Retrospective Analysis of the Safety and Cost Implications of Pediatric Contrast-Enhanced Ultrasound at a Single Center. AJR Am J Roentgenol. 2017;208:446-452. [PMID: 27959665 DOI: 10.2214/ajr.16.16700]

Pediatric gonadal torsion in radiology: A comprehensive literature and pictorial review using surgically proven cases

Pediatric gonadal torsion is a critical surgical emergency requiring immediate diagnosis and intervention to preserve reproductive capabilities. This review addresses the diagnostic challenges, imaging patterns, and management strategies for both ovarian and testicular torsion, including a brief discussion on the emerging role of Contrast-Enhanced Ultrasound (CEUS), therefore filling a significant gap in the literature. We emphasize the need for a high index of suspicion due to often nonspecific clinical presentations, particularly in ovarian torsion. An accurate and swift diagnosis allows conservative surgical intervention to be offered, which is crucial to maximize gonadal salvage and minimize recurrence. While we highlight CEUS's potential benefits in enhancing diagnostic clarity without ionizing radiation, ultrasound and other modalities such as MRI and CT, have a paramount role in this setting. Future research comparing CEUS with MRI is essential to validate its diagnostic accuracy and effectiveness, potentially revolutionizing acute care diagnostics. Incorporating CEUS into diagnostic workflows, along with a deep understanding of the condition's epidemiology, pathophysiology, and clinical presentation, may probably significantly improve patient outcomes. We detail the characteristic imaging features, diagnostic pitfalls, and differential diagnoses essential for radiologists, with particular relevance for residents and those with limited pediatric radiology exposure. This review aims to bridge existing knowledge gaps and serve as a robust educational tool, facilitating better clinical decision-making and outcomes in pediatric gonadal torsion cases.

Annual Renal Surveillance With Ultrasound in All Anorectal Malformations May Not Be Necessary

BACKGROUND

Children with anorectal malformations (ARMs) are at risk of renal anomalies. Therefore, we obtain annual renal ultrasounds (RUS) regardless of symptoms or complexity. The utility of aggressive screening in all ARM is unknown. Thus, we aimed to determine outcomes in children with all ARM managed on this protocol.

METHODS

We performed a single-institution review of children managed at a large pediatric colorectal center from 2014 to 2023 with less severe ARM (rectoperineal fistula, rectovaginal fistula, rectovestibular fistula, rectal/anal stenosis, and rectal atresia) with RUS obtained within 2 years of primary repair. We evaluated all RUS before and after repair. Demographics and clinical variables were collected, and descriptive statistics were computed.

RESULTS

There were 333 children meeting inclusion criteria; 197 had a postoperative RUS within two years of repair. Most (70.1 %) had a normal first postoperative RUS, and only four (2.0 %) progressed to become abnormal on subsequent studies. Only one of these patients (0.5 %) was asymptomatic at the time of RUS and had a finding necessitating further intervention. Children with an initially normal RUS underwent a median of 3 further RUS [IQR: 2-4], with 33 children (24.6 %) undergoing five or more normal RUS. Overall, 197 children with a normal postoperative RUS needed to be screened yearly to find one asymptomatic renal anomaly.

CONCLUSION

In a large cohort of children with mild ARM, only one child (0.5 %) benefited from screening RUS with an asymptomatic renal anomaly requiring intervention, suggesting that if RUS after primary repair of a mild ARM is normal, additional screening of the asymptomatic patient is not necessary.

LEVEL OF EVIDENCE

III = Retrospective Comparative Study.

How I Do It: Contrast-enhanced US Applications in Children

Contrast-enhanced US (CEUS) allows a detailed assessment of the tissue microvasculature after intravenous injection of contrast material. The use of CEUS also allows opacification of nonvascular hollow organs and fluid compartments after intracavitary instillation of dilute contrast material. This capability is far beyond that of grayscale and Doppler US techniques. The advantages of CEUS include its ease of use, high safety profile, and absence of ionizing radiation, making it an ideal tool for pediatric imaging. In 2016, the U.S. Food and Drug Administration approved CEUS for use in children for characterization of focal liver lesions and diagnosis of vesicoureteral reflux. Because the US contrast agent is distributed throughout the vascular pool, additional off-label imaging studies have focused on a variety of anatomic structures. This review of pediatric CEUS discusses the safety and technical aspects of CEUS, provides practical information on how to perform intravascular and intracavitary examinations, addresses the most common clinical applications of this method, and offers advice regarding the integration of CEUS into pediatric daily clinical practice.

Contrast-enhanced ultrasonography (CEUS) in the management of pediatric renal injuries: where are we now?

PURPOSE

Experience with CEUS in management of kidney post-traumatic injuries is limited, especially in pediatric age. This paper aimed to identify: clinical settings in which CEUS could be used as first diagnostic tool, skipping CT; CEUS ability to detect complications during non-operative management (NOM); and CEUS role in patients with collecting system injuries.

METHODS

Patients with renal trauma admitted between 2003 and 2023 were enrolled in a retrospective study. At T0, CT was performed in case of high-energy trauma, CT or CEUS in case of low-energy or/and localized trauma. CEUS was used during follow up (FU) in case of suspected complications and to follow healing of the lesions and urinomas.

RESULTS

Among 22 patients included, at T0 20/22 performed CT, 1/22 CEUS and 1/22 baseline US. During NOM CEUS was necessary: in early FU to rule out complications in 3/22 (1 anemization and 2 hematuria); in middle FU in 14/22 to authorize mobilization/discharge and monitor urinomas; in outpatient setting in 2/22, to authorize return to sport activities. Overall, a collecting system injury was detected in 6 patients by CT and in 1 by CEUS. In 3/7 a perirenal urinoma developed. All were monitored with CEUS or baseline US.

CONCLUSIONS

CEUS is useful as first imaging study in low-energy and localized trauma, but confidence with CEUS is still to be improved and spread, to replace CT in selected cases. CEUS is valuable for detecting complications, avoiding repeat CT in most of cases. In expert hands CEUS can identify and monitor leakage indirectly.

Polyneuropathy in Cerebrotendinous Xanthomatosis: Diagnostic Challenges and Potential for Therapeutic Intervention

Cerebrotendinous xanthomatosis (CTX) is a rare metabolic disorder caused by mutations in the CYP27A1 gene, leading to cholestanol accumulation in various tissues, including peripheral nerves. Polyneuropathy is an underrecognized feature with considerable variability in clinical presentation and neurophysiological findings in CTX. This review assesses the prevalence, clinical manifestations, and diagnostic methodologies of polyneuropathy in CTX, exploring its underlying mechanisms and potential treatment outcomes. A literature review was conducted using PubMed, Embase, and the Virtual Health Library databases with search terms related to CTX and polyneuropathy. A total of 892 articles were initially identified, with 59 selected for in-depth analysis. The review focused on studies examining peripheral nerve involvement in CTX, including nerve conduction studies, electromyography, and nerve ultrasound. Polyneuropathy in CTX was observed in 50% to 77.7% of patients across multiple case series. Neurophysiological findings varied, with reports of axonal, demyelinating, and mixed polyneuropathies. Clinical presentation included lower limb atrophy, pes cavus, and distal weakness, with sensory symptoms less frequently reported. Treatment with chenodeoxycholic acid (CDCA) showed potential in improving nerve conduction parameters, although the response was variable and dependent on the timing of intervention. Polyneuropathy in CTX presents significant diagnostic challenges due to its heterogeneous presentation and varying neurophysiological findings. Early recognition and intervention are crucial for improving patient outcomes. Peripheral nerve ultrasound is a promising diagnostic tool, complementing traditional neurophysiological assessments. Further research is needed to standardize protocols and explore the full therapeutic potential of CDCA in managing CTX-related polyneuropathy.

