Pediatric CT Imaging - Challenges and Siemens Healthineers Solutions Webcast

Well, I'm going to address pediatric CT imaging today. Some of the challenges and solutions. I'm Marilyn Segal from the Mail and Crowd Institute of Radiology in Saint Louis. And I'm delighted to be able to do this. The lecture objectives are to describe the challenges and performing CT in a young population. And then to identify Siemens technologies to address these challenges. So let's look at some background information. Here. Children have special problems that need to be addressed, and then young children. That usually means under five years of age. The problems are motion and poor inherent body contrast. Children of all ages. The issue is radiation exposure, starting with patient motion. It is a problem in young children. They scream, they move, they bounce, they fidget. They don't like the tables, they'd rather be on the floor. And no matter what, if you get them on that table, they're not going to hold their breath. So you've got a lot of options for motion. Well, the early solution. In imaging was sedation usually intravenous sedation. Of course that has problems, that does have some risk, but that's what we were using. But then Siemens came up with an answer and it is high pitched flash mode available on the dual source scanners and most recently the Neatome alpha. So the clinical benefits faster scan times. That means elimination of sedation. We do not sedate patients at this point in time and there's less motion. You get grade, image quality single source. Our pitch was less than 1.5, so it took a chest examination 4 seconds to be performed and the chest abdom and pelvis require 10 seconds. We sedated patients. When we had only a single source and used a pitch under 1.5 dual source scanners. Now we have a pitch equal or greater than three. We can perform a chest in less than one second, chest, abdomen, pelvis in four seconds. So we've a limited sedation in that very young population under 5. This is an example. These are neonates. Single source. The pitch was 1.2. That was the best we could do. It was a one second rotation time, and you can make a diagnosis of a right aortic arch, but there's a lot of motion. This patient was sedated and sedated. Patients breathe still and there was still motion on those scans, but it was improved well with the dual source scanners. We're using a pitch of three or a little higher rotation time, 0.28 seconds. Another right arch in this patient. Here's the right arch. An incredible 3D reconstruction, no motion artifact, and this patient was not sedated. Flash mode is an incredible technology, the second challenge in young children. They have small structures and they don't have. The fat that adults have around their organs, so there's poor definition of Oregon planes. Well, Siemens came up with some answers. Low kilovoltage scanning at 70 or 80KV and dual energy mono energetic imaging. And the benefit of both of these is improved contrast conspicuity. So just a couple of examples. This is an abdomen and a 7 year old boy he he came back for several exams. This is at 80 KV. This is at 100 KV. This was at 120KV. Great contrast AT80KV. You can see the vessels in the liver incredibly well, much better than in other KV's. Mono energetic images. Another way to improve contrast, Use your lower Kev. This is a great tool because it can compensate for poor Venus access. Children have small veins and we use small caliber catheters and we use small volumes of contrast. So sometimes you don't get the optimal contrast enhancement. You can solve that. Change your Kev use dual energy CT and use mono energetic images 50K E V60K E V70 OK same patient one scan we just selected different KEV's grade image quality at 50K EV much higher contrast so if you don't like your image. Play around with the the KE V's A big challenge is radiation exposure and the need for dose reduction. Children are more sensitive to radiation than adults. This is from the atomic bomb data, and it's from the Committee on Biologic Effects of Ionizing Radiation, the BEER report. Children in the first two decades and also young adults in the third decade have much higher risk and we're talking cancer mortality from radiation exposure than older adults. And females have a higher risk than males because of breast tissue. So does reduction is a key point and it's a challenge. How do you do it? There's some easy tricks. Limit the multiphase examinations. Every phase that's performed that isn't needed increases radiation. And then really important, use Siemens Automated technologies, fast care, automated centering, 10 filtration. So the number of contrast phases, a key concept. And pediatric CT image during one phase, you don't need multiple phases if you're doing angiography. Image in the arterial phase, if you're doing anything else, image in the venous phase. Where do we use multiphase imaging of liver masses for characterization than arterial and venous? We do not perform noncontrast scans. The goal here is to keep the dose as low as reasonably achievable. And a couple of examples, Pediatric tumors are large, you'll see them in the venous phase. This is a 12 year old with lymphoma anteromediostenal mass. This is the three-year old with the neuroblastoma in the posterior mediastinum and in the abdomen the common tumors we see and her and children under 5. Wellms, which is the renal tumor of childhood and neuroblastoma, the adrenal tumor, you're going to see these quite well. In the venous phase, you do not need arterial phase imaging. Use fast care technologies for dose reduction and these include automated MA modulation care dose, 4D automated 2 voltage and iterative reconstruction. Automated current or MA modulation. The MA is adapted to thickness of the area of interest. It's based on the topogram, the scout and attenuation measurements. That means body parts with less thickness need less radiation. So in the neck you don't need that much milliamperage. When you get to the shoulders and the bones, the milliamperage will increase. And then when you get to the lawn, the automated modulation will decrease the milli amperage. So with the modulated MAS you can see the curve in red. Your mean MAS is lower than if you used a fixed MAS. So it's a great way of dose reduction. This is a four year old who is suspected to have a lung anomaly. Every exam is performed with references. MAS&KV the reference here was 110 MA and if we had used this and you can get these estimates from the scanner, the dose and CTG I've all would have been 4.7 milligrams. But the automated technology said