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Update in Ultrasonography in Gynecology Final 24.5

Update in Ultrasonography in Gynecology Final 24.5

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Published by: hossam626 on Apr 07, 2010
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Based on sonar and related technologies, research on the use of ultrasound in medicine began shortly after World War II in a variety of centers in Europe and Japan, including pioneering work by Ian Donald et al in Glasgow.From the mid-1960s onward, rapid technological advances in electronics and piezoelectric materials led to substantial advancement – from bistable to grayscaleimages and from still images to real-time moving images.The fusing of Doppler ultrasound and ultrasound imaging and the subsequentdevelopment of color Doppler imaging provided enhanced ability to investigatehemodynamics, tumors, blood supply to organs, and other physical processes.The adoption of the microchip in the 1970s triggered exponential increases in processing power, facilitating the development of faster and more powerful systemsincorporating digital beam forming, signal processing advances, and new ways of developing and displaying data
(Margaret et al 1999)
Improved Images via Computer Technology
One of the most dramatic improvements in the ongoing development of ultrasoundimaging has been the application of technology originally developed for use incomputers. In the beginning, ultrasound technology was developed independently of computer technology. Existing scanners returned satisfactory images through electricalchannels, but the images could not be refined because computers for ultrasound imagingdid not exist. That all ended in the early 1980s with the development of thecomputerized beam former platform, which ushered in a whole new era in diagnosticultrasound imaging. With the wedding of computer technology and diagnosticultrasound, a computerized image formation process provided black-and-white imageswith superior resolution and clarity.
Doppler Imaging
Continuous wave Doppler instruments were available in the mid-1960s. However, itwasn’t until the introduction of pulsed-Doppler systems in the early 1970s that thetechnology had a major impact on ultrasound imaging, for the first time providingnoninvasive localized measurements of blood velocity. The introduction of duplex pulsed- Doppler in the mid-1970s, an important milestone, enabled 2D gray scaleimaging to be used in the placement of the ultrasound beam for Doppler signalacquisition. Doppler ultrasound analysis has been used in gynecology primarily todetermine blood flow in ovarian tumors with neoplastic characteristics
(Dickey 1997)
.Doppler ultrasound has the potential to study patterns of pelvic walls and hence identifyfunctional changes. The availability of pulsed Doppler instruments has made it possibleto sample signals at a chosen depth and thus to direct flow in any selected deep pelvicvessel. Transvaginal color Doppler is a system that uses pulsed Doppler that performsflow analysis at multiple points along each scan line of echo data. Flow information isthen color coded and displayed on the entire corresponding anatomical image. The mainadvantage of this is a rapid and definitive determination of the position of the smallvessel, accuracy of the measurements and precise indication of flow direction andvelocity. After simultaneous visualization of morphological and blood flow informationa pulsed Doppler gate is placed over the area of interest to provide flow velocitywaveforms which may be analyzed in a conventional fashion
(Kurjak and Kupesic2000)
In the case of power Doppler, no attempt is made to identify velocities. Instead, the totalsignal level across all frequencies at each depth is displayed. This gives a crude measureof how much energy or power there is in the local blood flow. It can be altered bychanging either the local mean velocity or the total mass of moving blood in the
locality. It has been described (wrongly!) as a perfusion map, although it can comeclose to this on occasions. There is no longer any angle dependency because velocitiesare not being measured. One advantage of power Doppler is its signal to noise ratio,which is normally better than that of its color flow counterpart. This improved signal-to-noise ratio will mean that small vessels can be imaged, which are otherwise invisible toultrasound.
Digital Beam formation
The development of a digital beam-former in the mid-1980s and the subsequentmigration to a digital platform by ultrasound manufacturers substantially raised the levelof performance industry-wide. This new technology allowed for more sensitive,consistent, and accurate acquisition of sonographic data, providing for higher-resolutionimages.
Harmonic Imaging
Harmonic imaging was first developed to increase blood flow detection sensitivity incolor and power Doppler applications using echo enhancing contrast agents. Based onresearch results using Contrast Harmonic Imaging (CHI), researchers investigated the possibility that harmonic imaging would also improve B-mode imaging without contrastagents, particularly in difficult-to-image patients. The subsequent introduction of TissueHarmonic Imaging (THI) has demonstrated that this technology can increase spatial andcontrast resolution and more effectively suppress artifacts compared with conventionalB-mode imaging not only in obese patients, but also in many other applications
(Burnset al, 1997)
