Job Aid Esensial CT Dual Energi

SIEMENS Healthineers The Essential Things of Dual Energy Imaging Nur Dwi Prasetyo Clinical Application Specialist Unrartristan Sinmans Unathrarn Cmhu 7017 Unrestricted © Siemens Healthcare GmbH, 2017 SIEMENS Healthineers Dual Energy Scan Is It A New Things? Author | Department2 Unrestricted © Siemens Healthcare GmbH, 2017 SIEMENS Healthineers .. Emotion SIRETOM - 1974 SIRETOM - 1975 Prototype of CT Head CT Scanner SOMATOM Scanner SENSATION - 2005 1ST 64 Slices CT – SOMATOM Cardiac Scanning EMOTION - 2001 Compact System SOMATOM DRIVE - 2015 2 x 128 Slices with STELLAR Detector HEL TEEL SOMATOM SOMATOM - 1977 SOMATOM FORCE - 2013 Body CT Scanner SOMATOM PLUS - 1987 2 x 192 Slices Dual Source Kidney 1st Slip Ring Technology SOMATOM Friendly SOMATOM DEFINITION - 2005 VOLUME ZOOM- 1ST Dual Tube Scanner 1998 MSCT – 0.5 Sec Rotation Speed SOMATOM SOMATOM DEFINITION FLASH - PERSPECTIVE - 2014 2009 1ST CT with Moodlight 2 x 128 Slices Dual and IVR SOMATOM Tube Scanner PLUS – S - 1991 SOMATOM AR – 1st Spiral Scan C/T - 1994 SOMATOM DEFINITION Technology 1st Compact CT SOMATOM PLUS 4 - 1997 EDGE - 2012 Console 1st Sub Second Tube STELLAR Detector Rotation (0.75 sec) Unrestricted © Siemens Healthcare GmbH, 2017 DECT : A flash back of history (1970’s – 1980’s) SIEMENS Healthineers .. • Main topics in 1970’s “ interaction of materials toward different energies” (Millner et al. 1979; Avrin et al. 1978; Chiro et al. 1979; Genant and Boyd 1977) • Only 1 type of DE capable scanner produced in 1980’s: SIEMENS SOMATOM DR 3. (Siemens Healthineers ; The History of Computed Tomography at Siemens) • By the 1980’s use DECT for densitometry (Nickoloff et all. 1988) Unrestricted © Siemens Healthcare GmbH, 2017 DECT : a flash back to history ( 1970’s – 1980’s ) SIEMENS Healthineers .. Radiology. 1988 Jul; 168(1):223-8. WORK IN PI Bone mineral assessment: new dual-energy CT approach. Tissue Signatures with Dual-Energy Computed Nickoloff EL1, Feldman F, Atherton JV. Tomography1 Author information Giovanni Di Chiro, M.D ., Rodney A. Brooks, Ph.D ., Robert M. Kessler, M.D ., Gerald S. Johnston, M.D ., A. Eric Jones, M.D ., Jean R. Herdt, M.D ., and William T. Sheridan Abstract Most clinical quantitative computed tomographic (CT) determinations of bone mineral content are har By providing information on two parameters, dual-energy computed tomography can offer clinically useful tissue sig- for the various substances contained within the spongiosa (spongy bone). In general, the presence o natures for metallic deposits (Ca) or injected iodine, as well (Hounsfield units) and leads to underestimation of bone mineral content. Collagen matrix has the opp as for different normal and abnormal types of brain paren- chymal tissues and CSF. Cerebral CT was performed on 36 patients and tissue differences analyzed using Hounsfield Extraction of information from CT scans at notation. different energies INDEX TERMS: Computed topography. head . Computed tomography. physics . Computed tomography, technique Michael R. Millner, William D. McDavid, Robert G. Waggener, Michael J. Dennis, Radiology 131:521-523, May 1979 William H. Payne, Victor J. Sank First published: January 1979 Full publication history DOI: 10.1118/1.594555 View/save citation Cited by (CrossRef): 0 articles ( Check for updates Citation tools v Unrestricted © Siemens Healthcare GmbH, 2017 DECT ‘s History : Clinical DECT Limitations SIEMENS Healthineers • Lacking stability of CT Density Values • Long scan time, which often cause patient motion during/ between Soft tissue density image scan. • Lower spatial resolution • Postprocessing difficulties • Iodinated contrast media examination was impossible. (Kelcz F, Joseph PM, Hilal SK (1979) Noise considerations in dual energy CT Calcium density image scanning Kalender et. Al. Radiology 164:419-423, 1987 Unrestricted © Siemens Healthcare GmbH, 2017 DECT : A flash back of history – 2000’s SIEMENS Healthineers • 2005 - First DSCT in the world • 2 x 64 slices • First routine clinical DE CT scanner in the world • 12 Dual energy classes / application • In one year > 500 installation • More than 800.000 scans Unrestricted © Siemens Healthcare GmbH, 2017 SIEMENS Healthineers Dual Energy CT : What and Why ? Restricted © Siemens Healthcare GmbH, 2016 Single Energy VS Dual Energy SIEMENS Healthineers Single Energy CT Imaging Dual Energy CT Imaging high kV low kV high kV Data imaging Attenuation B Attenuation A  Single energy patient irradiation  Two energies acquired simultaneously  Single attenuation data of materials obtain  Multiple attenuation data of materials obtain Author | Department 9 Unrestricted © Siemens Healthcare GmbH, 2017 Why Dual Energy ; Additional Information ? SIEMENS Healthineers . Unrestricted © Siemens Healthcare GmbH, 2017 Why Dual Energy ; Additional Information ? SIEMENS Healthineers Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT ; Requirements SIEMENS Healthineers .. The method of scanning by Different Different Energy Energy Material with Material with X Ray Quanta X Ray Quanta utilizing two different energy Different Different Spectrai Spectral level (high energy and low Properties Properties energy), to provide tissue Detector with Detector with Quanta Quanta Differentiation Differentiation characterization possibility Dual Energy Imaging Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT ; Differentiation of X Ray Quanta SIEMENS Healthineers Number of quanta 80 kV 140 kV overlap 80 kVp ................... .............................................................................................. 140 kVp 0 20 40 60 80 100 120 140 Conventional Photon energy Dual Source Dual Energy CT Fig. 1 Spectra of the Straton tube at 140 and 80 kV potential. • The peaks represent the characteristic lines of the tungsten anode Significant spectral overlap and the continuous spectrum is a result of Bremsstrahlung. The • mean photon energies are 53 and 71 keV, respectively Limits energy separation • Limits dose efficiency Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT ; Differentiation of X Ray Quanta SIEMENS Healthineers Number of quanta 70 80kVp Sn140kVp .......... SOMATOM Force ..... Tin Filter Applied 80 kV Sn150 kV overlap .......... 40 SOMATOM Drive SOMATOM Definition Flash 30 80 kV Sn140 kV 20 10 - ......... .................. 0 DE with Tin Filter Photon energy 0 20 40 60 80 100 120 140 • Minimized spectral overlap Fig. 3 X-ray spectra of the two tubes running at 80 and 140 kV with 0.9 mm titanium and 3.5 mm aluminum filters on both and • Increased energy separation an additional 0.4 mm tin filter on the high-energy tube • Complete dose neutrality Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT : Material with Different Spectral SIEMENS Healthineers .. Properties 10 TABLE 9-2 Atomic Number and K-Shell - Fe (26) Electron Binding Energy of 9 Ti (22) Radiologically Important A ........ 8 Elements CaHa (16,04) 7 ........................ PVC (14,06) Atomic K-Shell Electron Binding Energy (ke V) 6 Element Number (p/p)(E) / (p/p) H20 (E ...................... Kortikaler Knochen (13,23) Hydrogen 0.02 5 ·· AI (13) Carbon 0.3 4 HO (7,46) Nitrogen 7ª 0.4 Oxygen 0.5 3 Aluminum 13 1.6 2 Calcium 20 4.1 Molybdenum 42 19 1 .............................. PMMA (6,52) Rhodium 45 23 ........................................... Fett (5,88) lodine 53 33 -1 Barium 56 37 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 E (keV) Tungsten 74 69 not seen in CT-detector Rhenium 75 72 Lead 82 88 W.A. Kalender, Computertomographie,Publicis MCD Verlag, 2000 Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT : Material with Different Spectral SIEMENS Healthineers .. Properties Water lodine 10ª 104 TABLE 9-2 Atomic Number and K-Shell Compton Effect Compton Effect Electron Binding Energy of LL Photo Absorption Photo Absorption Radiologically Important 103 Coherent Scattering 103 Coherent Scattering Elements 102 Atomic K-Shell Electron 102 Element Number Binding Energy (ke V) 10 Hydrogen 0.02 101 Carbon 0.3 LLLLL Nitrogen 0.4 100 Oxygen 0.5 10º Aluminum 13 1.6 H (cm/g) H (cm"/g) 10 Calcium 20 4.1 Molybdenum 42 19 10 Rhodium 45 23 10 lodine 33 33 10-3 102 The Photoelectric interaction with the K-Shell is proportional to the third power of atomic number (Z) 104 50 10.3 Alvarez and Mackovski (1976) 100 150 0 50 100 150 O E (keV) E (keV) Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT : Different Energy and Different SIEMENS Healthineers Material 1.0E+02 Iodine Bone 56 keV 69 keV Mean energy of 80 1.0E+01 kV spectrum small decrease Mean energy of Attenuation 1.0E+00 100 kV spectrum small decrease 1.0E-01 10 30 50 70 90 110 130 150 Energy / keV Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT : Different Energy and Different SIEMENS Healthineers Material 1.0E+02 Iodine Bone 56 keV 92 keV Mean energy of 1.0E+01 80 kV spectrum Larger decrease Mean energy of Attenuation 1.0E+00 Sn140 kV spectrum Small decrease 1.0E-01 10 30 50 70 90 110 130 150 Energy / keV Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT : Different Energy with Different SIEMENS Healthineers Material lodine Iodine Bone Bone 80kV CT-value 140kV iodine 80 kV IDENTITY fat Blood Blood 0 HU Water Water plastic bone Fat Fat CT-value -1000 HU 140 kV Ai Air 0 HU Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT : Different Energy with Different SIEMENS Healthineers .. Material 80kV 100kV 120kV 140kV iodine fat plastic bone Higher CT Value in Low kV : Iodine, Bone, Metal Higher CT Value in High kV : Fat, Uric Acid, Plastic Almost same CT Value in any kV : Water, soft tissue, blood Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT : Detector with Quanta Separation SIEMENS Healthineers number of quanta ....... ....... CsI/ ZnSe ow kV Gd2O2S high kv overlap ........ J ....... TOP LAYER BOTTOM LAYER ........ Conventional photon energy Dual Energy CT Unrestricted © Siemens Healthcare GmbH, 2017 Principle of Dual Energy CT : Detector with Quanta Separation SIEMENS Healthineers .. number of quanta Tube B ........... low kV high kV with SPS II overlap O ......... @ low kV high kV with SPS Tube A ........... DE with Selective photon energy Photon Shield Unrestricted © Siemens Healthcare GmbH, 2017 DECT Basic : Dual Energy CT vs Standard CT? SIEMENS Healthineers Single energy CT : Dual energy CT : • Morphology/ anatomical • Additional information of object information of an morphology with neutral dose object/tissue • Tissue characterization • Metal artifact reduction • Iodine quantification Unrestricted © Siemens Healthcare GmbH, 2017 Why Dual Energy ; Dual Energy CT vs Standard CT? SIEMENS Healthineers Standar CT Dual Energy CT Unrestricted © Siemens Healthcare GmbH, 2017 Why Dual Energy ; Dual Energy CT vs Standard CT? SIEMENS Healthineers Standar CT Dual Energy CT Unrestricted © Siemens Healthcare GmbH, 2017 DECT : Why dual energy ? SIEMENS Healthineers A FO_DE_Pancreas, Northwestern Memorial Northwestern Memorial / CT 4 2015R2105 Ref.: Dual Energy *1/1/1948, M. 67Y SOMATOM Force DE #PP DE_Nephro 2.0 Qr40 2 [4|5] CT VA50A # 2015R2105 8/5/2015 7:32:03.44 AM 6 IMA 78 SP F253.6 App: Mixed 0.6 Mean: 92.9 HU Stddev: 17.6 HU R 10cm F CT_SOM8 DEGV/MIX SL 2.0 DE MIX 100/Sn150 (M 0.6) 450 +C 50 Single Energy CT IGK Kusumasuganda | HC SV CS APP AA Sn 125ml Iso 370 and Oral Page 26 | Restricted © Siemens Healthcare GmbH, 2016 DECT : Why dual energy ? SIEMENS Healthineers A CT FO_DE_Pancre FO DE Pancreas, Northwest FO_DE_Pancreas, Northwestern Memorial App: Mixed 0.6/ 100/ Sn150 FO_DE_Pancreas, Nort FO_DE_Pancreas, Northwestern Mean: -103.9/ -114.2/ -88.7 HU Northwestern Memorial / CT 4 2015R2105 2015R2105 2015R2105 Stddev: 7.2/ 8.4/ 10.5 HU Ref. : Dual Energy *1/1/1948, M. 6 #1/1/1948, M. 67Y 2015R2105 2015R2105 * 1/1/1948, M. 67Y *1/1/1948, M. 67Y 1/1/1948, M, 67Y lodine Density: 0.0 mg/ml / ??? SOMATOM Force DE #PP DE_NODE #PP DE Nephro 2.0 Qr4 DE #PP DE_Nephro 2. DE #PP DE_Nephro 2.0 Qr40 2 DE #PP DE_Nephro 2.0 Qr40 2 [4|5] Fat Fraction: 101.5 % CT VA50A # 2015R2105 # 2015R2105 # 2015R2105 # 2015R2105 # 2015R2105 8/5/2015 8/5/2015 8/5/2015 8/5/2015 7:32:03.44 AM 8/5/2015 7:32:00.23 AM 7:32:00.23 AM 7:32:00.23 AM 7:32:00.23 AM 6 IMA 78 10 IMA n.a. | 11 IMA n.a. 10 IMA n.a. | 11 IMA n.a. 10 IMA n.a. | 11 IMA n.a. 6 IMA n.a. | 17 IMA n.a. 30 % SP F253.6 SP F250.5 | SP F250.5 SP F250.5 | SP F250.5 SP F250.5 | SP F250.5 SP F253.0 | SP F253.0 CT App: Mixed 0.6/ 100/ Sn150 Mean: 92.6/ 113.3/ 61 .8 HU Stddev: 15.2/ 18.7/ 17.5 HU lodine Density: 3.4 mg/ml / ??? Fat Fraction: 19.7 % R R R R R 10cm CT 1 % App: Mixed 0.6/ 100/ Sn150 Mean: -97.0/-105.5/ -84.2 HU F Stddev: 6.3/ 9.2/ 8.5 HU lodine Density: 0.0 mg/ml / ??? Fat Fraction: 100.1 % a 50.00% CT_SOM8 DEG MPR FUSION MPR FUSION SL min DE MIX 100/Sn DE VNC/CLA MPR FUSION MPR FUSION DE VNC/CLA DE MIX 100/Sn150 (M 0.6)/FAT 600 60 +C DE VNC/CLA +C +C +C +C 150 O Dual energy CT IGK Kusumasuganda | HC SV CS APP AA Page 27 | Restricted © Siemens Healthcare GmbH, 2016 SIEMENS Healthineers Dual Energy Imaging Scanning Techniques and Application Approach 28 Unrestricted © Siemens Healthcare GmbH, 2017 Dual Energy System : Single and Dual Source SIEMENS Healthineers syngo. via2) SOMATOM Force SOMATOM Definition Edge syngo.via Frontier3) Acute Care Dual Energy SOMATOM = Drive Neurology FASTCARE Cardiac CARERight SOMATOM Perspective Oncology Perfusion Pediatrics SOMATOM Definition Flash Customer Services SOMATOM Definition AS Unrestricted © Siemens Healthcare GmbH, 2017 Dual Energy Acquisition SIEMENS Healthineers Fast kV Switching DE Slow kV Switching DE Dual Layer Detector DE X-ray OFF SFOU Low kV Slow Motion High kV 140KV TOP LAYER 80KV --------- BOTTOM LAYER Time Dual Source DE Twin Beam DE Dual Spiral DE 120 kV. Au SIEMENS Split Sn Healthineers filter Al Au120 kV Sn 120 kV 1st scan 140 kV SIEMENS .A ....................................................................................................................... Healthineers SIEMENS Healthineers ... 2nd scan 80 kV Unrestricted © Siemens Healthcare GmbH, 2017 Dual Energy Scan : Fast kV Switching SIEMENS Healthineers • Tube Voltage follow pulsed curved, projection data collected twice in every projection, high and low energy. 