Fine needle aspiration and biopsy of hemorrhagic thyroid cyst- case-2:

Ultrasound guided F\fine needle aspiration of fluid from a hemorrhagic thyroid cyst (see ultrasound video below):

The ultrasound images of the left lobe hemorrhagic cyst before and after aspiration of bloody thick fluid under ultrasound guidance:
The cyst measures 2.4 x 2.3 cms. before aspiration; observe the large amount of anechoic fluid within the large cyst in the left lobe. The right lobe appears normal. 

After aspiration the hemorrhagic cyst looks shrunken and collapsed; the cyst measures 1.9 x 2.2 cms.

 

The cyst looks more hyperechoic with loss of fluid content:

 

Further aspiration and the cyst collapses further. 
 

FNAC of thyroid cyst:

 
This was a large cystic lesion of the right lobe of thyroid. Ultrasound guided fine needle aspiration of the cyst helped to drain the contents of the cyst as well as to ascertain the nature of the cyst contents. Ultrasound guided aspiration done here shows the needle tip descending into the cyst (seen as the bright mobile echogenic focus in the cyst lumen). The ultrasound probe (here) is placed perpendicular to the long axis of the needle- resulting in the needle tip being visualized. If the needle's long axis is parallel to the ultrasound beam (and the ultrasound probe), a linear echo of the needle can be visualized.
See: http://radiographics.rsna.org/content/28/7/1869.full 

Sonography quiz- What is your diagnosis?

This was a male patient with history of hematuria. What is your diagnosis? This ultrasound video shows a transabdominal scan in the first 2 parts of the video; the last part of the video shows a Transrectal ultrasound (TRUS) imaging of the bladder of the urinary bladder.

Answer: this is a freely mobile calculus in the urinary bladder. Seen rolling across the inner bladder surface on change in position. The TRUS imaging of the this case needed a lot of patience to capture this rather elusive urinary bladder stone.

Ultrasound guided thyroid FNA biopsy:

FNA or fine needle aspiration of the thyroid is mainly used to distinguish benign from malignant thyroid nodules. However, it is also useful in the biopsy of diffuse enlargement of the thyroid as is seen in Hashimoto thyroiditis and diffuse infiltration of the thyroid in lymphomas and certain forms of metastases (colonic adenocarcinoma spreading to the thyroid). In the case of Hashimoto thyroiditis, FNA biopsy helps to distinguish Hashimoto thyroiditis from lymphomas and papillary carcinoma of the thyroid which may coexist with the primary disease.

Method: the aim of ultrasound guidance whilst performing the FNA biopsy is provide visualization of the needle tip and guide it to the exact location within the thyroid where the nodule is located or where there is maximum possibility of collecting diseased tissue. This short ultrasound video clip shows the needle tip (seen as an echogenic linear focus) moving to and fro within the left lobe of the thyroid. The aim of the FNA study in this case was to rule out lymphoma involving the thyroid:

 

References: http://radiographics.rsna.org/content/28/7/1869.full
(free article on Ultrasound guided FNA biopsy of the thyroid).

Carcinoma of urinary bladder on TRUS

Often carcinoma of the urinary bladder can mimic an enlarged prostate (usually the median lobe). The projecting median lobe of prostate can often appear bilobed or even polypoid on Transrectal ultrasound scan (TRUS). Carefully imaging the entire prostate and checking for continuity of the prostate and the mass can help verify the exact origin of the mass in question.
  This case study just highlights this dilemma. The patient, an elderly male had a mass or rather a pair of masses located very close to the bladder neck. On TRUS the prostate appeared small and showed no direct continuity with the masses. The ultrasound and color Doppler video clips demonstrates this very well.

PCO in adolescents

This 15 year old female child has irregular menses. The question is - can Polycystic ovary disease be seen at such a young age?
I believe the answer is yes!
Both ovaries show a volume of 10 cc. (definitely enlarged) and multiple small follicles (each of less than 7 mm.).
Ultrasound image of the uterus:

Image of the ovaries showing multiple small follicles:

Left ovary- note the large size and "string of pearls"
sign of follicles:

Right ovary also showing changes of PCO in this child:

Power Doppler image- both ovaries- PCO:

Visit: http://www.ultrasound-images.com/ovaries.htm#Polycystic_ovaries_%28polycystic_ovary_disease-_PCOD

Name the part of the fetus in this ultrasound video:

This is a part of the fetal head. Can you name the part of the fetus we are focusing on?
Hint: the baby is actively doing something...

