The Best of Both Worlds: Ultra-high-pitch Pulmonary Angiography with Free-Breathing Technique by Means of Photon-Counting Detector CT for Diagnosis of Acute Pulmonary Embolism.

RATIONALE AND OBJECTIVES: To assess image quality and radiation dose of ultra-high-pitch CT pulmonary angiography (CTPA) with free-breathing technique for diagnosis of pulmonary embolism using a photon-counting detector (PCD) CT compared to matched energy-integrating detector (EID)-based single-energy CTPA. MATERIALS AND METHODS: Fifty-one PCD-CTPAs were prospectively compared to 51 CTPAs on a third-generation dual-source EID-CT. CTPAs were acquired with an ultra-high-pitch protocol with free-breathing technique (40 mL contrast medium, pitch 3.2) at 140 kV (PCD) and 70-100 kV (EID). Iodine maps were reconstructed from spectral PCD-CTPAs. Image quality of CTPAs and iodine maps was assessed independently by three radiologists. Additionally, CT attenuation numbers within pulmonary arteries as well as signal-to-noise and contrast-to-noise ratios (SNR, CNR) were compared. Administered radiation dose was compared. RESULTS: CT attenuation was higher in the PCD-group (all P < 0.05). CNR and SNR were higher in lobar pulmonary arteries in PCD-CTPAs (P < 0.05), whereas no difference was ascertained within the pulmonary trunk (P > 0.05). Image quality of PCD-CTPA was rated best by all readers (excellent/good image quality in 96.1% of PCD-CTPAs vs. 50.9% of EID-CTPAs). PCD-CT produced no non-diagnostic scans vs. three non-diagnostic (5.9%) EID-CTPAs. Radiation dose was lower with PCD-CT than with EID-CT (effective dose 1.33 ± 0.47 vs. 1.80 ± 0.82 mSv; all P < 0.05). CONCLUSION: Ultra-high-pitch CTPA with free-breathing technique with PCD-CT allows for superior image quality with significantly reduced radiation dose and full spectral information. With the ultra-high pitch, only PCD-CTPA enables reconstruction of iodine maps containing additional functional information.

Virtual non-iodine photon-counting CT-angiography for aortic valve calcification scoring.

Photon-counting detector (PCD)-CT allows for reconstruction of virtual non-iodine (VNI) images from contrast-enhanced datasets. This study assesses the diagnostic performance of aortic valve calcification scoring (AVCS) derived from VNI datasets generated with a 1st generation clinical dual-source PCD-CT. AVCS was evaluated in 123 patients (statistical analysis only comprising patients with aortic valve calcifications [n = 56; 63.2 ± 11.6 years]), who underwent contrast enhanced electrocardiogram-gated (either prospective or retrospective or both) cardiac CT on a clinical PCD system. Patient data was reconstructed at 70 keV employing a VNI reconstruction algorithm. True non-contrast (TNC) scans at 70 keV without quantum iterative reconstruction served as reference in all individuals. Subgroup analysis was performed in 17 patients who received both, prospectively and retrospectively gated contrast enhanced scans (n = 8 with aortic valve calcifications). VNI images with prospective/retrospective gating had an overall sensitivity of 69.2%/56.0%, specificity of 100%/100%, accuracy of 85.4%/81.0%, positive predictive value of 100%/100%, and a negative predictive value of 78.2%/75.0%. VNI images with retrospective gating achieved similar results. For both gating approaches, AVCSVNI showed high correlation (r = 0.983, P < 0.001 for prospective; r = 0.986, P < 0.001 for retrospective) with AVCSTNC. Subgroup analyses demonstrated excellent intra-individual correlation between different acquisition modes (r = 0.986, P < 0.001). Thus, VNI images derived from cardiac PCD-CT allow for excellent diagnostic performance in the assessment of AVCS, suggesting potential for the omission of true non-contrast scans in the clinical workup of patients with aortic calcifications.

Image Quality and Radiation Dose of CTPA With Iodine Maps: A Prospective Randomized Study of High-Pitch Mode Photon-Counting Detector CT Versus Energy-Integrating Detector CT.

BACKGROUND. Dual-energy CT pulmonary angiography (CTPA) with energy-integrating detector (EID) technology is limited by the inability to use high-pitch technique. OBJECTIVE. The purpose of this study was to compare the image quality of anatomic images and iodine maps between high-pitch photon-counting detector (PCD) CTPA and dual-energy EID CTPA. METHODS. This prospective study included 117 patients (70 men and 47 women; median age, 65 years) who underwent CTPA to evaluate for pulmonary embolism between March 2022 and November 2022. Fifty-eight patients were randomized to undergo PCD CTPA (pitch, 2.0), and 59 were randomized to undergo EID CTPA (pitch, 0.55). For each examination, 120-kV polychromatic images, 60-keV virtual monogenetic images (VMIs), and iodine maps were reconstructed. One radiologist measured CNR and SNR. Three radiologists independently assessed subjective image quality (on a scale of 1-4, with a score of 1 denoting highest quality). Radiation dose was recorded. RESULTS. SNR and CNR were higher for PCD CTPA than for EID CTPA for polychromatic images and VMIs, for all assessed vessels other than the left upper lobe artery. For example, for PCD CTPA versus EID CTPA, the right lower lobe artery on polychromatic images had an SNR of 34.5 versus 28.0 (p = .003) and a CNR of 29.2 versus 24.4 (p = .001), and on VMIs it had an SNR of 43.2 versus 32.7 (p = .005) and a CNR of 37.4 versus 29.3 (p = .002). For both scanners for readers 1 and 2, the median image quality score for polychromatic images and VMIs was 1, although distributions indicated significantly better scores for PCD CTPA than for EID CTPA for polychromatic images for reader 1 (p = .02) and reader 2 (p = .005) and for VMIs for reader 1 (p = .001) and reader 2 (p = .006). The image quality of anatomic image sets was not different between PCD CTPA and EID CTPA for reader 3 (p > .05). The image quality of iodine maps was not different between PCD CTPA and EID CTPA for any reader (p > .05). For PCD CTPA versus EID CTPA, the CTDIvol was 3.9 versus 4.5 mGy (p = .03), and the DLP was 123.5 mGy × cm versus 157.0 mGy × cm (p < .001). CONCLUSION. High-pitch PCD CTPA provided anatomic images with better subjective and objective image quality versus dual-energy EID CTPA, with lower radiation dose. Iodine maps showed no significant difference in image quality between scanners. CLINICAL IMPACT. CTPA may benefit from the PCD CT technique.

