Tag Archives: Ultrasound

An Invaluable Tool in Your Practice: Musculoskeletal Ultrasound

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Musculoskeletal ultrasound (MSK US) has emerged as a powerful tool that is advancing pediatric sports medicine. Its noninvasive nature, real-time imaging capabilities, and portability make it invaluable for injury assessment and treatment planning. Let’s delve into some key points:

  • Utility in Sports Medicine: The American Medical Society for Sports Medicine (AMSSM) developed a recommended MSK US curriculum for sports medicine fellows in 2010 to help guide programs towards adequate training during their fellowship to meet the requirements of competency outlined by the American Institute of Ultrasound in Medicine (AIUM) Training Guidelines for the Performance of MSK US Examination. This was later revised in 2015 and it was where the term “sports ultrasound” was first introduced to reflect the use of ultrasound by sports medicine physicians for both musculoskeletal and non-musculoskeletal indications.  Since then, sports US has become nearly ubiquitous in sports medicine clinics, training rooms, and at sporting events across the country. Finally, in 2017, ultrasound training was formally added to the Accreditation Council for Graduate Medical Education (ACGME) core program requirements for sports medicine fellowships, including pediatric-based programs.
  • Pediatric Considerations: Skeptics may argue that ultrasound isn’t necessary for evaluating musculoskeletal (MSK) complaints in children, assuming they don’t experience the same amount of pathology as adults. However, as a pediatric sports medicine physician with a decade of ultrasound experience, I can attest that children do encounter similar MSK issues. Children exhibit both common MSK conditions (like tendinosis, ligament tears, muscle injuries, effusions, and fractures) and unique ones related to their growing skeletons (like osteochondral defects, Salter Harris injuries, apophysitis, and avulsion fractures). MSK US can play a role in evaluating all of these conditions at the point of care. 
  • Beyond Pediatric Sports Medicine: MSK Ultrasound is a valuable tool that extends beyond pediatric sports medicine as well. It is widely used in rheumatology clinics, where it helps diagnose conditions like synovitis, arthritis, and enthesitis. Emergency physicians can quickly identify joint effusions and dislocations, full-thickness tendon tears, and fractures, influencing acute management decisions. General pediatricians can benefit from MSK ultrasound, too, and this is not just ordering ultrasounds to rule out hip dysplasia in infants. Simple questions—like distinguishing between solid versus cystic soft tissue masses and assessing joint effusions—can guide primary care clinicians. When families seek answers about their child’s condition and treatment options, especially “How can we get them back to sports safely?” time is of the essence and point-of-care ultrasound (POCUS) becomes even more important!
  • Interventional Possibilities: While the volume of procedures may not match clinics focused on older athletes, there are still opportunities for the pediatrician. US guidance opens the door to injections of not only joints and their recesses but also within tendon sheaths, bursa, and perineural spaces. Therapeutic injections have their obvious role in successful treatment of pathologic conditions, but diagnostic injections can also play a crucial role, especially for patients with chronic pain. Precise targeting using ultrasound ensures accurate delivery of anesthetic injectates that can help inform the clinician of the etiology of pain, which often goes undiagnosed for years in the more challenging patient scenarios.         
  • Safety and Efficiency: Sonologists with diagnostic expertise can now confidently guide needles to precise locations, minimizing risks. Unlike radiography, which involves radiation exposure, ultrasound is radiation-free. This safety aspect is crucial, especially when discussing imaging options with pediatric patients and their families. For example, repeating radiographs or imaging contralateral sides for comparisons may be unnecessary if the pediatric clinician has POCUS in their toolbox.   

In summary, MSK ultrasound is a versatile tool that empowers clinicians across pediatric specialties to make informed decisions and provide better patient care. I challenge you to take advantage of all the great MSK US resources available through the AIUM and ask yourself how you could start incorporating this tool into your practice.

Drew Duerson, MD, RMSK, is a Sports Medicine physician in the Division of Sports Medicine at Nationwide Children’s Hospital. He is also a clinical associate professor of Pediatrics at the Ohio State University. Drew is a board-certified Pediatrician with a certificate of added qualification in Sports Medicine. He also holds a POCUS Musculoskeletal certification from the Alliance for Physician Certification and Advancement. 

Drew.Duerson@nationwidechildrens.org

@pedsmskusdoc

Drew Duerson, MD, RMSK

Interested in reading more about MSK ultrasound? Check out these on-demand webinars from the American Institute of Ultrasound in Medicine (AIUM):

Advancing Inflammatory Bowel Disease Management: Harnessing Intestinal Ultrasound for Screening and Monitoring

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Inflammatory bowel disease (IBD) encompasses a group of chronic inflammatory conditions of the gastrointestinal tract, primarily including Crohn’s disease and ulcerative colitis. The rate of patients affected by these conditions has been growing in the last decades, with an estimated 2.39 million Americans living with this diagnosis in 2020.1 About 25% of those affected are children.2 Active inflammation in the context of IBD increases the risk of disease complications, such as requiring surgery and developing colon cancer. However, symptoms have been shown to not accurately correlate to intestinal inflammation and ongoing bowel damage.3,4 Therefore, the assessment of disease activity relies on invasive techniques, such as colonoscopy and cross-sectional imaging (ie, Computer Tomography Enterography and Magnetic Resonance Enterography), which are costly and laborious tests. Repeated imaging using these techniques is important to assess for the complete reversal of inflammation, termed mucosal healing, which was shown to lead to much better long-term outcomes.5

Intestinal ultrasound (IUS) has emerged as a valuable technique for screening patients with concerning symptoms of IBD and monitoring individuals with known disease. It has the advantages of being feasible at the bedside in the gastrointestinal clinic, noninvasive, painless, requiring no preparation from the patient, and not exposing the patient to ionizing radiation. IUS has been used for monitoring disease activity for many years in Europe and is now being rapidly adopted in the United States.

