A mathematical model for the assessment of hemodynamic parameters using quantitative contrast echocardiography

Stratification of patients with liver fibrosis using dual-energy CT

Assessing the severity of liver fibrosis has direct clinical implications for patient diagnosis and treatment. Liver biopsy, typically considered the gold standard, has limited clinical utility due to its invasiveness. Therefore, several imaging-based techniques for staging liver fibrosis have emerged, such as magnetic resonance elastography (MRE) and ultrasound elastography (USE), but they face challenges that include limited availability, high cost, poor patient compliance, low repeatability, and inaccuracy. Computed tomography (CT) can address many of these limitations, but is still hampered by inaccuracy in the presence of confounding factors, such as liver fat. Dual-energy CT (DECT), with its ability to discriminate between different tissue types, may offer a viable alternative to these methods. By combining the "multi-material decomposition" (MMD) algorithm with a biologically driven hypothesis we developed a method for assessing liver fibrosis from DECT images. On a twelve-patient cohort the method produced quantitative maps showing the spatial distribution of liver fibrosis, as well as a fibrosis score for each patient with statistically significant correlation with the severity of fibrosis across a wide range of disease severities. A preliminary comparison of the proposed algorithm against MRE showed good agreement between the two methods. Finally, the application of the algorithm to longitudinal DECT scans of the cohort produced highly repeatable results. We conclude that our algorithm can successfully stratify patients with liver fibrosis and can serve to supplement and augment current clinical practice and the role of DECT imaging in staging liver fibrosis.

A Flexible Method for Multi-Material Decomposition of Dual-Energy CT Images

The ability of dual-energy computed-tomographic (CT) systems to determine the concentration of constituent materials in a mixture, known as material decomposition, is the basis for many of dual-energy CT's clinical applications. However, the complex composition of tissues and organs in the human body poses a challenge for many material decomposition methods, which assume the presence of only two, or at most three, materials in the mixture. We developed a flexible, model-based method that extends dual-energy CT's core material decomposition capability to handle more complex situations, in which it is necessary to disambiguate among and quantify the concentration of a larger number of materials. The proposed method, named multi-material decomposition (MMD), was used to develop two image analysis algorithms. The first was virtual unenhancement (VUE), which digitally removes the effect of contrast agents from contrast-enhanced dual-energy CT exams. VUE has the ability to reduce patient dose and improve clinical workflow, and can be used in a number of clinical applications such as CT urography and CT angiography. The second algorithm developed was liver-fat quantification (LFQ), which accurately quantifies the fat concentration in the liver from dual-energy CT exams. LFQ can form the basis of a clinical application targeting the diagnosis and treatment of fatty liver disease. Using image data collected from a cohort consisting of 50 patients and from phantoms, the application of MMD to VUE and LFQ yielded quantitatively accurate results when compared against gold standards. Furthermore, consistent results were obtained across all phases of imaging (contrast-free and contrast-enhanced). This is of particular importance since most clinical protocols for abdominal imaging with CT call for multi-phase imaging. We conclude that MMD can successfully form the basis of a number of dual-energy CT image analysis algorithms, and has the potential to improve the clinical utility of dual-energy CT in disease management.

In vitro evaluation of the impact of ultrasound scanner settings and contrast bolus volume on time-intensity curves

