superb microvascular imaging a sonographic technical advancedr. muhammad bin zulfiqar services...

Superb Microvascular ImagingApplications

Dr. Muhammad Bin ZulfiqarPGR IV New Radiology Department SIMS/SHL

Superb Microvascular Imaging

• Superb microvascular imaging is the latest in the technological advances in the field of sonography and offers clear visualization of the microvasculature without the need of contrast.

• In conjuction with contrast its efficacy flourished further.

Sara O hara, www.medical.toshiba.com

Modes Of SMI

• SMI operates in two modes.• Monochrome SMI (mSMI) which subtracts the

background image from the detailed vasculature.

• Color SMI (cSMI) which displays the flow components in color overlaid on the grayscale B mode image.

Dr. Jiro Hata, Seeing the Unseen New Techniques in Vascular Imaging. ©Toshiba Medical Systems Corporation 2014.

• We see that low flow velocities are lost in conventional color doppler due to clutter and other artifacts, while in SMI even low flow vasculature can be imaged.

Dr. Jiro Hata, Seeing the Unseen New Techniques in Vascular Imaging. ©Toshiba Medical Systems Corporation 2014.

• This Diagrammatic illustrations clearly shows that power, color and Advance doppler flow (ADF) have limitations regarding velocity range and resolution while SMI have no limitations and not influenced by motion artefacts.

Dr. Jiro Hata, Seeing the Unseen New Techniques in Vascular Imaging. ©Toshiba Medical Systems Corporation 2014.

Normal Appearance of Vasculature

• Sparse flow can be detected.• Fine details of vasculature can be elicited.

• Normal Vasculature of Placenta. (a). Conventional doppler (b,d,e). SMI techniques (c,f) pulsed doppler combined with SMI.

Comparison of color doppler (right) and cSMI (left) from the liver of a young patient. cSMI shows greater detail and better visualization of small branching vessels.

Sara O hara, www.medical.toshiba.com

• Comparison of gray scale (right) and cSMI (left) from the kidney of a young patient. cSMI shows greater detail and better visualization of small branching vessels up to the cortex at a high frame rate of 50 fps.

Sara O hara, www.medical.toshiba.com

Modes Of SMI• Comparison of color

doppler ( top right), cSMI (top left), gray scale (bottom right) and mSMI (bottom left) from the kidney of a young patient. cSMI and mSMI shows greater detail and better visualization of small branching vessels up to the cortex.

Sara O hara, www.medical.toshiba.com

• Comparison of gray scale (right) and cSMI (left) from the kidney of a 17 years young patient. cSMI shows greater detail and better visualization of small branching vessels up to the cortex at a high frame rate of 50 fps.

Sara O hara, www.medical.toshiba.com

• Gray Scale (right), mSMI (mid) and pulse Doppler (left) images of testis in a young patient with scrotal pain demonstrates good vasculature

Sara O hara, Toshiba superb microvascular imaging A new problem solving tooll in pediatric radiology www.medical.toshiba.com

• Conventional color Doppler poorly visualizes vasculature in a normal pancreas, SMI shows even fine vascular structure.

• In normal liver, we can see a tiny vessels just beneath the surface of the liver.

• cSMI (bottom) depicts more blood flow and better vessel detail than color doppler (top) in this suspicious lump in the neck. SMI provides stronger evidence than Color Doppler to not drain the suspected abscess.

Sara O hara, Toshiba superb microvascular imaging A new problem solving tooll in pediatric radiology www.medical.toshiba.com

Clinical Applications• Characterization of Reactive and Malignant Lymphadenopathy.• Characterization of blood flow in Malignancies.

– HCC, Gastric cancer, GIST, Bladder tumors, malignant melanoma, squamous cell carcinoma, Lymphoma.

• Characterization of Inflammatory Lesions– MSK (Rheumatoid Arthritis) – IBD (Crohn’s Disease, Ulcerative Colitis)

• Characterization of Placental Lesions• Others

– Placental Insufficiency– Testicular Torsion– Laceration of spleen and– Non occlusive mesenteric Ischemia etc.

• Placental Ischemia. SMI images show that the placental flow is sparse to absent. Baby delivered at 28 wks of gestation due to preeclampsia. Histological examination revealed extensive area of marginal infarction.

Dr. Pascale bach segura. Supurb microvasculature imaging in the analysis of fetoplacental microvascular blood flow. Toshiba medical system corporation 2015.

• Heterogeneous lesion of the subchorionic placenta close to the umblical cord insertion into the placenta.

• On color doppler only largest arteries are seen.• SMI shows microvasculature within the lesion, confirm the diagnosis

and evaluates hemodynamic decompensation by detecting microvascular areas and necrotic areas.Dr. Pascale bach segura. Supurb microvasculature imaging in the analysis of fetoplacental microvascular blood flow.

Toshiba medical system corporation 2015.

• The grayscale image (top right) shows a suspicious lesion near the surface of the liver. With conventional ADF (top left) at a velocity range of 9 cm/s some vessels can be recognized but the pattern of the tumor vessels cannot be determined. When we lower the velocity range to 3 cm/s (bottom right), the image is badly distorted by the clutter. Once we activate mSMI (bottom left), we can see the internal tumor vessels whose basket shape strongly indicates HCC

Dr. Jiro Hata, Seeing the Unseen New Techniques in Vascular Imaging. ©Toshiba Medical Systems Corporation 2014.

• Liver metastasis originating from a jejunal gastrointestinal stromal tumor (GIST)

Dr. Jiro Hata, Seeing the Unseen New Techniques in Vascular Imaging. ©Toshiba Medical Systems Corporation 2014.

• Bladder carcinoma

Dr. Jiro Hata, Seeing the Unseen New Techniques in Vascular Imaging. ©Toshiba Medical Systems Corporation 2014.

• Gastric cancer

Dr. Jiro Hata, Seeing the Unseen New Techniques in Vascular Imaging. ©Toshiba Medical Systems Corporation 2014.

• Cervical lymph nodes (malignant lymphoma)

• Malignant melanoma • Squamous cell carcinoma

• Gastrointestinal stromal tumor of the ileum

• Rheumatoid arthritis (radio-carpal joint)

• Subcutaneous abscess due to Crohn’s disease

• Necrotizing lymphadenopathy

• Laceration of the spleen

• Even on cSMI no blood flow is seen in left testis depicting Testicular torsion.

• NOMI (non-occlusive mesenteric ischemia

• mSMI detection of the urinary reflux in the renal pelvis (red arrow) in a peadiatric patient who is on treatment for UTI

Advantages• Provide exquisite vascular details quickly.• Save time.• Improve Diagnostic confidence compared with conventional

sonographic techniques.• SMI can rapidly confirm the presence or absence of blood flow in

cases of torsion and ischemia.• No need of Intravenous Contrast.• It offers

– Better detail resolution– Faster frame rates– Less clutter– Fewer flash artefacts

Take Home Message

• AS it has become cleared that SMI is far superior to conventional sonographic techniques so every sonographic imaging should be added with SMI