Abdominal Radiology

, Volume 43, Issue 1, pp 127–142 | Cite as

CEUS LI-RADS: algorithm, implementation, and key differences from CT/MRI

  • Stephanie R. Wilson
  • Andrej Lyshchik
  • Fabio Piscaglia
  • David Cosgrove
  • Hyun-Jung Jang
  • Claude Sirlin
  • Christoph F. Dietrich
  • Tae Kyoung Kim
  • Juergen K. Willmann
  • Yuko KonoEmail author


Contrast-enhanced ultrasound (CEUS) is a specialized form of ultrasound (US) performed with an intravenous injection of microbubble contrast agents. It has been successfully used for a variety of applications including characterization of liver tumors. In April 2014, the American College of Radiology (ACR) convened a working group of international experts to develop ACR CEUS Liver Imaging Reporting and Data System (CEUS LI-RADS). An initial version of CEUS LI-RADS was published in August 2016. Although the CEUS LI-RADS concept and principles for liver lesion characterization, using dynamic contrast enhancement features, are similar to those for CT or MRI, there are significant differences between CT/MRI and CEUS LI-RADS. Therefore, CEUS LI-RADS has different diagnostic features and a unique characterization algorithm. The size of a lesion, the type and degree of arterial phase enhancement, the presence of washout, and the timing and degree of washout are the major features used for categorization. This paper describes key differences between CT/MRI and CEUS, and provides a diagnostic algorithm of CEUS LI-RADS with detailed, step-by-step instructions and imaging examples of CEUS LI-RADS categories.





Contrast-enhanced ultrasound


Hepatocellular carcinoma


Liver Imaging Reporting and Data System


Intrahepatic cholangiocarcinoma


American College of Radiology


American Association for the Study of Liver Disease


Arterial phase hyperenhancement


Arterioportal shunts


Tumor in vein


Multi-Disciplinary Discussion



Images are from the University of Calgary using the contrast agent Definity (Lantheus Medical Imaging, Billerica MA).


