Recommended
More Related Content
What's hot
What's hot (20)
Similar to Elastography and ceus gilja
Similar to Elastography and ceus gilja (20)
More from SuzanneCain2
More from SuzanneCain2 (6)
Recently uploaded
Recently uploaded (20)
Elastography and ceus gilja
- 1. National Centre for Ultrasound in Gastroenterology Emerging techniques: Elastography and CEUS Odd Helge Gilja, MD, PhD Professor Department of Clinical Medicine University of Bergen Bergen, Norway
- 2. National Centre for Ultrasound in Gastroenterology Sonoelastography - Palpation imaging Soft tissue surface US probe Stiff tissue surface (Compression)
- 3. National Centre for Ultrasound in Gastroenterology Elastography is deformation Imaging Cecilie Brækhus from Bergen, Norway beating Holly Holm Deformation by the probe during liver surgery
- 4. National Centre for Ultrasound in Gastroenterology Elastography is Strain measurement • An object of initial length L0 that is stretched or compressed to a different length L, have a one- dimensional strain (ε) defined as: , 0 0 L LL − =ε
- 5. National Centre for Ultrasound in Gastroenterology Elastographic Association between Strain and Pathology Havre R. et al., Ultraschall 2012
- 6. National Centre for Ultrasound in Gastroenterology Topics: Ultraschall Med 2013;Jun:34:238-250 Download from www.efsumb.org
- 7. National Centre for Ultrasound in Gastroenterology EFSUMB Guidelines 2013
- 8. National Centre for Ultrasound in Gastroenterology New EFSUMB Liver Elasto guidelines • Work in-progress • International expert group,- n=25 • Consensus meeting London July 2016 – Liver guidelines – Published online in EJU 2017 • Consensus meeting in Frankfurt Febr 2018 – Non-liver guidelines
- 9. National Centre for Ultrasound in Gastroenterology Transient Elastography (Fibroscan) ARFI (Siemens) Real Time Tissue Elastography (Hitachi) ElastPQ (Philips) Supersonic Shear Imaging ShearWave Elastography (Airplorer) Elastography Point Shear Wave Elastography
- 10. National Centre for Ultrasound in Gastroenterology Available methods for elastography Transient Elastography Acoustic Raditation Force Imaging (ARFI) Point shear wave elastography (pSWE) Quasi static elastography (Strain imaging) Supersonic Shear wave imaging Fibroscanner® Echosens Siemens Phillips GE Several producers Supersonic imaging ® Aixplorer® Method: US probe with a thumper creates a physical push-pulse into the liver and US is used to track this shear wave Method: Acoustic pulse is deposited at user selected position, deformation and shear waves are recorded Method: Strain imaging By external or internal tissue movement Deposition of a parallel acoustic cones covering a larger area with shear wave tracking Quantitative shear wave speed, no image Qualitative map in ARFI. + Quantitative pSWE Qualitative: SR, Visual scores, Hepatic strain index, strain %, strain pattern analysis Quantitative and qualitative
- 11. National Centre for Ultrasound in Gastroenterology Strain Imaging Eur J Ultrasound, 2017
- 12. National Centre for Ultrasound in Gastroenterology SWE Mesurement Eur J Ultrasound, 2017
- 13. National Centre for Ultrasound in Gastroenterology SWE Imaging Eur J Ultrasound, 2017
- 14. National Centre for Ultrasound in Gastroenterology Transient elastography • Fibro Scan®, for liver tissue stiffness measurement • 3.5 MHz probe with 50 Hz thumper placed inter- costally over right liver lobe • Emits a vibration pulse (Shear wave) tracked by US into the liver tissue • Gives up elasticity in KPa • No US image – relatively easy to use Shear elasticity probe for soft tissues with 1-D transient elastography.Sandrin L, Tanter M, Gennisson JL, Catheline S, Fink MIEEE Trans Ultrason Ferroelectr Freq Control. 2002 Apr;49(4):436-46.
