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A Sonographer’s Guide to Contrast Enhanced Ultrasound

Corinne E. Wessner, BS, RDMS, RVT

Research Sonographer

Department of Radiology

Thomas Jefferson University

Philadelphia, PA

Ultrasound Contrast Agents

http://www.onlinejacc.org/content/45/3/329http://www.braccoforasustainablefuture.com/en/storytelling/new-milestones-with-microbubbles.html

• Microbubbles have a gas core, encapsulated with lipid, polymer, or protein layer

• Crosses the pulmonary capillary bed after intravenous injection

• Similar in size to a red blood cell (1-7 um)

Capabilities of Contrast-Enhanced Ultrasound

• Detect micro-perfusion

• Delineate anatomic structures

• Provide physiological information

• FDA approved in April 2016 for liver characterization of focal liver lesions in adult and pediatric patients

• Approved for suspected or known vesicoureteral reflux in pediatric patients

• Known globally as SonoVue (BraccoDiagnostics, Princeton, NJ)

• Non-refrigerated

• Easy to use & store

Lumason

https://imaging.bracco.com/us-en/products/contrast-enhanced-ultrasound/lumason

Lumason

3-Way stopcock

Lumason

Saline

Intravenous catheter

Contrast-Enhanced Ultrasound Software

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Pre-Imaging Contrast-Enhanced Ultrasound Optimization Contrast-Enhanced Ultrasound Software

Contrast-Enhanced Ultrasound Software

Liver Contrast-Enhanced Ultrasound Imaging Analysis

Arterial Phase Portal Venous Phase Late Phase

14 secs 41 secs 3:59 mins

Arterial Phase Portal Venous Phase

Late Phase

Late Portal Venous Phase

24 secs 49 secs 1:20 mins

3:18 mins

Liver Contrast-Enhanced Ultrasound Imaging Analysis

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Barr, R. J Ultrasound Med 2017;36:1225-1240B-Mode Arterial Portal

VenousDelayed

Liver Contrast-Enhanced Ultrasound Lesion Characterization Liver Case Study #1

• Patient History: Hypertension, alcoholism, liver disease, infectious viral hepatitis, hepatitis C,

intravenous drug use, presented to the ED with a left facial droop and weakness

Found to have had a right basal ganglia bleed and brief history of liver lesions

Diagnosis: Hepatocellular Carcinoma

Liver Case Study #2

• Patient History: History of solid, liver lesion measuring 3.2 cm visualized at an outside hospital

Patient recommended for MRI of abdomen & pelvis

Came to Jefferson for a second opinion

Jefferson hepatologist ordered a contrast-enhanced ultrasound

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Diagnosis: Focal Nodular Hyperplasia

Renal Contrast-Enhanced Ultrasound Imaging Analysis

Early Arterial Phase Cortical Phase Medullary Phase

Renal Contrast-Enhanced Ultrasound Lesion Characterization

Renal Case Study #1

• Patient History: Diabetes mellitus, heart disease, heart failure, hypertension, hyperlipidemia,

coronary artery disease, and breast cancer

Ultrasound & CT scan performed at an outside hospital

Patient presents to Jefferson with a 4.4 cm lower pole left renal mass

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Diagnosis: Renal Cell Carcinoma

Renal Case Study #2

• Patient History: Hypertension and end-stage renal disease

Routine renal US performed for transplant candidate evaluation and a 2.7 cm complex cystic right renal mass was identified and considered suspicious for neoplasm

The patient had a CT abdomen/pelvis on the same day for pre-transplant evaluation for iliac vessel calcificationso The right renal mass was identified

Two months later, a CEUS was performed

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Diagnosis: Cystic Renal Cell Carcinoma Interesting CEUS Clinical Applications

Kidney Ablation MonitoringPre-Kidney Ablation Monitoring

Post-Kidney Ablation Monitoring Post-Kidney Ablation Monitoring

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Abdominal Endovascular Aneurysm Repair Monitoring

Abdominal Endovascular Aneurysm Repair Monitoring

CEUS Imaging Challenges

Contrast-Enhanced Ultrasound Imaging Challenges: Superficial Lesions

Contrast-Enhanced Ultrasound Imaging Challenges: Heavy Breathing & Anatomy

Contrast-Enhanced Ultrasound Imaging Challenges: Depth

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Time Constraints

• Sonographer image acquisition

CEUS is a time sensitive examination

Critical to stay on the lesion during APHE and washout for image interpretation

Recordings need to be started at the beginning of injection in order to acquire APHE and possibly washout

• Examination length

Microbubbles last for only 4-6 minutes

Important for sonographers to preserve the bubbles and scan for 10-15 second intervals

o This allows sonographers to scan 6-10 minutes post injection to visualize late washout

Conducting a CEUS Examination

• Identify ROI on grayscale US pre-contrast Measure ROI in all imaging planes

• Certified medical professional place peripheral intravenous catheter

• Start activating contrast agent

• Go into contrast mode

• Contrast injected

• Sustain ROI imaging for 1-2 minutes

• Interpret and acquire CEUS imaging data; typically 10-15 secs per minute

• Permanently store examination

• Send to Picture Archiving & Communication System (PACS)

Contrast-Enhanced Ultrasound Key Points

• Check: Contrast clip length before beginning CEUS exam

Clip retrospective or prospective

• Optimize: Acoustic window

o Adjust window based on patient’s breathing

Contrast gaino Suppress surrounding soft tissue

o Grayscale gain in contrast setting

Focal zoneo Place focal zone at or below ROI

Conclusions

• CEUS is a challenging, new area for sonographers

• IV injection of contrast, image optimization, and acquisition timing are critical aspects

• Be mindful of CEUS artifacts and limitations

• You get access to a whole new level of physiological information we haven’t seen before

• Don’t be intimidated by time constraints and new imaging modes

Acknowledgements

Flemming Forsberg

John R. Eisenbrey

Maria Stanczak

Andrej Lyshchik

Laurence Needleman

Priscilla Machado

Kristen Bradigan

Nancy Pedano

Andrew Morris

Maris VanMeter

Kelly Byrne

Many Others to Numerous to Thank!

Thank You!Contact Information:

Corinne.Wessner@jefferson.edu@cori_wessner