Interactive Transcript
0:02
Hello and welcome to Noon Conferences
0:03
hosted by MRI Online. In response to
0:06
the changes happening around the world
0:07
right now in the shutting down of in-person
0:08
events, we have decided to provide free daily
0:10
Noon Conferences to all radiologists worldwide.
0:13
Today we're joined by Dr. Kathryn McGillen.
0:15
She is an assistant professor at
0:16
Penn State Hershey Medical Center.
0:18
She practices within the abdominal and
0:19
thoracic sections with a focus on advanced
0:22
ultrasound techniques, including contrast
0:23
enhanced ultrasound with a
0:26
specialty in endometriosis imaging.
0:30
A reminder that there will be time at the
0:31
end of this hour for a Q and A session.
0:33
Please use the Q and A feature to ask
0:34
all your questions, and we'll get to
0:36
as many as we can before our time is up.
0:38
That being said, thank you so much
0:39
for joining us today. Dr. McGillen,
0:41
I will let you take it from here.
0:43
Okay, thanks.
0:44
Uh, thanks to MRI Online for hosting this talk,
0:46
and thanks to you all who are joining me, uh,
0:48
for this introductory tour through contrast
0:50
ultrasound and some of its really cool indications.
0:53
A small word of warning
0:55
before we get started. There will be a few
0:57
audience response cases peppered throughout this.
0:59
Um, but I will let you know when they're coming,
1:01
and, um, I'm told you can move the box around if
1:03
it's blocking the image you're trying to look at.
1:06
So with that being said, let's get started.
1:10
Okay, so we're here to talk about microbubbles.
1:12
Um, this is my own little artist rendition, so it's,
1:15
you know, not the best, but I did what I could.
1:17
Um, but microbubbles in general, for contrast
1:19
ultrasound, they are smaller than a red blood cell,
1:21
which is important because they remain intravascular.
1:24
This is unlike CT or MRI contrast,
1:26
which diffuse out into the parenchyma.
1:28
These remain intravascular, and has a lot of the
1:30
cool stuff happens because of this factor.
1:34
So all of them have in common that they have a
1:35
lipid outer shell, which is echogenic on ultrasound.
1:38
So that's gonna be this part out here.
1:40
And then the central portion is contained usually of
1:42
a gas, in SonoVue or Lumason, as we call it in the US. Uh, its
1:46
made of sulfur hexafluoride, and definity, which
1:48
I spelled wrong, um, is composed of perfluorocarbon.
1:53
So these are a bit finicky, these microbubbles,
1:56
and they do burst with continuous ultrasound imaging.
1:59
So you have to be aware of what you're doing and
2:01
how long you're imaging in any particular plane.
2:04
What's cool about these is that there's no
2:05
renal-biliary excretion, since they do burst
2:08
either by the ultrasound itself or over
2:10
time, they, um, burst in the blood and then
2:14
they're exhaled—no renal-biliary excretion.
2:16
So we don't have to worry about those
2:17
factors. Because it is intravascular,
2:20
you can get multiple doses if
2:21
you burst all of the bubbles.
2:23
And it has a very safe risk and
2:25
allergy profile, which is great.
2:27
So, advantages for contrast ultrasound.
2:30
You get an image where you get the suppression
2:33
of the background tissue, which is essentially
2:34
a contrast-only image, which is really cool.
2:37
You get a true enhancement pattern of a lesion, unlike
2:40
a CT or MRI, where you're picking snapshots in time.
2:43
You can watch it for as long as you want to.
2:46
And then ultrasound in general is
2:48
high temporal and spatial resolution.
2:50
So you can see smaller septations and
2:51
nodules than you may be able to see on CT.
2:54
And again, it's intravascular.
2:56
So you can redose, unlike MRI or CT,
2:58
where contrast is in the parenchyma.
3:00
So you might have to wait, you know,
3:02
12–24 hours to redose somebody.
3:04
For patients, the advantage is that there's no
3:06
radiation, there's no renal excretion, so we're
3:08
not worried about their lab values beforehand
3:10
or after. A relatively safe allergy profile—
3:14
closer to MRI, much safer, fewer allergies
3:16
than people get with CT dye.
3:18
And then because it is ultrasound, there
3:20
is a cost savings compared to CT or MRI.
3:23
So disadvantages: if you do find
3:25
a tumor, you can't stage it.
3:26
This is ultrasound.
3:27
You're limited to what you can see.
3:29
It has the same depth and habitus issues
3:31
that ultrasound in general can have.
3:34
Um, with these you take a lot of cine clips, so
3:36
there can be, um, PACS and archiving issues.
3:38
At some places they create really large
3:40
files, and while you can look at multiple
3:42
lesions, 'cause you can dose multiple times,
3:44
you know, if you say had 10 lesions, that's
3:46
gonna be a limitation of contrast ultrasound.
3:49
So in general, it's a problem-solving tool.
3:52
If you have a very specific question,
3:53
it's really good for answering that.
3:56
So to go over how the imaging's done, it is done
3:59
in a low B-mode, and that's to avoid bursting
4:01
those bubbles. If you use the regular ultrasound,
4:03
you will burst them very, very quickly.
4:05
It does use harmonics, which is near-field imaging.
4:08
And unlike regular ultrasound, your focal
4:10
zone is going to be beyond the lesion itself.
4:13
And that's because you need the ultrasound beam to
4:15
penetrate the lesion completely before it diverges.
4:20
You don't want the lesion too close to the
4:21
transducer, 'cause you can get some artifacts,
4:23
but too far, it's a little Goldilocks here.
4:26
Um, less than 10 centimeters is generally optimal.
4:28
There are some systems out there that are
4:30
allowing better depth, up to 20 centimeters
4:32
or so, but most systems out there right
4:34
now, less than 10 centimeters is optimal.
4:37
And then after that, you wanna avoid
4:38
attenuating structures if you can.
4:40
So for example, you don't wanna image through
4:41
the spleen as a window to get to the kidney.
4:44
Sometimes you have to, though.
4:46
So what to do?
4:47
Here's an example of a Lumason.
4:48
Before it's used, it looks like a
4:49
little white powder at the bottom.
4:51
Uh, patients will need an IV,
4:53
generally 20 gauge or larger.
4:54
Again, because the bubbles are finicky.
4:56
If you have a smaller IV, you could burst them.
4:59
In our institution, the sonographer
5:01
does the pre-scanning with gray scale.
5:02
Before they show the
5:03
radiologist, they mix the contrast.
5:06
In general, these bottles or these vials come with a
5:08
total of five milliliters once you
5:10
reconstitute it, equivalent of about two liver doses.
5:15
The radiologist in our institution injects
5:17
the contrast and directs the imaging
5:19
of how long we wanna image at any time.
5:21
How long do we image overall? Up to five minutes or so.
5:24
At what points do you wanna image?
5:26
We would direct that.
5:27
And then you remember, just like ultrasound,
5:29
you can image in any plane. Patient can
5:31
be in any position, so they can be sitting
5:33
upright if that helps them to breathe better.
5:35
And if you can get a lesion within the right
5:38
plane, you can even image while the patient breathes.
5:40
Um, by keeping it in-plane, which
5:42
you can't really do with CT or MRI.
5:45
So here's the setup.
5:46
This is a reconstituted vial, Lumason.
5:48
It comes with a sterile saline syringe in the packet.
5:51
Looks like a sort of cloudy, white, milky material.
5:54
Once it's reconstituted, you gotta shake
5:56
it because it comes out very easily.
5:58
You have a three-way stopcock.
5:59
And what's important when you put this together
6:00
is that the contrast has to be at 180 degrees.
6:04
If you put it at the 90 degrees,
6:05
it doesn't like this sharp turn.
6:07
The bubbles are finicky, they break, and
6:08
then you get less contrast going into—
6:10
you get your image to be suboptimal.
6:12
So remember to always place it that way, 180 degrees.
6:15
So let's look at some pictures.
6:17
Let's start with the liver.
6:18
This is a busy slide.
6:19
This is from Burrows and Radiographics,
6:21
but it's a great slide, and if you
6:23
just concentrate at the top part.
6:25
This is really where your, your, your tree is.
6:27
Is there portal venous or late phase washout?
6:29
Yes.
6:30
Malignant. No, benign.
6:31
That's pretty much it.
6:33
It does get a little bit more complicated, of course,
6:35
'cause there's different patterns of enhancement,
6:37
of benign things, and there's different patterns of
6:39
enhancement of malignant, which we'll get to in a bit.
6:41
But this is really your tree right here.
6:43
Portal venous.
6:44
Does it wash out or not?
6:46
So here's, uh, to start with benign.
6:49
This is the cyst.
6:50
There's no enhancement.
6:51
You can see here, this is our low B-mode right here.
6:54
This is our subtraction, um, contrast image.
6:57
And you can see it's not pretty.
6:58
They don't look like cysts.
6:59
They're kind of hypoechoic on low B-mode.
7:01
The MI is 0.04, so it's low. It's not pretty, but you
7:06
can see the increased through-transmission behind it.
7:08
And here we are about 26 seconds after injection.
7:11
You can see there's absolutely no enhancement.
7:13
We still get the same artifact of
7:15
increased through-transmission.
7:16
On the contrast part of it here, um, you couldn't
7:19
make a diagnosis of a cyst off of just one image.
7:22
You need to prove that this didn't arterial enhance.
7:24
But this is the representative image.
7:26
Black hole, no enhancement.
7:27
This is a benign cyst.
7:30
So this is case one.
7:31
I'll have you pay attention to this.
7:32
On the next slide you'll get your
7:33
first question, the audience response.
7:36
So this is a patient who had an MRI.
7:38
This is the lesion in question, just
7:40
so you know what we're looking at.
7:42
So this is our T2-weighted image.
7:44
This was an outside MRI, so I don't know
7:46
what the read was, but they came to contrast
7:47
ultrasound, so I assume it was an indeterminate.
7:50
So a pre-contrast T1.
7:52
I have a couple post-contrasts here.
7:54
I have no subtraction images.
7:55
So with that in your mind, my best guess
7:57
is that they were concerned whether this
7:59
was true rim peripheral enhancement in the
8:03
lesion, or whether this was just artifactual.
8:05
So it came in contrast ultrasound.
