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1204 PART IV Obstetric and Fetal SonographyFIG. 34.31 Echogenic Mineralized Thalamostriate Vessels(Arrow). These vessels form an echogenic arborizing (branching) patternin the thalamus, which may be seen in normal fetuses but can beassociated with many fetal conditions.efects depending on the individual pathogens and time ofmaternal infection. Immunization, prenatal screening, and casemanagement protocols have been proposed. 232 he Zika infection(particularly in the irst trimester) tends to be very severe withmicrencephaly, microcephaly, cortical abnormalities, dysgenesisof the corpus callosum, and calciications, which are oten at thegray-white junction. 197In North America, CMV is most common intrauterine infection,afecting about 0.2% to 2.0% of live births, and is a commoncause of mental retardation and sensorineural hearing loss. henext most common infections in North America are toxoplasmosisand herpes simplex. he severity of injury oten relatesmore to the age when infection irst occurs and afects braindevelopment than to the speciic organism. Cerebral and noncerebralultrasound indings as noted below for CMV are sharedby many of the infections, so detection of any of these indingsshould include general assessment for infections. Unfortunately,several indings can appear or evolve in late pregnancy, so surveillancewith ultrasound should continue throughout pregnancy,with MRI employed as appropriate. 11,233-235Most mothers acquire primary CMV infection through contactwith infected persons, but reinfection can also occur. CMV afects1% to 2% of pregnancies, and vertical transmission to the fetusoccurs in 30% to 40%. About 10% to 15% of these have symptomsat birth, and of these about 20% to 30% die and 90% of survivorshave neurodevelopmental handicap. Of the 85% to 90% of infantswho appear normal at birth, 5% to 15% will develop late complicationsincluding hearing loss or developmental delays.Diagnosis of fetal infection can be made via amniocentesis.Ultrasound and MRI are used to help determine prognosis butare imperfect at predicting outcomes. he odds ratio of pooroutcome with noncerebral abnormality is 7.2 and with cerebralabnormality is 25.5; although the absence of indings is reassuring,it does not guarantee a good outcome. Cerebral and posteriorfossa indings include VM, increased periventricular echogenicity,calciications, ventricular synechiae, microcephaly, periventricularpseudocysts or other cysts, malformations of cortical development,and cerebellar abnormality (Fig. 34.32). Noncerebral indingsinclude echogenic bowel, hepatomegaly, IUGR, oligohydramniosor polyhydramnios, ascites or pleural efusion, livercalciications, and placental enlargement. 233-237Congenital toxoplasmosis is caused by the transplacentalpassage of the parasite Toxoplasma gondii from an infected motherwho is typically asymptomatic and acquires infection throughcontact with raw or undercooked meat, cat litter, or exposureto infected water or soil (gardening). In the United States, 15%of childbearing-age women are infected, and incidence ofcongenital toxoplasmosis is about 400 to 4000 per year. Interestingly,transmission to the fetus increases with gestational ageand is estimated at about only 6% to 15% in the irst trimesterbut increases to 60% to 81% in the third trimester. If untreated,about 20% to 50% develop infection. Fetal disease severity,however, decreases with age and is highest in the irst trimester.Prenatal cerebral indings may appear late ater 24 weeks andsuggest a poor prognosis and can include VM, cerebral calciications,echogenic parenchymal nodules, difuse periventricularechogenicity, callosal dysgenesis, microcephaly, IUGR, andhydrops. Most fetuses (70%-90%) are infected in later pregnancyand are asymptomatic at birth, but some manifest the diagnostictriad (chorioretinitis, hydrocephalus, intracranial calciications)and hepatosplenomegaly. Asymptomatic infants remain at highrisk of developing late chorioretinitis and neurologic deicits.Maternal serum testing and amniocentesis can conirm infection.Prenatal and postnatal therapy can improve outcomes. 232,238-240VASCULAR MALFORMATIONSA variety of vascular malformations are described prenatally,including the vein of Galen aneurysmal malformation, duralsinus malformation, and pial arteriovenous malformation. 