Morphometric evaluation of sesamoid bones of the first metacarpophalangeal joint with ultrasound.

OBJECTIVE: The purpose of our study is to demonstrate the role of ultrasound as a first-line technique in the evaluation of sesamoid bones of the first metacarpophalangeal joint. MATERIALS AND METHODS: In a 2 years period, we enrolled 117 healthy people, 60 men and 57 women, age range 24-35 years, mean 29 ± 4. We analysed both their ulnar and radial sesamoid bones within the metacarpophalangeal joint of the 1st finger of the dominant hand. RESULTS: For each sesamoid we measured the short and long axes diameter (mm); additionally, the relation between these parameters was used to calculate the Sesamoid Index, a classic radiographic index generally used to obtain volumetric information on the sesamoids. Additionally, we introduced and measured another index (the "Subsesamoid Index"), which we believe might be useful to measure the subsesamoid joint space. CONCLUSIONS: Ultrasound is able to provide all the anatomic information needed during the evaluation of sesamoid bones, thus replacing conventional radiography as the first-line diagnostic approach.

Ultrasonographic detection of synovial sarcoma of the knee.

In this case report is presented a 60 years-old patient with right knee periarticular synovial sarcoma in whom the final diagnosis was primarily assumed on the basis of an US examination. The usefulness of this diagnostic technique and the peculiar signs of SS are discussed.

The intersection syndrome: Ultrasound findings and their diagnostic value.

INTRODUCTION: The intersection syndrome is a well-known overuse syndrome of the distal forearm. It is characterized by noninfectious, inflammatory changes involving the area of intersection of the first (abductor pollicis longus and extensor pollicis brevis) and second (extensor carpi radialis longus and extensor carpi radialis brevis) extensor compartments in the dorsoradial aspect of the distal forearm. Imaging modalities used to diagnosis this syndrome include ultrasonography (US) and magnetic resonance imaging. The purpose of this report is to describe typical US findings in the intersection syndrome and to demonstrate the diagnostic value of this approach. MATERIALS AND METHODS: We reviewed US findings in 4 patients (mean age 40 years) referred to our staff for symptoms suggestive of the intersection syndrome (pain, swelling, erythema, and edema of the wrist). RESULTS: In all 4 cases, the US examination revealed peritendinous edema and synovial fluid within the tendon sheaths at the intersection between the first and the second dorsal extensor tendon compartments. DISCUSSION: Our experience shows that the intersection syndrome is associated with typical signs on US. This imaging modality can be considered a reliable tool for diagnosing this syndrome and may eliminate the need for other more expensive tests.

Ultrasound picture of a wooden splinter evolved in phlegmon of the hand.

INTRODUCTION: To demonstrate the usefulness of ultrasound (US) in quickly and effectively diagnosing the presence of a foreign body in the superficial soft tissues. MATERIALS AND METHODS: A young lumberjack underwent US examination due to pain and swelling of the back of his right hand. These symptoms are often due to the presence of a wooden splinter. RESULTS: On the back of the right hand, US demonstrated a hyperechoic line with acoustic shadowing surrounded by a hypoechoic halo suggesting a foreign body. Next to it in the same area, several hypoechoic areas were observed. CONCLUSIONS: US can quickly identify the exact position of a foreign body embedded in the skin and soft tissues; US can furthermore provide information about the inflammatory process and its spreading.

64-slice MDCT arthrography in shoulder instability: our experience.

PURPOSE: This study was performed to assess the diagnostic accuracy of air-contrast 64-slice multidetector computed tomography (MDCT) arthrography in the evaluation of glenohumeral joint instability by comparison with conventional arthroscopy. MATERIALS AND METHODS: Fifty patients with a history of shoulder instability underwent MDCT arthrography with thin collimation scans. The raw data were transferred to a workstation and processed using multiplanar reformation (MPR) and volume rendering (VR) algorithms. All patients subsequently underwent conventional arthroscopy. The results of the two techniques were compared and their sensitivity and specificity calculated. RESULTS: We diagnosed eight anterosuperior labrum lesions (group 1), 32 anteroinferior labrum lesions (group 2) and two posterior labrum lesions (group 3). Overall sensitivity and specificity (groups 1, 2, 3) were 88% and 100%, respectively. In group 1, sensitivity was only 66% (four false negatives), whereas in groups 2 and 3, it was 94% (two false negatives) and 100%, respectively. The labrum lesions were also found to be associated, with 100% sensitivity and specificity, with 20 lax capsules, 17 Hill-Sachs lesions, five Bankart lesions, two Perthes lesions and three complete rotator-cuff tears. CONCLUSIONS: Air-contrast MDCT arthrography is fast, reproducible, well tolerated and very accurate in the evaluation of lesions causing shoulder instability.

