AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Multimodali ty Imaging – Clinica lPersp ective
Michael W. Vannier, M.D.University of Chicago
Monday, July 28, 2008
Imaging Continuing Educati on Cours e
CE-Imaging: Mult imo dality Medical Imagin g - I
Case History
46 year old female with melanoma .
PET-CT exam for initi al stagin g.
Radiological Presentations Radiolog ical Presentations
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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Purpose
• Challenges in diagnostic imaging technology (2008)– The “evidence gap”; Overuse– Economics of diagnostic imaging– Oncology; Neuroimaging; Cardiovascular; Orthopedic
• Identify trends– 256-320 channel CT scanners *NEW*– Applications of high end scanners –
• Neuroimaging; Cardiac Imaging; etc.• 4D angiography; non-gated scanning
– Low end CT scanners:• Point of Care CT ; DentoMaxilloFacial/ENT
– CT in the cath lab (high end application to PCI)
Doctors often seem to prescribeCT and MRI scans when theyare of little or no medical use,perhaps explaining whyCanadians still face hefty delaysto get the tests, a new Ontariostudy suggests. Largepercentages of the scansreviewed by the researcherseither unearthed no medicalproblems, or detectedabnormalities that would notchange how the patient wastreated, raising questions aboutwhether they should have beenordered in the first place.
27 June 2008
(CANAD A)
Sunday, 29 June 2008
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Medical spending in the United States hascontinued to soar, reaching an estimates$2.25 trillion in 2007. The nation nowspends 50% more on health care per capitathan the next closest industrialized country,often with no better outcomes for patients.One reason is overuse of medicaltechnology.
The New York Times29 June 2008
US spends more for healthcare
Sources: Centers for Medicare and Medicaid Services, U.S. Departmentof Health and Human Services, Organization for Economic Cooperationand Development, New York Times
Medicare coverage ofcardiac computed tomography angiography
March 2008
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Lumbo sacral Spine CT
15 htt p://w ww.pedra d.org /asso ciatio ns/5364/ig/
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Recommended Protocol Templates in Excel™ Spreadsheets
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Multirow Detector CT (MDCT) Scanner128 detector rows; 256 slices (iCT) Increased Speed, Power, Coverage
•• Higher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolutionHigher temporal resolution–– 0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation0.27 sec rotation
•• Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power Increased Tube Power –– 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 120 kW / 1,000 mAmAmAmAmAmAmAmA–– XXXXXXXX--------Y and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulationY and Z focal spot modulation
•• Greater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotationGreater coverage per rotation•• 8 cm8 cm8 cm8 cm8 cm8 cm8 cm8 cm•• 256 slices256 slices256 slices256 slices256 slices256 slices256 slices256 slices
Nose to Toe Scan:168 cm in 22sec
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Multi-phase Cardiac Imaging less than 5 sec
More detectors(rows & channels)
Faster gantryrotation
Higher sourcebrightness
Focal spotmodulation
Larger scanneraperture
Table weight limitincreased
Lower dose
40-64 channels
256 channels
320 channels
256-320 detector row CT scannersEnables 4D CT angiography &Whole organ perfusion exam
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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Non-Gated Chest CT Scan
Excellent coronary visualizationRT=0.33sec
CT Bronchoscopy – Non-Gated Scan
MetroHea
132kg162cm50 BMI52 bpm
Large Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CTLarge Patient Cardiac CT
BMI = 5028
•• 4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan4.8 sec scan•• 2D Anti2D Anti2D Anti2D Anti2D Anti2D Anti2D Anti2D Anti--------Scatter Scatter Scatter Scatter Scatter Scatter Scatter Scatter
detector grid improves detector grid improves detector grid improves detector grid improves detector grid improves detector grid improves detector grid improves detector grid improves contrast resolutioncontrast resolutioncontrast resolutioncontrast resolutioncontrast resolutioncontrast resolutioncontrast resolutioncontrast resolution
•• Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for Smart Focal Spot for artifact eliminationartifact eliminationartifact eliminationartifact eliminationartifact eliminationartifact eliminationartifact eliminationartifact elimination
13 yr old Female
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Head & Neck
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MRI of Cerebral Ischemia
78 yo female 3 hrs after onset of aphasia during cardiac cath.FSE T2W Initial DWI Initial MTT
GregSorensen,MassachusettsGeneral Hospital
Early DWI/MTT mismatch, lesion growth
DWI 5 days later
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Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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Perfusion
MTTDWIT2
CT vs. MRIvs. xenon CT vs. PET vs. SPECT
Megan Strother, M.D., Vanderbilt University
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STROKEIMAGING
CTP MRP
Non-contrast CT MRI
Megan Strother, M.D., Vanderbilt University
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Imaging Ischemia--VascularAngiogram
1950-60’s (pre-CT era)
Vascular occlusion
Thrombolysis
Recanalization =Clinical improvement
24 hours
Megan Strother, M.D., Vanderbilt University
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Imaging Ischemia- Parenchyma
Head CT
<1/3 MCAterritory
No ICH
IV Thrombolysis
<3 hours
Megan Strother, M.D., Vanderbilt University
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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Tissue Cloc k
CBF CBVMTT
Wall Clock
Vascular Occlusion Parenchymal changeson non-contrast CT
.
