US

Cystic Hygroma
• Usually incidental solitary lesion
• Findings: bilobed cystic mass on back of neck
with a midline septum
• Assoc w/Turner (XO), trisomies 13, 18, 21, and 22
– Also, fetal alcohol syndrome, multiple pterygium
syndrome
• Cause is lymphatic obstruction
– Localized: solitary cystic hygroma
– Diffuse: fetal skin thickening, fluid within body cavities
(pleural/pericardial effusions, ascites), indicating fetal
hydrops
 Ectopic Pregnancy
• Risk factors: previous ectopic, PID, IUD
+ pregnancy
• Transvaginal US will diagnose all
gestational sacs when beta-HCG >
1,000
• Findings
– Extrauterine anechoic gestational sac containing a
fetus with or without a heartbeat
– Empty gestational sac outside the uterus
– Thick hyperechoic band surrounding a small
hypoechoic core  donut or ring
– Diffuse hyperechoic mass within fallopian tube
– No intrauterine gestation (+/- pseudogestational sac)
– Echogenic free fluid if ruptured
• DDx: corpus luteum cyst, heterotopic pregnancy
Adnexal Ectopic
Cornual Ectopic
Cornual Ectopic
 Heterotopic Pregnancy

• No risk factors: 1 per 7,000

• Risk factors: ovulation induction, h/o abx for PID,
endometriosis, previous ectopic
• High risk pts: 1 per 3,000
Heterotopic Pregnancy
 Adnexal Mass
(Mucinous
Cystadenocarcinoma)
• Rule out bad stuff: torsion, TOA, ectopic, cancer
– Check beta-HCG, Doppler
– Check fever, leukocytosis
• Premenopausal
– Unilocular: < 3 cm ignore; 5-7 cm 1 y f/u; > 7 cm remove
– Typical features of dermoid or endometrioma  CT/MR
– Complex: < 6 cm 6 w f/u; > 6 cm remove
• For postmenopausal, anything not a simple cyst
needs to be removed (1 y f/u if unilocular > 1 cm)
• Malignant features: irregular walls, mural/septal
nodules, thick/multiple septations, solid
• Doppler
– In general, malignant tumors have low
resistive index (RI) < 0.4 or pulsatility
index < 1
– Other suspicious features are lack of a
diastolic notch and flow in solid portions of
a mass
Endometrioma
Hemorrhagic Cyst
Hemorrhagic Cyst
Tubo-ovarian Abscess
Ovarian Torsion
 Dermoid
• Findings
– Cystic lesion w/echogenic shadowing nodule projecting
into lumen (Rokitansky nodule or dermoid plug)
– “Tip of iceberg”: Diffusely or partially echogenic mass
usually demonstrating sound attenuation (sebaceous
material & hair within cyst cavity)
– “Dermoid mesh”: Multiple thin, echogenic lines and dots
caused by hair in the cyst cavity (dot-dash appearance)
– Fat-fluid level
– On CT, 50% contain teeth, 90% contain fat
• CT/MR to confirm
• Tx: excision
 Pelvic Inflammatory Disease
(Pyosalpinx)
• Again, always ask for history of fever,
leukocytosis
• TOA: Painful complex adnexal mass
• Pyosalpinx: Serpiginous mass with
echogenic material
• TOA often bilateral, infection spreads from
one side to other
• As PID progresses ovary appearance varies
from enlargement to complex mass
Hydrosalpinx
 Hyperechoic Hepatic Lesion
(Hemangioma)
• DDx: hemangioma, focal fat, mets, HCC
• Hemangioma
– If < 3 cm, typically homogeneous hyperechoic
• May be hypoechoic in fatty liver
– Occasional posterior acoustic enhancement
– No detectable blood flow on Doppler
– If > 3 cm, tend to be heterogeneous
• If normal LFTs, no known primary, non
cirrhotic, asymptomatic then f/u US in 6 m
• Else, MR or SPECT Tc RBC scan
• Focal fat
– Geometric margins
– Lack of mass effect
• Hyperechoic mets
– Usually from GI tract (esp colon CA), but also RCC, islet
cell, carcinoid and chorioCA
– If calcified, colon and mucinous ovary, breast, stomach
– Mets often hyperechoic in center and hypoechoic in
periphery (“target” appearance, opposite hemangioma
pattern)
• HCC
– High flow in lesion
– Arterial-portal shunting
– Vascular invasion
Hepatic Metastases
Lymphoma
Echogenic HCC
 Pancreatic
Adenocarcinoma
• Most occur in head and present w/jaundice
• Most hypoechoic to rest of pancreas
• Pancreatic/common duct obstruction is
common
• Unresectability: hepatic or peritoneal mets,
involvement of extrapancreatic vessels,
invasion of adjacent organs besides
duodenum, malignant ascites
• DDx: focal pancreatitis, lymphoma, mets
 Pancreatic
Adenocarcinoma
 Internal Carotid Artery
Stenosis
• < 50%: PSV < 125 cm/s (EDV < 40 cm/s; SVR < 2.0)
• 50-69%: PSV 125-229 cm/s (EDV 40-99 cm/s; SVR 2-
3.9)
• ≥ 70%: PSV ≥ 230 cm/s (EDV ≥ 100 cm/s; SVR ≥
4.0)
• Near-occlusion: variable velocity
• Occlusion: absent flow on color/spectral Doppler
• PSV = peak systolic velocity
• SVR = systolic velocity ratio (ICA/CCA)
• EDV = end-diastolic velocity
• Tx
– Endarterectomy
• NASCET: symptomatic, 70-99% (> 50% in
select pts)
• ACAS: asymptomatic, 60-99%
– Stenting
• SAPPHIRE: high risk pts (approved for
symptomatic pts with > 70% stenosis)
• Aliasing
– Caused by inability to detect true peak
velocity b/c Doppler sampling rate is too
slow
– Highest velocities are cut off and wrap
around, appearing below the baseline
– Prevention: decrease probe frequency or
increase PRF or Doppler angle
ICA Occlusion
 Acute Cholecystitis
• Findings
– Gallstones
– Murphy sign
– Pericholecystic fluid
– GB wall thickening (> 3 mm)
– GB enlargement (> 5 cm transverse)
– Possible gangrenous cholecystitis
• Sloughed membranes
• Irregular striated lucencies in the wall
• Focal interruption of GB wall (perforation)
Gangrenous Cholecystitis
Cholelithiasis, WES Sign
Mirizzi Syndrome
Pericholecystic Abscess
 Emphysematous
Cholecystitis
• Elderly male diabetics
• Very bright echoes from a
nondependent portion with dirty
shadowing
• May have ring down artifact
• DDx: porcelain GB (confirm on XR/CT)
 Holoprosencephaly
• Alobar (MC), semilobar, lobar
• Alobar
– Monoventricle w/fused thalami
