Cerebellar tomographic attenuation of healthy felines

The cerebellum is responsible for coordination and maintenance of the fine control of muscle contraction. In cases of a suspected cerebellar disorder, a computed tomography scan can be performed to identify structural change. The aim of this study is to describe the cerebellar tomographic attenuation values in healthy cats since this variable is considered of great importance in the evaluation of images obtained by this imaging modality. A simple and a contrast enhanced brain computed tomographic scan were performed in 15 adult cats with no history of neurological symptoms and negative for feline leukemia and immunodeficiency virus. After acquiring the image, the measurement of the average attenuation of a cerebellar area of 2 centimeters in diameter was obtained. The cerebellar tomographic attenuation showed a variation from 14.60 to 25.50 HU in the simple scan and from 25.50 to 33.40 HU in the enhanced phase. Most animals (73.33%) had precontrast cerebellar attenuation values within the stipulated limit for the brain in a previous study (20-41 HU). Four animals in this study (26.67%) had values lower than 20 HU, which can be explained by differences in cellular composition between these two regions. The average value of contrast enhancement was 4.91 HU, and in none of the animals an enhancement greater than 10 HU was observed, which is in agreement with previous studies.

Elastografia acoustic radiation force impulse (ARFI), doppler e ultrassonografia contrastada do baço canino

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Ultrassonografia modo B de alta resolução modo Doppler e uso de contraste de microbolhas na avaliação testicular de gatos domésticos

Pós-graduação em Medicina Veterinária - FCAV

Computed tomographic dacryocystography in children undergoing balloon dacryoplasty

PURPOSE To ascertain whether the volume and circumference of the lacrimal sac and nasolacrimal duct as measured by contrast-enhanced computed tomographic dacryocystography (CT-DCG) before and after balloon dacryoplasty could be used to predict clinical success in children with congenital nasolacrimal obstruction. METHODS Nasolacrimal ducts of children aged 2 to 6 years with clinical signs of congenital nasolacrimal duct obstruction undergoing balloon dilation were imaged with contrast-enhanced CT-DCG before and 5 minutes after the procedure. The circumference of the most dilated portion of the lacrimal sac was measured on the axial plane. The volume of contrast within the nasolacrimal duct and sac was also measured before and after the procedure. Clinical success was defined as the disappearance of signs of epiphora. RESULTS A total of 18 nasolacrimal ducts of 13 children were included. The average circumference of the most dilated portion of the lacrimal sac was 1.30 +/- 0.45 cm (range, 0.64-2.50 cm) before the procedure. The average contrast volume was 0.12 +/- 0.08 cm(3) (range, 0.01-0.38 cm(3)) before and 0.07 +/- 0.06 cm(3) (range, 0.01-0.20 cm(3)) after (P = 0.01). Data were analyzed using multivariate logistic regression with a backward variable input model; a decrease in contrast volume before and after dilation (P = 0.04) was associated with clinical success, whereas the larger size of the most dilated portion of the lacrimal sac (P = 0.01) was associated with clinical failure. CONCLUSIONS Contrast-enhanced CT-DCG provides useful information about nasolacrimal anatomy in children with congenital nasolacrimal duct obstruction. The decrease in contrast volume before and after balloon dilation was predictive of success; A larger size of the most dilated portion of the lacrimal sac was associated with clinical failure. (J AAPOS 2012;16:464-467)

Left ventricular thrombus attenuation characterization in cardiac computed tomography angiography

