Arrival time parametric imaging of the hemodynamic balance changes between the hepatic artery and the portal vein during deep inspiration, using Sonazoid-enhanced ultrasonography: A case of Budd-Chiari syndrome.

This case report concerns a 40-year-old male who had previously been treated for an esophageal varix rupture, at the age of 30 years. The medical examination at that time revealed occlusion of the inferior vena cava in the proximity of the liver, leading to the diagnosis of the patient with Budd-Chiari syndrome. The progress of the patient was therefore monitored in an outpatient clinic. The patient had no history of drinking or smoking, but had suffered an epileptic seizure in 2004. The patient's family history revealed nothing of note. In February 2012, color Doppler ultrasonography (US) revealed a change in the blood flow in the right portal vein branch, from hepatopetal to hepatofugal, during deep inspiration. Arrival time parametric imaging (At-PI), using Sonazoid-enhanced US, was subsequently performed to examine the deep respiration-induced changes observed in the hepatic parenchymal perfusion. US images captured during deep inspiration demonstrated hepatic parenchymal perfusion predominantly in red, indicating that the major blood supply was the hepatic artery. During deep expiration, the portal venous blood flow remained hepatopetal, and hepatic parenchymal perfusion was displayed predominantly in yellow, indicating that the portal vein was the major source of the blood flow. The original diagnostic imaging results were reproduced one month subsequently by an identical procedure. At-PI enabled an investigation into the changes that were induced in the hepatic parenchymal perfusion by a compensatory mechanism involving the hepatic artery. These changes occurred in response to a reduction in the portal venous blood flow, as is observed in the arterialization of hepatic blood flow that is correlated with the progression of chronic hepatitis C. It has been established that the peribiliary capillary plexus is important in the regulation of hepatic arterial blood flow. However, this case demonstrated that the peribiliary capillary plexus also regulates acute changes in portal venous blood flow, in addition to the chronic reduction in blood flow that is observed in patients with chronic hepatitis C.

Arrival time parametric imaging using Sonazoid-enhanced ultrasonography is useful for the detection of spoke-wheel patterns of focal nodular hyperplasia smaller than 3 cm.

It is considered difficult to make a definitive diagnosis of focal nodular hyperplasia (FNH) of <3 cm when using conventional diagnostic imaging modalities. Typical FNH imaging findings are: i) central scar formation, ii) nutrient vessels extending radially from the center and iii) the presence of Kupffer cells. In a clinical setting, identification of a spoke-wheel pattern formed by nutrient vessels extending radially is a key feature in the diagnosis of FNH. In this study, we investigated the detection rate of spoke-wheel patterns of FNH <3 cm using arrival time parametric imaging (At-PI) technology with Sonazoid-enhanced ultrasonography (US). Five patients with FNH <3 cm who had undergone Sonazoid-enhanced US at the Toho University Omori Medical Center between February 2008 and March 2009 were included in the study. The mean tumor diameter was 20.2±7.2 mm. Lesions were enhanced with 0.5 ml Sonazoid US contrast agent and a video of the procedure was saved and used for At-PI analysis of contrast agent dynamics in FNH. Three ultrasonographic specialists examined the images and made a diagnosis of FNH based on the findings of spoke-wheel patterns. Similarly, micro-flow imaging (MFI) was performed to evaluate the contrast agent dynamics in FNH. Using MFI, FNH was diagnosed in 3 of the 5 cases by the three specialists, whereas At-PI enabled the identification of spoke-wheel patterns in all 5 cases. At-PI using Sonazoid-enhanced US is superior for detecting spoke-wheel patterns of FNH <3 cm.

Visualization of segmental arterialization with arrival time parametric imaging using Sonazoid-enhanced ultrasonography in portal vein thrombosis: A case report.

A 55-year-old male was admitted in mid-April 2011 with a fever of >39°C and pain in the lower right abdomen. A medical examination revealed sepsis originating from colonic diverticulitis. Abdominal B-mode ultrasonography (US) performed on admission detected thrombi in the superior mesenteric vein and in the right branch of the hepatic portal vein. Arrival time parametric imaging (At-PI) using Sonazoid-enhanced US showed arterialization of the entire right lobe of the liver. The treatment for the sepsis and portal thrombi that had been started upon admission dissolved the thrombi by day 22, with the exception of one thrombus in the P8 branch of the portal vein. At-PI performed on the same day confirmed arterialization in segment 8, but portal vein dominance was restored elsewhere. When the blood inflow from the hepatic portal vein was reduced, the hepatic arterial blood flow was increased to compensate for the reduction in the total blood supply. The At-PI functions used in the Sonazoid-enhanced US were simple yet effective in visualizing the changes in the hepatic hemodynamics caused by the portal thrombus.

Hepatic parenchymal hemodynamics of cholangitis with portal trunk thrombus using contrast-enhanced ultrasonography with Sonazoid: delineation of so-called central and peripheral zonal differentiation by arrival-time parametric imaging.

