A new nonlinear parameter in the developed strain-to-applied strain of the soft tissues and its application in ultrasound elasticity imaging

Non-invasive Measurement of the Viscoelasticity of the Optic Nerve and Sclera for Assessing Papilledema: A Pilot Clinical Study

OBJECTIVE

The purpose of this study was to evaluate our novel ultrasound vibro-elastography (UVE) technique for assessing patients with papilledema by non-invasively measuring shear wave speed (SWS), elasticity and viscosity properties of the optic nerve and sclera.

METHODS

Shear wave speeds were measured at three frequencies-100, 150 and 200 Hz-on the optic nerve and sclera tissues for assessing patients with papilledema resulting from idiopathic intracranial hypertension (IIH). The method was evaluated in six papilledema patients and six controls on two separate locations for each participant (i.e., optic nerve and posterior sclera). SWSs of the optic nerve and sclera were analyzed by using a 2-D speed map technique within a circular region of interest (ROI) (i.e., the diameter of the ROI was 1.5 mm × 3.0 mm at the optic nerve and sclera, respectively). Elasticity and viscosity were then analyzed using the wave speed dispersion over the three frequencies.

RESULTS

We measured values of SWS at both locations, optic nerve and sclera, of the right eye and left eye at three different frequencies in IIH patients and controls. The SWS (mean ± standard deviation [m/s]) of the right eye was significantly higher at the sclera in IIH patients compared with controls (i.e., patients vs. controls: 5.91 ± 0.54 vs. 3.86 ± 0.56, p < 0.0001 at 100 Hz), but there was no significant difference at the optic nerve (i.e., patients vs. controls: 3.62 ± 0.39 vs. 3.36 ± 0.35, p = 0.1100 at 100Hz). We observed increased elasticity (kPa) in IIH patients, indicating there are significant differences in elasticity between patients and controls at the optic nerve and sclera (i.e., right eye [patients vs. controls]: 14.42 ± 6.59 vs. 6.5 ± 5.71, p = 0.0065 [optic nerve]; 33.04 ± 10.62 vs. 9.16 ± 7.15, p < 0.0001 [sclera]). Viscosity was also (Pa·s) higher in the sclera and optic nerve of the left eye (i.e., left eye [patient vs. control]: 8.89 ± 4.37 vs. 7.27 ± 5.01, p = 0.3790 (optic nerve); 16.05 ± 10.79 vs. 8.49 ± 6.09, p < 0.0194 [sclera]).

CONCLUSION

This research illustrates the feasibility of using our UVE system to evaluate stiffness of different tissues in the eye non-invasively. It suggests that the viscoelasticity of the posterior sclera is higher than that of the optic nerve. We found that the posterior sclera is stiffer than the optic nerve in patients with papilledema resulting from IIH, making UVE a potential non-invasive technique for assessing papilledema.

Quantitative Ultrasound to Assess Skeletal Muscles in Post Stroke Spasticity

Quantitative ultrasound (QUS) techniques such as pixel intensity, ultrasound strain, and shear wave elastography have made it possible to identify the echogenicity (brightness) and mechanical properties (stiffness) of normal and pathological tissues. These techniques can be utilized as an alternative diagnosis tool to assess post stroke spasticity. Current clinical assessment methods include the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS), which can result in inconsistencies due to their subjective nature. QUS provides robust approaches to assessing muscle stiffness associated with post stroke spasticity. Computer-aided pixel count quantifies tissue echogenicity in grayscale image. A strain ratio in ultrasound strain imaging compares the stiffness and movement (lengthening or shortening) of a spastic muscle with nonspecific muscle. In addition, shear wave elastography provides the shear wave velocity of an affected muscle that directly associated with the muscle stiffness before and after treatment for spasticity. This article reviews the theory behind these aforementioned concepts and discuss the relations between QUS and skeletal muscles in post stroke spasticity.

Breast Tumor Diagnosis Using Finite-Element Modeling Based on Clinical in vivo Elastographic Data

OBJECTIVES

This study exploited finite-element modeling (FEM) to simulate breast tissue multicompression during ultrasound elastography to classify breast tumors based on their nonlinear biomechanical properties.

