This document summarizes a retrospective analysis of contrast enhanced ultrasound (CEUS) examinations performed at Södra Älvsborgs Sjukhus from 2011-2014. It analyzes the conclusiveness of CEUS for various organs like liver, kidneys, and spleen. It finds that CEUS was more accurate than CT or MRI in many cases, able to identify more lesions or characterize lesions that other modalities could not. It discusses areas for expanding the use of CEUS in the future, including for trauma, small parts, and extravascular applications. The document aims to evaluate the hospital's experience with CEUS to improve its use and planning going forward.

1. Södra Älvsborgs Sjukhus
Contrast Enhanced UltraSound (CEUS)
A retrospective analysis from 2011 to
2014 and plans for the future
Michail Papagiannakis, läkare, bild- och laboratoriemedicin
Andrea Radler-Boglari, läkare, bild- och laboratoriemedicin
Charjar Manucheri, överläkare, Capio
Södra Älvsborgs Sjukhus

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CEUS is a quite new method being practised
globaly the last 15 years.
It is a complementary method to baseline ultrasound.
It is patient friendly, with no radiation the contrast agent does not
affect the kidneys and is 10 times safer regarding allergies(1).
The contrast agent is purely endovascular so the method depicts
vessels(1), like a microangiogram visualising perfusion(2).
Diagnosis is based on specific paterns that various lesions may
show, and depends highly on the organ that is scanned(1).

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At SÄS we began using the method during 2008.
Requests and indications for the method are increasing,
so it was time to look back in time and assess our results, in order to
find our weaknesses and plan for the future.
.
We reviewed the reports from approximately 1383 examinations which
included CEUS of the liver, kidneys, spleen and various examinations
such as soft tissue and musculoskeletal, thyroid, appendix, abdominal
aorta, urinary bladder and other cavities.

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For the first part we defined conclusive the exams that reached a
diagnosis or a differential diagnosis and didn’t need a follow-up during
the next 5 months. In that way patients with a routine 6 month or yearly
follow-up were not classified as inconclusive.
For the second part we assessed how often CEUS or CT or MRI was
more accurate regarding diagnosis, number of lesions, or able to reach
a lesion. This part had the limitation that only a few patients had double
exams and the first exam was usually wrong or inconclusive.
We tried to figure out:
1) How often was the method conclusive,
giving a specific diagnosis,
or differentiating between benign and malignant lesions? And how often did
we have a false negative diagnosis?
2) How often was there discrepancy with CT and MRI?

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LIVER RESULTS
The conclusive exams had no follow-up with CEUS CT or MRI in a 5 month
period.
The pseudo lesions are usually focal fatty sparring which in 2 cases would get a
biopsy.
The no lesions column represents the inability of CEUS to identify isoechogenic
lesions without fusion imaging or artifacts from the other modalities.

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KIDNEY RESULTS
The majority of the cases were simple cysts that came for a CEUS to verify the findings or
to exclude atypias in hyperdense cysts.
The kidney is trickier to liver when using CEUS because it lacks the double perfusion (6).
BOSNIAK”S classification doesn’t apply 100% on CEUS and CE-MRI because they are
more sensible depicting vascularity. (7)

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SPLEEN RESULTS
CEUS
identified
a huge
splenic
infarkt
not
visible on
b-Mode.

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RESULTS FROM OTHER ORGANS
Limited number of studies globaly,but promising method in identifying perfusion, infarcts, abscesses(5,14,15,16,17).
Appendiceal abscess surrounded by phlegmon verified by operation
Peritrochanteric abscess Hemangioperycytoma verified by post-op biopsy

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Discrepancy between modalities
CEUS vs CT vs MRI
CEUS was more conclusive compared to CT in 98 cases in
liver, 8 cases in kidney and 3 cases in spleen.
In liver 45% of the cases was characterizing cysts. And many
cases were about hemangiomas.
CEUS has a higher sensitivity and specificity identifying
metastases(8,9,10).In fact we had cases were CEUS
identified more than double or triple lesions.
Small lesions 5-10 mm or smaller are difficult to assess with
CT
This is mainly because:
CEUS is a realtime exam.You are able to film the whole arterial , portal(in liver) and late phase.
Spatial resolution :Ultrasound>MRI>CECT,(F.Piscaglia, CEUS international course, Hanover, 2008)
Sonovue(Bracco) is a pure intravascular agent so in the late phase it stays in the vessels and has a high sensitivity in
depicting vascularity.(Ibiscus, Arlanda, 2014 ).
The other modalities have very specific protocols and in many cases the findings were incidental (cysts and hemangiomas).
Patients with reduced renal function cannot take CT or MRI contrast , but CEUS does not affect the renal function.
We did not find any cases of kidney and
spleen that had both CEUS and MRI.
Small lesions 5-10 mm or smaller are difficult
to assess with MRI

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Whats wrong with CT cysts and hemangiomas?
1)Fibrotic or partially thrombotised hemangiomas and metastases cannot be easily
differentiated by a single late phase CT, because they both show a hyperenhancing rim.
2) CEUS provides more information during all phases by filming and identifying specific
patterns can provide the right diagnosis.
3) Cysts are not always what they look like, hypervascular metastases can imitate them in
liver.

