彌 局 病因：肝炎 、淤膽、淤血 、營(yíng)養(yǎng)不良臨床：代償性、非代償病理：分級(jí)F0-檢 影像學(xué)檢 硬度檢 病理檢KudoM,ZhengRQ,KimSR,etal.Intervirology.2008;51Suppl1:17- 、超聲造影渡越時(shí)肝實(shí)質(zhì)特異顯像Sonazoid(AcousticStructurefication,ASQ)肝硬化的二維超聲表 彩色 超肝靜脈變細(xì)或不均，走形僵硬；局部流速增快或三相 門靜脈增寬門脈高壓時(shí)血流減慢 甚至逆流流速 門脈高壓（敏感性88%，特異性肝動(dòng)脈肝動(dòng)脈/門靜脈流速 門脈高壓（敏感性78%，特異性側(cè)枝循環(huán)形成，副臍靜脈開放、 、超聲造影渡越時(shí)肝實(shí)質(zhì)特異顯像Sonazoid(AcousticStructurefication,ASQ) 剪切波--Shear低頻震蕩波在肝組織中，通過(guò)探頭上的脈沖回波接受器波在組織中的，并測(cè)量速度。彈性波的速度越快，表明被檢 優(yōu)不123對(duì)F2-4之間的肝纖維化辨別4約1/5病例的測(cè)量值無(wú)法解軟>變形程度大硬>(壓③藍(lán)色③藍(lán)色領(lǐng)ROI內(nèi)相對(duì)ROI內(nèi)相對(duì)ROI內(nèi)相対閾值以下的像的比平均標(biāo)準(zhǔn)偏差值以下的像ROI內(nèi)的總像變形2值化藍(lán)色領(lǐng)域的周長(zhǎng)面積進(jìn)行計(jì)⑦對(duì)比⑥峰平均值的乖離4次中⑤偏3次中心變形數(shù)據(jù)變形數(shù)據(jù)分布無(wú)機(jī)與數(shù)據(jù)整體的關(guān)?相關(guān)病理分級(jí) 國(guó)立病院機(jī)構(gòu)南和歌山醫(yī)療センタ 藤本研治先肝硬度測(cè)值Intervirology.2010,53:76-AcousticRadiationForceImaging,探頭短時(shí)間內(nèi)發(fā)射高能脈沖波，使組織發(fā)生局 MirrenFR,etal.Radiology,2009,252(2):595-Stage StageARFIisARFIisapromisingmethodforassessingliver?brosisinchronicviralwithdiagnosticaccuracycomparabletothatofTEinthispreliminaryMirrenFR,etal.Radiology,2009,252(2):595-ShearWave cs Shearwavepropagationspeedrelatesdirectlytotheelasticityvalueoftissue(Young’sTissueelasticitycanbemeasuredinStanislasPol,etal.Non-InvasiveStagingofLiverFibrosiswithShearWave?ElastographyImaging.SWEvsc.F0-3vsF4b.F0-2vsF3-4c.F0-3vsF4b.F0-2vsF3-4a.F0-1vsF2-4SWEvs ThresholdStanislasPol,etal.Non-InvasiveStagingofJieZENG,GuangJianLIU,RongQinZHENG,MingDeToevaluatethediagnosticperformanceofSWEforstagingofhepaticfibrosisinpatientswithchronichepatitisBinfection.May2011-Nov2012,306patientswithExclusion<18yearsother infectionorbiopsysamples<15mmor<6portalascitesorcoagulationhepatocellulartransplantedhistoryofinterferonInvestigatorsandRadiologistswithoutanyinformationofthepatientsAtleast3months’experienceinSWEAixplorerultrasoundsystem icImagineS.A.)Convexbroadbandprobe(SC6-1,1-6MHz)SWE3daysbeforeorafterliverInter-costalsectionoftheright area(4.3×3.3cm,1cmdeeperthanGlisson’scapsule),ROI(3×3cm)5SWEimageseachAverageelasticity 3to5minperLiverBiopsyand USguidance,16GTemnoorMenghiniF0--noF1--portalfibrosiswithoutsepta;F2--portalfibrosisandfewsepta;F4-- Kruskal-Wallis’one-way ysis:SWEandMETAVIRROCcurves:overallaccuracyofOptimalcutoffComparisonbetweentheindexcohort(thefirst204patients)andthevalidationcohort(thelast102patients)P<0.05,two-sided;SPSS13.0(SPSS,Chicago,IL,CharacteristicsofIndex(n=(n=PAge,36.237.3Male,n81BMI,22.832.0[25.0-31.0[24.0-43.5[26.0-43.0[27.0-TBIL,14.4[10.8-14.8[10.9-ALB,42.6183.5198.999.5100.737175630482525133817Mean±SD;Mean[IQR];P<0.05,significant ElasticityincreasedwithincreasingofSWEmeasurementsofliverEachfibrosisEachfibrosisstagehadsignificantlyhighervaluesthanthoselessCorrelationbetweenSWEvaluesandfibrosis:?F0vsF1;?F1vsF2;§F2vsF3;?F3vsPerformanceofSWEforStagingLiverFibrosisinPatientswithHBVF0-1vsF2-AUROC

