Ultrasound A Core Review

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Ultrasound
A Core Review

Ultrasound
A Core Review

EDITORS
Ruchi Shrestha, MD
Assistant Professor
Division of Abdominal Imaging
Department of Radiology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

Ka‐Kei Ngan, MD
Assistant Professor
Division of Abdominal Imaging
Department of Radiology
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania

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Library of Congress Cataloging‐in‐Publication Data
Names: Shrestha, Ruchi, editor. | Ngan, Ka‐Kei, editor.
Title: Ultrasound : a core review / editors, Ruchi Shrestha, Ka‐Kei Ngan.
Other titles: Ultrasound (Shrestha) | Core review series.
Description: Philadelphia : Wolters Kluwer Health, [2018] | Series: Core review series | Includes bibliographical references and
index.
Identifiers: LCCN 2017032189 | ISBN 9781496309815 (paperback)
Subjects: | MESH: Ultrasonography | Examination Questions
Classification: LCC RC78.7.U4 | NLM WN 18.2 | DDC 616.07/543076—dc23 LC record available at
https://lccn.loc.gov/2017032189

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Contributors

Anil K. Dasyam, MD University of Pittsburgh School of Medicine
Associate Professor Pittsburgh, Pennsylvania
Division of Abdominal Imaging Theodore Schroeder, MD
Department of Radiology Division of Abdominal Imaging
University of Pittsburgh School of Medicine Department of Radiology
Pittsburgh, Pennsylvania Allegheny Health Network
Myra Feldman, MD Assistant Professor
Assistant Professor of Radiology Department of Radiologic Sciences
Cleveland Clinic Imaging Institute Drexel University College of Medicine
Section of Abdominal Imaging Pittsburgh, Pennsylvania
Cleveland, Ohio Biatta Sholosh, MD
Kelly Haarer, MD Assistant Professor
Assistant Professor Division of Abdominal Imaging
Division of Abdominal Imaging Department of Radiology
Department of Radiology University of Pittsburgh School of Medicine
University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
Pittsburgh, Pennsylvania Ruchi Shrestha, MD
Safwan S. Halabi, MD Assistant Professor
Clinical Assistant Professor Division of Abdominal Imaging
Division of Fetal and Pediatric Radiology Department of Radiology
Department of Radiology University of Pittsburgh School of Medicine
Stanford University School of Medicine Pittsburgh, Pennsylvania
Stanford, California Chris Somerville, MD
Matthew T. Heller, MD, FSAR Commonwealth Radiology
Associate Professor Richmond, Virginia
Division of Abdominal Imaging Paul J. Spicer, MD
Department of Radiology Assistant Professor
University of Pittsburgh School of Medicine Divisions of Breast and Musculoskeletal
Pittsburgh, Pennsylvania Imaging
Madelene C. Lewis, MD Diagnostic Radiology Resident Program
Associate Professor Director
Women’s Imaging Department of Radiology
Department of Radiology University of Kentucky
Medical University of South Carolina Lexington, Kentucky
Charleston, South Carolina Juliana J. Tobler, MD
Ka‐Kei Ngan, MD Assistant Professor
Assistant Professor Abdominal Imaging Section
Division of Abdominal Imaging Department of Radiology
Department of Radiology University of Cincinnati Medical Center
Cincinnati, Ohio

Series Foreword

Ultrasound: A Core Review covers the most important aspects of ultrasound in a manner that I am
confident will serve as a useful guide for residents to assess their knowledge and review the material
in a question‐style format that is similar to the core examination.
Dr. Ruchi Shrestha and Dr. Ka‐Kei Ngan have succeeded in producing a book that exemplifies the
philosophy and goals of the Core Review Series. They have done a meticulous job in covering key topics
and providing superb images. The multiple‐choice questions have been divided logically into chapters
so as to make it easy for learners to work on particular topics as needed. Each question has a
corresponding answer with an explanation of not only why a particular option is correct but also why
the other options are incorrect. There are also references provided for each question for those who
want to delve more deeply into a specific subject.
The intent of the Core Review Series is to provide the resident, fellow, or practicing physician a review
of the important conceptual, factual, and practical aspects of a subject by providing approximately 300
multiple‐choice questions, in a format similar to the core examination. The Core Review Series is not
intended to be exhaustive but to provide material likely to be tested on the core exam and that would
be required in clinical practice.
As Series Editor of the Core Review Series, it has been rewarding not only to be an author of one of the
books but also to be able to work with many outstanding individuals in the profession of radiology
across the country who contributed to the series. This series represents countless hours of work and
involvement by so many that it could not have come together without their participation. It has been
very gratifying to see the growing popularity and positive feedback the authors of the Core Review
Series have received from many reviews.
Dr. Ruchi Shrestha, Dr. Ka‐Kei Ngan, and their contributors are to be commended on doing an
outstanding job. I believe Ultrasound: A Core Review will serve as an excellent resource for residents
during their board preparation and a valuable reference for fellows and practicing radiologists.
Biren A. Shah, MD, FACR
Director, Breast Imaging
Director, Breast Imaging Fellowship
Associate Professor of Radiology
Virginia Commonwealth University
School of Medicine
Richmond, Virginia

Preface

The ABR Core Examination is an image‐rich, computer‐based multiple‐choice test that has replaced
the oral boards as the qualifying examination for radiology residents. The change from an oral
examination to the Core Examination has led to significant changes in both the content and format of
the test. There is now an increased emphasis on the understanding of imaging as it relates to the
broader clinical context as well as noninterpretive skills, which impact the practice of radiology,
especially with respect to physics, quality, and safety. As a result, the traditional methods of board
review are no longer sufficient for exam preparation.
This book has been designed as a comprehensive study guide for radiology residents with a vast
collection of image‐rich material adhering to the ABR question and answer format. Concise but
thorough explanations focused on both imaging features and relevant clinical considerations are
provided along with source references. This guide can also serve as preparation for the Certifying and
Maintenance of Certification (MOC) examinations.
We dedicate this book to our residents and fellows, who, with their curiosity and enthusiasm, inspire
us to be better educators every day. We would like to thank and commend our colleagues from the
various institutions around the country for their contributions to this book. Their expertise and
attention to detail has been greatly appreciated. This book would not exist without their efforts. We
are also very grateful to Dr. Biren Shah and the staff at LWW for their guidance. Finally, we are
eternally thankful to our wonderful families for their support and patience through countless hours of
work.
Ruchi Shrestha, MD
Ka‐Kei Ngan, MD

Contents

1 Hepatobiliary
2 Pancreas, Spleen, and Bowe
3 Urinary Tract and Adrenal Glands
4 Neck
5 Scrotum
6 Gynecology
7 First Trimester Pregnancy
8 Second and Third Trimester Pregnancy
9 Vascular
10 Musculoskeletal
11 Peritoneal Space, Retroperitoneum, Abdominal Wall, and Chest
Index

3a. This 50‐year‐old female
presented with right upper
quadrant pain, and images
of the common duct are
shown. What is the most
appropriate management?

A. Sphincterotomy
B. Cholecystectomy
C. ERCP
D. HIDA scan

3b. What is the most common complication associated with choledochoceles?
A. Malignancy
B. Liver abscess
C. Pancreatitis
D. Biliary and pancreatic calculi

3c. Which type(s) of biliary cyst is (are) commonly treated with a Roux‐en‐Y hepaticojejunostomy?
A. Types II and III
B. Types I and III
C. Types I and IV
D. Type V

4a. Shown here are transverse
and sagittal images of the
gallbladder. What is the most
concerning sonographic finding?

A. Presence of color Doppler flow
B. Wall discontinuity
C. Intraluminal mass
D. Absence of ring‐down artifact

4b. Patients with gallbladder carcinoma are most likely to also have:
A. Porcelain gallbladder
B. Sludge
C. Gallbladder polyps
D. Gallstones

4c. The most common appearance of gallbladder carcinoma is:
A. Mass replacing gallbladder lumen
B. Intraluminal polypoid lesion
C. Gallbladder wall thickening
D. Cystic mass within the gallbladder

5. This patient received a liver transplant 10 years ago and presents with liver dysfunction. What is
the most likely diagnosis?

A. Biliary anastomotic stricture
B. Recurrent primary sclerosing cholangitis
C. Hepatic arterial anastomotic stenosis
D. Portal vein anastomotic stenosis

6. A right upper quadrant ultrasound is performed. On
review of the study, the radiologist notices that the
gallbladder was not shown and requests that the
technologist obtain additional images to show the
gallbladder. This is an example of which quality process?
A. Quality improvement
B. Quality assurance
C. Quality control

7a. An image from a right upper quadrant ultrasound in a 42‐year‐old female with abdominal pain is
shown. What is the next best step in management of this patient?

A. Further characterization by MRI
B. Follow‐up imaging
C. Cholecystectomy
D. Hepatobiliary cholescintigraphy

7b. When evaluating patients with gallbladder polyps on ultrasound, which imaging feature is most
predictive of malignancy?
A. Adjacent gallbladder wall thickening
B. Internal vascular flow on Doppler imaging
C. Size >10 mm
D. Sessile shape

8. An echogenic focus is identified within the
gallbladder lumen. Which of the following maneuvers
could help distinguish a true lesion from an artifact?

A. Turn off harmonics.
B. Reposition the probe.
C. Increase transducer power.
D. Increase the depth.

9. A 34‐year‐old man has a history of acute myeloid leukemia (AML), status post chemotherapy, and
stem cell transplant. He is presenting now with acute right upper quadrant pain, weight gain, and
elevated liver function tests (LFTs). What is the most likely diagnosis?

A. Chemotherapy‐induced steatosis
B. Acute cholecystitis
C. Sinusoidal obstruction syndrome
D. Cirrhosis

10. Identify the labeled
structures:

11. A 38‐year‐old man with abdominal pain has the following finding on his ultrasound. He is
otherwise in good health. What is the most appropriate management for this process?

A. Consult surgery for cholecystectomy. There is a 20% increased risk for development of gallbladder
carcinoma.
B. Draw blood and test for
triglycerides. This finding is
associated with
hypertriglyceridemia.
C. No further workup is
necessary. This finding is almost
certainly benign.
D. Perform an MRCP for a
search for gallstones. This
finding frequently coexists with
gallstones.

12. Increasing the depth or width of the field of view will:
A. Decrease the frame rate
B. Increase the frame rate
C. Increase acoustic impedance
D. Decrease acoustic impedance

13. The speed of sound in soft tissues is:
A. 1,440 m/s
B. 1,540 m/s
C. 1,640 m/s
D. 1,740 m/s

14. This patient is being evaluated for abnormal liver enzymes in the setting of a previous liver
transplant. What is the most likely diagnosis?

A. Obstructing mass
B. Portal biliopathy
C. Choledocholithiasis
D. Biliary cast syndrome

15. Which of the following can cause “pseudo‐sludge” in the gallbladder?
A. Posterior acoustic enhancement
B. Side lobe artifact
C. Mirror image
D. Speed displacement

16. Which of the following anatomic structures is primarily
responsible for the artifact shown by arrow in this image?

A. Diaphragm
B. Lung
C. Liver
D. Pleura

17a. A 29‐year‐old female presents with right upper quadrant pain and fever. US and CT images are
shown. Which other organ may be affected in this patient?

A. Pancreas
B. Spleen
C. Kidneys
D. Adrenals

17b. What is the characteristic imaging finding seen in this entity?
A. Reverse target sign
B. Cluster of grapes sign
C. Water‐lily sign
D. Central dot sign

17c. Communication of the cystic hepatic lesions with which of the following structures will help
confirm the diagnosis in this patient?
A. Adjacent portal vein
B. Adjacent bile ducts
C. Adjacent hepatic artery
D. Adjacent hepatic vein

18. A 56‐year‐old female presents with diarrhea, right upper abdominal pain, malaise, and fever since
returning from a cruise 2 weeks ago. Laboratory tests reveal elevated white blood cell count and
elevated alkaline phosphatase.
What is the most appropriate next
step in management?

A. Percutaneous drainage
B. Imaging‐guided biopsy
C. Liver protocol MRI
D. Surgical resection

19. During a laparoscopic liver resection, the metal articulating liver retractor breaks and multiple 2‐
cm‐long cylindrical metal segments spill into the patient and are removed by the surgeon. On a follow‐
up abdominal ultrasound 3 months later, a shadowing foreign body was located in the right abdominal
wall. Upon retrospective review of the intraoperative closing films that were initially interpreted as
negative, a foreign body corresponding to the broken retractor can be seen in the overexposed corner
on one of the four intraoperative abdominal x‐rays. It could only be seen when the image was
brightened. In a model classification system, what kind of error(s) occurred?
A. Treatment error because the surgeon did not perform the operation correctly by using an outdated
retractor.
B. Treatment error because of an avoidable delay in treatment. The surgeon should have requested
repeat abdominal films immediately.
C. Communication error because the surgeon did not specify that the foreign body could be located in
the subcutaneous tissues.
D. Equipment failure due to a broken retractor and a diagnostic error because the radiologist initially
missed the foreign body.

20a. A 78‐year‐old male with a history of chronic hepatitis C and cirrhosis presents for surveillance
ultrasound that was followed by MRI. The lesion detected on these studies derives its blood supply
preferentially from:

A. Hepatic vein
B. Portal vein
C. Hepatic artery
D. Periportal collaterals

20b. Based on the ACR LI‐RADS v2017 for CT and MRI, the lesion shown is which of the following?
A. LI‐RADS 1
B. LI‐RADS 2
C. LI‐RADS 3
D. LI‐RADS 4
E. LI‐RADS 5

20c. “Threshold growth” of the lesion includes which of the following?
A. Diameter increase of 20% or more over a period of 6 months or shorter
B. Diameter increase of 30% or more over a period of 6 months or shorter
C. Diameter increase of 40% or more over a period of 6 months or shorter
D. Diameter increase of 50% or more over a period of 6 months or shorter

21. A 60‐year‐old female presents with a history of metastatic breast cancer. What is the most likely
explanation of the imaging appearance of the liver on US and CT?

A. Infiltrative lymphoma
B. Cholangiocarcinoma
C. Treated hepatic
metastases
D. Multifocal hepatocellular
cancer

22. A 17‐year‐old male presents with abdominal pain. Hepatomegaly and gynecomastia were noted
on physical examination. What is the most likely diagnosis?

A. Giant hemangioma
B. Focal nodular
hyperplasia
C. Hepatocellular
carcinoma
D. Fibrolamellar
carcinoma

23. A 50‐year‐old male patient presents with multiorgan metastases. A careful search for which
primary malignancy should be performed in this patient?

A. Lung cancer
B. Hepatocellular cancer
C. Colon cancer
D. Melanoma

24. The purpose of ACR Appropriateness Criteria is:
A. To promote proper performance of the examination in question
B. To establish minimum level of acceptable technical parameters and equipment performance
C. To assist referring physicians in making appropriate imaging decisions
D. To improve the quality, clarity, and communicative effectiveness of radiology reports

25. A 37‐year‐old female presents with abdominal pain, distension, and jaundice. What is the most
likely diagnosis?
A. Budd‐Chiari syndrome
B. Right heart failure
C. Acute hepatitis
D. Primary sclerosing cholangitis

26. A 50‐year‐old male presents with abdominal pain. Initial laboratory tests reveal elevated white
blood cell count. Sonographic Murphy sign was negative at the time of the ultrasound examination.
Which of the following is the most likely diagnosis?

A. Acute
cholecystitis
B. Gangrenous
cholecystitis
C. Acute hepatitis
D. Gallbladder
cancer

27. A 50‐year‐old female presents with vague abdominal pain, weight loss, jaundice, and pruritus.
What is the most likely diagnosis?

A. Cholangiocarcinoma
B. Hepatocellular carcinoma
C. Metastatic disease
D. Choledocholithiasis

28. Which of the following phenomena is predominantly
responsible for the ultrasound artifact indicated with arrow?

A. Reflection
B. Refraction
C. Scattering
D. Absorption

29. Which of the following is responsible for the
artifacts indicated by arrows in the image?

A. Reflection
B. Refraction
C. Absorption
D. Scattering

30. A 26‐year‐old female with left flank pain underwent
CT scanning using renal stone protocol, which showed a
hypoattenuating right hepatic lobe mass. A right upper
quadrant ultrasound was performed for further
evaluation of the mass. Which one of the following
features is commonly seen in this type of liver lesion?

A. Posterior acoustic shadowing
B. Lack of color Doppler flow
C. Internal hemorrhage
D. Primary malignancy

31. A 60‐year‐old male presents with abdominal pain and elevated liver enzymes. Which of the
following would be the most appropriate next imaging test for confirmation of the findings shown?

A. Hepatobiliary iminodiacetic acid
(HIDA) scan
B. Magnetic resonance
cholangiopancreatography (MRCP)
C. Pancreatic mass protocol CT
D. Endoscopic ultrasound (EUS)

Hepatobiliary: Answers and Explanations

1. Answer A. The first image shows a markedly thickened and striated gallbladder wall. The second
image shows a part of the liver parenchyma that appears normal. The gallbladder wall is considered
thickened when it is over 3 mm. Diffuse gallbladder wall thickening occurs in the setting of both biliary
and nonbiliary processes. Biliary etiologies include cholecystitis, gallbladder cancer,
adenomyomatosis, primary sclerosing cholangitis, and AIDS cholangitis. Nonbiliary causes due to
edema include hepatitis, ascites, cirrhosis, portal hypertension, hypoproteinemia, and lymphatic
obstruction. The initial evaluation of gallbladder wall thickening should include a careful assessment
for gallstones and a sonographic Murphy sign to exclude acute cholecystitis.
This patient overdosed on Tylenol. Gallbladder wall thickening can be the only sonographic sign of
acute hepatitis. Gallbladder wall thickening is hypothesized to be due to an inflammatory reaction,
such as hyperemia, in the serosal and muscular layers adjacent to the liver in response to necrosis and
inflammation of the liver tissues. Hepatomegaly and periportal edema (with relative echogenicity of
the biliary triads—“starry sky” appearance) can also be seen, especially in viral hepatitis.
The hepatic echotexture would be expected to be coarsened in a patient with cirrhosis (answer choice
B), and it is normal in this case. No gallbladder distension or gallstones are shown to support the
diagnosis of acute cholecystitis (answer choice C). Acalculous cholecystitis (answer choice D) usually
occurs in critically ill ICU patients, and the gallbladder would be expected to be distended in that case
as well.
References: Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:46–48.
Smith EA, Dillman JR, Elsayes KM, et al. Cross‐sectional imaging of acute and chronic gallbladder inflammatory disease. AJR Am J
Roentgenol 2009;192(1):188–196.

2a. Answer A. Focal thickening of the wall of the gallbladder fundus is noted to contain both a
rounded cystic focus and an echogenic reflector with comet‐tail artifact. The presence of an echogenic
focus with comet‐tail artifact is highly specific for adenomyomatosis and is the result of cholesterol
crystals within Rokitansky‐Aschoff sinuses. Adenomyomatosis is relatively common and is a
hyperplastic cholesterolosis of the gallbladder wall, a benign condition. Therefore, no further work‐up
is needed.

2b. Answer B. Although some data suggest a possible association of adenomyomatosis and
gallbladder carcinoma, there is no conclusive evidence yet for the increased risk for gallbladder
carcinoma. There is a clear association of adenomyomatosis (especially segmental type) with
gallstones, possibly related to fundal stasis.
References: Boscak AR, Al‐Hawary M, Ramsburgh SR. Best cases from the AFIP: adenomyomatosis of the gallbladder.
RadioGraphics 2006;26:941–946.
Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:45–46.

3a. Answer C. The differential diagnosis for cystic lesions within the porta hepatis includes hepatic
cyst, enteric duplication cysts, pancreatic pseudocyst, biliary cysts, and hepatic artery aneurysm. The
images show a fusiform cystic structure containing echogenic nonmobile tissue with papillary
projections. The structure communicates directly with the hepatic ducts (left side of image 1),
indicating a choledochocele. Type I choledochal cyst is the most common type of choledochal cyst,
accounting for 80% to 90%, and is confined to the extrahepatic bile duct. Type I choledochoceles are
associated with an increased risk of both cholangiocarcinoma and gallbladder cancer. The papillary

configuration and static nature of the intraluminal lesion are particularly concerning for a
cholangiocarcinoma. ERCP would be appropriate for further evaluation and would permit tissue
sampling for diagnosis.

3b. Answer D. Although cholangiocarcinoma is the most ominous complication, it is the second most
common complication behind calculus formation within the biliary tree, choledochocele, gallbladder,
or pancreatic duct. Other potential complications include pancreatitis, rupture in infants and neonates,
and, rarely, cholangitis, liver abscesses, portal hypertension, and ascites.

3c. Answer C. A large majority (~90%) of carcinomas related to choledochal cysts occur within types
I (fusiform extrahepatic) and IV (multiple intra‐ and extrahepatic). Hence, the general
recommendation is for those cysts to be completely removed. Patients with type II cysts can often be
treated with cyst excision, and those with type III cysts can be treated with sphincterotomy or
endoscopic resection. Choledochal cysts are a premalignant state, with cancer occurring more
frequently and earlier than in the general population. The risk increases with age. Observed cancer
types in these patients include adenocarcinoma (73% to 84%), anaplastic carcinoma (10%),
undifferentiated cancer (5% to 7%), squamous cell carcinoma (5%), and other carcinoma (1.5%). The
sites of malignancy are the extrahepatic bile duct (50% to 62%), usually within the choledochal cyst;
gallbladder (38% to 46%); intrahepatic bile ducts (2.5%); and liver and pancreas (0.7% each). Most of
the cancers are associated with type I choledochal cysts (68%) followed by type IV choledochal cysts
(21%) and <10% for other types.
References:
Kim OH, Chung HJ, Choi BG. Imaging of the choledochal cyst. RadioGraphics 1995;15:69–88.
Law R, Topazian M. Diagnosis and treatment of choledochoceles. Clin Gastroenterol Hepatol 2014;12(2):196.
Singham J, Yoshida EM, Scudamore CH. Choledochal cysts part 1 of 3: classification and pathogenesis. Can J Surg 2009;52(5):434–
440.

4a. Answer B. The echogenic mass within the gallbladder fundus with power Doppler flow indicates
a solid mass. The echogenic wall is interrupted anteriorly at the site of the mass. Although the
differential diagnosis for a polypoid lesion containing Doppler flow includes both gallbladder
carcinoma and benign polyp, the large size and replacement of the gallbladder lumen are features
concerning for malignancy. Wall discontinuity is an especially ominous sign of transmural tumor
spread, indicating at least an AJCC stage III tumor (not a candidate for curative resection) with a poor
prognosis. Although ring‐down artifact is a feature of adenomyomatosis, the absence of ring‐down
artifact alone does not exclude adenomyomatosis.

4b. Answer D. Gallstones are present in 70% to 90% of patients with gallbladder cancer. The risk for
malignancy is higher in patients with larger gallstones and longer duration of cholelithiasis.

4c. Answer A. 40% to 65% of patients with gallbladder carcinoma at initial detection are found to
have a mass nearly filling or replacing the gallbladder lumen. Gallbladder carcinoma presents as focal
or diffuse wall thickening in 20% to 30% of cases. In 15% to 25% of cases, gallbladder carcinoma is
initially detected as a polypoid lesion.
References:

Franquet T, Montes M, Ruiz de Azua Y, et al. Primary gallbladder carcinoma: imaging findings in 50 patients with pathologic
correlation. Gastrointest Radiol 1991;16:143–148.
Hsing AW, Gao YT, Han TQ, et al. Gallstones and the risk of biliary tract cancer: a population‐based study in China. Br J Cancer
2007;97(11):1577–1582.
Levy AD, Murakata LA, Rohrmann CA. Gallbladder carcinoma: radiologic–pathologic correlation. RadioGraphics 2001;21:295–314.

5. Answer C. Image A: irregular intrahepatic biliary ductal dilatation is shown with intraluminal
echogenic tissue along with a complex cystic intrahepatic collection. Images B and C: spectral hepatic
arterial waveforms show a parvus tardus waveform indicating an upstream stenosis. The constellation
of findings is compatible with hepatic arterial anastomotic stenosis resulting in biliary injury, known
as ischemic type biliary lesion (ITBL). Biliary complications occurring after liver transplantation
include bile leaks, anastomotic strictures, nonanastomotic strictures, and ampullary dysfunction. The
biliary epithelium is particularly vulnerable to ischemic injury because of its reliance on hepatic
arterial perfusion, whereas the hepatic parenchyma receives dual blood supply from the portal venous
and hepatic arterial system. Ischemic injury can result in biliary necrosis, cast formation, scarring, and
multifocal stenosis.
Reference: Seehofer D, Eurich D, Veltzke‐Schlieker W, et al. Biliary complications after liver transplantation: old problems and
new challenges. Am J Transplant 2013;13:253–265.

6. Answer C. Quality control (QC) is the process by which a desired level of quality is verified and
maintained in a product or service. QC requires planning, use of proper equipment, continued
inspection, and corrective action as necessary. A range of acceptable quality is determined to guide QC
measures.
Quality assurance (QA) is an older, less often used term, referring to a reactive, generally retrospective
process of determining who was at fault after a medical error is committed and sometimes involving
punitive measures.
Quality improvement (QI) is a continuous process of improving quality, often focusing on finding
weaknesses in the system in order to prevent errors from occurring rather than attributing blame to
individuals. QI activities involve measuring quality and determining how to make things better in an
ongoing fashion.
Reference: Quality and safety domain specification and resource guide, core exam study guide. Tucson, AZ: American Board of
Radiology, 2016:5.

7a. Answer C. Cholecystectomy is recommended for gallbladder polyps that measure >1 cm because
of risk of malignancy. Follow‐up imaging can be performed for gallbladder polyps that measure >6 mm
but <10 mm. There is no role for MRI or hepatobiliary cholescintigraphy in further characterization of
these lesions.

7b. Answer C. Size >10 mm is most predictive of malignancy.
Reference: Corwin MT, Siewert B, Sheiman RG, et al. Incidentally detected gallbladder polyps: is follow‐up necessary?—Long‐
term clinical and US analysis of 346 patients. Radiology 2011;258(1):277–282.

8. Answer B. The image shows an example of side lobe artifact from echogenic bowel being located
adjacent to the anechoic gallbladder lumen. In addition to the main ultrasound beam, an ultrasound
probe emits off‐center ultrasound pulses. When a strong reflector is encountered by one of these off‐
center pulses, it can be reflected back to the ultrasound probe and interpreted as being located in the
path of the main ultrasound beam. This artifact is generally only a problem when imaging anechoic,
fluid‐filled structures like the bladder or gallbladder, as the artifact from the side lobe is generally only
detectable when imaging an anechoic structure. However, it still occurs when imaging solid organs,
but the artifact is usually imperceptible.
The image (on the following page) shows the gallbladder from a slightly different angle than from the
image in the question. This image more convincingly shows the echogenic structure “within” the
gallbladder lumen to be artifactual. An additional clue
that the echogenic structure in the gallbladder is not a
gallstone but rather artifactual is the lack of clean
shadowing posterior to the echogenic focus that would
be expected from a stone. In this case, there is dirty
shadowing posterior to the gallbladder, suggestive of
bowel gas. The use of harmonic imaging can effectively
minimize side lobe artifacts, so turning off harmonics
would accentuate this artifact. Increasing transducer
power will increase the amplitudes of both the primary
beam and side lobes, so the artifact will increase.
Increasing the depth of imaging will not decrease this
artifact.

Reference: Feldman MK, Katyal S, Blackwood MS. US artifacts. RadioGraphics 2009;29(4):1179–1189.

9. Answer C. Image A shows a small amount of perihepatic ascites. Image B shows marked
gallbladder wall thickening, and Image C shows reversal of flow in the main portal vein. Based on the
clinical history and the provided images, the best answer is C, sinusoidal obstruction syndrome (SOS),
also known as venoocclusive disease (VOD).
SOS/VOD is thought to result directly from chemotherapy or radiation‐induced destruction of hepatic
microvasculature during cytoreductive HSCT (hematopoietic stem cell transplant) conditioning and
represents the most common cause of liver disease during the first 20 days after stem cell transplant,
affecting 10% to 60% of patients. Clinically, the patient presents with weight gain, painful
hepatomegaly, jaundice, and ascites, usually within 3 weeks following hematopoietic stem cell
transplantation. It may also happen following some forms of chemotherapy and liver transplantation.
Imaging findings mimic those of graft versus host disease (GVHD). Ultrasound findings include
hepatosplenomegaly, ascites, gallbladder/periportal edema, hepatofugal flow in the portal vein on
Doppler, and elevated RI (>0.75).
Chemotherapy‐induced steatosis is not the best choice because the liver is not more echogenic than
the adjacent kidney, as one would expect with steatosis. Also, the portal triads and diaphragm are
visible indicating normal acoustic penetration. Additionally, this does not explain the findings of
gallbladder wall thickening and ascites. Acute cholecystitis is not the best choice because the
gallbladder is not distended. It also does not explain the findings of ascites and hepatofugal flow in the
portal vein. Cirrhosis is not the best choice because it does not explain the marked gallbladder wall
thickening, nor is it the best fit for the clinical scenario.
Mahgerefteh SY, Sosna J, Bogot N, et al. Radiologic imaging and intervention for gastrointestinal and hepatic complications of
hematopoietic stem cell transplantation. Radiology 2011;258(3):660–671.

10. Answer key:
Caudate lobe
Left lateral segment
Fissure for ligamentum venosum
Umbilical portion of left portal vein
Main portal vein
Common bile duct
Right hepatic artery

11. Answer C. The three images show the gallbladder with multiple small polyps, the so‐called “balls
on the wall” sign seen in cholesterolosis. Cholesterolosis is a benign condition in which cholesterol
esters are deposited within the lamina propria of the gallbladder. Cholesterol polyps are by far the
most common type of gallbladder polyp. They are enlarged papillary fronds filled with lipid‐laden
macrophages and are not true neoplasms. They are adherent to the wall by a slender stalk, which is
rarely seen. They are usually 5 mm or less in size and rarely grow larger than 10 mm. They are
distinguished from stones by their lack of shadowing and nonmobility. Their nonmobility
distinguishes them from sludge balls. If there are multiple small polyps, they are almost certainly
cholesterol polyps and can be ignored. Therefore, answer choice C is the correct answer.
There is no association of cholesterol polyps with gallbladder cancer; therefore answer choice A is not
correct. The cause is unknown, but there is no association with serum lipid levels; therefore, answer
choice B is incorrect. Cholesterolosis has the same risk factors as cholelithiasis, but the two conditions
rarely coexist. Therefore, answer choice D is an incorrect statement.
Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences, 2011:209–210.

12. Answer A. Increasing the depth or width of the field of view will increase the image size and
reduce the frame rate. It has no effect on acoustic impedance.
Reference: Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:11.

13. Answer B.

14. Answer D. The ultrasound images show mild biliary dilatation in the setting of a prior liver
transplant as well as nonshadowing echogenic material within the extrahepatic bile duct. The hepatic
artery shows a “parvus et tardus” waveform, the typical Doppler waveform of an artery downstream
from an area of stenosis. Because of the biliary epithelium’s
reliance on hepatic arterial perfusion, biliary complications
are common in the setting of hepatic arterial stenosis. Biliary
cast syndrome (BCS) is among these potential complications
and has been reported in 4% to 18% of liver transplants.
Casts consisting of bilirubin, collagen, bile acids, and
cholesterol form within the bile duct lumen and lead to
biliary obstruction.
BCS is associated with increased morbidity, mortality, and
graft rejection. The increased echogenicity within the
common duct in this case is typical of biliary cast syndrome.

A noncontrast CT image shows tubular hyperattenuating material within the biliary tree also
representing cast. Given the constellation of findings typical of BCS, choledocholithiasis (answer choice
C) and an obstructing mass (answer choice A) are less likely. Portal biliopathy (answer choice B) is
biliary obstruction that can occur in the setting of cavernous transformation of the portal vein. The
numerous collateral vessels formed following thrombosis of the main portal vein in the porta hepatis
result in biliary obstruction.

Reference: Gor NV, Levy RM, Ahn J, et al. Biliary cast syndrome following liver transplantation: predictive factors and clinical
outcomes. Liver Transpl 2008;14(10):1466–1472.

15. Answer B. A strong reflector located outside the main ultrasound beam may generate echoes that
are detectable by the transducer. These echoes are falsely displayed as having originated from within
the main beam. This artifact is known as the side lobe artifact. It is more likely to be recognized when
the misplaced echoes overlap a structure that is normally anechoic, such as the gallbladder. Therefore,
in imaging of the gallbladder, which is normally anechoic, the side lobes can produce an artifactual
appearance of sludge.
References: Bushberg JT, Seibert JA, Leidholdt EM. The essential physics of medical imaging, 3rd ed. Philadelphia, PA: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2011:566–567.
Feldman MK, Katyal S, Blackwood MS. US artifacts. RadioGraphics 2009;29(4): 1179–1189. doi:10.1148/rg.294085199.

16. Answer B. The ultrasound image is of the right upper quadrant showing mirror image artifact.
Liver parenchyma is shown both below and above the diaphragm. Mirror image artifacts are
generated by the false assumption that an echo returns to the transducer after a single reflection. In
this scenario, the primary beam encounters a highly reflective interface. The reflected echoes then
encounter the “back side” of a structure and are reflected back toward the reflective interface before
being reflected to the transducer for detection. The display shows a duplicated structure equidistant
from but deep to the strongly reflective interface.
Gas is the best acoustic mirror in the body because it reflects almost 100% of the ultrasound beam. In
right upper quadrant US, the base of the right lung acts as an acoustic mirror. It forms a mirror image
of the liver and diaphragm. The trachea is another structure with a large smooth gas interface. It
therefore acts as a mirror on scans of the neck.
References: Feldman MK, Katyal S, Blackwood MS. US artifacts. RadioGraphics 2009;29(4):1179–1189.

17a. Answer C. The ultrasound image shows multiple coarse shadowing calcifications. At least two of
these calcifications are shown to be within a tubular anechoic structure (bile duct). The CT image
shows several cystic liver lesions, many with central intraluminal fibrovascular bundles corresponding
to portal vein radicals. Many cystic spaces also contain coarse calcifications. These imaging findings
are characteristic of Caroli disease.
Caroli disease is also known as communicating cavernous ectasia of the intrahepatic bile ducts and is
an autosomal recessive disorder. It results from the arrest of or a derangement in the normal
embryologic remodeling of ducts and causes varying degrees of destructive inflammation and
segmental dilatation. If the large intrahepatic bile ducts are affected, the result is Caroli disease,
whereas abnormal development of the small interlobular bile ducts results in congenital hepatic
fibrosis. If all levels of the biliary tree are involved, features of both congenital hepatic fibrosis and
Caroli disease are present. This condition has been termed Caroli syndrome. Caroli disease typically

manifests as saccular or fusiform cystic dilatations of the intrahepatic bile ducts up to 5 cm in
diameter, often containing calculi or sludge.
Autosomal dominant and autosomal recessive polycystic kidney, as well as medullary sponge and
medullary cystic kidney, can be seen in association with Caroli disease. Renal cysts are seen with
disorders of the ductal plate, and renal developmental abnormalities can be caused by the same
genetic determinants.
Levy AD, Rohrmann CA, Murakata LA, et al. Caroli’s disease: radiologic spectrum with pathologic correlation. AJR Am J Roentgenol
2002;179(4):1053–1057.
Santiago I, Loureiro R, Curvo‐Semedo L, et al. Congenital cystic lesions of the Biliary tree. AJR Am J Roentgenol 2012;198(4):825–
835.

17b. Answer D. The presence of portal radicles partially or completely surrounded by dilated bile
ducts (known as the central‐dot sign) is considered characteristic of Caroli disease. Ultrasound may
also show dilated intrahepatic bile ducts with intraductal calculi. Echogenic septa may traverse the
lumens of dilated bile ducts, an appearance termed intraductal bridging.
Reverse target sign (answer choice A) is described in hepatic cavernous hemangiomas due to a
hypoechoic center and a hyperechoic periphery.
Cluster of grapes sign (answer choice B) is described in pyogenic liver abscesses. Small pyogenic
abscesses of the liver, merging into a large cavity, form an image similar to a bunch of grapes.
Water‐lily sign (answer choice C) is characteristic of echinococcal infections when there is detachment
of the endocyst membrane, which results in floating membranes within the pericyst that mimic the
appearance of a water lily.
Reference: Vachha B, Sun MRM, Siewert B, et al. Cystic lesions of the liver. AJR Am J Roentgenol 2011;196(4):W355–W366.

17c. Answer B.
Reference: Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:99–100.

18. Answer A. The ultrasound images show a large irregular hypoechoic lesion in the right hepatic
lobe with irregular wall and septations. There is increased through‐transmission indicating
cystic/liquefied internal contents. There is some blood flow in the periphery of the lesion, but no blood
flow within the lesion. These imaging findings along with the provided clinical history are strongly
suggestive of a pyogenic liver abscess.
Pyogenic liver abscess secondary to appendicitis, diverticulitis, or other intra‐abdominal infective
processes has decreased dramatically because of improvements in the treatment of the primary
condition, which typically includes source control and early initiation of antibiotics. Nonetheless, these
diagnoses still account for approximately 20% of cases of pyogenic liver abscess. Biliary obstruction
(benign or malignant), stenting, or instrumentation is now a more common cause. Hematogenous
spread from other sources, such as bacterial endocarditis and intravenous drug abuse, can also result
in formation of liver abscess.
Antibiotics and ultrasound or CT‐guided drainage are the mainstays of therapy for pyogenic liver
abscess. Ultrasound or CT‐guided percutaneous drainage of abscesses is usually safe and effective.
Drainage catheters are left in place until the collection is completely evacuated, as determined by
serial imaging studies and the patient’s clinical course.
Imaging‐guided biopsy (answer choice B) would be indicated if this was a solid lesion, but patient
history and imaging characteristics of the lesion point toward abscess. If in doubt, an aspiration
followed by drainage can be performed. Liver protocol MRI (answer choice C) would be useful to

characterize an indeterminate solid liver lesion. Surgery (answer choice D) is reserved for cases where
percutaneous abscess drainage is unsuccessful or in patients who have coexistent intra‐abdominal
disease that requires operative management.
Ralls PW. Focal inflammatory disease of the liver. Radiol Clin North Am 1998;36(2):377–389.
Reid‐Lombardo KM, Khan S, Sclabas G. Hepatic cysts and liver abscess. Surg Clin North Am 2010;90(4):679–697.

19. Answer D. According to the report published in 1999 from the Institute of Medicine entitled “To
Err Is Human: Building a Safer Health System,” medical errors were defined as the failure of a planned
action to be completed as intended or the use of a wrong plan to achieve an aim. Medical errors are
multifactorial, and most were felt to be system errors rather than individual problems. Errors can be
classified into one of four main categories: (1) diagnostic errors, (2) treatment errors, (3) preventative
errors, and (4) other errors. The scenario described in the vignette best fits into two main categories
of medical error. Equipment failure falls into the “other error” category because of the retractor
breakage. There is no reason to believe that the surgeon was straying from standard surgical
procedure (answer choice A is incorrect). The other main source of error is caused by a missed
surgical foreign body on the closing films. Although the images were suboptimal and the finding was at
the edge of the film, the foreign body could be seen when the viewing parameters of the film were
optimized. Repeat films can be requested if necessary, but that is at the discretion of the radiologist
and clinicians. The surgical team would not have known where the foreign bodies were. Answer
choices B and C are not the best selections.
Reference: Diagnostic Radiology: Core Quality and Safety Study Guide manual on patient safety. Tucson, AZ: American Board of
Radiology, 2015:5.

20a. Answer C. Ultrasound images show a round lesion in the right hepatic lobe with a “target”
appearance. The lesion has an echogenic center with a thick hypoechoic halo. This ultrasound
appearance is strongly suggestive of malignancy. In a cirrhotic patient, the lesion should be considered
hepatocellular carcinoma (HCC) until proven otherwise. Further characterization was performed with
MRI using a liver‐specific protocol, which reveals arterial phase hyperenhancement and washout on
the delayed 5‐minute postcontrast image. These imaging features are diagnostic of hepatocellular
carcinoma.
Preferential arterial blood supply is one of the hallmarks of HCC. Therefore, arterial phase
hyperenhancement is the single most important imaging feature of HCC. The washout feature on
portal venous phase has been attributed to the diminished portal venous supply of HCC compared
with the surrounding liver.
Reference: Bashir MR, Hussain HK. Imaging in patients with cirrhosis. Radiol Clin North Am 2015;53(5):919–931.

20b. Answer E. The liver lesion shown here is >20 mm in size and shows arterial hyperenhancement
as well as delayed washout. According to the ACR LI‐RADS v2017 for CT and MRI, this would be a LI‐
RADS 5 lesion.
Reference: American College of Radiology. Liver Imaging Reporting and Data System version 2017.

20c. Answer D.According to the ACR LI‐RADS v2017 lexicon, threshold growth is defined as a
minimum increase in nodule diameter of 0.5 cm in addition to either at least 50% diameter increase
within 6 months or at least 100% diameter increase per year. New lesions measuring at least 1 cm that
were previously not seen on CT or MRI within the past 2 years are also considered threshold growth.
Reference: American College of Radiology. Liver Imaging Reporting and Data System version 2017.

21. Answer C. US and CT images show macronodular appearance of the liver with areas of capsular
retraction, heterogeneous parenchyma, trace ascites, and mild splenomegaly. In a patient with history
of metastatic breast cancer, this imaging appearance can be seen following chemotherapy and is
described as “pseudocirrhosis.” The pathogenesis has been proposed to be related to nodular
regenerative hyperplasia caused by chemotherapy‐induced hepatic injury resulting in capsular
retraction, decrease in hepatic volume, and caudate lobe enlargement. Findings of portal hypertension
such as ascites and splenomegaly may be also seen.
Reference: Viswanathan C, Truong MT, Sagebiel TL, et al. Abdominal and pelvic complications of nonoperative oncologic therapy.
RadioGraphics 2014;34(4):941–961.

22. Answer D. Ultrasound image shows a large lobulated hypoechoic and heterogeneous mass in the
medial segment of the left lobe. CT image confirms the finding and also raises suspicion for central
necrosis. A focus of calcification is also seen in the mass. There is overlying capsular distortion, and
small amount of ascites is present anterior to the liver. Additionally, bulky enlarged porta hepatis
lymph nodes are shown, strongly suggesting a malignant process. In a young patient with no prior
liver disease, the most likely diagnosis would be fibrolamellar carcinoma.
Fibrolamellar carcinoma is a variant of hepatocellular carcinoma seen in young patients usually
without previous liver disease. Patients may present with abdominal pain, hepatomegaly, and palpable
mass. Gynecomastia and venous thrombosis may be seen in some cases. Gynecomastia results from
conversion of circulating androgens to estrogens by the enzyme aromatase, which is elaborated by the
malignant hepatocytes of fibrolamellar carcinoma. In contrast to hepatocellular carcinoma, serum
alpha‐fetoprotein is generally not elevated.
Giant cavernous hemangioma (answer choice A) can have a central scar or necrosis and may
occasionally have central calcifications. The enhancement pattern of hemangiomas tends to follow the
blood vessels during all phases of enhancement and is peripheral, nodular, and discontinuous, with
eventual filling‐in on delayed phase images. Bulky lymphadenopathy and ascites, as in this case, will
not be seen.
Focal nodular hyperplasia (FNH) (answer choice B) has a female predominance, is usually isodense to
the liver on portal venous phase, and rarely has calcifications. Moreover, bulky lymphadenopathy will
not be associated with FNH.
HCC (answer choice C) is primarily seen in the adult population and in those with chronic liver disease.
Serum alpha‐fetoprotein is generally elevated. Venous invasion can be seen in large or infiltrative HCC.
References: Lewis RB, Lattin GE, Makhlouf HR, et al. Tumors of the liver and intrahepatic bile ducts: radiologic–pathologic
correlation. Magn Reson Imaging Clin N Am 2010;18(3):587–609.
McLarney JK, Rucker PT, Bender GN, et al. Fibrolamellar carcinoma of the liver: radiologic–pathologic correlation. RadioGraphics
1999;19(2):453–471.

23. Answer D. Ultrasound images show a nondependent, nonshadowing polypoid lesion in the
gallbladder with internal vascular flow. A large right adrenal mass is also shown in keeping with
provided clinical history of multiorgan metastases. In a patient with metastatic disease, a soft tissue
mass in the gallbladder is strongly concerning for melanoma metastasis. Usually other abdominal
metastases will also be present such as in the liver, adrenal glands, lymph nodes, etc.
Malignant melanoma is the most common cause of metastatic tumors of the gallbladder, accounting for
more than 50% cases of all gallbladder metastases. The exact mechanism is not clear, but it may be
because of the rapid hematogenous spread of melanoma. Other primary tumors, such as renal cell
carcinoma, may also metastasize to the gallbladder hematogenously. Advanced hepatocellular
carcinoma can locally extend and invade the gallbladder. Cholesterol polyps and adenomas also
present as polypoid lesions within the gallbladder, but they are usually much smaller compared to
malignant lesions.
References: Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:45.
Martel J‐P, McLean CA, Rankin RN. Melanoma of the gallbladder. RadioGraphics 2009;29(1):291–296.

24. Answer C. The ACR Appropriateness Criteria are a group of documents developed by the
American College of Radiology (ACR), whose primary purpose is to “assist referring physicians in
making appropriate imaging decisions for given patient clinical conditions.” Currently, these criteria
are the most comprehensive evidence‐based guidelines for diagnostic imaging selection, radiotherapy
protocols, and image‐guided interventional procedures. They embody the best current evidence for
selecting appropriate diagnostic imaging and interventional procedures for numerous clinical
conditions.
Reference: American College of Radiology. 2017 ACR Appropriateness criteria.

25. Answer A. Color and spectral Doppler images show absence of flow in the right and middle
hepatic veins. There is abnormal faint monophasic flow in the inferior vena cava (IVC). The caudate
lobe is markedly enlarged. There is small ascites. All these findings together with the clinical
presentation in a young female patient are most suggestive of Budd‐Chiari syndrome (BCS).
Budd‐Chiari syndrome is caused by obstructed hepatic venous outflow, resulting in progressive
hepatic failure, ascites, and portal hypertension. The obstruction can be anywhere from the small
hepatic veins to the junction of the IVC and the right atrium. Hepatic venous outflow obstruction
results in increase of sinusoidal pressure and diminished portal venous flow, resulting in centrilobular
congestion and ultimately necrosis and atrophy.
Causes of BCS include hypercoagulable states in young women on oral contraceptives, trauma,
pregnancy, extension of tumor into hepatic veins, etc. US findings include presence of ascites and
enlarged caudate lobe. The emissary veins from the caudate lobe drain directly into the IVC. This
increased blood flow through the caudate lobe leads to enlargement. Blood flow in hepatic veins and
IVC can be monophasic, reversed, or absent. The portal vein may also be affected and show either slow
or reverse flow.
Right heart failure will typically show dilated IVC and hepatic veins. Therefore, answer choice B is
incorrect. Acute hepatitis may show decreased echogenicity of the liver parenchyma, accentuated
brightness of the portal triads, hepatomegaly, and gallbladder wall thickening. It would not be
expected to show hepatic vein thrombosis as in this case. Therefore, answer choice C is incorrect. In
primary sclerosing cholangitis (PSC), there are irregularly distributed multifocal bile duct strictures of
intra‐ and extrahepatic bile ducts. However, because of the sclerotic nature of PSC, marked dilatation
of the intrahepatic ducts may be absent. The intrahepatic ducts are frequently not visualized on US.

Diffuse thickening of the common hepatic and common bile duct may be seen on US. Therefore,
answer choice D is incorrect.
Reference: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:104–107.

26. Answer B. The ultrasound images show a distended gallbladder filled with multiple gallstones.
The gallbladder wall is thickened and striated. There are focal areas of mucosal ulceration with small
amount of adjacent pericholecystic fluid/abscess. The third image shows sloughing of the mucosal
membranes. These findings are suggestive of gangrenous cholecystitis.
Gangrenous cholecystitis is a severe advanced form of acute cholecystitis. It is believed to result from
cystic duct obstruction, leading to marked distension of the gallbladder and ultimately ischemic
necrosis of the wall. Gangrenous cholecystitis is associated with significantly increased morbidity and
mortality and usually requires emergent surgery.
On ultrasound, there is heterogeneous or striated thickening of the gallbladder wall likely from
ulceration, hemorrhage, necrosis, or microabscesses in the gallbladder wall. The presence of
intraluminal membranes, which represent desquamated gallbladder mucosa, may be seen. Murphy
sign is absent in two‐thirds of patients because of necrosis of the nerve supply to the gallbladder.
Intramural abscesses or pericholecystic fluid collection or abscess caused by associated gallbladder
perforation may be seen.
Uncomplicated acute cholecystitis (answer choice A) would not be expected to cause the sonographic
findings of desquamated and ulcerated gallbladder mucosa as in this case. Moreover, sonographic
Murphy sign would also be expected to be positive in acute cholecystitis. In acute hepatitis (answer
choice C), there can be diffuse gallbladder wall thickening but without gallbladder distension. No soft
tissue mass is shown in this case to suggest gallbladder cancer (answer choice D).
References: Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clin North Am
2003;41(6):1203–1216.
Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences, 2011:205.

27. Answer A. Ultrasound images show marked intrahepatic biliary ductal dilatation. Intraluminal
mass is present in the proximal common bile duct up to the level of the biliary confluence. The imaging
appearance is most consistent with and concerning for cholangiocarcinoma.
Cholangiocarcinomas are malignant tumors arising from the biliary tract. Primary sclerosing
cholangitis is the most common risk factor for cholangiocarcinoma in the United States. Liver flukes
and hepatolithiasis are common risk factors in eastern Asia. Based on location, they are divided into
intrahepatic (about 10%), hilar (about 60%), and distal (about 30%) types. Hilar cholangiocarcinomas
are also called Klatskin tumors. Based on morphologic classification, they are classified into mass‐
forming, periductal infiltrating, and intraductal growth types.
Cholangiocarcinoma more commonly causes biliary obstruction than does hepatocellular carcinoma
(answer choice B). Metastases to bile ducts can (answer choice C) mimic cholangiocarcinoma, affecting
both the intrahepatic and extrahepatic ducts. History of malignancy and presence of multiple lesions
would help in making that diagnosis. Patients with choledocholithiasis (answer choice D) present with
right upper quadrant or epigastric pain, nausea, and vomiting. Ultrasound may reveal shadowing
ductal calculi, which are not a finding in this case.
References: Chung YE, Kim M‐J, Park YN, et al. Varying appearances of cholangiocarcinoma: radiologic–pathologic correlation.
RadioGraphics 2009;29(3):683–700.

28. Answer D. Ultrasound image shows acoustic shadowing posterior to a calcified gallstone.
Acoustic shadowing is mainly caused by sound absorption. Absorption refers to the loss of sound
energy secondary to its conversion to thermal energy. Absorption is greatest in bone/calcification,
followed by soft tissue, followed by fluid.

29. Answer B. Shadowing at the edges of fluid‐filled structures is caused by refraction. Refraction is
caused by the change in direction of the transmitted ultrasound beam at a tissue boundary when the
beam is not perpendicular to the boundary. It is commonly seen at fat–muscle and tissue–fluid
interfaces.

30. Answer B. Sagittal and transverse images of the right hepatic lobe show a hypoechoic liver lesion
with an echogenic rim. This is the “reverse target” appearance and is known to be quite characteristic
of cavernous hemangiomas. Although not very specific, posterior acoustic enhancement can be seen in
hemangiomas. Posterior acoustic shadowing (answer choice A) is not seen except in rare giant
hemangiomas, which may have central calcifications. Histologically, hemangiomas contain multiple,
small, blood‐filled spaces separated by fibrous septations and lined by endothelial cells. However,
blood flow in these spaces is too slow to be detected with Doppler techniques. Hemorrhage (answer
choice C) is not typical of hemangiomas. It can be seen in hepatic adenomas and hepatocellular
carcinomas. Because hemangioma are benign lesions, they would not be associated with a primary
malignancy (answer choice D).

31. Answer B. The ultrasound images show a dilated common bile duct with an echogenic focus with
posterior shadowing consistent with choledocholithiasis and intrahepatic biliary ductal dilatation. The
next most appropriate imaging test in this scenario would be MRCP, which can confirm the presence of
intraductal stones. MRCP is particularly helpful if the distal common bile duct is not reliably visualized
on ultrasound.
A HIDA scan (answer choice A) could be useful in an equivocal case of acute cholecystitis. If the
pancreatic duct is dilated, in combination with intrahepatic and extrahepatic biliary ductal dilatation,
it would be concerning for a pancreatic head or periampullary mass. In that case, a pancreatic mass
protocol CT (answer choice C) would be indicated. Endoscopic ultrasound (answer choice D) with
tissue sampling is indicated if a pancreatic mass is shown on imaging.
Reference: William D, Middleton BSH. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:94–96.

5. A 29‐year‐old female patient presents with Crohn disease and right‐sided abdominal pain. Two US
images obtained in the right abdomen are shown. What is the most likely diagnosis?

A. Acute appendicitis
B. Terminal ileitis
C. Intussusception
D. Incarcerated inguinal
hernia

6. Which of the following will improve axial resolution in an ultrasound image?
A. Increasing transducer frequency
B. Decreasing transducer frequency
C. Increasing the diameter of ultrasound beam
D. Decreasing the diameter of ultrasound beam

7a. A 79‐year‐old male presents to the emergency department with painless jaundice. Which of the
following structures are abnormal?

A. Pancreatic duct and common duct
B. Common duct and main portal vein
C. Main portal vein and splenic vein
D. Splenic vein and pancreatic duct

7b. Which of the following is the most common sonographic appearance of the lesion shown?
A. Hyperechoic and hypervascular
B. Hyperechoic and hypovascular
C. Hypoechoic and hypervascular
D. Hypoechoic and hypovascular

8. What is the purpose of using gel between the transducer and skin surface?
A. To displace air
B. To decrease friction
C. To improve glide
D. To improve patient compliance

9. Plan‐Do‐Study‐Act is a commonly used methodology for which of the following goals?
A. Quality control
B. High‐reliability organization
C. Quality improvement
D. Patient confidentiality

10. Compared to holding the transducer at an oblique angle to a tissue interface, perpendicular
orientation to the interface will:
A. Return more of the echo to the probe
B. Result in mislocalization of lesions because of refractive artifact
C. Diminish penetration of deeper tissues
D. Increase the likelihood of duplication artifacts

11. These are the ultrasound images from the left mid abdomen of a 70‐year‐old male with a history
of non‐Hodgkin lymphoma being evaluated for melena. What is the name of the sign that describes the
ultrasound findings?

A. WES (wall‐echo
shadow) sign
B. Pseudokidney sign
C. Yin–yang sign
D. Onion skin sign

12. A 70‐year‐old male with anemia and splenomegaly on
physical examination undergoes a left upper quadrant
ultrasound. Based on the imaging findings, what is the most
likely diagnosis?

A. Splenic infarcts
B. Leukemia
C. Lymphangiomas
D. Hemangiomas

13a. A 55‐year‐old male presents with intractable
chronic abdominal pain. What is the most likely etiology
for the condition shown in the ultrasound image?

A. Alcohol
B. Gallstones
C. Idiopathic
D. Heredity

13b. Aspiration of the lesion shown here in the same
patient is likely to reveal elevated levels of which of the
following?

A. Carcinoembryonic antigen (CEA)
B. Amylase
C. Lipase
D. Mucin

14. What is the best definition of “value” in health care?
A. Reduce cost of providing health care.
B. Increase quality of health care.
C. Provide a desired level of quality at low cost.
D. Provide care for more individuals.

15. A 25‐year‐old male presents with left upper quadrant pain. What is the most appropriate step for
further management?

A. Surgery or percutaneous
drainage
B. Anticoagulation
C. Supportive management
D. CT or MRI

16a. A 20‐year‐old female presents with left upper quadrant pain following blunt abdominal injury.