– Absent falx and corpus callosum
– Brain tissue surrounding monoventricle
– Failure of cleavage of prosencephalon
– Facial abnormalties (proboscis, cyclopia, cleft lip)
– Often assoc w/trisomy 13
– Assoc w/omphalocele, renal dysplasia,
polydactyly, CHD
Cleft Lip and Palate
 Hydranencephaly
• Caused by bilateral supraclinoid ICA infarcts
with loss of nearly all supratentorial brain
– Also may be caused by infection
• Findings: fluid-filled supratentorial space, falx
is present, thalami not fused, no or very little
(posterior circulation) brain tissue
• Normal face
• DDx: holoprosencephaly, maximal
hydrocephalus (mantle of surrounding brain
tissue)
 Portal Vein Thrombosis
• Bland thrombus
– Risk factors: portal HTN, hypercoag state, abdominal
infection/inflammation (appendicitis, pancreatitis)
– Variable gray-scale appearance
– Doppler is helpful, absence of flow
• Cavernous transformation: periportal collaterals
• Tumor thrombus
– Tends to expand the lumen more than bland
– KEY is blood flow within thrombus or arterial
waveform, usually hepatofugal
– Most likely tumor is HCC
Cavernous Transformation
Cirrhosis, Hepatofugal PV
Flow
Portal HTN: Pulsatile PV
Flow
• Causes of cirrhosis: alcohol abuse, viral
hepatitis, biliary disease,
hemochromatosis, parasitic disease
• DDx: infiltrating tumor including HCC,
mets (lung, breast, prostate)
• DDx pulsatile portal venous flow: severe
right heart failure, tricuspid
regurgitation, portocaval shunt, chronic
hepatitis
Tumor Thrombus
Tumor Thrombus
 Twin Gestation (Di-Di)
• Monozygotic twins: ~4 per 1,000 births
– 30% di/di (split within first 2 days of fertilization)
– ~70% mono/di (split 3 to 8 days)  risk of TTTS
– 1% mono/mono (split 9 to 12 days)
– Conjoined twins (> 12 days)
• Monochorionic vs. dichorionic
– If different sexes, dichorionic
• If same sex, could be either
– If 2 placentas, dichorionic
• If one, could be either (2 close together can look like one)
– Thickness of membrane separating fetuses
• > 2 mm: dichorionic
• 1-2 mm: monochorionic, diamniotic
• < 1 mm: mono/mono
– “Twin peak” or lambda sign (10-14 w): chorionic tissue
extending into inter-twin membrane at placenta, dichorionic
– In monochorionic diamniotic, intertwin membrane is very thin
and inserts in a “T” junction
– In 1st trimester, if 2 separate gestational sacs, dichorionic
• Chorionicity main factor in pregnancy
outcome
– Increased miscarriage and perinatal
morbidity/mortality in monochorionic vs.
dichorionic
• Twin-twin transfusion syndrome (stuck twin)
– One fetus has severe oligohydramnios and is
much smaller than the other twin (> 20% growth
discordance)
– Appears stuck to the uterus, not moving with
change in mother’s position
– Other fetus larger, nl or polyhydramnios, may be
hydropic
• Twin embolization syndrome
– Occurs following death of a monochorionic co-twin
– Surviving co-twin “bleeds” into circulation of dead twin
– Results in infarction of rapidly growing tissues (brain)
• Acardiac twin syndrome (TRAP syndrome)
– No functioning cardiac pump
– Blood supply entirely from co-twin
– Arterial-arterial and venous-venous anastomoses
– Anencephalic, microcephalic, acephalic
– Diffuse edema w/cystic hygromas
– UE rudimentary, LE more normal
– No heartbeat
Monochorionic, Diamniotic
Monochorionic,
Monoamniotic
Twin-Twin Transfusion
Conjoined Twins
 Twin Reversed Arterial
Perfusion (TRAP) Syndrome
 Uterine Leiomyoma
• Tend to grow during pregnancy
• If in lower uterine segment or cervix,
may necessitate C-section
• If large, may cause problem with fetal
growth
Lipoleiomyoma
 Congenital Diaphragmatic
Hernia
• MC noncardiac thoracic abnormality
• Usually posterolateral Bochdalek, about 10%
Morgagni (anteromedial)
• Usually see stomach in L chest w/no stomach
in abdomen
• Heart often displaced R or up
• On R more subtle, usually liver goes into chest
– May see portal and hepatic veins, GB, bowel
• Prognosis poor: pulmonary hypoplasia
Congenital Diaphragmatic
Hernia
• DDx nonvisualization of fetal stomach
– Swallowing abnormalities
– Esophageal obstruction
– Congenital diaphragmatic hernia
– Oligohydramnios
 Chiari 2
• Findings: calvarial lemon sign, posterior
fossa banana sign, myelomeningocele,
ventriculomegaly
• Almost all myelomeningoceles assoc
w/Chiari 2
• High morbidity and mortality
– 35% live-born die within first 5 y
• Chiari 2 main cause of death < 2 y
– 50% with IQ > 80
 Placenta Previa
• Findings: placental edge near or covering internal os
(cannot dx before 20 weeks)
• Complete/total: completely covers IO
• Partial: partially covers IO
• Marginal: at margin of IO
• Low-lying placenta: w/in 2 cm of IO
• Marginal sinus placenta previa
– Placental veins near or cross IO
– Maternal veins, not fetal (do not confuse with vasa previa)
• Full bladder can cause a false previa
• 5% have associated accreta/percreta
Vasa Previa
Bilobed Placenta w/Vasa
Previa
Velamentous Cord
Insertion
Succenturiate Lobe
 Gastroschisis
• Paraumbilical (not midline) so cord does
NOT insert onto, can see cord next to it
• No covering membrane, bowel floats freely
• Do not get ascites
• Small bowel protrudes through defect
• NOT associated w/chromosomal
abnormalities
– DO NOT need amniocentesis just for this
• Elevated MS-AFP in abdominal wall defects
• Omphalocele
– Midline defect at umbilicus w/herniation of
abdominal contents into base of cord
– Liver and bowel commonly present
– Covered by a membrane into which cord
inserts
– High incidence of chromosome anomalies
(40%) and cardiac, CNS, GI/GU anomalies
– Cannot dx before 12 w (physiologic
herniation)
Omphalocele
 Posterior Urethral Valves
