Carotid Plaque Vulnerability Assessment Using Ultrasound Elastography and Echogenicity Analysis.

OBJECTIVE: The purpose of this study was to evaluate ultrasound elastography and echogenicity analysis to discriminate between carotid plaques in patients with symptomatic internal carotid artery (ICA) stenosis versus patients with asymptomatic stenosis. SUBJECTS AND METHODS: Patients with symptomatic and asymptomatic ICA stenosis of more than 50% were recruited for the study. After both carotid arteries were scanned, plaque translation and elastography and echogenicity features were assessed. Parameters of index stenosis (i.e., symptomatic or more severe stenosis) were compared between populations. For further validation, parameters of index stenosis were also compared with those of the contralateral artery for segments with plaque. Segments without plaque on the index side were also evaluated between populations. ROC curve analyses were performed using a cross-validation method with bootstrapping to calculate sensitivity and specificity. RESULTS: Sixty-six patients with symptomatic (n = 26) or asymptomatic (n = 40) carotid stenoses were included. The maximum axial strain (p < 0.001), maximum axial shear strain magnitude (p = 0.03), and percentage of low-intensity of gray level (p = 0.01) of the index ICA were lower for patients with symptoms than for those without symptoms. In both groups, the contralateral ICA had translation and elastography and echogenicity parameters similar to those of the index ICA in patients with asymptomatic stenosis. The ROC curve for the detection of vulnerable plaques in patients with symptomatic stenosis was higher when ultrasound elastography and ultrasound echogenicity were used in combination than when each method was used alone (p < 0.001); a sensitivity of 71.6% and a specificity of 79.3% were obtained. CONCLUSION: This pilot study establishes the usefulness of combining elastography with echogenicity analysis to discriminate plaques in patients with symptomatic ICA stenosis versus asymptomatic stenosis.

Carotid artery intima-media thickness measurement in children with normal and increased body mass index: a comparison of three techniques.

BACKGROUND: Common carotid artery intima-media thickness is a marker of subclinical atherosclerosis. In children, increased intima-media thickness is associated with obesity and the risk of cardiovascular events in adulthood. OBJECTIVE: To compare intima-media thickness measurements using B-mode ultrasound, radiofrequency (RF) echo tracking, and RF speckle probability distribution in children with normal and increased body mass index (BMI). MATERIALS AND METHODS: We prospectively measured intima-media thickness in 120 children randomly selected from two groups of a longitudinal cohort: normal BMI and increased BMI, defined by BMI ≥85th percentile for age and gender. We followed Mannheim recommendations. We used M'Ath-Std for automated B-mode imaging, M-line processing of RF signal amplitude for RF echo tracking, and RF signal segmentation and averaging using probability distributions defining image speckle. Statistical analysis included Wilcoxon and Mann-Whitney tests, and Pearson correlation coefficient and intra-class correlation coefficient (ICC). RESULTS: Children were 10-13 years old (mean: 11.7 years); 61% were boys. The mean age was 11.4 years (range: 10.0-13.1 years) for the normal BMI group and 12.0 years (range: 10.1-13.5 years) for the increased BMI group. The normal BMI group included 58% boys and the increased BMI group 63% boys. RF echo tracking method was successful in 79 children as opposed to 114 for the B-mode method and all 120 for the probability distribution method. Techniques were weakly correlated: ICC=0.34 (95% confidence interval [CI]: 0.27-0.39). Intima-media thickness was significantly higher in the increased BMI than normal BMI group using the RF techniques and borderline for the B-mode technique. Mean differences between weight groups were: B-mode, 0.02 mm (95% CI: 0.00 to 0.04), P=0.05; RF echo tracking, 0.03 mm (95% CI: 0.01 to 0.05), P=0.01; and RF speckle probability distribution, 0.03 mm (95% CI: 0.01 to 0.05), P=0.002. CONCLUSION: Though techniques are not interchangeable, all showed increased intima-media thickness in children with increased BMI. RF echo tracking method had the lowest success rate at calculating intima-media thickness. For patient follow-up and cohort comparisons, the same technique should be used throughout.

Correction to: Carotid artery intima-media thickness measurement in children with normal and increased body mass index: a comparison of three techniques.

The original version of this article contained a mistake in Fig. 1: The old version was used during figure processing instead of the replacement. The correct figure is shown below. The original article has been corrected.

Ultrafast Myocardial Principal Strain Ultrasound Elastography During Stress Tests: In Vitro Validation and In Vivo Feasibility.

