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Point-of-Care Ultrasound: New Concepts and Future Trends
Yaoting Wang, MD, Huihui Chai, MD, Ruizhong Ye, MD, Jingzhi Li, MD, PhD, Ji-Bin Liu, MD, Chen Lin, Chengzhong Peng, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 268-276.   DOI: 10.37015/AUDT.2021.210023
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Ultrasound (US) technology, with major advances and new developments, has become an essential and first-line imaging modality for clinical diagnosis and interventional treatment. US imaging has evolved from one-dimensional, two-dimensional to three-dimensional display, and from static to real-time imaging, as well as from structural to functional imaging. Based on its portability and advanced digital imaging technique, US was first adopted by emergency medicine in the 1980s and gradually gained popularity among other specialists for clinical diagnosis and interventional treatment. Point-of-Care Ultrasound (POCUS) was then proposed as a new concept and developed for new uses, which greatly extended clinical US applications. Nowadays, artificial intelligence (AI), cloud computing, 5G network, robotics, and remote technologies are starting to be integrated into US equipment. US systems have gradually evolved to an intelligent terminal platform with powerful imaging and communication tools. In addition, specialized US machines tend to be more suitable and important to meet increasing demands and requirements by various clinical specialties and departments. In this article, we review current US technology and POCUS as new concepts and its future trends, as well as related technological developments and clinical applications.

Micro/Nanobubbles Driven Multimodal Imaging and Theragnostics of Cancer
Xiaoting Zhang, BS, Zhifei Dai, PhD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 163-172.   DOI: 10.37015/AUDT.2021.200053
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Ultrasound imaging has attracted great interest of researchers due to their application in cancer diagnosis and treatment. Ultrasound contrast agents, microbubbles and nanobubbles are widely explored as a multifunctional platform, not only carrying other contrast agents for multimodal imaging to complement the disadvantages of each imaging modality, but also carrying drug/gene for cancer theragnostic. In this article, the characteristics and differences of microbubbles and nanobubbles are briefly introduced and reviewed. Besides, the microbubbles and nanobubbles driven multimodal imaging and theragnostic of cancer are summarized.

Prenatal Ultrasound Diagnosis of Klippel-trenaunay Syndrome Associated with the Thickened Thigh and Dilated Inferior Vena Cava: A Case Report and Literature Review
Shiyun Peng, MM, Pan Yang, MM, Jinzhou Wan, MM, Siyu Yue, MB, Ling Wang, MB, Xiyue Zhang, MB, Fan Yang, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 313-316.   DOI: 10.37015/AUDT.2021.210012
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Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder. In this case study, we reported prenatal ultrasound study on a 33-year-old pregnant woman at the gestation of 26 weeks and 3 days, whose fetus was suspected of KTS associated with enlarged right thigh and dilated inferior vena cava. Additionally, we comprehensively reviewed literatures of prenatal KTS published on Medline to further understanding of the prenatal ultrasonographic manifestations of KTS.

Sonographic Features of Borderline Phyllodes Tumor of the Breast: A Case Report
Yaqin Sun, MD, Shumin Wang, MD, PhD, Zhanfei Zhe, MD, Xin Qi, MD, Li Li, MD, Qin Liu, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 262-264.   DOI: 10.37015/AUDT.2021.210006
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Phyllodes tumors of the breast are rare fibroepithelial neoplasm which are generally divided into benign, borderline, or malignant. In this case study, we reported a 40-year-old female presented with an asymptomatic right breast mass underwent sonographic evaluation. The surgical histopathology was diagnosed as borderline phyllodes tumor. Sonographic features of the tumor are described in detail, and the relevant literatures are reviewed and discussed.

Value of Ultrasound Images and Reports Scoring System in Quality Control
Li Qiu, MD, Yulan Peng, MD, Qiang Lu, MD, Yan Luo, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 245-248.   DOI: 10.37015/AUDT.2021.210003
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Objective: To assess the value of ultrasound images and reports scoring system for quality control in clinical ultrasound practice.
Methods: Ultrasound images and reports scoring system was established and implemented in the Department of Medical Ultrasound at West China Hospital of Sichuan University in 2014. The scoring system along with formulated corresponding management measures was used for quality control of ultrasound examination and clinical practice assessment. The quantitative scoring results were summarized and analyzed.
Results: Through the quantitative assessment of the quality of the images and reports of ultrasound examinations, the total report score in our department had risen from 4.93 in 2014 to 4.98 in 2018. “Inconsistency between description and conclusion” accounted for 46.47% of all report errors, which was the most common report error. The total image score also increased slightly to ≥ 4.98 during the past three years. The most common image error was “not saving color Doppler images”, which accounted for 84.48% of all image errors. The total score of images was higher than that of text reports.
Conclusion: It is important to establish the ultrasound images and reports scoring system for quality control of ultrasound practice. Using quantitative scores for ultrasound images and reports can improve the quality control of ultrasound examination and strengthen the management of clinical operation.

Targeted Delivery of Therapeutic Gas by Microbubbles
Lingling Xu, MM, Yihan Chen, MM, Qiaofeng Jin, PhD, Li Zhang, MD, Wenpei Fu, BS, Shan Lin, MM, Ling Lin, BS, Rui Wang, BS, Dandan Chen, MM, Zhengyang Han, MM, Mingxing Xie, MD, Yali Yang, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 173-182.   DOI: 10.37015/AUDT.2021.200059
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Gas therapy is a new therapeutic method that has been developed in recent years and shows great clinical prospects for the treatment of tumours and cardiovascular, nerve, and immune system diseases. Therapeutic gases, including oxygen, hydrogen, nitric oxide, hydrogen sulfide, xenon, and other bioactive gases are involved in modulating cell signaling pathways and have important physiological functions with substantial therapeutic potential. However, their precise delivery remains a major challenge. Recently, researchers began to use ultrasound to trigger microbubbles that have encapsulated these gases for intravenous administration. This not only enhances the contrast of ultrasound imaging, but also precisely releases gases in the targeted area using ultrasound-targeted microbubble destruction. This article reviews the latest advances in the use of microbubbles to load therapeutic gases for the treatment of diseases.