IUS Features of Intestinal Inflammation

IUS is generally performed using a high-frequency linear transducer to visualize the intestinal wall and surrounding structures in real-time and a curvilinear low-frequency transducer to assess for disease complications, often located in the pelvis. The thickness of the bowel wall, which comprises layers such as the mucosa, submucosa, and muscularis, measures under 3mm in healthy adults, but this measurement increases in the setting of inflammation.6 Bowel layers can be distinct or more disturbed depending on disease severity. Other important features include the presence of abnormal increased Doppler signals in and along the bowel wall, which are usually absent in healthy patients and progressively more prominent in diseased bowel. Furthermore, peri-intestinal fat can be increased in the presence of disease. Examples of these IUS features are illustrated in Figure 1.

Figure 1A
Figure 1B

Screening With IUS

One of the key advantages of IUS in IBD management is its ability to screen for the presence of disease in patients with nonspecific symptoms that could be due to IBD. By visualizing the thickness of the intestinal wall, the presence of bowel wall edema, and the extent of inflammation, ultrasound can help identify active disease and assess its severity. Indeed, a study demonstrated that IUS could distinguish between patients with Irritable Bowel Syndrome (IBS) or functional symptoms and patients with new or flaring IBD.7,8 The use of IUS by trained providers can help with resource allocation and expedite invasive testing in the right patient without delays, and avoid unnecessary invasive investigation in patients who do not require it.

Monitoring Disease Progression and Treatment Response

In addition to screening, IUS can have a central role in monitoring response to treatment. Although there is a growing armamentarium of treatments for IBD, no single treatment has led to endoscopic remission rates higher than about 40–50%.9 Repeat ultrasound examinations can track changes in the thickness of the intestinal wall and complications over time. This real-time feedback allows for the timely optimization of treatment strategies, with subsequent improvement in patient outcomes. This proactive approach to objective evaluation of disease activity and continuous optimization of therapies, named the treat-to-target approach, has been demonstrated to improve long-term complication-free remission.5,10 Moreover, ultrasound can detect complications such as strictures, abscesses, and fistulas, guiding treatment decisions and surgical planning.

Advantages of IUS

Several factors contribute to the growing popularity of IUS in IBD management:

  1. Noninvasive: IUS does not require the insertion of instruments into the body, minimizing patient discomfort and reducing the risk of complications.
  2. Radiation-free: Unlike CT scans, which involve ionizing radiation, ultrasound uses harmless sound waves, making it safe for repeated examinations by professionals, including in pregnant women and children.
  3. Real-time imaging: IUS provides immediate feedback, allowing healthcare providers to assess disease activity and complications on the spot.
  4. Cost-effective: Compared to other imaging modalities, IUS is relatively affordable, potentially increasing patient accessibility in various healthcare settings.

Conclusion

Intestinal ultrasound (IUS) has emerged as a valuable tool in the screening and monitoring of inflammatory bowel disease. Its noninvasive nature, lack of radiation exposure, real-time imaging capabilities, and cost-effectiveness make it an attractive option for healthcare providers and patients alike. By incorporating IUS into the diagnostic algorithm for IBD, clinicians can improve the accuracy of diagnosis, optimize treatment strategies, and enhance patient outcomes.

In the ever-evolving landscape of IBD management, IUS stands out as a versatile and effective imaging modality, offering valuable insights into disease activity and treatment response. As research continues to elucidate its utility and refine its techniques, IUS is poised to play an increasingly prominent role in the personalized care of individuals living with IBD.

References:

  1. Lewis JD, Parlett LE, Jonsson Funk ML, et al. Incidence, prevalence, and racial and ethnic distribution of inflammatory bowel disease in the United States. Gastroenterology 2023 Nov; 165(5):1197–1205.e2. doi: 10.1053/j.gastro.2023.07.003. Epub 2023 Jul 20. PMID: 37481117; PMCID: PMC10592313.
  2. Abraham BP, Mehta S, El-Serag HB. Natural history of pediatric-onset inflammatory bowel disease: a systematic review. J Clin Gastroenterol 2012; 46:581–589.
  3. Modigliani R, Mary JY, Simon JF, et al. Clinical, biological, and endoscopic picture of attacks of Crohn’s disease. Evolution on prednisolone. Groupe d’Etude Thérapeutique des Affections Inflammatoires Digestives. Gastroenterology 1990; 98:811–818. doi: 10.1016/0016-5085(90)90002-i. PMID: 2179031.
  4. Jharap B, Sandborn WJ, Reinisch W, et al. Randomised clinical study: discrepancies between patient-reported outcomes and endoscopic appearance in moderate to severe ulcerative colitis. Aliment Pharmacol Ther 2015; 42:1082–1092. doi: 10.1111/apt.13387
  5. Ungaro RC, Yzet C, Bossuyt P, et al. Deep remission at 1 year prevents progression of early Crohn’s disease. Gastroenterology 2020 Jul; 159(1):139–147. doi: 10.1053/j.gastro.2020.03.039. Epub 2020 Mar 26. PMID: 32224129; PMCID: PMC7751802.
  6. Novak KL, Nylund K, Maaser C, et al. Expert consensus on optimal acquisition and development of the international bowel ultrasound segmental activity score [IBUS-SAS]: a reliability and inter-rater variability study on intestinal ultrasonography in Crohn’s disease. J Crohns Colitis 2021; 15:609–616. doi: 10.1093/ecco-jcc/jjaa216. PMID: 33098642; PMCID: PMC8023841.
  7. Novak KL, Jacob D, Kaplan GG, et al. Point of care ultrasound accurately distinguishes inflammatory from noninflammatory disease in patients presenting with abdominal pain and diarrhea. Can J Gastroenterol Hepatol 2016; 2016:4023065. doi: 10.1155/2016/4023065. Epub 2016 Apr 20. PMID: 27446838; PMCID: PMC4904691.
  8. St-Pierre J, Delisle M, Kheirkhahrahimabadi H, et al. Bedside intestinal ultrasound performed in an inflammatory bowel disease urgent assessment clinic improves clinical decision-making and resource utilization. Crohns Colitis 360 2023 Sep 21; 5(4):otad050. doi: 10.1093/crocol/otad050. PMID: 37809033; PMCID: PMC10558199.
  9. Cholapranee A, Hazlewood GS, Kaplan GG, Peyrin-Biroulet L, Ananthakrishnan AN. Systematic review with meta-analysis: comparative efficacy of biologics for induction and maintenance of mucosal healing in Crohn’s disease and ulcerative colitis controlled trials. Aliment Pharmacol Ther 2017 May; 45(10):1291–1302. doi: 10.1111/apt.14030. Epub 2017 Mar 22. PMID: 28326566; PMCID: PMC5395316.
  10. Colombel JF, Panaccione R, Bossuyt P, et al. Effect of tight control management on Crohn’s disease (CALM): a multicentre, randomised, controlled phase 3 trial. Lancet 2017 Dec 23; 390(10114):2779–2789. doi: 10.1016/S0140-6736(17)32641-7. Epub 2017 Oct 31. Erratum in: Lancet 2018 Dec 23; 390(10114):2768. PMID: 29096949.

Mallory Chavannes, MD, MHSc, is an Assistant Professor of Pediatrics in the Division of Gastroenterology, Hepatology, & Nutrition, and is Medical Director of the Inflammatory Bowel Disease Program, at Children’s Hospital Los Angeles.

Ultrasound: A New Approach to Treating Addiction

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Addiction is a complex and multifaceted condition that affects millions of individuals worldwide. Traditional treatments, such as behavioral therapy and medication, have varying levels of success. However, recent advancements in medical technology have opened new avenues for treating addiction, one of which involves the use of ultrasound. Although still being studied, this noninvasive technique is showing promise in helping individuals manage and overcome addiction by targeting specific areas of the brain involved in addictive behaviors.

To appreciate how ultrasound can be utilized in treating addiction, you need to understand the neurological underpinnings of addiction. Addiction often involves the brain’s reward system, particularly areas like the nucleus accumbens and the prefrontal cortex. These brain regions are responsible for the pleasurable sensations associated with substance use and the subsequent cravings and compulsive behaviors.

When an individual consumes an addictive substance, it triggers the release of dopamine, a neurotransmitter associated with pleasure and reward. Over time, the brain’s chemistry and circuitry can become altered, making it difficult for the individual to experience pleasure without the substance and leading to a cycle of dependency.

Ultrasound, traditionally used for imaging purposes, has found a new role in neuromodulation—altering nerve activity through targeted delivery of stimuli. Focused ultrasound (FUS) is a technique that uses sound waves to target specific areas of the brain with high precision. This method can modulate neural activity without the need for invasive procedures or pharmaceuticals.

How It Works

  • Targeting Specific Brain Regions: Ultrasound waves are precisely focused on brain areas implicated in addiction. This targeting can help modulate the activity of neurons in these regions, potentially reducing cravings and compulsive behaviors associated with addiction.
  • Noninvasive and Safe: One of the significant advantages of ultrasound therapy is its noninvasive nature. Unlike deep brain stimulation, which requires surgical implantation of electrodes, ultrasound therapy involves no incisions or physical alterations to the brain.
  • Adjustable: The effects of ultrasound neuromodulation can be adjusted by changing the frequency and intensity of the sound waves. Additionally, the treatment can be halted without lasting damage if any adverse effects occur.

Recent studies and clinical trials have explored the potential of ultrasound in treating various forms of addiction. For example, a study (see the report by the Washington Post) being conducted at the University of Virginia has demonstrated that FUS could modulate brain activity in regions associated with drug cravings. Participants who received focused ultrasound treatment showed a reduction in cravings and an improved ability to manage their addiction.

The application of ultrasound in addiction treatment is still in its early stages, but the preliminary results are promising. As technology advances and our understanding of the brain’s role in addiction deepens, ultrasound could become a cornerstone in the arsenal against addiction.

Future research will likely focus on optimizing the parameters of ultrasound therapy, such as determining the most effective frequencies and durations of treatment. Additionally, long-term studies are needed to assess the sustained benefits and potential risks of this approach.

Ultrasound therapy represents a new development in the field of addiction treatment. By offering a noninvasive, adjustable, and effective method for modulating brain activity, ultrasound has the potential to change the way we approach addiction. As research continues to unveil the full capabilities of focused ultrasound, it may provide new hope for individuals struggling with addiction, leading to more effective and accessible treatments.

