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#115 problem solving challenging cases in ultrasound — Transcript

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0:00This morning we'll be talking about
0:02problem solving challenging cases with
0:04ultrasound.
0:08I have no disclosures relevant to this
0:10talk. And we'll start with a 33-year-old
0:12female who status post egg retrieval who
0:15presented with sudden onset left lower
0:17quadrant pain. The ovaries were enlarged
0:21symmetrically bilaterally which is
0:23expected in the setting of recent
0:25hormonal stimulation.
0:27Sometimes if there's pain on one side
0:29and the ovary is asymmetrically
0:30enlarged, we can use that as an
0:32indicator of pathology. But often times
0:34there's asymmetry and it doesn't help us
0:36one way or the other. In this case,
0:39there's asymmetry in the subjectively in
0:42the color Doppler flow between the two
0:44ovaries. So the left ovary has
0:45subjectively diminished flow and the
0:48resistance in the right ovarian arterial
0:51waveform is lower than the resistance in
0:54the left ovarian arterial waveform. So
0:57that suggests that there may be a
0:58problem with the arterial inflow or
1:01venus outflow on this left side. But we
1:04still don't really have enough
1:05information to decide whether or not the
1:07patient needs surgery.
1:09So looking in the left annexa, the left
1:12fallopian tube is thickened and has a
1:15bit of a swirled configuration.
1:18When the fallopian tube gets thickened,
1:19it can have a serpigenous shape to it.
1:22So again, we still don't have enough
1:23information, but if you look right here,
1:25and I'll show you a video clip of this.
1:28This is the key finding
1:31right here. There's about a 360 degree
1:35swirling of the left ovarian pedacle
1:38called the whirlpool sign. And this is
1:40diagnostic for an axel ovarian torsion.
1:44So based on this finding, we were able
1:46to send the patient to surgery and they
1:48confirmed the findings of left ovarian
1:50torsion times one and were able to spare
1:53the ovary and detors the ovary.
1:57This is another patient with vaginal
1:59bleeding and a positive pregnancy test.
2:02The original interpretation called this
2:04a fivew week intrauterine gestational
2:08sack that was thought to be likely an
2:11early pregnancy loss but a follow-up was
2:13needed.
2:15If you look at the adnoxa on this
2:18particular study,
2:20this is the ovary and then there was a
2:23finding that was just on the edge of
2:25this clip right here. It's a tubal ring
2:29that was partially imaged. So this is
2:32the ectopic pregnancy and the appearance
2:35of the endometrial cavity was just blood
2:37products in the cavity.
2:40A week later, we focused in on that
2:43finding and there's a heartbeat and a
2:46yolk sack in the and an embryo in the
2:48topic pregnancy that's now live. So a
2:51week ago, we could have given methatate
2:53that would have worked. Once there's a
2:55heartbeat, we need to do an intervention
2:57and in this case they did a surgical
2:59self injecttomy.
3:03Another patient, the diagnosis here was
3:06a possible miscarriage in progress. So
3:08let's look here at the uterus. This is a
3:10sagittal transvaginal ultrasound image
3:12of the uterus. We can see part of the
3:14endometrial cavity which looks
3:16decidualized but there's no pregnancy
3:18sack up there. In the cervical canal
3:22there's a gestational sack that's ovoid
3:24and a bit squished. Within the sack
3:28there's a yolk sack. So when we see a
3:29yolk sack without an embryo yet we call
3:31this 5 weeks 4 days. And we're looking
3:35at now a clip of the cervix.
3:38This is the only focused imaging besides
3:40the images that I showed you of the
3:42cervix. And if you look closely on this
3:44clip right here, anterior to the sack,
3:47you can see that there's motion. It's
3:49very subtle and very brief, but that
3:52motion is Venus flow around the sack. So
3:57if you can see flow around the sack,
3:59whether it's slow or low flow that
4:02you're catching on a grayscale clip,
4:04whether it's with power or a color
4:07Doppler or MVI, whatever you need to do
4:10to show that there's flow around the
4:11sack will confirm that the sack is
4:12implanted. So if you see an intact
4:15gestational sack with flow around it, we
4:17can't assume that that sack is passing
4:19through. It's implanted there.
4:23The other thing is if the sack is
4:25intact, it's almost certainly implanted.
4:27It's very rare for intact sacks to pass
4:32in a visible piece that looks like a
4:34gestational sack on ultrasound. Almost
4:35always they become masserated in the
4:37endometrial cavity and pass through
4:39looking like blood products. So if you
4:42can see a yolk sack, if you can see the
4:44margins of the sack, if there's still
4:45fluid in the sack, almost certainly it's
4:48implanted. And the reason why it's
4:50important to make that distinction is
4:51because if the gyns try to remove the
4:54sack, assuming that it's passing
4:57through, they could cause heavy
4:59bleeding. And we've [clears throat] had
5:00patients who needed uterine artery
5:02amilization in that setting. So we
5:04always make sure that they know that the
5:06sack is still implanted before they go
5:07in. You can do a DNC for this patient
5:09safely. They usually inject a little epi
5:11around it to reduce the risk of
5:13bleeding. But they need to know that
5:15they're removing a sack that's still
5:16implanted and they're not just taking a
5:18sack out that's passing through.
5:21So this was a week later since this was
5:23thought to be a sack that was passing
5:25through. They just got a followup and
5:27there's a heartbeat now. So at this
5:29point the patient needs a KCL injection.
