The Extended Fetal Cardiac Examination: Is It Feasible in a High-Risk Practice?

The aims of this study were to demonstrate the feasibility of obtaining additional cardiac views as proposed on an extended fetal cardiac examination and to see if there was any variation in individual components of that examination stratified by sonographer training, patient body habitus, or equipment. We retrospectively reviewed 200 consecutive detailed second-trimester high-risk fetal obstetric sonograms that included additional extended cardiac views. We analyzed the percentage of the time individual views were obtained, with variation based on (1) a sonographer with greater than 3 years of training compared with a group with 6 to 12 months of training, (2) 2 different ultrasound units, and (3) different body mass indices. Overall, the highest rate of visualization was achieved with the 4-chamber view (98.2%), whereas the 3-vessel tracheal view had the lowest percentage of visualization (40.2%), among the less experienced sonographers. Differences in successful completion of the extended cardiac views were not statistically different between the sonographer with a level of training greater than 3 years as compared with those with 6 to 12 months' training except for the 3-vessel tracheal view (P < 0.001). There is no statistically significant difference in our ultrasound equipment, when considering only inexperienced sonographers. Increasing body mass index had an inverse relationship with obtaining the components of the detailed cardiac examination. Using state-of-the-art ultrasound equipment and with focused additional training of obstetric sonographers, the majority of extended cardiac views can be obtained. There are exceptions.

A reminder of peristalsis as a useful tool in the prenatal differential diagnosis of abdominal cystic masses.

With routine antenatal ultrasound and recent advances in ultrasound technology, fetal intraabdominal cystic masses are recognized more often and are better characterized than in the past. They may be classified as solid and cystic, and may originate from multiple structures. When considering the extensive differential diagnosis of cystic masses, the observation of peristalsis narrows the possibilities to the gastrointestinal tract. To find this feature on ultrasound, the examiner must expressly think and look for it, otherwise it may be missed. Our case report illustrates one of those cases.

Fetal ultrasound: Early diagnosis and natural evolution of proximal femoral focal deficiency.

Proximal femoral focal deficiency is an extremely rare congenital anomaly with only a few case reports in the literature. This case illustrates one diagnosed by prenatal ultrasound. The diagnosis may be isolated or associated with other abnormalities and syndromes. This report describes the early obstetrical ultrasound diagnosis, its evolution and associated findings throughout pregnancy. To the best of our knowledge, it is the first report associating this diagnosis with sickle cell trait. Another finding in our patient was a concomitant intrauterine growth restriction that we attribute to placental infarctions and a retro placental hemorrhage, also on the basis of sickle cell trait. At birth, placental weight was under the 10th percentile for gestational age. Obstetrical ultrasound in the prenatal diagnosis of proximal femoral focal deficiency is important, because early recognition of this malformation could provide useful information to parents and physicians regarding newborn management and therapeutic planning.

Intra-renal splenosis mimicking a solid renal mass.

We present the case of a young woman found to have an exophytic solid renal mass who was referred to our institution for ablation of said mass versus partial nephrectomy. The patient had a history of splenectomy. Ultrasound demonstrated a homogeneous solid left renal mass, and the diagnosis of intra-renal splenosis was considered based on the patient's history. The diagnosis was confirmed using Tc-99 m heat-damaged red blood cell scintigraphy, obviating the need for an invasive procedure. The diagnosis of intra-renal splenosis should be considered for a solid renal mass with an appropriate history of prior splenic trauma or splenectomy.

Renal Cell Carcinomas: Sonographic Appearance Depending on Size and Histologic Type.

OBJECTIVES: Prior studies have demonstrated that approximately 10% of malignant renal cell carcinomas are as echogenic as angiomyolipomas on sonography. However, a recent presentation suggested that small (<1-cm) echogenic renal masses are always angiomyolipomas or other benign entities. We therefore examined our own cases of renal cell carcinoma, with corresponding sonography, to confirm that some renal cell carcinomas may also be detected as hyperechoic masses on sonography. METHODS: Institutional Review Board approval and Health Insurance Portability and Accountability Act compliance were maintained for this retrospective review of 91 pathologically proven cases of renal cell carcinoma, with corresponding sonography. Tumors were first differentiated by histologic cell type (clear cell, papillary, and chromophobe). Tumors were then stratified according to 2 size group parameters, falling into those that were 3 cm or larger and those that were smaller than 3 cm in diameter, with the less than 3-cm group further subdivided into 2 cm or smaller and greater than 2 cm. Tumor echogenicity was graded on a 5-point scale with respect to the renal parenchyma. RESULTS: Forty-six tumors (51%) were 3 cm in diameter or smaller, and most were found to be either isoechoic (35%) or mildly hyperechoic (26%) to the surrounding renal parenchyma. Of tumors smaller than 2 cm, most were either mildly hyperechoic (29%) or as hyperechoic as renal sinus fat (very hyperechoic; 29%). Tumors larger than 3 cm were found most often to be either isoechoic (49%) or mildly hyperechoic (33%), with only 4% found to be very hyperechoic. CONCLUSIONS: The sonographic appearances of renal cell carcinomas include a small population that are very hyperechoic on sonography and thus could potentially be misdiagnosed as angiomyolipomas.

Sonographic appearance of a dermoid cyst (mature cystic teratoma) of the spleen.

Splenic dermoids are rare, with few published case reports and no ultrasound images in the English literature. We report the case of a 57-year-old woman with that diagnosis and illustrate it with ultrasound, CT, and pathology images. We discuss the differential diagnosis of solid splenic lesions.

Sonographic appearance of adnexal torsion, correlation with other imaging modalities, and clinical history.

This pictorial essay illustrates the varied imaging appearances of adnexal torsion and its diagnostic pitfalls. This is a difficult diagnosis with many false positives and false negatives. Diagnosis is mostly based on clinical history and ultrasound examination, with computed tomography and/or magnetic resonance used to support the diagnosis and to exclude other pathologies.

Differentiation of ovarian endometriomas from hemorrhagic cysts at MR imaging: utility of the T2 dark spot sign.

PURPOSE: To determine sensitivity and specificity of the T2 dark spot sign in helping to distinguish endometriomas from other hemorrhagic adnexal lesions. MATERIALS AND METHODS: This HIPAA-compliant, institutional review board-approved retrospective study, with informed consent waived, included 56 women (mean age, 38.8 years; range, 18-66 years). With a radiology database search of pelvic magnetic resonance images from December 16, 2002, to July 24, 2012, 74 cystic hemorrhagic adnexal lesions with hyperintense signal on T1-weighted images were identified. Lesions were excluded if they had solid enhancing components. Final diagnosis was established with pathologic analysis for all endometriomas and neoplasms. Hemorrhagic cysts were diagnosed with pathologic analysis (n = 7), follow-up imaging (n = 13), or prior ultrasonography (n = 5). Two radiologists independently reviewed cases and recorded the presence or absence of T2 shading and T2 dark spots. T2 dark spots were defined as discrete, well-defined markedly hypointense foci within the adnexal lesion on T2-weighted images. Sensitivity, specificity, and positive and negative predictive values of the T2 dark spot sign in distinguishing endometriomas from nonendometrioma hemorrhagic lesions were calculated. RESULTS: Sixteen of 45 endometriomas (36%), zero of 25 hemorrhagic cysts, and two of four neoplasms (50%) (all serous cystadenomas) demonstrated T2 dark spots. Forty-two of 45 endometriomas (93%), 12 of 25 hemorrhagic cysts (48%), and four of four neoplasms (100%) demonstrated T2 shading. Sensitivity, specificity, positive predictive value, and negative predictive value of T2 dark spots for differentiating endometriomas from other hemorrhagic cystic ovarian masses were 36% (95% confidence interval [CI]: 19.8, 51.3), 93% (95% CI: 83.9, 100), 89% (95% CI: 63.9, 98.1), and 48% (95% CI: 34.8, 61.8), respectively, and for T2 shading, they were 93% (95% CI: 84.0, 100), 45% (95% CI: 27.8, 61.9), 72% (95% CI: 58.9, 83.0), and 81% (95% CI: 53.7, 95.0), respectively. CONCLUSION: The T2 dark spot sign has high specificity for chronic hemorrhage and is useful to differentiate endometriomas from hemorrhagic cysts. The T2 shading sign is sensitive but not specific for endometriomas. Online supplemental material is available for this article.

Methamphetamine use can mimic testicular torsion.

We report the case of a patient presenting with the classic clinical appearance of testicular torsion. Ultrasound showed testicular ischemia supporting the clinical diagnosis, but the lack of visualization of spermatic cord torsion was of concern. An attempt of clinical detorsion was considered unsuccessful and the patient was explored. No torsion was found. On postoperative review of the patient's medical history, we found methamphetamine use, with a positive urine test at the time of his emergent consultation for the scrotal pain episode. The use of amphetamines has been previously reported as the cause of ischemia of multiple organs, but we could not find previous reports of involvement of the testis mimicking torsion.

Ovarian fibromas and fibrothecomas: sonographic correlation with computed tomography and magnetic resonance imaging: a 5-year single-institution experience.

OBJECTIVES: To evaluate imaging characteristics of ovarian fibromas and fibrothecomas and to identify select clinical markers and imaging features to help in their diagnosis. METHODS: Over a 5-year period, 18 of 29 women with histologically proven fibromas or fibrothecomas underwent sonography, computed tomography (CT), or magnetic resonance imaging (MRI). On review of the images, tumor size, solid component characteristics, and cystic components were evaluated. Age, cancer antigen 125 (CA-125), and Meig syndrome were assessed. RESULTS: Eleven fibrothecomas and 7 fibromas were evaluated. Sonography was performed for 15 tumors, CT for 9, and MRI for 6. Mean age was 52.6 (range, 13-82) years. Mean tumor size was 8.8 (range, 2-18) cm. Seventy-two percent of the tumors were solid, and 28% had cystic components. On sonography, the solid components were isoechoic or hypoechoic compared to the uterus. On CT with contrast, 2 of 8 lesions (25%) showed enhancement. On T1-weighted MRI, 5 lesions (83%) showed an isointense signal, and 1 (17%) showed a hyperintense signal compared to the myometrium. On T2-weighted MRI, 4 of 6 lesions (67%) were hypointense; 1 (16.5%) was isointense; and 1 (16.5%) was hyperintense. Elevated CA-125 was present in 5 of 29 patients (28%). One had Meig syndrome. CONCLUSIONS: For a cystic adnexal mass where the primary consideration is commonly an epithelial tumor, the possibility of a cystic stromal tumor should also be considered. Unlike previous studies reporting both T1 and T2 hypointensity, fibrothecomas and fibromas can also show T1 and T2 isointensity and, exceptionally, hyperintensity. Vascularity, shown by Doppler flow and MRI and CT enhancement, is a characteristic of some fibromas and fibrothecomas. Although CA-125 is elevated in some patients, a true correlation is difficult to assess. Meig syndrome is infrequent.

Comparison of single versus multiple echogenic foci in the fetal heart regarding risk of aneuploidy.

OBJECTIVE: The purpose of this study was to investigate whether multiple echogenic cardiac foci (ECF) are associated with an increased risk of fetal trisomy 21 in our patient population. METHODS: During a span of 38 months, all women found to have an ECF on obstetric sonography were identified as study patients and grouped into single- and multiple-ECF groups. Age- and race-matched patients were identified as a control group. Fetal anatomic sonographic examinations were assessed for other markers of aneuploidy and major abnormalities. The baseline risk for trisomy 21 was assessed by maternal serum screening or age alone if no serum screening had been performed. Trisomy 21 was assessed by amniocentesis or clinically at birth. Both univariate and multivariate analyses were used to assess for associations with trisomy 21. RESULTS: Six of 71 patients (8.5%) with multiple ECF and 1 of 171 patients (0.6%) with a single ECF had trisomy 21. One of 242 control patients (0.4%) had trisomy 21. Logistic regression found multiple ECF (P < .008), the presence of a major finding or multiple minor findings (P = .0012), and a baseline risk for trisomy 21 of greater than 1 in 100 (P = .003) as independent associations with trisomy 21. CONCLUSIONS: Our results suggest that finding multiple ECF is a stronger predictor of trisomy 21 than what is described for a single ECF.

Increased rotational mobility of the testis after vasectomy: a sonographic study.

OBJECTIVE: The purpose of this study was to evaluate for increased mobility of the testis in postvasectomy patients by observing changes in the position of the testis-epididymis complex (TEC). METHODS: This was a retrospective study of 29 postvasectomy patients compared with 29 control patients without a history of vasectomy who were referred for scrotal sonography for various clinical indications over a 1 year-period. The position of the TEC was compared between the two groups. RESULTS: The post-vasectomy group had medial or posteromedial rotation in 13 of 58 testes (22%) compared with 3 of 58 (5%) in the control group. CONCLUSIONS: Our study found a statistically higher incidence of medial rotation of the testis in the vasectomy group compared with the control group. Given our findings, it seems reasonable to assume that iatrogenic changes to the structural support mechanism of the testis occur when vasectomy is performed, with a resultant increase in the mobility of the testis within the scrotum.