Contrast-enhanced Cone-beam CT Research Articles

Geometrical deployment for braided stent.

The prediction of flow diverter stent (FDS) implantation for the treatment of intracranial aneurysms (IAs) is being increasingly required for hemodynamic simulations and procedural planning. In this paper, a deployment model was developed based on geometrical properties of braided stents. The proposed mathematical description is first applied on idealized toroidal vessels demonstrating the stent shortening in curved vessels. It is subsequently generalized to patient specific vasculature predicting the position of the filaments along with the length and local porosity of the stent. In parallel, in-vitro and in-vivo FDS deployments were measured by contrast-enhanced cone beam CT (CBCT) in idealized and patient-specific geometries. These measurements showed a very good qualitative and quantitative agreement with the virtual deployments and provided experimental validations of the underlying geometrical assumptions. In particular, they highlighted the importance of the stent radius assessment in the accuracy of the deployment prediction. Thanks to its low computational cost, the proposed model is potentially implementable in clinical practice providing critical information for patient safety and treatment outcome assessment.

Pulmonary Artery Imaging in Patients with Chronic Thromboembolic Pulmonary Hypertension: Comparison of Cone-Beam CT and 64-Row Multidetector CT

PurposeTo compare the depiction of pulmonary arteries in pulmonary arterial catheter–based contrast-enhanced cone-beam CT with peripheral intravenous contrast-enhanced multidetector CT in patients with suspected chronic thromboembolic pulmonary hypertension. Material and MethodsIn 20 patients (15 men and 5 women, 63.4 y ± 16.3), cone-beam CT using a catheter placed in the main pulmonary artery and 64-row multidetector CT using an appropriate venous access were performed. Contrast enhancement was measured in the main pulmonary artery, the right and left pulmonary arteries, and the left atrium. The amount of peripheral vessel conspicuity adjacent to the pleural surface (distance from vessel-to pleura) was measured. Two readers (R1, R2) independently evaluated the pulmonary arteries for image quality and pathologic findings in both modalities. ResultsContrast density was higher in the main pulmonary artery and right and left pulmonary arteries (P < .002) and lower in the left atrium (P = .001) on cone-beam CT. The smallest distance between clearly delineated vessels and the pleura was significantly lower on cone-beam CT images (P < .0001). Interobserver agreement was good for cone-beam CT (κ = 0.79) and multidetector CT (κ = 0.78), whereas intermodality agreement was moderate (R1, κ = 0.60; R2, κ = 0.59). Both readers detected more weblike stenoses with cone-beam CT (76; 22%) compared with multidetector CT (25; 7%). ConclusionsCone-beam CT shows improved contrast between pulmonary arteries and the left atrium and allows a more detailed depiction of the pulmonary arteries.

Grading of Regional Apposition after Flow-Diverter Treatment (GRAFT): a comparative evaluation of VasoCT and intravascular OCT

BackgroundPoor vessel wall apposition of flow diverter (FD) stents poses risks for stroke-related complications when treating intracranial aneurysms, necessitating long-term surveillance imaging. To facilitate quantitative evaluation of deployed devices, a...

TU‐F‐CAMPUS‐I‐02: Contrast Enhanced Cone Beam CT Imaging with Dual‐ Gantry Image Acquisition and Constrained Iterative Reconstruction‐a Simulation Study for Liver Imaging Application

Purpose:Contrast time‐density curves may help differentiate malignant tumors from normal tissues or benign tumors. Repetitive scans using conventional CT or cone beam CT techniques, which Result in unacceptably high dose, may not achieve the desired temporal resolution. In this study we describe and demonstrate a 4D imaging technique for imaging and quantifying contrast flows requiring only one or two 360° scans.Methods:A dual‐gantry system is used to simultaneously acquire two projection images at orthogonal orientations. Following the scan, each or both of the two 360° projection sets are used to reconstruct an average contrast enhanced image set which is then segmented to form a 3D contrast map. Alternatively, a pre‐injection scan may be made and used to reconstruct a pre‐injection image set which is subtracted from the post‐injection image set to form the 3D contrast map. Each of the two 360° projection sets is divided into 12 subsets, thus creating 12 pairs of 30° limited angle projection sets, each corresponding to a time spanning over 1/12 of the scanning time. Each pair of the projection sets are reconstructed as a time specific 3D image set with the maximum likelihood estimation iterative algorithm using the contrast map as the constraint. As a demonstration, a 4D abdominal phantom was constructed from clinical CT images with blood flow through the normal tissue and a tumor modeled and imaging process simulated.Results:We have successfully generated a 4D image phantom, and calculated the projection images. The time density curves derived from the reconstructed image set matched well with the flow model used to generate the phantom.Conclusion:Dual‐gantry image acquisition and constrained iterative reconstruction algorithm may help to obtain time‐density curves of contrast agents in blood flows, which may help differentiate malignant tumors from normal tissues or benign tumors.

