Ultrasound imaging

A simple sonography quiz about male pelvis

2012-02-10T23:29:00.000-08:00

Name the structure arrowed in these images of the male pelvis:
(Hint: this is a normal ultrasound scan).
Transverse section of bladder:

Sagittal section of bladder:

Transverse section of urinary bladder:

Incompetent perforators in a case of varicose veins:

2012-01-28T08:37:00.000-08:00

A case of severe varicose veins in a 22 year old male patient:
Observe the to and fro flow of blood through incompetent perforators from the posterior tibial vein:

Some more perforators are seen lower down the leg arising from the posterior tibial vein:
The red color within the perforator suggests flow towards the probe (to the superficial veins of the saphenous system from the deep vein) which is abnormal.

The color Doppler ultrasound video of this case reveals the to and fro flow (superficial to deep veins and vise versa) across the incompetent perforator:

Another perforator vein is seen with blood flow towards the transducer (seen in red color) in this color Doppler video:

For more on this topic visit:
http://www.ultrasound-images.com/vascular.htm#Color_and_Spectral_Doppler_Examination_of_the_veins_of_the_Lower_limb

Normal and enlarged lymph nodes:

2011-11-23T18:33:00.001-08:00

This is a normal inguinal lymph node. Although a little prominent, it shows normal vascularity and clear differentiation between the central and peripheral regions- the central region being hyperechoic whilst the periphery shows lower echogenicity.

Enlarged and inflamed lymph node:

This lymph node (another patient) shows a markedly enlarged inguinal lymph node (1.2 x 2.7 cms.) with remarkable increase in its vascularity- a classic picture of inguinal lymphadenitis. This patient had a large infected wound in the foot.

Sonographic differentiation of some common renal masses:

2011-08-14T23:13:00.000-07:00

Angiomyolioma: Among the commonest solid renal masses is angiomyolipoma. This is a benign mass and is believed to be a variant of hamartoma of the kidneys. Composed of smooth muscle, vascular tissue and above all fat (adipose tissue), an angiomyolipoma is almost invariably echogenic and usually small in size (less than 2 cms.). However, these tumors can be isoechoic to renal tissue in rare cases, where the amount of adipose tissue within the mass is smaller in amount. Visit: http://www.ultrasound-images.com/kidneys.htm#Renal_angiomyolipoma_-%28AML%29_of_right_kidney
These masses are usually benign in the vast majority of cases and rarely pose an symptomatic problems for the patient. However, it is usually in cases where the angiomyolipoma is larger than 4 cms. that, severe hematuria may be an important symptom.
Also visit: http://ultrasound-images.blogspot.com/2011/08/sonography-of-angiomyolipoma.html
Hypertrophied column of Bertin: of Normal variants of the kidney like hypertrophic column of Bertin can also mimic a renal mass. However, careful sonography of the kidney will display the benign nature of this anatomical variant. See the ultrasound and color Doppler images below; the column of Bertin shows a prominent mass of renal cortical tissue extending deeper into the renal medulla separating the pyramids and also indenting the renal sinus. Color Doppler ultrasound imaging shows normal vascularity of this area, unlike the appearances of neovasculature (abnormal vessels) seen in malignant renal masses.

See: http://www.ultrasound-images.com/kidneys.htm#Hypertrophied_column_of_Bertin_or_Junctional_parenchyma

for more on this topic.

Renal cell carcinoma: is another tumor of the kidney that may pose a diagnostic dilemma to the sonologist. This tumor is usually inhomogenous, relatively hypoechoic and does not produce posterior shadowing, so typically seen in angiomyolipoma of the kidney. Color Doppler ultrasound often helps show abnormal vasculature in the malignant tumor. Besides, follow up ultrasound will show increase in tumor size and possible metastases to adjacent organs. See:
http://www.ultrasound-images.com/kidneys.htm#Case-2_%28Renal_cell_carcinoma%29
The ultrasound image below shows a typical case of renal cell carcinoma of the right kidney. The malignant tumor is seen at the lower pole of the kidney.

