Diagnostic Ultrasound

Description

Diagnostic Ultrasound, edited by Carol M. Rumack, Stephanie R. Wilson, J. William Charboneau, and Deborah Levine, presents a greater wealth of authoritative, up-to-the-minute guidance on the ever-expanding applications of this versatile modality than you'll find in any other single source. Preeminent experts help you reap the fullest benefit from the latest techniques for ultrasound imaging of the whole body...image-guided procedures...fetal, obstetric, and pediatric imaging...and more. This completely updated 4th Edition encompasses all of the latest advances, including 3-D and 4-D imaging, fetal imaging, contrast-enhanced ultrasound (CEUS) of the liver and digestive tract, and much more - all captured through an abundance of brand-new images. And now, video clips for virtually every chapter allow you to see the sonographic presentation of various conditions in real time! Cover 5TH EDITION Physics of Ultrasound Physics of Ultrasound Christopher R.B. Merritt CHAPTER OUTLINE Propagation of Sound BASIC ACOUSTICS Wavelength and Frequency Distance Measurement Acoustic Impedance Examples of Specular Reflectors Reflection Attenuation Refraction Tissue A c 1 = 1540 m/sec Tissue B c 2 = 1450 m/sec Transducer INSTRUMENTATION Transmitter Receiver Image Display Mechanical Sector Scanners Arrays Linear Arrays Curved Arrays Phased Arrays Two-Dimensional Arrays Transducer Selection IMAGE DISPLAY AND STORAGE SPECIAL IMAGING MODES Tissue Harmonic Imaging Spatial Compounding Three-Dimensional Ultrasound Ultrasound Elastography Key Points of Ultrasound Elastography Shear Wave Elastography Strain Elastography IMAGE QUALITY Spatial Resolution IMAGING PITFALLS Shadowing and Enhancement DOPPLER SONOGRAPHY Doppler Signal Processing and Display Doppler Instrumentation Limitations of Color Doppler Flow Imaging Advantages of Power Doppler Power Doppler Interpretation of the Doppler Spectrum Interpretation of Color Doppler Other Technical Considerations Doppler Frequency Wall Filters Spectral Broadening Major Sources of Doppler Imaging Artifacts Aliasing Doppler Angle Sample Volume Size Doppler Gain OPERATING MODES: CLINICAL IMPLICATIONS Bioeffects and User Concerns THERAPEUTIC APPLICATIONS: HIGH INTENSITY FOCUSED ULTRASOUND REFERENCES Biologic Effects and Safety J. Brian Fowlkes and Christy K. Holland REGULATION OF ULTRASOUND OUTPUT Factors Controlling Tissue Heating Spatial Focusing PHYSICAL EFFECTS OF SOUND THERMAL EFFECTS Ultrasound Produces Heat Temporal Considerations Tissue Type TABLE 2.1 Fetal Femur Temperature Increments a at 1 W/cm 2 Bone Heating Soft Tissue Heating Hyperthermia and Ultrasound Safety Thermal Index The Thermal Index Homogeneous Tissue Model (Soft Tissue) Tissue Model With Bone at the Focus (Fetal Applications) Tissue Model With Bone at the Surface (Transcranial Applications) Estimate of Thermal Effects Summary Statement on Thermal Effects EFFECTS OF ACOUSTIC CAVITATION Potential Sources for Bioeffects The AIUM Statement on Mammalian Biological Effects of Heat 24 The AIUM Statement on Mammalian Biological Effects of Heat 24 —cont’d Evidence of Cavitation From Lithotripters Sonochemistry Bioeffects in Lung and Intestine Ultrasound Contrast Agents The AIUM Statement on Mammalian Biological Effects in Tissues With G Considerations for Increasing Acoustic Output Mechanical Index Summary Statement on Gas Body Bioeffects OUTPUT DISPLAY STANDARD The AIUM Statement on Mammalian Biological Effects in Tissues With The AIUM Safety Statements on Diagnostic Ultrasound GENERAL AIUM SAFETY STATEMENTS EPIDEMIOLOGY CONTROLLING ULTRASOUND OUTPUT TABLE 2.2 Optimum Ultrasound Output: Lowest Power Output That Crea The AIUM Statement on Keepsake Fetal Imaging 107 ULTRASOUND ENTERTAINMENT VIDEOS Contrast Agents for Ultrasound Peter N. Burns CHAPTER OUTLINE REQUIREMENTS AND TYPES Blood Pool Agents Free Gas Bubbles Encapsulated Air Bubbles TABLE 3.1 Regulatory and Marketing Status of Some Current Ultrasoun Second-Generation Agents Selective Uptake Agents THE NEED FOR BUBBLE-SPECIFIC IMAGING Bubble Behavior and Incident Pressure TABLE 3.2 Three Types of Acoustic Behavior of a Typical Perfluoroca The Mechanical Index (MI) The Mechanical Index NONLINEAR ECHOES AND HARMONIC IMAGING Harmonic B-Mode Imaging Harmonic Spectral and Power Doppler Imaging Tissue Harmonic Imaging Pulse Inversion Imaging Pulse Inversion Doppler Imaging Plane-Wave Contrast Imaging Amplitude and Phase Modulation Imaging Temporal Maximum Intensity Projection Imaging DISRUPTING BUBBLES: INTERMITTENT IMAGING Triggered Imaging Intermittent Harmonic Power Doppler Disruption-Replenishment Imaging SAFETY CONSIDERATIONS AND REGULATORY STATUS THE FUTURE CONCLUSION REFERENCES PART TWO: Abdominal and Pelvic Sonography The Liver Stephanie R. Wilson and Cynthia E. Withers SONOGRAPHIC TECHNIQUE NORMAL ANATOMY Couinaud Anatomy TABLE 4.1 Structures Useful for Identifying Hepatic Segments TABLE 4.2 Couinaud Segments and Traditional Hepatic Anatomy Ligaments Hepatic Circulation Portal Veins Arterial Circulation Hepatic Venous System Normal Liver Size and Echogenicity DEVELOPMENTAL ANOMALIES Agenesis Anomalies of Position Accessory Fissures Vascular Anomalies CONGENITAL ABNORMALITIES Liver Cyst Peribiliary Cysts Autosomal Dominant Polycystic Disease Biliary Hamartomas (von Meyenburg Complexes) INFECTIOUS DISEASES Viral Hepatitis Clinical Manifestations Bacterial Diseases Fungal Diseases: Candidiasis Parasitic Diseases Amebiasis Hydatid Disease Schistosomiasis Pneumocystis carinii DISORDERS OF METABOLISM Fatty Liver Glycogen Storage Disease (Glycogenosis) Cirrhosis Elastography Cirrhosis: Sonographic Features Doppler Ultrasound Characteristics VASCULAR ABNORMALITIES Portal Hypertension n ear the umbilicus (Cruveilhier-Baumgarten syndrome) 86 Portal Vein Thrombosis Budd-Chiari Syndrome Portal Vein Aneurysm Intrahepatic Portosystemic Venous Shunts Aneurysm, Pseudoaneurysm, and Dissection Hereditary Hemorrhagic Telangiectasia Peliosis Hepatis HEPATIC MASSES Liver Mass Characterization Role of Microbubble Contrast Agents Liver Mass Detection HEPATIC NEOPLASMS TABLE 4.3 Schematic of Algorithm for Liver Mass Diagnosis on Cont Benign Hepatic Neoplasms Cavernous Hemangioma Focal Nodular Hyperplasia Hepatic Adenoma Fatty Tumors: Hepatic Lipomas and Angiomyolipomas Malignant Hepatic Neoplasms Hepatocellular Carcinoma TABLE 4.4 Schematic of Algorithm for Diagnosis of Nodules in Cirrh Hemangiosarcoma (Angiosarcoma) Hepatic Epithelioid Hemangioendothelioma Metastatic Liver Disease a n d o varian cystadenocarcinoma a nd t e ratocarcinoma. 203 HEPATIC TRAUMA Portosystemic Shunts Transjugular Intrahepatic Portosystemic Shunts Malfunction of Transjugular Intrahepatic Portosystemic Shunts: Sonograp Sonographically detected complications include the f o llowing: PERCUTANEOUS LIVER BIOPSY INTRAOPERATIVE ULTRASOUND Acknowledgment REFERENCES The Spleen Patrick M. Vos, John R. Mathieson, and Peter L. Cooperberg CHAPTER OUTLINE EMBRYOLOGY AND ANATOMY SONOGRAPHIC TECHNIQUE SONOGRAPHIC APPEARANCE PATHOLOGIC CONDITIONS Splenomegaly TABLE 5.1 Causes of Splenomegaly Types of Splenic Cysts Focal Abnormalities Splenic Cysts Nodular Splenic Lesions Causes of Splenic Nodules Focal Solid Splenic Lesions Focal Solid Splenic Masses Other Abnormalities Sickle Cell Disease Gaucher Disease Gamna-Gandy Bodies Splenic Trauma CONGENITAL ANOMALIES INTERVENTIONAL PROCEDURES PITFALLS IN INTERPRETATION REFERENCES The Biliary Tree and Gallbladder Korosh Khalili and Stephanie R. Wil CHAPTER OUTLINE THE BILIARY TREE Anatomy and Normal Variants Sonographic Technique Choledochal Cysts Caroli Disease Overview of Biliary Tree Obstruction Causes of Biliary Obstruction Choledocholithiasis Intrahepatic Stones Common Bile Duct Stones Mirizzi Syndrome Hemobilia Pneumobilia Biliary Tree Infection Acute (Bacterial, Ascending) Cholangitis Liver Flukes Recurrent Pyogenic Cholangitis Ascariasis HIV Cholangiopathy Immune-Related Diseases of the Biliary Tree Primary Biliary Cirrhosis and Autoimmune Cholangitis Primary Sclerosing Cholangitis Causes of Secondary Sclerosing Cholangitis IgG4-Related Cholangitis Cholangiocarcinoma Intrahepatic Cholangiocarcinoma Hilar Cholangiocarcinoma Criteria for Unresectable Hilar Cholangiocarcinoma Metastases to Biliary Tree THE GALLBLADDER Anatomy and Normal Variants Distal Cholangiocarcinoma Sonographic Technique Gallstone Disease Biliary Sludge Causes of Sonographic Nonvisualization of Gallbladder Acute Cholecystitis TABLE 6.1 Acute Calculous Cholecystitis: Pathologic-Sonographic Correl Causes of Gallbladder Wall Thickening o r diverticulitis, a n d even p y e lonephritis can demonstrate a Gangrenous Cholecystitis Perforated Gallbladder Emphysematous Cholecystitis Acalculous Cholecystitis Torsion (Volvulus) of Gallbladder Chronic Cholecystitis Porcelain Gallbladder Adenomyomatosis (Adenomatous Hyperplasia) Polypoid Masses of Gallbladder Cholesterol Polyps Adenomas, Adenomyomas, and Inflammatory Polyps Common Polypoid Masses of the Gallbladder Malignancies Gallbladder Carcinoma Patterns of Tumor Spread Sonographic Appearance REFERENCES The Pancreas Thomas Winter and Maryellen R.M. Sun ANATOMY AND SONOGRAPHIC TECHNIQUE Pancreatic Head Pancreatic Body Pancreatic Tail Pancreatic Parenchyma Fatty Pancreas Embryology and Pancreatic Duct Imaging Anatomic Variants Peripancreatic Structures ACUTE PANCREATITIS Approach to Imaging Imaging in Acute Pancreatitis TABLE 7.1 Causes of Acute Pancreatitis Ultrasound Findings TABLE 7.2 Sonographic Abnormalities in Patients With Acute Pancreat Complications Local Complications of Acute Pancreatitis Acute Fluid Collections Pseudocysts o f “ the u s ual s u s pects”: serous cystic neoplasm (microcystic Necrosis and Abscess Treatment Vascular Complications CHRONIC PANCREATITIS Approach to Imaging Ultrasound Findings Pseudocysts Portal and Splenic Vein Thrombosis Masses Associated With Chronic Pancreatitis PANCREATIC NEOPLASMS