1:36 PM, Abstract No. 120 - Multimodality 3D tumor segmentation in HCC patients treated with TACE

Rationale and Objectives To validate the concordance of a semiautomated multimodality lesion segmentation technique between contrast-enhanced magnetic resonance imaging (CE-MRI), cone-beam computed tomography (CBCT), and multidetector CT (MDCT) in patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE). Materials and Methods This retrospective analysis included 45 patients with unresectable HCC who underwent baseline CE-MRI within 1 month before the treatment, intraprocedural CBCT during conventional TACE, and MDCT within 24 hours after TACE. Fourteen patients were excluded because of atypical lesion morphology, portal vein invasion, or small lesion size which precluded sufficient lesion visualization. Thirty-one patients with a total of 40 target lesions were included into the analysis. A tumor segmentation software, based on non-Euclidean geometry and theory of radial basis functions, was used to allow for the segmentation of target lesions in 3D on all three modalities. The algorithm created image-based masks located in a 3D region whose center and size were defined by the user, yielding the nomenclature “semiautomatic”. On the basis of that, tumor volumes on all three modalities were calculated and compared using a linear regression model ( R 2 values). Residual plots were used to analyze drift and variance of the values. Results The mean value of tumor volumes was 18.72 ± 19.13 cm 3 (range, 0.41–59.16 cm 3 ) on CE-MRI, 21.26 ± 21.99 cm 3 (range, 0.62–86.82 cm 3 ) on CBCT, and 19.88 ± 20.88 cm 3 (range, 0.45–75.24 cm 3 ) on MDCT. The average volumes of the tumor were not significantly different between CE-MRI and DP-CBCT, DP-CBCT and MDCT, MDCT and CE-MRI ( P = .577, .770, and .794, respectively). A strong correlation between volumes on CE-MRI and CBCT, CBCT and MDCT, MDCT and CE-MRI was observed ( R 2 = 0.974, 0.992 and 0.983, respectively). When plotting the residuals, no drift was observed for all methods showing deviations of no >10% of absolute volumes (in cm 3 ). Conclusions A semiautomated 3D segmentation of HCC lesions treated with TACE provides high volumetric concordance across all tested imaging modalities.

P-001 High-Resolution Optical and Angiographic CT Imaging of Flow-Diverter Stents for Assessment of Vessel Wall Apposition

IntroductionIntracranial placement of flow-diverter (FD) stents provides a safe and effective treatment for aneurysms.1 However, long-term angiographic follow-up is indicated, since in-stent stenosis and late thrombosis as a consequence of...

Assessment of contrast enhanced respiration managed cone-beam CT for image guided radiotherapy of intrahepatic tumors.

Contrast enhancement and respiration management are widely used during image acquisition for radiotherapy treatment planning of liver tumors along with respiration management at the treatment unit. However, neither respiration management nor intravenous contrast is commonly used during cone-beam CT (CBCT) image acquisition for alignment prior to radiotherapy. In this study, the authors investigate the potential gains of injecting an iodinated contrast agent in combination with respiration management during CBCT acquisition for liver tumor radiotherapy. Five rabbits with implanted liver tumors were subjected to CBCT with and without motion management and contrast injection. The acquired CBCT images were registered to the planning CT to determine alignment accuracy and dosimetric impact. The authors developed a simulation tool for simulating contrast-enhanced CBCT images from dynamic contrast enhanced CT imaging (DCE-CT) to determine optimal contrast injection protocols. The tool was validated against contrast-enhanced CBCT of the rabbit subjects and was used for five human patients diagnosed with hepatocellular carcinoma. In the rabbit experiment, when neither motion management nor contrast was used, tumor centroid misalignment between planning image and CBCT was 9.2 mm. This was reduced to 2.8 mm when both techniques were employed. Tumors were not visualized in clinical CBCT images of human subjects. Simulated contrast-enhanced CBCT was found to improve tumor contrast in all subjects. Different patients were found to require different contrast injections to maximize tumor contrast. Based on the authors' animal study, respiration managed contrast enhanced CBCT improves IGRT significantly. Contrast enhanced CBCT benefits from patient specific tracer kinetics determined from DCE-CT.

