Utility of Contrast-Enhanced Ultrasound and 4-Dimensional Computed Tomography for Preoperative Detection and Localization of Parathyroid Adenomas Compared With Surgical Results.

OBJECTIVES: To investigate the accuracy, sensitivity, and specificity of contrast-enhanced ultrasound (CEUS) for detection of parathyroid adenomas and compare it to those of 4-dimensional computed tomography (4DCT), which has been established as a reliable, effective tool for preoperative localization of parathyroid adenomas. METHODS: About 27 patients with suspected parathyroid pathology underwent imaging evaluations with 4DCT and CEUS and 22 patients subsequently underwent surgical resection of parathyroid lesions. 4DCT and CEUS were performed and interpreted by consensus of two expert radiologists with extensive experience in each modality. Assessment for the side, z-axis (craniocaudal axis), and quadrant of the pathologically proven lesion was performed based on the surgical report. RESULTS: For single-gland disease, the accuracy for CEUS localization to the correct quadrant and side were 81.0 and 90.1% respectively. For single-gland disease, the accuracy for 4DCT localization to the correct quadrant and side were 81.0 and 90.5% respectively. 4DCT localization sensitivity and specificity were comparable to those for CEUS. 4DCT allowed for accurate diagnosis in multigland disease in contradistinction to CEUS. CONCLUSIONS: CEUS is a noninvasive, real-time imaging technique that has relatively high diagnostic confidence and accuracy of localization which are comparable to the accuracy of 4DCT for preoperative parathyroid adenoma detection, characterization, and localization. This technique should be considered for primary preoperative diagnosis, especially in younger patients.

Qualitative and Quantitative Contrast-enhanced Endoscopic Ultrasound Improves Evaluation of Focal Pancreatic Lesions.

BACKGROUND & AIMS: Endoscopic ultrasound (EUS) is a sensitive method to evaluate the pancreas but its diagnostic capability for several diseases is limited. We compared the diagnostic yield of unenhanced EUS with that of contrast-enhanced EUS for focal pancreas lesions and identified and tested quantitative parameters of contrast enhancement. METHODS: We performed a prospective tandem-controlled trial in which 101 patients with focal pancreas lesions (48 with masses, 28 with cysts, and 25 with pancreatitis) underwent conventional EUS followed by contrast EUS using intravenous perflutren microspheres. The diagnosis at each stage was scored and compared with a standard (findings from surgical pathology analysis, cytologic, and/or 6-month clinical follow-up evaluations). Quantitative parameters were generated by time-intensity curve analysis. Solid lesions were divided into derivation and testing cohorts for a crossover validation analysis of the quantitative parameters. The primary outcome was diagnostic yield of unenhanced vs contrast EUS in analysis of focal pancreas lesions. RESULTS: Contrast increased the diagnostic yield of EUS from 64% (65/101 lesions accurately assessed) to 91% (92/101 lesions accurately assessed); the odds ratio [OR] was 7.8 (95% CI, 2.7-30.2) for accurate analysis of lesions by contrast-enhanced EUS relative to unenhanced EUS. The contrast increased accuracy of analysis of pancreas masses (OR, 6.0; 95% CI, 1.8-31.8), improving assessment of neuroendocrine and other (non-carcinoma) tumors. Contrast increased the diagnostic yield for pancreas cysts to 96% (27/28) compared with 71.4% (20/28) for unenhanced EUS (P = .02), due to improved differentiation of mural nodules vs debris. Time-intensity curve analysis revealed distinct patterns of relative peak enhancement (rPE) and in-slope (rIS) for different lesions following contrast injection: for adenocarcinomas, values were low rPE and low rIS; for neuroendocrine masses, values were high rPE and normal IS; and for chronic pancreatitis foci, values were normal rPE and low rIS. In the validation cohort, these parameters correctly characterized 91% of lesions and improved yield relative to unenhanced EUS (OR, 10; 95% CI, 1.4-34.0). CONCLUSIONS: Contrast-enhanced EUS improves the accuracy of analysis of focal pancreas lesions, compared with unenhanced EUS. Integration of practical quantitative parameters, specifically relative peak enhancement and in-slope, might increase the diagnostic accuracy of contrast EUS. ClinicalTrials.gov no: 02863770.

