UTERINE AVMS WITH MYOMETRIAL PSEUDOANEURYSM

A young female with early pregnancy had h/o D&C done . She then developed excessive bleeding PV for 1 month. 

This case was evacuated with TVS ....showed some retained products of conception, & multiple vascular cystic areas in juxtaposed myometrium with mosaic Color flow signals on Doppler. A large rounded unilocular  intramural cystic mass was also noted anteriorly which showed color signals , s/o- pseudoaneurysm ( fig 1 to 4 ) . 

Fig 1- TVS sag scan shows some retained products in endometrial cavity &  a large round ed cystic mass in anterior uterine wall with mobile low level int. echoes . 

Fig 2- TVS transverse scan shows myometrial cyst 

Fig 3- TVS color Doppler scan Shows central RPOCs . Multiple anterior & posterior uterine wall vascular channels , s/o AVMs . The large anterior cystic mass with color flow indicative of pseudoaneurysm.

Fig 4 - TVS color Doppler TUI images depicting uterine AVMs & pseudoaneurysm  . 

Post gestational uterine AVMs are encountered in gynecological practice, but associated myometrial pseudoaneurysm is a rare entity . 

PS : 1) CASE & images courtesy- Dr Renu Sharma - Radiologist ( Sikar, Rajasthan , India)

2) The case study is intended for imaging specialists & medical practitioners for academic purpose only.

3) It needs further discussion & review of literature 

OCULAR LENS LUXATION

POSTERIOR DISLOCATION OF OCULAR LENS

CASE -

A 70y male sustained blunt ocular trauma with resulting loss of vision. HRSG of eye ball showed complete posterior dislocation of bulky thick walled ( cataractous ) lens [ fig 1& 2]. 

 Fig 1 - Ocular HRSG shows a biconvex echogenic structure lodged posteriorly in vitreous chamber near retina - dislocated bulky cataractous lens - likely due to rupture of weakened suspensory ligaments torned as a result of blunt ocular trauma

Fig 2 - Ocular HRSG shows complete posterior  luxation  of  lens 

ULTRASOUND IN HYDATID DISEASE

ULTRASOUND IN HYDATID DISEASE

Hydatid cyst is caused by  Echinococcus infection , resulting in cyst formation anywhere in the body. Humans are accidental host and the infection occurs by ingesting food contaminated with Echinococcus eggs.

Site preference -

•  Liver – commonest
•  Lung -  2^nd commonest
•  Spleen
•  Central nervous system
•  Retroperitoneal
•  Musculoskeletal organs

Two main strains -

1.  Echinococcus granulosus:  common
2. Echinococcus alveolaris/multilocularis: less common but more invasive

The cysts usually have three components:

·   pericyst:  usually made up of inflammatory tissue of host origin

·   exocyst

·   endocyst: scolices (the larval stage of the parasite) and the laminated membrane  

The world health organization 2001 classification of hepatic hydatid cysts 

 CL - Unilocular anechoic cystic lesion without any internal echoes and septations

CE 1 -Uniformly anechoic cyst with fine echoes settled in it representing hydatid sand

CE 2 -Cyst with multiple septations giving it multivesicular appearance or rossette appearance

          or honey comb appearance with unilocular mother cyst . This stage is the active stage .

CE 3 - Unilocular cyst with daughter cysts with detached laminated membranes appearing as water

            lily sign , & this is the transitional stage of the cyst .

CE 4 - Mixed hypo and hyperechoic contents with absent daughter cysts, these contents give an

           appearance of ball of wool sign indicating the degenerative nature of the cyst .

CE 5 -Arch like thick partially or completely calcified wall , & this stage of cyst is inactive and

          infertile.

Morphological classification of cysts

Type I: simple cyst with no internal echos or  architecture

Type II: cyst with daughter cyst(s) + matrix echos

Type IIa: round daughter cysts at periphery

Type IIb: larger, irregularly shaped daughter cysts occupying entire volume of the mother                                   cyst

Type IIc: oval masses with scattered calcifications and occasional daughter cysts

Type III: calcified cyst (dead cyst)
Type IV: complicated cyst, e.g. ruptured cyst

IMAGE PRESENTATIONS

Case 1-Simple type 1 (morphological), CLtype (WHO), Active Hydatid Cyst

Fig 1-Hepatic sonogram shows a large well defined unilocular cystic mass in right lobe.The wall of the mass is smooth regular and slightly echogenic.This is a unilocular Simple Type 1  active Hydatid Cyst.

