Search

Study Objective: Hematocolpos or hydrocolpos in menstruating women raises suspicion of a partial uterine or vaginal obstruction. The study objective is to report two unusual cases of a spastic pelvic floor leading to urine collecting in the vagina and mimicking an outflow obstruction., Design, Setting, Participants: The study took place at a tertiary care university's Reproductive Health Care Clinic for Women with Developmental Disabilities and involved two patients with spastic quadriplegic cerebral palsy and developmental disabilities who presented with irregular menses and abdominal pain and whose radiological evaluations were suspicious for an outflow obstruction. Medical records, including clinic visits, radiological findings, and surgical findings, were reviewed., Interventions: Both patients underwent ultrasound and MRI evaluation of their reproductive tracts that demonstrated fluid collections in the vagina. An examination under anesthesia was performed in one patient to rule out an obstruction. In the second patient, a pelvic examination under ultrasound observation revealed initial vaginal distension with urine, which resolved after placement of a speculum., Results: In both cases, the pseudo-obstruction was felt to be a urine-distended vagina due to a spastic pelvic floor., Conclusion: A spastic pelvic floor in an incontinent patient with spastic quadriplegia may result in urine accumulation in the vagina, mimicking an outflow tract obstruction. If the history, pelvic examination, and radiological images are inconsistent, performing an ultrasound-guided examination may assist with diagnosis.

Rationale and Objectives: The purpose of this study was to determine relative rates of missed diagnoses for radiologists as a measure of competence in interpreting chest radiographs., Materials and Methods: Cases involving differing interpretations of chest radiographs were collected from January 1994 through December 1999 by faculty (chest and nonchest radiology specialists) in an academic radiology department. A quarterly peer-review process designated cases months after the fact, and anonymously, as no miss or as class I (nondiagnosable), class II (very difficult diagnosis), class III (should be diagnosed most of time), or class IV (should almost always be diagnosed) missed diagnoses. The rates and classes of missed diagnoses were compared among chest faculty and for the nonchest radiology specialists as a group., Results: Chest radiologists read 184,977 studies, and nonchest radiologists read 300,684 studies. Of these, 243 missed diagnoses were classified (classes I and II, 184 cases; class III, 50; and class IV, nine). No difference was detected in the rate of class III and IV misses among chest faculty, but nonchest faculty had significantly more class III (P = .022) and class IV misses (P = .016)., Conclusion: Random sampling of differing interpretations can yield a relative rate of missed diagnoses for radiologists. No difference was detected in clinically important misses (ie, classes III and IV) among chest radiologists, but a statistically significantly higher rate of seemingly obvious misdiagnoses was found for nonchest specialty radiologists. Potential biases may have influenced this analysis, including disease prevalence, sampling, clinical factors, observer variability, and truth-in-diagnosis.

Purpose: To assess the accuracy of hysterosonography (HSG) and its role in diagnostic confidence and therapeutic clinical decision making among referring physicians caring for patients with postmenopausal bleeding (PMB)., Materials and Methods: One hundred twenty-three patients with PMB underwent transvaginal ultrasonography (US) and HSG. They were examined for cancer, polyp, leiomyoma, and hyperplasia. Physicians assessed the effect of the studies on diagnostic confidence and care, including biopsy, dilation and curettage, hysteroscopy, hormone manipulation, and/or patient reassurance. Abnormality was proved with histopathologic evaluation, and normality, with 6-month follow-up., Results: In 10 patients, HSG was unsuccessful, and in 15, follow-up was incomplete; this left 98 patients. Endometrial polyps were seen in 46 (47%) patients; leiomyoma, in 11 (11%); cancer, in four (4%); hyperplasia, in eight (8%); and normal findings, in 29 (30%). Our calculations yielded a sensitivity of 98% and a specificity of 88%. In 86 (88%) patients, US added certainty to the diagnosis; in 78 (80%), it resulted in a change in patient treatment., Conclusion: HSG and transvaginal US in patients with PMB improves diagnostic accuracy, clinical decision making, and the clinician's diagnostic certainty. In patients with benign causes of PMB, the absence of abnormality at HSG and a normal endometrial biopsy result may eliminate the need for further studies.

