Ultrasound elastography assessment of bone/soft tissue interface.

We report on the use of elastographic imaging techniques to assess the bone/soft tissue interface, a region that has not been previously investigated but may provide important information about fracture and bone healing. The performance of axial strain elastograms and axial shear strain elastograms at the bone/soft tissue interface was studied ex vivo on intact and fractured canine and ovine tibias. Selected ex vivo results were corroborated on intact sheep tibias in vivo. The elastography results were statistically analyzed using elastographic image quality tools. The results of this study demonstrate distinct patterns in the distribution of the normalized local axial strains and axial shear strains at the bone/soft tissue interface with respect to the background soft tissue. They also show that the relative strength and distribution of the elastographic parameters change in the presence of a fracture and depend on the degree of misalignment between the fracture fragments. Thus, elastographic imaging modalities might be used in the future to obtain information regarding the integrity of bones and to assess the severity of fractures, alignment of bone fragments as well as to follow bone healing.

Effect of permeability on the performance of elastographic imaging techniques.

Elastography is a well-established imaging modality. While a number of studies aimed at evaluating the performance of elastographic techniques are retrievable in the literature, very little information is available on the effects that the presence of an underlying permeability contrast in the tissue may have on the resulting elastograms. Permeability is a fundamental tissue parameter, which characterizes the ease with which fluid can move within a tissue. This parameter plays a central role both biomechanically in the description of the temporal behavior of fluid-filled tissues and clinically in the development of a number of diagnostic and therapeutic modalities. In this paper, we present a simulation study that investigates selected elastographic image quality factors in nonhomogeneous materials, modeled as poroelastic media with different geometries and permeability contrasts. The results of this study indicate that the presence of an underlying permeability contrast may create a new contrast mechanism in the spatial and temporal distributions of the axial strains and the effective Poisson's ratios experienced by the tissue and as imaged by the corresponding elastograms. The effect of permeability on the elastographic image quality factors analyzed in this study was found to be a nonsymmetric function of the underlying mechanical contrast between background and target, the geometry of the material and the boundary conditions.

Performance analysis of a new real-time elastographic time constant estimator.

New elastographic techniques such as poroelastography and viscoelasticity imaging aim at imaging the temporal mechanical behavior of tissues. These techniques usually involve the use of curve fitting methods being applied to noisy data to estimate new elastographic parameters. As of today, however, current elastographic implementations of poroelastography and viscoelasticity imaging methods are in general too slow and not optimized for clinical applications. Furthermore, image quality performance of these new elastographic techniques is still largely unknown due to a paucity of data and the lack of systematic studies that analyze their performance limitations. In this paper, we propose a new elastographic time constant (TC) estimator, which is based on the use of the least square error (LSE) curve-fitting method and the Levenberg-Marquardt (LM) optimization rule as applied to noisy elastographic data obtained from a material in a creep-type experiment. The algorithm is executed on a massively parallel general purpose graphics processing unit (GPGPU) to achieve real-time performance. The estimator's performance is analyzed using simulations. Experimental results obtained from poroelastic phantoms are presented as a proof of principle of the new estimator's technical applicability on real experimental data. The results of this study demonstrate that the newly proposed elastographic estimator can produce highly accurate and sensitive elastographic TC estimates in real-time and at high signal-to-noise ratios.

Elastography using harmonic ultrasonic imaging: a feasibility study.

Tissue Harmonic Imaging (THI) is a relatively new modality that has had a significant impact in the ultrasound field. In the recent past, imaging the mechanical properties of tissues using elastography has also gained great interest. In this paper, we investigate the feasibility of combining these two state-of-the-art ultrasound-imaging modalities. The performance of elastograms obtained using harmonic ultrasonic signals is studied with simulations and compared to the performance of conventional elastograms using standard statistical methods. Experiments are used as a proof of the technical feasibility of generating tissue-harmonic elastograms using experimental harmonic signals. The results of our simulation study indicate that all image quality factors considered in this study (elastographic signal-to-noise ratio, elastographic contrast-to-noise ratio and spatial resolution) may be improved when using harmonic ultrasonic signals, provided that the ultrasound system is characterized by high bandwidth, high sampling frequency and large lateral sampling. Preliminary experimental results suggest that it is technically feasible to generate experimental elastograms using harmonic signals, provided that the sonographic signal-to-noise ratio of the pre- and postcompression harmonic frames is sufficiently high to guarantee reliable values of correlation.

