ISSN 1617-2876March 2013toshiba medical systems MAGAZINE 201321From bone subtractionto organ perfusionCOMPUTED TOMOGRAPHYFly Thru andSmart Fusion:Advanced techniquesfor better diagnosticaccuracyULTRASOUNDEurope: Experienceswith Ultimax-iand first Raffine systemX-RAYFlow sensitive black blood imagingfor early detection of strokeMagnetic Resonance IMAGING
VISIONS 21 . 13 EDITORIALDear reader,3Sharing my passion for and deep interest in Japan andhaving actively studied martial arts together for manyyears one of my closest friends accompanied me on a visitto an international exhibition dedicated to the samurai1;the military nobility of pre-industrial Japan.The exhibition brings together unique items from privatecollections and museums in Japan and throughout Europe.It reflects an interesting time when warlords, the Daimyo,fought each other by employing the services of fearsomesamurai warriors and illustrates the highly developedwarrior culture of that period.Walking through the museum, we were veryimpressed by the beautiful armor, spectacular helmets andmagnificent swords that were deemed to reflect the ‘soulof the samurai’. Also on display were war banners, Nobori,from the Kitamura Collection, painted with family coats-of-arms and protective mythological figures, to identifythe samurai on the battlefield.One particular Nobori showed a Koi Carp bravelyclimbing a waterfall. Legend states that once caught, thefish will lay on the cutting board awaiting the knifewithout a quiver. In Koi symbolism, this has been likenedto a samurai warrior facing a sword. Ancient legend alsosaid that a Koi that succeeds in climbing the falls istransformed into a dragon. Based on that legend, the Koi,at that time, was symbolic of worldly aspiration andadvancement.The code of ethics, Bushido, imposed a lifestyle of honor,loyalty and respect within the warrior class. The samurai-elite devoted themselves with equal dedication to variousarts such as calligraphy and the tea ceremony, and theywore delicately crafted accessories, including Netsuke andInro lacquer work. A surprising element is the Dutchinfluence on the samurai warrior equipment, caused bythe special bond between the two countries.Working close to a decade at Toshiba, I can proudly saythat the same ethics, devotion and dedication is beingapplied daily to our product development and production,marketing and sales, service and support and above all, tothe way we work together with our customers to provideintegrated diagnostic solutions through long-termpartnerships.We are committed to achieving the best in patient safe-ty across all modality products and it is our dedication andcontinuous mission to improve the overall quality of life ofall people.Kind regards,Jack HoogendoornSr. Manager Marketing CommunicationsToshiba Medical Systems Europe BV1 Wereldmuseum Rotterdam, 11 October 2012 - 26 May 2013. E-mail: email@example.com, Web: www.wereldmuseum.nl
4EditorialPresident’s messageM. Prokop Clearly Better – Toshiba’s Vision EditionLaunched in EuropeCase story Musculoskeletal Disorders: DSA-like BoneSubtraction with 320 Detector Row CTJ. Hermans Whole Organ Perfusion of the PancreasUsing Aquilion ONEThe first new generation Aquilion PRIME Breaking New Ground in Scanning InnovationE. Kotter Initial Clinical Experiencewith 3D Interventional SoftwareVital Images Vital Signs Landmark Dealwith Skåne University Hospital F. Admiraal-Behloul Neuro-Microvascular Imaging at 1,5TUsing the Flow Sensitive Black Blood TechniqueA ground-breaking partnershipToshiba Medical Systems joinsManchester United33069121620222632Computed TomographyAdvanced VisualizationMRISports medicineThis edition of VISIONS magazine is coveringToshiba’s European region and as such reflectsproducts, technologies and services for that area.All mentioned products may not be available inother geopgraphical regions. Please consult yourToshiba representative sales office in case of anyquestions.VISIONS 21 . 13 CONTENTS With Toshiba’s newestand most advanced CT system,the AquilionTMONE /Vision Edition,diagnosis goes faster and safer –Pages 6 and 12Two experts in medical technology joinforces – Page 22
UltrasoundX-RayNewsEventsRaffine and Ultimax-i improve diagnosticsand workflow in Russia and Scotland.Page 54 and 58Two iconic brands come together:Toshiba supports Manchester UnitedFootball Club as its Official MedicalSystems Partner – Page 32VISIONS 21. 135E. G. GrantAdvanced Techniques in 4D Ultrasound:Fly ThruM. Filip, P. Linzer, D. SkoloudikVirtual Navigation – A New Modality inPerioperative Brain Tumor ImagingT. Fischer, A. Thomas, U. BickComplementary Mamma Diagnostics toCharacterize Focal Breast LesionsN. AzarAdvances in Ultrasound:Smart Fusion TechnologyEurope’s first RaffineRussian Lung Specialists Refine ImagingWith Toshiba SystemExperiences with the Ultimax-iScottish Hospital Opts for Flexibility in X-RayMeanwhile at ToshibaECR 2013The World of Imaging Meets in Vienna3641445054586366CONTENTS
VISIONS: Radboud University Medical Centeris the first hospital in Europe to receive a newToshiba Aquilion ONE Vision. What wasbehind the decision to choose the system?Prokop: I chose this system because of its superiorimage quality, fast rotation time, modified detectorsystem and ultra low-dose capabilities. I thoughtToshiba’s Aquilion ONE was a good machine thatbrought real advantages in both clinical practiceand research, and as a next generation system, theVision Edition offers even more benefits. As withProfessor Mathias Prokop is one of the world’s lead-ing experts on body imaging. With a particular in-terest in new CT technologies, he has explored theboundaries of this modality for the last 25 years,heading many research institutes and projectsworldwide. As Chairman of the radiology depart-ment at Radboud University Medical Center inNijmegen, one of the Netherlands’ most well-knownacademic hospitals, he recently acquired Toshiba’snew ViSION Edition™ system for his multi-disci-plinary team. This state of the art system, whichprovides new clinical options through its faster ro-tation time, improved dose efficiency, wider boreand enhanced range of applications, is the first tobe installed in Europe. VISIONS Magazine talked toProfessor Mathias Prokop to find out more abouthis decision to invest in the new system and experi-ences with it since installation in July 2012.Clearly Better –Toshiba’s Vision EditionLaunched in EuropeVISIONS 21.13 COMPUTED TOMOGRAPHY6Professor MathiasProkop and his teamare happy to usethe world’s mostadvanced dynamicvolume CT system.Being able toview imagesinstantaneously hasa huge impacton our work.“ “
and immediately accessible, affording us greater ca-pabilities in trauma and emergency care, cardiologyand neurology, and the chance to carry out a widerrange of perfusion techniques. With real-time con-struction of images we have far more scope to scantrauma and emergency patients and assess condi-tion quickly. The image subtraction feature on theVision Edition is improved, offering us enhancedoptions in this method, which minimizes artifacts.The software capabilities with the new machine areamazing. The perfusion software is so flexible thatwe can jump to imaging other organs without inter-rupting the examination on one. The new system hasgood warping capabilities for scanning all organs.We have already achieved good results with imag-ing spleen and kidneys. Bowel imaging is currentlynot quite so straightforward, but we are exploringthe possibilities with the Vision Edition. The newsoftware for brain imaging is a unique, new feature.This is a particular interest of mine. Advances in CTimaging of the brain could be beneficial in work-ing with stroke patients, for example. We haven’tyet explored the 3D fluoroscopy capabilities of themachine but with the Vision Edition this is avail-able. Dose reduction is so effective that we are ableto make CT scans using a dose range equivalent tothat used for X-ray – a substantial reduction of upto 75%.VISIONS: How was training to use theViSION Edition?Prokop: It was a very smooth transition into start-ing to use the new system as there is very little dif-ference in operation from the Aquilion ONE. Thereare no new operational issues and some things haveeven been made even easier and faster to use.its predecessor, we can scan all organs within onerotation. However, the gantry rotation is acceler-ated from 0.35 seconds with the Aquilion ONE to0.275 seconds with the Vision Edition. This fastertime opens up new possibilities for reducing theimpact of image artifacts and improving image ac-curacy in cardiac imaging, for example, or pediat-ric or emergency investigations, in which it can bedifficult to minimize movement of the patient, aswell as enabling us to perform a broader range ofperfusion examinations and increasing our work-flow. The Vision Edition has integrated AdaptiveIterative Dose Reduction (AIDR) 3D that enables usto achieve even lower dose scanning. Its wide, 78 cmbore set-up allows fast and easy set up for any typeof clinical examination.In addition, I was able to work together with theToshiba development team on certain issues whenthe system was in the final stages of development.I very much like to contribute to new things. I seethis as a way of providing input into the future of CT.VISIONS: You worked quite extensively withthe Toshiba team in Japan during developmentof the Vision Edition. What sort of issues wereyou involved in?Prokop: My collaboration involved developinga digital phantom to establish new standards forthe machine and exploring the effect of varyingmany factors, such as the influence of differentalgorithms, the timing of the scan, filtering andsequence of dose variables. Through these investi-gations, we discovered some optimum calibrationsfor separate components. One particular interestthat I have is exploring brain perfusion with themachine, since it is ideal for both research purposesand clinical practice, and I have been working withToshiba on this too.VISIONS: Now that it is installed, what do youparticularly like about the system?Prokop: The Vision Edition is altogether a veryimpressive scanner. There are many incrementalimprovements compared to the Aquilion ONE. Theimage quality achieved with the system is superior7Main entrance of the St. Radboud hospitalI chose this systembecause of its superiorimage quality,fast rotation time,modified detectorsystem and ultralow-dose capabilities.““
VISIONS 21.13 COMPUTED TOMOGRAPHYresearch. Being able to view images instantaneouslyhas a huge impact on our work. The system hasalready improved our workflow and we are able touse it for an increasing number of applications. Weare able to use lower than ever doses and achievehigher patient- and consultant satisfaction. It alsoreduces our costs.VISIONS: How about the service you havereceived from Toshiba?Prokop: We are very happy with the excellent serv-ice we received from Toshiba’s team in Japan andToshiba Medical Systems Europe in the Netherlands.As one of the first users of different generations ofCT scanners, I am familiar with the risks involved inpurchasing and installing new systems. I know whatcan happen and what the pitfalls are but in thisinstance, there were only very minor issues to workon. Overall, the collaboration during development,the added benefits of the new Vision Edition andthe service package provided by Toshiba have beenoutstanding.VISIONS: Thank you.VISIONS: What comments have yourcolleagues made about the new system?Prokop: The trauma unit in particular has benefit-ted already from the speed of the Vision Editionand the extended range of high quality images thatcan be achieved. Even the upper extremities, for ex-ample, can easily be scanned in very short spaces oftime. The emergency staff at the hospital continueto be amazed by the immediate diagnosis possi-bilities provided by the new machine. It is an idealsystem for use in trauma and emergency care. Ourneurologists are using the scanner for both regularneurological assessments and also advanced CT per-fusion techniques. They are exited about the imagequality produced by the system. Our cardiologistscan perform a broader range of examinations andare now using CT perfusion techniques, which theywere not able to perform before. It has actuallychanged the way our cardiologists think about theuse of CT in their field. I believe that CT will becomethe imaging modality of choice for an even widerrange of diagnostics, and with the Toshiba VisionEdition I am able to convince my colleagues of thistoo.VISIONS: What difference has the systemmade to the radiology department in general?Prokop: The department serves a total of 18 resi-dent radiology specialists, is staffed by 30 employ-ees and is used to diagnose approximately 100,000patients per year. The Vision Edition is a very wel-come addition to our two existing machines in thedepartment. It is in constant use for a very broadrange of applications from trauma and emergencycare and a wide range of clinical applications to8In addition to havingproduced hundreds ofscientific papers on lead-ing issues in body imag-ing, Professor Prokopis co-author of one ofhealthcare’s best knownreference titles on CTtechniques, Spiral andMultislice ComputedTomography of the Body, (ISBN 978-3-13-116481-0 (TPS, Rest of World), ISBN 978-0-86577-870-2 (TPN, The Americas), MathiasProkop and Michael Galanski. The title is aworldwide bestseller and whilst the book wasso advanced for its time that it still has perfectrelevance today, a new edition is currently inthe pipeline.Toshiba’s Aquilion ONE was a good machinethat brought real advantages in bothclinical practice and research. As a nextgeneration system, the Vision Edition offerseven more incremental benefits.““
