Ultrasound

Idiopathic Intracranial Hypertension and Optic Nerve Sheath Diameter

Lauren Ann Selame, MD^*and Zachary Risler, MD, MPH^*

DOI: https://doi.org/10.21980/J84631Issue 4:2 No ratings yet.

Optic nerve sheath diameter (ONSD) was measured via ultrasound with diameter 5.7mm on left and 6.2mm on right. In order to measure ONSD via optic ultrasound the high-frequency linear array probe (7.5-10-MHz or higher) is utilized in B-mode. The patient is positioned supine and an occlusive dressing, such as Tegaderm, is placed over a closed eyelid with copious conductive gel on top of the dressing. Being careful not to put pressure on the globe, an axial cross-sectional image of the globe is obtained. As demonstrated in the image “annotated left eye ONSD pre-lumbar puncture,” there are two main anechoic areas of the globe, the anterior chamber and the vitreous humor. These anechoic structures are separated by the hyperechoic iris, which surfaces the hyper-echoic-lined lens. At the back of the vitreous humor is the retina, which leads posteriorly into the optic nerve. The optic nerve is the hypoechoic structure posterior to the retina and surrounded by the hyperechoic subarachnoid space, which is encased by the hypoechoic dura mater. The outer edge of the hypoechoic dura matter is where the ONSD is measured.1 The user applies calipers to measure 3mm perpendicularly behind the retina along the hypoechoic optic nerve, and at this level the transverse dimensions of the ONSD are measured using calipers as shown in the images.Computed tomography (CT) of the head was performed and showed no abnormalities. Lumbar puncture was performed in left lateral decubitus position revealing elevated opening pressure of 29cm H2O. Thirty-five mL of clear cerebral spinal fluid was drained and was negative for all infectious studies. Optic nerve sheath diameter was again measured post-lumbar puncture with diameters 5.4mm on left and 5.4mm on right.

Visual EM Ophthalmology

Pericardial Clot on Point-of-Care Ultrasound

Rame Bashir, BS^*, Esther Kim, BS^*, Shadi Lahham, MD, MS^* and John C Fox, MD^*

DOI: https://doi.org/10.21980/J8ZH1TIssue 4:2 No ratings yet.

Focused assessment with sonography in trauma (FAST) scan was positive for a clinically significant pericardial effusion as evidenced by the hypoechoic fluid around the myocardium, indicated by the blue arrow in image 2. Findings are also consistent with tamponade process as evidenced by restricted expansion and collapse of the right ventricle during diastole. The hyperechoic floating structure between the pericardium and myocardium, adjacent to the right ventricle, represents a pericardial clot, indicated by the white arrow.The density of the pericardial clot differs from that of the myocardium, thus serving as an additional variable to avoid confusing this as part of the myocardial structure.

Cardiology/Vascular Ultrasound Visual EM

Arteriovenous Graft Pseudoaneurysm

Erik Madsen, MD^*, Lauren Sylwanowicz, MD^{^} and Alisa Wray, MD, MAEd^{^}

DOI: https://doi.org/10.21980/J8B06ZIssue 4:1 No ratings yet.

A bedside ultrasound of the mass demonstrated a large compressible hypoechoic structure (see purple outline) above the arteriovenous graft (see red outline). The contents demonstrated movement of fluid within the structure. This was confirmed with Doppler mode, which allowed for visualization of flow communicating between the structure and the underlying vessel, which is diagnostic for a pseudoaneurysm.

Visual EM Cardiology/Vascular

Radiolucent Foreign Body Seen on Point-of-Care Ultrasound but not on X-ray

Julian Jakubowski, DO^*

DOI: https://doi.org/10.21980/J8WS77Issue 4:1 No ratings yet.

X-rays of the foot were obtained and no radiopaque foreign body was visualized. Due to high clinical suspicion for retained foreign body, a point-of-care ultrasound was performed by applying a high-frequency linear probe at the area of discomfort. In the long axis an ovoid focus of hypoechogenicity (orange outline) is visualized. Within this finding there is a linear focus (yellow line) of increased echogenicity measuring 1 mm in diameter and 1 cm in length. On short axis view, a rectangle focus (green dot) demonstrating shadowing (blue highlight) is seen.

Ultrasound Visual EM

Brief Review of Intussusception Diagnosis and Management

Claire Thomas, MD^*, Wirachin Hoonpongsimanont, MD^*, Sara Paradise, MD^* and Mohammad Helmy, MD^{^}

DOI: https://doi.org/10.21980/J81P7FIssue 3:4 No ratings yet.

The patient’s abdominal ultrasound revealed intussusception in the right upper abdominal quadrant. The transverse ultrasound view showed a “doughnut sign” (dashed yellow line), telescoping bowel (yellow arrow), and invaginated hyperechoic mesenteric fat with crescent configuration (dashed orange line). The sagittal ultrasound view demonstrated the intussusception formed by the outer recipient bowel loop (yellow arrows), invaginated hyperechoic mesenteric fat (orange asterisks), and telescoping bowel centrally (red arrow).

