Contrast-enhanced ultrasound fundamentals: the pharmacodynamics and pharmacokinetics of contrast. Basics of contrast-enhanced ultrasound imaging

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A, B y C: lesión incidental pequeña diagnosticada por CEUS como hiperplasia nodular focal y que no requiere realización de otra prueba de imagen. A. Ecografía en modo B: lesión indeterminada de 1cm. B. Imagen CEUS en fase arterial (14 s IM 0,07) tras poner un trazo marcador en la imagen dual modo B de referencia al revisar el video: ese mismo trazo se copia en la imagen de contraste, sirve como guía y permite demostrar que el realce arterial comienza en el centro de la lesión. El tiempo real mostró realce en dirección centrífuga. C. A los 3,06 min no se observa lavado. D. Revisión de carcinoma hepatocelular tratado con radiofrecuencia con TC no concluyente (imagen dual a los 39 s, IM 0,079) que muestra realce en fase arterial de casi toda la lesión tratada, en relación con recidiva." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.T. Fontanilla Echeveste, T. Ripollés González, E. Aguirre Pascual" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M.T." 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Basics of contrast-enhanced ultrasound imaging" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.T. Fontanilla Echeveste, T. Ripollés González, E. Aguirre Pascual" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M.T." "apellidos" => "Fontanilla Echeveste" "email" => array:1 [ 0 => "fonteche@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "T." "apellidos" => "Ripollés González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "E." 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Bases de la imagen de ecografía con contraste" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2325 "Ancho" => 3000 "Tamanyo" => 862272 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Using the linear probe. (A) Torsion-related testicular infarction: absence of testicular enhancement with epididymal enhancement (e). (B) Scrotal lymphoma; mass (arrows) occupying almost the entire testicle (t) and enhancing more than the adjacent testicle. C. Metastatic cervical adenopathy from pulmonary carcinoma: low-uptake nodule (*) inside the adenopathy (a). (D) Hepatic haemangioma, arterial phase (15 sec MI 0.099) showing the characteristic peripheral globular arterial hyperenhancement (dotted arrows). Due to its small size and superficial location, it was performed with the linear probe." ] ] ] "textoCompleto" => "IntroductionContrast-enhanced ultrasound (CEUS) is a technique with numerous applications for the study of different disorders which is both accepted and recommended in clinical and radiological guidelines.<a class="elsevierStyleCrossRefs" href="#bib0005">1–3</a> Intravenous ultrasound contrast, solely with intravascular distribution, provides information about blood vessels and enables vascular studies to be performed and the vascularisation of different organs and lesions to be dynamically assessed, improving the sensitivity and specificity of basic ultrasound (B-mode and Doppler), and adding complementary information to other contrast imaging techniques.Its intracavitary administration makes it applicable to other indications. Being a portable, real-time, repeatable and highly enhancement-sensitive examination, CEUS provides reliable diagnoses made quickly, in any location, without having to move patients (ICU, intraoperative ultrasound).<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Ultrasound contrast has its own pharmacological characteristics, technical requirements and physical effects, which are explained below.Composition and characteristics of ultrasound contrastThe ultrasound contrast used in Spain for non-cardiological purposes is sulphur hexafluoride (SF6), marketed under the name SonoVue® (it is marketed in the USA as Lumason®). It is an inert gas, slightly soluble in blood and water in the form of microbubbles and surrounded by a lipid membrane.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Each SonoVue® package contains a 25 mg vial of freeze-dried powder containing the active ingredient and the other components of the molecule, and 5 ml of sterile 0.9% saline solution pre-filled in a syringe for injection into the vial. The contrast is reconstituted by mixing the saline solution with the powder and shaking vigorously for 20 sec to obtain a milky-looking microbubble suspension. Once reconstituted, it is chemically and physically stable for six hours, but must be shaken for 20 sec before each administration. If the suspension does not acquire a milky appearance after being shaken, it should be discarded, as it has probably lost its properties. Each vial of contrast has a two-year shelf life and does not require specific storage measures.Routes of administration, pharmacodynamics and dosageIntravenousThis is the most common application. The reconstituted and pre-shaken contrast is administered as a bolus through a peripheral line with a ≤20 Gauge lumen or through a central line, pushed by a 5–10 ml bolus of normal saline solution. It is important that nursing staff be trained on and familiar with how to reconstitute the contrast, shake it properly and wait to load and administer it as a bolus when the examiner so indicates.The contrast bubbles are small and stable enough to pass through the cardiac and pulmonary circulation and distribute throughout all the vessels of the body. However, due to their size (mean diameter of 2.5 μm), much larger than the contrast molecules used in CT and MRI scans, the distribution is purely intravascular, without an interstitial phase,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> which explains the differences in the enhancement of late-phase hepatic lesions.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Ultrasound contrast shows large, medium and small vessels (capillaries, sinusoids). The contrast arrival time depends on the subject's cardiac output and whether the venous line used is central or peripheral and so has a larger or smaller lumen. If a peripheral route is used, enhancement in the hepatic or renal artery is usually identified in 11−15 sec. The bubbles disappear within a few minutes due to the rupture and diffusion of the gas, which is eliminated by lung respiration (there is no urinary elimination). The lipid shell is metabolised in the liver. The duration of enhancement with diagnostic capacity varies in different organs, but ranges from three to five minutes. After 15 min, virtually 100% of the contrast has been eliminated. These kinetics are regardless of dose, age, gender and whether the person has pulmonary fibrosis.The dose administered depends on the subject's age, the ultrasound machine and probe used, and the organ under study. In general, with an abdominal probe, it is recommended to use 1.2–2.4 ml in adult subjects and 1–1.2 ml in children. Special situations such as transplanted kidney CEUS and intestinal CEUS with a microconvex probe require a lower dose (1–1.2 ml), while twice the dose (4.8 ml, full vial) should be administered if a linear probe is used to study soft tissues, such as the breast, testicles or intestines. The volume of contrast administered is very small and the amount of sulphur hexafluoride administered in a clinical dose is extremely low (a 2 ml dose contains 16 μl of gas), so there is no established dose limit.Intracavitary routeThe contrast can be administered in physiological or non-physiological cavities, mixing it with normal saline or water.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> The dose of contrast and the amount of saline or water to be administered depend on the volume of the cavity to be examined. As the volume of any cavity is less than the volume of the entire blood flow, the dose to be administered is lower than for intravascular use. The concentration of SonoVue® for intracavitary use described in the literature is highly variable: the most commonly reported concentration range is 0.1–1.0 ml of SonoVue®, or a few drops diluted in 10–20 ml of 0.9% saline solution. Some common doses are as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Intravesical use or urosonography: 0.5−1 ml in 500 cc of saline.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a></li><li class="elsevierStyleListItem" id="lsti0010">-Hysterosalpingogram<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> for the study of tubal patency: 1 ml of SonoVue® in 20 cc of normal saline solution.</li><li class="elsevierStyleListItem" id="lsti0015">-Other applications such as nephrostomy, cholangiograms, abscesses and fistulas. In general, 0.1 ml or about 4−5 drops of ultrasound contrast diluted in 20 ml or more of normal saline solution is recommended. In practice, it is best to start with a low dose of contrast solution and if this is insufficient, additional ultrasound contrast agent can be added.<a class="elsevierStyleCrossRef" href="#bib0035">7</a></li><li class="elsevierStyleListItem" id="lsti0020">-Oral: one or two drops in a glass of water. It is useful for differentiating collections of gastric and duodenal contents.</li></ul>As there is no circulation or haemodynamic forces, the duration of contrast in a cavity is 20−30 min, much longer than that of vascular enhancement.Physical basis and mechanism of actionContrast-enhanced ultrasound imaging is based on the microbubbles being subjected to a sound field and oscillating through their elastic membrane.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> The oscillation, which is not linear (asymmetric compression/expansion) causes emission of harmonic signals, which are used to obtain the CEUS image. To obtain the image, specific programs are used that allow resonance of the bubble without breaking it: they are preset to a low mechanical index (MI) for the incident sound beam, a parameter that is related to the acoustic power (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The most common MI for the convex probe is under 0.1, but the value depends on the ultrasound being used. With linear probes, somewhat larger MI are used: 0.1−0.15. In addition, these programs suppress the stationary basal image of the tissues using different methods, so that the image is almost black and the sensitivity to enhancement is enormous, which enables detection of very slow flows undetectable by Doppler scan, with very good resolution. The scan is performed in real time and the dynamics of the enhancement are seen throughout the duration of the microbubbles (3−5 min, depending on the organ). This allows CEUS to detect enhancements in the early arterial phase which may go unnoticed on CT or MRI.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The enhancement phases are superimposable on CT and MRI phases:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">•Liver: arterial phase 10−20 sec to 30−45 sec, portal phase 30−45 sec to 2 min and late phase 2 min to 4−5 min.</li><li class="elsevierStyleListItem" id="lsti0030">•Kidney: cortical phase 10−20 s to 30−45 sec, and parenchymal phase 30−45 sec to 3−4 min.</li><li class="elsevierStyleListItem" id="lsti0035">•Rest of organs: arterial phase 10−20 sec to 30−45 sec, and venous phase 30−45 sec with a variable duration shorter than in the liver, except in the spleen, where it lasts up to 5 min.</li></ul>CEUS imaging: semiology, optimisation and interpretationContrast-enhanced ultrasound is always performed after greyscale ultrasound, which is used to select the lesion or area to be examined and to obtain baseline and Doppler information. The morphological and temporal enhancement information provided by CEUS is used in the diagnostic process in different ways, depending on its application; studying the permeability of a large vessel is not the same as estimating the inflammatory activity in a loop affected by Crohn's disease, or characterising a focal liver lesion. Focal liver lesions constitute one of the fundamental and most complex applications of contrast-enhanced ultrasound, where a series of patterns, nomenclature and concepts have been described which, when combined, reach a diagnosis, and which are partially applicable to focal lesions in other locations (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>):<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040">-Enhancement intensity compared to adjacent parenchyma (for example, hyperenhancement, washout). It can be qualitative, by visual comparison, or quantitative if time-intensity curves (TIC) are performed.</li><li class="elsevierStyleListItem" id="lsti0045">-Temporal pattern of enhancement and washout. A timer on the screen constantly displays the time since the injection, in seconds. The enhancement process must be observed in all phases.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Early washout is considered as that occurring prior to 60 sec, and late washout, after 60 sec.</li><li class="elsevierStyleListItem" id="lsti0050">-Morphological pattern of enhancement: direction of enhancement (centrifugal or centripetal), distribution and vascular morphology (globular, peripheral, star-shaped, basket-shaped, homogeneous or heterogeneous enhancement, variegated vessels).<a class="elsevierStyleCrossRef" href="#bib0060">12</a></li></ul><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The calculation of TIC curves makes it possible to obtain quantitative parameters similar to those obtained in TIC curves using other imaging procedures.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Quantification can be applied in different scenarios such as, for example, to study the early response to treatment in Crohn's disease<a class="elsevierStyleCrossRef" href="#bib0070">14</a> or for the quantification of tumour perfusion.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Currently, CEUS imaging is good in high- and mid-range ultrasound machines and in general its presets are suitable for most examinations, so in most cases there are few adjustments to be made. The most determinant adjustments are the choice of approach, probe, frequency and MI.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The approach should aim to bring the lesion closer to the transducer, as sound is also attenuated at depth in CEUS and, in addition, the more superficial contrast can itself produce attenuation in deep areas. For example, if a hepatic lesion is deep with a subcostal approach, an intercostal approach is advised. Lowering the frequency by choosing the contrast preset for penetration or raising the MI will improve the visualisation of deep areas. However, for superficial lesions it is advisable to keep the mechanical index low (<0.1) and use the resolution mode. Superficial lesions, soft tissue lesions or small lesions are generally studied with linear probes, which require the administration of the entire vial of contrast (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Regarding the dynamics of the examination, it is recommended to do a continuous scan with recording of representative parts of each vascular phase or an intermittent one after the complete recording of the arterial phase in lesions where it is important for the microbubbles to remain intact over time.