Category: Podcasts

Ultrasound of Varicocele

In this radiology lecture, we review the ultrasound appearance of scrotal varicocele with three unique cases.

Key teaching points include:

  • Varicocele is abnormal dilatation of pampiniform venous plexus = Peritesticular veins.
  • Seen in up to 15% of adult and adolescent males.
  • Caused by incompetent or absent testicular vein valves.
  • Upper limit of normal for scrotal vein caliber = 2 mm, varicocele when greater than 2-3 mm.
  • Flow in varicocele usually too slow to detect with color Doppler and is typically better seen with Valsalva or with standing position.
  • 85% left sided, 15% bilateral: Left testicular vein drains into left renal vein at 90-degree angle, and superior mesenteric artery compresses left renal vein = Increased pressure and venous backflow. Right vein drains into IVC at acute angle.
  • Symptoms: Scrotal mass, pain, infertility/subfertility.
  • Low grade: Reflux only seen with Valsalva, inguinal canal/supratesticular location, vessels enlarged only in standing position.
  • High grade: Reflux seen at rest, infratesticular location, vessels enlarged in supine position.
  • Solitary right varicocele raises concern for compression of the right testicular vein from a retroperitoneal mass.
  • Ultrasound of upper abdomen should be considered when an isolated right-sided varicocele or asymmetrically large right-sided varicocele found.
  • However, most patients typically present with additional signs and symptoms of malignancy: “No patient in our cohort was found to have an unsuspected malignancy for which isolated right-sided varicocele was the only presenting sign.”*

*Gleason A, Bishop K, Xi Y et al. Isolated Right-Sided Varicocele: Is Further Workup Necessary? AJR 2019; 212:802-807

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

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Ultrasound of Achilles Tendinosis and Tear

In this radiology lecture, we review the ultrasound appearance of Achilles tendinosis, partial thickness tears and full thickness tears through four unique cases.

Key teaching points include:

  • Achilles tendon is strongest in body. Originates from soleus and gastrocnemius muscles, inserts onto posterior calcaneal tuberosity.
  • Achilles tendon tears = Most common ankle tendon injury.
  • Tendon enlargement greater than 1 cm in AP dimension = Abnormal.
  • Tendinosis appears as fusiform hypoechoic swelling of tendon without fiber disruption with increased blood flow (use power Doppler or microvascular flow).
  • Ultrasound highly sensitive and specific for partial and complete Achilles tears.
  • Partial tear = Hypoechoic/anechoic cleft that disrupts tendon fibers.
  • Full thickness tears = Usually 2-6 cm proximal to calcaneal insertion. Complete tendon fiber disruption and retraction. May see refractive shadowing at tendon stumps. Tendon gap may fill with mixed echogenicity fluid/hemorrhage or portion of adjacent fat pad.
  • Plantaris tendon = Thin tendon at medial aspect of Achilles, may mimic intact Achilles tendon fibers (plantaris usually stays intact with Achilles tear).
  • Dynamic imaging with passive ankle dorsiflexion and plantar flexion helps reveal tendon retraction at tear site.
  • Achilles tendon surrounded by a paratenon as opposed to a true synovial tendon sheath.
  • Paratendinitis = Hypoechoic swelling or anechoic fluid adjacent to tendon.
  • Achilles tendon ossification can occur with prior tendon rupture, surgery, or repetitive microtrauma.
  • Scar tissue in chronic tear can simulate tendon fibers (dynamic maneuvers helpful), and fibrous bridging may occur.

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Ultrasound of Uterine Adenomyosis

In this radiology lecture, we review the ultrasound appearance of adenomyosis through three unique cases, including an MRI example.

Key teaching points include:

  • Adenomyosis results from ectopic endometrial tissue in myometrium. Leads to dysfunctional smooth muscle hyperplasia/hypertrophy surrounding ectopic glands.
  • Cause unknown.
  • Common, usually multiparous women of reproductive age.
  • Additional risk factors: Early menarche, short menstrual cycles, high BMI = High estrogen exposure.
  • Rarely seen in postmenopausal patients, unless treated with tamoxifen for breast cancer.
  • Often asymptomatic, but can present with menorrhagia, dysmenorrhea, dyspareunia, and chronic pelvic pain.
  • For diagnosing adenomyosis, transvaginal US much more sensitive and specific (89%) than transabdominal imaging.
  • Most specific US findings: Linear echogenic striations/nodules radiating from endometrium into inner myometrium. Tiny myometrial and subendometrial cysts = Fluid-filled glands.
  • Additional US findings: Enlarged, globular uterus with diffuse myometrial bulkiness, myometrial heterogeneity, irregular endometrial-myometrial interface, hyperechoic islands, and pencil-thin “venetian blind” or “rain shower” shadowing. Cine clips extremely helpful.
  • Adenomyosis can cause asymmetric myometrial thickening.
  • Focal adenomyosis (adenomyoma) has ill-defined margins compared to fibroids, typically elliptical as opposed to rounded in shape.
  • May see abnormal vascular flow: Increased vascularity with tortuous vessels penetrating myometrium. Helps differentiate adenomyosis from fibroids, which tend to displace vessels and show circumferential flow.
  • On US, thickened junctional zone may manifest as a hypoechoic halo surrounding echogenic endometrium.
  • MRI “traditionally” the modality of choice to diagnose adenomyosis, and junctional zone thickened to 12 mm or greater highly specific. May contain punctate T2 hyperintense cystic foci/T1 hyperintense hemorrhage.
  • However, modern TV US shows comparable accuracy to MRI with no statistical significance between sensitivities and specificities: “Transvaginal US should be considered the primary imaging modality for the diagnosis of adenomyosis.”*
  • Treatment: Pain management, tranexamic acid, OCPs, GnRH agonists.
  • If severe, not relieved medically, and no desire for fertility: Hysterectomy.

*Cunningham RK, Horrow MM, Smith RJ, et al. Adenomyosis: A Sonographic Diagnosis. RadioGraphics. 2018; 38:1576-1589

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Ultrasound of Endometrioma

In this radiology lecture, we review the ultrasound appearance of endometrioma through three unique cases, including an MRI example.

Key teaching points include:

  • Endometriosis = Ectopic endometrial glands and stroma outside of the uterine cavity. Includes endometriomas, extraovarian implants and adhesions.
  • Endometriomas = Endometriotic cysts within ovary.
  • Endometriosis is seen in about 10% of women of reproductive age.
  • Presentation: Pelvic pain, dysmenorrhea, dyspareunia, infertility.
  • Ultrasound: Diffuse, homogeneous low-level echoes (most specific feature) yielding a ground glass appearance. May have posterior acoustic enhancement.
  • Endometriomas may have peripheral punctate echogenic foci. These foci have no internal vascular flow but can see twinkle artifact.
  • Vascular flow may be present in endometrioma septations.
  • Endometrioma vs. hemorrhagic cyst: Hemorrhagic cysts are acute, usually solitary and unilocular, whereas endometriomas are chronic, sometimes multiple and multilocular.
  • Endometriomas can rarely (1%) undergo malignant transformation into endometrioid carcinoma or clear cell carcinoma.
  • MR is the most specific imaging modality for diagnosis of endometrioma = Specificity 98%.*
  • Homogeneous, T1 “light bulb” bright, T2 dark = “T2 shading.”
  • Surgical treatment: Depends on disease severity from laparoscopic cyst aspiration/cystectomy to hysterectomy/oophorectomy.
  • Medical management may be attempted: Oral contraceptives, GnRH agonists

*Reference: Togashi K, Nishimura K, Kimura I, et al. Endometrial cysts: Diagnosis with MR imaging. Radiology. 1991;180:73-78.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Ultrasound of Testicular Torsion

In this radiology lecture, we review the ultrasound appearance of testicular torsion through three unique cases.

Key teaching points include:

  • Torsion occurs when spermatic cord twists and cuts off blood supply to the testis.
  • Bell-clapper deformity most common etiology: Abnormally high attachment of tunica vaginalis allowing spermatic cord rotation and testicular torsion (intravaginal).
  • Torsion has a bimodal distribution: First year of life (extravaginal), adolescents/young adults (intravaginal).
  • “Whirlpool” sign: Eddy swirl of coiled spermatic cord superior to testis, highly specific but less commonly seen than redundant spermatic cord.
  • Redundant spermatic cord AKA boggy pseudomass, torsion knot, epididymal-cord complex and should be avascular or only minimally vascular (unlike paratesticular neoplasm or acute epididymitis).
  • Testicles normally lie vertically, but horizontal or oblique (diagonal) lie suspicious for torsion.
  • Testicular enlargement, reactive hydrocele and scrotal skin thickening are secondary findings of torsion.
  • Marked testicular heterogeneity = Late torsion and nonviability/necrosis, more likely after 24 hours of symptoms.
  • Treatment: Detorsion and orchiopexy if salvageable, orchiectomy if not.

Reference: Bandarkar AN, Blask AR. Testicular torsion with preserved flow: Key sonographic features and value-added approach to diagnosis. Pediatric Radiology (2018) 48:735–744.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Ultrasound & CT of Renal Oncocytoma

In this radiology lecture, the ultrasound and CT appearance of renal oncocytoma is revealed.

