ULTRASOUND IMAGING IN BENIGN TESTICULAR CYSTS

https://youtu.be/jamnyu3pN4I

" Cervix sign" in congenital hypertrophic pyloric stenosis

Fig 1- Transverse epigastric high-resolution US scan of a neonate showing classical " Cervix sign " due to hypoechoic mural thickening of gastric pyloric canal , s/o Congenital hypertrophic pyloric stenosis.

SMA stenosis at origin on color & spectral Doppler

 Fig 1- Midline Sagittal color Doppler image upper abdomen showing narrowing  of SMA at origin with aliasing on color.

 Fig 2- Same color Doppler scan upper abdomen showing hypoechoic plaque at SMA origin with luminal narrowing & color aliasing.

Fig 3- Spectral waveform at stenosis showing high velocities

APPENDICITIS WITH PERFORATION AT TIP

ULTRASOUND EVALUATION OF APPENDICITIS WITH PERFORATION AT TIP

Clinicals- F/70y with pain RIF

Fig1- High resolution ultrasound scan of RIF shows thick walled tubulo target like gut Lesion consistent with inflamed appendix . A small breach is seen in mural continuity at tip with perifocal small amount of fluid and inflamed fat ( arrows) - s/o perforation.

Fig 2- HRSG scan of RIF shows inflamed appendix in longitudinal plane with small amount of fluid & fat reaction at tip ( indicative of perforation)

MOREL LAVALLEE LESION ON ULTRASOUND

" MOREL LAVALLEE LESION"

Clinicals - H/O trauma 

- Painful swelling anterior aspect of knee 

 Fig 1- Sagittal Extended field of view image anterior aspect of knee joint showing well defined area of  fluid collection in subcutaneous  fat plane with few thin septas & fat lobules . The lesion is extending above and below knee joint .

Fig 2- High resolution US scan anterior aspect knee joint showing fluid , thin floating septas & echogenic fat lobules with in superficial fascia & subcutaneous plane . The findings are consistent with "Morel Lavallee Lesion "

MOREL LAVALLEE LESION -  It is due to  closed degloving soft tissue injury associated with trauma . In this lesion skin & subcutaneous fat abruptly separate from underlying deep fascia forming a hemolymphatic mass . Thigh at greater trochanteric area is the most common site .

ULTRASOUND CHEST- Empyema thoracis & Enlarged Thymus

ENCYSTED /LOCULATED INFECTED PLEURAL EFFUSION [ EMPYEMA THORACIS]

Fig 1- Utrasound image of left side chest showing  thick walled loculated pleural effusion with internal echos and septas  - indicative of empyema .

Fig 2- CXR PA of the same case showing homogeneous opacity left mid and lower zone with smooth upper margin  . The opacity is obscuring cardiac and dome outline .

D/D - 1) Consolidation - point against - absent air bronchograms

2)- Pleural effusion  - point against - no mass effect - this can be explained as it is loculated empyema 

USG OF ENLARGED THYMUS 

CXR: Shows upper mediastinal widening

USG scan(chest, left parmedian TS view) of the same pediatric case: Shows enlarged thymus as well defined soft tissue mass in the region of superior mediastinum retrosternal space. 

USG scan(chest, left parmedian LS view) of the same pediatric case: Shows enlarged thymus as well defined soft tissue mass in the region of superior mediastinum retrosternal space, antero-superior to heart and great vessels. 

TRANSPERINEAL US SCAN DEPICTING ANAL FISTULA WITH PERIANAL ABSCESS

CASE  1- 

CLINICAL PROFILE  - A young female c/o pain during defecation  & some pus discharge per rectum 

EXAMINATION - High resolution transperineal USG  

Fig -1 , High resolution trans perineal US scan  showing  anal canal [ AC] in transverse plane with  hypoechoic fistula track at about 11 o' clock position  continuous with irregular right lateral perianal abscess .


                                                                    CASE 2

Fig 2 - High resolution trans perineal US scan  of another case showing  anal canal [ AC] in transverse plane with  hypoechoic fistula track at about 1 o' clock position  continuous with irregular left  lateral perianal abscess . 

SOFT TISSUE ULTRASOUND

                                      MYOCYSTICERCOSIS

CASE 1 -  A  case with small tender swelling right pectoral region

Fig 1-  High resolution US scan of right pectoral region shows a well defined rounded cystic lesion within pectoralis major  muscle with eccentric echogenic nidus - consistent with myocysticercosisi [ vesicular stage ] with subtle hypoechoic halo/edema around .  


                                                                CASE 2
 A young female presented with small  slightly painful nodule left breast

Fig 1 - High resolution US image of left breast showing a well defined round to oval slightly thick walled cystic lesion with eccentric echogenic mural nodule  , the findings are consistent with cysticercosis 

Fig 2- High resolution US & Elastography image of the breast cysticercus cyst   , with classical BGR pattern seen on elastography  

ULTRASOUND IN RIGHT ILIAC FOSSA PATHOLOGIES

ULTRASOUND IN POST APPENDECTOMY FECAL FISTULA


CASE - A case with RIF discharging  lesion . H/O -  appendectomy a month back .

 Fig 1 - High resolution right iliac fossa US scan - shows a well defined hypoechoic track like lesion with central echogenicitis [ arrows ] indicative of air foci extending from cecal area to open externally through abdominal wall, s/o fecal fistula.  The lumen of lesion is connected with lumen of cecum.  

TESTICULAR DOPPLER ; VARICOCELES - COLOR & SPECTRAL DOPPLER

CASE - A young man with mild left hemiscrotal swelling and dull ache !

Fig 1- Color doppler scrotal scan showing dilated & tortuous venous vessels  [ structures with red & blue color filled signals]

Fig 2- Spectral doppler display of scrotal veins showing blood flow augmentation & reversal [ paired arrows]on valsalva maneuver , and return to normal spectrum post release .  

OCULAR USG

Fig 1 - Ocular cysticercosis ;  High resolution ocular USG scan depicting a well defined ring lesion posteromedial aspect of eye ball ,consistent with cysticercus cyst [ vesicular stage ] with eccentric echogenic nidus[scolex] .  Retinal detachment is also evident.
[ Image courtesy: Dr  Ajay Khandelwal , Alwar -Raj, India ]

DUODENAL USG

Duodenal ulcer disease 

CASE 1

Fig 1 - Upper abdominal / right paramedian transverse & oblique high resolution US images shows a focal area of mucosal defect consistent with ulcer crater in first part of duodenum. The lesion depicts some air foci in it with underlying hypoechoic muscularis  propria thickening .


                                                              CASE 2

A young man with h/o chronic upper abdominal pain & occassional vomiting

Fig 1- upper abdominal TS & oblique US scan shows small hyperechoic area of ulcer crater along anterior dudenal wall with air foci within [ arrows]  . Adjacent hypoechoic muscle layer thickening
also noted .

Fig 2 - Upper GI endoscopy of the same case shows a large duodenal ulcer [ blue arrows]

                                                           
                                                                 CASE 3 
CLINICALS -  A young lady c/o pain upper abdomen since 15 to 20 days , with occ vomiting .

Fig 1- Epigastric USscan depicting duodenum in transversa plane with echogenic mural lesion consistent with ulcer crater [ arrow]

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