CEUS in abdominal trauma: multi-center study

Diagnostic value of enhanced-contrast ultrasound for cesarean scar pregnancy: A systematic review

BACKGROUND

Cesarean scar pregnancy, an uncommon ectopic pregnancy in which the embryo is implanted in the cesarean scar, poses significant risks without prompt diagnosis and treatment. Its prevalence has risen alongside increased cesarean section rates. Despite various treatment approaches, consensus remains elusive. Ultrasonography, particularly contrast-enhanced ultrasonography, shows promise in cesarean scar pregnancy diagnosis.

MAIN BODY

This systematic review, following PRISMA guidelines, explores contrast-enhanced ultrasound's diagnostic potential in cesarean scar pregnancy. We searched PubMed, Scopus, Web of Science, and Google Scholar up to August 2023. Selection involved two stages: title/abstract screening and full-text assessment. The included studies investigated contrast-enhanced ultrasound's diagnostic value in cesarean scar pregnancy, provided adequate data, and were peer-reviewed in English. Quality assessment followed the QUADAS-2 criteria. We extracted the diagnostic accuracy metrics: sensitivity, specificity, and accuracy. Out of 193 records, five studies met the inclusion criteria (2016-2020, China). Contrast-enhanced ultrasound displayed sensitivities of 77%-100% and specificities of 95%-100%. Two studies reported accuracy of 96.9%-97.8%. Compared with conventional ultrasound, contrast-enhanced ultrasound exhibited superior sensitivity, specificity, and accuracy. It also outperformed transvaginal ultrasound.

CONCLUSION

Enhanced-contrast ultrasound holds promise for diagnosing and managing cesarean scar pregnancy by visualizing scar vascularization in real-time, thereby reducing severe complication risks. This review highlights contrast-enhanced ultrasound as a transformative diagnostic tool for cesarean scar pregnancy management, despite existing evidence limitations.

Is it time to re-think FAST? A systematic review and meta-analysis of Contrast-Enhanced Ultrasound (CEUS) and conventional ultrasound for initial assessment of abdominal trauma

BACKGROUND

The Focused Assessment with Sonography for Trauma (FAST) examination using conventional ultrasound has limited utility for detecting solid organ injury. Therefore, this systematic review and meta-analysis compares the performance of contrast-enhanced ultrasound (CEUS) to conventional ultrasound when used as the initial assessment for abdominal trauma prior to computed tomography (CT) imaging.

METHODS

A systematic literature search of major databases was conducted of human studies investigating the diagnostic accuracy of conventional ultrasound and CEUS occurring prior to CT imaging for abdominal trauma. The study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The quality of studies was evaluated using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool. Paired pooled sensitivity and specificity between conventional ultrasound and CEUS were compared using data extracted from the eligible studies. Diagnostic odds ratio, number needed to diagnose values, and likelihood ratios were also determined.

RESULTS

Ten studies were included. More than half of the included studies demonstrated low risk of bias. Using McNemar's test to assess for paired binary observations, we found that CEUS had statistically higher sensitivity (0.933 vs. 0.559; two-tailed, P < 0.001) and specificity (0.995 vs. 0.979; two-tailed, P < 0.001) than conventional ultrasound in the setting of abdominal trauma, respectively. When divided into particular findings of clinical interest, CEUS had statistically higher sensitivity than conventional ultrasound in screening for active bleeding and injuries to all abdominal solid organs. CEUS also had superior diagnostic odds ratios, number needed to diagnose values, and likelihood ratios than conventional ultrasound.

CONCLUSION

The diagnostic value of CEUS was higher than that of conventional ultrasound for differentiating traumatic abdominal injuries when used as the initial assessment in the emergency department.

Contrast-enhanced ultrasound in pediatric blunt abdominal trauma: a systematic review

PURPOSE

Intra-abdominal injury is a major cause of morbidity in children. Computed tomography (CT) is the reference standard for the evaluation of hemodynamically stable abdominal trauma. CT has an increased risk of long-term radiation induced malignancies and a possible risk associated with the use of iodinated contrast media. Contrast-enhanced ultrasound (CEUS) might represent an alternative to CT in stable children with blunt abdominal trauma (BAT). Nonetheless, CEUS in pediatrics remains limited by the lack of strong evidence. The purpose of this study was to offer a systematic review on the use of CEUS in pediatric abdominal trauma.

METHODS

Electronic search of PubMed, EMBASE and Cochrane databases of studies investigating CEUS for abdominal trauma in children. The risk of bias was assessed using the ROBINS-I tool.

RESULTS

This systematic review included 7 studies. CEUS was performed with different ultrasound equipment, always with a curvilinear transducer. Six out of seven studies used a second-generation contrast agent. No immediate adverse reactions were reported. The dose of contrast agent and the scanning technique varied between studies. All CEUS exams were performed by radiologists, in the radiology department or at the bedside. No standard training was reported to become competent in CEUS. The range of sensitivity and specificity of CEUS were 85.7 to 100% and 89 to 100%, respectively.

CONCLUSION

CEUS appears to be safe and accurate to identify abdominal solid organ injuries in children with BAT. Further research is necessary to assess the feasibility of CEUS by non-radiologists, the necessary training, and the benefit-cost ratio of CEUS as a tool to potentially reduce CT scans.

The use of contrast-enhanced ultrasound in COVID-19 lung imaging

Lung ultrasound has become an essential tool for rapid bedside assessment in critically unwell patients, proving helpful in assessment of COVID-19 due to logistics of cross-sectional imaging. Contrast enhanced ultrasound (CEUS) further characterizes sonographic features of COVID-19 as multiple areas of infarction, a finding not reproducible on other widely available imaging modalities. CEUS also has the benefit of being cheap, radiation-free, without risk of nephrotoxicity, and can be performed at the bedside. It is predicted that lung CEUS in COVID-19 may help guide prognosis and management. We describe three cases of CEUS in COVID-19.