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> For example, in haemangiomas, intermittent examination is advisable to avoid rupturing the bubbles inside, which may produce a pseudowashout artefact. However, if an endoleak is being studied in the aorta after endovascular aneurysm repair (EVAR), continuous scanning and recording are essential and the duration of the bubbles is less important. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows other tricks worth knowing because they help you optimise the image.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The CEUS image has artefacts common to conventional ultrasound, such as posterior shadow and mirror image, and others typically found when using contrast (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). One of the most important is the pseudoenhancement artefact that occurs in lesions with very heterogeneous content (typically in hepatic or renal lesions treated with ablative techniques, although also in cysts with complex content) which consists of an increase in signal in the lesion that can be confused with enhancement.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> True enhancement is marginal, with bubble circulation identified, whereas pseudoenhancement is central or patchy, with no bubble circulation observed, is slowly progressive, and typically intensifies if a second dose is administered (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). One rare artefact is the appearance of patchy areas of increased hepatic echogenicity in B-mode, which may persist for up to 15 min. The cause is unknown and it has no pathological value. In endocavitary use, the appearance of posterior shadow is common, especially if the cavity is large, as in ultrasound cystography. This is solved by mobilising the contrast to prevent bubbles from floating using a gravity drip system or compression with a pressure cuff, and it is recommended to also move the bag with the mixture of saline and ultrasound contrast back and forth during the study.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Safety of SonoVue®As it is not eliminated via the urinary system, SonoVue® can be used in subjects with renal impairment; there is no risk of contrast nephropathy or systemic nephrogenic fibrosis. Its safety profile is very good, with the incidence of reported adverse reactions being very low, in the range of 0.033% to 0.088%.<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a> The vast majority are mild, immediate or in the first few minutes after administration of the contrast and self-limiting: erythema, dizziness, head pain, reactions at the injection site, nausea and vomiting, tachycardia and dyspnoea. The rate of serious adverse reactions in exposed subjects is 0.0086%<a class="elsevierStyleCrossRef" href="#bib0100">20</a> and the reported incidence of deaths is very low, at 0.0006%.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Adverse reactions are more common in inpatients than in outpatients. Although hypersensitivity reactions are very rare (<1/10,000), much less common than those associated with iodinated contrasts, there are isolated cases of anaphylactic shock. Type I immediate hypersensitivity to polyethylene glycol (PEG) or macrogol (a component of SonoVue®) is possible, so its use is contraindicated in subjects with known hypersensitivity to PEG. As PEG is a component of certain colonoscopy preparations and laxatives, it is recommended to ask subjects if they have had any adverse reactions to these preparations. There is no established published protocol for managing adverse reactions. It is advisable to apply the usual measures in place in each department for treating adverse reactions to other contrasts according to their severity. Severe cases require close monitoring and oxygen inhalation with anti-shock and anti-anaphylactic treatment; epinephrine, dexamethasone and rapid infusion of normal saline or lactated Ringer's solution for anaphylactic shock. If the subject has bradycardia, atropine can be used to increase the heart rate. If the subject has suffered cardiac arrest, CPR should be performed immediately. The safety profile is also very good in the paediatric age group<a class="elsevierStyleCrossRef" href="#bib0105">21</a> and no adverse reactions to intravesical use have been described.The following precautions are advised before administering contrast:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055">-Oral or written informed consent: explain the test to the subject and why it is being done and ask about history of drug or food allergies (severe adverse reactions were more common in people with a history of allergies).</li><li class="elsevierStyleListItem" id="lsti0060">-The test should be performed in a room prepared to handle adverse reactions to medication and in proximity to a resuscitation trolley. The subject's condition should be monitored during and after contrast administration (for 20−30 min).</li><li class="elsevierStyleListItem" id="lsti0065">-The intravenous line should be maintained for 30 min in subjects at risk or who have experienced discomfort.</li><li class="elsevierStyleListItem" id="lsti0070">-Recent acute coronary syndrome or clinically unstable coronary heart disease. Administer only after careful assessment of the benefit/risk balance and close monitoring of vital functions during and after administration.</li><li class="elsevierStyleListItem" id="lsti0075">-Record adverse reactions with the vial number and report them in the subject's medical records. Inform the pharmaceutical company that markets the contrast.</li><li class="elsevierStyleListItem" id="lsti0080">-Pregnancy: it has been shown that the contrast does not cross into the placental circulation and there have been no adverse effects on the foetus in the studies conducted, but its use is currently off-label.<a class="elsevierStyleCrossRef" href="#bib0110">22</a></li><li class="elsevierStyleListItem" id="lsti0085">-Breastfeeding: do not breastfeed for two hours after administration of SonoVue®.</li></ul>Contraindications include: hypersensitivity to the active substance or to any of the excipients, or history of hypersensitivity reaction to previous administration of SonoVue®; subjects with right-to-left shunts (this contraindication no longer exists in the USA), severe pulmonary hypertension (pulmonary arterial pressure >90 mmHg); uncontrolled systemic hypertension and adult respiratory distress syndrome.Applications and limitationsContrast-enhanced ultrasound has numerous applications: it can be applied intravenously to study any organ or vessel accessible to B-mode ultrasound.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The most common applications are briefly explained below; the rest can be consulted in the EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) and WFUMB (World Federation for Ultrasound in Medicine and Biology) guidelines.<a class="elsevierStyleCrossRefs" href="#bib0010">2,23–26</a> It should be noted that many of the applications are off-label and authorisation from the different medicines agencies vary between Europe and other non-European countries.LiverThe most established application, and recommended by the EFSUMB guidelines, is for the characterisation of indeterminate focal liver lesions in B-mode,<a class="elsevierStyleCrossRefs" href="#bib0010">2,27</a> as it can resolve on the go during the same procedure cases in which a definitive diagnosis is reached (for example, a haemangioma or focal nodular hyperplasia) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). It can also direct and expedite management (if metastasis, an extension CT will be performed; if suggestive of hepatocellular carcinoma, MRI is preferred). It can help characterise lesions not characterised by other imaging procedures<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a>: CEUS may demonstrate arterial hyperenhancement or a pattern of enhancement or washout not demonstrated on CT or MRI. In the context of chronic liver disease, the CEUS LI-RADS system allows interpretation of CEUS findings of focal lesions and production of standardised reports with the same categories as LI-RADS.<a class="elsevierStyleCrossRefs" href="#bib0145">29,30</a> Real-time scanning allows accurate assessment of washout time to differentiate hepatocellular carcinoma from other malignant hepatic lesions.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> CEUS also enables quantitative studies on tumour perfusion with TIC curves.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Although application of CEUS is less common for the detection of focal lesions, its use is accepted for the detection of hepatic metastases.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> CEUS makes it possible to characterise and study the internal structure of liver abscesses<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a> and determine whether they are susceptible to drainage. Although CT is the technique of choice in trauma patients, CEUS is indicated for the follow-up of already known visceral injuries and in children with low-intensity blunt trauma,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> in order to avoid radiation.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>The use of contrast is especially useful in liver transplantation to demonstrate vascular permeability or confirm vascular thrombosis,<a class="elsevierStyleCrossRef" href="#bib0185">37</a> as well as to determine the location and extent of areas of infarction,<a class="elsevierStyleCrossRef" href="#bib0190">38</a> which is essential information for deciding between revascularisation or retransplantation.Kidney and urinary tractRenal and urinary tract applications are off-label, but are among the most frequently used.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> CEUS is useful for differentiating pseudolesions from real lesions and in lesions which are indeterminate on CT, in order to differentiate solid lesions from cysts.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> In the case of renal cystic lesions, CEUS has a very high sensitivity for demonstrating enhancement in septa (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>), as well as excellent resolution for measuring their thickness and detecting the presence of mural nodules.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> This means cystic lesions can be categorised according to the Bosniak classification with a very good performance, both in the initial diagnosis and in the follow-up. It is less useful in the study of solid renal lesions, as, although there are some suggestive patterns in some neoplasms (hypovascular lesions are suggestive of papillary renal cell carcinoma) and some of the findings are associated with certain diseases (parenchymal phase washout occurs more in malignant lesions),<a class="elsevierStyleCrossRef" href="#bib0210">42</a> in general CEUS is not effective for characterising solid renal lesions. In the infectious context, CEUS is useful in the diagnosis and follow-up of acute pyelonephritis, especially to differentiate areas of focal pyelonephritis from abscess.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> As the contrast is not eliminated through the urinary tract, it cannot be studied directly, although it is useful for differentiating between clot and neoplasm in both the urinary tract and the bladder.<a class="elsevierStyleCrossRef" href="#bib0220">44</a> In renal transplantation, it is especially useful for studying vascular permeability, to confirm vascular thrombosis and to study areas of ischaemia (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).<elsevierMultimedia ident="fig0030"></elsevierMultimedia>Inflammatory bowel diseaseDiagnosis of inflammatory bowel disease (IBD) involvement and assessment of its extent and disease activity can be performed using B-mode ultrasound and a colour Doppler scan.<a class="elsevierStyleCrossRef" href="#bib0225">45</a> Contrast-enhanced ultrasound enables the study of disease activity with greater precision, especially in indeterminate cases with wall thickening without colour Doppler signal, and for early distinction between subjects who respond to treatment and those who do not by quantification with TIC curves (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).<a class="elsevierStyleCrossRefs" href="#bib0225">45,46</a> Another application is for differentiating inflammatory masses or phlegmons from abscessed areas and defining their size and extent, which can affect treatment.<a class="elsevierStyleCrossRef" href="#bib0235">47</a><elsevierMultimedia ident="fig0035"></elsevierMultimedia>Paediatric subjectsSonoVue® is approved in Spain in paediatric subjects for intracavitary CEUS of the urinary tract for the detection of vesicoureteral reflux. Intravenous use in children is compassionate, as it is not approved by the European Medicines Agency (EMA) (unlike in the USA, where it is approved by the Food and Drug Administration [FDA]). In children, CEUS is recommended for its many advantages: it is a technique with great diagnostic efficacy which can avoid the need for a CT or MRI, thus avoiding exposure to radiation and sedation/anaesthesia; it is an easy and convenient study which also improves the family experience compared to other imaging procedures, as it can be performed bedside; and it is safe. It has multiple applications similar to those in adults, including vascular assessment of transplanted organs.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> It also has excellent diagnostic efficacy in the detection of vesicoureteral reflux; the experts from the ESPR (European Society of Pediatric Radiology) Urogenital Task Force recommend the use of ultrasound cystograms instead of conventional cystograms, as it has been shown to provide comparable information, but with the absence of radiation (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>).<a class="elsevierStyleCrossRef" href="#bib0245">49</a> In paediatric subjects there are also other endocavitary applications, for example to determine the location of the tip of a catheter or the extent of drained collections.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> CEUS enables the diagnostic scope of ultrasound in children to be significantly expanded.<elsevierMultimedia ident="fig0040"></elsevierMultimedia>Interventional proceduresMany interventional procedures are performed under ultrasound guidance, so administering contrast is the natural way to guide, facilitate or improve these procedures.