A unified view of imaging the elastic properties of tissue

A novel stress sensor enables accurate estimation of micro-scale tissue mechanics in quantitative micro-elastography

Quantitative micro-elastography (QME) is a compression-based optical coherence elastography technique enabling the estimation of tissue mechanical properties on the micro-scale. QME utilizes a compliant layer as an optical stress sensor, placed between an imaging window and tissue, providing quantitative estimation of elasticity. However, the implementation of the layer is challenging and introduces unpredictable friction conditions at the contact boundaries, deteriorating the accuracy and reliability of elasticity estimation. This has largely limited the use of QME to ex vivo studies and is a barrier to clinical translation. In this work, we present a novel implementation by affixing the stress sensing layer to the imaging window and optimizing the layer thickness, enhancing the practical use of QME for in vivo applications by eliminating the requirement for manual placement of the layer, and significantly reducing variations in the friction conditions, leading to substantial improvement in the accuracy and repeatability of elasticity estimation. We performed a systematic validation of the integrated layer, demonstrating >30% improvement in sensitivity and the ability to provide mechanical contrast in a mechanically heterogeneous phantom. In addition, we demonstrate the ability to obtain accurate estimation of elasticity (<6% error compared to <14% achieved using existing QME) in homogeneous phantoms with mechanical properties ranging from 40 to 130 kPa. Furthermore, we show the integrated layer to be more robust, exhibiting increased temporal stability, as well as improved conformity to variations in sample surface topography, allowing for accurate estimation of elasticity over acquisition times 3× longer than current methods. Finally, when applied to ex vivo human breast tissue, we demonstrate the ability to distinguish between healthy and diseased tissue features, such as stroma and cancer, confirmed by co-registered histology, showcasing the potential for routine use in biomedical applications.

Analysis of friction in quantitative micro-elastography

Quantitative micro-elastography (QME) is a compression-based optical coherence elastography technique capable of measuring the mechanical properties of tissue on the micro-scale. As QME requires contact between the imaging window and the sample, the presence of friction affects the accuracy of the estimated elasticity. In previous implementations, a lubricant was applied at the contact surfaces, which was assumed to result in negligible friction. However, recently, errors in the estimation of elasticity caused by friction have been reported. This effect has yet to be characterized and is, therefore, not well understood. In this work, we present a systematic analysis of friction in QME using silicone phantoms. We demonstrate that friction, and, therefore, the elasticity accuracy, is influenced by several experimental factors, including the viscosity of the lubricant, the mechanical contrast between the compliant layer and the sample, and the time after the application of a compressive strain. Elasticity errors over an order of magnitude were observed in the absence of appropriate lubrication when compared to uniaxial compression testing. Using an optimized lubrication protocol, we demonstrate accurate elasticity estimation (<10% error) for nonlinear elastic samples with Young's moduli ranging from 3 kPa to 130 kPa. Finally, using a structured phantom, we demonstrate that friction can significantly reduce mechanical contrast in QME. We believe that the framework established in this study will facilitate more robust elasticity estimations in QME, as well as being readily adapted to understand the effects of friction in other contact elastography techniques.

Integrated Circuits for Medical Ultrasound Applications: Imaging and Beyond

Medical ultrasound has become a crucial part of modern society and continues to play a vital role in the diagnosis and treatment of illnesses. Over the past decades, the development of medical ultrasound has seen extraordinary progress as a result of the tremendous research advances in microelectronics, transducer technology and signal processing algorithms. However, medical ultrasound still faces many challenges including power-efficient driving of transducers, low-noise recording of ultrasound echoes, effective beamforming in a non-linear, high-attenuation medium (human tissues) and reduced overall form factor. This paper provides a comprehensive review of the design of integrated circuits for medical ultrasound applications. The most important and ubiquitous modules in a medical ultrasound system are addressed, i) transducer driving circuit, ii) low-noise amplifier, iii) beamforming circuit and iv) analog-digital converter. Within each ultrasound module, some representative research highlights are described followed by a comparison of the state-of-the-art. This paper concludes with a discussion and recommendations for future research directions.

A Model for Predicting Malignant Sub-pleural Solid Masses Using Grayscale Ultrasound and Ultrasound Elastography

This article aimed to establish a prediction model of grayscale sonography and ultrasound elastography for malignant sub-pleural solid masses and evaluate its diagnostic value. The study included 153 patients, including 89 patients with malignant tumors and 64 patients with benign diseases. Statistical differences between the malignant and benign groups were found in the factors of age, air bronchogram, borderline, shape and elasticity score (p < 0.05). Age, elasticity score and borderline were effective factors for predicting malignant sub-pleural solid masses, offering an area under the receiver operating characteristic curve (AUROC) value of 0.72 (95% confidence interval [CI] 0.64-0.80), 0.73 (95% CI 0.65-0.79) and 0.70 (95% CI 0.62-0.77), respectively. The AUROC value of the prediction model for malignant sub-pleural solid masses was 0.88 (95% CI 0.81-0.92), which indicates that the prediction model was able to improve the diagnostic accuracy and that it may prove a useful auxiliary diagnostic tool for malignant sub-pleural solid masses, especially in primary health care institutions in developing countries.

Vibration-Guided Transient Elastography: A Novel Fibroscan® Examination with Improved Guidance for Liver Stiffness Measurement

Vibration-controlled transient elastography-based FibroScan (Echosens, Paris, France) is today considered the reference device for non-invasive assessment of liver stiffness, and has been found to be a good surrogate marker of liver fibrosis. One major issue when using VCTE™ is the necessity to find an optimal measurement window before triggering measurements. In this article, a new method called vibration-guided transient elastography (VGTE) facilitating the localization of an optimal measurement window is proposed. VGTE relies on a combination of continuous and transient vibrations used to locate the liver and to measure liver stiffness, respectively. Two studies conducted on customized phantoms and on 31 volunteers compared VGTE with standard ultrasound-based tools. VGTE performed significantly better than standard ultrasound-based tools in detection of an optimal measurement window. The operator never failed to find a valid measurement window using VGTE. VGTE can also detect artifacts such as lungs, ribs and blood vessels.

