A novel ultrasonic technique for differentiating cysts from solid lesions: preliminary results in the breast

Hydrophone Spatial Averaging Correction for Acoustic Exposure Measurements From Arrays-Part I: Theory and Impact on Diagnostic Safety Indexes

This article reports underestimation of mechanical index (MI) and nonscanned thermal index for bone near focus (TIB) due to hydrophone spatial averaging effects that occur during acoustic output measurements for clinical linear and phased arrays. TIB is the appropriate version of thermal index (TI) for fetal imaging after ten weeks from the last menstrual period according to the American Institute of Ultrasound in Medicine (AIUM). Spatial averaging is particularly troublesome for highly focused beams and nonlinear, nonscanned modes such as acoustic radiation force impulse (ARFI) and pulsed Doppler. MI and variants of TI (e.g., TIB), which are displayed in real-time during imaging, are often not corrected for hydrophone spatial averaging because a standardized method for doing so does not exist for linear and phased arrays. A novel analytic inverse-filter method to correct for spatial averaging for pressure waves from linear and phased arrays is derived in this article (Part I) and experimentally validated in a companion article (Part II). A simulation was developed to estimate potential spatial-averaging errors for typical clinical ultrasound imaging systems based on the theoretical inverse filter and specifications for 124 scanner/transducer combinations from the U.S. Food and Drug Administration (FDA) 510(k) database from 2015 to 2019. Specifications included center frequency, aperture size, acoustic output parameters, hydrophone geometrical sensitive element diameter, etc. Correction for hydrophone spatial averaging using the inverse filter suggests that maximally achievable values for MI, TIB, thermal dose ( t ₄₃ ), and spatial-peak-temporal-average intensity ( [Formula: see text]) for typical clinical systems are potentially higher than uncorrected values by (means ± standard deviations) 9% ± 4% (ARFI MI), 19% ± 15% (ARFI TIB), 50% ± 41% (ARFI t ₄₃ ), 43% ± 39% (ARFI [Formula: see text]), 7% ± 5% (pulsed Doppler MI), 15% ± 11% (pulsed Doppler TIB), 42% ± 31% (pulsed Doppler t ₄₃ ), and 33% ± 27% (pulsed Doppler [Formula: see text]). These values correspond to frequencies of 3.2 ± 1.3 (ARFI) and 4.1 ± 1.4 MHz (pulsed Doppler), and the model predicts that they would increase with frequency. Inverse filtering for hydrophone spatial averaging significantly improves the accuracy of estimates of MI, TIB, t ₄₃ , and [Formula: see text] for ARFI and pulsed Doppler signals.

Therapeutic Ultrasound in Cardiovascular Medicine

An advantage of therapeutic ultrasound (US) is the ability to cause controlled biological effects noninvasively. Depending on the magnitude and frequency of exposure parameters, US can interact in different ways with a variety of biological tissues. The development and clinical utility of therapeutic US techniques are now rapidly growing, especially with regard to the application of US pulses for cardiac pacing and the potential treatment of cardiovascular diseases. This review outlines the basic principles of US-based therapy in cardiology, including the acoustic properties of the cardiovascular tissue, and the use of US in therapeutic cardiovascular medicine.

Production of acoustic radiation force using ultrasound: methods and applications

INTRODUCTION

Acoustic radiation force (ARF) is used in many biomedical applications. The transfer of momentum in acoustic waves can be used in a multitude of ways to perturb tissue and manipulate cells.

AREAS COVERED

This review will briefly cover the acoustic theory related to ARF, particularly that related to application in tissues. The use of ARF in measurement of mechanical properties will be treated in detail with emphasis on the spatial and temporal modulation of the ARF. Additional topics covered will be the manipulation of particles with ARF, correction of phase aberration with ARF, modulation of cellular behavior with ARF, and bioeffects related to ARF use.

EXPERT COMMENTARY

The use of ARF can be tailored to specific applications for measurements of mechanical properties or correction of focusing for ultrasound beams. Additionally, noncontact manipulation of particles and cells with ARF enables a wide array of applications for tissue engineering and biosensing.

Mechanical and Biological Effects of Ultrasound: A Review of Present Knowledge

Ultrasound is widely used for medical diagnosis and increasingly for therapeutic purposes. An understanding of the bio-effects of sonography is important for clinicians and scientists working in the field because permanent damage to biological tissues can occur at high levels of exposure. Here the underlying principles of thermal mechanisms and the physical interactions of ultrasound with biological tissues are reviewed. Adverse health effects derived from cellular studies, animal studies and clinical reports are reviewed to provide insight into the in vitro and in vivo bio-effects of ultrasound.

Speckle tracking and speckle content based composite strain imaging for solid and fluid filled lesions

Strain imaging though for solid lesions provides an effective way for determining their pathologic condition by displaying the tissue stiffness contrast, for fluid filled lesions such an imaging is yet an open problem. In this paper, we propose a novel speckle content based strain imaging technique for visualization and classification of fluid filled lesions in elastography after automatic identification of the presence of fluid filled lesions. Speckle content based strain, defined as a function of speckle density based on the relationship between strain and speckle density, gives an indirect strain value for fluid filled lesions. To measure the speckle density of the fluid filled lesions, two new criteria based on oscillation count of the windowed radio frequency signal and local variance of the normalized B-mode image are used. An improved speckle tracking technique is also proposed for strain imaging of the solid lesions and background. A wavelet-based integration technique is then proposed for combining the strain images from these two techniques for visualizing both the solid and fluid filled lesions from a common framework. The final output of our algorithm is a high quality composite strain image which can effectively visualize both solid and fluid filled breast lesions in addition to the speckle content of the fluid filled lesions for their discrimination. The performance of our algorithm is evaluated using the in vivo patient data and compared with recently reported techniques. The results show that both the solid and fluid filled lesions can be better visualized using our technique and the fluid filled lesions can be classified with good accuracy.

Measurement of sound pressure and temperature in tissue-mimicking material using an optical fiber Bragg grating sensor

PURPOSE

The experimental investigation of an optical fiber Bragg grating (FBG) sensor for biomedical application is described. The FBG sensor can be used to measure sound pressure and temperature rise simultaneously in biological tissues exposed to ultrasound. The theoretical maximum values that can be measured with the FBG sensor are 73.0 MPa and 30 °C.

