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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 17 Breast Scanning Protocol 449
NOTE: When positioning patients it may be helpful to use wedges,
sponges, or rolled towels.
Breast Lesion Survey Steps
NOTE: A localized lesion or any area of interest of the breast must be
evaluated in at least two scanning planes.
NOTE: A stand-off device may be helpful for the evaluation of superficial
lesions.
Longitudinal Survey
Scanning Plane Determined by Lesion Shape and Lie •
Approach Determined by Lesion Location
1. Begin scanning with the transducer perpendicular at the midpoint
of the most superior aspect of the lesion or area of interest.
2. Keeping the transducer perpendicular, slowly scan through and
beyond all of the margins of the lesion.
Axial Survey
Scanning Plane Determined by Lesion Shape and Lie •
Approach Determined by Lesion Location
1. Begin scanning with the transducer perpendicular at the midpoint
of the lesion or area of interest.
2. Keeping the transducer perpendicular, slowly scan through and
beyond all of the margins of the lesion
Required Images for Breast Lesion
NOTE: The location of the lesion must be recorded to accompany the
required images. The location of the lesion can be indicated by one of
the following methods:
• Shown on a diagram of the breast
• Specifying the quadrant
• Using clock notation and distance from the nipple
NOTE: Image labeling should include right or left breast, location of the
lesion, and transducer orientation with regard to the breast (axial or
longitudinal, radial or anti-radial).
450 PART V Small Parts Scanning Protocols
Breast Lesion • Right Breast or Left Breast • Longitudinal
Images
Scanning Plane Determined by Lesion Shape and Lie •
Approach Determined by Location
1. Longitudinal image of the LESION with measurement from the most
superior to the most inferior margin.
Labeled: SITE LOCATION AND SCANNING PLANE
2. Same image as number 1 without measurement calipers.
Labeled: SITE LOCATION AND SCANNING PLANE
Breast Lesion • Right Breast or Left Breast • Axial Images
Scanning Plane Determined by Lesion Shape and Lie •
Approach Determined by Location
3. Axial image of the LESION with measurements from the most anterior
to the most posterior margin and from the most lateral to lateral or lateral
to medial margin.
Labeled: SITE LOCATION AND SCANNING PLANE
4. Same image as number 3 without measurement calipers.
Labeled: SITE LOCATION AND SCANNING PLANE
Breast Lesion • Right Breast or Left Breast • Longitudinal
and Axial High and Low Gain Images
Scanning Plane Determined by Lesion Shape and Lie •
Approach Determined by Location
5. Longitudinal image of the LESION with high gain technique.
Labeled: SITE LOCATION, SCANNING PLANE, HIGH GAIN
6. Axial image of the LESION with high gain technique.
Labeled: SITE LOCATION, SCANNING PLANE, HIGH GAIN
7. Longitudinal image of the LESION with low gain technique.
Labeled: SITE LOCATION, SCANNING PLANE, LOW GAIN
8. Axial image of the LESION with low gain technique.
Labeled: SITE LOCATION, SCANNING PLANE, LOW GAIN
NOTE: Depending on the size and complexity of the lesion, additional
images (in at least two scanning planes) may be necessary to document
the extent of the lesion.
CHAPTER 17 Breast Scanning Protocol 451
Whole Breast Survey
Whole Breast Survey • Right Breast or Left Breast
1. Begin scanning the breast in question at the 12 o’clock position.
2. Transducer orientation is set up so that the breast is viewed in
sections from the nipple outward, where the orientation notch is
located.
3. Scan around the breast in a clockwise manner, covering all anatomy,
including the axillary regions.
NOTE: For diffuse disease, both breasts must be scanned.
Whole Breast Required Images
Whole Breast Images • Right Breast or Left Breast
1. 12 O’CLOCK IMAGE OF BREAST TISSUE with the base of the
transducer toward the nipple and the end of the transducer facing
outward so that the nipple area is closest to the top of the imaging
screen.
Labeled: 12 O’CLOCK RT LT
2. 3 O’CLOCK image (same orientation as number 1).
Labeled: 3 O’CLOCK RT LT
3. 6 O’CLOCK image.
Labeled: 6 O’CLOCK RT LT
4. 9 O’CLOCK image.
Labeled: 9 O’CLOCK RT LT
5. Axial image through the NIPPLE.
Labeled: NIP TRV RT LT
6. Longitudinal image through the NIPPLE.
Labeled: NIP SAG RT LT
7. Longitudinal image of the AXILLARY region.
Labeled: AXILLARY SAG RT LT
452 PART V Small Parts Scanning Protocols
8. Axial image of the AXILLARY region.
Labeled: AXILLARY TRV RT LT
9. The same corresponding images of the OTHER BREAST.
NOTE: In some cases, whole breast scanning includes images from
12 o’clock, 1 o’clock, 2 o’clock, 3 o’clock, etc. If so, label accordingly and
include nipple and axillary images.
