Source-detector trajectory optimization in cone-beam computed tomography: a comprehensive review on today's state-of-the-art.

Cone-beam computed tomography (CBCT) imaging is becoming increasingly important for a wide range of applications such as image-guided surgery, image-guided radiation therapy as well as diagnostic imaging such as breast and orthopaedic imaging. The potential benefits of non-circular source-detector trajectories was recognized in early work to improve the completeness of CBCT sampling and extend the field of view (FOV). Another important feature of interventional imaging is that prior knowledge of patient anatomy such as a preoperative CBCT or prior CT is commonly available. This provides the opportunity to integrate such prior information into the image acquisition process by customized CBCT source-detector trajectories. Such customized trajectories can be designed in order to optimize task-specific imaging performance, providing intervention or patient-specific imaging settings. The recently developed robotic CBCT C-arms as well as novel multi-source CBCT imaging systems with additional degrees of freedom provide the possibility to largely expand the scanning geometries beyond the conventional circular source-detector trajectory. This recent development has inspired the research community to innovate enhanced image quality by modifying image geometry, as opposed to hardware or algorithms. The recently proposed techniques in this field facilitate image quality improvement, FOV extension, radiation dose reduction, metal artifact reduction as well as 3D imaging under kinematic constraints. Because of the great practical value and the increasing importance of CBCT imaging in image-guided therapy for clinical and preclinical applications as well as in industry, this paper focuses on the review and discussion of the available literature in the CBCT trajectory optimization field. To the best of our knowledge, this paper is the first study that provides an exhaustive literature review regarding customized CBCT algorithms and tries to update the community with the clarification of in-depth information on the current progress and future trends.

A head coil system with an integrated orbiting transmission point source mechanism for attenuation correction in PET/MRI.

The combination of positron emission tomography (PET) and magnetic resonance imaging (MRI) provides a benefit for diagnostic imaging. Still, attenuation correction (AC) is a challenge in PET/MRI compared to stand-alone PET and PET-computed tomography (PET/CT). In the absence of photonic transmission sources, AC in PET/MRI is usually based on retrospective segmentation of MR images or complex additional MR-sequences. However, most methods available today are still challenged by either the incorporation of cortical bone or substantial anatomical variations of subjects. This leads to a bias in quantification of tracer concentration in PET. Therefore, we have developed a fully integrated transmission source system for PET/MRI of the head to enable direct measurement of attenuation coefficients using external positron emitters, which is the reference standard in AC. Based on a setup called the 'liquid drive' presented by Jones et al (1995) two decades ago, we built a head coil system consisting of an MR-compatible hydraulic system driving a point source on a helical path around a 24-channel MR-receiver coil to perform a transmission scan. Sinogram windowing of the moving source allows for post-injection measurements. The prototype was tested in the Siemens Biograph mMR using a homogeneous water phantom and a phantom with air cavities and a Teflon (PTFE) cylinder. The second phantom was measured both with and without emission activity. For both measurements air, water and Teflon were clearly distinguishable and homogeneous regions of the phantom were successfully reproduced in the AC map. For water the linear attenuation coefficient was measured as (0.096 ± 0.005) cm-1 in accordance with the true physical value. This combined MR head coil and transmission source system is, to our knowledge, the first working example to use an orbiting point source in PET/MRI and may be helpful in providing fully-quantitative PET data in neuro-PET/MRI.

A principal components analysis: how pneumatization and edentulism contribute to maxillary atrophy.

