Accuracy Assessment of Percutaneous Pedicle Screw Placement Using Cone Beam Computed Tomography with Metal Artifact Reduction.

Metal artifact reduction (MAR) algorithms are used with cone beam computed tomography (CBCT) during augmented reality surgical navigation for minimally invasive pedicle screw instrumentation. The aim of this study was to assess intra- and inter-observer reliability of pedicle screw placement and to compare the perception of baseline image quality (NoMAR) with optimized image quality (MAR). CBCT images of 24 patients operated on for degenerative spondylolisthesis using minimally invasive lumbar fusion were analyzed retrospectively. Images were treated using NoMAR and MAR by an engineer, thus creating 48 randomized files, which were then independently analyzed by 3 spine surgeons and 3 radiologists. The Gertzbein and Robins classification was used for screw accuracy rating, and an image quality scale rated the clarity of pedicle screw and bony landmark depiction. Intra-class correlation coefficients (ICC) were calculated. NoMAR and MAR led to similarly good intra-observer (ICC > 0.6) and excellent inter-observer (ICC > 0.8) assessment reliability of pedicle screw placement accuracy. The image quality scale showed more variability in individual image perception between spine surgeons and radiologists (ICC range 0.51−0.91). This study indicates that intraoperative screw positioning can be reliably assessed on CBCT for augmented reality surgical navigation when using optimized image quality. Subjective image quality was rated slightly superior for MAR compared to NoMAR.

CT pulmonary angiography: dose reduction via a next generation iterative reconstruction algorithm.

BACKGROUND: Computed tomography pulmonary angiography (CTPA) is the standard imaging modality for detection or rule out of pulmonary embolism (PE); however, radiation exposure is a serious concern. With iterative reconstruction algorithms a distinct dose reduction could be achievable. PURPOSE: To evaluate a next generation iterative reconstruction algorithm for detection or rule-out of PE in simulated low-dose CTPA. MATERIAL AND METHODS: Low-dose CT datasets with 50%, 25%, and 12.5% of the original tube current were simulated based on CTPA examinations of 92 patients with suspected PE. All datasets were reconstructed with two reconstruction algorithms: standard filtered back-projection (FBP) and iterative model reconstruction (IMR). In total, 736 CTPA datasets were evaluated by three blinded radiologists regarding image quality, diagnostic confidence, and detectability of PE. Furthermore, contrast-to-noise ratio (CNR) was calculated. RESULTS: Images reconstructed with IMR showed better detectability of PE than images reconstructed with FBP, especially at lower dose levels. With IMR, sensitivity was over 95% for central and segmental PE down to a dose level of 25%. Significantly higher subjective image quality was shown at lower dose levels (25% and 12.5%) for IMR images whereas it was higher for FBP images at higher dose levels. FBP was rated as showing less artificial image appearance. CNR was significantly higher with IMR at all dose levels. CONCLUSION: By using IMR, a dose reduction of up to 50% while maintaining satisfactory image quality seems feasible in standard clinical situations, resulting in a mean effective dose of 1.38 mSv for CTPA.

Spectral Photon-counting CT: Initial Experience with Dual-Contrast Agent K-Edge Colonography.

Purpose To investigate the feasibility of using spectral photon-counting computed tomography (CT) to differentiate between gadolinium-based and nonionic iodine-based contrast material in a colon phantom by using the characteristic k edge of gadolinium. Materials and Methods A custom-made colon phantom was filled with nonionic iodine-based contrast material, and a gadolinium-filled capsule representing a contrast material-enhanced polyp was positioned on the colon wall. The colon phantom was scanned with a preclinical spectral photon-counting CT system to obtain spectral and conventional data. By fully using the multibin spectral information, material decomposition was performed to generate iodine and gadolinium maps. Quantitative measurements were performed within the lumen and polyp to quantitatively determine the absolute content of iodine and gadolinium. Results In a conventional CT section, absorption values of both contrast agents were similar at approximately 110 HU. Contrast material maps clearly differentiated the distributions, with gadolinium solely in the polyp and iodine in the lumen of the colon. Quantitative measurements of contrast material concentrations in the colon and polyp matched well with those of actual prepared mixtures. Conclusion Dual-contrast spectral photon-counting CT colonography with iodine-filled lumen and gadolinium-tagged polyps may enable ready differentiation between polyps and tagged fecal material. © RSNA, 2016.