A. Splenic laceration
B. Subcapsular
hematoma
C. Splenic infarct
D. Splenic
pseudoaneurysm

16b. What is the next step in management for this patient?
A. Coil embolization
B. Splenectomy
C. Contrast‐enhanced CT
D. Follow‐up imaging surveillance

17. Which of the following is the most likely etiology for
these findings?

A. Sickle cell anemia
B. Prior trauma
C. Tuberculosis
D. Histoplasmosis

18a. A 25‐year‐old male presents with abdominal pain. Sagittal image of the right kidney and
transverse image of the right upper quadrant are shown. What is the structure indicated by the arrow?

A. Duodenal mass
B. Pancreatic head and uncinate
process
C. Right kidney
D. Gas from the stomach

18b. What is the most important role of ultrasound in the workup and management of acute
pancreatitis?
A. To identify and quantify pancreatic necrosis
B. To differentiate walled‐off necrosis from pseudocyst
C. To assess for the presence of a pancreatic divisum
D. To identify gallstones

19. A 35‐year‐old male presents for evaluation of a splenic lesion demonstrated on an unenhanced
chest CT. What is the most likely etiology of this abnormality?

A. Chronic infarct
B. True epithelial‐lined cyst
C. Parasitic cyst
D. Trauma

20. A 52‐year‐old female with left upper quadrant pain is
examined with a left upper quadrant ultrasound.
Abnormalities of which of the following sonographic findings
may permit diagnosis of portal hypertension?

A. Splenic echogenicity
B. Degree of splenic enlargement
C. Splenic vein Doppler
D. Presence of ascites

21. A 62‐year‐old male is referred for a therapeutic ultrasound‐
guided paracentesis for abdominal bloating and ascites. A
representative image is shown. What is the next best step?

A. CT abdomen and pelvis.
B. Nasogastric tube placement.
C. Perform paracentesis.
D. Send the patient home with instructions to return if ascites
worsens.

22. Two images of the left upper quadrant are shown. The image on the right was obtained 2 weeks
following the first. Which of the following choices best explains the change in the appearance of the
spleen?

A. Interval procedure
B. Infection
C. Malignancy
D. Rupture

23. A 70‐year‐old male with a history of nonalcoholic steatohepatitis receives an ultrasound. The
patient does not have a history of pancreatitis. What is the most likely diagnosis from the following
choices?

A. Mucinous cystic neoplasm
B. Intraductal papillary mucinous neoplasm
C. Solid pseudopapillary neoplasm
D. Serous cystadenoma

24. An ultrasound department
performed retrospective analysis of all
abdominal ultrasound examinations
performed in 1 week that showed
inadequate visualization of the
pancreas. The various contributing
factors were displayed in the graph
shown. This type of graphical tool is
called:

A. Flowchart
B. ROC curve
C. Pareto chart
D. Control chart

25. Identify the labeled anatomic structures.

26. Transverse image from an abdominal
ultrasound is shown. Match the labels with the
anatomic structures.

A Portal confluence
B Liver
C Pancreas
D Superior mesenteric artery
E Splenic vein
F Stomach

27. A 66‐year‐old male underwent ultrasound for evaluation of renal insufficiency. What is the most
likely diagnosis of the finding shown?

A. Lymphoma
B. Metastasis
C. Hemangioma
D. Hematoma

28. A 68‐year‐old female presented with vague abdominal pain. After initial physical examination and
laboratory tests were unrevealing, CT examination of the abdomen was performed. This prompted
further evaluation of a lesion by endoscopic ultrasound and fine needle aspiration. The fine needle
aspirate showed no atypical cells or elevated tumor markers. CT image and endoscopic ultrasound
image of the lesion are provided. What is the most likely diagnosis?

A. Pancreatic
adenocarcinoma
B. Pancreatic mucinous
cystadenoma
C. Pancreatic serous
cystadenoma
D. Pancreatic pseudocyst

Pancreas, Spleen, and Bowel: Answers and

Explanations

1. Answer B. Image of the right upper quadrant shows ring‐down artifact arising from a gas‐filled
loop of bowel.
In ring‐down artifact, the transmitted ultrasound energy causes resonant vibrations within fluid
trapped between multiple gas bubbles. These vibrations create a continuous sound wave that is
transmitted back to the transducer. This phenomenon is displayed as a line or series of parallel bands
extending posterior to a gas collection. Ring‐down artifact occurs most frequently because of gas and
has also been shown with metal.
Reverberation artifacts (answer choice A) occur when the ultrasound signal reflects repeatedly
between highly reflective interfaces that are usually in the near field. This is seen as multiple
equidistantly spaced linear reflections. Comet‐tail artifact (answer choice C) is a form of reverberation.
In this artifact, the two reflective interfaces and their sequential echoes are closely spaced. The later
echoes have decreased amplitude resulting in a reverberation artifact with a triangular, tapered shape.
Twinkle artifact (answer choice D) is due to a form of intrinsic noise within the Doppler circuitry of the
US machine and is commonly observed at color Doppler imaging when insonating certain rough
reflective surfaces.
References: Dillman JR, Kappil M, Weadock WJ, et al. Sonographic twinkling artifact for renal calculus detection: correlation with
CT. Radiology 2011;259:911–916.
Feldman MK, Katyal S, Blackwood MS. US artifacts. RadioGraphics 2009;29:1179–1189
Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:23.

2. Answer D. Acoustic impedance of a material is defined as the product of the density of the medium
and the speed of sound in that medium. It is a measure of the stiffness of a tissue. In the provided
choices, acoustic impedance is lowest in air, followed by fat, muscle, and bone. Bone and metal have
high acoustic impedance.
Reference: RSNA. RSNA/AAPM radiology physics educational modules.

3. Answer B. Fresnel zone is the near field of the ultrasound beam. It is near the transducer face and
has a converging beam profile. The far field or diverging field of the ultrasound beam is called the
Fraunhofer zone. Ultrasound imaging normally uses the Fresnel zone.
The length of the Fresnel zone is d2/4λ, where d is the diameter of the transducer and λ is the
wavelength. Therefore, Fresnel zone increases with increasing transducer size and frequency (i.e.,
lower wavelength).
Reference: Bushberg JT, Seibert JA, Leidholdt EM. The essential physics of medical imaging, 3rd ed. Philadelphia, PA: Wolters

4. Answer D. In this image, the structures we are interested in evaluating are displayed in the top half
of the image, whereas the bottom half shows information that is not useful or diagnostic. Decreasing
depth would eliminate the nondiagnostic information and allow us to evaluate the pancreas at an
increased frame rate.
The focal zone (answer choice A) should be set at or just below the structure of interest. In this case,
the focal zone (indicated by triangle on left side of image) is set appropriately, just below the pancreas.
Lowering frequency (answer choice B) allows for increased penetration at the expense of decreased

resolution. In this case, the pancreas is in the near field, and thus, we do not need to increase our
penetration to evaluate it. Increasing gain (answer choice C) will amplify the ultrasound signal causing
the image to have an overall brighter or more saturated look. Gain is set appropriately in this image.
Spatial compounding (answer choice E) reduces speckle and noise. Reducing the number of lines of
spatial compounding will cause the image to appear noisier. Increasing spatial compounding may
reduce diagnostically helpful artifacts such as acoustic shadow.
Reference: Hangiandreou NJ. AAPM/RSNA physics tutorial for residents: topics in US. RadioGraphics 2003;23(4):1019–1033.

5. Answer A. A blind‐ending structure representing the appendix contains an echogenic shadowing
appendicolith. The appendix is thickened at 9 mm. Other images on the study (not shown)
demonstrated the appendix to be noncompressible with fluid adjacent to its tip. Findings are
diagnostic of acute appendicitis. Sonographic evaluation of suspected acute appendicitis relies on the
use of a high‐resolution, usually linear probe and graded compression to optimize appendiceal
visualization. The primary diagnostic criterion is a thickened appendix >6 mm in diameter. Other signs
of acute appendicitis include lack of compressibility, echogenic inflamed periappendiceal fat,
hyperemia, appendicolith, and periappendiceal fluid. Terminal ileitis can exhibit similar features, so
careful assessment for a blind‐ending morphology is important to avoid this pitfall.
References: Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000;215(2):337–348.

6. Answer A. Axial resolution is the ability to separate two closely spaced objects in the direction of
the ultrasound beam. To avoid overlap of returning echoes, the distance between the two objects must
be at least one‐half of the spatial pulse length. Spatial pulse length (SPL) is the number of cycles
emitted per pulse by the transducer multiplied by the wavelength. Decreasing the spatial pulse length
will improve the axial resolution. This can be achieved by using a higher frequency, which will reduce
the wavelength and hence the spatial pulse length. The tradeoff is decreased tissue penetration.
Decreasing the diameter of ultrasound beam improves the lateral resolution, which is the ability to
separate two closely placed objects perpendicular to the ultrasound beam direction. The lateral
resolution is best at the near field–far field interface where the effective beam diameter is
approximately equal to half the transducer diameter.

7a. Answer A. The images show both a dilated pancreatic duct and a dilated common bile duct, with a
heterogeneous mass located in the pancreatic head. This imaging appearance is known as the “double‐
duct” sign, which is considered a hallmark for pancreatic head cancer. The dilated pancreatic duct
should not be mistaken for the splenic vein, which is located posterior to the pancreas. Also, a dilated
common duct (CD) could be confused for a vascular structure. However, the location of the CD to the
left of the portal vein on the transverse image should indicate which anechoic structure is the portal
vein and which is the CD. Color‐flow imaging should help confirm the identity of the CD.

7b. Answer D. Majority of pancreatic cancers appear hypoechoic on ultrasound compared to the
surrounding pancreatic parenchyma. Pancreatic cancer is a hypovascular tumor. It can cause
considerable desmoplastic reaction resulting in obstruction and dilatation of the pancreatic duct and
common bile duct. Therefore, tumors in the pancreatic head are usually detected when they are small
because of early biliary tract obstruction and jaundice compared to those in the body and tail, which
tend to present as larger masses and with vague symptoms. Approximately 60% to 70% pancreatic
cancers arise in the head, 10% to 20% in the body, and 5% to 10% in the tail.

8. Answer A. Reflection of ultrasound energy at a boundary between two tissues occurs because of
the differences in acoustic impedances of the two tissues. Air–tissue interfaces reflect almost all of the
incident ultrasound beam because of large differences in acoustic impedance between those two
media. Therefore, gel is applied between the transducer and skin surface to displace air and therefore
minimize differences in acoustic impedance.
Reference: RSNA. RSNA/AAPM radiology physics educational modules.

9. Answer C. The Plan‐Do‐Study‐Act (PDSA) is an iterative four‐step process used for quality
improvement. In this process, a specific perceived practice deficiency is identified and an appropriate
measurement is devised to assess the selected issue during the planning phase. A predicted result and
desired performance target are also determined. Next, during the Do phase, baseline measurements
are collected. Once an appropriate number of samples is collected, the data are studied and compared
with the anticipated result and target. If the measured performance does not meet the target, potential
root causes and other factors are examined. If the measured performance does meet the target, a plan
to sustain the performance goal is instituted. During the Act phase, a plan for improvement is devised
and implemented based on the root causes and factors identified during the Study phase. The PDSA

cycle is then repeated continuously until the goal is achieved, or may be intermittently used to confirm
that a performance goal is being maintained.
Reference: The American Board of Radiology. Quality and safety domain specification and resource guide. Tucson, AZ: The
American Board of Radiology, 2016.

10. Answer A. Because the angle of incidence and angle of reflection of sound are the same but in
opposite directions, a greater proportion of the reflected sound will be directed toward the probe
when the transducer is held perpendicular to a tissue boundary. Increasing the angle of the probe will
eventually result in all of the reflected energy to be directed completely away from the probe so that
the echo will not be detected at all.
Refraction occurs when the beam propagates obliquely through tissue boundaries through which the
speed of sound changes. This will result in mislocalization and sometimes artifactual duplication of
anatomic structures. Refraction also results in defocusing and weakening of the ultrasound beam,
compromising penetration and visualization of deeper tissues.

11. Answer B. Lymphomatous involvement of the colon in this patient results in a typical
sonographic appearance due to tumor infiltration—hypoechoic, concentric, long‐segment bowel wall
thickening with destruction of the wall layers and a central echogenic area with dirty shadowing
corresponding to air‐filled residual lumen. The peripheral hypoechoic thickened wall simulates renal
cortex, and central echogenic area simulates renal sinus fat; hence the name.
Wall‐echo shadow (WES) sign is described for cholelithiasis. Yin–yang sign is a color Doppler sign of
pseudoaneurysm. Onion skin sign has been described for testicular epidermoid and mucocele of
appendix.
References: Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:204, 206.
Ledermann HP, Börner N, Strunk H, et al. Bowel wall thickening on transabdominal sonography. AJR Am J Roentgenol
2000;174(1):107–115.

12. Answer B. The normal spleen has a homogeneous echotexture and is hyperechoic compared to
the liver and kidney. It measures up to 13 cm in length and normally has a crescentic configuration.
This patient has an enlarged spleen that contains multiple solid hypoechoic lesions. Lymphangiomas
are composed of multiple variably sized cystic spaces and are either anechoic or hyperechoic
depending on the cyst size. Hemangiomas are typically hyperechoic. Splenic infarcts may be
hypoechoic but are expected to be wedge shaped and peripherally located. In an older patient with
splenomegaly and multiple hypoechoic solid splenic lesions, a lymphoproliferative process must be
considered. This patient was diagnosed with chronic lymphocytic leukemia with leukemic splenic
infiltration. The differential diagnosis for solid hypoechoic splenic lesions is fairly extensive and
includes lymphoma, metastases, infarcts, abscesses, and sarcoidosis.

13a. Answer A. The ultrasound image shows heterogeneous pancreatic parenchyma with multiple
echogenic foci consistent with calcifications. The calcifications may or may not shadow depending on
their size. The imaging appearance is typical of chronic pancreatitis.
Chronic pancreatitis is an inflammatory disease process that leads to progressive and irreversible
structural damage of the pancreas resulting in permanent dysfunction of both endocrine and exocrine

pancreatic function. Histologic changes include acinar cell loss, islet cell loss, inflammatory cell
infiltrates, and eventually irregular fibrosis. Patients present with abdominal pain, malabsorption, and
diabetes.
Alcohol abuse is the most common cause of chronic pancreatitis in Western countries, accounting for
70% to 90% of cases (choice A is correct). Other etiologies include genetic (mutations in the cystic
fibrosis gene, hereditary pancreatitis), ductal obstruction (e.g., trauma, pseudocysts, stones, tumors,
pancreas divisum), tropical pancreatitis, systemic disease such as systemic lupus erythematosus,
hypertriglyceridemia, autoimmune pancreatitis, and idiopathic pancreatitis.
The classic sonographic sign of chronic pancreatitis is pancreatic calcifications. The intraductal
location of the calcifications may not be obvious on ultrasound, where they may seem scattered
throughout the pancreatic parenchyma as in this case. Other sonographic findings include duct
dilatation, pancreatic atrophy, irregular contours, and hyperechoic parenchyma due to fatty deposition
and fibrosis.
References: Perez‐Johnston R, Sainani NI, Sahani DV. Imaging of chronic pancreatitis (including groove and autoimmune
pancreatitis). Radiol Clin North Am 2012;50(3):447–466.
Zamboni GA, Ambrosetti MC, D’Onofrio M, et al. Ultrasonography of the pancreas. Radiol Clin North Am 2012;50(3):395–406.

13b. Answer B. The ultrasound image shows a large anechoic cystic lesion adjacent to the head of the
pancreas. Multiple echogenic calcifications are again shown in the pancreas. In this setting, the lesion
most likely represents a pancreatic pseudocyst.
In a pseudocyst, intracystic fluid will be expected to have a high amylase level and a low CEA and CA
19‐9 level. High amylase levels can also be seen in IPMNs. CEA and CA 19‐9 are also low in pancreatic
serous tumors. High CEA levels are seen in mucinous cystic neoplasms.
Reference: Al‐Hawary MM, Francis IR, Anderson MA. Pancreatic solid and cystic neoplasms. Radiol Clin North Am
2015;53(5):1037–1048.

14. Answer C. Two important components of value in health care are quality and cost. Value is the
efficient (low cost) use of resources, which yields a desired level of quality.
Reference: The American Board of Radiology. Quality and safety domain specification and resource guide. Tucson, AZ: The
American Board of Radiology, 2016.

15. Answer C. A wedge‐shaped peripheral hypoechoic splenic lesion with a coarsened echotexture
with its apex pointing to the hilum represents an acute splenic infarct. The diagnosis of splenic
infarction can be made with a high degree of confidence because of its characteristic shape, location,
and coarse echotexture. Splenic infarcts are a common cause of focal splenic lesions seen on imaging.
The most common etiologies include emboli or thrombosis of the splenic artery, splenic vein, or their
branches. Other etiologies include lymphoproliferative disorders and sickle cell anemia. Infarcts
usually become smaller and hyperechoic with time as the devitalized tissue is replaced by scar and will
be accompanied by overlying capsular retraction. However, the sonographic appearance of splenic
infarcts can vary and appear as mass‐like or nodular foci, requiring additional imaging with CT or MRI.
Although a workup to determine the etiology of splenic infarction is important, acute uncomplicated
splenic infarcts usually require only supportive therapy. Potential complications include abscess,
pseudocyst formation, rupture, and hemorrhage.
References: Goerg C, Schwerk WB. Splenic infarction: sonographic patterns, diagnosis, follow‐up, and complications. Radiology
1990;174(3):803–807.
Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed., 2 volume set. Philadelphia, PA: Elsevier Health Sciences,
2011:163.

16a. Answer A. An elongated hypoechoic focus within the splenic parenchyma contains no color flow
and represents a splenic laceration. No subcapsular or perisplenic collection is shown. The most
commonly injured intra‐abdominal organ following blunt trauma is the spleen. Splenic injuries range
from contusion to shattered spleen. Treatment decisions are based on clinical and hemodynamic
parameters and may include conservative management, embolization, and surgery. Although
subcapsular hematomas are also contained within the splenic capsule, they should be located along
the periphery of the spleen, follow the splenic contour, and typically have a crescentic shape. Splenic
infarcts and lacerations may be sometimes difficult to distinguish by imaging, but the clinical history
should permit differentiation. The sensitivity of ultrasound for the detection of pseudoaneurysms is
inferior to CT, but a sonographic diagnosis requires demonstration of internal flow.

16b. Answer C. Although splenic injuries can be demonstrated by ultrasound, CT provides a more
comprehensive evaluation for splenic injuries and perisplenic hematomas as well as assessment for
other intra‐abdominal organs and vessels.
2011:165–167.

17. Answer D. The differential diagnosis for splenic calcification is long and includes a variety of
etiologies. However, the size, morphology, and number of calcifications may provide a clue to their
cause. Multiple punctate calcifications are usually due to histoplasmosis, tuberculosis, or brucellosis.
When more than six calcified granulomas are identified, the most likely cause is histoplasmosis.
Histoplasma capsulatum is a fungus endemic to the Ohio River Valley. The fungal spores are inhaled
and form yeasts, which are then deposited into the bronchial lymph nodes. The organisms then
disseminate hematogenously, and some may be filtered by the spleen, where they incite an
inflammatory reaction, eventually forming granulomas and calcifying. Tuberculosis usually results in
fewer (<6) calcifications, typically smaller than those associated with histoplasmosis. Brucellosis
results in a few large rim‐calcified lesions. Traumatic injury may result in single or a few calcifications.
Sickle cell anemia results in multiple infarctions, eventually leading to a small densely calcified spleen.

18a. Answer B.The first
image demonstrates
retroperitoneal fluid
adjacent to the right
kidney. The presence of
perinephric fluid in the
setting of epigastric pain
raises the possibility of an
acute pancreatitis. The
second image shows an
engorged, heterogeneous
pancreatic head and
uncinate process (P). Note

the relationships of the gallbladder (G), second portion of duodenum (D), and pancreatic head on the
ultrasound and corresponding contrast‐enhanced CT at the same level. Also, note the presence of acute
peripancreatic collections on both sonography and CT.
18b. Answer D. A careful examination of the gallbladder and bile ducts for gallstones is the focus of
most sonograms performed for acute pancreatitis. There are numerous causes of acute pancreatitis,
but 80% of all cases are due to gallstones and alcohol abuse. All patients with acute pancreatitis,
including known alcoholics, need to be evaluated for the presence of gallstones or biliary ductal
dilatation because cholecystectomy with removal of common duct stones will prevent the recurrence
of gallstone pancreatitis.
Ultrasound evaluation of the pancreas can also play an important role in diagnosing unsuspected acute
pancreatitis or to confirm the diagnosis. The most common and least subjective sonographic finding is
extrapancreatic fluid and inflammatory change. Inflammation or fluid may be found within the
prepancreatic retroperitoneum, left and right anterior pararenal spaces, the perirenal spaces, and the
transverse mesocolon and is recognized by its anechoic appearance. More subjective findings include
pancreatic enlargement and decreased or heterogeneous glandular echogenicity.
Assessment for pancreatic necrosis and differentiation between necrotic and nonnecrotic collections
are best accomplished using contrast‐enhanced CT. However, ultrasound is often used to guide
aspirations and drainages of pancreatitis‐associated collections.

19. Answer D. There are two cystic lesions within the spleen. The larger lesion contains scant low‐
level internal echoes but no internal color flow. The most common cause of a splenic cyst is trauma.
Splenic hematomas evolve and become liquefied seromas surrounded by a pseudocapsule. The cyst
wall may sometimes calcify. True cysts are rare and are felt to be congenital. Although an old liquefied
splenic infarct may also wall off, this is less common.
Echinococcal cysts are usually caused by the tapeworm, Echinococcus granulosus. Although most
commonly involving the liver, other organs including the spleen can also be affected. Echinococcal
cysts have an external membrane and an internal germinal layer. The host forms a fibrous capsule
around the cyst. Hydatid cysts can have a variety of sonographic morphologies. They can appear as
simple cysts, cysts containing multiple daughter cysts, or cysts containing floating membranes or
debris. They may also have internal or peripheral calcification.
Vascular lesions can mimic cystic splenic lesions as well. These include aneurysms, pseudoaneurysms,
varices, and vascular malformations. These are distinguished by the presence of Doppler flow.

20. Answer C. The causes of splenomegaly are varied and numerous, including hematologic,
rheumatologic, infectious, congestive, and infiltrative processes. The most common are infection,
lymphoproliferative disorders, and cirrhosis.
Reversal of flow within the main portal vein or extrahepatic portal vein tributary such as the splenic
vein is a specific sign of portal hypertension. As a result of portal hypertension, a spontaneous
splenorenal shunt may form. Portal venous blood is diverted in a retrograde manner into the
retropancreatic segment of the splenic vein, through the shunt, and then into the left renal vein where
it mixes with the systemic venous blood. Splenic varices may also be demonstrated on Doppler
imaging.
Splenic echogenicity is not a reliable way to differentiate the causes of splenomegaly. The degree of
splenomegaly in general is not helpful to determine the cause of splenomegaly although massive

splenomegaly (>18 cm) is more often due to hematologic disorders such as thalassemia major;
infections due to leishmaniasis, malaria, and Mycobacterium avium‐intracellulare complex; and
infiltrative disorders like lymphomas, myeloproliferative neoplasms, and Gaucher disease.
The presence of ascites is a nonspecific sign and can be associated with a number of processes causing
splenomegaly.
References: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:152–154.
Wachsberg RH, Bahramipour P, Sofocleous CT, et al. Hepatofugal flow in the portal venous system: pathophysiology, imaging
findings, and diagnostic pitfalls. RadioGraphics 2002;22(1):123–140.

21. Answer A. The image shows only a small amount of ascites and dilated fluid‐filled bowel. The
patient’s bloating appears to be related to dilated bowel in addition to ascites. Identification of dilated
bowel should trigger a search for a cause on ultrasound. A CT should be performed subsequently to
confirm the presence of a bowel obstruction and to assess for a cause. Because of the small amount of
ascites and the presence of dilated bowel loops closely apposed to the abdominal wall, a therapeutic
paracentesis should not be performed at this time.
2011:296–299.

22. Answer A. The first image shows a normal size, shape, and echotexture of the spleen. Color
Doppler signal is demonstrated within the spleen. On the second image, obtained 2 weeks later, the
appearance of the spleen has been markedly altered. Marked coarsening of the parenchymal
echotexture and new capsular irregularity and retraction are consistent with a global splenic infarct.
Color Doppler signal is no longer demonstrated. The splenic infarct was due to interval splenic artery
embolization for a pseudoaneurysm.
References: Goerg C, Schwerk WB. Splenic infarction: sonographic patterns, diagnosis, follow‐up, and complications. Radiology
1990;174(3):803–807.

23. Answer B. A small cystic lesion within the pancreatic neck containing no Doppler signal is shown.
The differential diagnosis for unilocular cystic pancreatic lesions includes pancreatic pseudocyst, side‐
branch intraductal papillary mucinous neoplasm (IPMN), and unilocular serous cystadenoma.
Pancreatic cysts can also occur in association with von Hippel‐Lindau syndrome, autosomal‐dominant
polycystic kidney disease, and cystic fibrosis. Pancreatic pseudocyst may be suggested by a history of
pancreatitis or if there are imaging findings of pancreatitis. IPMNs are most commonly found in older
patients, and communication with the main pancreatic duct is an important component in making a
confident diagnosis. Serous cystadenomas are typically multilocular microcystic lesions but may
uncommonly be unilocular. Unlike IPMNs, they should not communicate with the pancreatic duct.
Reference: Sahani DV, Kambadakone A, Macari M, et al. Diagnosis and management of cystic pancreatic lesions. AJR Am J
Roentgenol 2013;200(2):343–354.

24. Answer C. Pareto chart is used to visually display a rank ordering of quality, safety, or risk factor
issues by importance or impact. A Pareto chart is arranged with the highest value at the top and the
lowest value at the bottom so that the major factors contributing to a particular effect are visually
displayed. It contains both bars and a line graph. The bars represent individual values, and the line
represents the cumulative total. Proper ordering is a vital step because it guides the team to

concentrate its efforts on factors with the greatest impact. The Pareto principle (PP) states that when
multiple variables affect a situation, a few of them are actually responsible for most of the impact.
Flowcharts are graphic diagrams or maps that illustrate the steps and decision points that make up a
work process. They represent a common understanding of the process and enable the team to examine
individual steps in order to identify problems and improvement opportunities.
ROC (receiver operating characteristic) curves are used to analyze the performance of a diagnostic
system. An ROC curve is a plot of test sensitivity (plotted on the y‐axis) versus its false‐positive rate
(FPR) (or 1 − speci icity) (plotted on the x‐axis). One of the most popular measures of the accuracy of a
diagnostic test is the area under the ROC curve. The ROC curve area can take on values between 0.0
and 1.0. A test with an area under the ROC curve of 1.0 is perfectly accurate because the sensitivity is
1.0 when the FPR is 0.0. In contrast, a test with an area of 0.0 is perfectly inaccurate. The ROC curve is
not affected by the prevalence of disease.
Control charts aim to analyze the performance of a process in a common language and as a function of
time. By analyzing performance, a control chart is used to control, monitor, and enhance process
performance over time by recognizing changes and their sources. A control chart uses samples of
success as the numerator and total opportunities as the denominator, and the events are graphed to
evaluate how a process changes over time. A line can be used to illustrate deviations of the data from
the average, and upper and lower control limits can be used to represent the acceptable range. These
lines can help determine whether the process change over time is stable (consistent) or is unstable
(unpredictable). This helps determine whether process variations are in or out of control.
Reference: The American Board of Radiology. Quality & safety domain specification & resource guide.

25. Answers
A. Superior mesenteric artery
B. Left renal vein
C. Right renal artery
D. Celiac artery
E. Superior mesenteric artery
F. Splenic vein
G. Pancreas
H. Distal esophagus

26. Answers
A. Liver
B. Stomach
C. Portal confluence
D. Splenic vein
E. Pancreas
F. Superior mesenteric vein

Reference: Hertzberg BS, Middleton WD. Ultrasound: the
requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:179–180.

27. Answer C. The patient underwent renal ultrasound and was incidentally found to have a large
splenic lesion. The lesion is homogeneous and hyperechoic without evidence of internal vascularity.
The lesion most likely represents a splenic hemangioma. Although hemangiomas in the liver can have
a variable appearance, majority of those in the spleen are homogeneous and hyperechoic. They are the
most common benign splenic tumors. Hamartomas and lymphangiomas are less common than
hemangiomas.
Splenic lymphoma can be unifocal or multifocal and is almost always hypoechoic. It is only rarely
hyperechoic. Splenic metastases can have a variable appearance on ultrasound. However, in most
cases, splenic metastases are present when a patient has widespread metastatic disease. It will be an
unlikely incidental finding such as in this case. The sonographic appearance of splenic hematoma will
vary with the phase when it is detected. Regardless, hematoma will usually have a more complex
appearance compared to the hemangioma shown in this case. In the acute phase, it is usually complex
and hypoechoic. When clot forms, it can become isoechoic to the splenic parenchyma. In the chronic
phase, with lysis and liquefaction of clot, it will be hypoechoic to anechoic.

28. Answer C. The CT shows a complex cystic lesion in the head of the pancreas. Endoscopic
ultrasound shows an anechoic lesion with lobulated margins and several internal septations that
converge radially with appearance of a central stellate scar. This sonographic appearance is suggestive
of serous cystadenoma of the pancreas.
Serous cystadenoma of the pancreas is a benign cystic tumor seen usually in middle‐aged and elderly
women. It is most often present in the pancreatic head. It contains multiple tiny cysts (usually >6),
each smaller than 2 cm in diameter. If the cysts are very small, the lesion may appear solid on US. A
central scar may be present and may appear as a central solid hyperechoic structure sometimes with
calcifications. Pancreatic ductal dilatation and parenchymal atrophy are usually not seen. In most
cases of cystic pancreatic lesions, the combination of lesion morphology and analysis of fine needle
aspirate can provide a definitive diagnosis. Fluid aspirate from serous cystadenoma shows low levels
of amylase, low carcinoembryonic antigen (CEA), and low carbohydrate antigen 19‐9 (CA 19‐9) levels.
Pancreatic adenocarcinomas are solid, hypoechoic infiltrative lesions that typically cause pancreatic
ductal dilatation and glandular atrophy. Mucinous cystic tumors occur 99.7% of the time in women.
They are premalignant or malignant lesions. Compared to serous cystadenomas, they occur at an
earlier age, approximately around 50 years. They are most commonly located in the pancreatic body
and tail. Mucinous cystic tumors are composed of a dominant cyst and are encapsulated. The cysts are
larger and fewer in these lesions. The fluid aspirate has low amylase, high CEA, and, when malignant,
also high CA 19‐9. Pancreatic pseudocysts are the most common cystic lesions of the pancreas. They
develop as a complication of acute or chronic pancreatitis or secondary to pancreatic trauma.
Pseudocysts are defined as fluid collections that become encapsulated and are seen more than 4 weeks
after the onset of symptoms. They are usually located near the pancreas, are anechoic, or may contain
low‐level internal echoes from debris or hemorrhage.
Zamboni GA, Ambrosetti MC, D’Onofrio M, et al. Ultrasonography of the pancreas. Radiol Clin North Am 2012;50(3):395–406.

2c. Which of the following is the most important risk factor for bladder cancer in the United States?
A. Smoking
B. Calculus
C. Recurrent urinary tract infections
D. Chemical carcinogens

3. A 32‐year‐old female receives an ultrasound as part of a routine obstetric workup and is found to
have an abnormality adjacent to the left kidney. What is the most likely diagnosis from the following
choices?

A. Adrenocortical
carcinoma
B. Adrenal adenoma
C. Adrenal pseudocyst
D. Adrenal
pheochromocytoma

4a. Imaging of the right flank was performed for flank pain in a 55‐year‐old male. What is the most
likely explanation for the sonographic appearance of the suprarenal lesion?

A. Blood products
B. Bowel gas
C. Calcification
D. Fat

4b. Which of the following factors is expected to introduce uncertainty in measurement of this mass?
A. Speed of sound within the mass is higher than within the liver.
B. Speed of sound within the mass is lower than within the liver.
C. Speed of sound is equal within the mass and liver.

4c. What is the most likely diagnosis for this lesion?
A. Adrenal myelolipoma
B. Renal cell carcinoma
C. Adrenal cortical carcinoma
D. Adrenal hemorrhage

4d. What is the likelihood of malignant transformation of adrenal myelolipomas?
A. 0%
B. 10%
C. 30%
D. 50%

5. The ultimate goal of root cause analysis (RCA) is to:
A. Identify individuals responsible for serious adverse events
B. Eliminate active errors
C. Eliminate latent errors
D. Identify the single root cause of an adverse event

6. According to the Joint Commission, “a sentinel event is an unexpected occurrence involving death
or serious physical or psychological injury, or the risk thereof.” These events signal the need for
immediate investigation and response. Which of the following sentinel events between 2004 and 2014
had the highest reported incidence?
A. Radiation overdose
B. Anesthesia‐related event
C. Medication error
D. Wrong patient, wrong site, wrong procedure

7a. A 53‐year‐old female
patient presents with low
urine output. Transverse and
sagittal US images of bladder
are shown. What is the most
likely diagnosis?

A. Bladder diverticulum
B. Ureterocele
C. Urachal cyst
D. Malpositioned Foley
E. Gartner cyst

7b. What is the most common histology for a neoplasm arising within a urachal cyst?
A. Adenocarcinoma
B. Clear cell
C. Squamous cell
D. Transitional cell

7c. Which key imaging feature of a Gartner duct cyst distinguishes it from other cystic lesions in the
female pelvis?
A. Location in the anterolateral vagina above the pubic symphysis
B. Direct communication with the urethra
C. Location in the wall of the cervix
D. Location in the posterior lateral aspect of the inferior one‐third of the vagina

8. Combining images from the same site using different scanning angles to reduce image speckle and
improve delineation of tissue interfaces is termed:
A. Spatial compounding
B. Tissue harmonic imaging
C. Three‐dimensional ultrasound

9. What is the clinical significance of side‐lobe artifacts?
A. They can produce the appearance of debris or tissue within fluid‐filled structures.
B. They can create the false impression of a duplicated structure such as the abdominal aorta.
C. They can create a series of regularly spaced echoes at increasing depth.
D. They can result in impaired penetration of deeper structures.

10a. The patient here has a history of epilepsy and had an
unwitnessed seizure. He is now complaining of left upper
quadrant pain and presents to the emergency department
where an abdominal ultrasound is ordered to evaluate the
pain. The scan showed no free fluid, hematoma, or other
findings suspicious for trauma, but the renal lesion shown
was incidentally noted on the scan. Based on the history
and imaging findings, what other extrarenal findings
might this patient have?

A. Acanthosis nigricans
B. Cherry angiomas
C. Facial sebaceous adenomas
D. Clubbing of the nails

10b. Which of the following would be the most appropriate next step?
A. A course of antibiotics and follow‐up with urology
B. CT scan to document the presence of fat
C. CT scan of the abdomen and pelvis to assess for lymphadenopathy
D. Consult with interventional radiology for embolization

11a. Two images are provided from a renal ultrasound on an asymptomatic patient. Which of the
following is the best diagnosis?

A. Right pelvic kidney
B. Horseshoe kidney
C. Diffuse
compensatory
hypertrophy of the left
kidney after right
nephrectomy
D. Crossed fused renal
ectopia

11b. In crossed fused renal ectopia, the location of the ureterovesical junction of the ectopic kidney:
A. Is associated with a ureterocele
B. Inserts on the contralateral side of the bladder
C. Is normally located
D. Is prone to reflux

12. During review of a right upper quadrant ultrasound for pain, a radiologist makes a diagnosis of an
acute cholecystitis. On a CT scan performed 1 year later, a right renal mass is discovered. In retrospect,
this was definitely present on the ultrasound and had grown in the interval. This is an example of what
category of radiologist error?
A. Perceptual error
B. Cognitive error
C. Negligence
D. Selection bias

13. A patient with a kidney transplant was being evaluated for a new elevation of creatinine levels.
Two sagittal color Doppler images at the hilum and a transverse image through the lower pole of the
left pelvic kidney transplant were obtained. What is the most significant abnormality depicted on the
image?

A. A perinephric fluid collection causing severe renal vein stenosis
B. An obstructing ureteral stone causing mild hydronephrosis
C. Subcapsular hematoma
D. Posttransplant lymphoproliferative disease

14. A 20‐year‐old male with proteinuria and azotemia undergoes a renal ultrasound to rule out
hydronephrosis. Sagittal and transverse views of the right kidney are provided. Both kidneys had the
same appearance. What is the most
likely cause of this patient’s renal
dysfunction?

A. Membranous glomerulonephritis
B. Renal vein thrombosis
C. Hydronephrosis
D. Xanthogranulomatous
pyelonephritis

15. A 36‐year‐old male presents with left lower quadrant pain 3
weeks following renal transplant. Sagittal ultrasound image of the
left lower quadrant renal allograft is provided. What is the most
likely diagnosis?

A. Urinoma
B. Lymphocele
C. Hematoma
D. Abscess

16a. A 42‐year‐old female with history of lung cancer presents with pelvic pain. Which of the
following is the most likely diagnosis?

A. Nabothian cyst
B. Gartner duct
cyst
C. Urethral
diverticulum
D. Metastasis
E. Bartholin cyst

16b. Which of the following often requires surgery?
A. Nabothian cyst
B. Gartner duct cyst
C. Ureterocele
D. Müllerian cyst
E. Bartholin cyst

17a. Which of the
following choices
represents the most
appropriate next step in
workup of this incidental
sonographic finding?

A. Follow‐up ultrasound
in 6 months
B. Surgical excision
C. CT or MRI
D. Biopsy

17b. In the absence of detectable Doppler flow within this mass, what is the most appropriate
management of this finding?
A. Follow‐up ultrasound in 6 months
B. Surgical excision
C. CT or MRI
D. Biopsy

18a. An ultrasound of the urinary bladder was performed for a patient with recurrent urinary tract
infections. Selected images of the midline tissues superior to the bladder are shown. What is the most
likely diagnosis?

A. Adhesion
B. Appendicitis
C. Urachal diverticulum
D. Ectopic ureter

18b. Which of the following is the most likely cause of a midline partially calcified soft tissue mass
found behind the rectus sheath located between the umbilicus and bladder dome?
A. Umbilical hernia
B. Adenocarcinoma
C. Transitional cell carcinoma
D. Lymphoma

19. A 65‐year‐old man is found to have a well‐defined
homogeneous renal lesion on a contrast‐enhanced CT
measuring 50 HU and undergoes an ultrasound for
further evaluation. Based on this image, which of the
following choices best describes the lesion?

A. Simple cyst
B. Complicated cyst
C. Cystic renal cell carcinoma
D. Indeterminate

20. A 65‐year‐old patient presents
with chronically elevated creatinine
and new oliguria. Which of the
following is the most likely
diagnosis?

A. Xanthogranulomatous
pyelonephritis
B. Emphysematous pyelitis
C. Renal abscess
D. Emphysematous pyelonephritis

21. Based on the images, which of the following is a likely predisposing risk factor for the entity seen
in these images in this otherwise healthy young male?

A. Nephrotic syndrome
B. Renal cell carcinoma
C. Smoking history
D. Crossed fused renal ectopia

22. Images from right upper quadrant
ultrasound of a 52‐year‐old male with
history of non–small cell carcinoma of
lung are shown. What is the next best
step in the management of this patient?

A. The hyperechoic areas in the mass
suggest myelolipoma. No further
evaluation is needed.
B. The lesion is solid and almost
certainly represents a perinephric
metastasis. Confirm with percutaneous biopsy.
C. Minimal heterogeneity of the mass favors adrenal adenoma. Recommend follow‐up imaging in 1
year to ensure stability.
D. Large size and heterogeneity favor metastasis, but it should be evaluated by adrenal mass protocol
CT or MRI to exclude an adenoma prior to percutaneous biopsy.

23a. A 38‐year‐old male presents with hematuria. A renal ultrasound was performed. Sagittal images
of the right kidney are provided. An incidental finding was noted in the pancreas as well. The patient’s
sibling was diagnosed with the same condition 2 years prior. What is the most likely diagnosis?

A. Tuberous sclerosis
B. von Hippel‐Lindau disease
C. Multiple endocrine neoplasia (MEN) I
D. Osler‐Weber‐Rendu syndrome

23b. Which additional imaging study should be performed and why?
A. MR brain to evaluate for subependymal tubers
B. Cardiac CT to evaluate for rhabdomyomas
C. MR brain to evaluate for intracranial AVMs
D. MR brain and spine to evaluate for hemangioblastomas

24a. A 50‐year‐old female with long‐standing history of
affective disorder presents with renal failure. Sagittal
image of the left kidney shows which of the following?

A. Renal microcysts
B. Renal cortical necrosis
C. Medullary nephrocalcinosis
D. Normal kidneys

24b. Which of the following imaging tests may be used to confirm this finding?
A. CT scan
B. MRI
C. Renal scintigraphy
D. Plain radiograph

25. A 47‐year‐old male with right flank pain undergoes an ultrasound. Images of the bladder are
shown. What is the best diagnosis based on these findings?

A. Ureterocele
B. Bladder diverticulum
C. Hematoma or fungal ball
D. Pseudoureterocele

26. A 47‐year‐old male presents with hematuria. Images from abdominal ultrasound are shown. The
patient is at increased risk for which of the following?

A. Renal cell carcinoma
B. Hypertension
C. Portal hypertension
D. Renal atrophy

27. A 52‐year‐old male outpatient underwent renal ultrasound.
Which ultrasound artifact is shown in the image?

Image courtesy of Biren Shah, MD, FACR, Associate Professor of
Radiology and Director of Breast Imaging, Virginia
Commonwealth University Health System, Richmond, VA.
A. Posterior acoustic shadowing
B. Dropout artifact
C. Ring‐down artifact
D. Side‐lobe artifact

28. Shown here are an ultrasound image of the right kidney in the transverse plane and an
unenhanced axial CT image of abdomen of a patient with chronic renal failure. What is the appropriate
management for this patient?

A. The echogenic rim and
diffuse acoustic shadowing in
the right kidney is consistent
with emphysematous
pyelonephritis. The patient
needs aggressive
management with antibiotics
and possible right
nephrectomy.
B. Diffuse cortical and
medullary nephrocalcinosis
with diffuse acoustic shadowing on ultrasound is concerning for oxalosis. If confirmed, the patient
needs simultaneous liver and renal transplantation.
C. Irrespective of etiology, the extensive renal parenchymal calcification and chronic renal failure
would require management with isolated renal transplantation.
D. Renal cell cancer is the most common renal neoplasm with calcification. The patient should
undergo targeted percutaneous renal biopsy to assess for malignancy.

29. Sagittal imaging from the pelvis of a 68‐year‐old male in
the intensive care unit was performed for hematuria
following Foley catheter placement. What is the most likely
etiology of hematuria?

A. Bladder cancer
B. Malpositioned Foley
C. Iatrogenic perforation
D. Abscess

30. Color and duplex Doppler images of a renal transplant are shown. What is the cause of the Doppler
abnormalities?

A. Renal artery pseudoaneurysm
B. Renal vein thrombosis
C. Renal arteriovenous fistula
D. Renal artery stenosis

31. In assessing a suspected solid renal mass using color and spectral Doppler, how might selecting a
probe with a higher transmitted frequency improve the sensitivity for detection of intralesional blood
flow?
A. A higher transmitted frequency increases the strength of reflection from RBCs.
B. A higher transmitted frequency reduces side‐lobe artifact.
C. A higher transmitted frequency improves tissue penetration.
D. A higher transmitted frequency reduces the Doppler frequency shift.

32. Prior to performing a diagnostic renal ultrasound, two patient identifiers should be used so that
the right patient receives the right invasive or noninvasive procedure. Acceptable identifiers include:
A. Location of patient
B. Room number of patient
C. Patient’s diagnosis
D. Home telephone number

33. Color and duplex imaging of a renal transplant is performed following a biopsy. What is the most
likely diagnosis for the lesion indicated by the arrow?

A. Arterial pseudoaneurysm
B. Abscess
C. Hematoma
D. Arteriovenous fistula

34. What effect on image resolution does changing from a 9‐ to 15‐MHz probe have when evaluating
superficial tissues?
A. Improve the ability to resolve two closely apposed structures located at the same depth
B. Improve the ability to resolve two closely apposed structures located at different depths
C. Decrease the ability to resolve two closely apposed structures located at the same depth
D. Decrease the ability to resolve two closely apposed structures located at different depths

35. A 46‐year‐old female with left upper quadrant fullness undergoes an abdominal ultrasound.
Which imaging study would be most appropriate to further evaluate these abnormalities?

A. Renal Doppler study to
assess for active
extravasation into the
subcapsular hematoma
B. Renal scintigraphy to
evaluate for the presence of
obstructive uropathy
C. CT to assess for other
sites of disease
D. Intravenous urography
to determine the level of
the urinary obstruction

36. What is the name of
the color Doppler artifact
shown?

A. Tissue vibration artifact
B. Aliasing artifact
C. Reverberation artifact
D. Twinkling artifact

37. Peer review programs are an important component of ongoing quality assurance processes. Cases
flagged in peer review:
A. Are selected based on discrepancy with pathologic or surgical proof of the final diagnosis
B. Form the basis for legal action against the original radiologist
C. Should automatically trigger an error‐correction event
D. Are flagged as a result of discordant interpretation by peer radiologists

38. How would decreasing the parameter indicated by
the arrow affect this image?

A. It would decrease the depth.
B. It would reduce the amount of color signal.
C. It would reduce the frame rate.
D. It would decrease the sampling rate.

39. A 45‐year‐old female presents with elevated serum creatinine 12 days status post renal
transplant. Images from a transplant ultrasound are shown. What is the best diagnosis?

A. Perinephric
hematoma or
urinoma
B. Subcapsular
hematoma
C. Lymphocele
D. Acute rejection

40. A 38‐year‐old male presents to the emergency department with left flank pain and fever. Which of
the following is the most appropriate step in patient management?

A. Shock wave lithotripsy or ureteroscopy
B. Ureteral stenting or nephrostomy tube placement
C. Observation with or without medical expulsive therapy

41. Which of the following choices lists the correct order of the relative speed of sound in tissues from
slowest to fastest?
A. Gas, fluid, soft tissue, bones
B. Bones, soft tissue, fluid, gas
C. Soft tissue, gas, fluid, bones
D. Gas, bones, soft tissue, fluid

42. Sonographic images are shown of a patient presenting with flank tenderness and fever. Based on
these images, what should be the follow‐up recommendations?

A. A repeat study does not
need to be performed if the
clinical signs of infection
resolve within 72 hours.
B. A follow‐up contrast‐
enhanced CT should be
performed to assess the
kidney for an underlying
neoplasm.
C. An echocardiogram should
be performed to assess for a
source of emboli.

43. The Doppler parameter indicated by arrows was altered between image 1 and image 2. Which of
the following can be seen in the spectral waveform as a result of this change?

A. It will result in
aliasing artifact.
B. It will cause
spectral
broadening.
C. It will provide a
higher peak systolic
velocity.
D. It will improve
detection of normal
flow.

44. A 91‐year‐old male with remote history of transurethral prostatectomy presents with abdominal
pain and lethargy. Transverse gray‐scale and duplex Doppler images of the pelvis are shown along
with an image from a pelvic CT performed 2 years prior for comparison. What is the most likely
diagnosis?

A. Pyuria
B. Fungal ball
C. Prostatomegaly
D. Malignancy

45. Compared with conventional fundamental ultrasound, what is a disadvantage of harmonic
imaging?
A. More severe side‐lobe artifact.
B. Wider harmonic beam results in diminished lateral resolution.
C. Decreased penetration.
D. Decreased image contrast.

46a. A 35‐year‐old male presents with history of recurrent urinary tract infections. Renal ultrasound
was performed. What is the most likely diagnosis?

A. RCC (renal cell cancer) with extension into left renal vein
B. Horseshoe kidney
C. Para‐aortic hematoma
D. Retroperitoneal lymphadenopathy

46b. Horseshoe kidneys are situated lower than normal because of:
A. Failure of the renal isthmus to ascend past the inferior mesenteric artery origin
B. Associated retroperitoneal fibrosis seen commonly with horseshoe kidneys
C. Derivation of blood supply exclusively from inferior mesenteric artery
D. Abnormal rotation of the renal pelves preventing normal ascent

47. A 61‐year‐old female presents with 4‐day history of
fever, nausea, vomiting, and right flank pain. Which one of
the following is the most important risk factor for the
abnormality shown?

A. Urinary tract obstruction
B. Female gender
C. Recurrent urinary tract infections
D. Diabetes mellitus

48. A 73‐year‐old severely malnourished female with a history of uterine cancer status post
hysterectomy and pelvic radiation. She has a chronic right ureteral stent, which is exchanged every 3
months for a presumed radiation‐induced ureteral stricture. She had a normal renal ultrasound 2
months ago. Which of the following options is the best choice for further workup and management of
this patient?

A. Nephrectomy
B. Referral to urology for treatment
of renal calculi
C. Short‐term follow‐up imaging
D. Percutaneous nephrostomy or
ureteral stent exchange

49a. A 51‐year‐old male with gross hematuria is evaluated with renal sonography. An image of the left
kidney is shown. From the choices listed, which would be most likely to have this appearance?

A. Adenocarcinoma
B. Squamous cell carcinoma
C. Angiomyolipoma
D. Transitional cell carcinoma

49b. What is the next best step for further management of this abnormal finding?
A. Nephrectomy
B. Ureteral stenting
C. CT
D. Retrograde urography

49c. The presence of which of the following features would best distinguish a renal cell carcinoma
(RCC) from a transitional cell carcinoma (TCC) in this patient?
A. Renal vein/caval tumor thrombus
B. Hydronephrosis
C. Retroperitoneal adenopathy
D. Presence of intralesional Doppler flow

50a. A 66‐year‐old male with acute renal insufficiency receives an
ultrasound. Sagittal image obtained from the midline ventral
abdomen is shown. The abnormal structure contains low‐resistance
arterial waveforms (not shown). Besides hepatocellular carcinoma
and renal cell carcinoma, which of the following is the most likely
tumor to cause this finding?

A. Primary leiomyosarcoma
B. Adrenal cortical carcinoma
C. Perinephric lymphoma
D. Retroperitoneal liposarcoma

50b. Prior to biopsy of this lesion, which preprocedural laboratory test needs to be performed?

A. Blood culture
B. Serum cortisol
C. ACTH
D. Plasma free metanephrines
and normetanephrines

51. The image here shows an echogenic structure in
the upper pole of the right kidney. Which maneuver
could you attempt to try and bring out a posterior
acoustic shadow?

A. Turn off the spatial compounding feature.
B. Turn off the tissue harmonic imaging feature.
C. Increase the overall gain.
D. Obtain an ultrasound elastography map.

52. Ultrasound images from renal artery Doppler of an obese male patient are provided. Which of the
following is a feature of the Doppler technique shown in these images?

A. Aliasing
B. Angle dependence
C. Increased sensitivity
for flow
D. Display of frequency
shift

53a. A 61‐year‐old male is found incidentally to have a
10‐cm exophytic renal mass. A representative power
Doppler image is shown. Select the best choice for further
management of this finding.

A. Perform further imaging.
B. Perform an image‐guided biopsy.
C. Refer to urology for surgical excision.
D. Recommend a 6‐month follow‐up study.

53b. The patient could not receive a contrast‐enhanced CT or MRI because of renal insufficiency and a
cardiac pacemaker. He then underwent a contrast‐enhanced ultrasound. What is the most likely
diagnosis?

A. Hemorrhagic cyst
B. Cystic renal cell carcinoma
C. Calyceal diverticulum
D. Oncocytoma

54. A 70‐year‐old female presents with gross hematuria. A transverse image of the left kidney is
shown.

Appropriate descriptors of the abnormality include:
A. Column of Bertin
B. Encapsulated
C. Peripheral
D. Infiltrative

Urinary Tract and Adrenal Glands: ANSWERS AND

EXPLANATIONS

1. Answer C. Sagittal images of both kidneys show generalized increased echogenicity of the renal
pyramids and associated posterior acoustic shadowing, consistent with calcium deposition. Color
Doppler image of the right kidney shows “twinkle” artifact from the renal calcifications. The findings
are consistent with medullary nephrocalcinosis. The common causes of medullary nephrocalcinosis in
the order of frequency are as follows: 40%, primary hyperparathyroidism; 20%, renal tubular acidosis
type I; and 20%, medullary sponge kidney. Other causes such as hypervitaminosis D states and milk–
alkali syndrome are less common. Chronic glomerulonephritis results in cortical nephrocalcinosis (and
not medullary nephrocalcinosis).

2a. Answer A. Bladder cancer is usually seen as a sessile or pedunculated mass projecting into the
bladder lumen. Immobility and presence of internal vascularity are useful distinguishing features.
Fungus balls and blood clots are mobile masses without vascularity. Bladder stones are mobile and
echogenic and show posterior acoustic shadowing.

2b. Answer B. Approximately 90% of bladder tumors are transitional cell carcinoma (TCC). The
majority of TCC arise at the trigone and along the lateral and posterior bladder walls. Squamous cell
carcinomas account for 5% to 8% of all bladder tumors. Adenocarcinoma of the bladder is rare (~2%
of all bladder tumors) and tends to occur in urachal remnants and in bladder exstrophy.
Neuroendocrine (small cell) tumor of the bladder is rarer, accounting for <0.5% of all bladder
neoplasms.

2c. Answer A. The pathogenesis for urothelial tumors is direct prolonged contact of the bladder
urothelium with urine containing excreted carcinogens. The most well‐established risk factor for
bladder cancer is cigarette smoking. Cigarette smoking accounts for one‐third to one‐half of all cases of
bladder cancer. There is also a well‐documented causal link between urothelial cancer and a variety of
occupational and environmental chemicals such as aniline, benzidine, aromatic amines, and azo dyes.
Therefore, occupational exposure to chemical carcinogens is the second most important risk factor
after smoking, estimated to account for as much as 20% of all bladder cancer. Chronic irritation from
bladder calculi and recurrent urinary tract infections is strongly associated with squamous cell
carcinoma.
Wong‐You‐Cheong JJ, Woodward PJ, Manning MA, et al. Neoplasms of the urinary bladder: radiologic‐pathologic correlation.
Radiographics 2006;26:553–580.

3. Answer C. A bilobed thin‐walled anechoic adrenal lesion containing a thin septation with no
internal color Doppler signal is shown. A thin smooth wall and lack of a solid component favors an
adrenal cyst, pseudocyst, or parasitic cyst. Whereas true adrenal cysts are lined by endothelium,
pseudocysts are surrounded by a fibrous capsule and are usually the sequelae of adrenal hemorrhage

or infection. In addition, neoplasms including adrenocortical carcinoma, pheochromocytoma, and
adenomas may undergo necrosis or degeneration leading to cystic components, which may be
extensive especially in larger tumors. Careful inspection on contrast‐enhanced CT or MRI should be
performed to exclude a solid tumoral component. There have only been a few reported cases of
entirely cystic pheochromocytoma.
References: Newhouse JH, Heffess CS, Wagner BJ, et al. Large degenerated adrenal adenomas: radiologic‐pathologic correlation.
Radiology 1999;210(2):385–391.
Lee TH, Slywotzky CM, Lavelle MT, et al. Best cases from the AFIP. Radiographics 2002;22(4):935–940.

4a. Answer D. A large echogenic suprarenal mass is shown with associated impairment of acoustic
penetration, indicating the presence of fat. Although gas can result in “dirty” acoustic shadowing,
linear high‐amplitude reflections are expected along the boundary closest to the probe. Blood products
can have a variety of appearances but would not be expected to shadow. Large calcifications typically
produce clean acoustic shadows.

4b. Answer B. The average velocities of sound in fat and
soft tissue are 1,450 and 1,540 m/s, respectively. Speed
errors result when the actual propagation speed through
a tissue varies from the calibrated velocity used by the
system (1,540 m/s). This leads to inaccurate
measurements between tissue boundaries. As a result of
slower propagation of sound through the fatty mass, the
portion of the diaphragm–lung interface deep to the
myelolipoma (yellow line) is incorrectly positioned
further from the probe than the adjacent interface deep to
the liver (white line). Although the diaphragm–lung
interface is smooth and continuous in reality, it takes on
an artifactual stair‐stepped appearance on ultrasound.