Is Contrast-Enhanced Ultrasonography a New, Reliable Tool for Early-Graft-versus-Host Disease Diagnosis?

Acute gastrointestinal graft-versus-host disease (GI aGVHD) is a significant and life-threatening complication in patients undergoing allogeneic stem cell transplantation (allo-SCT). Early diagnosis of GI aGVHD is crucial for improving patient outcomes, but it remains a challenge due to the condition's nonspecific symptoms and the reliance on invasive diagnostic methods, such as biopsies and endoscopic procedures. In recent years, interest in non-invasive diagnostic techniques for graft-versus-host disease has increased, with contrast-enhanced ultrasound (CEUS) being one of them. For this reason, we aimed to examine the potential of ultrasound as a non-invasive, safe, and cost-effective alternative for the early detection and monitoring of GI aGVHD in this review. Our narrative review aims to describe the use of multimodal US that includes conventional US (B-mode and Doppler US) and advanced ultrasound techniques such as CEUS and CRTE for the non-invasive diagnosis of GI GVHD. We browsed several databases, including PubMed, Scopus, Web of Science, and Google Scholar. The search spanned 2000 to the present, focusing on articles written in English that reviewed the use of these imaging techniques in the context of GI GVHD. Following our research, we noticed that CEUS offers several advantages, including the real-time visualization of the gastrointestinal wall, assessment of blood flow, and detailed microvascular analysis-all achieved without the use of ionizing radiation. This feature makes CEUS an appealing option for repeated assessments, which are often necessary in monitoring the progression of GI aGVHD. When used in conjunction with conventional gastrointestinal ultrasound (GIUS), CEUS provides a more comprehensive view of the structural and functional changes occurring in the GI tract, potentially enhancing diagnostic accuracy and allowing for earlier intervention. In comparison to traditional diagnostic methods like tissue biopsy or CT scans, CEUS is less invasive, quicker to perform, and better tolerated by patients, especially those in fragile health following allo-SCT. Its non-invasive nature and ability to provide immediate imaging results make it a valuable tool for clinicians, particularly in settings where minimizing patient discomfort and risk is paramount. However, despite these advantages, there are still gaps in the literature regarding CEUS's full diagnostic accuracy for GI aGVHD. Further research, including larger clinical trials and comparative studies, is needed to validate CEUS's role in routine clinical practice and to establish standardized protocols for its use. Nonetheless, CEUS shows considerable potential to transform the diagnostic approach to GI aGVHD by improving early detection, reducing the need for invasive procedures, and ultimately enhancing treatment outcomes for affected patients.

Effectiveness of contrast-enhanced duplex ultrasound for detecting renal artery stenosis: A systematic review

PURPOSE

Contrast-enhanced duplex ultrasound (CEUS) might be a useful tool to diagnosing renal artery stenosis (RAS). We amalgamated and reviewed the evidence assessing the diagnostic accuracy of CEUS on detecting RAS compared to angiography.

METHODS

This preregistered systematic review included studies that compared the presence of RAS via CEUS with angiography. Sources were searched in November 2022 and included Scopus, EMBASE, MEDLINE, CINAHL, and Academic Search Premier (n = 1717). The Quality Assessment of Diagnostic Studies 2 tool assessed study quality. Results are presented narratively.

RESULTS

The studies included (n = 11) had a total of 447 unique participants (193 females) and average age of 56 ± 9 years. Five of eleven studies investigated CEUS using SonoVue contrast agent and reported an average accuracy (91% ± 2%), sensitivity (91% ± 3%), specificity (90% ± 5%), negative predictive value (86% ± 6%), and positive predictive value (94% ± 1%) with all values >80%. The accuracy of CEUS using other types of contrast agent (n = 6), including Levovsit (n = 3/6), Definity (n = 1/6), perfienapent emulsion (n = 1/6), and perfluorocarbon-exposed sonicated dextrose albumin (n = 1/6) was mixed. These studies detected an average accuracy of 91 ± 11% (n = 2/3% > 80%), sensitivity of 98% ± 4%, (n = 3/3% > 80%), and specificity of 86% ± 10% (n = 2/3% > 80%). Included studies had generally low risk of bias and applicability concerns except for unclear flow and timing (n = 7/11) and applicability of patient selection (n = 4/11).

CONCLUSION

Despite being limited by the heterogeneity of included studies, our review indicates a high overall diagnostic accuracy for CEUS to detect RAS compared to angiography, with the largest evidence-base for SonoVue contrast. Radiologists and hospital decision makers should consider CEUS as an acceptable alternative to angiography.

Intracavitary Applications for CEUS in PTCD

Intracavitary contrast-enhanced ultrasound is widely accepted as a highly informative, safe, and easily reproducible technique for the diagnosis, treatment, and follow-up of different pathologies of the biliary tree. This review article describes the diverse applications for CEUS in intracavitary biliary scenarios, supported by a literature review of the utilization of the method in indications like biliary obstruction by various etiologies, including postoperative strictures, evaluation of the biliary tree of liver donors, and evaluation of the localization of a drainage catheter. We also provide pictorial examples of the authors' personal experience with the use of intracavitary CEUS in cases of PTCD as a palliative intervention. Intracavitary CEUS brings all the positive features of US together with the virtues of contrast-enhanced imaging, providing comparable accuracy to the standard techniques for diagnosing biliary tree diseases.

Use of CEUS for Imaging Evaluation of Pediatric Peritonsillar Abscess

PURPOSE

Peritonsillar abscess can be diagnosed by B-mode ultrasound and cross-sectional imaging. The latter (with MRI being the modality of first choice in children) is associated with higher effort and risk for pediatric patients due to the administration of X-rays and/or the need of sedation. The purpose of this study is to evaluate whether the introduction of CEUS into the diagnostic algorithm for suspected pediatric peritonsillar abscess is suitable and advantageous.

MATERIALS AND METHODS

Single-institution retrospective review of data of pediatric patients who were presented to the department of pediatric radiology for sonographic evaluation under the suspicion of peritonsillar abscess. Diagnostic performance of CEUS was evaluated by using surgical exploration or clinical follow-up as the reference standard.

