Wednesday, July 25, 2007
Imaging Continuing Education Course
Purpose
CE-Imaging: Multimodality Medical Imaging - I
The Current State of 3D and 4D
Imaging in Diagnostic Radiology
Michael W. Vannier, M.D.
University of Chicago
• Overview of Imaging Applications
– Multiple modalities: CT, MRI, PET, and combinations
– Oncology; Neuroimaging; Cardiovascular; Orthopedic;
Dental
• Identify trends
– Low end CT scanners (example of disruptive technology)
– Point of Care CT
– CT in the cath lab (high end application to PCI)
– Access to post-processing image visualization and
analysis tools
– Enterprise (client-server) capabilities
– New microprocessors
• DCE - Perfusion
• Surgical PACS
CONE BEAM CT
Hitachi MercuRay
NewTom QR 2000
J. Morita 3DX Accuitomo
Xoran/ISI
Xoran/ISI DentoCAT,
DentoCAT, Ann Arbor, MI
1
Diagnostic Imaging
Facial to Palatal
Distal to Anterior
Distal to Anterior
Facial to Palatal
Dentomaxillofacial Images
Sagittal MPR
Panoramic
2
8-Slice Portable CT Scanner
• Compact, lightweight, mobile, high speed, battery and line powered
multi-slice CT scanner
• 25 cm field of view, primarily head and neck.
• Up to 8 slices per revolution
• Wireless image transfer system (WITS)
• Non-contrast head CT; CTA; CTP
8-Slice Portable CT Scanner
Radiation Data
3
CT Scanner for ENT Office / Clinic
Manufacturer claims -
Follow-up to surgery
An example…
R
R
L
BUC
LING
L
4
An example…
•
•
•
•
•
•
P.O.C. option
Safer
Faster
Easier
Lower X-ray Radiation
Higher Quality Images
Quality Interaction of
Doctor and Patient
• Point-of-Care (e.g. ENT, allergy offices,
dental offices, …):
– Sinus CT, Ear CT, Brain CT, …
• Highly sophisticated, advanced
procedures performed at imaging
centers / hospitals:
– Cardiac CT, Virtual Colonoscopy, …
Traditional Model for
High-End Imaging
Point-of-Care Model For
High-End Imaging
State Radiation
Safety
Medical
Physicist
Medical
Physicist
Radiologist
PC Billing
Radiologist
Free Standing Imaging
Center / Hospital
Payor
State Radiation
Safety
PC Billing
Payor
TC Billing
TC Billing
RBM Vendor
Multiple Visits
Billing
Physician
RBM Vendor
Less Visits
Billing
Physician
Precert
5
Potential Benefits of
P.O.C. Imaging
•
•
•
•
•
Cost
Quality
Safety
Patient / Consumer Appeal
Physician Appeal
Cost
• RBM pre-certification: usage regulated
• Office visits: reduced
• Claims: streamlined
• Referral tracking, billing and paperwork:
electronically bundled
Potential Benefits of
P.O.C. Imaging
•
•
•
•
•
Radiology Reports by
Teleradiology
Cost
Quality
Safety
Patient / Consumer Appeal
Physician Appeal
6
Potential Benefits of
P.O.C. Imaging
•
•
•
•
•
Cost
Quality
Safety
Patient / Consumer Appeal
Physician Appeal
Low X-Ray Radiation Dose
Sinus CT with a full-body scanner
• Adult: 1.0-2.0 mSv
• Child: 1.0-2.0 mSv
Sinus CT with the MiniCAT™low-dose scanner
• Adult: 0.13 mSv (7-15 x lower radiation dose)
• Child: 0.07 mSv (14-28 x lower radiation dose)
Medical Imaging Workstations
Thick Client – expensive, with substantial
local processing capability
Thin Client – small, portable
Accessible throughout enterprise
7
Visualization
Systems
Thin Client Solutions
Why
What
Where
•Time is a
physician’s most
precious asset
•Images
•“Every 15-seconds
matters”
•All Key
Applications
•Scanner
•Workstation
•PACS
•Virtual Private Network
•Department
•Hospital
•Imaging Center
•Home
•3D Viewing
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Enterprise Visualization Network
Revolution in thin-client solutions
Adding applications and 3D to viewing
Modalities
PACS
Thin
Clients
Tech
at scanner
Department Workstations
CT Scan
Room
CT Control
Room
Workspace
Portal
Cath or EP Lab
3D Tech
at Workstation
Workstation
3D Lab
Any chair of
your choice
Home
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8
Thin Client Solutions
CT viewing plus
• Comprehensive Cardiac Analysis
• Brain perfusion-summary maps
• CT Angiography Applications
- AVA Stenosis and Stent Planning
• Lung Nodule Assessment
All
Key
Clinical
Applications
• Virtual Colonography
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9
10
11
12
45nm Microprocessor
Will become available in Q4’07
Server optimized…
Core 2, 4, 8, …
Integrating CT into the Cath Lab—
Current and Future Applications
Towards A New Interventional
Suite—X-CT Project
Combining Technologies and Merging Cultures
Traditional CT
Traditional CCL
Radiology
Dominated
Cardiology
Dominated
Technician Driven
Nurse Driven
John C. Messenger, MD, FACC
Associate Professor of Medicine
Director, Cardiac Catheterization Labs
University of Colorado Health Sciences Center
13
1. Acquisition of
Coronary Artery
Images
Traditional
PCI
2. Interpretation of
Images by
Cardiologist
Using Extracted 33-D Data for
Planning PCI
Construction of library of vessel curvature values
3. Patient selection for PCI
and planning for ad hoc PCI
•What to treat?
