Andrea Klauser

The EFSUMB guidelines and recommendations on the clinical practice of contrast enhanced ultrasound (CEUS): Update 2011 on non-hepatic applications

Authors F. Piscaglia1, C. Nolsøe2, C. F. Dietrich3, D. O. Cosgrove4, O. H. Gilja5, M. Bachmann Nielsen6, T. Albrecht7, L. Barozzi8, M. Bertolotto9, O. Catalano10, M. Claudon11, D. A. Clevert12, J. M. Correas13, M. D’Onofrio14, F. M. Drudi15, J. Eyding16, M. Giovannini17, M. Hocke18, A. Ignee19, E. M. Jung20, A. S. Klauser21, N. Lassau22, E. Leen23, G. Mathis24, A. Saftoiu25, G. Seidel26, P. S. Sidhu27, G. ter. Haar28, D. Timmerman29, H. P. Weskott30

EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: Basic principles and technology.

The technical part of these Guidelines and Recommendations, produced under the auspices of EFSUMB, provides an introduction to the physical principles and technology on which all forms of current commercially available ultrasound elastography are based. A difference in shear modulus is the common underlying physical mechanism that provides tissue contrast in all elastograms. The relationship between the alternative technologies is considered in terms of the method used to take advantage of this. The practical advantages and disadvantages associated with each of the techniques are described, and guidance is provided on optimisation of scanning technique, image display, image interpretation and some of the known image artefacts.

EFSUMB Guidelines and Recommendations on the Clinical Use of Ultrasound Elastography. Part 2: Clinical Applications

The clinical part of these Guidelines and Recommendations produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology EFSUMB assesses the clinically used applications of all forms of elastography, stressing the evidence from meta-analyses and giving practical advice for their uses and interpretation. Diffuse liver disease forms the largest section, reflecting the wide experience with transient and shear wave elastography . Then follow the breast, thyroid, gastro-intestinal tract, endoscopic elastography, the prostate and the musculo-skeletal system using strain and shear wave elastography as appropriate. The document is intended to form a reference and to guide clinical users in a practical way.

Carpal Tunnel Syndrome Assessment with US: Value of Additional Cross-sectional Area Measurements of the Median Nerve in Patients versus Healthy Volunteers

PURPOSE To improve accuracy in the diagnosis of carpal tunnel syndrome (CTS) by comparing cross-sectional area (CSA) measurements of the median nerve obtained at the level of the carpal tunnel (CSAc) with those obtained more proximally (CSAp), at the level of the pronator quadratus muscle. MATERIALS AND METHODS The study protocol was approved by the institutional review board, and all subjects gave written informed consent. One hundred wrists of 68 consecutive patients with CTS (16 men, 52 women; mean age, 57.9 years; range, 25-85 years) and 93 wrists of 58 healthy volunteers (16 male, 42 female; mean age, 55.1 years; range, 17-85 years) were examined with ultrasonography (US). Electrodiagnostic test results confirmed the diagnosis of CTS in all 68 patients. The US examiner was blinded to these test results. The CSA of the median nerve was measured at the carpal tunnel and proximal levels, and the difference between CSAc and CSAp (Delta CSA) was calculated for each wrist. RESULTS The mean CSAc in healthy volunteers (9.0 mm(2)) was smaller than that in patients (16.8 mm(2), P < .01). The mean Delta CSA was smaller in asymptomatic wrists (0.25 mm(2)) than in CTS-affected wrists (7.4 mm(2), P < .01). Receiver operating characteristic analysis revealed a diagnostic advantage to using the Delta CSA rather than the CSAc (P = .036). Use of a Delta CSA threshold of 2 mm(2) yielded the greatest sensitivity (99%) and specificity (100%) for the diagnosis of CTS. CONCLUSION Receiver operating characteristic analysis revealed improved accuracy in the diagnosis of CTS determined with the Delta CSA compared with the accuracy of the diagnosis determined with the CSAc.

