Doan Trang Nguyen

A review on electrical impedance tomography for pulmonary perfusion imaging

Although electrical impedance tomography (EIT) for ventilation monitoring is on the verge of clinical trials, pulmonary perfusion imaging with EIT remains a challenge, especially in spontaneously breathing subjects. In anticipation of more research on this subject, we believe a thorough review is called for. In this paper, findings related to the physiological origins and electrical characteristics of this signal are summarized, highlighting properties that are particularly relevant to EIT. The perfusion impedance change signal is significantly smaller in amplitude compared with the changes due to ventilation. Therefore, the hardware used for this purpose must be more sensitive and more resilient to noise. In previous works, some signal- or image-processing methods have been required to separate these two signals. Three different techniques are reviewed in this paper, including the ECG-gating method, frequency-domain-filtering-based methods and a principal-component-analysis-based method. In addition, we review a number of experimental studies on both human and animal subjects that employed EIT for perfusion imaging, with promising results in the diagnosis of pulmonary embolism (PE) and pulmonary arterial hypertension as well as other potential applications. In our opinion, PE is most likely to become the main focus for perfusion EIT in the future, especially for heavily instrumented patients in the intensive care unit (ICU).

The first clinical implementation of a real-time six degree of freedom target tracking system during radiation therapy based on Kilovoltage Intrafraction Monitoring (KIM)

PURPOSE We present the first clinical implementation of a real-time six-degree of freedom (6DoF) Kilovoltage Intrafraction Monitoring (KIM) system which tracks the cancer target translational and rotational motions during treatment. The method was applied to measure and correct for target motion during stereotactic body radiotherapy (SBRT) for prostate cancer. METHODS Patient: A patient with prostate adenocarcinoma undergoing SBRT with 36.25Gy, delivered in 5 fractions was enrolled in the study. 6DoF KIM technology: 2D positions of three implanted gold markers in each of the kV images (125kV, 10mA at 11Hz) were acquired continuously during treatment. The 2D→3D target position estimation was based on a probability distribution function. The 3D→6DoF target rotation was calculated using an iterative closest point algorithm. The accuracy and precision of the KIM method was measured by comparing the real-time results with kV-MV triangulation. RESULTS Of the five treatment fractions, KIM was utilised successfully in four fractions. The intrafraction prostate motion resulted in three couch shifts in two fractions when the prostate motion exceeded the pre-set action threshold of 2mm for more than 5s. KIM translational accuracy and precision were 0.3±0.6mm, -0.2±0.3mm and 0.2±0.7mm in the Left-Right (LR), Superior-Inferior (SI) and Anterior-Posterior (AP) directions, respectively. The KIM rotational accuracy and precision were 0.8°±2.0°, -0.5°±3.3° and 0.3°±1.6° in the roll, pitch and yaw directions, respectively. CONCLUSION This treatment represents, to the best of our knowledge, the first time a cancer patients tumour position and rotation have been monitored in real-time during treatment. The 6 DoF KIM system has sub-millimetre accuracy and precision in all three translational axes, and less than 1° accuracy and 4° precision in all three rotational axes.

Stereotactic prostate adaptive radiotherapy utilising kilovoltage intrafraction monitoring: the TROG 15.01 SPARK trial

BackgroundThis paper describes the multi-institutional prospective phase II clinical trial, SPARK: Stereotactic Prostate Adaptive Radiotherapy utilizing Kilovoltage Intrafraction Monitoring (KIM). KIM is a real-time image guided radiotherapy technology being developed and clinically pioneered for prostate cancer treatment in Australia. It has potential for widespread use for target radiotherapy treatment of cancers of the pelvis, thorax and abdomen.MethodsIn the SPARK trial we will measure the cancer targeting accuracy and patient outcomes for 48 prostate cancer patients who will be treated in five treatment sessions as opposed to the conventional 40 sessions. The reduced number of treatment sessions is enabled by the KIM’s increased cancer targeting accuracy.DiscussionReal-time imaging in radiotherapy has the potential to decrease the time taken during cancer treatment and reduce the imaging dose required. With the imaging being acquired during the treatment, and the analysis being automated, there is potential for improved throughput. The SPARK trial will be conducted under the auspices of the Trans-Tasman Radiation Oncology Group (TROG).Trial registrationThis trial was registered on ClinicalTrials.gov on 09 March 2015. The identifier is: NCT02397317

