This article outlines a roadmap to achieving and maintaining excellence in an ultrasound (US) practice. We present constructive advice on how US practices can achieve and maintain quality, patient and referring physician satisfaction, and efficiency in the setting of rising examination volumes. Accreditation, sonographer and resident/fellow physician training, advanced practice sonographers, and Picture Archiving and Communication System/Artificial Intelligence in US are discussed. Advice for how to begin offering new US examinations, begin a practice at new US locations, improve quality assurance, and enhance marketing are covered.

Ultrasound (US) is the imaging modality of choice for evaluation of superficial palpable lesions. A large proportion of these lesions have characteristic sonographic appearance and can be confidently diagnosed with US without the need for biopsy or other intervention. The Society of Radiologists in Ultrasound (SRU) recently published a Consensus Conference Statement on superficial soft tissue masses. The goal of this manuscript is (a) to serve as a sonographic pictorial review for palpable lesions based on the SRU statement, (b) present the typical sonographic features of palpable lesions that can be confidently diagnosed with US, and (c) provide an overview of other palpable lesions with a framework to interpret the US studies and advise on appropriate further management.

Current descriptions of ultrasound evaluations, including use of the term “point-of-care ultrasound” (POCUS), are imprecise because they are predicated on distinctions based on the device used to obtain images, the location where the images were obtained, the provider who obtained the images, or the focus of the examination. This is confusing because it does not account for more meaningful distinctions based on the setting, comprehensiveness, and completeness of the evaluation. In this article, the Society of Radiologists in Ultrasound and the members of the American College of Radiology Ultrasound Commission articulate a map of the ultrasound landscape that divides sonographic evaluations into four distinct categories on the basis of setting, comprehensiveness, and completeness. Details of this classification scheme are elaborated, including important clarifications regarding what ensures comprehensiveness and completeness. Practical implications of this framework for future research and reimbursement paradigms are highlighted.

Abstract On October 24, 2017, in Chicago, the Society of Radiologists in Ultrasound convened a panel of specialists in contrast-enhanced ultrasound (CEUS) to arrive at a white paper regarding the use of CEUS in noncardiac applications in North America. Recommendations are based on analysis of the current literature and common practice strategies. They represent a reasonable approach to introduce the advantages of this safe and noninvasive technique for the benefit of our patients. Characterization of liver nodules with CEUS, as the approval indication worldwide, is the major focus of this endeavor. In addition, many off label uses are reviewed and literature supporting these indications provided. Key Points (1) Contrast-enhanced ultrasound (CEUS) allows cross-sectional imaging of the liver, kidneys and multiple other solid and hollow viscera, providing excellent characterization of identified focal mass lesions. (2) Performed with the injection of a microbubble contrast agent, CEUS provides a safe and readily available imaging technique which requires no ionizing radiation, making it appropriate for use in all ages, in those with renal insufficiency and when a portable examination is needed. (3) The CEUS can be considered in abdominal imaging whenever blood flow information is of value to diagnosis. (4) Dynamic real-time acquisition and the use of a purely intravascular contrast agent are the 2 most essential technical aspects of CEUS imaging which distinguish it from both computed tomography and magnetic resonance scan.

On October 24, 2017, in Chicago, the Society of Radiologists in Ultrasound convened a panel of specialists in contrast-enhanced ultrasound (CEUS) to arrive at a white paper regarding the use of CEUS in noncardiac applications in North America. Recommendations are based on analysis of the current literature and common practice strategies. They represent a reasonable approach to introduce the advantages of this safe and noninvasive technique for the benefit of our patients. Characterization of liver nodules with CEUS, as the approval indication worldwide, is the major focus of this endeavor. In addition, many off label uses are reviewed and literature supporting these indications provided. Key Points (1) Contrast-enhanced ultrasound (CEUS) allows cross-sectional imaging of the liver, kidneys and multiple other solid and hollow viscera, providing excellent characterization of identified focal mass lesions. (2) Performed with the injection of amicrobubble contrast agent, CEUS provides a safe and readily available imaging technique which requires no ionizing radiation, making it appropriate for use in all ages, in those with renal insufficiency and when a portable examination is needed. (3) The CEUS can be considered in abdominal imaging whenever blood flow information is of value to diagnosis. (4) Dynamic real-time acquisition and the use of a purely intravascular contrast agent are the 2 most essential technical aspects of CEUS imaging which distinguish it from both computed tomography and magnetic resonance scan.

