Ultrasound Quarterly

Vol. 17, No. 3, pp. 129–155

© 2001 Lippincott Williams & Wilkins, Inc., Philadelphia

Some Misconceptions and Pitfalls in Ultrasonography

Hsu-Chong Yeh, M.D.
Professor of Radiology, Department of Radiology, Mount Sinai School of Medicine and Mount Sinai New York University
Medical Center, New York, New York, U.S.A.

Summary: There are many misconceptions in the field of ultrasonography. Some are
because of poor understanding of anatomy and/or embryological or developmental
features of certain organs, which have prevailed over the course of the centuries since
the discovery of these entities (e.g., column of Bertin and hypertrophic column of
Bertin). Some misconceptions derived from misinterpretation (e.g., double decidual
sac sign) or inadequate observation of ultrasonographic findings. (e.g., hyperechoic
stroma in polycystic ovarian syndrome). Key Words: Hypertrophic column of
Bertin—Milk of calcium–Renal cyst—Double decidual sac sign—Hashimoto thyroid-
itis—Polycystic ovarian syndrome.

Objectives: After reading this article and completing the
posttest, the learner should be able to:
● Summarize the anatomic detail and some developmental
features of certain common misconceptions of entities in
the kidney, early pregnancy, thyroid, ovary, diaphragm,
and abdominal aorta.
● Describe ultrasonographic findings based on a better un-
derstanding of the aforementioned anatomy, therefore
avoiding misdiagnosis and achieving accurate diagnosis
of these entities.
There are a few misconceptions pertaining to the column of
Bertin and renal lobes. The term “column of Bertin” is a
misnomer. When French anatomist Dr. Exupère Joseph
Bertin1 first described the cortical tissue between pyramids
in 1744, he called it cloisonné, which means partition or
septum. However, the term “cloisonné” was mistranslated
as column in English, and column of Bertin remains popu-
lar. Hodson’s1 attempt to revert it back to being called the
cloisonné of Bertin was in vain. Only a few people referred
to it as the septum of Bertin.2 It is evident that the column
is not the real feature of this structure if one look at a
tangential section of the kidney cortex (Fig. 1). The cortical
tissue between the pyramids form a honeycomb-like parti-
tion, and the pyramids are embedded within this honey-
comb. This can also be easily understood if one studies the
The author has disclosed that he has no significant relationship with or
financial interest in any commercial companies pertaining to this educa-
tional activity.
Address correspondence and reprint requests to: Dr. Hsu-Chong Yeh,
Department of Radiology, Box 1234, Mount Sinai—NYU Medical Center,
One Gustave L. Levy Place, New York, NY 10029. E-mail: hsu-
chong.yeh@mountsinai.org
embryologic development of the kidney. The adult kidney
consists of approximately 14 lobes. During early fetal life,
such lobes are like small individual kidneys called reniculi
(or renunculi) (Fig. 2). Each reniculus is like a small kidney
that consists of its own cortical and medullary tissues and its
own blood supply and collecting system. The central med-
ullary tissue (pyramid) is enveloped on all sides by cortical
tissue, except where the papilla (i.e., the tip of the pyramid)
emerges. There are two parts to the cortical tissue: 1) cen-
trilobe cortex (cortical arch)3 that covers the base of the
pyramid; and 2) mural cortex that wraps around the sides of
the pyramid. When the reniculi fuse to form a single kidney,
the centrilobar cortex of adjacent reniculi fuse to form the
renal cortex, whereas the mural cortices of adjacent reniculi
fuse to form the cloisonné (septum) of Bertin. Because mu-
ral cortices surround each pyramid, when multiple reniculi
fuse together, mural cortices naturally form honeycomb-like
partitions.
There are numerous lobules within the renal cortex and
septum of Bertin, approximately 20,000 lobules in the entire
kidney.3 The lobules radiate from the surface of the pyramid
outward in each reniculus; hence, in an adult kidney, the
lobules are perpendicular to the renal surface within the
renal cortex but parallel to the renal surface within the septa
of Bertin. The lobules contain renal tubules (cortical rays or
medullary rays of Ferrin).3 Within the interlobular spaces
are straight interlobular arteries and veins. Along the surface
of the pyramid are arcuate arteries that give rise to inter-
lobular arteries.
HYPERTROPHIC COLUMN OF BERTIN
A 2- to 3-cm mass-like structure is not uncommonly seen
in the kidney, usually at the junction between the upper and

129
130 H. C. YEH

TABLE 1. Previous terms used to describe

junctional parenchyma
Origin or nature
of the tissue Terms References
Hypertrophic or Hypertrophic column of 4–6
abnormally large Bertin
tissue Focal cortical hyperplasia 11
Large cloison 12
Malposition or displaced Lobar dysmorphism 7,8
tissue Malposition of renal lobe 7
Infolding cortical mass 13
Cortical invagination 10
with prominent
FIG. 1. Septa of Bertin, not column of Bertin. Tangential scan through column of Bertin
the lateral aspect of the renal cortex of a transplanted kidney showing Kidney within a kidney 12
septa of Bertin with a honeycomb appearance, but not the round cross-
section of a “column.” Multiple, round, hypoechoic pyramids are embed- Mass or pseudomass Renal pseudotumor 9,10
ded in each space of the honeycomb; therefore, “column of Bertin” is a Glomerular zone 14
misnomer. pseudotumor
Renal cortical nodule 4
Primary cortical nodule 15
middle thirds of the kidney. This has been observed in in- Intermediate cortical 3
mass
travenous urography and ultrasonography. Many terms (at
least 18) have been coined to name this structure.4–18 They Embryologic anomaly Aberrant lobule of renal 16
tissue
are listed in Table 1. The most commonly used terms are Benign cortical rest 17
hypertrophic column of Bertin,4–6 lobar dysmorphism,7,8 Cortical island of kidney 17
and renal pseudotumor.9,10 Most of the previously described Developmental Abortive attempt at 8
ultrasonographic features for diagnosing this entity are non- abnormality duplication of
renal parenchyma
specific2,5,6,19 They include: 1) lesion indenting on the renal
sinus laterally; 2) renal sinus engulfing the lesion in a claw- Supernumerary lobe Accessory renal lobe 18
like fashion (split sinus sign);2 3) clearly defined from the
renal sinus; 4) maximum dimension less than 3 cm; 5) con- will have the same echogenicity as the renal cortex. This
tinuous with the renal cortex; 6) echogenicity close to that presumption, based on common sense, may appear correct,
of the renal cortex; 7) engulfs papilla;2 and 8) companion but it is another misconception. In fact, the normal septa of
cortical projection.6 The first to fourth features are nonspe- Bertin is usually much more echogenic than renal cortex
cific and can be seen in any mass or mass-like lesion. The because of the anisotropic effect. This will be discussed in
fifth and sixth features are based on the presumption that it more detail later. The seventh feature is also called impris-
is a hypertrophic septum of Bertin. Because the septum of oned papilla and has been seen in angiography. It was de-
Bertin is a cortical tissue, as is the renal cortex, it naturally scribed as the central lucency sign8 in the angiographic

FIG. 2. Formation of renal lobe, cortex, and

septum of Bertin from the reniculus. A. The
reniculus (renunculus) consists of a central
core of medulla enveloped by cortical tissue.
B. The cortical tissue is divided into a centri-
lobar and a mural cortex. C. A group of ren-
iculi (two are shown here) fuse to form a kid-
ney, and each reniculus becomes a renal lobe.
Two layers of adjacent mural cortex fuse to
form the column (septum) of Bertin, whereas
the centrilobar cortex fuses to form the renal
cortex. The interlobular arteries run perpen-
dicular to the renal surface in the renal cortex,
but parallel to the renal surface in the column
of Bertin. The renal lobules are also in the
same orientation as the interlobular arteries, as
shown in A. a ⳱ artery.

