Go with the Flow: Vascular Considerations in Scrotal Imaging - HD

Introduction

Hi, my name is Tre Patel.
I work at the Mayo Clinic in Scottsdale, Arizona,
and my talk today is go with the flow
vascular considerations in scrotal imaging.
I have no disclosures to make.
Vascular considerations play an important role in
evaluation of the scrotum.
And in today's talk I'll be able to talk
to you about the anatomy
and technique of imaging, the scrotum, torsion, epi
oras and evaluation of a mass,
with vascular considerations.
We won't have time to talk about varicose seals or trauma,
but vascular considerations also play a role in evaluating
of those entities.

Vascular Anatomy

The arterial supply to the testis is primarily
through the testicular artery, which gives rise
to these capsular vessels,
which then ramify into the testicular parenchyma
and then drain through the pampiniform plexus
through the mediastinum testis.
There are two other arteries that supply structures that are
around the testes, and that includes the artery
of the ductus deens and the cremasteric artery.
All of these three vessels come through to the testicle
and its surrounding structures through the spermatic cord.
And we can take images of this on ultrasound
and see the capsular vessels
and the ramifying vessels,
with great clarity.

Doppler Technique for Scrotal Ultrasound

What I'd like to do first is tell you a little bit about the
doppler technique that's
used when evaluating the scrotum.
Obviously we want to use the highest frequency transducer,
apply the lowest filter
and the lowest pulse repetition frequency,
which basically means the lowest doppler scale.
When we're evaluating for color flow,
we don't have any concerns about power settings
and we'll use the highest power setting
and it's important to capture both color doppler
and spectral doppler images.
So it's important not only to get those other images
and this image that shows the vessels within the testicular
parenchyma, but also to apply a doppler ga
and to demonstrate this spectral waveform
because that can be also useful in evaluating any pathology.
What isn't commonly done.
But what is important to understand is that
the scrotum can also be imaged with mr.

MRI Technique for Scrotal Imaging

And, technique is just as important
to get right when you evaluate the scrotum with mr.
You wanna support the scrotum with sponge
or towels,
use a pelvic phased array coil or a surface coil.
And typically the best images are the fast spin echo T two
weighted images,
that we do in three planes.
Gadolinium enhanced images are very important in
evaluating scrotal pathology.
And we typically will do these
with a gradient echo series in the coronal or sagittal plane
and get three of the following
possible timeframes in our lab.
We'll do them at 61 20 and 180 seconds.
We'll do subtraction images
and then finally we'll get delayed
gadolinium enhanced T one images.

Normal Scrotal MR Images

And here are some representative images of a normal
scrotal MR examination in the coronal
and in the axial plane.
And you can see that the anatomy is really well depicted
with very homogeneous appearance of the testes.
And a slightly heterogeneous,
but typical location for the epididymus in other para
testicular structures.
And the dynamic gadolinium enhanced images,
are not
that revealing in a normal case,
as you can see in this instance,
where these satchel images were obtained
before administration of contrast and then at 30, 60
and 90 seconds after the administration of contrast.
And you can see progressive enhancement of these structures.
But since there's no pathology here, there's really nothing
to demonstrate other than that.

Dynamic Gadolinium Enhancement Analysis

Now wat Navi back in 2000,
had an excellent article
that described the normal dynamic MRI appearance.
And this is a somewhat complicated
figure that is in their article.
But if you were to take images in the gradient,
echo plane,
at 61 20
and 180 seconds as we do, you can see
that you're typically on the slope of the enhancement curve.
And because of that you can by way of getting those images,
talk about relative percent peak height of enhancement
and relative percent mean slope of enhancement.
Now to boil this down into very simple terms,
all we're really talking about is evaluating
how much the testis enhances and how fast it enhances.
And if you're gonna compare one testis to the other
or an area of suspected pathology to an area
that's suspected to be normal, we can see
and measure the percent of the peak height
or how much it enhanced in that area
and how fast it enhanced in that area.

Application to Clinical Conditions

So let's apply these doppler
and Mr techniques to evaluating three important conditions.
And the first is torsion.

