Pediatric Registry Review Flashcards
Curved Array Transducers
Crystals arranged in the shape of an arc. Provide a wide field of view in the near field.
Linear Array Transducers
Crystals arranged in a line. Rectangular shaped image. Evaluation of Neonatal spine, infant abdomens, bowel wall, brain, MSK, abdominal and superifical parts.
Phased Array Transducers
Crystals arranged in a line. Image produced is pie shaped or vector shaped. Possess a small footprint making them advantageous for intercostal scanning, echocardiography or chest. Also, head imaged.
Narrow bandwidths emit __ frequencies.
Few
Broad bandwidths emit __ frequencies.
Many; multi-hertz transducers have broad bandwidths, which allow the operator to change the frequency; harmonic imaging also results in broad bandwidths.
Frequency and Penetration are ___ proportional.
Inversely
Frequency and Spatial Resolution are __ proportional.
Directly
What is spatial resolution?
Capability of depicting structural detail (axial and lateral resolution)
Axial Resolution
display 2 closely spaced targets parallel to the sound beam as 2 distinct targets.
Dependent on the transducer’s spatial pulse length (SPL)
Spatial pulse length in ultrasound imaging describes the length of time that an ultrasound pulse occupies in space. Mathematically, it is the product of the number of cycles in a pulse and the wavelength. A shorter spatial pulse length results in higher axial resolution.
Lateral Resolution
ability of the transducer to display two targets perpendicular to the path of the sound beam as 2 distinct structures.
Improved with focusing and higher frequency transducers.
Propagation Speed of Soft Tissue
1540 m/s
Propagation Speed of Water
1480 m/s
Propagation Speed of Blood
1575 m/s
Propagation Speed of Bone
4080 m/s
Propagation speed is inversely proportional to:
density, elasticity and compressibility
Propagation speed is directly proportional to:
stiffness
Reflection
return of the sound beam back to the transducer; responsible for CREATING the image
Refraction
change of direction or bending of the sound wave as it passes from one tissue to another
only occurs if there is a change in velocity between 2 media and there is an oblique angle of incidence
Attenuation
weakening of the amplitude or intensity as it travels through a medium
Sources include absorption, reflection, scattering, refraction and interference
Dynamic range controls:
the number of gray shades represented in the display; the higher the dynamic range, the greater amounts of display and the lower the dynamic range, the less gray displayed (more contrasty)
Tissue Harmonic Imaging (THI)
improves the signal to noise ratio, reduces grating lobe artifacts, and improves lateral resolution.
What is the major benefit of Tissue Harmonic Imaging (THI)?
artifact reduction
B-Flow Imaging
displays the blood flow signal throughout an entire gray-scale image
can simultaneously visualize high and low velocities
detailed organ perfusion, such as renal or liver transplants, neonatal heads and superficial masses
Shear Wave Elastography
quantifies tissue stiffness
Strain Elastography
known as static or compression elastography; based on manual compression
Optimal spectral Doppler angle is ___ degrees.
zero degrees or parallel to vessel flow
zero is not always feasible; angles above 60 may result in errors of velocity calculations
Sample volume size or gate determines:
the number of blood cells sampled
Spectral analysis display demonstrates:
the direction and range of blood flow velocities in a structure of interest
Wall filter
sets the threshold or reject of low-level Doppler shift frequencies
Increasing the wall filter results in the ultrasound system being less sensitive to slow blood flow
Color Doppler displays:
mean or average Doppler velocities in a color format
Power Doppler displays:
total strength or amplitude of the Doppler signal within a specified region
represents the total number of RBCs in the region regardless of velocity
What is an artifact?
Any echo reflection anomaly in the image that does not correlate with actual tissue or structure
Posterior Acoustic Enhancement Artifact
A decrease in attenuation.
Mostly seen posterior to fluid filled structures such as cysts.
Focal Banding or Focal Enhacement Artifact
A region of echoes having increased or decreased strength, displayed across the width of an image
resolved by adjusting TGC’s
Shadowing Artifact
absence or reduction of echo signals distal or posterior to a strong reflecting structure
Indicative of calcium deposits, stones, gas, hard malignant masses, bone, etc.
Reverberation Artifact
occurs when the ultrasound beam is repeatedly reflected from an interface near the transducer
Seen as multiple equidistantly spaced linear reflections
Comet-Tail Artifact
Type of reverberation that occurs from two highly reflective interfaces and therefore echoes are closely spaced together
seen as multiple echogenic small bands (foreign bodies, surgical clips, needles, sutures, catheters, etc)
Ring Down Artifact
Type of reverberation that is thought to be a variation of comet-tail artifact; produced by small gas bubbles and appears as a single long, strong echo behind a reflector
Refraction Artifact
when the sound beam strikes adjacent interfaces of differing propagation speeds at an oblique angle; any other angle than 90 degree.
results in an incorrect location of structure
Grating Lobes Artifact
echoes placed laterally from true position
Section or Slice Thickness Artifact
Placement of echoes in the dependent portion of a fluid filled structure
Mirror Image Artifact
occurs in GS, CD and SD imaging.
near-total reflection occurs when an object is located directly in front of a highly reflective object. (diaphragm, pleura, bowel)
Aliasing Artifact
MOST COMMON artifact in Doppler Imaging
Occurs when the PRF is not high enough to sample the highest blood velocity
Color Bleeding/Blossoming Artifact
when color is seen beyond the area of interest
Color Noise Artifact
area of no flow are encoded with color
Flash Artifact
Wide region of a burst of color seen within a frame
Supine/Dorsal Decubitus
Pt lying face-up position on one’s back
Prone/Ventral Decubitus
Pt lying in face down position on one’s abdomen
Right Lateral Decubitus
lying on right side
Left Lateral Decubitus
lying on left side
Right Posterior Oblique
lying on right side at a 45 degree angle with left knee bent
Left Posterior Oblique
lying on left side at a 45 degree angle with right knee bent
Central Venous Line (CVL)
catheter is placed in a large vein in the neck, chest or leg that leads directly to the heart
Contact Precautions
Disease spreads through direct or indirect contact (open wound, draining of body fluids)
Gloves and Gown.
Droplet Precautions
Disease spread through acts such as talking, coughing and/or sneezing in which microorganisms travel no more than 3 feet from the pt
Face mask.
Airborne Precautions
Disease is spread through fine particles in the air (Tuberculosis)
Fit tested filtering face piece or a powered air-purifying respirator
Paracentesis
removal of peritoneal ascites
Thoracentesis
removal of pleural fluid
The liver, gallbladder and biliary system arise from the caudal end of the foregut during the __ week of gestation.
4th
The liver reaches its full development by age __.
15
The right lobe grows faster than the left
The ductal system is complete by the __ week of gestation.
10th
A connective tissue layer, known as ________, covers the surface of the liver and encapsulates all, but the smallest vessels in the liver.
Glisson’s Capsule
The right lobe of the liver is divided from the left lobe by:
the Main Lobar Fissure and Middle Hepatic Vein
Caudate Lobe is located ____ to the ligamentum venosum, ___ to the MPV and _____ to the IVC.
posterior to the ligamentum venosum
superior to the MPV
anterior medial to the IVC
Caudate lobe can be spared from disease due to a unique blood supply
Quadrate Lobe is located on the ___ surface of the liver and lies between the ____ and ____.
inferior surface of liver
lies between the GB fossa and falciform ligament
anterior to porta hepatis
Left lobe is separated by the caudate lobe and the ___ on the dorsal surface.
ligamentum venosum
Couinaud’s System
- Caudate Lobe
- Left Lateral Superior
- Left Lateral Inferior
4a. Left Medial Superior
4b. Left Medial Inferior - Right Anterior Inferior
- Right Posterior Inferior
- Right Posterior Superior
- Right Anterior Superior
What ligament connects the posterior liver to the diaphragm?
Coronary ligament
What ligament connects the anterior and superior surface of the liver to the anterior abdominal wall between the umbilicus and diaphragm?
Falciform Ligament
Continuous with the ligamentum teres
What ligament is continuous with the ligamentum venosum, lesser curvature of the stomach and first portion of the duodenum?
Gastrohepatic Ligament
What ligament surrounds the portal triad just proximal to the porta hepatis?
Hepatoduodenal Ligament
What ligament extends from the superior surface of the left lobe of the liver to the diaphragm?
Left Triangular Ligament
What ligament extends from the diaphragmatic surface of the right lobe to the diaphragm?
Right Triangular Ligament
What ligament is the obliterated remnant of the fetal umbilical vein?
Ligamentum Teres or Round Ligament
Originates at the umbilicus and anastomoses with the umbilical portion of the left portal vein
Liver length in neonate
4-5 cm
Liver length in adolescents
6-10 cm
Liver length in adults
15-17 cm
Neonate and young infant, liver parenchyma is ___ echogenicity of the renal cortex.
equal to
After 6 months of age, the liver parenchyma is ____ than the renal cortex.
more echogenic
Hepatic artery arises from ___ and supplies ___% of blood flow to the liver.
Celiac Trunk of the Aorta
25-30%
Hepatic artery branches into:
Proper Hepatic Artery and Gastroduodenal artery (GDA)
Before branching, the hepatic artery is referred to as the common hepatic artery.
The Proper Hepatic Artery branches into:
left and right hepatic arteries at the porta hepatis
The proper hepatic artery is ____ to the MPV and __ to the CBD.
anterior medial to MPV
medial to the CBD
Portal Vein supplies ___% of the bloody supply to the liver
70-75%
Portal Vein is formed by the confluence of the:
splenic vein and the SMV
Right Portal Vein divides into
anterior and posterior branches
Left Portal Vein divides into
medial and lateral branches
LPV connects the umbilical vein remnant through the ligament of teres
Connects the IVC through the ligament venosum which is known as the obliterated ductus venosus
Hepatic veins drain blood from the liver to the
IVC
Portal Vein size in children less than 10 years
8.5 mm
Portal vein diameter between 10-20 years
10 mm
What is the function of the liver?
- Reservoir for blood
- Removes damaged RBCs and bacteria by phagocytosis
- Reticuloendothelial cells (Kupffer cells) responsible for clearing pathogens - Metabolizes lipids, proteins, and carbs into energy sources
- Nutrient, mineral and vitamin storage
- Formation and Excretion of Bile
LFT’s (Liver Function Tests)
evaluate liver function and liver injury
ALT (Alanine aminotransferase)
an increase in ALT values indicates damage to the liver usually from hepatitis, hepatocellular disease, or biliary tract obstruction.
AST (Aspartate Aminotransferase)
Increases with hepatocellular disease as well as indicating skeletal and muscular damage
used for detecting liver damage due to hepatitis and cirrhosis
ALP (Alkaline Phosphatase)
increase in ALP indicates liver or bone disease
Children and Adolescents often have an increase in ALP because their bones are still developing and growing.
MOST SPECIFIC INDICATOR OF BILIARY OBSTRUCTION
Paget’s disease, a condition causing excess bone growth and formation, will have an increase in ALP.
Direct or Conjugated Bilirubin
Increase in direct bilirubin is associated with decreased hepatic excretion, hepatitis, cholestasis and biliary obstruction
Indirect or Unconjugated Bilirubin
Increase associated with hemolytic anemia, hepatitis and cirrhosis
Total Bilirubin
can be high in newborns due to physiologic jaundice but usually resolves itself in a few days.
Biliary Atresia can cause an increase in total bilirubin and unconjugated bilirubin
AFP (Alpha Fetoprotein)
used as a tumor marker to detect hepatomas and hepatoblastomas
associated with chronic liver disease and chornic hep B or C
Liver/GB/Pancreas Ultrasound NPO Prep for less than 4 years
NPO for 4 hours
Liver/GB/Pancreas Ultrasound NPO Prep older than 4
NPO for 5-6 hours
Reidel’s Lobe Variant
a tongue-like project of the right lobe that extends to the iliac crest
more common in females
Left Lobe Position Variant
left lobe may be located to the right of midline or may extend to the left lateral abdominal wall
Heterotaxy Syndrome (Situs Ambigus)
Associated with:
Sonographic findings:
disturbance in the usual location of the right and left distribution of the abdominal and thoracic organs
Associated with polysplenia, asplenia, cardiac defects, biliary atresia
Variable Sonographic findings:
- liver located in midline
- azygos or hemiazygous continuous of IVC
- PV and IVC variations may be seen
Caroli’s Disease
Associated with:
Clinic Presentation:
Sonographic Findings:
Congenital disorder resulting in multifocal cystic dilation of the intrahepatic bile ducts as a result of congenital hepatic fibrosis
Associated with fibropolycystic liver disease and polycystic kidney disease
Clinical:
- Intermittent RUQ pain
- Jaundice
- Fever
Sonographic:
- Polycystic Liver Disease
- Dilated Intrahepatic Ducts
- Intraductal Calculi
- Small PV branches with dilated bile ducts
Cystic Fibrosis
Clinical:
Sonographic Findings:
Results in replacement of pancreatic tissue with fibrosis and fat; autosomal recessive disorder
Clinical:
- Failure to thrive
- abdominal pain
- Jaundice
Sonographic:
- Increased liver echogenicity
- Micro or macro cysts on pancreas
- Small GB and cholelithiasis
Niemann-Pick Disease
Risk Factors:
Clinical:
Sonographic:
lipid storage disease; results in accumulation of lipids in brain, spleen, liver, lungs and bone marrow
Risk factors:
- inherited
- female
- fatal
Clinical:
- neurological symptoms
- feeding and swallowing issues
- elevated LFTs
Sonographic Findings:
- Hepatosplenomegaly
- Increased liver echogenicity
- Enlarged nodes
Gaucher Disease
Risk Factors:
Clinical:
Sonographic:
lysosomal storage disease which results in increased glucosyleramide
Risks:
- Jewish population
- Autosomal recessive disorder
Clinical:
- Hepatosplenomegaly
- Abdominal pain
- growth retardation
Sonographic:
- Increased liver echogenicity
- hepatosplenomegaly
- nodular spleen
Non-Alcoholic Fatty Liver Disease (NAFLD)
Associations:
Sonographic Findings:
Chronic liver condition due to hepatic fat accumulation or steatosis
Associations:
- Portal HTN
- Cirrhosis
- Hepatocellular Carcinoma
Sonographic Findings:
- Hepatomegaly
- Diffuse or focal areas of parenchymal echogenicity
- The walls of the portal veins blend in due to the increasing parenchymal echogenicity
Non-Alcoholic Steatohepatitis (NASH)
Fat accumulation plus inflammation, fibrosis and necrosis
What is the most common form of chronic liver disease in children?