RESULTS

284 children included in the study underwent B-mode ultrasound. Mean age of all patients was 6,23 years. Peritonsillar abscess was the diagnosis in 42 patients. Diagnosis of peritonsillar abscess was made by B-mode ultrasound alone in 13 of 42 patients (31 %). In 17 of 42 patients (40 %), diagnosis was made by a combination of B-mode ultrasound and CEUS. Sensitivity rose from 37 % to 86 % in cases where B-mode ultrasound remained unclear and CEUS was used.

CONCLUSION

Contrast-enhanced ultrasound (CEUS) is suitable and efficient for the diagnosis of peritonsillar abscess in pediatric patients. It increases the sensitivity for the diagnosis of peritonsillar abscess and thereby reduces the need of additional cross-sectional imaging for the pediatric patients.

Utility of contrast enhanced ultrasound (CEUS) in penile trauma

Penile traumatic injuries are rare with potentially severe consequences, with clinical assessment challenging due to pain and swelling. Ultrasound is the primary imaging modality for assessing the penis. It has a high spatial resolution and rapid availability and is portable. Contrast enhanced ultrasound is an advanced ultrasound technique that adds real-time dynamic vascular imaging safely, increasing diagnostic precision and confidence, allowing for better therapeutic management of traumatic penile injuries. Contrast enhanced ultrasound helps to delineate the extent of a haematoma, distinguishing this from the herniated corpus cavernosum, detecting the point of rupture of the tunica albuginea, showing vascular abnormalities, localising a dislocated penis and determining penile viability. The integrity of the urethra may be assessed with intracavitary contrast enhanced ultrasound. Additionally, contrast enhanced ultrasound allows monitoring of the response to endovascular and surgical treatment. This review aims to detail the anatomy and pathogenesis of penile trauma, to give guidance on optimising the contrast enhanced ultrasound technique and to obtain diagnostic examinations. Illustration of the spectrum of aspects of penile trauma will be complemented with a literature review.Critical relevance statement Contrast enhanced ultrasound is a safe and efficient imaging modality that allows for highly accurate diagnoses, helping achieve more successful and conservative treatments of penile trauma complications.Key points• Ultrasound is an accurate and safe imaging test for penile trauma.• CEUS adds dynamic vascular imaging in real-time increasing diagnostic confidence.• CEUS can delineate penile haematomas, locate fractures and demonstrate vessel integrity.• CEUS potentially allows for more conservative treatment of penile trauma complications.

Contrast-enhanced subharmonic aided pressure estimation for assessment of intracranial pressure in vivo

BACKGROUND

Intracranial pressure (ICP) monitoring in children currently requires invasive techniques. Subharmonic aided pressure estimation (SHAPE) uses contrast-enhanced ultrasound (CEUS) to measure intravascular and interstitial pressure, but utility in ICP measurements has yet to be explored.

OBJECTIVE

The objective of this study was to investigate SHAPE as a novel tool for noninvasive ICP measurements in fetal lambs.

MATERIALS AND METHODS

Eighteen fetal lambs at 107-139 days gestational age (term = 145 days) underwent subdural ICP catheter placement. The brain was imaged in the coronal plane in CEUS mode optimized for SHAPE, while infusing an US contrast agent into the fetal circulation. After SHAPE calibration, saline was infused via the subdural catheter to increase ICP. Five-second SHAPE cine clips were obtained at various ICPs. Subharmonic intensity values of the whole brain and thalami were correlated with ICP values using mixed effects linear regression analyses and the strength of the relationship was evaluated by Spearman's rank-order correlation.

RESULTS

Forty-nine experiments produced 723 datapoints, including SHAPE intensity values and mean ICP measurements. There was a statistically significant inverse relationship between SHAPE intensity values and ICP measurements in the whole brain and thalami (median rho value - 0.58 and - 0.56, respectively).

CONCLUSION

SHAPE intensity values of the brain demonstrate an inverse and statistically significant correlation with in vivo ICP measurements in an animal model.

Role and added value of contrast enhanced ultrasound of the painful scrotum in the emergency setting

Emergency imaging of the scrotum is part of routine medical practice. Indications include epididymitis/epididymo-orchitis, testicular torsion, trauma, tumors and infarction. Prompt diagnosis and management are needed to ensure optimal patient outcome. Ultrasound (US) is the initial, and often the only, imaging modality for testicular pathologies. Usually, B-mode and color Doppler US are adequate. In challenging cases, contrast-enhanced US (CEUS) facilitates final diagnosis or increases the examiner's confidence by confirming findings on non-enhanced US. This paper elaborates on the examination technique of CEUS for testicular pathologies, thereby showing its added value over baseline US techniques in the emergency setting.

Incidental Findings in Pediatric Patients: How to Manage Liver Incidentaloma in Pediatric Patients

The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled "Incidental imaging findings-the role of ultrasound". IFs in the liver of newborns and children are rare and much less commonly encountered than in adults; as a result, they are relatively much more frequently malignant and life-threatening, even when they are of benign histology. Conventional B-mode ultrasound is the well-established first line imaging modality for the assessment of liver pathology in pediatric patients. US technological advances, resulting in image quality improvement, contrast-enhanced ultrasound (CEUS), liver elastography and quantification tools for steatosis have expanded the use of ultrasound technology in daily practice. The following overview is intended to illustrate incidentally detected liver pathology covering all pediatric ages. It aims to aid the examiner in establishing the final diagnosis. Management of incidentally detected focal liver lesions (FLL) needs to take into account the diagnostic accuracy of each imaging modality, the patient's safety issues (including ionizing radiation and nephrotoxic contrast agents), the delay in diagnosis, the psychological burden on the patient and the cost for the healthcare system. Moreover, this paper should help the pediatric clinician and ultrasound practitioner to decide which pathologies need no further investigation, which ones require interval imaging and which cases require further and immediate diagnostic procedures.

Transtemporal brain contrast-enhanced ultrasound in children: preliminary experience in patients without neurological disorders

AIM

To evaluate the use of transtemporal brain contrast-enhanced ultrasound (CEUS) to assess cerebral blood perfusion in a cohort of children without neurological disorders.

METHODS

We included pediatric patients who were undergoing a clinically-indicated CEUS study. Brain scans were performed with a Siemens Sequoia scanner and a 4V1 transducer, that was placed on the left transtemporal bone. Brain scans were performed simultaneously with the images of the clinically-indicated organ of interest. Qualitative and quantitative analysis was performed to evaluate the hemispherical blood flow at the level of the midbrain during the wash-in and wash-out phases of the time-intensity curve. Clinical charts were reviewed to evaluate post-CEUS adverse events.

