Gout Imaging with Dual Energy

Hello everybody, my name is Doctor Heistand. I'm probably at the Department of Radiology at the University Hospital of Elegant today. I would like to give you a little overview about school teaching with dual energy CT. Gold is a chronic disease with the deposition of monastery murati crystals around the joints. It's a common and treatable form of an inflammatory arthritis. The prevalence of gold is quite high. It's given with around 3 to 6% in men and 1 to 2% in women in Western countries. It can have important negative effects on the musculoskeletal function and health related quality of life. The most common side of involvement is the first metatarsophalangeal joint. To perform the diagnostic gold standard, you have to perform in invasive puncture of the joint to confirm the presence of monocyte amuri crystals by polarizing light microscope you. You also can perform blood testings to get the serum urate levels. The same uric levels alone are not sufficient for the diagnosis of gout. In addition, you also can perform different types of imaging. You can use the radio graphs, but radiographs are usually normal in the beginning when the first presentation of the clinical symptoms in patients with gouts. You also can perform ultrasound examinations, which might show features of monocyte impurity crystal, the position with into joints, and of course you can run a dual energy CT which facilitates the visualization of the D position of euro to exit crystals around or within the joints by color coding them. Already in the year of 2014, dual Energy City was supposed by several rheumatologists for the diagnostic work up of asymptomatic patients with heavy your keemia dual energy city has become a relevant part in the diagnostic investigation of Gold Dual energy CT has the highest possible value, contributing to the recommended gout scoring system by the American College of Rheumatology and European League Against Rheumatism. Dual Energy City is basically a city which uses two different X Ray photos spectrums to create the images. The goal is to enable a differentiation classification of the tissue composition. Dual energy cities vary among the different city vendors. In the case of Siemens, there are three different dual energy city approaches which enable at the acquisition of Dual Energy CT for gout. First the dual spiral dual energy approach which uses repeated measurements of different voltages. Second, the twin beam Dual Energy, which uses a single source system with split filter technique. In 3rd Dual source dual Energy City approach using a dual source system with two detector arrays. On this slide you can see an example of a patient with gout acquired with the dual spiral dual energy CT approach. This repeated approach with different cavey and different in A levels is also recommended by Siemens because of the better spectral separation. You also can use the Twin beam dual energy CT approach to acquire gold imaging. This approach allows a simultaneous acquisition of high and locate the datasets in a single specter CT scan by splitting the X Ray beam with the two filters before it reaches the patient. And of course you also can use the dual source dual energy approach. In this case, two city datasets are acquired simultaneously with different kavian different MA levels, which are also allows. The visualization of Urity position. In our institution we have good experience with both Twin Beam, dual energy and tool source tool energy. You can use the preinstall settings of segments which guarantee is sufficient image in quality. This table provides a comparison of the examination protocols of the already seen examination of the feet and actually there are no relevant differences. Here on this slide you can see the typical positioning of the outstretched hands of a patient. For a dual energy CT scan for gold imaging in our institution, replace the hands quite close together. However, Siemens does not recommend a such a replacement. They recommend a wider distance between the hands to reduce possible artifacts, but we have not had any bad experience with this positioning at all. But the imaging itself replace the hands on a pillow to put the hands into the ISO center of the CT scanner. Without the pillow, the table would be too low and. And we also place a needle on the right hand side which can faciliate the later reading. And it does not make any add effects at all. Here you can see a nice example of a patient without the deposition of uric crystals. You can see the outstretched hands in the needle on the right hand side. On this slide you can see the positioning of the feet. The feet push against a box to have the foot sole almost in plain. For the imaging interpretation, you have to look for the presence of the color coded urate crystals at the articular periarticular sites. But you have to be aware of the artifacts, especially around the nail bed and the skin. But there are also some submillimetre or motion artifacts and also beam hardening artifacts or vascular artifacts which will see on the next slides. In this example you can see. The Europe deposition, which is color coded in green but the green signal around the nails of the big toes is an air effect which is commonly observed at this site. In the clinically routine, you can remove the areas around the nails to get reliable results of the total volume. This is an example. Of submillimeter and also vascular effects. On this slide you have a lot of supposed uriti position, but as you can see the you T position is secondary to motion add effect. If you want to perform follow-up examinations, you have to use the same settings to get reliable results. In this example, you can see what happens if you change the ratio with increasing the ratio you increases the sensitivity and then if they change the total volume of the you ready position. This is an example of a patient with a follow up examination with the same settings. After two months you can see the reduction in the total volume of the uriti position. And now will go on with a little demonstration in single via. Select the patient in the patient browser and open the patient by double clicking on the dual energy workflow. Open the gold application. Now you can look for the color coded green areas. Here in this example you have color coded areas around the big toes and as you can see we have a lot of color coded areas around the nails in this case. These are artifacts to get reliable results of the total volume which is given here. You have to remove these add effects or you can remove it. And now we have already used but reliable volume of the urity position in this patient. In conclusion, gout is a very common disease and the prevalence of God will increase over the next decades. There are many patients with poorly control disease. You can use the dual energy city approach as a noninvasive. Method for diagnostic work up. But be aware of artifacts when reading the images, use the same settings for your follow up examinations to get reliable results. Thank you very much.