Rationale and Objectives: Medical student surveys are used extensively in the development and modification of curriculum. The purpose of this study was to look at medical student surveys of a radiology lecture series, evaluating the accuracy of student perceptions of learning and factors affecting them., Materials and Methods: After a "Case of the Week" lecture series, 156 3rd-year medical students returned a survey evaluating the experience with 10 questions on a four-point scale (1 = disagree, 4 = agree very much) and took a clinical competency assessment (CCA) examination with a radiology substation. Survey responses were compared with actual examination performance, analyzed for how overall learning was characterized in specific educational objectives, and evaluated for factors affecting perceived learning., Results: The mean response for perceived CCA examination preparedness was 1.83. The mean radiology station test score was 90.43%. Correlations between student perception of learning and the scoring of focused learning objectives ranged from 0.33 to 0.48 (P < .01). Students responding 1 to items assessing perceived lecture organization, stimulation to read, and interest in the field of radiology had mean scores for perception of overall learning of 2.09-2.44 and mean scores for recommendation of course continuation of 1.68-2.46. Students responding 4 had means of 3.25-3.81 and 3.06-4.0, respectively., Conclusion: Student perceptions of the value of curriculum were inaccurate compared with external measures of performance, and students poorly related their general impressions to specific learning objectives. Perceived lecture organization, stimulation to read, and interest in radiology as a specialty affected perceived overall learning and perceived value of the lecture series.

Rationale and Objectives: The Comprehensive Clinical Assessment (CCA) examination at the University of Michigan Medical School is a series of test stations through which the mastery of clinical skills is evaluated. The purpose of this study was to determine whether student performance on the radiology station improved in years when radiology faculty presented case-of-the-week unknowns to the 3rd-year students., Materials and Methods: The authors compared four separate classes of medical students in examination years 1993, 1994, 1995, and 1996 by using the total CCA examination score, the radiology station score, and radiology station pass/fail rates. Radiology case-of-the-week presentations were given by the radiology faculty only in academic years 1993-1994 and 1994-1995 (examination years 1994 and 1995)., Results: The means and standard deviations of the radiology station scores for the examination years when case-of-the-week presentations were not given, 1993 and 1996, were 78.92 +/- 13.62 and 79.76 +/- 13.62, respectively. In the years case-of-the-week presentations were given, 1994 and 1995, the radiology station scores averaged 90.83 +/- 8.58 and 89.97 +/- 9.66, respectively (P < .001, global alpha = .05). Total CCA percentage correct scores were similar for all years studied. In 1993 and 1996, 7.6% and 5.3% of students, respectively, failed the radiology station. In 1994 and 1995, 0.4% and 0% of students, respectively, failed (P < .0001)., Conclusion: Case-of-the-week presentations by radiology faculty increased 3rd-year students' basic radiologic knowledge as evidenced by increased scores on the radiology station of the CCA examination.

Rationale and Objectives: Clinical competence certification is now required in some specialties in medicine. A Comprehensive Clinical Assessment (CCA) was created to test mastery of critical skills by students at the end of the 3rd year of medical school., Methods: The CCA is a series of stations that test skills the faculty consider important for all medical students (eg, breast examination, electrocardiogram reading, chest pain assessment, ophthalmology photographs). The radiology station was designed to evaluate imaging skills believed to be taught and learned in the core 3rd-year rotations., Results: External measures (National Board Examinations, grade point average, and overall score) of clinical performance of the 608 medical students who completed the CCA examination between 1991 and 1993 were found to be correlated with the radiology station scores., Conclusion: The radiology station in the CCA examination is a reproducible measure of clinical performance.

Malformations of the fetal skeleton can be classified into two major categories. The generalized skeletal dysplasias are characterized by abnormalities in multiple bones throughout the fetus. In contrast, focal skeletal abnormalities manifest a variable pattern both in distribution and extent of involvement. This pictorial essay illustrates the primary sonographic findings that indicate the presence of a skeletal abnormality. The major and minor sonographic features that allow formation of a reasonable differential diagnosis are also considered.

