​Congratulations to our ultrasound of the month winner for February, Dr. Alex Varasteh!
 
Dr. Varasteh identified a case of cardiac tamponade and correctly applied his POCUS skills to obtain all of the key ultrasonographic elements to make this life saving diagnosis.
 
In addition to having a pericardial effusion, there are three major echocardiographic signs indicative of cardiac tamponade: Chamber collapse, Inflow velocity respiratory variation, and a plethoric IVC.

1. Chamber Collapse. As intrapericardial pressure increases and begins to exceed intracardiac pressure, transmural pressure gradients are reversed resulting in chamber collapse. The RA and RV are the most compliant structures so they are often the first to collapse.
   1. RA diastolic collapse is typically the first sign, however can also occur in the absence of tamponade. This will occur in enddiastole when the RA volume is minimal and pericardial pressures are maximal.
   2. RV diastolic collapse will occur in early diastole when RV volume and pressure are low. This finding is less sensitive than RA collapse but highly specific for tamponade.

2. Inflow Velocity Variation:  When blood flows into the RV during diastole there is limited expansion of the cavity due to the reversal oftransmural pressure gradients (RV early diastolic collapse). This leads to decreased RV filling and subsequent decreased LV filling and drop in stroke volume This is the cause of the  classic clinical feature of cardiac tamponade known as pulses paradoxus- a decrease in systolic BP > 10 mmHg on inspiration. Just as volumes decrease, so do velocities. These velocities can be measured with ultrasound by using pulse-wave doppler. 
Tips for measuring mitral valve inflow variation: Place the doppler gate at the tips of the mitral or tricuspid valve leaflets in the apical 4 chamber view. Slowing the sweep speed can make it easier to visualize the respiratory cycle. Measure the fastest and slowest peak velocities and compare thevalues.  Mitral valve flow variation >30%, or tricuspid flow variation >60% are indicative of cardiac tamponade.

​Congratulations to the winners of the November and December ultrasounds of the month, Drs Daniels and Kopischke! Check your mail boxes next week for a Kaldis gift card.
 
Dr. Daniels used her POCUS skills to identify a case of pyelonephritis with developing renal abscess, and Dr. Kopischke detected a classic case ofhydronephrosis  with intrarenal stones.
 
Pyelonephritis
Ultrasound findings in acute pyelonephritis are often normal. In severe or chronic infections you may see pelvic wall thickening (Image 1,black arrow) or hypervascularity identified using color doppler. POCUS is more useful in identifying complications including emphysematous pyelitis and renal abscess. Emphysematous pyelitis is caused by gas forming bacteria and will have areas of hyperechogenicity within the renal parenchyma with classic “dirty shadowing.” Renal abscess will appear as well circumscribed hypoechoic areas with internal septations (image 2, black circle)

​Nephrolithiasis and Hydronephrosis
The primary application of renal POCUS is to evaluate for obstructive uropathy by identifying the presence or absence of hydronephrosis. Hydronephrosis can be graded from mild to severe depending on the amount of dilation of the collecting system( Image 1). A common clinical indication for renal POCUS is diagnose and grade the degree of hydronephrosis in renal colic. Depending on your pretest probability, you can forgo unnecessary CT scans and urology consults which in turn can decrease ED LOS. One proposed algorithm is listed below (Image 2). You can occasionally identify intrarenal stones which appear as hyperechoic foci within the collecting system with posterior shadowing (Image below)

Author: Arthur Forbriger 
Editor: Allison Zanaboni ​

“Mac on” vs “Mac off”
 
“Mac on” refers to when the retina is still attached to the macula. This  is an ophthalmologic emergency since there are much better visual outcomes if repair can be done prior to progressing to a “Mac off” detachment. The macula is located temporally to the optic nerve, so if you see the retina attached in this region, the patient should get an urgent ophthalmology consult. “Mac off” retinal detachments, as in this case, are less urgent since visual outcomes are similar despite timing of surgery. However the patient should have ophthalmology follow-up as these all typically require repair. 

​Tips for scanning the Eye

• Start with the asymptomatic eye for comparison
• Use high frequency probe 
• Place a generous amount of gel on top of the closed lid 
• Rest the transducer gently on the gel with your hand stabilized on the patient, avoiding pressure on the globe 
• Fan through the entire globe in the transverse and sagittal planes. 
• Use the standard gain setting  to visualize posterior structures including optic nerve sheath 
• You can increase the gain to examine the vitreous. 
• Have the patient look in all directions to evaluate for pathology. 

