Structures In Ultrasound Images Research Articles

Cross-modal Transfer Learning Based on an Improved CycleGAN Model for Accurate Kidney Segmentation in Ultrasound Images

ObjectiveDeep-learning algorithms have been widely applied in the field of automatic kidney ultrasound (US) image segmentation. However, obtaining a large number of accurate kidney labels clinically is very difficult and time-consuming. To solve this problem, we have proposed an efficient cross-modal transfer learning method to improve the performance of the segmentation network on a limited labeled kidney US dataset. MethodsWe aim to implement an improved image-to-image translation network called Seg-CycleGAN to generate accurate annotated kidney US data from labeled abdomen computed tomography images. The Seg-CycleGAN framework primarily consists of two structures: (i) a standard CycleGAN network to visually simulate kidney US from a publicly available labeled abdomen computed tomography dataset; (ii) and a segmentation network to ensure accurate kidney anatomical structures in US images. Based on the large number of simulated kidney US images and small number of real annotated kidney US images, we then aimed to employ a fine-tuning strategy to obtain better segmentation results. ResultsTo validate the effectiveness of the proposed method, we tested this method on both normal and abnormal kidney US images. The experimental results showed that the proposed method achieved a segmentation accuracy of 0.8548 in dice similarity coefficient on all testing datasets and 0.7622 on the abnormal testing dataset. ConclusionsCompared with existing data augmentation and transfer learning methods, the proposed method improved the accuracy and generalization of the kidney US image segmentation network on a limited number of training datasets. It therefore has the potential to significantly reduce annotation costs in clinical settings.

Segment anything with inception module for automated segmentation of endometrium in ultrasound images.

Accurate segmentation of the endometrium in ultrasound images is essential for gynecological diagnostics and treatment planning. Manual segmentation methods are time-consuming and subjective, prompting the exploration of automated solutions. We introduce "segment anything with inception module" (SAIM), a specialized adaptation of the segment anything model, tailored specifically for the segmentation of endometrium structures in ultrasound images. SAIM incorporates enhancements to the image encoder structure and integrates point prompts to guide the segmentation process. We utilized ultrasound images from patients undergoing hysteroscopic surgery in the gynecological department to train and evaluate the model. Our study demonstrates SAIM's superior segmentation performance through quantitative and qualitative evaluations, surpassing existing automated methods. SAIM achieves a dice similarity coefficient of 76.31% and an intersection over union score of 63.71%, outperforming traditional task-specific deep learning models and other SAM-based foundation models. The proposed SAIM achieves high segmentation accuracy, providing high diagnostic precision and efficiency. Furthermore, it is potentially an efficient tool for junior medical professionals in education and diagnosis.

US2Mask: Image-to-mask generation learning via a conditional GAN for cardiac ultrasound image segmentation

Cardiac ultrasound (US) image segmentation is vital for evaluating clinical indices, but it often demands a large dataset and expert annotations, resulting in high costs for deep learning algorithms. To address this, our study presents a framework utilizing artificial intelligence generation technology to produce multi-class RGB masks for cardiac US image segmentation. The proposed approach directly performs semantic segmentation of the heart’s main structures in US images from various scanning modes. Additionally, we introduce a novel learning approach based on conditional generative adversarial networks (CGAN) for cardiac US image segmentation, incorporating a conditional input and paired RGB masks. Experimental results from three cardiac US image datasets with diverse scan modes demonstrate that our approach outperforms several state-of-the-art models, showcasing improvements in five commonly used segmentation metrics, with lower noise sensitivity. Source code is available at https://github.com/energy588/US2mask.

TKR-FSOD: Fetal Anatomical Structure Few-Shot Detection Utilizing Topological Knowledge Reasoning.

Fetal multi-anatomical structure detection in Ultrasound (US) images can clearly present the relationship and influence between anatomical structures, providing more comprehensive information about fetal organ structures and assisting sonographers in making more accurate diagnoses, widely used in structure evaluation. Recently, deep learning methods have shown superior performance in detecting various anatomical structures in ultrasound images but still have the potential for performance improvement in categories where it is difficult to obtain samples, such as rare diseases. Few-shot learning has attracted a lot of attention in medical image analysis due to its ability to solve the problem of data scarcity. However, existing few-shot learning research in medical image analysis focuses on classification and segmentation, and the research on object detection has been neglected. In this paper, we propose a novel fetal anatomical structure fewshot detection method in ultrasound images, TKR-FSOD, which learns topological knowledge through a Topological Knowledge Reasoning Module to help the model reason about and detect anatomical structures. Furthermore, we propose a Discriminate Ability Enhanced Feature Learning Module that extracts abundant discriminative features to enhance the model's discriminative ability. Experimental results demonstrate that our method outperforms the state-of-the-art baseline methods, exceeding the second best method with a maximum margin of 4.8% on 5-shot of split 1 under 4CC. The code is publicly available at: https://github.com/lixi92/TKR-FSOD.

