ECR TODAY

DAIlY NEwS fROM EUROpE’S lEADINg IMAgINg CONgRESS

SUNDAY, MARCH 8, 2009

INSIDE TODAY ESR meets Sports Technology focus Switzerland Round-up on MRI

See page 2 See page 5 See page 17 Tough new questions Experts speculate confront radiologists on the future of in the molecular era cardiac MR and CT

By Philip Ward By Philip Ward

Crystal-ball gazing reached new levels at ECR on Future magnetic resonance systems used in Saturday, when Prof. Dieter Enzmann took dele- cardiovascular imaging will inevitably operate gates on ‘a trip to tomorrowland,’ as he at higher field strengths, including 7T, according referred to his W.C. Röntgen Honorary Lecture. to a leading cardiac radiologist.

“Radiology is in the information business, not the “The future will be about more Tesla,” Prof. film-reading business, and that information is in Matthias Gutberlet of the cardiac imaging unit, image phenotypes, at least currently,” said Enz- department of diagnostic and interventional mann, chair at the David Geffen School of Medicine radiology, Leipzig University and Leipzig Heart at the University of California, Los Angeles. Center, Germany, told attendees at Saturday’s car- diac categorical course. Radiologists are good at gathering imaging data, Prof. Dieter R. Enzmann from Los Angeles/US Prof. Matthias Gutberlet from Leipzig/DE and they do this is because it leads to information The crucial aspects in cardiac MR are the analysis of upon which others can act. This in turn leads to future more closely resembles a network of multi- ventricular function, myocardial perfusion and via- The main advantages of 3T are its perfusion/via- Opening Ceremony a medical decision. Currently this process relies ple alternative pathways, Enzmann said. bility, and imaging of the coronary , he said. bility, flow measurement, ‘tagging’/spectroscopy heavily on anatomic and physiologic information. applications, and effective imaging of the coronary Diseases are defined by the states of complex bio- Gutberlet emphasised this point by referring to arteries. Conversely, the main drawback is its high “The raison d’être of radiology is that there is a logic networks, and one of radiology’s goals is to research from the Society of Cardiovascular MR. cost and limited availability. medical decision. Without a medical decision, define the cell network and to establish its state. The SCMR asked its members: Which is the most there is not much need for radiology,” he said. important problem in your daily routine with car- In terms of image quality, all standard cardiac MR “What’s changing is that in medical decisions, “Radiology will be in the business of imaging bio- diac MR? A staggering 66% of the respondents sequences used for functional evaluation of left there are now additional factors to be considered.” logic networks and their states,” he predicted. “All replied imaging of the coronaries, whereas 17% ventricular function show an improved SNR and biological processes are driven by networks, not cited myocardial perfusion, 14% cited flow quan- contrast-to-noise ratio. In today’s molecular era, radiologists need new by simple pathways.” tification, 2% cited functional imaging, and 1% information, new imaging data, new knowledge, delayed enhancement imaging. “Image quality of MR flow measurements and and new experience. They will have to learn about Cancer is a paradigm for radiology’s network chal- myocardial tagging improves without changing integrated diagnosis by imaging phenotypes, lenges, and radiologists are uniquely positioned to Switching from 1.5T to 3T improves the image sequence parameters,” Gutberlet said. “In steady which consist of any observable physical or bio- detect and measure heterogeneity in cancer, he quality and doubles the signal-to-noise ratio state free precession (SSFP), sequence modifica- chemical characteristics of an organism. continued. In this context, it is important to regard (SNR). It reduces the acquisition time and tions are necessary.” cancer as a genetic disease that modifies the cell increases spatial resolution. Moving to 7T leads To offer an answer to any question, it is essential to network. Although this network is very complex, to further improvements in image quality by Furthermore, ‘excessive’ use of parallel ima- understand the question itself, but the questions a limited number of pathways cause abnormal increasing the SNR by around five times, i.e., ging enables improved spatial and/or temporal facing radiology are changing fast. Instead of being signaling in cancer. Therefore, cancer should be (SNR x 2) x 2.33, he explained. a straight and clearly defined road, radiology’s regarded as a signaling problem. continued on page 3

myESR.org 2 ECR TODAY 2009 HIGHLIGHTS Sunday, March 8, 2009

Swiss radiologists display their knowledge of high-field MR imaging systems

By Paula Gould

Switzerland is leading the way in terms of high- field MRI. The country has one of the highest densities of 3T systems in Europe, if not the world, delegates learned yesterday at the ‘ESR meets Switzerland’ session.

Of the 207 MRI systems installed in Swiss hospitals and clinics, 42 are 3T units. This means that there are five 3T scanners for every million Swiss residents. In comparison, the number of 3T MRI scanners per million inhabitants is half this number in Germany.

Swiss radiologists’ knowledge and expertise of high-field MRI was showcased at the 90-minute session, during which analogies were made between alpine peaks and the heights that radiologists are reaching at 3T. Presenters from four leading centres discussed the pros and cons of working at higher field strengths in a wide range of practical applications.

High-field MRI is playing a key role in management in Switzerland, according to Dr. Karl-Olav LØvblad, neuroradiologist at Geneva University Hospital. Because most 3T systems are sited in larger cities, air ambulances are used to transport stroke patients from remote, alpine Congress President Prof. Borut Marincek welcomes his fellow countrymen at yesterday’s ESR meets Switzerland session. locations to centres that have advanced imaging technology. better imaging. One downside, common to all Moving from 1.5T to 3T should boost diagnostic abdominal MRI at 1.5T. He then posed the “The problem with stroke imaging is that you applications, is that imaging is slower. The longer confidence when examining the knee, ankle, and question: why move to 3T at all when you can do have to do something very complex in a short T1 relaxation time means a longer TR. This shoulder, and when looking at cartilage defects. so much at 1.5T? space of time,” he said. is typically compensated for by using parallel However, returning to the mountain metaphors imaging. Some findings can also be missed on once again, Bonel observed that high-field MRI High-field MRI has traditionally presented Although CT is typically regarded as the high-field images. has yet to reach its peak. many challenges for abdominal radiologists, modality of choice when deciding which acute Weishaupt said. Issues associated with increased stroke patients should receive thrombolysis, MRI The higher spatial resolution realised at 3T has The case for 3T abdominal MRI has yet to energy deposition and acoustic noise, and greater may be a better bet. Diffusion-weighted MRI clear diagnostic advantages when imaging the be proven too, according to Prof. Dominik chemical shift artefacts are being overcome. is more sensitive to the detection of ischaemic hand and wrist, said Dr. Harald Bonel, radiologist Weishaupt, chair of radiology at Triemli He regards the major remaining problem to events. Moving from 1.5T to 3T for the scan at the University Hospital Inselspital, Bern, Hospital, Zurich. Weishaupt began his be B-field inhomogeneity and standing wave means double the signal-to-noise ratio, more who considered the topic of sports imaging. presentation by outlining the strengths of artefacts. BOLD contrast, and an increase in the effect of T1 relaxation of contrast. The benefits of 3T over 1.5T are clear-cut in a few abdominal imaging applications, Weishaupt New techniques that are under development said. For example, studies show that intrahepatic could tip the balance further in favour of MRI. bile ducts can be detected with more confidence at 3T may remove the when MRCP is performed at 3T. The diagnosis need for contrast altogether when studying of focal liver lesions also appears to be improved revascularisation, LØvblad said. Meanwhile, when imaging with SPIO contrast is performed susceptibility-weighted imaging has been shown on a high-field system. to demonstrate haemorrhages better than standard T2* imaging sequences. The thorny issue of: ‘Is the gain worth the financial pain?’ was also debated when the “Three-T does have an impact on stroke imaging floor was opened up to questions. All speakers because by simply going beyond research stressed that the choice of whether to invest in purposes it allows clinical implementation of 3T depended critically on local circumstances. new and improved sequences,” LØvblad said. A clinic with a large neuroimaging workload, for example, would be well advised to invest Another area where high-field MRI can make in a high-field system. For departments with a a difference is myocardial perfusion imaging, mixed caseload, including a high proportion of according to Dr. Jens Bremerich, radiologist abdominal studies, the case may not be so clear- at the University Hospital in Basel. The most cut. robust protocol for perfusion MRI is first pass Dr. Harald Bonel from Berne/CH Dr. Jens Bremerich from Basel/CH contrast-enhanced imaging, he said. Other Prof. Borut Marincek, co-moderator for the options include BOLD imaging, spin labelling, session, challenged Weishaupt directly to say and magnetisation transfer, though these are what type of system he would buy next. The currently regarded as works-in-progress. Institute of Radiology at Triemli Hospital currently has just one 1.5T MRI system and Patients scheduled for 3T perfusion MRI at the the purchase of a second scanner is planned. University Hospital in Basel are given adenosine Weishaupt confirmed that this is likely to be a 3T so that stress imaging can be performed. The system. alternative – to image whilst patients exercise – is not viable. It would be impossible to take a This morning’s ‘ESR meets’ session will turn the bicycle into the scanner bore, Bremerich joked. spotlight on to Croatia. Speakers will discuss the national mammographic screening programme, The 3T MRI examination can be used to acquire image-guided breast biopsies, endovascular int- information on mass and cardiac viability as racranial procedures and endovascular aortic well. As such, 3T MRI has an advantage over repair. , which will only offer data on perfusion, he said. The negative predictive value To attend the session head for Room A at 10:30. of normal adenosine stress perfusion MRI is ~99%, similar to that of perfusion scintigraphy.

Bremerich cautioned radiologists to remember that moving to 3T does not always mean Prof. Dominik Weishaupt from Zurich/CH Dr. Karl-Olof Løvblad from Geneva/VH myESR.org Sunday, March 8, 2009 HIGHLIGHTS ECR TODAY 2009 3

Vienna, ‘City Hospital management strategies of my dreams’ come under careful examination By Robert George, President, ISRRT

Vienna has always been a magical place for me. at Saturday’s symposium When my wife and I first had an opportunity to visit Europe in 1983, we made sure it was on our itinerary. The fact that our daughter and son were only nine and six years old, respectively, meant By Mélisande Rouger that we had to make each city we visited a special place for them. Vienna meant two things for them: European hospitals may vary a lot in terms of dancing white horses and waltz music. Of course, management, but all are aware of the necessity of it soon meant other things, such as Sacher-Torte harmonising both their medical and economic and Wiener Schnitzel. affairs. We enjoyed the Spanish Riding School and This process has reached Vienna, hometown of the Opera. We visited the wonderful statues of the ECR, where new plans are underway to opti- composers in the parks and talked about their mise the organisation of hospitals’ workload. beautiful memorials in the cemetery. The children In Milan, the European Institute of Oncology loved the ‘big church with the zig-zag roof’ and (EIO) is also an example of modernity. These the big bell. models, and many others, were presented on Saturday during the Hospital Management But the thing they still remember most vividly Symposium, an event co-organised by European is the famous Prater amusement park, with its Hospital. giant Ferris wheel (the Riesenrad, at the time, one of the largest in the world) and the merry- Dr. Leonardo la Pietra, chief medical officer of go-round with real horses pulling it around. the EIO, opened the symposium by speaking Dr. Leonardo la Pietra from Milan/IT Dr. Wilhelm Marhold from Vienna/AT his institution, which he described as a unique My subsequent visit to Vienna in 1992 coincided model in Europe. The EIO, a private non-pro- with the European Regional Congress of the fit organisation, is partly financed by national burden on the healthcare system is shared by “Medicine and economy are not a contradiction, ISRRT, the International Society of health services and concentrates on three core most developed countries. and they should not become one. They are like and Radiological Technologists, when I had activities: clinical work, research, and training. two fruits: combined together, they taste really the great privilege to represent Australia as its These challenges mean change is necessary. good,” he added. council member. I still recall the exhilaration It treats about 20,000 patients per year, and con- at walking down the main hall in the Hofburg tracts out most of its 1000 staff. Its modernity “Not only do we need new structures, but we Beyond the capital, Austrian hospital managers Kongresszentrum, proudly carrying our national is reflected in the fact that the average age of its must also change the organisation, the way of recognise the need for change, according to a flag, enjoying the warmth and hospitality of the staff is just 25. It covers almost all subspecialties life in our hospitals,” said Dr. Wilhelm Marhold, study led by a Vienna-based consulting group Viennese including the experience of a Heurigen except neurosurgery and paediatrics, and uses CEO of the Wiener Krankenanstaltenverbund involving CEOs of all major hospital groups in – their traditional places for having a glass of wine, the Joint Commission International Accredita- (KAV), Vienna Hospital Association. the country. and waltzing to a small orchestra in the amazing tion System to measure its performance. Rathaus. Currently equipped with 12 hospitals, the Aust- “90% of participants expect a rising need for The EIO attributes its success to the putting rian capital will welcome a new hospital in 2013, change, particularly regarding the adaptation of So why are these memories flooding back just the patient at the centre of all its activities. It is the Hospital North, construction of which will service portfolios, quality assurance of results, now? Because I’ve returned to attend my very also working towards more integrated medical start next year. This project will constitute the and continual improvement of processes,” said first ECR, and I can’t wait to renew my previous records, which should accompany the patient in locomotive for structural changes in the hospi- Stefan Furtmüller, project manager at Contrast experiences of such a great city. his or her journey through the healthcare system. tals of Vienna, Marhold stressed. Management-Consulting. Having attended many RSNA and UKRC and “Information technology, with the realisation of This opening will be accompanied by the The study, which focused on strategic goals ICR meetings, I am excited not only because of an electronic patient record, accessible online decommissioning of three hospitals, namely and challenges faced by hospital managers, also the location but because of the reputation that the from different places, could provide a valuable the Floridsdorf Hospital, the Semmelweis showed that private groups performed better in ECR has gained internationally. aid in the management of medication continu- Women’s Clinic and the Orthopedic Hospital the development of management tools and tech- ity,” la Pietra said, adding that the EIO plans to of Gersthof. But rather than a simple closure, niques than public ones. I presently have the privilege of being president of expand its coverage to include cardiology and the KAV will coordinate the transfer of their the ISRRT, the society representing over 350,000 neurology in the future. medical services to the Hospital North. This “The general conditions for hospital manage- technologists from more than 80 countries. Our decision reflects the evolution of medicine as ment are not easy, with too many stakeholders society has been associated with the ECR for In Vienna, hospital services are also being a field, and the need to harmonise healthcare and interest groups, different finance systems, many years, and we act in a coordinating role for modernised. More than 50% of Viennese hospi- with economy. etc. Nonetheless, the existing conditions and the ESR, chairing the technologists organizing tals were built during the Habsburg Empire, and structures still offer numerous opportunities to committee. the dilapidation of the buildings calls for massive “Today we do not need any more kingdoms of increase efficiency with regards to customised reinvestment. Also, most hospitals are located in specialisation; the fantastic progress we have seen and high-quality patient care. Business tools and What ISRRT brings to the ECR is an international the western part of the city, whereas all the eco- in medicine in recent decades must be accompa- methods can help here ... for most organisations perspective for technologists similar to the nomic and demographic development is taking nied by an evolution in hospital management,” there is still quite a lot of room for improvement,” radiologists’. This is evident when one peruses place on the east banks of the Danube. Further- said Marhold, who admitted that this would also he concluded. the excellent and comprehensive technical more, the Austrian population is ageing, and this lead to a loss of acute care. programme.

There is no doubt that ECR has the leading reputation for technological advancement in continued from page 1 (Cardiac) The future of cardiac CT is not just about ‘more presentations and education. For those of us who slices and more tubes’, Prof. Andreas F. Kopp, from have enjoyed ECR from afar, the excellent range resolution in all sequences, he noted. Reliable the department of radiology, Eberhard-Karls-Uni- of material made available during and after the flow measurements even in smaller vessels are versity, Tübingen, Germany, told course attendees. meeting is superb and almost makes not being in possible, for example in the coronary arteries, Vienna itself almost tolerable! and longer ‘tag persistence’ allows for a better The first generation of multidetector CT scanners analysis of diastolic function. (4-row) was first launched in 1998. The next gene- This year for me will be a milestone: my first ECR ration (16-row) was unveiled in around 2000, and and a special Australasian session as well. This is However, 7T systems are still scarce. The first the third generation (64-row) came in 2006. The made all the more enjoyable because those two installation of a Signa 7T machine took place fourth generation of machines (dual source, far- small children from 1983 I talked of earlier are at the Laboratory of Functional and Molecular field R-wave sensing [FFS], 128-row) is now star- now both radiographers like me and have both Imaging, National Institutes of Health, Bethesda, ting to emerge, as radiology moves beyond ‘the enjoyed the experience of working in the UK for Maryland, U.S., in 2003. It was followed by ins- Slice Race’, he noted. two years and traveling widely throughout Europe tallations at the University of Niigata in Japan, and, of course, visiting Vienna. University of California in San Francisco, and In terms of the mechanical design, the latest CT Stanford University. There will be further 7T scanners have to withstand very fast rotation. I will take great delight in e-mailing them images units in the future, he predicted. Centrifugal forces acting on the x-ray tube are of the Hofburg, the Schönbrunn Palace, some 75G for a 0.2 second rotation. Prof. Andreas F. Kopp from Tübingen/DE Sacher-Torte, and, of course, the Prater. I’m sure The development of dedicated cardiac MR sys- that, like many Australian radiographers, they tems is also a real possibility, said Gutberlet, Without expanding the limits of physics, Kopp’s than today‘s standard 64-row MDCT system, will mark March and the ECR on their calendars when he was asked about this topic by session ‘dream machine’ would have a wide detector he said. for some time in the future, as indeed should all moderator Prof. Maximilian Reiser from the (16-20 cm), new dose-efficient detector mate- technologists! University of Munich. Reiser was President of rial, a fast rotation speed (0.2 second), two x-ray “Even the smallest screw must be ready for 75G,” ECR 2008 and is 2nd Vice-President of the ESR’s sources, and unlimited computing power for he concluded. “Cardiac CT must be the driving Note: this column first appeared on DiagnosticImaging.com Executive Council. iterative reconstruction. It should not cost more force for innovations in CT.”

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Clinical cell imaging starts to loom large, but still waits tantalisingly on the horizon

By Paula Gould

Can we do cell imaging? Yes we can! Can we use the techniques in clinical practice? Not just yet, I’m afraid, but we may be there in another few years.

The message at yesterday’s New Horizons session on cell imaging was clear to all: techniques are certainly available that will let researchers iden- tify cells, either individually or in groups, but many unresolved issues need to be addressed before cell imaging can become part of the clini- cal radiologist’s tool kit.

“I think it has been well demonstrated over the past 10 years that cell tracking is feasible using different types of contrast agent, you can choose and pick,” said Dr. Mike Modo, a neuroscientist at King’s College London (KCL). Dr. Florence Gazeau from Paris/FR Dr. Mike Modo from London/UK Prof. Peter Friedl from Nijmegen/NL

Interest in cell imaging has been prompted by preclinical research into the healing effects of and/or exposed to a rapidly switching mag- hemisphere. The findings were confirmed on flu- for radiologists in terms of monitoring these stem cells. Transplanted stem cells could poten- netic field to induce a local heating effect in orescence imaging. therapies as they make their translation into the tially help repair damaged or diseased cells in tissue. clinic.” organs throughout the body. However, investi- Although initial attempts at clinical transla- gators need to be sure that the cells are reaching At KCL, researchers have been carrying out cell tion are in progress, not enough studies have Prof. Peter Friedl, principal investigator from the their intended targets. Cell imaging should also imaging using a bimodal contrast agent that been done on the long-term effects, accor- department of cell biology at the Nijmegen Cen- shed light on the mysteries of the repair process contains a fluorescent probe as well as a gado- ding to Modo. He reminded delegates that tre for Molecular Life Sciences, The Netherlands, itself. linium chelate. This allows investigators to dou- labelling can alter the behaviour of cells. Cell rounded off the session by discussing a novel ble-check their MRI findings, Modo explained. proliferation and viability can both be redu- optical imaging technique called multiphoton Florence Gazeau, Ph.D., researcher in biolo- Without this back-up, researchers may believe ced, and these effects can be observed just 24 microscopy. His talk was illustrated with images gical physics at the Université Denis Diderot, they are tracking labelled cells when in fact they hours after tagging. Researchers developing from preclinical studies. Development of a clini- Paris, showed how cells could be easily labelled are looking at artefacts, for example, from blood therapies that depend on transplanted stem cal system that could be used laparoscopically or with ultrasmall superparamagnetic iron oxide or air. cells being in situ for long periods will need to endoscopically is likely to take another five years, (USPIO) particles. On mixing, the magnetic check that their contrast labels do not impede he said. nanoparticles first clustered around individual He presented images from a study in which recovery. cells before becoming incorporated within the tagged cells had been injected into the brain of “ techniques used in clini- cells themselves. a stroke patient. Post-injection MRI showed the “We need to be mindful that we are not just cal practice today only have around 100 micron cells at the injection site. Seven days later these developing something that is interesting for us penetration. With this system, you could go up Cells tagged in this manner can then be imaged cells were again seen on MRI, having migrated in terms of preclinical studies,” Modo said. “We to 300 or 400 microns,” he noted. with MRI, manipulated using a magnetic field, to the infarcted brain tissue in the contralateral also want to develop techniques that are useful Refinements bring positive results at EPOSTM Spain takes

By Mélisande Rouger early lead over

Created in 2003, EPOSTM , the fully electronic sci- Serbia in Davis entific exhibition, has become an established part of ECR. Cup match A total of 844 electronic posters, comprising 409 Novak Djokovic suffered a shock defeat to David educational and 435 scientific exhibits, are on Ferrer, as Spain surged into a 2-0 lead over Serbia display at this year’s congress, in addition to 20 in the first round of their Davis Cup defence. Cases of the Day (five new cases each day) and the EURORAD radiological case database. Gale-force winds, reported to be up to 100 km per hr, in Benidorm had caused the tie to be delayed Poster submissions rows sharply during 2008, for 24 hours. When play eventually got underway, with 2,682 submissions in comparison with 2,273 the hosts wasted little time in establishing a in 2007. clear lead after world number one Rafael Nadal conceded only three games to Janko Tipsarevic. “Abdominal and cardio pathology have been Nadal triumphed 6-1 6-0 6-2 to win in just 96 leading subspecialty areas this year, even though minutes. Ferrer enjoyed a fairly comfortable 6-3 this is not a general trend. No subspecialty has 6-3 7-6 (7/4) triumph over world number three been left behind,” commented Prof. Yves Menu, Djokovic. 2nd Congress Vice-President for ECR 2009, who is responsible for the electronic scientific Helping hand: Prof. Yves Menu assists a visitor in the EPOSTM area. In skiing, ’s Klaus Kröll beat his compatriot exhibition. Michael Walchhofer and Canada’s Manuel Osborne-Paradis to win the men’s The exhibition, located on the first level of the Along with easing access at ECR this year, Menu ding five posters in a subspecialty to users,” Menu World Cup downhill in , Norway, Austria Center, has been moved from room R2 to and his team have been thinking of ways to explained. “We have guides for restaurants, for yesterday. Walchhofer, who finished 0.27s behind an adjacent, quieter room. The number of moni- improve the quality of the tool itself, for instance wines ... It would be great to have the same for Kröll, currently has a 75 point lead over his team tors has been reduced from 120 to 100, a decis- by making the search engine more user-friendly. electronic posters!” mate in the World Cup downhill standings ahead ion that should not harm the stream of delegates, Progress could also be made regarding free text of Wednesday’s season-finale in Are, Sweden.

Menu believes. On the contrary, the new location, search, which is still either too large or too limited. But EPOSTM would be nothing without the fantas- which offers more visibility and a studious atmos- tic work done by the jury, Menu stressed. “Results The lead in the race for the overall men’s World phere, should increase the overall value by making Menu plans to tackle precisely these issues. Ano- were remarkable this year, and I am very grateful Cup title is split between Croatian Ivica Kostelic it easier for delegates to find a seat. ther idea would be to imagine a user route in a to the jury for that. It is a lot of work in a short and Austria’s Benjamin Raich, both of whom failed subspecialty, to increase posters’ visibility. time, and they derive no glory for this since it to make an impact in yesterday’s competition. “Participants’ presence is more linked to the con- remains absolutely anonymous. I thank them all.” Kostelic finished in 42rd place, firmly outside the figuration of the room than the number of com- “The ten most widely consulted posters are usually points, while Raich was disqualified. Only eight

puters available. Last year, some of the exhibition the ten that receive a prize, which is fully justified. On Sunday and Monday, EPOSTM will open from points separate the leading duo from Norway’s was obscured by pillars, and participants could But it is more author than user oriented. Many 07:00 to 19:00. On Tuesday, it will open from 07:00 third-placed , who came in 13th not always see a free monitor. We even had free other good posters would be worth seeing, so we to 12:00. here, with Switzerland’s trailing by a seats at rush hour,” he said. are thinking of selecting and then recommen- further 74 points ahead of Sunday’s Super-G.

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Delegates who attend these events can claim CME points Optimising contrast media Gadolinium-based contrast use and CT techniques agents: New paradigms to enhance image quality for patient safety and and patient safety management

Chairman Moderator Dr Elliot K Fishman Dr Robert Brasch Johns Hopkins Hospital, Baltimore, Maryland, USA Professor of Radiology, Director, Centre for Pharmaceutical and , University of California, San Francisco, CA, USA

Scientifi c programme Scientifi c programme 12:30-13:45 14:00-15:30

Chairman’s Welcome & Introduction Bridging the gap between gadolinium-based contrast Dr Elliot K Fishman agent structure and the mechanisms underlying NSF Dr Ben Newton Challenging cases in current CT practice Project Director, GE Healthcare Dr Elliot K Fishman Understanding the risk factors to guide preventive Reviewing contrast media trials and examining care in renally impaired patients new techniques for assessing renal function Dr Steven Weisbord Dr Donal Reddan Assistant Professor of Medicine, Renal-Electrolyte Division, University College Hospitals Galway, Galway, Ireland University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA Optimising image quality in cardiac CT Dr Filippo Cademartiri Contrast-enhanced MRI and MRA: Azienda Ospedaliero-Universitaria/University Hospital, Parma, Italy essential and safe tools in everyday clinical practice Personalising the CT scanning protocol Dr Tim Leiner Department of Radiology, Maastricht University Hospital, to enhance patient care Maastricht, The Netherlands Dr Elliot K Fishman

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Harry’s Hot Shots from Day Two Who and what caught the eye of ECR Today’s valiant photographer, Harry Schiffer, on the second day of the congress? On this page is a selection of what Harry saw through Marincek promotes youth-friendly approach the lens of his camera during Prof. Borut Marincek paid a surprise visit to the Saturday’s activities at the Austria newly created ‘Residents and Students Lounge’ on the Center. first level of the congress venue, which turned out to be a great success among ECR’s younger visitors.

ESOR stages its first session at ECR The first ever session organised by the European School of Radiology at the ECR went ahead smoothly yesterday afternoon. The main aim of the session was to Something for nothing The free publications on provide insight into the various educational the first level have been programmes established for younger disappearing fast. radiologists during their training. ESR President Prof. Iain McCall outlined what the school means for the ESR, and ESOR Scientific Director and former ECR President Prof. Nicholas Gourtsoyiannis spoke about the value of education in partnership.

Hands-on Workshops Practical sessions held throughout ECR have been proving popular.

Join us in Berlin, please! CARS organiser Prof. Heinz Lemke and his team are at ECR to promote their congress, to be held from June 23–27.

PR in the ER makes rapid progress at ECR When the ‘ESR meets Emergency ’ session was wound up late afternoon on Saturday, it was being heralded as a public relations coup that would contribute to greater mutual understanding and respect between radiologists and their colleagues in the emergency room.

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Sunday, March 8, 2009 CLINICAL CORNER ECR TODAY 2009 9

Forensic imaging Old pose serious specialists seek Stroke action plans InSIde TOday diagnostic dilemmas mainstream recognition attract attention

See page 11 See page 15 See page 16

Interventional MR imaging represents promising clinical area for the future

By Paula Gould tions to be feasible, including the catheterisa- tion and stenting of coronary arteries, accor- If radiologists could design the perfect moda- ding to Prof. Dr. Gabrielle Krombach, professor lity for guiding interventional procedures, the of radiology at Aachen University Hospital, resulting technology would undoubtedly pro- Germany. duce high quality images without exposing patients to any ionising radiation. So given Emerging ablative techniques that use focussed the widespread availability of MRI, why are ultrasound may benefit from MR guidance as so many interventions still performed in the well. In addition to guiding the therapeutic suite? probe, MRI can also visualise the effects of tis- sue heating in real time, improving safety and The absence of ionising radiation is one of the efficacy. No other imaging modality offers this main arguments in favour of interventional dual benefit. MRI. However, even fervent supporters of this technology appreciate the many practical dif- In spite of these innovations, many routine ficulties involved in providing real-time MR image-guided interventions are currently per- image guidance. Despite this, the potential formed under x-ray , especially vas- benefits suggest that today’s interventional cular procedures. One reason is the lack of MR- More MR-compatible instruments are needed, so that MRI guidance is the future of , ‘toy’ could still become the routine ‘tool’ of compatible instruments. Making instruments MR-guided interventions can be performed safely, according to Prof. Dr. Arno Bücker. tomorrow. that can be used safely inside an operational according to Michael Bock, Ph.D. MR system means more than just selecting non- Speakers at this afternoon’s special focus ses- magnetic materials, said Michael Bock, PhD, “It is technically more demanding to do these restenosis drugs were actually reaching the ves- sion will explain exactly why interventional head of the interventional MRI research group kinds of things under MRI guidance, but once sel wall. Conventional angiography is unable to MRI is well worth the effort. at the German cancer research centre (DKFZ) you have the infrastructure set up, you realise show this kind of detail. in Heidelberg. that it is much easier to locate the target volume, The term ‘interventional MRI’ covers a broad put the in and perform the procedure. “Another point is that most interventional MRI spectrum of procedures, ranging from straight- “For example, if you think about a guidewire You have the 3D control, you see the soft tissues, procedures are done with a 1.5T system. If we forward biopsies to more complex cardiovascu- made from Nitinol. That will be non-magnetic, you see the blood vessels that lead to the lesion,” could do them at 3T, we would have a better lar repairs. To reflect this, the session will cover but it is also electrically conducting. As soon as Bock said. signal-to-noise ratio. This may be promising for a wide variety of clinical applications, with an you introduce it into the patient, it will act as interventions combined with molecular ima- emphasis on the future. an antenna,” he said. “When you perform an MR-guided cardiovascular interventions are by ging,” she said. imaging sequence, the wire will absorb radio- no means easy either. Realistically, these tech- Following the increased availability of MR frequency power and transfer this heat to the niques will only have a future if applications The special focus session will contain a conside- , some imaging clinics now use patient.” can be found that are impossible using any rable amount of information that is not availa- MRI to guide the biopsy of suspicious lesions other modality, Krombach said. The introduc- ble in textbooks or published articles, Bücker in the breast. Providing MR-based breast ima- The development of truly MR-compatible ins- tion of molecular imaging into the interventio- said. ging or even screening without this interventi- truments is a priority, and this message should nal arena may lead to the development of such onal capacity simply does not make sense, said be taken to manufacturers, Bock said. First and ‘killer applications’. For example, MRI could “This is something that is brand new, it is a hot Prof. Dr. Arno Bücker, who will chair today’s foremost, the wider availability of interven- be used during to check that anti- topic, and it is going to be the future,” he said. session. tional MRI would have real benefits to young children, especially those undergoing repeated “If you perform MRI and you see a lesion on the interventions or procedures lasting 30 minu- Special Focus Session images that was not visible on x-ray mammo- tes or more. Procedures performed under MR graphy, you need a way to localise and biopsy guidance should be safer for interventional Sunday, March 8, 16:00–17:30, Room Q that lesion under MRI guidance,” said Bücker, radiologists too. SF 12b Interventional MRI professor of radiology at Saarland University Hospital, Homburg, Germany. MRI offers the option of 3D visualisation, • Chairman’s introduction unlike fluoroscopy, which is limited to 2D A. Bücker; Homburg a.d. Saar/DE Interest in MR-guided endovascular inter- views. Functional information on blood flow • Interventional instruments meet MRI ventions is growing too. MRI has been used or oxygenation, for example, can be acquired M. Bock; Heidelberg/DE to guide puncture in the bile duct and renal too. system during percutaneous cholangiogra- • Cardiovascular interventions meet MRI G.A. Krombach; Aachen/DE phy with drainage and percutaneous neph- Switching to MR guidance would avoid the rostomy. The modality is then used to control risk of radiation skin burns to patients during • Ablation techniques meet MRI localisation of the catheter and guidewire. transjugular intrahepatic portosystemic shunt W.M.W. Gedroyc; London/UK (TIPS) placement. This liver interventional pro- • Panel discussion: MRI can visualise both the vessel wall and cedure involves a high cumulative x-ray dose. MRI-guided interventions: A tool or a toy? surrounding tissue when imaging vessels with The ability of MRI to visualise soft tissue could atherosclerotic plaque. Animal experiments also be helpful during embolisation procedures have shown almost all cardiovascular interven- in the liver.

MR-guided intra-arterial injection (Gd-DTPA) through a catheter positioned in the coeliac trunk with subsequent follow-up. In contrast to conventional fluoroscopy, full 3D datasets were acquired. (Provided by M. Bock)

myESR.org 10 ECR TODAY 2009 CLINICAL CORNER Sunday, March 8, 2009

Debate continues over what constitutes best practice for imaging GI/GU tracts in children

By Frances Rylands-Monk time and filtering, as well as timing and amount also aiming to create more homogeneity in CT of contrast, should be adapted. applications and protocols and to reassess pae- Speed is often essential when imaging the diatric indications for CT. paediatric gastrointestinal and genitourinary “Adult radiologists are not always sure what tracts, so CT serves as a swift diagnostic tool they are doing with children and sometimes Researchers at the University Hospital of Graz to answer clinical questions. However, pheno- perform a three or four phase CT using adult are trying to develop CT protocols for children mena such as over-ranging, over-sampling and protocols. In many cases the diagnostically with the Toshiba Aquilion One system, which over-beaming must be considered and parame- relevant information could be retrieved in one has been used at the centre for children since ters adapted to individualise CT examinations phase using a paediatric protocol with only 15% March 2008. and indications in children. of the radiation dose. In children, CT exami- nations should be done with age- and weight- At the ECR 2009 session, delegates can also In terms of the abdomen, a major indication for related children’s protocols, which are then learn about ultrasound, which can be an accu- CT is severe or multiple trauma. individually tailored depending on the query rate diagnostic tool in non-traumatic cases and body size,” Riccabona said. “We should get involving the acute abdomen, provided the Axial ultrasound scan obtained at the middle of “It’s fast, reveals all the therapeutically neces- all possible information from ultrasound.” technique is mastered. an intussusception shows the central limb of the sary information, and doesn’t miss fractures or intussusceptum eccentrically surrounded by the hyperechoic mesentery, a situation that produces the injuries to deeper regions,” said Prof. Michael Conventional dose estimation indices (CTDIs), “We should focus less on the number of ima- ‘crescent-in-doughnut’ sign. [From: Insussusception Riccabona, paediatric radiologist at the Univer- which concern the radiation dose likely to be ging modalities used to obtain a perfect image in Children: Current concepts in diagnosis and sity Hospital of Graz, Austria, who is speaking delivered in an investigation, derive from adults and more on safer, faster and less expensive enema reduction. Del Pozo G et al. Radiographics at Sunday afternoon’s refresher course on best and do not properly apply to children, he said. methods using the ALARA (As Low As Reaso- 1999;19(2):299-319.] practices for GI/GU tract imaging. In some In line with the ‘image gently’ campaign that nably Achievable) principle,” said the session’s cases, abdominal collections or abscess forma- began in the United States last year to improve co-speaker, Prof. Gloria del Pozo, paediatric tion and complications from other severe disea- the use of paediatric CT, there is a current effort radiologist at the ‘12 de Octubre’ University ses in smaller children require CT, while in in Europe to assess and improve paediatric CT Hospital, Madrid. “Not all cases of acute abdo- larger children, particularly obese adolescents, and create more applicable rules for dose reduc- men will require imaging methods. A careful queries such as appendicitis cannot sufficiently tion. To this end, work is in progress with a view clinical evaluation is essential before imaging be addressed by ultrasound, he added. to future delivery of adequate children’s calcu- is demanded, and ultrasound should be used in lations. selected patients, not as a screening test.” “We should start remembering that CT is a potentially harmful diagnostic tool and only “Currently, we use orienting calculations and In acute abdomen cases, patients will present use it if there is a valid indication. If you need correction factors from the literature on how to with sudden pain onset, sometimes with asso- to use it, then you must assure a proper protocol adapt the CTDI for reasonable use in children ciated vomiting or fever, which are very unspe- The US axial slides of the appendix. The hyperechoic as we have nothing better, but the ideal would and precautions to avoid repeating the proce- cific symptoms. may be the solution, layers (rings) correspond to the mucosal surface, dure if it doesn’t work out properly. Never fiddle be to have appropriate CTDI values for all depending on the condition or pathology. It is submucosa and serosa layers. When inflammation around,” warned Riccabona. children,” Riccabona added. imperative to define as soon as possible whether progresses, these rings gradually disappear from a precise case of acute abdomen needs surgical inner to outer. [From: Berrocal T and del Pozo G. In general, dedicated paediatric ultrasound Part of this work is being undertaken by the management, she said. Knowledge is essential of Imaging in Pediatric Gastrointestinal Emergencies. In: answers most clinical questions in children. European Society of Paediatric Radiology the common causes of acute abdomen in diffe- Radiological imaging of the digestive tract in infants When CT is called for, doctors should aim to (ESPR) which created a taskforce devoted rent age groups. In infants, the most common and children. Ed. Devos AS and Blickman H. Springer Verlag, Berlin, Heidelberg, New York. 2008. Chapter get all the information they need for therapeu- to improving paediatric CT. He hopes this surgical condition is intussusception, which has 1,1-78. ISBN 978-3-540-40733-1] tic decisions, but only irradiate the body areas research will eventually help to optimise the an 8–12 hour window to be managed by surgery. needed for diagnosis. Children have a large application of paediatric CT and change dose Rarer cases of midgut volvulus have a smaller variation in weight, body relationships and indices. A profound knowledge about the effects time window for surgery before it becomes life- the areas of the abdomen where the air is more breathing rate, and are much more radiation- of radiation on children is needed to issue easily threatening. To rule out these two conditions, densely concentrated. If ultrasound is not con- sensitive than adults. The basic rules need fine- applicable dose reduction recommendations for ultrasound is the best technique, with an almost clusive, then other techniques may be required tuning for paediatric imaging. Radiation dose, various child sizes and body areas. The ESPR’s 100% accuracy rate for intussusception, even in to rule out the pathology. KV, MA, increment, slice thickness, rotation taskforce, which started its work last year, is the hands of a trainee, according to del Pozo. The optimal imaging algorithm to diagnose or It is also important to make a differential diag- rule out appendicitis (the most common cause nosis with other pathologies such as tumours, of acute abdomen in children aged over three) by assessing characteristic signs visible on ult- is still controversial. In some countries, radio- rasound. The ‘crescent-in-doughnut’ sign is the logists prefer CT, but in del Pozo’s experience, hallmark to differentiate intussusception from it is not necessary. A normal appendix can be other pathologies, while the ‘whirlpool’ sign differentiated from an abnormal one through depicts rings around the mesenteric for ultrasound, said del Pozo, who will be presen- midgut volvulus. ting about appendicitis patterns on ultrasound during the ECR session. If the radiologist is not “The objective is to obtain characteristic images experienced, the most frequent mistake is to that may be used by all radiologists to reach an confuse the appendix with the ileum. accurate diagnosis. In the case of intussuscep- tion, an ultrasound-guided saline enema can Even when ultrasound is inconclusive, which then reduce the intussusception without using currently holds true for around 5–10% of acute radiation again following ALARA criteria,” she abdomen cases, surgeons at the Madrid hos- explained. pital prefer to wait, re-evaluate and even per- form repeat ultrasound or laparoscopy before A dilated bowel with many loops and abundant moving on to more sophisticated techniques gas may interfere with ultrasound, which may involving radiation and contrast. While the use consequently not be able to depict the struc- of plain film or CT may be justified when ultra- tures behind the gas for adequate characteri- sound is not conclusive, since 2000 the hospi- sation. However, if doctors know the available tal has only used CT as a second-line imaging ‘windows’ (lateral areas of abdomen, or the technique if there is a suspicion of obstruction Special appearance by Susan Griffith superior and inferior areas), they can avoid or perforation. and andy di Mino Refresher Course: Paediatric Featuring Tom Gaebel & Orchestra Sunday, March 8, 16:00–17:30, Room K RC 1212 Best practice for imaging the GI/GU tracts Moderator: Be a part of it ! M. Raissaki; Iraklion/GR

A. Ultrasound: Nothing else really matters? G. del Pozo; Madrid/ES Get your ticket at the Travel Service booth located in B. CT: Stop wasting time and get it right first time! the entrance hall, or buy it online at myeSR.org. M. Riccabona; Graz/AT C. MRI: Where are we at right now in GI/GU imaging? M. Claudon; Vandoeuvre-les-Nancy/FR myESR.org Sunday, March 8, 2009 CLINICAL CORNER ECR TODAY 2009 11

Occupational diseases pose serious diagnostic dilemmas for radiologists

By Paula Gould

Coughing, shortness of breath, chest pain, chest tightness, and an abnormal breathing pattern are common indications of lung disease. The question is: which one?

The list of likely diagnoses may well include a number of occupational lung diseases (OLD), depending on the patient’s history. But how many city-based radiologists have ever seen a case of Farmer’s lung? And would practitioners Left: Centrilobular and randomly distributed pleural nodules and large opacity (arrow) due to complicated silicosis based in rural areas think of considering coal (progressive massive fibrosis). Right: Egg-shell calcification (arrow) in lymph nodes. (Provided by K. Hering) workers’ pneumoconiosis? Wilhelminenspital and Otto Wagner Hospital plan to answer common questions rather than Knowledge of a patient’s exposure to inhaled and Medical Centres, Vienna, who will be chai- give a traditional lecture. matter can certainly help when initially diag- ring the session. nosing OLD. Diagnoses are not always straight- One topic that usually generates discussion forward, though. Take, for example, the case of Clinical tests, such as lung function assessments, is how to perform the HRCT examination, a patient whose imaging examination reveals a are often unable to detect the first signs of OLD, Hering said. High resolution, thin slices are singular pleural plaque. If that patient had pre- said Dr. Kurt Hering, radiologist at the Knapp- essential when looking for signs of pneumoco- viously worked with asbestos-containing mate- schafts-Hospital, Dortmund, Germany. Conse- niosis. Unenhanced CT examinations are pre- rials, can a diagnosis of asbestos-related pleural quently, CT can be a useful surveillance tool. ferred to avoid the side effects of the contrast Asbestosis with peripheral subpleural predomination, disease be made? Or is the patient’s occupatio- medium in ‘healthy’ subjects and difficulties intralobular interstitial and interlobular septal thickening, nal history merely coincidental and the abnor- “If you only have small pleural changes and no differentiating contrast-filling vessels from traction bronchiectases. (Provided by K. Hering) mal finding indicative of an entirely unrelated parenchymal changes, then the patient’s lung pleural plaques. lung condition? function will not be disturbed. These changes will only be shown on high resolution, radiolo- The session is recommended to all delegates This afternoon’s special focus session will pro- gical images,” he noted. who are unfamiliar with OLD. Despite legisla- vide insight into the diagnostic dilemmas asso- tion to improve industrial working conditions, ciated with OLD from a clinical and a radiologi- Guidance for classifying pneumoconioses the European radiological community may see cal perspective. Leading experts in the field will from chest radiographs has been provided by a steady increase in asbestosis cases over the also present the latest approaches to classifying the International Labour Office (ILO) since next 10 or 20 years, Hering said. This is due to Different types of pleural plaques, partially calcified, OLD using semi-quantitative and quantitative 1950. The latest guidance, ILO-2000, is accom- the time lag between asbestos exposure and the with subpleural fibrosis, more on the right than on the methods. panied by two sets of standard radiographs development of related conditions. left side (small arrows). (Provided by K. Hering) showing typical opacities and pleural abnor- Diseases caused by repeated and long-term malities. The sets include some composite “The incidence of bronchial carcinoma related exposure to inhaled irritants are also referred to images made up of quadrants from full-size to asbestos exposure and mesothelioma is going radiologists are familiar with these findings,” as pneumoconioses. The most common of these radiographs to highlight key findings. Debate up year on year. It is therefore necessary that he said. are asbestosis, silicosis, and coal-workers pneu- is ongoing about the technical quality of some moconiosis, which develop following repeated of these ‘reference’ images, which were acqui- exposure to asbestos, silica (quartz) and coal red many years ago. Special Focus Session dust. Less common pneumoconioses include Sunday, March 8, 16:00−17:30, Room F2 bird fancier’s lung, due to the inhalation of pro- A second classification system, for use with teins contained in bird droppings and feathers, high-resolution CT, is now available too. The SF 12a Occupational lung diseases (OLD) and byssinosis, a condition linked to cotton, International Classification for Occupational flax and hemp fibres. and Environmental Respiratory Diseases (ICO- • Chairman’s introduction ERD) was developed by experts from seven G.H. Mostbeck; Vienna/AT Imaging evaluations of OLD have traditionally different countries, in response to requests for • OLD: What the clinician wants to know been performed using chest . CT is a more standardised approach to CT-based dia- D. Nowak; Munich/DE now increasingly used as well to improve the gnosis. As with the ILO-2000 scheme, radiolo- • Quantitative imaging techniques in OLD accuracy of diagnoses and identify early signs gists have access to a series of reference images. A.A. Bankier; Boston, MA/US of disease. Hering will be sharing the podium with Dr. • Team teaching: All you ever wanted to know about ILO-2000 and “For the last century, we have known that wor- Karina Hofmann-Preiß, a private practice ICOERD-HRCT classifications and never dared to ask K.G. Hering; Dortmund/DE king with silica and dust hurts the . With radiologist in Erlangen, Germany. Together K. Hofmann-Preiß; Erlangen/DE multislice CT, we may be able to diagnose they will provide comprehensive coverage of these changes at an earlier stage,” said Prof. Dr. ILO-2000 and ICOERD-HRCT. The pair will be • Panel discussion: Gerhard Mostbeck, professor of radiology at the adopting a ‘team teaching’ approach, and they The ever-increasing importance of radiology in OLD News from the Italian Society of Medical Radiology

By Alfredo Siani, Naples/IT, SIRM President; tor, and is 50% co-owner of the journal of the and attended by approximately 50% of all Radiologists and Situation of Radiological Tech- Luigi Solbiati, Busto Arsizio/IT, Radiology Union, Il Radiologo. SIRM also offers SIRM members nology, Teleradiology, Privacy Rules, Outsour- SIRM Vice-President an e-mail account to all its members for free. • Organisation of residential and travelling cing, and Breast Imaging. courses and meetings The Italian Society of Medical Radiology Some years ago the society website was crea- • Coordination of research projects and multi- SIRM is ISO 9002 Board-certified and in 2009 (SIRM), founded in 1913, has a unique charac- ted (www.sirm.org): through this continuously centre studies established the Limited SIRM Co. for economic teristic among Italian medical societies in that updated website SIRM members can find official • Organisation of courses on scientific methods and financial administration. it has academic, hospital-based, and privately documents and pay their annual subscription for radiological research. practising radiologists as members. fee, as well as the professional insurance pre- The latest aim SIRM has decided to pursue is mium, which is offered under favourable finan- Courses and meetings are organised through that of fostering radiological research. A liberal SIRM owns its office in Milan and has recently cial conditions. the 19 Specialised Sections, which include donation has been requested from SIRM mem- purchased a location in Rome in association organ-specific and diagnostic modality-spe- bers together with the subscription fee. These with the societies of neuroradiology, radiothe- In order to continuously increase the scienti- cific sections, and the 18 geographic Regional donations and a sum of money allocated by rapy and the National Radiology Union. fic level and the internationalisation of Italian Groups of SIRM. SIRM will sponsor two biennial research pro- radiology, SIRM has focused its efforts on some jects, which will be selected among the anony- In addition, SIRM owns the official bilingual major topics: The most relevant documents delivered by mous proposals sent to a committee appointed (Italian-English) journal of the Society, La SIRM in the last few years are: National Guide- by the SIRM Board of Directors. Radiologia Medica, which has recently been • Organisation of the biennial National Con- lines on Diagnostic Radiology, Methodology and indexed and provided with its own impact fac- gress of Radiology, free for all SIRM members Volumes of Activity, a Census of the Number of

myESR.org 12 ECR TODAY 2009 CLINICAL CORNER Sunday, March 8, 2009

The Royal College of Radiologists: Delivering quality-driven radiology services in the 21st century

By Tony Nicholson, Leeds/UK Physicians and surgeons have been sub-spe- viding cheap radiology, with cost as the only is very poor across the UK. The Royal College cialising for many years. To provide the sort consideration. of Radiologists is trying to raise awareness of The UK has delivered health services in a tar- of service that these physicians and surgeons this issue and to suggest solutions by increa- get-driven culture for ten years and it would need requires radiologists who are equally Every country in Europe has a different system sing the number of designated interventional be wrong to say that this has not been effec- specialised. Many radiologists, recognising for recognising and confirming the skills and radiology posts within networks that allow tive. The recent publication of the National this, have embraced sub-specialisation. In abilities of its doctors. Despite legislation it is out of hours work compliant with the Euro- Health Service Review by Lord Darzi changes some cases this has been through year 6 ‘fel- highly unlikely that any one medical regula- pean Work Time Directive. We are also nego- emphasis towards quality rather than tar- lowship’ training but more often experience tory system will apply to the whole of Europe tiating changes to the funding system so that gets and those with a non-jaundiced outlook has substituted for training. All big organi- in the foreseeable future. Doctors in the UK there are recognised financial pathways for welcome this move. Many of the issues that sations take time to change and the Royal will soon be licensed and certified to practice interventional radiology. currently face UK radiologists are almost College is no different. The requirement to by the General Medical Council. Renewal will certainly the same issues that face colleagues deliver increasingly complex training cou- be every 5 years and the processes are likely across Europe. In no particular order some pled with the evolutionary move to sub- to be rigorous. The regulation of doctors that of these are: the ever increasing size of the specialisation gives the college two choices. applies to one country gives patients in that curriculum that has to be delivered within a Either extend training to 6 or 7 years or alter country confidence in their medical profes- five year training programme; the delivery of training to deliver core radiology followed sion. Such regulation should be considered sub-specialty services alongside those of core by sub-specialist training within the present sacrosanct at the moment. Ignoring these general radiology; the impact of teleradiology training period. There is a strong lobby that safeguards should not be permissible. Patients and out-sourcing on service delivery; and the feels that general radiologists are still vital to would want medical regulatory requirements provision of interventional and diagnostic many hospitals in the UK. This is still true that apply in one country to apply to those radiology services 24 hours a day, seven days and at the moment the generalist view pre- reporting outsourced images in another coun- The European Work Time Directive and a week. vails, but it would seem inevitable that sub- try until such time as there is uniform medical in particular the recent abolition of the opt specialisation is the way to go. Our challenge regulation across Europe. out clause is a subject that is exercising the Any doctors who began their careers in radio- is to keep the best of what we do now whist minds of all doctors in the United Kingdom. logy in the 1970’s will remember a time when delivering radiologists fit to practise in a sub- The provision of service 24 hours a day, seven A 48-hour week averaged out over 12 months radiology training consisted of plain film specialist world. days a week and 365 days a year, is increasin- with compulsory periods of rest will affect interpretation, along with barium screening gly becoming an issue in the UK. Increasingly many doctors in training as well as existing and Myodil or air injections into a patient’s Teleradiology is undoubtedly a major techno- patients and politicians demand instant access consultants. There is a strong feeling that it back. Angiography was a very big deal requi- logical advance that is to the massive benefit to medicine. This is right and proper and it will become impossible to deliver training ring general anaesthesia, CT and MRI didn’t of patients and radiologists alike. Used well it is what we would want if we were patients. within the current training period in a wor- exist commercially and B-mode ultrasound has the power to decrease morbidity and mor- However, massive resource is required to pro- king time maximum of 48 hours. Similarly was still in development. Training could easily tality and improve the lives of radiologists. vide such services. An example might be the compulsory rest periods for consultants may be fitted into three to five years. Now, with ult- Used badly it could have exactly the oppo- provision of interventional radiology out of actually diminish life quality by doubling the rasound, CT, and MRI becoming ever more site effect. Outsourcing of radiological ima- hours. Increasingly interventional radiology is number of weekends that a consultant has sophisticated, the irrepressible rise of inter- ges should always be considered second class becoming an acute specialty in stopping and to be available on call. The Royal College of ventional radiology and fusion imaging, it is radiology. An image viewed and reported preventing haemorrhage. Although the Bri- Radiologists along with several other colleges becoming increasingly difficult to make sure remotely without the benefit of clinical input tish Society of Interventional Radiologists has has asked for derogation and at the time of every radiologist is trained in all these moda- and discussion and without access to old films 530 members, only a small number of these writing this has yet to be decided. lities in all body systems. It is impossible to will never be as good as images viewed and are interventional radiologists, the majority demonstrate competence in all. reported in the hospital where they were taken being diagnostic radiologists who practise We would be surprised if any of the issues by an expert radiologist. Whilst outsourcing some aspect of intervention. As such their mentioned above were issues confined to the In the United Kingdom radiology depart- may well be necessary in hospitals where there training and skills are not geared towards United Kingdom. I am sure that many coun- ments increasingly require sub-specialists in are insufficient numbers of radiologists, we emergency work. Consequently the provi- tries in Europe are grappling with similar order to provide the quality service required. must not allow it to be seen as a way of pro- sion of out-of-hours interventional services problems.

The European Society of Neuroradiology – Diagnostic and Interventional Neuroradiology

By Marco Leonardi, Bologna/IT, This was initially proposed by the UEMS Sec- community. The ESNR continues to be devo- ESNR exchange programme aims to support and President ESNR; tion of Radiology and in the autumn the Neuro- ted to education and continues to organise the develop mobility and communication between Pia Maly Sundgren, Ann Arbor, MI/US , radiology Division within the UEMS Section of European Course of Diagnostic and Interventi- fellows and residents training in neuroradiology Editor ESNR Radiology was established. The work to build onal Neuroradiology (ECNR). This course has in Europe, and offers training in topics not availa- the Neuroradiology Division within the UEMS been organised since 1984 with the precise aim ble in home institutions. The programme supports During the past year there have been several Section of Radiology has already started and is of adhering as much as possible to the EC regu- educational and research cooperation between developments and changes in the European led by the Executive Committee of the Division lations for academic education programmes. As institutions of neuroradiology, and helps to build Society of Neuroradiology (ESNR). Professor and its first president, Professor Olof Flodmark. a matter of fact, the didactic credits provided by a network between the communities in Europe to Marco Leonardi will be the president of the We are all very excited by the new possibilities the course of study are intended to comply with support and train our radiologists. society for the coming two years and to assist provided by the strong support of the Board of the regulations for academic education pro- him in the executive committee and the sub- the UEMS Section of Radiology. grammes, such as 3rd level master’s degrees, and The field of neuroradiology and interventional committees he has a group of young, enthusias- some European universities have already recog- neuroradiology is constantly increasing. The tic European neuroradiologists to take the lead On of the society’s many issues is the fairly low nised the certified course of studies for obtain- scientific research spans over a broad range of in the many tasks and issues that lie ahead. number of paying members compared to the ment of a master’s degree, as part of their own topics and uses today’s most advanced radio- number of full-time practising neuroradiolo- educational programmes. The cycles are struc- logical techniques and methods. Neuroradio- The society has recently changed its name to gists in Europe. In an attempt to increase the tured in four modules held twice a year. At the logists all over Europe continue to be at the the European Society of Neuroradiology – Dia- number of members, which is important to end of each module a certificate reporting CME forefront of further development of existing gnostic and Interventional Neuroradiology to make our voice heard, the society has decided credits is issued after completing a test. Upon techniques and in the development of new reflect that it is a professional society represen- to give special benefits to full members such as completion of all four modules (one entire imaging techniques. Advances are constantly ting both diagnostic and interventional neuro- access to a dedicated website with continued cycle) the participant can ask to hold a final made in areas like brain tumour imaging, in the radiologists in Europe. The society continues updated information, course programmes, oral examination. If they pass, a certification is detection of structural and biochemical changes to organise annual scientific meetings, the last teaching files and links to other international issued by ESNR that they are a qualified neuro- underlying neurological diseases, in different of which was in Krakow, Poland in September societies, and to introduce lower registration radiologist (European Qualification in Neuro- ways to imaging treatment response, and in the 2008, and European training courses, and aims fees for the annual meeting for full members. radiology EQNR). The 10th cycle is directed by development of new coils and for more to be a forum for the professional development Prof. Massimo Gallucci from L’Aquila, Italy, advanced interventional procedures. Awareness of European neuroradiology. If radiology is to remain as a medical speci- and Prof. Alex Rovira from Barcelona, Spain. of the risks of radiation has resulted in ongoing ality and not be ‘bought up’ by other special- research to reduce the radiation doses in some One of the most important events of the past ties, then the education of future generations of The first course in the 10th cycle took place in Tar- neuroradiological examinations, for example, year was the creation of the Neuroradiology radiologists and neuroradiologists remains an ragona, Spain, on October 9–14, 2008, and the next with the implementation of ‘low dose’ CT-pro- Division of the UEMS Section of Radiology. important issue for the European radiological course will be held in Rome in spring 2009. The tocols for multi-trauma and spine imaging. myESR.org Sunday, March 8, 2009 CLINICAL CORNER ECR TODAY 2009 13

Ultrasound and MR imaging define the pattern and haemodynamics of vascular malformations

By Karen Sandrick time and to measure flow velocity to distingu- “The most important tool is the history of the ish low-flow from high-flow lesions. Low-flow patient: was the haemangioma present at birth, Patients with vascular malformations for the lesions link with or lymphatics, and high- and has there been progression or regression most part are forlorn cases because they have flow lesions connect to arteries or capillaries. in size? The principal imaging tool is ultra- pain and functional impairment as well as disfi- Contrast-enhanced ultrasound helps evaluate sound or Doppler ultrasound, which is done in gurement and yet their disease cannot be cured. low-flow malformations and monitor the abla- short intervals,” explained Mack. “The follow- It can only be controlled. tion area during , according to Dr. up period between examinations is one week Gianpaolo Carrafiello, an assistant professor of for each month of life. So if the patient is five “The best treatment option – removal of the radiology in the department of human mor- months old, the interval is five weeks. If the vascular lesion without leaving traces behind – phology, University Hospital, Varese, Italy. patient is seven months old, the interval is seven can rarely be obtained. Due to the morphologic weeks. The objective of the workup is to docu- appearance, especially in delicate areas like the MR imaging defines the full extent of vascu- ment the size and depth of the haemangioma, head and neck region, any intervention can lead lar malformations, as well as their relation- including photo documentation, which is nor- to severe side effects,” said Dr. Harald Kubiena, ships with surrounding structures. Spin-echo mally done by the clinical partners.” a surgeon in the division of and T1-weighted imaging evaluates anatomy, reconstructive surgery, Medical University of while short T1 inversion recovery (STIR) and MR imaging is performed if the haemangioma Vienna, Austria. T2-weighted imaging focuses on the breadth is close to the eyes or the central nervous system, and depth of the malformation. Dynamic or if infiltration of a cavernous haemangioma is Complex vascular malformations, such as peri- contrast-enhanced MRI differentiates low-flow not clear on ultrasound. MRI is also the imaging Prof. Dr. Martin G. Mack, acting director, department oral venous malformation, are particularly from high-flow vascular malformations, and method of choice for surgical planning. of diagnostic and interventional radiology, University debilitating. time-resolved MR angiography identifies arte- Hospital of Frankfurt, Germany, will discuss the characteristics of haemangiomas on ultrasound, rial feeders, nidus size and venous drainage. T2-weighted free-breathing turbo spin echo contrast-enhanced ultrasound, CT and MRI at “Suffering from a perioral venous malforma- Carrafiello will discuss these and other forms (TSE) and contrast-enhanced TSE with fat a special focus session on soft tissue vascular tion leads not only to severe functional pro- of imaging the haemodynamics and abnormal saturation are the most effective sequences for malformations. blems during eating, drinking and speaking, vascular channels of the malformations. identifying the distinguishing characteristics of but can also have a tremendous psychosocial haemangioma. impact, especially on younger patients. Pain Patients with soft tissue infantile haemangi- due to intralesional thrombosis is sometimes omas have a more hopeful course. Capillary “Haemangiomas have a markedly increased rhage and thrombosis can also cause an increase exceeded by the burden of disfigurement,” haemangiomas are benign, and although they signal on T1 and T2-weighted images. Haemor- in signal on T1-weighted images,” Mack said. noted Kubiena, who will discuss the indications enlarge during the first year of life, they start for treatment of angiomatous lesions in Sunday involuting in the second year, and by the age morning’s special focus session on soft tissue of nine, the vast majority of these lesions have Special Focus Session vascular malformations at ECR 2009. disappeared. Sunday, March 8, 08:30–10:00, Room G/H No single specialty has enough knowledge Cavernous haemangiomas, which are conside- SF 9b Soft tissue vascular malformations or expertise to diagnose and treat vascular red to be low-flow vascular malformations, are anomalies on its own, he explained. Diagno- deeper and have more blood-filled vessels, but • Chairman’s introduction: sis, treatment, and follow-up must be done by they are totally benign, said Prof. Dr. Martin G. Differences between vascular malformations and hemangiomas members of a multidisciplinary team. As mem- Mack, acting director, department of diagnostic R. Maroldi; Brescia/IT bers of the team, radiologists bring a variety of and interventional radiology, University Hospi- • Soft tissue hemangiomas: From US to MRI imaging tools to bear on the visualisation and tal of Frankfurt, Germany. Mack will review M.G. Mack; Frankfurt a. Main/DE delineation of the nature and architecture of a the use of ultrasound and MRI in the detection vascular lesion, its prognosis, and suitability for and follow-up of soft tissue haemangiomas. • Low-flow and high-flow : Is angiography always necessary? treatment. Most relevant here are ultrasound G. Carrafiello; Varese/IT and MR imaging. After determining that a child has a true infantile haemangioma rather than a vascular • Could you treat this ‘angiomatous’ lesion? Survival kit Although ultrasound can outline the edges of a tumour or malformation, the diagnostic wor- H. Kubiena; Vienna/AT vascular malformation, Doppler ultrasound is kup seeks to identify the phase of development • Panel discussion: needed to assess arterial and venous flow in real of the haemangioma. Which lesions should not be treated?

News from the Polish Medical Society of Radiology

By Jerzy Walecki, Warsaw/PL, The Polish Journal of Radiology lives now not opening up social services, such as discussion Editor-in-Chief, Polish Journal of Radiology; only with its long history and tradition, but groups and scientific blogs. Marek Graczynski, Warsaw/PL looking ahead to developing and adopting new trends and business models in modern The way the editorial office functions The achievements of each scientific society are scholarly publishing. has changed dramatically along with the inseparably connected with the intellectual introduction of the web-based mechanisms activity and professionalism of its members. The most important developments have been and services for manuscripts submission, This activity manifests itself in both the quality made in the organisation of the editorial processing and publishing. An online and quantity of academic publications. If a office and manuscript processing. The most manuscript submission service has made things given professional group enjoys the opportunity important aim for the editors and the publisher easier for authors and given them much more of running their own academic journal, then it is to maintain the high quality of publication, control over the whole process, as they are able becomes the face of that society. expansion of the readership and speed of to check the status of the submitted manuscript service. right from the journal’s website. The Polish Radiological Review (today Polish Journal of Radiology) has existed for more In order to build up and reinforce availability Taking care of publication transparency is yet than 80 years. As such distinction comes with on the international market, the Polish Journal another major focus of the editors. It is now some obligations, successive generations of of Radiology has developed a web-based required that authors indicate their role in the radiologists have taken care of maintaining electronic version of the journal. For the last research project and publication process. This the proper scientific standard of the journal by couple of years readers have been able to access information is published along with names and controlling the quality of the works published. our publication on our dedicated website affiliations of the authors. The very first issue of thePolish Radiological www.polradiol.com. Review from 1926 (volume 1), contains clinical Speed of publication is taken care of through The increasing quality of the Polish Journal of works on radiological diagnosis in gynaecology, Editors believe in unrestricted access to implementation of an online peer-review Radiology has encouraged the editors to apply orthopaedics, pulmonology and others. knowledge, and that is why the website provides system, through which the most suitable for evaluation at Thomson-Reuters for possible Moreover, this issue comprises a polemic free access to all published articles – abstracts reviewers are selected automatically, based on inclusion in the Science Citation Report and paper discussing mutual relations between and full texts, which is reinforced with an easy matching keywords. The review process itself Current Contents database. We are awaiting an radiologists and clinicians that continue today – to use and effective search engine. During 2009, is also conducted via the net, which enables answer in 2009. it has not lost any of its validity and importance the editors together with the publisher plan referees to evaluate manuscripts from anywhere despite the years that have passed since then. to enhance functionality of the web service, in the world.

myESR.org 14 ECR TODAY 2009 CLINICAL CORNER Sunday, March 8, 2009

Introducing the American Association for Women Radiologists

Since the mid 1980s women have played an in radiology. The most prestigious is the Marie important role in local, state and national Curie Sklodowska award. radiological societies and have gained signifi- cant recognition. Some women have risen to In 1991 AAWR incorporated the AAWR leadership positions. Research and Education foundation to sup- port professional development and research In order to promote, encourage and educate by women. The goal of the AAWR Research & all women radiologists, the AAWR was estab- Education Foundation is to provide Professi- lished in 1981 to address significant concerns onal Leadership Awards and Research Grants unique to women radiologists. to AAWR members. The Foundation sponsors one junior and one mid-career AAWR member At the present time, half of American medical to attend the Association of American Medical students and 42% of radiology residents are Colleges (AAMC) Professional Development women. Women constitute 32% of medical Seminars. faculty members; 38% are assistant professors, 28% associate and only 16% of women are full The AAWR Research & Education Foundation professors. Of division or section chiefs 19% is supported by donations from members and are women, as are only 10% of department support from corporate partners. chairs. (Data: AAMC 2005–06) Research Seed Grant The missions of AAWR are Purpose: To assist AAWR investigators in • To provide a forum for issues unique to gaining experience in testing hypotheses and women in radiology, radiation oncology and defining objectives before they apply for major related medical professions. The AAWR provides a forum for issues unique to women in radiology. grants from corporations, foundations or • To sponsor programs that promote opportu- government agencies, by underwriting preli- nities for women radiologists, radiation onco- lopment, gender equity, mentoring in radio- provide electronic publications, and to offer minary studies required prior to seeking major logists, and other related specialists. logy, and tailoring professional careers to help tools for community building and networking. funding for a project. • To facilitate communication amongst mem- balance the needs of home and the workplace. The members’ network section of the website bers and other professionals. includes the online membership directory, International Programme of AAWR • To encourage international collaboration Activities AAWR publications, and messages. AAWR has reached out to the global com- with women radiologists around the world Our Program Committee develops refresher munity of women radiologists by establishing courses at the RSNA and ARRS annual mee- The AAWR Committee to promote the advance- an international member category. Each year, Goals: tings. We hold luncheon discussion sessions at ment of women nominates nationally recognized AAWR senior leaders have attended the ECR • Advance the professional and academic stan- major national annual meetings. Our Interna- women candidates to hold office within major in order to recruit international members and ding of our members. tional Committee members have travelled to national and international radiological orga- promote the visibility of AAWR. The AAWR • Identify and address gender-specific issues. Europe, Africa and Asia to international radio- nizations. Prominent AAWR members include booth has been staffed for the past seven years • Increase and retain active members. logy meetings (ECR in Vienna; ICR in Marra- Theresa McCloud, immediate Past President of by the two co-founders of the International • Improve visibility and communication. kesh, Morocco; in Beijing, China) to work with the RSNA; Hedvig Hricak, president-elect of the Committee, Ewa Kuligowska, MD, Profes- • Increase women in leadership positions. women radiologists from around the world. RSNA; Kay Vydareny, President of the ARRS, sor of Radiology, Boston University School of • Identify and call attention to less pay for women AAWR has had a booth at the ECR for the last and others. There are at least 15 women chairs of Medicine (President of AAWR 2004), and Judy radiologists doing the same work as men. seven years in Vienna. radiology departments at present. Amorosa, MD, (President of AAWR 2005) • Establish networking to foster leadership Professor of Radiology, Robert Wood Johnson among women radiologists. Publications AAWR has addressed several gender-specific Medical School. We provide members with quarterly Focus issues: Benefits: newsletters, which are available online and • Maternity and radiation exposure – estab- Recently AAWR has established an Annual • Networking with other women in radiology with publications related to radiation protec- lishment of published guidelines for radiation International Award for Outstanding RSNA • Increased visibility of women in radiology tion. New members receive the Pocket Mentor, safety and a maternity policy for radiology Presentation. • Representation on the ACR board a manual for radiology residents and junior residents. • Sponsoring of activities that impact women faculty, which contains guidance and advice on • Balancing roles at home and at work through AAWR has become a significant resource for in radiology many work-related and personal matters. courses at national radiology meetings. women radiologists in the United States. It has • Mentoring programme • Childcare by offering childcare services at the potential to become a global resource for all Website & online member network national meetings. women radiologists in the near future. Programmes (www.aawr.org) We sponsor lectures and discussions on topics We have established a website to update AAWR AAWR has instituted several awards to reco- of interest to women including career deve- members on activities of the organization, to gnize outstanding accomplishments of women

Staff Box

Editorial Board ESR Executive Council Gabriel P. Krestin, Rotterdam/NL Managing Editors Art Direction Research Committee Chairman Julia Patuzzi, Vienna/AT Petra Mühlmann Iain W. McCall, Oswestry/UK Philip Ward, Chester/UK Éamann Breatnach, Dublin/IE ESR President Graphic Designer Education Committee Chairman Sub-Editor Robert Punz Christian J. Herold, Vienna/AT Luís Donoso, Sabadell/ES Simon Lee, Vienna/AT ESR 1st Vice-President Professional Organisation Marketing & Advertisements Maximilian F. Reiser, Munich/DE Committee Chairman Contributing Writers Erik Barczik ESR 2nd Vice-President John Bonner, London/UK E-mail: [email protected] Fred E. Avni, Brussels/BE Sarah Edwards, Vienna/AT Subspecialties Committee Chairman Borut Marincek, Zurich/CH Paula Gould, Holmfirth/UK Contact the Editorial Office Congress Committee Chairman Guy Frija, Paris/FR Emily Hayes, San Francisco, CA/US ESR Office National Societies Committee Chairman Monika Hierath, Vienna/AT Neutorgasse 9 Małgorzata Szczerbo-Trojanowska, Lublin/PL Simon Lee, Vienna/AT 1010 Vienna, Austria st 1 Vice-Chairperson Luigi Solbiati, Busto Arsizio/IT Lucie Motloch, Vienna/AT Phone: (+43-1) 533 40 64-16 of the Congress Committee Communication & International Relations Stefanie Muzik, Vienna/AT Fax: (+43-1) 533 40 64-441 Committee Chairman Yves Menu, Paris/FR Julia Patuzzi, Vienna/AT E-mail: [email protected] 2nd Vice-Chairman András Palkó, Szeged/HU Mélisande Rouger, Vienna/AT of the Congress Committee Finance Committee Chairman Frances Rylands-Monk, St. Méen Le Grand/France ECR Today is published 4x during ECR 2009. Karen Sandrick, Chicago, IL/US Circulation: 20,000 Adrian K. Dixon, Cambridge/UK Peter Baierl, Vienna/AT Printed by Angerer & Göschl, Vienna 2009 Publications Committee Chairman Executive Director myESR.org

The Editorial Board, Editors and Contributing Writers make every effort to ensure that no inaccurate or misleading data, opinion or statement appears in this publication. All data and opinions appearing in the articles and advertisements herein are the sole responsibility of the contributor or advertiser concerned. Therefore the Editorial Board, Editors and Contributing Writers and their respective employees accept no liability whatsoever for the consequences of any such inaccurate or misleading data, opinion or statement. Advertising rates valid as per January 2009. Unless otherwise indicated all pictures © ESR – European Society of Radiology myESR.org Sunday, March 8, 2009 CLINICAL CORNER ECR TODAY 2009 15

Forensic imaging specialists put their case for mainstream recognition

By Paula Gould

Forensic radiography sessions have become a fixture at conferences. Delegates are typically guaranteed a good visual show, with presenters displaying many novel images that would seldom be seen in clinical radiology departments. The sessions are, to some extent, radiology’s own ‘shock and awe’.

This afternoon’s session on forensic imaging could be a little different. Although attendees can still expect to see an impressive array of images, speakers will also stress the importance of organisation, training and professional recognition. The emphasis will be on a high quality service, not quirkiness.

The provision of forensic imaging services has traditionally been a bit haphazard, said Jonathan McNulty, lecturer in diagnostic imaging at the University of Dublin. That is now changing. Training and postgraduate education courses are being established, and local groups are banding together to form national and fuses radiological post-mortem data with information from optical surface scanning. A: 3D surface model of the gunshot wound to the head. B: 3D visualisation of the international organisations. gunshot. The head was virtually cut, and the CT and MRI images were laid on the cut surface. Defects of the brain tissue caused by the shot are visible. (Provided by M. Thali)

“People are coming to realise the need for dedicated teams and proper protocols,” McNulty taken to compare with ante-mortem dental techniques are also being tested as a way to course, held twice at year, attracts attendees said. “There are some expert centres in forensic records. Body parts were examined using determining time of . from institutions worldwide. The first advanced imaging in Europe, but the vast majority of sites digital and computed radiography. Virtopsy course will be held later in 2009. don’t have access to that kind of expertise.” “What is special about our method is that we “Radiographers are used to dealing with are documenting everything using imaging “We have seen a real change in people’s views,” he The value of an organised, professionally-led trauma, but some people would find that this methods, and merging everything in a single said. “When we started showing these techniques forensic imaging service will be illustrated wasn’t for them,” she commented. “We wouldn’t dataset. This is more than just post-mortem CT 10 years ago, many people said: ‘That’s science by Catherine Rock, chair of the International involve anyone who hadn’t been through some scanning,” Thali said. fiction. We are quite happy with the way we do Association of Forensic Radiographers (IAFR). kind of training. You are also working within our .’ Now the same individuals are The UK now has its own forensic radiography a very different kind of team, not just medical Interest in the Swiss group’s approach to starting to use some of these advanced forensic response team, composed of radiographers with professionals such as pathologists, but the forensic medicine is growing. A basic Virtopsy imaging techniques for themselves.” accredited training and experience in forensic police too.” and mass fatality imaging. A store of diagnostic imaging equipment that can be deployed in the During the session, Prof. Michael Thali, event of a major incident has also been funded director of the Institute of Forensic Medicine at by the UK government. the University of Bern, will show how advanced imaging techniques can aid scene-of-crime The response team received its first call-out investigations and post-mortem examinations on 7 July 2005, when bombs were detonated too. The ‘Virtopsy’ system pioneered at Bern simultaneously in London on three underground is an entirely imaging-led approach to forensic trains and a double-decker bus. A total of 24 investigation. Advocates for the system believe radiographers assisted with the subsequent that it may eventually replace invasive methods forensic investigation, imaging 56 bodies and of forensic pathology. ESOR 1,162 body parts over a 17-day period. european School of Radiology A key part of the Virtopsy approach is the 3D The aims of the imaging work were twofold: to representation of all objects involved in the identify victims of the bombings, and to identify incident under investigation. For example, foreign objects inside the body-bags that could if a patient has been killed whilst riding a potentially injure the pathologists or that might bicycle, investigators will make a virtual 3D AIMS 2009 – Advanced Multimodality be relevant to the police investigation. model of that bicycle, as well as the patient’s Imaging Seminars in China body. An optical measuring process known Whole bodies were scanned head-to-toe as photogrammetry is used to attain 3D with fluoroscopy on arrival at the emergency coordinates of discrete points on the objects Spring Seminars on Head and Neck Radiology mortuary, Rock said. These initial surveys were being modelled. Surface data are then acquired April 26 – Suzhou undertaken by teams of two radiographers and using 3D optical scanning. April 28 – Shenzhen April 30 – Guilin a pathologist. The scans showed the location of personal effects and sharp objects, as well as Cross-sectional imaging plays an important Summer Seminars on Oncologic Imaging prostheses or implants that could be used for role too. Anatomical information that would July 26 – Shenyang identification purposes. Injuries sustained by typically be collected during an invasive post- July 28 – Shi Jiazhuang victims were documented too. Once the body- mortem examination is acquired from whole- July 30 – Xian bag had been opened, intra-oral x-rays were body MRI and/or CT scans. MR spectroscopy The Advanced Imaging Multimodality Seminars are organised in close cooperation with the Chinese Soci- ety of Radiology (CSR). The programme comprises six Refresher Course: Radiographers courses per year, delivered in six different Chinese cities, with European and Chinese speakers carefully selected by Sunday, March 8, 16:00–17:30, Room L/M CSR and ESR/ESOR. RC 1214 Forensic Radiology Further details on the courses and registration Moderators: are available at www.myESR.org/esor. J. McNulty; Dublin/IE A.M.K. Thomas; Orpington/UK

A. The Bone Detectives (the role of medical imaging in forensic investigations) M.D. Viner; London/UK AIMS, the ESOR Visiting Seminars in China, are made B. The role of forensic imaging in the aftermath possible by an unrestricted educational grant from Bracco. of the London tube and bus bombings C. Rock; Huddersfield/UK C. Postmortem CT and MR imaging in forensic medicine M. Thali; Berne/CH

myESR.org 16 ECR TODAY 2009 CLINICAL CORNER Sunday, March 8, 2009

Stroke action plans attract attention

By Paula Gold

Stroke is the third leading cause of death in the West, after heart disease and cancer, and is responsible for 10% of worldwide. It can also be extremely disabling. Many survivors of acute stroke will be left with an unwanted legacy of physical and mental impairment.

Prompt, effective management of acute stroke victims could help reduce fatalities and leave fewer patients with lifelong, severe disabilities. A state-of-the-art symposium at ECR 2009 will con- 67-year-old woman with acute haemiplegia and aphasia treated with PTA and stenting. MRA shows occlusion of left middle cerebral artery. PTA of occluded segment with sider the roles that radiologists can play in diag- subsequent implantation of self-expanding led to full recovery of cerebral blood flow. (Provided by Prof. Dr. Gerhard Schroth) nosing and treating suspected stroke sufferers. routine, diagnostic workup. The question now patients. The manner in which these imaging sity Hospital, Switzerland. With recanalisation The session’s title, ‘Stroke management around is not whether to image, but which modality to findings are applied, however, is an area of rates now approaching 80%, every three proce- the clock’, reflects an important, underlying use, and how exactly to use it. some controversy. It is generally accepted that dures saves one patient from severe disability. message. If outcomes are to improve, then pati- patients should not receive clot-busting drugs ents must have access to experienced practitio- Von Kummer will address these issues by illus- more than three hours after the onset of stroke “Whenever we succeed in recanalising an ners who are fully familiar with stroke patho- trating the differing strengths of CT and MRI. symptoms. But this recommendation is based occluded blood vessel supplying the brain, physiology and its implications at any hour of Most patients will be examined with CT. The on studies that only used brain haemorrhage then the outcome of that patient is significantly the day or night. A 9am to 5pm commitment to scanners are more widely available than MRI and major infarction as contraindications to improved,” he said. service is simply no longer good enough. Stroke systems, and CT examinations are easier for drug therapy. Had evidence of reversible injury is a 24/7 problem that requires a 24/7 solution. sick patients to tolerate. An MRI scan will show been used to guide patient selection, then the Procedural details have changed very little over the brain pathology in broader detail, but this efficacy window for thrombolysis may have the years. The main difference is that interven- The role of radiology in stroke management is not always necessary. CT perfusion is also a been extended to well over four hours. tional radiologists now inject a clot-busting has changed significantly over the past 10 more robust technique than perfusion MRI. drug directly into the thrombus rather than just years, according to Prof. Dr. Rüdiger von Given the question marks hanging over the effi- in front of the occlusion site. If this strategy is Kummer, head of neuroradiology at Dresden The biggest advantage of MRI is the ability to cacy of thrombolysis, von Kummer recommends unsuccessful, then the next step may be to per- University Hospital, Germany. In some Euro- perform diffusion-weighted imaging (DWI), that the angiography suite is also prepared for form percutaneous transluminal angioplasty pean countries, suspected stroke sufferers were he explains. DWI is highly sensitive to the endovascular intervention when drug-based (PTA) with a balloon catheter or stenting. The not imaged at all a decade ago. Patients were small lesions caused by embolic events, which stroke treatments are to be used. If thrombolysis thrombus may be retrieved mechanically using recommended for treatment on the basis of cli- may by missed by CT. MRI can also reveal is not successful, then intra-arterial recanalisa- a variety of specially designed instruments. nical symptoms alone. signs of brain haemorrhage that are related to tion can begin almost immediately. the stroke being investigated, or occurred pre- Referrals for endovascular treatment from the Today, the situation is very different. Studies viously in the patient’s history. “The prognosis for these patients is very, very stroke team can come at any time, Schroth sta- showing that pre-treatment CT scans can poor if thrombolysis fails,” he said. “If there ted. The faster interventional radiologists can improve patients’ prognosis have been taken CT and/or MRI results are increasingly being is no recanalisation, the patient will get big respond, the more likely is a positive outcome. on board, and imaging has become part of the used to decide how to manage acute stroke infarctions and disability.” “If a patient comes in the early morning, the Endovascular recanalisation can be perfor- late afternoon, or during the middle of the med up to six hours after symptomatic onset night, we have to be prepared,” he said. “This of acute stroke with good results, said Prof. Dr. is one of the most cost-effective treatments in Gerhard Schroth, director of diagnostic and healthcare, given the high rates of handicap interventional neuroradiology at Bern Univer- associated with stroke.”

CT three hours after the onset of severe right- Diffusion-weighted MRI (DWI) within two hours of the sided hemiparesis and two hours after intravenous onset of moderate left-sided hemiparesis in a 62-year- thrombolysis in a 43-year-old woman. Note decrease old man. MRI was performed due to inconclusive CT in x-ray attenuation to brain tissue within the entire results. After initiation of thrombolysis, DWI shows areas territory of the left middle cerebral artery, indicat- of increased signal, indicating cellular oedema in both ing ischaemic oedema and irreversible tissue injury. cerebral and cerebellar hemispheres. These findings (Provided by R. von Kummer) prompted an ultrasound examination of the heart to look for a source of cerebral emboli. A dissection of the was diagnosed. (Provided by R. von Kummer)

State of the Art Symposium

Sunday, March 8, 16:00–17:30, Room C SA 12 Stroke management around the clock

• Chairman’s introduction: Acute stroke: Questions to be answered P.M. Parizel; Antwerp/BE

• What happens in acute stroke? R.G. Gonzalez; Boston, MA/US

• Diagnostic imaging: CT, MRI or both? R. von Kummer; Dresden/DE

• Endovascular treatment: Indications, technique and management issues G. Schroth; Berne/CH

• Panel discussion: Acute stroke: Management implications for the radiology department myESR.org Sunday, March 8, 2009 TECHNOLOGY FOCUS ECR TODAY 2009 17

Automated spine Experimental radiology InsIdE TodAy Vessel analysis assessment becomes at the Medical University techniques multiply feasible of Innsbruck

See page 21 See page 23 See page 24

MR vendors look for a patient-focused route to success in MR imaging

By John Bonner

In the gleaming technical exhibition at ECR 2009, vendors of MRI systems are showing just how their latest innovations will help to turn the imaging examination into a faster, less claustrophobic and altogether more pleasant experience for the patient.

Philips is unveiling its new Achieva 3.0T TX unit, which it describes as one of the most powerful systems currently available, enabling clinicians to obtain high-quality results across a wide range of applications and patient sizes.

Guido Stomp, director of the Philips Healthcare MR business line, explains that the improvement in performance with the new model has resulted from a change of emphasis from the RF signal receiving technologies to the signal transmission side. The product is equipped with a multiple transmission source that allows a uniform distribution of signal across the part of the body MultiTransmit effectively addresses dielectric shading, even in a patient with liver and ascites. Ascites Philips will introduce its Achieva 3.0T TX system at under examination. By adjusting the RF signal, patients are often challenging to image with MR due to the shielding effect of fluids. Large image: MultiTransmit. ECR 2009. (Provided by Philips) the system is able to eliminate the dielectric Inset: conventional 3.0T. (Provided by Bonn University Hospital, Germany, and Philips) shading artefacts that remain a major problem with 3T MRI.

“This means that we have far fewer repeat scans. The patient spends less time in the scanner and there is a faster throughput of cases,” he noted. “But there is not just a reduction in the number of retakes. The actual scan time can be up to 40% faster, which will make a considerable difference in situations like spinal imaging, where there is normally a need for high signal intensities.”

Improvements in the consistency of the images created will broaden the clinical utility of 3T systems, Stomp points out. Three Tesla machines have proved their worth in neuro and skeletal imaging, but problems with artefacts have sometimes limited their value in full-body imaging. He hopes that this ability to adapt to patients with wide variation in fat and fluid distribution will bring new opportunities for hospitals away from the main academic centres, which need to carry out larger numbers of breast, liver and abdominal examinations.

The clinical potential of the Achieva 3.0T TX Abdominal image taken on a Signa MR750 3.0T device using the LAVA-Flex application, The Syngo Blade facility allows motion artifact compensation, even in the case of is being assessed at the University of Bonn, a dual echo acquisition technique that reportedly provides consistent, detailed, 3-D severe movement. (Provided by Siemens) The wall was examined using a Germany, and the machine will become abdominal images in one breath hold. The user can select different output image types: high-frequency matrix linear transducer. (Provided by in-phase, opposed-phase, water and fat. (Provided by GE Healthcare) GE Healthcare) commercially available later this year.

Part of Siemens’ strategy for making imaging matrix). Its features include syngo actions that they would normally have to do including high-resolution dynamic breast examinations more comfortable has been to Tissue 4D, which offers dynamic evaluation with outside the room,” he said. “They can stay with the imaging with TIGRE, comprehensive motion- design systems that look less intimidating. Its quantification of tumour tissues in organs such as patient while they set up the exam, and our new compensated free-breathing abdominal studies latest product is the Magnetom Espree – Pink. the prostate and liver. This provides two evaluation software also simplifies the set up, which means with RADAR, non-contrast MRA with VASC, This dedicated 1.5T MR breast system combines workflows: standard and pharmacokinetic they can concentrate on looking after their patient.” brain ischaemia assessment with Advanced the open-bore design of the Magnetom Espree modelling (PKM). The latter function quantifies NeuroSuite, and white matter disease assessment with the Sentinelle Vanguard, a coil for breast the uptake of contrast medium and can be used The new system can also reduce the time spent with Diffusion TensorSuite. imaging and biopsies. for oncology workflow and follow-up studies. by the patient in the MRI suite. Its new RF Transmit system maximises performance with Allowing for both feet-first and head-first GE Healthcare is showcasing the Signa MR750 a 17% gain in scanning efficiency, while the The technical exhibition area is open positioning, the new unit is 125 cm long and has 3.0T, launched in Paris last October. This Optical RF technology allows up to a 27% higher a 70 cm open bore to enhance patient comfort product reportedly delivers up to 60% additional signal-to noise-ratio. This reduces the number of today from 10:00 to 18:00. and allow easy access for biopsies. It also offers a anatomical coverage and resolution compared acquisitions needed for a comprehensive breast comprehensive portfolio of routine and advanced with conventional systems, but the emphasis in examination from four to two, and will cut the applications for breast care, including syngo the design process has been as much on simplicity time needed for a full liver study from at least 25 Oasis incorporates a 1.2T vertical field magnet VIEWS for routine imaging, syngo GRACE for as on its technical performance, according to minutes down to 15 minutes, he noted. designed to meet the demands of today’s advanced spectroscopy, and syngo BLADE for motion-free Stefano Vagliano, GE’s general manager for MRI studies and image quality requirements. Its Pre-procedure liver imaging: dual-view fusion imaging imaging results. technologies in the European region. Hitachi Medical Systems has also made patient unobstructed viewing angle puts even difficult of real-time contrast-enhanced ultrasound with previ- comfort a priority in designing both the Oasis patients at ease, which decreases scan time and ously acquired CT volume dataset. (Provided by Dr. T. On its booth, Siemens is also showing its “It has a console on the machine itself, which 1.2T and Echelon XLS 1.5T machines. These increases throughput. De Baère, Institut Gustave-Roussy, Paris) innovation for oncology imaging, Tim (total enables radiographers to carry out many of the products feature a number of new applications,

myESR.org 18 ECR TODAY 2009 TECHNOLOGY FOCUS Sunday, March 8, 2009

Biomedical imaging advances in the Netherlands

By Bart M. ter Haar Romeny, radiologists and physicians need to analyse com- Eindhoven University of Technology, plex medical imaging data, advanced visualisa- the Netherlands tion and image analysis techniques are developed by the group. A strong focus is the development The research group Biomedical Image Analysis of techniques for Diffusion Tensor Imaging data (BMIA) at Eindhoven University of Technology, (DTI). The interactive visualisation tool (i.e. DTI- the Netherlands, is part of the Department of Bio- Tool, developed in-house) allows the visualisation medical Engineering. It has 500 students, making of DTI data. Techniques to visualise and analyse it the largest such institution in the Netherlands. High Angular Resolution Diffusion Imaging (HARDI) are now incorporated. HARDI allows The group, headed by Prof. Bart ter Haar Romeny, the distinction of intra-voxel fibre crossing. As focuses on the development of efficient diagnostic applications, the methods are applied to the brain workstation applications for diagnostic radiology, white matter, as well as to the heart and muscles. image-guided surgery and the life-sciences. To bene- fit from a multi-disciplinary approach the research 3. Cardiac Image Analysis and education is divided into a chain of 5 areas: Here it is all about quantitative image analysis: study of the detailed local deformation of the left Parameter map of contrast enhanced dynamic MRI of An example of DTITool: Muscle fibres through a slice 1. Algorithm Design for Medical Image Analysis ventricular wall during systole and diastole, with the breast. of the heart, depicted with diffusion tensor imaging. Powerful and smart algorithms form the core of high-resolution deformation analysis from tagged effective quantitative and CAD medical image MRI for non-invasive infarct assessment. Another detection of pulmonary emboli, and polyp detec- Meet this interesting group at the IMAGINE analysis tools. Many new methods are being deve- focus is the segmentation of the cardiac left atrial tion in low-dose virtual endoscopy. exhibition (ACV second level, opposite room loped, using state-of-the-art mathematics, in close myocardium with deformable models, to measure B). All the research topics described above (and collaboration with hospitals and industry. One local atrial wall thickness. This application should 5. Image-Guided Surgery more) are demonstrated and carefully explained focus is the analysis of tensor-valued images for serve as a guide for electrophysiologists during Located in the Maastricht University Hospital, the by a large crew. The Netherlands has a strong tra- diffusion tensor imaging applications, heart motion catheter ablation of atrial fibrillation. Image-Guided Surgery group closely collaborates dition in medical image analysis; come and see analysis and surgical navigation. Another focus is with the neurosurgery department. Together the the revolutionary developments and find out how trying to bio-mimic the segmentation and recogni- 4. Computer-Aided Diagnosis focus is on a variety of research topics. Currently they can improve your workflow. tion mechanisms of the spectacular human visual New quantitative CAD methods are developed a software tool is being developed for Deep Brain system. This led to many new and unconventional for dynamic contrast-enhanced MR images of Stimulation procedures to accurately locate the Web: www.bmia.bmt.tue.nl algorithms, such as for catheter detection at much the breast, in collaboration with Philips Health- stimulation target and the safest entry path. For lower x-ray doses than current clinical practice, care and the University of Chicago. Static and tumour resection surgery the work is focused heart motion quantification and image retrieval. dynamic MR images are acquired during diffu- on (GPU-based) multi-modal (mix of MR, CT, sion of a contrast agent in the breast tissue, expo- fMRI, DTI) planning tools. For the study of the Visit the 2. Multivalued Image Analysis and Visualisation sing cancerous disorders by means of characte- motility of the cervical spine the vertebra move- Nowadays, 3D medical imaging techniques allow ristic spatial and temporal enhancement pat- ments are analysed through x-ray video sequen- IMAGINE Area on nd complex measurements such as diffusion or flow. terns. The team exploits pharmacokinetic multi- ces and with newly developed software, interfaced the 2 level This data are difficult to understand without any compartment modelling and pattern recognition with Medtronic’s Stealth Station and Medtronic’s processing. To convey the information that the techniques. Other projects include the automated intra-operative MRI scanner, the Polestar N20.

myESR.org Sunday, March 8, 2009 TECHNOLOGY FOCUS ECR TODAY 2009 19

Improving early detection and diagnosis of breast cancer

The project HAMAM – Highly Accurate cancer detection, discrimination and therapeutic Breast Cancer Diagnosis through Integration effect. A multi-modal strategy will be followed of Biological Knowledge, Novel Imaging integrating results of work packages 3 and 5 into Modalities, and Modelling – is funded by the the research. The results of this work package European Commission within the Seventh will be added to other patient-specific multi- Framework Programme with a total of €3.6m. disciplinary data and used to define an integrated The 3-year project started in September 2008 assessment in work package 5. and consists of 9 international scientific partners from seven countries (listed at www.hamam- To carry out the tasks, two researchers were project.eu), with EIBIR as coordinating partner. recruited who both started in November 2008. Preparations were made to collect cases and Despite tremendous advances in modern literature research was performed to learn imaging technology, both early detection and about the most recent developments in the field. accurate diagnosis of breast cancer are still It was decided to first focus on research and unresolved challenges. Unnecessary biopsies development of breast MRI parameters, because are taken and tumours frequently go undetected MRI data is readily available at RUNMC. For until a stage where therapy is costly or reliable and automated feature extraction, unsuccessful. HAMAM will tackle this challenge segmentation of the various tissues encountered by providing a means to seamlessly integrate the Dr. Kathy Schilling from Boca Raton Community Hospital (United States) discusses the project work plan with in breast MRI has to be performed. available multi-modal images and the patient Prof. Ulrich Bick from Charité Berlin (left) and Clinical Advisory Board member Prof. Roland Holland from information on a single clinical workstation. University Hospital Nijmegen at the kick-off meeting. A whole unit is planned to be installed at RUNMC. At MeVis Research Gmbh, some preliminary work with 3DBUS has started. Initial experience with a few cases that are available indicates that stitching of different views and correction of motion artefacts are relevant issues to investigate. HAMAM is a successor of the very successful EU-projects SCREEN and SCREEN-TRIAL, Work Package 5 which brought major advances in European Integration of multi-disciplinary data breast cancer diagnosis. With HAMAM, Europe This work package is led by Eidgenoessische has the potential to strengthen its leadership Technische Hochschule Zuerich. The principal in the whole area of image-based breast cancer objective is to centralise the heterogeneous data diagnoses. collected by all partners in a structured fashion, and fuse this multidisciplinary information We are pleased to provide you with an overview for extracting new insight about breast cancer of the scientific progress achieved at work diagnosis and detection. package level during the first months of the project: The first step toward this goal is to define a common representation for the multidisciplinary Work Package 1 data which is compatible with both clinical Clinical and diagnostic requirements The kick-off meeting in Bremen, Germany, on October 20–21, 2008 was very productive and enabled the laying requirements and objectives, and machine out of a detailed work plan for the first project year. This work package is led by MeVis Research learning methods that shall be employed for Gmbh. The overall objective is to bring together extracting useful associations from the database scientists, clinicians, and engineers in order (February 2009). Consequently, visits are being to review the relevant existing knowledge scheduled with all partners in order to collect and data sources and to prioritise the specific the specific types of data they produce, as well as requirements of the project. their own needs, in order to reach a consensus.

The clinical project partners together with the In parallel, data transfer agreements will be set clinical advisory board members will define up with the clinical partners, so that ethical and detailed requirements from a clinical perspective legal issues, related to the hosting of sensible regarding the role of the different modalities for data in the centralised database server, are solved specific clinical questions, the tools needed for before the data collection phase begins. multi-modal breast diagnosis, and the clinical workflow represented by a set of use cases. Based Work Package 6 on this, software engineers and IT researchers Technical validation and verification will specify the architecture as well as relevant This work package is led by MeVis Research interfaces of a software prototype for multi- Gmbh. The objective of this work package is modal diagnosis of breast cancer. the validation and verification of the software application, algorithms and project database Finally, the work package comprises the design developed in HAMAM. The official start date and definition of a database for anonymised of WP 6 is September 2009. Nevertheless, single clinical data including lifestyle risk factors, work will start as soon as preliminary results are histopathology, family history information and obtained in the tasks of the other work packages. genetic test results both mutation analysis of known high penetrance breast cancer genes and Work Package 7 polymorphisms at loci known to predict breast The HAMAM-Website Clinical validation and verification cancer risk. To this end, a workshop will be held This work package is led by Radboud Universiteit back-to-back with ECR 2009. techniques have been identified, primarily in the College London. The aim of this work package Nijmegen – Stichting Katholieke Universiteit context of the new modalities like tomosynthesis, is to establish spatial correspondence between (RUNMC). The HAMAM project is very Work Package 2 PEM (Positron Emission Mammography) and 3D regions of the breast acquired by different strongly clinically oriented and is not intended Development of multi-modal environment breast ultrasound. Missing software components image modalities to enable effective synthesis to be an engineering solution to the wide This work package is led by MeVis Medical have been scheduled for development. and visualisation of multi-modal data for the variety of challenging problems often requiring Solutions. As part of the specification of the detection and diagnosis of breast lesions. Intra- complex technical solutions. Validation will multi-modal workstation for breast cancer During a meeting with the project partner modality image registration will be provided for include: usability (responsiveness, time gain, diagnosis to be developed by MeVis Medical Eidgenössische Technische Hochschule Zürich intra-modality fusion of images learning curve) in a clinical setting, the effect Solutions, efforts in Task 2.1 and Task 1.3 have in Bremen, topics related to the data connection and for the alignment of the DCE-MR images. on diagnostic accuracy, confidence of visual been focused on evaluating to what extent the between the workstation prototype and the Temporal registration methods will be developed and quantitative output. Activities in this work project specific requirements are already fulfilled HAMAM database were discussed, including to support the detection and diagnosis of lesions package will start in September 2009. by the software modules which are part of the the type of data that has to be exchanged, data as well as the estimation of therapeutic response. proprietary application platform MeVisAP. formats as well as outlines for software interfaces. Portraits of dedicated The results of this discussion have to be worked Work Package 4 staff as well as updates Based on the requirements for the clinical out in greater detail jointly by all project partners. Model-based analysis of integrated imaging data on progress reports scenarios identified during the HAMAM Kick-Off This work package is led by Radboud Universiteit are available at the Meeting in Bremen, missing software components Work Package 3 Nijmegen (RUNMC). The overall objective is to HAMAM project website providing basic functionalities such as data Imaging spatial correlation research image-derived quantitative diagnostic www.hamam-project.org. import or standard visualisation and interaction This work package is led by the University tissue model parameters focused on breast

myESR.org 20 ECR TODAY 2009 TECHNOLOGY FOCUS Sunday, March 8, 2009

Stereotactic of liver tumours proves effective

By Reto Bale, SIP –Microinvasive sent to the navigation system. After verification Therapy, Department of Radiology, of correct needle placement by means of image Medical University Innsbruck/AT fusion, a maximum of six RFA probes with an active tip of 3 cm are introduced into the coaxial Radiofrequency ablation is an effective technique needles to the pre-planned depth. for reproducible tumour destruction. Howe- ver, the size of the ablation zone is limited and Ablation depends on the RFA probe technology used. Des- Thereafter, the coaxial needles are retracted in perate local tumour recurrence rates in large liver order to avoid contact of the active uninsulated lesions require modifications of the conventional tip of the RFA probe with the coaxial needle. US and CT-guided approach. We present a novel Depending on the RFA technology used, a maxi- method of radiofrequency ablation of large liver mum of six electrodes are simultaneously acti- lesions by stereotactic placement of multiple RFA vated. An empirically calculated amount of RFA Planning CT: S.p. left hemihepatectomy with two Resovist-enhanced MRI 2 years after stereotactic RFA probes in order to achieve an overlapping abla- recurrent HCCs (3 cm and 10 cm). does not show any recurrence. energy is applied at every probe position. In the tion zone including a sufficient safety margin. case that the required necrosis is larger than the mattress (Medical Intelligence, Schwabmün- Registration active tip, step-by-step retraction and ablation is 3D- navigation system chen, Deutschland). After placement of skin After sterile washing and draping, registration is performed according to the virtual plan. Navigation systems show the actual position of markers, a contrast-enhanced helical CT scan performed by indicating the skin fiducials on the the probe with respect to cross-sectional ima- (Somatom Open, Siemens, Erlangen, Germany) patient with the navigation probe, thereby assig- Control CT immediately after RFA ges of the preoperative CT/MRI dataset(s) in with a slice thickness of 2 mm is obtained with ning each fiducial its corresponding position on After RFA a contrast-enhanced CT scan is real time. Instruments and anatomic structures respiratory triggering. The CT data are sent to the reconstructed 3D-data set. obtained with the coaxial needles in place, in are assumed as rigid bodies. The key step is the the navigation system in the CT room. order to compare the size of the induced necro- registration, during which the spatial configu- Placement of RFA probes sis with the original tumour size. After verifica- ration of the real patient is correlated with the Virtual planning of 3D – The Atlas needle holder (Medical Intelligence, tion of the necrosis covering the tumour and a pre-operative images of the patient. This is done distribution of RFA probes Schwabmünchen, Deutschland) is attached to safety margin of approximately 1 cm, one after by indicating the reference points (e.g. skin fidu- Pathways for multiple probes are planned on the the fixation system and adjusted using the Treon another coaxial needle is removed with tract cials) on the patient with the probe of the navi- 2D and 3D reconstructions of the CT data in order navigation system for every path. One after ablation. gation system and selecting the respective points to cover the whole tumour volume by overlapping another coaxial needle is advanced through on the dataset. After registration, the patient and necroses. Once the trajectory is planned, the path the adjusted aiming device to the pre-planned At IMAGINE 2009 the virtual planning work- the camera can be moved in respect to each other of the probe in the patient can be visualised virtu- depth, as indicated by the navigation system. station is exhibited and the initial results of without losing the spatial information. ally and changed according to the anatomy of the Every needle placement is performed with res- stereotactic RFA in the first 100 patients are patient. The trajectories for the different RFA pro- piratory triggering. shown. Interventional radiologists may try Procedure bes are optimised to a maximum distance of 2.5 cm to plan a virtual stereotactic RFA of a large Imaging and a minimum distance of 1.5 cm. In addition, Verification of correct needle placement tumour, based on anonymous datasets from After oral intubation the patient is rigidly the ribs and vital structures, including vessels, bile A native CT with the needles in place is obtained patients with liver tumours who have been tre- immobilisedRZ Ad_Hitachi_OASIS_260x195mm_23-01-09:RZ on the CT table by a vacuum duct andAd_Hitachi_OASIS_260x195mm_23-01-09 surrounding organs, have to be protected. with 23.01.2009 respiratory triggering17:04 Uhr and Seitethe dataset 1 is ated previously. .artundwork designbüro

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myESR.org Sunday, March 8, 2009 TECHNOLOGY FOCUS ECR TODAY 2009 21

Vessel analysis techniques multiply and begin to enter routine clinical use

By Javier Oliván Bescós, Joost Peters, dering mode (MPR, MIP, volume rendering) to A major achievement is that the local path tra- Raymond Habets, Jeroen Sonnemans, inspect the data (in this case, a 10 mm thick coro- cking algorithm is very fast, taking only tenths Marcel Breeuwer; Philips Healthcare Best, nal slab). of a second including the generation of the visu- The Netherlands alisations. The user thus receives live feedback The Vessel Exlorer should be considered as an about the local coronary anatomy. The fact that Current vessel analysis applications in the market advanced magnifying glass applied to a structure all visualisations are automatically properly alig- offer a range of tools such as segmentation, path- of interest. When the user needs to inspect a par- ned decreases the inter-user variability associated tracking and different 2D and 3D visualisation ticular location, a single mouse click computes with manual interactions. When different users modes. These applications are often perceived a local vessel centreline and segments the vessel click at about the same location, the same rende- as rather heavy and complex, needing a time- lumen at the cursor position. In the example rings will be generated. consuming sequence of pre-processing steps given, the user clicked at a location just above the before getting to the diagnostic task at hand: right carotid bifurcation. From the locally esti- For the coronary arteries the local path tracking measuring the vessel lumen to characterise the mated vessel orientation, we subsequently derive has been validated on 11 MR data sets used in Figure 1: MR angiography of the carotids. vascular pathology, such as stenosis or aneurysm. an MPR perpendicular (top right) and parallel the work presented in [1]. Four image processing Although today the pre-processing is more and (bottom right) to the vessel, that allows detailed experts were asked to manually delineate the cen- more automated, the user still needs to check the inspection of the vessel. Next to that we provide treline of the coronary arteries in these 11 data References results and edit these if necessary. an initial vessel diameter and cross-sectional area sets. For each coronary artery, the four centrelines [1] J. Sonnemans, Proc. SCMR 2008. measurement from the lumen segmentation, were averaged with the Repeated Averaging Algo- [2] V. Chalana et al., IEEE TMI 16(5):642-652, At this year’s IMAGINE exhibition we show a which can be edited by the user. rithm [2]. The averaged line was considered to be 1997. 3D CT/MR vessel analysis prototype based on the gold standard. Local centrelines of 5 cm were our innovative Vessel Explorer approach. Vessel When necessary, the user can easily navigate computed with the local path tracking algorithm Explorer aims to provide fast and robust tech- along the selected vessel by hovering the mouse at the middle point of each golden standard path. niques to analyse vessels locally, minimising the along the vessel in any of the views or by pressing Each local path was compared to the golden stan- required user interaction at the same time. the up/down keys. During navigation, the user dard using the Repeated Averaging Algorithm may select different vessels with a single mouse [2]. The mean error was 0.32 mm, with a standard Our Vessel Explorer offers a lightweight user click at any time. deviation of 0.08 mm. Currently our algorithms Visit the interface aimed at direct and easy measurement have been validated and parameterised not only of vessel diameter, area and lengths in 3D CT Fast and robust visual inspection of the coro- for coronary MR angiography but for all vascu- IMAGINE Area and MR angiography images, without any pre- nary arteries based on live path tracking lar anatomies in contrast-enhanced MR and CT processing steps. Although the intuitiveness of In Figure 2 we show an extension of the Vessel angiography. As shown in Figure 3, the local path nd the application is hard to capture in one image Explorer concept applied to a coronary artery. Here tracking also works in stenotic cases. on the 2 level we explain its basics in Figure 1, which shows a a local centreline is computed on the fly and it is screenshot of the application. used to compute a local curvilinear reformatted For more information about our research and a image at the bottom left. Using the mouse scroll demonstration of the algorithm, please visit us at In Figure 1, we inspect an MR angiogram of the wheel the local centreline and curvilinear reformat the IMAGINE exhibit. carotids. The user may employ any type of ren- can be extended or shortened.

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Figure 2: This image was captured after the user clicked at the location marked by the arrow. Based on the local Now more than ever, less is more. This centreline, a slab volume rendering (left), a cross section (top right), and a curvilinear reformatted image (bottom certainly applies to SharpView® CT, the right) were generated. product that enables CT-dose reduction by 30–70 percent*. And with preserved or even better image quality!

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SharpView® and SharpView® CT are registered trademarks SharpView AB owned and controlled by SharpView AB. The SharpView Storgatan 39, SE-582 23 Linköping, Sweden product is CE marked according to MDD 93/42/EEC and Phone +46 13 23 50 30, Fax +46 13 31 88 60 has a 510(k) clearance from the FDA. The Company’s quality www.sharpview.com | [email protected] Figure 3: The method applied to a stenotic coronary artery. system is certified according to SS-EN ISO 13485:2003.

myESR.org 22 ECR TODAY 2009 TECHNOLOGY FOCUS Sunday, March 8, 2009

Chest imaging experts confront hot issues

By Edwin J.R. van Beek, Iowa City, IA/US; Second, there is the increasing demand for more Jürgen Biederer, Kiel/DE accurate and quantitative imaging to detect disease earlier and allow for monitoring of chan- There are a number of ‘hot’ issues in chest ima- ges using sophisticated software. This demand is ging that are currently taking centre stage. First, part of the pharmaceutical industry’s interest in the issue of how to deal with acute chest pain is developing protocols to test safety and efficacy of increasingly being met by chest CT methods, new drugs without having to wait for the (often including CT pulmonary angiography, CT coro- late or insidious) onset of clinical changes, such nary artery angiography and CT . as events or changes in pulmonary function With advancing CT technology, the triple rule- tests. Furthermore, with the awareness that lung out study is taking the spotlight. Coupled with disease is often inhomogeneously distributed, these changes, there is the realisation that more drug delivery is being reassessed, requiring more appropriate triage of patients that are considered focal assessment of disease distribution. CT (and candidates is essential, as the radiation dose is to a lesser extent MRI) are subject to continuous significant and the easy availability of CT in the development to meet these demands. emergency setting has led to an increased use and decrease in prevalence of disease. Third, with this extensive use of CT for an incre- asing number of clinical applications, radiation Nevertheless, CT pulmonary angiography and exposure has become a most relevant issue. Tech- CT coronary angiography have proven to be very nical developments (attenuation-corrected dose robust tests in adequately selected patient popu- modulation, shutters to eliminate over ranging lations. What transpires is that the management in multiple row detector CT (MSCT) with large of acute chest pain is being reviewed as part of z-coverage and improvements in detector accu- Figure 1: Volumetric helical HRCT can be obtained with a tenfold reduced dose. dedicated patient care pathways, which includes racy) allow for routine dose reduction of chest other diagnostic tests and also allows for dedica- CT to 60%. However, by far the biggest potential ted protocols for CT applications. For instance, in to reduce radiation exposure down to less than at the higher end of the span (scanners without ent for computer-aided (CAD) nodule detec- patients in whom pulmonary embolism is more 10% is related to the right choice of protocol. the option to reduce collimation may require tion or volumetry. Diffuse lung disease can be likely, clinical decision rules, plasma D-dimer higher tube currents for the standard protocol). assessed with classic HRCT and interslice gaps. and (in some situations) ultrasonography or Unfortunately, an increasing variety of CT A refinement of this protocol with maximum Volume coverage is incomplete, but radiation perfusion scintigraphy are deployed prior to CT scanners with different imaging geometry and spatial resolution would be dedicated to vessel exposure is less than 1mSv. Volumetric helical pulmonary angiography. In patients with sus- diverse protocol recommendations of the ven- imaging (including triple rule out in the ER). HRCT can be obtained with a tenfold reduced pected coronary artery disease, calcium scoring dors for chest imaging makes a consensus dif- Depending on the z-coverage and collimation, dose (Figure 1), with satisfactory image quality. CT, stress and stress MRI may ficult. A schematic set of protocols for CT of the this infers a higher radiation exposure (Heff 4-10 Thus, a smart selection of suitable protocols can be used, whereas in acute settings CT coronary chest suggests adapted parameters for four diffe- mSv). However, many indications such as short- reduce radiation exposure to less than 10%. angiography is proving particularly useful in rent groups of indications. Tumour staging and term follow-up of lung parenchyma disease, eva- patients with a low to intermediate likelihood of any unclear situations call for the workhorse: a luation of ICU patients or lung cancer screening As a contribution to the discussion and a significant coronary artery disease (a large pro- contrast-enhanced helical scan with sufficient, can be sufficiently covered with a non-contrast- basis for ongoing development and continuous portion can have this excluded, and thus avoid but not necessarily maximum spatial resolution enhanced helical scan at tube loads of 20-40% improvement, protocol suggestions at the invasive catheter angiography or multiple tests and an effective dose of 2-10 mSv. Single row compared to the standard scan (Heff <1 mSv for current state of discussion are available at ECR1/4p AD:ECRTodayB/Wad 16/1/09 14:31 Page 1 delaying the final diagnosis). detector CT (SCT) range at the lower and MSCT SCT, 1.5-2.0 mSv for MSCT). This is still suffici- http://www.thieme-connect.de ePACS@ECR 2009 – Train your reporting skills for CT and MRI

By Thomas Moritz, Vienna/AT ePACS is a radiological e-learning project developed at the Medical University of Vienna Most of our medical knowledge derives from (MUV) with the support of the European Society of our radiological training, but it also comes Radiology. It combines electronic patient records, from the daily routine, from patients left in our a medical content management system, and hands and from our experienced colleagues and collaborative software (Unified Patient Project) mentors who we seek in doubt. E-learning is an with a Java™-based Dicom viewer (Tiani-spirit advancing new field in all medical specialties. viewer) in a browser-based learning environment. Roland Holland and Henny Rijken Its ability to simulate daily work to some extent provides us with a sheltered workshop, a place At the ECR (on the first level next to EPOSTM), to make mistakes and learn from them without ePACS offers expert knowledge from different harming our fellow men and women. radiological subspecialties to all interested Digital participants by utilising modern e-learning The field of radiology is especially suitable for such concepts. This year will be its third appearance simulation because radiologists are – in many cases at the ECR, where it will provide attendants Mammography – used to converting patients into greyscales or – in with a large collection of CT cases, comprising a these digital ages – into pixels to examine them. cardiac and an acute abdomen course. Moreover, this year’s collection will be enhanced by a SELF-ASSESSMENT However, radiology is not only pixels, so new musculoskeletal MRI course seeking to radiological e-learning cannot only be pictures convey basic and advanced MRI knowledge WORKSHOP and text. There are still our colleagues and of the musculoskeletal system to all interested mentors who help us out and this is where radiologists. Saturday 7th & Sunday 8th March, 2009 e-learning has more to offer than ‘classic’ CME points awarded Room 01, First Level, Austria Centre learning: interactivity. Once again the ePACS team is proud of having Learn how to read and manipulate digital convinced first-class experts in the respective It is known that a great deal of learning is a social fields to share their expertise. mammography images and assess your skills in process, a matter of interaction, observation and detecting cancers in their early stage. imitation. Michael Kerres defines e-learning In dedicated interactive teaching and blended Join a one-hour hands-on session led by Roland Holland as “learning where digital media is used to learning sessions ePACS will bring you close to MD, PhD and Henny Rijken, experts from the National present and distribute content and/or to aid these experts. You get the chance to discuss and Workshop Times interpersonal communication”. solve cases under their guidance – and be awarded! Expert and Training Centre for Breast Cancer Screening March 7th & 8th 8.30-9.30 at Radboud University Medical Centre, Nijmegen in Modern e-learning-applications try to Cardiac CT 9.45-10.45 the Netherlands. accommodate these learning-aspects. Some of C. Loewe; Vienna/AT 11.00-12.00 the techniques needed – some of the concepts of A. Stadler; Vienna/AT H. Wolf; Vienna/AT 12.15-13.15 the so-called Web 2.0 – have evolved over recent 14.30-15.30 months and years, and only some have been Emergency CT of the acute 15.45-16.45 used and tested systematically in an e-learning abdomen 17.00-18.00 context. The interaction within a forum, for H. Ringl; Vienna/AT instance, or the concept of ‘blended learning’, a Musculoskeletal MRI combination of virtual and physical teaching; M. Zanetti; Zurich/CH, © Carestream Health, Inc. 2009. both promising approaches to social e-learning. M. Breitenseher; Horn/AT

myESR.org Sunday, March 8, 2009 TECHNOLOGY FOCUS ECR TODAY 2009 23

Automated spine assessment becomes feasible

By C. Lorenz, T. Klinder, T. Blaffert, of individual vertebrae is needed, e.g. to assure represented as triangulated surface meshes, the 92% (59 out of 64 data sets), and the vertebra S. Kabus, S.P.M. Dries; Philips Research, that the correct vertebra is addressed by therapy. spinal canal is extracted. identification had an isolated success rate of Hamburg/DE 95% (56 out of the remaining 59 cases). The Since bony structures show high contrast in CT, Vertebra Detection: In order to simplify the final segmentation step resulted in a mean Due to clinical demand and advances in ima- this imaging technique is the modality of choice detection, a curved planar reformation (CPR) vertex-to-surface error of 1.8 mm as compared ging equipment technology, ever increasing for developing and demonstrating spine seg- is at first applied on the volume based on the to ground-truth segmentations, where vertices amounts of image data set the stage both for mentation. However, in spite of high contrast, extracted spine curve. Detection is carried out (points) are base elements of the triangulated adjunct and core automated processing appli- an exact segmentation of vertebrae still remains in the reformatted image. surface descriptions. cations. Probably the best example of clinical challenging due to sampling or reconstruction demand is the ambition to plan and follow-up artifacts, noise at object boundaries, similar Vertebra Identification: For identification, a References therapy like interventions and surgery accor- structures in close vicinity, or pathologies. similarity measure is evaluated between the T. Klinder, R. Wolz, C. Lorenz, A. Franz, ding to criteria measured with imaging. As an local image patch around the detected candida- J. Ostermann, Spine segmentation using articu- example, spine assessment typically involves Another key issue for automated image proces- tes and earlier trained models that contain typi- lated shape models, In: Proc. of Medical Imaging calculation of derived metrics, like vertebral or sing is the shape complexity of the objects to be cal gray values of the individual vertebrae and Computing and Computer Assisted Intervention. intervertebral height, foraminal width or area, segmented and their inter-patient variability. their local neighbourhood. Vol. LNCS 5241. pp. 227–234 (2008) angulations, offsets, density in ROIs, ideal access Although several vertebrae show typical charac- or fixation paths, etc. Once the anatomy is iden- teristics, e.g. thoracic vertebrae have articulations Vertebra Segmentation: The final segmentation is M. Ehm, T. Klinder, R. Kneser, C. Lorenz, Auto- tified, these derived metrics can be calculated with the ribs, the shapes of neighbouring verte- carried out by adapting triangulated shape models mated Vertebra Identification in CT images, simply by a computer system, and comparison brae are typically very similar, so that automa- (see Figure 2) of the individual vertebrae. The SPIE-MI 2009, to appear in Proc. of SPIE (2009) of cases based on anatomic correspondence can tic sequence identification is generally difficult adaptation algorithm uses additional features desi- be facilitated. But which human reader wants to obtain. In clinical practice, the identification gned for the segmentation of model ensembles. to input his or her fast anatomy identification problem is solved by searching for characteristic through not-so-fast computer user interfaces on vertebrae, e.g. the first cervical or first thoracic Results a regular basis? vertebra, and subsequently labelling the indivi- Evaluation is performed on 64 test image data Visit the dual vertebrae iteratively. In many cases, labelling sets in order to draw reliable conclusions. The Automated recognition of organs and tissues can be facilitated by the use of reference struc- test image set did not include the learning ima- IMAGINE Area on nd is referred to as segmentation, and its output tures, which again is impeded by reconstruction ges used to create the models. The spine curve the 2 level is inherently feasible to facilitate calculation of limited to a focused in-plane field of view, and of detection was successful on all data sets. The derived metrics and therapy plans. Segmen- course clinical question limited axial coverage. vertebra detection step had a success rate of tation can be further divided into detection (of the location of the object), segmentation Methods (in the strict sense of shape recognition) and Our method allows the automatic detection, identification (of nomenclature, e.g. vertebral identification, and segmentation of individual numbering). A reliable segmentation of the ver- vertebrae in arbitrary CT scans (cervical, tho- tebral column is deemed essential for numerous racic, and lumbar, but also whole-spine ima- orthopaedic, neurological, and oncological ges) even with a limited in-plane field of view, applications. In the context of computer-aided since it does not require any reference struc- spinal surgery, exact knowledge about the shape tures. As output, it provides a segmentation of individual vertebrae is of great importance, represented as labelled vertebrae in the form e.g. for biopsies, augmentation or implants like of triangulated surface meshes. The individual artificial discs or fusion instrumentation. Addi- components of our framework are outlined as Figure 1: Block diagram of framework. Based on the spine curve extraction, a curved planar reformat is applied tionally, the vertebral column may serve as a follows (see Figure 1): and the vertebrae are detected in the reformatted image. Found candidates are transformed back to the original reference structure, supporting the localisation image – visualised as spheres located between each vertebra. Afterwards, candidates are identified – visualised of other organs. In most cases not only a precise Spine Curve Extraction: Based on a progres- as pre-positioned models; colour coding illustrates labels of vertebra meshes. Finally, meshes are adapted to the shape segmentation but also an identification sive adaptation of small tube-shaped segments respective image structures.

(a) Sixth thoracic vertebra (b)

(c) (d) (e) (f)

Figure 2. (a) Illustration of a vertebra surface model showing the sixth thoracic vertebra. (b-d): Invariant features of vertebrae are used to define a vertebra coordinate system: Vertebral foramen (b), middle plane of upper and lower vertebral body surface (c) and sagittal symmetry plane (d). (e-f): Spine model as ensemble of mean vertebra models. Each shape model carries its own local coordinate system. Lateral (e) and ventral (f) views of the spine.

myESR.org 24 ECR TODAY 2009 TECHNOLOGY FOCUS Sunday, March 8, 2009

Experimental radiology flourishes at Medical University of Innsbruck

By Wolfgang Recheis, Innsbruck/AT

The Experimental Radiology team at the Medical University of Innsbruck, consisting of four phy- sicists, one mathematician, two computer scien- tists and three students, is currently pursuing two main topics: 1. Custom implant design of large bone defects 2. Texture analysis of the pulmonary parenchyma In the following draft we would like to describe our work.

Custom Implant Design for Large Bone Defects in Cranial Surgery Large skull defects (>100 cm²) are common sequelae of trauma, cancer, stroke, and re-const- ructive surgery. Aesthetically correct reconstruc- tion of the defect remains challenging because the majority of current implant design techniques are dependent on subjective procedures. We cur- rently transfer existing anthropological methods to neurosurgical planning in order to reduce the Reconstructed surface of the implant – the basis of Example of texture analysis for a female patient with fibrosing alveolitis and severe emphysema. The quantification dependence on subjective skills and improve the the negative of the real model. of the extent of disease patterns of the overall parenchyma including the colour-coding is shown. implant form. The suite of methods of 3D geome- tric morphometrics (GMM) aids us in the design are obtained using the Procrustes average shape. Texture Analysis of the Pulmonary Parenchyma (in the size of 15x15x15 voxels) and labelling task. We are using a database comprising over We consider additionally some landmarks on the Till now the objective, reproducible quantifica- them with disease patterns such as honeycom- 200 CT scans of the human skull. skull as missing to correctly compute the bound- tion of the extent of pulmonary disease patterns bing, ground glass opacity, normal lung, emphy- ary. This works well but the main challenge is to remains difficult. We focused our work on the sema, tree-in-bud, etc. We established a disease One specimen is selected as a template and land- calculate the inner surface and thus the thickness quantification of disease patterns in interstitial pattern database of several thousand VOIs thus marks and semi-landmarks are set on the segmen- of bone. Currently we use the average thickness of lung diseases. A fruitful and effective collabora- allowing us to quantify the extent of disease with ted outer surface of the skull. The template is used the unimpaired part of the skull. tion with the University of Parma and Bologna high accuracy. The continuing development of to perform thin plate spline warps to the patient’s (Team Prof. Zompatori) was established. the feature database and the inclusion of further skull. To guarantee matching, we specify a reduced We are still optimising the boundary algorithm. pathologic texture patterns will improve quanti- number of landmarks in the target specimens. In the future we will design the inner surface, con- In this project the texture analysis algorithm fication of disease and provide objective measu- nect both surfaces for the final implant, and eva- 3D-AMFM (Adaptive Multiple Feature Method) res of disease progression and possible healing Using this procedure all the landmarks of the spe- luate the quality of the implants. Currently we use contained in the software PASS (University of effects. cimens in the database can be obtained. The land- an in-house rapid prototyping machine to create Iowa, Physiologic Imaging, Head: Prof. Eric mark sets are then taken to compute a Procrustes negative models of the implant as a moulding tool Hoffman) was applied to patients with intersti- Finally we set up a collaboration with Defini- average shape. After these pre-processing steps we for the palacos implant for the neurosurgeon. tial lung diseases. The basis of the system is a ens in order to have a new impact on analysing can then apply the methods to the patient data. Bayesian classifier, which needs to be trained by medical imagery such as shape analysis of disea- We warp the landmarks to the region without This work is supported by the EU FP6 Marie Curie experienced radiologists. The sometimes tedious ses (differentiation between malign and benign defect. In the defected region missing landmarks Actions, contract number: MRTN-CT-2005-019564 training is based on setting volumes of interest tissue).

EIBIR Session at ECR 2009

An update on the European Institute for Biomedical Imaging Research Sunday, March 8, 2009 10:30–12:00, Room Z

Moderators: G. Krestin, Rotterdam/NL; J. Hennig, Freiburg/DE Visit the ECR 2009

10:30–10:40 Introduction and future strategies of EIBIR G. Krestin, ESR Representative at the Special Exhibition EIBIR General Meeting, Rotterdam/NL 10:40–10:50 Scientific activities of EIBIR, joint initiatives, FP6 project ‘Forensic Radiology’ J. Hennig, EIBIR Scientific Director, Freiburg/DE 10:50–11:05 Biomedical imaging research in the 7th Framework Programme st Ph. Jehenson, EU Commission, DG Research, Brussels/BE (tbc) Located on the 1 level opposite Room X. 11:05–11:25 ENCITE – a challenging project on cell imaging and tracking under FP7, coordinated by EIBIR M. Bernsen, Rotterdam/NL 11:25–11:55 HAMAM – an FP7 research project to improve breast cancer diagnosis, coordinated by EIBIR H. Hahn, Bremen/DE Discussion: Future trends and needs in biomedical imaging research

Visit the EIBIR Lounge in the entrance hall to get information on EIBIR’s activities and projects! www.eibir.org myESR.org Sunday, March 8, 2009 COMMUNITY NEWS ECR TODAY 2009 25

Don’t miss today’s InSIDE ToDAy Josef Lissner Recent news on the What’s on today Honorary Lecture Alliance for MRI in Vienna?

See page 29 See page 29 See page 30

The Viennese AKH: the fire under the ice Continuing its series on emergency departments, ECR Today visited the Wiener Allgemeines Krankenhaus (AKH), Vienna’s General Hospital, and discovered that things are not always what they seem ...

By Mélisande Rouger answers with PACS, but it’s so much better when we can directly talk to a colleague,” Laggner said. Wednesday, 2pm. The emergency department of the AKH is a model of tranquillity. Four people “We have a very good communication with Prof. sit quietly in the waiting room; a patient who Laggner and his team; it’s very important to have has been resuscitated earlier during the night is a close relationship between our specialties,” now resting in the intensive care unit, doctors agreed Dr. Ahmed Ba-Ssalamah, radiologist in noiselessly flipping through his charts. Softly charge of the AKH magnetic resonance imaging walking nurses disappear through doors three (MRI) unit. times their size while occasional phone rings hardly disturb the almost respectful silence of Close contact between both disciplines is the place. even more important when there could be a discrepancy between images and clinical But then again, appearances can be deceptive. information. For instance, in a case of acute abdominal pain, emergency physicians could “Nothing is predictable here; everything comes assume either cholycystitis or gastritis, whereas as a surprise,” said Prof. Anton Laggner, director the images could show pneumonia of the lower of the emergency department, which is located lobe of the lung. These potential errors mean that on ward 6D of the AKH. “What you see in the radiologist should be more involved in the shows like ‘Emergency Room’ or ‘Scrubs’ is quite diagnosis of emergency patients, Ba-Ssalamah representative of our work. Huge burdens can believes. “There should be more quality control come all at once. I wouldn’t say things become from radiologists. We work with images first, so “Interdisciplinary work is very important, especially in “Nothing is predictable here”: Prof. Anton Laggner, chaotic then, but when you’re not used to it, it we are not biased by the clinical information,” he the case of emergency medicine,” says Dr. Ahmed Director of the Emergency Department at the AKH, certainly looks like it!” said. This is even more important for US, since Ba-Ssalamah, radiologist in charge of the AKH caring for a patient in the intensive care unit. magnetic resonance imaging (MRI) unit at the AKH. images are, unlike computed (CT) In 2007 84,668 patients received treatment in the or MRI, not standardised and one can take the department; an average of 232 visits per day. On picture shot whenever one wants. weekends, up to 380 admissions can be registered daily, with a peak between 5pm and noon. In Between 20 and 30 emergency patients are sent May 2008 alone, a record 8,042 patients, almost to the radiology department daily for further 260 per day, were admitted to the department. examination, about 15 for a CT scan and 2 for an Enough to keep the 30 doctors and 60 nurses of MRI scan, Laggner estimates. CT is particularly the team busy, running in all directions. useful in detecting pulmonary embolism, , undetermined abdomen processes Accident or sports injury victims receive and sub-arachnoidal bleeding (SAB). MRI is treatment in a dedicated department on ward mainly used to monitor neurological processes. 6C, and the emergency department provides It is more appropriate than CT for visualising ESOR all other care from maxillary, orthopaedics, stones in the biliary system, gallbladder and European School of Radiology light surgery, urology, ear, nose and throat, liver, and it is also quite efficient in imaging the dermatology, gynaecology, ophthalmology and pelvis region in cases of ovarian torsion. In this neurology. Most cases are organ-related, 70% phenomenon, common among young women, of which are cardiovascular, including heart the ovary rotates on itself, causing a halt of blood attacks, angina pectoris and . Other supply. Patients present with acute pain in the ESMRMB School of MRI 2009 frequent cases involve poisoning, inflammation lower abdomen and it is crucial to diagnose the (gallstones, pancreatitis and abscesses), and problem as early as possible to operate. Finally, • Advanced MR Imaging of the Abdomen • Advanced MR Imaging of the Dubai/UAE, March 26–28 Musculoskeletal System acute neurological conditions ranging from loss MRI is often favoured in children and young • Applied MR Techniques, Basic Course Paris/FR, September 24–26 of consciousness to coma, epileptic episodes and patients because of its low radiation exposure. Iraklion/GR, April 23–25 • Advanced MR Imaging of the Abdomen headaches. • Advanced Cardiac MR Imaging Coimbra/PT, October 8–10 The accidents department is equipped with its Leuven/BE, May 14–16 • Clinical fMRI – Theory and Practice Most of these problems can be diagnosed and own traumatology centre with x-ray, US, CT and • Advanced Neuro Imaging: Thessaloniki/GR, October 15–17 cared for thanks to radiology. The emergency angiography scans, all of which are taken charge Diffusion, Perfusion, Spectroscopy • Advanced Clinical MR Angiography department is equipped with mobile chest x-ray by a radiologist on duty. If communication is Budapest/HU, June 25–27 Dublin/IE, October 22–24 machines and ultrasound (US) devices, which flawless with Prof. Laggner’s department, it may • Advanced MR Imaging in Paediatric • Advanced MRI of the Chest – NEW! can be carried directly from one patient’s bed be more difficult to get hold of Prof. Vilmos Radiology Heidelberg/DE, October 29–31 to another. US enables the detection of kidney Vecsei, who leads ward 6C. “Prof. Vecsei is an Genoa/IT, July 2–4 • Advanced Head & Neck MR Imaging and gall stones as well as fluids in the abdomen, emergency surgeon, so he spends most of his • Applied MR Techniques, Alicante/ES, November 5–7 acute appendicitis and ovarian cysts in the lower time in the operating room. We see him less. This Advanced Course • Advanced MR Imaging of the Gdansk/PL, July 9–11 abdomen. Emergency echocardiography is also is normal,” Ba-Ssalamah explains. “Still, for us, it Musculoskeletal System – • Advanced Breast & Pelvis MR Imaging Spanish Language widely used to observe pericardial and pleural would be better if both emergency and accidents Lausanne/CH, September 24–26 Santiago de Compostela/ES, November 12–14 effusion, as well as heart and valvular functions. would merge; it would improve communication a lot.” This will eventually happen, as the split Participants of advanced courses should be physicians who have either attended ESMRMB Usually the emergency performs these model only exists in the German speaking School of MRI Applied MR Techniques Courses or who have acquired knowledge in MRI examinations alone but depending on their world, and trauma surgeons are unable to find techniques from other sources. In addition they should have a minimum of 6 months experience and/or the complexity of the clinical work anywhere else in the European Union or in applied MRI in the relevant field. Further details on the courses and registration are available at www.esmrmb.org or www.myESR.org/esor. case, they might need radiological expertise. In the world. the AKH, help isn’t far from reach. A two-minute walk separates ward 6D and ward 6F, where one Communication, if excellent, can always be aisle of the radiology department led by Prof. improved, and an initiative such as ‘ESR meets Christian J. Herold deals with general, paediatric, Emergency Physicians’ will certainly help to do neurological and emergency radiology. so, both physicians believe. “Interdisciplinary work is very important, especially in the case of “We have a very close cooperation with emergency medicine. It will always benefit the radiology, partly thanks to this geographical patient,” Ba-Ssalamah concludes. proximity. Each time we have a question, we can The School of MRI is an initiative of ESMRMB in partnership with ESOR. just walk there. Of course, we could find some

myESR.org 26 ECR TODAY 2009 COMMUNITY NEWS Sunday, March 8, 2009

ESR meets Croatia

In Croatia, radiology is becoming more and more popular and advanced but faces numerous challenges,

including a lack of teachers in new modalities, insurance companies seeking a quick profit,´ and turf

^

´ battles. The new President of the Croatian Society of Radiology (CSR),´ Prof. Boris Brkljacic, explains, in ^ collaboration with his predecessor Prof. Ratimira Klaric-Custovic, how the CSR is dealing with those issues.

By Mélisande Rouger The Ministry of Health is responsible for the (the book was also widely distributed to neigh- approval of residencies to the different hospitals, bouring countries, especially Serbia and Bosnia- ECR Today: How is Croatian radiology doing and the Croatian Society of Radiology requested Herzegovina). BIRADS classifications are used and how does it position itself in Europe? an increase in the number of residencies. For- in screening and double reading is mandatory. Boris Brkljačić: Croatian radiology is doing rela- tunately we were successful, and the number of We published the booklet about breast cancer tively well. Over the last few years the number and radiologists has been increasing slightly over with all the necessary information that is distrib- quality of radiological equipment has increased the last few years, but we still lack radiologists, uted to women, along with the invitations that considerably, and new equipment was installed and good radiologists can easily find positions in are sent to women by local public health depart- in hospitals and other medical institutions in all major hospitals. The lack of radiologists is par- ments. One copy of the findings is sent to public Croatian regions. In 2007, new 1.5T MRI units ticularly noticeable in small provincial hospitals health departments who have complete control were installed in seven large university hospi- that many doctors find unattractive in career and statistical evaluation of data. Women also tals, and one 3T MRI scanner was installed at terms. In spite of the fact that radiology is an complete a questionnaire with their personal his- the Medical Faculty of the University of Zagreb. attractive specialty for young doctors, we will tory, which is analysed by public health depart- There are many multi-detector row CT scanners, have great difficulties in the near future, because ments. Around 140 Croatian radiologists are even in small and remote hospitals, and the qual- the number of medical students is too low for included in the screening programme. Due to ity of ultrasound scanners is quite high. Private- Croatian needs. the geographic form of Croatia, it was not pos- public partnership initiatives were legalised last The average age of board-certified medical doc- sible at this point to organise just a few screening year, and the first PET-CT system was installed in tors in all specialties in Croatia is now 55 years, centres, but we allowed utilisation of all mam- November 2007. and we will need to import doctors very soon. mography equipment in good shape (some 100 The recent ESR survey has demonstrated that Most probably we will import doctors from units less than 10 years old), and we have a spe- regarding the number of CT and MRI units per Bosnia, Serbia, Macedonia, and perhaps other cial subgroup in the Advisory Board that is in charge of quality control, consisting of medical number of inhabitants, as well as regarding the eastern European countries first, since salaries Prof. Dr. Boris Brkljacic, 45, works at the Department number of radiologists per number of inhab- in Croatia are considerably higher than in these physicists, , and two radiologists. of Diagnostic and Interventional Radiology at the itants, Croatia has better indicators than most countries (although the cost of living is also University Hospital ‘Dubrava’ in Zagreb. He specialises other transitional countries, and even better much higher). ECRT: In your presentation you mentioned in genitourinary and vascular imaging. than some established EU countries. that this programme already shows promising Radiology has become a quite attractive spe- ECRT: In October 2006, CSR introduced initial results. Could you be more specific? centres in Zagreb, Split, Rijeka, Osijek and cialty for young Croatian doctors. For exam- the national mammography screening pro- BB: 580,000 women were invited in the first two Slavonski Brod. Many young radiologists are ple, we currently have two radiology residency gramme. Can you tell us more about it? years of the programme. The participation rate attracted to this very dynamic subspecialty and positions in my hospital, and we received 36 BB: This is supposed to be a permanent pro- on the national level is 56%. However, there is more and more vascular and non-vascular inter- applications, while surgery received only 16 gramme that targets women in the age group very large variability in the participation rate ventions are being performed. applications for four positions. This would have of 50–69 years, who are invited for mammogra- between different counties, ranging from 42% been inconceivable ten or fifteen years ago. phy screening biannually, free of charge. Costs to 83%. The recall rate is 9.2% (BIRADS 0), ECRT: What are the main challenges faced by are covered by the state budget through the and we had 0.9% of BIRADS IV and 0.16% radiology in Croatia nowadays and what are ECRT: How many radiologists are currently national health insurance fund. The programme of BIRADS V findings. We cannot give exact the strategies developed by your society to working in Croatia? What is the proportion of is national and covers all Croatian regions, and numbers of confirmed cancers because the data cope with them? men, women and young people? What is the all women are targeted, regardless of their health is not being processed by the unified software BB: One of the problems is the education of radi- ratio of radiologists to inhabitants? insurance status. in all counties, which is still the major problem. ologists for some new imaging modalities, where BB: Currently we have 330 board-specialised The idea was first raised by the Ministry of Health There are more than 1,000 confirmed cancers, we lack experienced teachers. This is a particu- radiologists, including approximately 15 radi- back in 2002, to promote national programmes but this data is a few months old. Regarding the larly prominent problem in cardiac imaging, ologists who retired from academic hospitals, of early detection of breast cancer, colorectal can- participation rate we consider it relatively sat- where radiological training is insufficient, and but who still work in some private practices. cer and cervical cancer, and these programmes isfactory for the beginning; in five counties we there is currently not a structured programme Also, we have 64 residents in different phases were slowly developed by expert groups, where have seen a participation rate over 70%, which for subspecialty training. Luckily, through ESOR of training. The proportion of male/female radiologists were included from the beginning is excellent. programmes, one young radiologist was trained radiologists is 60% men and 40% women. in breast cancer screening. The Croatian Society in cardiac imaging, and this situation will hope- However, among residents and younger radi- of Radiology then formed a Radiology Advisory ECRT: What are the demographics of breast fully slowly improve. The problem is also in the ologists 60% are women, reflecting the ever Board consisting of nine prominent radiolo- cancer in Croatia? How does it compare to the training for PET-CT applications. higher proportion of women among medi- gists in the field, who worked together with the rest of Europe? Another major problem is turf battles. More and cal students in Croatia, since we now have Department of Public Health for more than one BB: In 2007 some 2,250 women were diagnosed more cardiologists and vascular surgeons want women comprising approximately two-thirds year prior to the commencement of the national with breast cancer, and 860 women died from to participate in and take over endovascular pro- of medical students in four Croatian medical screening programme. Prior to national mam- breast cancer. Currently one in 10.5–11 women cedures, like EVAR, peripheral arterial interven- faculties. The population of Croatia is 4.4 mil- mography screening, a very good programme in Croatia gets breast cancer. This is less than tions, etc. The Section of Interventional Radiol- lion, which means we have one board-certi- was performed on a small scale for a few years in the most developed countries where 1 in 8 ogy is fighting these tendencies vigorously, but fied radiologist per 13,300 inhabitants. in Rijeka county, and their experience was used women gets breast cancer, and we may expect the position of radiology is quite weak, since initially. With the help of Hedvig Hricak we got that the number of women getting breast cancer we are a smaller society than the cardiologists ECRT: How do you see the demography of permission from the American College of Radi- will increase with the ageing of the population. and do not have beds for patients. Turf battles your profession evolving in the near future? ology (ACR) to translate the BIRADS lexicon The problem is that mortality is still relatively will present a major challenge to radiology in BB: Over the last 7–8 years the number of radi- into the Croatian language, and in 2006 the book high compared to very developed countries, and general, and the situation in Croatia is more or ology residents has increased considerably. was given to all Croatian radiologists as a present we presume that the introduction of screening, less similar to that in other countries. PET-CT together with better oncology care will reduce is currently performed by both radiologists and the mortality considerably. , but we presume that turf bat- tles with nuclear medicine will not be the major ESR meets Croatia ECRT: Why did you choose to present sessions issue, unlike with cardiologists and vascular sur- on endovascular intracranial procedures and geons. Despite our efforts the prospects do not Sunday, March 8, 10:30–12:00, Room A endovascular aortic repair (EVAR)? seem too good for interventional radiology, and EM 3 Breast imaging and interventional radiology in Croatia today BB: In the ‘ESR meets’ sessions at the ECR, the our society is ready to implement all the strate- best radiology practices are usually presented. gies recommended by the ESR to cope with these Presiding: We are very proud to have two excellent inter- challenges. B. Brkljacic; Zagreb/HR ventional radiology centres. One is in Split, One very important problem is that a few insur- B. Marincek; Zurich/CH where they have been performing EVAR proce- ance companies have formed their own imaging I.W. McCall; Oswestry/UK dures for a long time, and have much experience centres, with very good equipment, and even • Introduction and many patients. The most prominent young plan to create small private hospitals. They attract B. Brkljacic; Zagreb/HR interventional radiologist from Split, Liana radiologists to these centres, offering them much Cambj-Sapunar, will present their results. The higher salaries than in academic institutions. It • National mammographic screening programme M. Marotti; Zagreb/HR best centre for neurointerventions is in Zagreb could potentially have a very negative impact on University Hospital Centre, and the pioneer of the development of radiology, since academic • Image-guided breast biopsies endovascular intracranial procedures in Croatia, institutions are the major sites where state-of- D. Miletic; Rijeka/HR Marko Radoš, will present their excellent results. the-art radiology is practiced, while private • Endovascular intracranial procedures institutions have profit as their major goal, and M. Radoš; Zagreb/HR ECRT: Is interventional radiology a popular tend to perform primarily lucrative examina- • Endovascular aortic repair subspecialty in your country? How does it tions, often exposing the population to unneces- L. Cambj-Sapunar; Split/HR compare to other subspecialties? sary procedures. This is mostly a political issue, BB: Interventional radiology is becoming more and we are fighting this through all possible legal • Panel discussion and more popular, and we have a few very good ways, but the outcome does not look too good. myESR.org Sunday, March 8, 2009 COMMUNITY NEWS ECR TODAY 2009 27

Other concerning issues are the tendencies of important for young Croatian radiologists, and some radiographers who want to introduce some we esteem these programmes highly and endorse aspects of U.K. practice to our system, which tra- them. We have also been fortunate enough to be EURORAD meets SERAM ditionally functions differently. The CSR does not able to send many young people to the USA for see any need that radiographers would or could education. Exchange of knowledge is extremely perform any imaging on their own, including important and education of young radiologists in ultrasound. the best institutions in Europe and worldwide is By Stefanie Muzik young radiologists enjoy the quiz cases or find very precious both for them and for the whole of useful information and knowledge provided by ECRT: Skilled staff are a prerequisite for the Croatian radiology. EURORAD, ESR’s electronic database for radio- short and well-explained cases. And this is what implementation and maintenance of high- logic teaching files, was established in 1999 and EURORAD is.” quality radiological services – what do you do ECRT: What are the potential benefits of is now one of the major educational tools of the to promote postgraduate education and train- the CSR taking part in the ‘ESR meets’ pro- society. Its main purpose is to provide training Modern education and the presence of English ing in modern imaging methods? gramme? and improve knowledge of clinical case reports, language in our daily life have almost repressed BB: The CSR in cooperation with Croatian BB: Croatia is a very small country, and our which are presented shortly and include top communication difficulties. Still, scientific Medical Faculties, and particularly with the influence on European radiology is very small. quality images. Since its beginning, EURORAD language is different and even if medical Medical Faculty of the University of Zagreb, However we have several very good radiologists, has grown continuously and now contains over ‘termini technici’ are unambiguous, training in introduced structured compulsory professional the quality of radiology has increased consider- 2,900 published cases, still with an increasing radiology – and all other specialties – is usually education for residents, who get 400 hours of ably in the last few years and we are very hon- trend. conducted in the mother tongue. Therefore, structured education in all fields of radiology, oured that the ESR has chosen Croatia for this not only the professional but also the linguistic and have to pass oral examinations in several year’s ‘ESR meets’ programme. This will be the To enable non-native English speakers to be able education for residents is essential and a core aim areas to become eligible to stand for the board opportunity for Croatia to present its radiology to get the best scientific content in their mother of EURORAD. Scientific English is most of the exam. The board exam is still practical and oral, to the European scene. It may also be the incen- tongue, ESR wanted to enlarge EURORAD’s time no problem for readers, “Maybe scientific held by the commission of three examiners, but tive for our radiologists, especially young ones, to scope by offering translations of the cases in English could be a problem for a number of the CSR is working hard to introduce the writ- submit many more papers for ECR and for pub- widely spoken languages. SERAM, the Spanish radiologists from Spain twenty to thirty years ten exam, as well. The CSR strongly supports lication in international magazines, because our society of medical radiology, was not only the ago, but it is now hard to find young professionals the educational activities of ESR. Two young scientific output is very low and does not reflect first institutional member of the ‘new’ ESR, but in my country who could not correctly interpret a residents underwent ESR training in cardiac the relatively good general quality of radiology in showed enthusiasm and acted as a pioneer in this paper published in English,” explains Prof. Garcia imaging and breast imaging in 2007, and many Croatia. residents attended Galen courses. One Galen course was held in Dubrovnik, in October 2007. ECRT: Do you expect a significant turnout The CSR has introduced an exchange programme from Croatian radiologists at ECR 2009 as a together with the Memorial Sloan Kettering Can- result of the CSR’s participation in ‘ESR meets’? cer Center and seven young radiologists attended BB: The turnout of Croatian radiologists at the a six-month comprehensive training programme ECR is always quite good, because Vienna is very in breast imaging in New York, thanks to the gen- close (the distance from Zagreb to Vienna is only erous support of Hedvig Hricak and the Evelyn 370km). We do expect that this year the turnout Lauder Foundation. will be somewhat larger than usual. The CSR strongly endorses CME activities for radiologists. We have biannual Hungarian-Slov- ECRT: What future trends and challenges do enian-Croatian radiology meetings, many Alpe- you foresee in radiology? Adria meetings, annual Adriatic Vascular US BB: It seems that technological advances are Society meetings, biannual interventional radi- becoming faster and faster. Molecular imaging ology section meetings, and national radiology will probably play an important role in the future, Dr. Anna Alguersuari Cabiscol from Sabadell/ES The enthusiasm of Prof. José María Garcia Santos congresses every four years. and radiology research is very wide. Many new, coordinates the translations for the new ESR/SERAM from Murcia/ES, Editor-in-Chief of Radiología, was fashionable things (equipment, new contrast initiative. crucial in the development of this initiative. ECRT: How is Croatian radiology meeting the media, etc) are not within the reach of Croatian growing need for a multidisciplinary approach radiologists, as well as cutting-edge research. As project. With the help of Prof. José María Garcia Santos. Nevertheless, “it sometimes represents a in radiology? a small and economically less-developed coun- Santos, Prof. Salvador Pedraza Gutiérrez, the considerable effort for a foreign reader; difficulties BB: The multidisciplinary approach is necessary try we can only follow major countries with a publications chairman of SERAM, and Dr. Anna are a lot greater when it comes to writing or and this process seems to be regulated mostly few years delay in the purchase of equipment Alguersuari Cabiscol, an agreement was easily speaking in English,” Dr. Alguersuari adds. Also spontaneously in various hospitals on a local and endorsement of new methods. Sometimes found in May 2008, and work started shortly the international exchange in meetings and basis. In many hospitals there are good and close it could be an advantage, as some methods that after. No less than 1,000 cases will have been educational programmes are of major importance cooperations with surgeons in many procedures seem to be promising in the beginning do not translated into Spanish by mid-2010. In return, for young doctors, therefore SERAM as well as (vascular and endovascular, radiofrequency abla- prove their worth after the proper research and a team of 40 translators and 10 proofreaders will ESR connects with other societies worldwide. tions, etc.), with nuclear medicine, gastroenter- clinical evaluation. be granted participation in ECR 2009 and 2010. “SERAM participates in the organisation of ologists (biliary interventions, etc.), but major several international courses and congresses, one problems exist with cardiologists. The CSR is ECRT: What was your main motivation for But who are the people involved? Dr. Anna of them virtual, ‘Radiología Virtual’, and annually ready to follow all the guidelines set by the ESR. choosing your profession? Alguersuari Cabiscol, who coordinates the awards scholarships to residents to attend the BB: After graduating I was most interested in translations, is currently a resident in radiology ECR and the RSNA,” stresses Dr. Alguersuari. ECRT: How would you judge the importance of internal medicine. Just by chance during the at Universitari del Parc Taulí in Sabadell/ES, Furthermore, “SERAM has signed agreements the exchange of knowledge between Croatian internship I happened to be in intense contact as well as being the resident representative on with South American radiological societies radiologists and the rest of the world? Is with ultrasound, and prior to residency started to the Educational Board of SERAM. Coming and has an educational vocation focused on Croatia’s place at the centre of Europe an work in the nuclear medicine department for one from a doctor’s family, she decided to become a the Spanish speaking radiological community,” advantage? year. I started to like imaging; many new things radiologist after her mother imbued her with a explains Prof. Garcia Santos. BB: Croatia has a very good geographic position. were happening, and MRI had just been intro- fascination for this specialty. Being a radiologist The proximity to Vienna enables approximately duced in Croatia. So when I got the chance to go in training herself, she understands perfectly the The team of translators is a well composed group 100 radiologists to attend every ECR. Participa- into radiology residency, I accepted, and now I importance of having good teaching material. of residents from various institutions around tion in ESOR’s educational programmes is very am very happy to be a radiologist. “Solving interesting cases with common pathology Spain. “Most of the translators and proofreaders for radiologists or doctors in training is always are residents in their third or fourth year of a good way to practice and to correlate practical training, or young radiologists that have recently skills with theoretical knowledge”, she says. finished their residency,” explains coordinator Dr. Alguersuari. Every month, a batch of Professor José María Garcia Santos is the cases is sent from the EURORAD office to Dr. head of the Neuroradiology section and Alguersuari, which allocates the cases to the training programme director for graduate translators and proofreaders afterwards and, medical education at the Diagnostic Radiology once finished and approved, sends them back Department of the ‘Hospital General to the office. As mentioned before, all people Universitario Morales Meseguer’ in Murcia/ES, involved are given the chance to participate in and the Editor-in-Chief of Radiología, the official ECR, including registration, accommodation Visit the journal of the Spanish Society of Radiology and travel. Financial reward is not their (SERAM). Prof. Garcia Santos’ way into radiology motivation, but practice in language skills, was rather fortunate: after his degree in 1987, he participation in a beneficial scientific meeting wanted to go into clinical diagnostics, but was and being part of an international exchange. Dr. Arts & Culture Booth ‘led astray’ as he reports. “You are persuaded by Alguersuari also underlines that “actually, a few those that teach you with enthusiasm or those of them that will not be able to come to Vienna in the entrance hall who speak to you about their profession with are also willing to carry on with the translations passion. A four-hour conversation on radiology next year.” The commitment of the translators is was enough to change my mind. The pivotal really outstanding, so much so that the end of the role of radiology in medicine, the technological project could be reached ahead of schedule. implications, and the feeling that radiology had a high component of intellectual work, provided The first Spanish translations will be published me with sufficient reasons to take one of the under www.eurorad.org after ECR 2009. best decisions in my life.” His participation in EURORAD comes from the belief in its benefits Links: for people in training. “A wide variety of well SERAM: www.seram.es presented clinical cases, quickly available online, Radiología: www.seram.es/revista Arik Brauer, Mein Vater im Winter, 1983 © Arik Brauer im Winter, Mein Vater Arik Brauer, is always a good education opportunity. Many EURORAD: www.eurorad.org

myESR.org 28 ECR TODAY 2009 COMMUNITY NEWS Sunday, March 8, 2009

News from the German Radiological Society

German Radiological Society: Careers in “The survey gives us a positive notion of our radiology become increasingly popular profession’s future in terms of personnel,” confirms Michael Laniado, MD, University of Recent Surveys of the German Radiological Dresden, President of the German Radiological Society show that taking a career as a consultant Society. “We are especially pleased by the high radiologist is becoming increasingly popular. quota of future women consultants, which has Especially for women who get to keep the option been increasing during the last couple of years. In of combining professional and family life, the some age-groups of advanced medical education concept of a radiologist’s profession is growing it represents almost 50 percent.” more attractive. A shortage of consultants, caused by recruitment problems and disadvantageous The German Radiological Society online: age distribution, as observed in other fields of www.drg.de specialisation, seems to be a problem that doesn’t concern radiology. 90th German Congress of Radiology in About 750 radiologists who are licensed to Cooperation with the German Oncological train young physicians as residents took part Society – Deutsche Krebsgesellschaft e.V. in the survey. Its results showed that there are approximately 7,000 practicing radiologists in The 90th German Congress of Radiology has found Germany. Within the following ten years almost its own special way to account for the outstanding 1,400 radiologists will retire from service for age role that medical imaging plays in diagnosis and reasons. On the other hand there are about 1,600 therapy of oncological diseases. For the first time, up-and-coming radiological residents who are the well-established congress, taking place in expected to pass the examination to become a Berlin from May 20–23, is going to proceed in Cancer diagnosis is the main issue of this year’s congress of the German Radiological Society. consultant radiologist within the next six years. cooperation with the Deutsche Krebsgesellschaft, i.e. the German Oncological Society. What makes a young physician choose a In accordance with the growing influence of from all over Germany and abroad. In addition radiology residence programme? Considering For Congress President Claus D. Claussen, imaging in oncology, radiologists and oncologists to scientific presentations and posters on the the results of a survey on young assistant MD, University of Tübingen, the cooperation will deal with a variety of oncological diseases in latest state of the art, participants will get the physicians, many young doctors underline with the largest oncological society underlines a total of 14 interdisciplinary sessions. In doing chance to increase their knowledge in certain the great diversity of their profession/field the close collaboration in research and so, they will not only discuss the diagnostic areas and discover new pieces of information and the key role it plays in clinical procedures. practice. “Cancer Diagnosis is one of the most potential of radiology but will also focus on through workshops, refresher courses and Additionally the compatibility of family and important fields in medical imaging. Nowadays minimally invasive treatments and radiotherapy. interdisciplinary case discussions. Furthermore, profession – due to well-organised working radiologists undertake tasks that surpass the a substantial industrial exhibition will present conditions in radiological units – represents an simple first recording of oncological diseases The 90th German Congress of Radiology will take the latest progress in medical technology. The incentive for junior consultants. The majority of by far. Accompanying the patient through the place in Berlin (Messe Süd) from May 20–23. congress language will be German. interviewees could imagine themselves working whole therapy sets up the frame for oncological The German Radiological Society (Deutsche in a medical practice after finishing their imaging. Particularly in success control radiology Röntgengesellschaft e.V.), as the organiser of More information about the congress: residency. grows more and more important.” the congress, expects about 7,000 participants www.roentgenkongress.de

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Distinguished expert in gastrointestinal radiology presents today’s Honorary Lecture In recognition of his crucial contribution to the development of gastrointestinal imaging, Professor Carlo Bartolozzi from Pisa, Italy, will present the Josef Lissner Honorary Lecture ‘Ode to the liver’ at ECR 2009.

By Mélisande Rouger of the Erasmus Course on Magnetic Resonance Josef Lissner Imaging, and was President of the European Carlo Bartolozzi was born in 1947 in Jesolo, Society for Magnetic Resonance in Medicine and Honorary Lecture Italy. He obtained his medical degree from Biology (ESMRMB) in 2000–2001. Sunday, March 8, 12:15–12:45, Room A Padova University in 1972. After completing ‘Ode to the liver’ his residency in 1977, he became Radiology His involvement in international radiology has Carlo Bartolozzi, Pisa/IT Assistant at the University of Florence and was gained him Honorary Membership of the Belgian promoted to Associate Professor in Radiology Radiological Society and Austrian Radiological in 1980. A decade later, he obtained full Society, and Corresponding Membership of professorship from the University of Pisa, and the Swiss Radiological Society and Turkish was appointed Director of the Chair of Radiology Radiological Society. and Chairman of the Radiology Residency Programme, positions he has held since. Prof. Bartolozzi is the ‘Hepatobiliary-Pancreas’ Section Editor of the journal European Radiology. Prof. Bartolozzi’s main interests are oncology From 2000 to 2004, he was the ‘Liver, biliary “I have been involved in every previous ECR held in Vienna, and I have and gastrointestinal radiology, fields in system, pancreas and spleen’ section editor of which he has experimented and developed EURORAD, a broad online teaching database of witnessed during the years its spectacular improvement in terms of scientific innovative techniques such as microbubbles in peer-reviewed case studies. A prolific writer, he content and a tremendous growth in international participation. I believe that ultrasound, perfusion imaging in MSCT and MR has also published 12 monographs and authored ECR has a key educational role and my co-workers regularly choose this congress for liver imaging. He was Director or co-authored over 250 papers. of the Department of Oncology, Transplants, to present their research and to update their knowledge. This year, it is a great and Advanced Technologies in Medicine of the He is married to Stefania, an Internal Medicine honour and privilege for me to deliver a lecture named after Joseph Lissner, one University of Pisa from 1999 to 2007. Professor, and has three children; Riccardo, a of the founding fathers of European radiology, to whom we all owe gratitude for mechanical engineer, and Sveva and Costanza, his pioneering vision of a ‘common house’ for all radiologists in Europe. Today, An eminent researcher, Prof. Bartolozzi was both university students in foreign languages. appointed President of the European Society His personal hobbies include the study of history in my opinion, Vienna represents our ‘home sweet home’ that allows us to meet of Gastrointestinal and Abdominal Radiology and art and the use of radiological investigations in the scientific environment of the congress as well as more informally outside, (ESGAR) in 2005–2007, and presided over the in these fields, which he describes as a bridge creating new acquaintances and reinforcing many deep friendships, which Annual ESGAR Meeting in Florence in 2005. between his radiology passion and humanistic represents the very texture that unites all of us throughout Europe.” He is also a Member of the Steering Committee interests.

Alliance for MRI faces a busy period ahead

By Monika Hierath Commissioner Spidla. An Alliance delegation will be produced by September and then a final • On 11 and 12 February 2009 DG Sanco and led by Prof. Gabriel Krestin, Mary Baker from report by the end of December 2009. DG Enterprise co-hosted a workshop on elec- During the second half of 2008 there were no si- The European Federation of Neurological As- tromagnetic fields. The important meeting was gnificant developments in respect of the revision sociations (EFNA) and Dr. Stephen Keevil met Unusually, due to time constraints, the first con- attended by representatives of the Alliance, en- of EU Physical Agents Directive 2004/40/EC on with the Commissioner and his services in or- sultation with social partners will be undertaken suring the presence of the MR community. electromagnetic fields. The work of the European der to discuss the revision of the Directive. The at the same time as the impact assessment. We are Commission and the social partners to prepare Alliance raised concerns regarding timing issu- given to understand that as a result the Advisory • The Swedish Presidency is planning to organise an amendment is getting underway only now in es and notably the likely publication in 2010 of Committee on Safety and Health (ACSH), which a conference in October 2009 on the future of 2009 and we look forward to working with the ICNIRP’s guidelines on extremely low frequen- comprises representatives from the employers, the EU Physical Agents Directive 2004/40/EC. Alliance members to ensure that the future of cy (ELF), which, it is supposed, will inform the unions and member states, and its EMF Working We understand that there will be a panel ses- MRI is fully safeguarded in the forthcoming pro- content of the revised Directive. The meeting Group will therefore be in regular contact with sion on medical applications and the Alliance posal by the European Commission. was very constructive and one outcome was the the contractors of the impact assessment report. will ensure that its position is represented. The Alliance for MRI is a coalition of European decision to re-establish the MR expert working Parliamentarians, patient groups, leading Euro- group to consider the need for limits in respect The report will look into different legislative op- pean scientists and the medical community, who of MRI. The Commissioner emphasised that he tions for the European Commission to propose. together are seeking to avert the serious threat is currently still investigating the various options One option is the proposal of new binding legis- posed by EU health and safety legislation to the for review and in principle welcomed the esta- lation based on the latest international recom- clinical and research use of Magnetic Resonance blishment of social dialogue on the healthcare mendations with conditional exemptions for Imaging (MRI). The Alliance was launched on part of the directive. specific cases. The Alliance supports this option the occasion of ECR 2007. as it is in line with its position requesting a dero- Next Steps in 2009 gation for MRI from the scope of the Directive. Activities of the Alliance for MRI Commissioner Spidla made clear to the Alliance July–December 2008 that he hopes to prepare a solid text for a revised The Alliance for MRI will seek a meeting with Directive before the end of his tenure (end 2009). the contractors appointed to undertake this im- Meetings with some key stakeholders In line with social policy legislation under Artic- pact assessment to ensure that the concerns re- The Alliance has sought to develop informal le 135 of the Treaty, two rounds of consultation garding the impact on MRI are well understood. dialogues with key stakeholders in view of the will be undertaken with social partners (i.e. em- 2009 will be a crucial year in the revision process of preparation of an amendment to the Directive to ployers and unions) before a proposal is formally Key Events the Directive. We look forward to cooperation with protect the future of MRI. adopted. The new Commission will then be in a • In early February the Scientific Committee on all our members and very much welcome support position to adopt a proposal for an amendment Emerging and Newly Identified Health Risks for the Alliance’s campaign. It will be important to MEPs and Unions early in 2010. (SCENIHR), established by DG Health and find the appropriate platforms to inform interested Meetings have been held with some key parliamen- Consumer Affairs (SANCO), published its re- parties about the future of the Directive and what tarians, including Dr. Peter Liese (EPP/DE) who It is envisaged that the text of the amendment, port on electromagnetic fields. Worryingly, is at stake for patients and research in Europe. has been supportive and sought clarification of the if uncontentious, will then be adopted (under the report, which is largely based on the 2007 scientific detail. We have also met with representa- co-decision) by April 2011, allowing one year for report, asserts that in medical applications We very much look forward to hearing from you tives from the Green Party who have raised a num- implementation by the Member States prior to of extremely low frequency fields (ELF), per- if you have any ideas as to how you can assist us ber of concerns on the issue. In addition, informal April 2012. sonnel exposure has to comply with the direc- in your member state or at EU level. meetings have been held with the European Fede- tive 2004/40/EC for occupational exposure. ration of Public Sector Unions (EPSU) to discuss Socio-economic impact The Alliance has published a response to this pa- Alliance for MRI Secretariat the application of the Directive to MRI workers. assessment of the Directive per on its website, articulating the difference bet- [email protected] In line with better regulation requirements, the ween MRI and mobile phones and power lines. Commissioner Spidla and European Commission commissioned a socio- Further information on the Alliance for MRI is the Commission services economic impact assessment of the Directive, • In early 2009, ICNIRP is expected to publish its available at www.alliance-for-mri.org A meeting took place on 10th December with which started in January; a preliminary report revised Static Field Guidelines.

myESR.org 30 ECR TODAY 2009 ARTS & CULTURE Sunday, March 8, 2009

What’s on today in Vienna?

Theatre Please note that all performances are in German! Akademietheater 21:00 Fantasma 1030 Vienna, Lisztstrasse 1 by René Pollesch phone: +43 1 51444 4145 www.burgtheater.at

Burgtheater 19:00 Trilogie des Wiedersehens 1010 Vienna, Dr. Karl-Lueger-Ring 2 by Botho Strauß phone: +43 1 51444 4145 www.burgtheater.at

Schauspielhaus 20:00 Zwei arme Polnisch sprechende Rumänen 1090 Vienna, Porzellangasse 19 by Dorota Masłowska phone: + 43 1 317 01 01 www.schauspielhaus.at

Theater in der Josefstadt 15:00 Reigen 1080 Vienna, Josefstädter Straße 26 by Arthur Schnitzler phone: +43 1 42 700 300 www.josefstadt.org 19:30 Besuch bei dem Vater by Roland Schimmelpfennig

Volkstheater 19:30 Drei Schwestern 1070 Vienna, Neustiftgasse 1 by Anton Tschechow phone: 43 1 52111 400 www.volkstheater.at Fantasma by René Pollesch © Reinhard Werner / Burgtheater Fantasma by René Pollesch © Reinhard Werner

Concerts & Sounds

Musikverein (Classical Music) 19:30 Vienna Symphony Orchestra 1010 Vienna, Bösendorferstrasse 12 conductor Andrey Boreyko www.musikverein.at R. Buchbinder, piano C. Debussy, M. Ravel, A. Zemlinsky

Porgy & Bess (Jazz) 20:00 Christian Muthspiel Trio ‘Dancing Dowland’ 1010 Vienna, Riemergasse 11 www.p orgy.at

© Bubu Dujmic / Wiener Symphoniker

Opera & Musical Theatre

Volksoper 19:00 Die Zauberflöte 1090 Vienna, Währingerstraße 78 Opera by Wolfgang A. Mozart www.volksoper.at

Wiener Staatsoper – 19:30 Carmen Vienna State Opera by Georges Bizet 1010 Vienna, Opernring 2 conducted by Nicola Luisotti www.wiener-staatsoper.at with Vesselina Kasarova, José Cura, Ildebrando D’Arcangelo, Genia Kühmeier

Raimundtheater 19:30 Rudolf – The Mayerling Affair 1060 Vienna, Wallgasse 18-20 Musical by Frank Wildhorn & Jack Murphy www.musicalvienna.at Die Zauberflöte by W.A. Mozart © Dimo Dimov / Volksoper Wien W.A. Mozart © Dimo Dimov / Die Zauberflöte by

myESR.org Celebrate the 200th anniversary of Joseph Haydn’s death

This year marks the 200th anniversary of the death of Joseph Haydn. It may seem paradoxical to speak of celebrating the anniversary of somebody’s death, but in the case of Joseph Haydn, who was without a doubt one of the most positive and life- affirming composers of all time, there is no paradox about it.

Visit www.haydn2009.at and find out more! © Schloss Esterházy Management 32 ECR TODAY 2009 COMMUNITY NEWS Sunday, March 8, 2009

Facts and Figures: European Radiology in numbers

By Simon Lee all maintained a high level of activity, while South Africa, Egypt, and India – one of last European Radiology, the flagship publication of Germany year’s ‘ESR Meets’ countries – have all made Germany 265 17.0% the European Society of Radiology, has come Others Italy 129 8.3% noticeably larger contributions. Within a long way since its foundation by Prof. Josef Korea, Republic of 123 7.9% Europe, this year’s high-flyers include Italy, Lissner in 1991. Now in its 19th year, the journal Japan 120 7.7% the UK, and the Netherlands, but it is once Greece Italy United Kingdom 106 6.8% is published twice as frequently, its content is Belgium China 103 6.6% again Germany, with an outstanding 17% of all accessible from any point on the globe, and Austria United States 90 5.8% submitted papers, who top the charts for 2008. it maintains a proud position as the leading Spain Netherlands 87 5.6% Korea, Republic of France 77 4.9% Turkey European general radiological journal. The past Switzerland 67 4.3% All of these facts and figures give the editorial two years have seen some significant changes Turkey 58 3.7% team something to be proud of, and of for European Radiology, as Prof. Adrian K. Switzerland Spain 39 2.5% course fresh targets to aim at as they attempt Japan Austria 38 2.4% Dixon has built upon the solid foundations laid Belgium 23 1.5% to maintain the high level of quality that France by his predecessor, Prof. Albert L. Baert. With Greece 23 1.5% European Radiology is renowned for. This will Others 213 13.6% a gradually expanding editorial office now United Kingdom surely be facilitated by the growing readership Netherlands firmly established in the ESR Office in Vienna, contributing an even higher volume of United States China Total 1,561 100.0% and with further staff assisting Prof. Dixon in submissions. All ESR members (almost 45,000 Cambridge, incremental changes have been and rising!) can now gain electronic access made in the average time between submission to European Radiology as part of their basic and publication, largely helped by the Editor-in Manuscript submissions received in 2008: by country. membership fee and a full subscription to the Chief limiting the time that papers spend going paper copy can also be included in the ESR through the peer-review process. with a grand total of 1,561 original manuscripts feedback. Due to a tightening of deadlines membership package for a modest additional submitted, improving on the previous year’s for reviewers in early 2008 the average time sum. Aside from such editorial intricacies, the figure by an amazing 27%. Due to pressure between submission and an editorial decision journal has also been given a dramatic boost on space in the journal, just 378 of those for an original article tumbled from 49 to 38 All of these issues and others surrounding by the release of the ISI Impact Factor for 2007, contributions made it onto the printed page, days, and thanks to the increase in submissions, European Radiology will be covered in depth announced in June 2008. The Impact Factor is meaning an even finer quality filter has had to Prof. Dixon assessed and made decisions on an today during the annual Editorial Board the clearest indicator of a journal’s scientific be maintained by the Editor-in-Chief. Even impressive 1,806 manuscripts in 2008 (roughly Meeting, where Prof. Dixon and Dr. Ute significance, and a fantastic rise from 2.554 to so, a healthy 24.2% of submitted manuscripts five each day), which goes to show how much Heilmann, representing publisher Springer, 3.405 means the journal is now placed 12th out were finally accepted for publication in 2008. work is involved in narrowing the high volume will discuss the progress over the last year and of 87 titles in the overall imaging field, having of work down to the best and most innovative outline their thoughts on the journal’s future been placed 22nd for 2006, marking a stark One of the aims of the editorial team for 2008 contributions. direction. With steady headway already made increase in the number of citations attributed was to reduce the time spent in review, along under the ESR umbrella, a rapidly growing to European Radiology over recent years. with the average turnaround time between Of the original works submitted to European readership, and an increasing source of top submission and the editor’s final decision, so Radiology, the number coming from beyond quality content, it seems that for European The number of papers received by the editorial as to publish topical findings as fast as possible, Europe’s borders continues to increase. The Radiology, the only way is up! office also reached new heights during 2008, and of course to provide authors with rapid Republic of Korea, Japan, and China have

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