I'm the chairperson for the SVU e-learning educational committee. And tonight we have a presentation from a fellow technologist that was inspired by the collaboration that we have on a daily basis. We work in a shared space, but we work for different departments. We're in the same institution, but she works for radiology and I'm with vascular surgery. So I've learned a lot from tonight's speaker. And so I asked her to give a talk from the dedicated general ultrasound tech's perspective about some of the things we come across when we're doing vascular studies that we categorize as incidental findings. Before we begin, here's a couple of notes from the SVU office that I need to share, especially for first-time attendees. The on-demand version of this webinar will be available in seven to 10 business days in the SVU catalog on the website, and it's gonna be free to members. I'm gonna ask that you please use the Q&A feature, not the chat or raise your hand features in the Zoom to ask any questions that come to mind during the presentation. At the end of the presentation, we should have some time for discussion. So you'll receive an email containing an evaluation that must be completed in order to obtain your CMEs for tonight's webinar. This email is gonna be sent to you within seven to 10 business days, so wait for that. Okay, so that's our announcements. And so tonight we're honored to have Desiree Freeman as our speaker. And Desiree is a registered diagnostic medical sonographer from the University of Chicago with over 20 years of clinical experience. She's also worked at Little Company of Mary and Condell Medical Center in the Chicagoland area since graduating from Southern Illinois University with a bachelor's of science degree in radiological science. Desiree enjoys seminars and wouldn't mind working for applications someday for one of the ultrasound companies. Desiree was a presenter for the Hepatoportal hands-on session last year at the annual conference for Society of Vascular Ultrasound. She has spoken at SDMS conferences on pediatric ultrasound and she enjoys providing hands-on training in her current role for the residents and fellows who are learning to perform ultrasound guided procedures. Desiree enjoys when there are less than 16 patients on her daily schedule, which doesn't happen too often, but otherwise she likes spa day, she likes being the mom of her teen girl. And I got one quick story I wanna tell you about Desiree and how she fell into this profession before we get started. So Des had complications during one of her pregnancies and her physician ordered an ultrasound exam. The sonographer reported an incidental finding of a rupture of the amniotic sac before labor, which resulted in her giving birth months earlier than she should have, but she delivered safely. After that ultrasound exam, Desiree thought to herself, what if that technologist had missed that finding? And she was so inspired by that sonographer's efforts that it made her wanna go into the profession herself because she said she wanted to see what others didn't see for the sake of the patients. So I just thought that story was a perfect segue into tonight's presentation, which is titled, Did You See That? Non-Vascular Incidental Findings. After her presentation, we'll have time for a short discussion. So please, as I mentioned earlier, just type in any questions that come to mind using the Q&A feature here in Zoom. And now please, if you would join me in welcoming our speaker tonight, Desiree Freeman. Thank you, Lori. Good evening, everyone. Fabric today, Did You See That? Non-vascular incidental finding. Here we have a disclosure page. I have nothing to disclose. We'll start off with neck pathology. Thyroid nodules. Cystic, hypoechoic, spongiform. Cysts. Thyroid nodules, these are fluid filled sacs and are often benign, especially if they are purely cystic. Hypoechoic nodules. Darker concerning for malignancy. Nodules with microcalcifications. Small, bright spots within the nodule. Spongiform nodules. These are mid-cystic and solid nodules. The thyroid nodule in the upper corner, you can appreciate a cystic nodule. It does have a few septations. Sorry. And so we can see a few septations here. In the nodule and below, this is what we consider a hypoechoic nodule. It's more of a solid nodule, darker. More on hypochord nodules. Nodules with irregular shapes or margins. These nodules may be more likely to be cancerous. Nodules with taller than wider shapes is another ultrasound feature that can be a predictor of malignancy. Nodules with eccentric locations of solid portions and particularly cystic nodules and eccentric location of the solid portion can be a predictor of malignancy. Nodules with chaotic intranodular vascularity, irregular blood vessel patterns within the nodules also can be a pre-indicator of malignancy nodules. We have two different characteristics of a spongiform nodule. One would be a mid-cystic nodule and one would be a solid nodule. The one in the upper corner is more of a solid nodule. It has a few little cystic components within it. The lower portion is more solid with a few anechoic structures. Neck pathology. We often find lymph nodes, small lymph nodes being shaped organs that are the size of a pea, oval or hypochord structures with a prominent echogenic hilum, which is a bright central area and a smooth, well-defined border. Lymph nodes are present throughout your body, including your armpits, neck, and groin. The way to identify abnormal node shape is round, absent hilum, intranodular necrosis, reticulation, which is retracting of the capsule, calcification, matting, soft tissue edema, peripheral vascularity. Another neck pathology that we often run across in ultrasound would be parotid gland lesions. Loculated hypochord vascular mass containing