DI EUROPE Diagnosis • Technology • Therapy • Prevention

APRIL/MAY 2019

MSK Imaging

Dual energy Cone beam CT arthrography of the knee joint acquired using Carestream’s On Sight extremity CBCT system. Images courtesy of W. Zbijewski, W Stayman and J. Siewerdsen. Johns Hopkins University, USA. EUROPE

Cardiac Imaging Special

CTCA and the SCOT- trial. A management strategy based on an imaging test for patients with suspected coronary heart disease can improve clinical outcomes Are coronary CT and CT-Based FFR set to become a game-changer in coronary disease ? An interview with Prof. PW Serruys Coronary CTA enhanced with CTAbased FFR analysis provides higher diagnostic value than invasive coronary angiography Efficacy study of CT-FFR software using 3D printed patient-specific coronary phantoms CAD-RADS: a new era in The role of Coronary coronary CTA reporting Cardiovascular Imaging. 3D imaging of the human carotid artery with volumetric CT Angiography in multispectral optoacoustic (vMSOT) News suspected coronary

MRI. Utilizing DICOM metadata to improve workflows heart disease Imaging News Industry News Technology Update

Book Review

­ DIEUROPE.com ­ European Diploma October 3-5, 2019 | Budapest, HU Annual Scientific Meeting in Breast Imaging European Society of Breast Imaging

» is a common European qualification for breast imagers, helping to Early bird fees standardise training and expertise in until June 30 breast imaging across Europe. » confirms specific competence of radiologists to perform, interpret and report , ultrasound, MRI and breast intervention. » will assist breast imagers in promoting their skills and experience in breast imaging when dealing with other clinical colleagues and the general public.

EXAMINATION DATE: October 3, 2019

APPLICATION DEADLINE: July 15, 2019 In cooperation with the Breast Diagnostics Section of the Hungarian Society of Radiologists NEW Eligibility criteria! www.eusobi.org

Please find all details, the NEW eligibility criteria and the application form at www.eusobi.org or email to [email protected] for any questions. DI EUROPE BY Alan barclay, Ph.D.

VOLUME 35, NUMBER 2 FROM THE EDITOR EDITORIAL ADVISORY BOARD Andreas Adam, London Richard P. Baum, Bad Berka Frits H. Barneveld Binkhuysen, Elias Brountzos, Athens Filipe Caseiro Alves, Coimbra Carlo Catalano, Rome Machine Learning: the need Maksim Cela, Tirana Patrick Cozzone, Marseille Katarzyna Gruszczynska, Anne Grethe Jurik, Arhus Andrea Klauser, Innsbruck Gabriel Krestin, Rotterdam to equip radiologists with sufficient Gabriele Krombach, Giessen Christiane Kuhl, Bonn Philippe Lefere, Roeselare Heinz U. Lemke, Kuessaberg Thoralf Niendorf, Berlin Anne Paterson, Belfast knowledge of the future Anders Persson, Linköping hans Ringertz,Stockholm Gustav von Schulthess, Zurich Valentin E.Sinitsyn,Moscow Patrick Veit-Haibach, Lucerne Thomas J.Vogl,Frankfurt his year, there was no prob- The question that radiologists lem in determining what was should pose is how best to prepare for EDITORIAL STAFF the hot topic at the recent this brave new world. Such prepara- Editor Alan Barclay, Ph.D. ECR meeting. The big sub- tion is complicated by the fact that E-mail: [email protected] ject on everybody’s lips this year is the many people are still not sure of the Tel. +32 479 370 364 T US Consulting Editor Greg Freiherr continued, exponential growth of arti- differences between the terms AI E-mail: [email protected] ficial Intelligence (AI). As the current and machine learning (ML) that are Publishers David Lansdowne October 3-5, 2019 | Budapest, HU E-mail: [email protected] president of the European Society of sometimes bandied about and used European Diploma Bob Warren Radiology, Professor Lorenzo Derchi, (in error) interchangeably. (ML is the E-mail: [email protected] Annual Scientific Meeting pointed out, one of the promises of subset of AI whose aim is to enable European Society of Breast Imaging AI is the possibility to make sense systems to learn by themselves using in Breast Imaging of the huge amounts of data that are provided data and to make accurate SUBSCRIBER SERVICES generated by a typical modern hospi- predictions). The use of ML in radiol- » is a common European qualification Telephone: +44 1442 877777 tal, which generates approximately 50 ogy is perhaps the most active area petabytes , or 50 million gigabytes per and it is important for radiologists to for breast imagers, helping to Subscription and article reprints: Early bird fees E: [email protected] annum, not just because of radiological understand its implications, since there standardise training and expertise in images but also from clinical notes, lab is a clear role for radiologists to play. Subscription rates per annum: until June 30 images and results and genomics. The breast imaging across Europe. Within Europe €60.00 As a group from Mass Gen Hospital ROW €110.00 amount of such data is so huge that in in the USA have pointed out, although » confirms specific competence of INTERNATIONAL SALES OFFICES practice no human can extract all the radiologists are currently expected to Europe, North America & Japan information — it is estimated that only understand the imaging process from radiologists to perform, interpret and DI Europe Ltd 3% of the data generated in the hospi- the production of ionizing radiation report mammography, ultrasound, Tel: + 44 (0)1442 877777 tal is actually used. Of course, data by in a CT scanner to the visualization of Marika Cooper themselves are useless. To be useful the a pixel on their monitor, there is cur- MRI and breast intervention. E-mail: [email protected] data must be analyzed interpreted and rently no such standard for ML. (Wood » will assist breast imagers in promoting acted upon. AI systems could help in et al. The need for an ML curriculum for this and thus open up the possibilities radiologists JACR 2018 doi.org/10.1016/ their skills and experience in breast of improved efficiency and, diagnos- j.jacr.2018.10.008). The group argue imaging when dealing with other China Korea tic accuracy and ultimately improved that if radiologists are expected to uti- Adept Marketing Young Media Inc patient outcomes. Prof Derchi also lize ML models safely and effectively clinical colleagues and the general 13F Por Yen Bldg 407 Jinyang Sangga 478 Castle Peak Road 120-3 Chungmuro 4 ga made allusion to the fear felt by many for imaging interpretation, education public. Cheung Sha Wan, Kowloon Chung-Ku, Seoul, Korea 100-863 radiologists that AI is an existential for all levels of background and expe- Hong Kong E-mail: [email protected] threat to the very profession of radiol- rience will be required, and a formal- E-mail: [email protected] Telephone: +82 2 2273 4819 Telephone: +852 2891 7117 Fax: +82 2 2273 4866 ogy. However whatever the threat the ized ML curriculum targeted toward Fax: +852 2893 2101 Contact: Young J. Baek reality is that AI is coming and in fact early career radiologists and trainees is EXAMINATION DATE: Contact: Adonis Mak is already here. And although radiol- urgently needed. October 3, 2019 ogy and image analysis are fields that The group concludes that the are particularly amenable to the appli- emergence of ML technology in APPLICATION DEADLINE: cation of AI, it should be noted that radiology cannot be denied. Rather DIAGNOSTIC IMAGING EUROPE is published six times a year by DI Europe Ltd many other healthcare disciplines (e.g. than succumbing to fear and scep- Printed by Manson, St-Albans, UK. Annual subscriptions are available for €60 July 15, 2019 within Europe where it is also sent free of charge to physicians and radiology department heads. Outside of Europe, there is an annual subscription charge robot-assisted or even hospi- ticism, future radiologists must be of €110 for air mail. Single copy price is €10. Editorial Advisory Board members suggest topics for coverage and answer questions for the editors. They do tal administrative workflows) are also equipped with a working knowledge In cooperation with the Breast Diagnostics Section not conduct a formal peer-review of all manuscripts submitted to DI Europe. set to undergo changes caused by the of ML to leverage the tools as they are of the Hungarian Society of Radiologists Copyright © 2019 DI Europe Ltd. All rights reserved. Reproduction in any form is forbidden without express permission of copyright owner. arrival of A . If only because of the deployed. To truly advance the stan- NEW Eligibility criteria! financial imperatives behind the imple- dard of patient care, radiologists will www.eusobi.org mentation of AI in healthcare there not only be required to appropriately DI Europe Ltd is no doubt that it is here to stay, and consume ML model output but also 2 Claridge Court Lower Kings Road grow. An analysis carried out by the participate in its development and Berkhamsted, Herts HP4 2AF UK consulting company Accenture esti- implementation to ensure that the Telephone: +44 1442 877777 Please find all details, Fax: +44 1442 70617 mated that the health AI market (not most critical challenges in the profes- the NEW eligibility criteria and the just radiology) would undergo 40% (!) sion are addressed. application form at www.eusobi.org compounded annual growth rate over Via such participation, a continuing, or email to [email protected] the next years although exactly when important role for the radiologist is the full impact of AI in radiology will assured, albeit somewhat changed from for any questions. DIEUROPE.com be felt is still not sure. today’s role. n

APRIL/MAY 2019 DI EUROPE 3 ®

APRIL/MAY 2019 EUROPE

COVER STORY

Computed Tomography Coronary Angiography and the SCOT-HEART trial. Front cover image results of the SCOT-HEART (Scottish Computed Tomography of the HEART) CT image from a 56 year old female with a his- randomised controlled trial, whose 5-year follow-up data have recently tory of atypical chest pain who particpated in the been published, have established the role of CT CoronaryAngiography for SCOT-HEART trial which showed that a signifi- patients with symptoms of suspected . . . 18 cantly lower rate of coronary heart disease death or non-fatal occurred in the CTCA group compared to the standard care group. Image courtesy of Dr. REPORTS Michelle Williams

Feature article

40 | MRI. Utilizing DICOM metadata to improve radiology workflows

Imaging News

The SYNTAX III trial showed that Coronary CTA enhanced with The feasibility of using volumet- 5| whole-body MRI stages there was almost perfect agree- CTA-based FFR analysis provides ric MSOT in clinical imaging of colorectal and cancers ment between heart teams who higher diagnostic value than the human carotid artery more quickly, cheaply used either invasive coronary invasive coronary angiography angiography (ICA) or Coronary CT Page 34 6| interventional radiology angiography (CCTA) to decide on Page 24 treatment of ‘tennis elbow’ the revascularization treatment in patients with severe CAD 6| 7T MRI tracks Multiple Page 21 Sclerosis

7| deep-learning model Feature Articles improves prediction of lung cancer survival Extremity CT: the basics and the promise. Report on the Carestream sponsored symposium “Advancements in Volumetric Extremity Imaging”.. . 10 7| experimental PET scan Efficacy study of CT-FFR software using 3D printed patient-specific detects abnormal tau coronary phantoms...... 27 protein in brains of former footballers CAD-RADS: a new era in coronary CTA reporting...... 30

8| AI software improves X-ray Cardiac Imaging News identification of pacemakers Personalized ultrasound scan showing helps patients reduce cardiovascular risk...... 14 8| interventional radiologists key to increasing access to MRI coronary wall thickness is independent marker of thrombectomies heart disease in women...... 14 PET/MRI predicts cardiovascular risk from arterial inflammation.. . . 15

Combined SPECT and cardiac MR imaging can help guide ventricular ablation...... 17 29 | Book Review Coronary Artery Calcium in South Asians...... 17 36-39 |Industry News

43-50 |Technology Update in the Next issue: Breast Imaging Visit us at DI EUROPE DIEUROPE.com

APRIL/MAY 2019 DI EUROPE 4 IMAGING NEWS Whole-body MRI stages colorectal and lung cancers more quickly, cheaply Colorectal cancer and non small cell lung determine the size of tumors and how much recorded, they considered images and cancer (NSCLC) are leading causes of can- they had spread, by five days for colorectal reports from WB-MRI. The panel were then cer-related deaths. In both diseases, accurate cancer patients and six days for lung cancer able to say whether their first treatment deci- staging is vital for optimal outcomes, par- patients. The treatments decided upon were sion would have been different based on ticularly for the identification of metastases. similar, since results from MRI were as accu- WB-MRI result. Patients were also followed Current staging pathways, such as up after 12 months to evaluate the those recommended by the UK’s accuracy of WB MRI compared National Institute for Health and with standard tests. Care Excellence (NICE) rely on Sensitivity and specificity of diag- several individual high technol- nosis for WB MRI did not differ ogy imaging modalities such as from those obtained by the stan- CT, PET-CT, and MRI, which dard tests for both cancers. The use differ in their diagnostic accura- of WB MRI reduced the time it cies across individual organs. For took to complete diagnostic tests, colorectal cancer, the guidance from an average of 13 days to an on staging pathways includes CT average of 8 days in the colorectal of the chest abdomen and pelvis, cancer trial and from 19 days to 13 supplemented by pelvic MRI for days in the lung cancer trial. Costs local staging of rectal cancer. It is were reduced from an average of also not unusual for patients to £285 to £216 in the colorectal can- undergo PET CT and/or liver cer trial and from an average of MRI if disease spread is suspected. Whole-body MRI at 1.5T acquired on a Siemens MAGNETOM Avantofit Courtesy £620 to £317 in the lung cancer Staging pathways in lung cancer W McGuire,, Paul Strickland Scanner Centre, Northwood, Middlesex, UK and trial. Siemens Healthineers are even more complex, with CT, In the colorectal cancer trial, agree- PET-CT, MRI, US and endobronchial/ per- rate as those of standard investigations, but ment with the final multi-disciplinary panel cutaneous biopsy all recommended at vari- the costs per patient were reduced by nearly treatment decision based on standard inves- ous points during staging. a quarter in the case of colorectal cancer and tigations and WB-MRI was high (95% and Since modern MRI scanners can image the were almost halved for lung cancer. More 96%, respectively), as were results for the entire body within 1 h, a multi-centric UK- research is needed to determine how this lung cancer trial (99% for standard investi- based group of researchers hypothesized affects outcomes for patients. gations, and 98% for WB MRI). that whole-body MRI (WB-MRI) — which The authors are aware that despite their The authors note that waiting times might typically scans from the head to mid-thigh accuracy and efficiency, that MRI scanners not be representative of other UK hospitals — is a potentially more accurate and safer are not as widely available as other imag- or of hospitals in other countries. A further alternative to standard multimodality stag- ing technologies and are in high demand. limitation of the lung cancer trial is that sen- ing pathways. “Our results, obtained in a real-world NHS sitivity in detecting the spread of cancers The group set up two large prospective, setting, suggest that WBMRI could be more - including the development of secondary multicentre trials, one for colorectal cancer suitable for routine clinical practice than the tumors and the spread to lymph nodes - was and one for NSCLC. They involved nearly multiple imaging techniques recommended low using both current standard imaging 500 patients across 16 hospitals in the UK. under current guidelines,” says lead author techniques and whole body MRI. The results of these trials have now been Professor Stuart Taylor from UCL, UK. Writing in a linked Comment, Professor published (Taylor SA et al. Diagnostic accuracy “While demand on NHS MRI scanners is cur- Andreas Schreyer from Brandenburg of whole-body MRI versus standard imaging rently high, adopting WB-MRI more widely Medical School, Germany, said of the pathways for metastatic disease in newly diag- could actually save rather than increase costs, colorectal cancer trial: “MRI has faced con- nosed non-small-cell lung cancer: the prospec- as well as reducing the time before a patient’s siderable backlash within the medical com- tive Streamline L trial Lancet Respir Med. May treatment can begin.” munity due to relatively high costs and the 9, 2019. Doi: /10.1016/S2213-2600(19)30090-6; For the first time, the two new trials compare high demand. This is why it is particularly Taylor SA et al Diagnostic accuracy of whole- the diagnostic accuracy and efficiency of important to think “outside the box” and look body MRI versus standard imaging pathways for WB-MRI with the standard NHS pathways, out for new medical pathways and paradigms metastatic disease in newly diagnosed colorectal which use a range of imaging techniques for and not to be driven by prejudices. Such new cancer: the prospective Streamline C trial, Lancet assessing colorectal and lung cancers. The pathways, e.g. the use of WB-MRI which Gastroenterol Hepatol. May 9, 2019 doi. 10.1016/ standard imaging tests were undertaken as are often thought of as more expensive and S2468-1253(19)30056-1). usual and the usual multi-disciplinary panel complex at first sight, can eventually change The findings show that WB-MRI scans made a first treatment decision based on clinical pathways while being more time- and reduced the average time needed to their results. Once this decision had been cost-efficient..”

APRIL/MAY 2019 DI EUROPE 5 IMAGING NEWS Interventional The TAE treatment can be completed in Twenty-five of the MS patients, or 80 radiology treatment approximately one hour and requires only percent, developed new cortical lesions, of ‘tennis elbow’ a needle insertion under local anesthesia and the 7T MRI detected them more to access the radial artery in the wrist. A frequently compared to previous stud- Tennis elbow, the painful chronic condi- is moved through the wrist to the ies at lower-field 3T MRI strength. On tion that can affect up to 3 percent of the elbow where the inflamed blood vessels average, the number of lesions that active adult population, can be effectively are embolized, preventing excessive blood developed in the cortical region was treated through transcatheter arterial flow to the affected part of the elbow. The more than twice the number that devel- embolization (TAE), the image-guided, treatment is safe and effective and doesn’t oped in the white matter of the brain. non-surgical treatment that decreases require physical therapy, researchers said. The total volume of cortical lesions was abnormal blood flow to the injured area to No adverse events were observed and no a predictor of neurological disability reduce inflammation and pain, according patients experienced negative effects to the at both baseline and follow-up assess- to research presented at the recent Society surrounding bones, ment. of Interventional Radiology’s 2019 Annual www.sirtoday.org/tae-could-offer-relief- “The 7T brain scans showed that the corti- Scientific Meeting (www.sirtoday.org/tae- from-tennis-elbow/) cal sulci are the regions where most of these could-offer-relief-from-tennis-elbow/). The lesions develop,” Dr. Mainero said. “We also condition, also known as lateral epicon- 7T MRI tracks Multiple found that these lesions can predict dis- dylitis, stems from repetitive stress injuries ability progression more than white matter that occur in activities such as sports, typ- Sclerosis lesions, which are the typical lesions of MS ing and knitting, and the injury can impact The development of scars, or lesions, we’ve been studying for years.” basic tasks that affect job performance and in the brain’s cortical gray matter is a While the reasons for the accumulation the quality of life. powerful predictor of neurological dis- of lesions in the sulci are not defini- ability for people with multiple sclerosis tively known, researchers note that the (MS), according to a recently published flow of cerebrospinal fluid is likely to be study (Treaba CA et al. Longitudinal restricted there, which might make the Characterization of Cortical Lesion sulci more vulnerable to inflammatory Development and Evolution in Multiple responses. Sclerosis with 7.0-T MRI. Radiology. 2019 The results suggest that assessment of cor- Apr 9:. doi: 10.1148/radiol.2019181719). tical lesions should represent a main com- The findings suggest a role for ultra-high- ponent in the evaluation of progression of field-strength MRI in evaluating the pro- disease burden in MS, gression of MS. “Tennis elbow can be difficult to treat, MS is a disease in which the body’s leaving many patients unable to perform immune system attacks the protec- the simplest tasks, such as picking up their tive covering surrounding the nerves children, cooking dinner, or even work- of the central nervous system. Recent ing on a computer. With this frustration, research has shown that cortical many patients turn to invasive major sur- lesions, or lesions in the gray matter gery after years of failed physical therapy of the outer layer of the brain, develop and medication use,” said Dr Y Okuno, early in the course of the disease. These lead author of the study. “We were inter- lesions are not easy to see with conven- ested to see if TAE, already in use in other tional-strength MRI. In the new study, areas of the body, would be effective for researchers tracked MS patients using this common, debilitating condition and a 7-Tesla MRI scanner to determine if help people immediately regain a range of the lesions are correlated with neuro- motion that many of us take for granted in logical disability and disease progres- Axial 7.0-T T2*-weighted images show examples of our everyday tasks .” sion. “In this study, we wanted to track leukocortical lesions (white arrows) and intracortical Dr. Okuno’s team conducted a prospec- the evolution of these lesions and better lesions (black arrows) along with juxtacortical and tive study in 52 patients with tennis elbow understand where in the cortex these periventricular white matter lesions in a a 40 year old woman with secondary progressive MS (SPMS). CREDIT who had not found relief from other forms lesions develop more frequently.” Radiological Society of North America of treatment. The patients received TAE The researchers followed 20 relapsing- and were followed for up to four years remitting and 13 secondary-progressive after the treatment. The researchers found MS patients over time, along with 10 “This can have a very powerful impact statistically significant reductions in sev- age-matched healthy controls. (Relapsing- on how we monitor patients with MS,” eral well-established pain-rating scores, remitting is the type of MS in which the said Dr C Mainero, lead author of the Additionally, images taken in 32 patients symptoms sometimes improve and some- study, “We can also use this tool to see how two years after undergoing TAE showed times worsen, while secondary-progres- potential treatments can affect the devel- an improvement in tendinosis and tear sive is characterized by more significant opment and evolution of cortical lesions.” scores. disability). doi: 10.1148/radiol.2019181719

