Clinical Applications of Contrast Ultrasound Beyond the Conventional - HD

Introduction

Hello everybody.

My name is Dr. Hashem, I'm from USC.

And today I'm gonna talk to you about an exciting topic entitled the Clinical Applications of Contrast Ultrasound Beyond the Convention.

For you who are not aware of this here in the United States, contrast ultrasound is being approved by the FDA over a year ago, and this imaging modality now is available in the United States only for characterization of focal liver lesions.

Alright, so if you see my disclaimer down here, it says that it's only available for use in the US for characterization of focal liver regions and left ventricular opacity only.

Given the title, most of the stuff performed here were done off label.

It's very important to understand if you wanna perform these studies on your patients in the future, you have to disclose to them that you are using the contrast as off-label.

Moving on, these are my disclosures and we're gonna discuss the outline based on the following.

We are gonna talk about these categories here one at a time and actually I'm gonna be presenting this PowerPoint as a pictorial essay, presenting cases from actual cases of patients who presented to our medical center.

And we perform these studies to solve problems.

As you can see, we're gonna cover areas like infection, vascular trauma, scrotum, the neck, and some new advances in the use of contrast ultrasound, like parametric imaging.

Infection

Discussing infection.

I'm gonna give you a first example of a female patient with known history of diabetes and acute renal and failure who presented with increased white count and a picture of septicemia to the emergency room.

Patient was admitted and ultrasound of her kidneys was requested.

If you look on the right hand side here on the ultrasound, you can see that we are using a high frequency probe nine megahertz with nice depth penetration.

And if you notice there is increased cortical echogenicity here in this part of the kidney with straight pattern similar to what you see with the CT scan if you do this with enhancement.

Now if we move on using our conventional other techniques to confirm the diagnosis, you can see that using power doppler with optimized sensitivity, you can identify this devoid area of vascularity as well as this area here in the mid kidney showing similar increased echogenicity.

All these features based on the standards that we are aware of and know of the gray scale and power doppler are consistent with the clinical history of pyelonephritis.

Now if you wanna investigate this further, given the fact that the patient had a very high white count on toxic, we still concerned about complicated pyelonephritis.

We do not see much of an abscesses with the kidneys by gray scale and color doppler, but watch when we inject the contrast ultrasound, you can see the contrast now is arriving into the kidney and you can see how it is homogeneously enhancing most of the kidney, except if you pay attention down the line here when you keep following the kidney, you can see those little small hypoechoic areas here in the kidneys and some changes suggestive of more than just simple pyelonephritis going on with this kidney.

Now if we keep scrolling this video further down here, you can see that there is this area that corresponds to this increased echogenicity area that we do not appreciate suggestive of an early abscess formation.

So again, same patient looking from a different angle with a second injection and you can see how the abscess now is showing nicely in this part of the kidney, which is really hard to see or justify based on the gray scale component of the image by itself.

Again, note the nine megahertz probe we're using with nice penetration to look at this kidney and that was very helpful in making the diagnosis.

Now if you look at this video clip down here in the same patient, you can see that the bubbles nicely should arrive and fill the cortex without any filling defects.

And you start to see the tiny abscess that we showed earlier up here is again starting to show up.

You scan in and out of the kidney and this is the beauty of the kidney and you can pick up these small micro abscesses in the kidneys.

So this patient definitely needed more than just sample oral antibiotics and be sent home.

This patient was admitted based on these findings for IV antibiotics to tackle the problem efficiently, more efficiently in this situation.

Alright, so now we're gonna move to the next case.

We have a 65-year-old male with low grade fever and right upper quadrant pain for two weeks.

Again, this patient presents to the emergency room, the emergency room because the patient has renal impairment, they only did contrast non-contrast enhanced CT scan showing few low density lesions in the liver that they couldn't tell whether it is due to infection or metastasis.

So they ask us to do and look at it with ultrasound and you can see we looked at this with ultrasound and you can see that there are multiple heterogeneous lesions in this liver with posterior acoustic enhancement which goes in line of abscesses.

So the color doppler also is just to give an idea about the distribution under side these abscesses.

So we decided to look at these abscesses for better characterizations and define what is really involved in the parenchyma of the liver and how many of those abscesses actually are there in the liver.

So on this slide you can see following the injection of contrast that if this area of concern was metastasis, you should have enhanced and wash out.

But the beauty of this is it shows you the exact size of the cavity, the hyperemia in the wall of the abscess cavity that sometimes you would see on CT scan with contrast and you can identify other tiny abscesses more defined and you can actually measure these more accurately than on the gray scale for purposes of either placing a drain or aspiration if clinically indicated.