METHODS

Numeric simulations were first calculated by using 3-dimensional (3D) virtual models with an assumed tumor's geometric dimensions but with actual material properties to test and validate the FEM. Further numeric simulations were used to construct 3D models based on in vivo experimental data to verify our models. The models were designed for each individual in vivo case, emphasizing the geometry, position, and biomechanical properties of the breast tissue. At different compression levels, tissue strains were analyzed between the tumors and the background normal tissues to explore their nonlinearity and classify the tumor type. Tumor classification parameters were deduced by using a power-law relationship between the applied compressive forces and strain differences.

RESULTS

Classification parameters were compared between benign and malignant tumors, for which they were found to be statistically significant in classifying the tumor types (P < .05) by both the validation and verification of FEM. We compared the classification parameters between the in vivo and FEM classifications, for which they were found to be strongly correlated (R = 0.875; P < .001), with no statistical differences between their outcomes (P = .909).

CONCLUSIONS

Good agreement between the model outcomes and the in vivo diagnostics was reported. The implemented models were validated and verified. The introduced 3D modeling method may augment elastographic methods to preliminary classify breast tumors at an early stage.

In silico simulation of liver crack detection using ultrasonic shear wave imaging

Background

Liver trauma is an important source of morbidity and mortality worldwide. A timely detection and precise evaluation of traumatic liver injury and the bleeding site is necessary. There is a need to develop better imaging modalities of hepatic injuries to increase the sensitivity of ultrasonic imaging techniques for sites of hemorrhage caused by cracks. In this study, we conduct an in silico simulation of liver crack detection and delineation using an ultrasonic shear wave imaging (USWI) based method.

Methods

We simulate the generation and propagation of the shear wave in a liver tissue medium having a crack using COMSOL. Ultrasound radio frequency (RF) signal synthesis and the two-dimensional speckle tracking algorithm are applied to simulate USWI in a medium with randomly distributed scatterers. Crack detection is performed using the directional filter and the edge detection algorithm rather than the conventional inversion algorithm. Cracks with varied sizes and locations are studied with our method and the crack localization results are compared with the given crack.

Results

Our pilot simulation study shows that, by using USWI combined with a directional filter cum edge detection technique, the near-end edge of the crack can be detected in all the three cracks that we studied. The detection errors are within 5%. For a crack of 1.6 mm thickness, little shear wave can pass through it and the far-end edge of the crack cannot be detected. The detected crack lengths using USWI are all slightly shorter than the actual crack length. The robustness of our method in detecting a straight crack, a curved crack and a subtle crack of 0.5 mm thickness is demonstrated.

Conclusions

In this paper, we simulate the use of a USWI based method for the detection and delineation of the crack in liver. The in silico simulation helps to improve understanding and interpretation of USWI measurements in a physical scattered liver medium with a crack. This pilot study provides a basis for improved insights in future crack detection studies in a tissue phantom or liver.

Acoustic Properties of Small Animal Soft Tissue in the Frequency Range 12-32 MHz

Quality assurance phantoms are made of tissue-mimicking materials (TMMs) the acoustic properties of which mimic those of soft tissue. However, the acoustic properties of many soft tissue types have not been measured at ultrasonic frequencies >9 MHz. With the increasing use of high-frequency ultrasound for both clinical and pre-clinical applications, it is of increasing interest to ensure that TMMs accurately reflect the acoustic properties of soft tissue at these higher frequencies. In this study, the acoustic properties of ex vivo brain, liver and kidney samples from 50 mice were assessed in the frequency range 12-32 MHz. Measurements were performed within 6 min of euthanasia in a phosphate-buffered saline solution maintained at 37.2 ± 0.2 °C. The measured mean values for the speed of sound for all organs were found to be higher than the International Electrotechnical Commission guideline recommended value for TMMs. The attenuation coefficients measured for brain, liver and kidney samples were compared with the results of previous studies at lower frequencies. Only the measured kidney attenuation coefficient was found to be in good agreement with the International Electrotechnical Commission guideline. The information provided in this study can be used as a baseline on which to manufacture a TMM suitable for high-frequency applications.