4c. Answer A. Although renal cell carcinomas may contain fat (from lipid‐producing necrosis,
intratumoral osseous metaplasia with fatty marrow elements, and entrapment of perirenal or sinus
fat), we would not expect them to be composed primarily of fat. Renal angiomyolipomas, adrenal
myelolipomas, and retroperitoneal liposarcoma can be mostly or purely composed of fat on imaging.
There are case reports of adrenal cortical carcinoma containing macroscopic fat, but in virtually all
cases, the presence of macroscopic fat within an adrenal mass permits a diagnosis of a benign lesion.

4d. Answer A. There is no recognized malignant potential for adrenal myelolipomas.
References: Kenney PJ, Wagner BJ, Rao P, et al. Myelolipoma: CT and pathologic features. Radiology 1998;208(1):87–95.

5. Answer C. Root cause analysis is a structured method borrowed from analysis of industrial
accidents to evaluate serious adverse events. It is a comprehensive process requiring data collection,
event reconstruction, record review, and interviews. Both active errors, those leading directly to the
event, and latent errors, hidden errors within the health care system contributing to the error, are
studied. This information is analyzed by a multidisciplinary team to determine how and why the event

occurred. The ultimate goal of RCA is to eliminate the various latent errors, which contribute to an
increased risk of similar future errors. Rather than a single root cause, often adverse events are caused
by multiple errors and system flaws.
Reference: American Board of Radiology. Quality and Safety Domain Specification and Resource Guide, Core Exam Study Guide.
Tucson, AZ: ABR, 2016:28.

6. Answer D. Between 2004 and 2014, there were 1,072 reports of wrong‐patient, wrong‐site,
wrong‐procedure sentinel events, representing the largest category. Radiation overdoses, anesthesia‐
related events and medication errors accounted for 36, 104 and 428 events, respectively.

7a. Answer D. Images show a Foley balloon posterior to the bladder with catheter extending caudally
in the vagina.
Bladder diverticula typically occur in the setting of bladder outlet obstruction. Connection to the
bladder is usually seen sonographically. Urethral diverticula arise from and are immediately
associated with the urethra. They are best seen on ultrasound by transvaginal or transperineal
imaging. Ureteroceles are formed from cystic dilatation of the intravesical segment of the ureter. On
ultrasound, they appear as cystic structures in the posterolateral bladder (expected insertion of
ureter). Urachal cysts occur because of incomplete closure of the urachus and are therefore located
along the anterior and superior aspect of the bladder. Although Gartner duct cysts are located in this
location (anterior lateral vagina above the pubic symphysis), the structure shown in this image is
clearly a Foley catheter with balloon in the midline vagina and catheter segment extending through the
balloon and caudally in the vagina.

7b. Answer A. 90% of tumors that arise within a urachal remnant are adenocarcinoma.

7c. Answer A. Gartner duct cysts are typically located in the anterior lateral vaginal wall above the
pubic symphysis. They may be seen in association with other wolffian anomalies such as renal
agenesis and ectopic ureter. Urethral diverticula can be confused with Gartner duct cysts because of
similar location and appearance. Urethral diverticula will show direct communication with the
urethra. Bartholin duct cysts are located in the posterior lateral inferior third of the vagina below the
level of the pubic symphysis. Nabothian cysts are located within the wall of the cervix.
References: Berrocal T, López‐Pereira P, Arjonilla A, et al. Anomalies of the distal ureter, bladder, and urethra in children:
embryologic, radiologic, and pathologic features. Radiographics 2002;22(5):1139–1164.
Chaudhari VV, Patel MK, Douek M, et al. MR imaging and US of female urethral and periurethral disease. Radiographics
2010;30(7):1857–1874.
Yu J‐S, Kim KW, Lee H‐J, et al. Urachal remnant diseases: spectrum of CT and US findings. Radiographics 2001;21(2):451–461.

8. Answer A. Spatial compounding combines images obtained from different scan angles into a single
frame. By utilizing multiple scan angles, lesion margins are better delineated because more of the
lesion margin is close to 90 degrees to the ultrasound beam. Orientation of a specular reflector 90
degrees to the beam maximizes the amount of reflected acoustic energy returning to the probe, leading
to more distinct boundaries for cysts and other masses. Additionally, although desirable acoustic
interfaces such as those found in renal cysts are reinforced through the summing of the images,

randomly located speckle noise is not reinforced, resulting in a significantly increased signal‐to‐noise
ratio.
2011:14–16.
9. Answer A. Side lobes are located outside of the primary desired acoustic beam but may interact
with tissues and return as an echo to the probe, thus creating artifactual low‐level echoes, which are
best appreciated within anechoic cystic and fluid‐filled structures. For example, side‐lobe artifact can
result in the appearance of gallbladder sludge.
2011:17.

10a. Answer C. The images show a homogeneously echogenic lesion at the upper pole of the left
kidney, with a maximal diameter of slightly <3 cm. The imaging features are characteristic of an
angiomyolipoma. AMLs are benign tumors composed of dysmorphic vessels, smooth muscle, and
mature fat. Eighty percent are sporadic, most frequently in middle‐aged women, and the other 20%
are associated with tuberous sclerosis (TS). Patients with TS often have mental retardation, seizures,
and facial sebaceous adenomas. Therefore, C is the correct answer. None of the other choices are
associated with TS.

10b. Answer B. Although a homogeneous, highly echogenic mass is very suggestive of AML,
approximately 10% of renal cell carcinoma (RCC) can mimic this appearance. One distinguishing
feature seen in up to 30% of AMLs is acoustic shadowing, which is extremely rare in RCC. Hyperechoic
masses that show no acoustic shadowing require further characterization with CT or MRI to
demonstrate fat. Choice B is the correct answer. Choice A is not correct because the lesion is
neoplastic, not inflammatory. Choice C would not be the most appropriate next step because the lesion
is statistically an AML, and confirmation of fat is likely all that is needed. Although bleeding is a serious
complication related to AMLs, it is rare when the lesions are <4 cm. Therefore, choice D is incorrect.

11a. Answer D. The images show an absent kidney in the right renal fossa. There are two normal‐
sized kidneys broadly fused together in the left renal fossa. At real time, the kidneys in this patient
extended into the left lower pelvis. A pelvic right kidney (choice A) is incorrect because pelvic kidneys
are not fused to the contralateral kidney. They remain on the ipsilateral side of the body but are found
more inferiorly. Horseshoe kidneys are usually fused at the lower poles and located more inferiorly
than normal, but each renal moiety will remain in the correct side of the body (option B). Diffuse
compensatory hypertrophy results in ipsilateral renal enlargement when the contralateral kidney is
absent or dysfunctional (option C), particularly when the renal insult occurs in utero or early in life.
The right kidney in this case is present and normal appearing, but is abnormally positioned.

11b. Answer C. Crossed renal ectopia occurs when there is in utero fusion of the metanephrogenic
blastema, not allowing for proper renal rotation or ascent. The ureterovesical junctions are not
affected, and both are in normal anatomical location. This is useful to remember when these patients
present with renal colic.

12. Answer A. The two broad categories of radiologist error are perceptual and cognitive
(interpretive) errors. Perceptual error occurs when an abnormality that can be seen in retrospect was
not identified by the interpreting radiologist at the time of the initial interpretation. “Satisfaction of
search,” in which identification of one abnormality results in a second abnormality being overlooked,
is one of many potential causes of perceptual error. Perceptual errors account for 60% to 80% of
radiologists’ errors. Cognitive error occurs when the radiologist identifies a finding but renders an
incorrect interpretation.

13. Answer B. The ultrasound shows a shadowing stone that was glimpsed on the sagittal and
transverse views in the proximal transplant ureter resulting in mild hydronephrosis. This is most
likely the cause of the elevated creatinine level. The ultrasound images also reveal a simple‐appearing
deep perinephric collection near the renal vein. Although color Doppler aliasing and perhaps some
luminal compression of the renal vein may be present, angle correction was not applied and a velocity
gradient was not measured, so the provided images are not sufficient to diagnose severe renal vein
stenosis (option A). The perinephric fluid collection shown remained stable 1 year later and was
thought to represent a lymphocele. Subcapsular hematoma and solid masses, as can be seen with
posttransplant lymphoproliferative disease, are absent (options C and D).
The clinical diagnosis of
obstructive uropathy
after renal transplant is
difficult because the graft
is denervated and
patients are
asymptomatic. The
diagnosis may remain
unsuspected until
hydronephrosis or
declining renal function is
discovered incidentally.
Mild, nonobstructive
pelvicaliectasis is common after renal transplant.

References: Rhee BD, Bretan PN Jr, Stoller ML. Urolithiasis in renal and combined pancreas/renal transplant recipients. J Urol
2005;161(5):1458–1462.

14. Answer A. Sonography is often used as a screening tool in patients presenting with elevated
creatinine to rule out underlying mechanical obstruction. Lack of obstruction usually indicates that
renal parenchymal disease is present. Sonographic appearance of various renal parenchymal diseases
such as acute tubular necrosis, glomerulonephritis, and acute interstitial nephritis affecting the
kidneys is difficult to distinguish on ultrasound. Patients often present with diffusely echogenic
kidneys, and biopsy may be needed in select patients to establish a specific diagnosis. The images
show a mildly enlarged, strikingly echogenic cortex relative to the spleen (when the spleen is used as
an external control) and the hypoechoic renal pyramids (when used as an internal control).

The color Doppler image of the renal vein confirms patency, and there is no dilatation of the renal
pelvis (choices B and C are incorrect). The hypoechoic rim around the kidney represents perinephric
fat, which appears hypoechoic relative to the echogenic renal cortex. Diffuse xanthogranulomatous
pyelonephritis does not have specific sonographic features but can be suggested when renal
enlargement, cortical thinning, dilated, debris‐filled calyces, large calculi, and perinephric fluid are
present (option D). This particular patient had a known history of idiopathic membranous
glomerulonephritis, an autoimmune disease.
Makker SP, Tramontano A. Idiopathic membranous nephropathy: an autoimmune disease. Semin Nephrol 2011;31(4):333–340.

15. Answer B. Sagittal ultrasound image of the left lower quadrant renal allograft shows a large
anechoic peritransplant fluid collection with few internal septations. This most likely represents a
peritransplant lymphocele. Lymphoceles are the most common fluid collections seen in renal
transplant recipients. They typically occur 1 to 3 weeks following surgery. They may be asymptomatic
or cause local pain and tenderness. Septations may be seen within lymphoceles, as in this case.
Lymphoceles form from leakage of lymph from recipient lymphatic channels. Large lymphoceles may
result in impaired graft function.
Urinomas are much less common. They occur because of breakdown of the ureter implantation into
the bladder. Therefore, they are usually in close proximity to and may exert mass effect on the bladder.
Hematomas are common in the early postoperative period. Small hematomas may be seen incidentally
at imaging. Large hematomas may result in pain. At ultrasound, hematomas usually appear as
heterogeneous perinephric collections. Abscesses typically appear as complex fluid collections
containing internal debris.
Moreno CC, Mittal PK, Ghonge NP, et al. Imaging complications of renal transplantation. Radiol Clin North Am 2016;54(2):235–
249.

16a. Answer B. The images show an ovoid circumscribed cystic lesion containing low‐level internal
echoes within the wall of the upper vagina. There is posterior acoustic enhancement and no internal
vascularity. The transvaginal probe indents the mass.
The wolffian (mesonephric) ducts, embryologic precursors to the vas deferens and seminal vesicles,
regress in the absence of testosterone and antimüllerian hormone. Gartner duct cysts (GDCs) are rare
remnants of regressed wolffian ducts. They are usually small (<2 cm) and located within the
anterolateral aspect of the upper vagina.
CT images with reformats demonstrate the Gartner duct cyst (arrow).

Nabothian cysts are located within the cervix, not the vaginal wall. A urethral diverticulum is located
around the urethra and not within the vaginal wall. It typically has a horseshoe shape. A metastasis
should have some internal vascularity. A necrotic metastasis could have a complicated cystic
appearance but would also have a more irregular wall. Careful scanning should show vascularity in
solid mural components. Bartholin cysts are located at or below the level of the pubic symphysis and
usually arise from the posterior vaginal wall.

16b. Answer C. Nabothian cysts, GDCs, müllerian cysts, and Bartholin cysts are usually incidental
findings.
Ureteroceles may require surgical repair. Asymptomatic orthotopic ureteroceles can be incidental.
Symptomatic orthotopic ureteroceles may require repair, though this can usually be done
endoscopically. Most ectopic ureteroceles require intervention. Those inserting on the bladder may be
repaired endoscopically; those inserting outside the bladder usually require open repair. In the
congenitally duplicated urinary tract, the obstructing ectopic ureterocele of the upper pole moiety
usually also requires open surgery.
References: Lui M‐W, Ngu S‐F, Cheung VYT. Mullerian cyst of the uterus misdiagnosed as ovarian cyst on pelvic sonography. J Clin
Ultrasound 2013;42(3):183–184.
Siegelman ES. Body MRI. Philadelphia, PA: Elsevier Health Sciences, 2005:291–292, 329–330, 418.

17a. Answer C. Images show a sharply demarcated partially exophytic solid‐appearing left lower
pole renal mass isoechoic to the renal parenchyma, which contains a few punctate calcifications. The
differential diagnosis for a solid renal mass includes renal cell carcinoma (RCC), angiomyolipoma,
oncocytoma, transitional cell carcinoma, lymphoma, and metastasis.
Transitional cell carcinoma and lymphoma typically have a more infiltrative appearance and do not
typically result in discrete exophytic masses. Additionally, the cortical epicenter of this mass argues
against a urothelial origin. Angiomyolipomas are typically hyperechoic and rarely contain calcification.
Renal oncocytomas are usually impossible to distinguish from RCCs preoperatively but rarely contain
calcification. Metastasis can be considered if there is a known malignancy.
Although this mass should be presumed to represent a renal cell carcinoma based on its solid
appearance, a CT or MRI would be an important study to perform prior to surgery for staging. Renal
mass biopsy is usually limited to cases in which the diagnosis of lymphoma or metastasis is suspected,
as these are not treated with surgical resection, or to cases in which the patient is not a surgical
candidate.

17b. Answer C. Although the presence of intralesional Doppler flow indicates a solid renal mass and
a renal cell carcinoma with a high degree of certainty, the absence of detectable flow does not exclude
a neoplasm. One reason is that some renal cell carcinomas
are hypovascular, although highly vascular tumors will
also usually exhibit less Doppler signal than the
surrounding renal parenchyma. The sensitivity for
detection of flow is also decreased when interrogating
deeper lesions. In the setting of an indeterminate renal
mass, CT or MRI is necessary for lesion characterization
and detection of enhancement. Contrast‐enhanced
ultrasound is also emerging as a highly sensitive method
for identifying blood flow within tumors.

References: Dyer R, DiSantis DJ, McClennan BL. Simplified imaging approach for evaluation of the solid renal mass in adults.
Radiology 2008;247(2):331–343.
Siegel CL, Middleton WD, Teefey SA, et al. Angiomyolipoma and renal cell carcinoma: US differentiation. Radiology
1996;198(3):789–793.

18a. Answer C. Deep to the anterior abdominal wall, a tubular blind‐ending structure extends
superiorly from the bladder dome. It contains a small amount of fluid. Close inspection reveals a
mucosal lining throughout the structure. Findings are compatible with a urachal diverticulum. See
additional CT images with multiplanar reformats on the next page. Arrows denote the diverticulum.
The urachus is the fibrous vestige of the
fetal allantois, a tubular structure
through which urine drains from the
bladder dome to the umbilicus during
the first trimester of pregnancy.

Normally, this channel obliterates after the first trimester of pregnancy, leaving the median umbilical
ligament, located within the extraperitoneal space of Retzius.
Incomplete obliteration results in a spectrum of urachal disorders. A patent urachus allows urine to
leak from the bladder to the umbilicus. A urachal cyst is located along the urachus without
communication to the umbilicus or bladder. A urachal sinus is a blind ending tract communicating
with the umbilicus. A urachal diverticulum is a blind ending tract extending from the bladder.

18b. Answer B. Urachal adenocarcinomas are a rare complication of urachal remnants. They may be
located anywhere along the course of the urachus, including the bladder dome, and often have a large
extravesical component. They are often large at presentation and often appear as partially calcified
mixed solid and cystic masses.
References: Aguirre DA, Santosa AC, Casola G, et al. Abdominal wall hernias: imaging features, complications, and diagnostic
pitfalls at multi–detector row CT. Radiographics 2005;25(6):1501–1520.
Gleason JM, Bowlin PR, Bagli DJ, et al. A comprehensive review of pediatric urachal anomalies and predictive analysis for adult
urachal adenocarcinoma. J Urol 2015;193(2):632–636.
Yu J‐S, Kim KW, Lee H‐J, et al. Urachal remnant diseases: spectrum of CT and US findings. Radiographics 2001;21(2):451–461.

19. Answer D. Renal lesions, which are higher in attenuation than water but well‐defined and
homogeneous, are usually best evaluated with a sonogram, as most of these lesions represent benign
cysts and can be effectively confirmed to be anechoic simple cysts on ultrasound. In this example, the
lesion margins are indistinct, an unexpected finding given its sharply circumscribed appearance on CT.
The renal capsule is also indistinct in spite of its fairly superficial location. These findings indicate that
the lesion is not optimally visualized and should trigger a
review of the technical parameters and scan technique.
Settings for both depth of field and focal zone are too deep
and should be corrected. Depth of field much greater than
the lesion depth decreases axial spatial resolution. Because
the focal zone is much deeper than the lesion, lateral
resolution is also compromised. Once these parameters are
corrected, the probe transmit frequency can also be
maximized to further improve image quality.
Optimized image of the left kidney is shown. The lesion
represents a simple benign renal cyst.


20. Answer B. There is mild hydronephrosis, and multiple linear high‐amplitude echoes with
posterior dirty acoustic shadowing representing gas are located within the renal pelvis. Findings are
compatible with emphysematous pyelitis, a urinary tract infection characterized by the presence of
gas within the collecting system. This diagnosis can be made once other causes of gas including recent
instrumentation, trauma, and fistulous communication with bowel are excluded. Emphysematous
pyelitis usually responds to antibiotic therapy without the need for an invasive procedure. It is
important to perform a CT in order to confirm the absence of renal parenchymal gas.

Coronal reformat from the patient’s CT scan shows
presence of gas in the collecting system.
Emphysematous pyelonephritis (EPN) is a severe life‐
threatening necrotizing renal parenchymal infection
usually occurring in patients with uncontrolled diabetes.
It is characterized by the presence of renal parenchymal
gas. Xanthogranulomatous pyelonephritis (XGP) is a rare
chronic granulomatous pyelonephritis resulting in a
nonfunctioning kidney. Various bacteria implicated with
XGP include Escherichia coli and Proteus mirabilis. In 90%
of cases, a staghorn calculus with hydronephrosis is
present. The kidney is eventually replaced by an
inflammatory mass, composed predominantly of lipid‐
laden macrophages. The inflammatory process may
involve the perinephric tissues or even nearby organs.
The sonographic diagnosis can be challenging because of
a lack of specific imaging findings, but the possibility of XGP should be considered if parenchymal
thinning, hydronephrosis with stones and debris, and perinephric fluid collections are present. In this
example, gas and collecting system dilatation are the only abnormalities.

Renal abscess usually appears as a complex fluid collection or complex cystic masses. In the case
shown here, the high‐amplitude echoes representing gas are clearly within the renal pelvis and not
within a separate fluid collection or cystic mass.
References: Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic‐pathologic review. Radiographics 2008;28(1):255–276.

21. Answer A. Echogenic material within the right renal
vein with adjacent color Doppler signal represents
subocclusive thrombus. Spontaneous renal vein thrombosis
is most commonly associated with malignancy, especially
renal cell carcinoma, and nephrotic syndrome. Other causes
include trauma, biopsy, oral contraceptives, hypovolemia,
and inherited hypercoagulable states. Although renal vein
thrombus in the setting of renal cell carcinoma usually
represents tumor thrombus, the pathogenesis of renal vein
thrombosis in the setting of nephrotic syndrome is poorly
understood.

Arrow denotes the subocclusive thrombus in the right renal vein.

22. Answer D. Large size and heterogeneity favor metastasis, but it should be evaluated by adrenal
mass protocol CT or MRI to exclude an adenoma prior to percutaneous biopsy.
Adrenal gland is the fourth most common site of metastasis, with lung, breast, melanoma, and
lymphoma being the most common primary neoplasms. The masses are solid on sonography and may
demonstrate internal heterogeneity. They are often indistinguishable from adenomas though they
usually tend to be larger and heterogeneous.
This mass is predominantly hypoechoic, which is not a characteristic sonographic appearance for
myelolipoma.
Although the lesion is solid and suspicious for metastasis, an adrenal adenoma cannot be excluded on
ultrasound, and further evaluation must be performed with adrenal mass protocol CT or MRI before
proceeding to an invasive procedure such as percutaneous biopsy.
Large size of the lesion and the heterogeneity favor metastasis over an adenoma. However, an atypical
adenoma cannot be excluded, and hence, further evaluation must be performed with adrenal mass
protocol CT or MRI before proceeding to percutaneous biopsy.

23a. Answer B. Gray‐scale and color Doppler images of the right kidney show multiple renal cysts
and a solid renal mass with internal vascularity. Transverse image through the head of the pancreas
shows a pancreatic head cyst with septations. These imaging findings along with the indication of a
family history suggest the diagnosis of von Hippel‐Lindau disease (VHL). VHL disease is inherited in an
autosomal‐dominant fashion. Abdominal manifestations of VHL include simple pancreatic cysts,
serous cystadenomas, pancreatic neuroendocrine tumors, benign renal cysts, renal clear cell
carcinomas, and pheochromocytomas. Central nervous system manifestations include
hemangioblastomas and retinal angiomas.

Tuberous sclerosis (TS) is an autosomal‐dominant, neurocutaneous disorder. The common
manifestations of TS include cortical or subependymal tubers and white matter abnormalities,
angiomyolipomas, cardiac rhabdomyomas, lymphangioleiomyomatosis. Cutaneous manifestations are
quite common and include facial angiofibromas (also called adenoma sebaceum), hypopigmented
macules (ash‐leaf spots), and ungual fibromas.
Multiple endocrine neoplasia type 1 (MEN1) is also inherited as an autosomal‐dominant disorder.
Manifestations include parathyroid, pancreatic, and pituitary tumors. Osler‐Weber‐Rendu syndrome
also known as hereditary hemorrhagic telangiectasia (HHT) is an autosomal‐dominant disorder that
leads to the formation of dysplastic blood vessels in the skin and mucous membranes and in organs
such as the lungs, liver, and brain.

23b. Answer D. As stated above, central nervous system manifestations such as hemangioblastomas
can be seen in patients with VHL. Therefore, D is the correct answer.
Subependymal tubers and cardiac rhabdomyomas are findings seen in tuberous sclerosis. Intracranial
AVMs have no association with VHL disease. They can be seen in other rare phakomatoses such as
Wyburn‐Mason syndrome and Osler‐Weber‐Rendu syndrome.

24a. Answer A. Ultrasound image of the kidney shows multiple punctate echogenic foci located in
both the renal medulla and cortex. The appearance is attributed to microcysts (1 to 2 mm) with
fibrotic margins and possible internal calcification, which can be seen in patients treated long‐term
with lithium for affective disorders. This is a case of lithium nephropathy.
In renal cortical necrosis, one may see loss of normal corticomedullary differentiation and areas of
increased echogenicity within the parenchyma. In medullary nephrocalcinosis, there is increased
echogenicity of the renal pyramids due to calcium deposition.

24b. Answer B. MR imaging has been demonstrated to be superior to ultrasonography and computed
tomography for the visualization of small renal cysts. On MRI, small T2‐hyperintense 1‐ to 2‐mm
round lesions are usually seen distributed randomly in the renal medulla and cortex.
Radionuclide techniques can demonstrate poor radiopharmaceutical excretion in diffuse renal
diseases. However, they are not disease specific. Plain radiographs will not be able to demonstrate the
morphologic changes seen in the kidneys in lithium nephropathy.
References: Di Salvo DN, Park J, Laing FC. Lithium nephropathy. J Ultrasound Med 2012;31(4):637–644.
Farres MT, Ronco P, Saadoun D, et al. Chronic lithium nephropathy: MR imaging for diagnosis. Radiology 2003;229(2):570–574.

25. Answer A. The thin‐walled cystic bulbous structure located at the right ureterovesical junction
projecting into the bladder lumen represents a simple ureterocele. Dilatation of the ureterocele and
upstream ureter and absence of a right ureteral jet on this image does not necessarily imply
obstruction. Ureteroceles can be observed to grow and shrink in real time as they fill and empty with
urine. A ureteral jet will also be visible as they empty. Ureteroceles are congenital focal dilatations of
the intramural portion of the distal ureters. They are classified as simple, occurring at the normal
ureteral orifice, or ectopic, occurring at another site such as the bladder neck, urethra, or vagina. In
adults, most ureteroceles are simple. Small ureteroceles are usually incidental and not the cause of the
patients’ symptoms, but larger ureteroceles >2 cm are more likely to result in obstruction or contain

calculi. In children, ectopic ureteroceles are more common and are associated with complete ureteral
duplication with ureteral obstruction.
Pseudoureteroceles are acquired dilatations of the ureterovesicle junction as a result of obstruction of
the ureteral orifice. These can arise from stones, tumors, or recent manipulation. They can be
recognized by the presence of an obstructing lesion or wall thickening.
Zagoria RJ, Dyer R, Brady C. Genitourinary imaging: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:153–156.

26. Answer B. The first two images show bilateral enlarged kidneys with innumerable renal cysts of
varying sizes. The third image shows multiple hepatic cysts. This imaging appearance is consistent
with autosomal‐dominant polycystic kidney disease (ADPKD).
ADPKD is the most common hereditary renal cystic disease. The cysts are distributed diffusely
throughout both kidneys and involve all portions of the kidneys. Extrarenal manifestations most
commonly include hepatic cysts. Less commonly, pancreatic cysts, ovarian cysts, splenic cysts,
arachnoid cysts, intracranial berry aneurysms with associated intracranial hemorrhage, abdominal
aortic aneurysm, cardiac valve abnormalities, abdominal wall hernias, and colonic diverticula can be
seen.
Renal complications of ADPKD include cyst hemorrhage, cyst infection, cyst rupture, and
nephrolithiasis. About 50% of individuals with ADPKD develop end‐stage renal disease. Intrarenal
ischemia caused by continued renal cyst expansion with resultant activation of the renin–angiotensin–
aldosterone system leads to hypertension. Therefore, choice B is the correct answer. The patient may
present with flank and back pain, hypertension, or nephrolithiasis with eventual progression to renal
failure.
There is no increased risk for renal cell carcinoma unless the patient is undergoing prolonged dialysis
(choice A).
Portal hypertension (choice C) is not a feature of ADPKD. It is seen in autosomal recessive polycystic
kidney disease (ARPKD). ARPKD is a heritable disorder characterized by nonobstructive renal
collecting duct ectasia, hepatic biliary duct ectasia and malformation, and fibrosis of both liver and
kidneys. In the kidney, the dilated collecting ducts and interstitial fibrosis may impair renal function
and result in hypertension and renal failure. In the liver, periportal fibrosis accompanies the
malformed and dilated bile ducts and may result in portal hypertension.
As mentioned earlier, the kidneys are enlarged bilaterally with multiple cysts present in ADPKD.
Therefore, renal atrophy (choice D) is incorrect.
Lonergan GJ, Rice RR, Suarez ES. Autosomal recessive polycystic kidney disease: radiologic‐pathologic correlation. Radiographics
2000;20(3):837–855.
Weber TM. Sonography of benign renal cystic disease. Radiol Clin North Am 2006;44(6):777–786.

27. Answer B. Dropout ultrasound artifact/dead element artifact occurs as a result of broken crystals
in the ultrasound probe. It is usually due to the ultrasound probe being dropped accidentally. It creates
a dark band on the ultrasound images corresponding to the broken elements in the ultrasound
transducer that radiates from the surface of the transducer. This type of artifact will move along with
the transducer and maintain a constant position with respect to the transducer.
All other choices are common ultrasound artifacts seen in routine ultrasound imaging and have been
discussed elsewhere in this text.
Jenderka KV, Kopp A, Liebscher E, et al. Simple test of transducer arrays by imaging of ultrasound emission into air. Biomed Tech
(Berl) 2013;58.

28. Answer B. Extensive calcification of the kidney is shown on ultrasound with posterior acoustic
shadowing. Diffuse medullary and cortical calcification of both normal‐sized kidneys is demonstrated
on CT, consistent with medullary and cortical nephrocalcinosis. Global calcification of renal
parenchyma with normal renal size is characteristic of oxalosis. Primary hyperoxaluria and oxalosis
occur because of an autosomal recessive defect in hepatic enzymes involved in glyoxylate metabolism
resulting in increased oxidation of glyoxylate to oxalate. Because the primary defect is in the liver,
these patients often have recurrent renal failure from oxalosis after isolated renal transplantation.
Hence, combined liver–kidney transplantation is recommended for primary hyperoxaluria and
oxalosis.
The echogenic rim and clean shadowing point to calcification rather than emphysematous
pyelonephritis which, in contrast, are characterized by echogenic foci with distal dirty shadowing
(choice A). Although it is true that chronic renal failure is best managed with renal transplantation, a
combined liver–kidney transplantation is advocated for patients with primary hyperoxaluria and
oxalosis because of the very high risk of recurrent renal failure from oxalosis after isolated renal
transplantation (choice C). Calcification in a renal mass should always raise concern for renal cell
cancer. But, in the provided images, there is no discernible mass, and the renal architecture as well as
contour are preserved, arguing against renal cell cancer (choice D).
References: Kuo LW, Horton K, Fishman EK. CT evaluation of multisystem involvement by oxalosis. AJR Am J Roentgenol
2001;177(3):661–663.
Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences, 2011:333–339,
350.

29. Answer B. The Foley balloon should always be visible within the bladder lumen following
placement. The balloon is located inferior to the bladder within the prostate. A malpositioned urinary
catheter within the prostate may result in acute mechanical obstruction and therefore requires
repositioning.
Reference: Patel A, Friedman EA. Obstructed or malpositioned urethral catheter induced acute kidney injury. Case Rep Nephrol
2012;2012:1–3.

30. Answer C. Color‐flow image obtained during diastole demonstrates focal abnormally increased
turbulent flow within the central allograft. Spectral analysis reveals a low‐resistance arterial
waveform with abnormally elevated diastolic velocities compared to segmental arterial waveforms
obtained away from the abnormality. Arteriovenous fistulae and pseudoaneurysms are the most
common vascular complications of renal biopsy, and most frequently occur in renal transplants. These
may be diagnosed with a high degree of accuracy using color Doppler and spectral analysis. Tissue
vibration from arteriovenous fistulae results in speckled mosaic color signal within the surrounding
perivascular tissues. Increased flow through the fistula results in abnormally increased diastolic flow
within the supplying artery as well as arterialization of the venous waveform. Gray‐scale images are
normal. Arteriovenous fistulae usually spontaneously resolve and require only sonographic
surveillance. Rarely do they require embolization or surgery.

31. Answer A. A higher transmitted frequency can improve the detection of slow blood flow through
two mechanisms: (1) The amplitude of echoes from small objects such as RBCs increases with the
fourth power of the transmit frequency; and (2) the Doppler shift frequency is proportional to the
transmit frequency and therefore increases with a higher frequency probe. However, higher frequency
sound waves penetrate tissues more poorly than do lower frequency waves. This counterbalances the

advantages of selecting high‐frequency transducers and will therefore require that a compromise be
made between penetration and flow sensitivity. Side lobes represent sound energy radiating away
from the central beam. Side lobes can produce low‐level artifactual echoes, which are best seen over
cystic structures. A higher transmitted frequency does not improve detection of blood flow by
decreasing side‐lobe artifact.
Reference: Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:18, 24.

32. Answer D. The identifier must be person specific and may be the patient’s name, assigned
identification number, telephone number, date of birth, government‐issued photo identification, or last
four digits of the social security number. The source of the identifiers may include the patient, relative,
guardian, domestic partner, or a health care provider who has previously identified the patient. The
other listed choices are not person specific.

33. Answer A. A small cyst‐like structure within the renal parenchyma contains swirling, so‐called
yin–yang, intraluminal flow. Spectral analysis with the Doppler gate positioned at the neck of the
lesion shows a biphasic (“to and fro”) waveform with reversed flow during diastole. These features are
diagnostic for a pseudoaneurysm. Renal pseudoaneurysms are almost always due to penetrating
trauma. Neither abscesses nor hematomas will contain internal flow. Increased blood flow through an
arteriovenous fistula is detected as increased low‐resistance flow on spectral analysis.

34. Answer B. Because the speed of sound remains constant within a particular tissue, sound
frequency and wavelength have an inversely proportional relationship. A higher transmit frequency
will produce a shorter wavelength. Shorter wavelengths will result in shorter sound pulses, improving
axial resolution, the ability to resolve structures located at different depths within the same field of
view.
Lateral resolution, or the ability to resolve different structures located at the same depth, is improved
by narrowing the beam at the level of interest. The operator adjusts the depth at which the beam is
most narrow by changing the focal zone.

35. Answer C. This is a case of perinephric lymphoma. The patient also has splenomegaly, as
suggested by the history. Renal ultrasound shows bilateral perinephric rind‐like hypoechoic tissue.
Choice A is incorrect because the configuration of the hypoechoic tissue suggests an extracapsular
location. Although a subcapsular hematoma may be hypoechoic, the absence of displacement of
adjacent cortical tissue argues against a subcapsular location. A subcapsular collection would also be
expected to form acute angles with the kidney near its margins.
The differential diagnosis for perinephric rind‐like solid tissue includes lymphoma, retroperitoneal
fibrosis, and Erdheim‐Chester disease. Perinephric lymphoma is rarely isolated and is usually the
result of contiguous spread from renal lymphoma or retroperitoneal tumor. Retroperitoneal fibrosis
typically involves the infrarenal aorta and common iliac arteries, but perinephric involvement may
occur with or without other sites of retroperitoneal fibrosis. Retroperitoneal fibrosis may also occur as
a component of a multifocal fibrosclerosis syndrome, including autoimmune pancreatitis, sclerosing
cholangitis, scleroderma, Riedel thyroiditis, and fibrotic orbital pseudotumor. Erdheim‐Chester

disease is a rare form of systemic non–Langerhans cell histiocytosis. These patients typically present
with lower‐extremity bone pain and have characteristic findings of the long bones of the appendicular
skeleton. Perirenal involvement can lead to renal parenchymal and ureteral compression resulting in
progressive renal failure. Choice C is the best choice, because a contrast‐enhanced CT would permit
assessment for renal or retroperitoneal lymphoma, retroperitoneal fibrosis, and signs of multifocal
fibrosclerosis. In cases in which the imaging, clinical, and laboratory findings do not permit a confident
diagnosis, a biopsy of the perinephric tissue can be performed.
Reference: Surabhi VR, Menias C, Prasad SR, et al. Neoplastic and non‐neoplastic proliferative disorders of the perirenal space:
cross‐sectional imaging findings. Radiographics 2008;28(4):1005–1017.

36. Answer D. Rapidly alternating red and blue signal on color‐flow imaging deep to certain
echogenic structures is termed twinkling. This is not generated by vascular flow but is an incompletely
understood artifact created when imaging certain materials. Thus, spectral analysis will not
demonstrate a spectral waveform but only broadband signal. This usually occurs when imaging
irregularly contoured highly reflective materials and has been most frequently described in
association with urinary tract calculi. However, twinkling artifact is not specific to urinary calculi and
may also accompany biliary calculi, adenomyomatosis, bowel gas, calcified renal masses, and vascular
calcifications. Twinkling artifact can be useful to improve detection of these tissues.
Although tissue vibration produced by arteriovenous fistulas will produce speckled mixed color signal,
this is not true twinkle and can usually be recognized by the presence of low‐resistance arterial
waveforms on spectral analysis. Aliasing artifact occurs when the pulse repetition frequency, or
sampling rate, is too low for a given vessel to assign a correct velocity. Reverberation artifact occurs
when the ultrasound beam encounters two strong parallel reflectors, generating additional echoes,
which are incorrectly displayed as signal deep to the actual reflectors.
Reference: Kim HC, Yang DM, Jin W, et al. Color doppler twinkling artifacts in various conditions during abdominal and pelvic
sonography. J Ultrasound Med 2010;29(4):621–632.

37. Answer D. The peer review process is intended to be a “safe” form of self‐regulation among
radiologists. Feedback is provided to the original radiologist. Peer review data have a special status
with regard to malpractice law, which fully protects it from medicolegal discovery. The “standard” for
peer review is peer consensus rather than pathologic or surgical proof of the final diagnosis.
Therefore, flagged cases are considered discrepant and not necessarily errors. Discrepant cases should
not result in error‐correction steps until after they have been formally reviewed by the peer review
committee.
Tucson, AZ: ABR, 2016:57–58.

38. Answer B. The arrow is pointing at the color‐write priority setting, indicated by the green
marker. This is the gray‐scale intensity threshold above which all color information is suppressed. A
lower threshold will reduce the amount of color signal displayed. This can be useful to suppress
unwanted extraluminal color artifact when imaging larger vessels such as the carotids and abdominal
aorta, which have a visible anechoic lumen. However, use of a lower color priority setting when
evaluating vessels that are too small to resolve on gray scale may completely suppress signal from real
blood flow.

39. Answer B. Gray‐scale image demonstrates a hypoechoic collection surrounding and compressing
the transplanted kidney compatible with a subcapsular hematoma. Because the hematoma is
contained within the fibrous capsule, it displaces the adjacent renal cortex away from the capsule
leading to its buckled appearance. Acute margins of the interface between the collection and the renal
parenchyma are also in keeping with its subcapsular location. Direct pressure on the renal tissue can
lead to impaired perfusion and ischemia, the so‐called Page kidney. In this case, diastolic flow reversal
indicates severely increased resistance to allograft perfusion, with a resistive index exceeding 1.0.
Hematomas can develop spontaneously or be the result of biopsy or trauma. They are common in the
immediate postoperative period but are usually small and resolve spontaneously. Larger hematomas
may become clinically relevant when they exert mass effect on adjacent structures and sometimes are
evacuated to preserve renal function.
Perinephric hematoma or urinoma is not the best option because of the subcapsular location of the
collection. Although lymphoceles are the most common perigraft fluid collection, they are anechoic
unless they become infected. Acute rejection can result in elevated intrarenal resistive indices with
absent or reversed diastolic flow but is not the best choice because of the presence of a subcapsular
collection.
Reference: Park SB, Kim JK, Cho K‐S. Complications of renal transplantation. J Ultrasound Med 2007;26(5):615–633.

40. Answer B. An echogenic shadowing calculus is located at the level of the left ureterovesicular
junction. Twinkling artifact has been shown to be a more sensitive indicator of urinary calculi than
acoustic shadowing, but both twinkling and shadowing are present on this study. Mild left
hydronephrosis containing low‐level echoes is concerning for pyonephrosis in the setting of fever. A
urinalysis (UA) would also be helpful to confirm the presence of pyuria, although a falsely negative UA
may occasionally result from complete ureteric obstruction. In the setting of suspected infection in
patients with obstructing stones, urgent drainage of the collecting system is required to evacuate the
infected urine and to allow the antibiotic to penetrate the infected kidney. Manipulation of an
obstructing calculus in the setting of active infection can lead to life‐threatening sepsis and is therefore
delayed until after the treatment of the obstruction and infection. Lack of decompression of the
collecting system has been shown to be independently associated with an increased risk of mortality.
Reference: Assimos D, Krambeck A, et al. Surgical management of stones: American Urological Association/Endourological
Society Guideline. J Urol 2016;196(4):1153–1160.

41. Answer A. Although the speed of sound within a given tissue is constant and does not vary with
wavelength or frequency, it varies between different tissues. Sound propagates faster through dense
tissues containing closely packed molecules and slower through less dense tissues. For the purposes of
diagnostic ultrasound, the speed of sound within soft tissues is assumed to be 1,540 m/s.

42. Answer A. Images demonstrate a mildly enlarged right kidney containing patchy geographic
areas of hyperechogenicity within the upper pole and decreased corticomedullary differentiation.
Decreased perfusion within the upper pole is also noted. No abscess or hydronephrosis is present.
Findings are compatible with an acute uncomplicated pyelonephritis.
The sonographic findings in cases of uncomplicated acute pyelonephritis are usually normal.
Occasionally, infection can result in patchy areas of increased and decreased parenchymal
echogenicity. The acute inflammatory process can result in focal vasoconstriction, causing ischemia.
Urothelial thickening can also be a manifestation of pyelonephritis. The principal role of ultrasound in
assessing patients with pyelonephritis is to identify complications such as abscesses and obstruction

and to assess for calculi that may lead to persistent infection. Patients with uncomplicated
pyelonephritis who respond to treatment within 72 hours do not require further imaging.

43. Answer B. Spectral broadening refers to the presence of a large range of flow velocities at a given
point in the pulse cycle. Spectral broadening can be artifactually produced by the selection of an
excessively large sample volume or by the placement of the sample volume too near the vessel wall,
where slower velocities are present. Spectral broadening is also seen from turbulent flow in high‐
grade vessel stenosis or when the system gain is too high.
2011:29.

44. Answer D. The first gray‐scale image shows a Foley balloon within a collapsed urinary bladder
and an adjacent left‐sided echogenic mass. Intervening bladder wall separates the mass from the
bladder lumen. The second gray‐scale image obtained closer to the bladder apex demonstrates
continuity of the mass with the collapsed bladder lumen via a bladder wall defect. Indeed, the prior CT
confirms the presence of a left‐sided diverticulum. Color and spectral analysis reveals intralesional
arterial flow, confirming a solid mass rather than pus or fungal ball. These findings represent a
neoplasm arising within a bladder diverticulum.
Primary neoplasms arising within bladder diverticula are most commonly transitional cell carcinoma
(TCC). Bladder diverticula are mucosal outpouchings through the detrusor muscle and have no outer
muscle layer. The resultant stasis increases the likelihood for infection and stone formation within
diverticula and also leads to a higher risk for malignancy compared to the rest of the bladder. Access to
diverticular TCCs for diagnostic and therapeutic
transurethral resection via a narrow neck can be
challenging. The lack of overlying muscle also increases the
risk for perforation rendering complete cystoscopic tumor
resection very difficult. Furthermore, the lack of a muscle
layer would theoretically permit tumors to spread into the
perivesicular tissues with more ease.

Yellow arrow points to the urinary bladder collapsed with a
Foley catheter. Orange arrow points to the soft tissue mass
in the bladder diverticulum.
Reference: Raheem OA, Besharatian B, Hickey DP. Surgical management of
bladder transitional cell carcinoma in a vesicular diverticulum: case report.
Can Urol Assoc J 2011;5(4):e60–e64.

45. Answer C. Tissue harmonic imaging is the imaging of the first harmonic frequency, which is twice
the transmitted fundamental frequency. Harmonics are not produced by the probe itself, but
generated within tissue as a result of interaction with the ultrasound beam. Returning signal at the
fundamental frequency is filtered out. Harmonic imaging has a number of benefits as a result of the
harmonic beam profile. The harmonic beam is narrower and has smaller side lobes compared to the
fundamental beam. Hence, both lateral resolution and tissue contrast (signal to noise) are improved.
Because the harmonics are generated within the tissues, the harmonic beams traverse less fat than do
their conventional counterparts and suffer less attenuation. As a result, harmonic imaging can improve
the quality of images obtained from obese patients. However, because adequate harmonic signals are

generated only when the acoustic energy is sufficiently high, the ability to penetrate deeper tissues is
less compared to conventional imaging.
Ultrasound technology update: harmonic imaging. GE Medical Systems, 1997:1–6.

46a. Answer B. Ultrasound images of both kidneys show poor demarcation of the lower poles.
Midline transverse images show a homogeneous hypoechoic band of tissue anterior to the abdominal
aorta and IVC. These findings together confirm the diagnosis of horseshoe kidney.
Horseshoe kidney is the most common congenital renal fusion anomaly. Horseshoe kidneys occur
when metanephrogenic blastema fuse prior to ascent. Most horseshoe kidneys are fused at the lower
pole. The isthmus is composed of functioning renal tissue in the majority of the cases and less
commonly made up of fibrous tissue. The horseshoe kidney is anterior to the abdominal great vessels
and derives its blood supply from the aorta and other regional vessels, such as inferior mesenteric,
common iliac, internal iliac, and external iliac arteries. Patients are predisposed to urinary obstruction
and stone formation and are at increased risk of renal trauma. There is also an increased risk of Wilms
tumor.

46b. Answer A. Horseshoe kidneys are usually lower than normal and the lower poles project
medially. The isthmus is an impediment to normal rotation and upward ascent as it encounters the
inferior mesenteric artery.
There is no association with retroperitoneal fibrosis (choice B). The horseshoe kidneys typically have
multiple renal arteries, which may arise from the aorta, the common iliac arteries, the internal iliac
arteries, or the inferior mesenteric artery (choice C). Although the renal pelves are abnormally rotated,
they are not the contributing factor for arrest of normal ascent (choice D).
Rumack CM, Wilson SR, Charboneau JW, et al. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Mosby, 2005:324.

47. Answer D. Ultrasound image demonstrates an enlarged right kidney with high‐amplitude,
nondependent echoes within the renal parenchyma. The echogenic foci have posterior “dirty
shadowing” suggestive of presence of gas. The findings are consistent with emphysematous
pyelonephritis.
Emphysematous pyelonephritis is a life‐threatening necrotizing infection of the kidneys characterized
by gas formation within or surrounding the kidneys. The majority (~90%) of patients have poorly
controlled diabetes. Nondiabetic patients either are typically immunocompromised or have associated
urinary tract obstruction secondary to urinary calculi, neoplasm, or sloughed papilla. Most patients
complain of fevers, chills, flank or abdominal pain, nausea, and vomiting. The most commonly
identified organisms are E coli, Klebsiella pneumoniae, and P. mirabilis. Candida is a rare cause.
Laboratory testing usually reveals hyperglycemia, leukocytosis, elevated serum creatinine, and pyuria.
Emphysematous pyelonephritis is seen more commonly in women than men.
Prompt diagnosis and treatment are necessary because of associated high morbidity and mortality. In
the past, treatment of emphysematous pyelonephritis usually involved nephrectomy or open drainage
along with systemic antibiotics. However, there has recently been a shift toward a nephron‐sparing
approach, including percutaneous drainage and antibiotic therapy with or without elective
nephrectomy at a later stage.
References: Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic‐pathologic review. Radiographics 2008;28(1):255–276.
Hammond NA, Nikolaidis P, Miller FH. Infectious and inflammatory diseases of the kidney. Radiol Clin North Am 2012;50(2):259–
270.

Weintrob AC, Sexton DJ. Emphysematous urinary tract infections.

48. Answer D. The patient has developed hydronephrosis containing low‐level echoes and multiple
rounded echogenic lesions within right renal collecting system. The rounded calyceal lesions are
highly concerning for fungal balls. The low‐level echoes are concerning for additional debris within the
urine, potentially representing pyonephrosis. The other differential consideration would be blood
clots. Although upper urinary tract urothelial tumor could have a similar appearance, this would be
unlikely given the recent normal ultrasound. These do not have the appearance of calculi as they do
not shadow.
Because of the possibility of pyonephrosis and fungal balls in the setting of a ureteral obstruction, the
first priority is to decompress the collecting system with a nephrostomy tube or by replacing the
ureteral stent. Once access to the renal collecting system is achieved, a specimen can be obtained.
Systemic antifungal therapy should be administered, and local antifungal therapy can also be given. A
nephrostomy tube may also provide access for direct extraction of fungal balls.
Fungal infection of the urinary tract can occur as a result of hematogenous dissemination or by
ascending infection. The most common fungal organism to affect the urinary tract is Candida albicans.
Risk factors include diabetes mellitus, chronic indwelling catheters, malignancy, chronic antibiotic or
steroid therapy, immunosuppressive therapy, and IV drug abuse.
References: Praz V, Burruni R, Meid F, et al. Fungal ball in urinary tract, a rare entity, which needs a specific approach. Can Urol
Assoc J 2014;8(1–2):e118–e120.

49a. Answer D. A large solid mass within the upper pole centered within the renal sinus is
concerning for a malignant lesion within the collecting system. The differential diagnosis for lesions
within the collecting system includes blood clots, fungus balls, fibroepithelial polyps, malakoplakia,
and calculi. An exophytic renal cell carcinoma protruding into the renal sinus could also have this
appearance. The most common urothelial tumor is transitional cell carcinoma (90%), followed by
squamous cell carcinoma and adenocarcinoma. Transitional cell carcinomas (TCCs) are divided into
papillary and nonpapillary. Papillary lesions are exophytic polypoid tumors with a stalk. These tend to
be slower growing and develop metastases later. Nonpapillary lesions are sessile lesions that are
usually high grade and infiltrating at presentation. They are often more difficult to detect on imaging.

49b. Answer C. Although the mass is detectable on ultrasound, further imaging is necessary to
confirm the presence of tissue enhancement expected in a neoplasm. Absence of enhancement may
allow for a diagnosis of blood clot or fungus ball. Additionally, a CT urogram helps distinguish between
a renal cell carcinoma and a urothelial neoplasm, by delineating the relationship of the mass to the
renal collecting system. After all, the incidence of renal cell carcinoma (RCC) is five to ten times higher
than TCC, so many centrally located renal masses are RCCs. Additionally, TCCs have a so‐called field
effect in which the presence of one transitional cell carcinoma indicates an increased risk for
malignancy for the entire urothelium. Therefore, further imaging is necessary to identify synchronous
tumors to guide potential surgery. CT is also superior to ultrasound for tumor staging.

49c. Answer A. Invasion of the renal vein by TCC is rare, so the presence of tumor thrombus would
strongly favor a renal cell carcinoma. Both centrally located RCC and TCC can obstruct the collecting
system and lead to hydronephrosis. Both tumors have a propensity for nodal metastases. The presence
of intralesional Doppler flow is helpful to confirm a solid mass but does not allow distinction between
RCC and TCC. Additionally, the absence of Doppler flow does not exclude the possibility of a solid
neoplasm when there is slow flow.

50a. Answer B. The image shows echogenic thrombus expanding the inferior vena cava. Thrombus
that expands the IVC is concerning for tumor thrombus. The presence of internal Doppler waveforms
is diagnostic of tumor thrombus. The most common causes for caval tumor thrombus are renal cell
carcinoma, hepatocellular carcinoma, and primary adrenal carcinoma. Although leiomyosarcoma is the
most common primary IVC tumor, it is rarely encountered compared to the other causes of tumor
thrombus.

50b. Answer D. Images demonstrate a suprarenal mixed solid and cystic mass at the expected
location of the right adrenal gland. In light of the large mass size, complex solid and cystic appearance
and findings suggesting caval tumor thrombus, findings are highly concerning for an adrenal cortical
carcinoma. Plasma free metanephrines and normetanephrines have the highest sensitivity and
specificity (97% to 100% and 85% to 89%, respectively) and are considered to be the best initial
screening test for pheochromocytoma. Pheochromocytoma must be ruled out biochemically prior to
an adrenal biopsy because of the risk of fatal hypertensive crisis during fine needle aspiration.
2011:439.
Zeiger M, Thompson G, Duh Q‐Y, et al. American association of clinical endocrinologists and American association of endocrine
surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract 2009;15(Suppl 1):1–20.

51. Answer A. In spatial compound imaging, multiple parallel ultrasound beams oriented in different
directions are averaged together to make a single image. This technique results in decreased image
speckle and noise but can also decrease posterior acoustic shadowing and posterior acoustic
enhancement.
Tissue harmonic imaging, a method that improves the signal‐to‐noise ratio of ultrasound images by
reducing artifacts, works by using returning echoes at twice the fundamental frequency of the
transmitted echo to generate the image. Increasing the overall gain is a postprocessing function that
would increase the brightness of the image. Ultrasound elastography displays the relative stiffness of
tissues.
Reference: Hangiandreou NJ. AAPM/RSNA physics tutorial for residents: topics in US. Radiographics 2003;23(4):1019–1033.

52. Answer C. The ultrasound images show power Doppler imaging of the renal artery. Power
Doppler imaging estimates the power of the Doppler signal rather than the mean frequency shift.
Because frequency shift data are not displayed, there is no aliasing. The power of the signal is not
affected by the Doppler angle. In power Doppler, noise is assigned a homogeneous background color
that does not greatly interfere with the image. This allows for the use of higher gain settings and
increased sensitivity for flow detection.

53a. Answer A. This is a large complex mass containing heterogeneous echogenic contents. Posterior
acoustic enhancement suggests a cystic lesion. Because of no detectable flow, a solid component
cannot be confirmed to indicate a cystic renal cell carcinoma. The differential diagnosis includes a
complex cyst such as a hemorrhagic cyst or abscess and cystic renal cell carcinoma. Further imaging
with a contrast‐enhanced study is necessary to determine if a solid component is present and to direct
appropriate management. Although a subset of complex cystic lesions can be followed, this is only
done after they are characterized as Bosniak IIF with CT or MRI.

53b. Answer B. Gray‐scale images (left) show the large complex cystic renal mass. Microbubble
contrast‐specific sequence (right) shows curvilinear enhancement of solid tissue along the deep wall
of the cyst, confirming a cystic renal cell carcinoma. Contrast‐enhanced US has been shown to have a
very high sensitivity and specificity for characterizing indeterminate renal masses, allowing for lesion
classification with a very high level of certainty. Contrast‐enhanced US is helpful for identifying
perfusion that may be too minimal to detect by MRI or CT because of blending of enhancement with
surrounding normal tissue. Microbubble contrast‐specific ultrasound settings suppress background
tissue, resulting in higher sensitivity for detection of flow within hypovascular tumors.
References: Barr RG, Peterson C, Hindi A. Evaluation of indeterminate renal masses with contrast‐enhanced US: a diagnostic
performance study. Radiology 2014;271(1):133–142.
Tamai HT, Takiguchi Y, Oka M, et al. Contrast‐enhanced ultrasonography in the diagnosis of solid renal tumors. J Ultrasound Med
2005;24(12):1635–1640.

54. Answer D. A centrally located heterogeneous infiltrative solid tissue replaces renal sinus fat and
extends into the renal parenchyma with ill‐defined nonencapsulated margins. The starred structure
does not have the appearance of a column of Bertin, as it is of heterogeneous echotexture unlike that of
the renal cortex. Additionally, a column would not have a mass‐like configuration on the sagittal image.
It has an elongated tubular configuration that contains color Doppler signal suggesting tumor within
either the collecting system or
renal vein. The sagittal image
also shows a dilated upper pole
calyx. A contrast‐enhanced CT
image shows the infiltrative
tumor extending into the renal
vein. Based on imaging, a
urothelial carcinoma was
suspected, but pathology
revealed an infiltrative renal
cell carcinoma with
sarcomatoid features.

2011:348–356.

3. Identification of which of the following imaging features in a cervical lymph node would be
concerning for malignancy?
A. Round shape
B. 6 mm short‐axis diameter
C. Hyperechoic hilum
D. Hilar vessels

4. According to both the 2005 Society of Radiologists in
Ultrasound (SRU) consensus statement and 2015
American Thyroid Association (ATA) guidelines, what is
the next best step in management for the 1.6 cm thyroid
lesion shown?

A. Fine needle aspiration
B. MRI for further characterization
C. PET‐CT
D. No additional management required

5a. The American College of Radiology formed an Incidental Thyroid Findings Committee on
managing incidental thyroid nodules (ITNs) detected on imaging in 2013. According to the guidelines
published in February 2015, incidentally detected thyroid nodules on CT, MRI, and extra thyroid
ultrasound (such as carotid Doppler) without suspicious features in the general population are
stratified based on which two main criteria?
A. Clinical symptoms and patient sex
B. Patient age and thyroid nodule size
C. The shape and number of nodules
D. Risk stratification and nodule appearance

5b. A 41‐year‐old man undergoes a chest CT pulmonary angiogram for shortness of breath where a
1.2‐cm incidental hypoattenuating nodule was found confined to the right thyroid lobe. Visualized
lymph nodes at the base of the neck measured <8 mm in short axis. According to the white paper on
incidentally detected thyroid nodules mentioned above, what would be the most appropriate next step
in management?
A. Recommend further evaluation with thyroid ultrasound.
B. Recommend further evaluation with thyroid ultrasound and ultrasound‐guided biopsy.
C. Recommend referral to an endocrinologist.
D. No further evaluation is recommended.

