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Slow Flow or No Flow? Color and Power Doppler US Pitfalls in the Abdomen and Pelvis¹

¹ From the Department of Radiology, University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received May 12, 2003; revision requested June 24 and received August 8; accepted August 14. Address correspondence to S.C.C. (e-mail: gadogrrl@hotmail.com).

View larger version (78K): [in a new window]   Figure 1a. Twinkle artifact behind a bladder calculus. (a) Longitudinal post-voiding US image of the bladder shows a hyperechoic, shadowing bladder calculus (arrow). (b) Transverse color Doppler US image shows twinkle artifact posterior to the stone. (c) Transverse power Doppler US image again shows the twinkle artifact. (d) Doppler spectrum shows noise.

View larger version (50K): [in a new window]   Figure 1b. Twinkle artifact behind a bladder calculus. (a) Longitudinal post-voiding US image of the bladder shows a hyperechoic, shadowing bladder calculus (arrow). (b) Transverse color Doppler US image shows twinkle artifact posterior to the stone. (c) Transverse power Doppler US image again shows the twinkle artifact. (d) Doppler spectrum shows noise.

View larger version (51K): [in a new window]   Figure 1c. Twinkle artifact behind a bladder calculus. (a) Longitudinal post-voiding US image of the bladder shows a hyperechoic, shadowing bladder calculus (arrow). (b) Transverse color Doppler US image shows twinkle artifact posterior to the stone. (c) Transverse power Doppler US image again shows the twinkle artifact. (d) Doppler spectrum shows noise.

View larger version (139K): [in a new window]   Figure 1d. Twinkle artifact behind a bladder calculus. (a) Longitudinal post-voiding US image of the bladder shows a hyperechoic, shadowing bladder calculus (arrow). (b) Transverse color Doppler US image shows twinkle artifact posterior to the stone. (c) Transverse power Doppler US image again shows the twinkle artifact. (d) Doppler spectrum shows noise.

View larger version (104K): [in a new window]   Figure 2a. Twinkle artifact behind atherosclerotic plaque. (a) Longitudinal US image of the right internal carotid artery shows two areas of atherosclerotic plaque (arrows). (b) Color Doppler US image of the same region shows typical twinkle artifact behind the plaque. (c) Doppler spectrum reveals noise in the region.

View larger version (91K): [in a new window]   Figure 2b. Twinkle artifact behind atherosclerotic plaque. (a) Longitudinal US image of the right internal carotid artery shows two areas of atherosclerotic plaque (arrows). (b) Color Doppler US image of the same region shows typical twinkle artifact behind the plaque. (c) Doppler spectrum reveals noise in the region.

View larger version (79K): [in a new window]   Figure 2c. Twinkle artifact behind atherosclerotic plaque. (a) Longitudinal US image of the right internal carotid artery shows two areas of atherosclerotic plaque (arrows). (b) Color Doppler US image of the same region shows typical twinkle artifact behind the plaque. (c) Doppler spectrum reveals noise in the region.

View larger version (151K): [in a new window]   Figure 3a. Twinkle artifact associated with adherent gallstones. (a) Transverse color Doppler US image of the gallbladder shows multiple areas of twinkle artifact associated with gallstones that have adhered to the mucosa. (b) Doppler spectrum of the artifact demonstrates noise but no flow.

View larger version (153K): [in a new window]   Figure 3b. Twinkle artifact associated with adherent gallstones. (a) Transverse color Doppler US image of the gallbladder shows multiple areas of twinkle artifact associated with gallstones that have adhered to the mucosa. (b) Doppler spectrum of the artifact demonstrates noise but no flow.

View larger version (105K): [in a new window]   Figure 4a. Twinkle artifact due to gallstones. (a) Decubitus US image shows small calculi (arrow) floating in a sludge-filled gallbladder. (b) Applied power Doppler US image shows twinkle artifact behind the calculi. (c) Doppler spectrum demonstrates no flow in the region of the artifact.

View larger version (58K): [in a new window]   Figure 4b. Twinkle artifact due to gallstones. (a) Decubitus US image shows small calculi (arrow) floating in a sludge-filled gallbladder. (b) Applied power Doppler US image shows twinkle artifact behind the calculi. (c) Doppler spectrum demonstrates no flow in the region of the artifact.

