Virtual Touch Turnover Workbook

SIEMENS User Services www.usa.siemens.com/education Virtual Touch™ Turnover Workbook Answers for life. User Services. Driven by More. More: Our philosophy for a lifelong improvement through continuing education and consulting. Working closely with you, we develop your personalized education and consulting strategy and support you and your staff with our comprehensive User Services to help gain: • More: Routine Confidence • More: Clinical Expertise • More: Superior Performance More: Personalized training, education, and consulting services from Siemens Healthcare Customer Services. For your leading edge in medical care. User Services. Driven by More. More: Personalized More: More: Superior Clinical Performance More: Routine Expertise Confidence 2 I Contact Information Summary Welcome to Siemens Healthcare Discover. Try. Buy. on webShop Siemens Healthcare is dedicated to helping you Do you want to “Discover. Try. 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Clinical Training and Siemens Training Centers Continuing Education Siemens Clinical Education Training Center – TDC2 Siemens Customer Care Center: 110 MacAlyson Court Call 1-800-888-7436 Cary, NC 27511 • Troubleshooting assistance • Immediate assistance for software applications and workflow issues • For Tech Support press option 2 / for applications support, press option 3 • Press the * key or enter the last six digits of your Functional Location Number • Press 7 for ultrasound Functional Location Number ____________________ Clinical Education Offerings: Serial Number ________________________________ Call 1-888-221-8010 (follow the prompts) IP Address System _____________________________ • Classroom Training (Offerings, Registration& Scheduling) Educational Symposia IP Address PACS _______________________________ • • On-site Training • Printed Self-studies • Virtual Education (Offerings & Registration) • Workshops & Fellowships Visit www.usa.siemens.com/clinicaleducation for more information regarding the current Siemens Clinical Training and Continuing Education portfolio. 3 II Contents I Contact Information Summary ............................................................................................... 3 II Contents .............................................................................................................................. 4 III Course Agenda .................................................................................................................... 5 IV Course Objectives ................................................................................................................ 6 I Strain Imaging ....................................................................................................................... 7 1.1 Objectives .................................................................................................................... 7 1.2 Basic Concepts ............................................................................................................. 7 2 Virtual Touch™ Imaging ........................................................................................................ 9 2.1 Objectives .................................................................................................................... 9 2.2 VTi Technology............................................................................................................. 9 2.3 VTi Transducers and Presets ........................................................................................ 11 2.4 VTi Scanning Techniques............................................................................................. 12 2.5 VTi (Gray Scale) workflow .......................................................................................... 12 2.6 VTi (Color) workflow................................................................................................... 12 3 Virtual Touch™ Quantification ............................................................................................. 13 3.1 Objectives .................................................................................................................. 13 3.2 VTq Technology.......................................................................................................... 13 3.3 VTq Transducers and Presets ....................................................................................... 15 3.4 VTq Scanning Techniques............................................................................................ 15 3.5 VTq Workflow............................................................................................................. 17 3.6 VTq Reporting ............................................................................................................ 17 4 Virtual Touch™ IQ ............................................................................................................... 18 4.1 Objectives .................................................................................................................. 18 4.2 VTIQ Technology ........................................................................................................ 18 4.3 VTIQ Transducers and Presets ...................................................................................... 22 4.4 VTIQ Scanning Techniques .......................................................................................... 23 4.5 VTIQ Workflow ........................................................................................................... 25 4.6 VTIQ Measurements and Reporting ............................................................................. 