Review Questions
Answers on page 630.
1. Breast sonography is used primarily
a) for breast microcalcification screening.
b) to assess breast ducts during lactation.
c) to characterize breast lesions.
d) for breast cyst aspirations.
2. The layers of the breast are
a) subcutaneous, mammary, retromammary.
b) mammary, retromammary.
c) fat, glandular, boney.
d) skin, parenchymal, stromal.
3. Sonographic appearance of the breast is influenced by
a) patient parity.
b) menopause.
c) patient age.
d) all of the above.
4. Sonographic findings of the breast are described by
a) clock notations.
b) quadrants.
c) a diagram of the breast.
d) any of the above.
5. Breast tissue is bordered by the
a) skin anteriorly; Cooper’s ligament posteriorly and laterally;
sternum medially.
b) skin anteriorly; pectoralis muscle posteriorly; axilla laterally;
sternum medially.
c) nipple anteriorly; pectoralis muscle posteriorly; Cooper’s ligament
laterally; sternum medially.
d) nipple anteriorly; Cooper’s ligament posteriorly; axilla laterally;
sternum medially.
CHAPTER 17 Breast Scanning Protocol 453
6. Whole breast scanning is recommended for evaluating
a) complications associated with breast implants.
b) diffuse diseases.
c) impalpable breast lesions.
d) palpable masses.
7. Breast lesions are characterized
a) by their composition.
b) as benign or malignant.
c) by size, shape, and echogenicity.
d) by size, shape, attenuation, and echogenicity.
8. Compression sonography is recommended when
a) scanning fibrocystic breasts.
b) assessing fatty breasts.
c) taking lesion measurements within dense breast tissue.
d) cystic lesions are evaluated.
9. The breast layer(s) that exhibits the most changes sonographically
is (are) the
a) mammary and retromammary layers.
b) mammary layer.
c) subcutaneous layer.
d) stromal layer.
10. The normal sonographic appearance of the breast
a) is heterogeneous.
b) is primarily low- to very low–level echo textures.
c) is homogeneous.
d) is primarily medium-level echo textures.
Lateral
Lateral
Anterior
Posterior
rebellum
Sagittal
Coronal
Lateral ventricle
Thalamus
Coronal
Vermis
ce
Fourth
ventricle
Midline
Sagittal
Neonatal Brain Scanning
Protocol
Kristin Dykstra Downey; Betty Bates Tempkin
Key Words
Anterior fontanelle
Aqueduct of Sylvius
Brain stem
Caudate nucleus
Cavum septum pellucidum and
cavum vergae
Cerebellum
Cerebral peduncle
Cerebrospinal fluid (CSF)
Cerebrum
Choroid plexus
Cisterna magna
Corpus callosum
Falx cerebri
Foramen of Magendie
Foramen of Monro
Foramina of Lushka
Germinal matrix
Hippocampal gyrus (choroidal
fissure)
Interhemispheric fissure
Lateral ventricles
Massa intermedia
Quadrigeminal plate
Sulci
Sylvian fissure
Tentorium
Thalamus
Vermis
CHAPTER 18
Objectives
At the end of this chapter, you will be able to:
• Define the key words.
• Distinguish the sonographic appearance of the neonatal brain
and the terms used to describe it.
• Describe the transducer options for scanning the neonatal brain.
• List the suggested patient positions (and options) when scanning
the neonatal brain.
• Explain the patient prep for a neonatal brain study.
• Distinguish neonatal brain normal variants.
• Name the survey steps and explain how to evaluate the entire
length, width, and depth of the neonatal brain.
• Explain the order and exact locations to take representative
images of the neonatal brain.
• Answer the review questions at the end of the chapter.
455
456 PART V Small Parts Scanning Protocols
Overview
Cranial Vault Anatomy and Sonographic Appearance
• Four ventricles
• Two lateral ventricles
n
n
• Third ventricle
n
n
• Fourth ventricle
n
n
• Corpus callosum
• Anatomy: Flat, broad nerve fibers between the right and left cere-
• Sonographic appearance: The parenchyma appears midgray or as
• Cerebrum
• Anatomy: The largest part of the brain that is divided into two
Anatomy: Cerebrospinal fluid-filled cavities within each cerebral
hemisphere. Cerebrospinal fluid (CSF) is a clear liquid produced
continuously in the ventricles that continually circulates through
the ventricles and subarachnoid space to distribute nutrients and
to serve as a shock absorber against injury for the brain and spinal cord. Each ventricle is divided segmentally into a frontal horn,
body, occipital horn, and temporal horn. The atrium or trigone is
the junction of the body and occipital and temporal horns.
Sonographic appearance: The ventricle walls appear echogenic
and curvilinear. These slit-like structures lie the same distance
from the interhemispheric fissure. The ventricle cavities contain CSF and appear anechoic.
Anatomy: The third ventricle is a small, teardrop-shaped, mid-
line cavity that lies between the thalami and is connected
to the lateral ventricles via the foramen of Monro (midline
channels that mark the communication between the lateral
ventricles and third ventricle).
