Computer-Assisted Detection of Cerebral Aneurysms in MR Angiography in a Routine Image-Reading Environment: Effects on Diagnosis by Radiologists.

BACKGROUND AND PURPOSE: Experiences with computer-assisted detection of cerebral aneurysms in diagnosis by radiologists in real-life clinical environments have not been reported. The purpose of this study was to evaluate the usefulness of computer-assisted detection in a routine reading environment. MATERIALS AND METHODS: During 39 months in a routine clinical practice environment, 2701 MR angiograms were each read by 2 radiologists by using a computer-assisted detection system. Initial interpretation was independently made without using the detection system, followed by a possible alteration of diagnosis after referring to the lesion candidate output from the system. We used the final consensus of the 2 radiologists as the reference standard. The sensitivity and specificity of radiologists before and after seeing the lesion candidates were evaluated by aneurysm- and patient-based analyses. RESULTS: The use of the computer-assisted detection system increased the number of detected aneurysms by 9.3% (from 258 to 282). Aneurysm-based analysis revealed that the apparent sensitivity of the radiologists' diagnoses made without and with the detection system was 64% and 69%, respectively. The detection system presented 82% of the aneurysms. The detection system more frequently benefited radiologists than being detrimental. CONCLUSIONS: Routine integration of computer-assisted detection with MR angiography for cerebral aneurysms is feasible, and radiologists can detect a number of additional cerebral aneurysms by using the detection system without a substantial decrease in their specificity. The low confidence of radiologists in the system may limit its usefulness.

SU-E-J-203: Determination of PTV Margin for Lung Tumor Using In-Treatment 4D CBCT.

PURPOSE: To determine a planning target volume (PTV) margin for lung cancer patients using a four-dimensional cone-beam CT (4D CBCT) acquired during volumetric modulated arc therapy (VMAT) treatment. METHODS: A VMAT plan for lung cancer patients was created by Pinnacle v9.0 (Philips) treatment planning system (TPS), where the gross target volume (GTVs) in each breathing phase was delineated by using 4D-planning CT scan (TOSHIBA and ANZAI). The VMAT treatment was performed with a stereotactic body frame after the registration using Elekta X-ray volume imaging (XVI) unit. Simultaneous cone-beam projection images were acquired for 3 or 4 fractions of 10 patients. The in-treatment 4D CBCT was reconstructed by dividing into four breathing phase bins. A total of 38 in-treatment 4D-CBCT sets were exported to Pinnacle TPS. The isocenter of in-treatment 4D CBCT was matched with that of 4D-planning CT. The tumor motion during treatment was manually tracked on in-treatment 4D CBCT, and the center-of-mass (COM) location of the tumor was estimated. Analyzing the tumor regions observed by in-treatment 4D CBCT, a PTV margin in our system was derived. RESULTS: The average difference in COM location of the tumor was less than 1mm for all directions, while the standard deviations (SD's) were about 1.3mm, 1.6mm, and 2.1mm for the lateral, the vertical, and the longitudinal directions, respectively. The large discrepancy more than 3mm was observed for one patient. The required PTV margin was about 3-4mm for the lateral and the vertical directions, whereas it was about 5mm for the longitudinal direction. CONCLUSIONS: The uncertainties of the tumor motion caused by respiration were observed by in-treatment 4D CBCT images. It was feasible to determine the PTV margin from 4D volume images. K. Nakagawa receives research funding from Elekta.

SU-E-J-33: Geometric Agreement Check for Imaging System with Radiation Beam by KV and MV-CBCT.

PURPOSE: The verification method of the geometry agreement between a light field and/or a laser coordinate and treatment beam should be easy and quick. In this presentation, we propose a novel QA method by using both kV- and MV-CBCT for kV-IGRT system. This method confirms the temporal unchanging the agreement of geometry in the kV-IGRT system with the treatment beam geometry. METHODS: 1) MV-flexmap: Sequential MV-projection images were acquired during gantry rotation by iViewGT (Elekta) and MV-CBCT was reconstructed by in-house software with a flexmap correction. The flexmap is displacement of gantry and detector panel related with gantry sag. The geometric change affects the deranging reconstructed image. To evaluate how much displacement of EPID panel and gantry was detectable, the images of 8mm diameter ball-bearing (BB) located at the radiation isocenter were reconstructed with improper Flexmap.2) A comparison between the kV-CBCT and the MV-CBCT: The kV-CBCT was provided by X-ray Volume image (XVI) system (Elekta). To confirm the agreement for the geometry between kV-IGRT system and treatment beam, the kV-CBCTs of BB are compared with that of MV-CBCTs. RESULTS: The flexmaps were modified to (b)1mm / (c)3mm shifted to the rotation direction and (d)3mm to the rotation axis. The MV-CBCT were reconstructed with the correct flexmap and with incorrect flexmap (b), (c) and (d).　The geometric confirmation for MV-CBCT was done by comparison of the width and center of the BB on the MV-CBCT. The discrepancy of center between kV-CBCT and MV-CBCT was less than 1mm. CONCLUSIONS: Less than 1mm of the geometrical changing to rotation direction for MV-detector panel could be recognized by reconstructed images of BB. Using kV- and MV-CBCT enable us to perform the simple comparison for geometrical non-idealities between the kV-IGRT system and the treatment beam. Dr. K. Nakagawa received research grant from Elekta.