- 15. National Centre for Ultrasound in Gastroenterology Liver Elastography 1. Vibration Controlled Transient Elastography (VCTE), Fibroscan The transient Shear Wave travels through the liver within tens of milliseconds which implies that the ultrasound-based imaging modality must be ultrafast to follow its propagation. Within these constraints stiffness can be deduced from the strain rate images of the Shear Wave propagation.
- 16. National Centre for Ultrasound in Gastroenterology
- 17. National Centre for Ultrasound in GastroenterologyCopyright ©2007 BMJ Publishing Group Ltd. Fraquelli, M. et al. Gut 2007;56:968-973 Transient elastography (TE) results according to A the fibrosis score (Metavir) B the necroinflammatory activity (195 patients who underwent both TE and liver biopsy) A B
- 18. National Centre for Ultrasound in Gastroenterology Cut-off values for fibrosis and cirrhosis Significant fibrosis (F2) – 1.34 m/s Cirrhosis (F4) – 1.80 m/s Meta-analysis Friedrich-Rust et al., J Viral Hepatitis 2012
- 19. National Centre for Ultrasound in Gastroenterology Liver Elastography with Fibroscan Advantages and Disadvantages 1. VCTE-Fibroscan Advantages • Produces a spatially and temporally localized excitation • Reference to a volume of scanned liver tissue • Can be operated by non-medical personnel • Limited intra-inter observer variability • Tested and validated Disadvantages • No US guidance, no US imaging information • Important number of technical failures
- 20. National Centre for Ultrasound in Gastroenterology Longitudinal and Shear Waves Ultrasound Wave Shear Wave ρ3 E tc = ρ K lc = cl ~ 1540 m/s in tissue ct = 1-10 m/s in tissue
- 21. National Centre for Ultrasound in Gastroenterology Acoustic Radiation Force Transducer Push pulse Shear wave depth lateral Force generated by a transfer of energy from an acoustic wave to the medium through which it is propagating Tissue displacement ~ size of red blood cell Track pulses
- 22. National Centre for Ultrasound in Gastroenterology Acoustic Radiation Force Transducer Push pulse Shear wave depth lateral Water Drop by Bill Bryne, https://www.flickr.com/photos/ 8099556@N08/3576252000/ Transmit tracking pulses to image shear wave motion Track pulses
- 23. National Centre for Ultrasound in Gastroenterology Acoustic Radiation Force Transducer Push pulse Shear wave depth lateral Track pulses Shear waves generated by a single push focused at 30 mm in a homogeneous phantom
- 24. National Centre for Ultrasound in Gastroenterology Combined-push Excitation Multiple push beams transmitted simultaneously Shear waves generated by multiple push beams
- 25. National Centre for Ultrasound in Gastroenterology Directional Filter Combined wave field Left traveling waves Right traveling waves
- 26. National Centre for Ultrasound in Gastroenterology Shear Wave Speed Estimation 1.2 ms ct = 3.0 m/s 0.85 ms ct = 4.2 m/s Shear Wave Speed Right Propagating Waves
- 27. National Centre for Ultrasound in Gastroenterology Combine Waves from Different Directions Blending Right Traveling Waves Left Traveling Waves
- 28. National Centre for Ultrasound in Gastroenterology Shear Wave Elastography compared to histological findings and Liver Fibrosis F1 F2 F3 F4 Ultrasound Med Biol. 2011 Sep;37(9):1361-73. Epub 2011 Jul 2011 Noninvasive in vivo liver fibrosis evaluation using supersonic shear imaging: a clinical study on 113 hepatitis C virus patients. Bavu E, Gennisson JL, Couade M, Bercoff J, Mallet V, Fink M, Badel A, Vallet-Pichard
- 29. National Centre for Ultrasound in Gastroenterology SWE correlation with F0-4 score FERRAIOLI ET AL., HEPATOLOGY, December 2012
- 30. National Centre for Ultrasound in Gastroenterology ROC for F0-1 versus F2-4 FERRAIOLI ET AL., HEPATOLOGY, December 2012
