Echocardiography Review Guide: Companion to the Textbook of Clinical Echocardiography

136 Pages·2015·93.563 MB·English

by  Catherine M. Otto, Rebecca G Schwaegler, Rosario V Freeman

Ultrasound
Teaching Manual
The Basics of Performing and Interpreting Ultrasound Scans
Matthias Hofer
3rd edition
(!)Thieme
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Ultrasound
Teaching Manual
An Introductory Workbook
Third expanded and revised English edition
Matthias Hofer
782 figures and 43 tables
I
Thieme
of
Matthias Hofer, MD, MPH, MME (University of Bern) Bibliographic information the German National Library
Diagnostic Radiologist
Head, Medical Education Pilot Project The German National Library lists this publication in the
Heinrich Heine University German National Bibliography; detailed bibliographical
P.O. Box 10 10 07 data are available on the Internet at http:L/dnb.ddb.de.
40001 DGsseldorf, Germany
Proprietary product names (trademartcs) are not specifically
With gynecologic images contributed by: identified as such. The appearance of a name without such
Tatjana Reihs, MD identification is not to be construed as a representation by
Dept. of Obstetrics and Gynecology the publisher that it is in the public domain.
Heinrich Heine University
P.O. Box 10 10 07 The work, including all parts thereof, is legally protected by
40001 DGsseldorf, Germany copyright. Any use outside the narrow limits set by copyright
legislation, without the publisher's consent, is illegal and li
able to prosecution. This applies in particular to duplications,
translations, preparation of microfilms, and storage and pro
cessing in electronic data systems.
1st German edition 1995
1st Japanese edition 1995
1 st Dutch edition 1996
2nd German edition 1997
1 st Greek edition 1997
1st English edition 1999
3rd German edition 1999
2nd Japanese edition 2000 Important note:
1st French edition 2001
1st Italian edition 2001 Like every science, medicine is undergoing continuous de
4th German edition 2002 velopment. Research and clinical experience are continu
1st Portuguese edition 2003 ously expanding our knowledge, in particular our knowl
1st Russian edition 2003 edge of proper treatment and drug therapy. Insofar as this
1st Spanish edition 2004 book mentions any dosage or application, readers may rest
1st Czech edition 2005 assured that the author and publisher have made every ef
2nd English edition 2005 fort to ensure that such references are in accordance with
5th German edition 2005 the state of knowledge at the time of production of the
2nd Italian edition 2006 book.
2nd Spanish edition 2007
2nd Greek edition 2008 Nevertheless, this does not involve, imply, or express any
1st Polish edition 2008 guarantee on the part of the publisher with respect to any
6th German edition 2009 dosage instructions and forms of application stated in the
7th German edition 2012 book. Every user is requested to examine carefully the
3rd Italian edition 2012 manufacturer's package inserts accompanying each drug
and to check, if necessary in consultation with a specialist,
whether the dosage schedules mentioned therein or the
contraindications stated by the manufacturers differ from
© 2013 Thieme Publishers, Stuttgart, New York the statements made in the present book. Such examina
Home page: http:/fwww.thieme.de tion is particularly important with drugs that are either rare
Printed in Germany ly used or have been newly released on the market. Every
dosage schedule or every form of application used is en
Design: Susanne Kniest, Kaarst tirely at the user's own risk. The user assumes sole respon
3rd English edition: sibility for every diagnostic and therapeutic application,
Inger Wollziefer, Berlin, www.designinger.de medication, and dosage. Consequently, the author and
Front-/ Backcover: Thieme Publishers publisher assume no responsibility and no liability whatso
Printing: Druckerei Steinmeier, Deiningen ever for any damages of any sort that may occur as a result
of use of information, in whole or in part, contained in the
ISBN 9783131110435 present book. We request every user to report to the pub
elSBN 9783131734433 lisher any discrepancies or inaccuracies noticed.
3
Tips for the Reader
How can you use this workbook optimally? • Find normal values and checklists. These are also provided
As you work through the individual chapters, you can benefit on laminated, water-resistant, pocket-sized cards.
from several methodical and didactic features:
Why is this book called a "workbook"?
