Name: Test Bank for Sonography Introduction to Normal Structure and Function, 3rd Edition: Curry
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ISBN-10 ‏ : ‎ 1416055568
ISBN-13 ‏ : ‎ 978-1416055563
Author: Reva Curry PhD RDMS RTR FSDMS

Gain a firm understanding of normal anatomy and physiology from a sonographic perspective! Sonography: Introduction to Normal Structure and Function, 3rd Edition shows normal anatomy as it appears during scanning, with labeled drawings explaining what you should notice. With this knowledge, you will be able to accurately identify sonographic pathology and abnormalities. Over 1,200 illustrations include the latest and best images from the newest ultrasound equipment, including 3D and 4D images. Written by expert educators Reva Curry and Betty Tempkin, this book provides complete preparation for the challenges you’ll encounter in the clinical environment.

SECTION I CLINICAL APPLICATIONS
CHAPTER 1 Before and after the ultrasound examination
Objectives
Key words
Before the ultrasound examination
Understanding universal precautions
Table 1-1 Sources of HBV/HIV Transmission and How Transmission Occurs
Table 1-2 Strategies to Reduce Exposure to Bloodborne Pathogens
Reviewing the ultrasound request form and patient chart
FIGURE 1-1 Radiology Department request form.
After the ultrasound examination
The sonographer’s technical observation
Interpretive report
BOX 1-1 PATIENT CHART
FIGURE 1-2 Example of sonologist’s final interpretive report.
CHAPTER 2 Ultrasound instrumentation: “knobology,” imaging processing, and storage
Objectives
Key words
Alphanumeric keyboard
Table 2-1 Keyboard Controls and Functions
FIGURE 2-1 Query worklist.
Primary imaging controls
FIGURE 2-2 Patient information page.
Table 2-2 Primary Imaging Controls and Functions
FIGURE 2-3 Imaging presets for ultrasound facility.
FIGURE 2-4A Incorrect TGC placement.
FIGURE 2-4B Correct TGC placement.
Basic operations of ultrasound system
FIGURE 2-5A Incorrect focal zone. The focal zone is too low in this thyroid examination, thus the thyroid mass cannot be accurately assessed. Observe the focal zone indicator on the right side of the screen.
FIGURE 2-5B Correct focal zone. Proper focal zone placement in the same patient. Notice that the focal zone indicator is at the same level as the mass. Now the internal components of the mass can be accurately assessed.
Table 2-3 Measurement Keys and Functions
FIGURE 2-6 Distance measurement. Note (1) calibers as shown on the screen measure 1.36 cm in length, and (2) calibers taken perpendicular to the first set of calibers measure 0.63 cm anteroposteriorly.
FIGURE 2-7 Circumference measurement. The trace/ellipse key is used to outline the circumference and calculate the measurement of this axial section of the common carotid artery.
FIGURE 2-8 Volume measurement. Complete measurements using the dual image feature to measure an abnormal mass in the right lobe of the thyroid gland. Three sets of measurements are taken: two in a longitudinal section of the mass, (1) long axis and (2) depth measurements; and (3) a width measurement in an axial section of the mass. Thus three dimensions of the mass are obtained and a volume measurement can be calculated: L × W × D = Volume.
Table 2-4 Additional Controls and Functions
Image processing and storage
FIGURE 2-9 Body patterns display. Various body parts can be shown on the imaging screen and on the images.
FIGURE 2-10 Color-flow Doppler and pulsed wave imaging. Black-and-white version of a color-flow Doppler image of the carotid artery with pulsed wave with measurements. (See Color Plate 1.)
FIGURE 2-11 Color-flow Doppler. Black-and-white version of a color-flow Doppler image of the right kidney. (See Color Plate 2.)
FIGURE 2-12 Power Doppler imaging. Black-and-white version of a power Doppler image of the right kidney. (See Color Plate 3.)
FIGURE 2-13 Color-flow Doppler box. Black-and-white version of a color-flow Doppler box steered to the right or toward the feet. (See Color Plate 4.)
BOX 2-1 TRANSDUCERS
Transducers available with most units
Small-footprint transducers
Table 2-5 Specialized Transducers and Functions
FIGURE 2-14 PACS image viewer.
FIGURE 2-15 Sonologist workstation. Area for image review and interpretation.
FIGURE 2-16 Simulated ultrasound report with images. Obstetric ultrasound report that includes sample images from the study.
CHAPTER 3 General patient care
Objectives
Key words
Interpersonal skills
FIGURE 3-1 Greeting patients with a smile and making eye contact, addressing them by their first and last name, and introducing yourself—all of these gestures help to establish a good rapport.
Ultrasound examination room
ULTRASOUND EXAMINATION ROOM STOCK ITEMS
Patient care during the ultrasound examination
FIGURE 3-2 Typical ultrasound examination room.
FIGURE 3-3 Assist inpatients with attached medical equipment such as IV poles or oxygen.
FIGURE 3-4 Ultrasound transducers are placed on the surface of the skin over various areas of interest. A water-soluble gel serves as a scanning couplant to reduce air between the transducer and skin surface, thus facilitating the imaging process.
Asepsis technique
CHAPTER 4 First scanning experience
Objectives
Table 4-1 How to Describe the Sonographic Appearance of Normal Body Structures
SCM (sternocleidomastoid muscle), OH, (omohyoid muscle), ST (sternothyroid muscle), SH (sternohyoid muscle), LCM (longus colli muscle), THY (thyroid), CCA (common carotid artery), JV (jugular vein), E (esophagus), TR (trachea), RLN (recurrent laryngeal nerve), VN (vagus nerve).
STO (stomach), AO, (aorta), IVC (inferior vena cava).
Table 4-2 Common Ultrasound Terms
FIGURE 4-8 How to Describe the Location of Abdominopelvic Cavity Structures. Descriptive divisions and surface landmarks of the peritoneal (abdominopelvic) cavity used by sonographers to accurately communicate the location of peritoneal structures. (Body structures not in the peritoneal cavity are discussed in later chapters.)
Body planes
Transverse plane
Sagittal plane
Coronal plane
FIGURE 4-9 Body Planes and Directional Terms. View of the body in the anatomic position: standing erect, arms at the sides, face and palms directed forward. Body planes are sagittal, coronal, and transverse. Directional terms are superior to inferior; anterior to posterior; medial to lateral; superficial to deep; proximal to distal; and ipsilateral to contralateral.
Sagittal scanning plane
2 sound wave approaches are possible
Anterior or posterior
FIGURE 4-10 A, Sagittal Plane Anterior Approach. Sagittal scanning plane image from an anterior approach, just to the left of the midline of the body. The structures visualized from anterior to posterior are the skin surface, abdominal wall tissues and musculature, long section of the left lobe of the liver, long sections of the lung, diaphragm, and esophageal-gastric junction (in the superior portion of the image), axial sections of the pancreas body, splenic artery and splenic vein, and longitudinal section of the superior mesenteric artery (in the inferior portion of the image) and long section of the abdominal aorta.
Coronal scanning plane
2 sound wave approaches are possible
Left lateral or right lateral
FIGURE 4-10 B, Coronal Plane Left Lateral Approach. Coronal scanning plane image from a left lateral approach, mid axillary line. The structures visualized from lateral to medial are the skin surface, abdominal wall tissues and musculature, long section of the spleen (in the superior portion of the image), longitudinal sections of the left kidney, psoas muscle, and abdominal aorta (in the inferomedial portion of the image).
Transverse scanning plane
4 sound wave approaches are possible
Anterior, posterior, left lateral, or right lateral
FIGURE 4-10 C, Transverse Plane Anterior Approach. Transverse scanning plane image from an anterior approach at the mid epigastrium. The structures visualized from anterior to posterior are the skin surface, abdominal wall tissues and musculature, axial section of the left lobe of the liver, long section of the pancreas neck and body, axial sections of the portal splenic confluence and superior mesenteric artery, long section of the left renal vein, and axial section of the aorta (in the middle portion of the image). In the right portion of the image, the longitudinal pancreas head, uncinate process, and portion of the left renal vein and axial sections of the gastroduodenal artery, common bile duct, and inferior vena cava. In the left portion of the image, a long section of the stomach, pancreas tail, splenic vein, left renal vein, and left renal artery.
Ultrasound scanning planes
FIGURE 4-11 Endocavital Scanning Plane Interpretations. Endovaginal imaging and endorectal imaging are obtained from an inferior transcavital approach, which is technically organ oriented. Image orientation still varies among institutions, authors, and textbooks. These examples represent the majority.
FIGURE 4-12 Neurosonography/Neonatal Brain Scanning Plane Interpretations. Neonatal brain imaging is obtained from a superior approach via the anterior fontanelle.
Clinical criteria
Imaging criteria
Scanning
FIGURE 4-13 Standard patient positions.
FIGURE 4-14 Transducer Positions and Motions. Different transducer positions and motions are routinely used to achieve the optimal image. They include the following: (A) Perpendicular, (B) Twisting, (C) Angled, (D) Subcostal, (E) Intercostal.
Longitudinal survey • abdominal aorta
Sagittal plane / transabdominal anterior approach
BIFURCATION ALTERNATIVE
Axial survey • abdominal aorta
Transverse plane/transabdominal anterior approach
Longitudinal images • abdominal aorta
Sagittal plane / transabdominal anterior approach
LABELED: AORTA SAG PROX
LABELED: AORTA SAG MID
LABELED: AORTA SAG DISTAL
LABELED: AORTA RT COR BIF (OR AORTA LT COR BIF OR AORTA SAG BIF RT OR LT)
Axial images • abdominal aorta
Transverse plane / transabdominal anterior approach
LABELED: AORTA TRV PROX
LABELED: AORTA TRV PROX
LABELED: AORTA TRV MID
LABELED: AORTA TRV MID
LABELED: AORTA TRV DISTAL
LABELED: AORTA TRV DISTAL
LABELED: AORTA TRV BIF
How to describe abnormal ultrasound findings
Table 4-3 Comparative Echogenicity
Sonographic characterization of pathology
Describing the sonographic appearance of diffuse disease
Describing the sonographic appearance of localized disease
Origin
FIGURE 4-48 Mass Origin. The liver appears to be compromised by an extrahepatic, right upper quadrant mass. The right kidney appears separate from the mass. The adrenal gland is not visualized.
Size
Composition
Solid masses
Cystic masses
FIGURE 4-52 Side Lobe Artifact. Transabdominal, sagittal scanning plane image of the midline of the female pelvis; shows reverberation artifact adjacent to the anterior bladder wall (small arrow) wall and side lobe artifact at the posterior aspect (large arrow).
Complex masses
FIGURE 4-56
FIGURE 4-57
FIGURE 4-59 Black and white version of color flow Doppler image. (See Color Plate 5.)
Other considerations
FIGURE 4-63 Refractive Shadowing. A, Fetal skull with refractive shadowing (arrows). (Half tone image courtesy the Group for Women, Norfolk, VA.) B, Longitudinal section of the gallbladder with refractive shadows seen at the curved edges. C, Intrahepatic cyst with refractive shadowing. (Halftone image courtesy Acuson Corp., Mountain View, CA.)
SECTION II SONOGRAPHIC APPROACH TO UNDERSTANDING ANATOMY
CHAPTER 5 Interdependent body systems
Objectives
Key words
Table 5-1 How Body Systems Relate
Nervous system
Central nervous system (cns)
Peripheral nervous system (pns)
Endocrine system
“Neuro” endocrine system
Pituitary anatomy
System functions
Table 5-2 Endocrine Glands: The Hormones They Secrete and Their Functions
Cardiovascular system
Arteries and veins
Pulmonary circulation
Systemic circulation
Atypical blood flow
The heart
Lymphatic system
Collection and transportation of fluid
Fat absorption
Immune function
Musculoskeletal system
Reproductive system
Male gamete production and maturation
Female gamete production and maturation
Fertilization
The excretory systems
Digestive system–urinary system–respiratory system
Digestive system
Urinary system
Anatomy
Filtration
Respiratory system
Anatomy
CHAPTER 6 Anatomy layering and sectional anatomy
Objectives
Key words
FIGURE 6-1 Body planes and directional terms.
FIGURE 6-2 Body cavities. Ventral cavity includes the thoracic, and abdominopelvic cavities. The thoracic cavity is an enclosed area that basically corresponds to the rib cage. It is separated from the abdominal cavity by the diaphragm. The abdominopelvic cavity extends from the diaphragm (superiorly) to the pubic bone (inferiorly). Dorsal cavity includes the cranial and spinal cavities. The cranial cavity (“calvarium”) contains the brain, the spinal cavity contains the spinal cord.
1. directional terminology
2. body divisions
Dorsal cavity
Ventral cavity
Abdominal cavity
Pelvic cavity
Table 6-1 Peritoneal Cavity Spaces
True pelvis
False pelvis
3. tissue layers
Somatic layers
Extravisceral layers (visceral layers)
Intravisceral luminal layers
Intravisceral nonluminal layers
FIGURE 6-3 Structural orientation.
4. structure classification
Musculoskeletal unit
Vascular unit
Visceral unit
Enclosing unit
5. structure orientation
FIGURE 6-4 A
FIGURE 6-4 B
FIGURE 6-4 C
FIGURE 6-4 D
FIGURE 6-4 E
6. sectional planes
Transverse plane
Sagittal plane
FIGURE 6-5
Coronal plane
7. body structure relationships
FIGURE 6-6
FIGURE 6-7
FIGURE 6-8 A
FIGURE 6-8 B
FIGURE 6-9
8. comparison of cadaver sections and ultrasound image sections
FIGURE 6-10
FIGURE 6-11
FIGURE 6-12
Abdominal layers
Most posterior layer
Figure 6-13 a. muscle layer
Anterior to muscle layer
Figure 6-13 b. kidneys and adrenal glands
Anterior and medial to kidneys and adrenal glands
Figure 6-13 c. inferior vena cava
Anterior and medial to kidneys and adrenal glands
Figure 6-13 d. abdominal aorta
Anterior to inferior vena cava and aorta
Figure 6-13 e. portal venous system
Anterior to portal vein, inferior vena cava, and right kidney
Figure 6-13 f. gallbladder and biliary tract
Anterior to the portal venous system, common bile duct, and inferior vena cava
Figure 6-13 g. pancreas
Anterior to the pancreas
Figure 6-13 h. gastrointestinal tract
Anterior to the pancreas, gallbladder and biliary tract, portal venous system, aorta, inferior vena cava, and kidneys
Figure 6-13 i. liver
Most anterior layer
Figure 6-13 j. muscle layer
Pelvic layers
Most posterior layer
A. true pelvis muscle layer
Anterior to true pelvis muscles
B. false pelvis muscles
Anterior to false pelvis muscles
C. rectum/colon
Anterior to rectum/colon
D. uterus/bladder
Anterior to rectum / colon
E. prostate gland / bladder
Most anterior layer
F. muscle layer
CHAPTER 7 Embryology*
Objectives
Table 7-1 Organogenesis
Keywords
NORMAL MEASUREMENTS
FIGURE 7-1 Aortic Development. Representation of aortic development of approximately the third embryologic week.
Embryologic development
Heart and abdominal aorta development
FIGURE 7-2 Inferior Vena Cava Development. Origin of the inferior vena cava and associated tributaries in the embryo.
Inferior vena cava (ivc) development
Table 7-2 Inferior Vena Cava (IVC) Sections at 6-8 Embryologic Weeks
FIGURE 7-3 Cardinal Venous System. Anterior view of the cardinal venous system.
Portal venous development
Biliary system development
Liver development
FIGURE 7-4 Portal Vein Development. Early embryo demonstrating origin of portal vein.
FIGURE 7-5 Primitive Gut Development. Median section of an embryo outlining the primitive gut.
Pancreas development
Urinary system development
Spleen development
FIGURE 7-6 Spleen Development. Early prenatal development of the spleen.
Gastrointestinal tract development
FIGURE 7-7 Midgut Development. A 10-week-old fetus with normal midgut herniation into the cord.
Table 7-3 Primitive Gut
Male pelvis development
FIGURE 7-8 Congenital Uterine Malformations. This figure illustrates some congenital uterine malformations with anatomic variations of the uterus, cervix, and vagina resulting from the incomplete fusion or agenesis of the müllerian ducts. Complete duplication of the vagina, cervix, and uterine horns is seen in uterus didelphys. The bicornuate uterus has two uterine horns that are fused at one cervix (uterus bicornis unicollis) or at two cervices (uterus bicornis bicollis). Uterus subseptus is a milder anomaly marked by a midline myometrial septum within the endometrial canal. In some cases, only one müllerian duct develops, forming a single uterine horn and a uterine tube continuous with one cervix and vagina (uterus unicornis).
Female pelvis development
Breast development
FIGURE 7-9 Congenital Uterine Malformation. This transverse scanning plane, transabdominal image of the pelvis demonstrates a bicornuate uterus containing a gestational sac within the right endometrial cavity. The gestational sac is anechoic and is surrounded by the hyperechoic decidual reaction of the endometrial lining. Myometrial tissue separates the endometrial canals of the left and right uterine horns.
FIGURE 7-10 Breast Development. Mammary ridges seen during prenatal development of fetus.
Thyroid and parathyroid development
Neonatal brain development
FIGURE 7-11 Breast Development. A, Connective tissue bud seen at approximately 10 weeks’ gestational age. B, Outward extensions into lactiferous ducts seen at approximately 4 months’ gestational age.
FIGURE 7-12 Thyroid Development. Embryonic migration of the thyroid gland. Broken line indicates migration.
FIGURE 7-13 Parathyroid Development. Migration of the thymus and parathyroid glands.
FIGURE 7-14 Brain Development. First stage of early development of the brain at 3½ weeks.
FIGURE 7-15 Brain Development. Developing brain at 5½ weeks.
Table 7-4 Brain Area Formation: 3-4 Embryologic Weeks
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
AFFECTING CHEMICALS
SECTION III ABDOMINAL SONOGRAPHY
CHAPTER 8 The abdominal aorta
Objectives
Key words
Table 8-1 Location of Abdominal Aorta and Branches Routinely Visualized with Ultrasound
FIGURE 8-1 Anterior and lateral views of the aorta.
NORMAL MEASUREMENTS
Location
FIGURE 8-2 Initial branches of the abdominal aorta.
FIGURE 8-3 ABDOMINAL AORTA AND BRANCHES (From Superior to Inferior)
FIGURE 8-4 Cross-section of the arterial wall.
Size
Gross anatomy
Physiology
FIGURE 8-5 Longitudinal section of the proximal portion of the abdominal aorta in a sagittal scanning plane.
Sonographic appearance
FIGURE 8-6 Sagittal scanning plane image showing longitudinal sections of the proximal aorta and superior mesenteric artery. Note the left lobe of the liver anteriorly. Also notice the body of the pancreas posterior to the left lobe and anterior to the superior mesenteric artery.
FIGURE 8-7 Transverse scanning plane image showing a short axis section of the aorta and longitudinal sections of the celiac artery, common hepatic artery, and splenic artery.
FIGURE 8-8 Sagittal scanning plane image of a longitudinal section of the mid aorta and its anterior branches, the celiac artery and superior mesenteric artery.
FIGURE 8-9 Transverse scanning plane image showing the short axis sections of the mid abdominal aorta and its superior mesenteric artery branch.
FIGURE 8-10 This transverse scanning plane image shows another axial section of the aorta (AO), as well as the superior mesenteric artery. Note how the superior mesenteric artery is anterior to the aorta and longitudinal section of the left renal vein. Directly anterior to the superior mesenteric artery, portions of the splenic vein can be seen forming a posterior border of the tail and body of the pancreas. The portal-splenic confluence can be seen anterior and slightly right lateral to the superior mesenteric artery.