Investigating the use of texture features for analysis of breast lesions on contrast-enhanced cone beam CT.

Cone beam computed tomography (CBCT) has found use in mammography for imaging the entire breast with sufficient spatial resolution at a radiation dose within the range of that of conventional mammography. Recently, enhancement of lesion tissue through the use of contrast agents has been proposed for cone beam CT. This study investigates whether the use of such contrast agents improves the ability of texture features to differentiate lesion texture from healthy tissue on CBCT in an automated manner. For this purpose, 9 lesions were annotated by an experienced radiologist on both regular and contrast-enhanced CBCT images using two-dimensional (2D) square ROIs. These lesions were then segmented, and each pixel within the lesion ROI was assigned a label - lesion or non-lesion, based on the segmentation mask. On both sets of CBCT images, four three-dimensional (3D) Minkowski Functionals were used to characterize the local topology at each pixel. The resulting feature vectors were then used in a machine learning task involving support vector regression with a linear kernel (SVRlin) to classify each pixel as belonging to the lesion or non-lesion region of the ROI. Classification performance was assessed using the area under the receiver-operating characteristic (ROC) curve (AUC). Minkowski Functionals derived from contrast-enhanced CBCT images were found to exhibit significantly better performance at distinguishing between lesion and non-lesion areas within the ROI when compared to those extracted from CBCT images without contrast enhancement (p < 0.05). Thus, contrast enhancement in CBCT can improve the ability of texture features to distinguish lesions from surrounding healthy tissue.

Optimized dynamic contrast-enhanced cone-beam CT for target visualization during liver SBRT

The pharmacokinetic behavior of iodine contrast agents makes it difficult to achieve significant enhancement during contrast-enhanced cone-beam CT (CE-CBCT). This study modeled this dynamic behavior to optimize CE-CBCT and improve the localization of liver lesions for SBRT. We developed a model that allows for controlled study of changing iodine concentrations using static phantoms. A projection database consisting of multiple phantom images of differing iodine/scan conditions was built. To reconstruct images of dynamic hepatic concentrations, hepatic contrast enhancement data from conventional CT scans were used to re-assemble the projections to match the expected amount of contrast. In this way the effect of various parameters on image quality was isolated, and using our dynamic model we found parameters for iodine injection, CBCT scanning, and injection/scanning timing which optimize contrast enhancement. Increasing the iodine dose, iodine injection rate, and imaging dose led to significant increases in signal-to-noise ratio (SNR). Reducing the CBCT imaging time also increased SNR, as the image can be completed before the iodine exits the liver. Proper timing of image acquisition played a significant role, as a 30 second error in start time resulted in a 40% SNR decrease. The effect of IV contrast is severely degraded in CBCT, but there is promise that, with optimization of the injection and scan parameters to account for iodine pharmacokinetics, CE-CBCT which models venous-phase blood flow kinetics will be feasible for accurate localization of liver lesions.

