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American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 2013SPECIAL INTEREST SESSIONSTUESDAY, APRIL 9, 2013, 8:15 AM–10:15 AMContrast-Enhanced Ultrasound in Pediatrics:What Have We Learned and How Can We Apply It?Moderator: Beth McCarville, MDCutting-edge Musculoskeletal Ultrasound: PeripheralNerves of the Upper ExtremityModerator: Corrie Yablon, MDVoiding UrosonographyKassa Darge Perelman School of Medicine, University ofPennsylvania, Radiology, Children’s Hospital of Philadelphia,Philadelphia, Pennsylvania USACurrently, the most widespread application of ultrasound contrastagents (UCAs) in children is for the diagnosis of vesicoureteral reflux(VUR). This entails the intravesical administration of a UCA and is knownas contrast-enhanced voiding urosonography (ceVUS). The procedure ofceVUS encompasses 5 steps: precontrast scan of the bladder and kidneys,intravesical UCA injection or infusion, postcontrast scan of the bladderand kidneys, during and postvoiding scans of the bladder and kidneys, andsuprapubic and transperineal scans of the urethra during voiding. The useof harmonic imaging or contrast-specific ultrasound (US) modalities withlow or high mechanical indices enables the conspicuous depiction of theechogenic microbubbles. The most widely used UCAs are the first- andsecond-generation ones, namely Levovist (Bayer-Schering, Berlin, Germany)and SonoVue (Bracco, Milan, Italy), respectively. The former onehas been withdrawn from the market, and thus currently only the secondgenerationUCA is being used. There are many comparative studies ofceVUS with the conventional reflux diagnostic methods, voiding cystourethrography,and direct radionuclide cystography. Not only is ceVUSa radiation-free method, but these studies have also demonstrated that it ismore sensitive in detection of VUR. The evaluations of the safety of intravesicalUCA administration have found that no adverse events directlyrelated to the UCA have been reported to date in children. This US methodis widespread in Europe. There is currently a concerted effort by the Societyof Pediatric Radiology Contrast-Enhanced Ultrasound Task Forceto promote research and application of this method.Contrast-Enhanced Ultrasound in Pediatric Abdominal TraumaAnnamaria Deganello Radiology, King’s College Hospital,London, EnglandThe objectives are to review the role of contrast-enhanced ultrasound(CEUS) in the setting of blunt abdominal trauma in the pediatricpopulation and illustrate its applications in a major trauma center, describingthe typical sonographic features of solid-organ injuries. CEUShas been proven to be a reliable and useful tool in the assessment of abdominaltrauma in the adult population, as it provides detailed evaluationof parenchymal, capsular, and also vascular injuries. In addition to its establisheduse in the liver, CEUS is applied, as an “off-label” use to thestudy of renal, splenic, intestinal, and testicular traumas. Equally, in the pediatricand young adult populations, CEUS has an increasingly importantrole, even though this area represents another off-label application of thetechnique. CEUS can depict active bleeding and posttraumatic pseudoaneurysmformation during the arterial phase, whereas in the late phase, itshows with accurate detail the extent of a parenchymal laceration, as thenoninjured tissue enhances. Trauma patients often need to be reassessedto monitor progression or ensure resolution of the injuries, and CEUS becomesa valid, safe, and readily available alternative to repeated computedtomographic (CT) imaging; this is crucial in the pediatric population,where limitation of radiation exposure is of paramount importance. Thetypical CEUS features of hepatic, splenic, and renal injuries will be described,including examples with CEUS/CT correlation.S37After attending this session, participants should know how andwhen to perform ultrasound examinations of the peripheral nerves of theupper extremity, including interventional techniques.Doppler