FIGURE 8-11 Transverse scanning plane image displaying short axis section of the mid aorta and longitudinal, curvilinear section of the right renal artery.
FIGURE 8-12 Sagittal scanning plane image delineating a longitudinal section of the inferior vena cava and short axis section of the right renal artery.
FIGURE 8-13 Longitudinal section of the distal aorta (arrows). Note decrease in aortic diameter.
FIGURE 8-14 Gray scale version of color Doppler transverse scanning plane image showing an axial section of the distal aorta just prior to bifurcation into the common iliac arteries. (See Color Plate 6.)
FIGURE 8-15 Transverse scanning plane image showing axial sections of the common iliac arteries just distal to the aortic bifurcation.
Sonographic applications
Normal variants
FIGURE 8-16 Normal right renal artery Doppler waveform. This is a low-resistance waveform (the diastolic flow is approximately one third of the peak systolic flow, indicating a low-resistance vascular bed).
FIGURE 8-17 Normal preprandial superior mesenteric artery Doppler waveform. The diastolic flow, as compared with the low-resistance renal artery waveform, is much less in relation to the peak systolic flow. The preprandial superior mesenteric artery waveform is considered a high-resistance waveform.
FIGURE 8-18 Doppler waveform throughout two cardiac cycles.
FIGURE 8-19 Normal aortic Doppler waveform.
FIGURE 8-20 Gray scale version of color Doppler transverse scanning plane sonogram demonstrating axial sections of the common iliac arteries. (See Color Plate 7.)
FIGURE 8-21 Gray scale version of color Doppler transverse scanning plane sonogram demonstrating flow within the aorta, celiac artery, splenic artery, and common hepatic artery. (See Color Plate 8.)
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 9 The inferior vena cava
Objectives
Key words
FIGURE 9-1 Sections of the inferior vena cava.
Table 9-1 Location of Inferior Vena Cava and Tributaries Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
Location
FIGURE 9-2 IVC AND MAJOR TRIBUTARIES
FIGURE 9-3 Longitudinal hepatic section of the inferior vena cava in a sagittal scanning plane image.
Size
Gross anatomy
Physiology
Sonographic appearance
FIGURE 9-4 Sagittal scanning plane image showing another longitudinal hepatic section of the inferior vena cava seen coursing posteriorly to the liver.
FIGURE 9-5 Sagittal scanning plane image demonstrating a longitudinal section of left hepatic vein emptying into the inferior vena cava.
FIGURE 9-6 Another depiction of a hepatic vein emptying into the IVC.
FIGURE 9-7 A, Axial section of the liver showing the middle hepatic vein and left hepatic vein emptying into the inferior vena cava. B, Gray scale version of a color image demonstrating the hepatic veins emptying into the inferior vena cava. (See Color Plate 9.)
Sonographic applications
Normal variants
FIGURE 9-8 Transverse scanning plane section of the abdominal vasculature demonstrating axial sections of the inferior vena cava, aorta, and superior mesenteric artery along with the longitudinal, curvilinear section of the left renal vein following a coursing posterior to the superior mesenteric artery and anterior to the aorta. Note the longitudinal section of the right renal artery.
FIGURE 9-9 An axial section of the IVC is clearly shown in this transverse scanning plane image. Note the longitudinal section of the left renal vein entering the medial aspect of the IVC. Anterior and medial to the IVC is an axial section of the SMA. Anterior to the SMA is a longitudinal section of the splenic vein. The most posterior vessel seen in this image is an axial section of the aorta, from which the longitudinal, curvilinear section of the right renal artery can be seen coursing its way to the right kidney.
FIGURE 9-10 Axial section of the liver demonstrating a normal spontaneous and phasic Doppler pattern from the left hepatic vein.
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
AFFECTING CHEMICALS
VASCULATURE
Inferior to superior
CHAPTER 10 The portal venous system
Objectives
Key words
Table 10-1 Location of the Portal Venous System Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
Location
Size
Gross anatomy
Physiology
Sonographic appearance
FIGURE 10-1 PORTAL VENOUS SYSTEM
FIGURE 10-2 Portal Vein Walls. Sagittal scanning plane image of the right lobe of the liver showing the difference between the sonographic appearance of portal vein walls and hepatic vein walls. Portal vein walls appear distinctively brighter because of their high collagen content and sheath covering.
FIGURE 10-3 Portal Splenic Confluence. Transverse scanning plane image of the mid-epigastrium demonstrating the origin of the portal vein.
FIGURE 10-4 Relationship of Splenic Vein and Main Portal Vein. Transverse oblique scanning plane image of the mid-epigastrium showing a longitudinal section of a portion of the splenic vein becoming the main portal vein.
Sonographic applications
Normal variants
FIGURE 10-5 Main Portal Vein Branches. A, Transverse scanning plane image of a longitudinal section of the main portal vein and its right and left branches. B, Another image of the main portal vein as it branches into right and left portal veins. Further branching from both right and left portal veins is evident in this image.
FIGURE 10-6 Left Portal Vein Branches. Transverse scanning plane image of the left lobe of the liver demonstrating the left portal vein dividing into its medial and lateral branches.
FIGURE 10-7 Right Portal Vein Branches. A, Transverse scanning plane image of the right lobe of the liver demonstrating the right portal vein dividing into its anterior and posterior branches. B, This transverse plane image clearly shows the vessels and structures near the liver as well as the right portal vein and its anterior and posterior branches.
FIGURE 10-8 Relationship of Superior Mesenteric Vein and Main Portal Vein. Sagittal oblique scanning plane image, just to the right of the midline of the body, showing a longitudinal section of a portion of the superior mesenteric vein becoming the main portal vein. Observe how the superior mesenteric vein passes between the neck (anteriorly) and uncinate process (posteriorly) of the pancreas. Note the axial section of the right renal artery posterior to the inferior vena cava.
FIGURE 10-9 Right Portal Vein. Sagittal scanning plane image showing the circular, short axis section of the right portal vein. Note the long section of anechoic duct directly anterior to the vein.
FIGURE 10-10 Left Portal Vein. Sagittal scanning plane image showing the circular, short axis section of the left portal vein.
FIGURE 10-11 Doppler Waveform Right Portal Vein. Longitudinal section of the right lobe of the liver in a sagittal scanning plane, demonstrating a normal Doppler waveform of the right portal vein. Note the phasic flow (variation) of the Doppler signal in response to respiration. In addition, note that the flow is above baseline. In this case, blood is flowing into the liver, which is normal.
FIGURE 10-12 Color Doppler Anterior Branch Right Portal Vein. Gray scale version of color Doppler, sagittal scanning plane image of the anterior branch of the right portal vein. (See Color Plate 10.)
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 11 Abdominal vasculature
Objectives
Key words
FIGURE 11-1 Abdominal arterial system.
Table 11-1 Location of Abdominal Aorta and Branches Routinely Visualized with Ultrasound
Table 11-2 Location of Inferior Vena Cava and Tributaries Routinely Visualized With Ultrasound
Table 11-3 Location of the Portal Venous System Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
The abdominal arterial system
Location
FIGURE 11-2 Gray scale version of Doppler color flow image of a longitudinal section of the abdominal aorta and the origins of the celiac and superior mesenteric arteries from the anterior wall of the aorta. (See Color Plate 11.)
FIGURE 11-3 Transverse plane, gray scale version of a color flow image of an axial section of the abdominal aorta showing the origin and longitudinal section of the left renal artery. (See Color Plate 12.)
FIGURE 11-4 A, Doppler spectral waveform from the suprarenal abdominal aorta. Note forward diastolic flow. B, Doppler spectral waveform from the infrarenal aorta, demonstrating the triphasic velocity waveform consistent with a vessel feeding a high-resistance vascular bed.
Size
Sonographic appearance
Hemodynamic patterns
FIGURE 11-5 Doppler velocity waveform from the celiac axis. Note constant forward diastolic flow.
FIGURE 11-6 A, Velocity spectral waveform recorded from the fasting superior mesenteric artery. B, Postprandially, the superior mesenteric artery diastolic flow component increases twofold to threefold in response to the metabolic demands imposed by digestion.
Doppler velocity spectral analysis
FIGURE 11-7 Doppler spectral waveform from a normal renal artery. The high diastolic flow component is consistent with a vessel feeding a low-resistance end organ.
FIGURE 11-8 A, Doppler velocity waveform recorded from normal renal parenchyma. B, Diastolic flow component of the renal parenchymal Doppler velocity signal decreases as renovascular resistance increases due to intrinsic renal pathology.
The abdominal venous system
Location
FIGURE 11-9 A, Abdominal venous system showing major branches. B, Portal venous system.
FIGURE 11-10 Transverse plane, gray scale version of a color flow image of an axial section of the abdominal aorta demonstrating its posterior relationship to the long section of left renal vein, axial section superior mesenteric artery, and long section splenic vein. (See Color Plate 13.)
FIGURE 11-11 Oblique, longitudinal, intercostal, gray scale version of a color flow image of main, right, and left portal veins. (See Color Plate 14.)
Size
Sonographic appearance
FIGURE 11-12 A, Gray scale version of transverse plane, color flow image of a longitudinal section of the hepatic artery at its origin from celiac artery bifurcation. B, Gray scale version of color flow image of hepatic artery as it courses with portal vein in the porta hepatis. (See Color Plates 15 and 16.)
Hemodynamic patterns and doppler spectral display
FIGURE 11-13 A, Gray scale version of Doppler spectral waveform from the distal inferior vena cava. B, Gray scale version of Doppler spectral waveform from the proximal inferior vena cava. (See Color Plates 17 and 18.)
FIGURE 11-14 Gray scale version of Doppler spectral waveform from the right renal vein. (See Color Plate 19.)
FIGURE 11-15 Gray scale version of Doppler spectral waveform from the left hepatic vein. (See Color Plate 20.)
FIGURE 11-16 Gray scale version of minimally phasic Doppler spectral waveform from the main portal vein. (See Color Plate 21.)
FIGURE 11-17 Gray scale version of low-resistance Doppler spectral waveform pattern from hepatic artery. (See Color Plate 22.)
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 12 The liver
Objectives
Key words
Table 12-1 Location of the Liver Routinely Visualized With Ultrasound
FIGURE 12-1 Transverse scanning plane image showing an axial section of the diaphragmatic undersurface and the posterosuperior liver surface.
NORMAL MEASUREMENTS
Liver Size
Location
Right posterosuperior surface
Inferior (visceral) surface
FIGURE 12-2 Anterior liver surface.
FIGURE 12-3 Posterior liver surface outlining the boundaries of the bare area.
FIGURE 12-4 Sagittal scanning plane image showing a longitudinal section of the left inferior margin of the left hepatic lobe. Note posteriorly, how the liver surrounds the IVC.
Right-sided inferior indentations
Left side of inferior surface
Posterior midportion of inferior surface
Right lobe
FIGURE 12-5 Transverse scanning plane of the midepigastrium. The falciform ligament appears in short axis as a triangular-shaped, bright, echogenic focus demarcating the lateral border of the quadrate (medial left) lobe.
FIGURE 12-6 Parasagittal scanning plane image just to the right of the midline of the body that demonstrates the liver’s caudate lobe posterior to the left hepatic lobe and a longitudinal section of the thin, bright ligamentum venosum. The left hepatic vein is seen coursing toward the inferior vena cava.
Left lobe
Caudate lobe
FIGURE 12-7 Longitudinal section of the right lateral margin of the liver illustrating the base of the livery pyramid. Note by the location of the transducer, how the right lobe of the liver lies close to the anterolateral abdominal wall.
Table 12-2 Lobar Liver Anatomy with Landmarks
Size
Table 12-3 Peritoneal Divisions
Gross anatomy
FIGURE 12-8 The inferior surface of the liver depicting the H pattern of lobar segmentation.
Table 12-4 H Pattern of Anatomic Lobar Segmentation
Table 12-5 Liver Division by Hepatic Veins
FIGURE 12-9 Transverse scanning plane image demonstrating the hepatic veins draining into the inferior vena cava. Anterior and posterior segments of the right hepatic lobe are prominently displayed. Recall that the right hepatic vein separates the anterior liver segments 5 and 8 from the posterior segments 6 and 7.
FIGURE 12-10 Transverse scanning plane image showing a section of the hepatic veins and inferior vena cava forming the “bunny sign.”
FIGURE 12-11 Transverse scanning plane image showing the left portal vein, demonstrating Couinaud’s liver segments 1 through 4. The umbilical portion of the left portal vein branches to liver segments 2, 3, and 4. Note the caudate lobe (segment 1) anterior to the inferior vena cava and posterior to the left portal vein at this level.
Table 12-6 Couinaud’s Liver Segmentation
Table 12-7 Couinard’s Liver Segmentation Identification
FIGURE 12-12 Parasagittal scanning plane image just to the right of the midline of the body, demonstrating the origin of the main portal vein. Note the papillary process of the caudate lobe.
FIGURE 12-13 Transverse scanning plane image showing the main portal vein entering the porta hepatis just anterior to the inferior vena cava then dividing into right and left branches.
FIGURE 12-14 Transverse scanning plane image showing the right portal vein. Note the longitudinal section of the right renal artery coursing posteriorly to the axial section of the inferior vena cava.
FIGURE 12-15 Sagittal scanning plane image showing longitudinal sections of the right kidney and right adrenal gland in contact with the bare area of the liver. Observe how the anterior kidney surface is separated from the posterior liver surface by Morison’s pouch, a peritoneal space that is not specifically appreciated sonographically unless it is abnormally filled with fluid. The bright, thin, curved line seen between the liver and kidney is the fibrous renal capsule.
FIGURE 12-16 Transverse scanning plane image demonstrating a longitudinal section of the falciform ligament coursing toward the anterior abdominal wall. Observe the characteristic sickle shape.
FIGURE 12-17 Transverse scanning plane image that shows the transverse fissure (ligamentum venosum) coursing toward the left portal vein, marking the anterior border of the caudate lobe.
FIGURE 12-18 Sagittal scanning plane image demonstrating a longitudinal section of the common bile duct coursing inferiorly to the head of the pancreas (this is at the level of the hepatoduodenal ligament).
Physiology
Metabolic functions of the liver
Detoxification of poisonous and harmful substances
Synthesizing blood proteins
Additional liver functions
Sonographic appearance
FIGURE 12-19 Sagittal scanning plane image that shows how the longitudinal section of the main lobar fissure appears as an echogenic line connecting the neck of the gallbladder to the right portal vein.
FIGURE 12-20 Transverse scanning plane image of the midepigastrium. Note the axial section of the falciform ligament and its characteristic pyramidal shape. This echogenic focus is also referred to as the round ligament or ligamentum teres at this level.
FIGURE 12-21 Transverse scanning plane image demonstrating longitudinal sections of the hepatic veins draining into the axial section of the inferior vena cava; providing sonographic segmentation of the hepatic lobes.
Sonographic applications
FIGURE 12-22 Black-and-white version of a color flow Doppler image showing the characteristic waveform of a normal portal vein. Note that the blood flow is in the direction of the liver toward the transducer. (See Color Plate 23.)
FIGURE 12-23 Black-and-white version of a color flow Doppler image demonstrating the characteristic arterial waveform of the normal hepatic artery. (See Color Plate 24.)
FIGURE 12-24 Oblique transverse scanning plane image of a liver section to evaluate the proximal portal end of the TIPS(s) shunt after placement.
FIGURE 12-25 Black-and-white version of a color Doppler evaluation of a TIPS(s) shunt connecting the hepatic vein to the intrahepatic portal vein. Note that the color blue represents flow away from the transducer (hepatic vein) and the color red represents flow moving toward the transducer (portal vein). (See Color Plate 25.)
FIGURE 12-26 Transverse scanning plane image showing an axial section of the liver at the level of the hepatic veins draining into the inferior vena cava. Observe the highly reflective terminal end of the TIPS(s) shunt within the right hepatic vein.
FIGURE 12-27 Sagittal scanning plane image of a woman with Reidel’s lobe, a tongue-like extension of the right lobe of the liver. This Reidel’s lobe extends inferiorly to the iliac crest.
Normal variants
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULTURE
AFFECTING CHEMICALS
CHAPTER 13 The biliary system
Objectives
Key words
FIGURE 13-1 Posteroinferior Surface of the Liver. Note the location of the gallbladder and biliary tract to adjacent anatomy.
Table 13-1 Location of Gallbladder and Biliary Tract Routinely Visualized With Ultrasound
NORMAL MEASUREMENTS
Location
Gallbladder
Hepatic ducts
FIGURE 13-2 The Biliary System. Gallbladder and biliary tract, including the pancreas’ pancreatic duct, and duodenum.
FIGURE 13-3 Common Hepatic Duct and Right Portal Vein Relationship. Sagittal scan demonstrating a longitudinal section of the common hepatic duct seen just anterior to the longitudinal section of the right portal vein. The common hepatic duct is often mistaken as the common bile duct, which is located more inferiorly and is more closely associated with the main portal vein.
Common hepatic duct (chd)
Cystic duct
Common bile duct (cbd)
Size
Gallbladder
FIGURE 13-4 Portal Vein, Hepatic Artery, and Common Duct Relationship. A, Observe how the common duct is anterolateral to the proper hepatic artery. Notice that the proximal common duct, the common hepatic duct, is anterior to the right portal vein branch and the distal portion of the common duct, the common bile duct, is anterior to the main portion of the portal vein. B, In an oblique transverse scanning plane image at approximately the angle of the solid line (approximately the same level as the right costal margin angle), one should see the relationship demonstrated in C. C, Note that the common bile duct and proper hepatic artery have approximately equal diameter. D, Oblique transverse scanning plane image demonstrating “Mickey’s Sign,” formed by the appearance of the axial sections of the extrahepatic portal triad. P, Main portal vein; C, common bile duct; H, proper hepatic artery.
Common hepatic duct (chd)
FIGURE 13-5 Common Bile Duct and Duodenum Relationship. A, Sagittal scanning plane image showing a longitudinal section of the supraduodenal and retroduodenal segments of the common bile duct. B, Longitudinal section of the infraduodenal segment of the common bile duct in a sagittal scanning plane.
Cystic duct
Common bile duct (cbd)
Gross anatomy
Gallbladder
FIGURE 13-6 Gallbladder Fundus. Sagittal scanning plane image demonstrating a longitudinal section of the gallbladder fundus. Notice the proximity of the axial section of the portal vein and longitudinal section of the inferior vena cava.
Hepatic ducts
Biliary ducts
Cystic duct
Physiology
FIGURE 13-7 Gallbladder Body and Neck. Longitudinal section of the gallbladder neck and body seen in a sagittal scanning plane. Note the long section of the right kidney immediately posterior to the gallbladder.
Sonographic appearance
Gallbladder
FIGURE 13-8 Gallbladder Shape. A, Sagittal scan; longitudinal section of the gallbladder. Note fundus shape and partial obscurity by bowel shadow. B, Transverse scan; axial sections of the gallbladder (anteriorly) and right kidney (posteriorly). C, Axial section of the body of the gallbladder (GB) in a different patient. Note the shape of the gallbladder. Observe the anechoic appearance and good through sound transmission seen just posterior to the posterior gallbladder wall. Also note the anechoic, similarly shaped, axial sections of the inferior vena cava (IVC) and aorta (AO), which should not be confused with the gallbladder.
FIGURE 13-9 Nondistended/Distended Gallbladder. A, An empty gallbladder can be difficult to distinguish from the portion of the duodenum shown next to it. Care must be taken not to confuse a normal, empty gallbladder with bowel or pathology. B, View of a normal, distended gallbladder (GB) in another patient. Note the proximity of the portal vein (PV), inferior vena cava (IVC), and liver.