The objective of this study was to assess in vitro the impact of ultrasound scanner settings and contrast bolus volume on time-intensity curves formed from dynamic contrast-enhanced ultrasound image loops. An indicator-dilution experiment was developed with an in vitro flow phantom setup used with SonoVue contrast agent (Bracco SpA, Milan, Italy). Imaging was performed with a Philips iU22 scanner and two transducers (L9-3 linear and C5-1 curvilinear). The following ultrasound scanner settings were investigated, along with contrast bolus volume: contrast-specific nonlinear pulse sequence, gain, mechanical index, focal zone depth, acoustic pulse center frequency and bandwidth. Four parameters (rise time, mean transit time, peak intensity, and area under the curve) were derived from time-intensity curves which were obtained after pixel by pixel linearization of log-compressed data (also referred to as video data) included in a region of interest. Rise time was found to be the parameter least impacted by changes to ultrasound scanner settings and contrast bolus volume; the associated coefficient of variation varied between 0.7% and 6.9% while it varied between 0.8% and 19%, 12% and 71%, and 9.2% and 66%, for mean transit time, peak intensity, and area under the curve, respectively. The present study assessed the impact of ultrasound scanner settings and contrast bolus volume on time-intensity curve analysis. One should be aware of these issues to standardize their technique in each specific organ of interest and to achieve accurate, sensitive, and reproducible data using dynamic contrast-enhanced ultrasound. One way to mitigate the impact of ultrasound scanner settings in longitudinal, multi-center quantitative dynamic contrast-enhanced ultrasound studies may be to prohibit any adjustments to those settings throughout a given study. Further clinical studies are warranted to confirm the reproducibility and diagnostic or prognostic value of time-intensity curve parameters measurements in a particular clinical scenario of interest, for example that of cancer patients undergoing vascular targeting therapies.

Contrast-ultrasound diffusion imaging for localization of prostate cancer

Prostate cancer is the most prevalent form of cancer in western men. An accurate early localization of prostate cancer, permitting efficient use of modern focal therapies, is currently hampered by a lack of imaging methods. Several methods have aimed at detecting microvascular changes associated with prostate cancer with limited success by quantitative imaging of blood perfusion. Differently, we propose contrast-ultrasound diffusion imaging, based on the hypothesis that the complexity of microvascular changes is better reflected by diffusion than by perfusion characteristics. Quantification of local, intravascular diffusion is performed after transrectal ultrasound imaging of an intravenously injected ultrasound contrast agent bolus. Indicator dilution curves are measured with the ultrasound scanner resolution and fitted by a modified local density random walk model, which, being a solution of the convective diffusion equation, enables the estimation of a local, diffusion-related parameter. Diffusion parametric images obtained from five datasets of four patients were compared with histology data on a pixel basis. The resulting receiver operating characteristic (curve area = 0.91) was superior to that of any perfusion-related parameter proposed in the literature. Contrast-ultrasound diffusion imaging seems therefore to be a promising method for prostate cancer localization, encouraging further research to assess the clinical reliability.

In vivo gas body efficacy for glomerular capillary hemorrhage induced by diagnostic ultrasound in rats

Glomerular capillary hemorrhage (GCH) in rat kidney provided a model for assessing in vivo gas body efficacy in diagnostic or therapeutic applications of ultrasound. Two diagnostic ultrasound machines were utilized: one monitored the harmonic B-mode contrast enhancement of the left kidney and the other exposed the right kidney for GCH production. Definity contrast agent was infused at 1, 2, 5, or 10 microL/(kg x min) and infusion durations were 30, 60, 120, or 300 s. Exposure of the right kidney was at a peak rarefactional pressure amplitude of 2.3 MPa at 1.5 MHz. The circulating dose was estimated with a simple model of agent dilution and gas body loss. For 300 s infusion at 5 microL/(kg x min), the left kidney image brightness increased to a plateau with an estimated 6.4 +/- 1.3 microL/kg circulating dose with no GCH in histological sections. Exposure of the right kidney with a 1-s image interval reduced the estimated circulating dose to 1.3 +/- 0.3 microL/kg and induced 68.4% GCH. Dose and duration increases gave rapidly diminishing treatment effectiveness per gas body. The effective in vivo agent dose in rats can be reduced greatly due to high gas body destruction in the small animal, complicating predictions for similar conditions of human treatment.

Nanorod-based flow estimation using a high-frame-rate photoacoustic imaging system

A quantitative flow measurement method that utilizes a sequence of photoacoustic images is described. The method is based on the use of gold nanorods as a contrast agent for photoacoustic imaging. The peak optical absorption wavelength of a gold nanorod depends on its aspect ratio, which can be altered by laser irradiation (we establish a wash-in flow estimation method of this process). The concentration of nanorods with a particular aspect ratio inside a region of interest is affected by both laser-induced shape changes and replenishment of nanorods at a rate determined by the flow velocity. In this study, the concentration is monitored using a custom-designed, high-frame-rate photoacoustic imaging system. This imaging system consists of fiber bundles for wide area laser irradiation, a laser ultrasonic transducer array, and an ultrasound front-end subsystem that allows acoustic data to be acquired simultaneously from 64 transducer elements. Currently, the frame rate of this system is limited by the pulse-repetition frequency of the laser (i.e., 15 Hz). With this system, experimental results from a chicken breast tissue show that flow velocities from 0.125 to 2 mms can be measured with an average error of 31.3%.

