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Intra-operative ultrasound has become a relevant imaging modality in neurosurgical procedures. While B-mode, with its intrinsic limitations, is still considered the primary ultrasound modality, intra-operative contrast-enhanced ultrasound (ioCEUS) has more recently emerged as a powerful tool in neurosurgery. Though still not used on a large scale, ioCEUS has proven its utility in defining tumor boundaries, identifying lesion vascular supply and mapping neurovascular architecture. Here we propose a step-by-step procedure for performing ioCEUS analysis of the brain, highlighting its neurosurgical applications. Moreover, we provide practical advice on the use of ultrasound contrast agents and review technical ultrasound parameters influencing ioCEUS imaging.

B-mode ultrasonography is used to determine the “morphology” of anatomical structures and organs; Doppler methods have the potential to offer “functional” information through blood circulation analysis.

We present an uncommon case of a patient presenting at the emergency department for severe vomiting, persisting for at least 12 hours, without nausea or abdominal pain. She initially referred vomiting food eaten several hours earlier and eventually a single episode of haematemesis with emission of a small amount of red blood and clots. She also reported the occurrence of acute dysphagia for solid food. The patient underwent oesophagogastroduodenoscopy (OGD), which showed that the lumen was almost completely narrowed by a submucosal bluish bulging from midoesophagus (19 cm from the incisors) to the cardia (located at 35 cm from the incisors). She therefore underwent chest CT showing a 15 cm long intramural oesophageal haematoma. Although the combination of vomiting and haematemesis is usually associated with Mallory-Weiss syndrome, in which a prompt OGD has a key role in the patient management, when these symptoms are associated with acute dysphagia, a possible intramural haematoma might be suspected. In this case, chest CT should take precedence, because it allows a quick and complete diagnostic appraisal. However, in this setting, although OGD can directly show typical findings (bluish swelling mucosa with or without a superficial tears), it might increase the risk of oesophageal haematoma rupture and intraluminal bleeding.

Purpose To investigate the imaging features of emerging COVID-19 pneumonia on chest ultrasound (US), radiographs (CXR) and computed tomography (CT) examinations performed at admission and to provide a comprehensive radiological literature review on ongoing radiological data from recent publications. Materials and methods In this retrospective single-center study, we enrolled consecutive patients from February 15, 2020, to March 15, 2020, with laboratory-confirmed SARS-CoV-2 hospitalized in Valduce Hospital (Como, Italy). Multi-modality imaging findings were evaluated and compared. Literature research was conducted through a methodical search on Pubmed and Embase databases. Results Fifty-eight patients (36 men, 22 women; age range, 18–98 years) were included in the study. Among these, chest US, CXR, and CT were performed respectively in twenty-two, thirty-two and forty-two patients. Lung US findings were consistent with diffuse B lines (100%) and subpleural consolidations (27.3%). CXR showed prevalent manifestations of consolidations (46.9%) and hazy increased opacities (37.5%). Typical CT features included bilateral and multilobar ground-glass opacities (GGO) with (59.5%) and without (35.7%) consolidations having a predominantly peripheral distribution (64.3%). Other imaging features included crazy paving pattern (57.1%), fibrous stripes (50%), subpleural lines (35.7%), architectural distortion (28.6%), air bronchogram sign (26.2%), vascular thickening (23.8%) and nodules (2.4%). Also, enlarged lymph nodes (14.3 %) and pleural effusion (7.1%) were observed. The literature review identified twenty-six original studies supporting our imaging chest findings. Conclusion The spectrum of chest imaging manifestations of COVID-19 pneumonia upon admission includes B-lines and consolidations on US, consolidations and hazy increased opacities on CXR, and multifocal GGO with consolidations on CT.