9Paget‘s diseaseVISIONS 21.13ComputeD tomographYin MR calcium does not directly interfere with thevisualization of the contrast media.The typical example of a non-lytic, enhancingbone anomaly with major diagnostic implications isthe so called bone marrow edema pattern (BMEP).BMEP can be present in association with multipletumors, inflammatory, degenerative and traumaticconditions and is composed of a mosaic of differenthistologic anomalies (fibrosis, trabecular thickening,cellular infiltration and to a lesser extent edema)1.BMEP invariably enhances and its identificationis important for lesion characterization and mayhave significant prognostic implications which candirectly influence patient management2. NormallyBMEP is only seen on MR since the normal boneprecludes the visualization of this anomaly on CT.DSA-like (Digital subtraction angiography) bonesubtraction is a CT technique that allows removal ofcalcifications and bone (both cortical and trabecu-lar) without affecting the visualization of adjacentcontrast enhanced structures. This technique allowsthe identification of contrast enhancement on CTof a non-lytic bone lesion and can be useful in vari-IntroductionCT is a frequently used imaging method for theevaluation of bone lesions and densely calcifiedsoft tissue musculoskeletal lesions. It elegantlydemonstrates the lesion’s contours and the reactivechanges of the bone and periosteum adjacent toit, features which are fundamental for lesion char-acterization. Some lesions however require furtheranalysis to reach a conclusive diagnosis or narrowdown the possible differential diagnosis. The intra-venous injection of contrast media is one of themost frequently used tools to help in the charac-terization of musculoskeletal lesions.On CT, enhancement after iodinated contrastinjection is readily seen in lytic and non-calcifiedsoft tissue lesions. The visualization of contrastenhancement in non-lytic bone lesions is howeverpractically impossible with conventional CT tech-niques because the high density of trabecular andcortical bone obscures the visualization of the hy-perdense iodinated contrast. This represents one ofthe main advantages of MRI over CT for the evalua-tion of non-lytic or densely calcified lesions becauseMusculoskeletal Disorders:DSA-like Bone Subtraction with320-Detector row CTP. TeixeiraUniversity Hospital(CHU) NancyRadiology Department,Nancy, FranceCase 1Focal lytic bone lesion with marked corticalthickening in an elderly patientCortical enhancement has a similar densitythan the cortical bone and is taken away withclassic bone subtractionWith DSA bone subtraction the full extentof cortical enhancement is demonstrated.This patient has a biopsy proven focalPaget’s diseaseMRI T2FSX-RayDSA bonesubtractionClassic boneremovalWhy is it different?
VISIONS 21.13 ComputeD tomographY10other hyperdense structureshave been completely re-moved and only the enhanc-ing structures remain (Case 1and 2).Image registration is atthe heart of DSA-like bonesubtraction. If the pre- andpost-contrast volumes are notmeticulously matched pixelby pixel, artifacts are intro-duced into the subtracted im-ages. Most of these artifactsare related to patient motionbetween the two acquisitions.Together with the greatly re-duced acquisition time pro-vided by current 320-detectorrow CT scanners (less than 0.5s for the whole volume) theuse of non-rigid registrationalgorithms can help overcomemotion related artifacts. Withthe development of robust registration algorithmsdedicated to the bone analysis, intra-osseous en-hancement can be confidently identified.Until now, this type of bone removal was not avail-able in clinical practice because the subtractionof conventional helical acquisitions is technicallydemanding and time consuming. 320-detector rowCT scanners can image up to 16 cm in a single rota-tion of the X-ray tube using a sequential acquisitionmode. Using this type of acquisition the subtractionof pre- and post-contrast volumes is simpler andfaster. Similar to DSA, a pre-contrast volume (mask)is subtracted from a post-contrast one and afterpost-processing a new volume, in which only con-trast enhancement remains, is generated.Materialand methodsDedicated bone subtraction algorithms were usedfor the evaluation of patients referred for CT imag-ing at our institution for the diagnostic work-up ofsuspected bone lesions. All CT images were acquiredwith a 320-detector row CT scanner (Aquilion ONE,Toshiba Medical Systems, Otawara, Japan) using asequential scan mode before and after injection ofiodinated contrast media. An iterative reconstruc-tion algorithm (AIDR 3D) was used and the tubeoutput parameters (kV, mAs) were adapted to thepatient body habitus in order to keep the exposuredose to a minimum.The images were then post-processed usingSURESubtraction Ortho software. The subtracted im-ages were compared to conventional CT images andcorrelated to MRI when available. Selected casesthat demonstrate the added diagnostic value ofDSA-like bone subtraction are presented.ous clinical settings such as tumor characterization,tumor staging, occult fractures and inflammatorydiseases. Additionally DSA-like bone subtractioncan be performed with conventional CT protocols(pre- and post-contrast) as well as with dynamicCT perfusion.DSA-like bone subtraction offers a great advan-tage over conventional density-based bone subtrac-tion techniques on CT. In the latter methods the boneand calcification are segmented from the adjacentvessels and soft tissue based on their density andmorphology. When there is intra-osseous enhance-ment there is no difference in morphology or in den-sity making it impossible to separate the bone fromcontrast enhancement. As a result, intra-osseouscontrast enhancement is removed along with thebone with the consequent loss of important diag-nostic information. In this manuscript a descriptionof the principles of this technique is provided alongwith examples of its clinical applications (Case 1 & 2).Basic principlesAs its name implies DSA-like bone subtraction usesthe same principle of bone subtraction as used forinterventional radiologic procedures. A mask forsubtraction of the anatomic region to be studiedis acquired before contrast injection. Contrast isthen injected and the post-contrast image acquisi-tion is performed normally. During post-processingthe two image sets are registered so that everyanatomic structure corresponds exactly. Finally theregistered image sets are subtracted. Since for X-ray based imaging methods calcium and metal areusually the only spontaneously dense structuresto be found before contrast injection the result ofthe subtraction is an image set in which bone andLocal stagingof a lyticbone lesion,64 year oldfemale,Femur sarcomaMRI(T2 fat saturated sag) CT perfusionCT perfusion CT with DSA-like bonesubtractionThis lesion has three components:Soft tissue (arrowheads), lytic bone (thin arrows) and nonlytic bone (fat arrows).As expected MR imaging can depict all three components.In conventional CT perfusion, however the nonlytic component is not seen.With DSA-like bone subtraction enhancement is seen in the nonlytic areasof the bone, matching the enhancement seen on MR.This information has obvious importance in the surgical planning.Case 2
11Clinical experienceThere are many potential clinical applications ofDSA-like bone subtraction. From our experiencethis technique is particularly useful in the followingclinical contexts:Identification of BMEPCT studies are often performed for the evalua-tion of osteomyelitis or spondylodiscitis, howeverstructural bone anomalies and bone changes maynot be present in the acute phase, precluding di-agnosis at this stage. In some clinical contexts,such as diabetic foot ulcers, decubitus ulcers, backpain and fever, the visualization of BMEP is highlypredictive of intra-osseous spread of infection andhas obvious implications for patient management.The presence of BMEP is also a key feature for thediagnosis of stress fractures and bone-on-boneimpingement (osteochondromas, hypertrophicbone callus, wrist and ankle impingement syn-dromes). When conventional CT is inconclusive, acomplementary imaging method, usually MRI orscintigraphy, has to be performed to reach diag-nosis3. The use of DSA-like bone subtraction algo-rithms can help identify areas of BMEP on CT scanswhich can expedite the diagnosis, since in manyof these cases CT is the first evaluation methodemployed. The ability to detect BMEP on CT alsoincreases the diagnostic possibilities when MRI isnot available (pacemaker, cochlear implants, agi-tated or claustrophobic patients).Localization of occult bone lesionsMultiple benign and malignant conditions maypresent as a non-lytic, non-sclerotic bone lesionswhich are not identifiable on conventional CT. Theidentification of an intra-osseous enhancing lesionis of significant clinical importance because thisfinding may be related to early metastatic diseaseor aggressive bone tumors. Although CT with bonesubtraction is not a screening tool, CT is performedin a wide set of clinical situations and the ability todetect this type of bone lesion may be important forpatient management. As with all current CT acquisi-tions, subtracted images can be reformatted in anyplane, which in our experience offers a welcome aidin the planning and execution of CT guided bonebiopsies.Characterization of lytic bone lesionsBone tumors occur frequently as non-specificlesions on imaging. The diagnosis in these tu-mors relies on invasive procedures (percutane-ous or surgical biopsy) for the histologic con-firmation of the lesion’s nature. Relatively fewlytic bone lesions are known to be associatedwith BMEP on the adjacent bone marrow, whichacts in these cases as a distinguishing feature.This is the case for osteoid osteomas, osteob-lastomas, chondroblastomas and eosinophilicgranulomas4. DSA-like bone subtraction addsthe possibility of using conventional CT to non-invasively diagnose these lesions, sparing thepatient additional invasive diagnostic tests.Local staging of lytic bone lesionsAggressive bone lesions may demonstrate micro-scopic invasion of the bone adjacent to its margins.The non-invasive differentiation between tumorinvasion and reactive bone change is difficult andsometimes impossible since both of these anoma-lies are associated with abnormal enhancement innon-lytic bone adjacent to a bone mass4. Accuratelocal staging is one of the cornerstones of curativesurgical resection of bone tumors. DSA-like bonesubtraction can demonstrate enhancement adja-cent to an aggressive bone lesion assisting in accu-rate local staging. Additionally this technique mayhave a potential role in association with other MRbased imaging techniques in the characterization ofperitumoral anomalies.Assist perfusion analysis(ROI placement) when performingCT perfusion of bone lesionsWith the major dose reduction offered by new de-velopments in CT technology, mainly related to bet-ter and larger detectors and iterative reconstructionalgorithms, CT perfusion can now be used in a widerrange of clinical applications. This is particularlytrue for the upper and lower limbs, where the tissuesensitivity to radiation is very low with a resultantlow effective dose. CT perfusion of bone lesions canbe difficult because of the adjacent high densitybone. Although contrast enhancement in non-lyticbone is measurable on CT perfusion it cannot beseen. How can you measure something you cannotsee? Where should you place the ROI? Bone sub-traction is of great assistance in these cases. Oncesubtraction allows the enhancing area to be visual-ized the ROI can be correctly placed increasing theaccuracy of CT perfusion results.ConclusionThe use of CT scanners with a wide detector designoffers the possibility of DSA-like bone subtraction,which has many potential applications in the evalu-ation of musculoskeletal disorders. This techniquehelps locate, characterize and stage malignant andbenign bone lesions. It also has an important role inCT perfusion of bone tumors, assisting in the selec-tion of the region to be analyzed. Enhancement ina non-lytic bone lesion may have major diagnos-tic implications and is currently evaluated by MRI.DSA-like bone subtraction increases the diagnosticpower of CT in various clinical situations helpingreach a conclusive or highly probable diagnosis forpatients with musculoskeletal disorders.References1 Blum A, Roch D, Loeuille D, Louis M, Batch T, Lecocq S, et al. [Bonemarrow edema: definition, diagnostic value and prognostic value].J Radiol. 2009 dez;90(12):1789-811.2 Walsh DA, McWilliams DF, Turley MJ, Dixon MR, Fransès RE, MappPI, et al. Angiogenesis and nerve growth factor at the osteochondraljunction in rheumatoid arthritis and osteoarthritis. Rheumatology(Oxford). 2010 out;49(10):1852-61.3 Toledano TR, Fatone EA, Weis A, Cotten A, Beltran J. MRI evaluationof bone marrow changes in the diabetic foot: a practical approach.Semin Musculoskelet Radiol. 2011 jul;15(3):257-68.4 James SLJ, Panicek DM, Davies AM. Bone marrow oedema associ-ated with benign and malignant bone tumours. Eur J Radiol. 2008jul;67(1):11-21.
