The case for sonohysterography:

For some time, sonohysterography was considered essential to diagnose endometrial polyps. Until, high resolution ultrasound and endovaginal probes challenged that assumption with stunning images on routine ultrasound scan. These images by Dr. Allen Worrall, Alaska, USA, show an instance, wherein, sonohysterography may well be advisable, to confirm the presence of a doubtful polyp

A comparison of sonographic features of intrauterine contraceptive devices (IUCD’s):

The Mirena IUCD

Mirena IUCD used in USA

Copper - T, IUCD

The copper- T, IUCD used in India.

Dr. Allen Worrall, of Fairbanks Clinic, Alaska, USA has this to say about IUCD or IUDs:
The hormone-containing Mirena IUCD is quite popular in the US now. It has a somewhat different sonographic signature than other IUCDs. (in the US, IUD mostly stands for IntraUterine Device). The presence and location of the Mirena IUCD is mostly from its acoustic shadow - you tend not to see the actual echo of the device very well.

This case is interesting because as I (Dr. Allen) scanned the uterus transversely, starting at the cervix, I could see the string as a bright echo with hardly any shadow, then suddenly there was no echo but an intense shadow, representing the shaft of the IUCD. The Mirena has two curved arms at the top that are supposed to extend out when the IUCD is properly positioned. On transverse view of the upper part of the uterus I could see that the arms were properly deployed.

This patient had this IUCD or IUD only for a few weeks and was complaining of cramps and bleeding. The doctor who put the IUD in wanted to be sure it was in proper position. I reported that it was OK.

This IUD was put in place because the patient was complaining of excessively heavy menses, and the Mirena IUD, because of its hormone content often results is less bleeding. Interesting to me, who can remember when IUDs had the reputation of causing abnormal, excessive, prolonged bleeding. Now they are used to treat those symptoms.
Images courtesy of Dr. Allen Worrall and Dr. Joe Antony.

The case of the knotty cord:

The umbilical cord connects the placenta (and thus the mother) to the baby. Occassionally, the cord can get knotted, presenting a real danger to the baby, by strangulation of its lifeline. We present a case of knot of the cord, diagnosed prenatally by color doppler imaging. The post delivery snaps confirm the presence of true knot of the cord. Images courtesy of Dr. Gidda Ramaiah, India. Check this link for pics and description: http://drjoea.googlepages.com/obstetric-2

On the importance of first trimester sonography:

Dr. Allen Worrall of Alaska, USA, has this to say about the role of the early first trimesterultrasound scan. The First ultrasound always sets the gestational age. Subsequent ultrasounds determine the growth of the baby. You never change a due date based on a second or third ultrasound (assuming in all cases of course that the first ultrasound was done correctly, by someone who knows what they are doing, and using a machine that accurately makes the measurements).

Why is the first ultrasound always the most accurate in determining gestational age? Because we use the size of the baby to determine gestational age, and we do not all weigh exactly the same at birth. The closer we get to term, the more our "genetic heritage" is manifesting itself to make us small, average, or large. Or to put it another way: at around 8-10 weeks gestation we all are about the same size for a given gestational age. At 34-36 weeks gestation some of us are going to be small for our gestational age, some of us are going to be just about the size expected for our gestational age, and some of us are going to be large for our gestational age.

Mean Sac Diameter (MSD) is not as accurate as CRL. MSD is best used at very early gestational age when all you can see is the yolk sac, perhaps a heart beat, but you really cannot see the embryo yet. We are talking about 5w and a few days, by high resolution transvaginal scan.

From me: that was beautiful; you could not have put it better.

