The Use of Handheld Ultrasound Devices-An EFSUMB Position Paper

Publisher Copyright: © 2018 Georg Thieme Verlag KG Stuttgart New York.The miniaturization of ultrasound equipment in the form of tablet-or smartphone-sized ultrasound equipment is a result of the rapid evolution of technology and handheld ultrasound devices (HHUSD). This position paper of the European Federation of Societies in Ultrasound and Medicine (EFSUMB) assesses the current status of HHUSD in abdominal ultrasound, pediatric ultrasound, targeted echocardiography and heart ultrasound, and we will report position comments on the most common clinical applications. Also included is a SWOT (Strength-Weaknesses-Opportunities-Threats) analysis, the use for handheld devices for medical students, educational & training aspects, documentation, storage and safety considerations.Peer reviewe

Ultrasonography of the healing process during a 3-month follow-up after a splenic injury

We present a 14-year-old boy with a grade III splenic injury due to a bicycle accident, who was treated conservatively. The boy’s medical history included splenomegaly due to thalassemia. The splenic lesion was initially investigated with computed tomography (CT) and then, was followed by ultrasonography for 3 months. CT revealed a large intraparenchymal hematoma which appeared hyperechoic on ultrasonography. During follow-up, the hematoma developed a more complex echogenicity and became gradually hypoechoic. The hematoma increased in size during the first week but then, started decreasing until it eventually resolved completely. The patient had an uneventful full recovery. In this report, we discuss the ultrasonographic changes of the hematoma throughout the healing process

A study of the vulnerable carotid plaque with colour doppler and contrast-enhanced ultrasound and comparison with multidetector computed tomography angiography and correlation with neurologic symptoms

