ORIGINAL RESEARCH

High Resolution Ultrasound Radiomics Differences in Carotid Plaques between Patients with and without Ischemic Stroke

Yang Shenglan, Luo Xiaoyu, Zheng Wendi, Yue Xiaoyu, Liu Wenhao, Pan Yanan, Zhou Yichun, Wan Xiaoyu, Xu Mingjun, Zhang Mei

2026, 10 (4): 233-244. DOI:10.26599/AUDT.2026.260034

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Background

High-resolution ultrasound (HRUS) provides improved spatial resolution for superficial vascular structures, while radiomics quantifies image intensity and texture patterns. However, the robustness of HRUS radiomics differences between carotid plaques from patients with and without ischemic stroke (IS) remains uncertain. This study aimed to identify radiomics features robustly associated with IS.

Methods

This retrospective study included a primary cohort of 1,148 patients (361 with IS and 787 without IS) and an additional population of 83 patients with IS and moderate or severe carotid plaque. We extracted 474 radiomics features in the primary cohort. Features meeting the reliability criterion were analyzed primarily using propensity score overlap weighting for eight clinical covariates. Associations were also assessed using covariate adjusted logistic regression, with false discovery rate correction applied to the overlap-weighted and covariate-adjusted analyses. LASSO selection stability was evaluated in bootstrap samples after penalty selection by the one standard error rule. A separate 1,000 iteration bootstrap of the full modeling pipeline provided internal validation. An expanded clinical model, interaction analyses, and a comparison of the two IS case cohorts were also performed.

Results

A total of 412 of 474 features (86.9%) met the ICC threshold of 0.80. After overlap weighting, all eight clinical covariates had absolute standardized mean differences below 0.01 (effective sample size = 817.2). Of the 403 estimable features, 73 were associated with IS after false discovery rate correction. Seven features in the primary cohort met all robustness criteria. Wavelet-LH_glrlm_RunEntropy showed the strongest inverse association in the weighted analysis (OR per SD, 0.60; 95% CI, 0.49 to 0.74; q < 0.001). In the expanded clinical model, all seven features retained the same association direction, and one remained significant after false discovery rate correction.

Conclusion

HRUS radiomics profiles differed between patients with and without IS in the overlap-weighted analysis. Seven features met the prespecified robustness criteria. These findings suggest that plaque echogenicity and spatial texture are associated with IS. Prospective multicenter validation is needed.

Knowledge Mapping of Ultrasound-guided Thermal Ablation Combined with Immunotherapy for Hepatocellular Carcinoma: A Systematic Bibliometric Analysis

Sui Yajuan, Meng Wenyi, Li Renjie, Li Lujing, Xu Zuofeng

2026, 10 (4): 245-258. DOI:10.26599/AUDT.2026.250115

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Background

Hepatocellular carcinoma (HCC) represents the sixth most prevalent cancer worldwide and ranks as the third leading cause of cancer-related mortality. Confronting therapeutic limitations including chemoresistance, tumor recurrence and high financial burdens, the integration of ultrasound-guided thermal ablation with targeted immunotherapy demonstrates potential transformative paradigm. Utilizing bibliometric methodologies, this study systematically delineates the scientific landscape and evolutionary trajectory of this combined therapeutic approach for HCC.

Methods

Our study systematically reviewed the Science Citation Index Expanded (SCI-Expanded) database (2000 to 6 November 2024) to retrieve studies on ultrasound-guided thermal ablation combined with immunotherapy for HCC. Bibliometric analysis using CiteSpace and VOSviewer analyzed geographical distribution, institutional collaborations, journal contributions, author networks, references, and keyword dynamics. Analytical methods included timeline visualization, co-occurrence networks, and citation burst detection.

