Ultrasound elastography and atenuation

in liver fibrosis and steatosis evaluation

31/01/2020

Kazimierz Kukulski

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Fibrosis the way we see liver function deterioration

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Steatosis, NAFLD, NASH

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Metabolic syndrome

Three or more of these traits:

• Large waist circumference — a waistline that measures at least 89 centimeters for women
and 102 centimeters for men

• High triglyceride level — 150 milligrams per deciliter (mg/dL), or 1.7 millimoles per liter
(mmol/L), or higher of this type of fat found in blood

• Reduced high-density lipoprotein (HDL) cholesterol — less than 40 mg/dL (1.04 mmol/L)
in men or less than 50 mg/dL (1.3 mmol/L) in women of this "good" cholesterol

• Increased blood pressure — 130/85 millimeters of mercury (mm Hg) or higher

• Elevated fasting blood sugar — 100 mg/dL (5.6 mmol/L) or higher

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Histopatology

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Steatosis, NAFLD, NASH

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Different methods of evaluation of liver diffuse disease

LF Index – shows correlation with Shear Wave Measurement (SWM),

the degree of fibrosis measures the propagation speed of the
measurement not affected by Shear Wave
degree of inflammation and Less dependent on examiner
interstitial pressure * technique

LF-Index (RTE) SWM

*Fujimoto K. et al, Oncology 2013;84(suppl 1):3–12
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Transient elastography

Low frequency and low

amplitude mechanical
vibration by probe
Propagation velocity of
pressure wave depends on
on tissue stiffness (Young's
modulus, E=3ρV2)
Used exclusively for
measurement of liver
fibrosis

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Transient elastography

Atenuation of wave
propagation is reported
on the left hand side
Wave velocity and
Interquartile Range of
velocities measured is
reported on the right
hand side

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SWM (point shear wave measurement)

Track1 Track pulses culate

Track2
Push Pulse
Time lag propagation speed:
Tx. Rx. “Track
Distance Track 1 Pulse (T1,T2)”
continuously
Track 2 Detect arrival
Time time at each
position
Focal Point
Shear Wave
Vs = Distance / Arrival time lag

F3 F4
F1 F2
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SWM: Measurement Result (Vs / IQR / VsN)

Vs Median IQR:
Value interquartile
range
Histogram
analysis VsN: Number
of valid Vs
measurements

0 1 2 3 4 m/s

Vs : Median Value of the histogram Widely distributed Vs values (IQR)

IQR : Interquartile range of Vs values (±25% of the median) Example with low VsN & poorer reliability
VsN : Success rate of the Vs (reliability indicator)
NOTE: If IQR is varied when VsN is high, the variation can be
regarded as disease-related.
0 1 2 3 4 m/s
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SWM : Reliability Indicator, VsN (in-vivo examples)

Higher VsN represents a valid detection of the shear wave propagation velocity.
Lower VsN represents an inaccurate detection due to the propagation across vessels,
hypoechoic regions (shadowing) or body motion.

VsN: 100%

VsN: 16%

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SWM: Calculation of VsN

Rejection conditions:
Vs less than or equal to zero (1)
Outside a certain defined range of Vs (2): 0.7-4m/s (1.47-48kPa)
When phase fluctuations are observed at a particular depth (3) (fluctuations are mainly generated by
small blood vessels and/or body motion)
(Total # Vs pts measured) – (Rejected # Vs pts)
VsN (%) = X 100
(Total # Vs pts measured)

Schematic of 3 rejection conditions:

Case (1),(2) : Relative to the Vs axis (horizontal)
Case (3) : Relative to the depth axis (vertical)

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the shear modulus
increases with vascular and interstitial pressure
• Deep inspiration
• Food
• Investigation minimum 3 hours after eating
• Coffee, smoking, drinking – stop as above (onle still water allowed)
• Alcoholic hepatitis
• Stifness decreases after 1-4 weeks abstinence !!!
• Exercises (for patients with cardiac failure even walk can be an exercise)
• Minimum rest 10min (time of regular abdominal check up)
• Hepatic inflamation • Amyloidosis
• Lymphomas
• Obstructive cholestasis
• Extramedullary hamopoiesis
• Hepatic congestion • Steatosis
• Acute toxic hepatitis (drug induced)
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Other factors influencing SW measurments

• Depth dependance
• Minimum 1cm below the capsule not deeper than 5cm
• Frequency dependance
• Higher frequency transducer – higher stifness values
• Region of the liver (left lobe bigger variations)

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Fibrosis evaluation

Median values of liver stiffness

Study based on 445 patients
Reliability index VsN > 50% improves diagnostic performance of SWM

Ruling-
Fibrosis Stage SWM, kPa in
Ruling-out Ruling-in Ruling-out
(interquartile range) F≥2 F=4 F=4
F≥2
(95% CI) (95% CI) (95% CI)
(95% CI)
Mild/No fibrosis (F0-F1) 4.8 (4.0-5.7)
Cutoff, KPa 6.78 5.55 9.15 8.41
Significant fibrosis (F2) 7.2 (5.7-9.0)
Sensitivity 76.9 90.6 83.3 90.6
Advanced fibrosis (F3) 8.5 (6.7-9.5)

Liver cirrhosis (F4) 14.0 (11-17) Specificity 90.3 72.2 90.1 82.2

Ferraioli et al., J Gastrointestin Liver Dis, 2017

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ATT

What Is the Attenuation Measurement Function (ATT)?