calcifications can indicate various conditions, including benign tumors, like pylomorphic adenomas, potentially malignant tumors, inflammatory processes like Sjogren's syndrome, or even infections. The nodules presented here will be considered complex nodules. However, you can appreciate some acoustic enhancement behind the anterior nodule. Other neck pathology. Here we have a well-defined oval, oblong, hypochord appearing structure, and, excuse me, with internal echoes lines parallel to the skin surface and minimal or no vascularity. This will be considered a lipoma. You can appreciate the vessels posterior to the lipoma, and it's very superficial. You can appreciate the carotid artery. Here, and here we have the lipoma. The neck lipoma was requested from dermatology. It was to access landmarks, the carotid, internal jugular vein, to avoid removal of an oar. Being that this is such a small space in a neck, the dermatologist wanted to be sure that this vessel was not encased, the carotid artery was not encased within the actual soft tissue, and that this would be a safe, clean removal. If so, I do know that we were told that they wanted to have vascular surgery on board as well, so a lot of planning was put for it with this neck lipoma. Next, we'll move on to joint pathology. Baker's cyst, a fluid field sac that develops behind the knee, often caused by an underlying knee problem that leads to increase in synovial fluid, the lubricating fluid in the knee joint. Here you can appreciate anechoic mass, a shapely defied posterior wall, and a posterior acoustic enhancement. Another image of the Baker's cyst. On this particular image, you can appreciate the joint space. So here's the joint space here, and you can see the actual fluid is screeding out into the soft tissue. extremity pathology, calf muscle mass. Here we have a hypoechoic nodule in the calf. So hypoechoic is the most common appearance is a well-defined homogeneous and hypoechoic bright mass. Hypoechoic, small, some hemangiomas can appear hypoechoic, darker or have mixed echoes. Well-defined margins, hemangiomas typically have sharp well-defined borders. Posterior acoustic enhancement is a common feature where the ultrasound signal is enhanced behind a lesion. So here we have a calf lesion with some vascularity, a vascular attack obtained this image and she actually asked me to come in and take a look with her and being a sonographer who scans MSK, of course I was thinking this would be some sort of malignancy because hemangiomas typically don't have this much blood flow as centrally. Calf muscles, so calf muscle masses, other location hemangiomas can occur in other areas such as the breast, skin, muscle and their ultrasound appearance can vary depending on the location. The most common hemangioma that we see here in abdominal ultrasound is liver hemangiomas, which are hepatic hemangiomas are more common and often appear as hypoechoic lesion, although they can also be hypoechoic in the presence of fatty liver. So this here is a picture of the technologist, she obtained a spectral flow to let everyone appreciate that it is actually blood flow and it's not just artifact. And clinical coordination, a CT scan was ordered and it did in fact confirm the vascular structure in question appears to have fat and is most compatible with a hemangioma. Complex cysts and extremities, here we have a complex cyst with internal debris, thicker irregular walls, solid appearing areas and increased blood flow within rather than a smooth fluid filled anechoic area. Again we can appreciate the complex cysts, some of the techniques that oftentimes will help you out to figure out to get the entire image on the screen, we use extended view, panoramic, on this one here is a dual screen and this lets you be able to appreciate the, to measure the full length and of the actual lesion. Image obtained here is another one we put colorful on, spectral box to appreciate the vessel that runs beneath it in case someone and this patient is sent for surgery, they're going to be aware of the surrounding anatomy. Another pathology that we can incidentally find, well you guys can incidentally find in vascular ultrasound is what's called a necrotic hematoma. It's a heterogeneous mass with variable echogenicity, potentially including hypoechoic, which is darker fluid areas and hypoechoic, brighter areas due to clot and maybe signs of fat necrosis or calcification or over the time. This patient here, she obtained a fall and had a hematoma over 20 years ago and she reported to her doctor that she felt like a crumbly rock like sack within the buttock and after scanning, we obtained this image here, no vascularity to it and the doctor, the radiologist indicated it might have been a necrotic hematoma because you can appreciate some shadow echoes, some shadowing within it, which lets you know that some areas have calcified because the sound wave beam cannot penetrate all the way through certain areas. Another interesting pathology that you will encounter sometime when you're covering a common femoral vein, some patients will have bilateral testicles in the inguinal canal, which are undescended testicles, which is cryptorhagis, appears as a homogeneously hypoechoic oval structure, similar to a normal testicle with the echogenic mediastinum testes. This patient is a patient who has cerebral palsy and the pediatric physician could not palpate the testicles within the scrotal sac. He was sent for ultrasound, again, to be aware of the anatomy surrounding and how far up the testicles were in the inguinal canal. In this particular case, the testicles were adjacent to the common femoral vein. So as you can see, the left inguinal canal, the testicles line anteriorly to the common femoral vein. And I was able to take a spectral of the vein below to just let the physician