Advanced imaging techniques for small bowel Crohn's disease: what does the future hold?

Treatment of Crohn's disease (CD) is intrinsically reliant on imaging techniques, due to the preponderance of small bowel disease and its transmural pattern of inflammation. Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are the most widely employed imaging methods and have excellent diagnostic accuracy in most instances. Some limitations persist, perhaps the most clinically relevant being the distinction between inflammatory and fibrotic strictures. In this regard, several methodologies have recently been tested in animal models and human patients, namely US strain elastography, shear wave elastography, contrast-enhanced US, magnetization transfer MRI and contrast dynamics in standard MRI. Technical advances in each of the imaging methods may expand their indications. The addition of oral contrast to abdominal US appears to substantially improve its diagnostic capabilities compared to standard US. Ionizing dose-reduction methods in CT can decrease concern about cumulative radiation exposure in CD patients and diffusion-weighted MRI may reduce the need for gadolinium contrast. Clinical indexes of disease activity and severity are also increasingly relying on imaging scores, such as the recently developed Lémann Index. In this review we summarize some of the recent advances in small bowel CD imaging and how they might affect clinical practice in the near future.

Broadband Acoustic Measurement of an Agar-Based Tissue-Mimicking-Material: A Longitudinal Study

Commercially available ultrasound quality assurance test phantoms rely on the long-term acoustic stability of the tissue-mimicking-material (TMM). Measurement of the acoustic properties of the TMM can be technically challenging, and it is important to ensure its stability. The standard technique is to film-wrap samples of TMM and to measure the acoustic properties in a water bath. In this study, a modified technique was proposed whereby the samples of TMM are measured in a preserving fluid that is intended to maintain their characteristics. The acoustic properties were evaluated using a broadband pulse-echo substitution technique over the frequency range 4.5-50 MHz at 0, 6 and 12 months using both techniques. For both techniques, the measured mean values for the speed of sound and attenuation were very similar and within the International Electrotechnical Commission-recommended value. However, the results obtained using the proposed modified technique exhibited greater stability over the 1-y period compared with the results acquired using the standard technique.

Ultrasound Strain Elastography in Assessment of Muscle Stiffness in Acute Levodopa Challenge Test: A Feasibility Study

To evaluate the feasibility of ultrasound strain elastography in assessing the response of muscle stiffness to the acute levodopa test, we prospectively performed strain elastography on the biceps brachii muscle (BBM) of 18 patients to diagnose Parkinson's disease. BBM and subcutaneous tissue strains (deformations) were produced by external compression with an ultrasound transducer and estimated using 2-D speckle tracking. We used the strain ratio (SR = BBM strain/reference strain) to assess BBM stiffness. The rate of increase in SR [rate = (SR after levodopa-SR before levodopa)/SR before levodopa] was used to assess the muscle stiffness response to levodopa. SR significantly increased after levodopa administration in 11 patients with Parkinson's disease (p = 0.02), whereas it did not in 7 patients with parkinsonian syndrome (from non-Parkinson's causes) (p = 0.14). The area under the receiver operating characteristic curve for the rate of increase in SR in determining Parkinson's disease was 0.96. The rate of increase in SR seems to be feasible in evaluating the effect of levodopa on muscle stiffness in the diagnosis of Parkinson's disease.

MR enterography-histology comparison in resected pediatric small bowel Crohn disease strictures: can imaging predict fibrosis?

BACKGROUND

Crohn disease is a chronic inflammatory condition that can lead to intestinal strictures. The presence of fibrosis within strictures alters optimal management but is not reliably detected by current imaging methods.

OBJECTIVE

To correlate the MRI features of surgically resected small-bowel strictures in pediatric Crohn disease with histological inflammation and fibrosis scoring.

