TRAINEE RESIDENT RADIOLOGISTS

Ultrasound notes

Dr.Hussein

2013

SPECIAL THANKS TO DR. SURA AND DR.SAMAR WITH MY BEST WISHES

Obstetrical ultrasound
The main steps are :
1_ Assess fetal life.
2_Multiplicity.
3_Presentation.
4_Parameters (BPD, HC, FL, AC)
5_Placental assessment.
6_Amount of liquor.
7_Fetal structures (if there are any anomalies).

Placental Assessment: By putting the probe transverse in the epigastric

region to detect site of placenta
Normal placental thickness is 3_5 cm
If thin < 3cm polyhydromnios.
If thick >5cmoligohydromnios.
Detection of liquor: by
1. Single pocket..in a free space contains no cord no limbnormally
2_8
2. AFI normally 5_20
Note: increase trimester .decrease AFI
*(In case of polyhydromnios assess the stomach if there is the double
bubble sign and also try to turn the patient on the left then on the right
so fluid will be in the dependant part and you will be able to examine
more clearly for fetal organs)
Detection of umbilical cord: umbilical cord contains 2 arteries and 1 vein
Its position detected according to fetal urinary bladder
(If you are not sure use Doppler so should be 2 umbilical arteries one on
each side of UB)

fetal u.bladder
Fetal u.bladder and stomach should be filled with fluid
Detect RI of the cord normally measures up to 0.66
Side effects of ultrasound on fetus:
1_Heating effects especially in early pregnancy.
2_Mechanical effects.
Early pregnancy parameter is CRLin fetal pole so we count the GA when
this fetal pole appears.
Detect any structural anomalies:
Ant abdominal wall defect :(a)Gastroschiasis (b)omphalocele
Middle cerebral artery (Imp)
According to fetal parameters:
CRL = Fetal pole .we measure it till 13_14 week of gestation.
If more than 13 week we measure ( BPD and FL)_
So fetal head bones should be seen at 13 week of gestation.
CRL =6 mm and no heart activity we should follow up for 2 weeks.
CRL>6 mm and no heart activity means dead fetus.
We should detect fetal heart at:
_4wk_Endovaginal and
6wk_trans abdominal
If gestational sac is empty without yolk sac we should follow up and
repeat u/s after 10 days
Normal pregnant HCG is 100O_3000
Endovaginal u/s _9 MHZ
4 Dimensional u/s means (3 dimension plus real)

Assess fetal parameters :( BPD, FL, AC, HC)

So IUGR: there will be a difference in the above more parameters
measurement of than 2 weeks
And usually we depend on AC of liver if AC less than 2 from BPD
means IUGR.
Assess fetal structures or anomalies:
Assess post cranial fossa thickness in 20G.W which is normally less or
equal to 5 mm
If increased fluid in post cranial fossa means increased thickness (Dandy
Walker syndrome)
Assess lung (which is normally moreechogenic on u/s than liver) so in
Pulmonary sequestration will be less echogenic
Assess fetal kidney if it is more echogenic possibility of PCKD
*You can see both kidneys by cross section and measure them so a
section that contain the spine and kidney on each side if you are not
sure about that you can use Doppler and see the 2 renal arteries
passing accordingly to each RT and LF kidney
*Assess the spine also by cross section for detection of meningocele as
may be in the cervical spine
Early pregnancy U/S:
Detect viability of the fetus: by M mode normal fetal heart rate 100_180
Detect multiplicity of the fetus by: 2 Yolk sac<6 mm_2 amniotic sacs_2
or 1 placenta
Avoid using color Doppler in early pregnancy in detection the fetal heart
because of its heating effect and more movement of fetus
Detect any uterine fibroid or ovarian or adnexal mass
*Be careful in advanced pregnancy ovaries will be pushed high so
examine them in the funds high in the abdomen.

Again talking about fibroids: 2 types

a.Subserosal :mass without surrounding tissue.
b.Intramural: mass with surrounding tissue
Monozygotic twins have more congenital anomalies than diazagotic twin
UB should be partially filled when we measure the cervical length and
placenta because if it is filled will lead to wrong measurement.
Gestational sac: should be measured from inner wall to inner wall and
the decidual reaction shouldnt be measured within it.
The placenta: there is normal line separates the uterus from placenta if
this line is obliterated.means accreta if this line is dark..means
bleeding.
Sex determined by endovaginal u/s by 10 wks

Regarding congenital anomalies:

_Anencephaly: not diagnosed before 14 weeks
_*Hydrocephaly: we should measure the seen brain tissue thickness
for the neurosurgeons to decide to use shunt or not if the
measurement is less than 2.5 cm (no shunt can be used)
-Encephalocele: if present, we should examine all spines for
(meningocele)

Normal Mental Thickness:

In 14 wks.fetus should swallow and urinate so the stomach and UB
should be seen at 14 wks.
In IUGR.commences in the AC and HC lastly affected so IUGR depends
on AC (AC)
Placental Detection:
Detected at 10 wks GA.
Detect its site through the umbilical cord