on different models, i.e. maximum slope and patlakplot. These models have different requirements andproduce different outcomes. The maximum slopeis a linear approach which computes the perfusionvalues based on the maximum slope of the arterialtime curve showing the arterial flow of the organ inml/min/100ml. The Patlak plot relies on the back-flow of contrast medium from the extravascular tointravascular compartments. The exchange of con-trast between blood and tissue is then calculatedon the Patlak plot, which uses linear regression toanalyze contrast uptake in tissue.Patient history and diagnosisA 64-year-old man with vague abdominal pain waspresented at our hospital after a transabdominal ul-trasound showed a hypoechoic mass of about 4 cmin the uncinate process of the pancreas. C-reactiveprotein, liver function tests, amylase, Hb and leuko-cytes were all within normal range. Because of thisfinding the patient was analyzed within a fast trackprotocol for workup of pancreatico-biliairy disease.After written informed consent was obtained thepatient participated in a study on CT perfusion ofthe pancreas and liver. The CT perfusion imageswere registered and the tumor in the pancreas wassubsequently analyzed according to the maximumslope model and the Patlak model. With both modelsa 4-5 cm mass was shown in the head of the pan-creas without obstruction of the common bile andpancreatic duct. The mass showed a large nonper-fused center. Towards the periphery of the tumor theperfusion gradually increased to normal pancreaticIntroductionAquilion ONE /Vision Edition, which has been intro-duced at the RSNA 2012, brings us a fundamentallynew way to use a computed tomography (CT) scan-ner. With its fastest rotation time of 0.275 ms andz-coverage of 16 cm this state-of-the art scannerprovides us and our patients with robust clinicalsolutions every time. Not only produces AquilionONE /Vision Edition the highest diagnostic imagequality with the lowest possible radiation exposureit also offers new clinical solutions, like dynamicimaging and whole organ perfusion. This new CTscanner allows us to scan dynamically with uniform(xyz) temporal resolution of 137.5 ms and 16 cmvolume coverage: from morphological to physiolog-ical diagnosis. Only few studies have been publishedabout CT perfusion of the pancreas, partly due to thesmall volume of coverage with previous scanners.Aquilion ONE /Vision Edition makes it possible toscan an entire organ such as the pancreas.During free breathing of the patient multiplesequential time points are acquired to obtain a tis-sue concentration curve. The time interval betweenacquisitions is small in the arterial phase (circa 2seconds), is larger in the parenchynal phase (circa3 seconds) and increases to 1 minute in the latevenous phase (Fig. 1).Because of movement of the pancreas in the z-axis during the acquisitions, the obtained high reso-lution perfusion images are registered with a sophis-ticated non-rigid algorithm, using one volume withmaximal enhancement as a reference scan. Subse-quently, perfusion maps can be calculated basedJ. J. HermansWhole Organ Perfusion of thePancreas Using Aquilion ONEVISIONS 21.13 COMPUTED TOMOGRAPHY12Fig. 1: Timesequence protocol
in the pancreatic head. FNA from the solid compo-nents demonstrated malignant cells belonging to acarcinoma of the pancreas.CommentsQuantitative analysis of tissue microcirculationcan possibly be used for biological characteriza-tion of solid pancreatic tumors and for evaluationof response to chemotherapeutic agents and-orradiotherapy. In the future perfusion parametersmight be used to predict tumor aggressiveness and/or to design an individually tailored therapeuticapproach.tissue. For perfusion analysis of the liver a dual inputmodel was used which showed a small hyperper-fused lesion of 5 mm in the caudate lobe and asmall non-perfused lesion of 5 mm in segment sixof the liver. On T2-weighted TSE and post-contrastMR images the lesion in the caudate lobe showedcharacteristics of a metastasis and the lesion in seg-ment six of a cyst. On MRI four more metastases inthe liver cupola were detected. Because the pan-creatic tumor was positioned rather caudal in thepancreas, the liver could not be completely coveredwithin the 16 cm dynamic volume. Therefore thesemetastases high in segment four and eight couldnot be analyzed for perfusion characteristics. Be-cause of the presence of liver metastases a curativeresection of the primary pancreatic tumor was nolonger feasible. To obtain a definitive diagnosis anendoscopic ultrasound (EUS) was performed whichshowed a multicystic mass with solid components13Max. slopeFig. 2: Two different models:maximum slope and Patlak plotFig. 3: A small lesion in segment six of the liver with high signal intensity on a coronalHASTE image without contrast enhancement in the late venous phase, characteristic of a small cystPatlak
Fig. 6: Maximumslope modela) contrast-enhancedCT image of a largetumor in thepancreatic head.b) Perfusion map of thetumor with ROI1 inthe central necrosisand ROI2 in theenhancing rimFig. 4: Small lesion inthe base of the caudatelobe with increasedsignal intensity on T2-weighted TSE with fatsuppression image andrim enhancement in thelate venous phase,characteristic of ametastasisVISIONS 21.13 COMPUTED TOMOGRAPHY14Fig 5: Shows the enhancementcurve in the aorta (artery)and in the pancreas tail (tissue)6a6b
15Fig. 7: Patlak graphbefore (a) and after (b)adjustment of start point(SP) and end point (EP)Fig. 8: Patlak modela: perfusion map of alarge tumor in the pancreatichead with central necrosis(ROI 1) with a rim ofenhancing tumor tissueb: perfusion map of thenormal pancreatic tail (ROI 1)7b8a8b7a
VISIONS: Why did you investin the Aquilion PRIME?Nigel Lewis: It is an unusual situation in that wewere acquiring the first new generation AquilionPRIME CT scanner. The Bradford Teaching Hospi-tal Trust had already invested in an Aquilion ONEscanner in 2012 for St Luke’s Hospital. We reallywanted a very high specification scanner that wouldefficiently and effectively execute a throughputof work across a wide variety of areas includingcancer staging, MSK, cardiac CT, CTCs all the wayNigel Lewis is Clinical Services Manager and Headof Profession at Bradford Royal Infirmary, one ofthe UK’s most respected centres for radiology. Thehospital has recently acquired an Aquilion PRIME CTscanner for his multidisciplinary team. The state-of-the-art technology installation means that BradfordRoyal Infirmary becomes a world reference centrefor the most advanced CT scanning equipmentavailable today.VISIONS magazine travelled to Bradford to talkwith Nigel Lewis and his team to find out moreabout the installation of the first new generationToshiba Aquilion PRIME CT scanner and his team’sexperiences with it, during and since installation inJanuary this year.With the newAquilion PRIMEBradford Royal Infirmarybecomes a worldreference centre for themost advanced CTscanning equipmentavailable todayBreaking New Groundin Scanning InnovationVISIONS 21.13 COMPUTED TOMOGRAPHY16Bradford Teaching Hospitals gainsthe first new generation Aquilion PRIMENigel Lewis: “With regardto the technology we can’tcompare it with anythingelse as its a new generationof equipment.”“ “
also helps Toshiba in helping define future develop-ments of its scanning platforms. The ongoing support from installation onwardssaw a team of five consultants from Toshiba including the machine technicians, software engineersthrough to advanced neuro imaging. We were alsovery interested in the shuttle helical function forbrain and future developments for body perfusionscanning. Ultimately, we were looking at spendinga significant amount of money for the best technol-ogy available. We needed to ensure it was future-proofed for up to 10 years.What really caught our attention was its smallerfootprint combined with its large diameter bore ofgantry, which enhances the patients experience asthey don’t feel so claustrophobic. Additionally theapplications packages like InstaView and HybridView with fast reconstruction are easily integratedwith our protocols and workflows.VISIONS: How closely did you work with theToshiba team prior to, and during installation?Nigel Lewis: I think we have a very special rela-tionship with Toshiba. We have had a very positiveexperience previously with the installation of theAquilion ONE at St Luke’s. Right from the very start,Toshiba Japan, together with the UK team wereheavily involved in the installation, acceptance test-ing, setting up of protocols and from the outset ofscanning procedures. We look at it going forward asa real partnership that helps us get the best out ofthe technology for the hospital and its patients, but17Jonathan Barber (left) and Nigel Lewiswere really impressed about the system setup and installation“Jonathan Barber: “We havebeen very impressed withthe Aquilion ONE and believethat the Aquilion PRIMEwill develop our examinationexpertise even further.”“
The Bradford RoyalInfirmary, one of theUK’s most respectedcentres for radiologyexaminations that we cannot currentlyoffer. We will realise real advances forbrain perfusion, body perfusion and forsome of the dual energy applications,like stone characterization, that we areplanning to design with Toshiba’s help.Ultimately we’ll be able to complete afull scan, quickly and effectively and getthe patient moving faster towards treat-ment and recovery.Anne Williams, CT Advanced Practitioner and TeamLeader: The scanning and table movement is ex-tremely quick and the design is extremely intuitive,which means that our staff can get to grips withthe best technology very quickly. We are increasingthe number of patients per session and reducingcontrast dose by at least fifty percent compared toprevious scanners we have used.VISIONS: Finally, what are your hopes for the sys-tem over the next year? What results do you hopeto achieve and how will you measure success?Nigel Lewis: We hope to demonstrate that the newGeneration Prime has significantly contributed toour scanning capacity and the development of ad-vanced scanning protocols, whilst being mindful ofthe complexity of examinations and the patientsexperience through access to this new technology.We are also looking forward to seeing the stafftraining and development at the same speed oftechnology innovation, both for scanning applica-tions and for reporting.It will definitely raise our profile as a worldreference centre and we’re looking forward to be-ing the first to see developments on the platform.We have a very good equipment base with ourAquilion PRIME and Aquilion ONE technology andlook forward to continuing to develop our clinicalservice to the benefit of both the patients and staff.VISIONS: Thank you very much for your time.We look forward to catching up againto find out what the partnership achieves overthe next year.and applications specialists on site throughout in-stallation and ‘going-live’ period.Jonathan Barber, Consultant Radiologist andDivisional Director for Clinical Support Services: It’sincredibly exciting. We have a very good relation-ship with Toshiba that is based on great experienceswith the technology and the service and support.We’ve been very impressed with the Aquilion ONEand believe that the Aquilion PRIME will develop ourexamination expertise even further.VISIONS: What has impressed you aboutthe system set up and installation?Nigel Lewis: Firstly, I think the installation was veryimpressive, the fact that it was a new scanner andthe support that was made available to the Trustboth in protocol design, selection and building andin the actual applications training for the staff. Ithink it’s over and above what we have experiencedbefore.With regard to the technology, we can not com-pare it with anything else as it is a new generation ofscanner. Aquilion PRIME will enable us to increasepatient throughput and to develop our scanningcapabilities with boby perfusion and dual energycapabilities.VISIONS: What benefits have been realizedwith the system in place?Nigel Lewis: Over the coming months our capacitywill increase. The scanner is obviously faster thananything we have been used to so that will realiseextra capacity and patient throughput. More im-portantly, we can actually plan forward and offerVISIONS 21.13 COMPUTED TOMOGRAPHY18“Anne Williams: “We are increasingthe number of patients persession and reducing contrastdose by at least fifty percent.”“