50 cm SFOV • Higher radiation dose problem due to no mA modulation • Less spectral separation • Limited dual energy application due to slow Slow Motion 140kV - 80KV - Time acquisition Unrestricted © Siemens Healthcare GmbH, 2017 Dual Energy Scan : Slow kV Switching SIEMENS Healthineers • Tube Voltage follow pulsed curved, projection data collected twice in every projection with X-ray OFF some beam off in front of patient to reduce dose • Higher radiation dose problem due to no mA modulation Low KV Less spectral separation High kV • • Limited dual energy application due to slow acquisition Unrestricted © Siemens Healthcare GmbH, 2017 Dual Energy Scan : Dual Layer Detector SIEMENS Healthineers • Fixed voltage (120 kV or 140 kV) to provide both low and high energy spectrum, separation using specific detector for both energy level • Limited dual energy application • Radiation dose (mainly for pediatric patient) and due to High electronic noise by detector geometry • Less spectral separation Unrestricted © Siemens Healthcare GmbH, 2017 DECT : Dual spiral dual energy SIEMENS Healthineers 1 st spiral 2 nd spiral @ low kV @ high kV Low kV scan high kV scan • Better spectral separation • Limited dual energy application due to slow acquisition Unrestricted © Siemens Healthcare GmbH, 2017 DECT Basic : Twinbeam dual energy SIEMENS Healthineers • Uses a split filter (Au and Sn) in the tube 120 kV. collimator housing. Au Split Sn • Better spectral separation filter D Au120 kV Sn120 kV • Each half of the detector acquires a complete spiral data set so that DE data is obtained. • Limited dual energy application due to slow acquisition Unrestricted © Siemens Healthcare GmbH, 2017 DECT Basic : Dual source dual energy SIEMENS Healthineers • Two X-ray spectra obtained simultaneously using Two independent tubes and corresponding Selective Photon Shield detectors • Tin filter shifts mean energy of the high kV spectrum up, increasing spectral separation • Characterize, highlight and quantify material • Dose-neutral compared to a single 120 kV scan due to Tin Filter • More dual energy application provided 80 kV 140 kV Attenuation A • Attenuation B Cross X Ray scattering Dual Source Unrestricted © Siemens Healthcare GmbH, 2017 How to Analyze Dual Energy Data ? SIEMENS Healthineers material labeling three material decomposition image quality improvement generic material differentiation Unrestricted © Siemens Healthcare GmbH, 2017 Clinical Application Calculation Base ; Material Labeling SIEMENS Healthineers .. HU (80kV) Voxels above Maximum Cortical Bone 1800 HU Cortical Bone HU are excluded Iodine Voxels Iodine Voxels Unsuppressed Unsuppressed - - Blood with CM Blood with CM -- Bone Voxels Bone Voxels Trabecular BoneSuppressed Trabecular Bone Suppressed (Removed) (Removed) HU 50 HU Soft Soft (140kV) Ticque Tissue 50 HU 1200 HU Author | Department 38 Unrestricted © Siemens Healthcare GmbH, 2017 Clinical Application Calculation Base ; Material Decomposition SIEMENS Healthineers .. Generic voxel Soft tissue Low_nc High_nc [1] CT App: VNC/ CM/ Mbled 0.5/ 80/ Sm140 Mean: 59.1/ 43.1/ 102 7/ 126,3/78-5 HU Stédev: 17:2/20 0/ 21 5/35.5/25.0 HU Min: 18.0/ 8 0/ 58 0/ 45 0/ 22.0 HU Mac 07.0/ 80.0/ 100.0/ 208.0/ 134 0 HU Area: 0.3 cm2 lodine Density. 17 mg/ml / 122 % Fat Fraction Fat Author | Department 39 Unrestricted © Siemens Healthcare GmbH, 2017 Clinical Application Calculation Base ; Optimum Contrast SIEMENS Healthineers .. High densities center 100% Low kV tube V 140,80 (M 0.3) aff mÁs 71/418 of mAs 100/425 100 SPILIAL SP 94 0 R 30 % of 80 kV image kV 80 Low densities eff mAs 418 ref MAS 425 width 30% Low kV tube + HU of Soft Tissue HU of high density Tissue 70% High kV tube mean CT values / HU Author | Department 40 Unrestricted © Siemens Healthcare GmbH, 2017 Clinical Application Calculation Base (LICENSE BASED) SIEMENS Healthineers .. Material Labelling Three Material Decomposition Calculi Characterization - Liver VNC - Bone removal head and body - Virtual Unenhanced - Gout - Bone Marrow - Hard Plaque - Brain haemorrhage - Lung Vessel - Lung PBV - Image Quality Improvement Heart PBV - Optimum Contrast - Lung Nodules - Monoenergetic Plus - General Material Recognition Rho Z - Author | Department 41 Unrestricted © Siemens Healthcare GmbH, 2017 Dual Energy : Single Source Scanner SIEMENS Healthineers syngo.CT DE Gout Monoenergetic syngo.CT DE syngo.CT DE Calculi Characterization Bone Marrow* 21 syngo.CT DE (Liver VNC) syngo.CT DE syngo.CT DE Virtual Unenhanced* Brain Hemorrhage Monoenergetic Plus* *availability may vary based on region **available only on syngo.via Frontier, research only Computed Tomography 42 Courtesy Ludwig Maximillian University, Großhadern, Munich, Germany Unrestricted © Siemens Healthcare GmbH, 2017 Dual Energy : Dual Source Scanner SIEMENS Healthineers