Again, the ultrasound contrast, if you compared here to the gray scale, it'll show you that you can absolutely make sure that this is not one abscess cavity as it was shown the gray scale.

These are two abscesses adjacent to each other without evidence of communication.

So the bottom line is contrast ultrasound can help you really define what is actually going on happening given the comparison between what the gray scale is showing and the high contrast definition that the contrast ultrasound is showing you, as in this example.

And this is the diagnosis based on this multiple liver abscesses, the patient was accordingly treated.

Vascular

Alright, now we move on to another area where ultrasound contrast can be of significant help, which is the vascular areas that you can evaluate and you always ask to look at with color doppler ultrasound and this is an example of a 55-year-old female with a history of cirrhosis who presented with abnormal liver function test.

If you look at the right hand side, the sonographer came and presented a highly qualified, so skilled, highly skilled, and I came and showed me this case and he said, I am worried about that the portal vein is clotted here and not that this is not just color doppler, this is a power doppler that should be the least sensitive to the angular of inclination so that you won't get this these filling defects when you are closer to 90 degrees to the plane of the imaging plane you're looking at to avoid pitfalls and called pseudo thrombosis or falsely called thrombosis.

So we decide despite our attempts and the high sensitivity levels of the power doppler to go ahead and inject contrast and to evaluate this portal vein.

And you can notice here that the contrast starting to arrive in the liver, which is during the arterial phase of the way it should be.

And then this is the portal vein at this point still void of any contrast, but immediately after you see the bubbles of the contrasts are filling the whole portal vein and there is no filling defects to suggest thrombosis and most likely the explanation behind this, it was because just a little bit of a sluggish flow in the portal vein as there was little delay on the contrast enhancement for the contrast to come in.

So contrast ultrasound made us avoid this pitfall of thrombosis of the portal vein and we called it patent portal vein.

There was no need to subject the patients to treatments like anticoagulation that carries a high risk of bleeding from somewhere else.

And that solved our problem in this instance.

Now it's worth mentioning that if you notice here there are the patient had cor cystectomy and there are surgical clips and these surgical clips are giving you this void here in the contrast.

So another pitfall you have to keep in mind that any metal or any shadowing that can go in the plane of your contrast study can mimic thrombosis.

This filling defect here is actually an artifact from the surgical clips and there is no thrombosis.

So this was our impression, no port vein thrombosis, of course the liver lack sera there, but that's a different issue there that we can keep an eye during follow-up to make sure the patient doesn't get HCC or if they do get that we pick it up early and the process of the follow-up over a period of some time.

Now we move on for another case of where under the topic vascular, this 4-year-old female with a history of left ovarian sarcoma status post-surgical resection.

So she had this ovarian sarcoma operated on a few years back and then she presented with abdominal pain and you can see the contrast ultrasound shows a hypoechoic mass here anterior to the anterior and lateral to the aorta at the level of the renal arteries.

So the patient of course had a CT scan as well.

So we decided for better localization to use a fusion ultrasound with the CT.

And you can see on this video clip this the kidney there is this enhancing mass sitting here in front of the aorta at the level of the renal arteries just like it is showing here with ultrasound because we matched the two imaging modality in the same plane on this patient using the fusion technology provided by the manufacturer.

So you can see the mass is very hypoechoic here and it is enhancing on the CT scan, but the thing is, if you notice, it looks like it is occupying the lumen of the left renal vein causing its expansion.

So based on this we decide to move on and scan the holy plane of what's going on from down up to see where is this going on.

And you can see on the video clip again, if I play it again from bottom up there is this gonadal vein there is going all the way up and is going into this left renal vein.

Remember the patient had history of sarcoma in the pelvis and their ovary and it was resected earlier, so we decided to go with contrast ultrasound to characterize this.

Is this a just bland thrombus or it is a tumor that invaded the renal vein And you can see obviously by the contrast enhancement that this mass is really a tumor that invaded the left renal vein coming up the already involved left gonadal vein as we've seen that on the CT scan consistent with recurrent disease

All we move on to the next example and this is a patient who had a kidney transplant with elevated peak systolic velocity in the main renal artery on color doppler and there was concern for stenosis, but the kidney function remained normal.

The patient is not hypertensive.

So we thought we do a contrast ultrasound on this renal artery and you can see there's the renal artery.

And the renal artery actually is nicely showing contrast filling the whole lumen.