6a. A 35‐year‐old otherwise healthy female was referred
for ultrasound after her thyroid was noted to be diffusely
enlarged on physical exam and thyroid function tests
were abnormal. After reviewing her ultrasound and
further questioning, she reports weight gain and
constipation. The most likely diagnosis is:
A. Multinodular goiter
B. Graves disease
C. Radiation/radioiodine‐induced hypothyroidism
D. Hashimoto thyroiditis
E. de Quervain (subacute granulomatous) thyroiditis

6b. Hashimoto thyroiditis is associated with an increased incidence of what type of malignancy?
A. Anaplastic thyroid carcinoma
B. Medullary thyroid carcinoma
C. Non‐Hodgkin thyroid lymphoma
D. Metastatic disease to the thyroid

7. A 46‐year‐old woman with painless swelling of both parotid
glands and dry mouth was referred for neck ultrasound. After
reviewing her ultrasound, the most likely diagnosis is:

A. HIV‐related lymphoepithelial cysts
B. Sjögren syndrome
C. Warthin tumor
D. Pleomorphic adenoma

8a. An 18‐year‐old woman presented to her family physician with neck swelling. Images from the
thyroid ultrasound and the lateral compartment lymph nodes are provided. What are the most likely
diagnosis and appropriate management?

A. Multinodular goiter; follow‐
up ultrasound in 1 year.
B. Multiple colloid cysts
throughout the thyroid; no
further follow‐up indicated.
C. Diffuse sclerosing variant of
papillary thyroid carcinoma;
biopsy followed by total
thyroidectomy and cervical lymph node dissection.
D. Diffuse metastatic disease to the thyroid; further imaging of
the chest, abdomen, and pelvis with CT is recommended to identify a primary malignancy.
E. Chronic lymphocytic thyroiditis; thyroid function tests and supplementation with Synthroid if
indicated.

8b. Which of the sonographic features listed below is most likely to be associated with a benign
thyroid nodule?
A. Spiculated or lobulated nodule margin
B. Microcalcifications
C. Taller‐than‐wide shape
D. Extension beyond the thyroid capsule
E. Spongiform composition

9a. A middle‐aged male with hyperparathyroidism underwent ultrasound and technetium‐99m
sestamibi scan. What is the most likely cause of this sonographic abnormality?

A. Renal failure
B. Parathyroid
carcinoma
C. Parathyromatosis
D. Thyroid
carcinoma

9b. After parathyroidectomy, what is the most common cause of persistent or recurrent
hyperparathyroidism?
A. Missed parathyroid tissue in normal position during previous surgery
B. Regrowth of resected tumor
C. Recurrent parathyroid cancer
D. Hyperfunctioning ectopic parathyroid tissue

10a. After a recent upper respiratory tract infection, a middle‐aged woman presents with anterior
neck pain, weight loss, lid lag, and sinus tachycardia to her physician who orders a thyroid ultrasound
(Figs. 1 and 2). Three weeks later, the neck pain spreads, and a repeat ultrasound (shown here) was
performed (Fig. 3). What is the most likely diagnosis?
A. De Quervain thyroiditis
B. Graves disease
C. Thyroid cancer
D. Thyroid lymphoma

10b. What would an iodine‐123 thyroid scan be expected to show in the early phase of subacute
thyroiditis?
A. Decreased thyroid uptake of radioactive iodine
B. Increased thyroid uptake of radioactive iodine
C. Normal thyroid uptake of radioactive iodine

11. A patient with thyromegaly and hyperparathyroidism is undergoing ultrasound. Images initially
obtained with a high‐frequency 15 MHz transducer only show the superficial aspect of a vague
hypoechoic nodule deep to the right midpole with poor color Doppler flow. What could the ultrasound
technologist do to improve both depth penetration and color Doppler sensitivity of the potential
parathyroid adenoma?
A. Switch to a lower‐frequency transducer.
B. Increase the wall filter.
C. Turn on spatial compounding.
D. Increase color Doppler gain.

12. A thyroid nodule shown here was detected in a young woman being evaluated for a palpable
thyroid nodule. What is the abnormality and the clinical significance of the finding shown by the
arrow?
A. Tissue vibration that occurs in stiff nodules because of adjacent
turbulent high‐velocity flow in the carotid artery in patients with
high‐grade carotid artery stenosis
B. Refractive edge shadowing that occurs at the junction of tissues
with different sound‐propagating speeds increasing the likelihood
that a nodule is malignant
C. Acoustic streaming at the edge of the nodule caused by tissue
heating from high‐energy sound waves
D. Capsular washout in thyroid nodules after microbubble infusion,
which has been associated with an increased risk of malignancy

13. The ultrasound technologist is concerned about an abnormality on the thyroid images he obtained
in a young patient who sustained blunt trauma to the neck. After reviewing the image provided, the
most likely cause for this abnormality and the best course of action are which of the following?

A. Malfunction of a transducer crystal has occurred, and
additional images should be obtained after the
sonographer replaces the transducer.
B. The finding is suspicious for a thyroid hematoma, and
a neck CT should be recommended for further
evaluation.
C. An artifact called focal zone banding is present, and
repeat images can be obtained after the number of focal
zones is reduced.
D. The appearance is due to poor transducer contact
with the skin, and repeat images can be obtained after more sonographic gel is applied.

14. A 65‐year‐old male presenting with a neck mass and left clavicular pain had the following images
obtained. Which of the sonographic findings shown below is the most important?

A. The irregular margin of the thyroid nodule
B. The lesion in the clavicle
C. The size of the thyroid nodule
D. The solid and hypoechoic nodule consistency

15. In the Just Culture Model proposed by David Marx, the response to an error or near miss is
determined by the cause of the error and not the severity of the event. In this environment, at‐risk
behavior is managed through:
A. Remedial action
B. Consolement
C. Creating incentives for better choices
D. Punitive means

16. A 37‐year‐old female presents with a painless palpable nodule anterior to the right ear. What is
the most likely diagnosis?

A. Warthin tumor
B. Adenoid cystic carcinoma
C. Mucoepidermoid
carcinoma
D. Pleomorphic adenoma

17. Which of the parameters listed on the
ultrasound display shown indicates the risk of
tissue heating during this ultrasound study?

A. TIS
B. TIB
C. MI
D. THI

18. A 52‐year‐old male presents for ultrasound‐guided fine needle aspiration biopsy of a painless
right neck lump. Which of the following is most likely to be present in the fine needle aspirate?

A. Malignant cells
B. Mycobacterium
tuberculous
lymphadenitis
C. Colloid
D. Hemosiderin‐laden
macrophages

Neck: Answers and Explanations

1a. Answer B. Thyroglossal duct cyst (TDC) is the most common congenital neck mass. It is located in
the midline (75%) or slightly off midline (25%) in the anterior neck. Most TDCs are located either at
the level of (15%) or immediately below (65%) the hyoid bone. They most commonly present as a
gradually enlarging painless mass in the midline of the neck in children or young adults. An
uncomplicated TDC may appear as an anechoic, well‐circumscribed cyst with increased through
transmission or can be pseudosolid in appearance with homogenous low‐level internal echoes because
of the presence of proteinaceous fluid content, cholesterol crystals, and keratin. TDCs with previous
infection or hemorrhage may appear as heterogeneous complex cysts with internal echoes.
The 2nd branchial cleft cyst (BCC) usually presents as a cystic neck mass posterolateral to the
submandibular gland, lateral to carotid space, and anterior to sternocleidomastoid. Most 2nd BCCs are
at or immediately caudal to the angle of mandible. A suppurative lymph node usually presents as a
painful neck mass with skin erythema, fever, poor oral intake, and elevated white blood cell count.
Cystic nodal metastases are most commonly from squamous carcinoma of the upper aerodigestive
tract and papillary carcinoma of the thyroid. The nodes are often multiple and on ultrasound usually
show a solid component with abnormal vascularity.

1b. Answer B. The presence of a normal thyroid gland should be confirmed during a preoperative
ultrasound of a TDC because if the ectopic thyroid tissue in a TDC is the patient’s only functioning
thyroid tissue, then a resection of the ectopic thyroid with the cyst will cause hypothyroidism.
Preoperative identification of normal thyroid gland on ultrasound is sufficient to exclude the diagnosis
of ectopic thyroid tissue and helps to avoid thyroid scintigraphy, which should be minimized, if
possible, especially in pediatric patients.
The presence of a solid vascular component in a TDC should raise the suspicion of thyroglossal duct
carcinoma. Fine needle aspiration (FNA) can be performed to confirm the diagnosis preoperatively.
Thyroglossal duct carcinoma is an uncommon complication of TDC, occurring in <1% of cases.
References: Ahuja AT, Wong KT, King AD, et al. Imaging for thyroglossal duct cyst: the bare essentials. Clin Radiol
2005;60(2):141–148.
Kutuya N, Kurosaki Y. Sonographic assessment of thyroglossal duct cysts in children. J Ultrasound Med 2008;27(8):1211–1219.

2. Answer B. Comet‐tail artifact is a form of reverberation artifact. Identification of a prominent (>1
mm) comet‐tail artifact posterior to a linear echo within a thyroid nodule is a key imaging feature of
colloid. An article by Malhi et al. showed that small (<1 mm) comet‐tail artifacts may be seen posterior
to echogenic foci in malignant nodules.
Acoustic shadowing is produced distal to a highly attenuating object such as a calcification.
Microcalcifications in thyroid nodules are often too small to produce a posterior acoustic shadow.
Increased through transmission occurs posterior to a weakly attenuating material. Whereas increased
through transmission may be seen posterior to a colloid cyst, it would not be expected to be seen
posterior to an echogenic focus of colloid. Refraction artifact occurs when the ultrasound beam travels
through two adjacent materials with different inherent sound propagation velocities. This artifact
results in misplacement of objects on the image.
References: Feldman MK, Katyal S, Blackwood MS. US artifacts. RadioGraphics 2009;29(4):1179–1189.
Frates MC, Benson CB, Charboneau JW, et al. Management of thyroid nodules detected at US: Society of Radiologists in ultrasound
consensus conference statement 1. Radiology 2005;237(3):794–800.

Malhi H, Beland MD, Cen SY, et al. Echogenic foci in thyroid nodules: significance of posterior acoustic artifacts. AJR Am J
Roentgenol 2014;203(6):1310–1316.

3. Answer A. Benign or reactive cervical lymph nodes tend to have an oval shape whereas malignant
lymph nodes tend to be round with a short‐axis‐to‐long‐axis ratio >0.5. There is no consensus for a
cutoff short‐axis diameter for cervical lymph nodes. Both malignant and reactive lymph nodes may
become enlarged. An echogenic hilum that is contiguous with the surrounding perinodal fat is
considered a benign appearance. An echogenic hilum may not be seen in smaller lymph nodes <5 mm.
Occasionally, malignant nodes will have an echogenic hilum, so this feature should not be considered
diagnostic of a benign lymph node in and of itself. Hilar vessels are expected in benign or reactive
lymph nodes. Malignant lymph nodes may show peripheral vascularity.
Reference: Ying M, Bhatia KSS, Lee YP, et al. Review of ultrasonography of malignant neck nodes: greyscale, Doppler, contrast
enhancement and elastography. Cancer Imaging 2013;13(4):658–669.

4. Answer D. This lesion is anechoic with posterior acoustic enhancement, which tells us that the
lesion is cystic, a benign pattern. There is no solid or nodular component. According to both SRU
consensus statement and 2015 ATA guidelines, fine needle aspiration is not necessary for entirely
cystic lesions. MRI and PET‐CT do not play a role in further characterization of thyroid nodules.
References: Frates MC, Benson CB, Charboneau JW, et al. Management of thyroid nodules detected at US: Society of Radiologists in
ultrasound consensus conference statement 1. Radiology 2005;237(3):794–800.
Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with
Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid
Nodules and Differentiated Thyroid Cancer. Thyroid 2016;26(1):1–133.

5a. Answer B. The American College of Radiology formed the Incidental Thyroid Findings Committee
to provide guidance on managing thyroid nodules detected on medical imaging (other than dedicated
thyroid ultrasound) that were previously unsuspected. The committee recommendations were
published in a white paper in February 2015. The goals of the committee were to determine which
incidentally detected thyroid nodules should undergo thyroid ultrasound, to reduce the costs and risks
associated with follow‐up ultrasound and thyroid FNA (fine needle aspiration), and to achieve
consistency in reporting and managing of incidental thyroid nodules and providing guidance to
radiologists who are concerned about not reporting or recommending additional workup for
incidental thyroid nodules that later prove to be clinically important.
It is known that thyroid nodules are very common, found in up to 50% of patients without clinical
history of thyroid disease, and majority of these nodules are multiple. Up to 25% of patients will have
an incidentally detected thyroid nodule when undergoing CT and MRI studies (which include the
thyroid). Malignancy rates vary based on how the nodule was detected. In large population‐based
studies, most incidentally detected thyroid nodules on ultrasound are found to be benign (the
malignancy rate was 1.6% in patients with 1 or more nodules). On the other hand, when the nodule
presents with focal uptake on 18FDG‐PET scans, as many as 33% to 35% are malignant. Although
autopsy studies have shown that the background rate of papillary thyroid cancer is as high as 36% of
thyroid glands, most are well‐differentiated small (<1 cm) papillary thyroid carcinomas with an
excellent prognosis. Other studies showed that thyroid cancers <2 cm also have an indolent course,
with 99.9% 10‐year survival rates.
A 3‐tiered system was adopted from Duke to guide the evaluation of incidentally detected thyroid
nodules based on the patient’s age and imaging findings. With this system, further evaluation with
thyroid ultrasound is considered for three groups: (1) nodules with certain imaging features
associated with high risk (suspicious adenopathy, local invasion, and PET avidity), (2) nodules ≥1 cm

in patients age <35 years, and (3) nodules ≥ to 1.5 cm in patients age ≥35 years of age. Studies have
shown that the application of these criteria could decrease the rate of thyroid ultrasound
recommendations by about 46% (compared to a 1‐cm size cutoff) and decrease the rate of ultrasound‐
guided biopsies by 35%. The 3‐tiered system has a 13% false‐negative rate, but when including all
thyroid cancers, this accounts for only 1.2% of all thyroid malignancies.
References: Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of
the ACR incidental thyroid findings committee. J Am Coll Radiol 2015;12(2):143–150.

5b. Answer D. According to the white paper on incidentally detected thyroid nodules proposed by
the Incidental Thyroid Findings Committee, in patients within the general population with normal life
expectancy and without suspicious imaging findings, it is the patient age and nodule size that
determine the need for additional workup. Further workup with thyroid ultrasound is recommended
for patients <35 years old with incidentally detected nodules measuring ≥1 cm in the axial plane. For
patients age 35 or older, the size cutoff for further evaluation is raised to 1.5 cm. In this scenario,
because the patient is above 35 years of age and the nodule measures under 1.5 cm, no further workup
is recommended. Patients with limited life expectancy and comorbidities do not need further
evaluation of incidental thyroid nodules unless it is warranted clinically or requested by the patient or
referring physician. The need for nodule biopsy is based on results of the thyroid ultrasound unless
the nodule is found to be 18FDG‐PET avid in which case a biopsy is recommended regardless of the
ultrasound appearance in patients with a normal life expectancy.
Reference: Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the
ACR incidental thyroid findings committee. J Am Coll Radiol 2015;12(2):143–150.

6a. Answer D. The ultrasound image reveals an enlarged, heterogenous thyroid lobe with
innumerable small hypoechoic foci termed micronodulation very characteristic of Hashimoto
thyroiditis (HT). Micronodulation is a highly sensitive sign of HT. It is caused by thyroid gland
infiltration and destruction of thyroid follicles by lymphocytes and plasma cells. An associated fibrotic
reaction then creates the appearance of echogenic bands in the gland in more advanced disease. Other
sonographic features often present are central compartment adenopathy (usually inferior to the
thyroid gland) and nodular contour of the thyroid gland. Vascularity of the thyroid is variable, but is
often increased.
HT is the most common cause of hypothyroidism in the United States. The onset of hypothyroidism
symptoms is often insidious including fatigue, dry skin, weight gain, and constipation. The condition,
as with other causes of thyroiditis, has a strong female predominance, presenting in young to middle‐
aged women with painless thyromegaly. Serology usually confirms positive autoantibodies to anti‐TPO
(antithyroid peroxidase) and anti‐Tg (antithyroglobulin).
Graves disease is an autoimmune disease of the thyroid gland also often associated with thyromegaly,
parenchymal coarsening, and diffuse hypoechogenicity due to the presence of large intraparenchymal
vessels and lymphocytic infiltration. Unlike in HT, the patients are hyperthyroid. The marked thyroid
hypervascularity that is seen in Graves’ on color Doppler has been termed “thyroid inferno.”
Micronodulation is not typical of Graves disease. Radiation‐induced hypothyroidism is incorrect
because the thyroid is usually small and is preceded by a history of radioiodine ablation or external
beam. de Quervain thyroiditis is a type of subacute thyroiditis that typically presents with painful,
hypoechoic, hypovascular lesions in the thyroid that can appear mass‐like or diffuse. The condition is
accompanied by hyperthyroidism at first, followed by a hypothyroid interval before returning to
normal.

Sholosh B, Borhani AA. Thyroid ultrasound part 1: technique and diffuse disease. Radiol Clin North Am 2011;49(3):391–416.

6b. Answer C. Primary thyroid lymphoma is a rare cause of malignancy accounting for <5% of
thyroid malignancies. Most thyroid lymphomas are non‐Hodgkin lymphoma type, arising de novo in a
patient with preexisting Hashimoto thyroiditis or secondarily involving the thyroid in generalized
lymphoma. Patients with Hashimoto thyroiditis have a relative risk of 67 of developing primary
thyroid lymphoma. The transformation from Hashimoto thyroiditis to primary thyroid lymphoma
occurs in about 0.5% of cases. Although most patients with thyroiditis do not proceed to lymphoma,
most cases of primary thyroid lymphoma do arise in a background of thyroiditis, which accounts for
approximately 60% to 90% thyroid lymphoma cases.
Thyroid lymphoma typically presents in older patients with a rapidly enlarging neck mass and
obstructive symptoms such as dysphagia and dyspnea. On ultrasound, lymphomatous tissue will
appear as large, solid, very hypoechoic pseudocystic masses. Posterior acoustic enhancement of the
lesion is useful in suggesting the diagnosis. The diagnosis is established and distinguished from
anaplastic thyroid carcinoma with fine needle aspiration biopsy and flow cytometry.
2011:724–726.
Stein SA, Wartofsky L. Primary thyroid lymphoma: a clinical review. J Clin Endocrinol Metab 2013;98:3131–3138.

7. Answer B. The ultrasound image shows an enlarged, diffusely coarsened and heterogenous
appearance of the parotid gland with innumerable small 2 to 3 mm hypoechoic lesions. These
hypoechoic lesions represent areas of nonobstructive sialectasis that can be seen on sialography.
These sonographic findings are characteristic of Sjögren syndrome, an autoimmune disease that
causes chronic inflammation of joints, salivary glands, and lacrimal glands resulting in gland
enlargement and dysfunction. Patients experience dry mucous membranes (dry mouth and dry eyes).
The condition is more common in women and involves the parotid gland more frequently than it does
the submandibular gland. In early stages, the parotid gland may appear normal on ultrasound. End‐
stage disease is characterized by gland atrophy. Ultrasound is used to monitor patients for
development of lymphoma, for which they are prone.
The differential diagnosis for the ultrasound appearance includes sarcoidosis, acute sialadenitis, and
granulomatous sialadenitis, which can cause diffuse heterogenous enlargement of the parotid glands,
but without numerous small hypoechoic foci associated with Sjögren disease. Acute sialadenitis is
painful and can be associated with clinical signs of infection, abscess formation, or calculus formation,
which can be readily identified on sonography.
Lymphoepithelial cysts, Warthin tumor, and pleomorphic adenoma are benign entities that present as
focal parotid lesions. Lymphoepithelial cysts present as multiple cysts in those affected with human
immunodeficiency virus infection. On ultrasound, Warthin tumor and the more common pleomorphic
adenoma present as circumscribed hypoechoic lesions with posterior acoustic enhancement. Both can
show internal cystic change and septations. Warthin tumors are multiple or bilateral in 10% to 15% of
patients.
Howlett DC. High resolution ultrasound assessment of the parotid gland. Br J Radiol 2014;76:271–277.
Onkar PM, Ratnaparkhi C, Mitra K. High‐frequency ultrasound in parotid gland disease. Ultrasound Q 2013;29(4):313–321.

8a. Answer C. The ultrasound reveals diffuse parenchymal microcalcifications throughout a mildly
diffusely enlarged thyroid gland without a focal or dominant mass, typical of this more aggressive
subtype of papillary thyroid cancer. Associated malignant‐appearing cervical lymphadenopathy
indicates the more aggressive nature of this disease.
Diffuse sclerosing variant of papillary thyroid carcinoma is an uncommon, more aggressive variant of
papillary thyroid carcinoma. The thyroid cancer is manifested by numerous microcalcifications
infiltrating the gland in a diffuse or regional pattern without forming a dominant mass. Pathologically,
the gland reveals extensive fibrosis and numerous psammoma bodies. It is more common in females
and affects younger patients, even in the pediatric population. This variant has a higher incidence of
lymph node metastases but has a similar prognosis to conventional papillary thyroid carcinoma due to
aggressive treatment protocols. Biopsy should be directed to an area containing microcalcifications
and lymphadenopathy.
Multinodular goiter (choice A) is incorrect because there are no focal thyroid nodules. The typical
appearance seen in multinodular goiter is that of multiple closely apposed solid nodules without
normal intervening thyroid parenchyma.
Although differentiating tiny, bright, nonshadowing foci of microcalcifications from colloid crystals can
be difficult, the lack of surrounding cystic spaces (which are often perceived with high‐resolution
transducers) and comet‐tail artifact suggest the presence of microcalcifications. Choice B is incorrect.
Psammoma bodies, which correspond to the microcalcifications seen on ultrasound, represent the
most important and specific feature of papillary thyroid cancer. Cervical adenopathy will be absent in
the presence of benign colloid cysts.
Metastatic disease to the thyroid is quite rare and would not show microcalcifications (Choice D). On
ultrasound, metastases usually appear as solid hypoechoic nodule(s) or can diffusely replace the
thyroid gland. Adenopathy can be present. Patients usually have a known diagnosis of malignancy at
the time thyroid metastases are discovered because these often occur late in the disease process.
Renal cell carcinoma is the most common malignancy to metastasize to the thyroid.
Chronic lymphocytic thyroiditis can cause thyromegaly and a heterogeneous, coarsened appearance of
the parenchyma but is not associated with microcalcifications. Mild cervical adenopathy is
characteristic, but the nodes are not frankly malignant appearing; usually, multiple mildly enlarged
hypoechoic lymph nodes are located in the central compartment below the thyroid gland. Choice E is
incorrect.
References: Oyedeji F, Giampoli E, Ginat D, et al. The sonographic appearance of benign and malignant thyroid diseases and their
histopathology correlate. Ultrasound Q 2013;29:161–178.
Pillai S, Gopalan V, Smith RA, et al. Diffuse sclerosing variant of papillary thyroid carcinoma—an update of its clinicopathological
features and molecular biology. Crit Rev Oncol Hematol 2015;94(1):64–73.

8b. Answer E. Spongiform composition refers to the replacement of at least 50% of an isoechoic
nodule by microcysts with intervening septa, resembling a sponge or honeycomb. Nodules with this
appearance are benign with a very high specificity (99.7% to 100%). On histopathology, they
represent colloid or hyperplastic nodules.
Most thyroid cancers are well differentiated, with papillary cancer being the most common thyroid
malignancy, constituting 75% to 90% of all cases. Various sonographic features of thyroid cancer have
been studied to help triage nodules for FNA biopsy by distinguishing suspicious from benign nodules.
The sonographic features that are most specific for malignancy include extension beyond the thyroid
capsule, malignant‐appearing adenopathy (especially when lymph nodes contain microcalcifications
or cystic degeneration), and the presence of microcalcifications (up to 95% specific). Other features of
malignancy include solid and hypoechoic composition, marked hypoechogenicity (the nodule is
hypoechoic relative to the strap muscle), thick and incomplete halo, spiculated or lobular margin,

taller‐than‐wide shape, refractive edge shadowing, and interrupted peripheral calcifications. Increased
central intranodular flow on color Doppler and macrocalcifications have also been associated with
increased risk. Strain elastography, which measures nodule stiffness, has also been very promising in
identifying malignant nodules. The more of these suspicious features are present in a given nodule,
the higher the likelihood of malignancy, particularly papillary thyroid carcinoma but also medullary
carcinoma.
Recently, a white paper from the American College of Radiology TI‐RADS committee has proposed
recommendations on risk stratification of thyroid nodules on the basis of their ultrasound appearance.
The basis of the classification system entails assigning numeric points for various sonographic features
of thyroid nodules; the more suspicious the feature, the more points are added to the sum. Nodules
with a total score of at least 3 points are assigned a TI‐RADS level 3 or higher where nodule size
determines corresponding recommendations for FNA biopsy or follow up.
References: Bonavita JA, Mayo J, Babb J, et al. Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules
can be left alone? AJR Am J Roentgenol 2009;193(1):207–213.
Desser TS, Kamaya A. Ultrasound of thyroid nodules. Neuroimag Clin North Am 2008;18(3):463–478.
Moon WJ, Jung SL, Lee JH, et al. Benign and malignant thyroid nodules: US differentiation—multicenter retrospective study 1.
Radiology 2008;247(3):762–770.
Nachiappan AC, Metwalli ZA, Hailey BS, et al. The thyroid: review of imaging features and biopsy techniques with radiologic‐
pathologic correlation. RadioGraphics 2014;34(2):276–293.
Oyedeji F, Giampoli E, Ginat D, et al. The sonographic appearance of benign and malignant thyroid diseases and their
histopathology correlate. Ultrasound Q 2013;29:161–178.
Tessler F, Middleton W, Grant E, et al. ACR Thyroid Imaging, Reporting and Data System (TI‐RADS): White Paper of the ACR TI‐
RADS Committee. J Am Coll Radiol 2017;14(5):587–595.

9a. Answer A. The ultrasound images show four oval hypoechoic nodules, two located deep to the
midgland of both thyroid lobes and two others near the lower poles. The appearance, location, and
delayed retention of radiotracer on technetium‐99m sestamibi scan are characteristic of multigland
parathyroid enlargement. Primary hyperparathyroidism is caused by autonomous production of
parathyroid hormone (PTH) by a single adenoma in 80% to 90% of cases, by multiple gland
enlargement in 10% to 20% cases and carcinoma in <1% of cases. On the contrary, secondary
hyperparathyroidism, as present in this patient, is seen in those with chronic renal failure in which
chronic hypocalcemia leads to compensatory multigland parathyroid hyperplasia. Less common
causes of secondary hyperparathyroidism include osteomalacia, rickets, and malabsorption.
Hyperplasia usually affects all four glands asymmetrically, whereas multiple adenomas may involve
two or possibly three glands. Because distinguishing hyperplasia from adenoma is difficult
pathologically and because the pattern of gland enlargement is inconsistent, when more than one
parathyroid gland is enlarged, it is simply referred to as multiple gland disease.
Parathyroid carcinoma (choice B) is a rare cause of primary hyperparathyroidism that is associated
with higher levels of serum calcium and an enlarged parathyroid gland. Histologic and sonographic
distinction from parathyroid adenoma is difficult, and the diagnosis is usually made by the surgeon
when a firm, adherent parathyroid gland has invasive features or when the postoperative histology
returns with atypia or carcinoma. When parathyroid carcinoma is initially diagnosed, it presents as a
solitary mass, not as multigland enlargement. Sonographic features that raise suspicion of parathyroid
carcinoma include size >2 cm, lobular contour, taller‐than‐wide shape, internal cystic component,
heterogenous internal architecture, and gross invasion of adjacent structures. When these are present,
it is important to notify the surgeon so that an en bloc resection with the ipsilateral thyroid gland can
be performed.
Parathyromatosis (choice C) is an uncommon condition where hyperplasia of preexisting parathyroid
rests are stimulated by the metabolic derangements associated with renal failure (secondary
hyperparathyroidism) or more commonly present with recurrent hyperparathyroidism after spillage

of parathyroid tissue at the time of parathyroidectomy. Growth of the scattered implants in the
anterior or deeper aspect of the neck results in multifocal ectopic parathyroid tissue. They have the
same sonographic appearance of a typical enlarged parathyroid gland, but the location is atypical from
normal parathyroid location. Fine needle aspiration with detectable parathyroid hormone level assay
would be diagnostic. Thyroid carcinoma (choice D) is incorrect, because unlike thyroid cancer, these
hypoechoic nodules are extrathyroid.
References: Johnson NA, Carty SE, Tublin ME. Parathyroid imaging. Radiol Clin North Am 2011;49(3):489–509.
Tublin ME, Yim JH, Carty SE. Recurrent hyperparathyroidism secondary to parathyromatosis clinical and imaging findings. J
Ultrasound Med 2007;26(6):847–851.

9b. Answer D. In one series of 102 patients with persistent or recurrent primary
hyperparathyroidism who underwent reoperation, the most common cause of failed parathyroid
surgery was failure to remove ectopic parathyroid tissue in 53% of the patients. Regrowth of resected
tumor (choice B) was found in only 3% of cases and tissue missed in normal position during previous
surgery (technical failure) occurred in 7% of patients (choice A). Although recurrent or incompletely
resected parathyroid carcinoma (choice C) can cause residual or recurrent hyperparathyroidism,
parathyroid cancer is uncommon (<1% of cases).
Ectopic location of a parathyroid gland is encountered in approximately 3% of patients. The most
common location for ectopic superior parathyroid adenomas is retrotracheal. Other sites of ectopic
parathyroid tissue include the carotid sheath, intrathyroidal, mediastinal, and low neck. Patient
positioning and optimal probe selection and scanning technique are critical for sonographic
localization. Supernumerary parathyroid glands (more than 4) are present in 2% to 9% of individuals.
References: Johnson NA, Carty SE, Tublin ME. Parathyroid imaging. Radiol Clin North Am 2011;49(3):489–509.
Shen W, Düren M, Morita E, et al. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg
1996;131(8):861–869.

10a. Answer A. The sonographic features of progressive hypoechoic, hypovascular patches in the
thyroid gland associated with pain is characteristic of de Quervain thyroiditis. The classic presenting
clinical symptoms include thyrotoxicosis and neck pain following a viral illness. The other options
provided are painless conditions. In Graves disease, in contrast to de Quervain thyroiditis, the thyroid
is usually hypervascular, and involvement is almost always diffuse although both present clinically
with hyperthyroid symptoms. Although thyroid cancer and lymphoma both usually present with focal
hypoechoic lesions, patients are not thyrotoxic. Patients with thyroid lymphoma may develop
compressive symptoms and hypothyroidism with diffuse involvement. The relatively rapid
progression of the thyroid gland involvement is very unusual in differentiated thyroid cancer but can
be relatively rapidly progressive in aggressive thyroid lymphoma. FNA biopsy may be necessary to
exclude malignancy in difficult cases.
De Quervain thyroiditis (subacute granulomatous thyroiditis) is a self‐limited thyroid condition
believed to be caused by a viral‐induced transient autoimmune response lasting weeks to months. It is
associated with a triphasic clinical course characterized by release of preformed thyroid hormone
causing hyperthyroidism because of thyroid follicle destruction, then hypothyroidism once the thyroid
hormone is depleted, and, finally, the return to a euthyroid state once the thyroid follicle regenerates
and thyroid synthesis resumes. De Quervain thyroiditis is the most common cause of a painful thyroid
gland. Clinically, the thyroid can be enlarged, painful to palpation, and associated with fever and
elevated erythrocyte sedimentation rate. The imaging appearance reflects the extent of thyroid
involvement. Sonographically, the gland shows hypoechoic, hypovascular ill‐defined patches due to

thyroid destruction and edema, associated with regional gland enlargement in the initial phase. Short‐
interval follow‐up ultrasound, when performed, can show progression of the hypoechoic patches to
the adjacent parenchyma, contralateral discontinuous involvement, or diffuse thyroid involvement.
Tenderness over the hypoechoic patches strongly suggests this diagnosis in the appropriate clinical
setting.

10b. Answer A. The early phase of subacute thyroiditis is characterized by thyroid destruction and
release of preformed thyroid hormone. An iodine‐123 scan would show markedly decreased tracer
uptake in the thyroid. The differential diagnosis of low uptake on the thyroid scan in a hyperthyroid
patient includes amiodarone toxicity and other causes of subacute thyroiditis such as postpartum
thyroiditis. Differential diagnosis for increased radioiodine uptake in hyperthyroid patients includes
toxic nodular disease and Graves disease.
References: Frates MC, Marqusee E, Benson CB, et al. Subacute granulomatous (de quervain) thyroiditis grayscale and color
Doppler sonographic characteristics. J Ultrasound Med 2013;32(3):505–511.

11. Answer A. Color Doppler sensitivity in the superficial field of view improves with higher‐
frequency transducers but at the cost of reduced penetration. Color Doppler signal for deeper vessels
and structures improves with lower transducer frequencies when the point of interest is at the depth
limit of the image. So, a balance is necessary to optimize color Doppler sensitivity and penetration for
different examinations. Switching to a lower‐frequency transducer, such as a 9‐MHz linear probe, will
improve gray‐scale penetration to both allow improved visualization of the deep parathyroid adenoma
and depict gland hypervascularity.
Increasing the wall filter (choice B) will filter out low‐velocity blood flow causing reduced color
Doppler signal of the deep adenoma. Spatial compounding (choice C), a technique where a single gray‐
scale image is created by averaging signal derived from sound steered at different angles, will improve
the contrast‐to‐noise ratio and may improve conspicuity of the adenoma but have no impact on color
Doppler sensitivity. Increasing color gain (choice D) will improve color Doppler amplification and
accentuate vascularity. Options B, C, and D will not affect depth penetration.

12. Answer B. Refraction occurs at the junction of tissues with different sound‐propagating speeds
resulting in a change in the direction of the sound wave. In tissues like the thyroid gland, refractive
edge shadowing is caused by the oblique angle of the sound beam at the edge of two tissues that have
different sound propagation speeds. The dense fibrous capsule around the periphery of some
papillary thyroid cancers can create this artifact. Sound attenuation posterior to the edge of a solid
nodule caused by this artifact increases the likelihood that a nodule is malignant. In some cases, the
fibrotic tumor composition results in shadowing arising from within the nodule. The other options are
incorrect distractors.
References: Henrichsen TL, Reading CC. Thyroid ultrasonography. Part 2: nodules. Radiol Clin North Am 2011;49(3):417–424.
Reading CC, Charboneau JW, Hay ID, et al. Sonography of thyroid nodules: a “classic pattern” diagnostic approach. Ultrasound Q
2005;21(3):157–165.

13. Answer C. The distinct linear nature of the echogenicity change on the image between the
superficial and deep aspects appears artifactual and should not be confused with pathology. Focal zone
banding artifact is caused by mismatched gain that occurs after pasting together of several individual
images obtained at each of the multiple selected focal zones depths. The artifact can be easily
eliminated by reducing the number of focal zones.
Transducer crystal malfunction (choice A) results in dark bands radiating from the surface of the
transducer, not in the lateral plane. Thyroid hematoma (choice B) is rare and infrequently reported in
the radiology literature, but would not have a linear appearance. Poor transducer to skin contact
(choice D) usually results when there is an inadequate amount of gel. Dark nonanatomic bands
radiating from the transducer surface result.
References: Fontan FP, Hernandez MS, Vazquez SP, et al. Thyroid gland rupture after blunt neck trauma: sonographic and
computed tomographic findings. J Ultrasound Med 2001;20(11):1249–1251.

14. Answer B. Multiple features of the thyroid nodule are worrisome for malignancy. The solid and
uniform consistency of the nodule with hypoechoic halo and lack of microcalcifications can be seen
with a follicular lesion. Nodule hypoechogenicity and focal penetration or invasion of the nodule
capsule by small tumor focus suggests follicular thyroid cancer. The most important imaging finding
in this case is the mass in the ipsilateral clavicle, which turned out to represent metastatic follicular
carcinoma. Mortality due to follicular carcinoma is 20% to 30% at 20 postoperative years, higher than
papillary thyroid cancer.
Follicular carcinomas tend to spread via the bloodstream. Distant metastases to bone, lung, brain, and
liver are more likely than cervical lymphadenopathy. Papillary thyroid cancer, on the other hand,
usually spreads via lymphatics and usually affects nearby draining cervical nodes.
2011:730–732.

15. Answer C. People who engage in at‐risk behaviors, such as “workarounds” of convenience that
undermine established safety precautions are counseled or coached by removing incentives for the
behavior, creating incentives for better choices, and increasing situational awareness. Remedial and
punitive actions are applied to people engaging in reckless behavior (choice A and D). Human errors
are managed by consolement because human error is inevitable and not the result of negligence.
Reference: American Board of Radiology. Diagnostic Radiology: Core Quality and Safety Study Guide. Tucson, AZ: American Board of
Radiology, 2016.

16. Answer D. Gray‐scale and color Doppler images of the right parotid gland show a well‐defined,
hypoechoic lesion with mild internal vascularity and increased through transmission. The most
common tumor of the salivary glands is pleomorphic adenoma and accounts for 70% of all salivary
gland tumors. Pleomorphic adenomas occur most often in the parotid gland and are benign neoplasms.
They contain both epithelial and myoepithelial tissues, with varied histology. They are usually
solitary, unilateral, and slow growing. On ultrasound, they are well‐defined, hypoechoic, lobulated
tumors with posterior acoustic enhancement. They may have mild internal vascularity.
Warthin tumor (choice A) is the next most common benign salivary neoplasm (5% to 10% of all
benign salivary neoplasms). They are usually oval, hypoechoic, well‐defined tumors and often contain
multiple anechoic/cystic areas. They are most likely to be bilateral or multifocal. The most common
malignant neoplasms occurring in salivary glands are mucoepidermoid carcinoma (choice C) and
adenoid cystic carcinoma (choice B), but they are much less common than pleomorphic adenomas.

Malignant tumors tend to be larger, more lobulated, and irregular than benign tumors, but there is
sufficient overlap. Usually, these can be easily biopsied with ultrasound guidance.
References: Bialek EJ, Jakubowski W, Zajkowski P, et al. US of the major salivary glands: anatomy and spatial relationships,
pathologic conditions, and pitfalls. RadioGraphics 2006;26(3):745–763.

17. Answer A. TIS or “thermal index soft tissue” indicates the potential risk of biologic effects from
ultrasound‐induced temperature increase in soft tissues. The TIB indicates the potential risk of
biologic effects from ultrasound‐induced temperature increases in bone. The mechanical index (MI)
indicates the potential risk of biologic effects from ultrasound because of mechanical mechanisms such
as cavitation and radiation pressure. THI stands for “tissue harmonic imaging.”
Reference: Bigelow TA, Church CC, Sandstrom K, et al. The thermal index. J Ultrasound Med 2011;30(5):714–734.

18. Answer A. Gray‐scale and color Doppler images of the right neck show a round cystic/necrotic
mass with internal septations and solid components. In an adult patient, a cystic neck mass is most
concerning for a cystic/necrotic lymph node. These can be seen in the setting of squamous cell cancer
of the head and neck and in papillary thyroid cancer. If there is presence of punctate calcifications
within the solid component of the cystic node, careful search for primary papillary carcinoma in the
thyroid gland should be performed. A common pitfall is to attribute a large cystic neck lesion in an
adult as a branchial cleft cyst. However, because the majority of cystic neck lesions in adult patients
are malignant, the lesion should be considered malignant until proven otherwise.
Mycobacterium tuberculous lymphadenitis (choice B) has a predilection for the posterior triangle of
the neck. On imaging, a necrotic discrete or conglomerate lymph nodal mass with surrounding soft
tissue edema is seen. Colloid (choice C) is commonly seen in fine needle aspirate from colloid nodules
or colloid cysts of the thyroid gland. This lesion is clearly external to the thyroid gland. It is in the right
lateral neck lateral to the common carotid artery and internal jugular vein. Hemosiderin‐laden
macrophages (choice D) can be seen along the wall of old hematomas. However, neck masses resulting
from trauma will have a characteristic history and physical findings.
References: Eisenmenger LB, Wiggins RH. Imaging of head and neck lymph nodes. Radiol Clin North Am 2015;53(1):115–132.

4a. A 70‐year‐old man presents to the emergency department with diffuse scrotal pain and swelling.
There is no history of trauma. Of the following choices, which underlying illness does he most likely
have?

A. Lymphoma
B. Congestive heart failure
C. Pseudomembranous colitis
D. Diabetes mellitus

4b. Which of the following is the appropriate management for this patient?
A. Consultation with medical oncologist
B. Echocardiogram
C. Optical colonoscopy
D. Emergent surgical debridement

5. A 28‐year‐old man presents to the emergency department, and a testicular ultrasound is requested.
The history provided by the ED is “right scrotal swelling.” Of the following choices, which is the most
likely correct history?

A. Acute‐onset scrotal pain and swelling
B. Palpable, painless testicular mass
C. Blunt scrotal trauma
D. Fever and pyuria

6. A 48‐year‐old male with scrotal pain receives a scrotal ultrasound. Based on these images, what is
the most appropriate next step in management?

A. Surgery
B. Reassurance
C. Further imaging
D. Follow‐up ultrasound in
6 months

7. A 53‐year‐old afebrile male with history of vasectomy presenting with left scrotal pain receives a
scrotal ultrasound. What is the most likely diagnosis?

A. Sperm granuloma
B. Varicocele
C. Germ cell tumor
D. Hematocele

8a. A 36‐year‐old man presents to the ED with acute left scrotal pain and swelling. Based on the
history and imaging findings, what is the appropriate next step in the management of this patient?

A. The patient can be discharged
with antibiotics and instructions to
follow up with urology.
B. CT scan of the abdomen and
pelvis for staging.
C. Discharge the patient with pain
medication and instructions to
follow up with urology.
D. Prompt surgical intervention.

8b. What is the salvage rate if surgery is performed after 12 hours?
A. 80% to 100%
B. Approximately 50%
C. Approximately 20%
D. 60% to 75%

9. A 50‐year‐old white male who has been receiving steroid supplementation for his entire life has
noticed for several years that his testes have been painless but lumpy and increasingly so in the past
month. Which of the following is the most appropriate management of these findings?

A. Antibiotics
B. Testicular biopsy
C. Bilateral orchiectomy
D. Increased steroid dosage

10. These are images from a scrotal ultrasound of a 63‐year‐old male presenting with low back and
scrotal pain. What is the next best step in management with regard to scrotal ultrasound findings?

A. Further evaluation with
MRI
B. Treatment with antibiotics
C. Urgent orchiectomy
D. No need for further
assessment or intervention

11a. A 30‐year‐old male presents with an
empty left scrotal sac. Where is the most
common location of the testis in this
condition?
A. Within the peritoneal cavity
B. Near the lower pole of the kidney
C. Near the internal inguinal ring
D. Caudal to the external inguinal ring

11b. This most common malignancy found in the undescended testis is:
A. Seminoma
B. Embryonal carcinoma
C. Teratoma
D. Yolk sac tumor
E. Choriocarcinoma

11c. The gold standard for identification of a malpositioned testis or to prove the absence of a testis in
boys is:
A. MRI
B. CT
C. US
D. Surgical exploration

12a. A 43‐year‐old male presents with a 2‐day history of worsening right scrotal pain. What is a
potential complication of this entity if left untreated?

A. Metastatic disease
B. Malignant degeneration
C. Testicular infarction
D. Fournier gangrene

12b. On a normal scrotal ultrasound, with respect to the testis, normal blood flow within the
epididymis:
A. Is equal
B. Is greater
C. Is less
D. Varies

13a. A 24‐year‐old male patient underwent ultrasound evaluation for right scrotal swelling. Three
images from this study are shown. What is the most likely diagnosis?

A. Acute epididymitis–orchitis
B. Left‐sided torsion
C. Testicular neoplasm
D. Testicular rupture
E. Intratesticular hematoma

13b. What is the most likely histology of this tumor?
A. Mixed germ cell tumor
B. Pure seminoma
C. Lymphoma
D. Leukemia

13c. What is the most common initial site of metastatic disease for germ cell testicular tumors?
A. Retroperitoneal lymph nodes
B. Ipsilateral inguinal lymph nodes
C. Peritoneum
D. Liver
E. Bone

13d. Which of the following is considered a risk factor for testicular cancer?
A. Cryptorchidism
B. Microlithiasis
C. Smoking
D. Orchitis

14. A 27‐year‐old male presents to the emergency department with left testicular pain following blunt
trauma. What finding is shown on this patient’s scrotal ultrasound and MRI?

A. Epididymitis–orchitis
B. Testicular abscess
C. Segmental infarct
D. Testicular mass

15. A 46‐year‐old male presents with a palpable lump on the penile shaft. Ultrasound images of the
area of concern are shown. The abnormality shown is present in which of the following anatomic
structures?

A. Epidermis
B. Subcutaneous
fat
C. Tunica
albuginea
D. Penile urethra

Scrotum: Answers and Explanations

1. Answer D. Images of the left testis show a well‐circumscribed solid mass with multiple concentric
hypo‐ and hyperechogenic rings giving it an “onion ring” appearance. There is lack of vascular flow on
color Doppler, and the surrounding testicular parenchyma is normal. The findings are pathognomonic
of epidermoid cyst of the testis, which is a rare but benign lesion.
Alternating hypo‐ and hyperechogenic concentric rings are considered to be characteristic of an
epidermoid cyst and correspond to its natural evolution. The lining of the cyst produces keratin in
successive layers by desquamating epithelium from the cyst wall, resulting in the onion ring
appearance.
Loya AG, Said JW, Grant EG. Epidermoid cyst of the testis: radiologic‐pathologic correlation. RadioGraphics 2004;24(Suppl
1):S243–S246.

2. Answer D. The potential for higher ultrasound intensities to cause biologic injury has been
established in the laboratory. A theoretical risk exists that diagnostic ultrasound can also produce
unwanted biologic effects on humans, especially on intrauterine gestations as a result of thermal and
nonthermal bioeffects. However, diagnostic ultrasound has an excellent safety record, and there have
been no reported incidents of adverse bioeffects on humans at diagnostic ultrasound levels in the
absence of contrast agents. In situations in which an ultrasound is clinically indicated, the benefit of
the ultrasound will outweigh the risks.
Reference: American Institute of Ultrasound in Medicine. Medical ultrasound safety, 3rd ed. Laurel, MD: American Institute of
Ultrasound in Medicine, 2014:23–28.

3. Answer C. Ultrasound images are typically composed of 640 × 480 or 512 × 512 pixels. Each pixel
has a depth of 8 bits (1 byte) of digital data, providing up to 28, that is, 256 levels of gray scale.
Kluwer Health/Lippincott Williams & Wilkins, 2011:542.

4a. Answer D. Images of the right testicle show multiple echogenic foci with “dirty” shadowing in the
scrotum posterior to the right testicle consistent with gas. In the setting of scrotal swelling, pain and
no history of trauma, the findings are consistent with Fournier gangrene. The most common
predisposing factors for Fournier gangrene are diabetes mellitus and alcoholism. Therefore, choice D
is the correct answer.
Coexisting diabetes mellitus has been found in up to 40% to 60% of patients with Fournier gangrene.
Other predisposing factors include indwelling Foley catheters, surgical procedures, malignancy,
steroids, chemotherapy, radiation therapy, prolonged hospitalization, and HIV. It occurs most
frequently in men aged 50 to 70 years. Multiple organisms are usually involved, including Klebsiella,
Streptococcus, Proteus, and Staphylococcus.
Congestive heart failure (choice B) and pseudomembranous colitis (choice C) are not risk factors.
Although malignancy can be associated with Fournier gangrene, lymphoma (choice A) is incorrect
because diabetes mellitus is a far more common cause.

4b. Answer D. The treatment of Fournier gangrene includes IV antibiotics, hemodynamic
stabilization, and immediate surgical debridement. Multiple debridements may be needed to remove
all nonviable tissue. Patients with incomplete debridement/drainage or who are treated with
antibiotics alone have a poor prognosis. The cause of death includes severe sepsis, multiple organ
failure, coagulopathy, acute renal failure, and diabetic ketoacidosis.
References: Levenson R, Singh A, Novelline R. Fournier gangrene: role of imaging. RadioGraphics 2008;28(2):519–528.

5. Answer C. Images 1 and 2 show a contour abnormality of the testicle at the lower end of the image.
Image 3 shows flow within the testicle, except for a peripheral hypoechoic area with no flow, and
geographic, non–mass‐like margins. There is disruption of the tunica albuginea, which is free floating
in image 1. The findings are consistent with testicular rupture.
The tunica albuginea is a thin, echogenic curvilinear structure completely surrounding the testes.
Disruption of the tunica along with extrusion of the seminiferous tubules is a specific sign of testicular
rupture. The contour abnormality at the lower end of the images represents the extruded seminiferous
tubules. In addition, there is a hydrocele containing low‐level echoes consistent with a hematocele.
Therefore, blunt scrotal trauma (choice C) is the correct answer. An intact tunica albuginea is crucial,
because, if intact, surgery is usually not indicated. If disrupted, testicular viability can be maintained
more than 80% of the time if surgery is performed within 72 hours. Afterward, viability drops to
below 50%. A disruption of the tunica albuginea is a definitive sign of rupture, but is often not
detected. A contour abnormality indicates extrusion of the seminiferous tubules and is a reliable
secondary sign.
Patients with intrascrotal hematoma or hematocele will typically undergo surgical exploration
because of the difficulty in excluding rupture in their presence. Testicular fracture indicates tearing of
the testicular parenchyma with or without disruption of the tunica albuginea. It appears as an
avascular or hypovascular intratesticular defect. Intratesticular hematoma is also common in
testicular trauma. When large, they can lead to testicular necrosis, and surgical exploration is
necessary.
Acute onset of testicular pain and swelling (choice A) can be seen in epididymitis–orchitis and torsion.
However, the contour abnormality and disrupted tunica would not be seen in either of these entities.
One would expect to see a mass with Doppler flow, and no disruption of the tunica if the patient had a
neoplastic process (choice B). Fever and pyuria (choice D) would be indicative of an infectious process.
Of the choices, the images support trauma, not infection.

6. Answer C. Multiple dilated veins within the right scrotum are compatible with a scrotal varicocele.
Varicoceles are usually the result of incompetent or congenitally absent valves within the testicular
vein. They are the most common correctable cause of male infertility. Diagnostic criteria include
dilated veins of the pampiniform plexus greater in diameter than 2 to 3 mm in standing or supine
positions and venous reflux on Doppler imaging during or without a Valsalva maneuver. The majority
of varicoceles (85%) are unilateral and left sided. Bilateral varicoceles constitute the majority of the
remainder of cases. Unilateral right‐sided varicoceles rarely occur. When they do, compression of the
right spermatic vein by a retroperitoneal mass or situs inversus should be considered.

7. Answer A. Sperm granulomas are presumed to be because of a necrotizing granulomatous
response to extravasated spermatozoa. They can be painful or asymptomatic and are most frequently
found in patients who have undergone vasectomy. Sperm granulomas are typically hypoechoic or
heterogeneous and often lack increased Doppler flow. Calcifications can be seen in chronic sperm
granulomas.
Varicoceles (choice B) are anechoic and tubular and contain Doppler flow. Germ cell tumors (choice C)
arise from the testis and not the epididymis. The lesion shown is solid and in the region of epididymis.
There is no peritesticular collection to suggest hematocele (choice D).
References: Black JA, Patel A. Sonography of the abnormal extratesticular space. AJR Am J Roentgenol 1996;167(2):507–511.

8a. Answer D. The first image is of the right testicle, which has a normal appearance and normal
color Doppler signal. The second image is of the left testicle, showing no detectable Doppler signal. The
third image shows asymmetry of flow on a side‐by‐side view, and the fourth image labeled “left
spermatic cord” shows a whirlpool appearance of the cord, the so‐called torsion knot. This is a case of
testicular torsion. In adults presenting with acute scrotal pain in the absence of trauma, the distinction
must be made between torsion and an inflammatory condition such as acute epididymitis. Testicular
torsion usually occurs as a result of a faulty attachment of the testis to the scrotal wall, most commonly
resulting in the bell‐clapper deformity. In this condition, the tunica vaginalis completely surrounds the
testis, causing the testis to be freely suspended by the spermatic cord in the scrotal sac. Prompt
surgical intervention (choice D) is necessary if the testis is to be salvaged.
The salvage rate is 80% to 100% if surgery is performed within 6 hours after the onset of pain but
drops to only 20% if surgery is delayed for more than 12 hours. In most cases of torsion, as in this
case, there will be no detectable flow. Some cases will show flow that is asymmetric, which is why
side‐by‐side images are mandatory. If the torsion is prolonged, there may be hyperemia in the tissues
surrounding the infarcted testis. Gray‐scale findings in torsion are variable, and echogenicity may be
normal, increased, or decreased, and the parenchyma may be homogeneous or heterogeneous. If the
testis is hypoechoic or heterogeneous, it is likely nonviable.
Choice A is incorrect because this is not a case of epididymitis. With epididymitis or epididymitis–
orchitis, one would expect to see increased flow on the side of pain, not decreased/absent flow as in
this case. If this was a case of tumor infiltration of the left testis, one would expect to see increased
flow in the affected parenchyma. Tumor most often presents as a painless mass, which is not how this
patient presented. Therefore, a staging CT scan (choice B) is not appropriate. Choice C is incorrect
because of the need for prompt surgical intervention, ideally within 6 hours, for salvage.

8b. Answer C. Approximately 20% is the correct answer, as discussed above.

9. Answer D. The history of lifelong steroid supplementation suggests a diagnosis of congenital
adrenal hyperplasia. Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder
resulting in an enzyme deficiency (usually 21‐hydroxylase deficiency) involved in the production of
cortisol and aldosterone. Low levels of glucocorticoids and mineralocorticoids lead to elevated levels
of adrenocorticotropin (ACTH), which in turn lead to adrenal hyperplasia. Adrenal rests are ectopic
foci of adrenal tissue that can be found in up to 50% of normal neonates within the retroperitoneum,
broad ligaments, ovaries, inguinal region, and testes. Normally, adrenal rests almost always regress.
However, elevated ACTH levels in the setting of CAH can maintain and grow the ectopic rests.

Testicular adrenal rests are usually bilateral and vary in size from 4 to 38 mm. They are usually
sharply demarcated hypoechoic lesions on ultrasound. Large lesions are palpable. As lesions enlarge,
they may compress the surrounding testicular parenchyma, leading to infertility or chronic pain.
An increase in size and number of testicular adrenal rests can occur if exogenous hormone therapy is
inadequate. Increasing the dose of exogenous hormone therapy until endogenous ACTH levels are
suppressed can result in regression of adrenal rest tumors. Therefore, choice D, increased steroid
dosage, is correct.
Testicular biopsy (choice B) and bilateral orchiectomy (choice C) are not the correct answers because
although the sonographic appearance of individual adrenal rests overlaps with testicular carcinoma,
the bilaterality of the lesions is very unusual for testicular cancer. Antibiotics (choice A) is also
incorrect because the sonographic mass‐like findings without pain or other signs of infection do not
indicate an infectious process.
Other differential considerations for bilateral testicular lesions include Leydig cell hyperplasia,
sarcoidosis, lymphoma, and metastases.
References: Dogra V, Nathan J, Bhatt S. Sonographic appearance of testicular adrenal rest tissue in congenital adrenal hyperplasia.
J Ultrasound Med 2004;23(7):979–981.
German‐Mena E, Zibari G, Levine S. Adrenal myelolipomas in patients with congenital adrenal hyperplasia: review of the
literature and a case report. Endocr Pract 2011;17(3):441–447.
Olpin JD, Witt B. Testicular adrenal rest tumors in a patient with congenital adrenal hyperplasia. J Radiol Case Rep 2014;8(2):46–
52.

