Ultrasound 1)CEUS (contrast enhanced ultrasound) 2) 2)Elastography 3) 3)Navigation systems logo_lf_mu CEUS Principle nGas bubbles reflect back ultrasound waves nThey are strictly intravascular, they do not penetrate into the extravascular space. nThey rupture and gas from them is excreted through the lungs n nus probe n SonoVue® nMicrobubbles stabilized by phospholipids nIt contains Sulfur-hexafluorid (SF6) – inert gas, excreted trough lungs respiration n nIncrease in signal intensity for 3-8 min. n n bublinky Liver B-mode nWhen you could say definite diagnosis: n nTypical liver cyst n n nCalcification SMIDOVAJANA20080603133249699 nAll other focal hepatic lesions are characterized not only by differences in echogenicity, but also due to different vascularization bearings and due to changes in perfusion kinetics. n nDue to the dual blood supply of the liver by portal vein and hepatic artery, we do not judge only according to whether they are hypo- or hypervascular but also saturation depends on the perfusion stage and thus on the histological structure Dose nNormal liver n n1,5ml i.v. bolus + FR n nCirrhotic liver, fat patient, deep lesion n n2,0 ml i.v. bolus + FR n n Hemangioma nthe most common benign liver tumor noften an incidental finding nusually stable, but can vary in time ncan also grow rapidly obr04 obr06 obr07 obr08 obr02 Focal nodular hyperplasia nSecond the most common benign liver tumor ncontains hepatocytes, elements of bile ducts, Kupffer cells, fibrous stroma and often "central scar"(50%) ntypically random finding in women Centrální jizva tvořena vaskulární či myxoidní tkáň s vysokým obsahem volné vody. Kolagen uvnitř jjizvy nemá organizovaná vlákna tak, jako je tomu ve šlachách, proto tolik nezkracují T2 relaxační čas. Periferně radiující septa také obsahují arteriální a venózní kanály a žlučovody. Hepatocellular adenoma nrelatively rare benign tumor is potentially malignant nAssociated with oral contraceptives, 90% young women . nFrequent cause of pain because of it contains necrosis and hemorrhage nprimarily arise from hepatocytes may contain fat, often contain intracellular glycogen, they tend to have a thin pseudocapsule, lack architectonics, there is a relatively small amount of bile ducts and often degenerative necrosis HA ninhomogeneity (hyperechoic districts of acute hemorrhage, hypo- to unechogenic in older bleeding) nhomogeneous saturation in the arterial phase, zero saturation in portovenose phase poorly distinguishable - coincides with the parenchyma in late (sinusoidal) phase pericapsular vessels. Liver absces nSymptoms are often non-specific n nFindings on nativ US is sometimes nonspecific and difficult to distinguish from tumor necrosis n nContent of the gas is a specific finding, but is present less than 20% of cases D:\kUCHAR_ABSCES\KucharJiri20100323091852908.jpg C:\Documents and Settings\Administrator\Dokumenty\Obrázky\vlcsnap-2011-12-12-22h45m21s178.png Hepatocelullar carcinoma nThe most common primary malignant liver tumors nassociated with cirrhosis, chronic active hepatitis, hemochromatosis nlarger HCC usually hypervascular HCC nIntensive saturation with a rapid increase (time to peak) in the arterial phase, a relatively rapid wash-out in portal phase V ultrazvukovém obraze vidíme nodulární formu HCC. V B módu je nádor hypo- až izoechogenní s hypoechogenní lemem a centrální hyperechogenitou (1a). V dopplerovském záznamu jsou patrné tepny v centru i v periferii nádoru (1b-d). Po aplikaci kontrastní látky (Sonovue) se sytí v arteriální fázi tepny v nádoru a nádor je nehomogenně hyperechogenní, v portální fázi, se sytí lem je nádor izoechogenní, patrná je stále tepna v centru a hyperechogenní sytící se lem kolem nádoru (1e,f). Cholangiocarcinoma •HCC less frequent and in older patients •hypovascular tumor Metastasis nthe liver is the most common