"Elasto-lung point": A new tool for the sonographic confirmation of pneumothorax

INTRODUCTION

Standard ultrasound gives the operator a dynamic morphology of the investigated anatomy, whereas ultrasound elastography (USE) provides quantitative and qualitative information about the elastic properties of the tissues.

OBJECTIVES

We designed a single-arm prospective study in order to investigate the feasibility of USE in the diagnosis of pneumothorax if a lung point sign is present.

METHODS

Thirty patients were enrolled in this protocol, from January 2017 to December 2018 at the Pneumology Department of the Azienda Socio-Sanitaria Territoriale Spedali Civili (Brescia, Italy). Patients who were suspected of having pneumothorax were previously evaluated with standard ultrasonography, and then, in the presence of lung point, we performed strain elastography. All patients were evaluated in supine and sitting positions with a linear probe (7.5 MHz). USE enhanced the air-tissue interface dividing the normal parenchyma from the air column of pneumothorax with a sharp line. We called this sign "elasto-lung point."

RESULTS AND CONCLUSION

The "elasto-lung point" was able to confirm the diagnosis of pneumothorax in every investigated patient. USE is a simple, reproducible and inexpensive technique that can contribute to the diagnosis of pneumothorax, such as the classic "stratosphere" or "Bar Code" sign in M-mode. No false negative cases were observed.

Group versus Phase Velocity of Shear Waves in Soft Tissues

Across the varieties of waves that have been studied in physics, it is well established that group velocities can be significantly greater than or less than phase velocities measured within comparable frequency bands, depending on the particular mechanisms involved. The distinction between group and phase velocities is important in elastography, because diagnoses are made based on shear wave speed estimations from a variety of techniques. We review the general definitions of group and phase velocity and examine their specific relations within an important general class of rheological models. For the class of tissues and materials exhibiting power law dispersion, group velocity is significantly greater than phase velocity, and simple expressions are shown to interrelate the commonly measured parameters. Examples are given from phantoms and tissues.

Analysis of the transient surface wave propagation in soft-solid elastic plates

In dynamic elastography, the goal is to estimate the Young's modulus from audio-frequency wave propagation in soft-tissues. Within this frequency range, the shear wavelength is centimeter-sized while the compressional wavelength is meter-sized. Thus, the experimental data are usually collected in the near-field of the source. Near-field effects have been widely studied for bulk wave propagation. However, the near- and transient-fields of surface and guided waves have received less attention. In this work, the transient surface displacement field in soft-solid elastic plates in vacuum is analyzed. Due to the high Poisson's ratio, mode conversion has special characteristics in soft-solids. They are analyzed through this work where it is shown that the transient-field over the surface can be interpreted by tracing a few reflections. The authors show the existence of a critical distance needed for the formation of Rayleigh-Lamb modes. Below this distance, only direct surface waves propagate without contribution from reflected waves. Thus, the dispersion curve differs from that predicted by Rayleigh-Lamb modes. Instead, the authors propose a model based on the interference of surface waves, which agree with the experimental data. In addition, the conditions needed in order to retrieve the shear wave phase velocity from the surface field are given.

Improving three-dimensional mechanical imaging of breast lesions with principal component analysis

PURPOSE

Elastography has emerged as a new tool for detecting and diagnosing many types of diseases including breast cancer. To date, most clinical applications of elastography have utilized two-dimensional strain images. The goal of this paper is to present a new quasi-static elastography technique that yields shear modulus images in three dimensions.

METHODS

An automated breast volume scanner was used to acquire ultrasound images of the breast as it was gently compressed. Cross-correlation between successive images was used to determine the displacement within the tissue. The resulting displacement field was filtered of all but compressive motion through principal component analysis. This displacement field was used to infer spatial distribution of shear modulus by solving a 3D elastic inverse problem.

RESULTS

Three dimensional shear modulus images of benign breast lesions for two subjects were generated using the techniques described above. It was found that the lesions were visualized more clearly in images generated using the displacement data de-noised through the use of principal components.

CONCLUSIONS

We have presented experimental and algorithmic techniques that lead to three-dimensional imaging of shear modulus using quasi-static elastography. This work demonstrates feasibility of this approach, and lays the foundation for images of other, more informative, mechanical parameters.

Recovering vector displacement estimates in quasistatic elastography using sparse relaxation of the momentum equation

We consider the problem of estimating the 2D vector displacement field in a heterogeneous elastic solid deforming under plane stress conditions. The problem is motivated by applications in quasistatic elastography. From precise and accurate measurements of one component of the 2D vector displacement field and very limited information of the second component, the method reconstructs the second component quite accurately. No a priori knowledge of the heterogeneous distribution of material properties is required. This method relies on using a special form of the momentum equations to filter ultrasound displacement measurements to produce more precise estimates. We verify the method with applications to simulated displacement data. We validate the method with applications to displacement data measured from a tissue mimicking phantom, and in-vivo data; significant improvements are noticed in the filtered displacements recovered from all the tests. In verification studies, error in lateral displacement estimates decreased from about 50% to about 2%, and strain error decreased from more than 250% to below 2%.