25 Appendix A: Virtual Touch™ Imaging Workflow (Gray Scale) .................................................... 28 Appendix B: Virtual Touch™ Imaging Workflow (Color)............................................................ 31 Appendix C: Virtual Touch™ quantification (VTq) Workflow (Liver)........................................... 34 Appendix D: Virtual Touch™ IQ (VTIQ) Workflow ..................................................................... 39 4 III Course Agenda Virtual Touch™ Imaging Review Virtual Touch™ Imaging WBT Virtual Touch™ Imaging Scanning Schedule 1-2 Volunteer Studies Liver Thyroid Breast Virtual Touch™ Quantification Review Virtual Touch™ Quantification WBT Virtual Touch™ Quantification Scanning Schedule 1-2 Volunteer Studies Liver Virtual Touch™ IQ Review Virtual Touch™ IQ WBT Schedule 1-2 Volunteer Studies Breast 5 Calcs 29 SIEMENS Gener Compound + 20-100% H3.00 MH THI 288 DRS5 Labels SC Of Breas OTCE M CEIST3 Page 1 Velocity EM Mass 17 =High Mass 20 Depth=1.3 cm Mass 3 [ VreHigh Site 1 Depth=0.8 cm Site 2 DE Vs=1.02 m/s Depth=1.0 cm Va=3.70 m/s Depth= 1.2 cm Lesion 1 Lesión 2 Lesion 3 0 Lesion som Fr78 IV Course Objectives Upon completion of this course, you will be able to: • Explain Strain Imaging • Explain ARFI Imaging • Explain how VTi technology works • Identify scanning techniques used with VTi • Perform a VTi exam • Describe how VTq technology works • Identify scanning techniques used with VTq • Perform a VTq exam 6 Workbook | Workbook Name I Strain Imaging 1.1 Objectives Notes By the end of this section, the technologist will be able to • Explain Strain Imaging • Explain ARFI Imaging 1.2 Basic Concepts • Strain imaging is an ultrasound imaging technique which provides information about the mechanical properties (stiffness) of tissue • Stiffness is relative to the surrounding tissue • Basic process is simple: • Deform tissue (in a region of interest) with a mechanical force, or stress • Compare before and after deformation images to show the tissue displacement • Calculate the strain which is the variation in displacement • Display the result as an elastogram • Strain imaging can help clinicians “see” the relative stiffness of a particular area that they may not be able to feel 1.2.1 Manual Strain • Force is created by pressure of the user transducer, patient respiration or cardiac motion (uniform) • Traditionally described as elasticity imaging 1.2.2 Acoustic • Force is created by the ultrasound beam (single pulse) • Referred to as Acoustic Radiation Force Imaging (ARFI) 111 111 11 7 Workbook | Workbook Name 1.2.3 Tissue Strain Analytics Notes Acoustic Radiation Force Impulse Manual (ARFI) Compression Technology Virtual Touch Virtual Touch Virtual Touch eSie Touch Imaging Quantification IQ Elasticity Imaging Application Images • At a high level all of the following technologies belong to Siemens’ suite of applications, known as Tissue Strain Analytics • Compression Elastography – which has been around for some time now and which utilizes very gentle transducer motion superficially on the patient to generate that stress. • Acoustic Radiation Force Impulse imaging (ARFI), where the source of the stress, rather than being a motion of the user’s hand, is actually an acoustic push pulse. That is, sound is used to compress and interrogate tissue. • As you can see in the image, there are 3 Virtual Touch™ applications which utilize AFRI technology, and one, eSie Touch Elasticity Imaging, which uses compression-based technology. • Virtual Touch™ Imaging (VTi)- provides a qualitative view of tissue stiffness • Virtual Touch™ Quantification (VTq) - provides a quantitative assessment, or measurement • Virtual Touch™ IQ (VTIQ) – provides a visual and quantitative assessment 8 Workbook | Workbook Name 2 Virtual Touch™ Imaging This training provides Ultrasound sonographers and physicians with relevant Notes information to enhance and improve their clinical knowledge of Virtual Touch™ Imaging (VTi) on the ACUSON S2000 ™and ACUSON S3000™ultrasound systems. 2.1 Objectives By the end of this section, the technologist will be able to • Explain how VTi technology works • Identify scanning techniques used with VTi • Perform a VTi exam 2.2 VTi Technology TRANSDUCER . Displacement is induced by an acoustic REGION OF push pulse INTEREST . Detection pulses track displacement on oxis to SOFT TISSUE STIFF LESION the push pulse within the ROI . The push/detect sequence is stepped across the ROI . The relative tissue displacements are mapped to the image • Virtual Touch™ tissue imaging utilizes acoustic push pulses (orange) and tracking beams (green arrow), sequenced across a user-defined region of interest, to generate an elastogram depicting the relative stiffness of tissue. • A Virtual Touch™ image is a grayscale or color-coded display of relative tissue stiffness in a user-defined region of interest. This information is computed by examining the displacements of tissue elements in response to an acoustic push pulse. • Virtual Touch™ imaging forms an image by combining independently acquired multiple lines of tissue displacement information as shown in the figure 9 Workbook | Workbook Name • In contrast to conventional ultrasound imaging pulsing strategy, Virtual Touch™ Notes imaging uses a three-step pulsing method. • First, a conventional ultrasound signal is acquired as a baseline in a narrow region of interest. • Second, a push pulse is applied along the center of this region of interest. • Third, another conventional ultrasound signal is acquired and is compared to the baseline to obtain tissue displacement. • The more elastic a given tissue element, the more displacement it experiences. This process is repeated for each axial line within the region of interest, as with a conventional B-mode image. • Displacement Strain determines the relative strain or elasticity of tissue. • The higher the strain the softer the lesion; MI: 1.7 SIEMENS 4C1 / *Abdomen-1 Detail " THI / H4.50 M 100% 0 dB / DR 75 SC Off Map A / ST 2 E 2/ P3 T3/BO Stiff tissue is dark, soft tissue light Cooling 4 13fps 10cm 34. 