Non-Alcoholic Fatty Liver Disease
Reye’s Syndrome
Disorder characterized by fatty infiltration of the liver and encephalopathy
Typically occurs in young children following a previous viral infection : cold, flu, chicken box, use of aspirin
Glycogen Storage Disease
Sonographic Findings:
Excessive glycogen accumulates in the organs (Type 1 or Von Gierke’s disease occurs in the neonatal period)
Sonographic:
- Increased liver echogenicity
- Hepatomegaly
- Associated liver cell adenomas
What is the most common inborn error of carbohydrate metabolism?
Glycogen Storage Disease
Cirrhosis
Risk Factors:
Clinical:
Sonographic:
Disease in which liver tissue is replaced with fibrotic scar tissue
Risk Factors:
- Biliary Atresia
- Cystic Fibrosis
- Chronic Hepatitis
Clinical:
- Hepatomegaly
- Jaundice
- Increase in bilirubin and LFT’s
- Ascites
Sonographic:
- Decreased liver size
- Nodular Surface
- Heterogenous Parenchyma
- Nodules
- Portal HTN
- Splenomegaly
- Ascites
Abscess
Collection of Pus
In infants, ____ are associated with infection from the umbilicus or mesentery.
Abscesses
Abscess associated with living conditions which have contaminated drinking water.
Amebic
Abscess secondary to infections from the bowel, trauma, or surgery.
Pyogenic
Abscess that occurs in immunocompromised patients and are usually due to candida albicans.
Fungal
Cavernous Hemangioma
Sonographic Findings:
large network of vascular endothelium-lined spaces filled with RBCs
occurs in older children and adolescents
Sonographic:
- Hyperechoic
- Single or Multiple
- Posterior Acoustic Enhacement
- Color & Spectral show slow flow
Hemangioendothelioma
Clinical:
Sonographic Findings:
benign mass composed of vascular spaces lined by several layers of endothelial cells
Typically diagnosed before 6 months of age
Clinical:
- hemangiomas of the skin
- abdominal distention
- ongestive heart failure
- Increased AFP
Sonographic:
- well defined
- hypoechoic nodule but can appear hyperechoic with cystic changes
- single or multiple
- Hepatic veins can be enlarged due to increased flow
What is the most common symptomatic vascular lesion of the liver?
Hemangioendothelioma
Mesenchymal Hamartoma
Sonographic Findings:
rare, benign tumor derived from periportal connective tissue or mesenchyme
Children less than 2
Sonographic Findings:
- large lesions
- complex
- poorly circumscribed
- swiss cheese appearance of liver
- avascular
Focal Nodular Hyperplasia (FNH)
Clinical:
Sonographic Findings:
mass comprosed of abnormally arranged hepatocytes, Kupffer cells, bile duct elements and fibrous connective tissue
Clinical:
- Hx of chemotherapy for neoplastic diseases
- enlarged mass may cause pain
- asymptomatic
Sonographic Findings:
- Solitary
- Well circumscribed
- Isoechoic to liver
- Central echogenic scar
- Peripheral blood flow and blood flow within mass
Hepatic Adenoma
Clinical:
Sonographic Findings:
Mass composed of abnormal hepatocytes
Clinical:
- Von Gierke’s disease or Type 1 glycogen storage disease
- asymptomatic
- pain may occur if mass bleeds
Sonographic Findings:
- Solitary
- well defined
- variable appearance
- peripheral flow and blood flow within
Hepatoblastoma
Clinical:
Sonographic Findings:
Malignant neoplasm of the liver (infant to 5 years)
Clinical:
- Associated with children with predisposing conditions
- most common indication is painless abdominal mass with elevated AFP levels
Sonographic:
- Hepatomegaly
- well defined mass
- heterogenous
- high velocity, low resistant flow pattern
What is the most common primary liver tumor in children?
Hepatoblastoma
Treatment of Hepatoblastoma depending on Staging
Stage 1: complete resection
Stage 2: resection with microscopic residual disease
Stage 3: resection with residual tumor, positive lymph nodes
Stage 4: metastic involvement
Hepatocellular Carcinoma
Clinical:
Sonographic Findings:
Primary malignancy of the liver
Clinical:
- over 3 years old
- preexisiting liver disease
Sonographic:
- solid, hyperechoic mass
- large
- well defined or ill defined borders
- tumor invasion or thrombus of Portal Vein
Lymphoma
Clinical:
Sonographic Findings:
Malignant neoplasm of the lymphatic system
Liver, Renal and Testicular involvement typically from Non-Hodgkin’s Lymphoma
Lung/Thymus involvement typically Hodgkin’s Lymphoma
Clinical:
- asymptomatic lymph node enlargement
- abnormal pressure and congestion in the face, neck and chest
- children over 5
Sonographic:
- Focal mass
- well-defined
- variable appearance
What is the most common malignancy to involve the spleen in children?
Lymphoma
Leukemia
Clinical:
Sonographic:
Malignant disease involving the blood-forming tissues (bone marrow, lymph nodes and spleen)
Testicular involvement may occur at the same time of initial involvement or may occur after bone marrow remission
Clinical:
- characterized by an abnormal increase in WBC
- easy bruising or bleeding
- non healing of minor wounds
Sonographic:
-Hypo or Hyperechoic lesions
Mets to the liver are typically from what malignant tumors?
Neuroblastoma
Wilm’s Tumor
Leukemia
Lymphoma
Portal Hypertension
Sonographic Findings:
Portal venous pressure exceeding 5 mmHg or portal vein to hepatic vein gradient greater than 10 mmHg
Caused by a disruption of the flow through the portal system (PV thrombosis)
Sonographic:
- Dilated MPV greater than 13mm
- Recanalized ligamentum venosum and/or ligamentum teres
- Hepatosplenomegaly
Treatment includes portosystemic shunts to reduce pressure within the portal system
In children portal hypertension is most commonly due to:
intrahepatic etiologies, cirrhosis and liver disease
Portal Vein Thrombosis
Clinical:
A total or partial obstruction of blood flow within the portal vein due to the formation of a thrombus
Cavernous Transformation occurs to bypass thrombotic site, hepatofugal flow happens because the collaterals can’t release the systems pressure
Clinical:
- trauma
- neonatal peritonitis
- umbilical catheterization
- sepsis
Hematoma
Sonographic Findings:
a collection of blood within or adjacent to liver usually from trauma
Commonly located in posterior segment of right lobe
Variable appearance based on age of hematoma
Biloma
collection of bile in the liver or peritoneal cavity which is a late complication of hepatic trauma
Sonographic findings:
- anechoic collection of fluid
- thin walled
- resolve spontaneously
What normal variant of the GB represents a bulge on the inferior surface of the infundibulum where stones can become impacted and obstruct the cystic duct?
Hartman’s Pouch
Size of GB less than 1 year of age (length and wall thickness)
Length: 1.5-3 cm
Wall: less than 3 mm
Size of GB older than 1 year of age (length and wall thickness)
Length: 3-7 cm
Wall: less than 3 mm
What duct joins the neck of the GB to the common hepatic duct (CHD)?
Cystic Duct
What is the accessory cystic duct?
Duct of Luschka
Associated with bile leaks following surgical procedures
Duct formed by the junction of the cystic duct and the common hepatic duct
Common Bile Duct (CBD)
Cystic Duct Size
1-5 mm in diameter
CBD Size Neonates: Children up to 1 year: 1-10 years: Adolescents and Young Adults:
Neonates: <1mm
Children up to 1: <2mm
1-10 years: <4mm
Adolescents/Yound Adults: <6mm
Where is bile stored in patients with a cholecystecomy?
proximal small intestine
after eating, the acids are then transported to the distal ileum for absorption and maintenance
What is the most common GB variant?
Junction fold - a fold at the GB neck
What is a fold at the GB fundus?
Phrygian Cap
Gallbladder Agenesis
complete absence of the GB with normal bile ducts
Biliary Atresia
Clinical:
Sonographic Findings:
Congenital obstruction of biliary system that can affect intra or extrahepatic ducts
Clinical:
- males
- jaundice
- acholic stools
Sonographic:
- GB may or may not be affected (abnormal looking GB if affected)
- “Triangle Cord Sign” : seen superior to PH which is a premature bile duct
Kasai Procedure and Liver Tx are treatments
Triangle Cord Sign
Echogenic structure resembling a triangle that is found superior to porta hepatis.
Sign of biliary atresia
Choledochal Cyst
Clinical:
Sonographic Findings:
Cystic dilation of the biliary tree
Clinical:
- Asian population
- Female
- Biliary Atresia
Sonographic:
- Saccular dilation of the CBD or CHD
- dilated cystic lesion that communicates with the bile ducts and is separate from the GB
Caroli’s Disease
Congenital disorder resulting in multifocal dilation of the intrahepatic ducts as a result of congenital hepatic fibrosis
Associated with polycystic liver and kidney disease
Cholelithiasis is most commonly seen in what age group?
Adolescents
GB Hydrops
massive distention of the GB in the absence of inflammation
Greater than 3cm in length in children less than 1 and greater than 7 cm in length in older children
Neonatal Cholestasis
Clinical:
Sonographic Findings:
Conjugated hyperbilirubinemia occurring in neonates
Clinical:
- jaundice
- acholic stools
- dark yellow urine
Sonographic:
- Dilation of the biliary ducts
- Gallstones
- Sludge
Acalculus Cholecystitis
Clinical:
Sonographic Findings:
Inflammation of the GB without gallstones
Clinical:
- critcally ill patients
- RUQ pain
- Fever/Vomiting
Sonographic:
- Edematous GB wall
- GB wall measures >3mm
- Pericholecystic Fluid
- GB Distention
Acute Calculus Cholecystitis
Clinical:
Sonographic Findings:
An acute inflammation of the GB usually from GB obstruction at the level of the cystic duct or GB neck
Clinical:
- RUQ pain
- Fever/Nausea/Vomiting
Sonographic:
- GB wall thickening
- Sludge
- Pericholecystic Fluid
- Hyperemia
- Positive Sonographic Murphy’s Sign
What is the most common cause of RUQ pain?
Acute Calculus Cholecystitis
Chronic Cholecystitis
Sonographic Findings:
Prolonged inflammatory condition that is caused by intermittent blockage of the cystic duct
Sonographic Findings:
- Contracted GB
- Stones
- Thick, hyperemic wall
- Sludge
Sclerosing Cholangitis
Sonographic Findings:
Inflammatory fibrosis of intra and extra hepatic ducts
Sonographic Findings:
- Dilated bile ducts
- Thickened bile duct walls
- Choledocholithiasis
- Cholelithiasis
Choledocholithiasis
Complete or partial obstruction of the bile ducts by biliary stones
large foci may cause intra or extra hepatic ductal dilatation
Mirizzi Syndrome
Extrahepatic biliary obstruction due to impacted cystic duct and associated extrinsic compression or inflammation of the cystic duct
Bile Plug Syndrome
Extrahepatic bile duct syndrome due to sludge
Echogenic debris within bile ducts
Rhabdomyosarcoma Liver/Renal
Clinical:
Sonographic Findings:
Rare malignant tumor made up of muscle tissue that arises from the porta hepatitis/trigone of bladder
usually found in children between 2-6 years and 14-18 years
Clinical: -obstructive jaundice -abdominal pain -weight loss elevated bilirubin, Alkaline phosphatase and WBC
Sonographic:
- echogenic mass within bile ducts
- may appear complex due to necrosis or hemorrhage
- absence of posterior shadowing
Granular Cell Tumor
Clinical:
Sonographic Findings:
non-epithelial tumor of the extrahepatic ducts
Clinical:
- female
- African American
- Adolescents
- jaundice
- abdominal pain
Sonographic:
- echogenic mass within the bile ducts
- may appear complex due to necrosis or hemorrhage
- absence of posterior shadowing
At approximately __ weeks of gestation the pancreas arises from two outpouchings on the endodermal lining of the duedenum dorsal wall.
5
The pancreas is a ____ organ located in the ___ pararenal space, ___ to the lesser sac.
Retroperitoneal
anterior
posterior
Pancreatic head is located
___ to the SMV.
____ to the IVC
____ to the MPV.
right lateral to the SMV
Anterior to the IVC
caudal to the MPV
The GDA is situated at the ____ border of the pancreatic head and the distal portion of the CBD lies ___ to the head.
GDA: anterior lateral
CBD: posterior lateral
What is the main pancreatic duct?
Duct of Wirsung
located within head and body of pancreas and merges with CBD
What is the accessory duct of the pancreas?
Duct of Santorini
Small branch of main pancreatic duct and located within head of panc
Main Pancreatic Duct Measurements
3 mm in the head
2 mm in the body
Which organ is an exocrine and an endocrine organ?
Pancreas
Exocrine: glands that secrete hormones through ducts
Endocrine: glands that secrete hormones without ducts
Pancreatic enzymes (exocrine):
Lipase breaks down ___.
Trypsin breaks down ___.
Amylase breaks down ____.
Lipase - fat
Trypsin - proteins
Amylase - carbohydrates
What hormones are released when food enters the GI tract?
Cholecystokinin, gastrin and secretin
What are the endocrine cells of the pancreas?
Islet cells of Langerhans
Pancreatic hormones (endocrine)
Alpha cells secrete ___.
Beta cells secrete ___.
Delta cells secrete ___.
Alpha - glucagon
Beta - Insulin
Delta - Somatostatin
Elevated serum and urine ____ values may indicate acute pancreatitis, pancreatic pseudocyst, intestinal obstruction, or mumps.
Amylase
Elevated levels of ___ indicate damage to the pancreas.
Lipase
An increase in ____ may indicate severe diabetes, chronic liver disease or over activity of the endocrine glands.