Periampullary Neoplasm Pancreatic Carcinoma Pancreatic Cancer Imaging: Three Key Concepts Detection of Pancreatic Cancer Ultrasound Findings Resectability Imaging Color Doppler Ultrasound Pancreatic Cancer Imaging: Suggested Approach TABLE 7.3 Pancreatic Color Doppler Score CYSTIC PANCREATIC LESIONS TABLE 7.4 Estimated Prevalence of Cystic Pancreatic Lesions a High-Risk Features of Cystic Pancreatic Lesions Simple Pancreatic Cysts cysts, s uch a s a u t osomal dominant polycystic kidney disease Cystic Neoplasms Serous Cystic Neoplasm Intraductal Papillary Mucinous Neoplasm Mucinous Cystic Neoplasm Solid-Pseudopapillary Tumor Rare Cystic Tumors OTHER PANCREATIC MASSES Endocrine Tumors Rare Cystic Pancreatic Tumors TABLE 7.5 Pancreatic Endocrine Tumors (PETs) Unusual and Rare Neoplasms Lipoma Metastatic Tumors CONTRAST-ENHANCED ULTRASOUND Acknowledgment REFERENCES The Gastrointestinal Tract Stephanie R. Wilson Gut Wall Pathology ANATOMY AND SONOGRAPHIC TECHNIQUE The Gut Signature TABLE 8.1 Gut Signature: Histologic- Sonographic Correlation Imaging Technique Doppler Evaluation of Gut Wall Contrast-Enhanced Ultrasound and Elastography of the Bowel Adenocarcinoma GASTROINTESTINAL TRACT NEOPLASMS Gastrointestinal Stromal Tumors Lymphoma Metastases INFLAMMATORY BOWEL DISEASE: CROHN DISEASE Crohn Disease on Sonography TABLE 8.2 Ultrasound Global Assessment Showing Crohn Disease Activit Classic Features Gut Wall Thickening Inflammatory Fat Lymphadenopathy Hyperemia Mucosal Abnormalities Conglomerate Masses COMPLICATIONS Strictures Incomplete Mechanical Bowel Obstruction Localized Perforation Inflammatory Masses Fistula Formation Perianal Inflammatory Disease ACUTE ABDOMEN Acute Abdomen: Sonographic Approach Right Lower Quadrant Pain Acute Appendicitis Acute Appendicitis: Sonographic Diagnosis Right-Sided Diverticulitis Sonography of Appendiceal Perforation Crohn Appendicitis Acute Typhlitis Mesenteric Adenitis With Terminal Ileitis Right-Sided Segmental Omental Infarction Left Lower Quadrant Pain Acute Diverticulitis Sonography of Diverticulitis OTHER ABNORMALITIES Mechanical Bowel Obstruction Paralytic Ileus Gut Edema Gastrointestinal Tract Infections AIDS Patients Pseudomembranous Colitis Congenital Cysts Ischemic Bowel Disease Pneumatosis Intestinalis Mucocele of Appendix Gastrointestinal Tract Hematoma Peptic Ulcer Bezoars Intraluminal Foreign Bodies Celiac Disease Cystic Fibrosis ENDOSONOGRAPHY Upper Gastrointestinal Tract Rectum: Tumor Staging of Rectal Carcinoma Anal Canal Fecal Incontinence Perianal Inflammatory Disease Sonography of Perianal Inflammatory Disease Acknowledgment The Kidney and Urinary Tract Mitchell Tublin, Deborah Levine, Wendy EMBRYOLOGY Development of the Kidneys and Ureter Development of the Bladder Development of the Urethra ANATOMY Kidney Bladder SONOGRAPHIC TECHNIQUE Sonographic Criteria for Hypertrophied Column of Bertin Kidney Ureter Bladder and Urethra Ureter HYDRONEPHROSIS Causes of Hydronephrosis PITFALLS IN ASSESSMENT OF OBSTRUCTION CONGENITAL ANOMALIES Anomalies Related to Renal Growth Hypoplasia Fetal Lobation Compensatory Hypertrophy Anomalies Related to Ascent of Kidney Ectopia Crossed Renal Ectopia Horseshoe Kidney Anomalies Related to Ureteral Bud Renal Agenesis Supernumerary Kidney Duplex Collecting System and Ureterocele Ureteropelvic Junction Obstruction Congenital Megacalices Congenital Megaureter Anomalies Related to Vascular Development Aberrant Vessels Retrocaval Ureter Anomalies Related to Bladder Development Bladder Agenesis Bladder Duplication Bladder Exstrophy Urachal Anomalies Anomalies Related to Urethral Development: Diverticula GENITOURINARY INFECTIONS Pyelonephritis Acute Pyelonephritis Acute Pyelonephritis on Sonography Renal and Perinephric Abscess Pyonephrosis Emphysematous Pyelonephritis Emphysematous Pyelitis Chronic Pyelonephritis Papillary Necrosis Sonographic Findings of Papillary Necrosis Tuberculosis Fungal Infections Candida Albicans Parasitic Infections Schistosomiasis Echinococcal (Hydatid) Disease Acquired Immunodeficiency Syndrome Cystitis Infectious Cystitis Malacoplakia Emphysematous Cystitis Chronic Cystitis Causes of Bladder Wall Thickening FISTULAS, STONES (CALCULI), AND CALCIFICATION Bladder Fistulas Renal Calculi Entities That Mimic Renal Calculi Ureteral Calculi Bladder Calculi Nephrocalcinosis GENITOURINARY TUMORS Renal Cell Carcinoma m e n a n d w o m e n equally. 1 2 2 V o n H i p pel–Lindau (VHL) di Imaging and Treatment Approaches Sonographic Appearance Biopsy and Prognosis Pitfalls in Interpretation Transitional Cell Carcinoma Renal Tumors 9.56 ). The differential diagnosis includes b lood clots, sloughed papillae, Ureteral Tumors Bladder Tumors Squamous Cell Carcinoma Adenocarcinoma Oncocytoma Angiomyolipoma Lymphoma Kidney Sonographic Appearance of Renal Lymphoma Ureter Bladder Leukemia Ureter Bladder Metastases Kidney Urachal Adenocarcinoma Rare Neoplasms Kidney RENAL CYSTIC DISEASE Cortical Cysts Approach to Complex Renal Cyst Discovered on Sonography Parapelvic Cysts Medullary Cysts Medullary Sponge Kidney Polycystic Kidney Disease Multicystic Dysplastic Kidney Lithium Nephropathy Multilocular Cystic Nephroma Localized Cystic Disease Neoplasm-Associated Renal Cystic Disease Acquired Cystic Kidney Disease Tuberous Sclerosis Von Hippel–Lindau Disease TRAUMA Renal Injuries IV: U t e r o pelvic j unction a vulsion VASCULAR ABNORMALITIES Renal Vascular Doppler Sonography Renal Artery Occlusion and Infarction Arteriovenous Fistula and Malformation Ureteral Injuries Bladder Injuries Renal Artery Stenosis Renal Artery Aneurysm Renal Vein Thrombosis Ovarian Vein Thrombosis MEDICAL GENITOURINARY DISEASES Acute Tubular Necrosis Acute Cortical Necrosis Glomerulonephritis Acute Interstitial Nephritis Diabetes Mellitus Amyloidosis (20%-25%), t u berculosis (50%), familial Mediterranean fever Endometriosis Interstitial Cystitis NEUROGENIC BLADDER BLADDER DIVERTICULA POSTSURGICAL EVALUATION Nephrectomy Urinary Diversion CONCLUSION Acknowledgment REFERENCES The Prostate and Transrectal Ultrasound Ants Toi SUMMARY OF KEY POINTS CHAPTER OUTLINE ANATOMY Zonal Anatomy Vascular and Neural Structures SONOGRAPHIC APPEARANCE EQUIPMENT AND TECHNIQUE BENIGN CONDITIONS Normal Variants Benign Prostatic Hyperplasia Chronic Prostatitis/Chronic Pelvic Pain Syndrome Prostate Cysts Seminal Vesicles and Vas Deferens INFERTILITY AND TRANSRECTAL ULTRASOUND HEMATOSPERMIA Hematospermia PROSTATE CANCER Epidemiology Prostate Cancer: Key Facts Prostate-Specific Antigen and Variants Role of Prostate-Specific Antigen (PSA) Screening Alternate Prostate Cancer Biomarkers Clinical Staging and Histologic Grading TABLE 10.1 Staging of Prostate Cancer, 2010 Therapy Sonographic Appearance of Prostate Cancer Gray-Scale Ultrasound Transrectal Ultrasound (TRUS) Findings Suspicious for Prostate Cancer Color Flow and Power Doppler Imaging Contrast-Enhanced Ultrasound Three-Dimensional Ultrasound and Transrectal Ultrasound–Magnetic Resonan Elastography Bowel Preparation Analgesia Anticoagulation ULTRASOUND-GUIDED BIOPSY Preparation for Biopsy Antibiotic Prophylaxis Technique Side Effects and Complications Indications and Sampling Indications for Prostate Biopsy mpMRI-TRUS Fusion Biopsy Transperineal Biopsy and Template Biopsy Biopsy After Radical Prostatectomy Biopsy in Men With Absent Anus OTHER APPLICATIONS OF TRANSRECTAL ULTRASOUND AND BIOPSY IN MEN AND CONCLUSIONS REFERENCES The Adrenal Glands Christina Marie Chingkoe, Olga R. Brook, and Deborah Levine SUMMARY KEY POINTS ANATOMY AND PHYSIOLOGY SONOGRAPHIC IMAGING AND SCANNING TECHNIQUE BENIGN ADRENAL MASSES Adrenal Adenomas Adrenal Pseudomasses Sonographic Features Myelolipomas Fat-Containing Suprarenal Masses Sonographic Features Pheochromocytomas Sonographic Features Adrenal Cysts Sonographic Features Cystic Adrenal Lesions Adrenal Hemorrhage Infectious and Inflammatory Masses Causes of Adrenal Calcification MALIGNANT ADRENAL MASSES Adrenocortical Carcinomas Metastases Sonographic Features Lymphoma Sonographic Features RARE ADRENAL MASSES INTERVENTIONS Ultrasound-Guided Biopsy and Interventions Endoscopic Ultrasound MANAGEMENT OF ADRENAL LESIONS Intraoperative Ultrasound Acknowledgments REFERENCES The Retroperitoneum Raymond E. Bertino and Elton Mustafaraj ATHEROSCLEROSIS ABDOMINAL AORTIC ANEURYSM Mortality Definition Pathophysiology Natural History and Medical Therapy Screening Recent Studies Ultrasound Approach Surveillance Sonographic Technique Computed Tomography False-Positive/False-Negative Results Ultrasound Versus Computed Tomography for Evaluation of Rupture Treatment Planning Postoperative Ultrasound Assessment OTHER ENTITIES CAUSING ABDOMINAL AORTIC DILATION Inflammatory Abdominal Aortic Aneurysm Arteriomegaly and Aortic Ectasia Penetrating Ulcer Pseudoaneurysm STENOTIC DISEASE OF THE ABDOMINAL AORTA DISEASES OF ABDOMINAL AORTA BRANCHES Renal Arteries Anatomy Renal Artery Stenosis and Renovascular Hypertension Clinical Findings in Patients With Hypertension That Increase Probabi Renal Artery Duplex Doppler Sonography Renal Artery Aneurysm Mesenteric Arteries Anatomy Mesenteric Ischemia Median Arcuate Ligament Syndrome Mesenteric Artery Duplex Doppler Sonography Iliac Veins and Inferior Vena Cava Anatomy Anatomic Variants Thrombosis Nutcracker Syndrome Pelvic Congestion Syndrome Inferior Vena Cava Neoplasms Other Inferior Vena Cava Findings NONVASCULAR DISEASES OF THE RETROPERITONEUM Solid Masses Retroperitoneal Fibrosis CONCLUSION Dynamic Ultrasound of Hernias of the Groin and Anterior Abdominal Deborah Levine, Lisa Napolitano, and A. Thomas Stavros CHAPTER OUTLINE TECHNICAL REQUIREMENTS THE REPORT FOR DYNAMIC ULTRASOUND OF GROIN HERNIAS HERNIA CONTENTS DYNAMIC MANEUVERS KEY SONOGRAPHIC LANDMARKS INGUINAL AND INGUINAL REGION HERNIAS TABLE 13.1 Types of Inguinal Hernias Indirect Inguinal Hernias Direct Inguinal Hernias Femoral Hernias Spigelian Hernias Sports Hernias ABDOMINAL WALL