Luuk J. Oostveen

Arm Raising at Exposure-controlled Multidetector Trauma CT of Thoracoabdominal Region: Higher Image Quality, Lower Radiation Dose

PURPOSE To evaluate the effect of arm position on image quality and effective radiation dose in an automatic exposure-controlled (AEC) multidetector thoracoabdominal computed tomography (CT) protocol in trauma patients. MATERIALS AND METHODS This retrospective study of the data of 177 trauma patients (117 male; median age, 39 years) was approved by the institutional ethics board, with informed patient consent waived. Patients underwent scanning by using an AEC 16-detector thoracoabdominal CT protocol in which both arms were raised above the shoulder region (standard-position group, 132 patients), one arm was raised and the other was down (one-arm group, 27 patients), or both arms were down (two-arm group, 18 patients). Objective and subjective image quality was assessed. Individual effective radiation dose was calculated from the effective tube current-time product per exposed section. For this purpose, section location-dependent conversion factors were derived by using a CT dosimetry calculator. The effect of arm position on effective dose was quantified by using linear regression analysis with correction for patient volume and attenuation. RESULTS Compared with the image quality in the standard-position group, the image quality in the one- and two-arm groups was decreased but within acceptable diagnostic limits. The median corrected effective dose in the standard-position group was 18.6 mSv; the dose in the one-arm group was 18% (95% confidence interval: 11%, 25%) higher than this, and that in the two-arm group was 45% (95% confidence interval: 34%, 57%) higher. CONCLUSION Omitting arm raising results in lower but acceptable image quality and a substantially higher effective radiation dose. Hence, effort should be made to position the arms above the shoulder when scanning trauma patients. Clinical trial registration no. NCT00228111.

In-vivo imaging of changes in abdominal aortic aneurysm thrombus volume during the cardiac cycle.

Purpose: To evaluate in-vivo thrombus compressibility in abdominal aortic aneurysms (AAAs) to hopefully shed light on the biomechanical importance of intraluminal thrombus. Methods: Dynamic electrocardiographically-gated computed tomographic angiography was performed in 17 AAA patients (15 men; mean age 73 years, range 69–76): 11 scheduled for surgical repair and 6 under routine surveillance. The volumes of intraluminal thrombus, the lumen, and the total aneurysm were quantified for each phase of the cardiac cycle. Thrombus compressibility was defined as the percent change in thrombus volume between diastole and peak systole. Continuous data are presented as medians and interquartile ranges (IQR). Results: A substantial interpatient variability was observed in thrombus compressibility, ranging from 0.4% to 43.6% (0.2 to 13.5 mL, respectively). Both thrombus and lumen volumes varied substantially during the cardiac cycle. As lumen volume increased (5.2%, IQR 2.8%–8.8%), thrombus volume decreased (3.0%, IQR 1.0%–4.6%). Total aneurysm volume remained relatively constant (1.3%, IQR 0.4–1.9%). Changes in lumen volume were inversely correlated with changes in thrombus volume (r=–0.73; p=0.001). Conclusion: In-vivo thrombus compressibility varied from patient to patient, and this variation was irrespective of aneurysm size, pulse pressure, and thrombus volume. This suggests that thrombus might act as a biomechanical buffer in some, while it has virtually no effect in others. Whether differences in thrombus compressibility alter the risk of rupture will be the focus of future research.

Impact of dynamic computed tomographic angiography on endograft sizing for endovascular aneurysm repair.

Purpose: To quantify dynamic changes in aortoiliac dimensions using dynamic electrocardiographically (ECG)-gated computed tomographic angiography (CTA) and to investigate any potential impact on preoperative endograft sizing in relation to observer variability. Methods: Dynamic ECG-gated CTA was performed in 18 patients with abdominal aortic aneurysms. Postprocessing resulted in 11 datasets per patient: 1 static CTA and 10 dynamic CTA series. Vessel diameter, length, and angulation were measured for all phases of the cardiac cycle. The differences between diastolic and systolic aneurysm dimensions were analyzed for significance using paired t tests. To assess intraobserver variability, 20 randomly selected datasets were analyzed twice. Intraobserver repeatability coefficients (RC) were calculated using Bland-Altman analysis. Results: Mean aortic diameter at the proximal neck was 21.4±3.0 mm at diastole and 23.2±2.9 mm at systole, a mean increase of 1.8±0.4 mm (8.5%, p<0.01). The RC for the aortic diameter at the level of the proximal aneurysm neck was 1.9 mm (8.9%). At the distal sealing zones, the mean increase in diameter was 1.7±0.3 mm (14.1%, p<0.01) for the right and 1.8±0.5 mm (14.2%, p<0.01) for the left common iliac artery (CIA). At both distal sealing zones, the mean increase in CIA diameter exceeded the RC (10.0% for the right CIA and 12.6% for the left CIA). Conclusion: The observed changes in aneurysm dimension during the cardiac cycle are small and in the range of intraobserver variability, so dynamic changes in proximal aneurysm neck diameter and aneurysm length likely have little impact on preoperative endograft selection. However, changes in diameter at the distal sealing zones may be relevant to sizing, so distal oversizing of up to 20% should be considered to prevent distal type I endoleak.