Electrode-skin contact impedance: In vivo measurements on an ovine model

The problem of electrical impedance between the skin and the electrode is an on-going challenge in bio-electronics. This is particularly true in the case of Electrical Impedance Tomography (EIT), which uses a large number of skin-contact electrodes and is very sensitive to noise. In the present article, contact impedance is measured and compared for a range of electrodes placed on the thorax of an ovine model. The study has been approved by the Westmead Hospital Animal Ethics Committee. The electrode models that were employed in the research are Ag/AgCl electrodes (E1), commonly used for ECG and EIT measurements in both humans and animal models, stainless steel crocodile clips (E2), typically used on animal models, and novel multi-point dry electrodes in two modifications: bronze plated (E3) and nickel plated (E4). Further, since the contact impedance is mostly attributed to the acellular outer layer of the skin, in our experiment, we attempted to study the effect of this layer by comparing the results when the skin is intact and when electrodes are introduced underneath the skin through small cuts. This boundary effect was assessed by comparison of measurements obtained during E2 skin surface contact, and sub-cutaneous contact (E5). Twelve gauge intradermal needles were also tested as an electrode (E6). The full impedance spectrum, from 500 Hz to 300 kHz, was recorded, analysed and compared. As expected, the contact impedance in the more invasive cases, i.e the electrodes under the skin, is significantly lower than in the non-invasive cases. At the frequency of 50 kHz which is commonly used in lung EIT acquisition, electrodes E3, E4 and E6 demonstrated contact impedance of less than 200 Ω, compared to more than 400 Ω measured for electrodes E1, E2 and E5. In conclusion, the novel multipoint electrodes proved to be best suited for EIT purposes, because they are non-invasive and have lower contact impedance than Ag/AgCl and crocodile clips, in both invasive and non-invasive cases. This further prompted us to design a flexible electrode belt using the novel multi-point electrodes for lung EIT on animal models.

Reducing false arrhythmia alarms in the ICU using multimodal signals and robust QRS detection

This study developed algorithms to decrease the arrhythmia false alarms in the ICU by processing multimodal signals of photoplethysmography (PPG), arterial blood pressure (ABP), and two ECG signals. The goal was to detect the five critical arrhythmias comprising asystole (ASY), extreme bradycardia (EBR), extreme tachycardia (ETC), ventricular tachycardia (VTA), and ventricular flutter or fibrillation (VFB). The different characteristics of the arrhythmias suggested the application of individual signal processing for each alarm and the combination of the algorithms to enhance false alarm detection. Thus, different features and signal processing techniques were used for each arrhythmia type. The ECG signals were first processed to reduce the signal interference. Then, a Hilbert-transform based QRS detector algorithm was utilized to identify the QRS complexes, which were then processed to determine the instantaneous heart rate. The pulsatile signals (PPG and ABP) were processed to discover the pulse onset of beats which were then employed to measure the heart rate. The signal quality index (SQI) of the signals was implemented to verify the integrity of the heart rate information. The overall score obtained by our algorithms in the 2015 Computing in Cardiology Challenge was a score of 74.03% for retrospective and 69.92% for real-time analysis.

Acoustic Signal Emission Monitoring as a Novel Method to Predict Steam Pops During Radiofrequency Ablation: Preliminary Observations

Steam pop is an explosive rupture of cardiac tissue caused by tissue overheating above 100 °C, resulting in steam formation, predisposing to serious complications associated with radiofrequency (RF) ablations. However, there are currently no reliable techniques to predict the occurrence of steam pops. We propose the utility of acoustic signals emitted during RF ablation as a novel method to predict steam pop formation and potentially prevent serious complications.

Reducing false arrhythmia alarms in the ICU by Hilbert QRS detection

In this study, we develop algorithms that reduce the arrhythmia false alarms in the ICU by processing the four signals of Photoplethysmography (PPG), arterial blood pressure (ABP), ECG Lead II, and Augmented right arm ECG. Our algorithms detect five arrhythmias including asystole, extreme bradycardia, extreme tachycardia, ventricular tachycardia (VT), and ventricular flutter or fibrillation (VF). Real time algorithm is provided. Our processing proceeded as follows. Firstly, preprocessing was applied to the ECG signals by two median filters in order to remove the baseline wander and high-frequency noise. Then a Hilbert-transform based QRS detector algorithm was used to detect R waves from the ECG signals. Following this, RR intervals were calculated from the available ECG signals. Pulse onset points of the pulsatile signals (PPG and ABP) were also detected and the signal quality index (SQI) of the four signals was measured. The ECG based RR intervals were combined with the pulsatile signal based RR intervals using the algorithms provided by the CinC2015 competition organizers. The combined RR intervals were thresholded at the clinically important values for the five arrhythmias. Template matching was used to detect ventricular tachycardia (VT) and power spectrum of ECG signals and identifying the VF frequency components employed to investigate ventricular fibrillation. Our highest overall result was a 98% True Positive Rate (TPR), 66% True Negative Rate (TNR) with a score of 74.03% for the retrospective algorithm. For the realtime algorithm, we achieved a 98% TPR, 65% TNR and a score of 69.92%.

