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Dual Energy CT 101: Implementation into Routine Practice

Dual Energy CT 101: Implementation into Routine Practice

Great, thank you. It's great to be here. Disclosures the first one here is relevant. I oversee an institutional research grant on dual energy CT that sponsored by Siemens. But I'm going to follow on one color, says excellent description of some of the fundamentals. I'll actually touch on again on a few of the key requirements of dual Energy CT acquisition and brief brief comparison of some of the different manufacturer approaches. I'll then talk a bit more about some of the new energy post processing techniques that are available to us clinically and show you a variety of applications that we use. And then I wanted to discuss a little bit about some of the different workflow options for getting dual energy CT data. In front of the radiologists. You've already seen this, so I will skip it, but I do want to touch on this one more time because it's very important. So what do we fundamentally need to do? Dual energy CT? The first thing we need is. To have tissues that show inherently different X Ray absorption behavior as a function of X Ray energy. So to reiterate on the Y axis, here we're showing Hounsfield units at low cavi on the X axis were showing House field units at high cavey, and as you all know, water and air are calibrated to be at zero and minus 1000 Hounsfield units at any KVP value. And So what we're really able to do with dual energy CT is to look specifically things that fall off of this identity line here. Iodine and bone or calcium as you go to higher concentrations, move farther and farther along these slopes, going to lower Hounsfield unit values at low Cave compared to high cavey and things like fat and also uric acid. I should point out which sits somewhere up here actually demonstrate higher Hounsfield unit values at High Cave, and so we need these materials to have inherently different behavior as a function of X Ray energy. And we also need as one Carlos pointed out. We need different enough energy Spectra to be able to demonstrate those underlying differences, because you can imagine if I have 140 KV here and 139 KV here, everything collapses back down to the identity line and we can't tell anything apart, so spectral separation is crucial. Where do I click the mouse? There it is. Thank you. OK, you've seen this as well, but I want to just mention this again to point out a very important difference. Make sure everyone one understands the difference between KVP&KEV because it becomes important in dual energy CT. So if we use a 140 KVPX Ray spectrum, that's this blue one. Here, what we're doing is we're putting 140 kilovolts across the X Ray tube. We're accelerating our electrons to 140K electron volts of kinetic energy. And we're slamming them into the anode, at which point they release a variety of X Rays of different energies ranging from low up to a maximum of 140 Kev. So the KVP value really defines the maximum KEVX Ray that we can produce, but there's a broad spectrum with a lot of energies below that, and so if I pick two of these. I picked two of these. Here 100 an 140 KVP you can see there's a tremendous amount of overlap between these two Spectra. This is bad spectral separation, so we have a couple of ways we can improve that spectral separation. We can go to an 8140 KV pair. You can see there's still a lot of overlap, but there's less than there was before or we can do what one Carlos mentioned. We can put it in filter in front of that high energy spectrum and that allows us to get rid of these. The low energy component of the spectrum. To reduce the overlap and improve spectral separation, which helps our dual energy post processing, I won't talk in great detail about the comparisons between these different techniques. I'll leave this in the syllabus for anyone interested, but I will touch a little bit on the Siemens approach, since this is specifically a Siemens session and I think the key thing here is that the advantage of having 2X tubes and two matching detector arrays is that we can put that in filter in front of that. Other source that's only possible if you have two different X Ray sources. There are a couple of limitations of this approach that are worth mentioning, which is that because we're cramming so much additional hardware into the same size gantry that we usually use the field of view of this high energy beam detector array is a little bit smaller, so we've got to make sure that we fit the important part of the patient anatomy within that 33 or 35 centimeter field of view, depending on which version of the scanner we've got. To reiterate the point about dose, these are the radiation doses from are roughly 10,000 initial scans that we did in the Ed with dual energy CT. I've got drive all on the Y axis. I've got patient weight on the X axis here, and the red bar here is the 25 milligray ACR diagnostic reference level that we're all familiar with. We do have a small number of scans that exceed that for very very large patients here, but the point is just that we can do very respectable low dose image Ng. Using this technology in fact, often better than our conventional single energy approach, is largely because these machines also come with all the other bells and whistles that our manufacturers have created to do really high quality low radiation dose imaging without sacrificing our diagnostic image quality. So virtual monochromatic image Ng Juan Carlos touched on this. What we're doing is we're using the information the X Ray absorption information from low and high energy to simulate what an image would look like if we