MATERIALS AND METHODS

We included children with Crohn disease who had symptomatic small-bowel strictures requiring surgical resection and had preoperative MR enterography (MRE) within 3 months of surgery (n = 20). Two blinded radiologists reviewed MRE examinations to document stricture-related findings. A pediatric pathologist scored stricture histological specimens for fibrosis (0-4) and inflammation (0-4). MRE findings were correlated with histological data using Spearman correlation (ρ) and exact logistic regression analysis.

RESULTS

There was significant positive correlation between histological bowel wall fibrosis and inflammation in resected strictures (ρ = 0.55; P = 0.01). Confluent transmural histological fibrosis was associated with pre-stricture upstream small-bowel dilatation >3 cm at univariate (odds ratio [OR] = 51.7; 95% confidence interval [CI]: 7.6- > 999.9; P = 0.0002) and multivariate (OR = 43.4; 95% CI: 6.1- > 999.9; P = 0.0006, adjusted for age) analysis. The degree of bowel wall T2-weighted signal intensity failed to correlate with histological bowel wall fibrosis or inflammation (P-values >0.05). There were significant negative correlations between histological fibrosis score and patient age at resection (ρ = -0.48, P = 0.03), and time from diagnosis to surgery (ρ = -0.73, P = 0.0002).

CONCLUSION

Histological fibrosis and inflammation co-exist in symptomatic pediatric Crohn disease small-bowel strictures and are positively correlated. Pre-stenotic upstream small-bowel dilatation greater than 3 cm is significantly associated with confluent transmural fibrosis.

Elastography Assessment of Liver Fibrosis: Society of Radiologists in Ultrasound Consensus Conference Statement

The Society of Radiologists in Ultrasound convened a panel of specialists from radiology, hepatology, pathology, and basic science and physics to arrive at a consensus regarding the use of elastography in the assessment of liver fibrosis in chronic liver disease. The panel met in Denver, Colo, on October 21-22, 2014, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies and are thought to represent a reasonable approach to the noninvasive assessment of diffuse liver fibrosis.

Ultrasound shear wave elastography helps discriminate low-grade from high-grade bowel wall fibrosis in ex vivo human intestinal specimens

OBJECTIVES

To determine whether bowel wall fibrosis can be detected in freshly resected human intestinal specimens based on ultrasound-derived shear wave speed.

METHODS

Seventeen intact (>3-cm) bowel segments (15 small and 2 large intestine) from 12 patients with known or suspected inflammatory bowel disease were procured immediately after surgical resection. Ultrasound shear wave elastography of the bowel wall was performed by two methods (Virtual Touch Quantification [VTQ] and Virtual Touch-IQ [VT-IQ]; Siemens Medical Solutions USA, Inc, Mountain View, CA). Eighteen short-axis shear wave speed measurements were acquired from each specimen: 3 from the 9-, 12-, and 3-o'clock locations for each method. Imaging was performed in two areas for specimens greater than 10 cm in length (separated by ≥5 cm). A gastrointestinal pathologist scored correlative histologic slides for inflammation and fibrosis. Differences in mean shear wave speed between bowel segments with low and high inflammation/fibrosis scores were assessed by a Student t test. Receiver operating characteristic curve analysis was performed.

RESULTS

High-fibrosis score (n = 11) bowel segments had a significantly greater mean shear wave speed than low-fibrosis score (n = 6) bowel segments (mean ± SD: VTQ, 1.59 ± 0.37 versus 1.18 ± 0.08 m/s; P= .004; VT-IQ, 1.87 ± 0.44 versus 1.50 ± 0.26 m/s; P= .049). There was no significant difference in mean shear wave speed between high-and low-inflammation score bowel segments (P > .05 for both VTQ and VT-IQ). Receiver operating characteristic curves showed areas under the curve of 0.91 (95% confidence interval, 0.67-0.99) for VTQ and 0.77 (95% confidence interval, 0.51-0.94) for VT-IQ in distinguishing low-from high-fibrosis score bowel segments.