10. Answer D. Tubular ectasia of the rete testis is an incidental finding that does not warrant any
further evaluation, intervention, or follow‐up. Multiple anechoic cystic or tubular spaces replacing the
mediastinum testis, often bilaterally, are the typical sonographic appearance and should not be
confused with testicular tumor or abscess.
No further evaluation is required as tubular ectasia of the rete testis is a benign entity. Therefore,
choice A is incorrect. Tubular ectasia of the rete testis is a noninfectious entity and does not need
treatment with antibiotics (choice B). A testicular abscess has the appearance of a more heterogeneous
complex fluid collection with peripheral hyperemia. Tubular ectasia of the rete testis is a benign entity
that does not require surgical intervention (choice C). Testicular malignancies often are solid or have
dominant solid components.

11a. Answer D. Images show a small testis with thick overlying tissue compatible with an
undescended left testis. Although undescended testes can occur anywhere within the retroperitoneum
from the level of the lower pole of the kidney to the inguinal region, approximately 80% are located in
the inguinal region. Most of those are just caudal to the external inguinal ring.

11b. Answer A. Complications associated with undescended testes include infertility, carcinoma,
torsion, and increased susceptibility to testicular traumatic injury. Although an undescended testis has
a significantly increased risk of developing cancer (usually seminoma), the normal descended testis is
also placed at an elevated cancer risk. This increased risk does not completely disappear following
orchiopexy and patients require continued surveillance for testicular cancer.

11c. Answer D. American Urological Association (AUA) guidelines recommend against the use of
imaging in the evaluation of boys with cryptorchidism. More than 70% of cryptorchid testes are
palpable and require no imaging. Patients with nonpalpable cryptorchid testes should undergo a
diagnostic laparoscopy to identify and treat the malpositioned testes. The investigation can end if
testicular absence is confirmed at surgery.
References: Kolon TF, Herndon CDA, Baker LA, et al. Evaluation and treatment of cryptorchidism: AUA guideline. J Urol
2014;192(2):337–345.

12a. Answer C. Enlargement and decreased echogenicity of the epididymis and right testis with
hyperemia are classic features of acute epididymitis–orchitis. Most commonly, inflammation of the
scrotum involves the epididymis as a result of a lower urinary tract infection. When inflammation
spreads into the testis, an epididymitis–orchitis results. Hence, isolated orchitis is much less common
than isolated epididymitis. Inflammation of the epididymis may be focal or diffuse, whereas
inflammation of the testis is much more frequently diffuse. When a focal hypoechoic hypervascular
intratesticular lesion is found in the setting of suspected inflammation, follow‐up sonography should
be performed to exclude an occult malignancy. Pain and tenderness of the abnormal testis without a
palpable mass or signs of an inflamed epididymis on imaging would favor a focal orchitis. The most
common complications of orchitis include pyocele, testicular abscess, and testicular infarction.

12b. Answer C. Vascularity of the normal epididymis is less than the testis. Normally, flow may not
necessarily be detectable on Doppler sonography.

13a. Answer C. Images show an intratesticular mass with cystic, solid, and calcified components
nearly replacing the right testicle. A thin rim of normal testicular parenchyma surrounds the mass.
Imaging features are consistent with neoplasm.
Although acute epididymitis–orchitis may cause the affected side to appear enlarged and hyperemic as
in this case, orchitis is not mass‐like and should also involve the epididymis. In this case, the
epididymis is normal. Both intratesticular hematoma and testicular rupture may cause heterogeneous
echogenicity of the testicle. Hematomas should be avascular on Doppler imaging. Testicular rupture is
also associated with irregular testicular contour or disruption of the tunica albuginea and is
accompanied by a hematocele.

13b. Answer A. Images show a mass with cystic, solid, and calcified components nearly replacing the
right testicle. The presence of cystic and calcified components, especially in this age demographic, are
most concerning for a mixed germ cell tumor. Pure seminomas are most often uniformly hypoechoic
on US. Although lymphoma and leukemia can be indistinguishable from mixed germ cell tumors, these
entities are less common at this age.

13c. Answer A. Testicular tumors spread via the lymphatic channels, which accompany the testicular
vessels. For this reason, the retroperitoneal lymph nodes are typically the first site of spread with
right‐sided tumors spreading to the right paracaval, precaval, and right retrocaval nodes and left‐sided
tumors spreading to the left para‐aortic and preaortic nodes. Hematogenous spread to the lungs, brain,
bone, and liver can also occur.

13d. Answer A. Risk factors for testicular cancer include personal history of germ cell tumor, family
history, cryptorchidism, infertility, and testicular dysgenesis. Although once thought to be associated
with cancer, microlithiasis is no longer believed to be a risk factor.
References: Kreydin E, Barrisford G, Feldman A, et al. Testicular cancer: what the radiologist needs to know. AJR Am J Roentgenol
2013;200(6):1215–1225.
Sohaib S, Koh D, Husband J. The role of imaging in the diagnosis, staging, and management of testicular cancer. AJR. Am J
Roentgenol 2008;191(2):387–395.
Woodward P, Sohaey R, O’Donoghue M, et al. From the archives of the AFIP: tumors and tumorlike lesions of the testis: radiologic‐
pathologic correlation. RadioGraphics 2002;22(1):189–216.

14. Answer C. Gray‐scale ultrasound image of the left testis shows heterogeneity of the testicular
parenchyma. Power Doppler fails to demonstrate vascular flow in a portion of the parenchyma. This
finding is confirmed on scrotal MRI, which shows lack of enhancement in a small peripheral portion of
the left testis with enhancement of the overlying intact tunica albuginea. The imaging appearance is
consistent with segmental infarction of the testis.
The upper pole of the testis is more prone to infarction because of dual supply to the lower pole from
the posterior epididymal artery. On ultrasound, a wedge‐shaped area of hypoechogenicity or
heterogeneity is usually seen with the vertex directed toward the mediastinum testis. There is lack of
flow on color or power Doppler imaging. Occasionally, the area of infarct may appear rounded on
ultrasound with surrounding mass effect. In such cases, it may be difficult to differentiate from
testicular tumor. MRI is helpful in these cases and will show an area of nonenhancement sometimes
surrounded by a rim of perilesional enhancement.
References: Harisinghani M, Rajesh A. Genitourinary imaging: a case based approach. London, UK: Springer, 2014:260–262.

15. Answer C. The images show a calcified plaque with posterior acoustic shadowing and no internal
blood flow or perilesional hyperemia. This imaging appearance is typical of Peyronie disease, which is
an idiopathic condition characterized by formation of fibrous plaques within the tunica albuginea of
the corpora cavernosa. This can result in penile deformity and curvature. The plaques are usually seen
as focal hyperechoic thickening of the tunica albuginea and may be calcified. They are usually found on
the dorsal surface of the penis, but they can also occur on the ventral and lateral surfaces.
Reference: Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier; 2016:173.

2a. A 30‐year‐old female is undergoing infertility workup. 3D coronal US image of the mid to fundal
uterus and transverse image through the lower uterine segment are shown. The imaging features are
most consistent with which uterine anomaly?

A. Bicornuate
B. Didelphys
C. Septate
D. Arcuate
E. DES drug related

2b. What is the significance of distinguishing a septate uterus from other uterine anomalies?
A. Septate uterus is associated with congenital renal anomalies that should be diagnosed with
additional imaging.
B. It is considered a normal anatomic variant that should have no effect on fertility.
C. Surgical correction can potentially improve reproductive outcomes.
D. Patients are at increased risk for vaginal clear cell carcinoma and should be screened.

3. A 23‐year‐old female outpatient presents with obesity, anovulation, and hirsutism. The patient had
a negative pregnancy test. What does the patient most likely have?

A. Ovarian torsion
B. Hyperstimulated ovaries
C. Polycystic ovary syndrome
D. Endometriosis

4. A 26‐year‐old female presents to the emergency department after sudden onset of right lower
quadrant pain, nausea, and vomiting. Laboratory values are as follows: WBC 8,500, beta‐hCG negative.
Images shown are from transvaginal ultrasound. Which of the following is the most likely diagnosis?

A. Oophoritis
B. Ovarian hyperstimulation
C. Polycystic ovarian syndrome
D. Ovarian torsion

5. A 65‐year‐old female outpatient presents with postmenopausal bleeding and the following images
on transvaginal ultrasound. Which of the following is the most appropriate next step for this patient’s
management?
A. Follow‐up ultrasound in 3
months to assess for resolution.
B. Send the patient for
hysteroscopy and tissue
sampling.
C. Send her to interventional
radiology for embolization as this
is a submucosal leiomyoma.
D. Send the patient for pelvic MRI
for better characterization of the
abnormality.

6. A 48‐year‐old woman presents with abnormally heavy menstrual bleeding, dyspareunia, and
uterine enlargement on physical exam. Her gynecologist requests a pelvic ultrasound. The first image
is transabdominal, and the second
image is a transvaginal image.

A. Lipoleiomyoma
B. Adenomyosis
C. Intramural leiomyoma
D. Endometrial polyp

7. A 28‐year‐old woman underwent CT of the pelvis because of minor trauma. Bilateral ovarian
masses were noted on the CT, and a pelvic ultrasound was recommended. Images shown are from
transvaginal ultrasound. The most likely diagnosis is:

A. Endometriosis with bilateral
endometriomas
B. Bilateral dermoid cysts
C. Tuboovarian abscesses
D. Bilateral hemorrhagic
ovarian cysts

8. Which of the following is a feature of the peer review system in radiology?
A. Standard for peer review is pathologic or surgical proof of the final diagnosis.
B. It is fully protected from medicolegal discovery.
C. It is available publicly so patients can compare quality data among hospitals.
D. The Joint Commission can review peer review data on individual radiologists to help make
accreditation decisions.

9. A 58‐year‐old female presents for an outpatient pelvic ultrasound for postmenopausal bleeding.
Which of the following is the most likely diagnosis?

A. Calcified uterine leiomyoma
B. Adenomyoma
C. Lipoleiomyoma
D. Uterine AVM

10. A 25‐year‐old female presents to
the emergency department with fever
and pelvic pain. Beta‐hCG is negative.
Which of the following is a
complication of the process shown in
these images?
A. Enterocolitis
B. Ovarian torsion
C. Tuboovarian abscess
D. Malignant degeneration

11. A 62‐year‐old female undergoes pelvic ultrasound for characterization of an incidental pelvic
lesion seen on trauma CT scan. Which of the following is the most appropriate management of this
finding?

A. The lesion is indeterminate—
recommend further characterization with
pelvic MRI.
B. The lesion is concerning for
malignancy—recommend surgical
evaluation.
C. The lesion is likely benign—
recommend follow‐up to document
resolution in 6 to 8 weeks.
D. The lesion is almost certainly benign—
recommend annual ultrasound.

12. Which of the following will help reduce or eliminate the
artifact seen in this image?

A. Increasing power output and gain
B. Repositioning the transducer
C. Using more ultrasound gel
D. Waiting for better bladder distension

13. A 29‐year‐old female presents with infertility, dysmenorrhea, heavy menstrual bleeding, and
intermenstrual bleeding. Images from pelvic ultrasound are shown. Which of the following is the most
likely diagnosis?

A. Normal endometrium
B. Endometrial
hyperplasia
C. Submucosal fibroid
D. Endometrial polyp

14. A 20‐year‐old female presents with a left adnexal mass. Based on the images provided, which of
the following is most concerning for malignancy?

A. Large lesion size
B. Presence of blood
flow
C. Absence of papillary
excrescences
D. Presence of solid
components

Gynecology: Answers and Explanations

1a. Answer C. Images of the left ovary show a rounded mass with low‐level homogeneous internal
echoes, increased through transmission, and lack of vascular flow. These findings are characteristic of
endometrioma. Endometriomas occur in females of menstrual age as a result of growth of endometrial
tissue within the ovaries. The tissue undergoes repeated cyclical hemorrhage and forms cystic lesions
containing degenerated blood products. The sonographic appearance of endometriomas can be
variable, although approximately 50% of endometriomas appear as unilocular cysts containing low‐
level internal echoes. Other variations include multiloculated, mixed solid cystic, and, rarely, anechoic
cystic morphologies. Although a cystic lesion containing homogeneous low‐level echoes is the classic
appearance of an endometrioma, this appearance can overlap with that of a hemorrhagic cyst.
Therefore, a 6‐ to 12‐week follow‐up ultrasound is suggested when encountering a lesion with these
characteristics for the first time in a patient of menstrual age to allow for the expected evolution of a
hemorrhagic cyst.
A hemorrhagic cyst (choice A) is usually a complex cystic mass with a lace‐like or reticular pattern of
internal echoes due to interdigitating fibrin strands or a solid‐appearing area with concave margins
and no internal flow on Doppler ultrasound due to a retracting clot within the cyst. A mature cystic
teratoma (dermoid) (choice B) usually contains hyperechoic components, lines and dots, and area of
acoustic shadowing, with no internal flow at color Doppler sonography. Tuboovarian abscess (choice
D) is commonly seen as a multilocular complex adnexal mass with internal echoes and septations.

1b. Answer D. Although the diagnosis of endometriosis is suspected based on the history, signs,
symptoms, physical exam findings, and imaging tests, laparoscopy is considered the gold standard for
the diagnosis of endometriosis.

1c. Answer C. Endometrioid carcinoma is the most common malignant neoplasm arising from
endometriosis followed by clear cell carcinoma.

1d. Answer D. Gastrointestinal tract involvement is seen in 5% to 37% of patients with
endometriosis. The rectosigmoid colon is the most commonly involved site followed by the small
bowel, the cecum, and the appendix, in order of decreasing frequency.
References: Gore RM, Szucs RA, Wolf EL, et al. Miscellaneous abnormalities of the colon. In: Gore RM, Levine MS (eds). Textbook of
gastrointestinal radiology, 3rd ed. Philadelphia, PA: Saunders Elsevier, 2008:1213.
Woodward PJ, Sohaey R, Mezzetti TP. Endometriosis: radiologic‐pathologic correlation. RadioGraphics 2001;21(1):193–216.

2a. Answer C. The images show two endometrial cavities with separation, which extends through the
lower uterine segment and cervix. The main differential is between septate, bicornuate, and didelphys
uterine anomalies. The 3D coronal image shows a single fundal contour, which extends above the
interostial line. This key imaging feature excludes both bicornuate and didelphys anomalies, which are
associated with a fundal cleft >1 cm. Arcuate uterus would be associated with a single uterine cavity.
DES (in utero diethylstilbestrol exposure) uterine anomalies are associated with an atrophic, T‐shaped
uterine cavity.

2b. Answer C. In certain cases, surgical resection of the fibrous septation can improve obstetrical
outcomes. Unicornuate, didelphys, and bicornuate uterus are associated with renal anomalies. Arcuate
uterine configuration is considered a normal anatomic variant that has no effect on fertility and is not
associated with renal anomalies. Patients with DES uterus are at increased risk for vaginal clear cell
carcinoma.
References: Behr SC, Courtier JL, Qayyum A. Imaging of Müllerian duct anomalies. RadioGraphics 2012;32(6):E233–E250.
Chandler TM, Machan LS, Cooperberg PL, et al. Müllerian duct anomalies: from diagnosis to intervention. Br J Radiol
2009;82(984):1034–1042.

3. Answer C. Both ovaries contain multiple small follicles that line up along the periphery of the
ovary, the so‐called string of pearls sign. Also, the ovarian stroma is prominent and echogenic. This
appearance, along with the provided clinical history, is most consistent with polycystic ovary
syndrome (PCOS). PCOS is an endocrine disorder characterized by hyperandrogenism and
anovulation/oligoovulation due to high levels of luteinizing hormone (LH) and low levels of follicle‐
stimulating hormone (FSH). Clinically, women present with infertility, hirsutism, obesity, acne, and
insulin resistance.
Ovarian torsion (choice A) is not the best choice because although there are multiple peripheral
follicles as is often seen in torsion both ovaries look fairly symmetric. Patients with torsion present
with pain and an enlarged ovary on the affected side. In torsion, the ovarian echotexture is often
heterogeneous, different from this case where the echotexture is homogeneous.
Hyperstimulated ovaries (choice B) are usually markedly enlarged with multiple cysts, often with
intracystic hemorrhage, ascites, and pleural effusions. Most often, this occurs in the setting of first‐
trimester pregnancy following ovulation induction for assisted fertility. The ovaries in this patient are
only mildly enlarged, and the question stated that she is not pregnant.
Although endometriosis (choice D) can be a cause of infertility, it is not the best choice because no
endometrioma is shown. Endometriomas usually have the appearance of complex ovarian cysts, often
containing uniform low‐level echoes. Other sonographic features include punctate echogenic mural
foci, fluid–fluid levels, internal septations, multilocularity, and solid‐appearing nodules due to clotted
blood. The ovaries in this case have none of these sonographic features.
Lee TT, Rausch ME. Polycystic ovarian syndrome: role of imaging in diagnosis. RadioGraphics 2012;32(6):1643–1657.

4. Answer D. The first image shows the left ovary, which is normal both in size and in morphology.
The next image shows the right ovary, which is enlarged relative to the asymptomatic left side. In
addition, the ovarian stroma is enlarged and heterogeneous, and the follicles are displaced
peripherally. The imaging findings, along with the clinical presentation and laboratory values, are
compatible with ovarian torsion (choice D). Clinically, patients with ovarian torsion present with acute
onset of pain, often with nausea and vomiting. Intermittent pain may precede the acute episode by
weeks. Ovarian torsion may present at any time in life, although relatively uncommon following
menopause. The risk is increased during pregnancy. The most constant finding in ovarian torsion is
unilateral enlargement of the torsed ovary. This is true even when the ovary shows Doppler flow,
which is thought to be the result of dual blood supply to the ovary. The torsed ovary can, in fact, show
arterial flow, venous flow, both, or neither. Therefore, in the appropriate clinical setting, an enlarged
ovary should suggest torsion even in the presence of Doppler flow. Additional findings include
heterogenous echotexture (from hemorrhage, edema, and necrosis), relative paucity of follicles, small
peripheral follicles, echogenic rings around the follicles (follicular ring sign), twisted pedicle, whirlpool
sign, and ovarian cyst.

Oophoritis (choice A) is not correct because of the clinical presentation. Although there can be relative
asymmetric ovarian enlargement, oophoritis typically presents in the context of pelvic inflammatory
disease, which has a different presentation of fever, cervical motion tenderness, and leukocytosis,
which this patient does not have. Ovarian hyperstimulation (choice B) is incorrect because it typically
involves both ovaries in a patient in the setting of first‐trimester pregnancy following ovulation
induction. This patient is not pregnant, and only one ovary is enlarged. Polycystic ovarian syndrome
(choice C) is incorrect because of the acute presentation, which is not a feature of PCOS.

5. Answer B. The first image shows an abnormally thickened endometrium with a solid mass
containing cystic spaces. The second image shows Doppler flow within the mass. Based on the images
shown and the clinical information provided, the best answer is B.
The patient is postmenopausal and presents with vaginal bleeding. According to a consensus
statement by the Society of Radiologists in Ultrasound, an endometrial thickness of >5 mm in a woman
with postmenopausal bleeding is abnormal. In a woman of this age group, the most likely causes are
hyperplasia, polyps, submucosal fibroid, and carcinoma. The endometrium in this patient is clearly
much thicker than 5 mm. In a postmenopausal patient, the endometrium is normally thin,
homogeneous, and <5 mm. If the endometrium is thicker than 5 mm in a woman with postmenopausal
bleeding, further evaluation with tissue sampling should be obtained. In a postmenopausal woman
who is not bleeding, the upper limit of endometrial thickness is controversial, but a threshold of 8 mm
(some suggest 11 mm) is advocated.
Choice A is not correct because the endometrium is clearly too thick to call normal in a woman of any
age. Also, there is clearly a mass in the endometrial canal. Although submucosal fibroids (choice C) can
cause bleeding, they are usually broad based, solid, hypoechoic masses with an outer layer of
echogenic endometrium. This lesion is not completely solid and is isoechoic to the myometrium.
Although the cystic components are more commonly present within polyps, they can also be identified
within hyperplasia and carcinoma. Therefore, a tissue diagnosis is needed. Choice D is not the correct
answer because imaging cannot reliably exclude carcinoma.

6. Answer B. The first image shows an enlarged uterus with a bulbous configuration, with marked
myometrial heterogeneity, especially along the anterior aspect. The second image (transvaginal)
shows similar findings with multiple echogenic and hypoechoic linear striations, the so‐called venetian
blind appearance. Also note the indistinct interface between the endometrium and the myometrium.
These findings are the result of adenomyosis. Adenomyosis is a common condition characterized by
the presence of endometrial glands and stroma in the myometrium. These patients present with
abnormally heavy vaginal bleeding, particularly at menses, dyspareunia, and an enlarged uterus. Very
commonly, there is greater involvement in the posterior wall. Adenomyosis comes in two forms:
diffuse, which is composed of widely scattered foci within the myometrium, and nodular, which
consists of circumscribed nodules called adenomyomas. Ultrasound findings include an enlarged,
globular uterus, disproportionate thickening of the posterior myometrium, myometrial cysts,
heterogeneous echotexture, linear shadows (“venetian blind”) pattern, and indistinct myometrial–
endometrial interface. MRI is highly accurate in the diagnosis of adenomyosis, which shows thickening
of the junctional zone (>12 mm) on T2‐weighted images, as well as poorly defined areas of decreased
T2 signal in the myometrium.

Lipoleiomyoma (choice A) are rare, fat‐containing, benign neoplasms that are well‐defined, solid
echogenic masses. Intramural leiomyoma (choice C) is incorrect because of the indistinct borders.
Although they can have a variety of appearances and can also have the “venetian blind” appearance,
they are well‐circumscribed masses. Endometrial polyp (choice D) is incorrect because the images
show that the abnormality is in the myometrium, not the endometrium. Also, polyps do not cause
dyspareunia or globular uterine enlargement.

7. Answer B. The first two images labeled “rt ovary” show a homogeneously echogenic mass within
the right ovary. Attenuation of the ultrasound beam results in poor visualization of the deep portion of
the mass, the “tip of the iceberg” sign. The second image shows shadowing deep to the mass. The next
two images are labeled “lt ovary” and show a cystic lesion containing multiple echogenic, linear
strands, the “dermoid mesh” sign. The second image of the left ovary also shows an echogenic mass
with attenuation of the ultrasound beam deep to the mass. Therefore, the correct answer is bilateral
dermoid cysts, choice B. Dermoids are benign ovarian germ cell tumors composed of mature epithelial
structures including skin, desquamated epithelium, hair, teeth, sebum, lipid, and calcification. They are
present from birth, grow slowly, and are often detected incidentally during imaging performed for
other reasons. Ten to twenty‐five percent are bilateral. Dermoids exhibit a variety of appearances. The
dermoid plug or Rokitansky nodule is an echogenic mass composed of a mixture of hair and sebaceous
material. Often, only the superficial portion of this lesion is well visualized because of attenuation of
the ultrasound beam, the “tip of the iceberg sign.” Some dermoids have multiple floating linear echoes,
which are hair, the “dermoid mesh” sign. The fluid component is sebum and can be anechoic or contain
low‐level echoes. A fat–fluid level is very uncommonly seen but is a very characteristic finding, as are
multiple echogenic floating spheres, which are fat globules. Some dermoids can show multiple
components. Most dermoids are surgically removed because of risk of torsion or malignant
transformation, which occurs in approximately 2% of dermoids.
Endometriomas (choice A) have a variety of appearances including homogeneous, low‐level echoes in
a ground‐glass pattern, punctate echogenic foci in the wall, and fluid–fluid levels. They are often
multiple and bilateral. The markedly hyperechoic tissues shown on this case are not typical of the low‐
level echoes within endometriomas. Also, hair would not be a feature of endometriomas. Tuboovarian
abscesses (choice C) are cystic masses and are often bilateral but also would not exhibit the distinctive
features already described for dermoids. Hemorrhagic cysts (choice D) can show reticular fine echoes
that tend to be lacy in appearance, not the straight linear echoes seen in this case. They can also
appear to be solid and be mistaken for the dermoid plug, but the dermoid plug is usually more
echogenic and will attenuate the ultrasound beam, whereas a hemorrhagic cyst will show posterior
enhancement. Also, hemorrhagic cysts are not typically bilateral.

8. Answer B. The standard for peer review is peer consensus, not pathologic or surgical proof of the
final diagnosis. Peer review data is immune to legal action and discovery. It is a safe form of self‐
regulation among qualified radiologists. The peer review data are not available for public reporting
nor can they be used by The Joint Commission to make accreditation decisions.
Reference: American Board of Radiology. Quality & Safety Domain Specification & Resource Guide, 2016.

9. Answer C. The first image shows a homogeneously echogenic intramural mass in the posterior
uterus. The second image shows no Doppler flow within this lesion. A highly echogenic mass within
the myometrium is virtually diagnostic of a lipomatous uterine tumor. These are uncommon benign
tumors consisting of variable portions of mature adipocytes, smooth muscle, or fibrous tissue. These
tumors histologically include pure lipomas, lipoleiomyoma, and fibrolipomyomas. The typical
ultrasound appearance is that of an echogenic solid mass with no Doppler flow. These tumors are
typically asymptomatic and require no treatment. It is important to localize these masses to the uterus
as the imaging appearance overlaps with the more common ovarian dermoid.
Choice A is incorrect because a calcified fibroid would show posterior shadowing, which this does not.
The typical appearance of an adenomyoma (choice B) is that of a heterogeneous nodule with indistinct
margins and cystic spaces, which is very different from the appearance of this. A uterine AVM (choice
D) is a lesion composed of multiple tubular or serpiginous cystic structures in the myometrium,
sometimes extending into the endometrium on gray‐scale imaging corresponding to vessels shown on
color Doppler imaging. They most often follow trauma secondary to pregnancy, dilatation and
curettage, or abortion.
References: Hertzberg BS, Middleton WD. Ultrasound: the requisites, 3rd ed. Philadelphia, PA: Elsevier, 2016:548–550, 559–561.

10. Answer C. Transvaginal ultrasound images of the left adnexa show a dilated tubular structure
filled with low‐level internal echoes (debris). The incomplete internal septations suggest that this
structure is the fallopian tube and not a cystic ovarian mass. The transverse image shows small
nodules along the wall of the tube, which represent thickened endosalpingeal folds (“cogwheel sign”).
The imaging appearance is consistent with pyosalpinx in the setting of pelvic inflammatory disease
(PID). Pyosalpinx occurs when adhesions obstruct the fimbriated end of the fallopian tube resulting in
accumulation of pus within the tube. The infection may progress and involve the ovary resulting in a
tuboovarian complex (TOC) or a tuboovarian abscess (TOA). In a TOC, the ovary and tube can be
identified as separate structures within the inflammatory mass. However, tuboovarian abscesses
(TOA) appear as complex multiloculated cystic and solid adnexal masses in which the fallopian tubes
and ovaries cannot be identified as discrete entities.
Absence of the “gut signature” in the tubular structure shown excludes enterocolitis. Moreover, the
clinical history also indicates a pelvic pathology (choice A). Ovarian torsion is not common in patients
with PID because of formation of adhesions in the pelvis from the inflammatory process (choice B).
Pyosalpinx is a manifestation of PID and is not associated with malignant degeneration (choice D).

11. Answer D. Images of the right ovary show a simple cyst with imperceptible wall, increased
through transmission and no internal septations or mural nodularity. According to the Society of
Radiologists in Ultrasound (SRU) consensus statement for Management of Asymptomatic Ovarian and
Other Adnexal Cysts Imaged at US:
In postmenopausal women,
Simple cysts ≤1 cm: are clinically inconsequential; do not need follow‐up.
Cysts >1 and ≤7 cm: are almost certainly benign; yearly follow‐up with US is recommended. (The cyst
in this question falls into this category, so choice D is correct.)
Cysts >7 cm: may be difficult to assess completely with US; further imaging with MR or surgical
evaluation should be considered.
Reference: Levine D, Brown DL, Andreotti RF, et al. Management of asymptomatic ovarian and other Adnexal cysts imaged at US:
Society of Radiologists in ultrasound consensus conference statement. Radiology 2010;256(3):943–954.

12. Answer B. The image provided shows low‐level echoes in the superficial aspect of the urinary
bladder. This is an example of reverberation artifact, which occurs when sound reflects off of strong
acoustic interfaces in the near field, and the returning pulse is strong enough to reflect off of the
transducer itself and back into the body so that it can interact with the same near‐field interfaces a
second time or multiple times. This produces an additional set of echoes that are interpreted as arising
deep to the original reflector. The reverberation artifact is usually not obvious in soft tissues. However,
the anechoic background of cystic structures allows the reverberations to be seen.
Reverberation artifact can be decreased or eliminated by decreasing power output and gain (choice A
is incorrect). They can also be minimized by positioning the transducer so that the cystic structure is
no longer in the near field. Using more ultrasound gel (choice C) will displace air between the
transducer and skin surface to eliminate reflection caused by air, but will have no impact on
reverberation artifact. Even if the bladder is more distended (choice D), it will still be in the near field
if all other parameters remain the same and, therefore, will have no impact on the reverberation
artifact.

13. Answer D. The first image shows a smooth echogenic mass expanding the endometrial cavity at
the fundus. The second image shows a feeding vessel extending to the mass. This appearance is
characteristic of endometrial polyp. Endometrial polyps are common benign hyperplastic overgrowths
of endometrial glands and stroma that form a projection from the surface of the endometrium. They
are one of the most common etiologies of abnormal vaginal bleeding in both premenopausal and
postmenopausal women. However, they may also be asymptomatic. Although the majority of
endometrial polyps are benign, a small percentage (0.5% to 3%) may be premalignant or malignant.
The typical sonographic appearance of endometrial polyp is a focal, round echogenic mass within the
endometrial cavity. The visualization of a feeding artery in the pedicle is characteristic of endometrial
polyp. If a feeding artery is not readily visualized, sonohysterogram may be required to confirm the
diagnosis.
The ultrasound images here show the typical appearance of an endometrial polyp. A normal
endometrium (choice A) would not be expected to have such appearance. Generally, endometrial
hyperplasia (choice B) is characterized by diffuse thickening of the endometrium as opposed to focal
nature of an endometrial polyp. Sonohysterography is helpful in differentiating between the two
entities. A vascular pedicle will not be expected to be seen in endometrial hyperplasia. A submucosal
fibroid (choice C) is usually hypoechoic with posterior shadowing and has an overlying echogenic
endometrium.
References: Jorizzo JR, Chen MYM, Riccio GJ. Endometrial polyps. AJR Am J Roentgenol 2001;176(3):617–621.

14. Answer B. The first image shows a large mixed solid and cystic left ovarian mass. The second
image shows low‐resistance arterial flow in the solid component of the lesion.
When evaluating a mixed solid and cystic ovarian lesion, the features that raise concern for
malignancy are thick irregular septa (>3 mm), wall thickening, and papillary excrescences, which are
solid nodules along the septations or along the wall. In cystic ovarian neoplasms, a solid nodule with
internal blood flow has the greatest chance of being associated with malignancy. Presence of very‐low‐
resistance arterial flow in the solid component raises the level of suspicion but is not specific for
malignancy. Low‐resistance flow can also be seen in corpus luteal cysts and high‐resistance arterial
flow can also be seen in portions of ovarian cancer.

Large lesion size is also an important factor. Larger masses (>10 cm) are more likely to be malignant.
Presence of papillary excrescences (not absence) and solid components will also increase concern for
malignancy. However, as mentioned above, the presence of internal blood flow has the greatest chance
of being associated with malignancy.

2a. A 29 years old hemodynamically stable female presents with right pelvic pain. Serum beta hCG is
3,520 mIU/mL. Images from transvaginal pelvic ultrasound are shown.

Based on the Society of Radiologists in Ultrasound (SRU) Multispecialty Consensus Conference on
“Early first trimester diagnosis of Miscarriage and Exclusion of a Viable Intrauterine pregnancy”
published in October 2012, which of the following is the most appropriate next step?
A. Imaging findings are diagnostic of pregnancy of unknown location. The patient should be referred
for the management of presumed
ectopic pregnancy by IM
methotrexate or other
pharmacologic or surgical methods.
B. A viable intrauterine pregnancy is
likely; serial beta hCG measurements
and pelvic sonography should be
performed.
C. A viable intrauterine pregnancy is
possible but unlikely; however, at
least one follow‐up hCG
measurement and follow‐up pelvic
US should be performed before
treatment for ectopic pregnancy.
D. Findings are diagnostic of failed
intrauterine pregnancy. The patient
should be referred for dilatation and
curettage.

2b. Additional images of the right adnexa are shown.

The positive predictive
value (PPV) of the findings
shown in establishing the
diagnosis of ectopic
pregnancy is:
A. 75%
B. 85%
C. 95%
D. 100%

3. What is the earliest intragestational sac structure to be visualized at ultrasound that can absolutely
confirm an intrauterine pregnancy?
A. Amnion
B. Embryo
C. Yolk sac
D. Placenta

4. A 31‐year‐old woman presents to the emergency department with persistent vaginal bleeding after
undergoing medical termination of pregnancy 4 weeks ago. Laboratory values are as follows: WBC
7,418, Hgb 6.1, Hct 19.1, beta‐hCG 2,717. What is the most likely diagnosis?

A. Endometrial
hematoma
B. Uterine arteriovenous
malformation
C. Retained products of
conception
D. Endometritis

5. Based upon the image, what is the
chorionicity and amnionicity of this
pregnancy?

A. Monochorionic, monoamniotic
B. Monochorionic, diamniotic
C. Dichorionic, monoamniotic
D. Dichorionic, diamniotic

6. In the setting of a positive pregnancy test, the
presence of an intrauterine fluid collection with a
smooth, rounded or oval contour most likely represents
which of the following?

A. Ectopic pregnancy
B. Intrauterine pregnancy
C. Adenomyosis
D. Spontaneous abortion

7. What is the crown rump length established by the Society of Radiologists in Ultrasound at which
cardiac activity should be present?
A. 3 mm
B. 5 mm
C. 7 mm
D. 9 mm

8. An anechoic round structure within the head at 8 to 10
weeks of gestation most likely represents which of the
following?

A. Normal ventricles
B. Ventriculomegaly
C. Rhombencephalon
D. Anencephaly

9. A 26‐year‐old female presents with pelvic cramping in
the first trimester. The clinical significance of the
abnormality shown depends on which of the following
criteria?

A. Length of time
B. Size
C. Gestational age
D. Patient’s age

10. Which of the following is the most accurate method to establish gestational age?
A. Mean gestational sac diameter
B. Date of last menstrual period
C. Crown‐rump length
D. Biometric variables from second trimester ultrasound

11. How many yolk sacs will be present in a monochorionic monoamniotic pregnancy?
A. 0
B. 1
C. 2
D. 3

12. A female presents with contractions and a pelvic
ultrasound was performed. Which of the following is shown in
the ultrasound image?

A. Placenta previa
B. Cervical funneling
C. Normal cervix
D. Artifactual shortening of the cervix

13. Which of the following should be used for a first trimester ultrasound performed earlier than 10
weeks’ gestation?
A. Tis
B. Tib
C. Tix
D. Tim

14. Obstetric ultrasound image of the umbilical cord is provided. The most likely diagnosis is:
Image courtesy of Donna Justis, RDMS, and Fidelma B. Rigby, MD, Virginia Commonwealth University
Health System, Richmond, VA.
A. Central insertion
B. Velamentous insertion
C. Eccentric insertion
D. Vasa previa

15. Which of the following should be used to document embryonic heart rate?
A. Spectral Doppler
B. M‐mode
C. Color Doppler
D. B‐mode

16. Which of the following is seen in a normal umbilical cord?
A. Two arteries and one vein
B. One artery and two veins
C. Two arteries and two veins
D. One artery and one vein

17. What is the normal placental thickness?
A. <2 cm
B. 2 to 4 cm
C. >4 cm
D. Variable based on patient’s age

18. What is the significance of the finding shown in this first trimester ultrasound?
Image courtesy of Hazem Hawasli, MD, Henry Ford Hospital, Detroit, MI.
A. They are detected in 80% of first trimester pregnancies.
B. They are more often located toward the placental insertion site.
C. They usually have no clinical significance.
D. The majority persist until delivery.

19. Which of the following actions would be expected to decrease the mechanical index?
A. Increase the center frequency of the ultrasound beam
B. Move focal zone closer to the transducer
C. Increase the ultrasound power output
D. Decrease the gain

20. The thermal index (TI) is:
A. A direct measurement of the temperature increase as a result of tissue absorption of ultrasound
B. An estimate of the increase in temperature of insonated tissues
C. Calculation based on the energy lost within tissues because of scatter
D. Not applicable when following the ALARA (as low as reasonably achievable) principle

21. The following image is from the pelvic ultrasound of a patient in the first trimester. Which of the
following is the most appropriate next step in management of this patient?
Image courtesy of Hazem Hawasli, MD, Henry Ford Hospital, Detroit, MI.

A. Reassure patient of normal pregnancy
B. Short interval follow‐up ultrasound
C. Serial beta hCG measurements
D. Counsel patient on embryonic demise

22. With regard to the potential adverse bioeffects of diagnostic ultrasound on humans:
A. Dose–effect studies have not shown any ultrasound‐induced biological effects.
B. The potential for adverse bioeffects is likely to decrease with more recent advances in ultrasound
equipment.
C. Recent discussions of ultrasound safety are the result of bioeffects having been detected in human
patients.
D. The potential for adverse biological effects exists and may increase with technological advances.

First Trimester Pregnancy: Answers and

Explanations

1a. Answer D.. The first image shows an enlarged uterus with an endometrial mass. The mass is solid
with multiple small cystic spaces, the so‐called “snowstorm” appearance. The next two images show
bilateral enlarged ovaries, each measuring over 7 cm and containing theca lutein cysts. The findings of
a solid/cystic endometrial mass with bilateral enlarged cystic ovaries is most consistent with a molar
pregnancy with bilateral theca lutein cysts in a patient with this history. The beta hCG level in these
patients is abnormally high, usually >100,000 mIU/mL. Theca lutein cysts occur in approximately 15%
to 30% of cases of molar pregnancy because of high hCG levels. This is a case of a complete
hydatidiform mole, which is the most common form of gestational trophoblastic disease. Clinical
presentation includes hyperemesis gravidarum, vaginal bleeding, and vaginal passage of vesicles
corresponding to hydropic villi. The uterus is typically large for dates. The conceptus is diploid with
the most common karyotype being 46, XX because of fertilization of an egg devoid of genetic material
by two haploid sperms with all genetic material being paternal in origin (“daddy’s little girl”).
Choices A and C are incorrect because of the history—one would not expect a woman with
endometrial cancer to present with emesis, nor would she pass vesicles. Also, the 37 year old is
younger than the typical patient with endometrial cancer, who is typically postmenopausal. The
patient has a normal WBC count, so B is not correct.

1b. Answer C. Persistent trophoblastic neoplasia (PTN) can occur after molar pregnancy—complete
or partial, normal pregnancy, abortion, or ectopic pregnancy. The most common form of PTN is
invasive mole characterized by trophoblastic tissue invading the myometrium. Other less common
forms include choriocarcinoma, which is prone to distant metastases, and placental site trophoblastic
neoplasia, which is the most lethal and rare form of PTN.

2a. Answer C. Pelvic US images show normal uterus and normal bilateral ovaries. No intrauterine
gestational sac or fluid is shown. No abnormal adnexal masses are shown either.
As per recommendations of the Society of Radiologists in Ultrasound (SRU) Multispecialty Consensus
Conference on “Early first trimester diagnosis of Miscarriage and Exclusion of a Viable Intrauterine
pregnancy” published in October 2012, if a single hCG measurement is ≥3,000 mIU/mL, a viable
intrauterine pregnancy is possible but unlikely. However, the most likely diagnosis is a nonviable
intrauterine pregnancy, so it is generally appropriate to get at least one follow‐up hCG measurement
and follow‐up ultrasonogram before undertaking treatment for ectopic pregnancy.

2b. Answer D. Images of the right adnexa show a living embryo with cardiac activity. In patients with
positive pregnancy test and no evidence of intrauterine pregnancy (IUP), the positive predictive value
(PPV) of this finding is 100% in diagnosing an ectopic pregnancy. The PPV of an adnexal mass
containing either a yolk sac or nonliving embryo also approaches 100%. A “Tubal” or “adnexal” ring
surrounding a fluid collection has PPV of 95% and a complex or solid adnexal mass without embryo,
yolk sac, or tubal ring has PPV of 92%.

References: Doubilet PM, Benson CB, Bourne T, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester.
Ultrasound Q 2014;30(1):3–9.

3. Answer C. The yolk sac is the primary maternal–fetal transport system before a functioning
placental circulation has fully developed. It is a round 3 to 5 mm cystic structure, found eccentrically
located within the gestational sac, and resides within the chorionic cavity. The yolk sac can be
visualized by approximately 5.5 weeks of gestational age.

Transvaginal US image of the uterus shows the
yolk sac (yellow arrow).
By approximately 6 weeks of gestational age, the
embryo can be identified as a 1 to 2 mm
echogenic focus along the periphery of the yolk
sac. It resides within the amniotic cavity.
The amniotic membrane is thinner than the yolk
sac and is seen more easily after 7 weeks but can
be seen as early as 6.5 weeks of gestational age.
The amnion and chorion fuse at 14 to 16 weeks.

Transvaginal US image of the uterus shows the amnion
(red arrow) and the embryo (white arrow).
References: Bree R, Edwards M, Bohm‐Velez M, et al. Transvaginal
sonography in the evaluation of normal early pregnancy: correlation
with HCG level. AJR Am J Roentgenol 1989;153(1):75–79.
Lindsay DJ, Lovett IS, Lyons EA, et al. Yolk sac diameter and shape at
endovaginal US: predictors of pregnancy outcome in the first trimester.
Radiology 1992;183(1):115–118.

4. Answer C. The first image shows an abnormally thickened endometrium containing a solid mass
with cystic spaces. The second image shows Doppler flow within the mass. Based on the images
provided, the clinical history, and laboratory values, the correct answer choice is C, that is, retained
products of conception. Women with retained products of conception (RPOC) typically present with
abnormal bleeding and is most common after second trimester spontaneous abortion, extreme
preterm birth, medical termination of pregnancy, and placenta accreta. The diagnosis is suggested
when there is a mass in the endometrial canal that shows Doppler flow. However, lack of flow does not
exclude RPOC. Calcifications in the mass, because of normal placental maturation, are highly
suggestive of RPOC.
Choice A, endometrial hematoma, is not the correct answer because there is Doppler flow in the mass,
which would not be present in a hematoma. Choice B, uterine arteriovenous malformation (AVM), can
occur in the post abortion and postpartum periods with severe vaginal bleeding. Sonographically, they
can present as multiple serpiginous structures within the myometrium, or as a myometrial or
endometrial mass. However, these lesions are rare, and the beta hCG level should not be elevated as it
is in this case. Choice D, endometritis, may show endometrial thickening and may or may not contain
fluid and gas. However, clinically these patients present with fever and an elevated WBC count. This
patient’s WBC count is normal.

2011:560–561, 1521–1523.
5. Answer D. This is an example of a dichorionic, diamniotic pregnancy. A thick membrane separates
the two fetuses. A thin membrane is what separates monochorionic, diamniotic twin pregnancies and
is usually barely perceptible on ultrasound. Also, this image is a good example of the “twin peak” or
“lambda” sign, where a triangular‐shaped portion of the chorion extends between the two chorionic
sacs. This sign helps to confirm the presence of two chorions. Once two chorions have been
established, the pregnancy must be dichorionic, diamniotic as dichorionic, monoamniotic twin
pregnancies do not exist.

6. Answer B. Although the presence of the intradecidual or double sac sign is highly suggestive of an
intrauterine pregnancy (IUP), the absence of these signs does not exclude an IUP. Fluid secretions or
blood within the uterine cavity in the setting of an ectopic pregnancy is referred to as a
pseudogestational sac or decidual cast but occurs in only approximately 10% of ectopic pregnancies.
The low incidence of pseudogestational sacs in addition to the much greater incidence of intrauterine
pregnancies in general results in a >99.5% likelihood that a smooth, rounded, or oval intrauterine fluid
collection represents a gestational sac in a pregnant patient. Therefore, these collections should be
treated as IUPs until proven otherwise.
The term pregnancy of unknown location is used when ultrasound shows no definite IUP and normal
adnexa. The differential diagnosis includes a very early IUP, occult ectopic pregnancy, and a completed
spontaneous abortion.
References: Barnhart KT. Ectopic pregnancy. N Engl J Med 2009;361(4):379–387.
Campion EW, Doubilet PM, Benson CB, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med
2013;369(15):1443–1451.
Doubilet PM, Benson CB. First, do no harm…to early pregnancies. J Ultrasound Med 2010;29(5):685–689.
Rodgers SK, Chang C, DeBardeleben JT, et al. Normal and abnormal US findings in early first‐trimester pregnancy: review of the
society of radiologists in ultrasound 2012 consensus panel recommendations. RadioGraphics 2015;35(7):2135–2148.

7. Answer C. Cardiac activity may be detected in embryos as small as 1 to 2 mm, corresponding to
approximately the 6th week of gestation. However, the absence of cardiac motion may be normal in
embryos smaller than 4 mm. In order to account for differing equipment types, measurement
variability, and other variations in ultrasound imaging, a crown‐rump length of 7 mm or greater has
been established by the Society of Radiologists in Ultrasound as the size at which cardiac activity
should be present. A definitive diagnosis of failed pregnancy requires that an embryo is at least 7 mm
and lacks cardiac activity.
References: Campion EW, Doubilet PM, Benson CB, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N
Engl J Med 2013;369(15):1443–1451.

8. Answer C. The rhombencephalon is visible on all exams at 8 to 10 weeks as an anechoic round
structure within the head, representing the developing hindbrain (medulla, pons, and cerebellum).
Anencephaly is the most common anomaly affecting the central nervous system and results from
failure of closure of the rostral portion of the neural tube. The important ultrasound feature is an
absent cranium, which allows diagnosis from 11 weeks onward.
Mild ventriculomegaly is defined as being present when the width of the lateral ventricle, measured at
the atrium, is ≥10 mm.

References: Cardoza JD, Goldstein RB, Filly RA. Exclusion of fetal ventriculomegaly with a single measurement: the width of the
lateral ventricular atrium. Radiology 1988;169(3):711–714.
Cyr DR, Mack LA, Nyberg DA, et al. Fetal rhombencephalon: normal US findings. Radiology 1988;166(3):691–692.
Johnson SP, Sebire NJ, Snijders RJM, et al. Ultrasound screening for anencephaly at 10–14 weeks of gestation. Ultrasound Obstet
Gynecol 1997;9(1):14–16.

9. Answer B. The ultrasound image shows a crescentic hypoechoic fluid collection adjacent to the
gestational sac in the endometrial cavity consistent with subchorionic hemorrhage.
The incidence of subchorionic hemorrhage in first trimester pregnancies with vaginal bleeding has
been reported to be 18% to 22%. Large hematomas encircling more than two‐thirds of the chorionic
circumference are associated with doubling of the risk of pregnancy loss.
References: Bennett GL, Bromley B, Lieberman E, et al. Subchorionic hemorrhage in first‐trimester pregnancies: prediction of
pregnancy outcome with sonography. Radiology 1996;200(3):803–806.
Leite J, Ross P, Rossi AC, et al. Prognosis of very large first‐trimester hematomas. J Ultrasound Med 2006;25(11):1441–1445.

10. Answer C. The most accurate assessment of gestational age during the first trimester up to and
including 13 6/7 weeks is based on measurement of the crown‐rump length (CRL), with an accuracy of
±5 to 7 days. Accuracy improves the earlier in the first trimester that measurements are taken. If
possible, the mean of three discrete CRL measurements should be used for dating. The embryo or fetus
should be imaged in a true midsagittal plane, with the genital tubercle and fetal spine in view. The CRL
is measured from the cranium to the caudal rump as a straight line. Mean sac diameter measurements
are not recommended for estimating the due date.
CRL measurements >84 mm (from ~14 0/7 weeks of gestation) are associated with decreasing
accuracy for gestational age determination. Therefore, second‐trimester biometric parameters should
be used for dating these pregnancies.
The date of last menstrual period (LMP) is typically used to provide an initial calculation of the EDD.
The EDD is LMP + 280 days. This estimate will become inaccurate in women who do not have a regular
28 day menstrual cycle or in those whose ovulation does not occur on day 14. Additionally, it is
estimated that only one half of women accurately recall their LMP. When first trimester gestational age
estimates from ultrasound differ by more than 7 days from LMP dating, the estimated due date (EDD)
should be changed to reflect the ultrasound dating.
Reference: American College of Obstetricians and Gynecologists Committee Opinion No. 611: method for estimating due date.
Obstet Gynecol 2014;124:863–866.

11. Answer B. The number of yolk sacs present in a gestational sac can help determine the
amnionicity of the pregnancy. The number of yolk sacs and the number of amniotic sacs match if the
embryos are alive. For a monochorionic monoamniotic pregnancy, there will be 2 embryos, 1 chorionic
sac, 1 amniotic sac, and 1 yolk sac.
Reference: Tan S, Pektas MK, Arslan H. Sonographic evaluation of the yolk sac. J Ultrasound Med 2012;31(1):87–95.

12. Answer B. The most sensitive predictor of preterm birth is ultrasound measurement of cervical
length. The risk of preterm labor increases with the degree of shortening and is also higher when
discovered earlier. Between 14 and 30 weeks of gestation, the cervix should measure more than 30
mm. Funneling of the cervix refers to an open internal os with gradual narrowing of the cervical canal.
Cervical funneling is almost always accompanied by cervical shortening. The risk of preterm birth is
not increased if cervical funneling is present without shortening.
References: Iams JD, Goldenberg RL, Meis PJ, et al. The length of the cervix and the risk of spontaneous premature delivery. N Engl
J Med 1996;334(9):567–573.
Woodfield CA, Lazarus E, Chen KC, et al. Abdominal pain in pregnancy: diagnoses and imaging unique to pregnancy—review. AJR
Am J Roentgenol 2010;194(6 Suppl):WS14–WS30.

13. Answer A. A Tis (thermal index for soft tissue) is used for gestations earlier than 10 weeks. A
thermal index for bone (Tib) is used for gestations at or later than 10 weeks when bone ossification is
evident.
Reference: AIUM practice parameter for the performance of obstetric ultrasound examinations. 2013.

14. Answer B. The ultrasound image shows insertion of the umbilical cord beyond the placental edge
consistent with velamentous cord insertion.
The typical location of the umbilical cord insertion is centrally within the placental substance.
Variations include eccentric and velamentous insertions. Eccentric insertions occur within 1 cm from
the placental edge. Velamentous insertions occur outside of the placenta along the chorioamniotic
membranes. From the site of aberrant insertion, umbilical vessels travel to the placenta between the
amnion and chorion, unprotected by Wharton jelly and are vulnerable to rupture. When the exposed
vessels cross the internal cervical os (vasa previa), they are particularly at risk of catastrophic
hemorrhage when the supporting membranes rupture or during labor.
Reference: Elasayes KM, Trout AT, Friedkin AM, et al. Imaging of the placenta: a multimodality pictorial review. RadioGraphics
2009;29(5):1371–1391.

15. Answer B. M‐mode imaging should be used instead of spectral Doppler imaging to determine
embryonic/fetal heart rate in order to provide the necessary diagnostic information with the lowest
possible ultrasonic exposure in keeping with the ALARA principle.
Reference: AIUM practice parameter for the performance of obstetric ultrasound examinations. 2013.

16. Answer A. The umbilical cord is considered to be normal when it contains two arteries and one
vein. The cord is a three‐vessel cord as long as any portion of the cord contains three vessels, even if
other segments contain only two vessels. Three vessel cords are found in 90% of singleton gestations.
Fetuses with two vessels cords (one artery and one vein) are at a higher risk for structural
abnormalities and growth restriction.

17. Answer B. Normal placental thickness is between 2 and 4 cm, measured near the midportion of
the organ. Thin placentas are associated with systemic vascular and hematologic disorders leading to
microinfarcts. Thick placentas are associated with fetal hydrops, antepartum infections, maternal
diabetes, and maternal anemia. Note that the placenta may appear to be thickened as a result of
myometrial contractions and adjacent fibroids.
Reference: Elasayes KM, Trout AT, Friedkin AM, et al. Imaging of the placenta: a multimodality pictorial review. RadioGraphics
2009;29(5):1371–1391.

18. Answer C. Pelvic ultrasound image from first trimester pregnancy shows a thin‐walled cyst at the
fetal insertion site of the umbilical cord.
Umbilical cord cysts may represent either true cysts (3.4% of first‐trimester pregnancies) or
pseudocysts. Pseudocysts are more common and represent localized edema and liquefaction of
Wharton jelly and have no epithelial lining. Both cyst types are usually located close to the fetal
insertion site and are not reliably distinguished by ultrasound. Most cysts found in the first trimester
resolve, and therefore have no clinical significance. However, a detailed fetal anatomic survey is
recommended when umbilical cord cysts are detected during the second or third trimesters. A 20%
increased prevalence of chromosomal or congenital defects has been reported in association with the
detection of umbilical cysts.
Arrow points to umbilical cord cyst at the fetal insertion site of the cord.
Reference: Moshiri M, Zaidi SF, Robinson TJ, et al. Comprehensive imaging review of abnormalities of the umbilical cord.
RadioGraphics 2014;34(1):179–196.

19. Answer A. The mechanical index (MI) and thermal index (TI) are attempts to assess the
mechanical and thermal bioeffects of an ultrasound beam. The MI is a measure of the potential of
inducing a cavitation‐related bioeffect with ultrasound. The mechanical index is the peak negative
(rarefactional) pressure/SQRT (center frequency of the beam). Therefore, the MI is inversely
proportional to the center ultrasound beam frequency and will decrease with increasing frequency.
The amplitude (and rarefactional pressure) of acoustic energy is greater near the probe as less energy
is lost to beam attenuation, so moving the focal zone closer would also increase the MI. Finally,
because gain does not affect the ultrasound energy, it does not affect MI.
Reference: AIUM. Section 7—discussion of the mechanical index and other exposure parameters. J Ultrasound Med
2000;19(2):143–168.

20. Answer B. The thermal index (TI) is an estimate of the increase in temperature within an
insonated tissue as a result of tissue absorption of acoustic energy. The TI is the ratio of the acoustic
power to the estimated acoustic power required to raise the tissue temperature by 1°C. Attenuation of
ultrasound energy occurs as a result of absorption and scatter. Absorption results in conversion of
acoustic energy to heat. Thermal and mechanical index values are intended to provide an indicator of
the relative risk of heating and cavitation effects to the sonographer for guidance in following the
ALARA principle.
Reference: American Institute of Ultrasound in Medicine. Medical ultrasound safety, 3rd ed. Laurel, MD: AIUM, 2014.

21. Answer D. Transvaginal ultrasound image from a patient in the first trimester of pregnancy
shows a highly echogenic yolk sac. The imaging appearance is consistent with a calcified yolk sac. A
calcified yolk sac has not been reported to be associated with a live embryo before the 12th week of
gestation and would be observed only with a dead embryo. The yolk sac would undergo calcification
within a few days after embryonic death has occurred. Therefore choice D, “Counsel the patient on
embryonic demise” is correct.
References: Harris RD, Vincent LM, Askin FB. Yolk sac calcification: a sonographic finding associated with intrauterine embryonic
demise in the first trimester. Radiology 1988;166:109–110.
Lyons EA, Levi CS. The first trimester. In: Rumack CM, Wilson SR, Charboneau JW (eds). Diagnostic ultrasound, 3rd ed. St Louis,
MO: CV Mosby Co., 2005:1070–1100.
Tan S, Pektas MK, Arsaln H. Sonographic evaluation of the yolk sac. J Ultrasound Med 2012;31(1):87–95.

22. Answer D. The American Institute of Ultrasound in Medicine (AIUM) approved the statement in
2005 that there was insufficient evidence of a causal relationship between diagnostic ultrasound and
adverse effects in humans. There have not been any known instances of injury arising from exposure
to diagnostic ultrasound. However, ultrasound performed at much higher intensities in dose‐effect
laboratory studies have demonstrated ultrasound‐induced bioeffects and tissue damage. As a result of
increasing applications found for diagnostic ultrasound and the need for greater diagnostic capability,
discussions between the medical community, equipment manufacturers, and the FDA have resulted in
a standard that allows for higher outputs. Thus, the equipment operators must be informed on the
prudent use of ultrasound imaging.