- 31. National Centre for Ultrasound in Gastroenterology GE-E9 SWE convex probe Mulabecirovic A., et al. UMB 2016, in press
- 32. National Centre for Ultrasound in Gastroenterology GE-E9 SWE linear probe Mulabecirovic A., et al. UMB 2016, in press
- 33. National Centre for Ultrasound in Gastroenterology GE-E9 Strain elastography Mulabecirovic A., et al. UMB 2016, in press
- 34. National Centre for Ultrasound in Gastroenterology Interobserver variation GE-E9 SWE Mulabecirovic A., et al. UMB 2017
- 35. National Centre for Ultrasound in Gastroenterology 4. SWE Advantages • Very good US imaging, precise ROI guidance • Real-time elasticity measurements • Measurements in kPa independent of the probe/ROI distance • Reduced number of technical failures Disadvantages • Dependence on the choice of intercostal space • Statistical analysis on static (frame) data • Progress in Inter-Intra Observer variability but still room for improvement Liver Elastography with Shear Wave Advantages and Disadvantages
- 36. National Centre for Ultrasound in Gastroenterology Liver Disease Fibrosis Cirrhosis Liver Cancer Approximately 20–30% of chronic hepatitis will develop cirrhosis and its complications within one or more decades after diagnosis Progressive fibrosis is a feature of almost all chronic liver diseases
- 37. National Centre for Ultrasound in Gastroenterology The Clinical Problem - Liver 1. Early diagnosis of Chronic Liver Disease • Accurate estimation of mild and particularly moderate and severe fibrosis, most studied in the setting of CHC patients but also in other liver diseases • Accurate non-invasive method for the early detection and diagnosis of cirrhosis 2. Treatment follow-up 3. The risk of HCC depends on the stage of liver fibrosis 4. Liver biopsy remains the “gold standard”
- 38. National Centre for Ultrasound in Gastroenterology
- 39. National Centre for Ultrasound in Gastroenterology El-Serag HB. N Engl J Med 2011;365:1118-1127 Distribution Rates of HCC
- 40. National Centre for Ultrasound in Gastroenterology Liver biopsy– gold standard? • Pain and discomfort • Risk of bleeding • Risk of perforation • Bad quality of biopsy • Sampling bias / error
- 41. National Centre for Ultrasound in Gastroenterology § Invasive procedure § Poor patient compliance § Risk of complications § Diagnostic accuracy of scoring systems § Intra- and interobserver variability in the assessment of the satge of fibrosis § Not an ideal procedure for repeated assessment of disease progression § High cost Limitations of Liver Biopsy
- 42. National Centre for Ultrasound in Gastroenterology Elastisity measurement of the liver by ultrasound
- 43. National Centre for Ultrasound in Gastroenterology New Guidelines 2017 Eur J Ultrasound, 2017 29 recommendations
- 44. National Centre for Ultrasound in Gastroenterology Liver elasto- graphy How to perform?
- 45. National Centre for Ultrasound in Gastroenterology Preparation of patients Eur J Ultrasound, 2017
- 46. National Centre for Ultrasound in Gastroenterology Confounding factors EJU, 2017
- 47. National Centre for Ultrasound in Gastroenterology Impact of normal values EJU, 2017
- 48. National Centre for Ultrasound in Gastroenterology EJU, 2019, in press22 recommendations, 13 clinical applications
- 49. National Centre for Ultrasound in Gastroenterology Crohn’s stenosis in Sigmoid Colon Resected specimenElastography Images: Prof. S. Ødegaard
- 50. National Centre for Ultrasound in Gastroenterology First ever Guidelines on Elastography 2012 Ultrasonogram (left) and elastogram (right) in a patient with Crohn’s disease scanned with 5,0 MHz frequency. The patient has a clearly thickened wall of the terminal ileum (white arrow) with a stenosis (green asterix). In the right panel, a corresponding blue color in the anterior wall indicate hard tissue (fibrosis) in the GI wall.
