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1196 PART IV Obstetric and Fetal Sonography26 wFIG. 34.23 Type 1 Lissencephaly (Miller-Dieker Syndrome) in26-Week Fetus. Note the mild ventriculomegaly and lack of sulcal formation.The insula is very smooth and shallow (arrow) and lacks the angularplateau appearance expected at this age. Brain shows increasedechogenicity associated with migrational disturbance.Fetal MRI and gene mutation analysis can help conirm thediagnosis. Postnatal outcome is poor but varies with the speciiccondition. 192,208Focal Cortical ChangesPolymicrogyria (PMG) is probably the most common malformationof cortical development. It is a heterogeneous malformationcharacterized by excessive numbers of small shallow, abnormalgyri and irregularity of the cortex/white matter interface. hedistribution may be focal or global. PMG may be isolated orassociated with many genetic and acquired conditions; however,in most cases the cause cannot be found. Mutations have beenfound in over 30 genes including the tubulin family and includemetabolic conditions such as peroxisomal disorders andDiGeorge syndrome (22q11.2). Nongenetic conditions includeinfection with CMV and hypoxia and ischemia.Focal cortical changes typically manifest in mid to latepregnancy and are diicult to detect with ultrasound, where thecortical contour can have a sawtooth appearance. hey aretypically found at MRI in fetuses referred for evaluation of otherabnormalities initially detected by ultrasound. PMG is the mostcommon cortical malformation in children with epilepsy andcan manifest with developmental delay. he heterogeneity ofcauses and manifestations makes counseling diicult 192,195,205,210(Fig. 34.25).Heterotopia describes localized nodules of disorganizedneurons in abnormal locations anywhere in the brain. On MRIthree types are described: periventricular nodular heterotopia,focal subcortical heterotopia, and band heterotopia. Only theperiventricular nodules are readily detectable on prenatalultrasound and visible as irregular lining of the ventricular surface(Fig. 34.26). he nodules are more conspicuous on MRI, whichcan also depict the intraparenchymal and cortical nodules, whichare diicult to recognize by ultrasound. Etiology is heterogeneous.Cases can be isolated but other CNS and somatic abnormalitiesare common, especially involving the corpus callosum. hediferential diagnosis includes ventricular irregularity associatedwith CMV, hemorrhage, and tuberous sclerosis. Prognosis variesdepending on underlying syndromes and associated abnormalitiesand ranges from essentially normal to having variable deicitsand epilepsy, which are common; in some the disorder islethal. 192,195,205,211Schizencephaly (split brain) is a rare structural malformationof the cerebrum characterized by congenital clets or defects thatextend through the hemisphere from ventricle to outer cortex.he clets are usually symmetrical and involve the parietal ortemporal regions. hey are lined by cortical gray matter otenwith PMG, unlike clastic injury resulting in porencephaly inwhich white matter lines the clets. he tracts may be open (openlip), allowing CSF communication between the ventricle andsubarachnoid space, or solid (closed lip, consisting of an abnormal,solid gray matter tract between the ventricle and brainsurface). Etiology can be destructive (encephaloclastic) ordevelopmental. Destructive etiologies include vascular injury,ischemia, teratogen exposure (e.g., cocaine), infections (especiallyCMV), and trauma, and appearances can be similar to porencephalyor hydranencephaly. Developmental cases are consideredto be related to PMG arising from disordered neuronal migrationand organization. Most cases are found in late pregnancy duringinvestigation of VM, but they have been seen in the middletrimester. he diagnosis rests on detection of the cerebral cletsor abnormal gray matter traversing from ventricle to cortex (Fig.34.27). here may be associated midline defects including SOD,dysgenesis of the corpus callosum, absence of the septi pellucidi,other malformations of cortical development, and optic nerveabnormalities. Fetal MRI allows superior characterization ofcortical and gray matter changes.Neurodevelopmental delay and seizures are common. Suspectedcases beneit from multidisciplinary consultation andcounseling. Prognosis relates to the size of the defect and associatedabnormalities. 19,195,205,212,213Other Malformations of Cortical DevelopmentCortical malformations can accompany infections, inborn errorsof metabolism (e.g., peroxisomal disorders), mitochondrialdisease, and conditions with unknown etiology. 91,188 Metabolicand neurodegenerative disorders can be associated withabnormal brain development but are typically not detectableprenatally by ultrasound. However, some are associated withdiverse changes such as IUGR, microcephaly or macrocephaly,abnormal corpus callosum, migrational and cerebellar abnormality,cerebral calciications, cerebral cysts, renal and hepatic changes,congenital heart disease, and hydrops. 214,215 he most commonis Zellweger (cerebrohepatorenal) syndrome, a lethal peroxisomaldisorder. Afected fetuses can have increased NT in theirst trimester and later show VM, subependymal germinolyticcysts, migrational abnormality, hepatomegaly, cortical renal cysts,and chondrodysplasia punctata. he diagnosis can be conirmedby DNA and biochemical testing of fetal cells obtained byCVS. 214-216