and surgeon know that this testicles is really close to the common femoral vein, again, for planning and surgery. Here we have what's the inguinal hernia, tissue often fatty or bow, bulging through weakness in the abdominal wall. Typically in the inguinal canal, which is the area near the groin. We can confirm this with doing a valsalva maneuver, bearing down as if we're having a bowel movement. The hernia sac will become more prominent as the abdominal contents push through the weakened area. A lot of times you'll see in the inguinal canal, again, when I'm turning the images of common femoral vein, you will see a sometimes peristalsis in structure and in the muscle wall with a valsalva, it'll confirm that this perhaps is a inguinal hernia. We'll move on to abdominal pathology. Pelvic mass, cystic masses appear as fluid-filled sites with thin, smooth walls. You can have a solid mass appear as an area of tissue with varying echogenicities, how well they deflect the sound wave. Here we have, which is a solid pelvic mass. We also, maybe say mixed cystic and solid, as you can see in this condition, various echoes and cystic structures within. So it can be seen in various conditions, including some of ovarian tumors. Other pelvic masses that you can appreciate will be ovarian cysts, uterine mass, fibroids, lymeomas, hydrosalpines, which is simply fluid within the fallopian tube. So sometimes you will look in the pelvic area if you're looking for iliacs and near the bifurcation. Sometimes you will see those cystic structures and it'll be, with hydrosalpines, it almost look like a break of worms. And also we can have atopic pregnancies, which of course, I'm sure you'll be able to appreciate that with the baby's heartbeat there. More abdominal pathologies that I try to stick around findings that you will see as a vascular tech. And I do know that you guys do a lot of renal Doppler studies. So a lot of times I get my colleagues, why it's me, hey, Desiree, what do you think this is? What do you think the structure is in the kidney? Well, here is a renal cyst, which is well defined, fine, roundish, anechoic structure and perceptibly near wall and thin epigenic firewall and increased through transmission manifest by acoustic enhancement. So this is a simple cyst. It's not really any turn of echoes. You can appreciate a little reverberation in the anterior field there just because of the settings of the Phillips machine. Also cystic structures that can be found within the kidneys at time will not always be cysts. You can have what's called hydronephrosis and it's anechoic. It's considered anechoic bear paw with dilated calyx. You represent finger like projectiles. A lot of times some people were mistaken this for a renal cyst. And if you were just get a full view of the kidney as much as possible, you can appreciate that those are calyxes and the actual renal cysts. And that will help with the diagnosis of the patients because if it's hydronephrosis and that's the instance into finding that's something that needs to be addressed a little bit more immediately as opposed to just a renal cyst. Next, we have renal stones. A lot of times you can have renal stones within the kidneys and I know you guys run across them often. It's considered a bright hypoechoic structure often accompanied by a dark acoustic shadow behind them due to the stone high density and inability to transmit sound waves. So I placed the calipers on this one image you can appreciate because a lot of times renal stones will blend in with the sinus fat and oftentimes you wouldn't necessarily appreciate the renal stone, but with the twinkle artifact, which we'll cover later, you will. Next, we'll go to measurement protocol. So in order to obtain a simple diagnostic image for a patient that will help with progressing the progress of treating the patient, if you were to get an anterior to posterior measurement, a length, a width, and at times, for instance, like the dual screen image, we show a fluid sac, you can get volume and we can follow growth with volume because sometimes by time the patient has gotten to general ultrasound from the incidental findings, some things can resolve or increase in size. So a volume sometimes can help with the treatment. So for protocol for measurements, you will try to get the best optimal image of the area in question. So here we have a lymph nodes and this is maybe the best image in long. You can appreciate the fatty hyaline. And here we measure the length of the lymph nodes, anterior to posterior. And the width of the lymph node. And oftentimes, we are encouraged to put color Doppler on anything that you're not sure where they might be and possibly throw a spectral fluid in it as well. With those measurement protocols, you have fully made a diagnosis for this patient. And by the time they come to me, I don't think they would need ultrasound because you guys did such a wonderful job. All right. Echotextile terminology, foci and debris. Foci, which is small, bright spots or areas of increased echogenicity, often resembling bone or calcification, commonly seen in fetal heart or thyroid nodules. Echogenic foci in thyroid nodules can appear as punctate small dot-like foci. And of course, the punctate dot-like foci, this will be considered foci. And we will also use interterm debris as well. Debris, which is, as we said, echogenic bright material within the urinary bladder, often floating or layering due to gravity. Debris often moves and layers in a gravity-dependent manner, suggesting it's not a fixed structure. A lot of times you can just apply a little pressure to the area and all of the echogenic foci will kind of move around within. Another terminology of echotextile spongiform, often used for thyroid nodules. A soft, porous, or honeycomb-like structure with numerous