Abdominal/Gastroenterology Pediatrics Visual EM

Point-of-care Ultrasound for the Diagnosis of Ovarian and Fallopian Tube Torsion

Tushank Chadha, BS^*, Maili Alexandria Drachman, MD^{^}, Michelle Bui, BS^* and Amal Shafi, BS^*

DOI: https://doi.org/10.21980/J8D06KIssue 3:4 No ratings yet.

The ultrasound video clip demonstrates a transverse view of the pelvis using the endocavitary probe. The bladder can be seen on the anterior portion of the scan (yellow arrow), while the uterus with an intrauterine pregnancy is visible posteriorly (blue arrow). The thickened appearance of the uterine wall is also indicative of pregnancy. A large, anechoic cystic structure measuring approximately 5 cm is seen in the vicinity of the patient’s left adnexa (pink arrow), which raises concerns for ovarian torsion.

Ob/Gyn Visual EM

Bedside Ultrasound of Retinal Detachment in a 19-year-old

Rami San Gabriel, BS^*, Maili Alvarado, MD^* and Vy Han, MD^*

DOI: https://doi.org/10.21980/J80W6TIssue 3:3 No ratings yet.

The ocular point of care ultrasound (POCUS) utilizing a high frequency linear probe shows a retinal detachment (RD) with a thick, hyperechoic undulating membrane in the vitreous humor that is anchored at the ora serrata anteriorly and the optic disc posteriorly. Note that the retina is detached all the way to the optic disc making it "mac off." The macula, and more specifically the fovea, is located in the central retina and contains a high concentration of cone photoreceptors responsible for central, high resolution, color vision. In a "mac on" RD, the retina detaches in the periphery but remains intact centrally. This is an ophthalmologic emergency and timely diagnosis and intervention can be vision saving. This patient also has evidence of a posterior vitreous hemorrhage which has a characteristic swirling appearance with kinetic exam on real-time imaging. The detached vitreous body is not as well defined and is not anchored posteriorly to the optic disc.

Ophthalmology Visual EM

The Role of Chest X-Ray and Bedside Ultrasound in Diagnosing Pulmonary Bleb versus Pneumothorax

Mohamad Moussa, MD^* and Venkat Reddy Vaddamani, BS^*

DOI: https://doi.org/10.21980/J8MP7QIssue 3:3 No ratings yet.

The patient was evaluated with bedside ultrasound for concern of possible pneumothorax. Imaging of the left lung with M-mode demonstrated a “sea shore” sign showing a wavy pattern below the pleural line caused by lung sliding as well as “comet tail” artifact caused by from the deep pleura. However, there was no lung sliding on the right shown by a lack of “comet tail” artifact and a “bar code” sign where M-mode shows straight lines throughout the image, this is caused by lack of motion below the pleura. This lack of lung sliding is consistent with possible pneumothorax or bleb. A two-view chest X-ray (CXR) revealed absent lung parenchyma in the right lung similar to a large pneumothorax (see red outline). Electronic medical record chart review revealed previous CXRs with similar findings. This patient was determined to have an acute COPD exacerbation with chronic blebs, but no pneumothorax.

Respiratory Visual EM

Fight Bite with Tendon Laceration

Michelle Chang, MD^*, Grant Wei, MD^*, Christopher J Bryczkowski, MD^*, Sha Yan, DO^* and Chirag N Shah, MD^*

DOI: https://doi.org/10.21980/J8MP7QIssue 3:3 No ratings yet.

The video shows a water bath ultrasound of the right 4th digit, demonstrating soft tissue swelling with a hypoechoic region along the tendon consistent with edema and tendon disruption (see video and annotated still image).

Orthopedics Trauma Visual EM

A Rare Cause of Pelvic Pain in a Teenage Girl

Amber Marie Hathcock, MD, MPH^*, Manish I Shah, MD, MS^*, Jennifer E Dietrich, MD, MSc^{^} and Esther M Sampayo, MD, MPH^*

DOI: https://doi.org/10.21980/J87D0WIssue 3:3 No ratings yet.

Due to pain out of proportion to her exam, an ultrasound of her pelvis was obtained and showed a blood-filled distended uterus, or hematometrocolpos (white arrow), with a 4.9 cm right ovarian cyst (blue arrow). A pelvic magnetic resonance imaging (MRI) then revealed an obstructed right hemi-vagina, normal left uterus and vagina and ipsilateral renal agenesis (red arrow) with normal left kidney (double arrow) consistent with obstructed hemivagina, ipsilateral renal agenesis (OHVIRA) syndrome. The patient underwent surgical repair with complete resolution of symptoms.

Ob/Gyn Visual EM