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Case report: lower extremity deep vein thrombosis following an intense calf workout

By Yim ES, Friedberg RP.


  1. Harvard Affiliated Emergency Medicine Residency, Beth Israel Deaconess Medical Center, Boston, MA;
  2. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; and
  3. Department of Orthopedic Surgery, Harvard Medical School, Boston, MA.


We report a case of a high-performance athlete with hemoglobin SC who presented with asymmetric calf soreness after an intense calf workout. By ultrasonography, he was diagnosed with a deep vein thrombosis (DVT) of his right calf. Subsequently he presented with a number of sequelae of sickle cell disease: acute chest syndrome, avascular necrosis of the hips, and chronic kidney disease. The case is instructive as an example of DVT after exercise of the lower extremities, which has not been documented well. The case also illustrates a number of health sequelae of sickle cell disease that mimic more common musculoskeletal complaints. Sports medicine providers will have to consider these uncommon but profound diagnostic entities when caring for athletes with sickle cell disease. The case further highlights how research can inform the clinical decisions and policies aimed at reducing the risk of life-threatening and lifelong sequelae of sickle cell disease in athletes.

Check out the full article on pubmed.gov

Accuracy of Point-of-Care Ultrasonography for Diagnosis of Elbow Fractures in Children


Department of Pediatrics, Division of Pediatric Emergency Medicine, Children’s Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY. Electronic address: jrabiner@montefiore.org.



We determine the test performance characteristics for point-of-care ultrasonography performed by pediatric emergency physicians compared with radiographic diagnosis of elbow fractures and compare interobserver agreement between enrolling physicians and an experienced pediatric emergency medicine sonologist.


This was a prospective study of children aged up to 21 years and presenting to the emergency department (ED) with elbow injuries requiring radiographs. Before obtaining radiographs, pediatric emergency physicians performed focused elbow ultrasonography. An ultrasonographic result positive for fracture at the elbow was defined as the pediatric emergency physician’s determination of an elevated posterior fat pad or lipohemarthrosis of the posterior fat pad. All patients received an elbow radiograph in the ED and clinical follow-up. The criterion standard for fracture was fracture on initial or follow-up radiographs.


One hundred thirty patients with a mean age of 7.5 years were enrolled by 26 sonologists. Forty-three (33%) patients had a radiograph result positive for fracture. A positive elbow ultrasonographic result had a sensitivity of 98% (95% confidence interval [CI] 88% to 100%), specificity of 70% (95% CI 60% to 79%), positive likelihood ratio of 3.3 (95% CI 2.4 to 4.5), and negative likelihood ratio of 0.03 (95% CI 0.01 to 0.23) for fracture. The interobserver agreement (κ) was 0.77. The use of elbow ultrasonography would reduce radiographs in 48% of patients but would miss 1 fracture.


Point-of-care ultrasonography is highly sensitive for elbow fractures, and a negative ultrasonographic result may reduce the need for radiographs in children with elbow injuries. Elbow ultrasonography may be useful in settings in which radiography is not readily accessible or is time consuming to obtain.

Copyright © 2012. Published by Mosby, Inc.

Check out the full article on pubmed.gov

Transcranial Doppler Ultrasonography: Clinical Applications


Normal mean flow velocity and PI
Normal mean flow velocity and PI

Transcranial Doppler (TCD) and transcranial Doppler Imaging (TCDI) is a noninvasive ultrasound technique that can be used to measure blood flow velocity within the circle of Willis and the vertebrobasilar system. By providing insight into cerebral hemodynamics, TCD can be used to evaluate a wide variety of intracranial and extracranial cerebrovascular abnormalities: vasoconstriction following subarachnoid hemorrhage, intracerebral arterial stenosis or occlusion, cerebral circulatory arrest and effects of internal carotid artery lesions on collateral competency. Additional uses include the continuous monitoring of a wide variety of cerebrovascular interventions. Diagnoses made with this technology are based on increased or decreased blood flow velocity, absence of blood flow, or alterations in the pulsatility index (PI), a measurement of resistance (Fig 1).