METHODS

In this study, measurement of sound pressure up to 5 MPa was performed at an ultrasound frequency of 2 MHz. A maximum temperature change of 6 °C was measured in a tissue-mimicking material.

RESULTS

Values yielded by the FBG sensor agreed with those measured using a thermocouple and a hydrophone.

CONCLUSION

Since this sensor is used to monitor the sound pressure and temperature simultaneously, it can also be used for industrial applications, such as ultrasonic cleaning of semiconductors under controlled temperatures.

Jitter reduction technique for acoustic radiation force impulse microscopy via photoacoustic detection

We demonstrate a jitter noise reduction technique for acoustic radiation force impulse microscopy via photoacoustic detection (PA-ARFI), which promises to be capable of measuring cell mechanics. To reduce the jitter noise induced by Q-switched pulsed laser operated at high repetition frequency, photoacoustic signals from the surface of an ultrasound transducer are aligned by cross-correlation and peak-to-peak detection, respectively. Each method is then employed to measure the displacements of a target sample in an agar phantom and a breast cancer cell due to ARFI application, followed by the quantitative comparison between their performances. The suggested methods for PA-ARFI significantly reduce jitter noises, thus allowing us to measure displacements of a target cell due to ARFI application by less than 3 μm.

Non-contact acoustic radiation force impulse microscopy via photoacoustic detection for probing breast cancer cell mechanics

We demonstrate a novel non-contact method: acoustic radiation force impulse microscopy via photoacoustic detection (PA-ARFI), capable of probing cell mechanics. A 30 MHz lithium niobate ultrasound transducer is utilized for both detection of phatoacoustic signals and generation of acoustic radiation force. To track cell membrane displacements by acoustic radiation force, functionalized single-walled carbon nanotubes are attached to cell membrane. Using the developed microscopy evaluated with agar phantoms, the mechanics of highly- and weakly-metastatic breast cancer cells are quantified. These results clearly show that the PA-ARFI microscopy may serve as a novel tool to probe mechanics of single breast cancer cells.

Quantitative analysis of liver fibrosis in rats with shearwave dispersion ultrasound vibrometry: comparison with dynamic mechanical analysis

Ultrasonic elastography, a non-invasive technique for assessing the elasticity properties of tissues, has shown promising results for disease diagnosis. However, biological soft tissues are viscoelastic in nature. Shearwave dispersion ultrasound vibrometry (SDUV) can simultaneously measure the elasticity and viscosity of tissue using shear wave propagation speeds at different frequencies. In this paper, the viscoelasticity of rat livers was measured quantitatively by SDUV for normal (stage F0) and fibrotic livers (stage F2). Meanwhile, an independent validation study was presented in which SDUV results were compared with those derived from dynamic mechanical analysis (DMA), which is the only mechanical test that simultaneously assesses the viscoelastic properties of tissue. Shear wave speeds were measured at frequencies of 100, 200, 300 and 400 Hz with SDUV and the storage moduli and loss moduli were measured at the frequency range of 1-40 Hz with DMA. The Voigt viscoelastic model was used in the two methods. The mean elasticity and viscosity obtained by SDUV ranged from 0.84±0.13 kPa (F0) to 1.85±0.30 kPa (F2) and from 1.12±0.11 Pa s (F0) to 1.70±0.31 Pa s (F2), respectively. The mean elasticity and viscosity derived from DMA ranged from 0.62±0.09 kPa (F0) to 1.70±0.84 kPa (F2) and from 3.38±0.32 Pa s (F0) to 4.63±1.30 Pa s (F2), respectively. Both SDUV and DMA demonstrated that the elasticity of rat livers increased from stage F0 to F2, a finding which was consistent with previous literature. However, the elasticity measurements obtained by SDUV had smaller differences than those obtained by DMA, whereas the viscosities obtained by the two methods were obviously different. We suggest that the difference could be related to factors such as tissue microstructure, the frequency range, sample size and the rheological model employed. For future work we propose some improvements in the comparative tests between SDUV and DMA, such as enlarging the harmonic frequency range of the shear wave to highlight the role of viscosity, finding an appropriate rheological model to improve the accuracy of tissue viscoelasticity estimations.

Simulation of nonlinear Westervelt equation for the investigation of acoustic streaming and nonlinear propagation effects

This study investigates the influence of blood flow on temperature distribution during high-intensity focused ultrasound (HIFU) ablation of liver tumors. A three-dimensional acoustic-thermal-hydrodynamic coupling model is developed to compute the temperature field in the hepatic cancerous region. The model is based on the nonlinear Westervelt equation, bioheat equations for the perfused tissue and blood flow domains. The nonlinear Navier-Stokes equations are employed to describe the flow in large blood vessels. The effect of acoustic streaming is also taken into account in the present HIFU simulation study. A simulation of the Westervelt equation requires a prohibitively large amount of computer resources. Therefore a sixth-order accurate acoustic scheme in three-point stencil was developed for effectively solving the nonlinear wave equation. Results show that focused ultrasound beam with the peak intensity 2470 W/cm(2) can induce acoustic streaming velocities up to 75 cm/s in the vessel with a diameter of 3 mm. The predicted temperature difference for the cases considered with and without acoustic streaming effect is 13.5 °C or 81% on the blood vessel wall for the vein. Tumor necrosis was studied in a region close to major vessels. The theoretical feasibility to safely necrotize the tumors close to major hepatic arteries and veins was shown.

Acoustic radiation force elasticity imaging in diagnostic ultrasound

The development of ultrasound-based elasticity imaging methods has been the focus of intense research activity since the mid-1990s. In characterizing the mechanical properties of soft tissues, these techniques image an entirely new subset of tissue properties that cannot be derived with conventional ultrasound techniques. Clinically, tissue elasticity is known to be associated with pathological condition and with the ability to image these features in vivo; elasticity imaging methods may prove to be invaluable tools for the diagnosis and/or monitoring of disease. This review focuses on ultrasound-based elasticity imaging methods that generate an acoustic radiation force to induce tissue displacements. These methods can be performed noninvasively during routine exams to provide either qualitative or quantitative metrics of tissue elasticity. A brief overview of soft tissue mechanics relevant to elasticity imaging is provided, including a derivation of acoustic radiation force, and an overview of the various acoustic radiation force elasticity imaging methods.