Ultrasound Elastography in Liver Tissue: Current Status
Mingzhu Zhang, MD, Zhaoyan Ding, MD, Xiaoyan Niu, MD, Yuxiu Gao, MD, Cheng Zhao, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 197-203.   DOI: 10.37015/AUDT.2021.210014
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Chronic liver disease is common in China and worldwide, with liver fibrosis as the primary pathological finding. Any chronic liver disease can lead to hepatic fibrosis and gradually develop into cirrhosis. Complications, such as portal hypertension, gastrointestinal bleeding, and liver failure can occur. Some patients even develop hepatocellular carcinoma. Thus, timely diagnosis of hepatic fibrosis is vital for the assessment of etiology, treatment, and prognosis. Conventional ultrasound imaging shows low sensitivity with its subjectivity for preliminary diagnosis of liver fibrosis, creating limitations in qualitative and quantitative evaluation. Ultrasound elastography is a recently developed technique that can help overcome these limitations. The elastic imaging method combines conventional ultrasound to assess liver stiffness along with routine examination. This "one-stop" check for liver disease opens new prospects for clinical and scientific research and improves the accuracy of disease diagnosis for broad clinical application. This article will review the current status of ultrasound elastography for its applications in chronic liver diseases.

Doppler-based Renal Resistive Index for Prediction of Acute Kidney Injury in Critically Ill Patients: A Systematic Review and Meta-analysis
Jianing Zhu, MD, Ying Zhang, MD, Xiaoming Li, MD, Qiuyang Li, MD, PHD, Yukun Luo, MD, PHD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 183-196.   DOI: 10.37015/AUDT.2021.210013
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Objectives: To determine the efficacy of Doppler-based renal resistive index (RRI) in the prediction of acute kidney injury (AKI) in critically ill patients.
Methods: A systematic review and meta-analysis of cohort studies was conducted. Relevant studies were identified in PubMed, Embase and Cochrane Library from inception to November 1, 2020, and reference lists of identified primary studies. Prospective studies that examined the diagnostic accuracy of RRI in AKI were included.
Results: Among the 126 articles identified, 18 were included, with a total of 1656 patients. Bivariate analysis yielded pooled sensitivity and specificity of 0.81 (95% CI 0.74-0.86) and 0.75 (95% CI 0.65-0.83), respectively. The summary positive likelihood ratio was 3.2 (95% CI 2.2-4.6), and negative likelihood ratio was 0.26 (95% CI 0.19-0.36).
Conclusion: Elevated RRI may be an early predictor of AKI in critically ill patients. Further large-scale prospective studies are needed to confirm the predictive efficacy and determine the performance and optimal cutoff value of RRI among the included studies.

Characterization of Breast Lesions: Comparison between Three-dimensional Ultrasound and Automated Volume Breast Ultrasound
Wanru Jia, MD, Jingwen, Zhang, MD, Yijie Dong, MD, Ying Zhu, MD, Xiaohong Jia, MD, Weiwei Zhan, MD, Jianqiao Zhou, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 204-211.   DOI: 10.37015/AUDT.2021.210007
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Objective: This study aimed to compare the diagnostic performance of three-dimensional ultrasound (3D-US) and automated breast volume scanner (ABVS) for the characterization of benign and malignant breast lesions.
Methods: Ninety patients who underwent surgery and preoperative conventional ultrasound (US), 3D-US, and ABVS examinations were enrolled in this study. The image quality and adjacent structures of the lesions in the coronal plane were compared. The combination of US, 3D-US, and ABVS for retraction phenomenon of the lesion was compared and the diagnostic performance of each combination was analyzed.
Results: ABVS displayed better image quality and adjacent structures than 3D-US (P < 0.001). The area under the curve (AUC) was 0.913, 0.842, and 0.871 for US, 3D-US, and ABVS, respectively. The AUC of the retraction phenomenon of the lesion was 0.732 and 0.810 for 3D-US and ABVS, respectively. When they were combined, US+ABVS showed the highest AUC of 0.924. No significant difference of diagnostic performances was found among conventional US, US+3D-US, and US+ABVS(P > 0.05).
Conclusions: Compared with 3D-US, ABVS seems to be superior in showing the retraction phenomenon of breast lesions and in the characterization of breast lesions alone or in combination with conventional US. Although no significant difference was observed between them, both ABVS and 3D-US provided valuable information in the coronal plane and improved our confidence level in breast lesion characterization, especially when combined with the conventional US.

Contrast-enhanced Ultrasound Assessment of Treatment Response in a Patient with Multifocal Hepatocellular Carcinoma Treated with Transarterial Chemo and Radioembolization
Esika Savsani, Mohamed Tantawi, MD, Corinne E. Wessner, MBA, RDMS, RVT, Philip Lee, MD, Andrej Lyshchik, MD, PhD, Kevin Anton, MD, PhD, Colette M. Shaw, MD, Ji-Bin Liu, MD, John R. Eisenbrey, PhD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 254-257.   DOI: 10.37015/AUDT.2021.210018
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Minimally invasive locoregional therapies have become important treatment options for patients with intermediate or late-stage hepatocellular carcinoma (HCC) who are ineligible for surgical resection or liver transplantation. Imaging modalities are essential for procedural guidance and for assessing treatment response thereafter. We report a unique finding of a patient with multifocal HCC treated with transarterial radioembolization (TARE) with yttrium-90 (Y90) and transarterial chemoembolization (TACE). We compared contrast-enhanced ultrasound (CEUS) with contrast-enhanced magnetic resonance imaging (CE-MRI) in the evaluation of treatment response to demonstrate advantages of CEUS imaging technique and its early detection of viable tumor.