site of distant metastasis nThey have great variability, may be cystic, solid, mixed, hypervascular or hypovaskular Colrectal carcionma metastasis obr01 obr02 obr03 obr04 obr05 obr06 obr07 Hypervascular metastasis (karcinoid) KOPECEKJIRI20080129102308634 obr04 KOPECEKJIRI20080129101842308 Kidneys When we use it nWe can differentiate solid lessions from cystic nGradeing of cystic lessions - Bosniak classification n n nCase 1 PeroutkovaEva20091208111827734.jpg PeroutkovaEva20091208112817104.jpg PeroutkovaEva20091208112827005.jpg PeroutkovaEva20091208111848258.jpg nChromofobe RCC Chromofobní RCC nCase 2 D:\kuba\Havlik onkocytom CT1.jpg D:\kuba\Havlik onkocytom CT2.jpg D:\kuba\Havlik onkocytom CT3.jpg D:\kuba\Havlik Onkocytom 2.jpg D:\kuba\Havlik Onkocytom 3.jpg nOnkocytoma Onkocytom OndrejkovaValerie20090113101433065.jpg nCase 3 AML kidney cysts n n nStandard: CT – Bosniak classification n n I, II - benigne n IIF - probably benigne, track n III - 50% maligne n IV - almost 100% maligne n n Bosniak I Kalenda_CT_kortikomed.jpg KalendaBohumil20081209085559995.jpg KalendaBohumil20081209090927931.jpg Bosniak II nthin septs, sometimes you can watch the gentle enhancement of septs Dolezal_UZ_kontr.jpg Stejný pac. CT a CEUS, jiný MR Bosniak IIF nMore septs, and theyr enhancement nwall thickening without enhancement nT2 TSE nT1 k.l. Bosniak III nthickened wall, or septum, with enhancementh KOLACKOVAJANA20080729130609388.jpg nMultilocular cystic nefroma Bosniak IV nSolid soft tissue nodul with enhancement Sochor_CT_nefrogr.jpg SochorRadomil20090414153930865.jpg stejný pac. Elastografie Radiologická klinika FN Brno a LF MU logo_lf_mu Basis principles of elastography nIt uses ultrasound to determine the difference in rigidity (elasticity) of the tissues nTissue stiffness is generally expressed by Young's modul (unit - Pa)) n n n n n nMore stiffness = higher Young model nthe ratio between the applied pressure (S) and the induced strain (e) Strain elastography nThis method use compression of tissue by own patients movement (breathing, moving of the heart and blood vessels) nIn this method we can only make color maps, but not mesure values of preasure n n Shear wave elastography nWith appropriate ultrasound waves, we can generate both longitudinal and transverse waves (shear waves) ntransverse waves (shear waves) formed as a response of elastic tissue resistance to vibrations with low frequency n nsource of vibration are pulses of acoustic pressure generated by focused ultrasound n nAnd we can measure it n n n n nE ... elasticity [Pa] nρ ... Density of environment [kg.m–3] nc ... velocity of propagation [m.s–1] Shear wave elastografie nOne point – static(number) n n n n n nDynamic – on line colour map Where we can use it nLover nGrade of fibrosis nSpleen nPortal hypertensis nThyroid gland nBrest lessions Navigation systems D:\znak_LF_cerveny_RGB_pozadi.emf D:\fn-brno-barva-pozitiv.jpg System functions n nreal-time fusion of US/CEUS with (CT, MR, PET/CT) n n nNavigated intervencion with special needles nBiopsi nAblacion n n n n n F:\přednášky\Čejkovice 2014\PercuNav\foto\zmens\DSC00553.JPG nMachine D:\radiol\přednášky\Čejkovice 2014\PercuNav\foto\DSC00542.JPG nEM field nGenerator nSensor Fusion CT +UZ Use of fusion Fusion + navigation - planning F:\CEUS a fuze\Ondrackova - fuze a biopsie\1.3.46.670589.33.1.25431418384255141962.27430042032029753788_006.jpg nComputed tomography n1) VIRTUAL COLONOSCOPY n n2) Spectral CT n VIRTUAL COLONOSCOPY Indication nExaminatio is intended to detect polyps and carcinomas, in case that the optical colonoscopy is: nincomplete (anatomy, spasm, stenosis, adhesion ..) nintolerance or rejection by the patient ncontraindicated nunclear findings at OC increased risk of complications during OC (anticoagulation, age ...) n n n n nIt is not yet approved for colorectal cancer