Gadolinium K-edge angiography with a spectral photon counting CT in atherosclerotic rabbits.

PURPOSE: The purpose of this study was to investigate the feasibility of gadolinium-K-edge-angiography (angio-Gd-K-edge) with gadolinium-based contrast agents (GBCAs) as obtained with spectral photon counting CT (SPCCT) in atherosclerotic rabbits. MATERIALS AND METHODS: Seven atherosclerotic rabbits underwent angio-SPCCT acquisitions with two GBCAs, with similar intravenous injection protocol. Conventional and angio-Gd-K-edge images were reconstructed with the same parameters. Regions of interest were traced in different locations of the aorta and its branches. Hounsfield unit values, Gd concentrations, signal-to-noise (SNR) and contrast-to-noise (CNR) were calculated and compared. The maximum diameter and the diameter of the aorta in regard to atherosclerotic plaques were measured by two observers. Images were subjectively evaluated regarding vessels' enhancement, artefacts, border sharpness and overall image quality. RESULTS: In the analyzable six rabbits, Gd-K-edge allowed visualization of target vessels and no other structures. HU values and Gd concentrations were greatest in the largest artery (descending aorta, 5.6 ± 0.8 [SD] mm), and lowest in the smallest (renal arteries, 2.1 ± 0.3 mm). While greater for conventional images, CNR and SNR were satisfactory for both images (all P < 0.001). For one observer there were no statistically significant differences in either maximum or plaque-diameters (P = 0.45 and all P > 0.05 in post-hoc analysis, respectively). For the second observer, there were no significant differences for images reconstructed with the same parameters (all P < 0.05). All subjective criteria scored higher for conventional images compared to K-edge (all P < 0.01), with the highest scores for enhancement (4.3-4.4 vs. 3.1-3.4). CONCLUSION: With SPCCT, angio-Gd-K-edge after injection of GBCAs in atherosclerotic rabbits is feasible and allows for angiography-like visualization of small arteries and for the reliable measurement of their diameters.

Dual-echo Dixon imaging with flexible choice of echo times.

In this work, a new two-point method for water-fat imaging is described and explored. It generalizes existing two-point methods by eliminating some of the restrictions that these methods impose on the choice of echo times. Thus, the new two-point method promises to provide more freedom in the selection of protocol parameters and to reach higher scan efficiency. Its performance was studied theoretically and was evaluated experimentally in abdominal imaging with a multigradient-echo sequence. While depending on the choice of echo times, it is generally found to be favorable compared to existing two-point methods. Notably, water images with higher spatial resolution and better signal-to-noise ratio were attained with it in single breathholds at 3.0 T and 1.5 T, respectively. The use of more accurate spectral models of fat is shown to substantially reduce observed variations in the extent of fat suppression. The acquisition of in- and opposed-phase images is demonstrated to be replaceable by a synthesis from water and fat images. The new two-point method is finally also applied to autocalibrate a multidimensional eddy current correction and to enhance the fat suppression achieved with three-point methods in this way, especially toward the edges of larger field of views.

Iterative reconstruction for differential phase contrast imaging using spherically symmetric basis functions.

PURPOSE: The purpose of this work is to combine two areas of active research in tomographic x-ray imaging. The first one is the use of iterative reconstruction (IR) techniques. The second one is differential phase contrast imaging (DPCI). METHODS: The authors derive a maximum likelihood (ML) reconstruction algorithm with regularization for DPCI. Forward and back-projection are implemented using spherically symmetric basis functions (blobs) and differential footprints, thus completely avoiding the need for numerical differentiation throughout the reconstruction process. The method is applied to the problem of reconstruction of an object from sparsely sampled projections. RESULTS: The results show that the proposed method can handle the sparsely sampled data efficiently. In particular no streak artifacts are visible which are present in images obtained by filtered back-projection (FBP). CONCLUSIONS: IR algorithms have a wide spectrum of proven advantages in the area of conventional computed tomography. The present work describes for the first time, how a matched forward and back-projection can be implemented for DPCI, which is furthermore free of any heuristics. The newly developed ML reconstruction algorithm for DPCI shows that for the case of sparsely sampled projection data, an improvement in image quality is obtained that is qualitatively comparable to a corresponding situation in conventional x-ray imaging. Based on the proposed operators for forward and back-projection, a large variety of IR algorithms is thus made available for DPCI.