8:08
Here's our gray scale, and here's
8:10
a clip of our post-contrast.
8:11
So if we can bring up that first question, the
8:14
question's going to be, and you can move this, is
8:17
it benign or malignant based off of the pattern?
8:22
And I will, as you're thinking about it, I
8:24
will point out that this lesion was right at 10
8:26
centimeters, so you don't see the back portion of it.
8:30
So if you were doing this in real life, you'd probably
8:32
reposition the patient for a second dose to get all
8:35
of that lesion within 10 centimeters of the probe.
8:39
Okay, great.
8:40
Great job.
8:40
So 87% said benign, and that's what this was.
8:43
There's no enhancement.
8:44
So we have very early, six seconds
8:46
after the contrast arrived.
8:48
Another one at 30 seconds, about a
8:50
minute, and then a minute and a half.
8:51
At this point, it's a black punched-out hole.
8:54
We don't see any definitive enhancement.
8:55
This is a cyst, even though it looks
8:57
kind of ugly here on the ultrasound.
8:59
Wasn't clear on the MRI.
9:01
We proved this was a cyst.
9:02
There's no peripheral enhancement.
9:03
This is isoechoic around this guy the entire time.
9:06
Stayed this way on
9:07
more delayed imaging.
9:08
This is a cyst.
9:09
End of story.
9:10
Don't need to do any further follow-up or workup.
9:13
Okay, so talking about more
9:15
benign lesions, go to hemangioma.
9:18
So these act very much like they do on CT or MRI.
9:21
So they can flash fill, or they
9:23
can fill in over several minutes.
9:25
And because they are slow flow, you wanna image
9:28
sparingly, or you can consider doing a second dose.
9:30
With the second dose,
9:31
you don't even image in the arterial
9:32
phase; you just wait till you have three,
9:34
four minutes out to see what happens.
9:36
And that is because if you image a hemangioma
9:39
the entire time, you just sit that probe
9:41
right on it, you're gonna cause late washout.
9:44
And that's because hemangiomas
9:45
are generally slow flow.
9:47
Vascular malformations.
9:48
So if you sit that ultrasound on it, you're
9:50
gonna burst the bubbles within the hemangioma
9:52
faster than those in the circulation,
9:54
and you cause a late washout artifact.
9:56
So that's something to be very aware of.
9:58
And that may be, if you're doing that, the
9:59
second dose may then help because you can
10:01
just wait and see if there's washout.
10:03
So here's an example.
10:04
This is a patient who had a history of trauma.
10:07
So she had some scarring over her liver and
10:09
had this big echogenic lesion right here.
10:12
She did not want an MRI because she'd
10:13
read about, um, gadolinium deposition
10:16
in the brain and just didn't wanna—
10:18
didn't wanna deal with it.
10:19
So she came in contrast ultrasound.
10:21
So here's the first image.
10:22
Again, I cut these a little bit,
10:23
but this is your gray scale.
10:24
And again, you can see not a pretty image, right?
10:27
But we knew we were on the lesion,
10:29
and that's what this really is for.
10:30
It's to help you know where you are.
10:32
So at this point, very early on, you
10:33
can see some peripheral enhancement.
10:35
And at this point, I don't know if this
10:36
is gonna be a malignant peripheral pattern
10:38
or if this is going to be something else.
10:40
So we watched, and now you start to see
10:42
maybe 30 seconds or so later, we now
10:44
have these kind of puddling of contrast.
10:46
This peripheral, this nodular,
10:48
discontinuous enhancement.
10:50
You know, waited another minute, took another
10:52
snapshot, and starting to fill in, right?
10:54
There's less centrally here, starting to fill.
10:56
In super delayed imaging, completely filled in.
10:59
And what's cool about this too is
11:00
you can see background liver contrast
11:02
is already starting to go away.
11:03
There's not a lot of contrast left in the
11:05
liver, but this is still holding onto it.
11:07
This is like a persistent enhancement pattern.
11:09
So this is a benign hemangioma.
11:11
She doesn't need an MRI, she doesn't need follow-up.
11:13
That's what this is.
11:15
Just to talk very quickly about regenerative
11:17
nodules. In my practice we do a lot of, uh,
11:20
cirrhosis patients, a lot of imaging of that.
11:22
So this comes up a lot.
11:23
These little tiny hypoechoic nodules in a
11:25
background of an echogenic liver that's cirrhotic.
11:28
It's a little bit of kidney right here, a little
11:29
bit gallbladder to let you know, regenerative
11:31
nodules can either isoenhance to background liver.
11:34
Again, my little drawing, not the best, but
11:36
did what I could. Or they can arterial enhance.
11:38
But what's important in how you differentiate these
11:41
is they are all isoenhancing on the delayed phase.
11:44
So here's a little nodule. Here we are on
11:46
arterial phase, and I put a little arrow here.
11:47
This was it right here.
11:48
And it's pretty much isoenhancing to liver around.
11:51
It looks pretty similar.
11:52
Here's the kidney enhancing on the delayed phase.
11:55
Again, here it is right around here,
11:57
and it's not really washing out.
11:59
You know, at first glance I was like, oh,
12:00
is this washed out or is it right up here?
12:02
Either way though, this is similar to
12:03
this, similar to this, similar to this.
12:04
It's not below background.
12:06
This is not washing out.
12:07
It's iso.
12:07
This is the regenerative nodule.
12:09
Just keep a close eye on it.
12:11
And then there are the category of challenging but
12:14
benign lesions, and that is your FNH and your adenoma.
12:17
If you're starting out in a practice with
12:19
this, I would not start with these cases.
12:20
I would not start with, you know,
12:22
the 20, 30-year-old females.
12:23
We're trying to differentiate these. These are
12:25
difficult, just like they can be in CT and MRI. But the
12:30
differentiating factor is this early arterial phase.
12:33
They're both gonna arterially enhance
12:34
early, just like they do on CT and MRI.
12:36
Difference is adenomas have this centripetal
12:39
type pattern of filling, whereas the FNH has a
12:42
centrifugal start centrally and kind of branches out.
12:45
So this early phase imaging, you
12:48
need to be watching very closely.
12:49
This happens so rapidly.
12:52
Other things that can differentiate: they
12:54
can both have this sustained enhancement,
12:55
but adenomas can have a weak washout.
12:58
So not super punched-out dark hole, but
13:01
just a mild washout. They can have that.
13:03
So let's show you some examples.
13:05
This was actually a male patient who had
13:07
a fatty liver, not cirrhotic, um, who
13:10
had an indeterminate lesion on CT/MRI.
13:12
It just wasn't clear what it was.
13:13
So it came to contrast ultrasound.
13:15
You can see it right here, kind of ill-defined,
13:16
hypoechoic in the background fatty liver.
13:20
And here it is super early on this kind of
13:23
centripetal type pattern where it fills in right here.
13:26
So we thought this is gonna be an adenoma.
13:28
And you can see this one's at 16 seconds.
13:31
You know, 15 seconds or so later, the
13:33
whole thing was just diffusely arterially
13:35
enhancing above background liver behind it.
13:38
Right?
13:38
So now we have an arterial enhancing lesion.
13:40
Thought it was probably centripetal.
13:42
So we go to delayed, and at three
13:43
minutes, there it is again.
13:45
You can see it has a mild washout.
13:47
We've got these little speckles still in
13:48
it, but it's definitely below background.
13:51
So if this was a cirrhotic patient, I would be worried
13:53
about an HCC, but I was assured he was not cirrhotic.
13:56
He was just a fatty liver at this point.
13:58
So I said, this is probably an adenoma.
14:00
We did not end up biopsying it, but we did have, um—
14:03
three months of stability, and
14:05
it's exactly the same size.
14:06
That's probably what this is.
14:08
Even though it was a male patient,
14:09
it's probably 'cause of background
14:10
fatty liver.
14:12
Here's another case, um, just to show you,
14:14
'cause we don't see a lot of these adenomas.
14:16
I'm gonna show a couple examples.
14:17
This was a 24-year-old female who had this
14:19
incidental large right lobe liver lesion.
14:23
So in arterial, um, time.
14:25
This a little bit quickly, at
14:26
five seconds, centripetal filling.
14:28
Not an easy one to figure out what this was.
14:30
This is one of our earliest cases,
14:31
and I'll admit we flubbed it.
14:33
Um, but centripetal filling, it's
14:34
definitely arterial enhancing very early on.
14:37
And then by five minutes, we
14:38
followed this out a long time.
14:39
You can see in the liver over here, liver right here.
14:42
We've lost almost all the contrast,
14:44
but the lesion is still enhancing.
14:47
So that is not a malignant pattern.
14:48
This is a benign pattern.
14:52
And so in retrospect, this is centripetal filling,
14:54
but because we weren't sure—this was one of our first
14:56
cases—she did get an MRI, and here you can see in
14:59
her T2, it's heterogeneously mildly T2 bright.
15:03
Sort of iso, but heterogeneous on your pre-
15:05
contrast, very bright on your arterial phase.
15:08
Imaging then becomes a little bit more
15:11
iso, but never completely enhances.
15:13
Still iso and delayed on our 20-minute VIBE phase.
15:16
It is not brighter than background, so it does
15:18
not, would not fit with an FNH classically.
15:21
And this was the money right here.
15:23
This was our in and out-of-phases.
15:24
And you can see there is drop-out of
15:25
signal in this lesion on the out-of-phase.
15:27
So it does contain fat.
15:29
And this was, um, eventually
15:30
biopsied, um, surgically removed.
15:32
And this was an adenoma, given its large
15:34
size, capsular position, risk of rupture.
15:38
So tough case.
15:39
So let's move on to the malignant cases.
15:40
So again, going back to the
15:41
Burroughs Radiographics article.
15:44
Malignant lesions—what they do is
15:45
arterially enhance, and they wash out easy.
15:47
That's it.
15:48
It is, of course, a little bit more complicated
15:51
than that if you're looking for an HCC.
15:53
And again, generally you're gonna have a
15:54
specific population where you're looking at this.
15:57
They're going to arterially enhance—either
15:58
dysmorphic, looks like an adenoma a little bit, right?
16:01
Or hyperenhancement early arterial,
16:05
late phase, which is what we normally
16:06
time the CT and MRI for—still enhancing.
16:08
And then you get this late mild washout.