CONCLUSIONS

Ex vivo bowel wall shear wave speed measurements increase when transmural intestinal fibrosis is present.

Ultrasound strain zero-crossing elasticity measurement in assessment of renal allograft cortical hardness: a preliminary observation

To determine whether ultrasound strain zero-crossing elasticity measurement can be used to discriminate moderate cortical fibrosis or inflammation in renal allografts, we prospectively assessed cortical hardness with quasi-static ultrasound elastography in 38 renal transplant patients who underwent kidney biopsy from January 2013 to June 2013. With the Banff score criteria for renal cortical fibrosis as gold standard, 38 subjects were divided into two groups: group 1 (n = 18) with ≤25% cortical fibrosis and group 2 (n = 20) with >26% cortical fibrosis. We then divided this population again into group 3 (n = 20) with ≤ 25% inflammation and group 4 (n = 18) with >26% inflammation based on the Banff score for renal parenchyma inflammation. To estimate renal cortical hardness in both population divisions, we propose an ultrasound strain relative zero-crossing elasticity measurement (ZC) method. In this technique, the relative return to baseline, that is zero strain, of strain in the renal cortex is compared with that of strain in reference soft tissue (between the abdominal wall and pelvic muscles). Using the ZC point on the reference strain decompression slope as standard, we determined when cortical strain crossed zero during decompression. ZC was negative when cortical strain did not return or returned after the reference, whereas ZC was positive when cortical strain returned ahead of the reference. Fisher's exact test was used to examine the significance of differences in ZC between groups 1 and 2 and between groups 3 and 4. The accuracy of ZC in determining moderate cortical fibrosis and moderate inflammation was examined by receiver operating characteristic analysis. The intra-class correlation coefficient and analysis of variance were used to test inter-rater reliability and reproducibility. ZC had good inter-observer agreement (ICC = 0.912) and reproducibility (p = 0.979). ZCs were negative in 18 of 18 cases in group 1 and positive in 19 of 20 cases in group 2 (p ≪ 0.001), and were positive in 18 of 20 cases in group 3 and negative in 17 of 18 cases in group 4 (p ≪ 0.001). The area under the receiver operating characteristic curve was 0.992 ± 0.010 for fibrosis and 0.988 ± 0.021 for inflammation. ZC had 100% sensitivity and 95% specificity when zero strain was used as the cutoff value to determine moderate cortical fibrosis and 94% sensitivity and 90% specificity for inflammation. ZC is a new strain marker that could be straightforward to interpret and perform, making it a potentially practical approach for monitoring progression of cortical fibrosis or inflammation in renal allografts.

3-D visualization and non-linear tissue classification of breast tumors using ultrasound elastography in vivo

The goal of the study described here was to introduce new methods for the classification and visualization of human breast tumors using 3-D ultrasound elastography. A tumor's type, shape and size are key features that can help the physician to decide the sort and extent of necessary treatment. In this work, tumor type, being either benign or malignant, was classified non-invasively for nine volunteer patients. The classification was based on estimating four parameters that reflect the tumor's non-linear biomechanical behavior, under multi-compression levels. Tumor prognosis using non-linear elastography was confirmed with biopsy as a gold standard. Three tissue classification parameters were found to be statistically significant with a p-value < 0.05, whereas the fourth non-linear parameter was highly significant, having a p-value < 0.001. Furthermore, each breast tumor's shape and size were estimated in vivo using 3-D elastography, and were enhanced using interactive segmentation. Segmentation with level sets was used to isolate the stiff tumor from the surrounding soft tissue. Segmentation also provided a reliable means to estimate tumors volumes. Four volumetric strains were investigated: the traditional normal axial strain, the first principal strain, von Mises strain and maximum shear strain. It was noted that these strains can provide varying degrees of boundary enhancement to the stiff tumor in the constructed elastograms. The enhanced boundary improved the performance of the segmentation process. In summary, the proposed methods can be employed as a 3-D non-invasive tool for characterization of breast tumors, and may provide early prognosis with minimal pain, as well as diminish the risk of late-stage breast cancer.