Evaluation of the AbdomenModerator: M. Robert De Jong, RDMS, RDCS, RVTSonographic Evaluation of Portal HypertensionMonzer Abu-Yousef Radiology, University of Iowa, IowaCity, Iowa USAIn this presentation, normal portal vein (PV) Doppler findingsand variations will be discussed. Typically, this has biphasic pattern withmild undulations. All waves are above baseline: V max = 19 ± 3; V min = 13± 3, with V min /V max ≥0.5. With Valsalva, flow becomes nonphasic. Postprandially,flow velocity and volume and PV diameter increase. TheDoppler ultrasound (US) findings in portal hypertension include increasedPV diameter, splenomegaly, ascites, loss of PV flow phasicity, decreasedPV flow velocity, reversed PV flow, and dilated portosystemic collaterals.The latter include a recanalized umbilical vein, flow reversal in the coronaryvein, dilated gastric varices, splenorenal collaterals, a recanalizedductus venosus, gallbladder varices, and perihepatic collaterals. The portosystemicshunts will also be discussed, with emphasis on the transjugularintrahepatic portosystemic shunt (TIPS), including Doppler US signsof TIPS malfunction, direct and indirect. Direct signs include velocity inany stent segment of 200 cm/s, interval velocity change in thesame area of >50 cm/s, velocity transition zone of >2 times, TIPS nonfillingor trickle flow, narrowing of the stent or the hepatic vein that drainsit, and aliasing seen in any segment of the stent on color Doppler. Indirectsigns include a decrease in PV velocity to 33% of baseline, antegrade flow in PV branches, flow seen inthe umbilical vein, loss of the triphasic flow pattern in the PV, worseningascites, and splenomegaly.Pathologic Findings in Abdominal VasculatureHanh Nghiem William Beaumont Hospital, Royal Oak,Michigan USAColor Doppler and spectral Doppler imaging have substantiallyenhanced the diagnostic capabilities of abdominal ultrasonography. Whenproperly performed, Doppler ultrasonography provides rapid, comprehensive,and accurate evaluation of the hepatic vasculature and major abdominalvessels. In this session, we will discuss the Doppler imagingappearances of Budd-Chiari syndrome, a manifestation of hepatic venousoutflow obstruction. Doppler imaging findings of hepatic artery abnormalitiesin native liver and abnormalities of the splenic vessels will alsobe reviewed, including vascular thrombosis and pseudoaneurysms. Participantsshould gain a greater understanding of the pathophysiology ofhepatic vein and splenic vein thrombosis, causes of elevated and decreasedhepatic arterial resistive indexes, and vascular thrombosis and pseudoaneurysmsof the hepatic and splenic artery in non–liver transplant patientsand recognize the sonographic images showing these conditions.
American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 2013Hands-on How to Do Ultrasound-GuidedInterventionsModerator: Dean Nakamoto, MDAfter attending this session, participants will be able to describeprebiopsy preparations, use and have hands-on experience with the techniquesof doing biopsies of soft tissue masses, thyroid nodules, breastmasses, the liver, and kidneys, and recognize and manage complications.Pearls From the Anatomic Survey (Skeletal Dysplasiaand Central Nervous System, Renal, and ChestAbnormalities)Moderator: Ana Monteagudo, MD, RDMSFetal Central Nervous SystemAna Monteagudo Obstetrics and Gynecology, New YorkUniversity School of Medicine, New York, New York USASmall-Animal Preclinical High-Frequency ImagingModerator: Michael Kolios, PhDAdvances in High-Frequency Transducers and ArraysK. Kirk Shung Biomedical Engineering, University of SouthernCalifornia, Los Angeles, California USAHigh-frequency ultrasound (HFU) allows improved spatial resolution.Biomedical applications have been found for HFU in preclinicalsmall-animal, intravascular, and eye imaging. Pediatric imaging is anotherarea that holds great promise. As a result, high-frequency linear arrays,phased arrays, and curved linear arrays have been developed to satisfythese needs. More recently, miniature