Dimitris Mitsouras

Medical 3D Printing for the Radiologist

While use of advanced visualization in radiology is instrumental in diagnosis and communication with referring clinicians, there is an unmet need to render Digital Imaging and Communications in Medicine (DICOM) images as three-dimensional (3D) printed models capable of providing both tactile feedback and tangible depth information about anatomic and pathologic states. Three-dimensional printed models, already entrenched in the nonmedical sciences, are rapidly being embraced in medicine as well as in the lay community. Incorporating 3D printing from images generated and interpreted by radiologists presents particular challenges, including training, materials and equipment, and guidelines. The overall costs of a 3D printing laboratory must be balanced by the clinical benefits. It is expected that the number of 3D-printed models generated from DICOM images for planning interventions and fabricating implants will grow exponentially. Radiologists should at a minimum be familiar with 3D printing as it relates to their field, including types of 3D printing technologies and materials used to create 3D-printed anatomic models, published applications of models to date, and clinical benefits in radiology. Online supplemental material is available for this article.

Applications of 3D printing in cardiovascular diseases

3D-printed models fabricated from CT, MRI, or echocardiography data provide the advantage of haptic feedback, direct manipulation, and enhanced understanding of cardiovascular anatomy and underlying pathologies. Reported applications of cardiovascular 3D printing span from diagnostic assistance and optimization of management algorithms in complex cardiovascular diseases, to planning and simulating surgical and interventional procedures. The technology has been used in practically the entire range of structural, valvular, and congenital heart diseases, and the added-value of 3D printing is established. Patient-specific implants and custom-made devices can be designed, produced, and tested, thus opening new horizons in personalized patient care and cardiovascular research. Physicians and trainees can better elucidate anatomical abnormalities with the use of 3D-printed models, and communication with patients is markedly improved. Cardiovascular 3D bioprinting and molecular 3D printing, although currently not translated into clinical practice, hold revolutionary potential. 3D printing is expected to have a broad influence in cardiovascular care, and will prove pivotal for the future generation of cardiovascular imagers and care providers. In this Review, we summarize the cardiovascular 3D printing workflow, from image acquisition to the generation of a hand-held model, and discuss the cardiovascular applications and the current status and future perspectives of cardiovascular 3D printing.

Prediction of coronary artery plaque progression and potential rupture from 320-detector row prospectively ECG-gated single heart beat CT angiography: Lattice Boltzmann evaluation of endothelial shear stress

Advances in MDCT will extend coronary CTA beyond the morphology data provided by systems that use 64 or fewer detector rows. Newer coronary CTA technology such as prospective ECG-gating will also enable lower dose examinations. Since the current standard of care for coronary diagnoses is catheterization, CT will continue to be benchmarked against catheterization reference points, in particular temporal resolution, spatial resolution, radiation dose, and volume coverage. This article focuses on single heart beat cardiac acquisitions enabled by 320-detector row CT. Imaging with this system can now be performed with patient radiation doses comparable to catheterization. The high image quality, excellent contrast opacification, and absence of stair-step artifact provide the potential to evaluate endothelial shear stress (ESS) noninvasively with CT. Low ESS is known to lead to the development and progression of atherosclerotic plaque culminating in high-risk vulnerable plaque likely to rupture and cause an acute coronary event. The magnitude of local low ESS, in combination with the local remodeling response and the severity of systemic risk factors, determines the natural history of each plaque. This paper describes the steps required to derive an ESS map from 320-detector row CT data using the Lattice Boltzmann method to include the complex geometry of the coronary arterial tree. This approach diminishes the limitations of other computational fluid dynamics methods to properly evaluate multiple coronary arteries, including the complex geometry of coronary bifurcations where lesions tend to develop.

Carr-Purcell-Meiboom-Gill imaging of prostate cancer: quantitative T2 values for cancer discrimination.

