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In the past 2 decades, sonoelastography has been progressively

used as a tool to help evaluate soft-tissue elasticity and add to
information obtained with conventional gray-scale and Doppler
ultrasonographic techniques.

Recently introduced on clinical scanners, shear-wave

elastography (SWE) is considered to be more objective,
quantitative, and reproducible than compression

SWE uses an acoustic radiation force pulse sequence to generate

shear waves, which propagate perpendicular to the ultrasound
beam, causing transient displacements. The distribution of shear-
wave velocities at each pixel is directly related to the shear
modulus, an absolute measure of the tissue’s elastic properties.
Shear-wave images are automatically coregistered with standard
B-mode images to provide quantitative colorelastograms with
anatomic specificity.

Shear waves propagate faster through stiffer contracted tissue,

as well as along the long axis of tendon and muscle.

There are four main types of sonoelastography techniques:

compression sonoelastography (2), transient elastography (2),
tension elastography (4), and shear-wave elastography (SWE) (2),
each with advantages and disadvantages.

Compression, Transient, and Tension Sonoelastography

Compression sonoelastography, which is commercially available

on most US machines, provides visualization of different tissue
displacements (ie, strain) by comparing US images before and
after light freehand transducer compression (ie, stress).

With this technique, compressive strain is lower in harder tissues.

On most modern US scanners, compression sonoelastography
provides a semiquantitative measurement of the strain ratio,
which represents an index of the relative elasticity between a
chosen region of interest (ROI) in the examined tissue and a
reference ROI, which is usually in the adjacent subcutaneous
tissues. However, compression sonoelastography is operator
dependent and provides only a qualitative measure of tissue
elasticity. As a result, it has limitations with reproducibility and
often suffers from the eggshell effect, in which harder tissues on
the boundary of a lesion cannot be deformed, limiting the
determination of internal strain.

Transient elastography uses low-frequency excitation pulses to

generate shear waves and measures only regional tissue elasticity
with limited depth. Whereas SWE provides an absolute measure of
the shear modulus from just the tissue displacements, transient
elastography requires computing tissue strain (ie, the spatial
gradient of displacements), which is a noisy mathematical
operation and provides only a relative measure of stiffness (soft vs
hard). However, transient elastography is easy to perform during
real-time imaging of dynamic tissue motion.
Tension elastography is a variation of compression elastography,
with tissue strain measured in response to an internally generated
tensile stress, which has been validated recently ex vivo. Tensile
force is created by voluntary isometric muscle contraction,
whereas the generated force is measured externally using a
dynamometer and data acquisition system. When compared with
compression sonoelastography, tension elastography provides
quantitative information related to tissue elasticity (elastic
modulus), which is relevant as the primary function of tendons is
to transmit tensile force from muscle to bone. Although this
technique is not yet commercially available, it holds great promise
as a new functional imaging test, which may guide treatment for
tendinopathies and other chronic tendon disorders.

Basic Physics of SWE

During the past decade, SWE, which is also called dynamic

elastography in research and clinical settings, allowing both
qualitative and quantitative measurement of tissue elasticity.

Shear-wave imaging is now Food and Drug

Administration–approved on most state-of-the-art US scanners
(including those offered by Philips, GE Healthcare, Siemens
Healthineers, Ultrasonix, and Supersonic Imagine) for diagnostic
imaging of the musculoskeletal system.
This technique is rapidly evolving for new applications and clinical
utility in musculoskeletal imaging.
By quantifying mechanical and elastic tissue properties,
SWE complements the diagnosis obtained at gray-scale (B-mode)
US and power and color Doppler US.

To simplify the explanation of the basic physics, the shear wave is

a transverse wave that occurs in an elastic medium that is subject
to a periodic shear force.