Photoacoustic flow measurements based on wash-in analysis of gold nanorods

In this study, photoacoustic flow measurement methods based on wash-in analysis are presented. These methods use the rod-to-sphere shape transformations of gold nanorods induced by pulsed-laser irradiation. Due to the shape dependence of the optical absorption of the gold nanorods, these shape transitions are associated with a change in the peak optical absorption wavelength. Pulsed-laser irradiation at the wavelength corresponding to the peak optical absorption of the original gold nanorods allows the particles that undergo shape changes to be viewed as "being destructed" by the laser irradiation at that wavelength, hence, flow information can be derived from the change in ultrasound intensity that is directly related to the wash-in rate of the gold nanorods and the laser intensity. Two flow estimation methods based on the wash-in analysis are described. The first method first applies high-energy laser pulses that induce shape changes in all the nanorods. A series of low-energy pulses then are applied to monitor the acoustic signal change as new nanorods flow into the region of interest. The second method uses single-energy laser pulses such that the "destruction" and "detection" are performed simultaneously. The simulation results show that it is valid to fit the time-intensity curves by exponential models. To demonstrate the validity of the proposed methods, an Nd:YAG pulsed laser operating at 1064 nm was used for optical irradiation, and a 1-MHz ultrasonic transducer was used for acoustic detection. Gold nanorods with a peak optical absorption at 1018 nm and a concentration of 0.26 nM were used to estimate flow velocities ranging from 0.35 to 2.83 mm/s. The linear regression results show that the correlation coefficients between the measured velocities and the true values are close to unity (> or = 0.94), thus demonstrating the feasibility of the proposed photoacoustic techniques for relative flow estimation.

Identification of cardiovascular dilution systems by contrast ultrasound

Indicator dilution techniques permit accurate measurements of important cardiovascular parameters, such as pulmonary blood volume (PBV) and ejection fraction (EF). However, their use is limited by the need for central catheterization. Contrast ultrasonography allows overcoming this problem. PBV and EF can be measured by a dilution system identification algorithm after detection of multiple dilution curves by an ultrasound scanner. In this paper, we present a system identification method that exploits the a priori knowledge on the dilution system and finds the optimum parameters for the parametric model representing the dilution system impulse response. No subsequent model interpolation is needed. Volume measurements show accurate in-vitro results and clinical feasibility, while 50 EF measurements in patients show a 0.88 correlation coefficient with echocardiographic biplane estimates. In conclusion, adding a priori knowledge to the system identification algorithm leads to increased accuracy and robustness of the method for PBV and EF measurements.

Photoacoustic flow measurements with gold nanoparticles

The hypothesis that quantitative blood flow measurements are feasible with the time-intensity based method in photoacoustic imaging using gold nanoparticles as contrast agent is experimentally tested. The in vitro results show good linearity between the measurements and the theory, thus suggesting the potential of relative photoacoustic flow measurements with gold nanoparticles.

Cardiac image segmentation for contrast agent videodensitometry

Indicator dilution techniques are widely used in the intensive care unit and operating room for cardiac parameter measurements. However, the invasiveness of current techniques represents a limitation for their clinical use. The development of stable ultrasound contrast agents allows new applications of the indicator dilution method. Ultrasound contrast agent dilutions permit an echographic noninvasive measurement of cardiac output, ejection fraction, and blood volumes. The indicator dilution curves are measured by videodensitometry of specific regions of interest and processed for the cardiac parameter assessment. Therefore, the major indicator dilution imaging issue is the detection of proper contrast videodensitometry regions that maximize the signal-to-noise ratio of the measured indicator dilution curves. This paper presents an automatic contour detection algorithm for indicator dilution videodensitometry. The algorithm consists of a radial filter combined with an outlier correction. It maximizes the region of interest by excluding cardiac structures that act as interference to the videodensitometric analysis. It is fast, projection independent, and allows the simultaneous detection of multiple contours in real time. The system is compared to manual contour definition on both echographic and magnetic resonance images.