Fig 2- High Resolution hepatic sonogram reveals classical double echogenic layered appearance indicating inner endocyst and outer ectocyst (arrows).

  

 Fig 3- Axial CT scan image showes a large well defined unilocular rounded hypodense non enhancing mass in right lobe liver with fluid density.

 Fig 4-Coronal reconstruction CT image of the same case.

 Fig 5- Per operative photograph of the same case shows underlying cyst with bulging hepatic contour. 

 Fig 6-Per op photograph shows exposed interior of the cyst after incision and deflation.

 Fig 7-Shows removal of endocyst.

Fig 8- Gross Specimen of removed endocyst. 

Case 2- Type 2a (morphological), CE 2 (WHO), Active Cyst

Fig 9- Hepatic sonogram shows large hydatid cyst with multiple peripheral daughter cysts and central echogenic matrix- Spoke Wheel appearance

Case 3- Type 2b (morphological), CE 2 (WHO), Active Cyst

Fig 10- TVS pelvic scan shows large multiloculated adnexal mass with Honey Comb appearance.In this case mother cyst is full of multiple small daughter cysts. As both ovaries were seen separate and normal, the diagnosis of adnexal (likely broad ligament) pelvic hydatid cyst was made.

Fig 11- Post operative specimens of the above pelvic adnexal hydatid cyst case proved to be broad ligament hydatid cyst (one of the rare entity). Gross specimens showing ectocyst (red piece), endocyst (white piece) and kidney tray containing daughter cysts. 

Fig 12- Hepatic sonogram shows a large rounded complex cystic mass in left lobe with Honey Comb appearance.

Fig 13-Hepatic sonogram shows a large complex cystic mass with multiple small daughter cysts see as mobile sediments, likely suggests detached daughter cysts.

Case 4 -  CE 3 (WHO) type transitional stage hydatid cyst
.

Fig 14- Hepatic sonogram shows large complex cystic mass right lobe with detached endocyst layer appearing as echogenic curvilinear structure.

Fig 15- Hepatic sonogram of another case shows collapsed hydatid cyst with detached undulated endocyst.

Case 4- CE 4 type collapsed consolidating (solid appearing) inactive hydatid cyst.

Fig 16- Hepatic sonogram shows large rounded hyper echoic solid appearing mass with multiple hypoechoic curvilinear echos clustered within mass without daughter cysts. It is suggestive of consolidating inactive hydatid cyst.

Case 5 - Type 3 (morphological), CE 5 (WHO) type collapsed consolidating (solid appearing) inactive hydatid cyst.

Fig 17- Hepatic sonogram shows a well defined rounded mass with echogenic rim calcification casting distal shadowing. Here the lesion is inactive and infertile with calcifying nature.

Case 6 - Type 4 (morphological) Complicated hydatid cyst.

Fig 18- Hepatic Sonogram shows complex cystic mass left lobe liver full of internal echos and multiple bright foci with dirty down shadowing,suggestive of air. The case was earlier diagnosed as simple type hydatid cyst, which at present appears complicated by air and infection.

P.S.-This presentation is intended for medical professionals and imaging specialists for                       academic purposes. It needs discussion and further review of literature.
           - My special thanks to Dr.Gaurav Bahety M.Ch. (Ped. Surgeon) and Dr.S P Sharma                      (Gen.Surgeon) for operative feedback, and Dr.Kartikeya Nathiya, Bhilwara, for article                layout and crafting.

References

1] For more detail study – ref.  http://radiopaedia.org/articles/world-health-organization-2001-classification-of-hepatic-hydatid-cysts

CONGENITAL POUCH COLON - a rare type high anorectal malformation

POUCH COLON - Is a congenital condition in which all or part of colon is replaced by a pouch like dilated colonic  structure that communicate distally with urogenital tract through a fistula .It is a rare high type anorectal malformation , with the size of pouch variable [ 5 to 15 cms ] . In this small bowel ( terminal ileum) opens into a blind pouch like colon . Rest of  colon , rectum , anal canal & anus are missing . There is usually associated fistula connecting pouch to Genitourinary system.