Tissue procurement system in Japan: the role of a tissue bank in medical center for translational research, Osaka University Hospital.

Although organ procurement has been regulated by The Organ Transplantation Law (brain-dead donors since 1997, donors after cardiac death since 1979), there has been no law or governmental procurement network (except for cornea) in Japan. Since the late 1980s, some university hospitals have developed original banks. Finally, in 2001 guidelines for tissue procurement were established by The Japanese Society of Tissue Transplantation and Japan Tissue Transplant Network (JTTN) to coordinate tissue harvesting. Five tissue banks were joined to the tissue transplant network (skin in one, heart valves in two, and bone in two). As the number of tissue banks is small, each bank cooperates on procurement, but cannot cover the entire country. With regard to skin transplantation, only one skin bank-The Japan Skin Bank Network (JSBN), which is located in Tokyo-has organized skin procurement. Therefore, it has been difficult to procure skin in areas distant from Tokyo, especially around Osaka. In order to improve such a situation, a tissue bank collaborating with the JSBN was established at The Medical Center for Translational Research (MTR), Osaka University Hospital in April 2008. The bank has played a role in skin procurement center in western Japan and supported procurement and preservation at the time of the skin procurement. Between April 2008 and September 2009, the bank participated in eight tissue procurements in the western area. In the future, the bank is planning to procure and preserve pancreatic islets and bones. Moreover, there is a plan to set up an induced pluripotent stem cells center and stem cell bank in MTR. This tissue bank may play a role to increase tissue procurement in Japan, especially in the western area.

Liver CT image processing: a short introduction of the technical elements.

In this paper, we describe the technical aspects of image analysis for liver diagnosis and treatment, including the state-of-the-art of liver image analysis and its applications. After discussion on modalities for liver image analysis, various technical elements for liver image analysis such as registration, segmentation, modeling, and computer-assisted detection are covered with examples performed with clinical data sets. Perspective in the imaging technologies is also reviewed and discussed.

Diffusion property following functional hemispherectomy in hemimegalencephaly.

Diffusion-tensor imaging (DTI), a unique magnetic resonance technique for analysis of diffusion-anisotropy of the brain, can identify subtle white matter changes in vivo. To investigate changes of truncated neurofibers, DTI was conducted prior to and following functional hemispherectomy in a female infant for refractory epilepsy associated with hemimegalencephaly. Anisotropy of the amputated pyramidal tract decreased relative to the unaffected side after surgery, which reflects secondary degeneration in neurofibers. In DTI applied to infants, differentiation between developmental changes and changes associated with the current phenomenon must be evaluated cautiously. Standardization of diffusion-tensor analysis of developmental change is desirable.

Three-dimensional white matter tractography by diffusion tensor imaging in ischaemic stroke involving the corticospinal tract.

Diffusion tensor MR imaging (DTI) provides information on diffusion anisotropy, which can be expressed with three-dimensional (3D) white matter tractography. We used 3D white matter tractography to show the corticospinal tract in eight patients with acute or early subacute ischaemic stroke involving the posterior limb of the internal capsule or corona radiata and to assess involvement of the tract. Infarcts and the tract were shown simultaneously, providing information on their spatial relationships. In five of the eight patients, 3D fibre tract maps showed the corticospinal tract in close proximity to the infarct but not to pass through it. All these patients recovered well, with maximum improvement from the lowest score on manual muscle testing (MMT) up to the full score through rehabilitation. In the other three patients the corticospinal tract was shown running through the infarct; reduction in MMT did not necessarily improve favourably or last longer, other than in one patient. As 3D white matter tractography can show spatial relationships between the corticospinal tract and an infarct, it might be helpful in prognosis of gross motor function.

Automated segmentation and visualization of the pulmonary vascular tree in spiral CT angiography: an anatomy-oriented approach based on three-dimensional image analysis.

A new method for automated segmentation of the pulmonary vascular tree in spiral CT angiography was developed based on 3D image analysis techniques and anatomic knowledge. For efficient and effective segmentation, an anatomy-oriented approach was introduced, in which several anatomic structures are segmented sequentially and the properties of each segmented structure are used for the next step of segmentation and for validation of intermediate results. By use of clinical data of 12 patients, parameters for segmentation were analyzed and optimized. The effectiveness of the segmentation method was evaluated through the visual assessment by comparison between images of the segmentation results by volume rendering and images of maximum intensity projection of the original volume data.

