PEPconnect

TwinBeam Dual Energy – Clinical Relevance in Daily Routine

TwinBeam Dual Energy – Clinical relevance in daily routine presented by Bhavin Jankharia, MD of Jankharia Imaging, at the 13th SOMATOM World Summit 2017 in Singapore.

So thank you for that kind introduction and it's a pleasure to be here. It's a warm morning outside. And I do not know why I couldn't get the other two or three minutes, but that's perfectly alright, and so I will take the next 12 or 13 minutes and talk to you about how we have incorporated dual energy in our clinical practice. And just so that you understand where I'm coming from, my work in a private practice in Mumbai are predominant. Work is non emergency. Non trauma work and a lot of our tumor work is essentially done on PET CT and therefore we do not do a lot of tumor imaging with dual energy on this particular scanner. For those of you who may not be aware of what the twin beam is, it's a single source dual energy scanner and you have a single beam. That's a 120KV beam that is split by Golden tin filters into high and low energy spectrum, and so it's a very elegant way of getting dual energy without having the large dual source machines with two generators and two tubes also in a private practice that becomes. Much more economical than having to have a dual source scanner, but this allows us to do most of the stuff that we would do with dual energy. Yesterday you've heard Doctor Megibow and today we've got a lot of other talks coming in and there will be a little overlap. But nevertheless, given that some of this was covered yesterday, I'm going to try and not talk too much about, let's say, urinary calculi and tumor related I odine Maps. Now, whenever we talk about dual energy, you have the four standard applications that we have. You have material differentiation which allows material removal. We have material optimization where you can see things better. We have material separation, as with uric acid calculi and mono sodium urate crystals, and we have material decomposition, which is where we do the I odine Maps or iron Maps, etc. Bone removal is probably one of the simplest things that we do with a dual energy scanner, and I won't spend a lot of time except to show you a couple of pictures of something that is very simple, straightforward and done with pretty much one. Click so becausw we have separate Spectra for bone and I odine you can pretty much remove the bone from the angiogram images extremely easily as compared to the traditional thresholding method that we've been using over the last 10 to 15 years. So just a simple example. This is a head and neck angiogram. Lots of bone in there one click and the bone goes and were able to see the vessels that well. Similarly in the lower limbs you can see. That there's a lot of bone which we all know one click the bone goes away and we can see the vessels and I won't spend a lot of time on this because this is simple and straightforward and we'll go on to some of the other applications. Where do you? Will energy makes a difference when we talk of material optimization. One of the things that we talk about is metal artifact reduction using a combination of monoenergetic image Ng. And I iterative reconstructions. And so we did this little experiment in our own scanner, where we looked at a patient who has a total hip replacement. And if you see this carefully between the 50KV and 100K, we you have significant reduction in artifact and you can see the difference very well here. We then added the interactive reconstructive reconstruction based artifact reduction or I'm are. And when you do the two things together, you can see a further improvement in the artifact reduction, and if you see the 50KV and 110KV again, there's a difference. But now see the 50KV with. I'm are, which is better than the one without and the 110KV with eyemart. Which is the best as far as artifact suppression is concerned, and so today when you have a patient with a total hip who has pain, this is a patient who came in about 10 years after a total hip was done. You can very easily see the Perry prosthetic austra lysis in the acetabulum. Unlike with them, our weather is always a little extra artifact, even with the best Mars that we can do here. The margins are extremely well defined, and all the information that the orthopedic surgeon once before going in for revision is available, including measurement of the angles, and if you scan the knee, you can also do the angles of anteversion. Etc. Here is a composite of a patient who came in seven years after a tear charge. You can see the cortical thickening here. The patient had pain in the proximal thigh. We did the Mars MRI. You can see that there is fluid here. There's a collection. The rest of the bone seems fine, but on the see T you can see the osteolytic lesion in the lateral cortex of the proximal femur with the abnormal soft tissue, which confirms the fact that this looks like osteomyelitis. We went in, aspirated it. And it turned out to be infection. Here's another patient that we did the earlier this month. That's the scanner gram. This patient was operated 10 days prior. This is the amount of metal because of the radical opathy we attempted a Mars Mr and we do Mars and Mars daily, and we did everything possible and this was the best image that we could get. So we shifted the patient onto the CT scanner. That's through the maximum metal that we have. There's no artifact. And then we figured out the cause of a pain because one of the screws is gone into the right S1S2 for am in it's compressing the right S1 nerve root. And that was the cause of her radical opathy. So that's as far as the metal artifact reduction is concerned, and we've incorporated Mars city into our regular daily practice in a big way. So we do Mars and more. We do more, see T. In some patients we do both and more and more. We believe, and hopefully we'll have more data that could be published as well. That probably Mar City has an edge over Mr in a significant number of circumstances. Then we come to material separation and analysis, and this is something that we heard yesterday when Doctor Megibow spoke about uric acid calculi. Basically, the city density ratio allows us to identify uric acid calculi, an mode mono sodium urate crystals without spending a lot of time. Here's a patient who has a renal calculus, electric