Case 1:

Views are of a neurosonogram of a premature infant. Performance of neuro-sonography is an art. Combination of safety and swiftness are important. Basically it is an important examination in a preterm neonate (28 weeks and around). Examination is performed within the environment of the infant, in the incubator. Abundant warm jelly is to be applied to the region of anterior fontanelle. Examination is performed without applying deep pressure. Views consist of coronal, sagittal and parasagittal sweeps. Documentation should be methodical, ideally labelled. Essentially, information obtained depends on the window available. Ventricular system and paraventricular structures are of importance. Normally ventricular capacity is less than 50% of the bifrontal skull dimensions. Ventricular cavity is echo free, except for the choroid plexus. Periventricular parenchyma is uniform bilaterally. Foci of bleeding are seen as areas of increased echogenicity in most cases.

Case 2:

Examination demonstrates normal appearance of the neonatal kidneys. Renal cortex may be slightly echogenic. Renal pyramids are somewhat large and hypoechoic. Doppler assessment of the renal parenchyma is useful. Renal pelvis is non-dilated.

Case 3:

Neuro-sonography reveals a choroid plexus cyst on the right side. This is noted either incidentally or in association with genetic syndromes. Can be unilateral or bilateral.

Case 4: Premature neonate, depressed activity, tense anterior fontanelle.

An example of the extensive, grade 3 germinal matrix haemorrhage is shown here. Note the hyperechoic areas along the floor of lateral ventricles. Ventricle is mildly dilated. Parenchyma appears normal. Grading of the germinal matrix haemorrhage is done according to the classification of Papile.

Case 5: Premature neonate, depressed activity, tense anterior fontanelle.

Examples of neurosonogram with the grade 4 haemorrhage. Note extensive hyperechoic area replacing the left lateral ventricle, extending to the adjacent parenchyma. Complete assessment of the cerebral parenchyma is limited. Right lateral ventricle is also dilated and shows enlarged echogenic choroid plexus which could be due to choroid plexus bleed. Also, evaluation of the posterior fossa is limited.

Case 6:

Neurosonography may be an initial step for the detection and evaluation of congenital CNS anomalies. As the midline structures are well visualised in the neurosonogram, anomalies like agenesis of corpus colossum are easily detected. Also characterisation of midline cysts are better done by neurosonography. Above examples show complete agenesis of the corpus callosum. Note that there is no ‘C’ shaped band above the third ventricle. We can also notice the unusual radiating gyral pattern along the medial part of the hemispheres. Extension of examination should be done to look for hydrocephalus and additional anomalies.

Case 7:

Hydrocephalus is one common entity which is well diagnosed in the early evaluation phase by sonography. initial sonography. Final details however are obtained with an MRI examination. Above examples shows gross lateral ventricular dilatation with absent midline septum. Ventricular size can be measured at the level of the interventricular foramen and compared with the bifrontal diameter at the same level. This record can be of value for follow-up. Additionally, in this case third ventricle is dilated and fourth ventricle not visualised. This is a case of a aqueductal stenosis.

Case 8:

Some exciting diagnoses can be made on a routine neurosonogram. One such entities is detection of an intracranial mass or rarely a vascular malformation. In this instance posterior coronal views of the vintage neurosonogram reveals a cystic structure in the midline, between the posterior part of the lateral ventricles, above the vermis. Portable doppler options were not available at the time of examination. Patient was examined with contrast CT image which shows a large aneurysmal dilatation of the vein of Galen. Patient also had congestive failure due to a large shunting. Chest radiograph shows cardiomegaly.

Case 9:

Another important observation in a neonate is a relatively large adrenal gland, almost 1/3 of the renal size. They tend to become relatively smaller with time. Cortical and medullary echoes can be differentiated clearly. Also sonography is a good method of evaluation of the adrenal haemorrhage.

Case 10:

Term neonate with a distended abdomen.

Examination was performed for evaluation of the newborn with a distended abdomen. Presence of peritoneal fluid is obvious with floating bowel loops. Meconium peritonitis could be one of the causes. Notice that the renal parenchyma is more echogenic with some obscuration of the corticomedullary interface.