Glucose
Annular Pancreas
Clinical:
Sonographic Findings:
Pancreatic head encircles the duodenum
Clinical:
- partial or complete duedenal atresia
- males
- asymptomatic
- vomiting
Sonographic:
-circumferential band of tissue surrounding the duodenum
Pancreatic Divisum
Clinical:
Sonographic Findings:
Complete or incomplete fusion of the pancreatic ducts
Complete: 2 seperate pancreatic duct systems
Incomplete: small branch between dorsal and ventral pancreatic ducts
Clinical:
- pancreatitis
- pancreatitis symptoms
Sonographic:
- difficult to visualize
- normal to enlarged pancreatic head
What is the most common pancreatic congenital variant?
Pancreatic Divisum
Ectopic Pancreatic Tissue
Clinical:
Presence of pancreatic tissue outside of the pancreas (greater curvature of stomach, pylorus, duodenal bulb, prox jejunum, ileum, Meckel’s diverticulum)
Clinical:
- severe epigastric pain
- biliary disease
- weight loss
Von Hippel-Lindau (VHL)
Sonographic Findings:
Tumors arising from multiple organs
Pancreatic cysts are a common lesion of VHL (Type 1 is NOT associated with pheochromocytomas and Type 2 is associated with pheochromocytomas)
Sonographic:
-anechoic fluid filled pancreatic mass(es) with through transmission
Shwachmann-Diamond Syndrome
Sonographic Findings:
congenital anomalies, exocrine pancreatic dysfunction, bone marrow failure, metaphyseal dysostosis and swarfism.
Sonographic:
Hyperechoic pancreas with variable size
Acute Pancreatitis
Clinical:
Sonographic Findings:
Sudden on set of inflammation to part or all of the pancreas
Clinical:
- elevated amylase
- elevated lipase
- eleaved WBC
- trauma
- hereditary
- viral infections
Sonographic:
- diffusely enlarged pancreas
- possible lymph nodes seen
- fluid collections
- abscess
- pseudocysts
Chronic Pancreatitis
Clinical:
Sonographic Findings:
Relapsing pancreatitis resulting in pancreatic fibrosis and destruction of pancreatic cells
Clinical:
- abdominal pain
- jaundice
Sonographic:
-calcifications
heterogenous
-increased echogenicity
Pancreatic Pseudocyst
Clinical:
Sonographic Findings:
Fluid collection of pancreatic enzymes with a fibrous capsule
Clinical:
- acute pancreatitis symptoms
- abdominal pain
- elevated amylase
Sonographic:
- variable location
- single or multiple
- well defined walls with variable internal appearance
Pancreaticoblastoma
Clinical:
Sonographic Findings:
Malignant neoplasm of the acinar cells of the pancreas
Clinical:
- occurs in the first decade
- males
- asian descent
- beckwith-wiedemann syndrome
- favorable outcome
Sonographic Findings:
- large
- well defined mass
- variable appearance
- vascularity within the mass
Adenocarcinoma
Clinical:
Sonographic Findings:
Aggressive malignant neoplasm arising from the ductal epithelium of acinar cells
Clinical:
- Diabetes
- Chronic Pancreatitis
- Abdominal pain
Sonographic Findings:
- poorly defined hypoechoic mass
- biliary and pancreatic duct dilatation
Islet Cell Tumor
Arise from the tissue of the Isles of Langerhans
Functional tumors: increased amounts of hormones
Nonfunctional tumors: may go undetected until they produce a palpable mass
Different types of Islet Cell Tumors:
Insulinoma (usually benign)
Gastrinoma (rare, malignant with mets to liver)
Nonfunctioning Tumors (malignant potential)
What is the most common type of Islet Cell Tumor?
Insulinoma
Types of trauma to the pancreas:
Sonographic Findings:
- Hematoma
- Laceration
- Fracture
- Posttraumatic pancreatitis
Sonographic Findings:
- pancreatic enlargement
- edematous pancreas
- fluid collections
- linear areas representing fractures or lacerations
Development of the urinary tract begins at ___ weeks.
4
What are the 3 sets of kidneys during the early development?
Pronephros
Mesonephros (functional embryonic kidney)
Metanephros (permanent kidney)
What do the pronephros regress?
When do the mesonephros regress?
When do the Metanephros regress?
Pronephros regress at 4 weeks.
Mesonephros regress at 9 weeks.
Metanephros develop into the permanent kidneys.
The kidneys develop in the pelvis and ascent into the abdomen. By what week are the kidneys in the normal position?
By 15-20 weeks gestation
Renal lobes are formed by the __ week of gestation.
28th
Kidney length:
Neonates
5 years
10+ years
Neonates: 3.4-5 cm
5 years: 5-8 cm
10 years: 6-11 cm
Large kidneys are defined as 2 standard deviations above the mean.
Small kidneys are defined as 2 standard deviations below the mean.
Newborn sonographic appearance of kidneys:
Cortex is more echogenic than the liver and spleen.
Sinus is not echogenic due to the lack of fat.
Pyramids are hypoechoic and triangular in appearance.
Infant greater than 6 months of age sonographic appearance of kidneys:
Cortex is hypoechoic to liver and spleen.
Increased echogenicity of sinus.
The renal artery enters the kidney hilum ___ to the ureter and ___ to the renal vein.
anterior to the ureter
posterior to the renal vein
so from anterior to posterior:
Renal Vein
Renal Artery
Ureter
Arterial System of Kidneys
Main renal artery -> segmental -> interlobar -> arcuate -> interlobular -> afferent arterioles
Venous System of Kidneys
Efferent arterioles -> interlobular veins -> arcuate veins -> interlobar veins -> segmental veins -> main renal vein
Layers of the bladder wall:
Serosa - outer layer
Muscle - middle layer
Mucosa - inner layer
Bladder wall thickness in a distended and non-distended bladder:
Distended: 3 mm
Non-Distended: 5 mm
Creatinine aids in determining ___.
Renal dysfunction
___ levels increase in acute or chronic disease, renal damage, and renal failure.
BUN (blood urea nitrogen)
Urinalysis are used to detect ___.
Chronic Renal Disease
Fetal Lobulation
Contour lobulation persisting after 5 years of life
Scalloped contour may appear similar to a cortical mass
Extrarenal pelvis
A renal pelvis that is normally positioned within the kidney sinus appears to bulbously extend outward in the absence of urinary tract obstruction
Column of Bertin
An inward extension of the cortex between the renal pyramids extending into the sinus
Mimics the appearance of a renal mass and splays the calyces
Dromedary Hump
A cortical bulge found on the lateral aspect of the left kidney
May be referred to as a pseudo tumor
Simple Ectopic Kidney
Results when the kidney fails to migrate into the renal fossa
Pelvic Kidney which can be small and malrotated
Crossed Ectopic Kidney
Both kidneys located on the same side of the spine; left kidney is typically located on the right
Ectopic kidney lies inferior to the normally positioned kidney and the upper pole of the ectopic kidney is fused to the lower pole of the normal kidney.
Unilateral Renal Agenesis
congenital absence of the kidney with the presence of a normal adrenal gland
Associated with chromosomal abnormalities and genito anomalies
High blood pressure may be present
Bilateral Renal Agenesis
Absence of both kidneys
Associated with Potter’s syndrome, oligohydramnios in uteruo and pulmonary hypoplasia
Fatal
Horseshoe Kidney
Fusion of the right and left kidneys which usually occurs at the lower poles
What is the most common renal anomaly?
Horseshoe Kidney
Renal Hypoplasia
A congenital small functioning Kidney
Unilateral - asymptomatic
Bilateral - hypertension, VUR
Duplex Collecting System
incomplete fusion of the upper pole moiety resulting in a complete or incomplete duplication of the renal collecting system
What is the most common urinary tract anomaly?
Duplex Collecting System
Patent Urachus
The urachus from the anterior bladder wall to the umbilicus remains open
Urachal Sinus Tract
Portion of the urachus at the umbilical end is open and the portion closest to the bladder is closed.
Urachal Cyst
Urine is trapped in the middle portion of the urachus
Urachal Diverticulum
Portion of the urachus at the umbilical end is closed and the portion closest to the bladder is open.
Megacystis
Enlarged bladder
Megacystis-Megaureter
Enlarged bladder and ureters
Megacystis-microcolon-hyperperistalsis syndrome
Enlarged bladder, ureters and renal pelvis
Dilated small bowel
Small colon
Hydronephrosis
Grading:
Failure of urine to drain from the kidney resulting in dilatation of the renal pelvis and calyces.
Grade 1: dilatation of the renal pelvis only
Grade 2: dilatation of the renal pelvis and some of the calices
Grade 3: dilatation of the renal pelvis and all of the calices
Grade 4: dilatation of the renal pelvis, all of the calices plus parenchymal thinning
Ureteropelvic Junction (UPJ) Obstruction
Obstruction of urinary flow due to an instrinsic narrowing at the UPJ level
Arise from calculi, infections such as pyelonephritis and hemorrhage
Dilated renal pelvis and/or calyces with a collapsed proximal ureter
What is the most common congenital urinary tract obstruction?
UPJ Obstruction (Ureteropelvic Junction)
Ureterovesical Junction (UVJ) Obstruction
obstruction of urinary flow at the insertion of the ureter into the bladder
neurogenic bladder in children with spinal anomalies and bladder outlet obstruction or PUV
Posterior Urethral Valve (PUV) Obstruction
Sonographic Findings:
Obstruction of urinary flow at the level of the posterior urethra valve in the urethra (results from an abnormal mucosal flap, fold or urethral tissue)
Sonographic:
- Hydro
- Dilated ureters
- Thin, hyperechoic parenchyma
- Loss of corticomedullary differentiation
- trabeculated, thick walled bladder
- keyhole bladder
What is the most common congenital urethral obstruction in male children?
PUV Obstruction
Multicystic Dysplastic Kidney
Sonographic Findings:
Congenital, non hereditary cystic renal disease
MCDK will eventually involute and the contralateral kidney will compensate for renal function.
If bilateral, the result is fetal demise.
Sonographic:
- Multiple anechoic cysts of varying sizes throughout kidney
- renal parenchyma not visualized
- large kidney progressing to unidentifiable kidney with increasing age
Autosomal Recessive Polycystic Kidney Disease (ARPKD)
Sonographic Findings:
Bilateral symmetric microcystic disease
Also known as infantile polycystic kidney disease
Sonographic:
- enlarged, echogenic, normal shaped kidneys
- microcysts in medulla and cortex
- medullary pyramids appear hypoechoic in the early stage and become hyperechoic with a loss of corticomedullary differentiation later on
Autosomal Dominant Polycystic Kidney Disease (ADPKD)
Sonographic Findings:
Uni or bilateral cystic disease
Also known as adult polycystic kidney disease (often associated with 4th decade of life)
Sonographic:
- enlarged, lobulated kidneys
- cysts of different sizes
- renal parenchyma between the cysts is normal
- normal tissue may become compressed due to cysts and later atrophy
Renal Dysplasia
Sonographic Findings:
Abnormal development of kidneys in the womb leading to abnormal kidneys
Associated with Prune Belly Syndrome and Eagle-Barrett Syndrome
Sonographic:
- kidneys will appear large or small
- abnormal renal parenchyma
- may or may not have renal cysts
- dilated renal collecting system or pelvis
Pyelonephritis
Sonographic Findings:
Infection of the upper urinary tract
Sonographic:
- normal to enlarged kidneys
- areas of increased or decreased echogenicity
- absence of perfusion
- loss of corticomedullary differentiation
Nephrocalcinosis
Sonographic Findings:
Calcium deposits in both kidneys
Seen in neonates with a metabolic disorder, which allows for the formation of calcium deposits later in life
Sonographic:
- echogenic pyramids
- shadowing may or may not be present
Renal Angiomyolipoma
Sonographic Findings:
Benign renal tumor composed of blood vessels, smooth muscle cells and fat cells. It is usually associated with Tuberous Sclerosis.
Sonographic:
- multiple hyperchoic masses in renal cortex
- cysts may be seen
- renal enlargement
Mesoblastic Nephroma (Fetal Renal Hamartoma)
Sonographic Findings:
Mass typically seen in the hilar region usually found in infants younger than 3 months.
Sonographic:
- Solid well defined lesion
- may appear cystic with changes due to hemorrhage or necrosis
- distorted collecting system or parenchyma
chemo is used if lesion is not completely resected. Surgery often requires a complete nephrectomy.
Nephrogenic Rests (NR)
Sonographic Findings:
Formed from persistent benign remnants of embryoic renal tissue beyond 36 weeks. Often stationary and slow growing but can develop into a Wilm’s Tumor.
Nephroblastomatosis describes multifocal or diffuse nephrogenic rests (found within intralobar and perilobar).
Sonographic:
- hypoechoic nodules with diffuse nephroblastomatosis
- renal enlargement with diffusely decreased echogenicity
What is the most common renal tumor identified in the neonatal period?
Mesoblastic Nephroma (Fetal Renal Hamartoma)
Wilm’s Tumor
Clinical:
Sonographic Findings:
Malignant tumor arising from mesodermal precursors of renal parenchyma and mesnephric remnants
Also referred to as nephroblastoma
Peaks at 3-4 years
Associated with Beckwith-Wiedemann Syndrome
Clinical:
- painless RUQ fullness
- asymptomatic
- palpable mass
Sonographic Findings:
- large, heterogenous solid well demarcated renal mass
- displaces other tissues
- renal vein or IVC thrombus
What is the most common pediatric malignant renal mass arising from the embryonal cells?
Wilm’s Tumor (Nephroblastoma)
What are the 5 stages of Wilm’s Tumor?
Stage l: unilateral mass; intact renal capsule post surgery
Stage ll: unilateral mass that has grown into nearby tissue/blood vessels; regional tumor excision
Stage lll: unilateral tumor; mass not completely removed by surgery
Stage lV: unilateral tumor; mets to lung, liver bone and/or brain
Stage V: bilateral renal masses
What is the different between neuroblastoma and Wilm’s Tumor?