Testicular Torsion

Now, testicular torsion is mistakenly considered the most
common cause of acute scrotal pain in
children, but that's not true.
The most common cause of acute scrotal pain in children,
as we will discuss later, it's actually torsion
of the appendix epididymus
or the appendix testis, not the testis itself.
Torsion of the testis is associated
with the bell clapper deformity,
and this is the condition in which the vaginal tunica
encircles the entire testes.
And I'll demonstrate with,
figures exactly what that means.
Note that torsion can occur between the testes
and the epididymus due to a long me memorium.
So this is less common,
but in this instance, if torsion were to occur
between the testis
and the epidermis, you would still have blood flow
to the epididymus but would not have
blood flow to the testis.
On the other hand, more commonly what you get is torsion.
Were both the testis
and the epididymus are involved in the tors segment.
And this schematic diagram
and this altered image through the scrotum,
an ultrasound kind
of shows you the way the scrotum is attached.
The way the testis is attached to the scrotal wall,
the tunica vaa encircles the testes,
but there's a bare area in which vessels come into the
testicular parenchyma.
And also the epidemy lies as you can see here.
And typically this is fairly broad,
but also in the longitudinal plane it goes from the top
to the bottom of the scrotum.
So this image which is taken
through the middle of the testes, shows you this connection
and this runs up and down the testes,
and up
and down the scrotal sac as we can imagine.
And this connection,
although seemingly thin, actually runs up above
and well below this particular image.
And it serves to anchor the testes to the scrotal wall so
that it can't flip.
But if that connection is very short,
meaning it doesn't run very high up
and very far down the testicular wall, the scrotal wall,
then you get a condition where it can twist on this
and cause torsion, torsion has some risk factors.
This usually or more commonly occurs in adolescents,
but note that it really can occur at any age.
It is thought to be sometimes initiated
by a forceful cremasteric contraction.
So trauma, arousal,
and strenuous activity have all been purported
to be incipient events that can lead to torsion.
But note that this can also just occur spontaneously.
The hallmark of the scrotal sonographic findings in torsion
is absence of blood flow.
Early or partial torsion can result in decreased
but not absent blood flow.
But the flow is really what dictates the finding.
And this precedes the gray scale findings.
However, by the time patients come
to the emergency room with their pain,
that can often progress.
And you'll have typically epidermal congestion,
a swollen hypo coic testis,
or even heterogeneous testicular parenchyma representing
ischemia of the testis itself that can manifest
with sonographic findings.
So here is a representative example.
We can see that the left testis is tors, it's swollen,
there is no demonstrable blood flow
nor Orleans is there any blood flow in the epidermis
or other paricular structures in this case other than a
small amount of flow here,
which presumably is coming from one of the other arteries.
Now remember that all the arteries come
through the spermatic cord.
And it's not the arterial twist.
Typically that leads to the absence of blood flow.
What happens is the twist in the,
in the structure that supports the scrotum,
the testicle,
leads to a vascular venous kinking
that impedes venous outflow
through the testicular parenchyma.
And that's why we're not seeing any blood flow in the testis
or the EPIs in this case.
But we're still seeing some blood flow in the para