small, flustered, microcystic spaces, separated by thin echogenic septa, often described as puffy, dense, and flustered microcystic spaces, separated by thin echogenic septa, often described as puffy, puff pastry. Microcystic spaces, these are small, fluid-filled areas within the nodule. We can appreciate just some fluid-filled areas within the nodule here. And here's the entire nodule. But the cystic structure alone pretty much favors a benign nodule. Next, we will have what's considered complex. Ultrasound can help differentiate simple from complex renal cysts. Complex renal cysts may be solid, not filled with fluid, internal echoes, irregular shape, or a thick outer wall. In this case, this is somewhat of an irregular shape. You can appreciate the internal echoes here. And this is a little projectile here. the stick nodules, simple nodules, simple CIS heart. A well-defined round or oval anechoic black mass with a thin small wall and posterior acoustic enhancement, which is increased through transmission. With this CIS, you can appreciate there's no internal echo. It does have somewhat of an irregular shape, but however, it doesn't have any of those little projectile finger light projecting within to the anechoic structure. So we will consider this a simple CIS. Acoustic shadowing. So here we have the renal stone without the calipers and acoustic shadowing, a common ultrasound artifact appears as a dark signal for area behind a structure like bone or a dense object. Due to the ultrasound being blocked or reflected rather than passing through, you will get the shadowing here. You can appreciate shadowing in both areas. And this is the stone here. Sometimes it blends in with the parenchyma. For confirmation, this is a confirmation of if it's a stone, when you're not sure if it's blending in, it's a twinkle artifact. Twinkling artifacts appears as a rapidly alternating red and blue color doppler signal behind certain stationary objects, which give the appearance of movement. In 1996, twinkling artifact was described by Rumani as an artifact generated by a strongly reflecting medium. So the previous, this is the same picture as the Reno stone that I showed you in the previous slide. Here, and the next image, the same exact image with color. And you can appreciate, you can appreciate the twinkle artifact. And here, this is a textbook twinkle artifact. So if you ever doubt if there's a stone, if it's shadowing, stones will always, this large will twinkle. Next, we have what's considered a calcification or calcified area. Appear as a hypochloric bright foci, potentially with shadowing and doppler ultrasound can show twinkling artifacts. So we put color on this image, which is of the thyroid. This is a big chunk coarse calcification within the thyroid. When in doubt, just throw color on anything that's echogenic centrally and it should shadow. They can be found within masses, outside of mass, or within ducts, sometime in the salivary gland. You can also sometimes appreciate stones within the ducts. And their appearance can help determine if the mass is benign or calcified. In ultrasound, thyroid nodules with coarse calcification have high suspicion for malignancy. Oftentimes, the first question radiologist will ask if you see anything echogenic within a nodule. First question is, is that a coarse calcification? Coarse calcifications can be sometimes what we would consider colloid twinkle artifact, because colloid nodules actually has punctate foci within as well, but it's no shadowing. Next, we have incidental findings in general ultrasound. So incidental vascular findings in general ultrasound. This is varicose of the left testicle in a 16-year-old male. And varicose appears as dilated, torturous veins in the pentiform plexus and the scrotum, often with a serpentine or egg of worm appearance, and may show blood flow reversal during a valsalva maneuver. This is another time that we, of course, use ultrasound valsalva maneuver to have the vessels dilate. And sometimes you will even measure the caliber. You'll calibrate just the vessels, how much they're dilated once they valsalva. And that's obtained through a black and white image. Another, this is the image just within the valsalva textbook varicose. And I went a little bit further with this kid because he was really nice and thin. And I really thought my radiologist would appreciate this because in the left testicle, I do know that it runs the risk of what's the Nutcracker syndrome, which is compression of the laparino vein. And sure enough, he did have it. My radiologist wasn't too impressed. He's a pediatric abdominal radiologist. I poured my heart out into this image. But 10 years later, I kept it in the archive and it came in handy. Another incidental finding, vascular finding in general ultrasound, a pseudoaneurysm generally appears as round sac close to and often with a connecting neck from the parenting vessel. This is another study of a patient. She had a lump in her arm. Previously, she had an angiogram, so she had a stick within the wrist. And I was able to appreciate the flow within this actual large complex structure. And for just following the measurement protocol, I threw a spectral colorful Doppler signal in there and it was the artery. On the previous image, I did want to mention that you can appreciate the neck of this actual pseudoaneurysm in this case. And that wraps up everything. Here we have a beautiful picture of the University of Chicago campus. This is the college campus and you can appreciate our beautiful Lake Michigan. And of course, none other than our Chicago skyline. Thank you. Thank you, Desiree. I'm going to start going through some of the questions that came in.

incidental findings

vascular studies

ultrasound technologist

pathologies

Doppler techniques

renal stones

patient care