On the differences between two-dimensional and three-dimensional simulations for assessing elastographic image quality: a simulation study.

In this work, we introduced an elastographic simulation framework, which estimates upper bounds on elastographic image quality by accounting for three-dimensional (3D) tissue motion and the 3D nature of the ultrasound beam. For the boundary conditions and the range of applied strains considered in this study, it was observed that for applied strains smaller than 0.7%, fast two-dimensional (2D) simulations and 3D simulations predicted similar upper bounds on elastographic signal-to-noise (SNR(e)) and contrast-to-noise ratios (CNR(e)); however, for applied strains greater than 0.7%, the predictions by 2D simulations grossly overestimated the achievable results when compared with upper bound results from 3D simulations. It was also found that linear increments in the elevational-to-lateral beamwidth ratio (beam ratio) resulted in nonlinear degradation in the achievable upper bounds on elastographic signal-to-noise ratio. For the modulus contrast ratio of ten between the target and the background, the peak difference in the prediction of contrast-to-noise by 2D and 3D simulations was approximately 10 dB, whereas, for modulus contrast ratio of 1.5, the peak difference increased to approximately 30 dB. No significant difference was observed between the spatial resolution predicted by 2D and 3D simulations; however, increase in beam ratio resulted in decrease in target detectability, especially at lower modulus contrast ratios.

The feasibility of using poroelastographic techniques for distinguishing between normal and lymphedematous tissues in vivo.

Lymphedema is a common condition involving an abnormal accumulation of lymphatic fluid in the interstitial space that causes swelling, most often in the arm(s) and leg(s). Lymphedema is a significant lifelong concern that can be congenital or develop following cancer treatment or cancer metastasis. Common methods of evaluation of lymphedema are mostly qualitative making it difficult to reliably assess the severity of the disease, a key factor in choosing the appropriate treatment. In this paper, we investigate the feasibility of using novel elastographic techniques to differentiate between lymphedematous and normal tissues. This study represents the first step of a larger study aimed at investigating the combined use of elastographic and sonographic techniques for the detection and staging of lymphedema. In this preliminary study, poroelastographic images were generated from the leg (8) and arm (4) subcutis of five normal volunteers and seven volunteers having lymphedema, and the results were compared using statistical analyses. The preliminary results reported in this paper suggest that it may be feasible to perform poroelastography in different lymphedematous tissues in vivo and that poroelastography techniques may be of help in differentiating between normal and lymphedematous tissues.

The feasibility of estimating and imaging the mechanical behavior of poroelastic materials using axial strain elastography.

In this paper, we have investigated the feasibility of imaging the mechanical behavior of poroelastic materials using axial strain elastography. Cylindrical samples obtained from poroelastic materials having different elastic and permeability properties were subjected to a constant compression force (a classical creep experiment), during which poroelastographic data were acquired. For comparison, we also tested a few gelatin phantoms and non-homogeneous poroelastic phantoms constructed by combining different poroelastic materials. From the acquired data, we generated time-dependent sequences of axial strain elastograms and effective Poisson's ratio elastograms, which were then used for generating axial strain and effective Poisson's ratio time-constant elastograms. Thereafter, the various poroelastographic images were analyzed to evaluate the presence of statistically significant differences among the two types of poroelastic samples and for image quality analysis. The results of this study demonstrate that it is technically feasible to use axial strain elastography to distinguish among homogeneous poroelastic materials characterized by different elastic and permeability properties. They also show that the use of axial strain elastography instead of effective Poisson's ratio elastography results in objectively higher quality poroelastograms of the temporal behavior of the poroelastic materials under loading. However, the use of effective Poisson's ratio elastography may in any case be required to verify that the temporal changes occurring in the axial strains of the homogeneous poroelastic samples are also accompanied by temporal changes of the effective Poisson's ratios and are therefore due to poroelastic behavior.

Visualization of bonding at an inclusion boundary using axial-shear strain elastography: a feasibility study.