Case 11:

Evaluation of the kidney is the second important examination of the neonatal assessment. Important observation is to document the size and appearance of parenchyma and document the extent of dilatation of the collecting system, if any. Renal pelvises are measured in the transverse images of the kidneys, documenting the antero-posterior dimension of the dilated renal pelvis perpendicular to the plane of the renal pelvis. This process needs little imagination and persistence. If attention is not paid to the technique, documented renal pelvic measurements are inaccurate

Case 12: 6-month-old child with a distended abdomen. Gross hepatomegaly on clinical examination.

Plain radiograph of the abdomen and hepatic neurosonogram is provided. Evidence of gross hepatomegaly is evident on the plain radiography. Also, a kind of a bulge is a noted along the inferior aspect. No calcifications are noted. Sonography longitudinal images demonstrate abnormal liver parenchyma showing a heterogeneous somewhat lobulated areas. Some areas are more hypoechoic. Appearance is that of an infiltrating large mass. In this age group hepatoblastoma is the most likely possibility. CT examination, plain and the post-contrast confirm a large hepatic mass extending into both lobes. Morphological features consistent with a hepatoblastoma.

Case 13: 2 month newborn with projectile vomiting.

This Illustration demonstrates the concept of measurement of hypertrophic musculature in pyloric stenosis. Sonographic examination is often performed in a young infant (6-12 weeks) with projectile vomiting. Obtaining good quality ultrasound images are a challenge. Demonstration can be facilitated by giving the child water or sweetened water to drink before the study (drink without any effervescence). Diagrammatic representation shows the concept of how to obtain optimal measurements. Muscle thickness can be obtained from anterior as well as the posterior wall or as a combined measurement of the transverse plane. Longitudinal measurements generally made at the maximum dimensions that are available in the longitudinal axis. Elongated Lumen of the pyloric canal can be seen as single or double echogenic area separated by hypoechoic lines. Normal upper range of pyloric muscle thickness measures around 3 mm (single wall) on cross section images, 15 -17 mm in long axis, total pyloric transverse measurement is generally less than 13 mm.

Case 14:

These neuro sonography images are obtained in the 90s, with a mechanical transducer, 5 MHz frequency. Technology has greatly improved, although reasonable information was obtained in the past. What do you think is likely abnormality in the scan? This patient had a left choroid plexus bleed. Note relatively large choroid plexus in the region of glomus and adjacent left temporal temporal horn.

Case 15: Suspected metabolic disorder in a child. Renal sonography

Longitudinal sonograms of the kidneys are provided.

This illustration is regarding the strength of sonography for detection of subtle changes in the kidneys for disease detection. If you notice, there is increased echogenicity of the renal pyramids. This entity is nephrocalcinosis, not multiple calyceal calculi–as there is no distal shadowing. Several metabolic disorders can lead to nephrocalcinosis. Common entities are drug induced, milk alkali syndrome, hypercalcaemic states, hypomagnesaemia etc. Medullary sponge kidneys with microcalculi can also mimic this entity. Students may go through a large list of other entities. Also, a sonologist should look for calculi in the collecting system and urinary bladder.

Case 16: Three-month child with seizures.

Images of the coronal neurosonogram and T2-weighted MR examination provided.

Intracranial, parenchymal haemorrhages on sonography are hyperechoic, as shown in the illustration. An area of suspected hemorrhage is noted in the left frontal region. Ipsilateral lateral ventricle is somewhat larger. MR examination with the T2 weighting shows hypointense region corresponding to areas of hemorrhage.

Case 17

Sonographic images in the left adrenal region.

Examination demonstrate well-defined cystic lesion with internal echoes in the left adrenal region. Adrenal is not separately seen.. There is no colour flow on Doppler images. This is a typical appearance of a adrenal pseudocyst. Often these lesions are asymptomatic, constitute up to 40% of adrenal cysts. More often seen in the neonates, after an episode of adrenal haemorrhage. In the older children sometimes cystic neoplasms, neuroblastoma could be a differential diagnosis.

