Power Doppler ultrasound evaluation of the shear rate and shear stress dependences of red blood cell aggregation

3D Single Vessel Fractional Moving Blood Volume (3D-svFMBV): Fully Automated Tissue Perfusion Estimation Using Ultrasound

Power Doppler ultrasound (PD-US) is the ideal modality to assess tissue perfusion as it is cheap, patient-friendly and does not require ionizing radiation. However, meaningful inter-patient comparison only occurs if differences in tissue-attenuation are corrected for. This can be done by standardizing the PD-US signal to a blood vessel assumed to have 100% vascularity. The original method to do this is called fractional moving blood volume (FMBV). We describe a novel, fully-automated method combining image processing, numerical modelling, and deep learning to estimate three-dimensional single vessel fractional moving blood volume (3D-svFMBV). We map the PD signals to a characteristic intensity profile within a single large vessel to define the standardization value at the high shear vessel margins. This removes the need for mathematical correction for background signal which can introduce error. The 3D-svFMBV was first tested on synthetic images generated using the characteristics of uterine artery and physiological ultrasound noise levels, demonstrating prediction of standardization value close to the theoretical ideal. Clinical utility was explored using 143 first-trimester placental ultrasound volumes. More biologically plausible perfusion estimates were obtained, showing improved prediction of pre-eclampsia compared with those generated with the semi-automated original 3D-FMBV technique. The proposed 3D-svFMBV method overcomes the limitations of the original technique to provide accurate and robust placental perfusion estimation. This not only has the potential to provide an early pregnancy screening tool but may also be used to assess perfusion of different organs and tumors.

Contrast Agent-Free Assessment of Blood Flow and Wall Shear Stress in the Rabbit Aorta using Ultrasound Image Velocimetry

Blood flow velocity and wall shear stress (WSS) influence and are influenced by vascular disease. Their measurement is consequently useful in the laboratory and clinic. Contrast-enhanced ultrasound image velocimetry (UIV) can estimate them accurately but the need to inject contrast agents limits utility. Singular value decomposition and high-frame-rate imaging may render contrast agents dispensable. Here we determined whether contrast agent-free UIV can measure flow and WSS. In simulation, accurate measurements were achieved with a signal-to-noise ratio of 13.5 dB or higher. Signal intensity in the rabbit aorta increased monotonically with mechanical index; it was lowest during stagnant flow and uneven across the vessel. In vivo measurements with contrast-free and contrast-enhanced UIV differed by 4.4% and 1.9% for velocity magnitude and angle and by 9.47% for WSS. Bland-Altman analysis of waveforms revealed good agreement between contrast-free and contrast-enhanced UIV. In five rabbits, the root-mean-square errors were as low as 0.022 m/s (0.81%) and 0.11 Pa (1.7%). This study indicates that with an optimised protocol, UIV can assess flow and WSS without contrast agents. Unlike contrast-enhanced UIV, contrast-free UIV could be routinely employed.

Bio-Impedance Sensor for Real-Time Artery Diameter Waveform Assessment

The real-time artery diameter waveform assessment during cardio cycle can allow the measurement of beat-to-beat pressure change and the long-term blood pressure monitoring. The aim of this study is to develop a self-calibrated bio-impedance-based sensor, which can provide regular measurement of the blood-pressure-dependence time variable parameters such as the artery diameter waveform and the elasticity. This paper proposes an algorithm based on analytical models which need prior geometrical and physiological patient parameters for more appropriate electrode system selection and hence location to provide accurate blood pressure measurement. As a result of this study, the red cell orientation effect contribution was estimated and removed from the bio-impedance signal obtained from the artery to keep monitoring the diameter waveform correspondence to the change of blood pressure.

Quantitative Measurement of Erythrocyte Aggregation as a Systemic Inflammatory Marker by Ultrasound Imaging: A Systematic Review

This systematic review is aimed at answering two questions: (i) Is erythrocyte aggregation a useful biomarker in assessing systemic inflammation? (ii) Does quantitative ultrasound imaging provide the non-invasive option to measure erythrocyte aggregation in real time? The search was executed through bibliographic electronic databases CINAHL, EMB Review, EMBASE, MEDLINE, PubMed and the grey literature. The majority of studies correlated elevated erythrocyte aggregation with inflammatory blood markers for several pathologic states. Some studies used "erythrocyte aggregation" as an established marker of systemic inflammation. There were limited but promising articles regarding the use of quantitative ultrasound spectroscopy to monitor erythrocyte aggregation. Similarly, there were limited studies that used other ultrasound techniques to measure systemic inflammation. The quantitative measurement of erythrocyte aggregation has the potential to be a routine clinical marker of inflammation as it can reflect the cumulative inflammatory dynamics in vivo, is relatively simple to measure, is cost-effective and has a rapid turnaround time. Technologies like quantitative ultrasound spectroscopy that can measure erythrocyte aggregation non-invasively and in real time may offer the advantage of continuous monitoring of the inflammation state and, thus, may help in rapid decision making in a critical care setup.

In vivo venous assessment of red blood cell aggregate sizes in diabetic patients with a quantitative cellular ultrasound imaging method: proof of concept

Background

Diabetic patients present higher level of red blood cell (RBC) aggregation contributing to the development of vascular complications. While it has been suggested that this hematology/rheology parameter could bring additional prognostic information for the management of those patients, RBC aggregation screening is not included as a clinical practice. Most medical centers are not equipped to measure properly this parameter, although sedimentation tests can bring some indication. Here, we aimed at evaluating the feasibility of using ultrasound to assess in-vivo hyper-aggregation in type 2 diabetic patients.