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.

Pneumatosis of the gastrointestinal tract is defined as presence of air in the wall of the gastrointestinal tract and can occur in any part of the gastrointestinal tract. It is most commonly seen in the intestine and very rarely in the esophagus. The exact pathogenesis is still unknown. It is managed primarily by conservative and non-surgical therapy, unless there are findings to suggest an acute abdomen or other co-morbidities. On review of literature, very few case reports of esophageal pneumatosis have been published. We present a rare case of pneumatosis of the esophagus with cytomegalovirus (CMV) infection.

Microbubble ultrasound contrast agents (UCAs) were recently approved by the Food and Drug administration for non-cardiac imaging. The physical principles of UCAs, methods of administration, dosage, adverse effects, and imaging techniques both current and future are described. UCAs consist of microbubbles in suspension which strongly interact with the ultrasound beam and are readily detectable by ultrasound imaging systems. They are confined to the blood pool when administered intravenously, unlike iodinated and gadolinium contrast agents. UCAs have a proven safety record based on over two decades of use, during which they have been used in echocardiography in the U.S. and for non-cardiac imaging in the rest of the world. Adverse effects are less common with UCAs than CT/MR contrast agents. Compared to CT and MR, contrast-enhanced ultrasound has the advantages of real-time imaging, portability, and reduced susceptibility to metal and motion artifact. UCAs are not nephrotoxic and can be used in renal failure. High acoustic amplitudes can cause microbubbles to fragment in a manner that can result in short-term increases in capillary permeability or capillary rupture. These bioeffects can be beneficial and have been used to enhance drug delivery under appropriate conditions. Imaging with a mechanical index of < 0.4 preserves the microbubbles and is not typically associated with substantial bioeffects. Molecularly targeted ultrasound contrast agents are created by conjugating the microbubble shell with a peptide, antibody, or other ligand designed to target an endothelial biomarker associated with tumor angiogenesis or inflammation. These microbubbles then accumulate in the microvasculature at target sites where they can be imaged. Ultrasound contrast agents are a valuable addition to the diagnostic imaging toolkit. They will facilitate cross-sectional abdominal imaging in situations where contrast-enhanced CT and MR are contraindicated or impractical.

Chronic kidney disease is most desirably and cost-effectively treated by renal transplantation, but graft survival is a major challenge. Although irreversible graft damage can be averted by timely treatment, intervention is delayed when early graft dysfunction goes undetected by standard clinical metrics. A more sensitive and specific parameter for delineating graft health could be the viscoelastic properties of the renal parenchyma, which are interrogated non-invasively by Viscoelastic Response (VisR) ultrasound, a new acoustic radiation force (ARF)-based imaging method. Assessing the performance of VisR imaging in delineating histologically confirmed renal transplant pathologies in vivo is the purpose of the study described here. VisR imaging was performed in patients with (n = 19) and without (n = 25) clinical indication for renal allograft biopsy. The median values of VisR outcome metrics (τ, relative elasticity [RE] and relative viscosity [RV]) were calculated in five regions of interest that were manually delineated in the parenchyma (outer, center and inner) and in the pelvis (outer and inner). The ratios of a given VisR metric for all possible region-of-interest combinations were calculated, and the corresponding ratios were statistically compared between biopsied patients subdivided by diagnostic categories versus non-biopsied, control allografts using the two-sample Wilcoxon test (p <0.05). Although τ ratios non-specifically differentiated allografts with vascular disease, tubular/interstitial scarring, chronic allograft nephropathy and glomerulonephritis from non-biopsied control allografts, RE distinguished only allografts with vascular disease and tubular/interstitial scarring, and RV distinguished only vascular disease. These results suggest that allografts with scarring and vascular disease can be identified using non-invasive VisR RE and RV metrics.