RESULTS

Five patients were evaluated (mean age 5.8 ± 5.1 years). Qualitatively, more avid enhancement in the midbrain than the cortex was observed. Structures depicted ranged between the centrum semiovale at the level of the lateral ventricles and the midbrain. A quantitative analysis conducted on four patients demonstrated less avid perfusion on the contralateral (i.e. right) side, with a mean left/right ratio ranging between 1.51 and 4.07. In general, there was a steep positive wash-in slope starting at approximately 10 s after contrast injection, reaching a peak intensity around 15-26 s on the left side, and 17-29 s on the right side. No adverse events were reported.

CONCLUSION

Transtemporal brain CEUS is feasible and safe in the pediatric population and allows qualitative and quantitative assessment of cerebral perfusion.

Novel Utilization of Ultrasound Enhancing Agents in Complex Congenital Heart Disease Following Superior Cavopulmonary Connection

BACKGROUND

Children with single-ventricle congenital heart disease typically undergo a superior cavopulmonary connection (SCPC) as the second stage in their surgical palliation. Postoperatively, stenoses of the SCPC and branch pulmonary arteries can occur. If there are clinical concerns and echocardiography is insufficient for diagnosis, patients undergo invasive evaluation with exposure to radiation and anesthesia. The use of ultrasound enhancing agents (UEAs) to improve echocardiographic diagnostic capabilities has not previously been described in this population.

METHODS

A single-center, retrospective case review was conducted of children who underwent echocardiography with UEA, following SCPC, from March 1, 2020, to April 15, 2022, at the Children's Hospital of Philadelphia. Twenty-two patients with hypoxemia or concern for obstruction following SCPC underwent UEA echocardiography. Extracted clinical data included patient demographics, echocardiographic images, angiography, surgical and transcatheter interventions, as well as available follow-up data.

RESULTS

Six of the 22 UEA echocardiograms demonstrated stenosis or occlusion of either the SCPC or a pulmonary artery. All six patients underwent cardiac catheterization and five required intervention. Angioplasty was performed in each case with one requiring subsequent surgical revision. Sixteen of 22 UEA echocardiograms demonstrated no evidence of stenosis. Ten of these 16 patients improved, while six experienced persistent hypoxemia prompting referral for cardiac catheterization. Angiography confirmed the UEA echocardiographic findings (absence of stenosis) in four of these six patients. There were no adverse reactions related to UEA administration.

CONCLUSIONS

Echocardiography with UEAs is a valuable and safe adjunctive imaging modality following SCPC, particularly when two-dimensional and color imaging is limited. This novel application of UEAs in complex patients with congenital heart disease provides an "angiogram-like" image, better delineating vessel walls and improving assessment of postoperative obstruction. As experience with UEAs increases in the congenital heart disease population, there may be opportunities to decrease invasive and costly procedures, while expediting the care of patients in need of intervention.

Ultrasound Contrast Stability for Urinary Bladder Pressure Measurement

The goal of this study was to evaluate ultrasound contrast microbubbles (MB) stability during a typical cystometrogram (CMG) for bladder pressure measurement application using the subharmonic-aided pressure estimation technique. A detailed study of MB stability was required given two unique characteristics of this application: first, bulk infusion of MBs into the bladder through the CMG infusion system, and second, duration of a typical CMG which may last up to 30 min. To do so, a series of size measurement and contrast-enhanced ultrasound imaging studies under different conditions were performed and the effects of variables that we hypothesized have an effect on MB stability, namely, i) IV bag air headspace, ii) MB dilution factor, and iii) CMG infusion system were investigated. The results verified that air volume in intravenous (IV) bag headspace was not enough to have a significant effect on MB stability during a CMG. We also showed that higher MB dosage results in a more stable condition. Finally, the results indicated that the CMG infusion system adversely affects MB stability. In summary, to ensure MB stability during the entire duration of a CMG, lower filling rates (limited by estimated bladder capacity in clinical applications) and/or higher MB dosage (limited by FDA regulations and shadowing artifact) and/or the consideration of alternative catheter design may be needed.

Contrast-enhanced ultrasound in detection and follow-up of focal renal infections in children

Objective:

Focal renal infections in children have to be diagnosed early in order to enable an appropriate antibiotic treatment. The purpose of this paper was to investigate the efficacy and clinical utility of intravenous renal contrast-enhanced ultrasound (CEUS) as an alternative imaging method for the diagnosis and follow-up of focal renal infections in children.

Methods:

Fourteen children aged from 6 months to 17 years (mean 6.5 years) in whom focal renal infection was suspected were included in this retrospective study. All data were obtained from medical and imaging records of the patients.

Results:

CEUS was performed for the diagnosis in all 14 children and then also for follow-up in seven children with renal abscess. In three children enhancement pattern was concordant with focal nephritis and in four children CEUS excluded focal renal infection and the diagnosis of pseudolesion was confirmed.

Conclusion:

Renal CEUS was proven to be an efficient and self-sufficient imaging in diagnosis and further follow-up of focal renal infections in children. CEUS patterns of focal renal infections are described as well as relevant CEUS enhancement patterns important for differential diagnosis. Renal abscess follow-up algorithm with CEUS is suggested.

Advances in knowledge:

All clinically relevant imaging data was obtained by CEUS and no other imaging was necessary for the diagnosis and follow-up.

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.

Microbubbles in the belly: optimizing the protocol for contrast-enhanced ultrasound of the pediatric abdomen

Intravenous contrast-enhanced ultrasound (CEUS) can serve as a diagnostic or problem-solving tool in pediatric imaging. CEUS of abdominal solid organs has been reported for a number of indications. The approach to the examination broadly falls into two categories: evaluation of a focal lesion or surveillance of an organ or organs for lesions or perfusion abnormalities. A consistent, technical imaging protocol for both of these clinical scenarios facilitates integration of routine use of CEUS in an imaging department. Here we review the CEUS imaging protocols for abdominal organs in children, including technical and solid-organ-specific considerations.

Comparison of Contrast-Enhanced Ultrasonography to Color Doppler Ultrasound in Evaluation of Carotid Body Tumors

Objective

The objectives of this study were to prospectively 1) explore the characteristics and enhanced patterns of carotid body tumors (CBTs) at color Doppler ultrasound (CDU) and contrast-enhanced ultrasonography (CEUS) qualitatively and quantitatively and 2) compare CDU and CEUS for their morphology and vascularity signature.

Methods

CDU and CEUS with Sonovue^® were used to evaluate 25 CBT lesions. The comparison between these ultrasonic modalities included the size, Shamblin type, vascularity, and feeding vessels of the lesion areas. The time–intensity curve (TIC) analysis was used to obtain the dynamics of the contrast-enhancement features of CBTs.

Results

The TIC analysis presented a fast wash-in [wash-in time: 3.00 ± 1.10 s, mean ± SD] and slow wash-out [wash-out time: 58.79 ± 24.21 s, mean ± SD] pattern in the CBT lesions, with a high area under the curve (AUC) of 669.68 ± 143.46 mm² (mean ± SD). In comparison with CDU, CEUS was superior in identifying Shamblin type I or III CBT lesions (χ² = 17.389, p=0.002). It detected a significant difference in the AUC between moderate and marked vascularity groups (563.33 ± 102.63 vs. 707.22 ± 138.81, t=-2.311, p=0.031.), while CDU observed no significant difference between these two groups. Although CDU was more sensitive than CEUS in detecting feeding vessels (100% vs. 88%), CEUS better visualized the origins of feeding vessels (χ² = 9.162, p=0.010).

