Large umbilical cord: a normal finding in some fetuses

We report two cases in which the umbilical cords of fetuses were large on prenatal ultrasound scans. The pregnancies terminated uneventfully, however, and the babies were healthy at birth and on follow-up visits. We discuss the various etiologies of a large umbilical cord and conclude that, although a large cord may suggest the presence of an underlying abnormality, in some instances it may represent a normal finding.

Objective measurement of hypertrophic burn scar: a preliminary study of tonometry and ultrasonography

Many people are burned each year and subsequently develop hypertrophic burn scars. An objective means for quantitatively measuring scar characteristics would be useful in monitoring resolution of the individual patient's scars as well as in evaluating different treatment protocols. Two methods for quantitative measurement of hypertrophic scars were evaluated in 4 patients at 8 scar sites over a 2-month period. A specially designed tonometer, the cicatrometer, assesses scar firmness and pliability. It is shown to provide a simple noninvasive means for objectively evaluating the progress of scar maturation and therapy. High-resolution ultrasonic scanning is shown to provide an objective, quantitative measurement of hypertrophic scar thickness, which can be compared between patients. This allows for the design of controlled trials comparing different treatment protocols.

Neuroblastoma metastatic to the testis: ultrasonographic screening as an aid to clinical staging

Secondary testicular tumors are rare, and to our knowledge only a few cases of metastatic neuroblastoma to the testicle have been presented in the literature. We report two cases in which high resolution ultrasonography was helpful in establishing the diagnosis of metastatic neuroblastoma. Because accurate staging is important in the choice of therapy, an aggressive search for the presence of metastatic disease is essential. The small size of the testes in young children makes physical examination difficult, and sonography can be of value.

Perfluorochemicals as liver- and spleen-seeking ultrasound contrast agents

In this study, Fluosol-DA, 20 per cent (composed of perfluorodecalin and perfluorotripropylamine) was tested as a liver-specific ultrasound contrast agent. Twelve normal rabbits were scanned, utilizing the Picker Microview (10 MHz), prior to and two days following the intravenous administration of 24 ml/kg of Fluosol (or 4.8 g/kg of perfluorochemicals) emulsion to ten of the rabbits and 24 ml/kg of Ringer's solution to two rabbits as control. In all ten rabbits given Fluosol, liver echogenicity increased relative to that of the kidney, whereas the liver remained less echogenic than the kidney in the two rabbits given Ringer's solution. Four independent reviewers correctly identified all rabbits that received Fluosol and both rabbits that received Ringer's solution. It is demonstrated that, similar to PFOB, Fluosol serves as an echogenic contrast material for ultrasound and opacifies the normal rabbit liver.

Occult spinal dysraphism in infants: screening with high-resolution real-time ultrasound

Spinal dysraphism refers to incomplete embryologic development of the dorsal midline. Frequently it is not clinically obvious, and lack of treatment can lead to progressive neurological damage. Early diagnosis of occult defects can allow appropriate surgical intervention and prevent neurological deficits. The authors have used high-resolution real-time ultrasound to screen infants with various cutaneous lumbosacral markers, all of whom were at risk of occult spinal dysraphism. Preliminary results suggest that ultrasound is a reliable screening procedure and could obviate the need for more costly and invasive tests.

Perfluoroctylbromide: a liver/spleen-specific and tumor-imaging ultrasound contrast material

The effect of perfluoroctylbromide (PFOB) on liver and tumor echogenicity was evaluated in rabbits. The echogenicity of the kidney, which is not affected by PFOB, was used as the basis for comparison in the liver studies. For the liver echogenicity study, sonography was performed on four rabbits, two with PFOB and two without PFOB, and four rabbits prior to and following the intravenous administration of 5 ml/kg PFOB. All livers were equal to or less echogenic than kidney in the control animals. All livers became more echogenic than kidney two days after administration of PFOB. The effect of PFOB on tumor echogenicity was evaluated in 18 rabbits with VX2 tumor implanted in the liver. Ultrasound studies of all rabbits were performed by the same physician before and two days after half the rabbits had received PFOB (5 ml/kg intravenously). The reviewers correctly identified all rabbits that received PFOB by visualization of an echogenic rim around the hepatic tumors.

High-resolution real-time ultrasonography of neonatal kidneys

A high-resolution real-time ultrasound system was used to evaluate 43 neonates who had problems referable to the kidney. In addition to a review of normal anatomic features portrayed by this instrument, a variety of pathologic states are illustrated. The system offers the dual advantages of superior spatial resolution and rapid survey capability when compared with traditional articulated-arm contact scanners. As with all sonographic investigations, functional immaturity or depressed organ function is no hindrance to obtaining diagnostic examinations.