<a class="elsevierStyleCrossRefs" href="#bib0255">51,52</a> It is used before, during and after ablative procedures in solid liver,<a class="elsevierStyleCrossRef" href="#bib0265">53</a> kidney (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>) and thyroid lesions, as a biopsy guide for lesions not visible in the baseline ultrasound, and to avoid taking samples in areas of necrosis. It is also useful for confirming patency or placement of drainage, biliary or nephrostomy catheters.<a class="elsevierStyleCrossRef" href="#bib0270">54</a>Vascular CEUSCEUS is very useful for demonstrating the patency of any arterial or venous vessel and of stents<a class="elsevierStyleCrossRef" href="#bib0275">55</a>; for example, vessels of the different organs, splenoportal axis, abdominal aorta<a class="elsevierStyleCrossRef" href="#bib0280">56</a> and iliac arteries, vena cava and iliac veins, carotid arteries<a class="elsevierStyleCrossRef" href="#bib0285">57</a> and subclavian arteries, and jugular and subclavian veins (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>). CEUS can distinguish between soft venous thrombosis and venous tumour thrombosis, by demonstrating arterial enhancement of the thrombus in the case of a tumour.<a class="elsevierStyleCrossRefs" href="#bib0290">58,59</a> It is also useful in subjects with complex abdominal surgery, to rule out vascular thrombosis. In addition to liver and kidney transplants, it is used in pancreas transplants and to demonstrate the viability of soft tissue and skin grafts. Being a real-time examination, CEUS is particularly useful in the study of subjects with abdominal aortic aneurysm after EVAR to establish the type of leak. Although the ideal test to study the complications of abdominal aortic aneurysms is CT angiography, CEUS can show complications such as dissection or rupture (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>). CEUS can also show active bleeding such as extravasation of contrast medium (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).<elsevierMultimedia ident="fig0045"></elsevierMultimedia>LimitationsContrast-enhanced ultrasound imaging has the limitations of any ultrasound: window and depth limitations (especially in the case of hepatic steatosis). It also has a size limitation: it depends on the probe, the organ and the conditions, but, in general, lesions smaller than 3−5 mm are not detected and characterising lesions smaller than 8 mm can be difficult, even if they are detected. Another limitation is the multiplicity of lesions, as it is very difficult to study all the lesions in all phases if they are not in the same plane, such that the advantage of the temporal resolution of CEUS compared to CT and MRI, being a real-time examination and seeing all phases, has the disadvantage of limited spatial resolution.ConclusionsCEUS is a portable technique with no radiation or renal toxicity which provides information that can be superimposed on CT and MRI and has the great advantage of obtaining the image in real time. CEUS has numerous applications for intravascular use and various intracavitary applications. The contrast composition and imaging bases of CEUS are different from those of CT and MRI, and there are technical issues which need to be understood in order to optimise the studies and the image. The pharmacodynamics and pharmacokinetics, as well as the purely intravascular condition of SonoVue®, translate into vascular information and dynamic information on lesion enhancement which can show some differences compared to CT and MRI in the steady state phase. The safety profile of SonoVue® is very good, with uncommon, generally mild and immediate adverse reactions with intravascular use and no adverse reactions in intracavitary use.FundingThis study has not received any type of funding.CRediT authorship contribution statement<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0090">1Responsible for the integrity of the study: M.T. Fontanilla Echeveste.</li><li class="elsevierStyleListItem" id="lsti0095">2Study conception: M.T. Fontanilla Echeveste and T. Ripollés González.</li><li class="elsevierStyleListItem" id="lsti0100">3Study design: M.T. Fontanilla Echeveste, T. Ripollés González and E. Aguirre Pascual.</li><li class="elsevierStyleListItem" id="lsti0105">4Data collection: M.T. Fontanilla Echeveste, T. Ripollés González and E. Aguirre Pascual.</li><li class="elsevierStyleListItem" id="lsti0110">5Data analysis and interpretation: M.T. Fontanilla Echeveste, T. Ripollés González and E. Aguirre Pascual.</li><li class="elsevierStyleListItem" id="lsti0115">6Statistical processing: not applicable.</li><li class="elsevierStyleListItem" id="lsti0120">7Literature search. M.T. Fontanilla Echeveste, T. Ripollés González and E. Aguirre Pascual.</li><li class="elsevierStyleListItem" id="lsti0125">8Drafting of the article: M.T. Fontanilla Echeveste, T. Ripollés González and E. Aguirre Pascual.</li><li class="elsevierStyleListItem" id="lsti0130">9Critical review of the manuscript with intellectually relevant contributions: M.T. Fontanilla Echeveste, T. Ripollés González and E. Aguirre Pascual.</li><li class="elsevierStyleListItem" id="lsti0135">10Approval of the final version: M.T. Fontanilla Echeveste and T. Ripollés González.</li></ul>" "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres2278370" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1897027" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2278369" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1897028" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Composition and characteristics of ultrasound contrast" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Routes of administration, pharmacodynamics and dosage" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Intravenous" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Intracavitary route" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Physical basis and mechanism of action" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "CEUS imaging: semiology, optimisation and interpretation" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Safety of SonoVue®" ] 10 => array:3 [ "identificador" => "sec0045" "titulo" => "Applications and limitations" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Liver" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Kidney and urinary tract" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Inflammatory bowel disease" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Paediatric subjects" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Interventional procedures" ] 5 => array:2 [ "identificador" => "sec0075" "titulo" => "Vascular CEUS" ] ] ] 11 => array:2 [ "identificador" => "sec0080" "titulo" => "Limitations" ] 12 => array:2 [ "identificador" => "sec0085" "titulo" => "Conclusions" ] 13 => array:2 [ "identificador" => "sec0095" "titulo" => "Funding" ] 14 => array:2 [ "identificador" => "sec0090" "titulo" => "CRediT authorship contribution statement" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-04-13" "fechaAceptado" => "2024-06-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1897027" "palabras" => array:5 [ 0 => "Contrast media" 1 => "SonoVue" 2 => "Ultrasound" 3 => "Examination technique" 4 => "Pharmacodynamics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1897028" "palabras" => array:5 [ 0 => "Medios de contraste" 1 => "SonoVue" 2 => "Ecografía" 3 => "Técnica de exploración" 4 => "Farmacodinámica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Contrast-enhanced ultrasound (CEUS) is a medical imaging technique that offers multiple advantages over other modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). These advantages include portability, no ionising radiation and no renal toxicity, with the great advantage of real-time imaging. CEUS has numerous established applications for the study of different pathologies, both intravenous and intracavitary administration. The contrast used is different in composition and function from CT or MRI contrast. It is a purely intravascular contrast and, therefore, the enhancement of the lesions may have some differences with respect to CT or MRI in the equilibrium phase. Ultrasound contrast has a very good safety profile, with infrequent, generally mild and immediate adverse reactions in intravascular use and no adverse reactions reported in intracavitary use. It is important to know the basics of contrast-enhanced ultrasound, the different ways to optimise the image and the different artefacts." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La ecografía con contraste (CEUS) es una técnica de imagen médica que ofrece múltiples ventajas frente a otras modalidades como la tomografía computarizada (TC) y la resonancia magnética (RM). Estas ventajas incluyen la portabilidad, la ausencia de radiación ionizante y la no toxicidad renal, con la gran ventaja de permitir la obtención de imágenes en tiempo real. CEUS tiene numerosas aplicaciones ya establecidas para el estudio de distintas patologías, tanto en su administración intravenosa como intracavitaria. El contraste utilizado tiene una composición y funcionamiento distintos al contraste de la TC o de la RM. Es un contraste puramente intravascular y, por tanto, el realce de las lesiones puede tener algunas diferencias respecto al TC o la RM en la fase de equilibrio. El contraste ecográfico tiene un perfil de seguridad muy bueno, con reacciones adversas poco frecuentes, generalmente leves e inmediatas en su uso intravascular y sin reacciones adversas reportadas en su uso intracavitario. Es importante conocer las bases de la ecografía con contraste, las distintas formas de optimizar la imagen y los distintos artefactos." ] ] "multimedia" => array:11 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1753 "Ancho" => 3341 "Tamanyo" => 273430 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "The behaviour of bubbles in the sound field depends on the amplitude of the incident wave, which is related to the acoustic power and the mechanical index (MI), and this in turn determines the intensity of the signal seen in the image and its duration. The acoustic power increases (from A to C) as the amplitude of the wave increases. When the power and amplitude are minimal (A), the bubbles do not oscillate and there is hardly any signal. With low power and amplitude (low mechanical index) (B) the bubbles oscillate with a minimal chance of their rupturing, thus achieving a long-lasting signal. With high power and amplitude (high mechanical index) (C) the bubbles break quickly, obtaining a very intense but short-lived signal. In practice, a low mechanical index is used, although it is a parameter that can be managed." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2014 "Ancho" => 3333 "Tamanyo" => 968856 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Enhancement intensity, temporal pattern and vascular pattern in two hepatic lesions. A and B. Hepatocellular carcinoma. (A) Arterial phase (18 sec MI 0.08) showing hyperenhancement in two nodules, with a peripheral vascular pattern with variegated vessels in the large nodule. (B) Faint and late washout (3 min 48 sec) typical for hepatocellular carcinoma: it is categorised (in this subject with chronic liver disease) as CEUS LI-RADS 5. The smaller nodule (white arrow in A) is indistinguishable in the late phase because it is in the attenuation zone produced by the contrast itself from the more superficial areas, like artefacts(*). (C and D) Metastasis of lung cancer. (C) Peripheral enhancement of the mass can be seen in the arterial phase; it is not uncommon for arterial enhancement in metastases to show up in CEUS when they are not identified in CT or MRI, because CEUS shows enhancement from the onset and the arterial CT and MRI phases are post-onset. (D) Marked, early washout (50 sec) typical for metastasis and/or cholangiocarcinoma in CEUS." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2325 "Ancho" => 3000 "Tamanyo" => 862272 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Using the linear probe. (A) Torsion-related testicular infarction: absence of testicular enhancement with epididymal enhancement (e). (B) Scrotal lymphoma; mass (arrows) occupying almost the entire testicle (t) and enhancing more than the adjacent testicle. C. Metastatic cervical adenopathy from pulmonary carcinoma: low-uptake nodule (*) inside the adenopathy (a). (D) Hepatic haemangioma, arterial phase (15 sec MI 0.099) showing the characteristic peripheral globular arterial hyperenhancement (dotted arrows). Due to its small size and superficial location, it was performed with the linear probe." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1888 "Ancho" => 2417 "Tamanyo" => 622724 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "CEUS artefacts. (A) Cotton-like appearance of the liver in B-mode 15 min after administration of SonoVue®. (B) Uterine leiomyosarcoma metastasis treated with radiofrequency. Residual tumour can be seen (dotted arrow), typically marginal. Pseudoenhancement is also seen, which is central (white arrow). (C) Glare artefact around the hepatic artery and its branches. (D) Pseudowashout artefact in haemangioma at 3 min." ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1792 "Ancho" => 3333 "Tamanyo" => 713021 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "CEUS liver applications. (A, B and C) Small incidental lesion diagnosed by CEUS as focal nodular hyperplasia and not requiring further imaging. (A) Ultrasound in B-mode: indeterminate lesion measuring 1 cm. (B) CEUS image in arterial phase (14 sec MI 0.07) after placing a marker trace on the reference dual B-mode image when reviewing the video: this same trace is copied to the contrast image, serves as a guide and shows that the arterial enhancement begins in the centre of the lesion. Real-time showed centrifugal enhancement. (C) At 3:06 min, no washout can be seen. (D) Review of hepatocellular carcinoma treated with radiofrequency with inconclusive CT (dual image at 39 sec, MI 0.079) showing arterial phase enhancement of almost the entire treated lesion, in relation to recurrence." ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1765 "Ancho" => 3333 "Tamanyo" => 968317 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "CEUS kidney applications. (A) Bosniak II-F renal cystic lesion. CEUS (here with maximum intensity projection [MIP] imaging) allows visualisation with high resolution and sensitivity of enhancing septa and measurement of their thickness. (B) Renal cancerous lesion treated with radiofrequency. Absence of enhancement can be seen compatible with coagulative necrosis. Non-suppressed echogenic baseline image artefact (arrow), which should not be confused with enhancement. (C) Transplanted kidney, portable ultrasound performed in ICU: anterior cortical infarction undetectable on baseline ultrasound. (D) Transplanted kidney (R): portable ultrasound performed in ICU showing significant stream of active bleeding (dotted arrow): the subject went directly to the operating theatre without the need for further imaging tests." ] ] 6 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1483 "Ancho" => 3341 "Tamanyo" => 456188 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Application in inflammatory bowel disease. Ultrasound images of a 32-year-old woman with severe Crohn's disease in the terminal ileum determined by endoscopy. (A) Longitudinal ultrasound image of the affected bowel segment with parietal thickening. (B) Ultrasound image showing intense enhancement of the bowel wall after injection of 2.4 ml of contrast, with a manually defined ROI on the bowel wall for measurement of vascularisation. The graph shows the corresponding time-intensity curve." ] ] 7 => array:8 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 2028 "Ancho" => 3333 "Tamanyo" => 830123 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Intracavitary use. (A, B and C) Three-month-old infant with febrile UTI with abnormal ultrasound with probable urinary tract dilation. (A) Normal-sized left kidney with adequate corticomedullary differentiation and ureteropyelolocalycial dilation grade II/IV (P2 according to the Urinary Tract Dilation [UTD] classification system). After urethral catheterisation, an ultrasound cystogram was performed, which showed passive vesicoureteral reflux reaching the upper excretory system in the left kidney (*) which increases with urination, grade 5/5 left. Patchy intrarenal reflux can be seen in the left kidney. (C) Normal male urethra: the perineal approach with a convex probe allows assessment of the urethra during the voiding phase of an ultrasound cystogram (dotted arrow). (D) Subject with jaundice and biliary stent. Percutaneous cholangiogram showing the common bile duct with obstructed metal stent (arrow)." ] ] 8 => array:8 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 1656 "Ancho" => 3333 "Tamanyo" => 780175 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "CEUS vascular applications. (A) Liver transplant. Large peripheral hepatic infarction shows up as absence of enhancement (*). Shows the patency of the main portal vein, the hepatic artery and the inferior vena cava. Mirror-image artefact of the inferior vena cava. (B) Carotid bifurcation, longitudinal slice. Occlusion of the internal carotid artery (ICA) and patency of the common carotid arteries (CCA) and external carotid arteries (ECA). CEUS is very useful in differentiating preocclusive stenosis from complete occlusion. (C) Portal vein tumour thrombosis. Increased and occupied portal vein in B mode and with enhancement in arterial phase (at 7 sec) with visualisation of arterial vessels inside the tumour thrombus (white arrow). (D) Double-lumen aortic dissection: more enhanced true lumen (earlier enhancement was seen in this lumen in real time) and less enhanced false lumen. The flow jet in the communication is identified (black arrow) using a higher mechanical index than usual (0.52)." ] ] 9 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CEUS: contrast-enhanced ultrasound; MI: mechanical index; TIC: time intensity curve." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Action \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Purpose/method \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comments \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Choice of approach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bring the lesion to the transducer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">By making the lesion less deep there is less attenuation and the enhancement can be seen better \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Choice of probe</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Convex in intra-abdominal or pulmonary lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dose 1−2.4 ml \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Microconvex in intestine and kidney transplantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dose 1.2 ml \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Linear in small, soft parts and intestine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dose 4.8 ml \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Choice of frequency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Choose penetration, general or resolution mode or manual adjustment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deeper lesions require a lower frequency and more superficial lesions a higher frequency. The higher the frequency, the greater the bubble rupture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administration of second or third dose</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To see other lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multiple lesions or lesions in other organs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To see the enhancement of a lesion again \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wait for the previous bubbles to disappear, which can be accelerated by using Flash with high MI, or by changing to B mode and using Doppler \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To see the enhancement of septa or hypovascular lesions more intensely \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cumulative effect: don't wait for the bubbles to disappear \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Keep mechanical index low <0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Generally in focal lesions and especially in haemangiomas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To be able to assess the late phase of the lesions and to avoid pseudowashout \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Raise mechanical index</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep lesions. Obese subjects. Fatty liver disease. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">For example, MI 0.09−0.12 instead of 0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To better view the septa in renal cystic lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">For example, MI 0.09 instead of 0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To see the enhancement pattern in liver lesions with very rapid arterial enhancement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Variable. You can go up in the arterial phase quite a bit until the bubbles disappear and then lower the MI to be able to identify the enhancement pattern again. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In purely vascular studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Variable. It is not so much the duration of the bubble that matters, but rather having a very good signal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjusting the focus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Keep deep to the lesion or area of study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">More bubbles are destroyed in the focus area \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adjusting the gain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Signal/noise optimisation intuitively \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Do not modify during the examination if TIC curves are to be taken, as this would alter the intensity measurements. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Using dual window B-mode/CEUS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommended in general and particularly for small lesions and as a biopsy guide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Once the lesion has been identified in the contrast-enhanced ultrasound, the dual image can be discarded \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of guide or measurement marker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Place a marker in the greyscale window when using dual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Makes it possible to locate small or iso-uptake lesions in the CEUS window \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermittent scanning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Focal lesions: view the entire arterial phase (and record the first 30−60 sec and then scan intermittently to minimise bubble rupture) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">View and record representative parts of each phase \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous scanning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Organ and vascular perfusion studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Required for TIC curves \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MIP (maximum intensity projection) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">To better delimit the septa in cystic lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Better resolution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In vascular studies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Better resolution \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Avoid shadowing in cystograms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mobilise the contrast to mix: saline in a drip (by gravity) or pressure cuff \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Avoid shadowing in oral CEUS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Give the first glass of water with a drop of contrast and a second glass without contrast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Avoid shadowing in other cavities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inject more saline without contrast so that it mixes in the cavity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3697163.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Image optimisation." ] ] 10 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CEUS: Contrast-enhanced ultrasound; MI: mechanical index." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CEUS artefacts \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cause/comments \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Action \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unsuppressed baseline hypersignal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Highly echogenic images: septa in cysts or calcifications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pay attention to the signal before applying CEUS. Lowering the gain partially decreases them \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Posterior reinforcement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cystic lesions or collections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Change of approach if there is doubt of enhancement in a deep lesion after reinforcement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Posterior shadow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calcifications or highly enhanced structure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Change of approach if the lesion to be studied remains in shadow \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reverberation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Important acoustic interfaces \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Change of approach if the lesion to be studied remains in the reverberation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mirror-image artefact \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Explore it \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pseudowashout \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bubble rupture in slow-flow lesion comparatively greater than in adjacent parenchyma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermittent scanning to minimise bubble rupture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pseudoenhancement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Highly heterogeneous lesions, typically after ablative treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recognise pseudoenhancement: non-marginal, slowly progressive, no temporal pattern of enhancement and washout \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glare or glow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased signal around the contrasted vessels or structures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administer the correct dose. Gets worse with higher doses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Saturation of enhancement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lower the gain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use a lower dose next time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep attenuation/shadow \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The surface bubbles themselves produce attenuation at depth \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Raise the MI to see deep areas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Destruction of microbubbles in the plane and on the surface \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The MI decreases in depth, greater destruction of bubbles occurs on the surface \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scan interrupted/change of plane \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Heterogeneous liver appearance in B mode \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown cause \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nothing can be done \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Colour Doppler artefacts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Blooming \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lower the Doppler gain. Wait for the bubbles to disappear \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spectral Doppler noise \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Linear images in the spectrumAudible noise like small pops \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wait for the bubbles to disappear \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased speed in spectral Doppler \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Approximately 5 cm/s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wait for the bubbles to disappear \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3697164.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Artefacts in contrast-enhanced ultrasound." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:59 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microbubble contrast for radiological imaging: 2. 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Update and good practice in the contrast media uses

Fundamentos de la ecografía con contraste: farmacodinámica y fármacocinética del contraste. Bases de la imagen de ecografía con contraste

M.T. Fontanilla Echevestea,

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fonteche@gmail.com

Corresponding author.