Conclusion

CEUS can better investigate the Shamblin type and vascularity of CBT lesions than CDU. CBTs displayed a fast wash-in, slow wash-out pattern with high AUC in the TIC analysis in the CEUS mode. CDU is more sensitive in detecting feeding vessels than CEUS, while CEUS can better visualize the origins of feeding vessels.

Contrast-enhanced ultrasound of the neonatal brain

Cranial US is an integral component of evaluating the neonatal brain, especially in the setting of critically ill infants and in the emergency setting, because cranial US can be performed portably at the bedside, is safe, and can be repeated whenever needed. Contrast-enhanced ultrasound (CEUS) involves intravenously injecting microbubbles to allow for improved visibility of large and small vessels to assess vascularity and is becoming a widespread technique to improve diagnostic performance of US across a broad spectrum of applications. CEUS has the potential to add value to routine brain US and become a useful adjunct to MRI in infants in need of bedside imaging. In this review we describe the basics of US contrast agents and CEUS technique, including safety considerations, and detail the potential clinical uses of brain CEUS.

Diagnostic criteria of perfluorobutane-enhanced ultrasonography for diagnosing hepatocellular carcinoma in high-risk individuals: how is late washout determined?

PURPOSE

The aim of this study was to investigate the optimal washout criteria of perfluorobutane-enhanced ultrasonography (PFB-US) for the diagnosis of hepatocellular carcinoma (HCC) in high-risk individuals.

METHODS

Participants at risk of HCC with treatment-naïve solid hepatic observations (≥1 cm) who underwent PFB-US from March 2019 to September 2020 were prospectively recruited. Arterial phase hyperenhancement (APHE), washout time, and washout degree were evaluated. The diagnosis of HCC was made by non-rim APHE with late and mild washout. The per-lesion diagnostic performance for diagnosing HCC using different cutoffs for late washout (50, 55, 60, 65, and 70 seconds postcontrast) and the different time windows for determining washout (until 2, 3, 4, 5, 6, 7, 8, 9, and 10 minutes postcontrast) were compared using the McNemar test.

RESULTS

In total, 101 participants with 113 observations (mean size, 33.5±2.8 mm; HCCs [n=82], non-HCC malignancies [n=16], benign [n=15]) were evaluated. Non-rim APHE was observed in 86.6% (71/82) of HCCs. As the cutoff time for late washout increased, the specificity increased to 100% (95% confidence interval [CI], 88.8% to 100%) at the 60-second cutoff with 62.2% sensitivity (95% CI, 50.8% to 72.7%). When the time window for determining washout became wider, the sensitivity and accuracy increased until 6 minutes, with 100% specificity at all times.

CONCLUSION

Determining washout within 6 minutes after contrast injection with a 60-second cutoff for late washout showed the highest sensitivity without losing specificity for diagnosing HCC using PFB-US in individuals at high risk.

Contrast-enhanced ultrasound is useful for the evaluation of focal liver lesions in children

Introduction

Contrast‐enhanced ultrasound (CEUS) is a widely used diagnostic method. In adults, it has been proven to be a useful alternative to CT and MRI for the characterisation of focal liver lesions (FLLs). However, since there is no official paediatric licensing for any ultrasound contrast agents in Europe, its use has been restricted.

Purpose

To retrospectively outline our experience with CEUS as a tool for the characterisation of FLLs in paediatric patients.

Methods

An eleven‐year retrospective single‐centre study. During this period, we identified 287 CEUS examinations performed on children, of these 36 were relevant first‐time examinations with the aim of characterising a focal liver lesion. Clinical and radiological data were collected from the hospital chart.

Results

The overall agreement between the CEUS diagnosis and the reference diagnosis for benign versus malignant differentiation was 75%. When analysing conclusive CEUS examinations only, the overall agreement was 96%. The specificity for correctly characterising a lesion as benign was 96%, and the negative predictive value was 100%. No side effects from CEUS were detected.

Conclusions

Our study reinforces that CEUS can be useful in the medical workup for the identification and classification of focal liver lesions in children.

Emerging contrast-enhanced ultrasound applications in children

Ultrasound contrast agent (UCA) use in radiology is expanding beyond traditional applications such as evaluation of liver lesions, vesicoureteral reflux and echocardiography. Among emerging techniques, 3-D and 4-D contrast-enhanced ultrasound (CEUS) imaging have demonstrated potential in enhancing the accuracy of voiding urosonography and are ready for wider clinical adoption. US contrast-based lymphatic imaging has been implemented for guiding needle placement in MR lymphangiography in children. In adults, intraoperative CEUS imaging has improved diagnosis and assisted surgical management in tumor resection, and its translation to pediatric brain tumor surgery is imminent. Because of growing interest in precision medicine, targeted US molecular imaging is a topic of active preclinical research and early stage clinical translation. Finally, an exciting new development in the application of UCA is in the field of localized drug delivery and release, with a particular emphasis on treating aggressive brain tumors. Under the appropriate acoustic settings, UCA can reversibly open the blood-brain barrier, allowing drug delivery into the brain. The aim of this article is to review the emerging CEUS applications and provide evidence regarding the feasibility of these applications for clinical implementation.

Contrast-enhanced ultrasound of the kidneys and adrenals in children

Pediatric applications of contrast-enhanced ultrasound (CEUS) are growing. Evaluation of the kidneys and adrenal glands in children using intravenous administration of US contrast agents, however, is still an off-label indication. Pediatric CEUS applications for kidneys are similar to those in adults, including ischemic disorders, pseudo- versus real tumors, indeterminate lesions, complex cystic lesions, complicated pyelonephritis, and abscesses. CEUS applications for evaluation of adrenal glands in children are limited, mainly focusing on the assessment and follow-up of adrenal trauma and the differentiation between an adrenal hemorrhage and a mass. This review addresses the current experience in pediatric CEUS of the kidneys and adrenal glands. By extrapolating the established knowledge for US contrast evaluations in the adult kidney to the pediatric context we can note opportunities for CEUS clinical use in children.

Contrast-enhanced ultrasound in pediatric interventional radiology

There is growing interest in the use of contrast-enhanced ultrasound (CEUS) in diagnostic and interventional radiology. CEUS applications in interventional radiology are performed with intravascular or intracavitary administration of microbubble-based US contrast agents to allow for real-time evaluation of their distribution within the vascular bed or in body cavities, respectively, providing additional information beyond gray-scale US alone. The most common interventional-radiology-related CEUS applications in children have been extrapolated from those in adults, and they include the use of CEUS to guide lesion biopsy and to confirm drain placement in pleural effusions and intra-abdominal fluid collections. Other applications are emerging in interventional radiology for use in adults and children, including CEUS to optimize sclerotherapy of vascular malformations, to guide arthrography, and for lymphatic interventions. In this review article we present a wide range of interventional-radiology-related CEUS applications, emphasizing the current and potential uses in children. We highlight the technical parameters of the CEUS examination and discuss the main imaging findings.

