Counter-propagating wave interaction for contrast-enhanced ultrasound imaging

Contrast-Enhanced Ultrasound to Assess Carotid Intraplaque Neovascularization

Contrast-enhanced ultrasound (CEUS) is increasingly being used to identify patients with carotid plaques that are vulnerable to rupture, so-called vulnerable atherosclerotic plaques, by assessment of intraplaque neovascularization. A complete overview of the strengths and limitations of carotid CEUS is currently not available. The aim of this systematic review was to provide a complete overview of existing publications on the role of CEUS in assessment of carotid intraplaque neovascularization. The systematic review of the literature yielded 52 studies including a total of 4660 patients (mean age: 66 y, 71% male) who underwent CEUS for the assessment of intraplaque neovascularization. The majority of the patients (76%) were asymptomatic and had no history of transient ischemic attack (TIA) or stroke. The assessment of intraplaque neovascularization was mostly performed using a visual scoring system; several studies used time-intensity curves or dedicated quantification software to optimize analysis. In 17 studies CEUS was performed in patients before carotid surgery (endarterectomy), allowing a comparison of pre-operative CEUS findings with histologic analysis of the tissue sample that is removed from the carotid artery. In a total of 576 patients, the CEUS findings were compared with histopathological analysis of the plaque after surgery. In 16 of the 17 studies, contrast enhancement was found to correlate with the presence and degree of intraplaque neovascularization on histology. Plaques with a larger amount of contrast enhancement had significantly increased density of microvessels in the corresponding region on histology. In conclusion, CEUS is a readily available imaging modality for the assessment of patients with carotid atherosclerosis, providing information on atherosclerotic plaques, such as ulceration and intraplaque neovascularization, which may be clinically relevant. The ultimate clinical goal is the early identification of carotid atherosclerosis to start early preventive therapy and prevent clinical complications such as TIA and stroke.

Fundamental wave amplitude difference imaging for detection and characterization of embedded cracks

An ultrasonic technique for imaging nonlinear scatterers, such as partially-closed cracks, buried in a medium has been recently proposed. The method called fundamental wave amplitude difference (FAD) consists of a sequence of acquisitions with different subsets of elements for each line of the image. An image revealing nonlinear scatterers in the medium is reconstructed line by line by subtracting the responses measured with the subsets of elements from the response obtained with all elements transmitting. In order to get a better insight of the capabilities of FAD, two metallic samples having a fatigue or thermal crack are inspected by translating the probe with ultrasonic beam perpendicular (i.e. parallel) to the crack direction which is the most (i.e. less) favorable case. Each time, the responses of the linear scatterers (i.e. conventional image) and nonlinear scatterers (i.e. FAD image) are compared in term of intensity and spatial repartition. FAD exhibits higher detection specificity of the crack with a better contrast than conventional ultrasound imaging. Moreover, we observe that both methods give complementary results as nonlinear and linear scatterers are mostly not co-localized. In addition, we show experimentally that FAD resolution in elevation and lateral follows the same rule as the theoretical resolution of conventional ultrasonic technique. Finally, we report that FAD gives the possibility to perform parametric studies which let the opportunity to address the physical mechanisms causing the distortion of the signal. FAD is a promising and reliable tool which can be directly implemented on a conventional open scanner ultrasound device for real-time imaging. This might contribute to its fast and wide spread in the industry.

Non-Local Based Denoising Framework for In Vivo Contrast-Free Ultrasound Microvessel Imaging

Vascular networks can provide invaluable information about tumor angiogenesis. Ultrafast Doppler imaging enables ultrasound to image microvessels by applying tissue clutter filtering methods on the spatio-temporal data obtained from plane-wave imaging. However, the resultant vessel images suffer from background noise that degrades image quality and restricts vessel visibilities. In this paper, we addressed microvessel visualization and the associated noise problem in the power Doppler images with the goal of achieving enhanced vessel-background separation. We proposed a combination of patch-based non-local mean filtering and top-hat morphological filtering to improve vessel outline and background noise suppression. We tested the proposed method on a flow phantom, as well as in vivo breast lesions, thyroid nodules, and pathologic liver from human subjects. The proposed non-local-based framework provided a remarkable gain of more than 15 dB, on average, in terms of contrast-to-noise and signal-to-noise ratios. In addition to improving visualization of microvessels, the proposed method provided high quality images suitable for microvessel morphology quantification that may be used for diagnostic applications.

