Showing papers in "Ultraschall in Der Medizin in 2018"

The EFSUMB guidelines and recommendations for the clinical practice of contrast-enhanced ultrasound (CEUS) in Non-Hepatic Applications: Update 2017 (Long Version)

Abstract: The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.

Die EFSUMB-Leitlinien und Empfehlungen für den klinischen Einsatz des kontrastverstärkten Ultraschalls (CEUS) bei nicht-hepatischen Anwendungen : Update 2017 (Kurzversion)

Abstract: The updated version of the EFSUMB guidelines on the application of non-hepatic contrast-enhanced ultrasound (CEUS) deals with the use of microbubble ultrasound contrast outside the liver in the many established and emerging applications.

EFSUMB Recommendations and Clinical Guidelines for Intestinal Ultrasound (GIUS) in Inflammatory Bowel Diseases

Abstract: The accuracy and usefulness of gastrointestinal ultrasound (GIUS) for detecting activity and complications of inflammatory bowel diseases (IBD), has been reported in studies, promoting this technique as an important tool for the management of IBD patients. Whilst well recognised by international guidelines, standardization and general agreement in the definition of the luminal and extra-intestinal features, still need to be well defined.A task force group of 17 experts in GIUS faced this issue, by developing recommendations and clinical guidelines for the use of GIUS in IBD, under the auspices of EFSUMB. This article presents the consensus on the current data on sonographic features of IBD and summarises the accuracy of different sonographic modalities for the management of IBD patients.

Interobserver Agreement for Contrast-Enhanced Ultrasound (CEUS)-Based Standardized Algorithms for the Diagnosis of Hepatocellular Carcinoma in High-Risk Patients.

Abstract: Objectives This pilot study aimed at assessing interobserver agreement with two contrast-enhanced ultrasound (CEUS) algorithms for the diagnosis of hepatocellular carcinoma (HCC) in high-risk patients. Methods Focal liver lesions in 55 high-risk patients were assessed independently by three blinded observers with two standardized CEUS algorithms: ESCULAP (Erlanger Synopsis of Contrast-Enhanced Ultrasound for Liver Lesion Assessment in Patients at risk) and ACR-CEUS-LI-RADSv.2016 (American College of Radiology CEUS-Liver Imaging Reporting and Data System). Lesions were categorized according to size and ultrasound contrast enhancement in the arterial, portal-venous and late phase. Interobserver agreement for assessment of enhancement pattern and categorization was compared between both CEUS algorithms. Additionally, diagnostic accuracy for the definitive diagnosis of HCC was compared. Histology and/or CE-MRI and follow-up served as reference standards. Results 55 patients were included in the study (male/female, 44/ 11; mean age: 65.9 years). 90.9 % had cirrhosis. Histological findings were available in 39/55 lesions (70.9 %). Reference standard of the 55 lesions revealed 48 HCCs, 2 intrahepatic cholangiocellular carcinomas (ICCs), and 5 non-HCC-non-ICC lesions. Interobserver agreement was moderate to substantial for arterial phase hyperenhancement (ĸ = 0.53 – 0.67), and fair to moderate for contrast washout in the portal-venous or late phase (ĸ = 0.33 – 0.53). Concerning the CEUS-based algorithms, the interreader agreement was substantial for the ESCULAP category (ĸ = 0.64 – 0.68) and fair for the CEUS-LI-RADS® category (ĸ = 0.3 – 0.39). Disagreement between observers was mostly due to different perception of washout. Conclusion Interobserver agreement is better for ESCULAP than for CEUS-LI-RADS®. This is mostly due to the fact that perception of contrast washout varies between different observers. However, interobserver agreement is good for arterial phase hyperenhancement, which is the key diagnostic feature for the diagnosis of HCC with CEUS in the cirrhotic liver.

Cognitive Functions of the Fetus.

Abstract: The human brain is intricately designed to execute cognitive functions, such as perception, attention, action, memory and learning. The complete nervous system is active during prenatal development and the aim of this review is to present data on fetal cognitive functions. The fetus processes sensory stimuli at a cortical level, including painful stimulus, from about 25 weeks of gestation onwards. At gestational week 34, the fetus is able not only to perceive complex acoustic external sounds but also to discriminate between different sounds. Fetal action planning is established by 22 weeks and investigations using four-dimensional ultrasound reveal that complexity of fetal motor action and behavior increases as pregnancy progresses. The capacity of the fetus to learn and memory are prodigious. At term, subcortical structures of the brain are well developed. There is high activity in primary cortical areas and low activity in association areas. Clinically relevant data on cognitive functions of the fetus could be important for the management of fetal pain and treatment of preterm infants as well as for improved neurodevelopmental outcome of fetuses from high-risk pregnancies. Finally, the brain’s developmental journey, including development of cognitive functions, continues with the same intensity in the postnatal period.