screening nReliable detection in larger polyps (above 5 mm) and cancers n Advantages VIRTUAL COLONOSCOPY nLow-dose technic (about 7-8 mSv) nNonivasive, no pain nYou can avaluate wall and surroundings of bowl, and i native picture whole abdomen. nYou see behind stenosis n nDisadvantages – les accurate nNo interventions nArteficial findings(faeces, resiodual intraluminal material) nExamination nPreparation for examination is same as on normal colonoscopy n+ nNight before posive contrast peroral for faecaes marking n+ closely before examination: nHypotony– 1ml Buscopan i.v. nInsuflation of CO2 on preasure between 6-25mmHg.. nThan CT examination two positions: on the abdomen and back nExamination n nClassic 2D CT nativ n nPrimary software automatic detection of polyps(CAD) nSecundary manual detection in n nComputer-aided detection CAD n6 mm měkkotkáňový polyp na colon ascendens – malý tubulární adenom nSubmucosal lipoma MRI – New methods ndiffusion-weighted imaging, (DWI) n ndiffusion tensor imaging, (DTI) n nFunctinal MRI (fMRI) Spectral CT nCT spectral data reconstructed using Compton scattering and photoeffect information is stored in SBI (Spectral Based Image) n nspectral data results can be displayed as normal grayscale CT or color map. n npixel intensity may correspond to: nHU nconcentrations of the material (mg / ml), e.g. iodine neffective atomic number (Zeff) n n n n Spectral CT usage nPerfusion maps in diagnosis of a.pulmonalis embolisation n nSpectral analysis of urinal stones n nDetection of hypervascular leasions(e.g. In liver): n n n n nA. pulmonalis branch embolasition Mixed urinary stone DWI: Diffusion weighted imaging nDifusion – random motion of water molecules in tissue (Brownův pohyb) n nAlteration of the process of diffusion is characteristic for certain pathological conditions http://quantumfreak.com/wp-content/uploads/2008/10/motion-of-molecules1.gif n n n n n nDWI b1000 anisotropic nDWI b1000 isotropic nDWI b0 nADC neADC Interpretation of DWI nRestriction od difusion: nHyperintens DWI B1000 nHypointens na ADC nDWI B0 = T2 nDWI B1000 nADC neADC Indications and practical use of DWI n nDetection of early ischemia, and differentiation from tumors nDifferential diagnosis of ring lesions nMore accurate differential diagnosis of tumors. Ischemia on DWI http://www.radiologyassistant.nl/images/thmb_48414dd3a5b4b_MR7.jpg Ischemia x tumor n nDWI B1000 nADC nT2 TSE tra. Dif. dg. of ring lessions nAbsces – restriction of diffusion: ↓ADC nTumors – facilitacion of diffusion - necrotic centre: ↑ADC Dif. dg. Ring lessions nCT k.l. nT2 TSE tra. nT1 SE k.l. tra. nFLAIR cor. nDWI b1000 nADC nAbsces Dif. dg. Ring lessions nMetastasis lung adenokarcinoma nT2 TSE tra. nT1 SE k.l. cor. nDWI b1000 nADC neADC Dif. dg. of tumors n DWI image depence on the histological structure of the tumor tissue: diffusion decreases with increasing cellularity, (↓ADC) lymfoma, high-grade glioma n nHigh ADC value - low-grade glioma – low cellularity Dif. dg. tumors nLymfoma nT2 TSE tra. nT1 SE k.l. sag. nDWI b1000 nADC Dif. dg. tumors nHigh-grade glioma nDWI B1000 nADC nT2 TSE tra. nT1 SE k.l. tra. DTI – diffusion tensor imaging §Method based on the principles of DWI § §Diffusion anisotropy in the white matter of the brain and spinal cord: the movement of water molecules occurs more easily along the nerve fibers § §DWI image signal intensity depends on the direction of the magnetic gradient adjunctive § §Repeated measurements with different directions of diffusion can detect the dominant direction of diffusion direction → During nerve pathways for example DTI nprocessing: nMap of fraction anisotrophy nDirectionally coded map of vectors of diffusion anisotropy n3D Fibertracking DTI - usage nMeasurement of fractional anisotropy and ADC evaluation for impairment of white matter: nNormal white matter - the