Masato Mashima

Three-Dimensional HDlive Rendering Images of the Fetal Heart

Our objective is to describe our experience with reconstruction of normal fetal cardiac structures and congenital heart anomalies using the 3-D HDlive rendering mode with spatiotemporal image correlation (STIC). Four normal fetuses and three fetuses with congenital heart anomalies (Ebsteins anomaly, hypoplastic left heart syndrome and tetralogy of Fallot) at 25-35 wk of gestation were studied using the 3-D HDlive rendering mode with STIC. In normal fetuses, the natural appearance of the dynamic motion of the foramen ovale flap and both atrioventricular valves was clearly visualized in real time in the four-chamber view. Moreover, new, realistic sensations of each leaflet of atrioventricular valves and semilunar valves of the pulmonary artery were obtained in the en face view of both atrioventricular valves and great vessels. In the case of Ebsteins anomaly, the procedure rendered the natural and anatomically realistic appearance of significantly low attachment of the tricuspid valve and atrialized portion of the right ventricle. In hypoplastic left heart syndrome, thickened tricuspid and dysplastic pulmonary valves were clearly revealed. In tetralogy of Fallot, an overriding aorta and ventricular septal defect were realistically depicted. The 3-D HDlive rendering mode with STIC provides entirely new visual experiences for obstetricians and pediatric cardiologists owing to the anatomically realistic depiction of normal and abnormal fetal cardiac structures of the beating heart.

HDlive imaging of intra-amniotic umbilical vein varix with thrombosis

We present a case of intra-amniotic umbilical vein varix with thrombosis using conventional two-dimensional (2D) sonography, power Doppler, three-dimensional (3D) HD-flow, and HDlive at 35 weeks of gestation. 2D sonography showed a large banana-like umbilical cord enlargement (100 × 43.3 × 45.9 mm) including umbilical vein varix (maximum vein diameter = 25.5 mm) with massive thrombosis. Power Doppler and 3D HD-flow revealed bidirectional turbulent blood flow inside the varix. The HDlive clearly demonstrated fragile massive thrombosis inside the varix. Elective cesarean section was performed on the same day in order to avoid additional risks of umbilical cord complications and umbilical venous embolism. A male infant weighing 2501 g was delivered with an umbilical artery pH of 7.334, and Apgar score of 8/9 at 1 and 5 min, respectively. The macroscopic and microscopic findings revealed umbilical cord vein varix with thrombosis. On the basis of the laboratory date of the neonate, the diagnosis of consumptive coagulopathy was made. However, the neonate followed a favorable course after delivery.

HDlive rendering image of cyclopia and a proboscis in a fetus with normal chromosomes at 32 weeks of gestation

The HDlive rendering mode with both adjustable lighting and new skin-like colors gives the embryo and fetus a natural and anatomically realistic appearance, and there have been a few reports on antenatal 3D HDlive rendering images of fetal superficial abnormalities [1]. We present our first experience of cyclopia and a proboscis in a fetus with normal chromosomes at 32 weeks of gestation reconstructed employing the 3D HDlive rendering mode. A 34-year-old woman, gravida 4, para 3, was referred to our ultrasound clinic at 32 weeks of gestation because of fetal holoprosencephaly, fetal proboscis, suspected diaphragmatic hernia, suspected fetal growth restriction (FGR), and hydramnios. She had received insulin injections since 21 weeks of gestation during this pregnancy because of type 2 diabetes. Two-dimensional (2D) sonography (Voluson E8, GE Healthcare, Milwaukee, WI, USA) revealed fetal alobar holoprosencephaly, cyclopia, a proboscis, diaphragmatic hernia, ventricular septal defect, FGR [estimated fetal weight was 1,418 g (-1.6 SD)], and hydramnios. The 3D HDlive rendering mode (Voluson E8, GE Healthcare, Milwaukee, WI, USA; curved array transabdominal transducer, 2–8 MHz) clearly depicted cyclopia and a proboscis (Fig. 1). Amniocentesis was performed at 32 weeks and 4 days, and chromosome analysis showed 46XY. At 36 weeks of gestation, a male infant weighing 2,140 g was delivered vaginally, with an umbilical artery pH of 7.431, and Apgar scores of 4 and 2 at 1 and 8 min, respectively. The baby died 2 h after delivery. Permission to conduct an autopsy was not granted by the parents. However, postmorten examination of the neonate confirmed the presence of cyclopia and a proboscis (Fig. 2). The 3D HDlive rendering images of the fetal face are more readily discernible than those obtained by conventional 3D sonography because the 3D HDlive rendering mode provides such extraordinarily realistic imaging of the fetal face that it is almost impossible to differentiate between actual photographs and HDlive scans [2]. In the present case, the 3D HDlive rendering mode showed the same anatomically realistic images with macroscopic findings of cyclopia and a proboscis. The 3D HDlive rendering mode has the potential to supplement conventional 2D ultrasound in diagnosing fetal facial anomalies, and it can assist in the prenatal understanding of the diagnostic challenges of complicated fetal facial anomalies [1].