DEGUM Recommendations on Infection Prevention in Ultrasound and Endoscopic Ultrasound

Abstract: Microbial contamination of ultrasound probes for percutaneous or endoscopic use is common. However, infectious diseases caused by transmission of microorganisms by US procedures have rarely been reported. In Germany, legal regulations address hygiene in ultrasound procedures. Based on these regulations and the available literature, an expert panel of the German Society of Ultrasound in Medicine (DEGUM) has formulated sophisticated recommendations on hygienic measures in percutaneous and endoscopic US, including US-guided interventions.

Novel Demonstration of the Anterior Femoral Cutaneous Nerves using Ultrasound.

Abstract: Purpose Neuropathy of the intermediate (IFCN) and medial femoral cutaneous nerve (MFCN) is a potential iatrogenic complication of thigh surgery and its diagnosis is limited. This study aimed to evaluate the possibility of the visualization and diagnostic assessment of the IFCN and MFCN with high-resolution ultrasound (HRUS). Materials and Methods In this study, HRUS with high-frequency probes (15 – 22MHz) was used to locate the IFCN and the MFCN in 16 fresh cadaveric lower limbs. The correct identification of the nerves was verified by ink-marking and consecutive dissections at sites correlating to nerve positions (R1 – 3), namely, the origin, the mid portion, and the distal portion, respectively. 12 cases with suspected IFCN and MFCN lesions referred to our clinic for HRUS examinations were also assessed. Results Anatomical dissection confirmed the correct identification of the IFCN in 16/16 branches at all of the different locations (100 %). MFCN was correctly identified at R1 + 3, in all cases (16/16; 100 %), and in 14/16 cases (88 %) at (R2). 12 cases of patients with IFCN and MFCN pathologies (all of iatrogenic origin) were identified. 9 instances of structural damage were visible on HRUS, and all pathologies were confirmed by almost complete resolution of symptoms after selective HRUS-guided blocks with 0.5 – 1 ml lidocaine 2 %. Conclusion This study confirms that the IFCN and the MFCN can be reliably visualized with HRUS throughout the course of these nerves, both in anatomical specimens and in patients.

A New Two-Dimensional Shear Wave Elastography for Noninvasive Assessment of Liver Fibrosis in Healthy Subjects and in Patients with Chronic Liver Disease.

Abstract: Purpose To assess the performance of two-dimensional shear wave elastography (2D-SWE) on the GE LOGIQ E9 ultrasound system in a cohort of healthy subjects and to investigate its accuracy in the staging of liver fibrosis in patients with chronic liver disease (CLD) using liver biopsy as a reference standard. Materials and Methods From October 2014 to June 2016, 54 healthy subjects and 174 patients with CLD were consecutively enrolled. Liver fibrosis stage was assessed by the METAVIR scoring system. 18 (10.3 %) and 17 (9.8 %) patients had advanced fibrosis and cirrhosis, respectively. The correlation of liver stiffness measurement (LSM) and continuous variable was assessed using the Spearman rank correlation. The accuracy of 2D-SWE was evaluated with areas under the receiver operating characteristics curves (AUROC). Results Reliable LSMs were obtained in all subjects. The interobserver agreement ICC was excellent: 0.847. In healthy subjects, gender, but not anthropometric and biochemical data, were correlated with LSM. In patients with CLD, LSM had a strong positive correlation with fibrosis stage (rho = 0.628; p > 0.001). The AUROC was 0.724 for mild fibrosis (F≥ 1), 0.857 for moderate fibrosis (F≥ 2), 0.946 for severe fibrosis (F≥ 3), and 0.935 for cirrhosis (F4). Likewise, good accuracy was observed in the HCV subgroup. The optimal cut-off value in differentiating healthy subjects from CLD patients with any fibrosis was 5.47 kPa with an AUROC of 0.875. Conclusion 2D-SWE is a reliable and reproducible method to assess LSM with good diagnostic accuracy to assess liver fibrosis in patients with CLD.

Fetal Abdominal Aorta: Doppler and Structural Evaluation of Endothelial Function in Intrauterine Growth Restriction and Controls

Abstract: Purpose The human aorta stores strain energy in the distended wall during systole through the extracellular matrix of the tunica media that could be influenced by blood pressure, flow, or increased peripheral resistance. In intrauterine growth restriction (IUGR) fetuses, the increased aorta intima media thickness (aIMT) could reflect a different extracellular matrix composition and, therefore, functionality. The aim of this study was to analyze the resistance to flow in the fetal descending aorta and its relation to aIMT and systolic and diastolic fetal abdominal aorta diameters in IUGR fetuses and controls. Materials and Methods This is a prospective case control study of single pregnancies collected at a tertiary center for feto-maternal medicine in Northeast Italy. An IUGR group as cases and a group of fetuses appropriate for gestational age (AGA) as controls were included. Results We found a greater PI of the fetal abdominal aorta in the IUGR group (1.82) than in the AGA group (1.21) (p Conclusion The change between the systolic and diastolic fetal abdominal aorta diameters in IUGR cases during the early third trimester of pregnancy was significantly increased and aIMT in the IUGR group was significantly correlated to systolic-diastolic diameter change and PSV, probably reflecting aortic wall adaptation to blood flow changes in IUGR fetuses.

