Fine‐tuning the Diagnosis of Fetal Scalp Cysts

Objective. The purpose of this series is to emphasize the importance of an exhaustive and appropriately conducted sonographic examination in the correct diagnosis of fetal cystic scalp lesions and the place of magnetic resonance imaging (MRI) in the diagnostic sequence. Methods. Transabdominal and transvaginal 2‐ and 3‐dimensional sonography with color and power Doppler imaging as well as 3‐dimensional rendering techniques such as inversion and Doppler angiography were used. In 1 case, an MRI study was performed. Results. In 1 case, the MRI missed and the different sonographic techniques correctly made the diagnosis of a meningocele. In the second case, sonography was sufficient to establish the diagnosis of an epidermal cyst. Conclusions. These 2 cases show the value of going the distance with the newly available high‐frequency sonography. Ultimately, the correct diagnoses were made with the tools offered by sonography without the need for any other imaging modality.     

Prenatally Diagnosed Fetal Split‐Hand/Foot Malformations Often Accompany a Spectrum of Anomalies

The purpose of this series was to identify cases that appeared on sonography to be split‐hand/foot malformations (SHFMs) in fetuses and correlate the sonographic findings, including 2‐dimensional (2D) and 3‐dimensional (3D) sonography, to outcomes. A retrospective review was conducted of sonographic studies from 2002 to 2012 at 2 fetal care centers. Data were collected with respect to the morphologic characteristics of split‐hand/foot abnormalities, the utility of 3D sonography, associated anatomic abnormalities, family histories, gestational ages at diagnosis, fetal outcomes, karyotype, and autopsy results. Ten cases were identified with gestational ages ranging from 15 to 29 weeks. Three‐dimensional sonography was helpful in defining anatomy in 7 of 9 cases in which it was performed. Bilateral SHFMs were found in 7 cases (3 cases involving both hands and feet, 2 cases isolated to hands, and 2 cases isolated to feet), whereas 3 cases showed unilateral split‐hand malformations. Associated anatomic anomalies were present in 6 cases, and 4 of these had recognized syndromes, including 2 with abnormal karyotypes, specifically, del(22q11) and del(7q31). Two cases occurred in the context of a positive family history of SHFM. Three cases were delivered at term, and 7 cases were electively terminated. In conclusion, SHFMs often occur with a broad range of chromosomal abnormalities, single‐gene disorders, and other congenital anomalies. Some apparent SHFMs turn out to be other limb anomalies, such as complex syndactyly. Prenatal screening using 2D sonography can identify SHFMs, and 3D sonography often further clarifies them.     

Three‐Dimensional Sonography of Biliary Tract Disorders

In this pictorial essay, we review the 3‐dimensional sonographic appearance of the normal gallbladder and biliary tree, as well as the appearance of congenital and acquired biliary tract disorders. Using examples, we demonstrate the advantage of 3‐dimensional scanning compared with 2‐dimensional sonography and, even in certain cases, magnetic resonance cholangiopancreatography.     

Comparison Between Exclusively Long‐Axis and Multiple‐Axis Sonographic Protocols for Screening of Rotator Cuff Lesions in Symptomatic Shoulders

Objective. The purpose of this study was to determine whether exclusively long‐axis sonography differs from a multiple‐axis scanning protocol as a screening tool for rotator cuff lesions in symptomatic shoulders when compared with magnetic resonance imaging (MRI). Methods. A total of 509 consecutive patients (mean age, 52.8 years) referred for MRI were also routinely evaluated by sonography. We initially performed exclusively long‐axis sonography and graded the rotator cuff as normal or abnormal. Patients subsequently underwent a full sonographic protocol using multiple‐axis views. Magnetic resonance imaging findings were compared with sonographic findings for both techniques. Results. The overall accuracy of sonography was greater than 90%. We found divergent results from different sonographic techniques in 34 patients. Of these, 8 were multiple‐axis false‐negative; 14 were exclusively long‐axis false‐negative; 6 were exclusively long‐axis false‐positive; and 6 were multiple‐axis false‐positive. All cases with divergent false‐negative findings on multiple‐axis sonography showed tendinosis on MRI. Causes for false‐negative findings on exclusively long‐axis sonography included tendinosis and partial‐thickness tears of the supraspinatus. No statistically significant difference was seen between both sonographic techniques compared with MRI in terms of accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (P > .05). Conclusions. Sonography is reliable for detecting rotator cuff abnormalities. Exclusively long‐axis sonography seems appropriate as a screening tool for rotator cuff lesions in symptomatic shoulders.     