OR VENTRAL HERNIAS Linea Alba Hernias Umbilical Hernias Paraumbilical or Periumbilical Hernias Incisional Hernias Multiple Hernias ADDITIONAL ISSUES REGARDING HERNIAS Recurrent Groin Hernias Hernia Complications Entities That Simulate Groin Hernias TABLE 13.2 Findings of Hernia Strangulation Entities That Simulate Anterior Abdominal Wall Hernias SUMMARY REFERENCES The Peritoneum Anthony E. Hanbidge, Korosh Khalili, and Stephanie R. Wilson CHAPTER OUTLINE PERITONEUM, OMENTUM, AND MESENTERY SONOGRAPHIC TECHNIQUE ASCITES PERITONEAL INCLUSION CYSTS (BENIGN ENCYSTED FLUID) MESENTERIC CYSTS PERITONEAL TUMORS Peritoneal Carcinomatosis Primary Tumors of Peritoneum O O Pseudomyxoma Peritonei INFLAMMATORY DISEASE OF PERITONEUM Abscess Tuberculous Peritonitis Sclerosing Peritonitis RIGHT-SIDED SEGMENTAL OMENTAL INFARCTION ENDOMETRIOSIS LOCALIZED INFLAMMATORY PROCESS OF PERITONEAL CAVITY LEIOMYOMATOSIS PERITONEALIS DISSEMINATA PNEUMOPERITONEUM CONCLUSION REFERENCES The Uterus Douglas Brown and Deborah Levine INTRODUCTION AND SCANNING TECHNIQUES Advantages of Transvaginal Sonography NORMAL UTERINE FINDINGS W h en o b taining a n e ndometrial thickness measurement, MÜLLERIAN DUCT ANOMALIES ABNORMALITIES OF THE MYOMETRIUM Leiomyoma Causes of Uterine Enlargement Leiomyomas: Sonographic Features Leiomyosarcoma Adenomyosis Adenomyosis: Sonographic Features ABNORMALITIES OF THE CERVIX Causes of Endometrial Thickening ABNORMALITIES OF THE ENDOMETRIUM Causes of Metrorrhagia Postmenopausal Endometrium Hormone Use Effects of Hormones on the Postmenopausal Endometrium Postmenopausal Bleeding The Obstructed Uterus: Hydrometrocolpos and Hematometrocolpos Causes of Endometrial Fluid Endometrial Hyperplasia Endometrial Polyps Endometrial Carcinoma Endometrial Sarcoma Endometrial Adhesions Endometrial Ablation SONOGRAPHY OF CONTRACEPTIVE DEVICES Intrauterine Contraceptive Devices Tubal Occlusion Devices Bleeding Postpartum Retained Products of Conception POSTPARTUM FINDINGS Normal Findings Endometritis Arteriovenous Malformation Findings After Cesarean Section Acknowledgment REFERENCES The Adnexa Rochelle Filker Andreotti and Lori A. Deitte CHAPTER OUTLINE NORMAL ANATOMY Technique Normal Sonographic Appearance of the Ovary and Fallopian Tube Changes During the Menstrual Cycle Postmenopausal Cysts Postmenopausal Ovary NONNEOPLASTIC LESIONS Functional Cysts Ovarian Remnant Syndrome Pregnancy-Associated Ovarian Lesions Surface Epithelial Inclusion Cysts Paraovarian and Paratubal Cysts Peritoneal Inclusion Cysts Polycystic Ovarian Syndrome Endometriosis Adnexal Torsion NEOPLASMS Ovarian Cancer ( 1 5 % - 2 0 % ) , s e x c o r d – s t r o m a l t u m o r s ( 5 % - TABLE 16.1 Ovarian Neoplasms Surface Epithelial–Stromal Tumors Serous Cystadenoma and Cystadenocarcinoma Endometrioid Tumor Clear Cell Tumor Transitional Cell Tumor Mucinous Cystadenoma and Cystadenocarcinoma Borderline (Low Malignant Potential) Tumors n e o p l a s m s , w i t h 9 5 % b e i n g b e n i g n cystic terat Th e o thers, including dysgerminomas a n d e ndodermal s inus Cystic Teratoma Cystic Teratomas: Sonographic Features Germ Cell Tumors Dysgerminoma Yolk Sac Tumor Sex Cord–Stromal Tumors Granulosa Cell Tumor Sertoli-Leydig Cell Tumor Th i s r a r e t u m o r , a l s o c a l l e d a n d r o b l a s t o Thecoma and Fibroma Metastatic Tumors FALLOPIAN TUBE Pelvic Inflammatory Disease TABLE 16.2 Sonographic Findings of Pelvic Inflammatory Disease Tubal Torsion Fallopian Tube Carcinoma VASCULAR ABNORMALITIES IN THE ADNEXA Ovarian Vein Thrombosis or Thrombophlebitis Pelvic Congestion Syndrome SONOGRAPHIC EVALUATION OF AN ADNEXAL MASS IN ADULT WOMEN TABLE 16.3 Society of Radiologists in Ultrasound Recommendations fo TABLE 16.4 Ten Simple Rules for Identifying a Benign or Malignant Postoperative Pelvic Masses NONGYNECOLOGIC ADNEXAL MASSES Gastrointestinal Tract Masses Urinary Tract Masses REFERENCES Ultrasound-Guided Biopsy of Chest, Abdomen, and Pelvis Theodora A. Potretzke, Thomas D. Atwell, J. William Charboneau, and CHAPTER OUTLINE PERCUTANEOUS NEEDLE BIOPSY Indications and Contraindications Periprocedural Antithrombotic Management Imaging Methods Ultrasound Computed Tomography Needle Selection Biopsy Procedure Needle Visualization Specific Anatomic Applications Liver Pancreas Kidney Adrenal Gland Spleen Lung Complications O t h e r m a j o r c o m p l i c a t i o n s s e c o n d a ry to biopsy ULTRASOUND-GUIDED DRAINAGE Indications and Contraindications Imaging Methods Catheter Selection Patient Preparation Diagnostic Aspiration Catheter Placement Drainage Procedure Follow-Up Care Catheter Removal Abdominal and Pelvic Abscesses: General Specific Anatomic Applications Liver Biliary Tract Bile Ducts. P ercutaneous t ranshepatic cholangiography Pancreas Spleen PERCUTANEOUS CYST MANAGEMENT Renal Cyst Kidney Liver Cyst Ovarian Cyst REFERENCES Organ Transplantation Derek Muradali and Tanya Punita Chawla CHAPTER OUTLINE Surgical Technique LIVER TRANSPLANTATION Normal Liver Transplant Ultrasound Biliary Complications Biliary Strictures Bile Leaks Recurrent Sclerosing Cholangitis Biliary Sludge and Stones Dysfunction of the Sphincter of Oddi Arterial Complications Hepatic Artery Stenosis Hepatic Artery Thrombosis Elevated Hepatic Arterial Resistive Index Hepatic Artery Pseudoaneurysms Celiac Artery Stenosis Portal Vein Complications Inferior Vena Cava Complications Hepatic Vein Stenosis Extrahepatic Fluid Collections Adrenal Hemorrhage Intrahepatic Fluid Collections Abscess Versus Infarct Intrahepatic Solid Masses Surgical Technique RENAL TRANSPLANTATION Normal Renal Transplant Ultrasound Gray-Scale Assessment Doppler Assessment Abnormal Renal Transplant Parenchymal Pathology Chronic Rejection Infection Prerenal Vascular Complications Arterial Thrombosis Renal Artery Stenosis Doppler Criteria for Renal Artery Stenosis Venous Thrombosis Renal Vein Stenosis Postrenal Collecting System Obstruction Arteriovenous Malformations and Pseudoaneurysms Fluid Collections PANCREAS TRANSPLANTATION Surgical Technique Venous Drainage Arterial Supply TABLE 18.1 Surgical Techniques for Pancreatic Transplantation Normal Pancreas Transplant Ultrasound Role of Contrast-Enhanced Ultrasound Abnormal Pancreas Transplant Arteriovenous Fistula and Pseudoaneurysms Rejection Pancreatitis Fluid Collections Duodenal leaks in systemic v e nous-bladder drainage Miscellaneous Complications POST TRANSPLANT LYMPHOPROLIFERATIVE DISORDER Treatment Options REFERENCES PART THREE: Small Parts, Carotid Artery, and Peripheral Vessel Sonography The Thyroid Gland Luigi Solbiati, J. William Charboneau, Vito Cantisani, Carl Reading, CHAPTER OUTLINE INSTRUMENTATION AND TECHNIQUE ANATOMY CONGENITAL THYROID ABNORMALITIES NODULAR THYROID DISEASE Nodular Thyroid Disease: Sonographic Evaluation Pathologic Features and Sonographic Correlates Hyperplasia and Goiter Adenoma Carcinoma Follicular Thyroid Carcinoma: Sonographic Features Anaplastic Thyroid Carcinoma: Sonographic Features Lymphoma Thyroid Metastases Fine-Needle Aspiration Biopsy TABLE 19.1 Diagnostic Yield of Thyroid Fine-Needle Aspiration (FNA) Sonographic Applications Detection of Thyroid Masses TABLE 19.2 Reliability of Sonographic Features in Differentiation o Differentiation of Benign and Malignant Nodules Thyroid Imaging Reporting and Data System Contrast-Enhanced Ultrasound and Elastography Guidance for Needle Biopsy The Incidentally Detected Nodule 1. Th e epidemic of thyroid nodules has resulted mostly from ultrasound 2. The incidence o f thyroid cancer is increasing. Evaluation of Nodules Incidentally Detected by Sonography DIFFUSE THYROID DISEASE 4. W h i c h i n c i d e n t a lly discovered nodules should be pursued? Diffuse Thyroid Diseases S u b a c u t e g r a n u l o m a t o u s t h y r o i d i t i s o r D Acknowledgment The Parathyroid Glands Bonnie J. Huppert and Carl Reading EMBRYOLOGY AND ANATOMY PRIMARY HYPERPARATHYROIDISM Prevalence Diagnosis Pathology Treatment Causes of Primary Hyperparathyroidism Vascularity Size Multiple Gland Disease Carcinoma SONOGRAPHIC APPEARANCE Shape Echogenicity and Internal Architecture ADENOMA LOCALIZATION Sonographic Examination and Typical Locations Ectopic Locations Retrotracheal/Retroesophageal Adenoma Mediastinal Adenoma Intrathyroid Adenoma Carotid Sheath/Undescended Adenoma PERSISTENT OR RECURRENT HYPERPARATHYROIDISM S E C O N D A R Y H Y P E R P A R A T H Y R O I D I S M PITFALLS IN INTERPRETATION False-Positive Examination Parathyroid Adenoma: Causes of Examination Errors False-Negative Examination ACCURACY IN IMAGING Ultrasound Other Modalities Importance of Imaging in Primary Hyperparathyroidism INTRAOPERATIVE SONOGRAPHY PERCUTANEOUS BIOPSY ETHANOL ABLATION REFERENCES The Breast Jordana Phillips, Rashmi J. Mehta, and A. Thomas Stavros CHAPTER OUTLINE APPLICATIONS OF BREAST ULTRASOUND BREAST ANATOMY AND PHYSIOLOGY SONOGRAPHIC EQUIPMENT SONOGRAPHIC TECHNIQUE Patient Position Annotation Documentation of Lesions Split-Screen Imaging Special Breast Techniques Doppler Sonography Elastography Three-Dimensional Ultrasound Contrast-Enhanced Ultrasound TABLE 21.1 Breast Imaging Reporting and Data System (BI-RADS) Categ REPORTING Normal Tissues and Variations Cysts and Cystic Masses Simple Cysts SONOGRAPHIC FINDINGS Complicated Cysts Complex Cystic and Solid Masses Solid Masses TABLE 21.2 Comparison of Morphologic and Histopathologic Features o Suspicious Findings Indistinct Margins Spiculation or Thick Echogenic Rim Angular Margins Microlobulations Not Parallel (Not Taller-Than-Wide) Orientation Duct Extension Acoustic Shadowing Hypoechogenicity Calcifications Associated Features Benign Findings Hyperechoic Tissue Parallel (Wider-Than-Tall) Orientation Thin Echogenic Capsule DIAGNOSTIC ULTRASOUND INDICATIONS Symptomatic Breast Breast Pain Palpable Abnormality Nipple Discharge Mammographic Findings Size Correlation Shape Correlation Location or Position Correlation Surrounding Tissue Density