Comparison of Diagnostic Efficacy of US, CT, and MRI for Pancreatic Intraductal Papillary Mucinous Neoplasms
Yue Yu, MM, Ling Zhang, MM, Bangwei Zeng, MM, Zhikui Chen, PhD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 291-297.   DOI: 10.37015/AUDT.2021.210008
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Objective: Imaging modalities for pancreatic intraductal papillary mucinous neoplasm (IPMN) often provide a large amount of information, and an adequate comparison of their diagnostic efficacies cannot be made by simply referring to the diagnostic accuracy rates. The aim of the study was to apply a novel scoring system to evaluate the pancreatic IPMN diagnostic efficacy of transabdominal ultrasound (TAUS), computed tomography (CT), and magnetic resonance imaging (MRI).

Methods: The clinical and diagnostic imaging data of 42 patients with pancreatic IPMN diagnosed at Fujian Medical University Union Hospital between January 2014 and November 2020 were retrospectively analyzed. We applied our scoring system for the quantitative, location, and qualitative diagnosis of each imaging modality, and the diagnostic efficacy was determined.

Results: The mean rank scores of quantitative diagnosis for MRI, CT, and TAUS were 53, 48.96, and 48.54, respectively (P = 0.267). The mean rank scores of location diagnosis for these three methods were 51.72, 49.58, and 48.97, respectively (P = 0.752). The mean rank scores of qualitative diagnosis for MRI, CT, and TAUS were 59.69, 41.08, and 51.18, respectively; the difference was statistically significant (P = 0.015).

Conclusions: The novel scoring system could comprehensively and accurately evaluate the diagnostic efficacy of TAUS, CT, and MRI for pancreatic IPMN. MRI had the highest quantitative, localization, qualitative, and comprehensive diagnostic efficacy.

Automated Measurements of Left Ventricular Ejection Fraction and Volumes Using the EchoPAC System
Xiaoxue Chen, MD, Shaoling Yang, PhD, Qianqian He, MD, Yin Wang, PhD, Linyan Fan, MD, Fengling Wang, MD, Kun Zhao, MD, Jing Hu, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 226-235.   DOI: 10.37015/AUDT.2021.200072
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Objective: To evaluate the clinical value of automated measurements by AutoEF (GE EchoPAC system, version 113) in left ventricular (LV) volumes and ejection fraction (EF) estimation based on the biplane Simpson’s method (manual method) in different clinical subsets.
Methods: A total of 322 subjects participated in this study (the common group). In the common group, 112 patients with coronary heart disease (CHD) were divided into the CHD group, and 34 CHD patients with LV wall motion abnormalities (WMA) comprising the CHD group, renamed the WMA group. LV volumes and EF were assessed using both manual tracing and automated estimation. Time spent on each method was documented. The agreements in echocardiographic measurements by different methods were assessed by intraclass correlation coefficients (ICC) and Bland-Altman analysis.
Results: The average analysis time of the automated method was 12 ± 1 s/patient with excellent repeatability. ICC revealed good consistency between manual and automated EF in all groups, especially in the CHD and WMA groups, although Bland-Altman analysis showed non-negligible bias in EF estimation between the two methods. ICC analysis showed a good correlation between automated and manual EF in all the good and poor image quality subgroups.
Conclusion: Automated method by AutoEF was a time-saving, excellent reproducible, and resistant to image interference approach, with a strong potential in left ventricular function measurements, especially for patients with CHD and/or WMA.

Cover, Foreword and Content
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 0-0.  
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Contrast-enhanced Ultrasound for Diagnosing Pancreatic Solitary Fibrous Tumor: A Case Report
Lei Chen, MM, Cong Chen, MM, Qingfu Qian, MM, Zhikui Chen, PhD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 265-267.   DOI: 10.37015/AUDT.2021.210004
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Solitary fibrous tumors (SFTs) are rare, especially in the pancreas. Here, we present a case of pancreatic SFT in a 45-year-old woman for its imaging characteristics on contrast-enhanced ultrasound (CEUS). On gray-scale imaging, the lesion was a regular, well-defined, and extremely hypoechoic mass in the body of the pancreas. On CEUS, it manifested as a slightly “slow wash-in and quick wash-out” heterogeneous enhancement. The patient underwent laparoscopic partial pancreatectomy, and the pathological findings confirmed the diagnosis of SFT with malignant potential. CEUS enabled real-time observation of the microcirculatory perfusion of the lesion, which is very useful when a differential diagnosis of pancreatic SFT is suspected.

Ectopic Pregnancy Implanted in the Diaphragm: A Case Report and Literature Review
Jing Ma, MD, Yuchen Wang, MD, Xiaohui Sun, MD, Aiqing Zhang, MD, Bo Zhao
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 26-28.   DOI: 10.37015/AUDT.2021.200065
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Abdominal pregnancy is a rare occurrence and the location is hardly seen in the upper abdomen. We described a case of a 34-year-old female presenting with upper abdominal pain and reflex sensitivity in the right shoulder. Ultrasound examination revealed a mass under the diaphragm which was suspected to be a liver abscess. The result of an enhanced CT scan was suggestive of an ectopic pregnancy between the diaphragm and right liver lobe. However, Laparoscopic surgery was performed and the histopathological examination confirmed the diagnosis of diaphragmatic pregnancy. By describing this case, we aim to share the value of patients with consistent upper abdominal pain and elevated serum hCG level, a thorough examination of the upper abdomen and pelvic with US as well as CT or MRI is crucial for timely diagnosis.