•How to treat?
•Equipment selection
•Visualization strategy
(Road Map)
4. Perform PCI
Messenger, Chen, Carroll, Burchenal, Kioussopoulos, Groves. 3-D coronary reconstruction from routine single-plane
coronary angiograms: Clinical validation and quantitative analysis of the right coronary artery in 100 patients.
International. J. Cardiac Imaging 2001.
3-D Features of a Coronary Tree
Derived from CTA or 2-D Projection Images
Coronary CTA Method
3-D Model
Proximal RCA
Radius of curvature=34.4°
Length=4.27 cm
Mid RCA
Radius of curvature=30.8°
Length=3.90 cm
Segmentation
Distal RCA
Radius of curvature=22.0°
Length=2.62 cm
Messenger, Chen, Carroll,
Burchenal, Kioussopoulos, Groves.
3-D coronary reconstruction from
routine single-plane coronary
angiograms: Clinical validation and
quantitative analysis of the right
coronary artery in 100 patients.
International. J. Cardiac Imaging
2001.
• 3-D volume rendering for global
assessment of vessel features
• Tree view for more in-depth analysis of
tortuosity, coronary ostial take-off, and
ascending aorta size and shape
14
A New Paradigm for Coronary Intervention
Perform PCI
Complete
Diagnostic
Imaging
Study (CTA)
Showing
Need for PCI
Case Specific Selection
of Equipment and
Working Views
Work Flow for CT images in the Cath Lab:
Live fluoro overlay, roadmapping
CT acquisition
Perform intervention under
X-ray using CT
Semi-automatic segmentation
(tissue, coronaries, chambers)
Register CT and X-ray
Imaging space
No
Significant CAD
Suspected
Analyze 3-D
Coronary
Artery Tree
Predict PCI
Difficulty and
Patient Risks
Medical management
Yes
Yes
Transfer CT data to
X-ray workstation
in Cath Lab
Need for
intervention?
Confirm diagnostic CT
with X-ray
TrueView map, multiplanar reformats,
3DQCA, Follow C-arm
Use of 3D coronary analysis for
procedural planning of PCI
No
Medical management or
Coronary bypass surgery
Use of TrueView™ for Analysis of
the coronary arterial tree
15
CT Integration in the Cath Lab
C-Arm Follow Function
• In-room simulation of any angiographic
projection by simply moving the gantry
51 Y/O, 180 lb female with newly diagnosed infiltrating
ductal carcinoma of the right breast and one positive
lymph node. ER (+), PR(+).
J. Boone, UC Davis
16
Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
17
Imaging Ischemia--Vascular
Imaging Ischemia- Parenchyma
Angiogram
1950-60’s (pre-CT era)
Head CT
Vascular occlusion
24 hours
<1/3 MCA
territory
No ICH
Thrombolysis
<3 hours
Recanalization =
Clinical improvement
Megan Strother, M.D., Vanderbilt University
Wall Clock
Vascular Occlusion
IV Thrombolysis
Megan Strother, M.D., Vanderbilt University
Perfusion
Parenchymal changes
on non-contrast CT
Tissue Clock
T2
CBF
MTT
CBV
.
