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Everything you need to know about Computed Tomography (CT) & CT Scanning

October 2018 Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ October 2018

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3D and Workflow

    • "Kawasaki’s disease (KD) is a vasculitis that predominantly affects children and can lead to the development of coronary artery aneurysms. These aneurysms can subsequently thrombose and occlude, which may lead to chest pain and other signs and symptoms of acute coronary syndrome in young patients. Coronary CT angiography, including 3D visualization techniques, is a common modality used in the follow-up of KD patients."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "The most important potential complication of KD is in- flammatory damage to the coronary arteries, which classically leads to the formation of coronary artery aneurysms. These aneurysms will often undergo vascular remodeling and partial
      thrombosis in order to produce a psuedonormal vascular lumen. However, progressive thrombosis and other stenotic processes such as fibrosis can, over time, precipitate cardiac ischemia that can lead to emergency room presentations for chest pain or other signs of acute coronary syndrome and necessitate invasive and/or surgical interventions."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • " While the advantages of this new technique are still under investigation, potential applications include improved visualization of complex anatomic structures that obviates the need for expensive 3D printing, better display of soft tissue texture that may improve detection and characterization of subtle lesions, improved pre-operative planning, and better trainee and patient engagement."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "As with other 3D visualization methods, CR would be expected to provide a global overview of the disease process that is not easily appreciated on 2D axial or multi-planar reformatted images. In particular, this may help to identify relatively distal, small caliber sites of aneurysmal enlargement, which stand out with high contrast on the 3D images but can be subtle when only 2D images are viewed."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "Given the anatomic complexity of the mediastinum with many adjacent vascular structures, it may be that CR has intrinsic advantages relative to other 3D methods in being able to accurately display the relative positions of those structures in a manner that may be more intuitively grasped in comparison to less photorealistic depictions. At the same time, the shadowing effects produced by CR can potentially obscure important sites of pathology, so a careful inspection of CR visualizations from multiple viewing angles and with multiple different window settings is necessary."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "Acute aortic injuries are not common in the setting of severe blunt trauma, but lead to significant morbidity and mortality. High- quality MDCT with 2D MPRs and 3D rendering are essential to identify aortic trauma and distinguish anatomic variants and other forms of aortic pathology from an acute injury. Misinterpretation of mimics of acute aortic injury can lead to unnecessary arteriography and thoracic surgery. Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering."
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "However, not all abnormalities of the aorta indicate an acute process, and multiple pitfalls that can mimic acute aortic injury have been described. Among these is the ductus diverticulum—a remnant of the ductus arteriosus that arises from the lesser curvature of the aortic arch, which can be mistaken for a traumatic aortic pseudoaneurysm, dissection, or incomplete rupture. The distal aortic arch, and in particular the undersurface, is the most common location for acute traumatic aortic injury. "
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "Cinematic rendering produces volume rendered images with photorealistic image quality. It uses a global illumination model, which takes direct and indirect illumination into account when constructing an image, to achieve rendering quality. The mathematical models that describe this visualization technology include complex integral equations that are solved numerically using the Monte Carlo integration. The result of the integration is a numerical rendering algorithm known as path tracing: thousands of light rays are traced to compute the resulting image."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "To achieve photorealistic quality an "environment map" or "light map" must be used as this light source provides realistic effects achieved by real world light scenarios. The light map consists of texture maps containing information on the brightness of surfaces in a virtual scene that allow the reproduction of the light environment in which the map was generated."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "The light model off of which cinematic rendering and classic volume rendering are based when reconstructing the images accounts for the difference between the two technologies. The primary reason why classic volume rendering results in images that are relatively less photorealistic is the use of the local lighting model – only local properties, such as the local gradient, influence the resulting image. Inversely, cinematic rendering assumes the global illumination model, which accounts for the impact that all light rays have on image reproduction."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "Additionally, cinematic rendering and classic volume rendering differ in their respective light sources. The light sources in classical volume rendering are either single unidirectional light sources or multiple light sources. Although cinematic rendering could use the same light sources as those of classic volume rendering, it also uses environment maps to produce the best visual results. Moreover, classic volume rendering assumes that light passing through the transparent participating medium is absorbed. This assumption leads to less realistic images because in reality light particles are scattered in such a medium. Thus, to achieve photorealism, classic volume rendering would have to account for scattering effects."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "In cinematic rendering, the most important parameter available to manipulate the resulting image is the transfer function. A parameter that was already available in classic volume rendering, the transfer function assigns a color and an opacity property to each voxel value. The opacity can be zero, one or any number between zero and one. If the opacity is zero, then the voxel value represents a vacuum that does not influence rendering computation. If the opacity is equal to one, then the voxel value represents a region that is fully opaque."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "The limitations related to cinematic rendering’s photorealistic quality also must be acknowledged. While photorealism improves the image quality and allows for a better perception of structures, it is possible to have scenarios when too much photorealism is bad. For example, if some tissue parts are obstructed from the light source, the tissue becomes darker, which can be very realistic but it can omit information about the vasculature."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • Cinematic Rendering: Future Directions
      ● Implement algorithm on faster hardware or GPU’s
      ● Optimization of lighting models may be possible with AI to select best parameters
      ● Integration into Radiology work flow
Cardiac

    • Coronary Artery to Pulmonary Artery Fistulae Involving both the LAD and RCA
      ● cinematic rendering makes use of a more complex lighting model that creates photorealistic images with improved detail and that demonstrate shadowing effects that allow for robust visualization of the relative positions of structures
    • "Cinematic rendering (CR) a new method of 3D computed tomography (CT) volumetric visualization that produces photorealistic images. As with traditional 3D visualization methods, CR may prove to be of value in providing important information when evaluating regions of complex anatomy such as the heart."