And obviously the velocities that were registered by doppler is most likely due to this acute angle of the re of the anastomosis.

There was no evidence of stenosis in this patient and this is The same artery from a different plane showing how the contrast is coming and going feeding the kidney.

And this is the iliac artery and this is the area of the anastomosis as evident on gray scale and on contrast ultrasound.

So there was no evidence of stenosis and the patient kidney function continued to be normal for some time following that study.

Neck Masses

Now the other thing is what's important is to keep on mind is when people present with neck masses, make sure that these masses are not vascular and we're gonna see some example of patients referred for biopsies and if you don't be careful about whether they're vascular or not, you may really cause harm to these patients as a result of bleeding and increased morbidity to these patients in the situation.

So carefully evaluation with ultrasound will help in these instances.

So this example is this patient presented with a large neck mass and you can see the large neck mass is occupying the right lobe of thyroid gland and there is some normal thyroid medial level echo tissue, but there's this hypoechoic mass that appears to extend outside of the capsule of the thyroid gland.

Now this gray scale images actually from a bubble contrast studies that I did a little bit earlier, and you can see there's still bubbles in the common carotid artery, but in the expected location of the internal jugular vein, there is nothing showing enhancement.

So this was an alarming feature for us to look into this.

So we decided to look at the internal jugular vein and this is, you can see when injecting the contrast, contrast comes into the carotid artery and of course we have to wait for it to go into the vein, but as it goes into the vein, it starts to fill this part of the IJV starts to fill or enhance with color doppler with some areas of void over there consistent with tumor thrombus or extension of the tumor secondary to direct invasion from the thyroid mass.

So we decide to do another injection, look at that in transverse plane.

And this second injection shows us that the mass in the thyroid is avidly enhancing over here showing some areas of potential necrosis.

And this is the normal tissue of the thyroid enhancing.

But if you compare this enhancing component of the thyroid to the part of the tumor there, you can see that washout started to happen in the thyroid.

Now of note, we don't have that much expertise and characterization of thyroid malignancies with contrast ultrasound.

So we are evaluating this as we speak in the process.

We have few researchers going on addressing this issue and maybe in the near future we are gonna have enough data to be able to characterize this.

But on the other hand, when you see something like that and you see that this mass is going and growing into the IJV, this is an alarming sign of direct invasion which really would have its impact on the surgical planning treatment and maybe prognosis in these patients.

So this was a thyroid carcinoma proven by biopsy invading the right internal jugular vein.

So we go again and we emphasize the fact is that every time before you try to attempt biopsying any neck mass on anybody, you have to apply color doppler or power doppler and make sure you use your highest sensitivity settings to make sure there are no vascular components that you may overlook when planning a biopsy.

Again, contrast ultrasound can help us avoid this without having any pitfalls about the color doppler power doppler settings.

You inject the contrast, you look at the mass, you see if it's avidly vascular.

So you can say there's no need to biopsy.

And this is a good example here if you this is young female who presented with a mass in her neck long standing and the referring physician requested us to biopsy it.

So prior to the biopsy we look at the mass of course with ultrasound with gray scale and color and you can see this is the right side of the neck.

And this is a video clip from the bifurcation of the carotid and you can see that there's a splaying of the anterior of the external and internal carotid arteries.

But we look at the mass bicolor doppler is still some vascularity but it's not that avid at the time.

So we thought well this may be not a carotid body tumor, maybe some other etiologies.

So to be on the safe side, we don't want biopsy carotid body tumor at this point.

If that's the case, we decided to go ahead and inject some contrast to characterize it and look at this, see the same splaying of the carotids after the bifurcation and this mass is really really avidly enhancing with bubbles.

So we decided there's no need to biopsy this patient, this patient is better off to go directly for surgical resection.

Now the thing is could can you biopsy these lesions?

Absolutely you could only if the patient underwent some procedure like embolization to measure blood supply to the mass to avoid the bleeding if the patient is not a candidate for surgery or there are other limitations to the surgery.

But in this instance, this patient was relatively young and we decided to opt out of the biopsy and accordingly we proceeded.

This is the same patient in a different plane and the sagittal plane and you can see how there is a major artery here, there is feeding this mass between splayed external and internal carotid art.

This is nice example that you can also use as a teaching point is you can always use something called tissue or hybrid mode depending on the manufacturer where you can see the gray scale overlaid on top of the contrast ultrasound to exactly identify the regions of anatomy you are studying.