Background. Contrast enhanced ultrasound (CEUS) is a dynamic and continuous modality providing real-time view of vascularization and flow distribution patterns of different organs and tumors. Nevertheless its intraoperative use for brain tumors visualization has been performed few times, and a thorough characterization of cerebral glioma had never been performed before.Aim. To perform the first characterization of cerebral glioma using CEUS and to possibly achieve an intraoperative differentiation of different gliomas.Methods. We performed CEUS in an off-label setting in 69 patients undergoing surgery for cerebral glioma. An intraoperative qualitative analysis was performed comparing iCEUS with B-mode imaging. A postprocedural semiquantitative analysis was then performed for each case, according to EFSUMB criteria. Results were related to histopathology.Results. We observed different CE patterns: LGG show a mild, dotted CE with diffuse appearance and slower, delayed arterial and venous phase. HGG have a high CE with a more nodular, nonhomogeneous appearance and fast perfusion patterns.Conclusion. Our study characterizes for the first time human brain glioma with CEUS, providing further insight regarding these tumors’ biology. CEUS is a fast, safe, dynamic, real-time, and economic tool that might be helpful during surgery in differentiating malignant and benign gliomas and refining surgical strategy.

The study was designed primarily to find the optimal dosage range of BR14 contrast-enhanced ultrasonography (CEUS) to detect malignant focal liver lesions. Secondary objectives were the evaluation of the safety profile and comparison with contrast-enhanced MRI (CE MRI). We studied 25 patients (9 females, 16 males, mean age, 66 years) with known hepatocellular carcinoma or liver metastases at 3 centers over a 3-month period. Each patient underwent a baseline examination and at least 3 CEUS examinations with ascending dose levels (0.25 mL; 1.0 mL; 4.0 mL) of BR14. CE MRI was performed 4 weeks before or after the CEUS examination. Dedicated liver maps were used to record the location, size, and type of detected lesions. Examination quality was documented and safety parameters were assessed. The number of lesions detected by BR14 CEUS increased with dosage, whereas the number of missed lesions and the lesion sizes decreased. Despite the increasing contrast enhancement, substantial differences among dosages were not seen for other image quality parameters. No significant changes were noted in safety parameters and no serious adverse events were reported. We conclude that the recommended dose level of BR14 is between 1 mL and 4 mL; at this dosage, lesion detection is comparable to that of CE MRI.

The objective of this study was to evaluate the concordance of US and contrast-enhanced US (CEUS) with CT in the assessment of solid organ injury following blunt trauma. Patients underwent complete US examination, including free fluid search and solid organ analysis. CEUS followed, using low-mechanical index techniques and SonoVue. CT was performed within 1 h. Among 156 enrolled patients, 91 had one or more abnormalities (n = 107) at CT: 26 renal, 38 liver, 43 spleen. Sensitivity, specificity, and accuracy for renal trauma at baseline US were 36%, 98%, and 88%, respectively, after CEUS values increased to 69%, 99%, and 94%. For liver baseline US values were 68%, 97%, and 90%; after CEUS were 84%, 99%, and 96%. For spleen, results were 77%, 96%, and 91% at baseline US and 93%, 99%, and 97% after CEUS. Per patient evaluation gave the following results in terms of sensitivity, specificity and accuracy: 79%, 82%, 80% at baseline US; 94%, 89%, and 92% following CEUS. CEUS is more sensitive than US in the detection of solid organ injury, potentially reducing the need for further imaging. False negatives from CEUS are due to minor injuries, without relevant consequences for patient management and prognosis.

Ultrasonography is an imaging method which is widely used in medicine and is based on the processing of the echo signal generated by the interaction between the matter and an ultrasound beam.

The effectiveness of contrast-enhanced ultrasonography (CEUS) in the evaluation of patients with acute renal infarcts was investigated, using contrast-enhanced helical computed tomography (CT) as the reference imaging procedure. Twenty-seven consecutive patients with acute renal infarcts detected with contrast-enhanced helical CT underwent CEUS. Digital cine-clips of CEUS were evaluated by two independent readers blinded to CT findings. Image quality was rated subjectively on a four-point scale. Then, readers were asked to assign a confidence level in diagnosis of renal infarct at the upper pole, medium portion, and lower pole of each kidney according to a five-degree scale, ranging from definitely absent to definitely present. ROC curve analysis was employed to assess the overall confidence of diagnosis of infarct, and weighted kappa values were calculated to assess inter-reader agreement. The subjective image quality of CEUS was lower than the image quality of CT at the upper poles. However, the diagnostic performance of CEUS was excellent (area under receiver-operator characteristic curve 0.992 +/- 0.006 for reader 1; 0.991 +/- 0.007 for reader 2), with very good inter-reader agreement (weighted kappa value = 0.83). CEUS is a reproducible tool to detect acute renal infarcts in men, with a diagnostic performance approaching that of CT.

