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1944 PART V Pediatric SonographyLeftLNG_FemurABLeftLNG_LeftLNG_CDFemurEFFIG. 56.1 Multimodality Interventional Procedure Guidance. Biopsy of posterior femur cortical aneurysmal bone cyst in a 15-year-oldwith 3 months of left thigh pain initially treated as a knee sports injury. (A) Transverse short-tau inversion recovery (STIR) magnetic resonanceimage mid left femur. Black arrows show eroded posterior bone cortex. White arrows show luid-luid levels. (B) Longitudinal ultrasound showingthe soft tissue component of the lesion (black arrows). (C) Color Doppler showed little internal blood low, but (D) moderate-size peripheral arterialvessels were identiied and avoided during the biopsy. (E) Axial cone-beam computed tomography scan showing initial guidance graticule and bonebiopsy device entering the posterior bone cortex to obtain initial soft tissue samples for frozen section analysis to minimize the risk of moreaggressive biopsy of a malignant lesion. Frozen section revealed a benign lesion. (F) Conventional luoroscopy then allowed further sampling fromall quadrants of the lesion.
CHAPTER 56 Pediatric Interventional Sonography 1945collections can be drained this way, the necessary skills foraccurate needle placement in small organs or near criticalstructures will never be learned. A single practitioner using anultrasound transducer in one hand and the access needle orother device in the other hand is far superior to the “where’s myneedle now?”–type verbal communication required when thereare two operators.Freehand Versus Mechanical GuidesMost ultrasound equipment manufacturers supply well-designedmechanical guides that attach to a transducer and allow a predictableneedle path to be visualized. hese guides are useful forkeeping the needle in the plane of the ultrasound beam and canbe used for lesions with a simple approach path or a wide accesswindow. Most devices require a disposable sterile kit when thedevice is used, adding to the cost of the procedure. Special needleguides are useful for the initial puncture for transrectal abscessdrainage, 3 although many practitioners use simple freehandultrasound guidance imaging of the rectal puncture needle usingan anterior view through the illed bladder.Freehand guidance is more diicult to learn but allows muchmore lexibility of approach. When the needle can be positioned45 to 90 degrees to the beam, even ine, 30-gauge needles areeasily visible. Freehand guidance allows the operator to choosethe most advantageous transducer geometry and to steer theneedle or biopsy device around other structures on the way tothe lesion. Accurate placement of local anesthetic on the peritoneum,pleura, and other sensitive structures is made easier byfreehand technique.Color Doppler UltrasoundColor Doppler has been advocated for visualization of the movingneedle during interventional procedures, but our experience hasbeen that the potential for better visualization of the needle tipis outweighed by the degradation of the gray-scale image andlash artifacts when color Doppler is active. Various needletracking devices are available to enhance the visualization of theneedle, but with the exception of the Yueh (Cook, Bloomington,IN) and Skater (InterV, Stenlose, Denmark) type sheathed accessdevices, which have very small holes in the catheter tip, thesedevices all add complexity and expense and are generally unnecessaryif accurate ultrasound technique is learned.FREEHAND TECHNIQUEFreehand technique requires that the transducer be held in onehand and the needle or biopsy device in the other. he interventionalphysician needs to be able to use either hand as theneedle or operating hand. For example, a biopsy specimen ofthe liver might be obtained by placing the transducer on theanterior abdominal wall using the right hand and making theneedle approach from the patient’s right lateral position, parallelto the table, using the let hand. A let-sided biopsy would bestbe performed by using the let hand for the transducer and theright hand for the needle approach from the let lank. Withsome practice and some simple rules, it is not diicult to usethe nondominant hand as the needle hand.Initial Needle Placement and Localizationhe most important technique to learn in freehand sonographyis needle localization. hese rules work equally well for a needleentry site near the transducer or one at a distance (Fig. 56.2).he entry point is chosen ater careful consideration of theanatomy and important structures such as ribs, large vessels,diaphragm, and bowel. Indentation of the entry site using a ingerto compress the skin (Fig. 56.3) allows the exact entry site to beassessed. Once the entry site is chosen, a last check can be madeby placing the transducer exactly over the marked entry pointfor a “needle’s-eye view” to ensure that there will be no surprisessuch as the internal mammary artery during mediastinal biopsyor inferior epigastric artery during paracentesis or abdominalabscess drainage, which may be overlooked unless speciicallylocalized. Once the entry path has been chosen and ater properapplication of local anesthetic, the needle or biopsy device is21ABFIG. 56.2 Common Approaches. (A) The most common entry sites are either (1) lateral (parallel to the transducer face) or (2) adjacent to thetransducer. (B) When the needle is parallel to the transducer face, a prominent reverberation artifact is seen, or a “comet-tail” artifact is seenwhen the needle is not parallel. The needle can be more dificult to locate in position 2.