Asteroid Hyalosis Masquerading as Vitreous Hemorrhage on Point‐of‐Care Sonography

Point‐of‐care ocular sonography is frequently used in the emergency department to evaluate patients with vision disorders. We describe a case series of 3 patients who ultimately had a diagnosis of asteroid hyalosis, a lesser‐known condition that on point‐of‐care sonography may be mistaken for vitreous hemorrhage. Asteroid hyalosis is considered a benign degenerative condition. In contrast, vitreous hemorrhage may be an ocular emergency that warrants an urgent ophthalmologic consultation if there is an underlying retinal tear or detachment. Although similar in appearance on sonography, recognition of the subtle pathognomonic sonographic features along with their clinical presentations can differentiate these diseases, with vastly different management strategies and dispositions.     

Prenatal diagnosis of vertebral deformities associated with pentalogy of Cantrell: The role of three‐dimensional sonography?

Pentalogy of Cantrell was diagnosed in a fetus at 14 weeks of gestation, on routine two‐dimensional sonographic examination with Doppler imaging, which revealed a midline supraumbilical abdominal wall defect including herniated liver, an ectopia cordis without intracardiac anomalies, and a large omphalocele containing intestines. Although left unilateral club foot deformity was also detected as an associated anomaly in the same examination, severe lumbar lordoscoliosis was only detected by using three‐dimensional sonography because of the spatial configuration of the deformity. After termination of the pregnancy, postnatal inspection of the fetus confirmed the diagnosis of pentalogy of Cantrell associated with skeletal deformities and revealed low implant ears as an additional finding. Although two‐dimensional sonography with Doppler imaging is sufficient to diagnose pentalogy of Cantrell, it may fail to show the complex vertebral deformities and three‐dimensional sonography may assist in visualizing the defect accurately. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound 38:446–449, 2010     

Delayed Absorption of Oxidized Cellulose (Surgicel) in Post‐Thyroidectomy Patients

Delayed absorption of oxidized cellulose (Surgicel; Johnson & Johnson, New Brunswick, NJ) may mimic a pseudoabscess or a recurrent mass on sonography after tumor surgery. Here we present 3 cases of thyroidectomy in which Surgicel was still apparent on sonography after 26 to 47 months of follow‐up. We show sonographic findings and discuss the utility of sonography for diagnosis of delayed absorption of Surgicel in post‐thyroidectomy patients.     

Three‐Dimensional Color‐Coded Duplex Sonography for Assessment of the Vertebral Artery Origin and Vertebral Artery Stenoses

Objective . The aim of the study was to assess the potential of 3‐dimensional (3D) color‐coded duplex sonography (CDS) for evaluation of the vertebral artery origin and stenoses in this location. Methods. To compare 2‐dimensional (2D) and 3D CDS, both techniques were performed in 25 healthy volunteers and in 18 patients with 21 stenoses of the vertebral artery origin. Stenoses were graded in line with hemodynamic criteria on 2D CDS and according to North American Symptomatic Carotid Endarterectomy Trial criteria on 3D CDS. In 6 patients, digital subtraction angiography (DSA) was performed additionally. Stenoses were graded according to North American Symptomatic Carotid Endarterectomy Trial criteria and compared with 2D and 3D sonographic data. Results. Overall correlation of both sonographic techniques concerning the grading of the stenoses was good (r = 0.69; P < .01). The interobserver correlation for assessment of stenoses by means of 3D CDS was high (r = 0.94; P < .01). Three‐dimensional CDS correlated excellently with DSA in 3 of 6 patients but showed only intermediate or no correlation in the remaining 3 patients. In contrast, spatial information on the stenotic morphologic characteristics was always very comparable with the results obtained by DSA. Conclusions. Three‐dimensional CDS represents a valuable tool for assessment of the origin of the vertebral artery, allowing important morphologic information on stenoses in this location. For grading of stenoses of the vertebral artery origin, 3D information should be combined with hemodynamic criteria obtained by spectral Doppler imaging in 2D CDS. Three‐dimensional CDS could be a valuable tool before interventional procedures of the proximal vertebral artery, saving time and avoiding iodinated contrast agents.     

