CT-Dual Energy - Myocardium - Tutorial

Hi, this is Morris, I've written. Welcome back to our tutorial series. This is the third out of 6 tutorials on my cardial improved assessment using dual energy CT. IRA Maps in dual energy, CT, and cardiac imaging is very useful for improved ischaemia visualization. In this particular case, for instance, we see the low cavey data set and the high cavey data set patient had chest pain and was suspected to have my cuddle infarction. And we see, especially in the locate the data set where you have increased contrast but also a. Increased noise, we see this hypodense area here on the lateral ventricle. And when we look at the Iran map. We see that this really AIDS individual assessment and especially delineation of the infected area. And it has been shown that this correlates very well also with SPECT imaging. And the good correlation of dual energy City Island Maps has also been shown for MRI in this case. For instance, we see on the short axis view on the island map on the lateral ventricle, distinct. Hypo perfused area. So there significant reduced. Attenuation here also in the papillary muscle. Nicely shown here on this four timberview. So to Landry, City allows us for the assessment of perfused my Cardium in cardiac city. So similar to palmonari angiography, you not only have the structural CTA images but also you can. Obtain information about the functional perfusion of the subsequent parenchyma. And it has been shown that IOTA Maps have incremental diagnostic value in addition to structural coronary CTA. So this is another good example. To show that dual energy city reconstructions should not be used. Alone, but rather as an add on to your standard CTA images. For instance, in this publication, it has been shown that coronary CTA. With a stenosis more than 50%. Can predict the and. A hyperperfusion with an area under the curve indicating accuracy with 0.72. The same accuracy was found for perfusion Maps alone. However, if both were positive, so when you have the combination of both image series, you increase your diagnostic accuracy and you can with greater accuracy predict if coronary stenosis leads to perfusion deficits in the my Cardium. You cannot only assess the my Cardium better in a subjective. Fashion, but also you can quantify your findings better using dual energy city. For instance, this patient had an acute lady occlusion nicely shown on this. See curved NPR here. And in traditional city we would only have mirror measurements that are based on. The density itself, so we only have Hounsfield numbers. And in comparison to their dual energy, city allows for a quantification of iodine uptake. In this item uptake in a specific volume that you measure. Is indicated in milligram iodine per milliliter volume that you measure, and. This directly indicates the perfusion in this volume. For instance, this patient due to the LRD occlusion, the Ellery territory. Was less perfused and when we draw Nera I hear in. This area will see that we have 1.2 milligram per milliliter in the infarcted area, versus 3.2 milligram per milliliter in this area. Of the left ventricle, which is normally perfused and was not affected by coronary artery disease. In when we analyze this case further, we can also add on noise optimized locate view virtual majetic images. And they also proved the visualization of the infected my cardio tissue. We see this, especially here in this. Image here when we have Angel level of 55. Multiplus with this window settings. With a with of 1200 and a level of 400. And. This again with altered Windows settings would look like this. So in this image here on the very right, you could probably argue this has the best image quality in comparison to the third image here. However, for my cuddle assessment. This image would be better. In that regard, so depending on your specific purpose, ultra the window setting. Depending