Feasibility and Efficacy of the Segmental Localization of Lumbar Vertebrae by Ultrasound vs X-ray Examination: A Prospective Comparative Study
Bo Yu, MD, Peng Huang, MD, Yukun Luo, MD, Mingbo Zhang, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 212-218.   DOI: 10.37015/AUDT.2021.200062
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Objectives: To explore the feasibility and efficacy of the segmental localization of lumbar vertebrae by ultrasound (US) compared with X-ray.
Methods: From February 2019 to May 2019, 43 patients (24 males and 19 females), with an average age of 46±15 years, were prospectively enrolled in this study. Longitudinal paramedian sagittal and transverse process sections were used to determine the lumbar segments by US scan. X-ray examination was used to verify the segmentation. The time for segmentation was recorded, and the learning curve of the average localization time was analyzed.
Results: Of all the enrolled patients, 5 had lumbar segmental and alignment abnormalities, and 38 had normal lumbar vertebrae. US accurately located vertebrae in 38 normal cases and 5 abnormal cases, with a 100% accuracy rate, as verified by X-ray examination. The localization time was significantly less for US than for X-ray examination, both in normal cases and in cases with segmental or alignment abnormalities (all P < 0.001). The learning curve of US-guided segmental localization continuously decreased with an increasing number of operations and entered the plateau stage after the third operation day.
Conclusions: The US-guided segmental localization of lumbar vertebrae is an accurate new method that is efficient and easy to learn and does not require radiation.

Utilization of Ultrasound for Management of Surgical Intervention of Secondary Hyperparathyroidism and Prolonged Hypocalcemia Post-Parathyroidectomy
Ying Liu, MM, Yang Zhou, MD, Hong Zhou, BS, Yuanyuan Chen, MM, Jian Wu, MD, Juan Wang, BS, Bin Wang, MM, Changyu Chen, MM, Ming Ye, MM
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 236-244.   DOI: 10.37015/AUDT.2021.200060
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Objective: To evaluate the application of ultrasound (US) for the surgical intervention in patients with moderate and severe secondary hyperparathyroidism (SHPT), and to identify the risk of prolonged hypocalcemia after parathyroidectomy (PTX).
Methods: A consecutive series of moderate and severe SHPT patients (n = 64) underwent ultrasound evaluation of parathyroid glands. Among the 64 patients who received 6-month medication therapies, ten patients with parathyroid hormone (PTH) 300~500 pg/mL were excluded from the study while 32 patients unresponsive to medication therapy (PTH > 500 pg/mL) received surgical interventions and 22 patients with PTH < 300 pg/mL received medication treatment alone. The correlations between the number, location, volume, sonographic features of parathyroid glands (PTGs), laboratory examinations, the duration of dialysis and the surgical necessity were analyzed. Total parathyroidectomy with synchronous auto-transplantation (PTX + AT) was performed in the surgical group. In both the surgical and medication group, patients with hyper-vascularity of the PTGs dominated (≥50%) were classified as a hyper-vascular subgroup, and the others as a hypo-vascular subgroup. The differences of post-operative calcium (Ca2+) levels and the incidence of prolonged hypocalcemia between hyper- and hypo- vascular subgroups were assessed.
Results: Sonographic evaluations revealed that the numbers of detectable PTGs were higher in the surgical group than that of the medication group (p < 0.05). The detection of supernumerary PTGs was higher in the surgical group than that in the medication group (13/121, 10.7% vs. 2/71, 2.8%, p < 0.05). Baseline PTH, >2 detectable PTGs, detection of supernumerary PTGs, patients with hyper-vascular, and the duration of dialysis were positively associated with the necessity of surgical intervention. For patients in the hyper-vascular subgroup, the serum Ca2+ level was lower than that in the hypo-vascularity subgroup (p < 0.01).
Conclusion: Ultrasonic features can provide useful information for management of surgical intervention of SHPT and prediction of the risk of prolonged hypocalcemia after PXT.

Clinical Applications of Crystal Vue Technology: A Review
Shijing Song, MD, Qingqing Wu, MD, Jingjing Wang, MD, Jinghua Li, MD, Dan Yan, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 1-6.   DOI: 10.37015/AUDT.2021.200067
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Three-dimensional (3D) imaging plays an important role in the construction of normal anatomy and abnormal structures. The 3D images can be obtained through computed tomography, magnetic resonance, ultrasonography (US) and other technologies with different values and prospects. 3D-US imaging has unique advantages such as being radiation-free, time-saving and cost-effective. The Crystal Vue is a novel 3D-US rending technology that provides valuable information in several obstetrical and gynaecological studies. This review focuses on the application of Crystal Vue technology in the evaluation of foetal skeleton, maxillofacial region, central nervous system, digestive tract and abnormally invasive placenta, cervical pessary, and ureteral stones.

Contrast Echocardiography Evaluation of Microcirculation of Myocardial Infarction Caused by Takotsubo Syndrome: Case Report and Literature Review
Rifei Li, MM, Yuanmei Zhang, MM, Chengkai Zhang, MM, Xuenian Huang, MM, Shangwei Ding, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 258-261.   DOI: 10.37015/AUDT.2021.210016
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Takotsubo syndrome (TTS) is also known as stress cardiomyopathy (SCM) or apical ballooning syndrome (ABS). TTS is reversible cardiomyopathy with a good prognosis. Although the patients have chest pain and ECG changes with typical acute myocardial infarction, they have angiographically normal coronary arteries or mild atherosclerosis. TTS can cause microcirculation dysfunction, leading to myocardial infarction with non-obstructive coronary atherosclerosis (MINOCA). Myocardial Contrast Echocardiography (MCE) can detect MINOCA caused by TTS by evaluating myocardial microcirculation. We report a case of MINOCA caused by TTS using MCE to evaluate myocardial ischemia in the subendocardial myocardium.

Echocardiography of Marfan's Syndrome Patient with New Gene Mutation of FBN1 with 13-year Follow-up
Jianping Xu, MS, Faping Cui, MS, Shuixiu Dou, MS, Jiafu Ou, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 249-253.   DOI: 10.37015/AUDT.2021.200070
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A case of Marfan syndrome was followed up by echocardiography for 13 years to observe the evolution of cardiovascular disease. The initial cardiovascular manifestations of this patient were "mitral myxoid degeneration, chordal rupture, leaflet prolapse, and massive regurgitation". Subsequently, after several years of development, the aortic sinus and ascending aortic aneurysm dilatation appeared and a new gene mutation site G4331A of FBN1 was found by genetic testing in this patient. Whether the new gene mutation site is related to the initial manifestation of the patient's cardiovascular disease with "mitral valve disease" remains to be further verified.

