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July 2003 (Vol. 41, Issue 4)
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Preface
RELATED SITES Women's imaging: obstetrics and gynecology
by Levine D
More periodicals: page xi
FIND A PERIODICAL
Full Text | PDF (45 KB)
FIND A PORTAL What's new in first trimester ultrasound
by Lazarus E
GO TO PRODUCT CATALOG
pages 663-679
Ultrasound detection of first trimester malformations: a pictorial essay
by Castro-Aragon I, Levine D
pages 681-693
Prenatal diagnosis for detection of aneuploidy: the options
by Budorick NE, O'Boyle MK
pages 695-708
Complications of monochorionic twins
by Feldstein VA, Filly RA
pages 709-727
PDF (1469 KB)
Tips and tricks of fetal MR imaging
by Levine D, Stroustrup Smith A, McKenzie C
pages 729-745
MR imaging of pelvic floor relaxation
by Fielding JR
pages 747-756
Imaging of female infertility
by Thurmond AS
pages 757-767
file:///C|/temporal/Radiologic%20Clinics%20Julio%202003.html (1 de 2)07/03/2004 19:34:23

Radiologic Clinics of North America
Ultrasonographic evaluation of the endometrium in postmenopausal vaginal

bleeding
by Davidson KG, Dubinsky TJ
pages 769-780
Sonohysterography
by O'Neill MJ
pages 781-797
MR imaging of the ovaries: normal appearance and benign disease
by Togashi K
pages 799-811
Osteoporosis imaging
by Link TM, Majumdar S
pages 813-839
Current uses of ultrasound in the evaluation of the breast
by Mehta TS
pages 841-856
Index
pages 857-862
PDF (67 KB)
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WOMEN’S IMAGING: OBSTETRICS AND GYNECOLOGY
CONTENTS
Preface xi
Deborah Levine
What’s New in First Trimester Ultrasound 663

Elizabeth Lazarus
Ultrasound performed during the first trimester confirms an intrauterine pregnancy,
establishes accurate dating, and is crucial in diagnosing early pregnancy failure and
ectopic pregnancy. As sonographic spatial resolution continues to improve, first
trimester sonography increasingly will offer early pregnancy screening for chromosomal
abnormalities and fetal structural abnormalities.
Ultrasound Detection of First Trimester Malformations: A Pictorial Essay 681

Ilse Castro-Aragon and Deborah Levine
With improvements in ultrasound technology, it is possible to detect many fetal malfor-
mations in the first trimester. This article illustrates the types of embryonic and fetal
anomalies that can be detected in the first trimester, including anencephaly, encephalo-
cele, hydrocephalus, omphalocele, gastroschisis, megacystis, and conjoined twins. The
authors also illustrate pitfalls in image interpretation of first trimester anatomy (includ-
ing the normal rhombencephalon and normal gut herniation) and prospectively unrec-
ognized cases of early omphalocele and anencephaly.
Prenatal Diagnosis for Detection of Aneuploidy: The Options 695

Nancy E. Budorick and Mary K. O’Boyle
Prenatal diagnosis for aneuploidy consists of invasive and noninvasive testing. Second
trimester biochemical screening is more accurate in determining risk for aneuploidy
than maternal age alone. One or more various major abnormalities identified on a second
trimester sonogram are indicative of an at-risk patient. Several minor ultrasound mark-
ers on a second trimester sonogram are sensitive and specific for aneuploidy, particu-
larly thickened nuchal fold and a shortened humerus. Other minor abnormalities
identified in the second trimester also may be associated with aneuploidy, but the
method of determining exact risk based on the presence or absence of these markers is
controversial. First trimester combined screening with nuchal translucency thickness
and biochemical markers shows promise in early and accurate identification of the
patient at risk for aneuploidy.
VOLUME 41 • NUMBER 4 • JULY 2003 v

Complications of Monochorionic Twins 709
Vickie A. Feldstein and Roy A. Filly
There are high risks associated with monochorionic twin gestations, partly related to the
shared placenta and the presence of intertwin vascular connections. Several potential
complications and syndromes are unique to monochorionic gestations. Obstetric sonog-
raphy, with the use of Doppler techniques, is used to diagnose and evaluate these
pregnancies. Being aware of the sonographic criteria for determining chorionicity and
recognizing the features that indicate twin-twin transfusion syndrome, acardiac para-
biotic twin, conjoined twins, and other complications are important for obstetric
management and optimizing outcome.
Tips and Tricks of Fetal MR Imaging 729

Deborah Levine, Annemarie Stroustrup Smith, and Charles McKenzie
MR imaging during pregnancy is being used increasingly to assess fetuses with compli-
cated or nonspecific ultrasound diagnoses. This article illustrates common artifacts and
other pitfalls in the performance of fetal MR examinations and suggestions of techniques
to improve image quality. Comparisons of anatomy visualized on fetal MR imaging ver-
sus ultrasound are demonstrated.
MR Imaging of Pelvic Floor Relaxation 747

Julia R. Fielding
MR imaging of female pelvic floor relaxation is a relatively new technique that, once
mastered, is quick to perform and interpret. Rapidly acquired T2-weighted images are
obtained in the sagittal plane at rest and at maximal strain. In symptomatic patients,
abnormal descent of pelvic viscera on sagittal images is indicative of muscle or fascial
weakness or tears. On axial images, the pelvic floor muscles can be assessed for tears and
fraying. This information can be used to plan optimal surgical repair.
Imaging of Female Infertility 757

Amy S. Thurmond
Normal reproduction requires healthy female anatomy. Cervical, uterine, tubal, ovarian,
and peritoneal factors can coexist and cause female infertility. Ultrasound, hysterosalp-
ingography, MR imaging, and fallopian tube catheterization are the radiologists’ arma-
mentarium for diagnosis. This article illustrates important findings in the infertile
woman. An understanding of these entities helps in accurate and sympathetic treatment.
Ultrasonographic Evaluation of the Endometrium in Postmenopausal

Vaginal Bleeding 769
Katharine G. Davidson and Theodore J. Dubinsky
Abnormal bleeding is one of the most frequent complaints of postmenopausal women
who seek gynecologic care. Ultrasound and biopsy are reasonable competing methods
for evaluating the cause of the bleeding in these women. Ultrasound has better sensitiv-
ity than biopsy in depicting nonmalignant causes of bleeding, so it can establish the
cause of bleeding in more patients than biopsy. Saline infusion sonohysterography is
helpful in depicting endometrial pathologic conditions but can be reserved for evaluat-
ing patients in whom the transvaginal ultrasound images do not clearly depict a focal
mass. Hysteroscopy is the standard for removing focal endometrial lesions, although it
is too expensive to be used routinely for diagnosis of endometrial abnormalities more
easily evaluated by ultrasound.
vi CONTENTS
Sonohysterography 781
Mary Jane O’Neill
Sonohysterography can distinguish focal from diffuse pathology reliably and has
become a crucial imaging test in the triage of postmenopausal bleeding and in pre-
menopausal patients with dysfunctional uterine bleeding or infertility. Polyps and
submucosal fibroids are the most common focal findings at sonohysterography. In post-
menopausal patients, detection and accurate localization of findings, rather than lesion
characterization, are the primary goals of the procedure. Most, if not all, focal lesions in
this patient population require tissue diagnosis, even when the imaging features suggest
benign lesions.
MR Imaging of the Ovaries: Normal Appearance and Benign Disease 799

Kaori Togashi
Ovaries can enlarge physiologically as a result of cyclic cyst formation. Such an enlarge-
ment and some benign conditions occasionally are mistaken as malignant disease pro-
cesses. Accurate diagnoses of benign conditions as normal, along with variations, as
opposed to neoplasia, inflammatory masses, and other etiologies of abnormal-appearing
ovaries, including torsion, help avoid unnecessary interventions. This article reviews the
MR findings of various benign conditions of adnexa that help to distinguish benign from
malignant conditions.
Osteoporosis Imaging 813

Thomas M. Link and Sharmila Majumdar
As populations age, osteoporosis becomes an increasingly important public health issue.
To prevent osteoporotic fractures, patients with osteoporosis must be diagnosed at an
early stage. According to the World Health Organization, osteoporosis is defined by bone
mineral density measurements that are compared with measurements of a healthy,
young, female population. The best established techniques to measure bone mineral den-
sity are dual energy x-ray absorptiometry of the lumbar spine and proximal femur and
quantitative CT of the lumbar spine. Conventional radiographs are not suited to assess
bone mass but are important in the diagnosis and differential diagnosis of osteoporotic
fractures. Quantitative ultrasound and structure analysis based on high-resolution MR
imaging and CT are newer techniques in the diagnosis of osteoporosis that also focus on
the assessment of bone structure.
Current Uses of Ultrasound in the Evaluation of the Breast 841

Tejas S. Mehta
Breast ultrasound is used routinely as an adjunct to mammography to help differentiate
benign from malignant lesions. In patients younger than 30 years of age or patients who
are pregnant, ultrasound may be the first or sole imaging modality to evaluate for breast
pathology. Other less common uses of breast ultrasound include potential staging of
breast cancer and evaluating breast implants. Ultrasound is useful in guiding interven-
tional breast procedures. Although still controversial, some studies have advocated using
ultrasound for screening for breast carcinoma in asymptomatic women. This article
reviews the multiple current uses of ultrasound in the evaluation of the breast.
Index 857
CONTENTS vii
FORTHCOMING ISSUES
September 2003
Renal Imaging
Philip J. Kenney, MD, Guest Editor
November 2003
Imaging the Acute Abdomen
Emil J. Balthazar, MD, Guest Editor
January 2004
Arthritis Imaging
Barbara N. Weissman, MD, Guest Editor
RECENT ISSUES
May 2003
Multislice Helical CT of the Thorax
Phillip M. Boiselle, MD, Guest Editor
March 2003
Advances in Intestinal Imaging
Dean D.T. Maglinte, MD, and
Stephen E. Rubesin, MD, Guest Editors
January 2003
Body MR Imaging
David A. Bluemke, MD, PhD, Guest Editor
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Radiol Clin N Am 41 (2003) 663 – 679
What’s new in first trimester ultrasound

Elizabeth Lazarus, MD
Department of Diagnostic Radiology, Brown Medical School, 593 Eddy Street, Providence, RI 02903, USA
With the widespread use of home pregnancy tests, identify the yolk sac, fetus, and embryonic cardiac
women are confirming pregnancy at earlier and activity earlier and can confirm intrauterine pregnan-
earlier points in gestation. The rapid technologic cies at younger gestational ages and at lower levels of
advances in sonography and the widespread use of human chorionic gonadotropin (hCG) [5 – 7].
endovaginal probes, has allowed imaging to keep Endovaginal probe transducer frequencies typ-
pace, providing women with specific information ically range from 5 to 7.5 mHz, and most of the data
regarding the status of their early pregnancies. Im- regarding early sac and embryo sizes are based on
proved spatial resolution in ultrasonographic images studies performed at these frequencies. Newer trans-
has allowed earlier confirmation of normal pregnan- ducers with higher frequencies of 10 mHz or higher
cies and earlier identification of pregnancy failures. provide better spatial resolution and can identify
The detection of ectopic pregnancy at younger gesta- features such as a yolk sac or double decidual reaction
tional ages has led to new, less invasive treatment at even earlier points in the pregnancy [8]. These
approaches. Recent studies indicate that the first higher resolution transducers also have the potential
trimester ultrasound may be effective in screening to provide earlier diagnosis of fetal abnormalities.
for chromosomal abnormalities and detecting struc-
tural defects. In this article, the author discusses
advances in first trimester ultrasound and their effects
on the interpretation of normal and abnormal studies. Normal pregnancy
Gestational sac
Transducer technology
The early embryo in the blastocyst stage is
The transvaginal probe has helped revolutionize implanted at approximately 6 to 7 days after fertiliza-
the assessment of early pregnancy and is believed to tion. The embryo becomes completely embedded in
be the transducer of choice for evaluating all early the endometrial decidua at 9.5 days after conception
pregnancies [1 – 3]. The higher frequency endo- (24 days after last menstrual period). By the end of
vaginal probes provide near field focusing and the the second week after fertilization, the conceptus has
ability to be positioned closer to the uterus, which grown to a total diameter of 2 to 3 mm and can be
provides better spatial resolution and improved diag- visualized with high-frequency endovaginal trans-
nostic accuracy. Transabdominal ultrasound provides ducers. During the third week after fertilization, the
little information regarding the fetus before the eighth exocoelomic cavity—a fluid filled cavity referred to
week of gestation. Before this gestational age, a small as the ‘‘gestational sac’’ by sonographers—can be
hemorrhage or clump of debris can be mistaken for seen routinely when it attains a diameter of 5 mm [9].
an embryo (Fig. 1) [4]. Endovaginal ultrasound can Early attempts to describe reliable ultrasono-
graphic finding of intrauterine pregnancy initially
were developed during the age of transabdominal
E-mail address: [email protected] imaging. These signs largely have been discarded or
0033-8389/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0033-8389(03)00039-3
664 E. Lazarus / Radiol Clin N Am 41 (2003) 663–679
Fig. 1. (A) Sagittal transabdominal image of 7-week gestational sac that contains amorphous echogenic material not clearly
identifiable as an embryo. (B) Endovaginal image obtained during the same examination clearly identifies the yolk sac and
embryo within the gestational sac.
supplanted by more reliable indicators that have reported a sensitivity rate of 92%, a specificity rate of
evolved in the age of transvaginal probes. To identify 100%, and an overall accuracy rate of 93%.
an intrauterine pregnancy before the development of This sign originally was described using trans-
a gestational sac, the concept of the ‘‘intradecidual abdominal sonography, however, and has not been
sign’’ was first introduced by Yeh et al in 1986 [10]. verified with transvaginal scanning. Laing et al’s
This sign describes a focal anechoic area eccentrically attempt to confirm the validity of this sign using
positioned in the endometrium that does not deform transvaginal scanning was not as successful. Detec-
the endometrium because of its small size (Fig. 2). tion of the intradecidual sign resulted in relatively
This sign is believed to represent the conglomeration poor sensitivity (34% – 66%) and specificity (55% –
of echoes caused by the embedded blastocyst, the 73%) rates [11]. These percentages demonstrated
proliferative plasmodial trophoblasts, and the adja- that the sign is unreliable and should not be used
cent decidua. Yeh et al were able to recognize the to verify a normal pregnancy in the age of trans-
appearance as early as 3.5 weeks’ menstrual age (or vaginal ultrasound.
1.5 weeks after conception), the same time at which The double decidual reaction reliably differentiates
pregnancy could be verified by the bioassay method between a true gestational sac and an intraendometrial
for hCG. For purposes of distinguishing between fluid produced from an ectopic pregnancy (pseudo-
early intrauterine and ectopic pregnancy, Yeh et al sac). The gestational sac first can be visualized endo-
Fig. 2. (A) Sagittal and (B) transverse sonographic views of the gravid uterus demonstrate the ‘‘intradecidual sac sign’’:
echogenic material surrounding a small cyst-like fluid collection located eccentrically within the endometrium.
E. Lazarus / Radiol Clin N Am 41 (2003) 663–679 665
lous space. Parvey et al found that this vascular flow

pattern was demonstrated in only 15% of early
pregnancies that did not have an identifiable embryo
or yolk sac on ultrasound. They then proposed
combining the Doppler signature with sonographic
identification of the inner chorionic rim and demon-
strated sensitivity and specificity rates of more than
90% for this combination in identifying an intra-
uterine pregnancy [15]. Doppler is not widely used
in this setting, however, mainly because of the
possible effects that the increased energy output
may have on the developing fetus [11].
Yolk sac
Fig. 3. Transverse endovaginal ultrasound at 5.5 weeks’ At the end of the second week after fertilization
menstrual age demonstrates the ‘‘double decidual reaction’’ of (4 weeks’ menstrual age), the primary (primitive) yolk
two concentric echogenic rings (arrows) around the intra-
sac begins to regress and the secondary yolk sac
uterine gestational sac implanted within the endometrium.
develops [16]. The secondary yolk sac is the first
object seen sonographically in the gestational sac
before the visualization of the embryo. It appears as a
vaginally at 4.5 weeks’ menstrual age but cannot be circular echogenic structure between 3 and 7 mm [17]
identified definitively as such before visualization of a and is initially detected in all patients by endovaginal
yolk sac or embryo [6,12]. The double decidual ultrasound by between 37 and 40 menstrual days
reaction was described by Bradley et al in 1982 (Fig. 4). Transvaginal scanning can demonstrate a yolk
as two concentric echogenic rings surrounding the sac with an hCG level as low as 2200 mIUnits/mL,
intraendometrial fluid collection that impress upon IRP [6].
the endometrial stripe in a normal early pregnancy The yolk sac is a valuable feature that distin-
(Fig. 3). The inner ring represents the decidua capsu- guishes normal intrauterine pregnancies. Ultrasono-
laris around the chorion, and the outer ring represents graphically visible before the embryo, detection of a
the decidua parietalis, separated by a thin rim of fluid yolk sac is a reliable indicator of a true gestational
in the endometrial cavity [13]. In an ectopic pregnancy, sac with a positive predictive value of 100% [14].
the decidual reaction presents as only a single echo- Because it confirms an intrauterine pregnancy, the
genic ring around the endometrial fluid collection. detection of a yolk sac in an endometrial fluid collec-
The double decidual reaction sign of intrauterine
pregnancy is present and identifiable from 2 to
9 weeks’ menstrual age but also was described before
the widespread use of endovaginal ultrasound. The
sign was considered useful in transabdominal scan-
ning between 4 and 6 weeks of age to establish an
intrauterine pregnancy before the yolk sac can be
visualized. It is universally present when the mean
sac diameter (MSD) is 10 mm. Using endovaginal
probes, however, a yolk sac almost always can be
identified at this point, which diminishes the use of
the double decidual reaction in distinguishing early
intrauterine pregnancies [14].
Some researchers have explored the concept of
using Doppler sonography to verify intrauterine preg-
nancies. Doppler ultrasound has been shown to
demonstrate a high-velocity, low-impedance arterial
flow adjacent to the developing trophoblast. This Fig. 4. Rounded echogenic structure (arrow) within the
pattern of flow is caused by the high pressure gradient gestational sac represents the early yolk sac, which distin-
between the maternal spiral arteries and the intervil- guishes this intrauterine fluid collection as a gestational sac.
Heartbeat
The cardiovascular system is the first embryonic

system to function, and the primitive heart begins to
beat at the end of the third week after fertilization
(4 weeks’ menstrual age) [18]. By the time the embryo
is visualized on a transabdominal scan, it should
demonstrate a heartbeat or be considered nonviable
[19]. Endovaginal ultrasonography can detect small
normal embryos before detecting their cardiac pulsa-
tions, however. In embryos smaller than 5 mm, the
fetal heartbeat may not be seen by endovaginal ultra-
sound because cardiac activity does not begin until the
Fig. 5. Tubular echogenic structure between calipers within
end of the 5 weeks’ menstrual age, when the embryo
the gestational sac represents the early embryo identified on
ultrasound as the embryonic pole. measures from 1.5 to 3 mm [19]. For embryos smaller
than 5 mm that lack a visible heartbeat on endovaginal
ultrasound, follow-up ultrasound is suggested to docu-
tion in a pregnant woman usually excludes the pos- ment cardiac activity.
sibility of ectopic pregnancy. The embryonic heart rate is earliest detectable by
the human eye. Heart rate measurement should be
performed via M-mode because it does not increase
Embryonic pole the power delivered to the tissue as much as does
pulse Doppler. Care should be taken that maternal
When neurulation occurs at approximately 40 uterine pulsations are not mistaken for embryonic
menstrual days, the trilaminar embryonic disk be- heartbeats (Fig. 6). Embryonic heart rates increase
comes the more recognizable tubular structure usually slowly between 6 and 9 weeks’ menstrual age and
referred to as the ‘‘fetal pole,’’ although at this gesta- then slowly decrease throughout the remainder
tional age ‘‘embryonic pole’’ is a more appropriate of the first trimester. The mean embryonic heart
term (Fig. 5). The embryonic disk lies adjacent to the rates as measured by Stefos et al were 111 F 14 beats
secondary yolk sac, which provides a useful landmark per minute (bpm) at 42 to 45 days’ gestation,
to look for early embryonic cardiac pulsations [18]. 125 F 15 bpm at 50 to 52 days’ gestation, and
Fig. 6. M-mode ultrasound identifies and measures embryonic cardiac activity (white arrows) and maternal cardiac activity
(black arrows).
157 F 13 bpm at 53 to 56 days’ gestation [20,21]. of the embryo. The MSD is a measurement of the
There is a low intraindividual variation in embryonic mean gestational sac size and is obtained by adding
heart beats at less than 10 gestational weeks, which the anteroposterior and craniocaudal diameters
indicates that a single measurement of embryonic obtained on the sagittal view of the uterus to the
heart rate is sufficient [22]. The presence of cardiac transverse diameter obtained on the transverse view
pulsations predicts a favorable pregnancy outcome in and dividing by three (Fig. 7) [12,25]. The sac size
90% to 97% of patients [23]. Once normal cardiac can be correlated with menstrual age in early preg-
activity is established, spontaneous abortion occurs in nancy by the following formula: menstrual age in
only 2% to 4% of cases [24]. days = MSD + 30 [12]. MSD increases approxi-
mately 1 to 1.5 mm/day for the first 50 to 60 days of
Age assessment pregnancy. Once the embryonic pole is detected,
measurement of the crown rump length of the embryo
The MSD provides the most accurate way to date is considered the most accurate ultrasonographic way
an early pregnancy on ultrasound before visualization to date the pregnancy [58].
Fig. 7. Measurement of the MSD. (A) Single measurement indicated by calipers obtained on the transverse view of the
gestational sac. (B) Anteroposterior and craniocaudal measurements obtained on the sagittal view of the gestational sac.
Early pregnancy failure
Studying normal healthy women, Wilcox et al

demonstrated a 31% rate of early pregnancy loss
[27], most of which occurs before the pregnancy is
confirmed by either an ultrasound or a chemical
pregnancy test. The presence of vaginal bleeding in
pregnancy increases the risk of miscarriage. Vaginal
bleeding occurs in approximately 25% of known first
trimester pregnancies, and of these, 50% abort [23]. In
these symptomatic pregnancies, ultrasound is impor-
tant because it identifies which of these pregnancies
may be viable and which ones will not be successful
pregnancies. This determination influences patient Fig. 8. Grossly distorted gestational sac with irregular mar-
management and significantly affects patient anxiety. gins contains no identifiable yolk sac or embryonic pole,
The best criteria currently available to verify a which is consistent with an early pregnancy failure.
normal early intrauterine pregnancy are [1] a yolk
sac within a gestational sac and [2] an embryo with contents at smaller MSD and earlier menstrual ages.
cardiac activity. Without one of these signs, the pos- Use of the higher frequency probe sometimes can
sibility of early pregnancy failure must be raised. Lack obviate the need for follow-up sonography. Discrim-
of normal growth on serial ultrasound also can be used inatory values that rely on the use of these high-
as a reliable indicator of a failed pregnancy [5]. frequency transducers likely will be established in
Because follow-up mandates a delay in diagnosis, the future.
however, many attempts have been made to define Other explanations for the range of discriminatory
ultrasonographic features that can identify the preg- values include the rare occurrences of early mono-
nancies that will fail as early as possible. chorionic twins or early ‘‘polyhydramnios.’’ Inexperi-
enced sonographers also may inadvertently miss a yolk
Major criteria for abnormal outcome sac or embryo that can be difficult to distinguish
against the wall of the gestational sac. Given the
Nyberg et al first introduced major and minor variation in published discriminatory sac sizes, in the
criteria to distinguish between normal and abnormal setting of a desired pregnancy, the discriminatory size
gestational sacs in 1986 using findings on transab- criteria should be conservative. The author recom-
dominal ultrasound. Major criteria exhibited 100% mends use of the upper limits in the literature of
predictive accuracy and 100% specificity for an abnor- 13 mm for visualization of a yolk sac and 18 mm for
mal pregnancy. These criteria included large sac size visualization of an embryonic pole. Serial ultrasounds
with a MSD of 25 mm or more with no embryo and in conjunction with hCG levels are often valuable [28].
20 mm or more with no yolk sac, and a grossly dis-
torted sac shape (Fig. 8) [23]. Minor criteria for abnormal outcome
Since Nyberg introduced the concept of ‘‘discrim-
inatory’’ gestational sac sizes at which a yolk sac or an Minor criteria for abnormal outcome, as estab-
embryo must be seen to be considered normal, others lished by Nyberg, are sonographic features that
have reexamined the discriminatory size criteria for suggest an abnormal outcome but lack the specificity
endovaginal ultrasound. The most widely accepted in isolation to diagnose early pregnancy failure.
discriminatory sac sizes using endovaginal ultrasound These criteria include deficient choriodecidual reac-
are 8 mm MSD for visualization of the yolk sac and tion, absent double decidual reaction, irregular con-
16 mm MSD for visualization of the embryo [2,5]. A tour of the gestational sac, and low position of the sac
range of values is reported in the literature, however, (Fig. 10) [23]. When three or more of these features
with values up to 13 mm for visualizing a yolk sac and are present on transabdominal ultrasound, the speci-
18 mm for visualizing an embryo (Fig. 9) [5,6,28]. ficity rate for pregnancy failure approaches 100%.
Some of this discrepancy can be explained by varia- Other researchers have identified additional fea-
tions in patient population and ultrasound transducer tures that portend a high likelihood of pregnancy
frequencies from 5 to 7.5 MHz [2]. Use of a higher failure, including a small sac size and slow embryonic
frequency 9-5 MHz transducer improves spatial res- cardiac pulsation rate. Small sac size is defined by a
olution of the gestational sac and can identify sac difference between the MSD and crown rump length of
Fig. 9. (A) Sagittal and (B) transverse views of a large intrauterine gestational sac with MSD larger than 19 mm with no
embryonic pole or yolk sac indentified, which is consistent with a nonviable early pregnancy.
Fig. 10. (A) Sagittal views of the uterus with close-up view of the gestational sac (B) demonstrate an irregularly shaped
intrauterine gestational ac that contains yolk sac positioned low within the uterus (arrow). This gestational sac had not grown
within the past week, which is consistent with a missed abortion.
less than 5 mm measured between 5.5 and 9 menstrual Ectopic pregnancy

weeks (Fig. 11). As indicated by Giacomello, this is
not true ‘‘oligohydramnios’’ because the small sac size The estimated number of ectopic pregnancies has
is caused by reduction of fluid outside of the amniotic been increasing steadily since 1970. This increased
membrane [29]. Bromley et al found small sacs to be incidence correlates with increasing prevalence of
predictive of miscarriage in 94% of cases [24]. In a risk factors, including infection by Chlamydia and
later study by Rowling, however, at least 35% of such other sexually transmitted diseases, ovulation induc-
cases progressed to a second trimester scan or a normal tion, tubal sterilization [32], and improved detection
delivery, which suggests this finding is not as dire as of ectopic pregnancies, which may have remained
first thought. In contrast, no researcher has found that otherwise unrecognized and possibly resolved with-
abnormally large gestational sac sizes in relation to the out intervention [33]. Ectopic pregnancy was the
embryonic pole predict poor outcome. This circum- leading cause of pregnancy-related maternal death
stance may explain the large sacs with MSDs up to in the first trimester in the United States from 1990
18 mm without a yolk sac that eventually develop into to 1992. During that time period, ectopic pregnancy
normal pregnancies [28]. accounted for approximately 2% of all reported
The embryonic heart rate increases between 6 and pregnancies and 9% of all pregnancy-related maternal
9 weeks’ gestation. At 6 weeks’ menstrual age, the deaths in the United States [32].
mean embryonic heart rate ranges from 90 to 133 bpm, The ‘‘classic’’ clinical triad of pain, abnormal
and at 9 weeks’ gestation it ranges from 144 to vaginal bleeding, and a palpable adnexal mass is
170 bpm. A slow embryonic heart rate is associated present in less than half of patients with ectopic preg-
with a poor outcome [30]. Specifically, rates below nancy. Of patients with these symptoms, most are
100 bpm before 6.3 weeks’ gestation and below not pregnant [34]. Because the clinical presentation
120 bpm between 6.3 and 7 weeks’ gestation have is neither sensitive nor specific, diagnosis relies on
been associated with a high risk of miscarriage. The a combination of clinical, biochemical, and imag-
lower the heart rate, the greater the chance of miscar- ing findings.
riage. Fetuses with heart rates below 80 bpm before Because any woman of child-bearing range is at
6.3 weeks’ gestation or below 100 bpm at 6.3 to risk for ectopic pregnancy, establishing the location
7 weeks’ gestation have rates of loss approaching of pregnancy is recommended for any pregnant
100% [20]. woman who presents for pelvic ultrasonography
Fetuses with abnormally rapid heart rates—defined [35]. Approximately 97% of all ectopic pregnancies
as higher than 135 bpm— before 6.3 weeks’ gestation occur in the fallopian tubes, specifically in the
or more than 155 bpm at 6.3 to 7 weeks’ gestation have ampullary region. They may occur occasionally in
been shown to have a good prognosis and a high the cervical region, interstitial portion of the fallopian
likelihood of a normal outcome [31]. tube, abdominal cavity, or ovary [36]. Transvaginal
ultrasound is clearly superior to transabdominal
ultrasound in evaluating the endometrium and
adnexa and provides a definitive diagnosis more
often and earlier than transabdominal ultrasound.
Endovaginal sonography may miss an ectopic preg-
nancy located high out of the field of view of the
endovaginal probe or when a pelvic mass, such as a
fibroid or bowel gas, is located between the vagina
and the adnexal mass [37 – 40]. In cases in which a
diagnosis of ectopic pregnancy can be made abso-
lutely on endovaginal ultrasound, transabdominal
scanning is not necessary [38]. A limited transabdo-
minal scan is recommended in all cases of suspected
ectopic pregnancy in which the endovaginal ultra-
sound does not provide a clear diagnosis, however.
Including the transabdominal study may increase the
Fig. 11. Embryonic pole comprises nearly the entire volume sensitivity rate up to 5% over transvaginal studies
of the gestational sac with 2 mm difference between the alone (Fig. 12) [40]. In this setting, it is not necessary
crown rump length and the MSD, which is consistent with a always to fill the bladder before the transabdominal
small sac size for the embryo. scan [41].
Fig. 12. (A) Endovaginal ultrasound shows a sagittal view of the uterus with a normal appearing endometrial stripe marked by
calipers. (B) Normal right ovary marked by calipers. (C) Transabdominal ultrasound of the right lower quadrant shows a complex
mass (arrow) high in the pelvis that contains a yolk sac and fetal embryonic pole, consistent with ectopic pregnancy.
Because the frequency of coexistent intrauterine formed to screen for a possible coexistent ectopic
pregnancy and ectopic pregnancy (heterotopic preg- pregnancy, especially in women who present with
nancy) is low at between 1/4000 and 1/7000 [42,43], pelvic pain and women with a history of assisted
the diagnosis of an intrauterine pregnancy effectively fertilization (Fig. 13) [36].
excludes ectopic pregnancy in most patients [39]. The rate of ectopic pregnancy is higher in women
Even in the presence of an intrauterine pregnancy, who undergo assisted fertility. Mol et al found an
however, evaluation of the adnexa should be per- overall incidence of ectopic pregnancy after in vitro
Fig. 13. Heterotopic pregnancy in a patient who had been taking Pergonal. (A) Intrauterine diamniotic twin pregnancy and (B)
large amount of echogenic free fluid in Morrison’s pouch (arrow) caused by heterotopic triplet pregnancy. The ectopic pregnancy
was removed surgically, and the patient delivered twins at term. (Courtesy of Deborah Levine, MD, Boston, MA.)
Fig. 14. Extrauterine gestational sac that contains yolk sac and embryonic pole in the adnexa, which are consistent with ectopic
pregnancy. (A) Transverse endovaginal image shows an empty uterus and left adnexal mass (arrows). (B) Close-up view of left
adnexa shows extrauterine gestational sac, which contains an embryonic pole marked by calipers and yolk sac.
fertilization and embryo transfer to be 5.1% [44]. The echogenic free fluid increases the sensitivity rate even
rate of heterotopic pregnancy has been increasing, higher to 56% [46]. Ultrasonographic assessment of
partly because of this expanding patient population. the pelvis has almost completely replaced culdocen-
The incidence of heterotopic pregnancy is approxi- tesis for the diagnosis of hemoperitoneum. Culdocen-
mately 1% of all pregnancies after in vitro fertiliza- tesis is invasive, less sensitive than transvaginal
tion [43,45]. In this population, ectopic pregnancy ultrasonography for the detection of blood, and has
cannot be excluded even if an intrauterine pregnancy a lower negative predictive value [47]. Transabdomi-
is detected. Because more than one embryo is typ- nal scanning of the paracolic gutters and Morrison’s
ically transferred after in vitro fertilization, hCG pouch may show free intraperitoneal fluid not appre-
levels are less helpful in diagnosing ectopic preg- ciated on the transvaginal approach [38,41].
nancy, and ultrasound plays an even larger role
in detection. Adnexal mass
An adnexal mass is the most common ultrasono-
Sonographic diagnosis of ectopic pregnancy: graphic finding in ectopic pregnancy, found in 65% to
specific findings 84% of cases [40,48 – 50]. The adnexal mass can
demonstrate various appearances. It can appear as a
The most specific sonographic sign of ectopic sac-like ring that correlates with an intact tube that
pregnancy is visualization of an extrauterine gesta- contains a gestational sac (Fig. 16). Alternatively, the
tional sac that contains a yolk sac or embryo (Fig. 14). mass can be solid or complex, which typically cor-
This sign carries a specificity rate of 100% but a low relates with an incomplete tubal abortion or, less
sensitivity rate of 15% to 20% [37,40,46]. likely, a ruptured tube (Fig. 17) [50]. The appearance
also can be subtle, recognized only by an asymmetry
Nonspecific findings
Free fluid
Small amounts of free pelvic fluid can be seen in
ectopic and intrauterine pregnancies. The presence of
echogenic fluid, especially when found in high
quantities or in association with an adnexal mass,
indicates a high risk of ectopic pregnancy. Echogenic
fluid correlates with hemoperitoneum at surgery
(Fig. 15) [47].
The presence of a moderate to large amount of
free fluid demonstrates a sensitivity rate of 28% but a
high specificity rate of 96% and positive predictive Fig. 15. Large amount of echogenic free fluid in the pos-
value of 86% for ectopic pregnancy. The presence of terior cul de sac in surgically proven ectopic pregnancy.
of an ectopic pregnancy, the endometrium can have a

varied appearance and may not add to the sono-
graphic diagnosis. The most common appearance of
the endometrium is normal or a generalized increased
echogenicity [37].
Pseudogestational sacs are endometrial fluid col-
lections surrounded by echogenic endometrium from
a prominent decidual reaction. These sacs are present
in approximately 5% to 10% of cases [36,37]. They
are typically lenticular in configuration with irregular
contour (Fig. 18) but can be smooth and rounded and
contain debris that could be mistaken for products
of conception.
Fig. 16. Complex adnexal mass (marked by calipers) caused The thickness of the endometrium does not help
by ectopic pregnancy. Sac-like area within the mass (arrows) distinguish between ectopic and normal or abnormal
likely represents the fallopian tube dilated by the extrauterine intrauterine gestations [52]. Although Lavie et al
gestation sac. found a sonographic three-layer endometrial pattern
similar to that seen in the late proliferative phase of a
normal pregnancy to have a sensitivity rate of 62.2%
between the size of the ovaries of 2 cm or more [37]. and a specificity rate and positive predictive value of
The size of the adnexal mass typically correlates well 100% for ectopic pregnancy [53], these findings have
with the size found at surgery with a discrepancy of not been reproduced by others [54]. A normal
less than 1 cm [50]. appearance of the pelvis on ultrasound with an empty
If the adnexal mass contains either a yolk sac or uterus does not exclude ectopic pregnancy.
an embryo, the specificity rate for ectopic pregnancy
approaches 100%. The presence of any extraovarian Serum human chorionic gonadotropin levels
adnexal mass in a patient with clinically suspected Serum hCG levels play an important adjunctive
ectopic pregnancy increases the likelihood of ectopic role with ultrasonography in the early diagnosis of
pregnancy to more than 90%, however [40,48,49]. ectopic pregnancy. A negative hCG level effectively
Other entities that can cause a complex adnexal mass excludes the possibility of pregnancy in the setting of
in this setting include an endometrioma, hemorrhagic a woman with pelvic pain. Many institutions rely
corpus luteal cyst with or without rupture, and hydro- on the discriminatory hCG level, usually held at
salpinx [39,49,51]. 2000 mIU/mL IRP for endovaginal scans, to help
distinguish ectopic from intrauterine pregnancy
Endometrial appearance [6,26,49,50]. The discriminatory level indicates the
Pregnancy, regardless of its location, produces a lowest hCG level at which an intrauterine gestational
decidual reaction in the endometrium. In the setting sac should be visualized [55]. If the hCG level is
above the discriminatory level and no gestational sac
Fig. 18. Elongated cresentic intrauterine fluid collection

Fig. 17. Solid echogenic mass medial to right ovary re- (arrow) caused by a pseudo-gestational sac from an ec-
presents the adnexal mass of an ectopic pregnancy. topic pregnancy.
is detected, the pregnancy may be abnormal, and pared with surgical treatment [32]. Administration of
ectopic pregnancy should be considered. Mehta et al methotrexate has become an increasingly popular
reported that 33% of 51 patients without a definite therapy for the treatment of ectopic pregnancy
gestational sac and with hCG levels more than [32,58,59]. Pharmacologic therapy often results in
2000 mIU/mL IRP had normal intrauterine pregnan- decreased patient morbidity and increased preser-
cies on follow-up [26]. Strict reliance on a single vation of reproductive capability [32]. Methotrexate,
discriminatory hCG value is probably unwise, and administered either intramuscularly or intratubularly
serial values can be more helpful in distinguishing [36,58], causes either resorption or tubular abortion
among intrauterine, ectopic, and failed pregnancies. of the conceptus. Women who demonstrate lack of
Ultrasound may provide valuable information regard- free fluid outside of the pelvis on ultrasound, hemo-
less of the hCG level. dynamic stability, and no other comorbid conditions
are considered candidates for medical therapy. Most
Management protocols limit candidates to women with an adnexal
mass of less than 3 to 4 cm, lack of embryonic cardi-
Managing ectopic pregnancy in the outpatient ac activity, and hCG levels of less than 5000 to
setting has become a more viable option with earlier 10,000 mIU/mL. Failure of treatment is most closely
detection through endovaginal ultrasound and sen- linked to high hCG levels and the presence of embry-
sitive hCG assays. Outpatient management strategies onic cardiac activity [58]. At follow-up of patients
include laparoscopic salpingectomy or salpingo- treated with methotrexate, ultrasound may dem-
stomy, methotrexate administration, and close mon- onstrate that the adnexal mass or affected fallopian
itoring for spontaneous resolution [32]. tube has grown in size and become more vascular.
Spontaneous resolution of ectopic pregnancy can Treatment success can be monitored with declining
occur. Early sonographic diagnosis of ectopic preg- hCG levels [58,59].
nancy likely identifies some cases that would have
escaped diagnosis because of spontaneous resolution
without intervention. Atri reported that 24% of Fetal abnormalities
ectopic pregnancies sonographically diagnosed over
a 19-month period resolved spontaneously [56]. A series of recent studies suggested that the sono-
Pregnancies that are more likely to resolve dem- graphic observation of increased fetal nuchal trans-
onstrate findings such as a longer time interval from lucency in the first trimester can be used as a screening
the last menstrual period [33], small adnexal masses tool for chromosomal defects. Some other fetal struc-
of less than 3.5 cm and preferably less than 2 cm, low tural abnormalities are also identifiable in the first
serum hCG levels of less than 1000 mIU/mL, rapidly trimester on ultrasound. As sonographic technology
decreasing hCG levels, lack of a gestational sac, and improves, better spatial resolution also may enable
no cardiac activity detected. The more advanced and earlier diagnosis of more structural abnormalities.
vascular the adnexal mass or hematosalpinx caused
by the ectopic pregnancy, the less likely it is to Nuchal translucency
resolve spontaneously [33,56]. While resolving, the
adnexal mass of an ectopic pregnancy may increase Szabo and Gellen [60] were the first to report an
in size and become more vascular on ultrasound [56]. association between increased nuchal translucency in
Ultrasound is not reliable for identifying cases that the first trimester and chromosomal abnormalities.
are undergoing spontaneous resolution. The diagnosis Nuchal translucency describes the subcutaneous
is based on continuing clinical stability of the patient accumulation of fluid in the back of the fetal neck,
and decreasing serial hCG levels [33]. which can occur early in pregnancy. On sonography,
Although spontaneous resolution of ectopic preg- nuchal translucency represents the maximum thick-
nancy may occur, expectant management of patients ness of the subcutaneous translucency between the
with confirmed diagnoses remains controversial. The skin and the soft tissue overlying the cervical spine
benefit of expectant management over other conserv- (Figs. 19, 20) [61,62]. According to the criteria
ative treatments, such as medical treatment with published by the Fetal Medicine Foundation [63],
methotrexate or minimally invasive laparoscopic sur- images of nuchal translucency must include a mid-
gery, has not been established [36,57]. sagittal section, sufficient magnification of the image,
Since the late 1980s there has been a shift toward differentiation between fetal skin and amnion, and
treating ectopic pregnancy in the outpatient setting placement of the calipers on the echogenic lines (on-
and reaping significant medical cost savings com- to-on measurement) so that the maximal thickness
lected population. The combination of first trimester

ultrasound evaluation with serum-free b hCG, preg-
nancy-associated plasma protein, and maternal age
data further improve the accuracy of risk assessment.
Currently two large, prospective, multicenter trials
are underway to provide further data on the role of
first trimester aneuploidy screening, including the
First and Second Trimester Evaluation of Risk for
Aneuploidy Trial in the United States and the Serum
Urine and Ultrasound Screening Study in the United
Kingdom [71].
A review of studies using nuchal translucency
measurements to screen the general population
revealed a range of Down syndrome (trisomy 21)
detection rates of 29% to 91%. [72]. Variability in
Fig. 19. Endovaginal ultrasound shows a sagittal view of
detection rates is caused by differences in study design,
the of 11-week embryo with thickened nuchal translucency such as time allowed for the study, patient follow-up,
shown separate from the amnion. cutoff measurement used, and differences in the mater-
nal age in the study population and experience of the
technologist [72,73]. The largest prospective trial
undertaken by Snijders et al on 96,127 patients found
of the lucent area is measured. The choice of trans- a detection rate of Down syndrome of 72% [63].
abdominal versus transvaginal approach is left to Even in chromosomally normal fetuses with
the examiner. increased fetal nuchal translucency, there is an in-
Because nuchal translucency increases with gesta- creased risk of poor prognosis because of a higher
tional age, a single measurement threshold to estab- incidence of spontaneous abortion and other structur-
lish a population at higher risk for aneuploidy used al fetal abnormalities, particularly cardiac abnormal-
over the first trimester may not be valid [64,65]. ities [66,68,74,75]. The likelihood of poor pregnancy
Although a gestational age-dependent normal range outcome also increases with larger nuchal trans-
may be most useful to minimize false-positive results, lucency measurements ranging from 32% at 3 mm
a discriminatory value equal to or more than 3 mm is to 100% at 5 mm [66]. At least one study that
most commonly used, which falls between the nine- examined early childhood follow-up of fetuses with
tieth and ninety-fifth percentile for crown-rump increased nuchal translucency has shown that cases
length when measured between 10 and 14 weeks’ with a normal karyotype and no additional abnormal-
gestation [61,66]. ities on follow-up sonography have a good prognosis
Using a cutoff of 3 mm, approximately 1% to 5% for normal delivery and early childhood. Typically,
of first trimester fetuses demonstrate nuchal trans-
lucency [61,63,67 – 69]. Depending on the cutoff
used, the prevalence of chromosomal abnormality in
fetuses with abnormal nuchal translucency ranges
from 19% to 75% [66], with the risk of aneuploidy
increasing with the degree of nuchal translucency. In
a screening population, Thilaganathan et al found
thickened nuchal translucency to have a positive
predictive value of 1:31 for Down syndrome and
1:12 for all major aneuploidies. These ratios compare
favorably to the positive predictive value for second
trimester maternal serum biochemistry of 1:50 [70].
Because of study differences in cutoff values,
study population, and technique, the precise sensitiv-
ity of screening with nuchal translucency is unclear.
Data support nuchal translucency measurement as an
effective noninvasive screening method for trisomy Fig. 20. Fetus at 10.5 weeks’ menstrual age with markedly
21 and other chromosomal abnormalities in an unse- thickened nuchal translucency.
Fig. 21. (A) Coronal and (B) sagittal ultrasound of a 12-week fetus with absence of the cranium and separation of the cranial soft
tissue into two masses (arrows), which are consistent with anencephaly.
thickened nuchal translucency does not lead to a length usually measures less than expected by gesta-
cervical structural abnormality in the child [68]. tional age. Because mineralization of the skull occurs
at approximately 10 weeks’ gestation, diagnosis theo-
retically can be made after this point. Two studies
Fetal structural abnormalities performed in the United Kingdom demonstrated that
in units in which the sonographer was instructed to
Improvements in sonographic resolution have look for signs of acrania, sensitivity rate for detecting
made it possible to detect the presence of a wide anencephaly in the first trimester was 100% with no
range of fetal defects in the first trimester. In some false-positive cases [78,79]. First trimester fetuses
cases, the sonographic features are similar to those with anencephaly may demonstrate the ‘‘Mickey
described on second and third trimester scans, and in Mouse Sign,’’ which describes the appearance of
other cases there are characteristic features unique to the cerebral lobes in the coronal plane as two semi-
these early studies [76]. First trimester ultrasound is circular structures above the orbits surrounded by
particularly sensitive in detecting abnormalities in the amniotic fluid (Fig. 21) [78].
central nervous system, cervical region, and renal and Several of the soft signs for aneuploidy typically
gastrointestinal organs and is weak at detecting spina examined in the second trimester also can be detected
bifida and cardiac and limb deformities. In a screen- in the first trimester. Whitlow et al studied soft
ing study of an unselected low-risk population of
more than 6000 pregnant women scanned between 11
and 14 weeks’ gestation, the detection rate for struc-
tural abnormalities was 68% in early pregnancy.
When combined with the second trimester scan, the
rate increased to 85% [77].
Anencephaly, characterized by absence of the
cranial vault and subsequent disruption of the cere-
bral cortex, was one of the first fetal abnormalities
diagnosed by ultrasound. The first trimester findings
are notably different from those identifiable on sec-
ond trimester scans [77]. Whereas in the second
trimester the diagnosis of anencephaly is made par-
tially by the finding of prominent orbits and no brain
tissue or skull above the orbits, the first trimester
diagnosis relies on noting the absence of cranium
because cerebral tissue (angiomatous stroma) still Fig. 22. Transverse image of a fetal head at 12 weeks’ men-
may be present. In anencephaly, the crown rump strual age demonstrates a choroid plexus cyst.
markers for aneuploidy, including pyelectasis, echo- pregnancy: correlation with HCG level. AJR Am J
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Radiol Clin N Am 41 (2003) 681 – 693
Ultrasound detection of first trimester malformations:

a pictorial essay
Ilse Castro-Aragon, MD, Deborah Levine, MD*
Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
Ultrasound is commonly performed in the first Dandy Walker cyst or hydrocephalus. Later in gesta-
trimester for determining cause of bleeding or pain, tion, the choroid plexus fills the lateral ventricle,
establishing dates, and evaluating nuchal translucency which occupies most of the hemisphere (Fig. 2) [5].
in screening for aneuploidy. With improvements in Calvarial ossification occurs at approximately
ultrasound technology, the fine structures of the 10 weeks’ gestational age, which is why anencephaly
developing embryo and fetus can be visualized (Fig. 3) is difficult to appreciate early in the first
[1,2], which allows for early detection of embryonic trimester (Fig. 4). Even after 10 weeks, the absence
and fetal structural abnormalities. A combination of of a calcified cranium may be overlooked because the
transabdominal and transvaginal scanning allows for underlying cranial tissue may appear normal [6]. In a
assessment of anatomy in up to 95% of fetuses at 12 to study by Johnson et al of 55,237 fetuses at 10 to
13 weeks’ gestation [3]. In a study of low-risk women, 14 weeks’ gestation, 47 fetuses were diagnosed with
68% of fetal structural abnormalities were detected anencephaly. In the initial portion of the study, the
during first trimester sonography [4]. Early detection diagnosis was missed in 8 of 31 fetuses. After review
of structural anomalies is helpful in the diagnosis of of these cases, sonographers were given feedback
aneuploidy and in counseling patients regarding regarding the first trimester appearance of anen-
potential outcome when chromosomes are normal. cephaly; in the second portion of the study, 16 of
This article illustrates pathologic conditions that can 16 cases were diagnosed. This demonstrates that
be detected in early pregnancy and potential pitfalls in attention to ossification of the skull aids in the early
the evaluation of the developing embryo and fetus. diagnosis of anencephaly. In this study, the diagnosis
of anencephaly was made when there was absence of
the calvarium, even if the underlying brain tissue
Central nervous system appeared normal. When tissue is visualized above
the orbits, some call this exencephaly (Figs. 5, 6).
The sonographic appearance of the brain in the Because nearly all cases of anencephaly in the first
first trimester is different from its appearance later in trimester have tissue present above the orbits, it is
gestation. Between 7 and 9 weeks’ gestational age, believed that exencephaly is a precursor to anen-
the developing rhombencephalon is visible as a cystic cephaly [7,8].
space in the embryonic head, which should not be Encephalocele is the least common open neural
mistaken for an abnormality (Fig. 1). This structure tube defect, with an incidence of 1 to 4:10,000 live
contributes to the fourth ventricle, the brain stem and births. The bony calvarial defect allows herniation of
the cerebellum, and should not be confused with a the meninges alone or the brain and the meninges out
of the boundaries of the skull. The most common site
* Corresponding author. of occurrence is the occipital midline (Fig. 7) (75%)
E-mail address: [email protected] followed by the frontal midline (13%) and the parietal
(D. Levine). regions (12%).
doi:10.1016/S0033-8389(03)00045-9
682 I. Castro-Aragon, D. Levine / Radiol Clin N Am 41 (2003) 681–693
translucency (Fig. 9) [10,11]. Even if the nuchal