Contrast‐Enhanced Sonographic Characteristics of Hepatic Inflammatory Pseudotumors

A hepatic inflammatory pseudotumor, which can be misdiagnosed as a malignant tumor, is a relatively uncommon tumor with nonspecific imaging manifestations. As a new diagnostic technique, contrast‐enhanced sonography has become increasingly important in the diagnosis of liver focal lesions. Here we present 3 cases of histologically confirmed hepatic inflammatory pseudotumors diagnosed with contrast‐enhanced sonography. “Fast‐in and centrifugal‐out” may be a characteristic contrast‐enhanced sonographic enhancement pattern in the diagnosis of hepatic inflammatory pseudotumors, which needs confirmation in further studies.     

Umbilical Cord Cysts

Objective. The purpose of this series was to determine whether the use of different 3‐dimensional (3D) sonographic modes allows better definition of umbilical cord cysts and pseudocysts in utero. Methods. Two cases of umbilical cord cysts and 1 of a pseudocyst were analyzed and compared with 2‐dimensional (2D), 3D, angiopower Doppler, tomographic ultrasound imaging (TUI), virtual organ computer‐aided analysis (VOCAL), and automatic volume calculation (AVC) sonographic modes. All cases were followed during pregnancy. A karyotype analysis was also obtained. Results. Three‐dimensional sonography, TUI, and VOCAL allowed clear visualization and evaluation of the sizes, locations, and numbers of umbilical cord cysts. A clear differentiation between a pseudocyst and the yolk sac was obtained with AVC and angiopower Doppler sonography. The 3D sonographic surface mode allowed better visualization of other accompanying fetal malformations. Conclusions. Three‐dimensional sonography allows for a more accurate diagnosis and provides a clearer visualization of malformations than 2D imaging. Cysts and pseudocysts can be defined much more accurately by using the different modes described here.     

Two- and three-dimensional sonographic diagnosis of fetal intra-abdominal umbilical vein varix: A case report

Fetal intra‐abdominal umbilical vein varix is a rare condition characterized by focal dilatation of the umbilical vein of the fetus. We report a case of fetal intra‐abdominal umbilical vein varix associated with additional sonographic abnormalities and detected at 31 weeks' gestation. Several follow‐up sonographic examinations were performed, and the prenatal findings were confirmed on postnatal ultrasound. The diagnosis was facilitated by the use of three‐dimensional power Doppler sonography. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2012;     

Two cases of vasa previa diagnosed prenatally using three‐dimensional ultrasonography

We report two cases in which we describe the impact of sonography (US) in the management of vasa previa. In the first case, with two‐dimensional US, the diagnosis of vasa previa was made at 21 weeks gestation. In the second case, using three‐dimensional US, the diagnosis of vasa previa was made at 19 weeks gestation. An elective Cesarean section was carried out at 34 weeks in both cases. Diagnosis of vasa previa is critical when low‐lying placenta or velamentous insertion of the umbilical cord is detected during the pregnancy. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound 38:389‐392, 2010     

Usefulness of Renal Volume Measurements Obtained by a 3‐Dimensional Sonographic Transducer With Matrix Electronic Arrays

Objective. The purpose of this study was to examine the feasibility of 3‐dimensional (3D) sonography using a matrix array transducer to measure renal volume. Methods. One hundred consecutive patients with a normal serum creatinine level and kidney appearance on computed tomography (CT) performed within 2 months before sonography were enrolled in this study. Two hundred individual renal volumes were blindly obtained by the ellipsoid formula, the stacked ellipse method, the voxel count method using routine 2‐dimensional (2D) sonographic data, 3D sonographic data using a matrix array transducer, and CT data, respectively. The voxel count method was validated as the reference standard by the water displacement method in 10 cadaveric pig kidneys (r = 0.99; P < .001). Renal volumes determined by 2D and 3D sonography were compared with volumes determined by CT. Results. Volumes determined by 2D sonography were significantly lower than those determined by CT (P < .001) but similar to those determined by 3D sonography (P = .78). The percent volume error of 3D sonography (mean ± SD, ?2.2% ± 3.7%) was significantly lower than that of 2D sonography (?15.7% ± 11.8%) with CT as the standard (P < .001). The correlation coefficient between 3D sonography and CT (r = 0.98; P < .0001) was better than that between 2D sonography and CT (r = 0.83; P < .0001). In addition, Bland‐Altman analysis revealed that the limits of agreement between 3D sonography and CT (?9.7% to 5.1%) were narrower than those between 2D sonography and CT (?45.6% to 9.8%). Conclusions. Three‐dimensional sonography with a matrix array transducer can significantly reduce renal volume measurement errors and offers a reliable means of determining renal volumes.     