, T. Ripollés Gonzálezb, E. Aguirre Pascualc

a Servicio de Radiología, Sección de Radiología Abdominal, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain

b Servicio de Radiología, Sección de Radiología Abdominal, Hospital Dr. Peset, Valencia, Spain

c Servicio de Radiología, Sección de Radiología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, Spain

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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Using the linear probe&#46; &#40;A&#41; Torsion-related testicular infarction&#58; absence of testicular enhancement with epididymal enhancement &#40;e&#41;&#46; &#40;B&#41; Scrotal lymphoma&#59; mass &#40;arrows&#41; occupying almost the entire testicle &#40;t&#41; and enhancing more than the adjacent testicle&#46; C&#46; Metastatic cervical adenopathy from pulmonary carcinoma&#58; low-uptake nodule &#40;&#42;&#41; inside the adenopathy &#40;a&#41;&#46; &#40;D&#41; Hepatic haemangioma&#44; arterial phase &#40;15&#160;sec MI 0&#46;099&#41; showing the characteristic peripheral globular arterial hyperenhancement &#40;dotted arrows&#41;&#46; Due to its small size and superficial location&#44; it was performed with the linear probe&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Contrast-enhanced ultrasound &#40;CEUS&#41; is a technique with numerous applications for the study of different disorders which is both accepted and recommended in clinical and radiological guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Intravenous ultrasound contrast&#44; solely with intravascular distribution&#44; provides information about blood vessels and enables vascular studies to be performed and the vascularisation of different organs and lesions to be dynamically assessed&#44; improving the sensitivity and specificity of basic ultrasound &#40;B-mode and Doppler&#41;&#44; and adding complementary information to other contrast imaging techniques&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Its intracavitary administration makes it applicable to other indications&#46; Being a portable&#44; real-time&#44; repeatable and highly enhancement-sensitive examination&#44; CEUS provides reliable diagnoses made quickly&#44; in any location&#44; without having to move patients &#40;ICU&#44; intraoperative ultrasound&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Ultrasound contrast has its own pharmacological characteristics&#44; technical requirements and physical effects&#44; which are explained below&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Composition and characteristics of ultrasound contrast</span><p id="par0020" class="elsevierStylePara elsevierViewall">The ultrasound contrast used in Spain for non-cardiological purposes is sulphur hexafluoride &#40;SF<span class="elsevierStyleInf">6</span>&#41;&#44; marketed under the name SonoVue&#174; &#40;it is marketed in the USA as Lumason&#174;&#41;&#46; It is an inert gas&#44; slightly soluble in blood and water in the form of microbubbles and surrounded by a lipid membrane&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Each SonoVue&#174; package contains a 25&#160;mg vial of freeze-dried powder containing the active ingredient and the other components of the molecule&#44; and 5&#160;ml of sterile 0&#46;9&#37; saline solution pre-filled in a syringe for injection into the vial&#46; The contrast is reconstituted by mixing the saline solution with the powder and shaking vigorously for 20&#160;sec to obtain a milky-looking microbubble suspension&#46; Once reconstituted&#44; it is chemically and physically stable for six hours&#44; but must be shaken for 20&#160;sec before each administration&#46; If the suspension does not acquire a milky appearance after being shaken&#44; it should be discarded&#44; as it has probably lost its properties&#46; Each vial of contrast has a two-year shelf life and does not require specific storage measures&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Routes of administration&#44; pharmacodynamics and dosage</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Intravenous</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is the most common application&#46; The reconstituted and pre-shaken contrast is administered as a bolus through a peripheral line with a &#8804;20 Gauge lumen or through a central line&#44; pushed by a 5&#8211;10&#160;ml bolus of normal saline solution&#46; It is important that nursing staff be trained on and familiar with how to reconstitute the contrast&#44; shake it properly and wait to load and administer it as a bolus when the examiner so indicates&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The contrast bubbles are small and stable enough to pass through the cardiac and pulmonary circulation and distribute throughout all the vessels of the body&#46; However&#44; due to their size &#40;mean diameter of 2&#46;5&#160;&#956;m&#41;&#44; much larger than the contrast molecules used in CT and MRI scans&#44; the distribution is purely intravascular&#44; without an interstitial phase&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which explains the differences in the enhancement of late-phase hepatic lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Ultrasound contrast shows large&#44; medium and small vessels &#40;capillaries&#44; sinusoids&#41;&#46; The contrast arrival time depends on the subject&#39;s cardiac output and whether the venous line used is central or peripheral and so has a larger or smaller lumen&#46; If a peripheral route is used&#44; enhancement in the hepatic or renal artery is usually identified in 11&#8722;15&#160;sec&#46; The bubbles disappear within a few minutes due to the rupture and diffusion of the gas&#44; which is eliminated by lung respiration &#40;there is no urinary elimination&#41;&#46; The lipid shell is metabolised in the liver&#46; The duration of enhancement with diagnostic capacity varies in different organs&#44; but ranges from three to five minutes&#46; After 15&#160;min&#44; virtually 100&#37; of the contrast has been eliminated&#46; These kinetics are regardless of dose&#44; age&#44; gender and whether the person has pulmonary fibrosis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The dose administered depends on the subject&#39;s age&#44; the ultrasound machine and probe used&#44; and the organ under study&#46; In general&#44; with an abdominal probe&#44; it is recommended to use 1&#46;2&#8211;2&#46;4&#160;ml in adult subjects and 1&#8211;1&#46;2&#160;ml in children&#46; Special situations such as transplanted kidney CEUS and intestinal CEUS with a microconvex probe require a lower dose &#40;1&#8211;1&#46;2&#160;ml&#41;&#44; while twice the dose &#40;4&#46;8&#160;ml&#44; full vial&#41; should be administered if a linear probe is used to study soft tissues&#44; such as the breast&#44; testicles or intestines&#46; The volume of contrast administered is very small and the amount of sulphur hexafluoride administered in a clinical dose is extremely low &#40;a 2&#160;ml dose contains 16&#160;&#956;l of gas&#41;&#44; so there is no established dose limit&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Intracavitary route</span><p id="par0040" class="elsevierStylePara elsevierViewall">The contrast can be administered in physiological or non-physiological cavities&#44; mixing it with normal saline or water&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The dose of contrast and the amount of saline or water to be administered depend on the volume of the cavity to be examined&#46; As the volume of any cavity is less than the volume of the entire blood flow&#44; the dose to be administered is lower than for intravascular use&#46; The concentration of SonoVue&#174; for intracavitary use described in the literature is highly variable&#58; the most commonly reported concentration range is 0&#46;1&#8211;1&#46;0&#160;ml of SonoVue&#174;&#44; or a few drops diluted in 10&#8211;20&#160;ml of 0&#46;9&#37; saline solution&#46; Some common doses are as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Intravesical use or urosonography&#58; 0&#46;5&#8722;1&#160;ml in 500 cc of saline&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Hysterosalpingogram<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> for the study of tubal patency&#58; 1&#160;ml of SonoVue&#174; in 20 cc of normal saline solution&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Other applications such as nephrostomy&#44; cholangiograms&#44; abscesses and fistulas&#46; In general&#44; 0&#46;1&#160;ml or about 4&#8722;5 drops of ultrasound contrast diluted in 20&#160;ml or more of normal saline solution is recommended&#46; In practice&#44; it is best to start with a low dose of contrast solution and if this is insufficient&#44; additional ultrasound contrast agent can be added&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Oral&#58; one or two drops in a glass of water&#46; It is useful for differentiating collections of gastric and duodenal contents&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">As there is no circulation or haemodynamic forces&#44; the duration of contrast in a cavity is 20&#8722;30&#160;min&#44; much longer than that of vascular enhancement&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Physical basis and mechanism of action</span><p id="par0070" class="elsevierStylePara elsevierViewall">Contrast-enhanced ultrasound imaging is based on the microbubbles being subjected to a sound field and oscillating through their elastic membrane&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The oscillation&#44; which is not linear &#40;asymmetric compression&#47;expansion&#41; causes emission of harmonic signals&#44; which are used to obtain the CEUS image&#46; To obtain the image&#44; specific programs are used that allow resonance of the bubble without breaking it&#58; they are preset to a low mechanical index &#40;MI&#41; for the incident sound beam&#44; a parameter that is related to the acoustic power &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The most common MI for the convex probe is under 0&#46;1&#44; but the value depends on the ultrasound being used&#46; With linear probes&#44; somewhat larger MI are used&#58; 0&#46;1&#8722;0&#46;15&#46; In addition&#44; these programs suppress the stationary basal image of the tissues using different methods&#44; so that the image is almost black and the sensitivity to enhancement is enormous&#44; which enables detection of very slow flows undetectable by Doppler scan&#44; with very good resolution&#46; The scan is performed in real time and the dynamics of the enhancement are seen throughout the duration of the microbubbles &#40;3&#8722;5&#160;min&#44; depending on the organ&#41;&#46; This allows CEUS to detect enhancements in the early arterial phase which may go unnoticed on CT or MRI&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The enhancement phases are superimposable on CT and MRI phases&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Liver&#58; arterial phase 10&#8722;20&#160;sec to 30&#8722;45&#160;sec&#44; portal phase 30&#8722;45&#160;sec to 2&#160;min and late phase 2&#160;min to 4&#8722;5&#160;min&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Kidney&#58; cortical phase 10&#8722;20&#160;s to 30&#8722;45&#160;sec&#44; and parenchymal phase 30&#8722;45&#160;sec to 3&#8722;4&#160;min&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Rest of organs&#58; arterial phase 10&#8722;20&#160;sec to 30&#8722;45&#160;sec&#44; and venous phase 30&#8722;45&#160;sec with a variable duration shorter than in the liver&#44; except in the spleen&#44; where it lasts up to 5&#160;min&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">CEUS imaging&#58; semiology&#44; optimisation and interpretation</span><p id="par0095" class="elsevierStylePara elsevierViewall">Contrast-enhanced ultrasound is always performed after greyscale ultrasound&#44; which is used to select the lesion or area to be examined and to obtain baseline and Doppler information&#46; The morphological and temporal enhancement information provided by CEUS is used in the diagnostic process in different ways&#44; depending on its application&#59; studying the permeability of a large vessel is not the same as estimating the inflammatory activity in a loop affected by Crohn&#39;s disease&#44; or characterising a focal liver lesion&#46; Focal liver lesions constitute one of the fundamental and most complex applications of contrast-enhanced ultrasound&#44; where a series of patterns&#44; nomenclature and concepts have been described which&#44; when combined&#44; reach a diagnosis&#44; and which are partially applicable to focal lesions in other locations &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Enhancement intensity compared to adjacent parenchyma &#40;for example&#44; hyperenhancement&#44; washout&#41;&#46; It can be qualitative&#44; by visual comparison&#44; or quantitative if time-intensity curves &#40;TIC&#41; are performed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Temporal pattern of enhancement and washout&#46; A timer on the screen constantly displays the time since the injection&#44; in seconds&#46; The enhancement process must be observed in all phases&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Early washout is considered as that occurring prior to 60&#160;sec&#44; and late washout&#44; after 60&#160;sec&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">Morphological pattern of enhancement&#58; direction of enhancement &#40;centrifugal or centripetal&#41;&#44; distribution and vascular morphology &#40;globular&#44; peripheral&#44; star-shaped&#44; basket-shaped&#44; homogeneous or heterogeneous enhancement&#44; variegated vessels&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></li></ul></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The calculation of TIC curves makes it possible to obtain quantitative parameters similar to those obtained in TIC curves using other imaging procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Quantification can be applied in different scenarios such as&#44; for example&#44; to study the early response to treatment in Crohn&#39;s disease<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> or for the quantification of tumour perfusion&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Currently&#44; CEUS imaging is good in high- and mid-range ultrasound machines and in general its presets are suitable for most examinations&#44; so in most cases there are few adjustments to be made&#46; The most determinant adjustments are the choice of approach&#44; probe&#44; frequency and MI&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The approach should aim to bring the lesion closer to the transducer&#44; as sound is also attenuated at depth in CEUS and&#44; in addition&#44; the more superficial contrast can itself produce attenuation in deep areas&#46; For example&#44; if a hepatic lesion is deep with a subcostal approach&#44; an intercostal approach is advised&#46; Lowering the frequency by choosing the contrast preset for penetration or raising the MI will improve the visualisation of deep areas&#46; However&#44; for superficial lesions it is advisable to keep the mechanical index low &#40;&#60;0&#46;1&#41; and use the resolution mode&#46; Superficial lesions&#44; soft tissue lesions or small lesions are generally studied with linear probes&#44; which require the administration of the entire vial of contrast &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Regarding the dynamics of the examination&#44; it is recommended to do a continuous scan with recording of representative parts of each vascular phase or an intermittent one after the complete recording of the arterial phase in lesions where it is important for the microbubbles to remain intact over time&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> For example&#44; in haemangiomas&#44; intermittent examination is advisable to avoid rupturing the bubbles inside&#44; which may produce a