translucency resolves, there is still an increased risk
of poor outcome, including cardiac anomalies, con-
genital diaphragmatic hernia, and growth restriction
[11 – 13]. A patient whose the fetus has been diag-
nosed with first trimester increased nuchal trans-
lucency should have a formal anatomic survey in
the mid-second trimester and should be followed to
assess adequate growth throughout pregnancy.
Generalized edema around the body of the fetus is
called lymphangiectasia (Fig. 10). This condition
carries a grim prognosis and is associated with
impending fetal demise.
Fig. 1. Rhombencephalon (arrow) in coronal plane; the

embryo is 8 weeks’ gestational age. This is a common pitfall Umbilical cord
for imaging interpretations and should not be mistaken for
an abnormal finding. Small umbilical cord cysts can be identified in the
first trimester (Fig. 11). These avascular structures
appear as echolucent cysts within the cord that do not
Hydrocephalus (Fig. 8) is not commonly visualized obstruct the flow from the umbilical arteries and vein.
in the first trimester because the ventricles normally There is a range of incidence reported with these
occupy most of the hemispheres (see Fig. 2). In severe cysts, from 0.4% [14] to 3.4%. [15] This variation in
cases, hydrocephalus can be diagnosed in the first reported incidence is likely caused by the amount of
trimester when the ventricle is enlarged, and the attention paid to the umbilical cord during scanning.
choroid plexus, which normally occupies the entire Umbilical cord cysts (Fig. 12) may be located any-
ventricle, is dangling and surrounded by fluid [9]. where along the cord and are separate from the mass
created by physiologic bowel herniation. In most
cases there is resolution of the cyst on follow-up
Nuchal translucency examination, but this does not completely exclude an
abnormality, and a detailed second trimester survey is
Increased nuchal translucency is associated with indicated [15 – 17]. In one study of pregnancies with
aneuploidy and poor obstetric outcome. The method umbilical cord cysts seen at 7 to 12 weeks’ gestation,
of measurement of the nuchal translucency for 26% were found to have fetal structural defects [15];
screening for aneuploidy is discussed elsewhere in however, in other studies none of the cases had
this issue. When the translucency contains septations, abnormalities on follow-up [14,17]. Whereas second
it carries a risk greater than that of simple nuchal trimester large, irregular cord cysts have a high
Fig. 2. Sagittal (A) and coronal views (B) of a 12-week gestational age fetus with a normal brain. Note that the choroid plexus
fills the ventricle, and the ventricle fills almost the entire hemisphere.
I. Castro-Aragon, D. Levine / Radiol Clin N Am 41 (2003) 681–693 683
Fig. 3. Anencephaly. Sagittal Gray-scale (A) and color Doppler (B) views show lack of an ossified cranium above the orbits.
The internal carotid arteries are seen to extend to the skull base and then abruptly terminate (arrows). (Courtesy of Dr. Peter
Callen, San Francisco, CA).
association with anomalies and poor outcome, small, herniation is more than 7 mm, an abdominal wall
smooth cysts that disappear after the first trimester defect is likely, because in normal fetuses this length
have a more benign course [18]. is 6 mm or less [19]. If the contents consist of liver or
stomach and if the protrusion is covered by membrane,
then an omphalocele is present (Figs. 14, 15). No
Anterior abdominal wall herniation should be visible once the crown rump
length is 45 mm or more [19,20]. Early diagnosis of
Physiologic herniation of the fetal bowel into the omphalocele is important because it is a common
base of the umbilical cord occurs normally between 8 feature of trisomies 18 and 13 [21,22]. In a study by
and 12 weeks’ gestation (Fig. 13). This midgut hernia- Snijders, 61% of cases of omphalocele detected in the
tion is visualized sonographically as slightly echo- first trimester were aneuploid [22].
genic areas in the base of the abdominal insertion of the If the bowel loops have an irregular margin,
umbilical cord. Failure of the intestinal loops to return then the defect is likely a gastroschisis (Fig. 16).
to the abdominal cavity results in the formation of an Differentiation of gastroschisis from omphalocele
omphalocele, which is a membrane-covered midline is important because gastroschisis is not associated
abdominal wall defect. When the length of the bowel with aneuploidy.
When the cord insertion site appears enlarged, it
is prudent to obtain a follow-up sonogram in 1 to
2 weeks. Because the bowel generally returns to the
abdominal cavity in that time period, the patient can
be counseled and managed appropriately.
Genitourinary tract
The fetal kidneys are echodense at 9 to 10 weeks’

gestation and become slightly echolucent at 11 weeks.
By 11 weeks’ gestation, one third of kidneys can be
visualized with transvaginal sonography, and by
13 weeks almost all kidneys can be visualized trans-
vaginally [23]. The fetal bladder is generally visual-
Fig. 12. Longitudinal view of umbilical cord from a scan at ized by 11 to 12 weeks’ gestation [24]. Because
11 weeks’ gestation. Color Doppler image delineates a 3-mm excretory function occurs after 11 weeks, renal tract
umbilical cord cyst (arrow). Sonographic follow-up showed anomalies are unlikely to be visualized before this
resolution of the cyst. The baby was normal at delivery. time. An enlarged bladder in the late first trimester
Fig. 4. (A) Sagittal view of embryo at 9 weeks and 3 days was interpreted as normal but with size less than dates. (B) Coronal
view of fetus during the second trimester demonstrates absence of brain structures above the orbits, consistent with anencephaly
that was missed in the initial scan.
has a differential diagnosis similar to that of an Skeletal anomalies

enlarged bladder later in gestation, including poste-
rior urethral valves, urethral atresia, megacystitis/ First trimester diagnoses of skeletal anomalies
megaureter, or anorectal imperforation (Fig. 17). have been reported [28 – 31]. Specific diagnosis is
The prognosis of early fetal megacystitis is dismal facilitated when the patient has a history of a prior
[25]. There is a high rate of aneuploidy (25%) and a affected pregnancy.
high percentage of associated malformations, espe-
cially intestinal malformations (33%) [26].
Triploidy
Congenital heart disease Triploidy is the most common chromosomal

anomaly in human gestation, and it occurs in 1% of
Diagnoses of congenital heart defects have been all conceptions [32]. It results from three complete
made as early as 10 weeks’ gestational age with the use sets of chromosomes (total of 69 chromosomes).
of transvaginal sonography [27]. When diagnosed in Most cases of triploidy end in spontaneous abortions
the first trimester, these defects commonly are asso- during the first trimester, which leads to a prevalence
ciated with abnormal fluid collections, such as ascites, of triploid pregnancy at 16 to 20 weeks’ gestation of
pleural effusions, pericardial effusion, and lymphang- 0.002% [33]. Usually these fetuses have congenital
iectasia [27]. abnormalities of multiple organ systems. They also
can have first trimester onset of intrauterine growth
restriction (Figs. 18 – 20) [34]. In a study of first
trimester diagnosis of triploidy of 58,862 singleton
fetuses at 10 to 14 weeks’ gestation, there were
18 cases of triploidy. Fetal defects were observed in
8 of 18 (44.4%), including holoprosencephaly,
omphalocele, and posterior fossa cyst. Increased
nuchal translucency, growth restriction, and placental
molar changes were present in 33%, 62%, and 67%
of cases, respectively [34]. There are two different
phenotypes depending on the parental origin of the
extra haploid set. The cases of triploidy that result
from a double paternal contribution have mild growth
restriction and a thick placenta with multiple cystic
Fig. 5. Exencephaly. Sagittal view of a fetus at 12 weeks’ spaces. The cases of triploidy with a double maternal
gestation. Note the presence of angiomatous stroma (arrow) contribution have severe asymmetric growth retarda-
above the skull base. The calvarium is not visualized. tion and normal appearing placentas [34]. When an
Fig. 6. Exencephaly. Coronal view of the fetus (A) and axial views of brain tissue (B) in fetus at 12 weeks and 4 days with absent
calvarium. Note the appearance of malformed cerebral hemispheres as demonstrated by lack of demonstrable cerebral ventricles.
early pregnancy is scanned and the placenta appears Conjoined twins

enlarged or has cystic spaces, a follow-up scan in 1 to
2 weeks is recommended. Conjoined twins are rare, estimated to occur in
Triploidy is different from a classic complete 1:30,000 to 1:100,000 live births [40]. Conjoined
hydatidiform molar pregnancy, in which there is no twins are monozygotic twins that had a late and
fetal tissue. Partial hydatidiform mole refers to the incomplete fission of the inner cell mass during the
combination of a fetus with localized placental molar third week of gestation. The sonographic signs
degeneration [35,36]. Histologically, it is character- include inability to visualize a membrane between
ized by focal swelling of the villous tissue, focal twins, inability to visualize a complete separation of
trophoblastic hyperplasia, and embryonic or fetal the twins, fetal spines in unusual proximity, unusual
tissue. In approximately 90% of cases, partial moles embryonic or fetal shapes, single cardiac pulsation
are triploid and have two sets of paternal and one set with two adjacent fetal poles or two cardiac pulsations
of maternal chromosomes [37,38]. After dilatation in a single fused fetal pole, and more than three
and curettage, persistent gestational trophoblastic vessels in the umbilical cord (Fig. 21). Sonography
disease develops in 4% to 11% of patients with a in the first trimester can delineate the extent of organ
partial mole [39]. sharing [41]. Common pitfalls for the diagnosis of
Fig. 7. Transabdominal (A) and transvaginal (B) views of the head in a 13-week gestational age fetus demonstrate herniated brain
tissue consistent with a large posterior encephalocele (arrowheads) with a normally ossified anterior skull (arrows).
Fig. 8. Coronal (A) and transverse (B) views of the lateral ventricles and coronal view of the posterior fossa (C) of a 12-week
gestational age fetus with dilatation of the lateral ventricles, seen as lucency in the cerebral hemispheres without choroid plexus.
The third ventricle is enlarged and there is splaying of the cerebellar hemispheres (long arrows). Although cerebellar
abnormalities are notoriously difficult to diagnose in the first trimester because the cerebellum is still developing, the
constellation of findings in this case is consistent with a Dandy Walker malformation.
Fig. 9. Sagittal (A), axial (B), and coronal (C) views of a 12-week, 3-day gestation demonstrate nuchal translucency with
septations. The extent of the translucency along the back of the fetus is denoted with calipers. This is clearly separate from the
amnion (arrow). Chromosomal analysis showed trisomy 21.
Fig. 10. Coronal view of a 12-week gestational age fetus with diffuse lymphangiectasia. Note diffuse lucency under the skin
(arrowheads), which is clearly separate from the amnion (arrow). Chromosomal analysis showed trisomy 18.
Fig. 11. (A, B) Transverse images of the fetal abdomen and umbilical cord at 9 weeks’ gestational age demonstrate a 4-mm cyst
(arrow) separate from the yolk sac (arrowhead). The cyst was not visualized 4 weeks later in a follow-up examination.
Fig. 13. Transverse view of the abdomen at 10 weeks and 2 days’ gestational age demonstrates physiologic bowel herniation.
Note the individual loops of bowel (arrow) within the base of the umbilical cord.
Fig. 14. Two fetuses with omphalocele and trisomy 18. Sagittal view (A) of 10-week gestation and transverse view (B) in a
12-week gestation each demonstrate an omphalocele (arrow).
Fig. 15. (A) Sagittal view of an 8-week embryo with a prominent cord insertion site (arrow). This was not noted prospectively.
(B) Follow-up examination at 16 weeks axial view of abdomen demonstrated an omphalocele. The chromosomal abnormality
was a de novo terminal deletion of the short arm of chromosome 5 with a karyotype of 46, XY, del(5) (p15.3).
Fig. 16. Sagittal view of the fetal abdomen at 11 weeks and 5 days’ gestation illustrates a prominent cord insertion site (arrow).
Follow-up was suggested, but the fetus was not scanned again until 19 weeks’ gestation, when the scan confirmed the presence
of gastroschisis.
Fig. 17. Sagittal view of a 13-week gestational age fetus shows a dilated pear-shaped bladder and a normal amount of amniotic
fluid. The presumed diagnosis was posterior urethral valves.
Fig. 18. Triploidy. (A) Sagittal view of uterus at 11 weeks’ gestation by unsure dates and 8 weeks 6 days’ gestation by crown
rump length. The placenta is slightly heterogeneous with some cysts. (B) Sagittal view of the placenta 3 weeks later shows an
enlarged placenta with multiple small cysts. (C ) Axial view at levels of chest shows diffuse skin thickening consistent with
lymphangiectasia. The combination of cystic placenta and abnormal fetus suggests the diagnosis of triploidy. Chromosomal
analysis showed triploidy, and histology of the placenta showed partial mole.
Fig. 19. Triploidy. (A) Transvaginal M-mode of a 7-mm embryonic pole demonstrates severe bradycardia (heart rate of 54). (B)
There are subtle placental cystic changes (arrow). The patient had a miscarriage, and histologic examination demonstrated a
partial mole.
Fig. 20. Triploidy. Sagittal view of fetus at 12 weeks’ gestation by dates and 10 weeks and 6 days’ gestation by crown rump
length. Note the small size of the fetal torso compared with the head caused by early asymmetric growth restriction.
Fig. 21. Conjoined twins at 7 weeks’ gestational age. Two heart beats were visualized.
Fig. 22. (A) Transverse view of a monoamniotic monochorionic twin gestation at 9 weeks 2 days. The fetal abdomens are imaged
together both in the transverse plane with no membrane seen between them. (B) Image obtained a few minutes later demonstrates
a separation between the embryos, and the more posterior twin is in the longitudinal plane. The change in position and seperation
of the twins exclude the possibility of conjoined twins.
Fig. 23. Intraamniotic hematoma mimicking conjoined twins. (A) Transvaginal view of an embryo at 9 weeks’ gestational age by
last menstrual period shows an abnormal embryonic contour (calipers). (B) M-mode shows that the cardiac activity is in the
posterior aspect of the tissue (arrow). Differential diagnosis was hematoma adjacent to the fetal pole or conjoined twins. Follow-
up showed resolution of the mass. There were no abnormalities at birth.
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[28] den Hollander NS, van der Harten HJ, Vermeij-Keers States, 1970 – 1977. Teratology 1982;25:301 – 8.
C, Niermeijer MF, Wladimiroff JW. First-trimester di- [41] Lam YH, Sin SY, Lam C, Lee CP, Tang MH, Tse HY.
agnosis of Blomstrand lethal osteochondrodysplasia. Prenatal sonographic diagnosis of conjoined twins in
Am J Med Genet 1997;73:345 – 50. the first trimester: two case reports. Ultrasound Obstet
[29] Meizner I, Barnhard Y. Achondrogenesis type I diag- Gynecol 1998;11:289 – 91.
Radiol Clin N Am 41 (2003) 695 – 708
Prenatal diagnosis for detection of aneuploidy: the options

Nancy E. Budorick, MDa,*, Mary K. O’Boyle, MDb
a
Department of Radiology, Columbia University, Columbia Presbyterian Medical Center, Milstein Hospital Building 4-156,
177 Fort Washington Avenue, New York, NY 10032, USA
b
Department of Radiology, University of California, San Diego, Medical Center, 200 West Arbor Drive, San Diego,
CA 92103-8759, USA
Remarkable strides have been made in the past age [3] because younger women have constituted
several decades in the area of prenatal diagnosis. This most of the child-bearing population, and only a
development largely has been driven by the evolution minority of trisomy 21 fetuses have been born to
of DNA analysis and changes in the childbearing women aged 35 and older (12.9%) [4]. Current birth
population. Screening tests of serum analytes and records in the United States indicate that there is a
ultrasound technology also have added to the current change in the child-bearing population, however,
complex algorithm that gives the lowest risk assurance with more women bearing children at advanced
of a euploid fetus. This article describes the available maternal age ( 35 years at time of delivery), such
invasive (definitive) and noninvasive (screening) test- that use of maternal age detects approximately 50%
ing that is available to diagnose aneuploidy, with of Down syndrome cases [5].
special emphasis on the role of ultrasound. Besides women aged 35 years or older at time of
delivery, patients at risk for fetal aneuploidy include
women with previous pregnancy complicated by
Background autosomal trisomy, a fetus with one major structural
defect or two or more minor structural defects
Autosomal trisomy is a result of meiotic non- identified at sonography, prior fetus with sex chro-
disjunction, which increases with maternal age, such mosome aneuploidy, parents with a known chro-
that at 35 years of age the inherent midtrimester risk mosomal translocation, parents who carry known
of trisomy 21, Down syndrome (DS), at 1/270, is chromosome inversions, and parents with aneuploidy
similar to the generally quoted rate of pregnancy com- themselves [6].
plication from amniocentesis at 1/200 [1,2]. There-
fore, at age 35 and older, genetic amniocentesis has
traditionally been offered routinely, since the risk of
Invasive testing: definitive detection/exclusion
pregnancy complication from amniocentesis is simi-
of aneuploidy
lar to the risk of carrying a fetus with autosomal
trisomy. Historically, most children with trisomy 21
Amniocentesis is a procedure usually offered
have been born to women younger than 35 years of
between 15 and 20 weeks’ gestation in which amniotic
fluid is removed under direct ultrasound guidance for
culture and cytogenetic analysis. The risk of preg-
nancy complication associated with amniocentesis is
* Corresponding author. Ultrasound – Department of
generally quoted as 1:200 (0.5%) [1,2]. Complications
Radiology, Milstein Hospital Building 4-156, Columbia include amnionitis, [7] rhesus isoimmunization, [8,9],
Presbyterian Medical Center, 177 Fort Washington Avenue, which can be prevented with prophylactic administra-
New York, NY 10032. tion of anti-D immunoglobulin to Rh-negative women,
E-mail address: [email protected] (N.E. Budorick). amniotic fluid leak or vaginal blood loss [10,11],
doi:10.1016/S0033-8389(03)00044-7
696 N.E. Budorick, M.K. O’Boyle / Radiol Clin N Am 41 (2003) 695–708
cramping and lower abdominal discomfort for up to situations in which a karyotype is urgently needed to
8 hours [12], and pregnancy loss [1,2]. Cytogenetic assist pregnancy management.
results are available between 10 and 14 days after the
procedure, and the diagnostic accuracy is more than
99% [13]. Noninvasive testing for aneuploidy
Early amniocentesis is offered between 11 and
13 weeks’ gestation for patients who desire earlier Maternal serum screening in the second trimester
evaluation of karyotype [14 – 17]. The complication
rate is higher than with traditional amniocentesis, Serum biochemical screening in the second tri-
however. The risk of pregnancy loss is 2.5% com- mester yields a higher case detection rate for aneu-
pared with 0.5% to 0.7% with traditional amniocen- ploidy than maternal age screening alone. Maternal
tesis [17]. Risk of talipes may be up to 1.4% over blood is drawn between 15 and 20 weeks’ gestation
that with traditional amniocentesis at 0.1% (back- for serum analyte evaluation. The results from 16 to
ground) [17]. Membrane rupture is more likely with 18 weeks’ gestation are the most accurate. Pregnan-
early amniocentesis, and there are significantly more cies complicated by fetal Down syndrome have
culture failures than with traditional amniocentesis maternal serum alpha-fetoprotein levels that are low
[17]. Because of these factors, early amniocentesis is (0.7 multiples of the median [MoM] or less) [28 – 30].
rarely performed. Human chorionic gonadotropin (hCG) levels are
In chorionic villus sampling, a sample of chorionic elevated (2.04 MoM or more) in fetal Down syn-
villi is removed from the placenta through a plastic drome [31 – 34]. A third serum analyte that is altered
catheter via transabdominal or transcervical approach in fetal Down syndrome is unconjugated estriol,
using ultrasound guidance. This procedure is per- which is also found at lower levels (0.79 MoM or
formed between 10 and 12 weeks’ gestation, so results less) in affected pregnancies [31 – 34].
are available earlier in pregnancy than in routine The relative risk of aneuploidy derived from
amniocentesis. The transcervical route is the most maternal serum screening of these analytes is factored
commonly used approach. The transcervical route with race and diabetic status to modify the maternal
can be used for either anterior or posterior placentas, age-related risk of aneuploidy [34 – 36]. At a 5% or
but there are several contraindications, including more screen-positive rate, these three analytes iden-
the absolute contraindication of an active cervical tify 60% of trisomy 21 in women younger than
infection and several relative contraindications, such 35 years of age. In women older than 35 years of
as vaginal infection, vaginal bleeding or spotting, age, it detects 75% or more of all trisomy 21 cases
extreme anteversion or retroversion of the uterus, and can detect other aneuploid fetuses, because the
and large patient habitus that prohibits access to the screen-positive rate increases with maternal age [37].
uterus or adequate visualization of intrauterine struc- Screen-positive cutoffs are chosen using either the
tures at sonography [18,19]. The transabdominal midtrimester Down syndrome risk of a 35-year-old
approach is used when the placenta is anterior or woman as the screen positive cutoff (1:250) or a
fundal and not easily sampled by the transcervical cutoff that results in an acceptable balance of high
route. The risk of pregnancy loss at 1.1% to 1.3% detection rate and low screen-positive rate (1:190 or
is 0.6% to 0.8% higher than with traditional am- 1:200) [6]. These screening protocols may face future
niocentesis [13,20 – 24]. Oromandibular-limb hy- revision, because they are based on calculations of
pogenesis is more common among chorionic villus risk as determined by the maternal age-related risk of
sampling – exposed infants, especially when per- Down syndrome calculated in the 1980s. Because
formed before 7 weeks’ gestation and less so after current rates of birth to women older than 35 years of
9 weeks’ gestation [24 – 26]. age have increased since the 1980s, the screening
Cordocentesis, or percutaneous umbilical blood premise may be obsolete [6].
sampling, is puncture of the umbilical vein under Multiple-marker screening also can detect 60% to
direct ultrasound guidance for karyotype analysis of 75% of trisomy 18 fetuses. The profile is low levels
the fetal blood cells. This technique has the advantage of all three analytes [38 – 41]. Other aneuploidies are
of available results within 24 to 48 hours, but the rate not detected with great frequency using biochemical
of pregnancy loss is relatively high, reported at less screening; however, those missed are usually lethal,
than 2% [2,27]. This technique is used for various such as trisomy 13, or are sex chromosome abnor-
nongenetic situations (eg, blood transfusion, fetal malities that are not associated with severe mental
blood evaluation). Regarding genetic uses, percuta- retardation or other severe physical or developmental
neous umbilical blood sampling is used for rare limitations [6]. A new and promising serum analyte
N.E. Budorick, M.K. O’Boyle / Radiol Clin N Am 41 (2003) 695–708 697
sonographic abnormality identified. Boxes 1 – 5 list

Box 1. Second trimester ultrasound
structural abnormalities associated with the more
findings in trisomy 21
commonly occurring aneuploidies.
Regardless of the age-based or serum biochemical-
Major structural abnormalities
based risk, a fetus with one or more of the major
structural abnormalities listed in Boxes 1 – 5 is at high
Cardiac defects
risk for aneuploidy. The benefit of undergoing inva-
Cystic hygroma
sive prenatal testing is generally considered worth the
Duodenal atresia
risk of serious complication of the procedure.
Generalized hydrops
Trisomy 21 is the most common of the auto-
somal trisomies, with a reported incidence of 1 in
Minor ultrasound markers
660 newborns [48]. Approximately one third of
affected fetuses have a major structural abnormality
Clinodactyly
on second trimester ultrasound, including cardiac
Echogenic intracardiac focus
anomalies (ventriculoseptal defects and common
Frontal lobe shortening
atrioventricular canals), ventriculomegaly, cerebellar
Hyperechoic bowel
hypoplasia, duodenal atresia (Fig. 1), hydrops, and
Mild ventriculomegaly
omphalocele (Fig. 2) [49 – 53] (see Box 1).
Nasal bone ossification abnormality
Trisomy 18 (Edward syndrome) is the second
Nuchal thickening 6 mm
most common autosomal trisomy at 3 per 1000 live
Pelvic angle widening
Pyelectasis 4 mm
Sandal gap foot deformity
Box 2. Second trimester ultrasound
findings in trisomy 18
recently introduced is dimeric inhibin A [42 – 44].
Inhibin A is generally elevated in pregnancies affec- Major abnormalities
ted by Down syndrome and is abnormally low in
pregnancies affected by trisomy 18. The four-analyte Agenesis of the corpus callosum
combination gives 67% to 76% detection of Down Arthrogrypotic hands/wrists
syndrome in women younger than age 35 [44,45]. Cardiac defects
Cerebellar dysgenesis
Second trimester ultrasound evaluation Clubbed feet
Cleft lip and palate
It is irrefutable that structural anomalies are asso- Cystic hygroma
ciated with aneuploidy. Using this information to Diaphragmatic hernia
determine or recalculate risk of an aneuploid fetus Intrauterine growth restriction
is an issue of controversy, however. The type and Microcephaly
degree of abnormality (major abnormality or minor Micrognathia
abnormality), the a priori risk of carrying an aneu- Neural tube defects
ploid fetus based on serum screening results, maternal Ocular abnormalities
age, or any other risks traditionally have been taken Omphalocele
into consideration when determining risk of fetal Polyhydramnios
aneuploidy. The precise manner in which these fac- Radial ray abnormalities
tors are weighted and used is complex, somewhat Rocker bottom feet
varied, and controversial.
Minor markers
Major ultrasound structural abnormalities
Brachycephaly/strawberry-shaped
Most major organ or structural abnormalities, skull
whether single or multiple, indicate risk for fetal Choroid plexus cysts
aneuploidy [46,47]. Certain abnormalities are more Limb shortening
common in particular types of aneuploidies, and a Single uterine artery
specific diagnosis may be suggested based on the
Box 3. Second trimester ultrasound Box 5. Second trimester ultrasound

findings in trisomy 13 findings in triploidy
Major abnormalities Major abnormalities
Cardiac defects Fetus

Central nervous system abnormalities Cardiac defects
Cystic hygroma Central nervous system anomalies
Facial abnormalities, including cleft lip Club feet
and palate Cystic hygroma
Echogenic kidneys (polycystic) Facial abnormalities, including
Intrauterine growth restriction hypertelorism
Holoprosencephaly Intrauterine growth restriction
Microcephaly Micrognathia
Neural tube defects
Ocular abnormalities Placenta
Omphalocele Hydatidiform placental changes
Polydactyly
Rocker bottom feet
malformation, and most eventually develop intrauter-
Minor markers
ine growth restriction. The typical arthrogrypotic
hand of trisomy 18 yields disordered ossification
Echogenic intracardiac focus
centers of the hand and fingers (Fig. 3). Cardiac
Mild ventriculomegaly
defects, clubfoot (Fig. 4), small omphalocele, and
Pyelectasis
cleft lip (Fig. 5) and palate are also major malforma-
Single umbilical artery
tions frequently seen in trisomy 18 (see Box 2).
Trisomy 13 (Pateau syndrome) has an incidence
of 1 in 5000 births and has a high infant mortality
births. It is more common in female live births by a rate, with most babies surviving less than 1 month
ratio of 3:1, with a multiplicity of associated struc- and few long-term survivors [48]. Major sonographic
tural and sonographic abnormalities [48] (see Box 2). abnormalities are seen in 91% of affected fetuses
Fetuses affected with trisomy 18 frequently die dur- [56]. The characteristic features of midline facial
ing pregnancy or undergo miscarriage. Fetuses car- abnormalities with holoprosencephaly (Fig. 6) are
ried to term usually die during the first year of life, typical sonographic findings. Polydactyly and poly-
with occasional survivors beyond 1 year being pro- cystic kidneys may mimic Meckel-Gruber syndrome.
foundly mentally retarded [48]. Cardiac anomalies and rocker bottom feet also may
Nyberg [54] and Benacerraf [55] have demonstra- be seen (see Box 3).
ted that fetal trisomy 18 largely can be detected Turner syndrome refers to XO karyotype that
sonographically; 80% to 83% of cases have a major results from absence of one sex chromosome. Turner
syndrome occurs in 1 in 200 live-born girls, but it is
estimated that most XO conceptuses result in first
trimester miscarriage. Fetuses that survive to the
Box 4. Second trimester ultrasound second trimester often have large, septated, cystic
findings in Turner syndrome (XO) hygromas [57] (Fig. 7), which variably involve the
entire fetus, with third-spacing in the pleural space,
Major abnormalities the peritoneum, and other potential spaces [58 – 60].
Cardiac anomalies are common [48].
Cardiac defects Triploidy syndrome results from a complete extra
Cystic hygroma set of chromosomes, which occurs in 2% of concep-
Hydrops tuses. In 70% of cases, the extra complement of
Renal anomalies chromosomes is paternally derived, caused either by
Shortened femur double fertilization of an egg or fertilization with a
diploid sperm. Few are the result of fertilization of a
Fig. 1. ‘‘Double bubble’’ appearance in the upper abdomen in a 22-week gestation. (A) The stomach and proximal duodenum are
fluid filled and dilated. (B) The two fluid-filled structures are seen to join, eliminating other diagnostic possibilities. There is
polyhydramnios from the upper tract gastrointestinal obstruction. This is characteristic of duodenal atresia, which may be seen in
trisomy 21.
diploid egg. The most common complement is XXY syndrome [64]. An ultrasound performed for detec-
and most of the rest are XXX. Miscarriage is com- tion of abnormalities that may alter a patient’s a priori
mon and accounts for 20% of abnormal spontaneous risk of aneuploidy is called the genetic sonogram.
abortuses. Toxemia may accompany a triploid preg- Use of minor ultrasound markers has changed
nancy [48]. Triploid fetuses typically have multiple from previously described scoring systems [65 – 69]
major malformations (up to 93% of cases) [61,62] to patient-specific risk adjustment schemata. Nyberg
and may have early-onset asymmetric intrauterine developed a method of risk assignment that is based
growth restriction, so the head may be disproportion- on the specific ultrasound findings combined with the
ately large compared with the body if detected in the a priori age-related risk of aneuploidy. This system is
second trimester [62]. When the extra chromosome called the Age Adjusted Ultrasound Risk Assessment
complement is maternally derived, the placenta is (AAURA) for Down syndrome [70,71]. In the
relatively small and there is severe intrauterine AAURA system, the ultrasound markers are not
growth restriction. When the extra chromosome considered equally but are weighted by the likelihood
complement is paternally derived, the placenta is
large and contains hydropic villi [63].
Minor ultrasound markers
Minor ultrasound abnormalities or minor ultra-

sound markers are abnormalities that are of limited
consequence in and of themselves but may indicate
risk of underlying karyotype abnormality. For the
most part, this category of abnormality is useful in
detection of Down syndrome and includes thickened
second trimester nuchal fold (Fig. 8), shortened
humerus, shortened femur, pyelectasis of 4 mm or
more (Fig. 9), echogenic intracardiac focus (Fig. 10),
hyperechoic bowel (Fig. 11), and mild ventriculome-
galy (Fig. 12) (see Boxes 1 – 3). Choroid plexus cysts Fig. 2. Omphalocele (arrows) in a 21-week gestation.
(Fig. 13) are another minor ultrasound marker, but The anterior abdominal wall defect is between the elec-
they are markers for trisomy 18 and not for Down tronic calipers.
Fig. 3. Arthrogryposis of the hands in a 19-week gestation. Two images, one slightly more volar (A) and one slightly more dorsal
(B), of the same hand demonstrate disarrayed ossification centers of the phalanges (between arrows). This appearance is
characteristic of fixed clenching and overlapping of the fingers that may be seen with trisomy 18.
ratios (of associated aneuploidy) of the individual of those from women aged 35 to 39 years (12.5% false-
sonographic findings. Using AAURA and a thresh- positive rate), and 100% of those from women aged
old of 1:200, 74% of fetuses with Down syndrome 40 years or older (false-positive rate = 0).
were identified overall: 61.5% of those from women Bromley [72] recently published a modification of
younger than 35 years (4% false-positive rate), 67.2% the sonographic scoring index system initially pub-
Fig. 4. Clubfoot in a 20-week gestation, in which there is an

abnormal relationship between the forefoot (short arrow)
and lower leg bones (long arrow), which remains fixed Fig. 5. Cleft upper lip (long arrow) in a 30-week gestation.
during fetal movement. This abnormality may be seen in any Nose (short arrow). Intact lower lip (dashed arrow). This
of the trisomy syndromes. abnormality may be seen in several of the trisomy syndromes.
for most of the markers were calculated as isolated

findings and as part of a multiple marker scheme
[72]. The greatest sensitivity rate for detection of
Down syndrome using this method was 80.5%
(12.4% false-positive rate), and the absence of any
markers decreased the risk of Down syndrome by
80% [72]. Thickened nuchal fold, short humerus, a
major structural abnormality, and any combination of
two minor ultrasound markers carried the most sig-
nificant risks for aneuploidy [72]. Other less formal-
ized scoring systems have demonstrated similar
associations with aneuploidy [73 – 76].
Several articles have described a risk reduction in
women at risk for fetal aneuploidy if the sonogram is
normal, first suggested by Nyberg [77]. In the at-risk
patient population described by Sohl et al [76], the a
priori risk of aneuploidy was 1:26 and the a priori
Down syndrome risk was 1:50. A normal sonogram
Fig. 6. Alobar holoprosencephaly in a 21-week gestation.
There is a monoventricle (arrows) with fused thalami reduced these risks to 1:67 and 1:120, respectively
(dashed arrows). [73]. Similar findings were demonstrated by Vergagni
[78], Bahado-Singh [79], Vintzileos [76], and Brom-
ley [72].
lished by Benacerraf [65 – 69]. In an evaluation of Various reviews have resulted in controversy re-
10 years worth of data, likelihood ratios of the differ- garding the use of ultrasound to assess and modify
ent sonographic markers were derived. Each patient’s risk for aneuploidy. Published likelihood ratios are
risk adjustment is achieved through Bayes Theorem: not entirely consistent, and practitioners are left with
a priori risk multiplied by the likelihood ratio yields a dilemma as to which likelihood ratios to use. The
the revised risk, and amniocentesis is offered when use of an isolated minor ultrasound marker in the risk
the revised risk is 1:270 or more. Likelihood ratios adjustment of a previously low-risk patient also may
Fig. 7. Large, septated cystic hygroma in a Turner syndrome (XO) fetus in an 18-week gestation. (A) Longitudinal image dem-
onstrates bulging, septated cystic hygroma in the neck region (arrows). (B) Axial image demonstrates the nearly circumferential
nature of this cystic hygroma (large arrows), with only sparing of the anterior chest skin (small arrows). Bilateral pleural
effusions are identified in the apical thoracic spaces bilaterally (*). (C) There also is ascites, surrounding suspended bowel loops
(arrow) and liver (dashed arrow).
isolated sonographic markers are not a complete

surprise. The management of an otherwise low-risk
patient with an isolated ultrasound marker has long
been and remains controversial. Risk modification for
aneuploidy with the use of multiple ultrasound
markers and the use of ultrasound markers in con-
junction with major fetal structural abnormalities,
biochemical screening, and maternal age are prudent
[82]. A fundamental issue that is still in question is
the assumption that maternal biochemical and sono-
graphic markers are independent variables of aneu-
ploidy risk assessment [82]. This assumption never
has been proven, however [81], and only if these are
independent screening variables can one be used ac-
curately to change the risk based on the other [81].
Fig. 7 (continued).
The presence of a choroid plexus cyst (see Fig. 13)
raises the risk for trisomy 18 but not Down syndrome
result in a significant number of patients with false- [64]. The incidence of choroid plexus cyst in the
positive results who consequently undergo substantial general population is 1.4%, and the incidence of
anxiety [80] and potential fetal loss if invasive testing choroid plexus cyst in fetuses with Down syndrome
is elected [81]. is also 1.4% [64]. Choroid plexus cysts are seen in
The conclusions reached by Smith-Bindman in a at least 25% to 30% of trisomy 18 fetuses [54,55].
recent metaanalysis of published ultrasound literature Some authors report association of cyst size ( > 1 cm)
regarding this subject surprised the ultrasound com- [83] and bilaterality [84] with a higher risk of trisomy
munity by putting forth a serious challenge to current 18, whereas other authors report no higher asso-
practices of risk modification based on ultrasound ciation with either cyst size or bilaterality [55,85].
findings [81]. In this comprehensive review, 56 ar- Management of a previously low-risk patient with an
ticles that described 1930 fetuses with Down syn- isolated choroid plexus cyst is somewhat controver-
drome and 130,365 unaffected fetuses were analyzed. sial. It is generally agreed that if an isolated choroid
Sensitivities for detection of Down syndrome of the plexus cyst is identified at sonography, however,
minor ultrasound markers were grossly inconsistent correlation with biochemical markers, maternal age,
across the different studies included in the metaanal-
ysis. The differences in accuracy were not caused by
threshold differences among the studies, year of
study, study design (case control versus prospective
study), risk of the patients, or setting of the study. The
most important variable that explained the extreme
variation of all the markers was whether the minor
ultrasound findings were isolated or non-isolated, and
most of the reported accuracy of minor ultrasound
markers in the various studies was the result of the
associated abnormalities in fetuses with non-isolated
findings. The conclusions from this metaanalysis,
however, are limited regarding the global use of
ultrasound to modify risk assessment for aneuploidy,
because the analysis only addressed minor ultrasound
markers seen in isolation. Minor ultrasound markers
seen in isolation were found not to be helpful in either
confirming or excluding Down syndrome, with the
exception of a thickened nuchal fold, which was Fig. 8. Nuchal fold thickening at 19 weeks’ gestation. Axial
associated with a 17-fold increased risk of Down image through the posterior fossa and neck demonstrates
syndrome [81]. a normal cisterna magna measurement (electronic caliper
Although the study raised much controversy in the ‘‘ +’’) at 4.6 mm and an abnormally thickened nuchal fold at
ultrasound community, the conclusions regarding 7.1 mm (electronic caliber ‘‘x’’).
Fig. 9. Pyelectasis at 16 weeks’ gestation. (A) In the axial image through the fetal kidneys, the anterior-to-posterior dimension is
measured (electronic ‘‘ +’’) and was more than 4 mm bilaterally. (B) In the coronal image, the configuration is that of a dilated
renal pelvis without caliectasis (arrows).
Fig. 11. Sagittal view of the fetal abdomen at 17 weeks’

Fig. 10. Echogenic intracardiac focus at 22 weeks’ gestation. gestation demonstrates a focally hyperechoic area (arrow)
There is a focal bright spot in the left cardiac ventricle in the expected location of the fetal bowel. (Dashed
(arrow) on the four-chamber view of the heart. arrow = stomach.)
(5.5% false-positive rate) [90], which is comparable

to second trimester serum screening. The problem
with these analytes is that free beta-hCG may not be
higher in Down syndrome fetuses compared with
euploid fetuses until 12 weeks’ gestation, and
PAPP-A loses its discrimination value after 13 weeks’
gestation [91].
First trimester ultrasound evaluation
Nuchal translucency refers to the normal clear area

in the fetal neck seen in early pregnancy that lies
between the skin and the soft tissues overlying the
Fig. 12. Mild ventriculomegaly at 21 weeks’ gestation. cervical spine. Nuchal translucency should be mea-
The ventricular atrium (electronic calipers ‘‘ +’’) measured sured with the fetus in a neutral position and in the
13 mm.
sagittal plane. With magnification, the fetus should
occupy at least three quarters of the image. Care
and other sonographic abnormalities is necessary should be taken to distinguish fetal skin from the
to determine whether invasive testing should be of- amnion. The proper nuchal translucency measurement
fered [64,86,87]. is the maximum thickness between the inner skin echo
and the most posterior echo of the neck soft tissues
(Fig. 14). Nuchal translucency is generally only used
First trimester screening between 11 and 14 weeks’ gestation. Ultrasound
measurement of nuchal translucency has been shown
Maternal serum screening in the first trimester to distinguish normal from abnormal gestations
[92 – 94]. The combined use of nuchal translucency
Much work has been done on serum analyte measurement and maternal age identifies 27% to 89%
testing in the first trimester for Down syndrome, of Down syndrome pregnancies with a screen positive
but the results are controversial. The best ana- rate of 2.8% to 9.3% [91]. Nuchal translucency
lytes from 11 to 14 weeks are free beta-hCG and increases with gestational age [95]. Use of multiples
pregnancy-associated plasma protein A (PAPP-A) of the median data (for gestational age) can help
[88,89]. Affected Down syndrome pregnancies have provide patient-specific risk when a nuchal trans-
a median-free beta-hCG of 1.79 MoM and a me- lucency measurement is obtained.
dian PAPP-A of 0.43 MoM. The combination of A newer and promising phenomenon recently
maternal serum analyte results and maternal age described by Cicero in the 11- to 14-week period is
gives a detection rate of 63% for Down syndrome absent nasal bone ossification, which in preliminary
Fig. 13. Multiple, confluent choroid plexus cysts in a Fig. 14. First trimester gestation with nuchal fold measure-
16-week fetus with trisomy 18. ment (electronic calipers ‘‘ +’’).
studies seems to have high specificity for Down determined. The goal of second trimester ultrasound
syndrome [96]. screening is to identify at-risk fetuses better and offer
invasive testing to a more select group of patients. As
Combined first trimester screening approach the value of first trimester screening becomes more
evident and practical, and if the risk of chorionic
The National Institutes of Health has funded a villus sampling becomes an acceptable norm, the
prospective, multicenter trial to evaluate first trimes- patient population that reaches the second trimester
ter screening that combines nuchal translucency of pregnancy will be select. Therefore, we can antici-
measurements with biochemical markers and mater- pate that second trimester screening and invasive
nal age a priori risk, called the First and Second testing may be needed only in a minority of cases,
Trimester Evaluation of Risk trial. In this study, and the practice standards of prenatal testing and
first trimester nuchal translucency measurement, sonography (including minor ultrasound markers)
PAPP-A and free beta-hCG levels, and maternal age will change entirely.
are factored to determine risk for Down syndrome. In
the second trimester, the same patients are reeval-
uated as a control. The second trimester evaluation
consists of screening with the four serum analytes References
(free beta-hCG, alpha-fetoprotein, unconjugated
[1] Hook EB, Cross PK, Schreinemachers DM. Chromo-
estriol, and dimeric inhibin A) and maternal age to
somal abnormality rates at amniocentesis and in live-
calculate risk of trisomy 21, trisomy 18, and neural born infants. JAMA 1983;249:2034 – 8.
tube defect. The results of this and other similar [2] Gardner RJM, Sutherland GR. Prenatal diagnostic pro-
trials will determine how first trimester screening cedures. Oxford Monographs on Medical Genetics
compares with second trimester screening and how 1996;29:336 – 44.
first trimester screening is ultimately implemented in [3] Shah YG, Eckl CJ, Stinson SK, Woods Jr JR. Bi-
this country. parietal diameter/femur length ratio, cephalic index,
and femur length measurements: not reliable screening
techniques for Down syndrome. Obstet Gynecol 1990;
Summary 75:186 – 8.
[4] Ventura SJ, Martin JA, Curtin SC, Mathews TJ, Park
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Radiol Clin N Am 41 (2003) 709 – 727
Complications of monochorionic twins