were magically able to irradiate it. The patient at a single cave level. In practice, we can't do this. We have these polychromatic Spectra with wide ranges in cave values, but we've got enough information to. Make images that would simulate that appearance. So here what I've got is a lesion at the bottom of this kidney on a coronial image. If I input a region of interest on it, I can't tell whether this is A and enhancing mass on this post, contrast scan, or whether this is an inherently hyperdense benign cyst because all I have is this post contrast image and my Hounsfield unit values are higher than simple fluid. So what can we do? We can do our virtual monoenergetic image in here and here you see that the yellow region of interest in this iodine Laden renal parenchyma demonstrates rapidly increasing Hounsfield unit values as we go to low cave levels. That's a classic appearance for iodine. The white region of interest in this lesion actually stays remarkably flat as a function of X Ray energy that only happens if you have no iodine in a lesion, because we know what iodine does. I just showed it to you on the yellow curve there, so from this we can tell that this is a non enhancing lesion that it's benign. It needs no further work up or anxiety on anybody's part and then for interest. I've also shown you in the pink there or lavender whatever color that is, that's that's the fact, and as one Carlos mentioned from his Phantom as you go to lower energy. That actually demonstrates lower Hounsfield unit values. Now some other places where you can use this. This is on the left. A conventional scan through the head following contrast administration on the right. This is a monoenergetic image at 45 Kev and a couple things to point out. First of all, you can see that the iodine in the vessels here gets dramatically brighter, so this is 1 great imaging of locate TV and virtual monoenergetic images. Is that we can use this to salvage angiographic studies that didn't go so well. Maybe we got our timing a little wrong, or something happened with the Ivy. But we can dial down to lower simulated K EV values and really salvage a great arterial phase scan. The other thing that you'll notice if you look at the Gray white differentiation in the deep structures of the brain here is it's really much more prominent at locate TV and if you plot that out. You can see here that as we go to locate the VR contrast to noise ratio really arises quite rapidly. So this is another great use of virtual monoenergetic image Ng. Now here's another place where we like it in the abdomen. I challenge anybody to tell me whether this patient has gallstones or not, and this is what this is. What noncalcified gallstones look like on many see T scans. This is the ultrasound. This is the MRI. These are some pretty large stones and we just can't see them because their attenuation value very closely matches that of the surrounding bile. But if we go to locate TV or to hike ATV, we can see we really improve the contrast to noise relative to the surrounding bile because the cholesterol it turns out gets much darker, similar to fat. As we go to low key values and it goes in the other direction, it goes to higher Hounsfield unit values compared to bile at high K EV. One color is also mentioned. Three material decomposition. I just want to reiterate it because it's such an important application that we use clinically and so here as he showed you, we've got Hounsfield unit at located on the Y axis against those at high KVP on the X axis we define our base material line with the typical attenuation values of fat and organ parenchyma. And as we add, iodine of different concentrations, we move farther and farther up those blue arrowed lines to higher Hounsfield unit values with a very characteristic slope. So iodine, as we've we're all familiar, creates an increase in Hounsfield unit values to a greater degree at low energy than at high energy. And what that means is that everything in that blue shaded area can be attributed to iodine in this decomposition scheme. So if I take a pixel and I drop it there, I can then determine how much of those Hounsfield unit values are due to iodine content and how much are due to the underlying virtual non contrast appearance of the area. So I can subtract out my iodine and create a virtual non contrast image or I can selectively look at the iodine content in this iodine map here? Here's an example. Again, this same lesion in the lower pole of the kidney that I showed you before for the virtual monoenergetic example, we can do our three material decomposition. I've got my virtual noncontrast image. I have my iodine map and the iodine overlay map, which is actually the one that I find by far the most useful clinically, simply superimposes these iodine map on top of the virtual noncontrast image. And what that allows us to see is that there's pure Gray in that lesion. I can see the lesion, but there's no color in it, so I know with a high degree of confidence that there is no iodine. This is a non enhancing benign hyperdense cyst. I showed you we can do our virtual monoenergetic imaging, but I want to show you as well here that we can do quantification on this lesion. So here if I put a region of interest here, I can determine that on our mixed image I have 67 Hounsfield units here which were using three material decomposition to split into a contribution of 65 Hounsfield units from our virtual noncontrast image an about two Hounsfield units due to contrast medium or iodine. And that correlate Stew and iodine concentration of pretty much 0. The other thing we can do with the virtual monoenergetic is we can create these artificial locate TV images that really accentuate that iodine content. Or we can create high K EV images where the iodine content is really much less apparent. Here's one example. These pulmonary emboli are not terribly hard for us to detect, but what we can't do in less, we use dual energy. CT is look at the iodine distribution within the lung and here we can see the large perfusion defects within the lung and to me the most compelling application of this is in its promise to prognosticate which patients are going to do poorly after pulmonary embolus, because they have a large portion of their lung that's negatively impacted. This is one of my favorite applications. I think Julia Fielding over there is the only one who likes reading polycystic kidneys. Most other people sort of cringe when they see one of these because these are painful to read. You've gotta compare a noncontrast scan to a post contrast scan there never perfectly registered, so you've got to try to place your regions of interest. Well, here, they're perfectly registered coregistered iodine information in virtual noncontrast information. So on a single iodine overlay image, I can tell very easily that those Red Arrows are. Pointing to iodine content within those enhancing masses within both kidneys. Whereas in contrast in this lesion that Green Arrow points to a lesion that's pure grey benign cyst, I don't have to think twice about it. Here's another example. We often find incidental lesions here. We find a 42 Hounsfield unit, adrenal nodule. Chances are it's probably an adenoma, but we can't prove it on a post. Contrast scan and less we do a virtual non contrast image that shows that this drops to five Hounsfield units. That's definitively an adenoma. Here's the comparison in and out of Phase MRI, showing the signal loss. And here is a previous non contrast CT with a similar low Hounsfield unit value. This is a patient who has a closed loop. Small bowel obstruction here the one of the challenges that we have in the ER is then figuring out which of these patients have dead bowel and which ones will do OK with conservative management with an iodine map we can see that while some of the adjacent bowel loops here show good mucosal enhancement, this affected loop is all grey. There is no contrast within this and this in fact was confirmed to be ischemic Bell that surgery. Here we have two patients who have right stuff in the Bell and the question we're often asked is that GI bleeding is that active extrav azatian of contrast within the bowel lumen, so we can do our virtual non contrast and iodine map imaging on the top you can see that bright stuff disappears on the virtual noncontrast, but it's present on the iodine map so we can definitively conclude that this is intraluminal iodine from an active GI bleed, and we can do this by the way without the usual. True Noncontrast scan that we perform as part of a GI bleeding study, and I would argue we don't need both an arterial and venous phase because we can use dual energy to definitively characterize this as iodine. The bottom image we do the same thing and look at that. This persists on the virtual noncontrast image an it is not present on the iodine map. We know definitively that this is not iodine within the bowel lumen. Turns out this is Pepto Bismal that the patient took for their abdominal discomfort before they came. To the ER. We can use this to characterize a lot of other areas this patient has had a prior stent graft in the aorta and we see bright material within the lumen of what should be the excluded aneurysm SAC. The question always arises, then, is this an endoleak with contrast in the lumen, or is this calcification in chronic mural thrombus? Here we can do our iodine map, which shows us bright material that disappears on the virtual noncontrast that is definitely iodine from an endoleak. But at the same time, if we look along the wall here, we can see there's this bright material that's on the iodine overlay map and also on the virtual noncontrast that does not behave as iodine should. And that's calcium. So one important thing to realize is that not everything bright on an iodine map is iodine. Calcium shows up on both. The reason for that is that it's not one of the materials the three materials that we ask the computer to decompose our image into, so it ends up represented as some combination. Of attenuation on both the iodine map and the virtual noncontrast image. Here's another example. This is a patient who's had an acetabular fracture. If we look at the red spots here, they persist on the iodine overlay. They disappear on the virtual noncontrast. That's iodine. Of course, extravasated around this fracture. If we look at these blue arrows here, that bit of material is present on both the iodine overlay and the virtual Mount contrast that's there for calcium. That's a bone fragment from the acetabular fracture, so we can easily tell iodine from calcium. This is a virtual non calcium technique where instead of subtracting the iodine out of the image, we adjust our algorithm so that we subtract calcium out of the image and what this allows us to do is to remove the density from these Bony trabeculae running through the hip here so that we can now see the underlying bone marrow edema. The reason we can't typically see bone marrow edema very easily on CT is we've got all that confounding density from the calcium. So here we have an MRI scan showing much more extensive bone marrow edema in the intertrochanteric region. Then we might have expected from just this little fracture here that looks to be isolated to the greater trochanters. Here's the Dual energy CT where we've subtracted out the calcium we've color coded the Hounsfield units to show us the bone marrow edema very nicely matching that in the MRI stir image. One of to me, one of the killer apps of Dual Energy CT is in handling incidental findings. We looked at our first 2400 belisi tease done dual energy in the Ed and we found that about 5% of our patients have lesions that are technically indeterminate based on Hounsfield unit density, we can't clearly call them benign cysts, but we found that at least half of these we could exonerate as benign due to the absence of any iodine content on our dual energy CT post processing. And if you multiply that 5.2 * 50%, you find that about 3% of all of the patients that come to the YD. We could potentially avoid further imaging in. If we use dual energy CT, but to do that we have to perform a routinely and this is one of the reasons that we do every single abdominal CT in the Ed. We don't try to select up front 'cause we never know what we're going to find an. This allows us to deal with these incidental findings much more easily. Another application that we particularly like is a calcium versus hemorrhage application. In our non contrast head CT's and here you can see that now the color code here is a calcium overlay and you can see those bright circles. There are calcifications within the choroid plexus, whereas the hemorrhage within the right lateral ventricle here and here. Is bright, but it's not orange, so this is hemorrhage compared with this bit. That's calcium. Another application we particularly like is a bone subtraction technique. One of the challenging tasks, particularly for our trainees, is finding subtle subdural hematomas. I wonder if anyone can see it here. It can be very hard, because subdural hematomas are bright just like the adjacent bone, and if I subtract the bone away using our calcium subtraction techniques with dual energy, I can easily see that subdural hematoma. There is extremely easy to miss if you're not careful about how you window and interpret these studies. Here's another example, very subtle subdural hematoma there, much easier to see when we subtract the distracting calvarium out of the way. You heard about material characterization for renal stones so we can easilly color code are calcium based stones as blue and are uric acid stones as red, allowing our urologists to initiate appropriate medical treatment to dissolve uric acid stones for those patients that have them. And we can similarly do uric acid image Ng in gout. Here we had a patient who came to the YD with a hot and swollen red toe. They were actually concerned about a septic joint. We also saw this sclerotic lesion in the calcaneus here so we thought this might actually be Galt gout instead of a septic joint. We do our dual energy CT. And we see everything color coded green here is uric acid deposits from gout that explains the erosive lesions in the great toe. But we also see a lot of soft tissue out that we would have had no idea was there on the X Ray alone. And this technique are rheumatologists love you'll hear from Salvus Nicolau a little later in the session has been a pioneer in this. This is really a fantastic way to noninvasively diagnose gout and also to monitor treatment. Now I want to take about one minute. I'm a little short on time unfortunately, but I want to talk a little bit about workflow. Let me skip over this stuff a little bit. There are a few different ways to handle workflow. I've tried to show you here that do energy see T really adds. I think a lot of great clinical value in our image Ng, but it's been a long time and we really haven't broken out into the mainstream yet. And the reason for that is there's a lot of learning curve, but I think most importantly. Is the workflow historically for dual energy CT has been as disruptive as the clinical value that it potentially adds and it's been too much for people to really adopt readily. The first workflow option that people tend to use as radiologist driven where we tend to make the radiologists go to the thin client software or go to the workstation and do the processing themselves, but our radiologist simply don't have time to do this and we've found that while we've been doing do energy routinely, very few of our radiologists actually take the time to. Process this image Ng so we then move to, making the text do it right. That's the solution. Are text must love that, and so we asked our text to always do certain dual energy post processing and send it to pack so it's delivered up to the radiologist to read it. The problem there is that our technologists really don't have the extra time to do this work and are not happy to have to work on a different platform than the console, which is where all the rest of their work does does happen. So finally, there are workflow improvements on the way. A lot of these. Workflow steps have been fully automated, so the next version of the software that we've been trialing allows us to simply send the thin source images to the server, and the server does the post processing and delivers the image into packs without any user interaction, either from the radiologist or the technologist. We send on our noncontrast head CT's we always send arbonne subtraction images in these two planes. We also send our calcium and virtual non calcium images. On our urine or CTS we always send axial and Corona lestone overlay images there in color so we can easily distinguish what types of stones we have. And finally for our contrast enhanced CT scans, we always send our axial anarcha Ronal images so that we can differentiate those lesions with iodine from those without. I'm sorry for going a couple minutes over here, but I'll conclude there and thanks very much for your attention.

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Utilization and Followup Utilizatiomand Followup Utilization and Followup_ Utiliqgtion and Followup Utilizayiom and Followup_ ViMual Non-Calcium Virtual Non-Calcium Subdura/ Hematoma Radiologist DHiven Ra io/ogist Driven Disruptive Technology Subdura/ Hematöma Radiologist DHven Accentuation or G W Differentiation Accentuation or GW Differentiation Technologist Driven "PACS-Ready" Driven "PACS-Ready" Driven 'PACS-Ready" 1_ Base material line defined by urine & renal tissue • New capabilities that fundamentally change the way • Indeterminate renal lesions in Dual Source DECT • Predefined DE processing performed by technologists, Detector Based Spectral CT Rapid kVSwitching DECT Rapid k V' Switching DECT Rapid k V Switching DECT • Noncontrast Head DECT: • Ureter CT: • Contrast Enhanced AbdomenlPelvis CT: 70 kev -420 70 -420 70 --420 70 -'20 70 kev 40 l0 kVp 80 kVp 70 • Automate rote technologist post-processing steps, oo us All post-processing performed on demand Iodine Bmne Iodine Bme Iodine Bone Iodine rone HU5 HU 5 40 42 20 140 40 80 • Image content at simulated kev values generated by GM-WM Contrast-to-Noise Rat10 GM-WM Contrast-to-Noise Ratio Iodine + Iodine Closed loop SBO *Fat, organ and Iodine 100kVp 120 000 Several different stone types 125/2406 = 5.2% of ED patients 1) Explain key requirements of Dual Energy CT we perform and interpret CT IOOkV 840kV Contrast Con trog Con tru 80 kVp low kVp IOOkVp 80kV image series sent to PACS, specific to the application CT-value eliminate their time requirement appropriate linear combinations of the basis material pairs • Axial and Coronal Stone • Axial and Coronal Iodine Overlay • Axial and Coronal Bone Ischemic bowel IOOkVp 80 kVp lo kVp 100 kVp 100kVp undergoing routine abd/pelvis CT Optimal for sites with a few power users DISCLAIMER Calculate position relative to separation line *Iodine quantification, calculation of a virtual non-contrast image low kVp 1o0 kVp Siemens: Institutional research grant on Dual • Improved diagnostic performance acquisition, and compare different manufacturer Dual Energy Dual Energy 101: 120 • Enough for -95% of cases Subtraction Overlay I overlay • Scanner or server configured to pre-process desired The statements by the Siemens' customer 70/137 (51%) lesions exonerated as Extensive CT Courses and Learning Modules Has not worked well in our setting with multiple ER Extract previously unavailable information content approaches Energy CT 80 kVp 80 W 80kV 80 kV described herein are based on results that were Implementation into CT-value benign on iodine maps ISCT DECT output, based on exam type Mixed VNC 20 45 120 1240 100 I map I overlay Overlay 40 Blood are available at OnDemand.isct.org radiologists in clinical routine Reduce radiation dose, IV contrast, imaging utilization ixed, . Mixed ixed, , Mixed, I overlay overlay achieved in the customer's unique setting. Since + 10dtne + Iodine + 10d1ne SIEMENS .. ISCT solving or quantitative assessments Water Potential to avert further workup in Routine Practice there is no "typical" hospital and many variables • Processed images automatically sent to PACS Healthineers • Post-processing learning curve 2) Describe a variety of dual-energy post- CT-value CT Value Why do we remain in early adopter / research mode? CT 40 40 120 t 40 ' 40 120 60 120 60 80 60 '00 120 , 20 120 ' 40 120 Bayer informatics: Advisory Board member ISCT & SIEMENS HEALTHINEERS I overlay VNC bdine map Iodine map Iodine Imaging VNC Mixed 2.8% of ER patients imaged by (keV) (keV) exist (e.g., hospital size, case mix, level of IT Norm ROI CT Norm CT ROI CT ROI Norm • Benefit of building familiarity, comfort with DE data in SIEMENS .. n-6Kase MR without any user interaction Iodine Bone Iodine overlay Iodine content Fat ISCT Sr, 140 Sn Training need for Radiologists on-con processing techniques valuable in clinical abdominal CT CT-value adoption) there can be no guarantee that other 120 40 20 Mean 7/ 7/ 8 Computed Tomography Mean Mean 8 140 190 keV. 120 190 keV, • L acetabular fx L acetabular fx routine exam review • WORKFLOW high kVp at high kVp Corrast Ennan.:-ernent Contrast Enran.:érnent 140 wp 140 40 1o0 kVp Contrast Enr ' • Contrast Contast Contrast • Cortrast contrast Contrast Err customers will achieve the same results. • PACS-ready images meet the clinical need in the • Time consuming: Radiologists cannot afford additional practice • —90 degree projection offset • —90 degree propecåion offset • Nearly aligned projections • Perfectly aligned projectms • Nearfectly aligned projections • Perfectly aligned projecbons • Perfectly aligned projectmns • Nearly aligned prqjecåions VNC VNC mage VNC Image Must perform routinely • Favors fully integrated and automated solutions • Axial Calcium overlay and 80 kVp 1241 [241 1201 • Several dense foci - Extrav vs fracture fragments ? Several dense foci - Extrav vs fracture fragments ? • Image domain processirg Air • Projection domain processng • Projection domatn processng • Image domain processirg • Image domain processrg • Projection domain processng • Image domain processirg • Similar challenges to Radiologist driven workflow: time on each scan App 80/ 801 • Fixed mA techmique • Fixed mA technique Fixed mA technique • TuJbe current modulation • Tube current modulabon • Tube current modulation • TIJbe current modulation Virtual Non-Calcium VNCa Mean Mean _ 22, 7/634 HIJ 69 7/ 63 71 63 7/63 Mean 8 Must favor specificity over sensitivity VNC Aaron Sodickson MD PhD Streamline workflow Materials must have distinct absorption characteristics • Red arrow extrav: + I overlay, - VNC Red arrow extrav: + I overlay, - VNC ISCT Iodine overlay Iodine content Iodine Bone Iodine Stddev 1 7/237/ 1 7/237/ 1 7/2371 • Post-processing learning curve shifted to technologists • Post-processing leaming curve shifted to technologists Stddev 1 • Tube B FOV Ijmltatm 33-35 cm • Full FOV • Tube B FOV 33mitatm 93-35 cm • Full FOV • Tube B FOV limitatm 33-35 cm • Full FOV • Tube B FOV Imtatm 33-35 cm • Full FOV • Tube B FOV 33-35 cm • Full FOV • Tube B FOV 33mltatm 9-35 cm • Full FOV • Tube B FOV limtatm 33-35 cm • Full FOV • Tube B FOV IimtatJM 33-35 cm • Full FOV / 23 • Full FOV • • Full FOV • FOV • Full FOV 3) Weigh varied post-processing workflow options • Interpretation - information content of each spectrum: to avoid false negatives (incorrectly 2801-31 I 280/-31 I 2801-31 1 2801-31 280/-31 11 280/-31 [email protected] • Patent size -250 lbs • Pabentstze -250 lbs • Patent size limitabon -250 lbs • -250 lbs • limitation -250 lbs • Patent size limitation -250 lbs • Pabent slzelmtabon -250 lbs • Patent srelmtabon -250 lbs • Pabentsrelmtabon -250 lbs • Pabentszelmtabon -250 lbs • Tin filtration of higher kV • Tin filtrabion of higher kV • DE data always acquired • WORKFLOW Blue arrow bone: + I overlay, + VNC DE information available, but rarely used in clinical 81 0/290/890/ 81 810/290/890/ 40 • Training need for technologists, radiologists calling cancer a benign finding) • How to extract meaningful data Different inherent absorption behavior (atomic number) Dlfferent inherent absorption behavior (atomic number) to no to W to to W no -ISO W no no Area qrn2- Area qm2- Area • Noninvasive diagnosis of uric acid content Calcium Overlay Images Di'•asnn