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.     

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.     

Two‐ and three‐dimensional prenatal sonographic diagnosis of prune‐belly syndrome

We report the prenatal diagnosis of 6 cases of Prune‐belly syndrome in the 2^nd trimester. The sonographic diagnosis was based on the findings of oligohydramnios, renal anomalies, and a lower abdominal cystic mass representing the abnormal dilatation of the bladder on conventional 2‐dimensional sonographic examination. We discuss the role of Doppler imaging and 3‐dimensional sonography as complementary methods to conventional sonography. Four of our 6 cases were confirmed with associated defects. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2010     

Prenatal Diagnosis of Placenta Accreta

Objective. The purpose of this study was to compare the accuracy of transabdominal sonography and magnetic resonance imaging (MRI) for prenatal diagnosis of placenta accreta. Methods. A historical cohort study was undertaken at 3 institutions identifying women at risk for placenta accreta who had undergone both sonography and MRI prenatally. Sonographic and MRI findings were compared with the final diagnosis as determined at delivery and by pathologic examination. Results. Thirty‐two patients who had both sonography and MRI prenatally to evaluate for placenta accreta were identified. Of these, 15 had confirmation of placenta accreta at delivery. Sonography correctly identified the presence of placenta accreta in 14 of 15 patients (93% sensitivity; 95% confidence interval [CI], 80%–100%) and the absence of placenta accreta in 12 of 17 patients (71% specificity; 95% CI, 49%–93%). Magnetic resonance imaging correctly identified the presence of placenta accreta in 12 of 15 patients (80% sensitivity; 95% CI, 60%–100%) and the absence of placenta accreta in 11 of 17 patients (65% specificity; 95% CI, 42%–88%). In 7 of 32 cases, sonography and MRI had discordant diagnoses: sonography was correct in 5 cases, and MRI was correct in 2. There was no statistical difference in sensitivity (P = .25) or specificity (P = .5) between sonography and MRI. Conclusions. Both sonography and MRI have fairly good sensitivity for prenatal diagnosis of placenta accreta; however, specificity does not appear to be as good as reported in other studies. In the case of inconclusive findings with one imaging modality, the other modality may be useful for clarifying the diagnosis.     

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.     

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     

Antenatal diagnosis of idiopathic dilatation of pulmonary artery with 3D power doppler imaging

We present a case of antenatal diagnosis of idiopathic dilatation of the pulmonary artery by three‐dimensional power Doppler imaging (HDliveFlow with silhouette mode). Two‐dimensional sonography clearly demonstrated a 10.4‐mm‐diameter fetal pulmonary artery (PA), whereas the aorta (Ao) diameter was 5.04 mm. HDliveFlow clearly demonstrated the spatial relationships and different sizes of PA and Ao. The PA size returned to normal (8.0 mm) on the 11th day after birth (Ao: 9.0 mm). HDliveFlow may be an adjunctive tool to two‐dimensional sonography to diagnose abnormalities of fetal great vessels. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45 :121–123, 2017;     

High‐Frequency Sonography in the Evaluation of Psoriasis

Objective. The purpose of this study was to show the potential of the latest sonographic equipment using high‐frequency probes and a very sensitive power Doppler (PD) technique in depicting both skin and nail changes in patients affected by psoriasis. Methods. The study was conducted in 30 patients with a diagnosis of psoriasis clinically performed by an experienced dermatologist and 15 healthy participants, using a currently available sonography system equipped with a variable‐frequency transducer ranging from 6 to 18 MHz and a Doppler frequency ranging from 7 to 14 MHz. Results. The images illustrated in this presentation are representative examples of the ability of sonography to show and characterize even minimal morphostructural and blood flow changes in patients with both psoriatic plaques and onychopathy. Conclusions. This report provides pictorial evidence that high‐resolution gray scale sonography with a PD technique is a real‐time and noninvasive imaging technique that can be used as an adjunct to the clinical evaluation in assessing psoriatic disease.     

Sonography of Fat Necrosis Involving the Extremity and Torso With Magnetic Resonance Imaging and Histologic Correlation