Contrast-enhanced ultrasound of blunt abdominal trauma in children

Trauma is the leading cause of morbidity and mortality in children, and rapid identification of organ injury is essential for successful treatment. Contrast-enhanced ultrasound (CEUS) is an appealing alternative to contrast-enhanced CT in the evaluation of children with blunt abdominal trauma, mainly with respect to the potential reduction of population-level exposure to ionizing radiation. This is particularly important in children, who are more vulnerable to the hazards of ionizing radiation than adults. CEUS is useful in hemodynamically stable children with isolated blunt low- to moderate-energy abdominal trauma to rule out solid organ injuries. It can also be used to further evaluate uncertain contrast-enhanced CT findings, as well as in the follow-up of conservatively managed traumatic injuries. CEUS can be used to detect abnormalities that are not apparent by conventional US, including infarcts, pseudoaneurysms and active bleeding. In this article we present the current experience from the use of CEUS for the evaluation of pediatric blunt abdominal trauma, emphasizing the examination technique and interpretation of major abnormalities associated with injuries in the liver, spleen, kidneys, adrenal glands, pancreas and testes. We also discuss the limitations of the technique and offer a review of the major literature on this topic in children, including an extrapolation of experience from adults.

European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB): An Update on the Pediatric CEUS Registry on Behalf of the "EFSUMB Pediatric CEUS Registry Working Group"

The European Federation of Ultrasound in Medicine and Biology (EFSUMB) created the "EFSUMB Pediatric Registry" (EFSUMB EPR) with the purpose of collecting data regarding the intravenous application of pediatric contrast-enhanced ultrasound (CEUS). The primary aim was to document the current clinical practice and usefulness of the technique and secondarily to assess CEUS safety in children. We issue the preliminary results of this database and examine the overall practice of CEUS in children in Europe.

Future developments in the imaging of the gastrointestinal tract: the role of ultrasound

PURPOSE OF REVIEW

The purpose of this review is to summarize the utilization and most recent developments with regard to the use of ultrasound when imaging the abdomen and gastrointestinal tract.

RECENT FINDINGS

Although the use of ultrasound to assess the anatomy of the various abdominal organs is well established within radiology and critical care, its use as part of functional and physiological assessment is still evolving. Recent developments have extended the use of ultrasound beyond standard B-mode/2D imaging techniques to incorporate more functional and haemodynamic assessment. These include the use of contrast-enhanced ultrasound (CEUS), elastography, and colour Doppler techniques.

SUMMARY

Whilst Doppler techniques are reasonably well established within critical care ultrasound (CCUS), especially in echocardiography, CEUS and elastography are less well known. CEUS utilizes a purely intravascular contrast agent whilst elastography measures the degree of deformation or stiffness in various organs. Whilst their use individually may be limited; they may play a role in a multiparametric assessment. Mirroring the overall trends in critical care ultrasound development, abdominal ultrasound assessment is best integrated in a holistic approach and adapted to the individual patient.

Conventional Ultrasound and Contrast-Enhanced Ultrasound in the Diagnosis of Splenic Diseases: A Systematic Review and Meta-analysis

Accurate diagnosis of splenic diseases is important for timely and accurate treatment. The objective of this study was to compare the accuracy of contrast-enhanced ultrasound (CEUS) and conventional ultrasound (US) in detecting splenic lesions. A systematic literature search was undertaken, and 8 studies met the inclusion criteria. The sensitivity and specificity of the consolidated results of CEUS were 0.95 (95% confidence interval [CI], 0.92-0.97) and 0.97 (95% CI, 0.90-0.99), respectively (I² = 27.4%; area under the curve [AUC] from a summary receiver operating characteristic curve = 0.97). The sensitivity and specificity of the consolidated results of conventional US were 0.70 (95% CI, 0.56-0.80) and 0.96 (95% CI, 0.76-0.99; I² = 83.4%; AUC = 0.84). In this systematic review and meta-analysis, the sensitivity and specificity of CEUS were higher than those of conventional US in diagnosing splenic lesions. Contrast-enhanced US is a promising method for accurately diagnosing splenic lesions.

Review of Multimodality Imaging of Renal Trauma

Blunt trauma accounts for more than 95% of traumatic renal injury and results from shear forces from rapid acceleration or deceleration and/or collision against the spine or ribs. The use of multiphasic contrast-enhanced computed tomography (CT) has proven pivotal in the evaluation and management of traumatic kidney injury, and CT imaging features provide the basis for nonsurgical staging. This article describes the epidemiology and mechanisms of blunt and penetrating traumatic renal injury and reviews the range of findings from various imaging modalities, with a particular emphasis on contrast-enhanced CT.

European Society of Paediatric Radiology abdominal imaging task force: recommendations for contrast-enhanced ultrasound and diffusion-weighted imaging in focal renal lesions in children

Contrast-enhanced ultrasound (CEUS) and diffusion-weighted imaging (DWI) are safe, repeatable imaging techniques. The aim of this paper is to discuss the advantages, technical factors and possible clinical applications of these imaging tools in focal renal lesions in children.

Contrast-enhanced ultrasonography (CEUS) in the follow-up of pediatric abdominal injuries: value and timing

AIMS

Primary aim was to investigate the value and safety of contrast-enhanced ultrasonography (CEUS) during follow-up (FU) of splenic, hepatic and renal post-traumatic injuries in a pediatric population. Secondary aim was to extrapolate appropriate timing of FU-CEUS.

METHODS

In a retrospective study, post-traumatic parenchymal injuries diagnosed with CT or CEUS, were subjected to non-operative management and followed with CEUS.

RESULTS

Forty-six patients were enrolled, with isolated or combined injuries, for a total of 30 splenic, 15 hepatic and 12 renal injuries. At admission 42/46 patients underwent CT and 4/46 underwent CEUS. During FU a total of 65 CEUS were performed: 16 within 72 h to check delayed active bleeding or parenchymal rupture; 24 between 5 and 10 days post admission, to pose indication to active mobilization or to discharge; 21 between 20 and 60 days post admission to document complete healing of the lesion or pose indication to discharge in most severe injuries. No complications related to CEUS were encountered.

CONCLUSIONS

CEUS is valuable and safe to follow patients with post-traumatic abdominal injuries, even if further data are needed for renal injuries. We propose a tailored approach based on injury grade and clinical course: in the first 3 days only in case of delayed bleeding or rupture suspect; between 5 and 10 days post trauma to ensure a safe active mobilization and/or pose indication to discharge, and over 20-30 days post trauma to pose indication to discharge in most severe injuries or document complete healing and permit return to sport activities.

Kidney and uro-trauma: WSES-AAST guidelines

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

Clinical use of contrast-enhanced ultrasound beyond the liver: a focus on renal, splenic, and pancreatic applications

Contrast-enhanced ultrasound (CEUS) is a relatively novel, but increasingly used, diagnostic imaging modality. In recent years, due to its safety, quickness, and repeatability, several studies have demonstrated the accuracy, specificity, and sensitivity of CEUS. The European Federation of Societies for Ultrasound in Medicine and Biology has recently updated the previous guidelines from 2012 for the use of CEUS in non-hepatic applications. This review deals with the clinical use and applications of CEUS for the evaluation of non-hepatic abdominal organs, focusing on renal, splenic, and pancreatic applications.

