P5539Genetic heterogeneity of spontaneous coronary artery dissection (SCAD)

Introduction

SCAD is a rare coronary event that may cause acute coronary syndromes (ACS). SCAD predominantly occurs in apparently healthy, young to middle aged women (up to 95% of cases). The known causes include: heritable connective tissue diseases, fibromuscular dysplasia, arteritis, contraceptives, cocaine abuse and chest trauma. A variable proportion of patients manifests progression to longer segments of the same vessel or recurrence of dissection in other coronary arteries. SCAD can be the first manifestation of a previously unrecognised systemic disease.

Methods

In 2010 we started collecting consecutive SCAD, as first clinical manifestation, in patients addressed to our attention for investigation of genetic or non genetic causes, after successful management of the acute phase and exclusion of systemic inflammatory and autoimmune diseases. All patients underwent genetic visit and counselling, collection of clinical reports and imaging records, clinical cardiologic evaluation with pan-angio CT scan, biochemical testing including coagulation-related tests, and and genetic testing of genes causing connective tissue diseases. Parallel clinical family screening and genetic testing were systematically performed.

Results

The series is constituted of 35 patients (28F and 7M) (age at onset, mean ± SD, 44±7.6 years) with ACS-SCAD (20 STEMI and 15 NSTEMI) and 9 second dissections in a different coronary artery. Two sisters had ACS-SCAD caused by dissection of the same coronary artery.

We identified pathologic mutations (n=19/35, 54%) in COL3A1 (n=3), FBN1 (n=1), FBN1+TGFBR1 (n=1), TGFBR1 (n=2), TGFBR2 (n=1), MYLK (n=1), SMAD3 (n=1), COL5A1 (n=1 homozygous), COL5A2 (n=1), MYH11 (n=1), TGFB2 (n=1), ABCC6 (1 homozygous), ELN (2 homozygous sisters and 1 heterozygous unrelated patient), NOTCH1 (n=1). In 8 (23%) patients we identified VUS classified as C3 because previously unreported and predicted as uncertain on the basis of in silico analyses. In the remaining 8 patients we only identified C2 variants. A second SCAD (14 days to 78 months after the first event) occurred in 9 patients (9/35, 25%) (COL3A1 (n=2), FBN1 (n=1), FBN1+TGFBR1 (n=1), MYLK (n=1), COL5A2 (n=1), NOTCH1 (n=1) COL5A2 (n=1) and 1 with a C2 variant in COL3A1. Two patients with thrombocytosis were carriers of the somatic JAK2 V617F mutation. Extra-coronary arterial dilations/aneurysms occurred in 13 families; in the follow-up 2 patients demonstrate dissection in non-coronary arteries.

Conclusions

Our series, with the potential bias of a referral centre for inherited cardiovascular disease, demonstrated that SCAD is the possible first manifestation of a genetic disorder and that neither disease gene or mutation predicts the risk of a second coronary event. SCAD is a potentially fatal coronary event associated with ACS, warning for familial disease and unpredictable risk of recurrence.

What is the role of contrast-enhanced ultrasound in the evaluation of the endoleak of aortic endoprostheses? A comparison between CEUS and CT on a widespread scale

OBJECTIVE

To evaluate the accuracy of contrast-enhanced ultrasound (CEUS) in comparison to CT angiography (CTA) to identify and classify endoleaks following abdominal aortic aneurism repair with endoprosthesis.

MATERIALS AND METHODS

A retrospective analysis of 181 patients treated with EVAR, from September 2009 to September 2014, was performed. Patients were evaluated with CEUS, CTA and angiography in the cases requiring treatment. Sac diameter, sac integrity, identification and classification of endoleaks were taken into consideration. Sensitivity, specificity, accuracy and negative predictive values were considered for each modality of endoleak identification.

RESULTS

Forty-two endoleaks (23.2%; type II: 39 cases, type III: 3 cases) were documented. Sensitivity and specificity of CEUS and CT were, respectively, 97.6 and 90.5, 100 and 100%. In two cases, CEUS was able to better classify endoleaks compared to CT.

CONCLUSIONS

CEUS accuracy to identify endoleaks following EVAR is similar to CT. CEUS should be considered as an effective modality for the long-term surveillance of EVAR because of its capability to correctly classify endoleaks with no ionizing radiation exposure.

EFSUMB Statement on Medical Student Education in Ultrasound [long version]

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound should be used systematically as an easy accessible and instructive educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and hands-on training should be implemented and adhere to evidence-based principles. In this paper we report EFSUMB policy statements on medical student education in ultrasound that in a short version is already published in Ultraschall in der Medizin 1.

Parotid Gland Lesions: Multiparametric Ultrasound and MRI Features

High-resolution ultrasound (US), as a readily available, cost-effective and harmless imaging technique, is appropriately the initial imaging modality for salivary gland lesions. Benign tumors are reported to present with regular and well-defined margins, a homogeneous hypoechoic structure and demarcated vessel distribution, whereas malignant lesions are irregular, heterogeneous and diffusely perfused. Ultrasound and color Doppler features of benign and malignant salivary gland lesions overlap, and many benign tumors, particularly pleomorphic adenomas, may appear irregularly shaped, with a heterogeneous echo-structure indistinguishable from a malignant lesion. Often skilled US operators are not always able to differentiate benign from malignant lesions. The introduction of US contrast agents has allowed further perspectives in the possible improvement of lesion characterization, and the emergence of US elastography, an innovative tool for assessing lesion stiffness/elasticity characteristics, has been advocated for differentiating salivary gland lesions. When lesions are atypical on US, contrast-enhanced magnetic resonance (MR) imaging is usually the definitive imaging modality. We present a current review of benign and malignant parotid gland tumors with emphasis on the role of multiparametric US and MR imaging.

EFSUMB statement on medical student education in ultrasound [short version]

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recommends that ultrasound should be used systematically as an easy accessible and instructive educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and hands-on training should be implemented and adhere to evidence-based principles. In this paper we summarise EFSUMB policy statements on medical student education in ultrasound.

Use of ultrasound-magnetic resonance image fusion to guide sacroiliac joint injections: a preliminary assessment

BACKGROUND

The sacroiliac joint is one of the sources of chronic lower back pain. Intra-articular injections of anesthetic drugs and/or steroids are currently used in these cases for diagnostic and therapeutic purposes. However, given the anatomic and functional complexity of the joint, imaging guidance is mandatory during such procedures. In this context, the technique of fusing images obtained with two different modalities can often overcome the limitations and enhance the advantages of single-modality guidance.

AIM

The aim of this study was to evaluate the technique of ultrasound (US)-magnetic resonance (MR) image fusion to guide intra-articular injections of drugs into the sacroiliac joint.

MATERIALS AND METHODS

We evaluated seven sacroiliac joints in six patients with sacroiliac pain syndrome (four females, two males; mean age 59 years; range 46-76 years). Five were candidates for radiofrequency thermolysis, and a therapeutic nerve block was performed in the sixth. Using the volume navigation system, we fused three-dimensional MR images with simultaneously acquired real-time ultrasound images and used them to guide the intra-articular injections.

RESULTS

In all patients, spatial accuracy was considered excellent, with definition of registration errors of less than 3 mm. The diagnostic blocks produced positive results in all patients with 80 % reductions in pain (measured with a Numerical Rating Scale, NRS) relative to baseline. The patient who underwent the therapeutic nerve block experienced complete resolution of symptoms that has been maintained over time. There were no complications.

