Sonographic findings of mesenteric panniculitis: correlation with CT and literature review

PURPOSE: To evaluate the sonographic findings of mesenteric panniculitis (MP) and correlate them with CT findings. METHODS: We retrospectively evaluated the clinical, CT, and sonographic findings in 26 cases of MP in our hospital between January 1997 and July 2003. We also reviewed the sonographic features of MP previously described in the literature. RESULTS: The sonographic findings were well correlated to CT in 24 of 26 patients (92%). In these 24 cases, abdominal sonographic examination revealed a hyperechogenic, well-defined fatty mass (corresponding to the pseudocapsule CT sign) in the root of the mesentery, displacing the bowel loops. We found a clear interface between MP and normal intra abdominal fat. Examination with color Doppler sonography revealed the nondeviated mesenteric vessels within the mass. The persence of MP improved sonographic transmission in 9 obese patients and enabled the retroperitoneal vessels to be clearly visualized. Sonography was unable to demonstrate the preservation of the fat nearest the mesenteric vessels corresponding to the "fatty halo" sign on CT. CONCLUSIONS: Sonography is useful in the diagnostic workup for MP. The characteristic sonographic features of MP (well-defined mass, homogeneous hyperechogenicity of the mass, nondeviated vessels within the mass, and displaced bowel loops) correlate well with CT findings.     

肿瘤样钙质沉着症影像学误诊2例分析并文献复习

目的：探讨肿瘤样钙质沉着症的临床及影像学特点,期望减少误诊。方法：回顾性分析2例经手术病理证实的肿瘤样钙质沉着症的临床及影像学资料。结果：临床表现为关节附近无痛性肿块;X线表现为关节周围团块状软组织钙化;MRI表现为T1WI不均匀低信号结节,T2WI不均匀高信号。结论：不侵及关节的软组织内多发性钙化性肿块是肿瘤样钙质沉着症的典型影像学表现,有助于诊断和鉴别诊断。     

The sonographic double-track sign: not pathognomonic for hypertrophic pyloric stenosis; can be seen in pylorospasm.

OBJECTIVE: The "double-track" sign has previously been reported as specific for hypertrophic pyloric stenosis when noted on an upper gastrointestinal series. The sign has been noted on sonographic examinations as well. We sought to determine whether this sign can also be seen in cases of pylorospasm diagnosed by sonography, proving it not to be pathognomonic for hypertrophic pyloric stenosis. METHODS: The data obtained prospectively from 91 consecutive patients studied between 1999 and 2002 by sonography for projectile vomiting were retrospectively reviewed. Cases with diagnoses of hypertrophic pyloric stenosis or pylorospasm were reviewed for the imaging finding of the double-track sign. RESULTS: Thirty-seven patients had a sonographic diagnosis of hypertrophic pyloric stenosis that was confirmed surgically. Twenty-six (70.2%) showed a sonographic double-track sign. Thirty-four patients had a sonographic diagnosis of pylorospasm that was confirmed by close clinical follow-up. Eighteen (52.9%) showed a sonographic double-track sign. CONCLUSIONS: The sonographic double-track sign can be seen in cases of pylorospasm as well as hypertrophic pyloric stenosis. It is not pathognomonic for hypertrophic pyloric stenosis.     

Diagnostic values of sonography for assessment of sternal fractures compared with conventional radiography and bone scans.

OBJECTIVE: This study was prospectively undertaken to evaluate the diagnostic value of sonography for detection of sternal fractures. We compared sonographic, conventional radiographic, and bone scan examinations of sternal fractures. METHODS: Fifty consecutive patients (26 male and 24 female; mean age, 45.2 years) were evaluated. Conventional radiography and sonography were performed in all patients, and bone scans were performed in 39 patients. All patients had acute pain and tenderness in anterior midline chest areas. Sonography was performed by 2 musculoskeletal radiologists within 1 to 2 days after admission. Patients underwent conventional radiography at admission and bone scans within 4 to 7 days after admission. Two radiologists reviewed all imaging findings by means of consensus. In addition, sonography was performed in 20 asymptomatic patients in a normal control group. RESULTS: Conventional radiography depicted sternal fractures in 12 of 50 patients. Sternal fractures were detected in 31 of 50 patients on sonography. Fractures on sonography were located in the manubrium (8 cases), upper sternal body (11 cases), mid sternal body (5 cases), and lower sternal body (7 cases). Bone scans showed sternal hot uptakes (accumulations of the radionuclide used) in 18 of 39 patients. In the control group, there were no bony defects or abnormal contours. CONCLUSIONS: We could detect sternal fractures more effectively with sonography than with conventional radiography and bone scans. In addition, sternal fracture locations showed relatively even distributions, and focal fractures in the manubrium were not easily detected on bone scans.     