6 DI EUROPE APRIL/MAY 2019 IMAGING NEWS Deep-learning model dataset of 581 images and an indepen- (CTE) in a small group of living American improves prediction dent validation dataset of 178 images from (NFL) players with cognitive, mood and lung cancer survival 89 patients with NSCLC who had been behavior symptoms (Stern RA et al. Tau treated with chemoradiation and surgery. Positron-Emission Tomography in Former Lung cancer is one of the most common The model’s performance improved with National Football League Players. N Engl J cancers and a leading cause of cancer the addition of each follow-up scan. The Med. 2019 May 2;380 :1716. doi: 10.1056/ death worldwide. Non Small Cell Lung area under the curve for predicting two- NEJMoa1900757). cancer (NSCLC) accounts for about 85 year survival based on pretreatment scans The researchers also found that the more percent of all lung cancers. The standard alone was 0.58, which improved signifi- years of tackle football played (across all assessment for diagnosis and response to cantly to 0.74 after adding all available levels of play), the higher the tau protein therapy for NSCLC patients relies heavily follow-up scans. Patients classed by the levels detected by the PET scan. on the measurement of maximum tumor model as having low risk for mortality had diameter, which is susceptible to varia- six-fold improved overall survival com- tions in interpretation between observ- pared with those classed as having high ers and over time. A multi-national risk. group of researchers hypothesized that Compared with the current clinical model that utilizes parameters of stage, gender, age, tumor grade, performance, smoking status, and clinical tumor size, the deep- learning model was more efficient in pre- dicting distant metastases, progression, and local regional recurrence. However, there was no relationship “Radiology scans are captured routinely between the tau PET levels and cognitive from lung cancer patients during follow- test performance or severity of mood and up examinations and are already in digi- behavior symptoms. tized data forms, making them ideal for CTE is a neurodegenerative disease that artificial intelligence applications,” said has been associated with a history of lead author Dr H Aerts “Deep-learning repetitive head impacts, including those models that quantitatively track changes associated with concussion symptoms in in lesions over time may help clinicians American football players. At the moment, tailor treatment plans for individual CTE can only be diagnosed after death patients and help stratify patients into dif- by a neuropathological examination, Like ferent risk groups for clinical trials.” He Alzheimer’s disease (AD), CTE has been Artificial Intelligence (AI) algorithms added “Our research demonstrates that suggested to be associated with a progres- could automatically quantify radio- deep-learning models integrating routine sive loss of brain cells. In contrast to AD, graphic characteristics that are related imaging scans obtained at multiple time the diagnosis of CTE is based in part on to, and may therefore act as, non-invasive points can improve predictions of survival the pattern of tau deposition and a relative radiomic biomarkers for immunother- and cancer-specific outcomes for lung can- lack of amyloid plaques. apy response (Trebeschi S et al Predicting cer. By comparison, a standard clinical Results showed that the tau PET levels Response to Cancer Immunotherapy using model relying on stage, gender, age, tumor were significantly higher in the former Non-invasive Radiomic Biomarkers. Ann grade, performance, smoking status, and NFL group (26 players) than in the con- Oncol. 2019 Mar 21. Doi 10.1093/annonc/ tumor size could not reliably predict two- trols (31 same age men) and the tau was mdz108). The group transferred learning year survival or treatment response. To seen in the areas of the brain which have from ImageNet, a neural network created the best of our knowledge, this study is the been shown to be affected in post-mortem by researchers at Princeton University first of its kind to investigate radiomics as cases of neuropathologically diagnosed and Stanford University that identifies a noninvasive for response to CTE. a wide range of ordinary objects from cancer immunotherapy” Interestingly, the former player and control the most relevant features, and trained Doi 10.1093/annonc/mdz108 groups did not differ in their amyloid PET their models using serial CT scans of measurements. 179 patients with stage 3 NSCLC who Experimental PET scan “Our findings suggest that mild cogni- had been treated with chemoradiation. tive, emotional, and behavioral symptoms The researchers included up to four detects abnormal tau observed in athletes with a history of repeti- images per patient obtained routinely protein in brains of tive impacts are not attributable to AD, and before treatment and at one, three, and they provide a foundation for additional six months after treatment for a total of former footballers research studies to advance the scientific 581 images. Using an experimental PET scan, research- understanding, diagnosis, treatment, and The investigators analyzed the model’s ers have found elevated amounts of abnor- prevention of CTE in living persons”, said ability to make significant cancer outcome mal tau protein in brain regions affected co-author Dr. E Reiman, predictions with two datasets: the training by chronic traumatic encephalopathy doi: 10.1056/NEJMoa1900757.

APRIL/MAY 2019 DI EUROPE 7 IMAGING NEWS

AI software improves clinicians need to determine the model “With a limited availability of provid- of a device to investigate why it has ers, thrombectomy is only available to 2 to X-ray identification of failed. Unless they have access to the 3 percent of eligible patients in the United pacemakers records where implantation took place, States,” said Dr. K Hong, of Johns Hopkins A recent publication by a team from staff must use a flowchart algorithm University. “Patients don’t plan where and Imperial College, London, UK describes to identify pacemakers by a process when they have a . Our model of the development, validation, and public of elimination. The flowchart shows training board-certified interventional availability of a new neural network- a series of shapes and circuit board radiologists can expand access to quality, based system which attempts to identify components of different pacemakers evidence-based care, and reduce the life- from a the manufac- designed to help identify the make long disability associated with stroke.” turer and even the model group of a and model of a patient’s pacemaker. pacemaker or defibrillator. (Howard, Not only is this time-consuming, but JP et al. Cardiac rhythm device identi- these flow charts are now outdated and fication using neural networks. JACC therefore inaccurate. This can result in Electro Physiology, 2019; doi: 10.1016/j. delays to delivering care to patients, jacep.2019.02.003) who are often in a critical state. In the new study, researchers trained a neu- ral network software program to iden- tify more than 1,600 different cardiac devices from patients. To use the neural network, the clini- cian simply uploads the X-ray image containing the device into a computer Thrombectomy, the treatment that and the software reads the image, to give clears a clogged artery in the brain, the result of the make and model of the increases the survival rates among device within seconds. those suffering an acute ischemic stroke, Saliency plots from the neural network can provide a The team tested the program on reduces the likelihood of resulting dis- guide where to look. Image courtesy of JACC Electro Physiology radiographic images of more than 1,500 abilities, and speeds function recovery. patients acquired at Hammersmith However, to gain these benefits, throm- Hospital, London between 1998 and bectomies must be initiated and per- The software has been able to identify 2018. They then compared the results formed quickly. Many hospitals do not the make and model of different car- with five cardiologists who used the have providers available to perform diac rhythm devices, such as pacemak- current standard flowchart algorithm these treatments and must transfer ers and defibrillators, within seconds. to identify the devices. patients to a facility where they can get Dr. J Howard, lead author of the study The team found that the software this care, losing valuable time. said: “Pacemakers and defibrillators have outperformed the current flow-chart The Johns Hopkins University team improved the lives of millions of patients based methods. The software was developed an interventional radiology from around the world. However, in 99 per cent accurate in identifying stroke team consisting of four interven- some rare cases these devices can fail and the manufacturer of a device, com- tional radiologists who were then spe- patients can deteriorate as a result. In these pared with only 72 percent accuracy cially trained by a neurointerventional situations, clinicians must quickly identify for the flow chart. doi: 10.1016/j. radiologist for six months. the type of device a patient has so they jacep.2019.02.003 “We wanted to change the dynamic can provide treatment such as changing in stroke care by bringing in a specialist the device’s settings or replacing the leads. Interventional to perform the care and build the infra- Unfortunately, current methods are slow structure necessary” said Dr. F Hui, “In a and out-dated and there is a real need to radiologists key to situation where every minute counts, we find new and improved ways of identify- increasing access to wanted to design our program to provide ing devices during emergency settings. Our the training and organization necessary new software could be a solution as it can thrombectomies to bring 24/7 highly trained stroke inter- identify devices accurately and instantly. Training interventional radiologists ventionalists online as quickly as possible.” This could help clinicians make the best to perform endovascular thrombecto- Once the interventional radiologists decisions for treating patients.” mies results in positive outcomes for were conducting the thrombectomies More than one million people patients experiencing stroke, according independently, the technical success around the world undergo implanta- to a study presented at the recent Society of thrombectomy carried out by the tion of a cardiac rhythm device each of Interventional Radiology Annual newly trained physicians was found to year. These devices are placed under the Scientific Meeting (www.sirmeeting. be equivalent to that of established neu- patients’ skin to either help the heart’s org) Expanding access to this treatment rointerventional radiologists and neu- electrical system function properly or provides patients timely access to this rosurgeons. measure heart rhythm. In emergencies, gold-standard treatment. sirmeeting.org.

8 DI EUROPE APRIL/MAY 2019 IMAGING NEWS

MRI at birth can premature infants who are at risk, one patients with aneurysmal SAH treated could use imaging to see who could at the authors’ neurocritical care unit predict cognitive have problems.” and neurosurgical ward between 2013 development at two and 2016. At five and ten days, the Gilmore said researchers at UNC and patients underwent both CT angiog- years of age elsewhere are working to find imag- raphy and . Cognitive ability is an important ing biomarkers of risk for poor cogni- The study is the first to directly com- predictor of mental health outcomes tive outcomes and for risk of neuro- pare the diagnostic performance of that is influenced by neurodevelop- psychiatric conditions such as autism the two tests, which are commonly ment. Evidence suggests that the and schizophrenia. In this study, the used for early detection of cerebro- foundational wiring of the human researchers replicated the initial find- vascular spasm (CVS) to detect the brain is in place by birth, and that ing in a second sample of children “dreaded secondary complication” of the white matter (WM) connectome who were born prematurely. DCI. “The optimal screening modal- supports developing brain function. “Our study finds that the white mat- ity for detecting symptomatic CVS is It is unknown, however, how the ter network at birth is highly predic- a matter of debate,” according to the WM connectome at birth supports tive and may be a useful imaging bio- researchers. emergent cognition. marker. The fact that we could rep- On both days, CT angiography licate the findings in a second set of showed CVS in at least one vessel in children provides strong evidence that nearly all patients. In contrast, tran- this may be a real and generalizable scranial Doppler showed CVS in finding,” he said. less than half of patients. Agreement doi. 10.1016/j.neuroimage.2019.02.060 between the two tests was just 0.47. Sixteen patients had DCI, while 12 patients had unfavorable outcomes CTA & Doppler both at six months. CT angiography was highly sensitive in predicting DCI have low accuracy for for prediction of DCI, but it had predicting delayed “extremely low” specificity compared to transcranial Doppler. On day five, ischemia after aneu- accuracy in predicting unfavorable rysmal subarachnoid outcomes was 61 percent with tran- scranial Doppler versus 27 percent Researchers at the University of hemorrhage with CT angiography. North Carolina School of Medicine The results suggest that CVS after used MRI brain scans and machine Both CT angiography and transcra- aneurysmal SAH is a common find- learning techniques at birth to pre- nial Doppler have limited accuracy dict cognitive development at age in detecting cerebral vasospasm and 2 years with 95 percent accuracy. predicting delayed cerebral ischemia (Girault JB et al. White matter connec- (DCI) in patients with subarachnoid tomes at birth accurately predict cog- hemorrhage (SAH) due to ruptured nitive abilities at age 2. Neuroimage. , according to a study pub- 2019 May 15; 192: 145-155. doi: lished in the inaugural edition of 10.1016/j.neuroimage.2019.02.060). Critical Care Explorations (van der In this study, a deep learning model Harst JJ et al. Transcranial Doppler was trained using cross-validation to Versus CT-Angiography for Detection classify full-term infants (n = 75) as of Cerebral Vasospasm in Relation scoring above or below the median to Delayed Cerebral Ischemia After at two years age using WM con- Aneurysmal Subarachnoid Hemorrhage nectomes generated from diffu- Critical Care Explorations 2019; 1;1) sion weighted MR images at birth. “Cerebral vasospasm is frequently ing, and that neither test is an accu- “This prediction could help identify present on CT angiography and tran- rate predictor of DCI or unfavorable children at risk for poor cognitive scranial Doppler, lacking accurate outcome. “Our study does not support development shortly after birth with prediction of DCI or unfavorable a prominent role of screening with high accuracy,” said senior author outcome after six months,” accord- TCD or CTA,” Dr. van der Harst and Dr. J H. Gilmore. “For these children, ing to the report by Dr. Joep van der coauthors conclude. “Detection of an early intervention in the first year Harst and colleagues of University of CVS that does not become clinically or so of life - when cognitive devel- Groningen, The Netherlands. manifest likely leads to overtreatment opment is happening - could help The prospective study of sub-arach- and prolonged hospital stay.” improve outcomes. For example, in noid haemorrhage (SAH) included 59 Critical Care Explorations 2019;1:1

APRIL/MAY 2019 DI EUROPE 9 SymposiuM REPORT

Extremity CT: the basics and the promise One of the regular features of the annual ECR meeting that is always highly appreciated by congress attendees is the program of industry-sponsored symposia. This year Carestream spon- sored a symposium on “Advancements in Volumetric Extremity Imaging”. This article summarizes one of the presentations in Dr. Ian Yorkston is Senior Research Scientist, this well-attended session, on the subject of “Extremity CT: the Clinical Applications Research, Carestream. basics and the promise”, which was given by Dr Ian Yorkston. email: Senior Research Scientist, Clinical Applications Research, john.yorkston@car- Carestream. estream.com

Principles and characteristics of Cone BeaM CT As a result of this relative engineering simplicity, cone-beam sys- Dr Yorkston began his presentation by describing the basic prin- tems are much lighter in weight, have a smaller footprint, are less ciples of cone-beam CT (CBCT) and the main differences of the expensive and are thus more cost-efficient than MDCT systems technology compared to classical CT. Traditional Multi Detector in routine clinical practice. One other consequence of the ability CT (MDCT) typically uses a relatively narrow detector and an to acquire a complete image at one time in one revolution, is that X-ray field of about 3 -10 cm, which necessarily means that it is not CBCT has a uniform, or isotropic, spatial resolution in all three possible to image an extended volume of the patient at one time. directions. In the Carestream CBCT system (POC Onsight 3D The solution to this in MDCT is to use spiral CT, in which the Extremity) the voxel dimension is 260 µm. The practical effect of X-ray tube and the detector are rotated at high speed – typically this can be seen in Figure 2 where a higher spatial resolution of 3-5 revs per second – and the patient is translated through this to CBCT can be seen compared to classical CT. build up an extended imaged volume. In contrast, cone beam technology involves a large area flat panel Applications of CBCT detector such that imaging one volume of the patient involves only The principles of CBCT imaging have already been put to prac- a single rotation. In contrast to MDCT, the patient doesn’t move. tical use in several well-established clinical applications where This means that, compared to an MDCT system, cone beam is commercially available systems are employed in daily routine. much simpler from an engineering point of view — in cone beam For example, CBCT has long been used in dental or ear, nose and there is no need for slip rings or sophisticated balancing of the many kilograms of detector and X-ray tube hardware that are rotating at high speed [Figure 1].

Figure 1. Left Panel. Traditional CT uses a relatively narrow detector and X-ray field so it is not possible to image an extended volume at one time. In spiral Figure 2. Images of tibio-femoral joint. Left panel. Conventional 3D CT CT, the X-ray tube and the detector are rotated at high speed in a spiral through Siemens Somatom Sensation. Right Panel. 3D Cone beam CT Carestream’s the center of which the patient is moved. Right Panel. Cone beam uses a large Onsight 3D Extrenity system showing higher spatial resolution. The inclusion area flat panel detector such that imaging one volume of the patient involves of model-based iterative reconstruction and advanced scatter correction only a single rotation. CBCT systems are much simpler than classical CT from algorithms have resulted in a significant improvement in the Hounsfield Units an egineering point of view. accuracy in the CBCT system.

10 DI EUROPE APRIL/MAY 2019 throat applications. Likewise, CBCT has been routinely used in fields such as radiation oncology treatment, where often CBCT is standard- of-care. Other established applications of CBCT include intra-opera- tive imaging and guidance, mammography, as well as in the veterinary field. However, for the purposes of his presentation, Dr Yorkston focussed only on CBCT in orthopedic/extremity applications.

Point-of-care On Sight 3D Extremity CT The CBCT system that Carestream (the POC On-Sight 3D extremity CBCT) has developed is specifically designed for the 3D imaging of extremities, i.e. hand, wrist, elbow, ankle, and foot. Introduced into the market last year, the new system provides either 2D or 3D imaging capabilities with excellent image quality at high spatial resolution — isotropic voxel spacing of 0.26 mm and a large field of view of more Figure 3. Designed primarily for office practices, the new On Sight 3D Extremity system than 20 cm. The system incorporates state-of-the art iterative recon- enables an efficient workflow that provides easy patient positioning through a lateral struction noise-reducing algorithms as well as advanced algorithms entry door. Images of upper and lower extremities can be acquired with maximum comfort for the patient. and can be easily acquired under weight-bearing conditions. for metal artefact correction. As for radiation dose, the cone beam principle means that the new system has lower doses of ionizing radiation than typical MDCT systems. Clinical applications Designed primarily for point-of-care or office practices, the new system The practical clinical consequences of the high image quality of the can be installed in a space as limited as 2.5 X 3 metres. There are no new systemhave been reported in several case studies of extremity special power requirements — the system plugs directly into standard imaging. 120V/230V mains outlets. The design enables an efficient workflow Wrist. Several reports have described the superiority of CBCT over that is particularly suited to office applications for example by providing projection X-ray for the detection of scaphoid fractures. [1, 2, 3]. easy patient positioning through a lateral entry door [Figure 3]. Patients Although relatively common, scaphoid fractures are typically difficult can be imaged either in sitting or standing position so images of upper to diagnose with confidence; accurate diagnosis is however more than and lower extremities can be acquired with minimum discomfort for usually important since inappropriate initial treatment can affect prog- the patient. Of particular clinical significance is the fact that images can noses and outcomes. The encouraging results of CBCT vs 2D X-ray in be easily acquired under weight-bearing conditions. the detection of scaphoid fractures suggest that, in the future CBCT Larger anatomy coverage. A design feature of the On-Sight 3D may become standard of care in this field. In another example of the Extremity is that the system incorporates three X-ray tubes arranged use of CBCT imaging of the wrist, fracturesof the triquetral bone was along the z-axis, thus resulting in a larger (approximately 50% larger) clearly identified by CBCT whereas the fractures were not visible with reconstruction volume than that of a single-tube design [Figure 4.] . 2D X-ray. [Dr T Jacques, Lille, France, personal communication]. The three-tube design also significantly reduces the so-called “cone- Knee. Likewise, in fractures of the knee, reports have described impact beam” artefact that can appear at the periphery of the reconstruction fractures of the posterior aspect of the lateral tibial plateau that are volume in single source systems. Yet another advantage of the three- clearly visible in CBCT but are not detectable by 2D X-ray [Dr T tube design is that this opens the way to future advanced acquisition Jacques, Lille, France, personal communication]. protocols such as dual energy imaging (see below) Ankle. The significance and importance of the new system being able to acquire images under weight-bearing conditions has been reported by a team from the University of Buffalo, NY, USA who investigated ankle syndesmosis injuries [4]. With standard 2D X-ray imaging, it is difficult to differentiate the stable or unstable status of these injuries, although such clinical differentiation is critical in terms of deciding treatment options, namely surgery/no surgery. The team from Buffalo found that the use of weight bearing CBCT (WB CBCT) enabled the clear differentiation of the stable/unstable status of supination - external rotation (SER) injuries [4].

Likely Future Developments Two highly promising and inter-related areas can be identified for the future development of CBCT, namely quantitative imaging coupled Figure 4. The On-sight 3D Extremity system incorporates three X-ray tubes, which results in with improved workflow tools. a larger reconstruction volume than that of a single-tube design and significantly reduces the so-called “cone-beam” artefact that may occur at the periphery of the reconstruc- An example of the potential of these approaches can be found in tion volume in single source systems. The three-tube design opens up the way to future foot/ankle trauma injuries where traditionally multiple measurements advanced acquisition protocols such as dual energy imaging. are made manually from weight-bearing classical X-Ray images. This

APRIL/MAY 2019 DI EUROPE 11 SymposiuM REPORT

used automated, algorithms to streamline the measurement-taking process in 3D images of Take home messages the tibiofemoral joint and so reduce the user- • POC Extremity CBCT systems are dependence of the metrics that are associated now a reality for routine clinical with manual identification of the anatomical applications. landmarks [5]. The Hopkins team found that the automated method for the measurement • The unique capabilities of such sys- of anatomical metrics of the tibiofemoral joint tems are being increasingly appreci- correlated with the data generated manually ated and reported in the literature. Figure 5. Automatic segmentation procedures will provide by expert radiologists, but, of course, without an efficient method of quantitatively extracting the maxi- the need for time-consuming and error-prone • The clinical significance of the infor- mum of data from information-rich 3D content. Continuing manual selection of landmarks [5]. Such kind mation-rich 3D image volume is development of semi and fully automated measurement of algorithms will be necessary to make the being actively evaluated. tools have the promise of providing the clinician with a full array of accurate 3D measurements in the foot, knee most of the increased amount of clinically rel- and hand in an efficient, reproducible manner that should evant information that is generated by CBCT • New automated data analysis tools enhance clinical decision making. Images courtesy of W. systems [Figure 5]. can significantly improve work flow Zbijewski, W Stayman and J. Siewerdsen. Johns Hopkins However the development of these automatic efficiency. University, USA. measurement tools will in itself be insufficient. What is needed in addition is to understand • New applications such as quantitative is a time-consuming process and frequently the clinical significance of the data. To address bone/joint health evaluation are being gives irreproducible results. Compared to 2D, this question, a “Weight-bearing Study Group” investigated. a 3-D image of course provides much more was established a couple of years ago. Involving information, enabling for example the pos- a collaboration of clinical and industrial par- • POC extremity CBCT systems have sibility of measuring subtle movement and ticipants, this international study group (www. the potential to become the new “stan- the relative rotation of bones. The practi- WBCTStudyGroup.com) has as its mission the dard of care” in a range of clinical cal problem is that the very increase in the promotion of dialogue and co-operation on situations. amount of information generated by 3 D weight-bearing CT research initiatives. The image acquisition means that even more time group is working actively to create standard- is needed for measurement/analysis. There are ized protocols for weight-bearing CT mea- more than thirty established measurements surements and analyses. Dual Energy CBCT of clinical relevance that can be taken from Developments in this field are not restricted The future implementation of dual energy 3D foot and ankle images. In the reality of to the foot/ankle. The team from Johns Hop- capabilities on the current CBCT sys- routine clinical practice, no-one has the time kins has been developing a novel methodol- tem would open up a huge potential with for such measurements, interesting though ogy of the characterization of knee joint space clinically significant applications in areas as they may be clinically. This is where we at morphology using high-resolution 3D images diverse as gout detection by the assessment Carestream see the future potential for auto- from CBCT of subjects with and without of uric acid levels in bone and soft tissue, mated measurement capabilities of 3D CBCT osteoarthritis (OA) [6]. in bone marrow edema detection, in the images. In already published work in this Other approaches to quantitative bone mea- assessment bone mineral density and also field, a team from Johns Hopkins University surements are being explored for the early the assessment of the integrity of joint spaces detection of osteoarthritis, with the objective in OA [Figure 6]. of developing improved metrics to identify and stage OA and the ultimate goal of improv- References ing the prediction of the osteoarthritic patient’s 1. Neubauer J et al. Comparison of the diagnostic accuracy of cone beam computed tomography and optimal response to therapy. for scaphoid fractures. Sci Rep. 2018; In addition to the study of overall bone mor- 8:3906. doi: 10.1038/s41598-018-22331-8. phology and joint space analyses, interest is 2. Edlund R et al. Cone-Beam CT in diagnosis of scaphoid fractures Skeletal Radiol 2016; 45: 197. also being focussed on trabecular pattern anal- doi: 10.1007/s00256-015-2290-6. ysis and bone density measurements to iden- 3. Borel C et al. Diagnostic value of cone beam Figure 6. The future incorporation of dual-energy imag- computed tomography (CBCT) in occult scaphoid and ing opens up many possibilites. The images above show tify potential OA patients pre-symptomatically wrist fractures. Eur J Radiol. 2017; 97: 59-64. doi: examples of DE arthrography. Iodinated contrast agent and also monitor their response to therapy. 10.1016/j.ejrad.2017.10.010. was injected into a cadaveric knee joint (left) and a cadav- The same approaches are being adopted to 4. Lawlor MC et al. Weight-Bearing Cone-Beam eric wrist (right). DE data were acquired using the On Sight assess the appropriateness of hardware place- CT Scan Assessment of Stability of Supination extremity CBCT system and a material decomposition External Rotation Ankle Fractures in a Cadaver ment and fracture risk in osteoporotic patients Model. Foot Ankle Int. 2018; 39: 850. doi: algorithm was applied to discriminate iodine and bone. as well as the assessment of fracture healing, 10.1177/1071100718761035. Iodine (red) and bone (blue) distributions are shown as 5. Brehler M et al. Atlas-based automatic measure- overlays on a grayscale composite image obtained from which is important in decisions regarding the ments of the morphology of the tibiofemoral joint. averaging the low and high energy reconstructions. The suitability of the patient to return to work. Proc SPIE Int Soc Opt Eng. 2017; 10137. doi: visualization of iodine enables assessment of the integrity Weight bearing CB CT datasets are also 10.1117/12.2255566. 6. Cao Q et al. Characterization of 3D joint space mor- of joint compartments and joint space narrowing due being investigated in the pre-operative to pathological changes such as osteoarthritis. Images phology using an electrostatic model (with application courtesy of W. Zbijewski, W Stayman and J. Siewerdsen. planning for total joint replacements sur- to osteoarthritis). Phys Med Biol. 2015; 60: 947. doi: 10.1088/0031-9155/60/3/947. Johns Hopkins University, USA. gery (e.g. knee or ankle).

