Contrast-Enhanced Versus Conventional and Color Doppler Sonography for the Detection of Thrombosis of the Portal and Hepatic Venous Systems
Sandro Rossi1,
Laura Rosa1,
Valentina Ravetta1,
Alessandro Cascina1,
Pietro Quaretti2,
Andrea Azzaretti2,
Paola Scagnelli2,
Carmine Tinelli3,
Paolo Dionigi4 and
Fabrizio Calliada2
1 Department of Internal Medicine VI, IRCCS Policlinico "S. Matteo,"
viale Golgi 19, Pavia 27100, Italy.
2 Department of Radiology, IRCCS Policlinico "S. Matteo," Pavia
27100, Italy.
3 Department of Biometrics and Clinical Epidemiology, IRCCS Policlinico
"S. Matteo," Pavia 27100, Italy.
4 Department of Surgery, IRCCS Policlinico "S. Matteo," Pavia 27100,
Italy.
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Fig. 1 —Contrast-enhanced sonography appearance of portal vein thrombi in
76-year-old man. Intercostal scan with longitudinal view of portal vein during
portal phase reveals enhanced lumen containing two nonenhanced areas that are
nonocclusive thrombi.
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Fig. 2A —Doppler spectral examination in 52-year-old man of enhancing
intrathrombotic signals detected during contrast-enhanced sonography. Oblique
subcostal scan with longitudinal view of common trunk of portal vein during
portal phase of contrast-enhanced sonography. Within enhanced lumen,
nonenhancing area (thrombus) measuring about 4.0 mm in diameter can be seen
adhering to wall of vein. At center of thrombus, pulsating punctate enhancing
signal reflects intrathrombotic vascularization.
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Fig. 2B —Doppler spectral examination in 52-year-old man of enhancing
intrathrombotic signals detected during contrast-enhanced sonography. Doppler
spectral examination of pulsating punctate enhancing signal within thrombus
reveals arterial waveform.
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Fig. 2C —Doppler spectral examination in 52-year-old man of enhancing
intrathrombotic signals detected during contrast-enhanced sonography. Helical
CT scans. In arterial phase (C), hyperdense area that represents
hepatocellular carcinoma (HCC) nodule is seen in segment IV of liver. On same
scan, in portal (D) and late (E) phases, branch of portal vein
adjacent to HCC nodule appears to be fully patent, with no sign of small
neoplastic thrombus seen on contrast-enhanced sonography.
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Fig. 2D —Doppler spectral examination in 52-year-old man of enhancing
intrathrombotic signals detected during contrast-enhanced sonography. Helical
CT scans. In arterial phase (C), hyperdense area that represents
hepatocellular carcinoma (HCC) nodule is seen in segment IV of liver. On same
scan, in portal (D) and late (E) phases, branch of portal vein
adjacent to HCC nodule appears to be fully patent, with no sign of small
neoplastic thrombus seen on contrast-enhanced sonography.
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Fig. 2E —Doppler spectral examination in 52-year-old man of enhancing
intrathrombotic signals detected during contrast-enhanced sonography. Helical
CT scans. In arterial phase (C), hyperdense area that represents
hepatocellular carcinoma (HCC) nodule is seen in segment IV of liver. On same
scan, in portal (D) and late (E) phases, branch of portal vein
adjacent to HCC nodule appears to be fully patent, with no sign of small
neoplastic thrombus seen on contrast-enhanced sonography.
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Fig. 3 —Helical CT scan shows malignant portal vein thrombus in 69-year-old
man. During arterial phase, thrombus appears as iso- to hypodense intraluminal
area with dense linear enhancement.
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Fig. 4 —Sonographically guided fine-needle aspiration biopsy of portal vein
thrombus in 69-year-old man. Sonography scan shows tip of needle is within
hypoechoic thrombus.
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Fig. 5 —Intercostal sonography scan reveals direct extension of
hepatocellular carcinoma tissue into main portal vein in 71-year-old man. This
finding represents unequivocal evidence of continuity between thrombus and
tumor tissue and is a reliable indicator of thrombus malignancy.
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Fig. 6 —Bar graph shows sensitivity of sonography (white bars),
color Doppler sonography (gray bars), and contrast-enhanced
sonography (black bars) in thrombus detection.
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Fig. 7 —Bar graph shows sensitivity of sonography (white bars),
color Doppler sonography (gray bars), and contrast-enhanced
sonography (black bars) in thrombus characterization.
