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In the hands of experienced examiners, the contrast enhanced sonography (CEUS) offers the possibility to analyze dynamic microcirculatory disturbances in real time dynamically without any risk for kidneys and thyroid gland even in severe progressing disease bedside. Based on severe COVID-19 infections, first experiences with abdominal CEUS examinations are presented. In the stage of an imminent organ failure with significantly reduced kidney and liver function, CEUS can be used to show a narrowing of the organ-supplying arteries, as well as a delayed capillary filling of vessels near the capsule, a regional reduced parenchymal perfusion or an inflammatory hyperemia with capillary hypercirculation. It is possible to quickly rule out organ infarction and to dynamically record the mesenteric arterial and venous blood flow.
AIM:
Use of contrast enhanced ultrasound (CEUS) in severe cases of COVID-19 infection to assess pulmonary changes near the pleura.
MATERIAL AND METHODS:
Bedside examinations by an experienced intensive care unit examiner using a multi-frequency probe (C1-6 MHz) with B-mode and CEUS to assess pleural-near changes in severe cases of COVID-19 infection with respiratory failure. CEUS with bolus delivery via a central venous catheter of 2.4 ml Sulphur hexafluoride microbubbles from the arterial phase (10–15 s) to the late phase of 5 min. Digital storage of cine sequences of the lung sound with abdomen for independent assessment with the subsequently performed contrast-enhanced dual-source CT.
RESULTS:
In 11 intubated and ventilated patients (arithmetic mean 62 years, 48 to 78 years, 3 women) with confirmed severe COVID-19 infections, a peripherally accentuated consolidation with irregular hyperemia was found in the CEUS and also in the CT examination. Of the 5 cases with pulmonary arterial embolisms, signs of right ventricular failure were found. In all cases, using CEUS low perfused areas of the pleura with adjacent hyperemia could be detected, while, with CT segmental contrast medium, gaps with subpleural compressions were found. Interstitial changes near the pleura led to B-lines and to ground glass opacities in the CT. Near the diaphragm a delayed arterial contrast of the liver was observed. In addition, in 2 cases partial atelectasis, in 3 cases marginal pleural effusions were found.
CONCLUSION:
CEUS opens up new possibilities for bedside monitoring of pleural reactive inflammatory or peripheral thrombus embolism in severe cases of COVID-19 infection.
AIM:
To evaluate the possibilities of flow detection using high resolution flow (HR Flow) and Glazing Flow technique in patients with liver parenchymal changes and flow changes in comparison to color-coded Doppler sonography (CCDS).
MATERIAL AND METHODS:
All examinations were performed using a multi frequency matrix convex probe with high resolution technique (SC6-1U/Resona7, Mindray, Shenzhen, China) by one experienced examiner to evaluate the venous, portal venous and arterial liver flow with digital documentation of the dynamic flow parameters like peak systolic flow, end-diastolic flow and resistance index. For liver parenchymal stiffness changes shear wave elastography was performed with at least 10 measurements. By two independent readers an elevation was performed to evaluate the image quality and the degree of flow artefacts, from 0 = not available to 5 points with excellent image quality without flow artefacts.
RESULTS:
All 40 patients (24 men, 16 women, age 27–83 years, mean 56±5 years) showed morphology changes from B-Mode of the liver parenchyma to inhomogeneous tissue with higher stiffness evaluated by the shear wave elastography (1.45 m/s up to 2.79 m/s±1.79 m/s, considering F1 up to F4 fibrosis) and in 15 cases histopathologically proven liver cirrhosis. In 9 cases after non-acute thrombosis flow reduction of the portal vein was the reason for the diameter less than 5 mm. Flow parameters for the venous flow were between 8 cm/s up to 29 cm/s, mean 14±4 cm/s, for the hepatic portal vein 5 cm/s up to 57 cm/s, mean 17±5 cm/s, for the hepatic artery systolic flow between 50 cm/s up to 127±33 cm/s, end-diastolic flow from 22 cm/s up to 47±8 cm/s. Resistance index for the hepatic artery was between 0.41 up to 0.73, mean 0.67±0.25. The image quality for CCDS over all cases was evaluated for CCDS between 1 up to 4. The mean quality was 2.5±0.5, for HR Flow in combination with Glazing Flow 3±0.5, with significant differences for the 2 readers (P < 0.01).
CONCLUSION:
Combination of HR Flow with Glazing Flow could be helpful to evaluate morphological und hemodynamic changes of liver arterial flow, portal venous and venous flow. Reduction of flow artefacts in combination with a higher image quality could be helpful for optimizing the digital measurements also for follow up examinations.