Shear is defined as change in the shape of a substance layer

without volume change, produced by a pair of equal forces
working in opposite directions along the two opposed sides of the
layer. After the shear interaction, the initial layer (tissue) will
resume its original shape, while the adjacent layers undergo
shear, and there will be further shifting of the shear wave, which
propagates as a transverse shear wave.

shear waves are generated using focused acoustic

radiation force from a linear US array, which by itself provides a
local stress and generates local displacement in the tissue.

Generated shear waves then propagate through the adjacent

tissues in the transverse plane, perpendicular to the primary wave
that produces the acoustic radiation force, at a much slower
velocity, causing shear displacements in tissue.

In step 2, fast plane wave excitation is used to track the tissue

displacement and shear wave velocities as the shear waves
propagate. Tissue displacement is calculated using a speckle
tracking algorithm.

In step 3, tissue displacement maps are used to calculate shear-

wave velocity (cs), frequently expressed in meters per second. The
distribution of shear-wave velocities at each pixel is directly
related to the shear modulus G, which is calculated by a simple
mathematical equation and expresses the tissue stiffness and
elasticity in units of pressure—normally kilopascals.
The shear modulus is defined as the ratio of stress to strain that is
given by G= ρcs2, where ρ is the material density. The Young
modulus (E [or λ]) is defined to be E = 3G for isotropic media.

The material density for soft tissue is typically estimated on the

basis of values published in the literature for the type of tissue
being examined, or approximated to be close to that of water (1
g/cm3).Note that there is a direct relationship between the shear
and the Young moduli, reported in some studies to be E = 2G(1+ υ),
where υ is the Poisson ratio. Because soft tissues with small
deformations (ie, quasi-static displacements) are usually assumed
to be incompressible (ie, υ = 0.5), G is sometimes converted
to E by the simple equation E = 3G for incompressible
media.Therefore, although some studies refer to shear-wave
values or to G, others report E on the basis of this relationship.
For the colorelastograms, red is usually defined for encoding hard
consistency, blue indicates soft consistency, and green and
yellow encode intermediate stiffness.

In comparison with compression sonoelastography, SWE is

considered to be more objective and reproducible and allows
direct assessment of tissue elasticity, with the possibility to obtain
quantitative measurements without the need for manual
shear waves propagate faster in stiffer and contracted
tissues and along the long axis of the tendon

A primary limitation of SWE is depth of penetration. Shallow

depths may be accommodated by applying a 5-mm layer of
coupling US gel as standoff.
The shape and size of the ROI for postanalysis is also limited on
some scanners. Most scanners require a timeout of a few seconds
before the next acquisition, which prevents real-time dynamic
imaging of structures in motion. Additionally, SWE is sensitive to
transducer pressure and angle, and the shear modulus depends
on the orientation of the probe relative to the examined structures.

SWE is an exciting and rapidly evolving US technique that allows

quantification of mechanical and elastic tissue properties.

It can be used to complement conventional US in the initial

characterization and posttreatment follow-up of various traumatic
and pathologic conditions of the musculoskeletal system.

This may be of great importance in early disease when an

abnormality of the musculoskeletal soft tissues cannot be
detected or characterized with conventional US methods.

It may also prove useful for staging chronic diseases, determining

therapeutic response, and monitoring age-related changes,
including sarcopenia and clinical frailty syndrome. New methods
in SWE, such as continuous-wave and 3D SWE, may add new
information not provided by conventional two-dimensional SWE.
Finally, future SWE studies that characterize musculoskeletal soft-
tissue masses may reveal yet another application of this evolving
technology, which offers much promise as an adjunct to
conventional US.

It consists of the generation of a remote radiation force by focused
ultrasonic beams, the so-called “pushing beams,” a patented
technology called “Sonic Touch.”
Several pushing beams at increasing depths are transmitted to
generate a quasi-plane shear wave frame that propagates
throughout the whole imaging area.
After generation of this shear wave, an ultrafast echographic
imaging sequence, the Ulmtraast Imaging System, is performed to
acquire successive raw radiofrequency dots at a very high frame
rate (up to 20,000 frames per second).
Based on Young’s modulus formula, the assessment of tissue
elasticity can be derived from shear wave propagation speed.
A color-coded image is displayed, which shows softer tissue in
blue and stiffer tissue in red. Quantitative information is delivered;
elasticity index (EI) is expressed in kilo-Pascal (kPa).
Both steps of SWE are achieved using a linear US probe without
requiring any intervention (as pressure) by the operator.


