Clinical Radiology (2002) 57: 157177 doi:10.1053/crad.2001.0918, available online at http://www.idealibrary.

com on

Review Advances in Ultrasound

C HR I S TO P H E R J . HA RV E Y *, J A M E S M . P I L C H E R {, RO B E R T J. E C K E R S L E Y *, M A R T I N J . K . B LO M L E Y *, D AV I D O . CO S G ROV E * *Department of Imaging, Hammersmith Hospital, Imperial College School of Medicine, London, U.K. and {Department of Imaging, St George's Hospital, London, U.K.
Received: 31 August 2001 Accepted: 9 September 2001 Ultrasound (US) has undergone dramatic changes since its inception three decades ago; the original cumbersome B-mode gantry system has evolved into a high resolution real-time imaging system. This review describes both recent advances in ultrasound and contrast media and likely future developments. Technological advances in electronics and computing have revolutionized ultrasound practice with ever expanding applications. Developments in transducer materials and array designs have resulted in greater bandwidths with improvements in spatial and contrast resolution. Developments in digital signal processing have produced innovations in beam forming, image display and archiving. Technological advances have resulted in novel imaging modes which exploit the non-linear behaviour of tissue and microbubble contrast agents. Microbubble contrast agents have dramatically extended the clinical and research applications of ultrasound. Not only can Doppler studies be enhanced but also novel non-linear modes allow vessels down to the level of the microcirculation to be imaged. Functional and quantitative studies allow interrogation of a wide spectrum of tissue beds. The advent of tissue-specic agents promises to improve the sensitivity and specicity of ultrasound in the detection and characterization of focal liver lesions to rival that of computed tomography (CT) and magnetic resonance imaging (MRI). Ultrasound has recently moved into therapeutic applications with high intensity focused ultrasound (HIFU) and microbubble assisted delivery of drugs and genes showing great promise. Harvey, C. J. et al. (2002) Clinical Radiology 57, 157177. # 2002 The Royal College of Radiologists Key words: ultrasonography, ultrasound technology, non-linear ultrasound imaging, ultrasound contrast agents, review.

Within just 30 years, diagnostic ultrasound (US) machines have progressed from cumbersome and expensive B-mode gantry systems that produced coarse, static, bi-stable images to hand-held devices capable of high resolution real-time grey-scale and colour Doppler imaging. Modern ultrasound machines are fully digital, which not only improves the signal to noise ratio of the returning echoes but also gives huge potential to the machine's performance with respect to beam formation, signal processing, image display and archiving [1]. Ultrasound may also be used to measure the elastic and dynamic properties of tissues. Technological advances have resulted in novel imaging modes such as those which exploit the non-linear behaviour of tissue and microbubble contrast agents. Microbubbles are safe and eective vascular echo enhancers which have extended the versatility of ultrasound and allow the microcirculation to be imaged as
Author for correspondence and guarantor of study: Dr C. J. Harvey, Department of Imaging, Hammersmith Hospital, Imperial College School of Medicine, Du Cane Road, London W12 0NN, U.K. Fax: +44(0)20 8 383 3121; E-mail: charvey_99@yahoo.com 0009-9260/02/030157+21 $35.00/0

well as providing functional data. They also have potential as tissue-specic and targeted therapeutic agents. High intensity focused ultrasound (HIFU) is another promising therapeutic application that is undergoing clinical evaluation. It is a testament to the importance of ultrasound that almost 25% of all imaging studies worldwide are ultrasound examinations. This article presents an overview of the developments in ultrasound and their applications.

COMPOSITION OF A REAL-TIME B-MODE ULTRASOUND SYSTEM

Real-time B-mode is most commonly used in clinical investigations and so it is important to outline the mechanisms by which such images are produced. Each image is formed line by line from information derived from the transducer which transmits and receives the ultrasound signals. The US echoes are converted by the transducer into electrical radiofrequency (RF) signals which undergo
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amplication (inuenced by the time gain compensation, TGC). In the US machine, the digitizer converts these analogue signals into RF digital signals and the amplitude, or envelope, of the signals is detected. This information is then read into the image memory (scan convertor) where it is converted into a format appropriate for TV display. The image data are usually manipulated by post-processing, logarithmic compression and interpolation between the lines. Developments at each stage of this pathway have enhanced the nal image and will be described.
DEVELOPMENTS IN TRANSDUCER MATERIALS AND CONSTRUCTION

ARRAY CONFIGURATIONS

Quadratic multi-dimensional arrays, known as 1.5D and 2D arrays, enable electronic focusing of the ultrasound beam in the z plane (slice thickness or elevation plane) which improves spatial and contrast resolution. 2D arrays are also capable of electronically steering the beam in any plane to produce a real-time volumetric image without moving the probe. However, the complex connections to the probe elements [6] and the amount of computing power required to deal with the signal from a 2D matrix means these arrays are still in the research phase.