- 51. National Centre for Ultrasound in Gastroenterology The Micro-Bubble
- 52. National Centre for Ultrasound in Gastroenterology Microbubbles f0 2f0 f0
- 53. National Centre for Ultrasound in Gastroenterology Sonazoid • Membrane is hydrogenated egg phosphatidylserine sodium (H • The gas is perfluorobutane (PFB)
- 54. National Centre for Ultrasound in Gastroenterology Some properties of Sonazoid • Narrow Size distribution • Very robust: Allow for high-MI scan (0,2-0,3) • Perform a post-vascular scan • Use higher frequencies • Phagocytosis by Kupffer cells in the liver Yanagisawa et al.
- 55. National Centre for Ultrasound in Gastroenterology Harmonic Imaging and CEUS Fundamental Imaging Harmonic Imaging
- 56. National Centre for Ultrasound in Gastroenterology Microbubbles Relationship bubble size and us-f ... with a resonance frequency in the range used for medical imaging
- 57. National Centre for Ultrasound in Gastroenterology Fine tuning the Instrument by adjusting the MI Non-linear response from microbubbles is based on two different mechanisms: – non-linear response from microbubble oscillations at low acoustic pressure, chosen to minimize disruption of the microbubbles. ”Low MI” Imaging. – high energy broadband non-linear response arising from microbubble disruption.
- 58. National Centre for Ultrasound in Gastroenterology New Guidelines for CEUS 2011 Ultraschall Med / EJU Aug. 2011Cited almost 1000 times
- 59. National Centre for Ultrasound in Gastroenterology New Liver CEUS Guidelines
- 60. National Centre for Ultrasound in Gastroenterology 3 Phases of Liver Perfusion • Arterial phase – 0-30 sec. • Portal phase – 30-120 sec. • Sinusoidal phase (Parenchymal) – 2-4 min • Postvascular phase
- 61. National Centre for Ultrasound in Gastroenterology Post-vascular Phase of Liver with 9 MHz Linear Probe
- 62. National Centre for Ultrasound in Gastroenterology Common Indications - Liver • Characterisation of focal lesions – FNH, haemangioma, adenoma • Detection of focal lesions – metastasis • In cirrhosis: Characterize nodules / HCC • Guiding of biopsies • Guiding of intervention,- eg. Ablation
- 63. National Centre for Ultrasound in Gastroenterology Focal Liver Lesions
- 64. National Centre for Ultrasound in Gastroenterology Haemangioma • Peripheral globular contrast pooling in arterial phase • Globular enlargement and centripetal fill-in • Nicolau (2004): – 19 of 22 hemangiomas could be correctly identified in the late phase (86.4%) and 18 in the vascular phase (81.8%). • Ding (2005): – sensitivity of 96.3% and specificity of 97.5% when centripetal fill-in enhancement was regarded as a positive finding of hemangioma.
- 65. National Centre for Ultrasound in Gastroenterology Referral from the CT-lab Haemangioma ?
- 66. National Centre for Ultrasound in Gastroenterology Peripheral Globular Enhancement …with slow sentripetal filling
- 67. National Centre for Ultrasound in Gastroenterology In Haemangiomas, be aware… • …not to use too high MI • …not to focus on one lesion in all phases • …to scan longer than 5 min. • …some h. never totally fill in, but it is still benign • …big h. may behave atypically (thrombosis)
- 68. National Centre for Ultrasound in Gastroenterology Focal Nodular Hyperplasia - FNH • FNH- a centrifugal stellate branching in early arterial phase • Spoke wheel pattern in approx 40% • Intense homogenous uptake • Iso- or hyperechoic lesion is seen in portal venous phase. • With these characteristic features: – sensitivity and specificity of contrast-enhanced low MI real-time US are 87.6% and 94.5%, respectively – Di Stasi 1996
- 69. National Centre for Ultrasound in Gastroenterology CEUS – Sonazoid - FNH
- 70. National Centre for Ultrasound in Gastroenterology Arterial Phase: 12 sec.
