Advanced Topics on Three-Dimensional Ultrasound in Obstetrics and Gynecology

Specific Three-Dimensional Display Modes: 3D Cine, 4D, TUI, VCI, Omniview, SonoVCAD, and STIC

Introduction

Three-dimensional ultrasonography (3DUS) is becoming increasingly used because some important benefits: improved accuracy in volume measuring [1, 2]; improved measurement reproducibility [3, 4]; reduced scanning time and improved workflow [5]; facilitates telemedicine [6]; and also provides some specific display modes that might help understanding the image and allow better diagnostic and predictive accuracy [7 - 10]. This chapter has the purpose to list and show some of these specific display modes: 3D cine, 4D, TUI (Tomography Ultrasound Imaging), VCI (Volume Contrasting Image), Omniview, VCAD (Volume Computed Aided Diagnosis) and STIC (Spatio-Temporal Image Correlation).

3D-cine

A static three-dimensional volume data set can be moved from one point to the other, as it was being recorded by a moving camera. Three-dimensional volume data set is rotated in its x or y axis, providing different angles views and a better depth perception. Starting and ending rotation positions can be defined in 360 degrees, but 45-60 degrees are ideals. Rotation velocity (slow to fast) and type of movement (loop or yoyo) can also be defined (Fig. 1).

Figure 1)

Fetal face rendering volume data set being prepared to 3D cine. Starting position at left and ending position at right.

Four-dimensional (4D) ultrasound

The software captures several consecutive 3D volume data sets, providing movement view for both obstetrcis [11, 12] and gynecologic exams [13, 14]. Each volume data set has less quality then if a single 3D volume was acquired in maximal quality, but it sufficient to permit assessing 3D images with movements. Through track ball movement, this feature allows any of 3D constituent volume data set to be chosen for rendering. All 3D resources as region of interest (ROI) edit, render surfaces, magicut, cine, light edit and others are available to be used (Fig. 2).

Figure 2)

Picture from a four-dimensional ultrasonography. At real time it is possible to see intrauterine fetal movement.

Tomography ultrasound imaging (TUI)

TUI is a three-dimensional image presentation mode in sequential plans, similar to a computed tomography (CT) exam [15 - 17]: number of sequential plans and distance from them can be adjusted. One advantage is the possibility to visualize several parallel planes in only one image, but reduced image size is a disadvantage; since it is possible to visualize all the sequential planes, in a larger view, by volume data set scan (Fig. 3).

Figure 3)

Fetal heart volume data set view from tomographic ultrasound imaging (TUI) 3x3.

Volume contrast imaging (VCI)

VCI is a render mode in order to improve image contrast, decreasing artifacts between tissues [18, 19]. It is similar to multiplanar, where each image represents a very slight slice from volume data set, viewed from longitudinal, coronal, transversal planes simultaneously. VCI has the same representation but each slice is a thicker slice from the volume data set, and transparency and slice thickness can be adjusted. This method was already show to improve the delineation between myometrium and endometrium (Fig. 4) or placenta [20, 21], fetal bones and soft tissue [22], and improved definition of the fetal central nervous system [23, 24], fetal thorax [25], and even pelvic floor assessment [26].

Figure 4)

Uterus volume data set without (top image) and with volume contrast imaging (VCI). Notice the better endometrial and miometrial definition.

Omniview

Omniview is 3D resource that allows rectifies and view curvilinear structures in the same plane (Fig. 5). Identifying both the uterine body and cervix at the same coronal plane [27], improved evaluation of fetal central nervous system [28, 29] and palate [30], and coronal visualization of entire vertebral lumbosacral spine [31] are some clinical appliances of Omniview.

Figure 5)

Uterus and cervix visualized at coronal plane after use of Omniview.

Volume computed aided diagnosis (VCAD)

VCAD aims to minimize operator dependence through image acquisition standardization [32]. The main clinical used are the fetal heart evaluation (SonoVCAD heart) [33] and the assessment of fetal head progression during labor (SonoVCAD labor) [34].