The extensive selection of transducers available is a testament to the diversity of ultrasound applications; indeed some of the most signicant advances in image quality and applications follow from innovations in transducer technology [2]. Broadband technology has facilitated the development of non-linear and harmonic imaging [3]. Future transducer developments will depend on array congurations, transducer materials and construction with the promise of higher frequency probes, higher element densities, innovative geometries, advances in beam forming and improved ferroelectrics [4]. Ultrasound transducers have a limited range of frequencies over which they are eective. This bandwidth is often dened as the width of the frequency response (transducer eciency vs frequency relationship) at half maximum transducer output. A large bandwidth improves contrast and spatial resolution (both axial and lateral), and oers the possibility of a multi-frequency single probe. It is also essential for harmonic imaging. From the surface, a typical transducer comprises: (1) a protective layer; (2) a lens; (3) matching layers; (4) an active ferro- or piezoelectric material (with electrodes and connections); and (5) a backing block. The increase in bandwidth is due to the advances made by manufacturers in producing multiple matching layers and so maximizing the electromechanical coupling coecient (a measure of the eciency of conversion of sound to electrical energy). The ferroelectric material used is paramount in the performance of the transducer. Lead zirconate titanate (PZT) has been used for decades but has a high acoustic impedance with a consequent high reection coecient at the front and back surfaces. This results in `ringing' which lengthens the transmitted and received pulses; it also causes echoes that are reected back into the tissue, producing reverberation artifacts, and decreases sensitivity because of the low transmission coecient across the front of the transducer. The solution is to combine PZT with a material of low acoustic impedance such as epoxy resin to form a composite. Channels are cut into the PZT and lled with epoxy to reduce the acoustic impedance mismatch at the transducer faces [2]. New piezoelectric materials, known as ferroelectric relaxors, are currently under evaluation [5]. They are much more ecient in their conversion of electrical to sound energy, with an acoustic impedance better matched to tissue than traditional piezoelectric materials.

HANAFY LENS

Modern transducers use a mechanical lens to focus the beam in the elevation plane. They have a single xed focus placed at the area of interest. However, the use of single xed focus results in image non-uniformity when signals are received away from the chosen focus. The Hanafy pianoconcave transducer design overcomes this by using a phased-array design (sector, linear or convex) with variable ceramic thickness in the elevation plane [7]. This improves elevation slice thickness control and increases transducer bandwidth (improved axial resolution).

DIGITAL ULTRASONIC IMAGING

Digital technology has revolutionized all stages of US systems [8]. One of the most important advances is the use of application specic integrated circuits (ASICs) whereby one superchip can replace several boards of electronics. ASICs mean that circuit complexity, speed and reliability can be increased while reducing relative cost, power consumption and size. Thus we have seen the evolution of small portable scanners with high resolution grey-scale, power and pulsed wave Doppler, tissue harmonic imaging and image/cine memory.

Digital Beam Forming

Digital beam forming has allowed the development of time-saving techniques which may be used to improve image quality, the size of the eld of view or the frame rate. Digital control of the transducer array can be used to steer the US beam and allows dynamic changes in both focusing and aperture to be made while receiving US echoes. This provides higher spatial resolution and, by reducing artifacts, improves image contrast.

IMAGE AND SIGNAL PROCESSING

A number of ingenious techniques have been developed by manufacturers to optimize US images by manipulating the RF digital signal, thus improving diagnostic eciency and reducing the operator dependent nature of US.

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Spatial Compounding
Spatial compounding is a technique which uses electronic beam steering of the transducer array to acquire overlapping scans (varying from three to nine frames) of an object from dierent angles. The scan lines are then averaged to produce a real-time compound image of improved quality

(better spatial resolution compared with the conventional B-mode image) because of reduction in speckle (Fig. 1). Compound imaging has found applications in imaging the peripheral vasculature, breast and musculoskeletal system [9] and may be combined with other modes such as harmonic imaging, extended eld of view and 3D US.

Fig. 1 Axial section of the pancreas in a 78-year-old lady presenting with obstructive jaundice. (a) The B-mode image shows an ill-dened lesion in the pancreatic head (arrow). (b) Compound imaging (SonoCT; Philips, Bothell, WA, U.S.A.) clearly denes a pancreatic head mass (arrow) with associated obstruction of the pancreatic duct (arrowheads).

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The basis of this technology is that the transmitted pulse is digitally encoded and the frequency response of the receiver is optimized according to the application and target depth. For example the transmit pulse can be modied by

varying the frequency or amplitude. This `code' can be looked for in the returning echoes so allowing weak echoes to be distinguished from background noise. The advantages are that higher frequencies improve spatial and contrast resolution down to greater depths (Fig. 2).

Fig. 2 Axial section of the thyroid in a case of multinodular goitre. (a) The B-mode image (13 MHz) shows multiple ill-dened thyroid nodules. (b) In coded excitation mode (Chirp) the higher frequencies (14 MHz) can be utilized to improve spatial and contrast resolution down to greater depths so that the multi-nodular pattern is clearly demonstrated.

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In addition the technique has been modied to image owing blood in B-mode without contrast agents (B-ow; GE Medical Systems Milwaukee, WI, U.S.A.; and Dynaow; Toshiba Medical Systems, Japan).

Automatic Gain Compensation Modes

Automatic gain compensation modes set the correct gain in 2D at any point across the image with one button press. This is achieved by the processor analysing the distribution of grey levels in each part of the image and adjusting the grey level of each pixel to optimize local contrast.