Sonography of Wharton duct calculus- video:

Ultrasound video clip shows the dilated duct of submandibular salivary gland (also called the Wharton duct).

  
This patient was a young adult male with typical history of pain in the left sublingual region whilst eating. There was also accompanying swelling of the left submandibular region with pain there when eating.
The ultrasound video clip shows the dilated submandibular salivary gland duct, measuring 4 mm.! Despite my best efforts with the small parts high frequency probe I could not detect the stone in the Wharton duct.
This was how the left submandibular salivary gland looked like:

There is a mild swelling of the left submandibular salivary gland compared to the right side.

The Wharton duct is clearly seen to be considerably dilated (ultrasound image above).

How can I be sure that the tubular structure shown in previous image is the Wharton duct? I switched on the color Doppler flow imaging and found (see image above), that this was indeed the Wharton duct and not a blood vessel.

I tried my best to find the terminal part of the duct with the stone in it, but failed. Finally I used the TV (endocavity) probe and managed to find the stone in the distal end of the Wharton duct.
For more on this topic visit: http://www.ultrasound-images.com/salivary-glands.htm#Calculus_in_left_Whartons_duct

Color Doppler imaging of the uterine artery

Color Doppler ultrasound and spectral Doppler imaging of the uterine artery is an important part of any obstetric Doppler imaging. The uterine arteries of both sides must be visualized first on color flow imaging, by tracing these vessels as they cross the external iliac artery and vein of each side. The uterine artery can sometimes be elusive for the novice; the trick I use, is to trace the full length of the external iliac vessels from the inguinal region upwards in long axes. This leads to a strange, but prominent artery crossing the iliac artery and vein in an oblique X manner- this is the uterine artery. Spectral Doppler trace will confirm the nature of the uterine artery. (The color Doppler video clip above shows the Right uterine artery in a 14 week old gestation).
When should the uterine artery be imaged? The uterine artery must be imaged from as early as 11- 14 weeks onwards to rule out/ predict a high risk pregnancy. 
Normal PI values at 11 to 13 weeks are usually greater than 2.5. However, lower PI and RI values may be seen on the ipsilateral side as the placenta (ie: if the placenta is located to the right lateral region of the uterus, the right uterine artery would have far lower PI and RI values than the left uterine artery).
The spectral Doppler trace below shows normal values in a 24 week old pregnancy:

With values of PI= 0.76 and RI of 0.5, this uterine artery is normal for 24 weeks.











Bifurcation of the uterine artery (normal anatomical variants of the uterine artery):

 

This patient showed a division (bifurcation) of the right uterine artery (see color Doppler video above), with both vessels seen crossing over the external iliac vessels of that side. The uterine artery is known to divide or in some cases to be duplicated on one or both sides. Both branches of the uterine artery on the right side are seen to lead to the parent vessel in the video above.  

References:
                 1) Uterine artery Doppler study in ICSI (intra-cytoplasmic sperm injection) pregnancies (free article)
                 2)  Doppler Study uterine artery of 17 to 24 weeks gestation in advanced maternal age
                 3)  Role of uterine artery Doppler in determining those women at risk of placental insufficiency -   this is an excellent article from centrus.com
                4) http://www.ultrasound-images.com/fetus-general.htm#Color_Doppler_imaging_of_the_uterine_artery

Retained placenta- Ultrasound video

  

This ultrasound video clip shows a echogenic, heterogenous endometrial mass in the uterus after delivery a few days ago. The patient had a history of inability to deliver the placenta. In view of such a history, and the large size of the mass in the endometrial cavity, this is a clear evidence of retained placenta.