DWI
MTT
CT vs. MRI
vs. xenon CT vs. PET vs. SPECT
Megan Strother, M.D., Vanderbilt University
Megan Strother, M.D., Vanderbilt University
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MR vs. CT
CT
MR
A
d
v
a
n
t
a
g
e
M
R
• No radiation
• Better contrast
Recommended
parameters
Scan parameters
with hair loss
•
•
•
•
•
•
•
•
•
•
•
•
120 kV
200 mAs
8mm
4 slices
1 sec/rotation
50 rotations
Megan Strother, M.D., Vanderbilt University
80 kV
150 mAs
10 mm
4 slices
1 sec/rotation
50 rotations
Megan Strother, M.D., Vanderbilt University
80 kV
• Double the enhancement level
compared with 120 kV (due to kedge of contrast)
• ½ the radiation dose
CT
MR
• Diffusion = Infarct
• MR = 94% sensitive and 96%
specific for infarct
• Non-contrast CT = 50%
accurate for acute infarct
Megan Strother, M.D., Vanderbilt University
A
d
v
a
n
t
a
g
e
M
R
Megan Strother, M.D., Vanderbilt University
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MRI of Cerebral Ischemia
Early DWI/MTT mismatch, lesion growth
CT
MR
FSE T2W
Initial DWI
Initial MTT
DWI 5 days later
• MR = whole-brain coverage
• CT limited by scanner (10-40 mm max)
• Post fossa obscured on CT by beamhardening artifact
78 yo female 3 hrs after onset of aphasia during cardiac cath.
Greg Sorensen, Massachusetts General Hospital
MR
CT
• Speed
• Accessibility
• Spatial Resolution on CTA
A
d
v
a
n
t
a
g
e
C
T
Megan Strother, M.D., Vanderbilt University
A
d
v
a
n
t
a
g
e
M
R
Megan Strother, M.D., Vanderbilt University
MR
CT
– Quantifiable
• MR relies on indirect T2* effects on tissue
from gad, therefore not quantifiable
A
d
v
a
n
t
a
g
e
C
T
Megan Strother, M.D., Vanderbilt University
20
CTP
MRP
quantifiable
whole-brain coverage
CTA vascular detail
no radiation
cheap
accessible
STROKE
IMAGING
Non-contrast CT
diffusion
STROKE
IMAGING
MRI
fast
CTP
MRP
Megan Strother, M.D., Vanderbilt University
CBF = CBV/MTT
• CBF = delivery of blood to tissue/unit time
(mL/100 g/min)
• CBV = measure of autoregulation
(mL/100g)
• MTT = avg time for RBC to flow through
capillary bed (sec)
Megan Strother, M.D., Vanderbilt University
S
C
A
N
P
R
O
T
O
C
O
L
1st
Non-contrasted
Head CT
2nd
CT Perfusion
3rd
CT angiogram
Megan Strother, M.D., Vanderbilt University
21
CBV
CPP
CBV/ MTT
8
6
4
2
CBF
CBV ratio ¾ = 8.5/4.2 = 2
New Developments and
Future Directions for CT
Revolution in Cardiovascular Imaging:
Structure, Function and Biology Program
Milan, Italy
October 6, 2006
Topic: Noninvasive Cardiology
Interviewee: Stephan Achenbach, MD, FACC
Interviewer: C. Richard Conti, MD, MACC
22
Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
23
Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
Surgical Workstations
BrainLab™
StealthStation™
“Neuronavigation”
(Proprietary Systems)
24
Surgical / Interventional PACS
Motivation
• Imaging in interventional radiology and
image-guided surgery are common
• There are few standards
• So, most equipment and software is not
interoperable
• There is a critical and immediate need
to develop standards to improve
surgical workflow, reduce variability and
control costs
MISS = Minimally Invasive Spine
Surgery
Operating Room for Cardiac Surgery
• Numerous tools and monitors are available in the OR.
• These workstations and other components are usually
not integrated and interoperability is typically poor.