Diffuse optical tomography of the breast: initial validation in benign cysts.

PURPOSE: The purpose of this study was to validate a newly developed diffuse optical tomography (DOT) system on benign cysts in the breast. PROCEDURES: Eight patients with 20 benign cysts were included. Study procedures consisted of optical breast imaging and breast magnetic resonance imaging (MRI) for comparison. A reconstruction algorithm computed three-dimensional images for each of the four near-infrared wavelengths used by our DOT system (Philips Healthcare, Best, The Netherlands). These images were combined using a spectroscopic model to assess tissue composition and lesion size. RESULTS: Twenty cysts were analyzed in eight patients. By using the spectroscopic information, 13 of 20 cysts (65%) were visualized with DOT, confirming their high water and low total hemoglobin content. Lesion size and location showed good agreement with MRI; Pearson correlation coefficient was 0.7 (p < 0.01). CONCLUSIONS: DOT can visualize benign cysts in the breast and elucidate their high water and low total hemoglobin content by spectroscopic analysis.

Diffuse optical tomography of the breast: preliminary findings of a new prototype and comparison with magnetic resonance imaging.

This paper presents an evaluation of a prototype diffuse optical tomography (DOT) system. Seventeen women with 18 breast lesions (10 invasive carcinomas, 2 fibroadenomas, and 6 benign cysts; diameters 13-54 mm) were evaluated with DOT and magnetic resonance imaging (MRI). A substantial fraction of the original 36 recruited patients could not be examined using this prototype due to technical problems. A region of interest (ROI) was drawn at the lesion position as derived from MRI and at the mirror image site in the contralateral healthy breast. ROIs were assessed quantitatively and qualitatively by two observers independently in two separate readings. Intra- and interobserver agreements were calculated using kappa statistics (k) and intraclass correlation coefficients (ICCs). Discriminatory values for presence of malignancy were determined by receiver operating characteristic (ROC) analyses. Intraobserver agreements were excellent (k 0.88 and 0.88; ICC 0.978 and 0.987), interobserver agreements were good to excellent (k 0.77-0.95; ICC 0.96-0.98). Discriminatory values for presence of malignancy were 0.92-0.93 and 0.97-0.99 for quantitative and qualitative ROC analysis, respectively. This DOT system has the potential to discriminate malignant from benign breast tissue in a reproducible qualitative and quantitative manner. Important technical improvements are required before this technique is ready for clinical application.

Selection of optimal wavelengths for spectral reconstruction in diffuse optical tomography.

Using lasers with different wavelengths in diffuse optical tomography (spectral DOT) has the advantage that the concentrations of chromophores can be reconstructed quantitatively. In continuous wave spectral DOT, it is furthermore possible to distinguish between scattering and absorption. The choice of the laser wavelengths has a strong impact on how well the scattering parameter and chromophore concentrations can be determined. Current methods to optimize the set of wavelengths disregard the sensitivity of the reconstruction result to uncertainties in the absorption spectra of the chromophores. But since available absorption spectra show significant deviations, it seems to be necessary to take this into account. The wavelength optimization approach presented here is an extension to a method of Corlu et al. The original method optimizes the wavelength sets such that scattering parameters and chromophore concentrations can be separated optimally. We introduce an additional criterion that evaluates the dependence of reconstructed chromophore concentrations on deviations of the extinction coefficients. The wavelength sets found by the new approach are different from those determined with the original method. Reconstructions of simulated data show the effect of using various absorption spectra for reconstruction with different wavelength sets and illustrate the advantages of the new wavelength sets.

Investigation of detection limits for diffuse optical tomography systems: II. Analysis of slab and cup geometry for breast imaging.

Using a statistical (chi-square) test on simulated data and a realistic noise model derived from the system's hardware we study the performance of diffuse optical tomography systems for fluorescence imaging. We compare the predicted smallest size of detectable lesions at various positions in slab and cup geometry and model how detection sensitivity depends on breast compression and lesion fluorescence contrast. Our investigation shows that lesion detection is limited by relative noise in slab geometry and by absolute noise in cup geometry.