Renal transplant elasticity ultrasound imaging: correlation between normalized strain and renal cortical fibrosis

After transplantation, over a widely variable time course, the cortex of the transplanted kidney becomes stiffer as interstitial fibrosis develops and renal function declines. Elasticity ultrasound imaging (EUI) has been used to assess biomechanical properties of tissue that change in hardness as a result of pathologic damage. We prospectively assessed the hardness of the renal cortex in renal transplant allograft patients using a normalized ultrasound strain procedure measuring quasi-static deformation, which was correlated with the grade of renal cortical fibrosis. To determine cortical strain, we used 2-D speckle-tracking software (EchoInsight, Epsilon Imaging, Ann Arbor, MI, USA) to perform offline analysis of stored ultrasound loops capturing deformation of renal cortex and its adjacent soft tissue produced by pressure applied using the scanning transducer. Normalized strain is defined as the mean developed strain in the renal cortex divided by the overall mean strain measured in the soft tissues from the abdominal wall to pelvic muscles. Using the Banff scoring criteria for renal cortical fibrosis as the gold standard, we classified 20 renal transplant allograft biopsy tissue samples into two groups: group 1 (n = 10) with mild (<25%) renal cortical fibrosis and group 2 (n = 10) with moderate (26%-50%) renal cortical fibrosis. An unpaired two-tailed t-test was used to determine the statistical difference in strains between patients with mild and those with moderate renal cortical fibrosis. Receiver operating characteristic curve analysis was performed to assess the accuracy of developed strain and normalized strain in predicting moderate renal cortical fibrosis. The reference strain did not significantly differ between the two groups (p = 0.10). However, the developed renal cortical strain in group 1 with mild fibrosis was higher than that in group 2 with moderate fibrosis (p = 0.025). The normalized strain in group 1 was also higher than that in group 2 (p = 0.0014). The areas under receiver operating characteristic curves for developed strain and normalized strain were 0.78 and 0.95, respectively. The optimal cutoff for distinguishing moderate renal cortical fibrosis was -0.08 for developed strain (sensitivity = 0.50, specificity = 1.0) and 2.5 for normalized strain (sensitivity = 0.80, specificity = 1.0). In summary, renal cortex strain is strongly correlated with grade of renal cortical fibrosis. Normalized strain is superior to developed strain in distinguishing moderate from mild renal cortical fibrosis. We conclude that free-hand real-time strain EUI may be useful in assessing the progression of cortical fibrosis in renal transplant allografts. Further prospective study using this method is warranted.

Nonlinear characterization of breast cancer using multi-compression 3D ultrasound elastography in vivo

The main objective of this article is to introduce a new nonlinear elastography based classification method for human breast masses. Multi-compression elastography imaging is elucidated in this study to differentiate malignant from benign lesions, based on their nonlinear mechanical behavior under compression. Three classification parameters were used and compared in this work: a new nonlinear parameter based on a power-law behavior of the strain difference between breast masses and healthy tissues, mass-soft tissue strain ratio and the mass relative volume between B-mode and elastography imaging. Using 3D elastography, these parameters were tested in vivo. A pilot study on 10 patients was performed, and results were compared with biopsy diagnosis as a gold standard. Initial elastography results showed a good agreement with biopsy outcomes. The new estimated nonlinear parameter had an average value of 0.163±0.063 and 1.642±0.261 for benign and malignant masses, respectively. Strain ratio values for the benign and malignant masses had an average value of 2.135±0.707 and 4.21±2.108, respectively. Relative mass volume was 0.848±0.237 and 2.18±0.522 for benign and malignant masses. In addition to the traditional normal axial strain, new strain types were used for elastography and constructed in 3D, including the first principal, maximum shear and Von Mises strains. The new strains provided an enhanced distinction of the stiff lesion from the soft tissue. In summary, the proposed elastographic techniques can be used as a noninvasive quantitative characterization tool for breast cancer, with the capability of visualizing and separating the masses in a three dimensional space. This may reduce the number of unnecessary painful breast biopsies.