Research design and methods

Seventeen diabetic patients and 15 control subjects underwent ultrasound measurements of RBC aggregation in both cephalic and great saphenous veins. Non-invasive in-vivo ultrasound measurements were performed using a newly developed cellular imaging technique, the structure factor size and attenuation estimator (SFSAE). Comparisons with an ex-vivo gold standard rheometry technique were done, along with measurements of pro-aggregating plasma molecule concentrations.

Results

In-vivo RBC aggregation was significantly higher in diabetic patients compared with controls for cephalic vein measurements, while a trend (p = 0.055) was noticed in the great saphenous vein. SFSAE measurements were correlated with gold standard in-vitro measures, fibrinogen and C-reactive protein plasma concentrations.

Conclusion

RBC aggregation can be measured in-vivo in diabetic patients using ultrasound. Prospective studies are needed to determine whether the SFSAE method could help clinicians in the early management of vascular complications in this patient population.

Measurement of the Doppler power of flowing blood using ultrasound Doppler devices

Measurement of the Doppler power of signals backscattered from flowing blood (henceforth referred to as the Doppler power of flowing blood) and the echogenicity of flowing blood have been used widely to assess the degree of red blood cell (RBC) aggregation for more than 20 y. Many studies have used Doppler flowmeters based on an analogue circuit design to obtain the Doppler shifts in the signals backscattered from flowing blood; however, some recent studies have mentioned that the analogue Doppler flowmeter exhibits a frequency-response problem whereby the backscattered energy is lost at higher Doppler shift frequencies. Therefore, the measured Doppler power of flowing blood and evaluations of RBC aggregation obtained using an analogue Doppler device may be inaccurate. To overcome this problem, the present study implemented a field-programmable gate array-based digital pulsed-wave Doppler flowmeter to measure the Doppler power of flowing blood, in the aim of providing more accurate assessments of RBC aggregation. A clinical duplex ultrasound imaging system that can acquire pulsed-wave Doppler spectrograms is now available, but its usefulness for estimating the ultrasound scattering properties of blood is still in doubt. Therefore, the echogenicity and Doppler power of flowing blood under the same flow conditions were measured using a laboratory pulser-receiver system and a clinical ultrasound system, respectively, for comparisons. The experiments were carried out using porcine blood under steady laminar flow with both RBC suspensions and whole blood. The experimental results indicated that a clinical ultrasound system used to measure the Doppler spectrograms is not suitable for quantifying Doppler power. However, the Doppler power measured using a digital Doppler flowmeter can reveal the relationship between backscattering signals and the properties of blood cells because the effects of frequency response are eliminated. The measurements of the Doppler power and echogenicity of flowing blood were compared with those obtained in several previous studies.

The effect of flow acceleration on the cyclic variation of blood echogenicity under pulsatile flow

It has been shown that the echogenicity of blood varies during a flow cycle under pulsatile flow both in vitro and in vivo. In general, the echogenicity of flowing whole blood increases during the early systole phase and then reduces to a minimum at late diastole. While it has been postulated that this cyclic variation is associated with the dynamics of erythrocyte aggregation, the mechanisms underlying this increasing echogenicity with flow velocity remain uncertain. The effect of flow acceleration has also been proposed as an explanation for this phenomenon, but no specific experiments have been conducted to test this hypothesis. In addition, the influence of ultrasonic attenuation on the cyclic variation of echogenicity requires clarification. In the present study, a Couette flow system was designed to simulate blood flowing with different acceleration patterns, and the flow velocity, attenuation, and backscattering coefficient were measured synchronously from 20%- and 40%-hematocrit porcine whole blood and erythrocyte suspensions using 35-MHz ultrasound transducers. The results showed ultrasonic attenuation exerted only minor effects on the echogenicity of blood under pulsatile flow conditions. Cyclic variations of echogenicity were clearly observed for whole blood with a hematocrit of 40%, but no variations were apparent for erythrocyte suspensions. The echogenicity did not appear to be enhanced when instantaneous acceleration was applied to flowing blood in any case. These findings show that flow acceleration does not promote erythrocyte aggregation, even when a higher peak velocity is applied to the blood. Comparison of the results obtained with different accelerations revealed that the cyclic variation in echogenicity observed during pulsatile blood flow may be jointly attributable to the effect of shear rate and the distribution of erythrocyte on aggregation.

In vivo vascular wall shear rate and circumferential strain of renal disease patients

This study measures the vascular wall shear rate at the vessel edge using decorrelation based ultrasound speckle tracking. Results for nine healthy and eight renal disease subjects are presented. Additionally, the vascular wall shear rate and circumferential strain during physiologic pressure, pressure equalization and hyperemia are compared for five healthy and three renal disease subjects. The mean and maximum wall shear rates were measured during the cardiac cycle at the top and bottom wall edges. The healthy subjects had significantly higher mean and maximum vascular wall shear rate than the renal disease subjects. The key findings of this research were that the mean vascular wall shear rates and circumferential strain changes between physiologic pressure and hyperemia that was significantly different between healthy and renal disease subjects.

Newtonian viscous effects in ultrasonic emboli removal from blood

We have modeled the removal of emboli from cardiopulmonary bypass circuits via acoustic radiation force. Unless removed, emboli can result in cognitive deficit for those undergoing heart surgery with the use of extracorporeal circuits. There are a variety of mathematical formulations in the literature describing acoustic radiation force, but a lingering question that remains is how important viscosity of the blood and/or embolus is to the process. We implemented both inviscid and viscous models for acoustic radiation force on a sphere immersed in a fluid. We found that for this specific application, the inviscid model seems to be sufficient for predicting acoustic force upon emboli when compared with the chosen viscous model. Thus, the much simpler inviscid model could be used to optimize experimental techniques for ultrasonic emboli removal.