Contrast-enhanced ultrasound (CEUS) in pediatric blunt abdominal trauma

Baseline ultrasound is the first-choice technique in traumatic hemodynamically stable children, and is essential in the early assessment of unstable patients to detect hemoperitoneum or other potentially fatal conditions. Despite the technological advancements in new ultrasound equipment and the experience of the operators, it is not always possible to rule out the presence of parenchymal traumatic lesions by means of baseline ultrasound nor to suspect them, especially in the absence of hemoperitoneum. For this reason, in the last decades, basic ultrasound has been associated with contrast-enhanced ultrasound (CEUS) to evaluate the stable little patient in cases such as low-energy blunt abdominal trauma. Because it relies on second-generation contrast agents, the CEUS technique allows for better detection of parenchymal injuries. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients affected by low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. A very important point in favor of CEUS is its capacity to help distinguish the healthy patient, who can be discharged, from the one needing prolonged monitoring, operative management or hospitalization. Finally, we also have the ability to follow-up on low-grade traumatic lesions using CEUS, always keeping in mind patients' clinical conditions and their hemodynamics.

Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma

BACKGROUND

Point-of-care sonography (POCS) has emerged as the screening modality of choice for suspected body trauma in many emergency departments worldwide. Its best known application is FAST (focused abdominal sonography for trauma). The technology is almost ubiquitously available, can be performed during resuscitation, and does not expose patients or staff to radiation. While many authors have stressed the high specificity of POCS, its sensitivity varied markedly across studies. This review aimed to compile the current best evidence about the diagnostic accuracy of POCS imaging protocols in the setting of blunt thoracoabdominal trauma.

OBJECTIVES

To determine the diagnostic accuracy of POCS for detecting and excluding free fluid, organ injuries, vascular lesions, and other injuries (e.g. pneumothorax) compared to a diagnostic reference standard (i.e. computed tomography (CT), magnetic resonance imaging (MRI), thoracoscopy or thoracotomy, laparoscopy or laparotomy, autopsy, or any combination of these) in patients with blunt trauma.

SEARCH METHODS

We searched Ovid MEDLINE (1946 to July 2017) and Ovid Embase (1974 to July 2017), as well as PubMed (1947 to July 2017), employing a prospectively defined literature and data retrieval strategy. We also screened the Cochrane Library, Google Scholar, and BIOSIS for potentially relevant citations, and scanned the reference lists of full-text papers for articles missed by the electronic search. We performed a top-up search on 6 December 2018, and identified eight new studies which may be incorporated into the first update of this review.

SELECTION CRITERIA

We assessed studies for eligibility using predefined inclusion and exclusion criteria. We included either prospective or retrospective diagnostic cohort studies that enrolled patients of any age and gender who sustained any type of blunt injury in a civilian scenario. Eligible studies had to provide sufficient information to construct a 2 x 2 table of diagnostic accuracy to allow for calculating sensitivity, specificity, and other indices of diagnostic test accuracy.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts, and full texts of reports using a prespecified data extraction form. Methodological quality of individual studies was rated by the QUADAS-2 instrument (the revised and updated version of the original Quality Assessment of Diagnostic Accuracy Studies list of items). We calculated sensitivity and specificity with 95% confidence intervals (CI), tabulated the pairs of sensitivity and specificity with CI, and depicted these estimates by coupled forest plots using Review Manager 5 (RevMan 5). For pooling summary estimates of sensitivity and specificity, and investigating heterogeneity across studies, we fitted a bivariate model using Stata 14.0.

MAIN RESULTS

We included 34 studies with 8635 participants in this review. Summary estimates of sensitivity and specificity were 0.74 (95% CI 0.65 to 0.81) and 0.96 (95% CI 0.94 to 0.98). Pooled positive and negative likelihood ratios were estimated at 18.5 (95% CI 10.8 to 40.5) and 0.27 (95% CI 0.19 to 0.37), respectively. There was substantial heterogeneity across studies, and the reported accuracy of POCS strongly depended on the population and affected body area. In children, pooled sensitivity of POCS was 0.63 (95% CI 0.46 to 0.77), as compared to 0.78 (95% CI 0.69 to 0.84) in an adult or mixed population. Associated specificity in children was 0.91 (95% CI 0.81 to 0.96) and in an adult or mixed population 0.97 (95% CI 0.96 to 0.99). For abdominal trauma, POCS had a sensitivity of 0.68 (95% CI 0.59 to 0.75) and a specificity of 0.95 (95% CI 0.92 to 0.97). For chest injuries, sensitivity and specificity were calculated at 0.96 (95% CI 0.88 to 0.99) and 0.99 (95% CI 0.97 to 1.00). If we consider the results of all 34 included studies in a virtual population of 1000 patients, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 28%, POCS would miss 73 patients with injuries and falsely suggest the presence of injuries in another 29 patients. Furthermore, in a virtual population of 1000 children, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 31%, POCS would miss 118 children with injuries and falsely suggest the presence of injuries in another 62 children.

AUTHORS' CONCLUSIONS

In patients with suspected blunt thoracoabdominal trauma, positive POCS findings are helpful for guiding treatment decisions. However, with regard to abdominal trauma, a negative POCS exam does not rule out injuries and must be verified by a reference test such as CT. This is of particular importance in paediatric trauma, where the sensitivity of POCS is poor. Based on a small number of studies in a mixed population, POCS may have a higher sensitivity in chest injuries. This warrants larger, confirmatory trials to affirm the accuracy of POCS for diagnosing thoracic trauma.

Emergency and critical care applications for contrast-enhanced ultrasound

INTRODUCTION

Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography.

METHODS

We performed a literature search and report clinical experience to provide an introduction to CEUS and describe its current applications for point-of-care indications.

RESULTS

The uses of CEUS include several applications highly relevant for emergency medicine, such as solid-organ injuries, actively bleeding hematomas, or abdominal aortic aneurysms. Compared with CT as the preeminent advanced imaging modality in the emergency department, CEUS is low cost, radiation sparing, repeatable, and readily available. It does not require sedation, preprocedural laboratory assessment, or transportation to the radiology suite.

CONCLUSIONS

CEUS is a promising imaging technique for point-of-care applications in pediatric and adult patients and can be applied for patients with allergy to CT contrast medium or with impaired renal function. More high-quality CEUS research focusing on accuracy, patient safety, health care costs, and throughput times is needed to validate its use in emergency and critical care settings.