Case 18:

Sonographic examination of the gallbladder is provided in the longitudinal views. This examination is performed in supine and erect position. Guess why this examination was done? Obviously there are echogenic foci in the gallbladder in the region of the body. This could be either a calculi or echogenic polyps. Calculi often tend to move in a distended gallbladder. In this patient despite of different position, echogenic foci were fixed. Patient underwent surgery and was demonstrated to have cholesterolosis of the gallbladder.

Case 19

Patient is an 8-month-old male with direct hyperbilirubinemia, on long term intravenous alimentation. Images of the sonography of the right hypochondrium are provided.

Not a challenging diagnosis, as observations are straightforward and labelled as well. Gallbladder is distended, thin-walled. There is tortuous dilatation of the biliary ducts and the common bile duct. There is an oval, minimally echogenic density in the distal common duct. There is no distal shadowing. Hence this structure could be a bile plug or an inspissated bile in the distal common duct.

This patient underwent cholecystotomy, subsequent contrast studies provided done through the cholecystotomy situ tube. You can see the filling defect in the dilated distal common duct, partially obstructing the flow of contrast. There is a passage of contrast into the duodenum and small bowel. Following drainage and repeated irrigation, there was dissolution of the bile plug.

Case 20

30-year-old female with incontinence. Patient had a history of previous hysterectomy.

Sonographic examination of the urinary bladder is shown in multiple views. This is a very rare case wherein anatomy is clearly delineated. If you see carefully you will notice a defect in the superior aspect of the urinary bladder with adjacent outpouching filled with fluid. Defects appear to vary in size during the phases of examination. Also note that the outpouching appears to have a lining. In the post-void examination, there is no visualisation of the cystic space. However, wall structure and a slightly hyperechoic lumen is seen. This is a case of a vesico-vaginal fistula. Such a clear-cut demonstration is rarely possible on sonography. Small lesions may need a battery clinical tests, cystography and contrast MR for diagnosis.

(Prepared in colloboration with Dr Hemanth)

Case 21

A 14-year-old female had a lower right quadrant pain of 2 weeks duration. History of fever with dysuria was present. Sonographic evaluation of the right eyelid fossa are provided. What is the general impression of sonographic images?

In Young patients with the history provided, possibility of an appendicular abscess is likely. There are irregular cystic areas with the low level internal echoes noted in the right iliac fossa. When there is established abscess anatomical details of the appendix are difficult to appreciate. In e subsequent image you will appreciate a trace of free fluid in the pelvis. Also the lesion apparently abutting the urinary bladder. While evaluating the patient, we came across the plain radiography. Is it a normal radiograph?

It should be clear that there is an obvious lack of bowel loops in the right leg fossa, due to the appendicular mass . Did you see Small calcific density at the right lumbar region? This is an appendiceal calculus , located somewhat high.

Case 22

Preterm neonate, routine screening sonography performed.

You have images of the kidneys, right kidney is somewhat small, shows echogenic cortex and hypoechoic medulla. Apart from a relatively small size of this kidney can be normal for a newborn. What about the left kidney? We are seeing multiple cystic spaces in the renal fossa. Left kidney not visualized elsewhere. So the cystic spaces with the echogenic septations represent multicystic kidney(MCKD) , a dysplastic renal disease. Size of the involved kidney can be either large or small. Infantile presentation may be due to a mass in the renal area. Late onset detection can be associated with a small cystic kidney. Pathologically described as pelvic infundibular and hydronephrotic type, depending on the distribution of cysts. Involvement of multicystic changes can be global, involving the whole kidney or may be partial. Associated anomalies are plenty, including contralateral dysplasia and other renal congenital anomalies (VUR, Obstruction and a ureterocele). Multicystic kidneys have atretic ureters. Condition is non genetic, may be associated with syndromes like Zellweger syndrome Meckel Gruber syndrome and Joubert syndrome

Case 26

Sonography of the upper abdomen of a newborn child is provided. Information in the grayscale and Doppler images are straightforward. In the grayscale images there are branching hypo echoic structures in the right lobe of liver, which on colour Doppler demonstrate components of arteries and veins. Clusters of communicating vessels are seen in the liver parenchyma. There is no mass-effect or displacement of adjacent structures. There are no additional components beyond the visualised vessels. This constitutes an arteriovenous malformation. Patient did not have evidence of congestive failure or enlarged heart or liver.