The acute effects of smoking on the cyclic variations in blood echogenicity of carotid artery

The objective of this research is to study the cyclic variations in echogenicity (CVE) as an acute response to smoking. CVEs, caused by the aggregation of red blood cells (RBC) were measured from the cross-sectional images of the common carotid artery using coded harmonic imaging of a commercial ultrasound system. The amplitude of the CVE (A(cve)) was analyzed among 28 smokers before and after smoking. A(cve) was increased in 22 smokers and decreased in six smokers after 1-2 cigarettes were smoked. Heart rate (HR) was also estimated from the ultrasonic images before and after smoking. The smokers were optimally divided into two clusters with respect to the change in A(cve) and the intrinsic characteristics of smokers (i.e., daily consumed cigarettes and smoking years) through a two-step cluster analysis (TSCA). The increase in A(cve) after smoking was significantly higher in the heavy smoker cluster compared with the light smoker cluster. The results suggest that the acute changes in A(cve) in response to smoking are different between heavy smokers and light smokers. This preliminary study demonstrates the potential application of coded harmonic ultrasound imaging to detect or characterize RBC aggregation. In addition, the results may be useful for understanding the acute physiologic changes caused by smoking.

Ultrasonic attenuation and backscatter from flowing whole blood are dependent on shear rate and hematocrit between 10 and 50 MHz

Ultrasonic backscatter has recently been used extensively to investigate erythrocyte aggregation, which is an inherent hematological phenomenon in the blood circulation system. The size of rouleaux can be estimated by measuring certain parameters of signals backscattered from flowing blood. However, most measurements of backscatter from blood use a constant value for the attenuation coefficient to compensate for the loss of ultrasound energy. This correction may be inaccurate because the attenuation varies with the blood properties, which prompted us to explore the effects of hemodynamic properties on ultrasonic attenuation and backscatter to better understand the blood rheological behaviors. Experiments were performed on porcine whole blood in a Couette flow apparatus. Ultrasonic attenuation and the backscattering coefficient of blood were measured at various frequencies (from 10 to 50 MHz), hematocrits (from 0 to 60%), and shear rates (from 0.1 to 200 s⁻¹). The results indicated that the attenuation and backscattering coefficients of blood are highly variable, depending in a complex manner on shear rate, hematocrit, and the measurement ultrasound frequency. The attenuation of blood decreased rapidly with increasing shear rates, eventually reaching a steady state asymptotically, and increased linearly with the hematocrit from 10 to 50 MHz at various shear rates, and also with the ultrasound frequency. The effect of erythrocyte aggregation means that the change in ultrasonic attenuation in blood with shear rate may be attributed to the absorption mechanism, which is enhanced by the increased blood viscosity at lower shear rates. Compensating the measured backscattering coefficients of blood for the shear-rate-dependent attenuation coefficient increased the accuracy of erythrocyte aggregation assessments. Together, the experimental results suggest that the shear-rate-dependent attenuation coefficient should be considered in future developments of ultrasonic technologies for characterizing blood rheology when the ultrasound frequency is higher than 20 MHz.

Flow behavior and applicability of models for different hemodynamic states

Arterial behavior analysis requires an accurate and dynamic knowledge of the stimuli and reactions involved. Belonging parameters quantification is performed by a data acquisition process and the application of existing models. However, it turns essentially to analyze the adjustment degree of the aforementioned models in terms of the arterial tree. Blood flow behavior as well as wall shear rate and the arterial compliance are anatomic location dependent. The main objective of the present work is to analyze the existing functional relationships between arterial wall and blood flow, in a particular place (brachial artery), in order to asses the specific model applicability, in cases such Poiseuille or Womersley models. In addition, due to the characteristic of the study, gender differential dynamic responses will be evaluated.

Assessment of blood coagulation under various flow conditions with ultrasound backscattering

Several in vitro studies have employed ultrasonic techniques to detect varying properties of coagulating blood under static or stirred conditions. Most of those studies mainly addressed on the development and feasibility of modalities and however were not fully considering the effect of blood flow. To better elucidate this issue, ultrasonic backscattering were measured from the coagulating porcine blood circulated in a mock flow loop with various steady laminar flows at mean shear rates from 10 to 100 s(-1). A 3 ml of 0.5 M CaCl2 solution for inducing blood coagulation was added to that of 30 ml blood circulated in the conduit. For each measurement carried out with a 10-MHz transducer, backscattered signals digitized at 100-MHz sampling frequency were acquired for a total of 20 min at temporal resolution of 50 A-lines per s. The integrated backscatter (IB) was calculated for assessing backscattering properties of coagulating blood. The results show that blood coagulation tended to be increased corresponding to the addition of CaCl2 solution: the IB was increased approximately 6.1 +/- 0.6 (mean +/- standard deviation), 5.4 +/- 0.9, and 4.5 +/- 1.2 dB at 310 +/- 62, 420 +/- 88, and 610 +/- 102 s associated with mean shear rates of 10, 40, and 100 s(-1), respectively. The rate of increasing IB for evaluating the growth of clot was estimated to be 0.075 +/- 0.017, 0.052 +/- 0.027, and 0.038 +/- 0.012 delta dB delta s(-1) corresponding to the increase of mean shear rates. These results consistently demonstrate that higher shear rate tends to prolong the duration for the flowing blood to be coagulated and to decrease the rate of IB. Moreover, the laminar flow was changed to turbulent flow during that the blood was clotting discerned by spatial variations of ultrasound backscattering in the conduit. All these results validate that ultrasound backscattering is feasible to be utilized for detecting and assessing blood coagulation under dynamic conditions.