pseudowashout artefact&#46; However&#44; if an endoleak is being studied in the aorta after endovascular aneurysm repair &#40;EVAR&#41;&#44; continuous scanning and recording are essential and the duration of the bubbles is less important&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows other tricks worth knowing because they help you optimise the image&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The CEUS image has artefacts common to conventional ultrasound&#44; such as posterior shadow and mirror image&#44; and others typically found when using contrast &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; One of the most important is the pseudoenhancement artefact that occurs in lesions with very heterogeneous content &#40;typically in hepatic or renal lesions treated with ablative techniques&#44; although also in cysts with complex content&#41; which consists of an increase in signal in the lesion that can be confused with enhancement&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> True enhancement is marginal&#44; with bubble circulation identified&#44; whereas pseudoenhancement is central or patchy&#44; with no bubble circulation observed&#44; is slowly progressive&#44; and typically intensifies if a second dose is administered &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; One rare artefact is the appearance of patchy areas of increased hepatic echogenicity in B-mode&#44; which may persist for up to 15&#160;min&#46; The cause is unknown and it has no pathological value&#46; In endocavitary use&#44; the appearance of posterior shadow is common&#44; especially if the cavity is large&#44; as in ultrasound cystography&#46; This is solved by mobilising the contrast to prevent bubbles from floating using a gravity drip system or compression with a pressure cuff&#44; and it is recommended to also move the bag with the mixture of saline and ultrasound contrast back and forth during the study&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Safety of SonoVue&#174;</span><p id="par0130" class="elsevierStylePara elsevierViewall">As it is not eliminated via the urinary system&#44; SonoVue&#174; can be used in subjects with renal impairment&#59; there is no risk of contrast nephropathy or systemic nephrogenic fibrosis&#46; Its safety profile is very good&#44; with the incidence of reported adverse reactions being very low&#44; in the range of 0&#46;033&#37; to 0&#46;088&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> The vast majority are mild&#44; immediate or in the first few minutes after administration of the contrast and self-limiting&#58; erythema&#44; dizziness&#44; head pain&#44; reactions at the injection site&#44; nausea and vomiting&#44; tachycardia and dyspnoea&#46; The rate of serious adverse reactions in exposed subjects is 0&#46;0086&#37;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and the reported incidence of deaths is very low&#44; at 0&#46;0006&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Adverse reactions are more common in inpatients than in outpatients&#46; Although hypersensitivity reactions are very rare &#40;&#60;1&#47;10&#44;000&#41;&#44; much less common than those associated with iodinated contrasts&#44; there are isolated cases of anaphylactic shock&#46; Type I immediate hypersensitivity to polyethylene glycol &#40;PEG&#41; or macrogol &#40;a component of SonoVue&#174;&#41; is possible&#44; so its use is contraindicated in subjects with known hypersensitivity to PEG&#46; As PEG is a component of certain colonoscopy preparations and laxatives&#44; it is recommended to ask subjects if they have had any adverse reactions to these preparations&#46; There is no established published protocol for managing adverse reactions&#46; It is advisable to apply the usual measures in place in each department for treating adverse reactions to other contrasts according to their severity&#46; Severe cases require close monitoring and oxygen inhalation with anti-shock and anti-anaphylactic treatment&#59; epinephrine&#44; dexamethasone and rapid infusion of normal saline or lactated Ringer&#39;s solution for anaphylactic shock&#46; If the subject has bradycardia&#44; atropine can be used to increase the heart rate&#46; If the subject has suffered cardiac arrest&#44; CPR should be performed immediately&#46; The safety profile is also very good in the paediatric age group<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> and no adverse reactions to intravesical use have been described&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The following precautions are advised before administering contrast&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Oral or written informed consent&#58; explain the test to the subject and why it is being done and ask about history of drug or food allergies &#40;severe adverse reactions were more common in people with a history of allergies&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">The test should be performed in a room prepared to handle adverse reactions to medication and in proximity to a resuscitation trolley&#46; The subject&#39;s condition should be monitored during and after contrast administration &#40;for 20&#8722;30&#160;min&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">The intravenous line should be maintained for 30&#160;min in subjects at risk or who have experienced discomfort&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Recent acute coronary syndrome or clinically unstable coronary heart disease&#46; Administer only after careful assessment of the benefit&#47;risk balance and close monitoring of vital functions during and after administration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Record adverse reactions with the vial number and report them in the subject&#39;s medical records&#46; Inform the pharmaceutical company that markets the contrast&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Pregnancy&#58; it has been shown that the contrast does not cross into the placental circulation and there have been no adverse effects on the foetus in the studies conducted&#44; but its use is currently off-label&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Breastfeeding&#58; do not breastfeed for two hours after administration of SonoVue&#174;&#46;</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">Contraindications include&#58; hypersensitivity to the active substance or to any of the excipients&#44; or history of hypersensitivity reaction to previous administration of SonoVue&#174;&#59; subjects with right-to-left shunts &#40;this contraindication no longer exists in the USA&#41;&#44; severe pulmonary hypertension &#40;pulmonary arterial pressure &#62;90&#160;mmHg&#41;&#59; uncontrolled systemic hypertension and adult respiratory distress syndrome&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Applications and limitations</span><p id="par0180" class="elsevierStylePara elsevierViewall">Contrast-enhanced ultrasound has numerous applications&#58; it can be applied intravenously to study any organ or vessel accessible to B-mode ultrasound&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The most common applications are briefly explained below&#59; the rest can be consulted in the EFSUMB &#40;European Federation of Societies for Ultrasound in Medicine and Biology&#41; and WFUMB &#40;World Federation for Ultrasound in Medicine and Biology&#41; guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;23&#8211;26</span></a> It should be noted that many of the applications are off-label and authorisation from the different medicines agencies vary between Europe and other non-European countries&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Liver</span><p id="par0185" class="elsevierStylePara elsevierViewall">The most established application&#44; and recommended by the EFSUMB guidelines&#44; is for the characterisation of indeterminate focal liver lesions in B-mode&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;27</span></a> as it can resolve on the go during the same procedure cases in which a definitive diagnosis is reached &#40;for example&#44; a haemangioma or focal nodular hyperplasia&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; It can also direct and expedite management &#40;if metastasis&#44; an extension CT will be performed&#59; if suggestive of hepatocellular carcinoma&#44; MRI is preferred&#41;&#46; It can help characterise lesions not characterised by other imaging procedures<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a>&#58; CEUS may demonstrate arterial hyperenhancement or a pattern of enhancement or washout not demonstrated on CT or MRI&#46; In the context of chronic liver disease&#44; the CEUS LI-RADS system allows interpretation of CEUS findings of focal lesions and production of standardised reports with the same categories as LI-RADS&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> Real-time scanning allows accurate assessment of washout time to differentiate hepatocellular carcinoma from other malignant hepatic lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> CEUS also enables quantitative studies on tumour perfusion with TIC curves&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Although application of CEUS is less common for the detection of focal lesions&#44; its use is accepted for the detection of hepatic metastases&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> CEUS makes it possible to characterise and study the internal structure of liver abscesses<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> and determine whether they are susceptible to drainage&#46; Although CT is the technique of choice in trauma patients&#44; CEUS is indicated for the follow-up of already known visceral injuries and in children with low-intensity blunt trauma&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> in order to avoid radiation&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">The use of contrast is especially useful in liver transplantation to demonstrate vascular permeability or confirm vascular thrombosis&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> as well as to determine the location and extent of areas of infarction&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> which is essential information for deciding between revascularisation or retransplantation&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Kidney and urinary tract</span><p id="par0195" class="elsevierStylePara elsevierViewall">Renal and urinary tract applications are off-label&#44; but are among the most frequently used&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> CEUS is useful for differentiating pseudolesions from real lesions and in lesions which are indeterminate on CT&#44; in order to differentiate solid lesions from cysts&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> In the case of renal cystic lesions&#44; CEUS has a very high sensitivity for demonstrating enhancement in septa &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; as well as excellent resolution for measuring their thickness and detecting the presence of mural nodules&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> This means cystic lesions can be categorised according to the Bosniak classification with a very good performance&#44; both in the initial diagnosis and in the follow-up&#46; It is less useful in the study of solid renal lesions&#44; as&#44; although there are some suggestive patterns in some neoplasms &#40;hypovascular lesions are suggestive of papillary renal cell carcinoma&#41; and some of the findings are associated with certain diseases &#40;parenchymal phase washout occurs more in malignant lesions&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> in general CEUS is not effective for characterising solid renal lesions&#46; In the infectious context&#44; CEUS is useful in the diagnosis and follow-up of acute pyelonephritis&#44; especially to differentiate areas of focal pyelonephritis from abscess&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> As the contrast is not eliminated through the urinary tract&#44; it cannot be studied directly&#44; although it is useful for differentiating between clot and neoplasm in both the urinary tract and the bladder&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> In renal transplantation&#44; it is especially useful for studying vascular permeability&#44; to confirm vascular thrombosis and to study areas of ischaemia &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Inflammatory bowel disease</span><p id="par0200" class="elsevierStylePara elsevierViewall">Diagnosis of inflammatory bowel disease &#40;IBD&#41; involvement and assessment of its extent and disease activity can be performed using B-mode ultrasound and a colour Doppler scan&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Contrast-enhanced ultrasound enables the study of disease activity with greater precision&#44; especially in indeterminate cases with wall thickening without colour Doppler signal&#44; and for early distinction between subjects who respond to treatment and those who do not by quantification with TIC curves &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#44;46</span></a> Another application is for differentiating inflammatory masses or phlegmons from abscessed areas and defining their size and extent&#44; which can affect treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Paediatric subjects</span><p id="par0205" class="elsevierStylePara elsevierViewall">SonoVue&#174; is approved in Spain in paediatric subjects for intracavitary CEUS of the urinary tract for the detection of vesicoureteral reflux&#46; Intravenous use in children is compassionate&#44; as it is not approved by the European Medicines Agency &#40;EMA&#41; &#40;unlike in the USA&#44; where it is approved by the Food and Drug Administration &#91;FDA&#93;&#41;&#46; In children&#44; CEUS is recommended for its many advantages&#58; it is a technique with great diagnostic efficacy which can avoid the need for a CT or MRI&#44; thus avoiding exposure to radiation and sedation&#47;anaesthesia&#59; it is an easy and convenient study which also improves the family experience compared to other imaging procedures&#44; as it can be performed bedside&#59; and it is safe&#46; It has multiple applications similar to those in adults&#44; including vascular assessment of transplanted organs&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> It also has excellent diagnostic efficacy in the detection of vesicoureteral reflux&#59; the experts from the ESPR &#40;European Society of Pediatric Radiology&#41; Urogenital Task Force recommend the use of ultrasound cystograms instead of conventional cystograms&#44; as it has been shown to provide comparable information&#44; but with the absence of radiation &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> In paediatric subjects there are also other endocavitary applications&#44; for example to determine the location of the tip of a catheter or the extent of drained collections&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> CEUS enables the diagnostic scope of ultrasound in children to be significantly expanded&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Interventional procedures</span><p id="par0210" class="elsevierStylePara elsevierViewall">Many interventional procedures are performed under ultrasound guidance&#44; so administering contrast is the natural way to guide&#44; facilitate or improve these procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">51&#44;52</span></a> It is used before&#44; during and after ablative procedures in solid liver&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> kidney &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41; and thyroid lesions&#44; as a biopsy guide for lesions not visible in the baseline ultrasound&#44; and to avoid taking samples in areas of necrosis&#46; It is also useful for confirming patency or placement of drainage&#44; biliary or