FIGURE 13-10 Gallbladder Wall Thickness. The thickness of the normal gallbladder wall is usually less than 3 mm. Cholecystitis and carcinoma are just two examples of pathologic states that may alter the thickness and appearance of the gallbladder wall. Care must be taken when adjusting technique to resolve actual wall thickness and not misrepresent the walls by setting the gain or power settings too high. Note that the American Institute of Ultrasound in Medicine (AIUM) recommends that any abnormality be documented at high and low gain settings in at least two scanning planes. This differentiation assists the interpreting physician with the diagnosis.
FIGURE 13-11 Main Portal Vein. The main portal vein (MPV) is a useful landmark when locating the gallbladder. This transverse scanning plane image shows that following the longitudinal MPV from its origin to the liver will reveal the right portal vein (RPV) branch, which is typically at a level just superior to the gallbladder. SV, Splenic vein; IVC, inferior vena cava; AO, aorta.
FIGURE 13-12 Relationship of Gallbladder, Duodenum, and Pancreas. A transverse scanning plane image through the mid-epigastrium may reveal the above relationship. Notice how the gallbladder is lateral to the duodenum, which is just lateral to the head of the pancreas.
FIGURE 13-13 Main Lobar Fissure and Gallbladder Relationship. The main lobar fissure helps to form the “bed” in which the gallbladder lies and serves as a useful landmark to help locate the gallbladder.
Ductal system
FIGURE 13-14 Hartmann’s Pouch. A dilatation located in the area of the neck of the gallbladder is called Hartmann’s pouch. This slight sacculation is also known as the infundibulum.
FIGURE 13-15 Wall Shadowing. Shadows and other minor distortions related to the edge of the gallbladder walls and distal to the spiral valves of Heister are common. High-frequency sound produces a particularly striking shadow from these areas because it is more easily reflected than the lower frequencies.
FIGURE 13-16 Relationship of Right Portal Vein, Proper Hepatic Artery, and Common Hepatic Duct. Slightly oblique, sagittal scanning plane image showing a longitudinal section of the common duct. An axial section of the proper hepatic artery is seen between the common hepatic duct portion of the common duct (anteriorly) and right portal vein (posteriorly).
FIGURE 13-17 Relationship of Infraduodenal Common Bile Duct, Pancreas Head, and Gastroduodenal Artery. Transverse scanning plane image of the mid-epigastrium demonstrating an axial section of the infraduodenal common bile duct on the posterolateral border of the pancreas head, posterior to an axial section of the gastroduodenal artery.
Sonographic applications
Normal variants
FIGURE 13-18 False Appearance of a Gallbladder Variation. In this sagittal scanning plane image, it appears that a septation is present in the gallbladder. However, when the patient’s position was changed, the gallbladder was observed folded onto itself (a normal variation) and not abnormally septated. Clearly, it is imperative that the patient be placed in at least two different positions during sonographic examination of the gallbladder and biliary tract to rule out normal variations from abnormalities.
Gallbladder
Typical Gallbladder Shape Variations. A, Bilobed gallbladder. B, True septated gallbladder. C, Gallbladder folded onto itself in what has been called the Phrygian gallbladder, named after the shape of a Phrygian cap seen in “D.” D, The Phrygian cap was worn by early Roman freed slaves and later by French revolutionaries as a symbol of liberty.
Biliary ducts
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 14 The pancreas
Objectives
Key words
Table 14-1 Location of the Pancreas Head, Uncinate, Neck, Body, and Tail Routinely Visualized with Ultrasound
Table 14-2 Components of Pancreatic Juice
FIGURE 14-1 Relationship of the pancreas, duodenum, and biliary system. Note that the head of the pancreas is partially surrounded by the C-loop of the duodenum. The union of the main pancreatic duct and distal common bile duct is shown.
NORMAL MEASUREMENTS
Location
FIGURE 14-2 The portal splenic confluence.
FIGURE 14-3 Correct caliper placement for measuring the anteroposterior dimension of the head, neck, body, and tail of the pancreas.
Size
Gross anatomy
Head
FIGURE 14-4 Celiac axis and branches. Note the gastroduodenal artery, the first branch of the proper hepatic artery.
FIGURE 14-5 A line drawn from the middle of the portal splenic confluence to the middle of the inferior vena cava to locate the uncinate process.
Neck
Body
Tail
Vascular anatomy
Physiology
FIGURE 14-6 The suprapancreatic, pancreatic, prepancreatic, and prehilar sections of the splenic artery are shown. Note the origin of the dorsal pancreatic, pancreatic magna, and caudal pancreatic arteries from the splenic artery.
Table 14-3 Pancreatic Hormones
Sonographic appearance
Transverse scanning plane images showing longitudinal pancreas
Head
Neck
Body and tail
Sagittal scanning plane images showing axial pancreas
Sonographic applications
FIGURE 14-7 A, B, C, Transverse scanning plane images of the mid-epigastrium showing longitudinal sections of the pancreas gland. Note the appearance and proximity of surrounding structures. The anechoic, axial sections of the common bile duct (posteriorly) and gastroduodenal artery (anteriorly) along the right lateral margin of the pancreas head are easily identified in these images.
FIGURE 14-8 A, B, C, Mid-epigastric transverse scanning plane images showing longitudinal sections of the pancreas gland and associated adjacent structures. In B and C, notice how the uncinate process is always present when the superior mesenteric vein is visualized. This is the level where the pancreas neck is directly anterior to the superior mesenteric vein (seen right between the neck [anteriorly] and uncinate [posteriorly]). At a level slightly superior to B and C, the uncinate process is no longer visualized and the pancreas neck is now visualized directly anterior to the portal splenic confluence.
FIGURE 14-9 A, B, C, Transverse scanning plane images of the mid-epigastrium. Longitudinal sections of the pancreas body are shown in A, B, and C. Notice how the body lies anterior to, and in the same plane with, the aorta and superior mesenteric artery, medial to the neck and tail, and posterior to the stomach and liver. A and C clearly demonstrate how the splenic vein runs along the posterior surface of the body.
FIGURE 14-10 In this transverse scanning plane image of the mid–epigastrium, it is easy to appreciate the anechoic longitudinal section of the splenic vein following along the curvilinear shape of the posterior surface of the pancreas body and tail. Notice how the splenic vein enlarges at the confluence, marking the entrance of the superior mesenteric vein.
FIGURE 14-11 Mid-epigastric transverse scanning plane image showing how the splenic vein hugs the posterior surface of the tail and body along its course to the confluence.
FIGURE 14-12 A, B, Sagittal scanning plane images just to the right of the midline, showing axial sections of the pancreas head and portal vein (PV) anterior to a longitudinal section of the inferior vena cava (IVC). Note the small, anechoic, axial section of the right renal artery posterior to the IVC. In B, the small, anechoic, longitudinal structure in the posterior portion of the pancreas head is the common bile duct.
FIGURE 14-13 Sagittal scanning plane image just medial to the level of the head of the pancreas. Note the axial sections of the pancreas neck and uncinate process separated by the anechoic, longitudinal section of the superior mesenteric vein. Note how the uncinate process sits directly anterior to, or in front of, the inferior vena cava. The level where the pancreas neck is anterior to the superior mesenteric vein and uncinate process is a level slightly inferior to the portal splenic confluence or portal vein, as clearly demonstrated in this image.
FIGURE 14-14 Sagittal scanning plane image of the abdomen at the level of the neck of the pancreas. Note the axial section of the mid-gray neck located immediately anterior to the anechoic long section of the superior mesenteric vein.
FIGURE 14-15 Sagittal scanning plane image of the abdomen just to the left of the midline, showing an axial section of the body of the pancreas inferior to the anechoic long section of the celiac axis/splenic artery, immediately anterior to the anechoic axial section of the splenic vein, anterior to the anechoic long sections of the superior mesenteric artery and aorta, and posterior to portions of the liver and fluid-filled stomach.
FIGURE 14-16 Sagittal scanning plane image of the abdomen just to the left of the midline, showing another axial section of the body of the pancreas inferior to the anechoic long section of the celiac axis/splenic artery, immediately anterior to the anechoic axial section of the splenic vein, anterior to the anechoic long sections of the superior mesenteric artery and aorta, and posterior to a portion of the liver.
FIGURE 14-17 Sagittal scanning plane image of the abdomen slightly left lateral to the aorta. An axial section of the tail of the pancreas is noted between the liver (anteriorly) and left kidney (posteriorly). Note the portion of bowel anteroinferiorly to the tail and the axial section of the anechoic splenic vein along the tail’s posterior margin.
FIGURE 14-18 A, Sagittal scanning plane image of the abdomen, just to the left of the midline, showing an axial section of the pancreas tail situated between a long section of the left lobe of the liver (anterosuperiorly) and long section of the left kidney (posteriorly). Note the anechoic axial section of splenic vein between the tail and left kidney. B, Transverse scanning plane image of the mid-epigastrium, demonstrating an enlarged tail of the pancreas. This patient has a congenital malformation in which the tail is partially duplicated. Note the proximity of the tail and left kidney.
Normal variants
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 15 The urinary system
Objectives
Key words
Table 15-1 Location of the Urinary System and Adrenal Glands Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
Location
Upper urinary tract: kidneys, ureters
Lower urinary tract: urinary bladder, urethra
Size
FIGURE 15-1 The Urinary Tract. A, Adrenal glands, kidneys, ureters, urinary bladder, and urethra. B, Frontal view of the urinary system shows how the ureters cross the iliac vessels anteriorly. C, Posterior view shows the urinary tract from behind. Note frontal placement of the ureters.
FIGURE 15-2 Frontal View of the Kidneys. Delineates the portions of the kidneys covered by the overlying adrenal glands, liver, duodenum, hepatic flexure, jejunum, stomach, splenic flexure, spleen, and pancreatic tail (see Tables 15-2 and 15-3).
Table 15-2 Anterior Structures That Cover the Right Kidney
Table 15-3 Anterior Structures That Cover the Left Kidney
Gross anatomy
Upper urinary tract: kidneys, ureters
FIGURE 15-3 Posterior View of the Kidneys. Delineates the portions of the kidneys covered by the overlying diaphragm, quadratus lumborum, psoas, and transversus muscles (see Table 15-3).
Table 15-4 Structures Posterior to Kidneys
FIGURE 15-4 Lower Urinary Tract in the Male. Note the three different parts of the male urethra.
FIGURE 15-5 Lower urinary tract in the female.
FIGURE 15-6 Four Layers Surrounding the Kidney. Fibrous capsule, perirenal fat, Gerota’s fascia, and pararenal fat.
FIGURE 15-7 Section of Internal Kidney Anatomy. Notice how the number of medullary pyramids equals the number of minor calyces, and also how the minor calyces form the border of the renal sinus. Observe how the ureter begins in the kidney as the renal pelvis.
FIGURE 15-8 Cortical and Juxtamedullary Nephrons. The loop of Henle is longer in the juxtamedullary nephron.
FIGURE 15-9 Renal Lobe. Note that the lobe is triangular and bordered by the interlobar vasculature. The arcuate and interlobular vessels and the surrounding cortical tissue form the base of the lobe.
Lower urinary tract: urinary bladder, urethra
FIGURE 15-10 Urinary Bladder. Note the triangular area, the trigone, where the ureters enter. Also shown is the lateral umbilical ligament.
FIGURE 15-11 Urinary Bladder. Difference between the appearance of an empty and distended urinary bladder. Note how the superior portion of the distended bladder moves toward the umbilicus.
Physiology
FIGURE 15-12 Enlarged View of Nephron. Glomerulus, proximal and distal convoluted tubules, loop of Henle, and collecting duct are shown. Note juxtaglomerular apparatus.
How the nephron works
Protective mechanisms that preserve nephron function
FIGURE 15-13 Dissected View of the Kidney. Observe how the apex of the medullary pyramid lies within the minor calyx and how several minor calyces empty urine into a single major calyx. Also, notice how the urine would empty from all of the major calyces into the renal pelvis and down the ureter on its way to the urinary bladder.
Table 15-5 Affecting Chemicals/Hormones—Hormones Associated with the Urinary System
FIGURE 15-14 Juxtaglomerular Apparatus. Note granular cells in the afferent and efferent arterioles. The macula densa are located in the distal convoluted tubule.
FIGURE 15-15 Sagittal scanning plane image showing a longitudinal section of the right kidney. The liver is superoanterior to the kidney. The curvilinear, highly echogenic line between the liver and right kidney is the renal capsule and site of Morison’s pouch, a peritoneal space that has the potential to abnormally fill with fluid. Note the anechoic medullary pyramids along the periphery of the bright, centrally located renal sinus.
Sonographic appearance
Upper urinary tract: kidneys, ureters
Kidneys
FIGURE 15-16 Transverse scanning plane, black-and-white version of color flow Doppler image of the right renal hilum. Axial section of the right kidney shows the renal hilum where the renal artery enters the kidney and the renal vein and ureter exit. (See Color Plate 26.)
FIGURE 15-17 Longitudinal section of the right kidney and liver, which is seen anteriorly. A low-gray section of the quadratus lumborum muscle can be identified posterior to the kidney. The renal sinus and true capsule appear highly reflective and in sharp contrast to the homogeneous mid-gray shades of the renal cortex and liver parenchyma. Note how the kidney appears hypoechoic relative to the liver.
FIGURE 15-18 Sagittal scanning plane image that shows a longitudinal section of the right kidney posteroinferior to the liver. The renal sinus appears bright and prominent with irregular borders that are marked by several anechoic medullary pyramids. Note the triangular shape of the urine-filled pyramids. The renal cortex appears homogeneous and smooth in contour.
FIGURE 15-19 A, Coronal scanning plane image showing a longitudinal section of the superior and mid-portions of the left kidney. Note the spleen superiorly. B, Coronal scanning plane and longitudinal view of the left kidney and spleen in a different patient. Note how the renal cortex appears hypoechoic relative to the appearance of the spleen. Note the distinct anechoic appearance and location of the prominent medullary pyramid.
FIGURE 15-20 A, Coronal scanning plane image demonstrating the long axis section of the left kidney. Note the well-defined renal sinus and its hyperechoic appearance relative to the renal parenchyma. B, Coronal scanning plane image showing a longitudinal view of the left kidney in a different patient.
FIGURE 15-21 Transverse scanning plane image showing axial sections of the right kidney, liver, inferior vena cava, aorta, psoas and quadratus lumborum muscles, and longitudinal sections of the right renal vein and portion of the pancreas head and view of the right kidney and liver. Notice how the kidney is sandwiched between the liver (anteriorly) and musculature (posteriorly).
FIGURE 15-22 Transverse scanning plane image demonstrating an axial section of the right kidney. Notice the distinctive shape of the short axis section of the kidney and its location between the anterior liver and posterior quadratus lumborum muscle. Observe how the homogenous columns of Bertin extend between the anechoic pyramids to meet the renal sinus. Note the portion of anechoic right renal vein and inferior vena cava just medial to the kidney.
FIGURE 15-23 Axial section of the left kidney and spleen. Observe the anechoic portion of left renal artery entering the renal hilum. Note the anechoic pyramids lateral to the highly reflective sinus.
FIGURE 15-24 Transverse scanning plane, black-and-white version of a color flow Doppler image of the renal hilum of the left kidney. (See Color Plate 27.)
Ureters
Lower urinary tract: urinary bladder, urethra
Urinary bladder
FIGURE 15-25 Renal Vasculature. A, Transverse scanning plane image of the mid-epigastric region. Note the renal veins anterior to the renal arteries. B, Renal vasculature well defined in a different patient.
Urethra
The adrenal glands
FIGURE 15-26 A, Long axis and anteroposterior measurements of the right kidney. The length (superior to inferior) and anteroposterior dimensions are measured and are within normal limits. B, Longitudinal section of the right kidney demonstrating the renal sinus measurement compared with the anteroposterior measurement. The anteroposterior renal sinus measurement is approximately one third that of the anteroposterior measurement. Note that a cortical thickness measurement can be obtained by subtracting the anteroposterior renal sinus measurement from the anteroposterior kidney measurement. C, Long axis and anteroposterior measurements of the right kidney in a different patient.
FIGURE 15-27 Pediatric kidneys in chronologic order by age in different patients. A, Fetal kidneys. B, A 3-week-old neonate. C, A 7-year-old child.
FIGURE 15-28 “Ureteral jets” is the term used to describe the sonographic appearance of urine entering the filling bladder. The ureteral jets are visualized in motion as the urine squirts into the bladder from the ureter(s). They appear barely echogenic yet hyperechoic relative to the anechoic appearance of the urine and therefore identifiable. A, Transverse scanning plane image of the pelvis. Ureteral jet identified in the posterior portion of the bladder, where the ureteral orifices are located. Note the symmetry of the bladder. B, Same patient; ureteral jet noted posteriorly from the left ureter.
FIGURE 15-29 Urinary Bladder. Sagittal scanning plane image of the pelvis showing longitudinal sections of the distended bladder, uterus, and vagina. Observe how the posterior surface of the bladder is somewhat indented by the uterus. Notice the smooth bladder contour and the bright appearance of the bladder wall, which is hyperechoic relative to the mid-gray appearance of the uterus and anechoic appearance of the urine-filled bladder lumen.
FIGURE 15-30 Adrenal Gland. Cross-section of an adrenal gland demonstrating the capsule, cortex, and medulla. The cortex is descriptively divided into zones, the zona glomerulosa, zona fasciculata, and zona reticularis.
FIGURE 15-31 Adrenal Vasculature.
FIGURE 15-32 Normal Renal Variants. A, Dromedary hump. B, Hypertrophied column of Bertin. C, Double collecting system. Includes double renal pelvis and partially bifid ureter. D, Horseshoe kidney, connected at the lower poles. E, Pelvic kidney.
Sonographic applications
Normal variants
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS/HORMONES
CHAPTER 16 The spleen
Objectives
Key words
Table 16-1 Location of the Spleen Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
Location
Size
FIGURE 16-1 NORMAL SPLEEN AND VASCULATURE
Gross anatomy
FIGURE 16-2 A, Microscopic organization of the spleen. B, Medial surface of the spleen. C, Surrounding splenic anatomic relationships (see Table 16-1).
FIGURE 16-3 A, Longitudinal section of the spleen with length and width measurements. B, Axial section of the spleen with depth and width measurements.
FIGURE 16-4 Suprapancreatic, pancreatic, prepancreatic, and prehilar sections of the splenic artery.
Physiology
Defense
Hematopoiesis
Rbc removal
Storage
Sonographic appearance
Sonographic applications
Normal variants
Accessory spleen
Asplenia
Splenomegaly
FIGURE 16-5 Normal Spleen. A, Longitudinal section. B, Axial section. C, Another axial section.
FIGURE 16-6 Splenic Kidney Interface. A, Coronal scanning plane image showing a longitudinal section of the normal interface between the spleen and left kidney. B, Same view as A, but in a different patient.
FIGURE 16-7 Splenic Hilum. A, Left lateral approach, transverse scanning plane image demonstrating the hilar area in this axial section of the spleen. B, Same view as A, clearly demonstrating the splenic hilum in a different patient.
FIGURE 16-8
FIGURE 16-9 A, Vascular anatomy of the spleen. B, Normal splenic hilum showing splenic vein and Doppler tracing.A, Coronal scanning plane image showing longitudinal spleen with splenomegaly and a section of accessory spleen (between calipers). B, Transverse scanning plane image from a left approach of same patient showing an axial section of the spleen with splenomegaly and a section of accessory spleen (between calipers).
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
AFFECTING CHEMICALS
LABORATORY VALUES
VASCULATURE
CHAPTER 17 The gastrointestinal system
Objectives
Key words
Table 17-1 Location of the Gastrointestinal System Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
Location
Mouth
Pharynx
FIGURE 17-1 The Gastrointestinal Tract.
