In this radiology lecture, we review the ultrasound appearance of ovarian serous cystadenocarcinoma!

Key teaching points include:

• Serous cystadenocarcinoma is the common ovarian malignancy and most common ovarian epithelial tumor
• High-grade and low-grade types
  Peak incidence 6th-7th decades
• Ultrasound appearance: Mixed cystic and solid mass with papillary projections and thick septations
• Elevated CA-125 in greater than 90%
• Serous tumors are more commonly bilateral than other tumors
• Four main categories of ovarian neoplasms: Epithelial (most common), germ cell (second most common), sex cord-stromal and metastases
• Epithelial ovarian tumors are thought to originate outside the ovary (within fallopian tube or endometrium) and involve ovary secondarily
• Epithelial ovarian tumor types: Serous, mucinous, endometrioid, clear cell and Brenner
• 60% of epithelial tumors are benign: Unilocular with thin wall or thin septations (less than 3 mm in thickness)
• 40% of epithelial tumors are malignant or borderline: Papillary projection (distinctive feature of epithelial tumors) with thick, irregular wall or septations (greater than 3 mm in thickness). Can also present as a large soft tissue mass with necrosis. Advanced findings include peritoneal implants, pelvic wall invasion, adenopathy and ascites

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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In this radiology lecture, we review the ultrasound appearance of parathyroid adenoma!

Key teaching points include:

• Benign tumor of the parathyroid glands
• Most common cause of primary hyperparathyroidism: Elevated serum calcium and parathyroid hormone (PTH) levels
• Ultrasound: Solid, homogeneous and very hypoechoic. Oval or bean-shaped, long axis oriented craniocaudal. Hypervascular. Majority posterior and inferior to thyroid. Hyperechoic line often separates adenoma from adjacent thyroid. Atypical features: Cystic degeneration, calcification.
• Tc-99m sestamibi: Radiotracer uptake persisting on delayed 2-hour images. Taken up by both thyroid and parathyroid tissue, but washes out more rapidly from thyroid. Greater than 90% predictive value for preoperative localization of parathyroid adenoma. SPECT aids with anatomic localization
• Ectopic locations in up to 5%: Lower neck, mediastinum, retrotracheal/retroesophageal, carotid sheath and intrathyroidal (typically more homogeneous than thyroid nodules and have a linear interface with gland)
• Larger adenomas can be multilobulated
• “Polar vessel” sign: Enlarged feeding artery or draining vein terminating at parathyroid adenoma

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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In this radiology lecture, we review the ultrasound appearance of parotitis in the pediatric population!

Key teaching points include:

• Parotitis = Inflammation of the parotid glands
• Acute parotitis is usually infectious, most commonly viral
• Mumps is most common viral cause in children, often bilateral
• Bacterial parotitis can cause suppurative parotitis seen in premature infants and immunosuppressed children
• Acute parotitis on US: Enlarged, heterogeneous, hyperemic gland(s) +/- lymphadenopathy
• Since can be bilateral, comparison scanning essential
• Bacterial parotitis may be complicated by abscess
• “Pomegranate sign” may be seen in setting of acute parotitis: Uniform anechoic foci scattered throughout the gland
• Juvenile recurrent parotitis (JRP) = Recurrent inflammatory parotitis in children of unknown etiology
• JRP is rare, but second most common cause of parotitis in childhood after mumps
• JRP often begins between age 3-6, typically resolves spontaneously after puberty
• Usually idiopathic, JRP can be presenting symptom of Sjogren’s syndrome, lymphoma, and underlying immunodeficiency
• JRP on US: May be unilateral or bilateral, multiple hypoechoic foci of salivary secretions scattered throughout the gland +/- central calcifications, color Doppler can be normal
• Additional causes of parotitis: Sialolithiasis/obstruction, autoimmune (Sjogren syndrome, chronic sclerosing sialadenitis), infectious (HIV, TB), and sarcoidosis (rare in children).

