Innovative Trends in Clinical CT

Thank you very much dear for the kind reduction. Ladies and gentlemen. Also like to really think a Siemens and Andre Harding in particular. And Thomas floor for. Inviting me and my group to this wonderful meeting and also giving the having the pleasure of a long term relationship and collaboration. Now for me as a clinical radiologist, it's really breathtaking to see that all this technically innovations that Thomas floor just eluded to really moved into new areas of patient diagnosis and actually having access to new patients that we did not really see in daily clinical routine. And this is basically particularly the patients with multimorbidity elderly patients. But now we be benefit from the low contrast dose. It's the cancer patients that really now benefit from the targeted therapies and the diagnosis done by City, particularly functional city. It's a low radiation dose for all of us and I think one of the most important things is really for our children. It's really the field of pediatric image Ng Incitti, which for me was unthinkable like five years ago and I think that's something that's really impressive. So if we go over the low contrast and Thomas of course showed. A lot of these things, it's really the speed of table. That's one of the number one innovations we know that the standards, even high-end city scanner, takes quite a time to actually scan a large field while contrast has to flow. And so basically this by nature increases dramatically the amount of contrast volume. Now if see, the scan is still not over yet, I go to a high end scanner as we see today it's a single second web in Sky scan the entire volume and the contrast dose by that already goes down. By a factor of 4. Basically, the second innovation clearly is the imaging close to the catch by 70 KV settings. And with this we even can split the dose by half and this for example is a 20CC contrast media dose, and for us this is amazing becausw many of you know I have a long term research background in MRI and this used to be the doses we do forget illenium contrast enhanced MRI angiography and now we here with see T. So this is really like a quantum leap with witnesses. Justin Biden five years and the last thing is again something for people from their Mario communities of high appeal, how Siti actually moved away from just. Routine technology into really a diverse field of active hardware and software development. It's a multi frequency split approach where we include the best of two worlds from dual energy, meaning the optimal noise from the standard cavey data set and the optimal contrast from the locate the data set. And as we all known from virtual monoenergetic simulations that at lower cavey settings contrast is increased. We can combine those two approaches and you see this in on the right side of the images. Combining the those two benefits together and you see the multiple frequency split approach has even doubled the contrast from the virtual monoenergetic images, and you see how high the contrast in that carotid artery is compared to the environment. So these are three major innovations that really have flawed. Started to go into very low doses with very high contrast. Now, low radiation those is a success story by itself, and I think we've seen that particularly for vascular imaging. The 70KV settings with fast table speed have really brought see T coronary CTS. Thomas just showed to a one or two millisievert or even below one millisievert imaging, and I think for all of us this was amazing when all of a sudden we saw individuals in the age of the 30 to 40 having .17 millisieverts setting. For a single shot CTA of the coronary arteries and now we basically really image in a totally different settings together with our friends from cardiology to really find the patients if they are at risk at younger age. And I think that by itself is clinical and innovation again. What appeals to me again though being compareable since to MRI community is the move into functional imaging based on those lower radiation dose. This is work for Matthias Mayer who showed that the retrospectively is Ichi gated CTA which had some shadow of doubt you to the higher doses with a 70K via settings actually could be reduced in those by more than half and now you all of a sudden can combine morphology and function like for example in this. Patient persistent atrial septal defect but you nicely see the contrast flow and you also have 100% robustness for in the coronary city. Angiograms with this retrospective image Ng. Also, the much higher focal spot, for example for in a year, imaging reduced those dramatically by eliminating the need for comb filter and having much lower dose in this respect. In this case it was 67% reduction dose for inner imaging, which I think is also very important clinical field. And one thing that I again find appealing becausw again, it's a different way from looking just at images to looking at disease. Is the spectral filtration with that in filter, eliminating the unnecessary radiation of low cavey components in the beam and basically just having those high KB settings for the lungs and by that actually we basically controlled use the those of a see T chest. To the dose of an X Ray. And with this actually we started now to do dynamic like biphasic imaging of the chest routinely to look at air trapping. And this is an example from the technology that Thomas showed where basically multiple parameters are automatically extracted from the lungs and those city parameters now can be correlated to bodyblade is Mogra Fi in inspiration and expiration. And then actually be move nowadays to a feature radiomics approach where we see a correlation map of inspiration and expiration, quantitative city parameters and body plate is mograph fee parameters and if we subtract those we see those parameters have the highest predictive value. For example, for functional air trapping. So for the radiologist in the room, this might be the images of the future which we are reading. It's still information. It's better information. It's more clinical information and the technology behind it is much more complex, so it's all of our unique competencies that we bring together to a higher level of clinical reading. And this is something of those clearly driven by technical innovations as well, such as the radiation reduction. The third part, and this directly mounts into this field, is functional imaging. Again, we have the dual energy approach and the 40 image Ng and I find it again appealing to have now a technology at hand for treatment monitoring, which was unthinkable in the parents of actually doing multiple Siti datasets on an individual 11 after the other. And you see how helpful this is, for example in this neuroendocrine tumor of the pancreas, where you see the earlier terial hansmann here of the mass lesion and immediately the blood flow Maps are automatically. Calculated showing the hypervascular tumor. And from Corporation with peaking utility on Medical Center, we could show that averaging the material faces and the Venus phases overtime provides you much better contrast in HC CU. Everyone sees the hypervascular lesion in that HTC much better on the upper images, which are the averages. Image averaged images over time compared to the individual phase. So this is really something that improves detection. And at the same time we have more information, but intriguingly less those. And so this is data from big data analysis. If you wish to say that dynamic volume perfusion cities were looked at and each organ doses were calculated and all the datasets over over large cohort have in combination a lower radiation dose than the standard triphasic CT. And this is adapted amount around the world. This is work from Hotmail, Accardi from the University of Zurich for example, they could show. That the hepatic arterial perfusion index and the portal venous liver perfusion are actually predictors of treatment benefit of a transitory key mobilization, and this is extremely valuable. How functions ET Now moves into a predictor of treatment response. Same is true from what Thomas just eluded to from the dual energy city. This is again the work from the multicenter case study, and you see that the iodine related attenuation and this is in the lower graph has the best separation. For treatment response versus progression much better than the known criteria that we were using now in the clinical routine so far. So this is the way we need to look at this in the future. Interventional radiology is more and more and in very important part we the radiologists have to move much stronger into treatment of our patients and I think city plays a very important role in this field. This, for example, is that I'm result profusion of a new small renal cell cancer. This was treated by thermal ablation, which has extremely good results, and the good thing is immediately after we can do monitoring of the treatment success and again, this is only feasible due to the low radiation, the high contrast, and the combination of very low contrast media that we can check this patient twice or three times, so it's some. Summary effect of many. Beneficial things that allows us to use this for treatment monitoring and at the same time see T and interventional angiography move together. This is the time result 4D CT of an HTC and we can take each individual time frame and fuses with into interventional angiography. You see how perfect that fit is and use it then in individual angiography use the blood volume Maps from the interventional suite from the seagull. A technology to really see whether tumor is and then also immediately measure to the effective treatment by taste. This is also, for example the case in other areas like reconstructive surgery, where time the soft imaging shows the deep inferior Eva gastric artery for the huge flap operations. But the most important thing is cities of this high contrast and high resolution allow a reverse bedside to bench approach, basically transforming our information back into the preclinical arena for research. And this is on a summer term force a 4D scan in a mouse, showing that small vascular loop in reconstruction service, active surgery and the time resolved imaging on CTA. For the first time and you see actually, this is not that the Recon didn't work. You see that that small shunt actually got a clue. Did you see? Still the chamber you still feeling of the training vein, but after that it's actually strong both, so that's what we can see. And that was a shunt placement failure. So this is a reverse bedside to bench approach possible on a thing, single city system. And I think this is a wonderful platform to really pivot research in this field. And finally. But I already mentioned pathetic population. Our pediatric chair is excited that we now have this possibility to redo ultra low dose imaging in small infants. We are for example a huge Center for congenital diaphragmatic hernia where a lot of the abdominal components are pressed into the chest. And this is for example a almost whole body scan of young infant at .3 Millisievert. So this is something really. Due to the 70 KV approach. Sometimes 70KV in small pediatric populations might not be optimal, and there's better ways, and this is a comparison with 100KV-10 filter and shown here that the 100K V tin filter even gives much lower doses in pulmonary image Ng. You see it here, how small. Actually the standard deviation is. It's consistently at the level of an X Ray. So basically there's almost no need anymore for doing an X Ray in this sick pediatric patients, and I think this is really impressive and changed our clinical management. Also, it obviated the need for sedation. This is a head to head comparison of the same patient who got a chest CT outside. This is on the left side you see some respiratory motion effect, but that's the one under full anesthesia and with eight times the dose then the image on the right. The image on the right is a single shot city. With high table speed and you see that this has only 1/8 of the dose but no respiratory motion, and there was no sedation due to the ultimate speed of the scanning process. And finally, bringing this back to functional image Ng C TI in this basically scaling open the arena for our vascular malformation center pediatric vascular malformation center because it's very robust in our intervention lists. Love it. You see that I'm results can hear of a huge of Tyra venous malformation of the finger and this is the assumed that you were at the third index. You'll see this. Small AVM that is now just being occluded by and including agent called Onyx to basically obliterate that nidus. So this is how city again moves from chest being an imaging study to being a treatment study. And of course this is something we will have to look into further in our workflow assessment in the future. So in summary, I think when I saw the field very much developing with a nude scanner technologies, I really have to see have to say that we scene totally new patients coming in to see T number one number two we see more interventional procedures done in radiology based on see T information. And #3 as Thomas already mentioned, we and Andre, we see that basically City is a perfect role model for a radiomics approach using quantitative information and scaling this to clinical and molecular data and becoming more informative on a higher level. Thank you very much.

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