Purpose. The aim of this paper was to report a heterogeneous latephase hepatic enhancement pattern observed after administration of a sonographic contrast agent and to present an aetiological hypothesis for the phenomenon. Materials and methods. A total of 1,729 (1,012 women and 717 men; age range 28–82; mean age 51) patients underwent contrastenhanced sonography of the liver. The examination was performed with a low mechanical index (MI

Endo vascular aortic repair [EVAR] is performed with low peri-operative morbidity and mortality rate and short hospital stay. However, EVAR needs a close and lifelong imagining surveillance for a timely detection of possible complications including endoleaks, graft migration, fractures, and enlargement of aneurysm sac size with eventual rupture. Contrast enhanced computed tomography [CTA] is actually considered the gold-standard in EVAR follow-up, but it is accompanied with radiation burden and renal injury due to the use of contrast media. In the last two decades several studies have shown the role of contrast enhanced ultrasound [CEUS] in post-EVAR surveillance, with very good diagnostic performance, absence of renal impairment, and no radiation, accompanied by low costs, in comparison with CTA. In numerous prospective studies and meta-analyses the detection and characterization of endoleaks with CEUS is comparable to that of CTA imaging. Nowadays, in the EVAR surveillance novel strategies which involve CEUS with a central role, are suggested by several authors and applied in many institutions. In this review article we will present a comprehensive overview and analyses of the literature on the CEUS state-of-art imagining of EVAR follow-up, with its technique, findings, diagnostic accuracy, and its role in the follow up program.

Resume Objectif Evaluer la faisabilite de l’echographie de contraste en temps reel pour l’etude des affections renales. Materiels et methodes Dix-huit patients (sex-ratio = 1, âge moyen 62,3 ±18,1 ans) presentant differentes affections renales ont beneficie d’une echographie de contraste temps reel avec injection en bolus de Sonovue ® (Bracco, Milan, Italie) a l’aide d’un appareil d’echographie Esatune ® (Esaote) utilisant un bas index mecanique (IM Resultats L’echographie de contraste a montre une nette amelioration dans la definition des limites des tumeurs et de leur structure, la detection de thrombus intravasculaires et la stadification des masses kystiques. L’injection de Sonovue ® permettait d’ameliorer la confiance diagnostique dans 83 % des cas ainsi que la concordance diagnostique avec l’examen de reference de 50 % (passant de 42 % sans contraste a 92 % apres injection). Conclusion L’echographie de contraste en temps reel semble apporter des elements objectifs de detection et caracterisation des lesions renales en particulier par une etude continue de la prise de contraste intralesionnelle des la phase arterielle. Si ces resultats etaient confirmes par une large etude, ceci aurait pour consequence d’ameliorer la prise en charge diagnostique des lesions renales.

Background One of the main challenges during skull base tumor surgery is identifying the relationships between the lesion and the principal intracranial vessels. To this end, neuronavigation systems based on preoperative imaging lack accuracy because of brain shift and brain deformation. Intraoperative navigated B-mode ultrasonography is useful in defining the extent of brain tumor. Doppler imaging adds information regarding flow entity in neighboring vessels. Second-generation ultrasound contrast agents improve the signal-to-noise ratio of B-mode imaging and permit the study of the vessel's course, blood flow, and perfusion characteristics of focal lesions. We report our experience using intraoperative navigated contrast-enhanced ultrasound to perform a navigated angiosonography (N-ASG) for the visualization of vessels in a series of 18 skull base tumors. Methods We performed N-ASG in a series of 18 skull base tumors (10 meningiomas, 3 craniopharyngiomas, 2 giant pituitary adenomas, 1 posterior fossa epidermoid, 2 dermoid cysts). N-ASG was obtained after craniotomy before resecting each lesion and during tumor removal, after intravenous injection of ultrasound contrast agent. Results In all 18 cases, major vessels and their branches were simultaneously identified (both high and low flow) using N-ASG, which allowed to visualize the whole length of each vessels. N-ASG was also useful in highlighting the lesion, compared with standard B-mode imaging, and showing its perfusion patterns. Conclusions N-ASG can be applied to skull base tumor surgery, providing helpful information about the relationship between principal intracranial vessels and tumors. This technique could be of assistance in approaching the tumor and avoiding vascular damages.

