NUC RAD SHARE

ULTRASOUND NORMAL VALUES / MEASUREMENTS

 
Ultrasound scan OB 3D baby NucRadSHARE




ABDOMEN ULTRASOUND

 

ABDOMEN

 

LIVER

▪Liver size ≤17cm in CC dimension

▪Biliary

     ▫Intrahepatic ducts ≤2mm

     ▫Normal CBD ≤6mm (≤60yo): add 1mm per decade over 60yo

     ▫Post-cholecystectomy CBD up to 1cm

     ▫Pediatrics CBD <4mm

 

GB

▪Gallbladder size

     ▫Wall <3mm

     ▫Diameter ≤4cm

     ▫Length <10cm

▪GB polyp ≥5mm consider follow up (≥1cm may consider surgery)

 

SPLEEN

▪Spleen size ≤13cm length (usually <7cm in width)

▪Splenic artery aneurysm ≥2.0-2.5cm consider endovascular therapy

 

PANCREAS

▪Pancreas size

     ▫Head width ≤3cm

     ▫Body width ≤2.5cm

     ▫Tail width ≤2.5cm

▪Pancreatic duct (≤3mm adults and up to 5mm in elderly patients)

     ▫Head ≤3mm

     ▫Body ≤2mm

     ▫Tail ≤1mm

 

ADRENALS

▪Adrenal size

     ▫limb length <5cm

     ▫limb width <7mm

 

KIDNEYS

▪Renal size

     ▫Length 9-12cm

     ▫Cortical thickness ≥1cm

▪Asymmetric renal length difference ≥1.5cm is usually significant

▪Renal artery aneurysm ≥2cm consider endovascular repair

 

BLADDER

▪Wall thickness: <4mm when distended and <8mm post-void

▪Post-void residual volume >100-150cc may need intervention

 

MISC

▪Normal ecogenicity of pancreas > spleen > liver > kidneys

▪Appendix <6mm and compressible is normal

▪Hypertrophic pyloric stenosis if pyloric muscle thickness >3mm and channel length >14mm

▪Visceral artery aneurysm ≥2cm

▪Normal anal sphincter muscle thickness 4mm


FEMALE PELVIS ULTRASOUND 

 

OVARIES

 

SIZE

NORMAL

▪ Pre-menopausal 5x3x2cm (volume 9cc for nulliparous and 15cc for     

  multiparous)

▪ Post-menopausal 2.5x2x2cm

▪ Pediatrics

     ▫ 6yo ~1cc

     ▫ Pre-pubertal (6-10yo) 1.2-2.3cc

     ▫ Pre-menarchal (11-12yo) 2-4cc

     ▫ Post-menarchal >2.5-18cc

 

ABNORMAL

▪ Pre-menopausal >18cc volume

▪ Post-menopausal >8cc volume

 

Note: volume = (L x H x W x 0.5)

 

SIMPLE CYST

APPEARANCE

▪ Circumscribed margins

▪ Posterior acoustic enhancement

▪ No internal echoes

 

PRE-MENOPAUSAL FOLLOW-UP

▪ Cyst ≤3cm (physiologic developing/dominant follicle; no f/u needed and

  do not have to describe)

▪ Cyst >3 and ≤5cm (mention but no f/u needed)

▪ Cyst >5cm and ≤7cm (yearly f/u)

▪ Cyst >7cm (further evaluation with MR or consider surgery)

 

POST-MENOPAUSAL FOLLOW-UP

▪ Cyst ≤1cm (inconsequential)

▪ Cyst >1cm and ≤7cm (almost certainly b9 but yearly f/u with u/s at least   initially)

▪ Cyst >7cm (further evaluate with MR or consider surgery)

 

 

HEMORR.