Statistical variations of ultrasound signals backscattered from flowing blood

The statistical distributions of ultrasonic signals backscattered from blood have recently been used to characterize hemodynamic properties, such as red blood cell (RBC) aggregation and blood coagulation. However, a thorough understanding of the relationship between blood properties and the statistical behavior of signals backscattered from flowing blood is still lacking. This prompted us to use the statistical parameter to characterize signals backscattered from both whole blood and RBC suspensions at different flow velocities (from 10 to 60 cm/s) and hematocrits (from 20% to 50%) under a steady laminar flow condition. The Nakagami parameter, scaling parameter, backscatter amplitude profile and flow velocity profile across a flow tube were acquired using a 10 MHz focused ultrasonic transducer. The backscattered signal peaked approximately at the centerline of the flow tube due to the effects of RBC aggregation, with the peak value increasing as the flow velocity of whole blood decreased. The Nakagami parameter increased from 0.45 to 0.78 as the flow velocity increased from 10 to 60 cm/s. The probability density function (PDF) of signals backscattered from flowing whole blood conformed with a pre-Rayleigh distribution. The Nakagami parameter was close to 1 for signals backscattered from RBC suspensions at all the flow velocities and hematocrits tested, for which the PDF was Rayleigh distributed. These differences in the statistical distributions of backscattered signals between whole blood and RBC suspensions suggest that variations in the size of dynamic scatterers in the flow affect the shape of the backscattered signal envelope, which should be considered in future statistical models used to characterize blood properties.

Experimental ultrasound characterization of red blood cell aggregation using the structure factor size estimator

The frequency dependence of the ultrasonic backscattering coefficient (BSC) was studied to assess the level of red blood cell (RBC) aggregation. Three monoelement focused wideband transducers were used to insonify porcine blood sheared in a Couette flow from 9 to 30 MHz. A high shear rate was first applied to promote disaggregation. Different residual shear rates were then used to promote formation of RBC aggregates. The structure factor size estimator (SFSE), a second-order data reduction model based on the structure factor, was applied to the frequency-dependent BSC. Two parameters were extracted from the model to describe the level of aggregation at 6% and 40% hematocrits: W, the packing factor, and D the aggregate diameter, expressed in number of RBCs. Both parameters closely matched theoretical values for nonaggregated RBCs. W and D increased during aggregation with stabilized values modulated by the applied residual shear rate. Furthermore, parameter D during the kinetics of aggregation at 6% hematocrit under static conditions correlated with an optical RBC aggregate size estimation from microscopic images (r(2)=0.76). To conclude, the SFSE presents an interesting framework for tissue characterization of partially correlated dense tissues such as aggregated RBCs.

Blood velocity field numerical assessment using a GPL code in case of intravascular Doppler catheter affections: comparative analysis of different rheological models

In the use of intravascular Doppler catheters, one of the most common techniques to study the coronary arteries, the velocity field measured is partially affected by the presence of the catheter itself inside the blood vessel. It is therefore fundamental to quantify the nature of this disturbance. This paper treats a numerical investigation of the problem considering the hypothesis of blood as a Newtonian, Cassonian and Power Law fluid, comparing the results. The code used for numerical simulation is a General Public License Finite Element code denominated TOCHNOG. The results obtained, realistic within the terms explained in the text, provide an insight in the rheological characterisation of blood flow.

[Validation of a new methodology for characterizing ultrasound contrast agents (UCA)]

PURPOSE

Validation of an experimental ultrasound system on erythrocyte suspensions with variable levels of aggregation and application to the echogenicity quantification of UCA under quasi-physiologic flow conditions. MATERIALS AND METHODS. The system is constituted with a Couette cell with variable applied shear rates, an ultrasound emitter/receiver and a digital scope for radio-frequency signal acquisition. Ultrasound indices (UI) were defined for the two experimental established protocols based on the gold standard laser methodology. Washed red cells with or without variable Dextran 70 kD concentrations were used to simulate a wide particle size range. A preliminary application to UCA was conducted with Levovist for calibration of the system.

RESULTS

For each protocol, applied ten times on identical whole blood samples, a student t-test revealed no significant variation for all UI. Results on washed red cells were in good agreement with Rayleigh's theory of ultrasound backscattering. Significant correlations were obtained between laser and UI for washed red cells with different Dextran concentrations. An elevation of 12.13 dB in backscattered intensity was obtained after addition of Levovist.

CONCLUSION

The constituted Couette system allowed reproducible and accurate echogenicity quantification of small scatterers such as UCA in quasi-physiologic blood flow conditions.

Real-time numerical simulation of Doppler ultrasound in the presence of nonaxial flow

Numerical simulations of Doppler ultrasound (DUS) relying on computational fluid dynamics (CFD) models of nonaxial flow have traditionally employed detailed (but computationally intensive) models of the DUS physics, or have sacrificed much of the physics in the interest of computational or conceptual simplicity. In this paper, we present a compromise between these extremes, with the objective of simulating the essential characteristics of DUS spectrograms in a real-time manner. Specifically, a precomputed pulsatile CFD velocity field is interrogated at some number, N, of discrete points distributed spatially within a sample volume of prescribed geometry and power distribution and temporally within a prescribed sampling window. Intrinsic spectral broadening is accounted for by convolving each of the point velocities with a semiempirical broadening function. Real-time performance is facilitated through the use of an efficient algorithm for interpolating the unstructured CFD data. A spherical sample volume with Gaussian power distribution, N = 1000 sampling points, and quadratic broadening function are shown to be adequate for simulating, at frame rates of 86 Hz on a 1.5 GHz desktop workstation, realistic-looking spectrograms at representative locations within a stenosed carotid bifurcation model. Via qualitative comparisons with matched in vitro data, these simulated spectrograms are shown to mimic the distinctive spectral envelopes, broadening and power characteristics associated with common carotid, stenotic jet and poststenotic recirculating flows. We conclude that the complex interaction between Doppler ultrasound and complicated clinically relevant blood flow dynamics can be simulated in real time via this relatively straightforward semiempirical approach.

