IMAGING ARTIFACTS IN DIAGNOSTIC ULTRASOUND—A REVIEW

Imaging artifacts commonly occur during routine ultrasonographic evaluation of patients and contribute to image inaccuracies. These artifacts are classified into artifacts arising from factors controllable prior to imaging or from sound beam interactions within the patient which may result in clinically useful or confusing artifacts. Artifact formation, and how this influences the anatomical image location, echogenicity, size and shape, is described. The clinical interpretation of artifacts is explained in order to gain maximum diagnostic information from an ultrasonographic image.     

DIAGNOSTIC ACCURACY OF TESTS BASED ON RADIOLOGIC MEASUREMENTS OF DOGS AND CATS: A SYSTEMATIC REVIEW

A systematic review of diagnostic tests based on radiologic measurements of structures in dogs and cats was done in order to reach generalizable conclusions about the value of making such measurements. Literature search was done using the ISI Web of Knowledge^SM for studies in the subject category Veterinary sciences. Studies were eligible for inclusion that employed length, angle, area or volume measurements from radiographic, ultrasonographic, CT or MR images of dogs or cats as a diagnostic test for a naturally occurring condition, compared the results of imaging with a reference standard, included at least 10 subjects, and sufficient data that a 2 × 2 table of results could be constructed. Quality of studies was assessed using the QUADAS‐2 tool. Twenty‐six studies were found describing 40 tests that satisfied the inclusion criteria. Tests were radiographic in 22 (55%) instances and ultrasonographic in 18 (45%). Quality of studies was generally low, with a risk of bias in patient selection in 92% studies, performance of the index test in 73% studies, and patient flow in 42% studies. Median (range) number of subjects was 64 (20–305), sensitivity was 77% (38–99%), specificity was 82% (50–99%), positive likelihood ratio was 4.1 (1–103), and negative likelihood ratio was 0.29 (0.01–1). Two studies that compared accuracy of radiographic measurements to subjective image interpretation alone found no difference. Evidence is weak that radiologic measurements of structures in dogs and cats are useful for diagnosis, hence measurements should not be emphasized as a basis for diagnosis in either teaching or clinical imaging reports.     

Diagnostic imaging of congenital porto-systemic shunts in dogs and cats: a review

An overview of clinical, laboratory, and diagnostic imaging features of congenital porto-systemic shunt (PSS) in dogs and cats is presented through the analysis of recent literature, and personal case log. Particular emphasis is given to diagnostic accuracy of ultrasonographic examination of PSS in the evaluation of shunt vessel anatomy, and of ancillary findings such as abnormalities of portal vein flow, portal branches, and liver size. Operative mesenteric portography to obtain information on PSS morphology and position, and quantitative hepatic scintigraphy, which allows the calculation of shunt fractions, are also described. Limitations for each diagnostic imaging technique are given.     

Contrast ultrasound: general principles and veterinary clinical applications

The concept of contrast enhancement has significantly extended the usefulness of ultrasound imaging in human medicine and medical research over the past decade. The persistence and efficacy of ultrasound contrast agents has been improved and specific imaging sequences have been developed. Contrast ultrasound provides Doppler and grey-scale enhancement. Doppler examinations are improved when studying deep or small vessels and vessels with low flow velocities. Specific contrast imaging sequences allow detection of tissue enhancement with grey-scale ultrasound which enables assessment of tissue perfusion. Major clinical applications of contrast ultrasound in the human medicine field are the heart, the parenchymal organs such as the liver, spleen and kidneys, and vascular applications. Many other interesting applications have been identified and beside their diagnostic value, intensive research is currently investigating the use of ultrasound contrast agents for therapeutic applications such as targeted delivery of drug- or gene-loaded microbubbles. In the last few years, contrast ultrasound has also been introduced in veterinary medicine. Its usefulness has been shown in diseases of the liver, spleen, kidney, pancreas, lymph nodes and superficial tumours. In the present article, an overview of the physical principles, imaging techniques and image analyses is presented. In addition, a literature review details the current use in veterinary medicine and areas of potential utilization are discussed.     