• Usually causes bilateral hydronephrosis,
dilated bladder, “keyhole” urethra
• Occurs only in males
• Pulmonary hypoplasia from
oligohydramnios
• DDx small thorax: oligohydramnios (PROM,
renal agenesis, renal obstruction), skeletal
dysplasias (Jeune, thanatophoric,
achondrogenesis)
 Groin Pseudoaneurysm
• Hypoechoic collection adjacent to
artery
• Color Doppler: swirling pattern w/flow
toward and away from transducer
• Characteristic to-and-fro waveform at
neck with flow above baseline in
systole and below in diastole
• Tx: US-guided thrombin injection
• AVF
– Bruit on physical exam
– Gray scale usually WNL
– Localized perivascular vibration  random
color in soft tissues
– Low resistance arterial flow (normal
femoral artery has muscular pattern)
– Venous flow is either arterialized (pulsatile),
or turbulent, or loses respiratory phasicity
 Deep Vein Thrombosis
(DVT)
• Findings: noncompressibility +/- echogenic
filling defect, absence of flow, venous
enlargement, loss of phasicity, loss of
augmentation
• Acute tends to enlarge vein with central clot
and peripheral flow
• Chronic tends to have nl or small vein, wall
thickening, central flow
• Tx: anticoagulation (IVC filter if
contraindication)
Normal Phasic Flow
Normal Augmentation
 Loss of
Phasicity/Augmentation
Left Iliac DVT
Postmenopausal bleeding
 Endometrial Thickening
(Hyperplasia)
• Normal premenopausal endometrium
– Up to 4 mm in menstrual phase (days 1-4)
– 8 mm in proliferative phase (days 5-14)
– 16 mm in secretory phase (days 15-28)
• Postmenopausal
– Bleeding: < 4 mm no bx, > 4 mm bx
– Not bleeding: < 8 mm no bx, > 8 mm bx (possible
f/u if on hormone therapy)
• DDx endometrial stripe thickening:
hyperplasia, polyps, cancer, submucosal
leiomyoma, retained products
• Hyperplasia
– Endometrium thickened diffusely or focally
– Uniform thickening favors hyperplasia
• Cancer
– Disruption of junctional zone favors CA
• Sonohysterography can characterize a
polyp/mass vs. uniform hyperplasia 
guides biopsy and other management
• See GU for FIGO staging of endometrial CA
Tamoxifen
Endometrial Polyps
Submucosal Leiomyoma
Endometrial Atrophy
 Renal Cell Carcinoma
• Include in DDx for any renal lesion that is
not a simple cyst
• See GU for Bosniak and staging
• On US, any solid part needs to be further
characterized by CT/MR for enhancement
• Hypoechoic (48%), isoechoic (42%), or
hyperechoic (10%) renal mass
• 20-30% have Ca+
• DDx: AML (look for fat on CT/MR)
Angiomyolipoma
 Failed First Trimester
Pregnancy
• Findings (TVUS)
– Mean sac diameter > 8 mm without yolk sac
– Mean sac diameter > 16 mm without embryo
– Empty amnion sign
– Poor color Doppler signal around gestation sac
– Absent cardiac activity in an embryo > 5 mm
• First trimester oligohydramnios
– MSD – CRL < 5 mm
• Follow up if possible normal IUP
Anembryonic Pregnancy
(MSD 20.3 mm)
Empty Amnion Sign
 First Trimester
Oligohydramnios
Fetal Demise: Spalding
Sign
 Urolithiasis
• DDx ureteral obstruction: stone, tumor, clot,
fungus ball, ureteritis cystica, ureterocele
• DDx nonobstructive dilation: reflux, primary
megaureter
• Acute obstruction findings
– New pelvicaliectasis c/w priors
– Cause for obstruction
– RI > 0.7 or difference in RI b/w sides > 0.1 suggests
obstruction
– Analysis of ureteral jets by color Doppler over 5 min
(before voiding)
 Double Bubble Sign
• 2 connected cysts in abdomen = stomach
and dilated duodenum
• Also see polyhydramnios b/c of obstruction
• DDx double bubble sign: duodenal atresia
(MC), duodenal stenosis, malrotation,
annular pancreas, Ladd bands
• Duodenal atresia assoc w/Down syndrome
 Focal Fat Sparing
• Findings
– Fatty liver (increased echogenicity, loss of
periportal echoes, decreased sound
transmission with depth)
– Characteristic locations: in front of right
portal vein or portal bifurcation, medial left
lobe adjacent to the main interlobar fissure,
around the GB
– Geographic shape, not spherical
– No mass effect on hepatic vessels
• DDx fatty liver
– Obesity
– Alcohol abuse
– Diabetes
– Steroid therapy
– TPN
– Hyperlipidemia
– Pregnancy
– Glycogen storage disease
 Hydatidiform Mole
(Complete)
• Complete mole
– Findings
• Enlarged uterus with hyperechoic tissue
(snowstorm) and good through transmission
• May see small cystic areas
• May have associated ovarian theca lutein cysts
(50%) and ascites
• 85% noninvasive, 13% invade myometrium, 2%
metastasize as chorioCA
– Tx: evacuate, observe for recurrence (f/u HCG)
• Partial mole
– Intrauterine gestation with focal placental
thickening and cystic changes
– Triploid karyotype
• Both associated with high risk for
preeclampsia/eclampsia, fetal
chromosomal and structural anomalies
DDx: Hydropic Placental
Degeneration
 Theca Lutein Cysts

• High beta-HCG
conditions
– Multiple
pregnancies
– Gonadotropin
therapy for
infertility
– Trophoblastic
disease
 Retroperitoneal
Adenopathy
• DDx: germ cell mets (young male),
lymphoma, primary retroperitoneal
sarcoma (liposarcoma, MFH,
leiomyosarcoma, malignant
schwannoma)
 Anencephaly
• MC open neural tube defect
• Absence of cerebral hemispheres and lack
of bony calvarium above orbits
• Resembles a frog, with big eyes and not
much above it
• Normal posterior fossa
• Variable amount of hyperechoic ill-defined
soft tissue above orbits covering the defect
(angiomatous stroma)
 Testicular Microlithiasis
• Findings: diffuse, punctate, nonshadowing,
hyperechoic foci throughout the testicle
• Benign but often assoc w/testicular CA (up
to 40%)
• Almost all are bilateral
• From concretions in seminiferous tubules
• Also assoc w/cryptorchidism, infertility
• Look for associated masses!