ABCCCDEFFIG. 34.24 Type 2 Lissencephaly (Cobblestone Cortex, Walker-Warburg Phenotype) at 21 Weeks. (A) Coronal view shows the large,smooth ventricles and the very small brainstem (arrow). (B) Defect in vermis (vermian hypoplasia; arrow). (C) Midsagittal view shows the Z-shapedkink in the brainstem (arrow), which represents failure of the brainstem to straighten and lose the early embryologic lexures, a process that normallyoccurs after 12 to 13 weeks. Also, the cerebellar vermis is very small (arrowhead). The third ventricle is malformed. The corpus callosum (cc) ismalformed and extremely elevated. There is a minute occipital encephalocele (open arrowhead). This fetus also had eye abnormalities. (D) In adifferent fetus at 36 weeks, transvaginal scan shows smooth cortex (agyria), abnormal for this gestational age. (E) Coronal T2-weighted magneticresonance image shows the smooth cortex and abnormal bands of high signal intensity in the parenchyma. Note the prominent extraaxial CSFspaces. (F) Another fetus with severe VM and lissencephaly caused by Walker-Warburg syndrome. Note that this is the same fetus shown in Fig.34.13B with a small cephalocele.
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viiiContributorsOlga R. Brook, MDAs
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xContributorsChristy K. Holland, Ph
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xiiContributorsRupa Radhakrishnan,
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xxiiContentsVOLUME IIPART IV Obstet
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xxivVideo ContentsVideo 12.8 Angiog
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xxviVideo ContentsVideo 26.20 High-
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xxviiiVideo Contents42 Fetal Measur
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2 PART I Physicsphysics. he amplitu
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4 PART I Physics× ms×FIG. 1.4 Ult
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6 PART I Physicsθ 1 = 20°Tissue A
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8 PART I Physicssignature. Broad-ba
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10 PART I PhysicsFIG. 1.13 B-Mode I
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12 PART I PhysicsIn these transduce
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14 PART I PhysicsFIG. 1.17 Tissue H
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16 PART I PhysicsKey Points of Ultr
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18 PART I PhysicsA - Normal liverv
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20 PART I PhysicsFIG. 1.27 Reverber
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22 PART I Physics-0 dBUncorrected-0
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24 PART I Physicsθ = 0°cos θ = 1
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26 PART I PhysicsABFIG. 1.38 Color
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28 PART I PhysicsChanges in Doppler
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30 PART I PhysicsABFIG. 1.44 Wall F
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32 PART I PhysicsABCDFIG. 1.46 Alia
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CHAPTER2Biologic Effects and Safety
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36 PART I PhysicsPressurePulse repe
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38 PART I PhysicsUltrasound imaging
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40 PART I Physicsacoustic power and
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42 PART I PhysicsFIG. 2.6 Acoustic
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44 PART I PhysicsThe AIUM Statement
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46 PART I Physics1. Current ultraso
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48 PART I PhysicsEPIDEMIOLOGYWith a
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50 PART I Physicscontrols whether t
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52 PART I Physics70. Hwang JH, Tu J
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54 PART I PhysicsA B 5 μmFIG. 3.1
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56 PART I Physicsstudies with Levov
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58 PART I Physicsabdominal organs.
