CT-Dual Energy - CTA of Thorax and Abdomen - Tutorial

Hi this is more tablished and welcome to our tutorial #5. Today we're going to see how dual energy technology helps us in the evaluation in CT, angiography of the thorax and abdomen. So let's get started. Virtual Noncontrast application is very important in dual energy city. We already talked about that. Dual Energy City allows for material differentiation, for instance cause iodine and calcium have different attenuation characteristics according to the energy that is penetrating the. And the material you can differentiate them and discriminate them very well. This is basically. Allowing us to subtract the iodine from the contrast enhanced image. And generate a virtually unenhanced image acquisition and. It has been stated that this virtual noncontrast or vincy. Images approve it atede that they may obviate the need for a routine Unenhanced image acquisition, and this offers the potential for substantial lower radiation dose. Of course, specially in younger patients. This is clinically very useful. However, if you really have a. Adult goal still for a true non contrast acquisition cause commonly the virtual contrast images do not reach the exact same image quality as true non con. So with dual energy scan mode you get. A biphasic city acquisition, basically with only a single image acquisition. So you have a contrast enhanced image series these. All. Are unenhanced images but one true unenhanced on the left side here and we have a virtual enhanced from this order Venus. Acquisition, and we have a virtually non con image from an aterial scan, so we see that the all this free nonconnah images are quite similar in image quality and Furthermore they also allow the reader for reliable Hounsfield units. Huntsville units measurements. Another important application in this has been one of the most important application of dual energy CT angiography for years is automated bone removal. Because you can discriminate item versus calcium, you can vice versa. Also subtract the calcium and all the skeletal structures. This is very useful. For a fast and accurate. 3D angiography? And. Automatic bone removal reduces there for the manual time requirements for post processing time with only one mouse click, you subtract all the bone structures and can directly go in the 3D volume rendered mode. And analyze your angiography data sets. This is very. Helpful in angiography of the thorax and abdomen and also in CTA studies of the lower extremity runoff, where normally it takes quite an amount of time to cut out all the different calcified structures. And traditional methods which are only based on density. They have shown inferior results with bone subtraction compared to dual energy automatic bone removal. So this works quite better. Another interesting application of dual Energy City and. And geography is virtual monogenetic imaging. And the main applications of this algorithm are contrast and image quality optimization. And. We think that this is actually the most important benefit is that you are able to salvage studies with poor contrast conditions. You get more flexibility in challenging scenario as a radiologist. And this substantial increase contrast that we already have seen in the prior tutorials. This could also lead to a possibility to reduce the contrast media priority and does allow for more gentle city imaging with lesser amount of contrast media. So we have less radiation with because we don't need in every case the true non contrast image acquisition and we could have less those in terms of contrast media. For instance, here we see. Varying energy levels for city and geography of the thorax and abdomen. And. In clinical practice for contrast optimization, vascular imaging, especially low energy levels of interest between 40 and 75 KV. Because these images provide. Improve contrast and also the best contrast to noise ratio. So this indicates objective image quality and also better subjective image quality. For instance, when you compare monogenic images here to the standard mixed image. We found in a prior study that 60 KV proves image quality. And 40K V. Increases the contrast even further and this. Leads to a superior. Delineation of tiny arteries so when small arteries are of interest like the renal arteries. For instance here or hepatic artery branches. This ultra low cavey images are. Also useful. I briefly mentioned that Multiplus may be useful for challenging cases. This is here an interesting case example of a patient with renal impairment. We will also have a look at this patient later in the hands-on section. This patient had actually renal failure, so we only could inject 40CC of contrast material. And in addition, at quite a desolate vein status of the four arm, so only very small Ivy access with maximum flow rate of two ML per second could be established. And that's these. Are the images. The upper images are the standard images. That could be acquired quite a reduced contrast here. The patient was known to have a ortak dissection in the prior stent placement, but headed to abdominal pain. And that was the reason for the scan. And. Whenever a poor contrast is encountered, morning plus really increases the Iran signal. In contrast, in this particular case, the arterial. Acquisition. I would consider this normally as non diagnostic however model plus. Increases the contrast in the order to diagnostic levels. You can see the false in the true lumen very nicely. And in addition, the venous scan also here for instance in the hepatic hepatic vein here. You see better contrast and. Better assessment in this particular case. Also, monogenic imaging offers a wide range of possibilities in the evaluation in emergency CTA, for instance. In this patient, this patient underwent liver transplantation had then a low blood pressure and acute decrease in hemoglobin. So bleeding was suspected postoperatively. And on standard images we see here. A very slight blush suggestive of active extravasation, however our confidence is low or so the delineation of this bleeding is not optimal and when we go to more getic. 