SonoVCAD heart (Sonography-based Volume Computer Aided Display heart) provides an immediate view of the six recommended volumetric fetal echocardiographic images, by the touch of scan button and a four chamber view. Some characteristics, as body mass index and fetal position, are associated with worse 3D image quality [33].

SonoVCAD labor (Sonography-based Volume Computer Aided Display labor) is a tool for the assisted monitoring of labor progression. It standardizes ultrasound image planes during the second stage of labor. Periodically acquired 3D volume data sets are analyzed in order to generate detailed images and objective data. Each volumes is automatically reference to the pubic bone which is used as a landmark to monitor changes during labor process, as skull contour position, head direction, midline and head progression [34].

Spatio-temporal image correlation (STIC)

STIC allows 3D acquisition of moving structures through a post processing volume set [35]. STIC volume acquisition collects one 3D data set consisting of a great number of 2D frames in a single slow sweep [36]; using either color Doppler or B mode pulsatility to determine heart rate and organize the acquired frames into several 3D datasets [37], one representing each phase of a single heart cycle [38, 39]. Acquisition time varies between 7.5 and 15 seconds and it is inversely proportional to image quality: more time results in better quality data-sets, but also increased risk of fetal movements and artifacts. Although STIC can be used for other purposes [40 - 43], this method is mainly employed to examine the fetal heart [44 - 49]. For such purpose, an appropriately regulation (heart occupying 30% to 50% of whole image) of the ROI yields a very high frame rate (> 100 fps) during 3D volume acquisition and the heart will entirely obtained [50]. Post processing analyses can be done in both render and multiplanar view (Figs. 6 and 7). The reconstructed volumes will represent several different moments of one cardiac cycle, and can be displayed automatically, resembling a real time scan. All scanning planes can be moved or rotated maintaining its synchronization with the cardiac cycle so that four chambers, long axes and all the different scanning planes can be visualized both as clips and as still images. Using the multiplanar view, it is possible to navigate through the entire volume examining each structure in its three orthogonal planes simultaneously.

Figure 6)

Fetal heart with spatio-temporal image correlation (STIC) and color Doppler.

Figure 7)

Fetal heart with spatio-temporal image correlation (STIC) and glass body.

Conclusion

3D and 4D technology application has a significant role in ultrasound, and its several different technologies may contribute to improve image quality and ultrasound diagnostic and predictive accuracy.

Notes

The author confirms that author has no conflict of interest to declare for this publication.

Acknowledgements

Declared none.

References

Volume Measurements by Three‐dimensional Ultrasound

Introduction

Assessment of foetal organ volume was one of the first applications of three-dimensional ultrasonography (3DUS) in obstetrics, dating from the mid-1990s. A group from the Department of Obstetrics and Gynaecology at the University of Taiwan pioneered volumetric evaluation of various foetal organs using the first generation of 3DUS equipment, Combison 530. Because foetal organs have irregular shapes, calculating their volume using mathematical formulas as the ellipsoid (height x width x length x 0.52) presents considerable errors; therefore, these pioneering studies aimed to determine new constants based on 3DUS for calculating volume using two-dimensional ultrasonography (2DUS), because at the time 3DUS was restricted to a few reference centres despite its promising nature [1, 2]. In both studies, the authors used the multiplanar method for calculation, which consists of assessing volume based on the three orthogonal planes. Later, the same group determined reference values for the volume of various foetal organs, such as the arm, thigh, cerebellum, lung, brain, adrenals, and liver, always using the multiplanar method for volume calculation [3 - 5]. As for determining volume in gynaecology, Kyei-Mensah et al. [6] conducted a pioneering study in 1996 evaluating the reproducibility of transvaginal 3DUS uterine and ovarian measurement, also using the multiplanar method.

Since the early 2000s, a new volumetric calculation technique known as virtual organ computer-aided analysis (VOCAL) has been available in some 3DUS devices. This volumetric calculation technique is based on rotating the object around an axis while using different rotation angles. This technique has been proven to be reproducible in vitro as well as in vivo, and studies alongside both the multiplanar method and magnetic resonance imaging (MRI) [7, 8]. Compared to the multiplanar method, VOCAL has the advantages of being faster and allowing area corrections at the end of the volumetric calculation. Several studies have been published on the assessment of foetal organs such as the cerebellum, lung, heart, adrenals, and kidneys [9 - 12]. This technique has been applied alongside power Doppler in gynaecology to assess the vascularization of the ovaries and endometrium [13, 14].