Results

A total of 931 publications (560 articles, 371 reviews) from 6,252 authors at 3,766 institutions worldwide were identified. These works were published in 341 journals and cited 4,522 references. Publications demonstrated a marked annual increase from 2000 to 2024, with China contributing 42.7% of total output, followed by the United States (n = 288) and Italy (n = 78). Sun Yat-sen University emerged as the most productive institution and Ping Liang authored the most papers (n = 13). Hepatology and Radiology ranked as top journals by impact factor and academic reputation. Keyword analysis revealed shifting research priorities, with current hotspots diverging significantly from prior decade trends.

Conclusion

This bibliometric analysis outlines two decades of progress in ultrasound-guided thermal ablation combined with immunotherapy for HCC, delineating key contributors (countries, institutions, authors) while highlighting needs for long-term efficacy studies and emerging research trajectories.

Indications for and Techniques of Microwave Ablation of Uterine Fibroids in Patients Seeking to Conceive

Zhang Jing, Zhang Bingsong, Wang Jing, Lin Xiaoliang, Dong Xuejuan, Ou Xianchun, Qi Xiaoguang, Wu Xinyao

2026, 10 (4): 259-263. DOI:10.26599/AUDT.2026.250035

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Objective

To investigate the indications and techniques of microwave ablation for uterine fibroids in fertility-seeking patients, and to evaluate its safety and pregnancy outcomes.

Methods

This prospective study analyzed 1,600 patients who underwent percutaneous microwave ablation, stratified by fertility desire. For the fertility-seeking group, protective interventions including intrauterine and pelvic saline isolation, as well as vaginal fornix support, were implemented. Patients were followed up to assess pregnancy rates, ovarian reserve (AMH), and obstetric outcomes.

Results

Menstrual patterns, sex hormone levels, and AMH values showed no significant changes post-ablation. Among 104 patients intending to conceive, 78 achieved successful pregnancy (75.0%), resulting in 52 healthy live births. Higher pregnancy success rates were observed in patients with FIGO type 0-IV fibroids and those ≤ 8 cm in diameter. Standardized protective measures effectively prevented thermal injury to the endometrium, serosa, and vaginal mucosa. Patients are advised to use contraception for 3-6 months post-procedure and attempt conception once the fibroid shrinks to ≤ 4 cm and uterine cavity morphology improves.

Conclusion

For fertility-seeking patients, FIGO types 0-6 uterine fibroids measuring ≤ 8 cm in diameter represent favorable indications. Adjunctive techniques during ablation, notably intrauterine catheter-mediated hydrodissection and artificial ascites, effectively preserve the structural integrity of the endometrium, uterine serosa, and ovaries.

REVIEW ARTICLE

Ultrasound-Stimulated Microbubbles in Cancer Therapy: A Review of Clinical and Translational Evidence

Khatami Seyedeh Mohaddeseh, Rahmani Arash, Liu Ji-Bin, Eisenbrey John

2026, 10 (4): 264-276. DOI:10.26599/AUDT.2026.260027

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Ultrasound-stimulated microbubbles (USMB) have evolved from a diagnostic contrast technology into an investigational cancer therapy. Acoustically driven microbubble cavitation generates localized mechanical effects that can permeabilize cell membranes, disrupt tumor vasculature, and transiently open biological barriers. This review synthesizes the clinical and translational evidence for USMB-based oncologic therapy across its three principal applications: radiosensitization, drug delivery, and thermal ablation. A narrative review of English-language literature was conducted using PubMed/MEDLINE through April 2026. Radiosensitization is most clinically advanced in liver malignancies, supported by phase 2 randomized data in hepatocellular carcinoma and an efficacy signal in intrahepatic cholangiocarcinoma, with early-phase trials in breast and head and neck cancer. USMB-enhanced drug delivery is most developed in glioma, where implantable and noninvasive focused-ultrasound systems for blood–brain barrier opening have shown feasibility, pharmacokinetic enhancement, and a recent overall-survival benefit; pancreatic cancer provides the strongest randomized evidence outside the brain and liver. Thermal-ablation enhancement remains predominantly preclinical. USMB shows growing clinical promise across multiple tumor types, but the evidence base is constrained by small, heterogeneous trials, the absence of completed phase 3 studies, and off-label agent use. Standardized protocols and larger randomized trials are needed before routine clinical adoption.