Transthoracic Ultrasound Elastography in Pulmonary Lesions and Diseases

Ultrasound elastography has shown promising result in the diagnosis of various diseases; however, its application for pulmonary diseases has yet to be clarified. This study aimed to assess the application and feasibility of ultrasound elastography in various pulmonary lesions and diseases. We enrolled 45 patients with radiographic evidence of pneumonia, tumors or obstructive pneumonitis, and 70 ultrasonic lesions were identified (eight necrosis, 17 atelectasis, seven consolidation and 38 tumors). Ultrasound elastography was performed and the strain ratio, which is the ratio of strain of the reference tissue to an equally measuring region of interest of a lesion, was measured. The strain ratio was significantly different among lesions with different ultrasound morphologies (1.03 ± 0.71 [necrosis] vs. 2.51 ± 1.14 [atelectasis] vs. 19.98 ± 15.59 [consolidation] vs. 36.19 ± 20.18 [tumor]; p < 0.05). The strain ratio of primary lung cancer was also significantly different from pneumonia (p = 0.023) and metastatic lung cancer (p = 0.015). In conclusion, transthoracic ultrasound elastography can differentiate pulmonary lesions with different ultrasound morphologies. ClinicalTrials.gov Identifier: NCT02636985.

Inferring spatial variations of microstructural properties from macroscopic mechanical response

Disease alters tissue microstructure, which in turn affects the macroscopic mechanical properties of tissue. In elasticity imaging, the macroscopic response is measured and is used to infer the spatial distribution of the elastic constitutive parameters. When an empirical constitutive model is used, these parameters cannot be linked to the microstructure. However, when the constitutive model is derived from a microstructural representation of the material, it allows for the possibility of inferring the local averages of the spatial distribution of the microstructural parameters. This idea forms the basis of this study. In particular, we first derive a constitutive model by homogenizing the mechanical response of a network of elastic, tortuous fibers. Thereafter, we use this model in an inverse problem to determine the spatial distribution of the microstructural parameters. We solve the inverse problem as a constrained minimization problem and develop efficient methods for solving it. We apply these methods to displacement fields obtained by deforming gelatin-agar co-gels and determine the spatial distribution of agar concentration and fiber tortuosity, thereby demonstrating that it is possible to image local averages of microstructural parameters from macroscopic measurements of deformation.

The simulation of magnetic resonance elastography through atherosclerosis

The clinical diagnosis of atherosclerosis via the measurement of stenosis size is widely acknowledged as an imperfect criterion. The vulnerability of an atherosclerotic plaque to rupture is associated with its mechanical properties. The potential to image these mechanical properties using magnetic resonance elastography (MRE) was investigated through synthetic datasets. An image of the steady state wave propagation, equivalent to the first harmonic, can be extracted directly from finite element analysis. Inversion of this displacement data yields a map of the shear modulus, known as an elastogram. The variation of plaque composition, stenosis size, Gaussian noise, filter thresholds and excitation frequency were explored. A decreasing mean shear modulus with an increasing lipid composition was identified through all stenosis sizes. However the inversion algorithm showed sensitivity to parameter variation leading to artefacts which disrupted both the elastograms and quantitative trends. As noise was increased up to a realistic level, the contrast was maintained between the fully fibrous and lipid plaques but lost between the interim compositions. Although incorporating a Butterworth filter improved the performance of the algorithm, restrictive filter thresholds resulted in a reduction of the sensitivity of the algorithm to composition and noise variation. Increasing the excitation frequency improved the techniques ability to image the magnitude of the shear modulus and identify a contrast between compositions. In conclusion, whilst the technique has the potential to image the shear modulus of atherosclerotic plaques, future research will require the integration of a heterogeneous inversion algorithm.

Ultrasound Imaging Techniques for Spatiotemporal Characterization of Composition, Microstructure, and Mechanical Properties in Tissue Engineering

Ultrasound techniques are increasingly being used to quantitatively characterize both native and engineered tissues. This review provides an overview and selected examples of the main techniques used in these applications. Grayscale imaging has been used to characterize extracellular matrix deposition, and quantitative ultrasound imaging based on the integrated backscatter coefficient has been applied to estimating cell concentrations and matrix morphology in tissue engineering. Spectral analysis has been employed to characterize the concentration and spatial distribution of mineral particles in a construct, as well as to monitor mineral deposition by cells over time. Ultrasound techniques have also been used to measure the mechanical properties of native and engineered tissues. Conventional ultrasound elasticity imaging and acoustic radiation force imaging have been applied to detect regions of altered stiffness within tissues. Sonorheometry and monitoring of steady-state excitation and recovery have been used to characterize viscoelastic properties of tissue using a single transducer to both deform and image the sample. Dual-mode ultrasound elastography uses separate ultrasound transducers to produce a more potent deformation force to microscale characterization of viscoelasticity of hydrogel constructs. These ultrasound-based techniques have high potential to impact the field of tissue engineering as they are further developed and their range of applications expands.

A comparison between different modes of real-time sonoelastography in visualizing myofascial trigger points in low back muscles

OBJECTIVE

Currently, there is a lack of objective means to quantify myofascial trigger points (MTrPs) and their core features. Our research compares (1) MTrPs and surrounding myofascial tissue using two-dimensional grayscale ultrasound (2DGSUS) and vibration sonoelastography (VSE); (2) the accuracy of both modes in visualizing MTrPs; (3) 'active' and 'latent' MTrPs, using VSE; and (4) the accuracy of both modes in visualizing deep and superficially located MTrPs.

METHODS

Fifty participants with more than two MTrPs in their quadratus lumborum, longissimus thoracis, piriformis, and gluteus medius muscles were assigned to an active MTrP (low back pain) group or a latent (currently pain free) MTrP group. MTrP identification was based on their essential criteria. An electronic algometer measured repeatedly the tenderness of MTrPs with reference to pressure pain threshold values. A handheld vibrator was applied over MTrPs, while VSE and 2DGSUS readings were taken using an EUB-7500 ultrasound scanner.