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60 PART I PhysicsHarmonic B-Mode Im
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62 PART I PhysicsFIG. 3.9 Contrast-
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64 PART I Physicsdramatic manifesta
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66 PART I Physics5 µmFIG. 3.15 Fra
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68 PART I Physicsplatelet lysis), n
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70 PART I PhysicsEnhancement1 2 3 4
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72 PART I Physics46. Hamilton MF, B
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PART TWO: Abdominal and Pelvic Sono
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76 PART II Abdominal and Pelvic Son
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100 PART II Abdominal and Pelvic So
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ABFIG. 5.20 Microabscesses in Two P
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ABFIG. 6.32 Distal Cholangiocarcino
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CHAPTER7The PancreasThomas Winter a
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CHAPTER8The Gastrointestinal TractS
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ABFIG. 8.16 Lymphadenopathy in Two
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A B CD E FG H IFIG. 8.23 Inlammator
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FIG. 8.56 Gastrointestinal Stromal
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CHAPTER9The Kidney and Urinary Trac
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Remnant ofpronephrosMesonephrosBMes
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CHAPTER11The Adrenal GlandsChristin
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CHAPTER12The RetroperitoneumRaymond
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CHAPTER13Dynamic Ultrasound of Hern
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CHAPTER14The PeritoneumAnthony E. H
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CHAPTER15The UterusDouglas Brown an
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CHAPTER16The AdnexaRochelle Filker
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692 PART III Small Parts, Carotid A
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CHAPTER20The Parathyroid GlandsBonn
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*** *FIG. 21.8 Terminal Ductolobula
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CHAPTER22The ScrotumDaniel Sommers
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CHAPTER23Overview of Musculoskeleta
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CHAPTER25Musculoskeletal Interventi
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ABCDFIG. 25.15 Biceps Tendon Sheath
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CHAPTER27Peripheral VesselsMark E.
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ABFIG. 27.29 Chronic Deep Venous Th
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1000 PART III Small Parts, Carotid
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e2APPENDIXUltrasound Artifacts: A V
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FIG. A.18 Comet-Tail Artifact. On c
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e12APPENDIXUltrasound Artifacts: A
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I-2 IndexAcetabulumdescription of,
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I-4 IndexAnemiafetal, hydrops from,
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I-6 IndexAttenuationcoeicient, 36of
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I-8 IndexBlood low. See also Cerebr
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I-10 IndexBreast(s) (Continued)thic
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I-12 IndexCat-scratch disease, pedi
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I-14 IndexChorion laeve, 1465-1466C
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I-16 IndexContrast agents (Continue
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I-18 IndexCyst(s) (Continued) Cyst(
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I-20 IndexDoppler ultrasound (Conti
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I-22 IndexEndocardial cushion(s), 1
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I-24 IndexFibroma(s) (Continued)par
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I-26 IndexGerminal epithelium, 565G
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I-28 IndexHematoma(s) (Continued)pe
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I-30 IndexHoloprosencephaly (HPE) (
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I-32 IndexImplants, breast (Continu
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I-34 IndexJaundice (Continued)bile
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I-36 IndexLipomyelocele, closed spi
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I-38 IndexMammary ductsnormal sonog
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I-40 IndexMolar pregnancy. See Hyda
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I-42 IndexNonrhizomelic chondrodysp