Ultrasound Quarterly, Vol. 17, No. 3, 2001

 MISCONCEPTIONS IN ULTRASONOGRAPHY
literature. Because a pyramid (the tip of which is the papilla)
surrounded by cortical tissue forms a renal lobe, the term
“lobar dysmorphisor” was coined based on this finding in-
dicating that this is a large and malpositioned renal lobe.
The eighth feature is an ancillary sign that is seen in some
cases when the junctional parenchyma extends to the medial
side of the kidney.
The so-called hypertrophic column of Bertin actually rep-
resents unresorbed polar parenchyma of either the superior
or inferior subkidney20 (Figs. 3–5), and not a single large
septum of Bertin. After studying 15- to 30-mm thick em-
bryo resin cases of the kidney, Fine and Keson21 found that
most kidneys develop by means of fusion of two kidneys
(upper and lower ones), which correspond to the upper and
lower groups of calyces. Although calyces are not usually
clearly delineated in ultrasonography, the echogenic renal
sinus fat in which the calyceal system is situated can be
clearly seen by ultrasonography in a normal kidney. A kid-
ney is composed of echogenic sinus fat enveloped by renal
parenchyma. The renal parenchyma consists of renal cortex,
pyramids, and septa of Bertin, which are all less echogenic
than the renal sinus fat. By carefully scanning the kidney
131
from the upper pole to the lower pole, and from one side to
the other on sagittal or coronal scanning, we have found
many kidneys that appear to form by fusing of the superior
and inferior kidneys.20 We called these two kidneys supe-
rior and inferior subkidneys. The upper pole of the inferior
subkidney usually overlaps the lower pole of the superior
subkidney. The former is located anterior to the latter at the
area of overlap. The so-called hypertrophic column of
Bertin represents unresolved renal parenchyma at the junc-
tion of two subkidneys; therefore, we call it junctional pa-
renchyma.20 Within the junctional parenchyma, there are
normal renal cortex, pyramids, and septa of Bertin. Between
the two subkidneys, an echogenic line may be seen. This is
called the junctional parenchymal line.20 A groove on the
surface of the kidney formed by this line appears as a small,
triangular defect that is called the junctional parenchymal
defect. When all elements and features of junctional paren-
chyma (e.g., renal cortex, pyramids, septa of Bertin, junc-
tional parenchymal line, and junctional parenchymal defect)
are identified and two fused subkidneys are recognized on
ultrasonography, the diagnosis of junctional parenchyma
can be certain, and a tumor can be excluded. Even if two
FIG. 3. A pseudotumor caused by
junctional parenchyma. A. A hy-
poechoic, mass-like lesion (m) is
seen in the kidney. B. Slightly differ-
ent scanning plane shows a promi-
nent pyramid (arrowhead) in the le-
sion. Therefore, the lesion most
likely represents junction paren-
chyma (JP). C. Further scanning
shows a junctional parenchymal de-
fect (arrowhead) and junctional pa-
renchyma line (arrow), confirming
that the lesion is indeed junctional
parenchyma (JP). The renal sinus fat
of the upper (U) and lower (L) sub-
kidneys appeared separate. Junc-
tional parenchyma (JP) represents the
lower parenchyma of the superior
subkidney; therefore, this is a supe-
rior subkidney type of junctional pa-
renchyma. D. Transverse scan shows
junctional parenchyma (JP) to be lo-
cated in the lateral aspect of the kid-
ney between the upper (U) and lower
(L) subkidney sinus fat. Arrow ⳱
junctional parenchymal line; black
arrowhead ⳱ junctional parenchy-
mal defect. E. Diagrammatic drawing
corresponding to C.
Ultrasound Quarterly, Vol. 17, No. 3, 2001
132 H. C. YEH
FIG. 4. Example of a gross specimen. The drawing from a kidney speci-
men with a double collecting system shows inferior subkidney type of
junctional parenchyma. The double collecting system is known to fre-
quently be associated with junctional parenchyma. Note that a pyramid
(arrow) appears to be cutoff or deformed by the junctional parenchyma
(arrowheads). From: Yeh HC, et al. Junctional parenchyma: revised defi-
nition of hypertrophic column of Bertin. Radiology 1992;185: 725–32.
subkidneys are not identified and a pyramid or pyramids are
seen within it, junctional parenchyma can be highly sug-
gested. Because all elements of the tissue are normal, there
is nothing hypertrophic or tumor-like about it. It is not a
displaced, malpositioned, or aberrant renal lobe or an em-
bryonic rest. It is not an infolding or invagination of cortical
tissue as previously described. In fact, all those previously
created terms pertaining to this entity as listed in Table 1 are
based on incorrect concepts.
Because junctional parenchyma is located between two
overlapping poles of two subkidneys, on transverse scan, it
can be seen located between two echogenic fatty renal si-
nuses in the lateral aspect of the kidney (Fig. 3). The echo-
genic renal sinus fat of the two subkidneys are usually fused
at the renal hilum. Occasionally, the fat of the two renal
sinuses are completely separate, and transverse scan through
this plane shows only renal parenchymal tissue, and a sag-
ittal or coronal scan will show a band-like area of junctional
parenchyma completely transecting the kidney. This has
been called the intermediate cortical mass, and it is most
likely that the kidney having this feature will have a double
pyelocalyceal system. When the connection of the two
echogenic renal sinuses is small, an intermediate cortical
mass may also be seen on certain sagittal or coronal scans.
Whether there is a double pyelocalyceal system in such
kidneys is difficult to determine on ultrasonography unless
Ultrasound Quarterly, Vol. 17, No. 3, 2001
FIG. 5. Junctional parenchyma simulating a mass. A. A hyperechoic
mass (arrowhead) is seen partly within the renal sinus. B. Scanning slightly
more laterally shows a pyramid (P) in the mass and a defect (arrow) on the
renal surface, associated with a demarcating line (arrowheads). This rep-
resents junctional parenchyma of inferior subkidney type.
the renal collecting system is dilated. However, it is quite
possible that a bifid renal pelvis may be present if there is no
duplication of the pyelocalyceal system. In general, there is
higher incidence of double or bifid renal collecting systems
in the kidneys with junctional parenchyma.
When two subkidneys fuse, either the upper polar paren-
chyma of the inferior subkidney or the lower polar paren-
chyma of the superior subkidney may be resorbed. The
remaining unresorbed polar parenchyma, which represents
junctional parenchyma, may be the lower polar parenchyma
of the superior subkidney (type 1, the superior subkidney
type) or the upper polar parenchyma of inferior subkidney
(type 2, the inferior subkidney type), or it may be a mixed
type (type 3) in which two junctional parenchymas are seen
because of a large amount of overlapping between two sub-
kidneys and partial (i.e., anterior half or posterior half) re-
sorption of these overlapping parts (Fig. 6).
The pyramid adjacent to the junctional parenchyma may
appear partly cut-off by the junctional parenchyma, and
sometimes it even appears displaced or distorted by the
junctional parenchyma20 (Fig. 4). This gives the appearance
of “mass effect” in the junctional parenchyma. This is an-
other reason why the junctional parenchyma may be mis-
taken for a tumor.
It is possible that all or most adult kidneys are formed by
fusion of two subkidneys. Because of various degrees of
resorption of junctional parenchyma, the amount of over-
 MISCONCEPTIONS IN ULTRASONOGRAPHY
FIG. 6. Classification of junctional parenchyma. From: Yeh HC, et al.
Junctional parenchyma: revised definition of hypertrophic column of
Bertin. Radiology 1992;185:725–32.
lapping of the two subkidneys, along with a difference in
alignment, allows the kidneys to have a variety of appear-
ances.
When two subkidneys are in straight alignment, the results
may be:
● The junctional parenchyma is completely resorbed and a
usual, normal, reniform kidney will be seen.
● The junctional parenchyma is resorbed, but the junctional
parenchymal line and the junctional parenchyma defect
remain (Fig. 7). An echogenic line will be seen at the
junction between upper and middle thirds of the kidney.
This echogenic line has been called the interrenicular
septum,22 which means a line between two renal lobes. In
FIG. 7. Junctional parenchymal line and defect. An echogenic line (ar-
row) is seen in this kidney with a small or no junctional parenchyma
because of near-complete resorption of polar parenchyma during fusion of
two subkidneys. The junctional parenchymal defect (arrowhead) can also
be seen.
133
fact, it is a line between two subkidneys and represents
the junctional parenchymal line.
● A part of the junctional parenchyma is not resorbed, and
various types of junctional parenchymas will be seen as
previously described (Fig. 6).
When two subkidneys are not in straight alignment, this will
result in a variety of appearances, some of which are shown
in Figure 8. This occurs mostly in the left kidney, and the
most common variety is a triangular kidney with dromedary
hump, i.e., a protrusion on lateral border of the kidney (Fig.
9). This protrusion represents the lateral aspect of the junc-
tional parenchyma.20 The cause of offset in alignment of
two subkidneys is not clear, but is probably caused by a
small renal fossa during early fetal life from a relatively
large spleen or some other causes. In cross-ectopic kidneys,
if the two fused kidneys are aligned in a craniocaudal di-
rection, their features may be quite similar to a kidney with
a junctional parenchyma, except that the cross-ectopic kid-
ney may be longer than normal.
TRUE HYPERTROPHIC SEPTUM OF BERTIN
In most individuals, the size of the septa of Bertin is quite
variable within the same kidney and in different individuals.
They range from small to larger than a pyramid. In the polar
regions, the pyramids are close together, and only small or
incomplete septa of Bertin may be seen. In the middle por-
tion of the kidney, the pyramids are farther separated and
the septa of Bertin are larger. Because septa of Bertin rep-
resents cortical tissue that surrounds a pyramid to form a
renal lobe, it has the same histologic structure as renal cor-
tex. It is therefore generally believed that a normal and a
hypertrophic septum of Bertin should have the same
echopattern as renal cortex. Contrary to this belief, the septa
of Bertin are usually much more echogenic than renal cor-
tex.20 This is because of the anisotropic effect20,23 (Fig. 10).
As previously mentioned, the renal cortex and septa of
Bertin are composed of numerous lobules. The orientation
of the lobules, the renal tubules that are contained in the
lobules (cortical rays or medullary rays of Ferrein),3 the
interlobular connective tissue, the interlobular arteries and
veins, and the like are all perpendicular to the renal surface
in the renal cortex; therefore, during ultrasonographic scan-
ning on sagittal or coronal plane, the sound beam will be
parallel to these structures, and only a few echoes will be
seen. In the septa of Bertin, these structures are parallel to
the renal surface and perpendicular to the sound beam.
Therefore, septa of Bertin will be much more echogenic
than renal cortex (Fig. 10). If one scans the kidney in the
craniocaudal direction or caudocranial direction, the echo-
genicity of the renal cortex and septa of Bertin will reverse,
i.e., the renal cortex will become more echogenic than septa
of Bertin. In the practical clinical setting, however, this is
Ultrasound Quarterly, Vol. 17, No. 3, 2001
134 H. C. YEH

FIG. 8. Three variations in offset align-

ment of two subkidneys. A, B, and C show
progressive increase in the degrees of an-
gulations of the long axis of two subkid-
neys. D, E, and F are corresponding draw-
ings. The angles between the two subkid-
neys in each kidney are shown in the right
lower corner of each drawing.

usually difficult to perform unless the kidney is horizontally
oriented, and ultrasound scanning may not show good detail
of the parenchymal tissue in the middle portion of the kid-
ney. A typical normal septum of Bertin is pear-shape, with
a small part pointing toward the renal surface20 (Fig. 10). A
large or hypertrophic septa of Bertin retains a pear-shape
and is highly echogenic20 (Fig. 11). It is always located
between two pyramids and usually partly protrudes into the
renal sinus. It may sometimes indent on the adjacent pyra-
mids on both sides (Fig. 12). A single or double hypertro-
phic septa of Bertin may be seen. It is usually located in the
anterior parenchyma in the middle portion of the kidney.
This is different from junctional parenchyma, which is usu-
ally located at the junction between the upper and middle
third of the kidney and between two renal sinus systems on
transverse scanning and along the lateral aspect of the kid-
ney. The characteristic pear-shape, homogeneous high-level
echoes, and location between two adjacent pyramids usually
allow the diagnosis of a true hypertrophic septum of Bertin
and differentiate it from an echogenic tumor, which is usu-
ally round. Color Doppler may show no detectable flow or
symmetrical vascular supply from adjacent arcuate vessels
without any irregular tumor vessels.
FETAL LOBATION, RENAL SCARS, CORTICAL
TUMOR, AND HYPERTROPHIC RENAL LOBE
It is well known that so-called fetal lobulation is a normal
variation of the kidney in which the lobular contour of the
fetal kidney remains in the adult kidney. In fact, as previ-
ously mentioned, a kidney consists of approximately 20,000
lobules and 14 lobes. There are numerous lobules in each
lobe. The renal lobules are too small to be delineated by
ultrasonography. What we see in fetal kidneys are lobes,
and the term “fetal lobulation” should, instead, be “fetal
lobation.” Although the term “lobulation” has been used to
describe a bumpy or undulated contour of an object, e.g., a
lobulated tumor, and is not necessarily related to true lob-
ules. Hence, fetal lobulation may mean that kidney has an