Comparison Of Contrast Enhanced Color Doppler Targeted Biopsy With Conventional Systematic Biopsy: Impact On Prostate Cancer Detection

Purpose: We performed a prospective study to determine whether a limited biopsy approach with contrast enhanced color Doppler ultrasound targeted biopsy of the prostate would detect cancer as well as gray scale US guided systematic biopsy with a larger number of biopsy cores.Materials and Methods: We examined 230 male screening volunteers with a total prostate specific antigen of 1.25 ng./ml. or greater and free-to-total prostate specific antigen less than 18%. Two independent examiners evaluated each subject and a single investigator performed 5 or fewer contrast enhanced targeted biopsies into hypervascular regions in the peripheral zone during intravenous infusion of the US contrast agent Levovist (Schering, Berlin, Germany). Subsequently another examiner performed 10 systematic prostate biopsies. The cancer detection rates of the 2 techniques were compared.Results: Cancer was detected in 69 of the 230 patients (30%), including 56 (24.4%) by contrast enhanced targeted biopsy and in 52 (22.6%) by system...

Real-Time Sonoelastography of Lateral Epicondylitis: Comparison of Findings Between Patients and Healthy Volunteers

OBJECTIVE The purpose of this study was to evaluate real-time sonoelastography in the assessment of the origins the common extensor tendon in healthy volunteers and in patients with symptoms of lateral epicondylitis. The findings were compared with those obtained at clinical examination, ultrasonography, and power Doppler sonography. SUBJECTS AND METHODS Thirty-eight elbows of 32 consecutively registered patients with symptoms of lateral epicondylitis and 44 asymptomatic elbows of 28 healthy volunteers were assessed with ultrasound and real-time sonoelastography. A clinical examination was performed, and pain was classified with a visual analog scale. RESULTS In healthy volunteers, real-time sonoelastographic images showed hard tendon structures in 96% of tendon thirds and mild alterations in 4%. Real-time sonoelastography of patients showed hard structures in 33% of tendon thirds but softening of different grades in 67%, a statistically significant difference in relation to the findings in healthy volunteers (p < 0.001). Lateral collateral ligament involvement and overlying fascial involvement were more commonly detected with real-time sonoelastography. The sensitivity of real-time sonoelastography was 100%, the specificity 89%, and the accuracy 94% with clinical examination as the reference standard. Good correlation with ultrasound findings was found (r > or = 0.900). No correlation was observed between ultrasound or real-time sonoelastographic findings and power Doppler sonographic findings, but power Doppler sonographic findings had a strong correlation with the visual analog scale score. CONCLUSION Real-time sonoelastography is valuable in the detection of the intratendinous and peritendinous alterations of lateral epicondylitis and facilitates differentiation between healthy and symptomatic extensor tendon origins with excellent sensitivity and excellent correlation with ultrasound findings.

Real-Time Sonoelastography: Findings in Patients with Symptomatic Achilles Tendons and Comparison to Healthy Volunteers

PURPOSE Real-time sonoelastography (SE), a newly introduced ultrasound technique, has already shown conclusive results in breast, prostate, and thyroid tumor diagnostics. This study investigated the performance of SE for the differentiation of Achilles tendon alterations of tendinopathy compared to clinical examination and conventional ultrasound (US). MATERIALS AND METHODS Achilles tendons in 25 consecutive patients with chronic Achilles tendinopathy and 25 healthy volunteers were examined clinically by US and by SE. RESULTS In the healthy volunteers, SE showed the tendon to be hard (93 %), while distinct softening was found in 57 % of the patients. SE showed more frequent involvement of the distal (64 %) and middle third (80 %) than the proximal third (28 %) of the Achilles tendon. Using SE a mean sensitivity of 94 %, specificity of 99 %, and accuracy of 97 % were found when clinical examination was used as the reference standard. The correlation to US was 0.89. Mild softening was found in 7 % of the healthy volunteers and in 11 % of the patients. CONCLUSION Our results emphasize that only distinct softening of Achilles tendons is comparable to clinical examination and US findings. However, mild softening might be explained by very early changes in tissue elasticity in the case of Achilles tendinopathy, which should be assessed in follow-up studies.