40K view reconstructions. We see that there is not only. At this blush here, present that we can now delineate better. There is. Furthermore, here contrast material, and there's another bleed here. And this pleading, for instance, was not visible on the standard images. So we are more confident in assessing the extent of bleeding. And you just have a better conspicuity of. The extra visited iodine. The same. We're actually here. This is the diagram showing the diagnostic accuracy for active arterial bleeding and the this curve here shows the largest. Area under the curve. That means the highest accuracy for bleeding detection compared to the predecessor algorithm and also the standard images. So improved and incremental diagnostic value for more. Plus at 40K V. And the same principle also works for endoleaks, for instance. Here, for instance, in this patient we see this contrast. Blush here outside the already extent that was inserted. And. Yeah, we can basically say in a nutshell that this locate monadic images may be helpful for every scenario where an increased contrast is needed to highlight certain structures depending on the individual case. So for instance, if you suspect penetrating ulcers are already aneurysms. If you want to assess the tiny arteries. Then Monoplace is always useful to highlight those structures and. Just improve your diagnostic confidence. It's also a is important that either if you. Want to highlight hyper or hypo perfused organs or structures for instance in inflammation versus infection. Both scenarios become more distinct. With locate the Mona getic images. And with that, I thank you very much for your attention. I hope this was helpful and now let's analyze some clinical cases. This is the case example we saw in the prior presentation of the patient with renal impairment that could only be examined with Ida in amount of 46 C. And first, I would say we. Talk about the importance of. Where you have to and re and we're not. Because all this area outside the field of view here. Doesn't contain dual Energy Information, so this patient was obese, so it's highly important that. We acknowledge the fact that. In obese patient, some parts of the body are not able to be analyzed with dual energy. So for instance, when you have a bleeding here outside the circle, you won't be able to increase the conspicuity of tool energy. Just for understanding, and when we hide this field of view, for instance now. It's more difficult to say where is the field of view and where is the area outside the circle. Just as a side node. Now let's have a look at this patient. And we see there is a. The status post stent insertion in the thoracic order due to a large dissection. Hyperdense area within the false lumen here. Not really. Suggestive of end League Bud. Definitely important to have a closer look in this particular area, and when we go down. Let's hide those lines. To have a better view. Then we see that this dissection extends through actually the whole. Abdominally order. And also extends into both iliac common arteries. And. In every dissection, now it's of interest. Where do the abnormal vessels arise from? For instance, on the left side of the kidney? We see that. The other is arising from the false lumen, and Furthermore has. Distinct software component here and for theory and geography study is probably difficult to have a better sufficient assessment here, so. Let's increase the contrast in this particular case. By means of monogenic plus. And let's calculate. Those images. Anne now. This actually would be our normal contrast. Let's go down to 40 KV and. So we see definitely substantial improvement of contrast in this patient, and see how nicely. The other is shown namuna getic images. I would also. Like to have a closer look at this particular area in the other planes. So let's. Have a look at this. In the sagittal planes? And now. We see. This is approximately. Obstructing 50% of the of the vascular lumen. With normal. Images this would actually very difficult to diagnose because of the poor contrast. Again, for comparison. If we would only have a look at our normal images. This would look like. This actually. Definitely difficult. To assess this stenosis without. Sufficient contrast. Also, the patient had abdominal pain, so it would be interesting here. 2. Analyze the perfusion of the esmay, which is actually. Also, rising from the false lumen. And we can go tomorrow plus here. And again we have a nice contrast now in the SM A and also it's segment subsegmental branches. So at least we can have a reliable. Statement here that it's there's no esmay occlusion. Present. Now if we go back to assess this predictor section further. Again, also what you see is that this image here is quite noisy, so the overall image impression. Is definitely affected by noise. However, what is of interest here is the contrast increase so. Again, do lenses not only about optimizing image quality, but for specific purposes and in this patient here. We can now. Assess the. This section much better. And for instance in this likely calcifications. We actually would like to exclude an end League. Or and extravasation more reliably so without a true Unenhanced image acquisition we could calculate this virtually. And when we go to this specific spot now we can take away the iodine from the image. And just be more confident or diagnosis that this is really calcifications and no. Endoleak so. Let's go up to this one structure that is most likely calcification. For instance here. Now we can completely take away the island and we see OK, this is complete. Just calcified structure within that robotic false lumen of this order dissection. Here's another interesting case example where dual energy is beneficial in CDN geography. This patient underwent bone biopsy of the pelvis and. And then. Earl knew large mass of the right. Lower abdomen. The bleeding was suspected because also hemoglobin levels were decreased. And we see this huge hematoma on the aterial CT scan. Now the question was if this is possible to be curable with embolization or coiling so we. Would like to see some material, extravasation of contrast and it's barely actually visible. The problem here is that the hematoma is already quite hyperdense configured. So it's a fresh matoma with white hyperdense blood here in the. Assessment if this is active, extravasation is definitely difficult with this contrast condition. When