Ultrasound elastography produces strain images of compliant tissues under quasi-static compression. In axial-shear strain elastography, the local axial-shear strain resulting from application of quasi-static axial compression to an inhomogeneous material is imaged. The overall hypothesis of this work is that the pattern of axial-shear strain distribution around the inclusion/background interface is completely determined by the bonding at the interface after normalization for inclusion size and applied strain levels, and that it is feasible to extract certain features from the axial-shear strain elastograms to quantify this pattern. The mechanical model used in this study consisted of a single stiff circular inclusion embedded in a homogeneous softer background. First, we performed a parametric study using finite-element analysis (FEA) (no ultrasound involved) to identify possible features that quantify the pattern of axial-shear strain distribution around an inclusion/background interface. Next, the ability to extract these features from axial-shear strain elastograms, estimated from simulated pre- and post-compression noisy RF data, was investigated. Further, the feasibility of extracting these features from in vivo breast data of benign and malignant tumors was also investigated. It is shown using the FEA study that the pattern of axial-shear strain distribution is determined by the degree of bonding at the inclusion/background interface. The results suggest the feasibility of using normalized features that capture the region of positive and negative axial-shear strain area to quantify the pattern of the axial-shear strain distribution. The simulation results showed that it was feasible to extract the features, as identified in the FEA study, from axial-shear strain elastograms. However, an effort must be made to obtain axial-shear strain elastograms with the highest signal-to-noise ratio (SNR(asse)) possible, without compromising the resolution. The in vivo results demonstrated the feasibility of producing and extracting features from the axial-shear strain elastograms from breast data. Furthermore, the in vivo axial-shear strain elastograms suggest an additional feature not identified in the simulations that may potentially be used for distinguishing benign from malignant tumors-the proximity of the axial-shear strain regions to the inclusion/background interface identified in the sonogram.

Assessing image quality in effective Poisson's ratio elastography and poroelastography: I.

The quality of strain estimates in elastography is typically quantified by several quality factors such as the elastographic signal-to-noise ratio, the elastographic contrast-to-noise ratio and the spatial axial and lateral resolutions. While theoretical and simulation works have led to established upper bounds of these image quality factors in axial strain elastography, the performance limitations of lateral strain elastography, effective Poisson's ratio elastography and poroelastography are still not well understood. In this paper, we investigate the theoretical upper bounds of image quality of effective Poisson's ratio elastography starting from an analysis of the performance limitations of axial strain and lateral strain elastography. In the companion paper, we extend our investigation to the theoretical upper bounds of image quality of poroelastography. In both these papers, we also analyse the application of techniques that can be used to improve the performance of these poroelastographic techniques under various experimental conditions.

Assessing image quality in effective Poisson's ratio elastography and poroelastography: II.

Poroelastography is a novel elastographic technique for imaging the time variation of the mechanical behaviour of poroelastic materials. Poroelastograms are generated as a series of time-sequenced effective Poisson's ratio (EPR) elastograms, obtained from the imaged material under sustained compression. In the companion report (Righetti et al 2007 Phys. Med. Biol. 52 1303), we investigated image quality of EPR elastography starting from a theoretical analysis of the performance limitations of axial strain elastography and lateral strain elastography. In this report, we extend this analysis to poroelastography. The theoretical analysis reported in these two companion papers allows understanding the performance limitations of these novel techniques and identifying the fundamental parameters that control their signal-to-noise ratio, contrast-to-noise ratio and resolution. The results of these studies also indicate that EPR elastograms and poroelastograms of reasonable image quality can be generated in practical applications that may be of clinical interest provided that advanced elastographic techniques in combination with other commonly employed imaging methods to increase signal-to-noise and contrast-to-noise ratios are used.

Signal-to-noise ratio, contrast-to-noise ratio and their trade-offs with resolution in axial-shear strain elastography.

In axial-shear strain elastography, the local axial-shear strain resulting from the application of quasi-static axial compression to an inhomogeneous material is imaged. In this paper, we investigated the image quality of the axial-shear strain estimates in terms of the signal-to-noise ratio (SNR(asse)) and contrast-to-noise ratio (CNR(asse)) using simulations and experiments. Specifically, we investigated the influence of the system parameters (beamwidth, transducer element pitch and bandwidth), signal processing parameters (correlation window length and axial window shift) and mechanical parameters (Young's modulus contrast, applied axial strain) on the SNR(asse) and CNR(asse). The results of the study show that the CNR(asse) (SNR(asse)) is maximum for axial-shear strain values in the range of 0.005-0.03. For the inclusion/background modulus contrast range considered in this study (<10), the CNR(asse) (SNR(asse)) is maximum for applied axial compressive strain values in the range of 0.005%-0.03%. This suggests that the RF data acquired during axial elastography can be used to obtain axial-shear strain elastograms, since this range is typically used in axial elastography as well. The CNR(asse) (SNR(asse)) remains almost constant with an increase in the beamwidth while it increases as the pitch increases. As expected, the axial shift had only a weak influence on the CNR(asse) (SNR(asse)) of the axial-shear strain estimates. We observed that the differential estimates of the axial-shear strain involve a trade-off between the CNR(asse) (SNR(asse)) and the spatial resolution only with respect to pitch and not with respect to signal processing parameters. Simulation studies were performed to confirm such an observation. The results demonstrate a trade-off between CNR(asse) and the resolution with respect to pitch.

