Ultrasound

Undifferentiated paediatric patients can be difficult to correctly classify with the correct condition. This may be, in part, due to the unique differences in how symptoms present as well as the challenges clinicians face in undertaking a complete examination where cooperation may be hindered due to pain, anxiety or limited understanding. Point-of-care ultrasound is now recognised as a valuable tool to assist acute paediatricians in their decision-making and diagnosis when incorporated into their clinical assessment.

We describe six cases which presented to the Paediatric Emergency Department, where point-of-care ultrasound played a crucial role in uncovering malignant or invasive lesions and subsequently expedited further investigations, leading to much quicker diagnosis.

The aim of this preclinical study was to test if the organic coating of two breast tissue clip markers (HydroMARK and UltraClip) can be sampled selectively by an ultrasound-guided core cut biopsy.

Ten clip markers of each type were inserted in four turkey breasts. Sonographic visibility was graded by the performing physicians. Core cut biopsy was performed, aiming to sample only the organic coating while leaving the clip marker in situ. Mammography, specimen radiography and gross inspection of the biopsy samples were conducted to evaluate dislocation or removal of the clips. The specimens were examined histopathologically to detect fragments of the coating material.

HydroMARK was superior regarding biopsy feasibility and detectability of the coating. The organic coating of HydroMARK could be sampled selectively without dislocating the clip marker. Fragments of the coating material were visible macroscopically in 7 out of 10 biopsy specimens and could be detected in the histopathologic workup in 5 out of 10 specimens. The coating material of the UltraClip was not visible in any sample.

This study showed that the organic coating could be identified in core cut biopsy samples, both on a macroscopic and microscopic level. This could potentially be used to verify representativity of minimal invasive biopsies.

Anterior talofibular ligament injury is the most common type in chronic ankle instability patients. While initial injuries are often treated conservatively, some patients still require surgery. Shear wave elastography provides quantitative, accurate assessment of ligament damage, offering an objective basis for surgical planning and rehabilitation monitoring.

Shear wave elastography quantified shear wave velocity of bilateral anterior talofibular ligaments in neutral and stressed positions in 30 chronic ankle instability patients’ group and 60 healthy controls’ group. Functional assessments included the Cumberland Ankle Instability Tool, American Orthopaedic Foot & Ankle Society scale, Foot and Ankle Ability Measure for Activities of Daily Living and Foot and Ankle Ability Measure for Sports (FAAM-S) and Visual Analogue Scale for pain.

Inter-observer and test–retest reliability for anterior talofibular ligament shear wave velocity were excellent (neutral position: intraclass correlation coefficient = 0.87, 0.93; stressed position: intraclass correlation coefficient = 0.89, 0.96). Shear wave velocity showed no significant differences by gender, age or body mass index. Chronic ankle instability patients had significantly higher shear wave velocity in affected anterior talofibular ligaments (neutral/stressed, p < 0.001) versus healthy controls; unaffected sides showed no difference. Affected ankles scored significantly worse on Cumberland Ankle Instability Tool, Foot and Ankle Ability Measure for Activities of Daily Living, Ankle Ability Measure for Sports, American Orthopaedic Foot & Ankle Society and Visual Analogue Scale (p < 0.001). Shear wave velocity in affected anterior talofibular ligaments (both positions) positively correlated with pain intensity (neutral: r = 0.488, p = 0.004; stressed: r = 0.514, p = 0.004). Neutral-position shear wave velocity negatively correlated with Foot and Ankle Ability Measure for Activities of Daily Living (r = −0.457, p = 0.011), but not with Ankle Ability Measure for Sports, American Orthopaedic Foot & Ankle Society or Cumberland Ankle Instability Tool scores.

Shear wave elastography noninvasively, conveniently and accurately assesses anterior talofibular ligament quality in chronic ankle instability patients, providing an objective approach for surgical decision-making and rehabilitation monitoring.

Diastolic dysfunction precedes ventricular contractility changes in the ischaemic cascade. Both diastolic and systolic left ventricle dysfunctions are known to alter left atrial myocardial deformation by impairing its phasic function, which can be evaluated using speckle-tracking echocardiography.

The aim of this study was to assess the accuracy of left atrial strain in detecting myocardial ischaemia in patients undergoing dobutamine stress echocardiography.