Wilms engulfs the kidney, renal parenchyma in origin and displaces the vessels
Neuroblastoma is 90% calcific, displaces the kidney, adrenal in origin and encases the IVC and aorta
Renal Cell Carcinoma
Sonographic Findings:
Malignant tumor of the renal parenchyma
Rare in first 2 decades of life (mean age is about 10 years in children)
More likely to metastasize to bone than Wilm’s
Associated with Von Hippel-Lindau Syndrome
Sonographic:
- hypoechoic, isoechoic, or hyperechoic mass
- homogeonous or heterogenous
- tumor extension in the renal veins and IVC
Rhabdoid Tumor
Sonographic Findings:
malignant tumor arising from the medulla of the kidney
highly aggressive
found before 1 year of age
Sonographic:
- large renal mass
- heterogenous
- poorly defined margins
- calcifications
- tumor extension into IVC and renal veins
Clear Cell Carcinoma
Sonographic Findings:
Malignant tumor arising from the medulla of the kidney
highly aggressive
peaks between 1-4 years of age
Sonographic Findings:
- heterogenous
- poorly defined margins
- cystic changes
Medullary Carcinoma
Sonographic Findings:
Malignant epithelial tumor arisisng from the renal pelvis
Highly agressive
males
african american
Associated with Sickle Cell Trait
Sonographic Findings:
- heterogenous mass
- areas of hemorrhage or necrosis
- fill renal pelvis
- hypovascular
- may invade surrounding structures
Henoch-Schonlein Purpura
rare, non-thrombocytopenic small vessel vasculitis of autoimmune hypersensitivity
males
3-10 years
Sonographic Findings:
- echogenic kidneys
- intussusception
- massive scrotal edema
- bowel wall edema
Left sided renal vein thrombosis is often associated with what?
Left adrenal hemorrage
What organ is the 3rd most frequent organ to be injured due to trauma?
Kidney
Lymphocele
accumulation of lymph fluid
result from renal transplant in which lymph fluid is leaked from severed lymphatic vessels or allograft
develops 2-8 weeks post surgery
Urinoma
collection of urine
associated with blunt trauma, transplant, postop complication and GI abnormality
Ureteroele
Diliation and herniation of the ureter into the bladder
Intravesical: within the bladder
Extravesicial: portion at the level of the bladder or neck of urethra
Ectopic: insertion of ureter into the bladder
Diverticulum
Herniation of the mucosa through the muscular wall
Arises from the base of the bladder or ureter orifice
What is the most common urinary tract infection in children?
Cystitis
Cystitis Cystica
nodular changes in bladder mucosa
Sonographic Findings:
- irregular bladder mass
- hyperechoic
- broad base
- may protrude into the bladder
What is the most common urethral tumor?
Urethral Polyp
What is the most common tumor of the genitourinary tract?
Transitional Cell Carcinoma
Transitional Cell Carcinoma
primary malignant epithelial tumor originating from the epithelial lining of the urinary tract
Sonographic Findings:
- polypoid protusion into bladder lumen
- focal irregular wall thickening
Neurogenic Bladder
A term used to describe a dysfunctional urinary bladder as a results of an injury to the central or peripheral nerves that controls bladder regulation.
Spina bifida is a risk factor.
Sonographic Findings:
- thick, irregular bladder wall with a small contracted or large bladder
- echogenic bowel mucosa
Adrenal glands are located ___, ____ and ____ to the kidneys within the perirenal fascia
anterior, medial and superior
Cortex comprises ___% of the gland and surrounds the adrenal medulla.
90%
How many layers does the adrenal cortex have?
3
Zona Glomerulosa
Zona Fasciculate
Zona Reticularis
Role of the adrenal cortex
secretes steroids:
produces aldosterone, glucocorticoids and stimulates production of testosterone and estrogen
Role of the adrenal medulla
regulates blood pressure and HR
secretes epinephrine and norepinephrine
In the fetus, the adrenal glands are ____ times larger than the adult.
10 to 20 times larger
Neonate adrenal size:
After one year adrenal size:
Infant measures 1/3 of renal length
After one year its 1/13
Adrenal Agenesis
absence of the adrenal gland or glands
If uni, associated with ipsilateral renal agenesis (and a decrease in size of remaining adrenal gland)
if bi, complete absence of cortisol, aldosterone and catecholamines
Adrenal Hypoplasia
Failure in the development of the adrenal cortex (x-linked)
Adrenal Hyperplasia
Sonographic Findings:
inherited disorder that results in low levels of cortisol and high levels of male hormones, causing development of male characteristics in females, and early puberty in both boys and girls
leads to ambiguous sexual development in newborn females
Sonographic Findings:
- enlarged gland
- abscence of central hyperechoic stripe
- accessory adrenal glands
Adrenal Rests or Accessory Glands
adrenal tissue in various locations in the body
Locations: celiac plexus testicles pelvis near the ovaries and broad ligament inguinal canal
Wolman Disease
Sonographic Findings:
A rare disorder of lipid and acid lipase which leads to an accumulation of cholesterol and triglycerides in organs
Adrenals are the organs most commonly affected
Sonographic Findings:
- bilaterally enlarged glands
- calcified with posterior shadowing
Adrenal Adenoma
Sonographic Findings:
Benign epithelial tumor that may be function or non functioning
associated with cushings and conn’s diease
Sonographic Findings:
-small, round, hypoechoic mass
Pheochromocytoma
Sonographic Findings:
benign tumor arising from adrenal medulla
2nd-5th decade of life
higher prevalence on the right
Clinical:
headache
excessive sweating
tachycardia
Sonographic Findings:
- focal solid mass
- variable appearance
- uni or bilateral
Neuroblastoma
Sonographic Findings:
malignant tumor that arises from the sympathetic nervous system, mostly from adrenal gland but can arise anywhere along the chain
In children less than 1, mets are usually to the liver and skin with good prognosis
In older children, mets to the bone results in poor prognosis
Sonographic Findings:
- heterogenous
- internal vascularity
- calcifications
- displacement of kidney as well as encasing IVC and aorta
What is the 3rd most common childhood tumor?
Neuroblastoma
Adrenal Hemorrhage
Secondary to a traumatic delivery or stress
Sonographic Findings:
- anechoic, avascular mass
- early stage: solid with diffuise or inhomogenous echogenicity
- late: mixed echogenicity with hypoechoic regions with later turn cyst like
Spleen Size
up to 3 months: less than 6cm in length
3 months - 12 years: 6-12 cm in length
Spleen Function
filter blood and produces immunity cells
Splenic Cleft
remnants of the grooves separating the splenic lobulations in utero
2-3 cm indentation in the splenic parenchyma
Sickle Cell Anemia
genetic mutation in african americans resulting in altered shape and plasticity of RBCS
leads to increased viscosity, stasis, small vessel occlusion, infarction and necrosis
Sonographic Findings:
- enlarged spleen in children (splenomegaly)
- atrophy later in life
Echinococcus
Parasitic infection cause by tapeworms
Most common cause of splenic cysts worldwide
Sonographic Findings:
- solitary cyst with or without daughter cysts
- echogenic septations
- egg-shell calcification of borders
Most common primary splenic tumor?
Hemangioma
Most common cause of focal splenic defects?
Infarction
Splenic Infarction
Sonographic Findings:
occlusion of segment of splenic arterial supply
Sonographic Findings:
- wedge shaped lesion
- variable echogenicity
What is most commonly caused to the spleen by pancreatitis?
Splenic vein thrombosis
What is the most frequently injured intraperitoneal organ in blunt abdominal trauma?
Spleen
What is also referred to as a splenic pseudocyst?
Posttraumatic Splenic Cyst
*A psuedocyst lacks epithelial lining
Gut herniates from the abdominal cavity into the base of the umbilical cord, rotating clockwise and returning to the abdomen by ____ weeks gestation.
12-14 weeks gestation
Cardiac sphincter is located between:
esophagus and stomach
Pyloric sphincter is located between:
stomach and duodenum
Duodenum envelops the
pancreatic head
Jejunum is located
midline and LUQ
Ileum is located
midline and RLQ
Normal appendix size
6mm or less
Gut signature appearance (lumen outward)
Hyperechoic - mucosal layer Hypoechoic - intramural layer Hyperechoic - submucosa Hypoechoic - muscularis propria Hyperechoic - serosal layer
Microgastria
Sonographic Findings:
Small underdeveloped stomach
Sonographic Findings:
Small tubular stomach
Midline positioned stomach
dilated esophagus
Meckel’s Diverticulum
Clinical:
Sonographic Findings:
Blind ending tube containing tissue layers found in the ileum
Most common congential diverticulum of the GI tract
Clinical:
- less than 2 years
- pain
- small bowel obstruction
- intussuception
Sonographic Findings:
- Hypoechoic tubular or cystic mass (either ML or RLQ)
- Hyperemia of the wall
What is the most common cause of GI bleeding in children?
Meckel’s Diverticulum
What is the most common congenital anomaly of the GI tract in children?
Meckel’s Diverticulum
Meconium Ileus
Sonographic Findings:
newborn bowel obstruction of the distal ileum due to abnormally thick and impacted meconium
Sonographic Findings:
- hyperechoic bowel
- dilated loops of bowel
- decreased peristalsis
Intussusception
Sonographic Findings:
The invagination of one portion of the bowel into another by peristalsis
Children 3 months - 3 years
Majority are ileocolic
Clinical:
- intermittent abdominal pain
- vomiting
- bloody and mucous stools
Sonographic Findings:
- doughnut or target sign in transverse
- sandwich or pseudokidney in long
Treatment:
- air reduction
- barium enema
- surgery
Malrotation and Midgut Volvulus
Complication of malrotated bowel resulting in proximal bowel obstruction or ischemia
SMA and SMV are compressed due to twisting of the bowel
Symptoms can mimic pyloric stenosis
Sonographic Findings:
- whirlpool sign
- dilated duedenum prox to obstruction
- inverted SMA and SMV
Urgent surgical repair is required to prevent bowel ischemia
Hypertrophic Pyloric Stenosis
Gastric disorder of the pyloric opening resulting in enlargement and thickening of the pyloric muscle
Canal becomes hypertrophied resulting in a narrow lumen and obstructing gastric contents into duodenum
Affects male infants more than females
2 weeks-10 weeks
Clinical:
- Failure to thrive
- palpable olive RUQ
- non bilious projectile vomiting
Pyloric Measurements:
Muscle Thickness: greater than 3 mm
Channel Length: greater than 17 mm
Pyloric muscle length: greater than 20 mm
Transverse diameter: greater than 10 mm
Crohn’s Disease
Sonographic Findings:
Chronic inflammatory condition of the GI tract
Most common inflammatory disease of the small bowel
Children over 10 years
Clinical:
- weight loss
- fever
- abdominal pain
- diarrhea
Sonographic Findings:
- target pattern
- thickened bowel wall
- non-compressible bowel loop
- reduction or loss of peristalsis
Appendicitis
Sonographic Findings:
Inflammation of the appendix
Cause by obstruction of the appendix lumen
Clinical:
- periumbilical/flank pain
- fever
- localized pain the RLQ (McBurney sign)
- Rebound tenderness
Sonographic Findings:
- target appearance in trans
- non-compressible
- echogenic fat surrounding
- periappendiceal fluid
- appendicolith
- greater than 6cm in diameter
What is the most common cause of emergency surgery in children?
Appendicitis
Bezoars
Sonographic Findings:
Gastric mass derived from partially digested or undigested material
Trichobezoar - hair or hair-like fibers
Phytobezoar - indigestible food fibers
Pharmacobezoar - medications
Clinical
- intestinal blockage
- ulcers
- GI bleeding
Sonographic Findings:
- complex mass
- echogenic linear structures
- with or without shadowing
Duplication Cyst of GI Tract
Sonographic Findings:
tubular or spherical congenital malformation of GI tract
Clinical:
- abdominal pain
- bowel obstruction
- palpable mass
- GI bleeding
Sonographic Findings:
- anechoic to hypoechoic mass
- gut signature features may be apparant
GI Polyps
Sonographic Findings:
Benign growths occuring on the lining of the GI tract (most common benign tumor of the small bowel in children)
Sonographic Findings:
- intraluminal nodules
- non-mobile
What is the most common benign tumor of the small bowel in children?
GI Polyps
Necrotizing Enterocolitis (NEC)
A common but serious GI disease occurring in premature infants.
Ischemic disease of GI tract.
Clinical:
- abdominal distention
- bile-stained vomiting
- signs of sepsis
- bloody stools
Sonographic Findings:
- bowel wall thickening
- free fluid
- portal venous gas
What is the largest endocrine gland in the body?
Thyroid
Function of Thyroid
maintains body metabolism, growth and development
Controls basal metabolic rate (BMR)
How many sets of parathyroid glands are there?
2 sets or four parathyroid glands with a possible fifth known as supernumerary
Thyroglossal Duct Cyst
Sonographic Findings:
congenital cyst of the neck
Sonographic Findings:
- midline cystic mass
- can be anechoic or irregular appearing (inflammed cyst)
What is the most common congenital cyst of the neck in children?