Objective. The purpose of this study was to describe the sonographic appearance of pathologically proven isolated fat necrosis involving the extremities or torso with magnetic resonance imaging (MRI) correlation. Methods. A query of the Department of Pathology database at our institution for the diagnosis of fat necrosis resulted in 1539 cases. Review of the cases and medical records excluded cases without sonographic imaging, those involving the breast, and those within or adjacent to a primary process, including masses or prior surgery, which resulted in a total of 5 cases of primary fat necrosis, 2 of which were evaluated with MRI. Sonograms were reviewed by 2 musculoskeletal radiologists and characterized with regard to location, echogenicity, shadowing, posterior through‐transmission, a hypoechoic rim or halo, definition of borders, homogeneity, a mass effect, and vascularity. The patient medical records, histologic results, and MRI findings were also reviewed. Results. Of the 5 cases of isolated fat necrosis, 2 involved the torso and 3 the lower extremities. On sonography, all were located in the subcutaneous fat; 2 were isoechoic; 3 were hyperechoic; 2 had a hypoechoic halo; none showed shadowing or posterior through‐transmission; 2 were well defined; 3 were masslike; 4 were heterogeneous; and 2 showed increased flow on color or power Doppler imaging. Magnetic resonance imaging showed an intermediate signal and either diffuse or ring enhancement. Conclusions. Isolated fat necrosis of the extremities and torso had 2 sonographic appearances, which included a well‐defined isoechoic mass with a hypoechoic halo and a poorly defined hyperechoic region in the subcutaneous fat.     

Posttraumatic Painful Hip

Objective. Nondisplaced hip fractures may be radiographically occult and require magnetic resonance imaging (MRI) or bone scintigraphy for diagnosis. Both examinations are expensive and are not readily available in many hospitals. Our objective was to evaluate sonography as a screening tool for occult hip fractures in posttraumatic painful hips in elderly patients. Methods. We prospectively evaluated 30 patients (mean age, 73 years), who were admitted for painful hips after having low‐energy trauma with nondiagnostic hip radiographs. After inclusion, patients underwent sonography of both hips for signs of injury. After completion of the sonographic examination and analysis of the results, patients underwent MRI of both hips. The sonographic findings were compared with the MRI findings, which served as the reference standard for accurate detection of a hip fracture. Results. Ten hip fractures were diagnosed by MRI. Sonography showed trauma‐related changes in all of those patients and in 7 additional patients, 3 of whom had pubic fractures. Sonography correctly identified 13 patients without hip fractures. The sensitivity of sonography was found to be 100%, whereas the specificity for hip fractures was 65%. Conclusions. Sonography for posttraumatic hip pain with negative radiographic findings did not result in a single missed hip fracture. Therefore, sonography may serve as an effective screening tool, mandating MRI only for cases with positive findings, whereas patients with negative sonographic findings need no further investigation. Sonography may therefore be very useful in hospitals around the world, where MRI may not be readily affordable or available.     

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.     

Diagnostic Accuracy of Sonographic and Clinical Parameters in the Prediction of Retained Products of Conception

Objective. The purpose of this study was to assess the diagnostic accuracy of different parameters (clinical and sonographic) in the prediction and management of retained products of conception (RPOC) in the late postpartum period. Methods. This was a prospective cohort 3‐year audit. Predefined data were collected and compared with histopathologic (HP) reports after uterine evacuation. The primary outcome measure was the diagnostic accuracy of different clinical and sonographic parameters, including color Doppler imaging in diagnosis of RPOC confirmed on HP reports. Secondary outcome measures were complication rates influencing maternal morbidity. Results. In total, 93 patients (0.92% of all deliveries) were selected. The presence of gestational tissue was confirmed on HP reports in 58% of cases. The likelihood ratio of sonography alone was 1.47 (95% confidence interval, 1.25–1.84), whereas that of sonography combined with color Doppler imaging was 2.16 (1.3–3.59), providing statistically significant accuracy regarding the prediction of RPOC. Conclusions. Sonography alone or combined with color Doppler imaging has better diagnostic accuracy than the usual clinical parameters used for the prediction of RPOC.     

Sonographic diagnosis of a glomus tumor of the thigh

Extradigital glomus tumors are a very rare entity. Here, we report a rare case of a glomus tumor in an atypical anatomic site: the thigh. The clinical features together with the results of MRI, and sonography and Doppler sonographic imaging helped to distinguish glomus tumor of the thigh from other soft tissue neoplasms. The tumor arising from the thigh was excised, and following surgery, the patient was symptom free without evidence of complications or recurrence. There have only been a few previously reported cases describing the use of Doppler sonography in the evaluation of extradigital glomus tumors. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45 :50–52, 2017     

Sonographic differential diagnosis of acute scrotum: real-time whirlpool sign, a key sign of torsion.