FIGURE 17-2 Sagittal scanning plane image of the abdomen just to the left of the midline, demonstrating the esophagogastric or esophagealgastric junction posterior to the left lobe of the liver.
Esophagus
Stomach
FIGURE 17-3 Transverse scanning plane image of the epigastrium, demonstrating the long axis of the pylorus.
FIGURE 17-4 Transverse scanning plane image of the mid epigastrium, showing the stomach wall anterior to the pancreas.
Small bowel
FIGURE 17-5 Transverse scanning plane image of the mid epigastrium, showing the duodenum/duodenal bulb. Note its location between the gallbladder and head of the pancreas.
Duodenum
Jejunum and ileum
Large bowel
Cecum
FIGURE 17-6 Longitudinal section of normal appendix seen in a sagittal scanning plane image of the right lower quadrant. Note that the appendix is not usually identified; this was a false positive.
FIGURE 17-7 Sagittal scanning plane image at the midline of the female pelvis showing the rectum, seen posterior to the vagina.
Ascending colon
Transverse colon
Descending colon
Sigmoid colon, rectum, and anus
Size
Pharynx
Esophagus
Stomach
Pyloric canal
Small bowel
Duodenum
Jejunum
Ileum
Large bowel
Gross anatomy
Esophagus
Stomach
Small bowel
Duodenum
FIGURE 17-8 Sagittal scanning plane image of the abdomen just to the left of the midline, demonstrating a longitudinal section of the left gastric artery.
Jejunum and ileum
Large bowel
Physiology
FIGURE 17-9 Sagittal scanning plane image of the abdomen just to the left of the midline, showing a longitudinal section of the superior mesenteric artery.
Sonographic appearance
FIGURE 17-10 Sagittal scanning plane image of the abdomen just to the left of the midline, showing a longitudinal section of the abdominal aorta obscured by overlying gas-filled bowel.
Table 17-2 The Five Layers of the GI Tract
Esophagus
Stomach
FIGURE 17-11 Sagittal scanning plane image just to the left of the midline, demonstrating the esophagogastric (EG) junction anterior to the abdominal aorta.
FIGURE 17-12 Transverse scanning plane image of the neck just to the left of the midline, showing an axial section of the esophagus posterior to the left lobe of the thyroid gland.
FIGURE 17-13 Sagittal scanning plane image of the abdomen, just to the left of the midline, demonstrating the collapsed stomach antrum anteroinferior to the pancreas.
FIGURE 17-14 Transverse scanning plane image of the epigastrium, just to the left of the midline, showing the fluid-filled stomach anterior to the left kidney.
FIGURE 17-15 Transverse scanning plane image of the mid epigastrium, showing gas in the duodenum mimicking stones in the gallbladder or a mass in the head of the pancreas.
Small bowel
Large bowel
FIGURE 17-16 Transverse scanning plane image of the mid epigastrium, demonstrating the duodenojejunal flexure posterior to the body and tail of the pancreas. The jejunum is that portion of small bowel located anterior to the left kidney.
FIGURE 17-17 Compressed section of the transverse colon noted on a sagittal scanning plane image of the abdomen, just to the left of the midline. The axial section of transverse colon is seen anterior to the longitudinal section of the aorta and inferior to the axial section of the pancreas.
Sonographic applications
FIGURE 17-18 Sagittal scanning plane image at the midline of the female pelvis, showing a longitudinal section of the sigmoid colon, superior and posterior to the uterus and vagina.
FIGURE 17-19 Transverse scanning plane image at the midline of the female pelvis, showing an axial section of the rectum posterior to the uterus and anterior to the piriformis muscles.
FIGURE 17-20 Endoscopic section of the upper esophagus, demonstrating wall layer separation.
FIGURE 17-21 Endoscopic section of stomach, demonstrating five identifiable wall layers.
Normal variants
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
SECTION IV PELVIC SONOGRAPHY
CHAPTER 18 The prostate gland and seminal vesicles
Objectives
Key words
Table 18-1 Location of Male Pelvis Structures Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
Location
Prostate gland
Seminal vesicles
Size
Prostate gland
Seminal vesicles
Gross anatomy
Prostate gland
FIGURE 18-1 Male Pelvis. Sagittal cross-section of the male pelvis, illustrating the relationships of genital organs to surrounding structures.
FIGURE 18-2 A, Zonal Anatomy of the Prostate Gland in the Coronal Plane. PG, Periurethral glandular tissue (or zone); CZ, central zone; T, transition zone; V, verumontanum; PZ, peripheral zone; U, prostatic urethra. B, Zonal Anatomy of Prostate Gland in the Sagittal Plane. SV, Seminal vesicles; CZ, central zone; E, ejaculatory duct; PG, periurethral glandular tissue (or zone); T, transitional zone; V, verumontanum; PZ, peripheral zone; FM, fibromuscular stroma; U, prostatic urethra.
Seminal vesicles
Physiology
Sonographic appearance
Prostate gland and seminal vesicles
FIGURE 18-3 A, Transverse scanning plane; transabdominal image of the prostate gland. B, Sagittal scanning plane; midline transabdominal image of the prostate gland.
Sonographic applications
Prostate gland
Seminal vesicles
FIGURE 18-4 Sagittal scanning plane; midline transrectal image of the prostate gland.
FIGURE 18-5 Transverse scanning plane; transrectal image demonstrating a long axis section of the seminal vesicles.
FIGURE 18-6 Sagittal scanning plane; transrectal image demonstrating the relationship of the prostate gland and seminal vesicles.
FIGURE 18-7 A, Transverse scanning plane; transrectal image of the prostate gland showing zonal anatomy. B, Another transverse scanning plane; transrectal image of the prostate gland showing zonal anatomy.
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 19 The female pelvis
Objectives
Key words
Table 19-1 Location of Female Pelvis Structures Routinely Visualized with Ultrasound
FIGURE 19-1 True and False Pelves. The linea terminalis extends from the sacral promontory, along the arcuate lines of the innominate bones, to the pubic symphysis. The true pelvis is the region deep to the linea terminalis. The false pelvis is the region of the abdominopelvic cavity that is superior to the linea terminalis and inferior to the iliac crests.
FIGURE 19-2 True Pelvis. The true pelvis is a bowl-shaped cavity that tilts inferoposteriorly.
NORMAL MEASUREMENTS
Location
False pelvis, true pelvis, pelvic skeleton, pelvic musculature, pelvic ligaments, pelvic spaces, genital tract (uterus, vagina, uterine tubes), ovaries, urinary bladder, pelvic colon
FIGURE 19-3 The Pelvic Skeleton.
FIGURE 19-4 False Pelvis Musculature. The psoas major muscles and the iliacus muscles join at the level of the iliac crests to form the iliopsoas muscles of the false pelvis. The iliopsoas muscles pass over the pelvic brim, exiting the false pelvis to reach the lesser trochanter of the femurs.
FIGURE 19-5 Abdominopelvic Muscles. A, The rectus abdominis muscles extend from the xiphoid process to the pubic symphysis along the anterior abdominal wall. The muscular rectus sheath surrounding the rectus abdominis muscles fuses midline at the linea alba. B, Axial section through the midabdomen. The skeletal muscles lining the abdominopelvic cavity include the rectus abdominis muscles anteriorly, the transverse abdominis muscles laterally, and the psoas major and quadratus lumborum muscles posteriorly.
FIGURE 19-6 True Pelvis Muscles. The obturator internus muscles line the lateral walls of the true pelvis. The piriformis muscles are situated in the posterior region of the true pelvis and course cross-grain to the obturator internus muscles.
FIGURE 19-7 The Pelvic Diaphragm. Three muscle pairs, the pubococcygeus, iliococcygeus, and coccygeus, form the floor of the true pelvis and provide support for the pelvic organs. A, Viewed from below. B, Viewed from above. C, Viewed laterally.
FIGURE 19-8 Broad Ligaments, Ovaries, and Uterine Tubes Locations. The ovaries are situated in the adnexa, the regions of the true pelvis posterior to the broad ligaments. The broad ligaments are double folds of peritoneum extending from the lateral aspects of the uterus to the pelvic wall. The uterine (fallopian) tubes, round ligaments, and ovarian ligaments are all located within the double folds of the broad ligaments.
FIGURE 19-9 Pelvic Ligaments and Pelvic Colon. The cardinal ligaments and the uterosacral ligaments provide rigid support for the uterine cervix. The round ligaments extend from the cornua to the anterior wall of the pelvis. These ligaments pass through the inguinal canal and are secured to the external genitalia. The round ligaments maintain the anterior bend of the normal anteverted uterus. The rectosigmoid colon lies within the true pelvis and is continuous with the descending colon in the left lower quadrant of the abdominopelvic cavity.
FIGURE 19-10 The Ovaries and Associated Ligaments. A, Each ovary is located on the posterior surface of each broad ligament and is anchored in this position by the ovarian and infundibulopelvic ligaments and the mesovarium. The ovaries are the only organs located within the peritoneal cavity that are not covered by peritoneum. B, The innermost ovarian tissue is the medulla, composed of ovarian vessels, nerves, and connective tissue. Follicular development takes place in the cortex of the ovary, which surrounds the medulla. The cortex is enclosed by a fibrous capsule called the tunica albuginea. The germinal epithelium is the outermost cellular layer.
FIGURE 19-11 Female Pelvis, Sagittal Plane Cross-Section. The peritoneal lining of the abdominopelvic cavity is seen covering the superior aspect of the urinary bladder, the uterus, and the anterior region of the rectum. The anterior and posterior cul de sacs are potential peritoneal spaces created by folds in the peritoneum.
FIGURE 19-12 Congenital Uterine Malformations. This figure illustrates different congenital uterine malformations with anatomic variations of the uterus, cervix, and vagina resulting from the incomplete fusion or agenesis of the müllerian ducts. Complete duplication of the vagina, cervix, and uterine horns is seen in uterus didelphys. The bicornuate uterus has two uterine horns that are fused at one cervix (uterus bicornis unicollis) or at two cervices (uterus bicornis bicollis). Uterus subseptus is a milder anomaly marked by a midline myometrial septum within the endometrial canal. In some cases, only one müllerian duct develops, forming a single uterine horn and a uterine tube continuous with one cervix and vagina (uterus unicornis).
FIGURE 19-13 Bicornuate Uterus. This transabdominal, transverse scanning plane image of the pelvis demonstrates a bicornuate uterus containing a gestational sac within the right endometrial cavity. The gestational sac appears anechoic and is surrounded by the bright decidual reaction of the endometrial lining. Notice how the homogeneous, mid-gray myometrial tissue separates the endometrial canals of the right and left uterine horns.
Size
Gross anatomy
Pelvic organs
FIGURE 19-14 Vaginal and Uterine Anatomy. The wall of the vagina comprises an inner mucosa, a middle smooth muscle layer, and an outer adventitia. The anterior and posterior fornices of the vagina are seen as spaces between the vaginal walls and the portion of the cervix protruding into the vaginal canal. The uterine wall comprises an inner mucosa, called the endometrium; a thick, smooth muscle wall, called the myometrium; and an outer serosa. The regions of the uterus include the cervix, isthmus, corpus, and fundus. Note the narrow anteroposterior dimension of the uterine cavity.
FIGURE 19-15 Genital Tract. In this coronal diagram of the genital tract, notice the three tissue layers that make up the uterine wall: endometrium, myometrium, and serosa. Note the uterine (fallopian) tubes adjoining the uterus at the cornua. The lateral fornices of the vagina are also evident.
FIGURE 19-16 Uterine Measurements. A, This transabdominal, sagittal scanning plane image shows the correct caliper placement for measuring the long axis and greatest anteroposterior measurements of the uterus. The length of the uterus is measured from the fundus to the inferior cervical region. The anteroposterior thickness is measured perpendicular to the length at the widest point of the uterine corpus. B, This transabdominal, transverse scanning plane image demonstrates the correct caliper placement for measuring the width of the uterus, which is taken at the widest point of the uterine corpus (or body) in a short axis section.
FIGURE 19-17 Uterine Position Variations. A, Anteversion. B, Anteflexion. C, Retroversion. D, Retroversion with retroflexion.
FIGURE 19-18 Uterine (Fallopian) Tubes Anatomy. The uterine (fallopian) tubes or oviducts are continuous with the endometrial cavity at the uterine cornua. The four regions of the oviduct include the interstitial segment, isthmus, ampulla, and infundibulum. A, The regions of the uterine tube. B, Cross-section through the ampulla of the tube. This section demonstrates the intricate folds of the mucosal lining. The wall of the oviduct comprises the inner mucosa, middle muscular, and outer serosal layers.
FIGURE 19-19 Urinary Bladder. The bladder wall is composed of an innermost mucosa; followed by a submucosal layer; a thick, middle muscular layer; and an outer serosal lining. The trigone is the region of the urinary bladder at which the ureters enter and the urethra exits this cavity.
Blood supply
Internal iliac artery, uterine artery, arcuate arteries, radial arteries, straight arteries, spiral arteries, ovarian artery, gluteal arteries, vaginal artery, azygos arteries, vascular arch, lymph nodes
Physiology
FIGURE 19-20 Genital Tract and Ovarian Vasculature. A, The uterine artery is a branch of the internal iliac artery. The uterus, vagina, and ovaries receive blood from branches of this artery, such as the vaginal artery branch, which supplies the vagina and fundus of the urinary bladder. The ovaries also receive blood from the ovarian arteries arising from the abdominal aorta. B, The arcuate arteries encircle the outer tissue of the uterus. The myometrium is penetrated by the radial arteries. The endometrium receives blood from the straight and spiral arteries. The spiral arteries become more dilated during the secretory phase of the menstrual cycle. During menses, the spiral arteries are shed along with much of the endometrial lining.
The ovarian cycle
The endometrial cycle
FIGURE 19-21 Follicle Growth and Development. Maturation of a follicle during the normal menstrual cycle.
FIGURE 19-22 Menstrual Cycle. The first day of bleeding corresponds to the first day of the female menstrual cycle. The thickened endometrial lining of the uterus is shed during menses. At this point, the production of follicle-stimulating hormone (FSH) promotes the follicular phase of the ovarian cycle. Developing follicles within the ovaries begin to produce estrogen, which in turn causes proliferation of the endometrial lining. At approximately day 14 of the menstrual cycle, luteinizing hormone (LH) peaks; at this point, ovulation occurs, and the graafian follicle releases a mature ovum. The latter half of the menstrual cycle corresponds to the luteal phase of the ovary, during which the corpus luteum produces estrogen and progesterone. These hormones promote the secretory phase of the endometrial cycle, during which the endometrium continues to thicken. Inhibited production of LH at the end of the menstrual cycle leads to a breakdown of the corpus luteum and the shedding of the endometrium with the onset of menses.
Sonographic appearance
Pelvic: skeleton, musculature, ligaments, spaces, organs, colon, vasculature
FIGURE 19-23 Transabdominal (TA), Sagittal Scanning Plane Pelvic Imaging. A, Illustrates how TA pelvic sonography is performed from an anterior approach using the fully distended urinary bladder as an acoustic window. B, Image orientation of the sagittal scanning plane on the image display monitor. The anterior portion of the pelvis is displayed in the near field of the image, and the posterior region of the pelvis is displayed in the far field of the image. In a TA sagittal scanning plane image, the left and right sides of the image correspond to the superior and inferior regions of the pelvis, respectively. C, TA sonogram from a midsagittal scanning plane. The fully distended urinary bladder is the large anechoic structure with bright walls in the near field of the image, anterior to the uterus. Notice the smooth contour and medium-gray echo texture of the uterine myometrium and vaginal walls. Note how the uterus is pushed superoposteriorly by the distended bladder and is roughly perpendicular to the ultrasound beam. D, Represents the caliper placement for measuring the long axis section of the uterus. *Denotes corresponding location.
FIGURE 19-24 Transabdominal (TA), Transverse Scanning Plane Pelvic Imaging. A, Illustrates the anterior transducer position for TA imaging of the pelvis in the transverse scanning plane. B, Image orientation of the transverse scanning plane on the image display monitor. The near and far fields of the image correspond to the anterior and posterior regions of the pelvis, respectively. The left and right sides of the image correspond to the right and left sides of the pelvis, respectively. C, TA transverse scanning plane sonogram of a short axis section of the uterus. Note the anechoic urinary bladder in the near field of the image, anterior to the medium-gray uterus. *Denotes corresponding location.
FIGURE 19-25 Transvaginal (TV), Sagittal Scanning Plane Pelvic Imaging. A, The transvaginal transducer position for TV imaging of the pelvis; B and C, The TV sagittal scanning plane image orientation and the rotation of the image on the display monitor. The apex of the TV image corresponds to anatomic structures that are closest to the face of the transducer. In the sagittal scanning plane, the near field of the TV image generally corresponds to the inferior region of the true pelvis. The far field of the TV image generally corresponds to the superior region of the true pelvis. The left and right sides of the display monitor correspond to anterior and posterior regions of the pelvis, respectively. D, Longitudinal section of the uterus from a midsagittal scanning plane in TV pelvic imaging. Note the limited field of view (compared with TA imaging) but the increase in anatomic detail. *Denotes corresponding location.
FIGURE 19-26 Transvaginal (TV), Coronal Scanning Plane, Pelvic Imaging. A, Illustrates the endovaginal transducer position for TV imaging of the pelvis. With an empty urinary bladder, the fundus of the anteverted uterus is tilted forward toward the anterior abdominal wall. Consequently, the TV coronal imaging plane demonstrates a short axis section of the anteverted or anteflexed uterus. B and C, Illustrate the TV coronal scanning plane image orientation and the rotation of the image on the display monitor. The near and far fields of the TV coronal scanning plane image correspond to inferior and superior regions of the pelvis, respectively. The left and right sides of the display monitor correspond to the right and left sides of the pelvis, respectively. D, Short axis section of the uterus from TV coronal scanning plane pelvic imaging. As mentioned previously, note the limited field of view, compared with TA imaging, but the increase in anatomic detail. *Denotes corresponding location.
FIGURE 19-27 Transvaginal (TV) Imaging: Anteroinferior Approach. Most TV imaging is performed from a standard inferior approach, as demonstrated in Figures 19-25 and 19-26. However, manipulation of the TV transducer causes variation from the standard TV image orientation previously described. For example, when the transducer handle is lifted anteriorly (toward the pubic symphysis), the sound beam is directed more posteriorly. In this case, the near and far fields of the sagittal image correspond to anterior and posterior regions of the pelvis, respectively, and the left and right sides of the image display monitor more closely correspond to superior and inferior regions of the pelvis. A posteroinferior TV approach would also cause significant variation in image orientation. Thus, image orientation for TV sonography may vary between authors and ultrasound texts.
FIGURE 19-28 Pelvic Skeleton. The lower vertebral spine forms the posterior boundary of the true pelvis. The vertebral bodies appear highly echogenic and cast posterior shadows.
FIGURE 19-29 Pelvic Skeleton. The iliac crest is easily identified as highly echogenic, extending superiorly on this longitudinal view. As with the spine, the iliac crest is reflective and casts shadows so that structures behind the crest cannot be visualized in this view.
FIGURE 19-30 Iliopsoas Muscles. This transabdominal, transverse scanning plane image of the pelvis demonstrates short axis sections of the iliopsoas muscles seen bilateral to the urinary bladder. These skeletal muscles have low-level echoes and appear hypoechoic relative to the echogenic appearance of the centrally located femoral nerve sheath.