2a. A primigravida is referred at 22 weeks of gestational age for follow‐up of prior abnormal prenatal
ultrasound findings and elevated maternal alpha fetoprotein (1,500 ng/mL).

What additional fetal
anatomic imaging should
be performed?
A. Fetal heart
B. Fetal brain
C. Fetal GU tract
D. Fetal GI tract

2b. Additional images from anatomic imaging of the fetal brain are provided.

A. Meckel‐Gruber syndrome
B. Dandy‐Walker sequence
C. Down syndrome
D. Chiari II malformation

3a. Prenatal
ultrasound
evaluation of a 29‐
week‐old fetus
was performed.
The following
images were
obtained at the
level of the fetal
chest and heart.

What cardiac chambers is the soft tissue mass occupying?
A. Right atrium and right ventricle
B. Left atrium and left ventricle
C. Right atrium and left ventricle
D. Left atrium and right ventricle

3b. Which of the following is most likely to be associated with this cardiac mass?
A. Down syndrome
B. Neurofibromatosis type 2
C. von Hippel‐Lindau
D. Tuberous sclerosis

4. A 21‐year‐old female presents for prenatal ultrasound at 26 weeks and 3 days of gestational age.
Which of the following features is most useful in distinguishing this entity from other congenital lung
masses?

A. Blood supply from
systemic artery
B. Blood supply from
pulmonary artery
C. Presence of mediastinal
shift
D. Absence of mediastinal
shift

5a. Below are images from fetal ultrasound at 18 weeks and MRI at 22 weeks of gestational age.
Postnatal radiograph of the neonatal chest and abdomen is also provided.

Fetal US at 18 weeks of gestational age.

Fetal MRI performed at 22 weeks of gestational age. Postnatal C&AXRay

Morbidity and mortality for this neonate is most likely dependent on which of the following?
A. Congenital heart disease
B. Pulmonary hypoplasia
C. Bowel obstruction
D. Urinary tract obstruction

5b. Which of the following is an appropriate indication for performing a fetal MRI exam?
A. Surveillance of fetal renal pelviectasis
B. Quantification of amniotic fluid volume
C. Assessment for pulmonary hypoplasia
D. Assessment for fetal hydrops

6. Increasing power output during a fetal ultrasound would be appropriate for which of the following
situations?
A. Use of a 12 MHz linear probe fails to visualize all of the fetal anatomy because of insufficient
acoustic penetration.
B. Multiple horizontal echoes are noted within the amniotic fluid close to the probe.
C. Insufficient acoustic penetration prevents complete evaluation of the fetus. The lowest frequency
probe is being used and the gain has been maximized.
D. To decrease the potential bioeffects.

7. Which of the following maneuvers can improve signal without causing an increase in temperature
in fetal tissue?
A. Increasing dwell time
B. Increasing power output
C. Increasing gain
D. Switching from B‐mode to color Doppler

8a. A 42‐year‐old female presents at 28 weeks of
gestation with shortened cervix and multiple fetal
anomalies diagnosed at an outside facility. Fetal
ultrasound at the level of the stomach is shown.

Which of the following syndromes is associated with
this abnormality?
A. Tuberous sclerosis
B. Neurofibromatosis type 1
C. Trisomy 21
D. Trisomy 13

8b. The fetus was delivered by emergent C‐section at 33 weeks
because of nonreassuring fetal heart tracing. Abdominal radiograph
on the first day of life is shown.

Which of the following is the appropriate definitive management for
this patient?
A. Surgical repair
B. Gastric decompression
C. Parenteral nutrition
D. Medical therapy

9. Which of the following ultrasound modes has the highest thermal index and therefore should be
avoided or used in moderation when imaging the embryo or fetus?
A. 3D/4D
B. Color/spectral Doppler
C. M‐mode Doppler
D. Gray‐scale cine

10. The following are images from fetal ultrasound performed at 14 weeks of gestation.

What is the most likely
diagnosis?
A. Gastroschisis
B. Omphalocele
C. Midgut volvulus
D. Small bowel atresia

11a. A 12‐week‐old fetus is being further evaluated for bilateral hydronephrosis (not shown). What is
the most likely etiology for hydronephrosis in this case?

A. Congenital ureteropelvic
junction (UPJ) obstruction
B. Posterior urethral valves
C. Neurogenic bladder
D. Ureterocele

11b. Which of the following portends a favorable prognosis in the setting of posterior urethral valves?
A. Oligohydramnios
B. Diagnosis at <24 weeks of gestational age
C. Perinephric urinoma
D. Urine ascites

12a. The following are images from fetal ultrasound at 32 weeks for follow‐up of a genitourinary
abnormality.

A. Multicystic dysplastic kidney
B. Mesoblastic nephroma
C. Autosomal recessive polycystic renal disease
D. Duplicated renal collecting system

12b. In the setting of a duplicated renal collecting system:
A. Upper moiety ureter inserts orthotopically.
B. Upper moiety ureter inserts ectopically.
C. Lower moiety ureter is associated with ureterocele.
D. Lower moiety ureter is associated with Hutch diverticulum.

13. A 41‐year‐old woman presents at 22 weeks of gestational age for routine fetal anatomic survey.
Images and measurements of the fetal extremities are shown below.

Which of the following is
the best predictor of
lethality in this patient?
A. Craniofacial anomalies
B. Pulmonary hypoplasia
C. Oligohydramnios
D. Genitourinary
anomalies

14. A 30‐year‐old female presents with a 23‐week‐old fetus. The patient was referred for intrauterine
growth restriction.

A. Trisomy 13
B. Trisomy 18
C. Trisomy 21
D. Turner syndrome (45 X)

15. Which of the following maneuvers can theoretically decrease the mechanical index of an
ultrasound study?
A. Set the focal zone further away from the transducer.
B. Increase the ultrasound beam output.
C. Turn on harmonics mode.
D. Decrease the transducer frequency.

16. Which of the following imaging techniques should be performed to confirm the presence of fetal
echogenic bowel in the second trimester?
A. Perform 3D/4D views.
B. Confirm blood flow with Doppler.
C. Turn off tissue harmonics.
D. Use a higher‐frequency transducer (>5 MHz).

17. A 37‐year‐old female presents with a 32‐week‐old fetus measuring small for dates. Images from
Doppler evaluation of the umbilical artery are provided at 32 weeks and 34 weeks of gestational age.
Regarding the umbilical artery Doppler examination shown, which of the following is concerning for
intrauterine fetal distress?

A. Increased peak systolic
flow
B. Decreased peak systolic
flow
C. Increased end‐diastolic
flow
D. Reversed end‐diastolic
flow

Fetal umbilical artery Doppler Fetal umbilical artery Doppler
at 32 weeks.
at 34 weeks.

18a. A 25‐year‐old female with previous ectopic pregnancy and Cesarean section delivery presents
for routine fetal anatomic survey at 20 weeks of gestational age. An image at the lower uterine
segment is shown.

What is the most likely
diagnosis?
A. Vasa previa
B. Placenta previa
C. Choriocarcinoma
D. Placental abruption

18b. Which of the following increases the likelihood of developing placenta previa?
A. Previous vaginal delivery
B. First pregnancy
C. Advanced maternal age
D. Gestational diabetes

19. A 32‐year‐old G2P1 undergoes obstetric ultrasound at 32 weeks of gestational age.

Which of the following is the most
likely diagnosis?
A. Cystic fibrosis
B. Meconium peritonitis
C. Meconium ileus
D. Fetal hydrops

Second and Third Trimester Pregnancy: Answers

and Explanations

1a. Answer C. The fetal US and MRI images show a single central ventricle and fused thalami. No falx
or interhemispheric fissure is present. These imaging findings are consistent with alobar
holoprosencephaly, which is the most severe form of holoprosencephaly. In alobar holoprosencephaly,
there is complete lack of separation of the cerebral hemispheres with a large posterior monoventricle.
Single midline structures such as the falx, interhemispheric fissure, septum pellucidum, and corpus
callosum are absent whereas paired midline structures such as the thalami and basal ganglia are fused.
Holoprosencephaly is a spectrum of congenital abnormalities ranging from incomplete formation of
the falx cerebri and interhemispheric fissure to a complete lack of separation of the cerebral
hemispheres with a large monoventricle. The three types of holoprosencephaly are alobar (most
severe), semilobar, and lobar (least severe). Septooptic dysplasia is considered the mildest form of
lobar holoprosencephaly.
In severe fetal hydrocephalus (choice B), the ventricles are severely dilated, but a thin rim of
preserved cortical tissue is present peripherally. Also, the middle cerebral arteries are preserved in
severe fetal hydrocephalus.
In hydranencephaly (choice A), the cerebral hemispheres of the brain are absent and replaced by sacs
filled with cerebrospinal fluid. An incomplete or complete falx is present. Hydranencephaly is believed
to result from occlusion of the middle cerebral or internal carotid arteries. Usually the cerebellum and
brainstem are formed normally because the posterior circulation is not affected.
Acrania (choice D) is a rare lethal congenital anomaly characterized by an absence of the calvarium.

1b. Answer D. The midline facial abnormalities associated with alobar holoprosencephaly are
cyclopia (single midline eye with failed development of nose with or without a proboscis),
ethmocephaly (small narrow‐set eyes with absence of nose), cebocephaly (small narrow‐set eyes with
a flattened nose and one nostril), cleft palate and lip, and solitary maxillary central incisor.
Facial and calvarial abnormalities help predict the severity of the brain malformation. Therefore, the
presence of facial anomalies should trigger careful search for brain anomalies. “The face predicts the
brain.”
References: Barkovich AJ. Congenital malformations of the brain and skull. In: Barkovich AJ (ed). Pediatric neuroimaging, 4th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2005:291–439.
Winter TC. Diagnostic imaging: obstetrics, 2nd ed. Lippincott Williams & Wilkins, 2011:1–2.

2a. Answer B. The first image is a sagittal view of the fetal spine showing an open spinal dysraphism
or neural tube defect from the L2 to S1 levels. The second image is a coronal view of the lumbosacral
neural tube defect with fluid sac containing spinal elements. These findings are concerning for
myelomeningocele. Because almost all fetuses with an open spinal neural tube defect are found to
have Chiari II malformation, further imaging of the fetal brain is recommended.

2b. Answer D. Axial views of the fetal head demonstrate a small posterior fossa, indentation of the
frontal bones, and enlarged lateral ventricles. (Fetal ventriculomegaly is defined as >10 mm width
across the atria of the posterior or anterior horn of lateral ventricles at any gestational age. The lateral
ventricles in this example measure 12.1 and 12.8 mm, respectively, which is considered moderate
ventriculomegaly).
Chiari II malformation (also known as Arnold‐Chiari malformation), is a congenital malformation of
the spine and posterior fossa. It is characterized by myelomeningocele, small posterior fossa with
descent of the brainstem and cerebellar tonsils, and ventriculomegaly. It is essential to obtain sagittal
and transverse views of the fetal spine on antenatal imaging to evaluate for neural tube defects.
Sonographic findings seen in Chiari II malformation include the lemon sign and the banana cerebellum
sign. The lemon sign is the indentation/concave deformity of the frontal bones. The banana cerebellum
sign describes the abnormal curved shape of the cerebellar hemispheres that is caused by obliteration
of the cisterna magna due to downward shifting of the posterior fossa structures.
Meckel‐Gruber syndrome (choice A) is a lethal autosomal recessive disorder characterized by cystic
dysplastic kidneys, occipital encephalocele, and postaxial polydactyly. In Dandy‐Walker malformation
(choice B), the fourth ventricle is dilated and communicates with the cisterna magna. The posterior
fossa is enlarged, and the tentorium is elevated. The major congenital anomalies in Down
syndrome/Trisomy 21 (choice C) include ventriculoseptal defect, atrioventricular septal defects,
duodenal atresia, and ventriculomegaly.
Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences, 2011:1133,
1257, 1365.
Woodward PJ. Diagnostic Imaging: Obstetrics, 2nd ed. Salt Lake City, UT: Amirsys, 2011.

3a. Answer B. The axial images at the level of the fetal chest (4‐chamber heart views) demonstrate
rounded, echogenic soft tissue masses occupying the left atrium and left ventricle (the most posterior
chamber of a normal fetal heart is the left atrium). The calipers in the second image correspond to a
pericardial effusion.
The three most common fetal cardiac masses are rhabdomyoma (58%), teratoma (19%), and fibroma
(12%). Rhabdomyoma is a benign myocardial tumor (hamartoma). Most of these tumors are
diagnosed before the age of 1 year and are often multiple. In most cases, these lesions regress
spontaneously and no treatment is required. Hemodynamically significant lesions can result in
congestive heart failure, hydrops, pericardial effusion, and arrhythmias by obstructing outflow tracts
or AV valves. They respond well to surgical excision.

3b. Answer D. There is well‐known association of cardiac rhabdomyomas with tuberous sclerosis.
Greater than 50% of patients with cardiac rhabdomyomas are found to have tuberous sclerosis.
Although tuberous sclerosis has many other manifestations in adult patients, they are rare in fetal life,
except for subependymal tubers in the brain.
Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences, 2011:1317–
1318.
Woodward PJ. Diagnostic Imaging: Obstetrics, 2nd ed. Salt Lake City, UT: Amirsys, 2011.

4. Answer A. Ultrasound images show a hyperechoic, wedge‐shaped, solid mass, near the base of the
left lung. Doppler interrogation demonstrates an artery arising from the aorta and supplying blood
flow to the mass. These imaging findings are most consistent with a bronchopulmonary sequestration.
Bronchopulmonary (BP) sequestration is a congenital lung malformation in which nonfunctioning
lung tissue is present without communication to the tracheobronchial tree. Bronchopulmonary
sequestrations receive vascular supply from a systemic artery arising either from the thoracic or
abdominal aorta. The two main types of bronchopulmonary sequestrations are intralobar and
extralobar. Intralobar sequestration shares pleura with the normal lung, and extralobar sequestration
is covered by its own separate pleura. Sequestrations are often found in the lower lobes and are more
common on the left.
Bronchopulmonary sequestrations are not supplied by pulmonary artery (choice B). Any large chest
mass, including a large BP sequestration, can result in mediastinal shift. The presence or absence of
this finding does not aid in distinguishing it from other lesions (choices C and D).

5a. Answer B. Ultrasound images of the fetal thorax at 18 weeks of gestational age show echogenic
contents in the left hemithorax with mediastinal shift to the right. MRI of the fetus in the coronal plane
at 22 weeks demonstrates multiple fluid‐filled bowel loops within the left hemithorax with shift of the
heart and mediastinum to the right. Postnatal radiography of the chest and abdomen demonstrates
air‐filled bowel loops in the left hemithorax with shift of the heart and mediastinum to the right. These
imaging findings are consistent with left‐sided congenital diaphragmatic hernia (CDH).
The herniated bowel loops cause mass
effect on the developing lung resulting
in pulmonary hypoplasia, which is the
main cause of morbidity and mortality
in these patients. Such neonates are
hypoxic and have persistent fetal
circulation due to pulmonary
hypoplasia and pulmonary
hypertension.

5b. Answer C Choice C, “Assessment for pulmonary hypoplasia” is the best answer because MR‐
derived fetal lung volumes will provide unique information which can help direct management
decisions. The other options are not appropriate indications for MRI because the information can be
obtained with US. According to the ACR–SPR Practice Parameter for the Safe and Optimal Performance
of Fetal Magnetic Resonance Imaging (MRI) published in 2015, fetal MRI is indicated in the following
situations:
 When an abnormality on ultrasound is not clearly defined and more information is sought in
order to make a decision about therapy, delivery, or to advise a family about prognosis. Example: a
potential anomaly in the setting of maternal obesity, oligohydramnios, or advanced gestational age.
 When an abnormality is identified on ultrasonography and the treating physician desires MR‐
specific information in order to make decisions about care. Example: calculation of MR‐derived fetal
lung volumes in cases of congenital diaphragmatic hernia.

 When a fetus is significantly at risk for abnormality that will affect prognosis even if no finding
is discovered with ultrasound. Example: neurologic ischemia after laser ablation of placental
anastomoses in twin‐to‐twin transfusion syndrome.
References: American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic
Resonance Imaging (MRI). Philadelphia, PA: ACR, 2015.

6. Answer C. In order to minimize the risk of potential bioeffects from ultrasound, power output and
examination time should be minimized as much as possible. Power output determines the amplitude
of the acoustic energy transmitted by the probe. Probe transmit frequency needs to be selected to
optimize tissue penetration, and gain settings must be optimized before increasing power.
Parallel echoes seen within anechoic structures near the probe represent reverberation artifact.
Reverberation artifact occurs when the beam encounters a highly reflective surface and reflects
multiple times between the surface and the probe face, creating a number of artifactual parallel echoes
deep to the original reflector.

7. Answer C. Increasing receiver gain improves signal without any effect on the output of the
outgoing ultrasound beam. Therefore, it will not cause increase in temperature and is safe to
manipulate.
Dwell time (choice A) is the actual scanning time/duration of exposure. The risk of tissue heating is
increased with the dwell time. Increasing power output (choice B) will result in higher exposure of the
patient to ultrasound energy. Temperature elevations become progressively greater from B‐mode to
color Doppler to spectral Doppler applications (choice D).
2011:41.

8a. Answer C. Fetal ultrasound shows dilated stomach in the left upper abdomen and dilated
duodenal bulb in the right mid abdomen consistent with a double‐bubble sign. It is important to show
communication between the two fluid‐filled structures to confirm that they are in fact the stomach and
duodenum. The presence of this finding should raise concern for duodenal atresia. Polyhydramnios is
also frequently seen in fetuses with duodenal atresia.
Approximately one‐third of fetuses with duodenal atresia have trisomy 21. Therefore, when the
double‐bubble sign is encountered, a detailed scan should be performed to evaluate for other
sonographic markers of trisomy 21.
The other answer choices including tuberous sclerosis, neurofibromatosis type 1, and trisomy 13 may
have gastrointestinal manifestations after birth. However, the presence of a double‐bubble sign in
utero due to duodenal atresia is unique to trisomy 21 (Down syndrome) and VACTERL (vertebral
defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb
abnormalities) sequence.

8b. Answer A. Abdominal radiograph of the neonate shows dilated stomach and duodenal bulb along
with lack of distal bowel gas. If the neonate presents with bilious emesis and decompressed stomach
on abdominal radiograph, an upper GI contrast study may be needed to exclude malrotation with
volvulus.

The definitive treatment for infants with duodenal atresia is surgery, with duodenoduodenostomy
being the procedure of choice. Gastric decompression and parenteral nutrition may be required to
stabilize the infant prior to surgery.
Juang D, Snyder CL. Neonatal bowel obstruction. Surg Clin North Am 2012;92(3):685–711.

9. Answer B. Absorption of sound waves may cause heating in tissue. The thermal index (TI) is a
measure of an ultrasound beam’s thermal bioeffects. It provides an indication of the relative potential
for increasing tissue temperature, but it is not meant to provide the actual temperature rise. It is often
displayed on ultrasound screens, along with the mechanical index.
Temperature elevations become progressively greater from B‐mode to color Doppler to spectral
Doppler applications. Color and spectral Doppler imaging uses increased levels of ultrasound output
power. Therefore, the use of color and spectral Doppler is discouraged when imaging an embryo.
Reference: Bigelow TA, Church CC, Sandstrom K, et al. The thermal index: its strengths, weaknesses, and proposed improvements.
J Ultrasound Med 2011;30(5):714–734.
Official statement. http://www.aium.org/officialStatements/17. Accessed March 1, 2017.

10. Answer B Ultrasound images of fetal abdomen demonstrate a midline abdominal wall defect with
herniation of abdominal contents, covered by a membrane, consistent with an omphalocele.
Omphaloceles are congenital defects in the abdominal wall at the umbilicus with herniation of
abdominal contents that are covered by a membrane. The covering membrane in omphaloceles
consists of the amnion and peritoneum and acts as a protective layer. The umbilical cord inserts into
the herniated sac, usually along its anterior portion.
Gastroschisis (choice A) is also an abdominal wall defect. It is usually to the right of the umbilicus. The
umbilical cord is normally inserted at the umbilicus in these cases. In gastroschisis, there is no
membrane covering the herniated abdominal contents, which freely float in the amniotic fluid. An
abdominal wall defect will not be seen in midgut volvulus and primary small bowel atresia (choices C
and D), although small bowel volvulus, intussusception, atresia, stenosis and growth restriction can be
seen as complications of abdominal wall defects.

11a. Answer B. Coronal images of the fetal abdomen and pelvis demonstrate a dilated urinary
bladder and dilated posterior urethra (keyhole sign). There is diffuse thickening of the bladder wall,
better appreciated on the second image. Note the absence of amniotic fluid compatible with
oligohydramnios. These imaging findings are characteristic of posterior urethral valves.
Posterior urethral valves are the most common cause of bladder outlet obstruction in the fetus. They
occur only in male fetuses. There is dilatation of the urinary bladder and the posterior urethra
proximal to the valves resulting in a characteristic “keyhole” sign. The urinary bladder is distended
and hypertrophied. In severe cases, oligohydramnios and renal dysplastic changes can occur and are
considered poor prognostic indicators.
Congenital UPJ obstruction (choice A) can be unilateral or bilateral. The urinary bladder is of normal
size and morphology in UPJ obstruction. Neurogenic bladder (Choice C) can be seen in fetuses with
spina bifida. Ureteroceles (choice D) appear as round thin‐walled cystic structures on the posterior
bladder wall at the level of the ureterovesical junction.

11b. Answer D. In severe cases of posterior urethral valves, the bladder or calyces may rupture
resulting in urine ascites or perinephric urinoma. Urine ascites portends a favorable prognosis as it
indicates relief of pressure in the dilated collecting system and prevention of further renal damage.
Although perinephric urinoma (choice C) also indicates decompressed renal collecting system, it can
compress the kidney and lead to renal injury. Oligohydramnios (choice A) and early in utero diagnosis
of posterior urethral valves (choice B) indicate poor diagnosis because of the pulmonary and urinary
tract sequelae.
1377.

12a. Answer D. Ultrasound images demonstrate a dilated left renal pelvis and dilated left ureter. A
thin‐walled cystic structure is present in the fetal bladder. Of the choices provided, this is most likely a
case of duplicated left renal collecting system with a dilated left upper pole renal pelvis and associated
ureterocele in the bladder. The most common sonographic appearance in duplicated renal collecting
system is hydronephrosis of the upper‐pole moiety, with a dilated ureter and a ureterocele within the
bladder. It is often difficult to identify two separate collecting systems or nondilated lower pole moiety
as it may be small or displaced by the dilated upper pole collecting system.
Duplicated renal collecting systems can have either complete or partial duplication of the ureters.
When there is complete duplication of the ureters, the upper pole ureter may insert into the bladder or
into the urethra or vagina. If in the bladder, it usually inserts medial and inferior to the lower pole
moiety ureter and frequently ends in a ureterocele.
In multicystic dysplastic kidney (choice A), the kidney is replaced by multiple cysts of varying sizes,
which do not communicate with each other (differentiating it from a dilated collecting system).
Mesoblastic nephroma (choice B) is the most common congenital renal tumor and is seen as a solid
mass in the kidney. It is a benign hamartoma. Autosomal recessive polycystic renal disease (ARPKD)
(choice C) is characterized by large bilateral echogenic kidneys. The renal cysts in ARPKD are below
the resolution of ultrasound but produce multiple acoustic interfaces that result in the characteristic
echogenic appearance.

12b. Answer B. The upper pole moiety ureter often inserts in the bladder ectopically medial and
inferior to the lower pole moiety ureter and frequently ends in a ureterocele. The lower renal moiety
ureter inserts orthotopically lateral and superior to the upper pole ureter. This is known as the
Weigert‐Meyer rule. Usually, the upper pole obstructs and the lower pole refluxes.
Therefore, choices A and C are incorrect. A Hutch diverticulum (choice D) is a congenital bladder
diverticulum, almost exclusively in males. It is present at the vesicoureteral junction and alters the
normal oblique insertion of the ureter resulting in vesicoureteral reflux.
1374.

13. Answer B. Ultrasound images of fetal extremities depict limb shortening (femur length <2.3
percentile, tibia and fibula length <5 percentile, and humerus length <5 percentile for gestational age)
along with abnormal angulation of long bones. These findings are concerning for skeletal dysplasia. A
short femur is defined as below the 5th percentile or below two standard deviations (SD) from the
mean for the gestational age. When the long bones measure less than two SD for gestational age, short‐
interval follow‐up ultrasound evaluation is recommended in 3 to 4 weeks to evaluate interval growth.

Pulmonary hypoplasia is the most important predictor of lethality in skeletal dysplasia. Fetal thorax
measurements such as thoracic circumference, thoracic/abdominal circumference ratio, thoracic
length, rib lengths, and AP diameter of thorax help evaluate for pulmonary hypoplasia.
Thoracic/abdominal circumference ratio of <0.8 is considered abnormal. Short and horizontal ribs
that do not encircle the chest and a bell‐shaped chest indicate pulmonary hypoplasia.
1396.

14. Answer B. Fetal ultrasound images depict choroid plexus cysts, ventricular septal defect, and
clenched hands with possibly overlapping fingers. These findings together are concerning for trisomy
18 (Edwards syndrome).
Trisomy 18 is the second most common autosomal aneuploidy (after trisomy 21). Most affected
fetuses die either in utero or soon after birth. Survivors beyond first year have severe mental and
physical disabilities. There is a high incidence of intrauterine growth restriction (IUGR) in fetuses with
trisomy 18. IUGR in combination with polyhydramnios is highly predictive of trisomy 18. Major
abnormalities seen in trisomy 18 include cardiac defects (such as AVSD, ventricular septal defect,
coarctation of the aorta, and hypoplastic left heart), CNS anomalies (abnormal cerebellum, abnormal
cisterna magna, neural tube
defects), cystic hygroma,
choroid plexus cysts,
strawberry‐shaped skull,
micrognathia, omphalocele,
diaphragmatic hernia,
clenched hands, radial ray
anomalies, and clubfeet and
rocker‐bottom feet.

1136.

15. Answer A. The mechanical index (MI) predicts cavitation. It evaluates the likelihood of cavitation‐
related adverse biological effects for diagnostically relevant exposures. The MI is proportional to an
ultrasound beam’s peak negative pressure. It is also inversely proportional to the frequency of the
beam. Therefore, higher frequencies have a lower mechanical index. MI can be decreased by setting
the focal zone further away from the transducer or by decreasing the ultrasound beam output. In the
United States, the FDA mandates that the MI be kept below 1.9.
Reference: American Institute of Ultrasound in Medicine. Section 7—discussion of the mechanical index and other exposure
parameters. J Ultrasound Med 2000;19(2):143–148, 154–168.

16. Answer C. The echogenicity of fetal bowel is a marker for many fetal anomalies. It is assessed
during the second trimester. Fetal bowel is considered echogenic when it is at least as echogenic as
bone. The iliac wing is the usual standard for comparison. Several factors, such as use of a high‐
frequency transducer (>5 MHz) or use of tissue harmonic imaging can erroneously increase bowel
echogenicity by increasing image contrast. Therefore, it is important to turn harmonics off and use
transducer frequency of 5 MHz or less when evaluating fetal bowel.
When echogenic bowel is an isolated finding, it is usually not clinically significant and resolves as the
pregnancy progresses. However, in association with other findings, it can be seen in cystic fibrosis,
chromosomal abnormalities such as trisomy 21, CMV, and some other in utero infections and bowel
obstruction.
References: Chasen ST. Fetal echogenic bowel. In: Post TW (ed). UpToDate. Waltham, MA: UpToDate, 2016.

17. Answer D. Ultrasound Doppler images of the umbilical artery demonstrate absence and reversal
of end‐diastolic blood flow, at 32 and 34 weeks, respectively.
In normal pregnancies, S/D (peak systolic/end diastolic) ratio in the umbilical artery decreases
throughout the second and third trimesters indicating decreasing placental resistance and increasing
diastolic flow. In the case shown here, the placental end‐diastolic flow is at first absent and
subsequently reversed. These Doppler findings are indicators of uteroplacental insufficiency and
intrauterine growth restriction.

18a. Answer B. Sagittal views of the lower uterine segment and cervix demonstrate the placenta
covering the entire internal cervical os.
A complete placenta previa is defined as complete coverage of the cervical os by the placenta. Marginal
placenta previa is when the placenta is at the edge of the internal cervical os. When the placental edge
is within 2 cm of the internal cervical os but does not cover any portion of the os, it is called a low
placenta. Painless vaginal bleeding after 20 weeks of gestation should raise concern for placenta
previa and should prompt sonographic examination before digital vaginal examination to avoid risk of
hemorrhage. Complications of placenta previa include severe hemorrhage, preterm birth, and need for
cesarean section.
Vasa previa (choice A) occurs when the umbilical cord vessels overlie the internal cervical os. It may
occur in cases of velamentous cord insertion or with umbilical cord vessels traversing between the
placenta and a succenturiate lobe. Choriocarcinoma (choice C)
is a type of gestational trophoblastic neoplasm (GTN). On
ultrasound, hypervascular heterogeneous endometrial
mass/es frequently with areas of necrosis and hemorrhage
are seen in a patient with persistent enlarged uterus, irregular
bleeding, and elevated beta hCG following evacuation of a
molar pregnancy. Myometrial or parametrial invasion may
also be present. Placental abruption (choice D) presents with
third trimester vaginal bleeding and abdominal pain. It is
characterized by hematoma between the placenta and the
uterine wall.

18b. Answer C. The risk for placenta previa increases with advanced maternal age. Other risk factors
include prior placenta previa, prior cesarean section, prior suction curettage, multiparity, smoking, or
cocaine use.
References: Lockwood CJ, Russo‐Stieglitz K. Clinical features, diagnosis, and course of placenta previa. In: Post TW (ed). UpToDate.
Waltham, MA: UpToDate, 2016.
1504.
Winter TC. Diagnostic imaging: obstetrics, 2nd ed. Lippincott Williams & Wilkins, 2011:1–2.

19. Answer D. Ultrasound images show fetal ascites, skin thickening, pleural effusion, maternal
polyhydramnios, and absence of end‐diastolic flow on umbilical artery Doppler interrogation. These
findings are most suggestive of fetal hydrops.
Fetal hydrops is the presence of excess fetal fluid due to imbalance of interstitial fluid. There are many
etiologies of fetal hydrops. Sonographic findings include ascites, pleural effusions, pericardial effusion,
subcutaneous edema, polyhydramnios, and placental edema. In cases of fetal hydrops, ultrasound
techniques such as biophysical profile, pulsed Doppler evaluation of umbilical and regional fetal
vessels, and cardiac assessment can be performed to evaluate fetal well‐being. Absence of end‐
diastolic flow in the case shown here is a poor prognostic sign.
Fetal hydrops is divided into two types, based on etiology: immune and nonimmune. Immune hydrops
results from maternal production of antibodies against fetal antigens whereas nonimmune hydrops
can result from a wide variety of etiologies, the most common being cardiovascular, chromosomal,
thoracic masses, twin‐to‐twin transfusion, and in utero infections.

References: Hertzberg BS,
Middleton WD. Ultrasound: the
requisites, 3rd ed. Philadelphia,
PA: Elsevier, 2016:318–320.
Rumack CM, Wilson SR,
Charboneau WJ. Diagnostic
ultrasound, 4th ed. Philadelphia,
PA: Elsevier Health Sciences,
2011:1424–1450.

5. What is the most likely etiology of the imaging findings shown for this liver transplant patient?

A. Hepatic vein thrombosis
B. Portal vein thrombosis
C. Hepatic artery thrombosis
D. Inferior vena cava thrombosis

6. What is the most common vascular complication of orthotopic liver transplant?
A. Portal vein thrombosis
B. Hepatic artery thrombosis
C. Hepatic vein thrombosis
D. Pseudoaneurysm

7. Following cadaveric liver transplantation 9 months ago, a patient undergoes surveillance
ultrasound and is found to have new‐onset ascites, pleural effusion, hepatomegaly, and distension of
the hepatic veins. The most likely explanation for these findings is:
A. Hepatic artery stenosis
B. Portal vein stenosis
C. Vena caval stenosis
D. Biliary stenosis

8. The following image was obtained immediately
following percutaneous biopsy of the transplanted
kidney. The most appropriate next step is:

A. Short‐term follow‐up ultrasound
B. CT angiography
C. Coil embolization
D. Surgical repair

9. A patient underwent renal transplant 8 months ago and
presents for follow‐up imaging. What is the significance of the
spectral waveform obtained during surveillance imaging?

A. Renal artery stenosis
B. Pseudoaneurysm
C. Arteriovenous fistula
D. Renal vein thrombosis

10. The technologist could not identify flow in the portal vein of a liver transplant patient. What
adjustments should be made to the wall filter and pulse repetition frequency (PRF)?
A. Decrease wall filter and decrease PRF
B. Decrease wall filter and increase PRF
C. Increase wall filter and decrease PRF
D. Increase wall filter and increase PRF

11. Spectral Doppler aliasing can be reduced by:
A. Decreasing the scale
B. Using a lower‐frequency transducer
C. Sampling at a greater depth
D. Choosing a Doppler angle closer to 0 degrees

12. Ultrasound images focused on the portal venous system are shown in a patient with known
cirrhosis and hepatocellular carcinoma. What is the most specific sign of the abnormality shown?

A. Cavernous transformation
B. Echogenic clot
C. Luminal expansion
D. Arterial flow within the clot

13. A 28‐year‐old male with right scrotal pain is referred for an ultrasound examination to evaluate
for testicular torsion. No color flow is detected within either testis. In order to ensure that the finding
is not artifactual, how should color priority threshold be adjusted?
A. Color priority threshold should be increased.
B. Color priority threshold should be decreased.
C. Color priority threshold does not affect Doppler sensitivity.

14. Which of the following will increase the Doppler sensitivity?
A. Increase wall filter.
B. Increase ensemble length.
C. Increase pulse repetition frequency.
D. Increase Doppler beam steering.

15. In the following hepatic venous waveform, during
which phase of the cardiac cycle does the annotated
portion of the hepatic venous waveform occur?

A. Early diastole
B. Late diastole
C. Early systole
D. Late systole

16. What is the most likely etiology of the high‐
velocity spikes in the following Doppler spectral
tracing of the portal vein?

A. Stenosis
B. Clot
C. Gas
D. Septic emboli

17. What is the most likely etiology for the following
spectral waveform obtained from this patient’s left
hepatic vein?

A. Mitral regurgitation
B. Right‐sided heart failure
C. Tricuspid regurgitation
D. Hepatic vein compression

18. Doppler interrogation of the distal right internal
carotid artery (ICA) was performed. Which of the
following most likely resulted in this waveform?

A. Ipsilateral ICA stenosis
B. Contralateral ICA stenosis
C. Ipsilateral ECA stenosis
D. Contralateral ECA stenosis

19. Which of the following is true of compound imaging?
A. Increases temporal resolution
B. Increases signal‐to‐noise ratio
C. Increases the field of view
D. Improves visualization of deep structures

20a. What is the best description of the
abdominal aorta? Sagittal (top) and transverse
(bottom) images are shown.

A. Saccular aneurysm
B. Fusiform aneurysm
C. Pseudoaneurysm
D. Ruptured aneurysm

20b. What is the annual risk of rupture for an abdominal aortic aneurysm >5 cm?
A. 0%
B. 2%
C. 5%
D. 10%
E. 20%

20c. When present, which of the following is associated with a 40% coincidence of abdominal aortic
aneurysm?
A. Thoracic aortic aneurysm
B. Renal artery aneurysm
C. Splenic artery aneurysm
D. Popliteal artery aneurysm

21a. A right upper quadrant ultrasound is
performed to evaluate this patient for abdominal
distension. Based on these color flow Doppler
images of the liver, select the best diagnosis.

A. Hepatic artery thrombosis
B. Intrahepatic portosystemic shunt
C. Cavernous transformation of the portal vein
D. Arteriovenous malformation

21b. What would be the ultrasound appearance of the main portal vein (MPV) in this patient?
A. MPV will not be seen.
B. MPV will be narrowed in caliber.
C. MPV will be of normal caliber.
D. MPV will be abnormally dilated.

22. The axial resolution of gray‐scale imaging is generally better than that of pulsed Doppler. Why?
A. Shorter pulse lengths are used in pulsed Doppler.
B. Longer pulse lengths are used in pulsed Doppler.
C. Axial resolution is independent of pulse length.
D. Axial resolution is equal to pulse length × 2.

23. Color and duplex Doppler sonography of
a transjugular intrahepatic portosystemic
shunt (TIPS) was performed for routine
follow‐up. What is the most likely diagnosis?

A. Normal TIPS
B. Hepatic vein stenosis
C. TIPS stenosis, portal end
D. TIPS stenosis, hepatic end
E. TIPS occlusion

24. High‐resolution ultrasound images from right forearm of a 55‐year‐old woman with erythema and
edema in the right forearm are shown. What is the most likely diagnosis?

A. Superficial
thrombophlebitis
B. Cellulitis
C. Acute deep venous
thrombosis (DVT)
D. Anterior interosseous
nerve syndrome (Kiloh‐
Nevin syndrome)

25. Right upper quadrant ultrasound showing transverse and long‐axis images of inferior vena cava in
a 56‐year‐old woman with abdominal pain are provided. What is the most likely diagnosis?

A. Severe tricuspid regurgitation (because of dilated IVC and hepatic veins)
B. Cranial extension of bland pelvic or lower limb deep venous thrombosis
C. Migration of an infrarenal IVC filter into retrohepatic portion of inferior vena cava
D. Leiomyosarcoma of inferior vena cava

26. Shown here are duplex Doppler ultrasound images of a 40‐year‐old woman undergoing
preoperative evaluation for a pancreatic head neuroendocrine tumor. The images show spectral
waveforms of celiac axis during expiration and inspiration. What is the next best step in management
of this patient?

A. The increased peak systolic velocity of celiac axis in expiration suggests collateral flow through
celiac axis to compensate for severe stenosis or occlusion of superior mesenteric artery. Patient needs
stenting of SMA.
B. The increased peak systolic velocity in the celiac axis confirms malignant infiltration of celiac axis
by the pancreatic tumor contraindicating Whipple procedure. Patient is only eligible for medical
management.
C. The increased diastolic flow in the celiac axis on expiration is suggestive of proximal aortic stenosis.
Patient needs to undergo placement of an aortic endovascular stent graft.
D. The findings are characteristic of median arcuate ligament compression of celiac axis. This patient
can benefit from surgical release of median arcuate ligament.

27. A 30‐year‐old female presents with gradually worsening left lower extremity pain and burning.
Her symptoms first began in 2011, and she decided to seek medical attention in 2014 when she
started having great difficulty walking. The patient underwent ultrasound, which prompted
subsequent MRI. Images from both studies are shown. What is the most likely etiology of her
symptoms?

A. Giant cell arteritis
B. Takayasu arteritis
C. Polyarteritis nodosa (PAN)
D. Granulomatosis with
polyangiitis (GPA)

28. A lower extremity venous Doppler study was performed. The left common femoral vein spectral
Doppler waveform is noted to be monophasic, whereas the right common femoral vein spectral
Doppler waveform is phasic. What is the significance of this finding?
A. Deep vein thrombosis is suspected upstream to the left common femoral vein.
B. Deep vein thrombosis is suspected within in the left common or external iliac vein.
C. Deep vein thrombosis is suspected within in the right common or external iliac vein.
D. This is an expected normal finding on lower extremity ultrasound examinations.

29. Ultrasound imaging of the left calf showed an expanded, noncompressible left gastrocnemius vein.
How should this finding be reported?
A. Positive for deep vein thrombosis.
B. Negative for deep vein thrombosis.
C. Positive for superficial thrombophlebitis.
D. Negative for superficial thrombophlebitis.
E. Indeterminate for deep vein thrombosis. Further imaging with MRV is advised.

30. A 50‐year‐old patient with a carotid bruit was referred for a neck ultrasound after an abnormality
was detected on the carotid artery Doppler. Images from a neck ultrasound, a T1‐weighted
gadolinium‐enhanced axial MRI at the level of the lesion, and a digital subtraction angiogram after
injection into the common carotid artery are provided. What is the most likely cause of the bruit?

A. Metastatic disease from thyroid
cancer
B. Carotid artery dissection
C. Ectatic innominate/proximal
common carotid artery
D. Carotid body paraganglioma
E. Large partially thrombosed carotid
artery aneurysm causing severe
stenosis

31. Which of the following will not affect the calculation of resistive index?
A. Doppler angle
B. Peak systolic velocity
C. End‐diastolic velocity
D. Absence of diastolic flow

32. Selected color and duplex Doppler images of a liver transplant are provided. What other
sonographic findings would support the diagnosis shown in the image?

A. Increased echogenicity of the portal triads
B. Parvus–tardus waveform of the
intrahepatic arteries
C. Thrombus in the IVC piggyback
anastomosis
D. Dilation of the portal vein in the porta
hepatis
E. Lack of flow in the right and left portal
veins

33. Changing the “Doppler scale” on the ultrasound machine results in change in which of the
following?
A. Gain
B. Field of view
C. Doppler angle
D. Pulse repetition frequency

34. Which one of the following will improve Doppler sensitivity?
A. Increasing wall filter
B. Decreasing gain
C. Increasing Doppler angle
D. Decreasing Doppler scale

35. To avoid aliasing artifacts, the pulse repetition frequency (PRF) must be:
A. At least two times the highest Doppler frequency shift
B. Same as the highest Doppler frequency shift
C. At least half of the highest Doppler frequency shift
D. At least a quarter of the highest Doppler frequency shift

36. Where does laminar flow occur in blood vessels?
A. In the center of large smooth vessels
B. In the periphery of large smooth vessels
C. At the bifurcation of large smooth vessels
D. At sites of stenosis in large smooth vessels

37. A 30‐year‐old male patient with left calf pain and swelling underwent lower extremity venous
ultrasound imaging. Gray‐scale images without (left) and with compression (right) are shown. Color
and spectral Doppler images are also shown. What is the most likely diagnosis?

A. Acute popliteal vein
thrombosis
B. Chronic popliteal vein
thrombosis
C. Normal study
D. Popliteal artery aneurysm

38. What is the range for the preferred Doppler angle?
A. 0 to 30 degrees
B. 30 to 60 degrees
C. 60 to 90 degrees
D. 90 to 120 degrees

39. What is the term describing the generation, growth, vibration, and possible collapse of
microbubbles within tissue as a result of ultrasound pressure waves?
A. Cavitation
B. Thermal bioeffect
C. Ring‐down artifact
D. Scatter

40a. A 48‐year‐old female complains of abdominal pain 4 days following right hepatic
trisegmentectomy (removal of the right hepatic lobe and medial segment of the left hepatic lobe) for
excision of liver metastases. Spectral Doppler sonography of the right upper quadrant was performed.
What is the most likely explanation of
these findings?

A. High‐grade stricture of the left
hepatic artery
B. Formation of arteriovenous fistula
C. Pseudoaneurysm of the left hepatic
artery
D. Expected postsurgical appearance of
left hepatic artery

40b. Which of the following artifacts is shown in
this color Doppler image of the left hepatic lobe
in the same patient?

A. Twinkling artifact
B. Comet‐tail artifact
C. Tissue vibration artifact
D. Blooming artifact

41. A 45‐year‐old female has a recurrent pulmonary embolism after placement of an IVC filter.
Transverse images at the level of the infrarenal abdominal aorta are shown. What is the most likely
source of her recurrent pulmonary embolism?

A. IVC filter
B. Right upper extremity
C. Right lower extremity
D. Left lower extremity

42. What is indicated by the arrow on these images?

A. Thrombus
B. Intima
C. Media
D. Adventitia

43. Doppler evaluation of a patient with cirrhosis was performed. The ultrasound images show:

A. Hepatopetal flow in the main portal vein and
hepatopetal flow in the recanalized paraumbilical vein
B. Hepatopetal flow in the main portal vein and
hepatofugal flow in the recanalized paraumbilical vein
C. Hepatofugal flow in the main portal vein and
hepatopetal flow in the recanalized paraumbilical vein
D. Hepatofugal flow in the main portal vein and
hepatofugal flow in the recanalized paraumbilical vein

44. In a complex system, hazards are prevented from causing human losses by a series of barriers.
Each barrier has unintended weaknesses. When, by chance, all weaknesses are aligned, the hazard
reaches the patient and causes harm. This tool used in risk analysis and management is called:
A. Swiss cheese model
B. Toxic cascade
C. Just culture
D. Person approach

45. A 62‐year‐old female with history of multiple myeloma presented with jaundice and
hepatomegaly. Ultrasound evaluation showed the following hepatic venous waveforms. Which of the
following choices represents the most likely etiology of the waveform abnormality shown?

A. Tricuspid regurgitation
B. Metastatic infiltration
C. Right heart failure
D. Portal vein thrombosis

46. Patient A and patient B have the same last names. Patient A was scheduled for inferior vena cava
filter placement, and patient B was scheduled for transjugular liver biopsy on the same day. The
radiologist inadvertently performed the transjugular liver biopsy on patient A. Who is the potential
“second victim” in this scenario?
A. Patient A
B. Radiologist
C. Radiology information system
D. Ultrasound department

47. When health care professionals are aware that they are being observed, they are significantly
more likely to comply with hand hygiene guidelines. This is an example of which of the following?
A. Weber effect
B. Hawthorne effect
C. Placebo effect
D. Pygmalion effect

48. Which of the following is the primary determining factor for grading carotid artery stenosis?
A. Internal carotid artery/common carotid artery peak systolic velocity (ICA/CCA PSV) ratio
B. Peak systolic velocity (PSV)
C. Presence of calcified plaque
D. Location of stenosis

49a. What degree of ICA stenosis is depicted in the images?

A. Complete
occlusion
B. <50%
C. 50% to 69%
D. ≥70%

49b. Which velocity parameters can be used to diagnose near‐complete occlusion of the internal
carotid artery (ICA)?
A. Peak systolic velocity (PSV) >230 cm/s
B. Peak systolic velocity (PSV) <100 cm/s
C. End‐diastolic velocity (EDV) >100 cm/s
D. None of the above

50. Which of the following can be characterized as a normal internal carotid artery?
A. Peak systolic velocity <100 cm/s with or without intimal thickening or visible plaque
B. Peak systolic velocity >80 cm/s without intimal thickening or visible plaque
C. Peak systolic velocity <125 cm/s without intimal thickening or visible plaque
D. Peak systolic velocity >230 cm/s without intimal thickening or visible plaque

51a. A 65‐year‐old woman presents with a
transient episode of dysarthria and ataxia. A
carotid artery Duplex US was performed. The
images show:

A. Flow reversal in the vertebral artery
B. Internal carotid artery occlusion
C. Contralateral vertebral artery occlusion
D. Ruptured atherosclerotic plaque

51b. The patient’s symptoms resolved upon arriving to the emergency department. Which maneuvers
may reelicit the patient’s symptoms?
A. Neck flexion
B. Neck extension
C. Arm exercise
D. Valsalva maneuver

52a. Which spectral Doppler waveform
characteristic is demonstrated?

A. Loss of respiratory phasicity
B. Loss of augmentation
C. Flow reversal
D. Decreased flow velocity

52b. Augmentation during a lower extremity venous examination consists of observing the spectral
Doppler waveform while compressing the:
A. Ipsilateral extremity distal to the transducer
B. Ipsilateral extremity proximal to the transducer
C. Contralateral extremity at the same level as the transducer
D. Lower abdomen

52c. What type of venous waveform is depicted?
A. Augmentation
B. Monophasic
C. Reversed
D. Respiratory phasicity

53a. A 25‐year‐old female presents to the
emergency department with left lower extremity
pain and swelling. A peripheral venous ultrasound
was performed. What is the most likely diagnosis?
A. Deep venous thrombosis (DVT)
B. Inguinal lymphadenopathy
C. Varicose veins
D. Pseudoaneurysm
E. Abscess

53b. What imaging feature favors an acute
versus chronic deep venous thrombosis
(DVT)?

A. Noncompressibility
B. No color flow
C. Vessel expansion
D. Hyperechoic thrombus

54. What do the color Doppler images demonstrate at the level of the stenosis?

A. Aliasing
B. Flow reversal
C. Decreased flow
D. “Twinkle” artifact

Vascular: Answers and Explanations

1. Answer C. After transplantation, the normal range of resistive indices (RIs) is 0.55 to 0.80.
However, approximately half of patients have elevated RIs in the immediate postoperative period; the
RIs typically normalize within 72 hours. Alternatively, RIs can be transiently low in the immediate
postoperative period because of anastomotic edema or hypotension in some patients; persistently low
RIs suggest arterial stenosis.
References: Platt JF, et al. Use of Doppler sonography for revealing hepatic artery stenosis in liver transplant recipients. AJR Am J
Roentgenol 1997;168(2):473–476.
Sanyal R, et al. Orthotopic liver transplantation: reversible Doppler US findings in the immediate post‐operative period.
RadioGraphics 2012;32:199–211.

2. Answer C. Normal diastolic flow is antegrade (above the baseline). The figure shows reversed
diastolic flow (below the baseline), indicating substantially increased vascular resistance in this
dysfunctional renal transplant. Reversed diastolic flow is an important but nonspecific finding in renal
transplant patients; differential considerations include external compression of the allograft (e.g.,
hematoma), renal vein thrombosis, rejection, glomerulosclerosis, and acute tubular necrosis. Although
renal vein thrombosis (answer choice A), external compression (answer choice B), and acute tubular
necrosis (answer choice D) can be seen in the acute and subacute settings, rejection is the most
common long‐term cause of reversed diastolic flow in renal transplant patients.
References: Baxter GM. Ultrasound of renal transplantation. Clin Radiol 2001;56:802–818.
Lockhart ME, et al. Reversed diastolic flow in the renal transplant: perioperative implications versus transplants older than 1
month. AJR Am J Roentgenol 2008;190:650–655.

3. Answer B. PSV − EDV/PSV.
References: Polak J, Pellerito JF. Introduction to vascular ultrasonography: expert consult—online and print, 6th ed. London:
Saunders, 2012. ISBN:143771417X.
Tublin ME, et al. The resistive index in renal Doppler sonography: where do we stand? AJR Am J Roentgenol 2003;180(4):885–
892.

4. Answer C. Pseudoaneurysm formation is an uncommon complication of orthotopic liver
transplantation but most commonly occurs at the site of arterial anastomosis. Pseudoaneurysms in
this location can be due to surgical technique, mycotic etiologies, or as a consequence of angioplasty.
Pseudoaneurysms of the more peripheral, intrahepatic branches of the hepatic arteries may develop
as a consequence of focal infection or liver biopsy.
References: Bhargava P. Imaging of orthotopic liver transplantation. AJR Am J Roentgenol 2011;196:WS15–WS25.
Caiado A, et al. Complications of liver transplantation: multimodality imaging approach. RadioGraphics 2007;27:1401–1417.

5. Answer C. The US image shows heterogeneous periportal fluid collections, whereas the CT image
shows biliary necrosis manifested as periportal hypoattenuation.
In the liver transplant patient, the hepatic artery is the sole blood supply to the biliary epithelium. In
the setting of hepatic artery thrombosis, the biliary epithelium becomes necrotic and results in
sloughing of cells and debris into dilated bile ducts. Venous thrombosis (hepatic veins, portal veins, or
IVC) may lead to areas of infarction and altered enhancement, but does not lead to biliary necrosis.
Additionally, the portal veins and IVC are shown to be patent in the figure.

Itri JN, et al. Hepatic transplantation: post‐operative complications. Abdom Imaging 2013;38:1300–1333.

6. Answer B. Hepatic artery thrombosis is the most common vascular complication affecting
orthotopic liver transplant and has been reported to occur in up to 12% of cases. The onset is variable
and can occur from days to months following the transplant surgery.
Singh A, et al. Post‐operative imaging in liver transplantation: what radiologists should know. RadioGraphics 2010;30:339–351.

7. Answer C. Suboptimal hepatic venous outflow leads to distension of the hepatic veins and IVC,
hepatomegaly, ascites, and pleural effusions. Vena caval or hepatic venous anastomotic stenosis can
occasionally be shown at gray‐scale imaging but is more commonly detected on color Doppler
evaluation as a focus of aliasing. Spectral Doppler will also show aliasing because of the increased
velocities at the site of stenosis and blunting of the upstream hepatic venous waveforms. Answer
choices A, B, and D are also complications of liver transplantation, but would not present with the
imaging findings listed in the question stem.
Itri JN, et al. Hepatic transplantation: post‐operative complications. Abdom Imaging 2013;38:1300–1333.

8. Answer A. Spectral Doppler evaluation demonstrates focal color aliasing at the renal transplant
superior pole biopsy site. There is a high‐velocity, low‐impedance waveform with increased diastolic
flow because of an arteriovenous fistula. The majority of arteriovenous fistulas are small, clinically
insignificant, and resolve spontaneously. Therefore, short‐term follow‐up can be performed to assess
for resolution. Coil embolization (answer choice C) and surgical repair (answer choice D) are required
in only a minority of cases.
References: Elsayes KM, Menias CO, Willatt J, et al. Imaging of renal transplant: utility and spectrum of diagnostic findings. Curr
Probl Diagn Radiol 2011;40(3):127–139.
Rajiah P, Lim YY, Taylor P. Renal transplant imaging and complications. Abdom Imaging 2006;31(6):735–746.

9. Answer A. The intrarenal segmental arterial waveform shows a rounded appearance of the
systolic peak, consistent with a tardus–parvus pattern. The tardus–parvus pattern gets its name
because the systolic peak is delayed (acceleration time >0.08 s) and the peak velocity is reduced.
A pseudoaneurysm (answer choice B) is characterized by disorganized spectral flow in its neck during
which high‐velocity flow is shown above and below the baseline (“to‐and‐fro” appearance). The
spectral waveform of an arteriovenous fistula (answer choice C) is characterized by a low‐resistance
pattern because of high systolic velocity and high diastolic velocity from the abnormal shunting
between an artery and vein. The spectral waveform of the renal artery in the setting of renal vein
thrombosis (answer choice D) is characterized by a high‐resistance pattern because of reversal of
diastolic flow.
References: Granata A, et al. Renal transplant vascular complications: the role of Doppler ultrasound. J Ultrasound
2014;18(2):101–107.
Rodgers SK. Ultrasonographic evaluation of the renal transplant. Radiol Clin North Am 2014;52(6):1307–1324.

10. Answer A. In order to detect slow flow, filter settings should be kept at the lowest possible
setting (generally in the 50 to 100 Hz range). Reducing the wall filter setting results in filling‐in of the
spectral data toward the baseline. In patients with slow flow, a high‐wall filter setting may obscure
low‐velocity blood and lead to an erroneous interpretation of vessel occlusion. The PRF indicates the
rate (frequency) at which data are sampled. This variable is directly related to the velocity range (or
scale) because higher‐flow velocities require more rapid sampling and a larger scale. If the PRF is set
too high, slower moving blood is difficult to appreciate and may be obscured. When the PRF is
reduced, the range of depicted velocities is reduced and slower flow can be appreciated qualitatively
and quantitatively.
References: Boote EJ. Doppler US techniques: concepts of blood flow detection and flow dynamics. RadioGraphics 2003;23:1315–
1327.
Kruskal JB, et al. Optimizing Doppler and color flow US: application to hepatic sonography. RadioGraphics 2004;24:656–675.

11. Answer B. Selecting a lower‐frequency transducer decreases the Doppler shift and will lead to a
reduction in aliasing.
Decreasing the scale (answer choice A) would lead to increased aliasing, whereas increasing the scale
would reduce aliasing. Choosing a sample volume at a greater depth (answer choice C) would increase
aliasing, whereas sampling at a less depth would lead to an increase of pulse repetition frequency and
serve to decrease aliasing. Answer choice D is incorrect as this would lead to higher‐frequency
Doppler signal detected and would increase aliasing; however, increasing the Doppler angle would
lead to decreases in Doppler shift and would serve to reduce aliasing.
References: Boote EJ. Doppler US techniques: concepts of blood flow detection and flow dynamics. RadioGraphics 2003;23:1315–
1327.
Kruskal JB, et al. Optimizing Doppler and color flow US: application to hepatic sonography. RadioGraphics 2004;24:656–675.