The journey to overcoming addiction is challenging, but with innovations like ultrasound therapy, there is renewed optimism for those seeking to reclaim their lives from the grip of addiction.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in reading more? Check out these posts from the Scan:

Burnout, the Force Propelling Sonographers Away From Their Calling

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Amidst the bustling corridors and resonant discussions of the 2024 AIUM Ultracon conference, a groundbreaking revelation emerged from the forefront of medical imaging research. Shedding light on the intricate interplay between Work-Related Musculoskeletal Disorders (WRMSDs) and the often-overlooked specter of sonographer burnout, the collaborative inquiry of my colleagues and I sought merely to confirm existing associations but ultimately challenged entrenched assumptions. What materialized from our investigation was a surprising insight: burnout, eclipsing the physical strains of the profession, emerges as the predominant force propelling sonographers away from their calling. This revelation, underscored by the poignant narratives of our colleagues, beckons us to embark on a journey that redefines our understanding of occupational health and demands a holistic approach to safeguarding the well-being of every sonographer.

Professional research informs us that WRMSDs can cause a sonographer to leave the profession and that both WRMSDs and burnout share similar root causes. The intent of our research was to forward the discussion on WRMSDs, by determining if there is an association between the two conditions; an association we did find: burnout was the reason for a sonographer to consider leaving the profession, not a WRMSD. That eye-opening finding reshaped how we viewed our research results. What if the profession, instead of focusing on education and engineering as the way to prevent WRMSDs, looked closer at the psychosocial causes of WRMSDs? 

We were happy to see so many stakeholders, such as radiologists and administrators, express concern for sonographer burnout. While it was gratifying to find so much support from our colleagues, we were saddened by the many sonographers who spoke with us about their own experiences with burnout. During Ultracon, sonographers came up to us and expressed their thoughts of leaving the patient care environment, or that burnout was the reason they had already changed jobs. They voiced concern that pizza parties were viewed as solutions when what they really need is meaningful change to the work and professional culture that prioritizes profits and throughput over people. Sonographers are suffering in silence, and simply want to know someone cares for their well-being.  

How can we move forward knowing that burnout is an issue for the profession and that it is also a factor related to the WRMSD epidemic? Larger research studies are needed on sonographer burnout for us to fully understand not only the scope of the problem but also its root causes.

We encourage other researchers to look at sonographer burnout as a single issue in addition to exploring its relationship to WRMSDs. If we hope to attract young, talented people to pursue a sonography career, we need to show that the career is worth it to them. It is up to us, sonologists, administrators, and sonographers, to work together to ensure that our profession supports the whole sonographer, mind, and body. 

Jennifer Bagley, MPH, RDMS, RVT, FAIUM, FSDMS, is a professor and sonography program director for the College of Allied Health at the University of Oklahoma Health Sciences in Oklahoma City, Oklahoma. She also currently serves on the AIUM Board of Governors.

Interested in reading more about Sonography? Check out these posts from the Scan:

Ultrasound in Medical Education: The Person Behind the Probe

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In this blog post, we are going on a trip.

That’s right, let’s go on a trip back in time.

Think back to your first time picking up an ultrasound probe.

What did it look like? Who was instructing you? What were you scanning?

Did you feel confused? Lost in the little black and grey lines wiggling in unison with every movement of your hand.

Was your mind filled with wonder and awe at the ability to see right through the skin in real time? Or were you struck with confusion and pessimism? This isn’t practical. There’s no way I (or my specialty) will need to use this.

For some of us, the first time touching an ultrasound probe was a very long time ago, for others (like myself) it was just a few short months ago.

I am fortunate that my institution has incorporated ultrasound into our medical curriculum. We have had access to handheld ultrasound probes from the very first month of medical school. We are taught the physics behind sound waves and tissue echogenicity. We are encouraged to complete online modules, take ultrasound quizzes, and practice scanning as much as we can.

Hours have been spent scanning myself and my peers, trying to figure out what is what. Our faculty advisor aptly dubbed the ‘ultrasound champion’ showed us the ropes of how to improve our scanning. He was readily available, willing to explain, and quick to show what different views look like.

When he took on a different position, us students quickly found out that an ultrasound is only as good as the person behind the probe. Without our ‘ultrasound champion’ around, we quickly hit a glass ceiling, unable to elevate to the next steps in our scanning abilities.

In the ‘champion-less era,’ we have found other sources of knowledge. From online resources provided by the AIUM, YouTube, POCUS101, and SonoSim we are able to see what different views can look like. We have reached out to faculty, and they have been quick to give us bits of knowledge or take part in scanning sessions when they are available. We have collaborated with other schools in state-wide competitions, have begun scanning at student-run free health clinics, and attended AIUM conferences. We are getting better.

I view ultrasound medical education curriculum and the opportunities afforded by surrounding myself in scanning as the ultimate bridge between preclinical studies and my future in clinical medicine. The hands-on attribute of scanning mixes well with time in the books. No matter which specialty I choose, ultrasound will be a part of it as point-of-care sonography continues to grow into the scope and forefront of medical practice. While most of my ultrasound exploration has been done independently, having access to an ‘ultrasound champion’ was critical in my initial interest and excitement for ultrasound. One that I wish I still had access to.

The future of ultrasound is bright, and I am excited to share that many medical students coming up in training are extremely excited about ultrasound. We want to get better. We also need ‘ultrasound champions’ to be the catalysts that make us better.

If you are an ultrasound champion at your institution, I encourage you to keep the excitement that you felt when mastering ultrasound. You are helping your students unlock that ability.

If you have not yet taken steps to share your ultrasound skills, I urge you to share your knowledge with someone who may benefit from it, whether the person is a training nurse, a medical student like me, or even a colleague. If you have the desire to make ultrasound education a cornerstone of your practice, explore becoming the ‘ultrasound champion’ at your institution.

