Contrast-Enhanced Ultrasound (CEUS)

Transcription

1 Contrast-Enhanced Ultrasound (CEUS) Odd Helge Gilja, MD, PhD Professor Department of Medicine Haukeland University Hospital Bergen, Norway

2 The Micro-Bubble

3 Contrast Agents - World View IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control, vol. 60, no. 1, January 2013

4 f 0 2f 0 f 0 Microbubbles

5 Sonazoid Membrane is hydrogenated egg phosphatidylserine sodium (HEPSNa) The gas is perfluorobutane (PFB)

6 Some properties of Sonazoid Narrow Size distribution Very robust: Allow for high-mi scan (0,2-0,3) Perform a post-vascular scan Use higher frequencies Phagocytosis by Kupffer cells in the liver Yanagisawa et al.

7 Fundamental Imaging

8 Harmonic Contrast Imaging

9 Fine tuning the Instrument by adjusting the MI Non-linear response from microbubbles is based on two different mechanisms: non-linear response from microbubble oscillations at low acoustic pressure, chosen to minimize disruption of the microbubbles. Low MI Imaging. high energy broadband non-linear response arising from microbubble disruption.

10 European Federation of Societies for Ultrasound in Medicine and Biology Euroson Congresses (Next: Vienna Aug 2011) Euroson Schools since 1992, No.=58 as of Sept-10 Young Investigator Awards Guidelines and Recommendations Minimum training recommendations 9 specific disciplinary guidelines Several on safety issues Contrast agents Ultraschall in der Medizin/European Journal of Ultrasound - Issue

11 New Guidelines 2008 Ultraschall/EJU 2008;29:28-44

12 New Guidelines for CEUS 2011 Ultraschall Med / EJU Aug. 2011

13 Indications - Liver Characterization of benign FLLs FNH, hemangiomas, adenomas Detection of focal lesions Metastasis Study FLL in cirrhosis Guiding of biopsies Guiding of intervention,- e.g. ablation

14 3 Phases in liver perfusion Arterial phase 0-30 sec. Portal phase sec. Sinusoidal phase 2-4 min

15 Referred from the CT-Lab Haemangioma?

16 Peripheral Globular Enhancement with slow sentripetal filling

17 Time Intensity Curves

18 Hyper-echoic Tumor

19 CEUS Arterial Phase

20 CEUS Portal Phase

21 Lesion in Liver S7

22 Haemangioma High Res

23 Portal Phase - Sonazoid

24 In Haemangiomas, be aware not to use too high MI not to focus on one lesion in all phases to scan longer than 5 min. some h. never totally fill in, but it is still benign big h. may behave atypically (thrombosis)

25 Focal Nodular Hyperplasia - FNH FNH- a centrifugal stellate branching in early arterial phase Spoke wheel pattern in approx 40% Intense homogenous uptake Iso- or hyperechoic lesion is seen in portal venous phase. With these characteristic features: sensitivity and specificity of contrast-enhanced low MI real-time US are 87.6% and 94.5%, respectively Di Stasi 1996

26 FNH

27 FNH- Arterial Phase

28 FNH

29 FNH Late Phase (Sinosoidal)

30 FLL with Doppler

31 CEUS Sonazoid - FNH

32 Arterial Phase: 12 sec.

33 Arterial Phase: 13 sec

34 Arterial Phase: 13 sec

35 Arterial Phase: 15 sec

36 CEUS Flash Central scarring

37 Liver cell adenoma Liver cell adenoma (LCA) is a rare primary benign neoplasm found mainly in young women with a history of oral contraceptive use The hypervascularity of adenomas can be demonstrated on Doppler,- sentripetal CEUS identification of the early and homogeneous hyperechoic enhancement in the periphery of the tumor, reflecting the presence of the subcapsular feeding arteries. The enhancement of LCA in the portal and late phases is nearly comparable with that of liver parenchyma, but LCA can remain slightly hypoechoic in relation to the adjacent liver

38 CEUS - Real-time Perfusion Dynamic abilities outperforms CT and MR

39 Fatty liver Dangerous!

40 A common problem: Focal Lesions in Fatty Livers

41 CEUS in FLL

42 Hyperechogenic tumors in young female 20 years

43 CEUS Biopsy showed fatty tissue

44 2 Years after

45 Cirrhotic liver and FLL - HCC? Common clinical problem Increasing incidence world-wide AFP has limited sensitivity US (and CT) without CA has low ability to detect and characterize lesions

46 The Sequence of HCC Development hepatic arterial supply abnormal arterial supply Arterial supply Portal supply portal supply LRN ~ LGDN ~ HGDN ~ e-hcc ~ wdhcc ~ classical HCC early HCC from: Matsui, Clin Hep Gastro, (based on CT-arterioportal-angiography)

47 CEUS in AIH HCC?

48 CEUS in AIH HCC? Arterial Phase

49 FLL with B-mode and Doppler

50 FLL Arterial Phase

51 Sinusoidal Phase

52 CEUS in a cirrhotic liver

53 Late Phase

54 FNH versus HCC FNH HCC

55 2. Detection of Focal Liver Lesions Hausken et al., 1999

56 Liver Metastasis? Before contrast injection

57 Liver Metastasis? After contrast injection

58 Parenchymal Phase ( 4 min)

59 High-Frequency 9 MHz LA

60 Kuppfer Phase 14 min

61 Cholangiocarcinoma

62 Cholangiocarcinoma

63 Cholangiocarcinoma Late Phase

64 Lymphoma of the Liver

65 Late phase of Lymphoma

66 Safety Considerations In general, UCA are extremely safe with a low incidence of side effects They are neither nephrotoxic nor cardiotoxic The incidence of hypersensitivity or allergic events are much lower than current X-ray or MR contrast agents It is not necessary to perform laboratory tests of renal function before administering them Contraindications: Serious cardiopulmonary disease, known allergic reaction to the agent, pregnancy

67 Conclusion Using 2. generation ultrasound contrast agents, the method is established as an important clinical tool SonoVue is easy to apply in a clinical setting and does not prolong the exam with more than 5-10 min Attention to Mechanical Index is crucial during CEUS Benign and malignant lesions of the liver and other organs can be differentiated and detected with high sensitivity and accuracy

68 Yes, we scan