A Comparative Study of Deep Learning Methods for Multi-Class Semantic Segmentation of 2D Kidney Ultrasound Images.

Ultrasound (US) imaging is a widely used medical imaging modality for the diagnosis, monitoring, and surgical planning for kidney conditions. Thus, accurate segmentation of the kidney and internal structures in US images is essential for the assessment of kidney function and the detection of pathological conditions, such as cysts, tumors, and kidney stones. Therefore, there is a need for automated methods that can accurately segment the kidney and internal structures in US images. Over the years, automatic strategies were proposed for such purpose, with deep learning methods achieving the current state-of-the-art results. However, these strategies typically ignore the segmentation of the internal structures of the kidney. Moreover, they were evaluated in different private datasets, hampering the direct comparison of results, and making it difficult to determination the optimal strategy for this task. In this study, we perform a comparative analysis of 7 deep learning networks for the segmentation of the kidney and internal structures (Capsule, Central Echogenic Complex (CEC), Cortex and Medulla) in 2D US images in an open access multi-class kidney US dataset. The dataset includes 514 images, acquired in multiple clinical centers using different US machines and protocols. The dataset contains the annotation of two experts, but 321 images with complete segmentation of all 4 classes were used. Overall, the results demonstrate that the DeepLabV3+ network outperformed the inter-rater variability with a Dice score of 78.0% compared to 75.6% for inter-rater variability. Specifically, DeepLabV3Plus achieved mean Dice scores of 94.2% for the Capsule, 85.8% for the CEC, 62.4% for the Cortex, and 69.6% for the Medulla. These findings suggest the potential of deep learning-based methods in improving the accuracy of kidney segmentation in US images.Clinical Relevance- This study shows the potential of DL for improving accuracy of kidney segmentation in US, leading to increased diagnostic efficiency, and enabling new applications such as computer-aided diagnosis and treatment, ultimately resulting in improved patient outcomes and reduced healthcare costs.1.

Utility of Artificial Intelligence for Real-Time Anatomical Landmark Identification in Ultrasound-Guided Thoracic Paravertebral Block.

Thoracic paravertebral block (TPVB) is a common method of inducing perioperative analgesia in thoracic and abdominal surgery. Identifying anatomical structures in ultrasound images is very important especially for inexperienced anesthesiologists who are unfamiliar with the anatomy. Therefore, our aim was to develop an artificial neural network (ANN) to automatically identify (in real-time) anatomical structures in ultrasound images of TPVB. This study is a retrospective study using ultrasound scans (both video and standard still images) that we acquired. We marked the contours of the paravertebral space (PVS), lung, and bone in the TPVB ultrasound image. Based on the labeled ultrasound images, we used the U-net framework to train and create an ANN that enabled real-time identification of important anatomical structures in ultrasound images. A total of 742 ultrasound images were acquired and labeled in this study. In this ANN, the Intersection over Union (IoU) and Dice similarity coefficient (DSC or Dice coefficient) of the paravertebral space (PVS) were 0.75 and 0.86, respectively, the IoU and DSC of the lung were 0.85 and 0.92, respectively, and the IoU and DSC of the bone were 0.69 and 0.83, respectively. The accuracies of the PVS, lung, and bone were 91.7%, 95.4%, and 74.3%, respectively. For tenfold cross validation, the median interquartile range for PVS IoU and DSC was 0.773 and 0.87, respectively. There was no significant difference in the scores for the PVS, lung, and bone between the two anesthesiologists. We developed an ANN for the real-time automatic identification of thoracic paravertebral anatomy. The performance of the ANN was highly satisfactory. We conclude that AI has good prospects for use in TPVB. Clinical registration number: ChiCTR2200058470 (URL: http://www.chictr.org.cn/showproj.aspx?proj=152839 ; registration date: 2022-04-09).