The first ultrasound elastography method became available 13

years ago in the form of transient elastography with Fibroscan. It
was the first technique providing non-invasive quantitive
information about the stiffness of the liver and hence regarding
the amount of fibrosis in chronic liver disease. The innovation was
enormous, since a non-invasive modality was finally available to
provide findings otherwise achievable only by liver biopsy. In fact,
prior to ultrasound elastography, a combination of conventional
and Doppler ultrasound parameters were utilized to inform the
physician about the presence of cirrhosis and portal hypertension
. However, skilled operators were required, reproducibility and
diagnostic accuracy were suboptimal, and it was not possible to
differentiate the pre-cirrhotic stages of fibrosis. All these
limitations were substantially improved by transient elastography,
performed with Fibroscan, a technology dedicated exclusively to
liver elastography.

The technique has been tested in nearly all liver disease

etiologies, with histology as the reference standard. Meta-analysis
of data, available in many etiologies, showed good performance
and reproducibility as well as some situations limiting reliability.
Thresholds for the different fibrosis stages (F0 to F4) have been
provided by many large-scale studies utilizing histology as the
reference standard .
Transient elastography tracks the velocity of shear waves
generated by the gentle hit of a piston on the skin, with the
resulting compression wave traveling in the liver along its
longitudinal axis. The measurement is made in a 4 cm long section
of the liver, thus able to average slightly inhomogeneous fibrotic
In 2008 a new modality became available, Acoustic Radiation
Force Impulse (ARFI) quantification, and classified by EFSUMB as
point shear wave elastography (pSWE), since the speed of the
shear wave (perpendicular to the longitudinal axis) is measured in
a small region (a "point", few millimeters) at a freely-choosen
depth within 8 cm from the skin. This technology was the first to be
implemented in a conventional ultrasound scanner by Siemens(®).
Although the correlation between Siemens pSWE and transient
elastography appeared high, the calculated thresholds for the
different fibrosis stages and the stiffness ranges between the two
techniques are not superimposable. Interestingly, pSWE appears
to provide greater applicability than transient elastography for
measuring both liver and spleen stiffness, which is a new
application of elastography, of interest for the prediction of the
degree of portal hypertension.
Nowadays other companies have started producing equipment
with pSWE technology, but only very few articles have been
published so far, for instance describing the use of Philips(®)
equipment, which was the second to provide pSWE. These articles
show preliminary good results also in comparison with TE. Not
enough evidence is currently available in the literature about the
elastographic performance of the products most recently
introduced to the market. Furthermore, with some products the
shear wave velocities generated by a single ultrasound acoustic
push pulse can be measured in a bidimensional area (a box in the
range of 2 - 3 cm per side) rather than in a single small point,
producing a so-called bidimensional 2D-SWE 1.
The stiffness is depicted in color within the area and refreshing of
the measurement occurs every 1 - 2 seconds. Once the best image
is acquired, the operator chooses a Region Of Interest (ROI)
within the color box, where the mean stiffness is then calculated.
2D-SWE can be performed as a "one shot" technique or as a semi-
"real-time" technique for a few seconds (at about 1 frame per
second) in order to obtain a stable elastogram. With either
technique, there should be no motion/breathing during image
A bidimensional averaged area should overcome the limitation of
pSWE to inadvertently investigate small regions of greater or
lesser stiffness than average. A shear wave quality indicator could
be useful to provide real-time feedback and optimize placement of
the sampling ROIs, a technology recently presented by
Toshiba(®)(i. e., transient elastography, pSWE and 2D-SWE),
leading to a bidimensional assessment of liver stiffness in real
time up to 5 Hz and in larger regions; thus this technique is also
termed real-time 2 D SWE. It has been available on the market for a
few years, and many articles have been published showing
stiffness values quite similar to those of Fibroscan(®); likewise,