Contrast-Enhanced Ultrasound Appearance of Hypervirulent Klebsiella pneumoniae Liver Abscesses.

There has been a paradigm shift with Klebsiella pneumoniae (KP) emerging as the most frequently isolated bacterium in pyogenic liver abscesses in immunocompetent patients. Colonization of this hypervirulent KP strain has led to community-acquired liver abscesses. Septic seeding to distant sites of the body has been recognized and is strongly associated with diabetes. Contrast-enhanced computed tomographic features have been described. Grayscale ultrasound (US) features remain inconclusive, with variable US appearances. Here we describe the contrast-enhanced US features of KP liver abscesses, which correlated with previously described computed tomographic findings. The use of contrast-enhanced US eliminates the need for radiation exposure.

Assessment of Fibrosis in Liver Transplant Recipients: Diagnostic Performance of Shear Wave Elastography (SWE) and Correlation of SWE Findings With Biopsy Results.

OBJECTIVE. Liver transplant patients are monitored for rejection and hepatic fibrosis and often undergo liver biopsies. The purpose of the present study is to determine whether noninvasive shear wave elastography (SWE) can quantify fibrosis in liver transplant recipients, with the aim of decreasing and possibly eliminating unnecessary biopsies for patients with suspected or progressive hepatic fibrosis. MATERIALS AND METHODS. Between May 1, 2015, and December 31, 2017, our prospective study evaluated 111 adult liver transplant patients (age range, 23-79 years) who underwent 147 ultrasound (US) SWE examinations of the right hepatic lobe followed by biopsies. SWE values were compared with the histologic fibrosis (Metavir) scores of the biopsy samples. SWE threshold values were determined using classification and regression tree analysis by anchoring to the degree of fibrosis. The sensitivity, specificity, positive predictive value, and negative predictive value (with 95% CIs) were calculated on the basis of the threshold value. Overall prediction accuracy was estimated using the AUC value from the ROC curve. RESULTS. From the 147 US SWE examinations and liver biopsies, consistent threshold values were identified for patients with no or minimal fibrosis (Metavir scores of F0 and F1, respectively) compared with significant fibrosis (Metavir scores of F2, F3, or F4). A median SWE value of 1.76 m/s or less denoted no or minimal fibrosis, whereas a value greater than 1.76 m/s denoted significant fibrosis. The sensitivity of US SWE examinations in classifying fibrosis was 0.77 (95% CI, 0.5-0.93). The specificity, positive predictive value, and negative predictive value were 0.79 (95% CI, 0.71-0.86), 0.33 (95% CI, 0.19-0.49), and 0.96 (95% CI, 0.91-0.99), respectively. CONCLUSION. Liver transplant patients may avoid liver biopsy if US SWE examination shows a median shear wave velocity of 1.76 or less, which corresponds to a Metavir score of F0 or F1, denoting no or minimal fibrosis.

The Value of Needle-Guidance Technology in Ultrasound-Guided Percutaneous Procedures Performed by Radiology Residents: A Comparison of Freehand, In-Plane, Fixed-Angle, and Electromagnetic Needle Tracking Techniques.

OBJECTIVES: Radiology residents typically learn ultrasound-guided procedures by performing supervised procedures on patients who may experience longer procedure times and higher complication rates. The purpose of this study was to determine if existing technologies, such as in-plane, fixed-angle guidance (IPFA) and electromagnetic needle tracking (ENT), can improve resident procedure time and accuracy. METHODS: Radiology residents (18 total) were randomized to 1 of 3 ultrasound-guidance technique groups-freehand, IPFA, or ENT-and instructed to place a needle into 4 liver lesions in a humanoid phantom, each increasing in difficulty. For each lesion, residents were timed from skin puncture to needle placement, and the number of times the needle was pulled back and redirected (pullbacks) was recorded. Primary outcomes were total time and total number of pullbacks for all 4 lesions. Secondary outcomes were individual time and number of pullbacks for each lesion. RESULTS: Compared to the freehand group, the IPFA and ENT groups demonstrated lower procedural time and number of pullbacks both in total and for each individual lesion. Differences in total time and total number of pullbacks were significant (P < .001), as were differences for lesion 3 (P = .002-.02) and lesion 4 (P < .001). Differences for lesions 1 and 2 were not statistically significant. CONCLUSIONS: Radiology resident procedure time and procedure accuracy (as judged by number of pullbacks) are significantly improved by the use IPFA and ENT guidance technologies.