12 DI EUROPE APRIL/MAY 2019

CARDIAC IMAGING NEWS

Personalized Swweden. “Information alone rarely and LDL cholesterol in both groups, but ultrasound scan show- leads to behavior change and the recall the reduction was greater in the inter- of advice regarding exercise and diet is vention group than in the control group. ing atherosclerosis poorer than advice about medicines. Risk A graded effect was also noted, with the helps patients reduce scores are widely used, but they might be strongest effect seen for those with the too abstract, and therefore fail to stimulate worst results. cardiovascular risk appropriate behaviors. This trial shows “The differences at a population level were A new randomized trial of over 3000 peo- the power of using personalized images modest, but important, and the effect was ple has found that sharing pictorial repre- of atherosclerosis as a tool to potentially largest among those at highest risk of car- sentations of personalized scans showing prompt behavior change and reduce the diovascular disease, which is encourag- the extent of atherosclerosis (vascular age risk of cardiovascular disease.” Of the ing. Imaging technologies such as CT and and plaque in the ) to patients participants in the Swedish Västerbotten MRI might allow for a more precise assess- and their doctors results in a decreased County cardiovascular prevention pro- ment of risk, but these technologies have risk of cardiovascular disease one year gramme, 3532 individuals were included a higher cost and are not available on an later, compared to people receiving usual in the study and underwent vascular equitable basis for the entire population. information about their risk. (Näslund ultrasound investigation of the carotid Our approach integrated an ultrasound U et al. Visualization of asymptomatic arteries. Half were randomly selected scan, and a follow up call with a nurse, atherosclerotic disease for optimum car- to receive the pictorial representation into an already established screening pro- diovascular prevention (VIPVIZA): a of carotid ultrasound, and half did not gramme, which means that our findings pragmatic, open-label, randomised con- receive the pictorial information. are highly relevant to clinical practice,” trolled trial. Lancet 2019; 393: 133 doi. Participants aged 40 to 60 years with one says Prof Näslund. org/10.1016/S0140-6736(18)32818-6 or more cardiovascular risk factors were Importantly, the effect of the intervention eligible to participate. All participants did not differ by education level, suggest- underwent blood sampling, a survey ing that this type of risk communications of clinical risk factors and ultrasound might contribute to a reduction of the assessment for carotid intima media wall social gap in health. The findings come thickness and plaque formation. from a middle-aged population with low Each person in the intervention group to moderate cardiovascular disease risk. received a pictorial representation of Formal cost-effectiveness analyses will plaque formation in their arteries, and be done after 3-year follow-up. a gauge ranging from green to red to Lancet 2019; 393: 133 doi.org/10.1016/ illustrate their biological age compared S0140-6736(18)32818-6 with their chronological age. They then received a follow up call from a nurse MRI coronary wall after 2-4 weeks to answer any questions. The same pictorial presentation of the thickness is ultrasound result was also sent to their independent marker Pictorial presentation of ultrasound results of the ath- primary care doctor. Thus, the study had erosclerotic carotid artery increased compliance to dual targets. of heart disease in life style recommendations. Image courtesy of Lancet Both groups received information about women their cardiovascular risk factors and a Smoking cessation, physical activity, motivational health dialogue to promote The thickness of the coronary artery , and antihypertensive medica- healthier life style and, if needed accord- wall as measured by MRI is an inde- tion to prevent cardiovascular disease ing to clinical guidelines, pharmacologi- pendent marker for heart disease in are among the most evidence-based and cal treatment. women, according to a recently pub- cost-effective interventions in health At one year follow up, the cardiovascu- lished study (Ghanem AM et al. Sexual care. However, low adherence to medi- lar risk score for all participants (3175 dimorphism of coronary artery disease cation and lifestyle changes mean that completed the follow up) was calcu- in a low- and intermediate-risk asymp- these types of prevention efforts often lated showing differences between the tomatic population: association with fail. two groups (Framingham Risk Score coronary vessel wall thickness at MRI in “Cardiovascular disease is the leading decreased in the intervention group but women, Radiology: Cardiothoracic Imag- cause of death in many countries, and increased in the control group [-0.58 vs ing. 2019; 1(1):e180007 doi/10.1148/ despite a wealth of evidence about effec- +0.35]; SCORE increased by twice as ryct.2019180007) tive prevention methods from medication much in control group compared to the Previous research has found limitations to lifestyle changes, adherence is low,” says intervention group [0.27 vs 0.13]). in cardiovascular risk assessment for Professor Ulf Näslund, Umea University Improvements were also seen for total women. For instance, there is evidence

14 DI EUROPE APRIL/MAY 2019 that the commonly used Framingham Abd-Elmoniem and colleagues devel- this process. Although atherosclerosis Risk Score, which provides estimates of oped and refined an MRI technique is known to be a chronic inflammatory cardiovascular disease risk based on age, that adjusts for the motions of breath- disease, the prevalence and distribution sex and other factors, underestimates ing and the beating heart to directly of inflammation at early disease stages the chance of heart attacks and other visualize coronary wall thickness. They was unknown. cardiovascular events in asymptomatic used the technique to assess coronary Dr. Valentín Fuster, CNIC Director and women. Imaging tools such as coronary artery disease in 62 women and 62 men lead investigator on the project, empha- computed tomography angiography with low to intermediate risks based on sized the power of modern diagnostic (CCTA) tend to be used in patients with their Framingham scores. The patients imaging technology, which “has revealed symptoms or more advanced cardiovas- also underwent CCTA to investigate the that inflammation is present in only 10% cular disease, but are not recommended association between vessel wall thickness of established plaques.” Stu d y c o aut h or for wider use in risk assessment among and CCTA-based coronary artery dis- Dr. J Sanz explained that “the atheroscle- the general population with no cardiac ease scores. rotic plaques showing signs of inflamma- symptoms. The results showed stark differences tion are large, have a high cholesterol con- Recently, cardiac MRI has emerged as between the two groups. tent, and tend to be located in the femoral a promising tool for early detection of “When we separated the patients into arteries at the arterial bifurcations.” Nev- coronary artery disease. MRI can detect men and women, coronary artery disease ertheless, “most inflammation identified thickening in the walls of the arteries, in men was, as expected, associated with in the arteries of this study subpopulation that occurs earlier in the course of heart aging and a high Framingham score,” said are located in vessel regions free of athero- disease than . Dr. Abd-Elmoniem. “However, in women, sclerotic plaques.” “Despite the significant advances in CCTA both age and the Framingham score were technology, it can be inappropriate to send not factors. Vessel wall thickness, as mea- all asymptomatic people to CCTA because sured by MRI, was the strongest variable of the exposure to radiation and the con- associated with coronary artery disease.” trast nedia doi/10.1148/ryct.2019180007 used for imag- ing,” said study PET/MRI predicts lead author Dr. K Z. Abd- cardiovascular risk Elmoniem. from arterial “MRI might PET/MRI examinations were carried out on the carotid be a safe alter- inflammation (above), the and the femoral arteries. Image native that Using advanced PET/MRI technol- courtesy of JACC can be used ogy researchers at the Centro Nacional more broadly de Investigaciones Cardiovasculares Sanz went on to explain that the study to assist in (CNIC), Madrid, Spain detected arterial data show inflammation in the arteries the diagnosis inflammation in regions that have yet to of “almost half of the participants, occur- of coronary develop atherosclerotic plaques (Fernán- ring more frequently in the femoral arter- artery disease dez-Friera L et al Vascular Inflammation ies.” Dr. Fernández-Friera added, “inflam- without expos- in Subclinical Atherosclerosis Detected mation was associated with the presence ing patients to by Hybrid PET/MRI. J Am Coll Car- of more risk factors; obesity and smoking a procedure diol. 2019; 73(12): 1371. doi: 10.1016/j. in particular were independent predictors that carries jacc.2018.12.075.) of the presence of arterial inflammation.” Coronary vessel wall MR some, albeit In the study, the research team used PET/ Dr. Fuster emphasized that these findings images and CT angiographic small risk. The MRI to analyze the inflammatory pro- demonstrate the power of PET/MRI tech- images (multiplanar reformat- advantage of cess in the arteries of a group of people nology to produce live images of inflamma- ted stretch view). Images in MRI in this sit- who had already developed atheroscle- tion related to systemic atherosclerosis, thus a 44-year-old asymptomatic uation is that it rotic plaques. The results show, for the enabling the study of the disease in early woman show, C, thicker coro- nary vessel wall (black arrows) can tell us that first time, that inflammation is present at stages and the identification of individuals measured at 1.7 mm on MR there is a thick- early stages of atherosclerosis, above all in likely to benefit from early medical inter- image and, D, more coronary ening before regions that have not developed plaques. vention. He added “Future studies should artery disease (white arrows) stenosis, which The study also shows that this arterial investigate whether inflammation precedes the on coronary CT angiographic is difficult to do atherosclerosis can be an early indica- development of the plaque and assess how the image in the left anterior descending artery. Image from with CCTA.” tion of the later appearance of plaques. quantification of inflammation might contrib- Radiology: Cardiothoracic Over a period The researchers are currently analyz- ute to the evaluation of cardiovascular risk.” Imaging, courtesy of RSNA of years, Dr. ing the role of arterial inflammation in doi: 10.1016/j.jacc.2018.12.075

APRIL/MAY 2019 DI EUROPE 15 BIR Annual Congress 2019 November 7 – 8 | etc.venues County Hall,

Day1 Day 2

• Artificial Intelligence CALL FOR • Post treatment imaging • Errors • Leadership & management • Imaging in obesity ABSTRACTS! • Incidentalomas • Dose Submit by • Radiation safety 31 May 2019

Key speakers include: Professor Andrew Scarsbrook and Professor Regina

Book by 31 August 2019 to get 15% off! Visit: www.bir.org.uk

British Institute of Radiology | Registered Charity Number: 21586 | www.bir.org.uk | 020 3668 2220 BIR Annual Congress 2019 CARDIAC IMAGING NEWS Combined SPECT and and possible future has and ethnic groups Specks of calcium November 7 – 8 | etc.venues County Hall, been challenging, with up to 50% of in the heart’s artery walls could be cardiac MR imaging patients suffering a recurrence dur- an important prognostic marker of can help guide ven- ing the 6 months following the abla- early cardiovascular disease in South tion. “The amount of scar tissue can Asians and may help guide treatment tricular tachycardia often account for more than half of in this population, according to a ablation the left myocardium,” n ot e d recent study. (Kanaya AM Incidence Dr. Timm Dickfeld, of the Univer- and Progression of Coronary Artery Adding functional imaging to struc- sity of Maryland School of Medicine. Calcium in South Asians Compared tural imaging of patients with ventricu- “Ablating such a large amount of the With 4 Race/Ethnic Groups. J Am lar tachycardia (VT) has the potential myocardium is often not desirable and Heart Assoc. 2019; 8 :e011053. to improve current VT ablation strat- very time-intensive.” doi: 10.1161/JAHA.118.011053). egies, according to newly published In the study, researchers followed 15 In a study of nearly 700 patients research (Imanli H et al. Ventricular patients with ischemic cardiomyopa- with ethnic backgrounds from India, Tachycardia (VT) Substrate Charac- thy who were scheduled for radiofre- Pakistan, Bangladesh, Sri Lanka, teristics: Insights from Multimodality quency ablation for drug-refractory VT. Nepal and Bhutan, UCSF research- Structural and Functional Imaging of Each patient underwent imaging with ers found that South Asian men had the VT Substrate Using Cardiac MRI 123I-MIBG SPECT and cardiac MRI, as the same high rates of change in cal- Scar, 123I-Metaiodobenzylguanidine well as high-resolution bipolar voltage cification of their artery walls over SPECT Innervation, and Bipolar Voltage. mapping. These three mapping tools a five-year period as white men, the J Nucl Med. 2019; 60: 79. doi: 10.2967/ assessed various adaptations found in group with the highest rates of car- jnumed.118.211698). Iodine-123 VT: abnormal innervation, tissue scar- diovascular disease. metaiodobenzylguanidine (123I-MIBG) ring and low-voltage area, respectively. SPECT imaging, when combined with The adaptations were then compared Day1 Day 2 cardiac magnetic resonance imag- to determine which were present in the ing (MRI), helped to identify specific affected heart tissue. subsets of heart tissue more prone to • Artificial Intelligence CALL FOR • Post treatment imaging Areas with abnormal innervation, , which may allow physi- • Errors • Leadership & management cardiac tissue scar and low bipolar cians to achieve improved VT suppres- voltage were seen in all patients. • Imaging in obesity ABSTRACTS! sion and shorter procedure times. While approximately 25 percent of • Incidentalomas Ventricular arrhythmias, are the patients had abnormalities found by • Dose Submit by all three mapping tools, researchers • Radiation safety found that significant areas of the affected heart tissue showed adapta- 31 May 2019 tions only noted by one or two of “While South Asians have high car- the tools. The largest of these areas diovascular disease rates, there are few had abnormal innervation only prospective studies in the world that (18.2 percent), cardiac scar tissue have focused on determining the risk and abnormal innervation (14.9 per- factors,” said lead author Dr. Alka Key speakers include: Professor Andrew Scarsbrook and Professor Regina cent), and MRI scar only (14.6 per- Kanaya, professor of medicine at cent). “Results from this study show UCSF. “The presence and change of that can be used to coronary artery calcium may be useful develop novel, cutting-edge strategies for risk prediction in this ethnic popu- for risk stratification and arrhythmia lation and may better guide the judi- treatment,” said Dickfeld. cious use of and other preventive Different colors further stratify EAM of LowVolt area doi: 10.2967/jnumed.118.211698 therapies.” according to voltage. Each green point represents VT Early signs of coronary artery calcifica- channel/exit site according to local bipolar voltage. Coronary Artery tion (CAC) can be detected through a Inage credit :Hasan Imanli et al. computed tomography (CT) scan. In Calcium in South other ethnic groups, high CAC scores have been proven to be an early sign of main cause of sudden cardiac death Asians those at high risk of developing cardio- in the United States and are responsi- South Asians are known to have vascular disease. ble for up to 300,000 deaths each year. a high chance of developing cardio- “Both CAC burden and progression have Ablation of ventricular tachycardia is vascular disease and represent more been shown to be independent predic- a proven treatment for arrhythmias than 60 percent of cardiovascular tors of coronary heart disease in whites, in patients with a history of heart disease patients worldwide. They Book by 31 August 2019 to get 15% off! blacks, Latinos and Chinese Americans,” attacks. Identifying the area of the also develop risk factors such as high Kanaya said “. increased scar tissue that is respon- , cholesterol and diabe- doi: 10.1161/JAHA.118.011053 Visit: www.bir.org.uk sible for the current arrhythmia tes at a younger age than other racial British Institute of Radiology | Registered Charity Number: 21586 | www.bir.org.uk | 020 3668 2220 APRIL/MAY 2019 DI EUROPE 17 Cardiac Imaging Computed Tomography Coronary Angiography and the SCOT-HEART trial

By Dr. R Ramaesh, Prof. D E Newby and Dr. M C Williams

Coronary heart disease (CHD) is a leading cause of and recruited a half of all eligible patients. The trial mortality and morbidity, and a frequent cause of pri- therefore investigated a clinical approach that is readily mary and secondary care attendance with chest pain. generalisable in the real world. It is therefore paramount that patients who are at high risk are identified early, and appropriate treatment The aim of the SCOT-HEART trial was to assess the organised. However, clinical assessment alone can be role of CT in the diagnosis, management and out- challenging, as patients often present with atypical come of patients with suspected compared to symptoms and pre-test probability scoring systems standard treatment. For patients in the CT group, the both under- and over-estimate risk. Furthermore, results of the coronary artery calcium score and CTCA whilst non-invasive testing with exercise electrocardi- were provided to clinicians. For patients in the stan- ography or functional testing can risk-stratify patients, dard care group, the 10-year cardiovascular risk score their application has not demonstrated an improve- was provided. The primary outcome was the diagnosis ment in clinical outcomes, such as rates of myocardial of angina secondary to coronary heart disease. Long infarction. On the other hand, Computed Tomography term assessment included outcomes such as death, Coronary Angiography (CTCA) provides a rapid, non- myocardial infarction, and coronary revascularisation. invasive method to evaluate the with a high diagnostic accuracy (sensitivity 96%, specificity At six-weeks, CTCA led to a change in the diagnosis of 72%, to detect a >70% stenosis [1]) and involves only a angina due to coronary heart disease in 23% of patients relatively low radiation dose. compared with just 1% of patients in the standard care arm (p<0.0001) [3]. According to the clinicians The results of the SCOT-HEART (Scottish Com- reporting the CTCA scans, this led to an increase in the puted Tomography of the HEART) randomised con- certainty (relative risk 3.76, 95% confidence interval trolled trial, whose 5-year follow-up data have recently (CI) 3.61 to 3.89, p<0·0001) but reduced the frequency been published, have established the role of CTCA (relative risk 0.78, 95% CI 0.70 to 0.86, p<0·0001) of the for patients with symptoms of suspected coronary diagnosis of angina due to coronary heart disease [3]. artery disease [2, 3, 4], leading to important changes This clarification of diagnosis had several important in guidelines. The SCOT-HEART trial was an open- implications for subsequent patient management. label, parallel-group, multicentre randomised control trial, recruiting patients who were referred to cardi- • Firstly, CTCA led to a change in medication use ology outpatient chest pain clinics by their primary in 23% compared to 5% in the standard care arm care physician or other healthcare providers. Over a (p<0.0001) [3]. This included an increase in the use of four-year period, 4146 eligible patients with suspected preventative medication (aspirin, statin, angiotensin angina due to coronary heart disease were randomised converting enzyme inhibitor). CTCA can therefore be to undergo standard care, or standard care plus com- used to target appropriate use of medical therapy. It is puted tomography (CT). An important strength of the likely that the early, confident diagnosis of coronary trial is the fact that SCOT-HEART had broad inclusion heart disease in the CTCA arm allowed for more fre- criteria, including patients between 18 and 75 years quent and effective preventative treatments.