Lung Function in Patients with Cystic Fibrosis before and during CFTR-Modulator Therapy Using 3D Ultrashort Echo Time MRI.

Background The triple combination of the cystic fibrosis transmembrane regulator (CFTR) modulators elexacaftor, tezacaftor, and ivacaftor (hereafter, elexacaftor/tezacaftor/ivacaftor) has a positive effect on lung function in patients with cystic fibrosis (CF). Purpose To compare three-dimensional (3D) ultrashort echo time (UTE) MRI functional lung data to common functional lung parameters in assessing lung function in patients with CF undergoing elexacaftor/tezacaftor/ivacaftor therapy. Materials and Methods In this prospective feasibility study, 16 participants with CF consented to undergo pulmonary MRI with a breath-hold 3D UTE sequence at baseline (April 2018-June 2019) and follow-up (April-July 2021). Eight participants received elexacaftor/tezacaftor/ivacaftor after baseline, and eight participants with unchanged treatment served as the control group. Lung function was assessed with body plethysmography and lung clearance index (LCI). Image-based functional lung parameters, such as ventilation inhomogeneity and ventilation defect percentage (VDP), were calculated from signal intensity change between MRI scans at inspiration and expiration. Metrics at baseline and follow-up were compared within groups (permutation test), correlation was tested (Spearman rank correlation), and 95% CIs were calculated (bootstrapping technique). Results MRI ventilation inhomogeneity correlated with LCI at baseline (r = 0.92, P < .001) and follow-up (r = 0.81, P = .002). Mean MRI ventilation inhomogeneity (baseline, 0.74 ± 0.15 [SD]; follow-up, 0.64 ± 0.11; P = .02) and mean VDP (baseline, 14.1% ± 7.4; follow-up, 8.5% ± 3.3; P = .02) decreased from baseline to follow-up in the treatment group. Lung function was stable over time (mean LCI: 9.3 turnovers ± 4.1 at baseline vs 11.5 turnovers ± 7.4 at follow-up; P = .34) in the control group. In all participants, correlation of forced expiratory volume in 1 second with MRI ventilation inhomogeneity was good at baseline (r = -0.61, P = .01) but poor during follow-up (r = -0.06, P = .82). Conclusion Noncontrast 3D UTE lung MRI functional parameters of ventilation inhomogeneity and VDP can be used to assess lung function over time in patients with CF and can add regional information to established global parameters, such as LCI. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Iwasawa in this issue.

Photon-counting CT for diagnosis of acute pulmonary embolism: potential for contrast medium and radiation dose reduction.

OBJECTIVE: To evaluate the image quality of an ultra-low contrast medium and radiation dose CT pulmonary angiography (CTPA) protocol for the diagnosis of acute pulmonary embolism using a clinical photon-counting detector (PCD) CT system and compare its performance to a dual-energy-(DE)-CTPA protocol on a conventional energy-integrating detector (EID) CT system. METHODS: Sixty-four patients either underwent CTPA with the novel scan protocol on the PCD-CT scanner (32 patients, 25 mL, CTDIvol 2.5 mGy·cm) or conventional DE-CTPA on a third-generation dual-source EID-CT (32 patients, 50 mL, CTDIvol 5.1 mGy·cm). Pulmonary artery CT attenuation, signal-to-noise ratio, and contrast-to-noise-ratio were assessed as objective criteria of image quality, while subjective ratings of four radiologists were compared at 60 keV using virtual monoenergetic imaging and polychromatic standard reconstructions. Interrater reliability was determined by means of the intraclass correlation coefficient (ICC). Effective dose was compared between patient cohorts. RESULTS: Subjective image quality was deemed superior by all four reviewers for 60-keV PCD scans (excellent or good ratings in 93.8% of PCD vs. 84.4% of 60 keV EID scans, ICC = 0.72). No examinations on either system were considered "non-diagnostic." Objective image quality parameters were significantly higher in the EID group (mostly p < 0.001), both in the polychromatic reconstructions and at 60 keV. The ED (1.4 vs. 3.3 mSv) was significantly lower in the PCD cohort (p < 0.001). CONCLUSIONS: PCD-CTPA allows for considerable reduction of contrast medium and radiation dose in the diagnosis of acute pulmonary embolism, while maintaining good to excellent image quality compared to conventional EID-CTPA. CLINICAL RELEVANCE STATEMENT: Clinical PCD-CT allows for spectral assessment of pulmonary vasculature with high scan speed, which is beneficial in patients with suspected pulmonary embolism, frequently presenting with dyspnea. Simultaneously PCD-CT enables substantial reduction of contrast medium and radiation dose. KEY POINTS: • The clinical photon-counting detector CT scanner used in this study allows for high-pitch multi-energy acquisitions. • Photon-counting computed tomography allows for considerable reduction of contrast medium and radiation dose in the diagnosis of acute pulmonary embolism. • Subjective image quality was rated best for 60-keV photon-counting scans.