 Bicornuate Uterus w/IUP
• Uterine anomalies
– Didelphys (5%): 2 uteri, 2 cervices, 2 vaginas
– Bicornuate (10%): 2 uteri, unicollis/bicollis
– Septate (55%): one uterus w/septum, one cervix
– Unicornuate (20%): one horn (1/2 of a uterus) and
one fallopian tube
– Agenesis/hypoplasia (10%)
• Increased incidence of spontaneous abortion
and infertility
• Urinary tract abnormalities in 20-50%, with
ipsilateral renal agenesis in 5-20%
 Fetal Hydrops
• Excessive fetal body water
• Findings: ascites, pleural effusions,
pericardial effusions, skin thickening,
placental enlargement, polyhydramnios,
+/- hepatosplenomegaly
• Immune: maternal exposure to fetal
antigens, usually Rh, causing fetal
hemolytic anemia
• Nonimmune
– Idiopathic
– Cardiac: arrhythmias, structural defect
– Fetal masses: teratoma and hemangioendothelioma
(increase cardiac output), any mass impeding cardiac
return
– Placental chorioangioma: AV shunting or fetal anemia
from hemolysis
– Chromosome: Turner and trisomy 21 (lymphatic
obstruction)
– Twin-twin transfusion syndrome (recipient)
– Infection: parvovirus (MC), any severe infection
• Tx: fetal blood transfusions (immune),
underlying cause (nonimmune)
 Multicystic Dysplastic
Kidney
• Paraspinous mass with macroscopic
cysts
• Overall kidney size is enlarged
• Bilateral in 20%
• Contralateral renal anomaly (non-
MCDK) in 40%
• Non-renal anomalies in 5%
• Follow amniotic fluid volume carefully
UPJ Obstruction (R), MCDK
(L)
 Ureteropelvic Junction
Obstruction (Bilateral)
• Hydronephrosis w/o hydroureter or bladder
dilatation
• Distention ends abruptly at UPJ
• Bilateral in 10%
• Contralateral renal abnormality in 25%
• Extrarenal anomalies in 10%
• Polyhydramnios in 1/3
• Oligohydramnios if obstruction is bilateral
and severe
 Acute Appendicitis
• Findings
– Tubular bowel in RLQ with diameter > 6 mm,
noncompressible and nonperistaltic
– Appendicolith: echogenic shadowing structure
– Periappendiceal inflammation seen as
increased echogenicity in fat
– Usually see hyperemia on Doppler
– Periappendiceal fluid collection suggests
perforation
• US accuracy about 90%
 Parathyroid Adenoma
• Findings
– Usually homogeneous hypoechoic,
hypervascular, long axis in the vertical direction
• If adenoma not found adjacent to thyroid,
MC ectopic locations are superior
mediastinum, retrotracheal,
tracheoesophageal groove, carotid sheath
• False positive: lymph nodes, thyroid nodules,
esophagus, longus colli
• False negative: small or ectopic
Parathyroid Carcinoma
 Thyroid Nodule (Colloid
Cyst)
• Nucs
– Hot: < 1% risk malignancy
– Cold: 15-20% risk, much less if multiple
• Benign US characteristics
– Uniform, well-defined thin hypoechoic rim, peripheral
eggshell Ca+, hyperechoic to gland, primarily cystic,
comet-tail artifact
• Cancer: solid, ill-defined, hypoechoic nodule,
punctate microcalcs, chaotic intranodular vessels
• Generally, biopsy anything over 1 cm
Benign (Follicular
Adenoma)
Malignant (Papillary CA)
 Renal AVF
• Usually post biopsy, trauma
• Findings
– Bursts of color (turbulence) in adjacent kidney
from vibration of briskly flowing blood in fistula
– Spectral tracing may show increased arterial
velocity, low resistance, high diastolic flow
– Draining vein shows turbulent pulsatility
(arterialization)
• May require embolization
 Trisomy 21
• Atrioventricular septal defect
• Duodenal atresia
• Increased nuchal translucency: at 11-14 w, > 3 mm abnl
• Second trimester minor markers (15-20 w): ≥ 1 marker seen
in 50-70% of T21 fetuses
– Nuchal thickening: > 5 mm abnl
– Short femur and humerus
– Echogenic bowel: as bright as bone
– Intracardiac echogenic focus: left or right ventricle, as bright as bone
– Renal pelviectasis: > 3 mm abnl, anterior-posterior measurement
– Absent or hypoplastic nasal bone
– Fifth finger clinodactyly: hypoplastic middle phalanx, distal finger
curves inward
– Sandal gap foot: wide gap b/w 1st and 2nd toes
• First trimester screening (11-14 w)
– Maternal serum free beta-HCG + pregnancy-
associated plasma protein A + nuchal
translucency measurement
– Sensitivity 80-90% for T21, 5% false-positive
• Second trimester screening (15-20 w)
– Maternal beta-HCG + estriol + alpha-
fetoprotein
– Sensitivity 60% for T21, high false-positive (
increased amniocentesis of nl pregnancies)
Echogenic Bowel
 Renal Artery Stenosis
• Suspect w/new onset HTN at extremes of age, or
HTN that is very difficult to treat
• Findings (diameter reduction > 60%)
– Peak main renal artery velocity > 200 cm/s (normal 75-
125 cm/s)
• May see aliasing
– Peak main renal artery/aorta velocity ratio > 3.5
– Other less useful criteria
• Tardus et parvus intrarenal arterial waveform
• Early systolic acceleration < 300 cm/s^2
• Acceleration time > 70 msec
• Difference in size b/w kidneys
• Intrarenal arterial RI < 0.5
 Choroid Plexus Cyst
• Unilateral or bilateral
• Assoc w/abnormal karyotypes esp
trisomy 18, but less commonly Down,
Turner, Klinefelter
• > 1 cm, offer amnio (controversial)
• 30% of trisomy 18 and 2% of normals
• Cysts usually resolve by 24 weeks
• Size and bilaterality are not helpful
• Trisomy 18
– Choroid plexus cyst + other anomalies
– Early intrauterine growth restriction
– Increased nuchal translucency
– Cardiac defects
– Clenched hands + overlapping index finger (50%)
– Arthrogryposis
– Rockerbottom foot
– Dandy-Walker variant (T18 common)
– Omphalocele: often bowel-containing (20%)
– Strawberry shaped calvarium (45%)
– Single umbilical artery
Choroid Plexus Cysts
AV Canal Defect
Strawberry Calvarium
Left Vertebral Artery
 Subclavian Steal
• Reversal of flow in vertebral artery indicates
stenosis or occlusion at origin of subclavian or
innominate artery
• May cause symptoms of vertebrobasilar
insufficiency, especially with arm exercise
• If partial/not severe, may have retrograde flow
in systole and antegrade in diastole
• If any doubt, ask for color flow in both carotid
& vertebral – should be going in the same
direction
Complete Subclavian Steal
 Ventriculomegaly
• Due to increased pressure (hydrocephalus)
or absence of brain tissue
• Atrio-occipital regions usually affected first
• Findings
– Atria measure > 10 mm
– “Dangling” choroid plexus
• Aqueductal stenosis common cause of
noncommunicating hydrocephalus
• Guarded prognosis (70% mortality)
• Many other associated anomalies
– Neural tube defects (myelomeningocele,
Chiari 2), holoprosencephaly, Dandy-
Walker, agenesis of corpus callosum,
aqueductal stenosis, cephalocele,
infection, hemorrhage, trisomies,
syndromes
Aqueductal Stenosis
 Epididymo-Orchitis
• Usually epididymis affected first, and
the testicle secondarily
– Viral infections (mumps) can cause
isolated orchitis
• Findings
– Enlarged, hypoechoic epididymis +/-