"Bright Band Sign" A Grayscale Ultrasound Finding in Hepatic Infarction.

Hepatic infarction is infrequent due to the dual blood supply of the liver and the compensatory relationship between the hepatic artery and portal vein. Most cases occur in liver transplants due to vascular complications. Grayscale sonography combined with color and spectral wave Doppler can assess for vessel patency and parenchymal abnormalities. Liver infarctions appear as hypoechoic nonvascular regions on conventional and Doppler sonography. Here, we describe a grayscale ultrasound feature within liver infarctions in 2 liver transplants and in 1 native liver due to iatrogenic complication. This feature is similar to those described recently in the literature within splenic infarcts.

Contrast-Enhanced Ultrasound Imaging of Breast Masses: Adjunct Tool to Decrease the Number of False-Positive Biopsy Results.

OBJECTIVES: This pilot study evaluated use of contrast-enhanced ultrasound (CEUS) to reduce the number of benign breast masses recommended for biopsy. METHODS: This prospective study included 131 consenting women, from October 2016 to June 2017, with American College of Radiology Breast Imaging Reporting and Data System category 4a, 4b, and 4c masses detected by mammography, conventional ultrasound (US), or both. Contrast-enhanced US examinations (using intravenous injection of perflutren lipid microspheres or sulfur hexafluoride lipid-type A microspheres) were performed before biopsy. Qualitative and quantitative CEUS parameters were compared with reference standard histopathologic results from biopsy of 131 masses. RESULTS: There were 109 benign, 6 high-risk, and 16 malignant masses, with a median size of 12 mm (range, 4 to 48 mm) on conventional US imaging. Of 131 masses, 93 (71%) enhanced on CEUS imaging, including 73 of 109 (67%) benign, 6 of 6 (100%) high-risk, and 14 of 16 (87.5%) malignant. Thirty-eight lesions did not enhance, including 36 of 109 (33%) benign and 2 of 16 (12.5%) malignant. Prediction models using recursive petitioning revealed that CEUS may reduce 31% (95% confidence interval, 23%, 40%) of benign biopsies for masses that are: nonenhancing with circumscribed margins or enhancing with an oval shape and homogeneous enhancement. Quantitative parameters indicated that benign masses had the longest time to peak (P = .078), highest time-to-peak ratio of mass to background (P = .036), lowest peak intensity (P = .021), and smallest difference in peak intensity between the mass and background (P = .079) compared to high-risk and malignant lesions. CONCLUSIONS: Contrast-enhanced US may be a valuable modality that can be used to predict benign pathologic results of breast masses, thereby reducing the number of biopsies.

An Objective Computer-Assisted Measurement of Sonographic Renal Cortical Echogenicity: The Splenorenal Index.

ABSTRACT: Renal cortical echogenicity represents a marker of renal function. However, evaluation of the renal echotexture is subjective and thus disposed to error and interrater variability. Computer-aided image analysis may be used to objectively assess renal cortical echogenicity by comparing the echogenicity of the left kidney to that of the spleen; the resultant ratio is referred to as the splenorenal index (SRI). We performed a retrospective review of all adult patients who received a renal ultrasound over a 45-day period at our institution. Demographic data and kidney function laboratory values were documented for each patient. Regions of interest (ROIs) were selected in the left renal cortex and spleen using ImageJ software. The SRI was calculated as a ratio of the mean pixel brightness of the left kidney cortex ROI to the mean pixel brightness of the spleen ROI. The SRI was then correlated with serum creatinine, blood urea nitrogen, and estimated glomerular filtration rate. We found that among the 94 patients included in the study, the SRI had a significant positive correlation with serum creatinine ( r = 0.43, P < 0.001) and serum blood urea nitrogen ( r = 0.45, P < 0.001) and negative correlation with estimated glomerular filtration rate ( r = -0.47, P < 0.001). Our data indicate that SRI may serve as a valuable tool for sonographic evaluation of renal parenchymal disease.