Photopic Ultrasound Imaging

Photopic Ultrasound Imaging (Elegra; Siemens, Issaquah, WA, U.S.A.) is a real-time or post-processing technology which takes advantage of the natural perception of light in the eye to optimize grey-scale tissue dierentiation. Automatic optimization systems are also available for power and spectral Doppler.
EXTENDED FIELD OF VIEW ULTRASOUND (EFOV)

EFOV images but this was sacriced when real-time US was developed. However, technological advances in computing mean that now we can produce high resolution EFOV images in grey-scale or Doppler (Fig. 3). EFOV imaging can be performed on supercial structures using linear array transducers or on abdominal/pelvic studies with a curvilinear probe [10]. The value of this technique is: (1) lesions and their anatomical relationships can be easily depicted for clinicians and radiologists; (2) it is an excellent teaching aid; (3) it allows measurements of large structures to be performed; and (4) it serves as a useful record for follow-up. EFOV is most useful for supercial structures such as the neck, scrotum, musculoskeletal system [11] and breast.
THREE-DIMENSIONAL (3D) ULTRASOUND

When US was introduced into clinical practice in the 1970s, articulated arm scanners were used to produce

Until comparatively recently, US has lagged behind both CT and MR in 3D imaging [12,13]. 3D US is based on reconstruction algorithms and is therefore dependent on high-quality 2D data which have been limited by problems such as speckle, grating lobe, clutter and other artifacts. Recent developments in harmonic imaging, non-linear signal processing and 2D matrix array transducers have reduced these problems. Advances in computing power have resulted in the recent production of a real-time 3D US

Fig. 3 An extended eld of view power Doppler image (Cscape, Siemens, Issaquah, WA, U.S.A.) showing a recanalized para-umbilical vein in a patient with portal hypertension. L liver, U umbilicus.

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Fig. 4 Tortuous vessels in a neurilemmoma, appreciated in both 2D and 3D (courtesy of Dr V. Jayaram).

system (so-called `4D' US imaging) (Voluson1 730; Kretztechnik AG, Zipf, Austria). Volume data can be displayed either as a series of multi-planar reformats (MPR), or as a rendered image allowing optimal appreciation of the relative position of structures, including owing blood, within that volume. Clinical applications are diverse and include obstetrics, intravascular, intervention, echocardiography, breast/small parts and tumour vascularity (Fig. 4). 3D US has been shown to be a useful supplement to 2D in the assessment of the fetal face [14] and skeleton and in volume measurements in obstetrics and oncology. In the interventional setting, 3D US [15] is used to guide radioactive seed inplants in the prostate, insertion of transjugular intrahepatic portocaval shunts and for breast biopsy, while a stereotactic system has been developed for needle delivery using electromagnetic position sensors. 4D US will nd applications in echocardiography and in needle guidance systems.
NEW IMAGING MODES

harmonic image. Therefore THI improves the signal to noise ratio and so contrast resolution. This technique is particularly well suited to imaging the `technically dicult' obese patient, the retroperitoneum and pelvic pathology [19,20]. Its value has been demonstrated in hepatic sonography where it provides extra information which alters management and reveals lesions not seen on conventional B-mode [21,22] even in cirrhotic patients [23]. Harmonic imaging increases diagnostic condence in dierentiating cystic from solid hepatic lesions [20], improves detection of stones in the gallbladder (Fig. 5) and biliary tree [20], improves pancreatic denition [19] and allows distinction of simple from complex renal cysts.
ALTERNATIVE ULTRASONIC IMAGING METHODS

A number of ultrasonic imaging methods that are currently being evaluated utilize physical behaviour of tissue other than that used in B-mode US (i.e. bulk modulus), to produce their image.

Tissue Harmonic Imaging

Tissue harmonic imaging (THI) is a grey-scale imaging technique that uses information from harmonic signals generated by non-linear propagation of a sound wave as it passes through tissue [16,17]. Non-linear transmission occurs because sound travels faster through compressed tissue than relaxed tissue and this results in distortion of the incident wave with production of higher frequency components which are multiples (harmonics) of the insonating fundamental frequency [18]. While conventional US transmits and receives at the same frequency, in THI a low transmit frequency is used and the second harmonic signal is used to form the image by separating it from the fundamental echoes using lters. Harmonic signals are generated within the tissue in the centre of the US beam (where the tissue experiences the higher acoustic intensities necessary for non-linear behaviour). The result is that the beam prole is improved because the weaker non-harmonic signals from multiple reections at the body wall (especially in the obese) and side-lobes do not contribute to the nal

Elastography
The stiness (Young's modulus) of tissue tends to alter (usually increase) with disease and can be imaged by measuring the tissue's distortion (strain) under an applied stress (e.g. compression via the transducer). Known as `elasticity imaging' or elastography, the images produced have very high contrast and may signicantly improve lesion detection within the breast, prostate and liver [24,25] (Fig. 6).

Vibro-acoustography
Vibro-acoustography is another method for imaging tissue elasticity. Two ultrasound beams with slightly dierent frequencies are focused on an object of interest. The resulting interference causes part of or the whole object to vibrate at a low frequency which is detected by a microphone (hydrophone). By scanning the two focused beams across the object an image is built up. This technique

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Fig. 5 Section through the gall-bladder of a 56-year-old lady presenting with abdominal pain. (a) The B-mode image suggests an ill-dened echogenic lesion in the gallbladder which is dicult to characterize further. (b) In tissue harmonic mode (THI) (Siemens, Issaquah, WA, U.S.A.) an echogenic 3 mm gallbladder polyp is clearly demonstrated (arrow).

