| Abstract|| |
Objectives : To evaluate the utility of distal augmentation in the diagnosis of intramuscular hemangiomas. Materials and Methods : A total of four patients were studied with a clinical suspicion of hemangioma. These patients were evaluated on B mode and color Doppler ultrasound and the findings were correlated with that of histopathology and surgery. Results : The sensitivity of distal flow augmentation in the diagnosis of superficial flow was noted. The procedure proved to be a useful adjunct to clinical examination and other Doppler findings in the diagnosis of these lesions. Conclusion : The procedure is non invasive, safe, practicable and thus a useful aid in diagnosis.
Keywords: Intramuscular hemangiomas, distal augmentation, phleboliths, low vascularity
|How to cite this article:|
Kharat A T, Choudhari K R, Kulkarni V M, Shetty S S. Flow augmentation technique as an imaging protocol for the evaluation of intramuscular hemangiomas. Indian J Radiol Imaging 2003;13:195-8
|How to cite this URL:|
Kharat A T, Choudhari K R, Kulkarni V M, Shetty S S. Flow augmentation technique as an imaging protocol for the evaluation of intramuscular hemangiomas. Indian J Radiol Imaging [serial online] 2003 [cited 2020 Jul 9];13:195-8. Available from: http://www.ijri.org/text.asp?2003/13/2/195/28659
| Introduction|| |
The utility of distal flow augmentation in color Doppler ultrasound in the diagnosis of intramuscular hemangiomas is a new imaging protocol. It is of immense diagnostic value and hence should be included in routine imaging. The examination is easy to perform, practicable, noninvasive, real time and dynamic. The findings were studied in relation to four cases.
The ultrasonic appearance of hemangiomas located within intramuscular region in the extremities and cranium were studied in four individuals of varying age groups.
Superficial hemangiomas have typical but variable gray-scale, spectral and color flow sonographic patterns. These fluctuations are probably related to phases of evolution. Echogenicity, compared to normal subcutaneous tissues, and the degree of vascularization were assessed qualitatively. 
The hemangiomas were typically ill-defined, hypoechoic and cystic in nature which showed sluggish spontaneous flow.
These lesions on distal augmentation showed a surge of flow in the cystic spaces to a varying extent suggesting their vascular origin, thus aiding in the diagnosis of these lesions as hemangiomas.
| Materials and Methods|| |
The study was carried out on clinically or radiologically suspected cases of intramuscular hemangioma. A total of four cases were studied. Two were involving the intramuscular portions of the volar muscles of the forearm, one in the volar muscles of the thenar eminence and one was involving the superficial temporal fossa.
We used WIPRO- GE Logiq 400 MD scanner with 11 MHz linear array superficial probe.
The hemangiomas in the extremity were examined with the patient in the sitting position. A firm support was given on the lap with the affected extremity resting on it. Examination was done in transverse and longitudinal plane with B mode and color Doppler mode. On the color Doppler mode the study was done initially without and then with distal flow augmentation. Gray-scale ultrasonography (US) coupled with color Doppler flow imaging has the advantage of providing a rapid, relatively inexpensive, and noninvasive assessment of lesion morphology and vascular components. Pulsed Doppler US permits spectral analysis of arterial and venous flow and measurement of flow velocities. 
The temporal fossa lesion was examined with the patient in supine position with compression being applied in the lower parietal region.
A 25 year woman with no prior history of any limb trauma presented for a routine radiograph of the left forearm for a dull pain. Recently she had noticed a swelling of the forearm.
The forearm showed no color discoloration.
A plain radiograph of the left forearm showed a fine small well defined calcific focus in the soft tissue suggestive of a phlebolith. No obvious bony lesion was seen.
On Grey scale imaging : A 7 x 5 cms ill-defined heterogeneous lesion distorting the normal muscle anatomy was noted. The lesion was predominantly cystic and showed numerous dilated channels. A solitary reflective focus was noted within the lesion suggesting a phlebolith.
On color Doppler mode : The lesion was predominantly cystic with slow spontaneous flow.
On spectral mode : The flow was confirmed to be a venous flow with no evidence of any arterial waveforms in the region of interest.
On distal augmentation : The flow pattern showed a significant improvement on distal forearm augmentation. A sudden spontaneous surge in flow was noted lasting for a short period of time.
A 55 year old female presented to the department for a radiograph of the right forearm as she had severe pain after a period of over exertion.
Plain radiograph right forearm revealed :Multiple phleboliths studded in the forearm. The lesion was suspected to be a hemangioma.