Mesenteric Vessel Patency Following HIFU Therapy in Patients with Locally Invasive Pancreatic Cancer.

Abstract: Purpose To evaluate the effects of HIFU therapy on visceral vessel patency in patients with inoperable locally invasive pancreatic cancer. Materials and Methods 50 pancreatic cancer patients (26 men, 24 women) aged 41 – 82 years (65.0 ± 10.2) underwent ultrasonography (US) and computed tomography (CT) examinations before and within one day after HIFU treatment, as well as at follow-up at six weeks, three months and six months. Evaluation and grading were performed by two experienced independent radiologists according to a classification scheme based on vessel involvement, vessel diameter, patency, and defects in flow. Results Before HIFU treatment, arterial vessel involvement was noted in 42 patients, venous involvement in 47, and 47 patients presented with both. Superior mesenteric artery occlusion was found in three carcinomas while nearly half of the cases (n = 24) displayed signs of superior mesenteric vein, portal vein, or splenic vein occlusion. High-grade tumor-associated arterial narrowing was seen in ten patients. Despite vessel encasement and partially extensive propagation of collateral vessels, it was possible to safely perform HIFU treatment in all patients without complications. US and CT studies performed within one day after therapy did not show any change in vessel patency in 47 patients (94 %). Follow-up controls at the six-week mark revealed increased vessel narrowing and finally occlusion after six months in 11 patients due to tumor progression. Conclusion This study demonstrates that HIFU treatment can be safely applied to pancreatic cancers enveloping large mesenteric vessels despite vessel narrowing or extensive collateral propagation. Most patients (94 %) did not experience adverse effects regarding vessel patency.

Ultrasound in the Re-Staging of Cervical Metastases after Chemoradiotherapy for Head and Neck Cancer.

Abstract: High-resolution ultrasonography, including color duplex modes, is a well-established and proven imaging method that is used in addition to computed tomography for re-staging after primary nonsurgical therapy for head and neck cancer in many European countries. No evidence-based international re-staging guidelines are available. Decisions as to whether to carry out neck dissection after primary radiotherapy or chemoradiotherapy are often made in the relevant tumor boards and are therefore subject to variance. High-resolution ultrasonography clearly detects morphological changes such as intranodal necrotic areas and alterations in the hilar vascularization pattern. Another important aspect of ultrasonography is that it allows accurate check-ups on dynamic changes during the follow-up period. This article reviews the role of ultrasonography in the follow-up and re-staging of patients with neck disease after primary chemoradiotherapy.

Validation of Multiparametric Ultrasonography Criteria with Digital Subtraction Angiography in Carotid Artery Disease: A Prospective Multicenter Study.

Abstract: Purpose The German Society of Ultrasound in Medicine (DEGUM) recently revised its multiparametric criteria for duplex ultrasonography (DUS) grading of internal carotid artery (ICA) disease. We determined the diagnostic accuracy of the revised DEGUM criteria for ultrasonography grading of ICA disease in a prospective multicenter study. Materials and Methods We evaluated consecutive patients who underwent digital subtraction angiography of the extracranial carotid arteries at four tertiary care hospitals. Blinded investigators graded ICA disease according to DEGUM-recommended ultrasonography criteria and calculated NASCET-type percent stenosis from angiography images. Endpoints included overall classification accuracy, prediction of clinically relevant disease categories and between-test agreement in the continuous range of percent stenosis. Results A total of 121 patients (median age: 69 [IQR, 16] years; 74 % men; median time between DUS and angiography: 1 day [IQR, 2]) provided 163 DUS-angiography carotid artery pairs. The classification accuracy of the DEGUM criteria to predict stenosis within 10 % increments as compared to angiography was 34.9 % (95 % CI, 28.0 – 42.6). The sensitivity of DUS for the detection of moderate (50 – 69 %) and severe (70 – 99 %) stenosis was 35 % and 81 %, with an overall accuracy of 73 % and 74 %, respectively. The specificity was 89 % and 69 %, respectively. Considering the continuous spectrum of the disease (0 – 100 %), the Bland-Altman interval limit of agreement was 51 %. Conclusion At laboratories experienced with ultrasound grading of the extracranial ICA, the revised DEGUM multiparametric ultrasonography criteria do not eliminate the need for a confirmatory test for the identification of clinically relevant grades of the disease.

Ultrasonography in Liver Vascular Disease.