The first clinical implementation of real-time image-guided adaptive radiotherapy using a standard linear accelerator

PURPOSE Until now, real-time image guided adaptive radiation therapy (IGART) has been the domain of dedicated cancer radiotherapy systems. The purpose of this study was to clinically implement and investigate real-time IGART using a standard linear accelerator. MATERIALS/METHODS We developed and implemented two real-time technologies for standard linear accelerators: (1) Kilovoltage Intrafraction Monitoring (KIM) that finds the target and (2) multileaf collimator (MLC) tracking that aligns the radiation beam to the target. Eight prostate SABR patients were treated with this real-time IGART technology. The feasibility, geometric accuracy and the dosimetric fidelity were measured. RESULTS Thirty-nine out of forty fractions with real-time IGART were successful (95% confidence interval 87-100%). The geometric accuracy of the KIM system was -0.1 ± 0.4, 0.2 ± 0.2 and -0.1 ± 0.6 mm in the LR, SI and AP directions, respectively. The dose reconstruction showed that real-time IGART more closely reproduced the planned dose than that without IGART. For the largest motion fraction, with real-time IGART 100% of the CTV received the prescribed dose; without real-time IGART only 95% of the CTV would have received the prescribed dose. CONCLUSION The clinical implementation of real-time image-guided adaptive radiotherapy on a standard linear accelerator using KIM and MLC tracking is feasible. This achievement paves the way for real-time IGART to be a mainstream treatment option.

Quantifying the accuracy and precision of a novel real-time 6 degree-of-freedom kilovoltage intrafraction monitoring (KIM) target tracking system

Target rotation can considerably impact the delivered radiotherapy dose depending on the tumour shape. More accurate tumour pose during radiotherapy treatment can be acquired through tracking in 6 degrees-of-freedom (6 DoF) rather than in translation only. A novel real-time 6 DoF kilovoltage intrafraction monitoring (KIM) target tracking system has recently been developed. In this study, we experimentally evaluated the accuracy and precision of the 6 DoF KIM implementation. Real-time 6 DoF KIM motion measurements were compared against the ground truth motion retrospectively derived from kV/MV triangulation for a range of lung and prostate tumour motion trajectories as well as for various static poses using a phantom. The accuracy and precision of 6 DoF KIM were calculated as the mean and standard deviation of the differences between KIM and kV/MV triangulation for each DoF, respectively. We found that KIM is able to provide 6 DoF motion with sub-degree and sub-millimetre accuracy and precision for a range of realistic tumour motion.

An interdimensional correlation framework for real-time estimation of six degree of freedom target motion using a single x-ray imager during radiotherapy

Increasing evidence suggests that intrafraction tumour motion monitoring needs to include both 3D translations and 3D rotations. Presently, methods to estimate the rotation motion require the 3D translation of the target to be known first. However, ideally, translation and rotation should be estimated concurrently. We present the first method to directly estimate six-degree-of-freedom (6DoF) motion from the targets projection on a single rotating x-ray imager in real-time. This novel method is based on the linear correlations between the superior-inferior translations and the motion in the other five degrees-of-freedom. The accuracy of the method was evaluated in silico with 81 liver tumour motion traces from 19 patients with three implanted markers. The ground-truth motion was estimated using the current gold standard method where each markers 3D position was first estimated using a Gaussian probability method, and the 6DoF motion was then estimated from the 3D positions using an iterative method. The 3D position of each marker was projected onto a gantry-mounted imager with an imaging rate of 11 Hz. After an initial 110° gantry rotation (200 images), a correlation model between the superior-inferior translations and the five other DoFs was built using a least square method. The correlation model was then updated after each subsequent frame to estimate 6DoF motion in real-time. The proposed algorithm had an accuracy (±precision) of  -0.03  ±  0.32 mm, -0.01  ±  0.13 mm and 0.03  ±  0.52 mm for translations in the left-right (LR), superior-inferior (SI) and anterior-posterior (AP) directions respectively; and, 0.07  ±  1.18°, 0.07  ±  1.00° and 0.06  ±  1.32° for rotations around the LR, SI and AP axes respectively on the dataset. The first method to directly estimate real-time 6DoF target motion from segmented marker positions on a 2D imager was devised. The algorithm was evaluated using 81 motion traces from 19 liver patients and was found to have sub-mm and sub-degree accuracy.