1 Fr79 • A lesion may appear a different shade of gray or color depending on the other tissues in the field of view. • Stiff tissue is dark, soft tissue light • For example, in a patient with normal dense breast tissue and fat, the fat will appear soft as it is the softest tissue in the field of view (FOV). However, if only fat is in the field of view, some of the fat will appear hard because it is the hardest tissue in the FOV VT Imaging demonstrates area of necrosis in tumor Soft region (arrow) 10 Workbook | Workbook Name Notes • VTI can improve detection in very subtle lesions • ARFI displacement images portray different, complementary information then matched to B mode images • Differentiating features between different masses can be identified 2.3 VTi Transducers and Presets • VTI is available on the following transducers and 6C1 HD presets Abdomen • 6C1HD-Abdomen preset • 4C1-Abdomen Preset Image 2D • 4V1-Abdomen Preset • 9L4- Breast and Thyroid Preset TEQ Set • VTi Maximum Depth 6C1HD, 4C1 and 4V1 is 16cm • VTi Maximum depth 9L4 is 6cm Persist 3 Timer Off FR Control Off UR Flip Off UD Flip Off Live Dual Off ASC Dual Off Blopsy Off Features sie EI Virtual Touch Protocol 11 Workbook | Workbook Name 2.4 VTi Scanning Techniques Notes • For best access to the right lobe of the liver, the patient should be positioned either supine or left lateral decubitus • Find a suitable window where the liver can be well visualized by placing the transducer within an intercostal space • Advise the patient to breathe normally and then to momentarily stop breathing 2.5 VTi (Gray Scale) workflow See Appendix A: Virtual Touch™ Imaging Workflow (Gray Scale) 2.6 VTi (Color) workflow See Appendix B: Virtual Touch™ Imaging Workflow (color) 12 Workbook | Workbook Name 3 Virtual Touch™ Quantification This training provides ultrasound technologists and physicians with relevant Notes information to enhance and improve their clinical knowledge of Virtual Touch™ Quantification, also referred to as VTq on the ACUSON S2000™ HELX Evolution and the ACUSON S3000™ HELX Evolution ultrasound systems. This module explains the technology and the clinical background and identifies what is required to successfully utilize and optimize VTq on the ACUSON S2000 HELX and the ACUSON S3000 HELX ultrasound systems 3.1 Objectives By the end of this section, the technologist will be able to • Describe how VTq technology works • Identify scanning techniques used with VTq • Perform a VTq exam 3.2 VTq Technology TRANSDUCER . Shear waves induced by a virtual extended shear REGION OF wave source INTEREST . Detection pulses track SOFT TISSUE .......................... displacement vs. time off axis to the acoustic push STIFF LESION pulse ................................ ............ . Time to Peak (TTP) is measured along each detection beam and speed is computed ...................... . The speed of shear wave propagation is related to tissue stiffness • Virtual Touch™ Quantification provides a numerical value of shear wave speed related to tissue stiffness at a precise anatomical location. • Virtual Touch™ quantification utilizes an acoustic push pulse (orange) to generate shear waves (blue) through a user-placed region of interest. • When detection pulses (green arrow) interact with a passing shear wave, they reveal the wave’s location at a specific time, allowing calculation of the shear wave speed. • This numerical value is related to the stiffness of the tissue within the region of interest. • In general, the more stiff a region of tissue, the greater a shear wave’s speed as it travels through this region. • Thus, the measured shear wave speed is an intrinsic and reproducible property of tissue. • Significant advantages with Siemens’ VTq is that ascites does not affect the ability to perform a measurement, nor does the BMI of the patient, as long as an acceptable ultrasound image can be obtained. • The same transducer used for imaging provides the measurement and does not require any repeat calibrations or any servicing • All technologies and features available on the ACUSON S2000 or S3000 are able to be used, providing a quick and easy assessment of anatomy, physiology of blood flow, and stiffness of tissues. 13 Workbook | Workbook Name 3.2.1 VTq Technical Overview] Notes MI: 1.7 SIEMENS 9L4 / General 2D THI / H8.00 MHZ 100% -7 dB / DR 70 1. Focused push pulse SC Off / DTCE M 2. Shear waves generated Map D / ST 3 Va=1.78 m/s 3. Tracking beams Shear waves Depth=1.8 cm detect shear wave peak 4. Linear regression performed Travel Distance 5. Confidence interval check 6. Shear velocity computed Travel Time Cooling 1 10fps 6cm 4 mx - Fr86 • The system transmits a focused push pulse. • Shear waves are then generated. • Tracking beams along both sides of the ROI will detect the shear wave peak as the wave propagates • A linear regression will be performed by the system along with a confidence interval check. • The shear velocity is then computed. 14 Workbook | Workbook Name Notes 3.3 VTq Transducers and Presets MI: 1.7 IR Vs=2:03 m/s Cooling 0 Depth: 5.4cm 9fps • VTq is available on the following transducers and presets • 6C1HD-Abdomen preset • 4C1-Abdomen Preset • 4V1-Abdomen Preset • 9L4- Breast and Thyroid Preset • VTq Maximum Depth 6C1HD, 4C1 and 4V1 is 8cm • VTq Maximum depth 9L4 is 5cm • ROI Size (Not adjustable): 10 x 5 mm (curved), 5 x 5 mm (9L4) 3.4 VTq Scanning Techniques 1,7 SIEMENS 4C1 / *ABDOMEN Liver General 2D 10 capsule ROI THI / H4,50 MHZ 15 dB / CD 70 SC Apag / DTCE B Mapa C / TE 2 ARFI value Vc=1.27 m/s Depth =3,0 cm ET Depth Blood vessels Gallblader 12cps 9cm • The Intercostal RT Lobe is the best scanning approach • Liver Segment 5 or 8 should be sampled • The ROI should be placed perpendicular to and at least 3 cm from the Liver Surface • Be sure to avoid Vessels & Biliary Structures • Apply minimal scan pressure • Have the patient breathe normally. No deep inhalations or holding of breath is required. • Acquire measurement as patient is asked to stop breathing momentarily. 15 Workbook | Workbook Name 3.4.1 Correct vs. Incorrect technique Notes 201 7 Abdomen #41/ ADOOIT General General THI THE 50 MHZ 100% The / H4 50 MHz SC OH/ OTCEL 0 OB J CR 75 Map D / ST 2 SC ON / OTCEL Map D / ST 2 Vs.X.XX m/s Va-0.81 m/s Depth=3.8 cm Depth=3.8 cm • This is an example of Incorrect transducer placement causing rib shadows (Image on the left) • Image on the right shows the correct transducer placement 3.4.2 Measurements LIVER 7:20:14 AM 12/11/2010 10.12.11-07:16:12-STD-1.3.12.2.110. MI: 1.2 SIEMENS 4C1 / Abdomen General 2D 100% THI / H4.50 MHZ 0 dB / DR 75 SC Off / DTCE L Map D / ST 2 Vs=X.XX m/s Depth=4.0 cm 8fps 14cm X4 0009] ] Fr79 • If xxx appears on the image, it means the shear wave velocity estimate is not valid. • Siemens recommends are using a total of 10 valid measurements per site. • Some might include non-valid measurements • For an acquired data, “X-X-X-X” will appear when the confidence level internally determined by the shear velocity estimation algorithm is below 0.8 on a 0 to 1 scale. • This means that the individual velocity estimates between tracking beams is varying too much to provide a reliable reading. • This is a safety feature to ensure invalid measurements are not misinterpreted. • Similar to a “quality factor”- like feature that has a minimum threshold to provide a reliable reading. • There are a few things that can cause an invalid measurement, individually or in combination: • Excessive tissue motion, such as cardiac pulsations in the tissue that disrupt the shear wave velocity estimate; • High attenuation of the signal in large patients, making it difficult for the system to identify the shear wave peak consistently as it propagates; • Very high stiffness of the tissue that causes the shear wave velocity estimate to become difficult (velocity out of range), lowering the confidence interval. 16 Workbook | Workbook Name 3.5 VTq Workflow Notes See Appendix C- Virtual Touch™ quantification (VTq) Workflow (Liver). 3.6 VTq Reporting Abdomen Shear Velocity Measurements Site 1 Site 2 Site 3 Vs (m/s) Depth (cm) Vs (m/s) Depth (cm) Vs (m/s) Depth (cm) 0.91 4.3 1.36 4.2 1.13 4.3 0.81 4.3 1.17 3.4 1.21 2.8 0.89 4.7 1.07 4.1 1.15 3.3 0.89 4.4 1.07 4.0 1.16 3.8 0.83 4.6 1.09 3.6 1.19 3.3 10 10 10 1010 0.73 4.8 .15 3.6 1.07 3.1 0.94 4.2 1.15 3.4 0.80 3.9 IQR and 1.07 3.3 0.89 3.8 Median 1.29 3.1 1.14 2.9 Median 0.89 1.12 1.15 Mean 0.85 1.15 1.16 Std Dev 0.07 0.11 0.06 IQR 0.09 0.10 0.06 Overall Statistics Median 1.077 Std Dey 0.16 Mean 1.05 IQR 0.26 • This is a copy of the patient report for 1 site measured. • Under the Site column you will see the different measurements taken. • The depth column corresponds to the depth each measurement was taken at. • A recommended method for determining technical adequacy of a Virtual Touch™ tissue quantification result is an IQR/Median shear velocity ratio of 0.3 or less. • This method improves comparability of data from patient to patient, but does not constitute a fixed manufacturer recommended protocol. • To delete a measurement click on the shredder icon next to the number 17 Workbook | Workbook Name 4 Virtual Touch™ IQ This training provides ultrasound technologists and physicians with relevant Notes information to enhance and improve their clinical knowledge of Virtual Touch™ IQ on the ACUSON S2000™ HELX Evolution and the ACUSON S3000™ HELX Evolution ultrasound systems. This module explains the technology and the clinical background and identifies what is required to successfully utilize and optimize VTIQ on the ACUSON S2000 HELX and the ACUSON S3000 HELX ultrasound systems 4.1 Objectives By the end of this section, the technologist will be able to • Explain how VTIQ technology works • Identify scanning techniques used with VTIQ • Perform a VTIQ exam 4.2 VTIQ Technology B Mode Elasticity Imaging VTIQ • Combination of Image and Quantification for higher diagnostic confidence • Newest version of Acoustic Radiation Force Impulse technology • High spatial resolution for visualization and quantification of heterogeneity in focal lesions • Higher reproducibility and repeatability than conventional elastography . Each "Phase" is focused at a specific depth location for maximum uniformity and excitation response 0 N/2+1 N/2+2 Phase I 0 N/2+1 N/2+2 Phase II Tracking vectors Excitation pulses VTIQ ROI ---- Each "Phase" is focused ata specificdepth location for maximum uniformity and excitation response Instead of pushing multiple times on the same location with short pulse repetition interval as used on Virtual Touch ™ Quantification, Virtual Touch IQ uses up to two phases of acquisitions One is used if ROI height is 1.5 cmor less, and two are used in larger ROI sizes Each phase is walked across the transducer aperture, alternating the spatial locations in the field of view • Adjustable ROI is utilized. • Once initiated, the push pulse steps methodically across the ROI numerous times depending on width. • Depending on image depth and ROI settings, there can be up to 256 push pulses and tracking vector sequences sent from the transducer 18 Workbook | Workbook Name Notes • The height of the VTIQ ROI will determine if there will be 1 or 2 phases. • When the ROI height is set to greater than 1.5 cm in size, a second phase is used to ensure uniformity throughout the entire ROI. There are two phases, or “halves” to the image. One stacked on top of the other. 4.2.1 Image Display Maps Shear Wave Velocity Shear Wave Quality SIEMENS SIEMENS Shear Wave Travel Time Shear Wave Displacement • VTIQ includes 4 image display maps to aid with interpretation of the image: Velocity, Quality, Time and Displacement • This is a phantom example of imaging a hard inclusion with the 4 maps available with VTIQ. Velocity Map • Velocity depicts the range of shear wave Shear Wave Velocity velocities from minimum to maximum. HOMENS • Shear wave velocity is slower in soft tissue and faster in stiff tissue. • The color bar displays the minimum and maximum range of the shear wave velocity. • The Shear Velocity ROI is 1.5mm x 1.5mm • Note: You can perform measurements only when the Shear Wave setting is Velocity 19 Workbook | Workbook Name Notes Quality Map Shear Wave Quality 1.0 _ HI Reliable SW Velocity estimate 0.87 ---- SW Velocity estimate may be unreliable 0.75 0.5 SW Velocity estimate not possible • Used to confirm that the shear wave formation was adequate and identify regions of the shear wave image where shear wave velocity estimations may be artificially low due to poor shear wave signal quality. • For example, in some exceptionally stiff breast lesions, it can be difficult to adequately visualize and measure shear wave velocities in the lesion because of high tissue attenuation. • Shear wave velocity measurements are reliable in locations of high signal quality and these locations are represented in green. • Measurements are unreliable in locations of low signal quality and these locations are represented in yellow/orange. • When the shear wave quality is orange/red, shear wave velocities cannot be estimated and the Velocity, Time and Displacement maps displays only 2D – mode information. • Use the quality map to indicate where shear wave velocity measurements should be taken, which are the green areas in the Quality display. • The graph depicts the use of color to represent shear wave quality. • The color indications in the Quality map help identify locations in the Velocity map where shear wave velocity estimations are reliable, may be unreliable, or could not be estimated. • The values in the left column indicate the quality index calculated by the system software. • Index values of 0 and 1.0 represent the minimum and maximum quality. • A threshold of 0.75 is used to determine that estimates of shear wave velocity are not possible. • When the quality index is below 0.75, the system displays only 2D-mode information 20 Workbook | Workbook Name Time Map Notes • Represents the relative travel time Shear Wave Travel Time differences of shear waves within the image • Can improve boundary definition in structures with elevated shear wave velocities. Displacement Map • Use to improve visualization of structural boundaries where large differences in Shear Wave Displacement shear wave amplitude can occur. • Indicates the relative differences of shear wave magnitude in the image and are represented in shades of blue. • The lightest blue represents the highest relative displacement magnitude. • Shear wave displacement is typically lower in very stiff tissue compared to softer tissue. • Correlate the Displacement map to the Quality map to understand if poor shear wave quality may be related to low shear wave displacement. • In general, high shear wave velocity (stiffness) is associated with low shear wave displacement. 21 Workbook | Workbook Name 4.3 VTIQ Transducers and Presets Notes BREAST 11:51:36 AM 9/17/2013 13.09.17-11:10:48-DST-1.3.12.2 ... SIEMENS 9L4 Breast Detail TIB: 0.6 2D -- 100% THI H9.00 MHZ OdB DR65 SC Off DTCE M MapE/ ST3 SW Velocity - Vs=6.20 m/s Depth=1.1 cm X Vs=5.77 m/s Depth=1.4 cm › Vs=4.77 m/s Depth=1.3 cm 4cm > Vs=3.19 m/s Depth=1.8 cm • VTIQ is available on the following transducers and presets • 9L4- Breast, Thyroid. • VTIQ Maximum Depth is 4cm • Maximum Velocity: 10 m/sec • The Shear Velocity ROI is 1.5mm x 1.5mm • Adjustable Shear Wave Velocity Scale for Color Coded display • Allows for stiffness visualization of lesions in one image with color coded display and localized velocity measurements 22 Workbook | Workbook Name 4.4 VTIQ Scanning Techniques Notes 20-100% • Identify the Maximum Vs in the Velocity Mode • Use the Quality Mode to verify Vs is valid in region of Max Vs • Avoid Vs measurements in regions of Low Quality • Adjust the Vs Scale if the measured Vs exceeds the max scale (High will be noted in the Vs measurement) then re-measure • Black Regions (See through to B mode) indicate that Vs in not measurable (low viscosity cysts) • High viscosity cysts with Shear Waves present appear Blue • Use mild compression 4.4.1 Hard lesions • Identify and measure Maximum Vs in the Velocity map • Use Quality map to verify Vs is valid in the region of Maximum Vs • Avoid Vs measurements in regions of low quality • Adjust Max Velocity scale if the measured Vs exceeds default setting • Black regions (see through to B-mode) indicate Vs not measurable 23 Workbook | Workbook Name 4.4.2 Cysts Notes • Low viscosity cysts should appear black (see through to B-mode) • High viscosity