CONCLUSIONS

US-MR imaging fusion guidance of sacroiliac joint injections is feasible and effective, in accordance with the data in the literature. The use of the MR for three-dimensional imaging eliminates the risk of radiation exposure.

EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 2: Clinical applications

The clinical part of these Guidelines and Recommendations produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology EFSUMB assesses the clinically used applications of all forms of elastography, stressing the evidence from meta-analyses and giving practical advice for their uses and interpretation. Diffuse liver disease forms the largest section, reflecting the wide experience with transient and shear wave elastography . Then follow the breast, thyroid, gastro-intestinal tract, endoscopic elastography, the prostate and the musculo-skeletal system using strain and shear wave elastography as appropriate. The document is intended to form a reference and to guide clinical users in a practical way.

EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology

The technical part of these Guidelines and Recommendations, produced under the auspices of EFSUMB, provides an introduction to the physical principles and technology on which all forms of current commercially available ultrasound elastography are based. A difference in shear modulus is the common underlying physical mechanism that provides tissue contrast in all elastograms. The relationship between the alternative technologies is considered in terms of the method used to take advantage of this. The practical advantages and disadvantages associated with each of the techniques are described, and guidance is provided on optimisation of scanning technique, image display, image interpretation and some of the known image artefacts.

E-learning in radiology: an Italian multicentre experience

OBJECTIVE

The aim of this study was to design, deliver and evaluate an e-learning teaching programme for post-graduate radiodiagnostics training that would involve various post-graduate schools throughout Italy.

MATERIALS AND METHODS

All of the Directors of Italian post-graduate schools of radiodiagnostics were sent an e-mail on 27 September 2010 informing them of our willingness to set up an e-learning project for the academic year 2010-2011 in the form of single-subject teaching seminars. The proposed subjects were the semeiotics of the various organs and apparatuses in the context of "Urgent/Emergency Pathology". After having received registrations, a calendar of lessons was planned to be held between 10 November 2010 and 12 October 2011. The validity of the project was tested by means of a multiple-choice questionnaire covering the technical and didactic quality of the entire project, to be completed by the students.

RESULTS

Fifty-one percent of the universities in Italy participated in the project: Trieste, Udine, Verona, Milan-Bicocca, Novara, Varese, Genoa, Sassari, Rome Campus, the Catholic University of Rome, Chieti, Foggia, Catania, Modena, Florence, Palermo, Bologna, Pavia, Parma and Ferrara. The lessons were attended by a total of 10,261 post-graduate medical students, for an average of 513.1 students per lesson. Seventy percent of the students judged the didactic content "excellent", 25% "good", and 5% "satisfactory"; none said it was unsatisfactory. In terms of visual quality (particularly the details of the radiological images proposed in the form of slides and/or video clips), 73% judged it "excellent", 20% "good", 6% "satisfactory", and 1% "poor". The audio quality was judged "excellent" by 71%, "good" by 22%, "satisfactory" by 6% and "poor" by 1%. In relation to judgement of audio and video quality, it has to be underlined that this was greatly affected by the hardware/software configuration and the band speed and technology of the Internet connection.

CONCLUSIONS

Technological evolution is overcoming all barriers, and technology is also having a positive impact on the approach to teaching. Our multicentre teaching experience merits the following considerations: the quality of the teaching product was certified by the students' judgements of its didactic content and the quality of reception; the economic cost of the teaching had a minimal impact on the post-graduate schools (€ 18 per lesson). In terms of breaking down national barriers, it is to be hoped that the coordination and integration of diagnostic imaging e-learning projects, with the participation of post-graduate schools in different European countries, can be developed not only in a spirit of "cultural sharing" and the exchange of teaching experiences.

Ultrasound guided fine-needle aspiration cytology of breast lesions

Breast biopsy consists in the collection of cells or tissue fragments from a breast lesion and their analysis by a pathologist. There are several types of breast biopsy defined on the basis of the type of needle used: fine-needle aspiration and biopsy performed with a spring-based needle. This article focuses on fine-needle aspiration performed under sonographic guidance.It is used mainly to assess cysts that appear to contain vegetations or blood or that are associated with symptoms; lesions and solid nodules that are not unequivocally benign; and axillary lymph nodes that appear suspicious on physical examination and/or sonography.In addition to distinguishing between benign and malignant lesions, ultrasound guided fine-needle aspiration also plays an important role in tumor grading and in immunocytochemical identifying specific tumor markers. This article describes the technique used and the possible causes of false negative and false positive findings. Despite its limitations, fine-needle aspiration has become a fundamental tool for the identification and preoperative management of malignant breast lesions.

Presurgical setting of secondary hyperparathyroidism using high-resolution sonography and color Doppler

PURPOSE

High-resolution sonography (US) with color Doppler imaging (CDI) is a simple, noninvasive, safe and repeatable technique able to highlight the presence of hyperplastic parathyroid glands and changes in their volume, structure, and vascularization during uremia. The primary aim of this study was to assess the diagnostic accuracy of US and the sensitivity for localizing parathyroid glands with a volume ≥ 500 mm(3). The secondary aim was to assess the parameters that define parathyroid glandular perfusion.

MATERIALS AND METHODS

The diagnostic use of US was assessed in 40 consecutive uremic patients with severe secondary hyperparathyroidism (sHPT) who were receiving maintenance hemodialysis or conservative therapy with a hypoproteic-hypophosphoric diet and had undergone parathyroidectomy. Prior to surgery (99m)TC-sestamibi scintigraphy (SM) was performed in all patients.

RESULTS

The sensitivity, specificity, positive predictive value and accuracy of US were 74 %, 75 %, 98 %, and 74 %, respectively. The sensitivity for localizing glands with a volume ≥ 500 mm(3) was 90 %. US and SM had a combined sensitivity of 83 %. The vascularization of parathyroid glands became more evident with increasing glandular volume. With CDI, the signs of hypervascularization (i. e. an enlarged feeding artery at the hilum, a peripheral arc of vascularity and/or ray-like endonodular vessels) were present in 77 % of glands with a volume ≥ 500 mm(3).

CONCLUSION

The sensitivity of US is higher than that of SM, but it cannot be compared with that of parathyroidectomy (74 vs. 95 %). However, US/CDI is able to characterize glands with different volumes and vascular patterns. Since glandular volume and vascularization are indicative of the severity of sHPT, this study suggests that the main role of US/CDI in the setting of sHPT should be to complete the diagnosis and to evaluate the morphological changes of enlarged glands during uremia in order to define surgical timing, rather than to assess the presurgical location of glands.

Detection of hepatic metastases from colorectal cancer: prospective evaluation of gray scale US versus SonoVue® low mechanical index real time-enhanced US as compared with multidetector-CT or Gd-BOPTA-MRI

PURPOSE

To compare ultrasound (US), low-mechanical index contrast enhanced US (CEUS) and multidetector-CT (MDCT) for the detection of hepatic metastases from colorectal cancer.

METHODS AND MATERIALS

From January to June 2006, 110 patients (65 males, 45 females; mean age 62 years; range 39-78) with suspected hepatic lesions from colorectal cancer were prospectively evaluated with US, CEUS and MDCT by two independent readers. Intraoperative ultrasonography (IOUS, n = 45) or a follow-up up for at least 6 months by using MDCT or Gd-BOPTA-enhanced MRI was considered the gold standard. McNemar test was employed.