BACKGROUND:Patients with chronic kidney disease are at increased risk of cystic kidney disease that requires imaging monitoring in many cases. However, these same patients often have contraindications to contrast-enhanced computed tomography and magnetic resonance imaging. This study evaluates the accuracy of contrast-enhanced ultrasound (CEUS), which is safe for patients with chronic kidney disease, for the characterization of kidney lesions in patients with and without chronic kidney disease.METHODS:We performed CEUS on 44 patients, both with and without chronic kidney disease, with indeterminate or suspicious kidney lesions (both cystic and solid). Two masked radiologists categorized lesions using CEUS images according to contrast-enhanced ultrasound adapted criteria. CEUS designation was compared to histology or follow-up imaging in cases without available tissue in all patients and the subset with chronic kidney disease to determine sensitivity, specificity and overall accuracy.RESULTS:Across all patients, CEUS had a sensitivity of 96% (95% CI: 84%, 99%) and specificity of 50% (95% CI: 32%, 68%) for detecting malignancy. Among patients with chronic kidney disease, CEUS sensitivity was 90% (95% CI: 56%, 98%), and specificity was 55% (95% CI: 36%, 73%).CONCLUSIONS:CEUS has high sensitivity for identifying malignancy of kidney lesions. However, because specificity is low, modifications to the classification scheme for contrast-enhanced ultrasound could be considered as a way to improve contrast-enhanced ultrasound specificity and thus overall performance. Due to its sensitivity, among patients with chronic kidney disease or other contrast contraindications, CEUS has potential as an imaging test to rule out malignancy.TRIAL REGISTRATION:This trial was registered in clinicaltrials.gov, NCT01751529 .

Malignant renal cell carcinoma (RCC) is a diverse set of diseases, which are independently difficult to characterize using conventional MRI and CT protocols due to low temporal resolution to study perfusion characteristics. Because different disease subtypes have different prognoses and involve varying treatment regimens, the ability to determine RCC subtype non-invasively is a clinical need. Contrast-enhanced ultrasound (CEUS) has been assessed as a tool to characterize kidney lesions based on qualitative and quantitative assessment of perfusion patterns, and we hypothesize that this technique might help differentiate disease subtypes. Twelve patients with RCC confirmed pathologically were imaged using contrast-enhanced ultrasound. Time intensity curves were generated and analyzed quantitatively using 10 characteristic metrics. Results showed that peak intensity ( p = 0.001) and time-to-80% on wash-out ( p = 0.004) provided significant differences between clear cell, papillary, and chromophobe RCC subtypes. These results suggest that CEUS may be a feasible test for characterizing RCC subtypes.

The current gold standard for monitoring renal transplant status is invasive biopsy, which is controversial due to its associated risk for morbidity and costs. A relevant biopsy alternative could be an imaging technique that exploits the viscoelastic properties of tissue given that renal disease may result in altered viscoelastic relationships between pelvis and parenchyma. Tissue viscoelasticity is delineated by VisR ultrasound, an acoustic radiation force (ARF)-based imaging method, by fitting displacements induced by two ARF impulses to the Mass Spring Damper (MSD) model. We hypothesize that VisR measures are relevant for noninvasively distinguishing biopsied and non-biopsied allografts by assessing viscoelastic similarity between pelvis and parenchyma in renal transplant patients. VisR derived metrics: τ, relative elasticity (RE), and relative viscosity (RV) were calculated in the regions of interest (ROI): outer, center, and inner parenchyma and outer and inner pelvis. The ratios of a given VisR measure for all possible ROI combinations were compared (Wilcoxon rank sum) between biopsied and non-biopsied patients. VisR τ, RE, and RV distinguished chronic allograft nephropathy, glomerulonephritis, vascular disease, and tubular and/or interstitial scarring in biopsied versus non-biopsied allografts (p <; 0.05). These results suggest that VisR measures may be relevant metrics for noninvasively monitoring renal transplant health.

Indeterminate cystic kidney lesions found incidentally are an increasingly prevalent diagnostic challenge. Standard workup includes Bosniak classification with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). However, these tests are costly and not without risks. Contrast-enhanced ultrasound (CEUS) is a relatively new technique with lower risk of adverse events than iodine-containing contrast or gadolinium. In our review of the evidence for characterization of cystic kidney lesions with CEUS, CEUS displayed sensitivity (89%-100%) and negative predictive value (86%-100%) comparable to contrast-enhanced CT or MRI, with no decrease in specificity compared with CT and only a slight decrease compared with MRI. (C) 2015 Elsevier Inc.