on if you want to visualize the left ventricular blood, for instance, or the my Cardium. So do Energy City and it's important to recognize is not only about improving image quality, but rather to obtain more functional and additional information in your patients. And when we see these three reconstructions, mono Plus and Iran Maps, we see that we have substantial. More information compared to the standard linear blended image where it would be actually very difficult to see this hyperperfusion in contrast to mono plus where you can for instance see here. Very nicely. Sharp dedication of the infected my Cardium. And. This strategy also works to increase. The visualization of late enhancement. In this patient, for instance. This patient had a history of prior my card infarction. And we see the scar tissue in the left my Cardium. Very distinctly here on monologic images. These are actually 55 KV and 40K V. With a good delation of the. Fibrotic tissue in contrast in standard. Linear blend images. This would be actually difficult. You could also. Here, make the diagnosis of late enhancement, but you are just more confidence. In your delineation. And also if this is definitely positive for late enhancement when you go towards the very low. Energy levels. And also you can quantify this when you measure the Hounsfield numbers. For instance healthy my card in here with 91 Hounsfield units compared to 130 in the late enhanced. Scar tissue. This increases virtually here to 220 versus 365, so the difference between those Michael areas is just. Also subjectively more conspicuous, but also quantitatively measurable. So. We could say that motor plus both improve the positive or the negative contrast depending on what specific purpose you're searching for in. And the individual case. So when you're starting with dual energy CT, it's very important to avoid an overwhelming number of reconstructions as an add on to your normal standard approach and to guide you in your reconstruction protocols, we suggested the following protocol in cardiac imaging. Your DECT dual entry. City data acquisition. You will obtain locate VPN and high kilovolt peak. Image data sets. So this is your source image material and we would suggest for routine reconstruction. To have, in addition to linearly blended images. Mono plus images or hear via my virtual majetic images at 55 KV and also iodine Maps. So these should be reconstructed in every individual case, and these are only two additional axial reconstruction series in. This is a reasonable strategy to have a more comprehensive and more accurate. Diagnostic approach in CTA. And then, depending on your individual case, we would suggest optionally to reconstruct a virtual non con. If you would need it and. When you even want to increase the contrast further, you can Additionally go to Ultra low cave levels with more plus, and when you for instance have metal artifacts, this will be covered in the next tutorial. You could reconstruct mono plus at higher cave levels. Thank you very much for your attention and now we will move on to the hands-on part with clinical cases. This patient had exertional chest pain and was suspected to have significant coronary artery disease. So coronary CT scan was acquired. And these are our conventional. CCD images we see. Calcified plaque here with all software components in the left coronary artery. The right corner artery. Actually it's barely accessible due to motion artifacts and also. In the. A lady. We see that here there is. Subtle blurring on the Unsharp vessel margin. So it's quite hard to define here whether significant corner, other diseases present with plugs. Or is this just an artifact? Let's also. Have a look at this area on the other planes. Here also. There is like a blurring. Contrast here, so it's definitely difficult to. Diagnose this properly when we go to the curved NPR of the entity here. You can also