Objective: To assess the value of acoustic radiation force impulse (ARFI) quantification/imaging in focal liver lesion (FLL) characterization. Material and methods: The study included 57 patients with 59 FLL. The final diagnosis based on the results of morphological examination (resected parts of the liver, biopsy samples) in 42 patients and on MRI/CT data - in 15 patients. There were 19 benign FLL (cavernous hemangioma - 7, focal nodular hyperplasia - 9, hepatocellular adenoma - 3) and 40 malignant FLL (liver metastases - 7, hepatocellular carcinoma - 9, hepatoblastoma - 15, cholangiocarcinoma - 6, embryonal sarcoma - 3). ARFI-quantification of FLL and liver tumors surrounding parenchyma was performed in all patients, ARFI-imaging of FLL in 41 patients with the use of Acuson S2000 ultrasound machine (Siemens, Germany) with a convex transducer (1-6 MHz). Results: The FLL stiffness measurement was unsuccessful in 2 of 59 (3.4%) cases (cholangiocarcinoma and focal nodular hyperplasia). Therefore, the final analysis of ARFI-quantification results was carried out for 57 FLL in 56 patients. Malignant FLL were significant stiffer in compare with benign FLL (shear wave velocity median was 2.700 m/s, interquartile range - 2.150-3.360 m/s versus 1.925 m/s and 1.280-2.780 m/s, respectively) (P = 0.0113). The optimal cut-off value of shear wave velocity for differential diagnosis of malignant and benign FLL was 2.05 m/s (AUC - 0.710, sensitivity - 82.1%, specificity - 66.1%). The significant difference in liver tumors surrounding parenchyma stiffness in patient with malignant and benign FLL were obtained (1.500 m/s and 1.228-2.043 m/s versus 1.165 m/s and 0.980-1.340 m/s, respectively) (P < 0.0011). The difference of FLL stiffness/liver tumors surrounding parenchyma stiffness ratio between malignant and benign FLL was insignificant (1.660 and 1.150-2.403 versus 1.880 and 1.390-2.230, respectively) (P = 0.7508). ARFI-imaging had no additional advantages over the combined use of B-mode and ARFI-quantification. Conclusion: ARFI-quantification/imaging has limited value in benign and malignant FLL characterization. Further prospective studies in this direction are required.

Objective: To reveal predictors of incomplete epicardial ligation (isolation) of the left atrial appendage (LAA) during off-pump coronary artery bypass grafting according to intraoperative transesophageal echocardiography (TEE). Material and methods: 37 patients with coronary heart disease (with arterial hypertension and atrial fibrillation in all cases) underwent epicardial LAA ligation during off-pump coronary artery bypass grafting. Mean age of patients was 58.7 ± 7.7 years (38-74 years), 35 (95%) of them were male. Echocardiography utilized iE33 (Philips, Netherlands) with a 1-5 MHz sector probe and a 2-7 MHz transesophageal sector probe. Pre- and post-LAA ligation intraoperative TEE monitoring performed in all cases. In pre-LAA ligation examination, width of LAA ostium, LAA length, width of LAA ostium/LAA length ratio, LAA area, LAA and LAA ostium blood flow, and LAA blood flow velocity were assessed. In post-LAA ligation examination, completeness of ligation was assessed in color Doppler ultrasound. If the presence of communication between LAA and LA was revealed, LAA ligation considered as incomplete and diameter of communication (width of LAA ostium after ligation) was measured. Results: In intraoperative TEE incomplete LAA ligation was detected in 10 (27%) patients. Significant differences of width of LAA ostium (P = 0.001), width of LAA ostium/LAA length ratio (P = 0.03), and LAA area (P = 0.005) between patients with complete and incomplete ligation were found when analyzing the data of pre-ligation intraoperative TEE. Width of LAA ostium ≥18.4 mm (sensitivity - 60.0%, specificity - 100.0%), width of LAA ostium/LAA length ratio ≥0.8 (sensitivity - 30.0%, specificity - 92.6%), and LAA area ≥4.21 cm2 (sensitivity - 60.0%, specificity - 100.0%) can be considered as the predictors of incomplete LAA ligation. Conclusion: The incidence of incomplete epicardial LAA ligation during off-pump coronary artery bypass grafting is 27%. A number of intraoperative TEE criteria for incomplete LAA ligation prognosis with ultra-high specificity were obtained, but sensitivity was only 30.0-60.0%.

The article presents a case report of cardiac myxofibrosarcoma in a 30-year-old patient, mimics the infective endocarditis, diagnosed with transthoracic echocardiography, cardiac MRI, and intraoperative transesophageal echocardiography. There was no data for metastasis in abdominal CE-CT. Left atrium upper wall tumor was surgically removed, but small unresectable residual tumor foci were left. The tumor was 6.0 × 4.0 × 3.5 cm in size with the 1.5 cm pedicle. Histological examination revealed a cardiac myxofibrosarcoma. The patient was moved from the cardiac surgery to oncological hospital for chemotherapy. Despite the treatment, the patient died in 11 months.

The brief review presents the main classifications, clinical manifestations, and diagnostic tools for carotid-cavernous fistulas. Ultrasound criteria of direct (high-speed) and indirect (low-speed) carotidcavernous fistulas diagnosis are considered in detail. The article presents a clinical case of direct carotid-cavernous fistula in a 35-year-old patient, occurring following traumatic brain injury. No signs of vascular brain pathology on MR-angiography in the emergency setting were revealed. Due to the clinical worsening (1 month after traumatic brain injury) Doppler ultrasound was performed. The following ultrasound signs were found: an increase of the right internal carotid artery diameter (6.4 mm versus 5.1 mm on the contralateral side), an increase of peak systolic velocity (105 cm/s versus 86 cm/s on the contralateral side) with a decrease of resistance index (0.43 versus 0.65 on the contralateral side); abnormal mosaic flow flash (3.5 cm2) in the right cavernous sinus area; an increase of the right superior ophthalmic vein diameter (3.3 mm versus 1.9 mm on the contralateral side) with blood flow arterialization and inversion of flow direction. The diagnosis confirmed by digital subtraction angiography and MR-angiography. The patient was undergoing surgical treatment. No signs of pathology were found on control Doppler ultrasound 3 month after surgery. This clinical case demonstrates the value of ultrasound in early recognition of the carotid-cavernous fistula and postsurgical follow-up.

Objective: To assess the value of ultrasound in the diagnosis of metatarsal region lesions, in particular, Morton’s neuroma and lipofibroma. Material and methods: The main group consisted of 144 patients with metatarsal pain radiating into the toes and metatarsal mass on ultrasound. Exclusion criteria were: the poor visualization of region of interest, previous surgery of Morton’s neuroma, an acute foot injury, the absence of morphological verification. The control group consisted of 25 patients with absence of symptoms and history of foot pathology. According to the morphological data main group was subdivided to subgroup of Morton’s neuroma (132 patients, 148 lesions) and subgroup of lipofibroma (12 patients, 12 lesions). In most cases masses occurred in females (92.4% of patients with Morton’s neuroma and 83.3% of patients with lipofibroma). In subgroup of Morton’s neuroma 55.3% of patients were aged 40-59 years. Ultrasound examination was performed with the use of iU22 scanner (Philips, Netherlands) with a 5-12 MHz linear probe and Logiq P-5 scanner (GE Healthcare, USA) with a 3-10 MHz linear probe. Numeric Rating Scale for Pain (NRS Pain) was used to assess the correlation between the size of lesion and pain severity. Results: In subgroup of Morton’s neuroma 64.9% of lesions were localized in the third intermetatarsal space, 31.1% in the second intermetatarsal space, and 4.1% in the first intermetatarsal space. In subgroup of lipofibroma 66.7% of lesions were localized in the second intermetatarsal space, 25.0% in the third intermetatarsal space, and 8.3% in the fourth intermetatarsal space. In B-mode ultrasound the hypoechogenicity of the lesion was the main diagnostic criterion of Morton’s neuroma (100.0%). In Doppler ultrasound the main diagnostic criterion for lipofibroma was the presence of vascularization (100.0%), whereas Morton’s neuroma was completely avascular in 100.0% of cases. There were no statistical differences of linear dimensions, area, and volume of lesions between subgroups (P > 0.05 for all comparisons). There were no significant differences between linear dimensions, area, and volume of lesions assessed by ultrasound and intraoperatively (P > 0.05 for all comparisons). The thickness of common plantar digital nerves proximal to the lesion location in the main group was significantly higher compared to the control group (P < 0.05). No significant correlation was found between the severity of pain and the maximal size of lesions (r_S = 0.1, P > 0.05 for both ultrasound and intraoperative size assessment). Conclusion: Ultrasound allows differential diagnosis of Morton’s neuroma and such a rare tumor as lipofibroma, against the background of similar symptoms.

In the brief pictorial review the novel ultrasound technologies, which begun to be used in everyday practice and research, are discussed. The place of microultrasound in the diagnostic classifier is considered. The ultrasound terminology is refined. The relationship between frequency, axial resolution, and penetration is discussed. Pictorial comparison of the nerve ultrasound capabilities with the use of different frequencies probes is presented.

The letter to the editor-in-chief focuses on place of renal artery ultrasound in the routine algorithm of examination of patients with arterial hypertension, due to entry into force of the updated Standard of medical care in arterial hypertension for adults - 2021. The value of renal artery ultrasound in patients with arterial hypertension according to current domestic and foreign guidelines is discussed. The most important parameters, necessary to be fixed in examination report, are presented.