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Real-Time Temporal Maximum-Intensity-Projection Imaging of Hepatic Lesions with Contrast-Enhanced Sonography

Stephanie R. Wilson1,2, Hyun-Jung Jang1, Tae Kyoung Kim1, Hiroko Iijima1,3, Naohisa Kamiyama4 and Peter N. Burns5

1 Department of Medical Imaging, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
2 Present address: Diagnostic Imaging, Foothills Medical Centre, 1403 29 St. NW, Calgary, Alberta T2R 1M5, Canada.
3 Present address: Department of Medicine, Hyogo University, Hyogo, Japan.
4 Toshiba Medical Systems, Tokyo, Japan.
5 Departments of Medical Biophysics and Medical Imaging, University of Toronto, and Imaging Research, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.


Figure 1
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  		Fig. 1A —Principles of real-time temporal maximum-intensity-projection imaging technique. Open-shutter photograph of fireworks in night sky is comparable with temporal maximum-intensity-projection image. Shutter of camera is held open for sufficient time to trace path of bright, moving object, such as sparks of fireworks. Method can be applied to echoes of individual bubbles of contrast agent detected with nonlinear sonography. (Courtesy of Ben Burns)

 

Figure 2
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  		Fig. 1B —Principles of real-time temporal maximum-intensity-projection imaging technique. Schematic shows two maximum-intensity-projection (MIP) imaging sequences. MIP imaging is initiated as bubbles arrive in field of view. Signal intensifies as bubble paths are tracked. Second sequence is initiated by high-mechanical-index frames that cause bubble disruption. Low-mechanical-index imaging then depicts new bubbles as blood flow carries them into scan plane. MIP processing produces image of track of echoes, revealing vascular structure.

 

Figure 3
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  		Fig. 2A —91-year-old man with hepatocellular carcinoma. Advantage of maximum-intensity-projection imaging of highly vascularized lesion. See also Figures S2C and S2D, cine loops, in supplemental data online. Conventional contrast-enhanced sonographic image shows only heterogeneous bright ball of enhancement with no vessel detail as contrast agent rapidly fills entire vascular bed.

 

Figure 4
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  		Fig. 2B —91-year-old man with hepatocellular carcinoma. Advantage of maximum-intensity-projection imaging of highly vascularized lesion. See also Figures S2C and S2D, cine loops, in supplemental data online. Maximum-intensity-projection image obtained 0.5 second after flash shows morphologic features of individual tumor vessels.

 

Figure 5
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  		Fig. 3A —24-year-old asymptomatic woman with incidentally discovered liver mass (focal nodular hyperplasia). Maximum-intensity-projection imaging shows vascular morphologic features and direction of lesional filling in highly vascularized lesion. See also Figure S3C, cine loop, in supplemental data online. Conventional sonographic image obtained 9 seconds after the end of saline flush shows homogeneous enhancement of mass. Lesional vessels are not visible because of very rapid homogeneous filling of vessels.

 

Figure 6
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  		Fig. 3B —24-year-old asymptomatic woman with incidentally discovered liver mass (focal nodular hyperplasia). Maximum-intensity-projection imaging shows vascular morphologic features and direction of lesional filling in highly vascularized lesion. See also Figure S3C, cine loop, in supplemental data online. Maximum-intensity-projection image obtained 0.4 second after flash shows stellate vessels and centrifugal filling pattern.

 

Figure 7
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  		Fig. 4A —45-year-old man with jaundice due to biopsy-proven, poorly differentiated adenocarcinoma. Images show advantage of maximum-intensity-projection imaging of poorly vascularized lesion. See also Figures S4C and S4D, cine loops, in supplemental data online. Conventional sonographic image obtained during wash-in of contrast agent shows isolated bubbles within tumor without vessel detail.

 

Figure 8
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  		Fig. 4B —45-year-old man with jaundice due to biopsy-proven, poorly differentiated adenocarcinoma. Images show advantage of maximum-intensity-projection imaging of poorly vascularized lesion. See also Figures S4C and S4D, cine loops, in supplemental data online. Maximum-intensity-projection image obtained 5.8 seconds after flash shows vessel detail within hypoperfused lesion.

 

Figure 9
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  		Fig. 5 —35-year-old man with hemangioma. See also Figure S5, cine loop, in supplemental data online. Maximum-intensity-projection (MIP) image shows rapidly perfused lesion. MIP image obtained 9.4 seconds after onset of arterial phase enhancement shows puddles of contrast material around periphery of lesion. Fine-vessel detail is evident in surrounding normal liver. If hemangioma is extremely slowly perfused, MIP technique may not depict vascularization within single breath-hold.

 

Figure 10
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  		Fig. 6 —54-year-old man with inflammatory bowel disease and incidentally detected liver mass. See also Figure S6, cine loop, in supplemental data online. Maximum-intensity-projection image of normal liver vasculature shows accumulated enhancement in 11 seconds after contrast material arrives in liver. Unprecedented depiction of vessel structure to fifth order branching is evident. Focal unenhanced region is slowly perfusing hemangioma, which does not have contrast accumulation, making diagnosis impossible.

 

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