defined thresholds based on histological findings have appeared
in several articles.
After this brief summary of the technological state of the art we
would like to mention the following critical issues that we believe
every user should note prior to providing liver stiffness reports. ·
The thresholds obtained from the "oldest" techniques for the
various fibrosis stages based on hundreds of patients with
histology as reference standard cannot be straightforwardly
applied to the new ultrasound elastography techniques, even if
based on the same principle (e. g. pSWE). In fact, the different
manufacturers apply proprietary patented calculation modes,
which might result in slightly to moderately different values. It
should be kept in mind that the range for intermediate fibrosis
stages (F1 to F3) is quite narrow, in the order of 2 - 3 kilopascal
(over a total range spanning 2 to 75 kPa with Fibroscan), so that
slightly different differences in outputs could shift the assessment
of patients from one stage to another.
Comparative studies using phantoms and healthy volunteers, as
well as patients, are eagerly awaited. In fact, the equipment might
not produce linear correlations of measurements at different
degrees of severity of fibrosis. As a theoretical example, some
equipment might well correlate in their values with an older
technique, such as transient elastography, at low levels of liver
fibrosis, but not as well in cases of more advanced fibrosis or vice
Consequentely, when elastography data are included in a report,
the equipment utilized for the measurement should be clearly
specified, and conclusions about the fibrosis stage should be
withheld if an insufficient number of comparative studies with solid
reference standards are available for that specific equipment.. ·
Future studies using histology as a reference might be biased in
comparison to previous studies, since nowadays fewer patients
with chronic hepatitis C or hepatitis B undergo biopsy. In fact, due
to wide availability of effective drugs as well as the use of
established elastography methods for patients with viral hepatitis,
most cases submitted to biopsy today have uncertain etiology or
inconsistent and inconclusive clinical data. Therefore,
extrapolated thresholds from such inhomogeneous populations
applied to more ordinary patients with viral hepatitis might
become problematic in the future, although no better solution is
currently anticipated. This situation might lead to the adoption of a
standard validated elastographic method as reference, but this
has to be agreed-upon at an international level..
Ultrasound elastography embedded in conventional scanners
usually allows the choice of where to place the ROI within the
color stiffness box and whether to confirm or exclude each single
measurement when determining the final value. Thus, the operator
has a greater potential to influence the final findings than with
Fibroscan®, where these choices are not available. This has to be
kept in mind to avoid the possibility that an operator could, even
inadvertently, tend to confirm an assumption about that specific
patient or to confirm the patient's expectations.

Ultrasound elastography measures the liver stiffness/elasticity by

assessing at least 100 times the proportion of the liver that a
biopsy does.
Transient elastography (TE) has been validated in multiple studies
but shear wave elastography (SWE) may be preferred because
unlike transient elastography, which consists of a vibrator
producing shear waves, the latter can perform a conventional
ultrasound at the same time.
The technique is integrated into an ultrasound system. The
principle behind the interpretation of shear wave elastography is
that shear waves produced by a focused ultrasound beam are
directly related to the stiffness of the liver from where they are
generated. SWE is also reportedly more accurate than TE in
assessing significant fibrosis (≥ F2).

Focal liver lesion – shear wave elastography shows radical

pattern of elasticity in FNH whereas adenomas &hemangiomas
are homogenous.
Scars from radiofrequency ablation or healed abscess have the
highest stiffness values among benign lesion.

Cholangiocarcinomas were the stiffest among malignant lesions.

Advantages : non invasive, painless & repeatable procedure.

It can evaluate a much larger liver volume than liver biopsy.
It can be used for initial assessment, monitoring as well as
diagnosis of complication( portal hypertension, esophageal
It can help in biopsy planning from stiffest regions to reduced
sampling error.