CYST

APPEARANCE

▪ Reticular pattern (“fishnet”) of internal echoes

▪ May have ecogenic clot w/o flow

 

FOLLOW-UP

▪ Cyst ≤3cm (no f/u needed)

▪ Cyst >3 and ≤5cm (describe but no f/u needed)

▪ Cyst >5cm (f/u u/s in 6-12wks to ensure resolution; image on day3-10 of

  menses)

 

 

ENDOMET-

RIOMA

APPEARANCE

▪ Homogenous low level internal echoes

 

FOLLOW-UP

▪ Short-term f/u initially in 6-12wks to exclude hemorrhagic cyst     

  mimickers, then yearly if no surgical removal

▪ Malignancy risk ~1% (endometroid or clear cell CA) if >9cm (not if

  <6cm) and age >45yo

 

 

DERMOID

APPEARANCE

▪ Focal ecogenic plug with acoustic shadowing

▪ Hyperechoic lines and dot internal echoes

 

FOLLOW UP

▪ F/u in 6-12mos interval regardless of age if no surgical removal

▪ Malignancy risk ~2% (SCC) if >10cm and age >50yo

 

COMPLEX CYST

INDETERMINATE BUT PROB B9

▪ Single cyst but w/ single thin septa <3mm or small wall calcification

▪ FOLLOW UP: use same f/u as simple cyst by size & age

 

INDETERMINATE BUT NOT HEMORRHAGIC / ENDOMETRIOMA / DERMOID

▪ Multiple septations <3mm

▪ Solid nodule w/o flow

▪ Focal wall thickening

▪ FOLLOW UP:

     ▫ Size>10cm (13% chance of malignancy so surgery is recommended)

     ▫ Pre-menopausal (6-12wks f/u; if persists, consider MR w/ gad and if

       not hemorrhagic  

       cyst  or endometrioma or dermoid, do surgery)

     ▫ Post-menopausal (surgery)

 

WORRISOME FOR MALIGNANCY

▪ Thick septa ≥3mm

▪ Solid nodule w/ flow

▪ Focal wall thick ≥3mm

▪ FOLLOW UP: no f/u; surgery recommended

 

CORPUS LUTEUM

APPEARANCE

▪ Thick crenulated wall

▪ Small cystic center

▪ May have surrounding “ring-of-fire” flow

 

FOLLOW UP

▪ No f/u needed if size ≤3cm

 

PCO

Polycystic Ovaries

 

APPEARANCE
▪ >10-12 peripheral follicles bilaterally

▪ Hyperechoic/hypervascular central stroma

▪ Ovarian volume >15cc

 

OHSS

 

Ovarian HyperStimulation Syndrome

 

APPEARANCE

▪ Bilateral enlarged ovaries >5-10cm in diameter

▪ Numerous thin-walled cysts >1cm

▪ May have ascites and pleural effusion

UTERUS

 

SIZE

NORMAL

▪Pre-menopausal 9x5x5cm

▪Post-menopausal 7x2x2cm

▪Pediatrics

     ▫Neonate (<1mo old) 4x2x2cm

     ▫Pre-pubertal child 3x1x1cm

     ▫Post-pubertal child 8x3x3cm

 

EMS

EndoMetrial Stripe

 

NORMAL

▪Pre-menopausal ≤15mm

     ▫Menses (day 1-5) <4mm

     ▫Proliferative phase (day6-10) 4-8mm

     ▫Secretory phase (day14+) ≤15mm

▪Post-menopausal

     ▫Without bleeding (or on Hormone Replacement) ≤8mm

     ▫With bleeding ≤5mm

 

ABNORMAL

▪Post-menopausal atrophy <3mm

▪Post-partum retained products of conception (RPOC) >5mm (<2mm

 RPOC unlikely)

▪DDX for thickened EMS= secretory phase; pregnancy; retained POC,

 hyperplasia; polyp; CA; Tamoxifen

PELVIS

 

FREE FLUID

▪Physiologic ~10cc in (may increase during ovulation)

 

PELVIC CONGEST-

ION

▪Pelvic veins >4-5mm in diameter

▪Slow flow ~3cm/s

▪Tortuous dilated pelvic venous plexuses and arcuate veins

▪Associated with dyspareunia 

 