calculus. It really just takes one click of a button. You get the city density ratios, you put it on a graph. The renal calculus is uric acid, but as the electric calculus is non uric acid and that information is something that we put in the reports. Now in every patient who comes to us for a see T Euro gram, whether it's a plain scan or with contrast. But the place where material separation has made a big difference in our practice is with gout. Right earlier the only patience of gout that we would see were the ones with plain Radiograph's, sometimes Mris of patients where the diagnosis are not being made, or sometimes when we were looking for complications. We know that the definition of gout today is the presence of pain and swelling and identification of Ms you crystals in the aspirate. Please understand that the serum uric acid levels do not have a bearing on the definative diagnosis of gout so you can have gout with normal serum uric acid levels and you can have high serum uric acid levels without having gout. Now the challenge here is that you. Can't aspirate Ms you crystals in every patient and even if you did try to aspirate the joint, it is not necessary that you will see the crystals within the aspirate, right? So if you have another way of identifying the MSU crystals, you can do that with ultrasound as well. It would help a lot with dual energy CT. We can see the MSU crystals and you can show them as green because I just looks very nice. But this is what it looks like. Proliferative tophaceous gout is not common in the tropical countries. This is something that you see more in the colder climates in the Western countries etc. In the tropical countries this is what we get. So this is a 1449 year old with pain and swelling of the ankle joint. You see one green crystal along the tip of the lateral malleola's and that is enough for us to say that the patient is gout. Here's another patient who had pain and swelling in the knee joint. Presumptive initial diagnosis was tuberculosis, and again you can see two crystals, one adjacent to the lateral meniscus, the other more anterior, and this is diagnostic of gout. So wild ECT has a very high sensitivity for tophaceous and prolifer ative gout. It does suffer in terms of sensitivity when it comes to non tophaceous gout, sauna per patient basis you will find sensitivities of about 64 to 75 depending on the study but on a per joint basis it drops to between 25 to 35. What do I mean? Here's a patient and just look at the history. It's pain and swelling in the left foot. Right wrist and the right MCP joint. But the crystal is in the right M TP joint right. The spin and swelling in the left foot in the right wrist is the symptom, but you have the crystal in the left fifth MCP joints, so the patient is gout. When you look at the patient as a whole, but the symptomatic joints are not showing the Ms you crystals. On DCT, but the patient still has gout and the diagnosis gets made. We also use CT now to monitor response to treatment. Here's a patient with crystals in the quadriceps and Patella tendon. Six weeks of allopurinol and the crystals have disappeared, so that's a good way of figuring out whether treatment is effective or not. Does it make a difference, right? So we've got this really nice study that was published last year in European radiology. Small numbers of patients. However, they clearly showed that if you use dectin patients with suspected or known gout, you can make a difference in about half of them. As far as management changes concern. And when you look at follow up about 83% of these patients benefited from the use. Of dual energy CT and more and more. If you keep looking at the literature you will find every couple of months a clinical paper and most of these papers are not written in the radiology journals, but will be in the rheumatology journals. We look at lower limb. From the need to the ankles and feet. If the patient only has lower limb symptoms. However, if the patient also has a problem, symptoms, the nurse scanning protocol is elbow to fingers and then knee to the ankle. Lastly, we look at material decomposition where we are able to look at the different properties of different elements based upon the cavi so you can see the biodyne curve and then the rest of the materials, whether it's calcium, water, etc. And therefore we know that IoT Maps can give us a lot of information. We've been trying to look at iron, but it's a little difficult now. In our practice we do. I odine Maps for lung nodule assessment post, RFA in the lungs as well, and for pulmonary thromboembolism in Doctor Remy Jardin is going to speak about pulmonary thromboembolism, so I'll just spend a minute on this. Here is an acute patient with shortness of breath. You can see the pulmonary thromboembolism, and here the dual energy allows us to see the extent of perfusion defects. Similarly, in chronic pulmonary thromboembolism, we have a. Bunch of findings that would allow us to make the diagnosis. So here's a patient who has a mosaic perfusion. You can see the regularity of the vessels, the cut off. Here is a linear defect, etc. All of this is suggestive of chronic petean. The presence of these perfusion defects allows us to make the diagnosis well too, but I won't spend a lot of time on this, except to say that the city allows better appreciation of peripheral emboli. It may allow differentiation of acute and chronic. Pulmonary thromboembolism and eventually quantification of blood flow is likely to help assess severity as well. So these are the other places where dual energy CT can be used and we will have talks today that will look at some of these aspects. But to summarize, we've looked at basic concepts of twin beam and then we've looked at the four major categories of dual energy use. We have material removal, which is we use it's predominantly for bone. But we also use it for calcium removal at times when this dense calcium, especially in the carotid arteries. Material optimization for metal artifact reduction combined with iterative reconstruction, that is, the eymar material separation, where we predominantly use it for uric acid and mono sodium urate crystals and material decomposition. Where we make these, I odine Maps in our practice predominantly for pulmonary thromboembolism and some of it for long nodules, etc. Thank you for attention.