Velocity measurement by vibro-acoustic Doppler

We describe the theoretical principles of a new Doppler method, which uses the acoustic response of a moving object to a highly localized dynamic radiation force of the ultrasound field to calculate the velocity of the moving object according to Doppler frequency shift. This method, named vibro-acoustic Doppler (VAD), employs two ultrasound beams separated by a slight frequency difference, Δf, transmitting in an X-focal configuration. Both ultrasound beams experience a frequency shift because of the moving objects and their interaction at the joint focal zone produces an acoustic frequency shift occurring around the low-frequency (Δf) acoustic emission signal. The acoustic emission field resulting from the vibration of the moving object is detected and used to calculate its velocity. We report the formula that describes the relation between Doppler frequency shift of the emitted acoustic field and the velocity of the moving object. To verify the theory, we used a string phantom. We also tested our method by measuring fluid velocity in a tube. The results show that the error calculated for both string and fluid velocities is less than 9.1%. Our theory shows that in the worst case, the error is 0.54% for a 25° angle variation for the VAD method compared with an error of -82.6% for a 25° angle variation for a conventional continuous wave Doppler method. An advantage of this method is that, unlike conventional Doppler, it is not sensitive to angles between the ultrasound beams and direction of motion.

Acoustic radiation force impulse (ARFI) imaging of zebrafish embryo by high-frequency coded excitation sequence

Acoustic radiation force impulse (ARFI) imaging has been developed as a non-invasive method for quantitative illustration of tissue stiffness or displacement. Conventional ARFI imaging (2-10 MHz) has been implemented in commercial scanners for illustrating elastic properties of several organs. The image resolution, however, is too coarse to study mechanical properties of micro-sized objects such as cells. This article thus presents a high-frequency coded excitation ARFI technique, with the ultimate goal of displaying elastic characteristics of cellular structures. Tissue mimicking phantoms and zebrafish embryos are imaged with a 100-MHz lithium niobate (LiNbO₃) transducer, by cross-correlating tracked RF echoes with the reference. The phantom results show that the contrast of ARFI image (14 dB) with coded excitation is better than that of the conventional ARFI image (9 dB). The depths of penetration are 2.6 and 2.2 mm, respectively. The stiffness data of the zebrafish demonstrate that the envelope is harder than the embryo region. The temporal displacement change at the embryo and the chorion is as large as 36 and 3.6 μm. Consequently, this high-frequency ARFI approach may serve as a remote palpation imaging tool that reveals viscoelastic properties of small biological samples.

AN OVERVIEW OF ELASTOGRAPHY - AN EMERGING BRANCH OF MEDICAL IMAGING

From times immemorial manual palpation served as a source of information on the state of soft tissues and allowed detection of various diseases accompanied by changes in tissue elasticity. During the last two decades, the ancient art of palpation gained new life due to numerous emerging elasticity imaging (EI) methods. Areas of applications of EI in medical diagnostics and treatment monitoring are steadily expanding. Elasticity imaging methods are emerging as commercial applications, a true testament to the progress and importance of the field.In this paper we present a brief history and theoretical basis of EI, describe various techniques of EI and, analyze their advantages and limitations, and overview main clinical applications. We present a classification of elasticity measurement and imaging techniques based on the methods used for generating a stress in the tissue (external mechanical force, internal ultrasound radiation force, or an internal endogenous force), and measurement of the tissue response. The measurement method can be performed using differing physical principles including magnetic resonance imaging (MRI), ultrasound imaging, X-ray imaging, optical and acoustic signals.Until recently, EI was largely a research method used by a few select institutions having the special equipment needed to perform the studies. Since 2005 however, increasing numbers of mainstream manufacturers have added EI to their ultrasound systems so that today the majority of manufacturers offer some sort of Elastography or tissue stiffness imaging on their clinical systems. Now it is safe to say that some sort of elasticity imaging may be performed on virtually all types of focal and diffuse disease. Most of the new applications are still in the early stages of research, but a few are becoming common applications in clinical practice.

Estimation of mechanical properties of a viscoelastic medium using a laser-induced microbubble interrogated by an acoustic radiation force

An approach to assess the mechanical properties of a viscoelastic medium using laser-induced microbubbles is presented. To measure mechanical properties of the medium, dynamics of a laser-induced cavitation microbubble in viscoelastic medium under acoustic radiation force was investigated. An objective lens with a 1.13 numerical aperture and an 8.0 mm working distance was designed to focus a 532 nm wavelength nanosecond pulsed laser beam and to create a microbubble at the desired location. A 3.5 MHz ultrasound transducer was used to generate acoustic radiation force to excite a laser-induced microbubble. Motion of the microbubble was tracked using a 25 MHz imaging transducer. Agreement between a theoretical model of bubble motion in a viscoelastic medium and experimental measurements was demonstrated. Young's modulii reconstructed using the laser-induced microbubble approach were compared with those measured using a direct uniaxial method over the range from 0.8 to 13 kPa. The results indicate good agreement between methods. Thus, the proposed approach can be used to assess the mechanical properties of a viscoelastic medium.

Acoustic radiation force-based elasticity imaging methods

Conventional diagnostic ultrasound images portray differences in the acoustic properties of soft tissues, whereas ultrasound-based elasticity images portray differences in the elastic properties of soft tissues (i.e. stiffness, viscosity). The benefit of elasticity imaging lies in the fact that many soft tissues can share similar ultrasonic echogenicities, but may have different mechanical properties that can be used to clearly visualize normal anatomy and delineate pathological lesions. Acoustic radiation force-based elasticity imaging methods use acoustic radiation force to transiently deform soft tissues, and the dynamic displacement response of those tissues is measured ultrasonically and is used to estimate the tissue's mechanical properties. Both qualitative images and quantitative elasticity metrics can be reconstructed from these measured data, providing complimentary information to both diagnose and longitudinally monitor disease progression. Recently, acoustic radiation force-based elasticity imaging techniques have moved from the laboratory to the clinical setting, where clinicians are beginning to characterize tissue stiffness as a diagnostic metric, and commercial implementations of radiation force-based ultrasonic elasticity imaging are beginning to appear on the commercial market. This article provides an overview of acoustic radiation force-based elasticity imaging, including a review of the relevant soft tissue material properties, a review of radiation force-based methods that have been proposed for elasticity imaging, and a discussion of current research and commercial realizations of radiation force based-elasticity imaging technologies.