Identification of ultrasound contrast agent dilution systems for ejection fraction measurements

Left ventricular ejection fraction is an important cardiac-efficiency measure. Standard estimations are based on geometric analysis and modeling; they require time and experienced cardiologists. Alternative methods make use of indicator dilutions, but they are invasive due to the need for catheterization. This study presents a new minimally invasive indicator dilution technique for ejection fraction quantification. It is based on a peripheral injection of an ultrasound contrast agent bolus. Left atrium and left ventricle acoustic intensities are recorded versus time by transthoracic echocardiography. The measured curves are corrected for attenuation distortion and processed by an adaptive Wiener deconvolution algorithm for the estimation of the left ventricle impulse response, which is interpolated by a monocompartment exponential model for the ejection fraction assessment. This technique measures forward ejection fraction, which excludes regurgitant volumes. The feasibility of the method was tested on a group of 20 patients with left ventricular ejection fractions going from 10% to 70%. The results are promising and show a 0.93 correlation coefficient with echographic bi-plane ejection fraction measurements. A more extensive validation as well as an investigation on the method applicability for valve insufficiency and right ventricular ejection fraction quantification will be an object of future study.

Transfer function analysis of ultrasonic time-intensity measurements

Time-intensity measurements of ultrasonic-contrast microbubbles based on the dilution theory have been used to assist blood flow estimation. The compartment model has been employed to describe the dilution process. Under the linear and time-invariant assumption, the time-intensity curve measured at the output of a compartment (i.e., blood mixing chamber) is the convolution of the input time-intensity curve with the compartment's transfer function. Thus, transfer function analysis is possible using deconvolution when the temporal variations in both the input and the output intensities are available. Note that the linear and time-invariant assumption requires a constant flow rate because, with flow pulsation, the flow rate changes with time and the mixing process becomes time varying. Thus, the purpose of this paper was to study the effects of flow pulsation on time-intensity measurements. In addition, a deconvolution technique based on a recursive least squares approach is used for transfer function analysis. Both simulations and experiments were performed; the results from which indicate that the pulsation generally does not affect the validity of time-intensity-based flow estimation. The proposed deconvolution technique is also effective for both constant and pulsatile flows; thus, permitting transfer function analysis in various flow conditions. One potential application of this transfer function analysis is to remove the effects of a noninstantaneous input function. The results from this paper lead to future work in brain-perfusion estimation based on extracranial time-intensity measurements.

Contrast-specific ultrasonic flow measurements based on both input and output time intensities

Ultrasonic contrast agents are used to assess perfusion conditions based on evaluation of the time-intensity curve. Such a curve reflects the concentration of microbubbles in the perfused area and the indicator-dilution theory is used to derive the volumetric flow rate from the measured concentration. Previous results have shown that the technique is not reliable in some conditions due to the shadowing effect. To overcome this problem, a contrast-specific technique using both the input and output time-intensity relationships is proposed; this contrasts with conventional techniques that utilize only the relationship directly from the perfused area. The proposed technique is referred to as the input-output time-intensity curve (IOTIC) method. In this work, the shadowing effect was studied experimentally and the efficacy of the IOTIC technique was assessed and compared with conventional techniques. The results indicate that the IOTIC technique eliminates the shadowing effect and provides a good correlation between the actual flow rate and measured flow-related parameters; thus, making quantitative estimation of perfusion feasible. Note that the IOTIC is applicable, based on the assumption that both the input and the output can be positioned within the same image plane; its clinical applications include situations where the perfused area cannot be effectively imaged by ultrasound (US). One example is the assessment of brain perfusion, and it will be used as a target clinical application of the IOTIC technique.

