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Li Y, Mashhood A, Mamlouk MD, Lindan CE, Feldstein VA, Glenn OA. Prenatal Diagnosis of Third and Fourth Branchial Apparatus Anomalies: Case Series and Comparison with Lymphatic Malformation. AJNR Am J Neuroradiol 2021; 42:2094-2100. [PMID: 34620588 DOI: 10.3174/ajnr.a7293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/19/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Third and fourth branchial apparatus anomalies are rare congenital anomalies. The purpose of this study was to investigate imaging features of these lesions on fetal MR imaging in comparison with lymphatic malformations, the major competing differential diagnosis in these cases. MATERIALS AND METHODS A retrospective review of our institutional fetal MR imaging database between 1997 and 2019 resulted in 4 patients with confirmed third and fourth branchial apparatus anomalies and 14 patients with confirmed lymphatic malformations. The imaging features were reviewed by consensus, and the Fisher exact test was used to evaluate statistically significant differences between these 2 populations. RESULTS Four cases of third and fourth branchial apparatus anomalies were imaged at 29 weeks 1 day (range, 23 weeks 1 day to 33 weeks 4 days). All 4 cases demonstrated unilateral, unilocular cysts without reduced diffusion or hemorrhage and a medially directed beaked contour that tapered between the spine and airway at the level of the piriform sinus. Compared with 14 cases of fetal lymphatic malformations imaged at 27 weeks 6 days (range, 21 weeks 3 days to 34 weeks 6 days), third and fourth branchial apparatus cysts were significantly more likely to be unilocular (P < .005) and to have a medially beaked contour (P < .005). The combination of features of unilateral, unilocular, and medially beaked contour was observed only in the fetuses with third and fourth branchial apparatus cysts (P < .001). CONCLUSIONS The presence of a left-sided unilocular cyst with a medially beaked contour tapering at the level of the piriform sinus suggests the diagnosis of third and fourth branchial apparatus anomaly. Accurate diagnosis in the prenatal period allows proper counseling, genetic work-up, and treatment, potentially sparing patients from recurrent infections and associated morbidity.
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Affiliation(s)
- Y Li
- From the Department of Radiology and Biomedical Imaging (Y.L., C.E.L., V.A.F., O.A.G.), Neuroradiology Section, University of California San Francisco, San Francisco, California
| | - A Mashhood
- Palo Alto Veteran Affairs Medical Center (A.M.), Stanford University, Palo Alto, California
| | - M D Mamlouk
- The Permanente Medical Group (M.D.M.), Kaiser Permanente Medical Center Santa Clara, Santa Clara, California
| | - C E Lindan
- From the Department of Radiology and Biomedical Imaging (Y.L., C.E.L., V.A.F., O.A.G.), Neuroradiology Section, University of California San Francisco, San Francisco, California
| | - V A Feldstein
- From the Department of Radiology and Biomedical Imaging (Y.L., C.E.L., V.A.F., O.A.G.), Neuroradiology Section, University of California San Francisco, San Francisco, California
| | - O A Glenn
- From the Department of Radiology and Biomedical Imaging (Y.L., C.E.L., V.A.F., O.A.G.), Neuroradiology Section, University of California San Francisco, San Francisco, California
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Harbell JW, Morgan T, Feldstein VA, Roll GR, Posselt A, Kang SM, Feng S, Hirose R, Freise CE, Stock P. Splenic Vein Thrombosis Following Pancreas Transplantation: Identification of Factors That Support Conservative Management. Am J Transplant 2017; 17:2955-2962. [PMID: 28707821 DOI: 10.1111/ajt.14428] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 01/25/2023]
Abstract
Prophylaxis for graft portal/splenic venous thrombosis following pancreas transplant varies between institutions. Similarly, treatment of venous thrombosis ranges from early re-exploration to conservative management with anticoagulation. We wished to determine the prevalence of graft splenic vein (SV) thrombosis, as well as the clinical significance of non-occlusive thrombus observed on routine imaging. Records of 112 pancreas transplant recipients over a 5-year period at a single center were reviewed. Venous thrombosis was defined as absence of flow or presence of thrombus identified in any part of the graft SV on ultrasound. Thirty patients (27%) had some degree of thrombus or absence of flow in the SV on postoperative ultrasound. There were 5 graft losses in this group. Four were due to venous thrombosis, and occurred within 20 days of transplant. All patients with non-occlusive partial SV thrombus but normal arterial signal on Doppler ultrasound were successfully treated with IV heparin followed by warfarin for 3-6 months, and remained insulin independent. Findings of arterial signal abnormalities, such as absence or reversal of diastolic flow within the graft, require urgent operative intervention since this finding can be associated with more extensive thrombus that may lead to graft loss.
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Affiliation(s)
- J W Harbell
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - T Morgan
- Department of Radiology, University of California San Francisco, San Francisco, CA
| | - V A Feldstein
- Department of Radiology, University of California San Francisco, San Francisco, CA
| | - G R Roll
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - A Posselt
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - S-M Kang
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - S Feng
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - R Hirose
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - C E Freise
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - P Stock
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
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Peyvandi S, Feldstein VA, Hirose S, Rand L, Brook MM, Moon-Grady AJ. Twin-reversed arterial perfusion sequence associated with decreased fetal cerebral vascular impedance. Ultrasound Obstet Gynecol 2015; 45:447-51. [PMID: 25157457 PMCID: PMC4503362 DOI: 10.1002/uog.14650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 08/10/2014] [Accepted: 08/13/2014] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Twin-reversed arterial perfusion (TRAP) sequence affects 1% of monochorionic twin pregnancies and is caused by abnormal vascular connections between a pump twin and an acardiac mass. The effects of abnormal vascular connections on cerebral vasculature in the pump twin are unknown. We hypothesize that abnormal cerebral vascular impedance, as assessed by the pulsatility index (PI), is present in pump twins and that fetal intervention alters cerebral impedance. METHODS Fetal echocardiograms performed between 2010 and 2013 in pregnancies diagnosed with TRAP (n = 19), recorded at presentation, and uncomplicated monochorionic twin pregnancies (controls, n = 18; 36 fetuses) were analyzed. In all subjects, the middle cerebral artery (MCA)-PI, combined cardiac output (CCO) and cardiothoracic ratio were calculated, and the values for cases and controls were compared. RESULTS The mean gestational age at the time of echocardiography was 20 weeks in both groups. MCA-PI was lower in TRAP cases than in controls (1.55 (95% CI, 1.47-1.64) vs 1.74 (95% CI, 1.65-1.82), respectively; P = 0.004). CCO in TRAP cases was mildly elevated for gestational age (199.7 (95% CI, 138.4-261.1) mL/min) compared with that of controls (131.4 (95% CI, 102.2-160.7) mL/min). In six TRAP cases with a second echocardiogram available, the mean MCA-PI increased after intervention, from 1.5 (95% CI, 1.3-1.7) to 1.8 (95% CI, 1.4-2.2). CONCLUSIONS TRAP pump twins have lower cerebral vascular impedance than do controls, suggestive of a brain-sparing effect. MCA-PI appeared to increase in a small group of pump twins after intervention. These findings suggest a fetal cerebral autoregulatory response to a high cardiac output state that begins to change after fetal intervention. The long-term implications for neurodevelopmental outcome warrant further study.