Detectability of motions in AAA with ECG-gated CTA : A quantitative study

PURPOSE ECG-gated CT enables the visualization of motions caused by the beating of the heart. Although ECG gating is frequently used in cardiac CT imaging, this technique is also very promising for evaluating vessel wall motion of the aortic artery and the motions of (stent grafts inside) abdominal aortic aneurysms (AAA). Late stent graft failure is a serious complication in endovascular repair of aortic aneurysms. Better understanding of the motion characteristics of stent grafts will be beneficial for designing future devices. In addition, these data can be valuable in predicting stent graft failure in patients. To be able to reliably quantify the motion, however, it is of importance to know the performance and limitations of ECG gating, especially when the motions are small, as is the case in AAA. Since the details of the reconstruction algorithms are proprietary information on the CT manufacturers and not in the public domain, empirical experiments are required. The goal of this study is to investigate as to what extent the motions in AAA can be measured using ECG-gated CT. The authors quantitatively investigate four aspects of motion in ECG-gated CT: The detectability of the motion of objects at different amplitudes and different periodic motions, the temporal resolution, and the volume gaps that occur as a function of heart rate. METHODS They designed an experiment on a standard static phantom to empirically determine temporal resolution. To investigate motion amplitude and frequency, as well as patient heart rate, they designed dynamic experiments in which a home-made phantom driven by a motion unit moves in a predetermined pattern. RESULTS The duration of each ECG-gated phase was found to be 185ms, which corresponds to half of the rotation time and is thus in accordance with half scan reconstruction applied by the scanner. By using subpixel localization, motions become detectable from amplitudes of as small as 0.4mm in the x direction and 0.7mm in the z direction. With the rotation time used in this study, motions up to 2.7Hz can be reliably detected. The reconstruction algorithm fills volume gaps with noisy data using interpolation, but objects within these gaps remain hidden. CONCLUSIONS This study gives insight into the possibilities and limitations for measuring small motions using ECG-gated CT. Application of the experimental method is not restricted to the CT scanner of a single manufacturer. From the results, they conclude that ECG-gated CTA is a suitable technique for studying the expected motions of the stent graft and vessel wall in AAA.

Automatic segmentation of the wire frame of stent grafts from CT data

Endovascular aortic replacement (EVAR) is an established technique, which uses stent grafts to treat aortic aneurysms in patients at risk of aneurysm rupture. Late stent graft failure is a serious complication in endovascular repair of aortic aneurysms. Better understanding of the motion characteristics of stent grafts will be beneficial for designing future devices. In addition, analysis of stent graft movement in individual patients in vivo can be valuable for predicting stent graft failure in these patients. To be able to gather information on stent graft motion in a quick and robust fashion, we propose an automatic method to segment stent grafts from CT data, consisting of three steps: the detection of seed points, finding the connections between these points to produce a graph, and graph processing to obtain the final geometric model in the form of an undirected graph. Using annotated reference data, the method was optimized and its accuracy was evaluated. The experiments were performed using data containing the AneuRx and Zenith stent grafts. The algorithm is robust for noise and small variations in the used parameter values, does not require much memory according to modern standards, and is fast enough to be used in a clinical setting (65 and 30s for the two stent types, respectively). Further, it is shown that the resulting graphs have a 95% (AneuRx) and 92% (Zenith) correspondence with the annotated data. The geometric model produced by the algorithm allows incorporation of high level information and material properties. This enables us to study the in vivo motions and forces that act on the frame of the stent. We believe that such studies will provide new insights into the behavior of the stent graft in vivo, enables the detection and prediction of stent failure in individual patients, and can help in designing better stent grafts in the future.