Abstract: Vascular liver diseases include a heterogeneous group of disorders affecting the micro- and the macro-circulation of the liver. Thrombosis and obstruction of the inflow (portal vein) and/or outflow venous system (Budd-Chiari syndrome), spontaneous porto-systemic shunts, diseases affecting the sinusoids, and hepatic vascular malformations are the most important vascular liver diseases. Thrombosis of the portal venous system and of the hepatic venous system occur most commonly and are potentially life-threatening conditions, while congenital and acquired pro-thrombotic diseases are major causal factors, together with local factors triggering thrombotic events. Despite their overall low prevalence, vascular liver diseases represent the second cause of portal hypertension in the Western world. Imaging techniques are of paramount importance in the diagnostic process, as well as in the follow-up of patients affected by these conditions. In this review, we focus on the role of ultrasonography in the management of vascular liver diseases by highlighting advantages and drawbacks of this imaging technique. In addition, we provide a state of the art presentation of the possibilities offered by ultrasound in the evaluation of vascular and parenchymal features in vascular liver diseases encompassing not only the use of grayscale imaging, but also the application of Doppler ultrasound, the measurement of hemodynamic parameters and the assessment of liver stiffness.

Fetal Skeletal Disorders

Abstract: Skeletal disorders of the fetus are quite common The incidence is about 5:1000 pregnancies The disorders affect the extremities or parts of them (dysmelia), the whole skeleton (skeletal dysplasia), the skull (craniosynostosis) and the spine (dysostosis, caudal regression) About half of these diseases are complex In the majority of cases the complex disorders are caused by single gene mutations or numeric or structural chromosomal aberrations We explain the classification and diagnostic criteria for prenatal expert and screening ultrasound based on frequent disorders The main diagnostic challenge concerning malformations of the limbs and craniosynostosis is to find out if they are isolated or symptoms of certain syndromes In skeletal dysplasia it is clinically important to differentiate lethal entities from non-lethal Skelettale Erkrankungen des Fetus sind mit 5:1000 Schwangerschaften relativ haufig Betroffen sein konnen einzelne Abschnitte der Extremitaten (Dysmelien), das ganze Skelett (Skelettdysplasien), der knocherne Schadel (Kraniosynostosen) und die Wirbelsaule (Dysostosen, kaudale Regression) In 50 % bestehen komplexe Krankheitsbilder Fur die Mehrzahl der Krankheiten sind genetische Ursachen (Einzelgen-Mutationen, numerische und strukturelle chromosomale Aberrationen) bekannt Anhand haufiger Krankheitsbilder werden diagnostische Kriterien fur die differenzierte Sonografie und das Ultraschall-Screening erlautert

True or false umbilical cord knot? Differentiation via 3D/4D color Doppler ultrasound

Abstract: True umbilical cord knots are actual knots in the umbilical cord formed during pregnancy, while a false umbilical cord knot is a bulge in the umbilical cord due to twisting of the vein around the arteries or around an overlap of umbilical cord loops lying against one another. True umbilical cord knots are relatively rare. Based on births, an incidence of 0.3 – 1.2 % is specified [1, 2]. Various factors are associated with the occurrence of an umbilical cord knot: grandmultiparity, chronic hypertension, diabetes, a long umbilical cord, a small fetus, a male fetus, monoamniotic twins, and patients who had undergone amniocentesis [2– 7]. While the risk of intrauterine death is 4 times higher in the case of true umbilical cord knots [2], there is no risk to the fetus in the case of false umbilical cord knots. However, even in the case of a true umbilical cord knot, there is no risk to the fetus as long as the knot is loose and blood circulation is not restricted. Wharton’s jelly provides a significant protective layer in this case. True umbilical cord knots typically appear in the form of a single knot. However, up to four true knots in one umbilical cord have been described [8]. It is assumed that umbilical cord knots are formed between 9 and 12 gestational weeks [2]. At this time there is significant amniotic fluid and fetal movement so that the fetus can slip through a loop of the umbilical cord during corresponding movements and gyrations. It is difficult to detect a true umbilical cord knot via 2 D ultrasound since it is a three-dimensional structure. In a retrospective study including 18 cases in which a true umbilical cord knot was found at the time of birth, Sepulveda et al. [1] were able to show that an umbilical cord knot was not detected during routine second-trimester ultrasound examination in any of these cases. Bohîlea et al. [9] specify a prenatal detection rate of 12%. Sonographic differentiation between a true and a false umbilical cord knot is even more difficult. Individual sonographic signs of a true umbilical cord knot have been described in the literature: umbilical cord in the form a four-leaf clover [10], an unusual multicolor umbilical cord pattern [4], or the “hanging noose” sign [11]. All of these signs can be indications of a true umbilical cord knot but do not provide definitive proof. Already in 2010, Guzikowski et al. [7] noted the advantages of 3D/4D color Doppler ultrasound for verifying an umbilical cord knot. Given the current quality of 3D/ 4D color Doppler ultrasound, it is now possible to more clearly verify a true umbilical cord knot on the basis of the three-dimensional image and to determine the degree of constriction (▶ Fig. 1). Differentiation from a false umbilical cord knot is also possible. In the case of an overlap of the umbilical cord simulating an umbilical cord knot, the false umbilical cord knot can be detected by rotating the volume and visualizing the umbilical cord (▶ Fig. 2a) from a different angle (▶ Fig. 2b). When detecting a true umbilical cord knot, blood flow measurements on Dop▶ Fig. 1 3D image of a true umbilical cord knot in an umbilical cord with a single umbilical artery (3D HDlive power Doppler). There is no compression of the two umbilical vessels.