FIGURE 19-31 Iliopsoas Muscles. Transabdominal, parasagittal image of the pelvis just lateral to the right ovary. This image demonstrates longitudinal sections of the iliopsoas muscle (shown by arrows), femoral nerve sheath, and external iliac vein.
FIGURE 19-32 Pelvic Musculature. Transabdominal, transverse scanning plane image of the pelvis demonstrating longitudinal sections of the obturator internus muscles located on each side of the urinary bladder (black arrows). Long sections of the bilateral levator ani muscles of the pelvic diaphragm are seen hammocking across the pelvic floor to meet posterior to the cervix (white arrows). Axial sections of the right iliopsoas muscle and right external iliac artery and vein are seen anterior to the right obturator internus muscle. The rectus abdominis muscle is seen lining the anterior abdominal wall, anterior to the urinary bladder.
FIGURE 19-33 Levator Ani Muscles. Transabdominal, transverse scanning plane image of the lower portion of the true pelvis demonstrating longitudinal sections of the bilateral levator ani muscles of the pelvic diaphragm meeting just posterior to the axial section of the cervix.
FIGURE 19-34 Piriformis Muscles. Transvaginal, coronal scanning plane image demonstrating a longitudinal section of the right piriformis muscle posterolateral to the uterus (arrows). The corresponding piriformis muscle on the left side is obscured by overlying bowel gas.
FIGURE 19-35 Broad Ligaments. Transabdominal, transverse scanning plane image showing a longitudinal section of the right broad ligament (between arrows), which appears as the region of medium- to low-level echoes extending between the uterine cornu and right ovary.
FIGURE 19-36 Vagina. This transabdominal, sagittal scanning plane image demonstrates a longitudinal section of the vagina, seen posteroinferior to the distended, anechoic urinary bladder and anterior to the rectum. Notice how the muscular walls of the vagina exhibit low- to mid-level echoes and are hypoechoic relative to the bright appearance of the mucosal lining of the centrally located vaginal canal.
FIGURE 19-37 Vagina. Transabdominal, transverse scanning plane image of the pelvis showing an axial section of the vagina, seen posterior to the urinary bladder and anterior to the rectum. The centrally located vaginal canal appears thin and hyperechoic relative to the vaginal walls.
FIGURE 19-38 Uterus. Transabdominal, midsagittal scanning plane image of the pelvis showing longitudinal sections of the uterus and vagina just posterior to the urinary bladder. Notice how the width of the uterine endometrium is greatest near the fundus and narrows toward the cervix. Remember that as the thickness of the endometrium changes cyclically with the menstrual cycle, so does its sonographic appearance. Note that the thick walls of the uterus normally compress together, collapsing the centrally located uterine cavity (endometrial canal), giving it a bright, single stripe appearance.
FIGURE 19-39 Uterus. The thickness of the endometrium is measured at its greatest dimension in a longitudinal section of the uterus.
FIGURE 19-40 Preovulatory Endometrium. Multilayered appearance of preovulatory endometrium. A, Transvaginal image showing a longitudinal section of the uterus. Notice the thickness of the endometrium. The bright, single stripe of the endometrial canal is hyperechoic relative to the surrounding low-gray appearance of the functional zone, the thickest portion of the endometrium. The functional zone is separated from the dark inner myometrial layer by the thin, bright basal layer of the endometrium. B, Transvaginal, coronal scanning plane image demonstrating a short axis of the uterus. The myometrium exhibits low- to mid-level gray echoes; the endometrium presents with a multilayered preovulatory appearance. C, Another longitudinal section of the uterus prior to ovulation. The multilayered appearance of the endometrium presents as a central bright stripe surrounded by a thicker, darker layer, which is surrounded by a thin, bright border.
FIGURE 19-41 Endometrial Secretory Phase. Transvaginal, sagittal scanning plane image showing a longitudinal section of the uterus and the appearance of the endometrium during the secretory phase. In addition to an increased overall thickness, the endometrial basal layer, functional zone, and canal become isoechoic.
FIGURE 19-42 Myometrium. The muscle fiber layers of the myometrium are well distinguished on this axial. The inner and outer layers appear hypoechoic compared with the mid-gray appearance of the intermediate layer.
FIGURE 19-43 Cervix. Transabdominal, sagittal scanning plane image of the pelvis showing a longitudinal section of the cervix at the most inferior aspect of the uterus, closest to the vagina. Notice how the anterior and posterior lips of the cervix can be distinguished as the cervix protrudes into the vagina.
FIGURE 19-44 Cervix. A, Transvaginal, sagittal scanning plane image that demonstrates a longitudinal section of the cervix. A slight quantity of anechoic fluid is seen within the cervical canal. A small nabothian cyst is seen within the wall of the cervix exhibiting posterior enhancement. B, Transvaginal, coronal scanning plane image showing an axial section of the cervix. Note the shadowing from the vaginal fornices. C, Transvaginal, sagittal scanning plane image of a longitudinal section of the uterus in an anteflexed uterus. A small quantity of anechoic fluid is seen in the endocervical canal and the posterior cul de sac.
FIGURE 19-45 Cervix. Transabdominal, transverse scanning plane image demonstrating shadowing from the vaginal fornices, which confirms that the axial section posterior to the urinary bladder is the cervix.
FIGURE 19-46 Ovaries. A, Transabdominal, parasagittal scanning plane image of the right side of the pelvis. Note the typical almond shape of the ovary. The ovaries appear medium- to low-gray and homogeneous unless otherwise interrupted by anechoic, fluid-filled follicles as seen in this image. B, The length and thickness of the ovary are measured on a long axis section. Since the position of the ovaries is not fixed, the long axis may be viewed in either a sagittal or transverse scanning plane. The length is calculated from the longest dimension of the ovary. The anteroposterior thickness is measured perpendicular to the length; width is measured on the largest axial section. C, This transabdominal, transverse scanning plane image demonstrates the anatomic position of the ovary relative to its surrounding structures. The iliopsoas muscle and external iliac vessels are seen anterior to the right ovary. The uterus is medial to the ovaries as seen in this image. D, Transvaginal imaging provides detailed anatomy of the ovaries as seen in this image.
Sonographic applications
FIGURE 19-47 Ovarian Follicles. A, B, and C demonstrate the sonographic appearance of normal ovarian parenchyma and developing follicles. Notice the detail afforded by transvaginal imaging in B and C.
FIGURE 19-48 Cumulus Oophorus. The cumulus oophorus appears as a thin, bright crescent along the wall of the mature follicle. The secondary oocyte is contained within the cumulus oophorus.
FIGURE 19-49 Graafian Follicle. Dominant follicles appear anechoic with smooth, thin bright walls, and are round or oval in shape. Mature follicles are usually 18 to 22 mm in size and exhibit posterior enhancement.
FIGURE 19-50 Post Ovulation. Following ovulation, the anechoic fluid of the ruptured graafian follicle can be identified in the posterior cul de sac, molding to the shape of surrounding structures. A, The posterior cul de sac is well delineated when fluid filled. Note the partially filled urinary bladder in the upper left corner, which correlates to an anteroinferior orientation in this transvaginal, sagittal scanning plane image. Notice how the inner mucosa of the bladder wall is less visible and the relaxed detrusor muscle and the peritoneal lining surrounding the bladder are clearly visualized. B, Obvious anechoic collection of fluid in the posterior cul de sac located posterior to the uterus.
Normal variants
Uterus, ovaries
FIGURE 19-51 Corpus Luteum. The internal echoes of a corpus luteum vary in appearance from multiple, fine, bright septations to diffuse, low-level echoes. This corpus luteum is visualized with multiple, fine septations.
FIGURE 19-52 Corpus Albicans. The corpus albicans is the remaining scar tissue in the ovary following regression of the corpus luteum. This transvaginal image shows the corpus albicans, which appears as a highly echogenic foci within the ovary.
FIGURE 19-53 Urinary Bladder. A, Longitudinal section. B, Axial section. The bright mucosal lining of the distended anechoic bladder is seen along its circumference. The muscular wall of the bladder is stretched thin due to distention; thus the detrusor muscle is not visible. Notice how the bladder appears square-shaped in a short axis section. The uterus can be identified in both images, posterior to the bladder.
FIGURE 19-54 Urinary Bladder. Transabdominal, sagittal scanning plane image of midline of the pelvis with a partially filled urinary bladder. In this case the detrusor muscle is relaxed and is seen as a low-gray layer of the bladder wall.
FIGURE 19-55 Pelvic Colon. A, This transabdominal, transverse scanning plane image shows a reflective portion of the sigmoid colon (arrows) posterior to the uterus. B, Detailed peristaltic loops of small bowel are often visualized during transvaginal imaging. Fluid-filled loops of bowel are seen resting in the anterior cul de sac in this sagittal scanning plane image.
FIGURE 19-56 Intrauterine Contraceptive Devices (IUDs).
FIGURE 19-57 Copper Seven IUD. A, The Copper Seven IUD is easily visualized in a longitudinal section of the uterus. This contraceptive device is highly echogenic and rests within the endometrial cavity. B, This transabdominal, transverse scanning plane image of the pelvis demonstrates the appearance of the Copper Seven IUD within the endometrial canal in this axial section of the uterus.
FIGURE 19-58 Lippes Loop IUD. This illustrates the typical sonographic appearance of the Lippes Loop IUD within the endometrial canal. Posterior shadowing is frequently associated with IUDs.
FIGURE 19-59 Post Hysterectomy Pelvis. This illustrates the typical appearance of the pelvis post hysterectomy. The vaginal cuff can be identified, and with the absence of the uterus, the ovary moves into the posterior cul de sac.
FIGURE 19-60 Retroverted Uterus. This transabdominal, sagittal scanning plane image demonstrates the typical appearance of a longitudinal section of a retroverted uterus. Notice how the fundus is tilted posteriorly. A retroverted uterus is considered to be a normal variation in uterine position.
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
Uterine vasculature:
Ovarian vasculature:
AFFECTING CHEMICALS
SECTION V OBSTETRICS
CHAPTER 20 First trimester obstetrics (0 to 12 weeks)
Objectives
Key words
NORMAL MEASUREMENTS
Maternal physiology and embryo development
Weeks 1 to 5—ovarian phase
FIGURE 20-1 Normal Events in the First Four Weeks of Gestation.
FIGURE 20-2 Corpus Luteum. During pregnancy, the corpus luteum may become enlarged and cystic as seen in this image.
Weeks 4 to 5
FIGURE 20-3 Implantation. Blastocyst implanting the decidualized uterine endometrium.
FIGURE 20-4 4 to 5 Weeks’ GA. The chorionic cavity (gestational sac) measures 5 mm in diameter and is well visualized sonographically. The bilaminar embryonic disk is situated between the newly formed amniotic cavity and secondary yolk sac. This anatomic relationship is described in sonography as the “double bleb sign.”
Weeks 6 to 10—embryonic phase
Week 6
Weeks 7 to 8
FIGURE 20-5 7 to 8 Weeks’ GA. The umbilical cord resolves, and the embryo changes from flat to C-shaped.
FIGURE 20-6 Decidualized Endometrium. Differentiation of the gravid endometrium into decidua basalis (implantation site), capsularis (overlies sac facing uterine cavity), and parietalis (remainder of endometrium).
Week 8
Week 10
Weeks 11 to 12—fetal phase
Development of the placenta
FIGURE 20-7 Placenta Development. Chorionic villi invade the decidua basalis, forming embryo-maternal circulation. Resulting intervillous spaces receive maternal blood from the spiral arteries that surround and perfuse villi containing fetal blood.
FIGURE 20-8 Amnion and Amniotic Cavity. The amnion or amniotic membrane enlarges to enclose the amniotic cavity.
Development of fetal membranes
FIGURE 20-9 Chorion and Chorionic Cavity. During development, the chorionic membrane and chorionic cavity shrink while the amniotic membrane and amniotic cavity enlarge to accommodate the developing embryo.
Development of amniotic fluid
Sonographic appearance of 1st trimester anatomy
Gestational sac appearance
Double sac sign
FIGURE 20-10 Double Sac Sign. When the fluid-filled gestational sac and the fluid-filled uterine cavity are identified together it is termed the double sac sign: a sign that distinguishes a pseudo sac from a gestational sac.
FIGURE 20-11 Yolk Sac. The secondary yolk sac is the first structure identified within the gestational sac. Sonographic identification of the yolk sac confirms pregnancy.
Yolk sac appearance
FIGURE 20-12 The Embryo. The early embryo is identified sonographically as a small, bright, focal thickening along the highly echogenic outside edge of the yolk sac.
FIGURE 20-13 7-week-old Embryo. As early as the 7th week, the embryo begins to assume a shape that reveals the head or crown at one end and rump at the other.
Embryo appearance
FIGURE 20-14 9.5-week-old Gestation. Note how the four developing limbs are seen and normal protruding caudate pole (“tail”) are observed at this stage of development.
FIGURE 20-15 Normal Gut Herniation in a 10.6-week-old Gestation. Note how the head becomes disproportionately larger than the body at this stage of development.
Umbilical cord appearance
Placenta appearance
FIGURE 20-16 Week 8 of Development.
FIGURE 20-17 Short Axis Umbilical Cord Views.
FIGURE 20-18 Early Placenta Development. The deciduas are clearly differentiated including the decidua basalis that combines with the chorion frondosum to become the placenta.
FIGURE 20-19 Black and white version of a color flow image demonstrating the placental cord insertion site.
Membrane appearance
FIGURE 20-20 Sonographic identification of the amnion and its cavity confirms the presence of an intrauterine gestational sac.
Amniotic fluid appearance
Sonographic determination of gestational age (ga)
FIGURE 20-21 Mean Sac Diameter (MSD). A, Three measurements of the gestational sac (length, depth, and width) are obtained, summed, and then divided by 3 to determine the MSD. Gestational age (GA) (in days) is calculated by adding 30 to the MSD (in millimeters): MSD + 30 = GA (in days). B, Demonstrates how to correctly measure the width of the gestational sac on an axial section.
Sonographic applications
FIGURE 20-22 Crown Rump Length (CRL). The CRL measurement is said to be the most accurate measurement for dating pregnancies. Note that correct caliper placement is from the top of the head or crown to the middle of the buttocks or rump.
FIGURE 20-23 Uterine Synechia. Considered a normal variation during the first trimester, synechiae are membranes formed from scarring or adhesions secondary to surgery or infection. They do not attach to the embryo/fetus and are not associated with gestational abnormalities.
Normal variations
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 21 Second and third trimester obstetrics (13 to 42 weeks)
Objectives
Key words
FIGURE 21-1 Lacunae. Lacunae are normal, small, anechoic pools of maternal venous blood that may visualized throughout the placenta during the 2nd and 3rd trimesters of pregnancy.
The placenta
FIGURE 21-2 Maternal Marginal Veins. Anechoic areas visualized along the uterine surface of the placenta represent maternal marginal veins.
FIGURE 21-3 Placental Grading. Classifications of the “aging” placenta. Notice the increase in calcifications (densities) and changes in contour from Grade 0 to III. Grade 0. Represents the normal placenta. The placental substance appears homogeneous, with medium- to low-level echoes that may be interrupted by anechoic lacunae. No densities are evident and contours are smooth. Grade I. The chorionic plate begins to show some signs of subtle indentations, a few scattered densities are present, and the basal layer appears anechoic. Grade II. Medium-sized indentations are evident in the chorionic plate, “comma-like” densities are prevalent throughout the placental substance, and a few small linear densities appear in the basal plate. Grade III. The chorionic plate contains indentations extending to the basal layer, dividing the placenta into segments. The placental substance appears complex, with both anechoic areas and bright focal areas representing large calcifications that may cast shadows. Long, linear densities are evident in the basal plate. In advanced stages they may appear as an unbroken line.
Amniotic fluid
FIGURE 21-4 Axial Skeleton. Short axis section of the fetal lumbar spine. Note how the anterior ossification center (centrum) of the vertebrae is equidistant from the two posterior ossification centers (lamina).
Fetal organ systems
Musculoskeletal system
Axial skeleton
Spine
Rib cage
Skull
FIGURE 21-5 Axial Skeleton. Short axis sections of A, cervical; B, thoracic; and C, sacral fetal vertebrae. In axial or “short axis” sections, these bright echoes are parallel, or actually converge toward each other. Normal vertebral laminae angle inward, the opposite of the outward splaying of the laminae observed with spina bifida, a bony anomaly. C, The distinctive appearance of the pelvic iliac bones serve as an excellent landmark for confirming the lower portion of the fetal spine.
FIGURE 21-6 Axial Skeleton. Observe in these images of longitudinal fetal spine sections how much wider the cervical spine is compared with the normal tapering of the vertebrae in the sacrum. Gaps between vertebral bodies are composed of the nonossified margins of adjoining vertebral bodies and the intervertebral disks. Spinal cord neural tissue appears hypoechoic compared with the bright appearance of the meninges and vertebral bodies.
FIGURE 21-7 Axial Skeleton. Observe how the cartilaginous fetal skull sutures appear hypoechoic relative to the bright reflection from the bones that make up the calvarium or “skull.” The sutures along with the fontanelles serve as the windows for sonographic brain imaging. These nonossified “gaps” between the bones of the skull allow the sound waves to pass through, making brain imaging possible.
FIGURE 21-8 Appendicular Skeleton. All five highly echogenic digits of this 33-week fetal hand are visualized. The areas between the pieces of bone are cartilages that assist hand movement. Note that the cartilages appears hypoechoic relative to the bright appearance of the bones.
Appendicular skeleton
Extremities
FIGURE 21-9 Appendicular Skeleton. Longitudinal sections of the femur. Note the bright, reflective appearance of the bone. The low-gray areas immediately adjacent to each bony end of the femur are the cartilaginous ends of the bone. Shadowing prevents the full thickness of the ossified diaphysis of long bones from being visualized. Therefore the width of the cartilaginous epiphysis can appear greater than the width of the bony diaphysis. When both femurs are visualized, the shadowing can also give the appearance that the femur in the far field of the image is bowed. The posterior shadow cast by the femur becomes more apparent as ossification increases with advancing gestational age.
Muscles
Cardiovascular system
FIGURE 21-10 Muscles. Current high-resolution ultrasound equipment makes it possible to differentiate the individual layers of the transversus abdominus muscles and the internal and external oblique muscles. These muscles can be identified as the anechoic areas between the bright subcutaneous and peritoneal fat.
FIGURE 21-11 Umbilical Vein /Left Portal Vein Circulation. US, Umbilical segment of left portal vein; LSB, lateral segment branch; MSB, medial segment branch; PT, pars transversa of left portal vein; RPV, right portal vein; S, stomach; A, aorta; IVC, inferior vena cava.
FIGURE 21-12 Umbilical Circulation. UC, Umbilical cord; UA, umbilical artery; UV, umbilical vein; LPV, umbilical segment of left portal vein; DV, ductus venosus; RHV, right hepatic vein; IVC, inferior vena cava.
FIGURE 21-13 Umbilical Cord Insertion. A, See Color Plate 28.
FIGURE 21-14 Fetal Heart. Two features unique to the fetal heart are the foramen ovale and ductus arteriosus. The foramen ovale is an opening between the atria of the heart; allowing blood to move from right to left in the atrial chambers. The foramen ovale may remain patent after birth, but it is held closed by the normal pressure gradient between left and right atria. The ductus venosus connects the pulmonary artery and the aorta. This duct allows blood to move from the pulmonary artery to the aorta. Because the fetal lungs do not have a respiratory function, they do not require large quantities of blood. The ductus arteriosus closes at (or shortly after) birth.
Heart chambers and septa
Cava, aorta, and pulmonary artery
FIGURE 21-15 Fetal Heart. Classic four-chamber heart view in a 34-week gestation.