Contrast-enhanced ultrasound: a comprehensive review of safety in children

Contrast-enhanced ultrasound (CEUS) has been increasingly used in pediatric radiology practice worldwide. For nearly two decades, CEUS applications have been performed with the off-label use of gas-containing second-generation ultrasound contrast agents (UCAs). Since 2016, the United States Food and Drug Administration (FDA) has approved the UCA Lumason for three pediatric indications: the evaluation of focal liver lesions and echocardiography via intravenous administration and the assessment of vesicoureteral reflux via intravesical application (contrast-enhanced voiding urosonography, ceVUS). Prior to the FDA approval of Lumason, numerous studies with the use of second-generation UCAs had been conducted in adults and children. Comprehensive protocols for clinical safety evaluations have demonstrated the highly favorable safety profile of UCA for intravenous, intravesical and other intracavitary uses. The safety data on CEUS continue to accumulate as this imaging modality is increasingly utilized in clinical settings worldwide. As of August 2021, 57 pediatric-only original research studies encompassing a total of 4,518 children with 4,906 intravenous CEUS examinations had been published. As in adults, there were a few adverse events; the majority of these were non-serious, although very rarely serious anaphylactic reactions were reported. In the published pediatric-only intravenous CEUS studies included in our analysis, the overall incidence rate of serious adverse events was 0.22% (10/4,518) of children and 0.20% (10/4,906) of all CEUS examinations. Non-serious adverse events from the intravenous CEUS were observed in 1.20% (54/4,518) of children and 1.10% (54/4,906) of CEUS examinations. During the same time period, 31 studies with the intravesical use of UCA were conducted in 12,362 children. A few non-serious adverse events were encountered (0.31%; 38/12,362), but these were most likely attributable to the bladder catheterization rather than the UCA. Other developing clinical applications of UCA in children, including intracavitary and intralymphatic, are ongoing. To date, no serious adverse events have been reported with these applications. This article reviews the existing pediatric CEUS literature and provides an overview of safety-related information reported from UCA uses in children.

Starting a pediatric contrast ultrasound service: made simple!

The addition of contrast US to an existing pediatric US service requires several preparatory steps. This overview provides a guide to simplify the process. Initially, it is important to communicate to all stakeholders the justifications for pediatric contrast US, including (1) its comparable or better diagnostic results relative to other modalities; (2) its reduction in procedural sedation or anesthesia by avoiding MRI or CT; (3) its reduction or elimination of radiation exposure by not having to perform fluoroscopy or CT; (4) the higher safety profile of US contrast agents (UCA) compared to other contrast agents; (5) the improved exam comfort and ease inherent to US, leading to better patient and family experience, including bedside US exams for children who cannot be transported; (6) the need for another diagnostic option in light of increasing demand by parents and providers; and (7) its status as an approved and reimbursable exam. It is necessary to have an UCA incorporated into the pharmacy formulary noting that only SonoVue/Lumason is currently approved for pediatric use. In the United States this UCA is approved for intravenous administration for cardiac and liver imaging and for vesicoureteric reflux detection with intravesical application. In Europe and China it is only approved for the intravesical use in children. All other applications are off-label. The US scanner needs to be equipped with contrast-specific software. The UCA has to be prepared just before the exam and it is important to strictly follow the steps as outlined in the packaging inserts in order to prevent premature destruction of the microbubbles. The initial training in contrast US is best focused on the frontline staff actually performing the US studies; these might be sonographers, pediatric or interventional radiologists, or trainees. It is important from the outset to educate the referring physicians about contrast US. It is helpful to participate in existing contrast US courses, particularly those with hands-on components.

Performance of Contrast-Enhanced Ultrasound in Thyroid Nodules: Review of Current State and Future Perspectives

Ultrasound has been established as a baseline imaging technique for thyroid nodules. The main advantage of adding CEUS is the ability to assess the sequence and intensity of vascular perfusion and hemodynamics in the thyroid nodule, thus providing real-time characterization of nodule features, considered a valuable new approach in the determination of benign vs. malignant nodules. Original studies, reviews and six meta-analyses were included in this article. A total of 624 studies were retrieved, and 107 were included in the study. As recognized for thyroid nodule malignancy risk stratification by US, for acceptable accuracy in malignancy a combination of several CEUS parameters should be applied: hypo-enhancement, heterogeneous, peripheral irregular enhancement in combination with internal enhancement patterns, and slow wash-in and wash-out curve lower than in normal thyroid tissue. In contrast, homogeneous, intense enhancement with smooth rim enhancement and "fast-in and slow-out" are indicative of the benignity of the thyroid nodule. Even though overlapping features require standardization, with further research, CEUS may achieve reliable performance in detecting or excluding thyroid cancer. It can also play an operative role in guiding ablation procedures of benign and malignant thyroid nodules and metastatic lymph nodes, and providing accurate follow-up imaging to assess treatment efficacy.

Contrast -Enhanced Ultrasound: State of the Art in North America

The Society of Radiologists in Ultrasound convened a panel of specialists in contrast-enhanced ultrasound (CEUS) to produce a white paper on noncardiac CEUS in North America. The panel met in Chicago, Illinois, on October 24 and 25, 2017. The recommendations are based on analysis of current literature and common practice strategies and are thought to represent a reasonable approach to introduce the advantages of this safe and noninvasive technique for the benefit of our patients. Characterization of liver nodules, and pediatric vascular and intravesicular applications comprise the approved indications for CEUS in the United States. They, along with the very successful off-label use of CEUS for the kidney, are included in this publication.Other off-label uses are presented with emphasis on their value and literature support in the online version.

Can contrast enhanced ultrasound (CEUS) be useful in the diagnosis of ovarian torsion in pediatric females? A preliminary monocentric experience

PURPOSE

To describe contrast enhanced ultrasound (CEUS) characteristics of ovarian torsion in pediatric females, assessing the potential diagnostic advantages of method as well as its limitations.

MATERIALS AND METHODS

A retrospective study design was used. Between January 2018 and December 2020 we analyzed all pediatric females who underwent explorative surgery with a suspected diagnosis of ovarian torsion, and who were previously evaluated by conventional ultrasound (US), color-Doppler ultrasound (CDUS) and CEUS.

RESULTS

We examined twenty pediatric females with a median age of 12 years. US identified 9/20 ovarian complex masses against 13/20 by CEUS. At US abdominal free fluid was shown in 13/20 patients and in 18/20 cases with CEUS. In our case series the evaluation of contrast enhancement at CEUS in the detection of ovarian torsions revealed a sensitivity of 94.1%, a specificity of 100% and an overall accuracy of 95%.