Another volumetric calculation technique called extended imaging virtual organ computer-aided analysis (XI VOCAL) has been available as part of the three-dimensional extended imaging program (3D XI - Samsung, Seoul, Korea). This technique consists of defining the external surface of any structure arranged in sequential adjacent planes on the device screen (multislice view), and at the end of the delimitation of the latter area, the device automatically provides the volume [15]. It has recently been demonstrated through an in vitro study that this technique is reproducible and valid, and also permits greater precision in calculation of irregularly-shaped objects [16]. In obstetrics, this technique has been used to assess the umbilical vesicle, embryo, placenta, and heart, as well as foetal limb volume [17 - 21].

More recently, General Electric introduced an automated technique for determining the volume of liquids called sonography-based automated volume count (SonoAVC, GE Healthcare Austria GmbH & Co OG, Zipf, Austria) [22, 23]. The main advantages of this method are reduced dependence on the observer and less time required for analysis. This method can be applied in two ways: one to measure the volume of ovarian follicles, a technique used to monitor controlled ovarian stimulation in assisted reproduction centres [22]; and a general application that can be used to estimate the volume of any structure containing fluid [23]. This technique proved to be valid and reproducible in estimating the volume of pre-ovulatory follicles measured just before aspiration [24], corresponding with VOCAL in estimating gestational sac volume [25], cardiac ventricular volume [26, 27]; volume of the renal pelvis [28], and even urine production [29]. However, there is some suspicion that this technique may underestimate measurements for volume [30 - 34] and diameter [35].

The objective of this chapter is to describe the techniques currently used for volumetric calculation via 3DUS in gynaecology and obstetrics.

VOLUMETRIC CALCULATION TECHNIQUES

Multiplanar

This method consists of assessing the volume of a given structure based on the three orthogonal planes (axial, transverse, and coronal) that compose the three-dimensional image. This technique consists of fixing a plane that is used to outline the outer surface of the structure in question and in turn determine an area, while a cursor moves along an axis on another plane, determining new planes to be outlined. The cursor movement distance is determined by the operator, and generally ranges from 1.0 to 3.0 mm. After moving the cursor over the analysed structure, the device combines the defined areas and automatically produces the volume (Fig. 1).

Virtual Organ Computer‐aided Analysis (VOCAL)

This method rotates the structure to be analysed on an axis, and the consecutive planes that determine the structure are gradually displayed on the monitor screen. The poles of the structure are marked with the aid of measuring callipers, with the structure defined along its outer surface by hand or in ball mode. The rotation angle varies depending on the program used; in the case of 4D view (General Electric Medical Systems, Healthcare, Austria) rotation may be made at 6, 9, 15

Figure 1)

Calculation of the foetal stomach through the multiplanar method. The axial plane is selected as referential and a cursor is dislocated across its axis with intervals of 3.0 mm. Simultaneously, in the sagittal plane, the external surface area of this organ is manually delimitated. When the cursor reaches the other extremity of the organ, the last area is delimitated. Automatically, the program provides the volume of the foetal organ.

Figure 2)

Calculation of the head and truck foetal volume through the VOCAL method. The callipers are positioned in the external extremities of head and truck embryo in the sagittal plane (A). At the end of the rotational process using a 30 degree rotation angle and the tracing of six consecutive planes, the program automatically reconstructs the image of the head and truck embryo and calculates its volume (B).

or 30°; with a 6° rotation, 30 consecutive planes will be delimited, whereas choosing a 30° rotation, 6 consecutive planes will be delimited. In the case of SonoView Pro (Samsung, Seoul, Korea) the rotation angles are 12, 18, and 30°. In each delimited plane the machine calculates an area, and at the end of the rotational process the program automatically calculates the volume and creates a three-dimensional reconstruction of the structure in question (Fig.