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Fig. 6 On the left a conventional B-mode breast image shows a well circumscribed echo-poor broadenoma (arrow). On the right an elastogram of the same lesion shows the hard outer rim of tissue (open arrow) in black with the softer central tissue in grey-white. The white line (arrowheads) is the chest wall (courtesy of Dr F. Fuechsel).

appears to be particularly adept at delineating calcium deposits within tissues, such as breast micro-calcications [26].

Acoustic Microscopy
The frequency of US transducers is increasing with the use of 30100 MHz probes a realistic proposition early in the 21st century. These transducers rely on single element mechanical devices and are based on the polymer ferroelectric polyvinylidene uoride (PVDF) which has a high bandwidth (4100%) but relatively poor sensitivity. Applications in ophthalmology and acoustic microscopy have developed. Ultrasound is poised to play an important role in the diagnosis and treatment of ocular diseases ranging from tumours, retinal and vitreous conditions (seen in diabetes and trauma) to anterior chamber disorders such as glaucoma. Acoustic microscopy utilizes a number of acoustic tissue characteristics such as attenuation and impedance to produce an image [27]. The technique has been applied to dermatological conditions [28], stomach tumours [29] and the kidney [30]. Acoustic microscopy is not yet a widespread diagnostic tool but it should soon be possible to insert an ultra-high frequency micro-transducer, via a ne bore needle, into tissue and obtain in situ histology [27].

be fully characterized and biopsied. In the future, therapy may be administered via this route. In intravascular US (IVUS) the vessel wall is displayed at 1030 MHz and this has been applied to the coronary and carotid arteries allowing plaque characterization, calculation of blood ow and shear wall stresses [32]. IVUS may also be used to guide and monitor angioplasty.

MICROBUBBLE CONTRAST AGENTS

ENDOLUMINAL US

The miniaturization of transducers has allowed interrogation of a wide variety of lumina [31]. There are now nanoprobes which can be inserted through a 21 G needle and catheters. Applications have been developed in the gastrointestinal tract, biliary system, urogenital tract and tracheobronchial tree allowing lesions dicult to access to

Ultrasound, unlike all other imaging methods, has lacked eective contrast agents until comparatively recently. This was rectied in the 1990s with the introduction of microbubbles which have revolutionized clinical and research applications in this eld [3335]. Microbubbles are less than 10 mm in diameter so they can cross capillary beds, and are safe, eective echo enhancers. Many new agents are under development and will reach the market in the near future. When administered intravenously, microbubbles remain within the vascular compartment though recently some agents have been to shown to exhibit a hepatosplenic tissue-specic phase (Table 1). To be eective as clinical tools, microbubbles must survive passage through the cardiopulmonary circulation to produce useful systemic enhancement. An ingenious range of methods is employed to achieve stability and provide a clinically useful enhancement period. Microbubbles consist of a gas (air or a peruorocarbon) which is stabilized by a shell (denatured albumin, phospholipid or surfactant or cyanoacrylate) (Table 1). Microbubbles produce marked augmentation of the ultrasound signal for several minutes after an intravenous bolus, or 1520 minutes after an infusion, with enhancement in grey-scale and Doppler signals of up to 25 dB (greater than 300 fold increase). The most widely used is Levovist (SH U 508A; Schering AG,

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Table 1 Classication of ultrasound microbubbles Microbubble First generation vascular Agitated saline Echovist* Second generation vascular Levovist (SHU 508A)* Albunex{ Third generation vascular Optison* (FS069) Echogen (QW3600) QW7437 Sonovue (BR1)* Denity (DMP115) PESDA Quantison Imagent (AFO150) Liver-specic agents Levovist (SHU 508A) Sonavist (SHU 563A) Sonazoid2 (NC100100) BR14 *Licensed for clinical use. { No longer commercially available. Schering AG, Berlin, Germany; Gas Air Air Air Air Peruoropropane Dodecauoropentane Peruorocarbon Sulphur hexauoride Peruoropropane Peruorobutane Air Peruorohexane Air Air Peruorocarbon Peruorobutane Stabilization None None Palmitic acid Sonicated albumin Sonicated albumin Liquid droplet, surfactant Liquid droplet, surfactant Phospholipids Phospholipids Sonicated albumin Dried albumin Surfactants Palmitic acid Cyanoacrylate Not public information Phospholipids Company

Schering Schering Tyco, St. Louis, MI, U.S.A. Tyco, St. Louis, MI, U.S.A. Sonus, Bothell, WA, U.S.A. Sonus, Bothell, WA, U.S.A. Bracco, Milan, Italy Dupont, Billerica, MA, U.S.A. University of Nebraska Andaris Ltd, Nottingham, U.K. Schering Schering Schering Amersham Health, Amersham, U.K. Bracco, Milan, Italy

Germany) which is licensed in many countries worldwide and consists of galactose microcrystals whose surfaces provide nidation sites on which air bubbles form when it is suspended in water; they are then stabilized by a trace of palmitic acid.