We need you behind the probe, showing us how it’s done so that we can be the ones behind the probe for years to come.

Brian Villa is a second-year medical student at a 4-year MD program in Florida, USA. During his very brief time in the medical field, he has taken a strong liking to point-of-care ultrasound and ultrasound in medical education. He is the leader of the Ultrasound Student Interest Group at his institution and has been included in conversations regarding ultrasound curriculum. He enjoys abdominal and thoracic ultrasound and his favorite view (as an avid fisherman) is the parasternal short axis ‘fish mouth’ mitral valve view.

Cesarean Scar Ectopic Pregnancy—The Importance of Ultrasound for Early Detection

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Cesarean scar ectopic pregnancy occurs when an embryo implants into or on a prior cesarean scar, and carries a high burden of maternal morbidity and increased risk of maternal mortality when left untreated.1 The estimated incidence is approximately 1 in 1800–2000 pregnancies after cesarean delivery.2 The key to prompt treatment is early identification, most commonly and easily accomplished with transvaginal ultrasound.

Cesarean delivery is the most commonly performed surgery in the world. In the United States, according to the Centers for Disease Control’s Stats of the States data from 2021,  the cesarean delivery rate varies from 24.3% in Utah to a high of 38.3% in Mississippi.3 While cesarean is often a necessary procedure in cases of fetal intolerance of labor, fetal malpresentation, or labor arrest, this surgery impacts future pregnancy, increasing the risks of the need for repeat surgical deliveries, uterine rupture during attempted labor, and placenta accreta spectrum disorders, the latter of which experts now recognize start as cesarean scar ectopic pregnancies.

Following any full-thickness myometrial surgery, just as with any other muscle, the transected myometrial fibers never truly heal together as they once were. Rather, the reapproximated ends are joined by a line of fibrosis, which may partially dehisce, and lack the usual thickness and elasticity of uncompromised myometrium. This scar sometimes retains some structural integrity, but often results in a “niche” or hollowed-out area within the muscle,4,5 where an embryo may implant.

Cesarean scar ectopic pregnancy (CSEP) is easiest to detect sonographically early in the early first trimester, when it can be recognized as a low implantation that is offset more anteriorly than normal, often leaving the endometrial cavity and cervical canal empty.6 Additional criteria for the diagnosis of  CSEP include thin or undetectable myometrium between the placenta and bladder and unusually increased vascularity between the placenta/sac and bladder or internal cervical os. 

Some experts have proposed simple-to-perform measurements, such as the “crossover sign,” whereby a line is drawn in the sagittal plane connecting the internal os with the fundus by drawing a line along the endometrial canal.7 When the superior-inferior diameter of the gestational sac is measured perpendicularly to this line, the relationship of the gestational sac to the endometrial line can be determined.6 In CSEPs in which a majority of the gestational sac is closer to the anterior wall (crosses over the endometrial line), there is a higher rate of severe forms of placenta accreta spectrum and risk for rupture when CSEPs are managed conservatively.7,8

As pregnancy progresses, the gestational sac may grow into the endometrial cavity, making the diagnosis more difficult. Treatment is also more difficult as pregnancy progresses, whereby medical or mechanical management options, such as use of a double balloon catheter are less effective, and surgical resection or combination therapy may be required. The risk of complications including uterine rupture, massive bleeding, and need for emergent hysterectomy that approaches 53% of reported cases are reasons why expectant management is not recommended, especially as early treatment has efficacy rates that are reported between 65% to more than 99% with low complication rates, and with a high likelihood of fertility preservation.  

Early recognition and referral are paramount and provide one more example of how ultrasound can and does save lives.

References:

1. Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, et al. Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2018; 51:169–175. doi:10.1002/uog.17568

2. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207:14–29.

3. Centers for Disease Control. Stats of the States – Cesarean Delivery Rates. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm. Accessed March 30, 2024.

4. Einerson BD, Comstock J, Silver RM, Branch DW, Woodward PJ, Kennedy A. Placenta accreta spectrum disorder: uterine dehiscence, not placental invasion. Obstet Gynecol 2020; 135:1104–1111. doi:10.1097/AOG.0000000000003793.

5. Jauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol 2022; 227:384–391. doi:10.1016/j.ajog.2022.02.038.

6. Timor-Tritsch IE, Monteagudo A, Calì G, D’Antonio F, Kaelin Agten A. Cesarean scar pregnancy: diagnosis and pathogenesis. Obstet Gynecol Clin North Am 2019; 46:797–811. doi:10.1016/j.ogc.2019.07.009.

7. Cali G, Forlani F, Timor-Tritsch IE, Palacios-Jaraquemada J, Minneci G, D’Antonio F. Natural history of Cesarean scar pregnancy on prenatal ultrasound: the crossover sign. Ultrasound Obstet Gynecol 2017; 50:100–104. doi:10.1002/uog.16216.

8. Calì G, Calagna G, Khalil A, Polito S, Labate F, Cucinella G, D’Antonio F. First trimester prediction of uterine rupture in cesarean scar pregnancy [published online ahead of print April 20, 2022]. Am J Obstet Gynecol. doi: 10.1016/j.ajog.2022.04.026.

9. Miller R, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine consult series #63: cesarean scar ectopic pregnancy. Am J Obstet Gynecol 2002 Sep: 227(3):B9–B20. doi: https://doi.org/10.1016/j.ajog.2022.06.024.

Karin A. Fox, MD, MEd, FACOG, FAIUM, is a Professor of Maternal-Fetal Medicine and Director of the Placenta Accreta Spectrum Disorders Program at the University of Texas Medical Branch at Galveston.