Linear image reconstruction for a diffuse optical mammography system in a noncompressed geometry using scattering fluid.

Diffuse optical tomography (DOT) is a potential new imaging modality to detect or monitor breast lesions. Recently, Philips developed a new DOT system capable of transmission and fluorescence imaging, where the investigated breast is hanging freely into the measurement cup containing scattering fluid. We present a fast and robust image reconstruction algorithm that is used for the transmission measurements. The algorithm is based on the Rytov approximation. We show that this algorithm can be used over a wide range of tissue optical properties if the reconstruction is adapted to each patient. We use estimates of the breast shape and average tissue optical properties to initialize the reconstruction, which improves the image quality significantly. We demonstrate the capability of the measurement system and reconstruction to image breast lesions by clinical examples.

Algebraic reconstruction techniques for spectral reconstruction in diffuse optical tomography.

Reconstruction in diffuse optical tomography (DOT) necessitates solving the diffusion equation, which is nonlinear with respect to the parameters that have to be reconstructed. Currently applied solving methods are based on the linearization of the equation. For spectral three-dimensional reconstruction, the emerging equation system is too large for direct inversion, but the application of iterative methods is feasible. Computational effort and speed of convergence of these iterative methods are crucial since they determine the computation time of the reconstruction. In this paper, the iterative methods algebraic reconstruction technique (ART) and conjugated gradients (CGs) as well as a new modified ART method are investigated for spectral DOT reconstruction. The aim of the modified ART scheme is to speed up the convergence by considering the specific conditions of spectral reconstruction. As a result, it converges much faster to favorable results than conventional ART and CG methods.

Evaluation of a preclinical photon-counting CT prototype for pulmonary imaging.

The purpose of this study was to investigate a preclinical spectral photon-counting CT (SPCCT) prototype compared to conventional CT for pulmonary imaging. A custom-made lung phantom, including nodules of different sizes and shapes, was scanned with a preclinical SPCCT and a conventional CT in standard and high-resolution (HR-CT) mode. Volume estimation was evaluated by linear regression. Shape similarity was evaluated with the Dice similarity coefficient. Spatial resolution was investigated via MTF for each imaging system. In-vivo rabbit lung images from the SPCCT system were subjectively reviewed. Evaluating the volume estimation, linear regression showed best results for the SPCCT compared to CT and HR-CT with a root mean squared error of 21.3 mm3, 28.5 mm3 and 26.4 mm3 for SPCCT, CT and HR-CT, respectively. The Dice similarity coefficient was superior for SPCCT throughout nodule shapes and all nodule sizes (mean, SPCCT: 0.90; CT: 0.85; HR-CT: 0.85). 10% MTF improved from 10.1 LP/cm for HR-CT to 21.7 LP/cm for SPCCT. Visual investigation of small pulmonary structures was superior for SPCCT in the animal study. In conclusion, the SPCCT prototype has the potential to improve the assessment of lung structures due to higher resolution compared to conventional CT.

[Pre- and intraoperative ultrasound imaging in neurosurgery]. / Prä- und intraoperative Ultraschallbildgebung in der Neurochirurgie.

Advanced applications of ultrasound in neurosurgery have been evaluated in two projects of the Ruhr Center of Excellence for Medical Engineering (KMR), Bochum, Germany. Engineers, neurologists, and neurosurgeons are cooperating within an interdisciplinary project structure, in order to practically approach neurosurgical problems by elaborating novel ultrasound-based technologies. On one hand, procedures have been implemented for an ultrasound-based registration of bone structures, applicable, amongst others, to the high-accuracy navigation of pedicle screws. On the other hand, concepts have been developed regarding a pre- and intraoperative application of ultrasound contrast agents for the detection of cerebral tumors and for the monitoring of surgery. In this article, both projects are discussed on the basis of the results obtained thus far and, furthermore, potentials of these concepts are presented that may complement or extend the scopes of the neurosurgical practice.

Grating-based phase-contrast and dark-field computed tomography: a single-shot method.