This case is an example of a hepatic arteriovenous malformation without congestive failure. This can be a case report for a publication, since there are not many examples of asymptomatic hepatic arteriovenous malformations. Few reports are available of hepatic arteriovenous malformation, often presenting with congestive cardiac failure. When shunting is large, interventional procedures can be a good option for treatment. Patients are managed conservatively. I do not have the long-term followup regarding the natural evolution of this process in this patient.

Case 27

Ultrasound of inguinal scrotal region is provided. This child had a clinical presentation of painless swelling in the scrotum. Clinical diagnosis is generally simple, that of inguinal scrotal hernia. Sonography occasionally helps to confirm the diagnosis of a hernia by detecting bowel loops entering the sac. Also it confirms the position of testis in the scrotal sac. In patients with patent processus vaginalis, abdominal fluid can extend to scrotal sac. The patient has combination of fluid and bowel in the inguinal scrotal hernia. Testes were located in the scrotal sac, anatomically appeared normal.

Case 28

A 55-year-old female with leg ischaemia, underwent sonography of the lower limbs.

Routine sonography of the lower limbs for vascular assessments concentrates mostly examination performed in the supine position, and documenting the vessel distribution, patency and flow. This case is an exception for the routine. When routine sonography of the lower limb vessels show atypical pattern, either by way of abnormal vessel location distribution or unusual vessel discontinuity with subsequent reconstruction in a relatively young patient, it needs thorough scrutiny. Initial sonographic assessment of this patient was considered consistent with the sequelae of vascular occlusion. Patient underwent CT examination as the clinical suspicion required, revealed the real abnormality, persistent sciatic artery with an aneurysm in the gluteal region. Repeat sonography was able to clearly demonstrate the aneurysm. Sonography essentially is an initial screening process for vascular disease in anatomically suitable regions. CT angiogram/MR angiography or catheter angiography reveal additional, clinically relevant information about the number of aneurysms and extent of vessel changes.

Case 29

This patient had progressive jaundice with direct hyperbilirubinemia and the enlarged liver. We have sonographic examination of the upper abdomen and the additional per-operative contrast studies. On sonography liver is enlarged, demonstrated heterogenous echoes. There was no obvious dilatation of the intrahepatic radicals. Gallbladder was somewhat small and common duct was not clearly visible. In this context biliary atresia and a Alagille syndrome can be entertained. Biliary atresia presents early. at this age tends to be severe. Gallbladder may or may not be visible. On sonography often shows the cord sign. On the other hand, Alagille syndrome can present insidiously, slightly later. This syndrome is characterized by abnormal facies, hypoplasia of the biliary ducts leading to progressive hepatomegaly, cholestasis, nutritional abnormalities, and the other multisystem manifestations. This is a genetic disorder.Our patient was operated. Per-operative cholangiography done through gallbladder showed hypoplasia of the intra and extrahepatic ducts. There was free passage of contrast to the bowel loops indicated patent common bile duct..

Case 31

A 27-year-old male patient who presented with cough, hemoptysis was investigated with the sonography of the abdomen and a CT examination of the chest. CT examination was reviewed before in case Chest 67.

Examination in the right hypochondrium demonstrates a spleen located under the right dome, normal size. Right kidney appears slightly echogenic show some mild insignificant dilatation of the pelvis. Presence of minimal right basal pleural fluid is noted. Examination in the epigastric and left hypochondriac region revealed a large vessel traversing vertically from the left renal hilar area to the atrium, mimicking left inferior vena cava. Liver was located in the central abdomen predominently extending to the left side. Hepatic veins show normal relation with inferior vena cava. Doppler flow revealed cephalic flow towards the venous atrium. Left kidney is normal. Now if you recall observations of the CT, overall findings are consistent with interrupted left inferior vena cava with additional azygos continuation. Inferior vena cava could not be demonstrsted below the level of renal veins. Findings are part of the heterotaxy syndrome with interrupted left inferior vena cava.

