Ultrasound contrast agents: an overview.

With the introduction of microbubble contrast agents, diagnostic ultrasound has entered a new era that allows the dynamic detection of tissue flow of both the macro and microvasculature. Underpinning this development is the fact that gases are compressible, and thus the microbubbles expand and contract in the alternating pressure waves of the ultrasound beam, while tissue is almost incompressible. Special software using multiple pulse sequences separates these signals from those of tissue and displays them as an overlay or on a split screen. This can be done at low acoustic pressures (MI<0.3) so that the microbubbles are not destroyed and scanning can continue in real time. The clinical roles of contrast enhanced ultrasound scanning are expanding rapidly. They are established in echocardiography to improve endocardial border detection and are being developed for myocardial perfusion. In radiology, the most important application is the liver, especially for focal disease. The approach parallels that of dynamic CT or MRI but ultrasound has the advantages of high spatial and temporal resolution. Thus, small lesions that can be indeterminate on CT can often be studied with ultrasound, and situations where the flow is very rapid (e.g., focal nodular hyperplasia where the first few seconds of arterial perfusion may be critical to making the diagnosis) are readily studied. Microbubbles linger in the extensive sinusoidal space of normal liver for several minutes whereas they wash out rapidly from metastases, which have a low vascular volume and thus appear as filling defects. The method has been shown to be as sensitive as three-phase CT. Microbubbles have clinical uses in many other applications where knowledge of the microcirculation is important (the macrocirculation can usually be assessed adequately using conventional Doppler though there are a few important situations where the signal boost given by microbubbles is useful, e.g., transcranial Doppler for evaluating vasospasm after subarachnoid haemorrhage). An important situation where demonstrating tissue devitalisation is important is in interstitial ablation of focal liver lesions: using microbubble contrast agents at the end of a procedure allows immediate evaluation of the adequacy of the ablation which can be extended if needed; this is much more convenient and cost-saving than moving the patient to CT and perhaps needing an additional ablation session at a later date. Similar considerations suggest that contrast-enhanced ultrasound might have a role in abdominal trauma: injury to the liver, spleen and kidneys can be assessed rapidly and repeatedly if necessary. Its role here alongside dynamic CT remains to be evaluated. Infarcts or ischaemia and regions of abnormal vascularity, especially in malignancies, in the kidneys and spleen seem to be useful and improved detection of the neovascularisation of ovarian carcinomas is promising. Similar benefits in the head-and-neck and in the skin while the demonstration of the neovascularisation of atheromatous plaques and of aggressive joint inflammation offer interesting potentials.