- 71. National Centre for Ultrasound in Gastroenterology Arterial Phase: 13 sec
- 72. National Centre for Ultrasound in Gastroenterology Arterial Phase: 13 sec
- 73. National Centre for Ultrasound in Gastroenterology Arterial Phase: 15 sec
- 74. National Centre for Ultrasound in Gastroenterology Detection of Focal Liver Lesions Hausken, Gilja et al., 199
- 75. National Centre for Ultrasound in Gastroenterology Liver Metastasis ? Before contrast injection
- 76. National Centre for Ultrasound in Gastroenterology Liver Metastasis ? After contrast injection
- 77. National Centre for Ultrasound in Gastroenterology Mets from Rectal Cancer
- 78. National Centre for Ultrasound in Gastroenterology Parenchymal Phase ( 4 min)
- 79. National Centre for Ultrasound in Gastroenterology High-Frequency 9 MHz LA
- 80. National Centre for Ultrasound in Gastroenterology CEUS in Liver Cirrhosis • AFP has limited sensitivity • CT and B-mode US has limited sensitivity • To characterise nodules (RN, LG-DN, HG-DN) • To evaluate HCC • To evaluate portal thrombosis – Benign or malignant infiltration ?
- 81. National Centre for Ultrasound in Gastroenterology hepatic arterial supply abnormal arterial supply Arterial supply Portal supply portal supply LRN ~ LGDN ~ HGDN ~ e-HCC ~ wdHCC ~ classical HCC early HCC from: Matsui, Clin Hep Gastro, 2005. (based on CT-arterioportal-angiography) The Sequence of HCC Development
- 82. National Centre for Ultrasound in Gastroenterology CEUS in cirrhosis (AIH) – HCC?
- 83. National Centre for Ultrasound in Gastroenterology CEUS in AIH – HCC? Arterial Phase Sonovue
- 84. National Centre for Ultrasound in Gastroenterology FNH versus HCC FNH HCC
- 85. National Centre for Ultrasound in Gastroenterology Non-liver CEUS Applications • Gallbladder tumors • Kidney scanning • Pancreas • Bladder reflux • Blaunt abdominal trauma • Transcranial scanning • Spleen • Intestines • Monitoring ablation • … > 30 different clinical applications of CEUS
- 86. National Centre for Ultrasound in Gastroenterology Gallbladder Tumor? or Sludge? Hi-res scanning in CEUS mode
- 87. National Centre for Ultrasound in Gastroenterology Another case – Sludge?
- 88. National Centre for Ultrasound in Gastroenterology B-mode Pancreatic Lesions
- 89. National Centre for Ultrasound in Gastroenterology Pancreatic Tumor – What kind? 3,5 MHz probe
- 90. National Centre for Ultrasound in Gastroenterology Pancreatic Tumor – High-f CEUS 9 MHz linear probe
- 91. National Centre for Ultrasound in Gastroenterology Crohn Patient
- 92. National Centre for Ultrasound in Gastroenterology CEUS of Jejunal loop and surrounding tissue
- 93. National Centre for Ultrasound in Gastroenterology Late Phase CEUS Imaging
- 94. National Centre for Ultrasound in Gastroenterology Safety
- 95. National Centre for Ultrasound in Gastroenterology Regarding Safety
- 96. National Centre for Ultrasound in Gastroenterology Conclusions • Many elastography methods • SWE and strain imaging are incorporated in most ultrasound scanners • Non-invasive estimation of liver fibrosis is key to evaluate disease progression and follow-up of therapy • CEUS is useful for detection and characterization of FLLs • Over 30 different clinical applications for CEUS
- 97. National Centre for Ultrasound in Gastroenterology From vision to decision… The lammergeier (bearded vulture) Photo: OH Gilja
- 98. National Centre for Ultrasound in Gastroenterology Dangerous or not ?
- 99. National Centre for Ultrasound in Gastroenterology Missing: Spiros Kotopoulis, Michiel Postema, Eva Fosse, Gulen Arslan Lied, Friedemann Erchinger, Geir Folvik, Jose FM Gomez, Veronika Solteszova, Dag M Ulvang, Torfinn Taxt, Helwig Hauser Thanks to The Ultrasound Group in Bergen
- 100. National Centre for Ultrasound in Gastroenterology Euroson 2020 i Bergen
- 101. National Centre for Ultrasound in Gastroenterology Bergen2020 – The gateway to the fjords The gateway to ULTRASOUND