Empowering Breast Cancer Precision Diagnosis with Advanced Ultrasound: From Radiomics to Radio-multiomics

Li Mo, Jin Letian, Xue Ge, Chen Jiye, Benariba Mohamed Aimene, Wang Vicky Yang, Teng Gaojun, Xu Dong

2026, 10 (4): 277-297. DOI:10.26599/AUDT.2026.260041

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Numerous research studies have revealed that breast cancer is characterized by substantial biological and molecular heterogeneity, which can neither be fully captured by conventional clinical medical imaging nor biopsy which is typically limited by sampling error and invasiveness. Despite the exhibited complexity, developments in ultrasound imaging technologies from morphological imaging only to multi-dimensional functional imaging coupled with quantitative analysis have significantly improved the diagnostic accessibility and efficiency for breast cancer patients. This review first summarizes recent advances in multi-modal ultrasound imaging encompassing microvascular and super-resolution ultrasound imaging with contrast enhancement, elastography and viscoelastic imaging, as well as quantitative analysis consisting of radiofrequency signal analysis, radiomics, and artificial intelligence-based image analysis for precision breast cancer diagnosis. Specific attention is given to their applications in benign-malignant differentiation, molecular subtype characterization, lymph node metastasis assessment. Beyond image-based analysis, the integration of ultrasound radiomics with genomic, transcriptomic, and other multi-omics data is emerging as a promising strategy for non-invasive molecular phenotyping, although its clinical application is still at its infancy. This review then discusses the transition from radiomics alone through radiogenomics to radio-multiomics, highlighting the potential of advanced ultrasound imaging technologies to bridge imaging phenotypes with underlying tumor biological behaviour in order to facilitate individualized diagnosis and treatment planning. Most radio-multiomics approaches remain at a preclinical or proof-of-concept stage and still require validation in large-scale paired cohorts. In addition, issues such as standardization, reproducibility, interpretability and data heterogeneity remain to be resolved. Finally, this review discusses current challenges that should be addressed before ultrasound-based radio-multi-omics can be translated to a viable clinical tool.

Research Progress and Clinical Translational Application of Ultrasound Localization Microscopy in Microcirculation Imaging

Han Xuedi, Cui Ligang

2026, 10 (4): 298-316. DOI:10.26599/AUDT.2026.260040

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As an emerging super-resolution ultrasound imaging technology, ultrasound localization microscopy (ULM) breaks the acoustic diffraction limit of conventional ultrasound. By localizing and tracking individual microbubble contrast agents at the sub-wavelength scale, ULM achieves high-precision visualization and quantitative evaluation of micron-level microvascular structures and hemodynamic parameters. Compared with traditional color Doppler flow imaging and contrast-enhanced ultrasound, ULM possesses superior spatial resolution and microcirculation quantification capability, enabling in-depth analysis of microvascular morphological remodeling and functional perfusion abnormalities. This review summarizes the core technical principles, optimized algorithms, and key technical bottlenecks of ULM, including microbubble signal separation, single-bubble localization accuracy, physiological motion artifacts, and prolonged acquisition duration. Furthermore, we comprehensively elaborate the preclinical and clinical application progress of ULM in multiple systems, covering neurovascular, renal, tumor, cardiovascular, endocrine and cardiac microcirculation diseases, with a specific focus on its novel clinical value in identifying vulnerable carotid atherosclerotic plaques. We also discuss the current limitations restricting large-scale clinical translation, standardized protocol establishment, and deep-tissue imaging performance of ULM, noting that the majority of existing human ULM evidence is still at the feasibility stage and large-scale prospective multi-center clinical validations are still needed. Targeting the above-mentioned translational bottlenecks, finally, this review prospects the future development directions of ULM, including artificial intelligence optimization, three-dimensional whole-organ imaging, multi-modal and multi-omics fusion. With continuous technical iteration, ULM is expected to become a novel non-invasive imaging modality for early diagnosis, risk stratification and therapeutic efficacy evaluation of microcirculation-related disorders.

