Arteries and Veins

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6.13 Joint Pain and Swelling

Fig. 236a, b Acute intertarsal synovitis between the navicular and cuneiform bones in a patient with SLE. N = navicular bone, C = first cuneiform bone, M = metatarsal bone

Scanning tips :

Dynamic examination with dorsiflexion of the ankle is helpful in detecting small amounts of effusion.

If necessary, ultrasound can help locate a suitable site for diagnostic needle aspiration of the effusion.

The examination should include metatarsal scans, as it is common to find associated inflammatory changes in that region (intertarsal or tarsometatarsal arthritis, see Fig.

Periarthritis (Fig. 237)

..............................................................................................................

Definition: painful swelling involving the ankle joint and distal lower leg. Exuda-

tive synovitis is not present in the ankle joint.

Sonographic findings: subcutaneous accumulations of fluid with no effusion in

the ankle joint.

236).

Principal Signs and Symptoms

Fig. 237a, b Periarthritis in Löfgren syndrome. The patient presented clinically with acute ankle swelling. Erythema nodosa

Tenosynovitis of the Malleolar Region (Fig. 238)

..............................................................................................................

Occurrence: frequently accompanies inflammatory diseases of the ankle joint

Sonographic findings: typical anechoicanechoic rim around the peroneus or tibia-

lis posterior tendon

177

6.14 Goiter, Hyper- and Hypothyroidism

Diffuse Goiter

..............................................................................................................

See also Palpable Masses, p. 102, and Thyroid Gland, p. 416.

Clinical manifestations: increased neck circumference, possible globus sensation,

swallowing difficulties. Large goiters may also cause superior vena cava compression, stridor, and recurrent respiratory tract infections. Adolescents are predominantly affected.

Diagnosis:

Examination, palpation: painless, generally soft mass of varying consistency depending on the presence of regressive changes

Laboratory findings: thyroid function values within normal limits; basal TSH is usually satisfactory

Sonography

Chest radiograph: tracheal displacement? p tracheal spot film

Principal Signs and Symptoms

Thyroid scintigraphy is rarely necessary.

Sonographic findings :

Volume increased to more than 20 mL (volume = length (cm) q width (cm) q depth (cm) q 0.5)

Homogeneous normal or dense internal echo pattern; echogenicity slightly increased with a coarser texture

Secondary nodules may develop

Regressive changes give rise to various features:

– Cysts: round, sharply circumscribed anechoic areas – Calcifications: echogenic specks with acoustic shadows

Accuracy of sonographic diagnosis: The diagnostic accuracy is 85 % when ultra-

sound findings are interpreted within the context of clinical and laboratory findings. CT and scintigraphy are unnecessary.

Nodular Goiter (Figs. 240 and 241)

..............................................................................................................

See also Thyroid Gland, p. 422; Palpable Masses, Nodular goiter, p. 102.

Clinical manifestations: same as diffuse goiter with palpable thyroid nodule

(nodular transformation of a goiter)

Fig. 240 Nodular goiter. The individual adenomatous nodules (A) are clearly delineated by their hypoechoic rims

Fig. 241 Thyroid nodule with a hypoechoic halo, found to contain vascularity on power Doppler imaging

180

6.14 Goiter, Hyper- and Hypothyroidism

Diagnosis:

Laboratory findings : hyperthyroid values (toxic nodular goiter)

Sonography

Scintigraphy: multifocal autonomy

Sonographic findings : Multiple hypoechoic or isoechoic nodules.

Accuracy of sonographic diagnosis: The sonographic findings plus the hyperthyr-

oid metabolic state strongly suggest the correct diagnosis. Radionuclide scanning of the thyroid gland confirms multifocal autonomy

hypoechoic nodule that is “hot” by scintigraphy p unifocal autonomy

multiple hypoechoic nodules that are “hot” by scintigraphy p multifocal autonomy

“diffuse” goiter (nonhomogeneous = nodular goiter or homogeneous = thyreoiditis, autoimmune thyreopathy) showing diffuse radionuclide uptake p disseminated autonomy.

Adenoma (Fig. 242)

..............................................................................................................

See also Thyroid Gland, p. 419; Fig. 623, p. 419.