BACKGROUND: Contrast-enhanced ultrasound (CEUS) is a dynamic and continuous modality which offers a real time, direct view of the vascularization patterns and tissue resistance for many organs. Thanks to newer ultrasound (US) contrast agents, CEUS has become a well-established, live-imaging technique in many contexts, but it has never been extensively used for brain imaging. In particular, the use of intraoperative-CEUS (iCEUS) imaging in Neurosurgery is very limited. in this study, we provide the first dynamic and continuous iCEUS evaluation of a variety of brain lesions. METHODS: We evaluated 96 patients undergoing iCEUS imaging in an off-label setting while being operated on for different brain lesions; iCEUS imaging was obtained before resecting each lesion, after intra-venous (IV) injection of ultrasound contrast-agent (UCA). A semi-quantitative, offline postoperative inter-observer analysis was performed, in order to visualize each brain lesion and characterize its perfusion features in correlation with histopathology. RESULTS: In all cases, the brain lesion was visualized intra-operatively with iCEUS; the afferent and the efferent blood vessels were identified, allowing to evaluate the time and the features of the arterial and venous phases and facilitating the surgical strategy. iCEUS also proved to be useful in highlighting the lesion as compared to standard B-mode. Specific perfusion patterns were identified according to histopathology. No adverse effects were observed. CONCLUSIONS: Our study is the first large-scale implementation of iCEUS in Neurosurgery as a dynamic and continuous real time imaging tool for brain surgery, providing a first iCEUS characterization of different brain masses. iCEUS ability to highlight and characterize brain tumor provides the neurosurgeon with important information, anytime during a surgical procedure, in order to refine and optimize the surgical strategy and, possibly, to further understand tumor biology. SECONDARY CATEGORY: Clinical Neuro-Oncology.

Computed tomographic (CT) colonography or virtual colonoscopy is a new diagnostic method for the colon and rectum, developed on the basis of spiral computed axial tomography and employing virtual reality technology. The aim of this study was to determine the sensitivity, specificity, and diagnostic accuracy of CT colonography compared with colonoscopy in a prospective, blinded study in one single institution in Italy.Ninety-nine patients randomly selected among those attending the open-access endoscopy unit for diagnostic colonoscopy underwent colonoscopy and spiral CT. The images obtained were transmitted to generate the virtual colonoscopy pictures. A supervisor compared the results with the findings of conventional colonoscopy.CT colonography diagnosed seven of eight tumors, one being missed because the patient had been inadequately prepared. In 28 patients, CT colonography identified 26 polyps of 45 (57.8% sensitivity, 92.6% specificity, 86.7% positive predictive value), regardless of their size. The sensitivity in detecting colonic polyps was 31.8% (7/22) in the first 25 cases and 91.6% (11/12) in the last 20 patients. CT colonography missed one flat adenoma, some angioectasias and colonic lesions because of portal hypertension in one patient, Crohn's disease ulcers in two patients, and ulcerative colitis lesions in three.CT colonography shows poor sensitivity for identifying colonic polyps and does not always detect neoplastic lesions. Flat lesions are impossible to see by this method.

