Diagnostic ultrasound is changing dramatically because of the development of a variety of high resolution real-time scanning instruments. Until recently the standard instrument was the articulated arm contact scanner. Real-time scanners were viewed as adjunct instruments for specific and limited pur poses. The roles are reversing with real-time instruments more frequently accepted as the primary diagnostic tool and the contact scanner becoming the ancillary instrument for use mainly for viewing a large field that cannot be scanned with real-time instruments. Two recent editorials stated that real-time instruments were used as the sole diagnostic instrument for between 80% [Cooperberg (2)] and 98% [Bartrum and Crow (1)] of their abdominal examinations. This book introduces the reader to the field of real-time scanning in the abdomen. It presupposes an understanding of basic physical concepts of ultrasound, the appearance of both normal and pathologic conditions as produced by static articulated arm contact scanning, and a familiarity with the techniques of contact scanning. It is designed to acquaint the reader with the spectrum of real-time instrumentation, provide a basic understanding of the physics of ultrasound as related to these instruments, emphasize the special skills required in the use of this equipment, and describe applications of real-time scanning for various parts of the abdomen. While numerous illustrations of both normal and pathologic anatomy are shown, the book is an all-inclusive study of abdominal pathology as demonstrated by real-time imaging.

Owing to the anatomic complexity of the neck and the diver sity of pathologic entities affecting it, the cervical region has long been of great semiological interest. Physical examination is an easy means of evaluating the size and origin of a solitary cervical mass, yet valid interpretation can prove difficult when the normal morphology of the neck has been altered; excellent examples are patients with extensive fibrosis or scarring secondary to previous irradiation or surgery. Like wise, physical examination cannot assess the relations of a pathologic process to adjacent structures - e. g., invasion can not be distinguished from simple displacement -and it is un suitable for monitoring therapeutic efficacy, such as the re sponse of metastatic nodes to medical management. Between physical examination, which remains fundamental, and exploratory surgical procedures, which are often the only means of obtaining indispensable anatomic proof for diagno sis, lie a number of recent imaging techniques including com puted tomography and magnetic resonance imaging using surface coils that provide invaluable information for the in vestigation of cervical pathologies. Real-time ultrasonogra phy occupies a privileged position because of its noninvasive ness, rapidity, and reliability, especially when performed by a specially trained examiner."

In January 1995, 300 participants from Asia, USA, and Europe lively discussed the "State of the Art and Future Aspects of CT" in Peking, China. The workshop was designed to cover all essential aspects of modern CT imaging including the historical development, different techniques, contrast agents, organ systems, and indications. The comparative evaluation of CT versus MRI and ultrasound was a central topic. Additionally, a special session was dedicated to "Angiography Tomorrow." This book summarizes the state of the art in both conventional and spiral CT imaging and provides some suggestions as for the future role of the method.

3.2 Technique ............. '. . . . . . . 123 3.3 Drainage Catheters: Materials and Selection . 139 3.4 The Loop Catheter . . . . . . . . . . 141 4 Aspiration of Pancreatic Pseudocysts 145 E. Concluding Remarks 149 151 References " Subject Index . 158 VII List of Contributors BURGER, H. R, Dr. med., Oberarzt, Institut fur Pathologie, Univer sitiit Zurich, SchmelzbergstraBe 12, CH-8091 Zurich EINIGHAMMER, H.J., Dipl. Phys., Dr. rer. nat., Neurologische Uni versitatsklinik, MoorenstraBe 5, 0-4000 Dusseldorf HAUKE, R, Dipl., Phys., Dr. rer. nat., Gesellschaft fur Medizin. Techn. Informationssysteme, MarienstraBe 2,0-7910 Neu-Ulm PEmo, G., Professor Dr. med., Leitender Arzt, Abteilung fUr Zytolo gie, Institut fur Pathologie, Universitatsspital, CH-8091 Zurich " ... so it is not good for men to fear all that is not already known and settled, and thus feel that it is bad and harmful to strive for a greater perfection than already exists." Holderlin to his mother, 16. November 1799 A. Introduction 1 General The modem cross-sectional imaging methods of sonography and computed to mography, developed in the early 1970s, have contributed greatly to noninva sive studies of the parenchymatous organs and permit the evaluation of patho logic changes in areas that were previously accessible only to invasive, indirect, or inadequate examination."