Distributed Cloud-based Ultrasound Platform: Innovative Pathway to Develop Ultrasound Imaging System
Jianqiao Zhou, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 33-37.   DOI: 10.37015/AUDT.2022.220002
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The current medical ultrasound imaging device is mainly divided into console ultrasound device and portable ultrasound device. In this article, a new concept along with an innovative pathway to develop ultrasound imaging devices, namely distributed cloud-based ultrasound system (DCUS), was proposed. In DCUS, the ultrasound probes from multiple terminals are used to complete the transmission and reception as well as analog-to-digital conversion of ultrasonic signals, and upload the original radio frequency (RF) signals or in-phase and quadrature (IQ) signals to the cloud server through ultra-bandwidth high-speed communication technology, while the centralized cloud server platform finishes processing of ultrasonic signals and transmits and distributes ultrasound imaging to each related terminal in real time. Various artificial intelligence (AI) algorithms can also be deployed on the cloud-based platform to achieve AI-powered imaging optimization, protocol standardization, and assisted diagnosis. Thus, by utilizing new cloud-based platform and super-high transmission technology and combining the advantages of console ultrasound and portable ultrasound systems with flexibility, high imaging quality and intelligent features, DCUS could become whole new ultrasound system for medical imaging applications in foreseeable future.

Contrast-enhanced Ultrasound Improves Technical Sufficiency of Fine-needle Aspiration in Suspicious Thyroid Nodules
Ying Fu, MD, Shi Tan, MD, LiGang Cui, MD, Fang Mei, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (3): 219-225.   DOI: 10.37015/AUDT.2021.200063
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Objectives: To evaluate contrast-enhanced ultrasound (CEUS) for guiding fine-needle aspiration (FNA) of suspicious thyroid nodules to obtain sufficient biopsy specimens.
Methods: A total of 236 uncertain thyroid nodules detected in 228 patients from October 2016 to March 2017 were retrospectively reviewed and analyzed in this study. Overall, 117 patients underwent CEUS-guided FNA, and 111 patients underwent ultrasound (US)-guided FNA. The target for aspiration was only at the enhanced area in the CEUS group. In the US-guided group, aspiration was conducted within the nodule at various angles and areas. The final cytopathologic findings were reported using the Bethesda criteria. The inadequacy, indeterminacy, malignancy, and benignity rates of FNA specimens were compared between two groups.
Results: There were no significant differences in age, sex, or nodule size between the two groups. The inadequacy rate in the CEUS group was significantly lower than that in the US group (P = 0.008). Twenty-two benign nodules were diagnosed using CEUS-guided FNA, whereas seven were diagnosed using US-guided FNA (P = 0.006). The indeterminacy and malignancy rates were similar for both groups.
Conclusions: CEUS-guided FNA improves the diagnostic success rate and reduces uncertainty by facilitating accurate biopsy of suspected thyroid nodules with microcirculation perfusion imaging.

Shear Wave Dispersion Imaging for Measuring Carotid Elasticity and Viscosity
Zhaojun Li, MD, PhD, Cuiqin Shen, MS, Qingqing Chen, MB, Lei Sha, MB, Xianghong Luo, MD, PhD, Lianfang Du, MD, PhD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 14-21.   DOI: 10.37015/AUDT.2021.200071
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Objective: To assess the viscoelasticity of the carotid artery using shear wave dispersion Imaging and to determine the relevant factors.
Methods: Ninety volunteers were recruited and divided into elder group and young group. Shear wave dispersion (SWD) imaging was applied to measure carotid viscoelasticity. The other arterial parameters, including arterial pulse wave velocity (PWV), inner diameter (CD), intima-medium thickness (CIMT), peak systolic velocity (PSV), mean flow velocity (MFV), and velocity time integral (VTI) of the common carotid artery (CCA) were also recorded by using ultrasound measurement.
Results: Measurements showed the SWD were lower, while CD, CIMT and PWV were higher in the elder group than those of young group. However, SWD was negatively correlated with VTI, and PSV respectively (r = -0.492 and -0.533, all P < 0.05). SWD was also positively correlated with MFV (r = 0.354, P < 0.05). In elder group, SWD was negatively correlated with PSV and PWV, respectively (r = -0.372 and -0.422, all P < 0.05) while in young group, SWD positively correlated with CD, CIMT and MFV (r = 0.531, 0.462 and 0.479 respectively, and all P < 0.05).
Conclusion: SWD imaging shown relationship with ultrasound parameters of carotid artery and has a potential for assessment of arterial viscoelasticity.

Ultrasound-guided Microwave Ablation of Adenolymphoma of Parotid Gland: A Case Report
Xiaohui Ji, MD, Juanjuan Li, MD, Dongxia Gao, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 22-25.   DOI: 10.37015/AUDT.2021.200046
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Adenolymphoma is the second most common benign parotid tumor after pleomorphic adenoma. Although microwave ablation (MWA) has been proved to be effective for benign breast and thyroid nodules, there are few studies on ablation of adenolymphoma of parotid gland. An 82-year-old male with adenolymphoma of bilateral parotid gland treated with ultrasound-guided MWA. After 12 months of follow-up, the volume of bilateral parotid nodules was significantly reduced without recurrence and obvious complications. In conclusion, ultrasound-guided MWA is a safe and effective method for patients with parotid adenolymphoma who cannot tolerate surgery.

Evaluation of Features of Adrenal Adenomas and Nonadenomas Using Dynamic Contrast-Enhanced CT Biomarkers
Xifu Wang, MD, Xizhong Dong, BS, Tingting Huang, MS, Jie Meng, BS, Yuanxun Kuang, MS, Jiwen Kang, BS, Renju Bai, MD, Zhaojun Li, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 304-312.   DOI: 10.37015/AUDT.2021.210020
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Objective: To investigate the correlation between the DCE-CT imaging biomarkers and histological biomarkers of tumor angiogenesis in adrenal adenomas and non-adenomas for the enhancement mechanism of DCE-CT.