Patients referred for dobutamine stress echocardiography due to suspected ischaemia were prospectively enrolled. Left atrial strain, including its three components – reservoir, conduit, and contractile – was analysed at each stage of dobutamine stress echocardiography. The diagnosis of myocardial ischaemia was defined as a new or worsening wall motion abnormality in at least two contiguous left ventricle segments during dobutamine stress echocardiography. Patients with a positive dobutamine stress echocardiography for ischaemia were compared with those with a negative dobutamine stress echocardiography for ischaemia.

A total of 56 patients were included. Patients with inducible ischaemia had significantly lower left atrial reservoir strain (LASr) values at rest and throughout all dobutamine stress echocardiography phases, with the lowest values at peak stress (27.6% (24.0 to 28.4) vs 34% (29.6 to 42.7), p < 0.001). LASr at rest and during low-dose dobutamine predicted ischaemia during dobutamine stress echocardiography (rest: area under the curve = 0.68, p = 0.038; low dose: area under the curve = 0.78, p < 0.001). An LASr cutoff of ⩽29.7% at peak stress yielded high diagnostic accuracy in detecting inducible ischaemia (area under the curve = 0.88, p < 0.001).

Assessment of left atrial strain in patients undergoing dobutamine stress echocardiography for suspected myocardial ischaemia has diagnostic value and can be integrated into conventional dobutamine stress echocardiography to corroborate the findings of a positive test.

A departmental audit identified a case of adenomyosis which had not been reported, highlighting the need to assess whether the current service provision is adequate in identifying patients with (possible) adenomyosis and how improvements in this part of the service could be made.

To assess whether sonographers are effectively identifying and reporting adenomyosis on transvaginal ultrasound.

A scoping review and retrospective service evaluation was undertaken which included (n = 79) adult female premenopausal patients with symptoms of adenomyosis who had undergone a transvaginal ultrasound scan during the first quarter of 2023. Patients were identified using the CRIS statistic module according to pre-defined inclusion and exclusion criteria. All data were anonymised and collated to include the patient age, referral information (symptoms), scan report and sonographer. The scan report and archived images were evaluated using the sonographic signs identified by the Morphological Uterus Sonographic Assessment group (Harmsen et al., 2022) and then compared to the original report.

In total, 21.5% (n = 17) of patients had signs of adenomyosis on image review, but only 23.5% (n = 4) of these were reported as such. The majority (n = 8) of unidentified cases were reported as having a ‘heterogeneous myometrium’. Inter-rater agreement ranged from 50% to 100%.

Most ultrasonic diagnoses of adenomyosis were not identified in our service which is likely due to a lack of internationally agreed criteria for ultrasound diagnosis of adenomyosis preventing adequate reporting.

Delphian (level VI) lymph nodes are often linked to head and neck malignancy, but their relationship with thyroiditis is less well described. Ultrasound is used in the assessment and workup for thyroiditis, but thyroid appearances can be variable and non-specific. The presence of a Delphian lymph node may help to determine the aetiology of inflammatory thyroid disease.

To investigate whether assessing Delphian lymph nodes on ultrasound can help predict the diagnosis of thyroiditis in children.

Retrospective review of scans from 70 children (1–17 years old) carried out by a single radiologist at a tertiary paediatric centre. The presence or absence of Delphian lymph nodes was assessed, as well as the thyroid size/volume, echogenicity and vascularity. Biochemical markers, where applicable, and clinical diagnoses were obtained and matched up to radiological findings. Markers included thyroid function tests (TFTs) as well as serum thyroid peroxidase antibody and thyroid receptor antibody.

Twenty-four patients had Delphian lymph nodes identified on ultrasound. There was statistical significance between the presence of Delphian lymph nodes and heterogeneous thyroid architecture (p < 0.001), thyroid enlargement (p = 0.002) and increased thyroid vascularity (p < 0.001). Although no significant association was identified between the size of the Delphian lymph node and the thyroid appearances on ultrasound or the biochemical results, there was a significant association between the presence of Delphian lymph nodes and the clinical diagnosis.

There is a significant association between the presence of Delphian lymph nodes on ultrasound with findings in thyroiditis. These include the presence of key biochemical markers and abnormal thyroid appearances on ultrasound – increased heterogeneity, size and vascularity.

Placenta accreta spectrum encompasses abnormal placental attachment disorders characterised by progressive invasion into the uterine wall. Its incidence is rising due to increasing caesarean section rates and advanced maternal age, posing significant risks such as haemorrhage, uterine rupture and hysterectomy. Early and accurate diagnosis is critical for optimizing maternal and neonatal outcomes.