Thyroglossal Duct Cyst
Hypothyroidism
Sonographic Findings:
loss of thyroid function resulting in inadequate thyroid hormone production
Most common cause is dysgenesis
Clinical:
- goiter
- abnormal facial features
- jaundice
- poor weight gain
- abnormal TSH (can be increased or decreased)
- Decrease in T3 and T4
Sonographic:
- normal echogenicity
- varying size (small or large)
Branchial Cleft Cyst
Sonographic Findings:
Congenital epithelial cyst
Most common non-inflammatory lateral neck mass in children
Sonographic Findings:
- variable appearance
- cyst like or hemorrhagic/infected
Cystic Hygroma
Sonographic Findings:
Cystic lymphatic malformation found posterior to the neck
Sonographic Findings:
- thin walled
- anechoic
- may have striations
Hashimoto Thyroiditis
autoimmune thyroid disease in which antibodies attack the thyroid tissue
Most common type of thyroiditis and thyroid dysfunction in children
Most common cause of acquired hypothyroidism
Clinical:
- painless enlargement of thyroid gland
- Increased TSH
- decreased T4
- decreased to normal T3
Sonographic Findings:
- varies with stage
- early: enlargement, hypo to hetero, ill-defined nodules
- late: small, hyperechoic, cervical adenopathy
- normal to decreased blood flow
Hyperthyroidism
Sonographic Findings:
Increased thyroid activity of the thyroid gland resulting in excessive release of thyroid hormones
Most commonly associated with Grave’s Disease
Clinical:
- weight loss
- tremor
- excessive sweating
Sonographic Findings:
- varies with cause
- gland enlargement
- normal to hypo
- hypervascularity (known as thyroid inferno)
Grave’s Disease
Sonographic Findings:
Autoimmune disorder caused by an over production of thyroid hormones
most common cause of hyperthyroidism in children
Clinical:
- irritability
- heat intolerance
- tachycardia
Sonographic Findings:
- gland enlargement
- lobulated
- normal to hypo
- hypervascularity (known as thyroid inferno)
Thyroiditis
Sonographic Findings:
Inflammation of the thyroid resulting in diffuse enlargement (usually from bacterial or viral infection)
Clinical:
- fever
- painful, enlarged thyroid
Sonographic Findings:
- enlarged thyroid
- lobulated
- single or multiple masses, some abscess
- hypervascularity
Thyroid Follicular Adenoma
Sonographic Findings:
Benign lesions from over-proliferation of thyroid follicular cells
most frequent benign neoplasm of the thyroid
Sonographic Findings:
- single or multiple
- well defined
- round or oval
- varying echogenicity
- hypoechoic halo
- vascular rim
Thyroid Multinodular Goiter
Enlarged thyroid containing multiple nodules
Clinical:
- adolescent girls near puberty
- previous radiation therapy
Sonographic Findings:
- enlarged, heterogenous gland
- variable echogenicity
- nodules
- blood flow normal to increased
Thyroid Papillary Carcinoma
Sonographic Findings:
malignant disease of the thyroid that arises from the thyroid tissue
accounts for 70-90% of thyroid cancers in children
(uncommon before age 15)
Clinical:
- normal thyroid function
- palpable neck mass
- cervical adenopathy
Sonographic Findings:
- solid lesion
- thick, irregular, or absent peripheral halo
- variable appearance
- calcifications
- irregular margins
- abnormal lymph nodes
Thyroid Follicular Carcinoma
Sonographic Findings:
Malignant disease of the thyroid originating from follicular cells
Clinical:
- normal thyroid function
- palpable neck mass
- female
Sonographic Findings:
- solid lesion
- thick, irregular, or absent peripheral halo
- variable appearance
- calcifications
- irregular margins
- abnormal lymph nodes
Thyroid Medullary Carcinoma
Sonographic Findings:
malignant disease of the thyroid arising from parafollicular cells and secretes calcitonin
Clinical:
- female
- strong family history
- elevated serum calcitonin
- palpable neck mass
- cervical lymphadenopathy
Sonographic Findings:
- solid lesion
- thick, irregular, or absent peripheral halo
- variable appearance
- calcifications
- irregular margins
- abnormal lymph nodes
Secondary Thyroid Carcinoma
Sonographic Findings:
malignant thyroid tumor that develop as a second primary tumor
higher mortality rate than primary tumors
Clinical:
- 15-19 years old
- palpable nodule
- cervical adenopathy
- possible pain or loss of voice
Sonographic Findings:
- small
- solid lesion
- thick, irregular, or absent peripheral halo
- variable appearance
- calcifications
- irregular margins
- abnormal lymph nodes
Primary Hyperparathyroidism
Sonographic Findings:
Diffuse enlargement with develops as a result of excess parathyroid hormone production.
Secondary hyperparathyroidism is a result of hypercalcemia
Sonographic Findings:
- enlarged parathyroid glands
- located separately from thyroid by thin echogenic line
- may appear as multiple homogenous low-level solid nodules
Fibromatosis Colli
Sonographic Findings:
Benign proliferation of fibrous tissue infiltrating the sternocleidomastoid muscle
Clinical:
- neonates and young infants
- found clinically as a palpable, non-tender mass in infants with torticollis
Sonographic Findings:
- focal hyperechoic mass within the body of SCM muscle
- diffuse enlargement of SCM
- heterogenous muscle echotexture
- enlargement noted with comparison to contralateral side
Cervical Adenitis
Sonographic Findings:
Infection of the lymph nodes in the neck
Common in pediatric population (usually caused by viral or bacterial infection)
Clinical:
- enlarged cervical nodes
- neck pain
Sonographic Findings:
- oval
- well-defined mass
- hypoechoic
- echogenic hilum
Left lung has __ lobes and the right lung has __ lobes.
Left: 2
Right: 3
Pulmonary Sequestration
Sonographic Findings:
Mass of non-functioning lung tissue separate from the normal tracheobronchial tree
two types: extralobar and intralobar
extralobar: congenital (associated with maternal hydrops and polyhydramnios)
intralobar: acquired (associated with pneumonia, bronchial obstruction)
Sonographic Findings:
- solid echogenic mass
- cystic changes may be seen
- mass is commonly triangular in shape
- color doppler shows an anomalous blood vessel connected to the aorta
Congenital Cystic Adenomatoid Malformation (CCAM)
Sonographic Findings:
Multicystic mass within the lung
also referred to as CPAM
Type 1: cysts greater than 2 cm
Type 2: multiple small cysts
Type 3: microcysts
Sonographic Findings:
- usually unilateral
- displacement of mediastinal structures may occur
- echogenicity varies with type (refer to above)
Congenital Diaphragmatic Hernia
Sonographic Findings:
herniation of abdominal viscera into the fetal chest as a result of a defect in the diaphragm
may contain stomach, intestines, liver and/or spleen
usually occurs on the left
2 types:
Bochdalek: defect in posterolateral (most common)
Morgagni’s: defect anterior
Sonographic Findings:
- absence of or incomplete visualization of diaphragm
- displaced heart
- stomach may appear as a cystic mass in chest
- hypoechoic or cystic structures respresenting bowel in chest
- liver may herniate if a right sided defect is present
Bronchogenic Cyst
Sonographic Findings:
failure of the fetal lung bud to develop into primitive lung tissue
variable locations
Sonographic Findings:
- well-defined
- round mass
- varying echogenicity depending on content
- peripheral flow
Cervical Thymus
Sonographic Findings:
thymic tissue positioned abnormally anywhere along the path of descent
Clinical:
- palpable, non tender, soft tissue mass
- bulging mass like projection from suprasternal region
Sonographic Findings:
- well defined
- homogenous, hypoechoic mass
- located in lower cervical area, anterior to trachea and inferior to thyroid
Pneumothorax
Sonographic Findings:
Abnormal collection of air or gas in the pleural space (collapsed lung)
Associated with trauma or known lung disease
Sonographic Findings:
-absence of normal sliding lung
Pleural Effusion
Sonographic Findings:
abnormal collection of fluid in the pleural space
Clinical:
- respiratory distress
- SOB
- cough
- abnormal x-ray
Sonographic Findings:
-anechoic fluid located in dependent lung portion
Lung Consolidation
Sonographic Findings:
Solidification of lung tissue due to an accumulation of solid and liquid material in the air space that is normally filled with air
affects lung ability to expand
Most common cause is pneumonia
Sonographic Findings:
- homogenous mass seen floating in pleural effusion
- air bubbles in bronchi during respiration
- absence of sinusoid sign (M-Mode)
Lung Teratoma
Sonographic Findings:
mass composed of hair, fat, bone, cartilage, muscle, GI tissue, thyroid tissue
Immature: solid, malignant
Mature: cystic, benign
Sonographic Findings:
- variable size and appearance
- compress or displace surrounding structures
- avascular to hypovascular
Pleuropulmonary Blastoma
Rare tumor derived from pulmonary tissue or the pleura
Type 1: cystic
Type 2 and 3: solid
Most common primary lung neoplasm in children
Sonographic Findings:
- variable appearance
- distort surrounding structures
What is the most common primary lung neoplasm in children?
Pleuropulmonary Blastoma
Diaphragmatic Paralysis
Sonographic Findings:
absence of diaphragmatic motion
unilateral or bilateral
Birth trauma, spinal cord injuries, neuropathic disease
Sonographic Findings:
- echogenic diaphragm
- absence or paradoxial motion of one side of the diaphragm motion during imaging
Diaphragm Inversion
Sonographic Findings:
Abnormal inverted position of the diaphragm
Sonographic Findings:
- inverted appearance
- abnormal movement
- presence of thoracic mass or fluid collection
Male scrotum arises from the ____ ducts.
mesonephric
Testicles arise in the fetal abdomen near the ____.
Kidneys
By the ___ month of gestation, testicles descent into the scrotum through the inguinal canal.
7th
Average scrotal thickness
2-8mm
Average testicular size in
neonate:
children up to 6 years:
Postpubertal:
neonate: 1.5 cm in length
children up to 6: 2 cm in length
postpubertal: 3-5 cm in length
volume of less than 5mL prior to age 12
Testicles are low to medium gray in infants and the echogenicity ___ after 8 years of age.
increases
Testicular Lab Values:
WBC increase with __
Testosterone increases with __
Hematocrit is abnormal in cases of ___
AFP increases with __
HCG increases with ___
WBC increase with INFECTION
Testosterone increases with MALIGNANCY
Hematocrit is abnormal in cases of TRAUMA
AFP increases with NON-SEMINOMA GERM CELL TUMOR
HCG increases with SEMINOMA AND NON-SEMINOMA TUMOR
Cryptochidism
Occurs when the testicles or teste has not descended into the proper location within the scrotal sac
80% are found in the inguinal canal
Smaller measurements than normal
Epididymitis
Sonographic Findings:
Infection of the epididymitis
Most commonly caused by a UTI in children
Clinical:
- pain increases over a period of 1 or 2 days due to the infection
- fever
- dysuria
- swollen testicle
- increased WBC
Sonographic Findings:
- enlarged head
- scrotal wall thickening
- decreased echogenicity
- increased flow to affect area(s)
What is the most common cause of acute scrotal pain in male children and adolescents?
Epididymitis
Orchitis
Sonographic Findings:
Inflammation of the testes
Secondary to epididymitis
Sonographic Findings:
Focal:
-hypoechoic areas within teste
-often mistaken for tumor
Diffuse:
-hypoechoic, hypervascular, reactive hydrocele in acute phase
-atrophied teste and thick scrotal wall in chronic phase
Hydrocele:
Hematocele:
Pyocele:
Hydrocele: abnormal accumulation of fluid
Hematocele: blood in scrotal sac; direct trauma to scrotum or pelvic region
Pyocele: pus in scrotal sac; trauma or ruptured abscess
What is most commonly caused by epididymo-orchitis?
Testicular Abscess
Teratoma/Testicular Germ Cell Tumor
Sonographic Findings:
benign and malignant forms
benign: prepubertal
malignant: older patients
ClinicaL:
- painless, palpable mass
- increased HCG, AFP and LDH
Sonographic Findings:
- mixed echogenicity mass
- cystic mass
Leydig or Interstitial Cell Tumor (testicular)
Sonographic Findings:
non-germ cell, stromal tumor
benign and malignant forms
testosterone producing tumors
peak occurrence in the first 2 years of life
Sonographic Findings:
- small, well defined, hypoechoic mass
- large, heterogenous mass with cystic spaces
Sertoli Cell Tumor (testicular)
Sonographic Findings:
non-germ cell, stromal tumor
some tumors are estrogen producing
typically seen in the first year of life
Sonographic Findings:
- small, well defined, hypoechoic mass
- large, heterogenous mass with cystic spaces
Gonadoblastoma
Sonographic Findings:
germ cell tumor comprised of a mixture of germ cell and sex-cord-stromal elements
Associated with dysgenetic gonads, turners syndrome and secondary sex organs
Sonographic Findings:
- solid mass
- hypoechoic
- cystic areas may be visible
Seminoma
Sonographic Findings:
Malignant germ cell tumor made up of seminomatous elements
present in adolescents
Clinical:
- gradual enlarging mass
- normal AFP
- increased HCG, PLAP, and testosterone
Sonographic Findings:
- hypoechoic mass
- echogenic band within mass
- hydrocele
- hypervascularity
Embryonal Cell Carinoma (Testicular)
Sonographic Findings:
malignant germ cell tumor
mets to lung, liver and brain
Sonographic Findings:
- hypoechoic mass
- ill defined borders
- invades tunica albuginea
Yolk sac tumor or endodermal sinus tumor (testicular)
Sonographic Findings:
malignant germ cell tumor
primarily in children less than 2
Sonographic Findings:
- variable echogenicity
- echogenic foci or cystic areas may be present
What is the most common primary germ cell testicular in prepubertal children?
Yolk Sac Tumor or Endodermal Sinus Tumor
Spermatic Cord Torsion
Intravaginal torsion: more common in puberty, occurs within tunica vaginals
Extravaginal: in utero or neonatal period; occurs proximal to tunica vaginals
Partial: 360 degree or less
Acute: before 24 hours of onset of pain
Chronic: 24-48 hours post onset of pain, may not be painful anymore
Torsion of Appendix Teste
torsion of testicular appendix
peak incidence 7-14 years of ago
The femoral head of the hip ossifies between ___ of age.
2-8 months
Pelvic bone anatomy:
Ilium:
Ischium:
Pubis:
Made up of the pelvic girdle
Ilium: broad portion of the hip bone
Ischium: lower posterior portion
Pubis: lower anterior portion
Convergence of the bones creates the concave hip socket
Femoral head lies within the ____
acetabulum
Barlow maneuver
procedure utilized to determine if the hip could become dislocated.
Hip is flexed with the thigh abducted.
Pressure is applied to the knee by pushing it posteriorly.
Ortolani Maneuver
procedure used to determine if the dislocated femoral head can be repositioned back into the acetabulum
Hip is flexed with thigh abducted
Thigh pulled anteriorly.
A “click” may be heard when it moves back in
Galeazzi’s or Allis’ Test
used for infants 3 months and older
the child is placed in a supine position with the hips and knees bent and feet flat
examiner looks for any unevenness between the knees - if one knee is lower than the other, there may be a hip dislocated on the lower side
Hip Coronal View
Neutral: neutral position with leg at a 15-20 degree flexion angle
Flexion: hip flexed at 90 degree angle referred to as "ball on a spoon" ball - femoral head acetabulum - scoop of spoon Iliac line - handle of spoon
Hip Transverse View
Neutral: leg at 15-20 degrees
referred to as a “U”
U is made up of metaphysis and ischium
Flexion: hip at 90 degrees referred to as the flower view Femoral head - "bloom" Ischium and pubis - "leaves" triradiate cartilage -- "stem"
Alpha Angle
most commonly as a measurement of acetabular concavity
angle greater than 60 is normal
angle between 50-59 represents immature hip
angle less than 50 indicates pathological condition
Beta Angle
indicates acetabular cartilaginous roof coverage
normal is less than 55 degrees
Femoral head coverage
percentage of femoral head covered by the acetabulum
coverage of 58% or greater is normal
Developmental Dysplasia of the hip (DDH)
most common form of dislocation is superiolaterally
Subluxation
femoral head is in contact with part of the acetabulum or is displaced but partly covered
soft tissue identified between the femoral head and acetabulum
Dislocation
femoral head has no contact with the acetabulum
thickened abnormal labrum may be present
irregular acetabular roof
Hip Effusion
increased amount of synovial fluid within the hip joint
greater than 2mm difference between hips
greater than 3 for up to 4 years
greater than 5 for 4-8 years
greater than 7 for 8+
Osteomyelitis
Sonographic Findings:
Infection in the bone that can be caused by infections traveling through the bloodstream or by spreading from nearby tissue.