      Cinematic rendering of cardiac CT volumetric data: Principles and initial observations
      Rowe SP, Johnson PT, Fishman EK
      J Cardiovasc Comput Tomogr. 2018 Jan - Feb;12(1):56-59.
    • "Appropriate selection of window presets using either a ramp (for tissues differing markedly in attenuation such as bone in comparison to adjacent soft tissue) or trapezoid method (for differentiation of similar attenuation structures such as adjacent soft tissues) and slab thickness will allow for appropriate display of pathology and will ensure that a finding of interest is not obscured by an overlying structure."
      Cinematic rendering of cardiac CT volumetric data: Principles and initial observations
      Rowe SP, Johnson PT, Fishman EK
      J Cardiovasc Comput Tomogr. 2018 Jan - Feb;12(1):56-59.
    • "While the shadowing effects that arise from the global lighting model that is used contribute to the photorealistic quality of the images, shadowing can also potentially obscure important pathology."
      Cinematic rendering of cardiac CT volumetric data: Principles and initial observations
      Rowe SP, Johnson PT, Fishman EK
      J Cardiovasc Comput Tomogr. 2018 Jan - Feb;12(1):56-59.
    • "Acute aortic injuries are not common in the setting of severe blunt trauma, but lead to significant morbidity and mortality. High- quality MDCT with 2D MPRs and 3D rendering are essential to identify aortic trauma and distinguish anatomic variants and other forms of aortic pathology from an acute injury. Misinterpretation of mimics of acute aortic injury can lead to unnecessary arteriography and thoracic surgery. Since most traumatic injuries occur in the distal arch, radiologists must be cognizant of the range of appearances of variants related to the ductus diverticulum. Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering."
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "However, not all abnormalities of the aorta indicate an acute process, and multiple pitfalls that can mimic acute aortic injury have been described. Among these is the ductus diverticulum—a remnant of the ductus arteriosus that arises from the lesser curvature of the aortic arch, which can be mistaken for a traumatic aortic pseudoaneurysm, dissection, or incomplete rupture. The distal aortic arch, and in particular the undersurface, is the most common location for acute traumatic aortic injury.
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • " CR differs from traditional VR in making use of a global lighting model that more realistically takes into account the interactions of propagating photons with the component materials of the imaged volume. As a result, this method enhances surface detail and creates lifelike shadowing effects in order to generate truly photorealistic visualizations from standard CT acquisition volumetric data. "
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • In this case series, we have demonstrated the ability of CR visualizations to effectively convey key anatomic information related to coronary artery aneurysms in patients with history of KD. While the role of imaging in following patients with KD has been previously investigated, this is the first reported experience with the novel CR visualization methodology, and these examples demonstrate the potential of this technique for evaluating such complex vascular pathologic states.