5:33So here's our M mode. This is our intact
5:35stack. Here's our color Doppler showing
5:37that it's implanted. It's still
5:39vascularized. There's even color Doppler
5:41flow in the embryo. Here's a nice 3D
5:44showing the endometrial cavity up here.
5:46This is the myometrium, the darker area
5:48around it. And this is the sack in the
5:50cervix. And then here's our needle using
5:53transvaginal ultrasound guidance to do a
5:55KCL injection into the sack. And then
5:58they can give methtoresate. And it takes
5:59several months, but this will all
6:01resorb. So this is one option for
6:03fertility sparing. If we have a
6:05pregnancy that's advancing and it's
6:06implanted in in the wrong location and
6:09the patient doesn't want surgery, this
6:10could have potentially also been treated
6:12with a DNC.
6:16Another case, this is a 35-year-old
6:18female with concern for right corntopic
6:20at an outside facility. Just so you
6:22know, we don't use the phrase coral
6:24anymore. We use the phrase interstitial
6:26ectopic because it's not implanted in
6:28the corner of the endometrial cavity but
6:30it's implanted in the interstitial
6:31segment of the fallopian tube which is
6:33the segment that tunnels through the
6:35myometrium before it reaches the enexa.
6:37So we'll look at some images of that. So
6:39this is transabdominal imaging
6:41transverse imaging at the uterine
6:43fundus. This echogenic area here is
6:47endometrium up at the fundus. You can
6:49see the two corial areas of the
6:50endometrium right and left. And this is
6:54the gestational sack which is surrounded
6:56by a thin rim of myometrium.
6:59Same [clears throat] thing here. Here's
7:00the endometrial cavity. Here's the
7:02gestational sack. And you can see that
7:05that corial section of the endometrium
7:07that point up at the corner is intact.
7:11So this pregnancy even on the
7:12transabdominal images we know is outside
7:15of the endometrial cavity and in the
7:16interstial segment of the fallopian
7:18tube.
7:20Transvaginally, we can see this
7:21pregnancy has a heartbeat. And then the
7:24same finding. Here's the endometrial
7:25cavity. Here's the corner of the
7:27endometrial cavity. And the pregnancy
7:30sack is outside of this cavity. The
7:32margin of the cavity is not going around
7:35the sack. So this is an interstatial
7:37ectopic. Everybody spends a lot of time
7:39measuring the overlying myometrium
7:41because there's literature that suggests
7:43that a certain cut off is more likely to
7:45be an interstitial ectopic. five
7:48millimeters is the standard measurement
7:50that we typically rely on. There's some
7:52literature that says you can go up to
7:53eight millimeters and still need to be
7:55thinking about it. We found that that's
7:57not very useful because it really
7:59depends on the how how advanced the
8:01pregnancy is. It's much more important
8:03now, especially that we have 3D and the
8:05the resolution is so good on the 2D to
8:08figure out whether or not the margin of
8:10the endometrium is surrounding the sack
8:12or if it's ending before the sack.
8:15So, this is what the 3D looked like. You
8:17can see the endometrial cavity is
8:20normally shaped here and there's no
8:22pregnancy within it. This pregnancy is
8:24really looking like it's in the section
8:25of the myometrium through which the
8:27interstitial segment of the fallopian
8:29tube tunnels. It doesn't really matter
8:32how much overlying myometrium there is,
8:34but it's usually less than 5 mm in these
8:36cases.
8:39Just for comparison, this is a
8:4031-year-old female who also has pain and
8:42bleeding in the first trimester. This is
8:44the transabdominal imaging. It looks
8:47almost identical to the previous
8:48patient. It's very hard to tell,
8:50especially transabdominally, except this
8:52is the endometrium here. And we really
8:55can't see that pointed corner of the
8:57endometrium preserved here. Looks like
8:59maybe there's a claw of endometrium
9:02going around the sack. The overlying
9:04myometrial thinning is similar to the
9:07other case, but the endometrial cavity
9:08looks like it's expanded around the
9:10sack. So when we look transvaginally
9:14also heartbeat similar to stationinal
9:16age but here this echogenic endometrium
9:20goes all the way around the sack.
9:22There's echogenic indometrium
9:24surrounding the sack. So this is an
9:25eccentrically located intrauterine
9:27gestational sack. It's not an
9:30interstatial ectopic and two weeks
9:32later. So the way to answer the question
9:34is get a follow-up assuming that the
9:36patient is clinically stable. And you
9:38can see that the sack is really
9:39expanding into the endometrial cavity
9:42and there's endometrium
9:44surrounding the sack. And now you can
9:46see a really nice smometrial coverage
9:49there. And this is what the 3D looks
9:51like. So the sack looks like it's
9:52sitting in the same position up in the
9:54corner of the uterus, but the corner of
9:56the endometrium is going around the sack
9:59instead of ending next to the sack.
10:02This patient had a normal term delivery.
10:07Another case, this is a 37year-old with
10:09first trimester bleeding.
10:13This single image, transabinal sagittal
10:15image of the uterus gives us the
10:17diagnosis, but there was a little bit of
10:19a of a struggle to make it here. But
10:21this is the gestational sack. This is
10:24the endometrial cavity here, which is
10:25empty myometrium. This is the anterior
10:29margin of the myometrium and the
10:30anterior lower uterine segment. And you
10:33can see that it's bulging and the sack
10:35is implanted. presumably in a C-section
10:38scar. So, the first question that needs
10:40to be answered here is, does this
10:41patient have a history of C-section? And
10:43the answer was yes. So, this is a
10:44C-section scar implantation.