• Secondly, CTCA led to a change in subsequent inves- The Authors tigations. An early criticism of the use of CTCA in the Dr. Rishikesan Ramaesh, Prof. David E Newby & Dr. Michelle C assessment of angina was that it would lead to more Williams frequent, potentially unnecessary, investigations. How- University of Edinburgh/British Heart Foundation Centre for ever, SCOT-HEART has proven the contrary to be true. Cardiovascular Science, In the CTCA group, there was a significant change Edinburgh, UK. in the number of subsequent planned investigations (15% vs 1%, p<0·0001) [3]. In the first 12 months, Corresponding author: there was a slight increase in the number of invasive Dr. Michelle Williams coronary angiograms performed in the CTCA group. email: [email protected] However, there was also a reduction in the number of

18 DI EUROPE APRIL/MAY 2019 Figure 1. CT (A, B) and invasive coronary angiography (C) images from a 56 year old female who attended the out patient department with a history of atypical chest pain. She was an ex-smoker with a family history of coronary artery disease. An exercise tolerance test was inconclusive. CTCA curved planar reformation (B) shows a mild calcified plaque and a severe non-calcified plaque (arrow) in the proximal LAD. Invasive coronary angiography (C) showed a severe stenosis in the proximal LAD (arrow) and this was treated with a coronary artery . patients with normal coronary arteries identified at inva- suspected coronary heart disease has been shown to sig- sive coronary angiography. Beyond the first year, patients nificantly improve outcomes. Indeed, the number needed in the CTCA group had lower rates of invasive coronary to test (NNT) for CTCA to prevent one fatal or nonfatal angiography, and at 5 years there was no difference in the myocardial infarction over 5 years is only 63 patients [4]. frequency of invasive coronary angiography between the two groups (23.6% vs 24.2%, hazard ratio 1.00, 95% CI At the same time as the initial SCOT-HEART trial results 0.88 to 1.13) [4]. Similarly, whilst there was a higher rate of were published, the results of the PROMISE trial were also coronary revascularisation in the CTCA arm in the first 12 published [6]. PROMISE was a large randomised con- months, at five years there was no difference between the trolled trial which compared CTCA with functional test- two groups (13.5% vs 12.9%, haz- ing. Over a three-year period, 10,003 ard ratio 1.07, 95% CI 0.91 to 1.27) patients were recruited and ran- [4]. This shows that patients in the “... significantly lower rate of coro- domised to anatomical testing with CTCA group had more appropri- nary heart disease death or non-fatal CTCA or functional testing (68% ate, timely use of invasive coronary myocardial infarction in the CTCA nuclear stress testing, 22% stress angiography and revascularisation group compared to the standard care and 10% exercise compared to those in the standard group... ” electrocardiogram). PROMISE dem- care group. onstrated no differences in mortality between the CTCA and functional The initial 1.7-year follow-up of the SCOT-HEART trial testing groups after 2 years of follow-up. Unfortunately, showed a 38% reduction in the rate of the combined longer term follow-up is not available. A meta-analysis of endpoint of fatal and non-fatal myocardial infarction in the 2-year combined results of PROMISE, SCOT-HEART patients in the CTCA group, which just failed to reach and other smaller studies, with a total of 14,817 patients, statistical significance (p=0·0527) [3]. A landmark analy- demonstrated that there was a 31% relative risk reduction sis was performed which censored the initial 50 days of of myocardial infarction for patients undergoing CTCA the trial period, which was the median time it took to compared to standard care, but no change in mortality [7]. perform imaging, communicate results to clinicians and patients and organise a change in management strategy. Subsequent registry studies have confirmed the ability of This showed a 50% reduction in the rate of myocardial CTCA to appropriately target medical management and infarction and death in the patients in the CTCA group revascularisation identified in SCOT-HEART. A large Dan- (hazard ratio 0.50, 95% CI 0.28 to 0.88, p=0.020) [5]. The ish registry study of 86,705 patients showed that there was 5-year results of the SCOT-HEART trial have recently a change in medication use in patients undergoing CTCA been published. This confirms the significantly lower rate compared to functional testing (26% vs 9% statin use, p of coronary heart disease death or non-fatal myocardial < 0.001 and 13% vs 9% aspirin use, p < 0.001) [8]. The infarction in the CTCA group compared to the standard PROMISE study and other registry studies have also shown care group (2.3% vs. 3.9%, hazard ratio 0.59, 95% CI 0.41 that CTCA can more appropriately select patients for inva- to 0.84, p=0.004) [4]. Thus, for the first time, a manage- sive coronary angiography and reduce the proportion of ment strategy based on an imaging test for patients with patients with normal coronary arteries at invasive coronary

APRIL/MAY 2019 DI EUROPE 19 Cardiac Imaging

Conclusion In conclusion, the SCOT-HEART trial has established the role of CTCA in patients with suspected coronary heart disease. CTCA lead to more appropriate targeted use of medical therapies, subsequent investigations and revascularisa- tion. Importantly, SCOT-HEART has shown, for the first time, that a management strategy based on an imaging test for patients with sus- pected coronary heart disease can improve clinical outcomes.

References Figure 2. A 49-year old male attended the cardiology outpatient clinic with a history of typical chest pain. He was 1. NICE. Chest pain of recent onset: assess- a non-smoker with no cardiovascular risk factors. He underwent CTCA which showed severe mixed plaque in the ment and diagnosis. NICE 2016. mid and distal left anterior descending coronary artery (A, curved planar reformation; B axial images). A cross 2. Newby D E, Williams M C, Flapan A D, sectional image through the plaque shows shows adverse plaque characteristics including positive remodelling and Forbes J F, Hargreaves A D, Leslie S J, et al. Role of multidetector computed tomog- low attenuation plaque. While waiting for an appointment for an outpatient invasive coronary angiogram, he was raphy in the diagnosis and management of admitted to the emergency department with a non-ST elevation myocardial infarction (NSTEM). Invasive coronary patients attending the rapid access chest pain angiography showed a subtotal occlusion in the LAD which was treated with a drug eluting stent. clinic, The Scottish computed tomography of the heart (SCOT-HEART) trial: study protocol for randomized controlled trial. Trials. 2012; angiography. Thus, the results of the myocardial infarctions occurred 13(1): 184. SCOT-HEART trial have been sup- in patients with normal functional 3. SCOT-HEART investigators. CT coronary angiography in patients with suspected angina ported by other subsequent research. stress tests or non-obstructive coro- due to coronary heart disease (SCOT-HEART): nary artery disease on CTCA. On an open-label, parallel-group, multicentre trial. CTCA now has a central role in the CTCA adverse coronary artery Lancet. 2015; 385(9985): 2383–2391. 4. SCOT-HEART investigators, Newby D E, UK NICE (National Institute of Health plaque characteristics can be iden- Adamson P D, Berry C, Boon N A, Dweck M and Care Excellence) guidelines for tified which correlate with invasive R, et al. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. The New England patients with stable chest pain [1]. assessment of plaque vulnerability. Journal of Medicine. 2018; 379(10): 924–933. The NICE guidelines no longer advo- In both the SCOT-HEART and 5. Williams M C, Hunter A, Shah A S V, Assi cate assessment of the pre-test prob- the PROMISE trial, the presence V, Lewis S, Smith J, et al. Use of Coronary Computed Tomographic Angiography to Guide ability of obstructive coronary artery of adverse coronary artery plaque Management of Patients With Coronary disease and CTCA is the first line test characteristics has been associated Disease. Journal of the American College of for patients with possible angina [Fig- with worse outcomes [9, 10]. How- Cardiology. 2016; 67(15): 1759–1768. 6. Douglas P S, Hoffmann U, Patel M R, ures 1 and 2]. The current European ever, at 5 years in the SCOT-HEART Mark D B, Al-Khalidi H R, Cavanaugh B, et Society of Cardiology and American trial this was not independent of al. Outcomes of anatomical versus functional testing for coronary artery disease. The New College of Cardiology reserve CTCA the overall coronary artery plaque England Journal of Medicine. 2015; 372(14): for certain subgroups. However, these burden assessed with the coronary 1291–1300. guidelines were artery calcium 7. Bittencourt M S, Hulten E A, Murthy V L, Cheezum M, Rochitte C E, Di Carli M F, published in “... SCOT-HEART has shown that a score. This & Blankstein R. Clinical Outcomes After 2013 and 2012, management strategy based on an is in keeping Evaluation of Stable Chest Pain by Coronary and are there- with our cur- Computed Tomographic Angiography Versus imaging test for patients with sus- Usual Care: A Meta-Analysis. Circulation: fore likely to be pected coronary heart disease can rent under- Cardiovascular Imaging, 2016; 9(4): e004419. revised. improve clinical outcomes...” standing of 8. Jørgensen M E, Andersson C, Norgaard B atherosclerosis L, Abdulla J, Shreibati J B, Torp-Pedersen C, et al. Functional Testing or Coronary Computed An ongoing challenge for patients as a dynamic process, where vul- Tomography Angiography in Patients With and clinicians is the fact that myo- nerable atherosclerotic plaques may Stable Coronary Artery Disease. Journal of the American College of Cardiology. 2017; cardial infarction frequently occurs stabilise without clinically apparent 69(14): 1761–1770. in coronary arteries without prior myocardial infarction. In addition, 9. Williams M C, Moss A J, Dweck M, Adamson obstructive coronary artery dis- the future cornerstone to improve P D, Alam S, Hunter A, et al. Coronary Artery Plaque Characteristics Associated With ease. In the SCOT-HEART trial, coronary artery disease outcomes Adverse Outcomes in the SCOT-HEART Study. patients with obstructive disease may be the early identification of Journal of the American College of Cardiology. had the highest rate of myocar- atherosclerotic plaque burden, prior 2019; 73(3): 291–301. 10. Ferencik M, Mayrhofer T, Bittner D O, dial infarction, but for those with to the onset of symptoms. With this Emami H, Puchner S B, Lu M T, et al. Use non-obstructive disease, the event in mind, the SCOT-HEART 2 ran- of High-Risk Coronary Atherosclerotic Plaque Detection for Risk Stratification of Patients rate was also higher than those domised controlled trial will assess With Stable Chest Pain: A Secondary Analysis with normal coronary arteries. In the use of CTCA in asymptomatic of the PROMISE Randomized Clinical Trial. the PROMISE trial over 50% of populations. JAMA Cardiology. 2018; 3(2): 144–152.

20 DI EUROPE APRIL/MAY 2019 Cardiac Imaging Are coronary CT angiography and CT-Based FFR set to become a game-changer in the diagnosis and treatment decisions in coronary artery disease? Ever since publication last year, the results of the SYNTAX III Revolution trial [1] have been making waves and stimulating intense debate between radiologists, interventional cardiologists and cardiac surgeons involved in the treatment of patients with coronary artery disease. The trial results showed that there was almost perfect agreement between heart teams who used either conventional invasive coro- nary angiography (ICA) or Coronary CT angiography (CCTA) to Prof PW Serruys decide which revascularization approach should be used for the Department of Cardiology, Imperial College of London, London, UK. email: treatment of patients with severe, multi-vessel coronary artery [email protected] disease. We wanted to find out more about the trial and the implications of the results, so we spoke to Prof. Patrick Serruys, Principal Investigator of the trial.

So, what is the significance of the find- that the technology — both hardware and at all levels of pre-test risk probability of Q ings of the SYNTAX III Revolution software — behind CT scans has made CAD. This is a radical departure from trial, Do the results mean that invasive dramatic and continuing advances over existing U.S. and European societal guide- coronary angiography will be replaced the years. In the SYNTAX III Revolution lines, which currently recommend limit- by coronary CT angiography ? trial, the multislice CT scanner used to ing the use of coronary CTA to patients carry out the CCTA examinations was with low to intermediate pre-test risk. Well that is a big question, but to cut to the Revolution scanner from GE Health- In practice, NICE proposed that in the the chase, yes many of us in the field do care [Figure 1]. With a 160 mm cover- UK the number of tests carried out in the believe that conventional ciné angiogra- age in the z-axis and 0.28 second rotation future by other cardiac imaging modali- phy that is used as a diagnostic tool will speed, the system allows the acquisition ties, such as stress echocardiography, progressively be replaced by multi-slice of the whole heart within a single beat; myocardial perfusion imaging, stress CT scans. More work and further tri- any motion artefacts can be handled by MRI, CT calcium scoring and invasive als will be needed, but the results of our post-processing; all-in -all a performance coronary angiography should be reduced SYNTAX III trial do suggest a promis- that was unimaginable several years ago. by 100%; 50%; 50%; 50%; 100% and ing, real change in future practice, with In addition CCTA exams carried out on 60% respectively. However, NICE pro- a central place for CCTA in guiding the Revolution multislice scanner involve posed a 400% increase in the number decisions for the treatment of patients relatively low levels of ionizing radiation of CT angiography tests to be carried with coronary artery disease. There are of approximately 5mSv versus a typical out. The contrast with NICE’s proposed many reasons and data to support this 10mSV for conventional angiography. usage of invasive coronary angiography belief, but one key underlying factor is The technological progress of mul- (60% decrease) is striking. In addition, a tislice CT scanners and their suitability financial analysis of the impact of these for cardiac imaging is beginning to be proposed NICE guidelines showed a recognized by the advisory authorities. cost saving of nearly 20 million pounds. Recently, the UK’s National Institute for Health and Care Excellence (NICE) The manufacturers of CT scanners are issued guidelines (CG95) for the manage- also aware of the increasing potential of ment of stable chest pain which recom- CT technology in cardiac imaging. To mended coronary CTA as a preference meet this potential GE Healthcare have over functional testing for the first-line for example recently introduced a new Figure 1. The CT scanner used in the Syntax III trial was the GE Revolution, a state-of-art system which test for evaluation of chest pain in patients CT system, the CardioGraphe specifically delivers high image quality through the conver- without known coronary artery disease designed for cardiology. The CardioG- gence of coverage, spatial resolution and temporal (CAD). Importantly, the NICE guidelines raphe is a small multi-slice CT scanner resolution suggest first-line coronary CTA testing which only takes up 15 sq metres floor

APRIL/MAY 2019 DI EUROPE 21 Cardiac Imaging

the patients’ clinical characteristics and co-morbidities, e.g. Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease, creatinine clearance, etc., etc. So we took the anatomic SYNTAX score and combined these with the clinical co- morbidities to create the SYNTAX II score, which was very reliable in predicting all- cause mortality at four years. This robust Figure 2. Specifically designed for cardiology, GE’s score allows for meaningful discussions CardioGraphe addresses the growing need for a CT between surgeons and patients in terms scanner that is optimized for cardiac applications . understandable to the patient. The score in fact became a decision maker so that space. The small size of the system means although the patient is unaware of the that the rotation speed can be high, so giv- underlying algorithms that generate the ing a temporal resolution of 120 msec. The score, it enables the patient to better appre- Figure 3. Using data from a standard CT dataset, the non- invasive HeartFlow Analysis from the HeartFlow company spatial resolution is about 285 micron, so ciate, in conjunction with the interven- creates a personalized 3D model of the coronary arteries not so far from the resolution of coronary tionalist or cardiologist, the relative chance and analyzes the impact that blockages have on blood flow. angiography which is typically 200 – 220 of mortality associated with the choice of The color-coding makes it easier for surgeons to identify the micron. Image quality is high and the system therapeutic route. For example it is now areas of the coronary tree needing attention. gives whole heart, one beat cardiac image possible to say to a patient “if you opt for acquisition. CABG surgery you have a 15 % chance that you will be dead in four years whereas if you So what was the design of Now let’s turn to the Syntax IIl opt for PCI the risk is 42%, or vice versa”. Q the SYNTAX III Revolution trial ? Q Revolution trial in more detail Powerful as the SYNTAX II score is, it The aim of the trial was to determine, the Yes but let’s first recap a bit on the various soon became clear that this was not the level of agreement bewteen heart teams on SYNTAX Scores, whole story. Even precise anatomical treatment decision-making using either Approximately 10 years ago I created the measurements of the coronary vascula- CCTA or conventional angiography. The original SYNTAX scoring system with ture such as measures of stenoses did not patients all had severe coronary artery dis- my team in the Thorax Center in Rotter- correlate with the actual physiological ease (so at the tip of the CAD pyramid, dam when we were conducting a large characteristics of the hemodynamic flow Figure 5) and the treatment options were trial comparing the two different cardiac as measured by Fractional Flow Reserve either CABG or PCI. The design of the trial revascularization approaches, namely (FFR). Traditionally FFR is measured in is shown in Figure 6. Separate heart teams, surgery (Coronary Artery Bypass Graft- the by the invasive procedure composed of an interventional cardiologist, a ing, CABG) versus Percutaneous Coro- based on the use of a pressure sensitive cardiac surgeon, and a radiologist (the inclu- nary Intervention (PCI) in patients with wire. In recent years the development sion of a radiologist in the heart team is an multi-vessel three vessel and main stem of advanced CT systems has enabled innovation) were randomized to assess the disease. The SYNTAX score we devel- the production of high quality images coronary artery disease with either coronary oped is an angiographic grading tool of the coronary tree to which sophisti- CTA or conventional angiography. Each to determine the complexity of coro- cated flow dynamic algorithms and soft- nary artery disease. One advantage of ware (for example from the Heart Flow the scoring system was that it forced the company) can be applied to generate an surgeons and the interventionalist car- FFR value derived from the CTA data-

diologists to closely examine the angiog- set (FFRCT). The correlation between the

raphy images before taking any decision FFR and FFRCT has been carefully stud- about the revascularization approach ied and has been shown to be quite good,

to be adopted. Although in the begin- with FFRCT having the clear advantage of ning, the surgeons and interventional not being as invasive as the conventional cardiologists did not fully understand wire-based system [Figure 3, 4] The UK’s the significance of the actual numerical NICE guidelines mentioned above pre- value the detailed attention they paid to dicted an additional cost saving if the

the angiography images was very useful. HeartFlow FFRCT was used rather than In addition, soon after its introduction, invasive investigation and treatment. we realized that the score correlated So, to recap, after the SYNTAX score based with the patient outcomes and so had on anatomy, we can add the physiological an important prognostic value. How- consequences of the anatomy via FFR and Figure 4. In the UK, there has been a rapid rise in

ever we also noted that the prognostic build in the effect of any co-morbidities to the number of FFRCT analyses being carried out. Data value of the score could be affected by yield the SYNTAX III score from 2018.

22 DI EUROPE APRIL/MAY 2019 optimal revascularization strategy that the heart teams came to, no matter whether they used conventional angiography or CCTA-derived information. As regards the secondary end-point,

namely the impact of CCTA and FFRCT, (i.e. without using any conventional angiography data) on the surgeon’s willingness to carry out CABG or not, it was found that 84% of the surgeons

who were presented with only the CCTA and FFRCT data indi- cated that they would be happy to base their CABG surgery decision on these data alone. Q And what are the implications of these findings ? Well as regards the agreement on treatment options between CCTA or conventional angiography, this clearly suggests the fea- sibility of treatment decision-making based solely on non-inva- Figure 5. Levels of severity of coronary artery disease. The patients in the SYNTAX III trial all had three vessel disease so were at the tip of the pyramid. sive imaging modality and dramatically extends the use of CCTA to patients with severe CAD. Some observers have described this as a “paradigm shift to a situation where CAD is diagnosed and heart team, blinded for the other imaging modality, quantified the thoroughly characterized non-invasively, with revascularization anatomical complexity using the SYNTAX score and integrated planning made in a collaborative fashion integrating the heart clinical information using the SYNTAX team”. The implications could be far- Score II to provide a treatment recom- reaching, particularly as regards the mendations based on mortality predic- “... the role of gate-keeper to cardiac future roles of the members of the tion at 4 years surgery will increasingly be fulfilled by heart team. Up till now the role of Thus, for the first time in a clinical trial the radiologist...” “gate-keeper” of access to the cardiac the clinicians, namely the two heart surgeon lay with the interventionalist. teams were randomized to the patients as opposed to the patients Now, given the potential of CCTA and FFRCT, the role of gate- being randomized to one methodology or another. :The primary keeper to will increasingly be fulfilled by the endpoint was the level of agreement between heart teams on the radiologist. In such a scenario, a third party, such as an internal revascularization strategy, with a secondary end-point being the medicine clinician can could request a multi-slice CT exam for impact of FFRCT alone on treatment decision and planning. the patient. As a function of the results, the radiologist would then propose the case to the surgeon or the interventionalist. So what were the results of the trial? Of course, the people in the diagnostic cath labs are uneasy with Q these scenarios, particularly since diagnostic conventional angi- The results were outstanding. We found that there was an almost ography is a significant revenue source for the cath lab. perfect statistical agreement on the decisions regarding the Q What are the next steps ? There are many next steps and one has already begun, namely a trial to confirm that surgeons are really confident to base

their surgical decisions on CCTA and FFR CT alone. Of course, the study of the cohort of the SYNTAX III Revolution trial suggested that they would be, but this was a retrospective analysis, and we have to recognize that surgeons are not (yet)

really familiar with analyzing multi-slice CCTA or FFRCT

data. So making a decision purely on CCTA and FFRCT data alone and without any access to conventional ciné angiog- raphy could be tough for a surgeon and at least require a learning curve. The CABG Revolution trial that we are cur- rently undertaking is designed to answer these questions.

In the longer term, who knows, we could imagine applying CCTA

and FFRCT to all categories of patients with CAD, not just the severe cases at the tip of CAD pyramid who participated in the SYNTAX III Revolution trial.