The aim of this present clinical pilot study is the display of typical perfusion results in patients with solid, non-cystic breast lesions. The lesions were characterized using contrast enhanced ultrasound (CEUS) with (i) time intensity curve analyses (TIC) and (ii) parametric color maps. The 24 asymptomatic patients included were genetically tested for having an elevated risk for breast cancer. At a center of early detection of familial ovary and breast cancer, those patients received annual MRI and grey-scale ultrasound. If lesions remained unclear or appeared even suspicious, those patients also received CEUS. CEUS was performed after intravenous application of sulfur hexafluoride microbubbles. Digital DICOM cine loops were continuously stored for one minute in PACS (picture archiving and communication system). Perfusion images and TIC analyses were calculated off-line with external perfusion software (VueBox). The lesion diameter ranged between 7 and 15 mm (mean 11 ± 3 mm). Five hypoechoic irregular lesions were scars, 6 lesions were benign and 12 lesions were highly suspicious for breast cancer with irregular enhancement at the margins and a partial wash out. In those 12 cases, histopathology confirmed breast cancer. All the suspicious lesions were correctly identified visually. For the perfusion analysis only Peak Enhancement (PE) and Area Under the Curve (AUC) added more information for correctly identifying the lesions. Typical for benign lesions is a prolonged contrast agent enhancement with lower PE and prolonged wash out, while scars are characterized typically by a reduced enhancement in the center. No differences (p = 0.428) were found in PE in the center of benign lesions (64.2 ± 28.9 dB), malignant lesions (88.1 ± 93.6 dB) and a scar (40.0 ± 17.0 dB). No significant differences (p = 0.174) were found for PE values at the margin of benign lesions (96.4 ± 144.9 dB), malignant lesions (54.3 ± 86.2 dB) or scar tissue (203.8 ± 218.9 dB). Significant differences (p < 0.001) were found in PE of the surrounding tissue when comparing benign lesions (33.6 ± 25.2 dB) to malignant lesions (15.7 ± 36.3 dB) and scars (277.2 ± 199.9 dB). No differences (p = 0.821) were found in AUC in the center of benign lesions (391.3 ± 213.7), malignant lesions (314.7 ± 643.9) and a scar (213.1 ± 124.5). No differences (p = 0.601) were found in AUC values of the margin of benign lesions (313.3 ± 372.8), malignant lesions (272.6 ± 566.4) or scar tissue (695.0 ± 360.6). Significant differences (p < 0.01) were found in AUC of the surrounding tissue for benign lesions (151.7 ± 127.8), malignant lesions (177.9 ± 1345.6) and scars (1091 ± 693.3). There were no differences in perfusion evaluation for mean transit time (mTT), rise time (RT) and time to peak (TTP) when comparing the center to the margins and the surrounding tissue. The CEUS perfusion parameters PE and AUC allow a very good assessment of the risk of malignant breast lesions and thus a downgrading of BI-RADS 4 lesions. The use of the external perfusion software (VueBox, Bracco, Milan, Italy) did not lead to any further improvement in the diagnosis of suspicious breast lesions and does appears not to have any additional diagnostic value in breast lesions.
Goal of the study was the assessment of AI-assisted diagnosis of solid thyroid foci with multimodal modern ultrasound imaging. 50 patients (26–81 years, 54.7±13.1 years) were included in the study. Multimodal ultrasound imaging by means of B-mode with linear probe (4–12 MHz) with option of automated documentation of findings by means of AI, with supplementary Ultra MicroAngiography (UMA) was used. Macrovascularisation was assessed by dynamic contrast ultrasonography (CEUS) with parametric evaluation and perfusion analysis, and microvascularization was assessed by combined strain and shear wave elastography on a novel high-performance ultrasound system (Resona R9/Mindray) by an experienced examiner with independent reading. The evaluation was performed according to TI-RADS III-V.
The volume of the thyroid lobes on both sides averaged 39 ml±5 ml (27 to 69 ml). The 13 cases of histologically confirmed thyroid carcinomas (8 papillary, 2 medullary, 2 microfollicular, 1 anaplastic CA) with a mean size of 15 mm±6 mm (9–21 mm) were correctly evaluated by TI-RADS V on the basis of irregular shape, induration > 2.5 m/s or > 30kPA and striking wash-out kinetics. Tumor lymph nodes could only be correctly detected preoperatively in one case of medullary carcinoma according to the surgical findings, based on irregular vascularization with UMA in roundish shape with cortex > 4 mm, transverse diameter up to 11 mm. In 25 cases of inhomogeneous nodular goiter an evaluation with TI-RADS III was performed in 31 cases, in 4 cases with incomplete marginal contour, partial marginal vascularization with UMA and partial wash out with indurations up to 2.5 m/s 30 kPA an evaluation with TI-RADS IV and surgical excision for nodular goiter. In 12 cases regressive nodular changes without relevant malignancy criteria resulted in nodular goiter, with focal changes up to 1.5 cm in diameter, classified as requiring control with TI-RADS III. There were no relevant changes in findings in the controls after 6 months. From the AI tool, the 20/25 goiter nodes were assessed as TI-RADS III, 7/12 adenomas, 5 goiter nodes, and 5 adenomas as TI-RADS IV, 5/13 carcinomas as TI-RADS IV, and 8/13 carcinomas as TI-RADS V.