US evaluation and diagnosis of rupture of the medial head of the gastrocnemius (tennis leg).

PURPOSE: The aim of this study is to demonstrate the diagnostic accuracy of ultrasonography (US) in the diagnosis of rupture of the medial head of the gastrocnemius muscle, also called "tennis leg" (TL). MATERIALS AND METHODS: Thirty-five consecutive patients with acute traumatic injury of the calf underwent US examination. There were 25 men and 10 women; mean age 47.5 years (range 35-60 years). All examinations were performed using a 5-12 MHz broadband electronic linear array probe. RESULTS: Thirty-three out of 35 patients had TL; 24 cases of partial rupture and nine cases of complete rupture were diagnosed. In the remaining two cases, both with symptoms suggesting TL, one patient had a tear of the proximal musculotendinous junction and one had a ruptured Baker's cyst. Fluid collections caused by the muscular rupture were visible as hypoechoic areas; in 80% of cases associated by a hyperechoic oval area due to hematoma and local inflammation. The degree of fluid collection in the patients with complete rupture (6-16 mm; mean: 9.7 mm) was significantly greater than the one seen in patients with partial rupture (4-8 mm; mean: 6.8 mm). CONCLUSIONS: US is the imaging modality of choice in clinical suspicion of TL, both in the initial workup of the patient and in the follow-up. US is easy to perform and is particularly useful to distinguish TL from other pathologies, especially ruptured Baker's cyst and deep vein thrombosis, which require a different therapeutic management.

Transrectal colour Doppler contrast sonography in the diagnosis of local recurrence after radical prostatectomy--comparison with MRI.

OBJECTIVE: To assess the usefulness of colour power-Doppler transrectal sonography before/after contrast agent in the detection of local recurrence in patients with rising prostate-specific antigen values after radical prostatectomy and to compare with magnetic resonance imaging . MATERIALS AND METHODS: 18 patients with rising prostate-specific antigen values after prostatectomy underwent digital rectal examination, bone scintigraphy, magnetic resonance imaging, transrectal colour power-Doppler sonography before/after contrast agent, and transrectal sonography-guided biopsy. Sensitivity, specificity, accuracy, positive and negative predictive values were calculated. Results were correlated using McNemar binomial 2-tailed P-test. RESULTS: Baseline and contrast-enhanced transrectal colour power-Doppler sonography and contrast-enhanced magnetic resonance imaging identified recurrent disease in 6, 10 and 10 patients, respectively. Biopsy confirmed recurrence in 10 patients, but was positive also in 2 additional patients who were negative at contrast-enhanced transrectal colour power-Doppler sonography and contrast-enhanced magnetic resonance imaging. The remaining 6 patients were negative also at diagnostic imaging and biopsy after 30 days. Grey-scale transrectal sonography values were: sensitivity 91.7 %, specificity 66 %, PPV 91.6 %, NPV 40 %. Baseline colour power-Doppler transrectal sonography values were: sensitivity 38.5 %, specificity 85 %, diagnostic accuracy 50 %, PPV 83.3 %, NPV 33.3 %. Contrast enhanced colour power-Doppler transrectal sonography and magnetic resonance imaging values were: sensitivity 76.9 %, specificity 100 %, diagnostic accuracy 83.3 %, PPV 100 %, NPV 62.5 %. CONCLUSION: Contrast-enhanced transrectal colour power-Doppler sonography increases specificity in the detection of local recurrence after prostatectomy. Magnetic resonance imaging yields equivalent accuracy. Biopsy remains the diagnostic gold standard, but the use of imaging methods may reduce the number of biopsies.