ACU[formula omitted]E-Net: A novel predict–refine attention network for segmentation of soft-tissue structures in ultrasound images

Segmentation of anatomical structures in ultrasound images is a challenging task due to existence of artifacts inherit to the modality such as speckle noise, attenuation, shadowing, uneven textures and blurred boundaries. This paper presents a novel attention-based predict–refine network, called ACU2E-Net, for segmentation of soft-tissue structures in ultrasound images. The network consists of two modules: a predict module, which is built upon our newly proposed attentive coordinate convolution; and a novel multi-head residual refinement module, which consists of three parallel residual refinement modules. The attentive coordinate convolution is designed to improve the segmentation accuracy by perceiving the shape and positional information of the target anatomy. The proposed multi-head residual refinement module reduces both segmentation biases and variances by integrating residual refinement and ensemble strategies. Moreover, it avoids multi-pass training and inference commonly seen in ensemble methods. To show the effectiveness of our method, we collect a comprehensive dataset of thyroid ultrasound scans from 12 different imaging centers, and evaluate our proposed network against state-of-the-art segmentation methods. Comparisons against state-of-the-art models demonstrate the competitive performance of our newly designed network on both the transverse and sagittal thyroid images. Ablation studies show that proposed modules improve the segmentation Dice score of the baseline model from 79.62% to 80.97% and 82.92% while reducing the variance from 6.12% to 4.67% and 3.21% in transverse and sagittal views, respectively.

Multi-level multi-type self-generated knowledge fusion for cardiac ultrasound segmentation

Most existing works on cardiac echocardiography segmentation require a large number of ground-truth labels to appropriately train a neural network; this, however, is time consuming and laborious for physicians. Self-supervision learning is one of the potential solutions to address this challenge by deeply exploiting the raw data. However, existing works mainly exploit single type/level of pretext task. In this work, we propose fusion of the multi-level and multi-type self-generated knowledge. We obtain multi-level information of sub-anatomical structures in ultrasound images via a superpixel method. Subsequently, we fuse various types of information generated through multi-types of pretext tasks. In the end, we transfer the learned knowledge to our downstream task. In the experimental studies, we have demonstrated the prove the effectiveness of this method through the cardiac ultrasound segmentation task. The results show that the performance of our proposed method for echocardiography segmentation matches the performance of fully supervised methods without requiring a high amount of labeled data.

Automatic Segmentation and Detection System for Varicocele Using Ultrasound Images

The enlarged veins in the pampiniform venous plexus, known as varicocele disease, are typically identified using ultrasound scans. The medical diagnosis of varicocele is based on examinations made in three positions taken to the right and left testicles of the male patient. The proposed system is designed to determine whether a patient is affected. Varicocele is more frequent on the left side of the scrotum than on the right and physicians commonly depend on the supine position more than other positions. Therefore, the experimental results of this study focused on images taken in the supine position of the left testicles of patients. There are two possible vein structures in each image: a cross-section (circular) and a tube (non-circular) structure. This proposed system identifies dilated (varicocele) veins of these structures in ultrasound images in three stages: preprocessing, processing, and detection and measurement. These three stages are applied in three different color modes: Grayscale, Red-Green-Blue (RGB), and Hue, Saturation, and Value (HSV). In the preprocessing stage, the region of interest enclosing the pampiniform plexus area is extracted using a median filter and threshold segmentation. Then, the processing stage employs different filters to perform image denoising. Finally, edge detection is applied in multiple steps and the detected veins are measured to determine if dilated veins exist. Overall implementation results showed the proposed system is faster and more effective than the previous work.

Spatial Coherence Beamforming With Multi-Line Transmission to Enhance the Contrast of Coherent Structures in Ultrasound Images Degraded by Acoustic Clutter.

This work demonstrates that the combination of multi-line transmission (MLT) and short-lag spatial coherence (SLSC) imaging improves the contrast of highly coherent structures within soft tissues when compared to both traditional SLSC imaging and conventional delay and sum (DAS) beamforming. Experimental tests with small (i.e., [Formula: see text]-3 mm) targets embedded in homogeneous and heterogeneous backgrounds were conducted. DAS or SLSC images were reconstructed when implementing MLT with varying numbers of simultaneously transmitted beams. In images degraded by acoustic clutter, MLT SLSC achieved up to 34.1 dB better target contrast and up to 16 times higher frame rates when compared to the more conventional single-line transmission SLSC images, with lateral resolution improvements as large as 38.2%. MLT SLSC thus represents a promising technique for clinical applications in which ultrasound visualization of highly coherent targets is required (e.g., breast microcalcifications, kidney stones, and percutaneous biopsy needle tracking) and would otherwise be challenging due to the strong presence of acoustic clutter.