Correlation Sonographic-Mammographic Confirmation NICHE APPLICATIONS FOR BREAST ULTRASOUND Infection Implants Breast Cancer Staging Sonographic–Magnetic Resonance Imaging Correlation ULTRASOUND-GUIDED INTERVENTION REFERENCES The Scrotum Daniel Sommers and Thomas Winter CHAPTER OUTLINE SONOGRAPHIC TECHNIQUE Scrotal Sonography: Current Uses NORMAL ANATOMY Pathologic Classification of Testicular Tumors 32 INTRATESTICULAR SCROTAL MASSES Malignant Tumors Germ Cell Tumors Non–Germ Cell Tumors Testicular Metastases Lymphoma and Leukemia Testicular Metastases Extramedullary Myeloma Metastatic Disease Benign Intratesticular Lesions Cysts Testicular Cystic Lesions Tubular Ectasia of Rete Testis Cystic Dysplasia Epidermoid Cysts Abscess I n patients with acquired immunodeficiency syndrome Segmental Infarction Adrenal Rests Splenogonadal Fusion Calcifications Scrotal Calcifications EXTRATESTICULAR PATHOLOGIC LESIONS Tunica Vaginalis Hydrocele, Hematocele, and Pyocele Paratesticular Masses Extratesticular Tumors/Masses Hernia Calculi Varicocele Fibrous Pseudotumor Polyorchidism Epididymal Lesions Cystic Lesions Tumors Sperm Granuloma Postvasectomy Changes in the Epididymis Chronic Epididymitis Sarcoidosis ACUTE SCROTAL PAIN Causes of Acute Scrotal Pain Torsion Epididymitis and Epididymo-orchitis Fournier Gangrene F o urnier gangrene i s a necrotizing fasciitis o f the perineum, TRAUMA CRYPTORCHIDISM REFERENCES Overview of Musculoskeletal Ultrasound Techniques and Applications Colm McMahon and Corrie Yablon CHAPTER OUTLINE GENERAL CONSIDERATIONS Doppler Imaging Elastography Extended Field of View Imaging MUSCLES TENDONS Sonographic Signs of Tendon Tears LIGAMENTS NERVES JOINT ASSESSMENT SOFT TISSUE MASSES TABLE 23.1 Fat-Containing Soft Tissue Lesions FOREIGN BODIES SOFT TISSUE INFECTION REFERENCES CONCLUSION The Shoulder Colm McMahon and Corrie Yablon CHAPTER OUTLINE CLINICAL PERSPECTIVE SHOULDER ANATOMY a n d also the coracoclavicular ligaments, which h e l p s tabilize SCAN TECHNIQUE TABLE 24.1 Routine Shoulder Ultrasound Protocol Biceps Tendon Evaluation Subscapularis Tendon Evaluation Supraspinatus Evaluation Infraspinatus, Teres Minor, and Posterior Shoulder Evaluation Rotator Cuff Musculature Evaluation ROTATOR CUFF DEGENERATION AND TEARS Background Tendinosis Full-Thickness Rotator Cuff Tears Partial-Thickness Rotator Cuff Tears Postsurgical Rotator Cuff Muscle Atrophy Subacromial-Subdeltoid Bursa Calcific Tendinitis LONG HEAD BICEPS TENDON PATHOLOGY ARTHROPATHY Degenerative Inflammatory Th e s h o ulder can be involved in inflammatory a rthropathies, i n c PITFALLS IN SHOULDER ULTRASOUND CONCLUSION REFERENCES Musculoskeletal Interventions Ronald S. Adler TECHNICAL CONSIDERATIONS INJECTION TECHNIQUE INJECTION MATERIALS INJECTION OF JOINTS (MTP) o r metacarpophalangeal (MCP) a n d interphalangeal SUPERFICIAL PERITENDINOUS AND PERIARTICULAR INJECTIONS Foot and Ankle Hand and Wrist INJECTION OF DEEP TENDONS F r equently r equested deep t endon injections include those f o r t Biceps Tendon Iliopsoas Tendon Abductor and Hamstring Tendons BURSAL, GANGLION CYST, AND PARALABRAL INJECTIONS Calcific Tendinitis INTRATENDINOUS INJECTIONS: PERCUTANEOUS TENOTOMY PERINEURAL INJECTIONS CONCLUSION REFERENCES The Extracranial Cerebral Vessels Edward I. Bluth, Stephen I. Johnson, and Laurie Troxclair CHAPTER OUTLINE INTRODUCTION: INDICATIONS FOR CAROTID ULTRASOUND EXAMINATION Indications for Carotid Ultrasound CAROTID ARTERY ANATOMY CAROTID ULTRASOUND EXAMINATION CAROTID ULTRASOUND INTERPRETATION Visual Inspection of Gray-Scale Images Vessel Wall Thickness and Intima-Media Thickening Plaque Characterization Ultrasound Plaque Classification System Ultrasound Types of Plaque Morphology Plaque Ulceration Ultrasound Features Suggestive of Plaque Ulceration Gray-Scale Evaluation of Stenosis Doppler Spectral Analysis Standard Examination Pitfalls in Interpretation Spectral Broadening High-Velocity Blood Flow Patterns TABLE 26.1 Diagnostic Criteria for Carotid Ultrasound Examinations TABLE 26.2 Alternative Diagnostic Criteria for Estimating Carotid A Color Doppler Ultrasound Optimal Settings for Low-Flow Vessel Evaluation Optimization of Color Doppler Low-Flow Vessel Evaluation Advantages and Pitfalls Color Doppler Evolution of Carotid Stenosis Power Doppler Ultrasound Power Doppler Evaluation of Carotid Stenosis Pitfalls and Adjustments Causes of Image/Doppler Mismatch Internal Carotid Artery Occlusion Internal Carotid Artery Occlusion Follow-Up of Stenosis Preoperative Strategies for Patients With Carotid Artery Disease Postoperative Ultrasound Carotid Artery Stents and Revascularization TABLE 26.3 Recommendations for Follow-Up Based on Ultrasound Assess Grading Carotid Intrastent Restenosis NONATHEROSCLEROTIC CAROTID DISEASE TABLE 26.4 Carotid Artery Stenosis Grading After Stent Internal Carotid Artery Dissection: Spectrum of Findings Pulsatile Neck Masses in the Carotid Region TRANSCRANIAL DOPPLER SONOGRAPHY VERTEBRAL ARTERY Anatomy Sonographic Technique and Normal Examination Subclavian Steal Abnormal Vertebral Artery Waveforms Stenosis and Occlusion Thrombosis INTERNAL JUGULAR VEINS Sonographic Technique Acknowledgment REFERENCES Peripheral Vessels Mark E. Lockhart, Heidi R. Umphrey, Therese M. Weber, and Michelle Sonographic Examination Technique Stenosis Evaluation PERIPHERAL ARTERIES Ultrasound Examination and Imaging Protocol Lower Extremity Arteries Normal Anatomy Peripheral Arterial Occlusion Peripheral Arterial Stenosis Aneurysm Pseudoaneurysm Arteriovenous Fistula Lower Extremity Vein Bypass Grafts Upper Extremity Arteries Normal Anatomy Ultrasound Examination and Imaging Protocol Arterial Occlusion, Aneurysm, and Pseudoaneurysm Arterial Stenosis Subclavian Stenosis Thoracic Outlet Syndrome Radial Artery Evaluation for Coronary Bypass Graft PERIPHERAL VEINS Sonographic Examination Technique Lower Extremity Veins Normal Anatomy Ultrasound Examination and Imaging Protocol Acute Deep Venous Thrombosis Residual (Chronic) Deep Venous Thrombosis Potential Pitfalls Complete Venous Doppler Versus More Limited Examinations Recommendations for Deep Venous Thrombosis Follow-Up Venous Insufficiency Venous Mapping Upper Extremity Veins Normal Anatomy Ultrasound Examination and Imaging Protocol Upper Extremity Acute Deep Venous Thrombosis Differentiation of Acute From Residual or Chronic Venous Thrombosis Potential Pitfalls Sonographic Examination Technique Vascular Mapping Before Hemodialysis Access Upper Extremity HEMODIALYSIS Arteriovenous Fistula and Graft Ultrasound Examination and Imaging Protocol Arteriovenous Fistula Graft Palpable Focal Masses Near Arteriovenous Fistula and Graft Arteriovenous Fistula Maturation Evaluation Arteriovenous Fistula and Graft Stenosis Arterial Steal Arm and Leg Swelling With Arteriovenous Fistula or Graft Arteriovenous Fistula and Graft Occlusion CONCLUSION REFERENCES Overview of Obstetric Imaging Deborah Levine TRAINING, PERSONNEL, AND EQUIPMENT Indications for First-Trimester Ultrasound Indications for Second- and Third-Trimester Ultrasound ULTRASOUND GUIDELINES First Trimester General Survey Guidelines for First-Trimester Ultrasound Second and Third Trimesters Survey Guidelines for Second- and Third-Trimester Ultrasound ROUTINE ULTRASOUND SCREENING Estimation of Gestational Age Indications for Detailed Fetal Anatomic Survey Identification of Twin/Multiple Pregnancies Screening and Perinatal Outcomes Benefits of Routine Second-Trimester Ultrasound Screening Three-Dimensional Ultrasound Prudent Use of Ultrasound Fetal Malformations: Diagnostic Accuracy MAGNETIC RESONANCE IMAGING CONCLUSION REFERENCES Bioeffects and Safety of Ultrasound in Obstetrics Jacques S. Abramowicz Scanning Mode System Setup INSTRUMENT OUTPUTS Dwell Time THERMAL EFFECTS Gestational age is critical when considering heat dispersion. BIOEFFECTS OF ULTRASOUND Animal Research MECHANICAL EFFECTS Human Studies Birth Weight Delayed Speech Dyslexia Nonright-Handedness Neurologic Development and Behavioral Issues IS DOPPLER DIFFERENT? Congenital Malformations Childhood Malignancies SAFETY GUIDELINES CONCLUSION TABLE 29.1 Duration of Obstetric Ultrasound as a Function of The REFERENCES The First Trimester Elizabeth Lazarus and Deborah Levine CHAPTER OUTLINE MATERNAL PHYSIOLOGY AND EMBRYOLOGY SONOGRAPHIC APPEARANCE OF NORMAL INTRAUTERINE PREGNANCY Gestational Sac β -hCG and Early Pregnancy Ultrasound Barriers to Use of Strict β -hCG Thresholds in Determination of Pre Embryo and Amnion Yolk Sac Embryonic Cardiac Activity Umbilical Cord and Cord Cyst ESTIMATION OF GESTATIONAL AGE Gestational Sac Size Crown-Rump Length EARLY PREGNANCY FAILURE TABLE 30.1 Rate of Spontaneous Abortion in Early Pregnancy Diagnostic Findings of Early Pregnancy Failure Diagnostic Findings of Early Pregnancy Failure Gestational Sac Mean Sac Diameter 25 mm or Greater and No Embryo Crown-Rump Length 7 mm or Greater and No Heartbeat Worrisome Findings of Early Pregnancy Failure Embryos With Crown-Rump Length Less Than 7 mm and No Heartbeat Gestational Sac With Mean Sac Diameter 16 to 24 mm and No Embryo TABLE 30.2 Worrisome Findings for Early Pregnancy Failure Gestational Sac Appearance Small Mean Sac Diameter in Relationship to Crown-Rump Length Abnormally Large Amnion With Respect to Embryo Size Yolk Sac Size and Shape Embryonic Bradycardia ECTOPIC PREGNANCY Clinical Presentation Sonographic Diagnosis Risk of Ectopic Pregnancy Heterotopic Gestation Serum β -hCG Levels Specific Sonographic Findings Nonspecific Sonographic Findings Adnexal Mass Free Fluid Endometrium Implantation Sites Pregnancy of Unknown Location Management EVALUATION OF THE EMBRYO Normal Embryologic Findings Mimicking Pathology Rhombencephalon Physiologic Anterior Abdominal Wall Herniation Abnormal Embryos GESTATIONAL TROPHOBLASTIC DISEASE Hydatidiform Molar Pregnancy Complete Molar Pregnancy Partial Molar Pregnancy Coexistent Hydatidiform Mole and Normal Fetus Persistent