Twin Beam Dual Energy Workflow

Hello everyone and welcome to ICT 2017 and it gives me great pleasure to speak to you regarding Twin beam, dual energy workflow and how to set up protocols for direct transfer to PAX. I don't. I don't hope to have mouse problems. OK, it's more disclosure. OK, I would like to begin this talk by talking about a little bit about experience with the different methods of scan acquisitions that we have our experience. Multiple part was in 2006 with a definition flash. But now we have two so matone forces 1 Ed and one an outpatient facility and it's pretty much the word course of our dual energy scanning from 7 to 7. We do approximately an average of 140 cases a day. And it seems to always be running and the benefit of this particular scanner, as you heard in other talks, is that you have two independent tubes and they run independently and have the kind of. Power behind it to deliver the kind of energy separation of the energy Spectra there. So it's really good and we do all dual energy CT on this machine. We then acquired aid on Edge scanner early on and it was a different type of acquisition, a bypass acquisition, one at high KVP and then followed rapidly by Aloke AVP and this kind of protocols here were used for like stone. Protocols and as well as modern metal artifact reduction. And that's been our experience with the dual spiral building and G acquisition on an edge. Then we upgraded to the twin Beam, which allowed us to do dual energy with a single pass. So in particularly carotid angiograms we were able to remove our neural DSA protocol and then just do carotid angiograms with one pass. So in essence saving radiation dose. But we're still working on that to fine tune that protocol. So that's a very basic difference between the different acquisitions. I how it works of you already heard this from previous talks, but I'm going to just mention it from a technological perspective. I know that there's a single tube and there is a two filter filter at the two band which attenuates the beam that goes through body and then you get better energy spectral. So there is an actual picture of the filter, and it's movable, so when you're not doing a twin Beam acquisition and moves out the way an when you bring it in is, then I'll actually a dual energy scanner. I think it's hot. So you saw this race. I'm just going to pass through. Again, with this technology you able to take biphasic exams and turn them into a single acquisition and get the mono energetic and all those really fantastic results that you get from dual energy technology and then what's kept intact is the characters. For deed it would of reconstruction and X care. So you can apply those those tools as well. But the real discussion here is that. Being able to create the rapid results, or let's say the direct results of the dual energy type of images to PACs is really what it's exciting here for me. Because it does take a technologist to do these processing and you know when you have this kind of workflow, anything that we can remove from the technologist and give it to the radiologist is good, but you know they don't want to do this. So what we all would love to have some sort of automation. I'm glad to hear that we be 20 is going to do it. So again, so fast the results direct transfer dual energy results from the scanner to PAX. Why is it important in our workflow at our institution we have two tech workflow and is still not enough to keep up with the demand for patient care and instead of having a technologist out of workstation create images, we prefer to have that technologist with a patient delivering better care. An more efficient workflow. So yes, we do do post processing. But we do have, sadly, radiologists, like Doctor Cyrus and that does his own. We have radiologists as well that do that, but not already. I'll just do it so we have to build it into our protocols and workflow. So what do we send to PAX? We pretty much send thick images coronas from Workstream 4D, and now we're sending monoenergetic images directly from the scanner 2 packs. What gets archived? We have two different packs archives. One is for the clinical and one is for storage. So if we want to actually do dual energy post processing retrospectively, we have the data. So we pretty much archive everything. So the types of exams that dual energy will benefit from. I just pretty much wrote a list here of the kinds of exams that are pretty much multiphasic in nature. He materials and the graphs. As I mentioned, the neuro DSA to reduce acquisition. We do a single password to in beam and we're getting as good a bone removal and we're still working on that to improve it chest we're doing for UNK, a logical purposes. We definitely do a metal artifact reduction on this system. Neck where we have like 3 phase. Next we really want to be able to use a reduced acquisition their renal masses as well as three phase livers and then of course the bread and butter stuff. We were able to do with the scanner. So I want to get into the less complex configuration on the edge, which is great. Pretty much you go to your configuration panel you select on your transfer button and what happens is you get another dialog box which you can add or new rule and give it a some sort of dropdown menu where you can say you want all completed images and you really don't care about