Just a very few years after Edler and Hertz had described the clinical use of M-mode echocardiographyl Satomura reported the application of Dop 2 pler ultrasound to the study of cardiac function. Yet Doppler ultrasound has been integrated into diagnostic practice in cardiology much more slowly than conventional (M-mode and two-dimensional) echocardiogra phy. Now, however, tremendous growth in the interest of clinicians in the diagnostic use of Doppler ultrasound can be observed and may in fact be due to the recent advent of color flow imaging. The reason for this growth may be that this method makes it possible to directly visualize the blood flow in the cardiovascular system in cross-sectional views. Moreover, the results are reproducible and much easier to understand than the older mapping techniques using a single-gate Doppler. In its short existence many different names have been used to describe this method, for instance, color Doppler, color flow imaging, real-time two-dimen sional Doppler echocardiography, and Doppler flow imaging. This diver sity reflects the large interest that many researchers have shown in this method. The technical development of color blood flow imaging (CBFI) - as this method will be called in this book - has not yet reached a universally accepted standard of performance in cardiology. Despite this state of flux and the uncertainty about future developments, I think it is justified to dedicate an entire book to this fascinating method."

Any book with the words percutaneous and interventional is immediately identified as one that brings to its readers a distillation of a number of new and exciting techniques. Percutaneous is not exactly a new word but it has come to take on an entirely new meaning in recent years. Interventional is a recent acquisition to medical language indicating an entirely new approach to many aspects of medical management. Exactly when is the right time to make a distillation of new thoughts and expertise requires something of the art of a master brewer. First the ingredients must be prepared, the recipe must be just right, there must be excellent quality control as well as the master brewer's touch to produce the product when the time is right. Dr. Lang has assembled just the right ingredients in the form of a very impressive team of experts in these new fields of uroradiology and urological management. Ventures into percutaneous urology may date back 30 years but the main growth in the range of procedures and the development of the technology has occurred only in the last 10 years. Relieving upper tract obstruction seemed a natural sequel to renal biopsy but the imagination to develop an effective treatment for stones was an impressive extension of the concept of minimally invasive surgery.

For the fourth English edition, this highly popular book has been thoroughly revised and updated to include such new sections as endoscopic digestive US and abnormalities related to AIDS. It is the only work available covering the diagnostic US of the whole abdomen, and its superb treatment of elementary symptoms enables beginners to become familiar with more complicated features. After an extensive technical introduction, the book covers the sonoanatomy and ultrasonic symptomatology of the diseases of the digestive system and the abdominal vessels. Numerous tips on avoiding pitfalls, as well as indications for other procedures, and backed by some 1000 illustrations, this is well on its way to becoming a standard text for practitioners and clinicians in the field.

Sonography is an ideal real-time imaging technique for the evaluation of muscles and tendons of the extremities, and this book is a useful reference for both the technique of examination and normal ultrasound anatomy. The first part considers technical aspects of the examination such as sonographic equipment, water-path systems, and dynamic maneuvers. The basic sonographic patterns of normal muscles, tendons, and other components of the extremities are then presented. Emphasis has been placed on pitfalls and artifacts. The other available imaging techniques for muscles and tendons are also discussed. The second part comprises an atlas of normal ultrasound scans of shoulder, arm, elbow, forearm, wrist, hand, thigh, knee, leg, ankle, and foot, with accompanying explanatory line drawings.

by Dr. Jan. J. Smulewicz Ultrasound imaging has reached a stage of sophistication where by diagnostic information can be gained without discomfort to the patient and with complete absence of morbidity and mortality. The procedure is quick, safe, noninvasive and in many instances can supersede and obviate more time-consuming procedures requiring catheterization, injection of a contrast material, and radiographic imaging. In obstetrical problems the danger of ionizing radiation to the fetus is eliminated. In debilitated and very ill patients this simple and painless method becomes the procedure of choice. Unique features of ultrasound equipment allow for pinpoint local ization oflesions and direct visual guidance of percutaneous puncture techniques for aspiration and biopsy. The accuracy of ultrasound guided punctures and the absence of side effects make this modality far superior to percutaneous invasive techniques performed with other imaging systems. Renal cyst puncture and amniocentesis are but two of the procedures in which ultrasonic guidance is the method of choice. v Dr. Hassani has throughly explained and carefully explored the wide variety of exam inations available with ultrasound. The large volume of material and the clear interpre- tion makes this book of great interest to all of the medical profession. In addition to the existing methods available for diagnostic in terpretations, this method of noninvasive diagnosis should find its way into every hospital or center where good medical care is provided. JanJ. Smulewicz, M.D."

Intrauterine Growth Restriction: Aetiology and Management will be the first book to focus exclusively on this extremely important and common complication of pregnancy. There have been many recent developments in our understanding of the aetiology and pathogenesis of the condition as well as in screening, monitoring and therapy. This book is unique in that it covers both the aetiology and pathogenesis as well as clinical management and also includes sections on definitions and potential future advances. Every aspect is covered by an international expert which will provide the reader with a valuable insight into this condition.