10:48This patient came back a week later.
10:51We're looking now at a sagittal view.
10:53Here's the endoservical canal. Here's
10:55the rest of the uterus. Here's the
10:57gestational sack. There's little areas
11:00here where there's no measurable
11:01myometrium because the sack is implanted
11:03in the scar. Sometimes the sack will
11:06expand down into the endocer cervical
11:08canal which makes it a bit easier to
11:10make the diagnosis and to counsel the
11:11patient. Sometimes the sack will expand
11:13up into the endometrial cavity in which
11:16case we refer the patients to to our
11:18accreta team and they talk about the
11:21risk of preterm delivery of need for
11:23hysterctomy of bleeding and um you know
11:27they they counsel patients about the
11:29options for continuing or not
11:31continuing. This is the same patient uh
11:34came back at 8 weeks 3 days. The
11:36endometrial cavity is up here and it's
11:38empty. The gistational sack is still
11:40centered in the anterior lower uterine
11:42segment with overlying myometrial
11:44thinning. So this is a developing
11:46C-section scar implantation
11:50and transvaginally we can see placenta
11:52is actually bulging into the scar. So
11:55this is a definite accreta and this
11:58early at 8 weeks if we can already see
12:00these findings we know that this is
12:02going to be severe accreta as the p as
12:03the pregnancy progresses. So here's the
12:06placenta bulging through the scar and
12:09just as a reminder is not placenta
12:11invading into the scar. Placenta can't
12:14do that. Placenta will not invade into
12:16normal myometrium. But placenta can
12:18track through a pre-existing defect that
12:22connects the endometrium to the
12:23myometrium or even to the sarosa or
12:25beyond. [clears throat] So a
12:27pre-existing defect with placenta
12:29tracking through it is essentially a
12:30dehissence. So that's what accreta is.
12:34This is early accreta.
12:38Uh, next case, this is a 30-year-old
12:40female with an indication of abdominal
12:42and pelvic pain and a history of prior
12:45C-section.
12:46And the report was the exam was limited
12:49and terminated due to patient pain and
12:51cooperation.
12:53So, we didn't get great transvaginal
12:55imaging here. Uh, but this is 9 weeks 5
12:58days by crown rump length. No cardiac
13:00activity seen. This was reported as a
13:03gestational sack in the lower uterus,
13:06possibly passing through. So here's the
13:08gestational sack. Here's the nonviable
13:11fetus. This is the uterus and the cervix
13:14is down here. All of this is placenta,
13:18which is implanted in the anterior lower
13:21uterine segment with overlying
13:23myometrial thinning. This patient's had
13:25a history of a C-section. So this is an
13:27accreta. We know that this is going to
13:29be a C-section scar implantation. And
13:31there's definitely a creda at this
13:33point. So the issue then is management.
13:36If we call this a nonviable pregnancy or
13:38an early pregnancy loss, the patient may
13:40be treated with medication or expected
13:42management to try to get this to pass.
13:47There's an accret approach would be
13:49dangerous result in heavy bleeding. So
13:51it's our job to make sure that we
13:53communicate that there's early accreta
13:55here. So we were able to get some
13:58transvaginal imaging and we can see this
14:01is placental tissue tracking into the
14:04C-section scar with overlying myometrial
14:07thinning little bit of bulging. So this
14:09is early agreed upon.
14:12The colored Doppler may or may not be
14:14helpful especially because this
14:16pregnancy was non viable at this point.
14:18But you can see this swirling motion
14:19here, swirling blood flow. So, we know
14:23that this is very vascularized and is
14:25still high risk for heavy bleeding.
14:31I think we talked about all that. Okay.
14:34Uh this is another patient, 17-year-old
14:36female with two days of right pelvic
14:38pain. She actually sat in an outside
14:40institution in agony before she was
14:43transferred to us. Here's a
14:45transabdominal image of the uterus. And
14:48behind the uterus, there's a big
14:49structure that has a cystic component.
14:52When we do the transvaginal exam, we can
14:54see in the left, there's a 6 cm simple
14:57cyst with a rim of tissue around it.
15:01Connected to that rim of tissue was this
15:05presumably ovary since it has follicles,
15:08which in and of itself measured 6 cm. So
15:12a general rule of thumb is that a normal
15:14ovary should be under four centimeters.
15:17Ovaries in the four to five and a half
15:20six centimeter range tend to be PMOS,
15:23but take proper measurements and make
15:25sure that it meets criteria. And over 6
15:27cm, we're worried about torsion, whether
15:29or not blood flow is present. So in this
15:32case, the the ovary that we're seeing,
15:34the left anexa, not including the cyst,
15:37is measuring over 6 cm. So at this point
15:39we're worried about torsion and we're
15:40not seeing flow of color doppler. So
15:42we're worried about compromised blood
15:44flow potential necrosis. On top of which
15:47there's also a 6 cm cyst within that
15:49ovary which likely served as a lead
15:52point. So the size range that is
15:55associated with the highest risk of
15:56causing torsion is 5 to 7 cm. Smaller
16:00lesions are less likely tors and larger
16:02lesions are unable tose because they're
16:04big and fixed in place. But five to
16:07seven centimeters is the highest risk.
