Live X-ray Images Research Articles

Prostate deformation during hypofractionated radiotherapy: an analysis of implanted fiducial marker displacement

BackgroundTo report prostate deformation during treatment, based on an analysis of fiducial marker positional differences in a large sample.Material and methodsThis study included 144 patients treated with prostate stereotactic body radiation therapy after implantation in each of 4 gold fiducial markers (FMs), which were located and numbered consistently. The center of mass of the FMs was recorded for every pair of X-ray images taken during treatment. The distance between each pair of fiducials in the live X-ray images is calculated and compared with the respective distances as determined in the CT volume. The RBE is the difference between these distances. Mean RBE and intrafraction and interfraction RBE were evaluated. The intrafraction and intefraction RBE variability were defined as the standard deviation, respectively, of all RBE during 1 treatment fraction and of the mean daily RBE over the whole treatment course.ResultsWe analyzed 720 treatment fractions comprising 24,453 orthogonal X-ray image acquisitions. We observed a trend to higher RBE related to FM4 (apex) during treatment. The fiducial marker in the prostate apex could not be used in 16% of observations, in which RBE was > 2.5 mm. The mean RBEavg was 0.93 ± 0.39 mm (range 0.32–1.79 mm) over the 5 fractions. The RBEavg was significantly lower for the first and second fraction compared with the others (P < .001). The interfraction variability of RBEavg was 0.26 ± 0.16 mm (range 0.04–0.74 mm). The mean intrafraction variability of all FMs was 0.45 ± 0.25 mm. The highest Pearson correlation coefficient was observed between FM2 and FM3 (middle left and right prostate) (R = 0.78; P < .001). Every combination with FM4 yielded lower coefficients (range 0.66–0.71; P < .001), indicating different deformation of the prostate apex.ConclusionsIdeally, prostate deformation is generally small, but it is very sensitive to rectal and bladder filling. We observed RBE up to 11.3 mm. The overall correlation between FMs was affected by shifts of individual fiducials, indicating that the prostate is not a “rigid” organ. Systematic change of RBE average between subsequent fractions indicates a systematic change in prostate shape.

Real-time registration of 3D echo to x-ray fluoroscopy based on cascading classifiers and image registration

Three-dimensional (3D) transesophageal echocardiography (TEE) is one of the most significant advances in cardiac imaging. Although TEE provides real-time 3D visualization of heart tissues and blood vessels and has no ionizing radiation, x-ray fluoroscopy still dominates in guidance of cardiac interventions due to TEE having a limited field of view and poor visualization of surgical instruments. Therefore, fusing 3D echo with live x-ray images can provide a better guidance solution. This paper proposes a novel framework for image fusion by detecting the pose of the TEE probe in x-ray images in real-time. The framework does not require any manual initialization. Instead it uses a cascade classifier to compute the position and in-plane rotation angle of the TEE probe. The remaining degrees of freedom are determined by fast marching against a template library. The proposed framework is validated on phantoms and patient data. The target registration error for the phantom was 2.1 mm. In addition, 10 patient datasets, seven of which were acquired from cardiac electrophysiology procedures and three from trans-catheter aortic valve implantation procedures, were used to test the clinical feasibility as well as accuracy. A mean registration error of 2.6 mm was achieved, which is well within typical clinical requirements.

Robust Multi-View 2-D/3-D Registration Using Point-To-Plane Correspondence Model.

In minimally invasive procedures, the clinician relies on image guidance to observe and navigate the operation site. In order to show structures which are not visible in the live X-ray images, such as vessels or planning annotations, X-ray images can be augmented with pre-operatively acquired images. Accurate image alignment is needed and can be provided by 2-D/3-D registration. In this paper, a multi-view registration method based on the point-to-plane correspondence model is proposed. The correspondence model is extended to be independent of the used camera coordinates and different multi-view registration schemes are introduced and compared. Evaluation is performed for a wide range of clinically relevant registration scenarios. We show for different applications that registration using correspondences from both views simultaneously provides accurate and robust registration, while the performance of the other schemes varies considerably. Our method also outperforms the state-of-the-art method for cerebral angiography registration, achieving a capture range of 18 mm and an accuracy of 0.22±0.07 mm. Furthermore, investigations on the minimum angle between the views are performed in order to provide accurate and robust registration, while minimizing the obstruction to the clinical workflow. We show that small angles around 30° are sufficient to provide reliable registration results.

Echocardiography to magnetic resonance image registration for use in image-guided cardiac catheterization procedures

We present a robust method to register three-dimensional echocardiography (echo) images to magnetic resonance images (MRI) based on anatomical features, which is designed to be used in the registration pipeline for overlaying MRI-derived roadmaps onto two-dimensional live x-ray images during cardiac catheterization procedures. The features used in image registration are the endocardial surface of the left ventricle and the centre line of the descending aorta. The MR-derived left ventricle surface is generated using a fully automated algorithm, and the echo-derived left ventricle surface is produced using a semi-automatic segmentation method provided by the QLab software (Philips Healthcare) that it is routinely used in clinical practice. We test our method on data from six volunteers and four patients. We validated registration accuracy using two methods: the first calculated a root mean square distance error using expert identified anatomical landmarks, and the second method used catheters as landmarks in two clinical electrophysiology procedures. Results show a mean error of 4.1 mm, which is acceptable for our clinical application, and no failed registrations were observed. In addition, our algorithm works on clinical data, is fast and only requires a small amount of manual input, and so it is applicable for use during cardiac catheterization procedures.

X-Ray Fused With Magnetic Resonance Imaging (XFM) to Target Endomyocardial Injections

Magnetic resonance imaging (MRI) permits 3-dimensional (3D) cardiac imaging with high soft tissue contrast. X-ray fluoroscopy provides high-resolution, 2-dimensional (2D) projection imaging. We have developed real-time x-ray fused with MRI (XFM) to guide invasive procedures that combines the best features of both imaging modalities. We tested the accuracy of XFM using external fiducial markers to guide endomyocardial cell injections in infarcted swine hearts. Endomyocardial injections of iron-labeled mesenchymal stromal cells admixed with tissue dye were performed in previously infarcted hearts of 12 Yucatan miniswine (weight, 33 to 67 kg). Features from cardiac MRI were displayed combined with x-ray in real time to guide injections. During 130 injections, operators were provided with 3D surfaces of endocardium, epicardium, myocardial wall thickness (range, 2.6 to 17.7 mm), and infarct registered with live x-ray images to facilitate device navigation and choice of injection location. XFM-guided injections were compared with postinjection MRI and with necropsy specimens obtained 24 hours later. Visual inspection of the pattern of dye staining on 2,3,5-triphenyltetrazolium chloride-stained heart slices agreed (kappa=0.69) with XFM-derived injection locations mapped onto delayed hyperenhancement MRI and the susceptibility artifacts seen on the postinjection T2*-weighted gradient echo MRI. The distance between the predicted and actual injection locations in vivo was 3.2+/-2.6 mm (n=64), and 75% of injections were within 4.1 mm of the predicted location. Three-dimensional to two-dimensional registration of x-ray and MR images with the use of external fiducial markers accurately targets endomyocardial injection in a swine model of myocardial infarction.

A system for real-time XMR guided cardiovascular intervention

The hybrid magnetic resonance (MR)/X-ray suite (XMR) is a recently introduced imaging solution that provides new possibilities for guidance of cardiovascular catheterization procedures. We have previously described and validated a technique based on optical tracking to register MR and X-ray images obtained from the sliding table XMR configuration. The aim of our recent work was to extend our technique by providing an improved calibration stage, real-time guidance during cardiovascular catheterization procedures, and further off-line analysis for mapping cardiac electrical data to patient anatomy. Specially designed optical trackers and a dedicated calibration object have resulted in a single calibration step that can be efficiently checked and updated before each procedure. An X-ray distortion model has been implemented that allows for distortion correction for arbitrary c-arm orientations. During procedures, the guidance system provides a real-time combined MR/X-ray image display consisting of live X-ray images with registered recently acquired MR derived anatomy. It is also possible to reconstruct the location of catheters seen during X-ray imaging in the MR derived patient anatomy. We have applied our registration technique to 13 cardiovascular catheterization procedures. Our system has been used for the real-time guidance of ten radiofrequency ablations and one aortic stent implantation. We demonstrate the real-time guidance using two exemplar cases. In a further two cases we show how off-line analysis of registered image data, acquired during electrophysiology study procedures, has been used to map cardiac electrical measurements to patient anatomy for two different types of mapping catheters. The cardiologists that have used the guidance system suggest that real-time XMR guidance could have substantial value in difficult interventional and electrophysiological procedures, potentially reducing procedure time and delivered radiation dose. Also, the ability to map measured electrical data to patient specific anatomy provides improved visualization and a path to investigation of cardiac electromechanical models.

Modality-integrated magnetic catheter tracking for x-ray vascular interventions

A novel setup for the integration of a magnetic tracking system (MTS) into a catheter laboratory environment by attaching the field generator of the MTS to the C-arm of the x-ray system was investigated. The metal interference of the x-ray system with the MTS then becomes static and can be calibrated. The registration of a tracked catheter to 2D live x-ray images with high and well-defined accuracy is thus possible for arbitrary C-arm positions. Interference with imaging by blocking the field of view is avoided. Real-time registration methods to maintain the registration of the catheter also to static 2D or 3D images (roadmaps), regardless of the C-arm rotation during catheter tracking, were investigated. Residual registration errors of the tracked catheter with respect to the static roadmaps (2D and 3D) were reduced by using the vessel geometry and shape information. The algorithms potentially allow for motion correction (e.g. due to respiration). Using the shape-based correction algorithms the average registration accuracies to static roadmaps for different C-arm angulations and catheter positions were determined to be 3.3–4.2 mm. The magnetic registration of the C-arm was furthermore allowed to compute the imaging geometry (position of the C-arm) and to produce virtual angiographic preview images before contrast injection and x-ray dose application. Thus, optimal projection geometries and collimator settings for the target region can be chosen in an ‘off line’ fashion. The proposed MTS-supported navigation setup on both 3D (static) and 2D (live and static) roadmaps merges the high resolution and real-time feedback of 2D x-ray images with the navigation support from 3D static images.