Cardiac ultrasound has rapidly developed into one of the most important clinical methods for diagnosis and follow-up of patients with heart disease and has changed the practice of cardiology permanently. In addition to improving image quality, most of the progress relies on digital image acquisition, storage, and quantitative analysis equipment. Automatic endocardial detection and three- dimensional reconstruction are now being developed. The progress with contrast echocardiography for myocardial perfusion imaging and results with tissue characterization is slow, but ever increasing, illustrating that the full potential of the method has not yet been explored. All of these digital techniques are extensively dealt with in this volume. Computerized tools will help the clinical cardiologists in their daily practice and stimulate further development to gen- uinely improve patient care in the coming years. We wish to thank the authors to this volume for their excellent contribution and Mrs. T. van der Kolk for secretarial assistance. IX Contributors F. J. ten Cate Thorax Center, Erasmus University, P. O. Box 1738, 3000 DR Rotterdam, The Netherlands R. Erbel II Medical Clinic, Johannes Gutenberg University, Langenbeckstr. 1, P. O. Box 3960, D-6500 Mainz, FRG Co-authors: R. Zotz, B. Henkel, G. Schreiner, C. Steuernagel, R. Zahn, H. Kopp, W. Clas, R. Brennecke, P. Schweizer, J. Meyer S. B. Feinstein Division of Cardiology, Box 44, University of Chicago, 950 East 59th Street, Chicago, IL 60637, USA D. G. Gibson Department of Cardiology, Brompton Hospital, Fulham Road, London SW3 6HP, UK Co-author: R. B. Logan Sinclair E.

New developments in the field of high resolution imaging focus on functional parameters pertaining to disease-specific medical imaging. Such new diagnostic strategies are possible using scintigraphic techniques and, more recently, by MRI and US. In addition, new therapeutic concepts, including gene therapy, require specific tracers or contrast media for therapy monitoring, for example, enzyme activity and changes in receptor expression. For this purpose scientists conducting basic research, expecially molecular biologists, and clinicians must collaborate in order to exploit the available interdisciplinary knowledge in the development of new imaging technologies so as to incorporate the molecular signals of diseases.

The aim of this work was not an exhaustive review of all pediatric echo graphic problems but a presentation of our daily experience with ultrasonography in pediatric practice. Several teams of pediatric radiologists from France and Belgium have combined their experiences to produce a practical book. The different authors have been chosen for their specific experience and their special area of work. The different chapters express therefore personal opinions. Unresolved questions are posed and ultrasonographic examinations are used in the diagnosis of different diseases, while the discoveries and ideas of the individual authors are described. Some fields are not included, such as echocardiography. Gabriel Kalifa Contents Chapter 1. Antenatal Diagnosis by Ultrasonography . . . . . . . . . . . . . . 1 . . . Introduction ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 Ultrasonography of a Normal Pregnancy ...................... 1 2.1 Timing of Successive Examinations. . . . . . . . . . . . . . . . . . . . . . . 1 2.2 Normal Fetal Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2.2.1 Central Nervous System .......................... 3 2.2.2 Chest........................................... 3 2.2.3 Abdomen....................................... 3 2.2.4 Skeletal System . . . . . . . . . . . . . . . . . . . . . . . . 3 . . . . . . . . . .

The history of the use of ultrasound in medicine has been one of evolution of technology and innovative methods of applying this technology to imaging body structures. Many scientists and clinicians have contributed to this evolution. Ophthalmic ultrasound has become an indispensible tool in ophthalmic practice, with its own instrumentation and techniques. Ultrasound frequencies used in ophthalmology have generally been higher than those used in general medicine because of a requirement for higher resolution and a lesser need for deep penetration. Most ophthalmic diagnostic equipment uses frequencies in the 10 MHz range. The use of ultrasound frequencies in the 50-100 MHz range is a relatively new development in ultrasound imaging of the eye. This technique has been developed in our laboratories over the past several years. We have progressed from the theoretical description of the basic science required, past the first in-vitro experiments in eye bank eyes, to the construction of an instrument capable of clinical application. We have gained broad clinical experience with this instrument in normal patients and patients with ocular disease. A commercial instrument based on our original clinical scanner has recently become available, allowing other clinicians to apply this tool to ophthalmic research and clinical practice. We have applied the term ultrasound biomicroscopy to this new imaging technique because of similarities to optical biomicroscopy, i. e. , the observation of living tissue at microscopic resolution.