Trophoblastic Neoplasia Invasive Mole Choriocarcinoma Placental-Site Trophoblastic Tumor Sonographic Features of Persistent Trophoblastic Neoplasia Diagnosis and Treatment CONCLUSION REFERENCES Chromosomal Abnormalities Bryann Bromley and Beryl Benacerraf CHAPTER OUTLINE FIRST-TRIMESTER SCREENING FOR ANEUPLOIDY Nuchal Translucency and Trisomy 21 Serum Biochemical Markers Combined First-Trimester Screening Integrated and Sequential Screening Standardization of Nuchal Translucency Measurement Technique Fetal Nuchal Translucency (NT) Measurement Technique Criteria for an Accurate Crown-Rump Length Nuchal Translucency and Other Aneuploidies Cystic Hygroma Nasal Bone Criteria for Nasal Bone (NB) Evaluation IVC Other Markers for Aneuploidy Reversed Flow in Ductus Venosus Tricuspid Regurgitation Thickened Nuchal Translucency With Normal Karyotype SECOND-TRIMESTER SCREENING FOR TRISOMY 21 Nuchal Fold TABLE 31.1 Likelihood Ratios (LRs) of Isolated Markers for Trisomy TABLE 31.2 Trisomy 21: Likelihood Ratios (LRs) of Cluster of Mark Trisomy 21: Common Second-Trimester Sonographic Markers Facial Profile (Nasal Bone) TABLE 31.3 Pooled Estimates of Detection Rates (DRs), False-Positiv Femur Length Humerus Length Urinary Tract Dilation Echogenic Bowel Echogenic Intracardiac Focus Structural Anomalies Adjunct Features of Trisomy 21 Combined Markers Trisomy 21: Revised Risk Ratio Calculations TRISOMY 18 (EDWARDS SYNDROME) Trisomy 18: Common Sonographic Findings Choroid Plexus Cysts Trisomy 13: Common Sonographic Findings TRIPLOIDY Triploidy: Common Sonographic Findings TRISOMY 13 (PATAU SYNDROME) MONOSOMY X (TURNER SYNDROME) PRENATAL SCREENING FOR ANEUPLOIDY WITH CELL-FREE DNA DIAGNOSTIC TESTING CONCLUSION REFERENCES Multifetal Pregnancy Mary C. Frates ZYGOSITY/CHORIONICITY DETERMINATION OF CHORIONICITY TABLE 32.1 Sonographic Findings Used to Assign Chorionicity and Am GENERAL ISSUES LOSS OF A TWIN COMPLICATIONS OF MONOCHORIONICITY Twin-Twin Transfusion Syndrome TABLE 32.2 Complications of Twin-Twin Transfusion Syndrome TABLE 32.3 Quintero Staging of Twin- Twin Transfusion Syndrome Twin Anemia Polycythemia Sequence Twin Reversed Arterial Perfusion Sequence MONOAMNIOTIC TWINS CONJOINED TWINS REFERENCES The Fetal Face and Neck Ana P. Lourenco and Judy A. Estroff SUMMARY KEY POINTS CHAPTER OUTLINE EMBRYOLOGY AND DEVELOPMENT Face Neck SONOGRAPHY OF THE NORMAL FETAL FACE ABNORMALITIES OF THE HEAD Abnormal Size Abnormal Shape Craniosynostosis Classification of Skull Deformities Based on Sutures Involved Wormian Bones Differential Diagnosis of Wormian Bones Differential Diagnosis of Frontal Bossing Forehead Abnormalities Encephaloceles Conditions Associated With Hypotelorism ORBIT ABNORMALITIES Hypotelorism Hypertelorism Microphthalmia and Anophthalmia Conditions Associated With Hypertelorism TABLE 33.1 Normal Orbital Diameters in the Fetus Coloboma Dacryocystocele Congenital Cataracts Associations With Microphthalmos Differential Diagnosis of Congenital Cataracts EAR ABNORMALITIES MIDFACE ABNORMALITIES Hypoplasia Absent Nasal Bone Differential Diagnosis of Cleft Lip and Palate Other Nasal Abnormalities Cleft Lip and Palate Associated Signs of Cleft Palate With Cleft Lip Bilateral Cleft Lip or Palate Median Cleft Lip or Palate Unusual Facial (Tessier) Clefts Unilateral Cleft Lip or Palate LOWER FACE ABNORMALITIES Macroglossia and Oral Masses Conditions Associated With Macroglossia Isolated Cleft of Secondary Palate Micrognathia and Retrognathia NECK ABNORMALITIES Nuchal Translucency and Thickening SOFT TISSUE TUMORS Lymphatic Malformation (Cystic Hygroma) Cervical Teratoma Thyromegaly and Goiter CONCLUSION Acknowledgments The Fetal Brain Ants Toi and Deborah Levine DEVELOPMENTAL ANATOMY Embryology TABLE 34.1 Differentiation of Brain Regions From Primary Vesicles Sonographic Anatomy Cranial Structures to Note at Routine Anatomic Scan o b literation s uggests Chiari II malformation a n d s p ina b ifida. a n d a rachnoid cysts. 45-47 Variants (Usually Normal) Choroid Plexus Cysts Blake Pouch Cyst Cavum Veli Interpositi VENTRICULOMEGALY AND HYDROCEPHALUS Pathogenesis of Ventriculomegaly Examples of Conditions Associated With Ventriculomegaly Ultrasound Evaluation of Ventriculomegaly SPECIFIC ABNORMALITIES ERRORS OF DORSAL INDUCTION Anencephaly and Exencephaly Cephalocele and Encephalocele TABLE 34.2 Features of Some Autosomal Recessive Syndromes Associate s yndrome, orofaciodigital syndrome, Bardet-Biedl syndrome, a u t o somal re Joubert Syndrome Meckel-Gruber Syndrome Amniotic Band Sequence/Limb–Body Wall Complex Ciliopathies Cranial Changes in Spina Bifida TABLE 34.3 Second-Trimester Cranial Signs Associated With Open Spina TABLE 34.4 First-Trimester Signs of Open Spina Bifida ERRORS OF VENTRAL INDUCTION Holoprosencephaly General Anatomic Classification of Holoprosencephaly 151,153 Factors Associated With Holoprosencephaly 149-151,153 Facial Changes Associated With Holoprosencephaly 155 Posterior Fossa and Cerebellum Dandy-Walker Malformation Vermis Hypoplasia or Dysplasia Mega–Cisterna Magna Rhombencephalosynapsis Other Posterior Fossa Abnormalities Arachnoid Cysts Malformations of Cortical Development Classification of Malformations of Cortical Development Microcephaly Hemimegalencephaly Other Malformations of Cortical Development Tuberous Sclerosis Absence of Septi Pellucidi and Septo-Optic Dysplasia Ultrasound Findings of Agenesis or Dysgenesis of Corpus Callosum INTRACRANIAL CALCIFICATIONS INFECTIONS VASCULAR MALFORMATIONS A variety o f vascular m alformations a r e described p r enatal Thrombosis of Dural Sinuses Hemorrhagic Lesions Hydranencephaly TUMORS Acknowledgments REFERENCES CONCLUSION The Fetal Spine Elizabeth Asch and Eric Sauerbrei DEVELOPMENTAL ANATOMY Embryology of the Spine TABLE 35.1 Spine Embryology During Third and Fourth Weeks After Co Ossification of the Fetal Spine Normal Position of the Spinal Cord TABLE 35.2 Timing and Pattern of Fetal Spine Ossification (10-22 We SCANNING TECHNIQUES Three-Dimensional Ultrasound Protocol to Evaluate Spina Bifida With Three- Dimensional Volume Data SPINA BIFIDA Folic Acid Fortification TABLE 35.3 Definition of Terms for Spinal Abnormalities Risk Factors for Neural Tube Defect (NTD) Pathogenesis and Pathology Alpha-Fetoprotein and Ultrasound Screening Causes of Elevated Maternal Serum Alpha-Fetoprotein Sonographic Findings in the Spine Associated Cranial Abnormalities Anatomic Landmarks Used to Establish Level of Bony Defect Associated Noncranial Abnormalities Sonographic Signs of Spina Bifida Fetal Surgery for Myelomeningocele Prognosis MYELOCYSTOCELE DIASTEMATOMYELIA SCOLIOSIS AND KYPHOSIS Causes of Scoliosis or Kyphosis SACRAL AGENESIS CAUDAL REGRESSION SACROCOCCYGEAL TERATOMA SIRENOMELIA Types of Sacrococcygeal Teratomas REFERENCES PRESACRAL FETAL MASS Presacral Masses The Fetal Chest Dorothy Bulas CHAPTER OUTLINE DEVELOPMENT OF STRUCTURES IN THE CHEST Pulmonary Development Normal Sonographic Features of the Fetal Chest Stages of Human Lung Development PULMONARY HYPOPLASIA, APLASIA, AND AGENESIS Normal Diaphragm Normal Thymus CONGENITAL PULMONARY AIRWAY MALFORMATION SPECTRUM Congenital Pulmonary Airway Malformation TABLE 36.1 Causes of Pulmonary Hypoplasia TABLE 36.2 Normal Thoracic Circumference Correlated With Gestational TABLE 36.3 Differential Diagnosis of Echogenic Lesion in Fetal Thor Bronchopulmonary Sequestration Congenital Lobar Overinflation PLEUROPULMONARY BLASTOMA P l e u r o p u l m o n a ry blastoma i s a r a r e p r i m a ry neopl CONGENITAL HIGH AIRWAY OBSTRUCTION BRONCHOGENIC CYST TABLE 36.4 Differential Diagnosis of Fetal Thoracic Cystic Lesio NEURENTERIC CYST PLEURAL EFFUSION Secondary p leural e ffusion occurs in a s sociation with a n e CONGENITAL DIAPHRAGMATIC HERNIA PERICARDIAL EFFUSION PULMONARY LYMPHANGIECTASIA Poor Prognostic Factors in Congenital Diaphragmatic Hernia Predictors of Decreased Survival in Congenital Diaphragmatic Hernia Other Hernias and Eventration Associated Anomalies TABLE 36.5 Sample Studies of Predictors of Survival in Left-Sided Morbidity and Mortality In Utero Therapy CONCLUSION REFERENCES The Fetal Heart Elizabeth R. Stamm and Julia A. Drose TABLE 37.1 Congenital Heart Disease and Associated Risk Factors TABLE 37.1 Congenital Heart Disease and Associated Risk Factors—cont TABLE 37.2 Recurrence Risks in Siblings for Any Congenital Hear TABLE 37.3 Suggested Offspring Recurrence Risk (%) for Congenital NORMAL FETAL CARDIAC ANATOMY AND SCANNING TECHNIQUES Common Indications for Fetal Echocardiography STRUCTURAL ANOMALIES Atrial Septal Defect Ventricular Septal Defect Atrioventricular Septal Defect Ebstein Anomaly A rrhythmias, particularly s u p raventricular tachycardias Hypoplastic Right Ventricle Hypoplastic Left Heart Syndrome Univentricular Heart Truncus Arteriosus Double-Outlet Right Ventricle Tetralogy of Fallot Transposition of Great Arteries Anomalous Pulmonary Venous Return Coarctation of Aorta Aortic Stenosis Pulmonic Stenosis Cardiosplenic Syndromes Asplenia and Polysplenia: Associated Findings Cardiac Tumors Cardiomyopathy A n i n c r eased incidence of a s ymmetrical septal hypertrophy Ectopia Cordis ARRHYTHMIAS Premature Atrial and Ventricular Contractions Tachycardia Bradycardia Congenital Heart Block The Fetal Gastrointestinal Tract and Abdominal Wall Nir Melamed, Anne Kennedy, and Phyllis Glanc THE GASTROINTESTINAL TRACT Embryology of the Digestive Tube Esophagus Esophageal Atresia TABLE 38.1 Types of Esophageal Atresia Stomach Small or Absent Fetal Stomach Absent Stomach Dilated Fetal Stomach Midline or Right-Sided Stomach Intraluminal Gastric Masses Small Bowel and Colon Bowel Obstruction Meconium Ileus Anorectal Malformations Enteric Duplication Cysts TABLE 38.2 Meconium Peritonitis Findings and Likelihood of Need f Meconium Peritonitis and Pseudocyst 3 8 . 