43 45 0.85 TwinBeam Dual Energy TwinBeam Dual Energy CT TwinBeam Dual Energy Gout and DECT Dual Energy Applications patite TwinBeam Dual Energy CT TwinBeam Dual Energy o, 80.000 0.65 43 450 26 17 1, TwinBeam Dual Energy CT Material Optimization Material Analysis — Material optimization 18 - known gout (G), 85 — Bhavin Jankharia Material Differentiation (Removal) — Material Differentiation (Removal) Gout Data Gout suspected (NG) suspected (NG) Peri-prosthetic Bhavin Jankharia SIEMENS .. Clinical Relevance in Daily Routine Applications Topics Material Decomposition Diagnosis Material Optimization 49-years old with pain and Material Diffmrentiation Material differentiation (removal) Imaging & Beyond by Jankharia The dual energy differentiation of bone and iodine infection Material Separation / Analysis Material optimization Dual Energy Concepts Dual Energy Applications Material decomposition Gout One episode of peripheral joint or bursal pain and Picture This, Material differentiation (removal) Basic concepts 80.000 1, o, Imaging & Beyond by Jankharia Monoenergetic Imaging swelling Healthineers Mumbai, India 27 (7G, 20NG) 20 (5G, 15NG) 16 (13G, 3NG) Diagnostic Impact No change in diagnosis Co change in diagnosis Material optimization — Material optimization Material decomposition Material characterization Material Diffmrentiation — Material Optimization DEC T may allow differentiation of acute and chronic O Siemens Healthcare GmbH 37-years old with • Identification of monosodium urate crystals (MSU) on mass map — Material Differentiation (Removal) — Material differentiation (removal) - Material differentiation (removal) Material separation / analysis gout and multi- Sn mass joint aspiration 16 (13G, 3NG) Co change in diagnosis system Material Diffmrenition — Material optimization Material Optimization nuinBeam Dual Energy - Material decomposition after DECT involvement 80.000 70,000 5.000 — Material separation / analysis -50 23 (15G, 8NG) Therapeutic impact No change in treatment Co change in treatment 50kev 70kev 510kev 710kev 510kev 510kev 50kev Material Optimization Material decomposition — Material optimization Peri-prosthetic osteolysis Clinical reLeuance in daily 49-years old with pain and swelling of the ankle joint 650 40 50- 70 40 70 130 60-years old lady 10 days post sx with right sided Left 5th MCP Picture Rt 1st MTP joint joint 02 16 20 (56, 15NG) No change in treatment radiculopathy Picture O Siemens Healthcare This Dual Energy Concepts Monoenergetic images Plan after DECT This pattern of florid gout 44-years old woman with pain and swelling in the left foot, 53-years old man with pain and swelling in the knee joint 53-years old woman with pain and swelling in the kneet joint, 42-years old with breathlessness -50- 1500- 600 200 300- Imaging Beyond 2500- 450- 550 550- 450 700- 500- is uncommon in India SIEMENS .. L Picture Picture w2 right wrist and right MCP joints Bhavin Jankharia by Jankharia 'o, o, o; on Imaging Beyond Sun Y et al. Int J Rheum Dis 2015; 18: 880 Sun Y et al. Neogi T et al. Ann Rheum Dis 2015; 74: 1789 McCollough C et al. Radiology 2015; Baer A et al. SMC Musculoskel Dis 2016; Baer A et al. BMC Musculoskel Dis 2016; Finkenstaedt T et al. Eur Rad 2016; 26: 3989 This Topics Healthineers Bongers et al. Schulz et al. A-JR 2012; 199: W646 Bhavin Jankharia by Jankharia

  • CT
  • CT Summit
  • SOMATOM World Summit
  • TwinBeam
  • twin beam
  • dual energy
  • DE
  • functional imaging