Megan Strother, M.D., Vanderbilt University
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MRCT
• No radiation• Better contrast
MR vs. CT
Megan Strother, M.D., Vanderbilt University
Advantage
MR
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MRCT
• Diffusion = Infarct• MR = 94% sensitive and 96%
specific for infarct• Non-contrast CT = 50%
accurate for acute infarct
Advantage
MR
Megan Strother, M.D., Vanderbilt University
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MRCT
• MR = whole-brain coverage• CT limited by scanner (10-40 mm max)• Post fossa obscured on CT by beam-
hardening artifact
Megan Strother, M.D., Vanderbilt University
Advantage
MR
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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MRCT
• Speed• Accessibility• Spatial Resolution on CTA
Advantage
CT
Megan Strother, M.D., Vanderbilt University
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MRCT
– Quantifiable• MR relies on indirect T2* effects on tissue
from gad, therefore not quantifiable
Megan Strother, M.D., Vanderbilt University
Advantage
CT
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MRP
STROKEIMAGING
fast
accessible
CTA vascular detail
cheap
quantifiable
CTP
diffusion
no radiation
whole-brain coverage
Megan Strother, M.D., Vanderbilt University
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1st
Non-contrastHead CT
2nd
CT Perfusion
3rd
CT angiogram
CT ScanProtocol
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
7/28/2008 45
Head & Neck
CT Scanning Protoco l – 320 ChannelWhole Head Dynamic CTA (Multiple Phases) (16 cm z-axis coverage)
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Whole Brain Perfusion (16 cm z-coverag e) Whole Brain Perfusio n
256 to 320 Channel MDCT Scanner (2008)256 to 320 Channel MDCT Scanner (2008)
•• 88--16 cm z16 cm z--axis coverage is well suited to evaluation of axis coverage is well suited to evaluation of cerebrovascularcerebrovascular disease, in stroke (arterial & venous) disease, in stroke (arterial & venous)
•• Whole brain perfusion examination is newWhole brain perfusion examination is new
•• Dynamic wholeDynamic whole--head CT angiography with high head CT angiography with high temporal resolutiontemporal resolution
•• Bone subtraction Bone subtraction –– petrouspetrous ICA, V4, stentsICA, V4, stents
•• Single 50 ml IV contrast material bolus injectionSingle 50 ml IV contrast material bolus injection
•• Combined with CTA of the supraCombined with CTA of the supra--aortic vesselsaortic vessels
Renal CT Angiography (CTA)Renal CT Angiography (CTA)Renal CT Angiography (CTA)Renal CT Angiography (CTA)Renal artery stenosis, trauma, transplant donor, neoplasm
But NOT renal fun ction
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
CT of the kidneys: current status
• Highest spatial reso lut ion (0.5 mm)(Coppe nrath EM et al. Eur Radiol 2006; 16: 2603 – 2611)
• Bi-/tri -phasic imag ing - hig h sensit ivit y for neoplasia(Walt er C et al. Br J Radiol 2003; 76: 696 – 703)
• CT urography - replacing con vention al urogr ams(Jung DC et al. Radiog raphics 2006; 26: 1827 -1836)
Challenges:• Renal function (perfu sion, cleara nce)?
(Daghini E et al. Radio logy 2007; 243: 405 – 412)
CH A RITE’
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NewTomNewTom QR 2000QR 2000
HitachiHitachi MercuRayMercuRay
J. Morita 3DXJ. Morita 3DX AccuitomoAccuitomo
CONE BEAM CTCONE BEAM CT
XoranXoran/ISI/ISI DentoCATDentoCAT, Ann Arbor, MI, Ann Arbor, MI
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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Facial to Palat al Distal to Anter ior
Dista l to Anterior Facial to Palat al
Diagnostic Imaging
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Dentomaxillofacial Images
Panor amic
Sagitt al MPR
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AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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8-Slice Portable CT Scanner
• Compact, lightweight, mobile, high speed, battery and line poweredmulti-slice CT scanner
• 25 cm field of view, primarily head and neck.• Up to 8 slices per revolution• Wireless image transfer system (WITS)• Non-contrast head CT; CTA; CTP
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8-Slice Portable CT Scanner
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Radiation Data
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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CT Scanner for ENT Office / Clinic
Manufacturer claims -
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R
L
L
BUC LING
Follow-up to surgery
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Low X-Ray Radiation Dose
Sinus CT with a full-body scanner• Adult: 1.0-2.0 mSv• Child: 1.0-2.0 mSv
Sinus CT with the MiniCAT™ low-dose scanner• Adult: 0.13 mSv (7-15 x lower radiation dose)• Child: 0.07 mSv (14-28 x lower radiation dose)
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Whichdo youprefer?