16:08So this patient was at high risk already
16:10just having that six centimeter cyst.
16:13So she went to surgery because she was
16:15young. The ovary was still live. They
16:17were able to detox the ovary, remove the
16:19cyst, and she did really well after
16:21that.
16:23Uh we couldn't get any flow there. This
16:25was actually the right ovary that was
16:27sitting in the left of nexus.
16:31This is another patient who came in with
16:33left pelvic pain with a history of
16:35hysterctomy and righterectomy.
16:37A 10 cm leftal mass was seen on CT. So
16:41the patient was sent for ultrasound. And
16:43this finding was seen transabdominally
16:45only because it was so high up we
16:46couldn't see it internally. But this is
16:48that 10 cm mass. This looks like an
16:51ovary because it has cysts on it. So we
16:53called this left ovarian portion. There
16:55was no flow. And uh the left ovary
16:57because it wasn't tethered into the
16:59pelvis by the normal ligamentous
17:02structures with the uterus and right
17:04ovary uh gone. The left ovary had lifted
17:08up out into the lower abdomen which is
17:10why we couldn't see it transvaginally.
17:12So they took this patient to surgery and
17:13this ovary was recepted. It was
17:15necrotic.
17:19Another companion case here. This is an
17:21asymptomatic patient who came in at 8
17:23weeks gestational age for a pregnancy
17:25study. And the right ovary looks normal.
17:28The left ovary is markedly enlarged and
17:30hyperemic. And the parankma is echogenic
17:32and heterogeneous. It looks very
17:34ademous. For all intents and purposes,
17:37this looks like a torsion except the
17:38hyperemia is a little bit atypical.
17:41But when the patient came back at 18
17:43weeks, they decided to watch her since
17:45she was asymptomatic and the left ovary
17:46looked completely normal. We have
17:49occasional cases like this. I can think
17:51off the top of my head of fewer than
17:53five that I've seen where the ovary
17:55looks
17:57to in the first trimester and the
18:00patients come back in second trimester
18:01and it looks completely normal. So if
18:03the patients are asymptomatic, we don't
18:05intervene and we assume that it's going
18:06to be okay. We just keep an eye on them.
18:09And uh so far we've not been able to get
18:11pathology on any of these ovaries
18:13because we're not operating on pregnant
18:15patients if we don't have good
18:16indication. But these ovaries always
18:18normalize by the second trimester.
18:22This is another case. The ovary here is
18:26the left ovary which was enlarged to
18:28about 4.5 cm. And these two images on
18:32the bottom are of the right ovary which
18:34was enlarged to 6 cm and demonstrated
18:37blood flow.
18:39So looking back this patient's ovaries
18:41meet criteria for PMOS even on prior
18:44imaging. So this ovary was probably just
18:48PMOS
18:49but this ovary with the peripheralized
18:52follicles admnastroma and now we're
18:54measuring at our 6 cm cutoff we start to
18:57worry about torsion this was an ovary
19:00with underlying POS and torsion which
19:02was confirmed at surgery and this ovary
19:04I think was salvageable
19:08uh this is another patient where the
19:09ovary is necrotic so there's no blood
19:11flow it's colored off with
19:15This is a pediatric case, a three-month
19:18old female with labial swelling and
19:20athemma for 4 days. The patient was
19:22treated with antibiotics for presumed
19:24infection with no response. So, they
19:27asked for an ultrasound. And we're
19:30looking here at the left labia, which
19:32contains a soft tissue structure with
19:35follicles. So this is an ovary that has
19:38herniated through the canal of nook to
19:41reach the labia and they're surrounding
19:43soft tissue adminus changes and
19:45inflammatory changes. So this was a
19:48torched ovary in the canal of nook.
19:52The canal of nook is analogous to a
19:53patent process vaginalis or an
19:55indirecting hernia in a female infant.
19:59And the round ligament follows this
20:01paritinium from the uterus near the
20:03insertion of the fallopian tube. This
20:05should close by 32 weeks similar to the
20:07process vaginalis in males. Up to 43% of
20:11herniated ovaries are incarcerated. And
20:14all of the patients with uh tor with
20:17herniation and or torsion have symptoms.
20:20So we don't have to worry about missing
20:21this in all premature infants and
20:23scanning everybody for these. But if
20:25they have swelling or redness, we should
20:26take a look.
20:29This is another patient. We're looking
20:32at the inguinal canal here on the left
20:34into the left labia. And this structure
20:36is the uterus. You can see the fundus
20:39here. Here's the endometrial cavity.
20:41This is the endocervical canal. This is
20:43transverse image of the uterus and the
20:45canal of nook. Here's the endometrium.
20:48And then you'll have to take my word for
20:49it. It's a little hard to tell on this
20:50image, but this was the leftover that
20:52came with it.
20:56And these are treated surgically.
21:00As another case, a 31-year-old female
21:02with a uterine anomaly seen at
21:04C-section. She came for an HSG. And we
21:07can see it looks like a unicorn
21:09morphology with a patent right fallopian
21:12tube. But we weren't sure we were
21:14getting the full picture. So while we
21:15had the fluid in the endometrium, we
21:17just wheeled an ultrasound machine into
21:19the fuosuite to get a full picture of
21:22what was going on. So here's the right
21:24uterine horn, the myometrium, and here's
21:26fluid in the endometrial cavity. And
21:28here's the left uterine rudimentary horn
21:32with no endometrial cavity and no
21:34communication. Here you can see the
21:36blood flow connecting the right horn and
21:40the left rudimentary horn. And this is
21:42what the right endometrial cavity looks
21:43like in sagittal distended with fluids.