Ultrasound Quarterly, Vol. 17, No. 3, 2001

 MISCONCEPTIONS IN ULTRASONOGRAPHY
undulated contour similar to a fetal kidney, whereas fetal
lobation means that a kidney retains a multiple lobar con-
tour similar to a fetal kidney; certainly, this is a much more
precise term and was coined by Hodson.1,24
The diagnosis of fetal lobation can be made by finding
that each bulge of the undulated renal contour corresponds
to each renal lobe. Because each renal lobe is formed by a
pyramid surrounded by cortical tissue, each bulge on the
renal contour should correspond to a renal lobe, i.e., each
bulge should overlie one pyramid and each indentation
should be between two lobes (Fig. 13). This is different
from renal scars, which may also result in indentations (or
cortical defects) and undulation on the renal contour. The
indentation (or indentations) from the scar is more likely to
be located in the middle of a bulge (a renal lobe) on the
renal contour or in a random fashion, rather than in between
two lobes (Fig. 14). A small tumor may also cause a bump
on the renal contour (Fig. 15). In diagnosing fetal lobation,
one should carefully examine each bulge on the renal con-
tour to be certain that each bulge corresponds to each renal
lobe so that a renal mass associated with fetal lobation may
not be missed.
A hypertrophic renal lobe may simulate a renal cortical
tumor (Fig. 16). Careful scanning to delineate the pyramid
within it and the symmetrical echogenic septa of Bertin on
both sides will allow a diagnosis of a hypertrophic renal
lobe.
135
FIG. 9. Dromedary hump caused
by offset alignment of subkidneys. A.
The left kidney appears small, 7.8
cm, because only the inferior subkid-
ney was delineated. The superior
subkidney was not well visualized
because it is in a slightly different
plane. B. Scanning slightly more me-
dially, both subkidneys are clearly vi-
sualized, and a correct measurement
(10.4 cm) was made. A triangular
kidney with a dromedary hump (ar-
rowhead) is now evident. C. Drawing
shows offset alignment of the two
subkidneys from side view (c) and
frontal view (d). Scanning along X
plane, only inferior subkidney is seen
(a). Scanning along Y plane, both
subkidneys are seen to be in offset
alignment (b), which is the cause for
kidney being triangular.
MILK OF CALCIUM IN A RENAL CYST
Milk of calcium in a renal cyst or calyceal diverticulum
had been considered to be exceedingly rare25 and, therefore,
only a few case reports26–30 had been published because of
its rarity until 1992, which is when we found that this is
actually common.31 Because milk of calcium contains cal-
cium, naturally, layering of highly echogenic material with
an acoustic shadow was thought to be the ultrasonographic
feature of this entity. In fact, in most instances, milk of
calcium does not cast an acoustic shadow because it is usu-
ally seen in small renal cysts, smaller than 1cm and only
occasionally larger than 1.6 cm. Each cyst usually contains
only a small amount of milk of calcium, which produces
reverberation echoes (Fig. 17). This phenomenon can also
occur with other small, highly reflecting particles, such as
cholesterol crystals and ground sand. The reverberation ech-
oes are caused by the ultrasound beam bouncing back and
forth within the aggregations of small, highly reflecting par-
ticles. When there is a larger amount of milk of calcium,
part of the sound beam will be absorbed or scattered away
from the transducer, and partial shadowing may occur.
When cysts are larger than 1.2 cm, more apparent acoustic
shadowing may be seen, and cysts smaller than 0.6 cm
usually have no acoustic shadowing. In a larger cyst, the
acoustic shadow will become more obvious as the layer of
milk of calcium increases in thickness. If one partly aspi-
rates the cystic fluid, the cyst becomes small, and the layer
Ultrasound Quarterly, Vol. 17, No. 3, 2001
136 H. C. YEH
FIG. 10. Anisotropic effect on septa of Bertin. A. Diagram shows a
kidney with its arterial system. The kidney is scanned (dashed lines) by a
curve-array transducer. Note that the interlobular arteries within the renal
cortex are perpendicular to the renal surface, but those within the septa of
Bertin are parallel to the renal surface. As shown in Figure 1, renal lobules
(and cortical rays) are also in the same orientation as interlobular arteries.
B. Diagram shows that in the area where the ultrasound beam is perpen-
dicular to the renal arteries (and also renal lobules and cortical rays), the
echoes are increased. These echogenic areas include the septa of Bertin
(arrows) in the middle portion of the kidney and the renal cortex in both
poles (arrowheads). Arrowheads ⳱ pyramids. C. Example of a normal
kidney showing the anisotropic effect. The septa of Bertin (black arrows)
are more echogenic than the renal cortex. The polar cortex (black arrow-
heads) are also hyperechoic. White arrowheads ⳱ pyramids.
of milk of calcium becomes thicker; therefore, acoustic
shadowing will appear or become more apparent. The pres-
ence and degree of acoustic shadowing also depends on the
scanning technique. Using a higher frequency transducer or
smaller or focused ultrasound beam will result in a more
obvious acoustic shadow. By scanning tangentially through
the milk of calcium, the sound beam may pass through a
Ultrasound Quarterly, Vol. 17, No. 3, 2001
thicker layer of milk of calcium, and acoustic shadowing
may become stronger.
The diagnosis of milk of calcium within a renal cyst is
usually easy and quite definite. When layering of highly
echogenic material is seen within the dependent portion of
a cyst with reverberation echoes and with or without only a
weak acoustic shadow, milk of calcium within a cyst is
highly suggestive. To bring out this feature, it is best to scan
the echogenic lesion with the transducer perpendicular to
the ground. If the echogenic material remains in the depen-
dent portion of the cyst when the patient turns in different
positions, the diagnosis is certain. If the cyst is small and
filled with milk of calcium, layering of milk of calcium will
be difficult to demonstrate. In such cases, the diagnosis may
be difficult because a small stone may also show no or only
weak acoustic shadowing. This, however, rarely occurs, and
most milk of calcium can be diagnosed by ultrasonography.
The diagnosis of milk of calcium in a cyst is important
because this is usually a benign condition that requires no
treatment in most cases. Misdiagnoses may result in unnec-
essary anxiety for patients, along with unnecessary follow-
up examinations and unnecessary treatments, such as litho-
tripsy, which is both ineffective32 and potentially harmful.
Milk of calcium can be misdiagnosed as other conditions,
such as:
1. Renal stone (Fig. 18). As already stated, a tangential
view of milk of calcium produces a round, echogenic
structure with an acoustic shadow, and no fluid-filled
cystic part is visualized. This can easily be mistaken for
a stone and usually occurs on a supine coronal scan of a
kidney, scanning from the flank. If reverberation echoes
are seen and the acoustic shadow is not as strong as
expected for a stone of this size, milk of calcium should
be suspected. Scanning carefully with the transducer per-
pendicular to the ground and with the patient in different
positions will clarify the diagnosis.
2. Angiomyolipoma (Fig. 19). Tangential views of milk of
calcium show a round, highly echogenic lesion. If little
reverberation echoes and no acoustic shadow are seen,
the lesion may be mistaken for an angiomyolipoma. An
aggregation of tiny cysts with milk of calcium may also
appear as a single echogenic lesion, similar to an angio-
myolipoma. Again, even small amounts of reverberation
echoes or acoustic shadowing should cause suspicion
that this is not an angiomyolipoma, and careful scanning
should be performed to clarify the diagnosis.
3. A cyst with calcified wall (Fig. 20). Calcification in a
cyst wall may be caused by chronic inflammation or
carcinoma; therefore, it is indicated that the cyst is not a
simple cyst. Two conditions with milk of calcium in a
cyst can be mistaken for calcification in a cyst wall: 1)
when milk of calcium is scanned with the transducer at
an oblique angle, the milk of calcium may appear as
 MISCONCEPTIONS IN ULTRASONOGRAPHY 137

FIG. 11. True hypertrophic septum

of Bertin in two patients. A. Coronal
scan of right kidney shows a large sep-
tum of Bertin (arrow) flanked by pyra-
mids (arrowheads) and protruding into
the renal sinus fat. B. Transverse scan
shows the large septum of Bertin (ar-
row) located anteriorly and flanked by
pyramids (arrowheads). C. Coronal
scan of right kidney on different pa-
tients shows double hypertrophic
septa of Bertin (arrows). They are
typically pear-shape. Arrowheads ⳱
pyramids. D. Transverse scan shows
that the large septum of Bertin (arrow)
is again located anteriorly.

calcification in a cyst wall. A proper scan as previously 1. No lesion detected.

mentioned will clarify the diagnosis; 2) when a small This happens if the cyst is small and close-spaced thin-
cyst with milk of calcium is adjacent to a larger simple sections are not performed.
cyst, the small cyst with milk of calcium may be mis- 2. Mistaken for a calcification or stone.
taken for calcification in the wall of a larger cyst. A This occurs if the fluid-containing portion of the cyst is
careful scanning to separate the two cysts will resolve the not delineated.
problem.
It is usually quite difficult to diagnose milk of calcium in
a cyst on computed tomography (CT) scan unless the cyst is
relatively large. This is because of the difficulty in delin-
eating the layering of milk of calcium. Even for a 1-cm cyst,
one may have to repeat close-space thin-section scanning to
see the layering of the milk of calcium. Depending on the
size of the cyst and amount of milk of calcium, CT scanning
may show milk of calcium in the cyst as:

FIG. 12. True hypertropic septa of Bertin compressing on pyramids. FIG. 13. Fetal lobation. A. Right kidney of a 35-week-old fetus. Note
Sagittal scan of the kidney shows two markedly enlarged septa of Bertin undulated renal contour caused by renal lobes (arrows). B. Similar lobation
(arrowheads) that indent on adjacent pyramids (P). The septa of Bertin are in an adult kidney. Each lobe contains a pyramid. Note the hyperechoic
highly echogenic. tissue between the two pyramids, representing septa of Bertin.