no. You know we'll modulate the dose and the mean MA came out forty. We used AKVP of 100. And the CTDI Vol was 2.2 dropping from 4.7. Great image quality. And this patient does have an anomaly. This is a four year old and this is lower overinflation, A congenital anomaly. But the key point great images at a low dose, an additional benefit of care dose, breast dose reduction. For a long time, we use business Shields to reduce dose to the breast and you could get a 30 to 50% dose reduction and that was accompanied by a 40 to 100% noise increase. If you use automated MA modulation, you get 30 to 60% dose reduction, little bit more than with the Shields and much lower noise. So overall win win scenario, the American Association of Physicists and Medicine came out with a position statement on the use of business shielding in 2012. And they said for equivalent levels of image noise, the percent dose reduction to the anterior surface, the breast from business shielding can be achieved just as well. By reducing the X-ray to current, fresh Shields are out. We don't use them. It's just not used anymore in pediatric radiology. The story goes on. Kara KV came along and it automatically suggests the best KV, again based on what it sees on the scout, the attenuation profile, and the study you want to perform. If you want to perform CT angiography, maybe just contrast enhance abdomen or chest. Maybe a bone examination or a non contrast. It's going to choose the KV only one KV for your examination. It works with the automated current modulation. The MA is still modulated. Example CTA 3 year old girl. Here's her toprogram. She's had surgery for congenital heart disease. Remember every exam has a reference So this said the reference was 120KV and it would have chosen 58 MA. And looking at the estimate for this on the scanner, the dose would have been 3.57 milligrams. We used care KV and care KV looked at this patient and said I'm going to change it to 70KV. We have to increase the MA to keep the image quality constant. But KV is stronger than MA and the dose goes down more than a half 1.6 milligrades and great images. This is a patient who had a surgical shot for congenital heart disease. Great images. In addition care KV lowers the dose and it improves image quality. So this patient had bowel disease came back. For some studies, here is one that was done with 100K V Before the time of care KV, the dose CTDA of all was 5.12 milligram. When we use care KV, it selected 80KV. The dose went down to 3.58 milligrams. And look at the contrast, it's much better. So care KV is a winner. Lower radiation dose improve contrast. The third automated technology is iterative reconstruction and it works by applying a noise reduction method to clean up the image noise levels. So what we do is we scan at a lower milliamperage, we reduce it 20 to 30%, then iterative reconstruction cleans up the image. So this is the use of an example of the use of iterative reconstruction. We reduced the MA 30%, that's a lot of noise and we cleaned it up with iterative reconstruction. Much better quality image and the dose decrease 30%. So let's review this. This has been my experience in over more than a decade. And every time I got a new technology and seem and share these with me, I would do a study over months of of exams and patients that were examined during the time period with the new technology. And when we first had KERA dose 4D and I did that study the mean from a range of studies was 8.3 Milli Gray CTDI valve. Care KV came along and so we use the combination of care KV and care dose 4D and the mean reduced to 6.0 milligres and then Sapphire and Admire came along traumatic dose reduction. So these technologies work together and again it's a winner really marked dose reduction. Another dose reduction technology that Siemens came up with was the 3D camera. For automated positioning, the camera is positioned above the table. Here's a close view of the camera. So it's an artificial intelligence tool that standardized patient centering based on the patient shape, where the patient is on the table and height. Here's the issue, Miss centering vertically or laterally can increase the dose in image noise because of inaccurate automated MA modulation, and errors are more likely in small patients doses to the thyroid and breast tissue, particularly increased in pediatric chest CG. So let's look at my experience again with the 3D camera and I analyzed our early experience. They show a number of patients who underwent chest, Ave. and pelvis exams in a short time period. The orange was the automated camera and it centered the patients closer to the ISO center. The Gray and the brown were manual positioning done by the technologist, so with the camera. The mean offset from the ISO center was 0.6 midline millimeters. With manual positioning it was 10.9 millimeters from optimal positioning. This ensures great image quality and low dose, so it's another great tool. And one more dose reduction tool is 10 filtration with single energy CT 10100 KV, also called spectral shaping. It's used in non contrast chest Ct's. I use it all the time in a high resolution chest CT and non contrast CT. So the 10 filter absorbs lower energy photons than his. Here your energies below. The broken orange line is 70 KV, the Blues 120KV, the continuous orange line is 10100 KV and the blue line is 10150 and pediatric imaging we use 10100 KV. So the lower photons, lower energies are absorbed. It increases dose efficiency and you get. Great image quality. Let me show you some results. We looked at 50 patients who had undergone high resolution chest CT before and after implementation of the 10 filter. Non 10 filters for comparison were performed with automated KV selection and they range from 8090, a hundred 120KV. The same patients were scanned before 10 and after 10 implementation with 10100 the CTDI was 0.74 milligrays with non ten 1.7 milligrays we've got a 56% decrease in CTDI valve and then the contrast to noise ratio which we measured was identical. So again, a great technology. This is an example. This is just standard chest high resolution CT and 100K V and this is 10100 KV, Same patient, lower dose and great image quality. Those savings good image quality. So to recap. The issues and Siemens solutions flash mode, great technology for motion reduction, low KV or kill electron Volt imaging, right way to improve contrast and then fast care 3D camera 10100 KV your dose reduction technologies so overall. We have challenges, but we also have some great solutions and all of these work together, so thank you for your attention.