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Asymptomatic disease Symptomatic disease Results 0,95 0,95 cm' V: 1.51 cm3 V: 0.95 cm3 1,54 cm3 1,54 crn3 • Gold standard: confirmation of monosodium urate crystals by For the proper use of the software or hardware, please always use the Operator Manual or Instructions • Chronic disease of deposition of monosodium urate crystals • Presence of color-coded urate at articular or periarticular site • Same settings for follow-up examinations Chronic disease of deposition of monosodium urate crystals • with Dual Energy Dual Energy CT Prevalence of gout is increasing wi Dual Energy Presence of color-coded urate at articular or periarticular site • TwinBeam Dual Energy • Dual Spiral Dual Energy • Dual Source Dual Energy Energy SPECIAL ARTICLE to reproduce any photograph showing recognizable persons. for Use (hereinafter collectively "Operator Manual") issued by Siemens Healthineers. This material is to be Gout imaging Rafael Heiss Gout imaging with Stage A stage D stage B stage D stage B polarising light microscopy CT that uses two x-ray photon spectrums to create images • Common and treatable form of inflammatory arthritis • Nailbed, skin, submillimeter, motion, beam hardening, and vascular • Many patients have poorly controlled disease Slice collimation [mm] 64 x 0.6 128 x 0.6 At high risk for Advanced gout SIEMENS in this training will not be updated on a regular basis and does not necessarily reflect the latest version of gout but without deposition depositionson deposition with deposition onth deposition requiring Differentiation and classification of tissue composition 2015 Gout Classification Criteria Serum urate testing artifacts should not be interpreted as DECT evidence of urate MSU crystal of MSU crystal without signs or prior or current specialized Scan time [s] • DECT: non-invasive diagnosis • Prevalence of gout is 3-6% in men and 1-2% in women • Dual Source Dual Energy wi Dual Energy symptoms of episodes of gout interventions • with Dual Energy • Dwil Sal Dual Energy • DECTs vary among CT vendors gout deposition CC (MC Imaging: Tube voltage [kV] The Operator Manual shall be used as your main reference, in particular for relevant safety information AuSn 120 80/Sn150 • Important effect on musculoskeletal function and health-related RIO RI • Dual Spiral Dual Energy An American College of Rheumatology/European League Against Rheumatism • Radiographs Radiographs 1.51 cm' 1,51 cm' 1.51 quality of life Eg. Individuals Eg. Individuals Effective mAs 329 215/150 • Same settings for follow-up examinations Collaborative Initiative local Siemens organization for further details. Thank you for your attention. V: 19.82 cm3 V: 29.87 crn3 V: 1.82 cm3 with with current or with • TwinBeam Dual Energy 1st scon 1st scan • Ultrasonography hyperuricaemia hyperuricaemia previous gout Tophi Fun Knochel S3 Findings Navigator and examples only. 'i • Most common site of involvement is the first metatarsophalangeal CTD1vol [mGy] 9.6 9.1 flares but no but no • Chronic gouty • Dual Energy CT (DECT) • Dwil Spiral Dual Energy • with Dual Energy Dual Source Dual Energy • Dual Spiral Dual Energy • TwinBeam Dual Energy arthritis symptoms or signs of gout, signs of gout, Radiographs • Radiographic 2nd scan 1st scan joint 80 scan and no evidence and with of MSU crystal Double contour sign on US Dalbeth et al. Neto et al. • Tophus on US Ann Rheum Dis, 2014 • Urate Universitätsklinikum deposition V: 2.45 cm3 V: 2.45 crn3 V: 24.81 cm3 V: 19.82 cm3 V: 11.56 cm3 Erlangen Neogi et al. Ann Rheum Dis, 2015 Dalbeth et al. Lancet, 2017 Universitätsklinikum Unlversltätskllnikum • crystals On Glazebrook et al. Radiology, 2011 Neto et al. Neto et al., https://usa.healthcare.siemens.com/ Erlangen Ogdie et al. Ann Rheum Dis, Oeogdie et al. Ann Rheum Dis, Oeogdie et al. Ann Rheum Dis, 2015 Neogie et al. Ann Rheum Dis, Neogi et al. Ann Rheum Dis, 2015 Neogi et al. Ann Rheum Dis, Neogi et al. Ann Rheum Dis, 2015 microscopy Mallinson et al. Am J Roentgenol, 2014 https://www.healthcare.siemens.com/ https://www.healthcare.siemens.com, 2016 2015 10:00