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Delivering Quality Care with the New Optima CT660: From Vision to Reality2

T H E m a G a z i N E O F C T • N O V E m B E R 2 0 1 1

Veo: Understanding the impact of iterative ReconstructionPage 54

Pediatric Hospitals Bring Low-dose CT to the middle EastPage 39

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2 A GE Healthcare CT publication • www.ctclarity.com

T A b l E o f C o n T E n T s

Publications Team

Kelley Knutson & Jodi YoungCT Clarity EditorsCT Education Managers

Jennifer MaGlobal Marketing Communications LeaderCT and Advantage Workstation

Mary Beth MassatWriter / Editorial Consultant

Nilesh ShahChief Marketing Officer, CT

IntegréDesign/Production

GE Contributors

Andrew AckermanCT Marketing Manager, Performance Segment, Americas

Olivier AddaCT Super Premium Strategic Product Manager, Europe, Middle East & Africa

Dr. Karthik AnantharamanCT Marketing Manager, South Asia

Christophe ArgaudModality Manager, CT, France

Paul Ayestaran Advanced Applications Specialist, Europe, Middle East & Africa

Chelsea BeelerCommunications Manager

Khodor BerroCT Modality Sales Specialist, Kingdom of Saudi Arabia

Nitin BhardwajClinical Applications Specialist, CT, India

Chuck BisordiCT Product Development Specialist

Valerie BrissartCT Marketing Director, Europe, Middle East & Africa

Eugene CharlestonAW Server Product Leader

Kenneth Denison, PhDCT Dose Leader

Melissa DesnoyersClinical Project Manager, CT

Paul EdwardsAW Product Manager

Jennifer EspositoDirector, Dose Services, Americas

Amanda FoxCT Product Developent Specialist

Benjamin FoxGlobal Public Relations Manager

Enrique Garcia-MuñizCT Marketing Manager, Latin America

Laurent GuiralCT & AW Cardiac Clinical Leader, Europe, Middle East & Africa

DeAnn HaasCT Marketing Manager, Leadership Segment, Americas

John JaeckleRegulatory Affairs Manager, MI & CT

Melissa Megumi Shiraishi KurikiCT Advanced Applications Specialist, Latin America

Elena LimCT Product Marketing Leader, Value Segment

Clinical Value: High-Definition CT Improves Triage and Door-to-treatment Times in Emergency Radiology page 34

Customer Spotlight: Seeing Beyond the Naked Eye page 16

GE Healthcare News

Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

CT Clarity, the Magazine of CT, Goes Digital . . . . . . . . . . . . . . . . .5

GE Launches New CT Low-dose Webinar Series . . . . . . . . . . . . .5

MD Connect: Connecting Your Oncology Team With Applications… Anywhere . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Low-dose CT Coming to Brazil . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Dose Check Aids Hospitals in Regulating Patient Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

General Electric to Expand in Russia With New Joint Ventures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Optima CT660: Taking Performance to a Whole New Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Customer Spotlight

A CT Designed for Broader Access . . . . . . . . . . . . . . . . . . . . . . . . .9

Delivering Quality Care: From Vision to Reality . . . . . . . . . . . 12

Seeing Beyond the Naked Eye . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Clinical Value

Meeting the Clinical Need for Low-dose Cardiac Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Implementing Ultra-low Dose CT with Veo at University Hospital, Brussels . . . . . . . . . . . . . . . . . . . . . . . . . . 21

BrightSpeed Elite with IQ Enhance Delivers Speed and Clarity in the Carolinas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

GE Healthcare News: Optima CT660: Taking Performance to a Whole New Level page 8

3www.gehealthcare.com/ct • November 2011

t a b l e o f c o N t e N t s

Emerging Applications in Musculoskeletal CT Imaging . . . . 27

4D CT With Respiratory Gating Helps Locate and Track Lesions to Reduce Target Volumes . . . . . . . . . . . . . 32

High-Definition CT Improves Triage and Door-to-treatment Times in Emergency Radiology . . . . . . . . 34

Pediatric Hospitals Bring Low-dose CT to the Middle East . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Case Study

Low-dose CTA With ASiR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Confirming a Diagnosis of Double Aortic Arch in a Newborn . . . . . . . . . . . . . . . . . . . . . . . . 46

Critical Low-dose Neuro Imaging with ASiR . . . . . . . . . . . . . . 48

Multi-modality Oncology Workflow for Comprehensive Follow-up and Treatment . . . . . . . . . . . . 50

Technical Innovation

Understanding the Impact of Iterative Reconstruction . . . 54

Integration and Information the Cornerstone of Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Photon Counting: A New CT Technology Just Over the Horizon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Beyond the Scan

Comprehensive Dose Management Services and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Does my Patient Need a CT Scan? . . . . . . . . . . . . . . . . . . . . . . 70

Worldwide Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

© 2011 General Electric Company, doing business as GE Healthcare . All rights reserved . The copyright, trademarks, trade names and other intellectual property rights subsisting in or used in connection with and related to this publication are the property of GE Healthcare unless otherwise specified . Reproduction in any form is forbidden without prior written permission from GE Healthcare .

LIMITATION OF LIABILITY: The information in this magazine is intended as a general presentation of the content included herein . While every effort is made by the publishers and editorial board to see that no inaccurate or misleading data, opinion or statements occur, GE cannot accept responsibility for the completeness, currency or accuracy of the information supplied or for any opinion expressed . Nothing in this magazine should be used to diagnose or treat any disease or condition . Readers are advised to consult a healthcare professional with any questions . Products mentioned in the magazine may be subject to government regulation and may not be available in all locations . Nothing in this magazine constitutes an offer to sell any product or service .

Colleen LockwoodCT Global Marketing Manager

Dusty Majumdar, PhDCT Marketing Manager, Premium Segment, Americas

Holly McDanielCT Product Development Specialist

Andrew MendenRegulatory Affairs Leader

Phil MohCT Masters Series Coordinator

Daniel Morris CT Global Marketing Manager

Vincent NorlockCT Global Marketing Manager

Alyssa NowakCT Product Development Specialist

Christoph ObermeierCT Clinical Education Manager, Europe, Middle East & Africa

Gobinda PalProduct Specialist, CT, India

Karen ProcknowCT Product Development Specialist

Linda PucekCT Segment Marketing Manager, Oncology, Americas

Rick RabySales Specialist, CT

Muhammad Sadiqur RahmanProduct Specialist, CT, Bangladesh

Sundar RKCT Clinical Applications Manager, India

Dario SalvadoriCT Performance & Value Strategic Product Manager, Europe, Middle East & Africa

Mark SemischLead Counsel, GE Healthcare Systems

Stephen SlavensRegulatory Affairs Director, AW

J. Eric StahreGeneral Manager, Global Premium CT

Laurent StefaniGlobal AW Marketing Manager

Andras SzentmiklossyGlobal Product Manager, Oncology

Cristian Toader, PhDCT Premium Strategic Product Manager, Europe, Middle East & Africa

Melhem YounanCT Clinical Leader, EAGM

Pengcheng ZhangMarketing Manager, Oncology

Patricia ZoltowskiCT Education Leader

*Trademark of General Electric Company .

iPad and iPhone are registered trademarks of Apple, Inc .

Android is a trademark of Google, Inc .

Beyond the Scan: Comprehensive Dose Management Services and Solutions page 68

Case Study: Confirming a Diagnosis of Double Aortic Arch in a Newborn page 46

Technical Innovation: Photon Counting: A New CT Technology Just Over the Horizon page 64


G E H E A lT H C A r E n E w s w E l C o m E

In this issue of CT Clarity, we share our customers’ stories on

how these commitments improve their day-to-day clinical

practice and research: How they are achieving high-quality

diagnostic exams with lower dose thanks to ASiR* and Veo*;

what the impact of high-definition imaging means for their

patients’ diagnoses and treatments; how implementing tools

can enhance workflow and raise clinical productivity to new

levels while expanding clinical collaboration; and, why it is

important to embrace the next era of CT innovation with

spectral dual energy and low-dose imaging.

We have only just begun.

Across the industry—from manufacturer to provider—we are all

more cognizant of the importance of ensuring that CT imaging

produces substantial benefits. In fact, the ability to reduce dose

without affecting image quality is the first thing our customers

say they need. Together, with our clinical partners, we are

exploring the future of low-dose imaging. In one of the first

global, multi-site, clinical trials of its kind, Dr. Rendon Nelson and

Dr. Ehsan Samei are leading the effort to determine, by body part

and anatomy, the dose reduction potential of Veo. Their initial

impression of Veo—it’s a positive game changer.

Professor Johan de Mey also shares his experience with Veo. It

is interesting to note that two stories—from opposite ends of

the world—convey a similar message: the value of Veo extends

beyond its low-dose capabilities. While the images Veo produces

are clearly different from filtered back projection (FBP), these

clinicians report seeing more information in the Veo images

than in FBP. Couple that with the potential to conduct CT scans

at previously unattainable low-dose levels, and the future of

CT looks promising indeed.

Our low-dose initiative involves more than just Veo and ASiR,

however. We’re introducing DoseWatch in conjunction with

comprehensive dose management services and solutions. At GE,

our low-dose CT approach is multi-faceted, including technology,

education, training, and implementation. We’re excited to provide

you with an array of tools that will help you conduct high-quality

CT studies at ultra-low doses.

The near future is even brighter. We continue to build upon

the foundation of Gemstone* Spectral Imaging (GSI) and high

definition (HD) to address current challenges in CT cardiac

imaging. Additionally, this year at RSNA we will display the

Discovery* CT750 HD FREEdom Edition (commercially available

only outside of the US), which is being designed to provide a new

standard in cardiac imaging.

As excited as we are for tomorrow’s advancements, we understand

that there are clinical demands and questions that our customers

need addressed today. Our customers have told us they need

better CT imaging workflows that enhance productivity and

clinical collaboration. Last issue, we introduced you to the

Dexus* workflow. In this edition, Dr. William Shuman shares his

experience with Dexus and why it is important not just for radiology

productivity, but for enhancing access to clinical information

and applications in any location, at any time. You can also read

Dr. Valerie Laurent’s case study on how OncoQuant*, part of

the Dexus family, has made a difference in oncology follow-up

and treatment.

GE’s investment in CT spans the world. We can be a better leader

by listening to our customers from every corner of the globe,

sharing the challenges they face each day, and addressing them

through innovation, research, and development. For many clinicians

throughout the world, offering access to CT imaging is the challenge.

The Brivo* CT315§ and CT325§ are helping to bridge this gap with

high-quality, cost-efficient CT systems. Our customers in India and

China share their initial experiences with the Brivo CT325 and the

impact on patient care.

And, you’ll read how hospitals are able to take their performance to

a whole new level with our exciting new Optima* CT660. Customers

in India, South America, France, and the US are using the

healthymagination and ecomagination validated Optima CT660

to improve their workflow, increase patient and referring physician

demand, enhance patient care, and optimize dose with ASiR.

Together with you, great care by design is attainable for all

countries, cultures, and people. And, if you can’t join us at RSNA

2011, I hope you’ll join us virtually at www.gehealthcare.com to

learn more about how we can all make an impact on the future

of healthcare through CT imaging.

Read on, enjoy, and thanks for your continued support. And,

don’t forget to check out the new digital edition of CT Clarity. n

Leadership, Excellence in Patient Care, ProductivityThree commitments that guide both GE Healthcare CT and our clinical partners

*Trademark of General Electric Company.§Brivo CT315 and CT325 are not for sale in the United States.

Not cleared by the US FDA.

Steve Gray, Vice President and General Manager,

Computed Tomography, GE Healthcare


a N N o u N c e m e N t s g e h e a lt h c a r e N e w s

GE Launches New CT Low-dose Webinar Series

Get the latest CT clinical, technical, and operational news

digitally—on the Web, iPad, iPhone, or Android tablet and phone.

CT Clarity is now available online at www.ctclarity.com.

Download the tablet and smartphone applications free of

charge at the Apple Store (www.apple.com) or Android Market

Apps (www.market.android.com). Or, simply scan the QR codes

with your smartphone!

Don’t miss exclusive content that can’t be found anywhere else—

videos, interviews, and expanded clinical images and cases. Easily

search for keywords and hot topics to locate the content that

interests you the most. Share links to articles via email or quick

links to social networks. You can still download the magazine as

a PDF for offline reading. Watch for updates to your app with the

latest news from GE CT. n

For over three decades, GE has been empowering clinicians

and technologists with radiation dose-reducing techniques. This

commitment included innovative education offerings that enable

our customers to maximize their use of these technologies to

image at doses consistent with the ALARA principle. GE will

continue to offer dose education through accredited webinars

that feature a variety of experts who share their experience on

reducing radiation dose. This content is now available to our

customers via the new CT Low-dose Webinar series.

GE offers six modules approved by the ASRT for Category

A CE credits (4.5 total credits):

• Radiation Dose—Current Issues and New Techniques;

• Reducing Radiation Risk in CT Scans for Children;

Download your CT Clarity magazine today at www.ctclarity.com or get your free CT Clarity app at www.apple.com and www.market.android.com. »

• Fundamentals of CT and Radiation Dose;

• Dose Reduction Techniques for Cardiac CT;

• Neuroimaging Considerations; and

• Techniques for Reducing CT Radiation Dose. n

CT Clarity, the Magazine of CT, Goes Digital

More information on the Low-dose Webinar Series can be found at www.gehealthcare.com/ctedu/dosewebinar. »

ctclarity.com Android Apple


G E H E A lT H C A r E n E w s A n n o u n C E m E n T s

MD Connect: Connecting Your Oncology Team With Applications… Anywhere

Recent innovations in oncology imaging and treatment have

made it possible to treat cancer more effectively. Specifically, more

precise and targeted treatment, coupled with earlier detection,

has led to a remarkable improvement in five-year, disease-free

survival rates for cancer patients. Yet, these new technologies

generate more sophisticated and detailed information that is used

throughout the care cycle, requiring clinicians to utilize different

workstations and applications. For caregivers/clinicians, this

translates to a more complex workflow for processing, connecting,

and collaborating across the continuum of oncology care.

MD Connect is a new, innovative, thin client solution designed

for oncology that addresses the need for a seamless workflow

from scan to plan and monitors treatment effectiveness to

help improve productivity across the cancer care continuum.

Powered by the GE AW Server, it enables plug-and-play access

via virtually any networked computer to the complete suite of

oncology applications from any location or department. As

part of the Dexus workflow environment, MD Connect provides

fast access to a complete portfolio of oncology and radiology

applications—all on one platform. These applications include:

sophisticated tools for virtual simulation; 3D image fusion;

4D motion management; tools to diagnose, stage, and monitor

treatment effectiveness; and more. The tools are designed

to transform the complex into routine and the routine into

more efficient.

MD Connect integrates with the Eclipse™ treatment planning

platform from Varian Medical Systems on one desktop and with

other DICOM-based treatment planning platforms. Compliant

with the IHE-RO standard, MD Connect interoperates across a

multitude of different oncology systems and manufacturers. nEclipse is a trademark of Varian Medical Systems, Inc.

ASiR technology is another CT

advancement that may offer dose

reductions for cardiac and whole-body exams.”**

Dr. Kuroki believes their new, low-dose CT systems will contribute

to the company’s broader vision of modernizing technology,

standardizing operations, and offering responsible, high-quality

imaging. “We looked for a company that shared our philosophy

and long-term vision, demonstrating commitment to the

sustainability and growth of the project,” says Dr. Kuroki. “In

GE, we found a partner that fulfilled all of our expectations and

offered a great cost/benefit ratio for the size of our project with

the Optima and BrightSpeed CT systems.” n

In a move that will broaden the availability and accessibility

of low-dose CT imaging across Brazil, DASA (Diagnosticos

da America SA) has ordered 21 low-dose CT scanners from

GE Healthcare. The sale includes BrightSpeed and Optima

systems featuring ASiR* and will be installed during the

4th quarter of 2011 and 1st quarter of 2012.

The São Paulo-based company is the largest medical diagnostics

provider in Latin America, operating 496 centers in Brazil, with

12,000 employees in 12 of Brazil’s 26 states.

According to Iugiro Roberto Kuroki, MD, Director, Medical Diagnostic

Imaging and Radiology at DASA, “The purchasing of low-dose CT

equipment is in synergy with the company’s philosophy of being

a pioneer in quality and medical responsibility and ensuring

patient access to state-of-the-art diagnostic testing. DASA be-

lieves that CT plays a key role in medicine today, and the

Low-dose CT Coming to Brazil

**In clinical practice, the use of ASiR may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.


a N N o u N c e m e N t s g e h e a lt h c a r e N e w s

The US Food and Drug Administration

has asked all CT manufacturers to pre-populate the CTDIvol Alert

Value at 1,000 mGy. GE’s Dose Check also provides an option to

set a second Alert Value that is applied for exams on patients

under an age threshold determined by each imaging facility.

GE Healthcare representatives will be contacting facilities to

schedule the installation of this FMI (Field Modification Instruction)

on select scanners and deliver an informational packet and

training materials that include:

• Multi-language, updated operator’s manual;

• Computer-based training materials: Dose Check Training

Tutorial & Video CDs; and

• Dose Check Quick Guide for console-side reference. n

As a leader in providing low-dose CT applications, GE Healthcare

invests in initiatives designed to help radiologists and medical

imaging professionals tailor exams to patients of all ages and

conditions. Our commitment to patient safety continues with the

implementation of Dose Check at no cost on most GE CT scanners.

Dose Check is part of the Medical Imaging & Technology Alliance’s

(MITA) Radiation Dose Reduction Plan and CT Dose Check global

initiative. It provides alerts and notifications to scanner operators

when pre-defined radiation dose levels—as determined and set

by the facility—will be exceeded. There are two levels of thresholds:

Notification Values and Alert Values. Notification Values apply

to a single image series (e.g. a single helical series) while Alert

Values apply to a complete exam. Both CTDIvol and/or DLP (Dose

Length Product) values can be set.

Dose Check Aids Hospitals in Regulating Patient Dose

For additional information on Dose Check and a list of scanners scheduled to receive it, please visit www.gehealthcare.com/LowerDoseByDesign. »

approach to growth. It draws on leading-edge R&D, engineering,

and manufacturing expertise from GE centers throughout the

world even as it meets the needs and creates value in our

customers’ home markets.”

The healthcare joint venture between GE and RUSSIAN

TECHNOLOGIES will start with the production of CT scanners and

then expand to other diagnostic medical equipment. The joint

venture may use the recently established joint GE Healthcare—

Medical Technologies Ltd. CT scanner assembly facility in Moscow.

In May 2010, GE Healthcare installed the first Russian-assembled

16-slice CT scanner in one of Moscow’s hospitals. The company

expects to supply over 60 more CTs to hospitals throughout

Russia by year-end 2011.

The Russian government plans to spend more than $30 billion

from 2011 to 2014 on healthcare. GE estimates current Russian

demand for CT scanners alone stands at 3,000 units. n

GE expanded its position in one of the world’s fastest growing

markets by finalizing agreements to set up two new joint

ventures—an Energy JV and Healthcare JV—in Russia. Russian

Prime Minister Vladimir Putin attended the signing ceremony

during the 10th International Investment Forum that took place

Sept. 16, 2011 in Sochi, Russia.

The Healthcare JV agreement was signed by RUSSIAN

TECHNOLOGIES Deputy General Director Dmitry Shugayev and

GE Chairman and CEO Jeffrey Immelt. This JV will manufacture,

assemble, sell, and service a wide range of high-tech medical

diagnostic equipment.

