Introduction to Emergency Medicine Ultrasound

Jan 7th, 2013Jan 9th, 2013

Houston, TX

US

http://www.aheconline.com/

The "Golden Hour" is one of the pillars of emergency medicine. Every minute lost can be a life lost. When you need ultrasound and there is no time to waste, it is not the time to learn on the job.

(A,B) Images from an initial ultrasound examination showed no identifiable lesions and received a consensus ultrasound category of US-1. Nearly the entire liver is visualized, with minimal shadowing (“s”, A and B), and the examination received consensus result of VIS-A. The AFP level was 7.1 ng/mL on assessment six months before the ultrasound, 9.1 ng/mL on assessment three months before examination, and 14.2 ng/mL on assessment on exam day. The AFP result was thus assessed as positive based on a progressive increase on two consecutive tests. The atient was considered to have negative surveillance result according to LI-RADS Ultrasound Surveillance v2017, but positive surveillance result according to LI-RADS Ultrasound Surveillance v2024. (C-D) Axial arterial-phase (C) and portal-venous phase (D) T1-weighted images from subsequent gadoxetic acid-enhanced MRI show a 2-cm arterial-phase hyperenhancing observation (arrow, C) with portal-venous washout (arrow, D) in segment 7. This observation was classified on MRI as LR-5, thus meeting the present study’s reference standard for diagnosis of HCC. The mass is located in the periphery of the liver, an anatomic area where ultrasound visualization can be challenging due to shadowing.

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Images in a 74-year-old male patient who presented at the hospital with acute symptoms of a right hemispheric ischemic stroke and a National Institutes of Health Stroke Scale (NIHSS) score of 24. (A) Nonenhanced CT image shows no signs of early infarction, whereas (B) CT perfusion image shows a large perfusion deficit in the territory of the middle cerebral artery and anterior cerebral artery caused by an extracranial occlusion in the right internal carotid artery. (C) Digital subtraction angiography shows the occlusion in the C1 segment. The extracranial occlusion was passed, reperfused, and subsequently stented (D, E). The final contrast injection did not reveal any intracranial occlusions within the territory of the internal carotid artery (F). At the 24-hour follow-up, there was no infarction on (G) the nonenhanced CT image, and the NIHSS score had decreased to 3 points. Image courtesy of RSNA.

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Images depict a 49-year-old female participant with cryptogenic cirrhosis who presented with a 3.2-cm liver lesion. This biopsy-confirmed hepatocellular carcinoma (HCC) with an initial categorization of Liver Imaging Reporting and Data System (LI-RADS) category LR-4 (probably HCC) at CT was upgraded to LR-5 (definitely HCC) at contrast-enhanced ultrasound (CEUS). (A) Precontrast CT images in the liver show vague hypoattenuation in the medial left hepatic lobe (arrows). (B) Arterial phase images demonstrate no definite arterial phase hyperenhancement (arrows). (C) Washout and an enhancing capsule (arrows) on a late-phase image resulted in an LR-4 categorization. (D) B-mode ultrasound shows a round hypoechoic nodule (arrows). (E) An early-phase CEUS image shows clear arterial-phase hyperenhancement (arrows); (F) No washout at one minute (arrows), and (G) late, mild washout at four minutes (arrows) resulted in a CEUS LR-5 categorization.

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(A,B) Images from an initial ultrasound examination showed no identifiable lesions and received a consensus ultrasound category of US-1. Nearly the entire liver is visualized, with minimal shadowing (“s”, A and B), and the examination received consensus result of VIS-A. The AFP level was 7.1 ng/mL on assessment six months before the ultrasound, 9.1 ng/mL on assessment three months before examination, and 14.2 ng/mL on assessment on exam day. The AFP result was thus assessed as positive based on a progressive increase on two consecutive tests. The atient was considered to have negative surveillance result according to LI-RADS Ultrasound Surveillance v2017, but positive surveillance result according to LI-RADS Ultrasound Surveillance v2024. (C-D) Axial arterial-phase (C) and portal-venous phase (D) T1-weighted images from subsequent gadoxetic acid-enhanced MRI show a 2-cm arterial-phase hyperenhancing observation (arrow, C) with portal-venous washout (arrow, D) in segment 7. This observation was classified on MRI as LR-5, thus meeting the present study’s reference standard for diagnosis of HCC. The mass is located in the periphery of the liver, an anatomic area where ultrasound visualization can be challenging due to shadowing.

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Images in a 74-year-old male patient who presented at the hospital with acute symptoms of a right hemispheric ischemic stroke and a National Institutes of Health Stroke Scale (NIHSS) score of 24. (A) Nonenhanced CT image shows no signs of early infarction, whereas (B) CT perfusion image shows a large perfusion deficit in the territory of the middle cerebral artery and anterior cerebral artery caused by an extracranial occlusion in the right internal carotid artery. (C) Digital subtraction angiography shows the occlusion in the C1 segment. The extracranial occlusion was passed, reperfused, and subsequently stented (D, E). The final contrast injection did not reveal any intracranial occlusions within the territory of the internal carotid artery (F). At the 24-hour follow-up, there was no infarction on (G) the nonenhanced CT image, and the NIHSS score had decreased to 3 points. Image courtesy of RSNA.

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Images depict a 49-year-old female participant with cryptogenic cirrhosis who presented with a 3.2-cm liver lesion. This biopsy-confirmed hepatocellular carcinoma (HCC) with an initial categorization of Liver Imaging Reporting and Data System (LI-RADS) category LR-4 (probably HCC) at CT was upgraded to LR-5 (definitely HCC) at contrast-enhanced ultrasound (CEUS). (A) Precontrast CT images in the liver show vague hypoattenuation in the medial left hepatic lobe (arrows). (B) Arterial phase images demonstrate no definite arterial phase hyperenhancement (arrows). (C) Washout and an enhancing capsule (arrows) on a late-phase image resulted in an LR-4 categorization. (D) B-mode ultrasound shows a round hypoechoic nodule (arrows). (E) An early-phase CEUS image shows clear arterial-phase hyperenhancement (arrows); (F) No washout at one minute (arrows), and (G) late, mild washout at four minutes (arrows) resulted in a CEUS LR-5 categorization.

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