不同大小肾透明细胞癌的超声造影声像图特征

目的探讨不同大小肾透明细胞癌（CCRCC）超声造影声像图特征及其在CCRCC诊断中的价值。方法对77例（80个肿瘤）经手术病理证实为CCRCC患者的常规超声及超声造影声像图进行回顾性分析，并按CCRCC最大瘤径，分为小肿瘤（≤30mm）、中等肿瘤（〉30mm）、大肿瘤（〉50mm）3组进行观察。常规超声观察肿块的血流显示程度、回声均匀度以及瘤周有无低回声晕。超声造影观察记录肿瘤的增强程度、增强均匀度以及有无包膜增强，并对3组肿瘤检查结果进行统计学分析。结果80个CCRCC中小肿瘤组32个，中等肿瘤组28个，大肿瘤组20个。常规超声显示小肿瘤组中回声呈不均匀者占18．8％（6／32），中等肿瘤组中占71．4％（20／28），大肿瘤组中为95％（19／20），3组间回声均匀度比较有显著性差异，但血流显示程度和假包膜征显示率在3组间差异无统计学意义。超声造影显示小肿瘤组中不均匀增强者占28．1％（9／32），中等肿瘤组中占85．7％（24／28），大肿瘤组中达100％（20／20）；中等肿瘤组的假包膜征显示率高于小肿瘤组及大肿瘤组，分别为71．4％（20／28）、50％（16／32）、25％（5／20）。增强均匀度以及假包膜征显示率在3组之间有显著性差异，3组CCRCC的增强程度均以中等、明显增强为主，差异无统计学意义。与常规超声相比，超声造影将肿瘤内血流显示丰富者由51．3％（41／80）提高至87．5％（70／80），假包膜征显示率由22．5％（18／80）提高至51．3％（41／80），两者之间有显著差异。肿瘤呈回声不均匀者在常规超声中占56．3％（45／80），超声造影中占66．3％（53／80），但两者之间差异无统计学意义。结论不同大小CCRCC在增强均匀度和假包膜征显示率两方面有不同的超声造影声像图特征。超声造影能更清晰地显示肾癌的血流灌注特点，为肾癌     

Tumoral calcinosis: seasonal biochemical studies and chemical studies of eyelid lesion

We recently described (Arch Ophthalmol 1988; 106:725-6) the presence of unique calcific lesions in the eyelids of a young woman with a history of hyperphosphatemic tumoral calcinosis. Here we document that no immediate family members showed similar lesions and that none was hyperphosphatemic. Dental roentgenography revealed characteristic abnormalities in the patient that confirmed the clinical diagnosis of tumoral calcinosis. Seasonal biochemical studies demonstrated persistently increased concentrations of phosphorus and 1,25-dihydroxyvitamin D in her serum. A calcific eyelid excrescence removed from the patient, studied by x-ray diffraction, was found to consist of crystals of hydroxyapatite. Microprobe analysis indicated the major elements in the deposit to be Ca, P, S, and Cl, just as in the periarticular deposits found in tumoral calcinosis. The Ca concentration in the patient's tear fluid, measured by atomic absorption spectrometry, was within the range found in tears of healthy volunteers. Phosphorus was undetectable (less than 30 mumol/L) in tears of the patient and the volunteers. These findings suggest that the eyelid lesions represent a new manifestation of the pathological process that produces the characteristic periarticular calcific masses of tumoral calcinosis.     

Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation.

OBJECTIVE: Determining the correct position of endotracheal tubes in critically ill patients may be complicated by external factors such as noise, body habitus, and the need for ongoing resuscitation. Multiple detection techniques have been developed to determine the correct endotracheal tube position, recently including the use of sonography to evaluate lung expansion and diaphragmatic excursion. These techniques have also been applied to diagnosis of right endobronchial main stem intubation, which may be confused with a unilateral pneumothorax in some cases. METHODS: We describe the sonographic findings in a case series of endobronchial main stem intubations and obstruction, highlighting the utility of this sonographic application. Previous literature and future applications are discussed. RESULTS: Sonographic detection of the sliding lung sign, the lung pulse, and diaphragmatic excursion can accurately detect main stem bronchial intubation as well as bronchial obstruction. CONCLUSIONS: Clinical use of lung sonography may decrease the need for chest radiography and may allow more rapid diagnosis of main stem intubation and bronchial obstruction.     

骶尾椎脊索瘤MRI征象与临床病理特征分析

目的探讨骶尾椎脊索瘤常规MRI及动态增强MRI(dynamic contrastenhanced magnetic resonance imaging,DCE-MRI)表现特征及其病理学基础。材料与方法观察21例骶尾椎常规MRI、DCE-MRI和HE染色病理表现,测取瘤体最大径与DCE-MRI的时间信号曲线(time-signal intensity curve,TSIC)和最大强化斜率(wash in rate,Wi R)、最大消退斜率(wash out rate,Wo R)及强化峰值时间(time to peak,TTP)。结果瘤体T2WI以高信号为显著特点。"足突边缘"征阳性18例的瘤体最大径大于阴性者(t=2.800,P=0.011)。脊索瘤信号在30 min内逐渐增强,TSIC缓慢持续上升,Wi R为0.75±0.05,Wo R为0,TTP为30 min。病理学主要表现是富含空泡细胞和液滴状细胞的瘤细胞巢间以大量黏液聚集。结论骶尾椎脊索瘤具有以椎体为中心的三维侵袭并椎前侵犯倾向的生物学行为特性,"足突边缘"征是其重要边缘形态特征。特征性的T2WI高信号、缓慢持续强化,与瘤细胞及黏液密切相关。     

Tubular ectasia of the epididymis: a sign of postvasectomy status

PURPOSE: To find out if "tubular ectasia of the epididymis" is suggestive of postvasectomy status. METHODS: Tubular ectasia of the epididymis is defined as enlargement of the epididymis with multiple interfaces (i.e., a speckled appearance). We found 24 cases exhibiting tubular ectasia of the epididymis over a period of six years. We reviewed the sonographic findings of tubular ectasia of the epididymis and evaluated the prevalence of associated findings. RESULTS: In 24 patients with tubular ectasia of the epididymis, 16 cases were bilateral, five were right-sided, and three were left-sided. Twenty-one patients had history of vasectomy, of the three remaining cases, 1 had history of inguinal hernia repair, one had prostatitis, and one had undetermined etiology. Associated abnormalities included dilated vas deferens (n = 4), tubular ectasia of the testis (n = 2), large spermatoceles (n = 6), hydrocele (n = 3), and varicocele (n = 4). In 2 cases, spermatic granulomas were suspected. CONCLUSION: Tubular ectasia of the epididymis is suggestive of postvasectomy epididymis. This sonographic feature is helpful in evaluating a patient with scrotal discomfort. However, this sign can also be associated with other causes of vas obstruction.     

Definitive diagnosis of intestinal volvulus in utero.

Midgut volvulus with or without intestinal malrotation can occur in fetal life. Several reports have described congenital midgut volvulus showing non-specific sonographic findings of intestinal obstruction and perforation in utero. None of the previously reported cases, however, were definitively diagnosed as midgut volvulus by fetal sonography. We report two cases both exhibiting the sonographic 'whirlpool' sign, in utero. Color Doppler interrogation provided a clue to the viability of the involved intestinal segment.     

Giant mucocele of the appendix: clinical and imaging findings in 3 cases.