Sonography of angiomyolipoma:

2011-08-12T19:56:00.000-07:00

This middle aged female patient shows two small, echogenic, rounded lesions in the right kidney. Typical location (the right kidney is the common site for angiomyolipomas) and characteristic ultrasound features are seen in this ultrasound video of the right kidney. The images below show the twin angiomyolipomas, one in the upper pole, and barely visible, and the slightly larger lesion in the lower pole.

If close to the renal sinus, renal angiomyolipomas may be confused with the sinus fat echoes. Fortunately, in this patient both lesions are well within the renal cortex.
Also, regarding angiomyolipomas- it may be noted that these kidney tumors may be associated with LAM, or lymphangioleiomyomatosis. This is a progressive lung disease consistent with numerous lung cysts leading to progressive COPD. There are only 2000 known cases in the world today. It is a women's disease presumably associated with estrogen. Women with LAM may present with pneumothorax in pregnancy. Chest x-ray does not show the lung cysts, but CT scan imaging is necessary to confirm the diagnosis. When angiomyolipomas are seen a good clinical history should be taken and the possibility of LAM should be considered. There is no cure however recent research has shown promise in drugs to slow the progression of LAM.
For more on this topic visit: http://www.ultrasound-images.com/kidneys.htm#Renal_angiomyolipoma_-%28AML%29_of_right_kidney

Congenital diaphragmatic hernia- perils and pitfalls

2011-07-24T20:12:00.001-07:00

It may initially appear that Congenital diaphragmatic hernia or CDH is a simple straightforward diagnosis on ultrasound imaging. But is it? I have come across many cases where the sonologist can miss this diagnosis in late 2nd trimester or early 3rd trimester fetuses. The reason is because many small diaphragmatic defects may cause only partial or intermittent fetal diaphragmatic hernia. Thus the sonographer or sonologist may not see any herniation of bowel or stomach in left sided diaphragmatic hernias or right lobe of liver in right sided hernias.

The ultrasound video clip shows one typical case of left sided congenital diaphragmatic hernia (CDH), with classic midline shift of heart to the right, literally pushed to a corner in the wrong side of the chest. In this case the ultrasound diagnosis of CDH was made late into 34 weeks of gestation.This can be a disaster for the mother, who might not have wished to continue the pregnancy.
What are the differential diagnoses of left sided congenital diaphragmatic hernia?
Almost any cystic lesion occupying the left hemithorax can be confused with CDH in fetal ultrasound. Among these conditions are- cystic adenomatoid malformation, bronchogenic cysts and pulmonary sequestration. Also, not to be ignored are intrathoracic teratomas, as the cystic components of this tumor can mimic a CDH. Even more ominously, these lesions mentioned above can co-exist with CDH, making a diagnosis of CDH even more complicated.
You may want to read more at: http://www.ultrasound-images.com/fetal-chest.htm#Congenital_diaphragmatic_hernia-_Left_%28CDH%29
What is the prognosis in such cases?
The earlier the diagnosis of congenital defects in the diaphragm are observed on ultrasound, the worse is the prognosis for the fetus. In fact, the detection of congenital hernia in 2nd trimester means that the severity of the congenital anomaly is more severe. Most cases are also associated with other fetal anomalies, notably involving the fetal heart. Also, invariably, the pressure from the herniated bowel and stomach, in this case means there would be severe hypoplasia of the lungs. In fact, despite surgery in the neonatal period, many such babies have pulmonary hypertension and respiratory difficulties. Also present in many neonates is the danger of mental retardation, trisomy 18 and trisomy 21 as well as neural tube defects. The fetus in this case showed no other major anomaly, but the severe midline shift is evidence of a large hernia with resultant pulmonary hypoplasia.