we go now to Mona Getic. Image in here. We probably could have a better contrast of iodine versus this hyperdense. Hematoma so let's have another look at this matoma and see if we see any. Active extravasation so far there's nothing. But what's that here? This has done the trick. We see. In Hyperdense area here. The contrast to the surrounding. Hematoma here becomes very conspicuous, so this is highly suggestive of active active bleeding, and when we compare it to standard images. We see that this is like more conspicuous using Moon magic plus. And so we know now by dual energy that this is already very suspicious for active bleeding. And we can further analyze this if when we go to. Virtual unenhanced application 'cause we don't have an. True unenhanced image, in this case available. But we can reconstruct this virtually and see if we can really remove the iodine from this area that we suspect now is suspicious for bleeding, so let's go here. So also on the island images you see that. The conspicuity of this particular area increases, and now let's take away the item from this image. And we see that this is decreasing. So. Now that's even more. Suggestive of active bleeding. And this patient was. Found to have an active bleed and then could be treated with embolization. End. And in addition to. This enhanced delineation of the active material extravasation. We can apply automated bone removal. 2. Allow us a quick and accurate 3D reconstruction so we click here on. Body bone removal and this provides us. With a direct and review. For instance, here we can just window this, but we have a direct NGO. With this volume rendered. Map here. And. Just to optimize the image quality, we would. Punch this tube out. Of the volume. Maybe go to a. Normal. Volume rendered reconstruction mode. So this is quite straightforward as opposed to. The manual. Post processing where you cumbersomely have to. Cut out all the. Different. Bony structure structures and in addition we have the option to. Show Plex here. And highlight them. Or we can also decide to include them in our rendered image. And if you would like to save this reconstruction, you simply go here to ranges. You click radio ranges. And. Then you just send her. This angiography in the center of the circle. Click start. And that's all you have to do for a quick body bone removal 3D reconstruction. I hope this are helpful and see you soon. Thank you very much for your attention.

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Any material used aféäsible feasible instance, calcium vs iodine / instance, calcium vs iodine in this training will not be updated on o regular basis and does not necessarily reßect the latest version of visualization in a patient SIEMENS the software and hardware available at the time of the training. 0 50 co.; The herein illustrated statements mode by Siemens' customers and physicians are based on their own Whenever a poor contrast is after endovascular aortic Contrast and image quality optimization oval allows for fast Automated bone removal allows for fast Autonyte# b Virtual non-contrast (VNC) images may obviate the need for 20 DE DE ME DE The Operator Manual shall be used as your main reference, in particular for relevant safety information and discrete opinion. 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Since there is no "typical" setting and many variables exist there can be no *roe Images *roe Noes Images o Findings NavOatOr for Mono+ at 40 kev for the [email protected] 1017 MA 37 PM o Findings Navigator o Navigator guarantee that other customers will achieve the same results. 100 Standard M_o.6 Standard Standard M_ko.6 sp L 100 E sp..2137 sp 60 80 20 ALI rights, including rights created by patent grant or registration of a utility model or design, are g IMA2g•2 or o Findings Navigator In a nutshell: low kev Mono+ may be helpful for every scnerio where an Certain products, product related claims or functionalities described in the material (hereinafter collectively sp sp sp F569g Mono+ allows for diagnostic kedu -ma 1.5 Qr40 3 [6171 Reduced manual time-requirements for detection of active arterial reserved. However, in doubt go for a true non-contrast acquisition! "Functionality") may not (yet) be commercially available in your country. Due to regulatory requirements, # 3659860 Potential contrast media reduction a priori — more a priori Some products/features (here mentioned) ore not necessarily commercially available in all countries. Window width 600, level 150 HU el 150 increased bontrast is needed to highlight certain structures — for instance, Vi ua non-con NC» increased contrast is needed to highlight certain structures — for instance, Virtual non-con (VNC) the future availability of said Functionalities in any specific country is not guaranteed. Please contact your rue non-con image contrast compared to image contrast Due to regulatory reasons their availability cannot be guaranteed. Please contact your Local Siemens Copyright O Siemens Healthcare GmbH, 2018 F 0.5 bleeding local Siemens Healthineers sales representative for the most current information. post-processing time MORITZ H. ALBRECHT, MD organization for further details. • Poor contrastin CTA of a patient after liver transplantation Poor contrastin CTA of a patient after liver transplantation gentle CT imaging penetrating ulcers, aortic aneurysms and tiny arteries 40-keV VMI+ Low kev reconstructions between 40 — 75 kev are of maior interest, as standard reconstruction Navigator (from portal-venous scan) (from pqrtal-venous scan) (from arterial scan) 70-kev VMI these images provide improved contrast, contrast-to-noise ratio (CNR) and • Mono+ at 40 kev allow enhanced depiction of extravasated contrast IOcm Or to highlight hyper- or hypoperfused organs (for instance, inflammation vs 80 80 20 100 VNC shows a similar image impression and reliable HU measurements subjective image quality LRQ material from the coeliac trunc infarction) 1 Specificity Manip VRT Manip MIP Tools 564 DE BR+PLQ DE B R+PLQ DE BR-PLQ Tools 395 Martin, Albrecht et al, European Journal of Radiology 2017 Martin, Albrecht et al, JVIR 2017 Martin, Albrecht, JVIR 2017 Albrecht, Wichmann et al, Investigative Radiology 2016 Courtesy of Carlo N. 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