HDlive and HD-flow images of early-stage nonhydropic mole.

We present our first experience of constructing an image of an early-stage complete hydatidiform mole employing HDlive. Conventional 2D sonography showed massive, lobulated, and mixed masses and intrauterine anechoic fluid collection. Smooth, lobulated masses were clearly recognized using HDlive. Small, irregular, cystic spaces inside the masses were also evident. HDlive provided anatomically realistic features akin to macroscopic specimens for physicians and pathologists, owing to the complete depiction of the inner surface of an early-stage nonhydropic mole.

HDlive rendering image of adnexal tumors: preliminary report

BackgroundOur objective is to present our first experience of adnexal tumors reconstructed employing the HDlive rendering mode.MethodsSeven adnexal tumors (one case each of chocolate cyst, benign cystic teratoma, serous cystadenofibroma, and torsion of the hydrosalpinx, and three cases of ovarian cancer) were studied using the HDlive rendering mode.ResultsIn the case of the chocolate cyst, the smooth inner wall with numerous tiny projections was clearly identified. In the case of benign cystic teratoma, a smooth hair ball inside the cyst was evident. In the case of the serous cystadenofibroma, a smooth, solid projection and relatively smooth septum were noted. In the three cases of ovarian cancer, numerous irregular papillae and irregular, thick septae were depicted. In the case of the bilateral hydrosalpinx with torsion of the right tube, different fluid contents were recognized.ConclusionThe HDlive rendering mode provides anatomically realistic features such as macroscopic specimens for physicians and pathologists due to the complete depiction of the inner surface of the adnexal tumors.

Immunoreactivity of glucose transporter 8 is localized in the epithelial cells of the choroid plexus and in ependymal cells

High fructose intake is known to be associated with increased plasma triglyceride concentration, impaired glucose tolerance, insulin resistance, and high blood pressure. In addition, excess fructose intake is also thought to be a risk factor for dementia. Previous immunohistochemical studies have shown the presence of glucose transporter 5 (GLUT5), a major transporter of fructose, in the epithelial cells of the choroid plexus and ependymal cells in the brains of humans, rats, and mice, while GLUT2, a minor transporter of fructose, was localized in the ependymal cells of rat brain. In this study, immunoreactivity for the fructose transporter GLUT8 was observed in the cytoplasm of the epithelial cells in the choroid plexus and in the ependymal cells of the brains of humans and mice. These structures were not immunoreactive for GLUT7, GLUT11, and GLUT12. Our findings support the hypothesis of the transport of intravascular fructose through the epithelial cells of the choroid plexus and the ependymal cells.

Microvascular imaging of thick placenta with fetal growth restriction

Seven normal pregnancies at 11-34 weeks and three cases of a thick placenta with fetal growth restriction (FGR) at 19, 31, and 33 weeks were studied to assess placental vascularity using two-dimensional (2D)/three-dimensional (3D)-SMI (Aplio 800 or i900, Toshiba Medical Systems, Tokyo, Japan).

