Recent advances in imaging techniques for hepatocellular carcinoma (HCC) offer the possibility of investigating contrast perfusion of liver nodules in cirrhosis. It is now accepted that a non-invasive diagnosis of HCC can be established based on the vascular pattern obtained with pure blood pool contrast agents. The diagnostic pattern consists of contrast enhancement in the arterial phase, indicative of arterial hypervascularization, followed by contrast wash out in the portal and late phases, which leads the nodule to show the same, or, more specifically, a lower contrast signal than the surrounding parenchyma. Such patterns can be obtained by CT, MRI and, more recently, by real time Contrast Enhanced Ultrasonography with second-generation ultrasound contrast agents. A typical vascular pattern in a nodule perceptible also without contrast is highly specific for HCC, so that non-invasive diagnostic algorithms have been developed and recently updated.