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Reverberation Effect: When Is It Thrombus And When Is It Artifact? Case Report And Review Of Literature.
Ashley Rosenberg1, Jeff Plum2, Michael F. Amendola, MD2.
1Ashley Rosenberg, Richmond, VA, USA, 2VA Medical Center/VCU Health System, Richmond, VA, USA.

Background: Despite improved image quality of ultrasound examination, identification of imagine artifacts is crucial for the correct diagnosis of patientís medical conditions. Reverberation artifact is one such effect that is created by attenuation between two specular reflections. This signal tempering can lead to complex imaging patterns that can be mistaken for a thrombus with a venous structure. Methods:We present a case of a 63-year old female who presented to our medical center for an ultrasound of her neck as a yearly follow up after thyroidectomy for thyroid cancer. Her past medical history was significant for diabetes mellitus type 2, obstructive sleep apnea, and congestive heart failure. Her thyroid cancer was papillary in nature for which she underwent a right thyroid lobe resection in 2012 and subsequent completion thyroidectomy. Her surveillance radiology department based duplex was concerning for thrombus in the left internal jugular (MOVIE 1 and 2). The patient denied any neurologic changes, weakness, dyspnea, fever or vision changes. A vascular surgery consult was obtained and a dedicated left venous duplex with Doppler examination was then undertaken in our lab. Initial B-mode image confirmed the reverberation artifact with and without enhancement (MOVIE 3 and 4). The left internal jugular vein did compress normally (IMAGE 1). Finial assessment of the left internal jugular vein with Doppler interrogation demonstrated normal flow dynamics as another confirmation ruling thrombus within the vein (MOVIE 5). Results:Venous ultrasound examination can produce false impressions of thrombus due to artifact. Reverberation can introduce a signal-dependent noise artifact which appears as a false image of thrombus. This artifact can be eliminated by altering the transducer angulation with and without compression as well as obtaining a formal Doppler exam of the vein for flow dynamics. Conclusions:As the grey scale imaging ultrasonography resolution improves, the incidence of those inappropriately diagnosed with thrombus may increase. It is of importance to examine the venous system with a dedicated Doppler exam to confirm flow limiting thrombus in addition to compression of the vein to effectively rule out venous thrombus. Vascular surgeons should be aware of this artifact and the potential limitations of simple grey scale examination of the venous system can produce.


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