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Affiliation(s)
- S. Peyvandi
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - V. A. Feldstein
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - S. Hirose
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - L. Rand
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - M. M. Brook
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - A. J. Moon-Grady
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
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AlRais F, Feldstein VA, Srivastava D, Gosnell K, Moon-Grady AJ. Monochorionic twins discordant for congenital heart disease: a referral center's experience and possible pathophysiologic mechanisms. Prenat Diagn 2011; 31:978-84. [DOI: 10.1002/pd.2819] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 06/01/2011] [Accepted: 06/01/2011] [Indexed: 11/10/2022]
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Esakoff TF, Sparks TN, Kaimal AJ, Kim LH, Feldstein VA, Goldstein RB, Cheng YW, Caughey AB. Diagnosis and morbidity of placenta accreta. Ultrasound Obstet Gynecol 2011; 37:324-327. [PMID: 20812377 DOI: 10.1002/uog.8827] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/25/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To examine the diagnostic precision of ultrasound examination for placenta accreta in women with placenta previa and to compare the morbidity associated with accreta to that of previa alone. METHODS This was a retrospective cohort study of all women with previa with/without accreta examined at the University of California, San Francisco (UCSF) between 2002 and 2008. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of ultrasound examination for the diagnosis of accreta were calculated and compared with results from similar studies in the literature. Univariable analysis was used to compare clinical outcomes. RESULTS The PPV of an ultrasound diagnosis of accreta was 68% and NPV was 98%. Ultrasound had a sensitivity of 89.5%. Compared with previa alone, accreta had an odds ratio (OR) of 89.6 (95% CI, 19.44-412.95) for estimated blood loss > 2 L, an OR of 29.6 (95% CI, 8.20-107.00) for transfusion and an OR of 8.52 (95% CI, 2.58-28.11) for length of hospital stay > 4 days. CONCLUSION Placenta accreta is associated with greater morbidity than is placenta previa alone. Ultrasound examination is a good diagnostic test for accreta in women with placenta previa. This is consistent with most other studies in the literature.
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Affiliation(s)
- T F Esakoff
- Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA.
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Keller RL, Glidden DV, Paek BW, Goldstein RB, Feldstein VA, Callen PW, Filly RA, Albanese CT. The lung-to-head ratio and fetoscopic temporary tracheal occlusion: prediction of survival in severe left congenital diaphragmatic hernia. Ultrasound Obstet Gynecol 2003; 21:244-249. [PMID: 12666218 DOI: 10.1002/uog.44] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To evaluate the reliability of sonographic lung-to-head ratio (LHR) measurement as a predictor of survival in fetuses with congenital diaphragmatic hernia (CDH) and to compare the probability of survival in those with temporary tracheal occlusion (TO) or standard care with respect to the LHR. METHODS Fifty-six fetuses with left CDH with liver herniated into the thorax at complete prenatal evaluation were included in logistic regression analyses of antenatal predictors of survival to hospital discharge. Sixteen subjects underwent TO and 40 received standard care. RESULTS LHR was a significant predictor of survival, with probability of survival increasing with increasing LHR (odds ratio (OR) 8.5, P = 0.04). When subjects with anomalies were excluded, the LHR effect was similar after adjustment for TO (OR 7.1, P = 0.11). Linear spline models suggested a plateau in survival at an LHR of 1.0 and all models suggested increased odds of survival with TO. Minimum LHR measurements had a high degree of inter- and intraobserver agreement (intraclass correlation coefficients of 0.70 and 0.80, respectively). CONCLUSIONS Calculation of the LHR in fetuses with CDH is a reliable and powerful predictor of survival to hospital discharge, although improving odds of survival may plateau at an LHR of 1.0. TO may have an independent benefit on survival to hospital discharge.
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Affiliation(s)
- R L Keller
- Department of Pediatrics and the Cardiovascular Research Institute, The Fetal Treatment Center, University of California San Francisco, San Francisco, CA 94143, USA
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Hiramoto JS, Feldstein VA, LaBerge JM, Norton JA. Intraoperative ultrasound and preoperative localization detects all occult insulinomas; discussion 1025-6. Arch Surg 2001; 136:1020-5. [PMID: 11529824 DOI: 10.1001/archsurg.136.9.1020] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
HYPOTHESIS Preoperative invasive localization procedures with intraoperative ultrasound (IOUS) can result in successful surgical treatment of occult insulinomas when noninvasive imaging study results are equivocal or negative. DESIGN Prospective study. SETTING Tertiary care university hospital. PATIENTS Thirty-seven consecutive patients with a biochemical diagnosis of insulinoma without multiple endocrine neoplasia (MEN). INTERVENTION All patients underwent portal venous sampling (PVS) (n = 22) or calcium angiogram (n = 15) followed by surgery with palpation and IOUS (n = 37). MAIN OUTCOME MEASURE Portal venous sampling, calcium angiogram, palpation, and IOUS were compared for accurate localization of insulinoma. RESULTS All patients were cured of hypoglycemia after surgery. Portal venous sampling correctly localized tumors in 17 (77%) of 22 patients. Calcium angiogram was correct in 13 (87%) of 15 patients. Palpation identified 24 (65%) of 37 tumors, and IOUS found 35 (95%) of 37 tumors. The 2 tumors missed by IOUS were located in the tail of the pancreas and were resected based on regional localization alone. CONCLUSIONS Intraoperative ultrasound is the single best localization study, but it will miss some tumors that regional localization can identify. Combining both modalities allowed surgical cure of all insulinomas in our study. Therefore, we recommend both IOUS and regional localization for insulinoma when preoperative imaging studies are equivocal.
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Affiliation(s)
- J S Hiramoto
- Department of Surgery, San Francisco Veterans Affairs Medical Center, Surgical Service (112), 4150 Clement St, San Francisco, CA 94121, USA
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Abstract
BACKGROUND/PURPOSE In the last 10 years, the ability to diagnose fetal tumors in the prenatal period has improved greatly because of technical advances in imaging. Early diagnosis and determination of tumor may affect prognosis. METHODS The authors retrospectively reviewed the records of 1316 fetuses who underwent sonographic evaluation for congenital defects at University of California-San Francisco over a 6-year period. Of these, 16 had fetal tumors and were followed up at our institution. There were solid or predominantely solid with small cystic component masses in one of 3 locations: cervical, mediastinal, or abdominal. Excluded from our study were those fetuses with either sacrococcygeal teratoma, congenital cystic adenomatoid malformation of the lung, or ovarian cyst, because these defects have been extensively reviewed elsewhere. In addition, masses that were primarily cystic also were excluded. Data collected included diagnosis, gestational age at diagnosis and at delivery, mode of delivery, fetal and neonatal survival, and disease confirmation. RESULTS Of the 16 fetuses, 4 had mediastinal tumors: 2 with pericardial teratomas (both of whom died in utero) and 2 with cardiac rhabdomyomas (1 died; the other presented tuberous sclerosis and is alive at 2 years of age). Four patients had cervical tumors (3 died; 1 survived and is alive and well), and 8 had abdominal tumors (3 with liver tumors, 4 with a left adrenal mass, and 1 with retroperitoneal teratoma). All eight patients with an abdominal tumor are alive and well. CONCLUSIONS Fetal tumors are rare, and the prognosis seems to depend on their location and size. Although easier to detect, cervical and mediastinal tumors have a worse prognosis. Abdominal masses are more difficult to detect but have a better prognosis.
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Affiliation(s)
- L Sbragia
- Fetal Treatment Center and the Department of Surgery, University of California San Francisco, CA 94143-0570, USA
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Abstract
CONTEXT Second-trimester prenatal ultrasound is widely used in an attempt to detect Down syndrome in fetuses, but the accuracy of this method is unknown. OBJECTIVE To determine the accuracy of second-trimester ultrasound in detecting Down syndrome in fetuses. DATA SOURCES English-language articles published between 1980 and February 1999 identified through MEDLINE and manual searches. STUDY SELECTION Studies were included if they recorded second-trimester findings of ultrasonographic markers, chromosomal abnormalities, and clinical outcomes for a well-described sample of women. A total of 56 articles describing 1930 fetuses with Down syndrome and 130 365 unaffected fetuses were included. DATA EXTRACTION Articles were independently reviewed, selected, and abstracted by 2 reviewers. Discrepancies in data abstraction were resolved by consensus with a third reviewer. Overall estimates of sensitivity, specificity, and positive and negative likelihood ratios were calculated for the following markers: choroid plexus cyst, thickened nuchal fold, echogenic intracardiac focus, echogenic bowel, renal pyelectasis, and humeral and femoral shortening. Results were stratified by whether markers were identified in isolation or in conjunction with fetal structural malformations. DATA SYNTHESIS When ultrasonographic markers were observed without associated fetal structural malformations, sensitivity for each was low (range, 1%-16%), and most fetuses with such markers had normal outcomes. A thickened nuchal fold was the most accurate marker for discriminating between unaffected and affected fetuses and was associated with an approximately 17-fold increased risk of Down syndrome. If a thickened nuchal fold is used to screen for Down syndrome, 15 893 average-risk women or 6818 high-risk women would need to be screened for each case of Down syndrome identified. For each of the other 6 markers, when observed without associated structural malformations, the marker had marginal impact on the risk of Down syndrome. Because the markers were detected in only a small number of affected fetuses, the likelihood of Down syndrome did not decrease substantially after normal examination findings (none of the negative likelihood ratios were significant). CONCLUSIONS A thickened nuchal fold in the second trimester may be useful in distinguishing unaffected fetuses from those with Down syndrome, but the overall sensitivity of this finding is too low for it to be a practical screening test for Down syndrome. When observed without associated structural malformations, the remaining ultrasonographic markers could not discriminate well between unaffected fetuses and those with Down syndrome. Using these markers as a basis for deciding to offer amniocentesis will result in more fetal losses than cases of Down syndrome detected, and will lead to a decrease in the prenatal detection of fetuses with Down syndrome.
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Affiliation(s)
- R Smith-Bindman
- Department of Radiology, University of California, San Francisco, 1600 Divisadero St, San Francisco, CA 94115, USA.
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Bredella MA, Feldstein VA, Filly RA, Goldstein RB, Callen PW, Genant HK. Measurement of endometrial thickness at US in multicenter drug trials: value of central quality assurance reading. Radiology 2000; 217:516-20. [PMID: 11058654 DOI: 10.1148/radiology.217.2.r00nv34516] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the value of central quality assurance (QA) reading of transvaginal ultrasonographic (US) images obtained to measure endometrial thickness and to assess image quality. MATERIALS AND METHODS Results of 2,000 US examinations performed in 1,000 subjects during one of two multicenter drug trials were evaluated. Endometrial thickness was measured at the study site; images were then sent to the QA center, where an experienced sonologist evaluated endometrial thickness and image quality. RESULTS In 360 (18%) of the 2,000 examinations, image quality was insufficient for central QA reading. Repeat examinations were requested, and suggestions for improvement in technique were provided. In 349 (97%) of the 360 examinations, repeat US images were of acceptable quality. In 99 (5%) of the 1,989 examinations in which endometrial thickness was measured, central measurement of thickness differed by more than 2 mm from that of the site. In a group (n = 300) that was followed up for 1 year, requests for repeat US examinations decreased from 24% at baseline to 11% at 1 year. CONCLUSION Central QA reading provides a consistent evaluation of endometrial thickness on US images obtained in multicenter drug trials and helps to ensure the acquisition of high-quality transvaginal US images. It further leads to demonstrable improvement in site performance.
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Affiliation(s)
- M A Bredella
- Department of Radiology, University of California, San Francisco, 505 Parnassus Ave, Suite M-392, San Francisco, CA 94143-0628, USA.
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Machin GA, Feldstein VA, van Gemert MJ, Keith LG, Hecher K. Doppler sonographic demonstration of arterio-venous anastomosis in monochorionic twin gestation. Ultrasound Obstet Gynecol 2000; 16:214-217. [PMID: 11169284 DOI: 10.1046/j.1469-0705.2000.00231.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Arterio-venous connections, which are known to occur in monochorionic twin placentae and are a mechanism for the development of twin-to-twin transfusion syndrome, can be demonstrated in utero by means of targeted sonography with the use of spectral and color flow Doppler techniques.
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Affiliation(s)
- G A Machin
- Departments of Genetics and Pathology, Permanente Medical Group, 280 West MacArthur Blvd, Oakland, CA 94611-5693, USA
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Feldstein VA, Machin GA, Albanese CT, Sandberg P, Farrell JA, Farmer DL, Harrison MR. Twin-twin transfusion syndrome: the 'Select' procedure. Fetal Diagn Ther 2000; 15:257-61. [PMID: 10971077 DOI: 10.1159/000021018] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Twin-twin transfusion syndrome (TTTS) is associated with a high risk of perinatal morbidity and mortality. The condition results from intertwin vascular connections in the shared placenta. We report here a case of early, severe TTTS that failed to respond to serial amniocenteses and that was successfully treated by means of superselective laser coagulation. METHODS A causative arteriovenous anastomosis was identified by means of prenatal obstetrical sonography, using color and spectral Doppler techniques. At fetoscopy, performed at 23 weeks' gestation, laser occlusion of only this connection was achieved. RESULTS This therapeutic intervention resulted in rapid resolution of all evidence of TTTS and a successful pregnancy outcome, with subsequent delivery of 2 healthy infants at 33 weeks' gestation. CONCLUSIONS The potentially fatal pathophysiology of TTTS was reversed by interruption of a single arteriovenous connection. We have termed this the sonographically evaluated, laser-endoscopic coagulation for twins ('Select') procedure.
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Affiliation(s)
- V A Feldstein
- Fetal Treatment Program and Department of Radiology, University of California, San Francisco, Calif. 94143-0628, USA.
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Lopoo JB, Paek BW, Maichin GA, Lipshutz GS, Jennings RW, Farmer DL, Sandberg PL, Feldstein VA, Filly RA, Farrell JA, Harrison MR, Albanese CT. Cord ultrasonic transection procedure for selective termination of a monochorionic twin. Fetal Diagn Ther 2000; 15:177-9. [PMID: 10782005 DOI: 10.1159/000021001] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Placental vascular communications can present a life-threatening problem in monochorionic twins when one fetus has a lethal anomaly. Although selective feticide is the best option for salvaging the normal twin, techniques normally employed (i.e. intracardiac potassium, air embolism) are not prudent given the common circulatory system. Furthermore, in monoamniotic, monochorionic twin gestations it is important to transect the umbilical cord completely to prevent entanglement of the dead fetus around the cord of the normal twin. We present two cases of monochorionic twins in which the cords were transected with a harmonic scalpel under ultrasonic guidance via one trocar. The harmonic scalpel is an instrument which can simultaneously coagulate and cut blood vessels or tissues. The cord ultrasonic transection procedure is a novel, minimally invasive technique which offers several advantages over the methods currently used for selective feticide in discordant monochorionic twin gestations.
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Affiliation(s)
- J B Lopoo
- The Fetal Treatment Center, University of California, San Francisco, Calif., 94143-0570, USA
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Abstract
BACKGROUND A subset of fetuses with sacrococcygeal teratoma (SCT) develops hydrops caused by high-output heart failure. Identification of fetuses at risk for hydrops is important because fetal intervention may reverse the pathophysiology of the disease. To date, no reliable sonographic prognostic factors have been identified. METHODS An experienced sonologist reviewed the sonographic records of 17 fetuses with SCT referred to the authors' institution. Size of the tumor was measured and corrected for fetal size. The appearance of the tumor (solid versus cystic) and its vascularity were graded on a subjective scale of 1 to 5. RESULTS Only 4 of 12 fetuses that had hydrops survived; of the survivors, 3 had undergone fetal intervention. All nonhydropic fetuses survived. Fetuses with hydrops had tumors that were mainly solid and highly vascular, whereas nonhydropic fetuses had predominantly cystic tumors with comparatively less vascularity. There was no significant difference in tumor size between these 2 groups. CONCLUSIONS Fetuses with SCT that are mainly solid in appearance and are highly vascularized have a higher risk of getting hydrops in utero. Tumor size is not an independent prognostic factor.
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Affiliation(s)
- B Westerburg
- Department of Surgery, University of California, San Francisco 94143-0570, USA
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Abstract
Venous thromboembolism (VTE) is a common disorder that is difficult to diagnose clinically but carries significant morbidity and mortality if untreated. Additionally, although demonstrated to be of benefit in cases of proven deep vein thrombosis (DVT) and pulmonary embolism (PE), anticoagulation therapy is not without risk. Because the clinical exam is known to be unreliable for the detection of both DVT and PE, many imaging modalities have been used in the diagnostic imaging algorithm for the detection of VTE, including chest radiography, ventilation/perfusion (V/Q) scintigraphy, pulmonary angiography, and recently, spiral computed tomography (CT) and magnetic resonance imaging (MRI). Chest radiographic findings in acute PE include focal oligemia, vascular enlargement, atelectasis, pleural effusions, and air space opacities representing pulmonary hemorrhage or infarction. The chest radiograph can occasionally be suggestive of PE but is more often nonspecifically abnormal. The main use of the chest radiograph in the evaluation of suspected PE is to exclude entities that may simulate PE and to assist in the interpretation of V/Q scintigraphy. Lower extremity venous compression ultrasonography (CU) is both sensitive and specific for the diagnosis of femoropopliteal DVT, and the value of negative CU results has been established in outcomes studies. However, the reliability of CU for the detection of isolated calf vein thrombosis is not well established, and the clinical significance of such thrombi is debatable. Additional methods such as color and spectral Doppler analysis are also useful in the diagnostic evaluation of DVT but are best considered as adjuncts to the conventional CU examination rather than as primary diagnostic modalities themselves. Compression ultrasonography and Doppler techniques are useful in the evaluation of suspected upper extremity DVT; spectral Doppler waveform analysis is particularly useful to assess for the patency of veins that cannot be directly visualized and compressed with conventional gray-scale sonography. V/Q scintigraphy has been the initial modality obtained in patients suspected of PE for a number of years. Although many studies have investigated the role of V/Q scintigraphy in the evaluation of VTE, the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study has provided the most useful information regarding the utility of V/Q scintigraphy in this setting. A high probability scan interpretation is sufficient justification to institute anticoagulation, and a normal perfusion scan effectively excludes the diagnosis of PE. A normal/near normal scan interpretation also carries a sufficiently low prevalence of angiographically proven PE to withhold anticoagulation. Although the prevalence of PE in the setting of low probability scan interpretations is low and several outcomes studies have demonstrated a benign course in untreated patients with low probability scan results, patients with inadequate cardiopulmonary reserve do not necessarily have good outcomes. Such patients deserve more aggressive evaluation. Patients with intermediate probability scan results have a 20% to 40% prevalence of angiographically proven PE and thus require further investigation. The radionuclide investigation of DVT includes such techniques as radionuclide venography and thrombus-avid scintigraphy. Although these methods have not been as thoroughly evaluated as CU, studies thus far have indicated encouraging results, and further investigations are warranted. Pulmonary angiography has been the gold standard for the diagnosis of PE for decades. Studies have indicated that angiography has probably been underutilized by referring physicians for the evaluation of suspected PE, likely because of the perception of significant morbidity and mortality associated with the procedure. (ABSTRACT TRUNCATED)
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Affiliation(s)
- M B Gotway
- University of California-San Francisco, USA
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17
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Abstract
PURPOSE To determine the diagnostic performance of specific ultrasonographic (US) features in discriminating endometriomas from other adnexal masses. MATERIALS AND METHODS Two sonologists independently reviewed the sonograms of 252 adnexal masses in 226 women and recorded US features by using a standardized checklist. The diagnostic performance of specific US features and overall reviewer impression in discriminating endometriomas from other adnexal masses were evaluated. RESULTS There were 40 endometriomas. Diffuse low-level internal echoes were present in 38 (95%) endometriomas and 40 (19%) nonendometriomas (positive likelihood ratio, 5). The positive likelihood ratio for the diagnosis of endometrioma increased to 8 if masses with neoplastic features at gray-scale US were excluded, allowing identification of 30 endometriomas (75%). The presence of multilocularity or hyperechoic wall foci further increased the positive likelihood ratio to 48, allowing the identification of 18 endometriomas (45%). CONCLUSION An adnexal mass with diffuse low-level internal echoes and absence of particular neoplastic features is highly likely to be an endometrioma if multilocularity or hyperechoic wall foci are present. A patient with a mass with diffuse low-level internal echoes and other US features may benefit from additional imaging.