Chef, ErrerFcy Divisnn Chéf, ErtVFcy Di'•asnn Chef, -ISO Calcium persists on both VNC & iodine maps in typical 3 material decomposition solving / quantitative applications Sn140 kV murnlU@3 HU at high kVp routine, even by the power users murnl muml/ muml / -03 murnl / murnl / -03 Graphics Courtesy Dr Manuel Patno Graphics Courtesy Dr Manuel Pabno Graphics Courtesy Dr Manuel Paino Gold standard: Loss of signal on out-of-phase chemical shift MRI Different enough spectra to make the inherent differences • Time consuming: Techs cannot afford additional time on each scan Drecbr of CT, & Wonen's Drecbr of CT, & Drecbr of CT. & Worren's DrecÜ of CT, Brgham & Woræn's ER101-ED-SUA5, Sun Educabon Exhibit Wortman, UJyeda, Fulwadhva, Sodickson ER101-ED-SUA5, Sun Education Exhibit Wortman, Uyeda, Fulwadhva, Sodickson ER101-ED-SUA5, Sun Education Exhibit Wortman, IJyeda, Fulwadhva, Sodickson ER101-ED-SUA5, Sun Edwcabion Exhibit Wortman, Uyeda, Fulwadhva, Sodickson ER101-ED-SUA5, Sun Educabion Exhibit Wortman, IJyeda, Fulwadhva, Sodickson ER102-ED-X, Education Exhibit: Uyeda, Richardson, Wortman, Sodickson ER101-ED-SUA5, Sun Edwabon Exhibit Wortman, Uyeda, Fulwadhva, Sodickson ER101-ED-SUA5, Sun Educabon Exhibit Wortman, Uyeda, Fulwadhva, Sodtckson ER101-ED-SUJA5, Sun Edi-cation Exhibit Wortman, Uyeda, Fulwadhva, Sodickson 120 Ed Fraction FdFracoon 40 60 80 40 60 80 60 '00 , 20 Energy tkeVl Energy [keVl ErErgy tkeVl tkeVl SSC06-02, 1040 am In rm N228 Admom, Wortman, Uyeda, Fulwadhva Sodickson ER106-ED- 104, amn Education Exhibit Wortman, Uyeda, Fulwadhva, Sodickson SSC06-02, 1040 am In rm N228 Admom, Wortman, Uyeda, Fulwadhva, Sodickson ER101-ED-SUA5, Sun Educabion Exhibit Wortman, Uyeda, Fulwadhva, Sodickson SSC06-02, 1040 am In rm N228 Admomi, Wortman, IJyeda, Fulwadh•a SSC06-02, 1040 am In rm N228 Admom, Wortman, IJyeda, Fulwadhva Sodickson SSC06-02 1040 In rm N228 Admom, Wortman, Uyeda, Fulwadhva SodicWl SSC06-02, 1040 In rm N228 Admom, Wortman, Uyeda, Fulwadh'.a SodicWl SSC06-02, 1040 In rm N228 Admoni Wortman, Uyeda, Fulwadhva SSC06-02, 1040 am In rm N228 Admom, Wortman, Uyeda, Fulwadhva ER106-ED- 104, am Education Exhibit Wortman, Uyeda, Fulwadhva, Sodickson ER102-ED-X, Education Exhibit: IJyeda, Richardson, Wortman, Sodickson ER101-ED-SUA5, Sun Education Exhibit Wortman, Iyeda Fulwadhva, Sodickson ER102-ED-X, Education Exhibit: IJyeda, Richardson Wortman, Sodickson ER102-ED-X, Education Exhibit: UJyeda, Richardson, Wortman, Sodickson ER102-ED-X, Educabion Exhibit: IJyeda, Richardson, Wortman, Sodickson 40 60 100 60 so 100 60 so 60 '00 60 so '00 so SO POX) M Agrawd R, Hkhn PE, DV Sepaatnn M A. 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Hævard '.4edical Schod Assætæ H•vard b&dical School • Potential to monitor treatment response Non-contrast CT with HIJ < 10 visible = spectral separation visiblo = spectral separation ' CT 2016 (keV) (Kev) Dual Energy CT for Abdominal and Pelvic Trauma: A Pictorial Revrew RSNA 2016 Dual Energy CT for Abdominal and Pelvic Trauma A Pictorial Rewew RSNA 2016 Dual Energy CT for Abdominal and Pelvic Trauma: A Pictorial Rewew RSNA 2016 Dual Energy CT for Abdominal and Pelvic Trauma• A Pictorial Rewew RSNA 2016 Dual Energy CT for Abdominal and Pelvic Trauma- A Pictorial Rewew RSNA 2016 Dual Energy CT for Abdominal and Pelvic Trauma- A Pictorial Rewtew RSNA 2016 Dual Energy CT for Abdominal and Pelvic Trauma. A Pictorial Review RSNA 2016 Dual Energy CT for Abdominal and Pelvic Trauma: A Pictorial Revtew RSNA 2016 CT RSNA 2016 Slide Courtesy: Wiåiam Moore, Marco Ptnho, Suhny Abbara_ UT Southwestem 2016 Slide Courtesy: Wiåiam Moore. 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