Sample Teaching Cases

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Ultrasound is used in many subspecialties in the field of radiology and is most frequently used in imaging of superficial soft tissues. 

Case US.1

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1. What device is shown in the image?

2. When is this device used?

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Case US.2

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Questions

1. What conditions are associated with the salient finding?

2. Which of these associations is the most concerning?

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Case US.3

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Questions

1. What is the most concerning potential complication of this lesion?

2. What are possible methods for treatment of this lesion?

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Answers 


Case US.1

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Answers 

1. What device is shown in the image?

The device in the image is an acoustic stand-off pad. 

2. When is this device used?

An acoustic stand-off pad is used to increase the distance between the ultrasound transducer and a superficial lesion when the lesion is larger than the width of the transducer. When used with a curved-array or sector transducer, a stand-off pad allows inclusion of the entirety of large, superficial lesions. Stand-off pads are most commonly used in evaluating large thyroid gland, breast and skin lesions.

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Case US.2

History

The patient is a 28-year-old male who presents for infertility workup.

Case 1.jpgDiagnosis

Testicular microlithiasis

Findings

Grey-scale ultrasonographic image demonstrates multiple punctate hyperechoic foci, consistent with calcifications. Additionally, a hydrocele is seen.

Answers

1. What conditions are associated with the salient finding? 

The ultrasonographic finding of testicular microlithiasis is associated with testicular neoplasms, infections, infarctions, Klinefelter's syndrome, cryptorchidism, Down's syndrome, male pseudohermaphroditism, pulmonary alveolar microlithiasis, previous radiotherapy, and subfertility states. Men can present with testicular pain, mass, atrophy, or enlargement as well as scrotal swelling, but they are frequently asymptomatic. Ultrasound, the modality of choice for testicular evaluation, reveals 1 – 3 mm hyperechoic foci in testicular microlithiasis. While usually diffuse and bilateral, when caused by infection or infarct, the calcifications may not be evenly distributed throughout the testes.

2. Which of these associations is the most concerning? 

Testicular microlithiasis is considered a “marker” for testicular neoplasms, in particular, intratubular germ cell neoplasia, which progresses to carcinoma in about 50% of cases. Neoplasms include seminomas, teratomas, mixed germ cell tumors, and Leydig cell tumors. Non-Hodgkin's lymphomas and leukemia have been reported in the setting of testicular microlithiasis. Therefore, ultrasonographic surveillance is employed.
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Case US.3

History

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The patient developed ecchymosis and pain at the site of prior catheterization access. 

Diagnosis

Femoral artery pseudoaneurysm

Findings

Grey-scale ultrasound (not shown) demonstrated an anechoic, cystic appearing structure adjacent to the femoral artery. Upon evaluation of the lesion by Doppler ultrasound, a narrow-neck (0.8 cm) was seen to communicate with the femoral artery, and the classic “yin yang” appearance were demonstrated, indicating the development of a pseudoaneurysm.

Answers 

1. What is the most concerning potential complication of this lesion?

The most serious complication of a pseudoaneurysm is rupture, which may be life threatening. Cessation of systemic anticoagulation is important to reduce the risk of hemorrhage. If the patient requires anticoagulation, therapeutic intervention should be performed on the pseudoaneurysm. Other sequelae include development of infection and compromise of nearby neurovascular structures due to mass effect.

2. What are possible methods for treatment of this lesion?

While spontaneous thrombosis may occur and intervention may not always be required, minimally invasive techniques have proven to be beneficial. When accessible by ultrasound, therapy can include serial ultrasound compression, but compression can be painful, prompting use of analgesics. Ultrasound-guided or angiography-guided injection of thrombogenic agents, such as thrombin, can be effective. Endoluminal exclusion of the pseudoaneurysm from the circulation can be performed by placement of a covered stent, bridging the pseudoaneurysm neck. If the supplying artery can be sacrificed, wire embolization may be performed. If the pseudoaneurysm is not manageable by these techniques, surgical intervention may be required.

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