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "Kawasaki’s disease (KD) is a vasculitis that predominantly affects children and can lead to the development of coronary artery aneurysms. These aneurysms can subsequently thrombose and occlude, which may lead to chest pain and other signs and symptoms of acute coronary syndrome in young patients. Coronary CT angiography, including 3D visualization techniques, is a common modality used in the follow-up of KD patients."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "The most important potential complication of KD is in- flammatory damage to the coronary arteries, which classically leads to the formation of coronary artery aneurysms. These aneurysms will often undergo vascular remodeling and partial
      thrombosis in order to produce a psuedonormal vascular lumen. However, progressive thrombosis and other stenotic processes such as fibrosis can, over time, precipitate cardiac ischemia that can lead to emergency room presentations for chest pain or other signs of acute coronary syndrome and necessitate invasive and/or surgical interventions."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • " While the advantages of this new technique are still under investigation, potential applications include improved visualization of complex anatomic structures that obviates the need for expensive 3D printing, better display of soft tissue texture that may improve detection and characterization of subtle lesions, improved pre-operative planning, and better trainee and patient engagement."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "As with other 3D visualization methods, CR would be expected to provide a global overview of the disease process that is not easily appreciated on 2D axial or multi-planar reformatted images. In particular, this may help to identify relatively distal, small caliber sites of aneurysmal enlargement, which stand out with high contrast on the 3D images but can be subtle when only 2D images are viewed."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "Given the anatomic complexity of the mediastinum with many adjacent vascular structures, it may be that CR has intrinsic advantages relative to other 3D methods in being able to accurately display the relative positions of those structures in a manner that may be more intuitively grasped in comparison to less photorealistic depictions. At the same time, the shadowing effects produced by CR can potentially obscure important sites of pathology, so a careful inspection of CR visualizations from multiple viewing angles and with multiple different window settings is necessary."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
Deep Learning

    • "Artificial neural networks are inspired by the ability of brains to learn complicated patterns in data by changing the strengths of synaptic connections between neurons. Deep learning uses deep networks with many intermediate layers of artificial "neurons" between the input and the output, and, like the visual cortex, these artificial neurons learn a hierarchy of progressively more complex feature detectors. By learning feature detectors that are optimized for classification, deep learning can substantially outperform systems that rely on features supplied by domain experts or that are designed by hand."
      Deep Learning—A Technology With the Potential to Transform Health Care
      Geoffrey Hinton
      published online August 30, 2018]. JAMA. doi:10.1001/jama .2018.11100
    • "Understandably, clinicians, scientists, patients, and regulators would all prefer to have a simple explanation for how a neural net arrives at its classification of a particular case. In the example of predicting whether a patient has a disease, they would like to know what hidden factors the network is using. However, when a deep neural network is trained to make predictions on a big data set, it typically uses its layers of learned, nonlinear features to model a huge number of complicated but weak regularities in the data. It is generally infeasible to interpret these features because their meaning depends on complex interactions with uninterpreted features in other layers."
      Deep Learning—A Technology With the Potential to Transform Health Care
      Geoffrey Hinton
      published online August 30, 2018]. JAMA. doi:10.1001/jama .2018.11100
    • As data sets get bigger and computers become more powerful, the results achieved by deep learning will get better, even with no improvement in the basic learning techniques, although these techniques are being improved. The neural networks in the human brain learn from fewer data and develop a deeper, more abstract understanding of the world. In contrast to machine-learning algorithms that rely on provision of large amounts of labeled data, human cognition can find structure in unlabeled data, a process commonly termed unsupervised learning.
      Deep Learning—A Technology With the Potential to Transform Health Care
      Geoffrey Hinton
      published online August 30, 2018]. JAMA. doi:10.1001/jama .2018.11100
    • "The creation of a smorgasbord of complex feature detectors based on unlabeled data appears to set the stage for humans to learn a classifier from only a small amount of labeled data. How the brain does this is still a mystery, but will not remain so. As new unsupervised learning algorithms are discovered, the data efficiency of deep learning will be greatly augmented in the years ahead, and its potential applications in health care and other fields will increase rapidly."
      Deep Learning—A Technology With the Potential to Transform Health Care
      Geoffrey Hinton
      published online August 30, 2018]. JAMA. doi:10.1001/jama .2018.11100
    • "In 1976, Maxmen predicted that artificial intelligence (AI) in the 21st century would usher in "the post-physician era," with health care provided by paramedics and computers. Today, the mass extinction of physicians remains unlikely. However, as outlined by Hinton2 in a related Viewpoint, the emergence of a radically different approach to AI, called deep learning, has the potential to effect major changes in clinical medicine and health care delivery."
      On the prospects for a (deep) learning health care system
      NaylorCD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
    • "Deep learning had intuitive appeal for health- related applications, given its demonstrable strengths in intricate pattern recognition and predictive model building from big high-dimensional data sets. These analytic capabilities have already proven useful for basic and applied researchers, ranging across health disciplines. Thus far, clinical application of deep learning has been most rapid in image-intensive fields such as radiology, radiotherapy, pathology, ophthalmology, dermatology, and image-guided surgery."
      On the prospects for a (deep) learning health care system
      Naylor CD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
    • "In many cases, interpretation of images by deep learning systems has outperformed that by individual clinicians when measured against a consensus of expert readers or gold standards such as pathologic findings. Clinically relevant applications have widened beyond image processing to include risk stratification for a broad range of patient populations (eBox in the Supplement), and health care organizations are capitalizing on deep learning and other machine-learning tools to improve logistics, quality management, and financial oversight. "
      On the prospects for a (deep) learning health care system
      Naylor CD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
    • "Digital imaging in all its forms is becoming more powerful and more integral to medicine and health care. Unlike deep learning, expert human interpretation fails to capitalize on all the patterns, or "regularities," that can be extracted from very large data sets and used for interpretation of still and moving images. Deep learning and related machine- learning methods can also learn from massively greater numbers of images than any human expert, continue learning and adapting over time, mitigate interobserver variability, and facilitate better decision making and more effective image-guided therapy."
