Dual Source CT in Pediatrics – How We Do It

Thank you very much for that introduction and thanks Simmons for inviting me to this prestigious meeting. This is where I work. This is our new hospital at Caroline's can we move there in November? last November we worked with the Flash system for about 6 seven years and now that we moved to the new hospital we have a force scanner and I will try to walk you through this. Well what do we do? We do all Pediatrics we do from head to toe with a dedicated pediatric scanner. I will talk to you a little bit. How we do it and what we do to get better. Well, first of all, when we moved to this new hospital, I felt we had to do something. We've had the flash scanner for quite some time and it helped us so much to reduce anesthesiology no sedation. But still there were a lot of patients that they didn't even want to enter the room so I felt I had to do something and we did. A invented our own audiovisual atmosphere we want to. I want the kids to feel at home to feel that they come to a nice environment instead of this hospital surrounding. So what we did we did we put two projectors. One of the scanner and one in the ceiling with moving pictures and just to give you a glimpse of what it looks like, this is just an example. Me we have a. They can choose between. 10 different This is just an example. We have 10 different themes and for the little ones we have this cartoons and they love it and I can give you millions of examples of kids that we didn't even think we could put on the table and they won't leave. They won't want to see them all, so this is really really nice and even for the text working in the lab they love working there because they are so proud to show the environment to the kids and the parents they they. They get a break. They come there. They're so worried about the kids disease they so worried about the results. And when they come into the environment, it's takes them off their feet so they don't talk about the disease. They don't worry, and the children really feel that, so they feel that the parents are calming down. They don't have to worry, so this makes it really much more easy. So what challenges do we have? We know this already motion speed and those will talk about that too. So Flash mode is fantastic. It's quick and can tolerate a great deal of motion as long as the patient stays on the table. This was a child coming from oh R had a congenital hip dislocation. They want to see that the hip is in place. The tech chose the wrong protocol and we said because the kid was kicking. His feet constantly was happy but kicking his feet. So OK we do a repeat scan. So we did a repeated scan with the flash mode and with the extremely low dose still kicking his feet. But you can now appreciate everything in the picture and you can say that the hip is in place. Speed is really important with coronaries. We've heard that in the previous talk we do. This was a child with cardiomyopathy. They was referred to us for any coronary anomalies. The patient had a heartbeat of 133 beats per minute. We did an ECG trade exam and you can see the beautifully the coronaries. Even though the heartbeat is so so high. OK, we started doing a lot of things we didn't do before with foreign bodies in the. Trachea or in the lungs they we used to doing this. Studies with fluoroscopy and plain film and with young doctors on call. They had difficulties interpreting these these films. So now we do sitting on everything and as you can see the dose is extremely low. We have an effective dose of .05 with a total DLP 01 for the whole scan. It's really amazing. So if we can do it with the small children, we can do it with all the ones and this was a teenager came with a recurrent numitor acts with the Palma nary blebs. We didn't have any but as you can see the dose is extremely low. How do we do it? We do it with outstanding teamwork. We have our physicists are two texts and myself. We work together as a team and we set up the protocols together. We do everything and we try to lower the dose continuously and we have these meetings and if we have trouble we have our Siemens contact and if we we're stuck we can always call Simmons and we will. Solve the problem together. OK, one typical task for the physicist would be CT or conventional X Ray for neck trauma. We all know that it's much easier to interpret the see T for neck trauma, but we have a lot of them. The kids they trip over and they come for a neck exam and it's really tricky to if it's a big dose difference to say OK will do city for everyone. So this is the table I got from my physicist. You can see with the Flash scanner we have the higher dose for the with the teenagers. So what was the decision? Well but the flash scanner was said. Only city in special cases with neurological symptoms or if cities performed anyway. With the four scanner we do city for all neck exam. We used tin filter and the image quality is beautiful even though the doses attempt of the one we had before. Before going further, I just want to we saw this in the previous talk, but I just have to mention it because we we did. We did this all wrong from the beginning and I I'm a bit embarrassed to show you this, but you still have to be very aware that if when you set your protocols you have to change the default protocols from Siemens because when dealing with children the whole you are so into the scan that you want to do so you lower the dose down to nothing. And you don't even think about the boldest tracking, so this is really very important that every time you have to think about this that those is equal to the scan itself. And it's really very embarrassing, but I've chose to show this anyway and we changed our protocols, so now it's nearly nothing compared to the actual scan. But think about this every time you take you making you protocol or every time you fail with your bowels bolus tracking. And taking a new bolus tracking, you really have to change it all over again. And this is my I want my Christmas present from Siemens is can please can I make my own defaults? Because then this would never happen. OK, next case, this is a one year old patient with several months of secretary diarrhea. Loss of about 2 liters of fluid every day, and it turns out to have a VIP producing tumor. Surgeries are the only cure. Chemo wouldn't help. So now we have the biggest challenge of the mall, the spinal arteries, the audio Adam Care which you need to use a bit higher dose in order to. Be able to appreciate this thin artery, but it's doable and I think you can see you can see it beautiful. The artery comes out here and it's really fantastic. This patient had an operation the surgeon could spare. The artery had to leave a bit of the tumor, but after surgery the child was without diarrhea and it's doing fine. This is the same. Thing another patient with a neuroblastoma that was going to surgery before surgery, then wanted to have a scan of these this artery to know the course of the order. And here you can follow it. Back to the OR in front to the aorta. Just be with me for two few seconds here and you can see that it's surrounded by tumor. But now the surgeon know exactly where it is and where to take care, and this patient was operated up on for 14 hours and they got rid of most of the tumor and she's doing fine. Another challenge we heard about yesterday is doing a CT during ECMO. I'm not going to go through with the details because that's a whole another lecture, but as we heard it's very tricky to know where to administer the contrast, where to expect it, and how to do it. But we still we do this, and it's a logistical problem that comes with with a tiny patient on the table is small thing in their this the patient and the rest is just. Personnel around the patient and the machinery and all the infusion pumps. And we don't use flash for obvious reasons. The patient could bleed out in seconds. This is a typical patient on ECMO, the congenital diaphragmatic hernia before surgery. We do this to help the surgeon to know how much lung tissue there is and all the other problems. All the vessels. So to be well prepared before surgery. This was the next cases. This is the patient with meconium aspiration was put on ECMO because of. They usually get better in a couple of days, but this patient did not improve, so we suspected something else and did a cardiac angiography on ECMO and it's beautiful and the dose is extremely low. We also do a lot of low dose exams for scoliosis. As we heard from Marilyn, we use the Flash mode, an extremely low dose before surgery for the surgeon to know. A. The planning and the after surgery. We don't use dual energy. We use the tin filter and we still go very low and we we don't have those such a problem with the artifacts it it works beautifully and we can tell whether where the screws are put properly and this is also important when you have these rods with hooks. The surgeon needs to know that there are hooks are put properly and it's easy to tell with the city. Last, I would like to show you a case. This is how we try to go further. This is a complex display, Shia and preoperative planning you are orthopedic surgeons. I've used to getting the NPR's and the 3D is 360 rotation of a 3D model and still this was a tricky case and the surgeon was very worried how to plan the operation. So we said OK, we try something new. So we did this 3D printing. And we printed this full size patient and the surgeon took the 3D model into the operating Theatre an she was thrilled afterwards she told me she couldn't have done it without. Does she changed her approach totally and put put the patient on the side and went in from the back and it was a very successful operation. So conclusion as everybody said before, dual source CT has given enough the perfect tool for scanning children. It's quick scanning with low dose without compromising image quality. Thank you.