Pentoxifylline attenuates the increase in whole blood viscosity after transfusion

BACKGROUND

Pentoxifylline improves tissue oxygenation and intestinal blood flow in models of haemorrhagic shock, and it has been used for the treatment of intermittent claudication due to its beneficial effects on haemorheology. We investigated the effects of pentoxifylline on whole blood viscosity during packed red-blood cell transfusion in critically ill adult patients.

METHODS

Twenty critically ill patients were randomly assigned to one of two groups (pentoxifylline group: n = 11, placebo group: n = 9) and prospectively studied. Forty-five minutes before and during the packed red-blood cell transfusion (10 ml min(-1)) over a period of 80 min, 1.5 mg kg(-1) . h(-1) pentoxifylline or placebo were administered intravenously. Haematocrit, plasma fibrinogen concentration, total protein concentration, whole blood viscosity (at a shear rate of 10 s(-1), 50 s(-1), and 100 s(-1)) and plasma viscosity were measured.

RESULTS

After the packed red-blood cell transfusion, haematocrit levels increased significantly in both groups (pentoxifylline group: from 26.1 +/- 2.8% to 33.0 +/- 3.2; placebo group: from 24.4 +/- 3.3% to 32.6 +/- 2.6%; means +/- standard deviation). Compared to baseline, whole blood viscosity increased in both groups at all shear rates after the transfusion, but the increase was significantly less in the pentoxifylline group (26 +/- 15% vs. 49 +/- 14%, 23 +/- 11% vs. 39 +/- 12%, and 22 +/- 11% vs. 35 +/- 12% for the pentoxifylline vs. placebo groups at shear rates of 10 s(-1), 50 s(-1), and 100 s(-1), respectively). Plasma viscosity, total protein concentration, and fibrinogen concentration remained unchanged and no significant differences among groups were observed.

CONCLUSIONS

These results suggest that pentoxifylline is effective in attenuating the increase in whole blood viscosity after a transfusion of packed red-blood cells. Plasma viscosity is not influenced by pentoxifylline.

Aggregate formation of erythrocytes in postcapillary venules

The purpose of the present study was to obtain information on erythrocyte aggregate formation in vivo. The movements of erythrocytes in postcapillary venules of the rat spinotrapezius muscle at various flow rates were recorded with a high-speed video camera before and after infusion of dextran 500. To distinguish aggregates, the following criteria were used: 1) a fixed distance (4 microm) between the center points of two adjacent cells, 2) lack of visible separation between the adjacent cells, and 3) movement of the adjacent cells in the same direction. Without dextran 500 infusion, 11 and 5% of erythrocytes formed aggregates in low (33.2 +/- 28.3 s) and high pseudoshear (144.2 +/- 58.3 s) conditions, respectively, based on the above criteria. After dextran 500 infusion, 53% of erythrocytes satisfied the criteria in the low pseudoshear condition (26.5 +/- 17.0 s) and 13% of erythrocytes met the criteria in the high pseudoshear condition (240.0 +/- 85.9 s), indicating erythrocyte aggregation is strongly associated with shear rate. Approximately 90% of aggregate formation occurred in a short time period (0.15-0.30 s after entering the venule) in a region 15 to 30 microm from the entrance. The time delay may reflect rheological entrance conditions in the venule.

Echogenicity variations from porcine blood I: the "bright collapsing ring" under pulsatile flow

The temporal and radial variations of the echogenicity from porcine blood were investigated using a linear M12L transducer with a GE LOGIQ 700 Expert system. The "bright collapsing ring" (BRCR) phenomenon, a bright echogenic ring converging from the periphery to the center of the tube wall and eventually collapsing during a pulsatile cycle in cross-sectional B-mode images, was observed from porcine blood in a mock flow loop within a 0.95-cm diameter tube under certain flow conditions. The BRCR phenomenon from porcine blood was stronger as the peak speed was increased from 10 to 25 cm/s, and the mean echogenicity and the "black hole" (BLH) phenomenon, a central echo-poor zone surrounded by a bright hyperechoic zone, became weaker. As stroke rate was increased from 20 to 60 beats/min (bpm), both the BRCR and the BLH phenomena became weaker. These two phenomena were observed at three transmitting frequencies (9, 11 and 13 MHz). As hematocrit was increased from 12 to 45%, the BRCR phenomenon became more apparent. The nonlinear behavior of backscatter as a function of hematocrit reaching a maximum at hematocrit of 10 approximately 20% was observed near the tube wall, but it changed at the center of the tube, indicating the importance of hemodynamics on the ultrasonic backscatter from flowing blood. The combined effects of shear rate and acceleration on red blood cell aggregation are suggested as a possible mechanism for these phenomena.

Application of validated ultrasound indices to investigate erythrocyte aggregation in pigs. Preliminary in vivo results

Although some studies concerning the ultrasound (US) characterization of erythrocyte aggregation reported in the literature have been conducted in vivo, none of them has led to quantitative indices. To achieve this objective, we first finalized a method on a hydrodynamic bench. Particularly, we define a kinetic protocol consisting of applying a 200 s(-1) shear rate followed up by a rapid decrease to reach a residual shear rate between 0 to 32 s(-1). From the backscattered intensity curve recorded all along the kinetic procedure, US dynamic parameters were defined and validated by correlation with reference laser indices obtained with the same model suspensions of erythrocytes (different concentrations of dextran 70 kD). A particular interesting behavior has been demonstrated when studying aggregation vs. the residual shear rate applied. The aim of the present study was to test the applicability of this aggregation kinetics protocol during in vivo investigations in pigs and possibly to recover the same aggregating behavior. The backscattered intensity was recorded all along the kinetic procedure as defined in vitro. Taking the derivative of the velocity profile recorded on 56 electronic windows, the shear rate was finely computed in the same measurement window where the backscattered intensity was calculated. Each US parameter could, therefore, be correlated with the residual shear rate corresponding to the same depth of measurement. We found that the blood aggregation behavior was identical to that observed in vitro. Apparently, a specific range of residual shear rates accelerates the activation of the aggregation process and the final aggregation level attained.