Surgery an essentially manual exercise in its early days, has progressively grown richer in complementary techniques helping the surgeon to perfect his movements and increase efficiency. This is particularly the case with digestive surgery, which has been thoroughly transformed by radiology, endoscopy and extemporaneous examinations effected during surgical intervention. Such methods make it possible for surgeons to develop subtle nuances in operative techniques and to specify indi cations more and more precisely. Ultrasonography must now be included among such techniques. It supplements them and can sometimes even replace them. For these reasons, this work devoted to the use of ultrasound by the surgeon during surgical intervention is of great interest. Two general conditions had to be met before ultrasonography could be em ployed in abdominal surgery: the method and apparatus had to be adapted to its surgical utilization, and the surgeon had to adapt to a nonsurgical technique. The first condition has been fulfilled for all purposes. Intraoperative sonograms can be generated at a very high rate and are proving to be more and more useful. The miniaturization of probes permits their application almost everywhere with opti mal results. Of course, the costs are still high, but one can expect them to decrease.

For doctors and students who wish to learn ultrasonography concisely yet comprehensively. The authors present the subject both systematically and practically, and with the facility of quick reference in mind, making generous use of flow-charts, tables and teaching-points. All general aspects of diagnostic ultrasound are covered, concentrating on those disorders encountered in the daily routine of scanning, but also referring to rarer conditions which need to be considered in differential diagnosis.

Sonography is a noninvasive diagnostic method that has gained an established place in many branches of medicine. Although the inability of ultrasound to penetrate bone delayed its application in the orthopedic field, the successful work of R. Graf in the early detection of pediatric hip disorders with ultra sound has served as an impetus for the increasing use of sonogra phy to detect and evaluate abnormalities of the musculoskeletal system. It is certain that further advances in this modality will be forth coming, and that sonography will be applied to new lines of inves tigation in orthopedic diagnosis. In Arthrosonography the authors use concise text and copious illustrations to demonstrate the potential applications of articular ultrasound, its diagnostic capabilities, and technical aspects of the ultrasound examination. Potential pitfalls are also explained. This book is the logical outcome of the application of diagnos tic ultrasound in orthopedics and rheumatology. It covers all basic practical aspects of arthrosonography and will be a valued re source for those concerned with the evaluation of the musculo skeletal system. HANS RETTIG Contents Introduction . . . . . . . . . . . . . 1 The Piezoelectric Effect - The Basis of Modem Sonography . . . . . . 1 Ultrasound Techniques. . . . . . . . . . . 1 General Principles of Diagnostic Ultrasound 2 Landmarks for Arthrosonography 6 Artifacts ........ . 6 Reverberations . . . . . 7 Hyperbolic Artifacts . . 7 Acoustic Mirror Image . 8 Special Phenomena in Arthrosonography 8 "Wandering Echo" Phenomenon . ."

Acoustical imaging has become an indispensable tool in a variety of fields. Since its introduction, the applications have grown and cover a variety of techniques, producing significant results in fields as disparate as medicine and seismology. Cutting-edge trends continue to be discussed worldwide.

This book contains the proceedings of the 27th International Symposium on Acoustical Imaging (AI27), which took place in Saarbrucken, Germany, from March 24th to March 27th 2003. The Symposium belongs to a conference series in existence since 1968. AI27 comprised sessions on:

• Medical Imaging,
• Non-Destructive Testing,
• Seismic Imaging,
• Physics and Mathematics of Acoustical Imaging,
• Acoustic Microscopy.

During two well-attended workshops the applications of quantitative acoustical imaging in biology and medical applications, and in near-field imaging of materials, were discussed. Based on its cross-disciplinary aspects, the authors of the papers of AI27 present experiments, theory and construction of new instruments.

Audience: This volume will be of interest to engineers and researchers of all levels in the field, in industry or academia, and for those newcomers who want to get acquainted with the state-of-the-art in acoustical imaging. "

Medical imaging has been transformed over the past 30 years by the advent of computerized tomography (CT), magnetic resonance imaging (MRI), and various advances in x-ray and ultrasonic techniques. An enabling force behind this progress has been the (so far) exponentially increasing power of computers, which has made it practical to explore fundamentally new approaches. In particular, what our group terms "model-based" modalities-which produce tissue property images from data using nonlinear, iterative numerical modeling techniques-have become increasingly feasible.