PROSTATE

▪Normal volume ~30cc


THYROID ULTRASOUND

 

THYROID

 

SIZE

NORMAL

▪Lobe length 4-6cm

▪Lobe diameter 1.3-1.8cm

▪Isthmus AP <1cm

▪Volume 20cc (+/- 5cc) males and 18cc (+/- 4cc) females

GOITER

▪Volume >25g

 

NODULES

LIKELY B9 FEATURES

▪Colloid cyst (cyst with bright echoes or avascular colloid clot)

▪Predominantly cystic nodule (without internal flow)

▪Spongiform nodule

▪Giraffe pattern

▪Diffusely hyperechoic nodule (especially if multiple)

 

SUSPICIOUS FEATURES

▪Micro-calcifications (highest specificity)

▪Diffusely hypoechoic solid nodule

▪Irregular/infiltrative margins

▪Taller than wide (larger AP dimension on transverse view)

▪Chaotic internal flow

▪Associated cervical adenopathy

 

HIGH RISK HISTORY

▪Thyroid cancer in first degree relative(s)

▪External beam radiation as a child

▪Exposure to ionizing radiation as a child

▪PET avid thyroid nodule

▪MEN2 syndrome

▪Familial Medullary thyroid carcinoma associated gene mutation

 

SIMPLIFIED NODULE GUIDELINE

▪Nodule <1cm without suspicious features or high risk history = consider

 6mos follow up

▪Nodule >5mm with suspicious features or high risk history = consider FNA

 

SIGNIFICANT GROWTH OF NODULE

▪Increase in volume by 50%

▪Increase in diameter by 20% within at least 2mm increase in two or more  dimensions

▪Growth of mixed solid/cystic nodule is judged by growth of solid component


TESTICULAR ULTRASOUND

 

TESTIS

 

SIZE

NORMAL TESTIS

▪Length up to 5cm

▪Width up to 4cm

 

NORMAL EPIDIDYMIS

▪Head 1.0-1.2cm

▪Body/tail 2.0cm 

 

PATHOLOGY

VARICOCELE

▪Dilated pampiniform plexus >3mm upon valsalva

 

MICROLITHIASIS

▪More than 5 micro-calcifications on a single image

▪Yearly follow up may be considered


OBSTETRICS (OB) ULTRASOUND

 

OB

 

VIABILITY

VIABILITY CRITERIA 

▪MSD >25mm (endovaginal) = should see Y-sac and embryo

▪CRL ≥7mm (endovaginal) or ≥15mm (transabdominal) = should have heartbeat

 

FOLLOW-UP OF PREGNANCY OF UNKNOWN VIABILITY

▪If see G-sac but no Y-sac à followup in 2wks or more à absence of embryo with a heartbeat is diagnostic of pregnancy failure

▪If see G-sac with Y-sac but no embryo à followup in 11 days or more à absence of embryo with a heartbeat is diagnostic of pregnancy failure

 

EARLY PREGNANCY DIFFERENTIAL DIAGNOSIS

▪Viable IUP

▪IUP of unknown viability (+/- suspicious for pregnancy failure)

▪Pregnancy of unknown location (if normal appearing endometrium ddx= early IUP vs occult ectopic vs completed spontaneous abortion; if abnormal appearing endometrium ddx= spontaneous abortion in progress vs indeterminate intrauterine fluid collection)

▪Non-viable IUP

 

GUIDELINES

▪G-sac appears at 4.5-5.0 wks (intradecidual sign or double sac sign)

▪Y-sac appears at 5.0-5.5 wks (normal size 3-5mm)

▪Embryo appears ~6.0 wks

▪Amnion usually seen at 7.0 wks

 

QUANTITATIVE Beta HCG

▪HCG>1000 = generally see gestational sac

▪HCG>7000 = generally see Y-sac

▪HCG>11,000 = generally see embryo

 