testicle
– Hypervascularity, scrotal wall thickening >
8 mm, +/- hydrocele
 Duplicated Collecting
System
• Case findings
– Cystic structure in upper pole of kidney
(obstructed upper pole collecting system)
– Cystic structure in bladder (ectopic
ureterocele)
 Renal Transplant
Complications
• Renal vein thrombosis
– Occurs within the 1st week after the
transplant
– Findings
• Enlargement of the kidney
• Absent venous flow by color and duplex
• Reversal of arterial flow in diastole (DDx: ATN,
rejection)
• Grey scale may show thrombus in the vein
 Renal Transplant
Complications
• Acute rejection
– Swelling of both parenchyma and urothelium
– Enlarged hypoechoic pyramids
– Decreased visibility of the renal sinus
– Areas of cortical hypoechogenicity
– Color/power Doppler may show diminished flow in
the periphery
– Doppler waveform shows reduced or absent
diastolic flow (elevated RI > 0.7)
– DDx: acute tubular necrosis, cyclosporin toxicity
• Acute tubular necrosis
– Swollen kidney with enlaged hypoechoic
pyramids and decreased diastolic flow
– Best way to distinguish with rejection is by
time course
• ATN usually occurs early in 1st week and resolves by
10 d
• Rejection occurs later, does not resolve quickly
• Cyclosporin toxicity occurs later, so does not
overlap with ATN, but does overlap with acute
rejection
 Intratesticular Mass
(Embryonal Cell Carcinoma)
• Solid intratesticular lesions tend to be malignant,
especially if palpable
• Most testicular tumors are hypervascular
• Most are germ cell in origin, MC seminoma (MC
tumor in young male), mixed germ cell next MC
• Seminomas usually homogeneous hypoechoic
• Teratomas generally malignant, heterogeneous
w/Ca+
• Embryonal and chorioCA generally more
aggressive looking
• Non germ cell mostly Leydig and Sertoli,
solid but variable echotexture
• Solid testicular masses could also be
leukemia or lymphoma
– Diffuse enlargement, heterogeneity, or focal
mass
– Both hypervascular
• DDx: testicular CA, epidermoid cyst,
lymphoma/leukemia, mets, focal infection,
hematoma, contusion, infarct
Seminoma
 Epidermoid Cyst
• “Target/bull’s eye” appearance of an avascular
testicular “mass”
• Sharply circumscribed encapsulated round “mass”
• “Onion-skin” appearance due to alternating hypo-
and hyperechoic rings
• Hyperechoic fibrous cyst wall +/- shadowing from
calcifications/ossifications
• Hypoechoic cyst contents (laminated keratin
debris)
• Color Doppler: avascular
 Testicular Rupture
• US 95% accurate for rupture
• Findings
– Loss of definition of testicular margins
– Loss of normal oval shape
– Protrusion of parenchyma beyond margins of
testicle
• Other sequela of trauma include contusion,
edema, hematoma, even torsion
• Sometimes tumors brought to attention (get
f/u of solid lesion post trauma)
Testicular Rupture
 Adrenal Lesions
(Hemorrhage)
• Normal adrenals: thin disc-like paraspinal
structures, echotexture similar to kidney,
hyperechoic medulla and hypoechoic cortex
• DDx enlarged adrenal in fetus/child:
hematoma (initially hyperechoic 
hypoechoic), neuroblastoma
• DDx in adult: adenoma, mets, carcinoma,
pheochromocytoma, myelolipoma,
hyperplasia (bilateral), cysts, hematoma
Normal Adrenal Gland
Myelolipoma
 Peripheral Arterial Occlusive
Disease
• Pulsed Doppler
– Normal
• Triphasic waveform, no spectral broadening
– 1-19% diameter reduction
• Triphasic waveform with minimal spectral broadening
• PSV increase < 30% relative to adjacent proximal segment
• Proximal and distal waveforms remain normal
– 20-49% diameter reduction
• Triphasic waveform, but reverse flow diminished
• Spectral broadening prominent
• PSV increase 30-100% relative to adjacent proximal segment
• Proximal and distal waveforms remain normal
– 50-99% diameter reduction
• Monophasic waveform, loss of reverse flow and forward flow throughout cardiac cycle
• Extensive spectral broadening
• PSV > 100% relative to adjacent proximal segment
• Distal waveform monophasic with reduced systolic velocity
– Occlusion
• No flow
• Distal waveform monophasic with reduced systolic velocity
• Bypass graft stenosis
– Most occur at proximal or distal
anastomosis
– Early causes: surgical problems with
anastomosis, clamp injuries, AV fistulas
– Late causes: intimal hyperplasia
Normal Peripheral Artery
 Medullary
Nephrocalcinosis
• Calcification in renal pyramids
• Early: hyperechoic rim surrounding pyramids
• With progression, will involve whole pyramid
and will shadow
• MC causes in adults: hyperparathyroidism,
medullary sponge kidney, renal tubular
acidosis
• MC cause in neonates: Lasix
– DDx: transient renal medullary hyperechogenicity
Cortical Nephrocalcinosis
• Cortical nephrocalcinosis
– Much less common
– MC causes: severe ischemia with cortical
necrosis, hyperoxaluria (cortical or
medullary), chronic glomerulonephritis
– Cortex calcifies, and entire kidney may
look echogenic or kidney may be almost
entirely obscured by shadowing
Portal venous gas.swf
 Portal Venous Gas
• MC causes: NEC and bowel infarction
– Less common: abdominal abscess, UC,
gastric ulcer
• Findings
– Moving hyperechoic foci in the lumen of
main portal vein and portal vein branches
– Hyperechoic foci in liver
– Doppler: sharp bidirectional spikes
superimposed on usual portal vein waveform
 Oligohydramnios
• Amniotic fluid index: add largest vertical
fluid pocket in each quadrant
– < 5 cm is oligohydramnios
• DDx (“DRIP”)
– Demise of fetus, drugs
– Renal abnormalities (bilateral renal agenesis and
anything leading to bilateral obstruction)
– IUGR
– Premature rupture of membranes, postmaturity
• Symmetric IUGR (diminished cellular growth)
– Occurs early in pregnancy from insult to mother
– Head and body equally affected
– Causes: chromosomal abnormalities, drug toxicity, in utero
infection
– Fetal weight < 10th percentile
• Asymmetric IUGR (fetal malnutrition)
– Constitutes majority of cases (90%)
– Initial loss of fetal subcutaneous tissues and glycogen stores
– Head and limbs affected to lesser extent
– Placental and maternal causes predominate: HTN, smoking,
DM, collagen vascular disease, placenta previa, placental
infarction
 Polyhydramnios

• Causes: idiopathic
(33%), maternal DM
(25%), multiple
gestations (10%),
fetal anomalies
(20%), fetal hydrops
(12%)
 Placental Abruption
• Premature separation of placenta from uterus
– May be marginal (MC), retroplacental, preplacental
• Usually presents w/vaginal bleeding, pain and
tenderness over the uterus
• Risk factors: prior hx (17x risk), trauma (7x
risk if MVA), HTN/cocaine, smoking, advanced
maternal age, leiomyoma (2.6x risk)
• Variable echotexture depending on age of
blood
– When isoechoic, can look like enlarged placenta
Placental Abruption
 Inguinal Hernia