Resolution of axial shear strain elastography.

The technique of mapping the local axial component of the shear strain due to quasi-static axial compression is defined as axial shear strain elastography. In this paper, the spatial resolution of axial shear strain elastography is investigated through simulations, using an elastically stiff cylindrical lesion embedded in a homogeneously softer background. Resolution was defined as the smallest size of the inclusion for which the strain value at the inclusion/background interface was greater than the average of the axial shear strain values at the interface and inside the inclusion. The resolution was measured from the axial shear strain profile oriented at 45 degrees to the axis of beam propagation, due to the absence of axial shear strain along the normal directions. The effects of the ultrasound system parameters such as bandwidth, beamwidth and transducer element pitch along with signal processing parameters such as correlation window length (W) and axial shift (DeltaW) on the estimated resolution were investigated. The results show that the resolution (at 45 degrees orientation) is determined by the bandwidth and the beamwidth. However, the upper bound on the resolution is limited by the larger of the beamwidth and the window length, which is scaled inversely to the bandwidth. The results also show that the resolution is proportional to the pitch and not significantly affected by the axial window shift.

A method for generating permeability elastograms and Poisson's ratio time-constant elastograms.

The feasibility of imaging the permeability and Poisson's ratio time-constant of porous media was investigated. The study involved the following steps. First, poroelastograms were generated from porous tofu phantoms under sustained compression. The sample materials used for the experiments were previously characterized through independent mechanical measurements. Second, corresponding Poisson's ratio time-constant elastograms were generated by calculating and displaying the decay time-constants of the local Poisson's ratios over the time interval in which the poroelastograms were acquired. Finally, for homogeneous samples, permeability elastograms were generated using the poroelastograms in combination with a previously proposed biphasic theoretical model, under very specific conditions. A comparison between the results obtained using poroelastography and those obtained through independent mechanical measurements suggests that poroelastography may be used for imaging the local time-dependent behavior of poroelastic media.

A new method for generating poroelastograms in noisy environments.

Poroelastography has been recently introduced as a new elastographic technique that may be used to describe the spatial and temporal behavior of poroelastic materials. The experimental methodology proposed thus far for phantoms and tissues in vitro requires the acquisition of a precompression rf frame, the application of a unit step strain compression to the sample and the acquisition of subsequent post-compression frames from the material. Elastograms and poroelastograms are generated by cross-correlating the sequentially-acquired postcompression frames with the reference precompression frame. The application of poroelastography to tissues in vivo must address the echo decorrelation problems that are encountered due to uncontrolled tissue motion, which may become significant shortly after the acquisition of the precompression frame. In this paper, we investigate the feasibility of performing poroelastography experiments using an alternative experimental scheme. In the proposed experimental methodology, the reference precompression frame is continuously moved while the time interval between the frames that are correlated is kept short. This allows long data acquisition times with simultaneous minimization of the decorrelation due to undesired tissue motion in vivo. We validated this new method using both a step and a ramp compression functions. We performed poroelastographic simulations and experiments in phantoms and in tissues in vivo. The results were compared to those obtained using the traditional acquisition methodology. This study shows that the two methods yield similar results in vitro and suggests that the new method may be more robust to decorrelation noise in applications in vivo.

Noise performance and signal-to-noise ratio of shear strain elastograms.

In this paper, we develop a theoretical expression for the signal-to-noise ratio (SNR) of shear strain elastograms. The previously-developed ideas for the axial strain filter (ASF) and lateral strain filter (LSF) are extended to define the concept of the shear strain filter (SSF). Some of our theoretical results are verified using simulations and phantom experiments. The results indicate that the signal-to-noise ratio of shear-strain elastograms (SNRsse) improves with increasing shear strain and with improvements in system parameters such as the sonographic signal-to-noise ratio (SNRs) beamwidth, center frequency and fractional bandwidth. The results also indicate that the amount of axial strain present along with the shear strain is an important parameter that determines the upper bound on SNRsse. The SNRsse will be higher in the absence of additional deformation due to axial strain.