Objective: The objective of the present study is to investigate if a multi-parametric vulnerability index improves diagnostic accuracy for the detection of symptomatic carotid plaques in patients with carotid disease. The diagnostic accuracy of CDI and CEUS for the diagnosis of ulcerated carotid plaque is also evaluated. Patients and methods: Cross-sectional observational study including 53 patients (38 males) aged 46-83 years of age. A number of 60 internal carotid artery plaques were examined with 30 being symptomatic (having caused TIA or stroke the last 6 months). The patients were examined with carotid conventional ultrasound, CEUS and MDCTA. Parameters evaluated included the degree of stenosis (DOS), Greyscale Median (GSM), a quantitative index of surface irregularity (Surface Irregularity Index–SII), based both on CDI (SII-CDI) and CEUS (SII-CEUS) and the presence of ulceration on CDI, CEUS and MDCTA. The multi-parametric vulnerability index (VI) investigated in this study derives from the equation VI=(DOS*SII)/(GSM+1) and based on the SII used, two indices were defined: VI-CDI and VI-CEUS. The inter-observer agreement was evaluated for SII-CDI and SII-CEUS. Moreover, the differences of degree of stenosis, GSM, SII and VI between symptomatic and asymptomatic plaques were examined. ROC analysis evaluated the diagnostic accuracy of DOS, SII and VI for the detection of symptomatic carotid plaque. The diagnostic accuracy of CDI and CEUS was examined for the detection of ulcerated carotid plaque, having MDCTA as the reference method.Results: Very good inter-observer agreement was found between the two observers for SII-CDI and SII-CEUS (ICC 0.99 and 0.963 respectively). Low agreement was found between the SII measured by the same observer using CDI and CEUS (ICC 0.521 and 0.755 for the two observers). The DOS was statistically significantly different between asymptomatic and symptomatic plaques (63.86±11.38 and 74.2±10.81 respectively, p<0.01). GSM differed statistically significantly between the two groups (37.5±89 and 13.5±89 respectively, p<0.01). SII-CDI did not differ significantly between the two groups, although SII-CEUS images showed a tendency to statistically significantly differ between the two groups (p<0.1). The VI differed statistically significantly between asymptomatic and symptomatic plaques using both the SII-CDI and SII-CEUS (respectively asymptomatic and symptomatic plaques: 16.73±186.22 and 61.01±513.23 with CDI while 25.9±241.41 and 88.34±563.27 with CEUS, p<0.001). On ROC analysis the degree of stenosis achieved an AUC of 0.756, VI-CDI 0.769 and VI-CEUS 0.791. CDI technique was 38.4% sensitive and 100% specific for diagnosing the ulcerated carotid plaque, while CEUS was 92.3% sensitive and 100% specific.Conclusion: Asymptomatic and symptomatic plaques differed significantly in terms of DOS, GSM and the examined VI while there was a tendency for statistically significant difference between the two groups for the SII-CEUS. The VI combining the degree of stenosis, GSM and SII is better than the DOS alone in terms of diagnostic accuracy for detection of symptomatic plaques. CEUS outperformed CDI in terms of sensitivity for diagnosing ulcerated carotid plaque.Σκοπός: Σκοπός της μελέτης ήταν να εξετάσει εάν ένας πολυπαραγοντικός δείκτης ευαλωτότητας (ΔΕ) της καρωτιδικής πλάκας βελτιώνει τη διαγνωστική ακρίβεια για τον εντοπισμό συμπτωματικών πλακών. Επίσης εξετάστηκε η διαγνωστική ακρίβεια της Colour Doppler Imaging (CDI) και Contrast-Enhanced Ultrasound (CEUS) για τη διάγνωση της εξελκωμένης καρωτιδικής πλάκας. Ασθενείς και μέθοδοι: Συγχρονική μελέτη παρατήρησης, στην οποία εξετάσθηκαν 53 ασθενείς (38 άνδρες) ηλικίας 46-83 ετών. Συνολικά εξετάσθηκαν 60 αθηρωματικές πλάκες έσω καρωτίδων, εκ των οποίων 30 συμπτωματικές, έχοντας προκαλέσει νευρολογική συμπτωματολογία με τη μορφή παροδικού ή μόνιμου ισχαιμικού ΑΕΕ τους τελευταίους 6 μήνες. Οι ασθενείς εξετάσθηκαν με συμβατική υπερηχογραφία, CEUS και MDCTA καρωτίδων, ώστε να καθορισθούν ο βαθμός της στένωσης (DOS), η διάμεσος τιμή ηχογένειας - Greyscale Median (GSM) της πλάκας, ένας ποσοτικός δείκτης της ανωμαλίας της παρυφής της πλάκας (Surface Irregularity Index–SII), τόσο με βάση την CDI (SII-CDI), όσο και την CEUS (SII-CEUS) και τέλος η παρουσία εξέλκωσης στην τεχνική CDI, CEUS και MDCTA. Ο δείκτης ευαλωτότητας που χρησιμοποιήθηκε σε αυτήν τη μελέτη προκύπτει από την εξίσωση ΔΕ=(DOS*SII)/(GSM+1) και αναλόγως του SII που χρησιμοποιήθηκε προέκυψε ο ΔΕ-CDI και ΔΕ-CEUS. Εξετάσθηκε η συμφωνία μεταξύ δύο παρατηρητών για το δείκτη SII-CDI και SII-CEUS, η διαφορά του βαθμού της στένωσης, των δεικτών GSM, SII και ΔΕ μεταξύ συμπτωματικών και ασυμπτωματικών πλακών και η διαγνωστική ακρίβεια του DOS, του δείκτη SII και του ΔΕ για τον εντοπισμό της συμπτωματικής καρωτιδικής πλάκας με βάση την ανάλυση ROC. Τέλος μελετήθηκε η διαγνωστική ακρίβεια της CDI και CEUS για τη διάγνωση της εξελκωμένης καρωτιδικής πλάκας με μέθοδο αναφοράς την MDCTA.Αποτελέσματα: Βρέθηκε πολύ καλή συμφωνία μεταξύ 2 παρατηρητών για τον δείκτη SII-CDI και SII-CEUS (ICC 0.99 και 0.963 αντίστοιχα). Χαμηλή συμφωνία βρέθηκε στην τιμή SII που προκύπτει από τον ίδιο παρατηρητή με την τεχνική CDI και CEUS (ICC 0.521 και 0.755 για τους δύο παρατηρητές). Ο DOS διέφερε στατιστικά σημαντικά μεταξύ ασυμπτωματικών και συμπτωματικών πλακών (63.86±11.38 και 74.2±10.81 αντίστοιχα, p<0.01). H GSM διέφερε στατιστικά σημαντικά μεταξύ ασυμπτωματικών και συμπτωματικών πλακών (37.5±89 και 13.5±89 αντίστοιχα, p<0.01). Ο SII-CDI δεν διέφερε στατιστικά σημαντικά μεταξύ ασυμπτωματικών και συμπτωματικών πλακών, ενώ ο SII-CEUS εμφάνισε τάση για στατιστικά σημαντική διαφορά (p<0.1) μεταξύ ασυμπτωματικών και συμπτωματικών πλακών. Ο ΔΕ διέφερε στατιστικά σημαντικά μεταξύ ασυμπτωματικών και συμπτωματικών πλακών τόσο με χρήση του SII-CDI, όσο και του SII-CEUS (αντίστοιχα ασυμπτωματικές και συμπτωματικές πλάκες: 16.73±186.22 και 61.01±513.23 με την CDI ενώ 25.9±241.41 και 88.34±563.27 με την CEUS, p<0.001). Στην ανάλυση ROC ο DOS είχε AUC 0.756, ο ΔΕ-CDI AUC 0.769 ενώ ο ΔΕ-CEUS 0.791. Η CDI ήταν 38.46% ευαίσθητη και 100% ειδική για τη διάγνωση της εξέλκωσης, ενώ η CEUS 92.3% ευαίσθητη και 100% ειδική. Συμπεράσματα: Οι ασυμπτωματικές και συμπτωματικές πλάκες διαφέρουν ως προς το DOS, το GSM και το ΔΕ που προτάθηκε, ενώ υπήρχε τάση να βρεθεί διαφορά ως προς το δείκτη SII-CEUS. O ΔΕ που συνδυάζει το βαθμό στένωσης, το GSM και το SII ξεπερνά το DOS μόνο του σε διαγνωστική ακρίβεια για τον εντοπισμό των συμπτωματικών πλακών. Η CEUS έδειξε πολύ μεγαλύτερη ευαισθησία της CDI για τη διάγνωση της καρωτιδικής εξέλκωσης