Quantitative, apparent T(2) values of suspected prostate cancer and healthy peripheral zone tissue in men with prostate cancer were measured using a Carr-Purcell-Meiboom-Gill (CPMG) imaging sequence in order to assess the cancer discrimination potential of tissue T(2) values. The CPMG imaging sequence was used to image the prostates of 18 men with biopsy-proven prostate cancer. Whole gland coverage with nominal voxel volumes of 0.54 x 1.1 x 4 mm(3) was obtained in 10.7 min, resulting in data sets suitable for generating high-quality images with variable T(2)-weighting and for evaluating quantitative T(2) values on a pixel-by-pixel basis. Region-of-interest analysis of suspected healthy peripheral zone tissue and suspected cancer, identified on the basis of both T(1)- and T(2)-weighted signal intensities and available histopathology reports, yielded significantly (P<.0001) longer apparent T(2) values in suspected healthy tissue (193+/-49 ms) vs. suspected cancer (100+/-26 ms), suggesting potential utility of this method as a tissue specific discrimination index for prostate cancer. We conclude that CPMG imaging of the prostate can be performed in reasonable scan times and can provide advantages over T(2)-weighted fast spin echo (FSE) imaging alone, including quantitative T(2) values for cancer discrimination as well as proton density maps without the point spread function degradation associated with short effective echo time FSE sequences.

Hydrokinetic approach to large-scale cardiovascular blood flow

We present a computational method for commodity hardware-based clinical cardiovascular diagnosis based on accurate simulation of cardiovascular blood flow. Our approach leverages the flexibility of the Lattice Boltzmann method to implementation on high-performance, commodity hardware, such as Graphical Processing Units. We developed the procedure for the analysis of real-life cardiovascular blood flow case studies, namely, anatomic data acquisition, geometry and mesh generation, flow simulation and data analysis and visualization. We demonstrate the usefulness of our computational tool through a set of large-scale simulations of the flow patterns associated with the arterial tree of a patient which involves two hundred million computational cells. The simulations show evidence of a very rich and heterogeneous endothelial shear stress pattern (ESS), a quantity of recognized key relevance to the localization and progression of major cardiovascular diseases, such as atherosclerosis, and set the stage for future studies involving pulsatile flows.

Cardiothoracic Applications of 3-dimensional Printing.

Medical 3-dimensional (3D) printing is emerging as a clinically relevant imaging tool in directing preoperative and intraoperative planning in many surgical specialties and will therefore likely lead to interdisciplinary collaboration between engineers, radiologists, and surgeons. Data from standard imaging modalities such as computed tomography, magnetic resonance imaging, echocardiography, and rotational angiography can be used to fabricate life-sized models of human anatomy and pathology, as well as patient-specific implants and surgical guides. Cardiovascular 3D-printed models can improve diagnosis and allow for advanced preoperative planning. The majority of applications reported involve congenital heart diseases and valvular and great vessels pathologies. Printed models are suitable for planning both surgical and minimally invasive procedures. Added value has been reported toward improving outcomes, minimizing perioperative risk, and developing new procedures such as transcatheter mitral valve replacements. Similarly, thoracic surgeons are using 3D printing to assess invasion of vital structures by tumors and to assist in diagnosis and treatment of upper and lower airway diseases. Anatomic models enable surgeons to assimilate information more quickly than image review, choose the optimal surgical approach, and achieve surgery in a shorter time. Patient-specific 3D-printed implants are beginning to appear and may have significant impact on cosmetic and life-saving procedures in the future. In summary, cardiothoracic 3D printing is rapidly evolving and may be a potential game-changer for surgeons. The imager who is equipped with the tools to apply this new imaging science to cardiothoracic care is thus ideally positioned to innovate in this new emerging imaging modality.

