Prospective evaluation of Doppler sonography to detect the twinkling artifact versus unenhanced computed tomography for identifying urinary tract calculi.

OBJECTIVES: The twinkling artifact is an emerging tool for identifying urinary tract calculi. The purpose of this prospective study was to evaluate the diagnostic accuracy of the twinkling artifact compared to unenhanced computed tomography in detecting urolithasis.
METHODS: After Research Ethics Board approval, 51 patients with flank pain from the emergency department were enrolled between November 2009 and September 2010. Patients received an unenhanced computed tomographic scan with 1.25-mm raw data and reformatted 5-mm axial and 2-mm coronal images. Blinded assessment of the urinary tract was performed with gray-scale and color Doppler interrogation. The number of calculi, location, size, kidney distance from the skin, body mass index of the patient, and sonographic image parameters were recorded.
RESULTS: There were 35 right-sided and 38 left-sided renal calculi, 14 right-sided and 21 left-sided ureteric calculi, and 6 bladder calculi (total, 114 calculi). Thirteen patients had no calculi. The average calculus size was 2.6 mm (range, 1-9 mm). There were 6 false-positive and 22 false-negative instances of twinkling artifacts. On gray-scale evaluation looking for an echogenic focus with shadowing, there were 8 false-positive and 40 false-negative findings. The positive predictive value (PPV) of the twinkling artifact for identifying calculi was 94%, and the sensitivity was 83%. The PPV of gray-scale sonographic shadowing was only 64.9%, and the sensitivity was 80.2%.
CONCLUSIONS: The twinkling artifact has a high PPV for detecting renal and urinary tract calculi. Evaluation for the twinkling artifact is a complementary technique to standard gray-scale shadowing of calculi and improves detection of urolithiasis on sonography.