Axial-shear strain imaging for differentiating benign and malignant breast masses

Axial strain imaging has been utilized for the characterization of breast masses for over a decade; however, another important feature namely the shear strain distribution around breast masses has only recently been used. In this article, we examine the feasibility of utilizing in vivo axial-shear strain imaging for differentiating benign from malignant breast masses. Radio-frequency data was acquired using a VFX 13-5 linear array transducer on 41 patients using a Siemens SONOLINE Antares real-time clinical scanner at the University of Wisconsin Breast Cancer Center. Free-hand palpation using deformations of up to 10% was utilized to generate axial strain and axial-shear strain images using a two-dimensional cross-correlation algorithm from the radio-frequency data loops. Axial-shear strain areas normalized to the lesion size, applied strain and lesion strain contrast was utilized as a feature for differentiating benign from malignant masses. The normalized axial-shear strain area feature estimated on eight patients with malignant tumors and 33 patients with fibroadenomas was utilized to demonstrate its potential for lesion differentiation. Biopsy results were considered the diagnostic standard for comparison. Our results indicate that the normalized axial-shear strain area is significantly larger for malignant tumors compared with benign masses such as fibroadenomas. Axial-shear strain pixel values greater than a specified threshold, including only those with correlation coefficient values greater than 0.75, were overlaid on the corresponding B-mode image to aid in diagnosis. A scatter plot of the normalized area feature demonstrates the feasibility of developing a linear classifier to differentiate benign from malignant masses. The area under the receiver operator characteristic curve utilizing the normalized axial-shear strain area feature was 0.996, demonstrating the potential of this feature to noninvasively differentiate between benign and malignant breast masses.

Biomedical applications of radiation force of ultrasound: historical roots and physical basis

Radiation force is a universal phenomenon in any wave motion, electromagnetic or acoustic. Although acoustic and electromagnetic waves are both characterized by time variation of basic quantities, they are also both capable of exerting a steady force called radiation force. In 1902, Lord Rayleigh published his classic work on the radiation force of sound, introducing the concept of acoustic radiation pressure, and some years later, further fundamental contributions to the radiation force phenomenon were made by L. Brillouin and P. Langevin. Many of the studies discussing radiation force published before 1990 were related to techniques for measuring acoustic power of therapeutic devices; also, radiation force was one of the factors considered in the search for noncavitational, nonthermal mechanisms of ultrasonic bioeffects. A major surge in various biomedical applications of acoustic radiation force started in the 1990s and continues today. Numerous new applications emerged including manipulation of cells in suspension, increasing the sensitivity of biosensors and immunochemical tests, assessing viscoelastic properties of fluids and biological tissues, elasticity imaging, monitoring ablation of lesions during ablation therapy, targeted drug and gene delivery, molecular imaging and acoustical tweezers. We briefly present in this review the major milestones in the history of radiation force and its biomedical applications. In discussing the physical basis of radiation force and its applications, we present basic equations describing the relationship of radiation stress with parameters of acoustical fields and with the induced motion in the biological media. Momentum and force associated with a plane-traveling wave, equations for nonlinear and nonsteady-state acoustic streams, radiation stress tensor for solids and biological tissues and radiation force acting on particles and microbubbles are considered.

Diversity of biomedical applications of acoustic radiation force

This manuscript is a summary of the paper presented at the ICU'2009 on biomedical applications of acoustic radiation force with emphasis on emerging applications in microfluidics, biotechnology, biosensors and assessment of the skeletal system. In this brief overview of current and projected applications of radiation force, no detailed description of the experiments illustrating particular applications are given as this would result in a far different and longer paper. Various mechanisms of acoustic radiation force generations and their biomedical applications are considered. These mechanisms include: (a) change in the density of energy of the propagating wave due to absorption and scattering; (b) spatial variations of energy density in standing acoustic waves; (c) reflection from inclusions, walls or other interfaces; and (d) spatial variations in propagation velocity. The widest area of biomedical applications of radiation force is related to medical diagnostics, to assessing viscoelastic properties of biological tissues and fluids, and specifically to elasticity imaging. Another actively explored area is related to manipulation of biological cells and particles in standing ultrasonic wave fields. There are several poorly explored areas of potential biomedical applications of ultrasound radiation force. A promising area of biomedical application of ultrasound radiation force is stirring and mixing of microvolumes of liquids in microfluidics and in various biotechnological application where diffusion rate is the main factor limiting the efficiency of the process of interest. A new technique, called "swept frequency method", based on the use of radiation force in the standing acoustic wave for microstirring of liquids is described. The potential applications of the ultrasound radiation force for assessment of skeletal system, where conventional bone ultrasonometry are inapplicable are considered.

Quantitative assessment of breast lesion viscoelasticity: initial clinical results using supersonic shear imaging

This paper presents an initial clinical evaluation of in vivo elastography for breast lesion imaging using the concept of supersonic shear imaging. This technique is based on the combination of a radiation force induced in tissue by an ultrasonic beam and an ultrafast imaging sequence capable of catching in real time the propagation of the resulting shear waves. The local shear wave velocity is recovered using a time-offlight technique and enables the 2-D mapping of shear elasticity. This imaging modality is implemented on a conventional linear probe driven by a dedicated ultrafast echographic device. Consequently, it can be performed during a standard echographic examination. The clinical investigation was performed on 15 patients, which corresponded to 15 lesions (4 cases BI-RADS 3, 7 cases BI-RADS 4 and 4 cases BI-RADS 5). The ability of the supersonic shear imaging technique to provide a quantitative and local estimation of the shear modulus of abnormalities with a millimetric resolution is illustrated on several malignant (invasive ductal and lobular carcinoma) and benign cases (fibrocystic changes and viscous cysts). In the investigated cases, malignant lesions were found to be significantly different from benign solid lesions with respect to their elasticity values. Cystic lesions have shown no shear wave propagate at all in the lesion (because shear waves do not propage in liquid). These preliminary clinical results directly demonstrate the clinical feasibility of this new elastography technique in providing quantitative assessment of relative stiffness of breast tissues. This technique of evaluating tissue elasticity gives valuable information that is complementary to the B-mode morphologic information. More extensive studies are necessary to validate the assumption that this new mode potentially helps the physician in both false-positive and false-negative rejection.