Seroma following lumpectomy in breast cancer:

2011-07-20T19:18:00.000-07:00

The ultrasound video clip of the breast above, shows a typical seroma of the breast following lumpectomy (removal of breast lump) and is a common sequel to such breast surgeries. The presence of particulate matter in the cystic collection (fluid) in the dead space left following breast lump removal, is an indicator of the presence of hemorrhage into the cavity. Most surgeons are of the opinion that larger seromas are formed following removal of large breast lumps and particularly following axillary lymph node dissection.
In the ultrasound video clip above note the motion of significant particles within the serous fluid. Presence of particles, mural nodules, septae are all evidence of hemorrhage following breast lumpectomy. The color Doppler ultrasound image below shows the absence of significant vascularity around the walls of the seroma, implying lack of wound/ wall infection or inflammation.

In the absence of history of breast surgery, such cystic lesions can confound the sonologist and lead to error in the diagnosis of breast seroma.
More information and ultrasound images of this case can be had at:
http://www.ultrasound-images.com/breast.htm#Breast_seroma_following_lumpectomy_for_breast_carcinoma

Breast ultrasound (google books)
(an excellent description of sonography of breast seroma)

Study of breast seroma

Ultrasound of suprapatellar hematoma

2011-07-15T20:20:00.000-07:00

The knee joint is an excellent example of superb ultrasound imaging using the newer high resolution sonographic probes in the market. Perhaps, ultrasound offers better resolution than MRI in studying certain aspects of knee joint pathology, the only hitch being the user dependence. This case study of suprapatellar hematoma or hemorrhagic effusion is a typical example. With the opportunity to image joints on both sides and actually study the effect of probe compression, sonography is in certain ways both cost effective and complementary to an MRI study of the knee joint. The extent of muscle, tendon and ligament detail that high resolution sonography of the knee joint offers, is at par if not better than MR imaging.
Visit: http://www.ultrasound-images.com/musculoskeletal.htm#Suprapatellar_effusion_%28suprapatellar_hematoma%29 a case of knee injury with hemorrhagic effusion extending into the suprapatellar bursa.

Schwannoma of parotid- a rare tumor

2011-07-13T19:56:00.000-07:00

The parotid salivary gland can sometimes yield surprises in the form of rare tumors. One such instance is a Schwannoma of the parotid gland. This tumor arises from the facial nerve as it courses through the salivary gland. Visit: http://www.ultrasound-images.com/salivary-glands.htm#Parotid_gland_Schwannoma
This site shows ultrasound images of this well defined facial nerve mass in the parotid. This tumor has not much literature published both online or in print, pertaining to its sonography. However, the case above of Schwannoma of the right parotid was confirmed histo-pathologically after biopsy.
On ultrasound this tumor has all the appearances of a benign well defined mass with nothing to point to its exact diagnosis, making precise diagnosis of Schwannoma of the parotid, difficult, on sonography.

Orchitis in neonates:

2011-02-17T19:01:00.000-08:00

This 15 days old male neonate has swelling of the left scrotum. Ultrasound images of the scrotum show a small left hydrocele with thickening of the scrotal wall. See image below:

The left testis also appears to have a shaggy outline suggesting inflammatory pathology of this organ.
Color Doppler image of the left scrotum show minimal increase in flow to the left testis:

However, this sign is not dependable in such young children, due to the poor pick up of color Doppler signals in neonatal scrotum.
Power Doppler study of the scrotum in this infant also proved to be only partially useful- see images below:

Both the above images show only the significant thickening of the left scrotal wall and not so much, the hyperemia.

Only the last image (above) shows some degree of increased flow (power Doppler image) in the left testis, and that too, at the lowest possible PRF (pulse repetition frequency) settings. This helped in ruling out left testicular torsion in this baby. The final diagnosis in this case, based on the ultrasound and color Doppler images above, was left orchitis, although mild in nature.
See this link for more: http://www.ultrasound-images.com/scrotum.htm
Also see: http://www.ultrasound-images.com/acute-scrotum.htm
Also:
http://www.ultrasound-images.com/ped-abdomen.htm

TRUS (transrectal ultrasound) imaging of bladder calculi:

2011-01-07T07:32:00.000-08:00

TRUS (transrectal ultrasonography) is a well established method of imaging of the prostate and seminal vesicles. So how good is this method at imaging of the urinary bladder in the male patient? The answer can be seen below: This elderly male (70 years) patient had a history of chronic retention of urine due to benign hypetrophy of the prostate. He presented with severe hematuria for which routine sonography of the abdomen suggested multiple small calculi in the urinary bladder. There was also moderate enlargement of the prostate. TRUS ultrasonogaphy revealed the true nature of the calculi and their exact number and size more effectively than the transabdominal ultrasound.
The ultrasound images below show the urinary bladder to contain at least 4 to 6 stones (calculi) each of 4 to 7 mm. size. A precise evaluation of the size of the prostate and the degree of intravesical enlargement is also possible on Transrectal ultrasound study (see image below).

The conclusion - transrectal ultrasound imaging is an excellent tool to image small urinary bladder stones that may be hidden from view or inadequately visualized on routine transabdominal ultrasound.

For more on urinary bladder ultrasound see: http://www.ultrasound-images.com/urinary-bladder.htm

Quiz- neck:

2010-11-30T08:46:00.000-08:00

Can anyone identify the structure (arrowed) in this ultrasound video of the neck. What does it show and what is the event that is happening? You may send your replies in the comments section, below.
OK folks- the answer is out: this sonographic video clip shows peristaltic activity within the cervical esophagus (the part of the esophagus extending from the glottis to the thorax). One can see echogenic (bright) particles (air bubbles and fluid) going down the lumen of the esophagus as the patient swallows.
In addition, further ultrasound video imaging shows (see below) some degree of reflux as fluid from the fundus of stomach (the upper part), regurgitates upwards into the lower part of the food pipe (esopahgus).

This lady had undergone a total thyroidectomy (surgical removal of the entire thyroid). Hence, the thyroid gland is not visualized in these clips.

Thickened colon:

2010-09-29T20:34:00.000-07:00

This ultrasound image shows grossly thickened wall of the large bowel (colon) in long section. The colonic wall thickness is a massive 1.1 cms. The anechoic line within the bowel represents the lumen. Note the diffuse increase in large bowel wall thickness, suggesting large area of involvement.

And the above Power Doppler ultrasound image of the same area shows hyperemia in addition. Clearly, this patient has a chronic inflammatory bowel pathology. The differentials in this case include- ulcerative colitis, Chrohn disease and also acute conditions like infective enteritis/ colitis. This patient had h/o diarrhea and bleeding per rectum with passage of mucus and pus. The clinical history, favors an infective etiology. A barium enema would be helpful as also colonoscopy. (ultrasound images are courtesy of Dr. Vikas Shukla, MD, India).
See: http://www.ultrasound-images.com/colon.htm for more images and description. on this topic.

Abdominal aorta and its main branches- Color Doppler video:

2010-09-20T09:36:00.000-07:00

The above color Doppler ultrasound video clip shows the normal upper part of the abdominal aorta withe 1st branch in the abdomen- the celiac artery, pointing almost perpendicularly from the anterior surface of the aorta. The aortic branch just below is the superior mesenteric artery, descending downwards.

The above Doppler video shows the celiac artery with the 2 main branches of this vessel- the branch heading towards the right being the common hepatic artery and the artery heading leftwards being the splenic artery. For more images and details on this topic visit: http://www.ultrasound-images.com/vascular.htm

Gall bladder calculi- Ultrasound video clips:

2010-09-18T03:17:00.000-07:00

This patient has multiple small calculi (each of 3 to 4 mm.) in the gall bladder. She tried various conservative remedies, despite which there has been no success.

For more on this topic visit: http://www.ultrasound-images.com/gall-bladder.htm

Case-2: showing motion of calculi within distended Gall bladder:

Ultrasound image shows one calculus in the gall bladder, in the dependent part, close to the neck. Not sure about the number of gall bladder stones....So what do we do?