Author: Arthur Forbriger 
Editor: Allison Zanaboni ​

Dr. Winkels diagnosed a molar pregnancy on ultrasound.  Note the 'cluster of grapes' or 'snowstorm appearance' within the uterus that is typically described.  Another finding in these images are the bilateral enlarged, cystic ovaries.  This is referred to as Hyperreactio Luteinalis, and is associated with significantly elevated bHCG (this patient >770, 000) and is seen in approximately 25% of patients with molar pregnancies. ​

Dr. Lew diagnosed Aortic Valve endocarditis on a patient who presented with vague symptoms and generalized weakness.  Her POCUS diagnosis resulted in a complete change in patient management and appropriate therapy for the endocarditis.  On the Ultrasound images, note the vegetation attached to the AV leaflets protruding into the LVOT.  ​

Here we are again!   Drum roll for August’s Ultrasound of the Monthaward, which goes to Dr. Ryan Rees! Please see the fellows for your prize.   This patient was a 62 y/o male who presented with new flashers and floaters of the right eye. Visual acuity in the affected eye was 20/70.    Dr. Rees astutely grabbed the ultrasound machine, selected the linear probe, adjusted the depth perfectly, and then cranked up the gain appropriately to get a good view into an otherwise deeply anechoic vitreous space. ​

​Clip 1 reveals a mobile hyperechoic tissue band that appears to be anchored laterally and floats above the back of the eye. Extraocular movements cause the band to “wiggle” after the eye has finished moving – a phenomenon called “after movement”. Choroidal detachment will look similar but will have very limited after movement. You’ll notice also in Clip 1 that the optic nerve is mostly not visible. The main differential diagnosis for clip 1 is retinal detachment vs. vitreous detachment (which can appear almost identical). The key differentiating factor is that thevitreous detachments do not necessarily anchor to the optic nerve and will exhibit fairly dramatic after movement for that reason (image below for reference). Clip 2 shows the retina peeling of just lateral to the optic nerve, thereby illustrating one ofthe key anchor points that help make the final diagnosis of retinal detachment. The other anchor “point” for the retina is the ora serrata (anterior margin of the retina that interfaces with the ciliary bodies).

Keep the interesting (and high quality) scans coming!
 Your Ultrasound Fellows,
Ian and Alek

Welcome to another academic year!

As your new US fellows, along with the Ultrasound Division, we would like to continue the Dr. Greenstein tradition of Ultrasound of the month.  Thanks to everyone for the great ultrasound images this past month - it was truly a challenge to pick the single best image of the month.  

The Ultrasound of the month winner for July is Dr. Kaitlin Parks.  Please see the fellows for your prize!

Dr. Parks had a great pick up of a type B aortic dissection on a patient with ESRD, HTN and a known pericardial effusion who presented with chest pain after a missed dialysis session.  Dr. Parks very appropriately performed a cardiac ultrasound.  After imaging the IVC, she noted an irregularity in the descending aorta, consistent with a dissection flap, prompting her to order a dissection protocol CT.   The CT confirmed the presence of a type B dissection originating at the distal margin of the left subclavian artery, terminating just superior to the origin of the SMA.   The patient was admitted to the ICU and was medically managed.  

The ultrasound clip below clearly demonstrates a mobile dissection flap within the lumen of the aorta.   The image appears to show the dissection flap terminating at the origin of the SMA (as read on the CT scan). 

CT scan image showing the type B dissection - note that the celiac trunk is supplied by the false lumen!

Keep up the great work!

Your Ultrasound Fellows,

Ian and Alek

CONGRATULATIONS to Dr. Jeffrey Ruggeri for March Ultrasound of the Month and CONGRATULATIONS to Dr. Arthur Forbriger for April Ultrasound of the Month!!!

Dr. Ruggeri found a large pericardial effusion in a patient with shortness of breath and was able to diagnose them with sonographic tamponade. He wisely used M-mode in parasternal long to assess for early diastolic RV collapse. The patient was admitted to the CCU and had a pericardiocentesis the following day. Strong work!
Dr. Forbriger was able to diagnose an incarcerated incisional hernia in a patient with abdominal pain and history of previous incisional hernia. Check out the attached clips! I personally have never seen ultrasound used for this clinical question but clearly it works! Notice the back and forth peristalsis of bowel contents which indicates obstruction. Dr. Forbriger was even able to capture images of the resolved hernia after manual reduction. Very cool! 

Your awards are in your mailboxes. Keep up the good work and keep the scans coming!