RESULTS

There was a significant difference between MTrP strain and that of the immediately surrounding myofascial tissue, as measured using VSE (P = 0·001). VSE visualized all superficial and deep MTrPs with an accuracy of 100% (for both groups); the blinded results obtained using 2DGSUS achieved 33% and 35% accuracy, respectively. There was no significant difference found between the tissue strain ratios of active and latent MTrPs (P = 0·929).

DISCUSSION

Sonoelastography can visualize superficial and deep MTrPs, and differentiate them from surrounding myofascial structure through tissue stiffness and echogenicity. VSE was more accurate than 2DGSUS in visualizing and imaging MTrPs.

A Modified Error in Constitutive Equation Approach for Frequency-Domain Viscoelasticity Imaging Using Interior Data

This paper presents a methodology for the inverse identification of linearly viscoelastic material parameters in the context of steady-state dynamics using interior data. The inverse problem of viscoelasticity imaging is solved by minimizing a modified error in constitutive equation (MECE) functional, subject to the conservation of linear momentum. The treatment is applicable to configurations where boundary conditions may be partially or completely underspecified. The MECE functional measures the discrepancy in the constitutive equations that connect kinematically admissible strains and dynamically admissible stresses, and also incorporates the measurement data in a quadratic penalty term. Regularization of the problem is achieved through a penalty parameter in combination with the discrepancy principle due to Morozov. Numerical results demonstrate the robust performance of the method in situations where the available measurement data is incomplete and corrupted by noise of varying levels.

Quantitative micro-elastography: imaging of tissue elasticity using compression optical coherence elastography

Probing the mechanical properties of tissue on the microscale could aid in the identification of diseased tissues that are inadequately detected using palpation or current clinical imaging modalities, with potential to guide medical procedures such as the excision of breast tumours. Compression optical coherence elastography (OCE) maps tissue strain with microscale spatial resolution and can delineate microstructural features within breast tissues. However, without a measure of the locally applied stress, strain provides only a qualitative indication of mechanical properties. To overcome this limitation, we present quantitative micro-elastography, which combines compression OCE with a compliant stress sensor to image tissue elasticity. The sensor consists of a layer of translucent silicone with well-characterized stress-strain behaviour. The measured strain in the sensor is used to estimate the two-dimensional stress distribution applied to the sample surface. Elasticity is determined by dividing the stress by the strain in the sample. We show that quantification of elasticity can improve the ability of compression OCE to distinguish between tissues, thereby extending the potential for inter-sample comparison and longitudinal studies of tissue elasticity. We validate the technique using tissue-mimicking phantoms and demonstrate the ability to map elasticity of freshly excised malignant and benign human breast tissues.

Crawling Waves Speed Estimation Based on the Dominant Component Analysis Paradigm

A novel method for estimating the shear wave speed from crawling waves based on the amplitude modulation-frequency modulation model is proposed. Our method consists of a two-step approach for estimating the stiffness parameter at the central region of the material of interest. First, narrowband signals are isolated in the time dimension to recover the locally strongest component and to reject distortions from the ultrasound data. Then, the shear wave speed is computed by the dominant component analysis approach and its spatial instantaneous frequency is estimated by the discrete quasi-eigenfunction approximations method. Experimental results on phantoms with different compositions and operating frequencies show coherent speed estimations and accurate inclusion locations.

WFUMB guidelines and recommendations for clinical use of ultrasound elastography: Part 1: basic principles and terminology

Conventional diagnostic ultrasound images of the anatomy (as opposed to blood flow) reveal differences in the acoustic properties of soft tissues (mainly echogenicity but also, to some extent, attenuation), whereas ultrasound-based elasticity images are able to reveal the differences in the elastic properties of soft tissues (e.g., elasticity and viscosity). The benefit of elasticity imaging lies in the fact that many soft tissues can share similar ultrasonic echogenicities but may have different mechanical properties that can be used to clearly visualize normal anatomy and delineate pathologic lesions. Typically, all elasticity measurement and imaging methods introduce a mechanical excitation and monitor the resulting tissue response. Some of the most widely available commercial elasticity imaging methods are 'quasi-static' and use external tissue compression to generate images of the resulting tissue strain (or deformation). In addition, many manufacturers now provide shear wave imaging and measurement methods, which deliver stiffness images based upon the shear wave propagation speed. The goal of this review is to describe the fundamental physics and the associated terminology underlying these technologies. We have included a questions and answers section, an extensive appendix, and a glossary of terms in this manuscript. We have also endeavored to ensure that the terminology and descriptions, although not identical, are broadly compatible across the WFUMB and EFSUMB sets of guidelines on elastography (Bamber et al. 2013; Cosgrove et al. 2013).

Analysis and measurement of the modulation transfer function of harmonic shear wave induced phase encoding imaging

Shear wave induced phase encoding (SWIPE) imaging generates ultrasound backscatter images of tissue-like elastic materials by using traveling shear waves to encode the lateral position of the scatters in the phase of the received echo. In contrast to conventional ultrasound B-scan imaging, SWIPE offers the potential advantages of image formation without beam focusing or steering from a single transducer element, lateral resolution independent of aperture size, and the potential to achieve relatively high lateral resolution with low frequency ultrasound. Here a Fourier series description of the phase modulated echo signal is developed, demonstrating that echo harmonics at multiples of the shear wave frequency reveal target k-space data at identical multiples of the shear wavenumber. Modulation transfer functions of SWIPE imaging systems are calculated for maximum shear wave acceleration and maximum shear constraints, and compared with a conventionally focused aperture. The relative signal-to-noise ratio of the SWIPE method versus a conventionally focused aperture is found through these calculations. Reconstructions of wire targets in a gelatin phantom using 1 and 3.5 MHz ultrasound and a cylindrical shear wave source are presented, generated from the fundamental and second harmonic of the shear wave modulation frequency, demonstrating weak dependence of lateral resolution with ultrasound frequency.