View larger version (158K): [in a new window]   Figure 4c. Twinkle artifact due to gallstones. (a) Decubitus US image shows small calculi (arrow) floating in a sludge-filled gallbladder. (b) Applied power Doppler US image shows twinkle artifact behind the calculi. (c) Doppler spectrum demonstrates no flow in the region of the artifact.

View larger version (116K): [in a new window]   Figure 5a. Twinkle artifact owing to renal calculi. (a) Longitudinal gray-scale US image shows a faintly echogenic region in the lower pole sinus but no definite renal stones. (b) Color Doppler US image depicts three calculi with twinkle artifact (arrows).

View larger version (47K): [in a new window]   Figure 5b. Twinkle artifact owing to renal calculi. (a) Longitudinal gray-scale US image shows a faintly echogenic region in the lower pole sinus but no definite renal stones. (b) Color Doppler US image depicts three calculi with twinkle artifact (arrows).

View larger version (118K): [in a new window]   Figure 6a. Edge artifact caused by bladder encrustation. (a) Transverse US image of the bladder (midline view) shows extensive bladder wall calcification (arrows). (b) Power Doppler US image demonstrates signal along the edges of the calcification. (c) Doppler spectrum fails to show any evidence of flow in the affected region.

View larger version (127K): [in a new window]   Figure 6b. Edge artifact caused by bladder encrustation. (a) Transverse US image of the bladder (midline view) shows extensive bladder wall calcification (arrows). (b) Power Doppler US image demonstrates signal along the edges of the calcification. (c) Doppler spectrum fails to show any evidence of flow in the affected region.

View larger version (116K): [in a new window]   Figure 6c. Edge artifact caused by bladder encrustation. (a) Transverse US image of the bladder (midline view) shows extensive bladder wall calcification (arrows). (b) Power Doppler US image demonstrates signal along the edges of the calcification. (c) Doppler spectrum fails to show any evidence of flow in the affected region.

View larger version (95K): [in a new window]   Figure 7a. Edge artifact in a large gallstone. (a) Longitudinal US image of the gallbladder shows a large, shadowing gallstone. (b) Applied power Doppler US image and Doppler spectrum show a rim of signal along the edge of the gallstone with no evidence of flow.

View larger version (116K): [in a new window]   Figure 7b. Edge artifact in a large gallstone. (a) Longitudinal US image of the gallbladder shows a large, shadowing gallstone. (b) Applied power Doppler US image and Doppler spectrum show a rim of signal along the edge of the gallstone with no evidence of flow.

View larger version (120K): [in a new window]   Figure 8a. Flash artifact due to motion of the fetal head. (a) US image of the cervix (C) and fetal head (H) obtained with fundal pressure being applied (left) shows a flash of color across the internal os simulating a vasa previa. On a US image obtained with no fundal pressure being applied (right), no color is demonstrated. (b) Doppler spectrum demonstrates the normal arterial flow pattern in a true vasa previa (compare with spectral noise in Figs 1d and 2c).

View larger version (72K): [in a new window]   Figure 8b. Flash artifact due to motion of the fetal head. (a) US image of the cervix (C) and fetal head (H) obtained with fundal pressure being applied (left) shows a flash of color across the internal os simulating a vasa previa. On a US image obtained with no fundal pressure being applied (right), no color is demonstrated. (b) Doppler spectrum demonstrates the normal arterial flow pattern in a true vasa previa (compare with spectral noise in Figs 1d and 2c).

View larger version (116K): [in a new window]   Figure 9a. Flash artifact due to fluid motion. (a) Longitudinal US image shows an enlarged, twisted right ovary. (b) Color Doppler US image shows flash artifact in moving fluid adjacent to the ovary, not in a peripheral vessel.

View larger version (54K): [in a new window]   Figure 9b. Flash artifact due to fluid motion. (a) Longitudinal US image shows an enlarged, twisted right ovary. (b) Color Doppler US image shows flash artifact in moving fluid adjacent to the ovary, not in a peripheral vessel.

View larger version (86K): [in a new window]   Figure 10a. Flash artifact in a patient with polycystic kidney disease. (a) Longitudinal US image of the superior pole of the right kidney shows a large, complex renal cyst (C). (b) Color Doppler US image shows multiple areas of color in the cyst that represent flash artifact. Note also the normal vessels in the adjacent liver. (c) Doppler spectrum of the vessel-like color pattern in the cyst fails to demonstrate a true vascular flow pattern.

View larger version (121K): [in a new window]   Figure 10b. Flash artifact in a patient with polycystic kidney disease. (a) Longitudinal US image of the superior pole of the right kidney shows a large, complex renal cyst (C). (b) Color Doppler US image shows multiple areas of color in the cyst that represent flash artifact. Note also the normal vessels in the adjacent liver. (c) Doppler spectrum of the vessel-like color pattern in the cyst fails to demonstrate a true vascular flow pattern.

View larger version (148K): [in a new window]   Figure 10c. Flash artifact in a patient with polycystic kidney disease. (a) Longitudinal US image of the superior pole of the right kidney shows a large, complex renal cyst (C). (b) Color Doppler US image shows multiple areas of color in the cyst that represent flash artifact. Note also the normal vessels in the adjacent liver. (c) Doppler spectrum of the vessel-like color pattern in the cyst fails to demonstrate a true vascular flow pattern.

View larger version (132K): [in a new window]   Figure 11a. Pseudoflow due to flowing urine within a bladder diverticulum. (a) Transverse US image demonstrates a bladder diverticulum (D). (b) Color Doppler US image shows pseudoflow secondary to flowing urine within the diverticulum. (c) Doppler spectrum shows a pattern that is inconsistent with vascular flow.

View larger version (117K): [in a new window]   Figure 11b. Pseudoflow due to flowing urine within a bladder diverticulum. (a) Transverse US image demonstrates a bladder diverticulum (D). (b) Color Doppler US image shows pseudoflow secondary to flowing urine within the diverticulum. (c) Doppler spectrum shows a pattern that is inconsistent with vascular flow.

View larger version (110K): [in a new window]   Figure 11c. Pseudoflow due to flowing urine within a bladder diverticulum. (a) Transverse US image demonstrates a bladder diverticulum (D). (b) Color Doppler US image shows pseudoflow secondary to flowing urine within the diverticulum. (c) Doppler spectrum shows a pattern that is inconsistent with vascular flow.

View larger version (140K): [in a new window]   Figure 12a. Pseudoflow due to ascitic motion adjacent to the ligamentum teres. (a) Color Doppler US image shows a simulated vessel coursing along the falciform ligament. (b) Doppler spectrum fails to document any flow.

View larger version (138K): [in a new window]   Figure 12b. Pseudoflow due to ascitic motion adjacent to the ligamentum teres. (a) Color Doppler US image shows a simulated vessel coursing along the falciform ligament. (b) Doppler spectrum fails to document any flow.

View larger version (126K): [in a new window]   Figure 13a. Pseudoflow due to ascitic motion in a patient with cirrhosis. (a) Color Doppler US image shows pseudoflow within ascites. (b) Doppler spectrum fails to show any evidence of normal blood flow. (c) Doppler spectrum demonstrates a unidirectional venous flow pattern (arrows) in the adjacent true collateral vessel.

View larger version (99K): [in a new window]   Figure 13b. Pseudoflow due to ascitic motion in a patient with cirrhosis. (a) Color Doppler US image shows pseudoflow within ascites. (b) Doppler spectrum fails to show any evidence of normal blood flow. (c) Doppler spectrum demonstrates a unidirectional venous flow pattern (arrows) in the adjacent true collateral vessel.

View larger version (92K): [in a new window]   Figure 13c. Pseudoflow due to ascitic motion in a patient with cirrhosis. (a) Color Doppler US image shows pseudoflow within ascites. (b) Doppler spectrum fails to show any evidence of normal blood flow. (c) Doppler spectrum demonstrates a unidirectional venous flow pattern (arrows) in the adjacent true collateral vessel.

View larger version (132K): [in a new window]   Figure 14. Pseudoflow caused by bladder jets. Transverse US image of the bladder (midline view) shows a jet of urine flowing from the left ureter, a finding that indicates that the ureter is not obstructed.