12. Answer D. Images show echogenic material in the left portal venous system with internal
vascularity on color Doppler interrogation, concerning for malignant portal venous thrombosis.
Tumoral neovascularity results in the disorganized formation of arteries and veins within the mass.
The ability of spectral Doppler interrogation to show an arterial waveform within an occluded portal
vein is the most specific sign of malignant portal venous thrombosis.
Echogenic clot (answer choice B) within the portal vein can be seen in both benign and malignant
etiologies and the degree of echogenicity is not a distinguishing feature. Additionally, the echogenicity
of a clot will vary depending on its age. Because tumor thrombus can be seen in the setting of a
normal‐sized portal vein, vessel diameter is not considered to be a distinguishing feature, thereby
making answer choice C incorrect. Cavernous transformation (answer choice A) refers to the
development of collateral vessels in or around the occluded portal vein. Although cavernous
transformation tends to be more associated with bland thrombus, it has also been documented in
cases of malignant portal vein thrombosis.
Reference: McNaughton DA, et al. Doppler US of the liver made simple. RadioGraphics 2011;31:161–188.

13. Answer A. The color priority threshold setting can
be adjusted to eliminate unwanted color Doppler signal
from a color flow image. Assuming that color flow should
only be seen in an anechoic blood vessel, the color
priority can be decreased to the point where color signal
is only displayed within anechoic structures. Any pixel
with a gray‐scale value above that of the color priority
threshold level will display the gray‐scale information
only, even if there is corresponding color Doppler
information. This can be useful to eliminate unwanted
signal outside of a known vessel. However, when
attempting to detect flow within small vessels, a too low
color priority threshold can lead to suppression of
desired signal.
Shown are two images from a scrotal ultrasound. The
first image shows no color signal within the testes. After
increasing the color priority threshold (yellow arrow),
vascular flow is demonstrated.


14. Answer B. Ensemble length (also known as dwell time) is the number of sound pulses used to
generate each individual line on a color Doppler image. Increasing the number of pulses per line
increases the sensitivity for the detection of a Doppler shift at any given location.
Increasing the wall filter (answer choice A) will increase the threshold below which frequency shifts
are not displayed, filtering out signal from slower flow. Increasing the PRF (answer choice C) will
decrease the sensitivity for the detection of slow flow. Increasing steering of the ultrasound beam
(answer choice D) using a linear array probe will decrease Doppler sensitivity for several reasons.
First, beams that are steered lose more of their energy to side lobes than beams that are not steered.
Second, echoes returning to the probe from the patient reach the surface of the transducer at an angle,
also resulting in a weaker signal.

15. Answer B. The yellow arrow shows the a wave, which
occurs in late diastole during atrial contraction; the normal a
wave corresponds to retrograde hepatic venous flow and is
shown above the baseline. The S wave (annotated by blue
arrow below) occurs in midsystole and represents antegrade
hepatic venous flow because of movement of the
atrioventricular septum toward the cardiac apex. The D wave
(annotated by red arrow below) occurs in early diastole
because of rapid filling of the right ventricle. Normally, the S
wave extends further below the baseline than the D wave. The
transitional v wave occurs between systole and diastole and
may extend above or below the baseline. An initial upward‐
sloping component represents continued but slowing right

atrial filling against a closed tricuspid valve. The peak of the v wave signals opening of the tricuspid
valve. Blood then moves from the right atrium into the right ventricle, resulting in the downward‐
sloping component of the v wave.
References: McNaughton DA, et al. Doppler US of the liver made simple. RadioGraphics 2011;31:161–188.
Scheinfeld MH, et al. Understanding the spectral Doppler waveform of the hepatic veins in health and disease. RadioGraphics
2009;29:2081–2098.

16. Answer C. The sharp, bidirectional spikes superimposed on the normal monophasic portal vein
waveform are due to intraluminal gas bubbles. During gray‐scale evaluation, the gas bubbles appear as
highly echogenic particles flowing within the portal vein. Portal venous gas may be due to life‐
threatening (i.e., bowel ischemia) and benign etiologies. Intraluminal clot (answer choice B) is
stationary and may appear as hypoechoic or echogenic, depending on the age and composition of the
blood products. Septic emboli (answer choice D) are not typically detected by US unless sufficiently
large. Stenosis (answer choice A) can result in turbulent, disorganized flow and result in elevated peak
velocities. However, clot, septic emboli, and stenosis do not produce the narrow, high‐velocity spikes
on the waveform that are shown in this case.
Reference: Abboud B, et al. Hepatic portal venous gas: physiopathology, etiology, prognosis and treatment. World J Gastroenterol
2009;15(29):3585–3590.

17. Answer C. In tricuspid regurgitation (TR), atrial contraction forces blood antegrade into the right
ventricle and also retrograde toward the liver producing a taller than normal retrograde (above the
baseline) a wave. During systole, the ventricle contracts and the tricuspid annulus moves toward the
cardiac apex. Because of the incompetent tricuspid valve, blood regurgitates through the tricuspid
valve into the right atrium, IVC, and hepatic veins; this results in an abnormally blunted or retrograde
(above the baseline) S wave. As the ventricle begins to relax, the tricuspid annulus returns to a normal
position, and blood is forced out of the atrium and into the IVC and liver; this produces an abnormally
tall, retrograde v wave. Although the atrium and ventricle are relaxed and the tricuspid valve open
during diastole, blood passively flows out of the liver and IVC into the heart; this produces the D wave,
which is the only antegrade wave (below the baseline).
In summary, the salient Doppler spectral findings are a pulsatile waveform, exaggerated (i.e., tall) a
and v waves, and a decreased or reversed S wave. With moderate TR, the S wave is not as deep as the D
wave; with severe TR, the S wave reverses (i.e., appears above the baseline) and merges with the a and
v waves to form a retrograde, complex a–S–v wave as in this case.
In right‐sided heart failure (answer choice B), the a and v waves are exaggerated, but the S and D
waves maintain a normal relationship (i.e., the S wave extends further below baseline than the D
wave). Mitral regurgitation (answer choice A) affects the left side of the heart and typically does not
alter the hepatic venous waveform. Compression of the hepatic vein (answer choice D) results in
blunting of the waveform (i.e., loss of phasicity) evidenced by reversal of the a wave and eventual
inability to distinguish the individual components of the normally phasic hepatic venous waveform.
References: Abu‐Yousef MM. Duplex Doppler sonography of the hepatic vein in tricuspid regurgitation. AJR Am J Roentgenol
1991;156(1):79–83.
McNaughton DA, et al. Doppler US of the liver made simple. RadioGraphics 2011;31:161–188.

18. Answer A. “Tardus” refers to a slow
systolic upstroke, resulting in a longer
acceleration time. “Parvus” refers to
dampening of the systolic peak, leading to a
decrease in amplitude and rounding of the
systolic peak. Tardus–parvus waveforms
commonly occur downstream to a significant
arterial stenosis. In this example, the slanted
configuration of the initial systolic upstroke
waveform component is indicative of a slow
systolic upstroke (tardus). The top of the
waveform is dampened and rounded rather
than sharply defined and peaked (parvus).
The cause of the parvus et tardus waveform
in this case was proximal ICA stenosis. This
is seen in the image.

The peak systolic velocity within the proximal internal carotid artery was markedly elevated.
According to a consensus paper written in 2003, following a conference of the Society of Radiologists
in Ultrasound, a velocity measurement of >230 cm/s is consistent with a stenosis >70%. The measured
velocity in this case met these criteria. Gray‐scale information also shows luminal narrowing by
atherosclerotic plaque.
Reference: Grant EG, et al. Carotid artery stenosis: gray‐scale and Doppler US diagnosis—Society of Radiologists in Ultrasound
Consensus Conference. Radiology 2003;229:340.

19. Answer B. Spatial compounding is a technique in which images acquired from multiple scan
angles are summed to produce the final image. Signal from strong reflectors is reinforced, whereas
random speckle noise is not, thereby significantly improving the signal‐to‐noise ratio. Additionally,
artifacts related to nonperpendicular reflectors are reduced, improving edge detail.
This increased SNR ratio comes at the expense of temporal resolution (answer choice A), because of
the increased time required for signal acquisition from multiple projections. The field of view is
unchanged in compound imaging (answer choice C). Imaging deep structures in obese patients is
compromised due to beam attenuation. Compound imaging is not very effective in improving the
signal to noise in these cases because all of the transmitted beams are severely attenuated. In this
circumstance, speckle and nonperpendicular reflectors play a relatively minor role in image
degradation.

20a. Answer B. Images show concentric dilatation of the abdominal aorta up to 6.6 cm, representing
a fusiform aneurysm. Eccentric echogenic thrombus is shown along with turbulent Doppler flow.
In contrast to fusiform aneurysms, saccular aneurysms exhibit eccentric dilatation and outpouching
along only a portion of the vessel wall circumference. On ultrasound, findings of a ruptured aneurysm
may include heterogeneously hypoechoic complex fluid around the aorta in a symptomatic patient.
Findings of aneurysm rupture are usually more easily seen on CT.
Pseudoaneurysms of the abdominal aorta are rare, and traumatic and autoimmune etiologies have
been described.
References: Borioni R, Garofalo M, Seddio F, et al. Posttraumatic infrarenal abdominal aortic pseudoaneurysm. Tex Heart Inst J
1999;26(4):312–314.

Kaufman JA, Lee MJ. Vascular and interventional radiology: the requisites. St. Louis, MO: Mosby, 2004.
Okita Y, Ando M, Minatoya K, et al. Multiple pseudoaneurysms of the aortic arch, right subclavian artery, and abdominal aorta in a
patient with Behçet’s disease. J Vasc Surg 1998;28(4):723–726.

20b. Answer D. The risk of rupture of an abdominal aortic aneurysm (AAA) varies with diameter.
The abdominal aorta is considered aneurysmal when its diameter reaches 3 cm. For aneurysms <4 cm,
annual risk of spontaneous rupture is near 0%. It increases to 1% to 3% for aneurysms measuring 4 to
5 cm. Small aneurysms <5 cm should undergo imaging surveillance every 6 to 12 months. Annual
rupture risk is 6% to 11% at 5 to 7 cm, and 20% for aneurysms equal to or larger than 7 cm. Open or
endovascular repair is usually performed when the aneurysm reaches 5 cm.
References: Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion
rate. J Vasc Surg 2003;37(2):280–284.
Kaufman JA, Lee MJ. Vascular and interventional radiology: the requisites. St. Louis, MO: Mosby, 2004.
Schwartz SA, Taljanovic MS, Smyth S, et al. CT findings of rupture, impending rupture, and contained rupture of abdominal aortic
aneurysms. AJR Am J Roentgenol 2007;188(1):W57–W62.

20c. Answer D. Popliteal artery aneurysm (PAA) is the second most common atherosclerotic
aneurysm. Thirty to fifty percent of patients with a PAA will also have an AAA. However, only 10% to
14% of patients with an AAA will have a PAA. As opposed to AAAs, PAAs are found almost exclusively
in men. The other aneurysms listed occur less frequently and have a lower association with AAA.
References: Diwan A, Sarkar R, Stanley JC, et al. Incidence of femoral and popliteal artery aneurysms in patients with abdominal
aortic aneurysms. J Vasc Surg 2000;31(5):863–869.
Wright LB, Matchett WJ, Cruz CP, et al. Popliteal artery disease: diagnosis and treatment 1. RadioGraphics 2004;24(2):467–479.

21a. Answer C. Multiple tortuous vessels are shown within the expected location of the portal vein,
representing dilated periportal and peribiliary veins. Cavernous transformation occurs as a result of
persistent occlusion or incomplete recanalization of the portal vein following portal vein thrombosis.
This network of collateral veins reconstitutes flow to distal nonobstructed portal veins. In spite of this
collateral pathway, most patients with cavernous transformation will still have portal hypertension.
Causes of portal vein thrombosis include cirrhosis, infection, hypercoagulable states, trauma, and
malignancy.
Periportal collaterals are not an expected finding in the setting of hepatic artery thrombosis (choice A).
Absence of arterial signal along the portal triads would suggest hepatic artery thrombosis, usually
occurring as a complication following liver transplantation.
Intrahepatic portosystemic shunting (choice B) can occur in the cirrhotic liver. However, it typically
occurs more peripherally, where similar‐sized portal and hepatic veins can form an aberrant
connection. Here, the tortuous vessels are in the porta hepatis, distant from the hepatic veins.
An arteriovenous malformation (AVM) (choice D) is unlikely given that the tortuous vessels extend
from the porta hepatis along the course of the right portal vein. A dilated feeding artery and draining
vein are often seen leading toward and away from an AVM.

21b. Answer A. In cavernous transformation of the portal vein, the native main portal vein (MPV) is
typically scarred down and difficult to see by ultrasound or cross‐sectional imaging. The collateral
veins that have developed to replace it in the porta hepatis are small caliber.
In acute portal vein thrombosis, the MPV is typically normal caliber or expanded. In portal
hypertension, the MPV may be dilated due to increased pressure. In intrahepatic portosystemic

shunts, portal veins can be dilated due to increased flow. AVM would show disorganized tangles of
smaller caliber vessels as well as feeding artery and draining vein.
References: De Gaetano AM, Lafortune M, Patriquin H, et al. Cavernous transformation of the portal vein: patterns of intrahepatic
and splanchnic collateral circulation detected with Doppler sonography. AJR Am J Roentgenol 1995;165(5):1151–1155.
Ginat DT. Thorium dioxide (thorotrast). In Ginat DT, Small J, Schaefer PW (eds). Neuroimaging pharmacopoeia. Dordrecht,
Netherlands: Springer International Publishing, 2015:119–122.
Kauzlaric D, Petrovic M, Barmeir E. Sonography of cavernous transformation of the portal vein. AJR Am J Roentgenol
1984;142(2):383–384.
Raby N, Meire HB. Duplex Doppler ultrasound in the diagnosis of cavernous transformation of the portal vein. Br J Radiol
1988;61(727):586–588.

22. Answer B. Axial resolution is the ability of the ultrasound beam to resolve two objects located
along the axis of the ultrasound beam. Axial resolution is half of the pulse length (pulse length ÷ 2).
Longer pulse lengths are used in pulsed Doppler to decrease variability in measurement of Doppler
shift. The tradeoff is decreased axial resolution.

23. Answer D. The transjugular intrahepatic portosystemic shunt is the most commonly performed
invasive procedure for alleviating the symptoms of portal hypertension (varices and refractory
ascites). Complications that can occur following the TIPS placement include stent occlusion, stent
stenosis, and hepatic vein stenosis. Signs of stent malfunction include the absence of in‐stent flow,
peak shunt velocities below 90 cm/s or above 190 cm/s, change in peak shunt velocity of 50 cm/s
between two studies, decreased peak velocities within the main portal vein <30 cm/s, hepatopetal
intrahepatic portal flow, and reversal of flow in the hepatic vein (suggesting hepatic vein stenosis).
Indirect signs of TIPS malfunction include increasing ascites and reappearance of varices (including
paraumbilical veins).
The images demonstrate borderline elevated peak velocities within the TIPS with aliasing at the
hepatic venous side. Additionally, hepatopetal flow is shown within the right portal vein. These
findings are concerning for a TIPS malfunction with stenosis at the hepatic venous end.
Reference: Darcy M. Review. Evaluation and Management of Transjugular Intrahepatic Portosystemic Shunts. AJR Am J Roentgenol
2012;199:730–736.

24. Answer A. Superficial thrombophlebitis or superficial venous thrombosis (SVT), is characterized
by thrombosis of a superficial vein and is associated with inflammatory reaction of adjacent tissue,
though the term has also been used to describe superficial vein thrombosis without associated
surrounding inflammatory changes. The ultrasound image in this patient demonstrates a long‐
segment occlusive thrombus with hyperemia of the circumferentially thickened wall. Patients often
complain of pain and physical examination reveals a palpable, tender, “cord”‐like subcutaneous
structure. Overlying skin is often erythematous and warm.
The hyperemia is limited to the tubular vein. Surrounding subcutaneous fat does not demonstrate
edema or hyperemia to suggest cellulitis (choice B).
The thrombosed vein is subcutaneous in location and does not represent deep venous thrombosis
(choice C).
The tubular structure depicted in the ultrasound image is subcutaneous in location, whereas median
nerve entrapment in anterior interosseous nerve syndrome along the volar aspect of forearm is
deeper in location. Also, the peripheral hyperemia is not a typical feature of anterior interosseous
nerve syndrome (choice D).

2011:1031–1033.

25. Answer D. The expansile heterogeneous mass with central calcification within the retrohepatic
inferior vena cava is highly suggestive of a neoplasm rather than bland thrombus. Though primary
tumors of inferior vena cava are rare, leiomyosarcoma is the most common tumor of the venous
system and its most common location is the inferior vena cava. Tumor thrombus in the inferior vena
cava is more often a result of direct extension of renal cell carcinoma, hepatocellular carcinoma and
primary adrenal carcinoma. Expansion of the inferior vena cava lumen and the presence of internal
vascularity are two features that distinguish tumor thrombus from a bland thrombus.
A. Tricuspid regurgitation can result in dilatation of inferior vena cava and hepatic veins but is not
associated with luminal thrombosis.
B. A bland thrombus in inferior vena cava, unlike tumor thrombus, should not cause such marked
expansion of the lumen.
C. Although the central shadowing calcification within the mass could be confused for an IVC filter, the
surrounding heterogeneous expansile mass strongly suggests a neoplastic entity.
Rumack, CM, Wilson, SR, et al. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Mosby, 2011:478–482.

26. Answer D. The increased peak systolic velocity in the celiac axis that improves with inspiration is
characteristic of median arcuate ligament compression of celiac axis. The velocity also improves with
erect positioning of the patient. Surgical release of the median arcuate ligament relieves compression
of celiac axis and improves blood flow.
A. The increased peak systolic velocity of celiac axis in expiration suggests luminal narrowing of celiac
and not of superior mesenteric artery. With median arcuate ligament compression of the celiac axis,
superior mesenteric artery provides collateral flow through pancreaticoduodenal arcade and
gastroduodenal artery.
B. Although increased peak systolic velocity in the celiac axis can be seen with any etiology including
atherosclerotic narrowing and malignant infiltration, respiratory variation with improvement of flow
velocity in inspiration is seen only with median arcuate ligament compression and not with the other
entities.
C. Increase in both peak systolic and end‐diastolic velocities is seen with celiac axis narrowing of any
etiology. Normalization of velocities during suspended inspiration or with erect positioning indicates
median arcuate ligament compression.
References: AbuRahma AF, Stone PA, Srivastava M, et al. Mesenteric/celiac duplex ultrasound interpretation criteria revisited. J
Vasc Surg 2012;55:428–436, e6; discussion: 435–436.
White RD, et al. The celiac axis revisited: anatomic variants, pathologic features, and implications for modern endovascular
management. RadioGraphics 2015;35(3):879–898.

27. Answer B. The ultrasound and MR images show diffuse homogeneous circumferential wall
thickening with moderate narrowing of the distal aorta and severe narrowing of the left iliac artery.
These findings indicate large vessel vasculitis, and in a young female patient, the most likely etiology is
Takayasu arteritis.
Takayasu arteritis is an idiopathic large‐vessel arteritis that involves the aorta and its major branches,
pulmonary arteries, and coronary arteries. The disease often manifests before the age of 40 years with
a distinct female preponderance. Patients typically present with nonspecific constitutional symptoms
during initial phase of the disease. Severe stenosis and occlusion of the proximal carotid and

subclavian arteries commonly lead to absence of pulses. Other characteristic clinical presentations of
Takayasu arteritis include claudication, vascular bruits, renal hypertension, and limb blood pressure
discrepancies.
Chronic granulomatous and lymphocytic inflammation affects the intima and media leading to arterial
wall thickening, focal stenosis, occlusion, or aneurysm formation. Sonographic findings include vessel
wall thickening, luminal narrowing or stenosis, vessel occlusion, and reduced pulsatility. Management
of Takayasu arteritis involves controlling the disease activity through medical therapy and decreasing
the effects of vascular compromise through surgical or endovascular interventions. Corticosteroid
therapy is the mainstay of medical therapy. Other immune‐modulating drugs (e.g., methotrexate,
azathioprine) are used in patients who do not respond to steroid therapy.
Giant cell arteritis (GCA) (choice A) is a granulomatous vasculitis affecting large‐ to medium‐sized
arteries. It is also known as temporal arteritis and tends to involve the extracranial carotid artery
branches such as the temporal artery. GCA typically affects older females, usually older than 50 years
of age, with a peak age of 70 to 80 years.
Polyarteritis nodosa (PAN) (choice C) is a systemic inflammatory necrotizing vasculitis that involves
small‐ to medium‐sized arteries eventually resulting in necrosis and vessel wall destruction. It has
slight male predominance and typically presents around the 6th decade. Twenty to thirty percent of
patients are hepatitis B antigen positive.
Granulomatosis with polyangiitis (GPA) (choice D), previously known as Wegener granulomatosis, is a
multisystem systemic necrotizing noncaseating granulomatous vasculitis affecting small‐ to medium‐
sized arteries, capillaries, and veins, with a predilection for the respiratory system and kidneys. There
is involvement of the upper respiratory tract leading to necrosis of nasal septum, tracheal necrosis,
lung nodules, and necrotizing glomerulonephritis.
Reference: Khosla A, Andring B, Atchie B, et al. Systemic vasculopathies. Radiol Clin North Am 2016;54(3):613–628.

28. Answer B. Decreased phasicity of a lower extremity deep vein spectral Doppler waveform raises
suspicion for downstream thrombus or narrowing. In the case of monophasic flow within the common
femoral vein, an attempt should be made to scan the external and common iliac veins to identify a
thrombus or compressing mass. If an abnormality is not identified or if the area is obscured, consider
imaging with another modality such as CT or MR.
Reference: Needleman L. Update on the lower extremity venous ultrasonography examination. Radiol Clin 2014;52(6):1359–
1374.

29. Answer A. The gastrocnemius veins are located in the calf and are considered part of the deep
venous system. Thrombus can be hypoechoic in the acute setting. Noncompressibility of a vein is
considered the most sensitive predictor of acute thrombosis. Findings are considered diagnostic for
acute deep vein thrombosis and MRV is not necessary.
Reference: Caggiati A, et al. Nomenclature of the veins of the lower limb: extensions, refinements, and clinical application. J Vasc
Surg 2005;41(4):719–724.

30. Answer D. The color Doppler ultrasound image depicts a hypoechoic, hypervascular solid mass
located at the carotid bifurcation, splaying the internal and external carotid arteries. Contrast‐
enhanced axial T1‐weighted MR image shows avid tumor enhancement. The digital subtraction
angiogram shows an early hypervascular tumor blush, and all of the modalities demonstrate the
characteristic nonocclusive splaying of the carotid bifurcation. This appearance is diagnostic of carotid
body tumors.

Carotid body tumors are rare, slowly growing, nontender, firm masses in the lateral neck that arise
from extra‐adrenal paraganglionic tissue in the carotid bifurcation. They most commonly present with
a painless neck mass, hypertension, or a carotid bruit because of their very high intratumoral
hypervascularity. The key diagnostic feature is their location at the carotid bifurcation, where they
characteristically splay the external carotid artery anteriorly and the internal carotid artery
posteriorly. On ultrasound, they usually appear as a solid, hypoechoic and hypervascular mass,
splaying but not occluding the internal and external carotid arteries. The intrinsic hypervascularity of
these tumors is apparent on color Doppler ultrasound when low‐flow settings are used. The majority
of the vascular supply is derived from the external carotid artery. They are bilateral in 5% of cases, but
these rates are higher if the disease is inherited. Carotid body tumors are usually benign, but a 6% rate
of malignant transformation has been reported. Current surgical and vascular techniques have
improved the safety and success of surgical resection, which is still considered the mainstay of
treatment.
Ectatic innominate or proximal common carotid artery can be the cause of a bruit but does not present
with a mass. Metastatic disease would not splay the carotid arteries, even when disease involves the
carotid sheath. Thrombosed carotid artery aneurysm and carotid artery dissection are not shown on
the image.
References: Dähnert W. Radiology review manual, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2011:388.
Stoeckli SJ, Schuknecht B, Alkadhi H, et al. Evaluation of paragangliomas presenting as a cervical mass on color‐coded doppler
sonography. The Laryngoscope 2002;112(1):143–146.

31. Answer A. Because the calculation of resistive index depends only on the ratio of systolic to
diastolic flow, it is independent of the Doppler angle.

32. Answer D. The images show aliasing at the main portal vein (MPV) anastomosis and a six‐fold
anastomotic‐to‐preanastomotic velocity ratio. A gradient greater than or equal to three‐ to fourfold
indicates stenosis. Poststenotic dilatation of the portal vein would support the diagnosis. Portal vein
stenoses in liver transplants usually occur at the end‐to‐end anastomosis and may be the result of
surgical technique, vessel kinking, hypercoagulable states, or donor–recipient vessel caliber mismatch.
A. Increased echogenicity of the portal triads is a nonspecific finding. Periportal edema decreases the
echogenicity of the liver around the triads. This gives the appearance of increased echogenicity of the
portal triads relative to the surrounding parenchyma (“starry‐sky” appearance). Pneumobilia can
increase the echogenicity of the bile ducts. Dirty shadowing from gas distinguishes this from other
causes.
B. Parvus–tardus waveform of the intrahepatic arteries is seen with hepatic arterial stenosis, not
portal venous stenosis.
C. Thrombus in the IVC piggyback anastomosis is a different (and rare) complication of liver
transplant.
D. Lack of flow in the right and left portal veins (RPV and LPV) can occur with portal vein occlusion,
though some flow is expected in stenosis. This patient did have slow flow in the RPV and LPV (not
shown).
References: Caiado AHM, Blasbalg R, Marcelino ASZ, et al. Complications of liver transplantation: multimodality imaging
approach. RadioGraphics 2007;27:1401–1417.
Pozniak MA, Tublin ME. Ultrasound evaluation of the transplanted liver, kidney, and pancreas. In: McGahan JP, Goldberg BB (eds).
Diagnostic ultrasound. New York: Informa Healthcare USA, 2008:301–338.

33. Answer D. The pulse repetition frequency (PRF) refers to the number of sound pulses
transmitted per second. On most ultrasound units, there is a control‐labeled Doppler scale. Adjusting
the Doppler scale is really changing the PRF. High PRFs result in a high Doppler scale, whereas lower
PRFs result in a lower Doppler scale. The advantage of a high PRF or high Doppler scale is display of
high‐velocity flow without aliasing. The advantage of a low PRF or low Doppler scale is improved
sensitivity to low‐velocity blood flow.

34. Answer D. Decreasing the Doppler scale will decrease the pulse repetition frequency and
therefore improve Doppler sensitivity. All the other choices will reduce Doppler sensitivity.

35. Answer A. Pulse repetition frequency (PRF) refers to the number of sound pulses transmitted per
second. Aliasing occurs when the Doppler sampling rate, that is, PRF is less than twice the Doppler
frequency shift. On Doppler waveforms, aliasing causes the high‐frequency components to wrap
around from the positive extreme of the scale to the negative extreme or vice versa. When aliasing
occurs on color Doppler images, the wraparound effect causes the color representing the highest
positive frequency shift to change to the color representing the highest negative frequency shift, or
vice versa. Aliasing can be diminished or eliminated by increasing the PRF. Another method of
decreasing aliasing is to decrease the observed frequency shift. This can be done by scanning the
vessel at a Doppler angle closer to 90 degrees or by switching to a lower‐frequency transducer.

36. Answer A. Fast, laminar flow occurs in the center of large, smooth wall vessels. Slower blood flow
occurs near the vessel walls because of frictional forces. Turbulent flow occurs at irregularities along
the vessel wall caused by plaque buildup and stenosis.
A small Doppler gate positioned in the center of the vessel will have a smaller and faster range of
velocities. A large Doppler gate that spans the entire lumen of the vessel will have a large range of flow
velocities.

37. Answer D. Images show a dilated structure deep to the compressible popliteal vein that contains
high‐resistance arterial waveforms and mural thrombus, representing a popliteal artery aneurysm.
The popliteal artery is located between the two heads of the gastrocnemius muscle, anterior (deep) to
the popliteal vein.
Popliteal artery
aneurysms (PAA) can be
true or false. True
aneurysms are usually
atherosclerotic, but may
be rarely associated with
connective tissue
disorders such as Marfan
syndrome or Ehlers‐
Danlos syndrome or, even
more rarely, with
pregnancy. The most
common peripheral
arterial aneurysms arise from the popliteal artery. False aneurysms are due to trauma or infection
(mycotic). Eighteen to thirty‐one percent of untreated PAAs are complicated by thrombosis, distal
embolization, or, rarely, rupture. Diagnosis and repair of PAAs are important because of the high rate
of complications associated with untreated aneurysms, regardless of size.
Reference: Wright LB, Matchett WJ, Cruz CP, et al. Popliteal artery disease: diagnosis and treatment. RadioGraphics 2004;24:467–
479.

38. Answer B. Doppler angle is the angle between the direction of blood flow and the direction of the
sound. The preferred Doppler angle ranges from 30 to 60 degrees. At larger angles (>60 degrees), the
apparent Doppler shift is small. Small errors in angle accuracy can result in large errors in velocity. At
very small angles (<20 degrees), refraction, critical angle interactions, and aliasing of the signal can
cause problems.

39. Answer A. Cavitation is a potential bioeffect produced by sound waves. Sound waves consist of
alternating positive and negative pressures. Negative, or rarefactional, pressure can lead to the
creation of microbubbles or the enlargement of existing microbubbles. The alternating pressures of
the sound wave may induce oscillation of the bubble size. The surrounding liquid medium may flow in
response, a phenomenon called microstreaming. Microstreaming has been observed to disrupt cell
membranes. Furthermore, bubbles expanded by negative pressure can then implode violently,
creating huge changes in temperature and pressure affecting the tissues immediately surrounding the
bubble, damaging cells, and generating reactive chemical species. It is important to be aware of the
theoretical potential for cavitation as a safety consideration when imaging microbubble contrast
agents or even when imaging tissues near gas bodies of other sizes such as lung and bowel.

40a. Answer A. Spectral Doppler interrogation shows markedly elevated velocities in the
midsegment of the left hepatic artery suggesting a high‐grade stricture. Additionally, spectral
broadening and decreased arterial resistance with increased diastolic flow are shown downstream to
the site of narrowing.
B. Arteriovenous fistula would be expected to show abnormal high‐velocity and low‐resistance
waveforms with difficulty differentiating between artery and vein in the region of abnormality.
C. Pseudoaneurysms have a swirling or “yin–yang” pattern of blood flow within the lumen and show a
to‐and‐fro waveform with antegrade flow during systole and retrograde flow during diastole.
D. Such high velocities as shown here in the left hepatic artery would not be an expected finding
postoperatively.
Reference: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 2‐Volume set, 4th ed. Philadelphia, PA: Elsevier Health
Sciences, 2011:29.

40b. Answer C. The ultrasound image shows color Doppler interrogation of the left hepatic artery.
There is random assignment of red and blue color outside the normal expected course of the vessel.
This is thought to result from turbulence in the vessel lumen, which causes vibration of the vessel
walls as well as the perivascular tissues. On color Doppler, it is displayed as Doppler frequency shift in
both directions (toward and away from the transducer) and displayed as red and blue color around
the site of turbulent flow. This artifact is most prominent during systole. It is seen at sites of
anastomotic narrowing, arteriovenous fistulae, and arterial stenoses.
Choice A—twinkling artifact—is commonly observed at color Doppler imaging when insonating
certain rough reflective surfaces, such as renal calculi. It appears as a discrete focus of alternating
colors. Twinkling artifact is felt to be likely because of a form of intrinsic noise known as phase/clock
jitter within the Doppler circuitry of the US machine.
Choice B—comet‐tail artifact—is a type of reverberation artifact. It is seen on gray‐scale ultrasound
when small calcific/crystalline/highly reflective objects are insonated. It can be seen in thyroid colloid
nodules, gallbladder adenomyomatosis, renal calculi, pancreatic calculi, etc.
Choice D—blooming artifact—is the presence of color beyond the vessel wall making the vessels look
larger than they really are. It is gain dependent and lowering the Doppler gain will decrease the
blooming artifact.
References: Middleton WD, Kurtz AB, Hertzberg BS. Ultrasound: the requisites, 2nd ed. Philadelphia, PA: Mosby, 2004:23–24.
Rubens DJ, Bhatt S, Nedelka S, et al. Doppler artifacts and pitfalls. Ultrasound Clin 2006;1(1):79–109.
doi:10.1016/j.cult.2005.09.009.

41. Answer D. Images demonstrate a duplicated IVC. The left IVC
is shown by the arrow. Duplication of the IVC is the result of a
persistent left supracardinal vein. The IVC develops during the 7th
to 10th weeks of gestation. Typically, the left common iliac vein
drains into the left IVC, which then drains into the left renal vein.
The left renal vein drains into the right‐sided IVC. Anatomy above
the renal veins is normal. Duplicated IVC is the most common of
the IVC anatomic variants. Other variants include transposed (left‐
sided) IVC and azygous continuation of the IVC. In this case, the
duplicated IVC was not recognized during the filter placement, so
the filter was placed into the right‐sided infrarenal IVC. Left lower
extremity thrombus was able to bypass the filter by way of the left
IVC.

References: Chuang VP, Mena CE, Hoskins PA. Congenital anomalies of the inferior vena cava. Review of embryogenesis and
presentation of a simplified classification. Br J Radiol 1974;47(556):206–213.
Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 2‐Volume set, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:475–476.

42. Answer B. The arrows point to an intimal flap within the abdominal aorta. Aortic dissections can
be easily identified on ultrasound if they are oriented perpendicular to the beam but can be
challenging or impossible to visualize when they are nearly parallel to the beam. Altering probe
placement and angle will improve flap visualization. Color Doppler imaging may also be helpful by
showing differential flow within the true and false lumens.

43. Answer D. The first US image shows portal venous waveform in the main portal vein below the
baseline. This indicates blood flow in the main portal vein away from the liver (hepatofugal). On the
same images, hepatic arterial blood flow is also shown above the baseline (in the opposite direction of
portal vein flow). The second and third images show flow in a large vessel extending out from the left
hepatic lobe, consistent with a recanalized paraumbilical vein. The flow in this vein is toward the US
transducer (therefore shown as red on color Doppler) but is directed away from the liver. These
findings are highly specific for portal hypertension in patients with advanced cirrhosis.
As the resistance to forward flow of blood in to the liver increases, initially, the portal vein pressure
increases, but eventually with increasing resistance, portosystemic collaterals form. One such
collateral is the paraumbilical vein, which runs in the falciform ligament and connects the left portal
vein to the systemic epigastric veins near the umbilicus.

44. Answer A. The Swiss cheese model was proposed by James Reason. According to this model,
every step in a process has the potential for failure, to varying degrees. The ideal system is analogous
to a stack of slices of Swiss cheese, where each slice is a defensive layer in the process and the holes
are opportunities for a process to fail. If an error allows a problem to pass through a hole in one layer,
the problem should be caught in the next layer as the holes are in different places. For a catastrophic
error to occur, the holes need to align for each step in the process allowing all defenses to be defeated
and resulting in an error.
Toxic cascade model presents an approach to patient safety that locates upstream sources and
downstream consequences of errors. It is conceptualized as a tiered diagram, presenting four levels
that are potential threats to patients’ safety. The four layers are trickles, creeks, rivers, and torrents.
Trickles are seemingly innocuous occurrences in everyday health care settings such as misfiled or
misplaced records. Their immediate consequence is usually frustration, inefficiency, and
inconvenience that are dealt with as they occur. Creeks are more obvious than trickles and are barriers
to safe care. Health care examples are prescribing drugs to patients who have an allergy as a
contraindication. Rivers are mistakes that are too large to be ignored. Errors of this type are
undiagnosed problems that result in actual harm to patients. Generally, courts, other providers, and
patients blame individuals for these mistakes. Upstream sources are rarely explored, leaving the
potential for future reoccurrences. Torrents are so powerful that to stop them seems impossible. Their
noise prevents conversation and makes critical thinking difficult.
In the just culture model, the focus is on identifying and addressing system issues that lead individuals
to engage in unsafe behaviors while maintaining individual accountability by establishing zero
tolerance for reckless behavior. It distinguishes between human error, at‐risk behavior, and reckless

behavior. In a just culture, the response to an error or near miss is predicated on the type of behavior
associated with the error, and not the severity of the event.
Person approach focuses on the unsafe acts (errors and procedural violations) of people at the sharp
end: nurses, physicians, surgeons, anesthetists, pharmacists, etc. It views these unsafe acts as arising
primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation,
carelessness, negligence, and recklessness. The associated countermeasures are directed mainly at
reducing unwanted variability in human behavior. These methods include poster campaigns that
appeal to people’s sense of fear, writing another procedure (or adding to existing ones), disciplinary
measures, threat of litigation, retraining, naming, blaming, and shaming.
References: Gregory B, Kaprielian VS. Anatomy of an error. Patient Safety ‐ Quality Improvement Modules. Department of
Community and Family Medicine, Duke University School of Medicine.
Reason J. Human error: models and management. BMJ 2000;320(7237):768–770.
The American Board of Radiology. Quality and safety domain specification and resource guide, 2016.

45. Answer B. This patient presented with diffuse hepatomegaly. Dampened phasicity of the right,
middle, and left hepatic venous waveforms was noted on spectral Doppler. Although no focal liver
lesions could be identified on ultrasound in this case, liver biopsy revealed diffuse plasma cell
infiltration in the liver. Dampening is indicative of venous outflow obstruction, which may be seen in
metastatic infiltration, cirrhosis, hepatic vein stenosis, or venoocclusive disease. Hepatic venous
waveform may be dampened in normal patients during maneuvers that increase intra‐abdominal
pressure such as during Valsalva or at end expiration.
Tricuspid regurgitation and right heart failure would be expected to show pulsatile hepatic venous
waveform. Portal vein thrombosis would not directly cause dampening of hepatic venous waveform.
Reference: Scheinfeld MH, Bilali A, Koenigsberg M. Understanding the spectral Doppler waveform of the hepatic veins in health
and disease. RadioGraphics 2009;29(7):2081–2098.

46. Answer B. A health care worker who is traumatized by an error or adverse patient event is
deemed to be a “second victim.” Frequently, second victims feel personally responsible for the
unexpected patient outcomes and may doubt their clinical skills and knowledge base. Many hospitals
have developed internal programs to identify, console, and advocate on behalf of such second victims.
Reference: The American Board of Radiology. Quality & safety domain specification & resource guide, 2016.

47. Answer B. According to the “Hawthorne effect” (or the “observer effect”), individuals alter or
improve their behavior in response to their awareness of being observed.
Weber effect states that adverse event reporting tends to increase in the first 2 years after
introduction of a new agent or use for a new indication, peaks at the end of the second year, and then
declines.
Placebo effect is a phenomenon in which a placebo, such as an inactive substance like sugar, distilled
water, or saline solution, can sometimes improve a patient’s condition simply because the person has
the expectation that it will be helpful.
The Pygmalion effect is the phenomenon whereby higher expectations lead to an increase in
performance.
Reference: The American Board of Radiology. Quality & safety domain specification & resource guide, 2016.

48. Answer B. The primary criteria used to determine the degree of carotid artery stenosis is the
peak systolic velocity (PSV) and percent narrowing of the lumen.
Internal carotid artery/common carotid artery peak systolic velocity ratio (ICA/CCA PSV ratio) and
ICA end‐diastolic velocity (EDV) are additional parameters to support grading of carotid artery
stenosis.

References: Grant EG, Benson CB, Moneta GL, et al.
Carotid artery stenosis: gray‐scale and Doppler US
diagnosis—Society of Radiologists in Ultrasound
Consensus Conference. Radiology 2003;229 (2):340–
346.
Tahmasebpour HR, Buckley AR, et al. Sonographic
examination of the carotid arteries. RadioGraphics
2005;25(6):1561–1575.

49a. Answer D. PSV is elevated >230 cm/s, and there is a calcified and noncalcified plaque occupying
>50% of the lumen. These findings are consistent with a >70% vessel stenosis.

49b. Answer D. In carotid arteries with near‐complete occlusion, peak systolic velocity is not a
reliable marker as the velocity can be very high, low, or even in normal range. The diagnosis is made
when severe narrowing is seen, but there is still flow through the lumen, called a “string sign” or
“trickle flow.” It is important to distinguish near‐complete occlusion from complete occlusion as near‐
complete occlusion remains a surgical candidate.
Reference: Tahmasebpour HR, Buckley AR, et al. Sonographic examination of the carotid arteries. RadioGraphics
2005;25(6):1561–1575.

50. Answer C. In order to consider an internal carotid artery “normal,” PSV needs to be <125 cm/s
but must not have intimal thickening or visible plaque. If PSV is < 125 cm/s with intimal thickening or
visible plaque <50% of the vessel lumen, the carotid artery should be classified as <50% stenosis.

Modified from Grant EG, Benson CB, Moneta
GL, et al. Carotid artery stenosis: gray‐scale
and Doppler US diagnosis—Society of
Radiologists in Ultrasound Consensus
Conference. Ultrasound Q 2003;19(4):190–
198.
Reference: Grant EG, Benson CB, Moneta GL, et al. Carotid
artery stenosis: gray‐scale and Doppler US diagnosis—
Society of Radiologists in Ultrasound Consensus
Conference. Radiology 2003;229 (2):340–346.

51a. Answer A.

51b. Answer C. This is a case of subclavian artery steal syndrome. Flow reversal in the ipsilateral
vertebral artery is an important finding in the diagnosis of subclavian artery steal. Stenosis in the
proximal subclavian artery will recruit flow from the vertebral artery when demand is created in the
ipsilateral arm. Reversal of flow through the vertebral artery occurs via the circle of Willis and can
produce symptoms of transient cerebral ischemia. Reversal of flow in the vertebral artery may only be
elicited after arm exercise in occult or partial subclavian steal. Fixed flow reversal in the vertebral
artery corresponds to complete subclavian steal.
Reference: Grant EG, Benson CB, Moneta GL, et al. Carotid artery stenosis: gray‐scale and Doppler US diagnosis—Society of
Radiologists in Ultrasound Consensus Conference. Radiology 2003;229 (2):340–346. doi:10.1148/radiol.2292030516.

52a. Answer B.

52b. Answer A.

52c. Answer D. Augmentation and respiratory phasicity are indirect markers of venous patency.
Augmentation is performed by compressing the distal extremity (the calf, during lower extremity
evaluation). Respiratory phasicity is observed due to the changes in venous return to the heart with
changes in intrathoracic pressure that occur with respiration. These findings alone cannot be utilized
to diagnose deep venous thrombosis as partially occlusive thrombus may still manifest respiratory
phasicity and flow with augmentation. The image demonstrates normal augmentation:

Reference: Fraser JD, Anderson
DR. Deep venous thrombosis:
recent advances and optimal
investigation with US. Radiology
1999;211(1):9–24.

53a. Answer A.

53b. Answer C. The images demonstrate classic features of deep venous thrombosis:
noncompressible venous structure with no color flow. A feature of acute thrombosis is expansion of
the vessel lumen. Acute clot may be hyperechoic, as in this case, but is often hypoechoic (or anechoic)
when hyperacute.
Reference: Fraser JD, Anderson DR. Deep venous thrombosis: recent advances and optimal investigation with US. Radiology
1999;211(1):9–24.

54. Answer A. The image demonstrates a 50% to 69% stenosis of the left proximal internal carotid
artery (PSV 160 cm/s and ≥50% luminal narrowing). Note that there is flow acceleration at the site of
luminal narrowing with aliasing at the site of highest velocity. Appropriate color velocity scale setting
is important to target the area of highest flow and to avoid missing a physiologically significant focus
of stenosis. Calcified plaque may demonstrate a “twinkle” artifact.
Reference: Tahmasebpour HR, Buckley AR, et al. Sonographic examination of the carotid arteries. RadioGraphics
2005;25(6):1561–1575.

1c. Pictured here is a normal long (left) and short (right) axis image of the median nerve. Which of the
following best describes the ultrasound appearance of a normal nerve?

A. Hyperechoic with a fiber‐like echotexture

B. Hyperechoic with a fascicular echotexture
C. Hypoechoic with a fiber‐like echotexture
D. Hypoechoic with a fascicular echotexture

1d. Pictured here is a normal anterior talofibular ligament.
Which of the following best describes the ultrasound
appearance of a normal ligament?

A. Hyperechoic with a fiber‐like echotexture
B. Hyperechoic with a striated appearance
C. Hypoechoic with a fiber‐like appearance
D. Hypoechoic with a striated appearance

2a. Pictured here is the normal appearance of hyaline articular cartilage of the femoral condyle of the
knee. Which of the following best describes the ultrasound appearance of hyaline cartilage?

A. Hypoechoic, homogeneous
B. Hypoechoic, heterogeneous
C. Hyperechoic, homogeneous
D. Hyperechoic, heterogeneous

2b. Pictured here is the normal appearance of fibrocartilage
within the knee meniscus. Which of the following best describes
the ultrasound appearance of fibrocartilage?

A. Hypoechoic, homogeneous
B. Hypoechoic, heterogeneous
C. Hyperechoic, homogeneous
D. Hyperechoic, heterogeneous

3. Pictured here is a split screen image of the patellar tendon and deep infrapatellar bursa in short
axis. The image on the left is the standard image whereas the image on the right suffers from
anisotropy artifact. Anisotropy can result if the probe is as little as how many degrees off axis from
perpendicular to the target?

A. 5 degrees
B. 15 degrees
C. 25 degrees
D. 35 degrees

4. Pictured here is a split screen image of the patellar tendon and deep infrapatellar bursa in long axis.
The image on the left is the standard image whereas the image on the right was obtained with spatial
compound sonography. What is a benefit of this technique?

A. Improves evaluation of deep structures
B. Improves tissue plane definition
C. Improves artifact from motion blur
D. Improves conspicuity of foreign bodies

5. Pictured here is a split screen image of the patellar tendon and deep infrapatellar bursa in long axis.
The image on the left is the standard image whereas the image on the right was obtained with
harmonics. What is a benefit of this technique?

A. Improves evaluation of deep
structures
B. Improves tissue plane definition
C. Improves artifact from motion blur
D. Improves conspicuity of foreign bodies

6. Pictured here is an extended field of view image of a portion of the quadriceps tendon and the full
length of the patellar tendon in long axis. Why does the patella produce a reverberation artifact?

A. Small radius of curvature and a smooth surface
B. Small radius of curvature and a rough surface
C. Large radius of curvature and a smooth surface
D. Large radius of curvature and a rough surface

7. Pictured here are two images of the patellar tendon both obtained in long axis. The images were
obtained with two different probes; otherwise all of the parameters remained the same between the
two images. Which of the following statements best describes the probes used to produce the images?

A. The image on the left is obtained with a 17‐MHz linear transducer.
B. The image on the left is obtained with a 9‐MHz curvilinear transducer.
C. The image on the right is obtained with a 17‐MHz linear transducer.
D. The image on the right is obtained with a 9 MHz curvilinear transducer.

8. Pictured here is a split screen of two images of the patellar tendon both obtained in long axis.
Which of the following techniques was used to acquire the images?

A. The image on the right is optimized for deeper structures with harmonics.
B. The image on the right is optimized for superficial structures with spatial compound sonography.
C. The image on the left is optimized for deeper structures with a 9 MHz probe.
D. The image on the left is optimized for superficial structures with proper placement of the focal
zones.

9. Pictured here is a split screen of two images of the common extensor tendon of the elbow. The
image on the left is the standard image whereas the image on the right is with strain elastography.
Which of the following statements best describes tendon elastography in this case?

A. The tendon is displaced more than the
subcutaneous tissues.
B. The tendon is displaced less than the
C. The tendon is displaced the same as the
D. The tendon is displaced less than the bone.

10. The two most common patient positioning techniques used to image the supraspinatus tendon are
the Crass and modified Crass positions. Why are these techniques used?
A. Allow for tendon movement out from under the acromion
B. Allow for easiest probe placement
C. Allow for greatest patient comfort
D. Allow for greatest technologist control of the probe

11. Pictured here are long‐axis (left) and short‐axis (right) images of a normal left rotator cuff tendon
with labels. Which label is properly matched with the correct anatomic structure?

A. A—Trapezius muscle
B. B—Subscapularis tendon
C. C—Hyaline articular cartilage
D. D—Lesser tuberosity

12. Pictured here are the long‐axis (left) and short‐axis (right) images of the right supraspinatus
tendon. What is the most likely diagnosis?

A. Normal tendon
B. Tendinosis
C. Partial‐thickness tear
D. Full‐thickness tear

13a. Pictured here are the long‐axis (left) and short‐axis (right) images of the right supraspinatus
tendon. What is the most likely diagnosis?

A. Normal tendon
B. Tendinosis
C. Partial‐thickness tear
D. Full‐thickness tear

13b. Which of the following statements best describes the cartilage interface sign in the images
shown?
A. The long‐axis image depicts the cartilage interface sign.
B. The short‐axis image depicts the cartilage interface sign.
C. Both the long‐ and short‐axis images depict the cartilage interface sign.
D. Neither the long‐axis image nor the short‐axis image depicts the cartilage interface sign.

14. Pictured here are the long‐axis (left) and short‐axis (right) images of the proximal right long head
of the biceps tendon. What is the most likely diagnosis?

A. Normal tendon
B. Tendinosis
C. Full‐thickness tear
D. Full‐thickness
retracted tear

15. Pictured here are the long‐axis (left) and short‐axis (right) images of the supraspinatus tendon.
What is the most likely cause of the hyperechogenicity within the tendon?

A. Disrupted tendon
fibers
B. Tendon sutures
C. Uric acid crystals
D. Calcium
hydroxyapatite
crystals

16. Pictured here is a long‐axis image of the right distal biceps in two different patients. Which of the
following statements best describes the images of the biceps tendon?

A. The image on the left is
normal; the image on the
right demonstrates a tear.
B. The image on the right is
normal; the image on the
left demonstrates a tear.
C. Both images are normal.
D. Both images
demonstrate a tear.

17. Pictured here is a long‐axis image of the right common extensor tendon of the elbow in two
different patients. Which of the following statements best describes the two images?

A. The image on the left
is normal; the image on
the right demonstrates
tendinosis.
B. The image on the
right is normal; the
image on the left
demonstrates
tendinosis.
C. Both images are normal.
D. Both images demonstrate a tendinosis.

18. A 30‐year‐old female presents with
radial‐sided wrist pain. What is the most
likely cause of pain?

A. Ligament tear
B. Nondisplaced fracture
C. Nerve impingement
D. Tenosynovitis

19. Pictured here is a ganglion cyst. What is the most common location for ganglion cysts of the wrist?

A. Volar, between the flexor carpi
radialis tendon and the radial
artery
B. Volar, within the carpal tunnel
C. Dorsal, adjacent to the
scapholunate ligament
D. Dorsal, adjacent to the
triangular fibrocartilage complex

20. A 50‐year‐old female presents with posterior knee pain and the provided images. What is
indicated by the star in the images?

A. Medial head of the
gastrocnemius tendon
B. Semimembranosus tendon
C. Lateral head of the
gastrocnemius tendon
D. Semitendinosus tendon

21. Pictured here are the short‐ (left) and long‐axis (right) images of tendinosis of the Achilles tendon.
Increased blood flow within the tendon on power Doppler images would suggest which of the
following?

A. Inflammation
B. Paratenonitis
C. Neovascularity
D. Tumor

22. A 40‐year‐old male presents with sudden onset of posterior ankle pain while playing tennis.
Which diagnosis is correct based on the long‐axis image?

A. Achilles tendinosis
B. Achilles tear
C. Plantaris tendinosis
D. Plantaris tear

23. Pictured here is a case of plantar fasciitis in long axis.
Which number best represents abnormal thickening of the
fascia?

A. >1 mm
B. >2 mm
C. >3 mm
D. >4 mm

24. A palpable mass is noted on the plantar aspect of the
foot. Based on the long‐axis image, what is the most likely
diagnosis?

A. Plantar fibromatosis
B. Plantar synovial sarcoma
C. Plantar lipoma
D. Plantar neuroma

25. A patient presents with swelling of the medial right thigh.
Based on the provided image, what is the most likely diagnosis?

A. Cellulitis
B. Abscess
C. Necrotizing fasciitis
D. Fat necrosis

26a. A 66‐year‐old male presents with acute pain, swelling, and redness in the left middle finger.

A. Acute fracture
B. Calcified
hematoma
C. Foreign body
D. Soft tissue mass

26b. All soft tissue foreign bodies are initially of which of the following echogenicities?
A. Hypoechoic
B. Hyperechoic
C. Mixed echogenicity

27. A palpable mass is noted in the right upper extremity. The mass has remained stable in size for 2
years and is not painful. Provided are a long‐axis ultrasound image, a long‐axis ultrasound image with
color, and an axial T1 MRI image respectively. Based on the images, what is the most likely diagnosis?

A. Abscess
B. Lipoma
C. Sarcoma
D. Hematoma

28. A palpable mass is noted in the right mid thigh. Provided are a short‐axis ultrasound image, a
short‐axis ultrasound image with color, an axial T1 MRI image, an axial T2 fat saturated MRI image,
and an axial T1 fat‐saturated postcontrast image respectively. The MRI was obtained 2 weeks after the
ultrasound. Based on the images, what is the most likely diagnosis?

A. Liposarcoma
B. Lipoma
C. Undifferentiated
pleomorphic sarcoma
D. Hematoma

Musculoskeletal: Answers and Explanations

1a. Answer A. The normal appearance of a tendon is hyperechoic with a fiber‐like or fibrillar
echotexture, noted by the hyperechoic linear echoes within the tendon. The fibrillar echotexture
within tendon represents the endotendineum, which is a combination of connective tissue, elastic
fibers, nerve endings, blood vessels, and lymph vessels. This appearance is best demonstrated on long‐
axis images (LAX), which is the image on the left. On long‐axis images, the proximal portion of the
structure is by convention placed on the left side of the image. The short‐axis image (SAX) is the image
on the right and is acquired 90 degrees to the long‐axis image, that is to say it is acquired transverse to
the long‐axis image. On each image, the Achilles tendon is superficial or near the top of the image.
Reference: Jacobson JA. Fundamentals of musculoskeletal ultrasound, 2nd ed. Philadelphia, PA: Elsevier, 2013:1.

1b. Answer D. The normal appearance of muscle is hypoechoic with hyperechoic fibroadipose tissue,
known as perimysium, intervening between the muscle bundles. The image on the left is the long‐axis
image whereas the image on the right is the short‐axis image. In both images, the gastrocnemius
muscle is more superficial whereas the soleus is deeper. Fascia separates muscles instead of being
within the muscle. The musculotendinous junction is not included in the provided images.

1c. Answer D. The normal appearance of a nerve is hypoechoic with fascicular echotexture.
Separating the individual hypoechoic nerve fascicles is the hyperechoic epineurium, a type of
connective tissue. This is best demonstrated by the image on the right, which is the short‐axis image,
where the nerve is seen superficially in the middle of the image with a honeycomb appearance of
hypoechoic nerve fascicles separated by hyperechoic epineurium. The image on the left is the long‐axis
image, where the nerve is the more hypoechoic superficial structure with more hyperechoic tendons
immediately deep to it.

1d. Answer B. The normal appearance of a ligament is hyperechoic with a striated appearance. The
ligament may appear less hyperechoic compared to a tendon because they are often adjacent to
hyperechoic fat, which makes the ligament appear less echogenic in comparison. Ligaments contain
striations within them, are more compact than tendons, and connect two osseous structures. The
image is a long‐axis image with the fibula on the left and the talus on the right side of the image.

2a. Answer A. The normal sonographic appearance of hyaline articular cartilage is homogeneously
hypoechoic. As chondromalacia develops, the appearance may change, typically becoming
heterogeneous.

2b. Answer C. The normal sonographic appearance of fibrocartilage is hyperechoic and
homogeneous. Fibrocartilage includes the meniscus of the knee and the labrum of the shoulder and
hip. Though these structures may be partially visualized with ultrasound, this is not typically
considered the preferred method of evaluation for these structures. Tears of the fibrocartilage may be
seen as a hypoechoic cleft within the otherwise hyperechoic structure.