OBJECTIVE: Clinical and imaging (sonographic and computed tomographic [CT]) findings in 3 cases of giant mucocele of the appendix are described. METHODS: Clinical records of 3 cases of giant mucocele of the appendix were reviewed. All patients had a basal B-mode sonographic examination and a contrast-enhanced sonographic examination using a second-generation low-mechanical index contrast medium. In all cases, a dual-phase spiral CT examination was carried out. RESULTS: In 2 cases, the abdominal masses were discovered in asymptomatic patients; 1 patient had vague abdominal discomfort. A pathologic diagnosis of benign cystoadenoma was found at pathologic examination in all cases, and malignant pseudomyxoma peritonei was disclosed in 1 patient 1 year later. Common sonographic findings were as follows: (1) a huge abdominal mass with a maximum diameter ranging between 20 and 25 cm; (2) a thin hyperechoic border without either solid vegetations or signs of infiltration of surrounding tissues; (3) a complex internal echo structure with anechoic lacunae interspersed between curvilinear, wavy bands of echogenic material (the so-called sonographic onion skin sign); and (4) avascularity of the masses shown on contrast-enhanced sonography with a low-mechanical index medium. At CT, a well-circumscribed cysticlike mass of low attenuation was displayed in all cases. There was lack of enhancement during a dual-phase examination in 2 cases; in the other, a small peripheral area of faint enhancement was appreciated. Only in the latter case could CT reliably assess the origin of the mass. CONCLUSIONS: It is suggested that a combination of sonographic (namely the onion skin sign) and CT findings may aid in the correct preoperative diagnosis of giant mucocele of the appendix.     

The onion skin sign: a specific sonographic marker of appendiceal mucocele.

OBJECTIVE: To evaluate the association of the onion skin sign as a sonographic marker for appendiceal mucocele. METHODS: The sonographic onion skin sign was considered specific for the preoperative diagnosis of appendiceal mucocele. Therefore, detection of this sign in a mass located in the right lower abdomen, unrelated to the female reproductive organs, indicated surgical intervention with a presumptive diagnosis of appendiceal mucocele. From 1998 through 2001, female patients who were found to have atypical cysts containing this sign underwent surgery. The cases were closely followed, and intraoperative findings and final histologic diagnoses were recorded. RESULTS: Appendiceal mucocele was the final diagnosis in all 7 patients in whom the onion skin sign was observed. One additional patient had an appendiceal mucocele with a sonographic picture of a clear tubular cystic structure. CONCLUSIONS: A sonographically layered cystic mass in the right lower quadrant of the abdomen in the presence of a normal ovary strongly suggests the diagnosis of appendiceal mucocele. Recognition of the sonographic onion skin sign in a cystic mass in the right lower quadrant may facilitate the accurate preoperative diagnosis of appendiceal mucocele.     

Mesenteric panniculitis. Part 1: MDCT--pictorial review

Mesenteric panniculitis is an uncommon benign inflammatory condition of unknown etiology that involves the adipose tissue of the mesentery and for which an extremely varied terminology has been used, causing considerable confusion. It can be evaluated as a single disease with two pathological subgroups: Mesenteric Panniculitis (MP), representing the very large major subgroup where inflammation and fat necrosis predominate and Retractile Mesenteritis (RM), much rarely found, where fibrosis and retraction predominate. In histo-pathological terms the preferred terminology is sclerosing mesenteritis. We hereby extensively illustrate the characteristic MDCT findings of MP through pictures selected among a collection of cases constituted over a 5-year period. All patients were scanned with 64-row MDCT equipment. We also review the literature and discuss the differential diagnosis. The radiological diagnosis of MP was based on classical CT signs described in the literature and comprising: the presence of a well-defined "mass effect" on neighbouring structures (sign 1) constituted by mesenteric fat tissue of inhomogeneous higher attenuation than adjacent retroperitoneal or mesocolonic fat (sign 2) and containing small soft tissue nodes (sign 3). It may typically be surrounded by a hypoattenuated fatty "halo sign" (sign 4) and an hyperattenuating pseudocapsule may also surround the all entity (sign 5). The last two signs are considered inconstant but very specific. The absence of histological verification constitutes the weakness of our study. The differential diagnosis of MP is extensive and includes all disorders that can affect the mesentery. The most common ones are lymphoma, well-differentiated liposarcoma, peritoneal carcinomatosis, carcinoid tumor, retroperitoneal fibrosis, lipoma, mesenteric desmoid tumor, mesenteric inflammatory pseudotumor, mesenteric fibromatosis and mesenteric edema. PET/CT is proved useful to correctly exclude mesenteric tumoral involvement in patients presenting with typical MR The course of MP is favorable in most cases and progression of MP to retractile mesenteritis not only appears very being rare but finally remains doubtful.     