16:11
So it is below background, but it's got
16:13
this kind of speckle of enhancement,
16:14
sort of a hypoenhancement pattern.
16:18
Other malignant lesions.
16:19
Metastases. They arterial enhance, but they
16:22
may peripherally arterially enhance, but
16:25
they have rapid and pronounced washout.
16:27
So by the late arterial phase, unlike an
16:29
HCC, they're already starting to wash out.
16:31
And when you get to the late phase, it's like a
16:33
punched-out black hole—almost looks like a cyst.
16:35
So this is the differentiation right here.
16:38
So with that in mind, the question is: how long
16:40
do I scan when I'm looking at a liver lesion?
16:42
So you do need to do intermittent, 'cause you—if
16:45
you wanna image out to four or five minutes, you're
16:46
gonna burst bubbles if you watch the whole time.
16:48
And you have to look through all of those images too.
16:50
And if they're not helping, I don't
16:52
like to take them, so clearly you have to
16:54
image through the entire arterial phase.
16:56
That's how we differentiate so many of these lesions.
16:59
I like to go entirely through one minute,
17:01
because that's when that rapid washout
17:02
is going to occur—within that one minute.
17:04
So that's gonna differentiate when I'm
17:06
worried about HCC versus other malignancy.
17:09
That one minute is crucial.
17:12
From there, I use intermittent delayed imaging.
17:14
Usually I start up again around three minutes,
17:15
to match our CT protocols and MRI protocols,
17:18
usually up to five minutes, but you can
17:20
go a little bit longer if you need to.
17:23
And because this is the longest phase, I
17:25
tend to scan through the rest of that liver,
17:27
liver lobe, whichever lobe I'm in, because
17:30
it's a long phase, uh, washout phase.
17:32
So you can look for any other additional lesions that
17:34
you may have missed on the arterial or the gray scale.
17:38
So ACR has a LI-RADS for specifically contrast-enhanced
17:42
ultrasound. It is not the same as the ultrasound LI-RADS.
17:45
Um, and it uses your L3, L4, and 5s,
17:47
and pretty much the same up here, right?
17:49
Typical phase enhancement.
17:50
Does it have washout—late and mild, yes or no?
17:53
But what's important here, and I
17:55
found here, is the LI-RADS M category.
17:57
We don't tend to use this a whole lot in CT/MRI.
18:00
I've used it more in contrast
18:02
ultrasound than I ever have in
18:03
CT/MRI. So I'm gonna focus on this for a second.
18:06
So LI-RADS M—meet any of the three criteria:
18:09
rim arterial phase enhancement, or early—
18:13
meaning less than 60 seconds—washout.
18:14
And again, that's why I image through 60 seconds.
18:17
Or marked washout, and that's the delayed,
18:19
when it looks like a punched-out lesion.
18:21
So the next question is, what does LI-RADS M mean?
18:23
That's what your hepatologist will wanna
18:25
know if you start saying this category.
18:27
So this is from VanderPol, 2019.
18:29
This was from CT and MRI, not from contrast-enhanced
18:33
ultrasound, but they did look at the LI-RADS M category.
18:36
They were almost all malignant—93%,
18:39
which is somewhere between LI-RADS 4
18:41
and 5 categories for malignancy.
18:43
And a little bit more than a third of them were HCCs.
18:46
So in general, if you call LI-RADS M, a third
18:49
of a chance it's gonna be an HCC, and then
18:51
somewhere around a third of a chance
18:52
it could be a mixed HCC–intrahepatic cholangiocarcinoma,
18:56
or it could be a cholangiocarcinoma. Less likely some
18:58
other malignancy, but certainly possible.
19:00
So that's what a LI-RADS M means.
19:01
A lot of times these need to
19:02
go to biopsy or further workup.
19:05
So let's see some more cases.
19:06
This was a 63-year-old male who had
19:09
hepatic fibrosis and came in for screening.
19:11
So we noticed he had a pretty heterogeneous
19:13
echogenic liver up here, and almost like this
19:15
geographic, like less echogenic liver back here.
19:18
And we're like, is this, is this a nodule right
19:20
here, or is this just part of, like, the whole
19:22
geographic, you know, change in this liver?
19:26
So we enhanced him.
19:28
And so you can already see the bubble
19:29
starting to flow in right here.
19:32
And we're having him just quietly breathing right now.
19:34
Now he takes a deep breath, we can see the hepatic
19:37
artery and the portal veins start to fill in there.
19:39
Portal vein's gonna come in in just a moment.
19:41
Here goes kidney,
19:44
breathing.
19:45
And now we're starting to see a lot of vessels here.
19:46
Right there is your portal vein,
19:48
and there's the lesion right there.
19:49
Arterial enhance—this guy
19:50
right here, arterial enhancing.
19:52
So by 30 seconds, this was already arterially enhancing.
19:55
He's gonna take another breath here.
19:56
Gets a beautiful vasculature in his liver.
19:58
Big breath there.
20:00
We come back through the liver.
20:04
Right here.
20:05
You can already see centrally.
20:06
This is starting to wash out by 46 seconds.
20:09
This was already starting to wash out, so
20:10
I'm already concerned seeing this, that this
20:13
is a LI-RADS M. Despite that he has cirrhosis,
20:15
fibrosis again.
20:16
Here it is right here, starting to wash
20:18
out, no longer that big arterial lesion.
20:21
So moving on to three minutes.
20:23
We'll see what happens.
20:24
This is gallbladder right here.
20:31
And there you go.
20:32
So this is sort of a punched-out lesion, little bits
20:34
of enhancement in it, but this is the marked washout.
20:38
And we'll swing back through in just a moment here.
20:42
And this is us scanning too, looking
20:43
for any other lesions. Punched-out lesion
20:45
right there that's pretty washed out.
20:47
So we call this a LI-RADS M, and because
20:50
the hepatologist is like, "You guys don't
20:51
say LI-RADS M very much from CT and MRI.
20:54
What does that mean?
20:55
Let's get a CT."
20:56
So they did, and this, I would argue, is a very
20:59
well-timed arterial phase, late arterial phase CT.
21:03
And I would challenge you to find a lesion
21:04
on this, and I will tell you it is on this
21:06
particular image. It was a right lobe lesion.
21:09
This was the delayed phase, and I
21:10
have it windowed fairly harshly.
21:12
This was three minutes.
21:13
And I'll tell you that our attending was
21:14
reading this, called me and said, "You know what?
21:16
I know what you saw on the contrast ultrasound.
21:18
It looks really convincing, but I don't see
21:19
anything on the CT that I can definitively call."
21:23
And so, because I'm obsessed with this,
21:24
I actually looked at the non-contrast,
21:27
which doesn't usually help a whole lot.
21:29
And here it is.
21:30
Now you can see this, and it looks just like
21:33
the arterial enhancement of the contrast.
21:35
If you go back.
21:36
And you squint.
21:37
This is a little, little bit
21:39
of enhancement right here.
21:40
Little bit of washout right there.
21:42
Super hard to see on a CT.
21:43
I think if this person had gone to a four-phase CT,
21:45
this probably would've been called negative or maybe
21:48
LI-RADS 3, or I don't think they would've come
21:51
down on tumor on this based off of the CT scan.
21:54
But super obvious on contrast
21:55
ultrasound. He ended up going to TACE.
21:58
So this is another patient, different example.
22:00
This was a 59-year-old cirrhotic.
22:02
He had a normal four-phase CT three months
22:05
before, but he came into the hospital in acute
22:07
decompensating liver failure and renal failure,
22:10
was about to get a transplant, and they just wanted
22:11
to make sure that there was nothing huge going on
22:14
that would take him out of transplant criteria.
22:16
So he has ultrasound. You can see he has cirrhosis,
22:19
and we found the liver lesion up near the dome.
22:22
You can see we are below our
22:23
10-centimeter mark right here.
22:25
The ascites again, because ultrasound
22:27
travels quicker through fluid, helps a little,
22:29
bit so we could get a little bit deeper,
22:31
so we couldn't get that lesion any closer.
22:34
So here we are in the arterial phase.
22:35
So we're at 41 seconds, approximately.
22:37
Here's your lesion right here.
22:40
And we struggle.
22:40
We're like, well, that looks like it's enhancing,
22:42
but it's not enhancing to liver above it,
22:44
but it's enhancing to liver next to it.
22:46
And that's what's important.
22:47
Is it enhancing compared to
22:48
background at the same level?
22:51
One caveat with this is you have to make sure
22:52
you're not imaging between ribs, and this
22:54
is just rib shadow, but you go to your gray
22:56
scale and you can see I have liver over here.
22:58
I have liver over here.
22:59
This is just contrast not picking up.
23:01
This is an enhancing lesion.
23:03
So if you weren't sure, you still go
23:05
to your delayed phase at three minutes.
23:06
Here's your lesion again.
23:07
And here we have washout.
23:09
We have speckles on there.
23:10
It's hypoenhancing, but it
23:11
is much less than background.
23:13
So we called this a LI-RADS 5.
23:16
He ended up going to liver transplant shortly after.
23:19
And this was proven on explant to be an HCC.
23:25
This is a look at his CT, his four-
23:27
phase CT from three months earlier.
23:28
Because whenever I find these, you
23:29
always look back just to see if you can
23:31
learn from it, if you can see something.
23:32
And I would argue if you, um, window it
23:35
pretty harshly and squint your eyes,
23:37
there's the lesion right there.
23:38
I think you can see the washout a little bit better.
23:40
This was a vessel washout right there.
23:42
There's the enhancement.
23:43
So again, I think contrast ultrasound is still not
23:46
the easiest case, but you could see it much more
23:48
definitively than the CT where it was not seen.
23:52
Okay, this is case two.
23:53
This is gonna be the next audience
23:54
response in just a moment.
23:56
This was a 74-year-old female.
23:58
She had cirrhosis.
23:59
She had an indeterminate dome lesion, which
24:01
we measured here, but the outside imaging
24:03
was not available for direct comparison.
24:06
So she had some renal failure, so they
24:07
didn't wanna give her a CT or an MRI.
24:10
There's your Doppler.
24:12
And so here comes question two.
24:14
So here's your arterial phase.
24:16
Lesion, I'll tell you is right here.
24:18
We did image between ribs.