Contrast-enhanced ultrasound (CEUS) for the characterization of intra-scrotal lesions.

Contrast-enhanced ultrasound (CEUS) has emerged as a promising imaging modality for the characterization of hepatic and renal lesions. However, there is a paucity of data describing the use of CEUS for the evaluation of intra-scrotal pathology. In the following review, we describe the clinical utility of CEUS for the characterization and differentiation of common and uncommon intra-scrotal conditions, including testicular torsion, infection, trauma, and benign and malignant intratesticular and extratesticular neoplasms. In addition, we outline key principles of CEUS and provide case examples from our institution.

Wearable bioadhesive ultrasound shear wave elastography.

Acute liver failure (ALF) is a critical medical condition defined as the rapid development of hepatic dysfunction. Conventional ultrasound elastography cannot continuously monitor liver stiffness over the course of rapidly changing diseases for early detection due to the requirement of a handheld probe. In this study, we introduce wearable bioadhesive ultrasound elastography (BAUS-E), which can generate acoustic radiation force impulse (ARFI) to induce shear waves for the continuous monitoring of modulus changes. BAUS-E contains 128 channels with a compact design with only 24 mm in the azimuth direction for comfortable wearability. We further used BAUS-E to continuously monitor the stiffness of in vivo rat livers with ALF induced by d-galactosamine over 48 hours, and the stiffness change was observed within the first 6 hours. BAUS-E holds promise for clinical applications, particularly in patients after organ transplantation or postoperative care in the intensive care unit (ICU).

Ultrasound Fusion: Applications in Musculoskeletal Imaging.

Ultrasound fusion is an established technique that pairs real time B-scan ultrasound (US) with other forms of cross-sectional imaging, including computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). Each of these imaging modalities has distinct advantages. CT provides superior anatomic resolution, with improved imaging of bone and calcified structures; MRI has superior contrast resolution; and PET provides physiologic information, identifying processes that are metabolically active (i.e., tumor, inflammatory conditions). However, these modalities are static. A key highlight of ultrasound is its capability of dynamic, real-time scanning. The ability to pair CT, MRI or PET with ultrasound can have significant advantages, both in diagnostic evaluation and when performing difficult or challenging image-guided interventions. Percutaneous interventions using ultrasound fusion have been described in the abdominal imaging literature; however, there have been very few musculoskeletal applications detailed in the literature. The purpose of this article is to review the basic concepts of real-time ultrasound fusion, and to detail, through the use of multiple case examples, its potential use as a safe and effective method for performing image-guided musculoskeletal interventions.

PET/CT Ultrasound Fusion for Percutaneous Biopsy: A Retrospective Single-Center Study and Review of the Literature.

PURPOSE: The aim of this study was to assess the diagnostic yield and complication rate of 18 F-FDG PET/CT ultrasound (US) fusion for percutaneous biopsy of FDG-avid lesions among patients with known or suspected malignancy. PATIENTS AND METHODS: We describe the clinical, imaging, and histopathologic features of 36 patients who underwent percutaneous biopsy using real-time PET/CT US fusion. In addition, we review the literature on PET/CT US fusion. Using Medline, the following MeSH terms were searched and relevant citations assessed: "fusion imaging," "PET/CT fusion," "PET/CT-guided biopsy," "PET/US fusion," "ultrasound fusion," and "ultrasound fusion-guided biopsy." RESULTS: A total of 36 patients (15 men, 21 women) with known or suspected malignancy and prior PET/CT imaging underwent percutaneous biopsy of FDG-avid lesions using PET/CT US fusion between October 2014 and July 2020. Coregistration was achieved using General Electric LOGIQ E9 software. Adequate tissue for analysis was obtained in all 36 patients. Histologic evaluation revealed malignancy in 14 patients (38.9%) and nonneoplastic tissue in 22 patients (61.1%). No intraprocedural or postprocedural complications were recorded. CONCLUSIONS: Fusion of PET/CT and US for percutaneous biopsy of FDG-avid lesions can be used to achieve excellent diagnostic yield with a low risk of complications.