Objective myocardial contractility assessment during stress tests aims to improve the diagnosis of myocardial ischemia. Tissue Doppler imaging (TDI) or optical flow (OF) speckle tracking echocardiography (STE) has been used to quantify myocardial contractility at rest. However, this is more challenging during stress tests due to image decorrelation at high heart rates. Moreover, stress tests imply a high frame rate which leads to a limited lateral field of view. Therefore, a large lateral field-of-view robust ultrafast myocardial regularized OF-TDI principal strain estimator has been developed for high-frame-rate echocardiography of coherently compounded transmitted diverging waves. The feasibility and accuracy of the proposed estimator were validated in vitro (using sonomicrometry as the gold standard) and in vivo stress experiments. Compared with OF strain imaging, the proposed estimator improved the accuracy of principal major and minor strains during stress tests, with an average contrast-to-noise ratio improvement of 4.4 ± 2.7 dB ( p -value < 0.01). Moreover, there was a significant correlation and a very close agreement between the proposed estimator and sonomicrometry for tested heart rates between 60 and 180 beats per minute (bpm). The averages ± standard deviations (STD) of R2 and biases ± STD between them were 0.96 ± 0.04 ( p -value < 0.01) and 0.01 ± 0.03% in the axial direction, respectively; and 0.94 ± 0.02 ( p -value < 0.01) and 0.04 ± 0.06% in the lateral direction, respectively. These results suggest that the proposed estimator could be useful clinically to provide an accurate and quantitative 2-D large lateral field-of-view myocardial strain assessment at high heart rates during stress echocardiography.

Fast-marching segmentation of three-dimensional intravascular ultrasound images: a pre- and post-intervention study.

PURPOSE: Intravascular ultrasound (IVUS) is a vascular imaging technique that is used to study atherosclerosis since it has the ability to show the lumen and the vessel wall. Cross-sectional images of blood vessels are produced and they provide quantitative assessment of the vascular wall, information about the nature of atherosclerotic lesions, as well as the plaque shape and size. Due to the ultrasound speckle, catheter artifacts, or calcification shadows, the automated analysis of large IVUS data sets represents an important challenge. METHODS: A multiple interface 3D fast-marching method is presented for the detection of the lumen and external vessel wall boundaries. The segmentation is based on a combination of region and contour information, namely, the gray level probability density functions of the vessel structures and the intensity gradient. The detection of the lumen boundary is fully automatic. The segmentation method includes an interactive initialization procedure of the external vessel wall border. The segmentation method was applied to 20 in vivo IVUS data sets acquired from femoral arteries. This database contained three subgroups: Pullbacks acquired before balloon angioplasty (n=7), after the intervention (n=7), and at a 1 yr follow-up examination (n=6). Results were compared to validation contours that were manually traced by two experts on more than 1500 individual frames. RESULTS: For all subgroups, no significant difference was found between the area measurements of the segmentation and validation contours for the lumen and external vessel wall. Moreover, high intraclass correlation coefficients (> 0.96) between the area of the manually traced contours and detected boundaries with the fast-marching method were obtained for both vessel layers over the whole database. The segmentation performance was also evaluated with point-to-point contour distances between segmentation results and manually traced contours. A good overall accuracy was obtained with average distances < 0.13 mm and maximum distances < 0.46 mm, indicating a good performance in regions lacking information or containing artifacts. Only small differences of less than a pixel (0.02 mm) were observed between the average distance metrics of each subgroup, which prove the segmentation consistency. CONCLUSIONS: This new IVUS segmentation method provides accurate results that correspond well to the experts' manually traced contours, but requires much less manual interactions and is faster.

Parameterized Strain Estimation for Vascular Ultrasound Elastography With Sparse Representation.

Ultrasound vascular strain imaging has shown its potential to interrogate the motion of the vessel wall induced by the cardiac pulsation for predicting plaque instability. In this study, a sparse model strain estimator (SMSE) is proposed to reconstruct a dense strain field at a high resolution, with no spatial derivatives, and a high computation efficiency. This sparse model utilizes the highly-compacted property of discrete cosine transform (DCT) coefficients, thereby allowing to parameterize displacement and strain fields with truncated DCT coefficients. The derivation of affine strain components (axial and lateral strains and shears) was reformulated into solving truncated DCT coefficients and then reconstructed with them. Moreover, an analytical solution was derived to reduce estimation time. With simulations, the SMSE reduced estimation errors by up to 50% compared with the state-of-the-art window-based Lagrangian speckle model estimator (LSME). The SMSE was also proven to be more robust than the LSME against global and local noise. For in vitro and in vivo tests, residual strains assessing cumulated errors with the SMSE were 2 to 3 times lower than with the LSME. Regarding computation efficiency, the processing time of the SMSE was reduced by 4 to 25 times compared with the LSME, according to simulations, in vitro and in vivo results. Finally, phantom studies demonstrated the enhanced spatial resolution of the proposed SMSE algorithm against LSME.