Department ofDiagnostic RadiologyUniversity HospitalFreiburg, GermanyBasic principlesToshiba supports three modes of CT fluoroscopy that covera wide range of interventional procedures.1. Continuous 3-slice fluoroscopy2. One shot 3-slice scan3. 3D interventional softwareContinuous 3-slice scan mode permits instrumenttracking in real-time, much like conventional fluoroscopy.This mode is frequently chosen for biopsies of lesions thatare prone to physiological movement.One shot 3-slice scan mode provides three consecutiveimages with full resolution and requires considerably lessdose and thus less exposure for patient and staff.3D interventional software provides an isotropic 0.5mm single exposure volumetric scan of up to 16 cm andis displayed in MPR. This technology allows the accurateplanning and tracking of the needle path in oblique anddouble oblique orientation with excellent spatial orienta-tion and excellent tracking targets with a low dose tech-nique.IntroductionDue to its excellent low contrast and highspatial resolution CT has a long history of be-ing the modality of choice for complex biopsyprocedures. While CT fluoroscopy (CTF), intro-duced by Toshiba in 1994, made proceduresfaster and safer the recent launch of 3D inter-ventional software is a further major advancein CT-guided biopsy techniques.Complex biopsies often require a needleapproach which traverses through the scanplane, making needle paths more difficult totrack. True 3D interventional software, madeavailable on the Aquilion ONE, helps tackleeven the most challenging biopsy proceduresand thus offers real clinical benefits. Remark-ably enough low dose parameter settings canbe maintained as the use of AIDR 3D is ac-companied by only a very minor penalty inreconstruction time.E. KotterInitial Clinical Experience with3D Interventional SoftwareVISIONS 21.13 COMPUTED TOMOGRAPHY20
Case studyA 78-year-old male with a spiculatedlung mass in the supero-posterior por-tion of the left lower lobe presented forcore biopsy. A low dose ultra-helical scanto localize the lesion was performed (Fig.1) with the patient in prone position.In a next step the volume reconstruc-tion of the ultra-helical scan was loadedinto the 3D interventional program andautomatically displayed in MPR for plan-ning purposes. Fig. 2a shows that the le-sion is situated directly behind the 8th ribrequiring an oblique approach throughthe 7th and 8th intercostal space (seeFig. 2b).A reduced scan range in 3D interven-tional software was used to track theneedle path in orthogonal and obliqueimaging planes. The needle was posi-tioned correctly in the lesion after onlytwo exposures (Fig 3).A core biopsy was performed and his-tological analysis confirmed a lung car-cinoma.Initial clinical experienceAt our clinical institution, we scheduleon average twelve biopsy procedures perweek. Since the introduction of 3D in-terventional software we have noticed aremarkable reduction in the time it takesto perform most interventions. In addi-tion, interventional radiologists carry outthe increasingly complex biopsy proce-dures with much more confidence. True3D image display no longer requires us tocreate a 3D “mind’s eye” view of patientanatomy. Direct and accurate visualiza-tion is provided in axial, coronal, sagittaland oblique planes. The 3D interventionaltool is now used exclusively for our CTinterventions and has proven to be anexcellent aid for our radiology residentsto quickly gain confidence and expertise.ConclusionToshiba’s 3D interventional software,available on the Aquilion ONE andAquilion PRIME systems, offers real-lifeclinical advantages for interventional CTprocedures. Examinations can be per-formed faster and with a higher degreeof accuracy.Fig. 1: Ultra-helical scanof whole thoraxto localizethe lesionFig. 2 a: Lesionis situated directlybehind the 8th ribFig. 2b: Obliqueplanning throughthe 7th and 8thintercostal spaceFig. 3: Obliquereconstruction clearlyshowing the positionof the needle in theperiphery of the lesion21
The company’s VitreaAdvanced software formspart of Vitrea Enterprise Suite and combines best-of-breed 2D, 3D and 4D clinical applications andworld-class services with a centralized solution formanaging volumetric image data across the medi-cal enterprise all accessible via the Web. The solu-tion offers advanced applications for cardiovascular,neurovascular and oncology, and offers integrationwith PACS in a few simple clicks. VitreaAdvancedaddresses the challenges of managing multipledisparate advanced visualization systems and isdesigned to improve performance and productivity,ensure scalability and redundancy. The system doesnot require proprietary hardware, allowing users toutilize their existing infrastructure. Skåne Univer-sity Hospital was attracted to the level of acces-sibility and performance offered by VitreaAdvanced.Vital Images also offers VitreaView, which is auniversal viewer that provides physicians with uni-versal access through a simple intuitive user inter-face for patient imaging. It offers secure integratedaccess to imaging through EMR, EHR, or HIE and alsoenables access to images from disparate databases,providing one integrated universal viewer. Institu-tions deploying VitreaView provide standardizationand access for medical professionals, enabling themSkåne University Hospital has emerged as one of theleading medical institutions in Scandinavia, a repu-tation enhanced through the bold and innovativestep to merge the two university hospitals of Malmöand Lund under one management team.This decision, taken by the regional council latein 2009, has enabled Skåne University Hospital tomove forward in offering ground-breaking medicalcare and innovation to the population of Swedenit serves.One area where the hospital is at the forefront ofcare is in radiology, diagnostics and imaging, withits use of the latest technology and systems.That took on a new dimension recently with thehospital becoming a landmark customer for an im-portant global healthcare IT provider.Vital Images, a Toshiba Medical Systems GroupCompany and leading provider of advanced visu-alization and analysis solutions for physicians andhealthcare specialists, signed Skåne University Hos-pital Malmö as its 5,000th healthcare IT and ad-vanced visualization solutions customer.With software utilized in hospitals in more 100countries, Vital is now supplying solutions to SkåneUniversity Hospital to help enhance the patient ex-perience across the region of Skåne.Lars Bååth, AssociateProfessor at SkåneUniversity HospitalMalmö meets withSatoshi Tsunakawa,President and ChiefExecutive Officer,Toshiba MedicalSystems Corpora-tion and the ToshibaTeam at RSNA.Vital Signs Landmark Deal withSkåne University HospitalVISIONS 21.13 ADVANCED VISUALIZATION22
23to optimize their time andfocus on patient care.Institutions deployingVitreaView provide stand-ardization and access formedical professionals, en-abling them to optimisetheir time and focus on pa-tient care. It was this levelof accessibility and perform-ance which attracted SkåneUniversity Hospital to thecompany.Lars Bååth, Associate Pro-fessor and head of the clini-cal department for radiologyat the hospital, said: “SkåneUniversity Hospital Malmömade the decision to pur-chase the Vital solution aftermonths of thoughtful con-sideration and evaluation ofall the leading solutions inthe market.“We are confident that the solution will ex-ceed the requirements we set forth and look forwardto a meaningful partnership with Vital.”The solution Skåne University Hospital has pur-chased which will facilitate post-processing of 4Dangiography of cerebral vessels; easy and automat-ed post-processing of CT perfusion of the brain; andeasy volume measurements such as measurementof the volume of cerebral haemorrhages and infarc-tions as well as brain tumours.Professor Bååth said a major factor in choosingthe Vital solution was because the system afforded“the possibility of different post-processing that arealmost automated, rapid and easy to handle.”He added: “As we purchased the Vitrea licensesincorporated in our PACS, it enables us to pick up thepatient in question from PACS at any work stationin the department, perform the post-processing andsave snapshots, batches or videos and send them toPACS for presentation at clinical conferences.“It enables us to perform different measurementsand analysis within the system such measurementsof different cerebral blood perfusion parameters,degree of internal carotid artery stenosis, and evalu-ation of plaque morphology.”He said because the solution offers automated/semi-automated post-processing software that iseasy, logical and robust, it will save the radiolo-gists time, especially in an emergency situation thatneeds rapid decision making.Patients will also benefit from the rapid deliveryof radiology reports as the post-processing is ex-tremely easy and automated.“It also enables measurements of values our availablesystem do not offer e.g. absolute values of cerebralblood flow,” added Professor Bååth.Vital is equally delighted to be partnering SkåneUniversity Hospital and see the institution becomesits 5,000th customer.Erkan A. Akyuz, president and chief executiveofficer at Vital, said: “We’ve had many notablemilestones since Vital’s inception in 1988, includingintroducing one of the first ever advanced visualiza-tion solutions to the market and, more recently, thenotable Toshiba acquisition last year.“Partnering with our 5,000th customer is a mile-stone we are particularly proud of, as it reflects theadoption of the solutions we develop as well as thecommitment our employees have to customers andtheir patients.”Vital continually invests in programs and tech-nology designed to enhance relationships betweencustomers, referring physicians, partners and pa-tients. Building on its knowledge and understandingof complex clinical workflow, Vital offers a compre-hensive suite of enterprise-wide advanced visualiza-tion and connectivity solutions.The merger of the two university hospitals inMalmö and Lund came into effect on January 1,2010, enabling the strengthened clinical researchand the university healthcare service in Skåne togain increased competitiveness from a Swedish andinternational perspective.The hospitals in Lund and Malmö have a long his-tory and have been operating side by side since thelatter part of the 19th century. The infirmary in Lund,