Ultrasonography in follow-up of soft tissue augmentation of the face with synthetic materials: a pilot study.

PURPOSE: To assess ultrasonography in the evaluation of reactions after soft tissue augmentation of the face with synthetic materials. MATERIAL AND METHODS: Six female patients (mean age 39+/-8 years) treated for facial tissue augmentation noticed unpleasant or painful effects in the intervention site after a mean of 24 months were evaluated with ultrasonography. Two patients had been treated with injections of microparticles, two with Gore-Tex implants, and two had been injected with liquid silicone. Fifteen female patients (age 27-55 years, mean 41+/-14 years) who had received the same treatment 14-48 months before without any complications were also evaluated and used as controls. Biopsy was performed in all patients, while four underwent re-intervention. RESULTS: In all patients with Gore-Tex implants, a thick, homogeneous hypoechoic halo was seen surrounding the implants. Small hypoechoic nodules were noticed in the patients who had been treated with microparticles and with liquid silicone. In two cases treated with liquid silicone the subcutaneous tissue was invaded by an irregular area of marked inhomogeneity. CONCLUSION: Sonography must be considered the method of choice for producing instrumental evidence of foreign body reactions after soft tissue augmentation of the face with synthetic materials.

Power Doppler sonography in knee arthritis--a pilot study.

We compared power Doppler sonography to laboratory indices of disease activity in patients with knee arthritis to determine the clinical relevance of hypervascularity. Eight healthy volunteers and 22 patients with symptoms and signs of knee arthritis were studied. Presence or absence of hypervascularity, synovial thickening, effusion, and Baker's cysts were recorded. Disease activity was measured by erythrocyte sedimentation rate, c-reactive protein, alpha2-globulins, sideremia, hemoglobinemia, and serum white cell count. Various grades of synovial hyperemia were found in 12/22 cases. Patients with and without synovial hypervascularity showed statistically significant differences in age (P=0.017), erythrocyte sedimentation rate (ESR) (P = 0.039), hemoglobinemia (P = 0.009), and sideremia (P = 0.012). Power Doppler sonography is able to demonstrate synovial hyperemia, which is correlated with some laboratory indices of inflammation.

Sonography of the cervical vagus nerve: normal appearance and abnormal findings.

OBJECTIVE: The purpose of this study was to assess the appearance of the cervical vagus nerve in healthy individuals and to investigate the potential role of sonography in revealing neck masses that cause vagal dysfunction. SUBJECTS AND METHODS: We examined 150 consecutive patients. In 144 patients the presence of thyroid, salivary gland, or lymph node disease was suspected. In three patients a cervical mass was palpable, and three patients had symptoms of dysfunction of the inferior laryngeal or vagal nerves. The pathologic diagnoses of the masses were obtained at biopsy. RESULTS: In 144 individuals the normal vagus nerve was recognized on each side of the neck as a thin band that occupied the posterior angle formed by the common carotid artery and the internal jugular vein. Three patients had tumors arising from the vagus nerve: one neurofibroma, one neurinoma, and one chemodectoma. These tumors were located in the neurovascular bundle and posterior to the vessels; their origin from the vagus nerve was clearly visible in all patients because of the contiguity of the mass with the nerve bundle. In the other three patients, sonography revealed an extrinsic mass that compressed and displaced the vagus nerve out of its longitudinal axis; two cases were hyperplastic nodules of the thyroid, and in one case the nodule was a branchial cyst. CONCLUSION: Sonography can reveal the vagus nerve in healthy conditions and correctly reveal the vagal origin of some tumors in the parapharyngeal spaces.

Ultrasound of the elbow.

Ultrasonography (US) is an efficient alternative to magnetic resonance (MR) imaging for evaluation of soft tissues of the elbow. US is able to diagnose several abnormalities affecting tendons, muscles, ligaments and bursae around the elbow joint. In cubital tunnel syndrome, US identifies ulnar nerve abnormalities and extrinsic lesions that may cause nerve entrapment. Occult fractures, osteophytes and intra-articular loose bodies can also be imaged. In para-articular swelling, US is able to assess the presence of capsular and synovial processes and to differentiate them from soft tissue tumors. Key advantages of this technique include cost-effectiveness, availability and ability to perform a dynamic examination.