OBJECTIVE: The aim of this retrospective cohort study was to investigate the role of sinus pneumatization and residual ridge resorption in maxillary bone loss in 400 computed tomography (CT) scans. MATERIALS AND METHODS: In 200 dentate and 200 edentulous patients, both sinuses were analysed using CT scans. The image analysis sequence consisted of manual placement of 24 reference points, followed by automated segmentation and final manual refinement. Finally, a principal components analysis was performed. RESULTS: A total of 788 sinuses were included into the analysis. The edentulous group (98 female: 67.77 ± 11.28 years, 99 male: 65.22 ± 9.87) was significantly older than the group with teeth (99 female: 46.89 ± 16.77 years, 96 male: 49.74 ± 16.2). Female and male patients did not differ regarding age. The alveolar height differed significantly between the groups (edentulous: 7.1 ± 4.3 mm, with teeth: 9.7 ± 4.1 mm), but not between gender (female: 8.3 ± 4.4 mm, male: 8.5 ± 4.4 mm). Principal components analysis was able to explain 90% of the variation in sinus morphology. CONCLUSIONS: Prolonged edentulism in the maxillary molar region leads to centripetal and to minor degrees centrifugal ridge resorption. Minor pneumatization occurs in the sinus walls, but the sinus depth underlies the anatomical variation independent of dentition.

On the dose sensitivity of a new CDMAM phantom.

For the technical quality assurance of breast cancer screening protocols several phantoms have been developed. Their dose sensitivity is a common topic often discussed in literature. The European protocol for the quality control of the physical and technical aspects of mammography screening suggests a contrast-detail phantom like the CDMAM phantom (Artinis Medical Systems, Elst, NL). The CDMAM 3.4 was tested with respect to its dose sensitivity and compared to other phantoms in a recent paper. The CDMAM 4.0 phantom provides other disc diameters and thicknesses adapted more closely to the image quality found in modern mammography systems. This motivates a comparison of the two generations using the same exposure parameters. We varied the time-current (mAs) within a range of clinically used values (40-140 mAs). All evaluations were done using automatic evaluation software provided by Artinis (for CDMAM 4.0) and the National Coordinating Centre for the Physics of Mammography, Guildford UK (CDMAM 3.4). We compared the relative dose sensitivity with respect to the different diameters and also computed the IQFinv parameter, which averages over the diameters as suggested in the manual for the phantom. The IQFinv parameter linearly depends on dose for both phantoms. The CDMAM 4.0 shows a more monotonous dependence on dose, the total variation of the threshold thicknesses as functions of the dose are significantly smaller than with the CDMAM 3.4. As the automatic evaluation shows rather different threshold thicknesses for the two phantoms, conversion factors for human to automatic readout have to be adapted.

A navigation system for flexible endoscopes using abdominal 3D ultrasound.

A navigation system for flexible endoscopes equipped with ultrasound (US) scan heads is presented. In contrast to similar systems, abdominal 3D-US is used for image fusion of the pre-interventional computed tomography (CT) to the endoscopic US. A 3D-US scan, tracked with an optical tracking system (OTS), is taken pre-operatively together with the CT scan. The CT is calibrated using the OTS, providing the transformation from CT to 3D-US. Immediately before intervention a 3D-US tracked with an electromagnetic tracking system (EMTS) is acquired and registered intra-modal to the preoperative 3D-US. The endoscopic US is calibrated using the EMTS and registered to the pre-operative CT by an intra-modal 3D-US/3D-US registration. Phantom studies showed a registration error for the US to CT registration of 5.1 mm±2.8 mm. 3D-US/3D-US registration of patient data gave an error of 4.1 mm compared to 2.8 mm with the phantom. From this we estimate an error on patient experiments of 5.6 mm.

Hidden discoligamentous instability in cervical spine injuries: can quantitative motion analysis improve detection?