Elasticity estimates from images of crawling waves generated by miniature surface sources

We describe a surface-based approach to the generation of shear wave interference patterns, called crawling waves (CrW), within a medium and derive local estimates of biomechanical properties of tissue. In previous experiments, elongated bars operating as vibration sources were used to generate CrW propagation in samples. In the present study, however, a pair of miniature circular vibration sources was applied to the overlying skin to generate the CrW within the medium. The shape and position of the miniature sources make this configuration more applicable for in vivo implementation. A modified ultrasound imaging system is used to display the CrW propagation. A shear speed mapping algorithm is developed using a detailed analysis of the CrW. The proposed setup is applied to several biomaterials including a homogeneous phantom, an inhomogeneous phantom and an ex vivo human liver. The data are analyzed using the mapping algorithm to reveal the biomechanical properties of the biomaterials.

Three-dimensional optical coherence elastography by phase-sensitive comparison of C-scans

We present an acquisition method for optical coherence elastography (OCE) that enables acquisition of three-dimensional elastograms in 5 s, an order of magnitude faster than previously reported. In this method, based on compression elastography, the mechanical load applied to the sample is altered between acquisitions of consecutive optical coherence tomography volume scans (C-scans). The voxel-by-voxel phase difference between the volumes is used to determine the axial displacement and determining the gradient of the axial displacement versus depth gives the local axial strain. We demonstrate sub-100-microstrain sensitivity and high contrast in elastograms, acquired in 5 s, of structured phantoms and freshly excised rat muscle tissue that are comparable in strain sensitivity and dynamic range to our previously reported B-scan-based method. The much higher acquisition speed may expedite the translation of OCE to clinical and in vivo applications.

Ultrasound elastography using multiple images

Displacement estimation is an essential step for ultrasound elastography and numerous techniques have been proposed to improve its quality using two frames of ultrasound RF data. This paper introduces a technique for calculating a displacement field from three (or multiple) frames of ultrasound RF data. To calculate a displacement field using three images, we first derive constraints on variations of the displacement field with time using mechanics of materials. These constraints are then used to generate a regularized cost function that incorporates amplitude similarity of three ultrasound images and displacement continuity. We optimize the cost function in an expectation maximization (EM) framework. Iteratively reweighted least squares (IRLS) is used to minimize the effect of outliers. An alternative approach for utilizing multiple images is to only consider two frames at any time and sequentially calculate the strains, which are then accumulated. We formally show that, compared to using two images or accumulating strains, the new algorithm reduces the noise and eliminates ambiguities in displacement estimation. The displacement field is used to generate strain images for quasi-static elastography. Simulation, phantom experiments and in vivo patient trials of imaging liver tumors and monitoring ablation therapy of liver cancer are presented for validation. We show that even with the challenging patient data, where it is likely to have one frame among the three that is not optimal for strain estimation, the introduction of physics-based prior as well as the simultaneous consideration of three images significantly improves the quality of strain images. Average values for strain images of two frames versus ElastMI are: 43 versus 73 for SNR (signal to noise ratio) in simulation data, 11 versus 15 for CNR (contrast to noise ratio) in phantom data, and 5.7 versus 7.3 for CNR in patient data. In addition, the improvement of ElastMI over both utilizing two images and accumulating strains is statistically significant in the patient data, with p-values of respectively 0.006 and 0.012.

JSUM ultrasound elastography practice guidelines: basics and terminology

Ten years have passed since the first commercial equipment for elastography was released; since then clinical utility has been demonstrated. Nowadays, most manufacturers offer an elastography option. The most widely available commercial elastography methods are based on strain imaging, which uses external tissue compression and generates images of the resulting tissue strain. However, imaging methods differ slightly among manufacturers, which results in different image characteristics, for example, spatial and temporal resolution, and different recommended measurement conditions. In addition, many manufacturers have recently provided a shear wave-based method, providing stiffness images based on shear wave propagation speed. Each method of elastography is designed on the basis of assumptions of measurement conditions and tissue properties. Thus, we need to know the basic principles of elastography methods and the physics of tissue elastic properties to enable appropriate use of each piece of equipment and to obtain more precise diagnostic information from elastography. From this perspective, the basic section of this guideline aims to support practice of ultrasound elastography.

Acoustic radiation force elasticity imaging in diagnostic ultrasound

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

Shear wave induced resonance elastography of venous thrombi: a proof-of-concept

Shear wave induced resonance elastography (SWIRE) is proposed for deep venous thrombosis (DVT) elasticity assessment. This new imaging technique takes advantage of properly polarized shear waves to induce resonance of a confined mechanical heterogeneity. Realistic phantoms (n = 9) of DVT total and partial clot occlusions with elasticities from 406 to 3561 Pa were built for in vitro experiments. An ex vivo study was also performed to evaluate the elasticity of two fresh porcine venous thrombi in a pig model. Transient shear waves at 45-205 Hz were generated by the vibration of a rigid plate (plane wavefront) or by a needle to simulate a radiation pressure on a line segment (cylindrical wavefront). Induced propagation of shear waves was imaged with an ultrafast ultrasound scanner and a finite element method was developed to simulate tested experimental conditions. An inverse problem was then formulated considering the first resonance frequency of the DVT inclusion. Elasticity agreements between SWIRE and a reference spectroscopy instrument (RheoSpectris) were found in vitro for total clots either in plane (r(2) = 0.989) or cylindrical (r(2) = 0.986) wavefront configurations. For total and partial clots, elasticity estimation errors were 9.0 ±4.6% and 9.3 ±11.3%, respectively. Ex vivo, the blood clot elasticity was 498 ±58 Pa within the inferior vena cava and 436 ±45 Pa in the right common iliac vein (p = 0.22). To conclude, the SWIRE technique seems feasible to quantitatively assess blood clot elasticity in the context of DVT ultrasound imaging.