Ultrasound of Thyroid Nodules

Abstract: Thyroid nodules are a common finding in the general population. Ultrasonography is the most sensitive imaging tool for diagnosing thyroid nodules. However, sonographic differentiation of hormonally active versus inactive nodules, and in particular benign versus malignant nodules, remains unreliable. In this context, thyroid scintigraphy has its clinical significance predominantly in diagnosing hormonal activity of thyroid nodules. However, most nodules are benign and a significant number of patients undergo surgery for diagnostic rather than for therapeutic reasons. Efforts of the past years aimed to improve sonographic risk stratification, to predict malignancy of thyroid nodules through standardized diagnostic assessment of validated risk factors, in order to select patients who require further diagnostic workup. In the last years, several imaging and reporting systems, giving standardized categories with rates of malignancy, were evaluated as a basis for further clinical management. Recent technological developments, such as elastography, also show promising data and might be implemented into clinical practice. Ultrasound-guided fine needle aspiration is the key element in the diagnosis of sonographically suspicious thyroid nodules and significantly contributes to the diagnosis of malignancy versus benignity. Schilddrusenknoten sind ein haufiger Befund in der Allgemeinbevolkerung. Die Sonografie ist dabei das wichtigste und sensitivste bildgebende Instrument der Schilddrusendiagnostik. Eine sichere Unterscheidung hormonaktiver und inaktiver Knoten sowie insbesondere benigner und maligner Knoten ist jedoch sonografisch bisher nicht ausreichend sicher moglich. Die klinische Bedeutung der Szintigrafie liegt daher in der Differenzialdiagnose der Hormonaktivitat von Schilddrusenknoten. Insgesamt ist das Risiko eines Schilddrusenknotens in der Allgemeinbevolkerung, maligne zu sein, als sehr gering einzustufen. Zur Risiko-Stratifizierung des Malignitatsrisikos von Knoten wurde daher in den vergangenen Jahren versucht, durch standardisierte Befunderhebung evaluierter Risikofaktoren eine bessere Selektion von Patienten, die einer weiteren Diagnostik zugefuhrt werden sollen, zu erzielen. Neuere technische Verfahren wie die Elastografie zeigen ebenfalls vielversprechende Daten und konnten Eingang in den klinischen Alltag gewinnen. Die sonografisch gesteuerte Feinnadelpunktion ist aktuell jedoch weiterhin das zentrale Element in der Diagnostik sonografisch suspekter Schilddrusenknoten und tragt wesentlich zur Sicherung der Diagnose Malignitat vs. Benignitat bei.

Strain Elastography: A Valuable Additional Method to BI-RADS?

Abstract: Background Breast lesions classified as BI-RADS-US 3 are probably benign and observation was recommended, while a considerable number of BI-RADS-US 4 lesions were benign, resulting in excessive biopsies. We focus exclusively on BI-RADS-US 3 and 4 lesions and hypothesize that improved diagnostic performance can be achieved by integrating real-time elastography (strain ratio) into the BI-RADS-US classification system. Method From April 2010 to September 2015, 1071 lesions were included in the final analysis. After the conventional ultrasound examination, the BI-RADS-US (2013) classification was used to evaluate the lesions. Then the strain ratios were calculated, and the final diagnosis was made on the basis of histological results. The sensitivity, specificity, accuracy, PPV and NPV were calculated and the AUCs were compared. Additionally, an analysis of the diagnostic performance expressed by the pretest and posttest probability of disease (POD) was performed in BI-RADS-US 3 and 4A lesions. Results With the cutoff point of 2.98, the sensitivity, specificity and accuracy of the strain ratio method were 86.9 %, 86.6 % and 82.6 %, respectively. In BI-RADS-US 3 lesions, a suspicious strain ratio significantly modified the POD from 1.3 % to a posttest POD of 29.8 %. In BI-RADS-US 4A lesions, a suspicious strain ratio significantly modified the POD from 8.5 % to a posttest POD of 48.7 %. Conclusion Ultrasonographic elastography (strain ratio) yields additional diagnostic information in the evaluation of BI-RADS-US 3 and 4 breast lesions. The strain ratios should be integrated into the BI-RADS-US classification system and into daily practice.