PURPOSE: Recent literature shows that occult discoligamentous injuries still remain difficult to diagnose in the first instance. Thresholds as indicators for discoligamentous segmental instability were previously defined. But, since supine radiodiagnostic is prone to spontaneous reduction of a displaced injury, and even some highly unstable injuries reveal only slight radiographic displacement, these criteria might mislead in the traumatized patient. A highly accurate radiographic instrument to assess segmental motion is the computer-assisted quantitative motion analysis (QMA). The aim was to evaluate the applicability of the QMA in the setting of a traumatized patient. METHODS: Review of 154 patients with unstable cervical injuries C3-7. Seventeen patients (male/female: 1:5, age: 44.6 years) had history of initially hidden discoligamentous injuries without signs of neurologic impairment. Initial radiographs did not fulfill instability criteria by conventional analysis. Instability was identified by late subluxation/dislocation, persisting/increasing neck pain, and/or scheduled follow-up. For 16 patients plain lateral radiographs were subjected to QMA. QMA data derived were compared with normative data of 140 asymptomatic volunteers from an institutional database. RESULTS: Data analysis of measurements revealed mean spondylolisthesis of -1.0 mm (-3.7 to +3.4 mm), for segmental rotational angle mean angulation of -0.9° (-11.1° to +17.7°). Analysis of these figures indicated positive instability thresholds in 5 patients (31.3 %). Analysis of center of rotation (COR)-shifts was only accomplishable completely in 3/16 patients due to limited motion or inadequacy of radiographs. Two of these patients (12.5 %) showed a suspect shift of the COR. CONCLUSIONS: Our data show a high rate of false negative results in cases of hidden discoligamentous injuries by using conventional radiographic analysis as well as QMA in plain lateral radiographs in a trauma setting. Despite the technical possibilities in a modern trauma center, our data and recent literature indicate a thorough clinical and radiographic follow-up of patients with cervical symptoms to avoid secondary complications from missed cervical spine injuries.

Dose sensitivity of three phantoms used for quality assurance in digital mammography.

Technical quality assurance (QA) is one of the key issues in breast cancer screening protocols. For this QA task, three different methods are commonly used to assess image quality. The European protocol suggests a contrast-detail phantom (e.g. the CDMAM phantom), while in North America the American College of Radiology (ACR) accreditation phantom is proposed. Alternatively, phantoms based on image quality parameters from applied system theory such as the noise-equivalent number of quanta (NEQ) are applied (e.g. the PAS 1054 phantom). The aim of this paper was to correlate the changes in the output of the three evaluation methods (CDMAM, ACR and NEQ) with changes in dose. We varied the time-current product within a range of clinically used values (40-140 mAs, corresponding to 3.5-12.4 mGy entrance dose and detector dose of 32-110 µGy). For the ACR phantom, the examined parameter was the number of detected objects. With the CDMAM phantom we chose the diameters 0.10, 0.13, 0.20, 0.31 and 0.5 mm and recorded the threshold thicknesses. With respect to the third method, we evaluated the NEQ at typical spatial frequencies to calculate the relative changes in NEQ. Plotting NEQ versus dose increment shows a linear relationship and can be described by a linear function (with R > 0.99). Every manually selectable current- time product increment can be detected. With the ACR phantom, the number of detected objects increases only in the lower dose range and reaches saturation at about 9 mGy entrance dose (80 µGy detector dose). The CDMAM can detect a 50% increase in dose over the examined dose range with all five diameters, although the increases of threshold thickness are not monotonous. We conclude that an NEQ-based method has the potential to replace the established detail phantom methods to detect dose changes in the course of QA.

SU-E-J-90: 2D/3D Registration Using KV-MV Image Pairs for Higher Accuracy Image Guided Radiotherapy.

PURPOSE: In this work, we investigate the impact of using paired portal mega-voltage (MV) and kilo-voltage (kV) images, on 2D/3D registration accuracy with the purpose of improving tumor motion tracking during radiotherapy. Tumor motion tracking is important as motion remains one of the biggest sources of uncertainty in dose application. 2D/3D registration is successfully used in online tumor motion tracking, nevertheless, one limitation of this technique is the inability to resolve movement along the imaging beam axis using only one projection image. METHODS: Our evaluation consisted in comparing the accuracy of registration using different 2D image combinations: only one 2D image (1-kV), one kV and one MV image (1kV-1MV) and two kV images (2-kV). For each of the image combinations we evaluated the registration results using 250 starting points as initial displacements from the gold standard. We measured the final mean target registration error (mTRE) and the success rate for each registration. Each of the combinations was evaluated using four different merit functions. RESULTS: When using the MI merit function (a popular choice for this application) the RMS mTRE drops from 6.4 mm when using only one image to 2.1 mm when using image pairs. The success rate increases from 62% to 99.6%. A similar trend was observed for all four merit functions. Typically, the results are slightly better with 2-kV images than with 1kV-1MV. CONCLUSIONS: We evaluated the impact of using different image combinations on accuracy of 2D/3D registration for tumor motion monitoring. Our results show that using a kV-MV image pair, leads to improved results as motion can be accurately resolved in six degrees of freedom. Given the possibility to acquire these two images simultaneously, this is not only very workflow efficient but is also shown to be a good approach to improve registration accuracy.