“The establishment of these joint ventures is a positive development

for both GE and Russia,” Immelt said. “We are very excited about

this long-term opportunity that firmly establishes GE’s business

in Russia and reaffirms our global leadership in the energy and

healthcare sectors. Our expansion in Russia reflects GE’s global

General Electric to Expand in Russia With New Joint Ventures


G E H E A lT H C A r E n E w s A n n o u n C E m E n T s

Hospitals today are faced with having to do more with less. In

the US, a global recession, healthcare reform, changes in the

delivery of patient care including the emergence of Accountability

Care Organizations, the need for low-dose initiatives, and lower

reimbursement have led hospitals to reevaluate purchasing

patterns and priorities.

As a result, hospital administrators are seeking

greater value in their capital equipment

purchases. They want to maximize return-

on-investment, achieve a lower total cost of

ownership, and create an avenue for growth

by developing additional service lines that help

attract new patient groups. Growth is an important

consideration in selecting a CT system that

provides high-quality images and superior

workflow across a plethora of studies—cardiac,

neuro, routine, and trauma/emergency—while opening

up new avenues for profitable growth. Hospital administrators

often seek a system that can help differentiate their services

from the competition.

The recently US FDA-cleared Optima CT660—a 64-channel detector

that is scalable from 32 to 128 slices and GE healthymagination

and ecomagination validated—fulfills these needs. It addresses

the key requirements that many C-suite hospital administrators

seek from new equipment acquisitions: patient care, financial

performance, operational excellence, and market growth.

The Optima CT660 consumes up to 60% less energy than previous

GE CT systems and boasts a 15% lower siting requirement

compared to other 64-channel detector scanners. Lower operational

costs translate to savings of potentially tens of thousands of

dollars over the life of the product. Plus, implementing a scanner

that emits up to 60% less carbon emission on the US grid is one

step toward becoming a “green” hospital.

Financial performance continues with service. GE’s service,

ranked No. 1 in service performance for CT systems by IMV Limited

in 2011,1 provides the highest number of CT field engineers of

any OEM. OnWatch Remote Services can often resolve 45% of

a CT scanner’s service issue(s) remotely.

Operational excellence is the key to market growth.

The Optima CT660 provides a comprehensive

suite of clinical capabilities—starting with the

GE-exclusive ASiR for low-dose imaging across

all anatomies. ASiR has been evaluated for its

lower-dose capabilities in over 75 published

studies. Ten million patients in more than

500 facilities worldwide have been scanned

using ASiR.**

Key applications on the Optima CT660 include: low-

dose cardiovascular imaging with SnapShot* Pulse and

consistent 0.625 mm data acquisition in CT Angiography;

VolumeShuttle* perfusion; Volume Helical Shuttle (VHS) for

perfusion studies up to 12 cm; Lung VCAR* and CTC Pro3D EC

applications for lesion detection, analysis, and follow-up; auto-

segmentation tools matching datasets to MR and PET/CT; and,

fast, efficient, one-touch workflow for emergency departments.

The 12-inch Xtream display on the gantry shows patient information,

protocol settings, and the ability to play relaxing videos. Automatic

patient positioning and a synchronized starting of the exam and

injection further streamline the study so facilities can maximize

patient throughput. The Optima CT660 also delivers a comfortable

patient experience.

The Optima CT660 brings together workflow efficiency, diagnostic

power, and lower equipment and operational costs to address a

new era of exceptional patient care, financial performance, and

operational excellence. n

Optima CT660: Taking Performance to a Whole New Level

References:

1. IMV ServiceTrak* Imaging CT Systems 2011 Report. IMV Medical Information Division, Des Plaines, IL.


To view a video about the Optima CT660, please visit www.ctclarity.com/ctclarity/201111#pg8. »


c u s t o m e r s p o t l i g h tb r i v o c t 3 2 5 i N i N d i a

Access to healthcare throughout India is improving as a result of Public-Private

Partnerships (PPP). An initiative by the Department of Health & Family Welfare of the

Government of West Bengal (WB) aims to make healthcare facilities available in the

district with the continued development of PPPs through the procurement cell West

Bengal Medical Services Corporation Ltd. (WBMSC). The Brivo§ CT325, a GE Healthcare

healthymagination-validated CT scanner, is a key contributor for increasing access

to advanced CT imaging in the state of West Bengal, India.

Brivo CT325 streamlines patient positioning, which often cuts in half the time it takes us to position the patient in the gantry.

Pranabananda Goswami, DMRD, MD

Mr. Govind Prasad Agarwal, Founder, Midnapore Diagnostics Pvt. Ltd.

A CT Designed for Broader AccessBy Pranabananda Goswami, DMRD, MD,

Jayati Bardhan, MD, Consulting Radiologists, and Mr. Govind Agarwal, Midnapore Diagnostics Pvt. Ltd.

§Brivo CT325 is not for sale in the United States. Not cleared by the US FDA.

C U S T O M E R S P O T L I G H T


C u s T o m E r s p o T l i G H T b r i v o C T 3 2 5 i n i n d i A

C u s T o m E r s p o T l i G H T

India’s first Brivo CT325 was installed at our facility, Midnapore

Diagnostics Pvt. Ltd. (MDPL), within the premises of R G Kar

Medical College & Hospital (Kolkata). Situated in the heart of

Kolkata, the hospital is a PPP venture between the Government

of West Bengal State and MDPL. Mr. Govind Prasad Agarwal

founded MDPL in 2002 with the objective of providing access to

radiology diagnostic facilities (CT & MRI) for the common people.

In February 2011, the new Brivo CT325 replaced a single-slice

CT. On average, we are performing 45 CT cases each day, which

exceeds 1,200 cases each month. In July 2011, we scanned

1,500 patients on the Brivo CT325, a record for monthly CT

scans at our facility. We are now very comfortable doing more

than 60 cases a day (including 25 to 30 body imaging cases),

which has substantially improved patient care. This was previously

not possible with our single-slice CT scanner. We anticipate that

we will be able to sustain similar capacities in subsequent

months, particularly due to the fact we’ve encountered no

unplanned downtime since the installation.

Midnapore Diagnostics Pvt. Ltd. within the premises of R G Kar Medical College & Hospital.

Volume-rendered 3D image is from digital tilt raw data.

A unique sub-mm high resolution CT image of the inner ear.

CT angiography of the Circle of Willis with faster coverage and high spatial resolution.

Volume-rendered 3D image illustrates a bone tumor in the pelvis.


c u s t o m e r s p o t l i g h tb r i v o c t 3 2 5 i N i N d i a

One of our requirements for a new CT scanner was faster

scanning time so that our radiology team could handle higher

patient volumes. Brivo CT325 streamlines patient positioning,

which often cuts in half the time it takes us to position the

patient in the gantry. Our technologists are also impressed with

the compact operating console and additional filming formats.

After six months of use, we are very satisfied with the speed

of the system and the quality of its images. Additionally, we

find the new unique Digital Tilt scan technique helps generate

excellent MPRs (Multi Planar Reformats) and display as routine

tilted images. We do not have to conduct another scan just

to obtain different reconstructions. And, the new innovative

table helps us complete the cases quickly and efficiently.

Perhaps most important to the sustainability of our PPP, the

volume-rendered 3D and HRCT (asymmetric scan) images

are catching the attention of many referring physicians.

In conclusion, we feel that the Brivo CT325 imaging capabilities

fulfill the various clinical needs of healthcare facilities like ours.

Its high image quality and dose-conscious design—combined

with a wide variety of proven, advanced applications—help

us make efficient and confident diagnoses across anatomies—

from the head down to the toes. This helps us provide better

support to other departments in the hospital and to our referral

doctors. Brivo CT325 thus lives up to its claim of extending

quality care to more people at an affordable cost. n

Its high image quality and dose-conscious design—combined with a wide variety of proven, advanced applications—help us make efficient and confident diagnoses across anatomies—from the head down to the toes.

Pranabananda Goswami, MD, DMRD, is a Consultant Radiologist at Midnapore Diagnostics Pvt. Ltd. (Kolkata, India). He also serves as Chief Radiologist and Radiology Director at VIP Apex Medical Center (Kolkata) and Chief Radiologist at ESI Hospital (Kolkata). Dr. Goswami received his medical degree and DMRD from the University College of Medicine (Kolkata) and his MBBS from R G Kar Medical College. He has also served as Assistant Professor of Radiology at R G Kar Medical College.

Portography study demonstrates excellent low contrast detectability.

Volume-rendered 3D image of the kidneys shows good spatial resolution.

MPR depicts the hip and head of femur.



C u s T o m E r s p o T l i G H T o p T i m A C T 6 6 0 i n i n d i A

In early April 2011, Meenakhi Mission Hospital and Research Centre (MMHRC) acquired

the first Optima CT660 in South India. Our radiology department is recognized as one of

the best in the region, providing various sub-specialties such as interventional radiology

in conjunction with a fully equipped and advanced diagnostic imaging department. The

acquisition of this new CT system will help us manage increasing patient volumes and

provide efficient diagnostic support to other specialties.

The key benefit for our patients is the system’s exceptional performance at low dose levels.

T. Mukuntharajan, MD, MBBS, DMRD

Delivering Quality Care: From Vision to Reality

By T. Mukuntharajan, MD, MBBS, DMRD, Head of the Department of Interventional Radiology & Radiodiagnosis; N. Karunakaran, MD, Consultant Radiologist; and R. Ganesh, MD, Consultant Radiologist, Meenakshi Mission Hospital and Research Centre


c u s t o m e r s p o t l i g h to p t i m a c t 6 6 0 i N i N d i a

The Optima CT660 system is the latest generation of multi-

detector CT from GE Healthcare. This new CT system provides

a streamlined workflow that assists our radiologists and

technologists in efficiently managing the heavy patient

workflow. Plus, the Optima CT660 is a GE ecomagination and

healthymagination validated product. The environment-friendly

power-save mode makes the system more energy efficient with

an average electric consumption of up to 60% less compared

to previous GE CT systems.

A key benefit for our patients is the exceptional performance of

the Optima CT660 at optimized radiation dose levels, including

generating high-quality diagnostic images with sub-millimeter

resolution and enabling high performance with innovations such

as backlit diode and high-density interconnects. Specialized

dose reduction techniques, such as Adaptive Statistical Iterative

Reconstruction (ASiR) and SnapShot Pulse (adaptive prospective

cardiac gating), may reduce patient dose for scans including

cardiac studies.**

In the first 72 hours after installation and calibration of the

system at our hospital, we conducted more than 100 patient

exams. This included a myriad of routine and advanced patient

studies including: coronary angiograms; CABG evaluations;

aorotograms; renal angiograms; multiphasic; and perfusion

studies. This system scans at a high pitch with a table speed

of 110 mm/s in the 0.625 mm detector configuration.

One of our initial cardiac studies was on a patient with a BMI

of 30.4 (see case 1). Generally, to achieve adequate image

quality and offset the increased attenuation due to higher

tissue mass, this patient would need to be scanned at higher

mAs, leading to a higher radiation dose. However, with the

Optima CT660, we acquired the coronary study in 5.1 sec with

a retrospectively gated cardiac acquisition technique using ECG

modulation at 100 kV. The mA range was 100 to 300, with peak

mA for mid-diastolic phase. The total dose for the coronary

acquisition was 3.85 mSv (DLP 275.03 mGy cm, conversion

factor ICRP 0.014*DLP).

** In clinical practice, the use of ASiR and SnapShot Pulse may reduce CT patient dose depending on the clinical task, patient size, anatomical location and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.

Case 1. CT Coronary study was performed with retrospective gated acquisition; the volume-rendered images and vessel tree projection show normal epicardial vessels.

In the first 72 hours after installation and calibration of the system at our hospital, we conducted more than 100 patient exams.


C u s T o m E r s p o T l i G H T o p T i m A C T 6 6 0 i n i n d i A

C u s T o m E r s p o T l i G H T

Another interesting case is an abdominal angiography for a

patient who presented with suspected SMA ischemia (see case

2). This study was also performed at very low mAs—with a

maximum of 58.8 mA. (The scan technique helical mode was

at 120 kV, 98 mA, 0.6 sec, pitch factor 1.375:1). Angiographic

and routine images from the same data demonstrate excellent

image quality even at a low mA. The total dose for the study

was 2.8 mSv, which is 70% less than the ICRP stated “nominal”

dose of 10 to 20 mSv (ICRP Publication 87, Managing Patient

Dose in Computed Tomography 30[4] Annals of ICRP 2002

[Obtained by EUR-16262 EN Abdomen and Pelvis factor of

0.017 x DLP.]).

The Volara XT* DAS system, a component of the Optima CT660,

provides a very high signal output at low photon levels. The

heavy attenuation produced by the metal hardware in the

patient does not result in severe photon starvation effect

and artifact from dense hardware (see case 3). (Total dose

of 6.3 mSv. DLP 422.96 mGy.cm. Obtained by EUR-16262 EN

Abdomen and Pelvis factor of 0.017 x DLP.)

The Optima CT660 also plays a very important role in our ability

to offer low-dose scanning, which is particularly important for

pediatric imaging. It includes GE’s pediatric color-coded protocols,

the use of 80 and 100 kV settings, and most importantly, the

effective utilization of high-yield performance of the detector

at low mA levels. Together, these features make this system

an appropriate CT imaging solution for pediatric studies.

Case 2. Abdominal angiography with suspected SMA ischemia. 3D volume-rendered image (far right) after one click Autobone Xpress* for removing bones. The VR IVUS ‘like’ view shows atheromatous mixed plaques along the lower aorta–iliac vessels.

Case 3. Axial images from a patient scan post laminectomy status with metal screws in situ—the adjacent bones close to the screws are well visualized without any beam hardening artifact or blooming.


c u s t o m e r s p o t l i g h to p t i m a c t 6 6 0 i N i N d i a

T. Mukuntharajan, MBBS, DMRD, is Head of the Department of Interventional Radiology & Radiodiagnosis, Meenakshi Mission Hospital and Research Center (Maduria, Tamilnadu, India). He received his MBBS and DMRD from Madurai Medical College. He specializes in vascular and interventional CT imaging, endoscopic ultrasound, echocardiography, and vascular and non-vascular interventional radiology procedures.

With over 700 beds, Meenakshi Mission Hospital & Research Centre (S.R. Trust ) has grown to be a multi-specialty hospital, touching lives in and around Madurai. The hospital extends the traditional Indian hospitality to international patients, combining it with cutting edge technology, clinical excellence, and compassion to deliver quality healthcare to all patients. S.R. Trust is a non-profit organization registered under the Indian Trust Act (May 9, 1985).

One pediatric case involved an eight-day-old baby who

suffered a head trauma (see case 4). The patient was not

opening their left eye after the trauma and a CT of the head

was ordered for a detailed evaluation. The exam included a

whole brain scan from the floor of orbits with a low-dose

technique and total reported dose of 0.83 mSv (DLP 75.83, ICRP

conversion factor of 0.011 *DLP for ‘zero’ age group), 80 kV, 120

mA, 1 sec axial mode, and detector configuration 0.625 X 32.

The study revealed no traumatic injury or bleed in the brain.

To summarize, after our initial experience scanning 100 patients

in three days, we found the Optima CT660 exhibited tremendous

capabilities in routine and complex studies and provided

exceptional image quality at optimized doses. We think the

Optima CT660 is an ideal CT scanner for virtually any radiology

department seeking eco-friendly, low power consumption,

patient comfort, fast workflow, and low-dose scanning capability

while delivering quality diagnostic images. n

Case 4. Axial images for brain with excellent grey white differentiation. 3D VR and Curved MPR for optic nerves are obtained from the same low dose scans.



C u s T o m E r s p o T l i G H T B r i v o C T 3 2 5 i n C H i n A

Yichun Yuanzhou Red Cross Hospital is a 318-bed, private, Tier-2 hospital—a medium-

sized hospital often referred to as a district, or township hospital. With more than 250

medical staff in the hospital and varied specialties in the facility, Yichun Yuanzhou Red

Cross Hospital is considered one of the larger and more advanced medical facilities in

Yichun Prefecture-level city.‡ In April 2011, Yichun Yuanzhou Red Cross Hospital installed

its very first CT system—the Brivo§ CT325.

Clinically, we are impressed that the system is easy to use yet doesn’t compromise image quality.

Dr. Yang Shenghong

Seeing Beyond the Naked EyeBy Dr. Yang Shenghong, Director of Radiology, Yichun Yuanzhou Red Cross Hospital

‡ A prefecture-level city is an administrative unit that typically comprises a main central urban area (often with the same name as the prefectural level city) and its much larger surrounding rural area containing many smaller cities, towns, and villages. The larger prefectural level cities can be over 100 km across in size. Prefectural level cities nearly always contain multiple counties, county level cities, and other such sub-divisions. (Source: Wikipedia)

§ Brivo CT325 is not for sale in the United States. Not cleared by the US FDA.


c u s t o m e r s p o t l i g h tB r i v o c t 3 2 5 i N c h i N a

When we began our search for a CT scanner, GE was a natural

choice for our hospital and five radiologists. We already

have GE X-ray, fluoroscopy, and ultrasound systems, and

our experience with these other systems has been very good.

So when we selected the Brivo CT325, we knew without

question that it would be a fine, quality system.

After seven months of using the new CT system, we have

realized many benefits for our patients and clinicians.

Clinically, we are impressed that the system is easy to use

yet doesn’t compromise image quality. We have found the

Brivo CT325 has excellent image quality in terms of low contrast

resolution and detectability, especially when compared to CT

systems in this segment that we’ve used at other hospitals. The

digital tilt feature can produce reconstructed images through

helical scanning, reduce scan time, and optimize CT study

workflow. Digital Tilt (DT) is an image reconstruction method on

CT systems that do not have gantry tilt capability. Reformatting

to obtain 2D/3D images with a helical scan is also possible for

certain anatomy such as the sinus or nasal bone.

Yichun Yuanzhou Red Cross Hospital

Ankle reconstruction

Lumbar reconstruction


C u s T o m E r s p o T l i G H T B r i v o C T 3 2 5 i n C H i n A


For radiologists, design and ergonomics complement the system’s

imaging capabilities. Thanks to a more efficient workflow,

lumbar spine scanning is more streamlined compared to other

CT systems we’ve used. With thin-slice imaging, we can better

visualize anatomy, especially the sinus. This was not attainable

with other CT scanners in this segment that we’ve encountered.

Currently, we conduct approximately 15 CT studies each day.

These CT scanning procedures have been well-received by

residents of the city, who have reported having positive CT

scan experiences. This is good news, given that we expect

patient volume to double within the next 12 months. While

today there are seven Brivo CT325 systems in the Jiangxi

Province, we are proud to be one of the first installed sites. n

Head reconstruction Chest reconstruction

Thanks to a more efficient workflow, lumbar spine scanning is more streamlined compared to other CT systems we’ve used.

Dr. Yang Shenghong is Head of the Department of Radiology and has more than 15 years of experience in his field.

Yichun Yuanzhou Red Cross Hospital in Yi Chun city, Yuanzhou district is located in the northwest of Jiangxi Province. In ancient times, Yuanzhou was known for its education, made famous by Han Yu, a renowned poet in the Tang Dynasty. Yuanzhou lies in Yichun Prefecture-level city and Yichun literally means “Pleasant Spring.”


c l i N i c a l v a l u ec a r d i a c i m a g i N g

In December 2010, Clinic “La Reine

Blanche” Orléans-France installed an

Optima CT660 with ASiR. In explaining

the reason to select the Optima CT660,

Olivier Genée, MD, cardiologist, says, “The

Optima CT660 fulfilled our requirement

for a 40 mm wide detector.” Another very

important consideration for the facility

is the issue of patient radiation dose,

he adds. With ASiR, the clinicians may

prescribe low-dose CCTA exams.

Predicting CCTA volume is a difficult

task, yet the clinic believed that a

scanner with advanced CTA imaging

capabilities and low dose would increase

patient and referring physician demand.

Therefore, the total cost of ownership—

including a smaller footprint that can

reduce siting costs and lower energy

consumption—was also an important

factor in the facility’s final decision. After

a thorough review of available solutions

and weighing the site’s requirements, Dr.