Added Value of Fetal MRI in the Evaluation of Fetal Anomalies of the Corpus Callosum: A Retrospective Analysis of 78 Cases

Abstract: Objective To evaluate the added value of fetal MRI to ultrasound in detecting and specifying callosal anomalies, and its impact on clinical decision making. Methods Fetuses with a sonographic diagnosis of an anomalous corpus callosum (CC) who underwent a subsequent fetal brain MRI between 2010 and 2015 were retrospectively evaluated and classified according to the severity of the findings. The findings detected on ultrasound were compared to those detected on MRI. An analysis was performed to assess whether fetal MRI altered the group classification, and thus the management of these pregnancies. Results 78 women were recruited following sonographic diagnoses of either complete or partial callosal agenesis, short, thin or thick CC. Normal MRI studies were obtained inµ19 cases (24 %). Among these, all children available for follow-up received an adequate adaptive score in their Vineland II adaptive behavior scale assessment. Analysis of the concordance between US and MRI demonstrated a substantial level of agreement for complete callosal agenesis (kappa: 0.742), moderate agreement for thin CC (kappa: 0.418) and fair agreement for all other callosal anomalies. Comparison between US and MRI-based mild/severe findings classifications revealed that MRI contributed to a change in the management for 28 fetuses (35.9 %), mostly (25 fetuses, 32.1 %) in favor of pregnancy preservation. Conclusion Fetal MRI effectively detects callosal anomalies and enables satisfactory validation of the presence or absence of callosal anomalies identified by ultrasound and adds valuable data that improves clinical decision making.

Fetal Cardiac Remodeling in Response to Anemia: Using Hemoglobin Bart's Disease as a Study Model.

Abstract: Objective To assess fetal cardiac remodeling in response to anemia, by comparing the fetal cardiac dimensions and global sphericity index (GSI) of normal fetuses and fetuses with anemia using fetal Hb Bart’s disease as a study model Methods Fetuses at risk for Hb Bart’s disease undergoing cordocentesis at 18 to 22 weeks of gestation were recruited Fetal cardiac dimensions including GSI (cardiac length to cardiac width ratio), interventricular septum thickness (IVST), left ventricular wall thickness (LVWT) and right ventricular wall thickness (RVWT) were measured Results 215 pregnancies at risk met the inclusion criteria, including 54 affected fetuses and 161 normal fetuses The mean GSI was significantly lower in the affected group (111 ± 006 vs 126 ± 009, p-value 0017) The GSI of the normal group was relatively constant regardless of gestational age The IVST and LVWT tended to increase, but not significantly, in the affected group, whereas the RVWT was minimally but significantly increased The ROC curve for GSI had an area under curve of 0844 The best cut-off of GSI was 117, giving a sensitivity of 741 % and a specificity of 882 % Conclusion Fetal cardiac remodeling in response to anemia causes a marked decrease in global GSI with minimal hypertrophy as an adaption to volume overload Importantly, GSI is a new maker for anemia and may play a role in clinical application for early detection of fetal anemia, possibly due to any cause Additionally, GSI measurement is simple and gestational age-independent

Ultrasound Nomograms of the Fetal Optic Nerve Sheath Diameter

Abstract: Objective To construct prenatal age-specific reference intervals for sonographic measurements of the optic nerve sheath diameter (ONSD) during gestation in normal fetuses. Materials and Methods Prospective cross-sectional study of fetuses assessed in antenatal ultrasound units between 2010 and 2014. The examination was based on a technique for the sonographic assessment of ONSD previously published by our group. The mean values and SDs of the ONSD were modeled as a function of the gestational week by curve estimation analysis based on the highest adjusted R2 coefficient. Repeatability tests were performed to assess intraobserver variability and interobserver agreement. Results During the study period 364 healthy fetuses were enrolled. The mean values for the ONSD varied from 0.6 mm at 15–16 weeks to 2.8 mm at 37–38 weeks. The ONSD grows in a linear fashion throughout gestation, with a quadratic equation providing an optimal fit to the data (adjusted R2 = 0.957). Conclusion Sonographic age-specific references for the fetal ONSD are presented. This data may assist in the decision-making process in fetuses with a suspected increase in intracranial pressure, or anomalies affecting the development of optic stalks, such as optic hypoplasia and septo-optic dysplasia.