Sonographic Findings:
- fluid collection adjacent to bony structures
- varying echogenicity
- joint effusion
Ventral hernias occur:
Umbilical hernias occur:
Spigelian hernias occur:
Inguinal hernias occur:
Ventral - anterior aspect of abdominal wall
Umbilical - umbilicus
Spigelian - through spigelian fascia or layer of tissue that separates the rectus muscles and the later obliques.
Inguinal - groin
Incarcerated Hernia
Hernia that is not reducible
treatment not always needed
Obstructed Hernia
incarcerated bowel loops that have become mechanically obstructred
treatment needed
Strangulated hernia
incarcerated contents with compromised vascularity
depending on content may need to have emergency surgical repair
What is the most common type of ventral hernia?
Umbilical
What type of hernias make up 75% of hernias?
Inguinal
More common on the right if unilateral
Indirect inguinal hernia: involves internal inguinal ring
Direct inguinal hernia: does not involve inguinal ring; common in athletes
Normal size of lymph nodes
Less than 10 mm or 1.0 cm
Abnormal sonographic appearance of lymph nodes
- loss of fatty hilum
- low to medium level echo pattern
- loss of normal shape
- lobular contour
- disruption of vascularity
Lymphadenopathy
enlargement of lymph nodes cause by inflammatory processes, primary tumor or metastatic spread of cancer
Floating aorta sign: obliteration of echogenic aorta wall
Silhouette sign: elevate celiac axis and SMA anteriorly
Sandwich Sign: visible nodes at the hilum of kidneys, liver and spleen
Features of malignant nodes
- round or oval
- eccentric cortical widening
- narrow or absent echogenic hilum
- displaced or distorted intranodal vessels
What is the most common site of primary lymphoma of the GI tract?
Stomach
Uterus is developed from
two Mullerian ducts or paramesonephric ducts
What are the 3 layers of the uterus?
Serosa - thin outer layer
Myometrium - middle layer (bulk of uterus)
Endometrium - innermost layer
Sonographic Appearance of Myometrium in the pre and postpubertal patient
Prepubertal: uniform homogenous texture, low to moderate echogenicity
Postpubertal: outer layer hypoechoic and may have anechoic spaces representing arcuate vessels; middle layer more echogenic; inner layer hypoechoic layer surrounding endometrium
What are the 2 layers of the endometrium?
Superficial layer or Zonus Functionalis
Deep or Basal layer
What layer of the endometrium thickens and sheds with menstruation?
Zonus Functionalis
Sonographic appearance of endometrium of children under 7
May not be noticeable.
In newborns, may be a thin echogenic line due to utero hormonal stimulation
Appearance and size of endometrium during the menstrual cycle:
Thin, echogenic line during menses (2-3 mm)
Thin, echogenic line during proliferative phase (4-8 mm)
Three-line sign during mid to late proliferative phase
Thick, echogenic line during secretory phase (8-14 mm)
Uterine Size in
Neonate:
Infancy to Young Adolescent:
Puberty:
Neonate: 2-4.5 cm (cervix is longer than uterine body)
Infancy to young Adolescent: 3-4 cm
Puberty: 5-8 cm (uterine growth begins at approximately 7-8 years of age)
Dextropositioned uterus
positioned to the right of midline
Levopositioned uterus
positioned to the left of midline
Retroflexed uterus
fundus and body is flexed posteriorly relative to the cervix
Anteflexed uterus
fundus and body is flex anteriorly relative to the cervix
common with a non-distended bladder
Retroverted uterus
fundus, body and cervix are positioned posteriorly relative to the vagina
common with a non-distended bladder
this position is associated with poor visualization of the endometrium and uterus
Anteverted uterus
fundus, body and cervix are positioned anteriorly relative to the vagina
cervix and vagina form at 90 degree angle
Size of ovary
Premenarche:
Menstrating:
Premenarche: 2.5 cm in length
Menstruating: 2.5 - 5 cm in length
Broad ligaments of the uterus
extend from the lateral aspect of the uterus
attaches to the uterus, fallopian tubes and ovaries
Round ligaments of the uterus
twits the uterine fundus in a forward position
Cardinal ligaments or transverse cervical ligaments of the uterus
inferior border of the broad ligaments
supports uterus and cervix
Uterosacral ligaments
extends from cervix to sacrum
supports the uterus and holds the uterus in place
Where is the anterior cul-de-sac or vesicouterine pouch located?
anterior to the uterus
lies posterior to the bladder
Where is the potserior cul-de-sac or rectouterine pouch or pouch of Douglas located?
posterior to the uterus
anterior to the rectum
common area of fluid collection due to secondary conditions
Where is the space of Retzius or previscal space located?
posterior to the pubic symphysis and anterior to the urinary bladder
presence of pathology tends to displace the bladder posteriorly
What arteries supply the ovary?
A dual blood supply supports each ovary
Ovarian gonadal arteries off of Aorta
Ovarian branch of the uterine artery
What glands play a role in the menstrual cycle?
Hypothalamus, anterior pituitary and ovaries
What hormone stimulates the pituitary gland to produce hormones?
Gonadotropin-releasing hormone
What hormone stimulates follicular growth and development within the ovarian cortex?
Follicle stimulating hormone (FSH)
What hormone stimulates ovulation along with the forming and maintaining of the corpus luteum?
Luteinizing hormone (LH)
What hormones do the ovaries release?
Estrogen and progesterone
What hormone is responsible for female secondary sex characteristics?
Estrogen
What hormone stimulates breast alveolar devlopment?
Progesterone
Endometrial Cycle phases:
Menstruation phase: days 1-5
Proliferative phase: days 6-14
Secretory phase: days 15-28
Primordial follicles become ___ which become ____ which become ____.
Primordial follicles become primary follicles.
Primary follicles become secondary follicles.
Secondary follicles become Graafian follicles.
Ovarian cycle phases:
Follicular phase: days 1-13
Ovulation: day 14
Luteal phase: days 15-28
Ambiguous Genitalia
physical appearance of the external genitalia cannot be clearly identified as male or female.
True isosexual precocious puberty
appearance of physical characteristics and hormones associated with puberty prior to age 8
Precocious pseudopuberty
appearance of physical characteristics and hormones associated with puberty prior to age 8 caused by adrenal or ovarian dysfunction.
associated with congenital adrenal hyperplasia, adenoma or carcinoma of adrenal gland, ovarian dysgerminoma, choriocarcinoma and follicular retention cysts
sonographically, uterus and ovaries will still look prepubertal
Vagina atresia
Sonographic Findings:
absence of the vagina
neonate or adolescent at the time of menarche
Sonographic Findings:
-fluid collections within vaginal or uterine cavity
Imperforate Hymen
Sonographic Findings:
persistence of the vaginal hymen or transverse septum
Associated with Mater-Rokitansky-Kuster-Hauser syndrome
Sonographic Findings:
-fluid collections within vaginal or uterine cavity
Aplasia or Agenesis of the uterus
Sonographic Findings:
absence of the uterus
Associated with Mater-Rokitansky-Kuster-Hauser syndrome
Sonographic Findings:
- uterus and cervix not identified
- vagina absent or small
- ovaries are seen
Unicornuate Uterus
Sonographic Findings:
one uterine horn and one fallopian tube develop
Sonographic Findings:
- difficult to differentiate from a normal uterus
- uterus appears small and laterally positioned
- loss of pear shaped uterus
Didelphys Uterus
two uterine horns
two cervices
two vaginas
Bicornuate uterus
septum is formed between the symmetrical horns which may extend from the external os or the internal os
Uterus Duplex Bicollis:
- two uterine hornes
- two cervices
- one vagina
Uterus Bicornis Unicollis:
- two uterine horns
- one cervix
- one vagina
Arcuate Uterus
Mild indentation of the endometrium in the uterine fundus
indentation of less than 1cm
Septate uterus
two endometrial cavities visualized
uterine fundus flay or mildly indented on transverse view
Gartner’s duct cyst
vaginal cyst
Nabothian or Inclusion Cyst
Cervical cyst
Pelvis Inflammatory Disease (PID)
inflammatory condition affecting all or some of the following: cervix, uterus, fallopian tubes, ovaries and peritoneal surfaces
usually results from a microorganisms ascent from the vagina and cervix to the endometrium and into the fallopian tubes
associated with STDS, most commonly gonorrhea and chlamydia
4 classifications: endometritis, salpingitis, tubo-ovarian abscess and peritonitis
Endometritis
Sonographic Findings:
Infection of the endometrium
Sonographic Findings:
- normal
- thickened endo
- fluid or air within
- increased vascularity
Salingitis
Sonographic Findings:
Infection of the fallopian tubes
hydrosalpinx: fluid filled fallopian tube
pyosalpinx: “beads on a string”
Sonographic Findings:
- distended
- serpiginous
- thickened wals
- fluid filled
Tubo-ovarian Abscess (TOA)
Sonographic Findings:
purulent material from fallopian tube travels to ovary causing ovary and tube to be adhered which results in an abscess
Sonographic Findings:
- large complex adnexal mass with irregular borders
- irregular margins
- fluid fluid level
- difficult to identify ovaries within mass
- may be uni or bilateral
Peritonitis
Sonographic Findings:
infectious spread to peritoneum
Sonographic Findings:
- free or loculated fluid in peritoneum cavities
- echogenic debris or septations
- bowel walls appear thick
Hydrocolpos
fluid filled vaginal cavity
Hydrometra
fluid filled endometrium
Hydrometrocolpos
fluid filled endometrium and vaginal cavity
Hematometra
blood filled endometrium
Hematometrocolpos
blood filled endometrium and vaginal cavity
Pyometra
infectious fluid trapped in endometrium
Leiomyoma, Fibroid or Myoma
benign tumor made up of smooth muscle cells and fibrous tissue that can undergo cystic degeneration
Sonographic Findings:
- various appearance
- variable number
- focal discrete mass
- diffuse irregular appearance of the uterus
- thin vessels with low velocity doppler
- no flow in masses undergo degeneration
Locations of Fibroid within the uterus:
Intramural: within myometrium
Submucosal: protrudes within endmetrium
Subserosal: projects from peritoneal surface
Pedunculated or exophytic: seperate pelvic mass attached by a stalk to the peritoneal surface of the uterus
What is the most common tumor of the female pelvis?
Fibroid
*uncommon in females less than 20 years of age
What is the most common malignancy of the pediatric female genital tract?
Rhabdomyosarcoma
presents within the first few years of life
usually arises from anterior wall of vagina
Clear Cell Adenocarcinoma of female genital tract
malignant tumor most commonly found in the vagina in pediatric patients
very aggressive in young children
family history of endometrium cancer
Neonatal ovarian cysts
functional ovarian cysts resulting from excessive stimulation of the fetal ovary from placental and maternal hormones
torsion if large
Polycystic ovarian syndrome (PCOS)
complex endocrine disorder associated with anovulatin and oligomenorrhea
Serous Cystadenoma
Sonographic Findings:
benign tumor containing serous fluid
-more frequent than mucinous cystadenoma
Sonographic Findings:
- large, unilateral ovarian cystic mass (4-20cm)
- thin walled
Mucinous Cystadenoma
Sonographic Findings:
benign tumor containing mucoid substance
Sonographic Findings:
- large unilateral mass
- multiloculated
- septations
- papillary projections
Ovarian Teratoma
Sonographic Findings:
Most common germ cell tumor location after infancy is the ovary.
Immature: solid, malignant
Mature: cystic, benign
Sonographic Findings:
-Tip of the Iceberg
Granulosa Cell Tumor
Sonographic Findings:
sex-cord stromal tumor typically occuring in children birth to 10 years of age
benign or malignant
Sonographic Findings:
- unilateral
- cystic with septations when large
- solid when small
What is the most common malignant ovarian neoplasm in childhood, adolescence and early adulthood?
Dysgerminoma
Yolk Sac Tumor or Endodermal sinus tumor
Sonographic Findings:
malignant germ cell tumor that resembles yolk sac, allantois and extraembryonic mesenchyme
second most common malignant ovarian germ cell tumor
highly aggressive
females under 20
Sonographic Findings:
-large slid mass
Sertoli-Leydig Cell Tumor or Androblastoma
Sonographic Findings:
sex cord stromal tumor that produces androgen
benign or malignant
associated with DICER1 gene
Clinical:
- pain
- virilization
- menstrual irregularity
- increased testosterone or other androgen
Sonographic Findings:
- range in size from 5-15 cm
- unilateral
- solid hypoechoic mass
- may appear as cystic or complex
Ovarian Torsion
partial or complete rotation of the ovarian pedicle typically caused by an ovarian mass
Ovarian Edema
Sonographic Findings:
enlargement of the ovaries due to stromal edema
Clinical:
- intermittent ovarian torsion
- pain
- pelvic distention
Sonographic Findings:
- enlarged ovary
- complex solid or multicystic mass
- venous and lymphatic occlusion without arterial occlusion
Peritoneal Inclusin Cyst
complex fluid filled mass in the peritoneal cavity
referred to as a pseudocyst
under normal conditions, the peritoneum absorbs fluid but causes of abnormal absorption include surgery, trauma, inflammation or endometriosis
Endometrioma or Chocolate Cyst
cystic mass filled with blood representing a localized form of endometriosis
Diffuse: most common form of endmetriosis
Localized: usually on ovaries
Sonographic Findings:
- variable size
- well-defined
- unilocular or multilocular mass
The lumen of the neural tube develops into the ____ and ____.
ventricular system and spinal cord
The cranial end of the neural tube has three distinct areas, which subsequently form the ____.
brain
The caudal end of the neural tube subsequently forms the ____.
spinal cord
Forebrain or Prosencephalon
largest component of the brain
comprised of the telencephalon and the diencephalon
Midbrain or Mesencephalon
connects the spinal cord and forebrain
Hindbrain or Rhombencephalon
joins with the spinal cord
comprised of metencephalon and myelencephalon
Dorsal Induction occurs between ___ - ___ weeks.