Antenatal ultrasonic evaluation of acardiac monsters

Acardiac monster represents a rare but serious complication of monozygotic twin pregnancy. Antenatal recognition is important because of accompanying obstetrical problems, including polyhydramnios, dystocia, and uterine rupture. While pathologic findings are varied, characteristic sonographic findings allow accurate prenatal diagnosis. Acardia must be distinguished from sacrococcygeal teratoma, omphalocele and macerated fetus.

Induction of ovulation and pregnancy with pulsatile luteinizing hormone releasing factor: dosage and mode of delivery

The efficacy of intravenous and subcutaneous routes for pulsatile delivery of differing dosages of synthetic luteinizing hormone releasing factor (LRF) for ovulation induction were evaluated sequentially in two patients with presumed deficiency of endogenous LRF: isolated gonadotropin deficiency and pituitary stalk transection with hyperprolactinemia. Observations were made of the amplitude and duration of the induced LH-FSH pulses, of follicular growth and ovulation (via ultrasound), and of ovarian steroids. Remarkable differences in each of these parameters were found between the two modes of LRF delivery. LRF pulses administered subcutaneously resulted in inappropriate gonadotropin secretion, arrest of follicular development, elevated ratios of E1/E2 and androgens/estrogens, and the appearance of acne - features of polycystic ovary syndrome. In contrast, the first intravenous course of pulsatile LRF induced orderly follicular maturation and ovulation with subsequent pregnancy in both subjects. From these findings we conclude that, in these patients, the intravenous mode of delivery of LRF pulses was superior to the subcutaneous route at all doses tested.

Maternal ultrasonography for the antenatal diagnosis of surgically significant neonatal anomalies

The increased use of ultrasonography in the management and evaluation of pregnancy has provided a unique opportunity to observe the anatomy of the developing fetus from 12 weeks gestation until term. Twenty-eight surgically important anatomic abnormalities have been diagnosed in utero by sonographic examinations at our affiliated institutions over the past three and a half years. These include ascites (five cases), gastroschisis (four cases), omphalocele (three cases), sacrococcygeal teratoma, cystic hygroma, hydrocele, duodenal atresia, multicystic kidney (two cases each), and one each of jejunal atresia, conjoined twins, ureteropelvic junction obstruction, urethral valves, urethral agenesis, and hydronephrosis secondary to reflux. Prenatal diagnosis by ultrasonographic examination has signifcantly improved perinatal management. Elective caesarean section has benefited infants with lesions causing dystocia, such as sacrococcygeal teratoma, omphalocele, and conjoined twins. Advance notification of surgeons and neonatalogists has reduced the delays of postnatal evaluation and treatment that contribute, significantly, to complications and death. In addition, transfer of the pregnant mother carrying an infant with a significant surgical anomaly to a center with facilities for neonatal surgery and specialized postoperative care can be properly planned for in advance. In the near future, intrauterine fetal surgery or palliative intervention may provide increased salvage of patients with obstructive uropathy and diaphragmatic hernia, both of which carry high mortality rates secondary to in utero damage. Sonography has proven useful in following the dilatation of either intestinal or urinary tract structures in utero. In our hands, maternal sonography has improved the surgical care of the newborn and may open a new frontier of intrauterine fetal surgery in the future.

Parathyroid adenoma: accuracy of preoperative localization by high-resolution real-time sonography

To assess the accuracy of high-resolution sonography of the parathyroid glands, a consecutive series of sonograms in 58 patients was reviewed. The study population was limited to patients thought clinically to have primary hyperparathyroidism and likely to have one enlarged adenomatous gland. Patients with renal failure or other evidence of secondary hyperparathyroidism were excluded. Typical sonographic features of parathyroid adenoma were observed. An overall accuracy of 92% was obtained for the identification of surgically confirmed parathyroid gland enlargement due to adenoma.

Ultrasonic demonstration of the inflamed appendix: case report

Ultrasound was used to visualize a grossly inflamed nonperforated appendix in a child with acute leukemia. The characteristic sonographic pattern of the gastrointestinal tract was altered, and showed thickening of the bowel wall. In this case, use of ultrasound as an initial screening procedure in a patient with abdominal complaints aided diagnosis of gastrointestinal tract abnormality prior to more traditional studies.