24:19
In this case, that's a rib shadow,
24:22
and here's your delayed phase.
24:23
If we can bring up question two, how
24:25
would you LI-RADS category, this lesion?
24:27
She is a cirrhotic.
24:33
Oh, and I have a little box.
24:34
So there we go.
24:36
Here's your little reminder of the categories.
24:38
I don't expect you to memorize that.
24:42
Okay.
24:43
So tricky one, right?
24:44
This is a hard one.
24:45
This was actually the first case we ever did.
24:47
So I was like, we have to be right.
24:48
We have to be right on this one because I wanted
24:50
to grow this business and prove that it worked.
24:52
So this ended up being, if you
24:54
look here, so there's our lesion.
24:56
This is our arterial phase enhancement.
24:59
So this is enhancing, and it's diffusely enhancing.
25:01
And then here at five minutes, lesion's right here.
25:04
And it's not really that punched
25:05
out look, it doesn't look cyst-like.
25:07
It's just kind of vaguely hypo
25:09
enhancing compared to background.
25:10
There's a little bit less enhancement in
25:13
here than there is the background around.
25:15
So we called this a RAD because it was greater
25:17
than 10 millimeters, and because this was our first
25:21
case, her renal function improved a little bit.
25:22
We called this malignant.
25:23
They wanted to get a CT.
25:25
And so here you go.
25:26
Here's your arterial phase.
25:27
Very subtle dome lesion, but it looks
25:29
pretty much the same size as what we saw.
25:31
Very clear.
25:32
Washout.
25:33
So this was called LI-RADS 5.
25:34
She went to TACE, there's your lesion right there.
25:37
So one year later she came back for follow-up.
25:39
She came, she did CTs in between,
25:41
but her renal function went down.
25:42
So she came back for contrast ultrasound, and
25:44
now we found a sort of bilobe appearance.
25:46
Looked a little bit different than it
25:48
did that first time around, and weird,
25:50
you know, color Doppler in that area.
25:52
So we enhanced her again.
25:54
And gray scale's not pretty, right? But you can see
25:57
there is a bilobe enhancing lesion right here.
26:00
That's early. Go to delayed around three minutes.
26:03
Here's your lesion here, and this is super subtle,
26:05
but you can see here, I think the arrows help
26:07
point it out.
26:07
This is vaguely hypoenhancing
26:09
compared to the rest of the liver.
26:11
This part of the lesion up.
26:12
Here was iso liver, but this part was less.
26:15
So we said, you know what?
26:16
I think this is treated. She's been TACE. I think
26:18
the upper part was TACE and treated appropriately.
26:21
I think this is residual tumor down here.
26:23
'Cause we have enhancement and we have washout.
26:26
And again, because this was early on, um, she did
26:29
end up getting a, I think they just followed her.
26:30
They got a CT in three months.
26:31
And so this shows you, here is the, the higher
26:34
lesion, which is completely TACE, right?
26:36
Completely treated, at least on this image.
26:38
And here's the second bilobe lesion, which already
26:39
looks like it's incompletely treated, right?
26:42
We don't have a circular TACE there.
26:43
We just have a little bit of rim there.
26:45
So you look at the arterial and washout
26:47
of the inferior lesion, and there's some
26:50
subtle enhancement, subtle washout.
26:51
So this matched what our contrast
26:53
enhanced ultrasound said.
26:54
She went back for a second TACE for,
26:56
uh, this incompletely treated lesion.
27:00
Okay, so we talked a lot about, um, cirrhotic.
27:03
So how about what does a metastatic lesion look like?
27:05
So this was a 56-year-old male
27:07
with melanoma on treatment.
27:08
He had this isolated liver lesion.
27:10
A little bit of central, probably necrosis, right?
27:13
Not a lot of color Doppler flow to it.
27:16
And here's our contrast imaging.
27:19
So our lesion is right here.
27:21
So keep an eye on this space.
27:22
See the, the bubbles start to flow in.
27:24
And this happens very rapidly.
27:26
We have rim enhancement right here.
27:28
We have rim enhancement, and now
27:30
it's already starting to wash out.
27:33
So I'm gonna play that again because there
27:35
is a perfusion artifact that occurs up here.
27:37
I'll show you it on the CTs.
27:39
So try not to watch that.
27:40
It's very easy to get distracted by it.
27:43
So there, right around here we have rim enhancement.
27:48
And then you get just to here and
27:49
it's already starting to wash out.
27:51
You get this hypoechoic portion.
27:52
So this is washing out within 30 seconds.
27:55
So this is a malignant pattern.
27:58
So here I, I annotated all these, especially
28:00
in the beginning when we were starting these.
28:02
Here's your enhancing rim.
28:03
I would argue this rim was much smaller than what
28:05
I thought it would be based off of the ultrasounds.
28:07
If I was biopsying this, I may have gone a little
28:10
bit too centrally and missed the viable tissue.
28:13
Here we are at just under one minute, and you can
28:15
see the whole thing is almost already washing out.
28:18
Less than a minute, delayed.
28:20
Phase at
28:20
three minutes, punched out.
28:21
Looks almost like that cyst that I showed you early on.
28:24
This is marked washout on the delayed phase.
28:26
So this is consistent with a
28:28
malignant pattern of washout.
28:31
And again, because this was early on when
28:33
we were doing this, he, uh, or he happened
28:35
to have a CT I think a few months earlier.
28:37
Which showed, there's your perfusion change right
28:39
there, which we had right here, the same match.
28:41
And again, we, we imaged, you
28:43
know, from below aiming up.
28:44
So that's why this was closer to the probe.
28:46
But the lesion looked the same, right?
28:48
Central necrosis, we're getting the same information,
28:50
maybe a little bit more 'cause you know which
28:52
tissue is viable if you're gonna biopsy.
28:53
It also had a PET shortly after the contrast
28:56
ultrasound, which shows the same thing.
28:58
This rim of tissue that is
29:00
viable, the central part is not.
29:02
So again, this can help you with a biopsy if you have
29:04
this patient on the table right then and right there.
29:07
Okay, so this is case three.
29:08
So this is our next audience
29:09
response right after this one.
29:11
So this patient had multiple hemangiomas in their
29:14
liver, but they also had a concerning lung lesion.
29:17
And they asked, um, for biopsy.
29:18
And I was on biopsy that day and I said,
29:20
you know, most of these I think are
29:22
hemangiomas, but I'm not sure what this
29:24
one is and I'm not sure what this one is.
29:26
So we got the MRI and you see,
29:28
you know, mildly T2 bright, right?
29:29
Looks like this.
29:29
Hemangioma back here though.
29:30
I'm not impressed.
29:31
Pre contrast.
29:33
Early phase, this guy enhances. This one,
29:36
maybe.
29:36
Maybe something's happening in
29:37
there a little bit more delayed.
29:40
Hard to say for sure.
29:41
Hard to say for sure what's going on out there.
29:44
And then here it is on a
29:45
little bit more delayed phase.
29:46
So I personally felt that this was not conclusive.
29:49
This could still be a real slow flow hemangioma,
29:51
given the T2 signal.
29:53
Um, it did not restrict diffusion.
29:55
I wasn't convinced. I didn't really wanna
29:56
biopsy this if this was a hemangioma.
29:59
And the other little guy was also not that concerned
30:01
about, so I said, you know, what we'll do is we'll
30:03
do a contrast-enhanced ultrasound, and if this
30:06
has a malignant pattern, we'll biopsy it, and if
30:08
not, then we'll know it's a hemangioma and we can
30:10
move on from there and just go to her lung biopsy.
30:13
So they agreed.
30:14
So let me show you these pictures first,
30:16
but this is your echogenic fatty liver.
30:18
Here is the lesion that the
30:19
question is gonna be about.
30:21
So it's hypoechoic there, which hemangiomas can be
30:23
in a fatty liver, but so can malignant lesions.
30:26
This is our arterial phase, and I'll show you.
30:28
Here's the lesion here.
30:30
Here's the lesion here.
30:31
And this little guy, the other little guy
30:32
I was talking about, this is it right out
30:34
here, and I'm gonna show you the delayed.
30:36
This is your delayed phase.
30:37
I do not have this one in the picture.
30:40
If we can bring up the question.
30:41
The question is about this lesion right here.
30:45
Is it benign so we don't biopsy it, or
30:47
is it malignant and we do biopsy it?
30:49
What pattern does it have?
30:53
If we can show the audience response question?
30:56
Perfect.
30:57
So is it a benign pattern, don't biopsy
30:59
it, or is it a malignant pattern?
31:01
Do biopsy it.
31:03
Okay, so this is a tricky one.
31:05
Um, but this one we felt it was read as
31:08
malignant, and I think that it probably is.
31:09
So they're actually coming back for biopsy
31:11
next week 'cause she had some infection
31:13
concerns that we wanna get under control first.
31:15
But, so this lesion right here, it is
31:18
enhancing, it is not super enhancing.
31:20
It's not as enhancing as this one
31:22
is, but I didn't do this case myself.
31:25
So it's entirely possible that we
31:26
missed the very early enhancement.
31:28
But regardless, this is enhancing.
31:30
It is not a cyst.
31:31
We can prove that it is not a hemangioma because if
31:33
it's a hemangioma, it should be filling in, and on the delayed
31:36
phase at three minutes, it's a punched out, washed out.
31:39
So we know it's not a cyst because it enhances here.
31:41
We know it's not a hemangioma because it washed out.
31:44
Um, so that really doesn't leave you much else.
31:47
Um.
31:48
Since it enhanced and it markedly washed out, I
31:50
think this is malignant, and so we're gonna biopsy it.
31:52
So I don't know yet for sure, but that's, I think
31:54
this is worthy of a biopsy at the very least.
31:58
This little guy here, just in contra-
31:59
distinction, arterially enhanced early.
32:01
And I do have another image
32:03
where it's within the field.
32:04
So here is our one that we're gonna biopsy
32:07
just slightly off the edge right here.
32:08
Washed out. This one persisted, this other
32:11
little guy, so I don't know what this is,
32:13
but it's arterial enhancing and persisting.
32:15
So I think it's benign.
32:17
It's probably a flash-filling hemangioma, but
32:19
regardless, it's a benign-appearing lesion.
32:21
Would not biopsy that.
32:22
This is the one we'll target.
