હદય ના સ્નાયુને પણ બીજા સ્નાયુ

હદય ના સ્નાયુને પણ બીજા સ્નાયુ 

Color Doppler Findings of Testicular Torsion

TESTICULAR TORSION

    Testicular torsion is a result of excessive mobility of testis. Most torsion is seen at puberty (intravaginal) with a peak during neonatal period ( extravaginal at the cord) and is usually bilateral requiring bilateral orchiopexy.

     Ultrasonography finding vary depending on the time elapsed between the onset of episode and the examination.

 Acute Phase ( within 6 hours)

 *  Normal findings

 *  Scrotal wall thickening

 * Enlarged hypoechoic testis and epididymis.

Early subacute phase (1-4 days)

 * Acute finding are more obvious

 *  Echofree area of liquefactive necrosis

 * Hypoechoic mass of hemorrhage.

Late subacute phase (5-10 days)

 *  Progressive decrease of early subacute phase findings

Chronic phase ( over 10 days)

*  Normalisation of findings

*  Testis small and echopoor

* Persistent epididymal enlargement and increased echogenicity
COLOR DOPPLER FINDINGS OF TESTIS

Acute phase (figs. 14.4)

  * Diminished or absent flow to the testis.

  * Normal peritesticular flow.

                        Figure 14.4: Torsion of testis - complete absence of color flow in the testis 

                                          ( lowest velocty setting used for Doppler study)

Late phase (3-8 Day) (figs.14.5 and 14.6)

  * Persistence of decreased flow to testis

  * Increased peritesticular flow.

            Figure 14.5: Late phase of testicilar- No flow seen in the testis. Peritesticular flow is present

Figure. 14.6 : Power Doppler highlights exuberant peritessticular flow and absence of flow in the                              testis

  Although much has been written about the usefulness of color Doppler to detect torsion of testis, recent studies indicate that surgery need not be delayed by an altrasound study if high degree of clinical suspicion persists. Color Doppler imaging is rendered less useful in following conditions:

1. Prepubertal testis which normally have low flow.

2. Ectopic testis.

3. Torsion detorsion state previously torsed testis is now reperfused

    and color flow may be normal or hypervascular.

4. Sevare epididymo-orchitis causing secondary ischemia.

   The recently reported most reliable sign is a  snail shell curl of the epididymis and not the color flow abnormalities.  

Doppler imaging senile Atophy of Testis

Senile Atrophy of Testis

      Age- related atrophy is evident ultrasonographically by multiple hypoechoic areas within the testis. On color Doppler imaging hypoechoic area appear avascular Figs 14.20 A and B)

             figs. 14.20 A : Findings in a 62- year-old man with senile testicular atrophy:gray scale                             image reveals multiple hypoechoic areas within the testis

Figs.14.20 B: Finding in a 62-year-old man with senile testicular atrophy: color Doppler flow image shows avascular nature of hypoechoic areas  

Doppler of Undesceded Testis

Doppler of Undescended Testis

Fig. 14.15. Gray scale image shows Empty right scrotal sac and testis in right inguinal region
s/o Undescended testis

      Undescnded testis (Fig. 14.15) is the most common congenital abnormality found in about 1 percent of boy and men and it occurs due to pathological impairment of hypothalamo pituitary gonadal axis. The incidence of malignancies encountered in this testis is up to 45-48 times higher than the general population and are also more prone to rupture, torsion and infertility. If repaired before 5 years of age, the risk for malignancy drops significantly. Fortunately most of the andescended testis are located in superficial soft tissue or inguinal canal and are readily detected in about 97 percent of cases. The search usually begins from the scrotum upward. The undescended testis is a small oval structures, may be slightly hypoechoic or isoechoic to the rarenchyma of normal testis. The undescended testis cannot be imaged if located in the abdominal cavity. Confusion with an enlarged lymph node in the inguinal region may be avoided by noting following points:

* Enlarged node is hypervascular as compared to virtual undescended testis.

* Lymph nodes are fairly fixed in position as compared to mobile undescended

    testis.         

Color Doppler of Varicocele

COLOR DOPPLER OF VARICOCELE

    Varicocele is the most common correctable cause of male infertility. Ultrasonography and color Doppler play an important role in the diagnosis, particularly in subclinical cases (10%). The veins of the pampiniform plexus are dilated to exceed 2 mm in diameter. The veins are characterized by retrograde flow in the internal spermatic vein. The examination performed in standing posture and during valsalva the veins often dilate to 3 mm and more (figs 14.16 to 14.17B)  

Fig.14.16: Longitudinal color Doppler image of the left spermatic cord
demonstrating dilated vascular channels suggestive of varicocele 

Fig. 14.17 B: Color Doppler in another patient shows dilated veins
during valsalva maneuver

Role of color Doppler in splenic lesions

Portal Hypertension

   Portal hypertension results in changes in various vessels along with development of multiple portosystemic collaterals.

    Along with dilatation of portal vein, varying degrees of dilatation of splenic and superior mesenteric veins also occur in portal hypertension. A caliber of splenic vein over 12 mm diameter or greater should be considered a specific sign of portal hypertension. Splenomegaly, usually associated with portal hypertension, is also responsible for dilatation of splenic vein possibly because of increased aplenic flow (fig. 10.1).

splenic vein with splenomegaly

                Figure 10.1: Dilated and tortuous splenic vein with splenomegaly

Dilatation of splenic artery was also found to accompany splenomegaly which is required to supply a more extensive capillary bed. Splenic artery dilatation was also found to occur more frequently in cirrhosis caused by chronic viral hepatitis than in alcohol abuse. A ratio between the diameter of the hepatic and splenic arteries above 0.9, measured at 1.5-3 cm from their origins, suggests an alcoholic cause for cirrhosis, whereas a lower ratio is indicative of an infectious cause.

     Another important sign of portal hypertension is the lack of variation in caliber with respiration in the splenic and superior mesenteric veins (fig. 10.2)

Figure 10.2:Splenic venous flow pattern in a portal hypertensive

    Along with hepatofugal portal flow, splenic vein also shows hepatofugal flow which has proved to be closely correlated with hepatic encephalopathy.

Figure 10.3:Voluminous lienored collaterals

    At level of lower splenic pole, lienorenal collaterals appear as tortuous vessels with a high velocity Doppler signal and a broad spectrum of frequencies due to turbulence (fig. 10.3). Their presence is often associated with flow reversal in the splenic vein.

Splenic Infarction

   Splenic infarcts occur in patients with myeloproliferative syndromes, hemolytic anemias and sepsis especially in sepsis associated with endocarditis. The striking clinical feature is sudden onset of pain in the upper left abdomen, occasionally associated with a painful restriction of the respiratory excursion or local pain on palpation. However, clinical diagnosis can be difficult because pain can be associated with almost all cases of splenomegaly and infarct may be silent.

   Splenic infarcts can be visualized at altrasound scanning and B-mode pulsed Doppler US can identify infarct related complications.

   For the imaging diagnosis of splenic infarstion, a wide range of ultrasound appearances have been observed. About 24 hours after therapeutic embolization of the splenic artery for treatment of portal hypertension, splenic infarcts appear as wedge-shaped, hypoechoic and well-demarcated lesions at sonography. This is the typical US appearance of acute stage without complications. Scar stage of infarction may be seen as in homogeneity of splenic texture months later.

     Severe infarct related complications might develop in the course of disease that can be detected by follow-up US and Doppler scanning. The findings that require surgical intervention are the following:

 1. Increasing subcapsular hemorrhage

 2. Extravasation of blood into peritoneal cavity

 3. Flow phenomena in the area of infarction as seen at B-mode pulsed Doppler     

      US.

    In patients demonstrating arterial signals within the infarction area, histological examination revealed superinfection of the splenic infarcts. The presence of arterial signals and increasing subcapsular hemorrhage were signs of occurrence of spontaneous splenic pupture. Hence with clear sonographic signs of life-threatening splenic rupture, splenectomy should be recommended.

Intrasplenic Pseudoaneurysm

      Post-traumatic pseudoaneurysm involving splanchnic arteries are very rare in the pediatric age group and affect mostly the splenic artery or intrasplenic arterial branches. Because of the potential life-threatening complications, intrasplenic pseudoaneurysm must be diagnosed and treated immediately. Although the trend in the management of blunt splenic injuries has been towards conservative treatment, formation of a pseudo-aneurysm at the site of a splenic hematoma may cause delayed splenic rupture requiring splenectomy. This has necessitated routine follow-up of blunt splenic injuries by color Doppler sonography or CT to detect pseudoaneurysm at an early stage when selective embolization might prevent expansions of the hematoma and rupture of the spleen.

     Intrasplenic pseudoaneurysm are formed by active bleeding from injured intrasplenic arterial branches. Although spontaneous thrombosis is possible, the usual evolution of the lesions is gradual expansion of the hematoma with eventual rupture of the splenic capsule. This unpredictable ominous complications necessitates a meticulous search for there lesions in all cases of blunt splenic trauma.

    Initial scanning in patients who have experienced blunt splenic trauma may be performed with color Doppler sonography or contrast-enhanced CT. Intrasplenic pseudoaneurysm apper on gray scale sonography as nonspecific anechoic lesions. Their aneurysmal nature can be revealed by the demonstration of arterial flow on color Doppler sonography. Turbulent arterial flow within the lesion suggests a diagnosis of pseudoaneurysm. Not all intrasplenic pseuoaneurysm develop at the time of initial trauma. Somelesions develop in a delaved fashion presumably because of gradual lysis of the clot sealing the injured arterial wall. Thus conservative management of blunt splenic trauma should include periodic follow-up with color Doppler sonography or CT even if admission scans are negative. Coil embolization of splenic artery is the preferred method for hemostasis of intrasplenic pseudoaneurysm.