  1. 1.
    Wilson SR, Jang HJ, Kim TK, Burns PN (2007) Diagnosis of focal liver masses on ultrasonography: comparison of unenhanced and contrast-enhanced scans. J Ultrasound Med 26(6):775–787CrossRefPubMedGoogle Scholar
  2. 2.
    Jang HJ, Kim TK, Wilson SR (2009) Small nodules (1-2 cm) in liver cirrhosis: characterization with contrast-enhanced ultrasound. Eur J Radiol 72(3):418–424. doi: 10.1016/j.ejrad.2008.08.011 CrossRefPubMedGoogle Scholar
  3. 3.
    Strobel D, Seitz K, Blank W, et al. (2009) Tumor-specific vascularization pattern of liver metastasis, hepatocellular carcinoma, hemangioma and focal nodular hyperplasia in the differential diagnosis of 1,349 liver lesions in contrast-enhanced ultrasound (CEUS). Ultraschall Med 30(4):376–382. doi: 10.1055/s-0028-1109672 CrossRefPubMedGoogle Scholar
  4. 4.
    Niu Y, Huang T, Lian F, Li F (2013) Contrast-enhanced ultrasonography for the diagnosis of small hepatocellular carcinoma: a meta-analysis and meta-regression analysis. Tumour Biol 34(6):3667–3674. doi: 10.1007/s13277-013-0948-z CrossRefPubMedGoogle Scholar
  5. 5.
    Hanna RF, Miloushev VZ, Tang A, et al. (2016) Comparative 13-year meta-analysis of the sensitivity and positive predictive value of ultrasound, CT, and MRI for detecting hepatocellular carcinoma. Abdom Radiol 41(1):71–90 ((NY)). doi: 10.1007/s00261-015-0592-8 CrossRefGoogle Scholar
  6. 6.
    Chou R, Cuevas C, Fu R, et al. (2015) Imaging techniques for the diagnosis of hepatocellular carcinoma: a systematic review and meta-analysis. Ann Intern Med 162(10):697–711. doi: 10.7326/M14-2509 CrossRefPubMedGoogle Scholar
  7. 7.
    Guang Y, Xie L, Ding H, Cai A, Huang Y (2011) Diagnosis value of focal liver lesions with SonoVue(R)-enhanced ultrasound compared with contrast-enhanced computed tomography and contrast-enhanced MRI: a meta-analysis. J Cancer Res Clin Oncol 137(11):1595–1605. doi: 10.1007/s00432-011-1035-8 CrossRefPubMedGoogle Scholar
  8. 8.
    Xie L, Guang Y, Ding H, Cai A, Huang Y (2011) Diagnostic value of contrast-enhanced ultrasound, computed tomography and magnetic resonance imaging for focal liver lesions: a meta-analysis. Ultrasound Med Biol 37(6):854–861. doi: 10.1016/j.ultrasmedbio.2011.03.006 CrossRefPubMedGoogle Scholar
  9. 9.
    Vilana R, Forner A, Bianchi L, et al. (2010) Intrahepatic peripheral cholangiocarcinoma in cirrhosis patients may display a vascular pattern similar to hepatocellular carcinoma on contrast-enhanced ultrasound. Hepatology 51(6):2020–2029. doi: 10.1002/hep.23600 CrossRefPubMedGoogle Scholar
  10. 10.
    Li R, Yuan MX, Ma KS, et al. (2014) Detailed analysis of temporal features on contrast enhanced ultrasound may help differentiate intrahepatic cholangiocarcinoma from hepatocellular carcinoma in cirrhosis. PLoS One 9(5):e98612. doi: 10.1371/journal.pone.0098612 CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Wildner D, Bernatik T, Greis C, et al. (2015) CEUS in hepatocellular carcinoma and intrahepatic cholangiocellular carcinoma in 320 patients—early or late washout matters: a subanalysis of the DEGUM multicenter trial. Ultraschall Med 36(2):132–139. doi: 10.1055/s-0034-1399147 CrossRefPubMedGoogle Scholar
  12. 12.
    Kono Y, Cosgrove D, Dietrich C, Jang HJ, Kim TK, Lyshchik A, Piscaglia F, Sirlin C, Willmann JK, Wilson S (2016) Contrast-enhanced ultrasound liver imaging reporting and data system for diagnosis of hepatocellular carcinoma: initial proposal. In: American Institute of Ultrasound in Medicine, New York. 16 Mar 2016–21 Mar 2016 2016. vol suppl. p S132Google Scholar
  13. 13.
    Jang HJ, Kono Y, Sirlin C, et al. (2015) Incorporation of CEUS into LI-RADS for diagnosis of hepatocellular carcinoma (HCC): a work in progress. In: Radiological Society of North America, Chicago, 29 Nov 2015–4 Dec 2015Google Scholar
  14. 14.
    Piscaglia F (2016) The new American CEUS LI-RADS classification of focal lesions in cirrhosis. In: Euroson Congress of the EFSUMB, Leipsig, Germany, 26–29 Oct 2016Google Scholar
  15. 15.
    Wilson SR, Kim TK, Jang HJ, Burns PN (2007) Enhancement patterns of focal liver masses: discordance between contrast-enhanced sonography and contrast-enhanced CT and MRI. AJR Am J Roentgenol 189(1):W7–W12. doi: 10.2214/AJR.06.1060 CrossRefPubMedGoogle Scholar
  16. 16.
    Claudon M, Dietrich CF, Choi BI, et al. (2013) Guidelines and good clinical practice recommendations for Contrast Enhanced Ultrasound (CEUS) in the liver—update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultrasound Med Biol 39(2):187–210. doi: 10.1016/j.ultrasmedbio.2012.09.002 CrossRefPubMedGoogle Scholar
  17. 17.
    Terzi E, De Bonis L, Leoni S, et al. (2017) CEUS LI-RADS are effective in predicting the risk hepatocellular carcinoma of liver nodules. Dig Liver Dis 49(Suppl 1):e22CrossRefGoogle Scholar
  18. 18.
    Choi J-Y, Cho HC, Sun M, Kim HC, Sirlin CB (2013) Indeterminate observations (liver imaging reporting and data system category 3) on MRI in the cirrhotic liver: fate and clinical implications. AJR Am J Roentgenol 201(5):993–1001CrossRefPubMedGoogle Scholar
  19. 19.
    Tanabe M, Kanki A, Wolfson T, et al. (2016) Imaging outcomes of liver imaging reporting and data system version 2014 category 2, 3, and 4 observations detected at CT and MR imaging. Radiology 281(1):129–139CrossRefPubMedGoogle Scholar
  20. 20.
    Galia M, Taibbi A, Marin D, et al. (2014) Focal lesions in cirrhotic liver: what else beyond hepatocellular carcinoma? Diagn Interv Radiol 20(3):222–228. doi: 10.5152/dir.2014.13184 CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Kono Y, Cosgrove D, Dietrich CF, Jang HJ, Kim TK, Lyshchik A, Piscaglia F, Sirlin CB, Vezeridis A, Willmann JK, Wilson SR (2016) Metaanalysis of diagnostic performance of CEUS LI-RADS® criteria for diagnosis of ≤ 2 cm hepatocellular carcinoma. In: AASLD Annual Meeting 2016, BostonGoogle Scholar
  22. 22.
    Jo PC, Jang HJ, Burns PN, et al. (2017) Integration of contrast-enhanced US into a multimodality approach to imaging of nodules in a cirrhotic liver: how i do it. Radiology 282(2):317–331CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Stephanie R. Wilson
    • 1
  • Andrej Lyshchik
    • 2
  • Fabio Piscaglia
    • 3
  • David Cosgrove
    • 4
    • 5
  • Hyun-Jung Jang
    • 6
  • Claude Sirlin
    • 7
  • Christoph F. Dietrich
    • 8
  • Tae Kyoung Kim
    • 9
  • Juergen K. Willmann
    • 10
  • Yuko Kono
    • 11
    Email author
  1. 1.Department of RadiologyUniversity of CalgaryCalgaryCanada
  2. 2.Department of RadiologyThomas Jefferson University HospitalPhiladelphiaUSA
  3. 3.Unit of Internal Medicine, Department of Medical and Surgical SciencesUniversity of Bologna, S. Orsola-Malpighi HospitalBolognaItaly
  4. 4.Hammersmith hospitalLondonUK
  5. 5.King’s College HospitalLondonUK
  6. 6.Department of Medical ImagingUniversity of TorontoTorontoCanada
  7. 7.Department of RadiologyUniversity of CaliforniaSan DiegoUSA
  8. 8.Caritas Krankenhaus Bad MergentheimBad MergentheimGermany
  9. 9.University of TorontoTorontoCanada
  10. 10.Stanford UniversityStanfordUSA
  11. 11.Division of Gastroenterology & HepatologyUniversity of CaliforniaSan DiegoUSA

Personalised recommendations