Trauma

Alright, we're gonna move on to trauma.

Now the thing is I need to emphasize the fact that you should not use this as the first line of evaluating trauma patients because you'll never know what other injuries the patient may have due to trauma.

And also we know that for sure that ultrasound is limited by the field of view.

Ultrasound is not a great tool to evaluate for bowel injuries and other small vascular injuries.

So I understand that you can use it in the ER as a fast scan to look for early important size of bleed or solid organ injuries.

But the point here is we do contrast.

We do not do contrast ultrasound at the time of presentation.

We do contrast ultrasound on these patients as a follow up.

What do I mean by follow up?

We like to follow up these patients for potential pseudo aneurysms in the at the site of either liver or spleen lacerations so that we can embolize them before the patients are sent out.

Most of the cases we perform are while the patients has been in the hospital for trauma for at least three to five days.

We look at the size of laceration, make sure there are no pseudo aneurysms before they get discharged.

So I'm gonna show an example here of a patient who had trauma and you can see he has a really good laceration to the spleen per splenic hematoma there.

And I like to use a fusion ultrasound because it's the only way I can tell I am in the exact location of the laceration because if you feel confident, you'll be able to identify the exact location with ultrasound you can do it, but I feel more comfortable sending the patients out home and be discharged if I use the fusion because I know I'm gonna be at the exact location of where the spleen neck injury was and look for potential pseudo aneurysms.

And you can see here with color doppler you don't see anything really out of the ordinary, but that may not be good for small pseudo aneurysms.

So we proceeded with contrast ultrasound.

I like to use my target points with this from the software that comes with the fusion kit on my system and look the area of laceration.

And you can see how beautiful that you only see the area of the laceration in the spleen and the intraparenchymal hematoma without evidence of pseudo aneurysms.

And you can sweep through the spleen, look at other areas like these tiny, small areas for potential pseudo aneurysms.

But our main focus is in the major area of the big laceration to exclude that possibility.

And while this we find this to be a good tool to stratify these patients and send them home, specifically young patients, we avoid exposing them to radiation or x-ray radiation they don't need.

So they can be closely followed up with contrast ultrasound if needed.

So we move on to another example of trauma.

So this middle aged woman reporting a history of fall a day earlier presenting to the ER with severe flank pain.

And this is the ultrasound that was performed at the time showing there is perinephric fluid here with some complexity.

But the thing is if you look at the gray scale by itself, you know the image is too fuzzy because of the patient's size and because of the bleed around the kidney and it's hard to figure out what is the source of this bleed.

So we proceeded with contrast ultrasound and this contrast ultrasound shows beautifully how when the contrast hits the kidney gives you a nice characterization of the volume of the size of the perinephric hematoma.

And also in this instance, if you pay attention good enough, you can see even the site of the laceration in the kidney.

And this is really better depicted on the next video clip here following the injection of the contrast here.

And if you keep looking, there is the site of the laceration in the kidney and that was the site of the injury that resulted in this sizable perinephric hematoma.

Now the patient was hemodynamically stable despite that the patient underwent angiography for embolization to ensure no further bleeding is gonna happen.

All right, so we move on to a young male after rollover accident and you can look at the CT scan again using the fusion technology.

This is really very very useful tool to give you exact localization of the laceration in the liver.

See that echogenic line on the on the spleen on the ultrasound corresponding exactly to that which shape elongated hypo density side of the laceration in the liver.

We inject the contrast And we watch the area of this laceration and you can see there is the area of laceration starting to fill in and showing the same area without evidence of any pseudo aneurysms of concern the patient can be discharged home.

Another example is we following up not only the splenic laceration that this instance of in a trauma patient showing laceration here to the spleen, laceration to the kidney.

And you see that this is few days after the initial scan, the laceration in the kidney, you can barely see it.

This amount of the perinephric hematoma is significantly smaller and the laceration of the spleen, of course you still can see it there, but there's not much really to raise any concerns for pseudo aneurysms or further loss or bleeding.

Incidental and Unusual Findings

Alright, now we're gonna move on for incidental findings on patients like who present with abdominal pain.

Actually this is not incidental finding, but this is unusual finding to what you expect to see when you're scanning patients with abdominal pain.

So this patient is referred by her primary care physician for abdominal pain.

And we look at this and the sonographer came up to me and said that I think there's a mass in the pancreas.

You know this is there really it looks rear on this ultrasound and you can see the pancreas, you can see the mass here on this video clip.

So if I freeze the video clip, you can see this mass here looks like it's impinging on the body of the pancreas area, body tear of the pancreas.

