Wednesday, November 23, 2011

Normal and enlarged lymph nodes:

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.  

Sunday, August 14, 2011

Sonographic differentiation of some common renal masses:

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:
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:
  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.  


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:
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.

Friday, August 12, 2011

Sonography of angiomyolipoma:

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:

Sunday, July 24, 2011

Congenital diaphragmatic hernia- perils and pitfalls

   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:
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.

Wednesday, July 20, 2011

Seroma following lumpectomy in breast cancer:

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:

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

Study of breast seroma

Friday, July 15, 2011

Ultrasound of suprapatellar hematoma

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: a case of knee injury with hemorrhagic effusion extending into the suprapatellar bursa.

Wednesday, July 13, 2011

Schwannoma of parotid- a rare tumor

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:
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.

Thursday, February 17, 2011

Orchitis in neonates:

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:
Also see:

Friday, January 7, 2011

TRUS (transrectal ultrasound) imaging of bladder calculi:

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: