Abstracts: ASUM Annual Scientific Congress 2011.

Objective : The current method used to determine the quality of ultrasound imaging is based on the detection rate of fetal anomalies. This method does not provide a realistic indication of image quality as it is strongly influenced by the frequency of obstetric ultrasounds scanned by the operator. Our aim is to provide a quantitative method of assessing image quality by evaluating images of normal cases in the second trimester of pregnancy. Methods : Six trained sonographers took images of three biometrical and seven anatomical standardised ultrasound planes at 18–22 weeks gestation. A minimum of 1560 routine second trimester ultrasounds were performed over a period of six months. One hundred normal cases were randomly selected and 10 images from each case were analysed. Four experienced reviewers assessed each image with predefined criteria. The scores acquired by each reviewer were analysed to determine the reproducibility of the quantitative method in assessing image quality. Results and conclusion : This study is still in progress and statistical analysis will be presented.

Ultrasound remains a cheap and effective tool in the investigation of disorders of the liver, gall bladder, biliary tree and pancreas. Intraoperatively it has three main roles. The first is the detection and staging of small volume tumours of the liver and pancreas that are unable to be visualised with conventional pre‐operative imaging. The second is the ability to identify the major vascular and biliary structures within the liver and pancreas and their relationship to tumours planned for resection. Third, ultrasound can be used to target and monitor intraoperative ablation of hepatic tumours. With the improvements in computed tomography, magnetic resonance imaging, endoscopic ultrasound and nuclear medical imaging many of the advantages of intraoperative staging ultrasound have been superceded. A discussion of the current utility of intraoperative ultrasound will be presented and examples of its use. A discussion of the intraoperative use of transoesophageal echocardiography in trauma patients will also be presented.

The aim of a venous ultrasound examination for varicose veins is to document the presence of incompetent veins and their superficial and deep venous communications. Despite such a relatively simple purpose, the complexity of veins appearing on a given patient's leg and inconsistent anatomical terminology have caused substantial confusion and anxiety among many who perform this examination. Furthermore there still remains considerable confusion regarding the technical advantages and disadvantages of specific techniques related to augmentation of venous blood flow, patient position and the definition of significant reflux. Despite the apparent complexity and confusion surrounding this examination there have been significant advances in unifying the anatomical terminology of the veins in the leg. In addition, a careful consideration of the pros and cons of the technical execution of this test, based on the principles of blood flow and venous physiology, will help a sonographer or sonologist make an appropriate choice for a given patient. This presentation will discuss both the terminology for describing the distribution of veins in the leg and discuss the techniques at our disposal to provoke and record blood flow so that complex networks of incompetent veins can be identified and documented with greater accuracy and consistency.

In my current position in ultrasound training for the Adelaide based ultrasound company Signostics, I was required to present workshops in Milan and Paris on lung ultrasound to European Signostic distributors and pulmonary physicians. As a clinical sonographer I was used to scanning for pleural effusions but what did I know about A‐ lines, B‐ Lines, E‐lines, comet tails, sea shore signs, barcode signs, batwing signs, lung pulse and their clinical significance? I didn't think we could scan lungs due to the reflection of sound by air. I was wrong. Scanning lungs is quick, easy and informative especially to the pulmonologist, intensivist and emergency physician and is often more sensitive than chest x‐ray. An interesting study of ultrasound artifacts and their clinical applications.

In blunt abdominal trauma the spleen is the most commonly injured organ. Unrecognised injury can lead to increased morbidity and mortality. Although CT is currently the imaging study of choice for splenic injury, ultrasound is gaining acceptance because it is less expensive, less invasive and relatively portable 1 . In recent years, the development of contrast‐enhanced ultrasound (CEUS) has improved the effectiveness of ultrasound in the diagnosis of splenic trauma 1 . By using a microbubble contrast agent and contrast‐specific imaging software, CEUS is able to detect the micro‐ and macro‐circulation of the targeted organ 2 . This technology has been proven useful in visualising injury size, completeness of injury extension, involvement of organ capsule and active bleeding within the traumatic spleen 3 . This paper will discuss the current standards of practice in splenic trauma imaging and review several cases performed at Royal Perth Hospital.

Well established guidelines exist for routine imaging of the fetal heart at the mid trimester fetal anomaly scan. However significant cardiac detail can be obtained at the time of nuchal translucency assessment at the 12‐week ultrasound. In nearly all patients it is possible to demonstrate four chambers, outflow tracts and a modified three‐vessel view. This poster will demonstrate the routine views that can be acquired of the fetal heart during the 12‐week ultrasound. It will show normal heart anatomy in both 2D and colour Doppler modes. The 12‐week examination is not as extensive as the 20‐week assessment; however there is evidence that we can detect many major cardiac abnormalities at this gestation. Early detection of cardiac anomalies facilitates patient management. This includes testing for aneuploidy, including 22q micro deletion, referral to paediatric cardiologist, and earlier counselling. Patients with a past history of major cardiac defects may feel some reassurance if the heart is developing as expected at the 12‐week stage. Therefore we believe that the 12‐week fetal heart assessment should be viewed as an easily achievable adjunct to early fetal assessment.

Ligament injuries around the ankle and the mid foot are among the most common sporting injuries. In ankle sprains, US is an excellent alternative to MR imaging to diagnose ligament injuries that affect this body area. The examination should be focused on clinical findings in an attempt to save time and increase the efficacy of the study. On the lateral aspect of the ankle, ligament injuries are usually secondary to inversion sprains. Injured ligaments may appear swollen with focal or diffuse hypoechoic areas. In complete tears, a hypoechoic gap reflecting the hematoma is seen within the ligament substance and the free ends of the torn ligament may appear retracted and wavy. Anterior talofibular ligament ruptures are usually associated with capsular breakage and passage of joint fluid into the anterolateral soft‐tissues of the ankle, whereas complete tearing of the calcaneofibular ligament may result in communication between the ankle joint and the peroneal tendon sheath. Because the intact calcaneofibular ligament tightens during dorsiflexion and pushes the peroneal tendons toward lateral, this manoeuvre can help to assess whether the ligament is torn. During scanning, stress e.g. (anterior drawer) tests can be helpful to assess ligament injures and joint instability. US has shown accuracy in the evaluation of anterior tibiofibular ligament tears. Isolated ruptures of the medial ligamentous complex of the ankle are rare. When the deltoid ligament ruptures US can be helpful to differentiate a ligament injury from a lesion of the overlying tibialis posterior, both conditions presenting with similar clinical symptoms over the medial ankle. In the mid foot, the spring ligament is a complex ligament which has its main function in supporting the head of the talus and stabilising the longitudinal arch of the foot. It consists of a superomedial calcaneonavicular, a medioplantar oblique and an inferoplantar component. From the biomechanical point‐of‐view, the first one is the most relevant and is amenable to US examination. Other midtarsal ligaments possibly involved in lateral ankle sprains are the dorsal talonavicular ligament, which joins the dorsal capsule of the talonavicular joint, and the dorsal calcaneocuboid ligament, lying over the lateral aspect of the calcaneocuboid joint. The injury of these ligaments is often associated with avulsion of a small fleck of bone. Finally, the bifurcate (Chopart) ligament is a strong “Y‐shaped” band consisting of a calcaneocuboid and a calcaneonavicular component. It may play a causative role in anterosuperior process calcanear fractures.

Assessment of the lateral cerebral ventricles is part of the midtrimester anomaly scan. The mean measurement of ventricular width is 6–7 mm. Measurements ≥ 15 mm are classified as severe ventriculomegaly and are associated with a poor prognosis. Approximately 0.7% of all fetuses will have at least one of the ventricles measuring between 10 and 15 mm and are said to have mild ventriculomegaly. While most of these fetuses will have a normal outcome, mild ventriculomegaly carries an increased risk of underlying chromosomal anomalies, congenital infections and developmental brain anomalies. Counselling parents in this scenario poses a significant challenge to the sonologist, and to the clinician, as some of these diagnoses will not be evident at the time of the initial scan. In this lecture we discuss definitions/terminology in this area, frequency of associated pathology and perinatal outcomes of mild ventriculomegaly. We will discuss a rational management plan for these pregnancies including the use of fetal MRI.

Objectives : To evaluate the additive value of ultrasound elastography (UE) to BI‐RADS for the differentiation of benign and malignant breast small lesions. Methods : Breast masses (≤ 2cm) with histological diagnosis examined by ultrasonography and UE in our department from April 2004 to December 2009 were reviewed. Conventional B‐mode ultrasound findings were classified according to the BI‐RADS classification. UE findings were classified according to the five‐point scale. Histological diagnosis was used as the reference standard. Results : 401 (246 benign, 155 malignant) from 370 consecutive patients were included in the study. Sensitivity and specificity were 90.3%, 68.3% for BI‐RADS; 72.3%, 91.9% for UE. The sensitivity of BI‐RADS was better than that of UE ( P < 0.05), while the specificity of UE was better than that of BI‐RADS ( P < 0.05). A revised BI‐RADS combined with UE results were proposed in this study. Sensitivity and specificity were 83.9% and 87.8% for revised BI–RADS. The diagnostic performance of revised BI‐RADS was better than BI‐RADS ( P < 0.05). Conclusions : UE could give BI‐RADS some help in the differentiation of benign and malignant small breast lesions. Revised BI‐RADS could improve the diagnostic performance.

Objective : To study the effect of live three‐dimensional ultrasound radiation on apoptosis of embryo‐cerebral cells and expression of caspase3 and caspase9 in mice with advanced pregnancy. Methods : Thirty pregnant mice were randomly divided into six groups, unexposed group, pseudo‐exposed group, 5 min‐exposed group, 10 min‐exposed group, 20 min‐exposed and 30 min‐exposed group, with five mice in each group. Exposed mice were irradiated under the system's probe for 5 to 30 min on pregnant day 16. On the 10th day after birth, the pups of each group were perfused and fixed with 4% paraformaldehyde; brain slices were made and stained with HE or terminal deoxynucleotidyl transferase‐mediated dUTP nick end labeling (TUNEL). Colorimetric method was used to measure caspase3 and 9 activity. Results : 1) TUNEL method: comparing with the un‐exposed group and pseudo‐exposed group, positive rate of apoptosis in 5 min‐exposed group had no statistically significant difference ( P > 0.05), but in 10 min‐exposed group, apoptosis positive cells were increased and the findings became remarkable in 20 min‐exposed and 30 min‐exposed groups which showed a statistically significant difference ( P < 0.01) compared with the other four groups. 2) Caspase3, 9 positive cells were detected in all groups and were remarkably increased in the exposed mice. Conclusion : Live three‐dimensional ultrasound irradiation for longer duration may result in higher Caspase3 and 9 activity that lead to excessive neuron apoptosis in fetal mouse cerebrum.

Trisomy 18 (Edward's syndrome) is associated with multiple abnormalities of many organ systems including CNS, CVS, GIT and MSK. It is also associated with early IUGR with polyhydramnios. It is generally considered to be a lethal condition either in utero or during the first year of life, hence leading to termination of pregnancy in most diagnosed cases. This is a case of mosaic trisomy 18 with multiple anomalies. Following diagnosis and subsequent counselling the patient decided to continue with the pregnancy. This offered a rare and unique opportunity to image the natural history of the syndrome prenatally and postnatally.

Patients who suffer a deep venous thrombosis (DVT) have a 25‐fold increased risk of chronic venous insufficiency (CVI). In a five‐year follow‐up study of 51 patients treated for lower limb DVT (49% proximal, 51% distal), CVI was assessed by clinical, etiologic, anatomic and pathophysiologic (CEAP) classification and reflux by Duplex ultrasound of DVT affected and unaffected limbs. After five years, moderate to severe CVI (CEAP class 4–6) was seen in 54% of proximal and 11% of distal DVT limbs. Reflux was detected in 96% of proximal DVT limbs, 36% of distal DVT limbs and in 52% of apparently unaffected limbs. This raises the question of potential haemodynamic or systemic effects on unaffected limbs. This was further examined in a prospective study of 20 patients with proximal DVT, studied at baseline, 3, 6 and 12 months. By 12 months there were 40% of DVT limbs in CEAP class 4–6 and 80% of these limbs showed reflux. None of the non‐DVT limbs were in CEAP class 4–6, but dilatation of the sapheno‐femoral junction was seen in 18/20 and four of these showed borderline reflux after six months. Similarly, we observed increases in the mean diameter of femoral and popliteal veins in unaffected limbs, suggesting a potential systemic effect of the contralateral DVT. Quantitative assessment of CVI in this population using Duplex ultrasound, and at pletysmography, showed that ultrasound indices (reflux duration, flow volume) lacked discrimination for CVI disease severity, whereas the venous filling index (VFI) determined by pletysmography gave very good discrimination. This technique now needs to be applied to further examine the potential systemic influence of a DVT on other veins.

1 Position the patient with the structure where you want the needle tip to end up pointing at the ceiling 2 Position the US screen so that you can see it comfortably 3 Position yourself so the needle is a continuation of your hands. Position the patient with the structure where you want the needle tip to end up pointing at the ceiling Position the US screen so that you can see it comfortably Position yourself so the needle is a continuation of your hands.

Large ganglia and breast cysts make the best targets for beginners.

1 Gentle, steady hands 2 Watch needle tip 3 Only the plunger of the syringe moves when you inject. Gentle, steady hands Watch needle tip Only the plunger of the syringe moves when you inject.

The purpose of this study was to list crucial sonographic findings that will be helpful for clinicians in the management of recurrent intussusception. Recurrent intussusception usually occurs at the same site and recurrent small bowel intussusception carries pathologic leading points such as polyps, tumors, infections, polyps, lymphomas, Meckel's diverticulum, duplication cyst, intraluminal hematoma, and adhesions that often lead the patient to an operation. We revised every 10 cases of recurrent intussusception that underwent pneumo‐reduction at least once in our hospital for the last three years. All except one of the cases recurred at the same site. The eight‐year‐old patient showed different manifestation while the location of intussusception was changed from ileocecal area to ileoileal area and recurred ileoileal intussusception did not have a certain pathologic leading point. The sonographic findings of ileoileal intussusception showed the new location and relatively short length of the lesion, which is less than 3.5 cm, no ascites, no proximal small bowel loop distention, and normal peristalsis. These findings could give an idea to doctors that this intussusception was not in surgical condition. We compared this extraordinary case with two others of each type of 10 intussusceptions and discussed sonographic findings of them by showing each case. Keywords: non‐surgical, recurrent, ileoileal, intussusception, sonography In the digital environment does lighting conditions have an effect on our perceptions of images? How much does it affect the quality of our images? Do we need to assess this further? Should there be a correlation between scanning room and reporting lighting conditions? Are we missing pathology? Should there be a set standard of light levels for scanning rooms? How much does it affect the quality of our images? Do we need to assess this further? Should there be a correlation between scanning room and reporting lighting conditions? Are we missing pathology? Should there be a set standard of light levels for scanning rooms? These questions were prompted by a perceived difference in images, viewed while scanning, then when reviewed in the collating area and again in the reporting offices. With the use of light meters, ultrasound phantoms and an assessment of the total gain, we defined the difference in image acquisition under differing lighting conditions. Do rooms need to be as dim? Does this affect our images? Should we also consider fatigue and eye strain? Do rooms need to be as dim? Does this affect our images? Should we also consider fatigue and eye strain? The purpose of the study was to describe the ultrasound appearances of male breast disease. Forty‐four male patients who underwent breast ultrasonography, with or without mammography, between January 2004 and December 2010 at Royal Perth Hospital were retrospectively evaluated. Results from private imaging reports for these patients were also included. Some patients had more than one diagnosis, resulting in 49 diagnoses. Thirty‐six (73.4%) diagnoses had pathological confirmation via fine‐needle aspiration (FNA), core biopsy, or surgical histopathology. The diagnoses in this series included three ductal carcinomas (6.1%), 20 cases of unilateral gynecomastia (40.8%), nine cases of bilateral asymmetric Gynecomastia (18.4%), one bilateral symmetric gynecomastia (2%), two abscesses (4%), three cases of fat necrosis (6%), one epidermal cyst (2%), one lipoma (2%), one chronic inflammation (2%), and eight cases of normal adipose tissue (16.3%). All malignant masses were detected by ultrasound, in which they appeared hypoechoic and irregular. gynecomastia appeared as retroareolar, hypoechoic, glandular tissue. The abscesses showed mixed echogenicity. Fat necrosis appeared hypoechoic with acoustic shadowing. The epidermal cyst was a well‐defined, oval‐shaped, hypoechoic lesion. The lipoma was well defined, lobulated, and hyperechoic. We concluded that ultrasonography is an essential and useful tool in the characterization of male breast disease.

This workshop will demonstrate a standard method of performing the commonly performed MSK injection procedures. Practical aspects of needle selection, syringe size/type, local anesthesia and sterility will be discussed. Techniques to ensure you can always see the needle tip will be demonstrated and there will be tips on how to perform your own quality assurance

Background : Recent studies have evaluated the fetal posterior fossa in an attempt to improve first trimester screening for open neural tube defects (NTD). Problems with fetal position and replicating imaging planes have hampered widespread application of these methods. Objective : To assess the posterior fossa using a novel imaging plane that demonstrates the aqueduct of Sylvius (AOS) and to measure the posterior fossa distance (PFD). Methods : Prospective 2D study of PFD in 57 normal fetuses. A posterior tilted transchoroidal axial image of the fetal cranium demonstrates the echogenic walls of the AOS. The PFD was measured from the posterior AOS canal to the inner occipital rim. Results : The PFD was measured in 54 of 57 fetuses (95%). PFD is positively correlated with CRL, BPD and HC. The reproducibility of the AOS to occipital measurement is dependent on the imaging plane. Further research is required to assess the usefulness of this measurement in the detection of open NTD. Intra and inter observer reliability studies are ongoing. Conclusion : Identification of the AOS appears to be a simpler method of posterior fossa assessment than previously described methods. Further research is required to assess the utility of this measurement in early screening for NTD.

1 Know the anatomy 2 Know what you are doing 3 Know why you are doing it 4 Tell the patient what you are going to do 5 Know the anatomy. Know the anatomy Know what you are doing Know why you are doing it Tell the patient what you are going to do Know the anatomy.

Aim : To review cases that underwent stereotactic‐guided core biopsy of ultrasonically occult mammographic parenchymal abnormalities in a screening population, in order to evaluate reasons for them to be obscured on sonography. Method : The database of BreastScreen Western Australia was searched, for the period January 2004 to December 2009. All cases satisfying the following criteria, a mammographic parenchymal abnormality, a negative ultrasound scan result and a biopsy under stereo guidance, were reviewed. Results : The study consisted of 469 cases accounting for 2.1% of all recalls to assessment. Histopathologically 79% of lesions were benign, 3.5% were borderline and 17.5% were malignant. Carcinomas comprised 68% invasive ductal carcinoma, 1% metaplastic carcinoma, 15% invasive lobular carcinoma and 16% ductal carcinoma in‐situ. Among invasive carcinomas there was significantly higher proportion of mucinous carcinoma accounting for 7%. The commonest lesion location was upper outer quadrants. Lesion size measured less than 15 mm in 78% of cases. Conclusion : Our study confirms that a stereotactic‐guided core biopsy needs to be performed on mammographic parenchymal abnormality suspicious of a carcinoma, regardless of a normal ultrasound scan finding. Small lesion size, localising difficulties and tumor characteristics contribute to their non‐visualisation on sonography.