46 year old female with melanoma.Renal artery stenosis, trauma, transplant donor, neoplasm But NOT...

AAPM 2007 - Multimodality MedicalImaging - I

Michael W. Vannier - University ofChicago

Multimodali ty Imaging – Clinica lPersp ective

Michael W. Vannier, M.D.University of Chicago

Monday, July 28, 2008

Imaging Continuing Educati on Cours e

CE-Imaging: Mult imo dality Medical Imagin g - I

Case History

46 year old female with melanoma .

PET-CT exam for initi al stagin g.

Radiological Presentations Radiolog ical Presentations



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Purpose

• Challenges in diagnostic imaging technology (2008)– The “evidence gap”; Overuse– Economics of diagnostic imaging– Oncology; Neuroimaging; Cardiovascular; Orthopedic

• Identify trends– 256-320 channel CT scanners *NEW*– Applications of high end scanners –

• Neuroimaging; Cardiac Imaging; etc.• 4D angiography; non-gated scanning

– Low end CT scanners:• Point of Care CT ; DentoMaxilloFacial/ENT

– CT in the cath lab (high end application to PCI)

Doctors often seem to prescribeCT and MRI scans when theyare of little or no medical use,perhaps explaining whyCanadians still face hefty delaysto get the tests, a new Ontariostudy suggests. Largepercentages of the scansreviewed by the researcherseither unearthed no medicalproblems, or detectedabnormalities that would notchange how the patient wastreated, raising questions aboutwhether they should have beenordered in the first place.

27 June 2008

(CANAD A)

Sunday, 29 June 2008



Medical spending in the United States hascontinued to soar, reaching an estimates$2.25 trillion in 2007. The nation nowspends 50% more on health care per capitathan the next closest industrialized country,often with no better outcomes for patients.One reason is overuse of medicaltechnology.

The New York Times29 June 2008

US spends more for healthcare

Sources: Centers for Medicare and Medicaid Services, U.S. Departmentof Health and Human Services, Organization for Economic Cooperationand Development, New York Times

Medicare coverage ofcardiac computed tomography angiography

March 2008



Lumbo sacral Spine CT

15 htt p://w ww.pedra d.org /asso ciatio ns/5364/ig/



Recommended Protocol Templates in Excel™ Spreadsheets

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Multirow Detector CT (MDCT) Scanner128 detector rows; 256 slices (iCT) Increased Speed, Power, Coverage

•• Higher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolution–– 0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation

•• Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power –– 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 mAmAmAmAmAmAmAmA–– XXXXXXXX--------Y and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulation

•• Greater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotation•• 8 cm8 cm8 cm8 cm8 cm8 cm8 cm8 cm•• 256 slices256 slices256 slices256 slices256 slices256 slices256 slices256 slices

Nose to Toe Scan:168 cm in 22sec



Multi-phase Cardiac Imaging less than 5 sec

More detectors(rows & channels)

Faster gantryrotation

Higher sourcebrightness

Focal spotmodulation

Larger scanneraperture

Table weight limitincreased

Lower dose

40-64 channels

256 channels

320 channels

256-320 detector row CT scannersEnables 4D CT angiography &Whole organ perfusion exam



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Non-Gated Chest CT Scan

Excellent coronary visualizationRT=0.33sec

CT Bronchoscopy – Non-Gated Scan

MetroHea

132kg162cm50 BMI52 bpm

Large Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CT

BMI = 5028

•• 4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan•• 2D Anti2D Anti2D Anti2D Anti2D Anti2D Anti2D Anti2D Anti--------Scatter Scatter Scatter Scatter Scatter Scatter Scatter Scatter

detector grid improves detector grid improves detector grid improves detector grid improves detector grid improves detector grid improves detector grid improves detector grid improves contrast resolutioncontrast resolutioncontrast resolutioncontrast resolutioncontrast resolutioncontrast resolutioncontrast resolutioncontrast resolution

•• Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for artifact eliminationartifact eliminationartifact eliminationartifact eliminationartifact eliminationartifact eliminationartifact eliminationartifact elimination

13 yr old Female



Head & Neck

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MRI of Cerebral Ischemia

78 yo female 3 hrs after onset of aphasia during cardiac cath.FSE T2W Initial DWI Initial MTT

GregSorensen,MassachusettsGeneral Hospital

Early DWI/MTT mismatch, lesion growth

DWI 5 days later

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Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany



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Perfusion

MTTDWIT2

CT vs. MRIvs. xenon CT vs. PET vs. SPECT

Megan Strother, M.D., Vanderbilt University

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STROKEIMAGING

CTP MRP

Non-contrast CT MRI


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Imaging Ischemia--VascularAngiogram

1950-60’s (pre-CT era)

Vascular occlusion

Thrombolysis

Recanalization =Clinical improvement

24 hours


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Imaging Ischemia- Parenchyma

Head CT

<1/3 MCAterritory

No ICH

IV Thrombolysis

<3 hours




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Tissue Cloc k

CBF CBVMTT

Wall Clock

Vascular Occlusion Parenchymal changeson non-contrast CT

.