Patch Based Texture Classification of Thyroid Ultrasound Images using Convolutional Neural Network.

Ultrasound (US) is an affordable and important imaging modality in medical imaging without potential hazards for patients and medical practitioners as compared to computed tomography which uses X-rays, magnetic resonance imaging which uses magnetic field and radio waves that could heat up the patient's body during long examinations, nuclear imaging, etc. Texture classification of anatomical structures in US images is an essential step for disease diagnosis and monitoring. In this work, we employed a convolutional neural network to segment thyroid gland in US images. This is particularly important for thyroid diseases diagnosis as they involve changes in the shape and size of the thyroid over time. The training of the Convolutional Neural Network (CNN) was not done directly on the acquired US images but on texture database that is created by dividing the thyroid US images of size 760 × 500 pixels into smaller texture patches of size 20 × 20 pixels. We obtained a Dice coefficient (DC) of 0.876 and Hausdorff Distance (HD) of 7.3 using the trained CNN that classifies the thyroid tissues as thyroid or non-thyroid. This approach was compared to the classic image processing approaches like active contours with edges (ACWE), graph cut (GC) and pixel-based classifier (PBC) which obtained a DC of 0.805, 0.745 and 0.666 respectively and Volumetric and Mass-Spring Models which obtained a HD of 11.1 and 9.8 respectively.

Ultrasound Image Segmentation: A Deeply Supervised Network With Attention to Boundaries.

Segmentation of anatomical structures in ultrasound images requires vast radiological knowledge and experience. Moreover, the manual segmentation often results in subjective variations, therefore, an automatic segmentation is desirable. We aim to develop a fully convolutional neural network (FCNN) with attentional deep supervision for the automatic and accurate segmentation of the ultrasound images. FCNN/CNNs are used to infer high-level context using low-level image features. In this paper, a sub-problem specific deep supervision of the FCNN is performed. The attention of fine resolution layers is steered to learn object boundary definitions using auxiliary losses, whereas coarse resolution layers are trained to discriminate object regions from the background. Furthermore, a customized scheme for downweighting the auxiliary losses and a trainable fusion layer are introduced. This produces an accurate segmentation and helps in dealing with the broken boundaries, usually found in the ultrasound images. The proposed network is first tested for blood vessel segmentation in liver images. It results in F1 score, mean intersection over union, and dice index of 0.83, 0.83, and 0.79, respectively. The best values observed among the existing approaches are produced by U-net as 0.74, 0.81, and 0.75, respectively. The proposed network also results in dice index value of 0.91 in the lumen segmentation experiments on MICCAI 2011 IVUS challenge dataset, which is near to the provided reference value of 0.93. Furthermore, the improvements similar to vessel segmentation experiments are also observed in the experiment performed to segment lesions. Deep supervision of the network based on the input-output characteristics of the layers results in improvement in overall segmentation accuracy. Sub-problem specific deep supervision for ultrasound image segmentation is the main contribution of this paper. Currently the network is trained and tested for fixed size inputs. It requires image resizing and limits the performance in small size images.

Anatomical Structure Segmentation in Ultrasound Volumes Using Cross Frame Belief Propagating Iterative Random Walks.

Ultrasound (US) is widely used as a low-cost alternative to computed tomography or magnetic resonance and primarily for preliminary imaging. Since speckle intensity in US images is inherently stochastic, readers are often challenged in their ability to identify the pathological regions in a volume of a large number of images. This paper introduces a generalized approach for volumetric segmentation of structures in US images and volumes. We employ an iterative random walks (IRW) solver, a random forest learning model, and a gradient vector flow (GVF) based interframe belief propagation technique for achieving cross-frame volumetric segmentation. At the start, a weak estimate of the tissue structure is obtained using estimates of parameters of a statistical mechanics model of US tissue interaction. Ensemble learning of these parameters further using a random forest is used to initialize the segmentation pipeline. IRW is used for correcting the contour in various steps of the algorithm. Subsequently, a GVF-based interframe belief propagation is applied to adjacent frames based on the initialization of contour using information in the current frame to segment the complete volume by frame-wise processing. We have experimentally evaluated our approach using two different datasets. Intravascular ultrasound (IVUS) segmentation was evaluated using 10pullbacks acquired at 20MHz and thyroid US segmentation is evaluated on 16 volumes acquired at [Formula: see text]MHz. Our approach obtains a Jaccard score of [Formula: see text] for IVUS segmentation and [Formula: see text] for thyroid segmentation while processing each frame in [Formula: see text] for the IVUS and in [Formula: see text] for thyroid segmentation without the need of any computing accelerators such as GPUs.