RESULTS

Reference standards revealed 430 metastases in 110 patients. On a patient-by-patients analysis, CEUS improved US sensitivity from 67.4-71.6% to 93.4-95.8% (p < 0.05). On a lesion-by-lesion analysis, CEUS improved the sensitivity of US from 60.9-64.9% to 85.3-92.8% (p < 0.001). The specificity increased from 50-60% to 76.7-83.3%. No significant differences in sensitivity or specificity between CEUS and MDCT were found. Contrast-enhanced US was significantly more sensitive than baseline US in the detection of metastases smaller than 1 cm (p < 0.001) with an increase in sensitivity from 29.1-35% to 63.3-76.6% no significant statistical difference was identified when compared with MDCT (sensitivity of 73.3-75.8%).

CONCLUSIONS

CEUS is significantly more accurate than US and highly comparable with MDCT in the detection of liver metastases from colorectal cancer. Therefore, in the evaluation of patients with suspected hepatic metastases from colorectal tumour, US examination must be performed after contrast administration.

Is contrast-enhanced US alternative to spiral CT in the assessment of treatment outcome of radiofrequency ablation in hepatocellular carcinoma?

PURPOSE

The present study was conducted to assess the efficacy of contrast-enhanced ultrasound with low mechanical index in evaluating the response of percutaneous radiofrequency ablation treatment of hepatocellular carcinoma by comparing it with 4-row spiral computed tomography.

MATERIALS AND METHODS

100 consecutive patients (65 men and 35 women; age range: 62 - 76 years) with solitary hepatocellular carcinomas (mean lesion diameter: 3.7 cm +/- 1.1 cm SD) underwent internally cooled radiofrequency ablation. Therapeutic response was evaluated at one month after the treatment with triple-phasic contrast-enhanced spiral CT and low-mechanical index contrast-enhanced ultrasound following bolus injection of 2.4 ml of Sonovue (Bracco, Milan). 60 out of 100 patients were followed up for another 3 months. Contrast-enhanced sonographic studies were reviewed by two blinded radiologists in consensus. Sensitivity, specificity, NPV and PPV of contrast-enhanced ultrasound examination were determined.

RESULTS

After treatment, contrast-enhanced ultrasound identified persistent signal enhancement in 24 patients (24 %), whereas no intratumoral enhancement was detected in the remaining 76 patients (76 %). Using CT imaging as gold standard, the sensitivity, specificity, NPV, and PPV of contrast enhanced ultrasound were 92.3 % (95 % CI = 75.9 - 97.9 %), 100 % (95 % CI = 95.2 - 100 %), 97.4 % (95 % CI = 91.1 - 99.3 %), and 100 % (95 % CI = 86.2 - 100 %).

CONCLUSION

Contrast-enhanced ultrasound with low mechanical index using Sonovue is a feasible tool in evaluating the response of hepatocellular carcinoma to radiofrequency ablation. Accuracy is comparable to 4-row spiral CT.

Knowledge of the bio-effects of ultrasound among physicians performing clinical ultrasonography: Results of a survey conducted by the Italian Society for Ultrasound in Medicine and Biology (SIUMB)

INTRODUCTION

Safety issues should always be kept in mind when using diagnostic ultrasound, which is associated with potentially hazardous bio-effects, especially with the introduction of new technologies.

AIM

To assess the level of awareness and knowledge of safety issues related to the clinical use of ultrasound among physician-members of the Italian National Society for Ultrasound.

MATERIALS AND METHODS

A questionnaire with 11 multiple-choice questions was sent to members of the Italian Society for Ultrasound in Medicine and Biology. The answers were forwarded from the Society's Secretariat to the investigators, who statistically analyzed the data.

RESULTS

The mean age of the 105 respondents was 44 years. The most frequent kind of ultrasound examinations (in addition to conventional B-mode) were: Doppler (74%), contrast-enhanced US (43%), and pediatric studies (43%). Only 50-60% of the responders knew the correct definitions of the terms thermal index and mechanical index. Almost all respondents understood the bio-effects reflected by the thermal index, but only a minority knew the most likely organ target of bio-effects related to the mechanical index and what do indicate the units in which the thermal index is expressed. The majority knew that fetuses are at higher risk of damage. Few respondents were able to identify the correct safety statements included in the recommendations of the International Ultrasound Societies.

CONCLUSION

In conclusion, the present findings indicate that greater efforts of National Ultrasound Societies are warranted in disseminating knowledge of the bio-effects of diagnostic ultrasound modalities among operators.

Contrast-enhanced ultrasonography during liver surgery

Worthy of wider evaluation

Hepatocellular carcinoma treated with radiofrequency ablation: comparison of pulse inversion contrast-enhanced harmonic sonography, contrast-enhanced power Doppler sonography, and helical CT

OBJECTIVE

The purpose of this study was to compare the efficacy of contrast-enhanced pulse inversion harmonic imaging with contrast-enhanced power Doppler sonography and helical CT to determine incomplete local treatment after radiofrequency ablation in patients with hepatocellular carcinoma.

MATERIALS AND METHODS

Thirty-five consecutive patients (24 men and 11 women; mean age, 64 years) with 43 hepatocellular carcinomas (3.6 +/- 1.1 cm) were treated using internally cooled radiofrequency ablation therapy. Therapeutic response was evaluated at 4 months with dual-phase contrast-enhanced helical CT, conventional power Doppler Sonography, and pulse inversion harmonic imaging using a sonographic contrast agent (SH-508). CT and sonographic studies were reviewed separately in random order by four radiologists at different consensus conferences. Sensitivity and specificity of the sonographic methods were determined using CT as a gold standard and results were compared using the McNemar test.

RESULTS

CT examinations identified residual tumor in 12 lesions (27.9%). Although conventional contrast-enhanced power Doppler sonography identified residual viable tumor foci in four incompletely treated lesions (9.3%), contrast-enhanced pulse inversion harmonic imaging identified residual tumoral enhancement in 10 lesions (23.3%). Thus, the sensitivity of pulse inversion harmonic imaging (83.3%) was significantly greater (p < 0.05) for detecting residual nonablated tumor compared with conventional contrast-enhanced power Doppler sonography.

CONCLUSION

Our study suggests that contrast-enhanced pulse inversion harmonic imaging may enable the detection of residual nonablated tumor in more cases than contrast-enhanced power Doppler sonography and may ultimately prove to be a useful adjunct for percutaneous ablation therapies. Nevertheless, contrast-enhanced axial imaging (CT or MR imaging) is currently the most sensitive test for managing thermal ablation for patients with hepatocellular carcinoma.