Computer Assisted Digital OR Suite for Endoscopic MISS
Problems: Image guided vs. n-D model guided therapy
Video Endoscopy
Monitor
Image Manager Report
C-Arm Images
MD’s
Staff
RN, Tech
EEG Monitoring
MRI Image PACS
C-Arm
Fluoroscopy
Left side of OR
Laser
generator
Image view
boxes
Chair for Computer Aided Medical Procedures
& Augmented Reality
EMG
Monitoring
Digital endoscopic OR suite facilitates MISS
Teleconferencing
- telesurgery
Courtesy of Dr. John Chiu
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Technology-Integration:
OR-Cockpit / OR-Anesthesia
Frontend-3
Frontend-2
Touchscreen
(anesthesia
Flatscreen
(surgery
cockpit)
Frontend-4
cockpit)
(image
viewer)
Themes, e.g. :
• Visualisation
• Device-Control
• Context
Information
• RFID triggert
Events
Frontend-Integration
SIEMENS
Integration-server
Pre-/intraop. Imaging
Link H-IT
Applications
(Endonavigation)
Enterprise Service Bus
web-service
enabled
HIS
System 1
System 2
conncector
TherapyPlanning
KARL STORZ
System 3
System N
Dräger
Frontend-1
Backend - Integration
(KVM switch/RDP)
• Application specifice Data- and EventSynchronisation (Workflow-controlled)
Source: C. Bulitta, SIEMENS
Source: C. Bulitta, SIEMENS
Need for integration technology and
standards
URL: medical.nema.org
There are many rudimentary surgical assist systems
in development or already deployed in the operating
room, mostly in an isolated fashion.
Their usability in the operating room, however, is
impeded by lack of integration.
In general, these systems are NOT interoperable.
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WG 24 “DICOM in Surgery“
Project Groups
DICOM in Surgery
• DICOM is the standard for storage,
transportation and display of radiology images
• DICOM has evolved from the needs of
radiology
– Strong for images and their evaluation
– Lacking other modalities
– Radiology centric world view
• DICOM is a good basis for image- and modelguided surgery
Hospital Workflows
•
•
•
•
•
•
•
•
•
•
•
PG1
PG2
PG3
PG4
PG5
PG6
PG7
PG8
PG9
PG10
PG11
WF/MI Neurosurgery
WF/MI ENT and CMF Surgery
WF/MI Orthopaedic Surgery
WF/MI Cardiovascular Surgery
WF/MI Thoraco-abdominal Surgery
WF/MI Interventional Radiology
WF/MI Anaesthesia
S-PACS Functions
WFMS Tools
Image Processing and Display
Ultrasound in Surgery
Example of workflow and levels of granularity
© Oliver Burgert
Start
preparation
Start
Discectomy
set/insert
needle
surgeon
desinfection
Diagnostic Workflow
X-ray
(find the right position)
surgeon
surgeon
Radiology Workflow
Cutting/dissection/suction
preparation
Finding the nerve
to care for
surgeon
OR-Workflow
With endoscope
Information
Flow
Positioning the microscope
Image Processing
Workflow
Surgical Workflow
Removing intervertebral disc
Surgical
Processes
End
preparation
Start
removing
Without endoscope
surgeon
Excision of tissue and
musculature
surgeon
Remove intervertebral disc
surgeon
Sewing/finish
Material Workflow
End
Discectomy
everything
removed?
surgeon
no
yes
Suction/
stop bleeding
surgeon
End
removing
Anaesthesia
Workflow
27
Sample Case – Surgical Planning
Humeral Non Union
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P2P „Good Practice“ Workflow Repository
Reference expert knowledge
Integration of Surgical Workstations
and Development of Workflows
Peer Expert I
• To some extent, surgical workstations
have already been integrated:
Peer Expert II
Repository of workflow
Generic models and
patient-spec. models
reference models (WFs, SIPs)
etc.
for medical techniques, WF graph
– HIFU = High intensity focused ultrasound
– DaVinci Surgical Robot
– And many others….
operating instructions,
etc.
aph
WF gr
Peer Expert III
Peer Expert IV
Da Vinci Robot
& Workstation
29
Conclusion
• Imaging modalities (e.g., CT scanners) are
becoming less expensive and more widely
available (at the Point of Care)
• High end specialty imaging (e.g., CT in the cath
lab) is in development
• Enterprise visualization and analysis provides
access to tools formerly only available at thick
workstations
• Surgical PACS depends on DICOM progress –
that may deliver interoperability of components
Acknowledgments
•
•
•
•
•
•
•
•
•
John Steidley, Ph.D., Philips Medical Systems
Heinz Lemke, Ph.D., USC & Leipzig Innovation Centre
Siemens Medical Solutions, Inc.
Mark Bohr, Intel Corp.
Predrag (“Pedja”) Sukovic, Xoran Technologies, Inc.
Bernhard Preim, University of Magdeburg, Germany
John C. Messenger, MD, FACC, University of Colorado
Megan Strother, MD, Vanderbilt University
Greg Sorensen, MD, Massachusetts General Hospital
•
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