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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In this radiology lecture, we review the ultrasound appearance of sublingual dermoid cyst and explain floor of mouth anatomy!

Key teaching points include:

• The floor of the mouth is a horseshoe-shaped area beneath tongue and in between sides of mandible, inferiorly bounded by mylohyoid muscle, and containing sublingual space (SLS)
• SLS medial border: Midline genioglossus/geniohyoid muscle complex; SLS inferolateral border: Mylohyoid muscle
• Anterior margin of hyoglossus muscle projects into posterior SLS
• Sublingual dermoid cyst is a rare, benign cyst with squamous epithelial lining and contains skin appendages
• Dermoid and epidermoid cysts are in same family, terminology often used interchangeably, although epidermoid cysts less common and tend to contain fluid contents only
• Dermoid cyst mean age of presentation late teens to twenties, average age 30
• Presents as a slowly enlarging neck mass, may cause dysphagia
• Often round or oval in shape and homogeneously hypoechoic with punctate echogenic foci
• May have pathognomonic “sack of marbles” appearance
• Relationship to mylohyoid is key for surgical planning: Intraoral resection for sublingual (above mylohyoid) location, extraoral approach for submental/submandibular (below mylohyoid) location
• Most cysts are midline
• DDx: Suprahyoid thyroglossal duct cyst, ranula (simple and diving), abscess and lymphangioma

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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In this radiology lecture, we review the ultrasound appearance of carpal tunnel syndrome!

Key teaching points include:

• Most common upper extremity entrapment neuropathy. Results from median nerve compression
• With carpal tunnel syndrome, see hypoechoic enlargement of the median nerve as enters carpal tunnel with flattening of nerve = Notch sign, also volar bowing of flexor retinaculum
• Median nerve area: Less than 8 mm2 = Normal; 8-12 mm2 = Borderline; greater than 12 mm2 = Abnormal
• Most accurate to compare nerve area at proximal pronator quadratus muscle and carpal tunnel: Increase of 2 mm2 or more from proximal to distal = 99% sensitive and 100% specific for carpal tunnel syndrome. Measure inside the echogenic epineurium
• Bifid median nerve: Normal variant in 15% of population, one trunk may take aberrant course through flexor digitorum superficialis musculature, and often associated with persistent median artery between the two trunks
• Important to recognize persistent median artery pre-operatively because could be damaged during surgery
• For diagnosis of carpal tunnel syndrome with bifid median nerve: Combined increase of 4 mm2 or more
• After carpal tunnel release surgery, median nerve may return to normal diameter or remain enlarged regardless of clinical outcome. Retinaculum may appear thickened or disrupted
• Carpal tunnel syndrome can be caused by extrinsic compression by a mass, ganglion cyst, or tenosynovitis

Reference: Klauser AS, Halpern EJ, De Zordo T, et al. Carpal tunnel syndrome assessment with US: value of additional cross-sectional area measurements of the median nerve in patients versus healthy volunteers. Radiology. 2009;250(1):171-177.

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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In this radiology lecture, we review the ultrasound appearance of ganglion cysts while highlighting relevant wrist ultrasound anatomy!

Key teaching points include:

• Ganglion cysts are viscous, mucin-filled collections lacking a synovial lining
• Most commonly occur at hand/wrist = Most common wrist mass
• Location: Dorsum of wrist (60%), frequently adjacent to scapholunate ligament; volar wrist (20%), often between radial artery and flexor carpi radialis tendon; flexor tendon sheath (10%); associated with DIP joint (10%)
• Grows out of tissues surrounding joint like a balloon on a stalk. May see a pedicle connecting to joint
• Usually well-defined and multilocular, can be unilocular
• Hypoechoic to anechoic with posterior acoustic enhancement
• Noncompressible: Dorsal joint recess and bursal collections will typically collapse with transducer pressure or wrist movement
• Typically no vascular flow, but septations may have vascularity. May see pulsation artifact from adjacent radial artery
• Volar cysts can extend towards median nerve and may cause carpal tunnel syndrome
• May displace or envelop radial artery
• Tx: Watchful waiting, percutaneous US-guided aspiration and steroid injection, excision
• Lister’s tubercle is a useful landmark for dorsal wrist anatomy
• Relevant dorsal extensor tendons (from radial side to ulnar): Compartment 2 = Extensor carpi radialis longus, extensor carpi radialis brevis, Compartment 3 = Extensor pollicis longus (on ulnar side of Lister’s tubercle), Compartment 4 = Extensor digitorum and extensor indicis
• Flexor carpi radialis overlies the ventral aspect of the scaphoid bone
• Pisiform and scaphoid bone form the proximal “twin peaks” of the carpal tunnel at the ventral wrist crease
• Median nerve diameter increase of 2 mm2 or more = Significant compression

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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Radiologist Headquarters has a new name: Radquarters! Same high-yield content, but now with a streamlined name that’s easier to remember.

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In this radiology lecture, we review the ultrasound appearance of acute epididymitis and orchitis!

Key teaching points include:

• Epididymitis = Inflammation of epididymis. Usually bacterial, most commonly due to retrograde ascent from bladder or prostate.
• Causative infectious agent varies based on age: Adults younger than 35: Neisseria gonorrhoeae, Chlamydia trachomatis (STDs). Adults older than 35: E. coli & other coliform bacteria.
• Non-infectious causes of epididymitis: Trauma, repetitive activities such as sports (most common causes in males prior to sexual maturity), torsed appendix testis or appendix epididymis, vasculitis, and medications (amiodarone).
• Presentation: Gradual onset of scrotal pain, swelling & urinary symptoms. Must exclude testicular torsion (usually more acute onset of pain).
• Epididymitis US findings: Epididymal enlargement, hyperemia, hypoechogenicity. Hyperemia usually precedes grey scale changes. Infection usually spreads from tail to body and head.
• 20-30% of epididymitis cases have associated orchitis: Scrotal infection typically starts with epididymis then spreads to testis, scrotal sac, or scrotal wall.
• Orchitis is less common than and usually secondary to epididymitis. Isolated orchitis uncommon, usually viral (mumps).
• Orchitis US findings: Testicular enlargement, hyperemia and hypoechogenicity.
• Complications: Scrotal wall inflammation, complicated hydrocele, pyocele (purulent fluid collection with mass effect), abscess (epididymal, testicular, scrotal wall), testicular ischemia and infarct due to obstructed venous outflow (decreased color Doppler testicular blood flow or reversed testicular diastolic arterial flow).

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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In this radiology lecture, we review the ultrasound appearance of acute cholecystitis, including gangrenous and emphysematous cholecystitis!

Key teaching points include:

• Acute cholecystitis = Acute gallbladder inflammation.
• Most often (95%) caused by an impacted, obstructing gallstone in the cystic duct or gallbladder neck = Acute calculous cholecystitis.
• Clinically presents as persistent RUQ pain that may radiate to right shoulder, often with N/V and fever.
• Ultrasound findings of uncomplicated acute cholecystitis: Gallstones, sonographic Murphy sign, gallbladder wall thickening (greater than 3 mm) and edema, gallbladder distention (greater than 4 cm short axis), and pericholecystic fluid.
• Sonographic Murphy sign = Maximal abdominal tenderness from transducer pressure over gallbladder. PPV of gallstones and a positive sonographic Murphy sign = 92%.
• Pericholecystic fluid occurs in less than 20% of patients with acute cholecystitis, usually seen in more advanced cases.
• Gangrenous cholecystitis = Most common complication of acute cholecystitis. Ischemia with necrosis of gallbladder wall. Increased mortality compared to uncomplicated acute cholecystitis.
• Ultrasound findings of gangrenous cholecystitis: Wall disruption, ulceration, mucosal irregularity, and/or focal bulge, sloughed mucosal membranes, pericholecystic fluid, less likely to have positive Murphy sign, and increased risk of perforation (usually at fundus).
• Emphysematous cholecystitis = Gallbladder wall necrosis with gas formation in wall and/or lumen. More common in elderly men with underlying diabetes. Higher risk of perforation, rapid progression, and increased mortality compared to uncomplicated acute cholecystitis. Emergent surgical intervention typically required.
• Ultrasound findings of emphysematous cholecystitis: Bright reflectors from nondependent portions of gallbladder wall, dirty posterior acoustic shadowing, and ring-down artifact. CT can confirm if necessary.