Validation for 2D/3D registration. I: A new gold standard data set.

PURPOSE: In this article, the authors propose a new gold standard data set for the validation of two-dimensional/three-dimensional (2D/3D) and 3D/3D image registration algorithms. METHODS: A gold standard data set was produced using a fresh cadaver pig head with attached fiducial markers. The authors used several imaging modalities common in diagnostic imaging or radiotherapy, which include 64-slice computed tomography (CT), magnetic resonance imaging using T1, T2, and proton density sequences, and cone beam CT imaging data. Radiographic data were acquired using kilovoltage and megavoltage imaging techniques. The image information reflects both anatomy and reliable fiducial marker information and improves over existing data sets by the level of anatomical detail, image data quality, and soft-tissue content. The markers on the 3D and 2D image data were segmented using ANALYZE 10.0 (AnalyzeDirect, Inc., Kansas City, KN) and an in-house software. RESULTS: The projection distance errors and the expected target registration errors over all the image data sets were found to be less than 2.71 and 1.88 mm, respectively. CONCLUSIONS: The gold standard data set, obtained with state-of-the-art imaging technology, has the potential to improve the validation of 2D/3D and 3D/3D registration algorithms for image guided therapy.

Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients.

BACKGROUND: Although the integral role of ED thoracotomy for open cardiac massage has been extensively reviewed in adult literature, this "heroic maneuver" remains very controversial and greatly debated in children. METHODS AND RESULTS: A retrospective cohort review of emergency thoracotomies in children, performed at a European Level I trauma center between 1992 and 2008 was undertaken. Clinical manifestation, injury mechanism and surgical treatment were described, with special regard to prognostic factors and outcome. A total of eleven thoracotomies were performed, ten for blunt injuries (91%), and one for perforating injury (9%), with a mean age of 7.8 years, range 2.6-15.4 years, comprising eight boys and three girls. The mean Injury Severity Score of the children with blunt force trauma was 46, ranging from 25 to 66 compared with 20 of the penetrating trauma victim. Ten of eleven patients (91%) who underwent ED thoracotomy died. Nine of them were in cardiac arrest on arrival. One patient who had a penetrating knife injury and had stable vital sign on arrival survived. CONCLUSIONS: Similar to previous studies, out data confirmed ED thoracotomy for children in cardiac arrest from blunt trauma had universally fatal outcome. The mechanism of injury and signs of life at arrival were predictive key factors that influence the outcome of ED thoracotomy.

Efficient implementation of the rank correlation merit function for 2D/3D registration.

A growing number of clinical applications using 2D/3D registration have been presented recently. Usually, a digitally reconstructed radiograph is compared iteratively to an x-ray image of the known projection geometry until a match is achieved, thus providing six degrees of freedom of rigid motion which can be used for patient setup in image-guided radiation therapy or computer-assisted interventions. Recently, stochastic rank correlation, a merit function based on Spearman's rank correlation coefficient, was presented as a merit function especially suitable for 2D/3D registration. The advantage of this measure is its robustness against variations in image histogram content and its wide convergence range. The considerable computational expense of computing an ordered rank list is avoided here by comparing randomly chosen subsets of the DRR and reference x-ray. In this work, we show that it is possible to omit the sorting step and to compute the rank correlation coefficient of the full image content as fast as conventional merit functions. Our evaluation of a well-calibrated cadaver phantom also confirms that rank correlation-type merit functions give the most accurate results if large differences in the histogram content for the DRR and the x-ray image are present.