syngo.CT DE Gout Optimum Contrast syngo.CT DE syngo.CT DE Brain Hemorrhage Bone Marrow* Monoenergetic syngo.CT DE (Liver VNC) Virtual Unenhanced* 2.1 syngo.CT DE syngo DE syngo.CT DE syngo DE syngo DE syngo.CT DE Monoenergetic Plus* Xenon Heart PBV Musculoskeletal Lung Nodules Virtual Unenhanced syngo DE syngo.CT DE syngo.CT DE syngo.CT DE Hardplaque Display Direct Angio Lung Analysis Calculi Characterization *availability may vary based on region **available only on syngo.via Frontier, research only Computed Tomography 43 Courtesy Ludwig Maximillian University, Großhadern, Munich, Germany Unrestricted © Siemens Healthcare GmbH, 2017 SIEMENS Healthineers Dual Energy CT : Non contrast application Available for dual spiral dual energy, twinbeam dual energy and dual source dual energy Restricted © Siemens Healthcare GmbH, 2016 DECT : Metal artifact reduction SIEMENS Healthineers ................... AFL SPINE2 124 kEV Metal artifact reduction Anonymous 70 kEV SOMATOM Definition Flash F CT 2012B [4]3] 11/14/2013 3:28:54.26 PM Dual energy monoenergetic provide 151 different 22 IMAn.a. SP F245.5 energy level, from 40 kEV - 190 kEV that can be used to improve contrast enhancement or RF reducing metal artifact 5cm MPR DE 100 600 150 Dual Energy Monoenergetic E = 124 keV 0 Courtesy of Vancouver General Hospital, University of British Columbia, Canada IGK Kusumasuganda | HC SV CS APP AA Page 45 | Restricted © Siemens Healthcare GmbH, 2016 Characterization of kidney stones with SIEMENS Healthineers syngo.CT DE Calculi Characterization SOMATOM Definition Edge 80/140 kV Spin: -0 Tilt -90 Eff. dose: 3.9 mSv Dual Spiral Dual Energy 80 kV [HU] 40 ,20 900 Hydroxylapatite O Oxalat 800 ic acid stone Non uric acid stone 700 - 600 - . .. - 220 500 :40 400 - 300 - - - Uric Acid 200 - Uric acid stone 100- Urine 0 - -140-kV [HU]- 90 180 270 360 450 540 630 IGK Kusumasuganda | HC SV CS APP AA Courtesy of Radiologie LMU Grosshadern/Munich, Germany Page 46 | Restricted © Siemens Healthcare GmbH, 2016 Visualization of gout with SIEMENS Healthineers syngo.CT DE Gout SOMATOM Definition AS+ 80/140 kV Eff. dose: 0.13 mSv Dual Spiral Dual Energy IGK Kusumasuganda | HC SV CS APP AA Courtesy of Nan Xi Shan Hospital/Guilin, China Page 47 | Restricted © Siemens Healthcare GmbH, 2016 Evaluate bones with SIEMENS Healthineers syngo.CT DE Bone Marrow SOMATOM Definition Flash CTDIvol: 7.59 mGy 100 [} DLP: 141 mGy cm 100 [HU] Dual Source Dual Energy Segmentation and assessment of bone marrow e.g. in oncology or trauma patients -150 [HU] -150 [} IGK Kusumasuganda | HC SV CS APP AA Vancouver General Hosp. and Univ./Vancouver, Canada Page 48 | Restricted © Siemens Healthcare GmbH, 2016 SIEMENS Healthineers Dual Energy CT : Contrast application Available for twinbeam dual energy and dual source dual energy Restricted © Siemens Healthcare GmbH, 2016 SIEMENS Healthineers Characterization Portal Venous Thrombus on Patient with Hepatocellular Carcinoma Unrestricted © Siemens Healthcare GmbH, 2020 SIEMENS What is the background? Healthineers To investigate the diagnostic accuracy of dual-energy CT with iodine quantification compared to conventional enhancement measurements in distinguishing bland from neoplastic portal vein thrombosis in patients with hepatocellular carcinoma. Unrestricted © Siemens Healthcare GmbH, 2020 SIEMENS Characterization of Portal Vein Thrombus Healthineers Portal vein thrombosis is a form of venous thrombosis affecting the hepatic portal vein, which can lead to portal hypertension and a reduction in the blood supply to the liver. The distinction between bland and neoplastic portal vein thrombosis (PVT) represents a watershed for the clinical management of A patients having hepatocellular carcinoma (HCC). Neoplastic portal vein thrombus is found in 6.5%–44% of patients with hepatocellular carcinoma (HCC). It renders a patient unsuitable for aggressive treatment approaches, such as surgical resection or chemoembolization, due to the unusually high incidence of tumor recurrence [1–3]. Bland thrombus occurs A, 53-year-old man with hepatocellular B, 67-year-old man with multiple in 4.5%–26% of patients with chronic liver disease and in 42% of patients with carcinoma. Axial portal venous phase liver lesions and α-fetoprotein HCC. It can be resolved after thrombolytic and anticoagulant therapy [4, 5]. CT shows biopsy-proven neoplastic (AFP) levels greater than 33 ng/mL, thrombus (ROI, A) in left portal vein. In concerning for neoplastic thrombus. Neoplastic and bland portal vein thrombi discrimination is of great clinical CT texture analysis, mean attenuation Axial portal venous phase CT of positive pixels value was 76.93, shows thrombus (ROI, A). In CT significance for determining the therapeutic approach, predicting survival, and entropy value was 4.93, and thrombus texture analysis, mean attenuation density was 75 HU, suggesting its of positive pixels value was 42.91, assessing candidates for liver transplantation. neoplastic nature. entropy value was 3.72, and thrombus density was 40 HU, suggesting its bland nature. Author | Department 52 Unrestricted © Siemens Healthcare GmbH, 2020 Post Processing wit DE Liver VNC Workflow SIEMENS Healthineers CT Dual Energy 200 [HU 200 [HUI CT Dual Energy FOV Reset Lays et Contrast Result State Table Heart Punch Archive Pubich Removal Isolation Mask Results Results Application Profile Liver VNC Liver VNC Resolution Maximum [HU] 3071 lodine Ratio 2.24 ¢ Calculate Fat Man O [HU] O THUI ....................................................................................................................................................................................................................................................................... A 200 [HU] Norm. ROI CT Findings Navigator App: 100/ Sn140 Mean: 274.8/ 136.1 HU Contrast Enhancement: 233.9 HU Name Value Source V [4] ROI 0.39 DE CT [5] Mono 0.19 DE CT [8] ROI 0.13 DE CT [9] ROI 8.97 DE CT [10] ROI 9.73 DE [11] ROI 3.87 DE GT [12] ROI 4.20 DE CT [13] ROI 7.50 DE CT Tools L Synch Align Full Text Hide Hide Lines Reset Graphics Timepoints [13] CT App: VNC/ CM/ Mixed 0.8/ 100/ Sn 140 App: VNC/ CM/ Mixed 0.8/ 100/ Sn140 [12] CT Mean: 16.4/ 89.0/ 105.4/ 116.4/ 66.1 HU Mean: 23.5/ 6.8/ 27.6/ 27.1/ 31.4 HU Stddev: 14.1/ 14.5/ 13.9/ 17.6/ 17.6 HU Stddev: 8.6/ 15.1/ 14.9/ 18.7/9.0 HU Mn: -6.0/ 63.0/ 88.0/ 90.0/ 36.0 HU Min: 9.0/-22.0/0.0/-9.0/ 16.0 HU Max: 36.0/ 26.0/ 44.0/ 48.0/ 40.0 HU Edit Max: 40.0/ 118.0/ 134.0/ 163.0/ 98.0 HU Layout Snapshot Print Image Export Undo Redo Area: 7.6 mm2 Area: 4.2 mm2 to Finding Image lodine Density: 3.7 mg/ml / 37.2 % Fat Fraction: 22.7 % lodine Density: -0.3 mg/ml / -2.6 % Fat Fraction: 14.5 % 12:26 PM O THU Author | Department 53 Unrestricted © Siemens Healthcare GmbH, 2020 200 [HU] SIEMENS Healthineers O ............. Norm. ROI CT [13] CT .............................. App: VNC/ CM/ Mixed 0.8/ 100/ Sn140 [12] CT App: 100/ Sn140 App: VNC/ CM/ Mixed 0.8/ 100/ Sn140 Mean: 274.8/ 136.1 HU Mean: 16.4/ 89.0/ 105.4/ 115.4/ 65.1 HU Mean: 23.5/ 6.8/ 27.6/ 27.1/ 31.4 HU Contrast Enhancement. 233.9 HU Stddev: 14.1/ 14.5/ 13.9/ 17.6/ 17.6 HU Min: -5.0/ 63.0/ 88.0/ 90.0/ 36.0 HU Stddev: 8.6/ 15.1/ 14.9/ 18.7/ 9.0 HU Max: 40.0/ 118.0/ 134.0/ 153.0/ 98.0 HU Min: 9.0/ -22.0/ 0.0/ -9.0/ 16.0 HU Area: 7.5 mm2 Max: 36.0/ 26.0/ 44.0/ 48.0/ 40.0 HU lodine Density: 3.7 mg/ml / 37.2 % Area: 4.2 mm2 Fat Fraction: 22.7 % lodine Density: -0.3 mg/ml / -2.6 % Fat Fraction: 14.5 % 0 [HU] Author | Department 54 Unrestricted © Siemens Healthcare GmbH, 2020 lodine quantification lodine quantification SIEMENS 100 Healthineers .. 4.0 80 in 3.0 60 2.5 - 2.0 - OO 40 1.5 - Sensitivity 20 1.0- Optimal threshold: 0.9 mg/ml 0.5+ Sensitivity: 100% lodine concentration (mg/ml) Specificity: 95.2% O 20 40 60 80 100 0 + O 1 - Specificity Bland Thrombus Tumor Thrombus (a) (b) Figure. (a) ROC curve representing the diagnostic performance of iodine quantification in discriminating between bland and neoplastic thrombi. Iodine quantification with a thrombus iodine concentration of 0.9 mg/ml yielded an area under the curve of 0.993 (95% CI: 0.88, 1.00). (b) Interactive dot diagram showing the individual data distribution using the optimised threshold of 0.9 mg/ml. Each dot represents the iodine concentration value for each of the portal thrombi. Bland thrombi (azure dots) are displayed in the left column. Neoplastic thrombi (green dots) are arrayed in the right column. Note that all the neoplastic thrombi (n=13) showed a greater than 0.9 mg/ml iodine concentration. All (n=20) but one bland thrombi had a less than 0.9 mg/ml iodine concentration. Source: Author | Department 55 Unrestricted © Siemens Healthcare GmbH, 2020 Virtual non-contrast enhanced (VNC) images SIEMENS Healthineers SOMATOM Definition Edge CTDIvol: 10 mGy DLP: 486.3 mGy cm 200 [HU] Eff. dose: 7.3 mSv TwinBeam Dual Energy 0 [HU] A VNC VNC and iodine (fused images) IGK Kusumasuganda | HC SV CS APP AA Courtesy of University Hospital of Basel, Basel, Switzerland Page 56 | Restricted © Siemens Healthcare GmbH, 2016 SIEMENS Healthineers Dual Energy Image Improvement Monoenergetic & Optimum Contrast Author | Department 57 Unrestricted © Siemens Healthcare GmbH, 2020 Dual Energy ; Monoenergetic SIEMENS Healthineers .. 70kV 140kV 1600 Showing last 5 findings CT value [HU] Finding PI 400 - 1200 1000 800 600 - 400 200 - Energy [kev] ........... 1 BD 40 50 60 70 100 110 120 130 140 150 160 170 180 190  With Monoenergetic, a new set of images is calculated that are equivalent to images acquired with a monoenergetic X-Ray beam of selectable energy between 40 and 190KeV.  By adjusting the Energy value with the Monoenergetic slider you can optimize the contrast between different materials, it helps for example to identify different materials. Unrestricted © Siemens Healthcare GmbH, 2020 Dual Energy ; Monoenergetic SIEMENS Healthineers Monoenergetic Monoenergetic Monoenergetic Monoenergetic E E E 40 40 190 40 70 190 40 100 190 40 190 190  extrapolate also to lower/higher energies  based on decomposition into iodine and water  best noise at about 70 keV  noise increase for low and high keV Author | Department 59 Unrestricted © Siemens Healthcare GmbH, 2020 Dual Energy ; Optimum Contrast SIEMENS Healthineers Optimum Contrast Optimum Contrast is a standard tool that is currently integrated as one of the DE application classes Combines high iodine contrast of 80 kV with low noise of 140 kV into a The tool is used to blend the low and high kV datasets to single dataset achieve the best contrast-to-noise ratio in the fused CT image for General Viewing The calculation is easy: 80 kV 140 kV High densities (Bone and Contrast), 100% from Low kV set to improve Contrast! Low densities (soft tissue), come 70% from High kV set and 30% from Low kV set, to minimize Noise without losing too much contrast! Middle densities come from a linear combination of Low and High kV sets Standard Mixed Optimum Contrast Unrestricted © Siemens Healthcare GmbH, 2020 Dual Energy ; Optimum Contrast SIEMENS Healthineers .. MA 65 O IMA 65 I DUAL 24 9 IMA 65 SPI DUAL 28 SPI DUAL 26 81 0 SP 81 0 SPY4.0 D R 10cm 140 kV 80 KV MAS 71 eft mAs 418 eff mAs 418 MÁS 100 ref mAs 425 ref MAS 425 T1 0.5 4.0.5 High kV Low kV Optimum Contrast  High kV image has low contrast enhancement but low noise  Low kV image has large contrast enhancement but huge noise  Optimum Contrast take best from both images! Author | Department 61 Unrestricted © Siemens Healthcare GmbH, 2020 Dual Energy scanning enables mono energetic images SIEMENS Healthineers TwinBeam Dual Energy scan CTDIvol: 8.8 mGy DLP: 582.1 mGy cm Eff. dose: 8.7 mSv TwinBeam Dual Energy Monoenergetic image at 70 keV Monoenergetic image at 50 keV IGK Kusumasuganda | HC SV CS APP AA Courtesy of University Hospital Erlangen-Nuremberg, Erlangen, Germany Page 62 | Restricted © Siemens Healthcare GmbH, 2016 SIEMENS Healthineers Dual Energy Image Improvement Bone Removal Angiography - Author | Department 63 Unrestricted © Siemens Healthcare GmbH, 2020 Bone removal with direct angio SIEMENS Healthineers .. Automatic Bone Removal Technique in Whole-Body Dual-Energy CT Angiography: Performance and Image Quality Boris Schulz1 OBJECTIVE. The purpose of this study was to evaluate the efficiency of automatic bone Katharina Kuehling removal in dual-energy CT angiography (CTA) of the trunk. Wolfgang Kromen SUBJECTS AND METHODS. Nineteen patients underwent dual-energy CTA of the Petra Siebenhandl trunk (tube A, 140 kV; tube B, 100 kV). In addition to the dual-energy dataset, an image Matthias Josef Kerl equivalent to that of a standard 120-kV single-energy examination was generated with both Thomas Josef Vogl tubes. Automated bone segmentation was performed on both datasets, and the results were Ralf Bauer analyzed. The time required for and subjective image quality of the maximum intensity pro- jections (MIPs) generated were evaluated. Unrestricted © Siemens Healthcare GmbH, 2020 Bone Removal with Direct Angio Dual Energy SIEMENS Healthineers .. Fig. 2-56-year-old man with implanted stent graft in the descending thoracic aorta. A-C, Frontal maximum-intensity- projection CT angiograms without bone removal (A), with attenuation-based automatic bone removal (B), and spectral automatic bone removal (dual- energy mode) (C) show implanted stent-graft in thoracic aorta. Bones (arrows, B) were missed on attenuation-based image. 30- Dual energy 25- Single energy 20- 15- 10 - 5 Error Rate (%) O A B C Ribs Clavicles Sternum Pelvic Bones Fig. 1-Graph shows percentage of bones not deleted in automated bone Vertebral Body Missed >50% Completely Missed Vertebrae Vertebral Body Missed <50% subtraction during whole- body CT angiography. Unrestricted © Siemens Healthcare GmbH, 2020 Bone Removal with Direct Angio Dual Energy SIEMENS Healthineers Dual energy Single energy A B 5 4 Fig. 4-42-year-old man for preoperative assessment of pelvic arteries (heart valve replacement). A, CT image obtained with single-energy threshold-based bone removal shows false-negative complete 3- occlusion of left internal iliac artery (arrowhead). On right side of pelvis, short segmented occlusions of smaller 2 arteries are visible false segmentations (arrow). B, Dual-energy CT image obtained with spectral