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Test your knowledge with practice questions including real ultrasound cases and scenarios.
A 60-year-old man presents to the emergency department with painful lump to the back of his head. 2 weeks prior he was hit in the head with a baseball bat and recently got his sutures removed. On physical exam he has a tender and fluctuant mass. The skin exam is limited because of his hair. A point-of-care ultrasound is performed as shown above. What is the next best step?
Soft tissue ultrasound is performed using a high frequency linear transducer. In this grayscale image, the mass appears as an anechoic rounded structure making it indistinct from a cyst, seroma, hematoma, abscess or vascular anomaly. The mass is also on top of the scalp and the hyperechoic stripe of the scalp creates a mirror artifact. Performing color Doppler on any mass will identify if there is a source of blood flow within the cavity. Color Doppler can also help delineate a lymph node from other pathology. The image above is a pseudoaneurysm that formed after trauma. Pseudoaneurysms occur due to extravasation of blood outside of the vessel wall and into the peri-vascular space.
Antibiotics and follow up (A) as well as Incision and Drainage (C) are incorrect answers because this is a pseudoaneurysm. An abscess is also an anechoic or hypoechoic fluid collection within a rounded cavity and often has irregular borders. Without using color Doppler, it can be indistinguishable from other fluid filled masses. Needle aspiration (B) is also an incorrect answer because puncturing the pseudoaneurysm may cause more complications including external hemorrhage. There are a few ways to treat a pseudoaneurysm. First compress the mass using a linear transducer for approximately 20 minutes until pseudoaneurysm communication is closed. Another treatment option is injecting thrombin into the pseudoaneurysm. If the first two treatments fail then the pseudoaneurysm may require surgical intervention.