32:25
Okay, great.
32:25
So biopsy aids, um, talked a little bit about that.
32:28
This is one more case to show this.
32:30
This was a 65-year-old, questionable
32:32
LRADs 5 lesion on MRI.
32:33
But he actually was a transplanted liver,
32:35
but he got what they thought was probably a
32:37
cirrhotic liver that was transplanted into him.
32:41
So they had this MRI, they got an ultrasound to see
32:43
if we could see it to biopsy that way, and it said
32:46
that it quote unquote, demonstrates the lesion.
32:48
Patient presents for biopsy.
32:49
Here's your MRI, here's your arterial phase.
32:51
It was this lesion.
32:52
I'm concerned, not the easiest one, right?
32:54
It's getting close to the heart and it's
32:56
pretty high up, pretty anterior near the lungs.
32:59
Here's where it was questionable, whether
33:01
it's enhancing right here or not, or
33:03
washing out, I'm not entirely convinced.
33:05
Again, here's your heart nearby.
33:08
This was the ultrasound where they said they saw it.
33:10
And when I took a look at this, 'cause
33:11
it's my biopsy day, I was like, I
33:13
don't think this is the same as this.
33:16
I couldn't figure out any way you could get this
33:18
anterior, nearly peripheral lesion to be this central.
33:22
So I'm like, wait, now we have two lesions.
33:24
What do I biopsy?
33:25
What if this is the cancer and I biopsy this,
33:28
or this was the cancer and I biopsied that.
33:31
So I wasn't sure what to do.
33:32
Neither of them seemed like super easy biopsies.
33:35
So we decided to contrast them and see what they did.
33:38
And that's how we would decide.
33:39
So this is the one of the lesions.
33:41
Turns out this was only visible with a really deep
33:43
breath hold, which is super hard to biopsy that way.
33:45
Biopsy.
33:45
The other one's hard to see.
33:46
But this is the, um, this is the lung right here.
33:49
So it was in this general area.
33:52
And I won't bore you too much with this
33:54
one because not a whole lot happens.
33:55
We were keeping our eye out here.
33:57
This was a little bit of post-surgical
33:59
scarring, most likely. Liver enhances here.
34:02
And unlike some of the other cases that I showed you.
34:04
Nothing really happens.
34:06
So nothing arterially enhanced, nothing washed out.
34:09
So I said, you know what, if I try and biopsy
34:11
this and miss it and it's negative, are
34:13
they gonna send him back for another biopsy
34:15
because they think it's a false negative?
34:17
Um, so with this, I said this isn't worth it.
34:19
There is nothing for me to
34:20
target in this particular area.
34:22
I don't necessarily believe
34:23
that this is, um, a lesion.
34:26
So we also, by, or, uh, enhanced
34:27
the other more central area.
34:30
Here it is right here.
34:31
Again, harder to see on these gray scale images, but
34:33
nothing was happening here in the arterial phase.
34:36
Oops.
34:36
And I'll tell you that nothing
34:37
happened on the washout either.
34:39
So I said these are probably, at least
34:40
this one is a regenerative nodule, and
34:42
there's nothing to do at this point.
34:44
Um, I didn't wanna biopsy.
34:45
I said it'll be a false negative and I could cause
34:47
a complication given where those lesions were.
34:50
So I said they weren't four or
34:51
fives, didn't perform the biopsy.
34:52
He got a bland TACE to further evaluate, just
34:54
to see there was a hypervascular mass somewhere,
34:57
but there was no focal Lipiodol uptake on CT.
35:00
Again, I'm not showing you exactly where the
35:02
lesions are, but that's because the entire
35:03
liver just looked like this, nothing focal,
35:05
and he's been doing well since this point.
35:08
So it can help you from a potentially risky
35:10
biopsy and requesting a repeat biopsy when
35:12
the first one is gonna presumably be negative.
35:15
So moving on to kidneys.
35:17
This is a great article by Barr in Radiology 2014.
35:20
I love this classification system.
35:22
Basically.
35:23
No contrast or few contrast bubbles and septations.
35:26
It's benign.
35:27
If it enhances, it's malignant.
35:29
That's pretty much it.
35:30
Um, caveat is I would not enhance AMLs.
35:33
Um, he can do it — Dr. Barr — and does pretty
35:35
well with it, but the rest of us mortals have
35:37
trouble with those just as you can on CT or MRI
35:40
imaging because AMLs are also gonna enhance.
35:42
I would not advise doing
35:43
these, but here are some cases.
35:46
Here's an indeterminate lesion in
35:47
the kidney, left kidney right here.
35:49
Looks a little hypoechoic.
35:50
So you could recommend an MRI, you could recommend,
35:52
you know, follow up in six months or a year.
35:54
But we contrasted them.
35:56
And again, lesion doesn't
35:57
look great on your gray scale.
35:58
This is a representative image.
36:00
It looked like this the entire
36:01
time during our scanning.
36:02
It never enhanced, never did anything.
36:03
So this is a cyst.
36:05
They don't need a more expensive MRI.
36:06
They don't need to come back for follow-ups.
36:08
This is benign. Period.
36:09
End of story.
36:12
This patient, on the other hand, came in
36:13
with hematuria and acute on chronic renal
36:15
failure, and we found this thing right here.
36:18
And because of a renal failure,
36:19
they didn't want an MRI or a CT.
36:21
So we got a contrast ultrasound.
36:23
And so here's her kidney, here's
36:25
the lesion, maybe some Doppler flow.
36:28
And really hard to see on our gray scale, right?
36:31
But you know, it's right here.
36:32
And again, we're right at our 10 centimeter mark.
36:34
So just to be aware of that.
36:36
And here's a representative
36:37
image of it at two minutes.
36:38
It enhanced a lot earlier as well.
36:39
But here's your lesion, here's
36:41
enhancement, here's your kidney behind it.
36:43
So we have an enhancing mass in the kidney.
36:45
This is a renal cell carcinoma until proven otherwise.
36:47
She ended up getting biopsy
36:48
and ablated at the same point.
36:50
And this was a clear cell RCC.
36:52
So these are much more straightforward cases.
36:54
Kidney lesions.
36:56
This is a 68-year-old male.
36:57
He had acute on chronic renal failure.
36:59
And you can see his kidney itself.
37:00
It's really hard to see, right?
37:01
It's small.
37:02
It's echogenic.
37:03
It's very nodular.
37:04
But he had this right here and
37:06
it kind of looks cystic, right?
37:07
But not quite.
37:08
Meeting all cyst criteria.
37:10
Put some Doppler on it.
37:11
You're like, oh, is that color Doppler flow?
37:13
Or you're like, wait a second.
37:14
There's a lot of red, blue, red, blue, everywhere.
37:17
Is this an artifact kind of
37:18
created by the sonographer?
37:20
And I think this was an image.
37:22
No, it was not done overnight.
37:24
Um, but we, we didn't call the patient back.
37:26
Instead, we called them back for contrast
37:27
ultrasound, and here's your lesion right here.
37:29
In this case, we got it in the point of view of
37:31
his breathing, so you can watch him breathing
37:32
as it goes back and forth, back and forth.
37:34
So we could watch it the whole time.
37:37
Now the bubbles are just
37:39
starting to come into the kidney.
37:44
And then you take a look right
37:45
here, there's our lesion, right?
37:47
There's our lesion.
37:48
It has central enhancement.
37:49
This is a renal cell carcinoma.
37:52
In his case, we don't have path proof because
37:54
it was small and he had a lot of comorbidities.
37:57
So they decided just to do surveillance with
37:59
him, which you can now just do with gray scale
38:00
ultrasound because we've now definitively
38:02
characterized this and didn't have to worry
38:04
about potentially worsening his renal function.
38:07
Okay, so the last section is vascular work.
38:10
So this is a picture of a liver portal vein.
38:12
We saw some echogenic material within it.
38:14
We gave some contrast because that was an
38:16
unexpected finding, and you can see that
38:19
never really fills in this portal vein.
38:21
If you remember some of the other
38:22
pictures, those portal veins are beautiful.
38:24
Don't see anything here, don't see
38:26
anything in a right branch over here,
38:27
either on delayed phase at three minutes.
38:30
Still never filled in.
38:31
So we said this is bland thrombus, it never filled in.
38:34
Got a CT, proves the same thing.
38:36
Here's that branch point thrombus we were looking at.
38:38
So bland thrombus right here.
38:40
On the other hand, this is another patient.
38:43
Big portal vein filled with echogenic material.
38:45
First I saw the same thing, like,
38:46
oh, it's not really enhancing.
38:47
Is this bland?
38:49
Then I realized we were below our
38:50
10 centimeter mark right here.
38:51
So what we did, because he was large and we
38:53
could not get this portal vein any closer, we
38:56
followed this into a more peripheral branch right
38:58
here where we still saw this material within it.
39:01
And now you can see this doesn't look like sort of
39:03
that punched out look or no enhancement that the
39:05
last case, there's all this speckly enhancement.
39:08
This is tumor in vein.
39:09
So we knew there's echogenic material, it's
39:10
thrombus, but now we've proven it's tumor.
39:13
Um, so this was probably an infiltrative cancer and he
39:15
ended up getting an AFP, and it was around 50,000 or so.
39:18
So this is tumor in vein.
39:20
So contrast ultrasound is great at
39:22
differentiating these two, but you can
39:24
do other work, um, that's vascular.
39:26
So moving on to endoleaks for
39:28
abdominal aortic aneurysms.
39:29
About half of people eventually develop one. CTA
39:32
and ultrasound with Doppler, the gold standards.
39:35
Um, and just to quickly review your endoleaks,
39:36
you have your type ones at the end of the grafts,
39:39
type three at the stent graft connections.
39:41
Type four is through the material itself, which
39:43
isn't that common, or type two, which is a
39:45
retrograde flow from the IMA or the lumbar arteries.
39:48
So we can look at this with contrast.
39:50
Ultrasound type one, three, and four are
39:52
all antegrade problems, graft problems.
39:55
So you'd expect that there be synchronous
39:57
enhancement within the sac at the same times
39:59
that the limbs fill, whereas a retrograde type
40:02
two leak, there should be delayed enhancement
40:04
because the limbs will fill first and then it
40:06
takes a while for the IMA or the lumbars to fill.