Comparison of new ultrasound index with laser reference and viscosity indexes for erythrocyte aggregation quantification

We have previously established new ultrasonic indexes for erythrocyte aggregation using a Couette device, and validated them toward the Rayleigh's theory and reproducibility. Two hydrodynamic protocols were applied on various suspensions and their aggregation degrees were characterized by: 1. for the decreasing shear rates protocol: the power P(US) at the nominal frequency of the transducer used; 2. for the kinetic protocol: aggregation times (latency and half-rise times), variation between initial disaggregated state (Vo) and final aggregated state (V(inf)) and AI(US), which is the integral of the kinetic curve over time. The objective of the present study was to demonstrate the ability of these indexes to characterize the aggregation dynamics of suspensions with various levels of aggregation induced by concentrations of dextran 70 kD (Dx) of 10, 20 and 40 g/L added to washed red cells resuspended in saline solution. The results showed a maximum of backscattered power (P(US)) for Dx = 40 g/L with the decreasing shear rates protocol. We measured a final aggregation level (V(inf)), a minimal aggregation time (T(m)) and a maximal value of AI(US) for Dx = 40 g/L with the aggregation kinetics protocol. On the other hand, viscosity is increased with dextran concentration. These evolutions of the ultrasound (US) indexes and viscosity with dextran concentrations are consistent with literature reports. In addition, a particularly interesting phenomenon of US backscattering enhancement was observed for kinetics with no null final shear rate, which has never before been reported in such a precise manner. By another way, each of the dextran suspensions was tested on the laser erythroaggregometer that is presently considered as the "gold standard" method for erythrocyte characterization. The laser indexes (aggregation time T(a), aggregation indexes AI(10s) and AI(60s)), deduced from a kinetic protocol, have similar significance to the US ones. Statistical comparisons have been done between laser and ultrasonic indexes and significant correlations (0.001 < p < 0.01) were obtained. The set of results allowed us to conclude that ultrasonic indexes are suitable markers for the erythrocyte aggregation.

Cyclic and radial variation of the Doppler power from porcine whole blood

The Doppler power from porcine blood was observed in a mock flow loop to have cyclic and radial variation during a pulsatile cycle. It was found to decrease with shear rate under steady flow, except near the center of the tube at which other mechanisms such as the effects of radial distribution on the rouleaux might be involved. Under pulsatile flow, the timing of the peak of the Doppler power measured at the center of the tube became closer to the peak systole from 20 to 60 beats/minute (BPM), and the power and velocity peaks coincided at 60 BPM. The overall radial variation of the Doppler power during a whole pulsatile cycle was prominent due to the increase of shear rate from the center to 4.5 mm radial position within a tube of 6.35 mm radius. The cyclic variation of the Doppler power varied with the radial position, being relatively large at the center, reaching a minimum at an intermediate radial position, and increasing again near the wall. The peak of the Doppler power occurred at early systole near the tube wall and lagged the flow closer to the center. The "black hole" phenomenon was observed only over portions of the flow cycle. All these complex variations of the Doppler power across the tube over a cycle are thought to be the result of red cell aggregation, which can be affected by shear rate and acceleration.

Noninvasive in vivo measurements of hematocrit

OBJECTIVE

To develop a clinically applicable method for noninvasive acoustic determination of hematocrit values in vivo.

METHODS

The value of hematocrit was determined initially in vitro from the pulseecho measurements of acoustic attenuation. The testing was carried out in a laboratory setup with an ultrasonic transducer operating at 20 MHz and with the use of human blood samples at 37 degrees C. The attenuation coefficient measurements in blood in vivo were implemented by multigated, 20-MHz pulsed Doppler insonation. The Doppler signal was recorded in the brachial and radial arteries. Both in vitro and in vivo hematocrit data were compared with those obtained by the centrifuge method.

RESULTS

The attenuation coefficient in vitro was determined from the measurements of 168 samples with hematocrit values varying between 23.9% and 51.6%. The attenuation from 20-MHz data was equal to 3.66 + 0.089 hematocrit (decibels per centimeter). The uncertainty of in vivo measurements in the brachial artery was determined to be within +/- 5% hematocrit. However, the measurements in the radial artery resulted in a clinically unacceptable uncertainty of +/- 20% hematocrit.

CONCLUSIONS

The method proposed appears to be promising for in vivo determination of hematocrit, because 5% hematocrit error is adequate for monitoring changes in patients in shock or during dialysis. It was found that the multigate system largely simplified placement of an ultrasonic probing beam in the center of the blood vessel. Current work focuses on enhancing the method's applicability to arbitrarily selected vessels and to reducing the hematocrit measurement error to much less than 5% hematocrit.

A new ultrasound principle for characterizing erythrocyte aggregation: in vitro reproducibility and validation

RATIONALE AND OBJECTIVES

There is no method currently available to quantify erythrocyte aggregation in vivo. In this work, using a Couette system, we defined new ultrasound indexes potentially applicable for non-invasive investigations.

METHODS

Two ultrasound protocols were developed: (1) a protocol in which decreasing shear rates ranging from 200 to 1 s-1 were applied to solutions; and (2) a protocol in which a 200 s-1 shear rate was initially applied followed by stoppage of flow (a kinetics protocol). New ultrasound indexes were defined as: the power PUS at the nominal frequency of each transducer, Rayleigh's slope (tangent of the curve PUS = f(log(F)) through the 3.5 to 15 MHz frequency bandwidth) and kinetic indexes characterizing the aggregation/aggregability of the suspension.

RESULTS

Using washed erythrocytes resuspended in saline, it was shown that the ultrasound intensity is dependent at 3.54 +/- 5.9% (NS) to the power of the frequency (theoretical value = 4). Using 10 total blood samples extracted from a single pig, good reproducibility for all indexes (5%) was demonstrated.