see. This unsharp by some margin, so there's definitely contrast more distally in the. Distal LD but the image quality in this particular patient. Is sub optimal? So difficult, definitely to make a firm diagnosis here. So in addition to the standard coronary CTA image acquisition, the patient also underwent. Stress induced imaging after the Ivy administration of a Denison in this stress acquisition, let's have a look at this. So these are the images. And this is our normal again or normal linear blended or linear mixed image with 60% low KV, 40% hundred, 50K V leading us to a blending ratio of 0.6. So this would be the standard images. Again, if you wouldn't like. To have this lines here you can uncheck. It can also uncheck the field of view, so I personally like it better to have an overview over the patient like this. And we were uncertain if they lead. Was affected by coronary artery disease or at least our diagnostic confidence was low in this particular area. And we could imagine. That there is. Maybe a slide? Decreased alternation in the septum, but this is not really significantly different to the rest of the. My Cardium, so for improved perfusion assessment now. We could simply go to Mona Getic images at 40 heavy to have an improved visualization of the my Cardium and item distribution within the cardiac tissue. So let's do that. Maybe as a last step before we also have a look here. On the other planes and. Definitely remains difficult to diagnose, so we go to monadic plus here. Click it. And then we. If you're more getic images with 40K V. And now let's have a look at the myocardium. In this particular area and what we see is that the interventricular septum here gets quite hypodense. And. Specially here on the. Corona lview this becomes quite conspicuous actually. And. I would say here maybe this is due to beam hardening. Then it's always useful to go in the sagittal's, and when you go through the sagittal images here, you see that this is particularly. Sup in the cardial. So this is definitely no beam hardening artifact, but the stress induced hypo perfusion perfusion deficit. And. We see this now. Also like on the on the axials that this is subendocardial but not completely reaching the complete. Intra articular septum again Windows settings are important, so make sure to have a. Window where you can really assess my Cardium. In this case, the left ventricular volume is of lesser interest, but rather the conspicuity of hyperref used areas in the my Cardium itself. And for comparison. Let's actually you show. A representative area again. Maybe here is like very nicely visualized. Your normal image impression would be. Like 75 KV. So this is what you get. Using Standard city imaging with dual energy moonlight Rettig. This image would be like that. So the subjective. Evaluation is definitely enhanced or diagnostic confidences. Better than without dual energy reconstructions and again. It's always useful to quantify your findings with dual energy. Arrow eye measurements. And for instance. We can. Measure this year in the infected area compared to an area of the left ventricle where we see normal. Perfusion. Let's see if we can magnify this a bit better. And what we see is, for instance, here we have. Like only a difference in Huntsville units using the normal mixture. Open 6 images in the in fact from 85. 