high-frequency arrays have beenstudied for intravascular and other clinical applications. In addition, ultrahigh-frequency high-performance single-element transducers have beeninvestigated for cellular applications. Technical advances that have beenmade in these areas and potential biomedical applications will be reviewedin this talk.A significant number of sonographers and sonologists count thefetal central nervous system (CNS) as the most challenging organ to scan.This has resulted in an explosion in the number of fetal magnetic resonanceimaging examinations of the CNS being ordered over the last fewyears. In this lecture, a systematic approach to the fetal CNS will be provided,as well as multiple imaging tips or pearls to improve the individualpractitioner ability to diagnose common as well as relatively rare anomaliesof the fetal CNS.SCIENTIFIC SESSIONSTUESDAY, APRIL 9, 2013, 11:00 AM–12:30 PMApplications of Therapeutic UltrasoundModerators: George Lewis Jr, PhD, Maggie Zhang, PhD1541279 Antitumor Effects of Combining Docetaxel and PaclitaxelWith the Antivascular Effects of Ultrasound-StimulatedMicrobubblesMargarita Todorova, 1,2 Vlad Agache, 1 Raffi Karshafian, 3Kullervo Hynynen, 1,2 David Goertz 1,2 *1 Sunnybrook ResearchInstitute, Toronto, Ontario, Canada; 2 Medical Biophysics,University of Toronto, Toronto, Ontario, Canada; 3 RyersonUniversity, Toronto, Ontario, CanadaObjectives—Docetaxel (DTX) and paclitaxel (PTX) are used totreat a broad spectrum of cancers. We previously reported that the combinationof DTX with ultrasound (US)-stimulated microbubble (MB) therapyresulted in enhanced antitumor effects in PC3 tumors. While the focusof US + MB therapy has been to promote drug uptake, these experimentswere conducted with exposures that produced a vascular shutdown. AsDTX and PTX can themselves induce antivascular effects, it was hypothesizedthat there may be an interaction between drug and MB antivasculareffects. In this study, experiments were conducted on a cell line that islargely resistant to DTX and exhibits only mild sensitivity to PTX.Methods—EMT6 tumors were initiated in Balb/C mice andwere exposed to pulsed 1-MHz US (1.6 MPa; n = 5–6/group) followingthe bolus injection of Definity MBs. The treatment scheme consisted of asequence of 50 0.1-millisecond bursts sent at 1 KHz, repeated every 20seconds for 3 minutes following MB injection. Growth delay experimentswere performed when tumors reached a size of 100 to 120 mm 3 . Thegroups were control, drug + MBs, US + MBs, and combined drug + US+ MBs. One set of experiments was performed with DTX at 5 mg/kg anda second set of experiments with PTX at 6 mg/kg, where drugs were injected10 minutes prior to US treatment. The effects of treatment on bloodflow were monitored with 7-MHz contrast imaging.Results—The exposure conditions were found to produce apronounced acute vascular shutdown within the tumors and resulted inMB inertial cavitation. Neither the DTX-only or PTX-only groups producedsignificant growth inhibition relative to controls. The US + MBgroup induced significant growth delays relative to control tumors. Boththe combined DTX + US + MB and the PTX + US + MB groups producedsignificant growth inhibition relative to the US + MB group.Conclusions—Given the low sensitivity of the tumor cell lineto these drugs, and that they have the capacity at these low dose levels toact in an antivascular manner, the results suggest that there may be a synergisticantivascular action between these therapies in addition to a druguptake mechanism.1540384 Dynamic Positron Emission Tomographic Imaging of DrugDelivery and Hypoxia Using Acoustic Droplet VaporizationMario Fabiilli, Morand Piert, Philip Sherman, Carole Quesada,Oliver D Kripfgans* Radiology, University of Michigan,Ann Arbor, Michigan USAObjectives—Perfluorocarbon (PFC) emulsions and acousticdroplet vaporization (ADV) have been used in therapeutic applicationssuch as drug delivery and embolotherapy. The objective of this work wasS38
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