On Grey scale imaging : The lesion was predominantly hypoechoic, ill defined with innumerous reflective foci which suggested phleboliths.
On color mode Doppler : The lesion showed slow spontaneous flow.
On distal augmentation :Sudden surge in flow was noted.
A 12 year old boy a known case of left temporal region hemangioma post operative, came after a gap of one year with recurrence of swelling and pain.
On gray scale imaging: The area under consideration showed distorted muscle pennate anatomy with multiple linear anechoic channels within in the muscle bulk.
On color flow mode: There was noted a slow flow state.
On distal augmentation. There was a surge in the flow of the lesion. The augmentation was given in the lower parietal higher temporal region.
A 22 years old medical student came for the examination of the left palm due to a soft tissue bulge over the thenar eminence since two months. There was a dull pain over the lesion.
On gray scale imaging: The lesion had a bizarre hypo echoic appearance with the area appearing thickened and swollen with linear anechoic spaces.
No calcification was noted on the ultrasound or on plain radiograph.
On color Doppler mode: The lesion showed a slow flow of low vascularity.
On distal augmentation: On digital pressure augmentation there was a surge in the flow of the lesion.
| Discussion|| |
Vascular anomalies of infancy and childhood can be divided into two major categories-hemangiomas and malformations-on the basis of the physical findings, clinical behavior, histological findings, and cellular kinetics .
Hemangiomas in the periphery such as in the upper limb and in the temporal fossa are predominantly hypo dense, ill defined and have slow spontaneous flow. All the cystic spaces represent vascular channels, but all aren't opacified on the Color Doppler mode with flow.
However on distal augmentation these channels are noted to fill with color suggesting that a sudden surge of flow is noted within this channel.
This suggests that the peripheral superficial hemangiomas are very slow flow lesions which may miss detection even on the low velocity settings. Power Doppler may help to some extent in diagnosing these lesions, but the distal compression technique provides a good modality to help diagnosing these lesions and confirming their vascular nature.
Compression applied is always distal and at a sufficient distance away from the hemangioma so as to avoid movement artifact in the region of interest due to motion and creating a false impression of flow. The compression must be sudden, firm and with immediate release. Controlled graded compression or prolonged compression does not aid in the diagnosis, Prolonged compression in fact may cause cessation of flow in the lesion. A few seconds need to elapse before repeating the above examination.
All vascular channels or sinusoidal spaces may not fill up with flow on compression. These channels opacify to varying extent.
Gray-scale ultrasonography (US) coupled with color Doppler flow imaging has the advantage of providing a rapid, relatively inexpensive, and noninvasive assessment of lesion morphology and vascular components. Pulsed Doppler US permits spectral analysis of arterial and venous flow and measurements of flow velocities. (Harriet J. Paltiel, MD, Patricia E. Burrows, et al.Soft-Tissue Vascular Anomalies: Utility of US for Diagnosis1 From the 1994 RSNA scientific assembly).
| Conclusion|| |
Intramuscular hemangiomas can be diagnosed by varying imaging modalities, high frequency transducers and multiple imaging sections.
These lesions showed slow spontaneous flow. Flow augmentation to varying degrees on distal pressure was a unique feature that aided in diagnosing these hemangiomas. The steady and progressive technologic progress of color Doppler US equipment now permits the integration of conventional morphostructural parameters with the biofunctional data of lesion flow patterns and relative qualitative features .
Knowledge of flow augmentation in a hemangioma is thus helpful in diagnosing these lesions and enhances diagnostic skill.
| References|| |
|1.||Bakhach S, Grenier N, Berge J, Leaute-Labreze C, Chateil JF, Douws C, Vergnes P, Taieb A. Color Doppler sonography of superficial capillary hemangiomas. J Radiol 2001 Nov;82(11):1613-9 |
|2.||Yang WT, Ahuja A, Metreweli C. Sonographic features of head and neck hemangiomas and vascular malformations: review of 23 patients. J Ultrasound Med 1997 Jan;16(1):39-44 |
|3.||Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg 1982; 69:412-422. [PUBMED] |
|4.||Iovane A, Midiri M, Caruso G, Princiotta C, lagalla R. Potential uses of color Doppler in periskeletal soft tissue neoplasms. Istituto di Radiologia P, Cignolini, Universita degli Studi di Palermo. Radiol Med (Torino) 1997 Dec;94(6):583-90. |
A T Kharat
Flat No-2Building No 34, Ranakpur Darshan Society, New Alandi Road, Vishrantwadi, Yerawada, Pune 411006
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]