295 So we only have a difference of 10 Hounsfield numbers and in comparison with more logic imaging we have virtual Hounsfield numbers of 140 in the stress in induced hypo perfusion. Compared to 220 in the normal, my Cardium. So here we have a difference of 80 hansfield with Standard City. We only would have in the stress induced ischaemia of 10 Hounsfield. Also here higher confidence and more conspicuity and improved quantification. So another. Useful option to quantify my current perfusion better. Is the reconstruction of island Maps. So when we switch from the mono getic to the hard perfuse blood volume mode? We can see this now color coded. In Iran Maps. Again, would you would go to the left side? You see the virtual noncontrast image? And you go on the right side. You see only the iodine image. Maybe here it's better to have a mix of 40 and 60% overlay. Let's angle this a bit. Better to have a better. Idea? What's going on in this? Stress induced ischaemia. And. We see now. It's like similar to our impression from the majestic images that this is quite hypo attenuated. Suggestive of a hyperperfusion and. When we would like to measure this, we first have to normalize or do energy. Contrast, so this would indicate no 280 Hounsfield units. And. Then we can check that. And get to the dual entry feature of interest circle. And drawn area in a representative. Every of hyperperfusion, for instance here. In this Roy. It says here zero point. 4 milligram. Per milliliter volume. So let's compare that to. Other areas of the left ventricle. My cardio which are. Not hyper fuse, for instance. Here we see an iodine uptake of 2.3 milligram per milliliter. So we could say the perfusion indicated by the iodine uptake. Is. Substantially increased in this healthy my Cardium versus in this stress induced ischaemia. So Despite that we have sub to sub optimal image quality in our structural coronary CTA scan we can. Assess this hyperperfusion in the stress induced. Image acquisition. Better, more accurately and also more comprehensive than compared to the Standard City approach. Let's have a look at another case. I actually. Last thing I would like to explain is also here. Again, you have virtual noncontrast 60 Hounsfield. You have a contrast uptake of 12 ounce field and in the standard image you had you would have 75 Hounsfield numbers. And then of course we have the your iron uptake. Just to explain what is shown in the. Dual energy measurements, because these are quite a lot of values, but after certain time it becomes more intuitively and then you only look at the island density and also the contrast media uptake. So this is quite conveniently becausw without having a true non con. It just subtracts those values and gives you the relative enhancement in this. Area of 6 square millimeters. OK, let's move on to the next patient. This was a patient with. Lymphoma and was scanned. For a follow up staging. Let's first have a look at the normal. Images and we see this huge lymphomas in the axilla on both sides in the mediastinal AM. And also. In the abdomen. Due to the obesity, image quality is maybe a bit noisy. In this particular case, but what I would like to show you in this example. Is first how? Virtual noncontrast imaging can help you. In addition to your. Standard approach, for instance, when we go now to virtual unenhanced. We go to the level of the LD here, 'cause there's. With a significant calcification present. And I just would like to demonstrate that when we go to the virtual non con, the calcification in the entity remains and is not over substracted. So dual energy is able to selectively subtract the calcific and iodine within the vessels and not. The calcium, so for instance here on the saddles, just focus on the calcification of the dorsal part of the. Optimal order here, for instance, when you would go up again and add your iodine signal. So. The calcifications are not affected, so it's really a substitute for a true Nonconnah image acquisition. And. In this virtual nonconnah workflow. It's very useful to obtain measurements without any misregistration. For instance, we. Could again normalize or. Dual energy contrast and we go to a dual energy arrow I. And measure as well. Also like this tiny lymph nodes when? We now switch just back to the structural CDA to get a bit better and topical assessment, so see here. I'm just switching back and forth between the standard and the dual energy images. So I would like to measure this. Part