40:09
So let's see a few quick examples.
40:11
This was a gentleman who had autosomal
40:13
dominant polycystic kidney disease.
40:16
He did get a CTA.
40:17
It showed that the sac had been enlarging and
40:20
they suspected a type two IMA endoleak, this very
40:23
subtle bit right here, but given where it was, they
40:25
couldn't exclude a type three from the left limb.
40:28
They also had a vascular ultrasound,
40:30
which was read as endo present.
40:32
But our CVIR doc took a look at
40:34
this and said, you know what?
40:35
This looks like it's coming from the right limb.
40:38
And since this is a patient with autosomal
40:40
dominant polycystic kidney disease and
40:41
has renal failure, he was trying to decide
40:44
which limb does he interrogate first.
40:46
How much contrast does he need to run to find?
40:49
Is it a type three, is it an IMA, or
40:50
is it coming from the right side?
40:52
Makes a big difference to how he runs
40:54
his procedure when the amount of contrast
40:56
really matters in this particular patient.
40:58
So we did a contrast ultrasound.
40:59
We used the cysts as a window from the kidneys.
41:03
Here is your aortic aneurysm, and here are
41:06
your limbs within the, uh, within the graft.
41:09
So you can already see that these are
41:10
filling, and there's no filling within the
41:13
sac at this point, just within the limbs.
41:15
Great.
41:15
No endoleak so far.
41:16
A few seconds later though, we
41:18
see filling within the sac.
41:19
Again.
41:20
Here is the sac.
41:20
There's filling.
41:21
We now diagnosed an endoleak. It is confirmed.
41:24
So now we have to figure out where is it coming from.
41:27
So two different things we can do.
41:28
This was a delayed at 3:41.
41:29
We see all these bubbles right here.
41:31
I did a flash burst, which is where you give a larger
41:34
MI and you burst all the bubbles within the plane.
41:37
And so that way you can see things
41:39
reperfuse without giving a second dose.
41:40
But when you do that, if you look at the MIs
41:42
right here, you can see the big difference.
41:44
I went from 0.05 to 0.77. You get a beautiful
41:47
ultrasound image, but it only lasts a half a second.
41:50
When we did that, we saw this more
41:52
linear enhancement right here.
41:53
I said, you know what?
41:54
I think this is the source, and
41:56
it's coming from the right.
41:57
So at that point, we stopped.
41:58
We gave a second dose, imaged particularly at
42:01
that area, and we saw on this sagittal plane,
42:03
here's your limb, here's your right limb.
42:05
We saw this coming from behind the limb and
42:08
going this place. We said, you know, this is
42:09
a right-sided lumbar artery type two, which
42:11
was not suspected based off of that CTA.
42:15
And so our interventionalists went up. They
42:16
did a flush catheter and they went up the right
42:19
side and they saw a little bit right here.
42:22
And then a little bit closer, subselecting,
42:24
they found that lumbar artery and they, they
42:26
took that out, and I would argue they gave a
42:28
lot less contrast because they didn't have to
42:30
exclude anything on the left side or an IMA.
42:32
They knew that was the culprit
42:34
based off of our pre-image.
42:36
So last audience response
42:38
question. This is another AAA.
42:39
This was a very large one.
42:42
Two different images.
42:43
So this is within the sac.
42:46
This is a little bit higher up.
42:47
This is a little bit lower down.
42:48
So if we can have the last question.
42:50
The question is, is there an endoleak?
42:52
Just a simple yes or no.
42:54
So this is higher.
42:55
This is lower.
42:57
Alright.
42:58
Excellent.
42:58
We do, right.
43:00
So we don't have any on this
43:01
particular view, but you have it here.
43:03
So the question is, is there, isn't there? This
43:05
isn't diagnosing where. It's just saying that
43:06
there is. And this was a ton. This was a large
43:09
endoleak, and this patient ended up being an IMA.
43:12
Okay, so just a few more
43:14
interesting cases to show you.
43:15
This was a patient with, um, a bleeding
43:18
disorder who had a subcapsular hematoma,
43:20
retroperitoneal hematoma, coming back in follow-up.
43:24
Um, he was—sorry—he was a hemophiliac, so they
43:26
wanted to follow up this subcapsular hematoma.
43:28
And you can see he has a little bit. You can
43:30
see it right here. Not like super suboptimal,
43:32
or is suboptimal imaging, but we contrasted it.
43:35
We put him in transverse. Here's his
43:36
kidney, here's this hypoechoic rind,
43:38
and you can see black hole, right?
43:40
There's nothing—no extravasation.
43:41
It is clearly getting smaller, getting better.
43:43
So you can use this in trauma follow-up,
43:45
particularly in kids who you may not wanna CT again.
43:48
So countless opportunities.
43:49
You can use transplant kidneys where they're
43:51
worried about the renal function post
43:53
ablation to see if there's anything residual
43:55
without getting a three-phase CT scan.
43:57
Trauma follow-ups, peds, which you can also do VCUGs.
44:00
We've done that in adults too.
44:02
Um, MSK, guiding biopsies, vascular work.
44:05
Some people are looking, um,
44:06
at torsion cases for scrotums.
44:08
You can do fertility workups with contrast ultrasound.
44:11
There's a lot of cool things out there, um,
44:13
especially if you can get your clinicians on board.
44:16
So here's some of the references that,
44:17
um, I referred to during the talk.
44:19
They're really fantastic ones.
44:21
And lastly, uh, thank you.
44:23
Um, I have a, we have a few
44:24
minutes left for questions.
44:25
If we don't get to them, you can always
44:27
send me an email, uh, here or you can find
44:29
me on Twitter, so that will open it up.
44:32
Perfect.
44:32
Thank you so much for your time today.
44:34
I wanted to thank all of you for participating
44:35
before we move into the Q&A. And just
44:37
to remind you that it will be made of—this
44:38
conference will be made available on demand on
44:40
MRIlOnline.com, and you can join us tomorrow.
44:43
Dr. Sspa will be with us for a radiological
44:46
assessment of pediatric foot alignment.
44:48
And then Dr. McGillen, if you don't
44:49
mind opening up the Q&A section.
44:51
I do see a few questions in there for you.
44:53
Great.
44:54
Um, so I'll put them right here.
44:56
Um, so the first question is, what is reimbursement
44:58
on average and is it covered by Medicare?
45:01
So, that's a great question and I think it's
45:02
gonna be a little bit different depending
45:03
on insurance coverages and everything.
45:05
And I don't know the exacts, um, but it is covered by
45:07
Medicare, but it is only covered for certain things.
45:09
So at this point it is for lesions only.
45:12
So if you do a liver lesion or a kidney
45:14
lesion, those are covered and reimbursed.
45:16
They're reimbursed at a higher rate than
45:18
a normal gray scale ultrasound would be.
45:20
Um, RVUs also go up as well.
45:22
Um, if you image something, let's say like a
45:25
scrotum because you're trying new and interesting
45:27
things and there's not a lesion, but you're
45:28
looking for torsion, you cannot technically
45:32
bill for that.
45:33
In that case, you can only
45:34
bill for the contrast itself.
45:35
So it is an increase, but it is not,
45:37
um, there's not reimbursement on that.
45:40
Um, as to how much contrast is, I honestly
45:43
don't know that because I'm not at all involved.
45:46
So I would say I believe it's around a hundred
45:50
dollars per vial for Lumason, but it's also, I
45:52
think, gonna depend on the institution you're at.
45:54
But that's around what Lumason is in general.
45:58
Okay.
45:58
Next question is, let's see.
46:02
Are the subtraction images automatically
46:04
buddied with the gray scale?
46:05
So I'll start with that.
46:06
Yes.
46:06
Yes, they are.
46:07
So when you wanna watch somebody breathe,
46:09
um, you can look for that, the lesion,
46:11
especially when they're small coming in or
46:13
coming out, that can absolutely help you.
46:15
Sometimes it's so fast on the ultrasound screen
46:17
in the room that I can't see it, but as long as
46:19
I captured all those pictures, I'll go back into
46:20
the reading room, look at them much more slowly,
46:23
and they, they do come together at all times.
46:25
They, they move together.
46:26
So that's great.
46:27
Um, oh wait, that was only part of the question.
46:30
Let me go back to that.
46:33
Um, it's still there.
46:34
It's just one down.
46:35
It's one down.
46:37
Okay.
46:38
Um, oh, there it is.
46:39
Is the post-process after you've completed the scan.
46:41
Oh, okay.
46:42
And do techs perform this nowadays?
46:43
Radiologist only.
46:44
Okay.
46:45
So it's there in the room as well, because
46:46
otherwise you can't see the lesion necessarily.
46:50
Um, so it is not a post-processing.
46:51
It's available instantaneously.
46:53
Um, at my institution, the techs
46:55
don't do these by themselves.
46:56
We do have a radiologist.
46:57
Sometimes we'll do a resident in, um, you
47:00
could technically do them with, you know,
47:02
either two techs or a nurse and a tech.
47:04
But to scan and to inject the contrast at
47:07
the same time, it needs to be two people.
47:09
It cannot be one person.
47:11
It's just not physically possible.
47:13
So if you train your techs and you have
47:15
like a protocolized image and you feel
47:16
very comfortable, especially, you know.
47:18
Say renal lesions, um, you could
47:20
have techs, two techs do them.
47:22
Uh, right now we still always have a
47:24
radiologist because we're on the newer side
47:26
and we don't have enough techs to spare.
47:28
Okay.
47:29
Next question.
47:29
Can contrast ultrasound be safely used in
47:31
pediatric patients and pregnant females?
47:34
If yes, do we need any blood in, uh,
47:35
investigations or pre-procedure evaluation?
47:37
So for pediatric patients, yes.
47:40
It is actually FDA approved, um, for VCUGs.
47:44
Um.
47:45
In the pediatric population.
47:46
So that is absolutely approved.
47:48
They do have a reduced dose.
47:49
I don't generally do peds, so I don't have
47:52
the dose memorized, but it is a per weight,
47:54
just like most pediatric medications.
47:56
So it's absolutely safe to use in pediatrics
47:58
for lesions as well, and not just VCUGs.
48:00
Um, but for lesion evaluation pre-
48:02
or pre-biopsy type stuff, pregnant
48:05
females is a completely different story.