Genée and his team found the Optima

CT660 best met their needs for an

advanced imaging system with low dose

capabilities—and lower operating costs.

Installation of the Optima CT660 has

modified the diagnostic path in the clinic.

For example, the clinic often requires a

CCTA after an inconclusive scintigraph

scan from a gamma camera before

the patient undergoes a therapeutic

angiography in the cath lab. Interestingly,

as the volume of cath lab procedures

increased, so too did the CCTA exams.

Meeting the Clinical Need for Low-dose Cardiac Studies

Figure 1. Myxome of the left atrium as seen in a retrospectively gated acquisition.

A

C

B

D

Figure 2. The vessel lumen is clearly seen as the calcium blooming is significantly reduced.

A

B


C l i n i C A l v A l u E C A r d i A C i m A G i n G

Dr. Genée says that the CCTA rules out false positives that often

appear during stress tests and supports treatment decisions

regarding coronary conditions. When the CCTA test indicates

a low probability of CAD, the patient can avoid a diagnostic

cath lab procedure. According to the clinic’s practice, patient

selection is determined with the help of a medical prescriber.

If the patient’s heart rate is over 65 bpm, the clinic uses beta-

blockers prior to the CCTA.

Dr. Genée finds that performing CCTA in an emergency setting

may be difficult due to patient arrhythmia or even fibrillation.

The team finds the post processing is very flexible and powerful.

Additionally, the Optima CT660 has allowed Clinic “La Reine

Blanche” Orléans-France to perform new types of cardiac CT

studies, further broadening its clinical expertise. The

clinic conducts examinations of myocardium function in

patients with certain non-echogenic tumors or inaccessible

trans-esophageal ultrasound. Vascular CT exams allow

for accurate diagnosis in cases of aorta dissection when

trans-esophageal ultrasound is not sufficient. Finally, after

the Optima CT660 installation, patients with an indication of

pulmonary embolism can now be examined on site without

transferring them to another hospital.

Asked what he would say to a colleague considering implementing

an Optima CT660, Dr. Genée says, “We are very satisfied

with the Optima CT660 with ASiR. It meets our expectations

and offers an excellent quality-to-investment ratio.” n

Figure 3. Approximately 50% stenosis seen in the RCA.

B

DC

A

Olivier Genée, MD, is a cardiologist at the Unité Cardiologique de la Reine Blanche (Orléans, France). He is also a specialist in emergency medicine. Dr. Genée received his initial medical training at the University of Lille, and worked in the cardiac intensive care unit of the University Hospital Center of Tours. He is an expert in treatments and non-invasive cardiac explorations, including transthoracic echocardiography, cardiac CT, and MRI. Dr. Genée is an associate member of the French Society of Cardiology, and a member of the French Society of Emergency Physicians. He is also a researcher and has authored several articles and publications in cardiology and emergency medicine.

Clinic “La Reine Blanche” Orléans-France is a medium-sized hospital of more than 200 beds. Since the clinic opened in 1970, its primary focus is cardiology and pathologies linked to cardiovascular such as diabetes, endocrinal disease, and kidney failure. The medical recruitment involves at least 20 cardiac CT Angiography (CCTA) exams each week. The clinic also has a follow-up care mission in cardiac, nutrition, and post pathologies recovery. Currently the Cardiology Department provides services to the Loiret and Romorantin-Lanthenay region. In 2013, the clinic plans to merge healthcare services to a new facility with two other institutions from Orléans: Polyclinic des Longues Allées and the Radiotherapy center COROM. This new clinic will have approximately 500 beds and offer all surgery activities, along with cardiovascular services, to the residents North of Orléans city.


c l i N i c a l v a l u ev e O : u lT R a - l O W D O S e

University Hospital, Brussels has been using Veo since March 2011.

In addition to ultra-low dose CT imaging—in some instances as

low as plain film radiography—Veo provides new possibilities for

the radiologist to tailor the scan parameters to the patient. For

example, radiologists for years have known that when looking

for a pulmonary embolism, the exam is tailored to the indication

by administering a faster rate of contrast and scanning the bolus

earlier. If the clinician is investigating the possibility of interstitial

disease in the lungs, then the radiologist would perform the CT

scan at a higher resolution and thinner slices.

These examples, while part of the typical radiology practice,

demonstrate the versatility of CT imaging that we have fine-tuned

over the course of 20 years. With Veo in our facility, we have

further expanded CT imaging into clinical possibilities. We have

achieved reduced mA and kV in the acquisition of diagnostic

images and thereby been able to reduce dose to previously

unthinkable levels.**

Enabled with Veo, these new possibilities can be further tailored

to the patient by adjusting CT parameters radiologists have used

for decades. In fact, Veo has opened up new possibilities for

challenging cases and sensitive patients. For example, while Veo

may allow scans at an ultra-low dose, we can still scan at typical

dose levels and obtain images with higher spatial resolution and

better delineation of structures.

The key to the successful implementation of these new scanning

possibilities is determining the appropriate patient group that

will benefit most from the Veo technology and understanding

how it can be used without impacting radiology workflow.

Workflow

Veo is a processing technique that generally requires more time

(estimated from 20 to 80 minutes) to generate a high-quality

image from an ultra-low dose acquisition. In our facility, this has

not presented any issues to our radiology workflow. As in most

Implementing Ultra-low Dose CT with Veo at University Hospital, BrusselsConsiderations for workflow and patient selection By Professor Johan de Mey, MD, PhD, Chair of Radiology, University Hospital, Brussels

** In clinical practice, the use of Veo may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.


C l i n i C A l v A l u E v E O : u lT R A - l O W D O S E

public hospitals across Europe and the US, radiologists perform

their interpretations and reporting in a reading room or back

office, well after the exam has been completed, and not in the

CT room or while the patient is in the scanner.

In our facility, the need for an immediate diagnosis occurs in

approximately 5% of our patients—i.e., emergency cases—and,

therefore, we use ASiR for low-dose CT studies in these instances.

However, even in emergency cases the physician must often

wait 30 minutes for laboratory results, so we believe the

additional time to utilize Veo is not an issue considering other

test results will require time for analysis.

For the technologist, workflow efficiency is also not compromised.

Even with an ultra-low dose scan, the CT scanner immediately

provides images so the technologists can evaluate that the proper

patient positioning was attained for displaying the anatomy or

pathology in question. Our technologist can determine from the

initial images that the exam acquired the desired anatomy.

Patient selection

A critical component to maintaining an efficient workflow using

Veo is identifying patients who would benefit most from an

ultra-low dose exam. Because we only have one Veo (box) at our

facility, we cannot utilize it on each patient receiving a CT scan.

As mentioned above, emergency cases should be evaluated

based on other dose lowering techniques available (e.g., ASiR).

Radiotherapy patients are also often excluded as the amount

of radiation dose from CT is small compared to the treatment

they received.

Although we continue to adapt the patient criteria for Veo

reconstructions, our facility has identified the following patient

groups, who may benefit most from a Veo scan: pediatric patients,

particularly those who require regular scanning and follow-up

due to a disease or affliction, young adults, adults with a disease

requiring regular X-ray or CT imaging follow-up, and adults with

kidney disease.

Veo provides new possibilities for the radiologist to tailor the scan parameters to the patient.

Professor Johan de Mey

A B C

Figure 1. A two-year-old patient with empyema. Exam conducted at DLP 27 mGy.cm with an effective dose of 0.9 mSv (Obtained by EUR-16262 EN, using a pediatric chest factor of 0.031*DLP). Acquisition parameters are 80 kV and 15 mAs.


c l i N i c a l v a l u ev e O : u lT R a - l O W D O S e

Historically in our facility, pediatric patients with cystic fibrosis

and no health complaints received a lung X-ray every two years.

This was the first pediatric group for which we utilized the Veo

reconstruction. In most cases, the patients are stable, and some

have previously identified lung lesions. We initiated a double-

blind study, substituting the X-ray with low-dose CT performed

at the same dose level as the X-ray. We noticed we could see

more anatomy with the volume CT than the prior X-ray. There were

cases where the CT demonstrated an evolution in pathology

that was previously deemed stable based on the X-ray data. CT

provided the ability to detect lesions more clearly, which in many

instances will impact patient treatment. We ultimately moved

all cystic fibrosis pediatric patients to Veo low-dose CT follow-up.

Young adults are another category where the benefit from ultra-low

dose CT is great. As with pediatrics, the patient’s history and

indications are reviewed to determine the best imaging option

and appropriate low-dose reduction.

Another group of patients who receive low-dose Veo CT scans

at University Hospital are those suffering from Crohn’s Disease.

These patients often have complaints related to this bowel

disease and receive CT exams.

Lastly, for patients with kidney disease we have adjusted our

protocols to lower kVs to help us address iodine use in patients

who may be sensitive to it.

Based on our experience, developing the proper Veo protocols—

both in patient selection and implementing low-dose imaging—is

important for successful implementation. As one of the first sites

to clinically use Veo, we continue to examine Veo’s potential and

implementation on specific patient groups.

One thing we learned is that we cannot uniformly lower dose for

every indication when changing the protocols. For each patient

group, we are still building our experience and determining the

appropriate dose levels. Additional scientific studies, including

the global multi-site clinical study that GE is sponsoring, will

provide additional information to help optimize dose level

protocols for each patient group. n

Johan de Mey, MD, PhD, is Chair of the Radiology Department at University Hospital, Brussels, and a Professor at Brussels University where he is also the coordinator for radiology resident training. Prof. de Mey earned both doctorate degrees at the Vrije Universiteit Brussels; his PhD thesis was CT fluoroscopy in interventional radiology. As Professor, he lectures on radiology anatomy, normal and pathologic radiology and emergency radiology.

Located in the heart of Europe, the University Hospital Brussels is one of Belgium’s premier centers of excellence in healthcare, biomedical research and medical education. One of seven University Hospitals in Belgium, it is closely associated with the Brussels University. University Hospital Brussels has gained recognition at both a national and an international level. With its 700 beds and staff of 3,000, close to 30,000 inpatients and 500,000 outpatients are treated every year.

www.gehealthcare.com/LowerDoseByDesign »

Figure 2. Maxillofacial CT of a nine-year-old patient with a fracture of the inferior orbita. Exam conducted at DLP 38.97 mGy.cm with an effective dose of 0.31 mSv (Obtained by EUR-16262 EN, using a pediatric head factor of 0.008*DLP). Acquisition parameters are 100 kV and 14 mAs.

A B C

Editor’s note: For more information on the global multi-site clinical study, please see article on page 54.


C l i n i C A l v A l u E B r i G H T S p E E d E l i T E w i T H i Q E n H A n C E

Carolinas Imaging Service (CIS) is a joint venture between

Charlotte Radiology and Carolinas HealthCare System located

in metropolitan Charlotte, NC. The group provides patients with

a freestanding, outpatient option across a multitude of imaging

systems and exam types.

In November, 2010, CIS decided to outfit its outpatient imaging

clinic in South Park with a BrightSpeed Elite CT. One clinical area

where the new system has made an impressive impact is in

musculoskeletal (MSK) imaging. Currently, between 15 to 20 MSK

CT studies are performed each day at CIS.

When it comes to MSK, James Coumas, MD, knows bones. He

graduated with a fellowship in musculoskeletal radiology from

Massachusetts General Hospital and reads MSK images full time.

“With 85 radiologists in our group, we have the ability to specialize

into specific regions of the body that interest us. For me, that is

the musculoskeletal system.”

Dr. Coumas is passionate about the work he does in MSK.

“Musculoskeletal radiology spans a spectrum of disease processes

as well as congenital and acquired abnormalities,” he says. “Whether

it’s a congenital anomaly, a response to a debilitating disease

process, an acute sports injury, or aged encumbered degenerative

arthritis, the musculoskeletal system is usually involved.”

The one thing Dr. Coumas loves about CT in general is the speed.

“A patient comes in with pain that is non-specific and CT is used

as a rule-out mechanism for the pain,” he explains. “The advantage

of CT is it takes two minutes; MR is 30 to 45 minutes. When you

are in pain, this is a long time to be on a table for a scan.”

Dr. Coumas is particularly excited about the BrightSpeed Elite

and the IQ Enhance (IQE) feature. IQE allows the group to use

their 16-slice scanner with faster pitch helical scanning at a

similar artifact index level compared to slower helical scanning

without IQE. This coverage speed is equivalent to that of wider

detectors (50 slice equivalent) at the same table speed. This

decreases the length of time per study without a corresponding

loss in image quality, he explains. In fact, Dr. Coumas prefers

using the IQE feature on all MSK cases.

He also does a great deal of referral work with orthopedic surgeons

who have had issues with certain implant recalls. “Artifact

reduction in prosthetic imaging is a large part of our business with

patients 40 to 60 years of age. It is important to have a scan that

you are able to see 360° around the prosthesis to determine if

there is anything loose, fractured, or dislocated (Figure 1).”

Dr. Coumas is enthusiastic about using the BrightSpeed Elite for

his patient cases. “We have 15 scanners in our group and for MSK

workups we currently send all our patients to the BrightSpeed.”

BrightSpeed Elite with IQ Enhance Delivers Speed and Clarity in the Carolinas

“ A patient comes in with pain that is non-specific and CT is used as a rule-out mechanism for the pain. The advantage of CT is it takes two minutes; MR is 30 to 45 minutes. When you are in pain, this is a long time to be on a table for a scan.”

Dr. James Coumas


c l i N i c a l v a l u eB r i g h t S p e e d e l i t e w i t h i Q e N h a N c e

Patient case with and without IQE

A 68-year-old male patient presented at CIS with a history

of mild chronic obstructive pulmonary disease (COPD). A

chest CT exam with contrast revealed a new right apical cavity

nodule. The comparison images (Figure 2) demonstrate how

the BrightSpeed Elite with IQE can help to reduce the amount

of streaking and windmill artifact in the coronal dataset.

Overall, the BrightSpeed Elite has been a positive decision for CIS.

It’s intelligent, versatile, and user-friendly. Dr. Coumas sums it up

best, “For routine body work, the Brightspeed Elite is all I need.” n

Figure 2. (A) With IQE and (B) without IQE.

A B

Acquisition Protocols:

kV: 120 mAs: 276-436 Slice thickness: 0.625 Coverage: 336 cm Pitch: 1.75

James M. Coumas, MD, specializes in musculoskeletal radiology at Carolinas Imaging Services. He earned his medical degree and completed his residency at the University of Massachusetts Medical School (Worchester) and a fellowship in musculoskeletal radiology at Massachusetts General Hospital.

Charlotte Radiology (CR) is one of the largest and most progressive radiology groups in the nation, serving Mecklenburg and surrounding counties since 1967. With 80+ radiologists with diverse and specialty training—including Mammography, Musculoskeletal, Pediatrics, and Interventional Radiology—CR provides 24/7 coverage for more than 11 hospitals and four outpatient imaging centers (including CIS). In addition to CIS, the group owns and operates 12 breast centers, two vascular and interventional clinics, and an MRI center.

Figure 1. (A) Volume-rendered image; (B) sagittal view image

A B

Acquisition Protocols:

kV: 120 mAs: 191-310 Pitch: 1.375:1 Coverage: 116 mm Scan time: 6.69 sec


C l i n i C A l v A l u E B r i G H T S p E E d E l i T E w i T H i Q E n H A n C E

Helical windmill artifact is caused by the aliasing of the signal.

Aliasing occurs when a signal is sampled too slowly or at a

frequency comparable to or smaller than the signal being

measured and, as a result, obtains an incorrect frequency

and/or amplitude.

The IQE algorithm dynamically detects the presence

of aliasing and automatically corrects for such artifact.

The following case is a great example of how the windmill

helical artifact surrounding bone can be minimized to enhance

the final outcome by scanning with IQE at a pitch of 1.75. This

scan, done in 5.4 seconds, demonstrates the excellent spatial

resolution as well as speed using BrightSpeed Elite with IQE.

Helical Artifact Index is defined as: ((SD value at ROI1)2-(SD

value at ROI2)2)1/2. Two helical data sets were acquired

to compute a Helical Artifact Index. n

Figure 3. (A) With IQE and (B) without IQE

A

Acquisition Protocol:

Scan type: Helical (IQE) kV: 120 mAs: 90-210 Pitch: 1.75 Coverage: 70 mm/s Scan time: 5.4 sec Gantry rotation: 0.8 sec Slice thickness: 1.25 mm SFOV: large DFOV: 32 cm Start/End: S200-I370 Reconstruction: 512 matrix

One data set was acquired at 1.75:1 pitch with table speed of 37.5 mm per rotation with IQE ON at 260 am and other using 0.562:1 pitch with table speed of 11.25 mm per rotation with IQE OFF at 160 mA.

IQE helps to minimize aliasing of the signal

B


c l i N i c a l v a l u em u s c u l o s k e l e t a l i m a g i N g

With the recent advances in technology and software development,

the utilization of CT in musculoskeletal (MSK) clinical imaging

has undergone tremendous improvements. The most observable

changes are the availability of High Definition (HD) CT data

acquisition and reconstruction, Gemstone Spectral Imaging (GSI)

with monochromatic data, effective metal artifact suppression,

and dynamic 4D evaluation of joints and tendons using volume

helical shuttle.

In this article, we share some of our early experiences with the

new Discovery CT750 HD installed at our hospital.

Emerging Applications in Musculoskeletal CT Imaging By K Murali MD(RD), PDCC, Director of Interventional Radiology, G. Francis DMRD, DNB (RD), Consultant Radiologist, and R. Madan, MBBS, MD, Consultant Radiologist, MIOT Hospital; Sundar RK, Clinical Applications Manager, CT, GE Healthcare

HD Imaging

The HD scanner can acquire 2.5 times more views per rotation

than a typical (non-HD) CT scanner. This results in improved

spatial resolution. The images below are acquired with a high

definition protocol where both HD standard and HD bone

images are reconstructed for analysis for soft tissue as well

as for pathologies involving bone and joints (Figure 1).

Comparative images of normal routine bone reconstruction

and HD scan and reconstruction (Figure 2) show improved spatial

resolution with higher bone details in the HD bone images.

Figure 1. (A) HD standard; (B) HD bone

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C l i n i C A l v A l u E m u s C u l o s k E l E T A l i m A G i n G

Figure 2. (A) Routine bone; (B) HD bone

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Figure 3. (A) HD standard; (B) HD bone

A B

The HD images clearly demonstrate the comminuted fracture of

calcaneus involving the posterior sub-talar joint. The visualization

of cortical margins and trabecular pattern is clearly seen in the

HD bone image. The spatial resolution of HD images can be up

to 230 microns (calculated using 0% MTF).

Using HD imaging in a knee study, we were able to appreciate

subtle findings such as a hair-line fracture of the patella in the

HD bone image and other soft tissue details in the HD standard

images (Figure 3).



Gemstone Spectral Imaging in implant studies

We use dual energy acquisition with fast kV switching enabled

by the Gemstone Detector in many of our studies on patients

with orthopedic implants. The results were unparalleled and

promising. With the GSI technique, we created monochromatic

images specific for bone and implants. The projection data

based reconstruction technique with metal artifact reduction

software (MARs) helps significantly in the reduction of artifacts

from high density metal implants and allows the accurate

visualization of the underlying bone and adjacent soft tissue.

The 100 keV monochromatic image with MARs was able to show

the implosion of implant into the joint space and producing

pressure erosion of the articular surface of femoral condyle.

The GSI monochromatic technique with MARs is highly useful in

external fixators. Unlike internal fixators, imaging with external

fixators involves more challenging issues due to an increase in

beam-hardening artifacts that are primarily due to the air gap that

exists between the body and the external fixator. We were able

to use GSI with MARs to resolve this complex situation (Figure 6).

