Extracranial and Intracranial Sonographic Findings in Vertebral Artery Diseases

Objective. The aim of this review is to illustrate the sonographic features that can be detected in vertebral artery (VA) diseases. Methods. We conducted a review of sonographic findings in VA diseases. Results. Various VA diseases are described, and sonographic techniques and features are discussed. Conclusions. Posterior circulation vascular imaging can be performed by means of various neuroimaging techniques. Intra‐arterial angiography remains the reference standard. The use of this technique has become even more widespread since it has become possible to perform endovascular procedures; it is, however, an invasive procedure that is associated with a not irrelevant level of risk. Computed tomographic angiography and magnetic resonance angiography with and without contrast agents have been proposed as less invasive alternatives, although these techniques can only be performed in the radiology unit and may not be readily available in daily clinical management. Sonography, which combines an extracranial and intracranial evaluation, is highly suited to the assessment of the vertebrobasilar system on account of its widespread availability and its unique capacity to study real‐time hemodynamics. Furthermore, new sonographic applications and sonographic contrast agents have improved the sensitivity and specificity of this technique with regard to diagnostic accuracy for the posterior circulation.     

Lumen reduction measurements of the internal carotid artery before and after Levovist enhancement: reproducibility and agreement with angiography.

Our aim was to assess reproducibility of three different lumen reduction measuring methods--North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial, and common carotid--using power Doppler and color Doppler sonography before and after Levovist enhancement. We included 20 symptomatic patients with mild or severe carotid disease. North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial, and common carotid measurements on longitudinal views and European Carotid Surgery Trial measurements on transverse views were performed. Examinations were repeated and the results compared to assess reproducibility of measurements. Correlation with angiography was obtained by calculating Pearson correlation coefficients. Reproducibility was significantly better (P < 0.05) for European Carotid Surgery Trial and common carotid measurements (95% limits of agreement between -10% to 10% and -19% to 17%) as compared to North American Symptomatic Carotid Endarterectomy Trial measurements (95% limits of agreement between -11% to 21% and -21% to 23%). Variability of measurements after enhancement increased slightly (not significant) for both power and color Doppler sonography. Additionally, European Carotid Surgery Trial measurements, using nonenhanced power Doppler or color Doppler sonography, did not correlate significantly with angiography, whereas North American Symptomatic Carotid Endarterectomy Trial and common carotid measurements correlated well with angiography, particularly in power Doppler mode after enhancement (r = 0.88 and r = 0.82, respectively). We conclude that for lumen reduction measurements of the internal carotid artery with power and color Doppler sonography, the common carotid method is the only method that is reproducible and has good correlation with angiography, which slightly improves after Levovist enhancement.     

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.     

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.     

Duplex sonographic criteria for measuring carotid stenoses

PURPOSE: The aim of this retrospective study was to determine optimal duplex sonographic criteria for use in our institution for diagnosing severe carotid stenoses and to correlate those findings with angiographic measurements obtained by the European Carotid Surgery Trial (ECST), North American Symptomatic Carotid Endarterectomy Trial (NASCET), and Common Carotid (CC) methods of grading carotid stenoses. METHODS: We analyzed the angiographic data using the ECST, NASCET, and CC methods and compared the results with the duplex sonographic findings. We then calculated the sensitivity, specificity, positive and negative predictive values, and accuracy of the duplex sonographic method. Taking these parameters into account, the optimal intrastenotic peak systolic velocity (PSV) and end diastolic velocity (EDV) were derived for diagnosing severe stenoses according to the 3 angiographic methods. RESULTS: Optimal PSV and EDV values for diagnosing a 70% or greater stenosis in our laboratory were as follows: with the NASCET method of angiographic grading of stenoses, PSV 220 cm/second or greater and EDV 80 cm/second or greater, and with the ECST and CC methods, PSV 190 cm/second or greater, and EDV 65 cm/second or greater. The optimal PSV and EDV for diagnosing a stenosis of 80% or greater with the ECST grading method were 215 cm/second or greater and 90 cm/second or greater, respectively. CONCLUSIONS: Duplex sonography is a sensitive and accurate tool for evaluating severe carotid stenoses. Optimal PSVs and EDVs vary according to the angiographic method used to grade the stenosis. They are similar for stenoses 70% or greater with the NASCET method and for stenoses 80% or greater with the ECST method.     