Artificial intelligence in coronary computed tomography angiography: Demands and solutions from a clinical perspective.

Coronary computed tomography angiography (CCTA) is increasingly the cornerstone in the management of patients with chronic coronary syndromes. This fact is reflected by current guidelines, which show a fundamental shift towards non-invasive imaging - especially CCTA. The guidelines for acute and stable coronary artery disease (CAD) of the European Society of Cardiology from 2019 and 2020 emphasize this shift. However, to fulfill this new role, a broader availability in adjunct with increased robustness of data acquisition and speed of data reporting of CCTA is needed. Artificial intelligence (AI) has made enormous progress for all imaging methodologies concerning (semi)-automatic tools for data acquisition and data post-processing, with outreach toward decision support systems. Besides onco- and neuroimaging, cardiac imaging is one of the main areas of application. Most current AI developments in the scenario of cardiac imaging are related to data postprocessing. However, AI applications (including radiomics) for CCTA also should enclose data acquisition (especially the fact of dose reduction) and data interpretation (presence and extent of CAD). The main effort will be to integrate these AI-driven processes into the clinical workflow, and to combine imaging data/results with further clinical data, thus - beyond the diagnosis of CAD- enabling prediction and forecast of morbidity and mortality. Furthermore, data fusing for therapy planning (e.g., invasive angiography/TAVI planning) will be warranted. The aim of this review is to present a holistic overview of AI applications in CCTA (including radiomics) under the umbrella of clinical workflows and clinical decision-making. The review first summarizes and analyzes applications for the main role of CCTA, i.e., to non-invasively rule out stable coronary artery disease. In the second step, AI applications for additional diagnostic purposes, i.e., to improve diagnostic power (CAC = coronary artery classifications), improve differential diagnosis (CT-FFR and CT perfusion), and finally improve prognosis (again CAC plus epi- and pericardial fat analysis) are reviewed.

Comparison of diagnostic quality of 3D ultrashort-echo-time techniques for pulmonary magnetic resonance imaging in free-breathing.

BACKGROUND: Ultrashort-echo-time (UTE) sequences have been developed to overcome technical limitations of pulmonary magnetic resonance imaging (MRI). Recently, it has been shown that UTE sequences with breath-hold allow rapid image acquisition with sufficient image quality. However, patients with impaired respiration require alternative acquisition strategies while breathing freely. PURPOSE: To compare the diagnostic performance of free-breathing three-dimensional (3D)-UTE sequences with different trajectories based on pulmonary imaging of immunocompromised patients. MATERIAL AND METHODS: In a prospective study setting, two 3D-UTE sequences performed in free-breathing and exploiting non-Cartesian trajectories-one using a stack-of-spirals and the other exploiting a radial trajectory-were acquired at 3 T in patients undergoing hematopoietic stem cell transplantation. Two radiologists assessed the images regarding presence of pleural effusions and pulmonary infiltrations. Computed tomography (CT) was used as reference. RESULTS: A total of 28 datasets, each consisting of free-breathing 3D-UTE MRI with the two sequence techniques and a reference CT scan, were acquired in 20 patients. Interrater agreement was substantial for pulmonary infiltrations using both sequence techniques (κ = 0.77 - 0.78). Regarding pleural effusions, agreement was almost perfect in the stack-of-spirals (κ = 0.81) and moderate in the radial sequence (κ = 0.59). No significant differences in detectability of the assessed pulmonary pathologies were observed between both 3D-UTE sequence techniques (P > 0.05), and their level of agreement was substantial throughout (κ = 0.62-0.81). Both techniques provided high sensitivities and specificities (79%-100%) for the detection of pulmonary infiltrations and pleural effusions compared to reference CT. CONCLUSION: The diagnostic performance of the assessed 3D-UTE MRI sequences was similar. Both sequences enable the detection of typical inflammatory lung pathologies.

Spectral Shaping Via Tin Prefiltration in Ultra-High-Resolution Photon-Counting and Energy-Integrating Detector CT of the Temporal Bone.