Case 32

This is patient, young hypertensive evaluated with Doppler examination of the kidneys. He also had plain radiography and an MR angiography. These images are illustrated in case 46 under CV section.

There are many observations in the US and Doppler examination. Significant change in the caliber of abdominal aorta in the upper and the lower part. Some transition to reduction in caliber normally occurs after the origins of the renal and mesenteric arteries. In this case this discrepancy appears very evident. Secondly, the right kidney demonstrates dilated renal pelvis. Both renal sizes appear normal. In the Doppler examination, technically optimal examination was possible on the right side, which loe PSV and spectral broadening. Doppler parameters are as follows: PSV 40cm/sec, ED 14 cm/sec, TA Max 25.4cm/sec, PI 1.2, RI 0.65. Limited information is available on the left side, with the low PSV and spectral broadening, PSV 35cm/sec and ED 20 cm/sec. Doppler observations were not classical for renal artery stenosis, partly contributed by suboptimal study.

Sonographic findings and classical studies can lead to the correct diagnosis. Technical precision and consistency is very important. Sonographic observation of importance in a typical case are shown below

(Radiologic Assessment of Native Renal Vasculature: A Multimodality Review. Sayf Al-Katib, Monisha Shetty, Syed Mohammad A. Jafri, and Syed Zafar H. Jafri RadioGraphics 2017 37:1, 136-156)

Case 33

Series of the sonographic images are provided in a 5-year-old patient with abdominal pain and vague mass. Though interpretation of sonography in static images has limitations, present examination does reveal soft tissue density in most of the central abdomen with echogenic areas interspersed between the soft tissue densities. The impression was that of large ,matted, bowel related mass involving the number of loops. Also, there are somewhat lobulated large soft tissue densities in the central and lower abdomen. Lesions were not very vascular. Kidneys appeared normal. Traces of peritoneal fluid are noted in the pelvis. Liver and spleen were normal. Urinary bladder showed debris inside. On sonography the impression was that of a bowel related mass with possible abdominal lymphadenopathy. CT examination revealed grossly thickened small bowel loops due to lymphoma, constituting a mass.

Case 34

A 2-month-old neonate with the abdominal mass is evaluated with an ultrasound, CT, and MRI examinations.

This is an old case; you can see that by sonography images. However, it shows something interesting in this neonate. There is an oblong, tortuous cystic structure just anterior to the kidney in the hepatic hilum. There is an additional cystic structure anteriorly. Common bile duct was not separately visualised in the extrahepatic part, whereas mild dilatation of the proximal intrahepatic duct was noted. A diagnosis of choledochal cyst was considered. The rest of the examination is somewhat easy to interpret. CT and MR examination demonstrated a large hugely dilated cystic structure replacing the common bile duct. Gallbladder is seen wrapping anteriorly. Dilatation is seen extending almost up to the head of pancreas distally and hepatic hilum proximally. There are no calculi nor any areas of pathological enhancement. This is a classic manifestation of type I choledochal cyst. Patient was operated on. On the per-operative contrast examination, a large choledochal cyst is seen with no free passage of a contrast into the bowel. Small overhanging structure on the right side is the gallbladder.

Choledochal cyst present in early life. It has a strong female predominance. Associated anomalies like. Biliary atresia and hepatic fibrosis may be seen. Anomalies of the biliary pancreatic distal ducts are often seen in association. There are many classifications based on the morphology.

Commonly accepted classification currently is one devised by Todani et al. (Radiopedia)

type I: most common, accounting for 80-90% ¹ (this type can present in utero)

• Ia: dilatation of extrahepatic bile duct (entire)

• Ib: dilatation of extrahepatic bile duct (focal segment)

• Ic: dilatation of the common bile duct portion of extrahepatic bile duct

• type II: true diverticulum from extrahepatic bile duct

• type III: dilatation of extrahepatic bile duct within the duodenal wall (choledochocoele)

• type IV: next most common

  • IVa: cysts involving both intra and extrahepatic ducts

  • IVb: multiple dilatations/cysts of extrahepatic ducts only

• type V: multiple dilatations/cysts of intrahepatic ducts only (Caroli disease)

• type VI: dilatation of cystic duct.