Three‐Dimensional Sonography of Placental Mesenchymal Dysplasia and Its Differential Diagnosis

Objective. Placental mesenchymal dysplasia (PMD) is an uncommon vascular anomaly of the placenta characterized by mesenchymal stem villous hyperplasia. Its main sonographic feature is a thickened placenta with hypoechoic areas, and an accurate sonographic diagnosis is challenging. The aim of this study was to report 2 cases of PMD and discuss the differential diagnosis of its sonographic features. Methods. Cases of placental masses were studied by 2‐dimensional (2D), 3‐dimensional (3D), and color Doppler imaging. Results. In case 1, a thick placenta with multiple hypoechoic areas was noted at 13 weeks' gestation. At 19 weeks, the multicystic area, clearly demarcated from a normal‐looking placenta, measured 6.5 × 8.5 cm and enlarged gradually. The patient gave birth to a 625‐g female neonate after spontaneous labor at almost 26 weeks' gestation. In case 2, a first sonographic examination at 25 weeks' gestation revealed a thickened placenta with hypoechoic areas and a fetus with a single umbilical artery and a ventricular septal defect. At 27 weeks, the abnormal area of the placenta measured 14.5 × 7.5 cm. At 32 weeks' gestation, a caesarean delivery was performed because of a nonreassuring fetal heart tracing, and a 1415‐g female neonate was delivered. Both cases were evaluated by 2D, 3D, and color Doppler imaging, and the pathologic features of both placentas were consistent with PMD. Conclusions. Placental mesenchymal dysplasia should be considered in the differential diagnosis of every placental mass, especially in cases of multicystic placental lesion with lack of high‐velocity signals inside the lesion, and a normal karyotype.     

SURGERY FOR ASYMPTOMATIC CAROTID ARTERY STENOSIS

SUMMARY The recent European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) have clearly defined a population who benefit from carotid artery endarterectomy (CAE). However these trials used different criteria to identify >70% stenosis of the internal carotid artery (ICA). The role of CAE in asymptomatic ICA stenosis has been investigated by the Carotid Artery Stenosis with Asymptomatic Narrowing Operation Versus Aspirin (CASANOVA) study, the Veterans Administration Asymptomatic Carotid Study (VAACS) and the Asymptomatic Carotid Artery Stenosis (ACAS) trials, all of which have design limitations. The Asymptomatic Carotid Stenosis Trial (ACST) is still recruiting patients but until the natural history of asymptomatic ICA disease is understood, the role of surgical intervention will continue to be controversial.     

Three‐Dimensional Sonographic Characteristics of Deep Endometriosis

Objective. The purpose of this presentation is to investigate the potential role of 3‐dimensional (3D) sonography in the assessment of deep endometriosis. Methods. Cases of deep endometriosis are presented to illustrate the spectrum of appearances obtained with 3D sonography. In addition, we evaluate the possible role of other functions included in 3D equipment, such as the niche mode and tomographic ultrasound imaging (TUI). Results. Three‐dimensional image rendering could allow a good analysis of the endometriotic nodule; in fact, in all presented cases, this reconstruction seems to clearly show the irregular shapes and borders of the lesions. This technique allows unrestricted access to an infinite number of viewing planes, which can be very useful for correctly locating lesions within the pelvis and evaluating the relationship with other organs. The stored 3D volumes can be reassessed and compared by the same or different examiners over time. This characteristic may be relevant for monitoring the effect of medical therapies over time. In the niche mode, sonographic imaging is represented as a “cut‐open” view of the internal aspect of the nodule and its surrounding tissue. This additional function, which is associated with TUI, could be particularly useful for evaluation of the extension of a nodule in the rectovaginal septum, the depth of infiltration, and the relationship with the rectosigmoid junction or ureter. Conclusions. In the near future, 3D sonography in deep infiltrating endometriosis could be an interesting mode of research with positive effects in everyday clinical practice.     

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.     

Sonographic Diagnosis of Congenital Variations of the Extracranial Vertebral Artery and Assessment of Its Circulation

Objective. The purpose of this study was to assess the value of sonographic examination of congenital variations of the extracranial vertebral artery associated with posterior circulation ischemia in children. Methods. Sonography was performed on the vertebral arteries of 82 patients aged 2.5 to 14 years with a history of headache, vertigo, and syncope. An additional 86 unaffected children aged 2 to 14 years were included as a control group. Indices such as the diameter, passage, and morphologic characteristics of the vertebral artery were measured, as well as the arterial volume. The median values of these parameters were used for comparisons. Results. A comparison between the control and 5 case groups showed that the bilateral diameter and volume in these 6 groups had significant variations (P < .05). A narrow diameter and abnormal passage of the vertebral artery resulted in reduced blood flow and an inadequate blood supply in the posterior circulation. There were 42 cases found to have congenital variations of the extracranial vertebral artery, 12 cases of congenital asymmetry, 15 cases of tortuosity, 5 cases of bilateral congenital asymmetry with tortuosity, 6 cases of congenital hypoplasticity, and 4 cases of an abnormal path. Conclusions. Certain children with a history of recurrent signs of vertigo, headache, and syncope were found to be afflicted with congenital variations of the extracranial vertebral artery. Sonography not only revealed the morphologic variations of the extracranial vertebral artery but also allowed an assessment of changes in blood flow such that posterior circulation ischemia could be determined.     