VISIONS 21.13 ADVANCED VISUALIZATIONwhich is one of the country’soldest hospitals, was establishedas early as 1768.Both hospitals started offwith a few beds and then grewin size over the years to meet ris-ing patient demand.Research and training are im-portant elements of what goeson at Skåne University Hospital,which is the third largest ofSweden’s seven university hos-pitals. Its three cornerstones areadvanced medical care; training;and prominent research and it has one of the larg-est emergency medicine hospitals in Sweden.Major investments have been made in the hospi-tal campuses in Malmö and Lund in recent decades,which have created an excellent environment forresearch scientists, students and care personnel.Questions and experience from meetings withpatients at the clinic are brought into the laboratorywith the research results fed back to the patients inthe form of new improved methods of diagnosis andtreatment, new drugs and new techniques.24
Skåne University Hospital’skey milestonesThe year 1768 saw the foundation of the Lund In-firmary and in 1857 Malmö’s general hospital inSlottsgatan was established, with an annex at JakobNilsgatan. In 1948, the Swedish government agreedto allow Malmö General Hospital to carry out clini-cal teaching.In 1989 the Medical Research Centre (Lund Uni-versity) was inaugurated and in 1993 the Lund In-firmary changed its name to University Hospital inLund while Malmö General Hospital (MAS) changedits name to the University Hospital MAS in 1994.In 2004 the Diagnostic Centre – one of theworld’s most modern departments for medical imag-ing, was established in Malmö, in 2006, there wasthe inauguration of the CRC, the Clinical ResearchCentre (Lund University) building and in 2008 Re-gion Skåne’s Competence Centre for Research(RSKC) formally opened, creating new opportuni-ties for advanced research on the basis of a centralbiobank department.Meanwhile, 2010 saw the merger of the Univer-sity Hospital in Lund and the University Hospital inMalmö to form Skåne University Hospital and in2012 Skåne University Hospital became the 5,000thhealthcare IT and advanced visualization solutionscustomer for Vital.The 780-bed Skåne University Hospital has 11,700employees, with an annual budget of SEK 10 bil-lion. On an average day at Skåne University Hos-pital: 24 children are born; 350 patients visit itstwo emergency departments; 151 patients havesurgery; there are 1,327 inpatients; 915 patientsare X-rayed; six scientific articles are published; andSEK 28 million are consumed.Its radiology department carries out about400,000 diagnostic exams a year, the lion’s shareof the 900,000 radiology examinations conductedannually by the 10 hospitals of the region.Within the Skåne region today, there is a unityin the equipment that the hospitals’ radiology de-partments use. All access the same and have imple-mented a cross-enterprise solution for distributedradiology cooperation within and outside the regionindependent of the supplier of RIS or PACS.By linking the hospitals’ radiology operations ina single shared RIS/PACS solution, an efficient flowof images and information was created throughoutthe region.Its infrastructure supports automatic sharingand distribution of radiology information to all de-partments involved in the radiology workflow.With the latest partnership with Vital, SkåneUniversity Hospital is moving its care in radiology,diagnostics and imaging onto yet another level.25
LSA branches can be clearly observed using dig-ital subtraction angiography, though this tech-nique is invasive. Recently, LSA branches havebeen successfully visualized with 7T MR imagingby using time-of-flight MRA1,3. Some relation-ships between decreased LSA visualization andhypertension or infarction at the basal gangliaand/or its vicinity were demonstrated3. However,the availability of 7T MR imaging systems is verylimited, and they are currently used for researchpurposes only.There is a great need for imaging the mi-crovasculature in the brain for the early de-tection of cerebrovascular strokes in routineclinical practice and for research purposes.However, the literature agreed that non-in-vasive imaging of cerebral microvascula-ture such as the LSAs requires ultra-high MRfield strength (7T) and could not be real-ized at lower field strengths (1,5T nor 3T)1-3.IntroductionCerebral magnetic resonance angiography (MRA)at 1.5T is generally limited to the time-of-flight(TOF) technique which is most widely used for thevisualization of macrovasculature in intracranialarterial diseases. The TOF technique at 1,5T has spa-tial and contrast resolution limitations for visual-izing slow-flow arterial branches mainly because ofspin saturation and relatively short T1.Current neuro-imaging techniques based oncomputed tomographic angiography or digital sub-traction angiography have been used to investigatevascular pathophysiology. However, the study ofmicrovascular diseases in vivo has been restrictedby their inherent invasiveness.Lenticulostriate arteries (LSAs) are one of themost important microvascular structures in the hu-man brain as they supply blood to the basal ganglia(Fig. 1) where ischemic and hemorrhagic cerebralstrokes often occur. The LSAs are end arteries thathave little or no collateral circulation.Neuro-Microvascular Imagingat 1,5T Using the Flow SensitiveBlack Blood TechniqueF. Admiraal-BehloulVISIONS 21.1326MRIToshiba MedicalSystems Europe,Zoetermeer,The NetherlandsFig. 1:LenticulostriateArteries anatomy.The horizontal M1segment givesrise to the (lateral)lenticulostriatearteries whichsupply part of headand body of caudate,globus pallidus,putamen and theposterior limb ofthe internal capsule.Often the mediallenticulostriatearteries arise fromthe A1-segmentof the anteriorcerebral artery.Faiza Admiraal-Behloul
A shorter TE value (~20ms) and a lower b-factorwould minimize the T2* effect and be more favora-ble to arterial imaging while minimizing the venous/parenchyma contrast allowing a better artery/veinsdiscrimination (see Fig. 3). The common imaging pa-rameters are TR=29 msec, TE=20 ms, flip angle=20°,MPG pulse b-factor= 2 s/mm2 acquisition matrixsize=256 x 224, FOV 205x179 mm in one axial 3Dslab of 160 slices. The scan resolution was 0.8 x 0.8x 0.8 mm (reconstructed into 0.4 x 0.4 x 0.4 mm inorder to increase apparent resolution) for a scantime of ~6,5 minutes.Clinical evaluationsT. Kodama and co-authors6 from the university ofMiyazaki (Japan) compared FSBB to SWI in thevisualization of venous malformation (VM), arterio-venous malformation (AVM) and dural arteriovenusfestulas (dAVF) using a 1.5T Vantage ZGV Atlas. Theyshowed that VMs were more clearly visualized onFSBB images than SWI. They found that small VMscould be missed on SWI images. In some cases, por-tions of draining veins could not be clearly visual-ized on SWI images. Their findings suggested thatdirection of vessels in respect to that of the mag-netic field affected their visualization on SWI im-ages. Furthermore, they found that drainage veinsof AVMs and dAVFs can be hyperintense on SWI im-ages probably because of their arterialization due tothe arteriovenous shunt. Even though SWI has flowcompensation, feeding arteries sometimes showedsignal loss. On FSBB images, all of arteries, niduses,veins, and hemorrhagic lesions appeared as “black”structures. In five patients with AVM or dAVF, prom-inent venous structures other than drainage veinswere clearly noted on FSBB images. These veinsseemed to reflect hemodynamic changes such asvenous congestion, collateral circulation, and stealphenomenon associated with the AVM and dAVF.Flow sensitiveblack blood imagingFSBB is a high resolution 3D gradient echo tech-nique which, unlike Susceptibility Weighted Imag-ing (SWI), uses a weak Motion Probing Gradient(MPG) pulse that dephases the water signals of theflowing blood and has no effect on the water signalin stationary tissues4,5.SWI is based on high resolution, three-dimen-sional (3D), fully velocity-compensated gradient-echo sequences using both magnitude and phaseimages. A phase mask obtained from the MR phaseimages is multiplied with magnitude images in orderto increase the visualization of the smaller veinsand other sources of susceptibility effects. The im-ages are then displayed using the minimal intensityprojection (minIP). Because the image contrast inSWI is mainly based on the susceptibility effect SWIis more successful at high (3T) and ultra-high (7T)field strengths. Furthermore, phase disturbance isobserved mainly in the vein and therefore not suit-able for arterial microvasculature imaging.With FSBB the signal from rapidly flowing bloodis attenuated by applying a very weak MPG for sig-nal dephasing, which mainly attenuates the signalfrom rapidly flowing blood in the artery, while thesignal from stationary or slow-moving componentsis not or much less affected. Since this techniquedoes not rely only on susceptibility effect only, itcan be successfully used at standard (1,5T) fieldstrength (see Fig. 2).Being a 3D gradient echo technique, FSBB can,like SWI, benefit from the susceptibility effect use-ful for venous signal visualization. When a long TEvalue is used (~40 ms) the T2* effect is increasedand the venous signal is attenuated which allowsa good contrast with the parenchyma. The typi-cal parameters for susceptibility oriented FSBB are:TE: 40 ms, TR: 50 ms, FA: 20, MPG pulse b-factor=4 s/mm2 acquisition matrix size=256 x 224, FOV 205x 179 mm in one axial 3D slab of 160 slices. The scanresolution is 0.8 x0.8 x 0.8 mm (reconstructed into0.4 x 0.4 x 0.4 mm in order to increase apparentresolution) for a scan time of ~6,5 minutes.27Fig. 2: Comparison between minIP SWI image(left) and minIP FSBB image (right) in a healthyvolunteer scanned at 1.5T. Note the increasedvessel/parenchyma contrast in FSBB.
