Understanding Reversed Cerebroplacental Ratio (CPR) in Late Pregnancy: Significance, Findings, and Management

Ultrasound and Doppler imaging 

findings in a 37 weeks pregnancy:

1. Umbilical Artery Doppler: Resistance Index (RI) of 0.69

2. Middle Cerebral Artery (MCA) Doppler: RI of 0.65

3. CPR = MCA RI / Umbilical Artery RI = 0.94 (reversed CPR)

Significance:

- A reversed CPR indicates a potential issue with fetal circulation.

- The increased resistance in the umbilical artery suggests reduced placental perfusion.

- The lower resistance in the middle cerebral artery indicates fetal brain sparing.

- These findings suggest fetal distress and potential compromise.

- In this case, the Doppler waveform of the Middle Cerebral Artery (MCA) shows a notable feature:

- Mild Increased Diastolic Flow: This indicates that during the diastolic phase of the cardiac cycle (when the heart is at rest and filling with blood), there is a higher-than-normal blood flow in the MCA. 

This finding suggests that the fetal brain is compensating for the reduced placental perfusion indicated by the reversed cerebroplacental ratio (CPR). The increased diastolic flow in the MCA is a protective mechanism to ensure that the baby's brain receives an adequate supply of oxygen and nutrients, even when the placental circulation is compromised. It signifies fetal brain sparing and is an important indicator for assessing the well-being of the fetus in cases of uteroplacental insufficiency.

Prognosis and Management:

1. Continuous fetal monitoring is essential to assess the baby's well-being.

2. Consultation with a maternal-fetal medicine specialist is crucial.

3. Depending on the severity, early delivery may be necessary to prevent further complications.

4. If the fetus is not in distress, close monitoring with repeated Doppler studies is an option.

5. The management plan should be individualized based on the specific clinical context and findings.

Timely and appropriate management is vital to ensure the best possible outcome for both the mother and the baby.

(Images in this case are courtesy of Dr Golam).

For more on this topic visit:

Ultrasound case studies in atlas format

Also available in India this ebook will be useful:

Assorted ultrasound cases ebook

An ebook on arterial Doppler in atlas format 

 Atlas of arterial Doppler ultrasound

Atlas of arterial Doppler Indian edition

Portal vein aneurysm, a sonography case study

What is a portal vein aneurysm?

A portal vein aneurysm is an abnormal dilation or bulging of the portal vein, which is the major blood vessel carrying blood from the digestive organs to the liver. It can be caused by various factors and may lead to complications such as thrombosis or rupture if left untreated.

Ultrasound imaging findings:

1. Location and Size: The ultrasound reveals a large portal vein aneurysm situated in close proximity to the head of the pancreas. The exact dimensions at almost 3 cms size, including length and diameter, are measured to assess the extent of the aneurysm accurately.

2. Shape and Morphology:  It appears as a localized, bulging outpouching of the portal vein, often with a spherical or elliptical configuration. It appears to communicate with the origin of the portal vein. 

3. Internal Characteristics: Within the aneurysm, the ultrasound can detect various internal characteristics, such as echogenicity. Thrombosis or blood clots may appear hyperechoic (bright) within the aneurysm, indicating a lack of blood flow within the dilated segment. Here, the walls of the aneurysm appear thickened due to possible partial thrombosis. Internal echogenicity is anechoic possibly due to acute thrombosis within the aneurysm. 

4. Color Doppler Flow: The Color Doppler imaging is crucial in evaluating blood flow within the aneurysm. In this case, it shows little to no color flow within the aneurysm, which is indicative of stagnant or no blood flow. This finding suggests fresh thrombosis or a blockage of blood flow within the aneurysm.

5. Adjacent Structures: The ultrasound may also assess nearby structures, such as the pancreas and surrounding blood vessels, to check for any compression or displacement caused by the aneurysm. Here the portal vein aneurysm compresses upon the right lobe of liver and pancreas. 

6. Portal Vein Evaluation: Beyond the aneurysm, the portal vein itself is evaluated for patency, diameter, and any abnormalities. This helps in understanding the overall vascular dynamics in the portal system.

( Images of this case are courtesy of Dr Golam)

Differential Diagnoses on Ultrasound:

Portal Vein Thrombosis: Thrombosis within the portal vein itself can mimic an aneurysm and may present with similar findings.Other 

Vascular Abnormalities: Differential diagnoses include arterioportal fistula, portal vein stenosis, or pseudoaneurysm.

Pancreatic Lesions: Tumors or pseudocyst of  head of the pancreas can sometimes appear as cystic masses on ultrasound.

What are the causes of portal vein aneurysm?

Portal vein aneurysms can be caused by various factors, including:

Chronic Liver Disease: Cirrhosis and other liver conditions can weaken the portal vein wall.

Pancreatitis: Inflammation of the pancreas may affect nearby blood vessels, leading to aneurysm formation.

Congenital Factors: Rarely, individuals may have a genetic predisposition to vascular abnormalities.

Trauma: Injury or abdominal trauma can damage the portal vein, promoting aneurysm development.