Dual‐energy cone‐beam CT with a flat‐panel detector: Effect of reconstruction algorithm on material classification

Cone-beam CT (CBCT) with a flat-panel detector (FPD) is finding application in areas such as breast and musculoskeletal imaging, where dual-energy (DE) capabilities offer potential benefit. The authors investigate the accuracy of material classification in DE CBCT using filtered backprojection (FBP) and penalized likelihood (PL) reconstruction and optimize contrast-enhanced DE CBCT of the joints as a function of dose, material concentration, and detail size. Phantoms consisting of a 15 cm diameter water cylinder with solid calcium inserts (50-200 mg/ml, 3-28.4 mm diameter) and solid iodine inserts (2-10 mg/ml, 3-28.4 mm diameter), as well as a cadaveric knee with intra-articular injection of iodine were imaged on a CBCT bench with a Varian 4343 FPD. The low energy (LE) beam was 70 kVp (+0.2 mm Cu), and the high energy (HE) beam was 120 kVp (+0.2 mm Cu, +0.5 mm Ag). Total dose (LE+HE) was varied from 3.1 to 15.6 mGy with equal dose allocation. Image-based DE classification involved a nearest distance classifier in the space of LE versus HE attenuation values. Recognizing the differences in noise between LE and HE beams, the LE and HE data were differentially filtered (in FBP) or regularized (in PL). Both a quadratic (PLQ) and a total-variation penalty (PLTV) were investigated for PL. The performance of DE CBCT material discrimination was quantified in terms of voxelwise specificity, sensitivity, and accuracy. Noise in the HE image was primarily responsible for classification errors within the contrast inserts, whereas noise in the LE image mainly influenced classification in the surrounding water. For inserts of diameter 28.4 mm, DE CBCT reconstructions were optimized to maximize the total combined accuracy across the range of calcium and iodine concentrations, yielding values of ∼ 88% for FBP and PLQ, and ∼ 95% for PLTV at 3.1 mGy total dose, increasing to ∼ 95% for FBP and PLQ, and ∼ 98% for PLTV at 15.6 mGy total dose. For a fixed iodine concentration of 5 mg/ml and reconstructions maximizing overall accuracy across the range of insert diameters, the minimum diameter classified with accuracy >80% was ∼ 15 mm for FBP and PLQ and ∼ 10 mm for PLTV, improving to ∼ 7 mm for FBP and PLQ and ∼ 3 mm for PLTV at 15.6 mGy. The results indicate similar performance for FBP and PLQ and showed improved classification accuracy with edge-preserving PLTV. A slight preference for increased smoothing of the HE data was found. DE CBCT discrimination of iodine and bone in the knee was demonstrated with FBP and PLTV at 6.2 mGy total dose. For iodine concentrations >5 mg/ml and detail size ∼ 20 mm, material classification accuracy of >90% was achieved in DE CBCT with both FBP and PL at total doses <10 mGy. Optimal performance was attained by selection of reconstruction parameters based on the differences in noise between HE and LE data, typically favoring stronger smoothing of the HE data, and by using penalties matched to the imaging task (e.g., edge-preserving PLTV in areas of uniform enhancement).

IV Contrast-Enhanced Cone Beam CT to Enhance Image Guidance for Liver SBRT

IV Contrast-Enhanced Cone Beam CT to Enhance Image Guidance for Liver SBRT

Target delineation for radiosurgery of a small brain arteriovenous malformation using high-resolution contrast-enhanced cone beam CT

Three years following endovascular embolization of a 3 mm ruptured arteriovenous malformation (AVM) of the left superior colliculus in a 42-year-old man, digital subtraction angiography showed continuous regrowth of the...

P-016 Quantitative Assessment of Stent Induced Neointimal Hyperplasia with Contrast Enhanced Cone-Beam CT: In Vivo Validation with Histomorphometry

IntroductionIntracranial stenting is an effective therapy for specific cerebrovascular disorders including treatment-resistant atherosclerosis, cerebral aneurysms, and arterial dissections. However, in-stent tissue growth (neointimal hyperplasia (NIH) and/or in-stent restenosis (ISR)), is...