Imaging of Benign and Malignant Breast Lesions Using Contrast-Enhanced Ultrasound: A Pictorial Essay.

ABSTRACT: Contrast-enhanced ultrasound is a promising noninvasive imaging technique for evaluating benign and malignant breast lesions, as contrast provides information about perfusion and microvasculature. Contrast-enhanced ultrasound is currently off-label use in the breast in the United States, but its clinical and investigational use in breast imaging is gaining popularity. It is important for radiologists to be familiar with the imaging appearances of benign and malignant breast masses using contrast-enhanced ultrasound. This pictorial essay illustrates enhancement patterns of various breast masses from our own experience. Pathologies include subtypes of invasive breast cancer, fibroadenomas, papillary lesions, fibrocystic change, and inflammatory processes. Contrast-enhanced ultrasound pitfalls and limitations are discussed.

Super-Resolution Ultrasound Localization Microscopy for Visualization of the Ocular Blood Flow.

OBJECTIVE: The ocular vascular system plays an important role in preserving the visual function. Alterations in either anatomy or hemodynamics of the eye may have adverse effects on vision. Thus, an imaging approach that can monitor alterations of ocular blood flow of the deep eye vasculature ranging from capillary-level vessels to large supporting vessels would be advantageous for detection of early stage retinal and optic nerve diseases. METHODS: We propose a super-resolution ultrasound localization microscopy (ULM) technique that can assess both the microvessel and flow velocity of the deep eye with high resolution. Ultrafast plane wave imaging was acquired using an L22-14v linear array on a high frequency Verasonics Vantage system. A robust microbubble localization and tracking technique was applied to reconstruct ULM images. The experiment was first performed on pre-designed flow phantoms in vitro and then tested on a New Zealand white rabbit eye in vivo calibrated to various intraocular pressures (IOP) - 10 mmHg, 30 mmHg and 50 mmHg. RESULTS: We demonstrated that retinal/choroidal vessels, central retinal artery, posterior ciliary artery, and vortex vein were all visible at high resolution. In addition, reduction of vascular density and flow velocity were observed with elevated IOPs. CONCLUSION: These results indicate that super-resolution ULM is able to image the deep ocular tissue while maintaining high resolution that is comparable with optical coherence tomography angiography. SIGNIFICANCE: Capability to detect subtle changes of blood flow may be clinically important in detecting and monitoring eye diseases such as glaucoma.

Contrast-Enhanced Ultrasound-Guided Interventions-The New Sheriff in Town?: A Case-Based Review of Problem Solving With Ultrasound Contrast.

Ultrasound (US)-guided intervention is a well-established medical procedure and offers advantages such as real-time guidance, portability, reduced cost, shortened procedure time compared with computed tomography, and lack of ionizing radiation. Ultrasound contrast agents (UCAs) are a useful adjunct to US-guided procedures. The addition of microbubble UCAs during US-guided interventions can assist with biopsy planning and lesion selection, aid in identification of target lesions, and direct the biopsy toward viable tissue. Ultrasound contrast agents have been in use outside of the United States for many years and have been used off label at select institutions across the United States before the Food and Drug Administration approval of Lumason (Bracco Diagnostics) for liver lesion evaluation in April 2016. After Food and Drug Administration approval, the use of UCAs has expanded rapidly, and UCAs are being used for a variety of clinical applications. Ultrasound contrast agents have been shown to be safe, and there is no renal toxicity. In this article, we will discuss the indications and techniques for using contrast-enhanced ultrasound during US-guided interventions, and we will present case examples where contrast-enhanced ultrasound added value.

Current Ultrasound Technologies and Instrumentation in the Assessment and Monitoring of COVID-19 Positive Patients.