cysts with shear waves present appear blue • Displacements may be high in cystic structures relative to tissue • Soft Lesions • Low Vs– consistent with surrounding fat and fibroglandular tissue • Use Quality map to confirm normal displacements and high quality 4.4.3 VTIQ Image Screen Layout Led weber 200006 Calcs 2D SIEMENS Breast General TIS:0.5 TIB 0.5 Compound 134ps 20-100% THI Shadow On H8.00 MHZ 28B DRES Labels CTIS SC On Breast DICEM DE/ST3 Page 1 L Mass 1 Vs-High Mass 2 0 Depth= 1.3 cm Mass 3 0 It Vs-High Site 1 0 Depth=0.8 cm Site 2 0 Vs=1.02 m/s Site 3 0 Depth=1.0 cm Va=3.70 m/s Site 4 0 Depth=1.2 cm Lesion 1 0 Lesion 2 0 Lesion 3 0 Lesion 4 0 Cooling 3 Site 1: 4 Valid/6 Total 4cm 1 -Virtual Touch™ IQ region of interest 2 -Color bar 3 -Measured results for shear wave velocity 4 -Measurement counter 5 -Measurement marker Measurement marker with unique identifier. 6 -Virtual Touch™ IQ measurement labels 7 -Virtual Touch™ IQ measurement tool 8 -Cooling Timer 24 Workbook | Workbook Name 4.4.4 Image Display Maps Notes B • Rotate the LCD control A to cycle through the different display setting maps (Velocity, Quality, Time and Displacement) 4.5 VTIQ Workflow See Appendix D: Virtual Touch™ IQ (VTIQ) Workflow 4.6 VTIQ Measurements and Reporting "> ? Calcs 20 SIEMENS 914 Breast General TIS: 0.5 TIB:0.5 Compound 4 13fps 2D-100% THI Shadow On H8.00 MHZ 2dB DR65 Labels CTI1 SC Off Breast OTCEM MapE/ST3 Page 1 SW Velocity R M L Mass 1/ Vs=High Mass 203 Depth=1.3 cm Vs=High Site 1 0 Depth=0.8 cm Site 2 0 % Vs=1.02 m/s Site 3 0 Depth=1.0 cm Vs=3.70 m/s Site 4 0 Depth=1.2 cm Lesion 1 0 Lesion 2 0 Lesion 3.0 Lesion 4 D 4cm Fr76 • Shear Wave Velocity calipers • Multiple (up to 24) calipers can be used • Only enabled in SW Velocity map • All other measurement tools accessible 25 Workbook | Workbook Name 4.6.1 Measurements Out of Range Notes SIEMENS 9L4 Breast Detail TIS: 0.6 TIB: 0.6 MI: 1.5 14fps 2D-100% THI H9.00 MHZ OdB DR65 SC Off DTCEM MapE/ST3 SW Velocity Vs=High Depth=1.4 cm X Vs=High Depth=1.1 cm Vs=4.10 m/s Depth=1.9 cm 4cm Vs=2.62 m/s Depth=0.9 cm • If you perform a measurement within the region of interest (ROI) that exceeds the current maximum velocity setting, the measured results display Vs=High appears • If you perform a measurement within the ROI that is lower than the current minimum velocity setting, the measured results display Vs=Low appears • The measured results display NA if the shear wave was not detected within the ROI or if you perform a measurement outside of the ROI. 1.5 3.0 Velocity A B • To adjust the range of velocities displayed press the LED control B to display either [Max Velocity] or [Min Velocity on the LED panel. • To change the maximum velocity displayed, rotate [Max Velocity]. • To change the minimum velocity displayed, rotate [Min Velocity]. • The system updates the shear wave velocities in the region of interest and the color or gray bar to depict the velocities within the selected range. • The selected maximum and minimum velocity values are displayed above and below the gray bar or color bar. 26 Workbook | Workbook Name 4.6.2 VTIQ Reports Notes VTIQ measurements can be labeled and stored calcs 2D MI: 1.0 • to the report Compound Shadow Off Labels Breast Page 1 R L O Mass 1 0-Mass 2 0-Mass 3 0_ Site 1 O Site 2 O Site 3 Labeled O Lesion 1 O-Lesion 2 measurements (to 0- Lesion 3 O Lesion 4 save to report) Patient Report Patient Information Breast Breast Shear Velocity Measurements Comme Images Labeled Site 2 Lesion 1 Depth [cm) Vs [m/s) Depth (cm) Vs (m/s) Depth (cm) 6.49 20 @ 3.50 1.6 5.94 2.1 @ Measurements 5.60 22 2.1 5.53 22 'Delete" 6.42 22 3 6.03 2.1 4.89 Median 5.51 Mean 5.60 0.20 Statistics (Like Overall Statistics Virtual Touch ™ Median Mean 5.23 Std Dev 4.90 FOR 1.15 Quantification ) 2.02 Comments End Exam New Patient Print Report Store Report • This is an example of a breast report. • Multiple measurements in one location will improve accuracy of a mean or median value • Measurements can be delete from the report by clicking the “shredder” icon 27 Appendix A: Virtual Touch™ Imaging Workflow (Gray Scale) 28 Virtual Touch™ Imaging Workflow (Gray Scale) 1. Optimize the 2D image: Click the Virtual Touch Imaging icon. 6C1 HD SIEMENS Abdomen 601 HD Image 20 Abdomen General TEQ Set TIS: 0.5 Persist 3 TIB: 0.5 MI: 1. Timer Off 29fps FR Control Off 2D - 100% THI LIR Flip Off H4.00 MHZ UID Flip Off 11dB DR65 ASC 3 Live Dual Off DTCEM ASC Dual Off MapE/ST2 Biopsy Off Features Sie El Virtual Touch Protocol Virtual Touch Imaging 2. Use the trackball and Next key to adjust the position and size of the ROI box (over the area of interest). 6C1 HD Abdomen Image 20 TEQ Set TIS: 0.5 Persist 3 TIB: 0.5 Timer Off MI: 1.4 11fps 20- 100% UR Flip Off THI H4.00 MHZ UID Flip Off 6dB DR65 Live Dual Off SC Off DTCEM ASC Duat Off MapE/ST2 Blopsy Off Features Sie Virtual Touch Protocol SIEMENS www.usa.siemens.com/healthcare 29 3. Press Update to begin start acquisition. Image freezes and displays VTI acquisition. SIEMENS 6C1 HD Abdomen General TIS:0.7 TIB: 0.7 20- 100% THI H4.00 MHZ 6OB DR65 SC Off DTCEM MapE/ST2 13cm 4. To exit VTI, click Virtual Touch Imaging or, press 2D. 13.10.17-10:08 6C1 HD Abdomen Image 2D TEQ Set Persist 3 Timer Off FR Control Off L/R Flip Off U/D Flip Off Live Dual Off ASC Dual Off Biopsy Off Features Sie El Virtual Touch Protocol Virtual Touch Imaging SIEMENS 30 www.usa.siemens.com/healthcare Appendix B: Virtual Touch™ Imaging Workflow (Color) 31 Virtual Touch™ Imaging Workflow (Color) 1. Optimize the 2D image: Click the Virtual Touch Imaging icon. 6C1 HD SIEMENS Abdomen 601 HD Image 20 Abdomen General TEQ Set TIS:0.5 Persist 3 TIB:0.5 MI: 1.4 Timer Off 29fps FR Control Off 2D -- 100% THI L/R Flip Off H4.00 MHZ U/D Flip Off 11dB DR65 ASC 3 Live Dual Off DTCEM ASC Dual Off MapE/ST2 Blopsy Off Features Sie El Virtual Touch Protocol Virtual Touch Imaging 2. Use the trackball and Next key to adjust the position and size of the ROI box (over the area of interest). 