21:49So uh patients with unicornate uterus
21:51will have a rudimentary horn in 65% of
21:53cases. 50% will be cavitary meaning they
21:56contain endometrial tissue in the center
21:59and only 30% of those patients will have
22:02a cavity that communicates with the
22:04primary horn.
22:07This is another patient a 28-year-old
22:09female with recurrent early pregnancy
22:11loss.
22:14These are three gray scale and a 3D
22:16image. Here's sagittal uterus with the
22:18endometrial cavity which at first glance
22:20looks pretty normal. When we look at the
22:22transverse image of the endometrial
22:24cavity, there's a tiny cyst. [snorts]
22:27For the most part, when we see tiny
22:29cysts in the endometrial cavity, we
22:30ignore them. But sometimes they can be
22:33uh associated with synchia. So we want
22:36to make sure that we're looking really
22:37carefully for a hypocoic band that may
22:40be crossing the endometrial cavity.
22:42Here's another transverse view of the
22:43endometrial cavity with a tiny cyst
22:45there. And here's the 3D. The only thing
22:48we're seeing here, and I wouldn't
22:49necessarily call this just based on the
22:523D, but there's a little triangular
22:54area that's subtly more echogenic than
22:56the rest of the endometrial cavity.
23:00So, here is a sonoistogram. We've got a
23:03catheter coming in through the cervix
23:04with a balloon inflated in the lower
23:06endometrium, and we've instilled sterile
23:08saline into the uterine cavity. The
23:11funal endometrium is nicely distended,
23:13but there's a point here in the middle
23:15that's not distending. And when you turn
23:17transverse on it, you can see the sinia
23:19crossing the endometrial cavity here.
23:22And then just to compare the 3D here
23:26with the fluid to the 3D that we saw
23:28before. There's that triangular finding.
23:30So sikia tend to have this triangular
23:32shape on the 3D.
23:35So then what we did was we here's the
23:37waisting. So you can see that's where
23:39the scar is. We inflated the balloon a
23:41few times right at the level of the scar
23:44and then redistended the endometrial
23:46cavity and you can see that that scar is
23:48gone and the wasting has improved. So we
23:50this wasn't the plan initially coming
23:52in. This was meant to be a diagnostic
23:54test only but we were able to treat the
23:56problem and solve the recurrent
23:58pregnancy loss problem on the spot. So
24:00this is what the 3D looks like before
24:02and after. So here's the endometrial
24:04cavity descended with fluid and here's
24:06the scar and after the procedure here's
24:08the endometrial cavity distended with
24:10fluid and the scar is gone and the
24:12cavity is no longer tempted at that
24:14level and the patient came back to us a
24:16few months later for an early obstetric
24:18study for a nice healthy pregnancy.
24:23Uh so switching gears here from gyn this
24:26is a four-year-old with known allerg
24:28syndrome. Uh this is just an interesting
24:30Doppler case. We're looking at a
24:32waveform here of the aorta which is
24:34normal and waveforms of the splenic
24:37artery, the main hippatic artery and the
24:39left hypatic artery. Originally the
24:42report made note of the fact that these
24:44arteries were patent but it also just so
24:46happens that they have TARDIS parvis
24:48waveform morphology in all three. So we
24:51know that the problem must be at the
24:53celiac trunk if we're seeing abnormal
24:55waveforms in the splenic and hypatic.
24:58So the patient came back for assessment
25:00of the celiac artery. Here's a color
25:03Doppler and spectral Doppler. You can
25:06see that there's aliasing and wasting
25:08narrowing in the proximal celiac artery.
25:12And when we get the spectral waveform at
25:14this point of the narrowing, there's
25:15very slow velocity tardis parvis flow
25:18there. So we know that there's a severe
25:19hemodynamically significant stenosis.
25:22And the patient went on to get a CT.
25:24This is the best image I could glean off
25:26this study, but you can see the
25:28narrowing in the proximal celiac artery
25:32and allerg syndrome is associated with
25:34widespread vasculopathy. So this was
25:36consistent with the diagnosis.
25:42Another case, a 102year-old female who
25:44had a palpable inguinal lump. This was
25:47originally reported as a cyst, which
25:49makes sense based on this image that was
25:51acquired. It's anolic with increased
25:53through transmission.
25:56But don't forget the color Doppler. It
25:57turns out this patient had massive
25:59inguinal lympadnopathy and a hematologic
26:02malignancy. So we can definitely make
26:04mistakes just based on the settings.
26:08Uh this is a 70-year-old who came in
26:10with fiber upper quadrant pain. The
26:12indication was choleaccyitis and the
26:14study was actually protocol as a right
26:16upper quadrant. So we were focused on
26:17the gallbladder and the biliary tree.
26:20But the patient pointed to where it
26:21hurt. It was well above where the
26:23gallbladder was. And it turned out they
26:24had had a fall a few weeks earlier and
26:27had hit the corner of a table and had
26:29severe pain that was improving. So we
26:32put the probe right over where it hurts.
26:33And you can see there's two bony
26:35fragments that are overlapping here.