FIGURE 21-16 Fetal Heart. Short axis section of the fetal thorax, illustrating the normal position of the heart.
Respiratory system
Upper respiratory tract
Lungs, ribs, and diaphragm
FIGURE 21-17 Fetal Heart. 27-week gestation. A, Atria. B, Ventricles.
Gastrointestinal system
FIGURE 21-18 Great Arteries and Outflow Tracts. Identification of the great arteries and outflow tracts in their usual positions confirms normal ventriculoarterial connections. Notice how the left atrium lies closest to the spine and the right ventricle lies closest to the anterior chest wall. Both atria and both ventricles are approximately the same size.
FIGURE 21-19 Fetal Diaphragm. The fetal diaphragm appears as a smooth, hypoechoic muscular boundary between the thorax and the abdomen.
Oral cavity and esophagus
Stomach and gallbladder
Liver
FIGURE 21-20 Fetal Stomach. The fluid-filled fetal stomach is routinely visualized on the left side of the abdominal cavity. It appears anechoic with relatively smooth walls. Stomach size and shape are determined by the amount of fluid it contains.
Pancreas
Spleen
FIGURE 21-21 Fetal Gallbladder. Short axis (“axial”) sections of the fetal abdomen. The bile-filled fetal gallbladder is typically visualized on the right side of the abdominal cavity. It appears anechoic with smooth walls. Gallbladder lie is variable; therefore, the long axis can be imaged in any scanning plane. The size and shape of the gallbladder depend on the amount of fluid (prior to bile production) or bile it contains. Note how the liver fills the majority of the abdominal cavity. In the early phases of pregnancy the liver margins may appear ill defined. Also, notice how the sonographic appearance of the fetal spleen is comparable to the fetal liver—that is, mid-gray and homogeneous (also with indistinct margins during early development).
Small and large bowel
FIGURE 21-22 Umbilical Portion of the Portal Vein. Short axis (“axial”) sections of the fetal abdomen. Note how the umbilical portion of the portal vein originates in the midline of the abdomen then curves toward the liver as the right branch of the portal vein becomes visible.
Genitourinary system
Kidneys
FIGURE 21-23 Umbilical Cord Insertion. Longitudinal sections of the umbilical vein and one artery as they enter the fetal abdominopelvic cavity.
FIGURE 21-24 Fetal Colon. The colon’s fluid-filled lumen appears anechoic and distinctly delineates portions of the ascending, transverse, and descending colon.
Cortex, medulla, and sinus
FIGURE 21-25 Fetal Kidneys. A, Longitudinal section of the fetal kidney (between measurement calipers). The distinctive elliptical shape and bright appearance of the renal capsule assist sonographic identification of the kidneys. Later in the trimester, the highly echogenic appearance of the retroperitoneal fat surrounding the kidneys also makes visualization easier. B, In this longitudinal section of fetal kidney the centrally located area of the renal sinus appears anechoic because the collecting system is marginally dilated with urine/fluid. C, In axial sections, the fetal kidneys appear round. Notice how closely they lie to the bilateral lumbar spinal ossification centers.
FIGURE 21-26 Fetal Urinary Bladder. The urine-filled fetal bladder is easily recognized in the fetal pelvis because of its characteristic anechoic appearance and midline position. Another distinction is the thin, bright appearance of the bladder wall that virtually disappears when the bladder is fully distended. Note the difference in size between these bladders. Changes in the volume of the urinary bladder not only confirm fetal urine production but also, with time, differentiate the bladder from pathologic structures in the pelvis, such as cysts, that have the same sonographic appearance.
Ureters
Urinary bladder
FIGURE 21-27 Fetal Genitalia. A, Female genitalia in a 32-week gestation. Female gender is confirmed only when the major and minor labia have been identified. B, Male genitalia in a 30-week gestation. Male gender is confirmed only when the scrotum has been identified.
Urethra
Genitalia
FIGURE 21-28 Fetal Adrenal Gland. The prominent size and low-gray sonographic appearance of the fetal adrenal glands make them distinguishable from surrounding structures.
Adrenal glands
Central nervous system
The brain
Brainstem
Cerebrum
FIGURE 21-29 Intracranial Anatomy. The cerebellum helps to coordinate movements, balance, and posture; it is located just below the cerebrum and appears low-gray, homogeneous, and symmetric. The anechoic cisterna magna, located at the base of the cerebellum is the largest cerebrospinal fluid (CSF)–filled cistern in the brain. The cerebrum is the center of higher mental faculties and accounts for the largest part of the brain; its hemispheres appear mid- to low-gray on ultrasound. Peripheral to the edges of the cerebrum are subarachnoid spaces that range in appearance from anechoic to varying levels of echogenicity; some are filled with anechoic CSF, some with echogenic mater, and some with areas of both. The ventricles appear anechoic because they are filled with cerebrospinal fluid; their walls appear bright.
Cerebellum
Meninges
Ventricles
Vasculature
The spinal cord
FIGURE 21-30 Intracranial Anatomy. The choroid plexus are bright, drumstick-shaped structures on either side of the falx cerebri within the lateral ventricles. The falx cerebri is the bright, reflective fold of dura mater in the cerebral fissure that separates the cerebral hemispheres. Except for the areas containing choroid plexus, the remaining portions of the lateral ventricles are clearly delineated by anechoic cerebrospinal fluid (CSF). Ventricle walls appear hyperechoic relative to CSF and mid- to low-gray brain matter.
Sonographic appearance
Intracranial anatomy.
FIGURE 21-31 Biparietal Diameter. This illustrates how the sound beam must be perpendicular to the parietal bones and intersect the third ventricle and thalami to obtain an accurate plane for a biparietal diameter (BPD) measurement.
Determination of gestational age during the second and third trimesters
Biparietal diameter (bpd)
Cephalic index (ci)
FIGURE 21-32 Head Measurement Levels. A, Demonstrates caliper placement (outer to inner) and anatomic level for a biparietal diameter (BPD) measurement. B, Position of calipers (outer to inner and outer to outer/horizontal) for BPD and fronto-occipital diameter (FOD) measurements. C, Demonstrates caliper placement (outer to outer/vertical) and anatomic level for a head circumference (HC) measurement.
FIGURE 21-33 Abdominal Measurement Level. Anatomic level for abdominal circumference (AC) measurement.
Head circumference (hc)
Abdominal circumference (ac)
FIGURE 21-34 Abdominal Measurement Level. Demonstrates caliper placement (outer skin edge to outer skin edge) and plane of section to obtain the abdominal circumference (AC) measurement. The AC is measured at the position where the short axis diameter of the liver is the greatest. Sonographically, this is identified as the short axis section where the anechoic right and left portal veins are continuous with one another. Some refer to this appearance as the “hockey stick.” Note that this is also where the shortest length of the umbilical portion of the left portal vein is visualized.
Femur length (fl)
Normal variants
FIGURE 21-35 Long Bone Measurements. The long axis of the femur and humerus are used for measurements to determine gestational age. If both cartilaginous ends of the long bones are visualized, this guarantees that the plane of section is the long axis. Measurement is confined to the ossified portions. A, Femur measurement. B, Humerus measurement.
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
ROUTINE MEASUREMENTS
AFFECTING CHEMICALS
VASCULATURE
Fetal circulation
FIGURE 21-36 Fetal Circulation.
CHAPTER 22 High-risk obstetric sonography
Objectives
Key words
High-risk pregnancies
Fetal sonographic biophysical profile
Table 22-1 Biophysical Profile Scoring
Doppler ultrasound evaluation
FIGURE 22-1 Ultrasound-pulsed Doppler interrogation of the umbilical artery. This is a normal low-resistance waveform.
FIGURE 22-2 Ultrasound-pulsed Doppler interrogation of uterine circulation during the 3rd trimester. The waveform on top of the line is a venous signal. The waveform under the line is that of a uterine artery. Note their similarity. The artery has a very low pulsatility.
Ultrasound-guided procedures
Amniocentesis
Chorionic villus sampling
Fetal blood sampling and fetal intravascular transfusion
Multifetal gestations
Embryology of multifetal gestations
FIGURE 22-3 Development of monozygotic and dizygotic twins including placentation.
Sonographic assessment of multifetal gestations
The expanding role of ultrasound in high-risk obstetrics
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
ROUTINE MEASUREMENTS
VASCULATURE
AFFECTING CHEMICALS
SECTION VI SMALL PARTS SONOGRAPHY
CHAPTER 23 The thyroid and parathyroid glands
Objectives
Key words
Table 23-1 Location of Thyroid and Parathyroid Glands Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
Thyroid gland
FIGURE 23-1 Axial Thyroid Anatomy. Note the parathyroid glands and relevant adjacent structures. Shaded circles represent normal location of parathyroid glands.
FIGURE 23-2 Transverse plane sonogram showing axial section of normal thyroid anatomy. Notice how the thyroid lobes are connected by the isthmus.
Location
FIGURE 23-3 Sagittal scanning plane sonogram showing longitudinal section of normal thyroid lobe anatomy and adjacent structures.
Size
Thyroid volume
Gross anatomy
FIGURE 23-4 Sagittal scanning plane image showing longitudinal section of thyroid gland. Note caliper placement measuring the length.
FIGURE 23-5 Transverse scanning plane image showing axial section of the left lobe of the thyroid gland. Note caliper placement (Dist 1 and Dist 2) measuring the anteroposterior (AP) diameter and width.
Physiology
FIGURE 23-6 Transverse scanning plane image showing anteroposterior measurement of the isthmus. Note the placement of the calipers.
Blood supply
Sonographic appearance
FIGURE 23-7 A, Frontal view of the thyroid and parathyroid regions. Dark circles indicate normal parathyroid location. B, Black and white version of color duplex longitudinal section of the thyroid gland and superior thyroid artery, demonstrating arterial flow with a peak systolic velocity of 0.212 m/s. Note superior thyroid vein flow below the baseline (see Color Plate 29). C, Black and white version of color duplex longitudinal section of an intrathyroidal artery and vein. The peak systolic velocity of the intrathyroidal artery is 0.150 m/s (see Color Plate 30). D, Black and white version of color duplex longitudinal section of the inferior thyroid artery, demonstrating arterial flow with a peak systolic velocity of 0.205 m/s (see Color Plate 31). E, Black and white version of color duplex longitudinal section of the inferior thyroid vein, demonstrating normal phasic flow (see Color Plate 32). F, Black and white version of power Doppler longitudinal section of the thyroid gland, demonstrating normal intrathyroid vascularity (see Color Plate 33). G, Longitudinal section of the upper pole of the thyroid and pyramidal lobe (calipers).
FIGURE 23-8 Longitudinal section of thyroid gland; 1-mm to 2-mm tubular structures (arrows) represent intrathyroidal vessels.
FIGURE 23-9 Transverse scanning plane image of left lobe of thyroid gland and relevant adjacent anatomic structures: thyroid (THY), common carotid artery (CCA), internal jugular vein (IJV), esophagus (E), trachea (TR), longus colli muscle (LCM), recurrent laryngeal nerve (RLN), vagus nerve (VN), sternohyoid muscle (ST), sternothyroid muscle (SCM), sternocleidomastoid muscle (SCM), and omohyoid muscle (OH).
Sonographic applications
FIGURE 23-10 Transverse scanning plane showing an axial section of the left lobe of the thyroid gland. Note the anatomic relationship and shapes of the trachea (TR), esophagus (E), longus colli muscle (LCM), thyroid (T), common carotid artery (CCA), and internal jugular vein (IJV).
FIGURE 23-11 Longitudinal section of the strap muscle and longus colli muscle (LCM) (arrows). Note their relationship to the thyroid gland.
Normal variants
Parathyroid glands
FIGURE 23-12 Parathyroid gland variations.
Location
Size
Gross anatomy
Physiology
Blood supply
Sonographic appearance
FIGURE 23-13 Longitudinal section of the thyroid gland, demonstrating a typical oval-shaped parathyroid adenoma. Notice how the adenoma is hypoechoic relative to the thyroid, oval, and located posterior to the thyroid lobe. Calipers measuring the length and anteroposterior (AP) diameter. Note the placement of the calipers (+, x).
FIGURE 23-14 Transverse scanning plane image through the mid left lobe of the thyroid, demonstrating a heterogeneous parathyroid adenoma. Calipers measuring the width and anteroposterior diameter. Note the placement of the calipers (Dist 1 and Dist 2).
FIGURE 23-15 Transverse scanning plane image through both thyroid lobes, showing a left parathyroid adenoma. Calipers measuring the width and anteroposterior diameter. Note the placement of the calipers (Dist 1 and Dist 2). Note the heterogeneity of the thyroid gland.
FIGURE 23-16 Transverse scanning plane, showing an axial section of the left lower lobe of the thyroid gland and a lobulated parathyroid adenoma. Note how the adenoma lies posterolateral to the thyroid and anterior to the longus colli muscle. Note the placement of the calipers (Dist 1 and Dist 2). Note that the longest axis of the adenoma is seen anteroposteriorly.
FIGURE 23-17 Black and white version of a color Doppler transverse scanning plane image of a mid left parathyroid adenoma. Note the hypervascularization of the adenoma. Color void areas represent cystic areas. Note the relationship of the adenoma to the thyroid gland, common carotid artery, and jugular vein (see Color Plate 34).
FIGURE 23-18 Black and white version of a color Doppler longitudinal section of a left parathyroid adenoma, demonstrating hypervascular arterial flow.
FIGURE 23-19 Black and white version of a power Doppler image of a parathyroid adenoma. Note the feeder inferior thyroid artery supplying the adenoma (see Color Plate 35).
Sonographic applications
Normal variants
FIGURE 23-20 A, Sagittal scanning plane image showing a 0.6-cm flat hypoechoic structure simulating a small parathyroid adenoma, posterior to the lower pole of the thyroid gland. Note the placement of the calipers. B, Black and white version of the color Doppler image of A. Notice how the hypoechoic structure fills with color, indicating a vascular structure and not a parathyroid adenoma (see Color Plate 36).
FIGURE 23-21 Longitudinal section of an enlarged hypoechoic cervical lymph node with echogenic hilum (arrow) adjacent to the common carotid artery. Note the placement of the calipers.
FIGURE 23-22 Black and white version of a power Doppler image of an enlarged cervical lymph node. Note the vascular flow within the hilum (see Color Plate 37).
FIGURE 23-23 Lateral section of mediastinum and neck, illustrating aberrant locations of parathyroid glands. Dark circles indicate aberrant locations: thymus gland, carotid bulb, retroesophageal, intrathyroidal, carotid sheath.
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS AND PROCEDURES
LABORATORY TESTS
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 24 Breast sonography
Objectives
Key words
Table 24-1 Location of Breast Structures Routinely Visualized with Ultrasound
FIGURE 24-1 Cross-section of breast demonstrating basic anatomy.
NORMAL MEASUREMENTS
Location
Size
Gross anatomy
FIGURE 24-2 Breast anatomy showing posterior pectoralis muscle.
FIGURE 24-3 Normal breast Anatomy.
Physiology
FIGURE 24-4 The anatomic layers of the breast.
Sonographic appearance
Sonographic applications
FIGURE 24-5 A, The fatty component of the breast. B, Ducts of the breast. C, The fibrous component of the breast (Cooper’s ligament). D, Glandular component of the breast. E, Normal posterior shadowing from nipple of the breast.
Normal variants
Advanced techniques in breast imaging
FIGURE 24-6 A, A breast cyst. B, A solid breast mass. C, Malignant mass. D, Fibroadenoma. E, Lymph node. F, Subareolar ducts.
FIGURE 24-7 A, Breast implant. B, Breast implant with small adjacent fluid collection. C, Breast implant edge contour.
FIGURE 24-8 A, Fine needle cyst aspiration. B, Surgical clip. C, Postsurgical scar tissue.
FIGURE 24-9 A, 3D/4D Breast lesion. B, 3D/4D Breast biopsy. C, B-CAD image.
FIGURE 24-10 The correct procedure for self-examination of the breast.
Breast self-examination
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
AFFECTING CHEMICALS
LABORATORY VALUES
VASCULATURE
SECTION VII SUPERFICIAL SONOGRAPHY
CHAPTER 25 Penile and scrotal ultrasound
Objectives
Key words
Table 25-1 Location of Male Pelvis Structures Routinely Visualized with Ultrasound
NORMAL MEASUREMENTS
Location
Scrotum and contents
FIGURE 25-1 Male Pelvis. Sagittal cross-section of the male pelvis, illustrating the relationships of genital organs to surrounding structures.
Size
Testis
Epididymis
Gross anatomy
Scrotum
FIGURE 25-2 Dissected scrotum and its contents.
Testis
Epididymis
FIGURE 25-3 Enlarged longitudinal cross-section of testis, epididymis, and ductus (vas) deferens, illustrating the complex network of ducts needed to transport sperm.
Ductus (vas) deferens
Spermatic cord
Penis
FIGURE 25-4 Gross anatomy of the penis.
Physiology
Sonographic appearance
Scrotal contents
FIGURE 25-5 Longitudinal section of the testis in the sagittal scanning plane.
FIGURE 25-6 Axial section of the scrotum/testes in the transverse scanning plane.
FIGURE 25-7 Black-and-white version of color Doppler in a longitudinal section of testis
FIGURE 25-8 Sagittal scanning plane image of longitudinal section of testis, demonstrating the mediastinum testis (arrows).
FIGURE 25-9 Transverse scanning plane image of an axial section of testis, demonstrating the mediastinum testis (arrow).
FIGURE 25-10 Anechoic hydrocele shown lateral to the axial section of testis.
FIGURE 25-11 Head of epididymis, denoted by E, is shown in this longitudinal section of the testis (T).
FIGURE 25-12 Longitudinal section of testis shows mid portion of the epididymis. Note calipers identifying the walls of the epididymis.
FIGURE 25-13 Tail of the epididymis, denoted by E, is shown in this longitudinal section of the testis (T).
FIGURE 25-14 Transverse scanning plane image demonstrating both right and left spermatic cords as they pass through the inguinal canal.
FIGURE 25-15 Longitudinal section of the spermatic cord.
FIGURE 25-16 Black-and-white version of color Doppler image demonstrating blood flow within the spermatic cord
FIGURE 25-17 Transverse scanning plane image of an axial section of the penis, showing the corpus spongiosum compressed by the transducer and the corpus cavernosa dorsal to the corpus spongiosum.
FIGURE 25-18 Longitudinal section of the penis, showing the corpus spongiosum (CS) and corpus cavernosum (CC) separated by the echogenic tunica albuginea (TA).
Penis
FIGURE 25-19 Black-and-white version of color Doppler transverse scanning plane image, demonstrating the location of the cavernosal arteries (arrows)
FIGURE 25-20 B-mode image of a longitudinal section of the corpus cavernosum, demonstrating the centrally located cavernosal artery (arrows).
FIGURE 25-21 Black-and-white version of color Doppler image of a longitudinal section of the cavernosal artery
FIGURE 25-22 Black-and-white version of power Doppler image of a longitudinal section of the cavernosal artery
Sonographic applications
Scrotum
Penis
Normal variants
Reference charts
ASSOCIATED PHYSICIAN
COMMON DIAGNOSTIC TESTS
VASCULATURE
AFFECTING CHEMICALS
SECTION VIII INTRODUCTION TO SPECIALTY SONOGRAPHY
CHAPTER 26 The neonatal brain
Objectives
Key words
FIGURE 26-1 Sagittal survey from the fulcrum of the anterior fontanelle. LV, Lateral ventricle; 3V, third ventricle; 4V, fourth ventricle.
FIGURE 26-2 A, Coronal survey from the fulcrum of the anterior fontanelle. B, Coronal image depicting ventricular depth and midline to lateral dimensions.