Ultrasound video clip shows what looked like a single stone in the gall bladder are in fact two separate and relatively large calculi. Observe the motion of the two gall bladder stones floating from the neck to fundus as patient turns from supine to left lateral posture.

And later, as the patient turns to the supine position from the left lateral posture, the stones are seen moving from the fundus to GB neck.

Conclusion: postural change can help visualize hidden gall bladder calculi.

Case-3: large gallbladder calculus:

Ultrasound image shows a large calculus (1.5 cms.) near the neck of gallbladder. Two questions arise here: is this a solitary calculus and is this a sludge ball or a calculus?

Ultrasound video clip above shows this is a single large calculus (seen moving from fundus of gallbladder to the neck, as patient rotates). Also not the strong acoustic shadow of the calculus, ruling out a biliary sludge ball.

And this video shows this whopper of a GB calculus dancing all the way from the neck of gall bladder to the fundus:

Another case of fine gall bladder calculi and biliary sludge in a 5 year old child:

It is pretty difficult to say clearly if those fine echoes in the gall bladder are sludge or calculi. Perhaps it is a mixture of both.

I posted another ultrasound video clip of this case via you tube. The difference in the imaging quality is striking.

The ultrasound image above shows distended gall bladder with abundant echoes within it (same case).

Ultrasound study of Sebaceous cyst:

2010-09-16T20:00:00.000-07:00

This patient had a large cystic mass on the anterior abdominal wall. Sonography of the lesion showed a hypoechoic, inhomogenous mass with no flow on color Doppler imaging. The above ultrasound images show the "mass" suggestive of a jelly like material within the lesion; these appearances are diagnostic of sebaecous cyst (epidermoid cyst). The neck or outlet of the sebaceous cyst is also visible in these ultrasound images. Obstruction of the outlet near the neck of the cyst due to dirt or keratinous material is the cause of the obstruction and formation of the epidermoid cyst. (These ultrasound images are courtesy of Mr. Shlomo Gobi, Israel.)
References: http://www.ultrasound-images.com/musculoskeletal.htm (free ultrasound images/ case study of epidermoid cysts).

Normal anatomy of fetal heart- color Doppler ultrasound:

2010-09-15T04:31:00.000-07:00

This color Doppler ultrasound video clip of the normal fetal heart, shows the flow across the foramen ovale, from the right atrium to the left atrium (seen in red). RA= right atrium, LA= left atrium, LV= left ventricle, RV= right ventricle. This was a normal 3rd trimester fetus.

This B-mode ultrasound video clip shows the fetal heart in a 4 chamber view, with the the foramen ovale in the interatrial septum. Note the valve of the foramen ovale bulging into the left atrium as blood gushes from the fetal right atrium to left atrium. As pressure builds in the left atrium, after birth, the valve leaflet of the foramen ovale presses against the foramen, and closes this opening.
Another video clip of the normal mobility of the fetal foramen ovale valve (see below). The arrow heads point to the foramen ovale valve.

For more images and material on normal fetal heart, and cardiac anomalies visit:

http://www.ultrasound-images.com/fetal-heart.htm

Ultrasound and Doppler videos of normal fetus:

2010-09-13T09:38:00.000-07:00

Ultrasound video clips of fetal movement in 9 week old fetus (first trimester):

To the layman, or the expectant mother the fetus begins to move when she actually feels the fetus kicking or punching within her womb. This is at about 22 to 26 weeks onwards. But the sonologist can detect fetal movement much earlier. In fact movements of the fetus begin in the early part of pregnancy (as early as 6 weeks) when the fetus actually stretches its back and neck.
This ultrasound video clip shows fetal movement in a 9 week old fetus:

This sonographic video clip shows the early limb buds actually moving (the limbs are not yet developed fully and hence the term limb buds).
Another ultrasound video clip of the same fetus (9weeks)- observe the sharp movements as the fetus kicks and wriggles:

Ultrasound video -Fetus at 13 weeks:

The ultrasound clip below shows the fetal legs (13 week old fetus):

Fetal spine at 13 weeks:

The video clip below shows long section of the fetal spine (13 weeks)- the spinal cord is barely visible within the bony canal. The resemblance to fish bone is striking at this age.