241he most common is the vein of Galen aneurysmal malformation,which is a congenital anomaly of midline choroidal and muralvessels that drain into and dilate the embryonic precursor of thevein of Galen, the median prosencephalic vein of Markowski,which in turn drains through an aberrant falcine sinus that canbe mistaken for the vein of Galen. In general, this anomalybecomes detectable in the third trimester as a cystlike midlinespace behind the thalamus with turbulent follow on Doppler(Fig. 34.33). In prenatal cases 81% are associated other abnormalitiesthat predict a poor outcome, including heart failure andcerebral abnormalities such as VM, malformations of corticaldevelopment, and ischemic and hemorrhagic changes. It is notassociated with chromosomal abnormality. Postnatal treatmentis with embolization, which is delayed to about 6 months unlessthere is heart failure. Outcome can be good in the few who haveisolated lesions and no heart failure. 11,241-243Pial arteriovenous malformations are abnormal, usuallysupratentorial, supericial arteriovenous communications eventuallydraining into and dilating the vein of Galen. hey may result
CHAPTER 34 The Fetal Brain 1205ABCDFIG. 34.32 Fetal Infection. (A) and (B) CMV infection shows enlarged ventricles with marked periventricular echogenicity (arrow) and smallsmooth brain (lissencephaly) (arrowheads). (B) Note calciication in the basal ganglia (lines), small smooth brain (arrow), and cortical cyst (c). (C)and (D) Zika infection. (C) Parasagittal transvaginal view of the fetal brain shows calciications at the gray-white interface and in the basal ganglia(arrows). (D) Oblique coronal view shows blood (arrow) posterior to the cerebellum in the region of the conluence of sinuses. (A and B courtesyof Dr. K. Fong, Mt. Sinai Hospital, Toronto, Ontario. C and D Reproduced with permission from Soares de Oliveira-Szejnfeld P, Levine D, Melo ASet al. Congenital brain abnormalities and Zika virus: what the radiologist can expect to see prenatally and postnally. Radiology.2016;281[1]:203-218. 197 )in heart failure. Treatment is with embolization early aterdelivery. 241Dural sinus malformations are congenital vascular malformations,characterized by massive dilation of one or more duralsinuses, which usually appear postnatally but can occur prenatallyas early as 19 weeks. here may be associated thrombus orarteriovenous istula. Color Doppler may be helpful, but in somethe low is too slow to create a signal. hese malformations canregress prenatally or progress to cause brain damage, hemorrhage,or heart failure. Evaluation includes detailed ultrasound andMRI. Treatment is with embolization, but only 10% have normaloutcomes. 241,242,244Thrombosis of Dural SinusesDural sinus thrombosis can be idiopathic (40%), but cases canbe seen with hypercoagulable states such as trauma, infection,polycythemia, and deiciency of physiologic anticoagulants (e.g.,antithrombin protein C, protein S, factor V Leiden). Ultrasoundtypically reveals an echogenic mass (the thrombus) surroundedby a hypoechogenic area in the region of the venous sinuses,generally near the torcula and associated with absence of low(Fig. 34.34). he more proximal sinuses may be dilated and thebrain compressed. Many dural thromboses are initially misdiagnosedas tumors or subdural bleed. Most cases are found in
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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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ABCDFIG. 33.13 Hypertelorism With E
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ABCDFIG. 33.16 Dacryocystocele. (A)
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Page 1325 and 1326: 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 and 1368: CHAPTER 34 The Fetal Brain 1195spor
Page 1369 and 1370: ABCCCDEFFIG. 34.24 Type 2 Lissencep
Page 1371 and 1372: CHAPTER 34 The Fetal Brain 1199ABFI
Page 1373 and 1374: CHAPTER 34 The Fetal Brain 120120 w
Page 1375: CHAPTER 34 The Fetal Brain 1203Ultr
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
Page 1419 and 1420: CHAPTER 36 The Fetal Chest 1247TABL
Page 1421 and 1422: CHAPTER 36 The Fetal Chest 1249Left
Page 1423 and 1424: CHAPTER 36 The Fetal Chest 12511ABC
Page 1425 and 1426: 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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Page 2107 and 2108:
Page 2109 and 2110:
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
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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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