Table 26-1 Location of Neonatal Brain Structures Routinely Visualized with Ultrasound
Location
Size
VENTRICLE MEASUREMENTS
Table 26-2 Major Brain Fissures
Gross anatomy
The brain
The ventricles
The cerebrum
The cerebellum
The brainstem (“hindbrain”)
Physiology
FIGURE 26-3 Brain Function. Various functional areas of the cerebral hemispheres. Lateral view of the brain.
The cerebrum
The diencephalon
The brainstem
FIGURE 26-4 Coronal image of the brain at the level of the bodies of the lateral ventricles.
The cerebellum
Sonographic appearance
Modified coronal plane cross-sections
FIGURE 26-5 Coronal image of the brain at the level of the frontal cerebral cortex.
FIGURE 26-6 Coronal image of the brain at the level of the septum pellucidum and frontal horns of the lateral ventricles, showing the head of the caudate nucleus.
FIGURE 26-7 Coronal image of the brain at the level of the basal ganglia.
FIGURE 26-8 Coronal cross-section of the brain at the level of the basal ganglia and corpus callosum.
FIGURE 26-9 Coronal image of the brain in the area of the foramen of Monro, the bilateral foramina that lie inferomedial to the bodies of the lateral ventricles and mark the communication between the lateral and third ventricles.
FIGURE 26-10 Coronal cross-section of the brain at the level of the thalamus.
FIGURE 26-11 Coronal image of the brain at the level of the bilateral thalami.
FIGURE 26-12 Coronal image of the brain at the level of the tentorium and fourth ventricle.
Modified sagittal plane cross-sections
FIGURE 26-13 Coronal image of the brain at the level of the trigone region of the lateral ventricles.
FIGURE 26-14 Coronal image of the brain at a level just posterior and cephalad to the trigones.
FIGURE 26-15 Sagittal cross-section of the brain at the level of the third ventricle.
FIGURE 26-16 Sagittal image of the midline of the brain.
Sonographic applications
FIGURE 26-17 Sagittal image of the brain at the level of the caudothalamic groove.
FIGURE 26-18 Sagittal image of the brain at the level where all the horns of the lateral ventricle can be identified.
FIGURE 26-19 Sagittal image of the brain either to the far right or far left of the midline. Reveals the temporal lobe and sylvian fissure.
Table 26-3 Sonographic Appearance of Major Brain Structures in the Neonate
Normal variants
FIGURE 26-20 Coronal image showing asymmetry in the size of the occipital horns of the lateral ventricles. Considered a normal variant that corrects itself with time.
FIGURE 26-21 Sagittal image of the brain showing temporary normal variations, the cavum septum pellucidum and cavum septum vergae that close prior to birth.
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
NORMAL MEASUREMENTS
Ventricular size
VASCULATURE
AFFECTING CHEMICALS
FIGURE 26-22 Coronal image at the level of the foramen of Monro. Correct level for measuring the lateral ventricles as shown.
FIGURE 26-23 Blood supply to the brain as seen from the inferior surface.
FIGURE 26-24 Lateral view of the head showing the major venous drainage of the brain.
CHAPTER 27 Pediatric echocardiography
Objectives
Key words
NORMAL VALUES FOR CHILDREN ARRANGED BY WEIGHT
Prenatal development
FIGURE 27-1 Ventral views of the developing heart at 20 to 25 days, showing fusion of the endocardial heart tube to form a single tube. Note bending to form the bulboventricular loop.
FIGURE 27-2 A, B, C, Sagittal sections of the heart during weeks 4 and 5, illustrating division of the atrioventricular canal. D, Coronal section of the heart at the plane shown in C. Note that the interatrial and interventricular septa have also begun to develop.
FIGURE 27-3 A-H, Partitioning of the primitive atrium, with the developing interatrial septum viewed from the right side. A1 to H1, Coronal sections of the developing interatrial septum at the plane shown in A. Note that as the septum secundum develops, it overlaps the opening in the septum primum (foramen secundum). The valve-like nature of the foramen ovale is illustrated in G and H. When pressure in the right atrium exceeds that in the left atrium (as in the fetus), blood passes from the right to the left side of the heart. When the pressures are equal or higher in the left atrium (as is normal after birth), the septum primum closes the foramen ovale.
FIGURE 27-4 Partitioning of the Primitive Heart. A, Sagittal section in week 5, showing the cardiac septa and foramina. B, Coronal section at a slightly later stage, illustrating the direction of blood flow through the heart and expansion of the ventricles. Note the formation of the interventricular septum and the interventricular foramen in both diagrams.
FIGURE 27-5 Closure of the interventricular foramen and formation of the membranous part of the interventricular septum. The walls of the truncus arteriosus, bulbus cordis, and right ventricle have been removed. A, At 5 weeks, showing the bulbar ridges and the fused endocardial cushions. B, At 6 weeks, showing that proliferation of subendocardial tissue diminishes the interventricular foramen. C, At 7 weeks, showing the fused bulbar ridges and the membranous part of the interventricular septum formed by extensions of tissue from the right side of the endocardial cushions.
FIGURE 27-6 Partitioning of the Bulbus Cordis and Truncus Arteriosus. A, Ventral aspect of the heart at 5 weeks. B, Transverse sections through the truncus arteriosus and bulbus cordis, illustrating the truncal and bulbar ridges. Note that the orientation is of looking down into the truncus arteriosus from above, keeping in mind the dorsal and ventral aspects of the truncal tube as the aorticopulmonary septum spirals within it. C, The ventral wall of the heart and truncus arteriosus have been removed to demonstrate these ridges. D, Spiral form of the aorticopulmonary septum. E, Ventral aspect of the heart after partitioning of the truncus arteriosus. F, Sections through the newly formed aorta (Ao) and pulmonary trunk (PT), showing the aorticopulmonary septum. G, At 6 weeks, the ventral wall of the heart and pulmonary trunk have been removed to show the aorticopulmonary septum. H, The great arteries twisting around one another as they exist in the normal neonatal heart.
Fetal circulation
Location
FIGURE 27-7 Incorporation of the bulbus cordis into the ventricles, and partitioning of the bulbus cordis and truncus arteriosus into the aorta and pulmonary trunk. A, Sagittal section at 5 weeks, showing the bulbus cordis as one of the five primitive chambers of the heart. B, Coronal section at 6 weeks, after the bulbus cordis has been incorporated into the ventricles to become the conus arteriosus (infundibulum) of the right ventricle and the aortic vestibule of the left ventricle.
FIGURE 27-8 Dorsal view at 8 weeks, showing the positions of the superior and inferior venae cavae with respect to the right atrium. The pulmonary veins, each with separate openings into the left atrium, are also shown.
Size
Gross anatomy
FIGURE 27-9 Fetal Circulation. The organs are not drawn to scale. Note that the three fetal shunts permit most of the blood to bypass the liver and the lungs: (1) the ductus venosus, (2) the foramen ovale, and (3) the ductus arteriosus.
FIGURE 27-10 Relative position of the heart with respect to other organs within the chest cavity. Note blocks denoting transducer positions that provide “windows” for imaging the heart. (1) Parasternal long axis and parasternal short axis positions. (2) Apical four chamber, apical five chamber, and apical long axis. (3) Subcostal or subxiphoid position. (4) Suprasternal notch position. (5) Right parasternal position. (6) Although not indicated by blocks, the supraclavicular fossa (right and/or left) is also sometimes used in obtaining echocardiographic images.
FIGURE 27-11 Neonatal heart, showing cardiac structure.
Cardiac perfusion and drainage
Cardiac conduction system
FIGURE 27-12 Neonatal Circulation. Adult derivatives of the fetal vessels and structures that become nonfunctional at birth are also shown. Arrows indicate the course of the neonatal circulation. The organs are not drawn to scale. After birth, the three shunts that short circuited the blood during fetal life cease to function, and the pulmonary and systemic circulations become separated.
FIGURE 27-13 A, Coronary arteries and their positions on the heart. B, Cardiac veins. These are anterior, or ventral, views. The dashed lines indicate the position of the vessels as viewed from the posterior, or dorsal, surface of the heart.
FIGURE 27-14 Cardiac conduction system and an electrocardiogram (ECG) tracing. The numbers on the ECG corresponding with the numbers indicated on the heart diagram relate the electrical activity of the heart to the waveform of the ECG.
Physiology
Sonographic appearance
FIGURE 27-15 Parasternal long axis and short axis planes, or cuts, through the heart.A, Echocardiographic sketch of the parasternal long axis view. B, Parasternal short axis view at the level of the aortic valve. C, Short axis view showing the coronary arteries. D, Short axis view at the level of the mitral valve. E, Short axis view at the level of the papillary muscles.
FIGURE 27-16 Echocardiographic images in the parasternal long axis view. A, Diastolic frame. B, Systolic frame. C, Late diastolic frame.
FIGURE 27-17 Parasternal long axis view, indicating cuts at the various levels where M-mode tracings will be recorded. The lower diagram is a schematic of an M-mode tracing at the various levels shown in the upper diagram. Currently, M-mode tracings are also being done in parasternal short axis views.
FIGURE 27-18 A, M-mode of the left ventricle in the parasternal long axis view. B, M-mode of the left ventricle in the parasternal short axis view.
FIGURE 27-19 M-mode tracing of the mitral valve in the parasternal short axis view.
FIGURE 27-20 M-mode tracing of the aorta and left atrium from the parasternal short axis view.
FIGURE 27-21 Echocardiographic images in the parasternal short axis view at the aortic valve level. A, With the valve closed. B, With the valve open. C, Parasternal short axis view showing black and white version of color flow through the tricuspid valve. Note the blue color as the flow turns to move away from the transducer (see Color Plate 43). D, As flow continues from C, it is going away from the transducer through the pulmonary valve and into the right and left pulmonary branches (see Color Plate 44). E, Pulsed wave Doppler at the pulmonary valve with normal velocity.
FIGURE 27-22 Echocardiographic images in the short axis plane at the level of the mitral valve.
Sonographic applications
FIGURE 27-23 Echocardiographic image of the left ventricle at the papillary muscle level.
FIGURE 27-24 Scanning planes of the apical views of the heart. A, Four-chamber view. B, Five-chamber view. C, Apical long axis view.
FIGURE 27-25 A, Echocardiographic images of the apical four-chamber view. B, Black and white version of color flow Doppler of the mitral valve. Echocardiographic image of inflow from the left atrium through the mitral valve into the left ventricle. The flow is red because it is moving toward the transducer positioned at the apex. Note the laminar flow (no turbulence) (see Color Plate 45). C, Pulsed-wave Doppler of the mitral valve. Pulsed-wave Doppler of mitral inflow. Again, note the laminar flow indicated by lack of echoes between the waves.
FIGURE 27-26 A, Echocardiographic images in the apical long axis view of two patients. Both are shown in the anatomically correct position. B, Apical long axis view showing black and white version of color flow in the left ventricular outflow tract, through the aortic valve and a limited section of the ascending aorta. The transducer is at the apex of the heart, with the flow moving away from it. Therefore the blood flow is shown in blue (see Color Plate 46).
FIGURE 27-27 Four planes in the subcostal position are shown. A, Four-chamber. B, Five-chamber. C, Long axis of right ventricular outflow tract. D, Short axis at aortic valve level.
FIGURE 27-28 Echocardiographic image in the subcostal four-chamber view for interrogation of the interatrial septum.
FIGURE 27-29 Subcostal four-chamber view showing the heart and surrounding area.
FIGURE 27-30 Schematic of the planes of sound through the heart in the suprasternal position. A, Long axis view. B, Short axis view.
FIGURE 27-31 A and B, Echocardiographic images of the aortic arch in long axis. B, Note the bifurcation of the innominate artery into the right subclavian and right common carotid arteries.
FIGURE 27-32 A and B, Echocardiographic image of the long axis view of the right ventricular inflow tract. A, Diastolic image. B, Systolic frame. C, Black and white version of color flow Doppler of the right ventricular inflow tract. The flow is toward the transducer from the right atrium through the tricuspid valve into the right ventricle (see Color Plate 47).
FIGURE 27-33 Echocardiographic image of the parasternal long axis of the right ventricular outflow tract. A, Systolic frame with the pulmonary valve open. B, Diastolic frame with the pulmonary valve closed.
FIGURE 27-34 Echocardiographic images of the proximal coronary arteries as they exit the aorta. A, View of the RCA, LCA and bifurcation, LAD, and LCX. Part of the aortic valve leaflets is seen within the aorta. B, Image of the LCA and branches. C, RCA. RCA, Right coronary artery; LCA, left coronary artery; LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery.
FIGURE 27-35 View of the coronary sinus from the apical four-chamber position.
FIGURE 27-36 A, Subcostal short axis, or sagittal, view of the heart showing the left ventricular outflow tract, aortic valve, and ascending aorta. Note the left main coronary artery. B, Subcostal or subxiphoid short axis view, demonstrating the right ventricular outflow tract, pulmonary valve, and main pulmonary artery. C, Subxiphoid short axis, aortic valve level, showing left and right atrium, tricuspid valve, right ventricular outflow tract, and main pulmonary artery.
FIGURE 27-37 Subxiphoid view of the superior and inferior vena cavae entering the right atrium.
Normal variants
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
FIGURE 27-38 Laboratory Values for The Heart. The percentages show the relative oxygen saturations of the blood in the various vessels and cavities of the heart. The numbers with the slash between them show the normal systolic and diastolic pressures, respectively. The pressure values in the atria are diastolic since they have no systolic pressure.
LABORATORY VALUES
VASCULATURE
AFFECTING CHEMICALS
CHAPTER 28 Adult echocardiography
Objectives
Key words
NORMAL M-MODE MEASUREMENTS
Prenatal development
Location
Size
Gross anatomy
FIGURE 28-1 The external structures and location of the heart in the thoracic cavity.
FIGURE 28-2 The internal structures of the heart.
FIGURE 28-3 Cardiac circulation.
Physiology
Circulatory system
Conduction system
The electrocardiogram
FIGURE 28-4 The conduction system of the heart.
FIGURE 28-5 Single beat on a normal electrocardiogram (ECG) demonstrating the QRS complex.
Systole/diastole
FIGURE 28-6 Parasternal long axis view.
Sonographic appearance
Two-dimensional echocardiography
FIGURE 28-7 Parasternal long axis view in diastole (A) and systole (B).
FIGURE 28-8 Parasternal short axis view at the level of the aortic valve during diastole.
FIGURE 28-9 Parasternal short axis view at the level of the aortic valve during systole.
FIGURE 28-10 Parasternal short axis view at the level of the mitral valve.
M-mode echocardiography
FIGURE 28-11 Parasternal short axis view at the level of the papillary muscles.
FIGURE 28-12 Apical four-chamber view.
FIGURE 28-13 The subdivisions of the left ventricular walls from an apical four-chamber view.
FIGURE 28-14 Apical five-chamber view.
FIGURE 28-15 Aortic arch from the suprasternal notch.
Doppler echocardiography
Normal doppler waveforms.
Mitral valve.
FIGURE 28-16 Proper calibration for an M-mode.
Aortic valve.
Aortic arch.
Tricuspid valve.
Pulmonic valve.
Transesophageal echocardiography (tee)
FIGURE 28-17 M-mode at the level of the aortic valve.
FIGURE 28-18 M-mode at the level of the mitral valve.
FIGURE 28-19 Proper labeling of the mitral valve.
FIGURE 28-20 M-mode at the level of the left ventricle.
3-dimensional echocardiography
FIGURE 28-21 M-mode through the tricuspid valve.
Sonographic applications
Normal variants
FIGURE 28-22 M-mode through the pulmonic valve with its proper alphabetical labels.
FIGURE 28-23 Doppler flow profiles of the mitral valve in both continuous wave (A) and pulsed wave (B).
FIGURE 28-24 Doppler flow profiles of the aortic valve in both continuous wave (A) and pulsed wave (B).
FIGURE 28-25 Doppler flow in the aortic arch. As flow moves toward the transducer in the ascending aorta, it appears above the baseline; as flow moves away in the descending aorta, it falls below the baseline.
FIGURE 28-26 Doppler flow profiles of the tricuspid valve in both continuous wave (A) and pulsed wave (B).
FIGURE 28-27 Doppler flow profiles of the pulmonic valve in both continuous wave (A) and pulsed wave (B).
FIGURE 28-28 Dedicated continuous wave probe.
FIGURE 28-29 TEE midesophageal view. Four chambers of the heart are demonstrated. The left and right atria and ventricles are seen. Note the mitral valve is more visible than the tricuspid valve.
FIGURE 28-30 TEE transgastric view. Trangastric view demonstrating the walls of the left ventricle and chamber size. Note the ventricular septum separating left and right ventricles.
FIGURE 28-31 TEE basilar view. Basilar view of the aorta, left and right atria, and the interatrial septum.
FIGURE 28-32 The depth of the LV chamber and mitral valve leaflets can be appreciated in this presentation.
FIGURE 28-33 Eustachian valve as seen in the right ventricular inflow view. Found in the right atrium, it is a normal variant.
FIGURE 28-34 Moderator band as seen in the apical four-chamber view. It is a normal structure found in the right ventricle.
FIGURE 28-35 Chiari network as seen in the right ventricular inflow view. It is a normal variant found in the right atrium.
FIGURE 28-36 Ectopic chordae as seen in the left ventricle of the apical long axis view. These are normal variants and can be found in either ventricle.
FIGURE 28-37 Interatrial septal aneurysm as seen in the apical four-chamber view. This is considered a normal variant and moves to and fro with respiration.
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
NORMAL DOPPLER VELOCITIES IN ADULTS
AFFECTING CHEMICALS
LABORATORY VALUES
CHAPTER 29 Vascular technology
Objectives
Key words
NORMAL MEASUREMENTS
FIGURE 29-1 The extracranial cerebrovascular system.
FIGURE 29-2 Circle of Willis.
Extracranial cerebrovascular system
Common carotid, internal carotid, external carotid, and vertebral arteries
FIGURE 29-3 Transverse plane; black and white version of Doppler color flow image of axial sections of common carotid artery, jugular vein, and thyroid gland. (See Color Plate 48.)
FIGURE 29-4 Black and white of Doppler color flow image of long axis section of carotid bifurcation demonstrating the common, external, and internal carotid arteries. Note the zone of retrograde flow in the carotid bulb caused by boundary layer separation. (See Color Plate 49.)
Size of the extracranial cerebrovascular vessels
Sonographic appearance of the extracranial carotid and vertebral arteries
Hemodynamic patterns of the extracranial carotid and vertebral arteries
FIGURE 29-5 Black and white of color flow image of long axis section of common carotid artery. Arterial wall definition reveals linear reflectivity resulting from the echogenicity of collagen found in the intima and media. (See Color Plate 50.)
FIGURE 29-6 Black and white version of Doppler color flow image of the vertebral artery origin. The subclavian artery is seen in the transverse plane just distal to the origin of the right common carotid artery. (See Color Plate 51.)
FIGURE 29-7 Carotid bifurcation demonstrating boundary layer separation in the carotid bulb.
FIGURE 29-8 Doppler spectral waveform from a normal common carotid artery.
FIGURE 29-9 Doppler spectral waveform from a normal internal carotid artery demonstrating constant forward diastolic flow.
Table 29-1 Diagnostic Doppler Velocity Criteria for Determining Degree of Carotid Artery Diameter Reduction
FIGURE 29-10 Doppler spectral waveform from a normal external carotid artery. Note the low diastolic flow component.
Doppler velocity spectral waveforms
Common carotid artery
Internal carotid artery
External carotid artery
FIGURE 29-11 Montage of Carotid Bulb and Doppler Spectral Waveforms. A, Recorded from the region of the flow divide with primarily forward flow. B, Recorded from the boundary layer showing separation of the flow stream into forward and reverse flows. C, The beginning of the reverse flow phase. D, Reverse flow occurring along the posterolateral wall of the bulb.