7 ) , echogenic bowel, dilated bowel, a n d p o l y h y d r a m n Echogenic Bowel Conditions Associated With Echogenic Bowel Liver Hepatomegaly Hepatic Calcifications Conditions Associated With Hepatic Calcifications Hepatic Cysts and Masses Gallbladder and Biliary System Nonvisualization of the Gallbladder Fetal Gallstones Choledochal Cyst Pancreas Pancreatic Cysts Spleen Splenomegaly Splenic Cysts Gastroschisis Epidemiology ABDOMINAL WALL Embryology Pathogenesis Prenatal Diagnosis Associated Conditions Management Omphalocele Epidemiology Prenatal Diagnosis Associated Conditions Management Bladder Exstrophy Cloacal Exstrophy Ectopia Cordis Other Complex Body Wall Defects Pentalogy of Cantrell Body Stalk Anomaly Amniotic Band Syndrome REFERENCES The Fetal Urogenital Tract Katherine W. Fong, Julia Eva Kfouri, and Kirsten L. Weind Matthews CHAPTER OUTLINE THE NORMAL URINARY TRACT Embryology Sonographic Appearance Amniotic Fluid Volume TABLE 39.1 Renal Lengths at 14-42 Weeks’ Gestation Amniotic Fluid Assessment a URINARY TRACT ABNORMALITIES Prenatal Diagnosis of Urinary Tract Abnormalities TABLE 39.2 Amniotic Fluid Index Values in Normal Pregnancy Evaluation of the Fetal Urinary Tract Bilateral Renal Agenesis Unilateral Renal Agenesis Renal Ectopia Bilateral Renal Agenesis Horseshoe Kidney Renal Cystic Disease Multicystic Dysplastic Kidney Obstructive Cystic Renal Dysplasia Autosomal Recessive Polycystic Kidney Disease Autosomal Dominant Polycystic Kidney Disease Syndromes Associated With Renal Cystic Disease M eckel syndrome, a l s o k n o w n a s M eckel-Gruber syndrome, Hyperechogenic Kidneys Renal Neoplasm Adrenal Mass TABLE 39.3 Suprarenal Masses Upper Urinary Tract Dilation TABLE 39.4 Urinary Tract Classification System and Follow-Up TABLE 39.5 Risk of Postnatal Pathology by Degree of Antenatal Hydr Ureteropelvic Junction Obstruction Vesicoureteral Junction Obstruction and Primary Megaureter Duplication Anomalies Duplex Kidney Findings Lower Urinary Tract Obstruction Vesicoureteral Reflux be a s sociated with o ther r enal a b n o rmalities, including Causes of Fetal Megacystis M e g a cystis-microcolon–intestinal hypoperistalsis syndrome In Utero Intervention: Fetal Vesicoamniotic Shunting and Cystoscopy Antenatal Predictors of Poor Postnatal Renal Function TABLE 39.6 Long-Term Outcomes After Prenatal Vesicoamniotic Shunting Nonvisualized Bladder Nonvisualization of Fetal Bladder: Etiology Bladder Exstrophy THE GENITAL TRACT Normal Genitalia Abnormal Genitalia Hydrocolpos CONCLUSION Acknowledgments REFERENCES Ovarian Cysts The Fetal Musculoskeletal System Phyllis Glanc, David Chitayat, and Sheila Unger TABLE 40.1 Major Categories of Skeletal Dysplasias 2 Resources for Molecular Tests for Diagnosis of Skeletal Dysplasias TABLE 40.2 Birth Prevalence of Skeletal Dysplasias NORMAL FETAL SKELETON Development Extremity Measurements TABLE 40.3 Normal Extremity Long-Bone Lengths and Biparietal Diamet Assessment of Skeletal Dysplasias: Key Features SONOGRAPHIC EVALUATION OF FETUS WITH SKELETAL DYSPLASIA Positive Family History Abnormal Bone Length or Appearance Patterns of Limb Shortening Th e s p ine i s a s sessed f o r segmentation a nomalies, kypho scol Additional Diagnostic Techniques Three-Dimensional Ultrasound Radiography Three-Dimensional Computed Tomography Magnetic Resonance Imaging Molecular Diagnosis Features Suggestive of Pulmonary Hypoplasia 52,53 Is There a Lethal Skeletal Dysplasia? LETHAL SKELETAL DYSPLASIAS TABLE 40.4 Severe Micromelia With Decreased Thoracic Circumference Sonographic Assessment of Bones Thanatophoric Dysplasia Sonographic Assessment of Bones—cont’d also associated with h ypochondroplasia, achondroplasia, and a c a n t h o Other anomalies may include horseshoe kidneys, hydrone p hrosis, congenita Achondrogenesis Osteogenesis Imperfecta Hypophosphatasia TABLE 40.5 Classification of Osteogenesis Imperfecta by Type Campomelic Dysplasia Short-Rib Polydactyly Syndromes T ype 1 (Saldino-Noonan) a n d type 3 (Verma-Naumoff ) Other Dysplasias O t h e r l e t h a l s k e l e t a l d y s p l a s i a s i n c l u d NONLETHAL OR VARIABLE PROGNOSIS SKELETAL DYSPLASIAS Heterozygous Achondroplasia TABLE 40.6 Rhizomelic Dysplasia: Key Features TABLE 40.7 Micromelic Dysplasia, Mild: Key Features TABLE 40.8 Micromelic Dysplasia, Mild and Bowed: Key Features Diastrophic Dysplasia Asphyxiating Thoracic Dysplasia ( 6 0 % ) w i t h r h i z o m e l i c p r e d o m i n a n c e , a l Ellis–van Creveld Syndrome Chondrodysplasia Punctata Dyssegmental Dysplasia Osteogenesis Imperfecta Types I, III, IV— Nonlethal Types LIMB REDUCTION DEFECTS AND ASSOCIATED CONDITIONS Proximal Focal Femoral Deficiency Radial Ray Defects TABLE 40.9 Nomenclature of Limb Anomalies R o berts syndrome, o r p seudothalidomide syndrome, i s a n a u t o Amniotic Band Sequence Caudal Regression Syndrome and Sirenomelia Arthrogryposis Multiplex Congenita A symmetrical limb e nlargement m a y be caused b y hemi h ypertrophy H e r e d i t a ry lymphedema type 1 (Nonne-Milroy lymphedema) HAND AND FOOT MALFORMATIONS digit. P ostaxial polydactyly (ulnar or fibular) is more common a n d i s s u c h a s F a n c o n i s yndrome, Holt-Oram syndrome, acrocepha losy e c t r o d a c t y l y – e c t o d e r m a l d y s p l a s i a c l e ſt i SKELETAL FINDINGS ASSOCIATED WITH ANEUPLOIDY Trisomy 21: Musculoskeletal Features Trisomy 18: Musculoskeletal Features Trisomy 13: Musculoskeletal Features SUMMARY Acknowledgments REFERENCES Fetal Hydrops Deborah Levine CHAPTER OUTLINE SONOGRAPHIC FEATURES Pleural Effusions Ascites TABLE 41.1 Nonimmune Hydrops: Common Causes and Associations a Pericardial Effusions Subcutaneous Edema ETIOLOGY Placentomegaly Polyhydramnios IMMUNE HYDROPS Noninvasive Assessment of Alloimmunization Measurement of Middle Cerebral Artery (MCA) Peak Systolic Velocity ( TABLE 41.2 Expected Peak Velocity of Systolic Blood Flow in the NONIMMUNE HYDROPS Pathophysiology Causes and Associations Cardiovascular Abnormalities Neck Abnormalities Thoracic Anomalies Gastrointestinal Anomalies M econium peritonitis i s a s sociated with fetal cystic fibrosis Urinary Tract Anomalies Lymphatic Dysplasia Chromosomal Anomalies Monochorionic Twins Tumors Anemia Infection Skeletal Disorders Endocrine Disorders Drugs Idiopathic Disorders DIAGNOSTIC APPROACH TO HYDROPS Genetic Disorders Metabolic Disorders History Complete Obstetric Ultrasound TABLE 41.3 Workup of Hydrops After Fetal Echocardiogram, Maternal Maternal Investigations Fetal Investigations Performing PUBS Postnatal Investigations FETAL WELFARE ASSESSMENT IN NONIMMUNE HYDROPS Fetal Transfusion OBSTETRIC PROGNOSIS Cavity Aspiration Maternal Complications (Mirror Syndrome) Delivery Predelivery Aspiration Procedures Postnatal Outcome REFERENCES CONCLUSION Fetal Measurements: Normal and Abnormal Fetal Growth and Assessment Carol B. Benson and Peter M. Doubilet SUMMARY OF KEY POINTS CHAPTER OUTLINE GESTATIONAL AGE DETERMINATION First Trimester TABLE 42.1 Gestational Dating by Mean Sac Diameter (MSD) in the TABLE 42.2 Gestational Dating by Ultrasound in the First Trimester TABLE 42.3 Gestational Age Estimation by Crown-Rump Length (CRL) Second and Third Trimesters Fetal Head Measurements TABLE 42.4 Gestational Age Estimation by Biparietal Diameter (BPD) Femur Length Abdominal Circumference TABLE 42.5 Gestational Age Estimation by Head Circumference (HC) Composite Formulas TABLE 42.6 Gestational Age Estimation by Femur Length (FL) Gestational Age Estimation by Ultrasound: Most Accurate Approach at TABLE 42.7 Gestational Age (GA) Assignment by Ultrasound: Most Accu WEIGHT ESTIMATION AND ASSESSMENT Estimation of Fetal Weight TABLE 42.8 Accuracy of Fetal Weight Prediction Formulas Recommended Approach Weight Assessment in Relation to Gestational Age TABLE 42.9 Approach to Fetal Weight Estimation TABLE 42.10 Fetal Weight Percentiles in the Third Trimester FETAL GROWTH ABNORMALITIES The Large Fetus General Population Diabetic Mothers TABLE 42.11 Sonographic Criteria for Large-for-Gestational Age (LGA) The Small-for-Gestational-Age Fetus and Fetal Growth Restriction Small-for-Gestational-Age Fetuses: Causes ASSESSMENT OF FETAL WELL-BEING TABLE 42.12 Sonographic Criteria for Large-for-Gestational Age (LGA) Fetal and Placental Risk Factors Associated With Fetal Growth Restri Maternal Risk Factors Associated With Fetal Growth Restriction Biophysical Profile TABLE 42.13 Biophysical Profile Parameters for 30-Minute Ultrasound E Fetal Doppler Ductus Venosus Doppler Middle Cerebral Artery Doppler Umbilical Artery Doppler Summary of Fetal Doppler REFERENCES Sonographic Evaluation of the Placenta Thomas D. Shipp CHAPTER OUTLINE PLACENTAL DEVELOPMENT Placental Appearance Placental Size Placental Vascularity and Doppler Ultrasound Amnion-Chorion Separation Elastography PLACENTA PREVIA PLACENTA ACCRETA PLACENTAL ABRUPTION PLACENTAL INFARCTION PLACENTAL MASSES MESENCHYMAL DYSPLASIA OF THE PLACENTA MOLAR GESTATIONS Gestational t r o p hoblastic disease consists o f complete mole MORPHOLOGIC PLACENTAL ABNORMALITIES Circumvallate Placenta Succenturiate Lobe Bilobed Placenta UMBILICAL CORD Size and Appearance Insertion Into the Placenta Velamentous and Marginal Cord Insertions Vasa Previa PLACENTA DURING LABOR AND POSTPARTUM Third Stage of Labor Retained Products of Conception CONCLUSION REFERENCES Cervical Ultrasound and Preterm Birth Hournaz Ghandehari and Phyllis Glanc CHAPTER OUTLINE PRETERM BIRTH SONOGRAPHY OF THE UTERINE CERVIX Transabdominal Approach Transperineal/Translabial Approach Transvaginal Sonography Technical Limitations and Pitfalls Standard Technique for Cervical Measurement Normal Cervix “Short” Cervix TABLE 44.1 Prediction of Spontaneous Preterm Birth Based on Gestat PREDICTION OF SPONTANEOUS PRETERM BIRTH Obstetric Factors Cervical Funneling Rate of Cervical Change Dynamic Cervical Change CERVICAL ASSESSMENT IN SPECIFIC CLINICAL SCENARIOS Asymptomatic Patients General Obstetric Population Screening Other Sonographic Features Cervix: Abnormal Findings on TVS a TAS Findings That Indicate TVS