Vickie A. Feldstein, MD*, Roy A. Filly, MD
Department of Radiology and of Obstetrics, Gynecology and Reproductive Sciences, University of California,
San Francisco, Medical Center, Box 0628, 505 Parnassus Avenue, Room L-374, San Francisco, CA 94143-0628, USA
Morbidity and mortality are significantly increased Embryology of twin placentation

in twin gestations compared with singleton pregnan-
cies [1]. Among twin pregnancies, the relative risk of Twin pregnancies result either from fertilization of
complications depends on whether each fetus is two ova (dizygotic) or from fertilization of a single
attached to its own placenta (dichorionic [DC]) or ovum with subsequent cleavage (monozygotic).
must share a placenta (monochorionic [MC]). The Dizygotic twins are more common (70%) than mono-
relative increase in risk of MC compared with DC zygotic twins (30%). All dizygotic twins have DC
twin pregnancies is of a magnitude similar to that of placentation, and all DC twins are diamniotic. Mono-
twin compared with singleton pregnancies. MC twins zygotic twins may be either DC (25%) or MC (75%)
have a higher prevalence of growth retardation and depending on the embryologic stage at which cleav-
death compared with DC twins, and several unique age occurs [6].
and threatening syndromes occur only in MC gesta- Unfortunately, two discrete placentas cannot al-
tions [2]. The high risks of MC twin gestations are ways be identified, even on gross pathologic inspec-
largely related to the vascular anatomy of the shared tion after the birth of DC twins. Occasionally, two
placenta and the presence of intertwin vascular developing placental masses abut and fuse; therefore,
connections. These anastomoses are implicated in a single placental mass is identified.
twin-twin transfusion syndrome (TTTS) and co-twin For monozygotic twins, the stage at which cleavage
sequelae after intrauterine demise of one twin. Only occurs determines the chorionicity and amnionicity of
MC twins can be monoamniotic. If the fetuses share the pregnancy. Dichorionicity occurs in approximately
a placenta and an amniotic cavity, they face a high 25% of monozygotic twins. For monozygotic twins to
risk of mortality [3,4]. be DC, division must occur before the fourth day after
The identification of a MC twin pregnancy has fertilization. If division occurs between the fourth and
important obstetric implications, some of which eighth days after fertilization (the blastocyst has
influence pregnancy management and limit certain formed, but the amnion is not yet developed), then
treatment options. The sonographic examination of MC diamniotic twins result. This occurs in approxi-
all twin pregnancies should include a specific effort mately 75% of MZ twin pregnancies.
to determine chorionicity and amnionicity [5]. Before Rarely, cleavage occurs after the eighth day after
considering the sonographic features useful in the fertilization—after the chorion and the amnion al-
prediction of chorionicity and amnionicity, it is ready have formed—and the twins share not only a
helpful to review the embryology of placentation in placenta but also a single amniotic cavity (mono-
twin pregnancies. amniotic). If division occurs after formation of the
amnion, the structure that cleaves is the embryonic
disc. If division of the embryonic disc is incomplete,
* Corresponding author. various degrees of twin conjoining result.
E-mail address: [email protected] Knowledge of the embryologic sequence is im-
(V.A. Feldstein). portant in understanding the imaging manifestations
doi:10.1016/S0033-8389(03)00046-0
710 V.A. Feldstein, R.A. Filly / Radiol Clin N Am 41 (2003) 709–727
of twin placentation, amnion formation, and some of

the unique syndromes seen in twins. Because all
dizygotic twins result from the implantation of two
blastocysts, all such twins must be DC. Only mono-
zygotic twins can have MC placentation. Because
placental formation precedes amnion formation, all
DC twins are also diamniotic. Conversely, all mono-
amniotic twins must be MC, and all conjoined twins
also must be monoamniotic and MC. No other em-
bryologic possibilities can occur.
Judging chorionicity and amnionicity

by sonography
Dizygotic twins are the more common twin type,

and all have DC placentation [1]. 25% of monozy- Fig. 1. Dichorionic twin pregnancy. Placental tissue (P) is
gotic twins also are DC. Approximately half of DC seen anterior and posterior. The amniotic and chorionic
placentas are fused along their border, and it may not layers have not yet fused; thus, the layers of the dichorionic
diamniotic intertwin membrane are visible (arrows).
be possible to identify two discrete placental masses.
The sensitivity of sonographic visualization of two
placentas in detecting dichorionicity is low; however, (fused) or MC. The next and simplest step to take
when two placentas are seen, dichorionicity can be in this circumstance is to determine fetal gender (see
predicted reliably (Table 1) (Fig. 1) [7]. Table 1). If one can show convincingly that one of the
Similarly, if a membrane is identified separating the twins is male and the other is female, then dizygocity
twins, diamnionicity can be predicted. In 90% of is confirmed and dichorionicity and diamnionicity
diamniotic pregnancies, a separating membrane can may be inferred with certainty (Fig. 2). Unfortunately,
be identified sonographically [8]. The visualization of if a single placental mass is seen and the twins are of
a membrane permits accurate prediction of diamnio- the same gender, zygosity remains uncertain and
nicity, but the inability to identify a membrane that chorionicity cannot be predicted.
separates the fetuses of a twin pregnancy is insufficient The membrane that separates the twins consists of
evidence to diagnose a monoamniotic twin pregnancy. two layers of amnion in a MC diamniotic twin
If a single placental mass is identified sonograph- pregnancy, whereas two layers of amnion plus two
ically, it is uncertain whether the placenta is DC layers of chorion separate the twins in a fused, DC
Table 1
Sonographic prediction of chorionicity and amnionicity
Sonographic findings Clinical/pathologic findings
Placental masses Membrane Twin genders Chorionicity amnionicity Zygosity
2 Yes Differ DC/DA DZ
2 Yes Same DC/DA Either
1 Yes Differ DC*/DA DZ
1 Yes Same DC*/DA Either
MC/DA
Thicka DC*/DA Either
Thina MC/DA MZ
1 Not seen Same Uncertain Either
(Stuck twinb) MC/DA MZ
(Entangled cord) MC/MA MZ
Abbreviations: DC, dichorionic placentation (nonfused); DA, diamniotic; DZ, dizygotic; DC*, dichorionic placentation (fused);
MC, monochorionic placentation; MA, monoamniotic; MZ, monozygotic.
a
For membrane thickness, probability of correct prediction is highest early in pregnancy.
b
Membrane present, although it may not be seen.
V.A. Feldstein, R.A. Filly / Radiol Clin N Am 41 (2003) 709–727 711
Fig. 2. (A) This twin is female. (B) This twin is male. This is a dizygotic—and necessarily dichorionic—diamniotic
twin pregnancy.
diamniotic twin pregnancy. Because of the additional weaknesses of the membrane thickness approach is
layers, the DC membrane is thicker than the MC the lack of a strict definition regarding what con-
membrane. It is theoretically and practically possible stitutes a thick versus a thin membrane. With in-
to determine chorionicity on the basis of the thickness creasing gestational age, membranes also become
of the visualized membrane (Fig. 3) [7,8]. One of the progressively thinner in appearance. Judgment of
Fig. 3. First trimester obstetric sonograms with comparison of membrane thickness. (A) In this case, a thick membrane (arrow) is
seen, which indicates dichorionic—and therefore diamniotic—gestation. (B) In comparison, a thin intertwin membrane (arrow)
is seen in this monochorionic diamniotic pregnancy. This thin membrane represents two opposing layers of amnion.
membrane thickness is always more accurate early Monochorionic twin syndromes

in pregnancy.
Although in some cases of MC diamniotic preg- Determining that twins are MC is important
nancy a membrane may not be visualized because it because of the extraordinary unique risk inherent in
is thin and wispy, in others it is not visualized because such pregnancies. When twins are MC, the probability
of its close apposition to the fetus in one amniotic sac. is high (85% – 100%) that the fetuses share vascular
This is caused by an abnormal volume of amniotic anastomoses at the placental level [3,11,12]. The high
fluid within the sac. This important phenomenon is risks of MC twin gestations are largely related to the
discussed in greater detail later. vascular anatomy of the shared placenta and the
The membrane that separates a DC placenta con- presence of intertwin vascular connections. These
tains fused chorionic leaves. Because chorion is anastomoses are implicated in several syndromes,
contained in the membrane, it is possible for cho- which can complicate MC pregnancies and are dis-
rionic villi to grow into the junction of the membrane cussed in detail later.
with the fused placental masses. This phenomenon
creates a distinctive appearance of the membrane Placental vascular anatomy
base, which Finberg has dubbed the ‘‘twin peak’’
sign (Fig. 4) [9]. Like other membrane-related signs Almost all MC placentas demonstrate intertwin
of fused DC placentation, this sonographic feature, vascular connections on postpartum placental injec-
when present, is most useful early in pregnancy. tion studies (Fig. 5) [11 – 13]. Three types of inter-
Recently, the accuracy of antenatal prediction of twin vascular connections can occur. Arterio-arterial
chorionicity in twin pregnancies was reported [10]. (A-A) anastomoses are frequent, direct, end-to-end
Antenatal chorionicity was determined using the connections on the placental surface. They do not
number of placental masses, the presence or absence communicate with the placental parenchyma. A-A
of a twin peak sign, and fetal gender. Chorionicity anastomoses are present in 75% of MC placentas,
was correctly determined in 95% of cases (91% of the and there is seldom more that one such connection per
MC and 96% of the DC pregnancies). If chorionicity placenta. Detection of A-A anastomoses by means of
was assessed before 14 weeks’ gestation, the correct Doppler ultrasound (US) findings has been reported
diagnosis was made in all except one case. Deter- [14]. A-A anastomoses are confirmed by means of
mination of chorionicity and amnionicity is impor- characteristic bidirectional pulsatile spectral Doppler
tant, is most reliable when done early in pregnancy, waveforms (Fig. 6). The demonstration of an A-A
and should be addressed in the initial sonographic anastomosis indicates, with certainty, monochorion-
examination of all twin pregnancies. icity. Veno-venous anastomoses that are seen in ap-
proximately 5% of MC placentas, and have not been
detected by US, also are direct end-to-end connections
coursing on the fetal surface of the placenta.
Arteriovenous (AV) anastomoses are a common
form of intertwin vascular connection and are impli-
cated as a causative mechanism in the development of
TTTS. AV anastomoses occur deep within the pla-
cental parenchyma and do not manifest abnormal
pathognomonic spectral Doppler waveforms. How-
ever, based on observations made at post-partum
placental injection studies, the characteristic anatomic
configuration of AV anastomoses has been delineated.
Normally, in singleton and twin gestations, an artery
and a vein are paired and are found along the fetal
surface of the placenta, emanating from and returning
to the fetal cord insertion site. An AV anastomosis is
referred to as a deep connection for it is within the
Fig. 4. Fused placental masses (P) in a posterior mono-
placental parenchyma, and not via a direct superficial
chorionic diamniotic twin pregnancy. Triangular wedge of connection on the surface of the placenta, that blood
chorionic tissue is shown protruding into the base of the passes from an arterial branch of one twin, across the
intertwin membrane (arrows), referred to as the ‘‘twin capillary bed of the cotyledon, into a draining venous
peak’’ sign. branch of the other twin. Placental injection studies
have shown that the feeding arterial and draining or decreased) amniotic fluid volume in the co-twin
venous components of an AV anastomosis approach sac can be the result of many causes, but is not a
each other along the placental surface ‘‘unpaired.’’ manifestation of TTTS. Concomitant oligohydram-
They abut ‘‘nose to nose’’ on the surface where they nios and polyhydramnios in a MC twin pair are the
dive through a common foramen to supply blood requisite sonographic findings for the diagnosis of
to and drain blood from a single shared cotyledon TTTS (Fig. 12).
(Fig. 7). They are distinguished from a normal artery/ It is critically important to be as certain as possible
vein pair not by unusual blood flow patterns or that twins are MC before the diagnosis of TTTS is
spectral Doppler waveforms, but by their distinctive suggested. If sonographic findings confirm dichorio-
anatomic configuration [15,16] (Fig. 8). nicity because of different genders of the twins, the
ability to identify two placental masses, early con-
Unequal placental sharing firmation of two gestational sacs, the ‘‘twin peak’’
sign, or a thick membrane, then a diagnosis of TTTS
Detailed US examination of twin pregnancies should not be made, regardless of other features that
should include biometric assessment and determina- may suggest it.
tion of estimated fetal weight (EFW). It is helpful In addition to monochorionicity, other sonog-
to calculate the percent discordance [(larger EFW - raphic findings must be present before TTTS can be
smaller EFW)/larger EFW 100] between MC diagnosed [18,19]. There is a discrepancy in volume
twins. Discordance is often caused by unequal paren- status and urine production between the twins; the
chymal sharing of the placenta, with one twin having recipient often has a distended bladder and the donor
a marginal/velamentous cord insertion and a small has a small or—in some cases—not visible urinary
parenchymal share, while the larger twin has a more bladder, despite the presence of kidneys. As a result,
central cord insertion [17] (Fig. 9). The smaller twin there is a visible disparity in the amount of amniotic
may be growth restricted and develop oligohydram- fluid surrounding each twin. This condition is often
nios, but this condition should not be diagnosed as accompanied by significant disparity in the size of
TTTS. US assessment of placental sharing may be the twins. Most often, one twin (the recipient) is
gleaned by demonstrating the cord insertion sites into normal sized or nearly so and the other (the donor) is
the placenta (Fig. 10). Discordant twins, without small and commonly satisfies the established crite-
evidence of TTTS, warrant close surveillance, but ria for intrauterine growth retardation. Alternatively,
rarely is therapeutic intervention indicated. the predicted weight of the smaller twin may not
be less than the tenth percentile for gestational age
Twin-twin transfusion syndrome but may be discordantly small compared with the
larger twin.
Twin-twin transfusion syndrome results from With TTTS, the disparity in the volume of amni-
intrauterine vascular shunting between the circula- otic fluid can progress to extremes, in which one twin
tions of twins who share a placenta, and it is the most is in a markedly polyhydramniotic sac and the other
common complication of MC twinning, occurring in is in a virtually anhydramniotic sac. The appearance
approximately 10% to 20% of MC twin pregnancies of this extreme disparity has come to be known as the
[2,12,13,18]. Via intertwin vascular connections, ‘‘stuck twin’’ sign [21,22]. The ‘‘stuck twin’’ phe-
blood is transfused from the donor, who becomes nomenon originally was described within the context
growth restricted and develops oligohydramnios, to of proving diamnionicity when no membrane was
the recipient, who develops circulatory overload and sonographically visible. One fetus of a twin pair
responds with polyuria, which results in polyhy- moved freely within a normal or increased amount
dramnios. The sonographic demonstration of oligo- of amniotic fluid, but the other fetus resided in a
hydramnios/polyhydramnios in a MC twin pair is position adjacent to the lateral or anterior uterine wall
indicative of TTTS (Fig. 11) [19]. Often, but not al- (Fig. 13). Changes in position of the pregnant woman
ways, there is also discordance in fetal size between failed to show an appropriate gravitational response
the smaller donor and larger recipient twin. The dif- by the ‘‘stuck twin,’’ which indicated that the fetus
ference in fetal size is often, at least in part, a re- was held in place by an unapparent membrane. Once
flection of unequal placental sharing. The donor twin convinced that the fetus is being held in place by a
often has a velamentous, marginal, or eccentric cord membrane, searching the margins of the fetus often
insertion site, and the recipient has a more central one discloses the membrane (Fig. 14). Since its original
[20]. It is important to remember that normal amni- description, it has been noted that the ‘‘stuck twin’’
otic fluid volume in one sac and abnormal (increased phenomenon occurs most commonly with TTTS.
Fig. 5. Postpartum placental injection specimen from a Fig. 7. This monochorionic twin placental vascular injection
monochorionic pregnancy. The vessels within the umbilical study shows an arteriovenous anastomosis with blood flow
cord of each twin (a, b) are cannulated and injected with dye. in the direction of the arrows, from donor (A) to recipient
This specimen shows multiple vascular connections between (b). The arterial (A) and venous (V) limbs of this anas-
the twins’ circulations. tomosis have a characteristic configuration. Also shown are
normal arterial/venous pairs for each twin (arrowheads).
Fig. 9. Unequal placental sharing. Twin A (a) has a large

cord that is centrally inserted into the shared monochorionic
placenta. Twin B (b) has a small cord with a velamentous
insertion and small placental share. The dotted line
delineates the placental equator, which roughly defines the
Fig. 8. Color Doppler sonogram of an arteriovenous placental territory perfused by each twin. Intertwin vascular
anastomosis with flow in the direction of the arrows. There connections occur at this level and cross this plane.
is pulsatile flow in the afferent arterial limb (A) from the
donor and continuous monophasic flow in the efferent
venous limb (V) toward the recipient.
Fig. 10. Color Doppler sonograms show cord insertion sites into the shared anterior monochorionic placenta. (A) Central cord
insertion site for this twin. (B) Eccentric, almost marginal cord insertion site at the lateral aspect of the placenta for this twin.
Fig. 6. (A) Overview and (B) close-up photograph of an injection study of a monochorionic placenta. The umbilical cord of each
twin (a, b) was injected. Their vascular connections include a superficial arterio-arterial anastomosis on the placental surface,
with flow in the direction shown (arrows). Also shown are examples of normal arterial/venous pairs for each twin (arrowheads).
(C) Spectral Doppler waveform of an arterio-arterial anastomosis with characteristic bidirectional pulsatile flow.
Fig. 13. (A) Severe twin-twin transfusion syndrome. There is marked polyhydramnios of the recipient twin (R) and marked
oligohydramnios of the donor twin (D), which appears ‘‘stuck’’ adjacent to the anterior uterine wall. (B) Color Doppler sonogram
through the pelvis of the stuck twin shows flow in the umbilical arteries, flanking an empty urinary bladder (*).
Fig. 17. Twin reversed arterial perfusion sequence. (A) Color Doppler sonogram shows close proximity of the two umbilical cord
insertion sites at the shared anterior placenta. Flow direction (arrow) within the umbilical artery (a) of the acardiac twin is
reversed. (B) Reversed umbilical arterial blood flow, away from the placenta and toward the abdomen, is shown on spectral
Doppler interrogation of the acardiac twin.
compared with 5% in which an A-A anastomosis was

found [23]. In the rare instances in which TTTS
develops despite the presence of an A-A anastomosis,
better outcomes have been reported [25 – 28]. This
information about placental vascular anatomy can be
used to understand the variability of pregnancies
complicated by TTTS and may help explain the
difference in response to therapy.
Twin-twin transfusion syndrome is a progressive
disorder with reported fetal mortality rate of more
than 90% if not treated. Without treatment, the
recipient twin may decompensate and develop hy-
drops (Fig. 15). TTTS is associated with a high risk
of miscarriage, perinatal death, and subsequent mor-
bidity that involves multiple organ systems in survi-
vors [29]. Donor and recipient twins are at risk.
Morbidity among survivors may include cardiac,
Fig. 11. Twin-twin transfusion syndrome. There is oligohy- renal, and serious neurologic impairment, especially
dramnios of the donor (D), which is ‘‘stuck’’ in the if there is in utero death of the co-twin [30]. Clinical
nondependent portion of the uterus, and polyhydramnios management of pregnancies complicated by TTTS is
of the recipient (R) in this monochorionic twin pair. one of the most difficult problems in obstetric prac-
tice, and there is ongoing controversy regarding this
issue. Because of the high morbidity and mortality
Wide variation in the manifestations of TTTS, rates for this complicated condition, various aggres-
including the gestational age at presentation, acuity sive and unusual therapies have been tried. The op-
of onset, and severity, has been observed, probably tions for obstetric management include pregnancy
reflecting the particular vascular anatomy, which is termination, amnioreduction, septostomy, selective
unique in each case. Researchers have theorized that fetal termination and, most recently, laser coagulation
the occurrence, range in manifestations, and course of of placental vessels.
TTTS in MC twin gestations relates to the particular
intertwin vascular connections within the shared
placenta. Several studies have revealed that the angio-
architecture of the MC placenta is related to and
responsible for the development of TTTS, the re-
sponse to treatment, and the outcome [23 – 28].
Twin-twin transfusion syndrome results from net
transfusion across an AV connection, from donor to
recipient, in the MC placenta [11,13]. Most MC
placentas demonstrate complicated anatomy with
multiple bidirectional connections, including A-A
anastomoses that prevent net transfusion. If trans-
fusion via an AV anastomosis is not compensated by
other vascular connections, which allow for return of
blood from recipient to donor, TTTS develops. The
median number of anastomoses in placentas from
pregnancies with TTTS is significantly less than in
placentas without TTTS. The anastomoses in the
TTTS group are significantly more likely to be of
AV than superficial (A-A or veno-venous) type [25].
The absence of an A-A anastomosis is associated Fig. 12. Twin-twin transfusion syndrome shown on a dual-
with a greater risk of developing TTTS, and the array sonogram. The donor twin (B) is located anteriorly
presence of an A-A anastomosis is protective within an oligohydramniotic sac, and the recipient twin (A)
[23,25 – 28]. TTTS was diagnosed in 58% of preg- is dependent within a polyhydramniotic sac. The recipient is
nancies in which no A-A anastomoses were detected, hydropic, with ascites (*).
Fig. 14. (A) The donor twin in this case of twin-twin transfusion syndrome is ‘‘stuck’’ within an anhydramniotic sac, closely
adherent to the anterior uterine wall. (B) Careful sonographic evaluation along the margins of the stuck donor twin reveals a thin
intertwin membrane (arrow) in this monochorionic diamniotic gestation.
Some cases of TTTS respond to serial, large- reported to be associated with an improved outcome
volume amniocenteses of the polyhydramniotic sac, for both twins [35]. In one series, the reaccumulation
and an overall survival rate of 50% to 60% has been of urine in the bladder of the ‘‘stuck’’ twin after
reported with this technique [31 – 34]. The mech- amniocentesis was a predictive prognostic marker
anism by which large-volume amnioreduction works of survival in both twins, with sensitivity and spec-
is not well understood. Some cases have demonstra- ificity rates of 100% [36]. Researchers have sug-
ted dramatic response after amnioreduction, with gested that this response results from the presence
demonstration of increased urine production and of compensatory connections which allow for blood
filling of the donor bladder on short-interval (ap- to return from recipient to donor, in addition to at least
proximately 24-hour) follow-up US (Fig. 16). The one causative AV anastomosis. The returning flow
presence of improved fluid volume within the donor may be improved as a result of the amnioreduction
sac with continued empty donor bladder may be seen procedure. In some cases, however, no such response
as a result of intentional or inadvertent septostomy. is seen, and alternate therapy could be considered for
The presence of a well-visualized donor bladder these twins.
can be considered a manifestation of ‘‘response’’ to Laser photocoagulation of the placental vascular
amnioreduction, however. Such response has been anastomoses has been advocated by several authors as
Fig. 15. Twin-twin transfusion syndrome with hydrops of the recipient twin. (A) Coronal sonogram through the abdomen reveals
ascites (arrow). (B) Transverse image through the chest shows an enlarged heart with a small pericardial effusion (arrow).
Fig. 16. (A) After large volume amnioreduction for twin-twin transfusion syndrome, fluid (*) is seen within the amniotic sac of
the donor twin (D). The thin intertwin membrane is visible (arrow). (B) Urine is seen within the donor bladder (arrow). Before
the procedure, the donor twin had appeared ‘‘stuck’’ with an empty bladder.
a more direct, definitive therapy that targets the caus- tions with fetoscopic guidance may be of greatest
ative mechanism [37 – 42]. Some investigators elect to need and benefit.
coagulate all vessels seen crossing the interfetal sep- Significant potential complications of TTTS are
tum, whereas others aim to coagulate only the interfetal demise and brain pathology of survivors. As-
twin communicating vessels by distinguishing them at sessment also can include MR imaging of the fetal
fetoscopy from appropriate arteriovenous pairs con- brain before and after intervention for TTTS. In utero
nected to only one twin [41,42]. MR imaging to assess for the presence of sonograph-
There are ongoing trials and recent reports of out- ically occult parenchymal brain injury also is particu-
comes from TTTS treated with amnioreduction com- larly helpful if there has been demise of one of a MC
pared with laser. In one series, the overall fetal survival twin pair. This application is discussed further in the
rate was not significantly different between cases following section on twin embolization syndrome.
treated with fetoscopic laser coagulation compared Because of the high mortality and frequently rapid
with serial amniocenteses (61%, 89/146, verses 51%, onset of severe TTTS, a high index of suspicion is
44/86; P = 0.239) [43]. Some reports of therapy for needed whenever a MC twin pair is identified. Even
TTTS do not distinguish severity, or they use amnio- an apparent minor degree of fluid imbalance between
reduction or laser photocoagulation exclusively. It is the amniotic sacs is an indication for careful short-
possible that neither therapy is optimal for all cases. term sonographic follow-up.
These therapies perhaps should be viewed not as
alternative or rival methods of treatment. Rather, it is Twin embolization syndrome
postulated that the treatment algorithm should rely on
careful sonographic assessment and observation of A rare complication of MC pregnancy follows the
response to treatment in sequence. Large-volume in utero demise of one twin [44 – 47]. Benirschke [3]
amnioreduction can be used as a therapeutic maneuver noted a case of hydranencephaly, splenic infarction,
and as a diagnostic one. If response is observed by US and bilateral renal cortical necrosis in a surviving
(if increase in size of donor bladder is observed monozygotic twin in which the co-twin had died in
24 hours after amnioreduction), the pregnancy could utero. He theorized that the infarcted organs in the
be observed carefully with US surveillance. If there is surviving twin resulted from transfusion of thrombo-
no response to amnioreduction, it is postulated that plastin-rich blood from the dead twin to the live co-
compensatory returning vascular connections are twin through the vascular anastomoses in the shared
absent or inadequate. For such pregnancies, selective placenta. Researchers also have theorized that clot
laser photocoagulation of intertwin vascular connec- or detritus from the dead twin embolizes into the
circulation of the surviving twin. Alternatively, the is not well known or understood. MRI can help assess
cessation of cardiac activity and the loss of vascular for the presence of brain injury that resulted from in
tone in the dead co-twin may result in a large amount utero events, which may be occult by US.
of blood volume entering the dead twin from the sur- It is likely that immediate injury is triggered by
viving twin. This extra volume may result in exsan- co-twin demise and that severe, irreversible damage
guination or profound hypotension. has occurred by the time the imaging abnormalities
More recently, researchers have postulated that are apparent. Outcomes are probably not improved by
rather than actual embolization, the injury suffered by triggering immediate preterm delivery of the surviv-
the surviving fetus after the in utero death of one of a ing fetus. Monitoring of MC pregnancies with a dead
MC twin pair results from a sudden change in twin may enable recognition of characteristic struc-
placental vascular territory perfused by the still beat- tural defects in the survivor, however. Recognition of
ing heart. The impact of co-twin demise and the this syndrome is especially important for providing
likelihood of resultant injury to the survivor is likely accurate counseling for parents about prognostic
related to the degree of placental sharing, the number implications and anticipated poor outcome.
and type of intertwin vascular connections, and the
timing of demise. Bajoria et al studied the outcome Acardiac parabiotic twin
for the surviving twin after intrauterine co-twin death
[30]. For MC twins without TTTS, perinatal mortality Acardiac parabiotic twins can be seen only in MC
was higher in the group with superficial A-A or veno- pregnancies [53 – 55]. Although some acardiac twins
venous channels than the group with only multiple have an anomalous heart, fundamentally what is seen
bidirectional AV anastomoses. In the MC twin preg- is a fetus in utero who, without the aid of a function-
nancies complicated by TTTS, however, perinatal ing cardiac pump within its own torso, continues to
outcome for the surviving twin depended on whether grow progressively, albeit abnormally, during gesta-
the recipient or the donor twin died first. Outcomes, tion. The co-twin, termed the ‘‘pump twin,’’ is pro-
including the presence of intracranial abnormalities at viding the blood supply to its anomalous sibling.
birth, were significantly worse if the recipient twin Among the vascular communications, at the least
died first. an A-A and veno-venous communication must be
The damage to the surviving fetus is related, at least present to complete the circuit. These large vascular
in part, to its gestational age at the time of death of the communications are often seen along the placental
co-twin. Demise of the co-twin early in pregnancy surface that courses between the cord insertion sites,
results in atresia and tissue loss; demise later in which are usually close in position. This circulatory
pregnancy results in tissue infarction, probably as a connection allows for blood to bypass the placenta and
result of hypoperfusion from hypotension and brady- perfuse the acardiac twin with ‘‘used’’ blood from the
cardia. Rapidly proliferating organs, such as the grow- pump twin. Perfusion of the acardiac fetus depends
ing brain, kidneys, and gut, seem to be particularly entirely on the blood supplied by the pump through the
susceptible [48]. Brain lesions noted with this syn- vascular anastomoses at the placental level.
drome include hydranencephaly, porencephaly, cystic In the acardiac fetus, the direction of blood flow in
encephalomalacia, and ex vacuo hydrocephalus. the umbilical cord is reversed [54]. In the umbilical
The prevalence of twin embolization syndrome in vein, flow is away from the fetus. Flow is toward the
the setting of antepartum demise of one of a MC twin fetus and away from the placenta in the umbilical
pair is not firmly established. When this syndrome artery (Fig. 17). This occurs because the blood enter-
occurs, however, the prognosis is grim. MR imaging ing the body of the anomalous fetus is being pumped
has the potential to enhance the ability to identify by the co-twin into the umbilical artery of the
brain abnormalities that may not be detectable by acardiac twin. This phenomenon has led to an alter-
means of obstetric sonography [49 – 52]. Because MR native name for this rare, anomalous situation, the
imaging has a higher intrinsic sensitivity than US to so-called twin reversed arterial perfusion sequence.
tissue contrast, fetal MR imaging offers the potential The acardiac parabiotic twin may share the same
to visualize subtle brain abnormalities. amniotic cavity with the co-twin, which places the
This technology is of particular use in the evalua- pregnancy at additional risk of cord knotting, although
tion of MC diamniotic twins. There is a high risk of these pregnancies are usually MC, diamniotic. A
neurologic handicap in survivors of TTTS and other disparity usually exists in the distribution of fluid
complications of MC placentation, including twin between the twins; the anomalous twin is in the
embolization syndrome. The timing and cause of the sac that contains less amniotic fluid (usually oligo-
brain injury suffered by MC twins with co-twin demise hydramniotic). The anomalous twin sac may be anhy-
territory. The mortality rate for the normal co-twin

has been estimated at 50% [53]. The possible peri-
natal sequelae of acardiac twin gestations include
cardiac failure of the pump twin, polyhydramnios,
hydrops, preterm delivery, and in utero demise [55].
If the pump twin can be delivered successfully
after a point of achieving viability, normal devel-
opment can be anticipated. The likelihood that the
normal fetus will die seems to be partly related to the
size of the anomalous co-twin; the larger the anom-
alous co-twin, the more likely the pump twin will not
survive. Sonographic factors cannot always reliably
predict which pregnancies are at highest risk and are
candidates for intervention before pump twin decom-
pensation or demise. There is another concern about
the possible risks faced by the pump twin. It is
Fig. 18. Coronal sonogram of an acardiac parabiotic twin. theorized that the pump twin is likely compromised
There is no head. There is diffuse integumentary edema and
by receiving into its circulation ‘‘twice used’’ blood,
cystic hygromas (*). No heart is present within the thorax.
which bypasses placental cotyledons going to and
returning from the acardiac twin.
dramniotic, with the acardiac twin apparently ‘‘stuck’’ The pump twin is at risk for high-output cardiac
to the uterine wall. failure and may develop hydrops. In such cases,
Acardiac fetuses have a relatively characteristic depending in part on gestational age, termination of
appearance (Fig. 18). Usually the fetus has no head, the acardiac twin may be required in an effort to
which leads to one of several synonyms for this entity, salvage the pump twin. The pump twin already
acardia acephaly. Anencephaly or severe micro- perfuses the entire placental parenchyma, and there
cephaly may be present, however. These fetuses tend is no danger of sudden alteration in placental per-
to have diffuse integumentary edema, and nearly all fusion when the cord of the acardiac twin is selec-
have cystic hygromas. The upper extremities are either tively occluded. The treatment goal for this condition
rudimentary or completely absent. The lower extrem- is to obliterate blood flow to the acardiac, nonviable
ities are better formed, and the femur, which often ap- fetus and protect the morphologically normal pump
pears normal in configuration, can be measured and twin without threatening its viability. In the past,
growth is evident when serial examinations are done. extraction of an acardiac parabiotic fetus was attemp-
Usually, the thoracic region of the fetus is charac- ted, although this was not often successful and is no
terized by the absence of any visible cardiac pul- longer performed. More recently, several other tech-
sation. Doppler flow signals can be obtained in the niques have been investigated with variable success.
umbilical cord, although the direction of flow is re- A new minimally invasive percutaneous technique
versed. Diagnosis of twin reversed arterial perfusion for selective reduction of the acardiac twin using
requires recognition that an absent heart beat may radiofrequency ablation has been described and has
mean an absent heart, not a heart that is not beating. been shown to be safe and effective [56]. Using real-
On targeted Doppler US interrogation, reversed arte- time US guidance, the radiofrequency ablation device
rial flow direction, from the placenta up the cord is inserted percutaneously into the mid-abdomen of
toward the abdominal wall of the acardiac fetus, can the acardiac fetus at the level of the umbilical artery
be shown and is definitive. and vein and deployed (Fig. 19). Radiofrequency
Identification of this syndrome has important ablation is a high-energy technique that is known to
clinical implications. The anomalous fetus has no be an efficacious modality for various clinical appli-
potential for survival. Unfortunately, there is substan- cations, most notably in treating malignant hepatic
tial risk to the morphologically normal pump twin neoplasms. As the radiofrequency ablation device is
who is providing the blood supply to the anomalous deployed into tissue, energy is disbursed to the tines,
fetus. The presence of an acardiac twin burdens the which causes a coagulative effect. In this setting, the
cardiac load of the pump twin. Hemodynamically, the device avoids injury to the potentially viable pump
fetus must circulate blood for its own body and for twin by directing energy, only to the tissue of the
the body of the co-twin. Because it has the only acardiac twin in contact with the tines. Often, the
beating heart, it is perfusing the entire placental acardiac twin is stuck within an oligohydramniotic
quency ablation with US guidance and other forms

of selective, minimally invasive, percutaneous ter-
mination recently described seems to protect the
pump twin effectively and improve outcome.
Twin reversed arterial perfusion sequence in acar-
diac MC twin gestations is a rare anomaly that
compromises the viability of the morphologically
normal, pump twin. At the least, careful monitoring
of this highly anomalous situation is warranted to
assess the normal co-twin for growth, development of
hydrops fetalis, or other evidence of decompensation.
Discordant anomalies
Monozygotic twins are usually discordant for lethal

major congenital anomalies. Although rare, a major
structural abnormality may be detected in one of a MC
twin pair, and the co-twin is usually spared. It is
Fig. 19. Transabdominal intraoperative ultrasound image
incorrect to assume that discordant malformed twins
reveals the radiofrequency ablation device (arrows) de-
ployed within the abdomen of the acardiac fetus (a). are dizygotic and therefore DC. A wide range of
discordant abnormalities have been seen in MC twin
pairs, including anencephaly and other neural tube
sac of a diamniotic gestation and is located away defects, diffuse lymphangiectasia, and diaphragmatic
from the potentially viable pump twin. hernia (Fig. 20) [11]. If the malformed twin is likely to
In twin pregnancies complicated by twin reversed die in utero or cause difficulties during pregnancy or
arterial perfusion sequence, the beating heart of the delivery, selective fetal termination is considered.
pump twin already provides all of the circulation to If selective termination is considered, firm deter-
and from the shared placenta and the acardiac twin. mination of the chorionicity of the gestation is
Obliteration of blood flow to the acardiac twin by essential to define fully the risks to the surviving
radiofrequency ablation does not alter the placental twin. DC twins are not at risk, whereas MC twins are
circulation provided by the pump twin. Radiofre- at risk for injury suffered at the time of co-twin
Fig. 20. Monochorionic twin pregnancy discordant for major anomaly. (A) Transverse sonogram through the abdomen of the
normal twin (a) and the thorax of the affected twin (b). This is not a case of twin-twin transfusion syndrome or acardiac,
parabiotic twin. Amniotic fluid volume was normal for each twin, and twin B was shown to have a beating heart with normal
flow direction in its umbilical artery. Twin B has diffuse lymphangiectasia with integumentary edema (arrowheads) and bilateral
pleural effusions (arrows). (B) On another image of twin B, multiple large cystic hygromas (*) are shown.
demise. In MC twin pregnancies with two living can be offered termination via vaginal delivery. In
fetuses, each with a beating heart, both provide blood late pregnancy, severity of conjoining influences
flow to and drain blood from a portion of the shared predictions of viability and decisions regarding mode
placenta. In almost all MC twin pregnancies, vascular of delivery. Cesarean section is reserved for poten-
communications at the placental level also connect tially viable and separable fetuses to minimize fetal
the circulations of the twins [13]. When selective morbidity and mortality and for conjoined twin con-
feticide is performed in the management of discor- figurations that obstruct labor.
dant lethal anomalies that affect one of a MC pair or The site and extent of twin fusion are highly
in other situations, including TTTS, twin emboliza- variable. Classification systems for conjoined twins
tion syndrome should be considered as an additional are based on the fused anatomic region. The name of
risk to the surviving twin. Isolated ligation or occlu- the region usually is followed by the suffix -pagus,
sion of the cord of the anomalous fetus is risky. In Greek for ‘‘fastened.’’ For example, craniopagus is
some instances, depending on the degree of placental head-to-head fusion; thoracopagus is chest-to-chest
sharing and the type of interfetal vascular connec- fusion; omphalopagus is abdomen-to-abdomen fusion.
tions, attempts should be made first to separate the These fusions are usually anterior-anterior and may
two circulations (eg, by means of selective laser involve more than one body region. The most common
occlusion at fetoscopy) before cord occlusion [57,58]. types of conjunction are thoracopagus, omphalopagus,
and thoraco-omphalopagus twins. Side-to-side fusions
Conjoined twins usually begin at the head or buttock end and tend to be
extensive. It is customary to name these large lateral
Conjoined twins are a rare malformation of mono- fusions, which incorporate multiple regions, on the
amniotic twins; the estimated incidence is 1:50,000 to basis of the anatomic part that remains separate. For
1:100,000 births [59]. As with all pathologic events example, dicephalus means two heads with fusion of
associated with monozygosity, conjoined twinning the thorax and abdomen (Fig. 21).
occurs sporadically. Conjoined twins develop from Prenatal sonographic diagnosis of conjoined twins
incomplete division of the embryonic disc. Division may be straightforward: joining of fetal parts may be
of the embryonic disc more than 13 days after obvious; however, a careful approach is necessary to
fertilization is usually incomplete and results in avoid misdiagnosis. The diagnosis should be consid-
fusion of the twins [6]. Most of these twins are born ered only when a single placental site is seen and no
premature, and the mortality rate is high. separating amniotic membrane is demonstrated (no
Prenatal diagnosis of conjoined twins and charac- DC or diamniotic twin gestation can be conjoined).
terization of the severity of the malformations is Significant sonographic findings include inability to
desirable for optimal obstetric management [60]. detect separate fetal skin contours, appearance of both
Severe forms of conjoined twins diagnosed early fetal heads persistently at the same level, no change
Fig. 21. (A, B) Conjoined twins: dicephalus. There is fusion of the thorax and abdomen, with separate calvaria and partially
duplicated spines.
sonographic visualization of a membrane does not,

on its own, predict monoamnionicity [7,10].
Lack of a separating membrane between the
fetuses allows the two umbilical cords to contact
each other and become tangled. Because several
loops of apparently intertwined umbilical cord may
be either the entangled cords of two twins or only the
redundant cord of a single twin folded on itself, it is
essential to trace both fetal cords to the entangled
mass before suggesting the diagnosis of monoamnio-
nicity [62].
A complication that accounts for most of the
increased mortality in monoamniotic twins is true
knotting of the cords (Fig. 23) [63]. A true knot may
cut off circulation and result in sudden fetal death,
and it undoubtedly accounts for the high fetal loss
Fig. 22. A single five-vessel cord is identified in a case of rate observed in this group. This appearance is the
conjoined twins. basis for the diagnosis of monoamnionicity and is the
only reliable feature for diagnosing this problem so-
in the relative position of the fetuses, bibreech posi- nographically. If the cords of the twins are entangled,
tion, and, less commonly, bicephalic presentation, it can be inferred accurately that no membrane sep-
backward flexion of the cervical spine, and a single arates the fetuses. Intertwining of twin extremities
umbilical cord with more than three vessels (Fig. 22). is not reliable because the extremities can deform a
Other findings include shared heart, liver, brain, or separating membrane.
other fetal organs [61]. An important adjunct to the diagnosis of mono-
Prenatal diagnosis of conjoined twins allows plan- amniotic twins is the use of CT amniography. If
ned obstetric management, including decisions on within hours after a single US-guided intraamniotic
approach for delivery and minimization of maternal injection of radiocontrast agent, it is swallowed
and fetal morbidity and mortality. Precise delineation and the contrast is seen in the intestinal tract of both
of the conjoining is important in determining the fetuses, monoamnionicity is confirmed [64]. When
likelihood of postnatal viability, separability, and monoamniotic nonconjoined twins are suspected
mode of delivery. The identification of a shared heart, but the sonographic findings are indeterminate, CT
in particular, carries a poor prognosis with essentially amniography is indicated.
no hope for successful postnatal separation. Prena- The potential for umbilical cord entanglement does
tally, sonography is the most definitive method for not exist in all monoamniotic twin pregnancies. All
diagnosis and characterization of conjoining, thereby
predicting chances for postnatal survival.
Monoamniotic twins
Sonographic identification of nonconjoined mono-

amniotic twin pregnancies is important prognostically
and can affect obstetric management. MC monoamni-
otic twin pregnancies have the highest mortality rate
of otherwise uncomplicated twin pregnancies [4].
This rate is related to a high frequency of compli-
cations present in all twin pregnancies (particularly
preterm delivery) and complications that are unique
to these gestations.
The lack of a membrane separating the twin
fetuses in monoamniotic pregnancies distinguishes
these pregnancies from all other twin pregnancies
and potentially permits prenatal sonographic diag- Fig. 23. Monoamniotic twin gestation with entangled
nosis. Studies have shown, however, that lack of umbilical cords shown by ultrasound.
conjoined twins are monoamniotic; however, such [2] Sebire N, Snijders R, Hughes K, Sepulveda W, Nic-
twins must move in unison. They cannot entangle their olaides KH. The hidden mortality of monochori-
cords to form true cord knots in the same way that onic twin pregnancies. Br J Obstet Gynaecol 1997;
104:1203 – 7.
nonconjoined monoamniotic twins can. In many con-
[3] Benirschke K. Twin placenta in perinatal mortality.
joined twins the umbilical cords are fused. The high
N Y J Med 1961;61:1499 – 508.
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Acknowledgment tion. Ultrasound Obstet Gynecol 2000;16:214 – 7.
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The authors would like to thank Dr. Geoffrey A. tification of arterio-venous anastomoses in vivo in
monochorionic twin pregnancies: preliminary report.
Machin, fetal/placental pathologist, for his contribu-
Ultrasound Obstet Gynecol 2000;16:218 – 22.
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Radiol Clin N Am 41 (2003) 729 – 745
Tips and tricks of fetal MR imaging

Deborah Levine, MDa,*, Annemarie Stroustrup Smithb,c,
Charles McKenzie, PhDa
a
b
Harvard Medical School, Boston, MA 02215, USA
c
Harvard-MIT Division of Health Science and Technology, Boston, MA 02215, USA
MR imaging during pregnancy is being used enced in detection and characterization of fetal anom-
increasingly to assess fetuses with complicated or alies, which lessens the perceived impact of MR
nonspecific ultrasound (US) diagnoses [1 – 13]. This imaging on patient care (Fig. 1).
article illustrates common artifacts and other pitfalls in
the performance of fetal MR examinations and sug- Is a recent ultrasound available for comparison?
gests techniques to improve image quality. Compari-
sons of anatomy visualized on fetal MR imaging Optimally, the US is performed immediately
versus US are demonstrated. The cases illustrated in before the MR examination (Fig. 2). Besides provid-
this article have been gleaned from more than 400 fetal ing sonographic diagnoses for comparison with the
MR imaging cases performed in the past 6 years at MR examination, an US that precedes the MR
Beth Israel Deaconess Medical Center (Boston, MA). examination is helpful in directing placement of the
surface coil to the area of interest in the fetus with
respect to the maternal body (Fig. 3).
Practical comments: how we perform fetal
MR examinations What type of consent should be obtained?
Is the study indicated? All pregnant patients should be informed regard-

ing the risks and benefits of MR imaging. The
A fetal MR examination may be ordered for an authors inform patients that no conclusive scientific
indication more appropriately answered by US. If the evidence supports a direct relationship between expo-
anatomy can be evaluated adequately on US, then the sure to MR imaging and any hazard to the developing
MR examination is likely not needed. fetus [14 – 21]. Because fetal cells in the first trimester
of pregnancy are particularly susceptible to damage
Is high-quality ultrasound available for comparison? by different types of physical agents, the authors limit
fetal examinations to the second and third trimesters.
Quality of US varies among sites. It is helpful to Rarely, they have found incidental abnormalities on
have a sonogram performed by an individual experi- MR examinations (Fig. 4), so they mention the risk of
increased anxiety caused by unexpected findings as a
risk of the procedure.
Cases illustrated in this article were obtained under NIH
grant NS37945. Review of cases was sponsored by a
grant from the Carl J. Shapiro Institute for Education
Patient positioning
and Research.
* Corresponding author. The authors place a patient in the supine position,
E-mail address: [email protected] with feet entering the magnet to minimize the pos-
(D. Levine). sibility of claustrophobia. A surface coil is centered
doi:10.1016/S0033-8389(03)00043-5
730 D. Levine et al / Radiol Clin N Am 41 (2003) 729–745
Fourier single shot fast spin echo sequences (SSFSE)

in the fetal sagittal, coronal, and axial planes using
each sequence as the scout for subsequent imaging.
They typically perform additional sequences with thin
cuts or higher matrix size through the region of
interest. A typical T2-weighted sequence uses echo
spacing of 4.2 milliseconds, echo time (TE)effective of
60 milliseconds, echo train length of 72, 4 mm slice
thickness, 26 30 cm field of view, 128 256
acquisition matrix, and a refocusing flip angle of 130°.
One T1-weighted sequence is used to look for
blood products or hemorrhage. The authors typically
use fast low angle shot (FLASH) technique with
the following parameters: repitition time (TR)/ TE =
88.5/4.1; flip angle = 80°; 5 mm slice thickness;
field of view = 30 35; matrix = 170 256; scan
time = 17 seconds (breath-hold).
Viewing the images
Fig. 1. Coronal MR image of a fetus at 19 weeks’ gestation When viewing (or filming) fetal MR imaging, one
referred for congenital diaphragmatic hernia. Confirmatory should enlarge the fetus to fill the image and then
sonogram showed an anechoic cyst in the chest, absent adjust window and level. This approach provides the
stomach below the diaphragm, and no mediastinal shift. best opportunity for evaluating the fetal anatomy.
Because of the lack of mediastinal shift, the confirmatory
sonographic diagnosis was believed to be a combination of Examination interpretation
foregut duplication cyst and esophageal atresia. MR showed
the diaphragm to be intact. Without a confirmatory US, this If a second opinion is good, a third opinion is
type of finding would suggest that MR showed increased even better. Just as the authors like to perform a
information compared with US. Because a confirmatory
sonogram was performed, the authors concluded that MR
showed no new information and did not change patient care.
over the region of interest (established on US per-

formed immediately before the MR study). A pillow
is placed below the patient’s knees. If the patient is
uncomfortable lying on her back for prolonged peri-
ods, then she is imaged lying on her side (Fig. 5).
Monitoring the examination
The quality of the fetal MR examination benefits

from having an individual who is knowledgeable in
fetal anatomy and the clinical question to be answered
present during the study. Because the fetus is in nearly
constant motion, decisions regarding choice of image
plane and whether the anatomy has been evaluated Fig. 2. Ultrasound of fetus at 31 weeks’ gestation with a
cystic brain lesion (calipers). This examination was
sufficiently must be made relatively quickly.
performed 3 days before the MR examination. This was a
fetus from a triamniotic dichorionic triplet pregnancy with
Protocol demise of one of the monochorionic pair. A repeat US (not
shown) performed immediately before the scheduled MR
The authors perform a three-plane T1-weighted examination showed demise of this fetus, and the MR
scout, followed by T2-weighted imaging with half examination was cancelled.
D. Levine et al / Radiol Clin N Am 41 (2003) 729–745 731
Fig. 3. Three images of a fetus at 35 weeks’ gestation with bladder exstrophy. Note the decreased signal in (B) and (C) relative to
(A) in the maternal anterior abdominal wall and in the fetal structures, because the images in (B) and (C) are obtained at the edge
of the surface coil.
confirmatory sonogram, they also like to get a evaluate scans frequently has clarified the diagnosis
second opinion on their reading of the MR exami- (Fig. 6).
nations. Their experience is in high-risk obstetric
imaging. They commonly have fetal MR examina-
tions double read by pediatric radiologists. This is a Anatomy better visualized with MR imaging
wonderful trade of information, because pediatric
imagers may not be as familiar with fetal diseases Several anatomic areas in the fetus are better
but have a wider differential for some of the rare visualized with MR imaging than with US. A few
childhood disease processes. This advantage is espe- examples include the thymus (Fig. 7), major airways
cially important in assessment of the fetal central (Fig. 8), spleen (Fig. 9), soft palate (Fig. 10), and
nervous system. Having a pediatric neuroradiologist esophagus (Fig. 11).
Fig. 4. Fetus at 35 weeks’ gestation referred for enlarged cisterna magna. Sonogram was normal (not shown). Sagittal (A) and
coronal (B) MR images show incidental finding of enlarged subtemporal vein (arrow). This is an example of the risk of MR
showing an unrelated finding that could increase parental anxiety. The patients were counseled that this was a vascular anomaly
that would have gone unrecognized if the MR examination had not been performed. Postnatal outcome was normal at 2 years
of age.
Fig. 5. Two fetuses at 28 weeks’ gestation. (A) The patient was scanned in supine position. (B) The patient was scanned in lateral
decubitus position.
Fig. 8. Trachea and carina. Coronal view of the chest at

33 weeks’ gestation shows the trachea, carina, and right and
left mainstem bronchi (arrows).
Fig. 6. Sagittal view of the brain of a fetus at 38 weeks’
gestation with a vein of Galen malformation. The pediatric
neuroradiologist also noted choroidal features of the venous
malformation. This put the patient at increased risk for fetal
intracranial hemorrhage, and the fetus was delivered by
cesarean section.
Fig. 9. Fetus at 32 weeks’ gestation. Note the spleen (s),

Fig. 7. Axial image of the fetal thymus at 32 weeks’ which is rarely seen in fetal US but routinely visualized on
gestation (arrow). fetal MR imaging. The liver (l) also is labeled.
Artifacts: what we see and what we should do
Motion artifact
Motion affects all fetal MR examinations because

of the combination of maternal motion (whole body,
breathing, bowel peristalis, and arterial pulsations)
and fetal motion. Because images are obtained in 300
to 400 milliseconds, SSFSE imaging allows for
diagnostic quality imaging despite motion.
Bulk motion
Maternal motion results in motion of the entire field
of view during the imaging sequence and generally
results in a blurring of the entire image, with ghost
images in the phase encoding direction (Fig. 12).
Movement of a small portion of the imaged area results
in a blurring of that small portion of the object across
the image. Bulk motion artifacts can be distinguished
from Gibbs or truncation artifacts because they extend
across the entire field of view, unlike truncation ar-
Fig. 10. This midline sagittal view of the face outlines the
tifacts, which diminish quickly away from the bound-
soft palate (arrow) at 33 weeks’ gestation. The oropharynx
being filled with amniotic fluid aids in evaluation of this ary that causes them. If bulk motion is present, one
structure, which typically cannot be seen by US. should remind the patient to keep still. In general,
breath-holding is not needed during subsecond im-
aging sequences, but if the patient is moving during
imaging, a breath-hold could be helpful.
Fluid motion
This artifact is characterized by a signal void that
occurs in fluid. Fluid motion artifact occurs when
Fig. 11. Distended distal esophagus at 36 weeks’ gestation.

At times, a distended lower esophagus can be visualized on
fetal MR (arrow). This was not present on other images Fig. 12. Bulk movement. Note the blur of the entire image
in the same region. This is a transient finding, likely caused (soft tissues and fetus) because of bulk movement of the
by reflux. patient during the scan.
Fig. 13. Fluid motion. Two adjacent images from the same sequence. (A) Fluid motion has caused the amniotic fluid (arrow) and
the fluid around the spinal cord to lose signal. (B) The amniotic fluid motion is not visualized (arrow), and the amniotic fluid and
cerebrospinal fluid around the spinal cord are of high signal intensity.
spins excited by a slice-selective radio frequency the assumption that dark fluid on SSFSE imaging is
pulse change position with respect to the slice or caused by motion is shown in Fig. 17, in which the
spatial encoding gradients before their signal is low signal is caused by blood products.
recorded. Motion artifact can be seen in amniotic
fluid (Figs. 13 – 15) and in other fetal fluid collec- Repeat visualization of structure or nonvisualization
tions, such as cerebrospinal fluid (Fig. 13) and fetal of a structure
urine (Fig. 16). Because fetal imaging is typically If the fetus moves during the sequence and the
performed with single shot sequences, only the slice movement is in plane with imaging, it is possible that
that was obtained during the motion is affected. As a portion of the anatomy will be seen more than once
long as the fetus is not continuously moving, then (ie, a leg or arm appears in two places in the same
typically only one or two slices are degraded by sequence) (Fig. 18). More commonly, an extremity
motion during a typical sequence acquisition. If the
affected slices are not in the region of interest, then
the sequence does not need to be repeated. A pitfall in
Fig. 14. Fluid motion around a fetus at 20 weeks’ gestation.