• Findings
– Echogenic mass with shadowing
(mesentery) and peristalsis if it contains
bowel
– May increase in size if pt stands or
Valsalvas
 Choledocholithiasis
• Intrahepatic biliary dilatation
– Parallel channels adjacent to portal veins, > 40% of
diameter of adjacent portal vein
• Biliary duct vs. vessel
– No flow w/Doppler
– Good through transmission
– Tortuous w/irregular walls
– Stellate configuration centrally, near porta hepatis
• Common duct: < 7 mm up to age 70 and then
add 1 mm per decade
– Except if s/p cholecystectomy, then 10 mm
• Choledocholithiasis
– Majority appear as highly echogenic foci
with posterior acoustic shadowing
– Small (< 5 mm) or soft pigmented stones
may not produce posterior shadowing
– Larger stone may cause biliary obstruction
with focal intrahepatic ductal dilatation
– MC in region of ampulla of Vater, high
chance of being obscured by bowel gas
• Mirizzi syndrome
– Common duct obstruction due to a stone in
the cystic duct or GB neck
– Obstruction caused either by stone or the
inflammation
– Think of this when stone seems to extend
beyond the confines of the common duct
 Echogenic Kidneys
• Assoc findings may include cortical thinning
and small size
• DDx small echogenic kidneys: chronic renal
disease (glomerulonephritis, HTN
nephrosclerosis, analgesics), medullary
cystic disease, bilateral RAS
• DDx large echogenic kidneys: diabetic
nephropathy (MC), acute glomerulonephritis,
ATN, SLE, HIV, lymphoma
HIV Nephropathy
 Cervical Incompetence
• Assoc w/preterm delivery
• Often result of trauma to cervix from prior
abortion or surgery
• Cervical length: normal > 3 cm, 2-3 cm
borderline, < 2 cm incompetent
• Opening of internal os > 3-6 mm also =
incompetence
• Image TV w/empty bladder or translabial
• Tx: cerclage
 Achondroplasia
• Autosomal dominant or spontaneous mutation
– Homozygous lethal, heterozygous not
• Normal early scan, rhizomelic long bone
shortening after 22 weeks
• Normal ossification without fractures
– No bowing or angulation seen prenatally
• Progressive macrocephaly w/frontal bossing
• Prominent thoracolumbar kyphosis
• Trident hand is characteristic
 Osteogenesis Imperfecta
• Presence of fractures distinguishes OI from
other skeletal dysplasias
• Callus formation gives bones a “crumpled”
appearance
• Decreased mineralization
• Multiple rib fractures (“beading”)
• Skull deformation from transducer pressure
(“soft” bones)
• DDx: hypophosphatasia
 Thanatophoric Dysplasia
• Lethal, not inherited
• TD type I: “Telephone receiver” femur
• TD type II: Kleeblattschädel (“cloverleaf”)
skull
• Short, bowed long bones
• Narrow thorax and short ribs
• Platyspondyly
• Normal ossification
• Trident shaped hands
 Achondrogenesis
• Autosomal recessive, usually lethal
• Severe micromelia
• Lack of vertebral ossification
• Disproportionately large head with either
normal or deficient ossification
• Small thorax with protuberant abdomen
• Short flared ribs with or without fractures
• Cystic hygroma
• Hydrops in 1/3
 Cystic Hepatic Lesion
(Biliary Cystadenocarcinoma)
• If simple or almost simple, probably hepatic cyst, very
common
• DDx complex hepatic cyst
– Necrotic tumor (mets or primary)
– Abscess (thick wall, +/- fluid/fluid levels and gas)
– Hematoma, hemorrhagic cyst
– Biloma
– Infection: echinococcus (daughter cysts), amebiasis (uniform
low level internal echoes)
– Biliary cystadenoma or carcinoma
– Hemorrhagic adenoma
– Aneurysm/pseudoaneurysm (always put color on everything!)
Echinococcal Cyst
Echinococcal Cyst
 Autosomal Recessive
Polycystic Kidney Disease
• Not really cysts, but tubular ectasia
• Findings
– Large echogenic kidneys, absent or small bladder
– Oligohydramnios from poor urine output
– May get pulmonary hypoplasia with Potter facies
• Meckel-Gruber syndrome: renal cystic
dysplasia (95-100%), encephalocele (60-
80%), postaxial polydactyly (55-75%)
Meckel-Gruber Syndrome
 Inferior Vena Cava
Thrombosis
• DDx: bland, tumor (HCC, RCC in adults,
Wilms in peds), membranous (echogenic web
near diaphragm)
• If see echogenic material in IVC, get Doppler
• If flow in clot  tumor thrombus
– Also, tumor tends to expand vein > bland
• Evaluate kidneys and liver carefully for tumor
• May cause Budd-Chiari (ascites, abdominal
pain, hepatomegaly) or lead to portal HTN
Budd-Chiari
Passive Hepatic
Congestion
 Perigraft Fluid Collection
(Lymphocele)
• Definitive dx established by US-guided needle aspiration
• Cystic structures: anechoic or hypoechoic with posterior
enhancement
• Lymphocele (MC, 4-8 w): well-defined, large anechoic or heavily
septated
• Urinoma (within 3 w): localized or free anechoic collections without
septations
• Hematoma (early postop): echogenicity depends on age of
collections
• Seroma (early postop): typically anechoic
• Abscess: typically complex cystic with irregular outline, thick wall
and echogenic internal debris
• Color Doppler: useful to differentiate from complex cystic masses
(vascularity)
 Epididymal Cyst
• 20-40% of asymptomatic males
• More common in adults
• Single or multiple, mostly in epididymal
head
• Simple or septated
• Spermatoceles have spermatic elements
(25% of cysts)
– Contain low level echoes
– More common after vasectomy
 Vein of Galen
Malformation
• Cystic structure posterior to 3rd
ventricle
• Ask for color Doppler
 Multiple Testicular Masses
(Lymphoma)
• DDx: leukemia/lymphoma (diffuse or
discrete), mets, abscesses, adrenal rest
– Less common: multiple primary tumors,
multiple infarcts or contusions, multifocal
orchitis
 Cardiac Rhabdomyoma
• Typically associated with tuberous
sclerosis
• Hyperechoic and arise from muscle of
the walls or septum
• If you see an intracardiac mass in
utero, this is the most likely diagnosis
Cardiac Rhabdomyoma
 Sacrococcygeal Teratoma
• MC congenital tumor, occurs in sacral
region
• 4 types, with type 1 completely external to
type 4 which is completely internal
• Often solid or mixed solid/cystic
• Can become malignant if not removed, with
types 3/4 having highest malignant
potential
• DDx: myelomeningocele
Sacrococcygeal Teratoma
 Adenomyomatosis
• Hyperplastic cholecystosis = cholesterolosis,
adenomyomatosis
• Adenomyomatosis: mural GB wall thickening due
to exaggeration of normal luminal epithelial folds
(Rokitansky-Aschoff sinuses) in conjunction
w/smooth muscle proliferation
• Cholesterolosis: deposition of foamy cholesterol-
laden histiocytes in subepithelium of GB;
numerous small accumulations (strawberry GB)
or larger polypoid deposit (cholesterol polyp)
• Cholesterolosis
– Multiple small GB polyps with no posterior
acoustic shadowing or “comet-tail” artifact
• Adenomyomatosis
– Focal or diffuse GB wall thickening
– Tiny echogenic foci in GB wall producing