testicular tissues as compared to the opposite normal side
where we see normal blood flow.
And if this progresses as it has in this case,
this becomes quite heterogeneous in the testis in farts,
but more the heterogeneity is due to the swollen
heterogeneous hemorrhagic appearance of the epididymus
and the cord that is in the tors segment.
The degree of torsion can vary.
And the salvageability varies depending on not only the
degree of torsion but how long the testis has been.
Tourist animal studies have shown
that if you have a complete torsion
of the testis within the first four hours, if you relieve
that torsion, the testis remains viable.
Whereas after 10 hours the testis is completely infarcted.
However, in humans in the natural state,
typically the degree of torsion isn't complete.
And even though patients may have had symptoms
for more than 10 hours, they can still have recovery
of testicular parenchyma if the diagnosis
is made expeditiously.
There are some clues
to partial torsion, which we'll talk about.
Asymmetry in the doppler signal is one of those clues.
But what I have found more useful in the cases
of partial torsion, which I have seen, which is not
that common, is that you can oftentimes see
that the epididymus itself is swollen
or that the cord is swollen
and you can see the kink in the cord.
So for example, in this case of partial torsion, you can see
that the left testis has a normal doppler
signal and waveform.
It's much harder to demonstrate flow in the right testis,
but there is demonstrable flow.
But notice how that we had to change our gain settings
to a more sensitive level and there's a lot more noise
because the signal is so much weaker in this right testis.
And when we image the right testis above the testes,
we see this kink in the cord and the epididymus
and this is the actual knot of the torsion.
This is commonly seen in cases of partial torsion.
So what you really wanna do when you suspect partial torsion
is look carefully at the epi demus
and the cord to see if you can see the twist itself.
As I mentioned previously,
testicular torsion is mistakenly considered
to be the most common cause
of acute scrotal pain in children, when in fact torsion
of the appendix testis is a more likely cause
of acute pain in a child.
And B de, bald de serato back in 2005
showed excellent examples of this
where the tourist appendix testes sticks out from the
epididymus and testis like a swollen thumb
and it does not have any blood flow.
And this is what you wanna look for in patients who have
torsion of the appendix testis to make that diagnosis.
Now again, this is a most common cause
for acute scrotal pain in children and
because of the inflammation there's hyperemia in the EPIs
and even perhaps in the surrounding scrotal wall
and the testis, you don't wanna mistake this as acute
epididimitis because you've seen this swollen
avascular appendix testis, you are able
to make the correct diagnosis.
Now there's a limited role for MRI in testicular torsion
and in fact in my practice I've never actually done an MRI
for testicular torsion,
but I can imagine that in a confusing case
or in children in whom flows difficult to demonstrate
with ultrasound MRI could be reassuring
or diagnostic for torsion.
So from the wat Nabi article, we can see
that here's an example of what we might look for.
This is the T two weighted image showing the testis
being somewhat swollen,
the epi dimus being somewhat enlarged and heterogeneous.
And with doppler, with
gadolinium enhancement you can see that the tunica
of the scrotal wall is enhancing, but the testis
and the epidermis are not enhancing on both the
early and the late phase.
And this is a case of acute testicular torsion.