Rotational and translational laxity after computer-navigated single- and double-bundle anterior cruciate ligament reconstruction.

Based on biomechanical cadaver studies, anatomic double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. Previously, the success of ACL reconstruction was believed to be mainly dependent on correct positioning of the graft, irrespective of the number of reconstructed bundles for which computer-assisted surgery was developed to avoid malpositioning of the tunnel. The aim of the present study is to compare rotational and translational stability after computer-navigated standard single-bundle, and anatomic double-bundle ACL reconstruction. The authors investigated 55 consecutive patients who had undergone the single-bundle or double-bundle ACL reconstruction procedure with the use of autogenous hamstring tendon grafts and EndoButton fixation, and the patients had been followed for a minimum period of 24 months. Intraoperative, anteroposterior and rotational laxity was measured with the computer navigation system, and compared between groups. Both surgical procedures significantly reduced anteroposterior displacement (AP) and internal rotation (IR) of the tibia compared to the pre-operative ACL-deficient knee (P < 0.05). No significant differences were registered between groups with regard to anteroposterior displacement of the tibia. A significantly greater reduction in internal rotation was noted in the double-bundle group (15.6 degrees) compared to the single-bundle group (7.1 degrees). The IKDC and Lysholm score were significantly higher in the double-bundle group. However, the results were excellent in both groups. The use of a computer-assisted ACL reconstruction, which is a highly accurate method of graft placement, could be useful for inexperienced surgeons to avoid malposition. Whether double-bundle ACL reconstruction, which was associated with improved rotational laxity and significantly better IKDC and Lysholm scores compared to the standard single-bundle ACL reconstruction procedure, provide an influence in terms of avoiding osteoarthritis or meniscus degeneration, long-term results of at least 5 years are needed.

Delayed recovery and late development of complex regional pain syndrome in patients with an isolated fracture of the distal radius: prediction of a regional inflammatory response by early signs.

We studied prospectively the regional inflammatory response to a unilateral distal radial fracture in 114 patients at eight to nine weeks after injury and again at one year. Our aim was to identify patients at risk for a delayed recovery and particularly those likely to develop complex regional pain syndrome. In order to quantify clinically the inflammatory response, a regional inflammatory score was developed. In addition, blood samples were collected from the antecubital veins of both arms for comparative biochemical and blood-gas analysis. The severity of the inflammatory response was related to the type of treatment (Kruskal-Wallis test, p = 0.002). A highly significantly-positive correlation was found between the regional inflammatory score and the length of time to full recovery (r(2) = 0.92, p = 0.01, linear regession). A regional inflammatory score of 5 points with a sensitivity of 100% but a specificity of only 16% also identified patients at risk of complex regional pain syndrome. None of the biochemical parameters studied correlated with regional inflammatory score or predicted the development of complex regional pain syndrome. Our study suggests that patients with a distal radial fracture and a regional inflammatory score of 5 points or more at eight to nine weeks after injury should be considered for specific anti-inflammatory treatment.

[Gunshot injuries--incidence and treatment]. / Schussverletzungen--ihre Inzidenz und Versorgung.

BACKGROUND: Gunshot injuries are very rare in the European Union. To show the requirements for the trauma surgeon to deal with gunshot injuries this analysis was performed. METHODS: Gunshot injuries seen at Lorenz Boehler Trauma Center from 1997 to 2004 were reviewed. The case histories of 67 patients were analysed for the cause of the gunshot injury, type of weapon, surgical intervention, days of treatment and outcome. RESULTS: The most commonly cause of gunshot injuries were criminal offenses (n = 35). Handguns were used most often (n = 32). The locations of injuries were evenly distributed over head (n = 18 ), trunk (n = 16), upper (n = 15) and lower limb (n = 18). Surgical treatment was performed in 57 patients. The median stay on ICU was 10 days. 6 patients died. CONCLUSION: Gunshot injuries are frequently not confined to the extremities. The challenge for the trauma surgeon is to deal with injuries of the head, chest and abdomen.