Ultrasound Quarterly, Vol. 17, No. 3, 2001

138 H. C. YEH
FIG. 14. Fetal lobation and scars. Sagittal scan of a kidney shows fetal
lobation (white and black arrows). An indentation (black arrow) in the
middle of the margin of a renal lobe is caused by scar. Extensive irregular
cortical defects (arrowheads) seen in the upper pole is caused by a scar or
scars. In one renal lobe, the pyramid (p) is only slightly decreased in size,
but the cortex is absent. The other pyramid (p’) is small.
3. Seen as a simple cyst.
This happens if a small amount of milk of calcium is not
delineated.
4. Mistaken for a solid lesion and a cancer cannot be ex-
cluded (Fig. 21).
This is caused by the partial volume effect on CT scan-
ning. Because milk of calcium may be associated with in-
flammation of the cyst, and because of the difficulty in
FIG. 15. Fetal lobation with a small mass. A. Fetal lobation. An apparent
small defect (arrowhead) or indentation is seen in a renal lobe. This simu-
lates a scar. B. Scanning in a slightly different plane shows a small mass
(arrow) and no scar.
Ultrasound Quarterly, Vol. 17, No. 3, 2001
FIG. 16. Hypertrophic renal lobe. A. Hypoechoic mass-like lesion (ar-
rowhead) is seen in the lower pole of the kidney. B. More careful scanning
shows a large pyramid in the lesion, indicating that this is a large renal
lobe. The pyramid is flanked by a slightly hyperechoic septa of Bertin.
scanning a small lesion and precisely evaluate the density
on CT scan, the lesion may even appear slightly enhanced
on CT scan after injection of contrast material, which fur-
ther raises the possibility of cancer. Such a lesion is fre-
quently referred to ultrasonography for clarification. If one
is not aware of this problem on CT and looks for a solid
mass on ultrasonography, no lesion will be found, resulting
in a nondiagnostic study. Finding a cyst with milk of cal-
cium in the same location as found on CT (best to compare
with the transverse scan) makes the diagnosis clear.
Multiple or even numerous cysts with milk of calcium in
a kidney is not uncommonly seen (Fig. 22). Milk of calcium
may also be seen in congenital or acquired polycystic kid-
neys and in ectopic or transplanted kidneys. Because milk of
calcium in a cyst is so common, it is frequently detected in
patients with renal colic or hematuria. However, milk of
calcium is usually not the cause of pain or hematuria. Oc-
casionally, milk of calcium in a cyst may disappear spon-
taneously on a follow-up examination or appear on a pre-
viously normal kidney.
Plain radiographs may show no calcification for a small
cyst with milk of calcium, or they may show a small, cal-
cified density or mottled densities when multiple cysts with
milk of calcium are present. It is usually difficult to dem-
onstrate layering of a small amount of milk of calcium on an
upright or cross-table radiograph. Most cases of milk of
 MISCONCEPTIONS IN ULTRASONOGRAPHY 139

FIG. 17. Milk of calcium in a renal cyst. A 33-year-old woman with hematuria. Radiograph, ultrasonogram, and CT scan were obtained elsewhere (not
shown), and a right renal stone was diagnosed. Our ultrasonograms revealed a right renal cyst with milk of calcium rather than a stone. Computed
tomography scans and radiographs were repeated thereafter. B and D. Longitudinal scans of the right kidney with the patient in the supine and prone
positions, respectively, show a cyst (arrowheads) with milk of calcium (arrows) layering in the dependent portion of the cyst. A. Unenhanced CT scan shows
a calcified lesion (arrow) similar to a stone. C. Repeat scanning at 0.5-cm intervals shows the stone is in fact a small cyst (arrowhead) with milk of calcium
(arrow) layering in the dependent portion Thin-slice CT scan was performed twice to obtain the image showing layering of milk of calcium. From: Yeh
HC, et al. Milk of calcium in renal cysts: new sonographic features. J Ultrasound Med 1992;11:195–203.

calcium cannot be diagnosed or detected on plain radio-
graphs because of their small size.
Fine-needle aspiration may show clear, yellow fluid or
dark brown, turbid fluid. It is usually difficult to aspirate the
calcified material to prove milk of calcium unless the cyst
contains a large amount of milk of calcium and unless a
prolonged, forceful suction is applied during aspiration.
YOLK SAC AND FETAL POLE
During early pregnancy, the earliest sign of intrauterine
pregnancy during ultrasonography is a small, cyst-like
structure “within” the anterior or posterior layer of endo-
metrium. This is called the intradecidual sign,33 and the
cyst-like structure represents an early gestational sac. This is
different from a pseudogestational sac in which the cyst-like
structure or fluid collection represents fluid or blood in the
uterine cavity and not within the endometrium. The early
gestational sac appears empty on ultrasonography. The first
structure to appear within the gestational sac is usually a
small bleb that has been considered to represent a yolk sac.
If the gestational sac grows to a certain size and still shows
no evidence of the yolk sac, it is considered to be a nonvi-
able gestation or a blighted ovum.34 The critical size of
discriminatory value of the gestational sac for diagnosing a
nonviable pregnancy has been decreased from 2 cm34 on
transabdominal scanning to 0.8 cm on current endovaginal
scanners.35 In fact, in the early gestational sac, there is an
inner cell mass that is usually too small to be seen by current
ultrasound equipment. The inner cell mass subsequently
forms an early amniotic sac, the roof of which is a germ disc
(bilaminate disc), i.e., the early embryo. Therefore, the first
bleb that appears in a gestational sac is an amniotic sac-
embryo complex36 and not the yolk sac. The yolk sac at this
Ultrasound Quarterly, Vol. 17, No. 3, 2001
140 H. C. YEH

FIG. 18. Milk of calcium in a renal cyst

simulating a stone in a patient with hema-
turia. A. Coronal view of the right kidney
shows a round, highly echogenic lesion
(arrowhead) in the upper pole of the right
kidney, casting an acoustic shadow. Pre-
liminary impression of the ultrasonogra-
pher was a renal stone. Note the acoustic
shadow is of mild to moderate degree,
which is unusual for a stone of this size.
There are reverberation echoes. B. Because
of suspicion for milk of calcium in A, scan-
ning with perpendicular ultrasound beam,
with the patient supine, from costal margin
shows layering (arrowhead) of echogenic
material. Perpendicular beam scanning was
also performed with the patient in the de-
cubitus (C) and prone positions ( D), again
showing layering of echogenic material in-
dicating milk of calcium.

early stage is called the primary yolk sac, which represents

the inner lining layer of the early gestational sac, and it is
not clearly separated from gestational sac wall. Therefore,
ultrasonography usually does not delineate the early pri-
mary yolk sac. As the gestational sac grows, the primary
yolk sac shrinks and starts to separate from the gestational
sac. The primary yolk sac may be seen at this stage if a
careful scan is performed (Fig. 23).
The term “fetal pole” has been used extensively in the
past. The term may have different meanings to different
people, and I do not think it is a good term to use. It origi-
nally meant amniotic sac-embryo yolk-sac complex.37 In
general, fetal pole refers to any structure that may be related

FIG. 19. Milk of calcium simulating an angiomyolipoma. A. Highly
echogenic lesion (arrowhead) in the upper pole of the kidney. There is no
acoustic shadow, and the lesion is somewhat similar to an angiomyoli-
poma. B. Because some reverberation was seen (A), milk of calcium was
suspected, and scanning with a perpendicular ultrasound beam with the
patient in the prone position was performed, demonstrating layering of
echogenic material, indicating milk of calcium.
FIG. 20. Milk of calcium versus calcified cystic wall in two patients. A.
Cyst (arrowhead) with small amount of milk of calcium (arrow) may
simulate calcification in the cystic wall. Careful scanning may be necessary
to show layering, reverberation echoes, and movement with gravity (not
shown) to confirm milk of calcium. B. Renal cyst (arrowhead) in another
patient shows calcification (arrow) in the cystic wall casting only a weak
shadow.