Medical ultrasound: imaging of soft tissue strain and elasticity

After X-radiography, ultrasound is now the most common of all the medical imaging technologies. For millennia, manual palpation has been used to assist in diagnosis, but it is subjective and restricted to larger and more superficial structures. Following an introduction to the subject of elasticity, the elasticity of biological soft tissues is discussed and published data are presented. The basic physical principles of pulse-echo and Doppler ultrasonic techniques are explained. The history of ultrasonic imaging of soft tissue strain and elasticity is summarized, together with a brief critique of previously published reviews. The relevant techniques-low-frequency vibration, step, freehand and physiological displacement, and radiation force (displacement, impulse, shear wave and acoustic emission)-are described. Tissue-mimicking materials are indispensible for the assessment of these techniques and their characteristics are reported. Emerging clinical applications in breast disease, cardiology, dermatology, gastroenterology, gynaecology, minimally invasive surgery, musculoskeletal studies, radiotherapy, tissue engineering, urology and vascular disease are critically discussed. It is concluded that ultrasonic imaging of soft tissue strain and elasticity is now sufficiently well developed to have clinical utility. The potential for further research is examined and it is anticipated that the technology will become a powerful mainstream investigative tool.

Acoustic radiation force-based elasticity imaging methods

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

What challenges must be overcome before ultrasound elasticity imaging is ready for the clinic?

Ultrasound elasticity imaging has been a research interest for the past 20 years with the goal of generating novel images of soft tissues based on their material properties (i.e., stiffness and viscosity). The motivation for such an imaging modality lies in the fact that many soft tissues can share similar ultrasonic echogenicities, but may have very different mechanical properties that can be used to clearly visualize normal anatomy and delineate diseased tissues and masses. Recently, elasticity imaging techniques have moved from the laboratory to the clinical setting, where clinicians are beginning to characterize tissue stiffness as a diagnostic metric and commercial implementations of ultrasonic elasticity imaging are beginning to appear on the market. This article provides a foundation for elasticity imaging, an overview of current research and commercial realizations of elasticity imaging technology and a perspective on the current successes, limitations and potential for improvement of these imaging technologies.

Real-time regularized ultrasound elastography

This paper introduces two real-time elastography techniques based on analytic minimization (AM) of regularized cost functions. The first method (1D AM) produces axial strain and integer lateral displacement, while the second method (2D AM) produces both axial and lateral strains. The cost functions incorporate similarity of radio-frequency (RF) data intensity and displacement continuity, making both AM methods robust to small decorrelations present throughout the image. We also exploit techniques from robust statistics to make the methods resistant to large local decorrelations. We further introduce Kalman filtering for calculating the strain field from the displacement field given by the AM methods. Simulation and phantom experiments show that both methods generate strain images with high SNR, CNR and resolution. Both methods work for strains as high as 10% and run in real-time. We also present in vivo patient trials of ablation monitoring. An implementation of the 2D AM method as well as phantom and clinical RF-data can be downloaded.

Solution of the nonlinear elasticity imaging inverse problem: The incompressible case

We have recently developed and tested an efficient algorithm for solving the nonlinear inverse elasticity problem for a compressible hyperelastic material. The data for this problem are the quasi-static deformation fields within the solid measured at two distinct overall strain levels. The main ingredients of our algorithm are a gradient based quasi-Newton minimization strategy, the use of adjoint equations and a novel strategy for continuation in the material parameters. In this paper we present several extensions to this algorithm. First, we extend it to incompressible media thereby extending its applicability to tissues which are nearly incompressible under slow deformation. We achieve this by solving the forward problem using a residual-based, stabilized, mixed finite element formulation which circumvents the Ladyzenskaya-Babuska-Brezzi condition. Second, we demonstrate how the recovery of the spatial distribution of the nonlinear parameter can be improved either by preconditioning the system of equations for the material parameters, or by splitting the problem into two distinct steps. Finally, we present a new strain energy density function with an exponential stress-strain behavior that yields a deviatoric stress tensor, thereby simplifying the interpretation of pressure when compared with other exponential functions. We test the overall approach by solving for the spatial distribution of material parameters from noisy, synthetic deformation fields.

Imaging the elastic properties of tissue: the 20 year perspective

After 20 years of innovation in techniques that specifically image the biomechanical properties of tissue, the evolution of elastographic imaging can be viewed from its infancy, through a proliferation of approaches to the problem to incorporation on research and then clinical imaging platforms. Ultimately this activity has culminated in clinical trials and improved care for patients. This remarkable progression represents a leading example of translational research that begins with fundamentals of science and engineering and progresses to needed improvements in diagnostic and monitoring capabilities applied to major categories of disease, surgery and interventional procedures. This review summarizes the fundamental principles, the timeline of developments in major categories of elastographic imaging, and concludes with recent results from clinical trials and forward-looking issues.

A high-frame-rate ultrasound system for the study of tissue motions

In this article, a technique for measuring fast periodic motion is proposed. The sequencing used in this technique is similar to the one used in conventional color Doppler systems. However, a phase correction algorithm is introduced which compensates for the acquisition delays. Criteria for the types of motion which could be detected correctly by the system are developed and presented. Effective frame rates of several hundred hertz to a few kilohertz have been achieved with the system. Applications of the system in tissue elastography are presented together with experimental results from tissue mimicking phantoms.