OBJECTIVES: Hardening the x-ray beam, tin prefiltration is established for imaging of high-contrast subjects in energy-integrating detector computed tomography (EID-CT). With this work, we aimed to investigate the dose-saving potential of spectral shaping via tin prefiltration in photon-counting detector CT (PCD-CT) of the temporal bone. METHODS: Deploying dose-matched scan protocols with and without tin prefiltration on a PCD-CT and EID-CT system (low-/intermediate-/full-dose: 4.8/7.6-7.7/27.0-27.1 mGy), 12 ultra-high-resolution examinations were performed on each of 5 cadaveric heads. While 120 kVp was applied for standard imaging, the protocols with spectral shaping used the highest potential available with tin prefiltration (EID-CT: Sn 150 kVp, PCD-CT: Sn 140 kVp). Contrast-to-noise ratios and dose-saving potential by spectral shaping were computed for each scanner. Three radiologists independently assessed the image quality of each examination with the intraclass correlation coefficient being computed to measure interrater agreement. RESULTS: Regardless of tin prefiltration, PCD-CT with low (171.2 ± 10.3 HU) and intermediate radiation dose (134.7 ± 4.5 HU) provided less image noise than full-dose EID-CT (177.0 ± 14.2 HU; P < 0.001). Targeting matched image noise to 120 kVp EID-CT, mean dose reduction of 79.3% ± 3.9% could be realized in 120 kVp PCD-CT. Subjective image quality of PCD-CT was better than of EID-CT on each dose level ( P < 0.050). While no distinction was found between dose-matched PCD-CT with and without tin prefiltration ( P ≥ 0.928), Sn 150 kVp EID-CT provided better image quality than 120 kVp EID-CT at high and intermediate dose levels ( P > 0.050). The majority of low-dose EID-CT examinations were considered not diagnostic, whereas PCD-CT scans of the same dose level received satisfactory or better ratings. Interrater reliability was excellent (intraclass correlation coefficient 0.903). CONCLUSIONS: PCD-CT provides superior image quality and significant dose savings compared with EID-CT for ultra-high-resolution examinations of the temporal bone. Aiming for matched image noise, high-voltage scan protocols with tin prefiltration facilitate additional dose saving in EID-CT, whereas superior inherent denoising decreases the dose reduction potential of spectral shaping in PCD-CT.

Real-time cardiac MRI using an undersampled spiral k-space trajectory and a reconstruction based on a variational network.

PURPOSE: Cardiac MRI represents the gold standard to determine myocardial function. However, the current clinical standard protocol, a segmented Cartesian acquisition, is time-consuming and can lead to compromised image quality in the case of arrhythmia or dyspnea. In this article, a machine learning-based reconstruction of undersampled spiral k-space data is presented to enable free breathing real-time cardiac MRI with good image quality and short reconstruction times. METHODS: Data were acquired in free breathing with a 2D spiral trajectory corrected by the gradient system transfer function. Undersampled data were reconstructed by a variational network (VN), which was specifically adapted to the non-Cartesian sampling pattern. The network was trained with data from 11 subjects. Subsequently, the imaging technique was validated in 14 subjects by quantifying the difference to a segmented reference acquisition, an expert reader study, and by comparing derived volumes and functional parameters with values obtained using the current clinical gold standard. RESULTS: The scan time for the entire heart was below 1 min. The VN reconstructed data in about 0.9 s per image, which is considerably shorter than conventional model-based approaches. The VN furthermore performed better than a U-Net and not inferior to a low-rank plus sparse model in terms of achieved image quality. Functional parameters agreed, on average, with reference data. CONCLUSIONS: The proposed VN method enables real-time cardiac imaging with both high spatial and temporal resolution in free breathing and with short reconstruction time.

Evaluation of combined late gadolinium-enhancement and functional cardiac magnetic resonance imaging using spiral real-time acquisition.

The purpose of the current study was to implement and validate joint real-time acquisition of functional and late gadolinium-enhancement (LGE) cardiac magnetic resonance (MR) images during free breathing. Inversion recovery cardiac real-time images with a temporal resolution of 50 ms were acquired using a spiral trajectory (IR-CRISPI) with a pre-emphasis based on the gradient system transfer function during free breathing. Functional and LGE cardiac MR images were reconstructed using a low-rank plus sparse model. Late gadolinium-enhancement appearance, image quality, and functional parameters of IR-CRISPI were compared with clinical standard balanced steady-state free precession breath-hold techniques in 10 patients. The acquisition of IR-CRISPI in free breathing of the entire left ventricle took 97 s on average. Bland-Altman analysis and Wilcoxon tests showed a higher artifact level for the breath-hold technique (p = 0.003), especially for arrhythmic patients or patients with dyspnea, but an increased noise level for IR-CRISPI of the LGE images (p = 0.01). The estimated transmural extent of the enhancement differed by not more than 25% and did not show a significant bias between the techniques (p = 0.50). The ascertained functional parameters were similar for the breath-hold technique and IR-CRISPI, that is, with a minor, nonsignificant (p = 0.16) mean difference of the ejection fraction of 2.3% and a 95% confidence interval from -4.8% to 9.4%. IR-CRISPI enables joint functional and LGE imaging in free breathing with good image quality but distinctly shorter scan times in comparison with breath-hold techniques.

A data-driven semantic segmentation model for direct cardiac functional analysis based on undersampled radial MR cine series.