48:07
Um, it is not approved for their use.
48:10
Um, as far as I know, I've talked to a bunch
48:14
of different people who do contrast and who do
48:15
a lot of contrast ultrasound, and none of them
48:18
have ever done a pregnant female. Theoretically,
48:21
it might be safe.
48:22
Um, I hear that there were some studies done, I
48:24
believe in Europe on twin-to-twin transfusions, which
48:28
would suggest that it's safe, but since it hasn't
48:30
been proven and there'd, you know, be a high low
48:33
risk in the sense probably nothing would happen.
48:34
But if something did, it's catastrophic.
48:36
Uh, I don't think anybody in the US
48:38
actually does them in pregnant females.
48:40
No procedure evaluation for, um,
48:42
pediatric patients. Just need their dose
48:44
or their weight to dose it appropriately.
48:47
Okay.
48:48
Next question is what timing
48:49
do you look for tumor thrombus?
48:52
Great question.
48:53
So that case that I showed you is actually the
48:55
only one I've seen so far for tumor thrombus.
48:57
Um, it's not that common, um, at least in my practice.
49:02
So that was the only one that I have.
49:03
And in that case, um, it's, it's really
49:06
just like an arterial, it should act because
49:08
right, if there's tumor in the vein,
49:09
it should still be fed by the artery.
49:11
So technically it should arterial enhance
49:13
and kind of wash out a little bit later.
49:15
I find that really hard to judge when you're
49:17
judging something that's in a portal vein.
49:19
Um, so basically it's almost like you have to
49:22
think backwards for a tumor thrombus, because if
49:25
there is any enhancement, then it is tumor thrombus.
49:28
If it is a bland thrombus,
49:29
there will be no enhancement.
49:30
So that's simple and easy.
49:31
So if you do see enhancement, that means it's tumor.
49:34
The next question is, of course, you
49:36
know, how can you tell tumor thrombus
49:37
from just regular portal vein flow?
49:39
And in that case, it's off
49:41
of your gray scale, your pre-
49:42
imaging. All of the cases where I've
49:44
found thrombus, whether tumor or bland,
49:47
we had a suspicion on the gray scale that there
49:49
was something echogenic in that portal vein.
49:51
And so that's when you go down that tree.
49:53
If I don't think anything's in there, I don't
49:55
think there's gonna be tumor thrombus either.
49:57
Um, and so far I haven't been wrong, so
50:01
keep my finger—knock on wood—for that one.
50:03
But that's how you would look for it.
50:04
So you can look for timing, but again, it
50:06
really just doesn't enhance or does it not.
50:09
Okay.
50:09
Next question.
50:11
Do you have any experience, thoughts on use
50:12
of contrast ultrasound in characterizing
50:15
indeterminate testicular lesions?
50:17
Great questions.
50:17
So I have no experience on it.
50:22
This is one of the areas which I think
50:23
would be really interesting to look at.
50:27
Um, in my experience, most testicular lesions
50:30
that are, you know, solid type lesion end
50:32
up coming out anyway, or they have a known
50:34
lymphoma or lung cancer type diagnosis.
50:36
So does enhancement or not really truly help?
50:40
Um, probably not.
50:42
There are those few indeterminate ones and I
50:44
think unfortunately they're so rare that we don't
50:46
have any answer out there in the literature yet.
50:48
But I think that would be super interesting to
50:50
see what they do and, you know, kind of follow
50:52
them short intervals and see, do they grow, do
50:54
they continue to enhance when they come out?
50:55
I have no experience in it yet, but I
50:57
think it's super interesting, would be
50:58
a really exciting thing to do with this.
51:01
Okay.
51:01
And that was just not a question, but a thank you.
51:04
Okay.
51:04
How do you approach polycystic kidneys
51:07
looking at complex cysts with solid components?
51:09
Great question.
51:10
Um, polycystic kidneys I feel like are the
51:12
bane of a lot of radiologists’ existence when
51:15
we're looking, um, to find the rare cancer
51:19
that's in them. You know, increased risk of
51:20
cancer, but still not that common, right?
51:22
And then they have all of
51:23
these variable density cysts.
51:25
A lot of times they can't get contrast
51:27
anyway, and so it can be really challenging.
51:30
Um, I think contrast ultrasound is
51:31
probably a really good modality for that.
51:33
If you can see all of the kidneys, and
51:35
that's, that's the hardest part, right?
51:36
'Cause they're huge kidneys, so you need to feel
51:39
confident that you have a window to see all of them.
51:41
It's not gonna be easy to compare to
51:43
priors, but you can look for enhancement.
51:44
I think it.
51:45
I think it would be a very reasonable way to do it.
51:48
Um, complex cyst with solid components.
51:50
Contrast ultrasound is great for that.
51:52
I didn't show you a case, but I
51:54
have one, um, in a youngish guy.
51:57
He is in his thirties and it looked like it was
51:58
probably gonna be a cyst, but we enhanced it anyway.
52:01
And he had this tiny little nodule in the back of
52:03
it and this weird rim enhancement that I honestly
52:05
would've called a cyst remote, like a complex cyst.
52:08
But it enhanced and it ended up, he went to surgery.
52:10
It was a clear cell carcinoma.
52:11
So contrast ultrasound is great for complex cysts
52:14
with solid components, like absolutely fantastic.
52:17
The, um, the subtraction type of imaging
52:19
that you get with it is just wonderful.
52:21
It's super helpful.
52:22
I definitely recommend it.
52:25
Okay.
52:25
Can you please revise some again for tubal patency?
52:29
I'm not entirely sure what that means, but if
52:32
we're talking about tubal patency for, um, like
52:34
infertility workups, I have not done them myself.
52:37
Um.
52:38
But a colleague at Einstein in Philadelphia does them.
52:41
Um, and what she does is she does a 3D ultrasound
52:44
to look at the uterus for anomalies and then
52:47
injects to look at the, um, like the endometrial,
52:50
not the endometrial line, but the shape of the
52:52
cavity, and then again injects it by hand, not IV.
52:56
Um, and then looks to see for fallopian tube
52:58
patency, to see if there's spill on either side.
52:59
The pictures I've seen are absolutely gorgeous.
53:02
That one, of course, requires buy-in from your OB-GYN
53:05
colleagues 'cause they're going to send you these
53:07
patients, but the images are absolutely gorgeous.
53:10
No radiation with this whatsoever, safe way to do it.
53:12
So I don't have any images of that to show
53:14
you, but it's really cool what they're doing.
53:16
Okay.
53:17
Next question.
53:17
After injecting contrast, how long do
53:19
you wait until you can do ultrasound?
53:21
Sure.
53:22
So in the beginning we would, I would inject
53:24
and then we would image the whole time.
53:25
And then sometimes it would take up
53:27
to 30 seconds to reach whatever organ.
53:29
And that was right when our timer stopped,
53:30
so we would miss the arterial phase.
53:32
So now that I'm a little bit more comfortable with
53:34
this, uh, I wait until we see the first few bubbles.
53:37
So I tell the sonographer when I'm injecting,
53:39
I tell them when I'm flushing, when I flush.
53:41
That's usually when they start the counter, but
53:43
they don't actually start the imaging itself
53:45
until they start seeing those first few bubbles,
53:48
um, because nothing's gonna happen before then.
53:49
And other than that, you're just creating more
53:51
images that you have to look through later.
53:53
Um, so everyone's different.
53:55
I find sometimes it takes as long as 30
53:56
seconds for the contrast to get to them.
53:58
Sometimes it shows up, you know,
53:59
five seconds after I've injected it.
54:01
But those first few bubbles are
54:02
usually my marker for starting.
54:05
Uh, so I don't, I don't have any images for
54:07
tubal patency, which is the next question,
54:09
um, because I have not done that myself.
54:11
Um, I'm not sure if they're in the literature at all.
54:14
Um, but I, I do know one person
54:16
doing, and they were cool pictures.
54:19
Uh, another lecture related to fertility workups.
54:22
So I don't do those with contrast ultrasound,
54:25
but if, um, people want that, I can suggest a
54:28
person who has done 'em and has pictures,
54:30
um, I can refer to that colleague as well.
54:33
Um, what's the role in tub-
54:35
-ency evaluation?
54:37
Sure.
54:37
So you can do it.
54:39
Um, again, I don't think it's been
54:40
published online as far as I've known.
54:42
I've not done a recent literature search.
54:44
Um, but it would work just like, um, like
54:47
you would do it under fluoroscopy, right?
54:49
You canalize the same way the cervix,
54:50
you inject a little bit of contrast.
54:52
You fill, um, the uterine cavity itself, and then you
54:56
look for spillage on either side, and that's just by
54:58
injecting fluid and kind of pushing it out, right?
55:00
So you can actually see the fallopian tubes
55:02
and you see the same kind of picture you
55:03
do as the contrast surrounds the ovaries.
55:06
So again, trying to paint a,
55:07
a sort of picture for you.
55:08
Um, but you can see if there's patency or not.
55:11
You can then see if a tube is
55:12
dilated, um, and things like that.
55:14
So it absolutely can be done.
55:16
You can, you know, tilt the patient a
55:17
little bit to try and help with that, but
55:19
it can be done similar to fluoroscopy.
55:23
Okay.
55:23
Recap on the type of endoleaks.
55:26
Sure.
55:26
So what I'll do, rather than just recapping
55:27
'em too much, I'm just gonna go backwards.
55:29
Sorry if I make anyone dizzy.
55:30
Here's the picture.
55:31
This is from JUM, um, Ultrasound Quarterly,
55:34
which I think was a nice example of these.
55:36
So these are the types of endo-
55:38
leaks that you have right here.
55:41
And what's really most important is
55:44
figuring out where it's coming from.
55:45
Sorry, I have kids in the background.
55:47
Um, but the antegrade, so the one,
55:49
three, and four is a graft problem.
55:51
So you get synchronous enhancement.
55:53
Type two endoleak are retrograde problem.
55:55
So you get delayed enhancement.
55:57
There's no literature saying exactly
55:59
what delayed means versus synchronous.
56:02
Um, it really depends on how
56:04
forceful that endoleak is.
56:05
If it's really just a slow, gradual leak or if it's
56:07
really under a lot of pressure, you know, so it can
56:09
show up, you know, five seconds might be the delayed.