Contrast-enhanced ultrasound (CEUS) of the abdominal vasculature

Vascular diseases account for a significant proportion of abdominal pathology and represent a common referral source for abdominal ultrasonographic examinations. B-mode, color Doppler, and spectral Doppler analyses are well-established in the evaluation of abdominal blood vessels although they may occasionally be limited by lower sensitivity for slow flow visualization or the deeper location of abdominal vascular structures. The introduction of microbubbles as ultrasonographic contrast agents has rendered contrast-enhanced ultrasound (CEUS), a valuable complementary ultrasonographic technique, which is capable of addressing clinically significant problems and guiding patient management. The purpose of this pictorial review is to analyze the use of CEUS in the evaluation of abdominal vascular pathology and illustrate such applications by presenting representative images. Pathology discussed includes abdominal aortic aneurysm, post-endovascular treatment aorta, portal vein thrombosis, abdominal vascular trauma, and organ transplantation along with its complications.

Point-of-Care Ultrasound in Trauma

The use of point-of-care ultrasound in trauma is widespread. Focused Assessment with Sonography for Trauma examination is a prototypical bedside examination used by the treating provider to quickly determine need for intervention and appropriate patient disposition. The role of bedside ultrasound in trauma, however, has expanded beyond the Focused Assessment with Sonography for Trauma examination. Advancements in diagnostics include contrast-enhanced ultrasound, thoracic, and musculoskeletal applications. Ultrasound is also an important tool for trauma providers for procedural guidance including vascular access and regional anesthesia. Its portability, affordability, and versatility have made ultrasound an invaluable tool in trauma management in resource-limited settings. In this review, we discuss these applications and the supporting evidence for point-of-care ultrasound in trauma.

Contrast enhanced ultrasound for the evaluation of blunt pediatric abdominal trauma

INTRODUCTION

Blunt abdominal trauma is a common problem in children. Computed tomography (CT) is the gold standard for imaging in pediatric blunt abdominal trauma, however up to 50% of CTs are normal and CT carries a risk of radiation-induced cancer. Contrast enhanced ultrasound (CEUS) may allow accurate detection of abdominal organ injuries while eliminating exposure to ionizing radiation.

METHODS

Children aged 7-18years with a CT-diagnosed abdominal solid organ injury underwent grayscale/power Doppler ultrasound (conventional US) and CEUS within 48h of injury. Two blinded radiologists underwent a brief training in CEUS and then interpreted the CEUS images without patient interaction. Conventional US and CEUS images were compared to CT for the presence of injury and, if present, the injury grade. Patients were monitored for contrast-related adverse reactions.

RESULTS

Twenty one injured organs were identified by CT in eighteen children. Conventional US identified the injuries with a sensitivity of 45.2%, which increased to 85.7% using CEUS. The specificity of conventional US was 96.4% and increased to 98.6% using CEUS. The positive predictive value increased from 79.2% to 94.7% and the negative predictive value from 85.3% to 95.8%. Two patients had injuries that were missed by both radiologists on CEUS. In a 100kg, 17year old female, a grade III liver injury was not seen by either radiologist on CEUS. Her accompanying grade I kidney injury was not seen by one of the radiologist on CEUS. The second patient, a 16year old female, had a grade III splenic injury that was missed by both radiologists on CEUS. She also had an adjacent grade II kidney injury that was seen by both. Injuries, when noted, were graded within 1 grade of CT 33/35 times with CEUS. There were no adverse reactions to the contrast.

CONCLUSION

CEUS is a promising imaging modality that can detect most abdominal solid organ injuries in children while eliminating exposure to ionizing radiation. A multicenter trial is warranted before widespread use can be recommended.

LEVEL OF EVIDENCE

Level II; Diagnostic Prospective Study.

Common and uncommon features of focal splenic lesions on contrast-enhanced ultrasound: a pictorial review

The characterization of focal splenic lesions by ultrasound can be quite challenging. The recent introduction of contrast-enhanced ultrasound (CEUS) has come to play a valuable role in the field of imaging splenic pathologies, offering the possibility of an ionizing radiation-free investigation. Because CEUS has been incorporated into everyday clinical practice, malignant diseases such as focal lymphomatous infiltration, metastatic deposits, benign cysts, traumatic fractures, and hemangiomas can now be accurately depicted and characterized without the need for further imaging. More specifically, splenic traumatic fractures do not require additional imaging by computed tomography (with ionizing radiation exposure) for follow-up, because splenic fractures and their complications are safely imaged with CEUS. In the new era of CEUS, more patients benefit from radiation-free investigation of splenic pathologies with high diagnostic accuracy.

Diagnostic accuracy of contrast enhanced ultrasound in patients with blunt abdominal trauma presenting to the emergency department: a systematic review and meta-analysis

We aimed to investigate the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) in evaluating blunt abdominal trauma for patients presenting to the emergency department. Electronic search of Scopus and Pubmed was performed from inception to September 2016. Human studies investigating the diagnostic accuracy of CEUS in identifying abdominal solid organ injuries were included. Risk of bias was assessed using the QUADAS tool. A total of 10 studies were included in the study and 9 of them were included for meta-analysis. The log(DOR) values ranged from 3.80 (95% CI: 2.81-4.79) to 8.52 (95% CI: 4.58-12.47) in component studies. The combined log(DOR) was 6.56 (95% CI: 5.66-7.45). The Cochran's Q was 11.265 (p = 0.793 with 16 degrees of freedom), and the Higgins' I² was 0%. The CEUS had a sensitivity of 0.981 (95% CI: 0.868-0.950) and a false positive rate of 0.018 (95% CI: 0.010-0.032) for identifying parenchymal injuries, with an AUC of 0.984. CEUS performed at emergency department had good diagnostic accuracy in identifying abdominal solid organ injuries. CEUS can be recommended in monitoring solid organ injuries, especially for patients managed with non-operative strategy.