F0-2vsF3-AUROC

F0-3vsAUROCPerformanceofSWEforStagingLiverFibrosisinPatientswithHBVTheTheaccuracyofSWEindetectingstageF2orstageF3orhigher,andF4diseasewereallValidityofDiagnosticDiagnosticcutpointsforSWEappliedtothevalidation7.5kPafor≥F2;9.2kPafor≥F3;11.3kPaforNosignificantdifferencebetweenindexandvalidationSWEandSWEforSWEforeachstagesignificantlybetterthanAUROCforSWEand0.91and0.66forstage0.93and0.69forstage0.96and0.80forstage

allAdvantageofSWEintegratedintoaconventionalUSUSguidance,LargerHighsuccessOver300patients,SWEfailedin4TEunsuccessfulandunreliableSWEeasy,wideavailabilityandhighsuccess*SirliR,etal.EurJRadiol2013,PerformanceofGoodresultsinHCV(AUROCfor≥F2,≥F3andF4allgreaterthanInthepresentstudy,HBVpatientsAUROCallover0.90inbothcohortsSWEaccurateandreliableforassessingliverfibrosisinHBVpatients*BavuE,etal.UltrasoundMedBiol2011;37:1361-*FerraioliG,etal.Hepatology2012;56:2125-TE:cut-offvalueswiderangesandoverlapsindifferentstudies*SWE:cut-offvaluesgoodHCV[7.1kPafor≥F2,8.7kPafor≥F3and10.4kPaforF4]*HBV[7.5kPafor≥F2,9.2kPafor≥F3and11.3kPaforF4]HBVliversslightlyharderthanHCV*TsochatzisEA,etal.JHepatol2011;54:650-*FerraioliG,etal.Hepatology2012;56:2125-APRIconsistsofobjectiveandreadilyavailablelaboratoryvalues:simple,noninvasiveindexSWEsignificantlybetterthanAPRI gnosingeachstageoffibrosis.BaselineUSfeatures:coarseechopatternofliverparenchyma,irregularornodularliversurfaceandbluntliveredgeThecomprehensivediagnosiscanbebasedonstandardultrasoundandelastography.USandSWE:usefulandeconomicalmethodforassessingliverfibrosis.LiverbiopsyasthereferenceAccuracymaybequestionableduetosampleobserverNotexcludingtheinfluenceoftransaminaselevelsHigherlevelsofALTassociatedwithhigherdiscrepanciesinliverstiffnessinpatientswithHBV.*BedossaP,etal.Hepatology2003;38:1449-FungJ,etal.AmJGastroenterol2011;106:492-SWEisanaccurateandvalidwaytostageliverfibrosisinpatientswithHBV. 、超聲造影渡越時(shí)肝實(shí)質(zhì)特異顯像Sonazoid(AcousticStructurefication,ASQ)Contrast-enhancedContrast-enhancedHepaticveintransmit肝硬化肝靜脈到達(dá)時(shí)間提早(平均肝硬化肝靜脈峰值時(shí)間提早(平均峰值強(qiáng)度增高(平均48.7以到達(dá)時(shí)間早于 肝硬化(100%)andspecificityAlbrechtT,etal.Lancet.1999;353:1579-Microflowimaging 成像（最大強(qiáng)度保持技術(shù)+閃爍再灌注成像 High-MI

BlackLow-MI

Burst Realtime

Burstscan

#of MFI評(píng)估肝內(nèi)血管形態(tài)改變對(duì)肝纖維化 vs.F2-F1-2vs.F3-F1-3vs.

SugimotoK,etal.EurRadiol.2010;20:2749-ParametricMFI到達(dá)時(shí)間成CEUSusingF1F1腎肝腎肝CurtseytoMr.YanoNormalParametricMFI到達(dá)時(shí)間成NormalCurtseytoMr.YanoParametricMFI對(duì)HCV肝纖維化的評(píng)Sonazoid

NoritakaWakui,etal.JUltrasoundMed2012;ParametricMFI對(duì)HCV肝纖維化的評(píng)肝肝纖維化加重紅色比例顯著增(F1vsF2;F1vsF3;F1vsF4;F2vsNoritakaWakui,etal.JUltrasoundMed2012;Liverfibrosis

0

Accuulation-liverAccmulation-RC

AccumulationAccumulaon-

0

0

SMI(SuperbMicrovascularImaging)ToshibaInnovationAdvancedDynamicFlow 高分辨HighDensityBeamForme 高密度波束形成RealtimeApplicationplatform 高速處ADF&ADF&性 SMI技術(shù)性能特點(diǎn)