Transvaginal 3D HD-flow in diagnosis of uterine arteriovenous malformation

‘‘Uterine arteriovenous malformation (AVM) is a rare lesion with a considerable risk potential. The clinical presentation varies from no signs, to various degrees of menorrhagia, to massive life-threatening vaginal bleeding; Clinical suspicion is essential for a prompt diagnosis and treatment’’ [1]. Conventional two-dimensional (2D) color/ power Doppler sonography is a valuable and noninvasive modality for the definitive diagnosis of pelvic AVM in clinical practice [2, 3]. Moreover, three-dimensional (3D) color/power Doppler sonography has the potential to provide an improved visualization and recognition of pelvic AVM [4–6]. ‘‘High definition-flow (HD-flow) is a bi-directional power Doppler technique that delivers high-definition axial resolution and increased sensitivity for imaging small vessels. In addition, it reduces the spatial overlap of tissue signals by the application of small sample volumes, and provides optimal clutter elimination with adaptive wall filtering. 3D HD-flow is unique for 3D reconstruction of fetal vascularities in the whole body’’ [7]. We present our experience of uterine AVM with heavy vaginal bleeding following uterine curettage, diagnosed by employing transvaginal 3D HD-flow with multiplanar and angiographic displays. A 25-year-old Japanese woman, gravida 5, para 0, was referred to our university hospital because of an episode of sudden episodic profuse vaginal bleeding following her menses. She had undergone dilatation and curettage due to first-trimester missed abortion 6 weeks previously. Urine hCG was negative on the visit. Transvaginal 2D sonography depicted an ill-defined, inhomogeneous lesion involving the endometrial and subendometrial tissues with variously sized hypoechoic cysts (Fig. 1). Transvaginal 2D HD-flow revealed a hypervascular lesion in the myometrium involving the endometrial and subendometrial tissues

Glucose transporter 8 immunoreactivity in astrocytic and microglial cells in subependymal areas of human brains

Glucose transporter 8 (GLUT8), a glucose/fructose transporter, has been shown to be expressed in neuronal cells in several brain areas. A recent immunohistochemical study has shown the presence of GLUT8 in the cytoplasm of epithelial cells of the choroid plexus and ependymal cells. In this study, localization of GLUT8 in glial cells was investigated using immunohistochemical methods. Immunoreactivity for GLUT8 was observed in cells showing astrocytic or microglial structural features located around the lateral ventricles. Confocal microscopic examination revealed that subependymal GLUT8-positive cells with large amounts of cytoplasm mainly show clear immunoreactivity for vimentin, while they were also colocalized with weak immunoreactivity for glial fibrillary acidic protein (GFAP) within the cytoplasm of some cells. In addition, some GLUT8-positive cells with small amounts of cytoplasm and small nuclei showed CD68 or HLA-DR immunoreactivity, indicating them to be cells of microglia/macrophage lineage. These findings suggest that glucose/fructose is transported into the cytoplasm of vimentin- or GFAP-positive astrocytic and CD68- or HLA-DR-positive microglial cells located around the lateral ventricle.

HDlive in the Assessment of Gynecologic Tumors

We present the latest HDlive images of uterine and adnexal tumors. Evaluation of these tumors with conventional twodimensional (2D) sonography has been the standard procedure for morphologic assessment, but the introduction of threedimen sional (3D), power Doppler and other recent modalities has been of great help in providing more specific details, espe cially in characterizing malignancy. HDlive is the latest ultra sound modality that enhances 3D and four-dimensional images. Several different gynecologic tumors were assessed using HDlive in this study. HDlive can provide realistic features of the inner surfaces and contents of tumors which are very similar to the gross specimens. An accurate characterization of gynecologic tumors is important when deciding on clinical management options. Therefore, HDlive may be a valuable tool in adjunct to other imaging modalities to achieve an accurate preoperative diagnosis.