      On the prospects for a (deep) learning health care system
      Naylor CD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
    • Deep learning shows promise for streamlining routine work by health care professionals and empowering patients, thereby promoting a safer, more humane, and participatory paradigm for health care. Different sources offer varying estimates of the amount of time wasted by health care professionals on tasks amenable to some automation (eg, high-quality image screening) that could then be rededicated to more or better care. A growing number of research studies also suggest specific possibilities for reduction in errors and improved work flow in the clinical setting with appropriate deployment of AI.
      On the prospects for a (deep) learning health care system
      Naylor CD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
    • Deep learning has enormous capacity to inform the process of discovery in health research and to facilitate hypothesis generation by identifying novel associations. Established and start-up companies are using deep learning to select or design novel molecules for testing as pharmaceuticals or biologics, with in silico exploration preceding in vitro examination and in vivo experimentation. Researchers across disciplines have also found unexpected clusters within data sets by comparing the intensity of activation of feature detectors in the hidden layers of deep neural nets. As always, however, basic and clinical experimentation remains essential to establish causation and causal pathways.
      On the prospects for a (deep) learning health care system
      Naylor CD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
    • "In the longer term, deep learning can relate those personalized features to the clinical course of similar patients, using data from millions of patient records containing billions of medical events. Thus, while concerns are understandably raised that automation could de- humanize clinical care, these advances could provide professionals and patients alike with vastly better and more specific information, and, as Fogel and Kvedar argue, give physicians more time "to focus on the tasks that are uniquely human: building relationships, exercising empathy, and using human judgment to guide and advise."
      On the prospects for a (deep) learning health care system
      Naylor CD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
    • Deep learning is diffusing rapidly through a combination of open- source and proprietary programs. Technology giants are making massive investments in the development of software libraries for deep learning, some of which are open sourced. These huge enterprises, as well as start-ups, are applying deep learning tools to health care all over the world. Moreover, many academic and nonprofit teams are publishing and sharing algorithms freely, and local development is now widespread.
      On the prospects for a (deep) learning health care system
      Naylor CD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
    • However, unlike a standardized diagnostic test or drug, the performance of deep learning and other machine-learning methods improves with exposure to larger or more relevant data sets, or with easily made modifications to the architecture of the models or training procedures. Regulators and technology assessors will need to distinguish issues inherent in decision-support algorithms from those attributable to misuse by clinical decision makers. Procurement agencies and health care administrators will need to be uncharacteristically nimble to keep up..
      On the prospects for a (deep) learning health care system
      Naylor CD
      [published online August 30, 2018]. JAMA. doi:10.1001/jama.2018.11103
Gallbladder

    • "Biliary complications are more common after laparoscopic than after open cholecystectomy and include bile duct damage, biliary obstruction, and dropped stones."
      Laparoscopic Cholecystectomy: Postoperative Imaging
      Thurley PD, Dhingsa R
      AJR 2008; 191:794–801
    • "The reported rate of bile duct injury after laparoscopic cholecystectomy varies among
      different series; however, a review of 5,913 cases over a 5­year period showed a 0.6% overall rate of bile duct injury, with the rate for individual surgeons ranging from 0.4% to 4%."
      Laparoscopic Cholecystectomy: Postoperative Imaging
      Thurley PD, Dhingsa R
      AJR 2008; 191:794–801
    • "Causes of biliary obstruction include retained gallstones, misplaced surgical clips, fibrosis secondary to inflammation from adjacent clips, and thermal injury from cautery devices. Although typically obstruction at the level of the common bile duct produces intrahepatic duct dilatation in both lobes, dilatation in a single lobe, most commonly the left ,may also occur."
      Laparoscopic Cholecystectomy: Postoperative Imaging
      Thurley PD, Dhingsa R
      AJR 2008; 191:794–801
    • "Spillage of gallstones occurs commonly during laparoscopic cholecystectomy, with a reported incidence of 0.1–20%. Fortunately, most of these stones do not cause symptoms, although if spillage does oc­cur every effort should be made to retrieve the stones in view of the small risk of devel­oping important complications. The most common complication reported in the literature is abscess, either in the abdominal wall or in the peritoneum."
      Laparoscopic Cholecystectomy: Postoperative Imaging
      Thurley PD, Dhingsa R
      AJR 2008; 191:794–801
    • "Vascular injuries during laparoscopic cholecystectomy most commonly occur in the surgical bed or the abdominal wall and are related to trocar insertion. A review of 14,243 laparoscopic procedures showed an overall hemorrhage rate of 4.1%, with bleeding rates of 2.3% intraoperatively and 1.8% postoperatively, although the reported incidence varies among series".