CONCLUSION

Although there is a known ultrasound semeiotics suggestive of ovarian torsion, it is not always possible to obtain a diagnosis of certainty with conventional US even with CDUS. The study reports that complementation with CEUS showed excellent agreement with surgery obtaining a diagnosis in almost all the pediatric females examined.

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.

Evaluation of the abdomen in the setting of suspected child abuse

Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises, identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse. Here we describe the clinical, laboratory and imaging evaluation of the abdomen in the setting of suspected child abuse.

Contrast-Enhanced Ultrasound in Children: Implementation and Key Diagnostic Applications

Contrast-enhanced ultrasound (CEUS) utilization is expanding rapidly, particularly in children, in whom the modality offers important advantages of dynamic evaluation of the vasculature, portability, lack of ionizing radiation, and lack of need for sedation. Accumulating data establish an excellent safety profile of ultrasound contrast agents in children. Although only FDA-approved for IV use in children for characterizing focal liver lesions and for use during echocardiography, growing off-label applications are expanding the diagnostic potential of ultrasound. Focal liver lesion evaluation is the most common use of CEUS, and the American College of Radiology Pediatric LI-RADS Working Group recommends including CEUS for evaluation of a newly discovered focal liver lesion in many circumstances. Data also support the role of CEUS in hemodynamically stable children with blunt abdominal trauma, and CEUS is becoming a potential alternative to CT in this setting. Additional potential applications that require further study include evaluation of pathology in the lung, spleen, brain, pancreas, bowel, kidney, female pelvis, and scrotum. This review explores the implementation of CEUS in children, describing basic principles of ultrasound contrast agents and CEUS technique and summarizing current and potential IV diagnostic applications based on pediatric-specific supporting evidence.

EFSUMB 2020 Proposal for a Contrast-Enhanced Ultrasound-Adapted Bosniak Cyst Categorization - Position Statement

The well-established Bosniak renal cyst classification is based on contrast-enhanced computed tomography determining the malignant potential of cystic renal lesions. Ultrasound has not been incorporated into this pathway. However, the development of ultrasound contrast agents coupled with the superior resolution of ultrasound makes it possible to redefine the imaging of cystic renal lesions. In this position statement, an EFSUMB Expert Task Force reviews, analyzes, and describes the accumulated knowledge and limitations and presents the current position on the use of ultrasound contrast agents in the evaluation of cystic renal lesions.

A pictorial review of the utility of CEUS in thoracic biopsies

Lung cancer is one of the commonest malignancies worldwide and necessitates both early and personalised treatment. A key requirement is histological sampling with immunohistochemistry obtained usually from percutaneous biopsy. Conventionally thoracic biopsies are performed using CT guidance, but more recently, there has been development of physician led ultrasound biopsy for pleural lesions. Contrast-enhanced ultrasound (CEUS) has been increasingly used in interventional procedures and is able to offer benefits for thoracic biopsies including improving lesional visualisation and characterisation, targeting viable tissue and avoiding critical vascular structures as well as evaluating for the presence of post-procedural complications. This educational review aims to benefits of the role of CEUS in thoracic biopsies.

Contrast-enhanced ultrasound of benign and malignant liver lesions in children

Contrast-enhanced ultrasound (CEUS) is increasingly being used in children. One of the most common referrals for CEUS performance is characterization of indeterminate focal liver lesions and follow-up of known liver lesions. In this setting, CEUS is performed with intravenous administration of ultrasound contrast agents (UCAs). When injected into a vein, UCA microbubbles remain confined within the vascular network until they dissipate. Therefore, visualization of UCA within the tissues and lesions corresponds to true blood flow. CEUS enables continuous, real-time observation of the enhancement pattern of a focal liver lesion, allowing in most cases for a definite diagnosis and obviating the need for further cross-sectional imaging or other interventional procedures. The recent approval of Lumason (Bracco Diagnostics, Monroe Township, NJ) for pediatric liver CEUS applications has spurred the widespread use of CEUS. In this review article we describe the role of CEUS in pediatric liver applications, focusing on the examination technique and interpretation of main imaging findings of the most commonly encountered benign and malignant focal liver lesions. We also compare the diagnostic performance of CEUS with other imaging modalities for accurate characterization of focal liver lesions.

Cholecystoduodenal fistula identified on oral contrast-enhanced ultrasound

We describe a case of a cholecystoduodenal fistula (CDF) diagnosed using oral contrast-enhanced ultrasound (CEUS). CDF is a rare type of biliary-enteric fistulation in which an abnormal communication forms between the gallbladder and duodenum. CDF are usually found in older patients, in the context of chronic cholecystitis, and can be associated with serious consequences. Given the non-specific presentation and limitations of the various imaging modalities, CDF are notoriously difficult to diagnose. CEUS is a recognised technique predominantly deployed for imaging following intravenous administration. Experience of CEUS has expanded into endocavitary use, including in the biliary and gastrointestinal systems. We describe a case of a CDF identified on intracavitary CEUS. This case report demonstrates oral ingestion of a diluted ultrasound contrast agent is a novel and safe mode of administration with stability of the contrast agent and the ability to define fistulation.

Additional value of superb microvascular imaging for assessing hepatic arterial blood flow after pediatric liver transplantation

BACKGROUND

The aim of this study was to explore the value of SMI compared with conventional ultrasonography for assessing hepatic arterial blood flow after pediatric liver transplantation.

METHODS

From March 2018 to November 2018, a total of 105 pediatric recipients with biliary atresia underwent liver transplantation in our hospital. Ultrasound examinations were performed at the bedside in the intensive care unit to check the patency of the blood flow in the hepatic allograft. CDI, PDI, cSMI, and mSMI were performed to assess the display, orientation, and distribution of the graft hepatic artery. Ultrasound examinations were performed by one radiologist, and the images were judged by two observers.

RESULTS

The median age, weight, and height of the recipients were 6.97 (5.92, 9.58) months, 6.50 (6.00, 7.80) kg, and 64.00 (62.00, 68.00) cm, respectively. The measure of kappa agreement was 0.902, 0.889, 0.882, and 0.882 for CDI, PDI, cSMI, and mSMI, respectively. HAT occurred in 7 pediatric recipients and was confirmed by CTA (computed tomography angiography) and surgery. The diagnostic performance of sensitivity, specificity, PPV (positive predictive value), NPV (negative predictive value), and accuracy were 100%, 92.86%, 50%, 100%, and 93.33% for CDI and 100%, 98.98%, 87.50%, 100%, and 99.05% for SMI.

CONCLUSIONS

As an additional method to CDI, SMI can clearly show the distribution of hepatic arterial blood flow and provide more details, thereby markedly improving the diagnostic performance of postoperative HAT.