Forty-eight fetuses were prospectively evaluated to (1) determine the normal size range of herniated midgut and (2) correlate sonographically the timing of midgut herniation with CRL. All fetuses of CRL 38 mm or less, and two of six fetuses with a CRL of 40 to 42 mm, demonstrated midgut herniation. No fetuses with a CRL greater than 44 mm had this finding. The cord containing midgut increased roughly from 4 to 7 mm, in maximum dimensions, for CRL of 19 to 41 mm. An anterior abdominal wall mass greater than 7 mm at any CRL, or of any size in a fetus of CRL greater than 44 mm, is suggestive of a fetal anomaly. Alternatively, a cord base "mass" within the 4 to 7 mm range for a CRL of 19 to 44 mm can be considered normal and not to require any follow-up.

A case of retroperitoneal extraosseous Ewing's sarcoma (EES) with renal involvement, which simulated an exophytic renal mass, is reported. EES is a rare soft tissue tumor that can occur anywhere in the soft tissues, but is seen most commonly in the extremities. Although EES is histologically similar to osseous Ewing's sarcoma, it is usually found in older patients. EES should be included in the differential diagnosis of soft tissue tumors, especially in the second and third decade of life.

Periventricular leukomalacia, a condition characterized by hpoxic-ischemic infarction of deep cerebral white matter, can now be recognized by cranial sonography. The case presented here demonstrates the association of periventricular leukomalacia present at birth with intrauterine paroxysmal supraventricular tachycardia.

Cranial sonography is an established procedure for the detection of neonatal intracranial hemorrhage. A 3 year experience in imaging such infants is reviewed. Representative examples are presented to comprehensively illustrate the spectrum of sonographic appearances of intracranial hemorrhage and its complications from the initial hemorrhage to resolution. Diagnostic problems in the initial staging of the grade of hemorrhage and in evaluating subsequent ventricular changes are addressed.

The sonographic features of eight surgically confirmed pheochromocytomas are described and correlated with pathologic findings. The purely solid masses were homogeneous or heterogeneous sonographically. Pathologic examination of the gross specimen provided explanations for the variety of sonographic findings. Two tumors had large cystic components due to old blood. Other hypoechoic areas corresponded to necrosis pathologically. Hyperechoic areas represented hemorrhage. Generally, pheochromocytomas are quite large, sharply marginated, and usually have a significant solid component with or without central necrosis or hemorrhage. Recognition of these features should facilitate their identification on sonography.

The sonographic appearance of normal neonatal cerebral sulci may mimic that of significant intracranial pathology. An echogenic pseudolesion can be seen when a sulcus is imaged through its long axis. Criteria are discussed for the differentiation of this normal variant from true parenchymal lesions with their attendant serious clinical implications.

We show, through correlation of fetal, neonatal, and necropsy brain sonography, that the three-parallel-echogenic-line configuration classically thought to represent fetal lateral ventricular margins on high axial images are actually extraventricular, lying within cerebral white matter. Accurate sonographic identification of fetal hydrocephalus is essential for appropriate patient management. Both qualitative and quantitative methods of determining ventriculomegaly have been described. The latter require identification of lateral ventricular walls for subsequent ventricular mensuration and comparison with hemispheric width. The parallel-line configuration, thought to represent ventricular margins, has been used for such measurements. We have--through careful fetal, neonatal, and necropsy specimen scanning in several planes--determined that the presumed ventricular wall echoes are actually extraventricular, arising from fibers within the cerebral white matter aligned perpendicular to the sonographic beam. This is identical to the etiology of the normal echogenic periventricular "blush" described in the neonate. Since these parallel echogenic lines do not represent actual ventricular margins, they should not be relied upon for the diagnosis of ventriculomegaly.

The authors reviewed the cranial sonographic findings in 8 pre-term neonates, each of whom had a clinical history and neurological outcome consistent with periventricular leukomalacia (PVL). Initially, echogenic intraparenchymal lesions were identified in a distinctive distribution at the external angle of the lateral ventricles, radiating anteriorly from the trigone to the foramen of Monro to varying degree. With time, predominantly multiseptate cystic components developed. These sonographic features are different from those of periventricular or intraventricular hemorrhage.

A review of cranial ultrasound examinations performed on 426 newborns over a 42-month period demonstrated a predominance of left-sided germinal matrix hemorrhage over both right-sided and bilateral germinal matrix hemorrhage. Distribution of intraventricular or intraparenchymal hemorrhage did not show this pattern. The reasons for left-sided predominance of germinal matrix hemorrhage remain speculative, and perhaps are related to cerebrovascular anatomic differences or to hemodynamic stresses related to patency of the ductus arteriosus.