Radiology grand rounds IX on Cochinblogs:

10 ways to limit your liability on call, in no particular order: by Mikhail Serebrennik
(quoted from http://www.filmjacket.com/news.php?readmore=54 with permission)
The most important thing is to escape responsibility or at least spread it among as many people as possible, so that you are never solely responsible for a suboptimal outcome. Here are 10 ways to do it.
Disclaimer: Of course, everything in this article is for entertainment purposes only; you should use sound medical judgment, reliable information sources and practice guidelines accepted at your institution at all times, and do everything in the best interest of patient care.
1. Request additional and/or short-term follow-up studies - if you don't know what the heck you are looking at, this may result in someone else having to read the additional/follow-up studies and carry a part of the burden of final decision.
2. Talk to the referring clinician - they may point you in the right direction and even give you the differential diagnosis. Armed with a decent differential, you may be able to produce a reasonable report.
3. Suggest clinical correlation. This is self-explanatory.
4. Call and wake up your attending - it's better to annoy them now than surprise them the next day. If your attending tells you to buzz off and hangs up on you, you've done your part - the responsibility has been spread.
You can read the rest of this piece at: http://www.filmjacket.com/news.php?readmore=54




























Dr. Sumer Sethi and Dr. Joe Antony invite case submissions for the next radiology grand rounds IX on cochinblogs. The cases and/ or articles related to radiology will be put on 25th Feb 2007. Anybody interested in radiology including sonography,
conventional radiology, CT scan, MRI etc. may submit their articles, cases etc. to drjoea@gmail.com .

Here is an interesting case.
A 32 yr old comes with history of non specific pain in the knee joint.
Clinically he is normal.
MRI shows a well defined a focal altered signal intensity lesion seen in close proximity to Post cruciate ligament . It is to be differentiated from PCL tear.
Diagnosis: Posterior cruciate ligament ganglion.

Brief description of Posterior cruciate ligament
· Prevents post displacement of tibia on femur
· Extends from med femoral condyle to post and inf to tibial articular surface
· Average length 38 mm and width midpart 13 mm
· Like ACL is intraarticular and extrasynovial
· Vascular supply from middle genicular artery of popliteal vessel
· Ganglion may attach to PCL
· It is differentiated from PCL tear by demonstrating intact underlying PCL and well defined nature of ganglion.
Case presented by Dr. MGK Murthy.



Dont forget to visit our sister site: the free gallery of ultrasound images

Here you'll find loads of interesting sonographic images with a brief description and the best reference links.




A hole in the ….? A case by Dr. G.C. George (http://med97um.net/george/ )



Many have heard of a hole in the heart but for this 58 year old gentleman, it was a totally different story. He was assisted into ER, wailing in pain with every single movement. It was all too sudden. Even taking a deep breath was difficult as the pain was excruciating. He was sweating, his pulse racing, he could barely speak because the slightest effort caused him intense pain.The pain occured suddenly, all over the abdomen causing it to be so “board -like” He could barely move. He requested to be propped up to allow him to breath easily. He never had any such pain before but recently was taking some herbal traditional medication for better health! Yeah sure! My medical officer was called up. A few minutes later, my phone rang and the events were so typical, that I waited eagerly hoping my medical officer would make the correct diagnosis. He sounded a little unsure but at the end of the sentence he blurted out the correct diagnosis. I gave my orders and this gentleman was prepared for surgery. So much for a better health! These are some pictures to help you bloggers complete the title of this article




Case presented by Dr. G.C. George.




The answer: Perforated Gastric ulcer.






The Grand Rounds archive and schedule is available at
http://www.radiologygrandrounds.blogspot.com/

and maintained by Dr.Sumer Sethi of Sumer's Radiology Site
http://sumerdoc.blogspot.com

Ultrasound scan of rupture of uterus:

Rupture of the uterus during delivery is a known complication of pregnancy. The commonest cause is vaginal delivery after a caesarean section. Other causes include, previous surgery for tumors like fibroids and also prior classical caesareans, where the incision was placed in the upper uterus. Labor inducing medications can also cause rupture. I present ultrasound images of uterine rupture with severe hemorrhage on my ultrasound gallery at: http://drjoea.googlepages.com/ultrasoundgallery-uterus
On ultrasound scan, the typical findings are breach of the uterine wall, with a hypoechoic collection of blood outside the uterus. Follow up scans revealed diminishing of the size of the collection. One of the images of this case is shown here. Images courtesy of Dr. Durr-e-Sabih, Pakistan.