5-6 weeks
neural tube is formed and closed.
abnormal closure results in abnormalities
Ventral induction occurs between ___ - ___ weeks.
7-12 weeks
prosencephalon, mesencephalon and rhombencelphalon form from the neural tube
Bones of the cranium
Frontal (1) Parietal (2) Temporal (2) Occipital (1) Ethmoid - between orbits Sphenoid - base of skull
Sagittal Suture
extends from anterior to posterior fontanelle
Coronal Suture
lies perpendicular to sagittal suture
located between frontal and parietal bones
Lambdoidal Suture
extends from posterior aspect of sagittal suture
located between occipital and parietal bones
Parietomastoid Suture
lies between parietal and temporal bones
When does the Anterior Fontanelle close?
typically between 9 months - 15 months of age
can remain open until 2
When does the Posterior Fontanelle close?
3 months
When does mastoid or posterolateral fontanelle close?
begins to close around 6 months of age but may remain open until 2 years
When does the sphenoid fontanelle or anterolateral fontanelle close?
closes around 6 months of age
used to evaluate circle of willis
Layers of meninges
Pia Mater: interal layer
Arachnoid: middle layer
Dura Mater: outer layer
What spaces allow CSF to exit the brain and enter the venous system?
Subdural Space: separates arachnoid layer from dura mater
Subarachnoid Space: separates arachnoid layer from pia mater
-contains CSF and vessels
Tentorium Cerebelli
fold of dura mater protruding into cranial cavity (tent-shaped fold over the posterior fossa)
separates the occipital lobes of the cerebrum from the cerebellum
used as a reference point to describe location of a lesion
infratentorial or supratentorial
Where is the majority of CSF produced?
By the epithelial cells of the choroid plexus
CSF Circulation
Choroid Plexus in lateral ventricles Foramen of Monro 3rd ventricle Cerebral Aqueduct/Aqueduct of Sylvius 4th ventricle Foramen of Magendie and Luschka Cisterna Magna and Subarachoid Space
What parts of lateral ventricle contain choroid plexus?
Body and Trigone or Atrium
Choroid plexus also located in 3rd and 4th ventricles
What part of the lateral ventricle contains the thickest portion of choroid plexus?
Trigone
largest part referred to as glomus
used as the landmark for measuring lateral ventricles
Third ventricle communicates with:
lateral ventricles and 4th ventricle
3rd ventricle is located between ___ and __.
the two hemispheres of thalami and inferior to cavum septum pellucidum
4th ventricle is located ___ and ____.
anterior to the cerebellum
posterior to the pons and medulla oblongata
What is the largest portion of the brain?
Cerebrum
consists of gray and white matter
Longitudinal Fissure or Interhemisheric fissure
separates cerebrum into right and left hemispheres
located in the midline
Lateral fissure or sylvian fissure
separates temporal lobe from the anterior and parietal lobes
contains MCA
Parietooccipital fissure
separates occipital lobe from parietal lobe and temporal lobe
Transverse fissure
separates occipital lobe of the cerebrum from the cerebellum
Central fissure or fissure of Rolando
separates frontal lobe from the parietal lobe
Cingulate Sulcus
parallel to corpus callosum
Central Sulcus
located between frontal and parietal lbes
Hippocampal Sulcus
extends from the posterior aspect of the corpus callosum to the temporal lobe
Cingulate Gyrus
located above corpus callosum
Hippocampal Gyrus
located on inferior surface
Cerebral Cortex
outermost layer of the cerebellum
outer layer of gray matter and an inner layer of white matter
Corpus Callosum
Thick band of myelin-coated nerve fibers connecting the cerebral hemispheres
forms most of the roof of the lateral ventricles
parallel to cavum setum pellucidum in sag lane
Cavum Septum Pellucidum
midline cystic structure not connected to the ventricular system or subarachnoid space.
Regresses during the gestation period.
Usually complete obliteration in most infants by 2 months of age
What structure of the basal ganglia is the main structure visualized with sonography?
Caudate Nucleus
Mass of gray matter located adjacent to the lateral ventricles
Thalamus
Paired ovoid structures connected by a band of tissue known as massa intermedia
Germinal Matrix
Highly vascular rudimentary embryonic structure that develops deep to the ependyma. Regresses during gestational period
Landmark area known as caudothalamic groove represents the germinal matrix between head of the caudate nucleus and the thalamus. It is considered a favorable region for the development of subependymal hemorrhages in the neonate.
Brainstem
Connects the cerebral hemispheres with the spinal cord and consists of the midbrain, pons and medulla oblongata
Cerebellum
Composed of two hemispheres. The vermis is located between the two hemispheres.
Located in the posterior cranial fossa, it is separated from the cerebrum by tentorium cerebelli.
Arterial vessels that supply blood to the brain
CCA ICA ECA Circle of Willis (MCA, ACA, PCA) Vertebral Artery Basilar Artery
Cerebral veins receive blood from the brain and drain the blood into ____
the venous sinuses of the dura mater and into the IJV.
Intracranial veins do not contain valves
Superior Sagittal Sinus
A dural sinus drains venous blood and reabsorbs CSF.
The superior sagittal sinus is located in the midline at the falx cerebri, receives blood from superior cerebral veins and is continuous with the transverse sinus
What are watershed areas?
Vascular beds between the end branches of major arteries.
Vulnerable to decreased perfusion pressure resulting in infarction.
Largest watershed area is the white matter located lateral and posterior to the lateral ventricles
What artifacts can be seen with cranial bones?
Refraction, reverberation and grating lobe artifacts
Atrium of Lateral Ventricle size
Mild dilatation:
Moderate dilatation:
Marked dilatation:
Mild: 8-10 mm
Moderate: 11-14 mm
Marked: >14 mm
Fissures appear ____ on ultrasound.
Echogenic
Sylvian fissure is Y shaped and separates the frontal lobe from the temporal lobe
Gyri appear ___ on ultrasound.
Hypoechoic
Sulci appear __ on ultrasound.
Echogenic
They may not be noted until 26 weeks gestation. Central sulcus of Rolando separates the frontal lobe from the parietal lobe.
Periventricular blush or halo
linear areas of increased echogenicity (less echogenic than choroid)
seen posterior to the occipital horns of the lateral ventricles and anterior to the frontal horns
What is the most common fontanelle used for intracranial imaging on neonates?
Anterior fontanelle
The posterior fontanelle is helpful in evaluating:
infratentorial contents and identification of hemorrhage in the occipital horn of the lateral ventricles
Mastoid or posterior-lateral fontanelle helpful in evaluating:
circle of Willis, ventricles and posterior fossa
Sphenoid fontanelle helpful in evaluating:
anterior horn of the lateral ventricles and the frontal lobe of the cerebrum
Foramen Magnum helpful in evaluating:
posterior fossa and upper spinal cord
Transcranial-squamous portion of temporal bone helpful in evaluating:
hydrocephalus and intraventricular hemorrhage
Agenesis of Corpus Callosum
Sonographic Findings:
partial or complete absence of the commisure connecting the cerebral hemispheres
Associated with:
Trisomy 8, 13 or 18
Porencephaly
Isolated Finding
Sonographic Findings:
- Absence of corpus callosum
- Absence of CSP
- Sulci radiate outward and resemble a sunburst sign
- widely separated lateral ventricles
Chiari Type 1 Malformation
caudal displacement of cerebellar hemispheres without displacement of fourth ventricle or medulla.
commonly found in children
Chiari Type 2 Malformation
Elongation and caudal displacement of the brainstem and cerebellum through the foramen magnum into the cervical spinal canal
Most common type
Highly associated with an open spinal defect
Anterior and inferior pointing of frontal horns of the lateral ventricles resulting in a bat-wing appearance
Chiari Type 3 Malformation
protrusion of the medulla, 4th ventricle, and entire cerebellum through an encephalomeningocele
rare
high mortality rate
Sonographic Findings:
- hydrocephalus
- gyral anomalies
- dysgenesis of corpus callosum
Chiari Type 4 Malformation
Severe hypoplasia of the cerebellum without displacement
rate
most severe form with high infant mortality
Sonographic Findings:
- severe hypoplasia of the cerebellum hemispheres without displacement
- hypoplasia of pons
- small posterior fossa
Dandy Walker Malformation
Severe Anomaly
Cerebellum vermis is absent or hypoplastic
Associations:
- agenesis of CC
- encephalocele
- microcephaly
- Trisomy 13, 18, 21
Sonographic Findings:
- large anechoic posterior fossa cyst
- splayed cerebellum hemispheres
- elevated tentorium
- enlarged lateral ventricles
- enlarged 3rd ventricle
- 4th ventricle communicating with cisterna magna
Dandy Walker Variant
Less severe and occurs more than DW malformation
Cerebellum vermis is hypoplastic
Sonographic Findings:
- normal cerebellum size and placement
- normal or slight enlargement of posterior fossa
- dilatation of aqueduct of sylvius
- enlarged 3rd and 4th ventricle
- communication seen between 4th ventricle and cerebellum vermis
Mega Cisterna Magna
Enlargement of the cisterna magna in the presence of normal cerebellum, cerebellum vermis and intracranial ventricle system.
Freely communicates with the 4th ventricle
Represents a normal variant
Sonographic Findings:
- enlarged anechoic cisterna magna
- normal size ventricles
- normal cerebellum vermis
Blake’s Pouch Cyst
posterior fossa cyst lesion resulting from ballooning of the posterior membranous area into the cisterna magna
rare
de Morsier Syndrome (aka Septo-Optic Dysplasia)
absence of cavum septum pellucidum with optic nerve hypoplasia
Sonographic Findings:
- agenesis of CSP
- fused frontal horns
Alobar Holoprosencephaly
midline malformation characterized by absence of the interhemispheric fissure, falx cerebri, and third ventricle. Single ventricle replaces bilateral lateral ventricles and fused thalami
Most severe form of holoprosencephaly
Clinical:
- cebocephaly
- cyclopia, anopthalmia or microphthalmia
- cleft lip
- low set ears
Semi-Lobar Holoprosencephaly
midline malformation characterized by cerebral hemispheres that are partially separated posteriorly and a single anterior ventricular cavity
Lobar Holoprosencephaly
Subtle derangement with the separation of the cerebral hemispheres except at the level of the cingulate gyri and anterior horns of the lateral ventricles
least severe form
Sonographic Findings:
- absence of CSP
- absent or hypoplastic cerebellar vermis
- dilated lateral ventricles
- fused squared shaped anterior horns
- third ventricle present
Cephalocele
herniation of meninges through a defect in bony cranium
Encephalocele
herniation of meninges and brain tissue through a defect in the bony cranium
Where is the most common location for a cranial defect to occur?
Occipital region
Ventriculomegaly
enlargement of the lateral ventricles
normal intraventricular pressure
normal head size
Hydrocephalus
enlargement of the ventricles
Increased intraventricular pressure
Increased head size
may be communicating or non communicating
communicating/non-obstructive: results from lack of circulation and absorption of CSF
non-communicating/obstructive: occurs when the flow of CSF is obstructed along one or more of the paths of within the ventricular system (aqueduct of sylvius stenosis is the most common cause of ventricular enlargement)
Hemimegalencephaly
abnormal enlargement of one of the cerebral hemispheres with the other being normal
rare
enlarged ventricle in the affected hemisphere
Heterotopia
neuron clusters in abnormal locations
rare
X-linked dominant
Associated with Lissencephaly
Sonographic Findings:
- abnormal wall indentations of the lateral ventricle
- normal or enlarged lateral ventricles
Lissencephaly
Smooth brain due to abnormally developed sulci and gyri
Type 1/Classical: 4 layers of the cortex instead of 6
Type 2/Cobblestone: migration interrupted at the surface resulting in over migration and clustering of the neurons
Sonographic Findings:
- absence of normal echogenic sulci pattern
- abnormal appearance or absence of sylvian fissure including lack of MCA pulsations
- enlargement of lateral ventricles
Macrocephaly
Enlarged occipital frontal head circumference greater than 2 standard deviations above the mean
enlargement not due to tumors or enlarged intracranial ventricles
Sonographic Findings:
- normal appearance of intracranial structures
- enlarged anechoic lateral ventricles
- irregular wall indentations of the lateral ventricles
- enlarged gyri
Microcephaly
Small occipital frontal head circumference greater than 2 standard deviations below the mean
can be congenital or occur in infancy
Associated with prenatal exposure to Zika Virus and Fetal Alcohol Syndrome
Sonographic Findings:
- normal appearance of intracranial structures
- calcifications
- partial or complete agenesis of the corpus callosum
- irregular wall indentations of the lateral ventricles
- absence or enlarged gyri
Schizencephaly
Clefts in the gray matter of the cerebral hemispheres which extend to the lateral ventricle
Type 1: no communication between lateral ventricles and subarachnoid space
Type 2: communication between lateral ventricles and subarachnoid space
Associated with vascular occlusion during brain development
Sonographic Findings:
- anechoic fluid filled clefts extending from the brain surface to the lateral ventricle
- unilateral or bilateral
- commonly located in the area of the Sylvian fissure
Hypoxic-Ischemic Injury
brain injury due to a disruption in cerebral blood flow and oxygen
hypoxic - reduction of oxygen
ischemic - reduction of blood flow
Maternal causes: chronic cardiac disease, lung disease, placental insufficiency, cocaine use, birth trauma, RH incompatibility
Neonatal causes: immature vasculature, absence of autoregulation in the white matter, alloimmune thrombocytopenia
Causes in older children: drowning, asphyxiation
Clinical:
- low five minute Apgar scores
- abnormal neurological exam
Sonographic Findings:
- diffuse echogenic brain tissue
- poorly defined sulci
- snowstorm speckling in the parenchyma
- loss of anatomical landmarks
- ventriculomegaly
- pulse wave shows elevation of RI and reversal of diastolic flow in the intracranial arteries
Periventricular Leukomalacia
infarction and necrosis of periventricular white matter
common hypoxic ischemic event in premature infants
Phases:
Acute - initial event
Chronic - occurs 2-3 weeks after onset
Atrophic - occurs 3-4 months after onset
Associated with immature vasculature in periventricular watershed, absence of autoregulation, infections, low birth weight infants
Sonographic Findings:
- bilateral involvement
- Acute Phase: no evidence of abnormalities, increased tissue echogencity surrounding ventricles
- Chronic Phase: echogenic areas replaced with anechoic cystic areas, septations may be seen in cystic areas
- Atrophic Phase: widening of interhemisphere fissure, enlarged subarachnoid spaces, widened cerebral sulci, ventriculomegaly
Porencephaly
vascular insult which results in cystic lesions forming in areas of tissue necrosis
may be referred to as porencephalic cyst
Sonographic Findings:
- anechoic cystic masses
- single or multiple
- no mass effect on other structures
Hydranencephaly
Destruction of cerebral hemispheres with replacement by CSF
Associated with occlusion of vessels involved in anterior circulation such as ICA
Clinical:
- enlarged head circumference
- irritability
Sonographic Findings:
- anechoic fluid filled cranial cavity
- echogenic interhemispheric fissure
- normal appearing thalami, cerebellum and brainstem
Arachnoid Cyst
cystic lesion containing CSF located between the layers of the arachnoid membrane
Cysts do not communicate with ventricles or CSF in surrounding surrounding subarachnoid space.