Fetal head at 13 weeks:
This video clip shows a transverse section of the fetal head with the main feature being the large whitish "masses" (lumps) within the fetal cranium- these are the choroid plexuses within the brain. This is a normal appearance and should not be mistaken for a fetal anomaly.

Fetal hand at 13 weeks:

It is difficult to capture the flicking, fleeting movements of the fetal limbs, at this young fetal age. But this ultrasound video shows the fetal hand with a glimpse of the fingers.

Umbilical cord at 13 weeks pregnancy:
The umbilical cord can be seen easily at very early stages of pregnancy. This color Doppler video clip shows the normal umbilical cord with the twisted umbilical arteries and veins seen well. Note the pulsations of the vessels within the cord.

Fetus at 16 weeks: (ultrasound video clips):

Fetal hands (open) with movement:

Even at this early stage of fetal development, the 16 week old fetus shows the well developed fingers, with the phalanges (bones of the digits) and the metacarpals (hand bones) seen as (hyperechoic) white lines.

And now the normal fetal head and brain at 16 weeks:

At 16 weeks, the fetal calvarium (head) is largely filled by the choroid plexus (the large whitish masses- arrowed), with the cerebrum (large brain forming a thin hypoechoic/ dark area around it). The choroid plexus is a vascular tissue that secretes fluid (the cerebro -spinal fluid) that bathes the brain and spinal cord and fills the cavity within the brain (the cerebral ventricles).

And now we see this ultrasound video clip of the fetal spine (16 weeks):

At this early age, the spine has the characteristic fish bone appearance. The early spinal cord occupies the spinal canal (seen as those long thin whitish- (echogenic) lines within the spinal canal.

And lastly, this coronal section (parallel to the face) video clip shows the fetal face with the eyes and mouth. Observe closely- the fetal mouth is seen opening and closing:

Fetal anatomy at 23 weeks:

Both fetal hands with the fingers are seen near the head in this fetal ultrasound video.

Fetal anatomy in 3rd trimester (last 3 months of gestation):

Here is a nice ultrasound video clip of fetus in the process of yawning. Observe how the lips open during the fetal yawn. This was a 3rd trimester (32 week old fetus).

Another ultrasound video of a third trimester (more than 24 weeks) fetus in the process of swallowing amniotic fluid. The fetal tongue, lips and nose are seen in profile (side view) in this sagittal section:

This sonographic video clip shows the fetal upper limb, including the elbow and the clenched fetal hand.

And this video of the fetal lower limb from the thigh to the foot. Observe the fetus attempting to "kick" the walls of the uterus.

From the external anatomy of the fetus to more serious study- the fetal arch of the aorta is seen originating from the left ventricle outflow tract and extending down to traverse the fetal thorax and abdomen as it becomes the fetal descending aorta, in these color Doppler ultrasound video clips (22 week old fetus). Arrows point to the fetal descending aorta:

There is some loss of quality of the uploaded ultrasound / color Doppler video video clips on this blog (I think that is the result of the conversion from mpg files to the flash player format on this blog). Those wishing to obtain the original videos in .mpg format can contact me at drjoea (at) gmail.com

Here is another color Doppler video of the fetal aorta. I believe one can see the fetal ductus arteriosus emerging from the inferior aspect of the arch of the aorta in these clips. For more images and discussion of normal fetal anatomy, visit: http://www.ultrasound-images.com/fetus-general.htm and
http://www.ultrasound-images.com/fetal-chest.htm
Fetal spinal cord (35 weeks gestational age):
Here are some still images showing the spinal cord of a fetus at 35 weeks gestational age:
I first captured this image showing the thoraco-lumbar region of the spinal cord with a convex 4 Mhz probe.

Then, I repeated the scan with a 9 Mhz probe. The tapered filum terminale and terminal part (conus medullaris) of the cord are seen in this ultrasound image (below):

The spinal cord (arrows) is the hypoechoic tubular structure between those 2 echogenic (bright) membranes (the dura mater) within the spinal canal.