Epididymitis and Orchitis

Let's turn our attention now to inflammation,
which is oftentimes the competing diagnosis
to the emergency room physician when presented
with a patient with acute scrotal pain.
Torsion being more common in adolescence is
different than epi, which is usually more common in
the adults beyond adolescents.
But there are overlapping instances of age range as well
as overlapping physical
and laboratory findings which result in confusion clinically
requiring imaging to make the diagnosis.
Because although epididimitis as you might expect,
will have skin edema and erythema, perhaps a fever
and pyoria, the same findings can be seen in torsion.
Now this netter diagram well illustrates why
epididymitis typically starts at the tail of the epididymus.
And that's because epididimitis is generally a caused
by retrograde spread of organisms from the bladder
or the prostate gland.
And these organisms spread down through the VAs deens
and get caught up in the filter
of the epididymus at the tail at this kink or bend.
And this is typically where epididimitis will begin.
Now epididimitis is the most common cause
of acute scrotal pain.
Again, as we discussed, it's due to the retrograde spread
of organisms from the bladder and prostate and
therefore it's usually confined
to the epididymus in about four out of five cases.
There can be coexisting oras
or inflammation of the testis in the other one-fifth
of the cases primary oras where you have inflammation
of the testicular parenchyma but not the epi.
Demus should raise in your mind a different possibility
and that is a viral epi, viral oras
or mumps oras,
which gets deposited
and seeded through a hematogenous origin rather than
this retrograde spread.
And that's why it'll oftentimes involve the testis without
involving the epidermis.
The sonographic findings in epididimitis are
that the epididymus becomes enlarged
and hypo coic, the echogenicity is actually quite variable,
but the enlargement,
is also variable can be focal or diffuse.
But the key diagnostic criteria that we use is
from the color flow.
So although the epididymus gray scale findings can be
suggestive and the test testis gray scale findings can be
suggestive where there can be focal enlargement
or diffuse enlargement of the testis as we see in this case
where the testis is hypo oak
and enlarged compared to the other side.
And the epidermis in this case is quite heterogeneous
and in this case enlarged compared to the testis.
The actual diagnosis is made on the color flow images.
And here we can see that there's a little bit
of complicated fluid next to an inflamed epididymus,
with some flow in the testis but much more flow in the EPIs.
And likewise here where there's skin thickening
and a hypoechoic en large testis,
the diagnosis is really established when we show
that there's increased blood flow in
that testicular parenchyma.
So hyperemia is the diagnostic clue that we'll use
to make the diagnosis of epididimitis enteritis.
And what we do is compare that hyperemia
to the contralateral epididymus
and to the ipsilateral testis.
The normal epididymus does indeed show flow.
And in up to 20% of cases
up epididimitis is only manifest as increased blood flow,
not enlargement of the epididymus.
Since the normal epididimitis does show flow, we have
to understand when we would invoke the possibility
of epididimitis rather than normal flow.
And that occurs when the flow in the EPIs is greater than
the flow in the testis and in the contralateral epidermis.
So for example, in this case
where the epidermis looks normal on the gray scale image,
color flow shows us
that there's much more flow in the epidermis than the testis
and that is not the usual condition.
This shows that there's inflammation of the epididymus
and the patient has epididimitis.
Sometimes that can be a difficult assessment to make,
especially since we start out
with a low pulse repetition frequency, meaning
that we have the lowest opular scale.
So this patient comes in
and if you were presented with these images
and didn't know the clinical history, you would not be able
to say whether the patient had epididimitis
or not, in which side the patient had epididymus
epididimitis on because as we can see at these settings,
with the 0.015 setting here,
as we see on these color scales,
we're seeing flow in the epi demus
and the testis in both the left and the right testis.
And you can't really tell whether there's more flow in the
epidermis than in the testis.
So what we have to do in this setting is
to change our pulse repetition frequency, change our scale,
increase the scale,
or in other words, decrease the sensitivity
until we find out whether there's more flow in the
epidermis or the testis.
And when we do that, as we do in this case, so here
with the scale at the lowest scale that we can get at 0.015,
we see flow both in the testis
and the epidermis on both the left and the on the right