6C1 HD SIEMEN Abdomen Image 2D TEQ Set Persist 3 Timer Off FR Control Off UR Flip Off UD Flip Off Live Dual Off ASC Dual Off Biopsy off Features Sie E Virtual Touch Protocol 3. Double-click Update. This will display a full screen image. SIEMENS 32 www.usa.siemens.com/healthcare 4. Press Update again to display VTI with color map. Image freezes and displays Color VTI acquisition. Note: System counts down time until transducer is cooled. SIEMENS 601 H Abdomen 20 %. 100% TH H4.00 MHZ 6dB DR65 sc Of DTCEN MapE/ST2 Cooling 1 13cm 5. To exit VTI, click Virtual Touch Imaging or press 2D. 6C1 HD 13.10.17-10:08 Abdomen Image 2D TEQ Set Persist 3 Timer Off FR Control Off L/R Flip Off U/D Flip Off Live Dual Off ASC Dual Off Biopsy Off Features Sie El Virtual Touch Protocol Virtual Touch Imaging SIEMENS www.usa.siemens.com/healthcare 33 Appendix C: Virtual Touch™ quantification (VTq) Workflow (Liver) 34 Virtual Touch™ quantification (VTq) Workflow (Liver) 1. Position patient in the left lateral decubitus position with right arm in maximum abduction. The best approach is through the right intercostal spaces. The transducer should be parallel to the ribs to reduce rib shadowing. VTq measurement should be acquired on arrested respiration. Deep inspiration is to be avoided due to potential effect on liver stiffness. 1.7 SIEMENS ........ 4C1 / *ABDOMEN Liver General capsule 2D 10 RO THI / H4,50 MHZ 15 dB / CD 70 SC Apag / DTCE B Mapa C / TE 2 ARFI value Vc=1.27 m/s Depth =3,0 cm Depth Blood vessels Gallblader 12cps 9cm TA Con Fr34 2. Once the appropriate window is obtained, activate from the Virtual Touch menu. 6C1 HD Abdomen mage 2D TEQ Set Persist 3 Timer Off FR Control Off L/R Flip Off UID Flip Off Live Dual Off ASC Dual Off Biopsy Off Features Sie Virtual Touch Protocol 3 sec eSieScan™ Protocols Pause Protocol End Protocol Show All Views Add View Rename View SIEMENS 35 www.usa.siemens.com/healthcare 3. Choose Liver Assessment to designate the site you are measuring and allow measurement data to be stored in the report. 6C1 HD Abdomen Image 2D TEQ Set Persist 3 Timer Off FR Control Off L/R Flip Off U/D Flip Off Live Dual Off ASC Dual Off Biopsy Off Liver Assessment Features Sie El Virtual Touch Protocol 4. Under the assessment menu choose either the site number or the liver segment. 6C1 HD Abdomen Image 2D TEQ Set Persist 3 Timer Off FR Control Off L/R Flip Off UID Flip Off Live Dual Off ASC Dual-Off Biopsy Off No Label Site 1 Site 3 Site 4 Lesion 1 Lesion 2 Lesion 3 Lesion 4 Liver Segment 1 Liver Segment 2 Liver Segment 3 Liver Segment 4A Liver Segment 4B Liver Segment 5 Liver Segment 6 Liver Segment 7 Liver Segment 8 5. Once an option is selected from the Liver Assessment drop-down, all subsequent measurements will be assigned the same label until either a new label is selected or a new patient VTq. As additional VTq measurements are taken, there will be a Total/Valid count indicator for the selected Liver Assessment label. 10 measurements per site are recommended to ensure statistical adequacy. When moving on to a different site or Liver Segment, open the Liver Assessment menu and select the desired label. SIEMENS 6C1 HD Abdomen General TIS: 0.8 TIB: 1.7 MI: 1.6 6fps 2D- 100% THI 5dB DR65 Sc Off DTCE M MapE/ST2 Liver Segment Depth=4.4 cm Cooling 3 Iver Segment 8: 2 Valid/2 Total 18cm VTq ROI is perpendicular to and approximately 2 cm below the liver capsule. 36 SIEMENS www.usa.siemens.com/healthcare 6. Cursor should be positioned at least 2 cm below and perpendicular to the liver capsule. SIEMENS 6C1 HD Abdomen General TIS: 0.8 TIB: 1.7 MI: 1.6 6fps 2D-100% TH H4.00 MHZ 5dB DR65 SC Off DTCE M MapE/ST2 Liver Segment Vs=1.74 m/s Depth = 4.4 cm Cooling 3 8: 2 Valid/2 Total 8cm 7. Once cursor is properly positioned instruct the patient to stop breathing and select Update. VTq measurement should be acquired on arrested respiration. Deep inspiration is to be avoided due to potential effect on liver stiffness. System will automatically freeze the image and acquire a shear wave value. The value is displayed in m/sec. NOTE: Advise the patient to breathe normally and to momentarily stop breathing and then take measurements. Avoid taking measurements during deep inspiration and breath hold as the literature cites that this action increases central venous pressure. Elevated central venous pressure can artificially elevate shear wave velocity measurements. SIEMENS 6C1 HD Abdomen General 20 - 100% THI H4.00 MHZ 5dB DR65 SC Off DTCE M MapE/ST2 Vs=2.17 m/s Depth= 4.8 cm Cooling 3 17cm 8. During Virtual Touch quantification acquisition, shear wave measurements may occasionally display as "X.XX m/s" in the measured results. This result indicates measurement failure and is typically caused by a low shear wave signal-to-noise ratio (SNR). 