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MRCT

• No radiation• Better contrast

MR vs. CT


Advantage

MR

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MRCT

• Diffusion = Infarct• MR = 94% sensitive and 96%

specific for infarct• Non-contrast CT = 50%

accurate for acute infarct

Advantage

MR


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MRCT

• MR = whole-brain coverage• CT limited by scanner (10-40 mm max)• Post fossa obscured on CT by beam-

hardening artifact


Advantage

MR



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MRCT

• Speed• Accessibility• Spatial Resolution on CTA

Advantage

CT


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MRCT

– Quantifiable• MR relies on indirect T2* effects on tissue

from gad, therefore not quantifiable


Advantage

CT

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MRP

STROKEIMAGING

fast

accessible

CTA vascular detail

cheap

quantifiable

CTP

diffusion

no radiation

whole-brain coverage


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1st

Non-contrastHead CT

2nd

CT Perfusion

3rd

CT angiogram

CT ScanProtocol



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Head & Neck

CT Scanning Protoco l – 320 ChannelWhole Head Dynamic CTA (Multiple Phases) (16 cm z-axis coverage)



Whole Brain Perfusion (16 cm z-coverag e) Whole Brain Perfusio n

256 to 320 Channel MDCT Scanner (2008)256 to 320 Channel MDCT Scanner (2008)

•• 88--16 cm z16 cm z--axis coverage is well suited to evaluation of axis coverage is well suited to evaluation of cerebrovascularcerebrovascular disease, in stroke (arterial & venous) disease, in stroke (arterial & venous)

•• Whole brain perfusion examination is newWhole brain perfusion examination is new

•• Dynamic wholeDynamic whole--head CT angiography with high head CT angiography with high temporal resolutiontemporal resolution

•• Bone subtraction Bone subtraction –– petrouspetrous ICA, V4, stentsICA, V4, stents

•• Single 50 ml IV contrast material bolus injectionSingle 50 ml IV contrast material bolus injection

•• Combined with CTA of the supraCombined with CTA of the supra--aortic vesselsaortic vessels

Renal CT Angiography (CTA)Renal CT Angiography (CTA)Renal CT Angiography (CTA)Renal CT Angiography (CTA)Renal artery stenosis, trauma, transplant donor, neoplasm

But NOT renal fun ction



CT of the kidneys: current status

• Highest spatial reso lut ion (0.5 mm)(Coppe nrath EM et al. Eur Radiol 2006; 16: 2603 – 2611)

• Bi-/tri -phasic imag ing - hig h sensit ivit y for neoplasia(Walt er C et al. Br J Radiol 2003; 76: 696 – 703)

• CT urography - replacing con vention al urogr ams(Jung DC et al. Radiog raphics 2006; 26: 1827 -1836)

Challenges:• Renal function (perfu sion, cleara nce)?

(Daghini E et al. Radio logy 2007; 243: 405 – 412)

CH A RITE’

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NewTomNewTom QR 2000QR 2000

HitachiHitachi MercuRayMercuRay

J. Morita 3DXJ. Morita 3DX AccuitomoAccuitomo

CONE BEAM CTCONE BEAM CT

XoranXoran/ISI/ISI DentoCATDentoCAT, Ann Arbor, MI, Ann Arbor, MI



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Facial to Palat al Distal to Anter ior

Dista l to Anterior Facial to Palat al

Diagnostic Imaging

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Dentomaxillofacial Images

Panor amic

Sagitt al MPR

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8-Slice Portable CT Scanner

• Compact, lightweight, mobile, high speed, battery and line poweredmulti-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

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8-Slice Portable CT Scanner

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Radiation Data



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CT Scanner for ENT Office / Clinic

Manufacturer claims -

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R

L

L

BUC LING

Follow-up to surgery

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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)



Whichdo youprefer?

Cereto m

Ceretom GE

GE

This is the same ptscanned wit hin 24hours using theCeretom portablescanner and thenour GE station aryscanner …

Ano ther Clini cal Example ….Patient500lb 38 year oldAfric an Americ anmale

SymptomsAphasi a and rightsided hemipares is.