Identification of feeding arteries to establish the intra- or extraparotid location of jugulodigastric nodules: value of color Doppler sonography.

OBJECTIVE: The objective of our study was to determine the value of color Doppler imaging as an adjunct to gray-scale sonography to reveal the intra- or extraparotid origin of jugulodigastric nodules of uncertain location. SUBJECTS AND METHODS: Forty nodules in the jugulodigastric area from 38 patients were imaged with gray-scale, color, and power Doppler sonography. Nodules receiving vessels from salivary glands were assumed to be intraglandular; those accepting vessels from paraparotid spaces were considered to arise from outside the gland. Imaging results were correlated with biopsy and surgical findings. RESULTS: In 38 of 40 cases, color and power Doppler sonography displayed discrete feeding arteries leading to the nodules: 25 nodules had one supplying artery, nine received two arteries, and four had three or more arteries. Intraparotid nodules received vessels from the gland in 20 cases. In two cases, the source of vessels was indeterminate. In two malignant tumors, multiple arteries derived from both the parotid and the neck spaces. All 14 extraparotid nodules received the arterial supply from paraparotid spaces. Color Doppler sonography enabled prediction of the intraglandular location of the nodules in 91% of cases and the extraglandular location in 87.5% of cases. The correct diagnosis was achieved in 34 of 40 nodules, with a global accuracy of 85%. CONCLUSION: Color Doppler sonography can help to assess the intra- or extraparotid location of jugulodigastric nodules. In practice, this technique can support the diagnosis when gray-scale sonography raises doubts about the origin of a jugulodigastric nodule.

Sonography of lacrimal glands in Sjögren syndrome.

This study evaluates the potential role of high resolution sonography and color Doppler sonography in the evaluation of the lacrimal glands in Sjögren syndrome. We examined 15 women (age range, 52-73 years) affected by Sjogren syndrome and 15 women with no history and signs of lacrimal disease (age range, 47-75 years). The lacrimal glands were visualized bilaterally in 6 of 15 patients. The lacrimal artery was detectable in all patients; the resistive index was higher than normal (0.72+/-0.04). An abnormal Schirmer test was present in six of six patients with visible glands and in two of nine patients with invisible glands; xerophthalmia was present in six of six patients with visible glands and in four of nine patients with invisible glands; high levels of serum immunoglobulins were present in six of six patients with visible glands and in three of nine patients with invisible glands. Sonography is able to provide noninvasively much of the information needed by the clinician.

[A statistical evaluation of the variability in the measurements of the resistive index in kidney transplantation]. / Valutazione statistica della variabilità nelle misurazioni dell'indice di resistenza nel trapianto renale.

INTRODUCTION: Doppler ultrasound (US) is a valuable tool to measure blood flow in the transplanted kidney, but its operator-dependence can greatly affect repeatability and reproducibility of measurements. Aim of this work was to evaluate intraobserver and interobserver variability in measuring the resistive index (RI) in renal transplants. PATIENTS AND METHODS: Ten renal transplant recipients were randomly selected among those undergoing follow-up and examined by two operators (FG and LB) with 3.5 MHz and 10 MHz scanheads to assess the variability of RI measurements. Each observer obtained two measurements of the RI with each scanhead within a 10-15 minutes' period. In all, 80 measurements were made, 4 per patient per observer. The statistical analysis included two-tailed Student's t-test for paired data and calculation of repeatability/reproducibility coefficients. RESULTS: Student's t-test analysis demonstrated a statistically significant difference (p = 0.037) between the means of the first and second measurements by FG with the 3.5 MHz scanhead and the first and the second measurements by LB with the same scanhead. Differences between the other means were not statistically significant. Intraobserver variability ranged 0.03 units (or 2.07%) and 0.07 units (or 4.24%), while interobserver variability was 0.04 units with both 3.5 and 10 MHz scanheads, or 3.61 and 3.73%, respectively. CONCLUSIONS: Doppler US of renal transplants has statistically quantifiable operator-dependent variability: the possible evidence of statistically significant differences can be minimized by having the same operator make the measurements. However, RI variations ranging 0.02 to 0.04 units should not be considered significant.