Linking optics and mechanics in an in vivo model of airway fibrosis and epithelial injury

Chronic mucosal and submucosal injury can lead to persistent inflammation and tissue remodeling. We hypothesized that microstructural and mechanical properties of the airway wall could be derived from multiphoton images. New Zealand White rabbits were intubated, and the tracheal epithelium gently denuded every other day for five days (three injuries). Three days following the last injury, the tracheas were excised for multiphoton imaging, mechanical compression testing, and histological analysis. Multiphoton imaging and histology confirm epithelial denudation, mucosal ulceration, subepithelial thickening, collagen deposition, immune cell infiltration, and a disrupted elastin network. Elastase removes the elastin network and relaxes the collagen network. Purified collagenase removes epithelium with subtle subepithelial changes. Young's modulus [(E) measured in kiloPascal] was significantly elevated for the scrape injured (9.0+/-3.2) trachea, and both collagenase (2.6+/-0.4) and elastase (0.8+/-0.3) treatment significantly reduced E relative to control (4.1+/-0.7). E correlates strongly with second harmonic generation (SHG) signal depth decay for enzyme-treated and control tracheas (R(2)=0.77), but not with scrape-injured tracheas. We conclude that E of subepithelial connective tissue increases on repeated epithelial wounding, due in part to changes in elastin and collagen microstructure and concentration. SHG depth decay is sensitive to changes in extracellular matrix content and correlates with bulk Young's modulus.

In vivo dynamic optical coherence elastography using a ring actuator

We present a novel sample arm arrangement for dynamic optical coherence elastography based on excitation by a ring actuator. The actuator enables coincident excitation and imaging to be performed on a sample, facilitating in vivo operation. Sub-micrometer vibrations in the audio frequency range were coupled to samples that were imaged using optical coherence tomography. The resulting vibration amplitude and microstrain maps are presented for bilayer silicone phantoms and multiple skin sites on a human subject. Contrast based on the differing elastic properties is shown, notably between the epidermis and dermis. The results constitute the first demonstration of a practical means of performing in vivo dynamic optical coherence elastography on a human subject.

Theoretical limitations of the elastic wave equation inversion for tissue elastography

This article examines the theoretical limitations of the local inversion techniques for the measurement of the tissue elasticity. Most of these techniques are based on the estimation of the phase speed or the algebraic inversion of a one-dimensional wave equation. To analyze these techniques, the wave equation in an elastic continuum is revisited. It is proven that in an infinite medium, harmonic shear waves can travel at any phase speed greater than the classically known shear wave speed, mu/rho, by demonstrating this for a special case with cylindrical symmetry. Hence in addition to the mechanical properties of the tissue, the phase speed depends on the geometry of the wave as well. The elastic waves in an infinite cylindrical rod are studied. It is proven that multiple phase speeds can coexist for a harmonic wave at a single frequency. This shows that the phase speed depends not only on the mechanical properties of the tissue but also on its shape. The final conclusion is that the only way to avoid theoretical artifacts in the elastograms obtained by the local inversion techniques is to use the shear wave equation as expressed in the curl of the displacements, i.e., the rotations, for the inversion.

Measurement of viscoelastic properties of tissue-mimicking material using longitudinal wave excitation

This paper presents an experimental framework for the measurement of the viscoelastic properties of tissue-mimicking material. The novelty of the presented framework is in the use of longitudinal wave excitation and the study of the longitudinal wave patterns in finite media for the measurement of the viscoelastic properties. Ultrasound is used to track the longitudinal motions inside a test block. The viscoelastic parameters of the block are then estimated by 2 methods: a wavelength measurement method and a model fitting method. Connections are also made with shear elastography. The viscoelastic parameters are estimated for several homogeneous phantom blocks. The results from the new methods are compared with the conventional rheometry results.

Quasi-Static Ultrasound Elastography

Elastography is a new imaging modality where elastic tissue parameters related to the structural organization of normal and pathological tissues are imaged. Basic principles underlying the quasi-static elastography concept and principles are addressed. The rationale for elastographic imaging is reinforced using data on elastic properties of normal and abnormal soft tissues. The several orders of magnitude difference between the elastic modulus of normal and abnormal tissues which is the primary contrast mechanism in elastographic imaging underlines the probability of success with this imaging modality. Recent advances enabling the clinical practice of elastographic imaging in real-time on clinical ultrasound systems is also discussed.In quasi-static elastography, radiofrequency echo signals acquired before and after a small (about 1%) of applied deformation are correlated to estimate tissue displacements. Local tissue displacement vector estimates between small segments of the pre- and post-deformation signals are estimated and the corresponding strain distribution imaged. Elastographic imaging techniques are based on the hypothesis that soft tissues deform more than stiffer tissue, and these differences can be quantified in images of the tissue strain tensor or the Young's modulus.Clinical applications of quasi-static elastography have mushroomed over the last decade, with the most commonly imaged areas being the breast, prostate, thyroid, cardiac, treatment monitoring of ablation procedures and vascular imaging applications.

Audio frequency in vivo optical coherence elastography

We present a new approach to optical coherence elastography (OCE), which probes the local elastic properties of tissue by using optical coherence tomography to measure the effect of an applied stimulus in the audio frequency range. We describe the approach, based on analysis of the Bessel frequency spectrum of the interferometric signal detected from scatterers undergoing periodic motion in response to an applied stimulus. We present quantitative results of sub-micron excitation at 820 Hz in a layered phantom and the first such measurements in human skin in vivo.

Linear and nonlinear elasticity imaging of soft tissue in vivo: demonstration of feasibility

We establish the feasibility of imaging the linear and nonlinear elastic properties of soft tissue using ultrasound. We report results for breast tissue where it is conjectured that these properties may be used to discern malignant tumors from benign tumors. We consider and compare three different quantities that describe nonlinear behavior, including the variation of strain distribution with overall strain, the variation of the secant modulus with overall applied strain and finally the distribution of the nonlinear parameter in a fully nonlinear hyperelastic model of the breast tissue.