Nonlinear X-wave ultrasound imaging of acoustic biomolecules

The basic physics of sound waves enables ultrasound to visualize biological tissues with high spatial and temporal resolution. Recently, this capability was enhanced with the development of acoustic biomolecules - proteins with physical properties enabling them to scatter sound. The expression of these unique air-filled proteins, known as gas vesicles (GVs), in cells allows ultrasound to image cellular functions such as gene expression in vivo, providing ultrasound with its analog of optical fluorescent proteins. Acoustical methods for the in vivo detection of GVs are now required to maximize the impact of this technology in biology and medicine. We previously engineered GVs exhibiting a nonlinear scattering behavior in response to acoustic pressures above 300 kPa, and showed that amplitude-modulated (AM) ultrasound pulse sequences that both excite the linear and nonlinear GV scattering regimes were highly effective at distinguishing GVs from linear scatterers like soft biological tissues. Unfortunately, the in vivo specificity of AM ultrasound imaging is systematically compromised by the nonlinearity added by the GVs to propagating waves, resulting in strong image artifacts from linear scatterers downstream of GV inclusions. To address this issue, we present an imaging paradigm, cross-amplitude modulation (xAM), which relies on cross-propagating plane-wave transmissions of finite aperture X-waves to achieve quasi artifact-free in vivo imaging of GVs. The xAM method derives from counter-propagating wave interaction theory which predicts that, in media exhibiting quadratic elastic nonlinearity like biological tissue, the nonlinear interaction of counter-propagating acoustic waves is inefficient. By transmitting cross-propagating plane-waves, we minimize cumulative nonlinear interaction effects due to collinear wave propagation, while generating a transient wave-amplitude modulation at the two plane-waves' intersection. We show in both simulations and experiments that residual xAM nonlinearity due to wave propagation decreases as the plane-wave cross-propagation angle increases. We demonstrate in tissue-mimicking phantoms that imaging artifacts distal to GV inclusions decrease as the plane-wave cross-propagation angle opens, nearing complete extinction at angles above 16.5 degrees. Finally, we demonstrate that xAM enables highly specific in vivo imaging of GVs located in the gastrointestinal tract, a target of prime interest for future cellular imaging. These results advance the physical facet of the emerging field of biomolecular ultrasound, and are also relevant to synthetic ultrasound contrast agents.

How to perform Contrast-Enhanced Ultrasound (CEUS)

"How to perform contrast-enhanced ultrasound (CEUS)" provides general advice on the use of ultrasound contrast agents (UCAs) for clinical decision-making and reviews technical parameters for optimal CEUS performance. CEUS techniques vary between centers, therefore, experts from EFSUMB, WFUMB and from the CEUS LI-RADS working group created a discussion forum to standardize the CEUS examination technique according to published evidence and best personal experience. The goal is to standardise the use and administration of UCAs to facilitate correct diagnoses and ultimately to improve the management and outcomes of patients.

Ultrasound propagation through dilute polydisperse microbubble suspensions

In a fully nonlinear model of wave propagation through bubbly media, computational complexity arises when the medium contains a polydisperse bubble population. This is because a nonlinear ordinary differential equation governing the bubble response must be solved for the current radius of each bubble size present at every spatial location and at every time step. In biomedical ultrasound imaging, commercial contrast agents typically possess a wide range of bubble sizes that exhibit a variety of differing behaviours at ultrasound frequencies of clinical interest. Despite the advent of supercomputing resources, the simulation of ultrasound propagation through microbubble populations still represents a formidable numerical task. Consequently, efficient computational algorithms that have the potential to be implemented in real time on clinical scanners remain highly desirable. In this work, a numerical approach is investigated that computes only a single ordinary differential equation at each spatial location which can potentially reduce significantly the computational effort. It is demonstrated that, under certain parameter regimes, the approach replicates the fully nonlinear model of an incident ultrasound pulse propagating through a polydisperse population of bubbles with a high degree of accuracy.