Infection: Infections in the portal vein may weaken its wall and contribute to aneurysm formation.

Unknown Causes: In some cases, the exact cause remains unclear (idiopathic).

Prognosis and Management:

Thrombosed Aneurysm: A thrombosed portal vein aneurysm may be managed conservatively with anticoagulation to prevent further thrombus formation.

Surgical Intervention: Large, symptomatic, or high-risk aneurysms may require surgical repair or endovascular intervention to prevent complications.

Regular Monitoring: Follow-up ultrasound examinations are crucial to monitor changes in aneurysm size, thrombosis, or complications.

Underlying Conditions: Treating any underlying conditions contributing to the aneurysm's formation, such as pancreatitis or cirrhosis, is essential.

You may find this ebook interesting:

Assorted ultrasound cases, ebook in atlas format

Understanding Fetal Aorta and IVC

 "Sagittal Section Ultrasound and Color Doppler: Understanding Fetal Aorta and IVC"

Ultrasound imaging during the second trimester of pregnancy provides crucial insights into fetal development. When assessing sagittal section ultrasound images, the simultaneous visualization of the fetal aorta and inferior vena cava (IVC) is important. Here's a concise breakdown of the ultrasound and color Doppler findings, as well as their significance:

1. Co-visualization: In the sagittal section, both the fetal aorta and IVC appear in the same image. This occurrence is not uncommon during routine fetal assessments.

2. Color Doppler Confirmation: Color Doppler ultrasound confirms the presence and flow patterns of these vessels. It distinguishes between the oxygen-rich aorta (bright red) and oxygen-poor IVC (blue).

3. Aorta and IVC Functions: The aorta carries oxygenated blood from the heart to the fetal body, while the IVC returns deoxygenated blood to the heart. Co-visualization indicates normal circulation.

4. Significance: Simultaneous visualization assures proper fetal circulation. Absence or abnormalities could signify congenital heart defects, requiring further evaluation and intervention.

5. Diagnostic Tool: These findings serve as diagnostic tools to assess fetal well-being and detect potential cardiac issues early in pregnancy.

6. Medical Decision-Making: Accurate identification of aorta and IVC helps guide medical decisions and interventions, ensuring a healthier outcome for both mother and baby.

In summary, the co-visualization of fetal aorta and IVC in sagittal section ultrasound, confirmed by color Doppler, is a crucial aspect of prenatal assessment. It aids in monitoring fetal health, diagnosing cardiac anomalies, and ensuring timely medical interventions if necessary.

Here's a nice atlas in ebook format on neonatal ultrasound:

Atlas of neonatal ultrasound

For Indian readers:

Atlas of neonatal ultrasound

All about arterial Doppler, an atlas in ebook format:

Atlas of arterial Doppler ultrasound

For Indian readers:

Atlas and basics of arterial Doppler

Anterior subserosal fibroid of uterus

Anterior Subserosal Fibroid of Uterine Fundus: Ultrasound and Color Doppler Imaging Insights

Ultrasound and color Doppler imaging findings:

1. Location: Anterior subserosal fibroid at the fundus of the uterus.

2. Size: 4 x 2 cm.

3. Compression: Exerts pressure on the bladder.

Possible problems:

1. Urinary Symptoms: Frequent urination, urgency, or even urinary retention.

2. Menstrual Irregularities: Heavy or prolonged periods.

3. Pelvic Pain: Discomfort or pain in the lower abdomen.

4. Fertility Issues: May interfere with conception or cause recurrent miscarriages.

Prognosis:

- Favorable with early detection and intervention.

- May not necessarily indicate malignancy.

Management:

1. Observation: If asymptomatic or mild symptoms.

2. Medications: Pain relief and hormonal therapy for symptom control.

3. Surgical Options: Myomectomy or hysterectomy for severe symptoms or fertility concerns.

4. Minimally Invasive Procedures: Uterine artery embolization or MRI-guided focused ultrasound for select cases.

Regular follow-ups and individualized treatment plans are crucial for managing anterior subserosal fibroids, ensuring improved quality of life and fertility preservation when needed.

For more on uterine fibroids:

Sonography of uterine fibroids

Sonography of uterine fibroids: kindle ebook USA

Large lipoma of chest wall

Ultrasound Imaging Findings of Large Lipoma of the Chest

Ultrasound Imaging Findings:

1. Hyperechoic Mass: Lipomas typically appear as well-defined, hyperechoic (bright) masses on ultrasound due to their high fat content.

2. Homogeneous Texture: Lipomas have a uniform texture, with a smooth and consistent echogenicity throughout the lesion.

3. Posterior Acoustic Enhancement: Lipomas often exhibit posterior acoustic enhancement, causing increased brightness behind the mass due to sound waves passing through the fatty tissue.

4. Well-Circumscribed Borders: These benign tumors have clear, distinct borders that differentiate them from surrounding tissues.

5. Lack of Vascularity: Lipomas usually lack significant blood flow, as they are non-vascular structures.

Differential Diagnoses:

1. Liposarcoma: It can mimic a lipoma but tends to be larger, more heterogeneous, and may show vascularity on imaging.

2. Sebaceous Cyst: These cysts may appear similar but tend to have a central punctum and may be associated with skin changes.