here. In the virtual. Unenhanced workflow. And when we measure this tiny lymph node. We first obtain. Data regarding virtual noncontrast would have 40. Hansfield numbers, so it would be. With this density. And when we add contrast, it is quantitatively indicated with 1600 units of enhancement leading to a contrast enhanced density of 55 pounds field. Units and when we extend this error text, this isn't very important button too. Keep in mind. We then add also the iron density of milligram premiere leader. And. A normal biphasic image inquisition. It would be difficult probably to obtain the same breath hold in the patient. Or non con and. Contrast enhanced images. And also we have this liver cyst for instance. Of course, dual energy. Perfusion measurements work in every structure and you always ensure that you have no misregistration. You literally measure exactly the same volume. And finally, this is also more convenient for you as a reader, and radiologists becausw the measurements are faster. You not have to Cumbersomely go back to the non con image data set so you only have this virtual non con. In contrast information in the same patient. Thank you very much for your kind attention and yeah, see you at the next tutorial.

CT i" cc TAI_ALL CC CT ALL CC cc TM ALL ALL cc-rx CT CT CT HLP CT CT Dual Energy CT Co ronary 200 CT co rotary CCTAI Jonann-W01tgang-Goeme Frat-Kurt am Main CT Dual Energy Coronary App: VNC/ CW Mixed 0.6 App: 90/ Sn150/ 40 App: 90/ Sn150/ 40 Mixed 0.6 200 CT. ccTAl IODINE MAPS FOR IMPROVED ISCHEMIA VISUALIZATION MONO + FOR IMPROVED ISCHEMIA VISUALIZATION MODINO +APS FOR IMPROVED ISCHEMIA VISUALIZATION M0N0+ FOR INCREASED LATE ENHANCEMENT MONO+ FOR INCREASED LATE ENHANCEMENT DUAL-ENERGY CT IN CARDIAC IMAGING IODINE MAPS MAY IMPROVE DIAGNOSTIC ACCURACY QUANTIFICATION OF MYOCARDIAL PERFUSION o. o, e, o, e, Curer* CT CT. App: 90/ Sn1SO/ 40 kew Mixed 0.6 App: 90/ Sn150/ 40 kew Mixed 0.6 Mean: 93.3/71.6/141.3184.6 HI-I Mean: 93.3/71.6/14 / 84.6 Mean: 93.3/71.61141.3184.6 HI-I Mean: 93.3/71.6/141.3184.6 H Mean: 93.3/71.6/14 HI-I Mean: U Mean: 93.3/71.6/141.3184.6 App: Mixed App: CM/ Mixed App: 90/ keV/ Mixed 0.6 Cl. Cl. 3/12,201S CT CT. cr. cr. 3/12,201s Mean: Mean Min: 580/.0/52.0/93.0/ 63.0 HU Min: 58.0/52.0/93.0/ 63.0 HU Max: 63.0/ 1.0/.0/ 16.0/77.0 HU Min: 58.0/52.0/93.0/ 630 HU Min: 58.0/52.0/93.0/ HU Min: 320/ 36.0/82.0/98.0/ 52.0 HU Mean: 61.81 12.3/75.1/80.6/ HU 88.0/39.0/178 0/75.0 Energy 88.0/39 HU HU Mean: 115.0/ 64.1/219.1/ 94.6 HU App: VNC/ CW/ Mixed sniS0 Meax: Max: 101 0/192.0/108.0 Max: 0/192.0/108.0 Max: 192.0/ Max: 101 Max: Max: 7.043.0/85.0/ 10.0/12.0 HU Stddev: 10.0/ 10.6/14.8/ 10.9 HU VS 2 VS CT [2] CT [18] CT 131 CT [2] CT. S Plus [PIS CT 117 OHU Area: 10.1 mm2 Area. 0.2 cm2 Area: 40.3 mm2 Area 02 cm2 Area: 50.9 mm2 Area: 0.2 cm2 Area 02 mm2 Area: 12cm2 Min: HU Max: App: CW Mixed App Mixed App; CW Mixed Area: 12cm2 Area: cm2 Area 04 Area: 12 cm2 Area 02 cm2 Area; Area: Area; 143.0/85.0/ 117.0 Max: 71.0,'36.0/ 102.0/116.0/ 82.0 Max: 74.0/-4.0/54.0/ 12.0/32.0 Hu App: VNC/ CW Mixed 0.6 App: VNCI CM/ Mixed 0.6/90/ Sni50 App: VNC/ CW Mixed 0.6/90/ Sni50 App: VNC/ CW/ Mixed 0.6/90/ Sni50 Area 02 cm2 App: VNC/ CW/ Mixed 0.6 App: VNC/ CM/ Mixed Sn150 CT Mean: 61.81 12.3/758 HU Mean: El .e/ 12.3/75.1/80.6/ HU Mean: 12.3/75.1/80.6/ HU IS 2 0140 2 • 0140 2 Area: mm2 Area: 12cm2 Area. 0.2 cm2 0.1 cm2 CT [141 CT Mean: 43.5/3, 1/46.6/47, 1/45.8 HU Stddev. 10.6/14.8/ 10.9 Stddev•. 