HARMONIC IMAGING

Interactions of Microbubbles with Ultrasound Waves

The interactions of microbubbles with an ultrasound beam are complex [36,37]. Since a microbubble is more compressible than soft tissue, when it is exposed to an oscillating acoustic signal, alternate expansion and contraction occurs. At low acoustic power (5100 KPa) these oscillations are equal and symmetrical (linear behaviour) and the frequency of the scattered signal is unaltered with the scattering intensity linearly related to that of the incident beam. As the acoustic power increases (100 Kpa 1 MPa), more complex non-linear interactions occur as the expansion and contraction phases become unequal because the microbubbles resist compression more strongly than expansion. Microbubbles resonate (in the diagnostic range (120 MHz)) and behave like a musical instrument, emitting harmonic signals at multiples (or fractions) of the insonating frequency. These harmonic signals are microbubble-specic and may be regarded as a signature or ngerprint unique to that agent. At still higher powers (although within accepted limits for diagnostic imaging) highly non-linear behaviour occurs with disruption or scintillation which may be imaged with a number of bubble-specic modes which allow dierentiation of contrast signal from background tissue.

Harmonics may be used to image US contrast agents by tuning the receiver to listen to a band of frequencies centred on a harmonic signal (usually the second harmonic 2fo, where fo is the centre frequency of the transmitted pulse) so the contrast signal is resolved from the background tissue [18]. This allows the microcirculation to be imaged and ow in vessels down to 100 mm in diameter can be demonstrated, permitting characterization of tumour vascularity [38]. 3D displays can be constructed to demonstrate vascular anatomy. This is a promising eld which has great potential, especially with the recent interest in monitoring the response of cancers to angiogenesis inhibitors. Harmonic imaging can be used to image the transient signals produced when microbubbles are disrupted at higher acoustic powers and this is important for those agents that have a stationary tissue-specic phase, as discussed below.

CLINICAL APPLICATIONS

Non-vascular Uses
Non-vascular uses include sonosalpingography in which fallopian tube patency is demonstrated by instilling Echovist (Schering AG, Berlin, Germany) into the uterine cavity and noting its passage along the tubes [39] and in the detection of vesico-ureteric reux when Levovist (Schering) is introduced into the bladder and the renal pelves and ureters are studied [40]. Both of these techniques have the advantage of avoiding ionizing radiation and have comparable sensitivity and specicity with conventional radiographic studies.

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The most important routine clinical applications have been in the rescue or improvement of Doppler studies that would otherwise fail because of weak signals attenuated by overlying tissues [3335,41] (Table 2). Microbubbles have important applications in echocardiography [42]. They are licensed for ventricular enhancement and delineation of endocardial borders allowing improved detection of wall motion abnormalities as well as converting non-diagnostic to diagnostic echocardiograms. The administration of contrast medium has been shown to enable more accurate measurement of left ventricular volume, ejection fraction, diagnosis and grading of valvular disease, thrombus detection, aortic dissection, detection of complications of myocardial infarction such as ventricular rupture and aneurysm formation, and improves assessment of systolic function compared to B-mode imaging. In stress echocardiography, contrast agents increase the number of interpretable segments, especially in the endocardium, which allows accurate assessment of global and regional left ventricular function [43]. At the myocardial level, contrast agents can be used to diagnose infarction and assess viability. Coronary artery stenoses can be localized and their severity quantied using intermittent harmonic imaging. Coronary ow rate (a measure of perfusion) may be calculated using bubble destruction and reperfusion methods, as discussed below [44]. The assessment of myocardial perfusion is still experimental but with advances in ultrasound technology and contrast agents the non-invasive echocardiographic diagnosis of both global and regional cardiac structure, function and perfusion is on the horizon.

NOVEL APPLICATIONS OF MICROBUBBLES

Quantication and Functional Studies

Quantication can be divided into `passive' and `active' methods. In the passive approach the passage of a contrast bolus is recorded with minimal microbubble disruption and so low insonating energies are employed. With active approaches, microbubbles are deliberately destroyed so that replenishment of a tissue bed can be measured while disruption of liver-specic agents produces strong transient enhancement when imaged in some non-linear modes such as phase inversion mode. Quantication is dependent on the nding that relative microbubble concentration is linearly related to Doppler signal intensity [45].
Table 2 Uses of ultrasound contrast agents in Doppler rescue studies