Coronary Enhancement for Prospective ECG-Gated Single R-R Axial 320-MDCT Angiography: Comparison of 60- and 80-mL Iopamidol 370 Injection

OBJECTIVE The objective of our study was to evaluate the difference in coronary enhancement provided by 60 versus 80 mL of contrast medium (370 mg I/mL) for prospectively ECG-gated single-heartbeat axial 320-MDCT. MATERIALS AND METHODS We retrospectively evaluated 108 consecutive 320-MDCT angiography studies. Group 1 (n = 36) received 60 mL of an iodinated contrast medium and group 2 (n = 72), 80 mL. All patients were imaged with a standardized protocol: iopamidol 370 followed by 40 mL of saline, both administered at a rate of 6 mL/s. Two imagers subjectively assessed image quality throughout the coronary arteries. Region-of-interest attenuation (HU) measurements were performed in the aorta plus the proximal and distal coronary arteries. RESULTS Subjective analysis of all coronary segments showed slightly better image quality for group 2. Patients in group 1 had significantly (p < 0.05) lower mean attenuation values for the individual coronary vessels. Nevertheless, 96.7% of all coronary segments in the group 1 patients had an attenuation of greater than 300 HU; when analysis was limited to group 1 patients with a body mass index of greater than 30, 92.8% of the segments were more than 300 HU, and all segments measured more than 250 HU. CONCLUSION An injection protocol based on 60 mL of iopamidol (370 mg I/mL) for prospectively ECG-gated wide-area detector single-heartbeat coronary CT angiography (CTA) has less coronary enhancement than a protocol based on 80 mL. However, using 60 mL, more than 96% of coronary segments had sufficient enhancement (i.e., > 300 HU), supporting the general use of 60-mL protocols for clinical wide-area detector coronary CTA.

Three-dimensional printing of MRI-visible phantoms and MR image-guided therapy simulation

To demonstrate the use of anatomic MRI‐visible three‐dimensional (3D)‐printed phantoms and to assess process accuracy and material MR signal properties.

In vivo differentiation of two vessel wall layers in lower extremity peripheral vein bypass grafts: Application of high‐resolution inner‐volume black blood 3D FSE

Lower extremity peripheral vein bypass grafts (LE‐PVBG) imaged with high‐resolution black blood three‐dimensional (3D) inner‐volume (IV) fast spin echo (FSE) MRI at 1.5 Tesla possess a two‐layer appearance in T1W images while only the inner layer appears visible in the corresponding T2W images. This study quantifies this difference in six patients imaged 6 months after implantation, and attributes the difference to the T2 relaxation rates of vessel wall tissues measured ex vivo in two specimens with histologic correlation. The visual observation of two LE‐PVBG vessel wall components imaged in vivo is confirmed to be significant (P < 0.0001), with a mean vessel wall area difference of 6.8 ± 2.7 mm2 between contrasts, and a ratio of T1W to T2W vessel wall area of 1.67 ± 0.28. The difference is attributed to a significantly (P < 0.0001) shorter T2 relaxation in the adventitia (T2 = 52.6 ± 3.5 ms) compared with the neointima/media (T2 = 174.7 ± 12.1 ms). Notably, adventitial tissue exhibits biexponential T2 signal decay (P < 0.0001 vs monoexponential). Our results suggest that high‐resolution black blood 3D IV‐FSE can be useful for studying the biology of bypass graft wall maturation and pathophysiology in vivo, by enabling independent visualization of the relative remodeling of the neointima/media and adventitia. Magn Reson Med, 2009.

High‐resolution peripheral vein bypass graft wall studies using high sampling efficiency inner volume 3D FSE

A 3D inner‐volume fast spin echo (3D IV‐FSE) sequence was developed for ECG‐gated, black‐blood, T1‐ and T2‐weighted vessel wall imaging of peripheral vein bypass grafts (PVBG). The sequence utilizes nonselective refocusing excitations to minimize echo spacings and a highly selective IV excitation scheme to minimize the need for oversampling of z‐encode slice selections. The method was tested in eight PVBG patients who also underwent 2D FSE graft imaging. High‐quality 3D imaging was achieved in all subjects, with significant spatial resolution and volume coverage gains compared to the more conventional 2D FSE sequences normalized for signal‐to‐noise ratios (SNRs) and scan times. Compared to previously proposed 3D IV‐FSE methods, nonselective refocusing resulted in a more than 20% FSE echo train sampling efficiency increase while the use of highly selective IV excitation resulted in a 30% improvement in slice oversampling efficiency. Magn Reson Med, 2008.