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I-44 IndexPancreas (Continued)percu
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I-46 IndexPeritoneum (Continued)tum
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I-48 IndexPosterior fossa (Continue
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I-50 IndexPyloric musclehypertrophy
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I-52 IndexSample volume size, Doppl
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I-54 IndexSpectral broadening, in D
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I-56 IndexSuperoanteromedial ridge,
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I-58 Indexhrombosis (Continued)of s
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I-60 IndexTrisomy 18 (Edwards syndr
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I-62 IndexUrinary tract, pediatric
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I-64 IndexWalker-Warburg syndromeco
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DIAGNOSTICULTRASOUND
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DIAGNOSTICULTRASOUND5TH EDITIONCARO
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ABOUT THE EDITORSCarol M. Rumack, M
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ContributorsviiCONTRIBUTORSJacques
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ContributorsixPeter M. Doubilet, MD
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ContributorsxiAna P. Lourenco, MDAs
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ContributorsxiiiWendy hurston, MDAs
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In memory of my parents, Drs. Ruth
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PrefacexviiPREFACEhe ith edition of
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AcknowledgmentsxixACKNOWLEDGMENTSWe
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ContentsxxiCONTENTSVOLUME IPART I P
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Video ContentsxxiiiVIDEO CONTENTS4
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Video Contentsxxv19 The Thyroid Gla
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Video Contentsxxvii33 The Fetal Fac
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Video Contentsxxix52 The Pediatric
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DIAGNOSTICULTRASOUND
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PART FOUR: Obstetric and Fetal Sono
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CHAPTER 28 Overview of Obstetric Im
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ABCDFIG. 28.9 Second-Trimester Biom
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CHAPTER 29 Bioeffects and Safety of
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CHAPTER 30 The First Trimester 1049
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CHAPTER 31 Chromosomal Abnormalitie
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ABCDFIG. 31.12 Sonographic Findings
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CHAPTER32Multifetal PregnancyMary C
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CHAPTER 32 Multifetal Pregnancy 111
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ABFIG. 32.5 Sonographic Findings Se
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CHAPTER33The Fetal Face and NeckAna
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CHAPTER 33 The Fetal Face and Neck
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Page 1317 and 1318: ABCDFIG. 33.13 Hypertelorism With E
Page 1319 and 1320: ABCDFIG. 33.16 Dacryocystocele. (A)
Page 1321 and 1322: CHAPTER 33 The Fetal Face and Neck
Page 1327 and 1328: ABCDEFFIG. 33.24 Unilateral Complet
Page 1339 and 1340: CHAPTER 34 The Fetal Brain 1167impo
Page 1341 and 1342: CHAPTER 34 The Fetal Brain 1169cmAB
Page 1343 and 1344: CingulatePOCalcarineAB21 wkCD25 wkI
Page 1345 and 1346: CHAPTER 34 The Fetal Brain 1173FIG.
Page 1347 and 1348: CHAPTER 34 The Fetal Brain 1175LTAR
Page 1349 and 1350: CHAPTER 34 The Fetal Brain 1177CC12
Page 1351 and 1352: CHAPTER 34 The Fetal Brain 1179SPEC
Page 1353 and 1354: CHAPTER 34 The Fetal Brain 1181ABCD
Page 1355 and 1356: CHAPTER 34 The Fetal Brain 1183asym
Page 1357 and 1358: CHAPTER 34 The Fetal Brain 1185FIG.
Page 1359 and 1360: CHAPTER 34 The Fetal Brain 1187Cere
Page 1361 and 1362: CHAPTER 34 The Fetal Brain 1189loba
Page 1363 and 1364: CHAPTER 34 The Fetal Brain 1191ABCF
Page 1365 and 1366: CHAPTER 34 The Fetal Brain 1193ABCF
Page 1367: CHAPTER 34 The Fetal Brain 1195spor
Page 1371 and 1372: CHAPTER 34 The Fetal Brain 1199ABFI
Page 1373 and 1374: CHAPTER 34 The Fetal Brain 120120 w
Page 1375 and 1376: CHAPTER 34 The Fetal Brain 1203Ultr
Page 1377 and 1378: CHAPTER 34 The Fetal Brain 1205ABCD
Page 1379 and 1380: VSSABHHPHCDEFFIG. 34.35 Intracrania
Page 1381 and 1382: CHAPTER 34 The Fetal Brain 1209VABC
Page 1383 and 1384: CHAPTER 34 The Fetal Brain 1211Huma
Page 1385 and 1386: CHAPTER 34 The Fetal Brain 1213121.
Page 1387 and 1388: CHAPTER 34 The Fetal Brain 1215221.
Page 1389 and 1390: CHAPTER 35 The Fetal Spine 1217ABCF
Page 1391 and 1392: CHAPTER 35 The Fetal Spine 1219L1S3
Page 1393 and 1394: CHAPTER 35 The Fetal Spine 1221FTFT
Page 1395 and 1396: CHAPTER 35 The Fetal Spine 1223FIG.
