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American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 2013SPECIAL INTEREST SESSIONSWEDNESDAY, APRIL 10, 2013, 8:15 AM–10:15 AMBreast UltrasoundModerator: Abid Irshad, MDClinical Breast Ultrasound in an Outpatient Community Breast CenterStamatia Destounis Elizabeth Wende Breast Care, LLC,Rochester, New York USAThis lecture will cover the clinical use of breast ultrasound in anoutpatient community breast center. Topics to be covered will include evaluationof breast pain, palpable abnormalities, breast lesions in young patients,breast-feeding/lactating patients, and patients with dense breastspresenting for additional screening ultrasound. Particular discussion willbe focused on screening breast ultrasound, in response to recent state legislationmandating that the patient be informed of her breast density. Inaddition, screening of the high-risk patient will be covered. Last, this lecturewill discuss the role of diagnostic breast ultrasound. The role of newtechnologies, including elastography and automated breast ultrasound,will be briefly discussed.Significance and Implications of Various Sonographic Features inBreast LesionsAbid Irshad Radiology, Medical University of South Carolina,Charleston, South Carolina USAThis lecture will encompass the diagnostic significance of varioussonographic features seen in breast lesions from a clinical and pathologicperspective. The management issues regarding concordance afterbiopsy of these lesions will also be discussed. Additionally, various sonographicfeatures seen in breast cancers will be individually discussed inlight of literature to see how confidently the biological behavior such asthe tumor grade and estrogen receptor/progesterone receptor/human epidermalgrowth factor receptor 2 status of these cancers can be predictedbased on these individual sonographic features.Ultrasound as a Problem-Solving Tool in Breast ImagingJulie Mack Radiology, Penn State Hershey, Hershey, PennsylvaniaUSABreast ultrasound is integral to the imaging evaluation of breastdisease, and core biopsy under ultrasound guidance provides a mechanismfor rapid diagnosis of breast pathology. This session will focus on theuse of breast ultrasound as a problem-solving tool in patients presentingwith mammographic or clinical evidence of breast disease. The sonographicfindings in a variety of breast abnormalities of the female and malebreast will be illustrated and correlated with the mammographic andmagnetic resonance imaging (MRI) findings. The utility of breast ultrasoundas a “second-look” exam after MRI will be discussed. Biopsyplanning and radiologic-pathologic correlation will also be emphasized.Finally, a brief review of the data on breast ultrasound as a screening toolwill be examined.Extracranial Ultrasound of the Head and Neck inChildrenModerator: Beth McCarville, MDThis session is designed to educate the radiologist and sonographerabout the value of ultrasound in assessing non-brain pathology inthe head and neck of children, including the thyroid, superficial masses,and ocular disease.Gynecologic Ultrasound: The Basics RevisitedModerator: Ana Monteagudo, MDGetting to Know Your Ultrasound Machine: Essentials of KnobologyAna Monteagudo Obstetrics and Gynecology, New YorkUniversity School of Medicine, New York, New York USA“Knobology” is defined as the functionality of controls on an instrumentas relevant to their application. In the case of ultrasound (US), itis the function of the controls (knobs) on the US machine. All machineshave essentially the same set of controls; however, in each brand, the controls(“knobs”) are arranged slightly differently. Therefore, it is imperativeto become familiar with the location of the controls on the machine thatyou are using on a regular basis. Adjusting the controls is a way to improvethe image quality, since a good image is an essential component ofmaking a correct and reliable diagnosis. Controls that change the followingparameters are indispensable: depth, gain, time-gain-compensation(TGC), focal zone, field of view, frame rate, “optimize” (this controlchanges several parameters as needed for a particular set of pictures), andzoom. Of course, there are many more of them; however, as you gain confidencewith the scanning and working with the US machine, the utility ofchanging other parameters will become evident. Improving images notonly requires knowing which control to use, but it also requires choosingthe right transducer for the scanning approach; transducers commonlyused in obstetrics and gynecology range from 3.5 to 7.5 MHZ (or higher).Low-frequency transducers achieve better penetration at the expense of alower resolution; these are the ones employed when scanning transabdominally.Higher-frequency transducers have less penetration, but theirreal value is the increased resolution, and these are usually used transvaginally.Last, besides knowing what each control does and which transducerto use, we must know the indication for the scan and the age and lastmenstrual period of the patient. They all assist in making the diagnosis.Innovative Directions in Fetal Cardiac ImagingModerator: Lami Yeo, MDThe objective of this session is to review several new directionsin the field of fetal cardiac imaging: imaging for fetal interventions, fetalmagnetic resonance imaging, and automated screening for congenital heartdisease.S73
American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 2013Lumps, Bumps, and Extremity Pain in the EmergencyRoom: What Is the Role of Ultrasound?Moderator: Leslie Scoutt, MDSonography of Abdominal Wall HerniasLevon Nazarian Radiology, Thomas Jefferson UniversityHospital, Philadelphia, Pennsylvania USASmall abdominal wall hernias may be difficult to palpate onphysical examination; therefore, hernias are an often-overlooked cause ofpain or other complications. Because of its real-time nature, ultrasoundhas taken a central role in the evaluation of abdominal wall hernias, sincemany hernias are not present in the resting state. Since dynamic maneuversmay be necessary for diagnosis, many hernias go undetected by computedtomography or magnetic resonance imaging. This presentation willdiscuss the anatomy and technique pertinent to the diagnosis of abdominalwall hernias. Pathologic examples of the different hernia types will bepresented using both static images and video clips.Lumps and BumpsJason