References 1. Collet et al. Coronary Computed Tomography Angiography for heart team decision-making in multivessel coronary artery disease. Eur Figure 6. Flow chart of the Syntax III Revolution trial. Heart J. 2018; 39(41): 3689 doi: 10.1093/eurheartj/ehy58

APRIL/MAY 2019 DI EUROPE 23 Cardiac Imaging Coronary CTA enhanced with CTA-based FFR analysis provides higher diagnostic value than invasive coronary angiography

By Dr. M Kruk, Dr. L Wardziak, Dr. M Demkow, Dr. C Kepka

INTRODUCTION coronary CTA over ICA. Such a development has Invasive coronary angiography (ICA) remains the the potential of bringing about a profound trans- gold standard for the diagnosis of coronary artery formation in the field of chest pain diagnostics. disease (CAD), and is recommended in patients In the light of this, we carried out a trial to test the with a higher probability of significant CAD, and hypothesis that the diagnostic accuracy of coro- who are potential candidates for further inva- nary CTA enhanced with CT-FFR would be higher sive therapies. Coronary computed tomography than that of the current reference method, ICA. angiography (coroanry CTA) has recently been gaining momentum as a noninvasive and effec- STUDY DESIGN & Methodology tive tool for ruling out obstructive CAD and is In a single-center prospective study we included recommended in patients with a lower probability 90 subjects with intermediate pre-test probability of CAD. of CAD. The patients underwent coronary CTA Both coronary CTA and ICA are anatomic imag- and had at least one intermediate coronary ste- ing methods that have high sensitivity. On the nosis (50-90%) as assessed visually on CTA; the other hand, both modalities suffer from low speci- patients were scheduled for ICA and invasive ficity in the detection of functionally significant FFR. coronary stenoses. Recently, it has been shown Coronary CTA was performed using a dual source that there is no difference betweeen coronary CTA CT scanner (2x128; Somatom Definition FLASH, and ICA in their ability to predict which coronary Siemens Medical Solutions, Forchheim, Germany) stenoses could cause myocardial ischemia [1]. according to standard procedures. The luminal This diagnostic equivalence of the two modali- diameter stenosis was assessed using a dedicated ties, coupled with the clear practical advantages workstation (SyngoVia, Siemens). CTA-based of the noninvasive method (lower patient risk and FFR was assessed using dedicated software (cFFR costs), is already sufficient for coronary CTA to be v2.1, Siemens) which is based on machine learn- considered as a challenger for the traditional role ing algorithms. Mid-diastolic reconstructed CTA of ICA in CAD diagnostics. datasets were analyzed on-site on the dedicated However, in addition, recent advances involving workstation to generate virtual FFR values in each the use of virtual fractional flow reserve (CT- location of the coronary tree based on CTA. FFR), i.e. FFR estimated via software using hemo- ICA and FFR were performed according to standard dynamic flow algorithms operating on coronary procedures, FFR was measured with the ComboWire CTA data sets, have shown that when coronary XT guidewire (Volcano Therapeutics, Rancho Cor- CTA is enhanced with CT-FFR, the specificity is dova, California). The pressure sensor was located improved [2,3,4,5,6 &7]. This combination may beneath the most distal stenosis and the FFR was actually translate into the diagnostic superiority of recorded during the intravenous adenosine infusion of 140 mµg/kg/min, for 3 min. A stenosis with FFR The Authors value ≤0.80 was considered to be hemodynamically Dr. Mariusz Kruk, Dr. Łukasz Wardziak, Dr. Marcin Demkow & significant. Coronary stenosis assessment based on Dr. Cezary Kepka ICA images was quantified using dedicated software Department of Coronary Disease and Structural Heart Diseases, (QCA 7.3, Medis Systems BV, Leiden, Institute of Cardiology, Netherland) by an independent observer blinded to Warsaw, Poland previous visual coronary CTA and FFR data.

Corresponding author The primary end-point of our trial was the Dr. Mariusz Kruk, comparison of the area under the ROC curves email : [email protected] between the percentage stenoses derived either

24 DI EUROPE APRIL/MAY 2019 There was no statistically signifi- cant difference in the areas under the curve for quantitative coronary angiography (QCA), ICA, quanti- tative CTA (qCTA) and coronary computed tomography angiogra- phy (CTA) in the identification of significant stenosis, [Figure 2]. The AUC for CTA-based FFR for the identification of significant stenosis was 0.835 (0.745 to 0.903) and was Table 1. Diagnostic parameters of qCTA, QCA, CTA based FFR for identification of significant stenosis (invasive significantly higher than any of the FFR≤0.80). PPV – positive predictive value, NPV – negative predictive value; QCA – quantitative coronary angiography, ICA – other AUCs [vs qCTA (p=0.010), vs invasive coronary angiography, CTA – coronary computed tomography angiography, qCTA – quantitative coronary QCA (p=0.004), vs CTA (p=0.007) computed tomography vs ICA (p=0.004)]. Detailed data are shown in Figure 2. from coronary CTA or ICA alone 93 (p=0.625) arteries had at least SIGNIFICANCE of the vs the CT-FFR results, in function- 50% stenosis by visual assessment, results ally significant stenoses (invasive 61 and 58 (p=0.749) arteries had at AND FUTURE DIRECTIONS FFR<=0.80). least 70% stenosis by visual assess- The results of our trial show that ment, respectively. The detailed the triage of chest pain patients RESULTS based on the use of noninvasive 96 intermediate stenoses in 90 sub- coronary CTA supported by CT- jects (mean age 63.4 years (±8.2), “... the use of noninvasive FFR analyses leads to more accu- 61 males) were analyzed. In 41 coronary CTA supported rate diagnoses than those based on patients, 41 stenoses (44%) were by CT-FFR analyses leads traditional, routine invasive coro- found to be functionally signifi- to more accurate diagnoses nary angiography. These results cant. The median FFR value was than those based on tradi- suggest that coronary CTA has the 0.83 [IQR 0.74 to 0.90] and the tional, routine invasive coro- potential to replace ICA, which median CTA-FFR value was 0.81 nary angiography....” could ultimately represent a veri- [IQR 0.75 to 0.89] (p=0.200). table revolution in coronary artery The median diameter stenoses, as disease diagnostics. assessed visually on CTA and ICA per-lesion diagnostic accuracy, were: 70±12 and 67±11 respectively, sensitivity, specificity, PPV and Coronary CTA is recognized as a and for quantitative assessment: NPV for visual and quantitative useful diagnostic tool in ruling out 52±12 and 47±12, respectively. On ICA, CTA and CTA based FFR val- significant CAD in patients with CTA and ICA, respectively 95 and ues are shown in Table 1. intermediate probability of CAD

Figure 1. Examples of the imaging methods used in the trial. (a) Left circumflex (LCx) coronary artery with 80% stenosis as assessed visually on coronary CTA and ICA. The red arrow indicates the tip of the pressure wire which is located distally to the stenosis (FFR=0,92). (b) QCA measurement of the stenosis, (c) CT reconstrucion of LCx (d) color-coded CTA-FFR rendering of the LCx artery. The red arrow indicates the position where the CTA-FFR measurement was taken (CTA-FFR=0,90). The FFR and CTA-FFR results were in agreement.

APRIL/MAY 2019 DI EUROPE 25 Cardiac Imaging

one method has been FDA-approved and is thus avail- able for routine clinical purposes. Our study reinforces the concept of the equivalence of coronary CTA with ICA in patients for whom ICA is currently indicated. This concept has been tested in two randomised trials: CAT-CAD and CONSERVE [8, 9]. The results of these trials showed that the use of CTA dramat- ically decreased the number of nonactionable ICAs (i.e. ICA not followed by further invasive therapies). Given the superiority of the combination of coronary CTA with added CT-FFR analysis over ICA in providing accurate diagnosis, our results may lead ultimately to the complete eradication of exploratory coronary invasive diagnostics, except for patients requiring immediate coronary inter- vention, such as in acute coronary syndromes.

CONCLUSIONS Our results indicate the superior diagnostic accuracy of conventional coronary CTA diagnostics coupled with additional CT-FFR analysis over ICA in patients with intermediate coronary stenosis.

REFERENCES 1. Budoff MJ, Nakazato R, Mancini GB, et al. CT Angiography for the Prediction of Hemodynamic Significance in Intermediate and Severe Lesions: Head-to-Head Comparison With Quantitative Coronary Angiography Using Fractional Flow Reserve as the Reference Standard. JACC Cardiovasc Imaging. 2016;9:559- 64. doi: 10.1016/j.jcmg.2015.08.021. Figure 2. Comparison of The Area Under Receiver Operating Characteristics Curves 2. Norgaard BL, Leipsic J, Gaur S, et al.l & NXT Trial Study (ROC) for CTA, qCTA, ICA, QCA, CTA-FFR. The AUC for CTA-FFR was significantly higher Group. Diagnostic performance of noninvasive fractional flow than any of the other AUCs [vs qCTA (p=0.010), vs QCA (p=0.004), vs CTA (p=0.007) reserve derived from coronary computed tomography angi- vs ICA (p=0.004)]. ography in suspected coronary artery disease: the NXT trial Abbreviations: QCA – quantitative coronary angiography, ICA – invasive coronary (Analysis of Coronary Blood Flow Using CT Angiography: Next angiography, CTA – coronary computed tomography angiography, qCTA – quantitative Steps). J Am CollCardiol 2014;63:1145–1155. doi: 10.1016/j. coronary computed tomography angiography, CTA-FFR – fractional flow reserve derived jacc.2013.11.043. from computed tomography 3. Min JK, Leipsic J, Pencina MJ, et al. Diagnostic accuracy of fractional flow reserve from anatomic CT angiography. JAMA 2012;308:1237-45. doi: 10.1001/2012.jama.11274. 4. Kruk M, Wardziak Ł, Demkow M et al. Workstation-Based and, unlike any other noninvasive coronary diagnostic Calculation of CTA-Based FFR for Intermediate Stenosis. JACC CardiovascImaging. 2016;9:690-9. doi: 10.1016/j. modality, has been shown to improve patient outcomes jcmg.2015.09.019. [7]. Several landmark studies, followed by other, smaller 5. Hecht HS, Narula J, Fearon WF. Fractional Flow Reserve and investigations, have focused on the evaluation of the Coronary Computed Tomographic Angiography: A Review and Critical Analysis. Circ Res. 2016;119:300-16. doi: 10.1161/ added diagnostic value of coronary CTA-based FFR CIRCRESAHA.116.307914. analysis compared to coronary CTA alone in predicting 6. Koo BK, Erglis A, Doh JH, et al. Diagnosis of ischemia- functionally significant coronary stenoses. The results causing coronary stenoses by noninvasive fractional flow of studies of CTA-FFR showed that the approach reserve computed from coronary computed tomographic angio- grams. Results from the prospective multicenter DISCOVER- resulted in an improvement in specificity and positive FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via predictive value of approximately 50% compared to Noninvasive Fractional Flow Reserve) study. J Am CollCardiol coronary CTA alone, while still maintaining high sen- 2011; 58:1989–97. doi: 10.1016/j.jacc.2011.06.066. 7. SCOT-HEART investigators, Newby, DA et al.. Coronary sitivity and negative predictive value [5]. CT Angiography and 5-Year Risk of Myocardial Infarction. Financial impact analysis of clinical studies involving N Engl J Med. 2018; 379(10): 924-933. doi: 10.1056/ CT-FFR have also shown a reduction in the overall NEJMoa1805971. 8. Rudziński PN, Kruk M, Kępka C, Schoepf UJ et al. The costs of CAD diagnostics when CT-FFR is used. value of Coronary Artery computed Tomography as the first-line anatomical test for stable patients with indications for inva- Several clinically validated CT-FFR methods have sive angiography due to suspected Coronary Artery Disease: CAT-CAD randomized trial. J Cardiovasc Comput Tomogr. 2018 been developed, based on different operational mod- Nov - Dec;12(6):472-479. doi: 10.1016/j.jcct.2018.08.004. els, e.g. on-site vs off-site analysis, various algorithms 9. Chang HJ, Lin FY, Gebow D et al. Selective Referral Using (based on either in silico simulation or machine learn- CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography for Suspected CAD: A Randomized, ing), and differing in the time needed to retrieve the Controlled, Open-Label Trial. JACC Cardiovasc Imaging. 2018 results (from minutes to hours). So far, however only doi: 10.1016/j.jcmg.2018.09.018.

26 DI EUROPE APRIL/MAY 2019 CARDIAC IMAGING Efficacy study of CT-FFR software using 3D printed patient-specific coronary phantoms

By Dr LM Shepard, Dr. KN Sommer, Dr. E. Angel & Prof CN Ionita

In the last decade 3D printing diagnostic software. Thus for technical efficacy studies, has made significant technologi- 3D printing can save significant time in the validation cal advances which have catalyzed process by reducing the wait time needed for medium acceptance and the development for or large patient cohorts. In addition, highly controlla- ble physiological measurements can be obtained using a various health related applications, 3D printed patient-specific phantoms in benchtop flow including development of comprehen- systems. sive patient-specific coronary phan- This work expands upon recent applications of 3D printed toms that mimic some of the tissue patient-specific coronary phantoms within a physiologi- mechanical properties while being cal benchtop flow system for accurate CT imaging of capable of sustaining physiological coronary blood flow [2, 3]. In our paper titled “Initial evaluation of three- flow and pressure conditions. In this dimensionally printed patient-specific coronary article, we present a summary of a phantoms for CT-FFR software validation” [4], we more extensive study where patient- investigated the technical efficacy of using 3D printed patient-specific coronary phantoms to specific phantoms were used for CT assess a CT-FFR research software (Canon Medical cardiac imaging, flow measurements Systems, Otawara Japan). Using CT imaging, the 3D and validation of a research level printed phantoms were successfully imaged using the patient coronary CT angiography (CCTA) pro- CT-FFR software currently being dev- tocol and were implemented in the CT-FFR soft- loped by Canon Medical Systems. ware to assess the accuracy of replicating the patient results. The accuracy of the phantoms was verified In recent years, 3D printing has become an invaluable using measurements from the CCTA images and tool in many medical applications. These include surgi- benchtop assessment of Fractional Flow Reserve cal planning, structural disease simulations, and device (FFR) for comparison with the reference invasive testing [1]. This technology provides the capability to FFR measurement. This research thus verifies the replicate complex patient anatomy and diseases. These use of 3D printed patient-specific phantoms as an phantoms can be used in both benchtop flow systems and invaluable tool for highly controllable benchtop can be imaged according to patient protocols, making experimentation and imaging for validation of this tool particulalrly useful for validation of image-based image-based diagnostic software.

The Authors Materials and Methods Patients included in this study gave written and Dr. Lauren M Shepard 1,2, Dr. Kelsey N Sommer 1,2 , informed consent following IRB approval. All patients Dr. Erin Angel 3 and Prof. Ciprian N Ionita 1,2 underwent clinically indicated 320-detector row CCTA 1. Department of Biomedical Engineering, University at followed by that included Buffalo, Buffalo NY 14228 USA invasive FFR measurement. The CCTA patient data 2. Toshiba-Canon Stroke and Vascular Research Center, was automatically segmented using a Vitrea worksta- University at Buffalo, Buffalo NY 14208 USA tion (Vital Images, Minnetonka, MN) to include the 3. Canon Medical Systems USA, Irvine CA 92780, USA aorta, left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA); contours were reviewed and edited as needed. The coronary vascula- Corresponding Author : Prof. Ciprian N Ionita. ture was manipulated into a previously reported three email. [email protected] branch approach [5] to create a phantom capable of

APRIL/MAY 2019 DI EUROPE 27 Cardiac Imaging

Figure 1. The five key steps in phantom design process, starting with CT angiography images from the patient, segmentation of the desired geometry, simplifying and smoothing of vasculature, designing a support for the vasculature and appending it, then finally 3D printing the phantom

undergoing physiologically accurate simulated flow and software have previously been published [6]. An exam- pressure conditions. The phantom creations steps are out- ple of patient data in the CT-FFR software is shown in lined in Figure 1. Figure 3.

Each phantom was established in a flow loop that simu- Results lates pulsatile flow rates mimicking those seen in the Pressure measurements were collected during flow experimen- coronary arteries using a CompuFlow 1000 program- tation to determine the benchtop FFR, defined as the ratio of mable physiological flow pump (Shelley Medical Imaging distal to proximal pressure. The benchtop FFR results were com- Technologies, London, Ontario, Canada). Each phantom pared to invasive FFR as well as the CT-FFR measured for both had pressure sensors appended to the aorta and three patient and phantom images. All FFR values were measured coronary arteries using access ports that were created at approximately the same location as the invasive FFR, about in the mesh manipulation to ensure each phantom was two lesion lengths below the distal end of the stenosis. Results undergoing physiologically accurate pressure conditions. showed agreement for treatment outcome in all cases except for Once physiological flow conditions were achieved, the one case measured in the phantom CT-FFR. Pearson correla- patient-specific phantoms underwent 320-detector row tion values for invasive FFR to patient CT-FFR and to phantom CCTA (Aquilion ONE, Canon Medical Systems), triggered CT-FFR were both 0.92. In addition, the patient CT-FFR and during the 70-99% R-R cycle by the CompuFlow 1000 phantom CT-FFR had a Pearson correlation value of 0.95. flow pump. Figure 2 demonstrates one of the phantoms In addition, CT-FFR was recorded at 10 mm increments from in the CT gantry and CCTA images. the ostium of each coronary artery, with a range from 10 mm Both the patient and phantom CCTA images were then to 100 mm in patient and phantom CT data. The Pearson cor- utilized in a CT-FFR algorithm that is currently an on- relation for all patient’s CT-FFR and phantom CT-FFR values site research tool (Canon Medical Systems). CT data was 0.81 and the absolute mean percent difference was 4.34%. between the 70-99% R-R cycle is imported into the Figure 4 displays the comparison of all CT-FFR results for the software to calculate CT-FFR. Details regarding this three main coronary arteries as well as a line of unity.

Figure 2. Phantom CCTA images of LCX (A) and phantom, outlined in red, in Aquilion ONE scanner for CCTA image acquisition.

28 DI EUROPE APRIL/MAY 2019 Figure 3. CT-FFR research software utilized for this research, patient data. Viewing imported images from 70-99% R-R and selecting the phase with the least amount of motion as the target phase (left image). Generation of centerline and contours (middle image). CT-FFR measurement with user control for distal measurement location indicated (right image).

2. Sommer K N, et al. Comparison of benchtop pressure gradient Conclusion measurements in 3D printed patient specific cardiac phantoms with We have expanded upon previous research using 3D printed CT-FFR and computational fluid dynamic simulations. SPIE Medical patient-specific phantoms to develop a system that utilizes Imaging. Vol. 10953. 2019: SPIE. these phantoms with physiological flow and pressure condi- 3. Shepard L M, et al. CT investigation of patient-specific phantoms tions for successful imaging to simulate coronary CT angiog- with coronary artery disease. in SPIE Medical Imaging. 2018. SPIE. raphy. We have presented the accuracy of 3D printed patient- 4. Shepard L M, et al. Initial evaluation of three-dimensionally printed specific phantoms produced using the current state of the art. patient-specific coronary phantoms for CT-FFR software validation. J Med Imaging (Bellingham). 2019; 6(2): 021603. As the temporal and spatial resolution of CT scanners and 5. Sommer K et al. Design optimization for accurate flow simulations the print resolution of 3D printers continue to advance, we in 3D printed vascular phantoms derived from computed tomography angiography in SPIE Medical Imaging. 2017 Fe;10138. 6. Ko B S et al. Noninvasive CT-derived FFR based on structural and fluid analysis: a comparison with invasive FFR for detection of func- tionally significant stenosis. JACC: Cardiovascular Imaging, 2017; 10(6): p. 663-673Book Review

Book Review Cardiac Mapping, 5th Edition Ed by M Shenasa, G Hindricks, D J Callans, J M

Figure 4. Comparison of all CT-FFR results for both the phantom and the patient. Miller, M E Josephson. Pub by Wiley-Blackwell. 2019. Pages 1304. anticipate this accuracy will continue to improve. Hardcover $ 420; ebook $ 336. 3D printing offers a unique benchtop solution as patient- specific phantoms can be created that replicate the mechanical The effective diagno- and elastic properties of vasculature. We have demonstrated sis and treatment of the capability of our patient-specific phantoms to undergo heart disease may vitally clinical CT protocols and be utilized within a CT-FFR soft- depend upon accurate ware. While the phantom accuracy and mechanical behavior and detailed cardiac of the phantoms can continue to improve, this is an important mapping and imag- first step towards using 3D printed patient-specific phantoms ing. However, in an era for software validation. As medical 3D printing continues to of rapid technological improve, we believe these patient-specific phantoms within advancement, medical benchtop flow systems can become a standard tool for vali- professionals can encoun- dation of not only a CT-FFR software, but any image-based ter difficulties maintain- diagnostic software. ing an up-to-date knowl- edge of current methods. References This fifth edition of the 1. Chepelev L et al., Radiological Society of North America (RSNA) much-admired Cardiac Mapping is, therefore, essential, 3D printing Special Interest Group (SIG): guidelines for medical 3D printing and appropriateness for clinical scenarios. 3D Printing in offering a level of cutting-edge insight that is unmatched Medicine, 2018; 4(1): p. 11. in its scope and depth.