For more details of this case of retained placenta visit:
http://www.ultrasound-images.com/placenta.htm#Retained_products_of_conception/_retained_placenta
References: http://www.jultrasoundmed.org/content/19/1/7.full.pdf

Ultrasound imaging of normal deep veins

 
The normal deep veins of the lower limb- the femoral and popliteal veins are usually studied to rule out deep venous thrombosis. One of the various methods of ruling out clot formation (thrombosis) in the deep veins is the application of mild pressure with the ultrasound probe on the deep vein. This method is called compression and the method is called testing the compressibility of the deep vein.
This ultrasound video clip (above) shows the femoral vein (FEM V.) and the popliteal vein (POPL V.), after probe pressure is applied to determine whether complete collapse of the veins is possible. The end stage shows total apposition of the walls of the vein as pressure is applied. This confirms the absence of thrombus (clot) within the vein. This testing of the normal compressibility of the femoral and popliteal veins must be done along the full extent of the deep veins. As one goes downwards along the course of the femoral vein to the mid thigh, this may be difficult due to the femoral vein entering the adductor canal.
   At this stage the sonologist may try looking for normal augmentation of flow by pressure on the calf muscles. A sharp augmentation spike on spectral doppler trace means there is no thrombus along the course of the deep veins till the calf.
For more on this topic visit: color Doppler and ultrasound study of the deep veins of lower limb.

Subendometrial or junctional zone contractions (endometrial peristalsis):

  
This transvaginal ultrasound video clip shows the changes that take place in the endometrium of the uterus, in the immediate post-ovulatory phase or days immediately after ovulation. This patient underwent medication for induction of ovulation. The first part of the ultrasound video clip shows the endometrium on day 1 after ovulation- the endometrial stripe shows early secretory changes. But this ultrasound video shows another more striking feature- slow but definite waves of peristalsis (contractions) in the endometrium  proceeding from the cervix of the uterus upwards to the fundus. These waves of contraction are called junctional zone contractions or subendometrial contractions. It is believed that these contractions help propel the sperms upwards in the uterine cavity to enable fertilization of the ovum.
  Junctional zone contractions or endometrial peristalsis is most obvious in the immediate post-ovulatory period and decrease after that. During menstruation too, subendometrial and uterine contractions help propel the blood and endometrial tissue downwards; here the peristalsis is from the fundus downwards.
References: 1) Google books description of endometrial peristalsis
2) Textbook of ultrasound (google books)- subendometrial contractions
3) article on junctional zone peristalsis- Ultrasound imaging

Cystitis cystica- transrectal Ultrasound video

I uploaded this excellent demonstration of a small 5 mm. cyst in the submucosal region of the urinary bladder on youtube. I was intrigued by the appearance of this small bubble close to the upper surface of the prostate and was confused if this was a prostatic lesion or a bladder pathology. Much research on the net confirmed that this was indeed cystitis cystica. See: Ultrasound images and case study of cystitis cystica
Some studies suggest that cystitis cystica or cystitis of the bladder with cyst formation, may not be as rare as one thinks. But I disagree, this being the first case I have come across after many years of urinary bladder and TRUS/ transrectal ultrasound imaging.

Puzzling case of parotid tumor:

This ultrasound and Color Doppler video clip of a right parotid tumor in a middle aged male patient shows the diagnostic dilemma in arriving at an exact pathological diagnosis. This tumor shows characteristics of both Warthin's tumor as well as pleomorphic adenoma. Sometimes, only the pathologist can make the "final diagnosis". What is apparent is that this is a benign mass of the parotid, with a higher likelihood of it being a Warthin's tumor.
See: Warthin's tumor of parotid

Dermoid cyst of ovary:

Dermoid cysts of ovary are also known as mature cystic teratoma or benign teratomas of the ovary. This young lady in her early twenties was found to have bilateral dermoid cysts of the ovaries, although small ones at 2 to 3 cms. size.

The above ultrasound video clip shows one such case with dermoid cysts in both ovaries.
The mature cystic teratoma or dermoid cysts are seen as hyperechoic masses in the ovaries.
See: http://www.ultrasound-images.com/ovaries.htm#Ovarian_dermoid_cyst_or_Cystic_teratomas

Adenomyomatosis of gallbladder

The ultrasound video clip above is a classic example of adenomyomatosis of the gall bladder. This word sounds similar to adenomyosis but there is a world of a difference between these two terms. Adenomyosis is a disease of the uterus and is characterized by development of endometrial tissue within the walls of the muscular layer of the uterus and is hence seen only in women.
   Adenomyomatosis, on the other hand, is a disease of the gall bladder and is of a chronic nature resulting in fine stones (GB calculi made of cholesterol usually) within crypts in the thickened gallbladder walls.
Read more on this topic at: http://www.ultrasound-images.com/gb-wall.htm#Diffuse_adenomyomatosis_of_gall_bladder
One more ultrasound video clip of this condition is shown below:
 
In addition to the diagnosis of adenomyomatosis of the gallbladder, observe the large stone or GB calculus seen in the gall bladder neck.