We carried out contrast-enhanced ultrasonography using Sonazoid for a patient who had portal thrombosis due to choledocholith and cholangitis, and the video images were analyzed by an offline procedure using arrival-time parametric imaging. Colors were changed with the time course from red to orange, yellow, green, light blue, and blue, with the time the contrast agent reached the right hepatic artery as the starting point. The central part of the liver was primarily colored blue, and the peripheral part primarily yellowish-green. In other words, we confirmed the central and peripheral zonal differentiation observed in the arterial phase of dynamic computed tomography by color mapping image of arrival-time parametric imaging. Particularly, real-time changes in the hemodynamics of the hepatic parenchyma could be captured by color mapping image using arrival-time parametric imaging.

Usefulness of arrival time parametric imaging in evaluating the degree of liver disease progression in chronic hepatitis C infection.

OBJECTIVE: To determine whether the degree of liver disease progression in chronic hepatitis C infection can be evaluated by arrival time parametric imaging using contrast-enhanced sonography with Sonazoid (perfluorobutane; GE Healthcare, Oslo, Norway). METHODS: In this study, 60 patients with liver disease in chronic hepatitis C infection were examined and compared with 10 healthy volunteers who served as controls. A recommended dose of the sonographic contrast agent Sonazoid was intravenously infused, and the S5 or S6 region of the liver and right kidney were observed concurrently while movies of the procedure were saved. Arrival time parametric images of liver parenchymal blood flow were created, with red pixels to indicate an arrival time of 0 to 5 seconds and yellow pixels to indicate an arrival time of 5 to 10 seconds. From the obtained images, the ratio of the red area to the entire enhanced area of the liver was calculated using image-processing software. Each participant was subsequently subjected to liver biopsy for liver fibrosis staging according to Metavir scores, and the determined fibrosis stage was compared with the ratio of red. The serum albumin level, platelet count, and prothrombin time were also compared with the ratio of red for each participant. RESULTS: The ratio of red increased significantly as liver fibrosis stage advanced (P < .01 for F1 versus F2; P < .01 for F1 versus F3; P < .01 for F1 versus F4; and P < .01 for F2 versus F4). As the ratio of red increased, significant decreases were observed in the serum albumin level (r = -0.29; P = .027), platelet count (r = -0.46; P = .0003), and prothrombin time (r = -0.46; P = .0002). CONCLUSIONS: Arrival time parametric imaging using Sonazoid-enhanced sonography enables noninvasive evaluation of the degree of progression of liver disease in chronic hepatitis C infection and is thus considered clinically useful.

A case of poorly differentiated hepatocellular carcinoma with intriguing ultrasonography findings.

A 60-year-old female was referred to the Toho University Omori Medical Center due to ultrasonography findings revealing a notable hepatic mass. The 44×32 mm isoechoic mass had a high-echo band along the margin in the liver. Contrast-enhanced ultrasonography (CEUS) with Sonazoid detected an enhancement pattern extending from the outer periphery to the inside of the mass in the vascular phase and a pattern similar to that of surrounding hepatic tissue in the post-vascular phase. High-flow hepatic hemangioma was suspected due to the hyperechoic rim-like high-echo band, the oval shape and the CEUS findings. However, computed tomography revealed a hypervascular hepatocellular carcinoma (HCC) pattern and the patient underwent surgery. Histopathological findings revealed poorly differentiated HCC. As poorly and moderately differentiated HCC types are conventionally classified as 'hypervascular HCC', few detailed ultrasonography (US) studies of poorly differentiated HCC are available. US characteristics of hypervascular HCC include the presence of a halo (hypoechoic band) around the lesion and reduced signal intensity in the post-vascular phase of CEUS. US in the patient revealed a mass with a hyperechoic band and a signal intensity in the post-vascular phase of CEUS that was almost identical to that of the surrounding liver parenchyma. These findings suggest poorly differentiated HCC and indicate that further research on hypervascular HCC is required.

Diagnosis of hepatic hemangioma by parametric imaging using sonazoid-enhanced US.

BACKGROUND/AIMS: Comparison of Parametric Imaging (PI) using Sonazoid-enhanced ultrasonography (US) and microflow imaging (MFI) to determine the possibility of hepatic hemangioma diagnosis using PI. METHODOLOGY: Twenty-two hepatic hemangioma nodules (mean±SD diameter: 31.6±19.1mm) undergoing Sonazoid-enhanced US between February 2008 and March 2009. After Sonazoid-enhanced US, COMMUNE ultrasonographic image analysis software was used for analysis of tumor imaging dynamics in the vascular phase using PI and MFI. In PI, 0s was set as the time contrast agent reached the tumor. Imaging within the tumor after 0s was color-coded according to time, and the images were displayed in color. In MFI, 0s was set as the time contrast agent reached the tumor. The path of microbubbles as it flowed through blood vessels was superimposed on the original B-mode images. Three trained physicians used these methods to analyze tumor imaging dynamics. RESULTS: All physicians concluded all cases were hepatic hemangioma regardless of method used. However, compared to MFI, PI allowed determination of more detailed blood flow dynamics in high-flow hepatic hemangioma, where blood flow speed was faster than in normal hepatic hemangioma. CONCLUSIONS: It is possible to diagnose hepatic hemangioma using PI using sonazoid-enhanced US.