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Affiliation(s)
- M D Patel
- Department of Radiology, University of California, San Francisco, USA
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18
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Wilkinson CC, Albanese CT, Jennings RW, Feldstein VA, Goldberg JD, Baehner FL, Farrell JA, Peacock WJ, Harrison MR. Fetal neurenteric cyst causing hydrops: case report and review of the literature. Prenat Diagn 1999; 19:118-21. [PMID: 10215067 DOI: 10.1002/(sici)1097-0223(199902)19:2<118::aid-pd478>3.0.co;2-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Routine prenatal ultrasound revealed a unilocular cystic mass associated with upper thoracic hemivertebrae that grew to 6 cm at 28 weeks and was associated with hydrops. A thoraco-amniotic shunt decompressed the cyst and resolved the hydrops, but the shunt occluded 17 days later. Preterm labour led to vaginal delivery at 31 2/7 weeks. Postnatally, the cyst was decompressed by thoracentesis due to respiratory distress. It was resected on day four of life. Severe tracheobronchomalacia was present post-operatively, presumably due to prenatal mass effect of the cyst. At one year of age, the child has recovered completely without adverse respiratory or neurological sequelae.
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Affiliation(s)
- C C Wilkinson
- Fetal Treatment Center, University of California, San Francisco 94143-0570, USA
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19
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Abstract
We observed that the fetal brain demonstrates relatively increased echogenicity of the basal ganglia compared with the thalami and cortical brain parenchyma, which we did not observe on neonatal sonograms. We hypothesized that the difference in relative echogenicity was due to differences in imaging techniques and anisotropic effects for prenatal and postnatal brain images. In 18 consecutive neonates, we obtained coronal images of the basal ganglia and thalami through the anterior fontanelle and axial images through the anterolateral fontanelle with both 5 and 7.5 MHz transducers. Two observers determined whether increased echogenicity or conspicuity of the basal ganglia was present, comparing the axial and coronal planes. We observed relatively increased echogenicity of the basal ganglia in the axial plane in 11 of the 16 examinations in this series. Of these 11, the increased echogenicity effect was manifest only in the axial plane in seven neonates. In the four instances in which the increased basal ganglia echogenicity was seen in both the coronal and axial planes, the effect was better shown in axial plane in all four. We did not observe any cases of increased echogenicity of the basal ganglia only in the coronal plane. The increased echogenicity was more conspicuous with the lower frequency transducer in 10 of the 11 examinations. We believe that the change in echogenicity of the basal ganglia is predominantly an anisotropic effect. Observing that increased echogenicity of the basal ganglia can disappear or decrease when comparing images in the axial to the coronal plane or be better demonstrated with lower frequency transducers might be a means by which to distinguish this phenomenon from true pathologic processes of the neonatal brain.
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Affiliation(s)
- V S Ashraf
- Department of Radiology, University of California, San Francisco, 94143-0628, USA
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20
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Smith-Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M, Brand R, Grady D. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 1998; 280:1510-7. [PMID: 9809732 DOI: 10.1001/jama.280.17.1510] [Citation(s) in RCA: 378] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Postmenopausal vaginal bleeding is a common clinical problem. Endovaginal ultrasound (EVUS) is a noninvasive diagnostic test that may help determine which women should undergo endometrial biopsy. OBJECTIVE To determine the accuracy of EVUS in detecting endometrial disease in postmenopausal women with vaginal bleeding according to hormone replacement use. DATA SOURCES Literature search of English-language and non-English-language articles published from 1966 through November 1996 using MEDLINE and by a manual search of bibliographies of published articles. STUDY SELECTION Studies were included if they prospectively collected EVUS measurements of endometrial thickness prior to obtaining endometrial tissue for histologic evaluation in postmenopausal women with vaginal bleeding. Of 85 studies that included data on EVUS and endometrial histology, 35 were included in the meta-analysis and included 5892 women. DATA EXTRACTION Articles were reviewed and independently selected and abstracted by 2 reviewers. Disagreement was resolved by consensus. DATA SYNTHESIS The overall summary mean weighted estimates of sensitivity and specificity were calculated for thresholds of endometrial thickness from 3 to 10 mm. Using a 5-mm threshold to define abnormal endometrial thickening, 96% (95% confidence interval [CI], 94%-98%) of women with cancer had an abnormal EVUS result, whereas 92% (95% CI, 90%-93%) of women with endometrial disease (cancer, polyp, or atypical hyperplasia) had an abnormal result. This did not vary by hormone replacement use. However, the number of women with normal histology who had an abnormal EVUS result did vary by hormone replacement use. In women who were not using hormone replacement therapy, 593 (8%) with normal histological findings had an abnormal EVUS result (specificity, 92%; 95% CI, 90%-94%), whereas 1544 (23%) using hormone replacement therapy had an abnormal EVUS result (specificity, 77%; 95% CI, 75%-79%). For a postmenopausal woman with vaginal bleeding with a 10% pretest probability of endometrial cancer, her probability of cancer is 1% following a normal EVUS result. CONCLUSION Endovaginal ultrasound has a high sensitivity for detecting endometrial cancer and other endometrial disease and can reliably identify postmenopausal women with vaginal bleeding who are highly unlikely to have significant endometrial disease so that endometrial sampling may be unnecessary.
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Affiliation(s)
- R Smith-Bindman
- San Francisco Veterans Affairs Medical Center, Department of Radiology, University of California, 94115, USA.
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21
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Affiliation(s)
- J LaBerge
- Division of Hematology/Oncology, UCSF Medical Center, San Francisco, CA, USA
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22
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Albanese CT, Lopoo J, Goldstein RB, Filly RA, Feldstein VA, Calen PW, Jennings RW, Farrell JA, Harrison MR. Fetal liver position and perinatal outcome for congenital diaphragmatic hernia. Prenat Diagn 1998; 18:1138-42. [PMID: 9854721 DOI: 10.1002/(sici)1097-0223(199811)18:11<1138::aid-pd416>3.0.co;2-a] [Citation(s) in RCA: 196] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Despite advances in postnatal care, patients born with a congenital diaphragmatic hernia (CDH) suffer substantial morbidity and mortality. The present study was undertaken to determine the prognostic influence of prenatally-diagnosed liver herniation in the hemithorax in fetuses with CDH. The medical records of 48 patients evaluated for a prenatally-diagnosed left CDH were retrospectively reviewed. Patients were analysed according to the position of the liver by prenatal ultrasound; 32 fetuses had a major portion of the liver herniated into the left hemithorax ('liver up') and 16 had an intra-abdominal liver ('liver down'). Liver position was determined using colour-flow Doppler ultrasonography. There were two fetal deaths in the liver-up group and one in the liver-down group. The liver-up group more frequently required extracorporeal membrane oxygenation (ECMO) support (53 per cent) compared with the liver-down group (19 per cent). Postnatal survival was significantly less in the liver-up group (43 per cent) vs. the liver-down group (93 per cent). Fetuses with congenital diaphragmatic hernia and liver herniated into the hemithorax have a much worse prognosis than similarly afflicted fetuses without liver herniation. Prenatal ultrasonographic diagnosis of congenital diaphragmatic hernia allows for preparation for a critically ill newborn and aids in prenatal family counselling.
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Affiliation(s)
- C T Albanese
- Department of Surgery, University of California, San Francisco 94143-0570, USA.
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23
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Abstract
OBJECTIVE This study was undertaken to determine if the diagnosis of cystic teratomas of the ovary can be made by experienced sonologists using only specific associated sonographic features. MATERIALS AND METHODS Two sonologists independently reviewed the sonograms of 252 adnexal masses. For each mass, each sonologist recorded sonographic features using a standardized checklist, which included four descriptions associated with cystic teratomas. From a list of diagnostic possibilities, each reviewer chose one specific conclusion, with emphasis on achieving the highest combination of sensitivity and positive predictive value for any particular diagnosis. The sensitivity, positive predictive value, and positive likelihood ratio for the diagnosis of cystic teratoma were evaluated for each sonographic finding and for each sonologist's interpretation. RESULTS Of the 252 masses, 74 cystic teratomas were found, 55 of which showed two or more associated sonographic features. Each reviewer had a 98% positive predictive value with 85% sensitivity for the diagnosis and identification of cystic teratomas (positive likelihood ratio = 152). The positive predictive value was 100% when an adnexal mass had two or more sonographic features associated with dermoid masses. The positive predictive value for individual sonographic features associated with dermoid masses was 80% for a shadowing echodensity, 75% for regionally bright echoes, 50% for hyperechoic lines and dots, and 20% for a fluid-fluid level. CONCLUSION An adnexal mass showing two or more of the sonographic features associated with cystic teratomas can be confidently diagnosed as a cystic teratoma.
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Affiliation(s)
- M D Patel
- Department of Radiology, Mayo Clinic Scottsdale, AZ 85259, USA
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24
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Lipshutz GS, Albanese CT, Feldstein VA, Jennings RW, Housley HT, Beech R, Farrell JA, Harrison MR. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg 1997; 32:1634-6. [PMID: 9396544 DOI: 10.1016/s0022-3468(97)90471-1] [Citation(s) in RCA: 226] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Accurate prenatal prediction of outcome for fetuses who have congenital diaphragmatic hernia (CDH) is very difficult. The authors previously reported a retrospective analysis of risk factors for fetal CDH and proposed a new index of severity: the lung-to-head ratio (LHR). The authors now report a prospective study to test whether this new index predicts neonatal outcome. METHODS Fifteen patients who had left-sided CDH were sonographically evaluated at the University of California, San Francisco (UCSF) and followed prenatally and postnatally. LHR was measured at 24 to 26 weeks' gestation. Outcome variables included survival and the need for extracorporeal membrane oxygenation (ECMO). RESULTS Overall survival was 47%. LHR ranged from 0.62 to 1.86. No patient with an LHR of less than 1.0 (n = 3) survived despite ECMO, whereas all patients with an LHR greater than 1.4 survived (n = 4), one requiring ECMO. LHR values between 1.0 to 1.4 were associated with 38% survival (n = 8), 75% requiring ECMO. Overall, survivors had a mean LHR of 1.4 +/- 0.33 and nonsurvivors, 1.05 +/- 0.3 (P < .05). CONCLUSION The LHR is a useful index to help predict neonatal outcome in patients who have left-sided CDH.
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Affiliation(s)
- G S Lipshutz
- Department of Surgery, Fetal Treatment Center, University of California, San Francisco, 94143, USA
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25
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Abstract
BACKGROUND Most tubal ectopic pregnancies become symptomatic in the first trimester and rarely progress to the second trimester. Elevated maternal serum alpha-fetoprotein (MSAFP) has rarely been associated with second-trimester tubal pregnancy. We present a case of a 20-week asymptomatic tubal pregnancy identified by elevated MSAFP. CASE An asymptomatic 22-year-old woman at 20 weeks' gestation was evaluated with a targeted fetal survey for an abnormally elevated MSAFP. The ultrasound examination revealed an extrauterine gestation. The patient was taken to exploratory laparotomy, and a total salpingectomy was performed. CONCLUSION Although rare, a second-trimester ectopic pregnancy must be considered in the differential diagnosis of elevated MSAFP. A careful ultrasound scan should rule out an extrauterine pregnancy.
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Affiliation(s)
- K E Grullon
- Department of Obstetrics, University of California, San Francisco, USA.
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26
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Abstract
Fetal chest masses are rare lesions that can be detected on prenatal sonography. This report of three cases of bilateral fetal chest masses (two bilateral congenital cystic adenomatoid malformations of the lung and one case of bilateral pulmonary sequestrations) serves to emphasize the occasional occurrence of bilateral masses and the variability in prognoses.
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Affiliation(s)
- K L Maas
- Department of Radiology, University of California, San Francisco 94143-0628, USA
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27
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Laing FC, Frates MC, Feldstein VA, Goldstein RB, Mondro S. Hemobilia: sonographic appearances in the gallbladder and biliary tree with emphasis on intracholecystic blood. J Ultrasound Med 1997; 16:537-543. [PMID: 9315209 DOI: 10.7863/jum.1997.16.8.537] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The purpose [corrected] of this study is to discuss the causes and sonographic appearances of blood in the gallbladder and biliary tree. Over a 12 year period, 18 patients with hemobilia had ultrasonographic examinations at one of three hospitals. Hemobilia was categorized as traumatic (50%), spontaneous (28%), or inflammatory (22%), with coagulopathy present in half of the cases. The sonographic appearances of intracholecystic blood varied, but with the exception of a single case, masslike intracholecystic material was present. Biliary dilatation occurred in five patients, with echogenic material visible in the extrahepatic bile duct in three of these cases.
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Affiliation(s)
- F C Laing
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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28
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Patel MD, Callen PW, Mar JB, Filly RA, Goldstein RB, Feldstein VA. Evaluation of a sonographic PACS in clinical practice: analysis of technical and analytical time savings. J Ultrasound Med 1996; 15:755-762. [PMID: 8908586 DOI: 10.7863/jum.1996.15.11.755] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The aim of this study was to generate quantitative data regarding technical and analytical time savings obtained by use of an ultrasonographic PACS. Data/time cards were recorded for each patient encountered in an outpatient diagnostic ultrasound facility for a 4 week period immediately before and a 1 year period after installation of a PACS environment. Use of a sonographic PACS resulted in a per case time savings of 293 s in the technical component and 51 to 63 s in the analytical component of an average ultrasonographic examination. We conclude that use of a PACS workstation has the potential to increase productivity for both the sonographer and the radiologist.
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Affiliation(s)
- M D Patel
- Department of Radiology, University of California School of Medicine, San Francisco, USA
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29
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Feldstein VA, Patel MD, LaBerge JM. Transjugular intrahepatic portosystemic shunts: accuracy of Doppler US in determination of patency and detection of stenoses. Radiology 1996; 201:141-7. [PMID: 8816535 DOI: 10.1148/radiology.201.1.8816535] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the accuracy of Doppler ultrasonography (US) in determination of patency and detection of stenosis in transjugular intrahepatic portosystemic shunts (TIPS). MATERIALS AND METHODS Retrospective review was performed of 251 Doppler sonograms obtained in 79 patients who underwent TIPS placement. Sonograms were evaluated for (a) the presence of a spectral waveform or color flow signal within the shunt, (b) the maximum peak flow velocity (Vmax) measured at the midportion of the TIPS, and (c) the direction of intraparenchymal portal venous flow. Independent review was performed of 116 transjugular portal venograms obtained after TIPS placement. RESULTS Doppler US showed TIPS occlusion in 25 of 26 (96%) cases and confirmed patency in 192 of 193 (99%) cases. Low Vmax within the TIPS (< 50 cm/sec) correlated to a diameter stenosis of 50% or greater at angiography in 25 of 32 (78%) stenotic cases and was not present in 71 of 72 (99%) cases in which no hemodynamically significant stenosis was seen. An interval change in direction of intraparenchymal portal venous flow from hepatofugal to hepatopetal was seen in association with TIPS stenoses in all stenotic cases and was not found in 24 of 26 (92%) cases in which stenosis was not seen. CONCLUSION Doppler US allows accurate determination of TIPS patency. A Vmax of 50 cm/sec or less within the shunt and interval change from hepatofugal to hepatopetal intraparenchymal portal venous flow are reliable indicators of stenosis.
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Affiliation(s)
- V A Feldstein
- Department of Radiology, University of California, San Francisco 94143-0628, USA
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30
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Kirsch CF, Feldstein VA, Goldstein RB, Filly RA. Persistent intrahepatic right umbilical vein: a prenatal sonographic series without significant anomalies. J Ultrasound Med 1996; 15:371-374. [PMID: 8731443 DOI: 10.7863/jum.1996.15.5.371] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Umbilical venous anatomy variation is considered extremely rare. The intrahepatic persistent right umbilical vein represents one version in the spectrum of umbilical vein variations. Prior reports of a prenatally diagnosed persistent right umbilical vein suggest it is strongly associated with severe fetal anomalies including congenital heart disease and gastrointestinal malformations. Our experience contrasts with these findings. Nine cases of intrahepatic persistent right umbilical vein were identified via prenatal sonography between July 1992 and January 1994. The gestational ages of the fetuses ranged from 20 to 36 weeks. Targeted fetal surveys were performed in all nine fetuses and formal fetal echocardiograms were obtained in six. All nine infants have been delivered. In nine cases, the intrahepatic persistent right umbilical vein was an isolated observation with no abnormalities identified pre- or postnatally except one case of hypospadias. Formal fetal echocardiography was normal in all six of the fetuses studied. Given previous reports describing a high risk of congenital malformations in association with the presence of a persistent right umbilical vein, the sonographic finding of this anomaly should still prompt targeted fetal sonography and fetal echocardiography. However, our series indicates that this vascular variant may occur as an isolated abnormality and may not necessarily represent the ominous finding suggested previously.
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Affiliation(s)
- C F Kirsch
- Department of Radiology, University of California, San Francisco 94143-0628, USA
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31
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Feldstein VA, Patel MD. Doppler ultrasonography of transjugular intrahepatic portosystemic shunts. West J Med 1996; 165:56-7. [PMID: 8855690 PMCID: PMC1307546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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32
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Abstract
PURPOSE To determine whether sonograms of the liver and spleen, obtained with 5-MHz linear-array transducers, aid in detection of hepatosplenic microabscesses in patients with acquired immunodeficiency syndrome (AIDS). MATERIALS AND METHODS Abdominal sonographic examinations (n = 111) were performed in 102 consecutive patients with AIDS. A 3.5-MHz sector transducer was used in each study, with additional images of the hepatic and splenic parenchyma obtained with a 5-MHz linear-array transducer. Each study was reviewed without benefit of the 5-MHz images, and categories of the hepatic and splenic parenchyma were as follows: 1, lesions definitely present; 2, lesions possibly present; and 3, lesions absent. The 5-MHz images were subsequently reviewed, and studies were recategorized. Findings were correlated with results of pathologic examination. RESULTS The 5-MHz scans enabled identification of focal hepatic or splenic lesions in 14 of 96 studies placed in category 2 or 3 on the basis of the 3.5-MHz sector scans. CONCLUSION In patients with AIDS, 5-MHz sonograms of the liver and spleen enable detection of microabscesses not confidently identified on 3.5-MHz scans.
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MESH Headings
- AIDS-Related Opportunistic Infections/diagnostic imaging
- AIDS-Related Opportunistic Infections/pathology
- Abscess/diagnostic imaging
- Abscess/microbiology
- Abscess/pathology
- Acquired Immunodeficiency Syndrome/diagnostic imaging
- Adult
- Candidiasis/diagnostic imaging
- Candidiasis/pathology
- Female
- Humans
- Liver Diseases/diagnostic imaging
- Liver Diseases/microbiology
- Liver Diseases/pathology
- Lymphoma, AIDS-Related/diagnostic imaging
- Lymphoma, AIDS-Related/pathology
- Lymphoma, Non-Hodgkin/diagnostic imaging
- Lymphoma, Non-Hodgkin/pathology
- Male
- Middle Aged
- Mycobacterium avium-intracellulare Infection/diagnostic imaging
- Mycobacterium avium-intracellulare Infection/pathology
- Pneumocystis Infections/diagnostic imaging
- Pneumocystis Infections/pathology
- Sarcoma, Kaposi/diagnostic imaging
- Sarcoma, Kaposi/pathology
- Splenic Diseases/diagnostic imaging
- Splenic Diseases/microbiology
- Splenic Diseases/pathology
- Splenic Neoplasms/diagnostic imaging
- Splenic Neoplasms/pathology
- Tuberculosis, Hepatic/diagnostic imaging
- Tuberculosis, Hepatic/pathology
- Tuberculosis, Splenic/diagnostic imaging
- Tuberculosis, Splenic/pathology
- Ultrasonography
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Affiliation(s)
- J G Murray
- Department of Radiology, University of California, San Francisco General Hospital, USA
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33
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Creinin MD, Feldstein VA. Conservative management options for cervical pregnancy; case reports and literature review. Int J Fertil Menopausal Stud 1995; 40:175-86. [PMID: 8520618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To describe three cases of cervical pregnancy treated successfully with different conservative methods and review the literature on conservative treatment of cervical pregnancy over the last 30 years. METHODS Three patients treated conservatively for cervical pregnancy are reported. The literature regarding the conservative management of cervical pregnancy since 1965 was compiled using a MEDLINE search for articles published since 1980 and by reviewing the reference lists of published manuscripts. RESULTS Three cases of cervical pregnancy were successfully treated using methotrexate with leucovorin rescue, methotrexate without leucovorin rescue, and curettage after angiographic embolization of the right hypogastric and left uterine arteries. Review of conservatively managed cases of cervical pregnancy since 1965 indicates that medical management with methotrexate and preoperative angiographic embolization of the uterine blood supply, when appropriate, results in successful treatment without the need for transfusion. CONCLUSIONS Clinical suspicion of cervical pregnancy early in gestation with preoperative diagnosis may safely allow conservative treatment. Different clinical scenarios may preclude or limit which conservative management options are best for each case.
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Affiliation(s)
- M D Creinin
- Department of Obstetrics, University of California, San Francisco, USA
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Abstract
Between 6.5 to 10 weeks of gestation, the length of the amniotic cavity is similar to that of the embryo. It follows that by the time an amniotic sac is detectable sonographically, an embryo of equal length should also be visualized. Retrospective review of case records at our institution revealed 15 patients in whom the amnion was visualized in the absence of an embryonic pole during first trimester sonography (endovaginal and transvesical). Indications for sonographic examination included gestational age estimation, discrepant size and dates, or vaginal bleeding. The mean sac diameter for the 15 gestations ranged from 14 to 36 mm, corresponding to gestational ages of 6.1 to 9.5 weeks. Ages based on the last menstrual period ranged from 6.1 to 11 weeks. A yolk sac was identified in all cases in addition to the amniotic sac, but neither an embryo nor cardiac pulsations were observed. In 12 of the 15 cases the size of the gestational sac was greater than 16 mm, such that the absence of an embryo also met an accepted criterion for a failed pregnancy. Follow-up in all cases confirmed early pregnancy failure. In this series the demonstration of an "empty amnion" (visualization of an amnion but no identifiable embryonic pole) was always associated with pregnancy loss. The "empty amnion" sign is helpful as an additional finding confirming early pregnancy failure.
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Affiliation(s)
- K M McKenna
- Department of Radiology, University of California, San Francisco 94143-0628, USA
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Levine D, Feldstein VA, Babcook CJ, Filly RA. Sonography of ovarian masses: poor sensitivity of resistive index for identifying malignant lesions. AJR Am J Roentgenol 1994; 162:1355-9. [PMID: 8191998 DOI: 10.2214/ajr.162.6.8191998] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Current research suggests that the resistive index of adnexal masses is a sensitive measure for distinguishing between benign and malignant ovarian masses. We devised a study to determine how morphologic findings on sonograms compare with the resistive index of benign and malignant lesions. SUBJECTS AND METHODS Pelvic sonograms were obtained in 34 women with 36 adnexal masses that were likely neoplastic or non-self-limiting (such as an endometrioma). Transabdominal and transvaginal sonograms were obtained, and the resistive index was calculated. A threshold resistive index of 0.4 was used to differentiate benign from malignant lesions. Masses were characterized prospectively as probably benign or possibly malignant on the basis of their sonographic appearance. Pathologic proof was obtained for 35 masses, and one mass was diagnosed on the basis of CT findings. RESULTS Seventeen lesions were deemed probably benign, and pathologic examination showed that all 17 were benign. The resistive index was greater than 0.4 in 14 of these 17 cases. Nineteen lesions were characterized as possibly malignant. On pathologic examination, six were benign neoplasms, five were nonneoplastic masses, and eight were malignant neoplasms. The resistive index was greater than 0.4 in 10 of the 11 benign lesions. It was less than 0.4 in only two of the eight lesions that were classified as malignant on the basis of both morphologic and pathologic findings. CONCLUSION Sonography is sensitive but not specific for distinguishing between benign and malignant ovarian neoplasms. Although use of the resistive index might improve specificity in the assessment of possibly malignant lesions, reliance on this parameter is potentially misleading, as six of eight malignant lesions in this series were miscategorized on the basis of their resistive index.
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Affiliation(s)
- D Levine
- Department of Radiology, University of California, San Francisco 94143-0628
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Feldstein VA, LaBerge JM. Hepatic vein flow reversal at duplex sonography: a sign of transjugular intrahepatic portosystemic shunt dysfunction. AJR Am J Roentgenol 1994; 162:839-41. [PMID: 8141003 DOI: 10.2214/ajr.162.4.8141003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- V A Feldstein
- Department of Radiology, University of California, San Francisco 94143-0628
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Abstract
Three cases of posttraumatic, high-flow arterial priapism are reported. In each, targeted color flow sonography was performed, demonstrating the site of intracavernosal arterial-sinusoidal fistula. Two of the three lesions could only be detected with the use of color Doppler sonography, emphasizing its role in the noninvasive diagnostic imaging work-up of this disorder.
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Affiliation(s)
- V A Feldstein
- Department of Radiology, University of California, San Francisco 94143
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