Background Contrast-enhanced ultrasound (CEUS) is a dynamic and continuous modality that offers a real-time, direct view of vascularization patterns and tissue resistance for many organs. Thanks to newer ultrasound contrast agents, CEUS has become a well-established, live-imaging technique in many contexts, but it has never been used extensively for brain imaging. The use of intraoperative CEUS (iCEUS) imaging in neurosurgery is limited. Objective To provide the first dynamic and continuous iCEUS evaluation of a variety of brain lesions. Methods We evaluated 71 patients undergoing iCEUS imaging in an off-label setting while being operated on for different brain lesions; iCEUS imaging was obtained before resecting each lesion, after intravenous injection of ultrasound contrast agent. A semiquantitative, offline interobserver analysis was performed to visualize each brain lesion and to characterize its perfusion features, correlated with histopathology. Results In all cases, the brain lesion was visualized intraoperatively with iCEUS. The afferent and efferent blood vessels were identified, allowing evaluation of the time and features of the arterial and venous phases and facilitating the surgical strategy. iCEUS also proved to be useful in highlighting the lesion compared with standard B-mode imaging and showing its perfusion patterns. No adverse effects were observed. Conclusion Our study is the first large-scale implementation of iCEUS in neurosurgery as a dynamic and continuous real-time imaging tool for brain surgery and provides the first iCEUS characterization of different brain neoplasms. The ability of CEUS to highlight and characterize brain tumor will possibly provide the neurosurgeon with important information anytime during a surgical procedure.

Background & Aims Computed tomographic colonography (CTC) is a reliable option for screening subjects who are unable or unwilling to undergo optical colonoscopy (OC). A colon capsule (PillCam Colon2 [CC2]; GivenImaging Ltd., Yokneam, Israel) has shown promising results in detecting polyps larger than 6 mm. We compared the accuracy of CC2 and CTC in identifying individuals with at least 1 polyp greater than 6 mm and subjects' attitude toward the procedures. Methods Fifty individuals (mean age, 59.2 ± 5.8 y; 58% male) with positive results from the immunochemical fecal occult blood test (iFOBT-positive) underwent CC2, CTC, and OC. The unblinded colonoscopy, integrating OC, CTC, and CC2 results, was used as the reference standard. In a per-patient analysis, the accuracy of CC2 and CTC were assessed for individuals with at least 1 polyp 6 mm or larger. Individuals were asked to choose which procedure they would be willing to repeat between CTC and CC2. Results The combination of OC, CTC, and CC2 identified 16 cases with at least 1 polyp 6 mm or larger (reference standard). CTC identified the polyps with 88.2% sensitivity, 84.8% specificity, a 3.0 positive likelihood ratio, and a 0.07 negative likelihood ratio. CC2 identified the polyps with 88.2% sensitivity, 87.8% specificity, a 3.75 positive likelihood ratio, and a 0.06 negative likelihood ratio. Thirty-nine subjects (78%) said they preferred CC2 to CTC. Conclusions CC2 and CTC detect polyps 6 mm and larger with high levels of accuracy; these techniques are effective in selecting iFOBT-positive individuals who do not need to be referred for colonoscopy. CC2 seems to be better tolerated than CTC, and could be a reliable alternative to CTC for iFOBT-positive individuals who are unable or unwilling to undergo OC. ClinicalTrials.gov number: NCT01744509.

We evaluated the adverse reactions (AR) rate produced in patients to see if any difference related to the diferent chemotoxicities of two low-osmolality contrast media (CM), could be detected. We compared the AR rate intravenous administration for brain or body computed tomography (CT) enhancement of either the ionic CM ioxaglate 320 mgI/ml or the non-ionic iopamidol 300 mgI/ml at a dose of 0.8 gI/kg. Three hundred and thirty patients (164 ioxaglate, 166 iopamidol) were studied according to a randomized double-blind design. AR reported by the patients (subjective) and/or observed by the radiologist (objective) were recorded by the radiologist on the patients record card. Laboratory test were performed prior to and 24 h after contrast administration. Fifty-nine mild to moderate AR occurred in 30 patients (18.3%) receiving ioxaglate, 4 mild to moderate AR occurred in 2 patients (1.2%) receiving iopamidol (P < 0.05). No severe AR occurred in either group. The results of our study are comparative to the available evidence from 16 comparative randomized trials of iopamidol versus ioxaglate both after intraarterial and intravenous administration that gave an overall odds ratio of 3.9 [confidence interval (CI) 95% = 3.1–4.9]. The diagnostic efficacy of the two CM was comparable. This study showed that the non-ionic CM iopamidol was better tolerated than the ionic ioxaglate after intravenous administration. We conclude that the chemotoxicity of the molecule influences the AR when CM with comparable osmolality are administered.