Evaluation of a new electromagnetic tracking system using a standardized assessment protocol.

This note uses a published protocol to evaluate a newly released 6 degrees of freedom electromagnetic tracking system (Aurora, Northern Digital Inc.). A practice for performance monitoring over time is also proposed. The protocol uses a machined base plate to measure relative error in position and orientation as well as the influence of metallic objects in the operating volume. Positional jitter (E(RMS)) was found to be 0.17 mm +/- 0.19 mm. A relative positional error of 0.25 mm +/- 0.22 mm at 50 mm offsets and 0.97 mm +/- 1.01 mm at 300 mm offsets was found. The mean of the relative rotation error was found to be 0.20 degrees +/- 0.14 degrees with respect to the axial and 0.91 degrees +/- 0.68 degrees for the longitudinal rotation. The most significant distortion caused by metallic objects is caused by 400-series stainless steel. A 9.4 mm maximum error occurred when the rod was closest to the emitter, 10 mm away. The improvement compared to older generations of the Aurora with respect to accuracy is substantial.

Risk analysis and safety assessment in surgical robotics: a case study on a biopsy robot.

One of the most important issues in medical robotics is safety and integration into the clinical workflow. If a robot is not safe and its use is complicated by difficult handling and complex user interfaces physicians would not use a robotic system during clinical patient trials, whatever the other advantages are. However, there are only few publications on this topic, in particular on risk management in developing a robotic prototype (for clinical trials). In this paper risk management and the safety of using robot-assisted surgery equipment are discussed and demonstrated exemplarily in the process of developing a prototype biopsy robot.

Fast DRR generation for 2D/3D registration.

We present a simple and rapid method for generation of perspective digitally rendered radiographs (DRR) for 2D/3D registration based on splat rendering. Suppression of discretization artefacts by means of computation of Gaussian footprints--which is a considerable computational burden in classical splat rendering--is replaced by stochastic motion of either the voxels in the volume to be rendered, or by simulation of a X-ray tube focal spot of finite size. The result is a simple and fast perspective rendering algorithm using only a small subset of voxels. Our method generates slightly blurred DRRs suitable for registration purposes at framerates of approximately 10 Hz when rendering volume images with a size of 30 MB on a standard PC.

Quantitative analysis of factors affecting intraoperative precision and stability of optoelectronic and electromagnetic tracking systems.

This study aims to provide a quantitative analysis of the factors affecting the actual precision and stability of optoelectronic and electromagnetic tracking systems in computer-aided surgery under real clinical/intraoperative conditions. A "phantom-skull" with five precisely determined reference distances between marker spheres is used for all measurements. Three optoelectronic and one electromagnetic tracking systems are included in this study. The experimental design is divided into three parts: (1) evaluation of serial- and multislice-CT (computed tomography) images of the phantom-skull for the precision of distance measurements by means of navigation software without a digitizer, (2) digitizer measurements under realistic intraoperative conditions with the factors OR-lamp (radiating into the field of view of the digitizer) or/and "handling with ferromagnetic surgical instruments" (in the field of view of the digitizer) and (3) "point-measurements" to analyze the influence of changes in the angle of inclination of the stylus axis. Deviations between reference distances and measured values are statistically investigated by means of analysis of variance. Computerized measurements of distances based on serial-CT data were more precise than based on multislice-CT data. All tracking systems included in this study proved to be considerably less precise under realistic OR conditions when compared to the technical specifications in the manuals of the systems. Changes in the angle of inclination of the stylus axis resulted in deviations of up to 3.40 mm (mean deviations for all systems ranging from 0.49 to 1.42 mm, variances ranging from 0.09 to 1.44 mm), indicating a strong need for improvements of stylus design. The electromagnetic tracking system investigated in this study was not significantly affected by small ferromagnetic surgical instruments.