POOR PROGNOSIS (SUPICIOUS FOR PREGNANCY FAILURE)

▪Empty amnion (no embryo)

▪Sustained bradycardia <80bpm

▪Small MSD relative to CRL (<5mm difference btwn MSD and CRL)

▪Enlarged Y-sac >7mm

▪Low-lying gestational sac

▪Subchorionic hemorrhage ≥40% of gestational sac volume

▪Thin poorly-ecogenic decidua

 

 

ANATOMY

SOFT MARKERS

▪Choroid plexus cyst(s) ≥3mm

▪Ecogenic intracardiac focus (as bright as bone)

▪Ecogenic bowel

▪Nuchal fold thickness ≥6mm

▪Pyelectasis ≥4mm (2nd trimester) and Persistent pyelectasis ≥7mm (3rd trimester)

▪Single vessel cord (single umbilical artery)

▪Ventriculomegaly  ≥1cm

 

BIOMETRY

▪Use biometry for CRL >6cm

▪In 2nd trimester, single best measure of GA is HC (others further improve prediction)

▪In 3rd trimester, single best measure of GA is FL (more reproducible than AC)

▪AC is least predictive of GA but most useful for EFW determination esp in 3rd trimester

▪Flattened head (dolicocephaly) or rounded head (brachycephaly) are normal variants (HC more reliable than BPD for GA)

▪Disproportionally small HC <3 SDs below mean for GA = microcephaly

 

NORMAL ANATOMIC MEASUREMENTS

▪Nuchal translucency (1st trimester) <3mm

▪Nuchal fold thickness (2nd trimester) <6mm

▪Choroid plexus cyst <3mm (≥3mm is abnormal)

▪Ventricles <1cm (Ventriculomegaly ≥1cm)

▪Trans-cerebellar diameter correlates in mm with gest age in mm upto 20wks (ie 20mm at 20wks; usually larger after 20wks; abnormal if 2mm less than gest age)

▪Cisterna magna 2-10mm

▪Nasal bone length ≥4mm (2.5th percentile is 4.4mm at 18wks and 5mm at 20wks)—look for hypoplastic or absent nasal bone

▪Fetal cardiac activity 100-180bpm (bradycardia <80-100 bpm)

▪Ecogenic intracardiac focus is significant if as bright as bone (be aware of normal variant moderator band within RV)

▪Renal length symmetric 20-22mm in length

▪Renal pelvis <4mm (Pyelectasis if ≥4mm in 2nd trimester; Persistent pyelectasis if ≥7mm in 3rd trimester)

▪3 vessel cord with 2 umbilical arteries (2 vessel cord = single umbilical artery)

 

PLACENTA/CERVIX

▪Placental thickness 1-4cm (<4cm in thickness)

▪Inferior placental tip should be >2cm from internal os of cervix (otherwise, consider low-lying placenta vs placenta previa)

▪Cervical length ≥2.5cm and closed (otherwise consider incompetent cervix and look for funneling)

 

 

GROWTH

GROWTH ASSESSMENT

▪Fetal scan for growth assessment should be down at least 2 weeks apart

▪Estimated fetal weight (EFW) within 10th to 90th percentile for gestational age

     ▫Macrosomia >90th percentile or >4000-4500g (also look for polyhydramnios)

     ▫SGA (small for gestational age) <10th percentile or <2500g at term

     ▫IUGR= SGA + AC <2.5th percentile (size<dates) à do cord doppler

             ▫Asymmetric IUGR (high HC:AC ratio; possible placental insufficiency)

             ▫Symmetric IUGR (normal HC:AC ratio; constitutionally small baby or

              genetic/chromosomal abnormality or TORCH infection or 

              maternal ETOH)

             ▫Check AFI (oligohydramnios can be seen with IUGR)

▪Large for gestational age (LGA) if 3rd trimester dates >2wks compared to clinical dates

 

