The Role of Superb Microvascular Imaging and Shear Wave Elastography in Differentiation of Thyroid Nodules from Intrathyroidal Ectopic Thymus in Children.

BACKGROUND: Ectopic thymus could be located intrathyroidal, therefore fine ultrasound details are useful for this differentiation. AIM: To investigate differences in stiffness and vascularity properties among thyroid nodules and intrathyroidal ectopic thymus (IET) by obtaining quantitative data in children. PATIENTS AND METHODS: Twenty-seven thyroid nodules and 20 IET in children were evaluated in terms of vascularity index (VI) via superb microvascular imaging (SMI) and stiffness by shear wave elastography (SWE). Differences in the volume, VI, and SWE parameters of the lesions were assessed by using the Mann-Whitney U test. Association of the age, lesion volume, SWE, and VI parameters was investigated by using Spearman's correlation analysis. The optimal cut-off values for stiffness and vascularity in the differentiation of nodules from IET were calculated with ROC analysis. RESULTS: The median (range) age of the participants with thyroid nodules and IET were 15.6 (10-18) years and 8.8 (3-14) years, respectively. The medians (range) VI of the IET and thyroid nodules were 4.7 (0.2-16) % and 23.8 (7.5-40)%, respectively. The median SWE values were 7.6 (4.4-9.5) kPa and 15.58 (8.5-23.4) kPa for IET and nodules, respectively. There have been highly significant differences among medians of volume, SWE, and VI values of the lesions. Significant positive correlations were found between VI and SWE parameters (p=0.001, r=0.64), and volume with VI (p=0.018, r=0.34) and SWE (p:0.001, r= 0.5). The diagnostic accuracies were 93%, 91% with the cut-off values as 9.2 kPa, 13% for the SWE and SMI, respectively. IETs were found to be less vascular and less stiff than thyroid nodules. CONCLUSIONS: IETs could be easily and confidently differentiated from nodules using SWE and SMI quantifications. This discrimination prompts the reduction of unnecessary interventional procedures.

Langerhans Cell Histiocytosis: Single Center Experience of 25 Years.

OBJECTIVES: To review a single center outcome of patients with Langerhans Cell Histiocytosis diagnosed at a tertiary referral hospital from Turkey.Methods: The files between 1989 and 2015 of 80 patients with LCH were retrospectively analyzed. RESULTS: During the 25 years, 80 patients were diagnosed with LCH. The median age at diagnosis was 53 months (2-180 months) and the median follow-up time of patients was 10 years and 9 months (24 months-25 years). Bone was the most frequently affected organ (n:60, 75%). Initially, 43 patients (54%) had single system (SS) disease, 20 patients (25%) had multisystem (MS) disease without risk organ involvement (MS-RO-), and 17 patients (21%) had a multisystem disease with risk-organ involvement (MS-RO+). The overall survival (OS) rate was 91%, and event-free survival (EFS) rate was 67% at 10 years. 10-year OS rate was lower for patients with MS-RO+ (65%) when compared to those with, MS-RO-, and SS (100%, 97%, p value=<0.001). The overall survival rate was also lower in patients with lack of response to systemic chemotherapy on 12th week (p=<0.001), younger age (<2 years) at presentation (p=<0.02), skin involvement (<0.001) and lack of bone lesions at presentation (<0.001). DISCUSSION: In the group with MS-RO+, OS is significantly low compared to other groups. Further efforts are warranted to improve survival in MS-RO+ patients.

Assessment of paediatric Hashimoto's thyroiditis using superb microvascular imaging.

AIM: To evaluate the role of superb microvascular imaging along with greyscale and Doppler imaging for thyroid gland evaluation in Hashimoto's thyroiditis (HT) versus control subjects. MATERIALS AND METHODS: The study included 33 healthy volunteers with normal ultrasound and laboratory findings and 70 patients with HT based on laboratory and sonographic findings who were undergoing follow-up and receiving medical treatment. HT patients were classified based on the modification of the scheme proposed by Sostre and Reyes that incorporates the extent of hypoechoic foci or patchy infiltration as grade A (foci involving <50% of the gland) and B (foci involving >50% of the gland). Thyroid volume, mean resistive indices, peak-systolic and end-diastolic velocities based on Doppler imaging, and vascularity index via superb microvascular imaging were obtained using a Canon Aplio 500 ultrasound device using a linear 10-14 MHz transducer. RESULTS: Patients with HT had significantly higher median thyroid volume and peak-systolic velocities (7.32 ml and 19 cm/s, respectively) compared to control subjects (4.62 ml and 16 cm/s, respectively). HT patients had significantly higher median vascularity index (VI; 13.5%) compared to control subjects (7.95%). A significant fair positive correlation with VI and anti-thyroglobulin antibody levels (r=0.356, p<0.05) and significant moderate positive correlation with VI and anti-thyroid peroxidase antibody levels (r=0.503, p<0.05) were found. In HT diagnosis, the optimal VI cut-off value was 10.58% with a sensitivity and specificity of 67.1% and 90%, respectively. CONCLUSION: Superb microvascular imaging appears to allow assessment of subtle vascularity changes in early HT stages that cannot be detected by Doppler parameters. This technique demonstrates excellent visualization of the microvascular structures and quantitative assessment based on a novel parameter such as VI.

Coeliac trunk and common hepatic artery variations in children: an analysis with computed tomography angiography.

BACKGROUND: Understanding the coeliac trunk (CeT) and hepatic artery anatomy is important not only in preventing iatrogenic injuries but also in planning surgical procedures in children. Therefore, the aim of this study is to analyse the prevalence of CeT and common hepatic artery (CHA) variations in the paediatric population. MATERIALS AND METHODS: One hundred and seventy-four children who underwent abdominal multidetector computed tomography (MDCT) angiography, either because of trauma or liver transplantation, were analysed retrospectively. The patterns of CeT, CHA and their variant branches were revealed and compared with previous studies involving adults. RESULTS: A total of 157 (90.2%) of the 174 patients had normal CeT anatomy, whereas 17 (9.8%) had variations. Five types of CeT variations were identified according to Song's classification in which 'hepatosplenic trunk + left gastric artery + superior mesenteric artery' was the most prevalent. One hundred-twelve (64.4%) of the 174 patients had normal CHA anatomy; however, 62 (35.6%) had variations. Six types of CHA variations were identified according to Michel's and Hiatt's classification. The most common was 'replaced left hepatic artery originating from left gastric artery'. CONCLUSIONS: The prevalences of CeT and hepatic artery variations are high in children, as they are in older patients. Awareness of these variations is important in terms of avoiding iatrogenic injury and in promoting surgical procedure planning for liver transplantation or abdominal tumour surgery.

Apparent diffusion coefficient measurement of ovarian stroma: A potential tool for the diagnosis of polycystic ovary syndrome.

PURPOSE: The purpose of this study was to assess the diagnostic value of measuring the apparent diffusion coefficient (ADC) of ovarian stroma in polycystic ovary syndrome (PCOS). MATERIALS AND METHODS: This study was approved by the institutional review board and informed consent was obtained from each women. A total of 17 women (mean age, 22.2 years±5.1 [SD]; range, 16-33 years) with a diagnosis of PCOS according to the Androgen Excess and PCOS Society criteria and 18 healthy women (mean age, 22.8 years±5.2 [SD]; range, 16-31 years) who served as a control group were included in this prospective study. ADC values of the ovarian stroma during the early follicular phase were calculated by two observers in the two groups. Comparisons were performed using the Student t-test. RESULTS: The mean ADC value in woman with PCOS (1.29±0.27×10-3 mm2/s; range: 0.59×10-3 - 1.88×10-3 mm2/s) was significantly lower than that in the control group (1.48±0.17×10-3 mm2/s; range: 1.12×10-3 - 1.86×10-3 mm2/s) (P<0.001). The ADC cutoff value for the determination of PCOS with maximum accuracy was 1.38×10-3 mm2/s (AUC: 0.720; 95% CI: 0.597, 0.843), yielding 78% sensitivity and 62.9% specificity. CONCLUSION: ADC values of ovarian stroma are lower in patients with PCOS than in control subjects. ADC measurement of ovarian stroma in women with PCOS might help improve the diagnosis of PCOS.

Vasculopathic changes in the cerebral arterial system with neurobrucellosis.

Brucellosis is a zoonotic disease characterized by multisystem involvement. Nervous system involvement is rare, with a reported incidence of 3%-13%. Brucellosis can also be manifested in the form of vasculopathy. Cerebral vasculopathy due to brucellosis is a very rare entity, with only a few cases reported in the literature. We present a patient with neurobrucellosis who had involvement of cerebral vasculature demonstrated by angiography.

Hoffa's recess in the infrapatellar fat pad of the knee on MR imaging.