At times, fluid motion is visualized as low signal in the
amniotic fluid rimmed by a bright ‘‘layer’’ (arrows). This
brightness is generally caused by a lack of motion at the Fig. 15. Fluid motion. Sagittal view of a fetus at 26 weeks’
periphery of the fluid space. The high signal intensity also gestation. The fetus was exhaling from the nose during
may be caused by subcutaneous fat (adjacent to the fetus) or image acquisition, which caused the fluid immediately
fluid in the subamniotic space, however. anterior to the face to lose signal, imitating a mass.
moves out of the image plane during sequence

acquisition and is not visualized.
Aliasing (wrap around)
This artifact can be identified when anatomic

structures that extend outside the field of view in
the phase encode direction appear to ‘‘wrap around’’
into the opposite side of the image. Depending on the
anatomy and the placement of the field of view, the
‘‘wrapped’’ anatomy may overlie and obscure other
anatomy. This artifact occurs because the tissue
outside the field of view is not correctly phase
encoded. Any excited tissue outside the field of view
still gives signal during readout, but tissue outside the
field of view has acquired a phase identical to a
position inside the field of view. Because the spatial
position is determined from the phase of the signal
emitted by the tissue, all signals with the same phase
Fig. 16. Fluid motion in the bladder. Transverse view of the are displayed in the same position inside the field of
bladder in fetus at 22 weeks’ gestation. Note loss of signal view [22]. The most straightforward method for
(arrow) caused by jet of urine entering the bladder. eliminating this artifact is to increase the field of
view so that it contains all maternal anatomy. This
method results in either reduced in-plane resolution
or increased scan times. For fetal imaging, it is best to
use the smallest field of view that permits imaging of
the region of interest (Fig. 19).
Fig. 17. Pitfall of fluid motion: dark fluid caused by blood products. (A) Sagittal T2-weighted image shows dark fluid above the
internal os (arrow). (B) Sagittal T1-weighted image (TR/TE 88.2/1.5) shows this same area to have heterogenous slightly
increased signal, consistent with marginal subchorionic hematoma (arrow). Also note the adnexal cyst (C).
Fig. 18. Two sequential images of the fetal hand at 32 weeks’ gestation. Moving extremities can cause a structure to be visualized
twice or not at all. In this case the same hand is seen twice: open with fingers extended (A) and in a more relaxed position (B).
Radio frequency interference Susceptibility artifact
This artifact is characterized by isolated lines or This artifact is characterized by localized distor-
broad bands of lines in the phase encode direction tions of the geometry or intensity of the image
being obscured by ‘‘zipper’’ artifacts (Fig. 20). Often, caused by inhomogeneities in the main magnetic
a single area of high signal-to-noise ratio (SNR) is field (Bo). Spatial distortion results from long-range
visualized (Fig. 21). This artifact occurs when un- field gradients, where Bo varies over scales that span
wanted radio frequency signals from outside the many voxels. These changes in Bo cause the spins
magnet are picked up during data reception. Most in different voxels to have slightly different preces-
causes of radio frequency contamination are beyond sion frequencies. Because spatial position is encoded
immediate control. A list of things to do if one sees this by the precessional frequency of the spins, these
artifact follows. alterations in frequency can make the signal from
spins in one location seem to come from a different
Ensure scanner room door is closed completely position, which results in geometric distortions of
when scanning. the image [22]. Susceptibility artifact is rare with
Shut off extraneous equipment inside the scan- SSFSE imaging, but it can occur (Fig. 22). Things
ner room. to do if you see this artifact include perform-
Ensure no wires from other medical equipment ing shimming to improve the Bo homogeneity,
are entering the scanner room from the outside. using shorter TE sequences, and increasing read-
Call service engineer. out bandwidth.
outside of the fetus, for example, in the placenta

(Fig. 24).
Image quality: what we see and what we can do
Signal-to-noise ratio
Because of the relatively small size of the fetus,

fetal MR imaging is commonly limited by SNR. Two
factors affect the SNR in an MR image: slice thick-
ness and matrix size. The SNR varies directly with
the size of the voxels in an image. For example, if the
thickness of slices in a two-dimensional image were
halved, thereby doubling the resolution in the slice
direction, the SNR of that image would be reduced by
a factor of two. Most structures in the fetal body are
well visualized with 4 mm slice thickness (Fig. 25).
Small or thin structures surrounded by fluid may not
be visible by MR imaging (Fig. 26).
Fig. 19. A fetus with tuberous sclerosis at 34 weeks’ With the exception of reducing slice thickness in
gestation. The oblique image plane with respect to maternal a two-dimensional acquisition, resolution in MR
anatomy (patient imaged in lateral decubitus position) gives
imaging is usually increased by increasing the num-
bright wrap around artifact. This artifact does not overlie the
area of interest in the fetal brain, because the subependymal
ber of encoding steps (either phase encoding or
tubers (arrows) are well visualized. frequency encoding steps) acquired in (at least) one
direction (ie, increasing the matrix size). The SNR of
an image varies as the square root of the number of
Gibbs ringing artifact
The Gibbs ringing artifact (also called a truncation

artifact) is typified by alternating bright and dark lines
running parallel to a sharp signal interface that
diminish quickly away from the boundary that causes
them (Fig. 23). Gibbs ringing occurs when the echo
has not decayed to zero at the edges of the acquisition
window [22], so it is most often seen in images when
a small acquisition matrix is used. As long as this
artifact is recognized and not confused with a real
structure, it typically does not limit fetal imaging.
This artifact can be reduced by increasing the resolu-
tion of the image or by applying a filter to the
reconstructed image. Both of these strategies entail
tradeoffs. Increasing resolution requires either longer
imaging times or reduced image SNR, whereas filter-
ing reduces the resolution of the reconstructed image.
Partial volume artifact

Fig. 20. Radio frequency interference. Coronal image of a
fetus with neural tube defect at 19 weeks’ gestation. Note
As in all tomographic imaging, if only a portion of the angular appearance of the mildly dilated cerebral
an anatomic region is in the slice, partial volume ventricles, which is characteristic of a neural tube defect.
artifact can occur. What is different in obstetric The image quality is diffusely decreased by lines running
imaging is that this artifact can include structures through the image.
Fig. 21. Radio frequency interference. Image of the fetal head at 22 weeks’ gestation (A) and twins at 24 weeks’ gestation (B). In
both of these images a bright area is seen that does not correspond to any anatomic structure. (A) The artifact is in the fetal brain
and could interfere with diagnosis. (B) The artifact is in the maternal soft tissues and is not important to making a diagnosis. Note
that the entire image is distorted by lines of alternating increased and decreased signal intensity.
Fig. 22. Susceptibility artifact. Coronal image through the Fig. 23. Gibbs ringing artifact. A fetus with bilateral cleft lip
uterus at 20 weeks’ gestation shows multiple geographic and palate and a pseudomass in the midline face at 18 weeks’
areas of increased and decreased signal in the amniotic gestation. Ripples of high and low signal intensity (arrows)
fluid. The pattern of these alternating lines suggests sus- radiating away from the fetal amniotic fluid interface are
ceptibility artifact. caused by Gibbs artifact.
encoding steps. If resolution in the frequency encode

direction is increased by doubling the number of
frequency encoding steps acquired (and keeping all
other imaging parameters the same), there are two
competing effects on the SNR of the resulting image.
The halving of the voxel size results in a halving of the
SNR, but the doubling of the number of encoding
steps results in an increase in SNR by a factor of
the square root of two. In combination, these two
effects result in a reduction in SNR of only a square
root of two, rather than the factor of two that
might be expected from the reduction in voxel size
(Fig. 27). It is important to realize that on some
magnets, the longer reconstruction times associated
with large matrices allow for more fetal motion
between sequence acquisitions.
A final consideration in maximizing SNR is
field of view. To ensure the best resolution pos-
sible, it is important to keep the field of view as
small as possible. Unlike typical abdominopelvic
imaging, however, wrap-around artifact into the
peripheral maternal anatomy is not a problem (see
Fig. 19).
Fig. 24. Partial volume artifact in a fetus at 19 weeks’
gestation. This image shows the fetal hand adjacent to the Patient body habitus and use of the surface coil
placenta. A prominent vein (arrow) in the placenta looks
like a hyperextended thumb. Because patients in the late stages of pregnancy
have larger and more protuberant abdomens than the
typical nongravid patient, patient body habitus must
be considered. Because the wall of the abdomen can
come close to the magnet bore, the surface coils gen-
Fig. 25. Slice thickness. A fetus at 19 weeks’ gestation with ventriculomegaly. (A) Slices are 4 mm thick. (B) Slices are 3 mm
thick. Note increased signal but increased blur in (A) compared with (B).
complete its prescan calibration. In these cases it is

necessary to remove the surface coils and use the
body coil alone for imaging. Surface coils are
helpful for increasing the SNR, but if a patient is
too large to tolerate a surface coil and still fit in the
magnet, imaging can be performed adequately with
the body coil (Fig. 28).
Signal inhomogeneity when using a phased array

surface coil
It is often advantageous to use a phased array

surface coil instead of the magnets built into the body
coil for signal reception [23]. Phased arrays give
Fig. 26. Difficulty in visualizing thin structures surrounded much better SNR than the body coil, in part because
by fluid. Axial MR in a fetus with an L4 neural tube defect the coil array can be placed much closer to the
at 26 weeks’ gestation. Although the soft tissue defect is anatomy of interest. Unlike the body coil, however,
well visualized by MR (arrow), the sac covering the defect the signal intensity of an image produced by phased
is not seen. The sac was visualized on US (not shown). array is not uniform and drops off with distance from
Nonvisualization of the sac on MR is caused by the thin size the array. A phased array image has high signal
of the sac wall and the partial volume averaging that occurs intensity at the abdominal wall, but the intensity is
because of cerebrospinal fluid inside the sac and amniotic significantly lower near the center of the abdomen.
fluid outside of the sac.
This decay in signal intensity results in a heteroge-
neous appearance to the image, and the varying signal
intensity can make the image difficult to interpret.
erally used for abdominal and pelvic imaging may Most magnets have an option to make the image
be placed closer to the body coil used for radio appear more homogenous by applying a surface coil
frequency pulse transmission. The proximity of the intensity correction that decreases signal intensity
surface coil array to the body coil can de-tune the near the array and increase it farther away from the
surface coil and result in failure of the magnet to array. It should be noted that such corrections cannot
Fig. 27. Sagittal views of the fetal head in fetus with tuberous sclerosis at 36 weeks’ gestation. (A) Image is taken with a
128 256 matrix. (B) Image is taken with a 256 512 matrix. Both images show the small nodules (subependymal tubers,
arrows) projecting into the ventricle. The image in (B) has better resolution than (A) but has the same diagnostic information.
eliminate the falloff in SNR with distance from the

array, so that the correction may result in increased
conspicuity of noise at large distances from the array.
Fat saturation
Fat saturation is generally of little use in fetal

imaging because the fetus has so little fat. Although
suppressing the abdominal fat of the mother may be
of some use for reducing the intensity of aliasing
artifacts in small field of view imaging, this must be
reconciled with the increased acquisition time that is
usually required for fat suppression.
Pitfalls in image interpretation on MR imaging
Some pathologic conditions have a slightly unex-

Fig. 28. Coronal image of the maternal abdomen obtained pected appearance on MR imaging. For example, in
with a body coil at 26 weeks’ gestation. This image was
some cases of nuchal thickening (Fig. 29), the more
obtained during an examination for atypical abdominal pain
complex cystic and solid appearance on US corre-
performed with the body coil rather than a phased array
surface coil. The fetal anatomy is still well visualized. sponds to a simple cystic appearance on MR imaging.
Some areas of pathology are better assessed by US
than by MR imaging, including small calcifications
(Fig. 30), small lesions (Fig. 31), and thin walls of
fluid collections (see Fig. 26).
Fig. 29. (A) Sonogram and (B) MR image of fetus with nuchal thickening. Note the soft tissue with septations behind the
neck seen on the sonogram (arrow). On MR imaging, the nuchal area has a more simple cystic appearance because of the high
fluid content.
Fig. 30. US (A,B) and MR imaging (C,D) in a fetus with a meconium pseudocyst (arrowheads) and intraabdominal
calcifications (arrows) at 19 weeks’ gestation. Whereas the pseudocyst is well visualized on MR imaging, the punctate
calcifications are not visualized.
Fig. 31. US (A,B) and MR imaging (C,D) in a fetus at 21 weeks’ gestation with a small echogenic mass in the liver. The mass is
well seen on US (arrows) but is not visualized on MR imaging.
Summary McArdle CR, et al. Fetal fast MR imaging: reproduci-

bility, technical quality, and conspicuity of anatomy.
The technique of performing fetal MR examina- Radiology 1998;206:549 – 54.
[10] Levine D, Barnes PD, Edelman RR. State of the art:
tions differs from routine pelvic MR imaging because
obstetric MR imaging. Radiology 1999;211:609 – 17.
the fetus is in motion, and image planes must be
[11] Levine D, Barnes P, Madsen J, Hulka C, Edelman RR.
selected orthogonal to fetal anatomy. The small size of Evaluation of fetal central nervous system abnormal-
the fetus also increases examination difficulty because ities with ultrafast MRI. Symposium Neuradiologicum
thin slices (limited by SNR) are often needed for XVI Proceedings 1998;242 – 3.
adequate examination of anatomy and pathology. [12] Hubbard AM, Crombleholme TM, Adzick NS. Prenatal
Knowledge of fetal anatomy and neonatal anatomy/ MRI evaluation of giant neck masses in preparation for
pathology are needed in the assessment of fetal the fetal exit procedure. Am J Perinatol 1998;15:253 – 7.
MR imaging. Knowledge of MR artifacts aids in [13] Hubbard AM, Harty MP, States LJ. A new tool for
image interpretation. prenatal diagnosis: ultrafast fetal MRI. Semin Perinatol
1999;23:437 – 47.
[14] Baker PN, Johnson IR, Harvey PR, Gowland PA,
Mansfield P. A three-year follow-up of children im-
aged in utero using echo planar magnetic resonance.
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Radiol Clin N Am 41 (2003) 747 – 756
MR imaging of pelvic f loor relaxation

Julia R. Fielding, MD
Department of Radiology, University of North Carolina at Chapel Hill, 101 Manning Drive, Campus Box 7510, Chapel Hill,
NC 27599, USA
Pelvic floor relaxation, which is the abnormal inserts on the parasymphyseal portion of the pubic
descent of the bladder, uterus/vaginal vault, or rec- rami. It extends posteriorly to form a sling around the
tum, is a significant women’s health issue that rectum, which serves two purposes: (1) the orifices of
affects primarily parous women older than 50 years. the pelvic floor are kept closed and (2) the bladder
The condition is worsened by obesity and chronic neck is elevated and compressed against the pubic
obstructive pulmonary disease. Up to 50% of such symphysis. Both muscles help to maintain a stable
women have some degree of genital prolapse. 10% to position of the pelvic organs and fecal and urinary
20% of this group seek help from a physician. continence. The iliococcygeus originates from the
Symptoms range from urinary or fecal incontinence same fibers as the external anal sphincter. From
to procidentia, but most women report increased there it extends laterally to insert at the arcus ten-
pelvic pain or pressure and protrusion of at least dineus, or white line of the pelvic sidewall, and pos-
some tissue, usually through the vagina [1 – 4]. Many teriorly to form a firm midline raphe just anterior to
women also must use manual pressure on the peri- the coccyx. The posterior raphe is often called the
neum or vaginal fornices to complete defecation. For levator plate. The iliococcygeus provides a physical
severely afflicted women such as these, pelvic floor barrier to organ descent and is the major support of
relaxation becomes a health and significant lifestyle- the posterior compartment.
limiting problem. Inferior to this level, the urethra and vagina extend
through the urogenital hiatus. The rectum extends
beyond the pelvic diaphragm at this level and is
Anatomy separated from the vagina by the perineal body and
anal sphincter.
The pelvic floor can be divided into three compart- The pelvic organs are also supported by a series of
ments: (1) the anterior compartment, which contains fascial condensations called ligaments. When the
the bladder and urethra, (2) the middle compart- muscles of the pelvic floor are damaged, usually
ment, which contains the vagina, cervix, and uterus, during childbirth, support of the pelvic organs falls
and (3) the posterior compartment, which contains to the fascia. The pubocervical fascia extends from
the rectum. the anterior vaginal wall to the pubis and supports the
All three compartments are supported by a remark- bladder. Elastic condensations of the endopelvic
able collection of fascia and muscle that forms the fascia, called the parametrium and paracolpium, sup-
urogenital diaphragm, or pelvic floor. The muscles port the uterus and vagina. The parametria are com-
that provide the major support of the pelvic organs posed of the cardinal and uterosacral ligaments, both
are two components of the levator ani: the pubo- of which elevate and provide superior support to the
rectalis and the iliococcygeus (Fig. 1). The pubo- uterine corpus. The paracolpium have been divided
rectalis, a portion of the pubovisceralis, arises and into three levels and extend from the vagina laterally
to the sidewalls [5]. The posterior wall of the vagina
and rectovaginal fascia supports the rectum, sigmoid
E-mail address: [email protected] colon, and portions of the small bowel. These fascial
doi:10.1016/S0033-8389(03)00042-3
748 J.R. Fielding / Radiol Clin N Am 41 (2003) 747–756
Fig. 1. Sagittal (A) and axial (B, C ) line drawings demonstrate the pubococcygeus and the iliococcygeus muscles that are the
major components of the levator ani. On sagittal images the pubococcygeal line is drawn from the last joint of the coccyx to
the inferior aspect of the symphysis. In contrast to the sagittal drawing, the anococcygeal raphe, or levator plate, usually parallels
the pubococcygeal line in women with intact pelvic floors. (From Cardozo L. Urogynecology. New York: Churchill-Livingstone;
1997. p. 325 – 6; with permission.)
J.R. Fielding / Radiol Clin N Am 41 (2003) 747–756 749
condensations are rarely seen using standard methods

of imaging but can be identified with MR imaging
and an endovaginal coil [6].
Laxity of the supporting muscles and stretching or
tearing of the fascial supports lead to pelvic floor
relaxation. These deficits become greater in the mid-
dle-aged and elderly population likely because of
diminished estrogen supply and blood flow to the
pelvic floor. Loss of the pubocervical fascia leads to
posterior descent of the bladder into the anterior
vaginal wall, formation of a cystocele, and associated
urinary incontinence. Loss of the paracolpia leads to
urethral hypermobility and is often associated with
intrinsic urethral sphincter damage. Damage to the Fig. 2. Coronal image obtained during a voiding cystoure-
parametria and paracolpia causes uterine descent and, throgram in a 72-year-old woman who complained of
in severe cases, procidentia. Tears in the rectovaginal urinary incontinence. A pessary is in place. The deformation
fascia lead to the formation of sigmoidocele and of the left aspect of the bladder wall (arrow) corresponded to
enterocele and, occasionally, rectal intussusception. a detrusor muscle contraction, which indicated the presence
of urge incontinence.
These women may present with constipation or a
feeling of incomplete defecation.
rogenic bladder is another significant finding. These
patients often have a history of spinal injury. The
Imaging techniques bladder remains contracted and severely trabeculated
during the entirety of the examination and may have a
For most patients with mild to moderate stress markedly tapered dome. Although voiding cystoure-
incontinence and pelvic floor relaxation, the com- thrography is rarely required to diagnose stress incon-
bination of physical examination findings and urody- tinence, it can be useful in severe cases in which the
namic pressure readings is diagnostic and no further bladder extends so far inferiorly that the bladder neck
imaging is required. For patients with severe urinary kinks, which masks symptoms [9].
or fecal incontinence believed to be multifactorial,
multiple compartment involvement, or failed prior Ultrasound
surgery, imaging can be valuable. Several techniques
can be used to evaluate the pelvic organs, including Ultrasound of the bladder neck or perineum is an
voiding cystourethrography (with or without concur- alternative way to diagnose stress incontinence.
rent video urodynamic tracings), ultrasound of the Again it is usually only of clinical use for assessment
bladder neck and anal sphincter, colpocystodefecog- of bladder neck mobility. Transrectal ultrasound has
raphy, and MR imaging. been shown to be reliable in the identification of
rectal sphincter tears and atrophy (Fig. 3) [10,11]. It is
Voiding cystourethrography often used before surgery to gauge the size and depth
of tear and identify adjacent hypoechoic scar tissue.
Voiding cystourethrography is often performed A small probe that provides circumferential images
during an incontinence evaluation to exclude ana- is placed in the rectal canal. Images are obtained at
tomic abnormalities, such as duplicated collecting 5-mm intervals along the length of the sphincter,
systems and ureters, bladder and urethral diverticula, approximately 2.5 cm. The normal internal sphincter
and vesicoureteral reflux. Even when these findings is a circumferential black band of uniform thickness.
are not present, examination of the bladder can pro- The external sphincter is harder to see because it is
vide useful information. Trabeculation is a sign of echogenic. Tears are defined as areas of discontinuity.
urge incontinence or detrusor overactivity (Fig. 2) [7]. Large tears respond poorly even to aggressive sur-
The hallmark of this disease is the sudden onset and gical intervention.
imminent need to void because of a bladder contrac-
tion. This is the most common type of incontinence in Defecography
elderly persons, and it affects up to 30% of persons
living at home and 50% of persons in long-term care Colpocystodefecography is a method of observing
institutions [8]. Identification of an unsuspected neu- all three compartments of the pelvic floor during rest,
contrast material in the vagina. In the upright posi-

tion, multiple spot fluoroscopic images are obtained
during pelvic floor maneuvers, concluding with def-
ecation. With pelvic floor contraction, a sharp ano-
rectal angle is an indicator of good muscular support;
however, specific measurements have not been found
useful. Retained barium within a portion of the
anterior rectum that bulges more than 2 cm into
the rectovaginal space is defined as an anterior
rectocele. Patients often are able to empty the rec-
tocele manually. Descent of small bowel loops into
the rectovaginal space is defined as an enterocele and
indicates a tear in the rectovaginal fascia (Fig. 4).
Many gastroenterologists believe that an enterocele
gives a patient the feeling of incomplete defecation
despite the presence of an empty rectum, which leads
Fig. 3. Axial image obtained during a transrectal ultrasound to persistent and ineffectual straining. Intussusception
of a 58-year-old woman with fecal incontinence. The usually involves only the rectum or rectosigmoid and
internal anal sphincter becomes increasingly hyperechoic resolves with cessation of Valsalva maneuver.
and thin (between arrows), which indicates damage to the
anterior portion, with a tear at the midline. MR imaging
upward contraction, and Valsalva maneuver. Because During the past 10 years, MR imaging has
it is done in the sitting position, it most closely emerged as a competitor to other imaging modalities
mimics the physiologic state [12]. In most institutions for evaluation of the female pelvic floor. The main
it is used primarily to identify posterior compartment advantages of MR imaging are ability to evaluate the
abnormalities, so the bladder is not opacified. 1 hour three compartments of the pelvic floor simultane-
before the study, the patient is a given a barium meal ously during rest and strain and direct visualization of
to coat the small bowel loops. Barium paste is placed supporting structures [13,14]. Disadvantages include
into the rectum, usually with the aid of a caulking the requirement that the examination be performed in
gun, and the patient places a tampon soaked in the supine or left lateral decubitus position, although
Fig. 4. Sagittal images obtained during defecography performed on a 56-year-old woman who complained of incomplete
evacuation. (A, B) The patient is in the sitting position on a commode chair. (A) The patient is evacuating the rectum. No anterior
rectocele is identified. (B) Multiple loops of small bowel extend posteriorly and inferiorly to the anorectal junction (arrow). This
is diagnostic of a rare posterior enterocele.
one group working with an open configuration mag- ing if necessary. If a perineal hernia or ballooning
net reported no significant difference between upright of the puborectalis is suspected, these images can be
and supine findings [15]. Because pelvic floor MR performed in the coronal plane. A standard fast
imaging is a relatively new technique, the remainder spin-echo or turbo spin-echo (Siemens) sequence is
of this article is devoted to a discussion of imaging then obtained in the axial view to provide high-
protocols and interpretation. resolution images of the supporting structures of
puborectalis, pubocervical fascia, and fascial con-
densations supporting the urethra. T1-weighted and
MR technique contrast medium-enhanced images are not required.
Room time for this examination is approximately
Obtaining high-quality, useful images requires 15 minutes. Comparison of this and similar MR tech-
careful attention to patient preparation and examina- niques with colpocystodefecography has revealed
tion technique. Just before imaging, the patient is good correlation [16].
asked to void, which prevents a distended bladder
from distorting adjacent anatomy. If the examination
is focused on the posterior compartment, 60 cc of MR anatomy
ultrasound gel is placed in the rectum using a small
catheter. A multicoil array, either pelvis or torso, is On sagittal images, the pubococcygeal line should
wrapped around the inferior portion of the pelvis and be drawn between the last joint of the coccyx and the
the patient is placed in the supine or left lateral inferiormost aspect of the symphysis. Urologists and
decubitus position. It is important that the coil be gynecologists use this line as an indicator of the
placed low enough so that prolapsing structures can pelvic floor. In early work, Yang et al [17] used
be seen. gradient echo images to define maximal normal
After a rapid T1-weighted or gradient echo large descent of the bladder base (1 cm below), vagina
field-of-view localizer sequence in the sagittal plane, (1 cm above), and rectum (2.5 cm below) with
the midline is identified. This image should encom- respect to the pubococcygeal line. In practical terms,
pass the symphysis, bladder neck, vagina, rectum, descent of the bladder or vagina more than 1 cm
and coccyx. The patient is then coached on how to below the pubococcygeal line indicates some degree
maintain maximum Valsalva. Most women can main- of laxity, whereas descent of more than 2 cm in a
tain maximal pressure for less than 10 seconds. Using symptomatic patient often requires surgical therapy.
an ultrafast T2-weighted imaging sequence, such as Rectal abnormalities, such as anterior rectocele, intus-
single shot fast spin-echo (on GE magnets [General susception, and enterocele, are identified in the same
Electric Medical Systems, Milwakee, WI]) or half fashion as with defecography. There are other impor-
Fourier acquisition turbo spin echo (on Siemens tant findings on sagittal images. The levator plate
magnets [Siemens Medical Solutions USA, Malvern, should remain parallel to the pubococcygeal line at all
PA]), sagittal midline images 10 mm in thickness are times. Caudal angulation of the levator plate more
obtained at rest and at maximal Valsalva strain. Table 1 than 10° indicates loss of pelvic floor support [18,19].
shows typical pulse sequence parameters. Each image Measurement of the H and M lines are useful
is obtained in approximately 3 seconds. The strain ways to quantify loss of pelvic floor support (Fig. 5)
images can be repeated after additional verbal coach- [20]. The H is drawn from the inferior aspect of the
Table 1
Pelvic floor protocol for evaluation of relaxation and incontinence
Slice thickness/ Flip Matrix freq Number
Sequence Plane TR (msec) TE (msec) FOV (cm) gap (mm) angle phase excitations
Localizer Sagittal 15 5 350 – 400 10 mm / 0 1° 160 256
HASTEa Sagittal NA 90 300 10 mm / 0 / 1 slice 180° 128 256 1 acq/
center low
T2 Turbo SE Transverse 5000 132 200 – 400 3 mm / interleaved 180° 270 256 2 acq
T2 Turbo SE Coronal 5000 132 200 – 240 5 mm / 1 mm 180° 270 256 2 acq
(optional)
Abbreviations: freq, frequency; HASTE, half Fournier single shot turbo spin echo; NA, not applicable; SE, spin echo.
a
Repeat this sequence at maximal strain (Valsalva).
Fig. 5. T2-weighted (2200/96) pelvic MR image of a 46-year-old healthy, continent volunteer. Sagittal images of the subject at
rest (A) and at strain (B) show minimal inferior movement of the pelvic viscera. The bladder neck is marked with a star. The
levator plate (black arrows) remains parallel with the pubococcygeal line (upper line of white solid arrows). The H (lower
line of white solid arrows) and M (open arrows) lines are less than 5 cm and 2 cm, respectively, which indicates an intact
levator hiatus. (From Fielding JR. Practical MR imaging of female pelvic floor weakness. Radiographics 2002;2:295 – 304;
with permission.)
symphysis pubis to the posterior wall of the rectum times rotates clockwise. This kinking of the urethra at
and measures the anteroposterior dimension of the the level of the bladder neck often masks the presence
pelvic hiatus. The M line is drawn as a perpendicular of stress incontinence. The more the patient strains,
from the pubococcygeal line to the posteriormost the less urine leaks out. A mobile urethra is also
aspect of the H line. It measures the height of associated with damage to the internal urethral
the hiatus. In healthy women, the H line should sphincter (Fig. 7). On axial images, the puborectalis
not exceed 5 cm, and the M line should not exceed may be avulsed or thinned, which indicates muscle
2 cm. Values more than these indicate loss of pelvic damage. Increased signal intensity of the puborectalis
floor support. compared with the obturator musculature likely indi-
Axial images should be reviewed for muscle cates fatty infiltration and has been reported in
integrity and signal intensity and for the vaginal
shape and location. The puborectalis should extend
from the parasymphysial insertion posterior to the
rectum. It should be of similar width along its entire
course without evidence of gaps or fraying (Fig. 6).
The width of the levator hiatus at the level of the
symphysis rarely exceeds 4.5 cm in healthy volun-
teers; however, there is some overlap with incontinent
patients. The vagina normally should be of an H or
butterfly shape and be centered in the pelvis [21].
Anterior compartment pathology
Women who present with severe stress inconti-

nence refractory to behavioral, drug, and surgical
therapy are good candidates for MR imaging. At
strain, the bladder neck extends well below the
Fig. 6. Axial T2-weighted image (4200/12) shows the
pubococcygeal line. Because of the strong attach- vagina to be butterly shaped and centered within the
ments anteriorly, the posterior wall of the bladder pubococcygeal sling (long arrows). Anteriorly the external
rotates posteriorly and inferiorly, impressing on the urethral sphincter and lateral pubovesical ligaments hold the
vaginal wall. The H and M lines are increased in urethra in place and form part of the extrinsic continence
length. During bladder descent, the urethra some- mechanism (short arrows).
Fig. 7. Stress incontinence and incomplete bladder emptying in a 55-year-old woman. Sagittal T2-weighted images (2200/96) at
rest (A) and at strain (B) show significant descent of the bladder, with rotation of the urethra into the horizontal plane (arrow)
with strain. This may mask stress incontinence. (From Fielding JR. Practical MR imaging of female pelvic floor weakness.
Radiographics 2002;2:295 – 304; with permission.)
association with stress incontinence [22]. Abnormal their uteri undergo reapproximation of the utero-
shape or location of the vagina is a good indication of sacral and cardinal ligaments in addition to a para-
a paravaginal tear (Fig. 8). These findings are critical vaginal repair.
to the referring surgeon. Large cystoceles with pre-
sumed paravaginal tears are usually treated with a
fascial repair and bladder suspension procedure. Posterior compartment pathology
When physical examination, urodynamics, and MR
imaging suggest a mobile urethra, a sling procedure is A rectocele or enterocele can occur alone or in
often performed to increase pressure on the urethra combination with other pelvic floor defects to form
and coaptation of the walls at rest.
Middle compartment pathology
Descent of the reproductive organs is almost

always associated with cystocele formation because
of the shared fascial supports. Gynecologists grade
descent by comparing organ location with bony and
soft tissue landmarks. On sagittal MR imaging,
descent of the uterus in addition to the vagina and
cervix usually indicates rupture of the cardinal or
uterosacral ligaments. It is not uncommon to identify
a uterine fibroid that prevents descent of the uterus
and masks the true degree of pelvic floor and sup-
porting fascial damage (Fig. 9). The H and M lines
again are of increased length. In cases of significant
middle compartment damage, axial images often
Fig. 8. A 64-year-old woman complained of dyspareunia.
show a flattened vagina and a widened hiatus Axial T2-weighted image (4400/12) of the pelvic floor shows
(Fig. 10). Perimenopausal or postmenopausal women posterior displacement of the right vaginal fornix and a com-
with significant anterior and middle compartment plete tear of the pubococcygeal sling (arrow). (From Fielding
relaxation often opt for hysterectomy with para- JR. Practical MR imaging of female pelvic floor weakness.
vaginal repair. Younger women who wish to retain Radiographics 2002;2:295 – 304; with permission.)
Fig. 9. A 63-year-old woman complained of incomplete bowel evacuation and pelvic pressure. Sagittal T2-weighted (2200/96)
MR image at rest (A) and at strain (B) show a large fibroid that is likely preventing descent of the anterior and middle
compartments. The levator plate is vertically oriented (black arrow), and there is development of a rectocele (white arrow),
which indicates significant damage to the posterior compartment. (From Fielding JR. Practical MR imaging of female pelvic
floor weakness. Radiographics 2002;2:295 – 304; with permission.)
global pelvic floor relaxation. Many of these patients New techniques

previously underwent hysterectomies that left them
with thinned or torn fascia. On sagittal MR imaging, Seated imaging
a rectocele is identified by anterior bulging of the
rectal wall, usually into the pouch of Douglas. Enter- During the past 5 years, several research groups
oceles occur when the rectovaginal fascia is torn, have reported on the feasibility and usefulness of
which allows small bowel loops to descend more than MRI in the upright position [13,24,25]. The primary
2 cm, again into the cul-de-sac. The levator plate advantage of this technique is that the seated position
often maintains its normal angulation, and the M and
H lines are normal or only minimally elongated with
an isolated anterior rectocele or enterocele. The
rectocele is treated with a posterior fascial repair.
Enterocele repair requires reapproximation of the
rectovaginal fascia.
Global pelvic floor relaxation
In severe cases, there is significant descent of the

contents of all three compartments of the pelvic floor
below the pubococcygeal line [23]. The levator plate
is nearly vertical, and there is extreme elongation of
the H and M lines (Fig. 11). On axial images there is
nearly always increased hiatal width and ballooning
of the iliococcygeus. This latter finding and any Fig. 10. A 58-year-old woman complained of pelvic
associated perineal hernias may be identified best pressure and had significant descent of the cervix on
on coronal images. Repair of these patients is com- physical examination. Axial T2-weighted (4400/12) image
plex and often includes hysterectomy and an anterior shows widening of the hiatus and descent of the pubococ-
and posterior fascial repair (Fig. 12). cygeal sling (arrows). The bladder neck is dilated (star).
Fig. 11. Pelvic pressure and protrusion of tissue through the pelvic floor in a 68-year-old woman. (A) Sagittal T2-weighted image
of the patient at strain shows global pelvic floor weakness with a severe cystocele and moderate descent of the uterus and rectum.
(B) Axial T2-weighted image (4400/12) shows the bladder protruding through the labia (arrow). (From Fielding JR. Practical
MR imaging of female pelvic floor weakness. Radiographics 2002;2:295 – 304; with permission.)
maximizes symptoms and imaging findings. Disad- of thin (3 mm) axial T2-weighted images that encom-
vantages include the low signal to noise images pass the important soft tissue organs and bony land-
obtained using available 0.5 T equipment. marks. A three-dimensional rendering program is then
performed that allows various degrees of opacity and,
Three-dimensional volumetric analysis depending on the program used, color. The model
pelvis can be rotated at will. This technique has been
The formation of three-dimensional models of the used to define the volume of the puborectalis in healthy
muscular supports of the female pelvic floor is pri- young women and demonstrate that diminished vol-
marily a research tool. The models can be used to ume correlates well with worsening pelvic floor
quantify muscle volume, simulate lithotomy views, relaxation [18,26]. It is hoped that in the future this
and plan resection of vulvar tumors or repair of the tool can be used to predict surgical outcomes, thereby
pelvic floor [26]. The technique is based on acquisition enabling correct triage of the patient at presentation.
Fig. 12. Cystocele and vaginal vault prolapse in a 74-year-old woman. (A) Sagittal T2-weighted MR image (2200/96) obtained at
maximal strain shows a large cystocele (arrow). (B) After surgical repair, midline image obtained with the same MR parameters
shows a small residual posterior fascial defect (arrow). (From Fielding JR. Practical MR imaging of female pelvic floor
weakness. Radiographics 2002;2:295 – 304; with permission.)
Summary mechanisms in the supine and sitting positions. AJR

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Radiol Clin N Am 41 (2003) 757 – 767
Imaging of female infertility

Amy S. Thurmond, MDa,b,*
a
Tualatin Imaging, 8950 Southwest Nimbus Avenue, Beaverton, OR 97008, USA
b
Department of Obstetrics and Gynecology, Oregon Health Sciences University, 8950 Southwest Nimbus Avenue,
Beaverton, OR 97008, USA
Normal reproduction life span of approximately 12 to 13 days. Estrogen

and progesterone stimulate growth and development
The female reproductive tract includes the vagina, of the secretory endometrium. The follicles that
uterus and cervix, fallopian tubes, and ovaries and the developed, but were not ovulated, become atretic.
hypothalamus and pituitary, breasts, and their sup- Sperm are deposited in the vagina and travel up the
porting structures. For the discussion of infertility, the cervix and uterus into the fallopian tube. Fertilization
article focuses on the structures of the female pelvis of the ovum occurs in the ampullary portion of the
and the monthly physiologic changes that allow fallopian tube. As the embryo begins to develop, it
conception to occur and are reflected in anatomic travels down the fallopian tube and into the uterine
changes that can be imaged. fundus, where it implants in the endometrium. If
The hypothalamus in the female controls the conception does not occur, the corpus luteum
monthly cycling of hormones responsible for normal regresses and its hormones are withdrawn, which
ovulation and the readying of the endometrium for results in endometrial shedding (menstruation). The
embryo implantation. Releasing factors from the cycle is repeated every month, with an average
hypothalamus stimulate production and release of duration of 28 days for the follicular, secretory, and
the anterior pituitary gonadotropins, follicle-stimu- regression phases.
lating hormone, and luteinizing hormone. Follicle-
stimulating hormone and luteinizing hormone cause
maturation of ovarian follicles signaled by increase in
follicular fluid and follicular estrogen production. Infertility
The increasing estrogen results in a surge of leutei-
nizing hormone, which in turn causes rupture of one Infertility affects one in seven American couples
follicle and expulsion of its ovum, which can then be [1]. Approximately 40% of the time the cause is
swept into the fimbriated end of the fallopian tube. attributable to the woman; 40% of the time the cause
The ruptured follicle develops into a corpus luteum, is attributable to the man. Approximately 20% of the
which produces progesterone and estrogen and has a time there may be combined or unexplained factors.
In the past, a radiologist or imaging specialist only
encountered the infertile couple at the time of hys-
terosalpingography, which remains a mainstay in the
diagnosis of uterine and tubal causes of infertility. In
* Department of Obstetrics and Gynecology, Oregon the past 15 to 20 years, however, there have been
Health Sciences University, 8950 Southwest Nimbus advances in treatment for the various causes of
Avenue, Beaverton, OR 97008. infertility, development of new imaging modalities,
E-mail address: [email protected] and improvement of old methods.
doi:10.1016/S0033-8389(03)00064-2
758 A.S. Thurmond / Radiol Clin N Am 41 (2003) 757–767
Traditionally, the causes of infertility are divided

into cervical, endometrial/uterine, tubal,
peritoneal, ovulatory, and male factor
Cervix
The cervix contains glands that secrete mucus and

crypts that harbor sperm. The hospitality of the cervix
to sperm is not evaluated by imaging the cervical
anatomy but is best determined by the postcoital test.
The postcoital test is performed within 24 hours of
intercourse and is accomplished by aspiration of the Fig. 2. Small, irregular, well-defined filling defect in the mid
cervical mucus, which is then examined microscopi- uterine cavity (arrow) is a synechia from prior miscarriage
cally. The quantity and motility of living sperm are with dilatation and curettage.
assessed. The most common cause of an abnormal
result, also called ‘‘hostile mucus,’’ is timing of the
test too early or too late in relation to ovulation. relative to the cervical canal. The size of the normal
The normal size and appearance of the cervix are cavity can vary, depending on the imaging modality
variable; therefore, diagnosis based on appearance used and whether uterine distention is being used. A
alone is difficult. An internal os region that is less subjective sense of normal size and shape, rather than
than 1 mm in diameter by hysterosalpingography numeric criteria, is most helpful. The uterine wall is
(HSG) in a woman with painful periods may indicate usually approximately 2 cm thick. The wall of the
cervical stenosis. An internal os wider than 1 cm or a uterus is best imaged by sonography or MR imaging,
funnel-shaped uterus and cervix in a woman with whereas the cavity is best imaged by contrast hysterog-
painless second trimester pregnancy confirms the raphy (Fig. 1).
diagnosis of incompetent cervix [2].
Uterine cavity filling defects
Uterus
Uterine cavity filling defects encountered during
Anomalies or defects that affect the size and shape HSG may be caused by synechia, which are scars that
of the uterine cavity and uterine wall also may affect result from uterine trauma, such as complications of
the blood supply and ability of the uterus to support pregnancy, curettage, uterine surgery, or uterine in-
the developing embryo and fetus. The normal shape fection. Synechiae are generally linear and irregular
of the uterine cavity is that of an inverted triangle (Fig. 2) and extend from one wall to the opposite
wall, which allows contrast agent to flow around
them only in one dimension. For this reason, they
are more easily defined than polyps, myomas, or
other masses that generally allow contrast agent to
flow around them in two dimensions. Polyps are
small and smooth, do not distort the shape of the
cavity, are often multiple, and are echogenic by
sonography (Fig. 3). Leiomyomas are usually larger,
more vascular, and single and do enlarge and distort
the cavity (Fig. 4). Air bubbles are round, smooth,
and mobile. Blood clots are lobulated avascular intra-
cavitary masses. Products of conception, if retained
from an earlier pregnancy, are usually irregular,
unlike the other entities described previously.
All intracavitary masses probably can interfere
with embryo implantation. Even small masses may
become inflamed and act like an intrauterine device
Fig. 1. Normal hysterosalpingogram demonstrates fallopian for contraception. Large masses may distort the
tube interstitial portion (short arrow), isthmic portion (long cavity and the blood supply to the developing em-
arrow), ampullary portion (double arrows). bryo. It is important to define the number, size, and
A.S. Thurmond / Radiol Clin N Am 41 (2003) 757–767 759
Fig. 3. Endometrial polyp demonstrated by (A) hysterosalpingography (arrows) and (B) transvaginal sonography (cursors).
location of uterine masses. Small, mostly intracavi- Bicornuate uterus is associated with a low incidence
tary masses can be removed hysteroscopically. Large of fertility complications and usually is not treated.
myomas with an intramural component may require An incompetent cervix is associated with bicornuate
uterine artery embolization or laparotomy with myo- uterus, and serial scanning during pregnancy to assess
mectomy. If surgical resection is planned, MR imag- cervical length can be helpful. Class V (septate
ing should be considered to differentiate myomas uterus) consists of two uterine cavities and a single
from adenomyosis [3], because the latter is not fundus. The septum also can involve the cervix and
resectable (Fig. 5). vagina (Fig. 8). Of the correctable lesions, a uterine
septum has the highest incidence of fertility and
Congenital uterine anomalies pregnancy problems; therefore the septum is usu-
ally removed hysteroscopically (Fig. 8B). Class VI
Congenital uterine anomalies have been estimated (T-shaped uterus) is caused by diethylstilbestrol ex-
to occur in at least 1% of women [4]. They are a posure in utero. Diethylstilbestrol was an estrogen
result of defects in paired müllerian duct develop- compound used in the United States in the 1950s,
ment, fusion, or resorption and are associated with 1960s, and occasionally in the 1970s in women with
renal anomalies in 20% to 25%. The anomalies have threatened abortion. In addition to a small, T-shaped
been classified into seven groups based on their uterine cavity, these women may have a mucosal
prognosis for future fertility and surgical treatment ridge or hood superior to their external cervix and
[4]. Class I (segmental müllerian agenesis) is mani-
fested by variable absence of the uterus or cervix. It
presents as absence of menstrual bleeding at puberty
and may be associated with pelvic pain because of
retrograde menses. It may or may not be surgically
correctable depending on the findings. Class II (uni-
cornuate uterus) is caused by absence of development
of one of the müllerian ducts (Fig. 6) and is almost
always accompanied by absence of the kidney on the
same side. There is an association with fertility and
pregnancy difficulties; however, there is essentially
no treatment. Class III (uterus didelphys) results in
two separate uterine horns, cervices, and vaginas. In
general, it is not associated with fertility or pregnancy
problems and usually is not treated. Class IV (bicor-
nuate uterus) is characterized by two separate uterine Fig. 4. Intracavitary myoma demonstrated by sonohyster-
horns, usually one cervix and one vagina (Fig. 7). ography. Color flow is visualized within the lesion.
Fig. 5. Uterine myoma suspected by clinical findings. (A) Transvaginal sonography demonstrates enlarged uterus with possible
mass. (B) Sonohysterography outlines ill-defined mass projecting into the cavity (arrows). (C) MR imaging demonstrates that the
mass is adenomyosis and not a myoma (arrows).
clear cell adenocarcinoma of the vagina. They do Fallopian tube

have fertility and pregnancy problems, and no defi-
nite treatment is known. Because of high association The fallopian tubes have a unique status in the
with cervical incompetence, serial scanning during body. Via the uterus, cervix, and vagina they connect
pregnancy to assess cervical length can be helpful. the peritoneal cavity to the external world [5]. Their
Finally, and most importantly, many anomalies occur function and their anatomy is complex and includes
that do not fit neatly into any of these described conduction of sperm from the uterine end toward the
categories. When in doubt, it is best to describe the ampulla, conduction of ova in the other direction from
anatomy completely without attaching a label to it. the fimbriated end to the ampulla, and support of the
Fig. 6. Unicornuate uterus by hysterosalpingography (A) and MR imaging (B). Note the nonfunctioning rudimentary horn (arrow).
early embryo and conduction of the early embryo from infundibulum, which is the trumpet-shaped distal end
the ampulla into the uterus for implantation. The of the tube that terminates in the fimbria. Patency of the
normal fallopian tube ranges in length from 7 to fallopian tubes is established when contrast medium
16 cm, with an average length of 12 cm. The tube is flows through them and freely around loops of bowel
composed of a ciliated mucosal epithelial layer sur- at the time of salpingography, using either fluoroscopic
rounded by three smooth muscle layers. The tube is or sonographic guidance.
divided into four regions (see Fig. 1): (1) the intramural The interstitial portion of the fallopian tube may
or interstitial portion, which occurs in the wall of the be delicate and thread-shaped or may be funnel-
uterine fundus and is 1 to 2 cm long; (2) the isthmic shaped, assuming the configuration of a small trian-
portion, which is approximately 2 to 3 cm long; (3) the gle or diamond. The isthmic portion is normally
ampullary portion, which is 5 to 8 cm long; and (4) the thread-shaped. Diameter of both regions is approxi-
Fig. 7. Bicornuate-septate uterus by hysterosalpingography (A) and MR imaging (B). The indentation of the serosal contour of
the uterine fundus though small makes this technically bicornuate uterus, and likely not clinically significant. Correct
categorization and determination of significance of uterine anomalies is debated by fertility specialists.
Fig. 8. Septate uterus. (A) Complete uterine and cervical septum by MR imaging. (B) Postoperative hysterosalpingogram
demonstrates normal cavity after resection of uterine septum; cervical septum was not resected to avoid incompetent cervix. Two
cervical canals are demonstrated (arrows).
mately 1 mm. Proximal tubal obstruction is obstruc- may be explained by a temporary or easily dislodged
tion in the first 3 to 4 cm of the tube. The cause of entity, such as amorphous debris in the tubal lumen.
proximal tubal obstruction is frequently unclear, but Tubal spasm, or some temporary inability to visualize
infection and subsequent inflammation are leading the fallopian tubes, does occur, however, probably
causes in all reported series [6]. Histopathologic much less often than originally proposed. It seems to
findings in resected proximal tubal segments include be a more common cause when the proximal tubal
plugs of amorphous debris, chronic inflammation, obstruction is unilateral. Placing the patient prone and
obliterative fibrosis, and salpingitis isthmica nodosa waiting 5 minutes before slowly reinjecting contrast
(SIN) (Fig. 9). Together these lesions account for agent into the uterus may help sort out patients with
70% to 85% of anatomic occlusions at the uterotubal temporary nonvisualization versus true mechanical
junction. Unusual causes include granulomatous or obstruction. If the proximal tubal obstruction persists
‘‘giant cell’’ salpingitis from tuberculosis, foreign despite these maneuvers, tubal catheterization with
bodies, and some parasitic infestations. Intraluminal selective salpingography can be performed (Fig. 9).
endometriosis occurs in approximately 10% of tubes Diverticula in the isthmic segment of the tube are
resected for proximal occlusion and may exist with- caused by SIN (Fig. 10). SIN was described more than
out relation to visible lesions elsewhere in the pelvis. 100 years ago as irregular benign extensions of the
Müllerian anomalies of the fallopian tube are rare, but tubal epithelium into the myosalpinx associated with
cornual occlusion is seen with variants of unicornuate reactive myohypertrophy and sometimes inflamma-
uterus, and atresia of tubal segments, including the tion. There is an association between SIN and pelvic
proximal isthmus, can occur. inflammatory disease; however, it is not clear whether
Several authors have noted a lack of major histo- SIN is caused by pelvic inflammation or whether SIN
logic findings in patients despite persistent proximal is congenital and predisposes to inflammation. SIN is
occlusion. It was assumed that the cause of this focal and located only in the isthmus in most affected
discrepancy was ‘‘tubal spasm,’’ which was estimated women; however, SIN occasionally can be found in
to be the cause in up to one third of women with the interstitial and ampullary segments. Compared
proximal tubal obstruction. No anatomic or functional with control populations, SIN has a higher incidence
proximal tubal sphincter was identified, however, and in women with tubal pregnancy and in women with
no reliable ’’antispasmodic‘‘ was discovered [7]. Care- proximal tubal obstruction. SIN associated with tubal
ful histologic analysis of tubal specimens resected for obstruction requires treatment to restore tubal pat-
proximal occlusion revealed amorphous debris in ency, which can be accomplished by fluoroscopically
approximately one third of women [8]. Discrepancy guided tubal catheterization and recanalization (see
between clinical and imaging diagnosis of proximal Fig. 9) [9]. If this approach fails, tubal patency can be
tubal occlusion and subsequent pathologic findings accomplished by surgical resection and anastomosis.
Fig. 9. Fallopian tube catheterization and recanalization in a woman with tubal obstruction associated with SIN. (A) Selective
salpingography demonstrates the proximal occlusion and isthmic diverticulae of SIN (arrows). (B) Small guidewire used to
recanalize occlusion. (C) Repeat selective salpingogram demonstrates a patent tube.
Whether SIN in the absence of tubal obstruction requires optimal tubal imaging, because the normal
requires surgical resection is debatable. rugal folds are subtle.
The ampullary portion is the longest portion of the Obstruction of the fimbrial portion of the tube is
tube. It gradually widens from 1 to 2 mm at its characterized by dilation of the ampullary portion of
proximal end to approximately 15 mm, where it joins the tube, which sometimes can be massive, and no
the fimbriated infundibular portion. Subtle ampullary free spill of contrast agent into the peritoneal cavity
rugal folds can be demonstrated by salpingography, despite adequate filling of the tubes and rolling the
and occasionally the fimbriae are outlined by contrast patient (see Fig. 10). The amount of dilation of the
material. Abnormal rugal folds imply damage of tube does not necessarily predict surgical results. A
the epithelium from infection and usually coexist dilated tube may be soft and pliable with an intact
with a dilated and sometimes distally obstructed tube epithelium and offer an opportunity for surgical
(Fig. 10). Abnormal rugal folds can occur in a patent correction. An obstructed but minimally dilated tube
tube, and they indicate reduced chances for concep- may have an indurated and thickened wall that cannot
tion. The visualization of abnormal rugal folds be reconstructed. The visualization of normal ampul-
embryos back into the uterine cavity [10]. The ‘‘take