Learning to segment key clinical anatomical structures in fetal neurosonography informed by a region-based descriptor.

We present a general framework for automatic segmentation of fetal brain structures in ultrasound images inspired by recent advances in machine learning. The approach is based on a region descriptor that characterizes the shape and local intensity context of different neurological structures without explicit models. To validate our framework, we present experiments to segment two fetal brain structures of clinical importance that have quite different ultrasonic appearances-the corpus callosum (CC) and the choroid plexus (CP). Results demonstrate that our approach achieves high region segmentation accuracy (dice coefficient: [Formula: see text] CC, [Formula: see text] CP) relative to human delineation, whereas the derived automated biometry measurement deviations are within human intra/interobserver variations. The use of our proposed method may help to standardize intracranial anatomy measurements for both the routine examination and the detection of congenital conditions in the future.

Accumulated Angle Factor-Based Beamforming to Improve the Visualization of Spinal Structures in Ultrasound Images.

In recent years, ultrasound has been increasingly used to guide needle insertion procedures for spinal anesthesia. The primary anatomical targets are facet joints and epidural spaces. For these procedures, accurate visualization of the spine anatomy is of critical importance. Challenges arising from the interactions between the ultrasound beam and spinal structures including tilt caused by specular reflections, off-axis interference, and reverberations often result in weakened and blurred vertebra surfaces. Previously, adaptive beamforming methods have been proposed to improve the resolution and contrast. However, most of these methods are not specialized for improving the contrast of specular targets like bones. In this paper, we propose an accumulated angle factor (AAF)-based beamforming method customized for bone surface enhancement. This approach applies a Hilbert transform on delay compensated channel data across the receive aperture. The accumulated phase change across the receive aperture is then calculated and utilized as the weight in the beamforming output. We compared our method with classical delay and sum (DAS) beamforming method and adaptive beamforming methods such as Wiener, phase coherence factor (PCF), CF, and generalized CF (GCF) beamforming. In 12 volunteer data sets, the mean contrast ratio between the vertebrae surface and the surrounding tissue for DAS, Wiener, PCF, CF, GCF, and the proposed AAF methods are 0.49, 0.64, 0.82, 0.77, 0.76, and 0.91, respectively. The contrast is significantly improved in the proposed method.

Automated annotation and quantitative description of ultrasound videos of the fetal heart.

Interpretation of ultrasound videos of the fetal heart is crucial for the antenatal diagnosis of congenital heart disease (CHD). We believe that automated image analysis techniques could make an important contribution towards improving CHD detection rates. However, to our knowledge, no previous work has been done in this area. With this goal in mind, this paper presents a framework for tracking the key variables that describe the content of each frame of freehand 2D ultrasound scanning videos of the healthy fetal heart. This represents an important first step towards developing tools that can assist with CHD detection in abnormal cases. We argue that it is natural to approach this as a sequential Bayesian filtering problem, due to the strong prior model we have of the underlying anatomy, and the ambiguity of the appearance of structures in ultrasound images. We train classification and regression forests to predict the visibility, location and orientation of the fetal heart in the image, and the viewing plane label from each frame. We also develop a novel adaptation of regression forests for circular variables to deal with the prediction of cardiac phase. Using a particle-filtering-based method to combine predictions from multiple video frames, we demonstrate how to filter this information to give a temporally consistent output at real-time speeds. We present results on a challenging dataset gathered in a real-world clinical setting and compare to expert annotations, achieving similar levels of accuracy to the levels of inter- and intra-observer variation.

Automatic segmentation of nerve structures in ultrasound images using Graph Cuts and Gaussian processes.