Carotid bulb
Vertebral arteries
The intracranial cerebrovascular system
Ophthalmic, terminal internal carotid, middle cerebral, anterior cerebral, anterior communicating, posterior communicating, posterior cerebral, vertebral and basilar arteries
Size of the intracranial cerebrovascular arteries
Sonographic appearance of the intracranial arteries
Hemodynamic patterns of the intracranial arteries
FIGURE 29-12 Black and white version of Doppler color flow image of intracranial circulation from a transtemporal window. MCA, Middle cerebral artery, ACA, anterior cerebral artery, PCA, posterior cerebral artery. (See Color Plate 52.)
Doppler velocity spectral data and flow direction
Middle cerebral and anterior cerebral arteries
Posterior cerebral artery
Ophthalmic artery
Carotid siphon
Vertebral and basilar arteries
FIGURE 29-13 Lower extremity peripheral arterial tree demonstrating the aortoiliac, femoropopliteal, and tibioperoneal systems.
FIGURE 29-14 Black and white version of Doppler color flow image of the aortic bifurcation. (See Color Plate 53.)
The lower extremity arterial system
Common iliac, external iliac, internal iliac, common femoral, deep femoral, popliteal, and tibial arteries
Sonographic appearance of the lower extremity peripheral arterial vessels
FIGURE 29-15 Transverse plane; black and white version of Doppler color flow image of axial sections of superficial femoral artery and vein in Hunter’s canal. (See Color Plate 54.)
FIGURE 29-16 Black and white version of color flow image of long axis section of popliteal artery. (See Color Plate 55.)
FIGURE 29-17 Black and white version of Doppler color flow image of long axis sections of posterior tibial and peroneal arteries surrounded by their companion tibial veins of the same name. (See Color Plate 56)
Size of the lower extremity arteries
Hemodynamic patterns in the lower extremity arterial system
Doppler velocity spectral waveforms
FIGURE 29-18 Doppler spectral waveform recorded from a lower extremity peripheral artery. Note the triphasic pattern of flow.
FIGURE 29-19 Normal Velocity Spectral Waveforms. A, Waveforms from the common femoral artery. B, Waveforms from the profunda femoris artery. C, Waveforms from the distal superficial femoral artery. D, Waveforms from the external iliac artery. E, Waveforms from the proximal superficial femoral artery. F, Waveforms from the popliteal artery. Note the decreases in peak systolic velocity between the external iliac artery and proximal superficial femoral artery and between the proximal superficial femoral artery and the popliteal vessel.
The lower extremity venous system
The deep venous system
FIGURE 29-20 A, Lower extremity deep venous system. B and C, Greater and lesser saphenous veins.
The superficial venous system
The perforating veins
Size of the deep and superficial veins
Sonographic appearance of the deep and superficial venous systems
Hemodynamic patterns of the lower extremity deep venous system
Doppler spectral analysis
FIGURE 29-21 A, Short axis section of vein showing collapse of the venous wall with low transmural pressure. B, Transverse plane; black and white version of Doppler color flow image of axial sections of superficial femoral artery and femoral vein. (See Color Plate 57.) C, Transverse plane: black and white version of Doppler color flow image of axial sections of superficial femoral artery and femoral vein demonstrating coaptation of the venous walls that occurs with gentle transducer pressure. (See Color Plate 58.)
FIGURE 29-22 Doppler spectral waveform recorded from the normal common femoral vein. Note phasicity of flow, which varies with the respiratory cycle.
FIGURE 29-23 Doppler spectral waveform demonstrating augmentation of venous flow with manual compression of the limb proximal to the transducer position.
FIGURE 29-24 Doppler spectral waveform demonstrating the absence of retrograde venous flow when the limb is manually compressed distal to the transducer position. The valve is competent, preventing reflux of blood with distal compression.
Quality assurance in vascular technology
Measurements used for test validation
FIGURE 29-25 Positive and negative noninvasive test results compared with the gold standard.
Table 29-2 Comparison of the Relationship Between Diameter Reduction and Area Reduction
Statistical correlation
Understanding the assigned values
FIGURE 29-26 Example of positive and negative noninvasive test results compared with the gold standard.
Understanding the columns and rows
Understanding the calculations
Summary
Reference charts
ASSOCIATED PHYSICIANS
COMMON DIAGNOSTIC TESTS
LABORATORY VALUES
NORMAL M-MODE MEASUREMENTS
VASCULATURE
AFFECTING CHEMICALS
SECTION IX ADVANCES IN ULTRASOUND
CHAPTER 30 Three-dimensional ultrasound
Objectives
Key words
FIGURE 30-1 A, Example of one of the original 3D images of the fetal face, circa 1989. B, Current example of 3D image of fetal face, 2007.
Methods
FIGURE 30-2 Multiplanar display of the fetal face highlighting the nasal bone. The original acquisition plane is shown in the upper left (sagittal), the upper right is 90 degrees to the original image (transverse) and the lower left is the coronal image.
Step 1: volume acquisition
Step 2: multiplanar display
Step 3: 3d rendering
FIGURE 30-3 3D surface rendering of a late third trimester fetus. Surface rendering can provide exquisite detail of fetal anatomy; even the hair is visualized in this example.
FIGURE 30-4 3D maximum mode rendering of the fetal spine. This mode makes it possible to count vertebrae and ribs.
FIGURE 30-5 3D minimum mode rendering of the adult liver vasculature. This example is displaying both the multiplanar views and the rendered image in the lower right corner.
Sonographic applications
Obstetrics
FIGURE 30-6 10-week-gestation fetus scanned with a 3D transvaginal transducer showing incredible detail of the developing fetus.
FIGURE 30-7 A, 3D surface rendering of a normal 18-week-gestation fetus. The anterior fontanelle is relatively large at this gestational age; plus a fetus of this gestational age does not have much subcutaneous fat, resulting in an image that is anatomically accurate but often frightening to the expectant parents! B, 3D surface rendering of a normal 34-week fetus. A fetus scanned in the third trimester will obviously look more like a newborn baby. This fetus is even smiling!
Gynecology
Abdominal
Small parts
FIGURE 30-8 A, Coronal plane of a uterus with an intrauterine device (IUD). The coronal plane demonstrates the outside contour of the uterus and shape of the endometrium. This is the best plane to identify congenital uterine abnormalities. B, 3D multiplanar display and 3D surface rendering (lower right) of a uterus with saline infusion. Notice how the endometrial polyp is clearly displayed in the coronal 3D rendering.
FIGURE 30-9 3D volume of an adult kidney. The lower right image is a surface rendering of the kidney. This acquisition was taken in the sagittal plane, but the volume can display all the transverse and coronal plane images as well, all from a single volume.
FIGURE 30-10 3D multiplanar and surface rendering of a breast lesion acquired with a high frequency small parts volume transducer.
Urology
Pediatrics
Advanced features
FIGURE 30-11 3D multiplanar display of the prostate gland. The transverse, sagittal, and coronal plane images of prostate anatomy are demonstrated.
FIGURE 30-12 3D multiplanar display of a neonatal brain. This acquisition took less than 3 seconds and contains all the required coronal and sagittal plane image sections, as well as transverse plane sections.
FIGURE 30-13 Tomographic display of a 3D acquisition of the normal fetal heart. This display can demonstrate the normal relationships of the outflow tracts from a single volume acquisition.
New technologies
FIGURE 30-14 A, 3D rendering using the inversion mode to show the fetal heart and great vessels. The diaphragm, stomach and gallbladder are also visualized because inversion mode takes any anechoic structure and displays them as solid structures. B, 3D multiplanar display and inversion mode rendering of a fetus with hydrocephalus. The 3D inversion mode rendering in the lower right corner demonstrates the dilated lateral ventricles; the black “holes” represent the choroid plexus within the lateral ventricles.
FIGURE 30-15 3D volume display of a stimulated ovary demonstrating SonoAVC. The right lower corner is the black-and-white version of the color flow image demonstrating the ovarian follicles. (See Color Plate 59.)
Summary
CHAPTER 31 Interventional and intraoperative ultrasound
Objectives
Key words
Ultrasound-guided intervention
Percutaneous biopsies
Percutaneous aspirations
FIGURE 31-1 Ultrasound-guided, percutaneous biopsy of a liver mass.
FIGURE 31-2 Ultrasound-guided, percutaneous biopsies of thyroid masses.
Percutaneous drainage procedures
FIGURE 31-3 Ultrasound-guided, percutaneous breast mass biopsy.
Intraoperative ultrasound
Equipment and transducers
Sterile field procedure
Applications
FIGURE 31-4 Black and white version of color flow Doppler, intraoperative image of a brain aneurysm. (See Color Plate 60.)
FIGURE 31-5 Intraabdominal Intraoperative Ultrasound Images. A, Intraoperative, longitudinal section of the normal liver. B and C, Transliver approach demonstrating small liver masses. D, Transverse scanning plane, intraoperative image of the mid-epigastrium. E and F, Axial gallbladder sections imaged intraoperatively. G, Trans-gallbladder approach showing a sludge-filled axial section. H and I, Intraoperative images showing the intimate relationship of the head of the pancreas, duodenum, common bile duct, and gastroduodenal artery. J, Black-and-white version of color flow Doppler, intraoperative image of the hepatic artery. (See Color Plate 61.)
FIGURE 31-6 A, Intraoperative, ultrasound image section of the kidney. B, Black-and-white version of the color flow Doppler of the same section. (See Color Plate 62.)
FIGURE 31-7 Vascular Intraoperative Ultrasound Images. A and B, Intraoperative images of longitudinal and axial sections of the internal common carotid artery. Note arterial wall detail. C and D, Black-and-white versions of intraoperative, color flow Doppler images of longitudinal sections of the internal common carotid carotid artery. (See Color Plates 63 and 64.) E, Intraoperative image showing plaque inside the internal common carotid artery. F, Intraoperative image of an arterial graft. Shows Doppler tracing. G, Black-and-white version of intraoperative, color flow Doppler image demonstrating an arterial graft. Note arterial wall details. (See Color Plate 65.)
Back Matter
Illustration credit page
Color plates
Plate 1 Color flow Doppler and pulsed wave imaging of a longitudinal section of the common carotid artery (see Fig. 2-10).
Plate 2 Color flow Doppler of a longitudinal section of the right kidney (see Fig. 2-11).
Plate 3 Power Doppler of a longitudinal section of the right kidney (see Fig. 2-12).
Plate 4 Longitudinal section of the common carotid artery with color flow Doppler box steered to the right or toward the feet. (see Fig. 2-13).
Plate 5 Bladder mass. Note the irregular borders (see Fig. 4-60).
Plate 6 Color Doppler, transverse scanning plane image showing an axial section of the distal aorta just prior to bifurcation into the common iliac arteries (see Fig. 8-14).
Plate 7 Color Doppler, transverse scanning plane sonogram demonstrating axial sections of the common iliac arteries (see Fig. 8-20).
Plate 8 Color Doppler, transverse scanning plane sonogram demonstrating flow within the aorta, celiac artery, splenic artery, and common hepatic artery (see Fig. 8-21).
Plate 9 Color Doppler, transverse scanning plane image showing hepatic veins emptying into the inferior vena cava (see Fig. 9-7, B).
Plate 10 Sagittal scanning plane image of a longitudinal section of the right lobe of the liver demonstrating normal color flow Doppler of the anterior branch of the right portal vein. Note that flow toward the transducer is indicated in red. Thus the flow is toward the transducer (into the liver) in this case (see Fig. 10-12).
Plate 11 Doppler color flow image of a longitudinal section of the abdominal aorta and the origins of the celiac and superior mesenteric arteries from the anterior wall of the aorta (see Fig. 11-2).
Plate 12 Transverse plane, color flow image of an axial section of the abdominal aorta showing the origin and longitudinal section of the left renal artery (see Fig. 11-3).
Plate 13 Transverse plane, color flow image of an axial section of the abdominal aorta, long section of left renal vein, axial section superior mesenteric artery, and long section splenic vein (see Fig. 11-10).
Plate 14 Oblique, longitudinal, intercostal, color flow image of main, right, and left portal veins (see Fig. 11-11).
Plate 15 Transverse plane, color flow image of a longitudinal section of the hepatic artery at its origin from celiac artery bifurcation (see Fig. 11-12, A).
Plate 16 Color flow image of hepatic artery as it courses with portal vein in the porta hepatis (see Fig. 11-12, B).
Plate 17 Doppler spectral waveform from the distal inferior vena cava (see Fig. 11-13, A).
Plate 18 Doppler spectral waveform from the proximal inferior vena cava (see Fig. 11-13, B).
Plate 19 Doppler spectral waveform from the right renal vein (see Fig. 11-14).
Plate 20 Doppler spectral waveform from the left hepatic vein (see Fig. 11-15).
Plate 21 Minimally phasic Doppler spectral waveform from the main portal vein (see Fig. 11-16).
Plate 22 Low-resistance Doppler spectral waveform pattern from hepatic artery (see Fig. 11-17).
Plate 23 Color flow Doppler image showing the characteristic waveform of a normal portal vein. Note that the blood flow is in the direction of the liver, toward the transducer (see Fig. 12-22).
Plate 24 Color flow Doppler image showing the characteristic arterial waveform of the normal hepatic artery (see Fig. 12-23).
Plate 25 Color Doppler evaluation of a TIPS shunt connecting the hepatic vein to the intrahepatic portal vein. Note that the color blue represents flow away from the transducer (portal vein) (see Fig. 12-25).
Plate 26 Transverse scanning plane, color Doppler image of the right renal hilum. Note the location of the renal artery and vein. Axial section of the right kidney shows the rounded pole. The liver is anterior (see Fig. 15-16).
Plate 27 Transverse scanning plane, color Doppler image of the renal hilum of the left kidney (see Fig. 15-24).
Plate 28 Color flow demonstration of the placental cord insertion site (see Figs. 20-19, 21-13, A).
Plate 29 Color duplex longitudinal section of thyroid gland and superior thyroid artery demonstrating arterial flow with peak systolic velocity of 0.212 m/s (see Fig. 23-7, B).
Plate 30 Color duplex longitudinal section of an intrathyroidal artery and vein. Peak systolic velocity of intrathyroidal artery is 0.150 m/s (see Fig. 23-7, C).
Plate 31 Color duplex longitudinal section of the inferior thyroid artery demonstrating peak systolic velocity of 1.205 m/s (see Fig. 23-7, D).
Plate 32 Color duplex longitudinal section of the inferior thyroid vein demonstrating normal phasic flow (see Fig. 23-7, E).
Plate 33 Color duplex longitudinal section of the inferior thyroid artery (see Fig. 23-7, F).
Plate 34 Color Doppler transverse scanning plane image of a mid left parathyroid adenoma. Notice the hypervascularization of the adenoma. Color void areas represent cystic areas (see Fig. 23-17).
Plate 35 Power Doppler image of a parathyroid adenoma. Note the feeder inferior thyroid artery supplying the adenoma (see Fig. 23-19).
Plate 36 Color Doppler sagittal scanning plane image showing a 0.6 cm flat hypoechoic structure simulating a small parathyroid adenoma posterior to the lower pole of the right thyroid lobe. Notice how the hypoechoic structure fills with color, indicating a vascular structure and not a parathyroid adenoma (see Fig. 23-20, B).
Plate 37 Power Doppler image of an enlarged cervical lymph node. Note the vascular flow within the hilum (see Fig. 23-22).
Plate 38 Color Doppler of longitudinal section of testis (see Fig. 25-7).
Plate 39 Color Doppler image showing blood flow within the spermatic cord (see Fig. 25-16).
Plate 40 Transverse scanning plane, color Doppler image showing cavernosal arteries location (see Fig. 25-19).
Plate 41 Color Doppler image of a longitudinal section of the cavernosal artery (see Fig. 25-21).
Plate 42 Power Doppler image of a long section of cavernosal artery (see Fig. 25-22).
Plate 43 Parasternal short axis view showing color flow through the tricuspid valve. Note the blue color as the flow turns to move away from the transducer (see Fig. 27-21, C).
Plate 44 As flow continues from Figure 27-21, C, it is going from the transducer through the pulmonary valve and into the right and left pulmonary branches (see Fig. 27-21, D).
Plate 45 Color flow Doppler of the mitral valve. Echocardiographic image of inflow from the left atrium through the mitral valve into the left ventricle. The flow is red because it is moving toward the transducer positioned at the apex. Note the laminar flow (no turbulence) (see Fig. 27-25, B).
Plate 46 Apical long axis view showing color flow in the left ventricular outflow tract, through the aortic valve and a limited section of the ascending aorta. The transducer is at the apex of the heart with the flow moving away from it. Therefore the blood flow is shown in blue (see Fig. 27-26, B).
Plate 47 Color flow Doppler of the right ventricular inflow tract. The flow is toward the transducer from the right atrium through the tricuspid valve into the right ventricle (see Fig. 27-32, C).
Plate 48 Transverse plane; color flow Doppler of the common carotid artery, jugular vein, and thyroid gland (see Fig. 29-3).
Plate 49 Color flow Doppler of the long axis section of the carotid bifurcation demonstrating the common, external, and internal carotid arteries. Note the zone of retrograde flow in the carotid bulb caused by boundary layer separation (see Fig. 29-4).
Plate 50 Color flow Doppler of the long axis section of the common carotid artery. Arterial wall definition reveals linear reflectivity resulting from the echogenicity of collagen found in the intima and media (see Fig. 29-5).
Plate 51 Color flow Doppler of the vertebral artery origin. The subclavian artery is seen in the transverse plane just distal to the origin of the right common carotid artery (see Fig. 29-6).
Plate 52 Color flow Doppler of the intracranial circulation from a transtemporal window. MCA, Middle cerebral artery; ACA, anterior cerebral artery; PCA, posterior cerebral artery (see Fig. 29-12).
Plate 53 Color flow Doppler of the aortic bifurcation (see Fig. 29-14). (Courtesy Advanced Technology Labs.)
Plate 54 Transverse plane, color flow Doppler of the superficial femoral artery and vein in Hunter’s canal (see Fig. 29-15).
Plate 55 Color flow Doppler of the long axis section of the popliteal artery (see Fig. 29-16).
Plate 56 Color flow Doppler of the long axis section of the posterior tibial and peroneal arteries surrounded by their companion tibial veins of the same name (see Fig. 29-17).
Plate 57 Color flow Doppler of axial sections of the superficial femoral artery and vein (see Fig. 29-21, B).
Plate 58 Color flow Doppler of axial sections of the superficial femoral artery and vein demonstrating coaptation of the venous walls that occurs with gentle transducer pressure (see Fig. 29-21, C).
Plate 59 3D volume display of a stimulated ovary demonstrating SonoAVC. The right lower corner is the color flow image demonstrating the ovarian follicles (see Fig. 30-15).
Plate 60 Color flow Doppler, intraoperative image of a brain aneurysm (see Fig. 31-4).
Plate 61 Intraoperative color flow Doppler image of the hepatic artery (see Fig. 31-5, J)
Plate 62 Color Doppler of intraoperative axial section of the kidney (see Fig. 31-6, B).
Plate 63 Intraoperative color Doppler image of the internal carotid artery (see Fig. 31-7, C).
Plate 64 Intraoperative color Doppler image of the internal carotid artery (see Fig. 31-7, D).
Plate 65 Intraoperative color Doppler image of an arterial graft (see Fig. 31-7, G).

Test Bank for Sonography Introduction to Normal Structure and Function, 3rd Edition: Curry

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