home baby rate’’ per embryo transfer procedure is
approaching 50% in some clinics.
Peritoneal cavity
Laparoscopy is the gold standard for visualizing

pelvic adhesions and endometriosis. Ultrasound visu-
alization of adhesions is definitive (Fig. 12), but the
sensitivity is poor, and the extent of disease cannot be
determined. Indirect evidence about peritubal disease
is obtained at the time of HSG from the pattern of spill
of contrast agent out the fimbriated end of the tubes
and into the peritoneal cavity. When contrast agent
flows freely around loops of bowel, one can be confi-
Fig. 10. Woman with untreated chlamydia infection as a dent that no significant pelvic disease exists (see Fig. 1).
teenager has severe bilateral salpingitis isthmica nodosa. The If contrast agent remains loculated around the tube
right fallopian tube is patent, and the left fallopian tube is outlining its wall or in the pelvis despite rolling the
occluded distally and demonstrates a hydrosalpinx. patient, one should be suspicious of peritubal and
pelvic adhesions (see Fig. 12), although patients with
these findings occasionally have a normal pelvis.
lary rugal folds probably improves the chances for Ovary and adnexa
successful tubal reconstruction.
Dilation of the ampullary portion of the tube in the Normal ovary
absence of complete occlusion indicates perifimbrial A follicle is recruited by unknown mechanisms to
phimosis, or adhesions around the fimbria that im- grow in the follicular phase, and it demonstrates an
pede egress of fluid. Adhesions around the tube are average increase in diameter of 2 to 3 mm/day. When
usually a result of chlamydial or gonococcal infection this ‘‘dominant’’ follicle attains an average diameter
or endometriosis. It may be difficult to differentiate a of 22 mm, it ruptures. Normal rupture can be accom-
dilated tube from loculated spill of contrast agent. panied by a decrease in size or an increase in size. On
Fimbrial phimosis can be mild or severe, but gener- sonography echoes in the lumen of the follicle may
ally the presence of at least a pinpoint opening in the appear. Fluid around the ovary also may be seen.
distal tube carries a more favorable surgical prognosis Ultrasound is considered by some to be the best
than complete occlusion. It also increases the risk of method for determining when ovulation will occur
post-HSG peritonitis, however. Patients with dilated and documenting when it has occurred [11]. The
tubes should receive a total of 5 days of antibiotics, variable appearance of the event makes the use of
usually doxycycline (100 mg) orally twice a day. If ultrasound problematic, however.
the patient is not already taking antiobiotics at the After menstruation, the ovaries should contain a
time of the procedure and a dilated tube or tubes few small follicles and sometimes a subtle heteroge-
are demonstrated, she should receive doxycycline neous area that may be the corpus luteum. The
(200 mg) orally before she leaves the department, presence of one or more cysts larger than approxi-
followed by 100 mg orally twice a day for 5 days [1]. mately 2 cm in diameter—particularly if accompa-
Persistent tortuosity of the tube in all projections is nied by a serum estradiol concentration of more than
associated with peritubal adhesions (Fig. 11), although 100 pg/mL—indicates persistent follicle activity that
some normal tubes can demonstrate this finding. could interfere with response to ovarian stimulation
A woman with severely damaged fallopian tubes medication. Suppression of the cyst or cysts with oral
but a normal uterine cavity is a good candidate for in contraceptives may be considered [12].
vitro fertilization and embryo transfer (see Fig. 10). In
vitro fertilization and embryo transfer consist of Polycystic ovary syndrome
ovarian stimulation, needle aspiration of the oocytes
from the follicles using transvaginal ultrasound Polycystic ovary syndrome is often found during
guidance, incubation of the oocytes with sperm, evaluation for infertility. The inhibition of release of
and catheter delivery of two to four developing follicle-stimulating hormone and leutinizing hormone
Fig. 11. A 29-year-old woman with infertility. (A) Hysterosalpingogram demonstrates occlusion of the right tube in the proximal
ampullary portion and tortuosity of the left tube, which is patent. MR imaging demonstrates a left ovarian endometrioma, which
is low signal on T2-weighted images (arrow) (B) and high-signal on T1-weighted images (arrow) (C). (D) T2-weighted MR
imaging demonstrates adhesions (arrows) that explain the tubal findings.
from the pituitary gland is the underlying mechanism syndrome as evidenced by low follicle-stimulating
of polycystic ovary syndrome. As a result, follicles in hormone and leutinizing hormone and high estrogen
the ovary begin to grow but do not develop properly. and androgen levels, however, and the ovary may
The immature follicles produce estrogen and andro- appear normal by ultrasound. The chronic elevation
gen that further inhibit the pituitary gland and prevent of estrogen may cause some women with polycystic
normal ovulation. A round ovary with multiple small ovary syndrome to develop irregular bleeding, a
immature follicles may be evident by ultrasound, thickened endometrium, or even endometrial carci-
and it confirms the diagnosis of polycystic ovary noma. The chronic elevation of androgens causes
syndrome (Fig. 13) [13]. A woman may have the some women to develop hirsutism.
Fig. 12. A 32-year-old woman with pelvic pain and infertility. (A) Transvaginal sonography demonstrates bilateral endometriomas
(arrows) that are composed of low-level echoes. (B) On the left side, an adhesion from the ovary to the posterior cervix is
demonstrated (arrow).
The most common cause of polycystic ovary cation for endometriotic implants is the ovaries, and
syndrome is obesity. Fat produces estrogen, which endometriomas are often bilateral (see Fig. 12). Endo-
inhibits follicle-stimulating hormone and leutinizing metriosis is the presence of endometrial tissue outside
hormone and leads to the cycle described previously. of the endometrial cavity. It usually presents in the
Other causes of polycystic ovary syndrome are dia- reproductive years and is probably caused by retro-
betes and adrenal, thyroid, or pituitary dysfunction, grade menstruation [14]. Pelvic pain and dyspareunia
which affects the delicate hormone balance required are associated with endometriosis, although some
for normal ovulation. women with extensive endometriosis may be asymp-
tomatic. Large endometriomas are likely to be diag-
Endometriosis nosed; however, small implants are not well visualized
by any imaging techniques.
Endometriosis may cause infertility because of
anatomic or chemical factors. The most frequent lo-
References
[1] Winfield AC, Wentz AC. Diagnostic imaging in in-

fertility. 2nd edition. Baltimore: Williams and Wil-
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[2] Hricak H, Chang YCF, Cann CE, Parer JT. Cervical
incompetence: preliminary evaluation with MR imag-
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[3] Togashi K, Ozasa H, Konishi I, et al. Enlarged uter-
us: differentiation between adenomyosis and leio-
myoma with MR imaging. Radiology 1989;171:
531 – 4.
[4] Buttram VC. The American Fertility Society classifica-
tion of adnexal adhesions, distal tubal occlusion, tubal
occlusion secondary to tubal ligation, tubal pregnancies.
Müllerian anomalies and intrauterine adhesions. Fertil
Steril 1988;49:944 – 55.
Fig. 13. A 24-year-old woman with infertility and polycystic [5] Woodruff JD, Pauerstein CJ. The fallopian tube. Balti-
ovary syndrome. Transvaginal sonography demonstrates that more: Williams and Wilkins; 1969. p. 22 – 32.
both ovaries are round and contain 10 to 12 small follicles and [6] Thurmond AS. Fallopian tube catheterization. In:
an echogenic stroma, consistent with the diagnosis. Thurmond AS, Jones MK, Cohen DJ, editors. Gyne-
cologic, obstetric, and breast radiology. Boston: Black- [11] Rosen GF. Ultrasound in reproductive endocrinology.
well Scientific; 1996. p. 127 – 31. In: Schlaff WD, Rock JA, editors. Decision making in
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agnosis of interstitial fallopian tube obstruction. Invest tific; 1993. p. 386 – 91.
Radiol 1988;23:209 – 10. [12] Worley RJ. Ovulation induction: clomiphene. In:
[8] Sulak PJ, Letterie GS, Coddington CC, et al. Histology Schlaff WD, Rock JA, editors. Decision making in
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[9] Thurmond AS, Burry KA, Novy MJ. Salpingitis isth- [13] Pache TD, Wladimiroff JW, Hop WC, Fauser BC. How
mica nodosa: results of transcervical fluoroscopic cath- to discriminate between normal and polycystic ovaries:
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[10] Bustillo M. Assisted reproductive technology in the [14] Klein NA, Olive DL. Management of endometriosis-
United States and Canada: 1992 results generated from associated infertility. In: Schlaff WD, Rock JA, editors.
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Radiol Clin N Am 41 (2003) 769 – 780
Ultrasonographic evaluation of the endometrium in

postmenopausal vaginal bleeding
Katharine G. Davidson, MDa, Theodore J. Dubinsky, MDb,*
a
Department of Anesthesiology, University of Iowa Hospitals and Clinics, 6 JCP, Iowa City, IA 52242, USA
b
Departments of Radiology, Obstetrics and Gynecology, Harborview Medical Center, University of Washington, Box 359728,
325 Ninth Avenue, Seattle, WA 98104, USA
Abnormal vaginal bleeding is a frequent presenting the Pipelle in postmenopausal women with sample
complaint in women in the postmenopausal or peri- size – weighted sensitivity rate of 99.6% [2].This
menopausal period. Postmenopausal bleeding (PMB) study was performed by sampling known cases of
may be defined as any vaginal bleeding in a postme- endometrial carcinoma while the patients were on the
nopausal woman not on hormone replacement ther- operating table. In the authors’ own attempt to per-
apy (HRT) or unscheduled bleeding in a woman on form a metaanalysis regarding endometrial biopsy,
HRT. The differential diagnosis is broad, but irregular they found that none of the literature met adequate
or excessive vaginal bleeding can signify an under- criteria to be included. The major problem with the
lying malignancy of the female genital tract. Bleeding biopsy literature is a lack of blinded studies with
occurs in 80% to 90% of women with endometrial adequate gold standard proof of outcomes.
cancer, and the prevalence of endometrial cancer Sensitivity rate for detection of atypical hyper-
among women who present with PMB has been plasia varied from 39% to 100%, with weighted sen-
reported to range from 1% to 60%, although a 10% sitivity rate of the Pipelle in postmenopausal women
prevalence of endometrial cancer in this population being 88% [2]. The false-negative rates for endo-
has been accepted by most authors [1]. All women metrial biopsy in the office may be more than 15%,
who present with postmenopausal bleeding should be whereas even dilation and curettage had up to 11%
evaluated for potential malignancy, including endo- false-negative rate for endometrial carcinoma [3,4].
metrial cancer, premalignant atypical endometrial One study reported only a 43% sensitivity rate for
hyperplasia, and cervical cancer. detecting endometrial carcinoma with endometrial
It is well established that women with PMB biopsy [5]. The actual sensitivity rate for endome-
require further evaluation to exclude carcinoma. To trial biopsy remains unknown, and only when large
date, however, no universal algorithm exists for enough trials using hysteroscopy as the gold stan-
proceeding with an evaluation of a woman with dard for evaluating endometrial disease are pub-
PMB. Tissue sampling is the most definitive diag- lished will this information become available for
nostic procedure; however, the techniques have accurate evaluation.
variable sensitivity and specificity. In a recent meta- Because up to 90% of PMB has a benign cause,
analysis of endometrial sampling methods, the sen- questions have arisen regarding the appropriate-
sitivity rate for detection of endometrial carcinoma ness of performing biopsies on all patients with
ranged from 25% to 100%, with the best results from bleeding. Subsequently, imaging techniques, mainly
transvaginal ultrasound, have been explored to help
determine which patients are at higher risk of ma-
* Corresponding author. lignancy and would benefit from tissue sampling
E-mail address: [email protected] and which are more likely to have a benign cause
(T.J. Dubinsky). for the bleeding.
doi:10.1016/S0033-8389(03)00060-5
770 K.G. Davidson, T.J. Dubinsky / Radiol Clin N Am 41 (2003) 769–780
In 2000, a panel of physicians convened by the excludes patients with endometrial carcinoma. In a
Society of Radiologists in Ultrasound met to discuss prospective study of 1110 women with PMB, endo-
the role of sonography in women with PMB. The metrial pathology was found most frequently with
panel members included experts in the fields of endometrial thickness more than 8 mm, and no
radiology, obstetrics and gynecology, gynecologic endometrial cancers were detected in women with
oncology, epidemiology, and pathology. The panel thickness of 4 mm or less [9]. Similarly, an evaluation
concluded that PMB demands further evaluation and of 419 women with PMB assessed the sensitivity of
that either transvaginal sonography or endometrial two thresholds: more than 4 mm and more than 8 mm.
biopsy could serve as the first diagnostic interven- The authors reported a sensitivity rate of 95.1% and
tion. The panel also concluded that further studies specificity rate of 54.8% for the 4-mm cutoff and
were needed to determine which approach is more 83.8% and specificity rate of 81.3% for the 8-mm
effective [6]. cutoff [10]. Using a threshold of 5 mm or less, a study
of 182 women with PMB found no cases of carci-
noma, but 3 patients had hyperplasia [11]. Another
Background study concluded that a threshold of 4 mm or less can
reliably exclude malignancy in women with PMB
Pelvic ultrasound has been used to evaluate the [12], with an estimated one case of carcinoma missed
uterine cavity for fibroids, endometrial thickness, for every 250 women scanned with a stripe of less
endometrial homogeneity, and the presence of abnor- than 5 mm [5].
mal vascularity within the endometrium. In the Some authors reported even a thicker stripe as an
absence of visible anomalies (such as fibroids), adequate threshold for excluding endometrial adeno-
endometrial thickness has been used as a marker for carcinoma. Mateos et al [13] reported a prospective
endometrial pathology. The technique most often trial of transvaginal sonography followed by endo-
used to evaluate the endometrial thickness is a metrial sampling in 168 women with PMB not on
measurement of the anterior and posterior layers of estrogen. Using a cut-off of 6 mm, they reported
the endometrium in the sagittal plane at the level of 88.6% sensitivity rate, 90.6% specificity rate, and
the maximal estimated thickness. This technique has 92% positive predictive value (PPV) for any endo-
been demonstrated to be highly reproducible with metrial pathology.
high intraobserver (r(I) = 0.96 – 0.97) and interob- One caution is that cases of endometrial carci-
server (r(I) = 0.954) reliability [7]. Some authors have noma have been detected in women with an endo-
suggested that assessing the morphology of the endometrial stripe as thin as 3 mm [14]. In one study, three
metrium based on ultrasonographic appearance may of nine cases of carcinoma had a thickness of 3 mm
add additional information. The presence of cysts [14]. This study also reported mean thicknesses lower
within the endometrium is associated with benign than that of most studies (6 mm for carcinoma),
origins of bleeding, such as polyps, whereas endo- however, which suggested that a difference in tech-
metrial hypoechogenicity and inhomogeneity are nique may partially account for their findings. Some
associated with an increased risk for malignancy. authors have suggested using 3 mm as a threshold to
Many studies have been conducted on the use of reduce the chance of missing cases of carcinoma at
transvaginal sonography to evaluate PMB. In 1997, the expense of specificity. The real issue with ultra-
Smith-Bindman et al [8] published a metaanalysis of sound concerns the outcome of symptomatic patients
the use of transvaginal ultrasound to evaluate endo- who are evaluated with ultrasound and found to have
metrial thickness in women with PMB. They included a thin endometrium or have biopsy that is negative
35 prospective trials with 5892 patients in their and then are followed on an annual basis. Because it
analysis. The authors determined that a threshold is accepted that both modalities miss some cases of
endometrial thickness of 5 mm had a sensitivity rate endometrial carcinoma, it becomes relevant to deter-
of 96% for endometrial carcinoma and 92% for other mine which cases are missed and for what reasons
endometrial disease. The sensitivities were not sig- and whether these women are ultimately diagnosed
nificantly different in women taking HRT. The spec- correctly in time to treat them successfully.
ificity of an abnormal thickness was lower (81% for
all endometrial disease), however, so that an abnor-
mal ultrasound result still must be followed with Atrophic endometrium
either tissue sampling or saline infusion sonography.
Many studies have shown that a threshold of Bleeding in postmenopausal women is commonly
5 mm for pursuing endometrial sampling reasonably caused by atrophy of the endometrium and exposure
K.G. Davidson, T.J. Dubinsky / Radiol Clin N Am 41 (2003) 769–780 771
Fig. 1. (A) Mid-sagittal ultrasound image demonstrates a thin atrophic endometrium. (B) Mid-sagittal image obtained during a
saline infusion sonohysterogram demonstrates virtually no endometrium consistent with atrophy.
of the vessels in the underlying myometrium. In the Sonographic appearance

absence of estrogen after menopause, the functional
layer is inactive and atrophies, which leaves only It may be difficult to detect a distinct polyp on
the shallow basalis layer. Atrophic endometrium ultrasound examination because the polyp may appear
on ultrasound has the appearance of a thin endo- as a diffusely thickened endometrium (Fig. 3). The
metrial stripe, often less than 3 mm (Fig. 1). Occa- presence of a polyp also can be suggested by a
sionally, early in menopause the glands may become hyperechoic mass surrounded by hypoechoic endo-
dilated and have a cystic appearance on ultrasound metrium (Fig. 4). Cystic spaces within the polyp may
and histologic evaluation. Biopsy is insensitive in be present. Although not necessary for diagnosis,
this population because tissue sample is often in- they are fairly specific for benign endometrial disease
adequate for diagnosis, but it is reasonable to fol- (Fig. 5). Polyps may be visualized more readily with
low women who have bleeding and a thin stripe the infusion of saline to distend the uterine cavity,
on ultrasound prospectively because of the overall saline infusion sonohysterography (SIS). With SIS, a
low risk of carcinoma or atypical hyperplasia in polyp appears as a smoothly marginated focal lesion
that population. that protrudes into the endometrial cavity. Not sur-
prisingly, a comparison study of transvaginal sonog-
Endometrial polyps
An endometrial polyp is a circumscribed over-

growth of the endometrial mucosa and occasional
stromal tissue that protrudes into the uterine cavity on
a fibrovascular stalk. The polyps can be singular or
multifocal. They are most often benign and, in post-
menopausal women, can show the typical atrophic
and cystic change of the rest of the endometrium on
pathologic evaluation. Adenocarcinomas may grow
in a polypoid fashion (Fig. 2), however, or can arise
within a polyp. A polyp that appears in a symp-
tomatic postmenopausal woman warrants biopsy.
A recent clinical trial of hysterosonography in
PMB found polyps in nearly 50% of the patients
[15]. Most polyps are benign proliferation mucosal Fig. 2. Mid-sagittal view from a saline infusion sonohystero-
tissue not clinically relevant except for their asso- gram demonstrates a large polypoid lesion. Histology re-
ciation with dysfunctional uterine bleeding. vealed endometrial carcinoma.
Fig. 3. (A) Mid-sagittal ultrasound image demonstrates a slightly heterogeneous thickened endometrium. (B) Sonohysterogram
image demonstrates a pedunculated heterogeneous mass consistent with a polyp (and less likely a fibroid).
raphy and SIS for detection of endometrial polyps significant form is hyperplasia with atypia that is
found a significantly greater sensitivity (93% versus believed to be a precursor to endometrial cancer.
65%) and specificity (94% versus 76%) for SIS over 30% to 40% of all carcinomas are noted to have
transvaginal sonography alone [16]. coexisting atypical hyperplasia [17]. The atypical
hyperplasia is often focal, however, and may be
found in the background of simple hyperplasia or
Endometrial hyperplasia normal endometrium.
Endometrial hyperplasia is a histologic diagnosis

characterized by overgrowth of glands with or with- Sonographic appearance
out stromal proliferation and is believed to result
from prolonged estrogen stimulation of the endome- On ultrasound, hyperplasia appears as a thickened
trium. Overgrowth of the endometrium is often asso- endometrial stripe (Fig. 6). In a complete scan of the
ciated with irregular and heavy vaginal bleeding. uterus, the thickening is more likely to be focal but
There are many different classifications based on the may involve the entire endometrium. It has a similar
appearance of the glands and stroma, but the most appearance to an endometrial malignancy on ultra-
Fig. 4. (A) Transverse ultrasound image demonstrates a small focal echogenicity within the endometrium consistent with a small
polyp. (B) The corresponding saline infusion sonohysterogram image demonstrates the small sessile polyp seen on the
transvaginal ultrasound image.
Fig. 5. Transverse ultrasound image demonstrates a small Fig. 7. Mid-sagittal view during saline infusion sonohyster-
cyst within the endometrium. A large polyp was demon- ography of an intramural fibroid with submucosal extension.
strated at saline infusion sonohysterography, and it was
removed at hysteroscopy.
trium), submucosal (protruding into the uterine cavity
sound, but the endometrial-myometrial interface is and distorting the endometrial cavity), or peduncu-
not disrupted. lated (arising from a stalk, similar to a polyp). Fibroids
with submucosal extent are believed to cause vaginal
bleeding by increasing the surface area of the endo-
Uterine leiomyomas metrium and disrupting the normal sloughing process
(Fig. 7). In postmenopausal women, these benign
Uterine leiomyomas, frequently referred to as fi- tumors usually regress, and malignant degeneration
broids, are common benign neoplastic growths of is rare. In the presence of continued hormonal stimu-
smooth muscle cells within the myometrium. They lation, however, they may continue to be symptomatic.
occur in up to 40% of women over the age of 35 [18]
and are seen on 75% of hysterectomy specimens [19]. Sonographic appearance
These benign tumors regress with estrogen with-
drawal. They are overgrowth of muscle tissue and Leiomyomas have a varied appearance on ultra-
are pseudoencapsulated and noninvasive. They can be sound depending on location within the uterus. A
subserosal (arising from the exterior surface of the generalized enlargement of the uterus, irregularities in
uterus), intramural (completely within the myome- the external surface or endometrial cavity, and areas of
hyperechogenicity or hypoechogenicity within the
surrounding myometrium all suggest leiomyomas.
Calcifications also may form within the leiomyomas
and be visualized sonographically. Submucosal leio-
myomas are the most likely to cause vaginal bleeding
and may appear as an area of increased echogenicity
bulging into the endometrial cavity with echogenicity
similar to that of the myometrium. It can be difficult to
distinguish a leiomyoma from a blood clot or a polyp
[20]. Leiomyomas also may obscure the endometrium
on imaging or cause an overestimation of endometrial
thickness, which would lead to further evaluation.
Endometrial carcinoma
Endometrial carcinoma, which arises within the

Fig. 6. Mid-sagittal view of a thickened endometrium in a glandular cells of the uterine lining, is most common
postmenopausal woman. Biopsy revealed hyperplasia. in postmenopausal women, with 70% of cases occur-
ring in women more than 50 years of age. It is the

most common gynecologic malignancy in the United
States. In postmenopausal women who present with
abnormal vaginal bleeding, the risk of cancer is
approximately 10%. The disease is surgically staged.
In early stages there is a high cure rate; survival
decreases once the malignancy has spread to adjacent
organs or lymph nodes. The mainstay of treatment is
surgical staging, with hysterectomy and lymph node
dissection as indicated, followed by radiation therapy
if there is evidence of extrauterine spread.
Sonographic appearance
Fig. 9. Mid-sagittal view of the endometrium in a postmen-
Signs suggestive of endometrial carcinoma on opausal woman shows a thickened endometrium with ill-
ultrasound include a distended or fluid-filled uterine defined margins. Histology revealed endometrial carcinoma.
cavity, an enlarged or lobular uterus, and prominent
echogenicity of the endometrium (Fig. 8). A normal
postmenopausal uterus usually measures less than Qualitative markers have been reported as sug-
50 cc [21], and uterine enlargement is seen in at least gestive of malignancy, including endometrial cavity
71% of women with endometrial adenocarcinoma fluid collection, irregularity of the myometrial-endo-
[22]. A recent study reported a 0.6% prevalence rate metrial interface (Fig. 9), and inhomogeneity of the
of endometrial cancer in women with PMB and endometrium. In 1995, Weigel et al [25] suggested
endometrial thickness of 4 mm or less. This preva- that the addition of assessment of the endometrium
lence increased to 19% in women a with thickness of for homogeneity, presence of a central echo, and
5 mm or more [23]. The authors concluded that in echogenecity would be most useful in assessing
women with endometrial thickness less than 4 mm, women whose endometrial stripe is in the ‘‘gray
endometrial biopsy may not be required. Many other area’’ of 4 to 10 mm. They calculated 100% sen-
authors agree with this threshold [24]. Others suggest sitivity of irregular endometrial interface in predicting
an even thicker threshold of 6 mm [14]. Several endometrial carcinoma. In cases in which intrauterine
studies suggested that an endometrial thickness of fluid is found, the measurement of endometrial thick-
more than 15 mm is highly specific for the diagnosis ness is calculated to exclude the fluid and measure
of endometrial carcinoma [24]. only the endometrium itself.
The sonographic texture of the endometrium also
has been studied as a marker of endometrial pathol-
ogy. In a retrospective study of 68 postmenopausal
women who underwent vaginal sonography, Hulka
et al [26] reported that cystic spaces within the
endometrium were predictive of polyps, endometrial
hyperplasia often appeared hyperechoic, and endo-
metrial carcinoma appeared heterogeneous. There
was also significant overlap in the diagnoses [26].
In a more recent study of 207 women with PMB, the
morphology of the endometrium was categorized as
homogenous, focally increased echogenicity, dif-
fusely increased echogenicity, or diffusely inhomo-
geneous in addition to measurement of endometrial
thickness. The authors reported that in three of three
cases of endometrial cancer with a thickness of less
Fig. 8. Diffusely thickened endometrium in a postmeno- than 6 mm, all had inhomogeneity. 10 of 11 cases
pausal woman. Because the risk for endometrial carcinoma is of endometrial cancer with a thickness of more than
high in this group of patients, she underwent endometrial bi- 6 mm also had an inhomogeneous endometrium [27].
opsy immediately, which confirmed endometrial carcinoma. Adding morphologic characteristics increased the
specificity and negative predictive value and de- diagnosis in 88% of patients and resulted in a change
creased the sensitivity rate from 100% to 77.8% in patient treatment in 80%.
[28]. The combination of quantitative and qualitative One study suggested that SIS may be as effective
findings may improve the predictive value of trans- as hysteroscopy in evaluation of the endometrium. In
vaginal sonography. a prospective study of 105 women with PMB and an
A study of SIS found that difficulty with disten- endometrial stripe of more than 5 mm, all patients
sion of the uterus at the time of saline infusion was were evaluated with SIS followed by hysteroscopy.
associated with a sevenfold increased risk of malig- The authors found a 96% agreement between SIS and
nancy, although in this study the sensitivity rate for hysteroscopy in the diagnosis of focal lesions and a
detecting carcinoma was less than that of conven- similar sensitivity rate (80%) for diagnosing polyps.
tional transvaginal sonography (44% versus 60%) Hysteroscopy distinguishes between benign and ma-
[29]. Sensitivity also may be improved by careful lignant lesions primarily because tissue sampling can
attention to technique. Fleischer [30] recommends (1) be performed during hysteroscopy. Hysteroscopy is
surveying the entire endometrium in the sagittal and the gold standard because of the ability to perform
coronal planes before measuring the anteroposterior directed biopsy. The limitations of hysteroscopy are
double-layer thickness in the sagittal plane near the the invasive nature, requirement for expensive equip-
fundus, (2) assessing the texture of the endometrium, ment, and general anesthesia. Office-based hystero-
(3) measuring uterine volumes, and (4) measuring scopy instruments that held the promise of increased
endometrial blood flow. convenience and affordability have not lived up to
Research has suggested that ultrasound may be expectations. A small study compared transvaginal
valuable in the staging of endometrial cancers [31] sonography, SIS, and hysteroscopy and found that
with regard to depth of invasion into the myome- patients rated transvaginal sonography as signifi-
trium. Surgical staging is currently the gold standard cantly less painful than the other two procedures [33].
and the standard of care. Distant metastases and Modalities such as color flow and power Doppler
lymph node involvement and myometrial extension imaging have been reported to increase the sensitiv-
are better evaluated with CT and MR imaging. Once a ity and specificity rates of ultrasound in detecting
diagnosis of endometrial carcinoma is established, endometrial pathology. Amit et al [34] reported on a
these are better imaging methods than ultrasound for prospective study of 60 women with PMB and
staging the disease. reported a sensitivity rate of 86% and sensitivity
rate of 89% for power Doppler (pulsatility index
point cutoff 1.0). On the other hand, Sheth et al [35]
Additional techniques evaluated color duplex Doppler in postmenopausal
women with thickened endometrial stripes and found
Other techniques have been proposed to add that low-impedence arterial flow in benign and
accuracy to the imaging of the endometrium. Saline malignant lesions was not significantly different.
infusion sonohysterography has been applied to the The presence of a single draining vessel is highly in-
evaluation of PMB because the infusion of saline into dicative of the presence of a polyp (Fig. 10), whereas
the endometrial cavity may improve the differenti- more diffuse flow with multiple areas of aliasing
ation of intraluminal masses and shape of the endo- increases the risk of carcinoma (Fig. 11). Lack of
metrium. Dubinsky and colleagues correlated SIS flow does not exclude the presence of an endoluminal
findings with pathologic diagnosis on curettage or lesion, however.
hysterectomy in 88 women with vaginal bleeding. Three-dimensional ultrasound is a technique with
The authors defined a suspicious endometrial appear- emerging applications that has been studied for evalu-
ance as either focal endometrial thickening ( > 4 mm) ation of PMB. In particular, the ability to produce
or a focal inhomogeneous endoluminal mass. For coronal images of the cornua may increase the sen-
detection of carcinoma using this definition, they sitivity of SIS slightly for lesions in this location that
found a sensitivity rate of 89% and specificity rate may be difficult to appreciate fully otherwise. Abnor-
of 46%. One case of carcinoma in situ was associated malities of the endometrium that occur in women with
with a benign-appearing endoluminal mass on SIS. congenital variants of the uterus also may be imaged
The authors concluded that all endoluminal masses to greater advantage with three-dimensional ultra-
require further evaluation to exclude carcinoma [32]. sound techniques. In general, however, the actual
More recently, Bree et al [15] estimated a sensitivity benefit of three-dimensional imaging in most patients
rate of 98% and specificity of 88% for SIS and is probably limited as long as careful attention is paid
estimated that the use of SIS added certainty to the to imaging technique.
Fig. 10. (A) Color flow image of the endometrium demonstrates a solitary feeding vessel. The presence of such a vessel
significantly increases the probability that a polyp is present. (B) In another patient with a polyp, during saline infusion
sonohysterography one large branching vessel is seen.
Yaman et al [36] demonstrated good reproducibil- Three-dimensional ultrasound also has been demon-
ity with three-dimensional technique in assessing strated to be a valid measurement technique in
endometrial volume with mean interobserver cor- assessing volume [37]. In one study, using a cutoff
relation of 0.95, which was superior to that of volume of 13 mL had a sensitivity rate and PPV of
two-dimensional thickness measurements (0.76). 100% and 91.7%, respectively, in diagnosing endo-
metrial cancer in women not on HRT with PMB [38].
In the latter study, the mean endometrial thickness
and volume in women later found to have endome-
trial carcinoma were 29.5 mm and 39 mL, respec-
tively, whereas women with atrophic endometrium
had a mean thickness of 5.3 mm and volume of
0.9 mm. Patients with hyperplasia or polyps were in
between, with a mean thickness of 15.6 mm and
volume of 5.5 mL [38].
Special populations
Certain populations present added difficulties in

the assessment of PMB. Women who are on tamox-
ifen therapy for breast cancer are one example.
Tamoxifen is a competitive inhibitor of the estrogen
receptor and is well documented to increase the risk of
Fig. 11. Color flow image of the same patient as in Fig. 6,
endometrial hyperplasia and carcinoma [39]. Oncolo-
which demonstrates scattered flow aliasing throughout the
endometrium. Angiogenesis and microarteriovenous fistula
gists have investigated the optimal strategy for fol-
formation occur as a part of endometrial carcinoma de- lowing these patients to detect endometrial anomalies
velopment. Although not of high sensitivity for detecting in the earliest stage possible. Transvaginal sonography
carcinoma, the presence of this pattern of flow is highly has been used for this purpose in asymptomatic
predictive for carcinoma. women because tamoxifen therapy may alter the
sonographic appearance of the endometrium. Recent states (obesity, chronic anovulation, unopposed estro-
studies suggest a high false-positive rate from screen- gen therapy), personal history of breast cancer with or
ing of asymptomatic women on tamoxifen because a without tamoxifen therapy, and family history of en-
physiologic thickened myometrium may be mistaken dometrial, ovarian, breast, or colon cancer. No studies
for endometrial hypertrophy by transvaginal sonog- in the literature actually provide any evidence for this
raphy [40]. This is probably better evaluated with SIS; practice, and a recent cost analysis by Medverd and
however, there is reluctance to subject all women Dubinsky [45] indicated that the prevalence of car-
on tamoxifen to annual SIS examinations. Current cinoma would have to be higher than is actually pres-
American College of Obstetrics and Gynecology recent in any of these populations to make biopsy more
ommendations for screening women on tamoxifen cost minimizing than ultrasound.
therapy include annual gynecologic examination with
Pap tests and bimanual examination.
Women on sequential HRT also present a diag- Summary
nostic challenge because most women continue to
have monthly bleeding and the primary symptom of Transvaginal ultrasound with SIS is a cost-min-
endometrial cancer may be disguised. In a premeno- imizing screening tool for perimenopausal and post-
pausal menstruating woman, endometrial thickness menopausal women with vaginal bleeding. Its use
varies from a mean of 4 mm in the early follicular decreases the need for invasive diagnostic procedures
phase to 11.5 mm just before menses [41]. Even long for women without abnormalities, and ultrasound
after menopause, the uterus retains the capacity to increases the sensitivity of detecting abnormalities
grow in response to hormonal administration. Re- in women with pathologic conditions. Vaginal sonog-
search has demonstrated that vaginal sonography is raphy is preferred over uniform biopsy of postmeno-
accurate is assessing endometrial thickness in this pausal women with vaginal bleeding because it (1) is
population [42]. The mean endometrial thickness a less invasive procedure, (2) is generally painless,
increases significantly with therapy, however, with a (3) has no complications, and (4) may be more
mean of 4.3 mm in one study. Another study of sensitive for detecting carcinoma than blind biopsy.
women with PMB reported that women on HRT had Transvaginal sonography is rarely nondiagnostic.
a mean thickness of 5.7 mm and increased the Endometrial sampling is less successful in women
threshold for thickened endometrium in their study with a thin endometrial stripe on ultrasound than in
from 4 mm or less in women not on HRT to 8 mm or women with real endometrial pathologic condition.
less in women in HRT [43]. A limitation of ultrasound is that an abnormal
The optimal timing for evaluation of the endo- finding is not specific: ultrasound cannot always
metrium in women on HRT is during the period reliably distinguish between benign proliferation,
immediately after withdrawal bleeding to avoid hyperplasia, polyps, and cancer. Although ultra-
false-positive results. Another trial that evaluated sound may not be able to distinguish between
endometrial thickness in postmenopausal women on hyperplasia and malignancy, the next step in the
HRT found a mean thickness of 3.2 to 3.6 mm. The clinical treatment requires tissue sampling. Because
authors also reported that 9% of these patients with of the risk of progression of complex hyperplasia to
an endometrial thickness of more than 4 mm had carcinoma, patients with this finding may benefit
abnormal endometrial findings on hysteroscopy with from hormonal suppression, dilatation and curettage,
endometrial biopsy [44]. A thickened endometrium endometrial ablation, or hysterectomy, depending on
was a more sensitive predictor of pathologic con- the clinical scenario. The inability to distinguish
dition than irregular bleeding. Although it is not these two entities based on ultrasound alone should
practical or cost effective to screen all postmeno- not be seen as a limitation because tissue sampling
pausal women on HRT for endometrial pathologic is required in either case. Occasionally (in 5% to
conditions, this study provided further evidence that 10% of cases), a woman’s endometrium cannot be
irregular bleeding in the absence of ultrasonographic identified on ultrasound, and these women also need
findings of endometrial proliferation is most like sec- further evaluation.
ondary to benign atrophic changes rather than abnor- Ultrasonography also may be used as a first-line
mal cellular proliferation. investigation in other populations with abnormal
In most gynecology training programs, students uterine bleeding. In a multicenter, randomized, con-
are taught that biopsy always should be performed trolled trial of 400 women with abnormal uterine
in women with high pretest probability for endome- bleeding, the investigators found that transvaginal
trial cancer. Such risk factors include hyperestrogenic sonography combined with Pipelle endometrial bi-
Fig. 12. Proposed algorithm for evaluating women with abnormal vaginal bleeding.
opsy and outpatient hysteroscopy was as effective as examination and endometrial biopsy and hystero-
inpatient hysteroscopy and curettage [4,8]. The sub- scopy as indicated [46].
jects included women older than 35 years with Hysteroscopy is likely to become the new gold
PMB, menorrhagia, intermenstrual bleeding, post- standard in the future because of its ability to visu-
coital bleeding, or irregular menses. Transvaginal alize directly the endometrium and perform directed
sonography may be a cost-effective, sensitive, and biopsies as indicated. As office-based hysteroscopy
well-tolerated method to evaluate most women with becomes more practical and widespread, the tech-
abnormal bleeding in combination with physical nique may become more cost effective. An evaluation
plan using transvaginal sonography as the initial [11] Briley M, Lindsell DR. The role of transvaginal ultra-
screening evaluation followed by endometrial biopsy sound in the investigation of women with post-meno-
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Gupta JK. The diagnostic accuracy of ultrasound scan
It remains unproven whether certain patients at
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Radiol Clin N Am 41 (2003) 781 – 797
Sonohysterography
Mary Jane O’Neill, MD
Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Harvard Medical School,
White Building Room 270, 55 Fruit Street, Boston, MA 02114, USA
Sonohysterography (SHG) is a valuable, min- therapy should be examined during the proliferative
imally invasive, sonographic examination that plays phase of the menstrual cycle (days 0 – 14) to
a crucial role in the triaging of abnormal uterine decrease the likelihood of false-positive findings
bleeding. SHG augments the traditional transvaginal [4]. During the secretory phase, the endometrium
ultrasound (TVUS) examination by distending the not only is thicker but also tends to appear more
endometrial canal with saline, which allows each heterogeneous and irregular in contour (Fig. 1). This
individual layer of the endometrial lining to be eval- appearance leads to increased rates of false-negative
uated separately. The single-layer evaluation made and false-positive diagnoses during SHG for endo-
possible with SHG significantly improves detection metrial pathology and decreases overall sensitivity
and characterization of focal and diffuse endometrial and specificity of the examination. During the
processes over that of TVUS alone [1 – 3]. Focal proliferative phase, the normal endometrium is thin
lesions involve less than 25% of the endometrial and homogeneous (Fig. 2), which allows much more
surface area and are unlikely to be diagnosed without definitive evaluation of endometrial and subendo-
hysteroscopically guided biopsy. Although the ability metrial processes.
to accurately detect focal endometrial lesions non-
invasively with SHG has had the largest impact on the
management of abnormal bleeding in postmenopausal
patients, the diagnosis and management of dysfunc-
tional bleeding and infertility in premenopausal
patients also have improved significantly. The
improvement is largely because of the detailed evalu-
ation that the study provided regarding the location
and extent of subendometrial processes that affect the
endometrium and endometrial cavity. This article
reviews the technique, indications, and diagnostic
findings during SHG.
Technique
Patient preparation
All premenopausal patients and all postmeno- Fig. 1. Coronal SHG in 33-year-old woman with inter-
pausal patients on sequential estrogen replacement menstrual bleeding preformed at day 23 of menstrual cycle.
The secretory endometrium is thick and heterogeneous
(arrows). The lobulated contour (arrowheads) can cause
E-mail address: [email protected] false-positive and false-negative findings at SHG.
doi:10.1016/S0033-8389(03)00038-1
782 M.J. O’Neill / Radiol Clin N Am 41 (2003) 781–797
Fig. 2. Repeat SHG in same patient performed at day 5 of

menstrual cycle. During the proliferative phase, the
premenopausal endometrium is thin and homogeneous
(arrows). Note the slight hypoechoic appearance to the
single layer of the premenopausal endometrium during Fig. 4. Sagittal SHG in 54-year-old woman with postmeno-
this phase. pausal bleeding demonstrates a normal single endometrial
layer. The postmenopausal endometrium is thin and almost
imperceptible (arrows). Pathology in this case was endome-
trial atrophy.
Few reports of pelvic infections have been related Catheter insertion

to SHG. Patients who are at increased risk of stasis of
saline within the pelvis because of tubal occlusion or The study can be performed through a balloon-
peritubal adhesions are at higher risk, however, and tipped catheter placed in either the cervical or endo-
they may benefit from antibiotic prophylaxis. Before metrial canal or a nonocclusive straight catheter
catheter insertion, a preliminary TVUS should be placed in the endometrial canal. Balloon catheters
performed to assess for preexisting ovarian or are less likely to become dislodged during ultrasound
adnexal pathology and document the current appear- probe insertion. If the balloon is initially inflated in
ance of the endometrial lining. The adnexa also the endometrial canal, the balloon should be deflated
should be assessed after the procedure to identify and the catheter retracted under sonographic guidance
the presence of any new adnexal collections. into the proximal cervical canal to ensure that the
Fig. 3. Sagittal SHG in 63-year-old woman with postmenopausal bleeding. (A) Initial saline infusion reveals no focal
abnormalities. The catheter (arrow) is in the inferior aspect of the endometrial cavity. (B) After retraction of the catheter into the
superior portion of the cervical canal (arrow), a focal endometrial lesion arising from the posterior endometrial surface in the
lower uterine segment is revealed (arrowhead). Pathology showed a benign endometrial polyp.
M.J. O’Neill / Radiol Clin N Am 41 (2003) 781–797 783
entire single layer thickness of the endometrium is less of the absolute thickness, the endometrium
completely evaluated without interference from the should be homogeneous in echotexture and smooth
catheter (Fig. 3). in contour [4].
If the cervical os is stenotic and cannot be accessed
with the 5 Fr catheter, access can be achieved using Postmenopausal
the Seldinger technique. This technique involves a
0.038 glide wire (Cook, Bloomington, IN) to gain The normal single layer of the postmenopausal
initial access into the endometrial cavity. Once this endometrium is homogeneously echogenic, smooth
wire has been introduced, a small 5 Fr tapered dilator in contour, and uniform in thickness (Fig. 4). The
(Cook, Bloomington, IN) can be advanced over the absolute thickness is considered normal or atrophic
wire. The study can be performed through the dilator if less than 2 mm in symptomatic women and 2 to
after the wire has been removed. Using this technique 3 mm in asymptomatic women on estrogen replace-
when routine catheter placement fails significantly ment or tamoxifen [5 – 7].
improves the technical success rate of SHG.
Normal endometrium by sonohysterography Indications
Premenopausal Triage of postmenopausal bleeding
The normal single layer of the premenopausal Until recently, triage of patients with abnormal
endometrium during the early proliferative phase is uterine bleeding was based primarily on the findings
slightly hypoechoic, thin, and homogeneous in thick- of office endometrial biopsy and TVUS [1,2]. With
ness (see Fig. 2). There is no widely accepted limit the advent of hysteroscopy and SHG, however, it is
to the single layer thickness in premenopausal pa- evident that most causes of postmenopausal bleeding
tients, but a single layer thickness more than 6 mm (PMB) are secondary to focal endometrial or sub-
is unusual and should be evaluated carefully and endometrial processes, such as endometrial polyps or
possibly biopsied in symptomatic women. Regard- submucosal fibroids. These entities involve only a
Fig. 5. (A) Sagittal SHG in 54-year-old woman with postmenopausal bleeding (PMB) demonstrates the typical appearance of an
endometrial polyp. The lesion is homogeneously echogenic and arises from a narrow stalk from the posterior endometrial surface
in this retroverted uterus (arrow). Note the normal thin remaining single layer of the endometrium (arrowheads). (B) Multiple
polyps identified (arrows) on coronal SHG in 52-year-old woman with PMB. It is not unusual to identify more than one
endometrial lesion at SHG. Each lesion should be localized accurately.
small proportion of the endometrial lining and are Triage of abnormal endometrium in asymptomatic
significantly underdiagnosed by office endometrial postmenopausal patients on estrogen replacement
biopsy secondary to sampling error [5 – 8]. therapy or tamoxifen
Because patient management is dictated by the
presence or absence of focal endometrial lesions, the Patients on estrogen replacement therapy and
primary goal of SHG is not to diagnose specific tamoxifen have a higher risk of focal and diffuse
endometrial lesions accurately but rather to determine endometrial pathology and commonly have abnor-
whether the abnormality that affects the endometrium mally thick or heterogeneous endometrial stripes
is focal or diffuse. If there is a focal abnormality, it without symptoms. SHG plays an important role in
must be localized accurately so that the hysteroscopic detecting potential focal endometrial lesions in this
surgeon can remove it reliably. Although imaging subgroup of asymptomatic patents.
features suggest particular diagnoses, none is sensi-
tive or specific enough to dictate patient care in the Dysfunctional uterine bleeding
setting of PMB [9,10]. In principle, all focal lesions
in symptomatic PMB should be investigated with Sonohysterography in the premenopausal patient
hysteroscopic sampling. population serves a more specialized role. Endome-
Fig. 6. (A, B) Doppler interrogation of the stalk of the polyp arising form the posterior endometrial surface in this 51-year-old
woman with postmenopausal bleeding (PMB) demonstrates the characteristic prominent color Doppler flow (arrows). (C) Doppler
interrogation of the base of a submucosal fibroid in a 56-year-old woman with PMB demonstrates a similar vascular pedicle
(arrow). This feature is most often seen in endometrial polyps but is nonspecific and is occasionally observed in other endometrial
and subendometrial pathologies.
trial polyps are less common in these patients but can premenopausal patient is the diagnosis of small foci
cause intermenstrual bleeding and infertility [1]. SHG of retained placental tissue in patients who remain
plays an important role in defining the extent of symptomatic after failed dilatation and curettage for
submucosal extension in patients with abnormal retained products of conception.
vaginal bleeding and suspected submucosal fibroids.
Assessing the extent of submucosal component can
help guide the mode of resection chosen by the Pathology
gynecologic surgeon.
Focal lesions
Infertility and pregnancy complications
Endometrial polyps
Because of the cross-sectional view of the cavity, Endometrial polyps are the most common focal
SHG plays an important role in the diagnosis and endometrial lesions and account for approximately
staging of intrauterine adhesions in patients with 30% of cases of PMB [1]. Histologically, polyps
infertility. Another more limited role of SHG in the represent hyperplastic growths of endometrial glands,
Fig. 7. (A) Coronal SHG in 57-year-old woman with postmenopausal bleeding (PMB) demonstrates an endometrial polyp with a
broad base of attachment (arrowheads). When this finding is observed, the interface between the base of the polyp and the
underlying myometrium should be scrutinized closely for any irregularities or evidence of invasion. (B) Sagittal SHG in a
57-year-old woman on tamoxifen reveals a large polyp with multiple intralesional cysts (arrowheads). This polyp had foci of
severe atypia at histopathology. (C) Sagittal SHG in a 61-year-old woman with PMB shows a broad-based, hypoechoic,
heterogeneous polypoid lesion arising form the endometrial surface in the fundus (arrow). Although this polyp represented a
benign polyp on pathology, this feature indicates a higher likelihood of more aggressive histology.
Fig. 8. (A) Coronal SHG in a 61-year-old woman on estrogen replacement therapy shows a benign broad-based endometrial
polyp with a normal distinct endometrial myometrial interface (arrowheads). (B) Coronal SHG in a 52-year-old woman with
postmenopausal bleeding shows a broad-based endometrial polyp with disruption of the smooth endometrial myometrial
interface (arrowheads). This finding suggests myometrial invasion. A benign polyp was found at histology with no myo-
metrial invasion or cytologic atypia.
and stroma and can be found in premenopausal and Most polyps, even those with typical benign
postmenopausal patients. Common presentations features, are eventually removed hysteroscopically
include PMB, intermenstrual bleeding, metorrhagia, because continued PMB complicates future clinical
and infertility [11]. patient management and because foci of hyper-
On SHG, polyps typically are well-defined, homo- plasia or carcinoma in situ cannot be excluded
geneous, echogenic solid lesions with a narrow base sonographically.
of attachment to the underlying endometrium (Fig. 5).
There is often a well-defined vascular pedicle within
the stalk when Doppler evaluation is performed, but
this is not a feature specific to polyps [12] (Fig. 6). It
is not unusual to identify more than one endometrial
polyp during SHG. This is one reason to perform
SHG for localization even in patients with strong
suspicion for focal endometrial lesions at TVUS. Ac-
curate detection and localization of the lesions before
operative hysteroscopy increase the success rate of
surgical resection.
Less commonly, polyps can have a broad base
of attachment, contain cystic components, and con-
tain areas of hypoechogenicity/heterogeneity within
the polyp (Fig. 7). The heterogeneity within en-
dometrial polyps most likely indicates prior hem-
orrhage, infarction, or inflammation [13]. The
interface between the endometrium and the under-
lying myometrium should be interrogated closely in
all focal endometrial lesions, particularly when the
Fig. 9. Sagittal SHG in 37-year-old patient with severe
point of attachment is broad based or other atypical menorrhagia shows a large submucosal fibroid (arrow). Sub-
features are present (Fig. 8). If the interface is mucosal fibroids tend to be more heterogeneous, hypo-
distorted or poorly visualized, the likelihood of a echoic, and larger than endometrial polyps. Note the thin
more aggressive process is significantly increased layer of normal endometrium covering this mass, which in-
[14,15]. dicates the submucosal location of the lesion (arrowheads).
Submucosal leiomyomas Pedunculated submucosal fibroids are completely