Recommendations for Improved Safety of Lung Ultrasound

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Lung ultrasound (LUS) has been emerging as a vital clinical tool. LUS aids in diagnosing a range of conditions, from pneumonia to respiratory distress syndrome or pulmonary edema. LUS was also very significant at the height of the COVID-19 pandemic, when point-of-care lung monitoring modalities were crucial.  

Diagnostic ultrasound standards and safety guidelines were established in the late 20th century to ensure the safety of ultrasound imaging and avoid ultrasound bioeffects in tissues. The Thermal Index (TI) and Mechanical index (MI) are two ultrasound exposure indices that respectively indicate the risks of tissue heating and cavitation and which must be displayed in real time during scanning. However, the lung is a tissue like no other, and the bioeffects observed in animal studies (in mice, rabbits, pigs, and monkeys) are very different from the bioeffects observed in other tissues. Capillary pulmonary hemorrhage is a unique bioeffect that is correlated to the MI. In order to avoid such specific ultrasound bioeffects, a new safety paradigm must be created for LUS.

Despite guidelines recommending MI ≤ 0.4, recent research suggests that a further reduction to MI ≤ 0.3 for enhanced safety might be needed. In addition, it is critical to account for the actual MI in situ, which is influenced by the thickness of the chest wall. This is particularly concerning in neonatal LUS safety, due to thin chest walls and intensive use.

Existing safety education varies among practitioners, and surveys indicate a lack of knowledge regarding lung ultrasound safety. In the absence of an appropriate preset, pre-installed on all machines, for neonatal LUS guaranteeing an MI ≤ 0.3, the risk of error and exposure to higher MI is significant. In pediatric and adult patients with a thicker chest wall, a higher MI would be acceptable, as long as adherence to the “as low as reasonably achievable” (ALARA) safety principle is maintained.

Overall, the recommendations for Improved Safety  of Lung Ultrasound are:

  1. To install a preset on all ultrasound machines limiting MI to ≤ 0.3 for neonatal cases.
  2. To provide a user-friendly means for practitioners to select the safety preset without manual adjustments.
  3. To allow higher MI values for pediatric and adult patients when needed for optimal imaging, considering higher ultrasound attenuation in thicker chest walls.
  4. To guide practitioners in adhering to the As Low As Reasonably Achievable (ALARA) principle and by considering the chest wall attenuation for MI > 0.3.
  5. To develop a specific Mechanical Index for Lung (MIL). The creation of a unique MIL for LUS, displayed on-screen to estimate pleural exposure accurately would increase safety and safety awareness among practitioners.

Enhancing safety in LUS requires a multifaceted approach, encompassing preset implementation, practitioner education, and technological advancements. The proposed recommendations aim to address current safety challenges, ensuring the continued effectiveness and safety of lung ultrasound in diverse clinical settings and for diverse populations (from neonates to high BMI patients). By combining technological innovations with user-friendly controls, the proposed safety paradigm seeks to strike a balance between optimal imaging outcomes and patient safety in the evolving landscape of LUS.

For more information, see the “Statement and Recommendations for Safety Assurance in Lung Ultrasound” from the American Institute of Ultrasound in Medicine (AIUM)

Marie Muller, PhD, is an Associate Professor of Mechanical and Aerospace Engineering at NC State University.

Introduction to the Emerging Field of Post Cranioplasty Neurosonography

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The field of neurosonography has evolved in the past few decades facilitating detailed anatomical evaluation of the central nervous system (CNS) of the unborn fetus (fetal neurosonography)1–2 and newborn child (neonatal neurosonography).3 During these early stages of life, neurosonography is possible due to the presence of physiologic acoustic windows such as the fontanelle and unfused sutures of the skull, allowing the ultrasound waves to penetrate the brain tissue. Both 2D and 3D ultrasound have been used to obtain the required images of neurosonography.4 This technique enables a high-resolution, safe, readily available, and relatively inexpensive modality to obtain a detailed evaluation of the intra-cranial anatomy and vascular system that may be comparable in quality to that of other imaging modalities such as MRI.5 As the fontanelle and cranial sutures close during early childhood and the skull bone thickens, ultrasound can no longer be used to generate images of the brain. Therefore, adult neurosonography has significant limitations with use limited to transcranial Doppler imaging.

Recently, full or partial replacements of skull composed of an ultrasound-penetrable synthetic substitute, ie sonolucent cranial implants, have been available for post craniotomy skull replacement. Early experience by neurosurgeons that elect to use this technique offer their patients the potential of postoperative bedside sonographic assessment of the CNS of these individuals.6

In this report, we share our collaborative experience and enthusiasm about the emerging field of post cranioplasty neurosonography. Craniotomy is one of the most common surgical procedures performed in the US with indications ranging from surgical evacuation of intracranial bleed, hydrocephalus, brain tumors, and vascular lesions. Sonolucent cranial implants may replace a portion of the native skull or be used as a fully customized implant to restore form and function for cranial reconstruction procedures. In addition to the different sizes and shapes, these next-generation implants allow for postoperative imaging with ultrasound.

The sonolucent implant provides an acoustic window via a synthetic adult “fontanelle”. Depending on the location and size of the device, the assessment of the brain may be facilitated in different planes and points of view. Most commonly, the implants are located above the pathology (figure 1) and off the skull midline with the sagittal sinus preserved. Thus, the acoustic window enables the ability to easily image the brain in the coronal (Figure 2) and axial (Figure 3) planes. In cases where the implant approaches or covers the midline, evaluation in the sagittal plane (paramedian and even midsagittal/median) is possible (Figure 4) in addition to that of the coronal plane. Moreover, the closer the implant is to the midline, the easier the access is to image both hemispheres.

