The 5 th Annual | Snowmass 2017:

Hot Topics
in Radiology
Thursday, February 16, 2017
Westin Snowmass Resort • Snowmass Village, Colorado

Educational
Symposia
 TABLE OF CONTENTS
Thursday, February 16, 2017

Advances in CT Neuroimaging (Lawrence N. Tanenbaum, M.D., FACR)........................................................................... 281

Dual Energy CT: How it Works, and Clinical Applications that Add Value -
With Workstation Case Review (Aaron Sodickson, M.D., Ph.D.).................................................................................... 307

MRI of Myocardial Ischemic Disease (Eric E. Williamson, M.D.)..................................................................................... 317

4D Flow: Technique and Clinical Applications - With Workstation Case Review (Thomas M. Grist, M.D., FACR)............. 327

CT Dosimetry, Radiation Risks and Dose Reduction Strategies (Aaron Sodickson, M.D., Ph.D.)....................................... 341

3D MSK MRI of Sport Injuries - With Workstation Case Review (Jan Fritz, M.D., P.D., D.A.B.R.).................................... 353

SAVE THE DATES - 2018 Winter Symposia

 281
Table of Contents
282
Table of Contents
 Innovations in Neuro CT:
Disclosures
leveraging technology
Lawrence N. Tanenbaum, M.D. FACR, is employed by an institution that provides
Siemens product reference services for compensation pursuant to a written agreement

Consulting:
Olea Medical Solutions Inc.

Scientific Advisory Board:

Bayer HealthCare Pharmaceuticals / Onyx Pharmaceuticals Partnership
Toshiba Medical Systems Corporation; Vital Images, Inc.

Lawrence N. Tanenbaum, M.D. FACR Industry-Sponsored Lectures:

Medical Director Eastern Region MSSM faculty occasionally give lectures at events sponsored by industry, but only if
Director Computed Tomography and MRI the events are free of any marketing purpose.
RadNet Bayer; GE HealthCare; Vital Images, Inc., Siemens Medical
nuromri@gmail.com
New York, NY

Radiation dose
Innovations in clinical CT

•  Radiation Dose
•  Dual energy
•  Workflow

Siemens, syngo Via, Bone Reading

Linear no-threshold theory of carcinogenesis

•  No safe dose of radiation
•  Dose effect data at high doses extrapolated
linearly downward to zero with no threshold

283
Table of Contents
 LNT theory of carcinogenesis Radiation carcinogenesis

•  Not possible to detect adverse health effects

•  Despite being the established paradigm and in below 100 mSv
widespread use, of questionable validity, utility –  International Commission on Radiological Protection
and applicability for estimation of cancer risk and the Health Physics Society
from low dose radiation exposures1-3

1)  Siegel Health Phys 2012; 102(1)

2)  Cutler Dose Response 2010;8(3)
3)  Calabrese Arch Toxicol 2013;87(12)

Special Report: Summit on Management of

American Association of Physicists in Medicine Radiation Dose in Computed Tomography
•  Risks of medical imaging at effective doses below 50
•  The risk of harm from effective doses of less than 100 mSv
mSv for single procedures or 100 mSv for multiple
is a highly controversial topic.
procedures over short time periods are too low to be
detectable and may be nonexistent. •  At the effective doses associated with CT (approximately 1–
12 mSv), the risks are extremely small or may in fact be
•  Predictions of hypothetical cancer incidence and
zero.
deaths in patient populations exposed to such low
–  annual effective dose to the U.S. population from naturally
doses are highly speculative and should be
occurring sources is, on average, 3 mSv (range 1–10 mSv)
discouraged.

McCollough CH et al. Achieving routine submillisievert CT

AAPM Position Statement on Radiation
scanning: report from the summit on management of radiation
Risks from Medical Imaging Procedures.
dose in CT. Radiology. 2012;

Radiation carcinogenesis Radiation carcinogenesis

•  Background radiation varies from a few mSv to •  No data have ever unequivocally demonstrated
260 mSv (Iran, China, India) the induction of cancer following exposure to low
–  No apparent increase in cancer incidence doses and dose rates
–  <100-200 mSv acute or chronic

284
Table of Contents
 Radiation carcinogenesis Radiation dose

•  DNA damage results from diagnostic CT

–  Relevance?
•  Spontaneous DNA mutation rate dwarfs the rate
due to background radiation
–  2.5 million times higher
•  Data actually supports hormesis model with
health benefits from low dose radiation 1

1) Doss Med Phys 2014;41(7).

Dose Reduction in Clinical CT Dose modulation

• Dose modulation
• Iterative reconstruction • x-y-z current modulation
• Existing protocol review - ALARA – in and through plane
– mA
– organ protective – X care
• Tailored kV
– Care kV

dose reduced SAFIRE

In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical
practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality
for the particular clinical task.

automatic
exposure X- CARE
control Organ sensitive protection
Organ protective modulation
current

91 mAs with X-CARE

without X-CARE
68 mAs

55 mAs

Low dose

230 mAs

mA High dose

modulation 230 mAs 1: Vollmar SV, Kalender WA. Reduction of dose to the female breast in thoracic CT: a comparison of standard-protocol, bismuth-shielded,
partial and tube-current-modulated CT examinations. Eur Radiol. 2008 Aug;18(8):1674-82.

285
Table of Contents
 Dose Reduction in Clinical CT Filtered-back projection (FBP)

• Existing protocol review - ALARA

• Dose modulation
• Iterative reconstruction
analytical reconstruction
formula

projection data final image

dose reduced SAFIRE

In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and
clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic
image quality for the particular clinical task. Courtesy Guang-Hong Chen, PhD U Wisconsin Medical Physics and Radiology

Novel reconstruction/ processing methods Novel reconstruction/ processing methods

• assumptions / errors made in image • lower noise data allows substantial

reconstructions introduce noise reduction in dose necessary to maintain
quality clinical images

Courtesy Guang-Hong Chen, PhD U Wisconsin Medical Physics and Radiology

projection data
Noise std (HU)
FBP IR
1 370 37
Iterative
2 160 47
reconstruction
3 333 44

FBP recon IR w/ stat

final image
update estimated image
2

1 3

forward projection estimated image

Courtesy Guang-Hong Chen, PhD U Wisconsin Medical Physics and Radiology

286
Table of Contents
 Iterative reconstruction
• novel reconstruction methods have the capability to
recognize and remove image noise
•  Siemens •  Philips
–  IRIS –  iDOSE
–  SAFIRE, ADMIRE –  iMR
•  GE •  Toshiba
–  ASIR –  AIDR
–  Veo, ASIR-V •  Vital
FBP SAFIRE
•  UW –  SPD
–  PICCS In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location,
and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain
diagnostic image quality for the particular clinical task.

standard LDCT standard

  No filtration on projection data

  preserved spatial resolution

FBP recon IR

1.8 mSv 1.2 mSv 1.8 mSv

Courtesy Guang-Hong Chen, PhD U Wisconsin Medical Physics and Radiology 28

low dose
0.8 mSv

287
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 Repeat scanning in the Neuro ICU

37.5 48 41 41 38 48
SAFIRE 614
120 kV
832
120kV
775
100 kV
775
100 kV
728
100 kV
832
120kV
ASIR FBP SAFIRE SAFIRE SAFIRE FBP

Standard 2.1 mSv ULDCT 0.7 mSv





Ultra low dose
Neurosurgical ICU SDCT (1/25/13) LDCT (1/26/13) ULDCT (1/28/13)

CTDIvol 12.2
DLP 213
0.5 mSv

ED= 2.23 mSv ED=1.56 mSv ED=0.58 mSv

CTDIvol=47.83 mGy CTDIvol=36.3 mGy CTDIvol=14.24 mGy
DLP= 971 mGy*cm DLP=678 mGy*cm DLP=253 mGy*cm

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SDCT (3/12/13) ULDCT (3/13/13)
SDCT (3/6/13) LDCT (3/11/13) ULDCT (3/14/13)

ED= 1.91 mSv ED=1.69 mSv ED=0.58 mSv

CTDIvol=48.67 mGy CTDIvol=36.65 mGy CTDIvol=14.55 mGy
DLP= 832mGy*cm DLP=736 mGy*cm DLP=254 mGy*cm
ED= 1.91 mSv ED=0.54 mSv
CTDIvol=48.67 mGy CTDIvol= 13.48 mGy
DLP= 832 mGy*cm DLP=235 mGy*cm

Results: Qualitative Analysis

  
LDCT SDCT ULDCT ULDCT


 

 


 

                       


 
                      

 
       

    
          

  Grades for image quality were averaged across both readers for analysis

  A p < 0.05 indicated a statistically significant difference

8/19 12 noon 8/19 8 PM 8/20 3PM 8/21 3PM

SDCT (3/6/13) LDCT (3/11/13) ULDCT (3/14/13)

Ultra low dose 0.5 mSv

Protocol review
opportunities
•  Lower mAs (higher NI)
–  dose reduction proportional to drop in mAs
–  sinus, temporal bone, skeletal, screening chest studies

Low dose 1.2 mSv

289
Table of Contents
 Paranasal sinus CT

90mA low kV

48
832

Protocol review 120kV

FBP
opportunities

•  Lower kVp
–  17% drop from 120 to 100 kV
yields an almost 40% reduction in
dose
–  Improved low contrast resolution

41
775
100 kV
SAFIRE




290
Table of Contents
 IR
Protocol review
opportunities
100 kV
•  Lower kVp
–  17% drop from 120 to 100 kV yields an almost 40%
reduction in dose
–  Tube current (mAs) must rise to compensate

Capable of up to 1300 mA
Allows use of low kV for all applications and body types

Lower kVp Techniques

– exception applies for contrast
enhanced imaging allowing
lower net dosing
•  adequate iodine visualization may not
require usual low noise levels
•  greater beam attenuation by better
approximation of iodine k-edge




•  attenuation values of iodine-enhanced
vessels at 80 kV are approximately two
times higher than at 140 kV 









Grant, K., Schmidt, B. (2011) . Care kV: Automated Dose-
Optimized Selection of X-ray Tube Voltage.










291
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Dose management efforts include:
lower tube current (mA)
image quality and signal to noise ratio can suffer
shorter scan lengths
more susceptible to physiologic variations
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appropriate sampling interval is controversial



 
•  Dose management
•  70 kV
•  Better match to iodine k-edge
•  Variable sampling interval
•  Breaks connection of window width to dose
•  Extended sampling period
•  Reduced variability without an increase in dose
•  Extracted time resolved CTA




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Spectral imaging Dual energy imaging

imaging techniques

Conventional DE Selective Photon Shield

•  dual source dual energy
–  two tubes 80 kV 80 kV
140 kV 140 kV
•  single source overlap overlap

–  dual layer detector

–  Fast kV switching @0.5msec
–  spin-spin
–  selective filtration “Twinbeam”

1: Schenzle JC et al. Dual energy CT of the chest: how about the dose? Invest Radiol. 2010 Jun;45(6):347-53.
2: Thomas C et al. Differentiation of urinary calculi with dual energy CT: effect of spectral shaping by high energy tin filtration. Invest Radiol. 2010 Jul;
45(7):393-8.

Dual Energy Spectral Head CT (DESCT) Clinical head CT images

reconstructed with
Improves Contrast Resolution over Monochromatic 65 KeV were
Polychromatic CT felt to provide better or
similar diagnostic quality
relative to 140 KVp.

Avi Bluestone MD/PhD, Amish Doshi MD, Puneet Pawha MD,

Bradley Delman MD, Lawrence N. Tanenbaum MD
65 KeV 140 KVp

295
Table of Contents
 Dual energy
Monochromatic 65 KeV CT
Bone removal
images were felt to provide better
or similar low contrast resolution
relative to 140 KVp.

SOMATOM Force
collimation: 2x 192 x 0.6 mm
spatial resolution: 0.24 mm
rotation time: 0.25 s
tube setting:
90/150 kV
65 KeV 140 KVp Courtesy of UMM, Mannheim, Germany

296
Table of Contents
 Dual energy CTA

50 keV 100 keV

Iodine conspicuity

297
Table of Contents
 Blended Iodine

Blood vs. iodine

Iodine overlay

Material quantitation – Iodine ~ 0 mg/ml

Iodine overlay Monoenergetic 65 kev

Subarachnoid
Hemorrhage
Dual-energy

298
Table of Contents
 Iodine vs. hemorrhage

Iodine vs blood
Quantitative
assessment

iodine VNC Iodine overlay

Monoenergetic imaging
40-190 keV

Instrumented
Spine

Tuned
monoenergetic

Courtesy of Massachusetts General Hospital

299
Table of Contents
 70 keV 90 keV 110 keV

70 keV 90 keV 110 keV

140 keV 170 keV 190 keV

Hardware loosening

Tuned monoenergetic

300
Table of Contents
 Metal artifact reduction iMAR
SOMATOM
Definition Edge
•  Add on processing to any acquisition
•  iMAR, smart MAR, OMAR collimation: 128 x
0.6 mm
•  Tuned to hardware type scan time: 7 s
scan length: 259.5
mm
rotation time: 1 s
tube setting:
120 kV, 206 eff. mAs
CTDIvol: 13.9 mGy
DLP: 392.2 mGycm
Eff. dose: 5.9 mSv

w/o iMAR iMAR

Courtesy of Luzerner Kantonsspital, Luzern, Switzerland

*iMAR is cleared for the potential to reduce artifacts.

iMAR

iMAR

*iMAR is cleared for the potential to reduce artifacts.

Courtesy of Prof. Lell, Erlangen, Germany

301
Table of Contents
 FAST Spine

Fast Spine Work Flow

Automated Adaptive Multiplane-multiangle
Oblique (AAMO) Adds Value in Spine CT

N. Titelbaum, I. Corcuera-Solano, A. Doshi, P. Pawha

L.N. Tanenbaum

Best mentored paper ENRS 2015

302
Table of Contents
 Automated adaptive multiangle-multidirectional oblique
Conclusion
•  AAMO rendering offers a significant
improvement in ease of interpretation, accuracy of
depiction of canal dimensions and greater
effectiveness of communication by disc level in
cervical and lumbar spine CT

AAMO FAST Spine orthogonal

syngo.via: CT Bone Reading

•  expedited reading process of oncological and trauma patients
•  better visualization of bone lesions and fractures
•  fully interactive with automatic labeling of spine and ribs

303
Table of Contents
 Innovations in Neuro CT
Innovations in Clinical Neuro CT leveraging new technology
summary

• perspective on radiation risk

• dual energy
• spine optimization and
workflow
Lawrence N. Tanenbaum, M.D. FACR
Director Computed Tomography and MRI
Mount Sinai Medical Center
www.drtmasters.com drt@drtmasters.com
New York, NY

304
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306
Table of Contents
 307
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308
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 Financial Disclosure
Dual Energy CT: How it Works, and
Clinical Applications that Add Value
Siemens: Institutional research grant on Dual
Energy CT
Aaron Sodickson MD PhD
asodickson@bwh.harvard.edu Bayer informatics: Advisory Board member
Division Chief, Emergency Radiology
Director, Brigham NightWatch Program
Medical Director of CT, Brigham Radiology Network
Associate Professor, Harvard Medical School

Brigham and Women’s Hospital

Harvard Medical School
asodickson@bwh.harvard.edu

Learning Objectives Conventional CT Imaging – Acquisition

1)  Explain key requirements of Dual Energy CT

Single X-ray spectrum
acquisition, and compare different manufacturer Polychromatic X-ray beam (Peak energy: 80 to 140kVp)

approaches
Default: 120kVp

X-ray intensity
2)  Describe a variety of dual-energy post-
processing techniques relevant to clinical
practice
20 40 60 80 100 120 140
Photon energy (keV)

asodickson@bwh.harvard.edu Slide Courtesy Dr. Manuel Patino, MGH

Material-dependent X-ray absorption Fundamental Needs for Dual Energy

80kV 100kV 120kV 140kV

80 kVp CT-value
iodine
low kVp
fat

bone plastic

CT-value
high kVp 140 kVp

  higher CT-value at 80kV: iodine, bone, metal ...

  higher CT-value at 140kV: fat, plastic, uric acid ...
•  Materials must have distinct absorption characteristics

  same (almost) CT-value: air, water, soft tissue, blood … of each spectrum:
•  Different inherent absorption behavior (atomic number)
•  Different enough spectra to make the inherent differences
visible = spectral separation asodickson@bwh.harvard.edu

309
Table of Contents
 Polychromatic X-ray Spectral Separation Manufacturer Acquisition Approaches
100 kVp Rapid kV Switching DECT Dual Source DECT Detector Based Spectral CT
80 kVp
140 kVp
100 kVp
120 kVp 140/80 kVp Sn140 - 150 kVp 120 kVp
140 kVp
80-100 kVp

0 20 40 60 80 100 120 140 0 20 40 60 80 100 120 140

x-ray energy (keV) x-ray energy (keV)

100 kVp •  Nearly aligned projections •  ~90 degree projection offset •  Perfectly aligned projections
80 kVp •  Projection domain processing •  Image domain processing •  Projection domain processing
140 kVp – Tin filter
140 kVp •  Fixed mA technique •  Tube current modulation •  Tube current modulation
•  Full FOV •  Tube B FOV limitation 33-35 cm •  Full FOV
•  Patient size limitation ~250 lbs •  Tin filtration of higher kV •  DE data always acquired

0 20 40 60 80 100 120 140 0 20 40 60 80 100 120 140 Graphics Courtesy Dr. Manuel Patino
x-ray energy (keV) x-ray energy (keV) Patino M, Prochowski A, Agrawal MD, Simeone FJ, Gupta R, Hahn PF, Sahani DV. Material Separation Using
Modified from: Johnson TRC. Dual-Energy CT: General Principles. AJR. 2012; 199(5_supplement):S3–S8. asodickson@bwh.harvard.edu Dual-Energy CT: Current and Emerging Applications. RadioGraphics. 2016 Jul;36(4):1087–105

Two Material Decomposition Two Material Decomposition – treated RCC

•  Assume everything composed of only 2 materials

•  Material basis pairs with different absorption
behaviors
•  Photoelectric / Compton Scatter
•  Iodine / Water
•  Each material decomposed into contributions from
the two basis materials
•  Calcium appears on both Iodine and Water images
•  Other materials can be generated by appropriate linear Iodine, no Water Water, no Iodine
combinations of the basis pairs
asodickson@bwh.harvard.edu Slide Courtesy Dr. Daniele Marin, Duke

Virtual Monochromatic Imaging Beam Hardening Artifact Reduction

•  Image content at simulated keV values generated by
appropriate linear combinations of the basis material pairs

58 keV 70 keV 80 keV

Figure from: Silva, Morse, Hara, Paden, Hongo, Pavlicek. Dual-Energy (Spectral) CT: 111 keV 127 keV 140 keV
Applications in Abdominal Imaging. Radiographics. 2011 Jul 18;31(4):1031–46. asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

310
Table of Contents
Spectral Detector CT– Gray – White Matter Differentiation:
Improved CNR at low monoE Non-Calcified Gallstones
Contrast (Stone-Bile HU)
60
70 keV ~ 120 kVp
40

20
T2 MR
0

-20

HU
-40

-60

-80

-100

-120
40 70 100 130 160 190
40 keV keV
US

190 keV

ER102-ED-X, Education Exhibit: Uyeda, Richardson, Wortman, Sodickson

Slide Courtesy: William Moore, Marco Pinho, Suhny Abbara. UT Southwestern 2016 What’s New in Gallbladder Imaging with Emphasis on Dual Energy CT. RSNA 2016

Three Material Decomposition – Iodine Lung PBV - Perfused Blood Volume

 Fat, organ and Iodine
 Iodine quantification, calculation of a virtual non-contrast image
150
Fat Organ
100
+ iodine + iodine

50 Organ
HU at low kVp

Iodine content
0

VNC image
-50

-100 Fat

-150
-150 -100 -50 0 50 100 150
HU at high kVp

asodickson@bwh.harvard.edu Slide content courtesy of Ferco Berger

Iodine Qualitative Assessment Bowel Viability / Perfusion

Closed loop SBO
Ischemic bowel

SSC06-02, 10:40 am in rm N228: Admoni, Wortman, Uyeda, Fulwadhva, Sodickson

Dual Energy CT for Polycystic Kidneys: A Multireader Study. RSNA 2016 Fulwadhva UP, Wortman JR, Sodickson AD. Use of Dual-Energy CT and Iodine Maps in Evaluation of Bowel Disease. Radiographics. 2016

311
Table of Contents
 Iodine Imaging – GI Bleeding? Iodine Quantification – 3 Material Decomposition

Mixed DE ROI extracts:

HU on mixed image (from

blended 80 and Sn140)
HU from iodine (contrast
media CM), from kVp pair
VNC HU info
HU on VNC image
Iodine density, based on
HU from iodine, kVp pair,
and patient size

Iodine map

Fulwadhva UP, Wortman JR, Sodickson AD. Use of Dual-Energy CT and Iodine Maps in Evaluation of Bowel Disease. Radiographics. 2016 asodickson@bwh.harvard.edu

Iodine Quantification – 2 Material Decomposition Pancreatic Necrosis

Slide Courtesy Daniele Marin MD ER179-ED-X, Education Exhibit: George, Wortman, Uyeda, Fulwadhva, Sodickson
Figure in press, Radiology Role of Dual Energy CT in Pancreatic Disease: A Pictorial Review. RSNA 2016

Iodine Imaging – Iodine vs Calcium Iodine Imaging – Iodine vs Calcium

150
I overlay

100

Iodine content
50
HU at low kVp

ium
lc
Ca

-50 VNC image VNC

-100
Iodine overlay VNC

-150
•  Calcium persists on both VNC & iodine maps in typical 3 material decomposition
-150 -100 -50 0 50 100 150
asodickson@bwh.harvard.edu
HU at high kVp asodickson@bwh.harvard.edu

312
Table of Contents
 DECT 3-Material Decomposition
Iodine & Virtual Non-Contrast (VNC)
150
CSF Brain
+ iodine + iodine
100
I+ I overlay VNC X
50 Iodine content

HU at low kVp
Brain
•  L acetabular fx 0
VNC image
•  Several dense foci - Extrav vs fracture fragments ? -50

•  Red arrow extrav: + I overlay, - VNC -100

CSF
•  Blue arrow bone: + I overlay, + VNC -150
-150 -100 -50 0 50 100 150

ER101-ED-SUA5, Sun Education Exhibit: Wortman, Uyeda, Fulwadhva, Sodickson

HU at high kVp
Dual Energy CT for Abdominal and Pelvic Trauma: A Pictorial Review. RSNA 2016 Potter C, Sodickson A. Dual Energy CT in Emergency Neuroimaging: Added Value and Novel Applications. Radiographics 2016

DECT 3-Material Decomposition Calcium vs Hemorrhage – Virtual Non-Calcium

Calcium & Virtual Non-Calcium (VNCa)
150
CSF Brain
+ calcium + calcium
100
X
50 Calcium content
HU at low kVp

Brain
0
VNCa image
-50

-100
CSF
-150

Calcium Overlay Images

-150 -100 -50 0 50 100 150

HU at high kVp
Potter C, Sodickson A. Dual Energy CT in Emergency Neuroimaging: Added Value and Novel Applications. Radiographics 2016 Potter C, Sodickson A. Dual Energy CT in Emergency Neuroimaging: Added Value and Novel Applications. Radiographics 2016

Bone Marrow Edema – Virtual Non-Calcium Material Characterization – Bone Removal

  Material characterization: Separation of two materials
 Assume mixture of blood + iodine (unknown density)
and bone marrow + bone (unknown density)
Separation line
600
Iodine pixels
500
Marrow+bone
HU at low kVp

400 Blood+iodine Bone pixels

300

200

100
Blood
0 Marrow

-100
-100 0 100 200 300 400 500 600
ER101-ED-SUA5, Sun Education Exhibit: Wortman, Uyeda, Fulwadhva, Sodickson HU at high kVp
Dual Energy CT for Abdominal and Pelvic Trauma: A Pictorial Review. RSNA 2016

313
Table of Contents
 Bone Removal - CTA Material Characterization – Renal Stones
•  Base material line defined by urine & renal tissue
•  Several different stone types
•  Calculate position relative to separation line
80 kV [HU]

e
lin
n
io
rat
pa
Se

Sn140 kV [HU]

Potter C, Sodickson A. Dual Energy CT in Emergency Neuroimaging: Added Value and Novel Applications. Radiographics 2016 Uric acid stone courtesy of Dr. Savvas Nicolaou

MSK Applications - Gout

Images courtesy of Dr. Stacy Smith

•  Noninvasive diagnosis of uric acid content

•  Potential to monitor treatment response asodickson@bwh.harvard.edu

314
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316
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318
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326
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 327
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328
Table of Contents
 4D Flow: Disclosures
Technique and Clinical Applications
•  Patent royalties: Wisconsin Alumni
Research Foundation
Thomas M. Grist, MD
University of Wisconsin – Madison
•  Institutional research support
–  GE HealthCare
–  Bracco Diagnostics
–  Siemens
–  Hologic, Inc.

Objective
•  Define the clinical inidications for novel
MRI techniques using 4D flow imaging and
apply these methods to the diagnosis of
various CV diseases
Outline
•  Clinical rationale minimally invasive MR vascular imaging
•  Background of flow measurement by MRI
•  Basics of phase contrast MRI
•  Important developments in 4D flow imaging for clinical
feasibility
•  Applications of qualitative flow imaging
•  Applications of quantitative flow metrics

Clinical Rationale
•  CT •  MRI
•  Excellent morphology •  Excellent function information
•  Quick •  Slow
•  Easy •  Challenging
•  Radiation •  No radiation

329
Table of Contents
 What specific question(s) would
you like answered by this exam?
Outline
•  Clinical rationale minimally invasive MR vascular imaging
•  Background of flow measurement by MRI
•  Basics of phase contrast MRI
•  Important developments in 4D flow imaging for clinical
feasibility
•  Applications of qualitative flow imaging
•  Applications of quantitative flow metrics

First NMR flow experiments Outline

•  Clinical rationale minimally invasive MR vascular imaging
•  Background of flow measurement by MRI
•  Basics of phase contrast MRI
•  Important developments in 4D flow imaging for clinical
feasibility
•  Applications of qualitative flow imaging
•  Applications of quantitative flow metrics

z
Phase y

x
φ

Magnetic Resonance Imaging, 1982, 1:197-203

330
Table of Contents
 Image Reconstruction from k-space All MR Images have Magnitude and Phase
log(Magnitude) Magnitude

Image space
k-space

2D FT
Phase Phase
π π

Magnitude Phase
0 0
Must perform phase subtraction any time measure
-π -π phase change from a physiological process

Bipolar Gradients in Presence of Moving Spins Phase Contrast Velocity Imaging

φ0v=0 Gz
Magnitude
Static My
Spins t
150

Mx Bo
Phase Diff Δφ
0 cm/s
φ0
Flow , z
y
Moving My φv x
x - 150
Spins Δφ Δφ
v = γ M = π Venc
1
ECG Gated

1D VE-MRI: mitral regurgitation 1D VE-MRI: Calculate QP/QS

1.  Mitral regurgitation on
CINE bSSFP 10 year old with partial anomalous pulmonary venous return
Anomalous
2.  Need PC MRI to pulmonary vein Aorta
quantify severity

3.  Segment MV to
calculate flow through
MV Forward flow
PA
5129 ml/min 3599 ml/min
Regurgitation
CTA – great anatomy, but no MRI – use phase contrast to
flow information calculate flow volumes

331
Table of Contents
 PC Mag Res Med Articles Outline
•  Clinical rationale minimally invasive MR vascular imaging
•  Background of flow measurement by MRI
•  Basics of phase contrast MRI
•  Important developments in 4D flow imaging for clinical
feasibility
•  Applications of qualitative flow imaging
•  Applications of quantitative flow metrics

Time-resolved 3-dimensional 3-directional

Velocity-encoded MRI
Visualization with fluid dynamics software
Acquisition:
•  Volumetric coverage with conventional cartesian encoding
•  3-directional flow encoding
•  ECG gating
•  Respiratory correction
Magnitude

Flow R/L

•  Clinically Impractical
–  Acquisition times 40 min – 4 hours

Flow, z
Flow, y
Flow A/P
Flow S/I

z Flow, x
y
x
Animation courtesy of M. Markl, Chicago, IL
Ensight, CEI Inc.

4D VE-MRI: Vascular applications 4D Flow at UW – Madison: PC VIPR

What information are we •  Dual-echo, 5-point encoding
interested in? Bipolar/dual echo velocity encoding
RF
kz
–  Anatomy Gz

θ
–  Flow ky Gx
ϕ
With 4D VE-MRI, anatomy and flow
Gy
data co-registered from same data
acquisition kx
S(t)
Animation courtesy of M. Markl, Chicago, IL

332
Table of Contents
 PC VIPR vs 3D Cartesian PC
Acceleration Factor 30 With Contrast AVM Patient
Cartesian 3D PC
Time: 7:22
S/I Coverage: 4 cm
Through-plane resolution 2mm
0.94 x 0.94mm

PC VIPR
Time: 7:30
S/I Coverage: 18 cm
Isotropic resolution PC Angiogram - MIP
0.63 x 0.63 x 0.63mm

Comprehensive PC MR Outline
Vascular Anatomy Velocity vector field 3D Velocity Fields
Cardiac gating
Volumetric Imaging •  Clinical rationale minimally invasive MR vascular imaging
Comprehensive Information •  Background of flow measurement by MRI
Vascular anatomy
3D Velocity fields •  Basics of phase contrast MRI
Hemodynamic parameters
+noninvasive •  Important developments in 4D flow imaging for clinical
feasibility
Post-processing and Visualization
Flow measurements Visualization Pressure gradients Wall shear stress •  Applications of qualitative flow imaging
400
350
300
•  Applications of quantitative flow metrics
flow [ml/s]

250
200
150
100
50
0
-50
0 200 400 600 800 1000
time [ms]

Flow Tracking with 4D MR Flow Flow Tracking with 4D MR Flow

Liver Flow
Portal Hypertension

Surgical Planning – Whipple Procedure

Confluence – Splenic and

superior mesenteric artery
Carotid arteries and
jugular veins
CHD

333
Table of Contents
 PC VIPR pre whipple PC VIPR pre whipple
celiac trunk SA
HA
BY
PA
GDA SMA GDA SS
collateral pathway collateral pathway
SMA - celiac trunk SMA - celiac trunk

superior and inferior

pancreaticoduodenal arteries

Intracranial Aneurysm: Predict risk of rupture?

4D Flow


 

 


Hope et al. Radiology 2010

Qualitative flow analysis in CHD with PC VIPR Acute aortic syndrome: dissection

Double inlet left ventricle status post Glenn Tetralogy of Fallot status post Fontan and
completed repair
Superior vena cava Superior vena cava
LPA MPA
RPA
RPA LA Aorta

RA
•  Patient presents with
RA LV
RV persistent pain despite HTN
Cases – Thoracic

treatment
IVC IVC
•  MRA Flow analysis for
Double inlet LV Corrected Tetrology of Fallot further evaluation

334
Table of Contents
 Acute aortic syndrome: dissection PC VIPR acute aortic dissection
Pre-repair
Cases – Thoracic

Pitfall of IR-SSFP: artifact mimicking FMD 66 yo F with portal HTN

•  No flow in MPV - ? thrombus
1
•  Reversed flow in LPV
2
3

4 Inhance Inflow IR CE MRA

66 yo F with portal HTN 66 yo F with portal HTN

•  Stomal varices draining

from SMV
•  Patent portal vein
(no thrombus)

PC-VIPR Magnitude PC-VIPR Flow Visualization

335
Table of Contents
 Vessel Selective Seeding Nidus seeding + Reverse tracking

Outline Renal flow

•  Clinical rationale minimally invasive MR vascular imaging
•  Background of flow measurement by MRI   

 

•  Basics of phase contrast MRI    





•  Important developments in 4D flow imaging for clinical  


feasibility
•  Applications of qualitative flow imaging
•  Applications of quantitative flow metrics

  

 


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Results: Linear Regression Arterial Day1

100
y = 0.94x + 0.25
80 R² = 0.93
QMRI2 (ml/cycle)

60

40

20

0
0 20 40 60 80 100
47 QMRI1 (ml/cycle)

336
Table of Contents
 Venous Day 1 vs Day2 Quantitative flow analysis:
30
y = 0.81x + 2.25 Atrial septal defect (ASD)
25 R² = 0.80
Superior vena cava Superior vena cava
20 PV
QDay2 (ml/cycle)

SMV
15 ASD
SV
10 RA RV
ASD RA
5 Patient 1 – QP/QS = 1.3 Patient 2 – QP/QS = 1.6
0
0 5 10 15 20 25 30
QDay1 (ml/cycle)

4D VE-MRI: Flow quantification Pressure gradient: Animal model 2

Animal model of renal artery stenosis1
What parameters should we measure?

Flow Q= ∑ v ΔA
i

∂v



Pressure Gradient ΔP ≈ − ρ
∂t
− ρv∇v ≈ − ρa




∂V

∇P = − ρ + (V • ∇)V + ρg + μ∇ 2V
Δx Z ∂t
Pulse Wave Velocity PWV =
Δt
= c
ρ
Pearson Correlation
dv
Shear Stress SS = − μ
dr r = 0.977; p < 0.001
95% CI: 0.939- 0.991
Others
1Bley TA, et al. Radiology 2011

Pressure gradient: Human studies Quantitative flow analysis: Measuring relative pressure
Repaired aortic coarctation with recurrent stenosis
18 month old with aortic coarctation
MIP

~27.5
mmHg

mmHg


∂V 



∇P = − ρ + (V • ∇)V + ρg + μ∇ 2V
P = pressure ∂t V = velocity P = pressure V = velocity

peak peak μ = viscosity g = gravitation μ = 4 cP (centipoise) g = 9.8 m/s

systole systole
ρ = density ρ = 1066 kg/m3
CE-MRA 3D stream-lines 3D pressure difference
Courtesy M Markl

337
Table of Contents
 Summary 4D Flow Acknowledgements
UW Radiology Hamburg, Germany
•  Phase contrast is cool! Medical Physics
•  Alejandro Roldan •  Thorsten Bley
•  Scott Reeder
•  Kevin Johnson
•  New “undersampling” methods reduce acquisition •  Oliver Wieben
•  Mark Schiebler Lubeck, Germany
•  Scott Nagle •  Alex Frydrychowicz
time and improve coverage and provide 4D flow Students •  Tom Grist
•  Christina Boncyk •  Pat Turski
•  Qualitative analysis of flow streamlines are a •  Ben Landgraf
Northwestern University
•  Michael Markl
Pediatric Cardiology
powerful method to demonstrate pathology •  Michael Loecher
•  Liz Nett
•  Sharda Srinivasan •  James Carr
•  Carter Ralphe
•  Quantitative measurements of pressure gradients •  Eric Niespodzany •  John Hokanson
Funding
•  Andrew Wentland •  Support from GE Healthcare
and flow rate are possible Biomedical Engineering
•  NIH 2R01HL072260-05A1
•  Naomi Chesler
•  Data processing and analysis is time intensive and
needs automation
WIMR

338
Table of Contents
 339
Table of Contents
340
Table of Contents
 341
Table of Contents
342
Table of Contents
CT Dosimetry, Radiation Risks, Disclosures
and Dose Reduction Strategies
Siemens: Institutional research
Aaron Sodickson MD, PhD
asodickson@bwh.harvard.edu
grant on Dual Energy CT
Division Chief, Emergency Radiology Bayer informatics: Advisory Board
Director, Brigham NightWatch Program
Medical Director of CT, Brigham Radiology Network member
Associate Professor, Harvard Medical School

Brigham and Women’s Hospital

Harvard Medical School asodickson@bwh.harvard.edu

Objectives Radiation Terminology

Absorbed Dose Gray (Gy, Joules/kg) •  Energy absorbed by tissue, divided by the tissue
mass
•  Understand basics of radiation exposure and Rad (1 Rad = 0.01 Gy)

radiation risk assessment Equivalent Dose Sievert (Sv) •  Reflects biological effect of ionizations in tissue
Rem (1 Rem = 0.01 Sv) •  Equals Absorbed Dose times Quality Factor QF
•  QF = 1 in diagnostic imaging (X-rays & γ-rays)
•  Recognize patient and imaging factors that
⇒ Equivalent Dose = Absorbed Dose
influence radiation dose and risk Effective Dose Sievert (Sv) •  Whole body Equivalent Dose causing the same
overall cancer risk as a nonuniform or partial-
•  Identify strategies to reduce radiation exposure body exposure
before, during, and after the scan •  Sum of each organ’s equivalent dose times that
organ’s relative risk of radiation-induced
carcinogenesis
•  Demonstrate uses and benefits of CT dose •  Commonly used to compare different exposures,
extraction tools even if they cover different anatomic regions

asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

A Drop in the Bucket Risks of low-dose Radiation

Reproduced from:
Brenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable
to low doses of ionizing radiation: assessing what we really know.
Proc Natl Acad Sci USA 2003;100:13761-13766

asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

343
Table of Contents
 BEIR-VII risk model Crude cumulative risk estimation
BEIR-VII Lifetime Attributable Risk (LAR)
of radiation-induced cancer above baseline •  Count ALL prior chest + abd/pelv CT’s
5.0 5.0 •  Divide by 10 (assumes 10 mSv per scan)
4.5 4.5
Female Cancer Incidence •  Adjust Female
for age/gender
Cancer Incidence
(multiply by y-axis)
100mSv)

100mSv)
mSv)
mSv)

4.0 Male Cancer Incidence 4.0

⇒Male Cancer Incidence
Approximate % LAR
3.5 3.5
•  Consider anticipated life expectancy
per100

100
3.0 3.0
•  Balance cumulative benefits vs

per
2.5 2.5
per

per
cumulative risks

(%(%
(%(%

2.0 2.0

LARLAR
LARLAR

1.5 1.5
Cancer risk 1:1000 for 10 mSv exposure Cancer risk 1:1000 for 10 mSv exposure
1.0 1.0

0.5 0.5

0.0 0.0
0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80

Extracted from: National Research Council. Age

Health at
risksExposure
from exposure to low Age at Exposure Extracted from: National Research Council. Age
Health at
risksExposure
from exposure to low Age at Exposure
levels of ionizing radiation: BEIR VII, Phase 2. National Academies Press, 2006 asodickson@bwh.harvard.edu levels of ionizing radiation: BEIR VII, Phase 2. National Academies Press, 2006 asodickson@bwh.harvard.edu

NEED: Validated Risk Models

•  Need better data in the low dose regime to
DIRECTLY test the dose-response curve

•  Need ACCURATE dosimetry in large

number of patients to detect increased
cancer incidence above 42% baseline

•  Informatics methods for large-scale dose

capture ⇒ testing of underlying risk models
asodickson@bwh.harvard.edu

Longitudinal Survey: Cumulative Scan Counts Cumulative Effective Dose

31,462 patients
31,462 patients

33% > 5 exams

15% > 100 mSv
5% > 22 exams 4% > 250 mSv
1% > 38 exams 1% > 400 mSv

Mean 6.1 exams Mean 54 mSv

Max 1375 mSv
Max 132 exams

Cumulative effective dose per patient, 22 year history

# CT exams per patient, 22 year history
Sodickson, Baeyens, Prevedello, et. al. Recurrent CT, Cumulative Radiation Exposure, and Sodickson, Baeyens, Prevedello, et. al. Recurrent CT, Cumulative Radiation Exposure, and
Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1) Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1)

344
Table of Contents
 Cumulative Cancer Risks Case example - FP
•  44 yo, numerous ED visits for flank pain
CA Incidence CA Mortality
•  PMH:
7% > LAR 1% 3% > 1%
–  Recurrent pyelonephritis
1% > LAR 2.6% 1% > 1.6%
–  Prior lithotripsy & stone extraction
–  Remote hx UC ⇒ proctocolectomy
Mean 0.3% Mean 0.2%
•  20 year imaging history:
Max 12% Max 6.8%
–  CT: 58 ureter, 10 abdomen/pelvis, 1 head
–  Nuclear Medicine: 3 renal studies
–  X-Ray: (~130) 12 IVP, 4 VCUG, 4 fluoro renal
interventions, 55 KUB, 40 CXR, 19 other
Lifetime Attributable Risk (%), Radiation-Induced Cancer –  Ultrasound: 62, abdomen or pelvis
Sodickson, Baeyens, Prevedello, et. al. Recurrent CT, Cumulative Radiation Exposure, and Griffey RT, Sodickson A. Cumulative Radiation Exposure and Cancer Risk Estimates
Associated Radiation-Induced Cancer Risk from CT of Adults, Radiology. 2009;251(1) in ED Patients Undergoing Repeat or Multiple CT. AJR. 2009 Apr 1;192(4):887–92

Case example - FP (cont’d) Incremental risks are similar

Are the benefits?
CT Findings:
Cumulative Effective Dose (mSv)

Exam indications - shades of gray

•  1 scan: 1 cm UPJ stone Episodic care decisions
–  After ultrasound showed hydronephrosis ⇒ cumulative benefit vs risk

•  1 scan: CT findings of pyelonephritis

–  Concordant clinical presentation
•  66 ureter or abd/pelv CT’s:
–  No obstructive uropathy
–  Incremental interval changes in size & location of
non-obstructing renal stones
Griffey RT, Sodickson A. Cumulative Radiation Exposure and Cancer Risk Estimates
in ED Patients Undergoing Repeat or Multiple CT. AJR. 2009 Apr 1;192(4):887–92 asodickson@bwh.harvard.edu

Patient FP - Cumulative Exposure and LAR

4000
at 1 X, 1/2 X, 1/4 X Projected CT Rates
25
What Can We Do?
3750
3500
(mSv)
(mSv)

3250 20
% Lifetime Attributable Risk

3000
Dose

(LAR) above baseline

2750
Exposure

2500
15
Effective

2250
2000
1750
Cumulative

10
1500
Cumulative

1250
1000
750 5
500
250
0 0
25 30 35 40 45 50 55 60 65 70 75 80
Age
asodickson@bwh.harvard.edu Sodickson A. Strategies for Reducing Radiation Exposure in Multi-Detector Row CT. RCNA 50 (2012) 1-14

345
Table of Contents
 Dose Reduction Opportunities Eliminate Unnecessary Repeat Exams
1.  Before Scan - Reduce Drip Rate
•  Imaging algorithms, evidence based imaging
•  Decision support: appropriateness, radiation risk
•  Non-ionizing alternatives? Ultrasound, MRI
2.  During Scan - Reduce Drop Size
•  Dose-optimized protocols - find the sweet spot
•  Lowest exposure appropriate for the clinical scenario
•  Robust, diagnostic quality exams
3.  After Scan
•  Capture patient / exam specific exposure information
•  Convert to patient dose using anatomy, size
4.  Continuous
Sodickson, Opraseuth, Ledbetter. Outside Imaging in ED Transfer Patients: CD Import Reduces
•  Longitudinal dose & risk monitoring in EMR Rates of Subsequent Imaging Utilization. Radiology 2011;260(2): 408-13
asodickson@bwh.harvard.edu

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•  34% of exams triggered the Duplicate DS system,

potentially redundant same body part CT w/in 90 days

⇒  Immediate cancellation rate of 6.0% of CT exams

•  vs 0.9% for exams not meeting duplicate criteria (p<0.001)
⇒  Incremental cancellation of 1.7% of all CT orders placed

•  Delivery of a relevant EMR data extract at point of care

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Graph shows CT pulmonary angiography (CTPA) use and yield before and after CDS implementation.
During the Scan: Reduce Drop SIZE
1.  Use size dependent protocols

 

0.6
2.  Understand & enable dose reduction tools

3.  Reduce # of passes through body region
4.  Reduce duplicate coverage


236
5.  Reduce mAs for high contrast imaging
6.  Optimize IV contrast infusion timing
7.  Lower kVp if patient size allows
(especially for CTA)
Raja AS, IP IK, Prevedello LM et al. Effect of Computerized Clinical Decision Support on the Use and
Yield of CT Pulmonary Angiography in the Emergency Department. Radiology 2012;262:468-474
8.  Use noise-reducing post-processing tools
Sodickson A. Strategies for Reducing Radiation Exposure in Multi-Detector Row CT. RCNA 50 (2012) 1-14

346
Table of Contents
 CTDIvol and DLP

Mean organ dose / CTDIvol across scanners

Morin, R. L. et al. Circulation
2003;107:917-922
•  Metrics of x-ray tube output
•  NOT patient dose, BUT
•  Often used to estimate dose
CTDIvol ~ organ dose
Phantoms
32 cm
Body DLP ~ effective dose
16 cm
Head

⎛2 1 ⎞
CTDI vol = ⎜ CTDI100, periph + CTDI100,center ⎟ pitch
⎝3 3 ⎠
Patient Perimeter (cm)
DLP = CTDI vol ∗ Exposed Length Turner, Zhang, Khatonabadi et al. The feasibility of patient size-corrected, scanner-
asodickson@bwh.harvard.edu
independent organ dose estimates for abdominal CT exams. Med Phys 2011;38(2):820-829
Dose / CTDIvol

Organ Dose vs Size Effective Dose ~ DLP X k-factor

•  For fixed CTDIvol, organ dose decreases with X2
increasing size.
DLP x k-factor method :
X •  Overestimates dose for large pts
CTDIvol

•  Underestimates dose for small pts

•  TCM increases CTDIvol with increasing
•  Population average across size, sex
patient size to maintain image quality. X4

Shrimpton. Assessment of patient dose in CT. Chilton, NRPB-PE/1/2004, 2004

=

Approx Eff Dose

mSv
•  Taken together, large patients still receive
Dose

X2
higher doses than smaller patients. 2.8
3.4

5.1
Sodickson, Turner, McGlamery, McNitt-Gray. Variation in Organ Dose Size 8.5
from Abdomen-Pelvis CT Exams Performed with Tube Current
Modulation (TCM): Evaluation of Patient Size Effects. RSNA 2010 asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

Pay attention to CTDIvol and DLP GE Dose Screen

•  Review on PACS
•  Familiarity with typical values, variation
with patient size
•  Allow identification of outliers
•  Important for QC
•  Diagnostic Reference Levels
Sodickson, Warden, Farkas et al. Exposing Exposure: Automated Anatomy-Specific CT Radiation Exposure
asodickson@bwh.harvard.edu Extraction for Quality Assurance and Radiation Monitoring. Radiology 2012; 264(2):397-405

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 Siemens Dose Screen Toshiba Dose Screens

Sodickson, Warden, Farkas et al. Exposing Exposure: Automated Anatomy-Specific CT Radiation Exposure Sodickson, Warden, Farkas et al. Exposing Exposure: Automated Anatomy-Specific CT Radiation Exposure
Extraction for Quality Assurance and Radiation Monitoring. Radiology 2012; 264(2):397-405 Extraction for Quality Assurance and Radiation Monitoring. Radiology 2012; 264(2):397-405

Philips Dose Screen/Sequence

•  Derived from 1st 3 years of ACR accreditation data (2002-2005),

2005 NEXT data and NCRP Report 172
•  “LAT dimensions are for average patients of the specified age.”
•  “Individual patients should not be compared against these values.”
ACR–AAPM PRACTICE GUIDELINE FOR DIAGNOSTIC REFERENCE LEVELS AND ACHIEVABLE DOSES IN MEDICAL X-
RAY IMAGING, Rev 2013, at:
Sodickson, Warden, Farkas et al. Exposing Exposure: Automated Anatomy-Specific CT Radiation Exposure http://www.acr.org/Quality-Safety/Standards-Guidelines/Practice-Guidelines-by-Modality/~/media/ACR/Documents/PGTS/
Extraction for Quality Assurance and Radiation Monitoring. Radiology 2012; 264(2):397-405 guidelines/Reference_Levels.pdf asodickson@partners.org

Exposing Exposure: Automated Anatomy

and Dose Extraction from PACS
Institutional Benchmarking

  
  



























400

350 Total
Abdomen/Pelvis
300
Head
250 Chest
200 Neck
150

100

50

0
Sodickson, Warden, Farkas et al. Exposing Exposure: Automated Anatomy-Specific CT Radiation Exposure
Extraction for Quality Assurance and Radiation Monitoring. Radiology 2012; 264(2):397-405
Jul-09

Jul-10
Oct-09

Apr-10

Oct-10

Jan-11
Jan-10

asodickson@bwh.harvard.edu

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 Facility Benchmarking Protocol Benchmarking

CTDIvol of Head CT’s, by Scanner CTDIvol of Head CT’s, by Protocol

asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

CT Protocol Quality Control High Outliers

CTDIvol of Head CT’s, ER scanner, by Patient
CTDIvol of Head CT’s, ER scanner

Is dose unnecessarily high?

Is dose too low?

Image quality inadequate?

asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

Low Outliers CT Protocol Quality Control

CTDIvol of PE CT, ER scanner, by Patient Weight
CTDIvol of Head CT’s, ER scanner, by Patient

asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

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 50
AAPM adult torso False Positive Alerts
CT Protocol Quality Control recommended dose
notification value Where Are the Alerts? Not Actionable
  Alert Fatigue
CTDIvol of PE CT, ER scanner, by Patient Weight CTDIvol of PE CT, ER scanner, by Patient Weight

True Positive Alerts

21
ACR adult Fixed Alert
chest DRL Value

Outliers have higher

than expected CTDIvol
relative to tube current False Negative Alerts  Missed Opportunity
modulation output of •  Potential for far higher dose than needed
similarly-sized patients •  Better than needed image quality

asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

Dose Trending Over Time Take-Home Points for Clinicians

CTDIvol of Abd/Pelv CT over time, ER scanner

Iterative recon implemented:

•  There’s a lot you can do to reduce radiation
30% dose reduction dose and risk

•  Pay particular attention to recurrent imaging in

frequent flyers – risks may accumulate

•  Look at the big picture over time

•  Don’t order unnecessary scans

asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

Take-Home Points for Clinicians Take-Home Points for Radiologists,

Technologists, Physicists
BUT
•  There’s a lot you can do to reduce radiation
•  Radiation risks are often exaggerated dose and risk without hindering diagnosis

•  Don’t unnecessarily scare your patients and •  Work together to optimize your technology
avoid imaging that will impact management
•  Gather data to identify opportunities for
•  Don’t order a suboptimal exam to avoid improvement and standardization
radiation
•  Don’t overdo it – a nondiagnostic scan
benefits no one
asodickson@bwh.harvard.edu asodickson@bwh.harvard.edu

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3D MSK MRI of Sport
Injuries - Workstation
Case Review
Jan Fritz, M.D., P.D.
Assistant Professor of Radiology
Johns Hopkins University School of Medicine
Musculoskeletal Radiology
Templated Reporting - Ankle
GENERAL:
• Alignment: Anatomical.
• Fluid:
– Tibiotalar: Physiological.
– Subtalar: Physiological.
• Articulations:
– Tibiotalar joint: Intact.
– Subtalar joint: Intact.
– Midfoot joints: Minimal arthrosis.
• Sinus tarsi: Intact.
MEDIAL:
• Tendons:
– Posterior tibial: Intact.
– Flexor digitorum longus: Intact.
– Flexor hallucis longus: Intact.
• Tarsal tunnel: Intact.
• Ligaments:
– Deltoid ligament complex -
deep: Intact.
– Deltoid ligament complex -
superficial: Intact.
– Spring (plantar calcaneo-navicular)
ligament: Intact.
LATERAL:
• Retromalleolar groove: Concave.
• Tendons:
– Peroneus longus: Intact.
– Peroneus brevis: Intact.
– Ligaments:
How to describe Meniscal Tears?
Templated Reporting - Knee
GENERAL:
• Fluid: Physiological.
ANTERIOR:
• Alignment: Anatomical.
• Quadriceps tendon: Intact.
MEDIAL:
• Medial meniscus: Intact.
• Cartilage: Intact.
• Patellar tendon: Intact.
• Cartilage: Intact.
• Hoffa fat pad: Mild edema.
• Medial collateral ligament: Intact.
• Posteromedial corner: Intact. INTERCONDYLAR:
• Anterior cruciate ligament: Intact.
LATERAL: • Posterior cruciate ligament: Intact.
• Lateral meniscus: Intact.
• Cartilage: Intact. MISCELLANEOUS
• Lateral collateral ligament complex: • Bones: Otherwise intact.
Intact. • Muscles: Intact.
• Posterolateral corner: Intact. • Nerves: Intact.
• Vessels: Intact.
• Proximal tibiofibular joint: Intact. • Other: [None]
Templated Reporting - Elbow
LATERAL CONT.
• Ligaments: GENERAL:
– Anterior inferior tibiofibular • Fluid: Physiological.
(syndesmosis): Intact.
POSTERIOR:
– Posterior inferior tibiofibular
(syndesmosis): Intact. • Triceps tendon: Intact.
– Anterior talofibular ligament: Intact. ARTICULATIONS:
• Olecranon: Intact.
– Posterior talofibular ligament: Intact. • Humeroulnar joint: Intact.
– Calcaneofibular ligament: Intact.
POSTERIOR: • Radiocapitellar joint: Intact.
ANTERIOR:
– Posterior talus: Intact. • Proximal radioulnar joint: Intact.
– Achilles tendon: Intact. • Biceps tendon: Intact.
– Plantar fascia: Intact.
• Brachialis tendon: Intact.
MEDIAL:
ANTERIOR:
• Bicipitoradial bursa: Intact.
• Ulnar collateral ligament: Intact.
• Tendons: • Flexor-Pronator Origin: Intact.
• Anterior tibial: Intact. MISCELLANEOUS
• Medial epicondyle: Intact.
• Extensor hallucis longus: Intact. • Bones: Otherwise intact.
• Extensor digitorum
• Cubital tunnel: Intact.
• Muscles: Intact.
longus: Intact.
•
• Nerves: Intact.
LATERAL:
• Vessels: Intact.
• Radial collateral ligament: Intact.
• Bones: Intact. • Other: [None]
• Muscles: Intact. • Lateral ulnar collateral ligament: Intact.
• Nerves: Intact. • Common extensor tendon: Intact.
• Vessels: Intact. • Lateral epicondyle: Intact.
• Other: None.
How to describe Cartilage Defects?
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 How to describe Tendon and Ligament Tears? Thank you!

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