6.8/ 10.0/ 10.6/14.8/ 10.9 HU Stddev: 10.0/ 10.6/14.8/ 10.9 HU Iodine Dens % Iodine nsp App: VNC/ CM/ Mixed Sn150 CT Mean. 39.0/ 15.9/55.1/60.6/ 46.4 Mean. 39.0/ 15.9/55.1 Mean: 39.0/ 15.9/55.1 Mean. 39.0/ 16.9/55.1 Mean. 15.9/55.1 61 75.1/80.6,'67.0 Hu Iodinefilap Min: 44.0/-4 0/54.0/52 HU Max: 63.0/ 114.0/ 144.0/77.0 HU 52 HU Virtual unennancea Heart Virtual Unennancea Comprehensive approach with enhanced capabilities V"lual Unennancea V,rlual Hear' V"lual unennanc Vrlual Unennancea vrlual Vtlual Unennancea Virtlual Unennancea Ptv Ftv Unennancea U r•nnancea IJnennancec3 Max: 74.0/-4.0/54.0/ 12.0/32.0 Hu Min: 320/ 36.0/82.0/98.0/ 52.0 HU Min: 52.0/38.0 HU Stddev: 17.6/ 17.2/ 151/22.8124.1 HU Stddev: 6.216.6/ 8.2/ 12.1/66 HU Stddev: 10.0/ 10.6/14.8/ 10.9 HU Stddev: 17.6/ 17.21 151/22.8/24.1 Stddev: 17.2/ 151/22.8/24.1 HU — 0140 2 —S 0140 2 IS 2 75.1/80.6/67 Hu Iodinefilap Iodine Map ine Map Hu pu HU MRI Max: 71 36.0,'102.0,' 116.0/82.0 Hu Max: 7.043.0/85.0/ 10.0/12.0 HU Min: 6.0/-42.0/ 10.0/-8%/-7.0 High kVp High kV Iodine Map Iodinefilap Iodine Den Low kV Monoerergetic Monærergetic pms Monoerergetic pms Monoerærgetic POs Monoerærgetic pms Wonosrzrgetic Plus pms POs Min: 6.0/-42.0/ 10-0/-8.0/-7.0 HU Min: 6.0/-42.0/ 10-0/ @.0/-7.0 HU 0 5/ 100' Stddev: 12.2/ 12.9/ 11.2 HIJ Stddev: 12.2/ 12.9/ 11.2/ 17.3/ 18.0 HU Stddev: 12.2/ 12.9/ 11.2 WV Reawng WV Rea d,ng Stddev: 12.2/ 12.9/ 11.2 HU Stddev: 10.0/ 10.6/14.8/ 10.9 HU Stddev: 10.9 Hu HU Area: mm2 Area: 5 mm2 Area 0.2 cm2 Area 02 mm2 Area: 0.2 cm2 Max: 79.0/44.0/88.0/ 104.0/92.0 HU Min: 32.0/ 36.0/82.0/98.0/ 52.0 HU Max: 63.0/ 114.0/ 144.0/77.0 HU Man: 32.0/ 3.0/88.0/ 104.0/ 2.0 HU Max: 63.0/ 114/8.0/ 144.0/77.0 HU Min: 62.0/ 46.0/ 1.-0/98.0/ 72.0 HU Max: 79 0/44.0/88.0/ 104.0/92.0 HU Min: HU 5' Max: 71.0,'36.0/ 102.0/116.0/ 82.0 Iodine Density: 2.3 mg/ml 21 87 % Iodine Density: 2.3 mg/ml 21 8 % Iodine Density: 043 mg/ml 3.78 % Iodine Density: 0.4 mg/ml 3.78 % Iodine Den Area: cm2 Area: 10.1 mm2 Area. 0.2 cm2 Area: 5.9 mm2 Area: 4.3 mm2 Min: 6.0/-10.0/26.0/ 20.0/ 12.0 HU Area: 0.2 cm2 Max: HU HU Hu Short Axis View Area: 10.1 mm2 Max: 71.0/36.0/ 102.0/ 116.0/82.0 HU Max: 1160,' 820 Area: 10.6 cm2 Area: 0.6 cm2 Area: cm2 Area: 0.2 cm2 Four DUAL-ENERGY CT TUTORIAL #3 Evaluation protocol Area: mm2 Area: 12cm2 Area: 0.2 cm2 Sensitivity Specificity p•value 5.9 mm2 AUC Iodine Density: 2.3 mg/ml 21 89 % Iodine Density: 0.1 mg/ml 10.9 % Iodine Density: 0.1 mg/ml 210.9 % DECT Data Acquisition Max: 64.0/47.0/80.0/ 96.0/86.0 HU Min: 32.0/ 36.0/82.0/98.0/ 52.0 HU CV 20 0 Iodine Dens m 13.7% Iodine Dens 0.4m Iodine m 113.7% THANK YOU! Area: 0.2 cm2 Area: 0m2 Are"2 cm2 cm2 WV WV Rea ding Rea mg Rea ding For the proper use of the software or hardware, please always use the Operator Manual or Instructions Iodine Densit :'O+mg/ml 19.5 % Iodine Density 1 2 ? 1 2 mg/ml j 80 [18] CT 131 CT App: 140/ _ App- 140/ _ 2. Mean 79 7 Hu 117 79 7 Hu . App: VNCI CM/ Mixed 0.6/90/ Sni50 App: VNC/ CW Mixed 0.6/90/ Sni50 App: VNC/ CM/ Mixed Sn150 1.2 mg/ m on Infarction Infarction WV WV Rea Mg Rea Mg Rea eng Incremental Stddev [181 CT Mean Mean: Mean: 48.8/ 50.9/98 4/ 119 91 65.9 HUI Mean: 48.8/ 50.9/98 4/ 119 91 65,9 HUI Area. 0.2 cm2 Area: 5.9 mm2 Area: 1.2 cm2 Area 0.2 cm2 Area: 0.2 cm2 Area: 4.3 mm2 Area: 40.3 mm2 Area. cm2 Area: 10.1 cm2 Area 02 cm2 Stddev: 6.216.6/ 8.21 12.1/66 HU Stddev: 6.216.6/ 8.2/ 12.1/66 HU Stddev: 10.0/ 10,6114.3/ 10.9 HU Stddev: 10.0/10.6/ 14.8/ 10.9 HU Min: 32.0/ 36.0/ 1.0/98.0/ 72.0 HU Min: 32.0/ 36.0/82.0/98.0/ 52.0 HU Min: 320/ 36.0/82.0/98.0/ 52.0 HU Min: 3.0/ 36.0/ 1.0/98.0/ 72.0 HU Max: 63.0/ 114/8.0/ 144.0/77.0 HU Max: 63.0/ 1.0/8.0/ 144.0/72.0 HU MYOCARDIUM Max: 58.0/ 63.0/ 114.0/ 144.0/77.0 HU Max: 63.0/ 114.0/ 144.0/77.0 HU Max: 63.0/ 114/.0/ 144.0/77.0 HU Max: 63.0/ 1.0/8.0/ 94.0/77.0 HU Min: 6.0/-42.0/ 10-0/-8.0/-7.0 HU Max: 63.0/ 1.0/8.0/ 144.0/72.0 HU Stddev 21 21 27 95% cCTA positive 0.723 the software and hardware available at the time of the training. diagnostic value Area: 50.9 mm2 Area: 0.2 cm2 Area: 4.3 mm2 Area 0.2 cm2 Area: 40.3 mm2 Area: 12cm2 Area. 0.2 cm2 Area: 02 cm2 Area: 5.9 mm2 Area: 4.2 cm2 Area: 1.1 mm2 Area 02 cm2 Area: 10.1 mm2 Area: 4.3 cm2 Area: 0.2 mm2 Area: 123 cm2 CT Iodine Density: 2.3 mg/ml 21 8 % Iodine Density: 243 mg/ml 213.7 % Iodine Densit : 2.3 1121.8% The herein illustrated statements mode by Siemens' customers and physicians are based on their own App: VNC/ CM/ Mixed 0.6/90/ Sni50 131 CT [18] CT [2] CT Area. 0.2 cm2 Area: 10.1 mm2 Area: mm2 Area: 02 cm2 Area: 12cm2 Area: 0.2 cm2 Area 0.2 cm2 Area cm2 Area 02 cm2 Area: 021 cm2 Area: 1.2 cm2 App Mixed Mixed (at least one stenosis >50%) The Operator Manual shall be used as your main reference, in particular for relevant safety information and discrete opinion. The speaker is responsible for obtaining permission to use any previously Mean Densey. Densey. 