Follow-Up High-Risk Obstetric Population Screening Risk Factors for Preterm Birth Symptomatic Patients Cervical Incompetence and Vaginal Pessary Vaginal Progesterone and 17-Alpha Hydroxyprogesterone Caproate MANAGEMENT PROTOCOLS FOR THE ABNORMAL CERVIX CONCLUSION Acknowledgment REFERENCES PART FIVE: Pediatric Sonography Neonatal and Infant Brain Imaging Carol M. Rumack and Amanda K. Auckland CHAPTER OUTLINE SONOGRAPHIC TECHNIQUE EQUIPMENT Coronal Imaging Coronal Brain Scans: Normal Structures M o v i n g p o s t e r i o r l y , t h e f r o n t a l h o r n s o Sagittal Imaging Sagittal Brain Scans: Normal Structures Posterior Fontanelle Imaging Mastoid Fontanelle Imaging Three-Dimensional Ultrasound STANDARDIZED REPORTS Standardized Views for Display Ultrasound of the Brain: Standard Report Template DEVELOPMENTAL ANATOMY Brain Sulcal Development and Subarachnoid Spaces Cavum Septi Pellucidi and Cavum Vergae Cavum Veli Interpositi Frontal Horn Variants Choroid Plexus and Variants Pitfalls in Neurosonography Germinal Matrix Calcar Avis Cerebellar Vermis Cisterna Magna CONGENITAL BRAIN MALFORMATIONS Congenital Brain Malformations Stages of Brain Development a DISORDERS OF NEURAL TUBE CLOSURE Chiari Malformations Chiari II Malformation: Sonographic Findings Th e r e i s u s u a l l y m a r k e d e n l a r g e m e n t o f t Agenesis of Corpus Callosum Agenesis of Corpus Callosum: Sonographic Findings Corpus Callosum Lipoma Dandy-Walker Spectrum Dandy-Walker Malformation: Sonographic Findings Posterior Fossa Cystic Lesions DISORDERS OF DIVERTICULATION AND CLEAVAGE: HOLOPROSENCEPHALY Septo-Optic Dysplasia Alobar Holoprosencephaly: Sonographic Findings Alobar Holoprosencephaly Semilobar Holoprosencephaly Lobar Holoprosencephaly Middle Interhemispheric Form of Holoprosencephaly DISORDERS OF SULCATION AND CELLULAR MIGRATION Schizencephaly Lissencephaly DESTRUCTIVE LESIONS Porencephalic Cyst Hydranencephaly Cystic Encephalomalacia Metabolic Disorders HYDROCEPHALUS Cerebrospinal Fluid Production and Circulation Causes of Hydrocephalus Level of Obstruction V e n t r i c u l a r e n l a r g e m e n t d o e s n o t a l w a y s Germinal Matrix Hemorrhage GMH m a y lead t o IVH, h y drocephalus, a n d porencephaly. HYPOXIC-ISCHEMIC EVENTS Arterial Watershed Determines Regional Pattern of Brain Damage TABLE 45.1 Patterns of Hypoxic- Ischemic Injury in Newborns Optimal Brain Ultrasound Screening in Premature Infants (Less Than 3 TABLE 45.2 Grades of Germinal Matrix Hemorrhage Subependymal Hemorrhage (Grade I Hemorrhage) Intraventricular Hemorrhage (Grade II Hemorrhage) Signs of Intraventricular Hemorrhage Intraventricular Hemorrhage With Hydrocephalus (Grade III Hemorrhage) Intraparenchymal Hemorrhage (Grade IV Hemorrhage) Cerebellar Hemorrhage Subarachnoid Hemorrhage Cerebral Edema and Infarction White Matter Injury of Prematurity or Periventricular Leukomalacia Term Infants With Hypoxic Ischemic Injury Focal Infarction Cerebral Infarction: Sonographic Signs Lenticulostriate Vasculopathy Hyperechoic Caudate Nuclei POSTTRAUMATIC INJURY Subdural and Epidural Hematomas INFECTION Congenital Infections Neonatal Acquired Infections Meningitis and Ventriculitis INTRACRANIAL MASSES Brain Tumors ( P N E T s ) , e p e n d y m o m a s , 2 2 4 a n d c h o r o i d p l Common Brain Tumors in First Year of Life Cystic Intracranial Lesions Arachnoid Cysts Porencephalic Cysts Choroid Plexus Cysts TABLE 45.3 Cystic Brain Lesions Sites of Arachnoid Cysts a Subependymal Cysts Periventricular Leukomalacia Galenic Venous Malformations Supratentorial Periventricular Cystic Lesions Frontal Horn Cysts Duplex Sonography of the Neonatal and Infant Brain Thierry A.G.M. Huisman and Andrea Poretti Doppler Optimization SONOGRAPHIC TECHNIQUE Approaches Doppler Optimization Safety Considerations TABLE 46.1 Factors That Change Resistive Index (RI) Doppler Measurements and Factors That Change Resistive Index NORMAL HEMODYNAMICS Normal Arterial Blood Flow Patterns TABLE 46.2 Range of Arterial Blood Flow Velocities in Full-Term In Normal Venous Blood Flow Patterns INTENSIVE CARE THERAPIES AND CEREBRAL HEMODYNAMICS Mechanical Ventilation TABLE 46.3 Mean Venous Blood Flow Velocities in Full-Term Newborns Extracorporeal Membrane Oxygenation Therapeutic Hypothermia and Brain Cooling Brain Death DIFFUSE NEURONAL INJURY Hypoxic Ischemic Injury and Asphyxia Cerebral Edema INTRACRANIAL HEMORRHAGE AND STROKE Focal Arterial Ischemic Stroke HYDROCEPHALUS VASCULAR MALFORMATIONS Dural Venous Sinus Thrombosis INTRACRANIAL TUMORS UNCOMMON VASCULAR APPLICATIONS PITFALLS OF DUPLEX SONOGRAPHY NEAR-FIELD STRUCTURES Differentiation of Subarachnoid From Subdural Fluid Collections Doppler Sonography of the Brain in Children Dorothy Bulas and Alexia Egloff SUMMARY OF KEY POINTS CHAPTER OUTLINE SONOGRAPHIC TECHNIQUE ULTRASOUND POWER SETTINGS TABLE 47.1 Tips for Performing Transcranial Doppler Sonography in LIMITATIONS AND PITFALLS IN TRANSCRANIAL DOPPLER CONTRAST ENHANCEMENT INDICATIONS FOR TRANSCRANIAL DOPPLER IMAGING Indications for Transcranial Doppler in Adults Additional Indications for Transcranial Doppler in Children Sickle Cell Disease Cerebrovascular Disease: Indicators in Children With Sickle Cell Dise TABLE 47.2 STOP Stroke Risk Categories Vasospasm TABLE 47.3 Severity of Vasospasm With Typical Velocities 29 Evaluation of Collateral Flow Headaches Sleep Apnea Hydrocephalus TABLE 47.4 Factors That Change Cerebral Doppler Indices Vascular Malformations Asphyxia Cerebral Edema and Hyperventilation Therapy Evaluation of Right-to-Left Shunt Brain Death Sonographic Criteria for Brain Death After Fontanelle Closure Neuromonitoring and Intraoperative Neuroradiologic Procedures Transcranial Doppler and Tissue Plasminogen Activator Functional Transcranial Doppler Other Potential Uses REFERENCES The Pediatric Head and Neck Rupa Radhakrishnan and Beth M. Kline-Fath CHAPTER OUTLINE NORMAL CERVICAL ANATOMY SUPRAHYOID SPACE Salivary Glands Normal Anatomy Inflammatory Lesions Masses Suprahyoid Cystic Lesions Differential Diagnosis of Suprahyoid Cystic Lesions Masticator Space INFRAHYOID SPACE Thyroid Gland Normal Anatomy TABLE 48.1 Normal Dimensions of the Thyroid Gland a Congenital Thyroid Lesions TABLE 48.2 Volume of Thyroid Gland and Thickness of Each Lobe a Differential Diagnosis for Infrahyoid Cystic Lesions Thyroid Masses Malignant Thyroid Nodule: Sonographic Characteristics Parathyroid Glands Other Cystic Lesions LACKING DEFINITION BY THE HYOID Congenital Lesions Branchial Anomalies Dermoid and Epidermoid Lesions Ectopic Thymus Teratomas Vascular Lesions Vascular Anomalies Vascular Malformations Vascular Anomalies 162 Vascular Tumors Other Congenital Lesions Iatrogenic Lesions Inflammatory Lesions Lymph Nodes TABLE 48.3 Age and Causes of Lymphadenopathy TABLE 48.4 Site of Node and Causes of Lymphadenopathy Fibromatosis Colli Masses Malignant Neoplasms Congenital Infantile Myofibromatosis REFERENCES The Pediatric Spinal Canal Ilse Castro-Aragon, Deborah Levine, and Carol M. Rumack EMBRYOLOGY SONOGRAPHIC TECHNIQUE AND NORMAL ANATOMY SPINAL ANOMALIES Tethered Spinal Cord SPINAL DYSRAPHISM Open Spinal Dysraphism TABLE 49.1 Clinical-Radiologic Classification System for Spinal Dysra Closed Spinal Dysraphism With a Subcutaneous Mass A. Myelocele B. Myelomeningocele C. Intradural Lipoma D. Lipomyelocele E. Lipomyelomeningocele Closed Spinal Defects Without a Subcutaneous Mass Simple Dysraphic States Complex Dysraphic States (Disorders of Gastrulation) Anomalies at Risk for Spinal Dysraphism TUMORS TABLE 49.2 Altman’s Classification of Sacrococcygeal Teratomas M C HEMORRHAGE AND INFECTION ARACHNOID CYSTS INTRAOPERATIVE AND OTHER USES OF SPINAL SONOGRAPHY The Pediatric Chest Chetan Chandulal Shah and S. Bruce Greenberg ULTRASOUND TECHNIQUE Indications for Extracardiac Chest Sonography PLEURAL EFFUSION AND EMPYEMA Sonographic Signs of Pleural Fluid Free Fluid Movement With Respiration Fluid Color Flow Doppler Signal Diaphragm Sign Displaced-Crus Sign Bare-Area Sign Sonography Versus Computed Tomography Scan Mass Versus Fluid Sonographic Signs of Pleural Fluid Parapneumonic Collections and Empyema Lung Abscess Versus Empyema LUNG PARENCHYMAL DISORDERS Pneumonia Round Pneumonia Chest Radiograph or Ultrasound? Atelectasis Congenital Pulmonary Airway Malformation Bronchopulmonary Foregut Malformation DIAPHRAGM DISORDERS a diaphragmatic hernia ( Fig. 50.27 ), a s u b p hrenic abscess, 34,35 VASCULAR DISORDERS Vascular Thrombosis Superior Vena Cava Thrombosis: Doppler Sonographic Findings Lymphovascular Malformation MEDIASTINAL MASSES Thymic Index Abnormal Location of Thymus Mimicking Mass Lesion Anterior Mediastinal Masses TABLE 50.1 Formula for Calculation of Thymic Index Lymphadenopathy Posterior Mediastinal Masses ULTRASOUND-GUIDED INTERVENTIONAL PROCEDURES OTHER LESS ESTABLISHED INDICATIONS TABLE 50.2 Normal Thymic Index Values for Children Younger Than 2 REFERENCES The Pediatric Liver and Spleen Sara M. O’Hara ANATOMY Portal Vein Anatomy Left Lobe of Liver Right Lobe of Liver Hepatic Vein Anatomy NEONATAL JAUNDICE Causes of Neonatal Jaundice Choledochal Cyst Spontaneous Rupture of Bile Duct Paucity of Interlobular Bile Ducts and Alagille Syndrome Biliary Atresia Neonatal Hepatitis Neonatal Jaundice and Urinary Tract Infection or Sepsis Inborn Errors of Metabolism Inborn Errors of Metabolism STEATOSIS Causes of Steatosis Diseases Associated With Gallstones in Children CIRRHOSIS CHOLELITHIASIS LIVER TUMORS Identification Benign Liver Tumors Hemangiomas Liver Masses in Children Infantile Hemangioendotheliomas Mesenchymal Hamartomas Adenomas Focal Nodular Hyperplasia Malignant Liver Tumors Hepatoblastoma Hepatocellular Carcinoma Undifferentiated Embryonal Sarcoma Biliary Rhabdomyosarcoma Metastases Detection of Tumor Angiogenesis LIVER ABSCESS AND GRANULOMAS Pyogenic Abscess Parasitic Abscesses Amebiasis Echinococcosis Schistosomiasis Granulomas of the Liver DOPPLER