Key teaching points include:

  • Oncocytomas are benign, solid tumors.
  • 13% patients have multiple oncocytomas, and 1/3rd have concurrent renal cell carcinoma.
  • Central stellate nonenhancing scar only seen in 1/3rd of cases, and more commonly in larger tumors.
  • Spoke-wheel angiographic pattern may be present, best visualized on ultrasound using microvascular flow, AKA superb microvascular imaging.
  • Often not possible to differentiate from renal cell carcinoma (RCC) with imaging.
  • Both oncocytoma and RCC can have central scar and/or spoke-wheel angiographic pattern.
  • Kim et al.* found segmental enhancement inversion (corticomedullary phase/early excretory phase) characteristic for oncocytoma, but subsequent studies have shown inconsistent results.
  • When evaluating a renal mass, if only have postcontrast and 15-minute delayed phase images, mass deenhancement of 15 HU or more suggests a solid mass, whereas no change is more consistent with a hyperattenuating cyst.**

*Kim JI, Cho JY, Moon KC, et al. Segmental enhancement inversion at biphasic multidetector CT: Characteristic finding of small renal oncocytoma. Radiology 2009;252(2):441–448.

**Macari M, Bosniak MA. Delayed CT to evaluate renal masses incidentally discovered at contrast-enhanced CT: Demonstration of vascularity with deenhancement. Radiology 1999;213:674-680.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Case of the Week: Ovarian Mucinous Cystadenocarcinoma (Ultrasound & MRI)

In this radiology lecture, we reveal the imaging appearance of mucinous cystadenocarcinoma of the ovary and explain differentiating features from serous cystadenocarcinoma.

Key points include:

  • A rare type of malignant ovarian epithelial tumor.
  • Often large at presentation, may be enormous.
  • Almost always multilocular.
  • Mucinous, proteinaceous and hemorrhagic material within loculi.
  • US: Scattered low-level echoes.
  • MRI: “Stained glass” appearance = Variable T1/T2 signal. Thick mucin = T1/T2 hyperintense.
  • Irregular, thick septations and solid components with internal vascularity and enhancement allow differentiation from mucinous cystadenoma.

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Ultrasound of Complete Molar Pregnancy

In this radiology lecture, the ultrasound appearance of complete molar pregnancy is revealed.

Key points include:

  • AKA hydatiform mole = Most common form of gestational trophoblastic disease.
  • Gestational trophoblastic neoplasia (GTN) less common = Invasive mole and choriocarcinoma.
  • Approximately 1/1,000 pregnancies is a molar pregnancy.
  • Most common in females under age 20 and over age 35.
  • Two types of molar pregnancy: Complete (most common) and partial.
  • Complete: Diploid (paternal DNA only), no fetus, more likely to be complicated by GTN.
  • Partial: Triploid (maternal and paternal DNA), abnormal fetus or fetal parts, harder to diagnose.
  • Complete hydatiform mole presentation: Vaginal bleeding, enlarged uterus inconsistent with dates, hyperemesis. Markedly elevated β-hCG level (variable for partial molar pregnancies).
  • Large theca lutein cysts due to ovarian stimulation from elevated β-hCG, but uncommon.
  • US: Heterogeneous, echogenic mass (“snowstorm” appearance), small anechoic cystic spaces (“cluster of grapes”) = hydropic chorionic villi.
  • Treatment: Dilation & curettage. β-hCG levels monitored until no longer detectable to confirm no residual disease.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit:   https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Case of the Week: Wandering Spleen (CT)

In this radiology lecture, we discuss the CT appearance of wandering spleen!

Key points include:

  • Extremely rare, usually between 20-40 years of age, more common in females.
  • Splenic mobility due to congenital or acquired abnormality of the normal peritoneal attachments/suspensory ligaments.
  • Splenic migration to lower abdomen/pelvis, may develop long vascular pedicle.
  • Twisting of pedicle can lead to splenic ischemia and infarction if not promptly treated.
  • Variable clinical presentation, patients often become symptomatic if torsion of pedicle occurs: Intermittent colicky pain, vague abdominal discomfort, abdominal mass, acute abdomen.
  • Treatment: Surgical detorsion and fixation of spleen (splenopexy), splenectomy may be required in setting of infarction.

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5 Cases in 5 Minutes: Musculoskeletal #4

Quiz yourself with this week’s interactive video lecture as we present a total of 5 interesting musculoskeletal radiology cases followed by a diagnosis reveal and key teaching points after each case, all in just a few minutes!

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