Differential Intensity Projection for Visualisation and Quantification of Plaque Neovascularisation in Contrast-Enhanced Ultrasound Images of Carotid Arteries

Studies have reported that intraplaque neovascularisation (IPN) is closely correlated with plaque vulnerability. In this study, a new image processing approach, differential intensity projection (DIP), was developed to visualise and quantify IPN in contrast-enhanced non-linear ultrasound image sequences of carotid arteries. DIP used the difference between the local temporal maximum and the local temporal average signals to identify bubbles against tissue non-linear artefact and noise. The total absolute and relative areas occupied by bubbles within each plaque were calculated to quantify IPN. In vitro measurements on a laboratory phantom were made, followed by in vivo measurements in which 24 contrast-enhanced non-linear ultrasound image sequences of carotid arteries from 48 patients were selected and motion corrected. The results using DIP were compared with those obtained by maximum intensity projection (MIP) and visual assessment. The results indicated that DIP can significantly reduce non-linear propagation tissue artefacts and is much more specific in detecting bubble signals than MIP, being able to reveal microbubble signals that are buried in tissue artefacts in the corresponding MIP image. A good correlation was found between microvascular area (MVA) (r = 0.83, p < 0.001)/microvascular density (r = 0.77, p < 0.001) obtained using DIP and the corresponding expert visual grades, comparing favourably to r = 0.26 and 0.23 obtained using MIP on the same data. In conclusion, the proposed method exhibits great potential in quantification of IPN in contrast-enhanced ultrasound images of carotid arteries.

Cumulative phase delay imaging for contrast-enhanced ultrasound tomography

Standard dynamic-contrast enhanced ultrasound (DCE-US) imaging detects and estimates ultrasound-contrast-agent (UCA) concentration based on the amplitude of the nonlinear (harmonic) components generated during ultrasound (US) propagation through UCAs. However, harmonic components generation is not specific to UCAs, as it also occurs for US propagating through tissue. Moreover, nonlinear artifacts affect standard DCE-US imaging, causing contrast to tissue ratio reduction, and resulting in possible misclassification of tissue and misinterpretation of UCA concentration. Furthermore, no contrast-specific modality exists for DCE-US tomography; in particular speed-of-sound changes due to UCAs are well within those caused by different tissue types. Recently, a new marker for UCAs has been introduced. A cumulative phase delay (CPD) between the second harmonic and fundamental component is in fact observable for US propagating through UCAs, and is absent in tissue. In this paper, tomographic US images based on CPD are for the first time presented and compared to speed-of-sound US tomography. Results show the applicability of this marker for contrast specific US imaging, with cumulative phase delay imaging (CPDI) showing superior capabilities in detecting and localizing UCA, as compared to speed-of-sound US tomography. Cavities (filled with UCA) which were down to 1 mm in diameter were clearly detectable. Moreover, CPDI is free of the above mentioned nonlinear artifacts. These results open important possibilities to DCE-US tomography, with potential applications to breast imaging for cancer localization.

Increasing specificity of contrast-enhanced ultrasound imaging using the interaction of quasi counter-propagating wavefronts: a proof of concept