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Fig. 8 —Schematic representations of thrombus patterns observed on
contrast-enhanced longitudinal sonography scan (A) of venous vessel and
orthogonal sonography scan (B) of venous vessel. = Pattern 2 can evolve into
pattern 1, 3, or 4 during portal and late phases. White lines into thrombus
represent visible arterial neovascularization. NO = nonocclusive thrombi, O =
occlusive thrombi.
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Fig. 9A —Nonenhancing contrast-enhanced sonography pattern in benign
nonocclusive thrombus in 48-year-old woman. Oblique sonography scan with
longitudinal view of stent inserted between portal vein and inferior vena cava
for treatment of Budd-Chiari syndrome.
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Fig. 9B —Nonenhancing contrast-enhanced sonography pattern in benign
nonocclusive thrombus in 48-year-old woman. Oblique contrast-enhanced
sonography scan with longitudinal view of stent. During portal phase of
contrast-enhanced sonography, uniformly nonenhancing area about 5.0 mm in
diameter is visible within enhanced lumen of stent.
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Fig. 10A —Nonenhancing contrast-enhanced sonography pattern in benign
occlusive thrombus in 63-year-old man. Simultaneous intercostal
(left) and color Doppler (right) sonography scans with
longitudinal view of portal vein. On sonography, lumen of portal vein is
completely filled with hypoechoic material representing occlusive thrombus.
Color Doppler sonography revealed no color signals within lumen of vein or
within thrombus.
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Fig. 10B —Nonenhancing contrast-enhanced sonography pattern in benign
occlusive thrombus in 63-year-old man. Intercostal contrast-enhanced
sonography scan with longitudinal view of portal vein. During portal phase,
uniformly nonenhancing area perfectly reproducing shape of vessel is visible
within portal vein.
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Fig. 11A —Blooming contrast-enhanced sonography pattern evolving into
multipunctate pattern in intensely vascularized malignant thrombus in
75-year-old man. Simultaneous oblique (left) and color Doppler
(right) sonography scans with longitudinal view of left branch of
portal vein. Sonography reveals echogenic area (thrombus) within vessel lumen.
Color signals are visible within thrombus.
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Fig. 11B —Blooming contrast-enhanced sonography pattern evolving into
multipunctate pattern in intensely vascularized malignant thrombus in
75-year-old man. Oblique contrast-enhanced sonography scan with longitudinal
view of portal vein during arterial phase. Within poorly enhanced lumen of
left branch of portal vein is diffusely enhanced area (arrows)
representing thrombus with rich internal neovascularity (blooming
pattern).
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Fig. 11C —Blooming contrast-enhanced sonography pattern evolving into
multipunctate pattern in intensely vascularized malignant thrombus in
75-year-old man. During portal phase of contrast-enhanced sonography scan
shown in B, lumen of portal vein is enhanced and thrombus appears as
predominantly nonenhancing area (arrows) containing multiple punctate
enhancing signals.
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Fig. 12A —Pulsating linear or punctate contrast-enhanced sonography pattern in
occlusive malignant thrombus in 63-year-old woman. Oblique color Doppler
sonography scan with longitudinal view of left branch of portal vein. Vessel
lumen is completely filled with hypoechoic material. No color signals were
detected within lumen of portal vein or within thrombus.
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Fig. 12B —Pulsating linear or punctate contrast-enhanced sonography pattern in
occlusive malignant thrombus in 63-year-old woman. Oblique contrast-enhanced
sonography scan with longitudinal view of left branch of portal vein during
arterial phase. Thrombus appears as predominantly nonenhancing area that
reproduces shape of vessel lumen; within its borders is pulsating linear
signal, which is indicative of arterial neovascularization.
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Fig. 13A —Pulsating multilinear or multipunctate contrast-enhanced sonography
pattern in occlusive malignant thrombus in 68-year-old man. Simultaneous
oblique subcostal (left) and color Doppler (right)
sonography scans show longitudinal views of right branch of portal vein.
Sonography scan reveals isoechoic area within vessel lumen (arrow)
representing thrombus; on color Doppler sonography, some color signals are
visible within boundaries of thrombus.
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Fig. 13B —Pulsating multilinear or multipunctate contrast-enhanced sonography
pattern in occlusive malignant thrombus in 68-year-old man. Oblique subcostal
contrast-enhanced sonography scan with longitudinal view of right branch
portal vein during initial portal phase. Thrombus (arrow) appears as
predominantly nonenhancing area reproducing shape of vessel lumen. Multiple
pulsating punctate and linear signals indicative of arterial
neovascularization are visible within its borders. Only proximal lumen of
portal vein appears enhanced.
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Copyright © 2006 by the American Roentgen Ray Society.