Since the emergence of the COVID-19 pandemic in December of 2019, clinicians and scientists all over the world have faced overwhelming new challenges that not only threaten their own communities and countries but also the world at large. These challenges have been enormous and debilitating, as the infrastructure of many countries, including developing ones, had little or no resources to deal with the crisis. Even in developed countries, such as Italy, health systems have been so inundated by cases that health care facilities became oversaturated and could not accommodate the unexpected influx of patients to be tested. Initially, resources were focused on testing to identify those who were infected. When it became clear that the virus mainly attacks the lungs by causing parenchymal changes in the form of multifocal pneumonia of different levels of severity, imaging became paramount in the assessment of disease severity, progression, and even response to treatment. As a result, there was a need to establish protocols for imaging of the lungs in these patients. In North America, the focus was on chest X-ray and computed tomography (CT) as these are widely available and accessible at most health facilities. However, in Europe and China, this was not the case, and a cost-effective and relatively fast imaging modality was needed to scan a large number of sick patients promptly. Hence, ultrasound (US) found its way into the hands of Chinese and European physicians and has since become an important imaging modality in those locations. US is a highly versatile, portable, and inexpensive imaging modality that has application across a broad spectrum of conditions and, in this way, is ideally suited to assess the lungs of COVID-19 patients in the intensive care unit (ICU). This bedside test can be done with little to no movement of the patients from the unit that keeps them in their isolated rooms, thereby limiting further exposure to other health personnel. This article presents a basic introduction to COVID-19 and the use of the US for lung imaging. It further provides a high-level overview of the existing US technologies that are driving development in current and potential future US imaging systems for lung, with a specific emphasis on portable and 3-D systems.

Color comet-tail artifact: clinical applications.

OBJECTIVE: This article explores the circumstances under which the color comet-tail artifact occurs and illustrates the clinical value of the artifact. CONCLUSION: Subtle abnormalities on gray-scale sonograms often are better appreciated and understood when the color comet-tail artifact is present. This artifact often is helpful in situations in which gray-scale imaging does not provide adequate information for a conclusive diagnosis. Visualization of the color comet-tail artifact can improve diagnostic confidence in a wide spectrum of clinical conditions encountered in sonographic practice.

Retrospective Analysis of Contrast-enhanced Ultrasonography Effectiveness in Reducing Time to Diagnosis and Imaging-related Expenditures at a Single Large United States County Hospital.

Hepatic and renal lesions detected during ultrasound examinations frequently require subsequent contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) for characterization, delaying time to imaging diagnosis and increasing overall health care expenditures. Contrast-enhanced ultrasonography (CEUS) is a comparatively low-cost diagnostic tool that is underutilized in the evaluation of such indeterminate or suspicious hepatic and renal lesions. A retrospective chart review of CEUS examinations performed in our department demonstrated significantly shorter time to imaging diagnosis with CEUS compared to CT or MRI, largely due to the ability to perform the CEUS examination at the time of initial examination. For example mean time to completion for outpatient examinations was 5.2, 52.3, and 123.5 days for CEUS, CT, and MRI, respectively. The majority (78.4%) of CEUS examinations were completed the same day as the initial examination. Additionally, 66.7% of CEUS examinations were deemed diagnostic, abrogating further workup with CT or MRI in most cases. Annual imaging cost reduction of up to US $117,000 is anticipated in our institution based on projected reductions in follow-up CT and MRI examinations. These results indicate when CEUS was used as a first step to characterize both incidental lesions in patients without known risk factors for malignancy as well as suspicious lesions in patients with risk factors it can greatly reduce time to diagnosis and health care expenditures.

Ultrasound, Computed Tomography, and Magnetic Resonance Imaging in a Patient With Medullary Cystic Kidney Disease.

Among the renal cystic diseases that result in end-stage renal disease, an important hereditary cause is medullary cystic kidney disease, which affects adults in an autosomal dominant pattern. It is characterized by progressive renal failure, tubulointerstitial fibrosis, and formation of small cysts in the renal medulla and corticomedullary junction. While the appearance of medullary/corticomedullary cysts may not be pathognomonic for medullary cystic kidney disease, encountering a patient with renal failure and medullary/corticomedullary cysts should prompt further investigation, given the implication of having the disease. Genetic testing can be used to identify potential renal donors as well as identify affected individuals in order to control risk factors for chronic renal disease that may mitigate the progression of the disease process. The treatment of choice is renal transplantation.