PURPOSE: Image acquisition and subsequent manual analysis of cardiac cine MRI is time-consuming. The purpose of this study was to train and evaluate a 3D artificial neural network for semantic segmentation of radially undersampled cardiac MRI to accelerate both scan time and postprocessing. METHODS: A database of Cartesian short-axis MR images of the heart (148,500 images, 484 examinations) was assembled from an openly accessible database and radial undersampling was simulated. A 3D U-Net architecture was pretrained for segmentation of undersampled spatiotemporal cine MRI. Transfer learning was then performed using samples from a second database, comprising 108 non-Cartesian radial cine series of the midventricular myocardium to optimize the performance for authentic data. The performance was evaluated for different levels of undersampling by the Dice similarity coefficient (DSC) with respect to reference labels, as well as by deriving ventricular volumes and myocardial masses. RESULTS: Without transfer learning, the pretrained model performed moderately on true radial data [maximum number of projections tested, P = 196; DSC = 0.87 (left ventricle), DSC = 0.76 (myocardium), and DSC =0.64 (right ventricle)]. After transfer learning with authentic data, the predictions achieved human level even for high undersampling rates (P = 33, DSC = 0.95, 0.87, and 0.93) without significant difference compared with segmentations derived from fully sampled data. CONCLUSION: A 3D U-Net architecture can be used for semantic segmentation of radially undersampled cine acquisitions, achieving a performance comparable with human experts in fully sampled data. This approach can jointly accelerate time-consuming cine image acquisition and cumbersome manual image analysis.

Pulmonary Imaging of Immunocompromised Patients during Hematopoietic Stem Cell Transplantation using Non-Contrast-Enhanced Three-Dimensional Ultrashort Echo Time (3D-UTE) MRI.

PURPOSE: To evaluate the feasibility of non-contrast-enhanced three-dimensional ultrashort echo time (3D-UTE) MRI for pulmonary imaging in immunocompromised patients during hematopoietic stem cell transplantation (HSCT). METHODS: MRI was performed using a stack-of-spirals 3D-UTE sequence (slice thickness: 2.34mm; matrix: 256 × 256; acquisition time: 12.7-17.6 seconds) enabling imaging of the entire thorax within single breath-holds. Patients underwent MRI before HSCT initiation, in the case of periprocedural pneumonia, before discharge, and in the case of re-hospitalization. Two readers separately assessed the images regarding presence of pleural effusions, ground glass opacities (GGO), and consolidations on a per lung basis. A T2-weighted (T2w) multi-shot Turbo Spin Echo sequence (BLADE) was acquired in coronal orientation during breath-hold (slice thickness: 6.00mm; matrix: 320 × 320; acquisition time: 3.1-5.5 min) and read on a per lesion basis. Low-dose CT scans in inspiration were used as reference and were read on a per lung basis. Only scans performed within a maximum of three days were included in the inter-method analyses. Interrater agreement, sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of 3D-UTE MRI were calculated. RESULTS: 67 MRI scans of 28 patients were acquired. A reference CT examination was available for 33 scans of 23 patients. 3D-UTE MRI showed high sensitivity and specificity regarding pleural effusions (n = 6; sensitivity, 92 %; specificity, 100 %) and consolidations (n = 22; sensitivity 98 %, specificity, 86 %). Diagnostic performance was lower for GGO (n = 9; sensitivity, 63 %; specificity, 84 %). Accuracy rates were high (pleural effusions, 98 %; GGO, 79 %; consolidations 94 %). Interrater agreement was substantial for consolidations and pleural effusions (κ = 0.69-0.82) and moderate for GGO (κ = 0.54). Compared to T2w imaging, 3D-UTE MRI depicted the assessed pathologies with at least equivalent quality and was rated superior regarding consolidations and GGO in ~50 %. CONCLUSION: Non-contrast 3D-UTE MRI enables radiation-free assessment of typical pulmonary complications during HSCT procedure within a single breath-hold. Yet, CT was found to be superior regarding the identification of pure GGO changes. KEY POINTS: · 3D-UTE MRI of the thorax can be acquired within a single breath-hold.. · 3D-UTE MRI provides diagnostic imaging of pulmonary consolidations and pleural effusions.. · 3D-UTE sequences improve detection rates of ground glass opacities on pulmonary MRI.. · 3D-UTE MRI depicts pulmonary pathologies at least equivalent to T2-weighted Blade sequence.. CITATION FORMAT: · Metz C, Böckle D, Heidenreich JF et al. Pulmonary Imaging of Immunocompromised Patients during Hematopoietic Stem Cell Transplantation using Non-Contrast-Enhanced Three-Dimensional Ultrashort Echo Time (3D-UTE) MRI. Fortschr Röntgenstr 2022; 194: 39 - 48.

Phantom study for comparison between computed tomography- and C-Arm computed tomography-guided puncture applied by residents in radiology. / Phantomstudie zum Vergleich zwischen Computertomografie- und C-Arm-Computertomografie-gesteuertem Punktionsverfahren bei Anwendung durch Weiterbildungsassistenten in der Radiologie.