Figure 5. (A) 140 kV; (B) 100 keV with MARs

A B

Figure 4. (A) A routine reconstruction at 140 kV from a GSI scan data shows significant beam hardening artifact from the implant hardware. (B) Monochromatic image generated from the same GSI acquisition at 100 keV demonstrates the subtle reduction of metal beam hardening artifact without significant difference. (C) The same image reconstructed with MARs in which artifacts were completely removed and we were able to assess the implant integrity and adjacent tissue as well.

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C l i n i C A l v A l u E m u s C u l o s k E l E T A l i m A G i n G

Figure 6. (A) 140 kV; (B) 70 keV with MARs

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Figure 7. (A) Upper limb angiogram for vascular assessment post external fixation of humerus fracture. Note the extensive beam-hardening artifacts from the metal implants obscuring the visualization of the brachial artery. (B) and (C) illustrate 70 keV monochromatic 3D MIP and 3D VR transparency images depicting the normal patent vessel.

A B C

CT is often used to rule out vascular injuries in pre-surgical

and post-surgical orthopedic patients. GSI with MARs helps

us diagnose the presence of vascular injury in these complex

cases with a high degree of confidence.

Figure 7 demonstrates the efficacy of MARs in studies involving

external fixators by removing beam-hardening effects from the

hardware. The 70 keV MARs images show the tibia and the tibial

condyles. The margins and cortex of tibial condyle is well

visualized compared to the 140 kV standard.

Figure 8. These images show dynamic sequences of the ankle joint from flexion phase to extension phase. This demonstrates movement of the non-united fracture fragment and focal reduction in posterior sub-talar joint space with apposition of the talus and calcaneus.



Figure 9. The coronal phased images reveal the movement of large fracture fragment in to the joint space.

Figure 10. The axial KCT images from flexion phase to the extension phase show the subluxation of patella.

Kinematic studies in musculoskeletal imaging

Kinematic evaluation of the joints involves the use of the Volume

Helical Shuttle (VHS) mode of image acquisition. A special

reconstruction algorithm—dynamic pitch reconstruction—is

used to help prevent artifacts due to movement. In our facility,

we have performed kinematic evaluation of studies for joints

including the elbow, wrist, knee, and ankle. Kinematic CT (KCT)

is highly useful in evaluating movement of loose bodies into the

joint space for assessing instability and predicting development

of arthritis.

With the advent of technological developments in CT such as

GSI, MARs, and HD, we are able to overcome previous limitations

in MSK CT imaging. The use of VHS in orthopedic studies has

resulted in the dynamic evaluation of joints. We have used

these new techniques very effectively in the evaluation of

MSK pathologies with a high degree of diagnostic confidence

and accuracy. n

G. Francis, MD, is a senior consultant radiologist at MIOT Hospitals Chennai specializing in MSK and vascular CT. He received his M.B.B.S. from Christian Medical College (Vellore), his D.M.R.D. from Stanley Medical College (Chennai), and his D.N.B. (radio diagnosis) BIR from Madras Medical College (Chennai).

K. Murali, MD, is the Director of Interventional Radiology at MIOT Hospitals Chennai practicing diagnostic and interventional radiology. He received his M.B.B.S. Coimbatore Medical College (City), medical degree from Gujarat University (City), and post-doctoral certificate in neuro and vascular. Dr. Murali has published twelve scientific articles, a text book chapter, and presented numerous scientific papers in national and international conferences.

R. Madan, MBBS, MD, is a Consultant Radiologist at MIOT Hospitals. Dr. Madan received his medical degree from the Government Medical College, Madurai, and his MBBS from Stanley Medical College. He spent three years as a senior resident at Sanjay Gandhi Post Graduate Institute of Medical Sciences. Dr. Madan’s areas of interest are musculoskeletal radiology and image-guided biopsy.

MIOT Hospitals Chennai is a 500-bed, multi-specialty hospital in India founded by a physician. The hospital is recognized as a leading center known for orthopedics and orthopedic research, including joint replacement surgery with 35,000 successful hip and knee replacement and revision surgeries. It is also the first hospital in the Asia-Pacific region and second hospital in the world to have a computer-integrated navigation system for joint replacement surgery. MIOT also has specialized centers for: nephrology, including the largest and most modern nephrology department in the country—performing five renal transplants each month and, in collaboration with Japan, kidney transplants across blood-type groups—and a state-of-the-art dialysis unit; thoracic and cardiovascular care offering endovascular grafting for aortic aneurysm by keyhole surgery procedures and beating heart surgery; neurology and neurosurgery; and pediatric cardiac surgery for treating congenital heart disorders.


C l i n i C A l v A l u E 4 D o n C o l o G y

In order to improve accuracy in radiation therapy for chest and

abdomen cancers, it is necessary to visualize, control, and track

patient specific respiratory motion. Tumors near or around the

diaphragm will likely move with respiration.

Without the means to limit respiration-induced target or organ

motion, large treatment fields have to be used, potentially

resulting in more irradiation of surrounding normal tissues. As

a result, the risk of complications may increase. Conversely, if

smaller treatment fields are used, the target may move out of

the treatment field resulting in an under dose to the target.

Some techniques such as breath-holding, forced shallow

breathing, and respiratory-gated treatment techniques have

been implemented to account for respiratory motion.

Therefore, precise targeting of the tumor and tracking

of respiratory motion are important to patient outcomes.

Since October 2009, we have used Varian’s Real-time Position

Management™ (RPM) System, which uses an infrared tracking

camera and reflective marker to measure the patient’s

4D CT With Respiratory Gating Helps Locate and Track Lesions to Reduce Target VolumesBy Xiaodong He, MD, Radiotherapy and Thermotherapy Center, Shanghai Pulmonary Hospital

Figure 1. (A) Illustrates lesion location in inspiration; (B) shows lesion location in expiration, demonstrating the movement of the lesion during the respiratory cycle.

A B

Real-time Position Management (RPM) System is a trademark of Varian Medical Systems, Inc.


c l i N i c a l v a l u e4 D o N c o l o g y

We are able to deliver effective patient treatment with customized treatment plans based on each patient’s respiratory cycle.

Dr. Xiaodong He

www.gehealthcare.com/aw/applications/ advantage-4d/ »

respiratory pattern and extent of motion. Advantage 4D*, a

respiratory motion management application on the Advantage

Workstation, helps providers analyze respiration-induced motion

of anatomy based on data acquired using the Varian RPM in

conjunction with the GE RT CT system.

Prior to treatment planning, patient CT images are acquired

and processed in 4D. The patient is scanned using a Cine CT

respiratory protocol and the respiratory waveform file is

simultaneously recorded with an external respiratory gating

system, e.g., RPM. The Advantage 4D software then sorts

and saves the Cine CT image data into phases and intensity

projections (MIP, Average, Min-IP).

With GE’s Cine acquisition, the CT images of the MIP dataset

are utilized in the treatment planning system. We then select

the 4D CT phases corresponding to the 30%~70% breathing

phases of the patient.

In our facility, we are using the 4D data and RPM on approximately

10% of patients—those who have stable and reproducible breathing.

We have found that 4D CT data aids in assessing the tumor

location. Using the GE Advantage 4D with the Varian RPM system

has helped us reduce the inner target volumes. The impact on

patient treatment since the implementation is impressive. We

are able to deliver effective patient treatment with customized

treatment plans based on each patient’s respiratory pattern. We

are experiencing a decline in acute radiation-induced pneumonia

rates, which further increases our confidence in 4D treatment

planning and ability to effectively irradiate the lesion and spare

more surrounding healthy tissue. n

Professor He Xiaodong, MD, is the Chief Physicist and Vice Director of the Radiation Oncology Department at Shanghai Pulmonary Hospital. His research of radiophysics, radiobiology, and thermotherapy includes dosage study on EPID; X-ray beam dose distribution reconstruction; electron beam dose calculating model; enlargement of volume effect in LQ model; bioequivalent DVH (BDVH) calculation; RF thermodosage theorem; and portal image processing technique. He is also well known in China for his expertise on moving target radiation therapy.

Shanghai Pulmonary Hospital is affiliated to Shanghai Tongji University (also known as Shanghai Occupational Disease Hospital). The hospital opened in 1933 and the radiation oncology department—dedicated for lung and esophagus cancers and mediastinal and metastatic tumors—was built in 1989. Oncology equipment includes two Linear Accelerators (one with RPM), a set of large aperture 4D CT simulators, one X-ray simulator, and several treatment planning systems.


C l i n i C A l v A l u E E M E R G E n C Y R A D i O l O G Y

CT has become an important diagnostic tool for the Emergency

Department (ED) physician. A recent study in the Annals of

Emergency Medicine found that in the US, approximately one in

seven ED patients received a CT scan as part of their evaluation.1,2

The top indications for CT use in the ED are abdominal pain, flank

pain, chest pain, shortness of breath, and trauma.

The study examined data from the National Hospital Ambulatory

Medical Care Survey on nearly 100 million patients receiving a CT

scan in the ED between 1996 and 2007. Between 1996 and 2007,

CT use during ED visits increased 330%, with the largest increase

in patients older than 79 (9.1% in 1996 to 29.1% in 2007).

However, the study found a correlation between CT use and

a drop in hospital admissions. According to one of the authors,

Keith Kocher, MD, University of Michigan, the likelihood of

hospitalization or transfer after a CT declined throughout the

study period, from 26% in 1996 to 12.1% in 2007. The rate

leveled off after 2003 despite a continued increase in the

adjusted, overall rate.

In addition to CT possibly correlating to a reduction in the rate

of hospitalization or transfers, the study also found it may impact

decisions about where hospitalizations occur, with a shift away

from expensive ICU admissions.

The following are profiles of two facilities utilizing CT in the ED to

positively impact patient outcomes and help clinicians make the

most appropriate care decisions.

1. Kocker KE, Meurer WJ, Fazel R, et al. National Trends in Use of Computed Tomography in the Emergency Department. Annals of Emergency Medicine 12 Aug 2011; published online

2. Barnes E. Rise in CT use linked to drop in hospital admissions. AuntMinnie.com. Available at http://www.auntminnie.com/index.aspx?sec=sup&sub=imc&pag=dis&ItemID=96135

St. Vincent Hospital

At St. Vincent Hospital (Indianapolis, IN), a Discovery CT750 HD

is an integral part of the hospital’s ED, Level II Trauma Center,

and Stroke Center of Excellence. Since opening the trauma

center, ED volumes have increased, says Nikki Duckworth, RT,

MBA, Manager of Medical Imaging Services. Today, the 39-bed

ED handles an average of 149 patients each day.

High-Definition CT Improves Triage and Door-to-treatment Times in Emergency Radiology

Figure 1. The Discovery CT750 HD scanner installed at St. Vincent Hospital.

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c l i N i c a l v a l u ee M e R G e N c Y R a D i O l O G Y

“For routine cases, the nurse manager alerts us when the patient

is ready for CT,” Duckworth explains. “In trauma cases, a mass

page goes out with an estimated time of arrival, so the patient

goes straight to the CT when stabilized.”

For the most severe trauma patients, the CT protocol includes

the head, cervical spine, chest, abdomen, and pelvis, says

Michael Skulski, MD, Chair of Medical Imaging at St. Vincent.

“We want to assess the patient as quickly as possible, and this

system is very good from that perspective.” In fact, Corey Graff,

RT(CT), CT technologist at St. Vincent, is impressed by the exam

split capability on the Discovery CT750 HD. “If I have a trauma

patient and don’t have a patient ID, I can scan all the exams

in our protocol, one after another, and at the end send all the

exams wherever they need to go. I don’t have to re-landmark

and that helps with the patient flow.”

Dr. Skulski adds, “The speed of this system has addressed

the issue of patient motion and with ASiR we’ve decreased

radiation dose by 30% to 40%.** Reformats are virtually

instantaneous, and the trauma surgeons are very impressed

with the quality of the images.”

Selecting the Discovery CT750 HD was a carefully considered

choice. Says Duckworth, “We needed a CT that was fast, could

potentially help us lower radiation dose, and handle a variety

of exams.” This system provides all of the above and more

for St. Vincent.

Dr. Skulski is also impressed with the potential he sees with

Gemstone Spectral Imaging (GSI)—another key factor in selecting

the system. In fact, a physician from another state sought out

St. Vincent because of the GSI technology and referred a hip

replacement patient to the hospital for evaluation. “We could

identify a non-union, incomplete fracture proximally to the hip

replacement, and I’m not certain we would have identified that

without GSI.”

While it is too early for Dr. Skulski to make any definitive clinical

statements on the value of GSI, he’s excited at the potential

benefits. “We are still learning the capabilities of GSI and

haven’t yet scraped the surface of its impact.”

“As a Stroke Center of Excellence, the VolumeShuttle technology has

helped simplify the protocol and added noticeable improvement

to the study by enabling an increase in the area of interest,”

explains Dr. Skulski. Plus, based on outcome data and the

desire to reduce door–to-treatment time, the institution has

changed its initial neuro/stroke protocol from three studies to

one. Stroke patients first receive a non-contrast CT head. After

TPA administration and evaluation, if another CT study is ordered

the patient then receives a non-contrast CT of the head, a CTA

of the head and neck, and CT perfusion—these three studies

comprised the original neuro/stroke protocol. “Our goal is to

improve door-to-treatment time for these patients so they can

begin their anti-coagulation therapy sooner,” explains Dr. Skulski.

With the revised CT protocol using the high definition capabilities

of the scanner, the CT study has dropped from approximately

15 minutes down to three.

Looking back at their system choice, the team at St. Vincent

is confident the Discovery CT750 HD will meet their present

and future needs. Adds Dr. Skulski, “I’m confident with this

scanner we are only at the beginning of exploring new

innovations from GE.”

** In clinical practice, the use of ASiR may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.

“ As a Stroke Center of Excellence, the VolumeShuttle technology has helped simplify the protocol and added noticeable improvement to the study by enabling an increase in the area of interest.”

Dr. Michael Skulski



Ludwig-Maximilians University Hospital

In the heart of Munich is one of Europe’s leading medical

research universities and public health centers. The nearly

1,000-bed University Hospital of the Ludwig-Maximilians

University (LMU) is home to one of the largest radiology

departments in Europe and chaired by Professor Maximilian

Reiser, FACR, FRCR, a world-renowned radiologist.

Nearly two years ago, the University Hospital at LMU installed

a Discovery CT750 HD in the ED. According to Professor Ulrich

Linsenmaier, Vice Chair for Clinical Operations in the Department

of Clinical Radiology, it is the most reliable scanner the hospital

has ever had in the ED with nearly no unplanned downtime.

“We’ve seen an increase in patient volume and our ability

to handle a series of emergency patients is important, as

in mass casualties,” Prof. Linsenmaier says. “Now, with the

Figure 2. Low-dose MDCT of the cervical spine; images were obtained on 64-row MDCT standard scanner using FBP (left, DLP of 265.05 mGy-cm) and on the new Discovery CT750 HD scanner using ASiR (right; DLP of 107.36 mGy-cm).

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“ By introducing volume image reading in the ED, the workup for a mass casualty patient has decreased from an average of 15 minutes to 8 minutes.”

Professor Ulrich Linsenmaier

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Figure 3. Whole-body MDCT in different patients after major trauma (polytrauma) obtained on a Discovery CT750 HD scanner using ASiR; images allow for a quick and comprehensive diagnosis of multiple injuries and fractures of the skull, spine, and even complex peripheral injuries involving bony and vascular structures at the same time.

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Discovery CT750 HD in our ED, we have a faster workflow

and prompt access to the imaging data, especially by volume

image reading.

“By introducing volume image reading in the ED, the workup

for a mass casualty patient has decreased from an average of

15 minutes to 8 minutes,” he says. Moreover, the axial, multiplanar,

and volume rendered images are readily available, an important

factor in ED imaging.

“The HD scan mode provides excellent spatial resolution and

scanning of large body volumes,” Prof. Linsenmaier explains.

“The protocols for major trauma patients include long scan fields,

and the X-ray tube performs remarkably well with virtually no

cooling problems,” he adds.

Reducing patient radiation dose with ASiR is an impressive

feature as well. In major trauma cases undergoing whole-body

CT, the ED department has decreased dose by nearly 30%,

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Michael S. Skulski, MD, is the Department Chair of Radiology at St. Vincent Hospital & Health Services at the 86th Street campus. He graduated from University of Cincinnati College of Medicine and completed a residency in Diagnostic Radiology at Mayo Clinic in Rochester, Minnesota, where he was Chief Resident. In addition, he completed a fellowship in cross-sectional imaging at the Mayo Clinic. Dr. Skulski’s special interests include body imaging, body intervention and non-invasive vascular imaging. He is also a member of the musculoskeletal team with a special interest in foot and ankle imaging.

Nikki D. Duckworth, MBA, RT, is the Manager of Medical Imaging Services at St. Vincent Hospital (Indianapolis) at the 86th Street campus. She graduated from: American Intercontinental University with an MBA in Operations Management; Indiana Wesleyan University with a BS in Business Management; and Indiana University with an AS in Radiologic Science. She is currently studying to become a Fellow of the ACHE (American College of Healthcare Executives). Before working in management, Nikki worked as a MRI, CT, X-ray, and Nuclear Medicine Technologist.

Corey W. Graff, RT(R)(CT), is a CT technologist at St. Vincent Hospital & Health Service (Indianapolis) at the 86th Street campus. He graduated from radiology school at Hancock Memorial Hospital (Greenfield, IN).

As a member of Ascension Health, St. Vincent Health is a part of the largest Catholic, mission-driven, not-for-profit health care system in the United States. St. Vincent Indianapolis Hospital recently earned the Distinguished Hospital for Clinical Excellence™ recognition by HealthGrades, the leading independent healthcare ratings organization.

Corey Graff

Nicole Duckworth

Professor Ulrich Linsenmaier, MD, PhD, is Associate Chair, Associate Professor of Radiology, and Managing Attending Radiologist in the Department of Clinical Radiology at Ludwig-Maximilians-University (Munich). He is the 2011-2013 President of the European Society of Emergency Radiology (ESER). Areas of professional interest include: emergency radiology; interventional radiology (IR); body imaging (MSCT, MRI); and neuroradiology (NR). Professor Linsenmaier has presented more than 200 scientific talks, received three scientific awards, and authored more than 70 original articles and five books. He is a reviewer for The Lancet, European Radiology, Investigative Radiology, European Journal of Radiology, RöFo, Der Radiologe, Der Unfallchirurg.

Munich University Hospital is comprised of two facilities: the nearly 973-bed University Hospital of the Ludwig-Maximilians University (LMU) and 1,349-bed Grosshadern campus. Approximately 500,000 patients receive medical care from the 45 departments and institutes at both campuses. Recognized as one of the major university hospitals in Europe, Munich University Hospital conducts 50,000 surgical interventions each year and is known for its pioneering work in cardiosurgery and outstanding transplantation expertise.

Hospital for Clinical Excellence is a trademark of HealthGrades.

Prof. Linsenmaier says. Significant dose reduction capabilities will

further impact the department’s choice of imaging device, as a

CT image can provide more information than digital radiography.

Currently, the University Hospital performs clinical low-dose CTs

of the C-spine between 0.7 and 1.1 mSv.

In addition to lowering dose, the Discovery CT750 HD is further

impacting the quality of patient care through new capabilities.

Specifically, larger perfusion volumes along with CT angiography

and temporal subtraction imaging (TSI) are used for diagnosing

stroke and pulmonary embolisms (PE).

With these imaging tools, the University Hospital now uses CT

in place of MRI diffusion imaging. “Our protocol combines native

CCT and CTA of the supra aortic vessels with a perfusion scan

of the cerebrum,” explains Prof. Linsenmaier. An additional

advantage of using CT for these patients is the availability

of the scanner 24/7 with direct access in the ED.

“Monitoring the patient is easier and we don’t have to transfer

them out of the ED,” he adds. “We can work up the patient in one

robust exam—this is an entirely new way for us to handle stroke

and PE patients.”