Sonography of the thickened gallbladder wall: a nonspecific finding

Twenty cases of sonographically visualized thickening of the gallbladder wall were reviewed and the clinical diagnoses compiled. In only eight of these patients was cholecystitis considered responsible for the finding. The rest had hepatitis, alcoholic liver disease with hypoproteinemia, heart failure, renal disease, and multiple myeloma; however, all lacked clinical evidence of gallbladder disease. Because of these findings, caution is urged in making the diagnosis of cholecystitis on the basis of wall thickening alone.

Ultrasonic imaging of the carotid arterial system

The ability of a B-mode, real-time, high frequency ultrasonic imager to diagnose carotid arterial disease was evaluated in 81 carotid arteries. The imager was relatively sensitive in detecting the presence of significant stenosis but was relatively insensitive in its ability to quantitate the degree of stenosis. The imager was unable to detect the presence of ulcerations. The oculoplethysmograph had a greater sensitivity, specificity and accuracy than the ultrasonic imager in diagnosing carotid arterial stenosis in the same group of patients. Ultrasonic imaging appears to be useful as a screening test of cerebrovascular disease when used in combination with the oculoplethysmographic test.

High resolution real-time sonography of hemodialysis vascular access complications

Chronic hemodialysis requires an adequately functioning, surgically created vascular access. Many operative techniques have been devised, and each is subject to a variety of complications that significantly shorten the life span of any shunt. Among these are stenosis, thrombosis, aneurysm, pseudoaneurysm, and infection. High resolution sonography is a promising means to evaluate most of these complications. To determine the potential capability of the technique for detecting graft complications, a retrospective review of 30 hemodialysis patients examined with high resolution sonography is presented. Sonographic findings in normal grafts and in a variety of vascular access problems are illustrated.

High-resolution real-time ultrasonography of thyroid nodules

High-resolution real-time ultrasonography was used to evaluate 98 patients with palpable abnormalities of the thyroid and positive isotopic studies. It confirmed 37 of 73 (51%) suspected solitary nodules. Of 25 patients thought to have multinodular goiter, sonography was supportive in 21 (84%). In patients with adenoma or adenomatous nodules, characteristic features included a sonolucent "halo". Colloid nodules tended to be more sonolucent than normal thyroid tissue, whereas Hashimoto thyroiditis was characterized by an enlarged gland and decreased echogenicity.

Intrauterine diagnosis of renal anomalies by ultrasonography

The diagnosis of renal disease was made antenatally in three patients by ultrasonographic examination. In two cases a multicystic kidney was detected in utero and removed shortly after delivery. In another case, a hydronephrotic kidney was detected in utero; repair was then performed early, before symptoms developed in the infant. Antenatal diagnosis of renal disease by ultrasonography may help reduce morbidity and mortality in some cases.

Accuracy of ultrasonography in diagnosis of hepatocellular disease

Retrospective evaluations were made of abdominal echograms in 61 patients who underwent liver biopsy within 3 weeks after ultrasound study. Without knowledge of clinical or biopsy data, determinations were made by two independent observers of: (1) liver size, (2) beam penetration, (3) echogenicity, (4) vascularity, (5) ancillary abnormality, and (6) diagnostic impression. Using these parameters, the presence of generalized parenchymal disease was identified in 81% of reviews of patients with cirrhosis. Thus, in patients with known cirrhosis, there was a 19% false negative rate. In normal patients, 76% were correctly called normal by the reviewers. However, in 24% generalized parenchymal disease was suggested (24% false positive). Patients with fatty liver could not be reliably distinguished from patients with cirrhosis, nor could patients with hepatitis be easily separated from those with normal livers. In all of these determinations, the combination of several features provided more diagnostic accuracy than any single echographic finding.

High-resolution ultrasonography of scrotal pathology

A prototype high-resolution (10-MHz) real-time ultrasonic system was used to study 22 patients who were ultimately proved to have intra- and extratesticular tumors, scrotal fluid collections, and inflammatory processes. In 5 of 6 patients with primary testicular masses, there were areas of decreased echogenicity within the testis when compared with surrounding normal tissue. In general, the method was highly effective in differentiating and characterizing testicular and extratesticular processes.

Ultrasonography of jaundice

Ultrasonography is proposed as a valuable first step in the study of the jaundiced patient. Utilizing modern gray scale technology, it is nearly always possible to determine whether or not dilatation of the biliary tree is present. In the presence of diffuse liver disease without obstruction, some assessment of the state of the parenchyma can often be made. In patients with obstruction, its severity and level are usually easy to determine. It may be considerably harder to correctly diagnose the etiology of the obstruction, and more invasive investigations will then be required.