28in terms of number, length,and image quality at ori-gins and distal areas ofvisualized LSA branches. Inall evaluated terms, FSBBwas significantly betterthan TOF.In a very recent study S.Okuchi and co-authors10from Kyoto UniversityGraduate School of Medi-cine, Kyoto (Japan), ex-amined the correlation ofLSA imaging findings usingFSBB in patients with la-cunar infarction comparedwith age matched con-trols. They prospectivelyenrolled fifteen patients (9men, 6 women, mean age73 years) with infarction atthe basal ganglia and/or itsvicinity, and 12 age-matched control subjects (6men, 6 women; mean age, 68 years). The authorsfound that patients with stroke had significantlyfewer LSA branches (average 6.3; 95% CI, 5.4–7.1)than controls (8.7; 95% CI, 7.8 –9.5) (P=.0003). Thetotal LSA lengths were 117 mm (95% CI, 96–138mm) for patients with stroke and 162 mm (95%CI, 133–91 mm) for control subjects (P=.01). Onlythe LSA branch numbers were significantly relatedto infarction while only hypertension was signifi-cantly related to total LSA length.Discussionand future workMicrovascular brain damage is mainly assessed byimaging the microbleeds (MB) and not by studyingthe microvasculature itself as this was not possiblein-vivo at clinical MR field strength (≤3T). However,at ultra-high field strength (≥7T) it has recently be-V. Sawlani and co-authors7 from Morriston andSingleton hospitals ABM university NHS trust (UK),showed the potential of the FSBB technique on a1.5T Vantage XGV Atlas system in several cerebralvascular diseases: FSBB was found a useful toolin imaging hemorrhages from trauma, visualizingblood products, venous sinus thrombosis but also inneuro-oncology (see Fig. 4). The microvasculatureand hemorrhage of the tumor could be depictedwith FSBB. These findings demonstrate the potentialof FSBB in tumor grading and in therapy monitoring.K. Gotoh and co-authors from Kyoto UniversityGraduate School of Medicine, Kyoto (Japan), com-pared FSBB to TOF in the visualization of the LSAs in21 healthy subjects (age range 19-44 years)8,9. Theyfound in9 a total of 145 LSA branches visualizedwith FSBB while only 66 branches were visualizedwith TOF. All the LSAs visualized with TOF were alsovisualized with FSBB. The images were evaluatedVISIONS 21.13 MRIFig. 3: FSBB image(minIP) clearlyshowing the LSAs(yellow arrows)at 1,5T field strengthin a healthy volunteerFig. 4: Primaryglioma withhemorrhage. (a)Flair image (b)minIP FSBB imageshowing complexmicrovasculatureof the tumor(Courtesy ofDr V. Sawlani,Morriston andSingleton hospitalsABM UniversityNHS trust)A B
29Toshiba is continuously working on further optimi-zation and innovation in cerebrovascular imaging13.Exiting clinical studies are taking place at luminarysites and more clinical evaluations of these innova-tive techniques are to be expected.References1 Cho ZH, Kang CK, Han JY, et al. Observation of the lenticulostriatearteries in the human brain in vivo using 7.0 T MR angiography.Stroke 2008;39:1604–062 Kang CK, Park CW, Han JY, et al. Imaging and analysis of lenticu-lostriate arteries using 7.0-Tesla magnetic resonance angiography.Magn Reson Med 2009;61:136–43 Kang CK, Park CA, Park CW, et al. Lenticulostriate arteries in chronicstroke patients by 7 T magnetic resonance angiography. Int J Stroke2010;5:374–804 Kimura T, Ikedo M, Furudate N, Takemoto S. Flow-sensitive suscep-tibility-weighted imaging. In: Proc Joint Annual Meeting, ISMRM-ESMRMB, Berlin; May 19–25, 2007:3015.5 suchiya K, Tateishi H, Yoshida M, et al. Flow-sensitive susceptibility-weighted imaging of the brain: initial experience in ischemic lesions.In: Proc Joint Annual Meeting ISMRM-ESMRMB, Berlin; May 19–25,2007:3016.6 Kodama T, Yano T, Tamura S, et al. Flow-sensitive black blood imag-ing for evaluating vascular malformations. In: Proceedings of the17th Annual Meeting of ISMRM, Toronto, Canada, 2008. (abstract3425).7 V.Sawlani, J. Spark, F. Admiraal-Behloul , Flow-Sensitive Black BloodImaging : Clinical Intracranial Applications, In: Proceedings of the20th Annual Meeting of ISMRM, Stockholm, Sweden, 2010. (ab-stract 2263).8 Gotoh K, Okada T, Miki Y, et al. Visualization of the lenticulostriateartery with flow-sensitive blackblood imaging in comparison withtime-of-flight MR angiography. In: Proceedings of the 17th AnnualMeeting of ISMRM, Toronto, Canada, 2008. (abstract 2893).9 Gotoh K, Okada T, Miki Y, et al. Visualization of the lenticulostri-ate artery with flow-sensitive black-blood acquisition in compari-son with time-of-flight MR angiography. J Magn Reson Imaging2009;29:65–6910 Okuchi S, Okada T, Ihara M, et al. Visualization of Lenticulostriate Ar-teries by Flow-Sensitive Black-Blood MR Angiography on a 1.5T MRISystem: A Comparative Study between Subjects with and withoutStroke. AJNR Am J Neuroradiol. 2012 Oct 11. [Epub ahead of print]11 Kimura T, Ikedo M, Takemoto S. Hybrid of opposite-contrast MR an-giography (HOP-MRA) combining time-of-flight and flow-sensitiveblack-blood contrasts. Magn Reson Med. 2009 Aug; 62(2):450-8.12 Tsuchiya K, Kobayashi K, Nitatori T, et al. Hybrid of opposite-contrastMRA of the brain by combining time-of-flight and black-blood se-quences: initial experience in major trunk steno-occlusive diseases.J Magn Reson Imaging. 2010 Jan; 31(1):56-60.13 Kimura T, Ikedo M, Takemoto S. Phase enhancement for time-of-flight and flow-sensitive black-blood MR angiography. Magn ResonMed. 2011 Aug; 66(2):437-47.come possible. Therefore, there is a growing interestin studying the microvasculature in small vessel dis-ease and neuro-degenerative disease, during life, atultra-high field. Unfortunately, ultra-high field MRscanners are still research systems not cleared yetfor clinical routine use. Therefore 7T MR systems arenot widely available; making it difficult to run largescale (multi-center) clinical studies at present time.FSBB is a new MR angiography technique thatallows the visualization of the cerebral microvascu-lature at clinical MR field strength (1,5T and 3T). Thistechnique is made available to the wider researchcommunity and can benefit all patients having ac-cess to standard clinical MR scanners.The FSBB technique was successfully used at 1.5Tto visualize the microvasculature of AVMs, braintumors, and even lenticulostriate arteries in healthyvolunteers and stroke patients.It is a promising technique and the increasedspatial resolution at 3T, down to 0.3 mm or less (seeFig. 5) opens the way to new clinical applicationssuch as small vessel and/or degenerative diseases(vascular dementia, Alzheimer’s diseases, Multiplesclerosis, etc.).Toshiba has recently proposed a hybrid version11,called Hybrid Opposite contrast MRA, combiningboth TOF and FSBB is a dual echo 3D gradient echotechnique for a bright blood visualization of themicrovasculature. K. Tsuchiya and co-authors fromKyorin University Faculty of Medicine,Tokyo (Japan),showed in their initial experience a great potentialof this technique for the visualization of collateralmicovasculature in major trunk steno-occlusive dis-eases12.Fig. 5: FSBB images (minIP) acquired on Titan 3T.Note the increased spatial and contrast resolution.
“Minimize. Visualize”.An Approach to Reaching theNext Level in Patient CareVISIONS 21.13 President’s Message30
doses and clearer images for the benefit of patients.One physician has applied this technology to facialtransplant surgery in order to improve the qualityof life of patients who have “lost” their faces interrible accidents. The high spatial resolution ofour CT systems makes it possible to visualize thesmall vascular details that are essential in surgeryto restore normal facial movements. A patient whowas desperate to undergo facial transplant surgeryafter suffering with “no face” for 18 months, madea remarkable recovery. This patient’s ability to makefacial expressions was restored, making it easier forthe patient to reintegrate into society. Our technology helped to make this possible.With regard to X-ray, we introduced our SpotFluoroscopy technology in the previous issue ofthis magazine. Spot Fluoroscopy has been widelyaccepted by both practitioners and patients. It hasbeen calculated that this unique dose reductiontechnology developed by Toshiba can provide reduction in both scattered dose and area dose dramatically. This is extremely useful for minimizingexposure during atrial fibrillation ablation procedures. Again, this is one of the ultimate expressionsof “Minimize, Visualize.”Finally, Toshiba has been selected as an official medical systems partner of Manchester Unitedin England. It is a very competitive process to benamed an official partner of this illustrious club,and we are looking forward to Man U’s continuedsuccess in the future.I deeply value our relationships with our partners and customers, and it is our customers whowill contribute the most to Toshiba’s future growth.I am sure that our customers will continue to be themost valuable asset of our company.Satoshi TsunakawaPresident and Chief Executive OfficerToshiba Medical Systems CorporationFor the past several years, we at Toshiba havebeen involved in system development work tofurther improve accuracy and workflow efficiencyin each modality. Progress has been remarkablyfast, but our team realized that in order to reachthe next level we must place even greater emphasison patient care.Our overall global key message is “Improving thequality of life, for patients, for practitioners, forall people.” This reflects our policy of taking thatextra step in customer care. In the previous issueof VISIONS, my message was that Toshiba is nowexpanding its focus to include the care of all people.At this time, we are especially focusing on the concept of “Minimize. Visualize.” Our goal is to demonstrate that we are a vendor that can continueto develop high-quality imaging technologies toensure accurate diagnosis and treatment with thelowest possible exposure dose. Let me now introduce some of the advances that have been achievedin each modality.With regard to MRI, the abstract for the REACTstudy has been accepted for presentation at ECR2013. Toshiba Medical Systems Corporation (TMSC)is sponsoring a multi-center trial known as the REnal Artery Contrast-free Trial (REACT). According toDr. Timothy Albert, who is the leader of the REACTproject, Time-SLIP, which is one of Toshiba’s non-contrast MR angiography (NC-MRA) techniques,will become a reasonable alternative for assessingrenal artery stenosis (RAS) and also for evaluatingpatients with renal dysfunction who cannot receivecontrast agents. I am very proud that we are able tosupply our cutting-edge technology in accordancewith our new concept, “Minimize, Visualize.”In ultrasound, we have developed Luminancetechnology. The objective of this technology is, ofcourse, to achieve better image quality, and it isespecially useful for visualizing the fetus. This 4Dtechnology provides “Picture Perfect” images, allowing expectant mothers to see the faces of theirunborn children more clearly than ever before.In CT, as you already know, we have successfullyincorporated AIDR 3D technology into all of ourCT systems. This technology ensures extremely low31Minimize. Visualize.