Fetal cardiac activity in 6 weeks embryo

This 6 week old pregnancy came for ultrasound imaging to check for the viability of the embryo. Ultrasound imaging could barely visualize the embryo, due to maternal obesity. On zooming in on the embryo, we could visualize this embryo with a suggestion of cardiac activity.


A color Doppler ultrasound study of the embryo showed this:

Clearly, the embryonic cardiac activity is visualized as a blip of color on Color Doppler. This helped avoid a transvaginal ultrasound scan study.

Spectral Doppler trace of the embryonic heart further confirmed normal cardiac activity and heart rate in the early embryo (HR= 130 beats/minute).
Visit: http://www.ultrasound-images.com/early-pregnancy.htm

Polycystic ovary- PCOD:

Polycystic ovaries (PCO or polycystic ovary disease- PCOD) and PCOS (polycystic ovarian syndrome) are the bane of the modern age women. A significant percentage of the female populace suffers from Polycystic ovaries. These ultrasound videos show the changes that take place in the PCO affected ovaries:

The above ultrasound video shows the right ovary of this young adult female patient. Observe the multiple cysts within the right ovary, all of which are small and located along the rim of the enlarged right ovary.

Similar change are observed in the left ovary (above).


The ultrasound video clip above shows both ovaries as we sweep across the pelvis with the endocavity sonographic probe. The uterus itself does not show prominent changes. However, the chief complaint of such patients is irregular menses with many reporting missing menstrual periods for as long as 1 to 5 months. Often medication alone cannot salvage the condition and surgical intervention is indicated, especially, when the patient wishes to conceive.
You can read and view more images of this case at:
http://www.ultrasound-images.com/ovaries.htm#Polycystic_ovaries_%28polycystic_ovary_disease-_PCOD

Milk of calcium cysts of the kidneys

Milk of calcium cysts must be differentiated from more ominous conditions like kidney stones and angiomyolipoma (a relatively common kidney tumor). These ultrasound videos show the typical feature of milk of calcium cysts- their tendency to gravitate to the dependent part of the cyst on postural change.

The video clip above shows the calcium salts in the right of the cyst (viewer's right), in the sitting posture.

Now observe the 2nd sonographic video clip above: the milk of calcium has shifted in position with change of the patient's position to the right lateral decubitus position.
References: http://bjr.birjournals.org/cgi/reprint/37/433/70.pdf 
Also:  http://www.ajronline.org/cgi/reprint/113/3/455.pdf
This link is also useful:  http://www.ultrasound-images.com/kidneys.htm#Milk_of_Calcium_cyst

Adenomyosis of the uterus

The uterus has two parts, functionally speaking, the endometrium (or the inner lining of the uterus) and the myometrium (the thick muscular wall of the uterus). During menses, a part of the endometrial lining is shed along with the menstrual blood. In women with adenomyosis there is ectopic (abnormally located) endometrial tissue located deep inside the wall of the uterus (myometrium). This ectopic (adenomyotic tissue) also undergoes menstrual bleeding resulting in severe pain within the wall of the uterus (dysmenorrhea). Many experts believe that adenomyosis is one of the leading causes of pain during menses in women. These ultrasound and color Doppler videos show marked congestion (increased vascularity) within the hyperechoic lesion in the posterior wall of the body of the uterus. This lesion represents the site of adenomyosis.

This is a transvaginal gray ultrasound video (above) showing the inhomogenous hyperechoic area in the posterior wall of the myometrium in the body of the uterus (arrows).
The color Doppler video below shows hypervascularity in the lesion:
  
This ultrasound and color Doppler video shows a transverse section of the uterus, panning the probe from superior to the inferior part of the uterus.(see below).

   

The adenomyotic lesion is seen to compress upon the endometrial stripe also, adding to the woes of the patient.

Lastly this Power Doppler video further shows the increased vascularity/ hyperemia of the entire uterus, besides that of the adenomyotic lesion.