601 H Abdorma Site 1 Vs=XXX m/s Depth=4.0 cm 2D- 10099 de DROP SC Off MBDE IST2 Cooling 3 16cm B mode image is suboptimal, causing shear wavevelocity measurement failure. SIEMENS 37 www.usa.siemens.com/healthcare 9. The system will display an onscreen progress bar that counts down time until transducer is cooled and ready to acquire again. NOTE: Be sure to store data after each acquisition to ensure that the measurement is entered into the report. SIEMENS 6C1 HD Abdomen General TIS: 0.9 TIB: 1.7 MI: 1.6 7fps 2D- 100% H4.00 MHZ 5dB DR65 SC Off DTCEM MapE/ST2 Vs=2.17 m/s Depth=4.8 cm Cooling 3 7cm 38 SIEMENS www.usa.siemens.com/healthcare Appendix D: Virtual Touch™ IQ (VTIQ) Workflow 39 Virtual Touch™ IQ (VTIQ) Workflow 1. To activate Virtual Touch IQ (VTIQ), click VTIQ on the image menu. The system activates a full screen format and displays a region of interest (ROI). Note: Color data and the Virtual Touch IQ color bar are displayed only in a full-screen format. In Dual-screen format, the system displays gray scale data and a gray bar. 6C1 HD Abdomen Image 2D TEQ Set Persist 3 Timer Off FR Control Off L/R Flip Off U/D Flip Off Live Dual Off ASC Dual Off Biopsy Off Features Sie El Virtual Touch Protocol 2. To adjust the adjust the size or position of the region of interest (ROI) prior to acquisition, press NEXT to activate either the positioning or sizing function for the ROI. Roll the trackball to reposition or resize the ROI. 0 SIEMENS 40 www.usa.siemens.com/healthcare 3. Press update to begin acquisition. 4. The system acquires a single image frame and then freezes the image and applies the velocity image display setting. During system freeze, a timer indicates the remaining time (in seconds) until the transducer is available for image acquisition. BREAST 11:30:50 AM 9/17/2013 13.09.17-11:10:48-DST-1.3.12.2. SIEMENS 91.4 Breast Detail MI: 1.5 20-100% THI H9.00 MHZ OdB DR65 SC Off DTCEM MapE/ ST3 SW Velocity Cooling 2 4cm 5. The system has 4 image display settings. Velocity, Quality, Time, and Displacement. To cycle through the different display settings rotate LCD control A. Showr Max Wave Velocky Velocity 6.5 1 A B SIEMENS www.usa.siemens.com/healthcare 41 6. Dual: In a dual-screen format, the system displays the 2D image on the left side and the ROI with the shear velocity data on the right side. To activate a dual display format, double-click UPDATE. The left image displays the ROI. The right image is blank. Click update again to display dual image. 7. To reactivate Virtual Touch IQ acquisition after the automatic freeze period ends:  Press GAIN FREEZE/CINE  Adjust the ROI size and position, if necessary  Press UPDATE to begin acquisition 8. You can measure the shear velocity anywhere within the region of interest. You can perform multiple shear velocity measurements on a single acquisition. To measure the shear velocity during system freeze, click Shear Velocity on the measurement menu. Note: You can perform measurements only when the Shear Wave setting is Velocity. ? Calcs 2D Compound Shadow on Labels Breast Page 1 R M L Mass 1 / Mass 2 0 Mass 3 0 Site 1 0 Site 2 0 Site 3 0 Site 4 0 Lesion 1 0 Lesion 2 0 Lesion 3 0 Lesion 4 0 9. Position the measurement caliper and then press SELECT. The stem displays the measured results for shear velocity in meters per second (m/s). SIEMEN Breast 2D- 100% THI H9.00 MHZ OdB DR65 SC Off DTCEM MapE/ST3 SW Velocity Vs=6.89 m/s Depth=1.1 cm X Vs=5.96 m/s Depth=1.2 cm Vs=7.26 m/s Depth=1.9 cm Vs=6.83 m/s Depth=1.5 cm SIEMENS 42 www.usa.siemens.com/healthcare 10. To adjust the range of velocities displayed press the LED control B to display either [Max] Velocity or [Min] Velocity on the LED panel. To change the maximum velocity displayed, rotate [Max Velocity]. To change the minimum velocity displayed, rotate [Min Velocity]. The system updates the shear wave velocities in the region of interest and the color or gray bar to depict the velocities within the selected range. The selected maximum and minimum velocity values are displayed above and below the gray bar or color bar. Note: If you perform a measurement within the region of interest (ROI) that exceeds the current maximum velocity setting, the measured results display HIGH for the shear velocity value. If you perform a measurement within the ROI that is lower than the current minimum velocity setting, the measured results display LOW. The measured results display NA if the shear wave was not detected within the ROI or if you perform a measurement outside of the ROI. 8.0 Shear Max Wave Velocity Velocity 6.5 1 A B 0.5 m/s 11. To Exit Shear Velocity Imaging, Click Virtual Touch IQ. Or, press 2D. 6C1 HD Abdomen Image 2D TEQ Set Persist 3 Timer Off FR Control Off L/R Flip Off U/D Flip Off Live Dual Off ASC Dual Off Biopsy Off Features Sie El Virtual Touch Protocol SIEMENS www.usa.siemens.com/healthcare 43 On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States. The information in this document contains general technical descriptions of specifications and options as well as standard and optional features which do not always have to be Local Contact Information present in individual cases. Siemens Medical Solutions USA, Inc. Siemens reserves the right to modify the 51 Valley Stream Parkway design, packaging, specifications and options Malvern, PA 19355-1406 described herein without prior notice. Please USA contact your local Siemens sales representative Telephone: +1-888-826-9702 for the most current information. www.usa.siemens.com/healthcare Note: Any technical data contained in this document may vary within defined tolerances. Global Business Unit Original images always lose a certain amount Siemens Medical Solutions USA, Inc. of detail when reproduced. Ultrasound 1230 Shorebird Way Mountain View, CA 94043 Order No. A914CX-CS-14506-P1-4A00 USA Printed in USA 06-2014 | All rights reserved Telephone: +1-888-826-9702 © 2014 Siemens Medical Solutions USA, Inc. www.usa.siemens.com/healthcare Global Siemens Headquarters Global Siemens Healthcare Siemens AG Headquarters Wittelsbacherplatz 2 Siemens AG 80333 Muenchen Healthcare Sector Germany Henkestrasse 127 91052 Erlangen Germany Telephone: +49 9131 84-0 www.siemens.com/healthcare www.siemens.com/healthcare