HomeRadioGraphicsVol. 35, No. 5 PreviousNext Genitourinary ImagingInvited Commentary: Role of US Contrast Agents in the Assessment of Indeterminate Solid and Cystic Lesions in Native and Transplant KidneysWui K. ChongWui K. ChongAuthor AffiliationsDepartment of Radiology, University of North Carolina at Chapel Hill Chapel Hill, North CarolinaWui K. ChongPublished Online:Aug 14 2015https://doi.org/10.1148/rg.2015150025MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1. Wei K, Mulvagh SL, Carson L, et al. The safety of Definity and Optison for ultrasound image enhancement: a retrospective analysis of 78,383 administered contrast doses. J Am Soc Echocardiogr 2008;21(11):1202–1206. Crossref, Medline, Google Scholar2. Cochran ST, Bomyea K, Sayre JW. Trends in adverse events after IV administration of contrast media. AJR Am J Roentgenol 2001;176(6):1385–1388. Crossref, Medline, Google Scholar3. Darge K, Papadopoulou F, Ntoulia A, et al. Safety of contrast-enhanced ultrasound in children for non-cardiac applications: a review by the Society for Pediatric Radiology (SPR) and the International Contrast Ultrasound Society (ICUS). Pediatr Radiol 2013;43(9):1063–1073. Crossref, Medline, Google Scholar4. Contrast-Enhanced Ultrasound Task Force. The Society for Pediatric Radiology. http://www.pedrad.org/Specialties/USContrastEnhanced.aspx. Accessed July 18, 2015. Google Scholar5. Piscaglia F, Nolsøe C, Dietrich CF, et al. The EFSUMB guidelines and recommendations on the clinical practice of contrast enhanced ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall Med 2012;33(1):33–59. Crossref, Medline, Google Scholar6. Chiu WC, Cushing BM, Rodriguez A, et al. Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST). J Trauma 1997;42(4):617–623; discussion 623–625. Crossref, Medline, Google Scholar7. Barr RG. Off-label use of ultrasound contrast agents for abdominal imaging in the United States. J Ultrasound Med 2013;32(1):7–12. Crossref, Medline, Google ScholarArticle HistoryPublished online: Aug 14 2015Published in print: Sept 2015 FiguresReferencesRelatedDetailsRecommended Articles Nontraditional Uses of US Contrast Agents in Abdominal Imaging and InterventionRadioGraphics2022Volume: 42Issue: 6pp. 1724-1741Contrast-enhanced US–guided Interventions: Improving Success Rate and Avoiding Complications Using US Contrast AgentsRadioGraphics2016Volume: 37Issue: 2pp. 652-664Artifacts and Technical Considerations at Contrast-enhanced USRadioGraphics2022Volume: 43Issue: 2Contrast-enhanced US Assessment of Focal Liver Lesions in ChildrenRadioGraphics2017Volume: 37Issue: 6pp. 1632-1647Optimizing Imaging of Pediatric Liver Lesions: Guidelines from the Pediatric LI-RADS Working GroupRadioGraphics2022Volume: 43Issue: 1See More RSNA Education Exhibits Contrast-enhanced Ultrasound As A Problem-solving Tool: A Guide To A Successful Integration Into Clinical RoutineDigital Posters2021Contrast-Enhanced Ultrasound (CEUS) in the Diagnosis and Management of Pediatric and Adolescent DiseaseDigital Posters2019Five Stages of Artifacts: Denial, Anger, Bargaining, Depression, and AcceptanceDigital Posters2019 RSNA Case Collection Colocolic IntussusceptionRSNA Case Collection2021Arterioportal fistulaRSNA Case Collection2021Acute appendicitisRSNA Case Collection2020 Vol. 35, No. 5 Metrics Altmetric Score PDF download

Doppler ultrasound is a noninvasive and accurate modality for evaluation of the liver and liver vasculature. Its real-time capability allows rapid diagnosis in a wide range of hepatic pathology. We review hepatic doppler in normal and diseased states, including portal hypertension, congestive cardiac failure, and portal and hepatic vein obstruction. Doppler evaluation of transjugular intrahepatic portosystemic shunts (TIPS) is also included.