Page 1397 and 1398: CHAPTER 35 The Fetal Spine 1225TABL
Page 1399 and 1400: CHAPTER 35 The Fetal Spine 1227Feta
Page 1401 and 1402: CHAPTER 35 The Fetal Spine 1229MMAB
Page 1403 and 1404: ABCDEFFIG. 35.15 Skin-Covered Myelo
Page 1405 and 1406: CHAPTER 35 The Fetal Spine 1233diic
Page 1407 and 1408: CHAPTER 35 The Fetal Spine 1235CCSC
Page 1409 and 1410: CHAPTER 35 The Fetal Spine 1237chon
Page 1411 and 1412: CHAPTER 35 The Fetal Spine 1239BSCT
Page 1413 and 1414: CHAPTER 35 The Fetal Spine 124162.
Page 1415 and 1416: CHAPTER36The Fetal ChestDorothy Bul
Page 1417 and 1418: CHAPTER 36 The Fetal Chest 1245seco
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CHAPTER 36 The Fetal Chest 1247TABL
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CHAPTER 36 The Fetal Chest 1249Left
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CHAPTER 36 The Fetal Chest 12511ABC
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CHAPTER 36 The Fetal Chest 1253ABCF
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CHAPTER 36 The Fetal Chest 1255cent
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CHAPTER 36 The Fetal Chest 1257Left
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CHAPTER 36 The Fetal Chest 1259ABCD
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CHAPTER 36 The Fetal Chest 1261RTLT
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CHAPTER 36 The Fetal Chest 1263ARig
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CHAPTER 36 The Fetal Chest 12659. B
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CHAPTER 36 The Fetal Chest 1267107.
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CHAPTER 36 The Fetal Chest 1269204.
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CHAPTER 37 The Fetal Heart 1271TABL
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CHAPTER 37 The Fetal Heart 1273TABL
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CHAPTER 37 The Fetal Heart 1275Plac
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CHAPTER 37 The Fetal Heart 1277ADop
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CHAPTER 37 The Fetal Heart 1279LVRV
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CHAPTER 37 The Fetal Heart 1281RARV
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CHAPTER 37 The Fetal Heart 1283RARV
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CHAPTER 37 The Fetal Heart 1285Norm
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CHAPTER 37 The Fetal Heart 1287RVLV
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CHAPTER 37 The Fetal Heart 1289RVTA
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CHAPTER 37 The Fetal Heart 1291LVRA
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CHAPTER 37 The Fetal Heart 1293Aspl
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CHAPTER 37 The Fetal Heart 1295PLVL
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CHAPTER 37 The Fetal Heart 1297HR-L
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CHAPTER 37 The Fetal Heart 129951.
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CHAPTER 38 The Fetal Gastrointestin
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UrogenitalsinusMesonephrosMesonephr
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CHAPTER 39 The Fetal Urogenital Tra
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CHAPTER 40 The Fetal Musculoskeleta
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CHAPTER 41 Fetal Hydrops 1413ABFIG.
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ABCDFIG. 41.2 Ascites. (A) Fluid ou
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CHAPTER 41 Fetal Hydrops 1417A B CD
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CHAPTER 41 Fetal Hydrops 1423later
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CHAPTER 41 Fetal Hydrops 1427CHABCH
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CHAPTER 41 Fetal Hydrops 1429Monoch
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CHAPTER 41 Fetal Hydrops 1431feedin
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CHAPTER 41 Fetal Hydrops 1433TABLE
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CHAPTER 41 Fetal Hydrops 1435sampli
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CHAPTER 41 Fetal Hydrops 1437Predel
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CHAPTER 41 Fetal Hydrops 143973. Ma
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CHAPTER 41 Fetal Hydrops 1441169. I
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CHAPTER42Fetal Measurements: Normal
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CHAPTER 42 Fetal Measurements 1445F
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CHAPTER 42 Fetal Measurements 1447T
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CHAPTER 42 Fetal Measurements 1451p
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CHAPTER 42 Fetal Measurements 1453d