BACKGROUND: Because of their similar visual appearance, differentiation of left ventricular thrombotic material and myocardial wall can be difficult in contrast-enhanced coronary computed tomography (CT) angiography. OBJECTIVE: We identified typical thrombi attenuation of left ventricular thrombi with the use of CT measurement. METHODS: Over a time period of 6 years; we retrospectively identified 31 patients who showed a left ventricular thrombus in CT angiography datasets. Patients underwent routine contrast cardiac CT to investigate coronary artery disease. CT attenuation of each thrombus was assessed in the 4-chamber view. CT densities were also determined in the ascending aorta, left ventricle, and myocardial wall both in the mid-septal and mid-lateral segments. The mean CT attenuation of thrombi and the difference between attenuation in thrombi, left ventricular cavity, and myocardial wall were determined. The ratio of attenuation values in thrombus versus aorta and myocardium versus aorta were also determined. RESULTS: Mean (+/- SD) CT attenuation of all left ventricular thrombi in 31 patients was 43.2 +/- 15.3 HU (range, 25-80 HU). Mean CT densities of septal and lateral myocardial wall were 102.9 +/- 23.1 HU (range, 63-155 HU) and 99.3 +/- 28.7 HU (range, 72-191 HU), respectively, and were thus significantly higher than the CT attenuation of thrombi (P < 0.001). A threshold of 65 HU yielded a sensitivity, specificity, and positive and negative predictive values of 94%, 97%, 94%, and 97%, respectively, to differentiate thrombus from the myocardial wall. The mean ratio between CT attenuation of thrombus and CT attenuation within the ascending aorta was 0.11 +/- 0.05 (range, 0.04-0.23), which was significantly lower compared with the mean ratio between CT attenuation of the myocardial wall and the CT attenuation within the ascending aorta. CONCLUSION: CT attenuation within left ventricular thrombi was significantly lower than myocardial attenuation in CT angiography datasets. Assessment of CT attenuation may contribute to the differentiation of thrombi. (C) 2012 Society of Cardiovascular Computed Tomography. All rights reserved.

Imagens contrastadas por manganês na fase aguda da epilepsia induzida por pilocarpina

As imagens de ressonância magnética são úteis no estudo de modelos experimentais de epilepsia do lobo temporal. A técnica manganese-enhanced MRI (MEMRI) é de interesse por combinar os efeitos provocados pelo manganês no aumento do contraste de populações celulares ativadas, ao competir com o cálcio na transmissão sináptica. Assim, o propósito deste estudo foi investigar a evolução temporal do contraste provocado pelo manganês na fase aguda da epilepsia do lobo temporal induzida por pilocarpina sistêmica e compará-las à expressão da proteína c-Fos. Nessa fase, a intensidade do sinal MEMRI foi analisada em três diferentes pontos temporais (5, 15 ou 30 minutos) após o início do status epilepticus (SE). O grupo que foi mantido em status epilepticus por 30 minutos mostrou diminuição na intensidade de sinal no CA1 e giro denteado (GD). Não houve diferenças entre o Grupo Controle e os outros grupos tratados com pilocarpina. A expressão da proteína c-Fos, nos mesmos animais, mostrou que, mesmo no status epilepticus de curta duração (5 minutos) já há ativação celular máxima nas sub-regiões do hipocampo (GD, CA1 e CA3). Nas condições experimentais testadas, nossos dados sugerem que o sinal MEMRI não foi sensível para identificar variações detectáveis da ativação celular na fase aguda do modelo de pilocarpina. Nossos achados não são consistentes com a ideia que o contraste por manganês reflete primariamente alterações na atividade celular durante o SE quando outros elementos modificadores do sinal podem atuar.

Conoscenza e consapevolezza sugli effetti biologici degli ultrasuoni nella pratica clinica in Italia: risultati di una inchiesta con questionario tra ecografisti della socetà italiana di ultrasonologia in medicina e biologia (S.I.U.M.B.)

Background New potential hazards in the use of ultrasound (US) are implied in new diagnostic applications of US, such as contrast enhanced US. Aim To assess the level of awareness and knowledge on safety issues of clinical use of US among physicians who are members of the Italian National Society for Ultrasound (SIUMB) Materials and methods A questionnaire including 11 multiple choice quiz was sent by e-mail to members of SIUMB, who preliminarly agreed to participate in this initiative. The answers were received anonimously and statistically analyzed. Results The number of returned valid questionnaires was 97 (8 were considered not valid for less than 10 answers filled). Mean age of the responders was 44 years old, and the average time the physician has been performing ultrasound examinations was 13 years. The principal workplace (70%) was a public Hospital. Physicians seemed to know the general definitions of principal safety-parameters, but few of them knew the definition of specific indexes. There was a general knowledge about the safe use of ultrasound in obstetrics, but there was a poor knowledge of biological effects of US: only about 37% answered correctly to questions about damage of vasculature of lung by high Mechanical Index US investigation and about the increase of temperature under the probe, according to the thermal indexes. Conclusion In conclusion the present findings indicate that greater efforts of National Ultrasound Societies are warranted in disseminating knowledge about the bio-effects of diagnostic ultrasound modalities among their members to prevent possible hazards.

