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 29 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 32 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 33 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 18 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 19 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 25 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. 26 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 28 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 • 30