Toshiba’s executiveteam at theOld Trafford ground,including footballstars Giggs,Kagawa and NaniPhotographsby Paul CooperAs Toshiba Medical Systems enters a partnershipwith English Premier League side ManchesterUnited to provide state-of-the-art medical equip-ment at the club’s training ground, team doctorSteve McNally outlines the benefits.The ground-breaking partnership between ToshibaMedical Systems and Manchester United is set toadd a whole new dimension to the treatment theclub’s medical staff can offer to players. In becomingthe club’s Official Medical Systems Partner, Toshibawill provide the football club with a CT scanner ca-pable of single rotation volumetric imaging, an MRIscanner and five ultrasound systems including theindustry-leading premium Aplio 500.Club doctor Steve McNally said the installationat the club’s Trafford Training Centre in Carringtonwould provide medical staff with improved diagnos-tic and screening tools that offer greater degrees ofaccuracy.This will allow them not only to monitor healingin injuries and fine-tune rehabilitation processesbut also to identify potential injuries and respondto them before they become serious. In addition, itwill offer the players more privacy and increasedconfidentiality when they are injured or ill and avoidthe need for them to attend private facilities off-site.Dr McNally said: ‘We’ve always been fortunateto enjoy good access to imaging facilities in theToshiba Medical Systemsjoins Manchester UnitedVISIONS 21.13 SPORTS MEDICINE32locality, but having such equipment on site will bemuch more convenient and less disruptive in termsof affecting training and rehabilitation programs.The convenience also means that we will have abetter opportunity to use imaging as part of ourdaily routine. It means more privacy, increased con-fidentiality, and a much better experience for theplayers as patients.’He said another benefit of having the equipmentavailable to the club’s medical team at Carringtonis that medical staff will be able to discover moreabout just what the different medical imaging mo-dalities can do for them. ‘We’ll find out which sys-tems are most appropriate at certain times: what isnormal, what is abnormal, and what is happening inthe evolution of an injury. We can monitor healingin various injuries much more closely.’The club already operates a comprehensive play-ers screening program, which includes undertakingdetailed medical histories and clinical examinationsin conjunction with functional tests, physical testsand some medical imaging.‘But we could start to utilise these imaging toolsto look in much more detail at the anatomy of play-ers; before they start pre-season training, what it islike after a certain phase of pre-season training, andwhat happens as they are exposed to the trainingloads and the game loads throughout the season,’Dr McNally explained.
radiation doses opens up a wider opportunity to useCT as a monitoring tool.’With MRI, the distinct advantage of the 3-Tesla isspeed of imaging and higher resolution, particularlyin joint injury.‘The increased detail and the facility to map thecartilage in joints over time will hopefully assist usin terms of the welfare of our players, but also it willallow us to assess the effects of our training programson their joints,’ Dr McNally added. However, he be-lieves the biggest long term benefit from the Toshibapartnership will be in the field of injury prevention bydetecting early pathological signs that would triggera managed response long before they become acuteor career-threatening injuries for players.Manchester United midfielder Ryan Giggs isequally excited about the partnership. ‘It’s fantasticto have such state-of the-art equipment at the train-ing ground. It means that having scans or medicalswill be much more convenient as everything is thereand to hand.’Giggs, who is 39 and still a regular first teamplayer, joined the club as a schoolboy when themedical team was smaller and access to advancedmedical equipment and physiotherapy was limited.With the additions at the Carrington training ground,he added: ‘It’s no surprise that United are workingwith Toshiba Medical Systems and will have the latestequipment, such as MRI and other scanners, on site.’‘So, we can build a more detailed profile of whathappens to the joints, the muscles, the ligaments,the tendons, the heart, the lungs and what effectsthe training program is having on those tissues andorgans.’Such medical scanning equipment offers the op-portunity to build complete medical profiles of play-ers and enhances monitoring of them as they developand age; from the youngest players at the club whoare only eight years old to those in their late 30ssuch as Ryan Giggs, Paul Scholes and more recentlygoalkeeper Edwin van der Sar, who was 40 when hestopped playing.From this, there will also be benefits for Toshiba,which will gain greater insights into sports medicine.The partnership is the first of its kind in the UKwith a football club and Dr McNally believes theToshiba equipment provided to the club’s medicalteam would help with the accuracy and speed ofdiagnosis of an injury leading to greater confidencein the treatment plan by both the patient and thetreating clinician.‘In combination with our expertise and experienceit allows us to inform our coaches and our team man-ager with a timely and likely prognosis so they canplan for the team and we can plan strategies aroundthe whole injury scenario - not just deal with the indi-vidual patient,’ he said, adding: ‘I think we could alsoutilise the systems to fine-tune our rehabilitationprocesses because we can monitor the progress andthe evolution of tissue healing alongside the observedfunctional improvements.’‘That will give us greater confidence in making acertain progression in a rehabilitation program andalso what types of exercise and loading we put on aplayer during that rehabilitation.’Levels of radiation exposure have always been aconsideration with CT scanners but Toshiba CTs arerenowned for having very low radiation exposure, al-lowing its potential use as a screening modality.Dr McNally said: ‘The fact that the Aquilion sys-tems are well-known for having significantly reducedMark Holmshaw,Toshiba’s Vice PresidentSales and Service Europe,is hopeful to introduceplans for screening andearly diagnosis.ManchesterUnited clubdoctor SteveMcNally believesthe biggestlong-termbenefit from thenew equipmentwill be throughthe early detec-tion of patho-logical signs toprevent injury.Chikao Kamijima, President & CEOof Toshiba Medical Systems Europe, shakeshands with Sir Alex Ferguson, ManchesterUnited, to confirm the partnership.33
Professorand Chairman,Departmentof Radiology,University ofSouthern California,Keck Schoolof Medicinemoving the observer’s eye according to the center lineof the blood vessel, intestinal tract, mammary ductor any other fluid-filled structure in the body. In this”auto“ mode, the system passes through the tubularstructure while deciding automatically which branchto follow, for example, through the branches of theportal vein.The second option is conducting manual FlyThru navigation, which is useful depending on whatis being imaged. In manual mode clinicians directthe arrow, or perspective line of sight, throughthe structure. For example, in manual naviga-tion when viewing a bifurcating vessel, there isthe ability to choose which of the two vessels tointerrogate. Likewise, when looking at a polyp inthe endometrium, clinicians can view from behindit and investigate another perspective. Thesetwo options for both automatic and manual modeprovide flexibility in using Fly Thru for various clinicalapplications.In addition to automatic and manual visualiza-tion modes, Fly Thru’s features make it easy to use.The Aplio 500 has rapid reconstruction time andthe ability to store the ultrasound volume directlyon the unit, allowing images to be viewed afterthe examination is complete. There is also an over-Ultrasound is a fast, non-invasive imaging technol-ogy often used as a first-line diagnostic exam, provid-ing clinicians the ability to diagnose disease quicklyand develop treatment plans. Recent advancementsin 3D and 4D ultrasound continue to expand clini-cal applications, and the introduction of Toshiba’sAplio™ 500 ultrasound system offers exciting newcapabilities.Toshiba’s Aplio 500 ultrasound system ena-bles clinicians to diagnose disease in new ways,using the most advanced visualization tools inthe industry. The system combines advanced imagingcapabilities, workflow automation tools and superiorergonomics for more accurate diagnoses and im-proved departmental efficiency.One of these advanced features is Toshiba’sFly Thru technology, an industry first using 4Dultrasound to ”fly through“ interiors of ducts andvessels for better exploration of lesions and massesand in communication when planning interventionalprocedures. Fly Thru gives a new perspective of 4Dimaging, namely, looking from the inside out. Thistechnology and the images it produces are unlikeanything previously found in the ultrasound world.It truly represents a completely unique method ofprocessing ultrasound images and a unique way oflooking at structures within the body.Fly Thru: a new perspectiveThe engineers who developed the technology referto this as ”perspective imaging“ because it producesa different perspective in the way clinicians viewvarious structures. Fly Thru’s images virtually travelthrough a body cavity and are very similar to thoseproduced by CT virtual colonoscopy. Fly Thru enablessonographers and physicians to interrogate anatomyfrom views never before seen in ultrasound, bringinga whole new dimension to the modality.Typical 4D imaging uses a parallel projectionso one’s viewpoint is essentially endless, howeverthis creates difficulties in seeing depth or whatis around the anatomy being imaged. Fly Thruis different from traditional 4D imaging, as ituses perspective projection, where the image is dis-played exactly as if you were doing an endoscopicprocedure.When using the Aplio 500 in practice, there arevarious ways to perform Fly Thru. First, the system it-self will automatically navigate through the structure,E. G. GrantAdvanced Techniquesin 4D Ultrasound: Fly ThruVISIONS 21.13 ULTRASOUND36Conventional3D imagingFly Thruperspective3D imaging
