Ultrasound has become a catalyst for innovation, new insights, and improved methods in a wide range of clinical procedures and medical research applications. A longstanding centerpiece in the practice of obstetrics, cardiology, and radiology, ultrasound research and development activity has surged in the past few years. This surge is evident in the double-digit growth rate of the portable ultrasound device market in non-traditional specialties, e.g., anesthesiology, musculoskeletal, and emergency medicine .
Kitware is on the leading-edge of ultrasound research and development. Working with academic and industrial pioneers, we are laying the groundwork for next-generation devices that will generate cost-savings for the healthcare system and, most importantly, save lives. In particular, we are focusing on approaches that enable low-cost ultrasound equipment to be used in a broad range of clinical contexts by relatively less experienced medical personnel. We envision ultrasound becoming the stethoscope of the future—pervasive in doctors offices, ambulances, and clinics around the world.
Four trends that are forming within the field of medical ultrasound research are as follows:
Trend #1: Measurement Automation
Fully realized, this trend will make it possible for users with almost no experience to deploy ultrasound imaging in multiple settings. The benefits will include 1) reduced costs to the healthcare system by targeting novice users as well as pre-hospital and in-home applications; 2) better patient outcomes, as imaging can be obtained earlier in and more frequently during the disease course; and 3) improved measurement standardization and inter-user reliability.
Trend #2: Multi-modality Image Fusion
The roles of fluoroscopy, computed tomography (CT), and magnetic resonance imaging (MRI) are well established for surgical planning; however, these planning images can only be acquired prior to or intermittently during surgeries. This leaves the surgeons to work with planning images that become increasingly irrelevant as the surgeons move or remove anatomical structures. Ultrasound, which can track real-time anatomical changes, can serve as a bridge between planning images and the actual conditions of the patients.
Trend #3: Computer-Assisted Ultrasound Probe Placement
Determining where to place an ultrasound probe and how to move that probe to view a particular anatomic structure requires significant training and expertise. Novel three-dimensional (3D) tracking technologies and image analysis methods are being integrated to provide real-time estimates of the anatomic location of an ultrasound probe, and robotic systems are being devised to automate probe placement for clinical and research applications, to bolster repeatability and efficiency.
Trend #4: Intervention Guidance
Those in the healthcare field will tell you that needle guidance is among the more procedurally frustrating aspects of their jobs. On average, three attempts are required to successfully find a vein and insert the needle, and failure isn’t as innocuous as you may believe. It can lead to hematomas, nerve damage, or infection. Ultrasound is quickly becoming an established instrument for vein localization, and emerging companion software, including augmented reality visualization systems, are being developed to further simplify this procedure.
Kitware…on the Leading-Edge of Ultrasound Research
The following projects represent a subset of the ongoing, ultrasound-based research and development being led or supported by Kitware. These projects range from cancer research to surgical planning. Kitware’s open-source philosophy spurs innovation, collaboration, and development in these exciting ultrasound augmentation efforts.
Trends: Measurement Automation, Computer-Assisted Probe Placement
The focused assessment with sonography for trauma (FAST) scan is a means to triage patients who may have internal bleeding due to abdominal trauma. By assessing four areas on the patient’s body with ultrasound, valuable information is provided that can help determine whether a patient is destined for observation, CT scanning, or the operating room. Unfortunately, while the cost of portable ultrasound systems continues to drop, the training required remains a major hurdle. Studies have shown that FAST is effective in pre-hospital settings ; however those studies have involved physicians and surgeons with up to 100 hours of specialized FAST training, and such extensive training isn’t practical for typical EMS personnel. The reality is that it has been estimated that the rate of preventable trauma-related deaths is 85% higher in rural populations than in urban populations , with pre-hospital patient care being an urgent and unmet need in rural and underserved populations [Trauma.org].
What can be done to bring the powerful diagnostic capabilities of ultrasound to the masses at the scene of accidents and natural catastrophes? Kitware is helping to spur the widespread adoption of trauma-focused ultrasonography by creating a portable and easy-to-use system that integrates (1) advanced machine learning methods with (2) low-cost ultrasound probes from Interson and (3) innovative augmented reality displays from InnerOptic. This project is being funded by the NIH and spearheaded by clinical collaborators in Trauma Surgery and Emergency Medicine at Washington University in St. Louis – Barnes-Jewish Hospital.