Submucosal fibroids are a common source of dys- endoluminal in location and are attached by only a
functional premenopausal bleeding. They also can small stalk to the subendometrium. These lesions are
interfere with implantation and cause recurrent mis- more difficult to distinguish sonographically from
carriage, infertility, and premature labor [16]. Al- endometrial polyps and can be misdiagnosed as
though fibroids are most often associated with endometrial lesions (Figs. 11D, 12).
dysfunction bleeding, they do play a role in the etiol- Adenomyosis in patients with suspected fibroids
ogy of PMB and account for approximately 10% of is occasionally seen during SHG (Fig. 13). Mild
cases [1]. displacement of the endometrial lining can be seen
During SHG, submucosal fibroids appear as in this entity, but intraluminal extension is rare.
broad-based, hypoechoic, submucosal masses that
lift up the normal endometrium and project to various
degrees into the endometrial canal (Fig. 9). When Endometrial hyperplasia
the endometrium can be seen lining the surface of Endometrial hyperplasia accounts for 4% to 8% of
the mass, the submucosal origin can be determined; cases of endometrial bleeding and is defined as a
however, this feature is not always present (Fig. 10). proliferation of endometrial glands of irregular size
In these cases, distinguishing submucosal from and shape, with an increase in the gland/stroma ratio
mucosal lesions is not as definitive. when compared with the normal proliferative endo-
One of the more important functions of SHG in metrium [11]. Endometrial hyperplasia ranges in
patients with suspected submucosal fibroids is to severity from simple hyperplasia without atypia, to
assess accurately the percent of protrusion of the hyperplasia with mild/ moderate atypia, to hyper-
volume of the fibroid into the endometrial canal. This plasia with severe atypia. Mild/moderate atypia has
information assists in triaging the patient to the most little or no malignant potential and is usually treated
appropriate means of fibroid resection. Hysteroscopic with removal of the exogenous agent or induction of
resection is generally reserved for fibroids that project menses with a progesterone analog. Severe atypia has
more than 50% of their volume into the endometrial a 20% risk of developing into endometrial carcinoma
canal. Open or laparoscopic myomectomy is required and is managed more aggressively with dilatation and
for lesions with less than 50% protrusion [16 – 18] curettage [8,19,20]. Risk factors for endometrial
(Fig. 11). hyperplasia include exposure to unopposed estrogen,
Fig. 10. (A, B) Coronal and sagittal SHG in two different postmenopausal patients with bleeding demonstrates submucosal
fibroid (arrows). These lesions could not be distinguished sonographically from polyps because the endometrial layer over the
lesions is atrophic and is not visualized. Definitive characterization with biospy proved that these lesions were fibroids. A more
typical appearing endometrial polyp also was found in the first patient (curved arrow).
Fig. 11. (A) Coronal transvaginal ultrasound in 47-year-old woman with heavy menses demonstrates a centrally located fibroid
(arrow). (B) SHG shows that this fibroid projects approximately 50% of its total volume into the endometrial cavity (arrows). (C)
Coronal SHG in a 32-year-old woman with dysfunctional uterine bleeding shows a submucosal fibroid with less than 50%
protrusion into the endometrial canal (arrows). (D) Sagittal SHG in a 47-year-old woman with postmenopausal bleeding
demonstrates a submucosal fibroid with more than 50% protrusion into the endometrial cavity (arrows).
tamoxifen usage, nulliparity, obesity, and hyperten- monly a broad-based, echogenic mass that does not
sion and diabetes. distort the endometrial-myometrial interface (Fig. 15).
Endometrial hyperplasia is usually a diffuse thick- When only focal thickening is observed, the lesion
ening of the echogenic endometrial stripe; however, should be sampled hysteroscopically to avoid the
focal areas of endometrial hyperplasia occasionally possibility of sampling error during office biopsy.
can be seen. The focal form of hyperplasia is more
difficult to differentiate from endometrial polyps dur- Endometrial cancer
ing SHG because of the considerable overlap of Endometrial carcinoma is the most common gyne-
sonographic characteristics of the two lesions. Hyper- cologic malignancy in the United States, and it affects
plasia and carcinoma in situ also can be contained predominantly postmenopausal women. Although
within otherwise benign endometrial polyps [21] endometrial cancer is the most prevalent gynecologic
(Fig. 14). Focal endometrial hyperplasia is most com- cancer, because of early detection, it accounts for
neous lesions should be viewed with increased con-

cern for carcinoma, particularly if distortion of the
endometrial-myometrial interface suggests myome-
trial invasion or inability to distend the endometrial
cavity adequately (Fig. 17) [22,23].
Intrauterine adhesions
Patients who present with infertility or recurrent
pregnancy loss are at increased risk for intrauterine
adhesions. Adhesions are poorly detected by TVUS
because they are compressed within the cavity and
the endometrium often appears normal. Occasionally
adhesions may be suspected when small echogenic
foci or linear hypoechoic bands are detected in the
endometrial lining [24].
Fig. 12. Coronal SHG in a 31-year-old woman with severe Sonohysterography is highly sensitive in detecting
bleeding demonstrates a large endoluminal submucosal and grading the severity of intrauterine adhesions
fibroid (arrow). Note the thin layer of endometrium on the [23,25]. SHG is more sensitive than even hysterosal-
surface of this lesion (arrowheads). pingography because of the improved cross-sectional
capabilities associated with ultrasound. Adhesions
just 1.5% of cancer deaths [11]. PMB is a common appear as mobile, thin or thick echogenic bands that
symptom of endometrial cancer and leads to early bridge the endometrial cavity (Fig. 18) [25]. As the
detection in most cases. Only 4% to 5% of cases of severity of adhesions progresses, the endometrial
PMB are caused by endometrial cancer, however cavity becomes less distensible during saline infusion
[1,4]. Endometrial cancer usually involves a large (Fig. 19) [26]. Adhesions are often associated with
percentage of the endometrial lining and is readily echogenic endometrial scars, but either entity can be
diagnosed with office endometrial biopsy. Lesions seen without the other (Fig. 20).
can be small and polypoid, however, and may
require a specific hysteroscopic biopsy for diagnosis Retained products of conception
(Fig. 16). Retained products of conception are usually com-
There is a wide variability in the SHG appearance pletely managed with TVUS and dilatation and
of endometrial cancer. Large, broad-based, heteroge- curettage without routine need for SHG. A small
Fig. 13. Coronal (A) and sagittal (B) SHG in a 36-year-old woman with heavy menses and suspected submucosal fibroid shows
the classic sonographic findings of adenomyosis. Note the presence of myometrial cysts (arrows), myometrial echogenic
nodules (arrowheads), and asymmetric anterior wall swelling causing a slight impression on the endometrial lining and cavity
(curved arrows).
Fig. 14. (A) Coronal SHG in a 73-year-old woman with postmenopausal bleeding (PMB) shows a lobulated polypoid mass (arrows)
arising from the posterior endometrial surface. The interface between the polyp and myometrium is normal (arrowheads).
Pathology demonstrated an endometrial polyp with foci of endometrial hyperplasia with severe atypia. (B) Coronal SHG in a
53-year-old woman with PMB demonstrates a broad-based, hypoechoic, lobulated polypoid lesion (arrows) with a poorly defined
interface with myometrium (arrowheads). Pathology revealed an endometrial polyp with foci of endometrial carcinoma.
percentage of patients remain symptomatic despite drug binding at the estrogen receptor has either
repetitive dilatations and curettage because of unde- proestrogenic or antiestrogenic effects depending on
tected foci of retained placental tissue. SHG is the the cell type. Both effects are seen within the endo-
ideal test to identify and localize the residual tissue in metrium, as evidenced by the increased rates of focal
these problematic cases. Retained products of con- and diffuse endometrial pathology and endometrial
ception can have a wide variety of appearances atrophy that have been reported in patients on tamox-
during SHG, but they tend to be more irregular in ifen [28,29]. When endometrial abnormalities are
contour and less homogeneous than typical endome- detected, there is an increased risk for more aggres-
trial polyps [27] (Fig. 21). sive histology within the lesion (Fig. 24) [24].
Tamoxifen also can cause cystic changes in the
Diffuse lesions inner myometrium just beneath the endometrium that
lead to pseudo-thickening of the endometrium on
Endometrial hyperplasia
Diffuse endometrial hyperplasia has a similar
appearance and etiology to that described for focal
hyperplasia, except the abnormality involves a larger
percentage of the endometrial lining (Fig. 22).
Endometrial cancer
Diffuse endometrial cancer has a similar appear-
ance and etiology to that described for focal cancer,
except the abnormality involves most of endometrial
lining. Interrogation of the myometrial-endometrial
interface along the entire base of attachment is crucial
in assessing the invasiveness of a lesion suspected to
represent endometrial carcinoma (Fig. 23).
Fig. 15. Sagittal SHG in a 61-year-old woman with
Tamoxifen-induced subendometrial changes
postmenopausal bleeding shows a long segment of focal
Tamoxifen is a nonsteroidal compound used in endometrial thickening in the posterior endometrial surface
prophylaxis and therapy of breast cancer in premeno- (arrows). The remainder of the endometrium is normal in
pausal and postmenopausal women. Tamoxifen thickness (arrowhead). The interface with the myometrium is
inhibits estrogen-dependent tumor growth by com- normal (curved arrows). Pathology revealed endometrial
peting with estrogen at its receptor sites. The effect of hyperplasia with mild atypia.
Fig. 16. Sagittal (A) and coronal (B) SHG in a 65-year-old patient with postmenopausal bleeding shows a broad-based
heterogeneous polypoid mass (arrows) with a poorly defined endometrial-myometrial interface (curved arrows). The anterior
endometrium is normal (arrowhead). Office biopsy suggested endometrial atrophy, but hysteroscopic biopsy revealed invasive
endometrial carcinoma.
TVUS (Fig. 25) [30]. This subendometrial process is endometrial thickening, such as endometrial cancer
poorly understood, and different theories exist for the and hyperplasia and aggressive tissue sampling must
pathophysiolgy of this lesion. The most widely be performed (Fig. 26) [30].
accepted theory is that tamoxifen causes a reactiva-
tion of preexisting adenomyosis with the inner layer
of the myometrium [31,32]. This process of cystic Sonohysterography triage of
degeneration of the inner myometrial layer is often postmenopausal bleeding
associated with endometrial atrophy, further compli-
cating diagnosis. If the endometrium is not clearly Postmenopausal patients can be divided into three
distinct from the cystic lesions, it is not possible to specific clinical categories: patients with PMB,
distinguish this process from other causes of true patients on estrogen replacement therapy, and patients
Fig. 17. Sagittal (A) and three-dimensional reformatted long axis (B) SHG in a 66-year-old woman on tamoxifen for breast
cancer. The endometrial cavity is nondistensible in the region of the heterogeneous, annular mass (arrows). The cavity above and
below the mass is filled with saline (arrowheads). Pathology revealed noninvasive endometrial carcinoma.
Fig. 18. Sagittal SHG in two different patients, both after hysteroscopic myomectomy, with mild (A) and moderate (B) uterine
adhesions (arrows). The cavity is still distensible in both cases. The thickness of the bridging band is thicker and more irregular
in the case of moderate adhesions.
on tamoxifen. In patients with PMB, TVUS is the recommend SHG for evaluation of all cases of
initial examination performed. If the endometrium PMB, even in cases in which the TVUS is normal [9].
measures less than 4 mm by TVUS, endometrial With SHG, a single layer thickness of the endo-
atrophy is likely to be the cause of the PMB, and metrium of less than 2 mm is considered diagnostic
continued follow-up or one-time biopsy confirmation of endometrial atrophy. Thickening of the endome-
of atrophic endometrium is generally performed. The trium more than 2 mm by SHG suggests diffuse
likelihood of endometrial carcinoma arising in a endometrial pathology, and office endometrial biopsy
homogeneous endometrium with a double layer of should be performed to obtain a specimen for diag-
4 mm is negligible [22]. If the endometrium measures nosis. When focal endometrial abnormalities are
more than 4 mm, is heterogeneous in echotexture, or identified, hysteroscopic-guided resection of the
is not visualized by TVUS, SHG is required to assess abnormality is required to avoid sampling error
for focal versus diffuse endometrial pathology. Some related to the nonspecific office endometrial biopsy
authors propose a more aggressive approach and [23,25].
Fig. 19. (A) Sagittal SHG in a 42-year-old woman with secondary infertility demonstrates a nondistensible cavity and irregular
endometrial lining with an echogenic, nonshadowing focus in the body of the uterus (arrow). (B) Sagittal T2-weighted MRI
reveals presence of hypointense linear adhesion within the T2 bright endometrium in the same location (arrow).
Fig. 20. (A) Coronal TVUS and SHG (B) in a 53-year-old woman with perimenopausal bleeding. The echogenic focus initially
believed to represent a polyp on TVUS (arrows) was shown after SHG to represent an area of fibrosis within the posterior
endometrial surface. No polypoid mass was detected on SHG, and endometrial biopsy revealed atrophy.
Asymptomatic postmenopausal patients who un- metrial lesions. SHG and office hysteroscopy dem-
dergo TVUS for the purpose of surveillance because onstrate high sensitivity and specificity for the
of hormone replacement therapy or tamoxifen ther- diagnosis of focal and diffuse endometrial lesions
apy are managed slightly differently from patients and can be used effectively in the triage of PMB.
with PMB. In patients on estrogen replacement ther- Reported sensitivity and specificity rates of SHG
apy, many observers allow the double-layer thickness for focal and diffuse endometrial lesions are 80%
of the endometrium to be up to 6 mm before more to 90%, similar to rates reported for hysteroscopy
specific evaluation with biopsy or SHG is attempted, [10,16,17,23,25]. Both methods are well tolerated by
provided the stripe remains smooth and homoge- patients and have high technical success rates.
neous. In cases in which the stripe appears thicker Because of the smaller size of the SHG catheters
than 6 mm but otherwise seems normal, reimaging and the ability of the fluid to pass by proximal
earlier in the hormonal cycle may eliminate the need lesions, fewer failures related to cervical stenosis
for additional evaluation [33]. Some observers sug-
gest SHG and histologic sampling in asymptomatic
patients on hormone replacement therapy when the
endometrial thickness is more than 4 mm [23].
Patients on tamoxifen therapy who have abnor-
mally thick or heterogeneous endometrial stripes are
managed more aggressively than patients in the two
other groups because of the higher incidence of
neoplasia in this group of patients [30]. Dilatation
and curettage provides a more complete method of
endometrial sampling in the cases of diffuse endo-
metrial pathology or abnormalities of the endome-
trial/myometrial interface than office endometrial
biopsy alone.
Fig. 21. Sagittal SHG in a 27-year-old woman with
persistent bHCG elevation and bleeding despite repeat dil-
Sonohysterography versus hysteroscopy atation and curettage. A small focus of placental tissue is
identified along the posterior endometrial surface (arrow)
Office hysteroscopy provides another minimally and resected hysteroscopically. Pathology revealed retained
invasive means of diagnosing focal and diffuse endo- products of conception.
Fig. 22. Sagittal (A) and coronal (B) SHG in a 67-year-old woman with postmenopausal bleeding. There is diffuse thickening of
each endometrial layer (calipers). The anterior endometrial surface demonstrates an irregular interface with the underlying
myometrium. Pathology revealed hyperplasia without atypia.
and proximal adhesions are encountered with SHG imaging test in the triage of PMB and in premeno-
when compared with hysteroscopy. pausal patients with dysfunctional uterine bleeding
or infertility. Polyps and submucosal fibroids are
the most common focal findings during SHG. In
Summary postmenopausal patients, detection and accurate
localization of findings, rather than lesion character-
Sonohysterography can distinguish focal from ization, are the primary goals of the procedure.
diffuse pathology reliably and has become a crucial Most, if not all, focal lesions in this patient popula-
Fig. 23. Sagittal (A) and coronal (B) SHG in a 72-year-old woman with postmenopausal bleeding. There is diffuse irregular
thickening of the posterior endometrial layer (arrows). The anterior endometrial surface is normal (arrowheads). The
endometrial-myometrial interface is highly irregular (curved arrows). Pathology revealed invasive endometrial carcinoma.
Fig. 24. Coronal SHG in a 65-year-old asymptomatic patient on tamoxifen shows a large polypoid lesion that contains multiple
cysts that arise from the lateral endometrial surface (arrow). Pathology revealed an endometrial polyp with foci of carcinoma in situ.
Fig. 25. (A) Sagittal TVUS in a 68-year-old asymptomatic patient on tamoxifen shows a markedly thickened endometrial stripe
(arrows). Multiple cysts are seen at the central and peripheral portions of the endometrial stripe (arrowheads). (B) Sagittal SHG
in same patient demonstrates that all of the cysts are subendometrial (arrowheads). The thin atrophic endometrial can be seen
overlying the largest of the subendometrial cysts (arrow). Endometrial biopsy performed under hysteroscopic guidance revealed
endometrial atrophy.
Fig. 26. (A) Sagittal SHG in a 76-year-old woman with postmenopausal bleeding on tamoxifen. Multiple peripheral cysts are
present (arrowheads), but the endometrial lining cannot be seen distinctly (arrows). Histology revealed endometrial atrophy. (B)
Sagittal SHG in a 69-year-old asymptomatic patient on tamoxifen demonstrates peripheral cysts (arrowheads) but no distinct
endometrial lining (arrow). The interface between the endometrium and myometrium also is indistinct. Histology revealed
noninvasive endometrial cancer.
tion require tissue diagnosis, even when the imag- postmenopausal bleeding. Acta Obstet Gynecol Scand
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[7] Gull B, Carlsson SA, Karlsson B, Ylostalo P, Milsom
T, Granberg S. Transvaginal ultrasonography of the
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Radiol Clin N Am 41 (2003) 799 – 811
MR imaging of the ovaries: normal appearance and

benign disease
Kaori Togashi, MD, PhD
Department of Diagnostic and Interventional Imageology, Graduate School of Medicine, Kyoto University,
54 Shogoin Kawaharacho, Sakyo-ku, Kyoto 606-01, Japan
The noninvasive nature of MR imaging is bene- masses, postcontrast and fat suppression or chemical
ficial in evaluations of what are probably benign shift images may be required. Chemical shift imaging
diseases in young women of reproductive age. Al- helps to distinguish fat from blood [6]. Postcontrast
though MR imaging is believed to be safe even images are highly accurate for detection and char-
during pregnancy, a cautious approach that involves acterization of complex adnexal masses [7].
waiting until after 12 weeks’ gestation is recommend-
ed [1,2]. Disadvantages of MR imaging are its high
cost and long scanning time. Its excellent tissue Normal and function related masses
contrast underscores its importance in the evaluation
of adnexal masses, however, because it allows spe- Normal ovaries on MR imaging
cific diagnoses of fat, blood, and fibrous tissue. Even
if normal in size, an ovary may present with tiny foci In women of reproductive age, normal ovaries
of endometrial implants or dermoid cysts that are were identified in 82 of 84 of cases on MR imaging
only identifiable on MR imaging; however, MR [8,9]. T2-weighted images reveal the zonal anatomy
imaging is generally used as a problem-solving of the ovary, which consists of lower intensity cortex
modality. When ultrasound results are inconclusive, and higher intensity medulla. Many cysts that exhibit
the use of MR imaging may alter treatment decisions, high intensity are embedded in the cortex. When less
eliminate the need for surgery, and result in reduced than 25 mm in diameter, these cysts are called
overall costs [3,4]. physiologic cysts and include follicles at various
stages of development, corpus luteum, and surface
inclusion cysts [8,9]. The size and number of cysts in
MR imaging technique ovaries of women of reproductive age change during
their menstrual cycle. A dominant follicle can enlarge
Fasting for several hours and the administration of by 20 to 25 mm [10]. The corpus luteum may present
an anticholinergic agent are mandatory conditions as a cyst with a thick, enhancing, and occasionally
when imaging the pelvis in nonpregnant patients. convoluted wall or as an enhancing nodule. A hemo-
With the use of a phased array multicoil, T1-weighted siderin deposit along the inner aspect of the cyst wall
images are obtained using a spin-echo technique, and may be observed as a line of high intensity on
T2-weighted images are obtained using a fast spin- T1-weighted images and as a line of low intensity
echo technique. Currently, ultrafast imaging tech- on T2-weighted images (Fig. 1) [8,9]. The presence
niques are not accepted as an alternative for fast of an enhancing nodule may cause a problem in
spin-echo technique [5]. In evaluations of pelvic differentiating a hemorrhagic corpus luteum cyst
from a malignant cyst. The corpus luteum gradual-
ly involutes into the corpus albicans, which is not
E-mail address: [email protected] perceptible on imaging findings. In postmenopausal
doi:10.1016/S0033-8389(03)00041-1
800 K. Togashi / Radiol Clin N Am 41 (2003) 799–811
Fig. 1. Normal ovary with a corpus luteum; a cyst distinctly larger than others. (A) T1-weighted image shows thin line of high
intensity that represents a hemosiderin deposit along the wall (arrowheads). (B) T2-weighted image shows a line of relatively
low intensity along the wall (arrowheads). (C) Postcontrast image shows a thick, enhancing, and convoluted wall.
women, ovaries show more homogeneous low sig- These cysts usually range from 3 to 8 cm and have a
nal intensity and are hardly identifiable because of thin wall filled with a simple fluid or a small amount
their fewer ovarian cysts. The hilum of the ovary of blood. Luteal cysts have a thick and enhancing
and the mesovarium may be identified as a well- wall. Luteal cysts are the masses most commonly
enhancing structure. encountered during pregnancy, and they typically
regress after 7 to 8 weeks’ gestation [10]. A small
Functional cysts amount of hemorrhage is common in a luteal cyst and
presents as a layer of low intensity at the bottom of
Functional cysts are common. When a follicle the fluid content on T2-weighted images. It is called a
fails to involute or ovulate, a follicular cyst develops. ‘‘hematocrit effect’’ [11]. With a larger amount of
K. Togashi / Radiol Clin N Am 41 (2003) 799–811 801
Fig. 2. Ovarian bleeding from luteal hematoma in acute phase. (A) T1-weighted image shows free peritoneal fluid of intermediate
signal and a mass (arrows) of mixed signal intensity that contains slightly higher signal intensity. (B) T2-weighted image shows
mass (arrows) of mixed signal intensity that consists of high and distinct signal intensity within a free fluid that shows a lower
signal than urine. (C ) The wall of luteal hematoma is enhancing (arrowheads).
hemorrhage, a hemorrhagic corpus luteum cyst devel-

ops. The signal intensity of hemorrhagic cyst varies
according to the age of the blood products [12]. The
most frequently encountered hemorrhagic corpus
luteum cyst is in the subacute phase, and it displays
high intensity on T1- and T2-weighted images. Cau-
tion is needed so as not to misdiagnose such a
hemorrhagic corpus luteum cyst as an endometrioma.
Follow-up studies show that hemorrhagic corpus
luteum cysts soon regress, whereas endometriotic
cysts persist [10].
Theca lutein cysts are less common because they
result from excessive human chorionic gonadotropic Fig. 3. Ovarian hyperstimulation syndrome. T2-weighted
image shows a huge mass composed of multiple uniformly
levels produced by multiple gestations or by gesta-
sized cysts.
tional trophoblastic disease.
Complications of functional cysts: ovarian bleeding

The so-called ‘‘polycystic ovarian syndrome’’
Probably the most common complication of a indicates a primary ovarian insufficiency, which
functional cyst is hemorrhage, which may be a small may be associated with oligomenorrhea, obesity,
amount and be limited to within the cyst or may cause and hirsutism. Polycystic ovaries are also encoun-
external bleeding and present with severe abdominal tered in various hormonal disorders, however, which
pain. Hemorrhagic corpus luteum cysts are the most reflects anovulation or infrequent ovulation. Imaging
common cause of ovarian bleeding. Acute hemor- findings alone are not specific, but identification of
rhage is of intermediate signal on T1-weighted multiple peripheral cysts beneath the capsule may
images and of distinct low intensity on T2-weighted help in the consideration of this condition [16].
images (Fig. 2) [12,13]. Hemoperitoneum appears
as a higher signal than simple fluid on T1-weighted Peritoneal inclusion cysts
images and as a lower signal on T2-weighted images
[13]. The treatment option for ovarian bleeding is Peritoneal inclusion cysts are a physiologic con-
usually just observation. Based on signal intensity, dition closely related to the function of ovaries.
MR imaging allows the accurate distinction of Normal peritoneum absorbs fluid produced by active
ovarian bleeding from other adnexal masses, such ovaries. Inflammation or adhesions deprive the peri-
as torsion or rupture, that require immediate sur- toneum of this ability, however, and as a result, fluid
gical intervention. retention develops adjacent to active ovaries in
women with a history of pelvic surgery or pelvic
Development of multiple functional cysts inflammatory disease. A peritoneal inclusion cyst
shows a peculiar configuration surrounded by the
Functional cysts can be multiple and simulate pelvic wall, pelvic organs, and bowel loops (Fig. 4)
multiloculated cystic neoplasia. Ovarian hyperstimu- [17]. Imaging findings are characteristic enough to
lation syndrome and hyperreactio luteinalis may make a preoperative diagnosis. An accurate diagnosis
present with extremely enlarged ovaries [14]. The of this condition based on imaging findings helps to
former condition is associated with induction of obviate multiple surgeries that arise from suspicion of
ovulation (Fig. 3). The latter condition is usually a recurrent ovarian tumor. Conservative treatment is
associated with gestational trophoblastic disease with the rule for this condition in contrast to other cystic
excessive human chorionic gonadotropin, but occa- masses, which basically require surgery.
sionally it is associated with an otherwise normal
pregnancy. Both conditions may be mistaken for a
malignancy, but the clinical history and their rapid Endometriomas
growth usually assist in leading to the correct diag-
nosis. The enlarged ovaries in these conditions con- After exclusion of a physiologic enlargement of
sist of multiple cysts of uniform size. In contrast, the ovary or functional cysts, one can consider the
multiloculated cystic neoplasia show variable size differential diagnosis of adnexal masses. Endome-
and shape of loculi separated by septa [15]. triomas are unique retention cysts and are benign
Benign neoplasia
Primary ovarian tumors arise from surface epithe-

lium, gonadal stroma, and primordial germ cells.
Surface epithelial tumors are the most common
ovarian tumors and are further subclassified into
serous, mucinous, clear cell, endometrioid, and transi-
tional cell tumors. Among these histologic subtypes,
serous, mucinous, and transitional cell tumors may
present as benign lesions. Although most ovarian
tumors should be evaluated surgically, to improve
the prognosis of patients, preoperative distinction
between benign and malignant tumors is mandated
for appropriate subspecialty referrals for possible ma-
lignant ovarian tumors [22].
Surface epithelial tumors
Serous and mucinous tumors are the most com-

mon surface epithelial tumors. They can vary from
entirely cystic to entirely solid, but benign diagnosis
should be applied only for lesions that do not have
solid tissue on imaging findings [7]. The serous
cystadenoma is usually unilocular and contains fluid
Fig. 4. Peritoneal retention cyst in a woman with a history of similar to that of simple fluid. The mucinous cyst-
pelvic surgery. T2-weighted image shows a cystic mass
adenoma is typically multiloculated and shows a
(arrowheads) adjacent to the ovary (arrows). The pelvic
wall and the ovary bound the border of the lesion.
stained-glass appearance (with compartments of
varying signal intensity) or daughter cysts. Thick,
mucinous content that occasionally exhibits low in-
tensity on T2-weighted images is also common in
mucinous tumors.
lesions. Because the lesion is filled with aged blood, A Brenner tumor is a benign transitional cell tu-
endometriomas typically exhibit high signal intensity mor and is a rare exception to the rule that the
on T1-weighted images and fat saturation images presence of solid tissue in a cystic mass indicates
[18]. The lack of reduction of signal intensity on malignancy [23]. A Brenner tumor presents as a solid
fat saturation images is important in the distinction nodule usually with another cystic mass (typically a
between endometriomas and dermoid cysts (Fig. 5) mucinous cystadenoma) (Fig. 6). The signal intensity
[6]. A diagnosis of an endometrioma can be reliable of the solid nodule is distinct low signal intensity on
if the lesion consists of multiple high-intensity cysts T2-weighted images, which reflects its fibrocollagen-
on fat saturation T1-weighted images. Another reli- ous nature, and helps make an accurate diagnosis.
able sign of endometriotic cysts is a cyst that exhibits MR imaging findings are essential for making a pre-
high signal intensity on a T1-weighted image and operative diagnosis of this benign tumor.
is of heterogeneous low intensity on a T2-weighted
image. This pattern of signal intensity is called Sex-cord stromal tumors
shading [18].
Even if the signal intensity is typical for an en- A solid component in an ovarian tumor usually
dometrioma, a benign diagnosis should be aban- suggests malignancy. Fibromas and thecomas are an
doned if vegetations are identified in a lesion. There exception to this rule, however. Such tumors are
is a rare benign condition called a decidualized endo- predominantly solid but are benign. Fibromas and
metrial cyst, however [19,20]. Clear cell carcinoma is thecomas typically show distinct low signal intensity
known to develop in an otherwise normal endome- on T2-weighted images, which reflects abundant
trioma, with an incidence of 0.04%. One should collagen [24,25]. Their signal intensity may change
search carefully for small vegetations and distinguish in the presence of edema and cyst formation, how-
them from clots adherent to the wall [21]. ever, which are other common findings of these
Fig. 5. Endometriomas. (A) T1-weighted image shows two cysts of high signal intensity. (B) T2-weighted image shows the cysts
to be of heterogeneous low signal intensity. The dorsal cyst shows a lower signal than that of the ventral one. If the lesion
exhibits high signal on T1-weighted image and low signal on T2-weighted image, the diagnosis of endometriotic cyst is reliable.
(C ) Fat suppressed image shows no reduction in signal intensity of the lesion. The diagnosis of an endometrioma is reliable if the
lesion consists of multiple high intensity cysts on T1-weighted and fat sat images.
tumors [24]. Cysts may be central or eccentric and called Meigs’ syndrome and can be a diagnostic
should be distinguished from necrosis by their thin pitfall. The hypointense signal of the tumor on T2-
walls and smooth inner surfaces. Benign ovarian weighted images is a diagnostic clue.
tumors, such as fibromas and thecomas, occasionally Although low signal intensity of solid tissue is
are associated with ascites and hydrothorax, which usually a reliable indicator of benignancy, it should
usually indicate malignancy. Such a condition is be noted that Krukenberg tumors also can exhibit low
Fig. 6. Brenner tumor associated with mucinous cystadenoma. (A) T1-weighted image shows two components that exhibit low
signal and intermediate signal intensities. (B) T2-weighted image shows a cystic component (representing the mucinous tumor)
and solid tissue (representing the Brenner tumor) that exhibits distinct low signal intensity. (C ) Postcontrast image shows a weak
enhancement in the solid tissue.
signal intensity [26]. Bilaterality and prominent that exhibits prominent high signal intensity on T1-
enhancement favor diagnosis of Krukenberg tumors and T2-weighted images and reduced signal on fat
[26,27]. saturation images (Fig. 7) [6,29]. Reduced signal
Sclerosing stromal tumors differ clinically from intensity on fat saturation image is a diagnostic sign
fibrothecomas by being most common in young for a dermoid cyst and distinguishes it from an
women. Important MR imaging findings are striking endometrioma. Rokitansky protuberances are fre-
enhancement, higher than that of the uterus, pseudo- quently identifiable and may resemble solid protru-
lobulation that consists of low intensity nodules set sions on precontrast images. Contrast enhancement
against high intensity background on T2-weighted is usually absent in these protrusions, however. Al-
images, and a peripheral rim [28]. Preoperative diag- though dermoid cysts are typically filled with seba-
nosis of this benign tumor may help to offer a less ceous fluid, huge dermoid cysts in younger age
invasive treatment option, such as laparoscopic sur- groups may be filled with simple fluid and have scant
gery. Because this tumor easily can be mistaken as a fatty tissue [30].
Krukenberg tumor on histologic studies, the role of Immature teratomas, malignant counterparts of
imaging is important. dermoid cysts, also present as huge cystic masses
filled with simple fluid and scant fatty tissue. As
Germ cell tumors with other germ cell tumors, dermoid cysts are
commonly associated with an elevated level of
Germ cell tumors are the most commonly encoun- serum marker CA 19-9. If the lesion is associated
tered tumors in children and young adults. More than with a slightly elevated level of alpha-fetoprotein, an
95% of germ cell tumors are benign dermoid cysts, immature teratoma should be considered, because the
which are referred to as mature cystic teratomas. two conditions are not distinguishable on imaging
Dermoid cysts are usually filled with sebaceous fluid findings alone.
Fig. 7. Dermoid cyst. (A) T1-weighted image shows a cyst that contains a layer of high and intermediate signal intensities.
(B) T2-weighted image shows that both contents exhibit high signal intensity. (C ) Fat suppressed image shows reduced signal
intensity of both contents, indicating fatty fluid. The upper layer represents pure sebaceous fluid, and the lower layer represents
sebaceous fluid mixed with hair or desquamated epithelium.
Struma ovarii is a germ cell tumor but consists is usually ill defined and associated with prominent
of a monodermal component with thyroid tissue, in ‘‘mesh-like’’ linear stranding that radiates from the
contrast to other teratomas, which have three dermal mass to the adjacent pelvic structures [32]. Lympha-
layers. MR imaging findings may be diagnostic of denopathy may be observed.
this condition. Typical findings include a multiloc-
ulated cystic mass with numerous minute loculi, Actinomycosis
thick content that exhibits low signal intensity on
T2-weighted images, and striking enhancement [31]. Granuloma may be caused by an actinomycosis
A thyroid scintigram may confirm a diagnosis. infection. Actinomycotic granulomata may lack typ-
ical clinical findings of inflammation from the begin-
ning. The lesion may have a cystic component, but it
Inflammatory masses predominantly presents as a solid mass that exhibits
low signal intensity on T2-weighted imaging. The
Chronic inflammatory masses develop as sequelae mass tends to show diffuse and widespread involve-
of acute pelvic inflammatory diseases or granuloma- ment of the uterus, bilateral adnexa, and muscles of
tous diseases. These conditions are occasionally mis- pelvic girdles, and it resembles extensive invasion by
taken as gynecologic malignancies because they uterine cancer [33]. Aggressive transfascial extension
frequently involve multiple pelvic organs and show is an important characteristic of actinomycosis, and
no obvious inflammatory signs. In some clinical set- the presence of transfascial extension should indicate
tings, MR imaging may offer an accurate diagnosis of actinomycosis in the absence of any known pelvic
these problematic conditions. malignancy. Identification of a foreign body, such as
an intrauterine contraceptive device, further favors a
Chronic stage of tubo-ovarian abscesses diagnosis of actinomycosis. Diagnosis is established
with identification of a sulfur granule within the mass
Acute pelvic inflammatory disease typically (Fig. 8).
presents with acute inflammatory symptoms, and
ultrasound is the modality of choice to evaluate this Tuberculosis
condition. If an acute condition is inadequately
treated, however, the lesion progresses insidiously Tuberculosis typically presents as adnexitis, lym-
to a chronic inflammatory mass. This progression phadenitis, or peritonitis. Prominent lymphadenop-
usually results in a mixed solid and cystic lesion athy associated with endometritis resembles an
having a thick wall with variable signal intensity of advanced uterine cancer, whereas massive ascites
the fluid. Hydrosalpinx and pyosalpinx are frequently and peritoneal enhancement mimic ovarian cancer
identifiable. Because of associated edema and a with peritoneal carcinomatosis. Diagnosis is difficult
tendency to adhere to the adjacent tissue, the lesion because symptoms are vague. Massive ascites, lymph
Fig. 8. Pelvic actinomycosis. (A) T1-weighted image shows a lesion that involves bilateral adnexa, the uterus, and left pyriform
muscle. This pattern of extension is called transfascial extension. (B) T2-weighted image reveals a predominantly solid mass of
relatively low signal intensity with a small cystic component (arrowheads).
node enlargement, and adnexal masses should indi- pin. With the advent of imaging findings and more
cate tuberculosis if the usual clinical evaluation has sensitive laboratory tests, most patients are identifi-
failed to identify gynecologic malignancies. Culture able while in an asymptomatic status. Sonographic
of abscess fluid or polymerase chain reaction analysis findings in association with elevated human chorionic
is necessary to confirm the diagnosis. gonadotropin and clinical findings, such as abnormal
vaginal bleeding after amenorrhea, are diagnostic in
many cases. If sonographic findings are inconclusive,
Other uncommon benign adnexal masses however, MR imaging helps to make a more confi-
dent diagnosis of ectopic pregnancy, because MR
Magnetic resonance findings occasionally help to imaging is sensitive for blood elements. Acute he-
make an accurate diagnosis of uncommon benign matoma exhibits intermediate signal intensity on
conditions that may resemble gynecologic malignan- T1-weighted images and distinct low signal intensity
cies. Examples discussed in this section include on T2-weighted images [13]. The wall in hematosal-
hematocele caused by ectopic pregnancy, torsed pinx is prominently enhanced, which represents
adnexal masses, massive ovarian edema, and solid increased blood flow because of implantation. Rare-
adnexal masses caused by endometriosis. ly, an undiagnosed ectopic pregnancy proceeds to
chronic stage hematocele and shows prominent high
Hematosalpinx and hematocele caused by signal intensity on T1- and T2-weighted images.
ectopic pregnancy
Ovarian torsion
Typical presentation of ectopic pregnancy is acute
abdominal pain and bleeding in a patient with a Acute abdominal pain is a typical presentation of
positive test result for b-human chorionic gonadotro- torsion, but it also frequently presents with vague
Fig. 9. Torsed ovary with massive hemorrhagic infarction. (A) T1-weighted image shows a mass of intermediate signal associated
with a beaked protuberance, which indicates a pedicle (arrowheads). (B) T2-weighted image shows distinct low intensity, which
indicates necrosis. (C) Postcontrast image reveals complete absence of any enhancement.
Fig. 10. Massive ovarian edema. (A) T2-weighted image shows the ovary (arrowheads), which is extremely swollen but still
keeps the shape of a fava been, and the ovarian hilum (arrows). Within the ovary, fine radiations from the hilum can be seen. (B)
Postcontrast image shows strong enhancement of the ovarian hilum (arrows) and a lack of enhancement of the entire ovary,
except for weak enhancement in the radiations.
symptoms that make clinical diagnosis difficult. vic structures, but it occasionally appears in an
Imaging findings vary according to the stage of adnexa. Because of a hard consistency of the lesion,
torsion (eg, the extent of edema and ischemia). With this condition may be mistaken for ovarian cancer on
hemorrhage and necrosis, torsion presents as a ne- palpation. MR imaging may be helpful in obtaining
crotic mass that lacks enhancement. At an early stage, an accurate diagnosis of endometriosis [38,39]. The
a torsed ovary is swollen with multiple follicles solid mass exhibits distinct low signal intensity on
separated by edematous stroma. In both stages, the T2-weighted images, which reflects its fibrocollage-
common finding is the presence of a thick pedicle nous nature. Punctate foci of high signal intensity on
between the mass and the uterus [34,35]. Another T1-weighted images are frequently identifiable within
important finding that favors a diagnosis of torsion is the solid mass. The presence of an endometriotic cyst
an absence or diminished enhancement of the mass. If further progresses a diagnosis of endometriosis.
one can make an early diagnosis of an incomplete
torsion with vague symptoms based on imaging
findings, prompt surgical intervention helps to sal-
vage ovaries (Fig. 9). Summary
Massive ovarian edema MR imaging enables a physician to make an accu-

rate diagnosis of various benign adnexal masses and
Massive ovarian edema likely occurs with in- helps to obviate unnecessary surgery.
complete and intermittent torsion of the ovaries,
which causes partial and recurrent obstruction of
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Radiol Clin N Am 41 (2003) 813 – 839
Osteoporosis imaging
Thomas M. Link, MDa,*, Sharmila Majumdar, PhDb,c
a
Department of Radiology, Technische Universität München, Ismaninger Straße 22, Munich D-81675, Germany
b
Departments of Radiology, Orthopedic Surgery and Growth and Development, University of California at San Francisco,
MRSC, Box 1290, AC 109, 1 Irving Street, San Francisco, CA 94143, USA
c
Department of Bioengineering, University of California at Berkeley, Evans Hall, Berkeley, CA 94720, USA
What is osteoporosis? defined osteoporosis on the basis of bone mineral

density (BMD) [4]. BMD that is more than 2.5 stan-
Osteoporosis was defined at the National Insti- dard deviations below that of a white, young, healthy
tutes of Health consensus conference as a disease female adult reference population (T-score) is defined
that is associated with a loss of bone mass and a as osteoporosis. BMD that is 1 to 2.5 standard devia-
deterioration of bone structure, both of which result tions below that of the young and healthy reference
in an increased bone fragility and susceptibility to population is defined as osteopenia (Box 1). This
fracture [1]. In 2000, this definition was modified to definition, however, originally was established only
osteoporosis being defined as a skeletal disorder for BMD of the proximal femur (and later of the
characterized by compromised bone strength that anteroposterior [AP] spine) determined using dual-
predisposes to an increased risk of fracture [2,3]. energy X-ray absorptiometry (DXA) but has been
Because this definition seems abstract, the following applied to define diagnostic thresholds at other skeletal
statements were added: Bone strength reflects the sites and for other technologies. Because of the dif-
integration of two main features: bone density and ficulty in accurate measurement and standardization
bone quality. Bone density is expressed as grams of between instruments and sites, controversy exists
mineral per area or volume. In any given individual, among experts regarding the continued use of this
bone density is determined by peak bone mass and diagnostic criterion [2,3]. It is also not clear how to
amount of bone loss. Bone quality refers to archi- apply this diagnostic criterion to ethnic groups and
tecture, turnover, damage accumulation (eg, micro- children and men.
fractures), and mineralization.
Because bone density is the parameter that can be
determined best in vivo, has a high precision, and
correlates well with the biomechanically determined Box 1. World Health Organization
bone strength (it explains approximately 70% of bone definition of osteoporosis, based on bone
strength [2,3]) the World Health Organization (WHO) mineral density and T-scores using dual
x-ray absorptiometry of the proximal
femur and spine [4]
Parts of this article have been adapted from Magnetic