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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In this radiology lecture, we review the ultrasound appearance of ileocolic and small bowel-small bowel intussusception in children!

Key teaching points include:

• Intussusception occurs when bowel is pulled into itself or into neighboring bowel.
• Intussusceptum is the prolapsing bowel pulled into intussuscipiens which receives the bowel.
• Two major types: Ileocolic and small bowel-small bowel.
• If ileocolic not reduced = Bowel ischemia and perforation.
• Most occur in children beyond 3 months of age.
• Usually no lead point in children (unlike adults), suspected that due to hypertrophic lymphoid tissue after infection.
• Clinical triad of colicky abdominal pain, vomiting, palpable abdominal mass seen in less than 50% of cases.
• Red-currant jelly stool = Stool mixed with blood and mucus, can be seen with bowel ischemia.
• Ultrasound gold standard in diagnosis: Sensitivity and specificity 98%, false negative rate less than 1%.
• “Target” sign (short axis) and “pseudokidney” sign (long axis) may be seen.
• Findings suggesting ileocolic (as opposed to small bowel-small bowel) intussusception: Location in right lower quadrant with absent normal ileocolic junction, hyperechoic center indicating mesenteric fat, diameter of hyperechoic core greater than outer wall, lymph nodes inside intussusception, larger AP diameter greater than 2 cm, and longer length greater than 3 cm.
• Treatment of ileocolic intussusception: Enema with air or contrast material.
• Findings suspicious for ischemia/necrosis and increased risk of enema reduction failure: Fluid trapped within the intussuscipiens, lack of internal vascular flow on Doppler within the intussusceptum, and irregular bowel wall or decreased bowel wall vascularity.

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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In this radiology lecture, we review the ultrasound appearance of polycystic ovarian syndrome (PCOS)!

Key teaching points include:

• PCOS often presents with the clinical triad of oligomenorrhea and/or anovulation, hirsutism, and obesity. Associated with subfertility and recurrent pregnancy loss.
• Rotterdam criteria (2003) states that PCOS diagnosis requires at least two of the following: Oligo- or anovulation (ovulatory dysfunction), hyperandrogenism (clinical and/or biochemical signs), and polycystic ovarian morphology on ultrasound.
• Ovaries can be sonographically normal in PCOS. “Hyperandrogenic anovulation” proposed as a more accurate term.
• Ovaries can also appear polycystic on ultrasound without clinical diagnosis of PCOS.
• Rotterdam description of polycystic ovaries: 12 or more follicles 2-9 mm in size, and/or ovarian volume greater than 10 cc in at least one ovary (with no dominant cysts).
• Specific diagnostic cutoffs debated, and 20-25 or more follicles has been more recently suggested as a more accurate cutoff.
• Supportive morphologic features of PCOS include the “string of pearls sign” (peripheral location of follicles) and prominent, hyperechoic central ovarian stroma.
• Ovarian morphology typically more important than ovarian size, although a single enlarged, polycystic ovary sufficiently meets ultrasound criteria for PCOS.
• The term “polycystic” is generally incorrect and “multifollicular” has been offered as a more accurate ultrasound description, but PCOS remains the most widely used term.
• In post-menopausal women with new or worsening hyperandrogenism, also consider androgen-secreting tumors of ovaries or adrenal glands.

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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