[Doppler ultrasonography of the upper mesenteric artery in chronic intestinal inflammation]. / L'eco Doppler dell'arteria mesenterica superiore nelle infiammazioni croniche intestinali.

PURPOSE: We evaluated the importance of dynamic studies of the superior mesenteric artery in defining the abnormal parameters that could help diagnose an inflammatory bowel disease. MATERIAL AND METHODS: Our patient population consisted of 10 normal subjects, 10 patients with active and 10 with inactive Crohn disease; 10 patients with celiac disease were also examined, before treatment and then after 6 months' dieting. We used a 5 MHz transducer, with 2.8 MHz Doppler frequency and PRF of 5 KHz; longitudinal scans were performed at 2-3 cm from the origin, with 50-60 degrees Doppler angle. The examination was performed after overnight fasting and at least 5 minutes' supine recumbency and then repeated 15 minutes after ingestion of a liquid meal. We measured the resistive index (RI) both on fasting and after the meal; the parameter defined as resistive difference (RD) was used to measure postprandial changes in resistance. RESULTS: In the healthy volunteers, RI on fasting was 0.81 +/- 0.02, versus 0.67 +/- 0.03 after the meal (RD 0.14 +/- 0.2). In the patients with inactive Crohn disease, RI on fasting was 0.82 +/- 0.03, versus 0.69 +/- 0.04 15 minutes after the meal (RD 0.13 +/- 0.3). In the patients with active Crohn disease, RI on fasting was 0.78 +/- 0.03, versus 0.70 +/- 0.02 after the meal (RD 0.08 +/- 0.03). In the patients with untreated celiac disease, RI on fasting was 0.78 +/- 0.05, versus 0.74 +/- 0.01 15 minutes after the meal (RD 0.04 +/- 0.01). In the patients with treated celiac disease, RI on fasting was 0.79 +/- 0.03, versus 0.70 +/- 0.02 after the meal (RD 0.09 +/- 0.02). CONCLUSIONS: The evaluation of postprandial flow changes in the mesenteric district is of more than physiologic interest because it can be the only way to detect an inflammatory disease which becomes apparent only during functional stress. Doppler US can therefore be proposed as a follow-up method to assess acute phase regression.

[Doppler color in superficial adenopathies]. / Il color Doppler nelle adenopatie superficiali.

INTRODUCTION: Superficial lymph nodes are frequently involved in different diseases. Their location makes them suitable for effective assessment with high-resolution US and color Doppler has been recently suggested as a tool for increasing sensitivity in lymph node studies. Thus, we investigated the main vascular patterns detectable in abnormal superficial lymph nodes. PATIENTS AND METHODS: We evaluated 260 nodes in 180 adult patients; the nodes were located in the cervicofacial ring (78, 30%), internal jugular stations (104, 40%), and supraclavicular (44, 17%), axillary (21, 8%), and inguinal (13, 5%) stations. Color Doppler was performed with 7.5-13 MHz linear transducers, with parameters adjusted for slow-flow detection (5-6 MHz frequency, 700-900 Hz PRF, 50 Hz band filter, high color persistence). Disease assessment required fine-needle biopsy (95 nodes in 95 patients) and clinical follow-up (165 nodes in 85 patients). RESULTS: Fifty-five nodes (21%) presented acute and 130 (50%) chronic inflammation: 75 nodes (29%) were metastatic. The following vascular patterns were detected: a single vascular pole (type I) was seen in chronic inflammation (72% sensitivity, 86% specificity, 57% positive and 92% negative predictive value); an enlarged single vascular pole, with 2-3 enlarged branches (type II) in acute adenitis (80% sensitivity, 81% specificity, 78% positive and 83% negative predictive value); multiple vascular poles with many deformed and displaced branches converging centrally (type III) in metastases (76% sensitivity, 100% specificity, 100% positive and 91% negative predictive value). CONCLUSIONS: We conclude that color and power Doppler are useful integrations to B-mode US because they can detect specific signs of malignancy such as peripheral vascular poles and intranodal displacement of vessels.

