Acute scrotal pain in pediatric patients: diagnosis with an innovative Doppler technique (MicroV)

ACR Appropriateness Criteria® Acute Onset of Scrotal Pain-Without Trauma, Without Antecedent Mass: 2024 Update

Acute scrotum is a medical emergency that requires prompt accurate diagnosis to appropriately triage potentially surgical conditions. Numerous differential diagnoses with overlapping clinical presentations make this a diagnostic challenge. Ultrasound is the established first-line imaging modality for acute scrotal disease and can be used to diagnose most scrotal disorders promptly and with high accuracy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The value of multimodal ultrasonography in the evaluation of late presenting testicular torsion in a rat experimental model

OBJECTIVE

To evaluate the value of multimodal ultrasonography (US) in a rat experimental torsion model after 6 h of torsion with different degrees.

METHODS

Twenty-one male rats were divided into three groups. Left testes of the rats were twisted around their vascular pedicle 360 degrees in group 1, 720 degrees in group 2, and 1080 degrees in group 3 and intact right testes of the rats were accepted as control group. Grey-scale US, superb microvascular imaging (SMI), colour Doppler ultrasonography (CDUS), strain elastography (SE), and two-dimensional (2-D) shear wave elastography (SWE) examinations were applied 6 h after torsion procedure and testes were removed for pathological evaluation.

RESULTS

Short-axis dimensions and volumes of the torsion side were higher than control testes. Lengths of the testes in the 3rd torsion group were smaller than the testes in groups 1 and 2 (P < 0.002). SMI was better than CDUS in recognizing blood flow in testicular tissue. Strain ratios were higher in group 1 and decreased with the increasing torsion degree. Emean and standard deviation (SD) measurements increased in the torsion side. Pathologically the mean testicular damage scores were statistically significant between torsion and control testes in all groups.

CONCLUSION

Our results showed that short-axis and volume measurements, SMI, 2D-SWE, and SE are effective in the evaluation and diagnosis of testicular torsion (TT).

ADVANCES IN KNOWLEDGE

Evaluation of affected testis and intact testis with multiparametric US in late presenting TT cases is more reliable than being dependent on a single sonographic modality.

Velocity field estimation in transcranial small vessel using super-resolution ultrasound imaging velocimetry

Based on the diameter and position information of small vessels obtained by transcranial super-resolution imaging using 3 MHz low-frequency chirp plane waves, a Gaussian-like non-linear compression was adopted to compress the blood flow signals in spatiotemporal filtering (STF) data to a precise region, and then estimate the blood flow velocity field inside the region over the adjacent time intervals using ultrasound imaging velocimetry (UIV). Imaging parameters, such as the mechanical index (MI), frame rate, and microbubble (MB) concentration, are critical during the estimation of velocity fields over a short time at high MB contrast agent concentrations. These were optimized through experiments and algorithms, in which dividing the connected domain was proposed to calculate MB cluster spot centroid spacing (SCS) and the spot-to-flow area ratio (SFAR) to determine the suitable MB concentration. The results of the in vitro experiments showed that the estimation of the small vessel flow velocity field was consistent with the theoretical results; the velocity field resolution for vessels with diameters of 0.5 mm and 0.3 mm was 36 μm and 21 μm, and the error between the mean velocity and the theoretical value was 0.7 % and 0.67 %, respectively.

Microvascular imaging ultrasound (MicroV) and power Doppler vascularization analysis in a pediatric population with early scrotal pain onset

INTRODUCTION

The power Doppler is a useful tool in the evaluation of pediatric acute scrotal pain. Nonetheless, it may have some inherent limitations in scrotal vascularization analysis, potentially causing unnecessary surgery. The microvascular imaging ultrasound (MicroV) is an innovative Doppler technique able to improve the detection of very low flow. This retrospective study aims to compare both power Doppler and MicroV in the evaluation of a pediatric population with early-stage scrotal pain onset, first in testis vascularization analysis, and second in their diagnostic performances.

MATERIALS AND METHODS

69 patients met the following inclusion criteria, age < 18-year-old, a clinical diagnosis of acute scrotal disease, pain onset ≤ 6 h, ultrasound examination (including B-mode, power Doppler, and MicroV), 3-months follow-up. For both power Doppler and MicroV, through a defined vascularization scale, it was evaluated the agreement in vascularization detection, and the sensitivity and specificity in US diagnostic abilities.

RESULTS

Retrospective diagnoses were of 8 testicular torsion, 15 orchi-epididymitis, and 46 children with other scrotal conditions. Power Doppler provided inconclusive US evaluation in 37.68% of the cases, while MicroV only in the 1.45% (p < 0.0001). Testicular torsion and orchi-epididymitis were identified, respectively, with MicroV in 100% (sensitivity, specificity, PPV, NPV, and accuracy of 100%) and 80% of patients (80% sensitivity, 100% specificity and PPV, 94.73% NPV, 95.65% accuracy); with power Doppler the identification was, respectively, of 87.5% (87.5% sensitivity, 100% specificity and PPV, 98.38% NPV and accuracy) and of 73.3% (73.33% sensitivity, 98.14% specificity, 91.66% PPV, 92.98% NPV, 92.75% accuracy).

CONCLUSIONS

Our findings indicate that MicroV is a reliable technique in vascularization detection of pediatric testes, being able also to detect vascularization in healthy testicles with no-flow at power Doppler examination. Moreover, MicroV could be a valuable ally in the US diagnostic of children with early-stage scrotal pain onset.