Drinking status of heavy drinkers detected by arrival time parametric imaging using sonazoid-enhanced ultrasonography: study of two cases.

Chronic heavy consumption of alcohol is associated with increased risks of developing liver cirrhosis, hepatocellular carcinoma, and esophageal varices. Cessation of alcohol consumption is the most important requirement in treating these diseases. However, judging whether patients have actually maintained abstinence from alcohol requires reliance on their reports, which vary substantially across individuals using the test methods currently available. Arrival time parametric imaging (At-PI) using Sonazoid-enhanced ultrasonography is regarded as a useful approach for assessing the progression of lesions that have developed in liver parenchyma. In this study, we report two cases for whom this approach was successfully applied to indicate the drinking status of a heavy drinker. At-PI enables approximate and objective assessment of the drinking status of patients, independent of their reports; therefore, it is a promising method for providing information about drinking status.

Recurrence incidence of small HCC in cirrhosis patients by ablation versus injection.

BACKGROUND/AIMS: The incidence of local recurrence of hypervascular hepatocellular carcinoma (HCC) (15 mm or less) was compared retrospectively between a group treated with radiofrequency ablation (RFA) using cool-tip (Radionics, USA) 10-mm electrodes and a group treated with percutaneous ethanol injection (PEI). METHODOLOGY: There were 23 patients who were treated for a total of 25 tumors during a 3-year period at our hospital. Ten of the tumors (11.1 +/- 2.7mm) were treated with RFA using cool-tip 10-mm electrodes and 15 tumors (10.6 +/- 2.7 mm) were treated with PEI. After treatment, progression was evaluated in enhanced CT scans every 3-6 months to confirm presence or absence of local recurrence. RESULTS: The number of recurrences, mean observation period, and mean recurrence period in the RFA group were 2 (20%), 6.6 months, and 6 months. The number of recurrences, mean observation period, and mean recurrence period in the PEI group were 2 (13.3%), 19.1 months, and 18 months. The period between treatment and recurrence tended to be longer in the PEI group than in the RFA group to be significant p < 0.05. CONCLUSIONS: The results suggest that PEI treatment is more effective in local treatment of hypervascular HCC with tumor diameters of 15 mm or less.

Evaluation of local recurrence after treatment for hepatocellular carcinoma by contrast-enhanced ultrasonography using Sonazoid: comparison with dynamic computed tomography.

PURPOSE: To evaluate the effectiveness of contrast-enhanced ultrasonography (CEUS) using Sonazoid for the diagnosis of the local recurrence after treatment for hepatocellular carcinoma (HCC) by comparing it with dynamic CT. METHODS: Seventy-one patients with 87 HCC lesions (mean +/- SD; 19.5 +/- 9.6 mm) underwent CEUS using Sonazoid and dynamic CT after radiofrequency ablation (n = 55), transcatheter arterial chemoembolization (n = 22), or radiofrequency ablation combined with transcatheter arterial chemoembolization (n = 10). Two hepatologists (observer 1; 10 years of experience, and 2; 20 years of experience) reviewed the CEUS and dynamic CT images independently and evaluated presence or absence of the local recurrence. Diagnostic performance for the local recurrence was assessed using receiver operating characteristic curve analysis. RESULTS: The Az value for dynamic CT was significantly lower in observer 1 than 2 (p < 0.05). The sensitivity of CEUS was 79% in observer 1 and 83.9% in observer 2, and that of dynamic CT was 83.9% and 90.3%, respectively. The specificity of CEUS was 96%, and that of dynamic CT was 92%, in both observers. CONCLUSION: This study suggests that CEUS using Sonazoid is less affected by the observer's experience and is more accurate in the diagnosis of local recurrence after treatment for HCC than dynamic CT.

Cool-tip 10-mm electrode useful for radiofrequency ablation of hepatocellular carcinoma.

BACKGROUND/AIMS: Whether a cool-tip 10mm electrode is useful for radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) has not been established. Accordingly, the present study goal was to determine this electrode is indicated for RFA of HCC. METHODOLOGY: This study was conducted with 30 HCC patients who were treated with a cool-tip 10-mm electrode over a period of about 3 years. Ten had hypervascular HCC nodules and 20 had hypovascular HCC nodules; mean tumor diameter was 10.5 +/- 1.8mm. Patients underwent follow-up CT scans every 3 to 6 months to detect local progression. RESULTS: Of the 30 lesions, 4 (13.3%) showed local progression. Enhanced CT imaging of the four cases with local progression revealed that two had hypervascular HCC. The remaining two cases had hypovascular HCC. CONCLUSIONS: The present study results suggest that, RFA with a cool-tip 10-mm electrode is indicated in cases of hypovascular HCC nodules if the lesion diameter is no more than 10mm. In addition, in order to avoid skin burns, only lesions at a depth of at least 16mm below the liver surface are suitable for this treatment. Because of its lesser invasiveness, the cool-tip 10-mm electrode appears to be more useful than other, more powerful, devices in patients with hepatic carcinoma.