But the thing is, if you look carefully you can see that this is the wall of the stomach and there was concern that maybe this is an exophytic mass arising from the stomach.

So we decided if you look at this video clip here, we gave her some water and we did that scan through filling the stomach with water and obviously the mass is arising from the greater curvature of the stomach.

We decide to do contrast ultrasound on this and again we are using a high frequency probe to look at this mass and you can see if you wait a little bit longer, this mass is really enhancing avidly enhancing with central necrosis over there.

So if this was pancreatic cancer, you have to keep in mind that contrast ultrasound behaves like contrast in CT and MR.

So this should not show much enhancement actually or to non or non enhancement if this was a pancreatic mass.

But we know that this ultrasound image proved the fact that this is arising from the stomach.

It's not a pancreatic mass good for the patient.

So after we did the contrast, we decided to give her more water and repeat another injection with contrast.

You can see the fluid filled the stomach over here, the mass is sitting over there and if you wait a little bit longer you can see the contrast starts to arrive into the mass showing enhancement.

Beautiful enhancement parenchyma. See there's no contrast.

They're gonna pick up in that fluid filling the stomach.

This is the beauty about contrast.

Ultrasound is so good to show you fluid around structures you're evaluating whether it is a hematoma fluid, simple ascites abscess, it'll show you these features because these features or these findings don't pick up contrast or the bubble contrast.

So then as always I tell my residents, go back and look at prior imaging.

So we went back in history three years and we found the mass on a chest CT scan showing partially the mass arising from the stomach.

This was taken out and was proven to be a GIST.

Scrotal Pathology

Alright, now we're gonna go outside of the abdomen and we're gonna explore other venues where contrast ultrasound can be helpful.

Contrast ultrasound can really be helpful in situations where you may think it's not a valid or important establish the diagnosis, but also it can solve problems when situations like the clinical history coincides with the trauma and there's a testicular mass.

I'm gonna look at these examples and share with you some of our experience.

So this is a young 35-year-old with worsening testicular pain, few days after being treated for or he keeps having pain and he came back to the emergency room.

And you can see following the injection, you can see how the testicle is enlarged and heterogeneous by grayscale ultrasound.

But we are comparing the abnormal testicle with the contralateral testicle on the left side.

Look how beautiful this normal testicle is showing enhancement on the other side you can see intense hyperemia surrounding the scrotum with near little to nothing really enhancing that right enlarged testicle.

There's little bit of stuff going in it, but there's not much going here.

So our concerns when we looked at this were most consistent with post infectious infarction.

Unfortunately this testicle was infarcted as evident by absence of blood flow.

If you look at the time intensity curve analysis, this is the normal blood flow to the left testicle, you see it's picking up and it just keeps going, going until the contrast really gets washed out.

But if you look on the other side, there's really not much.

You get this little artifact here and there from little motion of the bubbles, but there's really no enhancement whatsoever.

So this testicle was devascularized at the time of surgery and was consistent with infarction.

Alright, another example of scrotal pathology is we have a 25-year-old male with painless scrotal mass and you can see the testicle is enlarged, the right testicle is enlarged compared to the left on this video clip and it appears heterogeneous, but there's not definitive discrete mass here to show like this is maybe is it inflamed?

It is enlarged because of that.

But the history of the painless nature of the mass raised our concerns for potential neoplasms.

So we decided to go ahead and perform contrast ultrasound on this patient.

And again, this is the normal size left testicle, this is the global enlargement of the right.

And now you can see that this is different from the other case of the global enlargement is this is really really avidly enhancing mass in the right testicle as compared to the enhancement of the left, which appears to come later than the one on the right showing some areas of necrosis.

So our concerns were this is really alarming sign for primary testicular neoplasm and it was the patient was taken to surgery the next day and it was proven to be a primary seminoma.

So in comparison to the prior study we looked at, if you look at the time intensity curves, which are really helpful when you evaluate these abnormalities, is the fact that you can see that the mass on the right side that really replaced the most of the right testicle is showing avid arterial enhancement compared to the adjacent normal testicle.

Again, we really don't know the exact pattern of enhancement in testicular tumors with contrast ultrasound, we are studying this area as well.

But we know for sure from our experience that these tumors really enhance.

Now we cannot still have data enough to distinguish between different subtypes of primary testicular neoplasms, seminoma versus nonseminomatous tumor and that something is a matter of time where people start to investigate these areas to give you this patterns of enhancement based on the pathology.