APRIL/MAY 2019 DI EUROPE 29 Cardiac Imaging CAD-RADS: a new era in coronary CTA reporting

By Dr. S. Ramanathan

Coronary artery disease (CAD) is one of the Current status of Coronary CTA leading causes of death and of disability- Coronary CTA has now emerged as an effective non- adjusted life years (DALY) lost. Approximately invasive diagnostic test to evaluate coronary arteries 15.5 million persons ≥20 years of age in in patients with low to intermediate likelihood of the USA have CAD according to the 2016 obstructive CAD in outpatient as well as emergency Heart Disease and Stroke Statistics update settings. Due to rapid advancements in CT technol- ogy such as multislice CT (from 16 slice to 64 slice of the American Heart Association (AHA) [1]. and now reaching 320 slices), dual energy CT and It is well established that CAD has a long radiation dose reduction algorithms, moderate to asymptomatic latent period and mortality and high diagnostic accuracy has been achieved. The morbidity can be decreased by early detec- reported sensitivity and specificity for 64-slice CT tion and targeted preventive therapy. Various ranges from 85 to 99% and 86 to 96% respectively. imaging modalities for evaluating patients at Furthermore, with the advent of 320 slice Coronary CTA, the diagnostic accuracy has improved to 95% increased risk for CAD include Coronary CT with 100% negative predictive value for detection of angiography (Coronary CTA), cardiac MRI, >50% coronary stenosis [2,3]. cardiac perfusion , echocardiogra- The main clinical benefit of coronary CTA is derived phy, and positron emission tomography (PET). from its high sensitivity and negative predictive Among these non-invasive imaging modalities, value. This helps in confidently ruling out significant Coronary CTA has gained more acceptance CAD thereby avoiding further diagnostic tests and invasive procedures. The positive predictive value and popularity due to its high diagnostic of coronary CTA is lower, and especially interme- accuracy in the noninvasive estimation of diate lesions may be overestimated regarding their coronary arterial stenosis similar to invasive relevance [4]. coronary angiography (ICA). A new standard- Based on these various randonized controlled trials, ized reporting system CAD-RADS (Coronary the American Heart Association/Society of Cardio- Artery Disease Reporting and Data System) vascular Computed Tomography (AHA/SCCT) and the British National Institute for Health and Care was introduced in 2016 to develop a uniform Excellence (NICE) guidelines recommend Coronary reporting pattern to enable more effective CTA as an appropriate test to rule out obstructive communication of the results to the referring CAD in low-to intermediate risk patients with stable physicians. This review aims to explain the or acute chest pain [5,4] essential features of individual CADRADS cat-

egories, their clinical implications, potential Why CAD-RADS? benefits and pitfalls. SCCT guidelines published in 2009 and the last update in 2014 stressed the reporting of qualitative and quantitative coronary arterial stenosis, as the The Author main purpose of Coronary CTA is to rule out sig- nificant CAD. Due to recent technological advance- Dr. S. Ramanathan, ments the spatial and temporal resolution of current Department of Clinical Imaging, scanners has since improved drastically. This in turn Al-Wakra Hospital, Hamad Medical Corporation, facilitated development of various new scanning and Doha, Qatar. post-processing techniques like computed tomogra- & phy-derived fractional flow reserve (CT-FFR) and Department of Radiology, Weill Cornell Medical College, perfusion imaging. Hence Coronary CTA is no lon- Doha, Qatar ger just an anatomic imaging modality but is being increasingly used for characterizing the plaque mor- E-mail address: [email protected] phology to predict current and future cardiac events

30 DI EUROPE APRIL/MAY 2019 and also for functional imaging [6,7]. As the complexity of Coronary CTA has increased enormously, stan- dardization becomes a necessity to maximize the clinical impact. Various professional societies have issued guidelines and expert consen- sus documents on the performance, acquisition, necessary training, reporting, indications and radiation dose. The recent addition to this is the standardized reporting system CAD-RADS. Table 1. Summary of CAD-RADS categories and their interpretation The presence of common report- ing terminologies and categories with streamlined management rec- stenosis and to link this data to clini- categories is beyond the scope of this ommendations helps in simplifying cal patient management. The indi- mini-review but is freely available in the reporting structure and makes it cation for coronary CTA, scan pro- the source publication [8-10] more understandable for the refer- tocols and performance standards ring physicians. This is based on the remains the same. Interpretation, Modifiers success of similar models in breast training standards and quantifica- In additon to the main categories, (BIRADS), liver (LIRADS), and tion of coronary arterial stenosis is there is an option to add modifiers prostate imaging (PIRADS). It cre- based on the 2014 SCCT reporting at the end of each category (sepa- ates consistency in the conclusions rated by /) to provide additional rel- of the report which in turn guides evant information. Four modifiers the referring physicians to take clini- “... The presence of common are available: N (non-diagnostic), S cal decisions. Apart from decreasing reporting terminologies and cat- (stent), G (graft) and V (vulnerabil- the variability among the report- egories with streamlined manage- ity). If more than one modifier is ing radiologists, CAD-RADS also ment recommendations helps in applicable, they should be separated facilitates education, research, peer simplifying the reporting structure by the slash symbol “/” and written in review and quality assurance leading and makes it more understand- the same order as above. to improved patient care. able for the referring physicians...” Benefits of CAD-RADS [11] CAD-RADS categories guidelines in both acute and non- 1. Consistency - The most important A new standardized reporting sys- acute settings [7]. utility of any standardized report- tem proposed by the Society for Car- There are six CAD-RADS categories, ing system is improved consistency. diovascular Computed Tomography based on degree of luminal diam- This helps in providing a uniform (SCCT), the American College of eter stenosis. This is adapted from report consistently with the usage Radiology (ACR), and the North SCCT 2014 recommendations. They of common language and accepted American Society for Cardiovascular range from CAD-RADS 0 (absence terminologieOne recent study shows Imaging (NASCI), and was endorsed of plaques and stenosis) to CAD- excellent inter-observer agreement by the American College of Cardiol- RADS 5 (presence of at least one in assigning CAD-RADS categories, ogy (ACC) and published in JACC in total occlusion) in both acute and including the degree of stenosis and 2016 [8-10]. non-acute settings. It is based on the modifiers leading to a more consis- most severe coronary finding. Apart tent final report [12] This recommendation is intended from these six categories, an addi- for two groups of patients: tional category N is added which 2. Communication - In the long run, (1) Patients presenting with stable represents non-diagnostic study. Fur- using a consistent reporting template chest pain. thermore category 4 is subdivided in improves communication to the (2) Patients presenting with acute to 4A - single or two vessel 70-99% referring physicians as they get used chest pain, negative first troponin, stenosis and 4B-Left main >50% or what to expect in the report negative or non-diagnostic electrocar- 3- vessel obstructive (>70%) disease. diogram, and low to intermediate risk. This classification is applicable only 3. Clinical management - Including for vessels greater than 1.5 mm in the clinical pathway in the imaging CAD-RADS aims to classify CTA diameter. Detailed discussion on the report is the most innovative aspect based results on the severity of management strategies in individual of CAD-RADS. It helps in choosing

APRIL/MAY 2019 DI EUROPE 31 Cardiac Imaging

doi:10.1093/eurheartj/ehp571 the best investigation and further treatment options based on the categories thereby somewhat simplifying 3. Sun Z, Choo GH, Ng KH (2012) Coronary CT angiography: current the clinical management protocol status and continuing challenges. The British Journal of Radiology 2012; 85 (1013):495-510. doi:10.1259/bjr/15296170 4. Research - Uniform reporting helps in the future data col- lection in a more organized manner leading to more effective 4. Rybicki FJ, Udelson JE, Peacock WF et al. 2015 ACR/ACC/ AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/ research and education SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: Pitfalls of CAD-RADS [13,11] A Joint Document of the American College of Radiology 1. Misinterpretation - This is an inherent pitfall of coro- Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll nary CTA rather than CAD-RADS itself and can present Radiol 2016; 13 (2):e1-e29. doi:10.1016/j.jacr.2015.07.007 in the form of under- or over-estimation of the degree of stenosis and in the risk assessment of high risk plaque 5. Chest pain of recent onset: assessment and diagnosis. features, both leading to assign wrong categories Guidance and uidelines | NICE. https://www.nice.org.uk/guid- ance/cg95. Accessed 25th Feb 2018 2018 2. Misclassification - Some components of CAD-RADS 6. Abbara S, Arbab-Zadeh A, Callister TQ, et al. SCCT guidelines such as category N, 4A, 4B, grafts and can be a for performance of coronary computed tomographic angiography: potential source of error in the initial period due to a report of the Society of Cardiovascular Computed Tomography overlap and some similarities. These should improve Guidelines Committee. J Cardiovasc Comput Tomogr2009; 3 with continuous usage and training (3):190-204. doi:10.1016/j.jcct.2009.03.004

7. Leipsic J, Abbara S, Achenbach et al. SCCT guidelines for 3. Missing components - Although CAD-RADS system the interpretation and reporting of coronary CT angiography: a is extensive, few components like location and extent of report of the Society of Cardiovascular Computed Tomography disease, coronary anomalies and extra cardiac findings Guidelines Committee. J Cardiovasc Comput Tomogr 2014; 8 are not included. With accumulation of more data and (5):342-358. doi:10.1016/j.jcct.2014.07.003 knowledge, these might get a place in the future versions 8. Cury RC, Abbara S, Achenbach S, et al. CAD-RADS: Coronary Artery Disease - Reporting and Data System: An Expert 4. Misguidance - Although considered generally as a ben- Consensus Document of the Society of Cardiovascular Computed efit, recommendations regarding further investigations and Tomography (SCCT), the American College of Radiology (ACR) and treatment options included in the CAD-RADS can be a the North American Society for Cardiovascular Imaging (NASCI). potential pitfall as well. In clinical practice, there could be Endorsed by the American College of Cardiology. J Am Coll Radiol 2016; 13 (12 Pt A):1458-1466 e1459. doi:10.1016/j. many other factors apart from the stenosis which can influ- jacr.2016.04.024 ence the management along the individual physician judge- ment. Sometimes these can be different from the CAD- 9. Cury RC, Abbara S, Achenbach S, et al. CAD-RADS(TM) RADS recommendation and can thus be a source of conflict Coronary Artery Disease - Reporting and Data System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and Future of CAD-RADS the North American Society for Cardiovascular Imaging (NASCI). CAD-RADS is just the first step in the attempt to standard- Endorsed by the American College of Cardiology. J Cardiovasc ize enormously the increasing numbers of coronary CTA C omput Tomogr 2016; 10 (4):269-281. doi:10.1016/j. examinations. Many of the pitfalls described above can jcct.2016.04.005 be resolved in the future versions as we gain more experi- 10. Cury RC, Abbara S, Achenbach S, et al. Coronary Artery ence by using this system on a daily basis. There could Disease - Reporting and Data System (CAD-RADS): An Expert be additional categories and subcategories to include the Consensus Document of SCCT, ACR and NASCI: Endorsed by missing components. By having more healthy discussions the ACC. JACC Cardiovasc Imaging 2016; 9 (9):1099-1113. with clinicians, we can agree to minimal management rec- doi:10.1016/j.jcmg.2016.05.005 ommendations which will give the cardiologists enough 11. Ramanathan S, Al Heidous M, Alkuwari M (2019) Coronary space to make individualized patient decisions. Of course Artery Disease-Reporting and Data System (CAD-RADS): strengths more training and stimulating the residents, fellows and and limitations. Clin Radiol. doi:10.1016/j.crad.2019.01.003 young radiologists to strictly use the system is essential for its success and future improvements 12. Abdel Razek AAK, Elrakhawy MM, Yossof MM, Nageb HM Inter-observer agreement of the Coronary Artery Disease References Reporting and Data System (CAD-RADS(TM)) in patients with sta- ble chest pain. Pol J Radiol 2018; 83:e151-e159. doi:10.5114/ 1. Mozaffarian D, et al. Heart Disease and Stroke Statistics- pjr.2018.75641 Update: A Report From the American Heart Association. Circulation 2016; 133 (4):e38-360. doi:10.1161/cir.0000000000000350

13. Foldyna B, Szilveszter B, Scholtz JE, et al. (2017) CAD-RADS 2. de Graaf FR, Schuijf JD, van Velzen JE et al. (2010) Diagnostic - a new clinical decision support tool for coronary computed accuracy of 320-row multidetector computed tomography coro- tomography angiography. Eur Radiol. 2018; 28(4):1365-1372. nary angiography in the non-invasive evaluation of significant doi: 10.1007/s00330-017-5105-4 . coronary artery disease. Eur Heart J 2010; 31 (15):1908-1915.

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D8615-Pub-ESC-2018-Di-Europe_v1.indd 1 12/02/2019 14:28 Cardiovascular Imaging Non-invasive 3D imaging of the human carotid artery with volumetric multispectral optoacoustic tomography (vMSOT)

By I. Ivankovic & Prof. D. Razansky

The majority of ischemic are caused by atheroscle- described in recent clinical studies where MSOT has shown rotic carotid arteries, specifically in the carotid bifurca- its capability to image tissues in diseases such as breast cancer tion area [1]. Much effort in stroke prevention is directed [3] and inflammatory bowel disease [4]. OA imaging has towards early diagnostic or screening methods that could also been shown capable of imaging atherosclerotic disease categorize patients as either high or low risk. In such by utilising the absorption spectrum of lipids, which is a key screening methods it is essential to characterize the sta- constituent of vulnerable plaques. Ex vivo studies have shown bility of any atherosclerotic plaque rapidly and in a non- that by imaging at 1200nm a clear identification of plaque invasive manner. in human aorta is possible [5]. In vivo intravascular studies using an endoscopic device have demonstrated vulnerable Optoacoustic Imaging plaque detection in rabbits [6]. (Of course endoscopy is an OA imaging has attracted much attention in recent years invasive procedure and is not suitable for screening). because of its potential applicability to a range of bio- logical and medical imaging applications. OA is based on vMSOT Evaluation study the use of non-ionising laser light, which is absorbed by We carried out an evaluation study whose goal was to biomolecules at specific wavelengths, creating a transient investigate the feasibility of using volumetric MSOT in thermoelastic expansion which results in acoustic waves clinical imaging of the human carotid artery [7]. In this being emitted that can be detected by an ultrasound study we used a custom-designed probe, composed of a transducer. OA imaging can therefore provide images of spherical surface array capable of isotropic 3D resolution high optical contrast with spatial resolution equivalent of 200µm [Fig. 1 (A)], [8]. The probe has a central open- to that of typical ultrasound devices. OA imaging is par- ing to allow the laser output to pass through the fibre ticularly powerful in the near-infrared (NIR) window, bundle connecting the probe to the laser. A surface array since such light can penetrate deeper into human tissue. containing 256 piezoelectric elements detects the acoustic In the NIR wavelength range, oxygenated and deoxygen- signal. The OA signals that are generated are simultane- ated hemoglobin have different absorption spectra, thus ously acquired by a custom-built parallel data acquisition allowing the discrimination of and arteries in the system. human body. In addition, lipids, water and melanin also have strong absorption in the NIR wavelength window, To evaluate the system, we recruited 16 healthy volun- so offering a multispectral optical contrast image of liv- teers for non-invasive imaging of the carotid bifurcation. ing tissue [2]. For these reasons, OA imaging, and in particular imaging of the human vasculature has become an extremely active area of research and development.

The potential of the emerging imaging modality of Mul- tispectral optoacoustic tomography (MSOT) has been

The Authors Ivana Ivankovic M.Sc.1,2 and Prof. Daniel Razansky 1,2 1. Faculty of Medicine and Institute of Pharmacology and Toxicology, University of Zurich, Switzerland. 2.Institute for Biomedical Engineering and Department of Information Technology and Electrical Engineering, ETH Zurich, Zurich, Switzerland. Corresponding author : Figure 1. The imaging set up. D. Razansky. email: [email protected]

34 DI EUROPE APRIL/MAY 2019 images. In fact, US visualization of the whole carotid bifurcation in a single cross-section ususally requires a lengthy acquisition time to find the optimal ori- entation of the US probe. In contrast, a similar view can be directly obtained from the three-dimensional optoacoustic image.

Conclusion Overall, our study demonstrates the Figure 2 (A) Compounded image of scan of entire carotid artery (B) SNR plotted against carotid depth potential of volumetric multispectral (IC; internal carotid, EC; external carotid, CC; common carotid, SNR; signal to noise ratio) optoacoustic tomography for the char- acterisation of the carotid artery in a The volunteers were imaged in the volunteers. It could be seen that there volumetric, non-invasive, real-time and NIR wavelength range between 730- was a clear decrease in SNR in deeper handheld manner. Multispectral opto- 900nm and 1064nm, in compliance carotid arteries, mainly attributable to acoustics has the ability to identify clini- with the safety standards of the Amer- light attenuation [Figure 2B]. cally relevant biomarkers such as lipids, ican Laser Institute [9]. Within one Five volunteers were then imaged at which are a key feature in vulnerable single laser pulse, an entire volumetric wavelengths between 730-900nm for plaques. Our studies show that volumet- image (20mm x 20mm x 20mm) of the multispectral evaluation. It was found ric MSOT has a high potential for the carotid bifurcation could be acquired that the carotid artery was best visual- non-invasive and functional assessment of cardiovascular disease.

References 1. Mughal MM, Khan MK, DeMarco JK, Majid A, Shamoun F, Abela GS. Symptomatic and asymptomatic carotid artery plaque. Expert Rev Cardiovasc Ther 2011; 9(10): 1315 – 1330 2. Deán-Ben XL, Gottschalk S, McLarney B, Shoham S, & Razansky D. Advanced optoacous- tic methods for multi-scale imaging of in vivo Figure 3. Volumetric MSOT images of right carotid artery bifurcation at a wavelength range between 730-900nm dynamics. Chem Soc Rev. 2017; 46: 2158 - (V; , CB; carotid bifurcation) 2198. 3. Diot G, Metz S, Noske A, Liapis E, Schroeder B, Ovsepian S V, & Ntziachristos V. (2017). Multispectral optoacoustic tomography [Figure 1B]. Initially the handheld ised between 800-900nm, correspond- (MSOT) of human breast cancer. Clinical Cancer probe was moved freely around the ing to the increased absorption of oxy- Research. 2017; 23(22): 6912-6922. 4. Knieling F, Neufert C, Hartmann A, Claussen carotid bifurcation area and, once the genated hemoglobin and decreased J, Urich A, Egger C, & Kielisch C. Multispectral desired region was located, the probe absorption of deoxygenated hemo- optoacoustic tomography for assessment of Crohn’s disease activity. New England Journal of was held stationary for optimal image globin [Figure 3]. The differentiation Medicine. 2017; 376(13): 1292 -1294. acquisition. between arteries and veins is striking 5. Allen TJ, Hall A, Dhillon AP, Owen JS, Beard PC. when the appropriate wavelength is Spectroscopic photoacoustic imaging of lipid-rich Results plaques in the human aorta in the 740 to 1400 used for OA imaging. Multispectral nm wavelength range. J Biomed Opt 2012; 17(6): The scanned data sets consisted of mul- evaluation is critical in demonstrat- 061209. tiple 3D images, which were stitched ing the capabilities of MSOT. and is 6. Zhang J, Yang S, Ji X, Zhou Q, & Xing D. Characterization of lipid-rich aortic plaques by together by means of a spatial com- particularly so in detecting lipid rich intravascular photoacoustic tomography: ex vivo pounding algorithm, allowing for visual- vulnerable plaques, where lipids have a and in vivo validation in a rabbit atherosclerosis isation of the scan (area of 45mm2) of the peak absorption at 1200nm. model with histologic correlation. Journal of the American College of Cardiology, 2014; 64(4): carotid artery in one single image. The Anatomical features resolved from 385-390. common carotid (CC), internal carotid MSOT were validated against ultrasound 7. Ivankovic I, Merčep E, Deán-Ben XL, & (IC), external carotid (EC) and other (US) images in two volunteers, where the Razansky D. Real-time volumetric assessment of the human carotid artery with hand-held multi- small surrounding vessels can all be seen carotid arteries were scanned by an expe- spectral optoacoustic tomography. Radiology. at the same time [Figure 2A]. rienced vascular surgeon using a clinical 2019; 291(1): 45–50. The depth of the carotid arteries was B-mode ultrasound scanner. Whereas 8. Deán-Ben XL, Razansky D. Portable spherical array probe for volumetric real-time optoacoustic measured in all volunteers, and lay the entire carotid bifurcation area could imaging at centimeter-scale depths. Opt Express between 4-16mm depth from the skin be readily visualized with volumetric 2013; 21(23):2 8062–28071. surface. The signal to noise ratio (SNR) MSOT thanks to its three-dimensional 9. American Laser Institute. American National Standards for the Safe Use of Lasers was subsequently calculated. and plotted imaging capabilities, it was not easily ANSIZ136.1. Orlando, FL: American Laser against the depth of the carotid for all discernible in single cross-sectional US Institute, 2014.

APRIL/MAY 2019 DI EUROPE 35 INDUSTRY NEWS

Carestream to sell its “Philips partners with global healthcare Anyone is spreading benefits directly to healthcare IT business providers to connect people, information patients, allowing people throughout and technology with the commitment to the country to quickly view their imag- to Philips deliver on the quadruple aim of improved ing through a secure log-in. The move Carestream Health has signed an patient experiences, better health out- is helping to end a costly and outdated agreement to sell its healthcare infor- comes, improved staff experiences and reliance on CDs for the UK NHS. Annie mation systems (HCIS) business to lower costs of care,” said Robert Cascella, Pinfold, a senior PACS consultant at Philips. Carestream’s HCIS business Chief Business Leader Precision Oxford University Hospitals, said: “This unit provides imaging IT solutions to Diagnosis at Royal Philips. “This acqui- makes a real difference to our patients multi-site hospitals, radiology services sition will enhance our ability to pro- who need their imaging for all sorts of providers, imaging centers and specialty vide flexible solutions to hospitals and reasons, including the support of claims, medical clinics around the world. The health systems. The combination of our second opinions, specialist treatment or business has developed strong customer successful innovations in imaging system simply because they want to see their relationships in attractive, high-growth platforms, workflow optimization and images. We have seen a surge in imaging healthcare segments and is positioned artificial intelligence-enabled informatics, requests from patients since the high pro- for continued growth and success. As combined with Carestream’s cloud-based file General Data Protection Regulation a result of this acquisition, Philips’ enterprise imaging informatics platform (GDPR) came into place. Having access and complementary geographic footprint to IEP with Anyone is helping to man- will provide a solid foundation to deliver age this growing demand, with two thirds on the promise of precision diagnosis.” of patients who ask for their images now Carestream will retain its medical specifically requesting IEP with Anyone imaging, dental and industrial films, rather than CDs. We have been saving non-destructive testing, and preci- time and money – with each CD request sion coating businesses which are not from patients consuming up to 20 minutes impacted by the sale. “These established of staff time, and nearly £9 in produc- businesses have solid financial founda- tion and postage costs, compared to five tions, innovative technology platforms minutes and only pence through IEP with and have earned the trust of loyal cus- Anyone”. expanded healthcare IT business will tomers around the world,” said David feature Carestream’s enterprise imag- Westgate, Carestream CEO. “Our focus ing platform — including best-in-class will be on delivering innovation that is VNA, diagnostic and enterprise view- life changing — for patients, customers, ers, multimedia reporting, workflow channel partners, communities and other orchestrator and clinical, operational stakeholders — and we will grow the and business analytics tools — as part of company for long-term success.” its broad portfolio. “We have had global Carestream Sectra is the company which manages success in providing radiology and enter- Rochester, NY, USA the Image Exchange Portal for the NHS. prise imaging IT systems to help medi- www.carestream.com Jane Rendall, managing director for Sectra cal professionals provide quality care and in the UK and Ireland, said: “Physical media enhance their operations,” said Ludovic UK patients get is going out of fashion. The NHS needs to d’Aprea, Carestream’s General Manager provide information in a way that is acces- for Healthcare Information Solutions. nationwide online sible, fast, easy and secure. This extension “By becoming part of Philips, the HCIS access to their to one of the most widely used networks in business will have a greater opportunity the NHS allows that and is already helping to thrive and grow. Both organizations imaging scans thousands of patients each month ”. share a commitment to meaningful inno- A network that connects every Patients are given access to IEP vation, which is deeply embedded in each National Health Services (NHS) acute with Anyone by their hospital through company’s culture. Customers will have hospital in England is giving thousands a secure log-in. Their imaging remains access to a broader portfolio of healthcare of patients unprecedented and easy in the portal for up to 60 days during IT solutions to simplify medical image online access to their images such as which time they can use forwarding fea- management, enable effective collabora- x-rays, ultrasound, CT and MRI scans. tures to easily share with trusted third tion and enhance patient care.” The Image Exchange Portal, or IEP, is parties, who can view dynamic image Like Carestream, Philips has built a already relied on in the UK in the shar- sets from a secure link. strong, global business based on cus- ing of some 35-40 million images each SEctra tomer focus, world-class technical week between NHS professionals. Now Linköping, Sweden excellence and continuous innovation. an extension to the network, IEP with sectra.com/medical

36 DI EUROPE APRIL/MAY 2019 iCAD partners with “Models that accurately predict an indi- Cardiac Toolbox is designed to analyze vidual woman’s risk of developing breast cardiac ultrasound images based on more Karolinska to develop cancer are paramount to transitioning from objective and reproducible information, as AI-based breast cancer age-based screening to risk-based screening,” opposed to manual measurement or visual said Per Hall, Professor, Senior Physician, analysis methods which are currently used. risk prediction system Karolinska Institutet. “Most current risk DiA’s LVivo Toolbox is based on advanced iCAD have entered into an exclusive models are population-based and focus on pattern recognition and machine learning relationship with two leading researchers lifetime or long-term risk. Our research using algorithms which automatically imitate the at The Karolinska Institutet in Stockholm, the iCAD AI technology has shown that by way the human eye detects borders and Sweden, to develop an artificial intelli- simply using the information available in the motion. DiA’s automated tools deliver fast gence (AI)-based solution that will identify mammogram images, we can more accu- and accurate clinical indications to support a women’s individual risk of developing rately stratify women based on short-term the decision-making process. LVivo is both breast cancer. This partnership builds on risk. Understanding short-term risk will an existing research agreement in which open the door to new paradigms in both the prevention and treatment of breast cancer.” iCAD announced the commercial avail- ability of its ProFound AI for breast cancer detection in digital breast tomosynthesis in 2018. This delivers critical benefits, includ- ing improvement in cancer detection rates, a decrease in unnecessary patient recalls, the researchers at the Karolinska devel- and shorter reading times for radiologists. oped a breast cancer risk prediction model “We envision the field of mammography using information identified in mam- moving from age-based screening protocols vendor-neutral and easily implementable mography images provided by iCAD’s AI to “risk adaptive screening.” Concurrently, as part of the daily evaluation workflow. cancer detection and density assessment we foresee the emergence of individualized The integration of the LVivo toolbox will solutions. Promising early results based on breast screening protocols based on risk enable the support of DICOM clips from mammography images from over 70,000 characteristics,” said Mike Klein, Executive all ultrasound devices, thus making LVivo Swedish women enrolled in The Karolinska Chairman and CEO of iCAD. “This new AI analysis accessible to all users using the Mammography Project for Risk Prediction frontier of predictive risk assessment for can- PACS and ultimately improving patient of Breast Cancer (Karma) study indicated cer is indicative of the continued expansion c a r e . “A I is becoming a real driver in the that the model enabled early identifica- of our newly released ProFound AI offer- imaging arena. Through collaboration with tion of women who were at a high-risk for ing for breast cancer detection. Correlating strategic partners such as DiA, Ebit will offer breast cancer and it was determined that iCAD’s high cancer detection rates, low false healthcare providers with the best possible additional examinations were warranted. positive levels and a 50% reduction in read- tools added to its system in order to improve The Karma results have been improved ing time with the burgeoning volume of pat- patient outcomes”, said Franco Fontana, upon through the use of iCAD’s latest ent risk data, may provide a quantum leap Ebit’s CEO. “The SUITESTENSA CVIS ProFound AI algorithm. Among other in clinical efficacy and patient care” PACS system achieves a superior workflow things, the model now takes asymmetry of iCAD from patient admission through exam exe- mammographic features and masking of Nashua, NH, USA cution in addition to reporting, administra- tumors into consideration. iCAD and the www.icadmed.com tion and distribution by encompassing all Karolinska researchers now intend to col- cardiology specialties into one single plat- laborate to develop an innovative solution Esaote and DiA Imaging form. By joining forces with DiA, we are for commercial use to assess an individual’s expanding the boundaries of our system by risk of developing breast cancer. Analysis partner on equipping our customers with an advanced Breast cancer is the most prevalent can- advanced AI-based car- AI-based cardiac analysis toolbox”. E b i t ’s cer among women worldwide, impacting cardiovascular SUITESTENSA software, is over 2 million women each year. Breast diac ultrasound analysis a vendor-neutral comprehensive enterprise cancer screening and early detection are DiA Imaging Analysis, a leading pro- platform that allows physicians to archive, key to improving outcomes and survival vider of artificial intelligence (AI)-powered manage and share data reports and clini- rates. However, today, most mammography ultrasound analysis tools has announced cal images produced by any cardiological screening programs are not individualized, that it has partnered with Ebit (part of the equipment. so a significant need exists to be able to Esaote Group), to offer DiA’s LVivo Cardiac Hila Goldman Aslan, DiA’s CEO said identify individual risk of the disease in Toolbox as an integrated part of Ebit’s “The LVivo cardiac toolbox is the missing order to most effectively screen for breast SUITESTENSA CVIS (Cardiovascular link in making ultrasound accessible to users cancer. Information System) PACS. The LVivo with different experience levels.

APRIL/MAY 2019 DI EUROPE 37 INDUSTRY NEWS

With the LVivo toolbox as part of Ebit’s the medical team can accompany the papers and more than 250 publications, SUITESTENSA CVIS PACS, users will patient based on real-time data collec- VolparaDensity is the most clinically val- now be able to get automated and objec- tion and thus respond as needed. idated breast density assessment software tive AI analysis that reduces variability and The main purpose of the partner- in the world. Having an objective and val- increases efficiency in an effort to provide ship is to increase treatment success idated measure of breast density allows better patient care”. and improve the satisfaction of the providers to deliver personalized breast patients and their overall experience. care to their patients by easily identifying Esaote, Over the next ten years Siemens will women with dense breasts. Such women Genoa, Italy oversee, maintain and regularly replace have an increased risk of developing www.esaote.com/healthcare_IT the equipment in the areas of MRI, CT, breast cancer and are also at a greater angiography and ultrasound systems. risk of having a cancer go undetected Siemens partner with Siemens will also supply the appropriate using conventional 2D and 3D mam- software for the devices and keep them mography. Since both dense breast tissue Portuguese Heart updated and tumor lesions can appear white on a Center In addition to the digital solutions mammogram, women with dense breasts and services, the partnership also may benefit from additional screening The Hospital da Cruz Vermelha includes strategic consulting, change such as that delivered by the GE Invenia Portuguesa (Red Cross Hospital) in management consulting and staff edu- Automated (ABUS) Lisbon has signed a ten-year partnership cation. The Heart Center and Siemens which has been shown to find small, agreement with Siemens under which, Healthineers have also agreed to inten- invasive cancers missed by mammogra- Siemens Healthineers will manage the sify their cooperation in research and phy, particularly in dense breasts. medical imaging equipment in the Heart development “We are excited to expand access to Center for the next ten years. The Heart “Value partnerships from Siemens VolparaDensity as part of our prod- Center will focus on the full cardiovas- Healthineers focus on establishing flex- uct portfolio,” stated Luke Delaney, cular continuum – prevention, early ible and lasting business relationships General Manager of Automated Breast detection, treatment and follow-up of that ensure the reduction of operational Ultrasound at GE Healthcare. “Now, our cardiovascular diseases, aiming at being complexity through a single point of con- one of the most modern in Portugal. The tact for all medical device related issues value partnership with Siemens includes and budget safeguards”, said João Seabra, Global Head of Enterprise Services at Siemens Healthineers. “Value part- nerships enable healthcare providers to increase enterprise value to achieve their immediate and future goals and focus on patient care.” provision of solutions and services for Siemens Healthineers clinical workflow design, medical equip- Erlangen, Germany ment for cardiology, and maintenance www.siemens-healthineers.com/ customers outside the US will also have and technology development plans. access to a proven technology that will help Siemens Healthineers will also provide a them identify women who may benefit digital solution for a full patient-centric Volpara expands from a supplemental screening modality, view, including patient monitoring using such as the Invenia ABUS system. ” Dr. J P smart devices. The scope of the contract relationship with GE Russo, Section Chief of Women’s Imaging includes research & development, strate- Healthcare at St. Luke’s University Health Network gic consulting and ongoing change man- in Bethlehem, PA, said: “There are still agement with the aim of continuously Volpara Solutions have announced certain signs of breast cancer that are best improving the patient experience. This is the launch of an expanded agreement seen on a mammogram, which is why in accordance with the focus of the pri- enabling the worldwide distribution of the Invenia ABUS is used in addition to vately run Red Cross Hospital on seam- its industry-leading VolparaDensity mammography. ABUS screening helps find less patient monitoring and aftercare n software by GE Healthcare. Now cancers obscured by dense tissue. Accurate the follow-up of cardiovascular diseases. installed in more than 35 countries, the density measurements and quality imag- Patient monitoring has been structured VolparaDensity clinical application anal- ing are very important in breast cancer in such a way that different technologies yses mammograms using machine learn- detection. I encourage women to learn can be used. The patients can use their ing to provide radiologists with auto- their breast density, understand the risk, smart phones, smart watches and other mated, objective, and volumetric breast and talk to their healthcare providers to portable devices for the continuous density assessments and a breast density get the personalized healthcare they need.” transfer of health data. In addition, data category that has been shown to cor- Volpara Solutions from examinations or the laboratory, for relate to BI-RADS 4th and 5th Editions. Wellington,New Zealand example, can also be handled. In this way, With more than 100 peer-reviewed www.volparasolutions.com.

38 DI EUROPE APRIL/MAY 2019 Perspectum awarded Hopefully, this will enable us to improve specific features to enable patient stratification, which will accelerate electrophysiologists to perform cryoabla- grant for AI-powered diagnosis of diabetes-related complications tion procedures- with reduced need for MRI body scans in and support the development of personalized X-ray imaging. treatments.” Consultant in Endocrinology, Atrial fibrillation (AF) affects more than diabetes Diabetes and General Medicine at the 33 million people worldwide. Cryoballoon The British company Perspectum Royal Free London, Dr. Sarah Ali, added: ablation is used in a minimally invasive Diagnostics has announced that it has “Type 2 diabetes is dramatically increasing procedure to isolate the pulmonary veins, received an Innovate UK grant award to worldwide and can cause damage to mul- which are a source of erratic electrical sig- develop technology that will improve the tiple organs in time if not treated effectively. nals that cause AF. The technology uses diagnosis and monitoring of type 2 diabe- This innovative research study will allow us cold energy rather than heat (radio fre- tes. The grant will fund the development to visualize these organs early on in type quency (RF) ablation) to create scar tis- of specialized MRI powered by artificial 2 diabetes, which will assist pathways to sue and interrupt these irregular electrical intelligence for the examination of multiple stratify treatment in the management of the pathways in the heart. “This integrated solu- internal organs disease.” tion can guide physicians during the treat- Diabetes is a global pandemic, of ment of AF patients with ablation, as they increasing prevalence. At present, care for can view detailed, CT-like 3D anatomy, so diabetic patients is based on routine bio- reducing the need for X-ray imaging ,” s a i d chemical tests that independently monitor Marlou Janssen, Business Leader Philips glycemic control, cardiovascular (CV) risk, EPD Solutions. “Partnering with Medtronic chronic kidney disease (CKD) and liver extends the reach of our KODEX-EPD car- health. In order to tailor effective treatment, diac imaging and navigation system. Today, diagnosis must account for the presence this technology is simplifying navigation, and or absence of multi-organ complications. in the future it has potential for a wide range Professor Dan Cuthbertson, Consultant of applications, including addressing the key Diabeteologist at University Hospital unmet need of real-time therapy assessment Aintree, commented on the Perspectum’s – one of the more significant limitations of award: “The prevalence of obesity and type the current standard of care.” 2 diabetes is increasing at an alarming rate, and with it the rate of associated liver and cardiovascular complications. Screening An MRI scan highlighting different organs (Red = liver; for these liver and cardiovascular compli- yellow = kidneys; blue = pancreas; green = spleen), to enable identification of Type 2 Diabetes complica- cations is still sub-optimal and this multi- tions. (Image based on unpublished UK BioBank data, organ assessment in the diagnosis and treat- Perspectum Diagnostics) ment of type 2 diabetes allows us to better understand the prevalence and progression of disease as well as the impact of different “When available, physicians will have The work supported by the grant will treatments. It hopefully will lead to improved the ability to use an innovative cardiac involve the company stratifying patients treatment stratification.” imaging and mapping system during cryo- with type 2 diabetes using quantitative MRI Perspectum Diagnostics ablation procedures, while also realizing assessment of associated organs, including Oxford University the significant benefits of our best-in-class the liver, kidneys, pancreas, spleen and https://perspectum-diagnostics.com/ cryoablation therapy,” said Rebecca Seidel, aorta. Building on Perspectum’s existing vice president and general manager of the in-house capabilities, this project will pro- Philips to collaborate Atrial Fibrillation Solutions division, which vide disease stratification, improve patient is part of the Cardiac and Vascular Group compliance, reduce costs, and enable preci- with Medtronic on at Medtronic. “AF is a growing epidemic sion treatment. image-guided treatment and we are committed to providing solutions This multi-organ project was preceded to electrophysiologists that help address the by Perspectum’s MRI-based research using of atrial fibrillation needs of their patients.” the UK Biobank, which highlighted the Philips announced recently that it will Philips’ KODEX-EPD system uses significant burden of unrecognized liver be collaborating with Medtronic to fur- dielectric imaging to create CT-like 3D, disease, such as Non- alcoholic Fatty Liver ther advance the treatment of paroxysmal high-definition images of a patient’s car- Disease (NAFLD), which is three times atrial fibrillation (PAF), the common heart diac structures in real time. A completely more prevalent in type 2 diabetes. rhythm disorder. Through the agreement, new approach to imaging the heart, Dr. Gaya Thanablasingham, who spe- Medtronic will facilitate sales of products dielectric imaging offers many benefits cializes in Endocrinology and Metabolic on behalf of Philips to provide an innova- compared to current approaches, for Medicine at Oxford University Hospitals, tive, integrated image guidance solution for both cryo- and RF-ablation procedures. believes that “this project has the potential to cryoablation procedures. Philips will bring Philips greatly enhance our understanding of organ to market the novel KODEX-EPD car- Amsterdam, The Netherlands dysfunction and type 2 diabetes severity. diac imaging and navigation system with www.philips.com

APRIL/MAY 2019 DI EUROPE 39 Magnetic Resonance Imaging Utilizing DICOM metadata to improve radiology workflow

By Mr. I A Talati & Dr. R W Filice

As the need grows to provide patient-cen- As medical services are increasingly being tied to the tered care that is not only high in quality quality of patient care, radiologists must be cognizant of the need to optimize care while controlling costs [3]. but also cost-effective, radiology depart- In the real world radiology department, multiple moving ments must find methods to improve parts impact radiology workflow and efficiency. These the efficiency of their processes as well factors include patient registration, scheduling, proto- coling, reporting, but — importantly — the image acqui- as developing detailed level analyses to sition itself. This complexity is even more evident in a improve patient outcomes [1]. Radiology multicenter radiology enterprise which has the added departments handle a large amount of variabilities of protocol choices, the operation of the modality, and the experience of the radiology technolo- imaging data that must be processed, gists. Informatics techniques for imaging can be helpful organized and easily retrievable. A prime to organize and process the extensive data that radiology example is Magnetic Resonance Imaging departments produce, as well as to optimize protocols and evaluate the performance of complex workflows [4]. (MRI), a complex and potentially time-con- Radiology departments often use Radiology Information suming exam which is often hampered by Systems (RIS) to provide data related to examinations such process variability. MRIs are an excellent as volumes, turn-around times, and start/end times which can provide useful high-level overviews of examination target to review and streamline radiology efficiency. However, RIS data are often manually entered workflow. Radiology departments typically into the system and therefore subject to human error or rely on Radiology Information System (RIS) approximation, and do not include granular series, sequence, or other sub-examination level information. On the con- data, which while useful, often provides trary, Digital Imaging and Communications in Medicine limited and sometimes inaccurate infor- (DICOM) systems facilitate automatic data capture at a mation that limits the ability to fully assess highly detailed and granular level. This is useful in analyz- ing radiology information from complex imaging modali- radiology workflow processes and to ties such as magnetic resonance imaging (MRI) that utilize produce optimal interventions for multiple sequences and protocols within a single patient improvement. examination. Understanding these data may identify process variability or suboptimal utilization that affects patient sat- isfaction or interferes with clinical outcomes. The following This article summarizes a recent study that study aimed to determine if analyzing DICOM data from evaluated the use of Digital Imaging and MRI examinations would provide more useful feedback to Communications in Medicine (DICOM) meta- radiology staff [2].

data as an alternative to RIS data to opti- Design and Methodology mize quality control in radiology workflow [2]. Within a large and multi-center radiology department, we reviewed information related to MRI examinations of the abdomen, prostate, magnetic resonance The Authors (MRCP), and brain during a 30-day period. RIS data were Mr. Ish A Talati 1, 2 & Dr. Ross W Filice 1,2 compared to DICOM metadata that provided study, series, 1. Georgetown University School of Medicine, Washington, technologist, and timestamp information to evaluate the DC, USA time duration of the examinations and the steps within each 2. Department of Radiology, MedStar Georgetown University examination. Within the period, there were 519 examinations Hospital, including 24 different study descriptions. We then narrowed Washington, DC, USA these down to 443 examinations from the eight most com- mon study descriptions. Seventy-six studies were excluded Corresponding Author as they did not have enough series information, were incor- Dr. R W Filice, email: [email protected] rectly coded or were performed infrequently. The remaining

40 DI EUROPE APRIL/MAY 2019 especially in a large enterprise, and some manual coercion may be required to categorize examinations. We found that utilizing DICOM data to analyze MRI workflow was help- ful, but did slow down processing and also required human input. An option for managing this issue could be using internally recognized or com- mercially available standardized study descriptors, such as the RSNA RadLex Playbook [5]. Finally, we found that even with manual coercion of exami- nations, we still had to exclude 15% Figure 1 – Representative relationship between numbers of exams performed by a technologist to median exam of rare examinations due to the diffi- time for prostate MRI exams. Regression suggests that shorter median examination times are associated with culty of matching them to more com- technologists who have performed more exams. mon exams and protocols. Even so, the majority of examinations can be exams were matched by body part (brain, detailed than those offered by the RIS. evaluated for quality improvement. abdomen, and prostate) as well as by series By providing accurate timestamps and level data that included analogous tech- resulting duration of examinations, there Study Implications and Future niques and the same patient positioning. is improved feedback to technologists Directions The DICOM data were compared to RIS and site directors that allows them to tar- DICOM metadata provide valuable information to evaluate data accuracy and get inefficient areas within the radiology and much more granular informa- factors related to examination length. workflow for correction. DICOM data tion regarding MRI studies that help further revealed an association between to streamline workflow and reduce Results length of study and increased technolo- exam times thereby increasing effi- Manually tracked RIS timestamps com- gist experience, suggesting a benefit of ciency and patient satisfaction, and pleted by technologists were compared technologist specialization within a sub- hopefully augmenting the quality of to automatically generated DICOM exam set of exams [Figure 1]. care by decreasing variability. Using timestamps. Across all exam modalities, The analysis allowed easily reproduc- these granular level data enables large, RIS tracking times were consistently and ible scatterplots to quickly identify the multicenter radiology departments to substantially lower than DICOM data. technologists or exams that were outli- identify opportunities to improve their Additionally, evaluation of median exam ers in terms of time and efficiency [Fig- processes. Future directions will be to times stratified by technologist revealed ure 2]. This visual analysis simplifies extend this analysis to other examina- that shorter median examination times subsequent root cause analysis (RCA) tion types, to attempt to further auto- were associated with technologists who to determine the underlying cause. mate the analysis, and perhaps incor- had conducted more exams. porate artificial intelligence techniques Limitations to identify exam and body types to Discussion The study did reveal a limitation of facilitate this automation. Our results indicated that DICOM meta- utilizing DICOM level data. Examina- data are more accurate, reliable, and tion names may not be standardized, References: 1. Boland GW, Duszak R: The challenges in delivering the value chain. J Am Coll Radiol. 2015; 12(4): 409–411 2. Talati IA, Krishnan P, Filice RW Developing Deeper Radiology Exam Insight to Optimize MRI Workflow and Patient Experience. J Digit Imaging. 2019. doi: 10.1007/s10278-018- 0170-z. 3. Steele J, Reilly J. Bundled payments: bun- dled risk or bundled reward. J Am Coll Radiol. 2010; 7(1):43-9. 4. Mabotuwana T, Hall C. Using HL7 and DICOM to improve operational workflow in radi- ology. In Proceedings of the 10th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2017), pages 57-65 5 RSNA RadLex Playbook website. http://play- Figure 2 – Representative variability in series times for brain exams. book.radlex.org. Accessed December 3, 2018.