TYPES OF POUCH COLON

Type 1- Absent normal colon & the terminal ileum opens into colonic pouch

Type 2 - The ileum opens into short segment of cecum which then opens into pouch

Type 3 - A significant length of normal colon is present between ileum & pouch 

Type 4 - Near normal colon present with only part of colon [  rectum and sigmoid ] converted into a pouch

Below presented is rare type 1 pouch colon-

Clinicals- A day 2 neonate with distension abdomen & imperforate anus 

Fig1- Abdominal radiograph of a day 2 neonate shows a large gas shadow occupying more than half of abdominal diameter, is a distended pouch colon, in a case of imperforate anus . The radiographic finding is classical & sufficient to diagnose this anomaly ( pouch colon) . 

Fig2- Invertogram shows high type of ARM with a large gas shadow . Another gas shadow down to pouch is gas in the urinary bladder , s/o pouch vesical fistula .

Fig3- Peroperative photograph shows terminal ileum opening into pouch colon . A small rudimentary appendix is also seen attached to pouch colon . The pouch colon was deflated before delivery to exterior.

Fig4- fully delivered pouch colon with attached small appendix, and terminal ileum entering into it on right side . A fistula was also present connecting pouch to urinary bladder.

PS- The case study is intended for medical professionals for academic purposes. 

- I express my sincere thanks to Dr Gaurav Bahety , M.Ch ( ped surgery) , Bhilwara for sharing this case & operative feedback . 

TORSION OF TESTICULAR APPENDIX - a sonographic depiction

Fig 1- Testicular scan of a pediatric case with h/o left testicular pain . Scan reveals a well defined rounded echogenic spongiform lesion at supratesticular location in the groove between upper pole of testis & epididymis. It is bulky torsed appendix of testis . Testis & epididymis were normal . Minimal peritesticular fluid was also seen . 

PS - It is self limiting condition & can be managed conservatively. 

See another case - http://sonodigest.blogspot.in/2013/10/blog-post_282.html?m=1

WRIST LYMPHANGIOMA - an ultrasound evaluation

Clinical issue-

A 2 months young child with wrist swelling (mass ) on ventral aspect . Swelling being soft & trans illuminent. 

Fig 1- clinical Photograh showing swelling wrist on ventral aspect.

Fig 2- HRSG with color doppler scan of the lesion shows a well defined thin septated multiloculated mass with no internal vascularity except both radial & ulnar arteries visualised with color flow signals . Most of the loculas were echolucent & small in size . No significant solid component was seen . On the basis of USG findings a possible diagnosis of  lymphangioma was made .

Fig 3- Color doppler US scan of wrist shows both radial & ulnar arteries seen deep & separate from the mass . The flexor tendons were also seen separate. 

No bony or joint pathology was seen . The lesion was involving superficial fascial fat plane . 

PS - per operatively the mass was found to be lymphangioma & Histopathology confirmed it . 

As per literature it is one of the rare site for lymphangioma.

My special thanks to Dr Gaurav Bahety ( M. Ch. - pediatric surgery) , Bhilwara for feedback. 

BILATERAL URETEROCELE ....an ultrasound catch!!

Fig 1- A suprapubic US transverse scan shows bilateral cystic dilatation of intramural ureters -s/o Ureteroceles

Fig 2- Suprapubic oblique US scans  shows - Bilateral Ureteroceles with dilated lower ureters

Fig 3- 3D US scan of the same case depicting bilateral Ureterocele blebs at the base of U bladder . 

PS - Routine depiction....pt was asymptomatic

ULTRASOUND EVALUATION OF FOREARM ULNAR NERVE SCHWANNOMA

Schwannoma is an a well defined  encapsulated tumor of nerve sheath that grow eccentrically along the nerve axis, within the epineurium .  Schwannoma derive from cells representing the supporting tissue of a nerve, &  they typically appear as ovoid mass arising from the surface of a nerve separated from the unimpaired nerve fascicles . The nerve usually  stretched  & eccentrically courses over the capsule of the mass.  Sonography is usually unreliable in distinguishing between schwannomas and neurofibromas, as  both appears  as discrete homogeneous ovoid hypoechoic masses, with a healthy nerve at the proximal and distal ends of the mass .  A reliable sonographic diagnosis of a nerve tumor can only be made when the lesion found to be in continuity with nerve . The presence of cystic degeneration favours schwannoma rather than neurofibroma . Neurofibroma are surgically inseparable from the host nerve and can undergo malignant transformation ,where as schwannoa being discrete & eccentric ,  thus ,  often allowing the tumor to be surgically excised without loss of neurologic function.