Reduction of Coil Mass Artifacts in High-Resolution Flat Detector Conebeam CT of Cerebral Stent-Assisted Coiling

Developments in flat panel angiographic C-arm systems have enabled visualization of both the neurovascular stents and host arteries in great detail, providing complementary spatial information in addition to conventional DSA. However, the visibility of these structures may be impeded by artifacts generated by adjacent radio-attenuating objects. We report on the use of a metal artifact reduction algorithm for high-resolution contrast-enhanced conebeam CT for follow-up imaging of stent-assisted coil embolization. Contrast-enhanced conebeam CT data were acquired in 25 patients who underwent stent-assisted coiling. Reconstructions were generated with and without metal artifact reduction and were reviewed by 3 experienced neuroradiologists by use of a 3-point scale. With metal artifact reduction, the observers agreed that the visibility had improved by at least 1 point on the scoring scale in >40% of the cases (κ = 0.6) and that the streak artifact was not obscuring surrounding structures in 64% of all cases (κ = 0.6). Metal artifact reduction improved the image quality, which allowed for visibility sufficient for evaluation in 65% of the cases, and was preferred over no metal artifact reduction in 92% (κ = 0.9). Significantly higher scores were given with metal artifact reduction (P < .0001). Although metal artifact reduction is not capable of fully removing artifacts caused by implants with high x-ray absorption, we have shown that the image quality of contrast-enhanced conebeam CT data are improved drastically. The impact of the artifacts on the visibility varied between cases, and yet the overall visibility of the contrast-enhanced conebeam CT with metal artifact reduction improved in most the cases.

WE-G-217BCD-08: Image Quality Effects of Dynamic Iodine Concentrations for Contrast-Enhanced Cone-Beam CT.

To study the image effects of the time-wise dynamic aspect of intravenous contrast agents to enable contrast-enhanced cone-beam CT (CE- CBCT) localization of liver lesions for stereotactic body radiation therapy (SBRT). A model was developed to study dynamic IV contrast agents using static phantoms and to derive optimum parameters for CE- CBCT imaging. Ten samples containing iodine at 0-5 mg/mL were prepared in cylindrical tubes, corresponding roughly to 0-100 HU as measured by 120 kV helical CT imaging. Each sample was imaged separately in a tissue- equivalent phantom, yielding ten datasets (roughly 650 projections each) corresponding to these static CBCT images. To reconstruct images of dynamic contrast concentrations, the CBCT 2D projections were re- assembled to match the expected amount of contrast at different points in time. This model was applied to published hepatic contrast enhancement curves, and optimum imaging and contrast injection parameters were derived. A signal-to-noise ratio (SNR) decrease of 25%-75% in dynamic CE-CBCT images from ideal CT of samples with a 20-100 HU difference from water was observed in the un-optimized scans. This demonstrates the difficulty of CE-CBCT, and was noticed even in geometries that minimize or eliminate x-ray scatter, detector glare, and motion. Using our model, we found parameters for iodine injection, CBCT scanning, and injection/scanning timing which optimize contrast enhancement, and a 100% SNR increase with respect to the un-optimized scans was achieved. The effect of IV contrast is severely degraded in CBCT, and optimization of image and timing parameters is crucial for improved CE-CBCT imaging for target localization. CBCT has very low temporal resolution, and the pharmacokinetics of IV contrast must be carefully considered in order to apply this technique to localize liver lesions for SBRT. This model will be used to establish the feasibility of CE- CBCT for routine localization of liver lesions.

The Effect of Intracranial Stent Implantation on the Curvature of the Cerebrovasculature

Recently, the use of stents to assist in the coiling and repair of wide-neck aneurysms has been shown to be highly effective; however, the effect of these stents on the RC of the parent vessel has not been quantified. The purpose of this study was to quantify the effect of intracranial stenting on the RC of the implanted artery using 3D datasets. Twenty-four patients receiving FDA-approved neurovascular stents to support coil embolization of brain aneurysms were chosen for this study. The stents were located in the ICA, ACA, or MCA. We analyzed C-arm rotational angiography and contrast-enhanced cone beam CT datasets before and after stent implantation, respectively, to ascertain changes in vessel curvature. The images were reconstructed, and the vessel centerline was extracted. From the centerline, the RC was calculated. The average implanted stent length was 25.4 ± 5.8 mm, with a pre-implantation RC of 7.1 ± 2.1 mm and a postimplantation RC of 10.7 ± 3.5 mm. This resulted in a 3.6 ± 2.7 mm change in the RC due to implantation (P < .0001), more than a 50% increase from the pre-implantation value. There was no difference in the change of RC for the different locations studied. The change in RC was not impacted by the extent of coil packing within the aneurysm. The implantation of neurovascular stents can be shown to have a large impact on the RC of the vessel. This will lead to a change in the local hemodynamics and flow pattern within the aneurysm.