Intracranial Lesions

The use of TCD to screen and document intracranial arterial stenosis represents an evolution in the non-invasive evaluation of patients at risk for ischemic infarction. TCD is widely used in the evaluation of Sickle Cell disease.

The characteristic places where intracranial stenosis can be found include the middle cerebral, internal carotid siphon and the basilar arteries.

The sonographic findings associated with intracranial stenosis are those of increased flow velocities across the narrowed vascular segment.

A total trunk occlusion is characterized by an initial absence or severe reduction of the signal at the normal depths of insonation. Intra-arterial thrombolytic therapy may be utilized to enhance the recanalization process. TCD has been used to monitor flow before, during, and after neuroradiologic interventional procedures such as this.

Intracranial Microvascular Disease

High PI
High pulsatility index

Arteriosclerotic changes can also occur in smaller vessels of the cerebrovasculature. Unlike the large vessel focal stenosis described above, microvascular disease diffusely affects all vessels throughout the brain at distal levels of the arterial tree. Blood flow velocities in the basal arteries are normal throughout the entire circle of Willis but demonstrate a high pulsatility index (Fig 2). The elevated PI (>1.20), is reflective of the distal resistance created by the small vessel disease.


Extracranial Lesions

Low Pulsatility
Low pulsatility index

The atherosclerotic process is more frequent in the extracranial portions of the cerebral circulation, particularly at certain points such as the carotid bifurcation and the origin of the vertebral arteries. The effects of stenotic extracranial lesions upon the hemodynamics of the circle of Willis can be easily detected by TCD. Comparison of flow velocities from side to side along with the flow characteristics will yield an understanding of changes taking place intracrainally.


The characteristic findings of a severe proximal internal carotid stenosis include an ipsilateral “low -flow “state measurable at the MCA in conjunction with a low PI (Fig 3).

Supportive changes in the intracranial  collateral flow via communicating arterial pathways, provide the brain with protection from an ischemic insult. Alternatively, plaque at the bifurcation may still provide a source of distal emboli, which may also be detected by TCD.


MCA Vasospasm
MCA Vasospasm

Hemorrhage into the subarachnoid of the brain constitutes a dire cerebrovascular event. The presence of subarachnoid blood may trigger a severe vasospastic response during the first two weeks following  hemorrhage (7-10 days). The result is often variable degrees of ischemia often proportional to the amount of blood located at the affected artery. The distribution of the vasospasm varies depending upon extension of hemorrhage. The values for vasospasm differ for the middle cerebral artery and basilar artery. The characteristic findings in vasospasm include high flow velocities usually associated with musical murmurs secondary to the spasticity of the blood vessels wall (Fig 4).

Traumatic Head Injury

Following head injury, cerebral hemodynamics may be affected in a number of ways.  Post traumatic impairment of cerebral autoregulation may be identified by high systolic and diastolic mean flow velocities. The cerebral vasculature may lose their vasomotor tone resulting in a hyperemic vasodilatation. The increase of cerebral blood volume may lead to vasogenic edema with a corresponding increase in intracranial pressure. Ultimately this may lead to reduced cerebral perfusion pressure and increased intracranial pressure, ischemia or infarction. The transcranial Doppler PI can be used to diagnose increases in intracranial pressure. As pressure increases, the diastolic velocity drops to zero and the waveform appears spiked.

Cerebral Circulatory Arrest

Brain Death
Brain Death

Decisions regarding the omission or termination of life supporting care are based on specific protocols which include the demonstration of an absence of cerebral circulation by either angiography or nuclear flow studies. Transcranial Doppler can also be used to confirm cerebral circulatory arrest.

The appearance of the transcranial Doppler waveform in cerebral circulatory arrest reflects the progression of increased intracranial pressure and microvascular obstruction. The lack of peripheral perfusion results in a characteristic ”to-and-fro” pattern, called oscillatory flow reverberation (Fig 5).

Emboli Detection

Embolic Event
Embolic Event

Emboli identified by ultrasound are known as microembolic events (MEE) or high intensity signals (HITS).  They have intensities >10dB greater than the background Doppler signal and are transient (0.01-0.1 second) in duration. The sound produced is harmonic and often described as “chirps”, “whistles”, or “plops”, depending on size and composition (Fig 6). Artifacts usually produce a rough, sonorous, non-harmonic, scratchy sound of predominantly low frequency (<400 Hz). Bubble emboli, injected for evaluation of a patent foramen ovale, have higher strength signals for their size (up to 60dB).

Embolic Shower
Embolic Shower


They can produce so much signal reflection that TCD units show an overload on the visual display (Fig 7). It is necessary to measure these showers in total seconds of duration as it is impossible to determine the exact number of microemboli.


Transcranial Doppler ultrasonography provides unique insight into a variety of intracranial and extracranial vascular pathologic conditions and their effects on cerebral hemodynamics. It is hoped that these insights will lead to improvements in the diagnosis and therapy of intracranial neurovascular diseases.


Babikian VL. Transcranial Doppler Evaluation of Patients with Ischemic

Cerebrovascular Disease. In: Babikian VL, Wechsler L, eds. Transcranial

Doppler Ultrasonography. New York, NY: Mosby; 1993: 87-105.

Berger MP, Tegler CH. Embolus Detection Using Doppler Ultrasonography. In: Babikian VL, Wechsler L, eds. Transcranial Doppler Ultrasonography. New York, NY: Mosby, 1993: 232-245.

Compton JS, Teddy PJ. Cerebral Arterial Vasospasm Following Severe Head Injury: A Transcranial Doppler Study. Br J Neurosurg 1987; 1: 435-439.

Halsey JH Jr, Tan MJ. Evaluation of Acute Stroke. In: Newell DW, Aaslid R, eds. Transcranial Doppler. New York, NY: Raven, 1992; 145-151.

Harders AG, Gilsbach JM. Time Course of Blood Velocity Changes Related to Vasospasm in the Circle of Willis Measured by Transcranial Doppler Ultrasound. J. Neurosurg 1987; 66: 718-728.

Hassler W, Steimetz H, Gawlowski J. Transcranial Doppler Ultrasonography in Raised Intracranial Pressure and in Intracranial Circulatory Arrest. J Neurosurg 1988; 68: 745-751.

Ley-Pozo J, Ringelstein EB. Noninvasive Detection of Occlusive Disease of the Carotid Siphon and Middle Cerebral Artery. Ann Neurol 1990; 28: 640-647.

Newell DW, Eskridge JM, Mayberg MR, et al. Angioplasty for the Treatment of Symptomatic Vasospasm Following Subarachnoid Hemorrhage. J. Neurosurg 1989; 71: 654-660.

Newell DW, Seiler RW, Aaslid R. Head Injury and Cerebral Circulatory Arrest. In: Newell DW, Aaslid R, eds. Transcranial Doppler. New York, NY: Raven 1992; 109-121.

Schneider PA, Rossman ME, Torem S, et al. Transcranial Doppler in the Management of Extracranial Cerebrovascular Disease: Implication in Diagnosis and Monitoring. J Vasc Surg 1988; 7: 223-231.

Seiler RW, Newell DW. Subarachnoid Hemorrhage and Vasospasm. In: Newell DW, Aaslid R, eds. Transcranial Doppler. New York, NY: Raven, 1992; 101-107.

Sloan MA. Detection of Vasospasm Following Subarachnoid Hemorrhage. In: Babikian VL, Wechsler L, eds. In: Transcranial Doppler Ultrasonography. New York, NY: Mosby 1993; 105-128.

Wechsler LR. Role of Transcranial Doppler Ultrasound in Clinical Practice. In: Babikian VL, Wechsler L, eds. Transcranial Doppler Ultrasonography. New York: Mosby; 1993: 305-313.