and the left, sorry.
When we've changed that scale
and make it less sensitive, we can see
that the flow in the epidermis, it's much harder to detect.
We still have very good flow in the testis.
So this is not a case of epidermal hyperemia.
This is normal epidermal flow.
Similarly, on the contralateral side, by changing the scale,
we've lost the flow in the EPIs,
but we've maintained the flow in the testis.
So this is also normal.
So this patient does not have epididimitis here.
We've used comparison to the opposite side
and also used comparison to the testis.
So the tail of the epidermis here is not enlarged,
but we can't tell from this image alone whether it's
hyperemic, we might have the sense
that there's more blood flow in the tail
of the epidermis than the testis,
but a far better way to make that assessment is
to change the scale to make it a little less sensitive.
And you can see that now by making it less sensitive,
we've lost the flow in the testis,
but we've maintained the flow in the epididymus.
So this patient clearly does have more blood flow in his
epididymus than his testis
and so does have evidence of epidermal tail inflammation
and so has epididimitis.
And if you compare it to the opposite side, you can see
that there's flow in the testis.
There's no flow in the epididymus on the opposite side,
there's still flow here on this side.
And that also helps us to make that diagnosis.
Now mitis and or can lead to complications.
And it's important to use vascular considerations
to understand when you should suspect abscess
and the complications of abscess
and when you should suspect a different entity namely
infarction of the testis which can be focal or diffuse.
So this is an old image,
but it nicely shows
that the testis here on the right is being actually
compressed by this heterogeneous collection in this patient
who has right-sided epidermal oris
and in fact has an abscess.
So most abscesses are extra testicular
as we see in this case a large heterogeneous
septated fluid collection
that is compressing the testicular parenchyma Here blood
flow is demonstrable within this left testis
as we can see in this image.
And spectral flow looks normal.
That's all very reassuring
that the left testes has not infarcted.
This large collection is a big abscess
that's exerting mass effect upon the left testes.
That's in contradistinction to this case
where an intra testicular process is identified.
And yes, there is what appears
to be exuberant flow in the testicular parenchyma
and no flow in this area.
This could be an abscess in the testicle,
but it's more likely to be a focal infarction of the testis,
not an abscess.
Infarcts intestine are oftentimes in the acute setting round
as we see in this case.
Here's another example.
This patient has epididimitis
with increased blood flow in his epididymus,
also has a round mass
that's relatively avascular in the testis.
This is not an abscess.
There is still some blood flow in this area.
So this is not liquified tissue.
In fact, this is a focal infarct of the testis path proven
another case where the epididymus is not particularly
enlarged but is quite hyperemic.
The testis as we see on these two images, the upper half
and the lower half is quite heterogeneous.
With this s strided, heterogeneous hypoechoic area,
there is still blood flow in some
of the more normal appearing testicular parenchyma.
This is not a tumor,
this is not an abscess since we still see little
flow bits within this area.
This proved on surgery to be a fairly large area
of infarction of the left testis
and we can get spectral doppler clues as to this entity.
So this heterogeneous testis in a patient
who had inflammation of the left EPIs.
When we put color flow on, we see reversed flow in diastole.
This is a hallmark of microvascular coagulation.
What happens is in the infarcted area,
in this case practically the entire testis, the
small micro vasculature coagulates
and blood flow comes towards that.
Those small vessels can't go anywhere and much of it
or some of it comes backwards
and that's why we see this reverse to and fro flow.
Another case where the left testes is heterogeneous
and enlarged,
and color doppler spectral analysis shows
that we're getting a significant amount
of reverse flow in diastole.
This is a patient who has an infarcted left testis
as proven on pathology.
So you wanna suspect abscess when you see an extra
testicular heterogeneous fluid collection, oftentimes
with some mass effect on the testis.
And be sure to check the testicular blood flow
to see whether it's impinging upon testicular blood flow
because that would be an indication
for immediate surgical treatment of the abscess.
You wanna suspect infarction when you see an infiltrative
or even a mass like area in the testis
that may have some focal pore flow
or has reverse diastolic flow in
the setting of inflammation.