Sonographic septation: a useful prognostic indicator of acute thoracic empyema.

The aim of this study was to identify sonographic predictors of patient outcomes or need for surgical intervention of acute thoracic empyema. All patients with a clinical diagnosis of thoracic empyema underwent transthoracic ultrasonographic examination and thoracentesis at admission. According to the presence or absence of septa in sonographic images, the patients were classified into two groups: septated and nonseptated. Sonographic findings were analyzed with respect to duration of hospital stay, chest tube drainage, and treatment efficacy. A total of 163 consecutive patients were included in the study (83 patients with septated and 80 with nonseptated sonographic images). The mean duration of hospital stay (35.4 versus 27.0 days, P = 0.009) and chest tube drainage (13.1 versus 7.6 days, P < 0.001) for the patients with septa were significantly longer than for those without septa. The patients with septa were more likely to undergo intrapleural fibrinolytic therapy (63.8% versus 38.8%, odds ratio 2.79, P = 0.001) and surgical intervention (24.3% versus 7.5%, odds ratio 3.92, P = 0.004). We concluded that sonographic septation is a useful sign to predict the need for subsequent intrapleural fibrinolytic therapy and surgical intervention in cases of acute thoracic empyema. Early fibrinolytic therapy or even surgical intervention may be indicated in patients with sonographic septations.     

Ultrasonographic features of gastrointestinal duplications.

The variable sonographic appearance of duplication cysts is presented. Eighteen sonograms from 14 patients, aged 1 day to 8 years, were reviewed over an 8 year period. Water and other aqueous contrast agents were used in six patients as part of the sonographic evaluation. All lesions were confirmed by surgery. All but two patients were symptomatic. Twenty-four cysts were detected, ranging in size from 1.7 to 15.5 cm. The duplication cysts revealed a spectrum of sonographic findings (cystic to solid appearing masses). The mass characteristics, including the "muscular rim sign," and internal debris or hemorrhage, were demonstrated. Multiple unsuspected cysts (3 of 14 or 20%) and complications such as perforation were readily seen with ultrasonography. Serial sonograms demonstrated the changing morphology of two cysts. Other unsuspected intra-abdominal and pelvic pathologic conditions, including pyloric stenosis and ovarian cysts, were identified. Identification of the muscular rim sign is the most reliable indication of a duplication cyst. Multiple masses as well as possible accompanying anomalies in the abdomen and pelvis are readily evaluated with sonography. Lesions are easily followed with serial studies if there is no surgical intervention.     

Sonography of intramuscular myxomas: the bright rim and bright cap signs.

OBJECTIVE: The objective of this study was to retrospectively review sonographic images of pathologically proven soft tissue myxomas to determine whether a sonographic correlate to the bright rim and bright cap signs described in the magnetic resonance imaging literature is present. METHODS: The study group consisted of 6 patients with pathologically proven soft tissue myxomas (1 man and 5 women; age range, 41-72 years; mean, 56.5 years). The available sonographic images for each subject were retrospectively reviewed by 2 authors (L.F. and K.F.), with agreement reached by consensus. Among other findings, images were also reviewed for a peripheral rim of increased echogenicity (termed the "bright rim sign") and for the presence of a triangular hyperechoic area adjacent to at least one of the poles of the mass (termed the "bright cap sign"). RESULTS: The bright rim and bright cap signs were seen in 5 (83%) of the 6 myxomas. The single case without the bright cap sign was not the same case as the one lacking the bright rim sign. CONCLUSIONS: The sonographic bright rim and bright cap signs were associated with 5 (83%) of the 6 intramuscular myxomas. These findings correlate with their magnetic resonance imaging equivalents, which are well documented in the literature, due to muscle atrophy and adjacent fatty infiltration. Recognition of these features may assist in a more accurate sonographic diagnosis before biopsy.     