Power Doppler ultrasound of gallbladder wall vascularization in inflammation: clinical implications

We investigated the role of Power Doppler US in the diagnosis and follow-up of cholecystitis. We reviewed the examinations of 21 surgical patients aged 27-48 years with US findings of cholecystitis. We performed B-mode and then Power Doppler US. Wall thickness and US structure, the presence/absence of stones, and US Murphy's sign were assessed at B-mode US, whereas only the presence/absence of wall vascularization was studied with Power Doppler. B-mode and Power Doppler changes post treatment were also investigated. Ultrasound showed wall thickening in all patients. In addition, positive Murphy's sign and/or gallbladder stones were seen in 6 patients each at B-mode US and wall vascularization in 7 patients with Power Doppler. Acute cholecystitis was diagnosed in these patients. The other 14 patients presenting wall thickening but no vascularization and negative US Murphy's sign were diagnosed as having chronic cholecystitis; 10 of them had gallbladder stones. Two of seven acute cholecystitis patients were operated on in the acute stage for the onset of complications and histologic findings confirmed the US diagnosis. As for the remaining patients, histology diagnosed chronic cholecystitis in 17, whereas wall thickening was not inflammatory in 2 cases. All the cases with early wall vascularization were eventually diagnosed as cholecystitis. Power Doppler US permits confirmation of the diagnosis of acute cholecystitis and distinguishing of chronic disease, which helps in planning of surgery.

Topical role and future perspectives of sonographic contrast agents in the differential diagnosis of solid thyroid lesions

Gray scale sonography and US-guided biopsy are cost-effective and reliable procedures in the differential diagnosis of focal thyroid lesions. The frequent presence of multiple foci can make multiple biopsies intolerable to the patient. The use of a sonographic contrast agent (Levovist) composed of microbubbles was evaluated in the differential diagnosis of focal solid lesions of the thyroid. Time/intensity curves after bolus injection of contrast were studied with samplings at the level of focal lesions, extranodular parenchyma and common carotid in 29 lesions of 25 patients (16 females and 9 males) ranging in age 21 to 68 years. The evaluated parameters were: the curve morphology, the time to peak value, the mean enhancement time and the wash-in/out variate gamma curve. All focal lesions underwent biopsy. No significant differences were observed as for mean enhancement time while for time to peak values only two malignant lesions seemed to show values different from those of other solid lesions. Wash-in/out variate gamma curves seemed more interesting; they presented a dual morphology: 1) parenchymal for hyperplastic areas, pseudonodular neoformations during thyroiditis and healthy thyroid parenchyma, 2) vascular for malignant lesions and carotid lumen. Autonomous nodules showed an intermediate morphology. In spite of major limitations, the results seem to pave the way for additional possibilities of noninvasive differential diagnosis in the evaluation of focal solid thyroid lesions.

Selection of patients for carotid endarterectomy: the role of ultrasound

Stroke is the third leading cause of death in the western world and the major cause of disability among the middle aged and elderly populations. Carotid artery stenosis is the single most important risk factor for stroke. The North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial have demonstrated that the risk of stroke is reduced by surgery in patients with high grade stenosis. Carotid plaque morphology also plays an important role; plaques which are ulcerated and echolucent are associated with a higher risk of stroke. Arteriography has long been regarded as the gold standard diagnostic tool for evaluation of carotid artery disease, but it is an invasive and costly technique which carries the risk of potentially serious complications. Doppler ultrasound can provide functional and anatomical information on vessel stenosis and plaque morphology at sub-millimetric resolutions and is an inexpensive and noninvasive tool. Color and spectral Doppler ultrasound are now recognized as the best screening tests for carotid artery stenosis. The evidence for its use as the sole diagnostic imaging modality prior to carotid endarterectomy is examined. The recent availability of ultrasound contrast agents helps to distinguish between pseudo- and true occlusions, improves ultrasound images and should help to reduce operator variability.

[Evaluation of results of leg tendon reconstruction. Ultrasonography features]

INTRODUCTION

The role of ultrasound (US) in the postoperative assessment of tendon reconstruction is not clearly defined and there is no systematic arrangement of US patterns.

MATERIAL AND METHODS

We examined 34 patients submitted to surgery or conservative treatment for total/partial tear or musculotendinous detachment of patellar or Achilles tendon in the last 5 years. All patients underwent physical and US examinations.

RESULTS

The surgical tendon exhibited the same US patterns in 23/28 patients: it was markedly enlarged (three-/fourfold the normal diameter) and more rounded, with inhomogeneous and hypoechoic appearance not only at the tear/surgical site but also above and below it, for some cm. Small hyperechoic images, mainly dots, were seen in 19 cases, which were referrable to small calcifications and stitches. More and larger calcifications were found in 8 patients, where they were associated with anechoic degeneration areas. Color Doppler US showed moderate or strong hypervascularization around the tear in the first months postinjury. US patterns did not correlate with physical findings, but color Doppler patterns did. In 6 cases of musculotendinous detachment submitted to conservative treatment, US showed enlargement and hypoechogenicity in the injury site only, with no involvement of the remaining tendon. US was also used to time and guide drainage of perilesional hematomas, which were often quite large.

CONCLUSIONS

US is the method of choice in the postoperative follow-up of tendon tears and musculotendinous detachments because it shows abnormal signs which are missed at clinics and provides additional information needed for treatment planning.

Ultrasound contrast agents: basic principles

INTRODUCTION

Ultrasonography lacked substances to be administered to patients to improve or increase the diagnostic yield, which is peculiar considering that contrast agents have long been used with all the other imaging techniques. Fortunately some contrast agents, most of them consisting in gas microbubbles, have been recently introduced for ultrasound imaging too: this review will focus on their history, behavior, current applications and future developments. Echocontrast agent research is in progress and many new agents are expected to be marketed this and next year, to be added to Levovist by Schering AG (Berlin, Germany), to enhance the ultrasound signal safely and effectively. No definitive conclusions can be drawn yet on the actual merits of each contrast agent, but all of them seem to be both effective and safe, meaning that their future success will depend on the relative cost-effectiveness and peculiarities.

THE BASIC PRINCIPLES OF ECHOCONTRAST AGENTS

The microbubbles act as echo-enhancers by basically the same mechanism as that determining echo-scattering in all the other cases of diagnostic ultrasound, namely that the backscattering echo intensity is proportional to the change in acoustic impedance between the blood and the gas making the bubbles. The different acoustic impedance at this interface is very high and in fact all of the incident sound is reflected, even though not all of it will of course go back to the transducer. But the acoustic wave reflection, though nearly complete, would not be sufficient to determine a strong US enhancement because the microbubbles are very small and are sparse in the circulation. Moreover, reflectivity is proportional to the fourth power of a particle diameter but also directly proportional to the concentration of the particles themselves.

SECOND HARMONIC IMAGING

As we said above, the microbubbles reached by an ultrasound signal resonate with a specific frequency depending on microbubble diameter. However, the main resonance frequency is not the only resonance frequency of the bubble itself and multiple frequencies of the fundamental one are emitted, just like in a musical instrument. These harmonic frequencies have decreasing intensity, but the second frequency, known as the second harmonic, is still strong enough to be used for diagnostic purposes. The theoretical advantage of the harmonic over the fundamental frequency is that only contrast agent microbubbles resonate with harmonic frequencies, while adjacent tissues do not resonate, or else their harmonic resonation is very little. Thus, using a unit especially set to produce ultrasounds at a given frequency (3.5 MHz) and receive an ultrasound signal twice as powerful (7 MHz) it will be possible to show the contrast agent only, without any artifact from the surrounding anatomical structures, with a markedly improved signal-to-noise ratio. A similar effect to digital subtraction in angiography can thus be obtained, even though through a totally different process. Moreover, second harmonic imaging permits to show extremely small vessels (down to 40 microm) with very slow flow, which would be missed with a conventional method. B-mode imaging can also depict the microbubbles in the myocardium suppressing nearly all the artifacts from cardiac muscle motion. Recently a peculiar behavior of microbubbles has been observed which may permit contrast agent detection even in capillaries. This method is variously known as sonoscintigraphy, loss of correlation, stimulated acoustic emission and transient scattering. The contrast agent microbubbles reached by an ultrasound beam powerful enough explode producing a strong and very short backscatter echo which is read by the unit as a Doppler signal and results in a color pixel where the individual microbubble exploded.

