Radiology Lectures | Radquarters Daniel J. Kowal, MD

In this radiology lecture, we review the ultrasound appearance of interstitial ectopic pregnancy!

Key teaching points include:



* Interstitial ectopic pregnancies are rare, occurring in proximal (interstitial) portion of fallopian tube within muscle wall of uterus

* Much less common than tubal ectopic pregnancy occurring in the more distal ampullary and isthmic portions of fallopian tube

* Interstitial ectopic pregnancies are important because higher morbidity and mortality due to later presentation and risk of life-threatening hemorrhage

* Abnormally eccentric gestational sac with thin surrounding myometrium: less than 5 mm myometrial thickness highly suspicious

* “Interstitial line” sign: Thin echogenic line extending from endometrial cavity to ectopic gestational sac. Thought to represent interstitial portion of tube separating the ectopic pregnancy from the endometrium

* Medical: Systemic MTX, may also be injected into gestational sac

* Surgery: Cornual wedge resection when ruptured versus hysterectomy

* Can be confused with angular pregnancy: Rare, intrauterine pregnancy with implantation eccentrically high at the lateral angle of uterine cavity. More medial than interstitial ectopic pregnancies. No interstitial line sign, and greater than 5 mm thickness of overlying myometrial mantle

* Angular pregnancy can result in normal pregnancy, but increased risk of miscarriage and uterine rupture. Should be followed closely to ensure growth towards endometrial cavity

* Angular pregnancy is sometimes referred to as a “cornual pregnancy,” but controversial as earliest use of term cornual pregnancy refers to intrauterine implantations in anomalous unicornuate, bicornuate or septate uteri. To avoid confusion, best to specifically describe whether the gestational sac is intrauterine or ectopic



To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

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In this radiology lecture, we review the ultrasound appearance of ovarian serous cystadenocarcinoma!

Key teaching points include:



* Serous cystadenocarcinoma is the common ovarian malignancy and most common ovarian epithelial tumor

* High-grade and low-grade types

Peak incidence 6th-7th decades

* Ultrasound appearance: Mixed cystic and solid mass with papillary projections and thick septations

* Elevated CA-125 in greater than 90%

* Serous tumors are more commonly bilateral than other tumors

* Four main categories of ovarian neoplasms: Epithelial (most common), germ cell (second most common), sex cord-stromal and metastases

* Epithelial ovarian tumors are thought to originate outside the ovary (within fallopian tube or endometrium) and involve ovary secondarily

* Epithelial ovarian tumor types: Serous, mucinous, endometrioid, clear cell and Brenner

* 60% of epithelial tumors are benign: Unilocular with thin wall or thin septations (less than 3 mm in thickness)

* 40% of epithelial tumors are malignant or borderline: Papillary projection (distinctive feature of epithelial tumors) with thick, irregular wall or septations (greater than 3 mm in thickness). Can also present as a large soft tissue mass with necrosis. Advanced findings include peritoneal implants, pelvic wall invasion, adenopathy and ascites



To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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In this radiology lecture, we review the ultrasound appearance of parathyroid adenoma!

Key teaching points include:



* Benign tumor of the parathyroid glands

* Most common cause of primary hyperparathyroidism: Elevated serum calcium and parathyroid hormone (PTH) levels

* Ultrasound: Solid, homogeneous and very hypoechoic. Oval or bean-shaped, long axis oriented craniocaudal. Hypervascular. Majority posterior and inferior to thyroid. Hyperechoic line often separates adenoma from adjacent thyroid. Atypical features: Cystic degeneration, calcification.

* Tc-99m sestamibi: Radiotracer uptake persisting on delayed 2-hour images. Taken up by both thyroid and parathyroid tissue, but washes out more rapidly from thyroid. Greater than 90% predictive value for preoperative localization of parathyroid adenoma. SPECT aids with anatomic localization

* Ectopic locations in up to 5%: Lower neck, mediastinum, retrotracheal/retroesophageal, carotid sheath and intrathyroidal (typically more homogeneous than thyroid nodules and have a linear interface with gland)

* Larger adenomas can be multilobulated

* “Polar vessel” sign: Enlarged feeding artery or draining vein terminating at parathyroid adenoma



To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

Spotify: https://spoti.fi/462r0F2

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In this radiology lecture, we review the ultrasound appearance of parotitis in the pediatric population!

Key teaching points include:



* Parotitis = Inflammation of the parotid glands

* Acute parotitis is usually infectious, most commonly viral

* Mumps is most common viral cause in children, often bilateral

* Bacterial parotitis can cause suppurative parotitis seen in premature infants and immunosuppressed children

* Acute parotitis on US: Enlarged, heterogeneous, hyperemic gland(s) +/- lymphadenopathy

* Since can be bilateral, comparison scanning essential

* Bacterial parotitis may be complicated by abscess

* “Pomegranate sign” may be seen in setting of acute parotitis: Uniform anechoic foci scattered throughout the gland

* Juvenile recurrent parotitis (JRP) = Recurrent inflammatory parotitis in children of unknown etiology

* JRP is rare, but second most common cause of parotitis in childhood after mumps

* JRP often begins between age 3-6, typically resolves spontaneously after puberty

* Usually idiopathic, JRP can be presenting symptom of Sjogren’s syndrome, lymphoma, and underlying immunodeficiency

* JRP on US: May be unilateral or bilateral, multiple hypoechoic foci of salivary secretions scattered throughout the gland +/- central calcifications, color Doppler can be normal

* Additional causes of parotitis: Sialolithiasis/obstruction, autoimmune (Sjogren syndrome, chronic sclerosing sialadenitis), infectious (HIV, TB), and sarcoidosis (rare in children).



To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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In this radiology lecture, we review the ultrasound appearance of sublingual dermoid cyst and explain floor of mouth anatomy!

Key teaching points include:



* The floor of the mouth is a horseshoe-shaped area beneath tongue and in between sides of mandible, inferiorly bounded by mylohyoid muscle, and containing sublingual space (SLS)

* SLS medial border: Midline genioglossus/geniohyoid muscle complex; SLS inferolateral border: Mylohyoid muscle

* Anterior margin of hyoglossus muscle projects into posterior SLS

* Sublingual dermoid cyst is a rare, benign cyst with squamous epithelial lining and contains skin appendages

* Dermoid and epidermoid cysts are in same family, terminology often used interchangeably, although epidermoid cysts less common and tend to contain fluid contents only

* Dermoid cyst mean age of presentation late teens to twenties, average age 30

* Presents as a slowly enlarging neck mass, may cause dysphagia

* Often round or oval in shape and homogeneously hypoechoic with punctate echogenic foci

* May have pathognomonic “sack of marbles” appearance

* Relationship to mylohyoid is key for surgical planning: Intraoral resection for sublingual (above mylohyoid) location, extraoral approach for submental/submandibular (below mylohyoid) location

* Most cysts are midline

* DDx: Suprahyoid thyroglossal duct cyst, ranula (simple and diving), abscess and lymphangioma



To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

Spotify: https://spoti.fi/462r0F2

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In this radiology lecture, we review the ultrasound appearance of carpal tunnel syndrome!

Key teaching points include:



* Most common upper extremity entrapment neuropathy. Results from median nerve compression

* With carpal tunnel syndrome, see hypoechoic enlargement of the median nerve as enters carpal tunnel with flattening of nerve = Notch sign, also volar bowing of flexor retinaculum

* Median nerve area: Less than 8 mm2 = Normal; 8-12 mm2 = Borderline; greater than 12 mm2 = Abnormal

* Most accurate to compare nerve area at proximal pronator quadratus muscle and carpal tunnel: Increase of 2 mm2 or more from proximal to distal = 99% sensitive and 100% specific for carpal tunnel syndrome. Measure inside the echogenic epineurium

* Bifid median nerve: Normal variant in 15% of population, one trunk may take aberrant course through flexor digitorum superficialis musculature, and often associated with persistent median artery between the two trunks

* Important to recognize persistent median artery pre-operatively because could be damaged during surgery

* For diagnosis of carpal tunnel syndrome with bifid median nerve: Combined increase of 4 mm2 or more

* After carpal tunnel release surgery, median nerve may return to normal diameter or remain enlarged regardless of clinical outcome. Retinaculum may appear thickened or disrupted

* Carpal tunnel syndrome can be caused by extrinsic compression by a mass, ganglion cyst, or tenosynovitis



Reference: Klauser AS, Halpern EJ, De Zordo T, et al. Carpal tunnel syndrome assessment with US: value of additional cross-sectional area measurements of the median nerve in patients versus healthy volunteers. Radiology. 2009;250(1):171-177.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

Spotify: https://spoti.fi/462r0F2

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Facebook: https://www.facebook.com/Radquarters/

Twitter: https://twitter.com/Radquarters

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