Use of VEGFR-2 targeted microbubbles (BR55, Bracco imaging) for the early ultrasound evaluation of response to antiangiogenic treatment in a xenograft model of hepatocarcinoma

Aim: To evaluate the early response to treatment to an antiangiogenetic drug (sorafenib) in a heterotopic murine model of hepatocellular carcinoma (HCC) using ultrasonographic molecular imaging. Material and Methods: the xenographt model was established injecting a suspension of HuH7 cells subcutaneously in 19 nude mice. When tumors reached a mean diameter of 5-10 mm, they were divided in two groups (treatment and vehicle). The treatment group received sorafenib (62 mg/kg) by daily oral gavage for 14 days. Molecular imaging was performed using contrast enhanced ultrasound (CEUS), by injecting into the mouse venous circulation a suspension of VEGFR-2 targeted microbubbles (BR55, kind gift of Bracco Swiss, Geneve, Switzerland). Video clips were acquired for 6 minutes, then microbubbles (MBs) were destroyed by a high mechanical index (MI) impulse, and another minute was recorded to evaluate residual circulating MBs. The US protocol was repeated at day 0,+2,+4,+7, and +14 from the beginning of treatment administration. Video clips were analyzed using a dedicated software (Sonotumor, Bracco Swiss) to quantify the signal of the contrast agent. Time/intensity curves were obtained and the difference of the mean MBs signal before and after high MI impulse (Differential Targeted Enhancement-dTE) was calculated. dTE represents a numeric value in arbitrary units proportional to the amount of bound MBs. At day +14 mice were euthanized and the tumors analyzed for VEGFR-2, pERK, and CD31 tissue levels using western blot analysis. Results: dTE values decreased from day 0 to day +14 both in treatment and vehicle groups, and they were statistically higher in vehicle group than in treatment group at day +2, at day +7, and at day +14. With respect to the degree of tumor volume increase, measured as growth percentage delta (GPD), treatment group was divided in two sub-groups, non-responders (GPD>350%), and responders (GPD<200%). In the same way vehicle group was divided in slow growth group (GPD<400%), and fast growth group (GPD>900%). dTE values at day 0 (immediately before treatment start) were higher in non-responders than in responders group, with statistical difference at day 2. While dTE values were higher in the fast growth group than in the slow growth group only at day 0. A significant positive correlation was found between VEGFR-2 tissue levels and dTE values, confirming that level of BR55 tissue enhancement reflects the amount of tissue VEGF receptor. Conclusions: the present findings show that, at least in murine experimental models, CEUS with BR55 is feasable and appears to be a useful tool in the prediction of tumor growth and response to sorafenib treatment in xenograft HCC.

Accuratezza diagnostica dell'ecografia con mezzo di contrasto nel predire l'evoluzione a breve termine in pazienti con morbo di Crohn

Obiettivi. L’ecografia con mezzo di contrasto (CEUS) può fornire informazioni sulla microvascolarizzazione della parete intestinale nella malattia di Crohn. L’infiammazione della parete intestinale non sembra essere correlata alla quantità di parete vascolarizzata (studi di pattern di vascolarizzazione, SVP) ma all’intensità del flusso di parete in un determinato periodo di tempo (studi di intensità-tempo, SIT). Scopo dello studio è valutare se gli studi SVP e/o SIT mediante CEUS siano in grado di mostrare il reale grado d’infiammazione della parete vascolare e se possano predire l’attività di malattia a 3 mesi. Materiali e metodi: 30 pazienti con malattia di Crohn venivano sottoposti a SVP e SIT mediante CEUS e venivano rivisti dopo 3 mesi. L’eCografia era eseguita con uno strumento dedicato con un software particolare per il calcolo delle curve intensità-tempo e con l’ausilio di un mezzo di contrasto (Sonovue). L’analisi quantitativa consisteva nella misura dell’area sotto la curva (AUC) (con cut-off tra malattia attiva e inattiva di 15) e di un intensità media (IM) con un cut-off di 10. Tutti gli esami venivano registrati e analizzati in modo digitale. Risultati: A T0: CDAI era inferiore a 150 in 22 pazienti e superiore a 150 in 8 pazienti; a T3: CDAI era inferiore a 150 in 19 pazienti e superiore a 150 in 11 pazienti. A T0 sia la CEUS SPV che la SIT evidenziavano bassa specificità, accuratezza diagnostica e valore predittivo negativo; a T3 la CEUS SVP mostrava bassa sensibilità e accuratezza diagnostica rispetto alla SIT che era in grado, in tutti i casi tranne uno, di predire l’attività clinica di malattia a tre mesi. Conclusioni: in questo studio, la CEUS-SIT ha mostrato buona accuratezza diagnostica nel predire l’attività clinica di malattia nel follow-up a breve termine di pazienti con malattia di Crohn.