Ultrasound Quarterly, Vol. 17, No. 3, 2001

 MISCONCEPTIONS IN ULTRASONOGRAPHY
to the fetus during early gestation. However, because we are
now able to see the normal embryo or fetus, yolk sac, and
amniotic sac most of the time, we can use more precise
terms, such as fetus, amniotic sac, yolk sac, or double bleb
instead of fetal pole, which is poorly defined.
DOUBLE DECIDUAL SAC SIGN
It is believed that after the intradecidual sign seen in early
pregnancy, in the next stage of pregnancy, one may see a
double sac38 or a double decidual sac sign39 before the yolk
sac or embryo can be seen. In fact, the intradecidual sign
can be seen up to seventh week of pregnancy and not just
during the early weeks of pregnancy; although, the clinical
usefulness is during the early gestational stage when the
gestational sac appears empty. The double decidual sac sign
is also useful in this empty-sac stage. A true double-
decidual sac sign, however, is usually not present before
seventh week.33,40 Two echogenic rings, one inside the
other, during early pregnancy has been called the double
decidual sac sign. This is based on the assumption that each
echogenic ring represents one layer of decidua. In fact, to
have double layers of decidua surrounding a gestational sac,
the gestational sac has to be large enough to markedly dis-
place the decidua so that two layers of decidua will wrap
around the gestational sac to form a double decidual sac.
This usually occurs only after approximately 8 weeks of
gestation. By this time, the layers of decidua are markedly
stretched and close to each other, and it is difficult to de-
141
FIG. 21. Cyst with milk of calcium simulat-
ing a tumor on CT. A. Scanning without in-
jection of contrast medium, a small calcifica-
tion (arrowhead) was seen in the medial aspect
of the left kidney, but no obvious cyst was
seen. B. After injection of contrast medium, a
lesion (arrow) was seen. The attenuation value
of the lesion increased from 22.6 HU to 58.8
HU after the injection of contrast. This is
highly suspicious for carcinoma. C. Ultrasono-
graphic scanning with patient in the decubitus
position shows a 1-cm cyst with milk of cal-
cium. A ⳱ aorta. D. Scanning with the patient
in the prone position again shows the cyst with
milk of calcium, which has moved anteriorly
to the dependent portion. S ⳱ spine.
lineate as two layers on ultrasonography (Fig. 24). Even if
one carefully delineates the double decidual sac at this
stage, a well-formed fetus is always found in a normal preg-
nancy, and the double decidual sac sign is not necessary to
diagnose an intrauterine pregnancy. During earlier intrauter-
ine pregnancy, the gestational sac is located in a thickened
layer of decidua (the opposite layer of decidua is usually
thinner), and the thin line of the echogenic uterine cavity
between the two layers of decidua is usually straight or only
slightly displaced by the gestational sac. Therefore, two
layers of decidua really do not wrap around the gestational
sac to form the double decidual sac sign (Figs. 25,26). Evi-
dence that the double echogenic ring during early pregnancy
does not represent double decidual sac include: 1) to form a
double decidual sac, one should find a thin, echogenic, uter-
ine cavity ring between two echogenic decidual rings to
indicate that this is indeed the double decidual rings divided
by the uterine cavity, i.e., one should find a third, thin,
echogenic ring between the two thick, echogenic rings;
however, this has never been documented; 2) the hy-
poechoic ring between the two echogenic rings should be
determined. One speculation is that it represents fluid within
the uterine cavity. Fluid in the uterine cavity during early
gestation is unusual and may be abnormal. Fluid should be
flanked by two thin, echogenic lines (or rings) of decidual
surface; 3) the outer echogenic ring represents the basal
layers of the decidual, and the inner echogenic ring repre-
sents choriotrophoblastic tissue of the gestational sac. This
is usually evident on longitudinal scan of the uterus,
Ultrasound Quarterly, Vol. 17, No. 3, 2001
142
FIG. 22. Multiple cysts with milk of calcium in a kidney. A. A cyst
(arrowhead) with milk of calcium (arrow) is seen near the upper pole of the
kidney. B. Two more cysts (arrowheads) with milk of calcium (arrows) are
seen in the lower pole of the same kidney.
and double echogenic rings usually appear on oblique scan
(Fig. 26). The decidua on the same side of the gestational
sac is usually markedly thickened and poorly echogenic,
except for the basal layer, which is highly echogenic; 4) if
both echogenic rings represent two layers of decidua, then
where is the choriotrophoblastic ring, i.e., the gestational
sac? We should see triple echogenic rings because during
early pregnancy, the gestational sac is usually clearly sepa-
rated from the echogenic basal layer of the decidua.
Features of the double echogenic ring may also be seen in
cases of a pseudogestational sac.41 Therefore, it is not a
specific sign of an intrauterine pregnancy.
In sum, the ultrasonographic signs for early intrauterine
pregnancy are: 1) intradecidual sign; 2) single bleb sign
(i.e., embryo-amniotic sac complex; 3) double bleb sign
(i.e., yolk sac-embryo amniotic-sac complex). The double
decidual sac sign is not a reliable sign of an intrauterine
pregnancy, because it is virtually nonexistant in ultrasonog-
raphy.40
MICRONODULATION IN THE THYROID GLAND
Hashimoto thyroiditis is the most common form of thy-
roiditis. It is one of the most common causes of hypothy-
roidism. Therefore, it is frequently encountered in daily
clinical practice. Ultrasonographic diagnosis of Hashimoto
thyroiditis has been relatively difficult in the past. Other
than being able to confirm that a diffusely enlarged thyroid
Ultrasound Quarterly, Vol. 17, No. 3, 2001
H. C. YEH
FIG. 23. Single bleb stage: amniotic sac. A. Endovaginal scanning shows
a small gestational sac, with average diameter of 0.7 cm, containing a
single bleb (a) that represents an amniotic sac. The primary yolk sac (y) is
also visible as it is separating from the chorionic sac. B, C, D, and E.
Drawings showing formation of single bleb and double bleb. B. Drawing
shows an inner cell mass (icm) within blastocyst at the time of implanta-
tion. C. Drawing shows formation of amniotic sac (a). This is the single
bleb. The roof of the amniotic sac is the early embryo, the bilaminate germ
disc (g). The primary yolk sac (py) is the lining membrane of the gesta-
tional sac. D. Drawing shows shrinking of primary yolk sac (py), which is
separating from chorionic sac. g ⳱ germ disc; a ⳱ amniotic sac. E.
Drawing shows that the yolk sac (y) has shrunken to become the same size
as amniotic sac (a). Germ disc is located between the amniotic and yolk
sacs, and the yolk sac–germ disc amniotic sac complex forms double bleb.
gland did not contain a tumor, ultrasonography is consid-
ered by some authors42 to be of little value in diagnosing
Hashimoto thyroiditis. Other authors43–45 described the ul-
trasonographic features of Hashimoto thyroiditis as a dif-
fusely hypoechoic and inhomogeneous gland. These find-
ings, however, are nonspecific. In a reported series of 360
patients44 with a diffuse hypoechoic thyroid gland, only
34.2% proved to have Hashimoto thyroiditis. Because the
patients frequently are asymptomatic, clinical assessment
may be difficult. Sailer et al.44 performed a histologic ex-
amination of surgical thyroid specimens and found Hashi-
moto thyroiditis in 81 patients. The preoperative diagnosis
for the disease had only been made in three patients.
Ultrasonography is important in diagnosing Hashimoto
 MISCONCEPTIONS IN ULTRASONOGRAPHY
thyroiditis because of the recent discovery of a new sign,
micronodulation.46 The sign is highly characteristic and
highly specific, with a positive predictive value of 94.7%.
We have been using this sign to make initial diagnoses
before clinical awareness of the disease in 41 of 57 patients.
Micronodulation indicates numerous small, hypoechoic 0.2-
to 0.3-cm nodules, which can occasionally be as large as 0.6
cm, scattered throughout the entire thyroid gland (Fig. 27).
The micronodules are frequently surrounded by a thin, hy-
perechoic rim that makes them highly recognizable. The
hyperechoic rims are caused by fibrous strands, and the
hypoechoic micronodules are caused by massive infiltration
by an exudate of lymphocytes and some plasma cells.46 In
pathology, the micronodules correspond to accentuated lob-
ules.47 The micronodules are usually more apparent on ob-
servation during actual real-time scanning than on a static
hard-copy image. During real-time scanning, as one slowly
sweeps the transducer across the thyroid gland, numerous
micronodules appearing on consecutive images and are
much more impressive than when seen on a static image.
The background echogenicity of thyroid gland in Hashi-
moto thyroiditis is usually normal (50% of cases) or slightly
decreased (26% of cases), and in only 24% of the cases, it
was moderately hypoechoic. Therefore, previous descrip-
tions of a diffusely hypoechoic thyroid gland apply only to
a few cases.
Although micronodules may sometimes increase in size,
they rarely grow beyond 0.6 cm. Occasionally, masses of
various sizes may be seen in a thyroid gland with Hashi-
moto thyroiditis, and most masses are caused by this dis-
ease, as proven by fine-needle aspiration biopsy. The
masses may have a variety of echotextures, such as homo-
143
FIG. 24. True double decidual sac in patient in eighth week of
gestation. A. Sagittal endovaginal scan shows an intrauterine
gestational sac with a fetus and a yolk sac. The gestational sac
is surrounded by two layers of decidua (white arrowhead).
Small segment of uterine cavity line (UC) is seen between two
layers of decidua. B. Drawing showing true double decidual sac
(DDS) caused by marked displacement of uterine cavity (UC)
by a large gestational sac. C. Sagittal scan in a slightly different
plane shows more clearly the uterine cavity line (UC) and,
hence, the double layers of decidua (arrowhead).
geneously hypoechoic, target-shape, large hyperechoic, or a
complex mass with multiple small cystic areas. Therefore,
unlike the characteristic hypoechoic micronodules, the ul-
trasonographic features of masses caused by Hashimoto
thyroiditis may be entirely nonspecific, and needle biopsy
may be necessary for a definite diagnosis.
An increased risk of lymphoma in association with
Hashimoto thyroiditis has been reported in the literature.43
Lymphoma tends to be hypoechoic, and three such hy-
poechoic masses, which I have performed biopsy on, in
patients with this disease were caused by Hashimoto thy-
roiditis.
There is also an increased risk of papillary carcinoma, of
which I have seen a few cases, and the smallest mass was
0.8 cm (Fig. 28). They all contained stippled calcifications
caused by psammoma bodies. One should carefully evaluate
each nodule in Hashimoto thyroiditis, looking for stippled
calcifications, and if they are present, a fine-needle aspira-
tion biopsy should be performed.
THYROID CYST
Unlike renal cysts, which are common, simple thyroid
cysts with an epithelial lining are rare,48 and they are not
mentioned in some popular pathology textbooks. Most cyst-
like lesions in the thyroid gland actually have a thick wall
and represent benign colloid nodules or adenomatous nod-
ules that have undergone central cystic degeneration or
hemorrhage. The thick wall is usually isoechoic or only
slightly hyperechoic and is frequently poorly visualized
(Figs. 29,30). Therefore, the thick walls are frequently not
delineated or recognized on ultrasonography, and the cystic
Ultrasound Quarterly, Vol. 17, No. 3, 2001
144 H. C. YEH
FIG. 25. So-called double decidual sac sign in a patient at 6 weeks’ 2
days’ gestation. A. Endovaginal oblique scan of the uterus shows a double
echogenic ring, which is the so-called double decidual sac sign. Note the
uterine cavity line (white arrowheads) passes the anterior border of the
inner echogenic ring and does not run in a circle between the two echo-
genic rings. B. Longitudinal scan of the same patient shows the inner
echogenic ring actually represents the gestational sac (G), which is located
posterior to the uterine cavity line (white arrowheads). The uterine cavity
line is straight and not curved around the gestational sac (G). The outer
echogenic ring (B) actually represents the basal layer of decidua. The
decidua is thick, including the basal echogenic line (or ring) and the less
echogenic area, and not just the echogenic ring. The yolk sac is seen within
the gestational sac. The embryo is not shown in this section. From: Yeh
HC. Efficacy of the intradecidual sign and fallacy of the double decidual
sac sign in the diagnosis of early intrauterine pregnancy (letter). Radiology
1999;210:579–81.
lesions are frequently diagnosed as simply a “cyst;” there-
fore, only the cystic areas are measured for their size. Care-
ful scanning from various angles and with appropriate set-
tings with moderate contrast are important to bring out the
full detail of the thick wall and diagnose the nodule as a
mass with central cystic degeneration or hemorrhage rather
than as a simple cystic lesion. Some articles stress the un-
common occurrence of malignant tumor in thyroid
cysts.48,49 However, researchers also observe that cysts in
patients with cancer appeared to originate from necrosis of
the tumor;49 therefore, those cysts are more likely to have a
Ultrasound Quarterly, Vol. 17, No. 3, 2001
FIG. 26. Drawing depicting the formation of the double echogenic ring,
which is the so-called double decidual sac sign in a normal intrauterine
pregnancy. Left. Drawing of a sagittal scan shows a gestational sac (GS)
within the thickened posterior decidua. UC ⳱ uterine cavity line; BL ⳱
echogenic basal layer of decidua. Top right. Drawing of a transverse scan
again shows a gestational sac (GS) within the posterior decidua. A dashed
line indicates the scanning plane of the drawing in top right. Bottom
right. Drawing of oblique scan shows a double echogenic ring appearance
of the so-called double decidual sac sign. The inner echogenic ring repre-
sents the gestational sac (GS) (or choriotrophoblastic ring), and the outer
echogenic ring represents the basal layer (BL) of the decidua. The uterine
cavity line (UC) passes anterior to the gestational sac.
thick wall. Small cystic lesions smaller than 0.3 cm usually
represent dilated follicles and not true cysts (Fig. 31).
RECANALIZATION OF UMBILICAL VEIN
In adults, the umbilical vein is usually completely oc-
cluded, at least in its distal part, and becomes a fibrotic
cord-like structure, i.e., a round ligament. A remnant (or
vestige) of the umbilical vein of up to 10 cm in length may
be seen in 50% of healthy individuals.50 This is called
Baumgarten’s recess. Therefore, visualization of a short
segment of a patent umbilical vein within the round liga-
ment does not indicate portal hypertension. Baumgarten’s
recess is usually small but may be more prominent in cir-
rhosis, and it is always smaller than 3 mm in diameter.51
The inferior part of the round ligament is always occluded,
even in cirrhotic patients.50 Usually, there are one or two
paraumbilical veins connected to Baumgarten’s recess. This
is called Burrow’s vein, which is one of the three groups of
paraumbilical veins. The commonly described paraumbili-
cal vein is called Sappey’s inferior vein.52 The veins are
located in the extraperitoneal space of the anterior abdomi-
nal wall and communicate with inferior epigastric veins and
cutaneous veins at the umbilical region. As they ascend, the
veins traverse the inferior part of the falciform ligament,
running alongside the round ligament within the falciform
ligament (Fig. 32), and enter the liver to communicate with
the portal system in a variety of pathways. There can be one
or a few tiny collapsed paraumbilical veins in healthy indi-
viduals.50 They are usually not visualized by color Doppler
ultrasound. In portal hypertension, the paraumbilical veins
 MISCONCEPTIONS IN ULTRASONOGRAPHY 145