APRIL/MAY 2019 DI EUROPE 41 ESMRMB 2019 OCT. 3 – OCT. 5 ROTTERDAM/NL

The platform for physicians, engineers, , technologists and scientists interested in MR research and clinical practice

Focus Topics • Machine Learning in MRI • Gadolinium-free Imaging • Effi cient MRI

Early Registration Deadline: July 10, 2019 Become an ESMRMB Member & save even more!

www.esmrmb.org TECHNOLOGY update

Setting new standards in neuroradiology MRI contrast media ESMRMB 2019 injectors An angiography system with spe- or experiencing a delay in the flow of For radiology departments and cial functions for neuroradiology, the contrast agent. Volumes acquired at eight practices, the special multi-use recently introduced Artis icono biplane different time points during a 50-second concept for the disposables used in OCT. 3 – OCT. 5 from Siemens Healthineers, features sig- period help to assess the status of the col- ulrich medical’s new range of MRI nificantly enhanced 2D and 3D imag- lateral vessels in order to determine the contrast injectors means a much ing procedures, which improves image most appropriate treatment. simpler workflow, since after the ROTTERDAM/NL quality and reduces the radiation dose Artis icono biplane is a member of initial set-up, the systems are ready required. As the C-arm can now perform the Artis icono product family, which to go for the rest of the day. The new movement patterns, areas such as comprises novel angiography systems to preparation is extremely simple. the cranial base and skull cap can now permit both multidisciplinary and spe- All that is needed is to insert the The platform for physicians, engineers, radiographers, technologists be represented with practically no arti- cialized use. Whereas Artis icono biplane Easy-Click-Cassette, close the cover, and scientists interested in MR research and clinical practice facts in a 3D visualization. The extremely can be used for neuroradiological, car- connect the patient line, connect fast and flexible axial movements are the diovascular, and abdominal interven- the media container, and the system result of new, high- precision industrial tions, Artis icono floor, a floor-mounted is ready for the first injection. The drives from Siemens. Interventions are single-plane system, is used in vascular Easy-Click-Cassette remains in the highly efficient thanks to the intelli- and interventional oncology procedures. injector for 24 hours and according Focus Topics gent system control such as switching Until now, healthcare institutions have to the multi-use concept is ready seamlessly invested in for as many injections desired. The • Machine Learning in MRI between fixed-con- contrast medium is injected from 2D and 3D figuration the original media containers, which imaging systems means that multiple patients can be • Gadolinium-free Imaging during an tailored to treated in succession without chang- interven- particular ing the container. When it comes to • Effi cient MRI tion, thus clinical spe- the scan acquisition, the user has to making cialties. The perform only a few simple steps – intra-proce- new Artis everything else is taken care of auto- dural prog- icono sys- matically by the injector. Between ress checks tems adapt patients, all that needs to be changed much easier. flexibly is the patient-specific tubing, which Michael Scheuering, Head of to the differing needs of interventional takes just a few seconds. The multi- Interventional Radiology at Siemens radiology, neuroradiology, cardiology, use concept has been shown to be Healthineer, said “Improving the visual- and vascular surgery. For example, the ization of bleeding that occur anywhere lateral plane of the Artis icono biplane in the cranial area can make it possible to can be switched from a radiological to a skip prior conventional imaging for certain cardiological configuration and vice versa patients with a suspected stroke – which in just seconds, using the Lateral Plane means that these patients can be taken Switch. The expanded flexibility of the directly to the angio lab for diagnosis and floor stand and lateral plane makes Artis treatment, shortening the lead time before icono highly versatile to enable operators the vascular occlusion is removed. .” to get the most out of their system. This is A number of studies now show that a relevant operational advantage in light treatment in the form of thrombectomy of today’s increasing consolidation and can be extended to a broader range of cost pressures. patients than previously assumed. This In addition to the multidisciplinary lets neurointerventionalists treat isch- approach, connectivity and digitaliza- Early Registration emic stroke patients who were previously tion of interventional labs are becoming not eligible for this highly effective treat- increasingly important. With the Third Deadline: July 10, 2019 ment. Artis icono was developed to help Party Broker system, Artis icono provides a Become an ESMRMB physicians in stroke centers deal with the uniform interface to enable system param- Member & save even challenge of treating more patients faster eters to be readily shared with devices from more! and with greater accuracy. other manufacturers. Syngo DynaCT Multiphase was developed to provide time-resolved Siemens Healthineers DynaCT volumes to identify areas of Erlangen, Germanyt the brain suffering a reduced blood flow www.siemens.com

www.esmrmb.org APRIL/MAY 2019 DI EUROPE 43 TECHNOLOGY update

extremely successful and is helping users worldwide cope intuitively controlled by the physician. HoloLens is a self-contained with ever-increasing patient numbers. holographic computer that enables hands-free, heads-up interac- There are two device versions available. The Max 2M is a cost- tion with 3-dimensional digital objects. HoloLens 2 builds on the effective solution for lower patient volumes and is particularly breakthrough technology of HoloLens and is even more immer- suitable for first time automated contrast injector users. For larger sive, more comfortable and delivers more value right out of the box. patient volumes the Max 3 is recommended. This version features The concept is being used to gather further clinical insights to sup- three media connection points (one NaCl and two contrast media). port the development of future commercially-available augmented These enable the user to work with different contrast media and reality solutions for use in image-guided procedures. Philips previ- select the appropriate medium for each patient. Alternatively, if ously announced that it is developing an augmented reality solu- the same medium is placed in both connection points, the injector tion for spine, cranial and trauma procedures. automatically switches from the empty bottle to the second, full “The transition from open surgery to image-guided procedures bottle. This ensures there are no interruptions during a examina- has driven a seismic shift in improving patient outcomes and tion and minimizes leftover contrast medium. reducing costs – not least by dramatically reducing the length of Ulrich Medical provides wide-ranging, practice-focused train- time a patient stays in a hospital after their procedure,” s a i d D r ing program on their systems aas well as gemeral training on topics Atul Gupta, Chief Medical Officer for Image Guided Therapy at such as “Hygiene and Safety” for radiology specialists. Philips and a practicing interventional and diagnostic radiolo- gist. “On our Azurion platform we seamlessly integrate a range of ulrich Medical data sources in a way that’s intuitive to understand and control. Ulm, Germany By collaborating with Microsoft and HoloLens 2 we can now it www.ulrichmedical.de/en to the next level, immersing the physician in a tailored augmented reality environment. This concept allows the real world to be Augmented-reality concept for image-guided seen, superimposed with the live data and 3D medical imagery minimally invasive therapies needed to guide our precision therapy, and importantly also lets Philips has introduced a unique mixed-reality concept for the the interventionalist control Azurion with voice recognition, eye operating room of the future that was jointly developed between tracking and advanced gestures. It’s all about keeping our focus Philips and Microsoft. Based on the state-of-the-art technologies on the patient.” of Philips’ industry-leading Azurion image-guided therapy plat- “Mixed reality is giving people new ways to interact with the form and Microsoft’s HoloLens 2 holographic computing platform, digital and physical world, bringing the benefits of the digital revolu- the technology enables novel augmented- reality applications for tion to entirely new experiences across the globe,” said Alex Kipman, image-guided minimally invasive therapies. Technical Fellow, AI and Mixed Reality at Microsoft. “I am thrilled to see companies in a broad range of industries achieve more using the products that we build with our partners and our ecosystem. Mixed reality holds great potential in healthcare, and our collabora- tion with Philips shows how that potential is already beginning to be realized.” HoloLens 2 is complemented by existing and new Azure cloud services and with built-in AI, Since its global launch in February 2017, over half a mil- lion patients have been treated in more than 80 countries using the Azurion platform, which is powered by Philips’ proprietary ConnectOS and combines technical innovations in both software.

Philips Eindhoven, The Netherlands In contrast to open surgery, minimally invasive therapies only www.philips com. require a small incision. Dedicated instruments such as are inserted through the incision and guided to the treatment A practical approach to implementing AI area, which can include the heart, blood vessels, brain, liver and Tera Recon is a leader in the fields of advanced visualization other major organs. During such procedures physicians rely on and artificial intelligence industries and incorporates world-class advanced medical imaging technologies such as ultra-low dose image processing tools into next-generation medical image view- X-ray imaging and ultrasound, as well as other navigation tech- ing, interpretation, sharing and collaboration solutions. nologies, to visualize the intervention and guide their actions. The company has recognized the paradox of a huge and grow- Philips is a leading provider of high tech interventional suites and ing interest in artificial intelligence in radiology on the one hand hybrid operating rooms for such procedures. and, on the other, the frequent absence of a clear understanding on the part of many radiologists as to how to practically Implement The Philips and Microsoft augmented reality concept, built for AI in their daily practice. HoloLens 2, brings live imaging and other sources of vital data To address this issue, TeraRecon have produced an 8-page bro- currently displayed on large 2D screens into a 3D holographic aug- chure on the practical approach to implementing AI, available for mented reality environment that can be ergonomically, easily and free at www.terarecon.com/resources.

44 DI EUROPE APRIL/MAY 2019 REGISTER BY MAY 16 AND SAVE!

EEUROPEANT CONFERENCE2019 ON EMBOLOTHERAPY

EMBOLOTHERAPY

June 26-29 | Valencia | Spain MASTERING EMBOLISATION

Some highlights from the ET 2019 programme

Special Topic Sessions Examining the current evidence on new or controversial developments in embolotherapy

Technical Focus Sessions Highlighting the latest trends in specific embolic materials, delivery systems and advanced guidance modalities

Case Remedy Sessions Featuring case discussions including therapy options, technical aspects, outcome and follow-up

Morbidity and Mortality Conferences Looking at the “bad days” as well as the “good days” in the angiosuite

www.ETconference.org

Cardiovascular and Interventional Radiological Society of Europe C RSE SUBMIT Abstracts and clinical cases YOUR submission deadline SCIENCE 31 May

23rd Annual Congress of the EACVI www.escardio.org/EACVI TECHNOLOGY update

TriVu) to provide better diagnostic per- CE Mark for Wireless Breast formance while offering exceptional Lesion Localization System image quality on all conventional imag- The market leader behind the 3D ing modes thanks to preserved purity of Mammography exam, Hologic has the ultrasound signal. A new generation announced the granting of a CE Mark to of ShearWave (SWE PLUS), their LOCalizer wireless radio frequency even more powerful than previous ver- identification (RFID) breast lesion localiza- sions has also been introduced, making tion system. The system is designed for pre- it possible to view and measure tissue cise and easy marking and targeting of lesions stiffness in real time on a significantly for breast-conserving surgery guidance. improved colour map, notably in terms of The LOCalizer tag is designed to replace acquisition speed, size of the elastography the traditional wire-guided localization region of interest and examination depth. method, helping to provide increased com- It includes the SonicPad touchpad, fort and convenience for patients and their an unprecedented enhancement in the world of ultrasound systems, designed to simplify user experience. The SonicPad improves the radiologist’s workflow by

The company recognises that we are cer- tainly at the precipice of broadly implementing AI and machine learning (ML) in radiology and other specialties. To do so, it is important to leverage the lessons learned from deploy- ing other clinical applications while, at the same time, taking novel approaches. Failure to approach the opportunity from multiple per- spectives will slow the adoption and raise the cost. The path to a successful implementation healthcare teams. The tag can be implanted begins by realizing that the solution is often up to 30 days prior to a breast-conserving non-linear, an adjunct to clinical workflow, surgery, providing increased flexibility for and that typical approaches and integrations patients and providers. This improved will not suffice. It’s important to gather all the workflow is designed to help reduce sched- stakeholders and take a holistic approach. The uling and logistical hurdles for care teams starting point for these solutions to become and aims to deliver added convenience for mainstream is to recognize and prepare for an enhanced patient experience. Following some of the core differences in technology placement, the miniature implantable tag and workflow vs. PACS or VNA projects, and can be detected by a portable, handheld avoid thinking of AI as a singular applica- reader that indicates the location and dis- tion. This will require a new approach that reducing by approxi,ately 77% the user’s tance in millimeters to the lesion, enabling puts outcomes and workflow gains first and movements, thus reducing the time per the surgeon to pinpoint the correct area of technology second. exam of more than 30%. breast tissue for removal. All this and more is explained in “We are very excited to present Aixplorer Hologic has expanded significantly in the PDF on the Practical Approach to MACH 30. An increasing number of our recent years through insight-driven inno- Implementing AI. new ultrasound systems are being installed vation and strategic acquisitions to address across Europe; we have begun to install them the entire clinical continuum of breast TeraRecon in radiology departments of university hospi- health. Along with the LOCalizer system, Foster City, CA, USA tals and private radiology clinics in Germany, the company’s new products include the www.terarecon.com Romania, Italy and of course France. Users SmartCurve breast stabilization system, SUBMIT Abstracts and clinical cases underline the image quality and optimised Clarity HD high-resolution 3D imag- YOUR submission deadline Ultrafast 30 ultrasound diagnostic performance of the different modes, ing technology, the Viera portable breast SCIENCE 31 May system notably ShearWave PLUS, as well as the new ultrasound system, and the Brevera breast The latest example of disruptive tech- ergonomics making the ultrasound system biopsy system with CorLumina imaging nology from Supersonic Imagine, the new easier and quicker to use”, points out Michèle technology, which features real-time imag- Aixplorer MACH 30 system incorporates Lesieur, CEO of SuperSonic Imagine ing and sample verification. a new generation of UltraFast system rd 23 Annual Congress of the EACVI which helps optimise all modes of imag- Supersonic Imagine, HOLOGIC www.escardio.org/EACVI ing (Doppler UltraFast, Angio PL.U.S Aix en Provence, France Marlborough, MA, USA – Planewave UltraSensitive Imaging and www.supersonicimagine.com/ www.hologic.com

APRIL/MAY 2019 DI EUROPE 47 Barcelona, Spain September 7-11 CIRSE 2019

featuring

Early bird fees The world’s most comprehensive meeting until June 6! on image-guided therapies. Featuring 8 clinical tracks, including vascular, neuro and oncological interventions. View the programme at www.cirse.org!

Cardiovascular and Interventional Radiological Society of Europe TECHNOLOGY update

Interventional imaging micro- flexibility and torqueability for cine and perfusion imaging with free Barcelona, Spain catheters get CE approval improved trackability and highest breathing. The system also features Guerbet, has announced that performance standards. EasyTech technology enabling cli- September 7-11 SeQure and DraKon, th ecompany’s ”Guerbet is expanding its interven- nicians to improve workflow with two novel microcatheters used in tional portfolio with new solutions for automatic slice alignment for neuro, peripheral embolization procedures interventionalists, to further enhance spine and cardiac exams, as well as have received the CE mark for the and secure their embolization cases. WFS (Water Fat Separation) DIXON, delivery of intra-arterial therapy and This new range of microcatheters which allows clinicians to take four CIRSE 2019 embolic materials into all peripheral will allow us to help the interven- contrasts in just one scan to show vessels. tional radiology community deliver a uniform fat-suppression in difficult- The SeQure microcatheter is an higher quality of care during image- to-shim areas. innovative reflux control microcath- guided embolization procedures,” eter that uses flow dynamics to cre- commented Thomas Bonnefont, VP ate a fluid barrier designed to deliver Commercial Interventional Imaging. featuring more treatment to the target vessel Guerbet and reduce the risk of non-target Villepinte, France embolization, for reduced potential www.guerbet.com damage to surrounding tissue. The catheter consists of side slits whose size has been specifically designed to Innovative 1.5T MRI allow the outflow of contrast media, improves workflow with creating a fluid barrier around the clinical confidence microcatheter to reduce micro- Representing a new standard in spheres reflux and assist delivery to the premium wide-bore 1.5T mar- the target vessel. ket with new technology designed to boost productivity, enhance patient comfort and deliver diagnostic clin- ical confidence the Vantage Orian Existing patient-friendly MRI fea- 1.5T from Canon offers a range of tures from Canon are also included innovative hardware features. These in the system: the 71cm wide bore include a detachable table option and in-bore immersive virtual expe- enabling preparation outside the rience encourages patients to relax scan room, thus enhancing workflow and thus enables clinicians to pro- and allowing medical staff to respond duce stable, high-quality images; The image above shows a standard microcatheter, posi- to patient requirements quickly and Pianissimo technology significantly tioned in the artery irrigating the tumor. The emboliza- easily. The system also incorporates reduces the noise in and around the tion microspheres travel not only downstream (desired the company’s Saturn Technology for MR, as well as Pianissimo Zen quiet effect) but also upstream (undesired effect) in an arterial branch irrigating healthy tissues that need to high performance imaging capabil- sequences which further reduce be preserved. ity, including a new slim gradient noise to just above ambient noise with a maximum amplitude of 45 level, making exams even more com- mT/m and a slew rate of 200 T/m/ fortable and easier to complete. sec. Other features include PURERF Rx technology that gives an increase “We are committed to offering in Signal-to-Noise Ratio of up to 38 premium diagnostic imaging tools percent. A re-designed digital gantry to our customers, enabling them Early interface displays important patient- to deliver accurate, confident and related and coil information, allow- effective patient care,” said Dirk bird fees ing clinicians to ensure proper and Berneking, Senior Manager of the complete setup without leaving the MR Business Unit at Canon Medical The above image shows the anti-reflux microcatheter: The world’s most comprehensive meeting until June 6! Its design and technology result in sending the embo- patient’s side. Systems Europe. “The Vantage Orian lization microspheres downstream into the area to be The Vantage Orian also offers a was designed to increase productivity on image-guided therapies. treated. The healthy tissue continues to be irrigated by suite of software enhancements to while ensuring patient comfort and blood free of microspheres. help reduce scan time and increase delivering uncompromised clinical Featuring 8 clinical tracks, including productivity. These enhancements confidence.” vascular, neuro and oncological interventions. include the MultiBand SPEEDER, The DraKon peripheral micro- which enables clinicians to reduce Canon Medical Systems catheter is the same as SeQure but DWI acquisition times, and the k-t Europe View the programme at www.cirse.org! without the side slits. It has been SPEEDER (up to x8 accelerated), Zoetermeer, THE NETHERLANDS designed to optimize pushability, which allows high frame rate cardiac https://eu.medical.canon

Cardiovascular and Interventional Radiological Society of Europe APRIL/MAY 2019 DI EUROPE 49 TECHNOLOGY update

Hitachi introduces next generation CT and MRI systems

In a major launch of new products Hitachi’s next-generation iterative at the recent ECR meeting, Hitachi reconstruction function, the Intelli Healthcare introduced two new sys- IPV (Iterative Progressive recon- tems, one a CT system and the other struction with Visual modelling) MRI, each providing even higher lev- enables a large reduction in the noise els of diagnostic imaging solutions. associated with low levels of radia- The new CT scanner, the tion, so that image quality, texture and outstandiung clarity are main- tained. The Intelli IPV technology allows a reduction of up to 83% in The Echelon Smart 1.5T MRI enhances patient radiation dose. Thanks to Hitachi’s comfort through very quiet examination procedures SynergyDrive workflow solution thanks to the SoftSound Technology for silent gra- dients. New workflow concepts are designed for (see below), which combines auto- efficient and simple operations of coil setting, and mation, consistency and speed, the patient positioning. high level of image quality from the Scenaria View is not compromised, sharing. A broad range of choices The Scenaria View features an industry-leading even under the pressure of the high of clinical applications are available 800 mm bore, which, combined with its lateral side patient throughput that is a feature of to meet all the needs of individual slide table, reduces patient anxiety and allows easy modern busy CT departments. providers. SynergyDRive gives value patient positioning. not just to radiologists, technologists, SCENARIA View, features a totally As for MRI, the new ECHELON department administrators but also, new design that raises the bar for ver- Smart Plus is a next level 1.5T con- to patients. satility and affordability in the 64/128- ventional superconductive MRI sys- slice sector which is the “workhorse” tem, featuring state-of-the-art tech- segment of the overall CT market nology, enhanced productivity and and the one in which the most CT providing uncompromised diagnos- scans are performed. The new system tic value. The new system has a pow- enhances patient comfort through erful RF chain and features a 50cm its open design which, with its 80cm FOV in all axes. Multiple coil con- aperture provides improved flexibility nectors are available on the motor- The Echelon Smart 1.5T MRI provides high-speed in the scan plane and allows even the ized patient table for highly sensitive images of high clinical value largest of patients to be accommo- receiver coils. As well as meeting all dated and precise clinical targeting to the needs of the imaging profession- Mr. Jean-Luc Budillon, President be achieved. Even though the aperture als, the new system also enhances and COO of Hitachi Medical Systems has been widened, the gantry itself patient comfort through very quiet Europe commented about the two still remains compact, thanks to its examination procedures, thanks to new products being introduced to innovative internal design. the SoftSound Technology for silent Europe: “SCENARIA View changes the gradients. outlook for CT examinations. It com- bines all of Hitachi’s experience and Applicable to both CT and MRI expertise in a remarkable new product modalities, the high-speed image providing an unmatched combination reconstruction tool, SynergyDrive, of speed, comfort and quality. In MRI, impacts on a wide range of scan tasks, the ECHELON Smart Plus is consis- and with its sophisticated automatic tently cited as an example of Hitachi’s features, massively shortens scan social innovation, with its new work- time. SynergyDrive is a comprehen- flow concepts designed for efficient and sive hardware- and software-based simple operations of coil setting, patient system and is designed to streamline positioning and high speed, high clini- operations for MRI and CT exami- cal value imaging”. Compared to Filtered Back Projection (FBP) and iterative approximative-based reconstruction, the nations. The system comprehensively Intelli IPV (Iterative Progressive reconstruction with addresses the bottlenecks in the MRI Hitachi Medical Systems Visual modelling) system enables a large reduction and CT scanning process from start Europe in noise at low levels of radiation so that image qual- to finish — from patient registra- Zug, Switzerland ity, texture and clarity are maintained. tion to post-processing and image www.hitachi-medical-systems.eu/

50 DI EUROPE APRIL/MAY 2019 International Cancer Imaging Society FUTURE COURSES FOR 2019

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