Fig. 3: Fly Thruof the breastdemonstrating mildductal ectasia.(Image courtesy ofDr. T Kurida, KuridaClinic, Japan)Virtual hysteroscopyAs stated previously, Fly Thru holds great clinicalpromise in performing virtual hysteroscopy. Twounique ways to use Fly Thru for virtual hysteros-copy include identifying a polyp and manipulat-ing the image to view it from around the back formore accurate diagnosis (Fig. 1), and to assess thefallopian tubes (Fig. 2), which would be difficultto do with a traditional hysteroscopy.Virtual ductographyFly Thru for virtual ductography in the breast canshow very small structures only millimeters inview mode to look at fluid-filledbowel loops or pelvic struc-tures, like the uterus, when theyare surrounded by fluid. Withoverview mode, clinicians canalso manipulate the image andview different parts for expand-ed clinical applications.Fly Thru images are also ac-quired like any other normal 3Ddata set – the Fly Thru mode ispressed, the arrow is pointed inthe direction or at the structurebeing imaged and Fly Thru be-gins. There is a slight learningcurve for the manual navigationmode, but overall it is a veryeasy technology to use.Potential clinicalapplicationsThe images produced using FlyThru are extraordinary, and asa new technology, the clinicalapplications are just beginningto be explored. The first po-tential clinical application weforesee is imaging of the en-dometrium. The endometrium isa solid structure, but if it is dis-tended with fluid, as in the caseof a saline hysterosonogram,Fly Thru enables a virtual hys-teroscopy. This is a new way ofviewing polyps, myomata, syn-echiae or anything that is in themiddle of the endometrial canal.Fly Thru is also capable of see-ing relatively small fluid-filledstructures, for example, dilatedducts in the breast that couldassist in diagnosing intraduc-tal papillomas. Another area forpotential clinical application isvascular imaging, including ve-nous structures, TIPS, the aortaand endostents.Other areas with potentialFly Thru applications include ob-stetrics (OB), for early pregnancycases and complex fetal anom-alies, such as cleft palate andother facial anomalies. Another could be in the imag-ing of neonatal head, and a completely unique way ofviewing hydrocephalus in infants. The GI tract is alsoa fairly obvious area, with the ability to visualize thecommonductorpancreaticduct,thegallbladderorthegut. In the GU tract, hydronephrosis, stones, obstruc-tion, transitional cell carcinomas (TCC) or even blad-der lesions have been nicely evaluated with Fly Thru.As we continue to investigate the clinical possibilities,we are excited by the opportunities this technologypresents to improve patient diagnoses for many con-ditions. The following are specific clinical examplesdemonstrating Fly Thru’s potential.37Fig.1: Largeintrauterine polypFig. 2: Normalendometrial canalshowing cornua andleft fallopian tube(Image courtesyof Bill Smith, CDS,London, UK)
VISIONS 21.13 ULTRASOUND38Fig. 5: Middle hepatic vein.Fig. 8: Normal mid-abdominal aortaFig. 7:Patent TIPS stentFig. 4: Partial occlusive thrombosis of the portal vein(Image courtesy of Dr. Kinkel, Duren Hospital, Germany)Fig. 6: Tortuous superficial varicose vein (Image courtesyof Dr. J Hata, Kawasaki Medical University, Japan)Fig. 9: Eight-week fetus
39Early OBFly Thru can also be used for imaging early preg-nancies. In this instance, imaging is identical toa 3D sweep, so there is no added interrogation ofthese patients (Fig. 9).GallstonesFly Thru holds some potential for imaging solid mass-es that affect the gallbladder wall and provides a newand interesting perspective (Fig. 10).Bile duct dilationWhen imaging bile ducts, Fly Thru has the ability toshow ductal dilatation (Fig. 11). Traveling down theduct and into the area around the pancreatic heador ampullary region, a mass-like area can be seen onthe horizon which actually represents an ampullarytumor that would be difficult to see with traditionalimaging techniques.Dilated small bowelWhen it comes to imaging the bowel, Fly Thru produces images remarkably similar to virtual colonoscopy. In this small-bowel example of a patient withIleus, the valvulae conniventes can be viewed clearlyusing Fly Thru. Additionally, evaluating polyps ormasses of the wall with Fly Thru has the potential toprovide improved diagnoses (Fig. 12).size and would lend itself wellto the evaluation of intraductalpapillomas (Fig. 3). No othermodality can perform such im-aging.Portal venographyVeins are easily evaluatedwith Fly Thru. The portal veinsare relatively immobile andtherefore easy to image. Inthis example, Fly Thru is ableto fly out into the periphery ofthis portal venous branch.Portal vein thrombosisIn another clinical example,the mass-like structure in theimage actually represents anarea of portal vein thrombosis(Fig. 4).Hepatic veinsThe hepatic veins are often fair-ly large and easily interrogatedwith Fly Thru. Patients whohave undergone a liver trans-plant may develop stenosis, andthis could be a secondary wayof identifying areas of stenosis(Fig. 5).Peripheral veinsFly Thru can also visualize wallsand clots in the peripheral veins,both the deep and superficial (Fig. 6). 4D informationprovided by Fly Thru is superior to the traditional 2Dcross-sectional ultrasound view, and for the first timeever, you can get an image of the true cross sectionspace taken up by a clot.Transjugular intrahepaticportosystemic shunt (TIPS)Imaging of TIPS can be very challenging but ispotentially made easier with Fly Thru. Most ofthe stenoses that affect the TIPS occur in the he-patic veins. This area may be difficult to image, andthe only way to diagnose stenoses in this area cur-rently is by looking for Doppler abnormalities, suchas velocity elevation. In this particular case with FlyThru (Fig. 7), a real-time image shows the anatomicstructure of the TIPS and the ensuing hepatic veinafter it, indicating a functioning shunt.AortaWhen imaging the aorta, there are a couple of techni-cal challenges, most notably motion. Wall motion, ifsignificant, can be problematic when processing animage. With Fly Thru, clinicians can follow the aortadown and view the orifices of the vessels coming offof it, including the mesenteric and renal vessels, andthe Iliacs distally. It is a unique application, similarto an IVUS but without performing an interventionalprocedure. This obviously makes it safer and easier forthe patient (Fig. 8).Fig.10: Multiplesmall gallstonesFig.11: Intrahepaticbiliary ductal dilation(Images courtesy ofDr. J Hata, KawasakiMedical University,Japan)
VISIONS 21.13 ULTRASOUND40FuturepossibilitiesAs we continue to evaluatethe images produced by FlyThru, there are some addi-tional applications that holdgreat promise. One of thoseis using contrast with re-versed polarity. Outside theU.S., contrast is often usedwith ultrasound. While thisis off-label use in the U.S.,contrast is extremely safeand clinically important. Bytaking a contrast image, forexample, of the carotid ar-tery, Fly Thru is able to recon-struct the lumen of the vessel.In this image (Fig. 14), FlyThru is able to travel from thecommon carotid into the in-ternal carotid artery, provid-ing unique images of the bi-furcation. It is an interestingapplication which reversesthe normal polarity of theimage.ConclusionFlyThruhastheabilitytoyieldmore than just appealing im-ages and could potentiallyimprove the diagnoses ofmany diseases with ultra-sound. The pictures producedare incredible and previouslyunseen in ultrasound, provid-ing a unique form of imagingadaptation of 4D ultrasound.In addition, this provides apotentially powerful tool forcommunicating with a surgeon, an interventionalspecialist or the patient. For clinicians, this excit-ing new technology offers an untapped potential ofclinical applications to improve patient care withultrasound.Dilated distal ureterStructures at the distal ureter may also be evaluatedusing Fly Thru. This directed scan interrogates theureter moving out of the bladder (Fig. 13), giving usthe potential of directly visualizing occlusive kidneystones for the first time.Fig.14: Contrastenhanced imageof the carotidbifurcation(Images courtesyof Dr. J Hata,Kawasaki MedicalUniversity, Japan)Fig.13: Dilateddistal ureterFig.12: Smallbowel loops inabdominal ascites(Images courtesyof Dr. J Hata,Kawasaki MedicalUniversity, Japan)
VISIONS 21.13ULTRASOUNDSonoWand, a separate navigation system as an alternative to perioperative MRI, making it possible tofuse the image by linking the findings of preoperativenavigation (CT/MRI) with those obtained using perioperative ultrasound. Such a fusion of images seemsto successfully combine the advantages of both modalities into a single image and for most patientsrepresents a perfect alternative to perioperative MRI.Smart Fusion, the virtual navigation developed byToshiba is the next step to further improve imagefusion. Here, a separate navigation system is integrated directly into the ultrasound system (ToshibaAplio 500). Before the intervention, a study of pre-operative CT/ MRI investigations is downloaded inDICOM 3 format; the ultrasound is connected toan electro-magnetic field transmitter and the ulSummaryUltrasound (US) is gradually gaining in importancein neurosurgery alongside perioperative CT/MRI as auseful tool for imaging brain lesions pre- and perioperatively. The basic examination currently involvestwo-dimensional ultrasound imaging (B-mode). Toimprove and refine orientation within the operating field, 3D ultrasound imaging using computer-aided reconstruction of a series of consecutive 2DUS sections similar to CT/MRI was developed in thelate 1980s. Although the 3D ultrasound model significantly improved control over the procedure itself,perioperative MRI remained the most precise method,especially when small, deeply located brain lesions(cavernomas, small gliomas and similar lesions) wereconcerned. Norwegian neurosurgeons developedM. Filip1, P. Linzer1, D. Skoloudik2Virtual Navigation –A New Modality in PerioperativeBrain Tumor Imaging1Department of Neurosurgery, KNTB Zlín2Clinic of Neurology, University Hospital41
more recently accompanied by changes in behavior (depression, slowed mental reactions). Shewas examined by a neurologist and based on a CTscan with contrast medium she was diagnosedwith anterior cranial fossa meningioma (olfactory groove) 2 x 2 x 3 cm in size, with peri-focaledema of the adjacent cerebral tissue (Fig. 1).An implanted cardiac pacemaker prohibited the useof MRI. In view of the deep location and size of thetumor, we decided to perform a right-sided frontotemporal craniotomy and used the Toshiba fusionimaging solution, both to improve the precision ofthe access trajectory and to control the degree ofresection radicality in relation to the surroundingcerebral tissue.trasound probe is connected to a sensor that registers position within the electromagnetic field. Oncereference points have been registered, the systemcan simultaneously provide real-time ultrasound images and the corresponding CT/MRI images from thedownloaded dataset. Thus the probe can be usedfor preoperative examination and planning and forperioperative imaging with or without fusing bothmodalities. Our Department of Neurosurgery, KNTBZlín, in cooperation with the Department of Neurosurgery, UH Ostrava, has been testing this methodof perioperative imaging in brain tumor resectionssince June 2011. The first tests were conducted witha different vendor’s system. We started using theToshiba technology in May 2012.Case historyResection of anterior cranial fossameningioma (Fig. 1)The patient presented with headaches which shesaid she had been experiencing for several years,VISIONS 21.13 ULTRASOUNDFig.1: Preoperativecontrast CT scan(olfactory groovemeningioma)Fig. 3: Fusion of CT/ultrasound imagesduring perioperative trajectory planningin the coronal and horizontal planes42