While the potential for reducing dose in complex cases most

impresses Prof. Linsenmaier, he also recommends that other

hospitals seeking to add CT in their ED evaluate system reliability.

“For us, the most important factor is reliability with little unplanned

downtime followed by a strong industrial partner that can

provide excellent technical and applications support.”

He notes that using CT in the ED has increased exponentially

in large institutions over the last decades, and new capabilities

such as Iterative Reconstruction techniques will become even

more important to future CT purchasing plans. “Even with the

increase in scan volumes and use of CT in the ED, we can offer

patients low dose with the Discovery CT750 HD.” And that, he

says, is most impressive.

At both St. Vincent Hospital and the University Hospital of LMU,

CT is a crucial diagnostic tool for trauma and stroke patients.

Speed, image quality, and applications such as GSI, perfusion,

and volume rendering are impacting patient care. n


c l i N i c a l v a l u el o w - d o s e p e d i a t r i c i m a g i N g

Pediatric Hospitals Bring Low-dose CT to the Middle EastFor years, radiologists have been cognizant of the importance

of limiting pediatric patients’ exposure to radiation dose. Building

on the ALARA principle, the Image Gently Campaign specifically

targets awareness of radiation dose levels to children and

young adults.

However, reducing radiation dose based on a reduction in kV

sometimes results in noisy images that can negatively impact

the radiologist’s diagnostic capabilities. For acutely sick children,

such as those afflicted with heart ailments (anomalies) or

pediatric cancers, treatment planning often requires high-quality

CT images. Yet, radiologists may, in some instances, be hesitant

to order additional CT exams out of concern that the pediatric

patient is being repeatedly exposed to medical imaging radiation.

This is the case in the Kingdom of Saudi Arabia. There, two

leading hospitals are using ASiR to enable a reduction in the

radiation dose delivered to pediatric patients while maintaining

image clarity to provide effective patient treatment.**

The beat goes on

At King Abdulaziz Cardiac Centre, Dr. Fahad Al-Habshan, a

consultant in pediatric cardiology and cardiac imaging, uses

CT to image children prior to open heart surgery.

“We tried to use a lower radiation dose in our CT imaging, but the

images were noisy and hazy,” Dr. Al-Habshan says. “It is always a

balance between the radiation dose and the clarity of the image,

particularly when it comes to small children where we are

* *In clinical practice, the use of ASiR may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.

“ With ASiR, we obtain the same quality images at a much lower dose—it reduces the noise and produces crisp images.”

Dr. Fahad Al-Habshan


C l i n i C A l v A l u E l o w - d o s E p E d i A T r i C i m A G i n G

looking at small vessels and structures. We need to be very

accurate and precise in our diagnosis of pediatric cardiac

patients, and that has complicated our efforts to reduce dose.”

Specifically, the pediatric cardiology surgeons require high

quality images for surgical planning. “Everything in the operating

room is carefully planned; surprises add precious time that can

increase the complications for very young patients,” he adds.

Good images help the surgeon conduct the procedure in the

shortest time possible to minimize risk to the patient’s safety.

“Children are more sensitive to radiation,” says Dr. Al-Habshan.

However, when the hospital’s LightSpeed* VCT received an ASiR

upgrade in September 2009, low-dose CT imaging became a

reality. “With ASiR, we obtain the same quality images at a much

lower dose—it reduces the noise and produces crisp images,”

explains Dr. Al-Habshan. The difference is significant. “Today

with ASiR, almost all our children are imaged with less than

1 mSv radiation dose,” he adds.

“GE is focused on developing hardware and software that

enhance image quality and lower radiation dose,” says

Dr. Al-Habshan, “and I think that offers more benefit to

the patient than the number of detectors.”

Figure 1. Detecting aortic arch obstruction and coronary compression in a 13-month-old girl using gated CT angiography with ASiR (0.8mSv). (A) Sagittal view reveals the aortic arch and an area of coarctation. (B) 3D reconstructions of the heart demonstrating the aortic anastomosis and the Right Ventricle—Pulmonary Artery conduit. Calculated radiation dose: 20.57 X 2.16 X 0.018 = 0.8 mSv (obtained by 2007 ICRP recommendations using chest factor of 0.018 *DLP for children one to five years).

BA

Figure 2. Confirming a vascular ring with mirror-image branching using CT Angiography with ASiR (0.66 mSv). 3D reconstruction of the heart shows the complete vascular ring, formed by the right aortic arch and the left-sided ductus arteriosus, around the trachea and esophagus. Also seen are the airway and the nasogastric tube in the esophagus. Notice the mirror image branching of the aortic arch, which is very unusual with this type of vascular ring. Calculated radiation dose: 11.77 X 2.16 X 0.026 = 0.66 mSv (obtained by 2007 ICRP recommendations using chest factor of 0.026 * DLP for children under one year).



A ray of hope

As the first children’s cancer center in the Middle East, King

Fahad National Centre for Children’s Cancer and Research

is widely recognized as a leading institution that provides

comprehensive oncology care for pediatric cancer patients

throughout the region. The hospital aims to provide the best

level of care in medical imaging through the acquisition of

state-of-the-art equipment and techniques.

“We are very concerned about the possibility of our patients

being over-exposed to radiation dose in CT scanning,” says

Lefian Al Otaibi, MD, Acting Chairman of Radiology and Head

Section, Pediatric Radiology. The center treats patients ranging

in age from three months to 14 years.

Dr. Otaibi’s concern regarding dose began to diminish when

he learned more about ASiR during the installation of the

BrightSpeed Elite CT scanner. “We implemented it immediately

to see the difference in image quality and dose using ASiR, and

it was clearly noticed.”

Figure 3. Chest abdomen pelvis exam of 13-month-old pediatric patient; (A) volume rendered (VR) bone, liver, and kidney; (B) portal vein VR on coronal view; (C) VR with portal. Total acquisition time of 5 sec for 300 mm coverage using ASiR 50% for a DLP=59.04 mGy.cm (Equivalent dose = 0.8 mSv). DLP was 59.04 mGy.cm for an effective dose of 0.8 mSv (obtained by EUR-16262 EN, using a Chest pediatric factor of 0.013*DLP and an Abdomen Pelvis pediatric factor of 0.015*DLP).

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C l i n i C A l v A l u E l o w - d o s E p E d i A T r i C i m A G i n G

In fact, the reaction from radiologists was so positive that the

facility launched a new initiative to reduce unnecessary dose

to patients. The initiative includes two principles of radiation

protection: appropriate justification for ordering the procedure

and careful optimization of the radiation dosage used during

the procedure according to age and weight.

“ASiR has allowed us to lower the radiation dose delivered to

our patients compared to our previous scanner,” adds Dr. Otaibi.

“This is a department goal for all routine studies and with

all radiologists.”

The value of ASiR is most important in follow-up, or repeat

exams, particularly for oncology patients who must often

receive annual or bi-annual exams to detect any relapse.

According to Dr. Otaibi, ASiR offers the radiologists the ability

to conduct needed follow-up exams with decreased concerns

of additional radiation dose. “Without ASiR, there are some

follow-up exams we probably would not do,” he says.

In addition to potentially minimizing dose with ASiR, the facility

also utilizes the high pitch on the BrightSpeed Elite to decrease

scan time, says Abdulaziz Bawazeer, Radiology Supervisor.

Figure 4. Chest abdomen pelvis exam of 13-month-old pediatric patient; (A) Aorta plus Aorta VR; (B) MIP Liver and CAP Vessels; (C) Minip Lungs & Bronchus; Total acquisition time of 5 sec for 300 mm coverage using ASiR 50% for a DLP=59.04 mGy.cm (Equivalent dose = 0.8 mSv). DLP was 59.04 mGy.cm for an effective dose of 0.8 mSv (obtained by EUR-16262 EN, using a Chest pediatric factor of 0.013*DLP and an Abdomen Pelvis pediatric factor of 0.015*DLP).

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www.gehealthcare.com/LowerDoseByDesign »

Fahad Al-Habshan, MD, is a consultant in pediatric cardiology and cardiac imaging at King Abdulaziz Cardiac Centre, National Guards Health Affairs.

King Abdulaziz Cardiac Centre is a tertiary care cardiac center in Riyadh, Saudi Arabia, that conducts approximately 400 open heart procedures on children every year. It is affiliated with one of the largest medical institutions in Riyadh, and provides both adult and pediatric care. The center receives pediatric referrals from all over the country.

Lefian Al Otaibi, MD, is a Consultant Radiologist at King Fahad National Centre for Children’s Cancer and Research and King Faisal Specialist Hospital and Research Center.

Abdulaziz Bawazeer is the Radiology Supervisor at King Fahad National Centre for Children’s Cancer and Research.

The King Fahad National Centre for Children’s Cancer and Research opened in 1997. Located north of Riyadh on a two-acre site, it is an integral part of the King Faisal Specialist Hospital and Research Centre and provides both inpatient and outpatient services to Pediatric Hematology/Oncology patients. Seventy to 80 pediatric stem cell transplants are performed per year. The hospital is locally known as the Children’s Cancer Centre or CCC.

The King Faisal Specialist Hospital and Research Center (KFSH&RC) is a modern state-of-the-art hospital with 894 beds. Located in Riyadh, KFSH&RC is the national referral center for oncology, organ transplantation, cardiovascular diseases, neurosciences and genetic diseases. A full range of primary, secondary, and tertiary health care services is provided.

“When scanning children, we want them to spend less time

within the gantry,” he explains. “That will further help lower

radiation dose and reduce motion, which helps with image

quality. We also provide artwork on the walls of the room and

television screens to help keep the children more comfortable

and relaxed.”

With most patient cases being CAP or HN, both Dr. Otaibi

and Mr. Bawazeer believe it is imperative to reduce dose in all

procedures. Their results with ASiR are impressive; the studies

maintain image quality and provide good visualization of

contrast enhancement at lower dose and noise levels.

“We are confident our patients are receiving optimized dose

without affecting the diagnostic quality of the exam,” notes

Mr. Bawazeer. “And that provides the potential for outstanding

clinical outcomes.”

At King Abdulaziz Cardiac Centre and King Fahad National

Centre for Children’s Cancer and Research, ASiR enables

clinicians to provide the highest level of diagnostic care

at the lowest possible dose. n

“ ASiR has allowed us to lower the radiation dose delivered to our patients compared to our previous scanner. This is a department goal for all routine studies and with all radiologists.”

Dr. Lefian Al Otaibi

Abdulaziz Bawazeer


C A s E s T u d y L o w - d o s E C A r d i A C i m A G i n G

Contrast ProtocolBrand/type of contrast: Ioversol

Contrast injection rate: 5 cc/sec

Total contrast amount: 80 cc

Saline injection rate: 5 cc/sec

Total saline amount: 40 cc

Acquisition Protocol

Scanner: Optima CT660 with ASiR

Scan type/slice thickness:

Snapshot Pulse / 0.625 mm

Coverage: 40 mm

Rotation time: 0.35 sec

Total elapsed time: 5.1 sec

Total x-ray exposure time: 1.76 sec

mAs: 106.75

kV: 120

Recon kernel: Detail

SFOV: Cardiac large

DFOV: 25 cm

Heart rate: 47 BPM

BMI: 30

ASiR: 40%

Low-dose CTA With ASiRBy Roberto Cury, MD, cardiologist, IDS (Instituro de Diagnóstico de Sorocaba) and Melissa Megumi S. Kuriki, Advanced Application Specialist, GE Healthcare Latin America

When performing stent evaluation by CT, it is preferred to implement low radiation dose

particularly due to the patient’s previous exposure to radiation during the stent placement

procedure in the cath lab. The Optima CT660 may achieve low dose coronary CTA with

ASiR and provide high-quality images for visualizing the lumen and calcified plaque.**

Figure 1. 3D images of the heart showing stents in DCA, Mg, and RCA.

A B

Figure 2. Transparent 3D images showing calcification plaque inside of the stents.

A B

**In clinical practice, the use of Veo may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.


c a s e s t u d yL o w - d o s e c a r d i a c i m a g i N g

Patient history

The patient is a 51-year-old male with a BMI

of 30 and family history of coronary disease.

Patient had atypical chest pain at the time

and was indicated for CT to evaluate three

stents, LDA, OM, and RCA, implanted eight

months earlier to rule out in-stent restenosis.

Patient findings

Patient showed no sign of in-stent restenosis;

there was presence of discrete luminal

narrowing in the distal left main of the

coronary artery and the right coronary artery.

Discussion

The Optima CT660 with ASiR provides an

opportunity to conduct a low-dose CT study.

Using ASiR, patient dose was reduced with

high image clarity in the cardiac study. In

our region, the Optima CT660 is the first CT

scanner with low-dose technology, and it

helps demonstrate to patients our concern

regarding patient dose and the environment.

In particular with the cardiac exam, we have

better visualization of the coronary artery,

stents, and calcified plaque. We believe

this system is making a difference in our

clinical diagnosis. n

Figure 3. Oblique images of coronary artery showing stents and calcified plaque with high image quality without beam hardening.

A B

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Figure 4. CT coronary study with 2.57 mSv acquired in 5.1 sec with prospective gated acquisition. (DLP 183.77 mGy cm with a conversion factor of ICRP 0.014*DLP)

Roberto Cury, MD, PhD, FSCCT, is the Chief Executive Officer of Virtual Heart, the first cardiac imaging teleradiology group in Brazil. He is also a cardiologist and Director of Cardiac CT and MRI at Samaritano Hospital (Sao Paulo, Brazil). Dr. Cury received his doctorate degree from Santa Casa School of Medical Sciences in Brazil and finished his clinical fellowship in Cardiac CT and MRI at InCor, Heart Institute of Sao Paulo. Dr. Cury was a pioneer in Brazil in the field of Stress Myocardial Perfusion Cardiac CT and concluded his PhD at InCor, Heart Institute of Sao Paulo. He has contributed to the field of cardiovascular imaging with published papers, book chapters, case reports, and invited presentations. Dr. Cury is currently the Director of the SCCT Brazilian International Regional Committee.

Instituto de Diagnósticos Sorocaba (IDS) was founded in 1996 by radiologists who embraced a mission to provide differential and compassionate medical service. Today, IDS provides high-quality diagnostic care to approximately 500 patients each day, offering complete diagnostic services for various laboratory testing and diagnostic imaging, the latter including the latest advanced equipment such as the Optima CT660.

The organization’s management team guides and monitors all activities to ensure fulfillment of the company mission and philosophy and, as a result, IDS has won the confidence and loyalty of physicians and the local population.


C A s E s T u d y l o w - d o s E p E d i A T r i C C T A

Acquisition ProtocolScanner: LightSpeed VCT


Non-gated/ 0.625 mm

Scan range: 95 mm, aortic arch to diaphragm

mAs: 120 mA

kV: 80 kV

Gantry rotation: 0.4 sec

Radiation time: 0.9 sec

Reconstruction: ASiR at 30%

DLP: 9.36

Calculated radiation dose:

9.36 X 2.16 X 0.026 = 0.5 mSv (using ICRP 2007 conversion factor of 2.16)

Confirming a Diagnosis of Double Aortic Arch in a NewbornBy Fahad Al Habshan, MD, Consultant, Pediatric Cardiology and Cardiac Imaging and Program Director, Pediatric Cardiology Fellowship, King Abdulaziz Cardiac Center, National Guards Health Affairs

Managing children with congenital heart disease (CHD) requires accurate diagnosis prior

to intervention—a task most often accomplished with echocardiography as the primary

diagnostic tool. However, it is not always successful, given the ultrasound’s inherent

limitations in the presence of air, bone, scar, or obesity. In addition, this modality does

not always demonstrate in sufficient detail the complex extra-cardiac vascular

structures, and airway and lung pathologies associated with CHD.

When echocardiography is unable to render a definitive diagnosis, alternative tools

must be applied—tools such as CT angiography (CTA). It has been proven an excellent

alternative, generating detailed images of structures throughout the thorax. However,

the trade off is radiation exposure, which is of special importance for small children

and infants. With GE Healthcare’s Adaptive Statistical Iterative Reconstruction (ASiR), it

is now possible to capture high-quality CTA studies of small children and infants at very

low radiation dose levels.**

Patient history

A newborn was diagnosed antenatally with a double aortic arch. A non-gated, low-dose

CTA exam was ordered to help confirm the diagnosis and assess the airway.

Figure 1. (A) Axial MIP reconstruction at the level of the two aortic arches. RAA: right aortic arch, LAA: left aortic arch. (B) Dose report showing the very low dose with DLP of 9.36.

**In clinical practice, the use of ASiR may reduce CT patient dose depending on the clinical task, patient size, anatomical location and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.

A B


c a s e s t u d yl o w - d o s e p e d i a t r i c c t a

Results and findings

A double aortic arch with a complete vascular ring around the trachea

and esophagus is clearly visible in an axial view (Figure 1A). The radiation

dose report (Figure 1B) highlights the low dose used in this study. The 3D

reconstructions include a posterior view (Figure 2A), demonstrating the

double aortic arch with a complete vascular ring around the trachea and

esophagus. Another view (Figure 2B) shows the airway and nasogastric

tube in the esophagus.

The infant underwent surgery to divide the smaller left aortic arch and the

ligamentum arteriosum that is located on the left side. The CTA images

served as the surgeon’s primary roadmap for planning this repair; they

gave him a very clear image in his mind and on the operating-room

screen, improving the quality of care delivered to this patient.

Discussion

Recent advances in CTA have made it an even more useful diagnostic tool.

For example, state-of-the-art multi-detector CT scanners have reduced

scan times to just a few seconds. In children in particular, multi-detector

CTA’s speed may allow the physician to minimize or eliminate the need for

general anesthesia or deep sedation, which is a tremendous advantage

in this population. Furthermore, its spatial resolution promotes accurate

diagnosis of anomalies involving the systemic and pulmonary veins and

arteries, as well as the coronary vessels.

Fortunately, the issue of radiation exposure is now being addressed with

today’s most advanced CT scanners, thanks to new scanning protocols and

software. ASiR has demonstrated its ability to produce images of exceptional

clarity and signal-to-noise at lower radiation doses. The result is we can

scan many of our young patients, including infants and small children,

at doses of less than 1 mSv with consistently excellent image clarity. n

Figure 2. (A) 3D reconstruction with a posterior view showing both aortic arches. RAA: right aortic arch, LAA: left aortic arch. (B) 3D reconstruction with a posterior view showing both aortic arches, the airway (blue), and a nasogastric tube in the esophagus (green). RAA: right aortic arch; LAA: left aortic arch

A

B

Fahad Al Habshan, MD, is Program Director, Pediatric Cardiology Fellowship, at King Abdulaziz Cardiac Center, National Guard Health Affairs (Riyadh, Saudi Arabia). Dr. Habshan is also Assistant Professor, Cardiac Sciences at King Saud Bin Abdulaziz University for Health Sciences (Riyadh). He specializes in pediatric cardiology and cardiac imaging.

As the largest and most advanced medical complex in the Kingdom of Saudi Arabia, National Guard Health Affairs (NGHA) includes medical “cities”strategically located across the land. Perhaps the most impressive of them all is King Abdulaziz Medical City in the capital of Riyadh. This state-of-the-art center is equipped with nearly 1000 beds for conventional, surgical and emergency admissions, and offers nearly all medical specialities—from Pediatric Cardiology and Emergency care that are second to none, to the full range of leading-edge Ambulatory, Primary, Preventive, Surgical and Critical Care services. It boasts the lowest mortality and morbidity rates in the nation. Educating the healthcare providers of tomorrow is also high on the list of the NGHA’s objectives—an objective that is being addressed via the pioneering King Saud Bin Abdulaziz University for Health Sciences, where our author serves as an assistant professor of Cardiac Sciences.