Evaluation of Masses

So let's now turn our attention to evaluation of masses
or suspected masses
and how vascular considerations play a very important role
in the evaluation of those findings.
Now I'm gonna talk primarily about infarction,
but clearly you can make specific diagnoses
when you combine the vascular considerations
with the imaging appearance.
And so lymphoma
and plasma cytoma is a quite vascular nodule
that might exist within the test.
Epidermoid cysts have no vascularity.
And if you see an onion skin,
or rounded mass with layers that has no blood flow,
you might consider an epidermoid cyst.
And finally, a tal adenoid tumor
can be facilitated in this diagnosis
by evaluating the vascularity
and showing that this is actually on the capsule
of the testis underneath a capsular vessel.
Overlying a capsular vessel rather than
underneath the capsular vessel.
But again, as I said, I wanna turn my attention primarily
to evaluation of testicular infarcts.
There are multiple causes for infarcts, torsion,
inflammation, trauma, bilal phenomenon, and vasculitis.
And these are oftentimes confused for a possible neoplasm.
There are some features which clearly suggest infarct on the
gray scale images that would be when you see a band like
area or a zonal area of abnormality.
Typically with concave margins,
the involved testis may be small.
And especially if you see these sorts of things bilaterally,
then I think you can be very confident
that you're dealing with an infarction.
So an image like this where you see a band like area
of abnormality in the testis is not a mass
because masses do not grow in these stripe like regions.
Similarly, this has a similar appearance
where you have the testes
and a band like area with concave margins
that is not a testicular tumor
'cause tumors don't grow with concave margins.
This based on the gray scale image has a high suspicion
for an infarct.
But a case like this where the testis is small,
but there's a very heterogeneous area within the testis
that isn't band like is one
that would defy diagnosis without assessment
of the vascularity.
And in fact, this case where we, not we,
but this is an outside image that was sent to me,
where they suspected a mass in the testis proved
to be an infarct at pathology.
Here's a patient who comes in with acute pain
and you can see that there's a heterogeneous area in the
upper half of the testes.
And in fact, on the transverse image,
the sonographer has taken care to try to mark out what
she has perceived as being a focal mass in the testes.
So at this point with these calper
and with this area of abnormality, one might have predicted
that we're dealing with a cancer.
However, color flow helps us make the correct diagnosis
because although we're seeing good flow within the normal
testicular parenchyma in in the lower half of the testis,
we are not seeing any
or very little flow in this upper half.
That is not what we expect to see
with the testicular neoplasm.
And in fact, a testicular neoplasm as we see in this case
where we see heterogeneity of the
testis in a mass like area typically has increased blood
flow and certainly almost always has at least
as much blood flow as the area around it.
So a patient like this who has
what looks like two discreet masses within the testes,
when we put color flow
and we see that there is not any blood flow in these areas
should raise your suspicion for focal infarcts,
not testicular neoplasm.
And in fact, this is a case from the literature that shows,
areas of necrotizing vasculitis in a patient
who had a a vasculopathy,
not neoplasm.
And this patient would've benefited from further
evaluation or consideration of the fact
that there was no blood flow in these apparent masses did
not need to go on to this orchiectomy.
So when testicular infarct is a consideration,
I believe Mr can be quite helpful.
Now in this talk I'm talking about MRI,
but once contrast in ultrasound becomes more prevalent
and available, especially in the United States, I think
that contrast enhanced ultrasound can supplant MRI in the
evaluation of these suspected infarcts.
I'm gonna be talking about MRI,
but where I talk about MR, I consider that you might be able
to apply contrast enhanced ultrasound
to find the same diagnosis.
So we use MRI when the ultrasound findings are suspicious
for tumor, but the doppler does not support that suspicion.
In other words, where we think there's a rounded mass
but there's no increased
or even as much blood flow in that area
as in the surrounding normal
appearing testicular parenchyma.
We can use MRI to quantify the degree of vascularity
and to evaluate the margins and extent of the abnormality.
And by using this we can alter management.
The reason why contrast enhanced imaging can play such an
important role in distinguishing between tumors
and infarcts is obvious.
This is from the Wat Nabi article
and you can see that when we talk about
how fast things enhance
malignancies in the testis enhance much faster
than the normal testis.
There's no overlap
and clearly are distinguished from infarct which do not
enhance as much as normal testis.
Likewise, malignancies enhance more than normal testes
for the most part, in fact in all of Watanabe's series.
And this is clearly different than infarcts which do not
enhance as much as the normal testis.
And the fact that these areas of infarction are
so different than areas of neoplasm
with contrast enhancement allows us
to use contrast whether it be within MR
or ultrasound to help make the diagnosis when suspected.
So here's a case from Watanabe's article.
You can see that this heterogeneous mass on the T two
weighted images in the left testis has early enhancement
so it enhances faster
and enhances more than the normal testicular parenchyma both
in that testis and in the contralateral testis.
So this is clearly a tumor.
And here's an example from our case.