Tumor ablation monitoring is also possible real time with this


Limitations : parenchymal thickness < 4 cm under the probe,

ascites, severe obesity, absence of intercostal space sufficiently
wide for the probe. Male sex, body mass index > 30, metabolic
syndrome, acute viral hepatitis increased liver stiffness.

The use of shear wave elastography in the diagnosis and staging

of liver fibrosis has been increasing.
Being a non-invasive technique proves advantageous because
repeat measurements can be obtained in patients with chronic
progressive liver diseases.
However, this non-invasive procedure does have some pitfalls. It
is subject to intra- and inter-observer variability, validated cut-offs
have mainly only been demonstrated in hepatitis C; Acute hepatitis
can have false positives.

In patients with a high body mass index, erroneous values may be

obtained. A very practical pitfall is confounding factors such as
edema, inflammation, cholestasis and congestion. All these must
be put in context and a multidisciplinary clinical approach used in
the interpretation of the results.
Interpretation of liver fibrosis by shear wave elastography in kPa
divided the entity into no fibrosis (F0), mild fibrosis (F1), severe
fibrosis (F2), significant fibrosis (F3) and cirrhosis (F4).
Automatic median value generated by the ultrasound software
was used to establish the elastography grade as follows
< 4.6 = F0, 4.6-5.6 = F1, 5.7-7.0 = F2, 7.1-12.0 = F3 and > 12 = F4.
here are limitations associated with elastography, including the
confounding effects of inflammatory activity, and to a lesser
extent, steatosis, on liver stiffness evaluation.
There is also reduced accuracy observed in lower fibrosis stages
(F0-F2). Furthermore, the incidences of failed and unreliable
scans have been reported to be approximately 3% to 16% in
transient elastography but less in shear wave elastography
(figures not reported yet).
A typical liver biopsy covers 1/10000th of the liver while
elastography covers a larger area.


EI was significantly higher in malignant nodules [150 ± 95 (30–356)
kPa] than in benign nodules [36 ± 30 (0–200) kPa] and normal
thyroid glands [15.9 ± 7.6 (5–35) kPa] (P < 0.001). The cutoff level
of EI for malignancy was estimated as 65 kPa, for a positive
predictive value of at least 80%. With this cutoff value, from the
ROC curves, the characteristics of EI to predict malignancy were:
sensitivity = 85.2% (95% CI, 71.8; 98.6), specificity = 93.9% (95%
CI, 89.2; 98.6), positive predictive value = 80% (95% CI, 65.4; 94.6),
negative predictive value = 95.9% (95% CI, 92.0; 99.8), and AUC =
93.6 (95% CI, 86.9; 100)

SWE was a powerful tool for the diagnosis of malignancy in thyroid

nodules. EI was significantly higher in malignant than benign
nodules. Using a cutoff level of 65 kPa, the sensitivity and
specificity of the technique were 85.2 and 93.9%, respectively.

SWE is operator-independent and more reproducible than static
elastography. First, it is quantitative.

Second, it provides local elasticity estimation of nodules that is

unaltered by the presence of a hard area in the vicinity. This is of
major interest in cases of multinodular thyroid. This group of
patients may represent up to 40% of all patients referred for
thyroid nodules.


Most cases of multinodulargoiters are not suitable for static

elastography because the nodule to be examined with this
technique must be clearly distinguishable from other nodules in
the thyroid gland.

The accuracy of EI measurement may also be altered if nodules

are close to the carotid artery because arterial pulsation may
create elastographic images and therefore alter the adequate
acquisition and accurate interpretation of the data.

In nodules with a diameter greater than 3 cm, adequate

compression of the whole nodule may not be obtained.