Find it quickly .•. A unique feature of this book is that you can use every page as
• Find a chapter: you will find the respective tab for each a quiz to test your knowledge. The diagrams contain reference
chapter on page 5. numbers instead of labels. This means you can go through
• Find tough quiz questions for in-depth study, also explained the material a second time and use any figure to test which
on page 5. structures you know and which you still have to learn. The quiz
• Find cross-referenced figures: the figures are numbered questions and drawing exercises have a similar purpose.
according to the page on which they appear. For example,
Fig. 36.2 is on page 36. In this way, you can become familiar with several efficient
• Find an explanatory figure or diagram supplementing the study methods that allow you to integrate new material into
text. They are highlighted in light blue in the accompanying your long-term memory faster - even though this requires
text and are almost always on the same page, eliminating you to take a more active approach to learning. Not only do I
the need to page through the book looking for them. wish you good luck with this course, I also hope you have fun
• Find numbered structures. Their reference numbers appear doing it!
in bold in the accompanying text or on the back cover flap
(the same number is used throughout the entire book). Matthias Hofer, MD, MME, October 2012
• Find keywords on page 121 (or on pages 4 and 5).
List of Abbreviations
A. Artery ESWL Extracorporeal shock wave MRI Magnetic resonance Imaging
llthotrlpsy
Aa. Arteries mW Miiiiwatt
A. Femur length (fetus)
N:. Abdominal circumference (fetus) NHL Non-Hodgkin lymphoma
FNH Focal nodular hyperplasia
AC. Adrenal gland NT Nuchal translucency (fetus)
AIUM American lnstlb.Jte of Ultrasound FOO FronUH>cclpltill diameter (fetus) pp Parenchyma-pelvls (Index)
In Medicine Cil Gastrointestinal
PT Preterm newborn
AO Aorta HC Head circumference
PW Pulsed wave (Doppler)
ASD Abialsept;ildefect HCii Human chorionic gonadotropin
RI ResistiYe index
BPD Biparietal diameter (fetus) IHW Width of the SAS in the
RT Renal transplant
b/w Black-white (B-mode) ultrasound lnterhemispherlc fissure
SAS Subarachnold space
cm Chorionic cavity diameter IUD Intrauterine device sew Slnocortlcal width of the SAS
IVC Inferior vena cava
CCE Cholecystectomy
SD Standard deviation
a;w Craniocerebral width of the IVF In vitro fertlllzatlon
Slf Systemic lupus erythematosus
external subarachnoid space IVP Intravenous pyelogram
SMA Superior mesenterlc artery
CHI Contrast harmonic Imaging LA Lower abdomen
TCiA Transposition of the great arteries
CRL Crown-rump length (fetus) Ug. Ligament
THI Tissue harmonic Imaging
CSF Cerebrosplnal fluid LN Lymph node
UA Upper abdomen
CT Computed tomography M. Muscle
v.
Vein
cw
Continuous wave (Doppler) MA Mid-abdomen
Vv. Veins
d"" Diameter of the aorta MCL Mldclavlcular line
V5D Ventricular sept;il defect
DCiC Depth gain compensation MCU Mlcturatlng cystourethrogram
Y5 Yolk.sac
- voiding cystourethrogram
dw:: Diameter of the vena cava
MHz Megahertz (unit of frequency)
ERCP Endoscopk retrograde
cholanglopancreatography Mm. Muscles
4
Contents
1!4%%tM
Standard Planes (front cover flap) Abdomen
Physical Principles and Technique Kidney
Image Formation: Sound Transmission. Reflection 6 Normal Findings 47
Echogenicity, Frequency Ranges 7 Normal Variants and Cysts 48
Operation and Specification of an Ultrasound Unit 8 Kidneys and Urinary System in Pediatrics:
Selection of Ultrasound Units, Types ofTransducers 9 Normal Findings 49
so
Changes in the Renal Parenchyma
New Techniques
Degeneration and Inflammation 51
Panoramic Imaging, 3D, Clarify Vascular Enhancement 1 O
Urinary Obstruction 52
Harmonic Imaging 11
Differential Diagnosis of Urinary Obstruction 53
Phase Inversion, Contrast Enhancement 12
Urinary Obstruction and Reflux in Pediatrics 54
SonoCT 13
Voiding Cystourethrogram 55
Pulse Compression, Precision Up-Sampling 14
Kidney Stones and Infarcts 56
Diagnostic Ultrasound Catheter 15
Renal and Adrenal Tumors 57
Artifacts Renal and Adrenal Tumors in Pediatrics 58
Reverberation, Section Thickness, 16
Bladder
Distal Acoustic Enhancement
Normal Findings 59
Acoustic Shadowing, Mirror Image 17
Indwelling Catheter and Cystitis 60
Side Lobe Artifact, Quiz for Self Evaluation 18
Bladder in Pediatrics 61
Practical Tips and Tricks for the Beginner 19
Renal Transplants (RT)
l!J{io!.IM Abdomen Normal Findings 62
Complications 63
Retroperitoneum, Sagittal Plane Quiz for Self Evaluation 64
Upper Retroperitoneum, Normal Findings 21
Lower Retroperitoneum, Normal Findings 22 1!4$%1• Abdomen
Aortic Ectasia and Aneurysms 23
Gastrointestinal Tract
Retroperitoneal Lymph Nodes 24
Stomach 65
Other Clinical c.ases, Right Heart Failure 25
Small Bowel: Crohn Disease, Ascites, Hernias 67
Quiz for Self Evaluation 26
Gastrointestinal Tract in Children: lntussusception, 68
Contrast Enema
Appendicitis, Diarrhea, Hirschsprung Disease 69
Transverse Planes of the Upper Abdomen, Pancreas Colon: Fecal Impaction, Colitis, Diverticulitis 70
Basic Anatomy 27
Spleen
Normal Findings 28
Normal Findings, Curtain Trick 71
Acute and Chronic Pancreatitis, 29
Diffuse Splenomegaly, Systemic Hematologic 72
Age-related Echogenicity
Disorders
Pancreas: Other Cases 30
Focal Lesions: Infarcts, Lymphomatous Infiltration, 73
Lymph Nodes 31
Other Lesions
Porta Hepatis: Normal Findings 32
Size Measurements, Quiz for Self Evaluation 74
Porta Hepatis: Portal Hypertension, Lymph Nodes 33
Quiz for Self Evaluation 34 1!4{%1:W
Reproductive Organs
l!J{j,j,iM Abdomen Male Reproductive Organs
Prostate Gland, Prostatic Hypertrophy, 75
Liver
Testes and Scrotum
Organ Size, Lateral Angle, Gallbladder 35
Undescended Testis, Orchitis, Epididymitis, 76
Hepatic Venous Star, Right Heart Failure 36
Hydrocele, Inguinal Hernia
Normal Variants, Fatty Liver 37
Focal Fatty Infiltration 38 Female Reproductive Organs
Cysts, Parasites, and Hemangiomas 39 Endovaginal Ultrasound, Image Orientation 77
Other Focal Hepatic Lesions, Air in the Bile Ducts 40 Uterus: Normal Findings, Intrauterine Device 78
Cirrhosis and Hepatocellular Carcinoma 41 Uterine Tumors, Myoma, Adenocarcinoma 79
Liver Metastases, Quiz Question 42 Ovaries: Normal Findings, Volume Measurement, 80
Cycle Phases
Gallbladder and Bile Ducts
Ovaries: Cysts, Tumors, Infertility Therapy 81
Bile Ducts: Cholestasis 43
Pregnancy Testing, Ectopic Pregnancy 82
Gallstones and Polyps 44
Placenta Position and Gender Determination 83
Gallbladder: Cholecystitis 45
Biometry in the First Trimester: CCD, YSD, CRL 84
Liver and Gallbladder: Quiz for Self Evaluation 46
Biometry in the 2nd and 3rd Trimesters: BPD, FL, AC 85
5
Contents
Diagnosis of Malformations
Where Do I Find Which Chapter?
Cerebellum and CSF Spaces 86
Spine: Spinal Anatomy, Spina Bifida 87
Facial Bones, Nuchal Translucency, Hydrops Fetalis 88
Heart and Blood Vessels: Congenital Cardiac Shunts 89
Gastrointestinal Tract, Omphalocele, Kidneys 90
Bones of the Extremities: Clubfoot 91 Physical Principles and Technique 6
Reproductive Organs: Quiz for Self Evaluation 92
l!4{j,]1fM Head and Neck 1!4{{.],11
Neonatal Skull
Retroperitoneum 21
Normal Findings in the Coronal Plane 93
CSF Spaces, Normal Findings in the Sagittal Plane 95
Normal Variants: Cavum of the Septum Pellucid um, 97
Agenesis of the Corpus Callosum 1!4{j,j,fJ
Hemorrhages: Pathophysiology, Ultrasound 98
Transverse Planes of the UA, Pancreas 21
Morphology
Hydrocephalus, Cerebral Atrophy 99
Monitoring the Shunt in Hydrocephalus, Spinal Canal 100
Thyroid Gland
Normal Findings: Anatomy, Volumetric 101 Liver, Gallbladder, Bile Ducts 35
Measurements
Pathologic Cases: Goiter 102
Focal Solid Nodules, Thyroiditis, Volumetric 103
1!4{%11
Measurements
Neck Kidneys, Adrenal Glands, Bladder, RT 47
Lymph Nodes, Differential Diagnostic Criteria 104
Pediatrics: Hip
Preparation, Positioning the Newborn 107
Ultrasound Documentation Gastrointestinal Tract, Spleen 65
Setup and Measurement Errors 109
Classification of Infant Hips According to Graf 110
Head and Neck: Quiz for Self Evaluation 111
1!4{1o!.iii
Emergency Diagnostics 112
FAST: Focused Assessment with Sonography for Reproductive Organs, Malformations 75
Trauma
Images courtesy of Dr. Tatjana Reihs
Appendix
1!4{%il
Diagram Templates for Standard Planes 114
Primer of Ultrasound Findings 116 Head, Neck, Hip, and FAST 93
Index 120
Template for Report of Normal Ultrasound Findings 121
Answers to the Questions 122
Acknowledgments 126
Information About Practical Ultrasound Courses 126 Answers to Quiz Questions,
116
Ultrasound Primer
Table of Normal Values for Adults (back cover flap)
Table of Normal Values for Prenatal Care
Legend of numbered structures (inner back cover flap)
Do you want to do more than "just read"?
Experience has shown that readers and course participants benefit most from this book by applying a little determination and
learning to draw the standard planes from memory and solving the quiz questions by themselves. You will be surprised how
much quicker you will integrate this new material into your long-term memory. To find the relevant pages more easily, the quiz 9~'i.1
headings are marked in blue in the table of contents and the pages are marked with a blue tab in the margin:
Are you interested in pediatrics?
p
We have also introduced margin tabs to highlight pages with pediatric content. The tabs appear just above the lower corner of
the outer edge of each page. The tabs look like this:
Pediatric material is found on pages 49, 50, 53-55, 58, 61, 65, 68, 69, 74, 93-100, 107-110.
6
Physical Principles and Technique
Image Formation
Ultrasound images are generated not by X-rays but by sound
Sound Transmission in Human Tissue
waves that are sent by a transducer into the human body and
reflected there. In abdominal ultrasound, the frequencies 3 s
used generally are between 2.5 and 5.0 megahertz (MHz; see Liver 1549 m/s
p. 9). Spleen 1566 m/s mean= 1540 m/s
uscle 568 s
The primary condition required for sound wave reflections is Bone 3360 m/s
the presence of so-called "impedance mismatches." These
occur at the interface between two tissue layers with differ Table 6.1
ent sound transmission properties (interfaces in Fig. 6.2). It is
interesting to note that different soft tissues show only minor
differences in the transmission of sound (Table 6.1 ). Only air
and bone are marked by massively different sound transmis Trans Trans
sion in comparison with other human tissue. ducer ducer
For this reason ultrasound units can be operated at a prese
lected medium frequency of approximately 1540 m/s with
out producing any major inaccuracies in the calculated origin
("depth") of the echo. The processor computes the depth of
origin of the echo from the time difference detected between
Interface
emission of the sound impulse and return of the echo. Echoes A
from tissue close to the transducer (A) arrive earlier (tA) than
echoes from deeper tissues (tB. tc in Fig. 6.2a). The mean
Interface
frequency is strictly theoretical since the processor cannot B
know which type of tissue was traversed.