Cereto m
Ceretom GE
GE
This is the same ptscanned wit hin 24hours using theCeretom portablescanner and thenour GE station aryscanner …
Ano ther Clini cal Example ….Patient500lb 38 year oldAfric an Americ anmale
SymptomsAphasi a and rightsided hemipares is.
Issue sNo hospital in NYCwilling to scan apatient over 400lbs.Patient went 5 dayswithout a CT scan.
Imag ingLarge MCA infarctwith mass effec t &mid line sh ift.
CerebrovascularCerebrovascular EvaluationEvaluation
CT Perfusion (CTP)
CTA
MTT
CBF
CBV
•axi al, 1 cm slice, 1 slice /second,•acquis ition time is user defined (30-40 seconds)•reconst ructio n on the scanner in real time
Direct coronals
Direct coronal imagingDirect coronal imag ing
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
Direct Coronal Facial CT
CereTom GE Lightspeed
4 months apar t, same Pt, same dose, same reco n settin gsSummarySummaryAdvantages of Portable CT ImagingAdvantages of Portable CT Imaging
•• Mobi le and easy to move (unlike the patient!)Mobile and easy to move (unl ike the patient!)
•• Easy to operate for hosp ital & offic e perso nnelEasy to operate for hosp ital & offic e pers onn el
•• Plugs into 120v wall power outlet; or batteryPlugs into 120v wall power outlet; or battery
•• Compact & does not require roo m shieldingCompact & does not require room shield ing
•• Perform s axial and coronal images; canPerform s axial and coron al images; canprovide sagittal recon structions if needed;provide sagittal recon structions if needed;can provid e CTA and 3D images .can provid e CTA and 3D images .
•• Compatible with surgical naviga tion units.Compatible with surgical navigation units.
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Medical Imaging Workstations
Thick Client – expensive, with substantiallocal processing capability
Thin Client – small, portableAccessible throughout enterprise
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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Revolution in thin-client solutionsAdding applications and 3D to viewing
Techat scanner
PACS
3D Techat Workstation
CT ScanRoom
CT ControlRoom
3D Lab
WorkspacePortal
HomeAny chair ofyour choice
Cath or EP Lab
Department Workstations
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Thin Client SolutionsCT viewing plus
• Comprehensive Cardiac Analysis
• Brain perfusion-summary maps
• CT Angiography Applications
- AVA Stenosis and Stent Planning
• Lung Nodule Assessment
• Virtual Colonography
AllKeyClinicalApplications
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Integrat ing CT into the Cath Lab—Current and Future Applications
John C. Messenger, MD, FACC
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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3-D Model
Proximal RCARadius of curvature=34.4°Length=4.27 cm
Mid RCARadius of curvature=30.8°Length=3.90 cm
Distal RCARadius of curvature=22.0°Length=2.62 cm
Messenger, Chen,Carroll,Burchenal, Kioussopoulos, Groves.3-D coronary reconstruction fromroutinesingle-planecoronaryangiograms:Clinical validation andquantitativeanalysisof therightcoronary artery in 100 patients.International.J. CardiacImaging2001.
3-D Features of a Corona ry TreeDerived from CTA or 2-D Projection Images
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Comple teDiagnos tic
ImagingStudy (CTA)
Showin gNeed for PCI
An alyze 3-DCoronary
Artery TreePredict PCI
Difficulty andPatient Risks
Perform PCI
Case Specific Selectio nof Equipm ent and
Working Views
A New Paradigm for Coronary Intervention
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Use of 3D coronary analysis forprocedural planning of PCI
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AAPM 2007 - Multimodality MedicalImaging - I
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J. Boone, UC Davis 90
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51 Y/O, 180 lb female with newly diagnosed infiltratingductal carcinoma of the right breast and one positivelymph node. ER (+), PR(+).
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Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
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Bernhard Preim, Visualization Research Group, University of Magdeburg, Germany
AAPM 2007 - Multimodality MedicalImaging - I
Michael W. Vannier - University ofChicago
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Conclusion• Diagnostic imaging is subject to overuse with
limited evidence for a beneficial effect onoutcomes in some applications (e.g., cardiac)
• Imaging modalities (e.g., CT scanners) arebecoming both more and less expensive
• Low end scanners are available at the Point ofCare
• High end specialty imaging (e.g., CT in the cathlab) is in development
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Acknowledgments
• John Steidley , Ph.D., Philips Medical System s• GE Healthcare, Inc.• Siemens Medical Solu tion s, Inc.• Diego Ruiz, Johns Hopkin s Hospital• Predrag (“ Pedja” ) Suko vic , Xoran Technolo gies, Inc.• Bernhard Preim , University of Magdeburg , Germany• John C. Messen ger, MD, FACC, University of Colorado• Megan Strother , MD, Vanderbilt University• Patrik Rogalla , MD, Charit e’ Berlin• Ali sa Gean, MD, UCSF Radiolo gy• David Rosenbl um, DO, Case Wester n Reser ve Univ.