Image demonstrating the sonolucent burr hole cover and its use for ultrasound of the adult brain.
Figure 1: Left, An adult skull with a sonolucent implant. Right, Ultrasound of the adult brain in the coronal plane through a sonolucent implant.
Figure 2: Coronal view of the brain through a temporal sonolucent implant.
Figure 3: Axial view of the brain through a temporal sonolucent implant.
Figure 4A: Sagittal view through the lateral ventricle (paramedian).
Figure 4B: Median/midsagittal view through a sonolucent implant over the sagittal suture.

Post cranioplasty neurosonography can be done with point-of-care ultrasound by the neurosurgical or neurology teams in the acute postoperative period, in-office surveillance visit, or as a detailed evaluation in a neuro-radiology unit set up. We have used this technique in these setups to assess several postoperative parameters such as evaluation for possible midline shift, lateral ventricles for size, shape, potential bleed, and location of a shunt or ventricular catheter, patency of vascular anastomosis, as well as the evaluation of the brain parenchyma for postoperative pathologies such as presence of tumor or intracranial hemorrhage. Sequential surveillance is facilitated by the fact that the acoustic window is fixed so images are easily obtained in the exact same anatomical plane on subsequent scans.

As the clinical utilization of sonolucent grafts and experience with post cranioplasty neurosonography expand, there is much to be determined on how to best incorporate this emerging technology into patient care. For example, identifying the ideal diagnostic probe as there is no designated probe currently in the market. We have used both a curvilinear probe with a high-resolution abdominal setting and a cardiac phased array probe, ie, small footprint probes, with success. Indeed, the probe characteristics may vary between different lesions requiring different levels of penetration. As the implant is hard, and in many cases convex and of small size, a wide-sector, small footprint, high-resolution probe may offer the best access.

Future utilization and study will determine how post cranioplasty neurosonography influences the utilization of other imaging modalities (CT and MRI). Additional benefits potentially include decreased exposure to radiation, better point-of-care access to imaging, and a direct impact on healthcare costs.

Lastly, it is still to be determined which clinicians (neurosurgeons, neurologists, radiologists, neuro-intensivists, ACPs), and in which setup (point of care vs radiology suite) will master the techniques and take the lead in this emerging field. Regardless, it appears that the ultrasound community has a new and exciting opportunity at hand. 

References:

  1. Malinger G, Paladini D, Haratz KK, Monteagudo A, Pilu G, Timor-Tritsch IE. ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 1: performance of screening examination and indications for targeted neurosonography. Ultrasound Obstet Gynecol 2020; 56:476–484.
  2. Paladini D, Malinger G, Birnbaum R, et al. ISUOG Practice Guidelines (updated): sonographic examination of the fetal central nervous system. Part 2: performance of targeted neurosonography. Ultrasound Obstet Gynecol 2021; 57:661–671. https://doi.org/10.1002/uog.23616.
  3. Rossi A, Argyropoulou M, Zlatareva D, et al; ESNR Pediatric Neuroradiology Subspecialty Committee; ESPR Neuroradiology Taskforce. European recommendations on practices in pediatric neuroradiology: consensus document from the European Society of Neuroradiology (ESNR), European Society of Paediatric Radiology (ESPR) and European Union of Medical Specialists Division of Neuroradiology (UEMS). Pediatr Radiol 2023; 53:159–168. doi: 10.1007/s00247-022-05479-4.
  4. Bornstein E, Monteagudo A, Santos R, et al. Basic as well as detailed neurosonograms can be performed by offline analysis of three-dimensional fetal brain volumes. Ultrasound Obstet Gynecol 2010 Jul; 36(1):20–25. doi: 10.1002/uog.7527.
  5. Malinger G, Paladini D, Pilu G, Timor-Tritsch IE. Fetal cerebral magnetic resonance imaging, neurosonography and the brave new world of fetal medicine. Ultrasound Obstet Gynecol 2017; 50:679–680.
  6. Williams AL, Abu-Bonsrah N, Lee RP, et al. Letter: The role of sonolucent implants in global neurosurgery. Neurosurgery 2024; 94:e1–e5. doi: 10.1227/neu.0000000000002723.

Eran Bornstein, MD, FACOG, FAIUM

Dr Bornstein is an Associate Professor of Obstetrics & Gynecology at the Zucker School of Medicine at Hofstra, and the Director of the Center for Maternal Fetal Medicine and Ultrasound in OBGYN, at Lenox Hill Hospital, Northwell, in New York.

Netanel Ben-Shalom MD, FNPS

Dr Ben-Shalom is an Assistant Professor of Neurosurgery at the Zucker School of Medicine at Hofstra, and a neurosurgeon at Lenox Hill Hospital/Northwell, in New York.

David Langer, MD, FNPS

Dr Langer is an Associate Professor of Neurosurgery at the Zucker School of Medicine at Hofstra, and the Chair of the department of neurosurgery at Lenox Hill Hospital/Northwell, in New York.

You Won’t Be Left in the Dark at UltraCon (except during the total eclipse!)

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Have you considered how you will spend April 8 (well, April 6–10, 2024, actually)? The place to be on the 8th is somewhere you can be in the path of totality during the total solar eclipse, and what better place to be than Austin, TX, where you can see the eclipse and get your fill of everything ultrasound?

(and probably the cheapest way to get a hotel room is to register for UltraCon 2024 and grab a room while we still have affordable rooms in our block).