CONCLUSIONS

The microbubble contrast agents developed and introduced as safe and effective echo-enhancers in present-day clinical practice will open up new oppurtunities

Contrast enhancing agents in ultrasonography: clinical applications

INTRODUCTION

As ultrasound remains a poorly sensitive method, echocontrast agents make a real difference. At least 29 echocontrast agents are currently on trial worldwide; their chemical composition, mechanisms of action and possible clinical applications are different. The state of the art of echocontrast agents is discussed: their established applications, those expected in the near future and finally their hypothetical, ideal applications.

POTENTIAL CLINICAL APPLICATIONS

An extravascular and a vascular domain can be considered. The former includes the gastrointestinal tract and body cavities--both the normal (bladder, uterus, tubes and so on) and the abnormal (abscesses, fistulas, pericardium, peritoneum and so on) ones. Echocontrast agents can: (1) create or improve an acoustic window; (2) distend some organs and fill them with a liquid, with homogenous attenuation of the ultrasound beam; (3) displace the air-containing intestinal loops; (4) depict the walls, the shape and the contours of a normal or abnormal cavity; (5) detect abnormal communications, fistulas and drainages; and (6) evaluate the amount of fluid in the pleural, pericardial or peritoneal cavities. As for vascular applications, this domain sees the highest number of echocontrast agents on trial or on the market. The best know of them are: Levovist (Schering AG, Berlin, Germany), BR1 (Bracco, Milan, Italy) and EchoGen (Abbott, USA). All these act by enhancing arteries, veins and capillaries. The clinical applications validated in clinical trials mainly regard studies in intracranial and neck vessels and the vascularity of upper and especially lower limbs of renal vessels. Tumor macrovascularity (and in the future, hopefully microvascularity) can also be studied in parenchymatous and/or glandular organs, as well as in intra- and extra-abdominal parenchymatous organs in the periskeletal soft tissues. Clinical validation has also been obtained in the follow-up of tumors submitted to ablation therapy (chemoembolization, ethanol injection, thermal ablation) and in echocardiography, both for morphological studies in the cardiac cavities and for the cardiac wall perfusion.

CONCLUSIONS

In a subgroup of 513 out of 1275 patients examined Europe-wide, the contrast agent Levovist increased the diagnostic confidence from 27.4 +/- 22.5 to 77.2 +/- 22.5%. Such data encourage further trials to validate current preliminary results.

The latest in ultrasound: three-dimensional imaging. Part II

INTRODUCTION

The three-dimensional (3D) reconstruction of ultrasound images has become a widespread option in ultrasound equipment. Specific softwares have become available and 3D reconstruction feasible since the early 1990s, particularly since 1994.

POSSIBLE CLINICAL APPLICATIONS

Several clinical applications are feasible in all parenchymatous organs (mainly the liver and prostate), hollow viscera (e.g. the bladder and gallbladder), peripheral vessels (supra-aortic trunks and limb vessels) and central (the aorta and iliac arteries) or cerebral vessels. Moreover, tumoral vessels in parenchymatous organs can be reconstructed, and even the fetus in the uterine cavity, with excellent detailing. The recent introduction of echocontrast agents and second harmonic imaging has permitted to study normal and abnormal peripheral, central and parenchymatous vessels, with similar patterns to those obtained with digital angiography. The spatial relationships between the vascular structures of the liver, kidney and placenta were studied with 3D ultrasound angiograms. The applications of this new technique include the analysis of vascular anatomy and the potential assessment of organ perfusion. THE LATEST APPLICATIONS--INTRAVASCULAR STUDIES: Some catheters with an ultrasound transducer in the tip have been tested for intravascular studies. Just like conventional transducers, they provide two-dimensional (2D) images which are then postprocessed into longitudinal 3D or volume reconstructions. The former resemble angiographic images and can be viewed 3D rotating the image along its longitudinal axis. Volume images, which are more complex and slower to obtain, can be rotated on any spatial plane and provide rich detailing of the internal vascular lumen. The clinical importance of intravascular ultrasound with 3D volume reconstructions lies in the diagnosis of vascular conditions and the assessment and monitoring of intravascular interventional procedures--e.g. to detect inaccurate deployment of intravascular stents and endoluminal grafts during the maneuver. Three-dimensional reconstructions involve geometric data assembly and volumetric interpolation of a spatially related sequence of tomographic cross sections generated by an ultrasound catheter withdrawn at a constant rate through a vascular segment of interest, resulting in the display of a straight segment. Therefore particular care is needed and there are some useful hints to avoid mistakes.

CONCLUSIONS

Three dimensional reconstructions of B-mode and color Doppler images are no longer a work in progress and their clinical importance and possible applications are both established and ever-increasing. On the other hand, independent of the different types of energy used, also computed tomography and magnetic resonance 3D reconstructions are very useful from a clinical viewpoint and they have become an established routine technique for both these methods. It is very likely that 3D volume reconstructions in ultrasound will find numerous applications in the near future. They may help to increase the diagnostic confidence and to facilitate diagnosis, intraprocedure monitoring in interventional radiology and follow-up and also to reduce the number of invasive examinations with iodinated contrast agents. This could result in cutting the cost and duration of the most expensive examinations. New, although invasive, applications can be hypothesized for intravascular or intraluminal catheters with an ultrasound transducer inside.

New prospects for ultrasound contrast agents

Considering the several suggestions regarding the future developments of echocontrast agents, there is a striking difference between the few compounds actually available on the market and used in clinical practice and those undergoing experimental clinical trials. It is therefore difficult to predict what will be the actual impact of these agents in the next future. Future developments will probably go beyond color enhancement which was the end-point till a very short time ago. They can be schematically summarized as follows: (1) development of new substances which enhance both color and gray scales; (2) use of new-generation substances, such as BR1 (Bracco, Milan, Italy) and EchoGen (Sonus, Bothell, WA), which use a gas other than air, such as perfluorate compounds which are more stable and guarantee longer and stronger effects; (3) use of more complex compounds acting at different levels. For example, SHU 536A (Sonovist) produces resonance phenomena with the second and third harmonics, and also stimulated acoustic emission which permits the morphological study of liver parenchyma. Other promising compounds are liposomes and aerosomes. Among the new possibilities in recording and observing phenomena, we can distinguish two main application fields: one is based on the physics of ultrasound and related to the presence of microbubbles in an acoustic field. These phenomena are generally obtained increasing the emission acoustic pressure, which eventually results in microbubble destruction and they are called nonlinear because there is no direct relationship between emission and return frequencies. These phenomena, which are detectable only with dedicated equipment, include: the resonance phenomenon with harmonic emission; intermittent harmonic emission and stimulated acoustic emission. The other application field is not strictly related to ultrasound physics and includes all the systems which can detect the presence of microbubles qualitatively or quantitatively. Other possible applications are related to the possibility of acquiring not only morphological but also functional data, especially in cardiology and neurology. Finally, targeted agents are potentially capable of demonstrating receptor sites or specific molecules, which may open very interesting therapeutic routes.

[Assessment of varicocele recurrence with ultrasonography, color and power Doppler]

To study the postoperative recurrences of varicocele and the relationship between recurrences and sperm variables, we reexamined postoperatively 48 patients aged 14-56 years (mean: 25 years); the patients returned within a time range of 4 to 36 months. All the patients underwent physical examination, B-mode, color and power Doppler sonography (US); the images were acquired with the patient both supine and upright, both at rest and during Valsalva maneuver. We studied the incidence of recurrences and their bilaterality, the presence of reflux with or without functional maneuvers, associated conditions, surgical complications and the improvement of sperm variables; color and power Doppler findings were compared. The incidence of recurrences (28) and that of major complications (2) were related to the type of surgery: thus, no complications but 26 recurrences were found in the patients with spermatic vein ligation, versus only 2 recurrences but also 2 major complications (1 testicular ischemia and 1 hydrocele) in the patients with ligation of the spermatic cord venous channels. A right varicocele was found in 12 patients, which confirmed the frequent bilaterality of this condition; 8 patients with recurrences had improved sperm variables and 6 presented associated conditions. Our trial confirms that B-mode US, combined with color and power Doppler, can show recurrences, bilaterality, surgical complications and associated conditions and emphasize the role of these exams in the postoperative follow-up of varicocele. However, no method alone, without the evaluation of sperm variables, permits to select the patients to be reoperated on.

Long-term effects of intravenous calcitriol therapy on the control of secondary hyperparathyroidism

Although high-dose intravenous calcitriol has been shown to be effective in suppressing parathyroid hormone (PTH) secretion in dialysis patients with secondary hyperparathyroidism, an increasing number of patients is refractory to treatment. Only a few studies have evaluated the factors that can predict a favorable response to calcitriol, but contrasting results have been reported. This study was performed to evaluate the effect of high-dose intravenous calcitriol on parathyroid function and to investigate the factors that can predict a favorable response to treatment. Thirty-five dialysis patients were selected for intravenous calcitriol treatment (2 microg after dialysis for 12 months) because of increased PTH levels (>325 pg/mL). Before starting the treatment, the set point of calcium and the PTH-ionized calcium (ICa) curve was evaluated in each patient by inducing hypocalcemia and, 1 week later, hypercalcemia to maximally stimulate or inhibit PTH secretion. Parathyroid glands were assessed by high-resolution color Doppler ultrasonography. Throughout the study, calcium carbonate or acetate dosage was modified to maintain serum phosphate less than 5.5 mg/dL. Hypercalcemia was managed by reducing dialysate calcium to 5 mg/dL and, if necessary, calcitriol dose. The therapeutic goal was to reduce PTH levels below 260 pg/mL while maintaining normocalcemia. The patients who achieved the therapeutic goal were considered responders. Taking the data from the 35 patients together, we observed a significant decrease (P < 0.01) in alkaline phosphatase (from 252 +/- 106 IU/L to 194 +/- 81 IU/L) and PTH (from 578 +/- 231 pg/mL to 408 +/- 291 pg/mL), and a significant increase in serum ICa (from 5.1 +/- 0.2 mg/dL to 5.3 +/- 0.2 mg/dL; P < 0.001) after calcitriol therapy. PTH changes after therapy were not correlated to serum ICa changes, serum phosphate levels during treatment, and calcitriol dose. The response to therapy was heterogeneous because PTH levels markedly decreased over the treatment period in 18 responsive patients, whereas they increased or remained unchanged in 14 of 17 nonresponders. In three additional refractory patients, there was a decline in PTH of 20% to 35%, but this decline was associated with hypercalcemia. Pretreatment parathyroid gland size, serum ICa, PTH, maximal PTH induced by hypocalcemia, minimal PTH induced by hypercalcemia, the set point of ICa, and the ICa levels at which maximal PTH secretion and inhibition occurred were higher in the 17 refractory patients than in the 18 responsive patients. However, logistic regression analysis showed that among these parathyroid function parameters, the only significant predictors of a favorable response to calcitriol therapy were the parathyroid gland size and the set point of ICa. Throughout the study, serum phosphate and calcitriol dose were comparable in the two groups. In conclusion, the response to intravenous calcitriol therapy in dialysis patients with secondary hyperparathyroidism is heterogeneous, consisting of patients who are either responsive or refractory to treatment; refractoriness can be predicted by parathyroid volume and calcium set point.

[Bone callus: possible assessment with color Doppler ultrasonography. Normal bone healing process]

Conventional US demonstrates bone callus dimensions and structure, which permits to monitor the bone healing process. January, 1993, through May, 1995, we examined 108 patients with simple fractures of humerus, femur and tibia; all the fractures had been treated with an external or intramedullary metallic fixator. All the patients were submitted to conventional and color-Doppler US of the fracture focus on all possible scanning planes. We considered morphological parameters (the presence/absence of vessels, their number and shape) and functional parameters (the resistive index and the presence of a telesystolic notch). Color-Doppler US and the spectral analysis allowed us to add functional data, on bone callus and newly formed bone vascularization, to morphological studies. In the patients with positive fracture evolution, the caliber of afferent vessels progressively increased, their number decreased and branches appeared. The RI progressively increased, up to similar values to those of nutrient vessels (.36 to .90). Within the second month of fracture, a telesystolic notch appears: this indicates a muscular tunic in the vessel wall, meaning a mature, and no longer a newly formed, vessel. The normal evolution of bone healing may be interrupted by several mechanical and biohumoral factors which reportedly act in a similar way by reducing the number of vessels and increasing peripheral resistance in residual vessels because of fibrosclerotic involution of bone healing. Color-Doppler US permits noninvasive, repeatable and nearly real-time monitoring of bone fracture healing, which suggests this technique could be used: -to assess the results of treatment changes (e.g., loading, external fixator adjustments); -to study the definitive callus; -for the medicolegal assessment of delayed bone healing and of pseudoarthrosis; -for real-time treatment planning, according to color-Doppler findings, and to monitor treatment results.

Color Doppler imaging of liver metastases. The value phase-III of a US contrast agent: SH U 508 A (Levovist) Schering

In a phase-III multicenter clinical trial, the color Doppler vascular patterns were studied of 34 liver metastases in 18 patients before and after the i.v. injection of SH U 508 A (Levovist), with different US units and probes. The patients were selected as having poor color Doppler signals at unenhanced examinations. Lesion size ranged .8 to 9 cm (mean: 3.5 cm). The primary lesion site was the colon in 14 cases, the breast in 8 cases, the lung in 4, the stomach in 4 cases, the ovary in 3 and finally unknown in 4 cases. Each patient received two to four contrast agent injections, with suggested doses and concentrations (10 ml x 300 mg/ml, 8 ml x 400 mgr/ml). No adverse reactions were observed. Thirteen of 34 lesions exhibited no vascular signals at baseline examinations, 10 exhibited some perilesional color spots or small vessel branches, 5 some internal color spots or vessels and 4 small internal and peripheral vessels. After contrast agent infusion, the vascular patterns were better demonstrated in 28/34 lesions and the signal-to-noise ratio was markedly improved, in a concentration-dependent manner, from 40 to 240s. Five lesions remained avascular, 11 exhibited "basket"-like vascular patterns, 10 "internal flow" patterns and finally 10 lesions exhibited both. No major correlation was observed between vascular pattern and lesion size. To conclude, the use of the intravenous contrast agent SH U 508 A (Levovist) appears to be a promising technique to improve the color Doppler demonstration of focal metastatic liver lesions. Nonetheless, further studies on larger series of cases are needed to differentiate the different primary sites of the metastases.

[Doppler color-echo in the echographic evaluation of solid neoplasms of the breast: 5 years of experience]

In the last 5 years, 1,245 breasts have been examined with conventional and color-Doppler US. To assess color-Doppler capabilities and limitations, the results were critically reviewed only of the 311 patients who were operated and had unquestionable histologic findings. We investigated: 1) the number of "vascular poles", that is the vessels entering the examined mass from the periphery; 2) the presence of vessels with "abnormal" features, that is the vessels with varying diameters and/or with tortuous and erratic course; 3) the presence of vessels even on the mass interface only. The criterion indicated as no. 1, that is the presence of more than a vascular pole, exhibited 90.4% sensitivity and 70.7% prospective and 90.7% retrospective specificity. The criterion indicated as no. 2, that is the presence of vessels with anomalous features exhibited 75.1% sensitivity and 96.9% specificity. Using criterion no. 3 instead of no. 1, sensitivity would be increased from 90.4% to 96.5% but specificity would be decreased from 70.7% (and 90.7% retrospective specificity) to 46.9%, which was considered to be too low relative to the moderate increase in sensitivity. The positive predictive value of the presence of two vascular poles was 85% and that of the presence of vessels with anomalous course was 97.7%. Criteria no. 1 and 2 had 70.7% and 68.8% negative predictive value, respectively. In conclusion, the authors suggest the use of color-Doppler US to add further pieces of information to those obtained with conventional US.

[Echo-color Doppler in the study of hypothyroidism in the adult]

Color-Doppler US was performed on 20 patients with sub-clinic hypothyroidism which had been confirmed by laboratory tests. In all cases, color-Doppler US showed increased parenchymal flow, whose semiology was similar to the one known as "thyroid inferno" and currently associated, in the literature, with diffuse hyperfunction conditions. Quantitative measurements yielded no further element for differential diagnosis, while showing high flow speeds which were similar to those in hyperfunction. On the basis of consequent physiopathologic considerations, hypervascularization, as observed in hypothyroidism, is likely to be referred to the hypertrophic action of TSH, which was reported as high in all patients. In conclusion, the color-Doppler "thyroid inferno" pattern, which has been to date considered as specific of thyroid hyperfunction, has lost part of its diagnostic specificity, and further investigation--e.g. hormonal titers, scintigraphy--is needed for an unquestionable diagnosis to be made.

[CT in the diagnosis and treatment of lymphoceles following gynecologic cancer surgery]

The staging of gynecologic cancers requires the knowledge of lymph node status and thus pelvic and/or lumbo-aortic lymphadenectomy remains, to date, a widely used procedure. Lymphoceles are a frequent complication of surgical lymph node dissection. They are lymph collections in the retroperitoneum following the continuous drainage of afferent lymph vessels. To assess the incidence of this complication, its CT features and the role of diagnostic imaging to treat lymphoceles, 140 patients were retrospectively evaluated. Forty of them had undergone pelvic and/or lumbo-aortic lymphadenectomy for proved endometrial carcinoma, 51/140 for proved carcinoma of the cervix uteri, and 49/140 for proved malignant epithelial cancer in the ovary. CT exams were performed during the follow-up, not on a systematic basis but only when a recurrence was clinically suspected (117 cases), or in the presence of surgery and/or irradiation complications (11 cases), or to assess the extent of residual lesion during chemo/radiotherapy (12 cases). Fifty-three lymphoceles were observed in 36 patients: they were monolateral in 18 cases and bilateral in 16; in 34 cases the lymphoceles were found in the iliac space and in 3 cases only in the median perivascular lumbo-aortic space. In the patients with clinically suspected recurrence (117 patients, 27 lymphoceles), lymphoceles were associated with the recurrence in 25 cases, while they were the only CT evidence of a mass in 2 patients. In the cases with clinically suspected complications of former irradiation and surgery (11 patients, 3 lymphoceles), lymphoceles were correctly differentiated from abscesses (2 cases), seroceles (1 case), and hematomas (2 cases). In the group of asymptomatic patients monitored for residual disease (12 patients, 5 lymphoceles), lymphoceles were an occasional finding and, since they caused no complications to the urinary and GI tracts, they were never treated. Four asymptomatic patients only, with no evidence of disease, were submitted to transcutaneous aspiration and drainage under CT-US guidance (1.7 procedures per patient), and lymphoceles resolved in 3/4 cases. The only lymphocele recurring more than once required another laparotomy. In our experience, lymphoceles appear as a common sequela of pelvic lymphadenectomy for gynecologic cancer. CT has proved to be a useful diagnostic tool to assess and characterize the lesions, which must be differentiated from other postoperative complications and from recurring tumors. Lymphoceles needed to treatment in most cases and thus only symptomatic patients, with no cancer, were submitted to aspiration and drainage under CT-US guidance; the maneuver was successful on 75% of cases.

[Echographic assessment of the hand: normal anatomy and pathologic patterns]

Ultrasonography (US) can ben used to study the hand thanks to small-parts probes whose frequency ranges 7.5 MHz to 20 MHz. Due to the complex hand anatomy, the clinician often needs further data relative to periskeletal soft tissues and vessels, which are provided by color Doppler US. Our personal series included 465 patients and a group of 20 healthy volunteers. A silicon pad was used to ensure max. adhesion to probe surface, given the uneven surface of the examined structures. Besides normal anatomic patterns, US demonstrated pathologic features in tendons, sheaths and muscles. As for tendons, stenosing and hypertrophic-exudative tenosynovites were depicted, as well as cysts and ruptures. As for muscles, the main findings were ruptures and, rarely, tumors. Relative to joints, arthrogenous ganglia and rheumatism were observed. Finally, the carpal tunnel syndrome was accurately investigated, where US revealed tenovaginalitis with sheath thickening and deformed and compressed median nerve in the carpal tunnel. Also the benign and malignant masses whose primary location is the nervous tissue are easily demonstrated on US, their typical shape being ovalar. To conclude, US proved extremely accurate in all the surgical patients, exhibiting 100% sensitivity in all of them; its specificity ranged from 84% for tendons, to 81% for muscles, 79% for nervous tissues and finally 82% for joint disorders.

[Color-Doppler in the study of male sexual impotence]

The authors report their experience with color-Doppler US in the study of 54 male patients with sexual impotence. The examination includes two distinct phases; in between, the erection-inducing drugs is injected directly in the cavernous bodies. During the basal phase, B-mode information relative to both morphology and structure of cavernous bodies is collected. After injecting the drug, systolic and end-diastolic velocities are evaluated as flowmetric indices, together with the resistive index; these variables are derived from cavernous arteries, at scheduled time--i.e., 5, 10 and 20 minutes after the injection. Moreover, the examined patients were divided into 4 groups according to their clinical response to the pharmacologic test. Color-Doppler US proved to be quite sensitive in the identification of the patients with a vascular alteration, both venous and arterial, underlying their erectile dysfunction; as a matter of fact, venous flights are easily depicted with the use of colors. The authors believe that color-Doppler could eventually become a major exam in the diagnosis of sexually impotent patients, thus allowing the marked reduction of such invasive diagnostic techniques as selective angiography of internal pudendum arteries and dynamic cavernosography, which are poorly tolerated by the patients.