Clinical manifestations: same as with a goiter. The clinical presentation with a

hyperthyroid state may resemble that of Graves disease (with no ophthalmic symptoms or skin changes, see below).

Diagnosis: Function values are changed according to the morphology of the

adenoma.

Sonography, scintigraphy:

– Macrofollicular adenomas are usually hyperechoic by ultrasound and func-

tionally “cold” by scintigraphy. – Nodules that are hypoechoic by ultrasound are usually “hot ” by scintigraphy. – Autonomy can be detected by suppression scintigraphy.

Laboratory tests and further studies:

– Initially normal peripheral thyroid values and normal TSH (a “warm” nodule

may still be found at scintigraphy). FNAB is necessary to exclude carcinoma,

if scintigraphically “could” nodule. – Later, peripheral thyroid values are still normal; scintigraphically “hot”

nodule with suppressed (decreased) TSH – Possible hyperthyroidism (toxic adenoma)

Sonographic findings :

Well-defined nodule with smooth margins (beca use adenomas have a capsule)

Markedly less echogenic than the rest of the thyroid gland (isoechoic to the surrounding neck muscles)

Somewhat nonhomogeneous echo distribution

Usually surrounded by a hypoechoic (vascular) halo.

Principal Signs and Symptoms

Fig. 242 Thyroid adenoma. Nodular lesion (L) is markedly hypoechoic to the surrounding thyroid tissue (TG) and isoechoic to the surrounding neck muscles (M). CDS demonstrates the vascular supply to the adenoma

181

6.14 Goiter, Hyper- and Hypothyroidism

Accuracy of sonographic diagnosis: The changes in the thyroid gland are clearly

visualized. A complete hypoechoic or anechoicanechoic vascular halo, possibly combined with the absence of a scintigraphically “cold” nodule, strongly suggests the correct diagnosis. Additional tests are needed in these cases, depending on the functional status of the tumor. FNAB differentiates the lesion from a malignancy.

Graves Disease (Autoimmune Thyropathy, Figs. 243 and 244)

..............................................................................................................

Clinical manifestations :

Goiter (frequently present) : rapid increase in neck circumference, swallowing difficulties

Hyperthyroidism: nervousness (often presents as apathy in the elderly, mimicking hypothyroidism); sleep disturbance, sweating, diarrhea, tremor, muscle weakness, weight loss, hair loss, tachycardia, heart failure, angina pectoris

Principal Signs and Symptoms

Ophthalmic signs: generally bilateral (lymphocytic histiocytic infiltration of the orbits), exophthalmos, chemosis, conjunctivitis, periorbital swelling. Complications involving the cornea and optic nerve may also occur.

Cutaneous changes: localized myxedema (e.g., pretibial); orange-peel appearance of the skin, possible hyperpigmentation and pruritus

Diagnosis:

History, palpation: A normal-sized thyroid gland makes the diagnosis unlikely

Laboratory tests, thyroid function values:

– TSH low or not measurable; FT – If the diagnosis is still uncertain, additional laboratory parameters can be

and FT4elevated

determined: thyroid-stimulating immunoglobulin (TSI); TSH receptor anti-

bodies (TRAb) detected in 90 % of cases; microsomal antibodies (MAb, iden-

tical to peroxidase antibodies, TPO Ab) detected in 70 % of cases.

Percutaneous biopsy for histologic evaluation (diffuse lymphocytic infiltration) may be done if a thyroid malignancy is suspected.

Fig. 243 Graves disease: hypoechoic thyroid tissue (TG) with a greatly enlarged isthmus (I). CA = carotid artery, T = trachea

Fig. 244 The hypervascularity in Graves disease produces a “vascular inferno” pattern on CDS. Median transverse scan

182

of the neck. TR = trachea

6.14 Goiter, Hyper- and Hypothyroidism

Sonographic findings :

Diffuse or asymmetrical enlargement of the thyroid gland

Involvement of the isthmus

Bounded borders

Homogeneous, stippled hypoechoic parenchymal pattern

Focal changes appear hyperechoic to their surroundings

CDS: increased vascularity.

