Pediatric CT Imaging - Pediatric Experience with Photon-counting Detector CT Webcast

Welcome. This presentation is on photon counting detector CT, the Pediatric experience. I'm Marilyn Siegel in Saint Louis at the Washington University School of Medicine. I'm going to discuss the advantages of photon counting detector CT and pediatric imaging and of course show some clinical examples. What's my experience? He got photon counting detector CT in March 2022, the first Children's Hospital in the United States to get to the scanner. We're really busy. It is our workhorse. We do 20 to 25 patients a day since we've got it over 8000 cases and I think the number is really much higher than that. We do brain studies, high resolution lung. We do contrast enhanced chest and abdomen also non contrast enhanced cardiac CT, vascular CT, any study we do, what's your basic protocol? If you know they're two scan modes, there's standard and ultra high resolution depending on the clinical indication. The standard resolution the coverage is 144 by .4mm. We use that for contrast and non contrast body and CT angiography. Your other option is the ultra high resolution scan which is 120 by 0.2mm. We use that when we really want fine detail in lung and bone. The scans are done at 120 KV contrast non contrast body CTA. We use 10100 KV for the high resolution studies of the lung and bone. Those are our two options. We do use automated exposure control. We do our scans with high pitch in the body. We use 3.2. It minimizes motion. In small kids we rarely sedate and the number that I showed you the 8000 we in the body we may have sedated in this time period 15 patients in the extremity. We decrease the pitch to 0.8 to get better definition. Our rotation time is 0.25 seconds, so reconstructions after you get the images you've scanned. With two modes, you've scanned with a 0.2 thickness and a 0.4. If you use the 0.2mm thickness you need to reconstruct with threshold 3D, which on the scanners is termed T3D. If you perform your scan with the 0.4mm thickness you can do virtual mono energetic images for reconstruction. We prefer these over the T3D when we use 0.4mm thickness because they optimize contrast and you can do post processing spectral reconstructions. The Kev for the mono energetic images vary with the task. If we're doing CT angiography we use 55 Kev, if we're doing a contrast body 65. If we're doing non contrast body, 70 Kev. The kernel varies. We use BR40 for soft tissues and BL60 for the lung and BR64 for bone. Our quantum iterative reconstruction is always a strength of three and the slice thickness for our scans we acquired at 0.4. I should say 0.2 in the ultra high resolution one and 3mm and this just shows you the quantum iterative reconstruction levels. This was an image that was reconstructed at 60 Kev. The QIR is off here. This is a strength of one, the lowest strength and this is 3 and we really prefer the Qi R3. It's got great image Contrast and noise control blends them together. So what are the advantage to this? Then in clinical practice you get intrinsic spectral imaging, better contrast you can do post processing, smaller detector elements give you better spatial resolution. Photon counting, detector CT reduces electronic noise and you get improved dose efficiency. Intrinsic spectral imaging, we can reconstruct and we do every image at a low energy. So we reconstruct as I showed you at 55 to 70 Kev. When we acquire slice thickness at 0.4mm, we can acquire higher energy images or we use eye Mart iterative metal artifact reduction in patients with metal implants. And all of this is available on photon counting CT We can't acquire additional material decompensation images in selected scenarios, lung and vessel analysis, quantitative iodine analysis and this enables functional evaluation. So these are examples some some low kill electron Volt images and you can see that across the board the iodine increases with lower Kev 55 Kev. We use that for CT angiography 65 we use that more for contrast enhanced body CTS and 70 Kev images. We use this for some of the lung images and you get improved contrast across the board which increases lesion conspicuity. So you get this increased contrast at 55 Kev. It's also great for young children where you can't give a lot of contrast and so by adjusting the Kev you can increase the contrast and account for poor venous access so you don't have to re inject. So we use different kevs depending on the clinical tasks. Material decomposition images can be performed for further functional evaluation. We do iodine mapping, pulmonary blood volume, lung