In vitro in-stent restenoses evaluated by 3D ultrasound.

The purpose of this study was to quantify in-stent restenoses with 3D B mode and power Doppler ultrasound (U.S.) imaging. In-stent restenoses were mimicked with vascular phantoms in which a nonferromagnetic prototype stent (Boston Scientific) and a ferromagnetic clinical stainless steel stent (Palmaz P295) were embedded. Each phantom had an 80% in-stent stenosis and a 75% stenosis located outside the stent. These phantoms were compared to a reference phantom reproducing both stenoses without stent. Data sets of 2D cross-sectional U.S. images were acquired in freehand scanning using a magnetic sensor attached to the U.S. probe and in mechanical linear scanning with the probe attached to a step motor device. Each 2D image was automatically segmented before 3D reconstruction of the vessel. Results indicate that the reference phantom (without stent) was accurately assessed with errors below 1.8% for the 75% stenosis and 3.2% for the 80% stenosis in both B mode and power Doppler for the two scanning methods. The 80% in-stent stenoses in Boston Scientific and Palmaz stents were, respectively, evaluated at 73.8 (+/-3.2)% and 75.8 (+/- 3)% in B mode and at 82 (+/- 2.5)% and 86.2 (+/- 6.4)% in power Doppler when freehand scans were used. For comparison, when linear scans were selected, in-stent stenoses in the Boston Scientific or Palmaz stent were, respectively, evaluated at 77.4 (+/- 2.0)% and 73.8 (+/- 2.5)% in B mode and at 87.0 (+/- 1.3)% and 85.6 (+/- 5.8)% in power Doppler. To conclude, 3D freehand U.S. is a valuable method to quantify in-stent restenoses, particularly in B mode. It is thus hoped that, in the clinical setting, noninvasive 3D U.S. may provide sufficient precision to grade in-stent restenoses.

Atherosclerotic carotid bifurcation phantoms with stenotic soft inclusions for ultrasound flow and vessel wall elastography imaging.

As the complexity of ultrasound signal processing algorithms increases, it becomes more difficult to demonstrate their added value and thus robust validation strategies are required. We propose a method of manufacturing ultrasonic vascular phantoms mimicking an atheromatous plaque in an internal carotid artery bifurcation for applications in flow imaging and elastography. During the fabrication process, a soft inclusion mimicking a stenotic lipid pool was embedded within the vascular wall. Mechanical testing measured Young's moduli of the vascular wall and soft inclusion at 342 ± 25 kPa and 17 ± 3 kPa, respectively. B-mode, color Doppler, power Doppler, shear wave elastography, and strain elastography images of the different phantoms were produced to show the validity of the fabrication process. Because of their realistic geometries and mechanical properties, those phantoms may become advantageous for fluid-structure experimental modeling and validation of new ultrasound-based imaging technologies.

Characterization of atherosclerotic plaques and mural thrombi with intravascular ultrasound elastography: a potential method evaluated in an aortic rabbit model and a human coronary artery.

Plaque rupture is correlated with the plaque morphology, composition, mechanical properties, and with the blood pressure. Whereas the geometry can accurately be assessed with intravascular ultrasound (IVUS) imaging, intravascular elastography (IVE) is capable of extracting information on the plaque local mechanical properties and composition. This paper reports additional IVE validation data regarding reproducibility and potential to characterize atherosclerotic plaques and mural thrombi. In a first investigation, radio frequency (RF) data were acquired from the abdominal aorta of an atherosclerotic rabbit model. In a second investigation, IVUS RF data were recorded from the left coronary artery of a patient referred for angioplasty. In both cases, Galaxy IVUS scanners (Boston Scientific, Freemont, CA), equipped with 40 MHz Atlantis catheters, were used. Elastograms were computed using two methods, the Lagrangian speckle model estimator (LSME) and the scaling factor estimator (SFE). Corroborated with histology, the LSME and the SFE both clearly detected a soft thrombus attached to the vascular wall. Moreover, shear elastograms, only available with the LSME, confirmed the presence of the thrombus. Additionally, IVE was found reproducible with consistent elastograms between cardiac cycles (CCs). Regarding the human dataset, only the LSME was capable of identifying a plaque that presumably sheltered a lipid core. Whereas such an assumption could not be certified with histology, radial shear and tangential strain LSME elastograms enabled the same conclusion. It is worth emphasizing that this paper reports the first ever in vivo tangential strain elastogram with regards to vascular imaging, due to the LSME. It is concluded that the IVE was reproducible exhibiting consistent strain patterns between CCs. The IVE might provide a unique tool to assess coronary wall lesions.