Telerehabilitation for veterans with a lower-limb amputation or ulcer: Technical acceptability of data.

A study was undertaken to determine the technical acceptability of information available via a customized telerehabilitation system regarding patients with lower-limb ulcers or recent lower-limb amputations receiving care at a Veterans Affairs Medical Center. Among the 54 participants, 57 wounds (39 ulcers, 19 amputation incisions) were evaluated by means of still photographs and skin temperature data sent via ordinary telephone lines. Three experienced clinicians served as raters. Intrarater agreements and McNemar chi(2) tests were assessed between decisions made after telerehabilitation sessions and decisions made by the same rater after in-person sessions. Interrater agreements and kappa coefficients were assessed between two raters for both telerehabilitation and in-person sessions. The intrarater agreement on 57 wounds for the primary rater was 93%, and the McNemar test indicated no significant difference in the ratings (p < 0.63). Interrater agreement on 18 wounds was 78% (kappa = 0.55, p < 0.02) for the telerehabilitation sessions and 89% (kappa = 0.77, p < 0.001) for the in-person sessions. Most qualitative comments by three clinicians on picture quality (54/63 = 86%) and temperature data (39/44 = 88%) were favorable (good to excellent). The information yielded from this study provides evidence that the telerehabilitation system has the potential to present sufficient information to experienced clinicians so they can make informed decisions regarding wound management. The next phase of the study will include in-home trials and improvements in the technology.

The feasibility of using elastography for imaging the Poisson's ratio in porous media.

The feasibility of using elastography for experimentally estimating and imaging the Poisson's ratio of porous media under drained and undrained conditions was investigated. Using standard elastographic procedures, static and time-sequenced poroelastograms (strain ratio images) of homogeneous cylindrical gelatin and commercially available tofu samples were generated under sustained applied axial strain. The experimental data show similar trends to those that were observed in finite-elements simulations, and to those that were calculated from classical theoretical models proposed for biphasic materials with similar mechanical properties. To demonstrate the applicability of elastography to monitor time-dependent changes in nonhomogeneous porous structures as well, preliminary time-sequenced poroelastograms were obtained from two-layer porous phantoms and porcine muscle samples in vitro. The results suggest that elastography may have significant potential for quantitatively mapping the time-dependent mechanical behavior of poroelastic media, which is related to the dynamics of fluid flow and to the elasticity and permeability parameters of the media.

Differences in the compressive stress-strain response of infiltrating ductal carcinomas with and without lobular features--implications for mammography and elastography.

In a previous study, it was noted that in some cases when compressive strains greater than about 5% were applied to tumors removed from the breast, there was an abrupt and irreversible change in the tissue stiffness. The data from that study were further analyzed and infiltrating ductal carcinomas with and without lobular features were selected for additional testing to explore their behavior under compressive strains from 0-10%. Fresh tumor samples were tested using a servo-hydraulic Instron testing machine to apply ramp type displacement loads to the samples. The results show that when strains greater than 5% are applied to the tumor tissue without lobular features, there is an irreversible decrease in the stiffness of the tissue while no such change is noted in the other tumor tissue. The implications for this behavior in making mammographic and elastographic images of the breast were then explored using finite element simulations to determine under what compression conditions could the critical strain threshold be reached in the tumor tissue.

A noncontact wound measurement system.

The instrument described in this manuscript was developed to perform objective, quantitative measurements of wound healing, which will enable service providers to assess, improve, and individualize the treatment given to each wound patient. It was designed to produce measures that will enable the care provider to assess the current state of the wound as well as gain insight into the time course of the wound healing by comparing the series of wound data collected over time. The record provided by the instrument could also assist in legal defense; a need that, unfortunately, cannot be ignored. The system uses a structured lighting pattern captured on a digital photograph of a wound to calculate the area and volume of debrided wounds. We used plaster molds with spherical indentations to represent various wounds to evaluate the precision of the system. Results indicate that when at least 144 of the data points in the picture lie within the wound borders, the surface area and wound volume are repeatable and the precision is within +/-3% of the calculated values based on the geometry of the spherical indentation.