Clinical Applications of Contrast-Enhanced Ultrasound in the Pediatric Work-Up of Focal Liver Lesions and Blunt Abdominal Trauma: A Systematic Review

In pediatrics ultrasound has long been viewed more favorably than imaging that exposes patients to radiation and iodinated contrast or requires sedation. It is child-friendly and diagnostic capabilities have been improved with the advent of contrast-enhanced ultrasound (CEUS). The application of CEUS is indeed promising. However, no ultrasound contrast agent manufactured today is registered for pediatric use in Europe. The contrast agent SonoVue^® has recently been approved by the FDA under the name of Lumason^® to be used in hepatic investigations in adults and children. This article reviews the literature with respect to 2 specific applications of CEUS in children: 1) identification of parenchymal injuries following blunt abdominal trauma, and 2) classification of focal liver lesions. Applications were chosen through the CEUS guidelines published by the European Federation of Societies for Ultrasound in Medicine and Biology and World Federation for Ultrasound in Medicine and Biology. Literature was obtained by searching Medline and Pubmed Central (using Pubmed), Scopus database and Embase. CEUS proved to be an effective investigation in the hemodynamically stable child for identifying parenchymal injuries and for the characterization of focal liver lesions. CEUS showed comparable performance to CT and MRI with a specificity of 98% for identifying benign lesions and a negative predictive value of 100%. For the applications reviewed here, CEUS holds promising perspectives and can help reduce radiation exposure and use of iodinated contrast agents in pediatrics, thereby potentially reducing complications in routine imaging.

Effectiveness of contrast-enhanced ultrasound and serum liver enzyme measurement in detection and classification of blunt liver trauma

Objective

This study was performed to identify the correlation between contrast-enhanced ultrasound (CEUS) and contrast-enhanced multidetector computed tomography (CE-MDCT) as well as the correlation between serum liver enzyme concentrations and CE-MDCT in classification of the severity of blunt hepatic trauma using CE-MDCT as a reference standard.

Materials and methods

A blunt liver trauma model was created using 20 rabbits, and CE-MDCT, CEUS, and serum liver enzyme assays were performed. A radiologist and an ultrasound physician independently evaluated the degree of liver trauma. The diagnostic performance of CEUS and serum liver enzyme measurements was compared with that of CE-MDCT using Spearman’s correlation analysis and Pearson’s correlation analysis, respectively.

Results

Spearman’s rank correlation coefficient between the CEUS-based classification and CE-MDCT was 0.888. The aspartate aminotransferase and lactate dehydrogenase concentrations and the aspartate aminotransferase/alanine aminotransferase ratio were positively correlated with the grade of liver injury; Pearson’s correlation coefficients were 0.664, 0.704, and 0.503, respectively. The gamma-glutamyltransferase concentration had a significantly negative correlation with the grade of liver injury (r = −0.467).

Conclusions

CEUS and serum liver enzyme measurement exhibited high consistency with CE-MDCT for both detection and grading of intraparenchymal lesions in blunt liver trauma. These techniques may permit more accurate diagnosis of liver trauma.

Pediatric adrenal trauma: evaluation and follow-up with contrast-enhanced ultrasound (CEUS)

Adrenal trauma is rarely encountered in the pediatric population, often as a component of multi-organ injury and often presenting with hematoma formation. Contrast-enhanced computed tomography (CECT) is the established imaging modality both for initial evaluation and follow-up of patients with blunt abdominal trauma. In children, radiation exposure should be minimized and alternative imaging strategies are needed. Contrast-enhanced ultrasound (CEUS) has recently been successfully used for evaluation of patients with hepatic, renal and splenic injury. We present three cases of children with post-traumatic adrenal hematomas, which were initially diagnosed with CECT and subsequently followed up with CEUS, suggesting that CEUS may be considered for follow-up of adrenal injuries in children. CEUS improves the diagnostic capabilities by increasing tissue contrast and spatial resolution, readily differentiating viable from necrotic tissue in comparison to conventional ultrasound without the risk of iodine contrast agents and ionizing radiation of repeated CECT examinations.

Enhancing the role of paediatric ultrasound with microbubbles: a review of intravenous applications

Contrast-enhanced ultrasound (CEUS) represents a complementary technique to greyscale and colour Doppler ultrasonography which allows for real-time visualization and characterization of tissue perfusion. Its inherent advantages in the child makes ultrasonography an ideal imaging modality; repeatability and good tolerance along with the avoidance of CT, a source of ionizing radiation, renders ultrasonography imaging desirable. Although currently paediatric CEUS is principally used in an "off-label" manner, ultrasonography contrast agents have received regulatory approval for assessment of paediatric focal liver lesions (FLL) in the USA. The safety of ultrasound contrast-agents is well documented in adults, as safe as or even surpassing the safety profile of CT and MR contrast agents. Except for the established intracavitary use of CEUS in voiding urosonography, i.v. paediatric applications have been introduced with promising results in the abdominal trauma initial diagnosis and follow-up, characterization and differential diagnosis of FLL and characterization of lung, pleura, renal and splenic pathology. CEUS has also been used to detect complications after paediatric transplantation, evaluate inflammatory bowel disease activity and assess tumour response to antiangiogenic therapy. The purpose of this review was to present these novel i.v. paediatric applications of CEUS and discuss their value.

Ultrasound-based imaging methods of the kidney-recent developments

In recent years, several novel ultrasound (US)-based techniques have emerged for kidney diagnostic imaging, including tissue stiffness assessment with elastography, Ultrasensitive Doppler techniques, and contrast-enhanced ultrasonography to assess renal microvascularization. Renal elastography has become available with the development of noninvasive quantitative techniques, following the rapidly growing field of liver fibrosis diagnosis. With the increased incidence of chronic kidney disease, noninvasive diagnosis of renal fibrosis can be of critical value. However, it is difficult to simply extend the application of US elastography from one organ to the other due to anatomic and technical issues. Today, renal elastography appears to be a promising application that, however, still requires optimization and validation. New ultrasensitive Doppler techniques improve the detection of slow blood flow and can be used alone or after administration of US contrast agents. These microbubble-based agents are extremely well tolerated and can be administered even in cases of impaired renal function. Despite the lack of approval, they improve the characterization of atypical renal masses, complex cystic renal masses, and peripheral vascular disorders. Dynamic contrast-enhanced US is based on quantification of the signal intensity from region of interest and mathematical fits of the time-intensity curves. Perfusion-related parameters can be extracted for the monitoring of vascular changes in the renal parenchyma and in tumors in order to evaluate drug response. This estimation of renal perfusion depends on many parameters that should be kept constant for follow-up studies, and, when possible, an internal reference should be used to normalize the measurements.

Off-Label Use of Ultrasound Contrast Agents for Intravenous Applications in Children: Analysis of the Existing Literature

OBJECTIVES

The purpose of this study was to collect and analyze the published data related to intravenous (IV) use of ultrasound (US) contrast agents in children.