the processing of that. But images are going to make it to pack, so this is the first step. When you get your scanner to configure. This configuration page so that you know the images are going to reconstruct automatically. Go to packs. What's important here with a twin beam unlike a force scanner work that we used to with A&B, we have low and high so you need to have a low and high series in order to activate your ability to auto process the dual energy images. So here is a image of that where when you have the low and high, you cannot be able to get the kinds of monoenergetic Kev selection you have there, whether is less than 40 or 42 above 100K via mixed idein, a virtual noncontrast combined iodine versus virtual noncontrast an optimal contrast there, and this is on the auto transfer card. But it's also important to configure that transfer on the configuration page. So it's also important to look at your fast D results, and this is where you can figure that as well. So you notice that you have the dual energy algorithm, which is the virtual and enhance, and I'm not going to try to play with the mouse, but you can see up on the corner it says virtual and enhance you gotta select your voltage combination. So it's important because you have different options but you have to pick the AU 120 an SN120 and. Make sure that your algorithm parameters, an immaterial definition is what you radiologist and physicists choose to have. We particularly use the Siemens default. OK, here is the same page, but this time we chose the model energetic plus and we looked at the both cards to make sure that you look at this. If you're not happy with your initial images, but I know that many in Siemens worked hard to make those images look good at the default parameters. So. At first I was a little confused when we reconstruct twin beam dual energy results. We set up our Recon. We tell that we wanted virtual noncontrast and we set our slice thickness, algorithm and everything else. An what happened was we saw these images pop up and I didn't see any contrast removed so I said what happened. I think we may have an error here or something but you have to actually wait. 'cause it does take a little time to process these at the console. But after about 5 minutes you will be able to see the actual dual energy results that you see with the dark blue where it says virtual noncontrast mono 70 an iodine images. So it's not going to be right in front of you. It's going to be done in the background and after a few minutes you're going to see in auto population of these series which you then can put in your viewing card and look at. But by that time it's already on packs, so that's what's meant about the auto transfer. The packs that. As soon as they generated, they automatically go to PAX, but it's not something that you're going to appreciate up front. Just know that you have to wait a few minutes and then you get it on the browser, but love it. I'm glad that we can implement this. Technology is a very happy there's like thank you that we can actually do this. So here are some types of tool energy results, whether it's on the left hand side where you looking at a 70 KB monogenic image in the middle is an iodine image and also virtual noncontrast on your right and you notice it's kind of small font right now. But it does say automatic results and it tells you what it is and that's how you can identify that it's actually a direct result from the scanner console as opposed to a single via. Which we also have, because we have the force and we set it up in that same same fashion. So I'm glad that we're doing something right. Here is why our physicians like these kind of images. If you notice the image on the top is a little less contrast C than the bottom. That's because the bottom image is the model. Energetics Sir. KVI think it's a 70KV, but our doctors actually like 50K fees as default. But the inherent look is something that's unique to that particular image is not a window wing, is an inherent contrast that is much more. Contrast E and it helps pop out the different vessels in anatomy, so This is why they love those images. So again, it's important if you have a 3D lab which we do an you want to make. Make sure you send the right data set for the right purpose. Now you don't want to send the high and low to your 3D lab and Lester using single via, but you know not everybody uses single via for just 3D volume rendered images right? You don't need to fancy high and low, you get better ball remover yes, but some of our lab has many vendor and you want to make sure you send him the right data set 'cause if they're going to use. Role and try to do a 3D image is not going to look as good, right? It's pretty obvious, but if you the high if you send the high images it's going to look not as contrast see. So you want to make sure you send him the composed images so that they can use a vendor neutral 3D workflow and do their normal work. So it's important what data set you sent to make sure that they get the best kind of imaging possible. So here it was different about the force as opposed to the edges that there is no decomposition. So you don't have the ability to blend it the way you want to an it's important only because all radiologists in the chest section use like a .4 D composition in the Adam is used .6, so there is a fundamental