Intracranial hemorrhage is a complication of extracorporeal membrane oxygenation for the treatment of neonatal respiratory failure. A retrospective review of 35 neonates treated with extracorporeal membrane oxygenation was performed; ten had intracranial hemorrhage. Infants with intracranial hemorrhage had lower birth weights and were gestationally younger than infants with intracranial hemorrhage. Eight of eight neonates of less than 35 weeks' gestational age sustained intracranial hemorrhage. Six died immediately after extracorporeal membrane oxygenation was stopped. Two lived less than 1 year. Two of 27 neonates older than 34 weeks' gestational age sustained intracranial hemorrhage. One child is normal, the other died at 18 months of age. Based on the results of this study, the risk of intracranial hemorrhage appears low in neonates of greater than 34 weeks' gestational age who undergo extracorporeal membrane oxygenation treatment for severe respiratory failure. The use of extracorporeal membrane oxygenation, as it is presently performed, is contraindicated in neonates of less than 35 weeks' gestational age because of the risk of intracranial hemorrhage.

Intraoperative sonography is becoming increasingly important in neurosurgery. In this article, the authors provide step-by-step instructions, the basics of lesion localization, sonographic characteristics of the more common brain and spine lesions, and tables of references to sonographically described lesions in the literature.

Seventeen intraoperative spinal sonographic examinations were performed in 14 patients with intramedullary spinal cord neoplasms. Results of the ultrasound exams were correlated with preoperative imaging studies, surgical findings, and histopathologic analysis of the tumors. Intraoperative spinal sonography accurately localized the intramedullary tumors, often revealing the need for extension of the initial laminectomy. The neoplasms appeared as expansile echogenic masses, with cystic components in over half. Ultrasound was as accurate as preoperative imaging in the evaluation of solid neoplasms, and was superior to computed tomography (CT) and magnetic resonance imaging (MRI) for delineating the cystic components of neoplasms. Intraoperative sonography should be used routinely in all surgical cases of intramedullary spinal cord neoplasms.

Neonates with severe but reversible pulmonary disease may require therapy beyond conventional ventilatory care. Extracorporeal membrane oxygenation (ECMO) serves as a temporary artificial lung for such infants. Since anticoagulation with systemic heparin is required in the extracorporeal circuit, antecedent hemorrhage may be exacerbated or new hemorrhage precipitated in ECMO patients. While the "usual" periventricular/intraventricular hemorrhage seen in a premature infant may develop, contrasting hemorrhages of unusual extent, uncommon location, or demonstrating unique alterations in internal sonographic character may be precipitated, presumably due to the requisite anticoagulation. Representative examples of such variations are presented along with guidelines for the use of cranial sonography in selecting and monitoring ECMO patients.

With the use of new sonographic technology, we have observed that the echogenicity of kidneys is often equal to that of the liver in patients in whom there is no evidence of renal disease; this observation conflicts with the generally accepted notion that a normal kidney is always less echogenic than the liver. In order to reassess renal echogenicity as an indicator of disease, three experienced radiologists blindly reviewed the sonograms of the right kidney and liver in 153 patients. The prevalence of renal disease was 26% (40/153). Accepted sonographic criteria for abnormal renal echogenicity (kidney echogenicity greater than or equal to liver) were neither sensitive (62%) nor specific (58%) for renal disease, with a positive predictive value of 35%. Most of these inaccuracies occurred because 43 (72%) of 60 patients in whom renal echogenicity was equal to that of liver had normal renal function. If stricter criteria for abnormality were adopted (kidney echogenicity greater than liver), specificity (96%) and positive predictive value (67%) rose; however, sensitivity was only 20%. We conclude that renal echogenicity equal to the echogenicity of liver is not a good indicator of disease. Use of stricter criteria (kidney echogenicity greater than liver) provides a specific but insensitive test.