Reference: http://www.ajronline.org/cgi/reprint/164/2/421
http://www.jultrasoundmed.org/cgi/reprint/25/11/1397.pdf

Fetal ear (35 weeks gestational age):

This ultrasound image shows the fetal external ear with the external auditory canal (arrows):

These ultrasound video clips show the pinna of the fetal ear with the anechoic external auditory canal (external auditory meatus) reaching deep into the fetal skull.

The same part of the fetal ear seen with arrows pointing to the fetal external auditory canal (meatus) (the part of the external ear). The external auditory canal (meatus) is the part of the ear that extends from the pinna to the middle ear, (the part of the ear that can be seen).

Color Doppler ultrasound video clips of varicocele

2010-09-11T21:25:00.000-07:00

This case of recurrence of varicocele of the left scrotum; color Doppler ultrasound image shows a grade 3 varicocele of the left side. The pampiniform veins of the left side measure almost 4.4 mm on valsalva maneuver.

The right scrotum is also affected and show a grade 3 varicocele affecting a few vessels. Recurrence of varicocele after surgical correction is a known sequel of surgery.

This color Doppler video clip shows multiple veins dilating and filling up on Valsalva maneuver. The left of the video shows the appearance at rest in the left scrotum.

Same case: another video demonstrating the effect of breath holding for a few seconds. Note that the diameter of the veins (left scrotum) almost doubles on valsalva maneuver.

See: http://www.ultrasound-images.com/scrotum.htm for more on this topic

CASE-2: Grade -3 varicocele (bilateral) with severe reflux:

Color Doppler ultrasound video of Left scrotal varicocele:

The right scrotum also showed grade 3 varicocele:

The left half of the video clip shows the pampiniform veins at rest. The right half shows the pampiniform veins filling up during Valsalva maneuver. This patient has markedly low sperm count and poor motility of the sperms visualized on semen examination. Surgery may be the only method to improve his fertility and chances of having a child.

The above color Doppler image of the right scrotum shows the veins measuring 4.2 mm. in the right scrotum!!

The left scrotum showed veins measuring as high as 5.7 mm. on Valsalva maneuver (see color Doppler ultrasound image above).

Visit: http://www.ultrasound-images.com/scrotum.htm for more on this topic.

Breast cancer with spread to lymph nodes:

2010-09-10T07:37:00.000-07:00

3-D (3 dimensional) ultrasound image shown above, with the cancerous mass of the left breast seen seen within the breast tissue as a hypoechoic mass with irregular margins.

This ultrasound image of the left axilla shows the same patient with an enlarged hypoechoic group of lymph nodes. This suggests metastases of the carcinoma in the left breast to the axillary lymph nodes, an ominous sign.

B-mode 2 dimensional ultrasound image (above) of the same case shows a section through the carcinoma of the breast with the markedly hypoechoic mass appearing to infiltrate vertically through multiple layers of breast tissue. This is a clear hall mark of a malignant breast mass.

The above image shows both the carcinomatous mass in the left breast (same case) with the hypoechoic lymph node nearby, in the axilla. (All the above ultrasound images are courtesy of Dr. ravi Kadasne, MD, UAE). For more on this topic/ ultrasound study of breast cancer, visit:

http://www.ultrasound-images.com/breast.htm

Ultrasound video clips of large urinary bladder calculus:

2010-09-08T18:48:00.000-07:00

The large bladder stone is seen rolling from the right lateral wall of the urinary bladder (the patient was lying in right lateral decubitus position) to the posterior surface of the bladder as the patient turns to the supine position.

I repeated this with the patient lying supine initially. The bladder calculus is seen lying on the posterior wall, and as the patient rotates to the right lateral decubitus position, the urinary bladder stone is seen rolling to the surface of the right wall of the bladder. This simple maneuver helps confirm that the echogenic lesion in the urinary bladder is indeed a calculus, besides helping to visualize the full extent of the urinary bladder stone. Often, one should be able to see if this is a single calculus or multiple, with this simple procedure.