Grating-based X-ray interferometry offers vast potential for imaging materials and tissues that are not easily visualised using conventional X-ray imaging. Tomographic reconstruction based on X-ray interferometric data provides not only access to the attenuation coefficient of an object, but also the refractive index and information about ultra-small-angle scattering. This improved functionality comes at the cost of longer measurement times because existing projection-based signal extraction algorithms require not only a single measurement per projection angle but several with precise grating movements in between. This obstacle hinders the adaptation of grating-based interferometry into a continuously rotating gantry. Several solutions to this problem have been proposed but all suffer from major drawbacks. We present results using an iterative reconstruction algorithm working directly on the interferograms. The suggested direct approach enables improved image quality, since interpolations and unnecessary assumptions about the object are circumvented. Our results demonstrate that it is possible to successfully reconstruct the linear attenuation coefficient, the refractive index and the linear diffusion coefficient, which is a measure related to ultra-small-angle scattering, using a single measurement per projection angle and without any grating movements. This is a milestone for future clinical implementation of grating-based phase-contrast and dark-field contrast X-ray computed tomography.

Penalized maximum likelihood reconstruction for x-ray differential phase-contrast tomography.

PURPOSE: The purpose of this work is to propose a cost function with regularization to iteratively reconstruct attenuation, phase, and scatter images simultaneously from differential phase contrast (DPC) acquisitions, without the need of phase retrieval, and examine its properties. Furthermore this reconstruction method is applied to an acquisition pattern that is suitable for a DPC tomographic system with continuously rotating gantry (sliding window acquisition), overcoming the severe smearing in noniterative reconstruction. METHODS: We derive a penalized maximum likelihood reconstruction algorithm to directly reconstruct attenuation, phase, and scatter image from the measured detector values of a DPC acquisition. The proposed penalty comprises, for each of the three images, an independent smoothing prior. Image quality of the proposed reconstruction is compared to images generated with FBP and iterative reconstruction after phase retrieval. Furthermore, the influence between the priors is analyzed. Finally, the proposed reconstruction algorithm is applied to experimental sliding window data acquired at a synchrotron and results are compared to reconstructions based on phase retrieval. RESULTS: The results show that the proposed algorithm significantly increases image quality in comparison to reconstructions based on phase retrieval. No significant mutual influence between the proposed independent priors could be observed. Further it could be illustrated that the iterative reconstruction of a sliding window acquisition results in images with substantially reduced smearing artifacts. CONCLUSIONS: Although the proposed cost function is inherently nonconvex, it can be used to reconstruct images with less aliasing artifacts and less streak artifacts than reconstruction methods based on phase retrieval. Furthermore, the proposed method can be used to reconstruct images of sliding window acquisitions with negligible smearing artifacts.

Ultra Low Dose CT Pulmonary Angiography with Iterative Reconstruction.

OBJECTIVE: Evaluation of a new iterative reconstruction algorithm (IMR) for detection/rule-out of pulmonary embolism (PE) in ultra-low dose computed tomography pulmonary angiography (CTPA). METHODS: Lower dose CT data sets were simulated based on CTPA examinations of 16 patients with pulmonary embolism (PE) with dose levels (DL) of 50%, 25%, 12.5%, 6.3% or 3.1% of the original tube current setting. Original CT data sets and simulated low-dose data sets were reconstructed with three reconstruction algorithms: the standard reconstruction algorithm "filtered back projection" (FBP), the first generation iterative reconstruction algorithm iDose and the next generation iterative reconstruction algorithm "Iterative Model Reconstruction" (IMR). In total, 288 CTPA data sets (16 patients, 6 tube current levels, 3 different algorithms) were evaluated by two blinded radiologists regarding image quality, diagnostic confidence, detectability of PE and contrast-to-noise ratio (CNR). RESULTS: iDose and IMR showed better detectability of PE than FBP. With IMR, sensitivity for detection of PE was 100% down to a dose level of 12.5%. iDose and IMR showed superiority to FBP regarding all characteristics of subjective (diagnostic confidence in detection of PE, image quality, image noise, artefacts) and objective image quality. The minimum DL providing acceptable diagnostic performance was 12.5% (= 0.45 mSv) for IMR, 25% (= 0.89 mSv) for iDose and 100% (= 3.57 mSv) for FBP. CNR was significantly (p < 0.001) improved by IMR compared to FBP and iDose at all dose levels. CONCLUSION: By using IMR for detection of PE, dose reduction for CTPA of up to 75% is possible while maintaining full diagnostic confidence. This would result in a mean effective dose of approximately 0.9 mSv for CTPA.