Fifteen pregnancies occurring in 13 patients with congenital uterine anomalies were analyzed. The anomalies included bicornuate uteri (nine cases), subseptate uteri (two), septated uteri (one), and uterus didelphys (one). Identification of a bilobed uterine contour with an anterior and/or posterior indentation, an eccentrically located gestational sac, and echogenic endometrial debris in the nongravid horn, reliably indicated a coexistent uterine anomaly. Uterine anomalies became difficult or impossible to identify with increasing gestational age. Entities potentially confused with uterine anomalies include cornual leiomyomata, ectopic gestation, placental septations, and uterine scarring. Awareness of the sonographic findings of pregnancies in anomalous uteri should improve their detection and may alter obstetrical management.

Sonographic features of agenesis of the corpus callosum and its related intracranial abnormalities are described in four patients. A brief review of clinical, radiologic, and pathologic manifestations of agenesis of the corpus callosum is presented. Both agenesis of the corpus callosum and its potentially serious associated intracranial abnormalities can be effectively diagnosed with transfontanelle sonography.

Failure of first trimester pregnancy termination is an uncommon, although potentially serious complication of attempted therapeutic abortion. We report our experience in four patients with unsuspected congenital uterine anomalies in whom attempted pregnancy termination procedures failed to completely ablate the products of conception. When dilatation and curettage fails to produce embryonic tissue, sonography is indicated to exclude ectopic gestation or uterine anomaly. In patients who are known to have anomalous uteri, intraoperative real-time guidance may increase the success of pregnancy termination procedures and decrease the incidence of retained products of conception.

Intraoperative sonography is rapidly becoming a key diagnostic tool within the operative suite. Important applications are defined within the abdomen, vascular system, and other regions of the body. Intraoperative scanning may better define the normal anatomy and target pathology than preoperative studies. As with neurosurgical applications of intraoperative ultrasound, with the use of high-resolution, high-frequency real-time transducers, multiple transducer frequencies within one probe, and probe shapes specifically designed for certain types of operations, it is anticipated that the surgical use of intraoperative ultrasound will greatly increase in the future.

In a retrospective survey of a large obstetrical ultrasound experience, 10 echogenic adnexal masses in nine patients with a coexistent intrauterine pregnancy were detected and analyzed. Definitive follow-up data available for seven of the nine patients disclosed three ovarian teratomas, two hemorrhagic corpus luteum cysts, one endometrioma, one inflammatory mass, and one colonic pseudomass. In one additional patient, an echogenic ectopic pregnancy with an intrauterine pseudogestational sac simulated the above entities. Conservative management with follow-up sonography is generally indicated for echogenic masses coexistent with first-trimester intrauterine pregnancies.

A case of Budd-Chiari syndrome is presented in which computed tomography (CT) and ultrasonography suggested the correct diagnosis and excluded adjacent tumor as the cause of hepatic vein occlusion. The CT appearance in this case (homogeneously increased attenuation of an enlarged caudate lobe) differed from the appearance previously reported (patchy liver enhancement) in Budd-Chiari syndrome. Underlying mechanisms responsible for the different CT appearance are discussed.

Some of the difficulties in predicting fetal lung maturity with ultrasound are briefly reviewed. Technical factors play an important part in determinations of fetal lung maturity.

Membrane tenting during amniocentesis is a significant cause of dry taps, leading to immediate procedure failure or multiple needle insertions. Because of the increased risk of fetal loss and other minor complications reported with multiple taps, a means of accomplishing fluid retrieval on a single pass is desirable. We describe a new single-pass technique that involves further needle penetration into the posterior myometrium, under ultrasound guidance, physically displacing the obstructing membranes down the shaft away from the tip.

Myositis ossificans progressiva is a rare but progressively debilitating autosomal dominant disease characterized by extraskeletal ossification involving muscle connective tissue. This report is the first on pregnancy and induced abortion in a patient with myositis ossificans progressiva. Intraoperative sector scanning ultrasound was of limited benefit in evacuation of the uterine cavity. Conservative management of an incomplete termination resulted in no adverse sequelae.

Focal hepatic masses were delineated by ultrasonography in three of five patients with type I glycogen storage disease (von Gierke's disease). Small hepatic adenomas were visualized as solitary or multiple hyperechoic solid lesions within enlarged, abnormally echogenic livers of increased attenuation. Larger adenomas were heterogeneous, with hypoechoic foci presumed to be secondary to necrosis, hemorrhage, or both. A previously unreported ultrasonographic finding is the markedly enhanced sound transmission identified deep to these solid tumors.