[Role of echo-color Doppler in the diagnosis of breast diseases. Personal experience]

The role of color-Doppler US was investigated in the diagnosis of solid focal breast lesions. The results obtained with this method over the last two years were reviewed. Seventy-two patients with solid breast lesions were considered: conventional US scans of the nodules were performed first and color-Doppler scans followed, to depict vascularization. In benign focal lesions color-Doppler US never demonstrated more than a single vascular pole afferent to the lesion. In 92.5% of histologically malignant lesions, color-Doppler US easily demonstrated two or more feeding vessels. The analysis of our series confirmed the presence of a typical vascular pattern related to breast carcinoma which is easy to depict by means of color-Doppler US: this new technique is therefore of great value in the differentiation of benign from malignant breast masses, especially in the cases where conventional US and mammography alone failed to yield unquestionable and final results.

[Clinical applications of color-Doppler: the parathyroid glands]

The high-resolution appearance of enlarged parathyroid glands is well known. Thus, real-time gray-scale US alone fails to provide, in ENT surgery, adequate sensitivity and specificity rates to differentiate between parathyroid glands, hypoechoic thyroid adenomas and other hypoechoic neck masses. Since parathyroid tissue, in both normal and enlarged glands, is hypervascular, color-Doppler US is used as a sort of non-invasive angiography to identify parathyroid glands. The combined use of B-mode and color-Doppler US allows the vascular features of thyroid masses to be satisfactorily demonstrated, with easy differentiation between enlarged parathyroid glands, featuring diffuse internal vascularization, and thyroid adenomas characterized by rounded peripheral vessels and also lymph nodes and cysts exhibiting different vascular patterns. We studied 25 patients with clinical and biochemical signs of hyperparathyroidism (19 primary and 6 secondary) submitted to surgery in the last 20 months. Every patient was scanned with both B-mode and color-Doppler US. At surgery, 19 parathyroid adenomas were found--16 of them correctly identified preoperatively with color-Doppler US and 3 false negatives (retrotracheal glands). Moreover, 1 false positive was observed due to a small Plummer's adenoma misdiagnosed as an intrathyroid parathyroid adenoma: both lesions had the same vascular pattern on US images. Sensitivity was 84.5% and specificity 93.7%. In secondary HPT patients, 23 hyperplastic glands were found at surgery--21 of them correctly identified preoperatively by color-Doppler US, with 2 false negatives. No false positive was found. Sensitivity was 87.5% and specificity 100%. Sensitivity does not differ very much from what reported in literature. Specificity is clearly increased by the use of color-Doppler US. The possible source of error represented by Plummer's adenomas lead us to investigate pulsed Doppler capabilities in differentiating Plummer's adenomas from PT glands, since color-Doppler findings were similar in the two conditions. Peak velocities recorded with both color and pulsed Doppler showed velocity to range 6 to 40 cm/s in parathyroid glands (mean +/- SD: 14.6 +/- 11.7) and 38 to 120 cm/s in thyrotoxic nodules (mean +/- SD: 78.4 +/- 23). The statistical analysis of the results showed a highly significant difference between the two groups of velocities. Peak velocities as recorded in the main, vessels of the parathyroid glands with color and pulsed Doppler were correlated with the activity of the parathyroid glands.(ABSTRACT TRUNCATED AT 400 WORDS)

[Echography in the study of periskeletal soft tissues: technique, normal and pathologic pictures]

Ultrasonography (US) is the method of choice in the study of normal soft tissue patterns thanks to its intrinsic features. The exam must be performed following strict directions relative to US units (last-generation), to probes (high-frequency, high axial and lateral resolution, focusing), the type of scan (orthogonal and oblique scans), the use of silicon pads. Exam reporting and the exact knowledge of possible image artifacts are of the utmost importance. Normal patterns in the skin, subcutaneous tissue, striate muscles, tendons and bursae, nerves, vessels and bone are reported and correlated with the corresponding US patterns in pathologic conditions. In inflammatory processes, muscles and tendons exhibit blurred, irregular and poorly-defined outlines; neither the anatomical structures nor the tissues nearby are infiltrated. Similar patterns are observed in some benign tumors, while in malignant lesions soft tissue echostructure is more or less alterated and the adjacent tissues are infiltrated. Color-Doppler US yields morphologic and functional information as to pathologic vascularization; typical findings, similar to those obtained by means of angiography, are seen in malignant lesions.

[Portal hypertension of hepatic origin. A qualitative assessment by color and echo Doppler US]

One hundred and twenty-eight subjects were studied: 103 of them were affected with portal hypertension diagnosed both radiologically and clinically. Twenty-five healthy subjects were studied, as a control group, by means of combined real-time US and color Doppler. US parameters were evaluated, specific to chronic hepatopathy, together with the Doppler qualitative parameters relative to splanchnic vessels hemodynamics. Our results allowed a sort of noninvasive angiogram of the portal system to be obtained, which is to be of use for diagnosing portal hypertension, and for assessing its causes, risks, and consequences. This study was also aimed at suggesting an examination protocol for portal hypertension, employing real-time and color Doppler US, which any radiologist with enough experience in abdominal US could use. Color Doppler, although not strictly necessary to obtain good results, dramatically shortens execution times. Moreover, color Doppler allows the method to be more quickly learned.

[Color Doppler in the echographic evaluation of breast nodules]

The authors report on their experience with color Doppler sonography in the diagnosis of solid breast masses. Twenty-two patients were examined; breast masses were studied with B-mode US first, and then with color Doppler US to evaluate eventual tumor vascularization. Color Doppler US demonstrated only one vascular pole in histologically confirmed benign masses. On the contrary, in 92.8% of histologically confirmed malignant masses, color Doppler easily depicted 2 or more groups of nutritional arteries. Color Doppler makes the diagnosis of malignant masses easier, thus allowing, in the author's opinion, a reduction in the number of biopsies of solid breast masses clinically/mammographically detected. The use of color Doppler US is therefore suggested: the technique is noninvasive, fast, and easy and its widespread use would translate into advantages for both the patient and the clinician.

[Doppler color in the echographic study of hyperplastic parathyroid glands]

The sonographic examination of hyperplastic parathyroid glands is a well-known and appreciated technique. However, its diagnostic contribution is still somehow inadequate, due to the difficult differential diagnosis of the various solid hyperechoic nodular structures in the neck and to the presence of frequently ectopic glands. The combined use of B-mode and color-Doppler US allows the vascular features of suspicious parathyroid nodules to be satisfactorily demonstrated. Higher sensitivity and specificity than conventional US are the main advantages of this technique. Still, further research is needed for B-mode color-Doppler US to actually replace fine needle biopsy in confirming the diagnosis.

[Clinico-statistical review of 74 cases of subcutaneous rupture of the Achilles tendon]

The Authors report 74 cases of subcutaneous hole of Achille's tendon that were treated surgically. 52 patients were clinically controlled at a distance from 1 to 5 years. The functional result at a distance is good in 67,3% of cases, satisfactory in 25%, insufficient in 4%. They point out an hig incidence of local post-operating complications (29,8%), especially when the paratendinea medial incision has been made. The authors suggest to opt for a paratendinea lateral incision and, experimentally, to drop the use of hemostatic string.