      Laparoscopic Cholecystectomy: Postoperative Imaging
      Thurley PD, Dhingsa R
      AJR 2008; 191:794–801
    • "Laparoscopic cholecystectomy has an overall complication rate of approximately 3%. Because of the large numbers of laparoscopic cholecystectomies being per­ formed, it is not rare for patients to be referred for imaging investigations postoperatively. In view of this, it is essential that radiologists and surgeons are aware of potential comp­lications that may arise and their imaging appearances. Of equal importance is the recognition of normal findings after laparo­scopic cholecystectomy to avoid misinter­pretation."
      Laparoscopic Cholecystectomy: Postoperative Imaging
      Thurley PD, Dhingsa R
      AJR 2008; 191:794–801
Liver

    • "Primary hepatic lymphoma (PHL) is a rare primary liver tumor. Due to its clinical and radiological resemblance to liver metastases of adenocarcinoma, PHL is frequently diagnosed intra- or post-operatively. Since chemotherapy is the treatment of first choice for lymphoma, adjuvant chemotherapy should be given to patients for optimal treatment. The existing literature on PHL reveals the difficulties involved in diagnosis and treatment."
      Primary lymphoma of the liver - A complex diagnosis
      Steller EJA et al.
      World J Radiol. 2012 Feb 28; 4(2): 53–57.
    • "Primary hepatic NHL is very rare, only 0.016% of all NHL. Of all primary extranodal NHL only 0.4% arise in the liver. 1.1% of all primary hepatic tumors in 30 years in the Johns Hopkins tumor registry consisted of PHL. The incidence of hepatic involvement in NHL is described between 16% and 22%, stressing the importance of careful investigation to disseminated disease outside of the liver."
      Primary lymphoma of the liver - A complex diagnosis
      Steller EJA et al.
      World J Radiol. 2012 Feb 28; 4(2): 53–57.
    • "At initial presentation a third of patients present with a solitary liver nodule while another third have multiple lesions, and the remaining cases have diffuse infiltration of the liver."
      Primary lymphoma of the liver - A complex diagnosis
      Steller EJA et al.
      World J Radiol. 2012 Feb 28; 4(2): 53–57.
    • "On tri-phasic liver CT scan PHL usually presents itself as a hypodense lesion, with possible areas of inhomogeneity. Occasionally local areas of rim enhancement or calcifications may be seen."
      Primary lymphoma of the liver - A complex diagnosis
      Steller EJA et al.
      World J Radiol. 2012 Feb 28; 4(2): 53–57.
    • "Liver involvement by secondary Non Hodgkin’s lymphoma is relatively common. Primary liver lymphoma (PLL) is extremely rare. Among all extra nodal lymphomas, PLL constitutes <1% of all cases."
      PRIMARY LIVER LYMPHOMA
      S. Khalid et al.
      JBR–BTR, 2013, 96: 84-86.
    • "Four of eighteen patients presented with a single focal lesion. Thirteen of eighteen patients presented with multiple well defined focal lesions. One patient presented with a diffuse hepatic involvement. On triphasic CT, three patients showed gradual progressive contrast enhancement. Lesions remained isodense to the liver on the arterial phase with mild enhancement in the portal phase and showed washout on the delayed phase in two patients. The remaining thirteen patients showed multiple hypodense non-enhancing lesions."
      Multidetector CT (MDCT) Findings Of Primary Hepatic Lymphoma.
      El-Badrawy A et al.
      Gulf J Oncolog. 2016 Jan;1(20):64-70.
Pancreas

    • VIPomas are rare tumors with an incidence of 0.05% to 2.0% and can occur both in children and adults. In adults, they occur most commonly between the ages of 30 to 50 years and are mostly intra-pancreatic (95%). A small proportion of tumors secreting VIP have been reported as colorectal cancer, lung cancer, pheochromocytoma, neurofibroma, and ganglioneuroblastoma. Majority of VIPomas occur as isolated tumors, but in about 5% of patients, they are part of the multiple endocrine neoplasia type 1 (MEN1) syndromes. More than 50% of VIPomas have metastasized by the time of diagnosis.
    • Excessive secretion of VIP from the tumor has multiple effects on different organ systems, with its primary effects being on the GI system. VIP is a neurotransmitter belonging to the secretin- glucagon family and consists of 28 amino acids. It is a potent stimulator of intestinal cyclic adenosine monophosphate (cAMP) production and inhibitor of gastric acid secretion. It promotes vasodilation, glycogenolysis, lipolysis, and bone resorption. Effects secondary to these actions of VIP include huge secretion of water and electrolytes from the GI epithelial cells, hypokalemia, facial flushing, decreased gastric acidity, elevated blood glucose, and hypercalcemia.