Contrast-enhanced ultrasonography of the carotids

Contrast-enhanced ultrasonography of the carotids has recently emerged as a complementary examination to conventional carotid Doppler ultrasonography. It is an examination providing improved visualization of the vascular lumen, more accurate and detailed delineation of the vascular wall, and identification of atherosclerotic plaques. Moreover, contrast-enhanced ultrasonography has specific advantages over conventional ultrasonography and plays an important role in the diagnosis of the vulnerable carotid plaque, as it can identify intraplaque neovascularization and carotid plaque ulceration. Given the specific advantages and improved imaging of the carotids provided by this method, radiologists should be familiar with it. This pictorial essay illustrates the advantages of this technique and discusses its value in the imaging of carotid arteries

Two Congenital Anomalies in One: An Ectopic Gallbladder with Phrygian Cap Deformity

The gallbladder is affected by a large number of congenital anomalies, which may affect its location, number, size, or form. Some of these malformations are very rare and may lead to misdiagnosis. An ectopic gallbladder can be misinterpreted as agenesis of the organ or as a cystic hepatic mass when intrahepatic. Given the frequency and the wide acceptance of the ultrasonographic examination of the biliary tract, radiologists should be aware of these malformations. In some cases, ultrasonographic diagnosis can be difficult. However, the use of Computed Tomography can elucidate such cases. We present the case of a patient whose gallbladder had two combined malformations but caused no symptoms. Namely, the patient had a transverse ectopic gallbladder combined with a “Phrygian cap” deformity. The incidence of ectopic locations of the gallbladder is 0.1–0.7%, whereas the “Phrygian cap” deformity can be found in 4% of patients. There is no other cases with combination of these two entities reported in the literature. Ultrasonographic and CT findings are presented and aspects of this malformation are discussed. The clinical significance of ectopic gallbladder is also emphasized because it may alter the clinical presentation of biliary tract diseases and pose technical problems during surgery

Fountain’s Sign as a Diagnostic Key in Acute Idiopathic Scrotal Edema: Case Report and Review of the Literature

The acute idiopathic scrotal edema (AISE) is a self-limited disease of unknown etiology, characterized by edema and erythema of the scrotum and the dartos, without expansion to the underlying layers of scrotum’s wall or to the endoscrotal structures. Boys younger than 10 years old are usually involved in 60–90% of all cases. Diagnosis is made after exclusion of other causes of acute scrotum. We present a case of a 7-year old boy, who was admitted to the Emergency Department due to development of scrotal edema and erythema over the last 48 hours, which extended to the base of the penis. The patient mentioned that he first noticed the erythema on the anterior surface of the right hemiscrotum, which gradually extended. Physical examination did not reveal presence of pathology involving the endoscrotal structures, indicative of need for urgent surgical intervention. Transillumination was negative for blue dot sign. Ultrasonographic examination of the scrotum documented the homogeneity of the testicular parenchyma, while color Doppler revealed the presence of fountain’s sign (equal arterial blood supply to both testicles). Conservative strategy was followed and the patient gradually improved within the next three days. In conclusion, meticulous physical examination along with ultrasonographic examination of the suffering scrotum, especially with the highlighting of fountain’s sign with color Doppler, document the diagnosis of AISE. Thus, need for urgent surgical investigation of the suffering scrotum due to diagnostic doubt is limited

Imaging of a Renal Artery Aneurysm Detected Incidentally on Ultrasonography

Renal artery aneurysms occur with a frequency of less than 1% of the general population. Even if they are usually asymptomatic and incidentally found, they can be complicated with life-threatening conditions like rupture, thrombosis, embolism, or hypertension. Thus, once diagnosed, they should be fully evaluated with further imaging and treated when indicated. We present the case of a patient who was referred for ultrasonography for an unrelated reason. The examination demonstrated a hyperechoic focus near the right kidney. Further imaging workup with MDCT established the diagnosis of a right renal artery aneurysm which was saccular in shape and peripherally calcified. This ring-like calcification was also visible in a KUB radiography which was also performed. After presenting the case, various aspects of this rare entity are discussed

Abdominal Wall Abscess due to Acute Perforated Sigmoid Diverticulitis: A Case Report with MDCT and US Findings

Perforation of the inflamed diverticula is a common diverticulitis complication. It usually leads to the formation of a local abscess. In some rare cases, the inflammatory process may spread towards extra-abdominal sites like the anterior or posterior abdominal wall or the thigh and form an abscess in these sites. We present the case of a 73-year-old man with a history of pain at the lower left quadrant of the abdomen for 20 days and a visible mass in this site. Ultrasonography and computed tomography revealed this mass to be an abscess of the abdominal wall which had been formed by the spread of ruptured sigmoid diverticulitis by continuity of tissue through the lower left abdominal wall. Local drainage of the abscess was performed and the patient was discharged after alleviation of symptoms and an uneventful course. We also discuss causes of abdominal wall abscesses along with the possible pathways by which an intra-abdominal abscess could spread outside the abdominal cavity