Accuracy of sonographic diagnosis: The hypoechoic parenchymal pattern of

Graves disease combined with marked, balloon-like swelling of the isthmus suggests the correct diagnosis. The presence of typical clinical signs further supports the diagnosis, and the detection of typical antibodies confirms it. If there are no definite signs of autoimmune disease, Graves disease may be indistinguishable from diffuse autonomous hyperthyroidism even by scintigraphy.

Hashimoto Thyroiditis (Chronic Lymphocytic Thyroiditis, Autoimmune Thyroiditis, Fig. 245)

..............................................................................................................

Clinical manifestations: no pain or other complaints. As the disease progresses,

the goiter regresses and the thyroid gland shrinks in size.

With hypothyroidism: fatigue, hypersensitivity to cold, skin and hair changes (cold, dry, rough, pale yellow skin, coarse hair), thick tongue

The disease may begin with a hyperthyroid phase.

Diagnosis:

History and palpation : The thyroid gland initially has a tense, rubbery consistency.

Laboratory findings :

– Anemia, elevated ESR, dysproteinemia, hypercholesterolemia – Abnormal thyroid values : elevated TSH, low FT

mocrosomal thyroid antibodies (MAb, specifically antibody-TPO Ab) elevated

in 85 % of cases; antithyroglobulin antibodies elevated in 50 % of cases

Sonography

Percutaneous biopsy: Histology shows lymphocytic and plasma-cell infiltration with follicle formation, destruction, and atrophy.

Sonographic findings :

Diffusely hypoechoic (isoechoic or hypoechoic to the neck muscles)

Nonhomogeneous echo pattern

The thyroid gland is usually small (but may be enlarged).

, low FT4in some cases. Anti-

Principal Signs and Symptoms

Fig. 245 Hashimoto thyroiditis: small, hypoechoic thyroid lobe (TG), a pproximately isoechoic to the neck muscles (M). Its size is reduced to the approximate diameter of the common carotid artery (CA). JV = jugular vein

183

6.14 Goiter, Hyper- and Hypothyroidism

Accuracy of sonographic diagnosis: The echogenicity of the parenchyma should

always be compared with that of the neck muscles. When this is done, Hashimoto thyroiditis can be diagnosed with reasonable confidence and is usually distinguishable from Graves disease. Additional laboratory tests are necessary.

Acute Suppurative Thyroiditis

..............................................................................................................

See also Thyroid Gland, p. 420.

Classification:

Metastases: Most frequent sources are malignant melanoma, bronchial carcinoma, breast carcinoma, and esophageal carcinoma.

Parafollicular cells (medullary C-cell carcinoma): four subgroups, such as MEN – Papillary carcinoma (70 %) – Follicular carcinoma (15 %): like normal thyroid epithelium; has a capsule like

adenoma but is distinguishable from adenoma by infiltration of the capsule

or vessels; undergoes early distant metastasis (to lung, bone, CNS). Hürthle’s

tumor is particularly unfavorable because of its invasiveness – Anaplastic carcinoma (5 %): high-grade malignancy marked by extensive

local infiltration, refractory to treatment

Clinical manifestations: frequent neoplastic disease (bronchial tumor, breast car-

cinoma, malignant melanoma, esophageal carcinoma, also thyroid lymphoma) with metastasis; possible hyperthyroidism; stridor

Diagnosis:

History:

– Patients 50–70 years of age (papillary carcinoma has a second peak incidence

in the second and third decades of life) – Roentgen exposure in infancy and childhood, no hoarseness, known chronic

lymphocytic thyroiditis (Hashimoto), and a rapidly enlarging mass are

strongly suggestive of lymphoma.

Palpation: goiter with a solitary nodule, fast-growing. Lymph node metastases are often already present at the time of diagnosis. Tumor nodule has a hard consistency and is nontender.

Laboratory findings (usually have little significance): Most patients are euthyroid, and a small number are hyperthyroid. Serum calcitonin is a tumor marker for medullary C-cell carcinoma.

Sonography

FNAB is an essential study.

Scintigraphy may be done as an adjunct, demonstrating a cold nodule.