Multimodal ultrasound diagnostics supported by AI has a high diagnostic potential for the evaluation of solid thyroid lesions and standardizes the reporting with digital representative image documentation. CEUS perfusion and modern elastography techniques allow targeted follow-up of TI-RADS III findings.
BACKGROUND:
In recent years, follow-up after breast reconstruction with silicone implants and the detection of complications have been relieved by the possibility of improved diagnostic methods.
METHODS:
Between January 2015 and December 2019 a total of 40 patients (29–84 years) with silicone implants were included in this retrospective study. The implants were examined clinically and with modern imaging: general ultrasound imaging (US), magnetic resonance imaging (MRI), high resolution computed tomography (CT) and positron emission tomography –computed tomography (PET-CT). If necessary, a histological/cytological sample was taken. The breast implants were assessed by three radiologists specialized in breast imaging. The grade of capsular contracture was classified according to the Baker classification.
RESULTS:
All 40 women obtained a clinical examination and an US diagnostic to identify early and more common complications such as implant folding and capsular fibrosis. Depending on the clinical examination and ultrasound findings additional MRI (n = 10), CT (n = 9) and/or PET-CT (n = 2) were performed. 16 patients had implants folding proven with US (n = 16), MRI (n = 6) and CT (n = 1). The grade of capsular fibrosis was determined according to the Baker classification. The following results were obtained in our study: 25 breast implants with Baker grade I and eleven breast implants with Baker grade II, both proven with US; one breast implants with Baker grade III and one breast implant with Baker grade IV, proven with US (n = 2), MRI (n = 1) and CT (n = 1). One patient had intracapsular rupture and one patient had extracapsular rupture, both detected on CT and surgically proven. No patient had a silicone accumulation in the lymph nodes. One patient had pathologically enlarged axillary lymph nodes, which were evaluated as inflammatory changes in PET-CT. Long-term complications such as the development of malignant breast tumors could not be observed.
CONCLUSION:
To detect early complications after breast implant surgery, a regular clinical examination is indispensable. Imaging methods complement each other and if they are used multimodal, it is easier to identify early complications. Modern diagnostic modalities like ultrasound and magnetic resonance imaging expand the spectrum and improve diagnostic safety.
AIM:
To evaluate the use of dynamic contrast enhanced ultrasound (CEUS) with parametric color-coded imaging and time intensity curve analysis (TIC) for planning and follow-up after prostate arterial embolization (PAE).
MATERIAL/METHOD:
Before and after selective iliacal embolization by PAE with a follow up of 6 months 18 male patients (43–78 years, mean 63±3.5 years) with histopathological proven benign prostate hyperplasia were examined by one experienced examiner. A multifrequency high resolution probe (1–6 MHz) was used for transabdominal ultrasound and CEUS with bolus injections of 2.4 ml sulphur-hexafluoride microbubbles. Independent evaluation of color-coded parametric imaging before and after PAE by in PACS stored DICOM loops from arterial phase (10–15 s) up to 1min were performed. Criteria for successful treatment were reduction of early arterial enhancement by changes of time to peak (TTP) and area under the curve (AUC) by measurements in 8 regions of interest (ROI) of 5 mm in diameter at the margin and in the center and changes from hyperenhancement in parametric imaging (perfusion evaluation of arterial enhancement over 15 s) from red and yellow to blue and green by partial infarctions. Reference imaging method was the contrast high resolution 3 tesla magnetic resonance tomography (MRI) using 3D vibe sequences before and after PAE and for the follow up after 3 and 6 months.
RESULTS:
PAE was technically and clinically successful in all 18 patients with less clinical symptoms and reduction of the gland volume. In all cases color-coded CEUS parametric imaging was able to evaluate partial infarction after embolization with changes from red and yellow to green and blue colors in the embolization areas. Relevant changes could be evaluated for TIC-analysis of CEUS with reduced arterial enhancement in the arterial phase and prolonged enhancement of up to 1 min with significant changes (p = 0.0024). The area under the curve (AUC) decreased from 676±255.04 rU (160 rU–1049 rU) before PAE to 370.43±255.19 rU (45 rU–858 rU) after PAE. Time to peak (TTP) did not change significantly (p = 0.6877); TTP before PAE was 25.82±9.04 s (12.3 s–42.5 s) and after PAE 24.43±9.10 s (12–39 s). Prostate volume decreased significantly (p = 0.0045) from 86.93±34.98 ml (30–139 ml) before PAE to 50.57±26.26 ml (19–117 ml) after PAE. There were no major complications and, in most cases (14/18) a volume reduction of the benign prostate hyperplasia occurred.
CONCLUSION:
Performed by an experienced examiner CEUS with parametric imaging and TIC-analysis is highly useful to further establish prostatic artery embolization (PAE) as a successful minimal invasive treatment of benign prostatic hyperplasia.