The ultrasonographic deep sulcus sign in traumatic pneumothorax

A series of 186 patients with blunt chest trauma was studied with transthoracic ultrasonography to diagnose pneumothorax and to evaluate its size and location. The results were compared with bedside chest radiography and spiral CT scan. The prevalence of pneumothorax on CT scan was 56/186 (30.1%). Pneumothorax was proven on radiography in 30/56 cases without false positive results: "radiographic deep sulcus sign" was evident in 3/29 cases, 26/29 cases being occult. The ultrasound study demonstrated the presence of pneumothorax in 55/56 patients: one occult pneumothorax was missed and no false positive results were observed. The CT scan differed of +/-2.3 cm (range 1-5 cm) from the US study in evaluating size and location of pneumothorax. In conclusion, ultrasound study may detect occult pneumothorax undiagnosed by standard plain radiography. It reflects accurately the extent of pneumothorax if compared with CT scan, outlining the "ultrasonographic deep sulcus sign" on anterior chest wall.     

Utility of the sonographic whirlpool sign in diagnosing midgut volvulus in patients with atypical clinical presentations.

OBJECTIVE: To illustrate cases of midgut volvulus in 7 children, of whom only 2 were neonates, diagnosed initially by sonography using the whirlpool sign, and to emphasize the importance of considering malrotation and midgut volvulus in the differential diagnosis of acute or chronic abdominal pain in those beyond the neonatal period, the usual time of presentation for midgut volvulus. METHODS: The sonography computer database of a large pediatric hospital was reviewed over a 26-month period for sonographic reports that contained the key words midgut volvulus and whirlpool sign. From November 1999 until January 2002, 7 patients had a sonographic diagnosis of midgut volvulus on the basis of the whirlpool sign. Sonographic and surgical records of these patients were reviewed retrospectively. In addition, the department computer database of all contrast-enhanced upper gastrointestinal examinations performed over the same period was searched using the key words midgut volvulus, and an additional 2 cases of midgut volvulus were found, neither of which had undergone a prior or subsequent sonographic study. RESULTS: Seven patients, ranging in age from 1 day to 5 1/2 years were found to have the whirlpool sign on sonography performed for acute abdominal symptoms, including projectile nonbilious emesis, colicky abdominal pain with suspicion of intussusception, palpable abdominal masses, right lower quadrant abdominal pain with suspected appendicitis, and chronic diarrhea. Six of the 7 cases of midgut volvulus were confirmed with upper gastrointestinal examinations. One patient was taken directly to surgery on the basis of the sonographic findings alone. One patient had subsequent computed tomography of the abdomen for continued suspicion of an abdominal mass. All 7 cases were confirmed as midgut volvulus at surgery. CONCLUSIONS: The sonographic whirlpool sign is a valid and highly sensitive sign for the diagnosis of midgut volvulus secondary to malrotation, and sonographers should be aware that it frequently occurs beyond the neonatal period with symptoms other than bilious emesis.     

Follicular Ring Sign

The follicular ring sign is a novel, easily identifiable sonographic finding of ovarian torsion consisting of hyperechoic rings around the antral follicles. In a retrospective analysis of 15 consecutive patients with torsion undergoing surgery, the follicular ring sign was frequently present, starting early in the disease course. This sign could be valuable for accurate and early diagnosis of torsion in the absence of specific conventional sonographic features.     

Sonographic patterns of Caroli's disease: report of 5 new cases.

We have reviewed 5 cases of Caroli's disease, studied from 1982 to 1987, in order to define the validity of its sonographic signs. The "intraluminal portal vein" sign, found in all the cases, is emphasized. This sign may be easily identified and it is never encountered in other diseases. Recessive polycystic kidney disease was present in 3 cases, and congenital hepatic fibrosis was demonstrated in the 2 cases studied by liver biopsy.