Contrast-Enhanced Ultrasound Quantification Assessment of Focal Fatty Variations in Liver Parenchyma: Challenging the Traditional Qualitative Paradigm of Uniform Enhancement With Adjacent Parenchyma.

OBJECTIVES: The purpose of this study was to quantify contrast-enhanced ultrasound enhancement of focal fatty sparing (FFS) and focal fatty infiltration (FFI) and compare it with adjacent liver parenchyma. METHODS: This was a retrospective observational study yielding 42 cases in the last 4 years. Inclusion criteria were a focal liver lesion, adequate video availability, and an established diagnosis of FFS or FFI based on clinical or imaging follow-up or a second modality. Contrast-enhanced ultrasound examinations were performed with a standard low-mechanical index technique. Commercially available software calculated quantitative parameters for a focal liver lesion and a reference area of liver parenchyma, producing relative indices. RESULTS: In total, 42 patients were analyzed (19 male) with a median age of 18 (interquartile range, 42) years and a median lesion diameter of 30 (interquartile range, 16) mm. The cohort included 26 with FFS and 16 with FFI. Subjectively assessed, 27% of FFS and 25% of FFI were hypoenhancing in the arterial phase, and 73% of FFS and 75% of FFI were isoenhancing. In the venous and delayed phases, all lesions were isoenhancing. The peak enhancement (P = .001), wash-in area under the curve (P < .01), wash-in rate (P = .023), and wash-in perfusion index (P = .001) were significantly lower in FFS compared with adjacent parenchyma but not the mean transit time. In the FFI subgroup, no significant difference was detected. Comparing relative parameters, only the wash-in rate was significantly (P = .049) lower in FFS than FFI. The mean follow-up was 2.8 years. CONCLUSIONS: Focal fatty sparing shows significantly lower and slower enhancement than the liver parenchyma, whereas FFI enhances identically. Focal fatty sparing had a significantly slower enhancement than FFI.

Persistent Hypoglossal Artery.

Teaching point: Persistent hypoglossal artery is an extremely rare anatomical variant but has diagnostic and therapeutic relevance.

Tophaceous Gout at the Popliteal Sulcus.

Teaching point: Popliteal sulcus erosion with soft tissue mass: when in doubt, think of gout.

Xanthogranulomatous and Emphysematous Pyelonephritis: Two Rare Entities Occurring in One Kidney.

Teaching point: Both xanthogranulomatous and emphysematous pyelonephritis are severe renal inflammatory disorders, occurring simultaneously in extremely rare cases.

Caseous Calcification of the Mitral Valve.

Teaching Point: Caseous calcification of the mitral annulus is a benign mass-like lesion which can mimic cardiac tumor or abscess; therefore, multimodal imaging should be considered, avoiding unnecessary interventions.

Aortocaval Fistula: A Rare Complication of an Infrarenal Aortic Aneurysm.

Teaching Point: Aortocaval fistula is a rare complication of infrarenal aortic aneurysms.

Renal Angiomylipoma with Epithelial Cyst (AMLEC): A Rare Cystic Variant of Angiomyolipoma.

Teaching Point: AMLEC is a rare subtype of an angiomyolipoma (AML) and not a primary cystic lesion.

Behçet Disease.

Teaching Point: Although Behçet disease is a multisystemic and chronic vasculitis, it can be superimposed with a variety of acute vasculitis.

Intraoperative microvascular assessment with contrast-enhanced ultrasound (CEUS) during uterine artery embolisation (UAE): a case report and literature review.

The clinical success of uterine artery embolization is determined by its endpoint. An aggressive UAE could lead to endometritis and increases the risk of unintended embolization of other organs. Conversely, an incomplete procedure may result in a poor clinical outcome due to regrowth of the fibroids. We present a case with innovative use of intraoperative contrast-enhanced ultrasonography (CEUS) for the assessment of vascularity of the targeted fibroid to determine the endpoint of embolization perioperatively. We aim to report a case of the use of intraoperative CEUS during UAE to highlight the potential pitfall of its use and provide a review of its application in the literature. Our case affirms the reported usefulness and the practical feasibility to assess the vascularity of fibroids during UAE and highlights that caution should be made by operators in cases of multiple fibroids.

Craniofacial and Intracranial Langerhans Cell Histiocytosis.

Main Teaching Point: Multiple osteolytic calvarial lesions in a child raise suspicion of Langerhans cell histiocytosis.

Using contrast-enhanced ultrasound to guide a successful biopsy of a splenic sarcomatoid carcinoma.

INTRODUCTION: Splenic lesions are uncommon and frequently cause a diagnostic dilemma, often with non-specific findings on both ultrasound and cross-sectional imaging with histological confirmation necessary. To reduce patient morbidity, primarily from haemorrhage and to increase diagnostic yield, precise imaging and biopsy targeting are needed. CASE: We present a case of an indeterminate complex splenic lesion, with areas of necrosis which required histological diagnosis. Contrast-enhanced ultrasound-guided percutaneous core needle biopsy was undertaken to provide real-time imaging guidance, increasing viable lesion targeting and helping to avoid areas of necrosis. CONCLUSION: Contrast-enhanced ultrasound guidance of the percutaneous core needle biopsy allowed increased operator confidence in lesional targeting accuracy and reduced the number of passes required for biopsy, simultaneously maximising histological yield and minimising patient morbidity.