Similarly, elastography using external compression was

considered unreliable in nodules with calcified shells or rims
because the US beam does not cross these macrocalcifications,
and no tissue strain is obtained by the probe pressure. In these
cases, SWE may offer some advantages over this technique

The subtype of thyroid nodules may be the source of variations in


The place of SWE in the evaluation of thyroid nodules for potential
malignancy needs to be established. Actually, this evaluation is
based upon clinical examination, conventional US characteristics,
and FNA above all.

The lower sensitivity of US characteristics, alone or in association

with EI, leads us to support SWE as the first-line procedure in the
evaluation of thyroid nodules. When EI is at least 65 kPa, further
exploration is needed by FNA or thyroid surgery. For nodules with
an EI of less than 65 kPa, careful evaluation of US signs
associated with cancer may add useful information for the
management of patients. In conclusion, promising results have
been obtained with SWE in the evaluation of thyroid nodules.


BASIS OF USE OF ELASTOGRAPHY – Breast cancer tissue is

harder than the adjoining normal breast parenchyma due to
desmoplastic reaction.

Cut off point is taken between 3 & 4 for the malignant lesion, it
showed 86.5 % sensitivity, 89.8% specificity & 88.3% accuracy in
one study.

Simple cyst VS complex cyst – on elastography it gives target or

bulls eye appearance with central bright area surrounded by a
dark concentric rim.

Complex cyst with debris appears as a solid lesion but

elastography can help revealing the cystic nature of the lesion
with the typical target appearance.

Fibroadenoma – in atypical cases of fibroadenoma to elucidate the

benign nature of the lesion.
Invasive ductal carcinomas – on sonoelastography it appears
darker than the normal tissue or benign lesion.

Disadvantage : False negative elastogram in few well defined

benign looking masses, masses with tumour necrosis with
acoustic enhancement can mimic cysts.

Emerging application of SWE in differentiating between reactive &

metastatic axillary lymph nodes in breast carcinoma.

Cervical elastography in predicting delivery, detecting patients

with a high risk of pre term delivery.

Transvaginal elastography is helpful in evaluation of

benign(polyp/fibroid/erosion/inflammatory) & malignant lesions.
Cut off value of strain ratio of 4.53 or higher has been suggested
for confident diagnosis of malignancy. It also helps in the
detection of endophytic cancers & depth of invasion of stroma
which helps in staging.

Fibroids VS adenomyosis – elastography shows typical pattern of

a soft lesion(green) with central core which is even less
stiffer(red) which persist for both focal & diffuse variety however
fibroids in comparison are stiffer & shows blue colour on

Renal transplant assessment – to diagnose chronic allograft injury

by monitoring allograft stiffness, so patients with serial increase
can be subjected to a biopsy before renal function deteriorates.

Disadvantage - Subclincal rejection, infection or recurrence of

underlying disease cannot be detected.

Cardiovascular application – strain imaging of the myocardium(for

ischemia,infarction& scarring)& of atheromatous plaques& the
arterial wall(detection of vulnerable plaques & estimation of
arterial wall compliance)

Disadvantage – intravascular plaque evaluation is invasive


Venous thrombosis: new thrombi are at higher risk for

embolization than are more older fibrotic thrombi.(stiffness of a
thrombus increases with increasing age).

Elastography can visualize components of Skin and soft tissue

abscesses. Elastography differentiate between indurated tissue
surrounding the abscess cavity which helps to predict
progression to bacteraemia or the time to resolution. Asymmetry
of the inflammatory changes surrounding the abscess cavities has
been associated with a higher rate of failure after standard

Endoscopic ultrasonic elastosonography is used for pancreas

which shows uniform, homogenous green colour distribution (
intermediate stiffness) in normal condition & exclude
maliganancy. However blue predominant either homogenous or
heterogenous favours the diagnosis of the malignant tumour.

Disadvantage – inability to control tissue compression by EUS

transducer. Motion artifacts by respiratory or heart movments.
Large lesions can be under assessed ( portions of the lesion lying
out of the field of view), painful lesion leads to discomfort, non
axial transducer movments detrimentally affect elastogram.