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CHAPTER 42 Fetal Measurements 1455A
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CHAPTER 42 Fetal Measurements 1459A
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CHAPTER 42 Fetal Measurements 14618
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CHAPTER 42 Fetal Measurements 14631
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CHAPTER43Sonographic Evaluation oft
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CHAPTER 43 Sonographic Evaluation o
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CHAPTER44Cervical Ultrasound and Pr
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CHAPTER 44 Cervical Ultrasound and
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PART FIVE: Pediatric SonographyCHAP
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CHAPTER 45 Neonatal and Infant Brai
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CHAPTER46Duplex Sonography of the N
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CHAPTER 46 Duplex Sonography of the
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CHAPTER47Doppler Sonography of the
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CHAPTER 47 Doppler Sonography of th
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CHAPTER 48 The Pediatric Head and N
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CHAPTER 49 The Pediatric Spinal Can
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RA B CDEFGFIG. 49.27 Neuroblastoma
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CHAPTER50The Pediatric ChestChetan
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CHAPTER 50 The Pediatric Chest 1703
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CHAPTER 51 The Pediatric Liver and
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ABCFIG. 51.39 Hepatosplenomegaly. W
Page 1945 and 1946:
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CHAPTER52The Pediatric Urinary Trac
Page 1949 and 1950:
CHAPTER 52 The Pediatric Urinary Tr
Page 1951 and 1952:
TABLE 52.4 Mean Total Renal Volumes
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CHAPTER53The Pediatric Gastrointest
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CHAPTER 53 The Pediatric Gastrointe
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CHAPTER 54 Pediatric Pelvic Sonogra
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CHAPTER 55 The Pediatric Hip and Ot
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ABCDFIG. 55.13 Normal and Dislocate
Page 2111 and 2112:
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Page 2115 and 2116:
CHAPTER 56 Pediatric Interventional
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ABCFIG. 56.15 Access for Drainage o
Page 2133 and 2134:
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APPENDIXUltrasound Artifacts: A Vir
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APPENDIX Ultrasound Artifacts: A Vi
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IndexAAA anastomoses. See Arterial/
Page 2181 and 2182:
Index I-3Adnexa (Continued)transvag
Page 2183 and 2184:
Index I-5Arrays, transducer, 11-12A
Page 2185 and 2186:
Index I-7Bioefects (Continued) Biop
Page 2187 and 2188:
Index I-9Brain, neonatal/infant (Co
Page 2189 and 2190:
Index I-11Carcinoma(s) (Continued)
Page 2191 and 2192:
Index I-13Cervix (Continued)for sym
Page 2193 and 2194:
Index I-15Color Doppler ultrasound
Page 2195 and 2196:
Index I-17Cystic artery, 194promine
Page 2197 and 2198:
Index I-19Diabetes mellituschronic
Page 2199 and 2200:
Index I-21Echinococcal disease (Con
Page 2201 and 2202:
Index I-23Exudate ascites, 506-507E
Page 2203 and 2204:
Index I-25Gallbladder (Continued)ad
Page 2205 and 2206:
Index I-27Gyriabnormalities of, in
Page 2207 and 2208:
Index I-29Hernia(s). See also Diaph
Page 2209 and 2210:
Index I-31Hyperechoic tissue, in br
Page 2211 and 2212:
Index I-33Internal jugular vein (IJ
Page 2213 and 2214:
Index I-35Kidneys, pediatric (Conti
Page 2215 and 2216:
Index I-37Liver transplantation (Co
Page 2217 and 2218:
Index I-39Mesentery, small bowel, 5
Page 2219 and 2220:
Index I-41Nasal bone, fetal (Contin
Page 2221 and 2222:
Index I-43Orbits, fetal (Continued)
Page 2223 and 2224:
Index I-45Patau syndrome. See Triso
Page 2225 and 2226:
Index I-47Pleural efusionsfetal, 12
Page 2227 and 2228:
Index I-49Prostate (Continued)thera
Page 2229 and 2230:
Index I-51Renal transplantation (Co
Page 2231 and 2232:
Index I-53Shunt(s) (Continued) Skel
Page 2233 and 2234:
Index I-55Splenic vein (Continued)t
Page 2235 and 2236:
Index I-57Testis(es) (Continued)cys
Page 2237 and 2238:
Index I-59Transcranial Doppler (TCD
Page 2239 and 2240:
Index I-61Umbilical cord, 1481-1487
Page 2241 and 2242:
Index I-63Vein of Galen (Continued)
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