T-score > 1 Normal
resonance imaging of trabecular bone structure. Topics in T-score < 1, > 2.5 Osteopenia
Magnetic Resonance Imaging 2002;13:5. T-score < 2.5 Osteoporosis
* Corresponding author. T-score < 2.5 and Severe
E-mail address: [email protected] osteoporotic fractures Osteoporosis
(T.M. Link).
doi:10.1016/S0033-8389(03)00059-9
814 T.M. Link, S. Majumdar / Radiol Clin N Am 41 (2003) 813–839
As populations age, the incidence of osteoporosis estrogen receptor modulators, estrogen, and calcito-
and subsequent fractures increases. In Western civi- nin are effective drugs in preventing osteoporotic
lization—the United States and Europe—osteoporosis fractures. Research has shown recently that an estro-
is already the most prevalent bone disease and will gen/progestin replacement therapy has substantial
generate major problems for public health institutions side effects, including an increased risk of breast
[5]. In California, osteoporosis accounted for more cancer that increases with the duration of use [11].
than $2.4 billion in direct health care costs in 1998 Because of these side effects and to limit the sub-
and more than $4 million in lost productivity because stantial costs associated with these medications, sen-
of premature death [6]. Most of the cost results from sitive and specific diagnostic techniques are required
hip fractures and other fractures. Only 15% of costs to assess the risk of osteoporotic fractures. Therapy
are for people with a diagnosis of ‘‘osteoporosis’’ per also must be initiated at a relatively early stage before
se, and of this group, most of the costs are associated fractures occur.
with a secondary—not a primary—diagnosis. Ac- The best established diagnostic techniques to
cording to the International Osteoporosis Foundation, assess osteoporosis focus on BMD (ie, DXA and
more than 40% of middle-aged women will suffer QCT). Several newer emerging techniques are quan-
one or more osteoporotic fractures during their titative ultrasound and high-resolution tomographic
remaining lifetime. The most important fracture sites techniques that analyze bone structure, such as high-
are the proximal femur, spine, and distal radius. Hip resolution MRI and CT. Conventional radiographs
fractures are the worst complication of osteoporosis, are not suited for determining bone mass but are es-
with substantial morbidity and high 1-year mortality sential for assessing osteoporotic fractures, which are
rates. The rate of hip fractures is expected to triple particularly important in the spine.
over the next three decades [7,8]. Vertebral fractures
occur with a higher incidence earlier in life than other
types of osteoporotic fractures [9]. It is difficult to Imaging of fracture and deformity
determine the exact number of fractures that occur
annually, however, because many cases are clinically Osteoporosis-related vertebral fractures have im-
undetected [10]. portant health consequences for older women, includ-
Several therapies are available to prevent osteo- ing disability and increased mortality [12]. Because
porosis and osteoporotic fractures. In addition to these fractures can be prevented with appropriate
calcium and vitamin D bisphosphonates, selective medications, recognition and treatment of high-risk
Fig. 1. The spinal fracture index is a semiquantitative score that was developed by Genant et al [16] and differentiates four grades
of fracture. (From Genant HK, Wu CY, van Kuijk C, Nevitt MC. Vertebral fracture assessment using a semiquantitative
technique. J Bone Miner Res 1993;8:1137 – 1148; with permission of the American Society for Bone and Mineral Research.)
T.M. Link, S. Majumdar / Radiol Clin N Am 41 (2003) 813–839 815
patients are warranted. In a cross-sectional survey, Because most vertebral fractures do not come to
Gehlbach et al [13] analyzed 934 women aged clinical attention, the radiographic diagnosis is im-
60 years and older who were hospitalized and had a portant. The severity of vertebral fractures may be
chest radiograph obtained. Moderate or severe ver- visually determined from radiographs using a semi-
tebral fractures were identified for 132 (14.1%) study quantitative score, the so-called ‘‘spinal fracture
subjects. Only 50% of the contemporaneous radi- index,’’ which was previously developed by Genant
ology reports identified a fracture as present, how- et al (Fig. 1) [16]. In this score, four grades are
ever, and only 17 (1.8%) of the 934 participants had a differentiated: grade 0 = no fracture; grade 1 = mild
discharge diagnosis of vertebral fracture. Few hospi- fracture (reduction in vertebral height 20% – 25%);
talized older women with radiographically demon- grade 2 = moderate fracture (reduction in height
strated vertebral fractures were identified or treated 25% – 40%); grade 3 = severe fracture (reduction in
by clinicians. The results of this study should increase height more than 40%). Fig. 2 shows examples of
the awareness of the radiologist in diagnosing ver- different grades of osteoporotic fractures in the tho-
tebral fractures. The presence of one vertebral frac- racic and lumbar spine in postmenopausal patients.
ture increases the risk of any subsequent vertebral Several other scores have been developed, such as
fracture fivefold [14], and 20% of the women who the ‘‘spine deformity index’’ and the ‘‘radiological
have a recent diagnosis of a fracture will sustain a vertebral index’’ [17 – 19], but these scores are used
new fracture within the next 12 months [15]. less frequently.
Fig. 2. Spine radiographs. (A) Moderate grade 2 fracture of a thoracic vertebra (T9) with a height reduction of nearly 40%
(arrow). (B) Grade 1 fracture of a lumbar vertebra (L2) with a wedge-like deformity and a maximum height reduction of 20% to
25% (arrow).
Conventional radiographs of the spine are not nosis of osteoporotic and malignant pathologic frac-
suited to determine BMD in the early diagnosis of tures may be difficult. Fractures located above the
osteoporosis because it takes a bone loss of more T7 level, associated with a soft tissue mass or osseous
than 20% to 40% before osteoporosis is visualized in destruction and involving the posterior part of the
the radiographs [20]. Morphologic signs described on vertebrae in conventional radiographs, most likely are
spine radiographs, such as a coarse trabecular struc- malignant. CT and MRI may be helpful in differenti-
ture and a frame-like appearance of the vertebrae, are ating osteoporotic and malignant fractures and depict-
also not reliable [21]. ing multiple lesions, soft tissue masses, or destructive
Conventional radiographs are important in the changes (Fig. 4). Diffusion-weighted MR sequences
differential diagnosis of osteoporosis, however, be- and iron oxide contrast media in MRI have been used
cause several other diseases may present with bone successfully to differentiate malignant and benign
loss and fractures. In rare cases, osteoporosis may bone marrow pathologic conditions [22,23].
present with a coarse trabecular structure with thick Conventional radiographs of the proximal femur
vertical trabeculae suggestive of vertebral heman- and the distal radius are usually obtained after a low
gioma. This so-called ‘‘hypertrophic atrophy,’’ how- impact trauma with persistent symptoms in post-
ever, is generalized and the trabecular bone structure menopausal elderly individuals. In many cases, frac-
appears more coarse than in hemangioma (Fig. 3A). tures may be occult in conventional radiographs.
Important differential diagnoses in osteoporosis are Bogost et al showed that 37% of proximal femur
osteomalacia, hyperparathyroidism, renal osteopathia, fractures were not detected in conventional radio-
and malignant bone marrow disorders (eg, plasmo- graphs, which were demonstrated in MR scans of
cytoma and diffuse metastatic disease). Endplate frac- these patients [24]. Non-enhanced T1-weighted and
tures are found in Scheuermann’s disease (Fig. 3B) short T1 inversion recovery or spectrally fat saturated
and malignant lesions (Fig. 4). The differential diag- T2-weighted sequences are recommended in patients
Fig. 3. Differential diagnosis, conventional spine radiographs. (A) Osteoporosis presents with a coarse trabecular bone structure
similar to vertebral hemangioma (hypertrophic atrophy) (arrows). (B) Deformity of multiple vertebrae caused by Scheuermann’s
disease with fractured endplates and nonossified apophyses (arrows).
with a high clinical suspicion of fracture but negative Single-photon absorptiometry is another tech-
radiographs (Fig. 5). nique for measuring peripheral BMD that uses a
highly collimated photon beam from a radionuclide
source (such as iodine-125) to measure photon
Osteodensitometry attenuation [28]. This technique measures BMD of
the distal radius and the calcaneus. Because single-
Several techniques have been used to measure photon absorptiometry is a single energy technique, a
bone density. Photo densitometry was one of the first standardized water bath is required. This method has
quantitative techniques that was used to determine a high precision and low exposure dose, but the use
bone mass of the calcaneus, metacarpals, and pha- of a radionuclide source is a limitation of this
langes [25]. Digital x-ray radiogrammetry is a new technique. The same applies to dual-photon absorpti-
method that automatically identifies regions in radius, ometry, which may be used for the spine, hip, and
ulna, and the three middle metacarpals and measures total body because of the dual energy technique
bone density [26]. This method has a high precision (typically gadolinium-153 with energies of 44 and
and reliability and may be used in standard radio- 100 keV), which reduces the soft tissue contribution
graphs of the forearm to predict hip, vertebral, and substantially [29]. This technique has a high precision
wrist fracture risk [27]. and a low exposure dose, but the scanning time is
Fig. 4. Pathologic vertebral fracture caused by bone metastasis. (A) Conventional spine radiograph depicts fractures of two
thoracic vertebrae (arrows). Sagittal T1-weighted (B) and short T1 inversion recovery MR images (C) show multiple neoplastic
lesions (arrows) of the spine in addition to the vertebral fractures.
a low-energy beam is attenuated to a greater degree

than a high-energy beam. Contrast in attenuation
between bone and soft tissue is greater for the low-
energy beam than for the high-energy beam, such that
the attenuation profile of bone may be determined
by subtracting the low- and high-energy attenuation
profiles. Compared with dual-photon absorptiometry,
DXA has several advantages, including increased
precision, shorter examination time, finer collimation
with a better spatial resolution, and lack of radionu-
clide source decay [30,31]. The correlation between
BMD data obtained from dual-photon absorptiometry
and DXA of the spine and hip was excellent (r = 0.98
and = 0.95) [32]. DXA scanners provide either pencil
or fan beam techniques. Fan beam techniques are
faster. Precision of DXA is high and radiation expo-
sure is low (Table 1).
Using DXA, BMD is most frequently determined
at the spine (AP or lateral) (Fig. 6) and at the
proximal femur (Fig. 7). Whole body measurements
and measurements at the distal radius and the calca-
neus also may be obtained. The AP examination of
the lumbar spine is a standard procedure with a
precision in vivo of 1%, a radiation exposure effec-
tive dose of 1 to 50 mSv (the higher dose is required
for digital high-resolution images), and a high accu-
racy (4% – 10%) (see Table 1) [30,33,34]. For mon-
itoring BMD, the precision alone, however, is not the
only parameter required to assess the diagnostic
performance of a technique. One also must know
the annual rate of BMD loss in normal patients using
this technique and the least significant change
between two measurements, which for DXA and
QCT are shown in Table 2.
Using automated software, areal BMD (g/cm2) is
determined usually in L1-4. These projection images,
however, have several limitations: (1) Vertebrae with
Fig. 4 (continued ).
a larger size have a higher BMD. (2) Aortic cal-
cification and all other soft tissue calcifications in the
regions of interest (ROIs) increase BMD. (3) Degen-
relatively long. Because of isotope source changes, erative changes of the spine, including osteophytes,
single-photon absorptiometry and dual-photon ab- facet sclerosis, and degenerative disc disease, also
sorptiometry are of limited clinical significance and may increase BMD falsely (Fig. 6). In elderly
have been replaced by DXA, which uses an x-ray patients with substantial degenerative changes of
tube instead of a radionuclide source. Currently the the lumbar spine, AP DXA of the lumbar spine
most important techniques in osteodensitometry are may not be a suitable technique. Lateral DXA is less
DXA and QCT. influenced by these changes because it assesses only
the vertebral bodies and focuses more on trabecular
Dual X-ray Absorptiometry bone. Drawbacks of this technique are lower pre-
cision, higher radiation exposure, and superimposi-
As in dual-photon absorptiometry, the principal of tion of the pelvis and the ribs, however, which may
DXA is a dual-energy measurement that is based on limit analysis of the lumbar spine to L3 [35 – 37]. So
the fact that radiation of distinct energies is attenuated far, AP DXA is the standard DXA procedure to
by tissues to different extents. In soft tissue and bone, assess the lumbar spine.
Fig. 5. Osteoporotic proximal femur fracture caused by minor trauma. The femoral neck fracture was not depicted on the
conventional radiograph (A) but is clearly shown in the coronal short T1 inversion recovery MR image (arrow) (B). The MR
examination was performed because of persistent pain 4 days after the initial trauma.
When analyzing DXA scans, several pitfalls that trochanteric region, and the intertrochanteric region.
may be operator dependent must be considered, such Ward’s ROI has an inferior precision compared with
as mislabeled vertebrae, misplaced disk space mark- the other ROIs and is currently not used as a
ers, wrong sized ROIs, use of a fractured or deformed standard ROI. The precision for hip BMD and the
vertebra for measurement, and opaque artifacts in the annual rate of loss are lower compared with AP
analysis region. These analysis errors are of greater spine DXA and the least significant change is higher
magnitude than the machine’s intrinsic precision (Tables 1, 2).
errors [38]. DXA of the proximal femur is a particu- As in DXA of the lumbar spine, several operator-
larly important examination because it is currently dependent errors may occur in the proximal femur
one of the best techniques to assess fracture risk of and should be detected by the radiologist [38,40].
the hip (Fig. 7). The examination of the hip, however, Most of these errors are caused by improper position-
is more demanding than that of the spine [39]. The ing of the patient and the ROIs. Correct positioning of
proximal femur must be positioned in a standardized the patient includes internal rotation of the hip with a
fashion and several ROIs must be placed correctly. straight femoral shaft (the lesser trochanter should not
The correct location of these ROIs varies according to or just barely be visualized). Correct positioning and
the manufacturer. Standard ROIs are the neck region, size of the ROIs, in particular the neck box, may vary
the trochanteric region, and the intertrochanteric re- according to the manufacturer (eg, Lunar/GE systems
gion and Ward’s ROI (the square of 1 1 cm with have a standardized size of the neck box that is placed
the lowest density within the proximal femur). The automatically in the region of the neck with the
ROI that is used most frequently is the total femur. smallest diameter). Osteoarthritis, Paget’s disease,
The total femur ROI consists of the neck region, the fracture, vascular calcifications, calcific tendinitis,
Table 1
Accuracy, precision, and radiation exposure of techniques used for bone mineral density measurement
Radiation exposure,
Techniques Location Accuracy [%] Precision [%] effective dose [mSv]
Older techniques
Photo densitometry Phalanx, metacarpals 10 5 <5
DPA Lumbar spine, proximal femur 2 – 11 2–3 5
2–5 3
SXA Radius, calcaneus 4–6 1–2 <1
Dual energy QCT Lumbar spine 3–6 4–6 f500a
Standard techniques: axial skeleton

DXA Lumbar spine
AP 4 – 10 1 1 – 50b
lateral 5 – 15 2–6 3 – 50b
Proximal femur 6 1.5 – 3 f1 – 2c
Whole body 3 1 f3c
QCT (single energy) Lumbar spine 5 – 15 1.5 – 4 60 – 500d
Standard techniques: peripheral skeleton

DXA Radius 4–6 1 <1
Peripheral QCT Radius 2–8 1–2 f1
Abbreviations: DPA, dual photon absorptiometry; QCT, quantitative CT; SPA, single photon absorptiometry; SXA, single
x-ray absorptiometry.
a
125 kV/ 85 kV and 410mAs.
b
The low values apply for pencil beam scanners, whereas fan beam scanners have an effective dose that is threefold to
fivefold higher. The highest exposure doses were measured using a fan beam scanner with a high image quality.
c
For pencil beam scanners.
d
60mSv are obtained using a low dose protocol (80kV, 125mAs).
enostosis, and avascular necrosis of the hip are also low, which is a potential limitation for monitoring
potential sources of error. Conventional radiographs BMD. Dedicated devices have been developed that
may be required if an atypical density profile is are portable and inexpensive and have shorter scan
shown. If these lesions are too large or developmental times [49]. It has been shown that these techniques
dysplasia of the hip is found, BMD must be deter- may be useful in assessing osteoporosis and fracture
mined at a different site. risk [50]. In comparison with spine and hip DXA
Recently an upper neck region has been intro- measurements, however, the peripheral BMD mea-
duced that is supposed to predict the risk of femur surements are less suited to predicting fracture risk of
neck fractures better than the complete neck ROI the spine and proximal femur. They may be useful in
(Fig. 8) [41]. The thickness and porosity in the upper reducing the cost of detection of osteoporosis, how-
neck region are believed to be critical to maintaining ever, and provide a greater opportunity for identifica-
femoral strength. The upper neck region also dem- tion of women at risk for fracture [49].
onstrates a more rapid age-related decline than the
standard femoral neck region [42]. An automated hip Quantitative computed tomography
axis length measurement also is included in one of
the manufacturer’s newest software analysis pack- Standard QCT is performed on the lumbar spine;
ages, which is supposed to improve the prediction of usually the first to third lumbar vertebrae are ana-
proximal femur fracture (Fig. 8) [43 – 46]. Dual femur lyzed. In contrast to DXA, QCT allows a true den-
measurements are recommended to reduce precision sitometric, volumetric measurement (in mg/mL) of
error and facilitate the evaluation of skeletal response trabecular bone, whereas DXA gives an areal BMD
to therapy at the femur [47,48]. (in mg/cm2), which includes trabecular and cortical
Peripheral DXA techniques include those that bone. Because the trabecular bone has a substantially
analyze the distal radius and the calcaneus. These higher metabolic turnover, it is more sensitive to
techniques have high precision and low radiation changes in BMD (annual rate of bone loss in QCT
exposure, but annual BMD loss at these sites is 2% – 4% versus 1% in AP DXA of the spine). On the
other hand, the precision of QCT is lower than that assessment because these vertebrae usually have an
of DXA (1.5% – 4% versus 1%), and significant increased BMD.
longitudinal changes must be larger (6% – 11% ver- QCT may be performed at any CT system; how-
sus 3% – 4%) (Tables 1, 2). A big advantage of QCT ever, a calibration phantom is required and dedicated
is that it is not as susceptible to degenerative changes software improves the precision of the examination.
of the spine as DXA. Osteophytes, facet joint de- The patient is examined supine, lying on the phantom
generation, and soft tissue calcifications (particular- usually with a water- or gel-filled cushion in between
ly aortic calcification) do not falsely elevate the to avoid artifacts caused by air gaps. A lateral digital
BMD in QCT. As in DXA, however, fractured or radiograph respectively scout view is used to select
deformed vertebrae must not be used for BMD mid-vertebral slice positions of L1-3 parallel to the
Fig. 6. DXA. Anteroposterior spine of a 79-year-old postmenopausal, white woman. (A) The DXA scan of the lumbar spine with
L1-4 ROIs. Note that the areas of the facet joints in L1, L2, and L4 appear denser than in L3, which corresponds to degenerative
changes (osteoarthritis of the facet joints). (B) This is reflected in the absolute BMD data, in which the areal density in L1, L2,
and L4 is higher than in L3. Applying the WHO guidelines to the T-scores, L3 would be evaluated as osteopenic (T-score =
1.6), whereas the other vertebrae would be considered as normal. (B) The age-matched standard deviations (Z-scores) also are
shown, which are in or above the normal range. (C) The BMD of L3 is presented in relation to patient age, the absolute BMD
values (left), the T-scores (right), and the Z-score (gray areas).
vertebral endplates (Fig. 9). Automated software that solid-state ‘‘Cann-Genant’’ phantom (Fig. 10A) [57]
selects the mid-vertebral planes may be useful in and (2) the phantom developed by Kalender et al
reducing the precision error [51]. Usually a slice (Fig. 10B) [58,59]. The latter phantom has a small
thickness of 8 to 10 mm is used (Fig. 9). A low- cross-section and is constituted of only two density
energy, low-dose protocol (eg, 80 kVp and 146 mAs) phases: a 200 mg/mL calcium hydroxyapatite phase
is recommended to minimize radiation exposure and a water equivalent.
(down to an effective dose of 50 – 60 mSv, including Several ROIs have been used to determine the
the digital radiograph) [52]. Bone marrow fat in- BMD in the axial sections of the vertebrae. Manually
creases with age and may decrease BMD falsely. placed elliptical ROIs (Fig. 11A) and automated
The actual BMD may be underestimated by 15% to image evaluation with elliptical and peeled ROIs
20%. Because of age-matched databases, however, (Fig. 11B) have been described [58,60]. The ROI
the clinical relevance of this fat error is small [53]. A developed by Kalender et al uses an automatic
dual-energy QCT technique was described to reduce contour tracking of the cortical shell to determine a
the fat error. Because this technique has increased ROI analyzing trabecular and cortical (as visualized
radiation exposure and decreased precision, however, by CT) BMD separately [58]. The use of automated
its use is limited to research purposes [52,54]. ROIs improves the precision of BMD measurements
To transform the attenuation measured in Hounds- [59,61]. Steiger et al [60] have shown that elliptical
field units into BMD (mg/mL), calibration phantoms and peeled ROIs yield similar results and have a high
are required. The patient and the phantom are exam- correlation (r = 0.99).
ined at the same time, which is defined as simulta- Data obtained by QCT are compared with an age-,
neous calibration. The Cann-Genant phantom with sex-, and race-matched database (Fig. 12) [62,63].
five cylindrical channels filled with K2HPO4 solu- T-scores used for the assessment of osteoporosis ac-
tions (of known concentrations) was the first phantom cording to the WHO definition have been established
in clinical use [55,56]. Because of the limited long- for DXA but not for QCT, although they may be given
term stability of these solutions, however, solid-state by the software of the manufacturers. If these T-scores
phantoms with densities expressed in milligrams of are used to diagnose osteoporosis, a substantially
calcium hydroxyapatite/mL were developed, which higher number of individuals compared with DXA
do not change with time and are more resistant to will be diagnosed as osteoporotic, because BMD mea-
damage. Two phantoms are currently used: (1) the sured with QCT shows a faster decrease with age than
DXA (Fig. 12). Researchers have advocated using imal femur, is feasible within a few seconds. These
BMD measurements analogous to the WHO defi- data sets can be used to obtain three-dimensional
nition but with thresholds corresponding to lower images, which provide geometric and volumetric
T-scores. Felsenberg et al [52] classify BMD values density information. A drawback of these techniques,
from 120 to 80 mg/mL as osteopenic and BMD values however, is a relatively high exposure dose, which
less than 80 mg/mL as osteoporotic, which corre- has been estimated as high as 350 mSv for the spine
sponds to a T-score of approximately 3. and 1200 mSv for the hip using software developed
With spiral and multislice CT, acquisition of larger by Kalender et al [64]. The primary advantage of
bone volumes, such as entire vertebrae and the prox- volumetric QCT of the spine is an improved precision
Fig. 7. DXA. Proximal femur of a 53-year-old postmenopausal, white woman. (A) The DXA scan of the proximal femur with the
ROIs: the neck ROI (*), the trochanteric ROI (**), Ward’s ROI (arrow), and the intertrochanteric ROI (***). The total BMD is
determined from the measurements in the neck ROI, the trochanteric ROI, and the intertrochanteric ROI. Note that the lesser
trochanter is only barely depicted. Applying the WHO guidelines to the T-scores, the total proximal femur ROI is in the normal
range (B). This ROI also should be used for the diagnosis, although Ward’s ROI is within the osteopenic range. (C) The BMD of
the total femur ROI is presented in relation to patient age, the absolute BMD values (left), the T-scores (right), and the Z-score
(gray areas).
for trabecular BMD measurements, which was 1.3% underlying basis of this method is the attenuation
as determined during an in vivo study [65]. An of sound waves as they pass through bone and the
algorithm developed by Lang et al [66] processes time taken for a sound wave to propagate through
volumetric CT images of the proximal femur to bone. A transducer is placed close to an easily
measure BMD in the femoral neck, total femur, and accessible bone with little soft tissue overlying it,
trochanteric regions. This technique has a high pre- and as the signal travels through the bone it is
cision rate of 0.6% to 1.1% for trabecular bone and attenuated. The attenuation increases with frequency,
may be used to determine geometric measures, such and the rate of attenuation over a given frequency
as the cross-sectional area of the femur neck and the range is measured and provides a measure of broad-
hip axis length. These measurements may be useful in band ultrasonic attenuation. The speed of sound
optimizing fracture prediction of the proximal femur. is also measured by many commercial ultrasound
Dedicated peripheral QCT scanners have been de- devices, and this measure is obtained by the time
veloped to assess the BMD of the distal radius [67].
These scanners have a low radiation dose and a
high precision with a short examination time but Table 2
have the same limitations as peripheral DXA in the Least significant change for quantitative CT and dual x-ray
monitoring of patients with osteoporosis. Although absorptiometry and average annual bone mineral density
this technique is potentially suited to predict fracture loss and monitoring time interval in healthy women
risk, studies have shown the limitations of this after menopause
technique in predicting spine fractures and proximal Rate of BMD
hip fractures compared with other bone densitometry LSC (%) loss (%/y) MTI (y)
techniques [68 – 70]. DXA, femur 4–8 0.5 – 1 5–6
DXA, AP spine 3–4 0.5 – 2 3
Quantitative ultrasound DXA, radius 3 1 3
QCT 6 – 11 2–4 3
Quantitative ultrasound techniques recently have Peripheral QCT (radius) 3 1 3
been proposed for the assessment of osteoporosis, in Abbreviations: AP, anteroposterior; LSC, least significant
particular at peripheral skeletal sites such as the change; MTI, monitoring time interval; QCT, quantitative
calcaneus, tibia, and the phalanges [71 – 75]. The CT; y, year.
Fig. 8. (A) Advances in DXA of the proximal femur show the upper neck region (arrow), which constitutes the upper half of the
neck region and (B) the hip axis line, which includes a femoral and an acetabular part.
taken for the sound waves to travel between two MR imaging

transducers. The attenuation of the sound waves is
reduced when the number of attenuating elements— The three-dimensional, noninvasive imaging ca-
in the case of bone, the number of trabeculae—is pabilities of MR imaging have been used clinically to
reduced. From physical principles, the speed of assess and diagnose osteoporotic and vertebral frac-
sound in a given medium depends on the density tures [79 – 81]. In recent years, however, MR imaging
and elastic modulus of the medium. also has been developed to assess the characteristics
Ultrasound methods are attractive for the assess- of trabecular bone. MR imaging permits not only the
ment of osteoporosis because the cost of the equip- depiction but also the quantification of trabecular bone
ment is low, there is no ionizing radiation, and structure; hence its biomechanical properties. MR
the equipment is portable. Initial scanners required imaging can be used to assess the properties of
the foot be immersed in a water bath; however, the trabecular bone in two different ways. Cortical bone
newer systems are dry and use an ultrasound gel and trabecular bone have short intrinsic T2 (spin-spin
for contact. relaxation time) values and low water content, and
In vitro and in vivo studies have shown that speed they have relatively low MR detectable magnetization.
of sound decreases, and broadband ultrasonic attenu- The presence of bone in proximity to bone marrow
ation is reduced with reductions in bone density and results in a modification of the marrow relaxation
trabecular number, and hence in osteoporosis. Large times, T1 and T2. The magnitude of T1 modification
retrospective and prospective studies have shown that depends on the surface area to volume ratio of this
quantitative US measures provide a relative risk bone marrow interface, increases at higher magnetic
comparable to bone density measures in hip fracture field strengths, and increases when the number of bone
[75,76] and vertebral fracture [77]. The clinical issues and marrow interfaces increase, that is, as bone density
associated with the reliability and reproducibility of increases. The magnitude of T2 relaxation time
the ultrasound measures include reproducible place- changes are also governed by similar mechanisms as
ment of the transducers and temperature variations of T1 relaxation but are also affected by processes such as
the foot [78]. Research is ongoing to improve the diffusion. Magnetic susceptibility of trabecular bone
performance of this technique. is substantially different from that of bone marrow.
Fig. 9. QCT of the lumbar spine. (A) A lateral digital radiograph is shown with the mid-vertebral slice positions of L1-3 that
are aligned parallel to the vertebral endplates. (B) Depiction of a 10-mm thick section of L2 with the calibration phantom (*)
and the gel cushion (**). An automated, peeled ROI (which determines cortical and trabecular bone mineral density sep-
arately) was used.
This gives rise to localized inhomogeneities in the The impact of bone on the MR properties of mar-
magnetic field that depend on the number of trabecular row was first investigated in an in vitro experiment in
bone marrow interfaces, the size of the individual 1986 by Davis et al [82] at a field strength of 5.8 T.
trabeculae, and the field strength. The diffusion of The investigators found that as bone density in-
water in these magnetic field inhomogeneities results creased, there were concomitant increases in the mag-
in an irreversible loss of magnetization and shortens netic field inhomogeneities and decreases in T2*. At
the marrow relaxation time T2. This effect also a field strength of 0.6 T, Rosenthal et al [83] showed
depends on magnetic field strength and is greater at that in excised cadaveric specimens the relaxation
higher magnetic field strength. In addition to these time T2* of saline present in the marrow spaces was
effects on marrow relaxation, an effect may occur in shorter than that of pure saline. Calibration of T2*
the presence of trabeculae, that is, the modification of with measures of BMD have been undertaken in vitro
the marrow relaxation time T2*. In specific types of [83 – 89] and in vivo [90 – 94]. Investigators also have
MR imaging sequences (eg, gradient-echo sequences) found that T2* variations with bone density depend
in addition to diffusion-mediated loss of magnetiza- on the spatial resolution at which the images are
tion, the magnetization is further lost irreversibly as a obtained [90] and on the three-dimensional distri-
result of the field inhomogeneities. This loss results in bution of the trabecular bone, or structure, as shown
a characteristic relaxation time T2*, which includes in computer studies [85,95] and phantom experiments
the additional contribution caused by field inhomoge- [83,96 – 98].
neities and the T2 relaxation properties. This effect In the area of osteoporosis, the biomechanical
forms the basis of quantitative MR imaging. properties of trabecular bone are of ultimate impor-
Fig. 10. (A) QCT calibration phantoms show a solid-state ‘‘Cann-Genant’’ phantom, comprised of five density phases. (B) The
phantom developed by Kalender et al with a small cross-section, is comprised of two density phases.
tance. Using specimens from the human tibia [99] fact that the ultrasound measure is a single point
and vertebrae [100], it has been shown that T1/T2* measure and could be measuring a small and variable
increases linearly as the elastic modulus increases. region between subjects. The heterogeneity in the
Correlations between ultimate compressive strength bone density and its impact on T2* in the calcaneus
and T2* have been studied in porcine bone [86] and was quantified in vivo by Guglielmi et al [104], who
human vertebral samples [101]. showed that the shortest relaxation time occurs in the
Clinically, Sebag et al [102] showed qualitatively superior talar region that corresponds to the highest
that bone marrow in the presence of trabecular bone BMD. They also demonstrated a linear correlation
showed increased signal loss in gradient-echo images, between MRI and DXA measurements (r = 0.66 for
where T2* effects predominate. Subsequently, quan- T1/T2* versus BMD). In a case control study, T2*
titative estimates of T2* in regions of varying bone measures of the proximal femur distinguished
density, such as in the epiphysis, metaphysic, and between subjects with hip fractures and normal sub-
diaphysis, were measured by Ford et al [92] using a jects [105]. A combination of relaxation time mea-
technique known as interferometry and localized pro- sures and BMD improved the ability to discriminate
ton spectroscopy. In a small sample size, researchers persons with vertebral fractures from individuals
also have shown that T2* values potentially may without [106].
distinguish osteoporotics from normals [91]. In vivo
calibration of T2* with trabecular bone density has
been obtained from coincident measurements in the Imaging of trabecular bone structure
forearm, distal-femur, and proximal tibia using MRI
and QCT [103]. In the context of osteoporosis, in addition to the
Fransson et al [94] correlated T2* in the tibia with quantity (mass) or the density of bone mineral, other
measures of BMD in the proximal femur and calca- factors such as the extent of mineralization, the
neal ultrasound. The investigators found good corre- macro-architecture of the bone, the trabecular bone
lations between T2* with BMD but relatively lower micro-architecture, and bone turnover play a role in
correlation with ultrasound measures. This could be defining bone strength. Several methods to assess
caused by the significant heterogeneity of bone these parameters are under study, and they aim to
structure in the calcaneus and in the tibia and the extend knowledge in the area of bone biology.
Fig. 11. Different ROIs used for the analysis in QCT. (A) An elliptical ROI that was placed manually. (B) An automatically
placed ‘‘peeled’’ ROI, which determines trabecular and cortical BMD separately.
Fig. 12. Age-related decrease of BMD in QCT, which is more substantial than that found in DXA of the lumbar spine. The
BMD of L3 in an individual patient is shown in relation to age and age-matched normal BMD. Although manufacturers give
T- and Z-scores (in this 62-year-old female patient the T-score would be 3.2 SD and the Z-score 0.7), these are not
established for QCT.
Radiographic assessment the study of radiographic patterns of trabecular bone

and the relationship of these measures with respect to
The three-dimensional micro-architecture of a biomechanical properties of bone and osteoporotic
cube of trabecular bone (Fig. 13) and radiographs status in vivo [107 – 112]. Caligiuri et al [113 – 115]
obtained at different orientations depict the aniso- used projection lateral radiographs (nonmagnified
tropy of the micro-architecture of the trabecular medial-lateral) of the lumbar spine and determined
network (Fig. 13B – D) and reflect different radio- Fourier transform and fractal analysis based texture
graphic patterns depending on the orientation. Sev- measures. The investigators found that the texture
eral computer-based methods have been applied in measurements appeared more successful than BMD
Fig. 13. (A) Three-dimensional rendering of trabecular bone specimen imaged after photographing 5 mm thick layers in
sequence, using a serial grinder to reveal the subsequent layers. The radiographs in B – D, which were obtained using
different orthogonal projections, reveal differences in trabecular pattern caused by the anisotropy and orientation of the three-
dimensional trabecular network.
obtained with DXA in predicting the presence or used the same technique and found significant differ-
absence of fractures elsewhere in the spine. Buck- ences between patients with osteoporotic spine frac-
land-Wright et al [116] analyzed magnification radio- ture and age-matched controls.
graphs of lumbar vertebrae in an experimental and
clinical study using fractal signature analysis. Similar Quantitative ultrasound assessment
analysis by Link et al [117] using morphometric
texture parameters and direct magnification radio- In early studies, quantitative US was found to
graphs have shown that texture measures may have depend on the orientation of trabecular bone [123]
some relevance in predicting biomechanical prop- and researchers postulated that it provided a measure
erties. In the study by Veenland et al [118] on direct that was a combination of trabecular bone density and
magnification radiography of human cadaveric ver- structure, especially in the calcaneus. Subsequent
tebrae, texture parameters based on mathematical studies questioned the role of quantitative US in the
morphology were assessed. Multivariate regression assessment of trabecular bone structure and have
of fracture stress versus BMD and the textural param- shown that in the commercial ultrasound devices,
eters showed that for the female vertebrae, a com- ultrasound measures seem to depict bone density
bination of one texture parameter and BMD gave a alone [124].
better prediction of fracture stress than BMD alone.
Several authors used calcaneus radiographs to Assessment from three-dimensional
analyze bone structure with fractal dimension. Les- tomographic images
pessailles et al [119 – 121] performed in vitro and in
vivo studies and compared fractal dimension derived In addition to projection radiographs, new emer-
from a fractional Brownian motion model with bio- ging micro-CT methods and MR imaging methods
mechanical stability, bone histomorphometry, and are being used in the study of bone structure. Fig. 14
osteoporotic status. The authors found a significant shows a representative micro-CT image of an iliac
correlation between this texture measure and biome- crest biopsy of trabecular bone, and similar images of
chanical strength; however, BMD performed substan- the distal radius also may be obtained in vivo using a
tially better. In an in vivo study, Pothuaud et al [122] prototype device [125 – 128].
Fig. 14. (A) A three-dimensional rendering of a micro-CT image of trabecular bone obtained from an iliac crest biopsy. The
image resolution was 34 34 34 mm obtained using a Scanco, mCT 20 (Scanco, Switzerland). (B) An in vivo image obtained
through the distal radius using a prototype scanner. (Courtesy of Andres Laib, Scanco, Switzerland.)
With the advent of phased array coils and im- sures to investigate the resolution dependence of
proved software and hardware, it has been possible to MR-based measures and then calibrating MR-derived
push the frontiers of MR imaging. The three-dimen- measures of bone structure.
sional imaging capability, along with the fact that MR Hipp et al [129] compared the morphologic ana-
imaging is a nonionizing modality, makes it poten- lysis of 16 specimens of bovine trabecular bone
tially attractive as a tool for imaging trabecular bone using three-dimensional MR reconstruction (92
structure. The marrow surrounding the trabecular 92 92 mm3) and two-dimensional optical images
bone network, if imaged at high resolution, reveals (23 23 mm2) of the six faces of the samples. Rec-
the trabecular network (Fig. 15). Using such mCT and ognizing that it is not possible to reconstitute ac-
MR images, multiple different image processing and curately the ‘‘true’’ trabecular bone structure from
image analysis algorithms have been developed to high-resolution MR imaging, Majumdar et al [130]
quantify the trabecular bone structure in two or three introduced the notion of ‘‘apparent’’ trabecular bone
dimensions. The measures that have been derived so network. Whereas the ‘‘apparent’’ network is not iden-
far are many, and some of them are synonymous with tical to the ‘‘true’’ histologic structure, it still re-
the histomorphometric measures such as trabecular flects some ‘‘apparent’’ morphologic and topologic
bone volume fraction, trabecular thickness, trabecular properties that are highly correlated to the ‘‘true’’
spacing, trabecular number, connectivity, fractal structure [130,131]. These studies and others [132]
dimension, tubularity, and maximal entropy. show good correlation between the MR-derived and
Several calibration and validation studies have other high-resolution imaging – derived measures,
been undertaken in which MR-derived measures of such as trabecular separation and number, moderate
structure are compared with measures derived from correlation for trabecular bone volume fraction, and
other modalities, such as histology, micro-mCT, and poor correlation for trabecular thickness. These corre-
BMD, and with biomechanical parameters. One of lations indicate that MR imaging can depict trabecular
the primary issues in MR-derived visualization and bone structure, although the absolute measures differ
quantitation of structure arises from the fact that the from the measures obtained at higher resolution. The
spatial resolution of the MR images is often compa- poorer correlation of trabecular thickness is explained
rable to the thickness of the trabecular bone itself, by the fact that the image resolution is comparable to
which gives rise to partial volume effects in the the dimensions of the trabeculae being measured, and a
image. The image may not depict thin trabeculae or small sampling error, or a partial volume effect, in the
may represent an average or a projection of a few estimation leads to a large percentage error.
trabeculae. Recognizing that MR-derived measures The effect of slice thickness on standard morpho-
are not identical to histologic dimensions—a major logic measurements has been investigated by Kothari
focus in the field—has been used to establish mea- et al [131]. Vieth et al [133] compared standard
Fig. 15. Axial images of the distal radius obtained at 1.5 T (A) spin-echo and (B) gradient echo. The dark network
represents the trabecular bone network, whereas the higher intensity background represents marrow-equivalent material in
the trabecular spaces.
morphologic measurements of 30 calcaneus speci- related to horizontal and vertical ultimate stresses
mens using MR imaging (195 195 mm2 in-plane (r > 0.8, P < 0.001).
resolution and 300/900 mm slice thickness) and con- Link et al [136] used texture parameter measures
tact radiographs (digitized with 50 50 mm2 in-plane on high-resolution MRI (156 156 300 mm3) of
spatial resolution) of sections obtained from the same proximal femur and spine specimens. Whereas the
specimens. The results of this study showed that correlation between elastic modulus and BMD was
MR-based measurements were significantly corre- R2 = 0.66 for the spine specimens and R2 = 0.61 for
lated with those obtained from digitized contact the femur specimens, a multivariate regression model
radiographs. Partial volume effects caused by slice that combined BMD and texture parameters increased
thickness and image post-processing (thresholding) the correlation to R2 = 0.83 for spine and R2 = 0.72
had substantial impact on these correlations, how- for femur.
ever: the thicker the slice, the poorer the correlation. In vivo, the skeletal sites most commonly imaged
Lin et al [134] confirmed correlation between are the radius [130,137 – 142] and calcaneus
structure parameters derived from MR imaging and [143 – 146]. The distal radius is a site with a large
serial grinding images and established that the quantity of trabecular bone and is a common site for
heterogeneity of calcaneal bone structure, as deter- osteoporotic fractures. It is easily accessible with lo-
mined from MR imaging, is real and is correlated to calized surface (detection) coils, and subjects are
the magnitude of the spatial heterogeneity using able to tolerate immobilization comfortably for the
higher resolution microscopic images. period required for high-resolution imaging. The
The accuracy of a new model-independent mor- calcaneus, although not a typical site for osteoporotic
phologic measure, based on the distance transfor- fractures, has been used with success to predict frac-
mation technique applied to high-resolution MR ture at other sites, and this skeletal site is well adapted
imaging of human radius specimens with in vivo to high-resolution MR imaging. The phalanges
resolution of 156 156 mm2 in plane and 300 or recently have been of increased interest as a site for
500 mm in slice thickness, has been investigated by bone density measurement [147,148] and can be
Laib et al [135]. These measures were compared with imaged by high-resolution MRI.
high-resolution mCT images (34 34 34 mm3), and The image contrast can be manipulated in MR
good correlation was found between the two sets of imaging based on the specific pulse sequence used,
measurements, with the best R2 = 0.91 for TbN. and the appearance of trabecular bone can be varied
The feasibility of using MR imaging at the based on whether a spin-echo or gradient-echo
resolution of 117 117 300 mm3 to better predict sequence is used [149]. The high susceptibility dif-
mechanical properties was established by Majumdar ference between bone and marrow induces suscep-
et al [132] using a set of 94 specimens of several tibility artifacts at their boundary, which in the case of
skeletal sites, with a wide range of bone densities and in vivo imaging could have a high impact on the bone
structures. Among several results reported in this structure quantification [149]. Although spin-echo
study, it was shown that MR-based structural mea- images may be preferable to reduce this effect,
sures, used in conjunction with BMD (evaluated gradient-echo images acquire an equivalent volume
from quantitative CT measures), enhanced the pre- in considerably less time and can be exploited in vivo
diction of bone strength. Using a stepwise regression at several skeletal sites. By the optimization of the
model, including structural parameters in addition to pulse sequence timing (short echo time) in gradient-
BMD, resulted in an improvement of the prediction echo imaging, one can attempt to minimize the
of the mean elastic modulus (evaluated from non- susceptibility artifact. Fig. 15A shows a represent-
destructive testing). The adjusted correlation coeffi- ative axial scan through the distal radius using a spin-
cient increased from 0.66 to 0.76 for all specimens, echo – based method, whereas Fig. 15B shows a
0.71 to 0.82 for vertebral specimens, and 0.64 to 0.76 representative scan using a gradient-echo – based
for femoral specimens. technique. The quantitative evaluation of structure
MR imaging (117 117 300 mm3) of vertebral from these images also constitutes a major area of re-
midsagittal sections of lumbar vertebrae and standard search. The processing of high-resolution MR images
morphological parameters were calculated by Beuf et generally consists of several stages [140]. Newitt et al
al [101]. Ultimate stress was estimated in two per- [140] have shown that each stage must be stan-
pendicular directions (horizontal/vertical) using com- dardized and normalized to ensure a high degree of
pression testing applied to two cylindrical samples reproducibility. In particular, these authors described
drilled in each vertebra close to the midsagittal a standardized analysis system with considerable
section. All the morphologic parameters were cor- reduction of human interaction. The efficiency of
Fig. 16. Axial images through the distal femur at (A) 1.5 T and (B) 3 T. (Image obtained by David Newitt, UCSF, and Ann
Shimakawa, GE Medical.) The spatial resolution is 195 195 1000 mm for both, and the imaging time at 3 T is half the time
taken at 1.5 T.
this system was evaluated in terms of reproducibility parable to radius or spine BMD measures but was not
(2% – 4%) and has been applied successfully in sev- as pertinent as the competence of hip BMD alone.
eral cross-sectional [139,146,150 – 152] and longit- With the advent of higher field magnets for clinical
udinal studies [153,154]. imaging (Figs. 16,17) and computerized image pro-
Some noise reduction – based preprocessing tech- cessing, MR imaging promises to provide an impor-
niques have been applied before the binarization tant complement to standard methods of assessing
stage, such as low pass filtering [137] or histogram osteoporosis and response to therapy. Slices can be
deconvolution [155]. The use of some postprocess- obtained at a resolution of 195 195 1000 mm.
ing schemes after the binarization, based on either With higher field, improved coils, there is potential for
morphologic criterion relative to the shape and
morphology of the trabeculae [156] or topologic cri-
terion relative to the numbers of bone and mar-
row components [157], have been applied. Wu et al
[158] proposed a sophisticated histogram model
taking into account the partial volume effect charac-
terizing MR imaging using a probabilistic approach.
Hwang et al [159] used spatial correlation analysis
and deduced parameters such as intertrabecular spa-
cing, contiguity, and tubularity. A combination of
some of these parameters was predictive of the
vertebral deformity [160].
More recently, distance transformation technique
was applied to high-resolution in vivo MR imaging of
the distal radius (156 156 500 mm3) in post-
menopausal women [161]. Morphology-based
parameters were evaluated without assumption of
any structure model, and the most significant para-
meter in distinguishing subjects with vertebral frac-
ture (n = 88) from those without vertebral fracture
(n = 60) was the intraindividual distribution of
separation (standard deviation of the trabecular bone Fig. 17. A sagittal image through the calcaneus obtained
separation parameter). Using receiver operating curve at 195 195 500 mm at 3 T. (Image obtained by Ann
analysis, the competence of this parameter was com- Shimakawa, GE Medical.)
improving resolution, improving signal-to-noise ratio tality and quality of life after trochanteric hip fracture.
of the images, or reducing imaging time. Clearly with Public Health 2001;115:323 – 7.
the proliferation of high field systems and further [9] Meunier P, Delmas P, Eastell R, et al. Diagnosis and
management of osteoporosis in postmenopausal wom-
research in the area of imaging trabecular bone
en: clinical guidelines. International Committee for
structure, optimized protocols will emerge.
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Radiol Clin N Am 41 (2003) 841 – 856
Current uses of ultrasound in the evaluation of the breast

Tejas S. Mehta, MD, MPH
Breast ultrasound is used routinely as an adjunct Improper technique of breast imaging can result in
to mammography to help differentiate benign from improper interpretation of breast lesions. The Mam-
malignant lesions. In patients younger than 30 years mography Quality Standards Act passed by congress
of age or patients who are pregnant, ultrasound may in 1992 oversees aspects of screening mammography
be the first or sole imaging modality to evaluate for [4]. Although there are no such laws for breast
breast pathology. Other less common uses of breast ultrasound, the American College of Radiology has
ultrasound include potential staging of breast cancer guidelines for imaging the breast with sonography
and evaluating breast implants. Ultrasound is useful [5]. One study [6] reviewed 152 breast ultrasounds
in guiding interventional breast procedures. Although performed at 86 sites and found that 60.5% did not
still controversial, some studies have advocated using comply with at least one of the American College of
ultrasound for screening for breast carcinoma in Radiology guidelines. Some of these errors in com-
asymptomatic women [1 – 3]. This article reviews pliance resulted in misinterpretation of normal breast
the multiple current uses of ultrasound in the evalu- tissue as a mass, classic benign lesions as indeter-
ation of the breast. minate, and cancers as benign lesions [6].
Several recent studies have used relatively new
sonographic techniques of spatial compound imaging
Technique [7], tissue harmonics imaging [8], and three-dimen-
sional imaging [9 – 11] in the evaluation of breast
Breast ultrasound should be performed using a disease. Compound imaging of the breast has been
high-frequency transducer of 7.5 MHz or higher. A shown to increase lesion conspicuity by enhancing
linear array transducer is preferred. A standoff pad soft tissue contrast, improving the definition of tumor
may be used to evaluate superficial lesions. The margins, and improving evaluation of the internal
patient should be placed in a supine or oblique architecture and surrounding distortion. A potential
position, with ipsilateral arm above the head. The disadvantage of compound imaging is that it
breast is scanned in either the transverse and sagittal decreases acoustic shadowing [7]. No study has
planes or the radial and antiradial planes. The retro- evaluated if these improvements affect sensitivity
areolar area is evaluated by angling the transducer in and specificity of breast ultrasound. In the author’s
multiple planes to avoid shadowing artifact produced department, conventional and compound imaging
by the nipple. Focal zone placement should be techniques are used in scanning the breast, because
optimized and gain settings adjusted so that the fat it is easy to switch from one technique to the other.
in the breast appears gray. If a lesion is present, it A study that evaluated 73 breast lesions (25 cysts,
should be imaged in two planes, and the location 36 solid lesions, and 12 indeterminate lesions) with
should be noted by clock face position on the breast tissue harmonics imaging found that it was signifi-
and distance from the nipple. cantly preferred for lesion conspicuity and overall
image quality [8]. The study did not address whether
this improved the accuracy of ultrasound in diagnosing
E-mail address: [email protected] breast lesions, however.
doi:10.1016/S0033-8389(03)00040-X
842 T.S. Mehta / Radiol Clin N Am 41 (2003) 841–856
Another study that compared two-dimensional to Unlike other areas of the body, fat within the breast
three-dimensional ultrasound found that three-dimen- is hypoechoic. The dense breast tissue is echogenic
sional ultrasound had a higher specificity (64.1% by on ultrasound (Fig. 1). Solid masses are usually
two-dimensional imaging compared with 86.9% by hypoechoic, and caution should be made not to
three-dimensional imaging) for diagnosing malig- mistake an island of fat surrounded by dense breast
nancy [11]. The researchers evaluated 186 solid nod- tissue for a solid mass. Shadowing from Coopers
ules and used three-dimensional ultrasound to examine ligaments can be seen; however, this does not persist
the peripheral tissues of the lesion. Depending on the with compression or change in scanning plane and
pattern of peripheral tissue, all lesions were placed should not be mistaken for pathology.
into two groups. When hyperechoic bands of sur-
rounding fibrous tissue appeared to be pushed
smoothly aside from the central image, it was defined Gray-scale sonographic evaluation of the breast
as a ‘‘compressive pattern.’’ When thick hyperechoic
bands converged according to a stellar pattern, toward Cystic lesions
a hyperechoic, irregular rim that surrounded a hypo-
echoic central core of a mass, it was defined as a Ultrasound is 96% to 100% accurate in the diag-
‘‘converging pattern.’’ The researchers concluded that nosis of cysts [12 – 15]. In the 1970s, ultrasound
a compressive pattern on three-dimensional ultrasound decreased the number of biopsies for benign masses
provided an additional argument to alleviate biopsy for 25% to 35% by reliably identifying simple cysts
a lesion with a low index of suspicion on two-dimen- [15,16]. A simple cyst is defined as a thin-walled
sional ultrasound; however, if a lesion had suspicious anechoic lesion with sharp anterior and posterior
features on two-dimensional imaging, regardless of the borders and posterior acoustic enhancement (Fig. 2).
three-dimensional results, intervention was warranted. Reverberation artifact can result in linear internal
Three-dimensional imaging is cumbersome and time echoes at the anterior part of a cyst [15]. A proposed
consuming. In the author’s department, where all breast ultrasound lexicon [17] suggests that if a cyst
patients are scanned real-time by the radiologist, does not meet all of these criteria, it should be
three-dimensional imaging has been found to be of classified as either ‘‘complicated’’ or ‘‘complex.’’ A
little diagnostic value. ‘‘complicated’’ cyst has multiple low-level internal
echoes but other features of a simple cyst (Fig. 3).
One study that evaluated 308 such lesions with ultra-
Normal breast anatomy sound found a malignancy rate of 0.3%, which is lower
that the 2% for a Breast Imaging Reporting and Data
The skin is seen as an echogenic layer that System (BI-RADS) 3, probably benign [18] lesion,
measures up to 3 mm in thickness. Deep to the skin which suggests that such lesions can be managed with
is breast tissue, which has different appearances follow-up imaging studies instead of intervention [19].
depending on the overall density of the breast and In contrast, a ‘‘complex’’ cystic mass has suspicious
the distribution of fatty and fibroglandular tissue. features, such as a mural nodule, thick septations, or a
Fig. 1. Normal breast ultrasound. Arrowheads denote normal skin, and open arrows denote the interface between the breast tissue
and pectoralis muscles in a diffusely fatty (A) and diffusely dense (B) breast.
T.S. Mehta / Radiol Clin N Am 41 (2003) 841–856 843
diagnosis includes intracystic papillomas, necrotic

solid tumor, and cysts with adherent blood clot/debris.
Other cystic lesions that can have a ‘‘complicated’’ or
‘‘complex’’ appearance include abscesses and hema-
tomas. Often the clinical history is pertinent in making
such diagnoses and guiding management of these
lesions (Fig. 5).
Solid lesions
In addition to distinguishing cysts from solid

masses, a major advance in gray-scale ultrasound has
been the ability to help differentiate benign from
malignant solid lesions. Several studies have shown
that the addition of ultrasound to mammography can
Fig. 2. Simple cyst. Arrows mark a breast lesion that meets reduce the number of biopsies for benign solid lesions
all the criteria for a simple cyst. It is anechoic with a thin [21 – 24].
wall and enhanced through transmission.
A landmark study by Stavros et al [22] classified
750 solid lesions as benign, indeterminate, or malig-
nant based on sonographic appearances. Malignant
thick or irregular wall (Fig. 4). ‘‘Complex’’ cystic
features included spiculations, angular margins,
lesions should be classified as BI-RADS 4, suspicious,
marked hypoechogenicity, shadowing, presence of
and require aspiration or biopsy [17].
calcifications, duct extension, microlobulation, and a
When aspiration is performed, if a lesion does not
branching pattern. If a lesion had any of these features,
resolve to completion, biopsy of the remaining com-
it was classified as malignant. A lesion was classified
ponent should be considered to exclude malignancy.
as benign if it lacked all malignant features and was
When an aspirate is bloody, fluid also should be sent to
intensely or uniformly hyperechoic, or ellipsoid in
cytology, and subsequent biopsy may be necessary to
shape with a thin, echogenic capsule, or had two to
exclude malignancy. Intracystic carcinomas are rare
three gentle lobulations and a thin, echogenic capsule.
and account for less than 1% of breast cancers [20].
Indeterminate lesions were ones that did not meet
They are usually papillary carcinomas. The differential
criteria for malignancy or benignity. Based on this
classification scheme, the authors reported a sensitiv-
Fig. 5. Breast hematoma. Calipers mark a heterogeneous,

predominantly echogenic mass with multiple internal hypo-
echoic and anechoic cystic spaces. This patient presented a
Fig. 3. Complicated cyst. Calipers mark a ‘‘complicated’’ cyst few days after a severe motor vehicle accident with a palpable
with debris (d) at its dependent portion and reverberation lump and area of ecchymosis on the breast. Sonographic and
artifact (r) anteriorly. This cyst was aspirated with ultrasound clinical findings suggested presence of hematoma. Follow-up
guidance for symptomatic relief to complete resolution. showed this area to resolve completely in 2 months.
Fig. 4. Complex cyst. Ultrasound demonstrates a ‘‘com-

plex’’ cyst (open arrows) with soft tissue mass (arrowheads) Fig. 14. Inflammatory lymph node. Ultrasound of the
with internal power Doppler flow. Pathology revealed an axillary tail of the breast, performed for a newly palpable
intraductal papilloma. and mammographically enlarging nodule, shows a hypo-
echoic lymph node with small amount of fatty hilum and
typical branching vessels on power Doppler. Histology from
excisional biopsy revealed an inflammatory lymph node.
Fig. 12. Use of power Doppler to increase specificity for malignancy. (A) Gray-scale ultrasound of a palpable abnormality in a
28-year-old woman shows a relatively benign appearing nodule (calipers). (B) Power Doppler ultrasound shows hypervascularity
with multiple penetrating vessels. Histology from ultrasound-guided core biopsy revealed infiltrating ductal carcinoma.
ity rate of 98.4% and negative predictive value (NPV) tations in 4 of 38 (10.5%) cancers by at least one of the
of 99.5% [22]. three reviewers, however. A high interobserver vari-
Stavros et al have been criticized for including in ability for evaluating sonographic features of tumors
their study masses that by standard mammographic also has been reported by other researchers [27].
criteria should not have been biopsied [25]. Zonder-
land et al [24] used criteria similar to Stavros et al and Common features of some benign and malignant
classified lesions into five categories (benign, prob- solid lesions
ably benign, equivocal, probably malignant, and
malignant) based on mammography and combination Infiltrating ductal carcinoma not otherwise speci-
of mammography and ultrasound. In their study, for fied is the most common breast cancer [28]. This
patients who underwent mammography and ultra- cancer classically appears as an irregularly shaped
sound, the addition of ultrasound increased sensitivity hypoechoic mass with shadowing and distortion of
from 86% to 95% and specificity from 89% to 92%. the surrounding tissues (Fig. 6). Infiltrating lobular
Ultrasound increased diagnostic accuracy by diag- carcinoma, which comprises 7% to 10% of all breast
nosing 25 additional cancers out of the 338 total cancers [29,30], invades the breast tissue in a single-
cancers in their study population (7.4%) [24]. file pattern without a desmoplastic reaction, which
Skaane et al [21] examined 142 fibroadenomas and potentially makes it harder to detect on imaging. Up to
194 invasive ductal carcinomas with respect to shape, 12% of cancers may not be seen on ultrasound, and up
contour, echotexture, echogenicity, sound transmis- to 15% of those seen may present with only vague
sion, and surrounding tissues and found NPV of shadowing without a mass (Fig. 7) [2,31]. Medullary
100% for palpable tumors and NPV of 96% for non- carcinoma, although uncommon, can appear as a well-
palpable tumors, if strict criteria were applied. They defined solid mass with posterior acoustic enhance-
found that a thin echogenic pseudocapsule was a ment and be mistaken for a benign lesion on ultrasound
feature most predictive of benignity. Irregular shape [26,32]. Although ductal carcinoma in situ typically is
and contour, extensive hypoechogenicity, shadowing, seen as isolated microcalcifications on mammography,
echogenic halo, and distortion of the surrounding 6% to 10% can be seen as a solid mass on ultrasound
tissue were highly predictive of malignancy [21]. [33,34].
In a study by Rahbar et al, three radiologists each Inflammatory breast cancer typically produces
reviewed 162 solid masses [26]. Characteristics eval- nonspecific skin thickening on ultrasound. This thick-
uated included shape, margins, width-anteroposterior ening unfortunately is indistinguishable from other
dimension ratio, echotexture, echogenicity, posterior causes of skin thickening, including infectious causes,
echo intensity, presence/absence of pseudocapsule, such as mastitis. The presence of an abscess favors an
edge refraction, and calcifications. They found that if infectious etiology.
the three most reliable criteria were strictly applied, the Metastases to the breast are rare and can occur via
overall cancer biopsy yield would have increased from lymphatic or hematogenous spread [35]. Metastases
23% to 39%. They also found false-negative interpre- that occur via lymphatic spread can be indistinguish-
Fig. 6. Infiltrating ductal carcinoma. (A) Open arrows mark a 4-mm irregular, hypoechoic mass with shadowing. (B) In another
patient, arrows mark a 1-cm microlobulated hypoechoic mass with mild posterior acoustic enhancement. Both lesions had
histology of infiltrating ductal carcinoma.
Fig. 7. Infiltrating lobular carcinoma. Ultrasound shows a