C A s E s T u d y L O W - d O s E N E u R O W I T H A s I R

Contrast ProtocolBrand/type of contrast:

Iopamidol

Contrast injection rate:

4 ml/sec

Total contrast amount:

60 ml

Saline injection rate:

2 ml/sec

Total saline amount:

30 ml

Acquisition ProtocolScanner: Lightspeed VCT

with ASiR


Volume Helical Shuttle/5 mm

Coverage: 160 mm

Rotation time: 0.4 sec

Total elapsed time:

31.16 sec

Total x-ray exposure time:

17.16 sec

mAs: 150 mA

kV: 100

Need parameter

10 passes

Recon kernel: Soft

SFOV: 32.0 cm

DFOV: 22.1 cm

Effective dose (1207.30 [Total DLP] x 0.0023 [Tissue Factor] for head with phantom 16 cm = 2.77 mSv.

(As per ICRP-60 tissue weighting factor.)

Critical Low-dose Neuro Imaging with ASiRDetection of cerebral Arterio-Venous Malformation (AVM) using VHS on Lightspeed VCT

By Zakir Hussain, MBBS, MD, PhD, Fellow-AIE-Japan, Consultant Radiologist, Square Hospitals Ltd, Dhaka, Bangladesh; and Karthik Anantharaman, MD, Marketing Manager–CT (South Asia), Muhammad Sadiqur Rahman, Product Specialist–CT (Bangladesh), and Nitin Bhardwaj, Clinical Application Specialist–CT (East Zone–India) from GE Healthcare

Beginning with the first CT scanner, CT radiation dose has been a concern in

medical imaging. Even before the advent of multi-detector CT (MDCT), there have

been innovations aimed at developing different techniques to reduce radiation dose

and improve image quality. Dose reduction techniques such as Automated Exposure

Control and BMI-based protocols for cardiac scanning and application of different

image space filters have been successful in helping us limit radiation exposure to

patients undergoing CT scans.

All of these techniques provide the desired level of optimized dose management.

Filtered Back Projection (FBP), the conventional technique in use for almost three

decades to reconstruct the images from raw data, still falls short of expectations

when it comes to obtaining the full potential of reducing radiation dose.

A recent alternative technique is the use of Iterative Reconstruction (IR) to

overcome the limitations of FBP. Adaptive Statistical Iterative Reconstruction (ASiR)

is an IR technology that may help clinicians achieve a confident diagnosis with lower

dose.** ASiR may also enable improvement in low contrast detectability. In routine

imaging at Square Hospitals Ltd, Dhaka, we normally use 40% to 50% ASiR

consistently for all studies.

The following is a case that demonstrates the benefit of ASiR for us in low-dose,

critical, neuro-imaging applications.

Patient history

A 45-year-old male with known right fronto-parietal AVM presented to the radiology

department. Previous history revealed that a CT-guided stereotactic radiosurgery

was performed in November, 2000.

The Volume Helical Shuttle (VHS) scan technique was used to achieve the low-dose,

multi-phasic imaging of the brain vasculature.



c a s e s t u d yL O W - d O s e N e u R O W I t H a s I R

Results

Right-side frontal and parietal AVM was noted with right middle

cerebral artery (MCA) and right anterior cerebral artery (ACA)

as feeder vessels and superior sagittal sinus and branch of right

transverse sinus being the draining veins. Volume Helical Shuttle

(VHS) was a very useful technique to help us detect feeder and

draining vessels of an AVM.

Discussion

At Square Hospitals Dhaka, we recently upgraded our

LightSpeed VCT system to include ASiR. Until the upgrade,

physicians referring their patients for CT scans to our department

were concerned with the additional radiation exposure in follow-up

scans. This fear has now been addressed with the introduction

of ASiR on the upgraded LightSpeed VCT system. We can now

demonstrate to our referring physicians the capability to deliver

lower radiation dose with ASiR on our CT scanner and, hence, build

confidence among them to refer patients for follow-up studies.

In our experience, ASiR is a significant advancement in CT dose

optimization technology that balances image quality, noise, and

dose. ASiR has made low-dose imaging across body regions a

reality in our facility. In addition, VHS aids our clinical diagnosis

significantly through extended coverage with multi-phasic

information. It also helps achieve different phases of contrast

for the desired anatomy with a fixed amount of contrast. n

Mohammad Zakir Hussain, MBBS, MD, PhD, is a Consultant Radiologist and Head of the Department of Radiology and Imaging at Square Hospitals Ltd. (West Panthapath, Dhaka, Bangladesh). Dr. Hussain received his Doctor of Philosophy in Medical Science (Clinical Subject: Radiology) from the Yamanashi Medical University and his Bachelor of Medicine & Surgery (MBBS) Examination from the institute of Post Graduate Medicine & Research (IPGMR) under the University of Dhaka, Bangladesh. He also completed a post-doctoral fellowship at Yamanashi Medic al University (Japan). Dr. Hussain’s clinical interests are in MRI, CT, and MRS, with special emphasis on coronary CT angiogram and other CT and MR angiogram studies. He helped establish the Interventional Radiological Center of Square Hospital Ltd.

Square Hospitals Limited is a 320-bed, tertiary care hospital. The hospital is an affiliate partner of Methodist Healthcare (Memphis, TN USA), SingHealth (Singapore), Bangkok Hospital Medical Centre, (Thailand), and Christian Medical College (Vellore, India). Square Hospital is located in the heart of Dhaka and aims to serve a greater portion of the capital city. At present it is comprised of: The main hospital building is 18 stories and approximately 450,000 sq. ft.; the second building (ASTRAS) is located across the street and is 16 stories with 136,000 sq. ft.

Figure 1. VHS Study demonstrating AVM in the right frontal and parietal lobes where the feeder vessel is coming from the right MCA and the right ACA.

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B

E

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F


C A s E s T u d y O N C O L O G y W O R K F L O W

Acquisition ProtocolScanner: LightSpeed VCT

Scan type/slice

thickness:

Helical 1.25 mm

Pitch: 1.375

Rotation time: 0.6

mAs: 338

kV: 120

By Valerie Laurent, MD, PhD, radiologist, Central University Hospital, Nancy

Abstract

OncoQuant has proved to be an invaluable tool for tracking of oncology studies in

our facility. We can compare a seemingly limitless number of CT, MR, and PET exams.

Moreover, OncoQuant provides a structured workflow for using base lining and NADIR

to determine patient response to treatment according to RECIST guidelines.

Patient history

The patient is a 47-year-old male with liver metastases of an endocrine tumor

in the pancreas. Palliative treatment: first line chemotherapy in December, 2006.

Software

• Dexus workflow software(s) used: OncoQuant

• Length of time used at site: 1 year, used routinely (daily)

• Platform used (Wkst/Server): AW workstation

Patient findings

The patient returned for evaluation in December, 2010. There was a partial response

to treatment followed by progression, and the NADIR was set to the date with the best

response to treatment as per RECIST guidelines.

The summary table was used to assess the percentage of disease progression from

NADIR (Figure 1).

If the calculation is made from the original baseline, the tumor growth since December,

2006 is 11% (Figure 2). But it is important to consider that the gold standard is NADIR

according to RECIST guidelines. Using the RECIST methodology, the October, 2009

review becomes the new reference (NADIR) from which the progression of the disease

should be evaluated. Using the summary table in Figure 1, we can clearly see that there

is an evolution of 73% of the lesions based upon the RECIST 1.1 criteria (total of Dmax of

the initially identified target lesions). This indicates there is a progression of the tumor,

and, therefore, a need to change patient treatment.

Multi-modality Oncology Workflow for Comprehensive Follow-up and Treatment


c a s e s t u d yO N c O L O G y W O R K F L O W

Figure 1. Summary Table

Discussion

There are relative inconsistencies with the planning of treatment

and follow-up of oncology cases between different sites and

even between oncologists at the same hospital. Although the

results are directionally correct, repeatability and reproducibility

are often challenges when it comes to comparative results.

With OncoQuant, we were able to establish a consistent,

repeatable, and rapid diagnostic workflow across different cases

and physicians, even utilizing exams from several years prior as

a baseline. We came to find that through this workflow, we were

able to achieve:

• Quick comparison of follow-up exams from the baseline exam;

• Comparison of several exams without virtually any apparent limit;

• Cross registration of chosen target lesions from lesions in the

initial exam;

• Comparison of measurements obtained with an automatic

registration between the initial exam and follow-up exam; Figure 2. Reference of current to the baseline.


C A s E s T u d y O N C O L O G y W O R K F L O W

Valérie Laurent, MD, PhD, is a radiologist at the Central University Hospital, Nancy (Nancy-Brabois, France). Dr. Laurent has spent over 12 years focusing on abdominal imaging in oncology and during that time has used MRI and CT extensively. She recently received her doctorate degree in 2010.

The Central University Hospital of Nancy comprises a hospital network of over 1,600 beds serving over 600,000 patients with 30,000 emergency entries a year. There are two main locations: one in the center of Nancy and the other in the suburbs of Brabois.

Inaugurated in 1973, the Hospital Brabois for Adult Studies is the cornerstone of the Brabois hospital network serving first as a university hospital within close proximity to the Faculty of Medicine and secondly as the premier regional center for combating cancer with over 945 beds.

Figure 3. Tracking one of the targets on the three first exams.

A B

C

• Consistent results that are table and operator independent;

• Clinical answers that are less tedious to perform and more

objective and independent of the modality, acquisition

technique, and clinician;

• Automatic registration of either two or three different modalities;

• Comparison of parametric data, diffusion, perfusion curves,

and SUV integration of different morphological criteria: RECIST

1.1 (standard), RECIST 1.0, WHO, and any other configured/

user defined criteria; and

• Monitoring of volume evolution even if not stated in the

RECIST guidelines.

Overall, OncoQuant provides a structured and repeatable

workflow that improves the speed and efficiency of follow-up

reviews and creates a method to initiate a standardized

dialogue between several physicians in our network. n

© 2011 General Electric CompanyDOC 1041480

GE Healthcare

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T E C H n i C A l i n n o v A T i o n v E o

Understanding the Impact of Iterative ReconstructionA new paradigm in the assessment of radiation dose and image clarity

GE Healthcare CT is undergoing a multi-year commitment

to investigate a multi-center study to further demonstrate

the clinical translation of Veo, which is a full model-based

iterative reconstruction (MBIR) capability. The technical

innovation and design of this technique demonstrate the

potential for radiation dose reduction and improvements in

image clarity. CT Clarity recently spoke with two experts leading

the efforts to quantify the impact on diagnostic value: Ehsan

Samei, PhD, Professor of Radiology and Medical Physicist at

Duke University, and Rendon Nelson, MD, Reed and Martha

Rice Professor of Radiology at Duke University. Dr Samei and

Dr. Nelson share, in their words, what they have learned

from the phantom and clinical work to date.

Q: Why, in your opinion, are these studies important to undertake?

Dr. Samei: I believe that radiology is a science. As scientists

we make predictions, have expectations, and conduct studies.

Yet, ultimately, whatever we predict and expect to see must

be confirmed. We often find, from a theoretical or scientific

standpoint, that one solution could have certain advantages,

but when we conduct the clinical trial we realize that certain

nuances in that prediction may have been overlooked. Based

on this belief, while there is strong scientific evidence that the

new iterative reconstructions (IR) are advantageous, we want

to further investigate the potential of MBIR through a clinical trial.

In the spirit of scientific work, we need continued information

for ourselves and for our community—that what we predict

and claim is more broadly proven out.

Dr. Nelson: I agree with Ehsan that it’s important to validate the

results from the phantom trial that we conducted. In actuality,

what we originally projected to achieve in dose reductions (in the

patient trial) is likely more aggressive than what we found was

possible based upon the phantom data. Certain numbers, such

as contrast-to-noise-ratios (CNR), don’t tell the whole story.

There are other parameters indicating that while CNR is higher,

the noise is above and beyond a certain threshold where we are

comfortable diagnosing from those images. So now, we also

have to investigate if our predicted level of dose reduction is

adequate from a diagnostic standpoint.

More importantly, from my standpoint, this is an opportunity to

do something truly unique. The CT manufacturers are all talking

about dramatic dose reductions using IR, but the only way that

we can comprehensively demonstrate what a particular

technique can do in the varied and changing clinical setting is

through a comprehensive clinical trial that extends globally

across different practice settings.

Ehsan Samei, PhD


v e o t e c h N i c a l i N N o v a t i o N

Q: What interested you most in agreeing to participate in this clinical research?

Dr. Nelson: I’ve been reading CT scans for 25 years. We were

very excited when the first multi-slice scanners were introduced.

We had the opportunity to do fast imaging, thin slices, and

multi-planar reconstructions (MPRs) routinely. But then we

realized higher radiation doses were in some cases the price we

paid for these additional capabilities. Higher radiation dose has

become a public issue and I’m very interested in the impact of

it. It seems that while some headway has been made by the

manufacturers, the burden to reduce radiation dose remains

squarely on the shoulders of the radiologists. While we, as

radiologists, are getting better at interpreting higher noise

and lower quality datasets for diagnostic purposes, at times

we find ourselves on the edge of image quality. This study

represents an opportunity to address this challenge in a way

that doesn’t firmly rest on the radiologists’ ability to read

images with high noise.

Dr. Samei: What excites me about IR is that it highlights the

need for a better appreciation and quantification of image

quality in CT imaging. We have been very concerned about

radiation dose and there is a great deal of responsibility to

reduce radiation dose. But, while trying to reduce patient dose,

we need to realize that patients do not come to a medical center

to get dosed; rather they come to get imaged. So therefore, it is

Rendon Nelson, MD

extremely important that we do not compromise diagnostic

image quality in the process of acquiring patient images. IR, and

MBIR in particular, may help achieve a confident diagnosis with

lower dose.** That is the most exciting part here—finding a

better balance between image quality and radiation dose.

Q: Considering the various clinical tasks of high and low contrast and resolution, what has surprised you the most in your findings with MBIR?

Dr. Samei: CNR has been the basis of image quality quantification

for decades, starting with a 1948 landmark publication. An

underlying assumption is that the resolution of an imaging

system does not change as a function of dose or contrast. The

noise changes with lower radiation dose—the image becomes

grainier—but the resolution, or the sharpness of the features,

does not change.

What surprised me the most looking at MBIR is that resolution

does change as a function of contrast and dose. So, with MBIR it

was not what a CT medical physicist would naturally expect. As

a result, resolution can be potentially higher but on the flip side,

the methodology that we have relied upon these last 50 years

goes out the window. If the goal of optimizing imaging is to come

up with a balance between image quality and radiation dose,

then we don’t have an ideal metric to measure image quality

and achieve that balance. We cannot optimize something that

we cannot ideally measure. This “discovery” has initiated a new

line of research in imaging physics, namely to develop better

metrics of measuring image quality that can replace CNR.

Dr. Nelson: As Ehsan has alluded, the phantom study uncovered

higher CNR with the MBIR technique using up to 90% less dose.

Yet, when we looked comprehensively at the images, the noise

level at 90% less dose was not well received by the radiologists

who qualitatively examine the images. So, CNR is not the

whole picture.

Based on the phantom data, which we know does not always

directly translate to clinical acceptance, we can predict to

achieve a 70% dose reduction—and that is not from FBP but

rather from the ASiR technique. At our institution, ASiR protocols

reflect dose that is approximately 40% to 50%** of our current

standard of care FBP protocols, and MBIR will be investigated

at 70% lower than that. This is a very aggressive approach,

considering that in the abdomen and pelvis our ASiR dose is

typically 3 to 7 mSv. This very low dose provides interesting

ramifications from a clinical standpoint.

**In clinical practice, the use of MBIR and ASiR may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.



I would also add that clinically these images look different,

although they have very good spatial resolution and low contrast

detectability even at low doses. Different doesn’t mean bad; it

just means different and is something that imagers would have

to get used to, particularly those that have been doing

interpretations from FBP for many years.

Q: What have you found to be the most important lessons in assessing image quality and clinical value in the transition from FBP to MBIR?

Dr. Nelson: Through a consortium, whereby we selected a

small number of opinion leaders, initially there was a lot of

concern about the difference in image appearance. Not so

much the difference in noise but the different look and feel that

I alluded to earlier. But a very interesting thing happened. We

realized, as imagers, that even though the MBIR images looked

different, we weren’t missing anything and in some cases, we

saw more information. In our experience, a method for helping

radiologists get used to the different appearance of these

images is to start out by doing a side-by-side comparison of

standard-of-care dose FBP and MBIR datasets followed by a

gradual diminution in dose. Using this format, we have noted

a shift in the radiologist focus from concern over the different

‘look and feel’ to a discussion of ‘how low can I go’.

Dr. Samei: One of the amazing skills that a radiologist has

when interpreting an image is that he/she is able to distinguish

between artifacts and true anatomy. They know that noise is

a characteristic of acquiring images with a limited amount of

dose. Provided they know that the images are noisy, they can

feel confident reading through that noise.

With IR, we have changed the nature of noise. Essentially, our

task is to identify what is real and what is artifact, in the broad

sense of the word—something that is not reflective of patient

anatomy or function. With IR, there is still noise in the images;

even though the magnitude is lower, the texture of it is different.

As long as the radiologist knows that texture and understands

how it manifests itself, he/she will still be able to do a great job

reading through the image. So there are two elements: there is a

training element of understanding the noise texture, and another

element is quantifying the actual limitation that the noise texture

would put on the maximum amount of information that

radiologists can extract from the image.

Q: What can your peers expect to learn from both the phantom and the clinical study?

Dr. Samei: The phantom study provides us with new tools

and methods to characterize image quality for MBIR, taking

into account some of the resolution and noise features of the

reconstruction that I mentioned. It also provides us with a

scientific basis to determine what level of dose reduction is

possible with MBIR without compromising diagnostic quality.

The clinical study will help to substantiate the predictions of

the phantom study clinically, while at the same time providing

a wealth of information to refine the image quality

metrology further.

Dr. Nelson: The phantom study results were used to build the

multi-center trial, but from those results I hope that: a) they will

first be confident that the technique settings we’ve chosen are

adequate and that they can assimilate them into their own


v e o t e c h N i c a l i N N o v a t i o N

The Pilot Study of Model-based Iterative Reconstruction using 64-Slice Multidetector-Row CT Datasets Obtained from the

Central Nervous System, Thorax, and Abdomen is designed to provide further evidence of the diagnostic clinical value of Veo

image reconstruction. Prior phantom studies have demonstrated a significant dose reduction potential while maintaining

or improving quantitative image quality metrics as matched to observer results. This study translates those details into the

clinical population via acquisition of data at two different dose levels on the same study subject, then each are reconstructed

utilizing three techniques, FBP, ASiR, and Veo.

Image volumes from subjects scanned for pathology in the posterior fossa, lung cancer staging, focal liver lesions, or

kidney stones will be reviewed by two independent readers blinded to subject, radiation dose level, and image reconstruction

type. Readers rate the ability to detect and characterize pathology of interest as well as provide an overall indication of

diagnostic value including artifact level and impact to recommended treatment path. Incorporation of results from these

four anatomical regions at both radiation dose levels will enable evidence of clinical behavior in tissues presenting both

high and low contrast and resolution challenges for broad assessment of diagnostic image clarity.

Three leading academic institutions in the US are enrolling 120 subjects for this pilot study, which is underway.

Pilot results will be used to fine tune future studies across the globe.

practice; and b) that the image quality is such that they are

confident they can make diagnostic reads from images at this

low dose of radiation. Ultimately, our culture tends to get fired up

on something based on an issue and that’s true with radiation

dose. And that burden is upon us (and includes publishing the

results from this multi-center clinical trial) to prove to the public

that the doses used in CT imaging do not pose a medical

concern to them.

Q: Considering model-based iterative reconstruction, what do you see as the implications for CT imaging in clinical practice?