Complications

• Stone formation: most common

• Malignancy : cholangiocarcinoma

• Cyst rupture leading to bile peritonitis ( in a large cysts with neonatal presentation)

• Pancreatitis

(Radiopedia)

Case 35

Male Infant of 2 months old had a palpable lower abdominal swelling. Sonography and CT imaging was performed. Sonographic observations are simple, in the form of a unilocular cystic lesion in the right lumbar region, measuring approximately 4.5 x 3.5 cm. It extended from the lower pole of the kidney to the pelvis. There was a perceptible wall, not showing a typical layered appearance. Possibilities of the duplication cyst or an mesenteric cyst was entertained. CT examination showed a well-defined cystic lesion in the right lumbar region anterior to the colon. There was a perceptible uniformly enhancing wall. Secondary displacement of bowel loops was noted. Diagnosis of duplication cyst was made and was confirmed at surgery.

Duplication cysts of the bowel are often seen before the age of 2 years. It might involve partial or complete doubling of the bowel. 80% cystic and tubular variety. They may be asymptomatic or can present with bowel obstruction or bleeding

Case 36

This patient,7-yr.-old male had an abnormal appearance of the abdomen and absence of the testis in the scrotum. You have been provided with sonographic images and IVU. Other studies are available in GU system( case 64 ) Please go through all the images and see whether you can suggest a diagnosis.

To start with there is a very bizarre appearance of the left kidney with a hugely dilated baggy renal pelvis. Right kidney appeared normal. Urinary bladder was elongated slightly thick-walled. Small outpouchings are also noted in the urinary bladder.(Not shown in the illustration). On intravenous urogram. the dilated left renal pelvis is confirmed. Right renal collecting system shows mild dilatation. Anatomy of the calyces, however, not very well shown. Ureters are tortuous, laterally oriented. Urinary bladder showed near normal capacity, with a slightly irregular outline. Diagnosis?

Case 37

A 10-year-old, male patient had a mild painless swelling in the right parotid region. Patient was evaluated with sonography and CT scan.

Most information is available on sonography, there is a slightly heterogeneous,hypoechoic, well-defined superficial lesion in the parotid gland with a slightly bulging contour. On Doppler assessment there was vascularity in the central part of the lesion. Power doppler options were not available at the time. Based on sonography what are the likely differential diagnosis? In tthis context we can consider haemangioma, a lymph node or a rare benign salivary tumour. Intraparotid lymph nodes are fairly common observations, size may vary. If you notice this patient has grossly enlarged adenoids, it might indirectly give a clue to the reactive lymph node in the parotid gland..Histological confirmation is needed.

Case 38

Sonography of the newborn with a large head is provided in the coronal, sagittal and parasagittal planes. This examination allowed me to make a diagnosis of agenesis of the corpus callosum in association with a midline cyst. You can notice. In the most frontal coronal image that lateral ventricles are somewhat separated, shows minimal dilatation. Visualised third ventricle is relatively high. In the corresponding sagittal doppler image, you notice a vertically oriented anterior cerebral artery. Corpus callosum is not visualised. Additionally, there are cystic structures separated by thin septation - combined picture of dilated lateral ventricle in association with midline cystic lesion. The posterior, coronal images, additionally demonstrates a large defect in the cerebral parenchyma on the left side, creating an open communication with the extracerebral CSF spaces (schizencephaly) Posterior fossa structures are somewhat compressed with non-visualised fourth ventricle. Neuro-sonography, when performed meticulously, provides very important clues to the intracranial anomalies. Though this exercise appears academic in view of the availability of MRI, nevertheless, provides great satisfaction to the sonographer when the correct prediction is made. Representative MR images are shown, confirming agenesis of the corpus callosum, dorsal midline cyst and associated gross schizencephaly in the parietotemporal area.