FIG. 27. Micronodules: variation in size in four different patients with Hashimoto thyroiditis. A. Tiny micronodules, smaller than 0.2 cm. B. Small
micronodules (0.2 cm). C. Moderate micronodules (0.25–0.35 cm). D. Large micronodules (0.3–0.4-cm). From: Yeh HC, et al. Micronodulation:
Ultrasonographic sign of Hashimoto thyroiditis. J Ultrasound Med 1996;15:813–9.

engorge to allow collateral circulation. In 24 patients with
portal hypertension and paraumbilical collateral circulation,
Lafortune et al.50 found on umbilicoportography that most
patients (91.7%) had a single, dilated, paraumbilical vein,
and only two patients showed two veins. In all of our 27
patients, ultrasonography showed only a single vein.
The extrahepatic systemic connections of paraumbilical
veins have rarely been investigated in the past, and some
authors suggest in their illustrations that the vein connects
directly to the inferior vena cava at the umbilical region.53
Based on our research of 27 patients, there are at least four
types of pathways, none through the inferior vena cava54
(Fig. 33). The most common pathway is through the left,
right, or both external iliac veins (Fig. 34) via the inferior
epigastric veins within the extraperitoneal fat space (Fig.
35). In the second common pathway, the vein makes a sharp
turn upward to connect to the innominate vein in the chest
via the superior epigastric vein. In the third type, the vein
divides after exiting from the liver to connect to both the
external iliac vein inferiorly and the innominate vein supe-
riorly. The least common pathway is the greater saphenous
vein connecting via the superficial epigastric vein in the
subcutaneous space.
HYPERECHOIC STROMA IN POLYCYSTIC
OVARIAN SYNDROME
Polycystic ovarian syndrome (PCOS) is one of the most
common ovarian abnormalities in women of reproductive
age. It is one of the most important causes of irregular
menstruation, amenorrhea, and infertility in women. Ultra-
sonography has an important role in the diagnosis of PCOS.
Hyperechoic stroma in the ovaries has been considered one
of the most important ultrasonographic signs for the diag-
nosis of PCOS by many researchers.55–58 In fact, I have
rarely seen a truly hyperechoic stroma in patients with
PCOS. With PCOS, there are always multiple, moderate-
size, developing follicles, usually 0.5 to 0.8 cm, and there is
through transmission of ultrasound beams through the fol-
licles. This results in a hyperechoic area in the ovarian
stroma behind the follicles. For areas not behind the fol-
licles, the echotexture of the stroma is similar to that of the

Ultrasound Quarterly, Vol. 17, No. 3, 2001

146 H. C. YEH
FIG. 28. Hashimoto thyroiditis with a papillary carcinoma. A. Sagittal
scan of right lobe of thyroid shows numerous hypoechoic micronodules in
the thyroid gland. A hypoechoic mass (arrowheads) is seen on the anterior
surface of the lower pole of the right lobe of thyroid gland. Multiple
stippled calcifications are seen in the mass, which is highly suspicious for
papillary carcinoma. B. Transverse scan shows more clearly the multiple
stippled calcifications within the mass (arrowheads). Biopsy was per-
formed with a 25-gauge needle on the mass, which proved to be a papillary
carcinoma.
uterus and is not hyperechoic (Fig. 36). This effect can be
observed in the illustrated figures of the articles in which the
authors claim to have observed hyperechoic ovarian stroma
in PCOS.55,58 Therefore, the so-called hyperechoic stroma
as the most important sign for PCOS actually is caused by
through-transmission artifact. The most important diagnos-
tic sign for PCOS is multiple (more than five, based on our
research)59 developing follicles in each ovary. The size of
the ovary may not be important because in more than 25%
of patients, the ovaries are normal in size.59 In healthy in-
dividuals, one ovary may sometimes contains more than
five moderate-size, developing follicles; however, the other
ovary usually contains less developing follicles. After ovu-
lation, the follicles resorb and mostly disappear. But, new
follicles may appear during the next menstrual cycle. In
PCOS, patients may not have menstruation, or they may
have anovulatory cycles and the developing follicles may
Ultrasound Quarterly, Vol. 17, No. 3, 2001
FIG. 29. Cystic lesion of the thyroid gland. A. Sagittal scan of right lobe
shows a lesion possibly representing a simple cyst. B. Scanned more care-
fully, an isoechoic thick wall (between [+]) is delineated. C. After aspira-
tion, a solid mass (arrowheads) with a collapsed slit-like central cystic area
is seen. Aspiration at this time gained more tissue than did aspiration of the
cystic fluid.
not resorb. This results in more developing follicles in both
ovaries than in normal individuals.
DIAPHRAGMATIC SLIP SIMULATES
LIVER MASS
A diaphragmatic slip is a fold or strip of muscle protrud-
ing from the inferior surface of the diaphragm. In ultraso-
nography, a diaphragmatic slip frequently simulates a liver
mass60–62 (Figs. 37–39). The mass becomes more promi-
nent during deep inspiration because the diaphragmatic slip
will enlarge because of muscular contraction, forming a
deeper fold (Fig. 37). The mass may appear irregular in
shape, with heterogeneous echoes, or it may have a smooth
contour. An indentation may be seen on the superior surface
of the diaphragm at the diaphragmatic slip, especially dur-
ing inspiration, and a small piece of gas-containing lung
may be seen entering the indentation. It is more commonly
seen in the right anterior aspect of the dome of the dia-
phragm. Multiple, equally spaced diaphragmatic slips also
may be seen (Fig. 39). In the presence of subphrenic ascites,
a diaphragmatic slip may simulate a peritoneal tumor im-
plant on the inferior surface of the diaphragm60 (Fig. 38).
Ultrasonographic diagnosis can be easily performed by
slowly rotating the transducer during scanning (Figs.
 MISCONCEPTIONS IN ULTRASONOGRAPHY
FIG. 30. Complex thyroid mass. A. Lesion in the thyroid gland was
initially considered a cyst (arrowheads) with internal echoes. B. On careful
scanning, a thick, solid, isoechoic wall (arrowheads) is seen, indicating that
this is a mass with central cystic degeneration.
37,38). The diaphragmatic slip will become elongated and
can be seen obliquely across the diaphragm. The elongated
diaphragmatic slip contains multiple linear echoes, usually
up to four, caused by two layers of diaphragm (Figs. 37,38).
This feature is diagnostic for a diaphragmatic slip, and when
this is seen, a tumor can be excluded. When multiple dia-
phragmatic slips are seen, one may observe scalloping of the
diaphragm during deep inspiration (Fig. 39).
FIG. 31. Small cyst in the thyroid gland. Transverse scan shows a 0.2-cm
cyst (arrowhead) in the thyroid gland. This most likely represents an en-
larged follicle.
147
FIG. 32. Paraumbilical vein. A. Transverse scan of the epigastrium
shows the falciform ligament (f) just below the liver. The round ligament
(r) is at its posterior margin, and a slightly prominent paraumbilical vein (v)
is adjacent to the round ligament. B. Drawing of the view from within the
anterior abdominal wall. f ⳱ falciform ligament; r ⳱ round ligament; v ⳱
paraumbilical vein; D ⳱ diaphragm.
ABDOMINAL AORTIC ANEURSYM
There are some controversies and pitfalls pertaining to
abdominal aortic aneurysm. An abdominal aortic aneurysm
has been frequently defined as a focal dilatation of the ab-
dominal aorta to larger than 2.966,67 or 3 cm63–65 in diam-
eter. The size of normal aorta is highly variable and can be
as small as 1.2 cm in diameter in adults (Fig. 40). It is
usually larger superiorly, especially proximal to the renal
arteries. The normal aorta gradually tapers off distally.68
Focal dilatation of 3 cm compared with an aorta of 1.2 cm
is a 150% increase in diameter, but compared with an aorta
of 2.5 cm, there is only a 20% increase in diameter. There-
fore, the size of an aneurysm may have different clinical
significance in different patients. Other authors69–71 define
the diameter of the abdominal aorta as a ratio of more than
1.5, i.e., focal dilatation of the aorta with at least a 50%
increase in diameter compared with the expected normal
diameter of the aorta. In this regard, normal arterial diam-
eters determined from selected data in the literature should
be considered.69 Given the assumption that arterial (or aor-
tic) diameter proximal to a dilatation is normal, increase in
diameter greater than 50% of the artery proximal to the
Ultrasound Quarterly, Vol. 17, No. 3, 2001
148 H. C. YEH