1600 1400 1200 1000 800 400 200 50 60 90 600 30 40 70 80 10 20 8.7 6.4 3.4 7.6 6.2 2.6 3.3 0.6 8.3 6.0 2.7 35 -25 -55 -85 150 250 350 450 0.02 0.01 110 130 0.03 0.04 0.74 1.7 <0.001 21.3 Siemens Healthineers are neither the provider nor legal manufacturer of this video. Any claims and statements made in this video and any content shown in the video are under the sole responsibility of the provider. Additionally, the training may not be available in all countries and the content may not be commercially available in all countries. Please contact the provider for more information. Pediatric CT Imaging Challenges and Siemens Healthineers Solutions Marilyn J. Siegel, M.D. Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis, MO Please contact the SCHOOL OF MEDICINE MIR Mallinckrodt Institute of Radiology Washington University in St.Louis Lecture Objectives · Describe challenges in pediatric CT Identify Siemens Healthineers solutions Background · Children have special problems that need to be addressed . Young children (< 5 years) -Motion -Poor inherent contrast · Children of all ages Radiation dose Patient Motion . Problem in young children (< 5 yrs) -They scream -They move, bounce or fidget -They prefer floors to tables -They don't hold their breath Early solution was sedation Siemens Healthineers solution High-pitch, Flash mode available on dual source scanners AND NAEOTOM Alpha · Clinical benefit Faster scan times » Elimination* of sedation » Improved image quality-decreased motion artifact * Siemens Healthineers are neither the provider nor legal manufacturer of this video. Any claims and statements made in this video and any content shown in the video are under the sole responsibility of the provider. Single Source Dual Source Flash Vo Pitch < 1.5 Chest: > 4s Chest: < 1s CAP: >10 s CAP: 4 s Eliminated sedation Case Example: Flash Mode Pitch 1.2 Pitch 3 1s rotation time 0.28s rotation time Motion artifact No motion artifact Sedation No sedation 2nd Challenge Young Children · Small structures and little fat leading to poor definition of organ planes Siemens Healthineers solutions -Low kV (70/80 kV) scanning Dual Energy monoenergetic imaging · Benefit - improved contrast conspicuity Low kV Imaging Great contrast Abdomen- 7-year-old boy 80 kV 100 kV Improved Contrast at lower keV Can compensate for poor venous access and small contrast volumes 50 keV 60 keV 70 keV Abdomen - 10-year-old boy Contrast = 1140 HU Contrast = 740 Contrast = 580 3rd Major Challenge in Pediatric CT Dose Reduction . Children are more sensitive to radiation than adults CANCER MORTALITY (PER 100,000 PERSON FOR 0.1 Sv) 10 20 30 40 70 80 AGE AT EXPOSURE (YRS) MALE FEMALE Committee on the Biological Effects of Ionizing Radiation, Health Effects of Exposure to Low Levels of Ionizing Radiation: BEIR V, 1990 Dose Reduction Solutions The Easy Tricks · Limit the number of contrast phases Siemens Healthineers automated technologies -FAST CARE technologies Automated centering* -Tin filtration Limit Number of Contrast Phases · KEY CONCEPT: image during one phase -Arterial phase for CT angiography -Venous phase for other imaging Exception: liver masses (2 phases) · You don't need non-contrast scans Goal ALARA Pediatric Tumors Large and well seen in venous phase Use FAST CARE Technologies for Dose Reduction · Automated mA · Automated tube voltage Iterative reconstruction (ADMIRE) Raw data recon CARE Auto Dose4D kV 100 W Automated Current (mA) Modulation · mA is adapted to thickness of the area of interest, based on topogram attenuation measurements Parts with less thickness need less radiation Fixed mAs Modulated Automated mAs Modulation · 4 year old. R/O lung anomaly · Ref mAs 110 (4.7 mGy) kVp-100 CTDIvol 2.2 mGy Great image quality Additional Benefit of CARE Dose4D Breast Dose Reduction · Traditional: bismuth shields for dose reduction -30-50% dose reduction; 40-100% noise increase 30-60% dose reduction, 