Automated segmentation of colonic walls for computerized detection of polyps in CT colonography.

PURPOSE: A new method for fully automated segmentation of the colonic walls in volumetric CT data was developed for limitation of the search space in computerized detection of polyps. METHOD: For reliable segmentation, an anatomy-oriented approach was used, in which several anatomical structures are segmented in addition to the colon for utilization of their properties. RESULTS: The segmentation method was validated by use of 14 data sets, consisting of cases positive for colonic polyps. We found that the segmented colonic walls included all of the polyps. A subjective rating of the results was performed based on several criteria for visualization of anatomic detail of the colonic wall and mucosal surface. Except for a few cases in which insufflation of the colon was insufficient, all of the results included >95% of the colonic walls. CONCLUSION: This method for colonic wall segmentation is reliable and the segmentation results are applicable in both visualization of the colon and computer-aided diagnosis in the detection of polyps in CT colonography.

Augmented reality visualization system for intravascular neurosurgery.

We aimed to construct an augmented reality-based visualization system to support intravascular neurosurgery and evaluate it in clinical environments. Three-dimensional (3D) vascular models are overlaid on motion pictures from X-ray fluoroscopy by 2D/3D registration using fiducial markers. The models are reconstructed from 3D data obtained from X-ray computed tomographic angiography or from magnetic resonance angiography using the marching-cube algorithm. Intraoperative X-ray images are mapped as texture patterns on a screen object which is displayed with the vascular models. Distortion of X-ray fluoroscopy is eliminated by a new technique of screen mesh deformation. A quantity called reprojection distance was introduced to evaluate the reliability of the displayed images. It predicts the maximum registration error around the registered objects. Analyses of reprojection distances were performed using synthetic data consisting of marker coordinates with 2D or 3D errors. The tolerance of reprojection distance for the clinical environment was determined to be 3.0 mm. The system was tested in two clinical cases in which reprojection distances of 2.6 and 2.09 mm were obtained. Construction and evaluation of our prototype system were successfully carried out. Further development is planned employing a range sensor to permit markerless registration.

Volumegraph (overlaid three-dimensional image-guided navigation). Clinical application of augmented reality in neurosurgery.

OBJECTIVE: We have developed an overlaid three-dimensional image (Volumegraph)-guided navigation system that allows navigation during operative procedures. The three-dimensional image is superimposed on the patient's head and body via a semi-transparent mirror. The Volumegraph can display three-dimensional images in the air by a light beam which is based on CT/MRI. METHOD: The system consists of a Volumegraph (thin plate of three-dimensional recorded medium), a Volumegraphscope and an original designed triangular-shaped marker system for registration. The three-dimensional data obtained from CT and MRI before the operation were processed by a computer. Such image data are applied for preoperative investigation to recognize the three-dimensional structure of organs and tumor. These reconstructed three-dimensional images were superimposed and registered at the patient's head according to a fiducial marker (registration). Then the operator can operate with this three-dimensional-image-guided navigation system. RESULTS: Based on clinical application in 7 cases, the system was found to be advantageous because the surgical procedures could be navigated easily by augmented reality in the surgical field. Invisible parts of the surgical field were supplemented with the overlaid three-dimensional images (Volumegraph) as if it were the virtual operative field. At another time, spatial positioning and overlaid visualization by the Volumegraph was useful for identifying anatomical structures and functional location in the image. CONCLUSION: This preliminary study of overlaid three-dimensional-image-guided navigation demonstrated its clinical usefulness. The application of augmented reality in the surgical field makes it possible to do a neurosurgical intervention easily and accurately.

Development of an MRI-compatible needle insertion manipulator for stereotactic neurosurgery.

A variety of medical robots for stereotactic neurosurgery has been developed in recent years. Almost of all these robots use computed tomography (CT) to scan the brain of the patient before and during surgery. Currently, we are developing a needle insertion manipulator for magnetic resonance imaging (MRI)-guided neurosurgery. MRI techniques, including MRI angiography and functional MRI, are attractive for the development of interventional MRI therapies and operations. If a robot were available, these therapies would be minimally invasive, with more accurate guidance than is possible with current CT-guided systems. Actuation of a robot in an MRI environment is difficult because of the presence of strong magnetic fields. Therefore, the robot must be constructed of nonmagnetic materials. The system frame was manufactured using polyethylene terephthalate (PET) and was actuated using ultrasonic motors. Accuracy-evaluation procedures and phantom tests have been performed. The total accuracy of the system was approximately 3.0 mm. No artifacts caused by the manipulator were observed in the images.