Michael A. Speidel

Calibration of GafChromic XR-RV3 radiochromic film for skin dose measurement using standardized x-ray spectra and a commercial flatbed scanner

PURPOSE In this study, newly formulated XR-RV3 GafChromic film was calibrated with National Institute of Standards and Technology (NIST) traceability for measurement of patient skin dose during fluoroscopically guided interventional procedures. METHODS The film was calibrated free-in-air to air kerma levels between 15 and 1100 cGy using four moderately filtered x-ray beam qualities (60, 80, 100, and 120 kVp). The calibration films were scanned with a commercial flatbed document scanner. Film reflective density-to-air kerma calibration curves were constructed for each beam quality, with both the orange and white sides facing the x-ray source. A method to correct for nonuniformity in scanner response (up to 25% depending on position) was developed to enable dose measurement with large films. The response of XR-RV3 film under patient backscattering conditions was examined using on-phantom film exposures and Monte Carlo simulations. RESULTS The response of XR-RV3 film to a given air kerma depended on kVp and film orientation. For a 200 cGy air kerma exposure with the orange side of the film facing the source, the film response increased by 20% from 60 to 120 kVp. At 500 cGy, the increase was 12%. When 500 cGy exposures were performed with the white side facing the x-ray source, the film response increased by 4.0% (60 kVp) to 9.9% (120 kVp) compared to the orange-facing orientation. On-phantom film measurements and Monte Carlo simulations show that using a NIST-traceable free-in-air calibration curve to determine air kerma in the presence of backscatter results in an error from 2% up to 8% depending on beam quality. The combined uncertainty in the air kerma measurement from the calibration curves and scanner nonuniformity correction was +/- 7.1% (95% C.I.). The film showed notable stability. Calibrations of film and scanner separated by 1 yr differed by 1.0%. CONCLUSIONS XR-RV3 radiochromic film response to a given air kerma shows dependence on beam quality and film orientation. The presence of backscatter slightly modifies the x-ray energy spectrum; however, the increase in film response can be attributed primarily to the increase in total photon fluence at the sensitive layer. Film calibration curves created under free-in-air conditions may be used to measure dose from fluoroscopic quality x-ray beams, including patient backscatter with an error less than the uncertainty of the calibration in most cases.

Scanning-beam digital x-ray (SBDX) technology for interventional and diagnostic cardiac angiography

The scanning-beam digital x-ray (SBDX) system is designed for x-ray dose reduction in cardiac angiographic applications. Scatter reduction, efficient detection of primary x-rays, and an inverse beam geometry are the main components of the entrance dose reduction strategy. This paper reports the construction of an SBDX prototype, image reconstruction techniques, and measurements of spatial resolution and x-ray output. The x-ray source has a focal spot that is electronically scanned across a large-area transmission target. A multihole collimator beyond the target defines a series of x-ray beams directed at a distant small-area detector array. The prototype has a 23 cm X 23 cm target, 100 X 100 focal spot positions, and a 5 cm X 5 cm CdTe detector positioned 150 cm from the target. With this nonmechanical method of beam scanning, patient images with low detected scatter are generated at up to 30 frame/s. SBDX data acquisition is tomosynthetic. The prototype simultaneously reconstructs 16 planes spaced throughout the cardiac volume using shift-and-add backprojection. Image frames analogous to conventional projection images are generated with a multiplane compositing algorithm. Single-plane versus multiplane reconstruction of contrast-filled coronary arteries is demonstrated with images of the porcine heart. Phantom and porcine imaging studies show multiplane reconstruction is practicable under clinically realistic levels of patient attenuation and cardiac motion. The modulation transfer function for an in-plane slit at mechanical isocenter measured 0.41-0.56 at 1 cycle/mm, depending on the detector element to image pixel interpolation technique. Modeling indicates that desired gains in spatial resolution are achievable by halving the detector element width. The x-ray exposure rate 15 cm below isocenter, without table or patient in the beam, measured 11.5 R/min at 120 kVp, 24.3 kWp and 3.42 R/min at 70 kVp, 14.2 kWp.

FEM analysis of predicting electrode-myocardium contact from RF cardiac catheter ablation system impedance

We used the finite-element method (FEM) to model and analyze the resistance between the catheter tip electrode and the dispersive electrode during radio-frequency cardiac catheter ablation for the prediction of myocardium-electrode contact. We included deformation of the myocardial surface to achieve accurate modeling. For perpendicular catheter contact, we measured the side view of myocardial deformation using X-ray projection imaging. We averaged the deformation contour from nine samples, and then incorporated the contour information into our FEM model. We measured the resistivity of the bovine myocardium using the four-electrode method, and then calculated the resistance change as the catheter penetrated into the myocardium. The FEM result of resistance versus catheter penetration depth matches well with our experimental data.

Comparison of entrance exposure and signal-to-noise ratio between an SBDX prototype and a wide-beam cardiac angiographic system

The scanning-beam digital x-ray (SBDX) system uses an inverse geometry, narrow x-ray beam, and a 2-mm thick CdTe detector to improve the dose efficiency of the coronary angiographic procedure. Entrance exposure and large-area iodine signal-to-noise ratio (SNR) were measured with the SBDX prototype and compared to that of a clinical cardiac interventional system with image intensifier (II) and charge coupled device (CCD) camera (Philips H5000, MRC-200 x-ray tube, 72 kWp max). Phantoms were 18.6-35.0 cm acrylic with an iohexol-equivalent disk placed at midthickness (35 mg/cm2 iodine radiographic density). Imaging was performed at 15 frame/s, with the disk at mechanical isocenter and an 11-cm object-plane field width. The II/CCD system was operated in cine mode with automatic exposure control. With the SBDX prototype at maximum x-ray output (120 kVp, 24.3 kWp), the SBDX SNR was 107%-69% of the II/CCD SNR, depending on phantom thickness, and the SBDX entrance exposure rate was 10.7-9.3 R/min (9.4-8.2 cGy/min air kerma). For phantoms where an equal-kVp imaging comparison was possible (> or = 23.3 cm), the SBDX SNR ranged from 47% to 69% of the II/CCD SNR while delivering 6% to 9% of the II/CCD entrance exposure rate. From these measurements it was determined that the relative SBDX entrance exposure at equal SNR would be 31%-16%. Results were consistent with a model for relative entrance exposure at equal SNR, which predicted a 3-7 times reduction in entrance exposure due to SBDXs comparatively low scatter fraction (5.5%-8.1% measured, including off-focus radiation), high detector detective quantum efficiency (66%-73%, measured from 70 to 120 kVp), and large entrance field area (1.7x - 2.3x, for the same object-plane field width). With improvements to the system geometry, detector, and x-ray source, SBDX technology is projected to achieve conventional cine-quality SNR over a full range of patient thicknesses, with 5-10 times lower skin dose.

Reduction of image noise in low tube current dynamic CT myocardial perfusion imaging using HYPR processing: A time‐attenuation curve analysis

PURPOSE This study describes a HighlY constrained backPRojection (HYPR) image processing method for the reduction of image noise in low tube current time-resolved CT myocardial perfusion scans. The effect of this method on myocardial time-attenuation curve noise and fidelity is evaluated in an animal model, using varying levels of tube current. METHODS CT perfusion scans of four healthy pigs (42-59 kg) were acquired at 500, 250, 100, 50, 25, and 10 mA on a 64-slice scanner (4 cm axial coverage, 120 kV, 0.4 s∕rotation, 50 s scan duration). For each scan a sequence of ECG-gated images centered on 75% R-R was reconstructed using short-scan filtered back projection (FBP). HYPR processing was applied to the scans acquired at less than 500 mA using parameters designed to maintain the voxel noise level in the 500-mA FBP images. The processing method generates a series of composite images by averaging over a sliding time window and then multiplies the composite images by weighting images to restore temporal fidelity to the image sequence. HYPR voxel noise relative to FBP noise was measured in AHA myocardial segment numbers 1, 5, 6, and 7 at each mA. To quantify the agreement between HYPR and FBP time-attenuation curves (TACs), Bland-Altman analysis was performed on TACs measured in full myocardial segments. The relative degree of TAC fluctuation in smaller subvolumes was quantified by calculating the root mean square deviation of a TAC about the gamma variate curve fit to the TAC data. RESULTS HYPR image sequences were produced using 2, 7, and 20 beat composite windows for the 250, 100, and 50 mA scans, respectively. At 25 and 10 mA, all available beats were used in the composite (41-60; average 50). A 7-voxel-wide 3D cubic filter kernel was used to form weighting images. The average ratio of HYPR voxel noise to 500-mA FBP voxel noise was 1.06, 1.10, 0.97, 1.11, and 2.15 for HYPR scans at 250, 100, 50, 25, and 10 mA. The average limits-of-agreement between HYPR and FBP TAC values measured 0.02+∕-0.91, 0.04+∕-1.92, 0.19+∕-1.59, 1.13+∕-4.22, and 1.07+∕-6.37 HU (mean difference +∕-1.96 SD). The HYPR image subvolume that yielded a fixed level of TAC fluctuations was smaller, on average, than the FBP subvolume determined at the same mA. CONCLUSIONS HYPR processing is a feasible method for generating low noise myocardial perfusion data from a low-mA time-resolved CT myocardial perfusion scan. The method is applicable to current clinical scanners and uses conventional image reconstructions as input data.

Noise spatial nonuniformity and the impact of statistical image reconstruction in CT myocardial perfusion imaging

PURPOSE To achieve high temporal resolution in CT myocardial perfusion imaging (MPI), images are often reconstructed using filtered backprojection (FBP) algorithms from data acquired within a short-scan angular range. However, the variation in the central angle from one time frame to the next in gated short scans has been shown to create detrimental partial scan artifacts when performing quantitative MPI measurements. This study has two main purposes. (1) To demonstrate the existence of a distinct detrimental effect in short-scan FBP, i.e., the introduction of a nonuniform spatial image noise distribution; this nonuniformity can lead to unexpectedly high image noise and streaking artifacts, which may affect CT MPI quantification. (2) To demonstrate that statistical image reconstruction (SIR) algorithms can be a potential solution to address the nonuniform spatial noise distribution problem and can also lead to radiation dose reduction in the context of CT MPI. METHODS Projection datasets from a numerically simulated perfusion phantom and an in vivo animal myocardial perfusion CT scan were used in this study. In the numerical phantom, multiple realizations of Poisson noise were added to projection data at each time frame to investigate the spatial distribution of noise. Images from all datasets were reconstructed using both FBP and SIR reconstruction algorithms. To quantify the spatial distribution of noise, the mean and standard deviation were measured in several regions of interest (ROIs) and analyzed across time frames. In the in vivo study, two low-dose scans at tube currents of 25 and 50 mA were reconstructed using FBP and SIR. Quantitative perfusion metrics, namely, the normalized upslope (NUS), myocardial blood volume (MBV), and first moment transit time (FMT), were measured for two ROIs and compared to reference values obtained from a high-dose scan performed at 500 mA. RESULTS Images reconstructed using FBP showed a highly nonuniform spatial distribution of noise. This spatial nonuniformity led to large fluctuations in the temporal direction. In the numerical phantom study, the level of noise was shown to vary by as much as 87% within a given image, and as much as 110% between different time frames for a ROI far from isocenter. The spatially nonuniform noise pattern was shown to correlate with the source trajectory and the object structure. In contrast, images reconstructed using SIR showed a highly uniform spatial distribution of noise, leading to smaller unexpected noise fluctuations in the temporal direction when a short scan angular range was used. In the numerical phantom study, the noise varied by less than 37% within a given image, and by less than 20% between different time frames. Also, the noise standard deviation in SIR images was on average half of that of FBP images. In the in vivo studies, the deviation observed between quantitative perfusion metrics measured from low-dose scans and high-dose scans was mitigated when SIR was used instead of FBP to reconstruct images. CONCLUSIONS (1) Images reconstructed using FBP suffered from nonuniform spatial noise levels. This nonuniformity is another manifestation of the detrimental effects caused by short-scan reconstruction in CT MPI. (2) Images reconstructed using SIR had a much lower and more uniform noise level and thus can be used as a potential solution to address the FBP nonuniformity. (3) Given the improvement in the accuracy of the perfusion metrics when using SIR, it may be desirable to use a statistical reconstruction framework to perform low-dose dynamic CT MPI.PURPOSE To achieve high temporal resolution in CT myocardial perfusion imaging (MPI), images are often reconstructed using filtered backprojection (FBP) algorithms from data acquired within a short-scan angular range. However, the variation in the central angle from one time frame to the next in gated short scans has been shown to create detrimental partial scan artifacts when performing quantitative MPI measurements. This study has two main purposes. (1) To demonstrate the existence of a distinct detrimental effect in short-scan FBP, i.e., the introduction of a nonuniform spatial image noise distribution; this nonuniformity can lead to unexpectedly high image noise and streaking artifacts, which may affect CT MPI quantification. (2) To demonstrate that statistical image reconstruction (SIR) algorithms can be a potential solution to address the nonuniform spatial noise distribution problem and can also lead to radiation dose reduction in the context of CT MPI. METHODS Projection datasets from a numerically simulated perfusion phantom and anin vivo animal myocardial perfusion CT scan were used in this study. In the numerical phantom, multiple realizations of Poisson noise were added to projection data at each time frame to investigate the spatial distribution of noise. Images from all datasets were reconstructed using both FBP and SIR reconstruction algorithms. To quantify the spatial distribution of noise, the mean and standard deviation were measured in several regions of interest (ROIs) and analyzed across time frames. In the in vivo study, two low-dose scans at tube currents of 25 and 50 mA were reconstructed using FBP and SIR. Quantitative perfusion metrics, namely, the normalized upslope (NUS), myocardial blood volume (MBV), and first moment transit time (FMT), were measured for two ROIs and compared to reference values obtained from a high-dose scan performed at 500 mA. RESULTS Images reconstructed using FBP showed a highly nonuniform spatial distribution of noise. This spatial nonuniformity led to large fluctuations in the temporal direction. In the numerical phantom study, the level of noise was shown to vary by as much as 87% within a given image, and as much as 110% between different time frames for a ROI far from isocenter. The spatially nonuniform noise pattern was shown to correlate with the source trajectory and the object structure. In contrast, images reconstructed using SIR showed a highly uniform spatial distribution of noise, leading to smaller unexpected noise fluctuations in the temporal direction when a short scan angular range was used. In the numerical phantom study, the noise varied by less than 37% within a given image, and by less than 20% between different time frames. Also, the noise standard deviation in SIR images was on average half of that of FBP images. In thein vivo studies, the deviation observed between quantitative perfusion metrics measured from low-dose scans and high-dose scans was mitigated when SIR was used instead of FBP to reconstruct images. CONCLUSIONS (1) Images reconstructed using FBP suffered from nonuniform spatial noise levels. This nonuniformity is another manifestation of the detrimental effects caused by short-scan reconstruction in CT MPI. (2) Images reconstructed using SIR had a much lower and more uniform noise level and thus can be used as a potential solution to address the FBP nonuniformity. (3) Given the improvement in the accuracy of the perfusion metrics when using SIR, it may be desirable to use a statistical reconstruction framework to perform low-dose dynamic CT MPI.

Targeted transendocardial therapeutic delivery guided by MRI-x-ray image fusion.

Objectives: To validate a multi‐modality image fusion approach to guide catheter‐based, targeted transendocardial therapeutic delivery in a swine myocardial infarction (MI) model. Background: Biologic agents such as stem cells may curb post MI adverse ventricular remodeling if delivered by a transendocardial catheter directly into the infarct border. 3D visualization of the infarct and other cardiac surfaces is required to perform this task. We propose registering and overlaying magnetic resonance imaging (MRI) roadmaps onto live x‐ray fluoroscopy (XRF) to guide targeted transendocardial delivery. Methods: Custom software was used to register and overlay MRI models of the endocardium and infarct on live XRF by aligning common endocardial border features. In a swine MI model, transendocardial injections of co‐localizing imaging labels were performed, targeting a 20 mm perimeter around the infarct. Directed targeting error (DTE) was defined as the difference between the predicted injection site‐to‐infarct distance calculated by the image fusion system, to the actual distance determined by postprocedure in vivo MRI. The mobile image fusion system was designed to be vendor‐independent for imaging systems and transendocardial catheters. Results: Transendocardial injections were performed in all animals without complications. Mean DTE was 0.9 ± 5.0 mm (n = 8 swine). Time to register the images and establish a high quality roadmap was less than 12 min in all animals. Custom imaging tools to display injection sites and distribution were useful adjuncts during targeted injection procedures. Conclusions: Multi‐modality image fusion is a feasible and accurate platform technology to guide transendocardial injections precisely to the discrete infarct border.

Three-dimensional tracking of cardiac catheters using an inverse geometry x-ray fluoroscopy system

PURPOSE Scanning beam digital x-ray (SBDX) is an inverse geometry fluoroscopic system with high dose efficiency and the ability to perform continuous real-time tomosynthesis at multiple planes. This study describes a tomosynthesis-based method for 3D tracking of high-contrast objects and present the first experimental investigation of cardiac catheter tracking using a prototype SBDX system. METHODS The 3D tracking algorithm utilizes the stack of regularly spaced tomosynthetic planes that are generated by SBDX after each frame period (15 frames/s). Gradient-filtered versions of the image planes are generated, the filtered images are segmented into object regions, and then a 3D coordinate is calculated for each object region. Two phantom studies of tracking performance were conducted. In the first study, an ablation catheter in a chest phantom was imaged as it was pulled along a 3D trajectory defined by a catheter sheath (10, 25, and 50 mm/s pullback speeds). SBDX tip tracking coordinates were compared to the 3D trajectory of the sheath as determined from a CT scan of the phantom after the registration of the SBDX and CT coordinate systems. In the second study, frame-to-frame tracking precision was measured for six different catheter configurations as a function of image noise level (662-7625 photons/mm2 mean detected x-ray fluence at isocenter). RESULTS During catheter pullbacks, the 3D distance between the tracked catheter tip and the sheath centerline was 1.0 +/- 0.8 mm (mean +/- one standard deviation). The electrode to centerline distances were comparable to the diameter of the catheter tip (2.3 mm), the confining sheath (4 mm outside diameter), and the estimated SBDX-to-CT registration error (+/- 0.7 mm). The tip position was localized for all 332 image frames analyzed and 83% of tracked positions were inside the 3D sheath volume derived from CT. The pullback speeds derived from the catheter trajectories were within 5% of the programed pullback speeds. The tracking precision of ablation and diagnostic catheter tips ranged from +/- 0.2 mm at the highest image fluence to +/- 0.9 mm at the lowest fluence. Tracking precision depended on image fluence, the size of the tracked catheter electrode, and the contrast of the electrode. CONCLUSIONS High speed multiplanar tomosynthesis with an inverse geometry x-ray fluoroscopy system enables 3D tracking of multiple high-contrast objects at the rate of fluoroscopic imaging. The SBDX system is capable of tracking electrodes in standard cardiac catheters with approximately 1 mm accuracy and precision.

Low dose dynamic CT myocardial perfusion imaging using a statistical iterative reconstruction method

PURPOSE Dynamic CT myocardial perfusion imaging has the potential to provide both functional and anatomical information regarding coronary artery stenosis. However, radiation dose can be potentially high due to repeated scanning of the same region. The purpose of this study is to investigate the use of statistical iterative reconstruction to improve parametric maps of myocardial perfusion derived from a low tube current dynamic CT acquisition. METHODS Four pigs underwent high (500 mA) and low (25 mA) dose dynamic CT myocardial perfusion scans with and without coronary occlusion. To delineate the affected myocardial territory, an N-13 ammonia PET perfusion scan was performed for each animal in each occlusion state. Filtered backprojection (FBP) reconstruction was first applied to all CT data sets. Then, a statistical iterative reconstruction (SIR) method was applied to data sets acquired at low dose. Image voxel noise was matched between the low dose SIR and high dose FBP reconstructions. CT perfusion maps were compared among the low dose FBP, low dose SIR and high dose FBP reconstructions. Numerical simulations of a dynamic CT scan at high and low dose (20:1 ratio) were performed to quantitatively evaluate SIR and FBP performance in terms of flow map accuracy, precision, dose efficiency, and spatial resolution. RESULTS Forin vivo studies, the 500 mA FBP maps gave -88.4%, -96.0%, -76.7%, and -65.8% flow change in the occluded anterior region compared to the open-coronary scans (four animals). The percent changes in the 25 mA SIR maps were in good agreement, measuring -94.7%, -81.6%, -84.0%, and -72.2%. The 25 mA FBP maps gave unreliable flow measurements due to streaks caused by photon starvation (percent changes of +137.4%, +71.0%, -11.8%, and -3.5%). Agreement between 25 mA SIR and 500 mA FBP global flow was -9.7%, 8.8%, -3.1%, and 26.4%. The average variability of flow measurements in a nonoccluded region was 16.3%, 24.1%, and 937.9% for the 500 mA FBP, 25 mA SIR, and 25 mA FBP, respectively. In numerical simulations, SIR mitigated streak artifacts in the low dose data and yielded flow maps with mean error <7% and standard deviation <9% of mean, for 30 × 30 pixel ROIs (12.9 × 12.9 mm(2)). In comparison, low dose FBP flow errors were -38% to +258%, and standard deviation was 6%-93%. Additionally, low dose SIR achieved 4.6 times improvement in flow map CNR(2) per unit input dose compared to low dose FBP. CONCLUSIONS SIR reconstruction can reduce image noise and mitigate streaking artifacts caused by photon starvation in dynamic CT myocardial perfusion data sets acquired at low dose (low tube current), and improve perfusion map quality in comparison to FBP reconstruction at the same dose.

Motion artifact reduction in fan-beam and cone-beam computed tomography via the fan-beam data consistency condition (FDCC)

Motion contamination in computed tomography projection data causes significant artifacts in the reconstructed images. If during the tomographic acquisition the object is relatively stationary during a portion of the acquisition, and then moves significantly, the projection data after the motion will be inconsistent with the projection data during the period of relative stationarity. The fan-beam data consistency condition (FDCC) provides a means to directly estimate motion contaminated projection data based on all of the projection data acquired. Thus, the FDCC may be used to combat many types of motion contamination in computed tomography. This approach to motion artifact correction is novel as none of the previous methods for artifact correction utilized a direct estimation of motion contaminated data. Additionally, this methodology depends upon only a small amount of a priori information and is not based on a motion model. Another distinguishing feature of this method is that it operates directly in the projection space, and is completely independent of the reconstruction algorithm utilized. An example of clinical relevance of coronary motion artifact reduction is presented using both simulated projection data as well as projection data acquired with a porcine model using a state-of-the-art 64 row volumetric CT scanner. Significant reduction in motion related artifacts is achieved in both the simulation case and the porcine model.