difference in the look from different sections. So I'll doctors are getting used to the composed image on the edge, but they find the value in these images and are looking forward to fully implementing it. So that's one fundamental difference. Again, it's important to make sure you send the composed image, which you can auto process whatever results NPR is. You can do some auto process where those their tools, but it's really the low and high that gives you the drop down menu on your lower right hand corner to get you the dual energy results you're looking for. So that's one fundamental difference. The other fundamental difference here is the scan acquisition dose on all fours will have a lower quality reference masses post and edge, but we need that higher quality reference mass. Up front because the beam is being attenuated. So as you heard, another talks when you're trying to standardize between protocols. We do look at the CTI to make sure that we least know that output of the tube is similar, and then you work to look at the different kernels and you know, make sure you get that final look for your radiologists. So again, just some lexecon information. Is that on the force? Recons is called AB&M Hilo, an mixed and the edges call high and low and composed. There is no decomposition on the edge at the scanner. The initial recons does not look like the results it can take up to five minutes an you will see the automatic results on the browser as well as unpacks. So what's fundamentally true about any CT is ISA censoring, whether it's a dual source scanner or a single source scanner, but more importantly, if you on a dual source scanner ISIS entry is going to be even more critical, but we take both scanners as seriously and we try to be as on target as possible, and the way we do it is we look at both the horizontal and vertical line an we actually position the patient. All the mobilization devices to make sure they don't move, and. We also look at body size now on the force you know we want to make sure. Just like we said that we need to have the body or organ in both scan fields of use to get dual energy. Although we don't have this limitation on the edge is still important isocenter. And I must say that the only difference one domino imaging between a force an and edge is that we scan bottom up quarter cranial on the edge as opposed to cranial quarter downforce. And you know we were able to do a lot of different patient size but there is a recommended thickness that you don't want to go over, which I believe is 35 centimeters but we've been passed, that'll already. So again, we go bottom up. I think I'm told that the modulation works better when you start from the pelvis and go up. Yeah. So first of all the versions. The reason why this is so important to have direct results go to PAX is because a technologist has to come off the acquisition or Navigator and actually go to the workstation after they already network the images. And if you don't have single via and you got an old workstation, that means you have to wait for that transfer. You have to load the data you didn't have to select the type of mono, energetic or whatever dual energy result you want. Then make the batches and then continue on and you know can take time. So that's why I'm excited about this. But we do have single via an is kind of like a semi automatic thing as you mentioned Christy where you can set up on MM reading you can set up that all of the type of different results already been map for you and you can be able to simultaneously scroll through all these images which is a benefit number one for the radiologist in the technologist to be able to see. And if you notice let me start off with the upper left hand corner of the art and that's automatically map is automatic. It's in NPR. Your thin map yellow and your high. You mix your optimum contrast and slots. Look at, but it's fantastic in that one acquisition you can get all these kind of results and then go ahead because you already have it displayed for you. You already have everything synced to move simultaneously. You can then better be prepared to do your batch image Ng, whatever slice thickness you want and then proceed to send that to pack. So we kind of like set up us automatic semi automatic way of getting ready 'cause you know what you're going to do. To improve your efficiency, but by having the automatic results from the scanner is actually going to remove this and we just have to do the homework to say if we're going to create these images up front. We need to know a Swiss buff like metal artifact reduction. We have to talk to our radiologists about work, a EV they want or I die mass we want and we should do that. You know, you can get inefficient workflow. So again, for me it was that twin beam CT. Had, you know, pretty much reduced our neural DSA protocol, which stage radiation dose and doctor Adam Davis, our new radiologist was working with us diligently to make sure that the image quality is as good as a new road ESA or better and then also able to derive the other type of dual energy results that you get from dual energy. And also you know, metal artifact reduction is as effective and we use it routinely on a twin being. So with that I want to conclude and say thank you for your attention, I appreciate.

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