Aspetti diagnostici, strategie terapeutiche ed esito clinico dei tumori primitivi colangiocellulari insorti su cirrosi

Background: The recent increasing incidence of intrahepatic cholangiocellular carcinoma (ICC) in cirrhosis increased the problem of noninvasive differential diagnosis between ICC and hepatocellular carcinoma (HCC) in cirrhosis. In literature there isn’t data about treatment and prognosis of ICC in cirrhosis. Aim: To investigate the role of the different imaging techniques in the diagnosis of ICC in cirrhosis; to analyze treatments and prognosis with particular attention to factors associated with survival. Methods: The data of 30 cirrhotic patients with ICC were retrospectively collected; patients were referred to Liver Units (S.Orsola-Malpighi and S.Matteo Hospitals) between 2005 and 2011. The results of contrast-enhanced ultrasound (CEUS), computed tomography (CT) and magnetic resonance (MR) were evaluated; the enhancement pattern at different imaging techniques were analysed, with particular attention to misdiagnosis of HCC. We evaluated the different treatments and survival of the study group and then we performed the survival analysis of different clinico-pathologic factors. Results: Twenty-five patients underwent CEUS, 27 CT and 10 MR. In 3 cases (12%) CEUS misdiagnosed ICC for HCC, in 7 cases (26%) CT misdiagnosed ICC and in 1 case (10%) MR misdiagnosed ICC. Patient were followed for a mean of 30 months (range:4-86), with a mean survival of 30 months. Twenty-four out of 30 patients were treated with curative approach, while the other 6 underwent TACE (n=4), radioembolization (n=1) or systemic treatment with Gemcitabine (n=1). The univariate analysis revealed that CA19-9 levels, surveillance program and nodule size were significantly related with survival. By multivariate analysis only nodule size £ 40mm was significant (p=0,004). Conclusion: Diagnosis of ICC in cirrhosis remains difficult because there isn’t a typical enhancement pattern and in some cases it cannot be distinguished from HCC by the different imaging techniques. The study of survival related factors shows that nodule size ≤ 40mm is correlated with improved survival.

Automated Segmentation and Non-Rigid Registration for the Quantitative Evaluation of Myocardial Perfusion from Magnetic Resonance Images

Myocardial perfusion quantification by means of Contrast-Enhanced Cardiac Magnetic Resonance images relies on time consuming frame-by-frame manual tracing of regions of interest. In this Thesis, a novel automated technique for myocardial segmentation and non-rigid registration as a basis for perfusion quantification is presented. The proposed technique is based on three steps: reference frame selection, myocardial segmentation and non-rigid registration. In the first step, the reference frame in which both endo- and epicardial segmentation will be performed is chosen. Endocardial segmentation is achieved by means of a statistical region-based level-set technique followed by a curvature-based regularization motion. Epicardial segmentation is achieved by means of an edge-based level-set technique followed again by a regularization motion. To take into account the changes in position, size and shape of myocardium throughout the sequence due to out of plane respiratory motion, a non-rigid registration algorithm is required. The proposed non-rigid registration scheme consists in a novel multiscale extension of the normalized cross-correlation algorithm in combination with level-set methods. The myocardium is then divided into standard segments. Contrast enhancement curves are computed measuring the mean pixel intensity of each segment over time, and perfusion indices are extracted from each curve. The overall approach has been tested on synthetic and real datasets. For validation purposes, the sequences have been manually traced by an experienced interpreter, and contrast enhancement curves as well as perfusion indices have been computed. Comparisons between automatically extracted and manually obtained contours and enhancement curves showed high inter-technique agreement. Comparisons of perfusion indices computed using both approaches against quantitative coronary angiography and visual interpretation demonstrated that the two technique have similar diagnostic accuracy. In conclusion, the proposed technique allows fast, automated and accurate measurement of intra-myocardial contrast dynamics, and may thus address the strong clinical need for quantitative evaluation of myocardial perfusion.