Wagner Radiological Sciences, University of Oklahoma,Edmond, Oklahoma USAThis presentation will describe an algorithm-based approach tothe ultrasound evaluation of a superficial mass, based on patient history,physical examination, lesion location, and sonographic findings. Specifictopics will include identification of fluid collections, distinguishing nonneoplasticcauses of a lump from neoplasms, and the differential diagnosisof superficial neoplasms.Peripheral Arterial DiseaseModerator: John Blebea, MD, MBAUltrasound in the Preintervention Stage of Patient EvaluationGowthaman Gunabushanam Diagnostic Radiology, YaleUniversity School of Medicine, New Haven, Connecticut USA;Radiology, VA Medical Center, West Haven, Connecticut USAThis presentation will review the noninvasive evaluation oflower extremity peripheral arterial disease (PAD) in the vascular laboratory,including ankle-brachial index (ABI), toe-brachial index (TBI), pulsevolume recording (PVR), segmental blood pressure measurement, and ultrasoundof native arteries and bypass grafts. ABI is used to confirm vascularetiology and provide prognostic information in symptomatic patients.ABI is also used to screen high-risk asymptomatic patients for PAD andto monitor the efficacy of therapeutic interventions. ABI 1.3 as digital arteriesare usually spared the medial calcinosis that affects the more proximalarteries. Segmental pressure measurements and PVR help determinethe level of stenosis. A gradient >20 mm Hg between adjacent segmentsor between the two sides at the same level is significant. PVR provides anarterial pressure waveform profile by measuring limb volume changeswith each cardiac cycle. A normal waveform has a rapid upstroke, a sharppeak, a dicrotic notch, and a downslope bowed toward the baseline. Aslower rise time, flattened or rounded peaks, absence of a dicrotic notch,and a downslope bowed away from baseline suggest a proximal stenosis.Velocity criteria are used for grading stenosis on ultrasound. Peak systolicvelocity (PSV) of 200 to 350 cm/s and PSV ratio of 2 to 3.5 are suggestiveof moderate stenosis. PSV >350 cm/s and PSV ratio >3.5 are consistentwith severe stenosis.Ultrasound-Guided ThrombolysisModerator: George Lewis Jr, PhDMedical Technology and Instrumentation for Sonothrombolysis:Current, Pipeline, and Future PlatformsGeorge Lewis Jr Zetroz, Ithaca, New York USAUltrasound technologies to provide and monitor sonothrombolysiscan currently be grouped into two broad categories: (1) catheterdirectedand/or delivered ultrasound and (2) extracorporeal focused and/orapplied ultrasound. The first class of technology is generally minimally invasiveand carried out with a sterile field in an interventional radiologysuite. The second class of device covers a much larger use case scenariorelative to where it can be applied and used. In both categories of technology,sonothrombolysis effectiveness in thrombus dissolution is mostregularly measured with precontrast and postcontrast fluoroscopy. Morerecently, however, ultrasound imaging including B-mode, Doppler flow,and intravascular ultrasound is making its way into fully integrated closedloopsonothrombolysis treatment and monitoring systems. This talk willreview current sonothrombolysis ultrasound technologies, their performancecharacteristics, methods of use, and basic mechanisms of action inwhich they rely on. Catheter-directed ultrasound technologies includecommercial systems such as Ekos and Omnisonics, as well as pipelinetechnologies still undergoing research in academia and the private sector.Extracorporeal noninvasive technologies, including power Doppler, lowintensitytherapeutic ultrasound, plane-wave pulsed ultrasound, high-intensityfocused ultrasound, and histotripsy, will be described along withtheir current use case scenarios, characteristics, and regulatory pathways.The catheter-directed sonothrombolysis approaches will be compared andcontrasted to noninvasive sonothrombolysis. Additionally, recent innovationsin closed-loop sonothrombolysis treatment monitoring and crossoversonothrombolysis platforms will be discussed as a gateway into clinical researchpresentations.Sonothrombolysis: Techniques, Mechanisms, and SafetyZhen Xu Biomedical Engineering, University of Michigan,Ann Arbor, Michigan, USAUltrasound has been shown to promote clot breakdown, as botha stand-alone procedure and in conjunction with thrombolytic drugs orcontrast agents. In this talk, 3 sonothrombolysis approaches and their underlyingmechanisms reported in the literature will be reviewed. First, lowintensityultrasound is combined with fibrinolytic enzymes (such asplasminogen activator) to accelerate the clot dissolution. The mechanismunderlying this approach includes the accelerated transport of drug moleculesinto the clot and alteration in fibrin structure to enhance enzymebinding. Both of these effects are caused by stable cavitation (ie, microstreamingand bubble translation) and inertial cavitation (ie, intense localizedstresses and microjets). Microbubble contrast agents can be usedin conjunction with fibrinolytic enzymes to enhance cavitation and furtheraugment thrombolysis. Second, higher-intensity ultrasound and microbubblecontrast agents are used together to cause clot fragmentation.The microbubbles that accumulate at the surface or within the clot serveas cavitation nuclei. For this approach, the primary mechanism is inertialcavitation, where energetic bubble growth and collapse induce high localstress and microjets, resulting in clot microfragmentation. Third, veryhigh-intensity focused ultrasound pulses are used alone to produce rapidclot fragmentation. Similar to the second approach, the mechanism forthis method is also inertial cavitation, where pre-exiting gas nuclei in clotsare used to generate cavitation. No contrast agents or drugs are required.To conclude, safety studies of sonothrombolysis techniques will be discussed,including damage to vessel walls and surrounding tissue, changesin blood chemistry, and embolization.S74
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Small-Animal Preclinical High-Frequ
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2013 AIUM Award WinnersJoseph H. Ho
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2013 AIUM Award WinnersDistinguishe
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Rosa De Vermette, MD, RDCS,RDMS, RO
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