Three‐Dimensional Sonography in the Differential Diagnosis of Interstitial,Angular, and Intrauterine Pregnancies in a Septate Uterus

Interstitial, angular, and cornual pregnancies and intrauterine pregnancies in an anomalous uterus are separate entities, and the impact of each condition on obstetric outcomes is completely different. However, there is considerable confusion in understanding and managing the natural course of each condition due to a lack of uniform terminology. The single most important factor for differentiating these types of pregnancies is to make an early diagnosis. The differences between interstitial, angular, and cornual pregnancies on 2‐dimensional (2D) sonography are subtle. Although magnetic resonance imaging can be used to differentiate these conditions, it is not preferred as the initial assessment tool because of its limited availability and cost‐effectiveness. Three‐dimensional (3D) sonography has the advantage of providing views of the uterus that cannot be obtained with conventional 2D sonography. We describe 3 cases of interstitial, angular, and intrauterine pregnancies in a septate uterus that were clearly differentiated by 3D sonography. We demonstrate the differences in diagnostic imaging findings and emphasize the importance of 3D sonography in differentiating these entities.     

Fetal Megacystis

The purpose of our retrospective observational series was to determine whether the sonographic characteristics of fetal megacystic bladders can be used to reliably establish the most likely diagnosis in fetuses with this condition. The sonographic records of pregnant patients referred to our institutions over a 10‐year period who were found on initial 2‐dimensional sonography to be carrying fetuses with megacystis were examined for evidence of a keyhole sign, bladder thickness, amniotic fluid index, and fetal sex. When available, 3‐/4‐dimensional sonography, Doppler angiography, tomographic ultrasound imaging, virtual organ computer‐aided analysis, and automatic volume calculation were used as part of the detailed fetal anatomic survey. Twenty fetuses with megacystis were identified. Seventeen were male; 2 were female; and 1 had ambiguous genitalia. All male fetuses with megacystis originally had a diagnosis of prune belly syndrome. The diagnosis for 10 male fetuses with a keyhole sign was changed to megacystis secondary to posterior urethral valves. The fetus with ambiguous genitalia had prune belly syndrome. One of the female fetuses had a diagnosis of urethral atresia, and the diagnosis for the other female fetus was megacystis‐microcolon‐intestinal hypoperistalsis syndrome. In conclusion, in fetuses with megacystic bladders, it is possible to distinguish between cases with prune belly syndrome, posterior urethral valves, urethral atresia, and megacystis‐microcolon‐intestinal hypoperistalsis syndrome by a detailed anatomic survey using 2‐ and 3‐/4‐dimensioinal sonographic techniques.     

Clinical Application of a Modern High‐Definition Head‐Mounted Display in Sonography

Because of the remarkably improved image quality and wearability of modern head‐mounted displays, a monitoring system using a head‐mounted display rather than a fixed‐site monitor for sonographic scanning has the potential to improve the diagnostic performance and lessen the examiner's physical burden during a sonographic examination. In a preclinical setting, 2 head‐mounted displays, the HMZ‐T2 (Sony Corporation, Tokyo, Japan) and the Wrap1200 (Vuzix Corporation, Rochester, NY), were found to be applicable to sonography. In a clinical setting, the feasibility of the HMZ‐T2 was shown by its good image quality and acceptable wearability. This modern device is appropriate for clinical use in sonography.     

Prenatal diagnosis of Pentalogy of Cantrell in the first trimester: Is 3‐dimensional sonography needed?