Ultrasonographic Evaluation of the Distal Extremity

Despite the increasing use of magnetic resonance imaging (MRI), ultrasound remains a valuable tool to diagnose injuries that cause distal extremity lameness in the horse. The key to a successful examination is a strong knowledge of anatomy in combination with proper ultrasonographic technique and the patience and dedication to learn these skills. Similar to all imaging modalities, it is equally important to recognize and consider the limitations of ultrasound in this region so that findings can be interpreted appropriately. Ultrasound can be used to diagnose injuries to the deep digital flexor tendon (DDFT), straight distal sesamoidean ligament and branches of the superficial digital flexor tendon using standard pastern ultrasonographic technique. The addition of newer techniques to image the DDFT at the level of P2, the navicular bursa and the collateral sesamoidean ligament can enhance the diagnostic utility of ultrasound in horses with distal extremity lameness. Although visibility is limited, ultrasound can be used to diagnose collateral ligament injuries of the coffin joint in many affected horses. Transcuneal imaging may be useful in some horses to detect abnormalities of the distal sesamoidean impar ligament and navicular bone, but evaluation of the DDFT is limited. Ultrasound should be considered in all horses with distal extremity lameness, regardless of the ability to perform advanced imaging procedures. Information gained is often complementary to other imaging modalities and may provide the basis for recheck examination purposes.     

High-frequency ultrasonography of the skin of clinically normal dogs

OBJECTIVE: To assess the applicability of high-frequency diagnostic ultrasonography for evaluation and accurate measurement of the skin thickness of clinically normal dogs. ANIMALS: 26 healthy dogs (12 sexually intact males, 13 sexually intact females, and 1 spayed female) of various breeds and ages. PROCEDURE: Ultrasonographic examination of the skin and histomorphometric analysis of skin biopsy specimens obtained from the same site were performed. A 13-MHz linear-array transducer was used to obtain a series of ultrasonographic images of the skin in the flank region; images were analyzed and measured by use of imaging software. Cutaneous biopsy specimens were placed in fixative and then stained with H&E and Masson trichrome stains. Histomorphometric analysis was performed by use of an image analyzer. Thickness of the epidermis and dermis of each specimen was evaluated by use of a semiautomatic procedure of quantification. Data obtained from ultrasonographic and histologic measurements were compared by use of the Pearson correlation test. RESULTS: The ultrasonographic pattern of canine skin was consistently characterized by 3 distinct, defined echogenic layers corresponding to the epidermal entry echo, epidermis and dermis, and subcutaneous tissues. A positive correlation was found between ultrasonographic and histologic measurements of skin thickness. CONCLUSIONS AND CLINICAL RELEVANCE: Comparison between ultrasonographic and histologic appearance of the skin revealed that layering of canine skin (ie, epidermis and dermis) and the subcutaneous tissues may be recognized and measured by use of high-frequency ultrasonography. Thus, diagnostic ultrasonography may be a useful tool for the noninvasive evaluation of cutaneous disorders in dogs.     

EFFECTS OF FASTING AND INTRALUMINAL CONTRAST ENHANCEMENT ON ULTRASONOGRAPHIC APPEARANCE OF THE EQUINE SMALL INTESTINE

The equine small intestine is challenging to evaluate ultrasonographically. In humans, hydrosonography has been used to improve ultrasonographic images of the small intestine. We hypothesized that fasting horses for 24 h would enhance the ability to image the small intestine transabdominally by separating intestinal loops and reducing intraluminal gas, and that the administration of intragastric contrast agent would further improve that ability. Ten healthy horses were examined ultrasonographically under three treatment conditions: (a) regular diet, (b) after a 24‐h fast, and (c) fasted plus intragastric administration of water and mineral oil. During each phase of the study, 30‐s video clips were obtained from four predetermined abdominal windows, and were examined to determine diagnostic quality. Fasting improved the ability to obtain high‐quality images of the small intestine significantly. The addition of contrast agent resulted in qualitative improvement in image quality, but differences did not result in statistically significant improvement.     