Dr. Samei: There are two things. We have talked a great deal

about reducing radiation dose, and that is a huge implication

of IR clinically. But what excites me even more is that we have

the opportunity to be on the cutting edge of doing more with

medical imaging—extracting more meaningful information

about the patient. It is possible that we might not reduce dose

as dramatically, or even at all for certain applications, in order

to take advantage of the additional information we get from

IR. There are new applications that we may be able to explore.

So we could now have a new tool in our arsenal to obtain

better information from the patient that would be more

clinically meaningful.

Dr. Nelson: There are two challenges. First, we need to figure

out what radiation dose levels and reductions are appropriate

and reasonable using this technique, particularly in comparison

to the competitive IR techniques on the market right now.

Second, we have to become comfortable with the new look

and feel of these images. But remember like PACS, in a short

period of time, we will have a new group of radiologists coming

through the training programs who may never see an image

from FBP. Just like with all our 48 residents, they have never read

plain film, they are all trained using PACS. So it’s just a matter

of time to make that cultural change, but it will be a new

experience at the onset for those who have been reading images

from FBP for many years.

In terms of implications for CT imaging, I think MBIR will have

a higher impact on CT imaging of the chest, abdomen, and

pelvis. And, these anatomic regions are where we give the

highest dose levels since we often do multiple passes following

the administration of contrast material. We have no problem

doing that in MR but in CT the doses accumulate. So I think

we’ll see a big impact in CT body imaging.



Q: Any additional thoughts?

Dr. Samei: One of the beautiful things about CT imaging is

that the field was somewhat homogeneous before IR. Moving

forward, we’ll have a whole lot more heterogeneity in the CT

operation clinically—not in terms of one manufacturer but across

manufacturers. There is a new challenge for imagers—a call to

action—for standardization. In order to confirm the claims by

manufacturers, we need comparable images (from different

manufacturers), so I think we need to be mindful of that as IR

is rolled out.

I do, however, believe this clinical trial is a great step in that

direction, though limited to a single vendor trial. We should be

seeking to create a framework that different sites can implement,

so that we can all achieve a certain level of consistency in image

quality evaluation, in how we discuss image quality improvement,

and in dose reduction.

Dr. Nelson: We are embarking on a comprehensive

evaluation of a new technique and I’m hopeful that this will

set the precedence for future clinical trials that aim to provide

more comprehensive investigations of new techniques.

What I like about this MBIR trial is the technology is relatively

new and we’ll get the results in a relatively short period of time.

We’ll publish the results, hopefully in the next year, and the

impact should be much higher. So it will be interesting to see

what happens—it is a big commitment both financially and in

terms of allocating resources. It was a significant scientific

investment. We also encourage the radiology community

to continue evidence-based studies across the specialty. n

Ehsan Samei, PhD, DABR, FAAPM, FSPIE is a Professor of Radiology, the Director of Carl E. Ravin Advanced Imaging Laboratories, and the Founding Director of the Clinical Imaging Physics Group at Duke University. His research interests include advanced X-ray imaging techniques, translational medical imaging, and image quality and dose metrology aimed towards optimized interpretive, quantitative, and molecular performance. He has been the recipient of 20 extramural grants and has over 500 publications, including 130 referred papers.

Rendon C. Nelson, MD, FACR, FSCBT-MR, is the Reed and Martha Rice Professor of Radiology at Duke University. He is also a Fellow in the American College of Radiology and both a Fellow and Past President of the Society of Computed Body Tomography and Magnetic Resonance. He is a member of the Division of Abdominal Imaging at Duke with clinical interests in hepatobiliary and pancreatic imaging, virtual imaging, percutaneous image-guided intervention, and percutaneous thermal tumor ablation. His research interests include: (1) optimization of diagnostic imaging of the liver, specifically the detection and characterization of focal and diffuse processes by US, CT, and MRI; (2) optimization of radiation dose and image quality in multidetector CT of the body; and (3) percutaneous image-guided thermal ablation of hepatic and renal tumors.

As a leading academic medical center, Duke University is uniquely positioned to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries and educating future clinical and scientific leaders. Duke is a strong advocate of practicing evidence-based medicine and is a leader in efforts to eliminate health inequalities.

Each year, the 15,000 professionals of Duke University Health System serve patients through more than 60,000 hospital admissions and 1.8 million outpatient visits. For 21 consecutive years, Duke University Hospital has been named among the top 10 in the nation by U.S. News & World Report.

www.ctclarity.com/ctclarity/veosupplement2011#pg1 to read the full interview. »

GE Healthcare

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T E C H n i C A l i n n o v A T i o n d E x u s

Radiology embraced the digital revolution more than 20 years

ago. In most hospitals today, radiologists perform their diagnoses

in virtually an all-digital environment. Alternate care sites—

clinics and physician offices—are quickly following in the same

direction, if they are not already there. However, as imaging and

information technology advanced at varying levels over the past

two decades, radiology departments have become a multi-

system environment. As a result, radiologists utilize an array

of systems—many from different manufacturers—to read and

report the patient diagnosis. These systems include, but are not

limited to, PACS, RIS, HIS, Speech Recognition, and advanced

image processing.

As technology changes, so too does our expectation of the

technology. We expect it to positively impact patient care by

enabling us to see the body more clearly with advanced imaging

or post-processing techniques, and enhance our workflow

for physician accuracy and efficiency (particularly important

in emergency cases).

Yet, this multi-system electronic environment may present

a barrier to workflow and efficiency. Advanced processing

workstations were historically separate workstations. Native to

these systems are 3D and other advanced image post-processing

software. Radiologists had to pause in their analysis, physically

move to the image processing workstation, perform the image

analysis, and then push the data back to the PACS. In this

scenario, efficiency and seamless connectivity of patient

information was lost.

Recent integration of advanced processing capabilities

to the PACS diminished the need to utilize a stand-alone

workstation. This was often accomplished by providing

Integration and Information the Cornerstone of RadiologyBy William P. Shuman, MD, FACR, Director of Radiology, University of Washington Medical Center


d e x u s t e c h N i c a l i N N o v a t i o N

access to an advanced application server via the desktop.

While this configuration worked, it still presented significant

workflow challenges.

With multiple systems already open on the workstation—HIS,

RIS, PACS—the radiologist was required to navigate and locate/

manage the desktop mindshare. Perhaps more important is

speed and functionality. At the University of Washington, we

use most of our advanced processing capabilities (as do other

sites) with CT colonography, cardiac, spectral dual energy, and

vascular imaging. Having a dedicated advanced image processing

workstation (i.e., AW Workstation) just 20 feet away from the PACS

workstation made it tempting to go over and work on it. However,

this defeated the purpose of a single desktop. As radiologists are

well aware, interruptions to the diagnostic process, including

moving to a dedicated processing workstation, diminish

efficiency and productivity.

While increases in network and processing speed helped

address these issues, a fully integrated program that allowed

us to seamlessly access PACS, RIS, advanced image processing,

and other applications at the same time, on the same workstation,

was highly desired. At our facility, we recently implemented

a new solution that integrates GE’s new AW Server to our

RIS-driven workflow with impressive workflow efficiency results.

Dexus workflow

An integral part of Dexus is the AW Server integration to PACS

and RIS for a single imaging workflow. It also leverages a central

PACS database to enable access to a broad array of advanced

3D visualization and processing tools typically found on the AW.

This environment provides a substantial improvement in the

speed of image post-processing on the PACS. System usability

is also enhanced due to transparent image sharing between

AW and PACS.

By using a thin-client architecture, AW Server enhances the

value of remote access to patient information. This is especially

important for our multi-site healthcare system, where we now

have the ability to scan a patient at any location and provide

the same level of interpretation and analysis regardless of

where the radiologists are situated.


T E C H n i C A l i n n o v A T i o n d E x u s

William P. Shuman, MD, is Director of Radiology at UWMC and Vice Chairman and Professor for the Department of Radiology. Dr. Shuman received his medical degree from State University of New York Syracuse and completed a residency in radiology at the University of Vermont. Dr. Shuman is one of the leaders in creating cardiac CT at UW. Outside of UW, Dr. Shuman has served as Associate Editor for two leading academic peer reviewed journals in radiology, is currently on the Appropriateness Committee of the American College of Radiology, and is the President of the Society of Body CT/MR.

UW Medicine owns or operates Harborview Medical Center, University of Washington Medical Center, Valley Medical Center, Northwest Hospital & Medical Center, a network of seven UW Medicine Neighborhood Clinics that provide primary care, the UW School of Medicine, the physician practice UW Physicians, and Airlift Northwest. In addition, UW Medicine shares in the ownership and governance of Children’s University Medical Group and Seattle Cancer Care Alliance, a partnership among UW Medicine, Fred Hutchinson Cancer Research Center, and Seattle Children’s. The core hospitals, Harborview, UW Medical Center, and Northwest Hospital & Medical Center, together have about 69,000 admissions and about 1.4 million outpatient and emergency room visits to the hospitals and clinics each year. UW Medicine faculty includes four Nobel Prize winners, 33 Institute of Medicine members, 32 National Academy of Sciences members, and 16 Howard Hughes Medical Institute investigators. (Photo courtesy of UW Medicine.)

Speed has historically been an issue with advanced post-

processing in the PACS. It is important that speed be independent

of location—it is the same whether the images are being sent

from a facility in another city or state, or three doors down the

hall. By addressing the speed issue, we anticipate the AW Server

will further impact our ability to perform more advanced analysis

from virtually any location, including at-home night reads when

on-call. As radiology subspecialties continue to grow in demand,

speed will become even more important in the near future.

Clinical collaboration among and between specialties will also

be further enhanced. Utilization of advanced applications in

our diagnostic workflow will increase in our daily routine and

in training residents and fellows. When access was cumbersome

and required an interruption in workflow, there was a natural

reluctance on the part of the radiologist to use 3D image

analysis. Frankly, their productivity would decrease as they

fell further behind on their workload. Now with Dexus, we can

perform 3D analysis directly on the PACS on more patient cases

due to the increase in speed of access and performance, which

impacts the quality of patient care. In our facility, we estimate

that in approximately 10% to 15% of high-tech imaging, 3D

analysis will improve or change the diagnosis.

Finally, training is a critical component and should not be

overlooked. In my opinion, the best scenario is an intuitive

system and software that doesn’t require significant training.

The test of any training program is the extent to which staff

can fully utilize the software while maintaining efficiency—

two weeks after the training session is complete.

Our radiologists expect the new environment will offer the

referring physician, patient, and hospital (our employer) a better

balance between accuracy, quality, and productivity. The way

information from different systems and software is integrated

does matter. We’ve learned that one software environment

with a single database is critical for access to advanced

imaging functionality and the entire diagnostic and image

evaluation process.

Remember, as radiologists, we are integrators of information,

and the more our tools complete these tasks for us, the more

efficient we can be in our diagnoses and consultations. n

“ Remember, as radiologists, we are integrators of information, and the more our tools complete these tasks for us, the more efficient we can be in our diagnoses and consultations. ”

Dr. William P. Shuman

www.gehealthcare.com/aw »

GE HealthcareComputed Tomography

© 2011 General Electric Company *Trademark of General Electric Company.

No company has done more to bring low dose to patients than GE Healthcare. That’s no coincidence — in fact, it speaks to the single purpose that guides our business: helping you deliver high-performance care.

Our approach is built upon a foundation of low-dose technology. But it also encompasses the best practices and industry exposure we’ve amassed for decades. The result is a true end-to-end partnership designed to help you provide lower dose patient care, more efficiently, and more effectively.

You’re here to deliver high-performance care. We’re here to help you do it.

www.gehealthcare.com/LowDoseCT

GreaT Care by DesiGn.

PartnershipDecades of CT experience have made us a strong, dedicated partner who understands healthcare’s complexities

asir*

Lower image noise while improving low contrast

detectability and image quality.

Gemstone* spectral imagingExpand information for clinical

diagnosis and workflow.


T E C H n i C A l i n n o v A T i o n P H o T o n C o u n T i n G

Photon Counting: A New CT Technology Just Over the Horizon

By Tibor Duliskovich, MD, Medical Director CT, GE Healthcare

“CT is mature technology” is frequently heard, implying that

CT has reached its full potential—that nothing revolutionary

is coming down the road. This is simply not true.

In a previous edition of CT Clarity magazine you may remember

reading an article on dual energy CT and its clinical value

and indications. Dual energy imaging, or in GE terminology

“Gemstone Spectral Imaging” (GSI), uses two X-ray energies to

allow improved differentiation of tissues and materials. It also

enables virtual mono-energetic imaging. This post-imaging,

processing technique mimics the use of a very narrow energy

spectrum absorption and enhances material decomposition,

making identifying and removing specific materials from image

data possible. The GSI technique can also generate virtual

un-enhanced images from a single contrast data acquisition.

Clinical applications for GSI are still evolving and there is no

doubt that radiologists will find new ways of utilizing the

additional information that it provides.

X-rays (and all frequencies of light) may be thought of as waves

and particles. In fact, Albert Einstein won his Nobel Prize in

physics for the work he contributed to understanding this wave/

particle duality, and not for his more famous work on the theory

of relativity. Photon counting,** as the name implies, counts

individual X-ray photons (the particles that make up the X-ray

frequency light) hitting the surface of a single photosite of the

detector—essentially, detecting individual events on a nano-

second scale! Unlike all existing technologies that digitize an

integrated signal of an analog response of the detector to

hundreds of events, photon counting counts discrete events

(absorption of a single photon) and as such is “digital in nature”

at the detection phase. Therefore, the electronic noise present

in the detector is not sampled as it remains well below the signal

level created by the thousands of electron-hole pairs generated

by the impact of a single X-ray photon (Figure 1). This gives

very clear input to the reconstruction algorithms. In fact, the

detector resolution can be increased dramatically without a

corresponding increase in statistical noise to achieve higher

spatial and contrast resolution.

But that is not all. The flexibility of photon counting allows other

benefits as well, specifically leveraging the fact that the energy

of the photons may be recorded in as many discrete ranges

(bins) as necessary. Consider that in existing integrated detector

technologies we have two energy spectra along with significant

energy overlap between the two spectral bins (Figure 2).

**Technology in development that represents ongoing research and development efforts. These technologies are not products and may never become products. Not for sale. Not cleared or approved by FDA for commercial availability.


P h o t o N C o u N t i N g t e C h N i C a l i N N o v a t i o N

Figure 2. Different approaches to dual-energy acquisition: sequential acquisition and dual-tube detector techniques are prone to temporal mismatch. GSI effectively deals with temporal mismatch. Photon counting makes registration of all energy levels simultaneous and further improves energy separation.

Figure 1. Experimental validation of photon counting vs. conventional CT acquisition. The impact of “zero electronic noise” is apparent in ultra-low dose CT acquisitions. At high doses the “pile-up” effect makes counting individual photons difficult and lowers efficiency of photon counting detector. Technique: 80 kV, 5 mAs, 32*0.625 mm, 0.5 sec axial, 10 mA, window width-1600 HU, window level-160 HU.

The maximum energy for these is determined on the tube side

by switching the kV. However, in photon counting the energy is

discriminated on the detector side, so a single energy tube can

do the job. By separating photons into a larger number of narrower

energy bins, we can improve the mathematical reconstructions

to approach better estimates of true mono-energetic images

and not just simulate that effect mathematically as in the case

of dual energies. The increase in the number of energy bins

along with less energy contamination between the bins may

improve the precision of material decomposition (Figure 3). This

translates into higher-quality, virtual, un-enhanced images and

the ability to remove materials selectively without “bleeding” into


T E C H n i C A l i n n o v A T i o n P H O T O N C O U N T I N G

neighboring pixels or “contaminating” the data in the beam’s

path. With this technique, voxels containing iodine (contrast agent)

should be easily distinguished from non-contrast containing

voxels, so true vessel lumen may possibly be identified and

reconstructed in 2D and 3D with “suppressed” surrounding tissue.

This data may possibly also be used for high-energy virtual

reconstructions to calibrate PET standard uptake values more

precisely in hybrid PET/CT scanners and to tailor therapeutic

radiation treatment with the goal of better target delineation,

hence sparing healthy tissue.

Another potential benefit of detector-based photon counting

comes from the fact that X-ray tubes continue to operate in

standard conventional single-energy modes. All advanced X-ray

tube technologies including mA modulation, kVp modulation, and

focal spot modulation are planned to be used in photon counting

scanners. Therefore, the tube voltage could be continuously

modulated the same way we currently modulate the tube current

to account for differences in absorption of the body from different

angles. This may allow us to spare superficial tissues such as the

breasts by turning down the mAs while simultaneously increasing

the voltage. Based on the scout image data, it may also allow

a dynamic optimization of imaging protocols and avoidance of

so-called “photon starvation” in order to reduce overall dose

while maintaining diagnostic image quality. Furthermore,

a low kVp beam may be utilized on slim patients.

The beauty of this technology is that the detector always operates

in photon counting mode and the radiologist can decide after

the fact whether to reconstruct a standard CT image or a photon

counting image out of the raw dataset without a need to rescan.

So, for straightforward cases the exam could be fast and generate

fewer images for speed and throughput, yet for difficult cases

the radiologist would have a full arsenal of options to aid in

determining the diagnosis.

When not generating the photon-counting spectral images, the

specifics of absorption of different energy photons at different

depths enable precise weighting of each discrete energy level so

that their contribution to a standard CT image can be fine tuned.

As a result, we expect there will be better quality, standard CT

images with less noise.

The more energy bins we use in photon counting the closer we

can get to true K-edge imaging of multiple elements simultaneously.

Based on a specific “fingerprint” of a K-edge, i.e. the unique shape

of its mass attenuation coefficient, the element can be identified

with certainty (Figure 4). Tagging tumor cells with gold, tantalum,

or other materials and subsequently utilizing photon counting

technology holds hope for allowing reliable detection of very

small, distant metastasis rivaling the sensitivity of PET with the

spatial resolution of the most advanced CT scanners we

have today.

The counting of events happens on a nano-second scale,

enabling extreme precision in recording the energy and time of

the photon-material interaction. This information may be utilized

to eliminate artifacts caused by the non-simultaneous acquisition

of dual energy data, further improving image quality.

Figure 3. Photon Counting Prototype Clinical Study: Full FOV abdominal imaging. Improvements in material decomposition allow for Z-map images that are color coded according to tissue atomic number. Efficient energy separation allows for true mono-energetic images.


t e c h N i c a l i N N o v a t i o NP H O T O N C O U N T I N G

All indications of GSI imaging are expected to be applicable to

photon counting technology, as well. Additionally, scientists will

likely develop numerous new applications, expanding the clinical

utility of CT scanning and potentially allowing physicians to detect

disease earlier and with more confidence. The ultimate goal is to

improve patient outcomes.

This article provides only a glimpse of things that may be coming

in the not so distant future, possibly a few generations down the

road. There are even more CT innovations and discoveries yet to

come. Much hard work is needed to mature these new technologies

and generate clinical evidence to support them, otherwise

reimbursement and adoption will be a challenging hurdle.

CT has amazing potential above and beyond the benefits

it already provides! n

Figure 4. The identification of certain materials based on the unique shapes of their Mass Attenuation Coefficients (MAC). The sudden increase in X-ray attenuation at an energy level corresponding to the binding energy of K-shell electrons allows for 100% specific identification.