Ultrasound-Based Precision Assessment and Intervention of Vulnerable Atherosclerotic Plaques: From Plaque Characterization to Therapeutic Modulation

Sun Yang, Luo Wang, Zhang Qunxia, Ren Jianli, Wang Zhigang, Ran Haitao

2026, 10 (4): 317-333. DOI:10.26599/AUDT.2026.260037

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Luminal stenosis remains central to clinical decision-making but does not fully characterize the plaque features associated with instability and embolization. This narrative review examines the progression from ultrasound-based plaque characterization to therapeutic modulation, with carotid atherosclerosis as the principal clinical focus. Contrast-enhanced ultrasound (CEUS) has the strongest human evidence among advanced methods for microvascular plaque characterization, linking intraplaque enhancement with histologic neovascularization and symptomatic disease. Superb microvascular imaging, elastography, and ultrasound localization microscopy provide complementary measures of slow flow, tissue mechanics, and microvascular architecture. Molecular ultrasound has visualized endothelial activation, platelet deposition, and angiogenic targets in animal models; studies of human endarterectomy specimens have confirmed the expression and accessibility of several candidate vascular targets ex vivo. Experimental nanoscale probes also target foam-cell lipids and extracellular matrix within plaque. Ultrasound-targeted delivery and sonodynamic therapy (SDT) modify macrophages, matrix, and neovessels in experimental plaques. A randomized SDT trial in femoropopliteal disease reported reduced plaque inflammation and improved walking performance; small carotid or mixed-territory studies report imaging responses. Carotid stroke-prevention benefit remains to be established. Serial ultrasound measurements during lipid-lowering treatment provide a human application of imaging-based response assessment.

Decoding Hepatocellular Carcinoma Heterogeneity with Multimodal Ultrasound and Acoustic Radiomics

Cao Jiaying, Li Wenying, Qiu Yijie, Wei Li, Wang Ying, Huang Yunlin, Dong Yi, Dietrich Christoph F

2026, 10 (4): 334-345. DOI:10.26599/AUDT.2026.260028

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Hepatocellular carcinoma (HCC) is characterized by intratumoral heterogeneity (ITH), in which spatially and temporally evolving tumor subclones differ in angiogenesis, hypoxia, immune composition, proliferation, metabolism, and differentiation. This diversity determines tumor progression, recurrence, therapeutic resistance, and clinical outcomes among patients with similar disease stage. Molecular profiling has established ITH as a hallmark of HCC biology, while radiomics, radiogenomics, and habitat imaging based on computed tomography (CT) and magnetic resonance imaging (MRI) have demonstrated that clinically relevant heterogeneity can be assessed noninvasively. Ultrasound offers unique advantages for longitudinal tumor characterization because it is real-time, radiation-free, widely available, portable, and repeatable. Beyond conventional B-mode imaging, modern ultrasound interrogates complementary biological dimensions through contrast-enhanced ultrasound (CEUS), shear-wave elastography (SWE), quantitative ultrasound and radiofrequency (QUS/RF) analysis, and advanced microvascular imaging. Together, these techniques characterize tumor perfusion, biomechanical properties, tissue microstructure, and vascular architecture, providing a multidimensional assessment of intratumoral heterogeneity beyond conventional morphology. This narrative review summarizes the biological foundations of intratumoral heterogeneity in HCC and the benchmark established by CT- and MRI-based radiomics before examining how multimodal ultrasound may provide a biologically informed characterization of tumor heterogeneity. We discuss the emerging role of acoustic radiomics and artificial intelligence in integrating acoustic biomarkers to predict microvascular invasion, histological grade, recurrence risk, treatment response, and longitudinal changes in tumor biology. We propose a testable framework-the acoustic heterogeneity signatures-rather than an established clinical tool. The challenge is no longer to demonstrate that ultrasound contains biologically relevant heterogeneity, but to establish standardized acquisition protocols, biologically validated imaging biomarkers, and multicenter external validation. If these challenges can be overcome, multimodal ultrasound may evolve from a diagnostic imaging modality into a dynamic and interpretable biomarker platform for precision management of HCC, enabling individualized risk stratification, treatment selection, response assessment, and longitudinal disease monitoring.

