Vascular anomalies are classified into vascular tumors and vascular malformations. Vascular tumors demonstrate endothelial cell hyperplasia (commonest is infantile hemangioma) and tend to involute. In contrast, malformations have flattened endothelial cells and do not involutes spontaneously [12].
The ultrasound examination, however, has intrinsic limits. It cannot clearly define the limits in the case of very extensive and deep lesions, and it presents difficulties in exploring some areas such as those near bony and air-filled structures [13].
Cerbu et al. [14] concluded that most used imaging technique for diagnosing vascular anomalies in children is the U/S.
In our study; we aimed to determine the effectiveness and accuracy of U/S and color Doppler examination in evaluation of vascular anomalies, we enrolled 60 patient who met the inclusion criteria, there mean age was 12.2 ± 9.5 years.
Gender prevalence
Our study included 42 female and 18 male with the ratio 3:1, this agreed with the revised ISSVA 2014 classifications of vascular anomalies which showed same ratio of vascular anomalies seen in male and female patients (mainly in infantile hemangiomata).
Pathological entities
Our study was comprehensive and enrolled most of common vascular anomalies, in contrast to other studies as in Flors et al. [7], who were more concerned by venous malformations and Ballah et al. [15] who did their study about lymphatic malformations.
Lesion location
In our study, we found that 67% of the lesions were in the head and neck, 25% of the lesions were in extremities, and 8% were in the trunk.
Flors et al. [7] illustrated that venous malformations occur in the head and neck with 40% percentage, the trunk (20%), extremities encompass approximately 40%.
Lesions detection and classifications
I-Venous malformations
In our study, we compared the definition of venous malformations between two modalities U/S, color Doppler and MR examinations, we found that U/S can define 100% of lesions dimensions as well as lesions characterization, U/S had the superiority in determining the type of flow either low or high, it had superiority in the detection of cystic spaces and assessing the compressibility of lesions, MR imaging had advantage in the detection of larger and deeper lesions extent, Samadi and Salazar [1]; stated that US evaluation was the first modality for diagnosis of VM, MRI can provide significant information for treatment planning and improvement of symptoms (Figs. 7, 8).
II-Lymphatic malformations
In our study, we compared the extent and characterization of lymphatic malformations between U/S and MR examination, we found that U/S have superiority detection of cystic spaces and compressibility of the lesions, it was superior in the classification of lymphatic malformations, MR imaging had advantage in detection of deeper lesions and retro-orbital lesions.
Lymphatic malformations were represented in our study and were efficiently seen and diagnosed by U/S imaging (Figs. 9, 10).
III. High flow arterial malformations
In high flow arterial malformations, U/S and color Doppler were compared to angiography either CT or conventional, and they agreed in diagnosis of high flow malformations and showing their extensions; yet, angiography showed detailed assessment of the supplying arteries, and interventional angiography was used in therapy, No significant statistical difference between the two modalities in the detection of high flow malformations.
In this study, high flow arterial malformation showed by U/S moderate-sized vessels detected in soft tissues was detected, by color Doppler high flow was seen inside these vessels reaching 2.8 m/s with low resistivity indices (Figs. 11, 12).
V. Infantile hemangioma
Correlation between clinical data of infantile hemangioma and US accuracy, US and Doppler examination were able to detect nine cases of infantile hemangioma as well as the two cases of congenital hemangioma.
Infantile hemangiomata were presented in this study. It showed echogenic soft tissue and increased its internal vascularity in the patient's first visit (proliferative phase), follow-up in this case (after 2 years and 8 months) after oral propranolol treatment showed that the lesion became more echogenic and had subtle residual vascularity, prolonged periods of follow-up were due to COVID 19 lockdown, closing the outpatient clinics and reserving hospitals for only emergency cases (Figs. 13, 14).
In our study, U/S and color Doppler were an efficient tool to exclude swellings that were not vascular in origin; eg: fibrous tumors, dermal lesions, cysts…etc.
Treatment and follow-up
In this study, follow-up of 43 patients was done after treatment; 34 received bleomycin by intra-lesional direct injection (U/S guided), and 2 received endovascular sclerosing agent (Glue) (angiographic guided), 5 received propranolol, and 2 received corticosteroids injections intra-lesional.
Interval follow-up
In our study, follow-up of our patients was done by U/S every 1-month post-medications and 1 month post-intra-lesional injections, unless post-injection complaint was reported; as sudden onset of pain, acute redness, hotness progressive enlargement.
Hassan et al. [16] had done follow-up U/S and color Doppler examinations every 3 to 4 weeks; However, Mathur et al. [17] followed their patient's every 2 weeks. From our experience, these variations can vary widely according to patient's education, distance of travelling and interventional radiologist preferences and experiences.
Complications
U/S and color Doppler examination were efficient in detecting early post-intervention complications. It detected acute superficial thrombo-phlebitis post-sclerotherapy of left pre-auricular venous malformation which was treated conservatively. Skin ulceration/discoloration in case 1 was observed after post-embolization surgical resection; it was treated by regular disinfection and sterile dressing. We observed one case of subacute intra-lesional hemorrhage in case 5 which was aspirated under general anesthesia.
Follow-up by MR was done 1 months in some cases and at the end of treatment sessions in other cases (to limit exposure to general anesthesia, prolonged examinations and to decrease cost and repeated hospital visits for our patients).
Clinical versus radiological outcome
In our studies, the clinical outcome (pre-and post-procedure photographs and the follow-up notes) in some cases exceeded the radiological outcome (U/S and MR findings), patients had satisfactory results (regarding the cosmetic disfigurement and/or pain) although sizable residual lesions were observed in follow-up U/S and MR images, we believe that this is related to the size of the lesion sclerosed from its superficial prominent component; as the deeper component may be non-visualized and asymptomatic.