CONCLUSIONS

A suitable and reproducible methodology was developed and validated for studying erythrocyte aggregation in calibrated in vitro conditions.

Doppler power variation from porcine blood under steady and pulsatile flow

Although a number of recent studies have demonstrated that the echogenicity of blood varies as a function of time under pulsatile flow, the fundamental mechanisms responsible for it are still uncertain. To better understand this phenomenon, the Doppler power from porcine blood and polystyrene microsphere suspensions was measured at the center of the tube as functions of two crucial parameters, flow velocity and stroke rate (for pulsatile flow), under steady and pulsatile flow in a mock flow loop. In the present study, the experimental results were obtained with a 10-MHz pulsed Doppler system with a frequency response estimated more accurately by electronic injection, and validated by comparing to the radiofrequency (RF) signal acquired from the same Doppler instrument. The results show that the Doppler power from microspheres and porcine red blood cell (RBC) suspensions did not vary appreciably (< 2 dB), with either the speed or stroke rate (for pulsatile flow only) under steady and pulsatile flow. It was found that the Doppler power from porcine whole blood under steady flow decreased with the speed by approximately 13 dB from 3 to 33 cm/s and was only 3 dB higher than that from RBC suspension at 33 cm/s, suggesting minimal RBC aggregation in whole blood at this speed. The apparent cyclic variation from whole blood was observed at 20 and 40 beats/min (BPM). The cyclic variation became more obvious as the speed and stroke rate decreased. The mean Doppler power over a cycle increased as the peak speed decreased. The Doppler power reached a maximum near peak systole and a minimum at late diastole at the center of the tube. This pattern cannot be explained by RBC aggregation due to the shear rate alone, and may be attributed to acceleration and deceleration along with aggregation. The cyclic variation was not observed at 60 BPM, probably because of a lack of time for aggregation to occur.

In vivo measurements of ultrasonic backscattering in blood

Ultrasonic backscattering in blood including its dependence on the hematocrit, plasma proteins, shear rate, and flow disturbance, has been studied extensively theoretically and experimentally in vitro. However, much of the result has never been validated in vivo. To do so, backscattering measurements were made on pigs using a 10-MHz non-focused intravascular transducer in direct contact with blood. The probe was placed in either the abdominal aorta or the inferior vena cava. The backscattering coefficient (BSC) of blood flowing in these vessels as well as downstream from a stenosis was measured using an approach that was originally developed for measurements with focused transducers. With this approach, 6% porcine red cell saline suspensions prepared immediately after each in vivo measurement were used as the reference medium. Result from seven pigs at hematocrits ranging from 29 to 36% (31.9 +/- 2.5%) demonstrated that BSC of blood in the vena cava, (4.62 +/- 2.06) x 10(-5) cm-sr-1, is consistently higher than that in the aorta, (2.65 +/- 1.22) x 10(-5) cm-sr-1. The difference has been attributed to the lower shear rate and the formation of red cell aggregation in venous blood. These in vivo results are in agreement with those obtained in vitro. In response to stenoses created by ligating the aorta, backscattering of the blood measured downstream from the stenosis showed that the closer the site of measurement relative to the stenosis, the higher the backscatter, presumably resulting from the higher degree of flow disturbance. In vitro backscattering results on porcine whole blood were also acquired at 20 MHz with a Diasonics intravascular scanner.

Dependence of power Doppler image on a high pass filter instrumented in ultrasound machine

The aim of this study was to examine the influence of flow velocity, beam incident angle and a wall motion filter on the intensity of power Doppler image of steady flow in vitro. Power Doppler images of flow were recorded using a 7.5-MHz linear transducer with the fixed repetition frequency, gain and frame rate settings at the velocity levels of 15, 20, 35 and 65 cm/s with the beam incident angles of 30 degrees and 60 degrees. The power (P) of received Doppler signal was digitized to 25 gray values (G) for imaging using a wall motion filter with the transfer function: G = a x log P + b (a, b = constant values). Image intensity was measured at the center of the flow image off-line and compared with the flow velocity measured by conventional pulsed wave Doppler. Below the Nyquist limit, G increased as velocity increased, and G with the incident angle 30 degrees was lower than those with 60 degrees. Overall relationship between the Doppler shift frequency and the image intensity exhibited an excellent correlation when fit to the theoretical curve derived from the filter property (r = 0.97). The signal intensity of power Doppler image of flow depends upon the mean Doppler frequency shift or the flow velocity and was clearly affected by the wall motion filter.

Ultrasonic backscattering from porcine whole blood of varying hematocrit and shear rate under pulsatile flow

It was shown previously that ultrasonic scattering from whole blood varies during a flow cycle under pulsatile flow both in vitro and in vivo. It has been postulated that this cyclic variation may be associated with the dynamics of red cell aggregation because the shearing force acting on the red cell aggregates across the lumen is a function of time during a flow cycle. In all studies, the local shear rate variation as a function of time is unknown. The effect of shear rate on the red cell aggregation and, thus, on ultrasonic scattering from blood can only be merely speculated. One solution to this problem is to estimate the shear rate in a flow conduit by finite element analysis (FEA). An FEA computational fluid dynamics (CFD) tool was used to calculate local shear rate in a series of experiments in which ultrasonic backscattering from porcine whole blood under pulsatile flow was measured as a function of hematocrit and shear rate intravascularly with a 10-MHz catheter-mounted transducer in a mock flow loop. The results show that, at 20 beats per min (BPM), the magnitudes of the cyclic variation for hematocrits at 30, 40, and 50% were approximately 4 dB. However, at 60 BPM, the magnitude of cyclic variation was found to be minimal. The results also confirm previous findings that the amplitude and the timing of the peak of ultrasonic backscattering from porcine whole blood under pulsatile flow during a flow cycle are dependent upon the shear rate and hematocrit in a complicated way.