The risk of exposure to diagnostic ultrasound in postnatal subjects: nonthermal mechanisms

This review examines the nonthermal physical mechanisms by which ultrasound can harm tissue in postnatal patients. First the physical nature of the more significant interactions between ultrasound and tissue is described, followed by an examination of the existing literature with particular emphasis on the pressure thresholds for potential adverse effects. The interaction of ultrasonic fields with tissue depends in a fundamental way on whether the tissue naturally contains undissolved gas under normal physiologic conditions. Examples of gas-containing tissues are lung and intestine. Considerable effort has been devoted to investigating the acoustic parameters relevant to the threshold and extent of lung hemorrhage. Thresholds as low as 0.4 MPa at 1 MHz have been reported. The situation for intestinal damage is similar, although the threshold appears to be somewhat higher. For other tissues, auditory stimulation or tactile perception may occur, if rarely, during exposure to diagnostic ultrasound; ultrasound at similar or lower intensities is used therapeutically to accelerate the healing of bone fractures. At the exposure levels used in diagnostic ultrasound, there is no consistent evidence for adverse effects in tissues that are not known to contain stabilized gas bodies. Although modest tissue damage may occur in certain identifiable applications, the risk for induction of an adverse biological effect by a nonthermal mechanism due to exposure to diagnostic ultrasound is extremely small.

Feasibility of measuring acoustic streaming for improved diagnosis of rhinosinusitis

No noninvasive methods exist currently with the capability of distinguishing between various stages of a sinus infection. We studied a method based on induced acoustic streaming in the accumulated fluid within the maxillary sinuses. The hypothesis was that acoustic streaming will not be induced at clinically acceptable intensity levels in infectious mucous fluid because of its high viscosity, whereas detected acoustic streaming is a strong indication that the sinus content is a noninfectious serous fluid. As a model, an anthropomorphic sinus phantom with bovine cortical bone to mimic the bone surrounding the maxillary sinus was constructed. Milk (1.5% fat content) was used as model fluid. From fluid and bone attenuation measurements, an ultrasound frequency of about 5 MHz was estimated to produce the highest acoustic streaming in the sinus phantom. Simulations of the acoustic streaming in a sealed cavity also showed that the width of the ultrasound beam should be about half the size of the cavity to optimize the streaming velocity. With a 4.9-MHz continuous-wave transducer operating at a spatial peak temporal average intensity (I(spta)) of 640 mW/cm(2), an acoustic streaming velocity of 0.19 cm/s was generated and detected in the sinus phantom.

Ultrasound-biophysics mechanisms

Ultrasonic biophysics is the study of mechanisms responsible for how ultrasound and biological materials interact. Ultrasound-induced bioeffect or risk studies focus on issues related to the effects of ultrasound on biological materials. On the other hand, when biological materials affect the ultrasonic wave, this can be viewed as the basis for diagnostic ultrasound. Thus, an understanding of the interaction of ultrasound with tissue provides the scientific basis for image production and risk assessment. Relative to the bioeffect or risk studies, that is, the biophysical mechanisms by which ultrasound affects biological materials, ultrasound-induced bioeffects are generally separated into thermal and non-thermal mechanisms. Ultrasonic dosimetry is concerned with the quantitative determination of ultrasonic energy interaction with biological materials. Whenever ultrasonic energy is propagated into an attenuating material such as tissue, the amplitude of the wave decreases with distance. This attenuation is due to either absorption or scattering. Absorption is a mechanism that represents that portion of ultrasonic wave that is converted into heat, and scattering can be thought of as that portion of the wave, which changes direction. Because the medium can absorb energy to produce heat, a temperature rise may occur as long as the rate of heat production is greater than the rate of heat removal. Current interest with thermally mediated ultrasound-induced bioeffects has focused on the thermal isoeffect concept. The non-thermal mechanism that has received the most attention is acoustically generated cavitation wherein ultrasonic energy by cavitation bubbles is concentrated. Acoustic cavitation, in a broad sense, refers to ultrasonically induced bubble activity occurring in a biological material that contains pre-existing gaseous inclusions. Cavitation-related mechanisms include radiation force, microstreaming, shock waves, free radicals, microjets and strain. It is more challenging to deduce the causes of mechanical effects in tissues that do not contain gas bodies. These ultrasonic biophysics mechanisms will be discussed in the context of diagnostic ultrasound exposure risk concerns.

What is ultrasound?

This paper is based on material presented at the start of a Health Protection Agency meeting on ultrasound and infrasound. In answering the question 'what is ultrasound?', it shows that the simple description of a wave which transports mechanical energy through the local vibration of particles at frequencies of 20 kHz or more, with no net transport of the particles themselves, can in every respect be misleading or even incorrect. To explain the complexities responsible for this, the description of ultrasound is first built up from the fundamental properties of these local particle vibrations. This progresses through an exposition of the characteristics of linear waves, in order to explain the propensity for, and properties of, the nonlinear propagation which occurs in many practical ultrasonic fields. Given the Health Protection environment which framed the original presentation, explanation and examples are given of how these complexities affect issues of practical importance. These issues include the measurement and description of fields and exposures, and the ability of ultrasound to affect tissue (through microstreaming, streaming, cavitation, heating, etc.). It is noted that there are two very distinct regimes, in terms of wave characteristics and potential for bioeffect. The first concerns the use of ultrasound in liquids/solids, for measurement or material processing. For biomedical applications (where these two processes are termed diagnosis and therapy, respectively), the issue of hazard has been studied in depth, although this has not been done to such a degree for industrial uses of ultrasound in liquids/solids (sonar, non-destructive testing, ultrasonic processing etc.). However, in the second regime, that of the use of ultrasound in air, although the waves in question tend to be of much lower intensities than those used in liquids/solids, there is a greater mismatch between the extent to which hazard has been studied, and the growth in commercial applications for airborne ultrasound.