1.3 of iodine maps in Stddev Stddev 5 Man: 32.0/ 36.0/88.0/ 1.0/ 52.0 HU Area: 12cm2 Area: mm2 Area: 0.2 cm2 Area: cm2 Area: 5.9 mm2 Max: 58.0/ 63.0/ 114.0/ 144.0/77.0 HU Stddev: rgeuc Plus express written authority. Offenders will be liable for damages. CT CT. RAH Area: 10.1 mm2 Max: 101 0/192.0/108.0 5/ IOUSnt40 Low kVp Low kV High kVp High kV 512 Note: Some functions shown in this material are optional and might not be part of your system. The 200 200 u) 200 u] u] u) 230/71 7/338/ addition to Iodine 2.3 All names and data of patients, parameters and configuration dependent designations are fictional Perfusion defect on DECT 95% 0.672 0.723 Stddev 21 1 Stddev 21 Iodine Density: 243 mg/ml 213.7 % o Findings Navigator information in this material contains general technical descriptions of specifications and options as well cMPR r: 65MMl-EWå200 L400 65MMl-EW4200 L400 65MMl-E.Wå200 L400 55MMl-E.Wå200 L400 S5 VMI+ M 0.5 W800 L300 L400 and examples only. For optimal o Findings Navigator customer's unique setting. Since there is no "typical" setting and many variables exist there can be no myocardial iodine maps structural CCTA structural OCTA [email protected] 0 5 cm2 0 5 crn2 rqoo raoo raoo rqoo AINI+ r 300 r 900 o Findings Navigator guarantee that other customers will achieve the same results. SPECT -Standard Standard 4 0 mg/ml e Mono+ M no+ contrast and ALI rights, including rights created by patent grant or registration of a utility model or design, are Besides mere measurements based on CT Iodine maps aid in the visual Noise-optimized low kev virtual monoenergetic images (Mono+) also OE Noise-optimized kev virtue! monoenergetic images ('Viono+) e'so reserved. 0.13.,_ Routine Reconstruction Optional Reconstruction Optional Reconstruction Routine Reconstruction App CW 0 5/ Sn140 perfusion Mean 27 density (HU), dual-energy CT allows for • 2/374f292HU 208126 Either positive 100% 33% 0.67 0.04 0.23 0.04 assessment and delineation of Good correlation with SPECT Good correlation also with MRI Low kev virtual monoenergetic images (Mono+) allow for improved t • Copyright O Siemens Healthcare GmbH, 2018 provide improved visualization of infarcted myocardial tissue assessment organization for further details. Mar '890/ Mar quantification of iodine uptake Area 04 Area: 0m2 Area 0 4 VNCiCWMeedO hypoperfused myocardial tissue visualization of late enhancement in chronic infarction Adjustment of window settings is crucial 7/83 2,' 576 vs normal 3.2 mg/ ml vs normal 3F2 mg/ ml vs normai 3.2 mg! ml 200,' 21 200' 21 21 DECT allows for assessment of perfused myocardium in cardiac Both positive 67% 0.04 -33 .33 Iodine uptake in mg/ mL directly indicates odine uptake in mg/m directly indicates ,Mono+ both improve positive and negative contrast' Good correlation with SPECT Meax Mean Virtual Non- Linearly- VMI 55 kev VMI 120 kev VMI 40 kev VMI 120 kev VMI 420 kev 40 kev 40 kev 120 kev VMI 120 kev CT Contrast Blended Map Max Mean lodne 3 9 lodne 9 perfusion occlusion Perfusion Tools De Cecco, Schoepfet al, AJR 2014 Albrecht, Schoepf, De Cecco, EJR, subEyi!t9d Ruzsics, Schoepfet al, Circulation 2008 Vliegenthart, Schoepfet al AJR 2012 Albrecht, Schoepf, De Cecco, EJR, subEyi!t9 Albrecht, Schoepf, De Cecco, EJR, submitted Albrecht, Schoepf, Albrecht, Schoepf, Des Cecco, EJR, submitted Albrecht, Schoepf, De Cecco, EJR, submyitted De Cecco, EJR, submitted O [HUI O (HUI Mt(ing Ratio Mixing Ratio Ratio Ratio Mon 100% 212 pu pu 200