Detection methods implemented in present clinical ultrasound scanners for contrast-enhanced ultrasound imaging show high sensitivity but a rather poor specificity due to pseudo-enhancement (false detection of contrast agent) produced by nonlinear wave propagation. They all require linear ultrasound propagation to detect nonlinear scattering of contrast agent microbubbles. Even at low transmit pressure, nonlinear wave propagation occurs in regions perfused with contrast agent because contrast agent microbubbles can dramatically enhance the nonlinear elastic behavior of the medium. This image artifact hinders further development of contrast-enhanced ultrasound imaging toward reliable quantitative measurement of local concentration of contrast agent and blood perfusion kinetics. We propose in this manuscript a new detection method, with specific beamforming and pulsing scheme, that produces contrast images with highly reduced pseudo-enhancement. It is based on the interaction of two diverging wavefronts broadcasted by two single elements of a conventional probe array. The contrast image is formed line by line; one single image line is the line segment bisector defined by the centers of the two transmitting elements. Each image line is formed by a three-step pulse sequence: (1) transmission with one element, (2) transmission with the other element, and (3) transmission with both elements. The proof of principle is shown with numerical simulations and in vitro experiments. The method is implemented in a programmable ultrasound system and tested in a tissue-mimicking phantom containing a vessel filled with diluted contrast agent. At a given depth, increasing the distance between the two transmitting elements increases the angle describing the propagation directions of the two wavefronts. As a result, the nonlinear interaction between the two broadcasted waves is reduced. We show experimentally that increasing the distance between the transmitting elements from 0.6 to 24 mm reduces the amplitude of the pseudoenhancement at the far wall of the vessel relative to true contrast signal amplitude in the vessel by 12 dB, therefore improving specificity in the contrast-enhanced image.

Correction of Non-Linear Propagation Artifact in Contrast-Enhanced Ultrasound Imaging of Carotid Arteries: Methods and in Vitro Evaluation

Non-linear propagation of ultrasound creates artifacts in contrast-enhanced ultrasound images that significantly affect both qualitative and quantitative assessments of tissue perfusion. This article describes the development and evaluation of a new algorithm to correct for this artifact. The correction is a post-processing method that estimates and removes non-linear artifact in the contrast-specific image using the simultaneously acquired B-mode image data. The method is evaluated on carotid artery flow phantoms with large and small vessels containing microbubbles of various concentrations at different acoustic pressures. The algorithm significantly reduces non-linear artifacts while maintaining the contrast signal from bubbles to increase the contrast-to-tissue ratio by up to 11 dB. Contrast signal from a small vessel 600 μm in diameter buried in tissue artifacts before correction was recovered after the correction.

Ultrasound imaging for risk assessment in atherosclerosis

Atherosclerosis and its consequences like acute myocardial infarction or stroke are highly prevalent in western countries, and the incidence of atherosclerosis is rapidly rising in developing countries. Atherosclerosis is a disease that progresses silently over several decades before it results in the aforementioned clinical consequences. Therefore, there is a clinical need for imaging methods to detect the early stages of atherosclerosis and to better risk stratify patients. In this review, we will discuss how ultrasound imaging can contribute to the detection and risk stratification of atherosclerosis by (a) detecting advanced and early plaques; (b) evaluating the biomechanical consequences of atherosclerosis in the vessel wall;

Subharmonic, non-linear fundamental and ultraharmonic imaging of microbubble contrast at high frequencies

There is increasing use of ultrasound contrast agent in high-frequency ultrasound imaging. However, conventional contrast detection methods perform poorly at high frequencies. We performed systematic in vitro comparisons of subharmonic, non-linear fundamental and ultraharmonic imaging for different depths and ultrasound contrast agent concentrations (Vevo 2100 system with MS250 probe and MicroMarker ultrasound contrast agent, VisualSonics, Toronto, ON, Canada). We investigated 4-, 6- and 10-cycle bursts at three power levels with the following pulse sequences: B-mode, amplitude modulation, pulse inversion and combined pulse inversion/amplitude modulation. The contrast-to-tissue (CTR) and contrast-to-artifact (CAR) ratios were calculated. At a depth of 8 mm, subharmonic pulse-inversion imaging performed the best (CTR = 26 dB, CAR = 18 dB) and at 16 mm, non-linear amplitude modulation imaging was the best contrast imaging method (CTR = 10 dB). Ultraharmonic imaging did not result in acceptable CTRs and CARs. The best candidates from the in vitro study were tested in vivo in chicken embryo and mouse models, and the results were in a good agreement with the in vitro findings.