1-cm area of shadowing (s) with distortion of the surrounding Fig. 9. Fibroadenoma. Ultrasound shows an ovoid, well-
tissues but no discrete mass. Histology revealed infiltrating circumscribed nodule (F) isoechoic to the fatty breast
lobular carcinoma. tissue (f ) surrounded by dense breast tissue (d). Ultra-
sound-guided core biopsy was performed, and histology
revealed fibroadenoma.
able from inflammatory breast carcinoma [36]. Causes
of hematogenous metastases to the breast include
lymphoma, leukemia, melanoma, and lung cancer.
parallel to the chest wall, and they have a thin,
Many cases of metastatic disease to the breast present
echogenic capsule (Fig. 9). They can have a few
as multiple breast masses that involve one or both
macrolobulations and demonstrate posterior acoustic
breasts [36,37].
enhancement. They are similar in echogenicity to the
Sometimes it can be difficult to distinguish be-
fatty parenchyma and may be difficult to see sono-
tween architectural distortion that is caused by malig-
graphically in a fatty breast. When they calcify, the
nancy from architectural distortion that is caused by
macrocalcifications can obscure borders and cause
scar in an area of prior surgery [38]. When the ar-
shadowing that results in a ‘‘suspicious’’ appearance
chitectural distortion can be tracked through the breast
on ultrasound. Correlation with mammographic find-
to the skin scar, postoperative scar tissue is the more
ings, which are typical, should prevent further evalu-
likely diagnosis (Fig. 8).
ation or intervention of such lesions.
Fibroadenomas are some of the more common
Hyperechogenicity is a reliable predictor for be-
benign solid lesions seen on breast ultrasound. They
nignity but is seen in only 2% of masses [26]. Fat ne-
typically are ovoid in shape, with their long axis
crosis can have a variable appearance on ultrasound,
including a focal hyperechoic nodule (Fig. 10), echo-
genic nodule with central lucency, possible associated
Fig. 8. Scar tissue. Ultrasound of an area prior to surgery

was performed because of change on clinical examination.
There is a large area of hypoechoic architectural distortion
(D) with spiculations extending to the skin surface (arrows). Fig. 10. Fat necrosis. Calipers mark a hyperechoic, palpable
Patient underwent excisional biopsy based on clinical nodule excised for clinical reasons, with pathology showing
grounds. Histology revealed no evidence of malignancy. fat necrosis.
65% to 98% of malignant lesions [45 – 53]. Studies that

evaluated the number of detectable vessels showed a
significantly higher number of vessels in cancers than
in benign lesions [54 – 57]. Raza et al [46] character-
ized patterns of vascularity by Power Doppler ultra-
sound in 86 solid breast masses as none, peripheral,
central, and penetrating. They found that the addition
of Power Doppler to gray-scale evaluation increased
the sensitivity rate from 92% to 100% and NPV from
95% to 100% (Fig. 12). In their study, as in others
[45,52,58], penetrating vessels were more likely to be
present in malignant tumors. Although Doppler find-
ings cannot be used to determine histology, pure
invasive lobular carcinomas are less likely to have
Doppler detectable vessels compared with invasive
Fig. 11. Sebaceous cyst. Ultrasound with standoff pad shows
a hypoechoic lesion (c) with the skin layer (s) consistent carcinomas with ductal features [33,46,59].
with a sebaceous cyst.
Contrast-enhanced Doppler ultrasound
A few studies have assessed the role of contrast-

calcifications, and it can progress to have cystic spaces enhanced Doppler in helping distinguish benign from
within it. malignant breast lesions [54,60 – 62] and evaluating
Ultrasound also can be used to determine whether a breast cancer patients suspected of having recurrent
palpable or mammographically detected lesion is disease [63]. Currently, however, the use of contrast-
within the skin as opposed to within the underlying enhancement breast ultrasound is experimental.
superficial breast tissue. A sebaceous cyst (Fig. 11) is a Kedar et al [54] studied 34 patients (18 with cancer
common skin lesion seen while evaluating the breast. and 16 with various benign lesions) before and after
Once intradermal location is documented, no further contrast enhancement. They found that the appearance
imaging or intervention is necessary (unless required on contrast-enhanced ultrasound changed the diag-
for symptoms of infection). nosis in 4 patients, which increased the sensitivity rate
from 88.9%, specificity rate from 87.5%, and accuracy
rate from 88.2%, all to 100%. They found differences
Doppler imaging of benign and malignant lesions in enhancement, number of new detectable vessels,
and duration of enhancement between cancers and
Non – contrast-enhanced Doppler ultrasound benign lesions.
Huber et al [61] performed contrast-enhanced
Although gray-scale sonographic features are use- ultrasound in 47 patients (31 with cancer and 16 with
ful in distinguishing benign from malignant solid benign lesions) and found that cancers typically had
breast lesions, a significant number of breast masses early and marked enhancement followed by marked
do not present with the typical expected sonographic decline of color pixel density, whereas benign lesions
appearance [39 – 41]. Angiogenesis is defined as the had later enhancement. Given complexity of some
formation of new blood vessels through the sprouting time-color pixel density curves, however, contrast-
of capillaries from preexisting microvessels [42]. The enhanced Doppler assessment was of ‘‘limited value
formation of these new, abnormal vessels is associated for prospective diagnosis’’ [61]. Two other studies
with an increased risk of malignancy [43]. These [60,62] showed no role for contrast-enhanced Dopp-
concepts of angiogenesis have led researchers to assess ler to improve accuracy in distinguishing benign from
the use of Doppler ultrasound in distinguishing benign malignant lesions.
from malignant solid masses. Winehouse et al [63] evaluated contrast-enhanced
In 1988, Schoenberger et al [44] studied 38 patients color Doppler imaging in 58 patients suspected of
with pulsed duplex Doppler and reported 100% sen- having breast cancer recurrence. They reported a
sitivity and specificity rates for predicting malignancy. sensitivity rate of 94% and specificity rate of 67%
Since then, advances in technology and equipment with contrast enhancement. In their study, contrast
have led to detection of Doppler flow in many solid enhancement increased diagnostic accuracy from
lesions, including 14% to 60% of benign lesions and 80% to 90%.
Staging as high as 50% [78,79]. Various studies have examined

the role of axillary sonography in assessing nodal
Tumor size and grade status [78,80,81]. On ultrasound, lymph nodes that
have a prominent echogenic fatty hilum with thin,
Ultrasound cannot assess the size of a tumor uniform, homogeneous hypoechoic cortex are be-
accurately and usually underestimates the true size lieved to be ‘‘benign’’ (Fig. 13A). Lymph nodes that
[64]. Ultrasound also cannot assess tumor grade accu- have little to no fatty hilum and are predominantly
rately [33,47,59,65]. One study found that high-grade hypoechoic, inhomogeneous, or enlarged are believed
invasive ductal carcinomas were significantly larger to be ‘‘suspicious’’ (Fig. 13B) [81].
at time of diagnosis, however, and were more likely Verbanck et al [78] performed axillary ultrasound
to have better-defined margins and acoustic enhance- on 144 breast cancer patients. In their population, in
ment compared with low- and intermediate-grade which the prevalence of lymph node involvement was
tumors [66]. Some researchers believe that the 55.3%, they found ultrasound to have a sensitivity rate
enhancement is caused by increased tumor cellularity of 92%, specificity rate of 95%, positive predictive
[67,68], whereas others believe that the organization of value of 96%, and NPVof 91% in detecting malignant
the tissue in the tumor—and not the absolute amount nodes. Vaidya et al [80] performed axillary ultrasound
of fibrous tissue within the tumor—determines the on 200 breast cancer patients. They found that ultra-
enhancement characteristics [69]. sound had a specificity rate and positive predictive
value of 90%. When combined with clinical examina-
Nodal involvement: assessment of the axilla tion, the sensitivity rate and NPV were 82% and 76%,
respectively. In the subset of younger women, the
Lymph node status is an important prognostic sensitivity rate and NPV were even higher, at 91%
indicator of survival in patients with breast cancer and 89%, respectively. They concluded that ‘‘Using
[70,71]. Axillary node dissection is responsible for clinical exam and ultrasound to avoid axillary dissec-
much of the morbidity associated with breast surgery tion in some patients is feasible.’’
[72 – 74]. Sentinel node biopsy can predict the pres- Yang et al [82] performed color Doppler axillary
ence or absence of nodal metastases; however, suc- ultrasound on 81 women with breast cancer and 106
cess rates have varied depending on patient age, asymptomatic women. They found color Doppler flow
location of the primary cancer, and surgical technique in 84% of normal nodes and 88% of metastatic nodes
[75]. A patient with a T1 lesion who undergoes nodal in patients with breast cancer and 87% of normal
dissection has an 80% chance of having no nodal nodes in asymptomatic women. The presence of color
involvement, and a patient with a T2 lesion has a Doppler flow is highly nonspecific as a criterion for
65% chance of no nodal involvement [76,77]. malignancy. There is no method to distinguish Dopp-
Clinical examination is not a reliable method for ler flow in malignant nodes from inflammatory nodes
assessing nodal status and shows false-negative rates (Fig. 14) [83,84].
Fig. 13. Lymph nodes. (A) Calipers mark a benign axillary lymph node with echogenic, fatty hilum (h). (B) Calipers mark highly
suspicious, enlarged lymph node with no fatty hilum in a patient with breast cancer.
Nodal involvement: assessment of the primary cancer stereotactic procedures. There is no radiation, which
is particularly important to pregnant patients.
Several studies have evaluated the role of Doppler Fine needle aspiration biopsy in breast tumors was
flow in the primary breast carcinoma in assessing first reported by Fornage et al [93] in 1987. The
nodal status [33,47,48,85 – 87]. One study that used success rate is variable, however, and it requires
Power Doppler found that although many breast adequate sampling using proper technique and proper
cancers demonstrated flow with Power Doppler, handling of the specimen. It also depends on the
patients with cancers in whom vessels were not experience of the cytopathologist [94 – 96]. In the
detectable were unlikely to have lymph node involve- proper setting, fine needle aspiration biopsy can have
ment (NPV, 90%) [33]. Lee et al [48] used color a high sensitivity rate of 95% and NPVof 98% [97]. In
Doppler to study 32 breast cancers and found a the study by Fornage et al, in which one radiologist
significant association between higher tumor flow obtained all 1136 specimens, there were 27 (2%)
and nodal metastases for T1 lesions (V 2 cm) but inadequate samples. Of these, 14 occurred in the first
not for larger lesions. Holcombe et al [86] studied 150 samples and 13 in the subsequent 986 samples.
color Doppler flow in 28 breast cancers and found These results highlight the point that there is a ‘‘learn-
that when three or more vessels were seen on color ing curve’’ to the technique of performing fine needle
Doppler, the patients were more likely to have lymph aspiration biopsy [97].
node involvement. In 1993, Parker et al [98] reported the use of core-
needle biopsy of the breast using real-time ultra-
Screening ultrasound in patients with known sound. They used a 14-gauge needle and reported
breast cancer 100% accuracy after sampling 132 lesions, with no
complications. The following year, Parker et al [99]
Evaluation of mastectomy specimens has shown performed a larger, multi-institutional study that eval-
additional malignant foci in 30% to 63% of patients uated the results of core-needle biopsy in 6152 le-
believed to have unifocal breast cancer by clinical and sions, performed with sonographic or stereotactic
mammography evaluation [88,89]. Three studies guidance. They reported a cancer miss rate of 1.2%
[90 – 92] evaluated a cumulative total of 391 patients to 1.5% (depending on the inclusion or exclusion of
with known breast cancer or high suspicion of breast mammary intraepithelial neoplasia, respectively) but
cancer. Using whole breast(s) ultrasound, they found also pointed out that ‘‘surgical excisional biopsy is not
one or more additional cancers in 55 of 391 (14%) pa- perfect’’ either. In this larger study, there was a 0.2%
tients. Management was altered in 47 of these 55 wo- rate of clinically significant complications.
men (12% of total of 391 women). Based on these The results of these studies and others [100,101]
studies, some researchers advocate routinely scanning have led to the routine use of ultrasound in guiding
the ipsilateral or both breasts when an index lesion is for core-needle biopsy (Fig. 15A) and preoperative
seen. Others continue to scan only the region of in- needle location (Fig. 15B) of breast lesions.
terest. Some patients who have multifocal cancer and
have only been scanned in the region of interest may Intraoperative ultrasound guidance
escape detection because they are treated with post-
lumpectomy irradiation. Other patients may present Intraoperative ultrasound, when performed by
later with ‘‘recurrent’’ or ‘‘new’’ breast cancer lesions trained individuals, is another method of localizing
that actually were present but undiagnosed previously. breast lesions. Harlow et al [102] used intraoperative
ultrasound to excise 65 breast cancers and reported
achieving negative excision margins at first operation
Ultrasound-guided procedures in 97%. They point out certain advantages of intra-
operative ultrasound compared with preoperative
Fine needle aspiration biopsy and core needle biopsy needle location. The advantages include improved
patient comfort, more optimal choice of location of
Assuming a lesion can be seen, there are certain incision, and ability to evaluate the specimen and
advantages to performing aspiration, biopsy, or local- surgical bed such that if the lesion is found close to
ization with ultrasound guidance. The lesion can be margin, reexcision could be performed immediately
visualized at all times during sampling, which at time of initial operation.
ensures accurate needle placement. The procedure is Moore et al [103] evaluated 51 patients who
easier for the patient, who can be supine to slightly underwent lumpectomy for palpable breast cancer,
oblique versus upright or prone for mammographic or 27 of whom had intraoperative ultrasound and 24 of
Fig. 15. Ultrasound-guided procedures. (A) Core needle biopsy shows the biopsy needle (tip marked by arrows) through the lesion
(L) being sampled. (B) Preoperative wire localization shows the hook wire (arrowheads) to be through the lesion to be excised.
whom did not. They found surgical accuracy and Yang et al [109] examined 89 breast cancers with
margin status to be improved with intraoperative high-resolution ultrasound and found it to be 95%
ultrasound. They also reported no significant change sensitive and 91% accurate for detection of micro-
in operating room cost or length of total surgery time. calcifications. Gufler et al [107] examined 49 clusters
Smith et al [104] used intraoperative ultrasound to of microcalcifications seen on mammography and
assist in the excision of 81 lesions, including 25 can- found ultrasound to have an overall sensitivity rate
cers and 56 benign lesions. They reported 100% of 75%, with 66.6% sensitivity rate for detection of
accuracy of intraoperative ultrasound to localize the benign lesions and 100% detection of malignant in
lesions and 96% accuracy in predicting margins of situ and invasive cancers. Teh et al [110] used high-
the carcinomas. frequency ultrasound and Power Doppler to visualize
and biopsy microcalcifications in 37 patients. They
found the presence of Power Doppler flow helpful in
Microcalcifications on ultrasound directing successful biopsy in eight cases (including
benign and malignant lesions).
Thirty-five percent to 45% of nonpalpable breast
cancers detected at screening present as clusters of
microcalcifications on mammography [105]. With Screening for breast cancer
higher frequency transducers, we are more able to
detect mammographically isolated microcalcifications Mammography is the only widely accepted
with ultrasound (Figs. 16A, B). One study examined imaging modality used to screen for early, otherwise
76 patients with 7.5 MHz and 10 MHz transducers and occult breast cancers. Many lesions are indistinguish-
found increased visibility of microcalcifications from able by mammography. Three older studies reported a
45% to 74% in benign breast lesions and 91% to 97% cumulative total of 236 incidental sonographically
in malignant lesions [106]. The ability of ultrasound to detected lesions and found none to be malignant based
identify microcalcifications more often when associ- on either biopsy or long-term follow-up [13,111,112].
ated with a mass also has been reported by other More recent studies have shown that incidental cancers
authors [22,107,108]. The hypoechogenicity of the are detected with sonography performed in asympto-
underlying mass provides more contrast for detection matic patients and in patients being scanned for benign
of the echogenic nonshadowing foci that are the and malignant disease [1,3,22,97,113].
microcalcifications (Fig. 16C). Although ultrasound Buchberger et al [1] performed ultrasounds on
cannot be used to distinguish benign from malignant 6113 asymptomatic patients with dense breasts on
microcalcifications definitively, when the microcalci- mammography and found 23 malignancies in 21 pa-
fications are seen associated with a mass on ultrasound tients seen on ultrasound only. Of another 687 patients
(even if isolated on mammography), there is a higher scanned because of palpable or mammographic abnor-
incidence of invasive cancer [22,108]. malities, ultrasound found 5 additional cancers, 3 in
Fig. 16. Microcalcifications. (A) Screening mammogram (not shown) revealed an area of pleomorphic microcalcifications without
associated mass. Ultrasound of this region shows multiple tiny echogenic foci (open arrows) that correspond to the
microcalcifications seen mammographically. Ultrasound-guided core biopsy was performed, with specimen radiograph
demonstrating microcalcifications. Histology revealed high-grade ductal carcinoma in situ. (B) Another patient had multiple
more diffuse microcalcifications on mammography (not shown). Ultrasound that was performed for a lump was negative for the
area of clinical concern. Sonographic evaluation of the area of mammographic microcalcifications was performed. It showed tiny
echogenic foci (arrows) adjacent to small anechoic cysts consistent with microcalcifications within microcysts. Although no
histologic diagnosis is available, these have been stable mammographically for more than 2 years. (C) Ultrasound in another patient
shows a suspicious hypoechoic mass with tiny echogenic foci (arrows) within it. Histology revealed infiltrating ductal carcinoma.
women with malignant index lesions and 2 in women followed and others that were biopsied. The added
with benign index lesions. Gordon et al [113] scanned ‘‘cost’’ (of performing the test, potentially increasing
12,706 women with palpable or mammographic patient anxiety and discomfort, and potentially
abnormalities and found 44 additional cancers increasing morbidity from increased number of biop-
detected with ultrasound only. These cancers were in sies) must be weighed against the benefits of finding
30 women, 15 with malignant index lesions and 15 these sonographically detected cancers. The only way
with benign index lesions. Kolb et al [3] performed to determine the true independent contribution of
3626 ultrasounds in asymptomatic women with dense ultrasound to breast cancer screening is to perform a
breasts on mammography and found an additional randomized, blinded, controlled trial with death as an
11 cancers seen only on ultrasound. endpoint [114].
There is no current dispute that if ultrasound is
performed, incidental cancers will be found. The
controversies lie in weighing the benefits against the Breast implants
cost and assessing whether detection of these other-
wise occult cancers will result in increased patient MR imaging currently is more sensitive and accu-
survival. In addition to the incidentally found cancers, rate than ultrasound at evaluating silicone implants for
in three studies [1,3,113] ultrasound detected an addi- rupture [115]. When MR imaging is not readily avail-
tional 2088 benign lesions, some of which were able or if it cannot be performed (because of claustro-
phobia, internal metallic clips, or other causes), ultra-

sound is an alternative. An intact implant, without
rupture, appears anechoic with echogenic wall ante-
riorly on ultrasound [116]. Implant ruptures can be
classified as ‘‘intracapsular’’ or ‘‘extracapsular,’’ the
former having an intact fibrous capsule and the latter
having a ruptured fibrous capsule. Both of these types
of ruptures must be distinguished from a ‘‘gel bleed,’’
which results from leakage of silicone through the
prosthetic shell without a tear in the shell.
DeBruhl et al [117] described the ‘‘stepladder
sign,’’ in which multiple horizontal echogenic lines Fig. 18. Gynecomastia. Calipers mark an area of asym-
are seen within the lumen of the implant (Fig. 17). This metric breast tissue in a man who presented with a lump
is the term commonly used to describe intracapsular and breast pain. Sonographic findings, interpreted in
rupture. On ultrasound, this sign also can be seen in conjunction with mammographic findings (not shown), led
patients with heavy silicone gel bleed and in patients to the diagnosis of gynecomastia.
with severe capsular contractures, in which the fibrous
capsule compresses an intact implant and produces
infolding of the implant shell. In these cases, ultra- sensitivity rate. More subtle signs of extracapsular
sound results in a false-positive diagnosis of intra- rupture include focal extracapsular echogenic masses.
capsular rupture [117 – 119]. Venta et al [119] evaluated 236 implants with
Harris et al [120] described the ‘‘snowstorm sign’’ sonography. They found that abnormal sonographic
in cases of extracapsular rupture. There is increased findings were present in intact implants, many of
reverberation from leakage of silicone coming into these caused by ultrasound’s inability to distinguish
contact with the surrounding tissues. Their study prominent folds from rupture. They also reported that
found that 100% of patients who had this sign had a normal ultrasound was highly predictive of an intact
extracapsular rupture; however, it was only seen in implant, however, with NPV of 91%.
23% of patients with rupture and thus had a low
The male breast
Breast cancer in men is rare. It represents 1% of all

breast cancers and only 1% of all malignancies in men
[121]. Ultrasound has been used to evaluate the male
breast [122,123]. There is an overlap in appearance of
benign and malignant diseases using mammography
and ultrasound individually; however, the combina-
tion of these modalities is believed to improve accu-
racy. A common benign breast condition in men is
gynecomastia. Men with this condition usually present
with symptoms of a lump or pain. On ultrasound, this
can appear as subareolar hypoechogenic or hyper-
echoic fibroglandular tissue (Fig. 18).
Summary
Ultrasound is an important imaging modality in

evaluating the breast. One of the most common uses of
ultrasound is to help distinguish benign from malig-
nant breast disease, primarily with gray-scale ultra-
Fig. 17. Implant. Ultrasound shows a subpectoral implant sound but also with Doppler ultrasound. Another
(P, pectoralis muscle) with ‘‘stepladder sign’’ (arrowheads). common use is to provide guidance for interventional
Surgery revealed an intracapsular rupture. procedures. Less common uses include assisting in
staging of breast cancer and evaluating patients with [13] Sickles EA, Filly RA, Callen PW. Benign breast le-
implants. Recently there has been an interest in using sions: ultrasound detection and diagnosis. Radiology
ultrasound to screen asymptomatic women for breast 1984;151:467 – 70.
[14] Egan RL, Egan KL. Automated water-path full-breast
cancer, as is done with mammography. Further studies
sonography: correlation with histology in 176 solid
must be performed to assess if this reduces mortality
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Index
Note: Page numbers of article titles are in boldface type.
A B
Abdominal wall, ultrasonography of, in first trimester, Biopsy, fine-needle aspiration, of breast cancer,
683 – 684 ultrasonography in, 849
Abscesses, tubo-ovarian, MR imaging of, 808 – 809 Bleeding, ovarian, MR imaging of, 802
postmenopausal. See Postmenopausal bleeding.
Acardiac parabiotic twin, radiofrequency ablation of,
721 – 722 Bone mineral density, definition of, 813
ultrasonography of, 7190722 dual x-ray absorptiometry of, 818
Actinomycosis, ovarian, MR imaging of, 808 – 809 Bowel herniation, ultrasonography of, in first
trimester, 683 – 684
Adnexal masses, benign, MR imaging of, 809, 811
Breast cancer, screening for, ultrasonography in, 851
in ectopic pregnancy, ultrasonography of,
672 – 673 Breasts, ultrasonography of, 841 – 856
contrast-enhanced Doppler, 846 – 847
Aliasing, on fetal MR imaging, 736 for cystic lesions, 842 – 843
Amniocentesis, to diagnose aneuploidy, 695 – 696 for implants, 851 – 852
for microcalcifications, 850 – 851
Amnioreduction, for twin-twin transfusion syndrome, for solid lesions, 843 – 846
717 – 718 in males, 852
intraoperative, 849 – 850
Anencephaly, ultrasonography of, in first trimester,
non-contrast-enhanced Doppler, 846
676, 681
normal anatomy in, 842
Aneuploidy, prenatal diagnosis of, 695 – 708 screening, for cancer, 851
amniocentesis in, 695 – 696 for known cancer, 848 – 849
chorionic villus sampling in, 696 technique for, 841 – 842
cordocentesis in, 696 to guide fine-needle aspiration biopsy, 849
maternal serum screening in, 696 – 697, to stage cancer, 847 – 849
704 – 705 nodal involvement in, 847 – 848
ultrasonography in, 676 – 677, 697 – 699, 704 tumor size and grade in, 847
Down syndrome, 699 – 702 Brenner tumors, MR imaging of, 805
triploidy syndrome, 698 – 699
trisomy 13, 698 Bulk motion, on fetal MR imaging, 734
trisomy 18, 697 – 698, 702, 704
trisomy 21, 697
Turner syndrome, 698 C
Central nervous system, ultrasonography of, in first
Arterio-arterial anastomoses, in placenta, 712 – 713 trimester, 681 – 682
Arteriovenous anastomoses, in placenta, 713 Cervix, in female infertility, 758
Axillary involvement, by breast cancer, ultrasonog- Chorionic villus sampling, to diagnose
raphy of, 847 – 848 aneuploidy, 696
doi:10.1016/S0033-8389(03)00090-3
858 Index / Radiol Clin N Am 41 (2003) 857–862
Color duplex Doppler imaging, of postmenopausal Endometriosis, and female infertility, 766
bleeding, 775 solid, MR imaging of, 811
Computed tomography, quantitative, of osteoporosis, Endometrium, in ectopic pregnancy, ultrasonography
820 – 824 of, 673
in postmenopausal bleeding, ultrasonography of.
Congenital heart disease, ultrasonography of, in first
See Postmenopausal bleeding.
trimester, 684
sonohysterography of. See Sonohysterography.
Conjoined twins, ultrasonography of, 723 – 724
in first trimester, 691 – 692
Cordocentesis, to diagnose aneuploidy, 696
F
Cystourethrography, voiding, of pelvic floor relaxa-
tion, 749 Fallopian tube, in female infertility, 760 – 764
Cysts, breasts, ultrasonography of, 842 – 843 Fat saturation, on fetal MR imaging, 742
ovarian, MR imaging of, 800, 802 – 803 Female infertility, 757 – 767
cervix in, 758
congenital uterine anomalies and, 759 – 760
endometriosis and, 766
D fallopian tube in, 760 – 764
Defecography, of pelvic floor relaxation, 749 – 750 peritoneal cavity in, 764
polycystic ovary syndrome and, 764 – 766
Dermoid cysts, ovarian, MR imaging of, 808
uterine cavity filling defects and, 758 – 759
Digital x-ray radiogrammetry, of osteoporosis, 817 uterus in, 758
Discordant anomalies, in monochorionic twins, 722 versus normal ovaries, 764
versus normal reproduction, 757
Doppler imaging, of breasts, 846 – 847
Fetal abnormalities, ultrasonography of, in first
of postmenopausal bleeding, 775
trimester, 674 – 676, 682
Double decidual reaction sign, in ultrasonography, of
Fetal magnetic resonance imaging, 729 – 745
gestational sac, 664 – 665
artifacts on, 734 – 738
Down syndrome, maternal serum screening for, in aliasing, 736
first trimester, 704 bulk motion, 734
ultrasonography of, in second trimester, 699 – 702 fluid motion, 734 – 735
Dual x-ray absorptiometry, of osteoporosis, 818 – 820 Gibbs ringing artifact, 738
motion artifact, 734
partial volume artifact, 738
radiofrequency interference, 737
E repeat visualization or nonvisualization,
Ectopic pregnancy, hematosalpinx and hematocele 735 – 736
due to, MR imaging of, 809 susceptibility artifact, 737
ultrasonography of. See Ultrasonography, consent for, 729
in first trimester. image quality on, 738, 740 – 742
fat saturation, 742
Edema, ovarian, MR imaging of, 809, 811 patient body habitus and use of surface coil,
Edward syndrome, ultrasonography of, in second 740 – 741
trimester, 696 – 698 signal inhomogeneity, 741 – 742
signal-to-noise ration, 738, 740
Embryonic heartbeat, ultrasonography of, 666 – 667 indications for, 729
Embryonic pole, ultrasonography of, 666 interpretation of, 730 – 731
monitoring during, 730
Encephaloceles, ultrasonography of, in first
patient positioning for, 729 – 730
trimester, 681
pitfalls in, 742
Endometriomas, MR imaging of, 803 protocol for, 730
Index / Radiol Clin N Am 41 (2003) 857–862 859
versus ultrasonography, 729 Inflammatory masses, ovarian, MR imaging of,

viewing during, 730 808 – 809
Fetal structural abnormalities, ultrasonography of, in Intradecidual sign, in ultrasonography, of gestational
first trimester, 676 – 677 sac, 664
Fibroadenomas, of breasts, ultrasonography of, 845 Intrauterine adhesions, sonohysterography of, 789
Fibromas, ovarian, MR imaging of, 805
Fine-needle aspiration biopsy, of breast cancer, ultra-
sonography in, 849 K
Krukenberg tumors, MR imaging of, 805
Fluid motion, on fetal MR imaging, 734 – 735
Fractures, osteoporosis and, 814 – 817
L
Laser photocoagulation, for twin-twin transfusion
G syndrome, 718
Genitourinary tract, ultrasonography of, in first
trimester, 684 Leiomyomas, submucosal, sonohysterography
of, 787
Germ cell tumors, ovarian, MR imaging of, 808 uterine, and postmenopausal bleeding, ultrasonog-
Gestational sac, ultrasonography of, in first trimester, raphy of, 773
663 – 665
Gibbs ringing artifact, on fetal MR imaging, 738
M
Magnetic resonance imaging, fetal. See Fetal
H magnetic resonance imaging.
Heartbeat, embryonic, ultrasonography of, 666 – 667 of osteoporosis, 825 – 827
of ovaries. See Ovaries.
Hematoceles, MR imaging of, 809 of pelvic floor relaxation. See Pelvic
Hematosalpinx, MR imaging of, 809 floor relaxation.
of trabecular bone structure, in osteoporosis,
Herniation, of bowel, ultrasonography of, in first 830 – 834
trimester, 683 – 684
Maternal serum screening, to diagnose aneuploidy,
Hormone replacement therapy, and assessment of 696 – 697, 704
postmenopausal bleeding, 777
Metastatic disease, to breasts, ultrasonography
Human chorionic gonadotropin levels, in ectopic of, 845
pregnancy, 673 – 674
Micro-computed tomography, of trabecular bone
Hydrocephalus, ultrasonography of, in first structure, in osteoporosis, 830 – 831
trimester, 682
Microcalcifications, in breasts, ultrasonography
Hyperreactio luteinalis, MR imaging of, 802 of, 850 – 851
Hysterography, saline infusion. Monoamniotic twins, ultrasonography of,
See Sonohysterography. 724 – 725
Hysteroscopy, of postmenopausal bleeding, 775 Monochorionic twins, embryology of, 709 – 710
versus sonohysterography, 793 – 794 ultrasonography of, 709 – 727
chorionicity and amnionicity in, 710 – 712
for acardiac parabiotic twin, 719 – 722
I radiofrequency ablation of, 721 – 722
Implants, breasts, ultrasonography of, 851 – 852 for conjoined twins, 723 – 724
for discordant anomalies, 722
Infertility, female. See Female infertility.
for monoamniotic twins, 724 – 725
Inflammatory breast cancer, ultrasonography of, 845 for twin embolization syndrome, 719
for twin-twin transfusion syndrome, 714 – 719 P

amnioreduction for, 717 – 718 Partial volume artifact, on fetal MR imaging, 738
laser photocoagulation for, 718
Patau syndrome, ultrasonography of, in second
for unequal placental sharing, 714
trimester, 698
placental vascular anatomy in, 712 – 713
Pelvic floor relaxation, 747 – 756
Motion artifacts, on fetal MR imaging, 734
anatomy of, 747, 749
defecography of, 749 – 750
MR imaging of, 750 – 755
N anatomy in, 751 – 752
Nodal involvement, by breast cancer, ultrasonog- for anterior compartment pathology, 752 – 753
raphy of, 847 – 848 for middle compartment pathology, 753
for posterior compartment pathology,
Nuchal translucency, ultrasonography of, in first 753 – 754
trimester, 674 – 676, 682, 704 seated imaging in, 754 – 755
severe cases of, 754
technique for, 751
O three-dimensional volumetric analysis in, 755
Osteodensitometry, of osteoporosis, 817 – 818 ultrasonography of, 749
voiding cystourethrography of, 749
Osteoporosis, 813 – 839
and vertebral fractures, 814 – 817 Pelvic fluid, in ectopic pregnancy, ultrasonography
definition of, 813 – 814 of, 672
dual x-ray absorptiometry of, 818 – 820 Percutaneous umbilical cord sampling, to diagnose
MR imaging of, 825 – 827 aneuploidy, 696
osteodensitometry of, 817 – 818
plain films of, 816 – 817 Peritoneal cavity, in female infertility, 764
quantitative CT of, 820 – 824 Peritoneal inclusion cysts, MR imaging of, 803
quantitative ultrasonography of, 824 – 825
trabecular bone structure in, 827, 829 – 834 Photocoagulation, laser, for twin-twin transfusion
micro-CT of, 830 – 831 syndrome, 718
MR imaging of, 830 – 834 Placenta, vascular anatomy of, 712 – 713
plain films of, 829 – 830
quantitative ultrasonography of, 830 Plain films, of fracture and deformity, due to
osteoporosis, 816 – 817
Ovarian hyperstimulation syndrome, MR imaging of trabecular bone structure, in osteoporosis,
of, 802 829 – 830
Ovaries, MR imaging of, 799 – 812 Polycystic ovary syndrome, and female infertility,
for benign neoplasia, 803 – 805, 808 764 – 766
germ cell tumors, 808 MR imaging of, 803
sex-cord stromal tumors, 805, 808
Polyps, endometrial, and postmenopausal bleeding,
surface epithelial tumors, 804 – 805
ultrasonography of, 771 – 772
for bleeding, 802
sonohysterography of, 785 – 786
for endometriomas, 803
for functional cysts, 800, 802 – 803 Postmenopausal bleeding, color duplex Doppler
for hematosalpinx and hematocele, 809 imaging of, 775
for inflammatory masses, 808 – 809 Doppler imaging of, 775
for massive edema, 809, 811 hysteroscopy of, 775
for peritoneal inclusion cysts, 803 sonohysterography of, 771 – 772, 775, 783 – 784,
for solid endometriosis, 811 791 – 793
for torsion, 809 three-dimensional ultrasonography of, 775 – 776
normal ovaries, 799 – 800 ultrasonography of, 769 – 780
technique for, 799 atrophic endometrium in, 770 – 771
normal, versus female infertility, 764 endometrial carcinoma in, 773 – 775
Index / Radiol Clin N Am 41 (2003) 857–862 861
endometrial hyperplasia in, 772 – 773 of endometrial carcinoma, 788 – 790

endometrial polyps in, 771 – 772 of endometrial hyperplasia, 787 – 788, 790
in women on hormone replacement of endometrial polyps, 785 – 786
therapy, 777 of intrauterine adhesions, 789
in women on tamoxifen, 776 – 777 of normal endometrium, 783
uterine leiomyomas in, 773 of postmenopausal bleeding, 771 – 772, 775,
783 – 784, 791 – 793
Pregnancy, ectopic, hematosalpinx and hematocele
of retained products of conception,
due to, MR imaging of, 809
789 – 790
ultrasonography of. See Ultrasonography, in
of subendometrial changes, due to tamoxifen,
first trimester.
790 – 791
normal, ultrasonography of. See Ultrasonography,
of submucosal leiomyomas, 787
in first trimester.
patient preparation for, 781 – 782
versus hysteroscopy, 793 – 794
Q Stepladder sign, in ultrasonography, of breast
Quantitative computed tomography, of osteoporosis, implants, 852
820 – 824 Struma ovarii, MR imaging of, 808
Quantitative ultrasonography, of osteoporosis, Surface epithelial tumors, ovarian, MR imaging of,
824 – 825 804 – 805
of trabecular bone structure, in osteoporosis, 830
Susceptibility artifact, on fetal MR imaging, 737
R
Radiofrequency ablation, of acardiac parabiotic twin,
721 – 722 T
Tamoxifen, and assessment of postmenopausal
Radiofrequency interference, on fetal MR bleeding, 776 – 777
imaging, 737 subendometrial changes due to, sonohysterog-
Retained products of conception, sonohysterography raphy of, 790 – 791
of, 789 – 790 Teratomas, ovarian, MR imaging of, 808
Thecomas, MR imaging of, 805
S Three-dimensional ultrasonography, of postmeno-
Saline infusion hysterography. pausal bleeding, 775 – 776
See Sonohysterography.
Three-dimensional volumetric analysis, in ultra-
Salpingitis isthmica nodosa, and female infertility, sonography, of pelvic floor relaxation, 755
762 – 763
Torsion, ovarian, MR imaging of, 809
Sclerosing stromal tumors, MR imaging of, 805, 808
Trabecular bone structure, in osteoporosis.
Serum human chorionic gonadotropin levels, in ec- See Osteoporosis.
topic pregnancy, 673 – 674
Transvaginal ultrasonography, of tamoxifen-induced
Sex-cord stromal tumors, MR imaging of, 805, 808 subendometrial changes, 792
Signal-to-noise ratio, on fetal MR imaging, 738, 740 Triploidy, ultrasonography of, in first trimester, 684,
Single-photon absorptiometry, of osteoporosis, 686, 691
817 – 818 Triploidy syndrome, ultrasonography of, in second
Snowstorm sign, in ultrasonography, of breast trimester, 698 – 699
implants, 852 Trisomy 13, ultrasonography of, in second
Sonohysterography, 781 – 797 trimester, 698
catheter insertion for, 782 – 783 Trisomy 18, ultrasonography of, in second trimester,
of dysfunctional uterine bleeding, 784 – 785 696 – 698, 702, 704
Trisomy 21, ultrasonography of, in second of umbilical cord, 682 – 683

trimester, 696 transducer technology in, 663
of breasts. See Breasts.
Tuberculosis, ovarian, MR imaging of, 808 – 809
of monochorionic twins.
Tubo-ovarian abscesses, MR imaging of, 808 – 809 See Monochorionic twins.
Turner syndrome, ultrasonography of, in second of pelvic floor relaxation, 749
trimester, 698 of postmenopausal bleeding.
See Postmenopausal bleeding.
Twin embolization syndrome, ultrasonography quantitative, of osteoporosis, 824 – 825
of, 719 of trabecular bone structure, in
Twins, monochorionic. See Monochorionic twins. osteoporosis, 830
to diagnose aneuploidy. See Aneuploidy.
Twin-twin transfusion syndrome. transvaginal, of tamoxifen-induced
See Monochorionic twins. subendometrial changes, 792
Umbilical cord, ultrasonography of, in first trimester,
U 682 – 683
Ultrasonography, fetal, versus fetal MR imaging, 729 Umbilical cord sampling, to diagnose
in first trimester, 663 – 679, 681 – 693, 704 – 705 aneuploidy, 696
of anterior abdominal wall, 683 – 684
Uterine anomalies, congenital, and female infertility,
of central nervous system, 681 – 682
759 – 760
of congenital heart disease, 684
of conjoined twins, 691 – 692 Uterine bleeding, dysfunctional, sonohysterography
of early pregnancy failure, 668, 670 of, 784 – 785
of ectopic pregnancy, 670 – 674
Uterine cavity filling defects, and female infertility,
adnexal mass in, 672 – 673
758 – 759
endometrium in, 673
free fluid in, 672 Uterine leiomyomas, and postmenopausal bleeding,
management of, 674 ultrasonography of, 773
serum hCG levels in, 673 – 674 Uterus, in female infertility, 758
of fetal abnormalities, 674 – 676
nuchal translucency, 674 – 676, 682, 704
of fetal structural abnormalities, 676 – 677
of genitourinary tract, 684 V
of normal pregnancy, 663 – 667 Voiding cystourethrography, of pelvic floor relaxa-
age assessment in, 667 tion, 749
embryonic pole in, 666
gestational sac in, 663 – 665
heartbeat in, 666 – 667
yolk sac in, 665 – 666 Y
of triploidy, 684, 686, 691 Yolk sac, ultrasonography of, 665 – 666

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Ultrasonographic evaluation of the endometrium in postmenopausal vaginal

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What’s New in First Trimester Ultrasound 663

Ultrasound Detection of First Trimester Malformations: A Pictorial Essay 681

Prenatal Diagnosis for Detection of Aneuploidy: The Options 695

VOLUME 41 • NUMBER 4 • JULY 2003 v

Tips and Tricks of Fetal MR Imaging 729

MR Imaging of Pelvic Floor Relaxation 747

Imaging of Female Infertility 757

Ultrasonographic Evaluation of the Endometrium in Postmenopausal

MR Imaging of the Ovaries: Normal Appearance and Benign Disease 799

Osteoporosis Imaging 813

Current Uses of Ultrasound in the Evaluation of the Breast 841

VISIT THESE RELATED WEB SITE

For more information about Clinics:

What’s new in first trimester ultrasound

lous space. Parvey et al found that this vascular flow

The cardiovascular system is the first embryonic

Early pregnancy failure

Studying normal healthy women, Wilcox et al

less than 5 mm measured between 5.5 and 9 menstrual Ectopic pregnancy

of an ectopic pregnancy, the endometrium can have a

Fig. 18. Elongated cresentic intrauterine fluid collection

lected population. The combination of first trimester

Ultrasound detection of first trimester malformations:

translucency (Fig. 9) [10,11]. Even if the nuchal

Fig. 1. Rhombencephalon (arrow) in coronal plane; the

The fetal kidneys are echodense at 9 to 10 weeks’

has a differential diagnosis similar to that of an Skeletal anomalies

Congenital heart disease Triploidy is the most common chromosomal

early pregnancy is scanned and the placenta appears Conjoined twins

Prenatal diagnosis for detection of aneuploidy: the options

sonographic abnormality identified. Boxes 1 – 5 list

Box 3. Second trimester ultrasound Box 5. Second trimester ultrasound

Major abnormalities Major abnormalities

Cardiac defects Fetus

Minor ultrasound markers

Minor ultrasound abnormalities or minor ultra-

Fig. 4. Clubfoot in a 20-week gestation, in which there is an

for most of the markers were calculated as isolated

isolated sonographic markers are not a complete

Fig. 11. Sagittal view of the fetal abdomen at 17 weeks’

(5.5% false-positive rate) [90], which is comparable

First trimester ultrasound evaluation

Nuchal translucency refers to the normal clear area

of transcervical and transabdominal chorionic-villus Complications of fetal blood sampling. Am J Obstet

Complications of monochorionic twins

Morbidity and mortality are significantly increased Embryology of twin placentation

of twin placentation, amnion formation, and some of

Judging chorionicity and amnionicity

Dizygotic twins are the more common twin type,

membrane thickness is always more accurate early Monochorionic twin syndromes

Fig. 9. Unequal placental sharing. Twin A (a) has a large

compared with 5% in which an A-A anastomosis was

territory. The mortality rate for the normal co-twin