Time-intensity-based volumetric flow measurements: an in vitro study

Ultrasonic contrast agents have been used to assist blood flow measurements. Several contrast-specific flow measurement techniques have been proposed during the last few years. Among them, a method based on relative enhancement of the backscattered signal as a function of time is of particular interest. This method is also known as the time-intensity method. The method is based on the indicator-dilution theory, and the time-intensity curve is used to derive blood flow-related parameters such as the flow rate and the blood mixing volume. Previous in vitro studies done by other research groups were mainly based on a perfusion model or an artery model. Results showed that several parameters derived from the time-intensity curve had a good correlation with the flow rate under certain conditions. However, the studies did not focus on factors such as mixing volume, mixing chamber configuration and different types of mixing chamber. In this paper, dependence of the time-intensity curve is further studied. Specifically, two types of blood-mixing chambers were constructed. One was a spherical compartment phantom with two different sizes (260 and 580 mL) and different inflow/outflow configurations. The other was a perfusion phantom consisting of dialysis cartridges with the volume ranging from 114 to 351 mL. The time intensities were also measured at both the input and the output of the mixing chamber. A commercial agent (Levovist) and a self-made, albumin-based agent were used and the wash-out time constant and the mean transit time were derived for flow rates ranging from 500 to 1300 mL/min. For the perfusion phantom, results showed that the parameters had a good correlation with both the flow rate and the mixing volume. Results from the compartment phantom, on the other hand, indicated that the inflow/outflow configuration and the mixing size significantly affected the derived time constants. Potential applications of new volumetric flow estimation techniques based on both input and output intensities were also discussed.

Feasibility study of time-intensity-based blood flow measurements using deconvolution

Ultrasonic contrast agents have been used to enhance the acoustic backscattered intensity of blood and to assist the assessment of blood flow parameters. One example is the time-intensity method based on the indicator-dilution theory. In this case, a mixing chamber model can be employed to describe the concentration of the contrast agent as a function of time. By measuring the time intensities at both the input and output of the blood mixing chamber, blood flow information can be obtained if proper deconvolution techniques are applied. Note that most deconvolution techniques assume a linear and time invariant (LTI) system for the mixing of the contrast agent with blood. In this paper, the hypothesis that a blood mixing chamber is an LTI system was tested. Several aspects were studied. One aspect was the linear relationship between the concentration of the contrast agent and the backscattered intensity. The other aspect was the dependence of the derived time constants on the concentration. The concept of an effective mixing volume was also introduced and evaluated. Finally, the input and the output time constants were measured and compared to theory under the LTI assumption. Extensive experiments were performed. Two in vitro flow models were constructed and two contrast agents were used. Results indicated that the LTI assumption does not hold and quantitative flow estimation is generally not possible. Nonetheless, the indicator-dilution theory can still be applied if only relative measurements of the flow rate are required.

Sonographic investigation of flow patterns in the perfused human placenta and their modulation by vasoactive agents with enhanced visualization by the ultrasound contrast agent Albunex

PURPOSE

Our objective was to demonstrate sonographically the flow distribution in the circulation of human placentae as well as the sensitivity of the human fetal capillary bed to vasoconstriction and dilatation.

METHODS

Five human full-term placental lobules were maintained in vitro with fetal and maternal flow. Commercial ultrasound scanners were used for imaging. Albunex (1 ml bolus) was administered to the fetal "artery" to monitor patterns of flow. U46619 (1 ml, 10(-6) M; a thromboxane agonist and potent vasoconstrictor) and/or nitroglycerin (a potent vasodilator) were added to the fetal artery.

RESULTS

Following the addition of U46619, mean "fetal pressures" rapidly rose from 23.2 +/- 0.8 to 118 +/- 2. 9 mm Hg (mean +/- standard error of mean; p < 0.001); venous flow rates decreased. As demonstrated by color Doppler imaging, flow markedly changed from a pattern of general distribution throughout the lobule to flow only near the chorionic plate. Color persistence was 94.4 +/- 6.5 seconds with Albunex after nitroglycerin and 39.8 +/- 3.4 seconds with Albunex after injection of U46619 (p < 0.001). Nitroglycerin had no effect when injected by itself but returned "constricted" flow to a "normal" pattern when injected after U46619.

CONCLUSIONS

The contrast medium Albunex improved visualization of the fetal circulation throughout the lobule. Flow in the human placental capillary bed can be regionally manipulated throughout the placental lobule by vasomodulators and monitored by Albunex-enhanced sonographic examination.