internal organs were in the correct anatomic position and normally formed for a second trimester fetus. This report accentuates the importance of measuring nuchal translucency at 10–14 weeks of gestation in the fields of prenatal diagnosis over again.

Ultrasonographic urinary tract abnormalities in Schistosoma haematobium infection.

Evaluation of ultrasonographic abnormalities with active Schistosoma haematobium infection in Yemeni patients. As part of a cooperation between a private hospital and Schistosomiasis Control Project in Yemen, laboratory and ultrasonographic examinations were performed in 158 patients (8 females, 150 males, mean age: 17 years) with active Schistosoma haematobium infection. Upper urinary tract dilation, lower ureter changes and bladder wall abnormalities (thickness, hyperechogenicity and polypoid lesions) were registered. Laboratory findings and ultrasonographic changes were evaluated and assorted according to age groups of the patients. Twenty-eight patients (18%) showed no ultrasonographic morphological lesion. Bladder abnormalities (thickness, hyperechogenicity and polypoid lesions) were found in 130 patients (82%) and upper tract lesions in 86 patients (54%). No upper tract lesions were seen without bladder abnormality. Polyps within the lower ureteric lumen occurred in four patients. In patients with polypoid lesions, higher incidence of severe infection was found. One patient had urinary bladder mass. Urinary schistosomiasis has typical sonographic features, however, it may occur also without ultrasonographic morphological lesion. Upper tract lesions seem to develop only with lower tract abnormalities.

Sonographic features of benign papillary neoplasms of the breast: review of 22 patients

The sonographic features of 22 patients with histologically benign intraductal papillomas are presented, with clinical, mammographic, galactographic, and histopathologic correlation. The most common presenting feature in this series is a palpable central breast mass in an elderly woman. Sonography was abnormal in all 22 patients. The typical sonographic features include a well-defined, smooth-walled, solid, hypoechoic nodule or a lobulated, smooth-walled, cystic lesion with solid components. Dilated ducts are a common feature, often with visible solid intraluminal echoes. These findings suggest the diagnosis of an intraductal papilloma. The differential diagnosis includes fibroadenoma and phyllodes tumor (for large solid lesions) and intracystic carcinoma (for complex cystic lesions). Mammograms are frequently normal (36% of patients). When abnormal, the mammographic features are of a smooth-walled, well-defined mass or increased retroareolar opacity. Contrary to the reported literature, calcification was seen infrequently. We conclude that ultrasonography is useful in the detection and delineation of intraductal papillomas.

Sonographic evaluation of the uterus in postmenopausal women receiving tamoxifen: characterization of mid-uterine abnormalities

Background: Tamoxifen is known to exert agonist estrogenic effects on the uterus. Its use in postmenopausal women has also been associated with various endometrial and uterine abnormalities that can be detected by endovaginal sonography. Objective: To study postmenopausal patients receiving tamoxifen who were referred for evaluation following the detection of abnormal uterine findings by endovaginal sonography. Methods: Fifty-two women treated with tamoxifen for breast cancer who were found to have an abnormal uterine sonogram constituted the study population. Uterine sonograms were reviewed and clinical and sonographic data were correlated with the results of the histologic examinations. Results: Forty-five women demonstrated a thickened mid-uterine structure. Of these, in thirty-nine patients (87%) either no tissue or scant fragments of normal endometrium were obtained on curettage, and six women (13%) had endometrial hyperplasia. Seven women had fluid loculation lined by thin endometrium. Their subsequent histologic examination was normal. The sonograms of the women who demonstrated an appearance of a thickened endometrium but no neoplasia, characteristically demonstrated hyperechogenic cystic area with no midline echo. Conclusions: Among 52 postmenopausal patients receiving tamoxifen presented with an abnormal uterine sonogram, 39 (75%) women were found to have a thick mid-uterine structure resembling a thickened endometrium without histologic evidence of neoplasia. This phenomenon can be characterized by typical sonographic features, and may be differentiated from other uterine abnormalities.

Ovarian teratomas: a comparison of the sonographic appearance in prepubertal and postpubertal girls.