3. Answer A. Anisotropy is an important artifact to consider when imaging ligaments and tendons.
To avoid anisotropy, the ultrasound beam should be perpendicular to the target. If the beam is as little
as 5 degrees off perpendicular to the target, the image may suffer from anisotropy artifact. This artifact
causes the tendon or ligament to appear hypoechoic, which can mimic pathology such as tendinosis.
To confirm the finding is due to anisotropy, simply angle the probe so the beam is once again
perpendicular to the target; if the hypoechogenicity does not persist, it was the result of artifact.

4. Answer B. The provided images are long‐axis images of the patellar tendon, with a portion of the
patella on the left side of the images and tibial tuberosity on the right side of the images. Spatial
compound sonography incorporates sound beams from multiple different angles to form the image.
This improves tissue plane definition; however, it can have a smoothing effect and is more likely to
produce motion blur because the frames are compounded to produce the image. It may also reduce the
conspicuity of a foreign body because it can reduce the artifact associated with the foreign body,
thereby making it more difficult to visualize. In this example, the interface between the surface of the
tendon and adjacent fat is more clearly visualized.

5. Answer A. Tissue harmonic imaging allows harmonic frequencies produced during ultrasound
beam propagation to help produce the image. The benefits of this technique are improved
visualization of deep structures and improved visibility of the surface of joints and tendons. It may also
help visualize the borders of a mass or tendon tear. In this example, the deeper structures and the
surfaces of the bones are more clearly defined.

6. Answer C. The patella is creating reverberation artifact because it has a large radius of curvature
and a smooth surface. This may be referred to as a dirty shadow. If an object has a small radius of
curvature or a rough surface, it may produce a clean shadow.

7. Answer C. The image on the left was obtained with a 9‐MHz linear probe whereas the image on the
right was obtained with a 17‐MHz linear probe. The superficial structures in the image on the right are
more optimally visualized, particularly the echogenic fibrils within the tendon. For musculoskeletal
ultrasound, typically linear probes with frequencies >10 MHz are preferred. Lower frequency probes
may be used to visualize deeper structures. Curvilinear probes may be used for deeper structures as
well, particularly the hip.

8. Answer D. The image on the left is optimized for superficial structures whereas the image on the
right is optimized for deeper structures, both based on the position of the focal zones. The patellar
tendon in the left image is optimally visualized, whereas the tendon in the image on the right is not.
Neither image was obtained with harmonics. Both images were obtained with a 17‐MHz probe. It is
important to always adjust the focal zones over the target to be imaged.

9. Answer B. Strain elastography measures the elastic properties of tissue. The degree of elasticity of
a tissue is determined by the displacement of each structure within the box relative to one another
when they are placed under strain from the ultrasound probe. The less a tissue is displaced, the harder
or stiffer it is. The color scale can differ for each ultrasound manufacturer; in this case, the scale to
right shows that SF (soft) is red whereas HD (hard) is blue. Structures that are hard are not displaced
as much as soft structures. In this case, the tendon is hard relative to the subcutaneous tissues, which
are soft. Therefore, the tendon is displaced less under strain than the subcutaneous tissues.

10. Answer A. The purpose of the Crass and modified Crass position is to bring the supraspinatus
tendon out from under the acromion so it can be visualized. In the neutral position, the acromion
creates shadowing, which obscures a large portion of the supraspinatus tendon leaving it incompletely
evaluated. The Crass technique requires the patient to put the ipsilateral hand behind the back, which
brings the greater tuberosity anterior. The modified Crass technique requires the patient to put the
ipsilateral hand on the ipsilateral hip or as if it is in his or her back pocket. These techniques may
create some discomfort for the patient, particularly in the setting of a tendon tear.
Reference: Jacobson JA. Fundamentals of musculoskeletal ultrasound, 2nd ed. Philadelphia, PA: Elsevier, 2013:8–15.

11. Answer C. The two images were obtained in the modified Crass position, with the ipsilateral hand
positioned behind the patient’s back in the patient’s back pocket. This position brings the
supraspinatus tendon out from under the acromion so it can be visualized; otherwise the acromion
shadow would obscure its evaluation. One helpful way to understand the anatomy depicted in the
images is to realize that the long‐axis image is similar to the appearance of a coronal MRI image
whereas the short‐axis image is similar to a sagittal MRI image. The structures, which are typically
seen from superficial to deep, include the skin, subcutaneous tissue, deltoid muscle, subacromial
subdeltoid bursa, supraspinatus and/or infraspinatus tendon, hyaline articular cartilage, and humeral
cortex. In this case, A represents the deltoid muscle, B the supraspinatus tendon, C the hyaline
articular cartilage, and D the humeral cortex of the greater tuberosity. The hyaline articular cartilage is
the hypoechoic structure overlying the humeral cortex, and its surface is noted by the echogenic
reflection. The normal subacromial subdeltoid bursa either is not visible or is a thin hypoechoic
structure between the deltoid muscle and the tendon. When the bursa contains fluid, such as in
bursitis or a full‐thickness rotator cuff tear, it will distend and become visible. The long‐axis image will
demonstrate either the supraspinatus or infraspinatus tendon whereas the short‐axis image typically
will demonstrate both tendons. The structure labeled E in the short‐axis image is the long head of the
biceps tendon. The subscapularis tendon, which inserts onto the lesser tuberosity, is visualized with a
different technique whereas the teres minor tendon is not typically evaluated with a routine shoulder
ultrasound.

12. Answer C. The first thing to notice in the images is the focal hypoechogenicity of the tendon on
both the long and short‐axis images abutting the hyaline articular cartilage. This focal hypoechoic area
persisted even with changing the angle of the transducer, suggesting it was not the result of anisotropy
artifact. Tears of the rotator cuff tendons are divided into partial‐thickness and full‐thickness tears.
Partial‐thickness tears are then subdivided into articular‐sided tears (meaning the tear extends to the
hyaline articular cartilage but not the bursa), intrasubstance tears (meaning the tear is within the
tendon and does not extend to either the hyaline articular cartilage or the bursa), or bursal‐sided tears
(meaning the tear extends to the subacromial subdeltoid bursa but not the hyaline articular cartilage).
In this case, the tear extends to the hyaline articular surface consistent with an articular‐sided partial‐
thickness tear.

13a. Answer D. The images depict a tear of the supraspinatus tendon that extends from the bursal
surface to the articular surface, consistent with a full‐thickness tear of the entire tendon. The tendon is
retracted several centimeters. There is also a full‐thickness retracted tear of the infraspinatus tendon.

13b. Answer B. The short‐axis image depicts a prominent reflection of the sound beam from the
surface of the hyaline articular cartilage. This is called the cartilage interface sign and is most
commonly seen in the setting of a full‐thickness tear. It is a subjective sign and may also be seen in the
setting of articular‐sided partial‐thickness tears, tendinosis, and even normal tendons. The long‐axis
image depicts herniation of the deltoid muscle into the space the supraspinatus tendon would
normally occupy.
References: Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Berlin, Germany: Springer, 2007:253.
Jacobson JA. Fundamentals of musculoskeletal ultrasound, 2nd ed. Philadelphia, PA: Elsevier, 2013:32.

14. Answer B. The two images depict tendinosis of the proximal long head of the biceps tendon. The
long‐axis image demonstrates tendinosis proximally within the tendon whereas the distal part of the
tendon is normal. Tendinosis is noted on ultrasound as hypoechogenicity within the affected portion
of the tendon with swelling of the tendon. The tendon fibers remain intact; therefore fibers remain
visible within the affected area as seen in this case. Tendinosis is composed of eosinophilic, fibrillar,
and mucoid degeneration. No acute inflammatory cells are seen; therefore the term tendinitis is not
preferred.

15. Answer D. There is diffuse hyperechogenicity within the tendon on both the long‐axis and short‐
axis images. This is the result of calcium hydroxyapatite deposition disease, also known as calcific
tendinosis. The crystals may be within the tendon or within the overlying subacromial subdeltoid
bursa. The crystals may cause shadowing. Calcifications that are amorphous and without shadowing
are typically more painful. Percutaneous lavage and aspiration can be performed to help with
symptoms. Tendon sutures may also be hyperechoic, but individual sutures may be visualized, and
they do not typically occupy the entire tendon. Also, there may be associated osseous anchors in the
humeral head. Uric acid crystals are not typically within the tendon but instead reside on the surface of
the hyaline articular cartilage.

16. Answer B. The image on the left demonstrates a tear whereas the image on the right is normal.
The normal image demonstrates the distal biceps tendon inserting onto the radial tuberosity, whereas
the abnormal image demonstrates the tendon to be torn and retracted with an empty space containing
blood products where the tendon should reside. Two important things to remember about the distal
bicep tendon: First, the distal tendon does not have a tendon sheath, and second, when it tears, the
description of the tear should include the stumps’ location relative to the lacertus fibrosus.

17. Answer A. The image on the left is normal whereas the image on the right demonstrates
tendinosis. The osseous structure on the left side of each image is the lateral epicondyle whereas the
osseous structure on the right side of each image is the radial head. The common extensor tendon
originates from the lateral epicondyle. The normal appearance of the tendon is hyperechoic whereas
tendinosis is seen as a more hypoechoic tendon with an outwardly convex margin due to swelling of
the tendon. There is often irregularity of the cortex of the lateral epicondyle in cases of tendinosis. In
our case, there is also a component of mild interstitial tearing of the tendon on the background of
tendinosis. Tendinosis of the lateral epicondyle is often called tennis elbow.

18. Answer D. The image depicts tenosynovitis of compartment 1 of the dorsal wrist, known as de
Quervain disease. The tenosynovitis is seen in this case as synovial thickening within the tendon
sheath. Tenosynovitis can also be seen as fluid or hyperemia within the tendon sheath, tendinosis, or
irregularity of the adjacent radius. Compartment 1 contains the abductor pollicis longus and extensor
pollicis brevis tendons.

19. Answer C. Ganglion cysts are the most common masses of the wrist. Their most common location
is the dorsal wrist arising adjacent to the scapholunate ligament. The second most common location is
the volar wrist between the flexor carpi radialis tendon and radial artery, which is what is pictured in
this case. Ganglion cysts may appear as a simple anechoic cyst with no nodularity and increased
through‐transmission. However, the appearance of ganglion cysts can be highly variable; therefore,
understanding the common locations for these masses helps make a more confident diagnosis when
the ultrasound appearance is not that of a classic cyst.

20. Answer A. Baker cyst is a common finding that can be seen in up to 50% of patients over the age
of 50 years. It is most commonly the result of distention of the semimembranosus–medial
gastrocnemius bursa with fluid from the knee joint due to a communication of the joint and bursa. The
communication is acquired from both an increased intra‐articular pressure due to joint fluid resulting
from internal derangement and degenerative weakening of the joint capsule. The key to diagnosing a
Baker cyst is visualizing the communication it has with the knee joint. This is noted by a concave
lateral fluid collection with a classic C‐shape that wraps around the medial head of the gastrocnemius
tendon (noted by the star in the images). The cyst courses between the medial head of the
gastrocnemius tendon and the semimembranosus tendon, which is not well visualized in the images. It
is important to visualize this appearance because not all cystic‐appearing structures in the posterior
knee actually represent a Baker cyst. Baker cysts may include complex fluid, hemorrhage, or synovial
hypertrophy such as in pigmented villonodular synovitis. Therefore, not all Baker cysts are anechoic.

This can therefore lead to confusion as some sarcomas may mimic a Baker cyst; however, identifying
the classic C‐shaped appearance provides confidence in the diagnosis. The lack of vascularity on the
color image also suggests that the diagnosis of a cyst is more likely.

21. Answer C. Increased flow within a tendinotic tendon on color or power Doppler images suggests
neovascularity within the tendon. Power Doppler is the preferred method of evaluation between the
two. This neovascularity is typically a random pattern of vessels within the tendon and can be seen in
severe cases of tendinosis. Dry needling or tenotomy of the tendon can be used to make the tendon
bleed, which causes growth factors to be released and stimulates healing of the tendon. Some have
looked at sclerosing the vessels within the tendon to promote healing. Tendinosis is the preferred
term instead of tendinitis because this does not represent a true inflammatory process. Paratenonitis
would demonstrate increased blood flow surrounding the tendon within the paratenon but not within
the tendon. This is because the Achilles tendon is surrounded by a paratenon instead of a synovial
sheath.
Reference: Jacobson JA. Fundamentals of musculoskeletal ultrasound, 2nd ed. Philadelphia, PA: Elsevier, 2013:308–315, 364–367.

22. Answer B. The image demonstrates a full‐thickness tear of the Achilles tendon. The Achilles
tendon typically tears approximately 2 to 6 cm proximal to the calcaneal insertion of the tendon. A gap
is seen between the tendon stumps, which often fills with a combination of hemorrhage and fat from
Kager fat pad. The plantaris tendon is stronger than the Achilles tendon and is seen along the medial
border of the Achilles tendon. An intact plantaris tendon in the setting of a full‐thickness Achilles tear
can be mistaken for a partial‐thickness Achilles tear with the medial portion of tendon being intact.
Plantar and dorsiflexion dynamic maneuvers can help determine if there is a partial‐ or full‐thickness
tear.

23. Answer D. Plantar fasciitis, or plantar fasciopathy as it is sometimes called because it does not
truly represent an inflammatory process, is typically the result of repetitive microtrauma,
degeneration, and/or edema. Thickening of the fascia in long axis of >4 mm is typical of this diagnosis.
An acute partial‐thickness tear may also present as thickening with a torn portion of the fascia. A full‐
thickness tear will have complete disruption of the fascia.

24. Answer A. The hypoechoic, elongated mass near the top of the image is contiguous with the
plantar fascia, consistent with plantar fibromatosis. This results from fibroblastic proliferation. It often
occurs in multiple sites and is bilateral. The imaging appearance is nonspecific; therefore the diagnosis
is based more upon the location of the mass and its continuity with the plantar fascia. Neuromas,
sarcomas, and lipomas are less likely to be located along the plantar surface of the foot.

25. Answer A. This image depicts cellulitis of the medial thigh. Cellulitis initially appears hyperechoic
with thickened subcutaneous tissues. Over time, the appearance may change to hypoechoic or
anechoic branching fluid channels, as noted in this case. These channels, with time, may merge
together leading to the formation of an abscess. Necrotizing fasciitis is noted by anechoic perifascial
fluid with gas within the deep fascia. Gas will create either a dirty shadowing or comet‐tail artifact. Fat
necrosis is typically more focal than cellulitis, though it may also have a hyperechoic appearance.

26a. Answer C. US images in the region of concern show a linear echogenic structure in the soft
tissue of the finger with mild surrounding edema and hyperemia. The findings are consistent with
presence of a small foreign body in the soft tissues.
Reference: Hertzberg BS, Middleton WD. Ultrasound: the requisites. Philadelphia, PA: Elsevier, 2016:276.

26b. Answer B. At sonography, all foreign bodies are initially hyperechoic, regardless of their
composition. The brightness of the reflection may vary with the size and type of the foreign body as
well as its orientation with respect to the ultrasound beam. The surface of the foreign body is more
echogenic and conspicuous when the sound beam is perpendicular to the surface of the foreign body.
Foreign body artifact depends on the surface attributes of the foreign body more than on its internal
composition. For example, a foreign body with a smooth and flat surface, such as glass, produces
posterior reverberation artifact. A foreign body with an irregular surface and small radius of curvature
usually shows posterior shadowing. Many foreign bodies show both shadowing and reverberation
artifact.
Inflammatory tissue may surround the foreign body and produce a hypoechoic halo. Abscess
formation will appear as a complex fluid collection. In many cases, color Doppler will show an
inflammatory hyperemia surrounding the foreign body.
Although ultrasound can accurately identify and localize all soft tissue foreign bodies, it is most
important in evaluation of foreign bodies that are not radiopaque on radiography, such as those
composed of wood or plastic.
References: Hertzberg BS, Middleton WD. Ultrasound: the requisites. Philadelphia, PA: Elsevier, 2016:276.
Middleton WD, Teefey SA, Boyer MI. Sonography of the hand and wrist. Ultrasound Q 2001;17:21–36.

27. Answer B. Soft tissue lipomas are common masses. They may occur anywhere, but most
commonly they involve the shoulder, upper extremity, trunk, and back. They may be within the
subcutaneous tissue, muscle, or tissue planes. The most common sonographic appearance is a
homogeneous, isoechoic or minimally hyperechoic mass, with little or no vascularity on color or power
Doppler. The mass should be soft and pliable when pressure from the transducer is applied. If a
lipomatous mass is growing in size or becomes painful, then MRI should be considered to evaluate for
a potential liposarcoma.

28. Answer D. The sonographic appearance of a hematoma varies over time. Initially, fresh fluid may
be highly reflective resembling a pseudosolid appearance. Later in its course, the hematoma becomes
anechoic as a result of liquefaction of the clot. Thin strands may be seen within the hematoma because
of fibrin organization, as in this case. Fluid levels may also be seen. The MRI appearance in this case
with a thin enhancing rim is typical of a hematoma once it has liquefied. A sarcoma would have
internal enhancement within the mass.
Reference: Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Berlin, Germany: Springer, 2007:26–27.

3. A 86‐year‐old male with a history of usual interstitial
pneumonia (UIP) pattern pulmonary fibrosis was incidentally
found to have a new right lung nodule on a radiograph and CT
scan of chest. Shown here is an image from ultrasound of the
right chest demonstrating the nodule. What is the next best
step in management of the nodule?

A. The appearance is classic for pleural effusion. No biopsy is
required.
B. The sonographic appearance is nonspecific, and
ultrasound‐guided biopsy should be performed to assess for
possible malignancy.
C. The patient should be transferred to a CT suite as lung masses cannot be biopsied under ultrasound
guidance.
D. The sharply defined deep margins suggest consolidation. Treat with antibiotics.

4. A 80‐year‐old woman with detected abdominal mass. Shown here are axial CT image of lower
abdomen and transverse ultrasound image of right lower quadrant. What is the next best step in
management of this patient?

A. The hyperechoic area around
the hypoechoic lobulated mass
suggests acute bleed.
Mesenteric catheter angiogram
should be performed on an
emergent basis.
B. There is no safe approach to
perform percutaneous biopsy of
the mass. Laparoscopic biopsy is the only way to sample the mass.
C. The apparent “mass” seen on CT scan is unopacified small bowel and has characteristic ultrasound
appearance of normal small bowel. No further evaluation is necessary.
D. Ultrasound‐guided fine needle aspiration of the mass can be safely performed with needle
traversing the surrounding bowel loops.

5. A 24‐year‐old male presents with complaint of a 1‐cm nontender palpable nodule in the right groin.
Images from targeted sonography of the lesion of concern are shown. What is the most likely
diagnosis?

A. Spermatocele
B. Incomplete
descended testis
C. Indirect inguinal
hernia
D. Encysted hydrocele
of the cord

6. A 25‐year‐old female recently established care with a new primary care physician and presented
for her first annual routine visit. She is sent from her primary care physician’s office for evaluation of
an imaging finding seen on an outside hospital CT scan from 5 years prior. She is asymptomatic. What
is the most likely diagnosis?

A. Pseudomyxoma peritonei
B. Abdominal abscess
C. Lymphangioma
D. Urinoma

7. With regard to relative ultrasound power, what is the difference in ultrasound power
corresponding to an increase of 3 dB?
A. Doubling
B. Half
C. 10‐fold
D. 100‐fold

8. Which of the following are components of spatial resolution in ultrasound?
A. Axial, elevational, and coronal resolution
B. Axial, coronal, and sagittal resolution
C. Axial, sagittal, and elevational resolution
D. Axial, lateral, and elevational resolution

9. A 28‐year‐old male presents with painful bulge in right lower abdomen 3 weeks following right
lower quadrant renal transplant. What is the most likely etiology of his symptoms based on the
ultrasound images?
A. Pseudoaneurysm of the
inferior epigastric artery
B. Peritransplant
lymphocele with internal
fluid turbulence
C. Elevated resistive index
suggesting transplant
rejection
D. Anastomotic stenosis of
the transplant renal artery

10a. A 58‐year‐old female has a palpable mass near the umbilicus.
Sagittal image of the abdominal wall is shown. What is the most
likely diagnosis?

A. Incarcerated umbilical hernia containing strangulated bowel
B. Abdominal wall hematoma
C. Desmoid tumor
D. Umbilical hernia containing fat

10b. This patient had marked tenderness to compression with the probe. What does this finding
suggest?
A. Infection
B. Presence of strangulated bowel
C. Nothing
D. Potentially clinically significant hernia

11a. A 20‐year‐old male with right groin swelling. Three sagittal images from a cine sequence during
valsalva maneuver of the right groin and upper scrotum and a corresponding sagittal color flow image
are shown. Which vessel is indicated by the orange and yellow color signal?

A. External iliac artery
B. Femoral artery
C. Internal iliac artery
D. Inferior epigastric artery

11b. What is the diagnosis?
A. Direct inguinal hernia containing fat
B. Indirect inguinal hernia containing fat
C. Direct inguinal hernia containing bowel
D. Indirect inguinal hernia containing bowel

12. A 72‐year‐old male presents with weight loss, night sweats, and mildly elevated liver enzymes.
Which of the following is shown?

A. Pancreatic head mass
B. Periportal lymphadenopathy
C. Left hepatic mass
D. Hilar cholangiocarcinoma

13. An ultrasound‐guided biopsy is requested for an abdominal wall 1.5‐cm subcutaneous nodule
found to have intense FDG uptake on PET‐CT. Which of the following transducers is best tailored for
this purpose?
A. Phase array transducer
B. Linear array transducer
C. Curved array transducer
D. Mechanical transducer

14. Which of the following is a specular reflector?
A. Liver
B. Diaphragm
C. Spleen
D. Uterus

15. What is the distance of the transducer from a reflector if the time from the transmission of pulse
to return of echo is 0.125 ms (velocity of sound is 1,540 m/s)?
A. 7.625 cm
B. 8.625 cm
C. 9.625 cm
D. 10.625 cm

16. A minimum of 75 AMA Category 1 CME credits is required every 3 years. This satisfies which of
the following four parts of the Maintenance of Certification?
A. Professional Standing
B. Lifelong Learning and Self‐Assessment
C. Cognitive Expertise
D. Practice Quality Improvement

17. Which of the following errors occur at the sharp end of a process?
A. Organizational errors
B. Active errors
C. Latent errors
D. Equipment errors

Peritoneal Space, Retroperitoneum, Abdominal Wall,

and Chest: Answers and Explanations
1a. Answer A. The image shows irregular peritoneal soft tissue thickening anteriorly and small
volume abdominal ascites. In a male patient, metastatic disease from GI primary is the most common
cause of peritoneal carcinomatosis. Although malignant mesothelioma could have a similar
appearance, this condition is less common. Cirrhosis with associated portal hypertension is a common
cause of ascites. Simple ascites from portal hypertension is not accompanied by peritoneal soft tissue
mass as shown in this case.

1b. Answer A. As in pleural mesothelioma, asbestos exposure has been shown to be a risk factor for
peritoneal mesothelioma. Smoking is not a reported risk factor for mesothelioma. Tuberculous
peritonitis is an infectious disorder, which may result in similar imaging findings including ascites, but
is not considered a risk factor for mesothelioma. Mesothelioma is more common in men than women.
References: Diop AD, Fontarensky M, Montoriol PF, et al. CT imaging of peritoneal carcinomatosis and its mimics. Diagn Interv
Imaging 2014;95:861–872.
Levy AD, Shaw JC, Sobin LH. From the archives of the AFIP: secondary tumors and tumorlike lesions of the peritoneal cavity:
imaging features with pathologic correlation. RadioGraphics 2009;29:347–373.
Park JY, Kim KW, Kwon HJ, et al. Peritoneal mesotheliomas: clinicopathologic features, CT findings, and differential diagnosis. AJR
Am J Roentgenol 2008;191:814–825.

2. Answer D. The first image shows a hypoechoic, heterogeneous soft tissue mass with irregular
margins in the abdominal wall at the site of c‐section scar. The second image shows a feeding vascular
pedicle entering the mass. The history and imaging features are characteristic of scar endometrioma.
Scar endometriomas most commonly develop following c‐section or hysterectomy but have also been
reported in laparoscopic trocar tracts, amniocentesis needle tracts, episiotomy sites, and in the vulva
following excision of Bartholin gland cyst. Many patients with scar endometriosis do not have signs or
symptoms of peritoneal endometriosis, leading many to believe that endometrial cells are transported
to ectopic sites, particularly during surgical procedures that open the uterus. Women with
symptomatic scar endometriosis present with a small, tender abdominal or pelvic wall mass at a
previous surgical incision site—usually previous c‐section, hysterectomy, or other
gynecologic/obstetric procedure. Typically symptoms occur at the time of menses and include
abdominal or pelvic wall pain and swelling. However, some patients are asymptomatic. Painful
swelling may worsen during coughing and exertion and may be confused with postoperative hernia.
Recurrent cyclical pain, a result of response to monthly ovulatory hormonal influences, is essentially
diagnostic of scar endometriosis.
Desmoid tumors (choice A) are rare fibromatous lesions that do not metastasize but can be locally
invasive and recur locally following surgery. They frequently occur at incision sites. They may be
sporadic or associated with Gardner syndrome. Although there is overlap in imaging features with scar
endometriosis, the clinical history of worsening pain during menstruation is typical of scar
endometriosis, not desmoid tumor. Stitch granuloma (choice B) may have a similar imaging
appearance and occur at the site of scar, but the history of worsening symptoms at menses is typical of
scar endometriosis, not stitch granuloma. Hematoma (choice C) would be avascular and would not
have a feeding vascular pedicle. The history is also not consistent with hematoma.
References: Gidwaney R, Badler R, et al. Endometriosis of abdominal and pelvic wall scars: multimodality imaging findings,
pathologic correlation, and radiologic mimics. RadioGraphics 2012;32(7):2031–2043.

3. Answer B. The sonographic appearance is not classic for effusions, consolidation, or atelectasis.
The sharply defined deep margins are suspicious for a lung tumor. Pleural‐based masses, especially
the larger ones, if visible at ultrasound, can be safely and quickly biopsied under ultrasound guidance.
Ultrasound‐guided percutaneous biopsy in this patient revealed small cell carcinoma of the lung.
A. Choice A. The lesion is not anechoic to convincingly suggest an effusion. Also, the lobulated margins
of the lesion argue against a collection.
B. Choice C. When visible, pleural‐based lung masses can be biopsied under ultrasound guidance. In
fact, ultrasound‐guided biopsy not only is safe but also has additional advantages over CT scan. These
include lack of ionizing radiation, ability to continuously visualize biopsy needle in real time during
respiration, and the option to choose from multiple angles of needle trajectory.
C. Choice D. The well‐defined deep margins of the lesion favor a tumor. Consolidation tends to have
poorly defined deep margins and contains sonographic fluid‐ or air bronchograms within.
Rumack CM, Wilson SR, et al. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Mosby, 2011:603–619.

4. Answer D. The hypoechoic mass is surrounded by small bowel loops along the anterior and lateral
aspects, but this does not preclude percutaneous biopsy as trans‐enteric fine needle aspiration is safe.
A. Choice A. The hyperechoic area around the mass represents mesenteric/omental fat and not blood.
Hematoma is anechoic in the acute stages and later often evolves into a complex collection with
variable hypo to anechoic components, septations, and layering debris.
B. Choice B. Laparoscopic biopsy is not the only option for sampling the mass. A less invasive and quick
option is ultrasound or CT scan–guided trans‐enteric biopsy.
C. Choice C. Typical ultrasound gut signature consists of outer thin hypoechoic rim representing the
muscularis mucosa and muscularis propria, and an inner echogenic mucosa–lumen interface. In the
image, the lesion is lobulated and heterogeneously hypoechoic throughout without the classic
sonographic gut signature, suggesting a mass rather than normal bowel.
References: Carberry GA, Lubner MG, Wells SA, et al. Percutaneous biopsy in the abdomen and pelvis: a step‐by‐step approach.
Abdom Radiol 2016;41(4):720–742.
Rumack CM, Wilson SR, et al. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Mosby, 2011:270–271.

5. Answer D. Ultrasound images show an anechoic oval structure along the right inguinal canal
superior to and separate from the right testis and epididymis. No vascular flow is present within the
cystic lesion. This represents an encysted hydrocele of the cord. Encysted hydrocele of the cord
(hydrocele of the spermatic cord) is a rare anomaly that results from an aberration in the closure of
the processus vaginalis. It is a loculated fluid collection along the spermatic cord, separate from the
testis and the epididymis and located above them.
There are three types of spermatic cord hydroceles: communicating, funicular, and encysted.
A communicating hydrocele is associated with complete patency of the processus vaginalis. At US, it
appears as a fluid collection that extends from the pelvis through the deep inguinal ring to the
scrotum. A funicular hydrocele is a result of abnormal obliteration of the deep inguinal ring, with
constriction just above the testis. At US, it resembles a peritoneal diverticulum, appearing as a fluid
collection that communicates with the peritoneum at the deep inguinal ring and that does not
surround the testicle. Funicular hydroceles become larger with increased intraperitoneal pressure
during straining and smaller during relaxation. An encysted hydrocele is enclosed between two
constrictions at the deep inguinal ring, just above the testis. It does not communicate with the
peritoneum. An encysted hydrocele may be located anywhere along the spermatic cord. It may be any
size or shape, but it does not change with increased peritoneal pressure. At US, an ovoid or a round

mass is seen in the groin along the spermatic cord; internal echogenicity varies depending on the
contents.
Spermatoceles (choice A) are cystic lesions that occur in the head of the epididymis and are filled with
spermatozoa‐containing fluid. Low‐level echoes and septations can be seen in the lumen of
spermatoceles. A normal descended testis is shown inferior to the encysted hydrocele. Therefore,
choice B is incorrect. The images here do not show any herniation of mesenteric fat or bowel loops
into the inguinal canal or scrotum. Therefore, choice C—indirect inguinal hernia is incorrect.
References: Garriga V, Serrano A, Marin A, et al. US of the tunica vaginalis testis: anatomic relationships and pathologic conditions.
RadioGraphics 2009;29(7):2017–2032.

6. Answer C. A CT image from 5 years prior shows a low attenuation lesion occupying the periportal
space, encasing multiple vessels, and conforming to the surrounding structures. Ultrasound evaluation
of this lesion shows multiple thin‐walled small cystic spaces. In an asymptomatic patient who has had
this lesion for several years, the most likely diagnosis from the choices provided would be an
abdominal lymphangioma.
Lymphangiomas are benign lesions of vascular origin that show lymphatic differentiation. They occur
predominantly in the cervical and axillary regions. They are quite rare in the peritoneal cavity. In the
abdomen, lymphangiomas occur most commonly in the mesentery, followed by the omentum,
mesocolon, and retroperitoneum.
Histologically, lymphangiomas are thin‐walled cystic masses. They may contain large macroscopic
cysts or microscopic cysts. The dilated lymphatic spaces are lined with attenuated endothelial cells
resembling the cells that line normal lymphatics.
The ultrasonographic appearance of lymphangioma is described as a cystic lesion with multiple thin
septa (honeycomb or cobweb pattern). CT may show enhancement of the cyst wall and septae. The
fluid component is typically homogeneous with low attenuation values. On MRI, the cyst contents are
low in signal intensity on T1‐weighted images and high in signal intensity on T2‐weighted images.
Magnetic resonance imaging is the most useful preoperative radiological tool for diagnosis and in
surgical planning.
Choice A. Pseudomyxoma peritonei (PMP)—would not be expected to be stable over several years.
The low attenuation lesion in this case has smooth borders on CT scan. There is no evidence of
scalloping of the liver surface, which is commonly seen with PMP.
Choice B. Abdominal abscess—is a collection of purulent material in the abdomen. It would be
accompanied by constitutional symptoms such as pain and fever.
Choice D. Urinoma—would not be expected to be seen in an otherwise healthy, asymptomatic patient.
Moreover, the low attenuation lesion in this case is not in the perinephric space, which is where a
urinoma would be expected to be seen.
References: Levy AD, Cantisani V, Miettinen M. Abdominal lymphangiomas: imaging features with pathologic correlation. AJR Am J
Roentgenol 2004;182(6):1485–1491.
Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 2‐Volume set, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:529.

7. Answer A. The decibel scale is used to compare different levels of ultrasound power. The decibel
value equals 10 times the log10 of the ratio of the intensities being compared. In this example, 10(log10 ×
2) = 3 dB. It follows that‐3 dB corresponds to halving of acoustic power. A 10‐fold increase in sound
intensity corresponds to 10(log10 × 10) = 10 dB. A 100‐fold increase in sound intensity corresponds to
10(log10 × 100) = 20 dB.
Sciences, 2011:7.

8. Answer D. Axial, lateral, and elevational resolution are the three components of spatial resolution
in ultrasound. Axial resolution is the ability to separate two closely spaced objects in the direction of
the ultrasound beam. Lateral resolution is the ability to separate two closely spaced objects
perpendicular to the direction of the ultrasound beam. Elevational/slice thickness resolution is
perpendicular to the image plane.

9. Answer A. Ultrasound images show relatively normal appearance of the right lower quadrant
renal transplant. Targeted imaging of the right lower abdomen shows a lenticular heterogeneous
lesion most consistent with rectus sheath hematoma. Color Doppler interrogation shows classic “yin‐
yang” pattern of color flow in the central anechoic portion. Spectral Doppler interrogation shows to‐
and‐fro pattern of blood flow indicating blood flow into the pseudoaneurysm during systole and out of
the pseudoaneurysm during diastole. In this location, this most likely is secondary to iatrogenic injury
to the right inferior epigastric artery.
No significant peritransplant fluid collection is shown. Moreover, internal fluid turbulence is neither
expected in a lymphocele nor will it show the typical to‐and‐fro pattern as shown here. So, choice B is
incorrect.
Spectral Doppler interrogation of the cystic lesion in the anterior abdominal wall is shown, with
waveform typical of pseudoaneurysm. This does not indicate transplant rejection. So, choice C is also
incorrect.
The transplant renal artery is neither shown nor interrogated on these images. So, choice D is also
incorrect.
2011:138–139.

10a. Answer D. A deep fascial defect with a narrow neck is demonstrated. Echogenic tissue without
bowel wall signature, compatible with fat, is seen to extend through the defect. The imaging
appearance is consistent with fat‐containing umbilical hernia. Umbilical hernias are a result of dilated
umbilical rings.

10b. Answer D. Sonographic evaluation of abdominal wall hernias should seek to determine the
location, type, reducibility, size, and contents of the hernia. The presence or absence of hernia
tenderness may indicate whether the hernia is clinically significant or incidental.
Sciences, 2011:504–508.

11a. Answer D.

11b. Answer: B. Valsalva cine
sequence demonstrates a sliding
hernia containing echogenic
tissue directed toward the
scrotum (yellow arrows). This has
a similar echotexture to adjacent
fat within abdominal wall, and no
bowel wall signature or
associated gas artifact is
demonstrated. This is a fat‐
containing inguinal hernia. The
inferior epigastric artery arises
from the distal external iliac
artery and travels medially and
superiorly along the posterior
surface of the rectus abdominus
muscle. The internal inguinal ring
is located between the angle
formed between the distal external iliac artery and the origin of the inferior epigastric artery. As the
inguinal canal courses inferiorly and medially, it crosses the inferior epigastric artery by passing
superficially over it. This example shows the relationship of the herniated tissue passing anterior to
the inferior epigastric artery (blue arrow), confirming an indirect hernia. In contrast, direct inguinal
hernias originate at a weak point within the transversalis fascia medial and inferior to the inferior
epigastric artery origin. Both types of inguinal hernia exit through the superficial inguinal ring, but
only the indirect hernia can enter the scrotum.
Sciences, 2011:490–497.

12. Answer B. Ultrasound images depict several large round masses at the porta hepatis and
adjacent to the pancreatic head. The imaging appearance is consistent with enlarged periportal lymph
nodes. There is mild mass effect on the common bile duct resulting in mild intrahepatic biliary ductal
dilatation. Vessels at the porta hepatis are encased by the lymph nodes but are patent. Enlarged
abdominal lymph nodes can be seen in infectious, inflammatory, and neoplastic processes. However,
concern for malignancy increases with increasing size of the lymph nodes, as in this case. Enlarged
lymph nodes can be difficult to detect as they may be isoechoic to the adjacent solid abdominal organs.
A pancreatic head mass (choice A) is unlikely as no pancreatic ductal dilatation is shown. Patients with
pancreatic head adenocarcinoma typically present with painless jaundice because of the infiltrative
nature of pancreatic cancer resulting in pancreatic and biliary ductal dilatation. The lesions shown are
separate from the liver parenchyma. Therefore, they are unlikely to represent hepatic masses (choice
C). Hilar cholangiocarcinoma (choice D) is difficult to visualize on ultrasound and usually manifests as
intrahepatic biliary ductal dilatation with abrupt termination of the bile ducts at the level of the hilar
mass. It is often poorly defined and usually isoechoic to the liver parenchyma.

13. Answer B. Linear array transducers have the crystal elements placed on a flat linear surface so
that a rectangular image is produced. Groups of adjacent elements are activated to produce each sound
pulse. These have the advantage of very high resolution when evaluating superficial structures but
have a limited depth of field.
A linear transducer will be best suited for biopsy in this case. Phase array probes are smaller and all of
the crystals are activated with each pulse. These generate a sector image through the use of beam
steering. They produce a wide field of view for deeper structures but a very small field of view for
superficial tissues. The small transducer size permits their use when the patient’s anatomy or
presence of external hardware and bandages precludes the use of a larger probe. Curved array
transducers are designed to image both superficial and deeper tissues with a large field of view by
arranging the crystals along a curved plane but have a lower spatial resolution than their linear array
counterparts. Mechanical transducers are rarely used and rely on oscillation or rotation of a single
piezoelectric crystal, which both transmits and receives sound.

14. Answer B. Specular reflectors are large and smooth surfaces that reflect sound like a mirror
when the ultrasound beam strikes them at 90 degrees and produce a strong echo. Diaphragm is an
example of a specular reflector.
Solid organs such as the liver, spleen, and uterus are diffuse reflectors. They have much smaller
interfaces that are smaller than the wavelength of sound used for imaging. The echoes from these
interfaces are scattered in all directions. This accounts for the characteristic echo patterns seen in
solid organs and tissues.
2011:5–6.

15. Answer C. If an ultrasound pulse is transmitted into the body and the time until an echo returns
is measured, the depth of the interface that generated the echo can be calculated, provided the
propagation velocity of sound for the tissue is known. In this case, the time from the transmission of
pulse to return of echo is 0.125 milliseconds, that is 0.000125 seconds. Therefore, the distance that the
sound has traveled must be 1540 m/s × 0.000125 seconds = 0.1925 m = 19.25 cm. The time in
milliseconds provided here includes the time for sound to travel to the reflector and then return along
the same path to the transducer (i.e., time for return trip). Therefore, the distance from the transducer
to the reflecting interface must be 19.25 cm/2 = 9.625 cm.
2011:4.

16. Answer B. The ABR Maintenance of Certification (MOC) program builds on the validity of the
initial certification process and provides a framework for self‐regulation by the profession to improve
quality of care. The program evaluates, on a continuous basis, the six essential competencies initially
developed in residency training: Medical knowledge, Patient care and procedural skills, Interpersonal
and communication skills, Professionalism, Practice‐based learning and improvement, and Systems‐
based practice. MOC uses four parts to evaluate these competencies. These are:
1. Evidence of Professional Standing
 This part requires valid, unrestricted licensure in all states of practice.
2. Lifelong Learning and Self‐Assessment
 A minimum of 75 AMA Category 1 CME credits is required every 3 years. At least 25 of these
must be Self‐Assessment CME (SA‐CME).
3. Cognitive Expertise
 This part requires passing the most recent summative decision for the online longitudinal
assessment or passing a traditional exam in the previous 5 years.
4. Practice Quality Improvement (PQI)
 Diplomates complete at least one Practice Quality Improvement (PQI) Project OR Participatory
Quality Improvement Activity every 3 years.
Reference: Maintenance of Certification (MOC)—The American Board of Radiology. Accessed September 24, 2016.

17. Answer B. Sharp end of a process is the actual person who performs the process/task. Example—
a surgeon who holds the scalpel or a nurse who administers medication to the patient. In contrast,
blunt end are parts of the process farther away from the action itself. Regulators, accreditors,
administrators, and designers function at the blunt end.
Active errors occur at the sharp end of the process. They are errors that occur at the point of interface
between humans and a complex system.
Latent errors occur at the blunt end. These are decisions made away from the bedside that impact
care. Latent errors are hidden problems within health care systems that contribute to adverse events.
The other two answer choices—organizational errors and equipment error are also examples of latent
errors.
References: The American Board of Radiology. Quality & safety domain specification & resource guide, 2016.
Swiss Cheese Model—Anatomy of an Error. Duke University. Accessed September 26, 2016.

Index

A Amnionicity
Abdominal abscess Amylase
Abdominal aortic aneurysm (AAA), annual risk Anencephaly
of rupture Aneurysm, fusiform
Abdominal radiograph Angiomyolipoma (AML)
Abdominal wall Anisotropy
hernia Aortic dissections
umbilical hernias Appendicitis, acute
Abnormal liver enzymes Arcuate ligament
Absorption Arterial pseudoaneurysm
Achilles tendon Arteriovenous malformation (AVM)
full‐thickness tear Artifact
Acoustic impedance aliasing
Acoustic shadow blooming
ACR Appropriateness Criteria comet‐tail
ACR LI‐RADS v2017 dropout
Acrania focal zone banding
Active errors foreign body
Acute appendicitis mirror
Acute cholecystitis refraction
gangrenous cholecystitis refractive edge shadow
uncomplicated reverberation
Adenoma, pleomorphic ring‐down
Adenomyomas side lobe
Adenomyomatosis speed propagation
Adenomyosis tissue vibration
Adrenal cortical carcinoma transducer crystal malfunction
Adrenal gland twinkle
Adrenal myelolipoma Augmentation
Adrenal pseudocyst Autosomal‐dominant polycystic kidney disease
Adrenocorticotropin (ACTH) (ADPKD)
Alcohol abuse Axial resolution
Alobar holoprosencephaly B
American College of Radiology (ACR) Baker cyst
American College of Radiology TI‐RADS BCS. See Biliary cast syndrome (BCS); Budd‐
committee Chiari syndrome (BCS)
American Institute of Ultrasound in Medicine Biliary cast syndrome (BCS)
(AIUM) Biliary cyst, Roux‐en‐Y hepaticojejunostomy
2015 American Thyroid Association (ATA) Biliary
guidelines bile

biliary, cholangio‐ Cluster of grapes sign
Caroli disease Color‐flow image
cholangitis Comet‐tail artifact
choledochal cyst Common bile duct
choledochocele Common duct (CD)
choledocholithiasis Congenital adrenal hyperplasia (CAH)
comet‐tail Control chart
common duct Crass technique
ERCP Crossed renal ectopia
Bladder cancer Crown‐rump length (CRL)
risk factor Cryptorchidism
types Cyst(s)
Bladder diverticula baker
Blood vessels, laminar flow choledochal
Blooming artifact dermoid
Branchial cleft cyst (BCC) echinococcal
Bronchopulmonary (BP) sequestration ganglion
Budd‐Chiari syndrome (BCS) hemorrhagic
C lymphoepithelial
Cardiac activity, in embryos renal cell carcinoma
Cardiac chambers TDC
Cardiac mass thyroglossal duct
Caroli disease D
Carotid artery Duplex US De Quervain thyroiditis
Carotid body tumors Decibel scale, of ultrasound power
Cartilage interface sign Deep infrapatellar bursa
Caudate lobe Deep vein thrombosis (DVT)
Cavernous transformation vessel expansion
Cavitation Desmoid tumors
Cellulitis Diabetes mellitus
Central dot sign Doppler angle
Cervical funneling Doppler ultrasound
Cervical lymph node arcuate ligament
Chemotherapy‐induced steatosis color Doppler artifact
Chiari II malformation color Doppler image
Cholangiocarcinomas color Doppler interrogation
Cholecystectomy color Doppler sensitivity
Cholecystitis, acute color Doppler signal
gangrenous intralesional Doppler flow
uncomplicated lack of color Doppler flow
Choledochal cysts pulse repetition frequency
Choledochoceles spectral Doppler aliasing
Cholelithiasis spectral Doppler interrogation
Cholesterol polyps spectral Doppler waveform
Cholesterolosis tissue vibration artifact
Choriocarcinoma Dropout artifact
Chorionicity Duplex Doppler images
Cirrhosis Dwell time

E comet‐tail artifact
Echinococcal cysts polyps
Echogenic clot pseudo‐sludge
Ectopic pregnancy wall
Emphysematous pyelitis/Emphysematous thickening
pyelonephritis (EPN) Gallstones
Endometrial polyp Ganglion cyst
Endometrioid carcinoma Gartner duct cysts (GDCs)
Endometriomas pelvic pain
scar Gastrocnemius veins
Endometriosis Gastroschisis
diagnosis Gestational age
rectosigmoid colon Giant cavernous hemangioma
Endoscopic ultrasound (EUS) Giant cell arteritis (GCA)
Epididymis Granulomatosis with polyangiitis (GPA)
Epididymitis–orchitis, acute Graves disease
ERCP H
Erdheim–Chester disease Harmonic imaging
F disadvantage
Facial sebaceous adenomas harmonic frequencies
Fetal brain use
Fetal echogenic bowel Hashimoto thyroiditis (HT)
Fetal hydrops malignancy
Fetal ultrasound micronodulation
Fibrocartilage, hyperechoic, homogeneous Hawthorne effect
Fibrolamellar carcinoma Health care worker
Field of view Hemangioma
Fissure for ligamentum venosum Hematoma
Flank pain Hematuria
Flowcharts etiology of
Focal nodular hyperplasia (FNH) Hemorrhagic cysts
Focal zone banding artifact Hepatic arterial blood flow
Foley balloon Hepatic artery
Foley catheter right hepatic artery
hematuria Hepatic artery thrombosis
malpositioned Hepatic venous waveforms
Foreign body Hepatitis
Fournier gangrene acute
Fresnel zone biliary etiologies
Fungal infection, of urinary tract Hepatobiliary iminodiacetic acid (HIDA) scan
Hepatocellular carcinoma (HCC)
G HIDA scan. See Hepatobiliary iminodiacetic acid
Gallbladder (HIDA) scan
adenomyomatosis Hilar cholangiocarcinomas
carcinoma Histoplasmosis
cholecystitis Holoprosencephaly, alobar
cholelithiasis Horseshoe kidney
cholesterolosis/gallstones Hutch diverticulum
cholesterol polyp

Hyaline articular cartilage von Hippel Lindau disease
anatomic structure xanthogranulomatous pyelonephritis
hypoechoic, homogeneous L
Hydranencephaly Laparoscopy
Hyperfunctioning ectopic parathyroid tissue Last menstrual period (LMP)
Hyperparathyroidism Latent errors
Hyperstimulated ovaries Leukemia
Hypertension Ligament
Hypoechoic nerve fascicles arcuate
Hypothyroidism hyperechoic with striated appearance
I Linear array transducers
Imaging‐guided biopsy Lipoleiomyoma
Incidental Thyroid Findings Committee Lipomas, soft tissue
Incidental thyroid nodules (ITNs) LI‐RADS 5 lesion
Inferior epigastric artery Liver
Inferior vena cava abscessacute hepatitis
Internal carotid artery (ICA) biliary, bile
characteristics Caroli
stenosis cholangiocarcinoma
velocity parameters cirrhosis
Internal carotid artery/common carotid artery dysfunction
peak systolic velocity ratio (ICA/CCA PSV ratio) FNH
Internal inguinal ring HCC
Intimal flap LFT
Intrauterine pregnancy (IUP) parenchyma
Iodine‐123 scan portal
Ischemic type biliary lesion (ITBL) portal hypertension
J pseudocirrhosis
Just Culture Model resistive indices in
sinusoidal obstruction syndromesteatosis
K transplantation
Kidneys cadaveric
abscessarteriovenous fistulacalculicalyces color and duplex Doppler images
duplicated renal collecting system orthotopic, vascular complication
ectopic rejection
failurehorseshoe venoocclusive disease
hydronephrosislesionsmass Liver function tests (LFTs)
medullary pyramid Lower extremity
medullary spongemicrocysts Lung
multicystic dysplastic Lymphangiomas
nephrectomy Lymphocele
nephrocalcinosisoncocytomas Lymphocytic inflammation
perinephric Lymphoepithelial cysts
pyelitis
pyelonephritis M
pyonephrosis Magnetic resonance cholangiopancreatography
renal cell carcinoma (MRCP)
transplantcreatinine levels Magnetic resonance imaging (MRI)
urinomavein thrombosis fetal

Main portal vein (MPV) intraductal papillary mucinous neoplasm
Maintenance of Certification (MOC) program (IPMN)
Mechanical index (MI) pancreatic
Meckel‐Gruber syndrome pancreatitis
Medical errors pseudocysts
Melanoma serous cystadenoma
Membranous glomerulonephritis ultrasound evaluation of
Metastatic colon cancer visualization of
Metastatic disease Whipple
Metastatic infiltration Pancreatic ductPancreatitis, chronic
Microcalcifications, in thyroid nodules Parathyroid carcinoma
Mild ventriculomegaly Parathyroid gland
Modified Crass technique parathyroid
MPV. See Main portal vein (MPV) parathyroid carcinoma
MRCP. See Magnetic resonance parathyromatosis
cholangiopancreatography (MRCP) primary hyperparathyroidism
Müllerian cyst Parathyromatosis
Multinodular goiter Pareto chart
Multiple endocrine neoplasia type 1 (MEN1) Partial‐thickness tear
Muscle, fibroadipose septa Parvus
N Patellar tendon
Nabothian cysts Peak systolic velocity (PSV)
Nephrotic syndrome Peer review process
Nerve, hypoechoic with a fascicular in radiology
echotexture Pelvic pain
Non‐Hodgkin thyroid lymphoma Pelvic kidney
Normal placental thickness Perceptual error
Percutaneous drainage
O Percutaneous nephrostomy
Obstructive uropathy, clinical diagnosis Perinephric fluid collection
Omphalocele Perinephric lymphoma
Oophoritis Periportal lymphadenopathy
Osler‐Weber‐Rendu syndrome Peritoneal mesothelioma, risk factor for
Ovarian torsion Persistent trophoblastic neoplasia (PTN)
Ovary Person approach
corpus luteum Placebo effect
ovarian Placenta previa
ovarian carcinoma Placental abruption
ovarian cyst Plan‐Do‐Study‐Act (PDSA)
ovarian follicle Plantar fibromatosis
ovarian torsion Plantaris tendon
polycystic ovary syndrome Pleomorphic adenoma
P Polyarteritis nodosa (PAN)
Pancreas Polycystic ovary syndrome (PCOS)
adenocarcinomas Polyp(s)
chronic pancreatitis cholesterol
head and uncinate process endometrial
head mass Popliteal artery aneurysms (PAA)
Portal vein

gas Reverse target sign
stenosesthrombosis, acute Rhabdomyoma
Positive predictive value (PPV), of adnexal Rhombencephalon
mass Right heart failure
Posterior urethral valves Ring‐down artifact
Postnatal radiograph ROC (receiver operating characteristic) curve
Power Doppler Root cause analysis (RCA)
Practice Quality Improvement (PQI) Roux‐en‐Y hepaticojejunostomy
Pregnancy S
dichorionic, diamniotic Scar endometriomas
ectopic Scrotal pain
intrauterine acute
Primary hyperparathyroidism imaging
Primary sclerosing cholangitis (PSC) Scrotum
Primigravida blunt scrotal trauma
Pseudoaneurysms epididymis
Pseudocirrhosis Fournier gangrene
Pseudomyxoma peritonei (PMP) hydrocele
Pseudoureteroceles orchitis
Pulmonary hypoplasia rete testis
Pulse repetition frequency (PRF) sperm granulomas
Pygmalion effect testicular
Pyogenic liver abscess testis
Pyonephrosis varicocele
Q Segmental infarct
Quadriceps tendon Seminoma
Quality assurance (QA) Sentinel events
Quality control (QC) Sharp end process
Quality improvement (QI) Sialadenitis, acute
R Side‐lobe artifact
Radiologist clinical significance
Radionuclide techniques Sinusoidal obstruction syndrome (SOS)
Refraction Sjögren syndrome
artifact Smoking
Refractive edge shadow 2005 Society of Radiologists in Ultrasound
Remedial action (SRU) consensus statement
Renal. See Kidneys Soft tissue lipomas
Renal artery stenosis Soft tissue, speed of sound in
Renal cell carcinoma (RCC) Spatial pulse length (SPL)
Resistive index (RI) Spatial resolution
calculation of Spectral broadening
formula for Spectral Doppler aliasing
in liver Spectral Doppler sonography
Respiratory phasicity Spectral Doppler waveform
Retained products of conception (RPOC) Specular reflectors
Rete testis Speed of sound
Retroperitoneal fibrosis Sperm granulomas
Reverberation artifact Spleen

calcification Graves disease
echogenicity Hashimoto thyroiditis
infarction malignancy
laceration micronodulation
lymphoma Incidental thyroid Findings Committee
mass incidental nodules
pseudocyst iodine‐123 scan
splenic vein Doppler lymphoma
splenomegaly nodule
Spongiform composition 3‐tiered system
Steroid supplementation thyroiditis
Subcapsular hematoma Tissue vibration artifact
Superficial thrombophlebitis Toxic cascade model
Superficial venous thrombosis (SVT) Transducer and skin surface
Supraspinatus tendon Transducer crystal malfunction
calcium hydroxyapatite crystals Transitional cell carcinoma (TCC)
full‐thickness tear Transjugular intrahepatic portosystemic shunt
partial‐thickness tear (TIPS)
Swiss cheese model Transvaginal ultrasound images
T Transverse gray‐scale
Takayasu arteritis Transverse image
Tardus Trauma
Telephone number, patient identifiers Tricuspid regurgitation (TR)
Tendinosis Trisomy 18
Tenosynovitis Trisomy 21
Testis Tuberculous peritonitis
biopsy Tuberous sclerosis (TS)
cancer, risk factors Tuboovarian abscess (TOA)
color Doppler signal Tubular ectasia
complications Tumoral neovascularity
cryptorchidism Tunica albuginea
location Twinkle artifact
images U
infarction Umbilical cord
neoplasm Umbilical portion of left portal vein
orchitis Urachus
rete urachal adenocarcinomas
segmental infarct urachal cysts
seminoma urachal diverticulum
surgical exploration Ureteroceles
testicular torsion Urethral diverticula
vasectomy Urinalysis (UA)
Thermal index (TI) Urine ascites
Thermal index soft tissue (TIS) Urinoma
Threshold growth Usual interstitial pneumonia (UIP) pattern
Thyroglossal duct cyst (TDC) Uterine anomaly
Thyroid imaging features
carcinomaDe Quervain thyroiditis surgical correction

V
Value
Varicoceles
Vasa previa
Vasectomy
Vena caval stenosis
Venoocclusive disease (VOD)
Ventriculomegaly, mild
von Hippel‐Lindau disease (VHL)
W
Wall discontinuity
Wall‐echo shadow (WES) sign
Warthin tumor
Water‐lily sign
Weber effect
WES (wall‐echo shadow) sign
Wolffian (mesonephric) ducts
X
Xanthogranulomatous pyelonephritis (XGP)
Y
Yolk sac

Ultrasound A Core Review

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Hepatobiliary: Answers and Explanations

Pancreas, Spleen, and Bowel: Answers and

Urinary Tract and Adrenal Glands: ANSWERS AND

Neck: Answers and Explanations

Scrotum: Answers and Explanations

Gynecology: Answers and Explanations

First Trimester Pregnancy: Answers and

Fetal US at 18 weeks of gestational age.

Fetal MRI performed at 22 weeks of gestational age. Postnatal C&AXRay

Second and Third Trimester Pregnancy: Answers

Vascular: Answers and Explanations

A. Hyperechoic with a fiber‐like echotexture

Musculoskeletal: Answers and Explanations

Peritoneal Space, Retroperitoneum, Abdominal Wall,

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