HUS Cranial Ultrasound: From Technical Innovations to Clinical Applications

Chen Guangwen, Li Yiming, Zhang Zixin, Ding Wenyi, Ding Hong

2026, 10 (4): 346-359. DOI:10.26599/AUDT.2026.260045

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Conventional adult transcranial ultrasound allows bedside acquisition of cerebral structural and hemodynamic data, featuring repeatable radiation-free scanning tailored to clinical monitoring demands. Nevertheless, its clinical application is substantially limited by the adult temporal bone, which induces ultrasonic signal attenuation, wavefront distortion and reverberation artifacts. High-penetration ultrafast cranial ultrasound (HUS) effectively overcomes these skull-derived imaging limitations through synergistic integration of low-frequency single-crystal phased array detection, ultrafast plane-wave imaging, spatiotemporal clutter suppression, and high-resolution transcalvarial reconstruction. This innovative platform achieves contrast-free two-dimensional transtemporal imaging with a structural resolution of 1-2 mm, enabling clear visualization of basal anatomical landmarks, the Circle of Willis, proximal intracranial arteries, and major intracranial venous structures. This review summarizes the technical innovations of HUS and its progress in applications including the diagnosis of neurodegenerative diseases such as Parkinson’s disease, noninvasive monitoring of intracranial hemorrhage and intracranial pressure in neurocritical care, integrated cervico-cerebrovascular evaluation, and psychiatric disorders. The clinical utility of HUS for refined bedside management of intracranial pathologies is discussed.

Wearable Ultrasound in Cardiovascular Monitoring: Clinical Evidence and Translational Challenges

Han Xiao, Ma Xia, Yu Fengxia, Cai Linkun, Ren Pengling, Shi Xian-Quan, Wang Zhenchang

2026, 10 (4): 360-375. DOI:10.26599/AUDT.2026.260039

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Objective

Wearable ultrasound is emerging as a promising approach for continuous cardiovascular monitoring, extending conventional ultrasound from intermittent examinations to prolonged, hands-free assessment. This review summarizes recent progress in these major cardiovascular applications, with particular attention to their clinical validation and translational potential.

Methods

A literature search was performed using PubMed (January 2021 to August 2026) utilizing keywords related to wearable ultrasound (e.g., "wearable", "skin-mounted", "ultrasound", "Doppler") combined with cardiovascular terms. Eligible original research articles, including human studies, animal investigations, and ultrasound sensing-platform studies that demonstrated relevant mechanisms or technical feasibility, were selected.

Results

Recent advances in flexible transducers, stable acoustic coupling, and automated signal analysis have enabled continuous cardiac imaging, non-invasive blood pressure monitoring, and dynamic assessment of vascular hemodynamics and arterial stiffness. Current studies have demonstrated continuous acquisition of cardiac images and functional parameters, cuffless blood pressure tracking under dynamic conditions, and wearable measurement of vascular flow and local arterial mechanical properties. Among these applications, continuous cuffless blood pressure monitoring currently has the most mature clinical validation. However, most applications remain at the physiological validation or early clinical feasibility stage, and evidence for long-term reliability, generalizability, and clinical benefit is still limited.

Conclusion

Future research should focus on robust continuous monitoring in real-world patients and on demonstrating whether wearable ultrasound can provide clinically actionable information beyond conventional intermittent ultrasound.