Case 43 : 2-yr-female with abdominal pain and jaundice.

Case 44

Sonographic images of the brain in the sagittal, parasagittal and coronal plane are provided. Preterm neonate was investigated for brain changes as the patient was on prolonged respiratory support. This is an interesting example of a cystic periventricular leukomalacia. Typically, early subtle germinal matrix hemorrhages are located in the region of the caudothalamic groove. On follow-up over a period of a few days, hemorrhage resolves leaving a cystic space. This patient does have cystic spaces around the frontal horn in the region of caudothalamic groove. Frontal horns of lateral ventricles appear smaller and located medially. Additionally, there are cystic changes in the subcortical parenchyma along the medial aspect of the frontal lobes. Adjacent brain shows hyperechoic changes. This is not a very typical location for cystic periventricular leukomalacia. Classical changes are observed on the peri trigonal areas in the parieto-occipital regions. Also noticed that the extradural CSF space is somewhat wide, likely to be due to some cerebral volume loss.

Case 45

Lower dorsal and lumbar images in the sagittal and axial planes are provided in a premature child with no neurological abnormality. Basically, study provides an idea regarding normal spinal sonography. Typical indications for spinal sonography are suspected closed/skin covered spinal dysraphism.

Sagittal images are provided over the lower dorsal and lumbar spinal canal. Interfaces of skin, subcutaneous planes and posterior spinal elements are clearly visible. Spinal theca is enveloped externally by slightly hyperechoic extrathecal fat. Lumbar theca is shown as CSF containing space in which lumbar spinal cord, conus medullaris and the filum terminale are clearly visible. In the sagittal image cord shows the central canal indicated by a white arrow. Normally lumbar spinal cord does not extend below the level of L2 vertebra. Distal extent of theca can be seen up to S2 level. Smooth determination to the conus is also indicated by a triangle. More distally sagittal images provided slightly hyperechoic appearing filum terminale. Generally, filum terminale measures less than 2 mm. Mild prominence of the central canal and an occasional small cyst in relation to the terminal cord are considered normal variations. Axial images at appropriate level showed typical cross-sectional imaging appearance. Spinal cord is slightly hypoechoic, surrounded by a clear hyperechoic pial interface. Central canal is seen as a bright central dot. Surrounding the cord and cauda equina are well delineated by CSF spaces. On Doppler examination, further information can be obtained about the epidural venous plexus as shown in the color Doppler images.

Case 46

Coronal and parasagittal neurosonography images of a premature neonate with a tense fontanelle, presented. Observations are straightforward in this case. You might have noticed moderate lateral ventricular dilatation, showing intraventricular hyperechoic areas. On the right side some CSF spaces can be seen around the hyperechoic choroid plexus. Left frontal horn is completely obliterated due to intraventricular bleeding with the periventricular extension. Note the extent of parenchymal hemorrhage extending to the temporal region as well. Hemorrhage appears to be located in the choroid flexes as well as showing extension into the periventricular parenchyma. Extension into the left choroid plexus in the temporal horn is very extensive compared to the contralateral side. Since the hemorrhage is bilateral no gross midline shift is visualized. However, you can clearly note that mass-effect from the left cerebral hemisphere is more extensive, leading to right-sided inclination of the interhemispheric fissure. This is a very advanced grade 4/5 IVH.

Case 47

6-month-old child with a distended abdomen was investigated with a sonography. Subsequent plain and contrast enhanced CT examination of the abdomen is provided. Patient clinically had enlarged liver.