PURPOSE: Comparison of puncture deviation and puncture duration between computed tomography (CT)- and C-arm CT (CACT)-guided puncture performed by residents in training (RiT). METHODS: In a cohort of 25 RiTs enrolled in a research training program either CT- or CACT-guided puncture was performed on a phantom. Prior to the experiments, the RiT's level of training, experience playing a musical instrument, video games, and ball sports, and self-assessed manual skills and spatial skills were recorded. Each RiT performed two punctures. The first puncture was performed with a transaxial or single angulated needle path and the second with a single or double angulated needle path. Puncture deviation and puncture duration were compared between the procedures and were correlated with the self-assessments. RESULTS: RiTs in both the CT guidance and CACT guidance groups did not differ with respect to radiologic experience (p = 1), angiographic experience (p = 0.415), and number of ultrasound-guided puncture procedures (p = 0.483), CT-guided puncture procedures (p = 0.934), and CACT-guided puncture procedures (p = 0.466). The puncture duration was significantly longer with CT guidance (without navigation tool) than with CACT guidance with navigation software (p < 0.001). There was no significant difference in the puncture duration between the first and second puncture using CT guidance (p = 0.719). However, in the case of CACT, the second puncture was significantly faster (p = 0.006). Puncture deviations were not different between CT-guided and CACT-guided puncture (p = 0.337) and between the first and second puncture of CT-guided and CACT-guided puncture (CT: p = 0.130; CACT: p = 0.391). The self-assessment of manual skills did not correlate with puncture deviation (p = 0.059) and puncture duration (p = 0.158). The self-assessed spatial skills correlated positively with puncture deviation (p = 0.011) but not with puncture duration (p = 0.541). CONCLUSION: The RiTs achieved a puncture deviation that was clinically adequate with respect to their level of training and did not differ between CT-guided and CACT-guided puncture. The puncture duration was shorter when using CACT. CACT guidance with navigation software support has a potentially steeper learning curve. Spatial skills might accelerate the learning of image-guided puncture. KEY POINTS: · The CT-guided and CACT-guided puncture experience of the RiTs selected as part of the program "Researchers for the Future" of the German Roentgen Society was adequate with respect to the level of training.. · Despite the lower collective experience of the RiTs with CACT-guided puncture with navigation software assistance, the learning curve regarding CACT-guided puncture may be faster compared to the CT-guided puncture technique.. · If the needle path is complex, CACT guidance with navigation software assistance might have an advantage over CT guidance.. CITATION FORMAT: · Meine TC, Hinrichs JB, Werncke T et al. Phantom study for comparison between computed tomography- and C-Arm computed tomography-guided puncture applied by residents in radiology. Fortschr Röntgenstr 2022; 194: 272 - 280.

Self-configuring nnU-net pipeline enables fully automatic infarct segmentation in late enhancement MRI after myocardial infarction.

PURPOSE: To fully automatically derive quantitative parameters from late gadolinium enhancement (LGE) cardiac MR (CMR) in patients with myocardial infarction and to investigate if phase sensitive or magnitude reconstructions or a combination of both results in best segmentation accuracy. METHODS: In this retrospective single center study, a convolutional neural network with a U-Net architecture with a self-configuring framework ("nnU-net") was trained for segmentation of left ventricular myocardium and infarct zone in LGE-CMR. A database of 170 examinations from 78 patients with history of myocardial infarction was assembled. Separate fitting of the model was performed, using phase sensitive inversion recovery, the magnitude reconstruction or both contrasts as input channels. Manual labelling served as ground truth. In a subset of 10 patients, the performance of the trained models was evaluated and quantitatively compared by determination of the Sørensen-Dice similarity coefficient (DSC) and volumes of the infarct zone compared with the manual ground truth using Pearson's r correlation and Bland-Altman analysis. RESULTS: The model achieved high similarity coefficients for myocardium and scar tissue. No significant difference was observed between using PSIR, magnitude reconstruction or both contrasts as input (PSIR and MAG; mean DSC: 0.83 ±â€¯0.03 for myocardium and 0.72 ±â€¯0.08 for scars). A strong correlation for volumes of infarct zone was observed between manual and model-based approach (r = 0.96), with a significant underestimation of the volumes obtained from the neural network. CONCLUSION: The self-configuring nnU-net achieves predictions with strong agreement compared to manual segmentation, proving the potential as a promising tool to provide fully automatic quantitative evaluation of LGE-CMR.

Deep learning-based segmentation of the lung in MR-images acquired by a stack-of-spirals trajectory at ultra-short echo-times.

BACKGROUND: Functional lung MRI techniques are usually associated with time-consuming post-processing, where manual lung segmentation represents the most cumbersome part. The aim of this study was to investigate whether deep learning-based segmentation of lung images which were scanned by a fast UTE sequence exploiting the stack-of-spirals trajectory can provide sufficiently good accuracy for the calculation of functional parameters. METHODS: In this study, lung images were acquired in 20 patients suffering from cystic fibrosis (CF) and 33 healthy volunteers, by a fast UTE sequence with a stack-of-spirals trajectory and a minimum echo-time of 0.05 ms. A convolutional neural network was then trained for semantic lung segmentation using 17,713 2D coronal slices, each paired with a label obtained from manual segmentation. Subsequently, the network was applied to 4920 independent 2D test images and results were compared to a manual segmentation using the Sørensen-Dice similarity coefficient (DSC) and the Hausdorff distance (HD). Obtained lung volumes and fractional ventilation values calculated from both segmentations were compared using Pearson's correlation coefficient and Bland Altman analysis. To investigate generalizability to patients outside the CF collective, in particular to those exhibiting larger consolidations inside the lung, the network was additionally applied to UTE images from four patients with pneumonia and one with lung cancer. RESULTS: The overall DSC for lung tissue was 0.967 ± 0.076 (mean ± standard deviation) and HD was 4.1 ± 4.4 mm. Lung volumes derived from manual and deep learning based segmentations as well as values for fractional ventilation exhibited a high overall correlation (Pearson's correlation coefficent = 0.99 and 1.00). For the additional cohort with unseen pathologies / consolidations, mean DSC was 0.930 ± 0.083, HD = 12.9 ± 16.2 mm and the mean difference in lung volume was 0.032 ± 0.048 L. CONCLUSIONS: Deep learning-based image segmentation in stack-of-spirals based lung MRI allows for accurate estimation of lung volumes and fractional ventilation values and promises to replace the time-consuming step of manual image segmentation in the future.

Image Quality Assessment for Clinical Cadmium Telluride-Based Photon-Counting Computed Tomography Detector in Cadaveric Wrist Imaging.

OBJECTIVES: Detailed visualization of bone microarchitecture is essential for assessment of wrist fractures in computed tomography (CT). This study aims to evaluate the imaging performance of a CT system with clinical cadmium telluride-based photon-counting detector (PCD-CT) compared with a third-generation dual-source CT scanner with energy-integrating detector technology (EID-CT). MATERIALS AND METHODS: Both CT systems were used for the examination of 8 cadaveric wrists with radiation dose equivalent scan protocols (low-/standard-/full-dose imaging: CTDIvol = 1.50/5.80/8.67 mGy). All wrists were scanned with 2 different operating modes of the photon-counting CT (standard-resolution and ultra-high-resolution). After reformatting with comparable reconstruction parameters and convolution kernels, subjective evaluation of image quality was performed by 3 radiologists on a 7-point scale. For estimation of interrater reliability, we report the intraclass correlation coefficient (absolute agreement, 2-way random-effects model). Signal-to-noise and contrast-to-noise ratios were calculated to provide semiquantitative assessment of image quality. RESULTS: Subjective image quality of standard-dose PCD-CT examinations in ultra-high-resolution mode was superior compared with full-dose PCD-CT in standard-resolution mode (P = 0.016) and full-dose EID-CT (P = 0.040). No difference was ascertained between low-dose PCD-CT in ultra-high-resolution mode and standard-dose scans with either PCD-CT in standard-resolution mode (P = 0.108) or EID-CT (P = 0.470). Observer evaluation of standard-resolution PCD-CT and EID-CT delivered similar results in full- and standard-dose scans (P = 0.248/0.509). Intraclass correlation coefficient was 0.876 (95% confidence interval, 0.744-0.925; P < 0.001), indicating good reliability. Between dose equivalent studies, signal-to-noise and contrast-to-noise ratios were substantially higher in photon-counting CT examinations (all P's < 0.001). CONCLUSIONS: Superior visualization of fine anatomy is feasible with the clinical photon-counting CT system in cadaveric wrist scans. The ultra-high-resolution scan mode suggests potential for considerable dose reduction over energy-integrating dual-source CT.

Three-dimensional Ultrashort Echotime Magnetic Resonance Imaging for Combined Morphologic and Ventilation Imaging in Pediatric Patients With Pulmonary Disease.

PURPOSE: Ultrashort echotime (UTE) sequences aim to improve the signal yield in pulmonary magnetic resonance imaging (MRI). We demonstrate the initial results of spiral 3-dimensional (3D) UTE-MRI for combined morphologic and functional imaging in pediatric patients. METHODS: Seven pediatric patients with pulmonary abnormalities were included in this observational, prospective, single-center study, with the patients having the following conditions: cystic fibrosis (CF) with middle lobe atelectasis, CF with allergic bronchopulmonary aspergillosis, primary ciliary dyskinesia, air trapping, congenital lobar overinflation, congenital pulmonary airway malformation, and pulmonary hamartoma.Patients were scanned during breath-hold in 5 breathing states on a 3-Tesla system using a prototypical 3D stack-of-spirals UTE sequence. Ventilation maps and signal intensity maps were calculated. Morphologic images, ventilation-weighted maps, and signal intensity maps of the lungs of each patient were assessed intraindividually and compared with reference examinations. RESULTS: With a scan time of ∼15 seconds per breathing state, 3D UTE-MRI allowed for sufficient imaging of both "plus" pathologies (atelectasis, inflammatory consolidation, and pulmonary hamartoma) and "minus" pathologies (congenital lobar overinflation, congenital pulmonary airway malformation, and air trapping). Color-coded maps of normalized signal intensity and ventilation increased diagnostic confidence, particularly with regard to "minus" pathologies. UTE-MRI detected new atelectasis in an asymptomatic CF patient, allowing for rapid and successful therapy initiation, and it was able to reproduce atelectasis and hamartoma known from multidetector computed tomography and to monitor a patient with allergic bronchopulmonary aspergillosis. CONCLUSION: 3D UTE-MRI using a stack-of-spirals trajectory enables combined morphologic and functional imaging of the lungs within ~115 second acquisition time and might be suitable for monitoring a wide spectrum of pulmonary diseases.

Cardiac real-time MRI using a pre-emphasized spiral acquisition based on the gradient system transfer function.

