Contrast-Enhanced Ultrasound (CEUS) Odd Helge Gilja, MD, PhD Professor Department of Medicine Haukeland University Hospital Bergen, Norway
The Micro-Bubble
Contrast Agents - World View IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control, vol. 60, no. 1, January 2013
f 0 2f 0 f 0 Microbubbles
Sonazoid Membrane is hydrogenated egg phosphatidylserine sodium (HEPSNa) The gas is perfluorobutane (PFB)
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.
Fundamental Imaging
Harmonic Contrast Imaging
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.
www.efsumb.org 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 4-2004
New Guidelines 2008 Ultraschall/EJU 2008;29:28-44
New Guidelines for CEUS 2011 Ultraschall Med / EJU Aug. 2011
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
3 Phases in liver perfusion Arterial phase 0-30 sec. Portal phase 30-120 sec. Sinusoidal phase 2-4 min
Referred from the CT-Lab Haemangioma?
Peripheral Globular Enhancement with slow sentripetal filling
Time Intensity Curves
Hyper-echoic Tumor
CEUS Arterial Phase
CEUS Portal Phase
Lesion in Liver S7
Haemangioma High Res
Portal Phase - Sonazoid
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)
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
FNH
FNH- Arterial Phase
FNH
FNH Late Phase (Sinosoidal)
FLL with Doppler
CEUS Sonazoid - FNH
Arterial Phase: 12 sec.
Arterial Phase: 13 sec
Arterial Phase: 13 sec
Arterial Phase: 15 sec
CEUS Flash Central scarring
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
CEUS - Real-time Perfusion Dynamic abilities outperforms CT and MR
Fatty liver Dangerous!
A common problem: Focal Lesions in Fatty Livers
CEUS in FLL
Hyperechogenic tumors in young female 20 years
CEUS Biopsy showed fatty tissue
2 Years after
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
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, 2005. (based on CT-arterioportal-angiography)
CEUS in AIH HCC?
CEUS in AIH HCC? Arterial Phase
FLL with B-mode and Doppler
FLL Arterial Phase
Sinusoidal Phase
CEUS in a cirrhotic liver
Late Phase
FNH versus HCC FNH HCC
2. Detection of Focal Liver Lesions Hausken et al., 1999
Liver Metastasis? Before contrast injection
Liver Metastasis? After contrast injection
Parenchymal Phase ( 4 min)
High-Frequency 9 MHz LA
Kuppfer Phase 14 min
Cholangiocarcinoma
Cholangiocarcinoma
Cholangiocarcinoma Late Phase
Lymphoma of the Liver
Late phase of Lymphoma
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
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
Yes, we scan