vessel analysis and stone analysis. This is one example of a three-year old boy with dyspnea. This patient had a narrowed left main stem bronchus right here. There's also a lot of soft tissue in the mediastinum because he has fibrotic tissue in response to an old infection. This is all scarring. This is 120 KV image. This is the iodine image. You can still see the narrow bronchus. There is no iodine or there's diminished iodine in the left lower low. And this is the pulmonary blood volume and lung vessel image superimposed. The normal vessels are on blue, you have red vessels in the left lower lobe indicating decreased flow. You have decreased perfusion, this blue color and this gives information that this stenosis is significant. It's impacting function of the left lower lobe and this is a four year old girl with Dysmia. And by the way in neither of these cases, neither of these patients were sedated 120 KV. There is a pulmonary embolism. OK. The question is how significant is it, is it impacting flow to the lung? If you look at the pulmonary blood volume image and the lung vessel superimposed, there's this wedge shaped area with diminished flow, color-coded red. So this embolus is having an impact on the lung. So great information. So let's look at the second advantage, smaller detector elements which allow higher spatial resolution, smaller detector pixel, so better spatial resolution. As I mentioned you can scan with 0.2 or 0.4mm thickness well on the dual source on the force we had 0.6mm. So much thinner collimation and this impacts our the appearance and the findings we get especially in high resolution non contrast lung CT cardiovascular CT angiography. Looking at the coronary artery bone CT neurovascular imaging, we get great spatial resolution better than on the dual source. Let's look at an example high resolution chest CT. We scanned these as I mentioned with 10100 KV. We use the ultra high resolution mode 120 by 0.2mm pitch 3.2. Because it's .2 you have to use threshold reconstruction. You can't do the mono energetic. We do a lot of imaging of chronic lung disease and lung transplant. This is a 16 year old who's had a lung transplant. Photon counting CT dual source are the force. This is 0.2 millimeters 10100 KV on the four 0.6 millimeters 10100 KV. First of all look at the doses .61 point 08, that's a 41% dose reduction. Look at the images. Better anatomic definition. Even at lower doses the vessels, they're sharper here than here. The mosaic appearance, the air trapping, these black areas, sharper, better defined on photon counting, better resolution. This is a 14 year old girl with cystic fibrosis. Photon counting CT. Dual source CT cystic fibrosis is associated with Bronchiectasis dilated bronchi. These are the dilated bronchi. This is the dual source. These are the dilated bronchi. The walls are better defined here, they're clearer. These are the fissures in the long normal fissures. Much better seen on photon counting than on dual source 0.2mm 0.6mm sharper definition of bronchi and we get a dose reduction. Another example, we use this in our CT angiography. We do both non gated and gated imaging. I'm just going to show you the non gated. Right now we use 120KV standard resolution 144 by 0.4mm pitch 3.2. We reconstruct with virtual monoegetic imaging at 55 Kev. So we'll look at some coronary anomalies and congenital heart disease. 2 one year old infants photon counting CT dual source or force 0.4mm collimation 0.6 This is the coronary artery left coronary artery, this is the coronary artery. Better definition in these young patients, better definition on photon counting CT than a conventional CT It's just remarkable. Look at the dose 0.67 milligram photon, counting 0.97 million Gray on the dual source. That's a 31% dose reduction. And this is congenital heart disease. This is a four year old boy who had surgery and what they did is they pulled the pulmonary artery in front of the aorta. This is the pulmonary artery aorta photon counting dual source. And the point is look at the definition and the contrast on the photon counting and the dual source, incredibly better on photon counting. And in the heart, these muscles trabeculation muscles are much better seen on photon counting. So win, win situation. And in this case it was 85, 85% dose reduction. So again dose reduction and superior image quality. What about bone musculoskeletal CT and we're going to focus on bone at this point. I'm not showing the CT angiography not enough time, but we do a lot of bone imaging. We use 120KV ultra high resolution mode for better detail, 0.2mm thickness. We decrease our pitch so we get better detail and because it's 0.2 we're using threshold reconstruction. One example 15 year old girl who fell. We do a lot of CT in children to see if the fracture goes into the joint space. Photon counting. You can see the fracture and you can see the fracture on the dual source force. Look at the detail, the bone trabeculation much better on photon counting, much better definition of the fracture margins and the joint space looks good. OK, another advantage reduction of electronic noise. Let me show you a couple of examples and now we'll look at some contrast enhanced examinations. We do these with 120 KV standard resolution, 144 by 0.4mm pitch 3.2. We're going to do our mono energetic reconstruction at 60 Kev, I think 60 to 65 Kev actually between those work well. We do a lot of masses in trauma, so this is a 5 month old, not sedated photon counting dual source 120KV-70 KV 0.4mm collimation, 0.6mm collimation on the force, I think it's clear that there is less motion, less noise on this photon counting image. It's a great advantage in young patients who don't have a lot of intrinsic contrast. You get superior images on photon counting and a 15 year old girl who had her left lung removed for a malignant tumor. So all of this is just fluid filling that empty space photon counting CT dual source CT120KV80KV. Less noise, better contrast on photon counting. We've looked at the examples many areas and photon counting is a winner. It's also a winner when it comes to doses. This is an article we published this year. I did this in collaboration with Siemens. We looked at high resolution chest CT. We compared 23 patients on photon counting or the alpha and we compared them to 23 patients study on the dual source CT or force. We match them for age and body circumference, average patient 4.5 years, no one was sedated and we found significantly lower radiation dose and milli amperage on photon counting CT. So if you look at the CTDI file in the dose lung product, we had a 42% reduction, 26% reduction significant and the milli amperage was reduced about 26% significant reduction. We have more information on doses. We recently actually in April looked at the scans we did on photon counting detector CT and compared them to scans on the 4th. We looked at contrast enhanced CT, we had 11176 cases on the photon counting detector CT 892 on the force and found significant dose reductions in chest contrast enhanced, chest CT 43% reduction, contrast enhanced abdomen pelvis 50% reduction and in chest CT angiography 63% reduction. In addition, there was decreased motion artifact to the faster scans. Basically no one was sedated, just we had a small number as I mentioned before sedated. Overall we don't use sedation at this point. So how do we sum it up? Photon counting detector CT promotes standardization. It's easy for the technologist. We're acquiring all scans at a single KV, either 120KV or 10100 KV. All scans are going to be reconstructed either as virtual monitor genic images or threshold T3D images depending on the clinical tasks. All standard resolution at 0.4mm are spectral images which allow you to do some terrific post processing. So there's no more decision about what's your KV, what's your reconstruction, Am I going to do dual energy because I want spectral imaging. It's built in it's standardized bottom line photon counting detector. CT is a big win. Lower doses, better resolution of smaller structures, noise reduction and routine spectral data. So that pretty much sums up photon counting detector CT. It's a great quantum leap actually in imaging, and at that point we'll stop.

80 42% <0.001 26% 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. Photon Counting Detector CT Pediatric Experience Marilyn J. Siegel, M.D. Mallinckrodt Institute of Radiology Washington University School of Medicine St. Louis, MO SCHOOL OF MEDICINE Mallinckrodt Institute of Radiology Washington University in St.Louis MIR Objectives · Discuss advantages of photon-counting detector CT (PCD-CT) in pediatric imaging Experience with PCCT at St Louis Children Hospital · PCD-CT started in March 2022 · 20-25 patients/day (in and out patients) Brain CT /CTA High resolution lung CT (HRCT) Contrast enhanced chest and abdomen Cardiac CT - Vascular CT Basic Body Protocol PCD-CT Acquisition Parameters . Scan modes: standard and ultrahigh resolution (UHR) · Standard resolution: 144 x 0.4 mm -- contrast + non contrast body, CT angiography (CTA) UHR: 120 x 0.2 mm -- HRCT lung and bone · kVp: 120 kVp for contrast/non contrast body, CTA Sn100 kVp: HRCT lung, bone mAs: automated exposure control · Turbo flash pitch: body CT: 3.2, extremity: 0.8 Rotation time: 0.25s Reconstructions . 0.2mm thickness slices: recon with T3D. · 0.4mm thickness: VMI (mononergetic) -Prefer VMI over T3D-optimize contrast · keV for VMI vary with task: 55 keV CTA, 65 keV contrast body, 70 keV non-contrast body Kernel Br40 soft tissue, B160 lung Br64 bone Slice thickness: 0.4, 1, 3 mm QIR levels VIM reconstructed at 60 keV QIR off QIR 1 QIR 3 QIR 3 best for image contrast and noise control Advantages of PCD-CT compared with conventional CT · Intrinsic spectral imaging: better contrast · Smaller detector elements: higher spatial resolution Reduction of electronic noise Improved dose efficiency Intrinsic Spectral Imaging · Every image can be reconstructed at low energy: 55 to 70 keV · Higher energy images or IMAR used in patients with metal implants for artifact reduction · Additional material decomposition images are performed in selected scenarios: lung and vessel analysis, quantitative iodine analysis-enable functional evaluation Low keV (55-70 keV) Images · Iodine increases with lower keV · Improved contrast and lesion conspicuity - compensate for poor venous access 55 keV 65 keV 70 keV Material Decomposition Images for Pulmonary blood volume Lung vessel analysis Stone analysis 3-year-old boy Dyspnea · Narrowed left main bronchus with surrounding soft tissue mass, representing fibrotic tissue · Clinical question: is lung perfused? 120 kV 4 year old girl dyspnea Perfusion/vessel image shows parenchymal infarcts Smaller Detector Pixels Improved spatial resolution · 0.2 - 0.4 mm (PCD-CT) vs 0.6 mm (EID-CT) · Greatest impact on High resolution non-contrast lung CT Cardiovascular CTA (coronary artery) Bone CT Neurovascular imaging Benefit: better definition of small structures High resolution chest CT Sn100 kV, UHR ( 120 x 0.2 mm), pitch 3.2, T3D recon Chronic lung disease Lung transplantation 16-year-old, post lung transplant Photon-counting Dual source CT 0.2 mm / Sn100 kV CTDIvol 0.61mGy CTDIvol 1.08 mGy Beter anatomic definition at lower doses 14-year-old girl, Cystic Fibrosis Sharper definition of bronchi Non-gated Cardiovascular CTA 120 kV ., standard resolution (144 x 0.4 mm) pitch 3.2, 55 keV Coronary anomalies Congenital heart disease Coronary Artery CT Two one year old infants 0.4 mm collimation CTDIvol 0.67mGy Congenital Heart Disease 4 yo boy-Post surgical evaluation Musculoskeletal CT 120 kV, UHR mode (120 x 0.2 mm) pitch 0.8, T3D. Evaluation of cortex and trabecular bone · 15 year old girl post fall · Great bone detail Advantages of PCCT compared with conventional CT · Intrinsic spectral imaging: better CNR · Smaller detector pixel size: higher spatial · Reduction of electronic noise · Improved dose efficiency Contrast Enhanced Chest and Abdomen CT 120 kV, standard resolution (144 x 0.4 mm). Pitch 3.2, 60 keV Masses Trauma Abdomen: 5-month-old follow up renal tumor 120 kVp, 0.4 mm collimation 70 kVp, 0.6 mm collimation PCD-CT Less noise, less motion Chest: 15-year-old, pneumonectomy for malignant nerve sheath tumor What about the dose? · It's a win: Lower doses Doses: High Resolution Chest CT Comparison of PCD-CT to Dual Source CT Published AJR 2023 online · N=23 on Alpha, N=23 on Dual Source CT · Matched for age and circumference · Average patient age 4.5 yrs Significantly lower radiation dose on PCD-CT Variable PCCT DSCT % Reduction P-Value 0.41 + 0.1 DLP (mGy-cm) mAs 48.00± 14 202 + 36 13.7+ 2.9 Doses: Contrast-enhanced CT Chest, Abdomen/pelvis, CAP · 1176 PCD-CT scans, 892 Force · Significant dose reductions (p <. 001) Chest 43%, A/P 50%, chest CTA 63% · In addition, decreased motion artifact due to the faster scan times Virtually no sedation Conclusions: PCCT in children · PCD-CT promotes standardization · All scans acquired at a single kV (120 kV or Sn100 kV) All scans reconstructed as VMI or T3D depending on clinical task · All standard resolution scans are spectral · No more decision about kV, reconstruction or Dual Energy CT Bottom Line: PCD-CT is a big WIN · Better resolution of smaller structures Routine spectral data WiN The statements by Siemens Healthineers' customers described herein are based on results that were achieved in the customer's unique setting. Because there is no "typical" hospital or laboratory and many variables exist (e.g ., hospital size, samples mix, case mix, level of IT and/or automation adoption) there can be no guarantee that other customers will achieve the same results. NAEOTOM Alpha is not commercially available in all countries. Their future availability cannot be guaranteed. 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