METHODS

We searched the literature to collect all of the published studies reporting the IV administration of a second-generation US contrast agent in children.

RESULTS

We analyzed 9 case series and 5 case reports, as well as 5 individual cases, of pediatric contrast-enhanced US use reported in a study group that also included adults. We found that 502 children underwent contrast-enhanced US examinations (mean age, 9.7 years; range, 1 day-18 years). Most patients (89%) were injected with the sulfur hexafluoride contrast agent SonoVue (Bracco SpA, Milan, Italy). The mean dose used was 1.5 mL (range, 0.1-9.6 mL). Only 10 patients (2%) had adverse reactions related to the contrast agent administration: 1 life-threatening anaphylactic shock and 9 mild transitory adverse effects. We additionally found 38 papers in which the study groups included at least 1 child; thus, we obtained a total of 540 reported cases of off-label use of IV US contrast agents in children. The most frequent target organ was the liver, and most indications were related to space-occupying lesion characterization and abdominal evaluations after blunt trauma. Some studies also evaluated the diagnostic performance of contrast-enhanced US in different clinical scenarios and found very good accuracy. Concordance between contrast-enhanced US imaging and the respective reference-standard imaging methods ranged between 83% and 100% in different studies.

CONCLUSIONS

Our results support the idea that the IV use of US contrast agents in children is safe, feasible, diagnostically robust, and effective.

Contrast-enhanced ultrasound (CEUS) in blunt abdominal trauma

Baseline ultrasound is essential in the early assessment of patients with a huge haemoperitoneum undergoing an immediate abdominal surgery; nevertheless, even with a highly experienced operator, it is not sufficient to exclude parenchymal injuries. More recently, a new ultrasound technique using second generation contrast agents, named contrast-enhanced ultrasound (CEUS) has been developed. This technique allows all the vascular phase to be performed in real time, increasing ultrasound capability to detect parenchymal injuries, enhancing some qualitative findings, such as lesion extension, margins and its relationship with capsule and vessels. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients with low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. Several studies demonstrated its ability to detect lesions occurring in the liver, spleen, pancreas and kidneys and also to recognize active bleeding as hyperechoic bands appearing as round or oval spots of variable size. Its role seems to be really relevant in paediatric patients, thus avoiding a routine exposure to ionizing radiation. Nevertheless, CEUS is strongly operator dependent, and it has some limitations, such as the cost of contrast media, lack of panoramicity, the difficulty to explore some deep regions and the poor ability to detect injuries to the urinary tract. On the other hand, it is timesaving, and it has several advantages, such as its portability, the safety of contrast agent, the lack to ionizing radiation exposure and therefore its repeatability, which allows follow-up of those traumas managed conservatively, especially in cases of fertile females and paediatric patients.

International guidelines for contrast-enhanced ultrasonography: ultrasound imaging in the new millennium

The intent of this review is to discuss and comment on common clinical scenarios in which contrast-enhanced ultrasonography (CEUS) may play a decisive role and to illustrate important points with typical cases. With the advent of CEUS, the scope of indications for ultrasonography has been dramatically extended, and now includes functional imaging and tissue characterization, which in many cases enable tumor diagnosis without a biopsy. It is virtually impossible to imagine the practice of modern medicine as we know it in high-income countries without the use of imaging, and yet, an estimated two thirds of the global population may receive no such care. Ultrasound imaging with CEUS has the potential to correct this inequity.

Role of US Contrast Agents in the Assessment of Indeterminate Solid and Cystic Lesions in Native and Transplant Kidneys

Ultrasonography (US) is often the initial imaging modality employed in the evaluation of renal diseases. Despite improvements in B-mode and Doppler imaging, US still faces limitations in the assessment of focal renal masses and complex cysts as well as the microcirculation. The applications of contrast-enhanced US (CEUS) in the kidneys have dramatically increased to overcome these shortcomings with guidelines underlining their importance. This article describes microbubble contrast agents and their role in renal imaging. Microbubble contrast agents consist of a low solubility complex gas surrounded by a phospholipid shell. Microbubbles are extremely safe and well-tolerated pure intravascular agents that can be used in renal failure and obstruction, where computed tomographic (CT) and magnetic resonance (MR) imaging contrast agents may have deleterious effects. Their intravascular distribution allows for quantitative perfusion analysis of the microcirculation, diagnosis of vascular problems, and qualitative assessment of tumor vascularity and enhancement patterns. Low acoustic power real-time prolonged imaging can be performed without exposure to ionizing radiation and at lower cost than CT or MR imaging. CEUS can accurately distinguish pseudotumors from true tumors. CEUS has been shown to be more accurate than unenhanced US and rivals contrast material-enhanced CT in the diagnosis of malignancy in complex cystic renal lesions and can upstage the Bosniak category. CEUS can demonstrate specific enhancement patterns allowing the differentiation of benign and malignant solid tumors as well as focal inflammatory lesions. In conclusion, CEUS is useful in the characterization of indeterminate renal masses and cysts.

The use of contrast-enhanced ultrasound in blunt abdominal trauma: advantages and limitations

Computed tomography (CT) is the imaging method of choice in the assessment of multiple trauma patients. However, in patients who suffered from low-energy abdominal trauma, the use of CT is controversial, since the probability of injury is low and therefore most of the studies are normal. Thus, conventional US imaging has increasingly been employed as the initial imaging modality in the work-up of minor traumatic emergency condition. More recently, the introduction of a new contrast-enhanced ultrasound (CEUS) technique, using second-generation ultrasound contrast agents, has led to a notable increase in the diagnostic accuracy of US in many organs. Therefore, in trauma patients, following assessment with conventional US imaging, a CEUS exam can be performed, to provide a more reliable assessment of solid organ injuries. CEUS has the potential to detect active bleeding from a variety of traumatic origins. Similar to CT, active extravasation is considered when there is evidence of contrast agent collection with echogenicity similar to that of an adjacent vessel. On the other hand, at least some drawbacks have to be addressed, including operator competence and reduced panoramic view. Moreover, CEUS, like conventional US imaging, cannot depict some lesions, such as diaphragmatic ruptures, bowel, and mesenteric traumatic injuries. This technique represents a non-invasive and repeatable method that can be performed at patient's bedside and is therefore extremely helpful for the follow-up of solid organs traumas managed conservatively, especially in pediatric patients and women of fertile age. Moreover, it may reduce the number of CT scans and expedite patient discharge.