AMNIOTIC FLUID

▪Amniotic fluid index (AFI) 5-20cm

     ▫Polyhydramnios >20-25cm (single max vertical pocket depth >8cm)

     ▫Oligohydramnios <5cm or <5th percentile (single max vertical pocket depth   

       <2cm)

 

CORD & MCA DOPPLER

▪Fetal cord Doppler (assess umbilical arterial waveform for reduced/absent/reversed diastolic flow and corresponding abnormal resistive index)

▪Fetal MCA Doppler (assess fetal middle cerebral artery S/D ratio which is normally greater than umbilical artery S/D ratio)

 







FETAL ANATOMIC SURVEY CHECKLIST FOR 2nd TRIMESTER ULTRASOUND 

                Fetal OB anatomy survey ultrasound imaging checklist chart         



VASCULAR  ULTRASOUND

 

VASCULAR

 

AORTA

ABDOMINAL AORTA

▪Ectasia 2.5-2.9cm

▪Aneurysm ≥3cm

COMMON ILIAC ARTERY

▪Ectasia 1.5-2.4cm

▪Aneurysm ≥2.5cm

POPLITEAL ARTERY

▪Ectasia 1.0-1.9cm

▪Aneurysm ≥2cm (1/3 associated with AAA)

SPLENIC ARTERY 

▪Aneurysm ≥2.5cm, consider endovascular repair

 

CAROTIDS

ICA STENOSIS

▪NORMAL or STENOSIS <50%

     ▫PSV <125cm/s

     ▫ICA/CCA ratio <2

     ▫ICA EDV <40cm/s

▪STENOSIS 50-69%

     ▫PSV 125-230cm/s

     ▫ICA/CCA ratio 2-4

     ▫ICA EDV 40-100cm/s

▪STENOSIS ≥70%

     ▫PSV >230cm/s

     ▫ICA/CCA ratio >4

     ▫ICA EDV >100cm/s

 

RAS

RENAL ARTERIAL STENOSIS CRITERIA

▪Renal artery PSV >200cm/s

     ▫EDV >150m/s suggests >80% stenosis

     ▫RI >0.8 predicts response to renal vascularization

▪Renal artery to aortic PSV ratio >3.5

▪Intra-renal arterial systolic rise (acceleration time) ≥0.07s (parvus-tardus)

 

TIPS

TIP SHUNT DYSFUNCTION

▪Intra-shunt PSV <50-60m/s or >200-250m/s

▪Change in PSV of +/- 50m/s compared to baseline scan

▪Decrease in PSV by <2/3rd (66% less than) compared to baseline scan

▪Hepatofugal flow within main portal vein

 

PAD

PERIPHERAL ARTERIAL DISEASE CRITERIA

▪Mild stenosis (1-19%)

     ▫Distal-to-proximal PSV ratio <2:1

     ▫Triphasic waveform

▪Moderate stenosis (20-49%)

     ▫Distal-to-proximal PSV ratio <2:1

     ▫Biphasic waveform

▪Severe stenosis (50-99%)

     ▫Distal-to-proximal PSV ratio >2:1 (>4:1 suggest >70%; >7:1 suggest

      >90%)

     ▫Monophasic waveform

 

PERIPHERAL ARTERIAL GRAFT ASSESSMENT

▪Minimal graft stenosis (<20%)

     ▫Distal-to-proximal PSV ratio <1.4

     ▫PSV <125cm/s

▪Moderate graft stenosis (20-50%)

     ▫Distal-to-proximal PSV ratio 1.5-2.4

     ▫PSV <180cm/s

▪Significant graft stenosis (50-75%)

     ▫Distal-to-proximal PSV ratio 2.5-4.0

     ▫PSV >180cm/s

▪High-grade graft stenosis (>75%)

     ▫Distal-to-proximal PSV ratio >4.0

     ▫PSV >300cm/s

 

PERIPHERAL ART STENOSIS AFTER PERC REVASCULARIZATION

▪Distal-to-proximal PSV >2

▪PSV >180cm/s