Ultrasound and matter—Physical interactions

The basic physical characteristics of ultrasound waves are reviewed in terms of the typical displacements, velocities, accelerations and pressures generated in various fluid media as a function of frequency. The effects on wave propagation of interfaces are considered, and the way in which waves are reflected, transmitted and mode converted at interfaces introduced. Then the nonlinear propagation of high amplitude ultrasound is explained, and its consequences, including the generation of harmonic frequencies and enhanced attenuation, considered. The absorption of ultrasonic waves and the resulting heat deposition in absorbing media are described together with factors determining the resulting temperature rises obtained. In the case of tissue these include conduction and perfusion. The characteristics of cavitation in fluid media are also briefly covered. Finally, secondary nonlinear physical effects are described. These include radiation forces on interfaces and streaming in fluids.

Quantification of risk from fetal exposure to diagnostic ultrasound

Biomedical ultrasound may induce adverse effects in patients by either thermal or non-thermal means. Temperatures above normal can adversely affect biological systems, but effects also may be produced without significant heating. Thermally induced teratogenesis has been demonstrated in many animal species as well as in a few controlled studies in humans. Various maximum 'safe' temperature elevations have been proposed, although the suggested values range from 0.0 to 2.5 degrees C. Factors relevant to thermal effects are considered, including the nature of the acoustic field in situ, the state of perfusion of the embryo/fetus, and the variation of sensitivity to thermal insult with gestational stage of development. Non-thermal mechanisms of action considered include acoustic cavitation, radiation force, and acoustic streaming. While cavitation can be quite destructive, it is extremely unlikely in the absence of stabilized gas bodies, and although the remaining mechanisms may occur in utero, they have not been shown to induce adverse effects. For example, pulsed, diagnostic ultrasound can increase fetal activity during exposure, apparently due to stimulation of auditory perception by radiation forces on the fetal head or auditory structures. In contrast, pulsed ultrasound also produces vascular damage near developing bone in the late-gestation mouse, but by a unknown mechanism and at levels above current US FDA output limits. It is concluded that: (1) thermal rather than nonthermal mechanisms are more likely to induce adverse effects in utero, and (2) while the probability of an adverse thermal event is usually small, under some conditions it can be disturbingly high.

Acoustic streaming in lithotripsy fields: preliminary observation using a particle image velocimetry method

This study considers the acoustic streaming in water produced by a lithotripsy pulse. Particle image velocimetry (PIV) method was employed to visualize the acoustic streaming produced by an electromagnetic shock wave generator using video images of the light scattering particles suspended in water. Visualized streaming features including several local peaks and vortexes around or at the beam focus were easily seen with naked eyes over all settings of the lithotripter from 10 to 18 kV. Magnitudes of the peak streaming velocity measured vary in the range of 10-40 mm s(-1) with charging voltage settings. Since the streaming velocity was estimated on the basis of a series of the video images of particles averaged over 1/60s, the time resolution limited by the video frame rate which is 1-2 orders of magnitude larger than driving acoustic activities, measured velocities are expected to be underestimated and were shown a similar order of magnitude lower than those calculated from a simple theoretical consideration. Despite such an underestimation, it was shown that, as predicted by theory, the magnitude of the streaming velocity measured by the present PIV method was proportional to acoustic intensity. In particular it has almost a linear correlation with peak negative pressures (r=0.98683, p=0.0018).

Model-based ultrasound tomography: Tissue phantom experiments

We present a detailed experimental study to evaluate our finite element based nonlinear reconstruction algorithm for recovery of acoustic properties in heterogeneous scattering media. Using a circularly scanning ultrasound system at 500 KHz, tissue phantom experiments were performed to study spatial resolution and contrast issues in model-based ultrasound tomography. Our results show that both acoustic attenuation and speed images can be quantitatively reconstructed in terms of the location, size, shape, and acoustic property value of the target when different contrast levels between the target and background were used. We also demonstrate that a high contrast target as small as 3 mm in diameter can be quantitatively resolved with our acoustic speed and attenuation images.

Acoustic streaming in ovarian cysts

OBJECTIVE

The purpose of this study was to investigate the hypothesis that endometriomas do not show acoustic streaming and then to quantify the streaming velocity of the particles within ovarian cysts that do show acoustic streaming.

METHODS

Ovarian cysts greater than 2 cm in diameter, with internal echoes seen on B-mode sonography, were prospectively evaluated for the presence of acoustic streaming. If acoustic streaming was present, a 2-mm pulsed Doppler sample volume was then placed within the distal portion of the cyst, and the streaming velocity was recorded. Follow-up included review of subsequent sonographic examinations, surgical notes, and histopathologic reports, with the latter being considered the final results if available.

RESULTS

Acoustic streaming was detected in 10 (38%) of 26 ovarian cysts, but of the 10 endometriomas, none (0%) showed acoustic streaming (P = .002). Acoustic streaming was detected in 86% (n = 6) of cystadenomas. Four of these were serous cystadenomas, which all showed acoustic streaming, with a velocity range of 1.5 to 3.6 cm/s. Two mucinous cystadenomas showed acoustic streaming with velocities of 0.8 and 2.0 cm/s.

CONCLUSIONS

Endometriomas appear as cysts containing homogeneous, low-level, "ground glass" echoes on gray scale sonography. Other types of ovarian cysts can also have these appearances. Endometriomas do not show acoustic streaming. Cystadenomas may have streaming velocities within a defined range. Acoustic streaming assessment may therefore prove to be an additional useful tool in assessing ovarian cysts and in completely excluding endometrioma as a diagnosis if a cyst shows acoustic streaming.

Outcomes of sonography-based management of breast cysts

BACKGROUND

Ultrasound is commonly used during diagnosis of breast lesions. Our purpose was to study the role of sonography for risk stratification of malignancy in the diagnosis and management of palpable breast cysts.

METHODS

This was a cohort study of 176 patients with palpable breast cysts. Sonographic findings were correlated with clinical and pathologic outcomes.