Following a bolus injection of microbubbles, their passage through a tissue of interest, such as a tumour or organ, can be quantied to generate transit time curves, as with nuclear medicine, CT and MRI [45]; from these, functional information can be derived to yield indices such as bolus arrival time, time to peak intensity, area under the curve, wash in/ wash out characteristics as well as more complex deconvolution indices. Since ultrasound contrast agents are conned to the vascular space (unlike CT and MR agents which diuse into the interstitial space) they may provide unique functional information not obtainable by other means. An important application is the study of hepatic vascular transit times after a peripheral bolus injection of a microbubble, while interrogating a hepatic vein with spectral Doppler. Early arrival of contrast medium is seen in cirrhosis and malignancy because of an increased hepatic arterial supply and arteriovenous shunting. This technique has been shown to be a highly sensitive indicator of cirrhosis and metastases [46,47]. Large prospective trials are presently underway to assess the predictive value of this technique for the presence of micrometastases in cancer patients before they can be detected by conventional imaging and as a non-invasive means of diagnosing cirrhosis in chronic liver disease. Time intensity curves can be drawn for an area of interest to document microbubble transit through, for example, a tumour bed [48]. The indices (e.g. bolus arrival time) derived from them can be used to construct true functional images by displaying them on a pixel-by-pixel basis as an overlay on the grey-scale image [49] (Fig. 7). They are particularly promising for heterogeneous tissues such as tumours. These combined structural and functional maps hold great potential. Active quantitation methods are based on the destruction of microbubbles and observing the eects on contrast enhancement (`reperfusion kinetics'). Intermittent high power ultrasound pulses are used to destroy microbubbles within the beam and the rate of replenishment in the eld can be used to calculate indices such as microcirculatory ow rate, a measure of tissue perfusion. Wei and colleagues applied the principle to the measurement of myocardial blood ow in dogs [50] by infusing microbubbles while scanning intermittently. They observed an exponential relationship between pulsing interval (PI) and video intensity (VI): VI VImax 1 eb:PI where VImax is the maximal video intensity, seen at long pulsing intervals and b is the constant describing the rate of rise of VI. The initial up-slope of this curve is proportional

. Assessment of portal venous patency in cirrhosis (dicult because of increased liver attenuation of the ultrasound beam and/or weak venous signals due to slow ow) . Diagnosis of renal artery stenosis (dicult because of technical problems with deep abdominal vessels) . Tight carotid artery stenosis (to distinguish total occlusion from trickle ow) . Transjugular intrahepatic porto systemic shunts (TIPS shunts) (often no signal can be obtained without contrast agent) . Transcranial Doppler (skull bone causes attenuation resulting in a high failure rate without contrast agent)

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to microbubble speed as they rell the slice being insonated. Wei et al. observed a good correlation between ow rates and this value in vitro and in vivo in a number of dierent conditions. Recent exciting innovations have seen the development of low mechanical index (MI) modes such as power pulse inversion (Philips, Bothell, WA, U.S.A.) and the contrast pulse sequence (CPS) (Siemens, Issaquah, WA, U.S.A.) which allow real-time perfusion imaging displaying the harmonic bubble signal on a tissue background (Fig. 8). A high energy pulse of ultrasound can be administered to destroy the bubbles and tissue rell observed with nondestructive low MI imaging to demonstrate tissue perfusion in real-time. The rate of this relling is a measure of regional tissue blood ow and has been used in the assessment of ischaemic myocardium and in renal transplants [51].

Microbubbles were initially thought to be solely blood pool agents but recently some have been shown to have a hepatosplenic-specic parenchymal phase following disappearance from the blood pool. Agents known to exhibit this late phase are Levovist [52], Sonavist (Schering, Berlin, Germany) [53], Sonazoid2 (NC100100; Nycomed, Oslo, Norway) [54] and BR14 (Bracco, Milan, Italy) [55] (Table 1). In this state the bubbles are stationary, as shown by the absence of conventional Doppler signals. Their site of hepatic accumulation is unknown but may be within the reticulo-endothelial system, or they may simply pool in sinusoids. This late phase has a variable duration lasting under about 30 minutes with Levovist but longer with other agents such as Sonazoid and Sonavist.

Fig. 7 Functional image of the right lobe of liver in a 58-year-old man with metastatic insulinoma. (a) B-mode image showing a metastasis (arrow). (b) A functional overlay has been superimposed on the image depicting arrival time of microbubbles after a bolus injection (range 2030 s). Note the early arrival time (5 25 s, red area) of contrast agent in the metastasis compared to the adjacent parenchyma. (Reproduced with permission from Harvey et al. [35]).

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The tissue-specic phase can be imaged by bubble-specic modes such as loss of correlation (LOC) [52] and phase inversion [56].

Phase/Pulse Inversion Mode (PIM)

The development of this novel mode was prompted by the desire to overcome the loss of spatial resolution of narrow band (dual frequency) harmonic imaging. PIM uses the full bandwidth of the transducer which results in superior spatial resolution and more contrast than harmonic grey-scale or conventional colour Doppler [56]. PIM detects non-linear echoes from microbubbles [56]. Alternate pulses, 1808 out of phase, are transmitted down

each ultrasound line and the summed echoes from the pair are used to form one image line. Echoes from linear and non-linear sources can be separated since non-linear signals, such as those from microbubbles, summate while linear signals cancel. Liver malignancies appear as defects surrounded by an intensely bright parenchyma in the late phase of Levovist (LP-PIM) (Fig. 9). To achieve this liver-specic eect, it is helpful to mimimize US examination of the area of interest during the blood pool phase (i.e. for at least 2 minutes after injection) otherwise the agent may be destroyed. Imaging in LP-PIM has been shown to increase sensitivity in the detection of focal liver malignancies by improving their conspicuity [5759]. In a multi-centre study of 123 patients, the sensitivity to liver metastases increased from 71% to

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Fig. 8 Haemangioma in a 47-year-old lady. (a) The baseline US shows a large heterogeneous liver lesion (arrowheads). (b) Following a bolus injection of Sonovue (Bracco, Milan, Italy) the vascular phase was imaged using the novel real-time non-destructive contrast pulse sequence mode (CPS; Siemens, Issaquah, U.S.A.). Characteristic peripheral globular enhancement (arrows) is present. (c) After several minutes continuous imaging centripetal lesion lling-in (arrows) is seen, strongly suggestive of a haemangioma.

88% and the mean size of detectable lesions improved by 50% to under 1 cm [60]. However, there are limitations. With Levovist, the eect is transient and the cine loop is needed to review the area examined but this should be rectied with the introduction of sturdier agents such as Sonazoid, which may be durable enough to allow biopsy proof to be obtained when focal liver defects are only seen after the addition of contrast medium. In addition, recent studies have shown the vascular phase can improve the characterization of focal lesions such as haemangiomas which exhibit peripheral globular enhancement and centripetal lling-in analogous to that seen on CT [61,62] (Fig. 8). Contrast agents have been shown to be useful in improving the detection of hepatocellular carcinoma (HCC), in dierentiating HCC from regenerating nodules and to detect recurrence in treated lesions (Fig. 10). Two dierent approaches are used for this. First, the hypervascularity of HCC can be exploited on arterial phase imaging to improve detection of small lesions [6163]. Second, most HCC show as defects on late phase imaging with liverspecic agents, again improving their detection, while signal enhancement similar to surrounding parenchyma is seen within regenerating nodules [64].

Loss of Correlation Mode and Applications

In this mode, microbubble disruption is seen as a transient strong signal in colour or power Doppler. Several mechanisms appear to be at work and this has given rise to confusion regarding nomenclature with terms such as loss of correlation (LOC), stimulated acoustic emission (SAE) and sono-scintigraphy being used. Conventional autocorrelator

colour Doppler systems compare trains of ultrasound pulses looking for changes. The sudden disappearance of a reector registers as a dramatic loss of correlation between pulses and this is interpreted as strong transient signals on Doppler. It is probable that this `passive' loss of correlation eect is more important than the `active' emission eects from microbubble disruption. Despite this observation, the term `stimulated acoustic emission' continues to be used. In LOC mode malignant liver tumours appear as defects surrounded by a colour mosaic pattern when the liver is scanned some minutes after the administration of liverspecic agents. Blomley et al. demonstrated that LOC improved the conspicuity of liver metastases as well as revealing new lesions not seen on conventional B-mode [65] (Fig. 11). It revealed subtle or isoechoic metastases and increased the sensitivity of ultrasound to the detection of metastatic disease. In a further study of the specicity of LOC, a spectrum of benign and malignant focal liver lesions were assessed for LOC activity in the late phase of Levovist [66]. Metastases and hepatocellular carcinoma showed no or low LOC signals while haemangiomas and focal nodular hyperplasia (FNH) (Fig. 12) had signicantly higher scores. However, LOC imaging has limitations. Its transient nature means that frames have to be reviewed in the cine loop (therefore not real-time), the eect falls o at depths greater than 1012 cm and is very dependent on the focal zone and its spatial resolution is that of colour Doppler; two to four times worse than grey-scale. Recently developed LOC based modes overcome some of these limitations; one such mode is ADI (Agent Detection Imaging; Siemens, Issaquah, WA, U.S.A.) which exhibits better spatial lling since it is less focal zone dependent and has excellent spatial resolution (Fig. 12) [67].

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High Intensity Focused Ultrasound (HIFU)

HIFU as a therapeutic technique is not a new concept, but recent advances in probe design and alternate ultrasonic imaging methods make it likely to become a realistic clinical tool in the near future [68]. The principle of HIFU is that a

highly focused ultrasound beam is used to destroy a dened volume of tissue by inducing a rapid rise in temperature to greater than 508C. Maintenance of this temperature for 13 s results in cell death, a single US exposure destroying a 0.5 ml volume of tissue. The surrounding tissue is not damaged. This non-invasive technique has been used to treat malignant tumours of the liver, prostate and kidney

Fig. 9 Longitudinal section of the left lobe of liver in a 74-year-old man with carcinoma of the colon. (a) Conventional B-mode shows a heterogeneous liver echotexture but no denite focal lesions. (b) Interrogation of the same area in pulse inversion mode (PIM) (Philips, Bothell, WA, U.S.A.) following Levovist reveals multiple metastases, some as small as 3 mm (arrow). Note the characteristic bright halo around the metastases. (Reproduced with permission from Harvey et al. [58]).

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Fig. 10 Follow-up US in a 46-year-old lady who had undergone chemoembolization of an hepatocellular carcinoma (HCC). (a) The baseline US shows an HCC with areas of necrosis. (b) Power Doppler interrogation shows no evidence of tumour recurrence. (c) Following a bolus injection of the microbubble Sonovue (Bracco, Milan, Italy) the vascular phase was imaged using contrast coherent imaging mode (CCI; Siemens, Issaquah, WA, U.S.A.) and shows an avidly enhancing peripheral lesion (arrow) which was conrmed to be a recurrent HCC.

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and benign breast tumours via a percutaneous or transrectal approach without the need for general anaesthesia [69,70]. Although promising, HIFU is currently limited by the amount of tissue that can be destroyed by a single US exposure, the time required between exposures to allow local tissue cooling, the inability to treat through bone, and diculty in monitoring therapy in real-time. Technological advances promise to overcome many of these problems. Currently HIFU tissue ablation damage is best observed using MR [70] which renders the treatment cumbersome and expensive. Since B-mode US does not distinguish

between coagulated and normal tissue, alternate ultrasonic imaging methods such as elastography, reex transmission imaging and thermal imaging are likely candidates to depict the tissue damage (Fig. 13). Future applications could include re-vascularization of the myocardium by the creation of channels in the ventricular wall [71] and the emergency treatment of internal haemorrhage by inducing haemostasis within bleeding vessels [72], for example after trauma, biopsy or catheterization. HIFU could also be deployed intraoperatively, for example in the treatment of liver metastases.

Fig. 11 Section through the right lobe of liver in a 76-year-old man with pancreatic carcinoma. (a) The baseline B-mode image shows a subtle metastasis (arrow). (b) Imaging in stimulated acoustic emission (SAE) mode 3 minutes after Levovist not only improves the conspicuity of the metastasis but also reveals a further metastasis (arrow) which cannot be seen in B-mode.

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Ultrasound Drug and Gene Delivery

Intravascular US is known to enhance the eects of thrombolytic drugs. The addition of microbubbles further enhances thrombolytic activity by aiding penetration of the drug into the thrombus [73,74]. Delivery to a thrombus can be accentuated by incorporating ligands on the surface of the microbubble that recognize receptors on the cell

membrane, for example incorporation of a surface ligand that binds GPIIB/IIIA receptors on activated platelets [75] (Fig. 14). US causes a transient increase in cell membrane permeability in a process known as sonoporation (Fig. 15). Using this technique, tissues can be targeted so that cellular uptake of a drug (e.g. a chemotherapeutic agent) or a gene

Fig. 12 This 34-year-old man presented with abdominal pain. (a) The B-mode image shows an echo-poor lesion in the left lobe of liver (arrows). (b) Twenty-ve seconds after a bolus injection of Levovist, the vascular phase was imaged in Agent Detection Imaging mode (ADI; Siemens, Issaquah, WA, U.S.A) and shows the lesion to be hypervascular (arrow) suggesting focal nodular hyperplasia (FNH).

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Fig. 12 (c) Imaging in the liver-specic phase of Levovist (5 minutes after injection) in ADI mode shows signal within the lesion (arrows), equal to adjacent liver parenchyma, which supports the diagnosis of FNH which was subsequently conrmed.

is achieved [76]. Sonoporation requires high acoustic powers (beyond that used in the diagnostic range but equivalent to those used in physiotherapy) but the power needed is markedly reduced when microbubbles are present. A drug or gene vector can be incorporated in or on the surface of the microbubbles and tracked in the circulation with an imaging beam; when they are exposed to high power US, the microspheres rupture, releasing the agent in the vicinity of the target tissue [73,74]. In the case of oncological drugs this has the advantage of decreasing the dose of the drug needed, so reducing systemic side-eects. Encouraging

initial in vitro studies have demonstrated sonoporation without inducing cell death [77]. In another study, transfection of a reporter gene in a mouse heart model increased 10-fold using a microbubble carrying an adenovirus gene vector [78].

Interventional Procedures
There is a wide range of dedicated interventional transducers (i.e. intraoperative, laparoscopic, transrectal, Siterite2 Dymax Corp., Pittsburgh, PA, USA for intrave-

Fig. 13 The gure on the left shows a cross-section of a lesion produced by a high-intensity focused US (HIFU) beam in liver ex vivo. The middle gure shows a B-mode image in which the lesion is ill-dened. The right hand gure shows an elastogram in which the lesion is clearly visualized (courtesy of Dr J. Bamber and Dr M. Doyley).

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Fig. 14 Schematic diagram of a microbubble manufactured for drug delivery. The interior of a microbubble may be loaded with drugs and gas. A stabilizing material, in this case a lipid, surrounds the peruorocarbon gas. Drugs may be incorporated by themselves or, if insoluble, in an oil layer. Protein ligands on the microbubble surface may be targeted to a specic tissue. (Reproduced with permission from Blomley M et al. Microbubble contrast agents a new era in US. BMJ 2001; 322: 12221225).

SUMMARY

Ultrasound has undergone an impressive metamorphosis since its beginnings and now occupies a pivotal role at the forefront of radiological practice and research. The ultrasound revolution has mainly been due to technological advances in electronics and computing and is responsible for the diversity of imaging modes at the sonographer's disposal. Microbubble contrast agents have dramatically extended the clinical and research applications of ultrasound. The specialty has progressed to encompass therapeutic options. If the future of ultrasound echoes the past, its potential is boundless.

Fig. 15 Gene delivery using microbubbles and ultrasound. Ultrasound waves burst the gas-lled gene-laden microbubbles and also cause sonoporation (transient non-lethal cell membrane perforation) which allows the genetic material to enter the target cells. (Reproduced with permission from Blomley M et al. Microbubble contrast agents: a new era in US. BMJ 2001; 322: 12221225).

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