Diagnosis of placenta accreta spectrum is possible in early pregnancy using transvaginal ultrasound. Key indicators include caesarean scar pregnancy, anterior myometrial thinning, placental lacunae, loss of the clear zone, bladder wall interruption and uterovesical hypervascularity. These findings facilitate early counselling and tailored management to mitigate emergency surgical complications. Evaluating the gestational sac’s relationship with the endometrial cavity in early pregnancy is essential in predicting pregnancy progression and associated risks, including uterine rupture or the need for caesarean hysterectomy. When transvaginal ultrasound provides limited views, transabdominal ultrasound may offer superior views to understand the relationship between the gestational sac and the endometrial cavity. Serial ultrasound monitoring is recommended in women with risk factors, particularly if they are symptomatic, to track pregnancy progression accurately.

This pictorial review consolidates early gestational imaging findings to enhance diagnostic precision. It highlights standardised ultrasound criteria proposed by international consensus groups and explores magnetic resonance imaging as an adjunctive tool for cases with inconclusive ultrasound findings. By providing a comprehensive visual guide, this review aims to improve early detection, refine surgical planning and enhance maternal outcomes in placenta accreta spectrum management.

Pulmonary infarction is an ischaemic necrosis resulting from pulmonary arterial occlusion, occurring in approximately one-third of pulmonary thromboembolism cases. While computed tomography angiography remains the gold standard for diagnosis, its use in follow-up is limited by radiation exposure. Thoracic ultrasonography, a bedside, radiation-free and repeatable modality, may serve as an alternative tool for monitoring pulmonary infarction.

We present a 44-year-old woman who developed sudden dyspnoea and back pain 1 week after venous surgery. Computed tomography angiography confirmed pulmonary thromboembolism, and persistent flank pain was attributed to pulmonary infarction. Thoracic ultrasonography revealed a hypoechoic, pleural-based consolidation in the left hemithorax measuring 19 × 11 mm. The patient was treated with anticoagulation and followed weekly with thoracic ultrasonography. Her symptoms improved, and by the sixth week, the consolidation had completely resolved.

Pulmonary infarction has traditionally been associated with poor outcomes in older patients with comorbidities; however, it may also occur in young, otherwise healthy individuals. The clinical significance of pulmonary infarction remains uncertain, although some studies suggest potential associations with delayed recovery and functional impairment. Thoracic ultrasonography demonstrates good sensitivity and specificity in detecting pulmonary infarction and offers several advantages over computed tomography angiography for follow-up, including safety, accessibility and repeatability. Evidence suggests that infarct resolution typically occurs within 6 to 12 weeks, a period during which thoracic ultrasonography may be effectively utilised to monitor lesion regression.

This case highlights the role of thoracic ultrasonography in the follow-up of pulmonary infarction. Although limited to peripheral, pleura-based lesions, thoracic ultrasonography represents a safe, practical and repeatable imaging modality for monitoring pulmonary infarction resolution and may reduce the need for repeated computed tomography angiography in clinical practice.

Limb body wall complex is a rare polymalformative syndrome which consists of an abdominal and/or thoracic wall defect with an extremely short umbilical cord associated with kyphoscoliosis, intestinal malrotation, and lower limb defects.

A 31-year-old primigravida presented with monochorionic monoamniotic twin pregnancy with discordant anomaly. One fetus had exomphalos, acrania, bilateral talipes, a single umbilical artery, kyphoscoliosis and a short umbilical cord, findings suggestive of limb body wall complex. An ultrasound one week later revealed an unfortunate intrauterine fetal demise of both twins. The postmortem examination confirmed the antenatal diagnosis of limb body wall complex. Since the parents were anxious to avoid any risk of recurrence in subsequent pregnancies, skin samples of both babies were sent for genetic workup. The Chromosomal Micro Array of both fetuses was reported to be normal.

Different pathophysiologic mechanisms have been proposed to explain the anomalies associated with limb body wall complex. These include early amnion rupture, vascular disruption, and embryonic maldevelopment. Differential diagnosis must be made with isolated gastroschisis, isolated omphalocele, and other polymalformative syndromes such as pentalogy of Cantrell.

Early morphological assessment of the fetus at the time of the first-trimester screening scan can be of utmost importance to diagnose a polymalformative syndrome, which may be incompatible with life. An omphalocele, even in the absence of genetic or chromosomal abnormalities, may be associated with a lethal syndrome, that is, limb body wall complex. This should specifically be thought of and searched for, especially in fetuses who present with omphalocele in combination with curvature abnormalities of the spine.