Shearwave dispersion ultrasound vibrometry (SDUV) for measuring tissue elasticity and viscosity

Characterization of tissue elasticity (stiffness) and viscosity has important medical applications because these properties are closely related to pathological changes. Quantitative measurement is more suitable than qualitative measurement (i.e., mapping with a relative scale) of tissue viscoelasticity for diagnosis of diffuse diseases where abnormality is not confined to a local region and there is no normal background tissue to provide contrast. Shearwave dispersion ultrasound vibrometry (SDUV) uses shear wave propagation speed measured in tissue at multiple frequencies (typically in the range of hundreds of Hertz) to solve quantitatively for both tissue elasticity and viscosity. A shear wave is stimulated within the tissue by an ultrasound push beam and monitored by a separate ultrasound detect beam. The phase difference of the shear wave between 2 locations along its propagation path is used to calculate shear wave speed within the tissue. In vitro SDUV measurements along and across bovine striated muscle fibers show results of tissue elasticity and viscosity close to literature values. An intermittent pulse sequence is developed to allow one array transducer for both push and detect function. Feasibility of this pulse sequence is demonstrated by in vivo SDUV measurements in swine liver using a dual transducer prototype simulating the operation of a single array transducer.

Measurement of tissue mechanical properties with shear wave dispersion ultrasound vibrometry (SDUV)

Shear wave dispersion vibrometry (SDUV) produces motion in tissue using sequential pulses of ultrasound radiation pressure. The resulting motion of the tissue in the form of propagating shear waves can provide information about the material properties of the tissue given the appropriate equations of motion for the geometry of the tissue. An example application of the method is described to measure material properties in bovine tissue.

Elastography in the management of liver disease

Normal liver tissue is soft and pliable. With inflammation, however, many of the cells die and are replaced by collagenous fibrils and the tissue gets stiffer. The progress is often slow-extending over decades in many cases. When liver stiffness increases by a factor of about five, the condition is called cirrhosis, a disease with serious medical implications. After the onset of cirrhosis, the probability of developing hepatic cancer increases at the rate of about 5% per year. Precise, noninvasive measurement of liver stiffness, a simple application of elastography, promises to be a safe, inexpensive method to monitor the progress of liver patients, improve outcome, save many lives and much suffering and reduce the cost of medical care.

Narrowband shear wave generation by a Finite-Amplitude radiation force: The fundamental component

A highly localized source of low-frequency shear waves can be created by the modulated radiation force resulting from two intersecting quasi-continuous-wave ultrasound beams of slightly different frequencies. In contrast to most other radiation force-based methods, these shear waves can be narrowband. Consequently, different frequency-dependent effects will not significantly affect their spectrum as they propagate within a viscoelastic medium, thereby enabling the viscoelastic shear properties of the medium to be determined at any given modulation frequency. This can be achieved by tracking the shear wave phase delay and change in amplitude over a specific distance. In this paper we explore the properties of short duration (dynamic) low-frequency shear wave propagation and study how the shear displacement field depends on the excitation conditions. Our investigations make use of the approximate Green's functions for viscoelastic media, and the evolution of such waves is studied in the spatiotemporal domain from a theoretical perspective. Although nonlinearities are included in our confocal source model, just the properties of the fundamental shear component are examined in this paper. We examine how the shear wave propagation is affected by the shear viscosity, the coupling wave, the spatial distribution of the force, the shear speed, and the duration of the modulated wave. A method is proposed for estimating the shear viscosity of a viscoelastic medium. In addition, it is shown how the Voigt model paremeters can be extracted from the frequency-dependent speed and attenuation.

Harmonic pulsed excitation and motion detection of a vibrating reflective target

Elasticity imaging is an emerging medical imaging modality. Methods involving acoustic radiation force excitation and pulse-echo ultrasound motion detection have been investigated to assess the mechanical response of tissue. In this work new methods for dynamic radiation force excitation and motion detection are presented. The theory and model for harmonic motion detection of a vibrating reflective target are presented. The model incorporates processing of radio frequency data acquired using pulse-echo ultrasound to measure harmonic motion with amplitudes ranging from 100 to 10,000 nm. A numerical study was performed to assess the effects of different parameters on the accuracy and precision of displacement amplitude and phase estimation and showed how estimation errors could be minimized. Harmonic pulsed excitation is introduced as a multifrequency radiation force excitation method that utilizes ultrasound tonebursts repeated at a rate f(r). The radiation force, consisting of frequency components at multiples of f(r), is generated using 3.0 MHz ultrasound, and motion detection is performed simultaneously with 9.0 MHz pulse-echo ultrasound. A parameterized experimental analysis showed that displacement can be measured with small errors for motion with amplitudes as low as 100 nm. The parameterized numerical and experimental analyses provide insight into how to optimize acquisition parameters to minimize measurement errors.

Evaluation of 3D modality-independent elastography for breast imaging: a simulation study

This paper reports on the development and preliminary testing of a three-dimensional implementation of an inverse problem technique for extracting soft-tissue elasticity information via non-rigid model-based image registration. The modality-independent elastography (MIE) algorithm adjusts the elastic properties of a biomechanical model to achieve maximal similarity between images acquired under different states of static loading. A series of simulation experiments with clinical image sets of human breasts were performed to test the ability of the method to identify and characterize a radiographically occult stiff lesion. Because boundary conditions are a critical input to the algorithm, a comparison of three methods for semi-automated surface point correspondence was conducted in the context of systematic and randomized noise processes. The results illustrate that 3D MIE was able to successfully reconstruct elasticity images using data obtained from both magnetic resonance and x-ray computed tomography systems. The lesion was localized correctly in all cases and its relative elasticity found to be reasonably close to the true values (3.5% with the use of spatial priors and 11.6% without). In addition, the inaccuracies of surface registration performed with thin-plate spline interpolation did not exceed empiric thresholds of unacceptable boundary condition error.