In Placenta Previa:
1_marginal (3 cm distance from cervical canal)
2_partial near cervical canal
3_compelete covers cervical canal
The Difference BetweenPlacenta&Clot
Placenta: vascular, not indented by fetal head
Clot: a vascular, indented
Ectopic Pregnancy: signs on u/s:
1_single decidual reaction.
2_central sac (yolk sac)
3_others: in next page
A fluid collection in pelvis
B_adnexal sac
C_thick endometrium with fetus in the fallopian tube
D_no Doppler signal on endometrium
E_HCG positive with HCG titre *(normally HCG > 1600) while in ectopic
pregnancy HCG is equal to 1000 on 1st day and will be 600 on 2nd day so
HCG decreased.
With ectopic pregnancy may be there is 2 GS (intrauterine_intopic)
&(extrauterine_ectopic).
Ectopic pregnancy may be associated with no misperiod.
Ectopic pregnancy is a vascular while ruptured luteal cyst is highly
vascular.
Cervical ciculage should be done after 16 weeks(after formation lower
uterine segment).

Endovaginal u/s should be used after 16 weeks.

Normal cervical canal length is 35 mm.
If it is 25_35mmcirculage is indicated.

Shape of cervical canal:

T_shape. Closed (normal).
Y_shape (Some amniotic fluid will be in the canal).
V_shape (More amniotic fluid will be in the canal).
U_shape (urgent delivery)

Abdominal Ultrasound
LIVER:
N.B: liver segment: divided by hepatic veins into.medial &lateral
segments.
Divided by portal veins into..upper &lower segments.

N.B :Portal vein: is better seen with IVC.

N.B: Liver is considered enlarged if its span is more than 15 cm, or
The AP diameter + transverse diameter of rt. Lobe is equal or more than
25 cm.
N.B: the average of US probe:
1) Curved 3.5 5 MHz
2) Linear 7.5 10 MHz

N.B: early sign of portal HTN is recanalization of ligamentum teres(

falciform lig.).
N.B: normal G.B. volume is 50 cc.
KIDNEY U/S:
Normal pyramids disappear between the age of 20_45yrs.
So they appear in <20 &>45 yrs and if not present we depend on arcuate
artery to measure the cortical thickness.
A Cortical thickness: in sagittal view
Measured in sagittal position at middle pole of kidney (if the patient age
is <20 or >45).
While if patient age(20_45yrs) or pyramids not appear,we depend on
Doppler study of arcuate artery and measure cortical thickness from
arcuate artery to renal capsule at middle pole.
(Normal cortical thickness less or equal to 1.5 cm).
B_Parenchymal thickness:
Measured in transverse probe position from renal sinus to renal capsule
at the middle pole and it is normally measured 1.5_2.5 cm
Normal IVC in Abdomen:
1_red by Doppler when the probe received the pulse at Rt subcostal
oblique view.
2_blue when the probe away from the pulse at epigastric view.

Appendicitis:
On u/s Appendix appears as Eye _sign surrounded by edematous
omentum (blinded tube).
Normal diameter of appendix is 6_7 mm.
.

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*In general PRF . Pulse repetitive flow

In artery

needs high PRF (3.5)

In vein

needs low PRF (1.0)

Other Notes:
*In Gynecological u/s: uterine artery enters through the cervix so
measure pulsation or Doppler of uterine artery near cervix.
*Normal Lymph Nodes:
An oval shape (width > length) with intact hilum.
*In Malignancy:
A round shape (width = length) with loss of central hilum.

U/S Notes By Dr. Salam:

U/S:
1_wide information.
2_available.
3_safe.
*Superficial: Breast, Scrotum, Thyroid, Joint and Eyes.
*Glands which depends on volume:
A_Ovary.
B_Thyroid.

Standard Abdominal U/S:

1_Start with Central Transverse Epigastric Position: We see:
_Lt lobe of the liver
_Falciform ligament

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_portal vein
_Pancreas (head), stomach& duodenum
_aorta
_IVC
_celiac v.
2_Central Longitudinal EpigastricPosition: we see:
_IVC
_aorta
3_Turn the patient to the it lateral position: we see:
_gall bladder
_hepatic veins
_Rt kidney
_splenic vein
4_Turn the patient to the rt lateral position: we see:
_spleen (normal size is 12.5 _13.5 cm) if >13.5 typically enlarged.
_Lt kidney.
5_Urinary bladder should be filled to avoid mistake of uterine polyps
(pelvic u/s)
6_Bowel loops & gas shadow.
.
Regarding DVT: assess:
A_flow
B_thrombus
C_compressibility

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Q/How can we differentiate between fat & muscle layers on Thigh u/s:
A/Fat lobulated shadow.
Muscle fibers.. Linear echogenicity.

Rgarding Obstetrics U/S:

IUCD: normal position should be more than 1.5 cm from the funds if the
distance is less than 1.5 cm that will mean migration of IUCD to upper
part of Uterus.
So < 1.5 cm means upper migration of IUCD.