Issue sNo hospital in NYCwilling to scan apatient over 400lbs.Patient went 5 dayswithout a CT scan.

Imag ingLarge MCA infarctwith mass effec t &mid line sh ift.

CerebrovascularCerebrovascular EvaluationEvaluation

CT Perfusion (CTP)

CTA

MTT

CBF

CBV

•axi al, 1 cm slice, 1 slice /second,•acquis ition time is user defined (30-40 seconds)•reconst ructio n on the scanner in real time

Direct coronals

Direct coronal imagingDirect coronal imag ing



Direct Coronal Facial CT

CereTom GE Lightspeed

4 months apar t, same Pt, same dose, same reco n settin gsSummarySummaryAdvantages of Portable CT ImagingAdvantages of Portable CT Imaging

•• Mobi le and easy to move (unlike the patient!)Mobile and easy to move (unl ike the patient!)

•• Easy to operate for hosp ital & offic e perso nnelEasy to operate for hosp ital & offic e pers onn el

•• Plugs into 120v wall power outlet; or batteryPlugs into 120v wall power outlet; or battery

•• Compact & does not require roo m shieldingCompact & does not require room shield ing

•• Perform s axial and coronal images; canPerform s axial and coron al images; canprovide sagittal recon structions if needed;provide sagittal recon structions if needed;can provid e CTA and 3D images .can provid e CTA and 3D images .

•• Compatible with surgical naviga tion units.Compatible with surgical navigation units.

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Medical Imaging Workstations

Thick Client – expensive, with substantiallocal processing capability

Thin Client – small, portableAccessible throughout enterprise



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Revolution in thin-client solutionsAdding applications and 3D to viewing

Techat scanner

PACS

3D Techat Workstation

CT ScanRoom

CT ControlRoom

3D Lab

WorkspacePortal

HomeAny chair ofyour choice

Cath or EP Lab

Department Workstations

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Thin Client SolutionsCT viewing plus

• Comprehensive Cardiac Analysis

• Brain perfusion-summary maps

• CT Angiography Applications

- AVA Stenosis and Stent Planning

• Lung Nodule Assessment

• Virtual Colonography

AllKeyClinicalApplications

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Integrat ing CT into the Cath Lab—Current and Future Applications

John C. Messenger, MD, FACC



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3-D Model

Proximal RCARadius of curvature=34.4°Length=4.27 cm

Mid RCARadius of curvature=30.8°Length=3.90 cm

Distal RCARadius of curvature=22.0°Length=2.62 cm

Messenger, Chen,Carroll,Burchenal, Kioussopoulos, Groves.3-D coronary reconstruction fromroutinesingle-planecoronaryangiograms:Clinical validation andquantitativeanalysisof therightcoronary artery in 100 patients.International.J. CardiacImaging2001.

3-D Features of a Corona ry TreeDerived from CTA or 2-D Projection Images

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Comple teDiagnos tic

ImagingStudy (CTA)

Showin gNeed for PCI

An alyze 3-DCoronary

Artery TreePredict PCI

Difficulty andPatient Risks

Perform PCI

Case Specific Selectio nof Equipm ent and

Working Views

A New Paradigm for Coronary Intervention

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Use of 3D coronary analysis forprocedural planning of PCI

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J. Boone, UC Davis 90

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51 Y/O, 180 lb female with newly diagnosed infiltratingductal carcinoma of the right breast and one positivelymph node. ER (+), PR(+).

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Conclusion• Diagnostic imaging is subject to overuse with

limited evidence for a beneficial effect onoutcomes in some applications (e.g., cardiac)

• Imaging modalities (e.g., CT scanners) arebecoming both more and less expensive

• Low end scanners are available at the Point ofCare

• High end specialty imaging (e.g., CT in the cathlab) is in development

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Acknowledgments

• John Steidley , Ph.D., Philips Medical System s• GE Healthcare, Inc.• Siemens Medical Solu tion s, Inc.• Diego Ruiz, Johns Hopkin s Hospital• Predrag (“ Pedja” ) Suko vic , Xoran Technolo gies, Inc.• Bernhard Preim , University of Magdeburg , Germany• John C. Messen ger, MD, FACC, University of Colorado• Megan Strother , MD, Vanderbilt University• Patrik Rogalla , MD, Charit e’ Berlin• Ali sa Gean, MD, UCSF Radiolo gy• David Rosenbl um, DO, Case Wester n Reser ve Univ.

46 year old female with melanoma.Renal artery stenosis, trauma, transplant donor, neoplasm But NOT...

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