RESULTS

Mean cyst size was 2.0 +/- 1.8 cm. Cysts were simple, complex and probably benign, and complex and suspicious for neoplasm in 82.25%, 10.25% and 7.5% of patients, respectively. Thick cyst wall (P = 0.0001), mural tumor (P <0.00001), eccentric mass (P = 0.034), and internal septae (P = 0.031) were predictive of neoplasm. Of cysts >3 cm, 33% were cancerous (P = 0.000027). After 378 days of follow-up, 26 % of cysts had recurred. Recurrence was more frequent in patients with bilateral or multiple cysts (P = 0.004).

CONCLUSIONS

Sonography is useful in risk stratification of malignancy in breast cysts. There is a high risk of recurrence after cyst aspiration.

Mechanical Bioeffects of Ultrasound

Ultrasound is used widely in medicine as both a diagnostic and therapeutic tool. Through both thermal and nonthermal mechanisms, ultrasound can produce a variety of biological effects in tissues in vitro and in vivo. This chapter provides an overview of the fundamentals of key nonthermal mechanisms for the interaction of ultrasound with biological tissues. Several categories of mechanical bioeffects of ultrasound are then reviewed to provide insight on the range of ultrasound bioeffects in vivo, the relevance of these effects to diagnostic imaging, and the potential application of mechanical bioeffects to the design of new therapeutic applications of ultrasound in medicine.

Acoustic streaming: an in vitro study

The aims of this study were, first, to determine if cyst size and cyst-to-transducer distance have an impact upon acoustic streaming and, second, to investigate the effect of cyst content viscosity on acoustic streaming using an artificial ovarian cyst model. Artificial ovarian cysts were constructed and suspended in a tissue-mimicking bath. Although there was no subjective difference in acoustic streaming velocity between cyst sizes during B-mode insonation, with colour Doppler and pulsed Doppler examination, higher acoustic streaming scores were recorded for larger cysts. When the cyst-to-transducer distance was increased, the acoustic streaming velocity was noted to decrease in all scanning modalities. The second stage of the study demonstrated decreasing acoustic streaming velocity as the viscosity of the cyst content was increased. The finding of a clear association between cyst content viscosity and acoustic streaming velocity raises the exciting possibility that we may be able to make estimations of the viscosity of ovarian cyst contents, in the clinical setting, by sonographic means.

Acoustic streaming: a new technique for assessing adnexal cysts

OBJECTIVES

To determine whether acoustic streaming has clinical value in the differentiation between various ovarian and adnexal cysts.

METHODS

We assessed 29 adnexal cysts, for which pathological diagnosis was available, for the presence of acoustic streaming during B-mode and color sonographic evaluation.

RESULTS

Acoustic streaming was detected in 15 (52%) of the cysts. The most common cyst, endometrioma (n = 7), did not exhibit acoustic streaming in any case, while of the remaining 22 cysts, 15 exhibited acoustic streaming (P = 0.0017). Dermoid cysts exhibited acoustic streaming in two of six (33%) cases. In addition acoustic streaming was noted in two of two (100%) hemorrhagic cysts, eight of ten (80%) cystadenomas, two of three (67%) malignant cysts and in the one abscess.

CONCLUSIONS

Acoustic streaming is the first sonographic feature that may be able to completely exclude endometrioma as a possible diagnosis for an adnexal cyst.

Application of nonlinear phenomena induced by focused ultrasound to bone imaging

A tissue deformability image is obtained with the vibroacoustography imaging method using mechanical low-frequency (LF) excitation. This ultrasonic excitation is created locally by means of a focused annular array emitting two primary beams at two close frequencies, f(1) and f(2) (f(2) = f(1) + f(LF)). The LF acoustic emission resulting from the vibration of the medium is detected by a sensitive hydrophone and then used to form the image. This noninvasive imaging method was demonstrated in this study to be suitable for bone imaging, with x and y transverse resolutions less than 300 micro m. Two bone sites susceptible to demineralization were tested: the calcaneus and the neck of the femur. The vibroacoustic method provides valuable ultrasonic images regarding the structure and the elastic properties of bone tissue. Correlation was made between vibroacoustic bone images, performed in vitro, and images acquired by other imaging methods (i.e., bone ultrasound attenuation and x-ray computerized tomography (CT)). Moreover, the amplitudes of vibroacoustic signals radiating from phosphocalcic ceramic samples (bone substitute) of different porosity were evaluated. The good correlation between these results and the description of our images and the quality of vibroacoustic images indicate that bone decalcification could be detected using vibroacoustography.

Acoustic radiation force impulse imaging: in vivo demonstration of clinical feasibility

The clinical viability of a method of acoustic remote palpation, capable of imaging local variations in the mechanical properties of soft tissue using acoustic radiation force impulse (ARFI) imaging, is investigated in vivo. In this method, focused ultrasound (US) is used to apply localized radiation force to small volumes of tissue (2 mm(3)) for short durations (less than 1 ms) and the resulting tissue displacements are mapped using ultrasonic correlation-based methods. The tissue displacements are inversely proportional to the stiffness of the tissue and, thus, a stiffer region of tissue exhibits smaller displacements than a more compliant region. Due to the short duration of the force application, this method provides information about the mechanical impulse response of the tissue, which reflects variations in tissue viscoelastic characteristics. In this paper, experimental results are presented demonstrating that displacements on the order of 10 microm can be generated and detected in soft tissues in vivo using a single transducer on a modified diagnostic US scanner. Differences in the magnitude of displacement and the transient response of tissue are correlated with tissue structures in matched B-mode images. The results comprise the first in vivo ARFI images, and support the clinical feasibility of a radiation force-based remote palpation imaging system.

Quantitative investigation of acoustic streaming in blood

Acoustic streaming may have practical utility in diagnostic medical ultrasound in distinguishing between stagnant blood and tissue as well as clotted and unclotted blood. This distinction can be difficult with conventional ultrasound but have high value in managing trauma patients with internal hemorrhage. Ultrasound energy applies a force to blood by momentum transfer, resulting in bulk streaming that is a function of the acoustic attenuation, sound speed, acoustic intensity, blood viscosity, and the boundary conditions posed by the geometry around the hematoma. A simple tubular model was studied analytically, by finite element simulation, and experimentally by in vitro measurement. The simulation agreed closely with measurements while the analytic solutions were found to be valid only for beam diameters approximating the diameter of the tubular channel. Experimentally, the acoustic streaming in blood decreased as the blood began to clot and the streaming flow was not detected in clotted blood. In contrast, the echogenicity of the same blood samples did not change appreciably from the unclotted to the clotted state for the stagnant blood studied. Streaming detection appears to offer a potential tool for improving hemorrhage diagnosis.