FIG. 33. Drawings show four major types of

paraumbilical systemic collateral venous cir-
culation. pu ⳱ dilated paraumbilical vein; ie
⳱ inferior epigastric vein; sfe ⳱ superficial
epigastric vein; se ⳱ superior epigastric vein;
it ⳱ internal thoracic vein (internal mammary
vein). From: Yeh HC, et al. Paraumbilical ve-
nous collateral circulations: color Doppler ul-
trasound features. J Clin Ultrasound 1996;24:
359–66.

dilatation may also be considered an aneurysm.69 However,
because all aneurysms grow from small size, all small fo-
cal dilatations of the aorta should be reported. Because pa-
tients are usually asymptomatic before the rupture of an
aneurysm, and because the mortality rate of spontaneous
rupture of an aortic aneurysm is high (>70%),72 patients
who have a small aneurysm with a diameter ratio smaller
than 1.5 should be followed-up to prevent spontaneous rup-
ture of aneurysms. Therefore, defining an abdominal aortic
aneurysm to be more than 3 cm in diameter or as having more
than 1.5 in diameter ratio is indeed not appropriate. A smaller
focal dilatation should also be included with the term “aneu-
rysm,” but at the same time, one should include diameter ratio

FIG. 35. In a patient with type 1A paraumbilical systemic collateral venous

FIG. 34. Sagittal scan just superior to the left inguinal region shows the
left inferior epigastric vein (IEGV) joining the external iliac vein (EIV).
There are mixed color Doppler signals at the junction of the two veins
caused by turbulence. From: Yeh HC, et al. Paraumbilical venous collateral
circulations: color Doppler ultrasound features. J Clin Ultrasound 1996;
24:359–66.
circulation, a sagittal scan of the anterior abdominal wall just above the
umbilicus shows a dilated inferior epigastric vein in the extraperitoneal fat
space, i.e., posterior to the rectus muscle (M) and anterior to the peritoneum
(P). There is a small amount of ascites (a). Note that the distended vein
displaces the peritoneum posteriorly. From: Yeh HC, et al. Paraumbilical
venous collateral circulations: color Doppler ultrasound features. J Clin Ul-
trasound 1996;24:359–66.

Ultrasound Quarterly, Vol. 17, No. 3, 2001

 MISCONCEPTIONS IN ULTRASONOGRAPHY
FIG. 36. Normal echogenicity of ovarian stroma in polycystic ovarian
syndrome. A. Transverse endovaginal scan shows numerous, prominent,
developing follicles in the right ovary. There is a highly echogenic area
(arrowhead) medially in the ovary caused by through transmission artifact
distal to a prominent follicle. In the area (open arrow) where no near-field
follicle is seen, the ovarian stroma has the same echogenicity as the uterus
(U) does. B. Transverse scan of left ovary shows a similar appearance as
in right ovary, i.e., echogenic area (arrowhead) is distal to follicles, and in the
area not behind the follicle, the echogenicity is the same as in the uterus (U).
149
or percentage of dilatation. In my experience, focal dilata-
tion of 2.5 cm or less or less than 1.5 in diameter ratio is
quite common. We should diagnose these small aneurysms
and not completely ignore them. Cook and Gallard73 re-
ported a mean growth rate of aneurysm in the 2.5- to 3.9-cm
group to be 2.2 mm during the first year, 2.8 mm during the
second year, and 1.8 mm during the third year. Correspond-
ing growth rates in the 4- to 4.9-cm group were 2.7 mm, 4.2
mm, and 2.2 mm for the first, second, and third years,
respectively. They suggest a policy of annual screening for
aneurysms measuring 2.5 to 2.9 cm and six monthly screen-
ings for those ⱖ4 cm. The growth rate for aneurysms
smaller than 2.5 cm is not known, but they probably should
be screened annually or at least biannually. The risk factors
associated with rapid expansion should also be considered
when determining the interval for follow-up examination.
According to Chang et al.,74 the risk factors for rapid ex-
pansion are advanced age, severe cardiac disease, previous
stroke, and history of cigarette smoking.
The measurement of an abdominal aortic aneurysm has
been considered to be more accurate on CT than on ultra-
sonography,72 and ultrasonographic measurements are fre-
quently performed on transverse images. Correct measure-
ment on ultrasonography is frequently more accurate than
on CT without high-resolution, three-dimensional recon-
struction, and the measurement on sagittal or coronal im-
FIG. 37. Diaphragmatic slip
simulates a liver mass. A. Sagittal
scan of the right lobe of the liver
shows a mass-like lesion (white
arrowheads) at the dome of the
liver. B. Scanning during deep in-
spiration, the lesion (white arrow-
heads) becomes more prominent.
It is associated with an indenta-
tion (black arrowhead) of the dia-
phragm superior to the lesion.
The indentation contains gas that
may represent lung. C. Rotating
the transducer while scanning,
the lesion (white arrowheads) be-
comes elongated and finally ap-
pears to run obliquely across the
diaphragm. It contains linear ech-
oes. This confirms the lesion to
be a diaphragmatic slip.
Ultrasound Quarterly, Vol. 17, No. 3, 2001
FIG. 38. Diaphragmatic slip
simulates peritoneal masses. A.
Sagittal scan of right hemidia-
phragm shows large amount of as-
cites in subphrenic region. Two
mass-like lesions, a and b, are at-
tached to the inferior surface of the
diaphragm. Note the slight indenta-
tion (arrowheads) of the diaphragm
at the mass-like lesion. B. As one
rotates the transducer to the oblique
position, the lesion (a) stretch out to
become a four-line structure. This
represents two layers of diaphragm
that fold to form a band-like struc-
ture. The central two lines represent
space between two layers of dia-
phragm. Another diaphragmatic slip
(b) is also seen, but not as clearly.
C. Scanning in at a slightly different
angle, the inferior slip (b) is now
clearly visualized as a four-line
structure. D. Computed tomography
scan from a different patient shows
a diaphragmatic slip (arrowhead)
with a two-layered structure. Com-
puted tomography scan from: Yeh
HC, et al. Anatomic variations and
abnormalities in the diaphragm seen
with US. Radiographics 1990;10:
1019–30.

FIG. 39. Diaphragmatic slips associated

with scalloping of the diaphragm. A. A mass-
like lesion in the liver and some smaller pro-
trusions (small arrowheads) from the dia-
phragm represent diaphragmatic slips. B. On
deep inspiration, the diaphragmatic slips (ar-
rowheads) become more prominent because of
muscular contraction. This is associated with
indentations (arrows) of the diaphragm. Be-
tween the indentations are superior bulgings
(between arrows) of the diaphragm, i.e., scal-
loping of the diaphragm. C. Computed tomo-
gram from a different patient shows similar
findings, scalloping of the diaphragm, because
of contraction of the diaphragmatic slips (ar-
rowheads). Note that the indentations (arrows)
of the diaphragm are seen. Computed tomog-
raphy scan from: Yeh HC, et al. Anatomic
variations and abnormalities in the diaphragm
with US. RadioGraphics 1990;10:1019–30.
 MISCONCEPTIONS IN ULTRASONOGRAPHY
FIG. 40. Small aortic aneurysm. Sagittal scan of the distal abdominal
aorta shows a 1.6-cm aneurysm (arrow). The normal aorta superior to the
aneurysm measures only 1.2 cm in diameter (arrowhead). Therefore, the
aneurysm is 33.3% larger than the normal aorta.
ages is more accurate than on transverse images. To accu-
rately measure diameter, one should measure the maximum
diameter at the plane that is perpendicular to the long axis of
the aneurysm. In the supine position, the lumbar spine
curves forward distally, as does the aorta. Therefore, to
accurately measure diameter on transverse scan, one has to
151
tilt the transducer slightly caudad to obtain an appropriate
scanning plane for measuring the aneurysm. However, pre-
cisely tilting the transducer to the correct degree can be
difficult, especially if the aorta is tortuous. One may think
that an appropriate transverse scanning plane can be
determined by performing sagittal scanning, then turning
the transducer 90° to the selected point. Frequently, this is
not quite accurate, and it is much easier and more precise to
measure the maximum diameter on longitudinal scan-
ning because real-time ultrasound scanning is good for fol-
lowing the long axis of a tortuous aorta or aneurysm. One
should measure the anterior-posterior diameter on sagittal
scanning and the transverse diameter on coronal scan-
ning, the latter can be performed in the decubitus or, some-
times, the supine position. By measuring on the longitu-
dinal scan, an appropriate plane can be selected and the
maximum diameter is easier to determine. Furthermore, be-
cause lateral resolution usually is not as good as depth
resolution, and because refractory shadowing may also
obscure the lateral wall on ultrasonography, measuring
the transverse diameter on transverse section is usually less
desirable.
FIG. 41. Iliac artery aneurysm
simulates an abdominal aortic aneu-
rysm on CT. A. Computed tomogra-
phy scan shows a calcified, normal-
size aorta deviated to the right. B. An
abdominal aortic aneurysm of 5.9 cm
in transverse diameter was diagnosed
on this image. Note the multiple sur-
gical clips to the right of the aneu-
rysm. C. A 3-cm aneurysm is seen in
the left iliac artery. These were three
consecutive CT images. D. Ultra-
sound scan shows normal-size aorta
down to the bifurcation (arrow-
heads). E. Oblique scan shows a 2.5-
cm aneurysm (arrow) in the left com-
mon iliac artery. F. Drawing showing
how the left iliac aneurysm can be
mistaken for a large aortic aneurysm.
a, b, and c represent the section
planes of the CT scans on the top,
middle, and bottom left images, re-
spectively. d and e represent ultra-
sound-section planes on the top and
middle right images, respectively.
Note that in the b section plane, the
transverse diameter, including nor-
mal distal aorta and left iliac aneu-
rysm, simulates a large aortic aneu-
rysm.
Ultrasound Quarterly, Vol. 17, No. 3, 2001
152 H. C. YEH