In case of vaginal bleeding in early pregnancy, we should assess

the following
1- Viability of fetus
2- Gestational sac
3- Hemorrhage in cul-de-sac
Regarding US of pancreas :if it is difficult to be visualized then:
1- Let patient drink water ,or
2- Valsalva maneuver (pancreas will be pushed upward) ,or
3- Examine patient in erect or sitting position.
N.B: pancreas is a retroperitoneal organ except its tail which
is intraperitoneal.
Signs of IUD ( intra uterine death):
1- Early echogenicity of head (spladings sign)
2- Collection of fluid intraperitoneally
3- Collection of fluid in the subcutaneous spaces of scalp and
skin
4- No fetal heart beat.

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Doppler notes:

Anatomy of lower limb veins:

Superficial veins:

1) Greater saphenous veins.: start on the medial aspect of dorsum of

the foot &pass anterior to medial malleolus ,ascend vertically lie
post. To medial side of the knee &anterior to the thigh.
It drains to CFV.
Its diameter less than 4mm.
2) Short saphenous vein: start at lateral side of the dorsum of the foot
&pass posterior to lateral malleolus ,it ascend on the back of the
calf &drain in to the popliteal vein.

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Deep veins:
Usually 2 veins accompany one artery.
They are :
1. Posterior tibial vein.
2. Anterior tibial vein.
3. Popliteal vein.
4. Femoral vein.
1&2 are draines to popliteal vein.

Anatomy of inguinal area:

Each artery is accompanied by 2 or more veins.

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).

A transverse image of a duplicated or bifid

superficial femoral vein with the artery (A) lying adjacent to the paired veins.

Method of DVT examination:

1. Supine :(for GSV&CFV)
2. Prone :( SSV&popliteal vein).
3. if the examination is difficult we do the following :
Compress the area of the thigh or leg just below the probe to
increase the flow to the veins & fill them &by using
Valsalva maneuver.
Or augmentation method by asking the patient to raise the
great toe.
Or by sitting position, the feet is touching the ground.
Or using the tourniquet (better to see the superficial veins).
Veins on Doppler US:

Normal vein is compressible on pressure (the probe must be

transverse i.e. perpendicular to the long axis of the vein) .
On Valsalva maneuver, the diameter of the vein is increased
normally.

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 Through the valve, the flow is in one direction by closure of the

valve the flow is stopped (no reverse flow).
Veins have no wall.
The veins are non pulsatile..
PRF decreased to 1 in veins.
Arteries on Doppler US:

They are pulsatile.

Have a wall (intima media).
Not affected by valsalva.
Non compressible.
PRF must increase to 3.5.

DVT:
Early signs of DVT:
Absent movement of one side of the venous valve on
respiration which will lead to reverse flow.
Other signs:

Veins are non compressible.

Double in size during valsalva.
No flow.
Reverse flow during valsalva.
Acute thrombus(less than 24 hr) anechoic as a filling defect.
Chronic thrombus(more than 24hr) echogenic
On Rx by warfarin lead to recanalization of the collateral to
become smaller in size.

Notes:
1. Communicating (perforating) veins connect the superficial veins to
deep one usually can not be seen except when there is
incompetence of the valve.
2. Turbulent flow at venous valve is normally present &should not be
misdiagnosed as reverse flow.
3. The anterior tibial veins pass above the fibula midway &go down
down between dorsum of the foot.

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4. RI (resistive index) =peak systolic velocity-end diastolic

velocity\peak systolic velocity.
=PSV-EDV\PSV
RI related reversely to the EDV (so when the diastolic velocity
increases lead to decrease in RI).
In pelvic& thyroid malignancy lead to increase in diastolic flow
&so decrease RI.
In normal ovulation, need high diastolic flow & decrease in RI.
Breast CA has increase RI due to un known cause.
In fetal umbilical artery if diastole reach zero, increase RI means
structural abnormalities.
Common carotid artery: normal diameter is 7 mm.
CCA divided to external carotid (contain valves) & internal carotid
artery (contain no valves).
Normal vertebral artery diameter is 5mm.
Thyroid US:
Assess the size, echo texture, capsule, retrosternal area &LN
enlargement.
Benign nodule of the thyroid:
1.
2.
3.
4.
5.
6.

Cystic (an echoic )

Regular outline.
Less vascularity, normal RI (rim of vascularity).
Capsule is intact.
No LAP.
No calcification.

Malignant thyroid nodule:

1.
2.
3.
4.
5.
6.

More solid lesion (hypoechoic )

Irregular border.
Highly vascular
Invasion of the capsule.
LAP.
Micro calcifications.

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Thyroid diameters :
Isthmus up to 1cm.
AP diameter up to 2 cm (>2.5 cm is enlarged)
Transverse diameter is 3cm (if >4 cm is enlarged
Craniocaudal diameter is 4 cm (>6cm is enlarged).

I hope the success for all my colleagues in TRAINEE RESIDENT

RADIOLOGIST GROUP

With my best friends

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