maximum diffusion along the long axis of the nerve bundles nAbnormal white matter - an increase of diffusivity of water molecules throughout the nerve tracts → reduce diffusion isotropy → DTI has the potential for earlier detection of pathology of white matter than conventional display n3D fibertracking - displaying of neural pathways eg. To assess the relationship to tumor DTI fibertracking: glioma gr. II nTractus corticospinalis nFasciculus uncinatus DTI fibertracking: glioma gr. III nRadiatio optica nT2 TSE tra. nDWI b0 cor. DTI fibertracking: metastasis nTractus corticospinalis DTI fibertracking: spine tumor nT2 TSE sag. nT2 FFE tra. nmapa FA One of the modern applications of magnetic resonance imaging Allows direct display of functionally active cortical areas Totally non-invasive examination, relatively easy for patients What can be displayed: motor functions, auditory and visual centers, memory, speech and cognitive functions, emotions… SPM2 Philips_Achieva_3T Bold efekt Blood oxygen level dependency(BOLD): The basic principle of fMRI The dependence of the MR signal intensity on the ratio of oxyhemoglobin / deoxyhemoglobin lKortical activity: lTransient increase in the concentration deoxyHb → decrease in T2 * signal lvasodilation with increased blood flow → ↓ deoxyHb and increase in T2 * signal image_preview fMRI examination •Examination of the entire brain •multiply repeated a certain kind of activity (finger movement, speech ..) alternating with the rest sections •Statistical analysis reveals a difference in signal intensity in different areas of the brain by comparing blocks of stillness and blocks of activities nIndication of fMRI nPreoperative mapping of functional cortical centers nAssessment of functionally important areas related to tumor n n n n nwww.fmri.org nFMR low-grade glioma nFinger of right hand movement nSekvence •Single shot EPI •TR 3000ms, TE 50ms •80 dyn. akvizic •Overlay statistických map na referenční sken T1 true IR fMRI – visiom kortex n n n n n fMRI use in preoperative planning lRule of fMRI: l ldetermination of lateralization of speech lPreoperative view of eloquent cortical areas related to tumor lPeroperativ navigation of stimulating electrods l l l n PET/MR nHybrid method nPositron emission tomography nMagnetic resonance n1 device – MR + PET n https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcTaN1YXUBfwiPRChFDS7vWkc1np_SzripoD-IPWsqC2wlI 2uu3s PET nTomographic method, three-dimensional mapping of radioactivity nPrinciple - detection of photons(gama radiation) - during annihilation of positrons and electrons nPositron - radiopharmaceutical - short half-life - beta + decay nTwo 511keV photons - two registration at one time nDetectors - ring - coincidence connection nActivity at individual points DSCN3717 ndd ndd Radiopharmaceuticals n18FDG – aerobic glycolysis n18FLT – fluorothymidin - cell proliferation n Na18F – bone recovery n18Fcholin – prostate carcionoma n18Fflutemetamol – brain Alzheimer disiese n68Ga DOTA– neuroendocrinal tumors Indication nOncology (staging, control of treatment effectiveness, monitoring after treatment) n nInflammation (investigation of inflammation origin, vasculitis, sarcoidosis, inflammation of the heart, suspected inflammatory changes around implanted foreign materials n nRheumatology (eg polymyalgia) n nCardiology - myocardial viability n nEndocrinology (detection of hyperfunctional parathyroid glands) n nNon-tumorous pathology of CNS (Neurodegenerative diseases) Benefits of PETMR x PETCT nNo radiation load x CT nPETCT – mean dose 5 - 23 mSv, PET 3-5 mSv nExcellent tissue contrast MR nPossibility to combine with more advanced techniques such as perfusion, DWI, angiography, spectroscophy nDisadvantage the length of the examination and basic MRI contraindications n nlymfoma nMetastais in liver CA of rectum