“comet-tail” artifacts
– Cystic spaces within GB wall
• DDx diffuse GB wall thickening
– Systemic edema: CHF hypoalbuminemia,
sepsis, renal disease
– Adjacent inflammation: hepatitis, pancreatitis
– Cholecystitis (acute or chronic)
– Ascites
– AIDS
– Contraction (nonfasting)
• DDx focal GB wall thickening
– GB carcinoma, adenomyomatosis, cholecystitis
(gangrenous), mets
Adenomyomatosis
 Autosomal Dominant
Polycystic Kidney Disease
• Findings
– Large kidneys with multiple cysts
– MR to further evaluate complex cysts
 Hematometrocolpos
• Fluid in endometrial cavity may be blood, mucus, or
purulent material
• Hematometra: blood in endometrial cavity
• Hematocolpos: blood filling the vagina
• Postmenopausal causes of fluid in uterine cavity:
cervical stenosis, cervical CA, endometrial CA,
endometrial polyps, pyometrium
• Premenopausal: congenital obstruction (imperforate
hymen, vaginal septum, vaginal or cervical atresia),
acquired cervical obstruction (instrumentation,
radiation, or CA), menorrhagia, and pregnancy
 Varicocele
• Dilated serpiginous veins of pampiniform plexus
• 15-20% of males
• MC correctable cause of male infertility
• 85% occur on left (left spermatic vein drains into
left renal vein; because SMA compresses left
renal vein, pressure on left > right), 15%
bilateral
• DDx isolated right-sided varicocele: compression
of right spermatic vein by retroperitoneal
masses, situs inversus
• US Findings
– Gray-scale: numerous, dilated, tortuous,
tubular channels in peritesticular tissues
• Upper limit of normal caliber scrotal veins is 2
mm
– Readily detectable Valsalva-induced flow
augmentation on color Doppler when
patient is supine
• May be accentuated in upright position
 Hashimoto Thyroiditis
• Autoimmune disease that affects primarily women
between 40 and 60 y
– Autoantibodies to thyroid proteins, esp thyroglobulin
• MC cause of hypothyroidism, goiter in adults in US
• May coexist w/other autoimmune disorders
(Sjögren syndrome, lupus, rheumatoid arthritis,
fibrosing mediastinitis, sclerosing cholangitis,
pernicious anemia)
• Pts at slight increased risk of developing thyroid
lymphoma
• Findings
– Diffuse thyroid enlargement with
inhomogeneous low-density parenchyma
– Thin, echogenic fibrous strands may cause a
multilobulated or micronodular appearance
– No normal parenchyma is present
– Often the gland is extremely hypervascular
– Pattern of multiple, tiny nodules, 1 to 6 mm in
size, is highly indicative of the disease
– In end stage, the gland becomes atrophic
 Intussusception
• See Peds
 Hydrocele
• Scrotal fluid collections
– Hydrocele: accumulation of serous fluid b/w visceral
and parietal layers of tunica vaginalis
• MC cause of painless scrotal swelling
• Many cases are idiopathic
• May accompany malignant tumors, torsion, inflammation
– Funiculocele (hydrocele of cord): hydrocele fluid
accumulates in spermatic cord in unobliterated
portion of tunica vaginalis
• Appears superior to the testis
• Distinguished from spermatocele because does not arise
from epididymis
• Scrotal fluid collections (cont.)
– Hematoceles result from trauma or surgery
– Pyoceles usually result from rupture of an
abscess into space b/w layers of tunica
vaginalis
• Internal septations and loculations
common with hematoceles and
pyoceles, often in conjunction with
scrotal wall hyperemia
Hematocele
 Prostate Carcinoma
• MC malignant tumor and second MC cause of cancer-
related mortality in men
• MC in blacks, less common in whites, uncommon in Asians
• 50% in 50s and 80% in 80s will have at least microscopic
foci of prostate cancer
• Most clinically occult
• Screening: digital rectal examination and serum prostate-
specific antigen (PSA) testing
– Normal serum PSA level is 0 to 4 ng/mL; borderline 4-10 ng/mL;
abnormal > 10 ng/mL
• 70% of cancers occur in peripheral zone, 5% in central
zone, 20% in transitional zone
• Findings
– Distinct hypoechoic nodule
– Poorly marginated hypoechoic area in peripheral zone
– Mass effect on surrounding tissues
– Asymmetric enlargement of the prostate
– Deformation of prostatic contour
– Focal increased vascularity in peripheral zone with color flow US
• DDx peripheral hypoechoic nodule in prostate: carcinoma,
benign prostatic hypertrophy, prostatitis, atrophy,
fibrosis, infarction, fibromuscular hyperplasia
• Indications for US-guided needle biopsy: suspicious
palpable nodule, suspicious nodule visualized by US, or
elevated PSA
 Tubular Ectasia of the Rete
Testis
• May mimic a complex intratesticular mass
• Findings
– Multiple small spherical or tubular cystic
structures in region of mediastinum of testis
– Usually bilateral, although can be asymmetric
– Nearly all cases assoc w/abnormalities of
epididymis, including spermatocele, epididymal
cysts, or history of epididymitis or vasectomy
• Does not require further evaluation or f/u
Low Intrauterine Device
IUD w/Uterine Perforation
 Hypertrophic Pyloric
Stenosis
• Most often presents b/w 2-10 w
• US is preferred examination
• Findings
– > 3 mm in thickness, and the pyloric canal
is elongated beyond 15-18 mm
– Pylorus is in fixed spasm and very little
fluid passes through it
• Tx: pyloromyotomy
Hypertrophic Pyloric
Stenosis
• UGI
– “Double/triple track sign”:
crowding of mucosal folds in
pyloric channel
– “String sign”: passing of
barium streak through
pyloric channel
– “Mushroom sign”:
indentation of base of
duodenal bulb
– “Caterpillar sign”: gastric
hyperperistaltic waves
 Aortic Dissection
• US not primary tool for evaluation
• CTA preferred for suspected cases
• See Chest
 Chronic Pancreatitis,
Pseudocyst
• Caused by recurrent and prolonged bouts of acute
pancreatitis  parenchymal atrophy and progressive
fibrosis
• MC causes: alcohol abuse (70%) and biliary stone disease
(20%)
– Many of remaining pts may have autoimmune pancreatitis that
responds to steroid therapy
• Findings
– Dilation of pancreatic duct (70-90%), usually in a beaded pattern
– Pancreatic atrophy
– Calcifications (40-50%; usually alcoholic) in parenchyma
– Fluid collections
Acute Pancreatitis
 Cholangiocarcinoma
• See GI
Congenital Pulmonary Airway
Malformation
• See Peds
• DDx fetal intrathoracic mass
– CPAM
– Pulmonary sequestration
– Laryngeal/tracheal/bronchial atresia
– Congenital diaphragmatic hernia
– Bronchopulmonary foregut abnormality
– Teratoma
Pulmonary Sequestration
Pulmonary Sequestration
Hypoplastic Left Ventricle
 Transposition of the Great
Arteries
• Findings: parallel orientation of great
arteries with absence of normal
“crossover” as the vessels leave the
heart
 Clubfoot (Talipes
Equinovarus)
• 1 in 1,000 births, M:F 2-3:1
• Hindfoot equinus, hindfoot varus, and
forefoot varus
• Findings: bones of foot in same plane