Peripheral Nerve Blocking (PNB), is a procedure used for performing regional anesthesia, that comprises the administration of anesthetic in the proximity of a nerve. Several techniques have been used with the purpose of locating nerve structures when the PNB procedure is performed: anatomical surface landmarks, elicitation of paresthesia, nerve stimulation and ultrasound imaging. Among those, ultrasound imaging has gained great attention because it is not invasive and offers an accurate location of the nerve and the structures around it. However, the segmentation of nerve structures in ultrasound images is a difficult task for the specialist, since such images are affected by echo perturbations and speckle noise. The development of systems for the automatic segmentation of nerve structures can aid the specialist for locating nerve structures accurately. In this paper we present a methodology for the automatic segmentation of nerve structures in ultrasound images. An initial step is carried out using Graph Cut segmentation in order to generate regions of interest; we then use machine learning techniques with the aim of segmenting the nerve structure; here, a specific non-linear Wavelet transform is used for the feature extraction stage, and Gaussian processes for the classification step. The methodology performance is measured in terms of accuracy and the dice coefficient. Results show that the implemented methodology can be used for automatically segmenting nerve structures.

Detection and Measurement of Fetal Anatomies from Ultrasound Images using a Constrained Probabilistic Boosting Tree

We propose a novel method for the automatic detection and measurement of fetal anatomical structures in ultrasound images. This problem offers a myriad of challenges, including: difficulty of modeling the appearance variations of the visual object of interest, robustness to speckle noise and signal dropout, and large search space of the detection procedure. Previous solutions typically rely on the explicit encoding of prior knowledge and formulation of the problem as a perceptual grouping task solved through clustering or variational approaches. These methods are constrained by the validity of the underlying assumptions and usually are not enough to capture the complex appearances of fetal anatomies. We propose a novel system for fast automatic detection and measurement of fetal anatomies that directly exploits a large database of expert annotated fetal anatomical structures in ultrasound images. Our method learns automatically to distinguish between the appearance of the object of interest and background by training a constrained probabilistic boosting tree classifier. This system is able to produce the automatic segmentation of several fetal anatomies using the same basic detection algorithm. We show results on fully automatic measurement of biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), humerus length (HL), and crown rump length (CRL). Notice that our approach is the first in the literature to deal with the HL and CRL measurements. Extensive experiments (with clinical validation) show that our system is, on average, close to the accuracy of experts in terms of segmentation and obstetric measurements. Finally, this system runs under half second on a standard dual-core PC computer.

Integrating Diagnostic B-Mode Ultrasonography Into CT-Based Radiation Treatment Planning

This paper presents methods and a clinical procedure for integrating B-mode ultrasound images tagged with position information with a planning computed tomography (CT) scan for radiotherapy. A workflow is described that allows the integration of these modalities into the clinic. A surface mapping approach provides a preregistration of the ultrasound image borders onto the patient's skin. Successively, a set of individual ultrasound images from a freehand sweep is chosen by the physician. These images are automatically registered with the planning CT scan using novel intensity-based methods. We put a particular focus on deriving an appropriate similarity measure based on the physical properties and artifacts of ultrasound. A combination of a weighted mutual information term, edge correlation, clamping to the skin surface, and occlusion detection is able to assess the alignment of structures in ultrasound images and information reconstructed from the CT data. We demonstrate the practicality of our methods on five patients with head and neck tumors and cervical lymph node metastases and provide a detailed report on the conducted experiments, including the setup, calibration, acquisition, and verification of our algorithms. The mean target registration error on nine data sets is 3.9 mm. Thus, the additional information about intranodal architecture and fulfillment of malignancy criteria derived from a high-resolution ultrasonography of lymph nodes can be localized and visualized in the CT scan coordinate space and is made available for further radiation treatment planning.

Ultrasound imaging for high intensity focused ultrasound therapy

We have investigated the use of ultrasound-based imaging to develop a non-invasive, safe and real-time method of guidance and monitoring for HIFU therapy. HIFU application was synchronized with the imaging frame rate to allow interference-free visualization of the region of interest. The regions treated with HIFU at intensities above the cavitation threshold appear immediately (within 30–60 ms) as hyperechoic structures in ultrasound images, confirmed to be due to microbubble activity at the focus. This HIFU dose is shown to produce minimal tissue damage, in the form of capillary rupture in an area of approximately 0.5 mm around the focus. The appearance of hyperechoic regions is potentially useful for pre-treatment targeting to ensure that the focus is located at the correct spot. The hyperechoic structures persist for 1–2 min, while the microbubbles still remain at the focus, before being absorbed. Microbubbles at the focus also provide a shield for HIFU, to prevent thermal damage of the healthy tissues located post-focally. Challenges of ultrasound-image-guided HIFU are in monitoring the tissue thermal behavior in and around the focus, and follow-up monitoring of tissues treated with HIFU. Ultrasound imaging is developing into a promising method for guidance of HIFU therapy. [Work funded by DoD, NIH.]