How Much Should I Record During a CEUS Examination? Practical Aspects of the “Real-Time” Feature of a Contrast Ultrasound Study

Abstract: The application of microbubble contrast agents to the ultrasound examination over the last 20 years has revolutionised the assessment of focal liver lesions [1], has been applied to many other organs in the body [2, 3] and is now an established adult application, with the use in paediatric patients increasing [4]. The technique is safe and repeatable [5, 6]. A contrast-enhance ultrasound (CEUS) examination generates a substantial amount of data for storage with the use of continuous recording, so much so that in Departments of Radiology, where a Picture Archiving System (PACS) stores data for a considerable number of imaging examinations, rumblings of discontent from the PACS manager can be heard. The misconception that the “video-clips” from a CEUS occupy too much storage is a fallacy, as many whole body computed tomography (CT) examinations from a trauma patient, with reconstruction in thin slices and 3-D, can occupy a large amount of storage space. The perception is that the “new-boy on the block” will clog up the PACS with superfluous images; perhaps better to make room for other imaging modalities. There is no battle to be fought here; we can help ourselves. There is perhaps no real need to take long and extensive real time “video-clips” of the entire CEUS examination, but to record only the most informative sections. This is not a new concept, and it is worthwhile revisiting the background to extensive image storage as there are very good technical reasons not to perform a continuous recording, making the CEUS examination recording shorter and even more useful [7]. Characterisation of focal liver lesions with CEUS represents the single most important application of CEUS with numerous studies confirming the accuracy of this technique in comparison with CT, and near ability to match Magnetic Resonance (MR) imaging [8, 9]. The arterial phase and the late portal venous phase are crucial to the assessment for characterisation; the washout particularly important with hepatocellular carcinoma, which may be delayed as opposed to metastatic lesions where washout is relatively early [10]. With a focal liver lesion, the arterial pattern, particularly in the benign lesion is paramount to the interpretation, but this phase lasts only for 30 to 40 seconds at most, and is nearly always informative by 20 to 30 seconds [11]. The washout phase starts early for the metastatic lesion, often before 60 seconds and will continue to wash-out for the rest of the examination. A hepatocellular carcinoma will washout slowly and may not demonstrate this washout for 180 seconds or more, depending on the cell differentiation. A most unlikely scenario is that a lesion that washes out then reaccumulates contrast and enhances over time; in-filling of a benign haemangioma is an exception where the characteristic globular in-filling is diagnostic. The essence of this is twofold; it is unlikely that extending the “video-clip” beyond 60 seconds will capture any further relevant information, and recording of washout is a prolonged effort, not needing continuous image storage. More important is the potential for microbubble “destruction” with prolonged, intense scanning over one area, with near field lesions most vulnerable, resulting in “pseudo-washout” [12, 13]. In short, continuous scanning for the first 60 seconds and then intermittent scanning after Annamaria Deganello Maria E. Sellars Gibran T. Yusuf Paul S. Sidhu Editorial

Etiology and Prognosis of Severe Ventriculomegaly Diagnosed at Late Gestation.

Abstract: Objectives We sought to assess the causes and outcomes of severe VM diagnosed de novo after 24 weeks of gestation where a mid-trimester anomaly scan was described as normal. Methods Multicenter retrospective study of five European fetal medicine centers. The inclusion criteria were normal anatomy at the mid-trimester scan, uni/bilateral finding of posterior ventricle measuring ≥ 15 mm after 24 weeks with neonatal and postnatal pediatric and/or neurological assessment data. Results Of 74 potentially eligible cases, 10 underwent termination, the outcome was missing in 19 cases and there was 1 neonatal death. Therefore, 44 formed the study cohort with a median gestation at diagnosis of 32 + 0 weeks (25 + 6 – 40 + 5). VM was unilateral in five cases. Agenesis of the corpus callosum (ACC) and grade III/IV intraventricular hemorrhage (IVH) accounted for 14 cases each. ACC was isolated in 9 fetuses. Obstructive abnormalities included 5 arachnoid and 1 cavum velum interpositum cyst. Four fetuses had an associated suspected or confirmed genetic condition, 2 congenital infections, 1 abnormal cortical development and the etiology was unknown in 3/44. Postnatal assessment at median 20 months (3 – 96) showed 22/44 (50 %) normal, 7 (16 %) mildly abnormal and 15 (34 %) severely abnormal neurodevelopmental outcomes. Conclusion One half of babies with severe VM diagnosed after 24 weeks have normal infant outcome with ACC and IVH representing the most common causes. Etiology is the most important factor affecting the prognosis of fetuses with severe VM diagnosed at late gestation.

Standards of hygiene for ultrasound-guided core cut biopsies of the breast

Abstract: Purpose The aim was to obtain an overview of the hygiene measures undertaken during ultrasound guided core cut biopsies of the breast by experts certified by the German Society for Ultrasound in Medicine in order to derive recommendations for clinical routine, taking into account the available literature and the lack of evidence based guidelines. Materials and Methods A survey was conducted with all members of the levels I to III of the breast ultrasound working group of the German Society for Ultrasound in Medicine. The estimation of the risk of infection after a core cut biopsy of the breast was asked for as well as the hygiene measures undertaken in practice to avoid infection. Results The risk of infection after a core cut biopsy of the breast was estimated to be one per thousand (median value). The most commonly performed hygiene measures were a spray, wipe, spray desinfection (98.1 %) and the use of sterile gloves (54.7 %). Conclusion Due to the very low risk of infection we recommend the routine use of gloves and an adequate skin disinfection. Contact of the transducer or of an unsterile contact medium with the biopsy needle is considered highly unlikely und should be avoided.