3. Hemangioma: Vascular tumors may show significant blood flow and a different echogenicity pattern.

Prognosis:

Lipomas are typically benign and do not pose a significant health risk. They rarely become malignant, and the prognosis is excellent.

Management:

1. Observation: Asymptomatic lipomas may be left alone and monitored.

2. Surgical Removal: Indicated for large, symptomatic, or cosmetically bothersome lipomas. Excision is curative.

3. Biopsy: If there is uncertainty about the diagnosis, a biopsy may be performed.

Always consult a healthcare professional for proper evaluation and management.

Fatty Liver with Focal Fatty Sparing: insights

A case study of focal fatty sparing:

Ultrasound Imaging Findings:

1. Hepatic Steatosis: The ultrasound reveals diffusely increased liver echogenicity, indicative of fatty liver disease.

2. Focal Fatty Sparing: A notable exception in this case is the periportal region, which displays reduced echogenicity, signifying focal fatty sparing.

3. Hepatomegaly: Liver size is often enlarged due to fat accumulation.

Color Doppler Ultrasound Findings:

Normal Blood Flow: Typically, blood flow within the liver vasculature remains unaltered in the area of focal sparing. 

Ultrasound images of the case:

Focal sparing near periportal region:

Note proximity to portal vein:

Note location close to GB and portal vein 👆

Prognosis and Management:

1. Prognosis: Fatty liver with focal sparing is generally less severe than diffuse steatosis. Prognosis is favorable with early detection.

2. Management: Lifestyle modifications, including diet and exercise, are crucial to reduce fat accumulation. Regular monitoring is essential to prevent progression to more severe fatty change. 

What is focal fatty sparing of liver 🤔?

Focal fatty sparing of the liver is a condition in which there are areas of normal liver tissue surrounded by fatty liver. This can be seen on ultrasound as hypoechoic (darker) areas within the liver. The sparing may be due to a variety of factors, including anatomical variations, vascular anomalies, and metabolic disorders. Focal fatty sparing is usually a benign condition, but it can sometimes be mistaken for a tumor or other lesion

Which parts of the liver are affected?

Adjacent to the porta hepatis (the area where the hepatic artery, portal vein, and bile duct enter the liver)

The gallbladder fossa

The falciform ligament

The subcapsular region (the outer layer of the liver)

These locations are thought to be spared from fatty infiltration due to variations in vascular supply. The porta hepatis is a region with a rich blood supply, while the gallbladder fossa and falciform ligament are areas that are not as well-vascularized. The subcapsular region is also less likely to be affected by fatty infiltration because it is not as well-perfused with blood.

Focal fatty sparing can also occur in other locations, but it is less common. 

For more such interesting cases:

Assorted ultrasound cases

Also visit:

Fatty liver sonography

Egg shell calcification in thyroid nodule

In a recent ultrasound imaging study of a patient's thyroid, two notable findings in the right lobe were observed:

1. Eggshell Calcification Nodule: A distinct nodule was identified, characterized by a thin, calcified rim resembling an eggshell. Such nodules typically exhibit benign behavior and a low likelihood of being cancerous.

2. Honeycomb Pattern Nodule: Another nodule displayed a unique honeycomb-like pattern on the ultrasound image. While these nodules are generally benign, they do carry a slightly higher risk of malignancy compared to those with eggshell calcification.

Notably, both nodules displayed an absence of internal blood flow, as indicated by the lack of vascularity on color Doppler ultrasound.

Prognosis and Management:

For the patient's prognosis and management:

- Eggshell Calcification Nodule: This nodule's benign nature suggests a favorable prognosis, with continued monitoring through regular ultrasounds to track any changes.

- Honeycomb Pattern Nodule: While still usually benign, these nodules warrant vigilant monitoring due to their slightly increased risk. Fine-needle aspiration biopsy may be considered to assess malignancy risk.

- Surgical Intervention: If malignancy is confirmed or if the nodules exhibit significant growth, surgical removal may be recommended.

- Medication: In cases requiring surgical intervention, thyroid hormone replacement therapy may be necessary.

For a short ebook on Thyroid diseases try this:

All about thyroid disease

Same ebook is available also at:

Thyroid disease ebook

Bilateral simple renal cortical cysts

Ultrasound Imaging Findings:

Kidneys contain two simple cysts, measuring 3 and 4 cms.

No internal septations or mural nodules present.

No internal echoes or vascularity detected.

Bosniak Grade: These cysts fall into Grade I, indicating minimal complexity.

Prognosis and Management:

Simple renal cysts of this nature typically have an excellent prognosis.

Regular monitoring via ultrasound is advisable to ensure stability.

Interventions such as drainage or surgical removal are rarely necessary.

Consultation with a urologist is recommended for personalized guidance.

In summary, these small simple renal cysts with no concerning features carry a favorable prognosis, requiring only periodic monitoring to ensure stability.

Sonography of renal cysts

Amazon Kindle ebook on ultrasound imaging