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American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 20131536801 Cloacal Exstrophy: When an Omphalocele Is Not Just anOmphaloceleReza Pakdaman, 1 * Anne Kennedy, 1,2 Mark Molitor, 3 JaniceByrne, 2 Paula Woodward 1,2 1 Radiology, 2 Obstetrics and Gynecology,3 Surgery, University of Utah, Salt Lake City, Utah USAObjectives—(1) Illustrate additional congenital abnormalitiesthat, when seen in a fetus with an omphalocele, should lead to the diagnosisof cloacal exstrophy. (2) Illustrate the role of fetal magnetic resonanceimaging (MRI) in making the diagnosis. (3) Correlate prenatalfindings with postnatal imaging and surgical findings in survivors. (4) Illustrateautopsy findings.Methods—Retrospective review of 7 cases seen at 1 institution.Prenatal findings were correlated with postnatal multimodality imaging,surgical, or autopsy results.Results—7 cases were seen for prenatal ultrasound (US). FetalMRI was performed in 4. See Table 1 for US findings. Pregnancy outcomeswere live birth in 4, perinatal death in 1, intrauterine demise in 1,and termination of pregnancy in 1.Conclusions—The presence of an omphalocele should alert thesonologist to perform additional views and seek other anomalies in an effortto refine the diagnosis. In particular, inability to demonstrate a normalbladder and rectum and the presence of spine abnormalities shouldheighten suspicion for cloacal exstrophy. Cloacal exstrophy is a rare anomalynot associated with aneuploidy; however, the condition requires multiplesurgeries, and survivors require lifelong specialist care. Faced with thelong-term consequences of this condition, families may choose terminationof pregnancy. Therefore, correct prenatal diagnosis is of paramountimportance. In ongoing pregnancies, delivery should be planned at an appropriatefacility with the resources to manage children with complexmetabolic, surgical, and psychosocial needs.Table 1. US FindingsCase AWD Bladder Anus Spine Genitalia1 Y N NA Ab NA2 Y N N Ab Amb3 Y N N Ab Amb4 Y N NA NA Bifid5 Y N NA Ab Amb6 Y N NA Ab NA7 Y N NA Ab NAAb indicates abnormal; Amb, ambiguous; and AWD, abdominal wall defect.1536808 Imaging Spectrum of Fetal Autosomal Recessive PolycysticKidney DiseaseTony Trinh, 1 * Anne Kennedy, 2,3 Joe Sherbotie, 4 Janice Byrne 31School of Medicine, 2 Radiology, 3 Obstetrics and Gynecology,4Nephrology, University of Utah, Salt Lake City, Utah USAObjectives—(1) Illustrate the spectrum of findings of fetal autosomalrecessive polycystic kidney disease (ARPKD). (2) Correlate fetalstudies with postnatal imaging or autopsy results.Methods—Retrospective review of cases seen at a single referralcenter.Results—Renal enlargement was our most consistent finding.Most kidneys looked normal up to 20 weeks but abnormally echogenickidneys were seen as early as 16 weeks. Echogenicity varied from theclassic highly echogenic pattern with loss of normal architecture to increasedechogenicity with identifiable medullary pyramids to a pattern ofvery echogenic pyramids similar to that seen in medullary sponge kidneyin adults. Amniotic fluid volume was variable from severe oligohydramniosto normal. Not all cases had evidence of pulmonary hypoplasia.Conclusions—Not all cases of ARPKD present with the classicfindings of large, brightly echogenic kidneys and severe oligohydramnios.This reflects the variable phenotype with perinatal, neonatal,and infantile types described. It is very important that sonologists recognizethe full spectrum of findings to suggest ARPKD and differentiate itfrom other causes of renal enlargement or abnormal renal echogenicity.Fetuses with echogenic kidneys require postnatal follow-up. The prognosisis variable. Awareness of the possibility of ARPKD will result in appropriatetesting of the parents for recessive gene carrier status. Affectedcouples will have a 1:4 recurrence risk for future pregnancies.1536912 Abnormal Ultrasound Findings in Patients With ClinicalSuspicion of Chronic Liver Disease in Sokoto and ItsEnvironsSadisu Maaji,* Abdulmuminu Yakubu, Danielle OdunkoRadiology, Usmanu Danfodiyo University Teaching Hospital,Sokoto, Nigeria; Radiology, Federal Medical Center BirninKebbi, Birnin Kebbi, NigeriaObjectives—To describe the pattern of abnormal ultrasonographicfindings in patients with clinical suspicion of chronic liver diseasein Nigeria, especially from the northwestern region.Methods—A total of 61 consecutive patients with clinical signsand symptoms of chronic liver disease attending medical outpatient clinicsat the Department of Medicine, Usmanu Danfodiyo University TeachingHospital, and Federal Medical Center Birnin Kebbi were scanned atradiology departments for any abnormal intra- abdominal findings fromMay 2011 to April 2012. The exclusion criteria were patients with confirmedliver biopsy or diagnosis of chronic liver disease. Patients with cardiaccirrhosis and tropical splenomegaly syndrome were also excluded inthis study.Results—A total of 61 abdominal ultrasound examinationswere performed during this study period. All the cases met the