nephrostomy catheters&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Vascular CEUS</span><p id="par0215" class="elsevierStylePara elsevierViewall">CEUS is very useful for demonstrating the patency of any arterial or venous vessel and of stents<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a>&#59; for example&#44; vessels of the different organs&#44; splenoportal axis&#44; abdominal aorta<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> and iliac arteries&#44; vena cava and iliac veins&#44; carotid arteries<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> and subclavian arteries&#44; and jugular and subclavian veins &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41;&#46; CEUS can distinguish between soft venous thrombosis and venous tumour thrombosis&#44; by demonstrating arterial enhancement of the thrombus in the case of a tumour&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">58&#44;59</span></a> It is also useful in subjects with complex abdominal surgery&#44; to rule out vascular thrombosis&#46; In addition to liver and kidney transplants&#44; it is used in pancreas transplants and to demonstrate the viability of soft tissue and skin grafts&#46; Being a real-time examination&#44; CEUS is particularly useful in the study of subjects with abdominal aortic aneurysm after EVAR to establish the type of leak&#46; Although the ideal test to study the complications of abdominal aortic aneurysms is CT angiography&#44; CEUS can show complications such as dissection or rupture &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41;&#46; CEUS can also show active bleeding such as extravasation of contrast medium &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Limitations</span><p id="par0220" class="elsevierStylePara elsevierViewall">Contrast-enhanced ultrasound imaging has the limitations of any ultrasound&#58; window and depth limitations &#40;especially in the case of hepatic steatosis&#41;&#46; It also has a size limitation&#58; it depends on the probe&#44; the organ and the conditions&#44; but&#44; in general&#44; lesions smaller than 3&#8722;5&#160;mm are not detected and characterising lesions smaller than 8&#160;mm can be difficult&#44; even if they are detected&#46; Another limitation is the multiplicity of lesions&#44; as it is very difficult to study all the lesions in all phases if they are not in the same plane&#44; such that the advantage of the temporal resolution of CEUS compared to CT and MRI&#44; being a real-time examination and seeing all phases&#44; has the disadvantage of limited spatial resolution&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0225" class="elsevierStylePara elsevierViewall">CEUS is a portable technique with no radiation or renal toxicity which provides information that can be superimposed on CT and MRI and has the great advantage of obtaining the image in real time&#46; CEUS has numerous applications for intravascular use and various intracavitary applications&#46; The contrast composition and imaging bases of CEUS are different from those of CT and MRI&#44; and there are technical issues which need to be understood in order to optimise the studies and the image&#46; The pharmacodynamics and pharmacokinetics&#44; as well as the purely intravascular condition of SonoVue&#174;&#44; translate into vascular information and dynamic information on lesion enhancement which can show some differences compared to CT and MRI in the steady state phase&#46; The safety profile of SonoVue&#174; is very good&#44; with uncommon&#44; generally mild and immediate adverse reactions with intravascular use and no adverse reactions in intracavitary use&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0285" class="elsevierStylePara elsevierViewall">This study has not received any type of funding&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">CRediT authorship contribution statement</span><p id="par0230" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">1</span><p id="par0235" class="elsevierStylePara elsevierViewall">Responsible for the integrity of the study&#58; M&#46;T&#46; Fontanilla Echeveste&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">2</span><p id="par0240" class="elsevierStylePara elsevierViewall">Study conception&#58; M&#46;T&#46; Fontanilla Echeveste and T&#46; Ripoll&#233;s Gonz&#225;lez&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">3</span><p id="par0245" class="elsevierStylePara elsevierViewall">Study design&#58; M&#46;T&#46; Fontanilla Echeveste&#44; T&#46; Ripoll&#233;s Gonz&#225;lez and E&#46; Aguirre Pascual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">4</span><p id="par0250" class="elsevierStylePara elsevierViewall">Data collection&#58; M&#46;T&#46; Fontanilla Echeveste&#44; T&#46; Ripoll&#233;s Gonz&#225;lez and E&#46; Aguirre Pascual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">5</span><p id="par0255" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; M&#46;T&#46; Fontanilla Echeveste&#44; T&#46; Ripoll&#233;s Gonz&#225;lez and E&#46; Aguirre Pascual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">6</span><p id="par0260" class="elsevierStylePara elsevierViewall">Statistical processing&#58; not applicable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">7</span><p id="par0265" class="elsevierStylePara elsevierViewall">Literature search&#46; M&#46;T&#46; Fontanilla Echeveste&#44; T&#46; Ripoll&#233;s Gonz&#225;lez and E&#46; Aguirre Pascual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">8</span><p id="par0270" class="elsevierStylePara elsevierViewall">Drafting of the article&#58; M&#46;T&#46; Fontanilla Echeveste&#44; T&#46; Ripoll&#233;s Gonz&#225;lez and E&#46; Aguirre Pascual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">9</span><p id="par0275" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant contributions&#58; M&#46;T&#46; Fontanilla Echeveste&#44; T&#46; Ripoll&#233;s Gonz&#225;lez and E&#46; Aguirre Pascual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">10</span><p id="par0280" class="elsevierStylePara elsevierViewall">Approval of the final version&#58; M&#46;T&#46; Fontanilla Echeveste and T&#46; Ripoll&#233;s Gonz&#225;lez&#46;</p></li></ul></p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Composition and characteristics of ultrasound contrast"
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          "titulo" => "Routes of administration&#44; pharmacodynamics and dosage"
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    "fechaAceptado" => "2024-06-30"
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            1 => "SonoVue"
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            3 => "Examination technique"
            4 => "Pharmacodynamics"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1897028"
          "palabras" => array:5 [
            0 => "Medios de contraste"
            1 => "SonoVue"
            2 => "Ecograf&#237;a"
            3 => "T&#233;cnica de exploraci&#243;n"
            4 => "Farmacodin&#225;mica"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Contrast-enhanced ultrasound &#40;CEUS&#41; is a medical imaging technique that offers multiple advantages over other modalities such as computed tomography &#40;CT&#41; and magnetic resonance imaging &#40;MRI&#41;&#46; These advantages include portability&#44; no ionising radiation and no renal toxicity&#44; with the great advantage of real-time imaging&#46; CEUS has numerous established applications for the study of different pathologies&#44; both intravenous and intracavitary administration&#46; The contrast used is different in composition and function from CT or MRI contrast&#46; It is a purely intravascular contrast and&#44; therefore&#44; the enhancement of the lesions may have some differences with respect to CT or MRI in the equilibrium phase&#46; Ultrasound contrast has a very good safety profile&#44; with infrequent&#44; generally mild and immediate adverse reactions in intravascular use and no adverse reactions reported in intracavitary use&#46; It is important to know the basics of contrast-enhanced ultrasound&#44; the different ways to optimise the image and the different artefacts&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a con contraste &#40;CEUS&#41; es una t&#233;cnica de imagen m&#233;dica que ofrece m&#250;ltiples ventajas frente a otras modalidades como la tomograf&#237;a computarizada &#40;TC&#41; y la resonancia magn&#233;tica &#40;RM&#41;&#46; Estas ventajas incluyen la portabilidad&#44; la ausencia de radiaci&#243;n ionizante y la no toxicidad renal&#44; con la gran ventaja de permitir la obtenci&#243;n de im&#225;genes en tiempo real&#46; CEUS tiene numerosas aplicaciones ya establecidas para el estudio de distintas patolog&#237;as&#44; tanto en su administraci&#243;n intravenosa como intracavitaria&#46; El contraste utilizado tiene una composici&#243;n y funcionamiento distintos al contraste de la TC o de la RM&#46; Es un contraste puramente intravascular y&#44; por tanto&#44; el realce de las lesiones puede tener algunas diferencias respecto al TC o la RM en la fase de equilibrio&#46; El contraste ecogr&#225;fico tiene un perfil de seguridad muy bueno&#44; con reacciones adversas poco frecuentes&#44; generalmente leves e inmediatas en su uso intravascular y sin reacciones adversas reportadas en su uso intracavitario&#46; Es importante conocer las bases de la ecograf&#237;a con contraste&#44; las distintas formas de optimizar la imagen y los distintos artefactos&#46;</p></span>"
      ]
    ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The behaviour of bubbles in the sound field depends on the amplitude of the incident wave&#44; which is related to the acoustic power and the mechanical index &#40;MI&#41;&#44; and this in turn determines the intensity of the signal seen in the image and its duration&#46; The acoustic power increases &#40;from A to C&#41; as the amplitude of the wave increases&#46; When the power and amplitude are minimal &#40;A&#41;&#44; the bubbles do not oscillate and there is hardly any signal&#46; With low power and amplitude &#40;low mechanical index&#41; &#40;B&#41; the bubbles oscillate with a minimal chance of their rupturing&#44; thus achieving a long-lasting signal&#46; With high power and amplitude &#40;high mechanical index&#41; &#40;C&#41; the bubbles break quickly&#44; obtaining a very intense but short-lived signal&#46; In practice&#44; a low mechanical index is used&#44; although it is a parameter that can be managed&#46;</p>"
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      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Enhancement intensity&#44; temporal pattern and vascular pattern in two hepatic lesions&#46; A and B&#46; Hepatocellular carcinoma&#46; &#40;A&#41; Arterial phase &#40;18&#160;sec MI 0&#46;08&#41; showing hyperenhancement in two nodules&#44; with a peripheral vascular pattern with variegated vessels in the large nodule&#46; &#40;B&#41; Faint and late washout &#40;3&#160;min 48&#160;sec&#41; typical for hepatocellular carcinoma&#58; it is categorised &#40;in this subject with chronic liver disease&#41; as CEUS LI-RADS 5&#46; The smaller nodule &#40;white arrow in A&#41; is indistinguishable in the late phase because it is in the attenuation zone produced by the contrast itself from the more superficial areas&#44; like artefacts&#40;&#42;&#41;&#46; &#40;C and D&#41; Metastasis of lung cancer&#46; &#40;C&#41; Peripheral enhancement of the mass can be seen in the arterial phase&#59; it is not uncommon for arterial enhancement in metastases to show up in CEUS when they are not identified in CT or MRI&#44; because CEUS shows enhancement from the onset and the arterial CT and MRI phases are post-onset&#46; &#40;D&#41; Marked&#44; early washout &#40;50&#160;sec&#41; typical for metastasis and&#47;or cholangiocarcinoma in CEUS&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 2325
            "Ancho" => 3000
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Figure "
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Using the linear probe&#46; &#40;A&#41; Torsion-related testicular infarction&#58; absence of testicular enhancement with epididymal enhancement &#40;e&#41;&#46; &#40;B&#41; Scrotal lymphoma&#59; mass &#40;arrows&#41; occupying almost the entire testicle &#40;t&#41; and enhancing more than the adjacent testicle&#46; C&#46; Metastatic cervical adenopathy from pulmonary carcinoma&#58; low-uptake nodule &#40;&#42;&#41; inside the adenopathy &#40;a&#41;&#46; &#40;D&#41; Hepatic haemangioma&#44; arterial phase &#40;15&#160;sec MI 0&#46;099&#41; showing the characteristic peripheral globular arterial hyperenhancement &#40;dotted arrows&#41;&#46; Due to its small size and superficial location&#44; it was performed with the linear probe&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1888
            "Ancho" => 2417
            "Tamanyo" => 622724
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CEUS artefacts&#46; &#40;A&#41; Cotton-like appearance of the liver in B-mode 15&#160;min after administration of SonoVue&#174;&#46; &#40;B&#41; Uterine leiomyosarcoma metastasis treated with radiofrequency&#46; Residual tumour can be seen &#40;dotted arrow&#41;&#44; typically marginal&#46; Pseudoenhancement is also seen&#44; which is central &#40;white arrow&#41;&#46; &#40;C&#41; Glare artefact around the hepatic artery and its branches&#46; &#40;D&#41; Pseudowashout artefact in haemangioma at 3&#160;min&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1792
            "Ancho" => 3333
            "Tamanyo" => 713021
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CEUS liver applications&#46; &#40;A&#44; B and C&#41; Small incidental lesion diagnosed by CEUS as focal nodular hyperplasia and not requiring further imaging&#46; &#40;A&#41; Ultrasound in B-mode&#58; indeterminate lesion measuring 1&#160;cm&#46; &#40;B&#41; CEUS image in arterial phase &#40;14&#160;sec MI 0&#46;07&#41; after placing a marker trace on the reference dual B-mode image when reviewing the video&#58; this same trace is copied to the contrast image&#44; serves as a guide and shows that the arterial enhancement begins in the centre of the lesion&#46; Real-time showed centrifugal enhancement&#46; &#40;C&#41; At 3&#58;06&#160;min&#44; no washout can be seen&#46; &#40;D&#41; Review of hepatocellular carcinoma treated with radiofrequency with inconclusive CT &#40;dual image at 39&#160;sec&#44; MI 0&#46;079&#41; showing arterial phase enhancement of almost the entire treated lesion&#44; in relation to recurrence&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 1765
            "Ancho" => 3333
            "Tamanyo" => 968317
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CEUS kidney applications&#46; &#40;A&#41; Bosniak II-F renal cystic lesion&#46; CEUS &#40;here with maximum intensity projection &#91;MIP&#93; imaging&#41; allows visualisation with high resolution and sensitivity of enhancing septa and measurement of their thickness&#46; &#40;B&#41; Renal cancerous lesion treated with radiofrequency&#46; Absence of enhancement can be seen compatible with coagulative necrosis&#46; Non-suppressed echogenic baseline image artefact &#40;arrow&#41;&#44; which should not be confused with enhancement&#46; &#40;C&#41; Transplanted kidney&#44; portable ultrasound performed in ICU&#58; anterior cortical infarction undetectable on baseline ultrasound&#46; &#40;D&#41; Transplanted kidney &#40;R&#41;&#58; portable ultrasound performed in ICU showing significant stream of active bleeding &#40;dotted arrow&#41;&#58; the subject went directly to the operating theatre without the need for further imaging tests&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 1483
            "Ancho" => 3341
            "Tamanyo" => 456188
