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Examination of vascular structures and flow dynamics is important in order to differentiate benign from malignant FLL. Diagnostic ultrasound in combination with contrast-enhanced ultrasound (CEUS) has a high accuracy and diagnostic value for focal liver lesions (FLL) ((Claudon M et al. Ultraschall in Med 2013; 34:11-29 and Friedrich-Rust M et al. Liver Int 2013; 33: 739-755). CEUS ideally allows the visualization of the spoke wheel sign in the arterial phase which is very specific for FNH (EASL Clinical Practice Guidelines. J Hepatol 2016; 65: 386-398). Conventional colour Doppler has limitations in visualizing microvasculature and low velocity blood flow. Superb Micro-Vascular Imaging (SMI) is a novel ultrasound Doppler technique. With high resolution imaging, minimal motion artefacts and high frame rates. SMI has not been studied in FNH lesions, which have a unique vascular supply that is diagnostic in most cases. Diagnosis of this benign FLL is important to avoid unnecessary biopsies and surgical procedures.

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The diagnostic value of the novel SMI technique for diagnosing FNH lesions in comparison to Doppler ultrasound and CEUS was studied beetween . SMI offers a unique algorithm allowing visualization of microvasculature with low velocity flow without the need of a contrast agent. SMI analyzes clutter motion and uses a new adaptive algorithm to identify and remove tissue motion and reveal true blood flow. CEUS was performed as standard of reference by using an intravenously injected contrast agent and was performed according to international guidelines (Claudon M et al. Ultraschall in Med 2013; 34:11-29). Representative still images and video clips were recorded.