Diagnostic imaging of the equine tarsal region using radiography and ultrasonography. Part 1: the soft tissues

The equine tarsus is the most commonly affected hindlimb region associated with lameness. Diagnostic imaging is routinely applied but because of its complexity, being composed of 10 multifaceted bones and different joints, multiple ligaments, tendons and bursae, imaging this region can be a challenge. This is the first part of a two-part review of the structures and disorders of the equine tarsus. It describes the principal disorders affecting the soft tissues of the tarsal region and addresses some of the technical aspects in taking radiographic, ultrasonographic and scintigraphic images of the different soft tissue lesions. Where applicable, comments on the diagnostic use of contrast radiography, arthroscopy and tenoscopy are made. In current clinical practice a combination of radiography and ultrasonography is still most frequently used to arrive at a diagnosis.     

ULTRASONOGRAPHIC FINDINGS IN HORSES WITH FOOT PAIN BUT WITHOUT RADIOGRAPHICALLY DETECTABLE OSSEOUS ABNORMALITIES

Foot pain is an important cause of lameness in horses. When horses with foot pain have no detectable radiographic abnormalities, soft‐tissue assessment remains a diagnostic challenge without magnetic resonance (MR) imaging. Ultrasonography can provide an alternative to MR imaging when that modality is not available but the extent of changes that might be seen has not been characterized. We reviewed the ultrasonographic findings in 39 horses with lameness responding positively to anesthesia of the palmar digital nerves and without radiographically detectable osseous abnormalities. Thirty of the 39 horses had lesions affecting the deep digital flexor tendon (DDFT), 27 had abnormalities in the distal interphalangeal joint of which six had a visible abnormality in the collateral ligament. Ultrasonographic abnormalities were seen in the podotrochlear bursa in 22 horses and in the ligaments of the navicular bone in two horses. Abnormalities of the navicular bone flexor surface were detected in eight horses. In three of the 39 horses, only the DDFT was affected. The other 36 horses had ultrasonographic abnormalities in more than one anatomical structure. Based on our results, ultrasonographic examination provides useful diagnostic information in horses without radiographic changes.     

Ultrasonographic evaluation of abdominal distension in 52 camels (Camelus dromedarius)

The purpose of this study was to assess the diagnostic value of ultrasonography in the evaluation of abdominal distension in 52 camels (Camelus dromedarius). The conditions included trypanosomiasis (n=35), intestinal obstruction (n=12) and ruptured urinary bladder (n=5). Fifteen clinically normal camels were included as controls. Transabdominal and transrectal ultrasonography was carried out on all camels. In animals with trypanosomiasis, ultrasonographic findings included accumulation of massive amounts of hypoechoic abdominal fluids where liver, intestine, kidney, spleen and urinary bladder were imaged floating. Except in two cases of bile duct calcification and one of hepatic abscessation, no detectable abnormal sonographic lesions were detected while imaging the hepatic and renal parenchyma, and the heart and its valves and major blood vessels. In camels with intestinal obstruction, ultrasonographic findings included distended intestinal loops with markedly reduced or absent motility. In one camel, the intestinal lumen contained localised hyperechoic material that was consistent with a foreign body. Hypoechoic fluid with or without fibrin was seen between intestinal loops. In camels with ruptured urinary bladder, ultrasonographic findings included collapsed and perforated bladder, echogenic blood clots within the urinary bladder and peritoneal cavity, increased thickness of the bladder wall, floating intestines in hypoechogenic fluid and echogenic calculi within the urethra. Ultrasonography was considered a useful tool for the evaluation of dromedary camels with abdominal distension.     