The aim of this study was to evaluate the clinical and economic consequences of the introduction of contrast-enhanced ultrasonography (CEUS) into the diagnostic clinical algorithm for the characterization of incidental focal liver lesions (FLLs).This prospective study enrolled 485 subjects at three hospitals in Italy. Two diagnostic algorithms were utilized: (1) a classic patient work-up, which included baseline US followed by a CT or MR examination, and (2) a new patient management scheme in which, following the baseline US, a CEUS examination was performed. For each pathway, both direct and indirect health costs for the National Health System (NHS) at two of the three hospitals involved in the study were calculated. Clinical outcome was measured in terms of number of cases correctly diagnosed, using contrast-enhanced CT/contrast-enhanced MR as the reference standard.CEUS correctly differentiated (benign vs. malignant) 559 of 575 lesions (97.2%), with a sensitivity of 98.1% and a specificity of 95.7%. Histological characterization was correct in 502 of 575 lesions (87%) with a sensitivity of 90.5% and a specificity of 85.4%. In terms of cost, the conventional diagnostic algorithm incurred for the NHS a total cost of Euro 134.576,60 vs. Euro 55.674,30 with CEUS, for a saving of Euro 78.902 (Euro 162 per patient). For the hospitals, the total cost was Euro 147.045 without CEUS vs Euro 61.979 with CEUS, for a saving of Euro 85.065,96 or Euro 175,39 per patient.The routine use of CEUS for the characterization of FLLs provides significant cost savings, both for the NHS and for the hospital.

The purpose of this study was to demonstrate the improvement in diagnostic quality and diagnostic accuracy of SonoVue microbubble contrast-enhanced ultrasound (CE-US) versus unenhanced ultrasound imaging during the investigation of extracranial carotid or peripheral arteries. 82 patients with suspected extracranial carotid or peripheral arterial disease received four SonoVue doses (0.3 ml, 0.6 ml, 1.2 ml and 2.4 ml) with Doppler ultrasound performed before and following each dose. Diagnostic quality of the CE-US examinations was evaluated off-site for duration of clinically useful contrast enhancement, artefact effects and percentage of examinations converted from non-diagnostic to diagnostic. Accuracy, sensitivity and specificity were assessed as agreement of CE-US diagnosis evaluated by an independent panel of experts with reference standard modality. The median duration of clinically useful signal enhancement significantly increased with increasing SonoVue doses (p

The introduction of perfluoro-based contrast agents such as SonoVue together with sensitive realtime scanning modes such as cadence contrast pulse sequences (CPS) have made possible significant advances in the management of patients with pathology affecting large vessels. This has been particularly valuable in aortic graft procedures where the lack of nephrotoxicity allows multiple repeat studies for follow-up of leaks. It has also proved valuable in situations where the flow is very slow and undetectable on conventional Doppler

Ultrasound (US) plays a secondary role to computed tomography (CT) in the diagnostic assessment of traumatic lesions involving abdominal organs, especially in the case of major trauma (Becker et al. 1998; Boioli et al. 1993; Brown et al. 1998; Harris et al. 2001; Mirvis 2000; Sherck et al. 1984; Shuman 1997). Because US has a relatively limited panoramic capacity, it does not detect lesions of hollow internal organs reliably. On the whole it has a lower sensitivity and specificity than CT in the diagnosis of parenchymal damage to the liver, kidney and spleen.

The aim of the study was to assess the effectiveness and safety of iomeprol (300 mg I/ml) in CT of the brain. Thirty-one patients were enrolled according to strict inclusion and exclusion criteria necessary for a phase II study. The efficacy was judged to be good in 10 patients and excellent in 21. None of the patients showed clinically significant changes in vital parameters, ECG and EEG tracings or laboratory tests. Among the 31 patients there were no subjective reactions and only 1 patient complained of a side-effect. Taking into account the results of this multicentre trial we can conclude that iomeprol is a good contrast medium with excellent local and systemic tolerability.