Color Doppler sonography of focal lesions of the skin and subcutaneous tissue.

We evaluated with color Doppler sonography 71 visible and palpable nodules of the skin and subcutaneous tissue from 51 patients. The nodules were classified as avascular (type I), hypovascular with a single vascular pole (type II), hypervascular with multiple peripheral poles (type III), and hypervascular with internal vessels (type IV). Of the 32 malignant nodules, 9% showed a type I pattern, 50% had a type III pattern, and 41% had a type IV pattern; of the 39 benign nodules, 86% showed a type I pattern and 14% had a type II pattern. The sensitivity and specificity of hypervascularity in malignant lesions were 90% and 100%, respectively, whereas the sensitivity and specificity of hypovascularity in benign lesions were 100% and 90%, respectively. The authors conclude that color Doppler sonography is able to increase the specificity of ultrasonography in the evaluation of nodular lesions of the skin.

Evaluation with Doppler sonography of mesenteric blood flow in celiac disease.

OBJECTIVE: The aim of this study was to investigate with Doppler sonography the variations of resistance in the superior mesenteric artery, both at fasting and in the postprandial state, in patients with celiac disease. SUBJECTS AND METHODS: Twenty-five patients with celiac disease (20 women, five men; mean age, 30 +/- 7 years) and 10 healthy volunteers (seven women, three men; mean age, 28 +/- 6 years) were examined with Doppler sonography. Nineteen patients were untreated (no dietary restrictions) and six patients were treated with a gluten-free diet at the time of the examination. Imaging was performed at both fasting and 15 min after an 1890-kJ meal. We introduced a parameter called "resistive difference," defined as the mathematic difference between the resistive index measured at fasting (highest value) and that measured at 15 min after the meal (lowest value) as a way to express the postprandial resistive change in the superior mesenteric artery. RESULTS: Untreated patients with flat mucosa showed a resistive difference of 0.03 +/- 0.05, followed by untreated patients with mucosal subatrophy (0.05 +/- 0.04), treated patients (0.09 +/- 0.02), and healthy volunteers (0.12 +/- 0.04). A statistically significant difference was noticed between the resistive difference of healthy volunteers and both those of the untreated patients with subatrophy (p = .016) and of the patients with complete atrophy (p = .011), as well as between the resistive difference of the treated patients and both those of the untreated patients with subatrophy (p = .021) and of the patients with complete atrophy (p = .020). CONCLUSION: We believe that Doppler measurement of resistive difference in the superior mesenteric artery can be an effective way to express severity of celiac disease and to document its regression after diet therapy.

Doppler sonography of the superior mesenteric artery in Crohn's disease.

OBJECTIVE: The aim of this study was to evaluate blood flow in the superior mesenteric artery (SMA) in patients with active and inactive Crohn's disease (CD) using Doppler sonography to dynamically assess the changes of resistance in both fasting and postprandial states. SUBJECTS AND METHODS: Doppler sonography of the SMA was performed on 15 patients (mean age, 38 +/- 4 years) with active CD and on 15 patients (mean age, 41 +/- 5 years) with inactive CD. Imaging was performed at both fasting and 15 min after an 1890-kJ meal. A preliminary examination of 10 healthy volunteers with no signs of intestinal disease (mean age, 28 +/- 2 years) was necessary to define the parameters of normality. Because we wanted to express the postprandial resistive change in the SMA, we introduced a parameter called resistive difference (RD), defined as the mathematic difference between the resistive index measured at fasting (highest value) and measured at 15 min after the meal (lowest value). RESULTS: By evaluating the relationship between the RD and extension of disease, we found a direct correlation between progressive extension of disease and reduction of the RD in patients with active CD (correlation coefficient, .98) whereas we found no such correlation in patients with inactive CD (correlation coefficient, .05). CONCLUSION: We believe that Doppler sonography of the SMA is a promising noninvasive method to detect inflammatory disease of the small bowel, to evaluate its extension, and to document resolution of disease after therapy.