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0035"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Application in inflammatory bowel disease&#46; Ultrasound images of a 32-year-old woman with severe Crohn&#39;s disease in the terminal ileum determined by endoscopy&#46; &#40;A&#41; Longitudinal ultrasound image of the affected bowel segment with parietal thickening&#46; &#40;B&#41; Ultrasound image showing intense enhancement of the bowel wall after injection of 2&#46;4&#160;ml of contrast&#44; with a manually defined ROI on the bowel wall for measurement of vascularisation&#46; The graph shows the corresponding time-intensity curve&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 2028
            "Ancho" => 3333
            "Tamanyo" => 830123
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0040"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Intracavitary use&#46; &#40;A&#44; B and C&#41; Three-month-old infant with febrile UTI with abnormal ultrasound with probable urinary tract dilation&#46; &#40;A&#41; Normal-sized left kidney with adequate corticomedullary differentiation and ureteropyelolocalycial dilation grade II&#47;IV &#40;P2 according to the Urinary Tract Dilation &#91;UTD&#93; classification system&#41;&#46; After urethral catheterisation&#44; an ultrasound cystogram was performed&#44; which showed passive vesicoureteral reflux reaching the upper excretory system in the left kidney &#40;&#42;&#41; which increases with urination&#44; grade 5&#47;5 left&#46; Patchy intrarenal reflux can be seen in the left kidney&#46; &#40;C&#41; Normal male urethra&#58; the perineal approach with a convex probe allows assessment of the urethra during the voiding phase of an ultrasound cystogram &#40;dotted arrow&#41;&#46; &#40;D&#41; Subject with jaundice and biliary stent&#46; Percutaneous cholangiogram showing the common bile duct with obstructed metal stent &#40;arrow&#41;&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "fig0045"
        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 1656
            "Ancho" => 3333
            "Tamanyo" => 780175
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0045"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">CEUS vascular applications&#46; &#40;A&#41; Liver transplant&#46; Large peripheral hepatic infarction shows up as absence of enhancement &#40;&#42;&#41;&#46; Shows the patency of the main portal vein&#44; the hepatic artery and the inferior vena cava&#46; Mirror-image artefact of the inferior vena cava&#46; &#40;B&#41; Carotid bifurcation&#44; longitudinal slice&#46; Occlusion of the internal carotid artery &#40;ICA&#41; and patency of the common carotid arteries &#40;CCA&#41; and external carotid arteries &#40;ECA&#41;&#46; CEUS is very useful in differentiating preocclusive stenosis from complete occlusion&#46; &#40;C&#41; Portal vein tumour thrombosis&#46; Increased and occupied portal vein in B mode and with enhancement in arterial phase &#40;at 7&#160;sec&#41; with visualisation of arterial vessels inside the tumour thrombus &#40;white arrow&#41;&#46; &#40;D&#41; Double-lumen aortic dissection&#58; more enhanced true lumen &#40;earlier enhancement was seen in this lumen in real time&#41; and less enhanced false lumen&#46; The flow jet in the communication is identified &#40;black arrow&#41; using a higher mechanical index than usual &#40;0&#46;52&#41;&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0050"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CEUS&#58; <span class="elsevierStyleItalic">contrast-enhanced ultrasound</span>&#59; MI&#58; mechanical index&#59; TIC&#58; <span class="elsevierStyleItalic">time intensity curve</span>&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Action&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Purpose&#47;method&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Choice of approach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bring the lesion to the transducer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">By making the lesion less deep there is less attenuation and the enhancement can be seen better&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Choice of probe</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Convex in intra-abdominal or pulmonary lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dose 1&#8722;2&#46;4 ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Microconvex in intestine and kidney transplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dose 1&#46;2 ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Linear in small&#44; soft parts and intestine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dose 4&#46;8 ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Choice of frequency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Choose penetration&#44; general or resolution mode or manual adjustment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deeper lesions require a lower frequency and more superficial lesions a higher frequency&#46; The higher the frequency&#44; the greater the bubble rupture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Administration of second or third dose</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">To see other lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple lesions or lesions in other organs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">To see the enhancement of a lesion again&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wait for the previous bubbles to disappear&#44; which can be accelerated by using Flash with high MI&#44; or by changing to B mode and using Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">To see the enhancement of septa or hypovascular lesions more intensely&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cumulative effect&#58; don&#39;t wait for the bubbles to disappear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Keep mechanical index low &#60;0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Generally in focal lesions and especially in haemangiomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">To be able to assess the late phase of the lesions and to avoid pseudowashout&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Raise mechanical index</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deep lesions&#46; Obese subjects&#46; Fatty liver disease&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">For example&#44; MI 0&#46;09&#8722;0&#46;12 instead of 0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">To better view the septa in renal cystic lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">For example&#44; MI 0&#46;09 instead of 0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">To see the enhancement pattern in liver lesions with very rapid arterial enhancement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Variable&#46; You can go up in the arterial phase quite a bit until the bubbles disappear and then lower the MI to be able to identify the enhancement pattern again&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In purely vascular studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Variable&#46; It is not so much the duration of the bubble that matters&#44; but rather having a very good signal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adjusting the focus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Keep deep to the lesion or area of study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">More bubbles are destroyed in the focus area&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adjusting the gain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Signal&#47;noise optimisation intuitively&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Do not modify during the examination if TIC curves are to be taken&#44; as this would alter the intensity measurements&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Using dual window B-mode&#47;CEUS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recommended in general and particularly for small lesions and as a biopsy guide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Once the lesion has been identified in the contrast-enhanced ultrasound&#44; the dual image can be discarded&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use of guide or measurement marker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Place a marker in the greyscale window when using dual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Makes it possible to locate small or iso-uptake lesions in the CEUS window&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intermittent scanning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Focal lesions&#58; view the entire arterial phase &#40;and record the first 30&#8722;60&#160;sec and then scan intermittently to minimise bubble rupture&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">View and record representative parts of each phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continuous scanning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Organ and vascular perfusion studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Required for TIC curves&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MIP &#40;<span class="elsevierStyleItalic">maximum intensity projection</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">To better delimit the septa in cystic lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Better resolution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In vascular studies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Better resolution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid shadowing in cystograms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mobilise the contrast to mix&#58; saline in a drip &#40;by gravity&#41; or pressure cuff&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid shadowing in oral CEUS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Give the first glass of water with a drop of contrast and a second glass without contrast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid shadowing in other cavities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inject more saline without contrast so that it mixes in the cavity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CEUS&#58; <span class="elsevierStyleItalic">Contrast-enhanced ultrasound</span>&#59; MI&#58; mechanical index&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CEUS artefacts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cause&#47;comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Action&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unsuppressed baseline hypersignal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Highly echogenic images&#58; septa in cysts or calcifications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pay attention to the signal before applying CEUS&#46; Lowering the gain partially decreases them&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posterior reinforcement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cystic lesions or collections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Change of approach if there is doubt of enhancement in a deep lesion after reinforcement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posterior shadow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcifications or highly enhanced structure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Change of approach if the lesion to be studied remains in shadow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reverberation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Important acoustic interfaces&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Change of approach if the lesion to be studied remains in the reverberation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mirror-image artefact&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Explore it&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pseudowashout&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bubble rupture in slow-flow lesion comparatively greater than in adjacent parenchyma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intermittent scanning to minimise bubble rupture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pseudoenhancement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Highly heterogeneous lesions&#44; typically after ablative treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recognise pseudoenhancement&#58; non-marginal&#44; slowly progressive&#44; no temporal pattern of enhancement and washout&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glare or glow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased signal around the contrasted vessels or structures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Administer the correct dose&#46; Gets worse with higher doses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Saturation of enhancement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower the gain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Use a lower dose next time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deep attenuation&#47;shadow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The surface bubbles themselves produce attenuation at depth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Raise the MI to see deep areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Destruction of microbubbles in the plane and on the surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The MI decreases in depth&#44; greater destruction of bubbles occurs on the surface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scan interrupted&#47;change of plane&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heterogeneous liver appearance in B mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nothing can be done&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Colour Doppler artefacts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Blooming</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lower the Doppler gain&#46; Wait for the bubbles to disappear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spectral Doppler noise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Linear images in the spectrumAudible noise like small pops&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wait for the bubbles to disappear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased speed in spectral Doppler&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Approximately 5&#160;cm&#47;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wait for the bubbles to disappear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Artefacts in contrast-enhanced ultrasound&#46;</p>"
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        0 => array:2 [
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                          "etal" => false
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                            0 => "S&#46;R&#46; Wilson"
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                          "etal" => false
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                            1 => "C&#46; Fang"
                            2 => "D&#46;Y&#46; Huang"
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                      "doi" => "10.1007/s13244-018-0601-x"
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                    0 => array:2 [
                      "doi" => "10.1055/a-0586-1107"
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                    0 => array:2 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "V&#46; Engels"
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                            2 => "M&#46; Mart&#237;nez-Moya"
                            3 => "M&#46; Garc&#237;a-Espantale&#243;n"
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                      "Revista" => array:6 [
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                        "volumen" => "61"
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                        "paginaInicial" => "31"
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2024.10.003

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