A Method to Visualize 3‐Dimensional Anatomic Changes in the Cervix During Pregnancy

Objective. The purpose of this study was to develop a method to visualize 3‐dimensional (3D) anatomic changes in the cervix and lower uterine segment during the antepartum period. Methods. An observational study of patients with both uncomplicated and complicated pregnancies was performed. To visualize 3D anatomic changes, solid models were constructed from 3D sonographic data. Model construction followed a 3‐step protocol. First, 3D transvaginal sonographic data of the cervix and lower uterine segment were obtained. Second, sonographic data were exported to a medical image‐processing program, which was used to align 3D sonographic data obtained from a single patient at different time points. Last, sonographic data were used to guide construction of solid models using mechanical design software. Anatomic changes were visualized by comparing solid models constructed from sonographic data obtained at different time points. Results. From 16 patients who consented, 5 patients were selected for this study. Two to 4 models were derived from each of the 5 patients at 15 to 38 weeks' gestation. To show anatomic changes in the cervix and lower uterine segment, solid models from different time points in the same patient were superimposed. A total of 16 solid models were constructed. In addition, 3D changes associated with second‐trimester cervical failure and successful therapeutic cerclage were shown. Conclusions. A method to visualize 3D cervical changes is presented, revealing complex anatomic changes in the lower uterine segment, cervical stroma, and cervical mucosa as pregnancy progresses.     

Three‐Dimensional Power Doppler Assessment of Uterine Vascularization in Women With Primary Dysmenorrhea

Objective. The aim of this study was to assess myometrial vascularization with 3‐dimensional (3D) power Doppler angiography (PDA) in women with different grades of primary dysmenorrhea at the moment of maximum menstrual pain in an effort to improve the pathophysiologic knowledge of one of the most common gynecologic conditions. Methods. This was a cross‐sectional study involving 70 voluntary women that studied or worked at the Clinica Universitaria de Navarra between January 2006 and January 2008. All women underwent transvaginal sonographic 3D PDA on the day of maximum pain after the onset of menstruation or during the first 24 to 48 hours of the new cycle if no pain was present. Three groups were defined according to a visual analog scale: no pain to mild dysmenorrhea, moderate dysmenorrhea, and severe dysmenorrhea. Vascularity assessment was done on the basis of 3D vascularity indices: the vascularization index (VI), flow index (FI), and vascularization‐flow index (VFI). Results. The mean VI and VFI for the inner 5 mm of the myometrium and the total myometrium were significantly higher in the women with severe dysmenorrhea than in those with no pain to mild dysmenorrhea (P < .05). The VI, FI, and VFI in the women with moderate dysmenorrhea did not differ significantly from those in the women with severe dysmenorrhea. Conclusions. This study evaluated the use of 3D PDA for assessing uterine and specifically myometrial vascularization. Our data indicate that women with severe dysmenorrhea have increased myometrial vascularization during the early menstrual phase compared with women without pain.     

双源64层CT在椎动脉狭窄诊断中的价值

目的 评价双源64层CT血管造影(CTA)在椎动脉狭窄诊断中的价值.方法 后循环脑缺血症状患者61例,均同时接受数字减影血管造影术(DSA)与CTA检查;使用双源64层CT进行扫描,运用最大密度投影(MIP)、多平面重组(MPR)、曲面重组(CPR)、和容积再现(VR)技术进行重组和轴位像放大以精确测量狭窄血管和正常血管的直径;采用北美症状性颈动脉内膜切除实验(North American Symptomatic Carotid Endarterectomy Trial,NASCET)方法进行血管狭窄程度分级,CTA和DSA检查结果分别由2名高年资放射科医生进行测量.结果经CTA和DSA检查的122支血管中,共有100支具有一致性;狭窄率≥70%时,CTA的敏感度96.4%,特异度96.8%,阳性预测值90.0%,阴性预测值98.9%;≥50%时,CTA的敏感度97.9%,特异度89.2%,阳性预测值85.5%,阴性预测值98.5%,CTA与DSA的狭窄率有很高的相关性(r=0.98,P<0.01).结论 CTA在诊断椎动脉狭窄程度上与DSA有很高的相关性,可作为椎动脉狭窄筛选的常规检查手段.     