The role of CEUS in the assessment of haemodynamically stable patients with blunt abdominal trauma

Computed tomography (CT) still represents the preferred imaging method in the assessment of patients presenting with multiple trauma. Nevertheless, in patients with low-energy abdominal trauma, the use of CT is debated because of the possible unnecessary radiation exposure. Accordingly, conventional ultrasound (US) imaging has been increasingly employed as the initial imaging modality in the workup of minor traumatic emergency conditions. Focused assessment with sonography for trauma is widely used to detect free intra-abdominal fluid, but its role is controversial, because the absence of free fluid does not exclude the presence of injuries to abdominal organ. Injection of an ultrasound contrast agent (UCA) may give the radiologist relevant additional information to that obtained with conventional US. Thus, in trauma patients, following early assessment with conventional US imaging, a contrast-enhanced US (CEUS) can provide a more reliable evaluation of solid organ injuries and related vascular complications, including active bleeding, pseudoaneurysms, and artero-venous fistulas. CEUS cannot replace abdominal CT, but it represents a noninvasive and repeatable imaging tool capable of providing a reliable assessment of trauma severity and expedite the patient's treatment.

Blunt abdominal trauma: role of contrast-enhanced ultrasound (CEUS) in the detection and staging of abdominal traumatic lesions compared to US and CE-MDCT

PURPOSE

This study was undertaken to evaluate the accuracy of contrast-enhanced ultrasound (CEUS) in the detection and grading of abdominal traumatic lesions in patients with low-energy isolated abdominal trauma in comparison with baseline ultrasound (US) and contrast-enhanced multidetector computed tomography (CE-MDCT), considered the gold standard.

MATERIALS AND METHODS

A total of 256 consecutive patients who arrived in our Emergency Department between January 2006 and December 2012 (159 males and 97 females aged 7-82 years; mean age 41 years), with a history of low-energy isolated abdominal trauma were retrospectively analysed. All patients underwent US, CEUS with the use of a second-generation contrast agent (Sonovue, Bracco, Milan, Italy) and MDCT. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) and overall accuracy for the detection of lesions and free peritoneal fluid on US and CEUS, and sensitivity for the grading of lesions on CEUS were calculated compared with the CT findings, in accordance with the American Association for the Surgery of Trauma criteria.

RESULTS

CE-MDCT identified 84 abdominal traumatic lesions (liver = 28, spleen = 35, kidney = 21) and 45 cases of free intraperitoneal fluid. US depicted 50/84 traumatic lesions and 41/45 cases of free peritoneal fluid; CEUS identified 81/84 traumatic lesions and 41/45 free peritoneal fluid. The sensitivity, specificity, PPV, NPV and overall accuracy for the identification of traumatic abdominal lesions were 59, 99, 98, 83 and 86 %, respectively, for US and 96, 99, 98, 98 and 98 %, respectively, for CEUS. The values for the identification of haemoperitoneum were 91, 99, 95, 98 and 97 %, respectively, for US and 95, 99, 95, 99 and 98 %, respectively, for CEUS. CEUS successfully staged 72/81 traumatic lesions with a sensitivity of 88 %.

CONCLUSIONS

In patients with low-energy isolated abdominal trauma US should be replaced by CEUS as the first-line approach, as it shows a high sensitivity both in lesion detection and grading. CE-MDCT must always be performed in CEUS-positive patients to exclude active bleeding and urinomas.

Recent advances in molecular, multimodal and theranostic ultrasound imaging

Ultrasound (US) imaging is an exquisite tool for the non-invasive and real-time diagnosis of many different diseases. In this context, US contrast agents can improve lesion delineation, characterization and therapy response evaluation. US contrast agents are usually micrometer-sized gas bubbles, stabilized with soft or hard shells. By conjugating antibodies to the microbubble (MB) surface, and by incorporating diagnostic agents, drugs or nucleic acids into or onto the MB shell, molecular, multimodal and theranostic MBs can be generated. We here summarize recent advances in molecular, multimodal and theranostic US imaging, and introduce concepts how such advanced MB can be generated, applied and imaged. Examples are given for their use to image and treat oncological, cardiovascular and neurological diseases. Furthermore, we discuss for which therapeutic entities incorporation into (or conjugation to) MB is meaningful, and how US-mediated MB destruction can increase their extravasation, penetration, internalization and efficacy.

Real-time 3-dimensional contrast-enhanced ultrasound in detecting hemorrhage of blunt renal trauma

OBJECTIVES

The objective of this study is to evaluate the diagnostic value of real-time 3-dimensional contrast-enhanced ultrasound in the hemorrhage of blunt renal trauma.

METHODS

Eighteen healthy New Zealand white rabbits were randomly divided into 3 groups. Blunt renal trauma was performed on each group by using minitype striker. Ultrasonography, color Doppler flow imaging, and contrast-enhanced 2-dimensional and real-time 3-dimensional ultrasound were applied before and after the strike. The time to shock and blood pressure were subjected to statistical analysis. Then, a comparative study of ultrasound and pathology was carried out.

RESULTS

All the struck kidneys were traumatic. In the ultrasonography, free fluid was found under the renal capsule. In the color Doppler flow imaging, active hemorrhage was not identified. In 2-dimensional contrast-enhanced ultrasound, active hemorrhage of the damaged kidney was characterized. Real-time 3-dimensional contrast-enhanced ultrasound showed a real-time and stereoscopic ongoing bleeding of the injured kidney. The wider the hemorrhage area in 4-dimensional contrast-enhanced ultrasound was, the faster the blood pressure decreased.

CONCLUSIONS

Real-time 3-dimensional contrast-enhanced ultrasound is a promising noninvasive tool for stereoscopically and vividly detecting ongoing hemorrhage of blunt renal trauma in real time.

Contrast enhanced ultrasound (CEUS) in blunt abdominal trauma

In the assessment of polytrauma patient, an accurate diagnostic study protocol with high sensitivity and specificity is necessary. Computed Tomography (CT) is the standard reference in the emergency for evaluating the patients with abdominal trauma. Ultrasonography (US) has a high sensitivity in detecting free fluid in the peritoneum, but it does not show as much sensitivity for traumatic parenchymal lesions. The use of Contrast-Enhanced Ultrasound (CEUS) improves the accuracy of the method in the diagnosis and assessment of the extent of parenchymal lesions. Although the CEUS is not feasible as a method of first level in the diagnosis and management of the polytrauma patient, it can be used in the follow-up of traumatic injuries of abdominal parenchymal organs (liver, spleen and kidneys), especially in young people or children.