PURPOSE: Segmented Cartesian acquisition in breath hold represents the current gold standard for cardiac functional MRI. However, it is also associated with long imaging times and severe restrictions in arrhythmic or dyspneic patients. Therefore, we introduce a real-time imaging technique based on a spoiled gradient-echo sequence with undersampled spiral k-space trajectories corrected by a gradient pre-emphasis. METHODS: A fully automatic gradient waveform pre-emphasis based on the gradient system transfer function was implemented to compensate for gradient inaccuracies, to optimize fast double-oblique spiral MRI. The framework was tested in a phantom study and subsequently transferred to compressed sensing-accelerated cardiac functional MRI in real time. Spiral acquisitions during breath hold and free breathing were compared with this reference method for healthy subjects (N = 7) as well as patients (N = 2) diagnosed with heart failure and arrhythmia. Left-ventricular volumes and ejection fractions were determined and analyzed using a Wilcoxon signed-rank test. RESULTS: The pre-emphasis successfully reduced typical artifacts caused by k-space misregistrations. Dynamic cardiac imaging was possible in real time (temporal resolution < 50 ms) with high spatial resolution (1.34 × 1.34 mm2 ), resulting in a total scan time of less than 50 seconds for whole heart coverage. Comparable image quality, as well as similar left-ventricular volumes and ejection fractions, were observed for the accelerated and the reference method. CONCLUSION: The proposed technique enables high-resolution real-time cardiac MRI with no need for breath holds and electrocardiogram gating, shortening the duration of an entire functional cardiac exam to less than 1 minute.

Twin robotic x-ray system in small bone and joint trauma: impact of cone-beam computed tomography on treatment decisions.

OBJECTIVES: Trauma evaluation of extremities can be challenging in conventional radiography. A multi-use x-ray system with cone-beam CT (CBCT) option facilitates ancillary 3-D imaging without repositioning. We assessed the clinical value of CBCT scans by analyzing the influence of additional findings on therapy. METHODS: Ninety-two patients underwent radiography and subsequent CBCT imaging with the twin robotic scanner (76 wrist/hand/finger and 16 ankle/foot/toe trauma scans). Reports by on-call radiologists before and after CBCT were compared regarding fracture detection, joint affliction, comminuted injuries, and diagnostic confidence. An orthopedic surgeon recommended therapy based on reported findings. Surgical reports (N = 52) and clinical follow-up (N = 85) were used as reference standard. RESULTS: CBCT detected more fractures (83/64 of 85), joint involvements (69/53 of 71), and multi-fragment situations (68/50 of 70) than radiography (all p < 0.001). Six fractures suspected in radiographs were ruled out by CBCT. Treatment changes based on additional information from CBCT were recommended in 29 patients (31.5%). While agreement between advised therapy before CBCT and actual treatment was moderate (κ = 0.41 [95% confidence interval 0.35-0.47]; p < 0.001), agreement after CBCT was almost perfect (κ = 0.88 [0.83-0.93]; p < 0.001). Diagnostic confidence increased considerably for CBCT studies (p < 0.001). Median effective dose for CBCT was 4.3 µSv [3.3-5.3 µSv] compared to 0.2 µSv [0.1-0.2 µSv] for radiography. CONCLUSIONS: CBCT provides advantages for the evaluation of acute small bone and joint trauma by detecting and excluding extremity fractures and fracture-related findings more reliably than radiographs. Additional findings induced therapy change in one third of patients, suggesting substantial clinical impact. KEY POINTS: • With cone-beam CT, extremity fractures and fracture-related findings can be detected and ruled out more reliably than with conventional radiography. • Additional diagnostic information provided by cone-beam CT scans has substantial impact on therapy in small bone and joint trauma. • For distal extremity injury assessment, one-stop-shop imaging without repositioning is feasible with the twin robotic x-ray system.

Three-dimensional Ultrashort Echo Time MRI for Functional Lung Imaging in Cystic Fibrosis.

Background In cystic fibrosis (CF), recurrent imaging and pulmonary function tests (PFTs) are needed for the assessment of lung function during disease management. Purpose To assess the clinical feasibility of pulmonary three-dimensional ultrashort echo time (UTE) MRI at breath holding for quantitative image analysis of ventilation inhomogeneity and hyperinflation in CF compared with PFT. Materials and Methods In this prospective study from May 2018 to June 2019, participants with CF and healthy control participants underwent PFTs and functional lung MRI by using a prototypical single breath-hold three-dimensional UTE sequence. Fractional ventilation (FV) was calculated from acquired data in normal inspiration and normal expiration. FV of each voxel was normalized to the whole lung mean (FVN), and interquartile range of normalized ventilation (IQRN; as a measure of ventilation heterogeneity) was calculated. UTE signal intensity (SI) was assessed in full expiration (SIN, normalized to aortic blood). Obtained metrics were compared between participants with CF and control participants. For participants with CF, MRI metrics were correlated with the standard lung clearance index (LCI) and PFT. Mann-Whitney U tests and Spearman correlation were used for statistical analysis. Results Twenty participants with CF (mean age, 17 years ± 9 [standard deviation]; 12 men) and 10 healthy control participants (24 years ± 8; five men) were included. IQRN was higher for participants with CF than for control participants (mean, 0.66 ± 0.16 vs 0.50 ± 0.04, respectively; P = .007). In the 20 participants with CF, IQRN correlated with obstruction markers forced expiratory volume in 1 second-to-forced vital capacity ratio (r = -0.70; 95% confidence interval [CI]: -0.92, -0.28; P < .001), mean expiratory flow 25% (r = 0.78; 95% CI: -0.95, -0.39; P < .001), and with the ventilation inhomogeneity parameter LCI (r = 0.90; 95% CI: 0.69, 0.96; P < .001). Mean SIN in full expiration was lower in participants with CF than in control participants (0.34 ± 0.08 vs 0.39 ± 0.03, respectively; P = .03). Conclusion Three-dimensional ultrashort echo time MRI in the lungs allowed for functional imaging of ventilation inhomogeneity within a few breath holds in patients with cystic fibrosis. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Wielpütz in this issue.