Background: Twinkle artifact, also known as color Doppler comet-tail artifact,
occurs behind very strong, granular, and irregular reflecting interfaces such as
crystals, stones, or calcification. This is visualized as a random mixture of red and
blue pixels in the high-frequency shift spectrum located deep to the interface. Study
results have suggested that the sonographic twinkling artifact may aid in the detection
of renal stones with a variety of reference standard imaging modalities, including
abdominal radiography, excretory urography, gray-scale sonography, and CT. Material and
methods: Our retrospective observational study included children who had undergone
abdomen/renal ultrasound for kidneys stones in our radiology department between 2013 and
2019. Presence of the twinkle artifact, and stone numbers and sizes were documented. CT
examinations done <3 months prior to or after US were retrospectively assessed to
confirm the presence of kidney stones as a reference standard. Results: Thirty-three
abdominal renal US scans of 33 patients (21 males, 12 females) fulfilled the entry
criteria. The interval between the US and CT was <3 months for all patients. The
median overall age of the patients was 4 years (IQR: 3.125, range: 1– 165 months), The
median number of days between the US and CT was 13 (IQR: 26, range: 0–81 days). US
detected 33 hyperechoic foci suspected to be stones; 26 were confirmed as true positive
(i.e. showed the twinkle artifact and were seen in CT), 4 were false positive (showed
the twinkle artifact but were not seen in CT), and 3 were false negative (did not show
the twinkle artifact but were seen in CT). The overall median stone size was 2 mm in the
right kidney, and 5 mm in the left kidney (IQR: 6,11 mm), respectively. Twinkle artifact
sensitivity was found to be 89.7% (95% CI 39.574%–90%). The twinkle artifact was
assessed in all true-positive stones, determining a relatively high PPV of 26/29 (86.7%)
for the twinkle artifact. The twinkle artifact was not dependent on stone size.
Specificity for the twinkle artifact could not be calculated due to a lack of true
negatives. Conclusion: The twinkle artifact is a sensitive US tool for detecting
pediatric kidney and ureter stones, but with a small risk of false positive
findings.