Principal Signs and Symptoms

185

6.14 Goiter, Hyper- and Hypothyroidism

Fig. 246 Papillary carcinoma of the right lobe of the thyroid gland: multiple hypoechoic masses, partially infiltrating the anterior neck muscles. The left thyroid lobe appears normal (SieScape panoramic image, courtesy of Dr. Strobel, Erlangen,

Principal Signs and Symptoms

Sonographic findings: A very dominant, hypoechoic nodule is strongly suggestive

Germany)

of carcinoma, especially in cases where bleeding has caused rapid enlargement.

Cystic node morphology: anechoicanechoic round lesion; percutaneous aspiration and cytologic examination of the cyst contents are usually diagnostic and therapeutic.

Solid node morphology: hypoechoic, nonhomogeneous, ill-defined margins, with or without a peripheral halo. Possible diagnoses: – Parafollicular (C-cell) carcinoma – Follicular carcinoma with a capsule – Papillary carcinoma without a capsule, glows slowly by infiltration, spreads

to cervical lymph nodes – Anaplastic carcinoma

Mixed node morphology: May be seen with any carcinoma: – Cystic lesions with intralesional hemorrhage, nonhomogeneous – Stippled and coarse calcification patterns

Metastases: round lesions, can be differentiated only by FNAB; primary tumors at other sites

Lymphoma: focal, relatively hypoechoic, ill-defined margins

Accuracy of sonographic diagnosis: Solid and cystic lesions can be identified

sonographically in almost all cases. The differentiation of benign and malignant lesions relies on aspiration cytology or, if necessary, excisional biopsy for further (operative) treatment planning.

Caution: All hypoechoic nodules i 10 mm that do not have a closed hypoechoic

rim require cytologic or even surgical investigation.

Amyloidosis

..............................................................................................................

Classification:

Primary amyloidosis

Amyloidosis associated with plasmacytoma

Secondary or reactive amyloidosis : in chronic infectious diseases or chronic inflammatory processes

Familial amyloidosis

Local amyloidosis: presents like a tumor, occurs predominantly in endocrine organs

Age-related amyloidosis

Amyloidosis during chronic dialysis therapy

186

6.14 Goiter, Hyper- and Hypothyroidism

Clinical manifestations: depend on the underlying disease. Local amyloidosis of

the thyroid gland may present like a simple goiter (see above). Functional deficits are generally rare but are common with medullary thyroid carcinoma.

Caution: The carcinoma cells may be missed by FNAB.

Diagnosis:

Palpation: firm thyroid gland

Sonography of the thyroid gland and parenchymal abdominal organs; echocardiography

Percutaneous thyroid biopsy

Rectoscopy with rectal biopsy to distinguish a systemic disease from local amyloidosis (biopsy specimen is fixed in alcohol and sent to pathology for definitive evaluation)

Investigation of other underlying diseases (see above)

Sonographic findings :

Enlarged thyroid gland

Echo pattern is usually homogeneous but may be irregular in some cases

Coarse, high-level internal echo pattern.

Accuracy of sonographic diagnosis: As with most focal lesions, a specimen should

be taken for cytologic evaluation.

Principal Signs and Symptoms

187

7.1 Examination

7 Arteries and Veins

7.1 Examination

Abdominal Vessels

..............................................................................................................

Scan planes :

Arteries and Veins

Upper abdominal transverse scan (see p. 22)

Upper abdominal longitudinal scan (see p. 29)

Supplementary scan planes

Sonographic anatomy and normal findings:

Aorta (Figs. 247–249): – The aorta runs anterior and slightly to the left of the vertebral column,

appearing as a smooth, throbbing, largely anechoic vascular band. It gives

off parietal and visceral branches before dividing into the common iliac

arteries just below the umbilicus. – The aortic wall presents a three-layered structure: two echogenic zones

separated by a hypoechoic zone (the two inner layers represent the thick-

ness of the intima and media, respectively).

Inferior vena cava (see Fig. 35), p. 28; Fig. 476, p. 324) : The inferior vena cava ascends to the right of and parallel to the aorta, its parietal and visceral tributaries (renal veins) corresponding to the aortic branches. It has a “soft” consis-

188

Fig. 247 Parietal and visceral branches of the aorta

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