Blood Flow in the Internal Carotid Artery With Common Carotid Artery–Occluding Lesions in Takayasu Arteritis

Objective. The purpose of this study was to investigate carotid artery hemodynamics and blood flow involving external carotid artery (ECA) and internal carotid artery (ICA) patency in patients with Takayasu arteritis (TA). Methods. The common carotid artery (CCA), ECA, ICA, and vertebral artery (VA) were examined in 19 patients with TA involving ECA and ICA patency and in 19 healthy control participants. Bilateral carotid sonographic studies were performed with the use of 5‐ to 8‐MHz linear transducers. Results. Patency of the ECA and ICA was noted in 14 bilateral, 2 right‐sided, and 3 left‐sided CCA lesions. Flow in the ECA was retrograde, whereas flow in the ICA was directed cephalad and showed a low‐frequency, damped waveform or even a veinlike waveform. The peak systolic velocity (PSV) of the ICA in the patients was significantly lower than that in the control participants (P < .001). A good correlation was observed in the PSV between the ECA and ICA (r = 0.77). The VA displayed normally directed flow, a significantly larger diameter, and a higher flow velocity (P < .001). Conclusions. Color duplex sonography can identify special features of TA with CCA‐occluding lesions and permit quantification of carotid artery flow velocities and VA diameters both efficiently and practically.     

Comparison of 3‐ and 2‐Dimensional Sonographic Techniques for Counting Ovarian Follicles

Objective. The purpose of this study was to compare 3‐dimensional (3D) and 2‐dimensional (2D) ovarian follicle counts and 3D counts using stored volumes between experienced and inexperienced operators. Methods. Follicles larger than 5 mm were counted on 1 randomly selected ovary. Two‐dimensional follicle counts were compared with stored 3D volumes by the same experienced operator (registered diagnostic medical sonographer [RDMS]). Counts using 3D stored data were compared between the experienced operator and inexperienced operator (principal investigator [PI]). The mean difference in follicle counts was computed, and a 1‐sample Student t test was performed to test the hypothesis that the mean of the differences was 0. Comparison of the 2 methods and observers by Bland‐Altman plots was used to determine any systematic differences based on the total number of follicles per selected ovary. Results. Mean differences differed from 0 (P < .005) for all 3 comparisons: 2D RDMS versus 3D RDMS, 2D RDMS versus 3D PI, and 3D RDMS versus 3D PI. For the comparison of 2D versus 3D counts done by the RDMS, 5 ovaries (10%) had a difference of more than 5 follicles counted; for the 2D RDMS versus 3D PI, 11 ovaries (22%) had a difference of more than 5 follicles; for the 3D RDMS versus 3D PI, 8 ovaries (16%) had a difference of more than 5 follicles. Mean differences in counts ranged 0.29 to 1.04 for ovaries with 10 or fewer follicles compared with 3.94 to 9.00 for ovaries with more than 10 follicles. Conclusions. Follicle counts using 3D volumes were similar to 2D counts, and 3D follicle counts done by an inexperienced operator were similar to counts done by an experienced sonographer.     

Three‐Dimensional Power Doppler Vascular Sonographic Sampling for Predicting Ovarian Cancer in Cystic‐Solid and Solid Vascularized Masses

Objective. The purpose of this study was to explore the role of 3‐dimensional (3D) power Doppler (PD) sonography to discriminate between benign and malignant cystic‐solid and solid vascularized adnexal masses and to define cutoff values for 3D PD indices to be used in a clinical setting. Methods. A total of 143 consecutive women (mean age, 50.4 years; range, 17–82 years) with diagnoses of cystic‐solid or solid vascularized adnexal masses on B‐mode and 2‐dimensional PD sonography were evaluated by 3D PD sonography before surgery. Three‐dimensional PD sonography was used to assess vascularization within papillary projections and solid areas with a virtual organ computer‐aided analysis program. Three‐dimensional PD vascular indices (vascularization index [VI], flow index [FI], and vascularization‐flow index [VFI]) were automatically calculated. A definitive histologic diagnosis was obtained in each case. Results. A total of 113 masses (74%) were malignant, and 39 (26%) were benign. Morphologic evaluation revealed 30 unilocular solid masses (19.7%), 43 multilocular solid masses (28.3%), and 79 mostly solid masses (52%). The mean VI (9.365% versus 3.3%; P < .001), FI (34.318 versus 28.794; P < .001), and VFI (3.233 versus 1.15; P < 0.01) were significantly higher in malignant tumors. No differences were found in the resistive index, pulsatility index, and peak systolic velocity. Receiver operating characteristic analysis revealed an area under the curve of 0.77 (95% confidence interval, 0.69–0.85), 0.71 (0.60–0.81), and 0.75 (0.66–0.83) for the VI, FI and VFI, respectively. For reducing the false‐positive rate by almost one‐third, sensitivity values for the VI (cutoff, 1.556%), FI (25.212), and VFI (0.323) were 92%, 95%, and 93%, respectively. Conclusions. Three‐dimensional PD vascular indices could be helpful for reducing the false‐positive rate in cystic‐solid and solid vascularized adnexal masses.     