Sonographic appearance: Walls appear echogenic. The cavity
contains CSF and appears anechoic.
Anatomy: A small, thin, arrowhead-shaped, midline cavity
that appears to project into the cerebellum. It is vaguely seen
except with massive ventricular dilatation. It is located below
and connected to the third ventricle by a small channel, the
aqueduct of Sylvius, a narrow opening for the passage of
CSF. It directs CSF into the subarachnoid space through the
foramen of Magendie and foramina of Lushka, three small
holes in the floor of the fourth ventricle.
Sonographic appearance: Walls appear echogenic. The cavity
contains CSF and appears anechoic when seen.
bral hemispheres that form the roof of the lateral ventricles.
medium-level echoes.
identical, symmetrical right and left hemispheres that communicate through the corpus callosum and are separated from each
CHAPTER 18 Neonatal Brain Scanning Protocol 457
other at the midline by a deep groove, the interhemispheric
fissure. Each cerebral hemisphere is divided into four lobes,
named after the overlying cranial bones:
n
n
n
n
Frontal lobe
Parietal lobe
Temporal lobe
Occipital lobe
• Sonographic appearance: Midgray with medium-level echoes.
• Cavum septum pellucidum (anterior portion) and cavum vergae
(posterior portion)
• Anatomy: Small cavities filled with CSF that filters from the ven-
tricles through the septal laminae. They have no connection
with the ventricles. They separate the frontal horns of the lateral
ventricles, forming their medial margins at the midline of the
brain. They close before birth.
• Sonographic appearance: Appear moderately gray and comma-
shaped sagittally or triangular coronally.
• Thalamus
• Anatomy: Two large, egg-shaped thalami lie on each side of the
third ventricle, forming most of its lateral walls.
• Sonographic appearance: Homogeneous and midgray with
medium-level echoes.
• Cerebellum
• Anatomy: Constitutes the second-largest portion of the brain, it
lies immediately posterior to the fourth ventricle and occupies
the majority of the posterior fossae of the skull. Composed of
symmetrical, bilateral hemispheres connected by the vermis, its
medial portion.
• Sonographic appearance: parenchyma appears midgray or as
medium-level echoes. The central echogenic portion of the cerebellum is the vermis.
• Cisterna magna
• Anatomy: Largest expanded subarachnoid space in the brain.
Located at the base of the cerebellum in the posterior portion of
the brain.
• Sonographic appearance: The cavity contains CSF and appears
anechoic.
• Choroid plexus
• Anatomy: Special blood vessels located in the ventricles that
produce CSF.
• Sonographic appearance: Consists of two curvilinear, highly echo-
genic structures that arch around the thalami anteriorly from
the floor of the body of the lateral ventricle and posteriorly to
the tip of the temporal horn. Note that the choroid plexus does
not extend into the frontal or occipital horns.
458 PART V Small Parts Scanning Protocols
• Aqueduct of Sylvius
• Anatomy: Midline channel that connects the third and fourth
ventricles.
• Sonographic appearance: Rarely seen sonographically unless
dilated.
• Foramen of Monro
• Anatomy: Narrow, midline channels that connect the third
ventricle with each lateral ventricle for the passage of CSF.
• Sonographic appearance: Anechoic area just posterior to the level
of the frontal horn of each lateral ventricle.
• Brain stem
• Anatomy: Columnar-appearing structure that connects the fore-
brain and the spinal cord. Consists of the midbrain, pons, and
the medulla oblongata.
• Sonographic appearance: Midgray with medium- to low-level
echoes.
• Interhemispheric fissure
• Anatomy: Deep groove or indentation separating the right and
left cerebral hemispheres. Contains the falx cerebri (fold of the
dura mater).
• Sonographic appearance: Thin, linear, echogenic, midline structure.
• Massa intermedia
• Anatomy: Pea-shaped, soft tissue structure that is suspended
within the third ventricle with no known function.
• Sonographic appearance: Midgray with medium-level echoes and
is best seen with ventricular dilatation.
• Hippocampal gyrus (choroidal fissure)
• Anatomy: Convolution on the inner surface of the temporal lobe
of the cerebrum.
• Sonographic appearance: Echogenic, spiral-like fold embodying
each temporal horn.
• Cerebral peduncle
• Anatomy: Y-shaped structure inferior to the thalami and fused at
the level of the pons.
• Sonographic appearance: Midgray with low-level echoes.
• Sulci
• Anatomy: Grooves separating the gyri on the surface of the brain.
• Sonographic appearance: Echogenic, spider-like fissures separating
the gyri or folds of the brain. The premature neonate usually has
fewer sulci than a full-term infant.
• Tentorium
• Anatomy: Dura mater flap that separates the cerebral hemispheres
from the other structures in the brain.
• Sonographic appearance: Echogenic structure (tent-shaped
coronally).