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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 1311 and 1312:
Page 1313 and 1314:
Page 1315 and 1316:
Page 1317 and 1318:
ABCDFIG. 33.13 Hypertelorism With E
Page 1319 and 1320:
ABCDFIG. 33.16 Dacryocystocele. (A)
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ABCDEFFIG. 33.24 Unilateral Complet
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CHAPTER 34 The Fetal Brain 1167impo
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CHAPTER 34 The Fetal Brain 1169cmAB
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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
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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
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CHAPTER 34 The Fetal Brain 1189loba
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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 and 1376:
CHAPTER 34 The Fetal Brain 1203Ultr
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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.
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CHAPTER 35 The Fetal Spine 1217ABCF
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CHAPTER 35 The Fetal Spine 1219L1S3
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CHAPTER 35 The Fetal Spine 1221FTFT
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CHAPTER 35 The Fetal Spine 1223FIG.
Page 1397 and 1398:
CHAPTER 35 The Fetal Spine 1225TABL
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CHAPTER 35 The Fetal Spine 1227Feta
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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
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CHAPTER 35 The Fetal Spine 1235CCSC
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CHAPTER 35 The Fetal Spine 1237chon
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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
Page 1429 and 1430:
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
Page 1471 and 1472:
CHAPTER 37 The Fetal Heart 129951.
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Page 1477 and 1478:
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.
Page 1587 and 1588:
ABCDFIG. 41.2 Ascites. (A) Fluid ou
Page 1589 and 1590:
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
Page 1607 and 1608:
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
Page 1615 and 1616:
CHAPTER42Fetal Measurements: Normal
Page 1617 and 1618:
CHAPTER 42 Fetal Measurements 1445F
Page 1619 and 1620:
CHAPTER 42 Fetal Measurements 1447T
Page 1621 and 1622:
Page 1623 and 1624:
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
Page 1635 and 1636:
CHAPTER 42 Fetal Measurements 14631
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CHAPTER43Sonographic Evaluation oft
Page 1639 and 1640:
CHAPTER 43 Sonographic Evaluation o
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CHAPTER44Cervical Ultrasound and Pr
Page 1669 and 1670:
CHAPTER 44 Cervical Ultrasound and
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Page 1681 and 1682:
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PART FIVE: Pediatric SonographyCHAP
Page 1685 and 1686:
CHAPTER 45 Neonatal and Infant Brai
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CHAPTER46Duplex Sonography of the N
Page 1747 and 1748:
CHAPTER 46 Duplex Sonography of the
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Page 1761 and 1762:
Page 1763 and 1764:
CHAPTER47Doppler Sonography of the
Page 1765 and 1766:
CHAPTER 47 Doppler Sonography of th
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Page 1799 and 1800:
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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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Page 1859 and 1860:
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Page 1863 and 1864:
Page 1865 and 1866:
RA B CDEFGFIG. 49.27 Neuroblastoma
Page 1867 and 1868:
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Page 1873 and 1874:
CHAPTER50The Pediatric ChestChetan
Page 1875 and 1876:
CHAPTER 50 The Pediatric Chest 1703
Page 1877 and 1878:
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CHAPTER 51 The Pediatric Liver and
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Page 1943 and 1944:
ABCFIG. 51.39 Hepatosplenomegaly. W
Page 1945 and 1946:
Page 1947 and 1948:
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
Page 2007 and 2008:
CHAPTER 53 The Pediatric Gastrointe
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Page 2041 and 2042:
Page 2043 and 2044:
CHAPTER 54 Pediatric Pelvic Sonogra
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Page 2057 and 2058:
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Page 2063 and 2064:
Page 2065 and 2066: CHAPTER 54 Pediatric Pelvic Sonogra
Page 2093 and 2094: CHAPTER 55 The Pediatric Hip and Ot
Page 2109 and 2110: ABCDFIG. 55.13 Normal and Dislocate
Page 2115: CHAPTER 56 Pediatric Interventional
Page 2119 and 2120: CHAPTER 56 Pediatric Interventional
Page 2131 and 2132: ABCFIG. 56.15 Access for Drainage o
Page 2141 and 2142: APPENDIXUltrasound Artifacts: A Vir
Page 2143 and 2144: APPENDIX Ultrasound Artifacts: A Vi
Page 2167 and 2168:
APPENDIX Ultrasound Artifacts: A Vi
Page 2169 and 2170:
Page 2171 and 2172:
Page 2173 and 2174:
Page 2175 and 2176:
Page 2177 and 2178:
Page 2179 and 2180:
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)
Page 2243 and 2244:
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Page 2249:
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