You can see from our cases you can see that
the left testis here enhances much faster than the right
testis and enhances more than the right testis
and suspicious for
a possible neoplasm in the appropriate setting.
And in fact, this wasn't a diagnostic dilemma on
the ultrasound.
This is that right testis, left testis.
And you can see that the mass is clearly obvious
has increased blood flow.
So why would we even do any contrast enhanced imaging here?
The reason we did contrast enhanced imaging in this case
with MRI is
because the contralateral testers had a
heterogeneous area within it.
It does look somewhat band like
and it did not have increased blood flow.
But in the setting of a patient
who has a contralateral testicular malignancy, we needed
to worry a bit about the possibility
of a synchronous lesion on the other side.
And the MRI shows us that the testis,
which is smaller than the tumor filled testis,
has a band like area that does not enhance as much
as the other testes
and is has the characteristic shape of an infarct
and we're able to prevent having
to do a bilateral orchiectomy in this patient,
who has
a unilateral testicular neoplasm.
So if we go back to this case, again,
this is an area in the upper half of the testis
that may have looked somewhat nodule and mass like
but with color flow.
The doppler did not support the possibility
of malignancy in this area to prove
that we did a contrast enhanced mr.
You can see that there's an area
of dark signal on the T two.
So we're already thinking that this is not a neoplasm.
And on these images, the early
and late subtraction phases, you can see that this area
of the testis doesn't enhance as fast
and doesn't enhance as much as a normal testis
and is an area of infarction.
So we were able to save this patient from having
to have an orchiectomy
or surgical evaluation of this infarct.
Another case is this a mass or an infarct?
On the gray scale image, I challenge anyone
to not be suspecting the possibility of a mass.
This looks like a mass with some concave,
convex margins.
However, on color flow,
the Doppler signal did not support the possibility
of malignancy because there was much more flow in the
surrounding testes than in this area of involvement.
And the MRI shows us on these enhanced axial
and sagittal images that this area did not enhance as much
as the lower testes.
I'm not showing you the dynamic enhancement images,
which showed that this didn't enhance as fast
as the normal testis.
And on the T one weighted images we can see bright signal.
This was an area of hemorrhagic infarction.
Another case a striated testis this patient.
And in this case the interpreting physician could not be
sure that they weren't dealing
with some infiltrative process wanted reassuring.
So doppler was applied
and sure enough we were not able
to find much flow in this area.
So that's reassuring that we're not dealing
with the neoplasm and MRI was performed to further confirm
and allay the patient's fears that there was any problem.
The lower half of the testis is not enhancing
as much as the upper half.
This is the area where we suspected a possible abnormality
and in fact we can see some retraction of the capsule here.
Another case, is this going to be a mass
or is this going to be an infarct?
Without consideration of the vascularity of this,
you will not be able to make that diagnosis.
This has a rounded mass within the upper half
of this testis, which could certainly be a neoplasm,
but does not have the doppler signal
to support that possibility.
So you must consider the possibility
of infarction an MRI was performed showing
that this area did not enhance as much as the normal testis.
This is not a neoplasm, this is an infarct.
And you can also get some other clues as to
that possibility in that the left testes
that harbors this area is smaller than the right.
And that's another feature.
Is this a mass or is this an infarct?
Well, obviously now you've gotten the point of,
of all these cases this is going to be an infarct.
But the MRI
and in this case, admittedly not the best looking MRI
shows theory did not enhance as much in this axial MRI,
showing us the lack of enhancement of this area,
which proved to be a hemorrhagic infarct.
This is the MRI as well showing the hemo citrin deposit on
the edge of this T one hyperintense.
This is not T one,
but on this hyperintense area, how about this?
This doesn't look particularly mass like,
but was somewhat firm on physical examination
and very unusual in that it was,
quite, extensive.
So, this proved to be not an area
of dystrophic calcification,
but a germ, a burned out germ cell neoplasm.
And we made that diagnosis
because on the MRI, we wanted
to assess the flow of the lesion.
The T two shows a band like area.
But you can see here on the pre
gadolinium dynamic study, there's no T one signal here.
But then with the gadolinium injection,
we see increased flow in this area on the early images.
And we must be concerned about the
possibility of malignancy.
This patient did go to the OR
and had a burned out germ cell neoplasm
and this was written up in the Journal of Ultrasound
and Medicine back in 2007.

Conclusion

So vascular considerations can be very useful when
considering a specific diagnosis,
particularly when infarction is in your
differential diagnosis.
And again, I've shown you, many examples of
how Mr helps us in this regard,
but I strongly suspect that as soon as
contrast enhanced ultrasound becomes something
that we can all use here in the United States
and perhaps is being used
and is being used around the world,
you can use contrast enhanced ultrasound to help
with this same, thought process and evaluation.
So my exhortation to you is to go with the flow.
This helps us in evaluating suspected torsion, inflammation
and masses, particularly when the flow
does not support the possibility of neoplasm.
Thank you.