Postoperative scoliosis Preoperative scoliosis When setting up protocols; when setting up protocols; case 2 Motion 1. Motion case 3: SIEMENS scoliosis PO-ppperative scoliosis case I Astrid 'TJoeüT'J-ery of Adamkievicz gTJoeü1'tery of Adamkievicz an-ery of Adamkievicz of Adamkievicz afterieof Adamkievicz Conclusion Ri9are of the dose contribution from ROare of the dose contribution from Roare of the dose contribution from RO9are of the dose contribution from filhaliarteries, Adamkievicz "Outstanding teamwork" children Always change from default Decision? j haf 17teries, Adamkievicz gG9avare of the dose contribution from avare of the dose contribution from of the dose contribution from Gioy,comventional X-ray for necktrauma? CT 01' conventional X-ray for necktrauma? CA 0M conventional X-ray for necktrauma? CA soy comventional X-ray for necktrauma? and bolustracking. •m and bolustracking. Lena Gordon Murkes, MD Flash Flashscan , Flashscanner : SIEMENS 24-Apr-2014 13:11 Department Of Pediatric Radiology, Department of Pediatric Radiology, Only CT in special rad ologisl Lena Gordon Murkes, MD Ward: 02-Nov-2012 08:43 Sieme cases with SIEMENS .. Physician: L ena Gordon Murkes, MD Lena Gordon Murkes, MD SIEMENS Karolinska University Hospital, Operator: Ward: Karolinska University Hospital, neurological Heat Spend that extra moment on distraction" pend that extra moment on distraction" Physician: Department Of Pediatric Radiology, Total rnAs 359 Total rnAs 8359 Operator. symtoms or if CT is Total DLP 1 3 rnGycm Total DI-P 1 3 rnGycm Stockholm, Sweden Karolinska University Hospital, Stockholm, Sweden Healthineers performed anyway Total rnAs 839 Total mAs 839 Total DLP 39 rnGycm Total DLP 1 39 rnGycm Total DI-P 39 rnGycm Scan mAs ref. CTDlvolt CTDlvol* cSL m Gy mGycm mm Scan mAs ref. CTD1vor* CTDlvort CTDlvolt CTDlvor CTDlvol* CTDlvor* cSL Forcescanner: 0.715 m Gy m Gycm m Gycm mGycm mm Patient Position F-SP Flashscan , rnA 1.03 L 0.02 L 10.0 0.6 Topogram F Topogram S mm ms Flashscan , Patient Position F-SP Motion 1. Motion 80 210 0.69 L 210 2.5 2.3 10.8 Topogram Topogram F Topogram S 35 0.07 L 0.03 L 12.0 0.6 10.0 80 10.6 15 120 80 0.89 L 6.69 L 0.14 L 0.68 L 0.02 L 0.07 L 0.21 0.61 re onn 35 2.5 2.0 10.6 10.0 0.6 0_ 18 14 11 CTDlvol O,04mGy Contrast 2. Speed 210 Eff dose O,05msv Eff dose O,05mSv 0.28 reMonitoring 120 1.03 L 6.69 L 0.07 L 0.02 L ådiögrapher ådiographer radiogra DLP 1 DLP 153 Monitoring Monitorin 80 80 10.0 10.6 11 0.89 L 0.68 L Contrast 0.21 0.28 10.8 nasn rin 6.69 L 0.89 L 0.69 L 0.14 L .28 10.6 20.0 3. Dose CTDlvolt CTDlvol CTDlvol* CTDlvol 1,27mGy FLASH TDlvol O,48mGy 210 56 f 204 10.0 10.6 flash Artärfas 80 12.0 20.0 0.89 L 18 14 12 35 19 Eff dose 0,05 mSv Eff dose O,05 mSv DLP 153 DLP 1 DLP 34 DLP 1 DLP 24,7 100 kV Sn Eff doseO,4mSv SIEMENS .. SIEMENS ... SIEMENS CTDlvol 8 DLP 170 HOSPITAL Eff dose O,4mSv Eff dose O,45mSv 11 12 15 14 13 18 120 19 210 eff dose 0,5mSv Healthineers