Intravascular ultrasound image segmentation: a three-dimensional fast-marching method based on gray level distributions.

Intravascular ultrasound (IVUS) is a catheter based medical imaging technique particularly useful for studying atherosclerotic disease. It produces cross-sectional images of blood vessels that provide quantitative assessment of the vascular wall, information about the nature of atherosclerotic lesions as well as plaque shape and size. Automatic processing of large IVUS data sets represents an important challenge due to ultrasound speckle, catheter artifacts or calcification shadows. A new three-dimensional (3-D) IVUS segmentation model, that is based on the fast-marching method and uses gray level probability density functions (PDFs) of the vessel wall structures, was developed. The gray level distribution of the whole IVUS pullback was modeled with a mixture of Rayleigh PDFs. With multiple interface fast-marching segmentation, the lumen, intima plus plaque structure, and media layers of the vessel wall were computed simultaneously. The PDF-based fast-marching was applied to 9 in vivo IVUS pullbacks of superficial femoral arteries and to a simulated IVUS pullback. Accurate results were obtained on simulated data with average point to point distances between detected vessel wall borders and ground truth <0.072 mm. On in vivo IVUS, a good overall performance was obtained with average distance between segmentation results and manually traced contours <0.16 mm. Moreover, the worst point to point variation between detected and manually traced contours stayed low with Hausdorff distances <0.40 mm, indicating a good performance in regions lacking information or containing artifacts. In conclusion, segmentation results demonstrated the potential of gray level PDF and fast-marching methods in 3-D IVUS image processing.

Development of a photoacoustic, ultrasound and fluorescence imaging catheter for the study of atherosclerotic plaque.

Atherosclerotic cardiovascular diseases are a major cause of death in industrialized countries. Molecular imaging modalities are increasingly recognized to be a promising avenue towards improved diagnosis and for the evaluation of new drug therapies. In this work, we present an acquisition system and associated catheter enabling simultaneous photoacoustic, ultrasound and fluorescence imaging of arteries designed for in vivo imaging. The catheter performance is evaluated in tissue-mimicking phantoms. Simultaneous imaging with three modalities is demonstrated at frame rates of 30 images per second for ultrasound and fluorescence and 1 image per 13 seconds for photoacoustic. Acquired radio-frequency ultrasound data could be processed to obtain radial strain elastograms. With motorized pullback, 3D imaging of phantoms was performed using the three modalities.

Performance evaluation of a medical robotic 3D-ultrasound imaging system.

3D-ultrasound (US) imaging systems offer many advantages such as convenience, low operative costs and multiple scanning options. Most 3D-US freehand tracking systems are not optimally adapted for the quantification of lower limb arterial stenoses because their performance depends on the scanning length, on ferro-magnetic interferences or because they require a constant line of sight with the US probe. Robotic systems represent a promising alternative since they can control and standardize the 3D-US acquisition process for large scanning distances without requiring a specific line of sight. The performance of a new prototype medical robot, in terms of positioning and inter-target accuracies (i.e., difference between measurements and ground truth values) was evaluated with a lower-limb mimicking phantom throughout the robot workspace. The teach/replay repeatability (i.e., difference between taught and replayed points) was also assessed. A mean positioning accuracy between 0.46 mm and 0.75 mm was found on all scanning zones. The mean inter-target distance accuracy varied between 0.26 mm and 0.61 mm. Teach/replay repeatability below 0.20mm was also obtained. Additionally, a 3D reconstruction of in-vitro stenoses was performed with the robotic US scanner. The quantification error of a 80% area reduction (AR) stenosis was 3.0%, whereas it was -0.9% for a less severe 75% AR stenosis. Altogether, these results suggest that the robot may be of value for the clinical evaluation of lower limb vessels over long and tortuous segments starting from the iliac artery down to the popliteal artery below the knee.

Automatic 3D segmentation of intravascular ultrasound images using region and contour information.

Intravascular ultrasound (IVUS) produces images of arteries that show the lumen in addition to the layered structure of the vessel wall. A new automatic 3D IVUS fast-marching segmentation model is presented. The method is based on a combination of region and contour information, namely the gray level probability density functions (PDFs) of the vessel structures and the image gradient. Accurate results were obtained on in-vivo and simulated data with average point to point distances between detected vessel wall boundaries and validation contours below 0.105 mm. Moreover, Hausdorff distances (that represent the worst point to point variations) resulted in values below 0.344 mm, which demonstrate the potential of combining region and contour information in a fast-marching scheme for 3D automatic IVUS image processing.