Interface
c
Fig. 6.2 a Fig. 6.2 b
Which Component of the Sound Wave is Reflected?
Fig. 6.2a shows three tissue blocks traversed by sound waves sound waves deep to this structure from which it can gener
that differ only minimally in their transmission velocity (in ate an image. Instead, the total reflection creates an acoustic
dicated by similar gray values). Each interface only reflects a shadow (45).
.J ) t ).
small portion of the original sound waves ( as echo (
The right-hand diagram shows a larger impedance mismatch Conclusion: Intestinal or pulmonary air and bone are impen
at the interface A between the different tissues (Fig. 6.2b). etrable by sound waves, precluding any imaging deep to these
t )
This increases the proportion of reflected sound waves ( structures. The goal will later be to work around intestinal air
in comparison to the tissues shown on the left. However, what or ribs by maneuvering the transducer. The pressure applied to
happens if the sound waves hit air in the stomach or a rib? the transducer against the abdominal wall (see p. 19) and the
This causes a so-called "total reflection," as illustrated at inter acoustic gel that displaces air between the surface of the trans
face B (Fig. 6.2b). The transducer does not detect any residual ducer and the patient's skin (see p. 20) play a significant role.
From a "Snowstorm" to an Image •••
Do not get discouraged if at first you can only make a blinding "snowstorm" on ultrasound images. You will be surprised how
soon you will recognize the ultrasound morphology of individual organs and vessels. Fig. 6.3 shows two round polyps (65) in the
gallbladder (14), visualized as a black
structure. The surrounding gray "snow
storm" corresponds to the hepatic
parenchyma (9), which is traversed
by hepatic vessels (10, 11 ). How can
you quickly work out which structures
in the image appear bright and which
are dark? The key lies in the concept of
echogenicity (see p. 7).
9 9
Fig. 6.3 a Fig. 6.3 b
7
Physical Principles and Technique
What Does the Term "Echogenicity" Mean?
Tissues or organs with many intrinsic impedance mismatches
produce many echoes and appear "hyperechoic" = bright. In Please use the These appear an
contrast, tissue and organs with few impedance mismatches following terms: echoic(= black):
appear "hypoechoic" = dark. Consequently, homogeneous
fluids without impedance mismatches (blood, urine, bile, ce Hyperechoic (= bright) Blood, urine, bile,
rebrospinal fluid, pericardia! or pleural effusion, ascites, cyst cerebrospinal fluid,
secretion) appear "anechoic" = black. Hypoechoic (=dark)
pericardia! or
pleural effusion,
The number of impedance mismatches does not depend on Anechoic(= black)
ascites, cysts
the physical density(= mass per unit of volume). This is best
illustrated with a fatty liver.
On this noncontrasted CT scan (Fig.
Fatty liver Normal liver
7 .1 a), the parenchyma of a fatty liver
(9) appears darker (i.e., less dense) than
hepatic vessels or normal liver (Fig.
7.lb). This is due to the lesser density
of fat in comparison with normal liver
tissue.
On ultrasound the fatty deposits pro-
CT
duce more impedance mismatches
(Fig. 7 .1 c) than in normal liver tissue
(Fig. 7 .1 d). Consequently, a fatty liver
appears more echogenic (brighter)
on ultrasound despite its significantly
lower physical density.
A common misunderstanding:
What do ultrasound examiners mean
when they refer to a "dense liver"?
Either they are not expressing them
selves clearly or they have failed to us
grasp the fundamental principle of
ultrasound imaging and how it differs
from radiography. Ultrasound does not
visualize physical tissue densities but
differences in sound transmission (im
pedance mismatches) which are unre
lated to density.