We report the prenatal diagnosis of 2 cases of Pentalogy of Cantrell in the first trimester. In case 1, sonographic evaluation revealed ectopia cordis, omphalocele, and cystic hygroma at 10 weeks' gestation. In case 2, sonographic assessment during the first trimester detected ectopia cordis and omphalocele at 11 weeks' gestation. In both cases, the patient opted for elective pregnancy termination, and Pentalogy of Cantrell was confirmed in 2 male fetuses. We discuss the role of Doppler imaging and 3-dimensional sonography as complementary methods to conventional sonographic assessment of abdominal wall defects at early pregnancy.     

First Experience Using 4‐Dimensional Hysterosalpingo‐Contrast Sonography With SonoVue for Assessing Fallopian Tube Patency

This study was conducted to describe our first experience using transvaginal 4‐dimensional (4D) hysterosalpingo‐contrast sonography with SonoVue (Bracco International BV, Amsterdam, the Netherlands) for diagnosis of fallopian tube patency. The study was prospective and conducted in a university hospital setting. The sonographic procedures included 2‐dimensional transvaginal sonography for evaluating uterine and ovarian mobility, observing intubation, and determining the initial plane and 4D hysterosalpingo‐contrast sonography for observing periovarian and pelvic diffusion. Ninety‐six outpatients visiting infertility clinics underwent 4D hysterosalpingo‐contrast sonography. All patients finished the examination successfully. A total of 192 fallopian tubes were assessed, of which 95 (49.5%) were classified as type A (the tube was patent, and the contrast agent flowed smoothly through it), 72 (37.5%) as type B (the tube was patent, but the contrast agent did not flow smoothly inside it), and 25 (13.0%) as type C (blocked). Sixteen patients underwent laparoscopy or laparoscopy combined with hysteroscopy; 28 tubes (87.5%) were concordant with laparoscopy. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index for 4D hysterosalpingo‐contrast sonography versus laparoscopy were 81.8%, 90.5%, 81.8%, 90.5%, and 0.72 respectively. In total, 92.7% of patients did not require a hospital stay after 4D hysterosalpingo‐contrast sonography, and none need resuscitation. The others stayed in the hospital for clinical observation because of a severe vasovagal reaction or severe pain but received only bed rest without any medical treatment. Forty patients (41.7%) felt slight pain; 39 (40.6%) felt moderate pain; and 15 (15.6%) had a vasovagal reaction. No procedure or postprocedure complications occurred in any patient. In conclusion, 4D hysterosalpingo‐contrast sonography with SonoVue is an available screening method for assessment of tubal patency and is tolerable for most patients.     

Correlation of Quantified Contrast‐Enhanced Sonography With In Vivo Tumor Response

Objective.. The purpose of our study was to establish in vivo criteria for monitoring tumor treatment response using 3‐dimensional (3D) volumetric gray scale, power Doppler, and contrast‐enhanced sonography. Methods.. Twelve mice were implanted with Lewis lung carcinoma cells on their hind limbs and categorized to 4 groups: control, chemotherapy, radiation therapy, and chemoradiation. A high‐frequency ultrasound system with a 40‐MHz probe was used to image the tumors. Follow‐up contrast‐enhanced sonography was performed on days 7 and 14 of treatment with two 50‐μL boluses of a perflutren microbubble contrast agent injected into the tail vein. The following contrast‐enhanced sonographic criteria were quantified: time to peak, peak intensity, α (microvessel cross‐sectional area), and β (microbubble velocity). Three‐dimensional power Doppler images were also obtained after the acquisition of contrast data. On day 15, the tumors were excised for immunohistochemical analysis with CD31 fluorescent staining. Results.. The tumor size and 3D power Doppler vascular index showed no statistically significant correlation with microvascular density in all examined groups. Among all of the analyzed contrast‐enhanced sonographic parameters, relative α showed the strongest correlation with the histologic microvessel density (Pearson r = 0.93; P < .01) and an independent association with the histologic data in a multiple regression model (beta = .93; R² = 0.86; P < .01). Conclusions.. Of the various examined sonographic parameters, α has the strongest correlation with histologic microvessel density and may be the parameter of choice for the noninvasive monitoring of tumor angiogenic response in vivo.