Alternative Breast Imaging: Four Model-Based Approaches explores our research on four such modalities, particularly with regard to imaging of the breast: (1) MR elastography (MRE), (2) electrical impedance spectroscopy (EIS), (3) microwave imaging spectroscopy (MIS), and (4) near infrared spectroscopic imaging (NIS). Chapter 1 introduces the present state of breast imaging and discusses how our alternative modalities can contribute to the field. Chapter 2 looks at the computational common ground shared by all four modalities. Chapters 2 through 10 are devoted to the four modalities, with each modality being discussed first in a theory chapter and then in an implementation-and-results chapter. The eleventh and final chapter discusses statistical methods for image analysis in the context of these four alternative imaging modalities.

Imaging for the detection of breast cancer is a particularly interesting and relevant application of the four imaging modalities discussed in this book. Breast cancer is an extremely common health problem for women; the National Cancer Institute estimates that one in eight US women will develop breast cancer at least once in her lifetime. Yet the efficacy of the standard (and notoriously uncomfortable) early-detection test, the x-ray mammogram, has been disputed of late, especially for younger women. Conditions are thus ripe for the development of affordable techniques that replace or complement mammography. The breast is both anatomically accessible and small enough that the computing power required to model it, is affordable.

This book provides a comprehensive reference and practical guide on the application of US to penile diseases and conditions. After introductory chapters on technical requirements and penile anatomy, subsequent chapters offer a systematic overview of the diverse applications of color Doppler US. The topics covered include erectile dysfunction, Peyronie's disease, priapism, trauma, tumors, the postoperative penis, inflammation, and fibrosis. Each topic is introduced by a clinical overview with the purpose of clarifying the problems and elucidating what the urologist may expect from color Doppler US. Thereafter, performance of the US study is explained and the pathological anatomy reviewed. High-quality images obtained with high-end US equipment are included. Each chapter also contains a section on the diagnostic information provided by other imaging modalities, and in particular MRI.

Since the first edition of this book, sonography of the peripheral nervous system has evolved further. This second, revised edition includes many state-of-the-art high-resolution images, the text has been adapted to reflect the current state of the literature, and information is presented using a more modern layout. This book provides a practical, clinically oriented overview of all aspects of sonographic diagnosis and interventional therapy of the peripheral nervous system.

Since 1968, the International Acoustical Imaging Symposium has provided a unique forum for advanced research, promoting the sharing of technology, developments, methods and theory among all areas of acoustics. Volume 28 of the Proceedings offers an excellent collection of papers presented in six major categories, offering both a broad perspective on the state of the art in the field as well as an in-depth look at its leading edge research.

"Duplex Sonography" is the first comprehensive text written about this modality. The book offers the reader detailed information about all major uses of duplex and is introduced by a brief chapter on the physical principles of doppler ultrasound as it relates to duplex scanning. "Duplex " "Sonography" is intended to provide relevant information on all aspects of the technique, ranging from the basics of performing the examination to the features of sometimes complex pathological states. The book is intended for anyone interested in non-invasive vascular diagnosis including radiologists, vascular surgeons and ultrasound/peripheral vascular technologists. Other groups may find individual chapters appealing: carotid/cardiac sonography for cardiologists, fetal sonography for obstetricians or carotid sonography for neurologists. Each chapter is not only a guide to duplex evaluation, but also provides valuable information about vascular dynamics of the organ system under discussion. Physicians or technologists reading this book should come away with a well-rounded background in state-of-the-art duplex sonography and will undoubtedly discover new possibilities for using this non-invasive vascular technique.

Today, coronary artery disease is one of the major causes of mortality and morbidity in the Western World. In the last decade many major diagnostic and therapeutic advances have been made, considerably furthering our potential in the management of coronary artery disease. At the same time, a new generation of cardiac tools has appeared. The field which has, perhaps, undergone the most important technological innovations is echocardiography. Nowadays, in fact, the world of ultrasounds ofters the cardiologist a wide range of technical applicatons: two-dimensional real-time imaging, intra-and extra-cardiac Doppler flow measurements, real-time imaging of cardiac struc ture and flow by 2D color Doppler, high resolution cardiac imaging by transesophageal echocardiography, tissue characterization by analysis of ultrasound wave characteristics, information on myocardial perfusion by con trast echocardiography, etc. Thanks to these technical improvements and to its consequent increased potentiality, echocardiography now plays an impor tant and irreplaceable role in the management of all cardiac diseases. In the field of coronary artery disease, echocardiography can reliably be used not only in the acute phases of the disease to derive useful functional and prog nostic information but also as a stress diagnostic procedure (thanks to new stress modalities and the continuing improvement of reviewing digital sys tems) for the diagnosis of coronary artery disease and for the evaluation of various therapeutic interventions. Furthermore, other promising applications of ultrasounds in this disease are currently being investigated: tissue charac coronary artery anatomy terization, myocardial contrast echocardiography, and flow evaluation by specially-designed ultrasound catheters."