Because most CT scans are performed in the axial plane
only, an aneurysm of a tortuous aorta can be difficult to
accurately measure. An iliac artery aneurysm may even be
mistook for a large aortic aneurysm (Fig. 41). Unless a
high-resolution, three-dimensional reconstruction is per-
formed, an accurate measurement of an aortic aneurysm on
a tortuous aorta with a complicated curve can be difficult on
CT scanning. In a tortuous aorta with a complicated curve,
one part of the aorta may be in one oblique direction and
another part in another oblique direction. When measuring
these two aneurysms, one should scan along the central axis
of each aneurysm and measure each aneurysm in two dif-
ferent images. This can be performed with ultrasonography
(Fig. 42).75 Double aneurysms adjacent to each other may
sometimes be difficult to recognized on the axial CT scan
(Fig. 42). A small aneurysm is also easily missed on CT
scan (Fig. 43).
How should the aneurysm be measured? Some people
measure from the outer wall to inner wall, from the inner
wall to inner wall,75 or with no criteria at all. Because
gray-scale ultrasound has been greatly improved, the actual
thickness of the wall of an aortic aneurysm can be clearly
delineated, unless heavy calcification is present. One should
measure from outer wall to outer wall of the aneurysm.
When the wall of the aneurysm is thick, it may result in a
significant difference in the result of measurement if the
measurements are performed from the outer wall to inner
wall or the inner wall to inner wall. The measurement of
outer wall to outer wall will correlate much better with the
surgical findings, and if one consistently measures in the
same manner each time, the progressive change of an an-
eurysm during follow-up examinations will be more pre-
cise, even if performed by a different ultrasonographer. Ac-
curate measurement of the aneurysm is important. One of
the criteria for surgical indication for abdominal aortic an-
eurysm is an increase in diameter of 1 cm over the course of
1 year. If follow-up examination is performed within 6
months or less, an increase in diameter of 0.5 cm will be
clinically highly significant. If intraobserver or interob-
server error is larger than 0.3 cm, then, when an increase in
diameter of 0.6 cm is encountered on follow-up examina-
tion, the clinical significance of this finding may be uncer-
tain. This is because this may actually mean a difference of
only 0.3 cm, or maybe up to 0.9 cm, which is highly sig-

FIG. 42. Double abdominal aortic aneurysms in a

markedly tortuous aorta causing difficult interpreta-
tion on an axial CT scan. A. Ultrasound scan shows
two aneurysms in the distal abdominal aorta. The aorta
is markedly tortuous, curved to the right, then buckled
forward toward the left, then turns to the right again.
Dashed line indicates the long axis of the aorta. Maxi-
mum external diameter (between arrowheads of the
superior aneurysm) is measured. The wall of the distal
aneurysm is not clearly delineated in this scan and,
therefore, the distal aneurysm cannot be measured ac-
curately on this scan. B. Scanning along the long axis
of distal aneurysm, now the wall of the distal aneu-
rysm (arrows), is better seen and the aneurysm can be
measured. The portion of aorta between the two an-
eurysms is also better visualized. The superior aneu-
rysm, however, is not seen along its central axis and
appears smaller. C. Left drawing shows the three-
dimensional view of the double aneurysms. Right
drawing shows three consecutive scanning planes for
CT scans in the top, middle, and bottom right images.
Dashed line ⳱ central axis of aorta and two aneu-
rysms. Dotted line ⳱ correct diameters of two aneu-
rysms measured with ultrasound. Open dotted line ⳱
maximum diameter measured on CT in bottom left
image. D, E, and F. Three consecutive CT scans from
the superior aneurysm down to the distal aneurysm.
This was read as a single aneurysm, with the maxi-
mum dimension measured at the distal aneurysm (be-
tween arrowheads). The distal aneurysm is actually
smaller than the superior one, but because of the near-
horizontal position, it was markedly overmeasured
and was thought to represent the maximum diameter
of the single aneurysm. Ultrasound measurements: su-
perior aneurysm ⳱ 5 cm, distal aneurysm ⳱ 3.7 cm.
Computed tomography measurement: only one aneu-
rysm, 6.8 cm in maximum diameter.

Ultrasound Quarterly, Vol. 17, No. 3, 2001

 MISCONCEPTIONS IN ULTRASONOGRAPHY
nificant. In my experience, when the aneurysmal wall is
clearly delineated on both sides and the measurement is
performed on proper sagittal or coronal plane, the intraob-
server error is usually less than 0.1 cm.
CONCLUSION
The term “column of Bertin” is a misnomer, and “septum
of Bertin” (or “cloisonné of Bertin”) is the proper term.
Although septum of Bertin has the same histologic structure
as renal cortex, it is usually much more echogenic than renal
cortex because of the difference in orientation of the lobules
and vessels. This is caused by the anisotropic effect.
The terms “hypertrophic column of Bertin” and “lobar
dysmorphism” should be called “junctional parenchyma,”
which represents the unresorbed renal parenchyma at the
junction of two subkidneys that fuse to form a normal kid-
ney. The renal cortex, pyramid, and septa of Bertin within
the junctional parenchyma are all normal, and there is noth-
ing hypertrophic or displaced. When the elements of the
junctional parenchyma are delineated by ultrasonography,
the diagnosis is certain and tumor can be excluded.
A true hypertrophic septum (or septa) of Bertin is usually
hyperechoic, pear-shape, and symmetrically flanked by the
pyramids. It is usually located in the anterior aspect of the
midportion of the kidney, whereas a junctional parenchyma
is usually located in the lateral aspect of the kidney at the
junction between the upper and middle thirds of the kidney.
The term “fetal lobulation” should be more properly
153
FIG. 43. Small abdominal aortic
aneurysm. A. Sagittal scan shows a
small aneurysm in the distal abdomi-
nal aorta 2.16 cm in external diam-
eter. Normal aorta superior to the an-
eurysm measures 1.71 cm, i.e., the an-
eurysm is 20.8% larger than normal.
B. Transverse scan shows an oval
(taller than it is wide) 2.42-cm aneu-
rysm. It was measured along the plane
of the solid line in A rather than the
dashed line. The dashed line is the
correct plane for measurement be-
cause it is perpendicular to the long
axis of the aorta. Note the indistinct
lateral wall of the aneurysm, which
makes it difficult to obtain an accurate
transverse diameter. C, D, and E.
Consecutive CT scans from the nor-
mal aorta to the aneurysm. Because of
the small difference in aortic caliber,
the aneurysm in E was not detected.
Note the oval shape of the aneurysm
similar to that in B.
called “fetal lobation.” To differentiate this entity from scars
and tumors, one should carefully examine each renal lobe
that consists of a pyramid overlaid by a “bump” of cortex on
the renal contour.
Milk of calcium in a renal cyst is common, contrary to the
belief that it is rare. Ultrasonography is much better than CT
for diagnosing milk of calcium, and even a tiny 0.2-cm
lesion can be detected. On CT, milk of calcium can be
mistaken for a stone or tumor. On ultrasonograph, however,
milk of calcium sometimes may mimic a stone, angiomyo-
lipoma, or cyst with calcified wall. A small bleb that first
appears in the gestational sac (single-bleb sign) represents
an embryo–amniotic sac complex and not a yolk sac.
The double decidual sac sign has been considered one of
the most important signs of an intrauterine pregnancy before
the amniotic sac, yolk sac, or embryo can be seen. In fact,
the double decidual sac sign is formed only after approxi-
mately the eighth week of pregnancy and is difficult to
delineate. Even if it is delineated, a live fetus should be
seen, and so there is no need for the double decidual sign to
diagnose an intrauterine pregnancy. The double echogenic
rings during early pregnancy do not represent the double
decidual sign.
Micronodulation is a highly specific and useful sign for
Hashimoto thyroiditis. Because of the increased incidence
of papillary carcinoma in Hashimoto thyroiditis, one should
carefully look for stippled calcifications in the nodules.
Recanalization of the umbilical vein rarely occurs. The
collateral vein seen is usually a dilated paraumbilical vein
Ultrasound Quarterly, Vol. 17, No. 3, 2001
154 H. C. YEH
that may drain through the inferior epigastric–external iliac
veins or the superior epigastric–internal thoracic veins.
Hyperechoic stroma is not a common or important sign in
polycystic ovarian syndrome. The hyperechogenicity of the
stroma is usually caused by increased through transmission
caused by the presence of multiple developing follicles.
Bilateral, multiple, developing follicles are the most impor-
tant diagnostic feature for polycystic ovarian syndrome.
Diaphragmatic slips may simulate liver masses. Scanning
along the long axis of the slip shows a band-like structure
with multiple linear echoes. This is the diagnostic feature.
Defining an abdominal aortic aneurysm as having a di-
ameter greater than 3 cm or with a diameter ratio of greater
than 1.5 will prevent many patients who have smaller an-
eurysms from needing follow-up examinations. Measure-
ment of an aneurysm should be performed on a longitudinal
scan along the long axis of the aneurysm. When the aorta is
markedly tortuous with multiple aneurysms, each aneurysm
should be measured along its own long axis.
Acknowledgment: The author thanks Ms. Gwen Hanley for her
excellent secretarial work.
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Ultrasound Quarterly, Vol. 17, No. 3, 2001