CASE – A 35 y male presented with a small nodular swelling in distal part of  left forearm along ulnar aspest near wrist . The nodule was slightly painful and causes pain in ulnar half of hand on compressing it . No overlying skin changes or pulsations seen . No any pain noted on digital or wrist movements.

AT USG – A well defined encapsulated  oval hypoechoic solid nodular mass of about  16 x 10 x 12 mm size noted in inter mascular plane along ulnar vessels proximal to left wrist [ fig 1 ]. The lesion was  seen along ulnar nerve with neural fascicular continuity present &  established proximal & distal to the mass [ fig 2]. No significant internal vascularity or cystic or calcific foci noted . Adjacent ulnar vessels were  also seen normal . No muscle or bony or wrist  joint pathology seen . In view of encapsulated  focal nodular mass along ulnar nerve, a possible diagnosis of nerve tumor , likely schwannoma was made .  The lesion was proved ulnar nerve schwannoma  at surgery & biopsy [ fig 3 & 4 ].  

                                   Fig 1- LS & TS US scans of left distal forearm proximal to wrist,  showing a well defined hypoechoic  solid nodular mass adjacent to ulnar vessels [ along neurovascular bundle ] 

                                  Fig 2 - LS scan with conjoint image of the mass  , here the mass shows ulnar nerve fascicular continuity at its both proximal & distal ends , suggests the diagnosis of nerve tumor[ schwannoma ]

                                 Fig 3 - Per operative view of the nerve tumor . The tumor was removed without any neural damage .

                                     Fig 4 - Post operative gross specimen of dissected ulnar nerve sheath tumor [ schwannoma ]

PS – The case study in intended for medical professionals & imaging specialists for academic purpose.

  - My special thanks to Dr. Vishal Gupta , orthopaedic surgeon , Bhilwara [ raj., India ] , for operative feed back.


Read More: 1[  http://www.ajronline.org/doi/full/10.2214/ajr.182.1.1820123

                   2]  Peer et al J Ultrasound Med 21:315–322, 2002

NASOLABIAL CYST - An ultrasound evaluation

The nasolabial cyst is a rare non-odontogenic [ extraosseous ] cyst usually develops in the lower region of the nasal ala . Mostly its etiopathogenesis is uncertain .  It is more common in females at about age of forty . The cyst grows slowly and measures between 1.5 and 3 cm in size  It is characterized clinically by a floating structure in the nasolabial sulcus, which usually elevates the upper lip. It is also known as nasoalveolar cyst or Klestadt’s cyst . Its treatment is surgical excision through sublabial incision. Its recurrence is uncommon after complete removal .

CASE - This  is a 43 yrs female patient that presented with a firm swelling in the right alar region of the nose at nasolabial junction , slightly elevating the part of upper lip and nasal ala ; the clinical features suggested a nasolabial cyst.  HRSG scans revealed a well defined subtle thick and regular walled cystic lesion measuring  about 12 x 9 x 11 mm size in the  right ala of the nose [ fig 1-2 ].  No internal echos or septa or solid mural nodule is seen . It is slightly abutting underlying bone .

Fig 1- Slight oblique USG scan of right nasolabial junction showing  a well defined rounded cystic mass consistent with nasolabial cyst. No internal echos or septa or solid mural nodule is seen . Its wall is subtle thick & regular.

 Fig 2- Orthogonal US scans showing the dimensions of  the cyst

PS : The case is intended for academic purpose .

Ref : 1] http://radiopaedia.org/articles/nasolabial-cyst

ULTRASOUND IN MID GUT MALROTATION

EPIGASTRIC WHIRLPOOL SIGN:

noted in midgut malrotation with transposition of SMA/SMV , & in some cases SMV winds around SMA in clockwise manner due to mesenteric twist & volvulus giving this whirlpool sign on ultrasound & color doppler  ( fig 1)

Fig 1- Epigastric  TS  US & Color doppler scan of a neonate with vomiting - shows classical whirlpool sign due midgut malposition & volvulus 

Fig 2- Midgut malrotation with volvulus at surgery ( photo courtesy- Dr Gaurav Bahety , pediatric surgeon, Bhilwara )