Sonography was performed in 17 pediatric patients with 18 benign cystic teratomas of the ovary in order to compare the appearance of this entity in prepubertal and postpubertal girls. Particular attention was paid to the frequency of the characteristic features of this lesion, particularly mural nodules and acoustic shadowing. Of the eight lesions in children less than 13 years old, five were complex lesions and three were cystic. Mural nodules were found in three (38%) of eight lesions and acoustic shadowing in one (13%). Of the 10 lesions in the patients 13 years old or more, seven were complex and three were solid. Seven (70%) of 10 lesions contained a mural nodule, seven (70%) had acoustic shadowing, and one (10%) had a fluid/fluid level. Our experience suggests that typical sonographic features of ovarian teratomas occur more frequently in postpubertal than prepubertal girls.

Macrocephaly Is Not Always Due to Hydrocephalus

Macrocephaly is a clinical symptom with a heterogeneous cause. Besides enlarged ventricles (hydrocephalus) it can be caused by increased brain volume, expanded extracerebral spaces, intracranial cysts, and dilated vessels. Drawing on the experience of more than 8 years using transfontanellar sonography including Doppler techniques, some typical clinical and sonographic features of several forms of macrocephaly are addressed. Besides isolated familial or sporadic megalencephaly, extracerebral fluid collections are the main explanation of macrocephaly. Subdural effusions with compression of the brain by increased intracranial pressure should be differentiated from craniocerebral disproportion without increased intracranial pressure. Subependymal and subarachnoidal cysts may cause extraodinary displacements and compression of brain structures; nevertheless, the prognosis is rather optimistic, for the brain structure itself is generally not destroyed. In some infants with complex genetic, neurocutaneous, and neurometabolic syndromes, macrocephaly is an early clinical sign. The outcome in these infants is very different and dependent on the dysfunction of the brain by the specific disease (eg, storage of neurotoxic substances, dysplasia, gliosis, vascular disturbances, or brain tumors). In infants with vascular malformations the diagnosis can be established more exactly by using Doppler techniques. I recommend some practical diagnostic procedures in cases of macrocephaly. Nevertheless, in many patients with increased head size an exact statement about the further prognosis cannot be established by one examination; therefore, a developmental evaluation in combination with regular sonographic evaluation is the most valuable method in taking care of all infants with macrocephaly.

Sonographically detectable cysts in polycystic kidney disease in newborn and young infants

Autosomal dominant (adult type) and autosomal recessive (infantile type) polycystic kidney disease are 2 distinct forms of hereditary cystic renal disease with differing pathologic and clinical features. Glomerulocystic kidney disease is probably a separate entity, whose pathologic features may closely resemble those of autosomal dominant polycystic kidney disease, especially in small infants. An example of each of these conditions in a small infant is presented, all of which had sonographically detectable cysts. Pathologic correlation was available in each case. While there are typical sonographic features of autosomal dominant and autosomal recessive polycystic kidney disease in newborn and young infants, there is no specific appearance of either condition, and glomerulocystic kidney disease can apparently resemble either one. Other investigations, particularly family studies and pathologic verification, are important in order to establish the correct diagnosis.

Results of real-time sonography and raster mammography of 200 breast cancers

The article reports on 200 patients with histologically verified carcinomas of the breast in whom both real time mammasonography and grid mammography were performed. The indications for additional use of real time sonography in the diagnosis of malignant diseases of the female breast were a palpable node or a suspicious finding in mammography. All patients were examined with a high resolution realtime scanner with a 7.5 MHz transducer. The diagnostic criteria of sound deep to the mass (type I-IV), the regularity of the conteur of the mass, and the presence or absence of internal echoes. The typical sonographic features of histologically different types of carcinoma of the female breast are demonstrated by means of case examples. Mammasonography offers a high degree of accuracy in preoperative differential diagnostic assessment of tumour status in malignant processes of the breast. The combined mammographic-sonographic evaluation is the method of choice in clinical evaluation of masses of the female breast.

Parathyroid adenoma: accuracy of preoperative localization by high-resolution real-time sonography.

To assess the accuracy of high-resolution sonography of the parathyroid glands, a consecutive series of sonograms in 58 patients was reviewed. The study population was limited to patients thought clinically to have primary hyperparathyroidism and likely to have one enlarged adenomatous gland. Patients with renal failure or other evidence of secondary hyperparathyroidism were excluded. Typical sonographic features of parathyroid adenoma were observed. An overall accuracy of 92% was obtained for the identification of surgically confirmed parathyroid gland enlargement due to adenoma.