The effect of hemodynamics, vessel wall compliance and hematocrit on ultrasonic Doppler power: an in vitro study

Previous in vitro studies in rigid tubes under pulsatile flow conditions have reported a lack of a cyclic variation in blood echogenicity that contradicts in vivo results. To investigate whether or not these variations can be attributed to the compliance of the vessel wall, a series of in vitro experiments with compliant tubes, under pulsatile flow conditions, was performed. Two important factors that may affect the Doppler power were investigated: 1. the dependence on hematocrit and 2. the effect of the vessel wall elasticity. In the present study, it is shown that, at the low beat rates, the peak of the mean Doppler power within the flow cycle depends on the vessel wall compliance. When the vessel becomes more compliant, the peak is shifted from the early to the late systole. Additionally, there is a correlation between the power peak and hematocrit that is more evident in compliant vessels. At a higher pulsation rate of 37 beats/min, a different variation is observed. A drop in the power occurs near peak systole in compliant tube experiments and is more pronounced as the vessel becomes more constricted. The observed power drop agrees with previously reported in vivo results, but is not seen in rigid tube experiments. The results of this study suggest that proper interpretation of cyclic variations in Doppler power requires a knowledge of hemodynamic parameters, such as the modulus of elasticity of the vessel wall, propagation velocity or, possibly, the phase angle of input impedance.

An in vitro study of the effects of Doppler angle, fibrinogen, and hematocrit on ultrasonic Doppler power

For a better understanding of the relationship between the Doppler power and erythrocyte aggregation of whole blood under steady flow in a conduit, the effects of Doppler angle, fibrinogen concentration, and hematocrit were investigated in a mock flow loop. The results show that, at a mean shear rate of 102 s(-1), there was minimal angular dependence; but at a mean shear rate of 52 s(-1), there was a weak angular dependence as the Doppler angle was varied from 40 degrees to 70 degrees . These results suggest that there was, perhaps, no or little alignment of the red cell aggregates at high shear rates. The Doppler power was found to increase nonlinearly as the fibrinogen concentration was increased; and the effect of other plasma proteins on red cell aggregation may not be negligible, although fibrinogen is the dominant factor. The results show that the variation of the Doppler power over the lumen is hematocrit dependent for hematocrits below 26%

Effects of a sudden flow reduction on red blood cell rouleau formation and orientation using RF backscattered power

In most studies that were aimed at evaluating the kinetics of red blood cell (RBC) aggregation, human blood was initially circulated at a high shear rate to disrupt the aggregates, and measurements were performed following a complete flow stoppage, during the process of rouleau formation. However, it is known that a very low shear rate can enhance the formation of aggregates, as demonstrated by the modal relationship of the shear-rate dependence of RBC aggregation. The objective of the present study was, thus, to evaluate the influence of sudden flow reductions compared to a complete flow stoppage on the kinetics of rouleau formation, using ultrasound backscattering. Horse blood models, characterized by different aggregation levels, were obtained by diluting the plasma with a saline solution in different proportions. Blood was circulated in a 12.7-mm vertical tube at a flow rate of 1250 mL min-1 (prereduction flow rate) to disrupt the aggregates. The ultrasound radiofrequency (RF) signal was recorded from the center of the tube following different levels of sudden flow reduction or complete stoppage (postreduction flow rate). All measurements were performed over 2 min, using a 10-MHz transducer. No power increase was observed after complete flow stoppage. For postreduction flow rates varying between 20 and 160 mL min-1, the backscattered power increased proportionally with the kinetics of RBC aggregation. The echo buildup was also faster and stronger when the postreduction flow rate was increased. An unexpected pattern of variation of the backscattered power was found for horse RBCs characterized by high kinetics of rouleau formation. The power increased rapidly to a plateau, followed by another rapid increase and another plateau. Rouleau formation, random disorientation and reorientation were postulated to explain the phasic power increases observed.

Differences in the erythrocyte aggregation level between veins and arteries of normolipidemic and hyperlipidemic individuals

The objectives of this study were to detect differences in the Doppler power backscattered by blood in vivo, and to identify factors affecting the backscattered power. The main hypothesis was that variations in the erythrocyte aggregation level between veins and arteries of normolipidemic and hyperlipidemic individuals can be detected with power Doppler ultrasound. Doppler measurements were performed at 5 MHz, with an Acuson 128 XP/10 system, over the carotid artery and jugular vein, external iliac artery and vein, common femoral artery and vein and popliteal artery and vein. Doppler signals were recorded at the center of each vessel to optimize the detection of erythrocyte aggregation, and processed off-line to obtain the backscattered power. The power of each recording was compensated for Doppler gain differences, tissue attenuation with depth and transmitted power variations occurring with pulse-repetition interval modifications. Results showed statistically stronger backscattered power in veins compared to arteries for the iliac, femoral and popliteal sites. In comparison with healthy subjects, stronger powers were observed in hyperlipidemic patients for the femoral and popliteal sites. Power differences were also found between peripheral measurements. On the other hand, no difference was observed between the power measured in the carotid artery and jugular vein for both groups of individuals. Multiple linear regression analyses were performed to identify factors affecting the backscattered power. Results showed a correlation (r) of 71.2% between the Doppler power in the femoral vein and the linear combination of two parameters: an erythrocyte aggregation index S10 measured with a laser scattering method, and the diameter of the vessel measured on B-mode images. Statistically significant linear correlation levels were also found between S10 and the Doppler power in various vessels. In conclusion, this study showed that power Doppler differences exist in vivo in large vessels between veins and arteries of normolipidemic and hyperlipidemic individuals. The Doppler power variations were also shown to be related to erythrocyte aggregation.