- S. Aylward, M. McCormick, HJ. Kang, S. Razzaque, R. Kwitt, M. Niethammer, “Ultrasound Spectroscopy” Proceedings of the International Symposium on Biomedical Imaging (ISBI), Prague, 2016 (Presentation)
Trends: Measurement Automation, Multi-Modality Image Fusion, Computer-Assisted Probe Placement
With the University of North Carolina at Chapel Hill and SonoVol, a preclinical ultrasound startup, Kitware is participating in the development of tools and technologies to help cancer researchers track tumors in animal models. One biomarker of cancer malignancy is tortuosity of vessels within the tumor—an indicator of how well the tumor is nourished. One goal of our collaboration is to monitor tumor vessels with high-frequency ultrasound and advanced image-analysis algorithms, enabling researchers to investigate how tumors respond to potential anti-cancer drugs. This project is funded by the NIH and NSF, with grants to Kitware, UNC, and SonoVol. Once realized, this approach will facilitate drug development and help researchers in academia and industry identify promising therapies earlier.
- SE. Shelton, BD. Lindsey, R. Gessner, Y. Lee, S. Aylward, H. Lee, E. Cherin, F. Stuart Foster, PA. Dayton; “Acoustic angiography: a new high frequency contrast ultrasound technique for biomedical imaging.” Proc. SPIE 9871, Sensing and Analysis Technologies for Biomedical and Cognitive Applications 2016, 987109 (May 19, 2016); doi:10.1117/12.2229179.
- R. C. Gessner, S. R. Aylward, and P. A. Dayton, “Mapping Microvasculature with Acoustic Angiography Yields Quantifiable Differences between Healthy and Tumor-bearing Tissue Volumes in a Rodent Model,” Radiology, vol. 264, no. 3, pp. 733–740, 2012.
Trend: Computer-Assisted Ultrasound Probe Placement, Intervention Guidance
Google’s Project Tango is an exciting new tablet platform with motion-detecting and depth-sensing technology to track objects in the tablet’s environment. Kitware is leveraging this system and building upon their extensive expertise with vessel modeling to locate veins in a patient, compute the path for a needle to reach a vein, and then interactively instruct the clinician on how move the needle to make it follow the computed path.
One particularly innovative aspect of the system is that it provides guidance to the clinician via an integrated pico projector that displays the location of the vein and needle guidance instructions directly on the patient’s skin. Once developed, this will bring subcutaneous anatomy and instruments to the surface, making imprecise needle sticks a thing of the past. Collaborators for this project are Interson, InnerOptic, and Washington University in St. Louis.
- Roland Kwitt, Danielle F. Pace, Marc Niethammer, Stephen R. Aylward: Studying Cerebral Vasculature Using Structure Proximity and Graph Kernels. MICCAI (2) 2013: 534-541
- Roland Kwitt, Nuno Vasconcelos, Sharif Razzaque, Stephen R. Aylward: Recognition in Ultrasound Videos: Where Am I? MICCAI (3) 2012: 83-90
Trend: Multi-modality Image Fusion, Intervention Guidance
An effective, non-invasive malignancy assessment of common prostate lesions can prevent unnecessary surgical removal of the prostate. Via a subcontract from Duke University on an NIH-funded grant, Kitware is registering MRI images with multiple novel ultrasound imaging modalities with the goal of improving the standard of care for prostate cancer.
Trend: Multi-modality Image Fusion, Intervention Guidance
During jaw correction surgery, the condyle can dislocate in the temporomandibular joint. Such dislocations can be difficult to detect and even more difficult to correctly fix during surgeries.
With a grant from the NIH, the Denofacial Deformities Clinic at The University of North Carolina at Chapel Hill is funding Kitware to develop ultrasound-to-CT registration methods that can help intra-operatively detect the occurrence of and guide the correction of these dislocations. This work also features ultrasound segmentation techniques, novel visualization methods, and high-precision ultrasound probe tracking technologies.
Kitware…Collaborating With You
The projects listed above and numerous other commercial and academic collaborations have created a synergy of expertise, software infrastructure, and innovation for ultrasound research and development at Kitware. Many of these methods are available as open-source software via 3D Slicer, ITK, and extensions to ITK such as TubeTK.
 Analysis of the U.S. Medical Ultrasound Imaging Systems Market Growth to be Driven by Emerging Market Segments (2011). Frost &Sullivan.
 Nelson BP, Chason K, “Use of ultrasound by emergency medical services: a review” Int J Emerg Med. 2008 Dec; 1(4): 253–259.
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