• Fat tissue increases the ultrasonic attenuation.
• ATT is a function to assess the attenuation coefficient generated in the ultrasonic propagation
process.
• The extent of fatty liver can be evaluated and estimated by attenuation coefficient value.

Low Attenuation Rate – normal liver

High Attenuation Rate – fatty liver tissue

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ATT concept

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Steatosis grades according to ATT and CAP

Grade ATT median (95% CAP median (95% CAP median (95%
Cut off confidence level) confidence level) confidence level)
dB/cm/MHz dB/m M-probe dB/m XL-probe

S0 0,57 (0,54-0,60) 195 (187-210) 207 (197–224)

S>1 0,58 230 230
S1 0,63 (0,62-0,67) 253 (226-268) 283 (252–302)
S>2 0,68 270 267
S2 0,72 (0,56-0,76) 270 (220-301) 271 (233–329)
S=3 0,72 324 290
S3 0,87 (0,74-0,97) 337 (273-401) 323 (272–378)

Koizumi Y, Hirooka M, Tamaki N, Yada N, Nakashima O, Izumi N, et al. (2019) New diagnostic technique to evaluate hepatic steatosis using the
attenuation coefficient on ultrasound Bmode. PLoS ONE 14(8): e0221548. https://doi.org/10.1371/journal.pone.0221548
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Different methods of Elastography

RTE SWM
*Fujimoto K. et al, Oncology 2013;84(suppl 1):3–12
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 Model by: KAROUMPALIS IOANNIS M.D
CONSULTANT GASTROENTEROLOGIST
DISTRICT HOSPITAL OF ATHENS “G.GENNIMATAS”
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Methodology of RTE in LF evaluation

Courtesy: Dr.N.Postnova NVD Hospital

Moscow
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 Transducer Palpation

Frame 1 Frame 2
Before Compression Under Compression
Frame 1 Frame 2 Large strain → soft

Small strain → hard

Extended Combined© Hitachi

Author: M.Daniel Autocorrelation
Medical Systems EuropeMethod
Holding AG 2013. All rights reserved.
Strain Elastographyfibrosis: strain imaging and LF
Index

F1 F2 F3 F4

LF Index = 1.23 LF Index = 2.15 LF Index = 3.07 LF Index = 3.83

LF Index = - 0.00897×MEAN - 0.00502×SD + 0.0232×%AREA

+ 0.0253×COMP + 0.775×SKEW - 0.281×KURT + 2.08×ENT
+ 3.04×IDM + 40.0×ASM - 5.54 Fujimoto K. et al ; Kanzo 51(9) ; 539-541 (2010)
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 RTE (Real-time Tissue Elastography)of liver
fibrosis: strain imaging and LF Index

F1 F2 F3 F4
convex
transducer
Automatic
compression
of liver from
the heart beat
LF Index = 1.23 LF Index = 2.15 LF Index = 3.07 LF Index = 3.83

• Use the same transducer as for B-mode imaging

• Wide FOV enables easy ROI position free from vessel artifacts and
rib shadowing
• Good reproducibility
Fujimoto K. et al ; Kanzo 51(9) ; 539-541 (2010)
• Very good penetration for difficult-to-image patients © Hitachi Medical Systems Europe 2015. All rights reserved.
 LFI

Russian Liver Fibrosis study Japonese Liver Fibrosis study

F0-F1 2.3 (2.0 – 2.5)

F0-F1/F2 cut off 2.6

F2 2.7 (2.2 – 3.1)
F2/F3 cut off 2.9
F3 3.2 (2.8 – 3.4)
F3/F4 cut off 3.6
F4 4.4 (3.7 – 5.0)
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Ascites

RTE

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Methodology of RTE in LF evaluation

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Complete solution

SWM ATT RTE

Absolute values Absolute values of Not influecnced by:
of spead or atenuation acute inflamation
elasticity modulus no correlation joundice
Not influenced by: between ATT and congestion
steatosis fibrosis stage (portal
activity grade hypertension)

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Combi Elasto results

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F index, A index

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Yada N, et al: Diagnosis of Fibrosis and Activity by a Combined Use of Strain and Shear Wave Imaging in Patients with Liver
Disease. Digestive Diseases 2017; 35(6): 515-520. doi: 10.1159/000480140.

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© Hitachi Medical Systems Europe 2015. All rights reserved.
© Hitachi Medical Systems Europe 2015. All rights reserved.