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1)Late phase abdominal CT: malignancy cannot be excluded. Lesion with rim like enhancment
CEUS reveals a
globular, slow,
succesive
,centripetal
contrast
enhancment,
typical for
hemangioma.No
washout!

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2) a hemangioma that wasn’t there in previous exams , in a patient with
hepatitis, arterial phase CT aorta Centripetal globular enhancement???
Fast
chaotic
uptake
with
basket
sign and
delayed
washout
HCC

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These are not cysts…..
CT too small lesions to characterize , b-Mode ultrasound reveals cysts, CEUS for metastasis screening at 120 sec
reveals cysts, but something didn’t fit. Follow up in 3 months.
B –Mode still reveals cysts Arterial phase

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CT and MRI vs CEUS
CT vs CEUS
CT is less sensible showing vessels and the
BOSNIAK classification of renal cysts
was build for this method, so there is no
“overdiagnosis” from CT(7).The clasificiation will be
revised to include CEUS and MRI.
MRI vs CEUS
MRI with liver specific
contrast is considered to be
the gold standard in the liver
imaging.(T.Albrecht, CEUS
international course,
Hanover , 2008.
CEUS suffers from the same
limitations as b-Mode and
worse, so something you
cannot see is maybe there.
Operator dependency, air
artifacts, fatty liver can
destroy your exam and self
confidence.

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So what should we try next????Extravascular CEUS!(18)
Voiding Urosonography mainly for reflux
Cheap method
No radiation
Comparable to the MCU (11,13)
Safe for the patient(12,13)
Why cheap?
MCU needs 200mL(140mg/mL) iodine contrast = 2135 SEK.
CEUS needs 1 drop of Sonovue and 200mL saline = 200mLX6SEKNACL
0.9%+1/20000X800sek<61SEK
VUS in an adult
0,1mL Sonovue
(Bracco) in the
Urinary Bladder via
Foley
Right Kidney No
reflux
Left Kidney No Reflux

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EVAR endo-leaks, active bleeding of solid organs or vessels(15,16,17).
EVAR negative for endo-leak verified
with CT
EVAR endo-leak type II verified with CT

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Reumatology Orthopeadics Small parts
CEUS is by far more sensitive to depicting vascularity.
It can be used to identify neo-vascularization in joints or tendons especially after sclerotherapy(CEUS international
course,Hanover 2009) .
In differential diagnosis of abscess vs cellulitis or diffuse inflamation, and identifying compartment syndrome since it is
the only method to visualize only perfusion. (L.Thorelius, CEUS international course,Hanover 2008) .
Identifying scrotal infarcts or perfusion defects or verifying scrotal tumors by depicting vascularity changes.(20)
Thickend synovium with increased vascularity not depicted by doppler Indicative of synovitis

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TRAUMA
As probably the most sensitive modality in active bleeding CEUS can be used for screening of low energy abdominal
trauma in order to reduce radiation, cost and risk of CIN.
Or it can be used for follow up of traumatic patients were the ultrasound can go to the patient and not vise versa .
Spontaneous Splenic rupture splenomegali,Mononoucleosis patient.Active bleeding,bubles escape into the subcapsular hematoma

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AV fistula with active bleeding pseudoaneurysm, hematoma.
DOPPLER B-MODE
Active bleeding of a pseudo aneurysm Surrounding hematoma without any bubbles

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We need to be more practicing
CEUS
What it takes to practise CEUS
Very good ultrasound technique.Working with B-Mode at least 2 years.
Knowing all the tricks of your machine.
Able to do biopsies.
Take courses.
Do supervised training.
Close cooperation with clinicians.
A minimum of 300-500 cases per year necessary to keep competence (EFSUMB
guidelines for the good practice of CEUS)
A plan is under construction!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

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LITERATURE
http://intrasas.vgregion.se/sv/SIW/Organisation/Bild--och-laboratoriemedicin/Bild--och-
funktionsmedicin/Ultraljud/Styrdokument-UL/Kontrastforstarkt-ultraljud-CEUS/
www.efsumb.org
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