    • Diagnosis of VIPoma is made in patients with secretory diarrhea usually greater than 3.0 liters per day with a serum VIP level around 250 to 500 pg/ml (reference range is less than 190 pg/ml). Secretory diarrhea has a low fecal osmotic gap of less than 50 mOsm/kg. It is important to repeat levels of VIP to confirm diagnosis since levels may not be elevated between episodes of watery diarrhea. It is also imperative to determine VIP levels when the patient is symptomatic, as the VIPoma may only secrete VIP intermittently. Hence, a normal level may be a false negative. Among children suspected with VIPoma, catecholamine levels should also need to be measured. Levels of pancreatic polypeptide are elevated in tumors originating from the pancreas.
    • "Management changes included a change in diagnosis in 8.7%, change in clinical stage in 8.7%, change in treatment in 17.9%, and further workup needed in 19.0% of patients, respectively. No change in management occurred in the remaining 61.5% of cases."
      Subspecialized radiology review at multidisciplinary pancreas conference: impact on patient management.
      Chingkoe CM et al.
      Abdom Radiol (NY). 2018 Oct;43(10):2783-2789
    • "Subspecialized abdominal radiologist reinterpretation in the context of more comprehensive patient information heavily impacts the multidisciplinary management of patients with pancreatic disorders."
      Subspecialized radiology review at multidisciplinary pancreas conference: impact on patient management.
      Chingkoe CM et al.
      Abdom Radiol (NY). 2018 Oct;43(10):2783-2789
Practice Management

    • Is there more information on a CT scan than we are currently using?
      ● Axial CT
      ● Multiplanar CT (coronal, sagittal, oblique)
      ● 3D Imaging ( SSD to MIP to VRT to CR)
      ● Augmented Reality
      ● AI and Deep Learning including Radiomics
      ● The unknown that is coming
    • CT Imaging of the Pancreas
      ● Challenges
      ● Detection of a pancreatic abnormality
      ● Classification of a pancreatic abnormality
      ● Differential diagnosis
      ● Staging of a tumor
      ● Patient management and triage
Quotes

    • "Reports that say that something hasn't happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns- the ones we don't know we don't know." 
      ― Donald Rumsfeld
    • "as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns- the ones we don't know we don't know." 
      ― Donald Rumsfeld
    • " as we read a CT scan, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns- the ones we don't know we don't know. Can AI help us with these issues? "
    • "Over the years I’ve come to be wary of using the words always and never. They are two of the more dangerous words in the English language." 
      ― Donald Rumsfeld, Rumsfeld's Rules: Leadership Lessons in Business, Politics, War, and Life
    • "The world is run by those who show up." 
      Donald Rumsfeld, Rumsfeld's Rules: Leadership Lessons in Business, Politics, War, and Life
    • "The success of an organization will depend on the people you surround yourself with." 
      Donald Rumsfeld, Rumsfeld's Rules: Leadership Lessons in Business, Politics, War, and Life
Vascular

    • "Given the anatomic complexity of the mediastinum with many adjacent vascular structures, it may be that CR has intrinsic advantages relative to other 3D methods in being able to accurately display the relative positions of those structures in a manner that may be more intuitively grasped in comparison to less photorealistic depictions. At the same time, the shadowing effects produced by CR can potentially obscure important sites of pathology, so a careful inspection of CR visualizations from multiple viewing angles and with multiple different window settings is necessary."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "Cinematic rendering (CR) is a new 3D post-processing tool that provides even greater anatomic detail than traditional volume rendering. In this case series, CR is used to impart to radiologists a better understanding of various anatomic configurations that can be seen with a ductus diverticulum. "
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "Among these is the ductus diverticulum—a remnant of the ductus arteriosus that arises from the lesser curvature of the aortic arch, which can be mistaken for a traumatic aortic pseudoaneurysm, dissection, or incomplete rupture. The distal aortic arch, and in particular
      the undersurface, is the most common location for acute traumatic aortic injury. "
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "Differentiation of a ductus diverticulum from an aortic injury can be difficult, but it is of paramount importance in order to spare patients the morbidity of unnecessary thoracic surgery. This becomes more challenging in the setting of other thoracic traumatic injury, especially mediastinal hematoma, as demonstrated in this case report. Additional cases are also presented to demonstrate the range appearance of the ductus diverticulum using cinematic rendering, a novel method 3D CT visualization method that provides unprece- dented anatomic detail.
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "However, not all abnormalities of the aorta indicate an acute process, and multiple pitfalls that can mimic acute aortic injury have been described . Among these is the ductus diverticulum—a remnant of the ductus arteriosus that arises from the lesser curvature of the aortic arch, which can be mistaken for a traumatic aortic pseudoaneurysm, dissection, or incomplete rupture. The distal aortic arch, and in particular
      the undersurface, is the most common location for acute traumatic aortic injury. "
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "Differentiation of a ductus diverticulum from an aortic injury can be difficult, but it is of paramount importance in order to spare patients the morbidity of unnecessary thoracic surgery. This becomes more challenging in the setting of other thoracic traumatic injury, especially mediastinal hematoma, as demonstrated in this case report."
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "One of the most pronounced advantages of cinematic rendering is the production of realistic shadowing effects, allowing for very clear representation of the relative positions of objects within the imaged volume; this is well demonstrated, where the shadowing from the aortic arch onto the underlying ductus diverticulum and pulmonary arterial vasculature allows the viewer to easily grasp the internal arrangement of these structures."
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "One of the advantages of volume rendering over maximum intensity projection is the ability to convey 3D anatomic relationships. For complex anatomic configurations like the thoracic aorta and pulmonary arteries, the lighting model in cinematic rendering adds even greater anatomic detail, as demonstrated by these cases."
      MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury
      Steven P. Rowe, Pamela T. Johnson, Elliot K. Fishman
      Emergency Radiology (2018) 25:209–213
    • "Cinematic rendering produces volume rendered images with photorealistic image quality. It uses a global illumination model, which takes direct and indirect illumination into account when constructing an image, to achieve rendering quality. The mathematical models that describe this visualization technology include complex integral equations that are solved numerically using the Monte Carlo integration. The result of the integration is a numerical rendering algorithm known as path tracing: thousands of light rays are traced to compute the resulting image."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "To achieve photorealistic quality an "environment map" or "light map" must be used as this light source provides realistic effects achieved by real world light scenarios. The light map consists of texture maps containing information on the brightness of surfaces in a virtual scene that allow the reproduction of the light environment in which the map was generated."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "The light model off of which cinematic rendering and classic volume rendering are based when reconstructing the images accounts for the difference between the two technologies. The primary reason why classic volume rendering results in images that are relatively less photorealistic is the use of the local lighting model – only local properties, such as the local gradient, influence the resulting image. Inversely, cinematic rendering assumes the global illumination model, which accounts for the impact that all light rays have on image reproduction."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "Additionally, cinematic rendering and classic volume rendering differ in their respective light sources. The light sources in classical volume rendering are either single unidirectional light sources or multiple light sources. Although cinematic rendering could use the same light sources as those of classic volume rendering, it also uses environment maps to produce the best visual results. Moreover, classic volume rendering assumes that light passing through the transparent participating medium is absorbed. This assumption leads to less realistic images because in reality light particles are scattered in such a medium. Thus, to achieve photorealism, classic volume rendering would have to account for scattering effects."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "In cinematic rendering, the most important parameter available to manipulate the resulting image is the transfer function. A parameter that was already available in classic volume rendering, the transfer function assigns a color and an opacity property to each voxel value. The opacity can be zero, one or any number between zero and one. If the opacity is zero, then the voxel value represents a vacuum that does not influence rendering computation. If the opacity is equal to one, then the voxel value represents a region that is fully opaque."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • "The limitations related to cinematic rendering’s photorealistic quality also must be acknowledged. While photorealism improves the image quality and allows for a better perception of structures, it is possible to have scenarios when too much photorealism is bad. For example, if some tissue parts are obstructed from the light source, the tissue becomes darker, which can be very realistic but it can omit information about the vasculature."
      MDCT angiography with 3D rendering: A novel cinematic rendering algorithm for enhanced anatomic detail
      Johnson PT, Schneider R, Lugo-Fagundo C, Johnson M, Fishman EK
      AJR 2017 Aug;209(2):309-312
    • Cinematic Rendering: Future Directions
      ● Implement algorithm on faster hardware or GPU’s
      ● Optimization of lighting models may be possible with AI to select best parameters
      ● Integration into Radiology work flow
    • "Kawasaki’s disease (KD) is a vasculitis that predominantly affects children and can lead to the development of coronary artery aneurysms. These aneurysms can subsequently thrombose and occlude, which may lead to chest pain and other signs and symptoms of acute coronary syndrome in young patients. Coronary CT angiography, including 3D visualization techniques, is a common modality used in the follow-up of KD patients."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "The most important potential complication of KD is inflammatory damage to the coronary arteries, which classically leads to the formation of coronary artery aneurysms. These aneurysms will often undergo vascular remodeling and partial
      thrombosis in order to produce a psuedonormal vascular lumen. However, progressive thrombosis and other stenotic processes such as fibrosis can, over time, precipitate cardiac ischemia that can lead to emergency room presentations for chest pain or other signs of acute coronary syndrome and necessitate invasive and/or surgical interventions."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • CR differs from traditional VR in making use of a global lighting model that more realistically takes into account the interactions of propagating photons with the component materials of the imaged volume. As a result, this method enhances surface detail and creates lifelike shadowing effects in order to generate truly photorealistic visualizations from standard CT acquisition volumetric data."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • " While the advantages of this new technique are still under investigation, potential applications include improved visualization of complex anatomic structures that obviates the need for expensive 3D printing, better display of soft tissue texture that may improve detection and characterization of subtle lesions, improved pre-operative planning, and better trainee and patient engagement."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • In this case series, we have demonstrated the ability of CR visualizations to effectively convey key anatomic information related to coronary artery aneurysms in patients with history of KD. While the role of imaging in following patients with KD has been previously investigated, this is the first reported experience with the novel CR visualization methodology, and these examples demonstrate the potential of this technique for evaluating such complex vascular pathologic states.