ASSESSMENT OF LIVER DISEASE AND PORTAL HYPERTENSION IN CHIL Basic Principles Normal Flow Patterns in Splanchnic Vessels Possibilities and Pitfalls Sonographic Technique Child With Liver Disease: Doppler Examination for Portal Hypertension Abnormal Flow Patterns Within the Portal System Absent Doppler Signal Arterialized Portal Venous Flow Causes of Absent Doppler Signal Reversed or To-and-Fro Flow Abnormal Hepatic Arterial Doppler Patterns Portal Venous Hypertension Prehepatic Portal Hypertension Causes of Portal Vein Thrombosis Intrahepatic Portal Hypertension Causes of Cirrhosis in Children Suprahepatic (Posthepatic) Portal Hypertension Causes of Hepatic Venous Occlusive Disease Surgical Portosystemic Shunts Hepatic Shear Wave Elastography DOPPLER SONOGRAPHY IN CHILDREN RECEIVING LIVER TRANSPLANT Pretransplantation Evaluation Posttransplantation Evaluation Multiorgan Transplants THE SPLEEN Causes of Splenic Enlargement Acknowledgment REFERENCES The Pediatric Urinary Tract and Adrenal Glands Harriet J. Paltiel and Diane S. Babcock CHAPTER OUTLINE PEDIATRIC URINARY TRACT SONOGRAPHY Technique TABLE 52.1 Patient Preparation for Urinary Tract Ultrasound TABLE 52.2 Reference Values for Infant Kidney Length (in Centimeter TABLE 52.3 Reference Values for Infant Kidney Volume (in Milliliter TABLE 52.4 Mean Total Renal Volumes (Values Are Mean ± Standard TABLE 52.5 New Centiles for Renal Growth of the Solitary or Singl TABLE 52.6 Shape and Correction Coefficient (k) for Bladder Volume Normal Renal Anatomy Normal Bladder Anatomy CONGENITAL ANOMALIES OF THE URINARY TRACT Renal Duplication Other Renal Anomalies CAUSES OF HYDRONEPHROSIS Ureteropelvic Junction Obstruction Ureteral Obstruction PRENATAL PRESENTATION POSTNATAL PRESENTATION Bladder Outlet Obstruction Vesicoureteral Reflux Prune-Belly Syndrome Megacystis-Microcolon-Malrotation– Intestinal Hypoperistalsis Syndrome Bladder Exstrophy Urachal Anomalies URINARY TRACT INFECTION Acute Pyelonephritis Chronic Pyelonephritis Neonatal Candidiasis Cystitis MEDICAL RENAL DISEASE Acute Kidney Injury Common Causes of Acute Kidney Injury Chronic Kidney Disease TABLE 52.7 Kidney Disease Outcomes Quality Initiative—Stages of Chr Causes of Cortical Nephrocalcinosis Medullary Nephrocalcinosis URINARY TRACT CALCIFICATION Renal Cortical Calcification TABLE 52.8 Causes of Medullary Nephrocalcinosis 86 Urinary Stasis Renal Vein Thrombosis Calcifications Dystrophic Calcification Urolithiasis RENAL TRAUMA RENAL VASCULAR DISEASE Doppler Sonographic Examination Technique Normal Vascular Anatomy and Flow Patterns Causes of Increased Resistance to Intrarenal Arterial Flow Causes of Increased Resistive Index in Renal Arteries Clinical Applications Vessel Patency Acute Renal Vein Thrombosis Causes of Acute Renal Vein Thrombosis TABLE 52.9 Causes of Renovascular Hypertension 112 Renal Artery Stenosis RENAL TRANSPLANTATION Vascular Complications R e nal a rtery thrombosis with associated graſt infarction Perinephric Fluid Collections Parenchymal Abnormalities Urologic Complications Tumors RENAL CYSTIC DISEASE Autosomal Recessive Polycystic Kidney Disease Autosomal Dominant Polycystic Kidney Disease Multicystic Renal Dysplasia Nephronophthisis and Medullary Cystic Disease Congenital Renal Cysts Tuberous Sclerosis and Von Hippel–Lindau Disease Acquired Cysts Mesoblastic Nephroma RENAL TUMORS Wilms Tumor Renal Cell Carcinoma Angiomyolipoma Multilocular Cystic Nephroma Renal Lymphoma Bladder Tumors PEDIATRIC ADRENAL SONOGRAPHY Normal Anatomy Congenital Adrenal Hyperplasia TABLE 52.10 Adrenal Measurements in Neonates: Mean ± SD (Mean Per Neonatal Adrenal Hemorrhage Neuroblastoma Beckwith-Wiedemann syndrome, H irschsprung disease, neurofibromatosis Pheochromocytoma Adrenocortical Neoplasm a n d Li-Fraumeni syndrome. 238 The Pediatric Gastrointestinal Tract Susan D. John and Martha Mappus Munden CHAPTER OUTLINE ESOPHAGUS AND STOMACH Normal Anatomy and Technique Stomach: Optimal Measurements Esophagus Stomach Hypertrophic Pyloric Stenosis Hypertrophic Pyloric Stenosis T C Normal Pseudothick Normal Pylorospasm and Minimal Muscular Hypertrophy Pitfalls in Sonographic Diagnosis Pitfalls in Diagnosis of Hypertrophic Pyloric Stenosis (HPS) Gastric Diaphragm Gastritis and Ulcer Disease Bezoar Congenital Duodenal Obstruction DUODENUM AND SMALL BOWEL Duodenal Hematoma Small Bowel Obstruction Intussusception Sonographic Signs of Intussusception Ectopic or Imperforate Anus COLON INTESTINAL INFLAMMATORY DISEASE Causes of Intestinal Wall Thickening Sonographic Signs of Necrotizing Enterocolitis Appendicitis Sonographic Signs of Appendicitis Sonographic Signs of Appendiceal Perforation Gastrointestinal Neoplasms and Cysts PANCREAS Normal Anatomy and Technique Pancreatitis Pancreatic Masses p a n c r e a s i n c l u d e l ymphangioma, solid pseudopapillary tumor Pediatric Pelvic Sonography William L. Simpson, Jr., Humaira Chaudhry, and Henrietta Kotlus Rosen SONOGRAPHIC TECHNIQUE NORMAL FEMALE ANATOMY The Uterus TABLE 54.1 Pediatric Uterine Measurements The Ovary The Vagina TABLE 54.2 Pediatric Ovarian Volume Measurements OVARIAN ABNORMALITIES Ovarian Cysts Complications: Torsion, Hemorrhage, Rupture Acute Ovarian Torsion: Sonographic Findings Polycystic Ovarian Disease (Stein-Leventhal) Massive Ovarian Edema Ovarian Neoplasms Ovarian Masses in Children Embryonal carcinoma a n d e ndodermal s inus t umors a r e less co UTERINE AND VAGINAL ABNORMALITIES Congenital Anomalies Neoplasm Pregnancy Infection Pelvic Inflammatory Disease Pelvic Inflammatory Disease: Sonographic Findings Foreign Bodies ENDOCRINE ABNORMALITIES Precocious Puberty Causes of Primary Amenorrhea NORMAL MALE ANATOMY The Prostate The Scrotum The Testes CONGENITAL MALE ABNORMALITIES Acute Scrotal Pain or Swelling ACUTE SCROTAL PAIN OR SWELLING with or without o r chitis, torsion of the testicular appendages, t e s t i Sonographic Signs of Testicular Torsion Color Doppler Sonography in Testicular Torsion Epididymitis on Color Doppler Ultrasound Torsion on Color Doppler Ultrasound SCROTAL MASSES Intratesticular Causes 50. Both seminomas (malignant) a n d gonadoblastomas (the m a jorit syndrome, male pseudohermaphroditism, a n d t rue hermaphroditism. Extratesticular Causes Paratesticular Tumors a n d fi b r o sarcoma. 1 7 5 , 1 8 7 , 1 8 LOWER URINARY TRACT Congenital Anomalies Causes of Bladder Outlet Obstruction The Ureter Neurogenic or Dysfunctional Bladder Infection Neoplasm Trauma Postoperative Bladder Presacral Masses in Children o r o bstruction, calculi, e xtravasation, a bscess, urinoma, h e PRESACRAL MASSES REFERENCES The Pediatric Hip and Other Musculoskeletal Ultrasound Applications Leslie E. Grissom and H. Theodore Harcke DEVELOPMENT DYSPLASIA OF THE HIP Clinical Overview Risk Factors for Development Dysplasia of the Hip (DDH) Indications for Hip Ultrasound 8 Dynamic Sonographic Technique: Normal and Pathologic Anatomy History Technical Factors Coronal/Neutral View Coronal/Flexion View Transverse/Flexion View Alternative Views Evaluation of the Infant at Risk Evaluation During Treatment OTHER PEDIATRIC MUSCULOSKELETAL ULTRASOUND APPLICATIONS Nondevelopmental Dysplasia Hip Abnormalities Painful Hip and Hip Joint Effusion Teratologic Hip Dislocation Atypical Hips Congenital Foot Deformities Club Foot Vertical Talus Congenital Limb Deformities Proximal Focal Femoral Deficiency Tibial Hemimelia Congenital Nonhip Dislocations Elbow and Knee Dislocations Brachial Plexus Injury Patellar Dislocation Inflammation Infection Noninfectious Inflammation Trauma Popliteal Cysts SUMMARY REFERENCES Pediatric Interventional Sonography Neil Johnson and Allison Aguado CHAPTER OUTLINE GENERAL PRINCIPLES The Patient Personnel and Equipment TABLE 56.1 Computed Tomography (CT) Versus Ultrasound for Intervent ULTRASOUND TECHNIQUES Equipment and Transducers One Operator Versus Two GUIDANCE METHODS Multimodality Interventional Suites Freehand Versus Mechanical Guides Color Doppler Ultrasound FREEHAND TECHNIQUE Initial Needle Placement and Localization Locating the Needle After Insertion Correcting the Needle Angle Correcting the Off-Target Needle Training Aids for Freehand Sonographic Intervention NEEDLES, WIRES, CATHETERS, AND BIOPSY DEVICES Chiba Needles Drainage Catheters Initial Puncture Device Biopsy Devices Colon or Bowel ANATOMY Diaphragm SEDATION LOCAL ANESTHETIC TECHNIQUE Ultrasound-Guided Deep Local Anesthetic Administration ANTIBIOTICS THE TYPICAL PROCEDURE Prior Consultation and Prior Studies Coagulation Studies Aims and Expectations Initial Ultrasound Scan Should Occur Before Sedation Pus Catheter Fixation May Be Difficult in Infants Postprocedure Care and Follow-Up SPECIFIC PROCEDURES Abscess Drainage Transrectal Drainage Central Venous Access Pleural and Peritoneal Drainage Peripherally Inserted Central Catheter Lines Mediastinal Mass Biopsy Appendiceal Abscess Drainage Percutaneous Cholangiography and Drainage Targeted Organ Lesion Biopsy Musculoskeletal Procedures Head and Neck Lesions NOTE FROM THE AUTHORS REFERENCES Ultrasound Artifacts: A Virtual Chapter APPENDIX Korosh Khalili, Hojun Yu, Alexander Jesurum, and Deborah Levine CHAPTER OUTLINE ASSUMPTIONS IN GRAY-SCALE IMAGING Velocity of Sound Attenuation of Sound Path of Sound Beam Profile PROPAGATION VELOCITY ARTIFACT ATTENUATION ERRORS Shadowing Increased Through Transmission PATH OF SOUND-RELATED ARTIFACTS Mirror Image Artifact Comet-Tail Artifact Refraction Anisotropy Reverberation Artifact GAS-RELATED ARTIFACTS Reverberation Artifact Ring-Down Artifact Dirty Shadowing Artifact Side Lobe and Grating Lobe Artifacts BEAM PROFILE–RELATED ARTIFACTS Partial Volume Averaging DOPPLER IMAGING ARTIFACTS Loss or Distortion of Doppler Information Artifactual Vascular Flow Tissue Vibration Artifact Click f o r video s h o wing t issue vibration a rtifact in patient Aliasing and Velocity Scale Errors Spectral Broadening Blooming Artifact Twinkle Artifact Acknowledgment REFERENCES