Methods: Forty-two patients with 45 adrenal masses including 27 adenomas and 18 non-adenomas diagnosed pathologically were enrolled in this study. The features of DCE-CT (imaging biomarkers) and tumor angiogenesis (histological biomarkers) in adrenal masses were evaluated, and their correlations were explored.

Results: The enhanced features of DCE-CT in adrenal masses were classified: rapid washout group and slow washout group. Type A and C of time density (TD) curves, relative washout rate (Washr) ≥34%, and absolute washout rate (Washa) ≥43% belonged to the rapid group. In contrast, type B, D and E, Washr <34%, and Washa <43% belonged to the slow group. There was significant difference between the biomarkers of DCE-CT in adrenal masses. The rapid group was mainly found in adenomas, whereas the slow was mainly present in nonadenomas. The tumor angiogenesis, histological biomarkers, including microvessel density (MVD), vascular endothelial growth factor (VEGF), and microvascular ultrastructures demonstrated significant difference between the rapid and the slow washout group revealed by DCE-CT. The MVD and VEGF expression in rapid group were remarkably higher than those in slow group. Meanwhile, the tumor angiogenesis was also significantly different between adenomas and nonadenomas. The MVD and VEGF expression were also significantly higher in adenomas than those in nonadenomas. Furthermore, different microvascular ultrastructures were identified between adenomas and nonadenomas, which were in accordance with those between the rapid and the slow group. Microvascular ultrastructures in adrenal adenomas and/or the rapid group showed regular lumens and nonstenosis; more pinocytotic vesicles and fenestrations of endothelium; widening of the intercellular space; uniform thinning and better integrity of basal membrane; regular and uniform thinning, along with less stroma of extra vessel space. In comparison, opposite microvascular ultrastructures, in adrenal nonadenomas and/or the slow group.

Conclusion: The close correlation of DCE-CT imaging biomarkers and histological biomarkers of tumor angiogenesis was found between adrenal adenomas and nonadenomas. Tumor angiogenesis in adrenal adenomas and nonadenomas were shown the different enhancement characteristics at DCE-CT.

Absence of the Horizontal Portion of the Left Portal Vein Diagnosed by Ultrasound and Computed Tomography
Yanling Cheng, MM, Xi Liu, MD, PhD, Wenxiao Zhu, BM, Chuang Gao, BM, Hao Sun, BM, Hongtao Li, BM
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 321-324.   DOI: 10.37015/AUDT.2021.210002
Abstract82)   HTML7)    PDF 106

The absence of the horizontal portion of the left portal vein is rare, and it is often not diagnosed by ultrasound. This article reports a case where ultrasound identified a structural anomaly between the gallbladder and the round ligament of the liver, and then computed tomography confirmed the absence of the horizontal portion of the left portal vein. We proposed the possible etiologies from an embryonic development perspective, and described the questions to be further investigated after a literature review.

Etiologies and Adverse Outcomes of Fetuses with Short Femur Length Based on Proportion and Percentile Categorization
Jianan Li, BS, Hong Xu, MD, Mei Shen, BS, Shiyu Li, BS, Longxia Wang, MD, Yanping Lu, MD, Qiuyang Li, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 7-13.   DOI: 10.37015/AUDT.2021.210015
Abstract81)   HTML19)    PDF 79

Objective: To compare the etiologies and adverse outcomes of pregnancies with short fetal femur length (FL) categorized based on relative proportion and percentile placement.
Methods: Fetuses (n = 254) with short FL measured by ultrasound were classified into four groups: severe and disproportionate short FL (group A); severe and proportionate short FL (group B); mild and disproportionate short FL (group C); mild and proportionate short FL (group D). Etiologies and outcomes of pregnancies were compared between groups.
Results: A larger percentage of skeletal dysplasia occurred in group A (28.57%) than in the other three groups (group B: 1.85%; group C: 4.08%; group D: 0). Groups A and B also had higher rates (group A: 40.82%, group B:33.33%) of fetal growth restriction (FGR) than groups C and D (group C: 4.08%; group D:3.92%). No difference in chromosomal and genetic anomalies was detected among groups (P = 0.307); however, the rate of chromosomal and genetic testing in group A was higher than in group D (P = 0.001). Group A (57.14%) had a significantly lower rate of live birth than the other three groups, and group D (98.04%) had a higher live birth rate than groups B (87.04%) and C (83.67%). Considering only living fetuses, higher rates of preterm birth (P < 0.001), low birth weight (LBW) (P < 0.001), neonatal intensive care unit (NICU) admission or pediatric hospital referral (P = 0.004), Apgar score (1 min/5 min) ≤7 (P < 0.001) and fetal distress or neonatal asphyxia (P = 0.004) were found in group A compared to group D.
Conclusion: Fetuses with severe and disproportionate short FL should be flagged for possible skeletal dysplasia. Fetuses with severe short FL should be watched for FGR prenatally. Invasive prenatal tests are recommended for fetuses with severe and disproportionate FL but not recommended for those with mild and proportionate short FL. Outcomes of fetuses with severe and disproportionate short FL were worse than that of fetuses with mild and proportionate short FL.

Quantitative Evaluation of Cirrhosis by Geometrical Characteristics of Hepatic Capsule Based on High-frequency Ultrasound Imaging: an Experimental Study
Jialin Song, MS, Xiang Liu, MD, Jianquan Zhang, MD, Jiaqi Zhao, MD, Lulu Zhao, MS
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 298-303.   DOI: 10.37015/AUDT.2021.200073
Abstract78)   HTML16)    PDF 125

Objective: To explore the feasibility of quantitative evaluation of cirrhosis by geometrical characteristics of hepatic capsule based on high-frequency ultrasound imaging.