inclusioncriteria. The mean age was 46 ± 12.6 years (range, 50 years). The meanliver sizes were 13.25 ± 1.48 cm (range, 11 cm) and 14.00 ± 0.77 cm(range, 0.77 cm) for right and left lobes, respectively. The mean spleensize was 15.9 ± 1.22 cm (range, 6 cm). The sex distribution was 43 males(70.49%) and 18 females (29.5%). Of the 61 cases included, the indicationsfor abdominal ultrasound were hepatitis in 1 (1.61%), liver cirrhosisin 20 (50.82%), obstructive jaundice in 2 (3.28%), chronic liver disease in25 (40.98%), and chronic abdominal swelling in 2 (3.2%). Gallbladderwall thickening was demonstrated in 49 (80.33%) of the patients, while 12(19.67) showed a normal gallbladder wall. Ascites was demonstrated in 45(73.77%) of the patients, and the remaining 16 (26.23%) of the patientshad no ascites. Destroyed intrahepatic vascular architecture was demonstratedin 58 (95%), while 3 (4.9%) showed normal vascular architecture.Conclusions—Ultrasound is useful in the diagnosis of chronicliver disease in daily clinical practice. However, the sensitivity can be improvedif a high-frequency probe is used and done by experienced anddedicated operators. Liver biopsy remains the gold standard, especiallywhen patients are clinically asymptomatic.1536944 Carotid Ultrasound May Not Be Sufficient to PerformCarotid EndarterectomyRobert Colvin, 1 * Alvaro Magalhaes 2 1 Kansas City Universityof Medicine and Biosciences, Kansas City, Missouri USA;2Radiology, University of Missouri, Kansas City, Missouri USAObjectives—Evaluate the accuracy of ultrasound to determinetreatment of carotid artery stenosis when compared to advanced imagingmodalities.Methods—This study consisted of 47 patients who underwentimaging for carotid artery stenosis by magnetic resonance imaging withangiography or computed tomography with angiography at a Midwest regionalmedical center over a 27-month period. The results of the previouslyobtained duplex ultrasound studies were compared to results fromadvanced imaging studies.S93
American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 2013Results—Of the 47 patients, 12 (25.53%) had a carotid arterystenosis percentage diagnosed by ultrasound that agreed with the advancedimaging modality. Fifteen (31.91%) patients likely would have had alternatetreatment based on their advanced imaging studies. Based on the acceptedcurrent treatment, carotid endarterectomy for a symptomatic patientwith >70% stenosis by ultrasound, 3 patients would have undergone an unnecessarycarotid endarterectomy. Additionally, 12 patients would havemet criteria for carotid endarterectomy and not received one.Conclusions—Clinicians must consider that many patients mayreceive inappropriate treatment of carotid artery stenosis if ultrasound isthe sole modality used for diagnosis. Eighty percent of endarterectomiesare performed based on ultrasound alone in the United States, meaning alarge impact on American health care overall. While more research isneeded, alternate imaging and close monitoring may be required with atypicalor symptomatic patients before medical management or carotid endarterectomyis chosen as treatment.1536948 Efficacy of Ultrasound-Guided Injection of the SternoclavicularJoint SpaceYisrael Katz,* Oliver Joseph, Oleg Uryasev, John McNamara,Apostolos Dallas Virginia Tech Carilion School of Medicine,Roanoke, Virginia USAObjectives—The sternoclavicular joint (SCJ) space can be affectedby various osteoarthropathies, including degenerative, crystal deposition,and inflammatory. Like other osteoarthropathies, corticosteroidinjections could likely provide therapeutic relief to individuals with SCJosteoarthropathy. While the literature discusses the success of computedtomography (CT)-guided injection, we hypothesize that ultrasound (US)can be used to guide SCJ intra-articular injection without exposing patientsto unnecessary radiation.Methods—This study serves as a pilot study. The SCJ was injectedbilaterally on 4 nonembalmed cadaveric models. The anatomy forall cadavers was within normal limits, with the exception of 1, which hadmarked musculoskeletal deformity of the lower limbs; an identical procedurewas followed, and pathologic anatomy did not affect data collection.A 10–5-MHz small linear array transducer (L38n) was used. The SCJwas palpated, and the transducer was aligned parallel to the angle of theSCJ. Using a short-axis approach, US-guided injection was performed. A1.5-in 22-gauge needle with 0.25 mL of 0.5% methylene blue was used.Incisions were made parallel and perpendicular to the SCJ. The joint capsulewas dissected to visualize the dye as confirmation. Attempts wereclassified according to accuracy and precision. Accuracy measured if thejoint space was stained with dye; precision measured if the injection waslocalized without damage to adjacent anatomy.Results—Bilateral injections on all 4 cadavers were accurateand precise.Conclusions—US is inexpensive, quick, and minimally invasivecompared to CT. Given that CT-guided intra-articular SCJ injection with acorticosteroid and anesthetic has provided symptomatic relief to patientswith SCJ pain, the analogous procedure can be performed under US guidance.Future phases of this study will expand the current data set and investigatethe efficacy of US-guided SCJ injection in patients with SCJ arthralgia.1536971 Efficacy of Ultrasonographically Guided AnteriorInterosseus Nerve Perineural Injection at Its BifurcationFrom the Median NerveElizabeth Glazier,* Oleg Uryasev, Oliver Joseph, JohnMcNamara, Apostolos Dallas Virginia Tech Carilion Schoolof Medicine, Roanoke, Virginia USAObjectives—Compression of the anterior interosseus nerve(AIN) immediately distal to its bifurcation from the median nerve (MN)results in Kiloh-Nevin syndrome. Like other nerve compression syndromes,corticosteroid injections are a potential therapeutic modality. Wehypothesize that one can effectively inject the AIN perineural space at itsbifurcation from the MN.Methods—This study serves as a pilot study. The AIN perineuralspace was injected bilaterally on 4 cadaveric models. Cadavericanatomy was unremarkable with the exception of 1, which had markedmusculoskeletal deformity that did not affect the upper extremities. Anidentical procedure was followed, and pathologic anatomy did not affectdata collection. A 10–5-MHz linear array transducer was used. The transducerwas placed transversely through the antecubital fossa. The MN wasidentified proximally as it coursed over the supracondylar eminence. Itappeared spindle shaped with alternating hyperechoic and hypoechoicbands. The MN was traced inferolateral to the origin of the pronator teresmuscle, where the AIN bifurcation was visualized. Ultrasonographically(US) guided injections were achieved with a long-axis, medial-to-lateralapproach with a 22-gauge syringe and 0.35 mL of 0.5% methylene blue.Anatomic dissection and dye visualization allowed for confirmation.Attempts were classified according to accuracy and precision. Accuracymeasured nerve staining; precision measured localized injection withoutdamage to adjacent structures.Results—Six of 8 (75%) injections were accurate, while 4 of 8(50%) were precise.Conclusions—AIN perineural injection at its bifurcation fromthe MN is significant. Such ability can likely provide symptomatic reliefwith corticosteroid administration to patients with Kiloh-Nevin syndrome.US is inexpensive, quick, and minimally invasive. Future phases of thisstudy will expand on our current data set and, pending such results, investigateefficacy of US-guided AIN perineural corticosteroid injectionsin patients with Kiloh-Nevin syndrome.1536975 Efficacy of Ultrasonographically Guided Injection of theUlnar Nerve Perineural Space at the Guyon CanalJeffrey Heimiller,* Oliver Joseph, Oleg Uryasev, JohnMcNamara, Apostolos Dallas Virginia Tech Carilion Schoolof Medicine, Roanoke, Virginia USAObjectives—The ulnar nerve (UN) can become compressed asit passes through the Guyon canal (GC). Like other nerve compressionsyndromes, corticosteroid injection is a therapeutic modality. We thereforehypothesize that ultrasonographic (US) guidance can aid in effectiveUN perineural injections in the GC at the level of the pisiform.Methods—This is a pilot study to explore the feasibility of USguidedinjections of the UN perineural space in the GC at the level of thepisiform. Injections were performed on 4 unembalmed cadavers, 1 ofwhich had marked musculoskeletal deformity that did not affect the upperextremities. The GC was imaged in the transverse plane at the level of thepisiform, and 0.25 mL of 0.5% methylene blue dye was injected into theUN perineural space using a long-axis approach from the medial end ofthe probe, just superficial to the pisiform. Anatomic dissection was performedsubsequently to evaluate injection accuracy and precision: accuracyrefers to nerve staining, while precision denotes that adjacentstructures were not damaged.Results—Six of 8 (75%) were accurate. All injections were precise.Conclusions—This study was able to demonstrate an effectivemeans of visualizing and injecting the UN perineural space at the GCunder US guidance. Inaccuracies were primarily operator dependent. Theoperator for most injections was a second-year medical student with noprior experience performing perineural injections. Initial attempts establishedan effective protocol. In the method described here, the operatordiscovered and consistently visualized a narrow window immediately superficialto the pisiform that allowed for repeatedly accurate and preciseinjections. Despite the initial learning curve, the operator was overall successfulwith accuracy of 75% and precision of 100%. US is a viable meansof increasing the accuracy and precision, and therefore effectiveness, ofUN perineural injections into the GC, but it must be combined with aworking knowledge of superficial landmarks and target anatomy.S94
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Small-Animal Preclinical High-Frequ
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2013 AIUM Award WinnersJoseph H. Ho
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2013 AIUM Award WinnersDistinguishe
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