Entwicklungen zur Absolutquantifizierung der Lungenperfusion mittels kontrastmittelverstärkter Magnetresonanztomographie

Die regionale Bestimmung der Durchblutung (Perfusion) ermöglicht differenzierte Aussagen über den Gesundheitszustand und die Funktionalität der Lunge. Durch neue Messverfahren ermöglicht die Magnetresonanztomographie (MRT) eine nicht-invasive und strahlungsfreie Untersuchung der Perfusion. Obwohl die Machbarkeit qualitativer MRT-Durchblutungsmessungen bereits gezeigt wurde, fehlt bisher eine validierte quantitative Methode. Ziel dieser Arbeit war eine Optimierung der bestehenden Messprotokolle und mathematischen Modelle zur Absolutquantifizierung der Lungenperfusion mit Magnetresonanztomographie. Weiterhin sollte die Methodik durch Vergleich mit einem etablierten Referenzverfahren validiert werden. Durch Simulationen und Phantommessungen konnten optimale MRT-Messparameter und ein standardisiertes Protokoll festgelegt werden. Des Weiteren wurde eine verallgemeinerte Bestimmung der Kontrastmittelkonzentration aus den gemessenen Signalintensitäten vorgestellt, diskutiert und durch Probandenmessungen validiert. Auf der Basis dieser Entwicklungen wurde die MRT-Durchblutungsmessung der Lunge tierexperimentell mit der Positronenemissionstomographie (PET) intraindividuell verglichen und validiert. Die Ergebnisse zeigten nur kleine Abweichungen und eine statistisch hochsignifikante, stark lineare Korrelation. Zusammenfassend war es durch die Entwicklungen der vorgestellten Arbeit möglich, die kontrastmittelgestützte MRT-Durchblutungsmessung der Lunge zu optimieren und erstmals zu validieren.

Studio sulla perfusione di fegato e milza in animali non convenzionali mediante ecografia e tomografia computerizzata (TC) con mezzo di contrasto

Il presente studio rappresenta la prima applicazione della tecnica CEUS in alcune delle più diffuse specie non convenzionali, nonché la prima nei rettili. In particolare è stata investigata la perfusione di fegato e milza in 10 conigli, 10 furetti e il fegato in 8 iguane. Per quanto riguarda i mammiferi, la tecnica è risultata di facile attuazione e i risultati ottenuti erano equiparabili a quelli documentati per i piccoli animali. Maggiore variabilità si è messa in evidenza a livello splenico in entrambe le specie e nel coniglio rispetto al furetto. Nelle iguane è stata necessaria una modifica del protocollo a seguito dei tempi più lunghi delle fasi di wash in e di wash out. Le curve ottenute erano caratterizzate da picchi più bassi e TTP più lunghi, con wash out incompleto anche dopo 10 minuti di indagine. Nelle iguane l’indagine del fegato è stata approfondita grazie all’esecuzione di TC dinamiche con MDC, studio pioneristico per quanto riguarda la medicina dei rettili. L’esecuzione è avvenuta senza problemi in anestesia generale. Diffusione del MDC e conseguenti variazione di HU a livello aortico e epatico sono state considerate contemporaneamente, con costruzione di curve HU-tempo piuttosto ripetibili, entrambe caratterizzate da un wash in rapido, un picco, particolarmente alto a livello aortico, e da una fase di wash out più lento, anche qui incompleto dopo i 600 secondi di indagine. Una certa variabilità è stata notata in tre individui, risultato attendibile conseguentemente alla forte dipendenza da fattori intriseci ed estrinseci del metabolismo e della funzionalità epatica dei rettili. L’intero protocollo è stato applicato in un furetto e due iguane patologiche, al fine di evidenziare le potenzialità cliniche delle tecniche. Sebbene il numero esiguo di casi non permetta di trarre conclusioni a questo riguardo, l’ultimo capitolo della tesi vuole essere uno spunto per studi futuri.