Contrast-enhanced ultrasound performed under urgent conditions. Indications, review of the technique, clinical examples and limitations

Contrast-enhanced ultrasound (CEUS) is an imaging technique with various indications, most of which refer to scheduled examinations. However, CEUS can also be performed under urgent conditions for the investigation of many different clinical questions. This article reviews basic physics of ultrasound contrast agents and examines the commonest urgent clinical applications of CEUS. These include, among others, abdominal solid organ trauma and infarcts, scrotal and penile pathology and blood vessel imaging. Patients can be examined with a very short time delay at their bedside, without exposure to ionising radiation or risk of anaphylactic reaction and renal failure, while contraindications are minimal. CEUS technique is described for various urgent indications and imaging examples from our department's experience are presented. Safety matters and limitations of CEUS are also mentioned. Teaching Points • Contrast-enhanced ultrasound (CEUS) can be performed urgently for various clinical applications. • Abdominal indications include solid organ trauma and infarcts. • CEUS in abdominal organ trauma correlates well with CT and can replace it for patient follow-up. • CEUS images testicular torsion, infection and infarction, as well as testicular and penile trauma. • Blood vessels can be assessed with CEUS for obstruction, aneurysm, thrombosis and dissection.

Contrast-enhanced ultrasound in abdominal imaging

The administration of a contrast agent is considered an essential tool to evaluate abdominal diseases using Ultrasound. The most targeted organ is the liver, especially to characterize focal liver lesions and to assess the response to percutaneous treatment. However, the expanding abdominal indications of contrast-enhanced ultrasound make this technique an important tool in the assessment of organ perfusion including the evaluation of ischemic, traumatic, and inflammatory diseases.

Contrast-enhanced ultrasound in testicular trauma: role in directing exploration, debridement and organ salvage

We describe the use of contrast-enhanced ultrasound as an additional imaging technique during an ultrasound examination of a traumatised testis, allowing for confident testicular preserving surgery to be performed.

[Contrast-enhanced sonography for blunt force abdominal trauma]

With the introduction of second generation ultrasound contrast agents, contrast-enhanced ultrasound (CEUS) has become available as an adjunct to the conventional FAST (focused assessment with sonography in trauma) protocol and B-mode sonography of the abdomen after blunt force abdominal trauma. Results from several controlled studies indicate excellent diagnostic accuracy of CEUS for the exclusion of clinically relevant parenchymal injuries after blunt force abdominal trauma. Particularly in younger, hemodynamically stable patients this technique could contribute to a reliable exclusion of parenchymal injuries without the use of ionizing radiation. This report provides details on the technical performance of CEUS, shows examples of typical CEUS findings after blunt abdominal trauma and summarizes the current clinical evidence regarding the use of CEUS after blunt abdominal trauma.

Contrast-enhanced sonography in blunt scrotal trauma()

The scope of this study was to determine whether contrast-enhanced ultrasonography (CEUS), compared with basic US, can increase diagnostic confidence and provide relevant information on blunt scrotal trauma. Over a period of 75 months we examined 40 patients seen consecutively for blunt scrotal trauma using high-resolution US, color-power Doppler, low mechanical index CEUS, and power Doppler after IV administration of contrast medium (SonoVue(®)). In the 24 cases that were positive, concordance between basal US and CEUS findings was grade 0 (absent) in 4 cases, grade 1 (low) in 3, grade 2 (moderate) in 8, and grade 3 (high) in 9. The relevance of the additional information provided by CEUS was classified as follows: high in 4/40 (10%), moderate 7/40 (17,5%), low 13/40 (32,5%), none in 14/40 (35%). Our findings demonstrate that CEUS is appreciably more sensitive in detecting damage caused by blunt scrotal trauma, particularly small lesions. It is also useful for differential diagnosis and marginalization of corpuscular fluid collections, fractures, and above all ruptures, which require immediate surgery. In our series 2 out of 3 (67%) patients with testicular rupture were diagnosed only by CEUS. We feel that the use of CEUS can significantly improve diagnostic confidence in cases of closed scrotal trauma although these conclusions need to be confirmed in larger case series.

Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs

Background

In recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization.

Aim

The purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney.

Results

The management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the literature is whether a whole body MDCT survey should be implemented in the primary survey.

Characterization of nontraumatic focal splenic lesions using contrast-enhanced sonography

PURPOSE

To compare contrast-enhanced sonography (CEUS) with contrast-enhanced CT in the assessment of nontraumatic focal lesions of the spleen.

METHODS

CEUS and CT findings in 22 patients with fever of unknown origin and ultrasound-detected splenic focal lesions were analyzed retrospectively. CEUS was performed using an ultrasound unit equipped with a 3.6-MHz probe and contrast-specific software. A 4-ml bolus of second-generation contrast medium was used. The CEUS examinations included a 4-minute recording following injection of the contrast medium. MRI, splenic biopsy, or ultrasound follow-up were used if findings from CT were inconclusive.

RESULTS

The final diagnoses were as follows: seven splenic infarcts, five hemangiomas, three lacerations, two benign cysts, one lymphoma, one granuloma, one abscess, and two lesions of unknown etiology. CEUS and CT had the same specificity (77.2%). Both CEUS and CT failed to characterize nodular hypovascular lesions with a hypoenhancing pattern.

CONCLUSIONS

CEUS is as effective as CT for characterizing nontraumatic focal lesions of the spleen. If CEUS findings are consistent with a benign splenic lesion, CT seems to be of limited additional value.

The current role of contrast-enhanced ultrasound (CEUS) imaging in the evaluation of renal pathology

BACKGROUND

By using a microbubble contrast agent and contrast-specific imaging software, the contrast-enhanced ultrasound (CEUS) is able to depict the micro and macrocirculation of the target organ.

METHODS

A review of the peer reviewed literature was done regarding the current role of ultrasound CEUS imaging in the evaluation of renal pathology with reference to the diagnosis of renal ischaemia, in the characterization of complex cystic lesions and in those with equivocal enhancement at CT.

RESULTS

CEUS provides information on tissue perfusion and may play a role in kidney mass characterization similar to the role of contrast-enhanced CT and MRI. In this context, the characterization of cystic lesions is probably the most consolidated field of application of contrast agents on kidney ultrasound imaging. Finally, CEUS provides a good alternative to CT, especially in patients with contraindications to iodinated contrast agents.

CONCLUSIONS

The usefulness of CEUS in these applications is confirmed by extensive literature production and this article focuses on the potential clinical applications of recent advances in CEUS technology in urology.