See: http://www.ultrasound-images.com/urinary-bladder.htm for more on this topic.

Ultrasound imaging of EIF (echogenic intracrdiac focus):

2010-08-31T07:04:00.000-07:00

This 23 week old fetus showed a echogenic focus in the left ventricle, within the mitral valve. These ultrasound video clips show the echogenic intracardiac focus in detail despite the cardiac pulsations. These foci are not uncommon in Asians and some statistics state that these may be seen in as many as 30 % of the fetuses in Asians. See: http://www.jultrasoundmed.org/cgi/reprint/17/2/127.pdf

Also: http://www.ultrasound-images.com/fetal-heart.htm

Here is one ultrasound video of this pathology:

The vast majority of fetuses with anomaly have normal karyotyping and hence echogenic intracardiac foci are considered a normal variant. However, the importance of the presence of EIF lies in the fact that there is a small risk of aneuploidy in such fetuses. This risk increases with maternal age (after the age of 35 years).

A calcific fibroid in the broad ligament:

2010-08-30T09:37:00.000-07:00

This gray scale B-mode ultrasound video clip (transabdominal imaging) of the uterus, shows a rounded mass with rim calcification to the right of the uterus. This was not sufficient to determine if the mass was uterine or ovarian in origin. Hence, I conducted a transvaginal ultrasound study of the pelvis:

The solid, calcific, mass appears to clearly attached to the uterus along the right lateral aspect of the body of uterus, and possibly located partially within the broad ligament on the right side. Here are two more transvaginal ultrasound video clips of the same case.

Here is one more sonographic video clip of the same case; on probe pressure on the right ovary the ovary appears separate from the mass, which is now clearly identified as a subserous (subserosal) broad ligament fibroid.

Abbreviations: UT= UTERUS; M= MASS (FIBROID); RT. OV = RIGHT OVARY; BL= BLADDER.

Reference: http://www.ultrasound-images.com/uterus.htm

http://emedicine.medscape.com/article/405676-overview

Torsion testis- ultrasound/ Color Doppler video tutorial:

2010-08-28T03:31:00.001-07:00

How does one diagnose torsion of the testis? The clinical examination of a torsed testis is characterized by pain and swelling of the scrotum on the side of torsion. In addition the testis is tender. This condition is seen mainly in the age group from 12 to 18 years.

The easiest and most inexpensive diagnostic method for torsion of testis is color Doppler examination of the scrotum. Whilst absence of vascularity or (poor or absent flow in the affected testicle) remains the hall mark of torsion, there are additional signs of a torsed testis. These include (see the color Doppler ultrasound video clip above), a hypoechoic, swollen testis with a grossly thickened, edematous spermatic cord. The Color Doppler video above shows the mediastinum of the left testes is in an abnormal location, actually pointing laterally. This is also a diagnostic feature of torsion of the testis.

This color Doppler video shows a transverse section through the left testes, as we pan from the upper pole to the lower pole. Along with the avascular left testis, note the mass formed along the lateral aspect of the testis by the enlarged and equally avascular left spermatic cord. Any vessels seen in this imaging of torsion of the left testis are within the edematous left scrotal wall, an inflammatory response to the left testicular ischemia.

This video clip shows Power Doppler imaging of torsion of the left testes. Again, note the striking absence of blood flow within the left testes.
Here are a couple of still ultrasound images of the same case:

In the color Doppler image above note the stark contrast between the normally vascular right testis to the total absence of flow in the left testis.

In the lower image, observe the thickened cord, almost the same size as the adjacent left testis.
You can learn more on this topic at: http://www.ultrasound-images.com/acute-scrotum.htm

My newest blog on all things ultrasound:

2010-08-28T02:00:00.000-07:00

Welcome to my new blog on sonography, ultrasound imaging and all things related to ultrasound. You can expect a lot of high quality ultrasound images and sonographic video clips on this blog.
Joe.