26:37This is the rib with the fracture
26:40fragment and the rest of that rib. This
26:42is a rib fracture on ultrasound.
26:45Ultrasound is more sensitive than
26:46radiography for rib fracture. Uh, in one
26:49study, 18 of 20 who had negative chest
26:51X-rays had positive ultrasound. And you
26:53can also assess for associated findings
26:56in the chest and in the upper abdomen
26:58underneath those ribs. That's also
27:00useful for non-acal trauma in children.
27:02So, um, consider ultrasound for bone
27:05imaging. Here's another example. A
27:07marathon runner or somebody who was
27:09training for the marathon had foot pain.
27:12This is the affected site and this is
27:14the adjacent metatarsal. This is all
27:16perryostial reaction. So this
27:18[clears throat] is a healing metatarsal
27:20fracture and this is the associated
27:22radioraph. Here's the impacted
27:24metatarsal with the fracture and the
27:26perryostial reaction that we can see on
27:28ultrasound. And then the normal
27:30neighbor.
27:33Uh so we're going to go over a few cases
27:35with contrast enhanced ultrasound. This
27:38is a 37year-old female with an
27:40indeterminate liver mass on CT. She was
27:43listed for renal transplant but could
27:46not stay on the list if she had a
27:49malignancy but because of the renal
27:51impairment they didn't want to give MRCT
27:53contrast so they asked us to try to help
27:55with ultrasound contrast. So here's the
27:57lesion. It's hypoacoic. There's a little
28:00bit of flow maybe around the periphery.
28:02It was hard to tell since it was so
28:04small.
28:06So this is the contrast enhanced
28:08ultrasound. This is microbubble
28:09contrast. You can see the dual screen
28:12image. Here's the gray scale and here's
28:13the arterial phase and this is the
28:15portal venus phase. We can see that this
28:18lesion is arteriorly hyperenhancing
28:20relative to the background liver. And on
28:22the portal venus phase, it's still a
28:24little bit bright relative to the
28:26background liver. So there's no wash
28:27out. So the absence of wash out is
28:30reassuring. This was the lirads 3 and
28:32this turned out to be an atypical
28:34hemangi.
28:36Another
28:38patient 54 with cerosis and an
28:41indeterminate lesion on MR. Uh there was
28:44one acute CT. I don't think we have the
28:46images for that. Um couldn't see it on a
28:49follow-up CT. They weren't able to find
28:51it on a grayscale ultrasound. So
28:53typically even if we're not able to see
28:55it on an ultrasound, we have the
28:57patients come in and we make an attempt
28:59to find it. Oftentimes we're able to
29:01tease it out if we're really spending
29:02our time to focus on that. So here's the
29:04lesion on MR. We didn't have an arterial
29:06phase. We just had a portal venus
29:08feeding phase. And on the delayed phase,
29:10they thought maybe there was subtle wash
29:12out. So she came to us. This is arterial
29:16here. And this is delayed. So we'll
29:18start with the arterial phase.
29:26So the lesion's right here. And you can
29:29see that there's no arterial
29:31hyperenhancement.
29:33So that's reassuring.
29:35it does fill in.
29:37And then on the delayed,
29:41keep your eye right here. So now what
29:43we're looking for is wash out and we
29:46don't see any wash out. So this lesion
29:48was there was a little bit of delayed
29:49enhancement very early on in the
29:51arterial phase, but for the rest of the
29:52study it was isoenhancing to the
29:54background liver and this was a
29:56regenerative nodule.
30:00This is a 70-year-old male with
30:02hepatitis C, normal AFP, and a liver
30:05lesion on an outside CT. We also had an
30:07MR. I think that there was an issue
30:10technically with the postcontrast
30:12images. They weren't sure what was
30:14happening there, so they asked us to
30:15take a look with ultrasound. We can see
30:17a hypocoic lesion near the liver dome
30:19with no flow with colored Doppler.
30:22Here's the arterial phase. And this was
30:25a little bit tricky because the patient
30:27was breathing. But right here, it's
30:29coming in and out. There's a subtle
30:31arterial hyperenhancement
30:33when the patient breathes and brings the
30:35lesion into view for us.
30:38And then on the delayed,
30:41again, it's really tricky because the
30:43patient's breathing, but there's very
30:44subtle early wash out here. So, this was
30:48a lirad 5 and a well differentiated HCC.
30:55a 78-year-old male with a growing renal
30:58mass. Here's the grayscale ultrasound.
31:01It's echogenic and no flow with color
31:04Doppler.
31:07Here's the mass on the dual screen. This
31:09is the grayscale. Here's contrast.
31:13Right here we can see the mass is
31:16hypoenhancing relative to the background
31:18parankma.
31:19This is papillary RCC. Here's
31:24the wash out.
31:29Another patient was sent to us with an
31:30indeterminate renal mass on CT, which is
31:33right here. This is what it looks like
31:35on grayscale ultrasound. It's hypoacoic,
31:38heterogeneous. A couple little dots of
31:41possible flow on color Doppler versus
31:43artifact if you couldn't tell.
31:46Here's the contrast enhanced ultrasound.
31:48There's no enhancement. So this is a
31:50complex renal cyst
31:55and then there's a larger cyst to it.