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.     

椎动脉闭塞的声像图特征和诊断价值

目的 探讨椎动脉闭塞的二维和多普勒超声声像图特征。方法 回顾性分析超声诊断的11例椎动脉闭塞声像图特点。结果 经三维核磁血管显像(3D MRA)证实10例为椎动脉闭塞，1例为椎动脉广泛狭窄。超声诊断正确率为91％。椎动脉闭塞以右侧多见，二维超声显示椎动脉管壁为两条平行的线状高回声，管腔内充满低回声，无搏动性。彩色和脉冲多普勒超声未测及血流信号。结论 超声是诊断椎动脉闭塞首选和可靠的非介入性影像检查方法。     

Three‐Dimensional Vascular Indices Calculated Using Conventional Power Doppler and High‐Definition Flow Imaging

Objective. The purpose of this study was to determine whether there are differences in 3‐dimensional (3D) vascular indices when calculated using high‐definition flow imaging (HDF) and power Doppler imaging (PD). Methods. Twenty‐five consecutive asymptomatic premenopausal women (mean age, 31 years; range, 28–33 years) without a history of gynecologic disease who attended routine gynecologic checkups were included in the study. All women had regular menstrual cycles, and none had uterine or myometrial disease detected on basal transvaginal sonography. All women underwent 3D transvaginal sonography. In each patient, a first volume using conventional PD was obtained, immediately followed by a second volume using HDF. Volumes were stored and subsequently analyzed for calculating 3D vascular indices (vascularization index [VI], flow index [FI], and vascularization‐flow index [VFI]) from the endometrium. Results. The median VI, FI, and VFI were significantly higher when calculated using HDF compared with conventional PD (P < .05). Conclusions. Three‐dimensional vascular indices calculated using HDF are higher than those calculated using conventional PD.     

First‐Trimester Assessment of the Nasal Bones Using the Retronasal Triangle View

Objective. The purpose of this study was to evaluate a new sonographic technique for identifying the nasal bones using the retronasal triangle view, ie, the coronal plane at which the palate and frontal processes of the maxilla are simultaneously visualized. Methods. Three‐dimensional (3D) volumes were acquired from women undergoing first‐trimester sonographic screening for aneuploidy by 2 accredited operators. Those data sets in which the fetal face was clearly identified were selected for offline analysis by 2 other observers who were unaware of the sonographic or clinical findings. The nasal bones were classified as both present, only 1 present (right or left), or absent according to the presence or absence of 2 small paired echogenic linear structures at the upper tip of the retronasal triangle as determined by 3D navigation in the coronal plane and compared to those findings obtained by 3D navigation in the sagittal plane. Additional 3D data sets involving a subset of 4 first‐trimester fetuses with trisomy 21 and absent nasal bones were also analyzed retrospectively and included randomly in the study group. Results. A total of 110 3D data sets were analyzed, of which 86% were obtained transabdominally and 14% transvaginally. The quality of nasal bone identification was classified subjectively by the observers as good in 67% of cases, fair in 29%, and poor in 4%. The nasal bones were classified as at least 1 present in 106 of the cases (96%) and absent in 4 (4%), with complete agreement between observers in both the sagittal and coronal planes (κ = 1). Discrimination between the right and left nasal bones was possible in 89% and 93% for observer A and in 96% and 96% for observer B by assessing the sagittal and coronal views, respectively (right nasal bone: κ = 0.90 [95% confidence interval (CI), 0.79–1]; left nasal bone: κ = 0.85 [95% CI, 0.60–0.99]). The nasal bones were not identified at the level of the retronasal triangle view in any of the fetuses with trisomy 21 and absent nasal bones. Conclusions. This study shows that the nasal bones can be confidently identified as paired echogenic structures located at the upper tip of the retronasal triangle. This coronal view of the fetal face offers the possibility of screening for the presence or absence of the nasal bones in the first trimester, especially when the standard midsagittal views of the fetal face are suboptimal because of fetal or maternal factors. Because both nasal bones can be evaluated simultaneously in the coronal plane, the retronasal triangle view may be advantageous over the conventional midsagittal view assessment, in which only 1 of the 2 nasal bones is evaluated.