Methods: Rabbits with models of cirrhosis were established and then were divided into four groups: control, 6-week, 12-week and 18-week groups. Two-dimensional high-frequency ultrasound images of hepatic capsule of all rabbits were collected to obtain hepatic capsual contours and key points refltected shapes of these contours (shape control points) which were approximated by the principle of vertical gradient maximization under the manual supervision. Subsequently, the number of continuous segments of the contour line, the mean value and variance of angles between adjacent seed points were extracted to evaluate the continuity and smoothness of the contour line of the hepatic capsule.

Results: With aggravating cirrhosis, the number of segments required to make the sum of lengths of continuous segments reach up to 80% of the total width of the imaging section was gradually increased. The differences between the control group and 18-week group (P = 0.025) as well as between 6-week group and 18-week group (P = 0.004) were statistically significant. Similarly, the mean value and variance of the angles were also gradually increased, and the differences between the control group and the 6-week (P = 0.015, P = 0.036), 12-week (P < 0.001, P = 0.002) and 18-week groups (P = 0.023, P < 0.001) were statistically significant. In addition, the difference in variance of angles between the 6-week group and 18-week group (P = 0.030) was statistically significant.

Conclusion: Sonographic analysis of geometrical characteristics of the hepatic capsule could be used to partially indicate the presence of early-stage cirrhosis, which could provide a quantitative method for non-invasive assessment of cirrhosis.

Application Value of Two-Dimensional Ultrasound Combined with Contrast-Enhanced Ultrasound for the Diagnosis of Multiple Bile Duct Hamartomas: A Case Report
Tong Zhang, MD, Xiaolin Yin, Shuang Zheng, MD, Mingwei Sui, MD, Dezhi Zhang, MD
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 317-320.   DOI: 10.37015/AUDT.2021.200064
Abstract77)   HTML7)    PDF 118

Bile duct hamartomas (BDHs), also known as von Meyenburg complexes, are small neoplasms of the liver, of which the pathology is a benign bile duct malformation. We report a case of multiple BDHs of a 55-year-old male diagnosed using two-dimensional (2-D) ultrasound combined with contrast-enhanced ultrasound (CEUS) and further clinically diagnosed using magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP). The 2-D ultrasound showed diffusely distributed hyperechoic nodules and cystic masses in the liver, accompanied by small strong echoes with a comet tail sign. The CEUS showed that the hyperechoic nodules observed no abnormal enhancement in the arterial phase and equal enhancement with the surrounding liver tissue in the portal vein and delayed phase. We conclude that the appearance of BDHs on ultrasound has distinct characteristics and can be used as the preferred method for diagnosis. The CEUS can differentially diagnose the disease and improve diagnostic accuracy. Therefore, 2-D ultrasound, combined with CEUS, is a helpful method for diagnosing BDHs.

Cloud-based Ultrasound System: Feasibility and Potential
Ji-Bin Liu, MD, FAIUM, Editor-in-Chief, AUDT
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 38-38.   DOI: 10.37015/AUDT.2022.220004
Abstract76)   HTML6)    PDF 71
Neurofibromatosis with Intrahepatic, Retroperitoneal and Pelvic Involvement: A Case Report and Literature Review
Danqing Huang, MS, Min Tang, MS, Aimei Li, MD, Decai Yu, MD, Jun Chen, MD, Min Wu, MS, Wenping Wang, MD, Wentao Kong, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 29-32.   DOI: 10.37015/AUDT.2021.200066
Abstract58)   HTML7)    PDF 71

Neurofibromatosis type 1 (NF1) is a benign peripheral nerve sheath tumor, which can primarily cause neurocutaneous manifestations. We herein present a rare case of periportal neurofibromatosis with intrahepatic, retroperitoneal and pelvic involvement. The patient underwent abdominal ultrasound (US), magnetic resonance imaging, and a positron emission tomography-computed tomography. Despite these various imaging features, a diagnosis of lymphomas could not be entirely excluded. The patient therefore underwent US-guided biopsy, and a diagnosis of intrahepatic neurofibromatosis was made. Through retrospective analysis of this case along with literature review, we concluded that distributing along the Glisson’s sheath may be a characteristic in the diagnosis of NF that involves liver.

Cover, Foreword and Content
Advanced Ultrasound in Diagnosis and Therapy    2021, 5 (4): 0-0.  
Abstract34)      PDF 32
Emerging Applications of Contrast-enhanced Ultrasound in Trauma
Brenda E. Tester, BS, MS, Ji-Bin Liu, MD, John R. Eisenbrey, PhD, George Koenig, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 39-47.   DOI: 10.37015/AUDT.2022.220017
Abstract22)   HTML9)    PDF 23

The use of contrast-enhanced ultrasound (CEUS) has expanded over the past decade to include a variety of diagnostic and therapeutic applications. These include urgent clinical situations that require timely diagnosis and subsequent treatment. With the introduction of microbubble ultrasound contrast agents (UCAs), CEUS provides increased sensitivity and specificity over conventional ultrasound. Within the trauma setting, CEUS benefits include point of care imaging and an ability to monitor perfusion in real-time. Additionally, UCAs are non-nephrotoxic, and can be used when contrast enhanced CT is contraindicated. In this review, we discuss recent advancements of CEUS within trauma settings.

Guidelines for Echocardiographic Diagnosis of Cardiomyopathy: Recommendations from Echocardiography Group of Ultrasound Medicine Branch in Chinese Medical Association, Echocardiography Committee of Cardiovascular Branch in Chinese Medical Association
Echocardiography Group of Ultrasound Medicine Branch in Chinese Medical Association, Echocardiography Committee of Cardiovascular Branch in Chinese Medical Association
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 72-94.   DOI: 10.37015/AUDT.2022.210021
Abstract21)   HTML8)    PDF 51
Ultrasonographic Features of Intrathyroidal Thymic Carcinoma: Review and Analysis of 10 Cases
Yanhai Wang, MD, Hua Yang, MD, Hanqing Liu, MD, Xiaoli Luo, MD, Luying Liu, BS, Pingting Zhou, BS
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 58-63.   DOI: 10.37015/AUDT.2022.220013
Abstract17)   HTML2)    PDF 21

ObjectiveIntrathyroidal thymic carcinoma (ITTC) is a rare epithelial tumor of the thyroid gland. Since ITTC is rare, its imaging findings have not been well defined. In the present study, we studied the US appearance of ITTC by analyzing ten cases retrospectively.