Ecografia bidimensionale e con mezzo di contrasto nello studio delle patologie gastro-intestinali del gatto

L’ecografia del tratto gastroenterico è una delle metodiche d’elezione nella valutazione diagnostica delle patologie gastrointestinali nel gatto. In questa tesi dottorale sono presentati i risultati di tre studi in cui l’ecografia convenzionale e con mezzo di contrasto è stata impiegata in gatti sani o con patologie gastroenteriche. Lo scopo del primo studio, prospettico, è stato quello di determinare lo spessore ecografico dei singoli strati di parete nell’intestino tenue in una popolazione di gatti sani. Lo strato mucoso è risultato significativamente più spesso nel duodeno e nel digiuno, per la maggiore grandezza dei villi in queste porzioni dell’intestino tenue. A livello dell’ileo, gli strati di maggior spessore sono risultati quello sottomucoso, per l’abbondante presenza di aggregati linfoidi, e quello muscolare, a causa delle caratteristiche anatomo-funzionali di sfintere che questo tratto intestinale svolge. Il secondo progetto, retrospettivo, nasce dalla collaborazione tra due centri universitari, uno italiano e uno americano, con l’obiettivo di confrontare lo spessore della tonaca muscolare intestinale in gatti affetti da Inflammatory Bowel disease (IBD) o da neoplasie intestinali. In questo studio, l’ipertrofia della tonaca muscolare (ITM) è stato maggiormente osservato in gatti con IBD rispetto a gatti con neoplasie intestinali, ma non sono state evidenziate differenze di spessore della tonaca muscolare tali da poter differenziare le due patologie. Lo scopo del terzo progetto, prospettico, è stato quello di descrivere il pattern di perfusione parietale del piccolo intestino, valutato mediante uso di mezzo di contrasto ecografico, in gatti con ITM associata a IBD. In tutti gli animali studiati, l’ITM si è associato a una modesta assunzione del mezzo di contrasto rispetto agli altri strati della parete intestinale. Questi risultati confermano che l’ITM che si osserva in gatti con IBD non è associato a significativi aumenti della vascolarizzazione di tale strato parietale.

Identificazione di markers morfologici e sierologici di vulnerabilità della placca carotidea

Introduzione: L’indicazione alla rivascolarizzazione carotidea è comunemente posta in base alla percentuale di stenosi, alla presenza di sintomi neurologici ed alle condizioni cliniche del paziente. Una placca ad elevato potenziale embolico viene definita “vulnerabile”; la sua caratterizzazione, tuttavia, non è universalmente accettata ai fini della rivascolarizzazione. Lo scopo dello studio è indagare il ruolo del mezzo di contrasto ecografico (CEUS) nell’identificazione della placca carotidea vulnerabile. Materiali e Metodi: I pazienti sottoposti a endoarterectomia carotidea, sono stati valutati mediante TC cerebrale preoperatoria e CEUS. Le microbolle di contrasto rilevate nella placca, indicative di neovascolarizzazione, sono state quantificate in dB-E ed istologicamente valutate per cinque caratteristiche: (densità dei microvasi, spessore del cappuccio fibroso, estensione delle calcificazioni, infiltrato infiammatorio e core lipidico) il valore da 1 a 5, ottenuto in cieco, indica in grado di vulnerabilità della placca. L'ANOVA test, il test di Fisher e t Student sono stati usati per correlare le caratteristiche dei pazienti ed istologiche col valore di dB-E. Risultati: Di 22 pazienti (range 2-7.8, media 4.85 ±1.9 SD) vi era un numero più alto di sintomatici (7.40 ± 0.5) rispetto agli asintomatici (3.5 ± 1.4) (p = 0.002). Un più alto valore di dB-E si associava con la presenza di un sottile cappuccino fibroso (<200 µm, 5.96±1.5 vs. 3 ± 1,p = 0.01) ed un maggiore infiltrato infiammatorio (3.2 ± 0.9 vs. 6.4 ± 1.2, p = 0.03). Placche con vulnerabilità 5 si associavano ad un valore più alto di dB-E rispetto alle placche con vulnerabilità 1 (7.6 ± 0.2 vs. 2.5 ± 0.6, rispettivamente, p=0.001). Preoperatoriamente, le lesioni emboliche ipsilaterali alla TC, correlavano con un più alto valore di dB-E (5.96±1.5 vs. 3.0±1.0, p=0.01). Conclusioni: Il valore di dB-E alla CEUS indica l’estensione della neovascolarizzazione della placca carotidea e può essere utilizzato come marker di vulnerabilità della placca.