The infrapatellar fat pad of Hoffa is a structure that is located in the space between the back side of the patellar ligament and the real capsule. It is routinely visualized on magnetic resonance (MR) images of the knee. The purpose of this study was to determine the prevalence and shape of a fluid-like indentation at the inferior posterior margin of the infrapatellar fat pad of the knee (recess) and to look for a relation between the liquid image in the fat pad and joint effusion. Three hundred and fifty consecutive MR imaging examinations of the knee were evaluated for the presence, location, size and shape of a recess in the infrapatellar fat pad and existence of joint effusion. The study population consisted of 145 females and 205 males aged between 5 and 80 years old (mean age 37.5 years). The recess in the infrapatellar fat pad was revealed on MR imaging in 54 of 350 knees (15.43%) and had a variable shape, consisting of 35 linear or ovoid (64.81%), five pipe-shaped (9.26%) and 14 globular (25.92%). Additionally, one ganglion cyst was observed in the infrapatellar fat pad. Globular and pipe-shaped recesses may be confused with cystic infrapatellar fat pad pathologies such as ganglion cyst, meniscal cyst, loose body or nodular synovitis. The existence of an infrapatellar fat pad may not be related to the presence of joint effusion.

Duplex sonography of the carotid arteries in patients with pure aortic regurgitation: pulse waveform and hemodynamic changes and a new indicator of the severity of aortic regurgitation.

PURPOSE: To determine the changes of multiple hemodynamic parameters and pulse wave contour in pure aortic regurgitation (AR) and to present a new indicator of the severity of AR (shrink ratio of proximal common carotid artery). MATERIAL AND METHODS: The sonograms of 42 patients (31 M, 11 F; 16-68 years) with pure AR and 18 control subjects (15 M, 3 F; 20-47 years) were assessed for velocities and indices, and change of pulse wave contour (bisferious pattern, zero level and retrograde diastolic flow) in each carotid artery. Shrink ratio (maximum diameter-minimum diameter/maximum diameter) of each proximal common carotid artery was calculated. RESULTS: Bisferious waveforms seen in patients with AR grade 1, grade 2, and grade 3-4 were 66%, 83%, and 88%, respectively. Diastolic reversed flow was determined in 7 (39%) of 18 patients with AR grade 3-4. Three patients (25%) with AR grade 2 and 4 patients (22%) with AR grade 3-4 had zero level diastolic flow in the common carotid artery. Statistically significant changes of decreased end-diastolic velocity, increased peak systolic velocity/end-diastolic velocity, resistivity index, and pulsatility index were revealed, especially in AR grade 3-4 compared to controls. Significantly increased shrink ratio was seen only in AR grade 3-4. CONCLUSION: Increased shrink ratio or changes in hemodynamics or pulse waveform can be used in recognition of AR.

Emergency endovascular embolization of traumatic intrarenal arterial pseudoaneurysms with N-butyl cyanoacrylate.

AIM: The aim of this study is to report the effectiveness of selective endovascular embolization with N-butyl cyanoacrylate (NBCA) in the treatment of traumatic intrarenal arterial pseudoaneurysms. MATERIALS AND METHODS: Five patients (four males and one female) presented with massive haematuria. Five pseudoaneurysms were detected angiographically, and in all of the cases the aetiology was penetrating trauma. The pseudoaneurysms ranged in size between 7 and 30 mm (mean: 13.8 mm). After the superselective catheterization with a microcatheter-microguidewire system, embolization was performed using NBCA and Lipiodol mixture. RESULTS: All the pseudoaneurysms were successfully embolized and excluded from the circulation without any other major intrarenal arterial branch occlusion. There were no major or minor complications related to the embolization procedures. Haematuria ceased in 1-3 days after the embolization, and during the follow-up period both re-bleeding and deterioration of renal function did not occur. CONCLUSION: The endovascular management of renal artery branch pseudoaneurysms by embolization with NBCA is a reasonable and an effective therapeutic technique.

The value of ultrasonography in interrupted inferior vena cava with azygos continuation.

The cardiosplenic syndromes represent a complex set of abnormalities of the thorax and viscera resulting from abnormal folding of the embryo during early development. Anomalies of venous development include interruption of inferior vena cava (IVC), and in combination with situs inversus referred to as the polysplenia syndrome. We present a 23-year-old male previously diagnosed as having a persistent left IVC on venography whereas ultrasonographic examination clearly demonstrated interrupted IVC with azygos continuation along with situs inversus.