bone removal shows neither of the apparent pathologic 1 findings in A. Image Quality Score Fig. 3-Graph shows Aorta SMA results of subjective image quality assessment of individual arteries with Renal Artery maximum-intensity- Vertebral Arteries Carotid Arteries Subclavian Arteries Mammary Arteries projection technique. Left Hepatic Artery Right Hepatic Artery Gastroduodenal Artery Internal Iliac Arteries External lliac Arteries SMA = superior mesenteric artery. Common Femoral Arteries Unrestricted © Siemens Healthcare GmbH, 2020 Bone removal with direct angio SIEMENS Healthineers SOMATOM Def Flash CTDIvol: 6.44 mGy DLP: 1007.8 mGy cm Eff. dose: 12 mSv Dual Source Dual Energy IGK Kusumasuganda | HC SV CS APP AA Courtesy of University Hospital Erlangen-Nuremberg, Erlangen, Germany Page 67 | Restricted © Siemens Healthcare GmbH, 2016 Bone removal in complex body regions with SIEMENS Healthineers syngo.CT DE Direct Angio SOMATOM Definition Flash 100/Sn140 kV Eff. dose: 0.75 mSv Dual Source Dual Energy IGK Kusumasuganda | HC SV CS APP AA Courtesy of Academisch Ziekenhuis/Maastricht, Netherlands Page 68 | Restricted © Siemens Healthcare GmbH, 2016 SIEMENS Healthineers Dual Energy Information Improvement Brain Hemorrhage - Author | Department 69 Unrestricted © Siemens Healthcare GmbH, 2020 Dual Energy ; Brain Hemorrhage SIEMENS Healthineers Axial images (mixed - UL, fused - LL, iodine - LR) at two different levels (Figs. 1a and 1b) show hyperdensities in the left basal ganglia, the thalamus, the insula and the lateral sulcus, slightly compressing the left lateral ventricle. In the VNC (UR, Figs. la and 1b) images, the hyperdense area was only seen in the left insula (Fig. 1a, arrow), suggesting a small hemorrhage with significant iodine extravasation. (UL - upper left; UR - upper right; LL - lower left; LR - lower right) IGK Kusumasuganda | HC SV CS APP AA Page 70 | Restricted © Siemens Healthcare GmbH, 2016 Differentiate between hemorrhage and iodine with SIEMENS Healthineers syngo.CT DE Brain Hemorrhage SOMATOM Definition Flash CTDIvol: 36.43 mGy DLP: 615 mGy cm Eff. dose: 1.29 mSv Dual Source Dual Energy IGK Kusumasuganda | HC SV CS APP AA Courtesy of Starship Children Hospital/Auckland, New Zealand Page 71 | Restricted © Siemens Healthcare GmbH, 2016 Distinguish between plaques and iodine with SIEMENS Healthineers syngo.CT DE Hardplaque Display SOMATOM Definition Flash CTDIvol: 8.24 mGy DLP: 331 mGy cm Eff. dose: 1.03 mSv Dual Source Dual Energy IGK Kusumasuganda | HC SV CS APP AA Courtesy of Centre Cardio-Thoracique de Monaco/Monaco Page 72 | Restricted © Siemens Healthcare GmbH, 2016 SIEMENS Healthineers Characterization of Pulmonary Emboly - Author | Department 73 Unrestricted © Siemens Healthcare GmbH, 2020 SIEMENS What is the background? Healthineers To investigate and distinguish the presence or absence of PE and the occlusive or non occlusive PE using iodine quantification based on material decomposition evaluation. Unrestricted © Siemens Healthcare GmbH, 2020 Imaging of Pulmonary Emboly using Dual Energy SIEMENS Healthineers Mixed DE Contrast Image Iodine Map Image of DE Contrast Image Author | Department 75 Unrestricted © Siemens Healthcare GmbH, 2020 Imaging of Pulmonary Emboly using Dual Energy SIEMENS Healthineers .. Mixed DE Contrast Image Iodine Map Image of DE Contrast Image Author | Department 76 Unrestricted © Siemens Healthcare GmbH, 2020 Evaluation of Iodine Map SIEMENS Healthineers Normal Lung Non Occlusive Occlusive Parenchyma Parenchyma Defect Parenchyma Defect Iodine uptake 1.89 mg/ml Iodine uptake 0.83 mg/ml Iodine uptake 0.27 mg/ml Author | Department 77 Unrestricted © Siemens Healthcare GmbH, 2020 Evaluation of perfusion defects with SIEMENS Healthineers syngo.CT DE Lung Analysis SOMATOM Definition Flash CTDIvol: 8.71 mGy DLP: 262 mGy cm Eff. dose 3.67 mSv Dual Source Dual Energy IGK Kusumasuganda | HC SV CS APP AA Courtesy of Hospital do Coracao/Sao Paulo, Brazil Page 78 | Restricted © Siemens Healthcare GmbH, 2016 Dual Energy visualization of iodine uptake in the SIEMENS Healthineers myocardium – syngo.CT DE Heart PBV Determine the extent of myocardial injury due to ischemia Detect subtle perfusion defects in the myocardium RFP Quantify the iodine uptake in mg/mL Applicable to both first pass and late enhancement scanning IGK Kusumasuganda | HC SV CS APP AA Courtesy of Johann Wolfgang Goethe Universität Frankfurt, Germany Page 79 | Restricted © Siemens Healthcare GmbH, 2016 SIEMENS Healthineers Nur Dwi Prasetyo CT Application Specialist HC APC ASN INA SV-CS EX Arkadia Office Park Tower F 18th Floor Jakarta Selatan P +62 (21) 27543100 F +62 (21) 27543101 M +62 8118 755 766 E nur.prasetyo@siemens-healthineers.com Unrestricted © Siemens Healthcare GmbH, 2017