Real-Time Sonoelastography Findings in Healthy Achilles Tendons

OBJECTIVE Real-time sonoelastography is a new ultrasound-based technique able to assess tissue elasticity that has already shown feasibility in tumor diagnosis. The aim of this study was to assess the performance of real-time sonoelastography in depicting the Achilles tendons of healthy volunteers and to compare sonoelastography findings with conventional ultrasound findings. MATERIALS AND METHODS Eighty asymptomatic Achilles tendons of 40 healthy volunteers (19 men, 21 women; mean age, 38 years; range, 20-76 years) were examined on real-time sonoelastography and ultrasound. The Achilles tendons were divided into the following thirds for image evaluation: proximal (musculotendinous junction), middle (2-6 cm above insertion at the calcaneus), and distal (insertion at the calcaneus). Longitudinal and axial images of each tendon third were obtained using ultrasound and real-time sonoelastography. Real-time sonoelastography images were evaluated by reviewers using an experimentally proven color grading system. RESULTS The Achilles tendons showed mainly a hard structured pattern (86.7%) (208/240 tendon thirds) on sonoelastography; however, mild softening was found in 12.1% (29/240) of the tendons. Distinct softening corresponding to alterations found also on ultrasound and, therefore, suggesting subclinical changes was detected in 1.3% (3/240). The overall correlation (kappa) between real-time sonoelastography and ultrasound findings was 1.00. CONCLUSION In healthy volunteers, the Achilles tendon appeared hard on real-time sonoelastography with excellent correlation to ultrasound. Further investigation including pathologic tendons should be performed to prove the value of real-time sonoelastography in the assessment of Achilles tendinopathy.

Detection of prostate cancer with a microbubble ultrasound contrast agent

The diagnosis of prostate cancer is currently limited by the low sensitivity and specificity of systematic conventional grey-scale ultrasonography. We assessed contrast-enhanced colour Doppler ultrasonography by means of a microbubble ultrasound contrast agent to detect tumour vascularity and improve the diagnosis of prostate cancer. The use of a microbubble ultrasound contrast agent for transrectal colour Doppler targeted biopsy significantly improved the detection of prostate cancer compared with systematic biopsy following conventional grey-scale ultrasonography (p<0.001). Contrast-agent enhanced colour Doppler imaging may allow for limited targeted biopsies (five or less), which reduces costs and morbidity.

Radiation dose reduction by using 100-kV tube voltage in cardiac 64-slice computed tomography: a comparative study.

OBJECTIVE To evaluate a 100-kilovoltage (kV) tube voltage protocol regarding radiation dose and image quality, in comparison with the standard 120 kV setting in cardiac computed tomography angiography (CCTA). METHODS 103 patients undergoing retrospective ECG-gated helical 64-slice CCTA were enrolled (100 kV group: 51 patients; 120 kV group: 52 patients). Inclusion criteria were: (1) BMI <28 kg/m(2); (2) weight <85 kg; (3) coronary calcium score <300 Agatston Units (AU). Quantitative image quality parameters were calculated [image noise, contrast-to-noise ratio (CNR), intracoronary CT-attenuation (HU)]. Each coronary artery segment (AHA/ACC-16-segments-classification) was evaluated for image quality on a 4-point scale. RESULTS There was no statistical difference in age, gender, BMI and eff. tube current (mAs), and the use of ECG-tube current modulation (50.9% vs. 50% of patients) between both groups. 84.2% of patients in the 100 kV group had zero calcium score or less than 100 AU, the remaining had between 100 and 300 AU. The effective radiation dose was significantly lower in the 100 kV group with mean 7.1 mSv+/-2.4 (range, 3.4-11.1) compared to the 120 kV group with 13.4 mSv+/-5.2 (range, 6.3-22.7) (p<0.001) (dose reduction, 47%). In the 100 kV group, the use of ECG-dependent tube current modulation reduced the radiation exposure (by 44.8%) to 5.3 mSv+/-1.1 (range, 3.4-8.5 mSv) (p<0.001), the dose without was 9.6 mSv+/-1.1 (range, 6.3-11.1). Image noise in the coronary arteries was not different between both groups with 29.8 and 30.5 SD [HU], respectively. CNR in the 100 kV group was with 20.9+/-6.8 for the coronary arteries and with 19.9+/-5.9 for the aorta similar to the 120 kV group. Intraluminal CT-attenuation (HU) of the coronary arteries were higher in the 100 kV group (p<0.001). Image quality on 100 kV scans was excellent in 86.3%, good in 9.2%, acceptable in 3.1% of coronary segments; 1.4% were non-interpretable (in 1/4 due to increased image noise because of BMI >25 kg/m(2)). CONCLUSIONS The 100 kV protocol significantly reduces the radiation dose in CCTA in patients with a low BMI <25 kg/m(2) and a low calcium load while maintaining high image quality and the advantages of helical scan algorithm.