Quantitative spectral K-edge imaging in preclinical photon-counting x-ray computed tomography.

OBJECTIVES: The objective of this study was to investigate the feasibility and the accuracy of spectral computed tomography (spectral CT) to determine the tissue concentrations and localization of high-attenuation, iodine-based contrast agents in mice. Iodine tissue concentrations determined with spectral CT are compared with concentrations measured with single-photon emission computed tomography (SPECT) and inductively coupled plasma mass spectrometry (ICP-MS). MATERIALS AND METHODS: All animal procedures were performed according to the US National Institutes of Health principles of laboratory animal care and were approved by the ethical review committee of Maastricht, The Netherlands. Healthy Swiss mice (n = 4) were injected with an iodinated emulsion radiolabeled with indium as multimodal contrast agent for CT and SPECT. The CT and SPECT scans were acquired using a dedicated small-animal SPECT/CT system. Subsequently, scans were performed with a preclinical spectral CT scanner equipped with a photon-counting detector and 6 energy threshold levels. Quantitative data analysis of SPECT and spectral CT scans were obtained using 3-dimensional volumes-of-interest drawing methods. The ICP-MS on dissected organs was performed to determine iodine uptake per organ and was compared with the amounts determined from spectral CT and SPECT. RESULTS: Iodine concentrations obtained with image-processed spectral CT data correlated well with data obtained either with noninvasive SPECT imaging (slope = 0.96, r = 0.75) or with ICP-MS (slope = 0.99, r = 0.89) in tissue samples. CONCLUSIONS: This preclinical proof-of-concept study shows the in vivo quantification of iodine concentrations in tissues using spectral CT. Our multimodal imaging approach with spectral CT and SPECT using radiolabeled iodinated emulsions together with ICP-based quantification allows a direct comparison of all methods. Benchmarked against ICP-MS data, spectral CT in the present implementation shows a slight underestimation of organ iodine concentrations compared with SPECT but with a more narrow distribution. This slight deviation is most likely caused by experimental rather than technical issues.

Spectral CT: a technology primer for contrast agent development.

Recent developments in spectral CT systems featuring binned photon-counting detector technology have enabled an imaging concept on a pre-clinical level that has been coined K-edge imaging. This exciting concept allows the selective and quantitative imaging of contrast media by exploiting the K-edge discontinuity in the photo-electric component of X-ray absorption. An ideal application for K-edge imaging is CT imaging of target-specific and conventional contrast agents that have been designed to be spectral-CT-visible. Current limitations in detector hardware, however, result in typically high noise levels that hamper the application of K-edge imaging. In order to battle noise and assure sufficient sensitivity, the development of dedicated K-edge contrast media in combination with advanced image processing techniques is imperative. This work attempts a comprehensive overview on how the concert of dedicated contrast media, optimized data acquisition and innovative data processing techniques improve sensitivity of K-edge imaging which will foster clinical translation of the technology.

Statistical reconstruction of material decomposed data in spectral CT.

Photon-counting detector technology has enabled the first experimental investigations of energy-resolved computed tomography (CT) imaging and the potential use for K-edge imaging. However, limitations in regards to detecter technology have been imposing a limit to effective count rates. As a consequence, this has resulted in high noise levels in the obtained images given scan time limitations in CT imaging applications. It has been well recognized in the area of low-dose imaging with conventional CT that iterative image reconstruction provides a superior signal to noise ratio compared to traditional filtered backprojection techniques. Furthermore, iterative reconstruction methods also allow for incorporation of a roughness penalty function in order to make a trade-off between noise and spatial resolution in the reconstructed images. In this work, we investigate statistically-principled iterative image reconstruction from material-decomposed sinograms in spectral CT. The proposed reconstruction algorithm seeks to minimize a penalized likelihood-based cost functional, where the parameters of the likelihood function are estimated by computing the Fisher information matrix associated with the material decomposition step. The performance of the proposed reconstruction method is quantitatively investigated by use of computer-simulated and experimental phantom data. The potential for improved K-edge imaging is also demonstrated in an animal experiment.