.Following the realization that ultrasound has some nonlinear properties. Returningechoes produced by the media are not only at the original fundamental generated by thetransducer but at several different frequencies-multiples of the original one andsecondary to vibrations of the contrast agent bubbles. Insonated tissues will also vibrateunder the influence of the changing pressures induced by the incident ultrasound wave,and they will reflect echoes at different frequencies. Whereas this was once considerednoise or artifact and was suppressed or was assumed to be too weak to be measured, theinformation has now been captured and turned into meaningful data. A low-frequencytransducer may be used (affording better penetration) but the image resolution isimproved since the returning frequency is twice as high.Harmonics are generated while the ultrasound wave travels through the tissues duringthe transmit phase of the pulse-echo cycle. The returning echoes, at higher frequency,travel only one way-back to the transducer, thereby reducing potential confusinginformation. Only echoes not at the "right" frequencies are canceled upon reception,thus reducing artifacts. Depending on the equipment vendor, this is called tissueharmonic imaging, native tissue harmonics, and so forth. The result is better signal-to-noise ratio with improved contrast and spatial resolutions. Since time (which equalsdepth, in ultrasound) is necessary for generation of the harmonics, they are helpful inlarger, harder-to-image patients. Its advantages are less obvious in patients easier toscan, although some practitioners turn it on simply because of the better contrast.Improved imaging of the liver, gallbladder, pancreas, pelvis, kidneys, andretroperitoneal lymph nodes is on record
(Shapiro et a. 1998)
Contrast-enhanced ultrasound (CEUS)
The introduction of US contrast agents has totally changed the depiction of specificvascular signs for a definite diagnosis by allowing a marked increase in signal from thevessels, especially with modern non-linear imaging techniques.Contrast-enhanced ultrasound (CEUS) allows an adequate depiction of vessels inrelation to the pure intravascular characteristics of those agents, reinforced by the real-time assessment of the enhancement after contrast injection. The availability of thisimaging technique for transvaginal applications has allowed physicians to use CEUS in
gynecology, such as in ovarian or uterine lesions, for a better assessment of vascular  patterns that could play a role in diagnosis management. Micro-bubbles represent anentirely new class of materials that are mainly used as intravascular contrast agents for US, though they can also be instilled into the urinary bladder to look for ureteric refluxand into the uterus to check tubal patency. Their effect depends on the compressibilityof gases, which is markedly different from the near-incompressibility of tissue.Exploiting this difference has led to the development of several multi-pulse sequencesthat cancel tissue signals and emphasize those from the micro-bubbles, thus improvingthe contrast-to-tissue signal ratio. Overlay or side-by-side displays allow the agentimage to be viewed along with the grey-scale image to facilitate locating the region of interest
(Abramowicz 1997)
.Ultrasound images depend on echoes being produced by the insonated structures(acoustic backscatter). It is therefore easy to conceptualize that increasing the amount of echo-producing substance in the insonated area will create additional echoes and thus, if  properly processed additional information. This may be important when dealing withtiny vessels beyond the resolution of gray-scale ultrasound, color imaging, or power Doppler.In oncology Ultrasound contrast media (UCM) may offer tremendous advantages. Neoangiogenesis (creation of new blood vessels) is common to all malignant tumors,and these new vessels are usually abnormal-irregular in size, branching, anddistribution, with flow in bizarre directions. Ultrasound alone cannot detect these smallvessels but with the addition of UCM, they may be visualized. This has already beendemonstrated in breast cancer and undoubtedly will move into other areas like ovariancancer screening. In obstetrics and gynecology, the use of UCM is limited, but placental perfusion and ovarian tumors are potential areas for this modality
(Abramowicz 1997)
.Following an intravenous (IV) injection, the UCA reaches the organ of interest (such asthe ovary) and time intensity curves can be created to evaluate the degree, speed (slope)and duration of pixel enhancement produced by the UCA (transit time studies).Generally, tumors demonstrate steeper rises and slower washouts secondary toangiogenesis. Furthermore, benign and malignant processes can be differentiated sincein malignancy, absorption should be faster and the UCA should remain in tissues longer and should be excreted faster. Malignant tumors have a larger number of vessels andhigher pixel density when examined with color Doppler. This has already been shownin breast, liver and prostate cancers and undoubtedly will be in the future in other fieldssuch as ovarian cancer screening
(Abramowicz 2005)
3D Imaging
The first 3D scanner was produced in 1974, but it was not computerized and proved adisappointment. However, computerized modeling of ultrasound images began in the1980s and the result of that research, combined with 3D scanning technology,ultimately led to the development of improved 3D imaging. This provided clinicianswith a level of imaging detail substantially better than what had been previouslyavailable. And as data acquisition and display continue to improve, 3D imaging will beincreasingly more clinically useful. In gynecology, 3-D offers indisputable advantages –  planes not otherwise accessible are available, e.g. the coronal plane in uterine imaging.This may be particularly helpful to assess the uterine contour, both external and withinthe endometrial cavity, for instance for the diagnosis of congenital Müllerian anomaliesor adnexal pathology
(Merz 1999)
Why 3 D US?
Two-dimensional US is a flexible, cost-effective imaging tool that allows users to seeand record a large variety of thin anatomic sections in real time. However, conventionalUS has several disadvantages that 3D US has the potential to rectify. One of its major 

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