as those of tibia/fibula
 Rocker Bottom Foot
(Congenital Vertical Talus)

• Bottom of the foot

is convex with
protrusion of the
heel
• Assoc w/trisomy 18
 2-Vessel Cord
• Findings
– Axial image of pelvis shows 1 umbilical
artery
– Color Doppler shows 2 vessels in umbilical
cord
• High association (50%) w/other
anomalies
 Bowel Obstruction
(Jejunal Atresia)
• Findings
– Dilated bowel filled with fluid and debris
– Peristalsis within dilated loop
– Polyhydramnios, greater w/proximal
obstruction
 Osteogenesis Imperfecta
• Findings
– Compressibility of skull with external
pressure
– Easy visibility of intracranial structures due
to poor ossification
– Fractures
 Placental Chorioangioma
• Benign vascular placental mass
supplied by the fetal circulation
• Findings
– Solid hypoechoic, sometimes septated,
mass in the placenta, usually close to the
chorionic surface
– Doppler demonstration of arterial
waveforms at fetal heart rate in vessels
supplying tumor is diagnostic
 Dandy-Walker
Malformation
• Maldevelopment of roof of fourth ventricle
• Findings
– Cisterna magna is enlarged and communicates
directly with fourth ventricle through its absent
roof
– Posterior fossa is enlarged, and tentorium is
elevated
– Hypoplasia or absence of cerebellar vermis and
cerebellar hemispheres
– Hydrocephalus is usually present
DDx: Mega Cisterna
Magna
DDx: Arachnoid Cyst
 Mesoblastic Nephroma
• MC renal tumor of the neonate
• Like Wilms tumor, arises from
metanephric blastema, and these
tumors are indistinguishable on US
 Amniotic Band Syndrome
• Caused by early (before 10 w GA) disruption of
amnion  allows fetus to enter chorionic cavity
• Fetus becomes entangled in fibrous bands that cross
chorionic cavity
• Entrapment of fetal parts results in amputation
deformities
– Asymmetric absence of cranium resembling anencephaly,
encephaloceles, gastroschisis and truncal defects, spinal
deformities, and extremity amputations
• Amniotic bands trapping the fetus may be visualized
• DDx: amniotic synechiae, circumvallate placenta
Amniotic Synechiae
Circumvallate Placenta
 Meconium Peritonitis
• Results from perforation of a bowel
segment
• Spillage of meconium into peritoneal
cavity causes sterile peritonitis  Ca+ in
peritoneal cavity, meconium
pseudocysts, ascites, bowel dilatation,
polyhydramnios
• Causes: meconium ileus (cystic fibrosis),
bowel atresia, volvulus
 Diastematomyelia
• Spinal cord is “split” into two
hemicords by a sagittal bony or
cartilaginous spur
• Most occur in lower thoracic region and
are accompanied by vertebral
segmentation abnormalities
• Syrinx develops in 50%
 Fetal Gallstones
• Rare benign findings
• Can spontaneously resolve
• DDx: liver calcifications, meconium
peritonitis
 Upper Respiratory Tract
Atresia
• Laryngeal, tracheal
• Findings
– Markedly enlarged and echogenic lungs
– Bronchi may be dilated, filled with fluid
– Bilateral
 Splenic Mass
(Hemangioma)
• Hemangioma
– Variable size & echogenicity, well defined hyperechoic
solid to mixed to purely cystic lesion
• Hamartoma
– Well-defined, homogeneous echogenic mass, good
through transmission & posterior enhancement
– Increased blood flow on color Doppler
• Lymphoma
– Three macroscopic patterns: diffuse/infiltrative,
miliary/nodular, focal hypoechoic/cyst-like (without
posterior acoustic enhancement)
• Leukemia & myeloproliferative disorders
– Diffuse enlargement of spleen with variable
echogenicity
– Very rarely focal hypoechoic nodular lesions
• Metastases
– Multiple focal lesions with variable size &
appearance
– Iso-/hypo-/hyperechoic
Hamartoma
Lymphoma
Candida Microabscesses
Splenic Infarct
 Transplant Hepatic Artery
Stenosis
• Tx: angioplasty, stenting
• US w/Doppler is imaging method of choice for evaluation of liver
transplant
• Peritransplant fluid collections common in immediate posttransplant
period
– Simple anechoic: ascites, bile, and lymph
– Fluid w/particulate matter: usually pus or blood
• Hepatic artery complications (60% of vascular complications)
– Thrombosis, stenosis, and pseudoaneurysms
– Thrombosis and stenosis of portal vein or IVC are uncommon
• Bile leaks, bile duct anastomotic strictures, necrosis of bile ducts,
and stones in bile ducts account (25% of complications)
• Posttransplant lymphoproliferative disorder occurs 4 to 12 m after
transplantation
• Findings
– Hepatic artery thrombosis: no arterial signal detected
on duplex or color Doppler
– Arterial stenosis
• PSV > 200 cm/s or focal increases of greater than threefold
suggest stenosis > 50%
• Parvus tardus waveforms distal to stenosis
– Portal vein, hepatic vein, IVC thrombosis: same
appearance as in native livers
– Portal vein stenosis: threefold to fourfold focal increase
in flow velocity in portal vein
– Stenosis of IVC at superior anastomosis: focal velocity
elevation, loss of pulsations in hepatic veins and
proximal IVC, hepatic vein flow reversal
– Rejection: loss of hepatic vein pulsatility reported
Umbilical Artery
 Umbilical Artery Doppler
• Umbilical artery S/D ratio considered abnormal
if > 3 at 30 w
– Before 20 w, high resistance flow
– As pregnancy progresses, placental resistance
decreases
• MCA doppler
– Provides measure of fetal CNS vascular resistance
– With fetal hypoxia  cerebrovascular impedance
decreases (MCA/UA S/D ratio < 1.1 = bad)
– Increased PSV seen w/fetal anemia
• PSV (cm/s) ~ 2 x GA (w) = moderate to severe anemia
Normal S/D Ratio
MCA Doppler
 Velamentous Cord
Insertion
• Cord inserts on membrane rather than
placenta
Marginal Cord Insertion
 Multiple Echogenic Hepatic
Foci
• DDx
– Viral hepatitis
– Candidiasis
• 4 patterns: “wheel-within-a-wheel,” “bull’s
eye,” hypoechoic nodule, echogenic foci
– AIDS
• PCP
• MAI
• CMV
Hepatic Candidiasis
 Polycystic Ovarian
Syndrome
• Clinical and biochemical dx based on findings of
hirsutism, amenorrhea, infertility, obesity
• Polycystic ovaries defined as 12 or more follicles in
at least 1 ovary measuring 2-9 mm in diameter or a
total ovarian volume of > 10 cm3
– May be oriented peripherally (“string of pearls”)
• Rotterdam criteria (2 out of 3)
– Oligoovulation and/or anovulation
– Excess androgen activity
– Polycystic ovaries
– + Exclude other endocrine disorders (hyperprolactinemia,
hypothyroidism, congenital adrenal hyperplasia)
 Scrotal Pearl (Scrotolith)
• Calcified bodies within the scrotum
• No clinical importance
• May represent a loose body caused by torsion of
appendix testis or epididymis
• DDx: healed meconium peritonitis
• DDx intratesticular macrocalcifications
– Large cell calcifying Sertoli cell tumor, burned-out germ
cell tumor (Azzopardi tumor), posttraumatic change
• DDx epididymal calcifications
– Inflammatory conditions: TB, trauma
Torsion of Appendix Testis