Ultrasonographic appearance of the bovine uterus during the estrous cycle

The uteri of 22 Holstein heifers were monitored during 58 interovulatory intervals by transrectal ultrasonographic imaging. The ultrasonographic appearance of the uterus was influenced by the stage of the estrous cycle. Profound changes in characteristics visualized by ultrasonography included thickness of the uterine body, ultrasonographic evidence of edema, and accumulation of intravaginal and intrauterine fluids. Scores representing intravaginal fluid, intrauterine fluid, ultrasonographic texture, and number of gray-scale zones (comprising the image of the uterus) increased before ovulation, then decreased until approximately day 3 to day 6 (ovulation = day 0). The scores for uterine shape and number of cross sections of a uterine horn in one 5-MHz field began to increase before ovulation, reached a high plateau during the period associated with maximal progesterone production, and decreased before the time associated with estrus and ovulation.     

CONTRAST‐ENHANCED ULTRASOUND OF THE NORMAL CANINE PROSTATE GLAND

Canine prostate gland abnormalities affect a large number of adult male dogs. In veterinary medicine, the commonly used methods to diagnose canine prostate gland disease are digital rectal examination and abdominal ultrasound. We evaluated the ability of ultrasound contrast agent to provide additional information about the vascularity of the canine prostate gland; such information could be useful in detecting early prostate gland disease and in staging disease known to be present. We characterized the ultrasonographic appearance of prostate gland vascularity in 10 healthy dogs before and after the injection of an ultrasound contrast agent (Levovist^?). Before injecting Levovist^?, the prostate gland blood flow was classified as poor in all dogs, whereas after contrast agent injection blood flow was classified as moderate or good, in 3 and 7 dogs respectively. Knowledge of the status of prostate gland vascularity could be useful for the characterization, diagnosis and therapeutic monitoring of canine prostate gland lesions.     

Persistent hyperplastic tunica vasculosa lentis and persistent hyaloid artery in a 2-year-old basset hound.

A 2-year-old Basset hound with unilateral persistent hyperplastic tunica vasculosa lentis and primary vitreous is described. There was leukokoria in the left eye, caused by bluish-white polar densities and haemorrhagic discoloration in the nucleus of the lens. Ultrasonographic examination of the eye revealed a small hyperechoic lens and a hyperechoic linear soft-tissue strand extending from the posterior pole of the lens through the optic disc. Power Doppler imaging revealed blood flow in this persistent hyaloid artery, but 5 months later, immediately prior to surgery, there was no flow in this artery. Ultrasonography, including Power Doppler imaging, was useful to confirm the diagnosis and to estimate the complications of surgery, especially the risk of vitreal haemorrhage after cutting of the persistent hyaloid artery. Comparison of the ultrasonographic images with those obtained by computed tomography suggested that the resolution of computed tomography is inadequate for identifying structures as fine as a persistent hyaloid artery.     

Intra‐operative imaging of surgical margins of canine soft tissue sarcoma using optical coherence tomography

Optical coherence tomography (OCT) is a rapid non‐invasive imaging technique that has shown high sensitivity for intra‐operative surgical margin assessment in human breast cancer clinical trials. This promising technology has not been evaluated in veterinary medicine. The objective of this study was to correlate normal and abnormal histological features with OCT images for surgical margins from excised canine soft tissue sarcoma (STS) and to establish image evaluation criteria for identifying positive surgical margins. Fourteen client‐owned dogs underwent surgical resection of a STS and OCT imaging of 2 to 4 areas of interest on the resected specimen were performed. Following imaging these areas were marked with surgical ink and trimmed for histopathology evaluation. Results showed that different tissue types had distinct characteristic appearances on OCT imaging. Adipose tissue exhibited a relatively low scattering and a honey‐comb texture pattern. Skeletal muscle and sarcoma tissue were both dense and highly scattering. While sarcoma tissue was highly scattering, it did not have organized recognizable structure in contrast to muscle which showed clear fibre alignment patterns. In this investigation, we showed different tissue types had different and characteristic scattering and image texture appearances on OCT, which closely correlate with low‐power histology images. Given the differentiation between tissue types the results support that OCT could be used to identify positive surgical margins immediately following resection of STS. Further research is needed to assess the diagnostic accuracy of this method for surgical margin assessment.     