Methods Patients were identified by searching the surgical pathology records at our hospital. There were three male and seven female patients ranging in age from 40 to 79 years. The ultrasound (US) features were evaluated, and the relevant clinical data were combined with the fine needle aspiration (FNA) results from previous publications.

Results The average length of the nodules was 48 mm. Of all ten nodules, half were located in the right lobe of the thyroid, and half were located in the left lobe, either immediately adjacent to the lower lobe or within the lower part of the thyroid lobe. All nodules manifested with a completely solid composition and heterogeneous hypoechoic echogenicity. Three nodules had striped hyperechogenicity within the nodule. All nodules had irregular margins. Seven had a horizontal shape, and three had a vertical shape. Four nodules manifested with mainly peripheral vascularity, two nodules showed mainly central vascularity, and three had mixed vascularity. The vascularity of one remaining nodule was unknown. Cervical lymph node metastasis was detected in two cases by US examination. According to previous literature, FNA cytology revealed atypical type of thyroid cancer, poorly differentiated carcinoma, or a high-grade malignant thyroid neoplasm without further definitive classification.

ConclusionA large cancer-like nodule located within the lower thyroid in middle-aged people, combined with an atypical type of thyroid cancer after FNA, indicated that ITTC should be considered.

Follicular Thyroid Neoplasmon Conventional and Contrast-enhanced Ultrasound
Xuehong Diao, MD, Lin Chen, MD, Bo Yu, MS, Jiamei Jin, MS, Jia Zhan, MD, Yue Chen, BS
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 48-57.   DOI: 10.37015/AUDT.2022.210026
Abstract16)   HTML2)    PDF 19

Objective: The aim of this study was to identify features of follicular thyroid neoplasm by conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS) based on morphological and pathological correlations and make diagnostic strategy for predicting malignancy.

Methods: Conventional US and CEUS were performed in 21 follicular thyroid cancers (FTCs) and 35 follicular adenomas (FAs) that were pathologically approved. Sonographic features were retrospectively reviewed, and diagnostic performance were analyzed using pathology as reference standard.

Results: The most useful character in diagnosis of FTC by conventional US was round shape (OR=6.6), followed by absent of halo sign (Odds ratio, OR = 4.79) and calcification (OR = 3.875). Among all CEUS morphological and blow flow findings, incomplete rim enhancement pattern (OR = 19.2) and the presence of perfusion defects (OR = 5.454) were the most effective features to discriminate between FTC and FA. Based on the five discriminatory parameters, a diagnostic criterion was established to assess the risk of FTC. The sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and accuracy for predicting malignancy were 81.0 %, 80 %, 70.8 %, 87.5 % and 80.4%, respectively.

Conclusions: CEUS provided additional sonographic features which is helpful for predicting potentially malignancy of follicular thyroid neoplasm.

Incidental Ultrasound Findings of a Giant Retroperitoneal Schwannoma: A Case Study
Jiaqi Zhao, MD, Weiqing Li, MD, Xiaolin Ma, MD, Rui Chen, MD, Lin Chen, MD
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 64-67.   DOI: 10.37015/AUDT.2022.210010
Abstract13)   HTML3)    PDF 3

Schwannoma in retroperitoneal region is quite rare. In this report, we presented such a rare case of a large size schwannoma in a 23-year-old man admitted with a complaint of mild pain in his right lower abdomen. The abdominal ultrasonography detected a round-shaped heterogeneous hypoechoic mass with a few blood flow signals at the retroperitoneal area inferior to the right kidney. The contrast-enhanced ultrasound demonstrated a well-demarcated hypoechoic mass with minor vascularization. Computed tomography (CT) diagnosed the retroperitoneal mass as a malignant neoplasm. After surgical resection, histopathologic examination revealed that the mass was a benign cellular schwannoma. Besides the rare case of schwannoma in retroperitoneal region, we believe that multimodal sonographic patterns are conducive to the preoperative diagnosis of retroperitoneal neurilemmoma.

Diagnosis of Anomalous Origin of Left Main Coronary Artery from Right Sinus of the Valsalva Based on the “Seagull Sign” in Echocardiography: A Case Study
Yun Zheng, MM, Shiwen Fu, MM, Wei Miao, MM, Shanshan Qu, MM, Junhua Wang, MM, Liping Guo, MM, Xihe Sun, MM
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 68-71.   DOI: 10.37015/AUDT.2022.210032
Abstract11)   HTML0)    PDF 6

The anomalous origin of the left main coronary artery from the right sinus of the Valsalva (ALCA) is rare, and varies significantly in congenital heart disease. Patients are usually asymptomatic, and in most cases, coronary abnormalities are discovered by chance at autopsy after coronary angiography or sudden cardiac death. As a routine physical examination procedure, echocardiography is particularly important for the rapid and sensitive diagnosis of ALCA. We report a case of ALCA using echocardiography. “Seagull sign” is a direct ALCA sign manifesting on the short axis section of the artery with two vessels coming from the right coronary sinus. Based on this case, we propose this specific ultrasound sign as a way to improve the diagnostic rate.

Cover, Foreword and Content
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (2): 0-0.  
Abstract7)      PDF 25
Cover, Foreword and Content
Advanced Ultrasound in Diagnosis and Therapy    2022, 6 (1): 0-0.  
Abstract3)      PDF 2

Open Access, Peer-reviewed

ISSN 2576-2516 (Online)

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