Dimitrios Rafailidis

Two Congenital Anomalies in One: An Ectopic Gallbladder with Phrygian Cap Deformity

The gallbladder is affected by a large number of congenital anomalies, which may affect its location, number, size, or form. Some of these malformations are very rare and may lead to misdiagnosis. An ectopic gallbladder can be misinterpreted as agenesis of the organ or as a cystic hepatic mass when intrahepatic. Given the frequency and the wide acceptance of the ultrasonographic examination of the biliary tract, radiologists should be aware of these malformations. In some cases, ultrasonographic diagnosis can be difficult. However, the use of Computed Tomography can elucidate such cases. We present the case of a patient whose gallbladder had two combined malformations but caused no symptoms. Namely, the patient had a transverse ectopic gallbladder combined with a “Phrygian cap” deformity. The incidence of ectopic locations of the gallbladder is 0.1–0.7%, whereas the “Phrygian cap” deformity can be found in 4% of patients. There is no other cases with combination of these two entities reported in the literature. Ultrasonographic and CT findings are presented and aspects of this malformation are discussed. The clinical significance of ectopic gallbladder is also emphasized because it may alter the clinical presentation of biliary tract diseases and pose technical problems during surgery.

Imaging of the malignant peripheral nerve sheath tumour with emphasis οn ultrasonography: correlation with MRI

Malignant peripheral nerve sheath tumours affect 0.001xa0% of the population. The epithelioid subtype accounts for only 5xa0% of them. We herein present a patient with a palpable mass on the left calf, which was investigated by ultrasonography, ultrasonographically guided fine-needle biopsy and MRI. Ultrasonography estimated the size of the tumour and evaluated its echotexture. Doppler technique detected characteristic corkscrew-type blood vessel entering in the upper pole of the mass. T1-weighted, fat-suppression and gadolinium-enhanced MRI sequences confirmed ultrasonographic findings. In conclusion, although final diagnosis was established by biopsy, ultrasonography and MRI proved complementary in the characterization of the lesion and planning of surgery.RiassuntoI Tumori Maligni della Guaina del Nervo Periferico (MPNST) colpiscono il 0,001xa0% della popolazione generale. Il sottotipo epitelioide rappresenta solo il 5xa0%. Presentiamo qui un paziente con una massa palpabile sul polpaccio sinistro, che e’ stata studiata con l’ecografia seguita dalla biopsia con ago sottile ecograficamente guidata ed MRI. Con l’ecografia sono state valutate le dimensioni del tumore e l’eterogeneita della sua consistenza. Con la tecnica Doppler e’ stato rivelato un vaso sanguigno di tipo caratteristico di “cavatappi” entrare nel polo superiore della massa. MRI sequenze T1 weighted, di soppressione del grasso e dopo somministrazione di mezzo di contrasto paramagnetico hanno confirmato i risultati ecografici. In conclusione, anche se la diagnosi finale e’ stata stabilita tramite biopsia, l’ecografia e la risonanza magnetica hanno fornito dati complementari riguardo alla caratterizzazione della lesione ed alla pianificazione dell’operazione.

Contrast-enhanced ultrasonography of the carotids

Contrast-enhanced ultrasonography of the carotids has recently emerged as a complementary examination to conventional carotid Doppler ultrasonography. It is an examination providing improved visualization of the vascular lumen, more accurate and detailed delineation of the vascular wall, and identification of atherosclerotic plaques. Moreover, contrast-enhanced ultrasonography has specific advantages over conventional ultrasonography and plays an important role in the diagnosis of the vulnerable carotid plaque, as it can identify intraplaque neovascularization and carotid plaque ulceration. Given the specific advantages and improved imaging of the carotids provided by this method, radiologists should be familiar with it. This pictorial essay illustrates the advantages of this technique and discusses its value in the imaging of carotid arteries.

Swirling of microbubbles: Demonstration of a new finding of carotid plaque ulceration on contrast-enhanced ultrasound explaining the arterio-arterial embolism mechanism.

Carotid plaque ulceration is a well-established feature of vulnerability, associated with high risk for neurological symptoms. From a pathogenetic point of view, the mechanism responsible for occurrence of symptomatology relies on the aggregation of platelets within the ulcer cavity, activation of coagulation mechanism, formation of thrombus and arterio-arterial embolization of thrombotic material in the central nervous system. Many imaging modalities including unenhanced ultrasound, computed tomographic angiography and magnetic resonance angiography have been used to image and diagnose carotid plaque ulceration with varying success. Contrast-enhanced ultrasound has been recently introduced in the study of carotid disease offering improved flow visualization and better plaque surface delineation. We present a case where contrast-enhanced ultrasound visualized the swirling pattern of movement of the microbubbles within the ulcer cavity. These findings illustrate the underlying hemodynamic mechanism of arterio-arterial embolization and can be proposed as a new finding of plaque ulcerations on contrast-enhanced ultrasound.

Sonography of the scrotum: from appendages to scrotolithiasis.

In this pictorial essay, we review and discuss the varying morphologic characteristics of scrotal appendages and calculi. Characteristic sonograms obtained from patients with coexisting hydrocele are presented, and recent literature is included. Hydrocele greatly facilitates the imaging of these intrascrotal structures, as it acts as a “water path”. On the one hand, torsion of a scrotal appendage should always be included in the differential diagnosis of acute scrotum, especially in children. On the other hand, scrotolithiasis may occasionally cause mild discomfort. As a consequence, and given the widespread use of sonography for the evaluation of both acute and chronic conditions of the scrotum, radiologists should be familiar with these entities.

Nonobliteration of the Processus Vaginalis Sonography of Related Abnormalities in Children

The objective of this pictorial essay is to systematically classify processus vaginalis–related disorders in the light of embryology and present illustrative sonograms with corresponding diagrams. Failure of the processus vaginalis to obliterate during gestation results in a wide spectrum of anomalies, including communicating and noncommunicating hydroceles and inguinal and inguinoscrotal hernias, along with other related disorders of the genital system. There are varying classifications in the literature regarding the aforementioned entities. Proper and timely diagnosis of these entities is essential, given the differences in treatment. Although physical examination can narrow the differential diagnosis, sonography plays an essential role in establishing the diagnosis.

A comparative study of color Doppler imaging and contrast-enhanced ultrasound for the detection of ulceration in patients with carotid atherosclerotic disease

ObjectivesTo evaluate the diagnostic accuracy of color Doppler imaging (CDI) and contrast-enhanced ultrasound (CEUS) for diagnosing carotid ulceration, having multi-detector computed tomography angiography (MDCTA) as the reference method.MethodsPatients with carotid disease referred for ultrasound (US), either due to the occurrence of neurovascular symptoms or for screening purposes, were included in this study if at least one plaque causing moderate (50–69%) or severe (70–99%) internal carotid artery stenosis was detected. Carotid US with CDI technique, CEUS, and MDCTA were performed in all patients, investigating the presence of ulceration. The agreement between modalities was evaluated using kappa statistics.ResultsThe study population included 54 patients (median age 62xa0years, inter-quartile range 16.2) and 66 carotid arteries. The mean degree of stenosis was 68.5% (SD 12.2%) while 47.1% of plaques were symptomatic. MDCTA characterized 28.8% of plaques as smooth, 45.5% irregular, and 24.3% ulcerated. Flow reversal was detected with CDI in 65.5% of ulcerations, while swirling of the microbubbles and neovessels adjacent to the ulcer were detected with CEUS in 17.64%. The agreement for ulceration diagnosis was moderate between CDI and CEUS (kappa 0.473) and between CDI and MDCTA (kappa 0.473) and very good between CEUS and MDCTA (kappa 0.921). The sensitivity, specificity, and positive and negative predictive values of CDI for the diagnosis of ulceration were 41.2%, 97.95%, 87.5%, 82.8% respectively, while CEUS respective measures were 94.1%, 97.95%, 94.1%, and 97.95%.ConclusionCEUS outperformed CDI in terms of agreement with MDCTA and diagnostic accuracy for the diagnosis of ulcerated carotid plaque.Key Points• Superficial ulceration is a significant feature of carotid plaque vulnerability.• Color Doppler imaging has the potential to demonstrate carotid plaque ulceration but is characterized by limited sensitivity and moderate agreement with the reference method of multi-detector computed tomography angiography.• Contrast-enhanced ultrasound outperforms color Doppler imaging in terms of sensitivity for the detection of carotid plaque ulceration and in agreement with the reference method of multi-detector computed tomography angiography.

Fountain’s Sign as a Diagnostic Key in Acute Idiopathic Scrotal Edema: Case Report and Review of the Literature

The acute idiopathic scrotal edema (AISE) is a self-limited disease of unknown etiology, characterized by edema and erythema of the scrotum and the dartos, without expansion to the underlying layers of scrotums wall or to the endoscrotal structures. Boys younger than 10 years old are usually involved in 60-90% of all cases. Diagnosis is made after exclusion of other causes of acute scrotum. We present a case of a 7-year old boy, who was admitted to the Emergency Department due to development of scrotal edema and erythema over the last 48 hours, which extended to the base of the penis. The patient mentioned that he first noticed the erythema on the anterior surface of the right hemiscrotum, which gradually extended. Physical examination did not reveal presence of pathology involving the endoscrotal structures, indicative of need for urgent surgical intervention. Transillumination was negative for blue dot sign. Ultrasonographic examination of the scrotum documented the homogeneity of the testicular parenchyma, while color Doppler revealed the presence of fountains sign (equal arterial blood supply to both testicles). Conservative strategy was followed and the patient gradually improved within the next three days. In conclusion, meticulous physical examination along with ultrasonographic examination of the suffering scrotum, especially with the highlighting of fountains sign with color Doppler, document the diagnosis of AISE. Thus, need for urgent surgical investigation of the suffering scrotum due to diagnostic doubt is limited.

Multiparametric ultrasound findings in a patient with polyorchidism

Polyorchidism is a rare condition usually incidentally discovered in young patients investigated with ultrasound for unrelated reasons. It is characterized by the presence of unilateral or, rarely, bilateral supernumerary testes which, depending on the type of polyorchidism, may have their own epididymis and vas deferens. Ultrasound, including B-mode and color Doppler technique, represents the primary imaging modality for the evaluation of scrotal diseases, including the characterization of supernumerary testes, which normally appear identical to the ipsilateral testicular parenchyma on every ultrasonographic technique performed. The role of MRI is thus limited to confirming ultrasonographic findings and excluding the presence of malignancy. Contrast-enhanced ultrasound is a recently introduced ultrasonographic technique providing detailed and sensitive visualization of the perfusion pattern of structures. It can thus be added to the conventional ultrasonographic examination in order to establish the diagnosis, negating the use of more expensive and time-consuming imaging modalities. We present a young patient with an incidentally found supernumerary testis, where new distinctive ultrasonographic findings, like the identification of transmediastinal vessels and a cystic appendage along with the perfusion pattern on contrast-enhanced ultrasound, established the diagnosis of polyorchidism.

Ultrasonography of the healing process during a 3-month follow-up after a splenic injury

We present a 14-year-old boy with a grade III splenic injury due to a bicycle accident, who was treated conservatively. The boy’s medical history included splenomegaly due to thalassemia. The splenic lesion was initially investigated with computed tomography (CT) and then, was followed by ultrasonography for 3 months. CT revealed a large intraparenchymal hematoma which appeared hyperechoic on ultrasonography. During follow-up, the hematoma developed a more complex echogenicity and became gradually hypoechoic. The hematoma increased in size during the first week but then, started decreasing until it eventually resolved completely. The patient had an uneventful full recovery. In this report, we discuss the ultrasonographic changes of the hematoma throughout the healing process.