Advances in the Application of Ultrasound Localization Microscopy in the Diagnosis of Andrological Diseases

Wu Mingtai, Zhang Shijun, Xu Li, Jiang Lixin

2026, 10 (4): 376-384. DOI:10.26599/AUDT.2026.260036

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Male infertility, testicular tumors, and prostate cancer impose a substantial burden on male reproductive health and quality of life. Microcirculatory abnormalities are strongly correlated with the development and progression of these diseases; however, existing imaging modalities, constrained by their spatial resolution, are unable to visualize micrometer-scale microvascular structures in vivo. Ultrasound localization microscopy (ULM) combines imaging depth with high spatial resolution, surpassing the acoustic diffraction limit of conventional ultrasound and enabling the reconstruction of microvascular networks at the micrometer scale, while simultaneously providing multiple quantitative parameters. This article reviews the research progress of ULM in the diagnosis of andrological diseases and discusses the current challenges and future prospects.

Percutaneous Intramyocardial Septal Radiofrequency Ablation (Liwen Procedure) for Hypertrophic Cardiomyopathy: A Decade of Evolution, Clinical Experience and Future Perspectives

Liu Liwen, Li Jing, Dang Shaonan, Hsi David H., Ta Shengjun

2026, 10 (4): 385-393. DOI:10.26599/AUDT.2026.260038

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Hypertrophic cardiomyopathy (HCM) is an inherited cardiomyopathy. For patients with obstructive hypertrophic cardiomyopathy (oHCM) who remain symptomatic despite medical therapy, septal reduction therapy can be performed. Surgical septal myectomy and alcohol septal ablation are the treatments for relieving left ventricular outflow tract obstruction and can effectively improve patients’ quality of life. In recent years, percutaneous intramyocardial septal radiofrequency ablation (PIMSRA/Liwen procedure) has emerged as a novel treatment for oHCM. This review traces its ten-year development from animal experiments to clinical application, covering technical principles, safety, and efficacy. Additional potentially extended applications are being explored, including non-obstructive HCM and other coexisting cardiac conditions. Future directions include longer-term follow-up, and multicenter collaboration to validate efficacy and safety in HCM patients. This review summarizes the current knowledge on PIMSRA/Liwen procedure and raises several issues that deserve further investigation.

Current Status and Prospects of Simulation-based Medical Education in Ultrasound

Lu Weidan, Zhao Ruina, Liu Jibin, Zhang Bo

2026, 10 (4): 394-402. DOI:10.26599/AUDT.2026.260044

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Simulation-based ultrasound education (SBUE) is an important component of ultrasound education and prepares learners before they begin clinical practice. It has gradually evolved from single-skill training centered on phantoms and task trainers into an educational system that emphasizes clinical contexts, continuous assessment, and the development of clinical competence. This review summarizes the developmental history, major modalities, educational implementation and evaluation, current limitations, and future directions of SBUE. Major SBUE modalities include physical models, virtual simulation, standardized patients (SPs), scenario-based simulation, and telesimulation. Courses should be designed around clinical tasks, competency objectives, and available resources, with staged feedback and continuous assessment to improve performance on specific tasks over both the short and long term. Evidence that these gains translate into clinical performance and patient outcomes remains limited. Future studies should focus on developing a competency-based system with refined tiered frameworks and longitudinal assessment pathways, as well as exploring applications of artificial intelligence and other emerging technologies in ultrasound simulation education.

Applications of Carotid Ultrasound and Transcranial Color-coded Sonography/Transcranial Doppler in Carotid Artery Revascularization

Jia Lingyun, Hua Yang

2026, 10 (4): 403-412. DOI:10.26599/AUDT.2026.250077

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Stroke stands as a leading cause of mortality worldwide, with carotid artery stenosis being a major factor of ischemic stroke. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the primary revascularization strategies for this condition. Imaging methods play a pivotal role in providing clinicians and surgeons with crucial information, aiding in diagnosis, risk stratification, peri-operative evaluation, and post-surgical follow-up of patients. This review summarizes the literature available in the PubMed database from the past 25 years and discusses current research investigating the applications of carotid duplex ultrasonography (CDU), transcranial color-coded sonography (TCCS), and transcranial Doppler (TCD) in the revascularization of carotid arteries.