Frame VelocitySMI具有兩種成像模式monochromecolorcSMImSMI:c mSMI屬性、性的成像技清晰呈現(xiàn)微小血管的極低速血流信高幀頻、無(wú)運(yùn)動(dòng)顯示普通彩色無(wú)法顯示的極低速血信好處、提高了的準(zhǔn)確減少了不必要的造影劑使データご提 東邦大學(xué)醫(yī)療センター大森病院 先Liverspecificphase(Kupffer醫(yī)生博 0%47%99%99%0%47%99%YanagisawaK,etal.UltrasoundMedBiol.2007;33:318- 獲獲得最佳的超聲傳導(dǎo)和直接觀 游離微泡自由懸與Kupffer細(xì)胞無(wú)接黏附微泡貼附于Kupffer細(xì)胞表吞噬微泡位于Kupffer細(xì)胞靜止::移動(dòng):快 壓縮:破裂:USUS微泡表游離微 聲壓黏附微聲壓吞噬聲壓靜0.170.31移0.31-0.31壓0.35-0.40-0.40-破0.40-0.40-0.52- 氣體:過(guò)氟丁烷外殼直徑2.4-濃度YanagisawaK.UltrasoundMedBiol.2007;33:318-WatanabeR.InvestRadiol聲MI: MI: 50-200破裂>200頻 頻FR:15HzvsFR:15Hzvs1MI=0.21-0.44MI=0.21-0.44是使游離微泡發(fā)適合用于連續(xù)成MI=0.44-0.75時(shí)移動(dòng)明顯，可能細(xì)胞接觸的機(jī)會(huì)，有助于Kupffer細(xì)胞吸附和吞噬微MI>1.03時(shí)導(dǎo)致微泡破裂，該條件可在間歇成像時(shí)使運(yùn)動(dòng)方式：靜止 、移形態(tài)改變：壓縮、破 線陣探頭(PLT(肝臟形態(tài);門靜脈、肝靜脈及肝動(dòng)脈血流信息;脾臟大小;腹兩種造影劑CEUS肝、脾實(shí)質(zhì)增強(qiáng)表現(xiàn)的觀 Sonazoid-CEUS肝、脾實(shí)質(zhì)增強(qiáng)水平的定量測(cè)TIC曲線繪定定量測(cè)量示意正常肝臟組 正常肝臟組肝纖維化組 肝纖維化組

肝硬化組肝硬化組肝纖維化/硬化標(biāo)準(zhǔn)

肝纖維化/硬

彩彩 數(shù)CEUS血管

纖

硬化肝

纖維化

硬化肝

正常肝 纖維化肝硬化肝KupfferKupffer期：300肉眼脾臟增強(qiáng)均勻，水平與肝臟相仿或略高于肝SonoVue-CEUSSonoVue-CEUS此期基本無(wú)增Sonazoid-CEUSKupffer Sonazoid-CEUSKupffer正常肝纖維化肝硬化肝Kupffer期高級(jí)動(dòng)態(tài)血流成肝硬化 肝實(shí)質(zhì)增強(qiáng)水平明顯低于脾KupfferKupffer期肝實(shí)質(zhì)肝實(shí)質(zhì)增強(qiáng)水平明顯降低且顯著低于脾臟視為肝纖維化/硬Sonazoid-Sonazoid-預(yù)測(cè)值常規(guī)超預(yù)測(cè)值P=0.017,Fisher’sexactG1vsG2vsG1vsG1G1G2：G3：Sonazoid-CEUSSonazoid-CEUSKupffer期脾臟增強(qiáng)Sonazoid-CEUSSonazoid-CEUSKupffer期肝臟、脾臟增強(qiáng)水平的差G1vsG2G2vsG3G1vsG3G1：G2：G3： 肝纖維化和肝硬Levovist-CEUS肝增強(qiáng)顯像達(dá)30分鐘，與微泡被Kupffer細(xì)胞吞噬有大鼠的Sonazoid-CEUS證明Kupffer細(xì)胞吞噬微泡造成肝臟特本研究中SonoVue-CEUS5分鐘時(shí)肝實(shí)質(zhì)增強(qiáng)基而Sonazoid-CEUS10分鐘仍顯示肝臟均勻增Sonazoid-CEUSKupffer0Sonazoid 300血 肝 脾 肝脾Kupffer期肝實(shí)質(zhì)增強(qiáng)水平取決于Kupffer細(xì)胞吞噬或吸附的微泡數(shù)但CEUS仍無(wú)法區(qū)分肝纖維化與肝直觀顯示目 定量分析能顯示Kupffer期正常肝、纖維化肝臟與硬化肝臟實(shí)質(zhì)增強(qiáng)水平的差 不同于測(cè) 信號(hào)強(qiáng)能夠獲取圖像的增益、動(dòng)態(tài)范圍 測(cè)量果成參的較小可為觀反織增情定量分析法是將So-S 臟漫 的趨勢(shì)Sonazoid- 為Sonazoid-為Sonazoid-肝纖維化/硬化的臨床應(yīng)用奠定實(shí)驗(yàn) 、超聲造影渡越時(shí)肝實(shí)質(zhì)特異顯像Sonazoid(AcousticStructurefication,ASQ)組織聲學(xué)結(jié)構(gòu)Acoustic fication, 肝 肝硬化