Fig. 7.1
Generation and Frequency Ranges of Sound Waves So-called "multi-frequency transducers" have the additional
Sound waves are generated by what is known as the "piezo capability to increase or decrease this center frequency and
electric effect." The pressure waves of an echo distort crystals, the surrounding bandwidth of transmitted sound frequencies.
causing them to emit an electrical impulse. The reverse takes In thin patients or children, for instance, the bandwidth can
place during transmission. A transducer includes many such be shifted (say 4-8 MHz with a center frequency of 6 MHz) to
crystals. Depending on the impulse applied, they can produce achieve better spatial resolution. However, this decreases the
sound waves of various frequencies specified in megahertz depth penetration of the sound waves.
(MHz). A "3.75-MHz" transducer does not exclusively emit
pressure waves (sound waves) at a frequency of 3.75 MHz; In very obese patients, the use of lower frequencies (1-5 MHz
that is merely the specified median frequency (= "center with a center frequency of 2.5 MHz) can be appropriate to
frequency"). In fact, such a transducer may emit sound wave achieve the necessary penetration, but at the cost lower reso
frequencies between, for example, 2 and 6 MHz. lution (see p. 9). Newer methods base their image generation
on frequency shifts or harmonic frequencies of the echo in
relation to the original ultrasound impulse (see p. 11 ).
8
Physical Principles and Technique
Operating an Ultrasound Unit
Many controls on different ultrasound units are quite simi The overall amplification (gain) of the received echoes is usu
lar in function and arrangement regardless of the manufac ally controlled by a gain knob (F) that is normally a little larger
turer. Therefore this section will look at the console of one than the other controls. The amplification of echoes can also
unit, which will then be used to introduce common technical be selectively adjusted with a series of sliding controls (G),
terms. each for a specific depth range. The better units allow fine
One common feature on almost all units is the freeze but incremental adjustment of the magnification or visualized
ton (E) in the lower right corner of the console (Fig. 8.1 ). This depth (depth/range) as required (H).
freezes the moving image. It is recommended to rest one fin
ger of your left hand lightly on the trackball or over this but It requires some practice to operate the trackball (I) with the
ton during the examination to minimize delay in capturing a left hand to take measurements or set markers. In general,
desired image. this must be preceded by activating one of the measurement
Before you begin, do not forget to enter the patient's name (A, programs (J) or the comment mode (K). To make review of
B) to eliminate any possible confusion in your imaging docu the images easier for others, the appropriate body marker
mentation later. The buttons for selecting a new menu (C) or (L) can be selected to mark the position of the transducer on
transducer (D) are usually found at the top of the console. The the image before printing (M). The remaining functions vary
menu function allows you to store predefined programs for among the different manufacturers and are best learned in
specific examinations with optimized settings for frequency clinical practice.
range, transducer type, penetration depth, etc. These pro
grams make it easy to switch quickly between studies of dif
ferent regions such as from an abdominal to a thyroid scan.
Fig. 8.1 Console and keyboard
B
A Begin a new patient
B Enter name (ID)
C Change menu
D Change transducer
E Freeze
F Gain
G Depth gain compensation
H Depth/ range
I Trackball for positioning markers or measuring points
J Measurements
K Comment
L Body marker ("Where was the transducer placed?")
M Image recording/ printer
F
Specification of an Ultrasound Unit
Aside from price and image quality, you should carefully eval field of view of the supine patient, for instance beneath the
uate the user friendliness. For example, small units may have ceiling. This will allow you to explain findings during the study.
only one transducer plug. This can later become rather an This additional investment can improve the doctor-patient
noying when different types of transducers are often required relationship and enhance the reputation of your practice or
(seep. 9). hospital.
In view of the increasing digitalization in hospitals and phy Although they probably stand to gain the most, pediatricians
sician's offices, it is advisable to test the new unit for several are not the only ones to benefit from a unit with digital stor
days for compatibility with the existing data storage system. age (cine loop) of sufficient capacity to allow flashbacks for
Unexpected problems invariably arise or are revealed with two or more seconds after freezing. This option allows one to
in the scope of the supplier's customer service. Resolving record optimal images and use them for measurements even
them up front avoids subsequent disappointments or time in restless patients (or where the image was frozen too late)
consuming or costly upgrades. To create a patient-friendly without having to repeat the examination. This option is now
environment it is advisable to install a second monitor in the also available even in smaller B-mode units.