Objective. The purpose of this study was to prospectively investigate the role of high‐resolution and color Doppler sonography in the differential diagnosis of acute scrotum and testicular torsion in particular. Methods. Patients who underwent sonography for acute scrotum between April 2000 and September 2005 were included in the study. Gray scale and color Doppler sonography of the scrotum was performed. The spermatic cord was studied on longitudinal and transverse scans from the inguinal region up to the testis, and the whirlpool sign was looked for. Results. During this period, 221 patients underwent sonography for acute scrotum. Sixty‐five had epididymo‐orchitis with a straight spermatic cord, a swollen epididymis, testis, or both, an absent focal lesion in the testis, and increased flow on color Doppler studies along with the clinical features of infection. Three had testicular abscesses. Sonography revealed features of torsion of testicular appendages in 23 patients and acute idiopathic scrotal edema in 19. Complete torsion was seen in 61 patients who had the whirlpool sign on gray scale imaging and absent flow distal to the whirlpool. There was incomplete torsion in 4 patients in whom the whirlpool sign was seen on both gray scale and color Doppler imaging. Nine patients had segmental testicular infarction, and 1 had a torsion‐detorsion sequence revealing testicular hyperemia. In 14 patients, the findings were equivocal. There was a complicated hydrocele, mumps orchitis, and vasculitis of Henoch‐Schönlein purpura in 1 patient each. Five patients had normal findings. Fourteen were lost for follow‐up. Conclusions. Sonography of acute scrotum should include study of the spermatic cord. The sonographic real‐time whirlpool sign is the most specific and sensitive sign of torsion, both complete and incomplete. Intermittent testicular torsion is a challenging clinical condition with a spectrum of clinical and sonographic features.     

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.     

Complementary Roles of Sonography and Magnetic Resonance Imaging in the Assessment of Fetal Urinary Tract Anomalies

Objective. The purpose of our study was to determine whether fetal magnetic resonance imaging (MRI) provides additional information that might affect the obstetric management of pregnancies complicated by sonographically diagnosed fetal urinary tract anomalies. Methods. Fetal MRI and sonography were used to study 39 women with suspected fetal urinary tract anomalies in the second and third trimesters of pregnancy. Results. In 24 of 39 cases (61%), fetal MRI confirmed the sonographic diagnosis. In 14 cases (36%), fetal MRI modified the initial sonographic diagnosis and counseling but did not change obstetric management. In 1 case (3%), the addition of fetal MRI resulted in a substantial change in the management of the pregnancy. Conclusions. During the second and third trimesters of pregnancy, fetal MRI showed fetal urinary tract anomalies in excellent anatomic detail. Fetal MRI is a useful complementary tool in the assessment of sonographically diagnosed fetal urinary tract anomalies. In a small percentage of cases, it can have a substantial impact on obstetric management.     

Metastatic Squamous Cell Carcinoma Presenting as Diffuse and Punctate Cervical Lymph Node Calcifications

Objective. The purpose of this series was to show the sonographic appearance of calcified cervical lymph nodes and the utility of sonographically guided fine-needle aspiration biopsy (FNAB) in the setting of metastatic squamous cell carcinoma (SCC). Methods. Two cases of confirmed metastatic SCC to cervical lymph nodes were identified. Sonography and sonographically guided FNAB were performed in both cases with positron emission tomography (PET)/computed tomography (CT) correlation. Results. In case 1, sonography identified a diffusely calcified, avascular cervical lymph node. Positron emission tomography/CT suggested granulomatous disease as a cause for hypermetabolism; however, sonographically guided FNAB identified metastatic SCC. In the second case, FNAB initially performed without sonographic guidance did not show malignancy. Subsequent FNAB with sonographic guidance identified an abnormal cervical lymph node with focal calcifications and internal color Doppler flow. Metastatic SCC was diagnosed on histopathologic examination. Subsequent PET/CT confirmed multiple punctate calcifications in a hypermetabolic lymph node. Conclusions. Calcifications in cervical lymph nodes from metastatic SCC are very rare. These 2 cases show the variable sonographic appearances and the utility of sonographically guided FNAB in establishing the correct diagnosis.     

Migrated Essure permanent birth control device: Sonographic findings

We report a case of a migrated Essure permanent birth control device. The correct diagnosis was made on conventional two‐dimensional and three‐dimensional pelvic sonography 7 years after placement of the device when the patient presented with persistent right‐sided pain. The 3‐month post placement hysterosalpingogram had shown an appropriately occluded right fallopian tube but had overlooked the abnormal position of the right Essure device, which was too proximal and extending slightly in the uterine cavity. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42:223–226, 2014     

Bilateral epidermoid cysts of the testis: sonographic and MRI findings

Epidermoid cysts of the testis are rare benign lesions, without malignant potential, that can be managed conservatively with cyst enucleation and testis-sparing surgery. Bilateral epidermoid cysts in the testes have been reported very infrequently. We report the sonographic and MRI findings in a patient who presented with a palpable nodule in only 1 testis, but in whom sonography showed bilateral lesions. On sonography, the cysts had an internal "onion-ring" structure; color Doppler signals were absent. On MRI, the cysts had a laminated appearance, with alternating low- and high-signal-intensity areas on T2-weighted images. These imaging findings and the negative results of laboratory tests for tumor markers suggested the correct diagnosis, and testis-sparing surgery could be performed.     

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.