Ultrasound in transition - sonographers and student sonographers in Austria.

Abstract: Ultrasound pioneers come from many different countries and from various areas of specialization so that the organization of US is highly heterogeneous in medical fields in Europe as well as around the world [1, 2]. This is also reflected in the scientific representation of US that is traditionally organized in AT, DE, and CH in large interdisciplinary US societies (Austrian Society of Ultrasound in Medicine (ÖGUM), German Society of Ultrasound in Medicine (DEGUM), Swiss Ultrasound Society in Medicine (SGUM)). US is an integrative part of the student curriculum of Austrian medical universities and also an integrative part of physician training in many areas of specialization in accordance with the “new” training regulations from 2015.

Endobronchial Ultrasound (EBUS) - Update 2017.

Abstract: Endobronchial ultrasound (EBUS) has revolutionized the diagnosis of lung cancer over the last decade This minimally invasive diagnostic method has also become increasingly important in the case of other diseases such as sarcoidosis, thereby helping to avoid unnecessary diagnostic interventions This review article provides an update regarding EBUS and discusses current and future developments of this method

Sonographic Diagnosis of Meningoencephalitis in Newborns and Infants.

Abstract: Prenatal, neonatal meningoencephalitis and infections of the brain in older infants are often associated with serious complications which can be diagnosed by sonography through the open fontanelles. Most frequently postmeningitic hydrocephalus and subdural effusions occur. Rarer complications are brain abscesses and ventriculitis which are caused by gram negative bacteria such as E. coli, Serratia marcescens, Proteus and Enterobacter. A serious complication after ventriculitis is the development of compartment hydrocephalus. Multifocal small echogenic lesions scattered all over the brain are suspicious of fungal infections. Stripe-like echogenicities in the basal ganglia of newborns are typical for prenatal infections such as infections with cytomegalovirus, rubella, herpes, toxoplasma gondii and HIV. Late sequelae are intracranial cysts, multifocal encephalomalacia and intracranial calcifications. Color Doppler shows increased perfusion of the brain in the acute phase of the disease. Brain abscesses and infarcts are characterized by decreased or missing perfusion. Spectral Doppler shows increased flow velocities. Increased intracranial pressure causes an increase of the flow velocities in the intracranial part of the internal carotid artery in comparison with the extracranial part. All complications can be diagnosed by ultrasound. Other imaging methods such as MRI are only occasionally necessary. Pranatale und neonatale Meningoencephalitiden sowie Infektionen des Gehirns bei alteren Sauglingen gehen oft mit schweren Komplikationen einher, die sich bei offener Fontanelle sonografisch hervorragend erfassen lassen. Am haufigsten kommt es zum postmeningitischen Hydrocephalus und Subduralerguss. Seltenere Komplikationen sind Hirnabszesse und die Ventrikulitis, die durch gramnegative Erreger wie E. coli, Serratia marcescens, Proteus und Enterobacter verursacht werden. Eine seltene, aber schwerwiegende Komplikation ist die Entwicklung eines Kompartmenthydrocephalus. Multifokale echogene Foci, die uber das gesamte Gehirn verteilt sind, sind verdachtig auf eine durch Candida albicans hervorgerufene Meningoencephalitis. Streifenformige Echogenitatsvermehrungen im Bereich der Basalganglien beim Neugeborenen sind verdachtig auf das Vorliegen einer pranatalen Infektion mit dem Cytomegalie-, HIV-, Herpes- oder Rotelnvirus oder Toxoplasma gondii. Spatfolgen sind intrakranielle Zysten, die multizystische Encephalomalazie und intrakranielle Verkalkungen. Mit der farbkodierten Dopplersonografie lasst sich in der akuten Phase der Erkrankung eine vermehrte Perfusion finden. Demgegenuber sind Infarkte und Abszesse durch eine erniedrigte oder fehlende Durchblutung gekennzeichnet. Mit der gepulsten Dopplersonografie lassen sich erhohte Flussgeschwindigkeiten nachweisen. Ein assoziierter erhohter intrakranieller Druck ist durch einen Anstieg der Flussgeschwindigkeiten im intrakraniellen Anteil der A. carotis interna im Vergleich zum extrakraniellnen Anteil gekennzeichnet. Alle postinfektiosen Komplikationen, die nach Meningoencephalitis auftreten konnen, lassen sich sonografisch erfassen, sodass andere Schnittbildverfahren wie das MRT nur selten erforderlich sind.