Contrast-enhanced US in Pediatric Patients: Overview of Bowel Applications

Contrast material-enhanced US is a technique that is approved by the U.S. Food and Drug Administration for the characterization of liver lesions and intravesicular applications in children; however, contrast-enhanced US has several other pediatric applications in clinical practice. The most common application is for patients with inflammatory bowel disease (IBD). Contrast-enhanced US can be used to diagnose IBD, distinguish regions of active or chronic inflammation of the bowel wall, and evaluate associated complications such as abscesses, fistulas, and strictures. Dynamic contrast material evaluation provides qualitative and quantitative information about mural and mesenteric blood flow, which is essential in the determination of disease activity in these patients. It also has the potential to provide a means of monitoring the response to therapy beyond endoscopy or MR enterography. In addition to its use for IBD, contrast-enhanced US can be used to assess for bowel perfusion when problem solving in patients with necrotizing enterocolitis, neonatal bowel infarction, or intussusception. It is a useful imaging technique to fortify diagnoses that may otherwise be indeterminate, such as appendicitis, epiploic appendagitis, intraluminal bowel masses, and complex cysts. Finally, innovative applications such as shear-wave elastography have the potential to provide information about the stiffness of the bowel wall. Online supplemental material is available for this article. ©RSNA, 2020 See discussion on this article by Watson and Humphries.

Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver - Update 2020 - WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS), first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications.The 2012 guideline requires updating as previously the differences of the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including the United States Food and Drug Administration (FDA) approval as well as the extensive Asian experience, to produce a truly international perspective.These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCA) and are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis to improve the management of patients.

Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound (CEUS) in the Liver-Update 2020 WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS

The present, updated document describes the fourth iteration of recommendations for the hepatic use of contrast-enhanced ultrasound, first initiated in 2004 by the European Federation of Societies for Ultrasound in Medicine and Biology. The previous updated editions of the guidelines reflected changes in the available contrast agents and updated the guidelines not only for hepatic but also for non-hepatic applications. The 2012 guideline requires updating as, previously, the differences in the contrast agents were not precisely described and the differences in contrast phases as well as handling were not clearly indicated. In addition, more evidence has been published for all contrast agents. The update also reflects the most recent developments in contrast agents, including U.S. Food and Drug Administration approval and the extensive Asian experience, to produce a truly international perspective. These guidelines and recommendations provide general advice on the use of ultrasound contrast agents (UCAs) and are intended to create standard protocols for the use and administration of UCAs in liver applications on an international basis to improve the management of patients.

Role for contrast-enhanced ultrasound in assessing complications after kidney transplant

Kidney transplantation (KT) is an effective treatment for end-stage renal disease. Despite their rate has reduced over time, post-transplant complications still represent a major clinical problem because of the associated risk of graft failure and loss. Thus, post-KT complications should be diagnosed and treated promptly. Imaging plays a pivotal role in this setting. Grayscale ultrasound (US) with color Doppler analysis is the first-line imaging modality for assessing complications, although many findings lack specificity. When performed by experienced operators, contrast-enhanced US (CEUS) has been advocated as a safe and fast tool to improve the accuracy of US. Also, when performing CEUS there is potentially no need for further imaging, such as contrast-enhanced computed tomography or magnetic resonance imaging, which are often contraindicated in recipients with impaired renal function. This technique is also portable to patients' bedside, thus having the potential of maximizing the cost-effectiveness of the whole diagnostic process. Finally, the use of blood-pool contrast agents allows translating information on graft microvasculature into time-intensity curves, and in turn quantitative perfusion indexes. Quantitative analysis is under evaluation as a tool to diagnose rejection or other causes of graft dysfunction. In this paper, we review and illustrate the indications to CEUS in the post-KT setting, as well as the main CEUS findings that can help establishing the diagnosis and planning the most adequate treatment.

The role of contrast-enhanced ultrasound (CEUS) in the evaluation of scrotal trauma: a review

Testicular trauma is common, usually trivial and rarely requires hospital attendance, but if it does, then imaging becomes essential as scrotal assessment may be difficult due to pain and/or scrotal disruption. Ultrasound (US) assumes a crucial role as other cross-sectional modalities have a limited use in the acute presentation. Despite the acceptable accuracy of conventional US techniques, there are limitations which hinder a thorough evaluation, critically the assessment of tissue viability, crucial for clinical management and prognosis. Contrast-enhanced ultrasound (CEUS) has been shown to offer improved flow visualisation and tissue perfusion compared with conventional Doppler techniques. CEUS can accurately and confidently demonstrate the viability of testicular parenchyma, delineate fracture lines and haematomas and guide treatment for testis-sparing surgery or orchidectomy. The purpose of this review is to present the literature, familiarise physicians with the principles of CEUS and findings of scrotal trauma and illustrate the main abnormalities through characteristic and educative cases.

Improved Diagnostic Sensitivity of Bowel Disease of Prematurity on Contrast-Enhanced Ultrasound

Bowel diseases of prematurity, including necrotizing enterocolitis, are dreaded ailments of neonates. Early diagnosis is difficult, with clinical and radiographic findings often inconclusive. We present a novel use of contrast-enhanced ultrasound in detection of pediatric bowel disease. Early identification of compromised blood flow or an at-risk bowel can be quantitatively detected and monitored. This ability has implications for guidance of emerging therapies, allowing targeting of inflammation. These findings represent an advancement in detection of bowel disease in neonates.

Contrast enhanced ultrasound: comparing a novel modality to MRI to assess for bowel disease in pediatric Crohn's patients

Background

To demonstrate the feasibility and reliability of a novel imaging modality, contrast enhanced ultrasound (CEUS), in evaluating for distal small bowel inflammation in pediatric Crohn's disease (CD), and compare this to concurrently obtained magnetic resonance imaging (MRI) findings.

Methods

Pediatric patients diagnosed with or having suspicion of CD with small bowel involvement, whose disease merited imaging with an MRI, concurrently underwent imaging with CEUS. We assessed the ability of CEUS to demonstrate distal small bowel disease by evaluating wall thickness, enhancement pattern, mucosal disruption and pericolonic inflammation. Concordance between imaging modalities was then assessed.

Results

Twenty patients were recruited for the study, 16 with known CD, 3 with concern for CD, and one with known colitis, but unknown bowel disease status. Six patients (3 with prior diagnosis of CD, 3 without) had absence of bowel enhancement on both ultrasound and MRI. Eleven patients with findings of inflammation and enhancement on MRI also had concurrent evidence of enhancement on CEUS. Three patients who had no evidence of inflammation on MRI, with known CD, had prominent bowel enhancement on CEUS. One patient with known colitis, whom we enrolled to evaluate for small bowel disease, had no evidence on either MRI or CEUS, however CEUS showed significant fat stranding around the colon, supporting the diagnosis of CD.

Conclusions

The sensitivity of CEUS to detect bowel inflammation when seen on MRI was 100%. In addition, CEUS may also have the ability to detect bowel inflammation, even in the presence of a normal MRI.