References

1. J. Eric Tkaczyk, Rogerio Rodrigues, Jeffery Shaw, Jonathan Short, Yanfeng Du, Xiaoye Wu, Deborah Walter, William Leue, Daniel Harrison and Peter Edic, “Atomic number resolution for three spectral CT imaging systems”, Proc. SPIE 6510, 651009 (2007);

2. J. Eric Tkaczyk, David Langan, Xiaoye Wu, Daniel Xu, Thomas Benson, Jed D. Pack, Andrea Schmitz, Amy Hara, William Palicek, Paul Licato and Jaynne Leverentz, “Quantization of liver tissue in dual kVp computed tomography using linear discriminant analysis”, Proc. SPIE 7258, 72580G (2009);

3. J. Eric Tkaczyk, Kristian Andreini, Tan Zhang, Kevin G. Harding, Gil Abramovich, Yana Williams, Christopher A. Nafis and Wenwu Zhang, “CZT smart dicing strategy for cost reduction using defect imaging and random-access machining”, Proc. SPIE 7806, 78060L (2010);

4. J. Eric Tkaczyk, Vladimir Lobastov, Daniel D. Harrison and Adam S. Wang, “Contrast-to-noise of a non-ideal multi-bin photon counting x-ray detector”, Proc. SPIE 7961, 79613O (2011);

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6. Adam S. Wang, Norbert J. Pelc, “Synthetic CT: Simulating low dose single and dual energy protocols from a dual energy scan”, Med. Phys. 38, 5551 (2011);

7. Wang, A.S.; Pelc, N.J.; “Sufficient Statistics as a Generalization of Binning in Spectral X-ray Imaging“, Medical Imaging, IEEE Transactions on, 30 Issue:1, (2011)

8. Ehsan Samei, Norbert J. Pelc, “Impact of photon counting detector spectral response on dual energy techniques”, Proc. SPIE 7622, 76223L (2010);

9. Taguchi K, Zhang M, Frey EC, Wang X, Iwanczyk JS, Nygard E, Hartsough NE, Tsui BM, Barber WC.’ “Modeling the performance of a photon counting x-ray detector for CT: energy response and pulse

pileup effects”, Med Phys. 38(2):1089-102, (2011)

10. Srivastava, S.; Taguchi, K.; “Improved contrast-to-noise ratio of photon counting clinical x-ray CT images using a model-selection based approach”, Nuclear Science Symposium Conference Record (NSS/MIC), 2010 IEEE

11. X. Wang, K. Taguchi, E. C. Frey, D. Meier, D. J. Wagenaar and B. E. Patt, “Material separation in x-ray CT with energy resolved photon-counting detectors”, Proc. SPIE 7961, 79611V (2011);

Tibor Duliskovich, MD is Medical Director, Computed Tomography, at GE Healthcare. Dr. Duliskovich earned his medical degree from Semmelweis Medical University (Budapest) and was a staff radiologist at Haynal Imre Medical University (Budapest). He led Organizational and Methodological Department at the National Institute of Radiology and Radiation Physics in Hungary, where his department oversaw the design, manufacturing, installation and servicing of medical imaging devices to ensure safety and effectiveness. Prior to assuming his current position at GE, he has held various management positions at medical device and healthcare informatics companies, including DigiX, Inc., Wuestec, Inc., StorCOMM, Inc. Aspyra, Inc.; and Philips Healthcare. Dr. Duliskovich joined GE in January 2011, and in his medical affairs role supports regulatory submissions, marketing, scientific publications, patient safety, and the medical risk assessment process across the CT products; and helps align clinical research activities with business needs from a medical perspective.


b E y o n d T H E s C A n d o s E M A n A G E M E n T

Comprehensive Dose Management Services and Solutions

GE Healthcare has long recognized the benefits and risks of

radiation in diagnostic imaging and continually strives to develop

technologies and solutions to assist medical imaging providers in

managing these risks. Earlier this year, the US Joint Commission

issued a sentinel event alert on the radiation risks of diagnostic

imaging,1 signaling that accrediting agencies (such as Joint

Commission) may begin inspecting dose management, tracking,

and reporting.

Although dose management is an industry-wide patient care

concern that requires a collaborative effort between physicians,

facilities, and manufacturers, GE Healthcare offers several

programs to help medical imaging providers improve patient

care by better managing, tracking, and reporting dose. GE’s

dose services and solutions assist a medical imaging provider to

monitor and report dose, provide additional or refresher training

for the facility’s staff, optimize protocols to enable low-dose

studies, and perform quality control and quality assurance

testing for regulatory and accreditation organizations.


b e y o N d t h e s c a Nd o s e M a N a G e M e N t

Dose services and solutions

For many healthcare facilities, particularly small- to medium-sized

sites, capturing, reporting, and monitoring dose is a challenging

task. Optimizing protocols to further lower dose may fall outside

the realm of expertise for the facility’s staff.

GE Healthcare offers a three-tiered approach to address clinical

informatics, education and optimization, and medical physics.

1. Clinical informatics includes: DoseWatch, an information

technology application that facilitates the tracking, reporting,

and monitoring of dose from multiple manufacturers and

multiple types of imaging devices; Innova Dose Reports for

interventional fluoroscopy provides detailed analytics and

alerts for the end user; and, integration with RIS and PACS to

enhance patient care and facilitate the clinicians’ access to a

patient’s dose exposure history by anatomy and utilize statistical

data/benchmarking to identify opportunities for improvement.

2. Education and optimization services encompass training and

protocol optimization support.

3. Medical physics solutions provide contract services for

accreditation and periodic acceptance and local regulatory

testing, technical support, and consulting.

DoseWatch

GE Healthcare now offers a comprehensive dose tracking and

management system with DoseWatch. Through a facility’s

existing network and IT infrastructure, DoseWatch captures

dose information from imaging devices and organizes the data

by modality and type of imaging protocol. The DoseWatch

database stores all data, records dose by patient, and retains

key acquisition parameters.

In fact, after one year of using DoseWatch, CHU Strasbourg

(France) reports a facility dose reduction due in part to using

Dose Watch in their QA program. “We are all very pleased with

the progress we have made using DoseWatch,” says Professor

C. Roy, MD, Director of Radiology. “We conduct close to 100 CT

exams each day, and thanks to DoseWatch we can get the dose

information we need in a very useable format to help us better

manage our imaging program.”

With the dose monitoring solution, Professor Roy can evaluate

dose management and optimization over a six-month period.

She notes that DoseWatch interfaces directly to the CT system

so it is transparent to the radiology workflow and does not slow

down the examination time.

Professor Roy is also impressed with the ability to access the

patient’s dose history in a few mouse clicks. This is an important

feature as many hospitals are concerned about the dose exposure

for acute-care patients—many who require follow-up CT exams—

and young adult or pediatric patients.

Using DoseWatch, clinicians at CHU Strasbourg can help determine

the appropriate dose level per procedure that can be shared

throughout the imaging and interventional community. That’s

because DoseWatch captures dose information during the

procedure, and that data can then be used to help define dose

targets by type of exam—such as neuro, abdomen, and thorax.

As a result, the number of procedures that may have exceeded a

predetermined dose level in the past have now been reduced at

CHU Strasbourg. The bottom line, it is the patient who wins in terms

of obtaining their diagnostic procedure at a dose that is ALARA.

Adds Professor Roy, “Thanks to this software, we are now

clearly below the target limits set out in the rules while

maintaining the diagnostic quality exams we need. I believe

that with DoseWatch, we have indisputably raised the overall

quality of our medical imaging.” n

For more information on Dose Watch, visit www.gehealthcare.com/ResponsibleImaging. »

Joint Commission Sentinel Event Alert

On August 24, 2011, the Joint Commission issued a Sentinel

Event Alert on the dangers of medical radiation. The

announcement also states that the Centers for Medicare &

Medicaid Services (CMS) will require accreditation of facilities

providing CT, MR, PET, and nuclear medicine in non-hospital

sites beginning January 1, 2012. Additional accredited

requirements may exist on a state-by-state basis.

To view the alert, which contains suggestions by

the Joint Commission for accredited facilities, visit

http://www.jointcommission.org/assets/1/18/SEA_471.PDF

Reference:

1. Available at: http://www.jointcommission.org/assets/1/18/SEA_471.PDF


b E y o n d T H E s C A n C T A n d r A d i A T i o n d o s E

Today’s diagnostic imaging portfolio offers the clinician

many options: ultrasound, MR, X-ray, SPECT, PET, fluoroscopy,

and CT. In fact, each imaging modality visualizes different

properties of human anatomy or function, and that is

why these technologies are generally not completely

interchangeable.

Does my Patient Need a CT Scan? By Tibor Duliskovich, MD, Medical Director CT, GE Healthcare


b e y o N d t h e s c a Nc t a N d r a d i a t i o N d o s e

During my radiology residency, I had a patient with metastatic

liver disease that I diagnosed using ultrasound. The patient

was taken to CT for a pre-operative scan and, given the

technology available at the time, the lesions were not visible

on the non-contrast or contrast CT. My supervisor suspected

I may have made a mistake until she repeated the ultrasound

herself and verified my initial finding.

Examples like this demonstrate what experienced clinicians

already know—that each imaging modality has its strengths

and weaknesses. This is why all the modalities have a

complementary place in the differential diagnostic workup

of a patient. Some may perform better than others in

a particular case—it depends upon the patient’s needs

and the clinical situation at hand. While the above example

highlights a case where CT at that level of development was

not the optimal diagnostic tool for a specific patient, rest

reassured that CT is a vital clinical tool and is here to stay.

In light of recent publicity over radiation from medical

imaging, the public may have forgotten the reason we built

the CT machines in the first place: to help clinicians accurately

diagnose a multitude of life-threatening conditions promptly

with virtually no contraindications. CT is used to determine

emergency treatment pathways, diagnose pathology, monitor

disease treatment, plan radiation therapy, calibrate nuclear

medicine images, and much more. CT scanners help physicians

make informed treatment decisions and save lives every day!

Despite the clear benefits of CT, it is not the answer to all

situations. Once a clinical decision is made to utilize medical

imaging, physicians have an array of diagnostic procedures

at their disposal. Because of this, many institutions follow

evidence-based protocols, called appropriateness criteria,

which take into account the advantages and disadvantages

of each modality for a given clinical imaging task for that

patient. By adhering to these guidelines, providers enhance

the quality of care and contribute to the most efficacious use

of different medical imaging modalities. These professional

guidelines, such as those developed by the American College

of Radiology,1 assist referring physicians and other providers

in making the most appropriate imaging or treatment decision

for a specific clinical condition.

Ultimately, the healthcare professional has the responsibility

to make the best decision for each individual patient and

to select the proper diagnostic algorithm. A healthcare

professional bases his/her decisions on the patient symptoms,

the clinical question being assessed, the patient’s medical

history, the presence of any contraindications to certain

procedures or tests, and many other factors. If CT is deemed

the best choice to achieve the optimal clinical outcome for

the patient, the treating physician will prescribe a specific

type of CT exam. The imaging department will carry out the

prescription consistent with their best practices, available

technology, and in accordance with the current state of

medical practice. The single most important driving force

behind prescribing a CT scan is that the benefit to the patient

outweighs the risks, including the small risk of ionizing radiation,

and no more appropriate alternative procedure is available to

achieve the optimal clinical result.

X-rays are ionizing radiation used in many imaging modalities

to produce images. The image is formed by the portion of X-ray

photons that are not absorbed in the patient’s body, but instead

pass through it to the detector. This should make it clear why,

without radiation, there is no CT image! If there is not enough

radiation the result will be a “noisy” image, which may not be

suitable for diagnosis.


b E y o n d T H E s C A n C T A n d r A d i A T i o n d o s E

This could lead to a repeat exam, a false positive finding requiring

additional tests and a delay in diagnosis, or, even worse, a false

negative finding. Repeating a CT exam would subject a patient to

additional radiation and, in some instances, intravenous contrast.

For these reasons, radiologists and technologists are trained

to select the proper imaging protocols to answer the clinical

question while keeping the patient’s radiation exposure under

tight control. This is known as the ALARA (As Low As Reasonably

Achievable) principle and it is fundamental to the appropriate use

of CT and other imaging techniques that involve ionizing radiation.

ALARA is based on the assumption that the amount of radiation

utilized should always be the minimal amount required to achieve

the desired result—a clinically useful image.

Although there is no definitive evidence of harm caused by

small amounts of radiation, such as the radiation levels received

annually from so-called “background” sources (e.g., radon),

minimizing radiation exposure is prudent. Therefore, the medical

profession has adopted the no-threshold linear model of

response to radiation, which assumes that the risk of exposure

to ionizing radiation is cumulative over a lifetime and there is no

threshold below which there are no potential effects. On the other

hand, others have adopted a “heuristic” view of ionizing radiation,

with some of the scientific literature supporting the notion that

small amounts of radiation may be beneficial. Regardless of one’s

view, the medical profession agrees that imaging should be

justified, optimized, and in accordance with ALARA to minimize

radiation exposure for patients.

From my perspective as a radiologist, in order to best serve

patients it is preferable to make a confident diagnosis rather

than save a millisievert or two, as the correct diagnosis is

a proven way to save lives. Patients typically feel the same

way and readily support a recommendation for imaging after

consultation with their physician about the risks and benefits

of the exam.

All CT manufacturers are investing in dose reduction

technologies. GE Healthcare is leading the way with the design

of X-ray tubes, collimation, dual energy, automatic beam

modulation, detector technologies, and noise and artifact

reduction algorithms. For more information on GE’s low-dose CT

technology, see www.gehealthcare.com/LowerDoseByDesign.

In addition, GE is incorporating the new MITA dose check feature

on our CT scanners. It provides alerts and notifications to scanner

operators when pre-defined radiation dose levels—as determined

and set by the facility—will be exceeded. There are two levels

of thresholds: Notification Values and Alert Values. Notification

Values apply to a single image series (e.g. a single helical series)

while Alert Values apply to a complete exam. CTDIvol and/or

DLP (Dose Length Product) values can be set. This feature also

is designed to check changes to protocols and keep a record if

levels are exceeded. Furthermore, GE makes available personnel

training and awareness of the relevance of dose reduction, and

this is conveyed to customers during each interaction.

Taking our commitment even further, GE is supporting a dozen

or so clinical studies across the globe focused on specific clinical

applications that are investigating pushing the dose limits even

lower. These studies will provide us with clinical evidence to

make crucial decisions on potentially reducing dose levels

further while providing adequate clinical imaging. There are

also new technologies on our horizon (see photon counting

article on page 64) that may provide additional radiation

dose reduction for our patients.

In addition to technical innovation, GE actively participates

in industry and professional groups working on national dose

registries and other policy initiatives to support and expand

the science behind CT for the benefit of our customers and

their patients. n

For a full list of references,

visit www.ctclarity.com/ctclarity/201111#pg72.

Tibor Duliskovich, MD, is Medical Director, Computed Tomography, at GE Healthcare. Dr. Duliskovich earned his medical degree from Semmelweis Medical University (Budapest) and was a staff radiologist at Haynal Imre Medical University (Budapest). He led the Organizational and Methodological Department at the National Institute of Radiology and Radiation Physics in Hungary, where his department oversaw the design, manufacturing, installation and servicing of medical imaging devices to ensure safety and effectiveness. Prior to assuming his current position at GE, he has held various management positions at medical device and healthcare informatics companies, including DigiX, Inc.; Wuestec, Inc.; StorCOMM, Inc.; Aspyra, Inc.; and Philips Healthcare. Dr. Duliskovich joined GE in January 2011, and in his medical affairs role supports regulatory submissions, marketing, scientific publications, patient safety, and medical risk assessment process across the CT products; and helps align clinical research activities with business needs from medical perspective.

References

1. Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx


b e y o N d t h e s c a Nw o r l d w i d e e d u c a t i o N

A clinical education specialist by your side whenever you need it

AppsLinq* is a new remote training service for troubleshooting

and training that will help your CT department solve application-

related problems, improve efficiency, and develop important

new skills.

Enabled through broadband connectivity, a clinical education

specialist can follow the CT console or AW workstation in real

time through a secure Broadband connection. This allows CT

application training to take place as if the clinical education

specialist is in the imaging department by your side.

Redefining applications training

AppsLinq revisits traditional online training and places emphasis

on practicality. It combines the hands-on benefits of on-site

training with the convenience and fast response time of distance

learning. Also, it allows training to be conducted in available time

slots within the hectic schedule of an imaging department.

Once the intial training on-site has been delivered, AppsLinq

provides an ideal solution to complete your ongoing training

in combination with technology and clinical classrooms. n

For the latest information on training for Europe, Middle East,

and Africa, visit www.gehealthcare.com/clinicaleducation. »“I forgot how to…”

“Help me with an advanced application...”

Refresh training on CT or workstation applications

Quick support to avoid patient flow disruptions

Application support to prepare challenging exams

Customized training sessions to best fit the day’s busy schedule

Europe, Middle East, and Africa Clinical Education


b E y o n d T H E s C A n w o r l d w i d E E d u C A T i o n

CT Masters Series

The CT Masters Series are advanced training courses designed

for radiologists, cardiologists, and radiologic technologists.

The courses provide a unique opportunity for participants to

learn from experts and receive individual attention in order

to maximize their learning experience and ensure that they

acquire the skills and confidence necessary for success.

Training is offered in cardiac CT angiography, peripheral

CT angiography, Gemstone Spectral Imaging, virtual

colonoscopy, and CT dose reduction. The CT Masters Series

curricula are designed with industry requirements in mind. The

cardiovascular-focused courses are endorsed by the Society

of Cardiovascular Computed Tomography (SCCT). n

United States Clinical Education

CTA of the Coronaries: From Novice to Expert

Tracy Q. Callister, MD, FSCAI

Hyatt Place

Hendersonville, TN

Cardiac CTA: Beyond the Coronaries Tracy Q. Callister, MD, FSCAI

Hyatt Place

Hendersonville, TN

Cardiac CTA: Advanced Course

Matthew Budoff, MD

Harbor UCLA

Los Angeles, CA

Peripheral CTA: Advanced Course

Matthew Budoff, MD

Harbor UCLA

Los Angeles, CA

Cardiovascular


b e y o N d t h e s c a Nw o r l d w i d e e d u c a t i o N

For dates, CME information, and training opportunities,

visit: www.gehealthcare.com/gectmasters

or call 262-312-7148.

India Clinical EducationHealthcare in India, like many emerging economies, is challenged by the small population of trained radiologists and radiology

technicians across the region’s vast geography. This lack of coverage is the main barrier to increasing access to healthcare

in the region. To address this challenge, GE Healthcare’s South Asia CT Team is initiating a training program for radiology

technicians in association with the Society of Indian Radiographers (SIR), the largest radiographer society in the region. The first

residential training program is expected in the fourth quarter of 2011 with plans to initiate training programs at a later date for

radiology consultants in advanced CT Technologies, such as low-dose CT imaging and Gemstone Spectral Imaging.

For more information on CT Educational programs in South Asia, please email [email protected] n

Cardiovascular CTA for Technologists

Joey Glass, RT(R)(CT)

Cardiology Associates

Mobile, AL

Cardiovascular CTA for CT Technologists

Rob Jennings, RT(R)(CT)

Judy Lane, RT(R)(CT)

Fairfax Radiological Consultants, P.C.

Fairfax, VA

Cardiac Imaging with CT: Advanced Certification

Ronald P. Karlsberg, MD

Cardiovascular Medical Group

of Southern California

Beverly Hills, CA

Cardiovascular

Gemstone Spectral Imaging Workshop

James P. Earls, MD

GE Healthcare Institute,

Waukesha, WI

Gemstone Spectral Imaging

Virtual Colonoscopy for Radiologists

Abraham H. Dachman, MD, FACR


Waukesha, WI

Virtual Colonsocopy

CT Dose Reduction and Scanning Techniques

Mannudeep K. Kalra, MD


Waukesha, WI

Low Dose Imaging

More Clarity. Now on tap.

GE Healthcare

Now you can have complete issues of GE Healthcare’s CT Clarity, the Magazine of CT, right at your fingertips when you’re on the go. The CT Clarity App links you to a vital source for the latest news about GE Healthcare CT on your iPad, iPhone, or Android tablet or phone. Download the free tablet and smartphone applications at the Apple Store (www.apple.com) or Android Market Apps (www.market.android.com). Or, simply scan the QR code below with your iPhone.

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