Color Doppler detection of acoustic streaming in a hematoma model

Accurate differentiation between stagnant blood and soft tissue or clotted and unclotted blood has potential value in managing trauma patients with internal hemorrhage. Determination by regular ultrasound (US) imaging is sometimes difficult because the sonographic appearance of blood, clots and soft tissue may be similar. A hematoma model was developed to investigate the use of acoustic streaming for hematoma diagnosis in an in vivo environment. The results showed that a derated spatial peak temporal average (SPTA) intensity of 30 W/cm(2) was needed to generate color-Doppler-detectable streaming in stirred blood. The streaming velocity increased in proportion to the derated intensity. Streaming was also detected in stagnant blood, but at higher intensities. In clots, streaming was not detected even at high intensities. The streaming detection may be a valuable tool for improving the distinction between liquid blood and clots or soft tissue in hematoma diagnosis.

Measurement of acoustic streaming using magnetic resonance

Magnetic resonance imaging (MRI) has been used to explore acoustic streaming caused in water under ultrasonic exposure conditions similar to those used for diagnostic applications. Streaming was established in an enclosed tube with acoustically transparent end windows, using a pulsed, weakly-focused transducer of acoustic frequency 3.5 MHz. Phase-detection MRI was used to image and quantify streaming profiles in the region of the acoustic focus. Acoustic powers in the range 0.4 mW to 100 mW were used. The sensitivity of the technique enabled streaming velocities down to 0. 1 mm s(-1) to be measured, generated by acoustic power less than 1 mW. In addition, acoustic streaming generated within open meshes with minimum pore dimensions of 3.0 mm and 2.0 mm was measured. The flow velocity in the coarser mesh reached 0.9 mm s(-1) at 95 mW total acoustic power. These observations demonstrate that acoustic streaming is probably a much more general phenomenon in diagnostic ultrasound (ultrasound) than previously recognised. The combination of magnetic resonance and ultrasound shows promise as a diagnostic method for the differentiation of cystic lesions in vivo, and for their characterisation, with sensitivity significantly greater than using ultrasound alone.

Internal deformation of a uniform elastic solid by acoustic radiation force

Tissue elasticity estimation is a growing area of ultrasound research. One proposed approach would apply acoustic radiation force to displace tissue and use ultrasonic motion tracking techniques to measure the resultant displacement. Such a technique might allow noninvasive imaging of tissue elastic properties. The potential of this method will be limited by the magnitude of displacements which can be generated at reasonable acoustic intensity levels. This paper presents methods for estimating the internal displacements induced in an elastic solid by acoustic radiation force. These methods predict displacements on the order of 400 microns in the human vitreous body, 0.008 micron in human breast, and 0.020 micron in human liver at an acoustic intensity of 1.0 W/cm2 (in water) and an operating frequency of 10 MHz. While the displacement generated in the vitreous should be readily detectable using ultrasonic methods, the displacements generated in the breast and liver will be much more difficult to detect. Methods are also developed for predicting the time dependent temperature increases associated with attenuated acoustic fields in the absence of perfusion. These results indicate promise for radiation force imaging in the vitreous, but potential difficulties in applying these techniques in other parts of the body.

The use of acoustic streaming in breast lesion diagnosis: a clinical study

Results from a clinical study are presented, in which ultrasonically-induced acoustic streaming was successfully used to differentiate fluid-filled lesions (cysts) from solid lesions in the breast. In this study, high-intensity ultrasound pulses from a modified commercial scanner were used to induce acoustic streaming in cyst fluid, and this motion was detected using Doppler methods. Acoustic streaming was generated and detected in 14 of 15 simple cysts, and 4 of 14 sonographically indeterminate breast lesions. This lesion differentiation method appears to be particularly suited for diagnosis of small, possibly newer, cysts that appear indeterminate on conventional sonography due to their size. The results indicate that this method would be a useful adjunct to conventional sonography for the purpose of breast lesion classification.

Colour Doppler induced streaming: an indicator of the liquid nature of lesions

As sound waves traverse tissue, interaction with reflecting or absorbing obstacles results in a transfer of momentum from the wave to the medium. This generates a local force in the direction of propagation. If this occurs in a fluid medium, sufficient pressure may be generated to cause flow--"streaming". Generally, it is difficult to demonstrate this streaming in images using the usual diagnostic B-mode intensities, but the increased intensities in a colour Doppler (or power) region of interest enhance the phenomenon. This allows streaming to be both visualized by the motion of small particles and detected by colour change on the colour Doppler B-mode image. Borders of streaming between the simple grey scale image and the colour region may be easily seen, with retrograde flow in the regions subjected to a lower intensity. This phenomenon has been demonstrated in ocular, scrotal, thyroid, breast, ovarian and inflammatory collections or lesions, confirming the liquid nature, occasionally of fluid which is very echogenic due to contained debris. The technique is recommended as another tool which is available to most general ultrasound departments and will assist in the characterization of tissue.

Studies of acoustic streaming in biological fluids with an ultrasound Doppler technique

Acoustic streaming generated by diagnostic ultrasound fields is an important area for study both for safety reasons and because of its potential application as a diagnostic tool. A method of investigating streaming in biological fluids is reported. A number of fluids were insonated using a 3.5 MHz weakly focused single element transducer which was driven in pulsed mode. Streaming was detected in each fluid using an 8 MHz continuous wave Doppler system. The maximum streaming velocity was obtained by spectral analysis of the Doppler signal. Using this system longitudinal streaming profiles were measured. At an acoustic power of 150 mW the maximum streaming velocities detected were: 9.3 cm s-1 in water, 6.8 cm s-1 in 4.5% human serum albumin (HSA) solution and 4.9 cm s-1 in blood, when transmission was through a water path of approximately 10 cm into a 3 cm sample of fluid. When measurements were made in the biological fluids alone, without a water path, the maximum streaming velocities were reduced.