Evaluation for abdominal distension and suspected organomegaly are frequent indications of sonography. An idea about the common causes of gross organomegaly child should be in the mind. Metabolic disorders, infiltrative disorders, neoplastic processes like lymphoma, metastasis, cardiac failure and some rare hereditary conditions constituting most of the conditions

Sonography is vital in documenting enlargement, by size criteria appropriate for the age and excluding obvious mass lesions. Volume of the liver can be roughly estimated by formula. Volume = maximum cranio-caudal dimension x maximum latero-lateral dimension x maximum antero-posterior dimension x 0.31. CT evaluations provide more accurate volume estimation is by dedicated software. Segmental volume estimation is also possible with the detailed color coding. Diffuse hepatomegaly can be because by steatosis, storage disease (glycogen storage disease), infiltrations (lipid storage disorders, haemochromatosis etc), acute inflammation and the cardiac failure. Hyperechoic parenchymal changes are noted in hepatic steatosis, glycogen storage Disease and haemochromatosis. Hypoechoic changes may be observed in congestive failure and occasional rare malignant infiltrations. Our patient had minimally hyperechoic parenchyma. Spleen and kidneys were also mildly enlarged. Vascular structures under review are within normal limits. CT examinations confirmed the suspected sonographic observations. On biopsy patient had type 1 a Glycogen storage disease.

Case 48

Neurosonography: Coronal, parasagittal and sagittal images are provided in a premature child on ventilatory support and sepsis.

This illustration provides near normal appearance of the ventricular system. No structural congenital anomalies are shown. However, you can appreciate a minimal hyperechoic peri-trigonal parenchyma, probably either representing a normal variation or showing early changes of periventricular leukomalacia. Additionally, if you carefully observe this patient has linear hyperechoic areas in the sylvian regions. Changes are best shown on the parasagittal images, where linear hyperechoic areas are seen to diverging from Limen insulae. This represents a vascular calcification in the branches of middle cerebral artery. Dichotomous branching is clearly visible on both sides (white arrow) Doppler examination demonstrate that vessels are patent. This entity is described as the mineralizing vasculopathy. Also known by names like lenticulostriate/thalamostriate arteriopathy. This observation is seen in large number of conditions like sepsis, congenital heart disease, CMV, rubella, toxoplasma, chromosomal disorders and occasionally in normal individuals. Findings often resolves spontaneously. It is not generally associated with ischemic sequelae in the vascular territory.

Lenticulostriate vasculopathy is detected in cranial sonography in 0.4% of all liveborn neonates and 1.9–5.8% of ill neonates, Changes can be either unilateral or bilateral, with a branching, linear (strip-like), or punctate shaped pattern. Histopathological examination shows that most lenticulostriate arteries involved show thickened and hypercellular walls without fibrosis or hyalinization, but with intramural and perivascular deposition of amorphous basophilic material, iron, and calcium and signs of vessel wall damage.

A poor outcome can be expected when a severe underlying condition coexists. In the absence of known associated conditions, a good short-term prognosis is expected. Unfavorable behavioral and neurological features may become apparent in later period, hence neonatal observations of vasculopathy needs a close neurodevelopmental follow. (ref)

(Makhoul IR, Eisenstein I, Sujov P, et al Neonatal lenticulostriate vasculopathy: further characterization Archives of Disease in Childhood - Fetal and Neonatal Edition 2003;88:F410-F414.)

Case 49

Neonate with bilateral intermittent inguinal swelling was investigated with the sonographic examination. Examination of the pelvis was unremarkable showing a partially distended urinary bladder. Examination in the inguinal region revealed presence of bilateral inguinal testes. Interestingly the testes showed smooth free movement into the scrotum and inguinal region during the examination. Patent processus vaginalis, partly fluid filled, was also clearly shown in which the testis showed free movement. No bowel contents were noted. This is a case of a retractile testis.

If the baby has a retractile testis, no surgical referral is required, unless the testis undergoes secondary ascent to become an undescended testis over time. Therefore, all boys with a retractile testis should undergo an annual physical examination to ensure that the testis remains retractile or that it has descended and has not secondarily become an undescended testis.

Surgical treatment for undescended testis should be performed between 12 and 18 months of age, to maximize fertility potential and to prevent loss of germ cells. A single randomized controlled trial comparing testicular growth after orchidopexy indicated that early surgery (at nine months) was followed by catch-up testicular growth, which was not seen after late surgery (at three years) (Dave S. A four-month-old boy with bilateral undescended testes. CMAJ. 2016;188(15):1098-1099. doi:10.1503/cmaj.141015)