56:11
It can be up to like 20 or 30 different seconds.
56:14
So this one's gonna depend on the degree.
56:19
Okay, next question.
56:19
Is there a role in differentiating testicular
56:22
lesions, malignant versus benign?
56:24
Uh, I don't know of anyone doing that.
56:26
I think that you could, and I
56:27
think that would be interesting.
56:29
Usually you wouldn't need it necessarily because
56:31
a lot of the benign testicular lesions, you know,
56:34
might be calcified or, you know, are fairly already
56:36
well-defined epidermoids, that kind of thing.
56:39
But if you did have an indeterminate one,
56:40
again, I think that would be an interesting
56:43
role rather than just getting, you know, a
56:44
three-month follow-up or urology consult.
56:47
I do think there would be, but I don't think
56:49
it's been studied yet, so we don't know exactly
56:51
what we're looking for for these indeterminate ones.
56:54
Okay.
56:55
Um, can you—I'm sorry.
56:57
Do you perform ultrasound for vascular patency on post-
56:59
liver transplant patients, e.g., hepatic arterial flow?
57:02
Um, I have done it on one because the,
57:04
there was a duplex ultrasound that they
57:06
weren't sure whether it was patent.
57:07
We have a different vascular ultrasound lab.
57:09
It is not our radiology department.
57:11
Um, so they just wanted to know
57:12
was it patent or was it not?
57:13
And so we were able to answer
57:15
that question for the most part.
57:17
Um, the limiting factor is
57:19
going to be the depth, right?
57:20
If these are larger patients, if they're
57:21
larger livers, you are not going to be
57:24
able to necessarily see, you know, the
57:25
hepatic artery from where its take-off.
57:27
You're going to see it in the liver,
57:28
you're gonna see it in the hilar area.
57:31
So you may be able to answer this, but if it's really
57:33
a very more peripheral portion, you may just not
57:35
see it unless you have one of the newest, um, newest
57:38
machines and platforms, which are really super cool.
57:41
Um, but we have done it.
57:42
You absolutely can do it.
57:43
And you can do it for things like if you had
57:44
a pseudoaneurysm or you were worried about
57:46
that, you can image pseudoaneurysms just
57:48
like you would a post-transplant liver.
57:51
So definitely a very good use for it.
57:54
Okay.
57:55
And.
57:57
Okay.
57:57
Tubal patency question again. Again, it
57:59
doesn't have a defined role, but people are doing it.
58:02
So I think, you know, if that starts
58:03
getting published and getting out there,
58:04
I think it could have a role in that.
58:06
And I think it's great because it's no radiation.
58:08
Um, but we're not, it's, I
58:10
don't think it's out there yet.
58:11
Um, and very, you know, broadly used at this point.
58:15
Okay, what is the frequency of the
58:16
probe that can be used in contrast?
58:17
Great.
58:18
So again, it's gonna depend a little bit
58:19
on your system and your system settings.
58:22
So in some of the newer ones, every single probe,
58:24
including a transvaginal, can do contrast ultrasound.
58:27
So if you're gonna buy one of these, I would recommend
58:29
making sure your system can use any kind of probe.
58:31
You can use the nonlinear for peds or cardiac applications.
58:34
The one caveat is if you are using a higher
58:37
frequency probe like a 9 linear, you will
58:39
usually have to double your contrast dose.
58:42
So often that is not a problem, um,
58:44
but you do have to be aware of it.
58:45
I have messed around with a kidney lesion
58:47
just to see if that was really true.
58:49
Uh, and it was, 'cause I did a regular dose
58:51
the first time with a deeper probe, used a
58:53
superficial and I could not see very much at all.
58:55
So you really do need to double your dose.
58:59
Okay.
58:59
Is there a role for contrast ultrasound,
59:01
early rejection of transplant kidney?
59:03
Um, that's a yes and a no type of question.
59:06
It's not going to tell you that
59:07
it's rejecting necessarily.
59:09
You're gonna see like a parenchymal problem,
59:10
but you might be able to catch either the
59:12
vascular problem if there's a, you know,
59:14
something wrong with the artery or the vein, or
59:16
it will show you if there's altered perfusion
59:19
potentially because of an artery or vein problem.
59:21
So.
59:22
I think that there has been some use of it.
59:24
There is some literature out there, I think it's
59:26
mostly out of Europe, um, that they've done this
59:29
in the past again, and they've been doing contrast
59:30
a lot longer than it was approved in the US.
59:32
I think it's only been approved since
59:33
2016, so we're a little bit behind on that.
59:36
Um, Southeast Asia also has a
59:38
lot of work on this as well.
59:40
Um, so it is possible, so you could look for. It
59:42
wouldn't be rejection per se, but it would exclude
59:44
other things like, you know, is there a hematoma,
59:45
is there active extravasation, is there a hematoma?
59:48
That kind of things.
59:49
That's what it's really used for, useful
59:51
for in the early phase of a transplant,
59:53
kidney, pyelonephritis, that kind of thing.
59:56
Um, excluding those other things
59:57
as the cause of the rejection.
60:00
Okay, role of contrast-enhanced ultrasound.
60:02
Endometriosis.
60:03
Oh, great question.
60:04
Uh, my other thing that I
60:05
really like is endometriosis.
60:07
Um, sorry, I have a kid screaming in the background.
60:10
Um, the role of contrast ultrasound—
60:12
that I have not seen published anywhere, um,
60:15
it's something we're thinking about doing,
60:16
but it depends on your endometriosis, right?
60:19
If you have the deep infiltrating
60:20
type, that is a fibrotic process, so
60:23
that theoretically should not enhance.
60:26
But what it would show is that the endometriosis,
60:30
um, does not enhance while, you know, say the bowel
60:32
that it's on or the ligament that it's adjacent to
60:35
does enhance, and it might make it show up brighter.
60:37
So the endometriosis itself does not enhance.
60:40
Or should not really enhance.
60:41
Theoretically, I think the things around it
60:44
will, which may make it show up and prove
60:46
that it's not just like a folded loop of
60:47
colon, but that it truly is an endometriosis
60:50
deposit on the colon, that kind of thing.
60:52
But I don't think that's been studied.
60:54
Um, so I think that's another interesting thing to
60:56
try, especially now that transvaginal probes, um,
60:59
for most systems do have contrast software on it.
61:03
Okay.
61:03
Adverse effects of contrast-enhanced
61:05
ultrasound in chronic kidney disease?
61:07
None.
61:07
And that's part of the beauty of this and why,
61:09
um, our hepatologists have really gotten on
61:11
board with this, because a lot of their patients
61:13
do have chronic kidney disease. Doesn't affect
61:15
the kidneys at all, because it's intravascular.
61:17
So they don't excrete it whatsoever.
61:19
It just stays intravascular within the blood pool the
61:22
entire time until the little bubbles rupture, and
61:25
then you actually breathe out the byproducts.
61:28
That's how your body gets rid of 'em.
61:30
So it is not excreted through the kidneys.
61:32
It does not affect them negatively in any which way.
61:35
So that's what it is, what's one of the, uh,
61:37
the really cool things—one of the only contrasts
61:39
that can do that. No kidney problems whatsoever.
61:41
So that never, you never have to
61:43
check labs, anything like that.
61:45
Okay.
61:46
And then what could the future
61:47
role be in characterization of thyroid
61:49
lesions, benign versus malignant?
61:50
Um, good question.
61:52
I think that there might be some literature
61:53
on this. I'm not a hundred percent sure. Um,
61:56
theoretically, in my head with this, um, is that—
62:02
we know that there are thyroid lesions with
62:03
Doppler, color Doppler, and we know that there is
62:06
a higher rate of malignancy in those, but we also
62:08
know a lot of benign ones also rapidly enhance.
62:12
So just enhancement alone if we contrasted them,
62:14
I don't think would be really helpful, because
62:16
I think both benign and malignant enhance.
62:18
I don't think it's specific
62:19
enough, um, to differentiate.
62:21
Um, could there be a pattern, kind of
62:23
like how we talked about in the liver?
62:24
That, I don't know.
62:26
That's a good question, and I don't know if it's
62:27
been studied, so I'll have to look into that
62:29
myself as well to see if it's already out there.
62:32
Um, but it would really have to be
62:34
a pattern differentiation, because
62:35
I think both types would enhance.
62:38
Okay.
62:38
And then any role in breast ultrasound?
62:40
So, caveat, I'm not a breast, um, person.
62:43
I don't read them.
62:44
I don't perform those kind of biopsies, so I,
62:46
I'm not that familiar with their literature.
62:49
That being said, I personally think
62:51
this would be a great utility for it.
62:53
Um.
62:55
A lot of the information it can show
62:56
you is similar to MRI in other lesions.
62:58
You know, is there enhancement?
62:59
Is there not? Enhancement patterns and such forth.
63:01
So I think it could be really useful in breast.
63:04
Um, I believe some people are studying that.
63:07
Again, I've not done any deep dive
63:09
into the literature in that whatsoever.
63:11
Um, our breast, um, images use a different
63:15
machine that does not have contrast.
63:16
So I've not approached them on that, which is
63:18
another reason I just haven't looked into it.
63:20
I think that there could be, and I think
63:21
it could be a really interesting, um, way
63:24
to use contrast ultrasound in the breast.
63:27
Um, again, no radiation type things.
63:29
Not that you use radiation much in breast
63:31
imaging anyway unless you're being treated, but
63:33
I think it's just another safe way, um, that you
63:36
could potentially kind of guide your biopsies.
63:38
But again, I'd have to do a deeper dive.
63:39
I don't know if benign things like fibroadenomas
63:41
enhance, that kind of stuff, but I think that would
63:43
be a really interesting, um, question to look into.
63:49
Okay.
63:50
Perfect.
63:50
I think that's all the questions.
63:52
I bring this to a close.
63:52
I wanna thank you, Dr. McGillen, for your
63:54
time today, and thanks to all of you for
63:55
participating in this noon conference.
63:56
Again, it will be made available
63:57
on demand on MRIonline.com.
64:00
In addition to all previous noon conferences, please
64:02
follow us on social media at MRI Online for
64:05
updates and reminders for upcoming noon conferences.
64:07
Thanks again and have a wonderful day.
64:10
Thank you.
© 2025 Medality. All Rights Reserved.