But again the pattern here may not be as important as our areas in the liver and the kidney because these testicular masses most of the time have to completely come out and be excised.

So we believe that if we only characterize that this is most likely a tumor, we've done our job and that will help establish the diagnosis and get the patients taken care of, have their surgeries operated on and treated and followed up their protocols down the line.

Neck Masses (Continued)

So we move on to another area where we are now studying neck masses with contrast ultrasound.

This is actually a part of the project we are currently doing and hopefully we will come up with the results by the end of this year.

But this is an example of a female who was suspected to have hyperthyroidism the female with PTH and elevated calcium levels.

So ultrasound can be challenging sometime to distinguish between parathyroid adenomas and lymph nodes in the neck at the same expected locations of enlarged parathyroids.

So this is an example of this patient and you can see that there's a hypoechoic mass here behind the thyroid gland, which has what they call the typical polar arterial supply suggestive of parathyroid adenoma.

Now, there's no doubt you could have raised that possibility given the history and establish that in your report based on the gray scale and the color doppler.

But we are trying to find a way that maybe these patients can just go for contrast ultrasound to make this diagnosis.

And we are studying the enhancement patterns of these.

And you can see the parathyroid really enhances avidly as well as the adjacent thyroid.

And this is really difficult to just make your assessment by eyeballing these micro bubbles enhancement patterns due to the very close timing of the arrival time of the contrast.

So for these cases, you really need to look at them frame by frame and do time intensity curves analysis and then maybe use a hybrid component of your soft contrast software to see that which one it really enhances before the other.

So we are looking into this and we are analyzing these enhancement pattern to come to conclusion.

And at the same time, we're trying to compare that to four D CT scan now four D CT scan or the establish itself as a good diagnostic tool for differentiating adenomas from lymph nodes.

However the risk of radiation when you do CT scan, despite the fact that people claim they use low dose CT scan remains a risk for the lifetime risk from this radiation.

And we're trying to minimize the whole purpose of this is we're gonna try to minimize the exposure of our younger population to radiation and minimize the life risk down the line now.

New Advances in Contrast Ultrasound

And the last thing I would like to talk about now is just like what's new therefore contrast ultrasound.

A lot of experimental studies has been done in Asia, in Europe, and we are newcomers to the contrast ultrasound here in the United States for reasons beyond the discussion of this topic.

However you can use contrast ultrasound for parametric imaging.

What does that mean? What does mean is you can quantify the amount of bubbles that arrive to the liver and the kidney, for example, to be able to distinguish different disease patterns of hepatitis, alcoholic hepatitis or cirrhotic hepatitis secondary to other causes of cirrhosis.

So this are these areas are also wide open for exploration and research, and hopefully we start to see more and more of this data coming out to help us establish these differentiation in an attempt to minimize the number of course of interventional procedures like biopsies.

Not to mention the risk associated with these biopsies of morbidity, mortality, and longer hospital stays for these patients in case things go wrong.

Conclusion

So in conclusion, I managed to give you an idea where you can explore beyond the liver with the use of contrast ultrasound.

The contrast ultrasound is really a big leap for all of us here in the United States and should be excited about it.

In my book, I think the sky is the limit.

If you see it, you can use it.

But remember as of now, if you want to use anything outside of the liver, you have to be able to explain to the patients that you're using this contrast as off-label.

Explain the benefits risks like any other procedure you perform and make sure it is documented.

The other important thing is that there will be a big change on how we practice sonography here in this country and in the near future.

Sonographers will need to get involved in the process.

Just like CT technologist, MRI technologist, they got involved in the process of understanding the contrast, they're injecting, be part of the injections and monitoring the patients.

All these things will happen, but we need to start earlier than later in the process to educate our sonographers what to expect from them down the line.

Now success depends on how we prepare now and not later.

The other thing is start implementing the use of contrast ultrasound early train your staff, physicians and sonographers so they can be ready to accommodate referrals.

For contrast ultrasound studies, there are now courses across the country where you can go and attend these workshops on how to start contrast practice and how to implement it in your practice.

The other important thing, you need to educate your referrals, your physicians, your clinicians that work in your group about the advantages of contrast ultrasound, how contrast ultrasound can save money, how contrast ultrasound can save your patient population from excess radiation exposure when compared to CT scan.

All these things are very important to help you establish a healthy practice of contrast ultrasound.

And I hope that topic today give you a hint and idea about contrast ultrasound and how to proceed with it now and in the future.

And thank you for your attention.