31:59Uh so this is just a paper from our
32:01group comparing color Doppler and
32:04contrast enhanced ultrasound for
32:06indeterminate renal lesions and the
32:09conclusion was that contrast enhanced
32:11ultrasound is more sensitive for solid
32:14component. So even in the absence of
32:16color doppler flow if we not definitely
32:21a simple cyst
32:23to [clears throat] sure that complexes
32:25amount
32:28is one of our examples in aal transplant
32:30patient there's an echogenic mass with
32:33no flow with color doppler but definite
32:35enhancement with contrast enhanced
32:37ultrasound
32:39and that was neoplastic. Uh here's
32:42another example. This is a patient with
32:44possible minimal enhancement on CT. On
32:47MR, it was T2 dark, T1 intermediate.
32:52Here's the T1. Here's the T2. The
32:56postcontrast imaging was a little bit
32:59difficult because of mis misregistration
33:01and there was loss of signal in the
33:03inphase imaging. So thought to represent
33:05hemositerin. Here's the out of phase.
33:07Here's the inphase. So they sent the
33:09patient for contrast enhanced ultrasound
33:11and here's an echogenic mass. There's a
33:13large simple cyst next to it. There's no
33:15color Doppler flow. So we give contrast
33:19lesion is right here.
33:27And there's definite
33:29arterial hypoenhancement.
33:32And on the delayed phase here there's
33:35wash out. So this is likely a papillary
33:38RCC. I think because of the small size,
33:40this patient is undergoing um imaging
33:42surveillance instead of biopsy.
33:49So for all of these patients with uh any
33:51lesion with enhancement, we generate a
33:53time intensity curve for contrast
33:54enhanced ultrasound. This is a different
33:56lesion. We haven't seen this lesion yet,
33:58but just as an example, we can place a
34:01region of interest on the mass and then
34:02a comparison region of interest on the
34:04background renal cortex. And in this
34:07lesion, you can see there's subtle
34:08arterial hyperenhancement relative to
34:10the background cortex and then wash out
34:13relative to the background cortex. And
34:15this was a biopsy proven papillary renal
34:17cell carcinoma.
34:19Just for comparison, this is a low-risk
34:22liver lesion which was lirad 2A. We put
34:25a region of interest on the lesion and a
34:27region of interest on the background
34:28liver parankma making sure to avoid any
34:31vessels. And here we can see there's a
34:33tiny bit of arterial hyperenhancement
34:35relative to the background parankma but
34:37there's no wash out. So this puts the
34:40lesion in a low risk category.
34:44This is a transplant patient with
34:46concern for transplant renal artery
34:48stenosis. The velocity at the origin of
34:51the transplant renal artery was 323 cm/s
34:55which is elevated in the first few
34:57months after transplant. The velocity
34:59may be elevated and be normal. So we
35:01wouldn't consider this worrisome at that
35:03time point but this transplant was
35:04placed over two years ago. So now we do
35:06worry about transplant renal artery
35:08stenosis. Uh but the background parankma
35:11also looks abnormal with an elevated RI.
35:13So we weren't sure if it was a parankal
35:15issue or an arterial issue. Uh this is
35:18the grayscale imaging of the renal
35:20transplant with echogenic cortex. The
35:22color Doppler flow is adequate.
35:26Here's the contrast enhanced ultrasound.
35:38Wait for the heart to bring us the
35:39bubbles. Here we go. So here's the
35:41anastmosis and it's widely patent. So
35:44this is negative for transplant renal
35:46artery stenosis.
35:50Just to confirm the patient went on to
35:53conventional angography which concluded
35:55the same thing. No transplant renal
35:57artery stenosis.
36:00This is another patient also with
36:02elevated velocity in the main renal
36:03artery and tardis parvis waveforms in
36:05the kidney. This was 450 cm/s in the
36:09proximal transplant renal artery.
36:13And here's the contrast enhanced
36:14ultrasound. You can see the narrowing in
36:17the transplant renal artery. Here's the
36:19anastmosis. So it's just beyond the
36:21anastmosis. This was a true stenosis.
36:26We can also do imaging for the
36:27transplant renal vein. Sometimes it's
36:30harder to see the vein itself, but we
36:32can see evidence of the ve the venus
36:34stenosis. On this patient, the power
36:36Doppler flow is diminished in the
36:38transplant. The intrarenal arterial
36:41waveforms are high resistance. The main
36:43renal artery is high resistance but
36:45patent.
36:48This is now after the patient received
36:51Heperin. So we're seeing better flow
36:53with power Doppler. We're seeing a
36:56little bit of diastolic flow here now in
36:57the main renal artery. And we could see
37:00flow in the main renal vein. But there
37:02was a visible focal narrowing in the
37:04vein.
37:05But when we give contrast, there's brisk
37:08normal arterial inflow with diffuse
37:11normal cortical enhancement. But on the
37:14delayed phase, the microbubbles didn't
37:16clear. So in a normal transplant, the
37:18microbubbles clear by about 2 and 1/2 to
37:213 minutes. And this image was taken at 6
37:24minutes, and the kidney is still filled
37:26with microbubbles. So we know that
37:28there's delayed venus outflow.
37:31Another
37:33patient in the immediate posttop period
37:36got this study where they could see some
37:39color doppler flow in the lower pole but
37:41no color doppler flow in the upper pole.