B-MODE AND DOPPLER ULTRASOUND IMAGING OF THE SPLEEN WITH CANINE SPLENIC TORSION: A RETROSPECTIVE EVALUATION

The ultrasonographic appearance of splenic torsion has been described; the splenic parenchyma can be normal, hypoechoic or anechoic with interspersed linear echoes (coarse/"lacy" appearance). The ultrasonographic parenchymal appearance of 15 dogs in this report with splenic torsion varied: mottled hypoechoic regions (n=2), diffusely hypoechoic (n=11) and normal (n=2). Because splenic torsion causes vascular congestion due to splenic vein compression and eventual thrombosis, visible splenic vein intraluminal echogenicities compatible with thrombi were seen in 13 dogs using B-mode. Using spectral Doppler and color Doppler imaging of the splenic veins, no measurable flow velocities were detected in any of the 15 dogs. The varied B-mode ultrasonographic appearance of the splenic veins for intraluminal echoes and spectral or color Doppler evaluation for absent velocity flow.     

Multi-detector computed tomography of an aortic dissection in a cat

Contrast enhanced, multi-detector computed tomography (MDCT) is a useful diagnostic imaging modality that has become increasingly available in veterinary medicine. Multi-planar and three-dimensional reconstructions allow accurate and comprehensive assessment of cardiac and vascular lesions with short image acquisition times. ECG-gated, contrast enhanced MDCT was used to assess the lesion extent and therapeutic options in a case of aortic dissection diagnosed in a hypertensive cat.     

Diagnostic imaging of the equine fetlock region using radiography and ultrasonography. Part 2: the bony disorders

The metacarpophangeal/metatarsophalangeal (fetlock) joint in the horse is commonly associated with equine lameness and diagnostic imaging is routinely used to investigate disorders of the joint and its surrounding tissues. This review describes the osseous disorders of the fetlock as well as the technical aspects of taking radiographic and ultrasonographic images of the different lesions. In current clinical practice, a combination of radiography and ultrasonography is still the most frequently used approach to arrive at a diagnosis.     

Principles and applications of the balanced steady-state free precession sequence in small animal low-field MRI

Magnetic resonance imaging (MRI) in small animal practice is largely based on classic two-dimensional spin-echo, inversion recovery and gradient-echo sequences which are largely limited by low spatial resolution, especially in low-field (LF)-MRI scanners. Nowadays, however, the availability of volumetric sequences can open new perspectives and enhance the diagnostic potential of this imaging modality. Balanced steady-state free precession (bSSFP) is a three-dimensional gradient-echo sequence in which image contrast is given by the ratio of T2 and T1, resulting in low soft-tissue signal, poor cerebral grey/white matter distinction and a bright signal from free fluid and fat. Such properties, along with a high signal-to-noise ratio and a very high spatial resolution deriving from acquisition of contiguous blocks of data, make this sequence perfectly suited for morphologic imaging, particularly for fluid-containing structures. Although bSSFP is widely adopted in human medical imaging, the use of this sequence in veterinary radiology is limited to anatomic studies of the inner ear and quadrigeminal cistern. This review aims to discuss the technical background of the bSSFP sequence and its possible advantageous applications in small animal LF-MRI for different specific disorders of the spine (arachnoid diverticula, small disc herniation, facet joint synovial cysts), brain (supracollicular fluid accumulation, traumatic injuries) and ligaments (complete and partial tears).     

Ultrasound evaluation of tympanic bulla in calves

An ultrasonographic approach for the tympanic bulla in calves is described. Ultrasound evaluation was performed through a lateral approach on 7 fetuses, 2 newborn calves, and 4 living calves of various ages. The probe was positioned caudal to the vertical mandibular ramus, ventral to the base of the ear. Three different positions of the probe were used. The tympanic bulla and adjacent structures were successfully identified and their ultrasonographic appearance described. Fluid within the tympanic bulla was visualized in 12 bullae in the cadavers and in 6 bullae in live calves. Ultrasound imaging has been shown to be useful but its diagnostic value remains to be studied in clinical cases of otitis media in calves.