The AIUM brings our annual meeting to Austin, TX, for the first time, and there will be lots to take in. We are bringing back Educational Tracks. No matter where your interests lie, MSK or Fetal Echo or General US or OB or GYN, there is a track for you! There is something for you, whether you are early in your career or an experienced sonographer/sonologist. You will hear presentations from experts that will keep you up to date on changes in the field and tell you what is coming down the pike. For our members who are deep into the basic sciences, some presentations will stimulate new thinking and show you what other colleagues are up to. One of the best parts of the program is that you aren’t stuck in one track—you can mix and match to customize your experience. Check out the tracks here.

UltraCon brings you more than just the educational tracks. Is there a product that you have always wanted to develop and commercialize? Perhaps an invention, a training program, or another idea you are sure could be monetized? If so, the AIUM’s Shark Tank is for you! Put together your best proposal and present it to our panel of experts from industry, venture capital, and academia. $1,000 is up for grabs, but win or lose, you will gain valuable insights and critical appraisal of your concept, along with suggestions for what you need to do to take your proposal to the next step.

Scientific sessions run throughout the meeting, allowing you to hear cutting-edge research that will help answer some of the questions you might be having or possibly give you ideas to pursue on your own. You will hear from young researchers just starting out their careers as well as experienced scientists who have gotten us where we are today but aren’t done leading us yet.

One of the best aspects of the annual meeting is the chance to hear from luminaries and others with cutting-edge ideas, whether in ultrasound directly or in fields that will impact ultrasound, such as artificial intelligence and other new technologies. This year’s plenary sessions will be captivating as we hear from Dr Omar Ishrak on the future of ultrasound technology and from Dr Gil Weinberg on an amazing application of ultrasound to offer amputees the opportunity to play musical instruments.

Other talks will cover how CPT codes are developed, how to efficiently complete your application for accreditation, and so much more that will round out your experience in Austin.

UltraCon 2024 promises to be a Top Shelf event that you really don’t want to miss—and yes, we have scheduled a break to go outside to see the eclipse, so you won’t be asked to decide between these 2 once-in-a-lifetime events! Note that our hotel block is probably the least expensive deal in town, as our rates were negotiated years ago before many were paying attention to this eclipse. It is entirely possible we will sell out our block of rooms, so make your plans and register as soon as possible!

David C. Jones, MD, FACOG, FAIUM, the AIUM’s President Elect, is a Professor at the University of Vermont and the Director of the Fetal Diagnostic Center at the University of Vermont Medical Center.

Echocardiography: Visualizing Our Most Vital Organ—The Heart

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Among the constant advances in medical imaging, one innovation, ultrasound, stands out for its ability to assist us in the care of our most vital organ—the heart. Ultrasound imaging is commonly associated with monitoring pregnancies and, as a result, has become established in cardiology. This imaging modality is a noninvasive means of viewing the heart’s chambers and valves, and, in honor of Heart Health Month, I will give an overview of echocardiography and how ultrasound is a safe and effective tool in the medical care of the heart.

The Symphony of Sound Waves

Ultrasound technology relies on sound waves beyond the range of human hearing to create detailed images of the heart. Echocardiography, the specialized use of ultrasound for cardiac imaging, enables healthcare professionals to visualize the heart’s structure, function, and blood flow in real time. This noninvasive procedure has become a cornerstone in diagnosing and managing various cardiovascular conditions.

Diagnosis With Precision

One of the most remarkable aspects of ultrasound in cardiac care is its precision in diagnosing a wide array of heart conditions. From detecting congenital heart defects in newborns to assessing valve function and identifying structural abnormalities, echocardiography provides clinicians with a comprehensive view of the heart’s health.

Real-Time Insight Into Function

Unlike static imaging techniques such as X-rays or CT scans, echocardiography allows for dynamic, real-time assessment of the heart’s function. This invaluable feature aids in diagnosing conditions like heart failure, where the heart’s pumping efficiency is compromised. Clinicians can observe the heart’s ejection fraction, chamber dimensions, and wall motion, facilitating prompt and accurate treatment decisions.

Guiding Treatment Strategies

Ultrasound not only assists in diagnosis but also plays a crucial role in guiding treatment strategies. For patients with heart rhythm abnormalities, echocardiography helps identify the underlying causes, allowing for the implementation of targeted interventions such as ablation procedures. Additionally, it provides essential guidance during surgical interventions, ensuring precise and successful outcomes.

Monitoring Cardiovascular Health

Cardiac care extends beyond diagnosis and treatment; ongoing monitoring is essential for individuals with chronic cardiovascular conditions. Ultrasound enables clinicians to track changes in the heart over time, adjusting treatment plans as needed. This proactive approach enhances patient outcomes and contributes to the overall management of cardiovascular health.

Advancements in Technology

As technology continues to advance, so does the capability of ultrasound in cardiac care. 3D and 4D echocardiography now offer even more detailed and immersive views of the heart’s anatomy and function. These innovations provide clinicians with enhanced diagnostic tools, fostering a deeper understanding of cardiac physiology and pathology.

Patient-Friendly and Accessible

Beyond its diagnostic and therapeutic benefits, ultrasound in cardiac care is remarkably patient-friendly. The procedure is noninvasive, painless, and does not involve ionizing radiation, making it a safe option for individuals of all ages when performed by professionals. Moreover, the widespread availability of ultrasound machines ensures accessibility for patients across diverse healthcare settings.

Conclusion

As technology continues to evolve, so too will the capabilities of ultrasound, promising an even brighter future for the millions whose hearts need extra care.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in learning more about echocardiography? Check out the following posts from the Scan: