Imaging: Beyond the Normal Patient

Sep 13th, 2013

Omaha, NE

US

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Phone:800-239-1361

This new course will visit each area out of the norm that challenges us and discuss the dos and don'ts for optimal image quality and patient care.

(A,B) Images from an initial ultrasound examination showed no identifiable lesions and received a consensus ultrasound category of US-1. Nearly the entire liver is visualized, with minimal shadowing (“s”, A and B), and the examination received consensus result of VIS-A. The AFP level was 7.1 ng/mL on assessment six months before the ultrasound, 9.1 ng/mL on assessment three months before examination, and 14.2 ng/mL on assessment on exam day. The AFP result was thus assessed as positive based on a progressive increase on two consecutive tests. The atient was considered to have negative surveillance result according to LI-RADS Ultrasound Surveillance v2017, but positive surveillance result according to LI-RADS Ultrasound Surveillance v2024. (C-D) Axial arterial-phase (C) and portal-venous phase (D) T1-weighted images from subsequent gadoxetic acid-enhanced MRI show a 2-cm arterial-phase hyperenhancing observation (arrow, C) with portal-venous washout (arrow, D) in segment 7. This observation was classified on MRI as LR-5, thus meeting the present study’s reference standard for diagnosis of HCC. The mass is located in the periphery of the liver, an anatomic area where ultrasound visualization can be challenging due to shadowing.

LI-RADS ultrasound surveillance version 2024 improves HCC detection

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Images in a 74-year-old male patient who presented at the hospital with acute symptoms of a right hemispheric ischemic stroke and a National Institutes of Health Stroke Scale (NIHSS) score of 24. (A) Nonenhanced CT image shows no signs of early infarction, whereas (B) CT perfusion image shows a large perfusion deficit in the territory of the middle cerebral artery and anterior cerebral artery caused by an extracranial occlusion in the right internal carotid artery. (C) Digital subtraction angiography shows the occlusion in the C1 segment. The extracranial occlusion was passed, reperfused, and subsequently stented (D, E). The final contrast injection did not reveal any intracranial occlusions within the territory of the internal carotid artery (F). At the 24-hour follow-up, there was no infarction on (G) the nonenhanced CT image, and the NIHSS score had decreased to 3 points. Image courtesy of RSNA.

EVT promising in patients with extracranial ICA occlusions

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Images depict a 49-year-old female participant with cryptogenic cirrhosis who presented with a 3.2-cm liver lesion. This biopsy-confirmed hepatocellular carcinoma (HCC) with an initial categorization of Liver Imaging Reporting and Data System (LI-RADS) category LR-4 (probably HCC) at CT was upgraded to LR-5 (definitely HCC) at contrast-enhanced ultrasound (CEUS). (A) Precontrast CT images in the liver show vague hypoattenuation in the medial left hepatic lobe (arrows). (B) Arterial phase images demonstrate no definite arterial phase hyperenhancement (arrows). (C) Washout and an enhancing capsule (arrows) on a late-phase image resulted in an LR-4 categorization. (D) B-mode ultrasound shows a round hypoechoic nodule (arrows). (E) An early-phase CEUS image shows clear arterial-phase hyperenhancement (arrows); (F) No washout at one minute (arrows), and (G) late, mild washout at four minutes (arrows) resulted in a CEUS LR-5 categorization.

CEUS resolves indeterminate CT, MRI liver observations

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LI-RADS ultrasound surveillance version 2024 improves HCC detection

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The 2024 version of the LI-RADS Ultrasound Surveillance system improves detection of hepatocellular carcinoma (HCC) over earlier iterations.

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(A,B) Images from an initial ultrasound examination showed no identifiable lesions and received a consensus ultrasound category of US-1. Nearly the entire liver is visualized, with minimal shadowing (“s”, A and B), and the examination received consensus result of VIS-A. The AFP level was 7.1 ng/mL on assessment six months before the ultrasound, 9.1 ng/mL on assessment three months before examination, and 14.2 ng/mL on assessment on exam day. The AFP result was thus assessed as positive based on a progressive increase on two consecutive tests. The atient was considered to have negative surveillance result according to LI-RADS Ultrasound Surveillance v2017, but positive surveillance result according to LI-RADS Ultrasound Surveillance v2024. (C-D) Axial arterial-phase (C) and portal-venous phase (D) T1-weighted images from subsequent gadoxetic acid-enhanced MRI show a 2-cm arterial-phase hyperenhancing observation (arrow, C) with portal-venous washout (arrow, D) in segment 7. This observation was classified on MRI as LR-5, thus meeting the present study’s reference standard for diagnosis of HCC. The mass is located in the periphery of the liver, an anatomic area where ultrasound visualization can be challenging due to shadowing.

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Endovascular thrombectomy (EVT) and best medical treatment are both effective and safe options for patients with acute extracranial internal carotid artery occlusions.

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Images in a 74-year-old male patient who presented at the hospital with acute symptoms of a right hemispheric ischemic stroke and a National Institutes of Health Stroke Scale (NIHSS) score of 24. (A) Nonenhanced CT image shows no signs of early infarction, whereas (B) CT perfusion image shows a large perfusion deficit in the territory of the middle cerebral artery and anterior cerebral artery caused by an extracranial occlusion in the right internal carotid artery. (C) Digital subtraction angiography shows the occlusion in the C1 segment. The extracranial occlusion was passed, reperfused, and subsequently stented (D, E). The final contrast injection did not reveal any intracranial occlusions within the territory of the internal carotid artery (F). At the 24-hour follow-up, there was no infarction on (G) the nonenhanced CT image, and the NIHSS score had decreased to 3 points. Image courtesy of RSNA.

CEUS resolves indeterminate CT, MRI liver observations

By Amerigo Allegretto

Contrast-enhanced ultrasound (CEUS) can resolve some high-risk indeterminate liver observations initially seen on CT or MRI.

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Images depict a 49-year-old female participant with cryptogenic cirrhosis who presented with a 3.2-cm liver lesion. This biopsy-confirmed hepatocellular carcinoma (HCC) with an initial categorization of Liver Imaging Reporting and Data System (LI-RADS) category LR-4 (probably HCC) at CT was upgraded to LR-5 (definitely HCC) at contrast-enhanced ultrasound (CEUS). (A) Precontrast CT images in the liver show vague hypoattenuation in the medial left hepatic lobe (arrows). (B) Arterial phase images demonstrate no definite arterial phase hyperenhancement (arrows). (C) Washout and an enhancing capsule (arrows) on a late-phase image resulted in an LR-4 categorization. (D) B-mode ultrasound shows a round hypoechoic nodule (arrows). (E) An early-phase CEUS image shows clear arterial-phase hyperenhancement (arrows); (F) No washout at one minute (arrows), and (G) late, mild washout at four minutes (arrows) resulted in a CEUS LR-5 categorization.

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