10-30% noise increase -"win-win" scenario REVERSE 2012 AAPM Position Statement on the Use of Bismuth Foam Backing Shielding for the Purpose of Dose Reduction in CT scanning 2012 Geleijins Eur Radiol 2006; 16:2334 Vollmar, Kalendar Eur Radiol 2008 FRONT Shielding for the Purpose of shielding current" 2012 AA scanning 2012 scanning Geleijins Eur Radiol 2006; 16:2334 scanning Feb 2012 · "For equivalent levels of image noise, the percent dose reduction to the anterior surface from bismuth shielding can be achieved by reducing the x-ray tube scanning American Association of Physicists in Medicine website. www.aapm.org/org/policies/details. Breast shields are out! The Story Goes On --- CARE kV . Automatically selects the optimal kV based on the attenuation profile from the scout and diagnostic task · Chooses one kV for entire scan · Works with AEC, mA is still modulated Task 140 W 70 kV 120 W CARE kV Chest CTA · 3-year-old girl REF: 120 kV / 58 mA 3.57 mGy · 70 kV / 158 mA 1.6 mGy CARE kV · Lowers radiation dose AND 50.0cm KV 80 mA 459 100 kV, CTDIvol=5.12 mGy 80 kV, CTDIvol=3.58 mGy Iterative Reconstruction · IR works by applying noise reduction methods to clean up image noise levels · Scan at lower mA . Then IR "cleans up" the image noise 30% mAs reduction IR 3X less noise High noise Lower dose (30%) Summary: My Experience in Dose Reduction (mGy) Over Past Decade EXAM IR + + CARE Dose + Abd/pelvis Chest CTA mean Dose Another Dose Reduction Technology 3D Camera* for Automated Positioning · Positioned above the table · AI tool that standardized isocentric positioning based on patient shape, position and height Center the Patient · Mis-centering (vertically or laterally) can increase dose* and image noise due to inaccurate automated mAs modulation · Errors are more likely in smaller patients . Doses to thyroid and breast tissue substantially increase in pediatric chest CT Habibzadeh MA, et al Impact of miscentering on patient dose and image noise in CT imaging. Phys Med 2012; 28:191-199 Kaasalainen et al. Effect of vertical positioning on organ dose, image noise and contrast in pediatric chest CT-phantom study. Pediatric radiology 2013; 43:673 - 684 3D Camera: Our Experience Chest, Abdomen, Pelvis scans from Oct 26 - Feb 26 manual patient More accurate positioning camera- too high augmented around isocenter with camera overruled too low Manual positioning tends to be below isocenter isocenter offset [mm] patient diameter [mm] Camera: decreased mean isocenter offset - 0.6mm vs 10.9 mm for manual positioning p<0.001 Ensured consistent low dose One More Dose Reduction Tool Tin Filtration Single-Energy CT (Sn100 kV) Also called Spectral Shaping Sn100 kV · Intended for use in non-contrast chest CT · Tin filter absorbs low energy photons increasing dose efficiency 0.04 - 0.03 - Rel. intensity --- 70kV --- 120 kV Sn150 kV Energy/keV uS 0.01 - US 0.02 - Dose Results 50 patients who had undergone high resolution chest CT before and after implementation of the tin filter · Non-tin scans were performed with auto kV selection (80, 90, 100, 120 kV.) Sn 100 Non-tin P value Age (yrs) 12 (4-15) 12 (4-14) NS CTDIvol (mGy) CNR 56% decrease CTDIvol Siegel et al. JCAT 2022; 46:64-70 100 kV vs Sn100kV 100 kV, CTDIvol=2.08 mGy Sn100kV, CTDIvol=0.9 mGy Dose savings + Great image quality Recap: Siemens Healthineers Great Solutions to Challenges in Pediatric CT Motion reduction -Flash mode Contrast optimization -Low kV/keV imaging Dose reduction* technologies -FAST CARE -3D camera Sn100 kv HANK YOU Siemens Please note that the learning material is for training purposes only. For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively "Operator Manual") issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Please note: Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively "Functionality") may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Siemens Healthcare GmbH 2023 SIEMENS Healthineers