37:44It was thought to be likely technical
37:45because of this big fluid collection
37:47anterior to the kidney. It was difficult
37:49to see back there but just in case we
37:52give contrast to make sure used. And
37:56here's the large fluid collection
37:57anterior to the kidney. And here's the
37:59upper pole of the transplant kidney with
38:00microbubbles filling the cortex. So this
38:03was normal. This patient did not need to
38:05go back to the O.
38:08This is another renal transplant with an
38:11area of decreased flow with color
38:13Doppler and heterogeneity in the lower
38:15pole cortex which was thought either to
38:18be a lymphop proliferative disorder or
38:20an infarct.
38:22When we give contrast, we can see that
38:24it's a huge fluid collection that's
38:27impacting the parankma of the lower
38:29pole. And when we follow this around,
38:32after we gave the contrast, we could see
38:34that this fluid collection extended
38:35really far around the kidney and
38:37inferior to the kidney. So this was
38:39actually a big abscess.
38:43Another
38:45patient, a young patient with a sports
38:48related trauma. The clinical team didn't
38:51want to follow the patient with CT
38:52because of their age. So they asked us
38:54to follow with contrast enhanced
38:56ultrasounds. We can see on the grayscale
38:58and the power Doppler, this is a complex
39:00splenic laceration.
39:02And when we give contrast enhanced
39:04ultrasound, we could actually see even
39:05more detail about the areas of
39:07hypoerusion relative to this complicated
39:10laceration. And as we clicked through,
39:12this extended a lot further than we
39:14expected based on the grayscale and the
39:16Doppler imaging. So we were able to uh
39:19fully assess and follow this lesion with
39:21contrast enhanced ultrasound.
39:24We're also using contrast for gyn. This
39:27is a patient with an indeterminate
39:28cervical lesion. Looked like a complex
39:31cyst with septations in the absence of
39:33flow, but we weren't sure. So we give
39:35contrast enhanced ultrasound. And we see
39:37individual microbubbles traversing the
39:39septations but no enhancing solid
39:41component. So this was a complex neopian
39:44cyst.
39:46We're also using it for
39:48hyrocontrastography to assess the
39:50fallopian tubes. After we give sterile
39:53saline to assess the endometrial cavity.
39:55Historically we would use airrated
39:57saline to assess the fallopian tubes.
39:58And this is what it looks like. It's
40:00very hard to see. So you really have to
40:03catch that micro second where those
40:06little air bubbles are coming out the
40:07fallopian tubes and into the edexa they
40:10can blend in with the air in the bowel.
40:12So it's doable but it's tricky when we
40:14use contrast. This is not on the chroma
40:17setting where the contrast looks orange.
40:18It happens to be on grayscale setting
40:20here but it's the same information. We
40:22can see the left fallopian tube is
40:24opacified and we can see spill. We saw
40:26the spill at real time and the right
40:28fallopian tube didn't fill. So this is
40:31really useful. The nice thing about the
40:33microbubble contrast for
40:34sonhysterography is also that the
40:37patients have a lot less pain and it
40:39sticks around for a while. So once you
40:41put the contrast into the endometrium
40:43and the fallopian tubes, you look for
40:44the spill. You can look into the
40:46culde-sac to see if any contrast is
40:48spilled there to prove that at least one
40:50tube is open. if you're having trouble
40:52seeing the tubes and then you can come
40:54back and get more detailed imaging of
40:55the endometrial cavity and the fallopian
40:57tubes because the microbubbles stay as
40:59opposed to the airrated saline which
41:01comes and goes very quickly. So we can
41:04get a little bit more information and
41:05it's a little bit easier to do and much
41:07more comfortable for the patients.
41:10And one more case here a 39year-old
41:13female who had a growing ovarian lesion
41:15which was indeterminate for enhancement
41:17on MR came to us. So here's the lesion
41:22with an echogenic component with blood
41:24flow. On some of the prior imaging, it
41:26was unclear whether or not this had
41:27blood flow and then the MR was
41:29indeterminate. So we were using this
41:31test primarily to figure out if this was
41:33enhancing and the patient did not want
41:35surgery without the contrast. So we did
41:37the contrast enhanced ultrasound. In the
41:39arterial phase, there's definitely
41:41enhancement and there was very quick
41:43wash out. So looking back at the MR, we
41:46thought maybe the struggle with the
41:48enhancement interpretation was that the
41:50imaging had been acquired at the time of
41:52the wash out. So there was a little bit
41:53of contrast left, but it had come in and
41:55out so quickly it was just hard to
41:57capture that information. With contrast
42:00enhanced ultrasound, we take a
42:01continuous 3minut clip. So we're seeing
42:04the wash in and the wash out and the and
42:06all of that dynamic imaging so we don't
42:08miss it. This is the time intensity
42:11curve. Here's the lesion. And here's an
42:13attempt at the background ovarian
42:14parankma and you can see that there's
42:17arterial hyperenhancement with wash out
42:19relative to the background parankma. So
42:21this was a cirrus borderline cyadnal
42:24carcinoma and fortunately it was stage
42:26one
42:29uh an abdominal sorry I do have another
42:31case here. This is an abdominal aortic
42:32aneurysm status post repair. There was
42:35no endolink on a prior CT but over one
42:38year there had been about half a
42:39centimeter of growth. So we use contrast
42:42enhanced ultrasound to demonstrate that
42:44there's contrast in the lumen and then
42:46there's contrast leaking out into the
42:48excluded sack. So this is positive for
42:50an end week
42:53and that's it.

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