Primary cysts are congenital
Secondary cysts are caused from infection, injury or hemorrhage
Supratentorial is the most common location
Clinical:
- asymptomatic
- headaches
- nausea and vomiting
- dizziness
Sonographic Findings:
- anechoic
- thin smooth walls
- round
- increased posterior enhancement
- internal debris may be seen with infection or hemorrhage
Astrocytoma
A type of glioma originating from star-shaped astrocytes
Most common type of glioma tumor in children
Most common spinal cord tumor in children
Associated with Tuberous Sclerosis
Sonographic Findings:
- focal or diffuse
- variable echogenicity and size (isoechoic when located within spinal cord)
Intracranial Lipoma
lesion derived from the overgrowth of fat cells
Associated with epilepsy
May present with seizures
Sonographic Findings:
- echogenic
- may contain calcifications
- variable locations (most occur near midline)
- single or multiple
Papilloma of Choroid Plexus
Benign epithelial tumor made up of choroid plexus cells that produce CSF
Associated with Von Hippel-Lindau syndrome
Sonographic Findings:
- solid mass
- echogenic
- enlarged ventricles may be seen
- vascular
Tuberous Sclerosis Complex
multi-stem disease associated with the development of benign tumors in numerous parts of the body
CNS is frequently affected
Sonographic Findings:
- multiple
- echogenic
- found in parenchyma and periventricular regions
Intraventricular Hemorrhage (IVH)
most common type of IVH in infants
usually occurs in the first 3 days of life
less common in the full term newborn
Associated: infants born before 32 weeks, infants weighing less than 1500 grams, coagulation disorders, unknown etiology
Clinical:
- hypoxia
- HTN
- apnea
- lethargy
- decreased muscle tone
- low hematocrit
IVH Grade 1
results from the rupture of very fine network of blood vessels located in the germinal matrix (caudothalamic groove most common location)
Seen in up to 70% of premature infants on assisted ventilation
Sonographic Findings:
- echogenic area in caudothalamic groove
- resolution of blood clots results in echogenicity changes resulting in a cystic lesion (subependymal cyst)
IVH Grade 2
extension of the subependymal hemorrhage into the lateral ventricle without ventricular dilatation
Sonographic Findings:
- abnormal echogenicity within the lateral ventricle
- echogenic layering within the occipital horn
- completely fill ventricles
- thickened appearance of choroid plexus (color doppler can differentiate the vascular choroid from the avascular blood clot)
- anechoic central areas with resolution
IVH Grade 3
germinal matrix IVH with dilatation of ventricles
dilatation is caused by interference of CSF flow - blood clot is blocking the aqueduct of sylvius or the 3rd or 4th ventricle
Sonographic Findings:
- abnormal echogenicity within the lateral ventricle
- enlarged ventricles
- resolution results in anechoic central areas and eventual decreased size of ventricles
IVH Grade 4
germinal matrix IVH with hemorrhage in the cerebral cortex typically in the periventricular region of the frontal and parietal lobes
Sonographic Findings:
- variable
- echogenic debris within ventricle that extends beyond the walls of the ventricle
- complex cystic mass connected to the ventricle
Cerebellar Hemorrhage
presence of cerebellum or posterior fossa hemorrhage
in preterm neonates: germinal matrix bleeding near the 4th ventricle
in term: associated with traumatic delivery or coagulopathy
Sonographic Findings:
- variable
- loss of definition of cerebellum and 4th ventricle
- echogenic areas within cerebellum
- cystic areas with regression
- enlargement of intracranial ventricles
Subarachnoid Hemorrhage
blood in the subarachnoid space
more commonly seen in full term neonates than preterm
Sonographic Findings:
- thick echogenic interhemispheric and sylvian fissures
- thick echogenic subarachnoid space
- enlarged ventricles
Subdural or Epidural Hemorrhage
blood in the subdural or epidural space
Associated with birth trauma and coagulopathy
Sonographic Findings:
- Infratentorial: fluid collection between the tentorium and cerebellum; hydrocephalus
- Supratentorial: widened interhemispheric fissure, fluid collection in the interhemispheric fissure, mass effect
Vein of Galen Aneurysm
Intracerebral AVM which results in a dilated vein of Galen
referred to as Galenic venous malformation
Sonographic Findings:
- midline, anechoic cystic mass
- located between lateral ventricles, posterior to the foramen of monroe and superior to the third ventricle
Maternal infections affecting the fetus or neonate are at an increased severity if occurrence is before ____ weeks gestation.
20-24
Toxoplasmosis (TORCH) Other Agents Rubella Cytomegalovirus Herpes Simplex Virus
Toxoplasmosis: infection resulting from the parasite toxoplasma gondii
Other Agents: syphilis, HIV, Varicella-Zoser
Rubella: contagious viral disease
Cytomegalovirus: most common congenital viral infection
Herpes: common viral infection
Sonographic Findings:
- calcifications
- hydrocephalus
- subependymal cysts
- increased echogenicity
- enlarged ventricles
- anechoic cystic areas
- cerebral edema
Meningitis
inflammation of the protective membrane, meninges, of the brain
most cases occur in children less than 2
Clinical:
- fever
- seizures
- irritability
- apnea
- bulging fontanelle
- N/V
- headache
- lethargy
Sonographic Findings:
- normal appearing brain or increased echogenicity
- widened and echogenic sulci
- extra-axial fluid
- focal or diffuse
- enlarged ventricles
Encephalitis
inflammation of the brain parenchyma either from an infection or immune system reaction
Frequently involves the meninges resulting in meningoencephalitis
Sonographic Findings:
- focal, diffuse or patchy parenchymal echoes
- increased echogenicity of gyri
- decreased appearance of vascular pulsations
Ventriculitis
inflammation of the ependymal lining of the intracranial ventricles
complication of meningitis, abscess rupture or VP shunt infection
Sonographic Findings:
- slit like ventricles in acute phase
- enlarged ventricles
- hyperechoic, thick, irregular walls
- irregular, hyperechoic choroid plexus
Multicystic Encephalomalacia or white matter necrosis
focal or diffuse cystic lesions n the area of the damaged brain tissue
end result of meningoencephalitis or hypoxic-ischemic events
Cerebral Edema
presence of excess fluid in the gray and white matter in response to a brain insult
associated with full term infants who have experience a hypoxic-ischemic event
Clinical:
- bulging anterior fontanelle
- splaying of cranial sutures
- enlarged head circumference
Sonographic Findings:
- Initial phase: slit like ventricles, diffuse echogenic brain, poorly defined sulci, snowstorm speckling, loss of anatomical landmarks
- Mid phase: generalized brain atrophy, porencephaly or encephalomalacia
- Following Severe Infarction: brain volume loss, compensatory enlargement of ventricles, enlargement of extra axial spaces
How many:
cervical vertebrae thoracic vertebrae lumbar vertebrae fused vertebrae of sacrum coccygeal vertebrae
7 cervical 12 thoracic 5 lumbar 5 fused 4 coccygeal
What is the terminal end of the spinal cord called?
Conus Medullaris
For neonates, the terminal end should be located no lower than __.
L3
What is the extension of the pia mater called? It is located at the inferior end of the conus medullaris and extends approximately to the second sacral vertebra.
Filum Terminale
echogenic cord like structure. Pulsations from the cauda equina can be seen around the filum terminale,
What is the bundle of approximately 10 nerve roots that continue distal to the spinal cord? It resemble’s a horse’s tail and is located at the inferior end of the conus medullaris.
Cauda Equina
echogenic nerve roots
Lumbar Cistern
Enlargement of the subarachnoid space between the conus medullaris and the inferior end of the subarachnoid space and dura matter
located at the lower portion of the spinal dural sac from the first lumbar to the second sacral vertebra
At what level does the spinal cord terminate into the conus medullaris?
T12 - L1 or L2
What is the area routinely sampled in lumbar punctures?
Lumbar Cistern
Conus Medullaris should be situation at the level of ___ or above.
L3
Filar Cyst
ovoid cystic structure located inferior to the tip of the conus medullaris within the filum terminate.
No clinical significance and is a common finding.
Ventriculus Terminalis
slight widening or oval cystics areas of the central canal of the spinal cord.
Located within conus medullaris.
Regresses and typically not visible after the first few months of life.
Caudal Regression Syndrome
spectrum of structure defects involving the lower spine, sacrum and coccyx
Type 1: severe, high lying cord and an abrupt wedge-shaped terminus of the cord
Type 2: less severe, low lying tethered conus medullaris
Type 1 is more common
There is an increased frequency in diabetic mothers
Sonographic Findings:
- absence of bony structures in the lower spine, sacrum and or coccyx
- rounded or blunted end of conus medullaris
- tethered cord
Diastematomyelia
partial or complete cleft of the spinal cord resulting in two hemicords
most commonly occurs in the thoracolumbar region
Sonographic Findings:
- two spinal cords are seen on transverse view (Resembles a figure eight, cords appear hypoechoic)
- presence of a spur may appear hypoechoic or echogenic
Tethering of the spine
abnormal caudal fixation of the spinal cord below L3
Associated with VACTERL and anal or urogenital malformations
Cutaneous markers:
- hair tuft
- sinus tract
- skin tag
- dimple
- pigmented nevi
Sonographic Findings:
- abnormal caudal position
- conus medullaris often eccentrically located
- diminished cord motion
- short thick filum terminale
Dorsal dermal sinus
A long, thing epithelium lined sinus extending from the dorsal skin surface to the spinal cord, cauda equine or arachnoid
most common location is the lumbar sacral region
Clinical:
- small midline back dimple
- discharge from dimple
- other cutaneous markers
Sonographic Findings:
- echogenicity varies depending on location
- elongated structure
- extends superiorly from the skin surface into the subcutaneous tissues or into the area of the spinal cord
Syringohydromyelia
Dilatation of the central canal of the spinal cord and the presence of cysts in or lateral to the spinal cord
Syringomelia - fluid filled cyst that forms within the spinal cord
Hydromela - dilatation of the central canal of the spinal cord
Associated with myelomeningocele and Chiari malformation
Sonographic Findings:
- anechoic dilatation of the central canal
- cysts in or lateral to the central canal
What is the most common type of lipoma of the spine?
Lipomyeloceles or Lipomyelomeningocele
appears as an echogenic mass within the spinal cord
Sacrococcygeal Teratoma
Variable appearing neoplasm seen that can be externally, internally, or both internally and externally.
Occurs more in females.
Most often presents as a skin covered mass.
Ependymoma
Common intramedullary spinal tumor in children
Clinical:
- pain
- weakness
- sensory change
Sonographic Findings:
- well defined
- echogenic
- smooth walls
- can occur anywhere along the spinal cord
Dysraphism
Refers to a group of disorders in which the posterior bony elements of the spine do not close properly
usually an isolated finding with spina bifida
Spina Bifida Aperta or Overt Dysraphism
contents of the canal protude through a bony defect in the spine and outside of the body into a CSF filled space.
Non skin covered, open neural tube defect
Typically found in the lumbar sacral region
Associated with myelocele, meningocele and myelomeningocele
Spina Bifida Occulta
bony defect of the spine associated with cutaneous markers such as an abnormal hair tuft, collection of fat or dimple.
typically does not involve spinal nerves. Referred to as hidden spina bifida.
Associated with lipomyelomeningocele, thickened filum terminale, diastematomyelia
Myelomeningocele or Myelocele
Myelomeningocele: protruding sac of CSF containing the spinal cord and meninges
Myelocele: protrusion of the spinal cord
most common congenital spine malformations
occurs most frequently in the lumbosacral spine
Protruding sac may rupture
Sonographic Findings:
- tethered cord
- cranial abnormalities
- splayed echogenic vertebral bodies
- anechoic fluid filled mass with internal echogenicities which could represent the spinal cord and nerves
Lipomyelocele and Lipomyelomeningocele
Types of spina bifida occulta
Both are contained by intact skin and contain a fatty mass
Lipomyelocele: fatty mass extending through soft tissues, dura, and vertebral elements where it is contiguous with a low lying spinal cord
Lipomyelomeningocele: fatty mass extending through soft tissue vertebral elements, and dura where it attaches to the spinal cord
Sonographic Findings:
- vertebral bony abnormality
- echogenic mass continuous with the back and extending through the defect and inserting into or adjacent to the cord
- dilated subarachnoid space
Sonographic findings of infection of the spinal cord:
Sonographic Findings:
- presence of echogenic debris
- increased echogenicity of normal structures
- irregular borders of normal structures
- abscess formation
Risk factors: invasive procedure, open defect, dorsal sinus tract or bacterial/viral infections
Sonographic findings of trauma of the spinal cord:
Sonographic Findings:
- cord disruption
- variable echogenicity in the area of hemorrhage
- debris in subarachnoid space
- displaced of the cord due to epidural or subdural hemorrhage
Associated with non-traumatic and traumatic birth including use of forceps and breech delivery