Cumulative phase delay between second harmonic and fundamental components--a marker for ultrasound contrast agents

Several imaging techniques aimed at detecting ultrasound contrast agents (UCAs) echo signals, while suppressing signals coming from the surrounding tissue, have been developed. These techniques are especially relevant for blood flow, perfusion, or contrast dispersion quantification. However, despite several approaches being presented, improving the understanding of the ultrasound/UCAs interaction may support further development of imaging techniques. In this paper, the physical phenomena behind the formation of harmonic components in tissue and UCAs, respectively, are addressed as a possible way to recognize the origin of the echo signals. Simulations based on a modified Rayleigh, Plesset, Noltingk, Neppiras, and Poritsky equation and transmission and backscattering measurements of ultrasound propagating through UCAs performed with a single element transducer and a submergible hydrophone, are presented. Both numerical and in vitro results show the occurrence of a cumulative time delay between the second harmonic and fundamental component which increases with UCA concentration and propagation path length through UCAs, and that was clearly observable at frequencies ( f0 = 2.5 MHz) and pressure regimes (mechanical index = 0.1) of interest for imaging. Most importantly, this delay is not observed in the absence of UCAs. In conclusion, the reported phenomenon represents a marker for UCAs with potential application for imaging.

Assessment of carotid atherosclerosis, intraplaque neovascularization, and plaque ulceration using quantitative contrast-enhanced ultrasound in asymptomatic patients with diabetes mellitus

AIMS

Patients with diabetes mellitus (DM) are at severely increased risk of developing atherosclerosis. Intraplaque neovascularization (IPN) and plaque ulceration are markers of the vulnerable plaque, which is at an increased risk of rupture and may lead to cardiovascular events. The aim of this study was to assess the prevalence of subclinical carotid atherosclerosis, intraplaque neovascularization (IPN), and plaque ulceration in asymptomatic patients with DM.

METHODS AND RESULTS

A total of 51 asymptomatic patients with DM underwent standard carotid ultrasound in conjunction with contrast-enhanced ultrasound (CEUS) to assess the prevalence of subclinical atherosclerosis, IPN, and plaque ulceration. Subclinical atherosclerosis was defined as the presence of atherosclerotic plaque, according to the Mannheim consensus. Semi-automated quantification software was used to assess IPN in suitable plaques. Plaque ulceration was defined as a disruption of the plaque-lumen border of ≥ 1 × 1 mm. A total of 408 carotid segments in 102 carotid arteries were investigated. Forty-six (90%) patients had subclinical atherosclerotic plaques, with a median plaque thickness of 2.4 mm (inter-quartile range 1.9-3.0). CEUS revealed IPN in 88% of the patients. In 10 carotid segments (8%), the plaque had an ulcerated surface. The presence of IPN could not be predicted by the presence of clinical characteristics including complications of DM (P > 0.05).

CONCLUSION

Patients with DM have a high prevalence (90%) of subclinical carotid atherosclerosis. Severe IPN and plaque ulceration, which are markers of the vulnerable plaque type, were detected in, respectively, 13 and 9% of these patients.

New quantification methods for carotid intra-plaque neovascularization using contrast-enhanced ultrasound

As carotid intra-plaque neovascularization (IPN) is linked to progressive atherosclerotic disease and plaque vulnerability, its accurate quantification might allow early detection of plaque vulnerability. We therefore developed several new quantitative methods for analyzing IPN perfusion and structure. From our analyses, we derived six quantitative parameters-IPN surface area (IPNSA), IPN surface ratio (IPNSR), plaque mean intensity, plaque-to-lumen enhancement ratio, mean plaque contrast percentage and number of micro-vessels (MVN)-and compared these with visual grading of IPN by two independent physicians. A total of 45 carotid arteries with symptomatic stenosis in 23 patients were analyzed. IPNSA (correlation r = 0.719), IPNSR (r = 0.538) and MVN (r = 0.484) were found to be significantly correlated with visual scoring (p < 0.01). IPNSA was the best match to visual scoring. These results indicate that IPNSA, IPNSR and MVN may have the potential to replace qualitative visual scoring and to measure the degree of carotid IPN.