White Matter and Gray Matter Segmentation in 4D Computed Tomography

Modern Computed Tomography (CT) scanners are capable of acquiring contrast dynamics of the whole brain, adding functional to anatomical information. Soft tissue segmentation is important for subsequent applications such as tissue dependent perfusion analysis and automated detection and quantification of cerebral pathology. In this work a method is presented to automatically segment white matter (WM) and gray matter (GM) in contrast- enhanced 4D CT images of the brain. The method starts with intracranial segmentation via atlas registration, followed by a refinement using a geodesic active contour with dominating advection term steered by image gradient information, from a 3D temporal average image optimally weighted according to the exposures of the individual time points of the 4D CT acquisition. Next, three groups of voxel features are extracted: intensity, contextual, and temporal. These are used to segment WM and GM with a support vector machine. Performance was assessed using cross validation in a leave-one-patient-out manner on 22 patients. Dice coefficients were 0.81 ± 0.04 and 0.79 ± 0.05, 95% Hausdorff distances were 3.86 ± 1.43 and 3.07 ± 1.72 mm, for WM and GM, respectively. Thus, WM and GM segmentation is feasible in 4D CT with good accuracy.

Comparing dual energy CT and subtraction CT on a phantom: which one provides the best contrast in iodine maps for sub-centimetre details?

ObjectivesTo compare contrast-to-noise ratios (CNRs) and iodine discrimination thresholds on iodine maps derived from dual energy CT (DECT) and subtraction CT (SCT).MethodsA contrast-detail phantom experiment was performed with 2 to 15 mm diameter tubes containing water or iodinated contrast concentrations ranging from 0.5 mg/mL to 20 mg/mL. DECT scans were acquired at 100 kVp and at 140 kVp+Sn filtration. SCT scans were acquired at 100 kVp. Iodine maps were created by material decomposition (DECT) or by subtraction of water scans from iodine scans (SCT). Matched exposure levels varied from 8 to 15 mGy. Iodine discrimination thresholds (Cr) and response times were determined by eight observers.ResultsThe adjusted mean CNR was 1.9 times higher for SCT than for DECT. Exposure level had no effect on CNR. All observers discriminated all details ≥10 mm at 12 and 15 mGy. For sub-centimetre details, the lowest calculated Cr was ≤ 0.50 mg/mL for SCT and 0.64 mg/mL for DECT. The smallest detail was discriminated at ≥4.4 mg/mL with SCT and at ≥7.4 mg/mL with DECT. Response times were lower for SCT than DECT.ConclusionsSCT results in higher CNR and reduced iodine discrimination thresholds compared to DECT for sub-centimetre details.Key Points• Subtraction CT iodine maps exhibit higher CNR than dual-energy iodine maps• Lower iodine concentrations can be discriminated for sub-cm details with SCT• Response times are lower using SCT compared to dual-energy CT

Lung iodine mapping by subtraction with image registration allowing for tissue sliding

Pulmonary embolism is a fairly common and serious entity, so rapid diagnosis and treatment has a significant impact on morbidity and mortality rates. Iodine maps representing tissue perfusion enhancement are commonly generated by dual-energy CT acquisitions to provide information about the effect of the embolism on pulmonary perfusion. Alternatively, the iodine map can be generated by subtracting pre- from post-contrast CT scans as previously reported. Although accurate image registration is essential, subtraction has the advantage of a higher signal-to-noise ratio and suppression of bone. This paper presents an improvement over the previously reported registration algorithm. Significantly, allowance for sliding motion at tissue boundaries is included in the regularization. Pre- and post-contrast helical CT scans were acquired for thirty subjects using a Toshiba Aquilion ONE scanner. Ten of these subjects were designated for algorithm development, while the remaining twenty were reserved for qualitative clinical evaluation. Quantitative evaluation was performed against the previously reported method and using publicly available data for comparison against other methods. Comparison of 100 landmarks in seven datasets shows no change in the mean Euclidean error of 0.48 mm, compared to the previous method. Evaluation in the publicly available DIR-Lab data with 300 annotations results in a mean Euclidean error of 1.17 mm in the ten 4DCT cases and 3.37 mm in the ten COPDGene cases. Clinical evaluation on a sliding scale from 1 (excellent) to 5 (non-diagnostic) indicates a slight, but non-significant, improvement in registration adequacy from 3.1 to 2.9.

Brain tissue segmentation in 4D CT using voxel classification

A method is proposed to segment anatomical regions of the brain from 4D computer tomography (CT) patient data. The method consists of a three step voxel classification scheme, each step focusing on structures that are increasingly difficult to segment. The first step classifies air and bone, the second step classifies vessels and the third step classifies white matter, gray matter and cerebrospinal fluid. As features the time averaged intensity value and the temporal intensity change value were used. In each step, a k-Nearest-Neighbor classifier was used to classify the voxels. Training data was obtained by placing regions of interest in reconstructed 3D image data. The method has been applied to ten 4D CT cerebral patient data. A leave-one-out experiment showed consistent and accurate segmentation results.

Author Correction: White Matter and Gray Matter Segmentation in 4D Computed Tomography

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.