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "As with other 3D visualization methods, CR would be expected to provide a global overview of the disease process that is not easily appreciated on 2D axial or multi-planar reformatted images. In particular, this may help to identify relatively distal, small caliber sites of aneurysmal enlargement, which stand out with high contrast on the 3D images but can be subtle when only 2D images are viewed."
      Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
      Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
      Emergency Radiology (2018) 25:449–453
    • "Mycotic aneurysms are uncommon but emergent conditions in which infection of a vessel leads to a contained rupture. Progression to frank rupture, thrombosis, distal embolization, and death can occur. The widespread availability of computed tomography (CT) and its ability to obtain high-resolution, contrast-enhanced, volumetric images rapidly has made it the modality of choice for evaluating mycotic aneurysms. Three-dimensional CT visualizations can provide important information to surgeons and interventionalists prior to attempting repair of these lesions."
      3D CT cinematic rendering of mycotic aneurysms Rowe SP, Chu LC, Zimmerman SL, Fishman EK
      Emerg Radiol (2018). https://doi.org/10.1007/s10140-018-1643-6
    • "In this case series, we demonstrate the appearance of mycotic aneurysms with the novel 3D CT visualization methodology known as cinematic rendering (CR). CR makes use of a more complex lighting model than has previously been utilized with other 3D CT techniques, allowing for enhanced surface detail and realistic shadowing effects. These features of CR may have utility in evaluating mycotic aneurysms and in pre-procedural/pre-operative planning, although a prospective study definitively evaluating this has not yet been performed."
      3D CT cinematic rendering of mycotic aneurysms
      Rowe SP, Chu LC, Zimmerman SL, Fishman EK
      Emerg Radiol (2018). https://doi.org/10.1007/s10140-018-1643-6
    • "Infected (mycotic) aneurysms are contained ruptures that occur as a result of direct infection of a vessel. These lesions can manifest in any artery in the body and can be asymptomatic, present with hemorrhage, or can produce localized or systemic symptoms of infection. While any infectious agent could, in theory, cause a mycotic aneurysm, the most common causative genera are Staphylococcus and Streptococcus."
      3D CT cinematic rendering of mycotic aneurysms
      Rowe SP, Chu LC, Zimmerman SL, Fishman EK
      Emerg Radiol (2018). https://doi.org/10.1007/s10140-018-1643-6
    • "Computed tomography (CT), particularly with an arterial phase acquisition, is the modality of choice for the evaluation of mycotic aneurysms . The acquisition of volumetric data composed of isotropic voxels with modern multidetector CT scanners facilitates the creation of 3D visualizations such as volume rendering (VR) that can assist surgeons and interventionalists in planning open surgical or endovascular repair."
      3D CT cinematic rendering of mycotic aneurysms
      Rowe SP, Chu LC, Zimmerman SL, Fishman EK
      Emerg Radiol (2018). https://doi.org/10.1007/s10140-018-1643-6
    • "CR makes use of complex path tracing of projected light rays within the context of a global illumination model in order to create images. This allows the method to take into ac- count the effect on projected rays from scatter and even from materials within adjacent voxels through which the ray does not pass. As a result, relative to traditional VR which uses ray casting and a local lighting model for image creation, CR images typically have much high levels of surface detail and realistic shadowing."
      3D CT cinematic rendering of mycotic aneurysms
      Rowe SP, Chu LC, Zimmerman SL, Fishman EK
      Emerg Radiol (2018). https://doi.org/10.1007/s10140-018-1643-6
    • "An experienced reader at our institution is able to utilize appro- priate pre-set window width and level values to create the images and interpret the findings in approximately 5 min; thus, the inclusion of CR images does not significantly impede clinical workflow."
      3D CT cinematic rendering of mycotic aneurysms
      Rowe SP, Chu LC, Zimmerman SL, Fishman EK
      Emerg Radiol (2018). https://doi.org/10.1007/s10140-018-1643-6
    • "In particular, the realistic shadowing that is intrinsic to the CR technique displays the relative relationships of vessels and other structures in an intuitive manner that is likely to prove helpful to interventionalists and surgeons."
      3D CT cinematic rendering of mycotic aneurysms
      Rowe SP, Chu LC, Zimmerman SL, Fishman EK
      Emerg Radiol (2018). https://doi.org/10.1007/s10140-018-1643-6
© 1999-2018 Elliot K. Fishman, MD, FACR. All rights reserved.