Contrast-Enhanced Angiographic Cone-Beam CT of Cerebrovascular Stents: Experimental Optimization and Clinical Application

With modern imaging techniques, visualization of neurovascular stents remains challenging. We present a method for contrast-enhanced C-arm CBCT that provides detailed and simultaneous visualization of neurovascular stents and host arteries. CBCT was performed with a rotational angiography system by acquiring 620 projection frames over a 200° arc at 80 kVp and a total of 260 mAs. A superselective intra-arterial contrast injection protocol was optimized in swine experiments and implemented in 57 clinical examinations. High-resolution 3D reconstructions were evaluated by 3 blinded interventional neuroradiologists. Reviewers rated the images by answering questions related to both the quality of the stent and artery visualization and the clinical utility of the images. Raw agreement statistics, ICC, and κ statistics were computed for the questionnaire results. Of 57 clinical evaluations, 5 were not evaluated due to the use of large balloon-mounted stents (n = 4) and a failed contrast injection (n = 1). In 50 of 52 evaluated examinations, the reviewers agreed that simultaneous stent and vessel visualization was of diagnostic quality. There was strong agreement that stent-vessel wall apposition could be assessed (κ = 0.79). CBCT detected contrast filling defects (κ = 0.85) and vascular calcification (κ = 0.68). Artifacts resulting from the aneurysm coil mass impaired the delineation of adjacent structures (κ = 0.72). We have developed a technique that enables simultaneous clinically useful imaging of neurovascular stents and their host arteries that is unobtainable with other current imaging modalities. Further improvements are required to reduce artifacts from large coil masses due to x-ray scattering.

Adaptive radiotherapy based on contrast enhanced cone beam CT imaging

Cone beam CT (CBCT) imaging has become an integral part of radiation therapy, with images typically used for offline or online patient setup corrections based on bony anatomy co-registration. Ideally, the co-registration should be based on tumor localization. However, soft tissue contrast in CBCT images may be limited. In the present work, contrast enhanced CBCT (CECBCT) images were used for tumor visualization and treatment adaptation. Material and methods. A spontaneous canine maxillary tumor was subjected to repeated cone beam CT imaging during fractionated radiotherapy (10 fractions in total). At five of the treatment fractions, CECBCT images, employing an iodinated contrast agent, were acquired, as well as pre-contrast CBCT images. The tumor was clearly visible in post-contrast minus pre-contrast subtraction images, and these contrast images were used to delineate gross tumor volumes. IMRT dose plans were subsequently generated. Four different strategies were explored: 1) fully adapted planning based on each CECBCT image series, 2) planning based on images acquired at the first treatment fraction and patient repositioning following bony anatomy co-registration, 3) as for 2), but with patient repositioning based on co-registering contrast images, and 4) a strategy with no patient repositioning or treatment adaptation. The equivalent uniform dose (EUD) and tumor control probability (TCP) calculations to estimate treatment outcome for each strategy. Results. Similar translation vectors were found when bony anatomy and contrast enhancement co-registration were compared. Strategy 1 gave EUDs closest to the prescription dose and the highest TCP. Strategies 2 and 3 gave EUDs and TCPs close to that of strategy 1, with strategy 3 being slightly better than strategy 2. Even greater benefits from strategies 1 and 3 are expected with increasing tumor movement or deformation during treatment. The non-adaptive strategy 4 was clearly inferior to all three adaptive strategies. Conclusion. CECBCT may prove useful for adaptive radiotherapy.

Feasibility of contrast-enhanced cone-beam CT for target localization and treatment monitoring

A dog with a spontaneous maxillary tumour was given 40 Gy of fractionated radiotherapy. At five out of 10 fractions cone-beam CT (CBCT) imaging before and after administration of an iodinated contrast agent were performed. Contrast enhancement maps were overlaid on the pre-contrast CBCT images. The tumour was clearly visualized in the images thus produced.

220 On-line tumor perfusion measurement with contrast enhanced cone beam CT

220 On-line tumor perfusion measurement with contrast enhanced cone beam CT