 

For more on this topic: http://www.ultrasound-images.com/uterus.htm#Adenomyosis_of_uterus

Copper -T (IUCD)

Visualizing the IUCD or intra-uterine contraceptive device by sonography is perhaps the easiest and best way to determine if the IUCD is in its proper location. Normally, the copper-T should be seen with its horizontal arm in the fundus and the vertical part of the T in the body of uterus (within the uterine cavity). The ultrasound images below show the normally located IUCD

The dense white stripe seen in the uterine cavity, is the IUCD, seen in both transverse and sagittal planes.
These videos show the method of scanning the uterus to detect the IUCD:

  
Problems with IUCD or IUD (intra-uterine devices) include, migration of the IUCD/ IUD through the wall of the uterus (ie: the myometrium), to enter the wall of the uterus, by literally piercing the uterine wall, over a period of time. Other complications include infection/ sepsis of the uterus. Ultrasound imaging helps to detect all these problems accurately. Where needed, a transvaginal scan of the uterus and pelvis can help exclude such complications. In rare cases, the IUCD/ IUD might be found within the pelvis, outside the uterus.

Normal coiled nature of umbilical cord:

The normal umbilical cord is coiled with the umbilical arteries twisting around the umbilical vein in a spiral manner. This color Doppler video clip demonstrates just that:

 

This was a 23 week old pregnancy. The placenta is anteriorly located with the cord suspended well within the abundant amniotic fluid.
See more details of this case at:
http://www.ultrasound-images.com/umbilical-cord.htm#Normal_coiling_of_the_umbilical_cord

Nuchal cord in late 3rd trimester pregnancy:

This color Doppler ultrasound video shows a color Doppler video of a single loop of type A nuchal umbilical cord:


The above youtube video showed a sagittal section of the anomaly.
Below is another color Doppler video of the same case, this time showing a axial section through the cord anomaly:

Parotid cysts- more queries than answers:

Cysts of the parotid gland are relatively rare. However, ultrasound is useful in detecting them with ease, especially with the new high definition probes now available. These ultrasound videos demonstrate one such case:

 

Observe carefully- there are two cysts, not one. The smaller cyst is 4mm. in size compared to the 20 mm. of the larger cyst. My personal intuition is that these are retention cysts of the parotid gland. See some more color Doppler /ultrasound videos of this case:

 

The ultrasound features of this cystic lesion are also similar to those of a benign mass of the parotid that has undergone cystic degenerative changes (much like the central necrosis that occurs in neoplasia like fibroids of the uterus).

View more images of this case and detailed description at: http://www.ultrasound-images.com/salivary-glands.htm#Cystic_lesion_of_parotid_salivary_gland

Hyperechoic fetal kidneys

This 22 week old fetus shows bilateral hyperechoic enlarged kidneys:

 

The above ultrasound video clip shows a transverse section through the fetal kidneys. Observe the relative increase in echogenicity of the fetal kidneys, making it a little more echogenic than the adjacent fetal liver.

  

 The above ultrasound video shows a good view of the left fetal kidney. The kidney is difficult to visualize due to its hyperechoic nature.
This color Doppler ultrasound video clip below shows relatively poor flow in the affected left fetal kidney (coronal section):

  

 

The above color Doppler ultrasound video clip shows the fetal right kidney, with similar features as the left kidney. Color Doppler brings out the kidney into better view, by showing the renal arteries.

  This lady also has another child with suspected autosomal recessive polycystic kidney disease (ARPCKD).

Here are some of the still ultrasound and color Doppler images of this same fetus:

Clearly the images and ultrasound video clips above suggest a autosomal recessive polycystic kidney disease in this 22 week old fetus. No definite cystic areas are seen in the kidneys, but the other features are suggestive of this congenital disease of the kidneys. Observe the liqor and the urinary bladder (both appearing normal), suggesting that despite the serious nature of the renal disease, there is relatively normal kidney function at present.
See this link for more on this topic:
http://www.ultrasound-images.com/fetal-urogenital.htm#Fetal_polycystic_kidneys_%28autosomal_recessive_polycystic_kidney_disease-_ARPKD%29
You might also find these links useful: http://www.sonoworld.com/fetus/page.aspx?id=1519
                                                         http://radiographics.rsna.org/content/20/3/837.full