We have built new asymmetric stents for minimally invasive endovascular treatment of cerebral aneurysms. Each asymmetric stent consists of a commercial stent with a micro-welded circular mesh patch. The blood flow modification in aneurysm-vessel phantoms due to these stents was evaluated using x-ray angiographic analysis. However, the density difference between the radiographic contrast and the blood gives rise to a gravity effect, which was evaluated using an initial optical dye-dilution experiment. For the radiographic evaluations, curved-vessel phantoms instead of simple straight side-wall aneurysm phantoms were used in the characterization of meshes/stents. Six phantoms (one untreated, one treated with a commercial stent, and four treated with different asymmetric stents) with similar morphologies were used for comparison. We calculated time-density curves of the aneurysm region and then calculated the peak value (Pk) and washout rate (1/τ) after analytical curve fitting. Flow patterns in the angiograms showed reduction of vortex flow and slow washout in the dense mesh patch treated aneurysms. The meshes reduced Pk down to 21% and 1/τ down to 12% of the values for the untreated case. In summary, new asymmetric stents were constructed and their evaluation demonstrates that they may be useful in the endovascular treatment of aneurysms.
aneurysm; cerebral aneurysm; angiography; time-density; blood flow; flow evaluation; flow modification; stent; asymmetric stent; interventional neuroradiology
An asymmetric stent with low porosity patch across the intracranial aneurysm neck and high porosity elsewhere is designed to modify the flow to result in thrombogenesis and occlusion of the aneurysm and yet to reduce the possibility of also occluding adjacent perforator vessels. The purposes of this study are to evaluate the flow field induced by an asymmetric stent using both numerical and digital subtraction angiography (DSA) methods and to quantify the flow dynamics of an asymmetric stent in an in vivo aneurysm model. We created a vein-pouch aneurysm model on the canine carotid artery. An asymmetric stent was implanted at the aneurysm, with 25% porosity across the aneurysm neck and 80% porosity elsewhere. The aneurysm geometry, before and after stent implantation, was acquired using cone beam CT and reconstructed for computational fluid dynamics (CFD) analysis. Both steady-state and pulsatile flow conditions using the measured waveforms from the aneurysm model were studied. To reduce computational costs, we modeled the asymmetric stent effect by specifying a pressure drop over the layer across the aneurysm orifice where the low porosity patch was located. From the CFD results, we found the asymmetric stent reduced the inflow into the aneurysm by 51%, and appeared to create a stasis-like environment which favors thrombus formation. The DSA sequences also showed substantial flow reduction into the aneurysm. Asymmetric stents may be a viable image guided intervention for treating intracranial aneurysms with desired flow modification features.
Stent; Aneurysm; Digital Subtraction Angiography; Computational Fluid Dynamics; Image guided interventions; CT; image-based finite element models of physiology; image-based biomechanical models; circulation; porosity; wall shear stress
We study the properties of a new microangiographic system, consisting of a Region of Interest (ROI) microangiographic detector, x-ray source, and patient. The study was performed under conditions intended for clinical procedures such as neurological diagnostic angiograms as well as treatments of intracranial aneurysms, and vessel-stenoses. The study was performed in two steps; first a uniform head equivalent phantom was used as a “filter”. This allowed us to study the properties of the detector alone, under clinically relevant x-ray spectra. We report the detector MTF, NPS, NEQ, and DQE for beam energies ranging from 60–100kVp and for different detector entrance exposures. For the second step, the phantom was placed adjacent to the detector, allowing scatter to enter the detector and new measurements were obtained for the same beam energies and detector entrance exposures. Different radiation field sizes were studied, and the effects of different scatter amounts were investigated. The spatial distribution of scatter was studied using the edge-spread method and a generalized system MTF was obtained by combining the scatter MTF weighted by the scatter fraction with the detector MTF and focal spot unsharpness due to magnification. The NPS combined with the generalized MTF gave the generalized system NEQ and DQE. The generalized NEQ and the ideal object detectability were used to calculate the Dose Area Product to the patient for 75% object detection probability. This was used as a system optimization method.
MTF; NPS; NEQ; DQE; system; generalized; detectability; observer; angiography; microrangiography
Standard objective parameters such as MTF, NPS, NEQ and DQE do not reflect complete system performance, because they do not account for geometric unsharpness due to finite focal spot size and scatter due to the patient. The inclusion of these factors led to the generalization of the objective quantities, termed GMTF, GNNPS, GNEQ and GDQE defined at the object plane. In this study, a commercial x-ray image intensifier (II) is evaluated under this generalized approach and compared with a high-resolution, ROI microangiographic system previously developed and evaluated by our group. The study was performed using clinically relevant spectra and simulated conditions for neurovascular angiography specific for each system. A head-equivalent phantom was used, and images were acquired from 60 to 100 kVp. A source to image distance of 100 cm (75 cm for the microangiographic system) and a focal spot of 0.6 mm were used. Effects of varying the irradiation field-size, the air-gaps, and the magnifications (1.1 to 1.3) were compared. A detailed comparison of all of the generalized parameters is presented for the two systems. The detector MTF for the microangiographic system is in general better than that for the II system. For the total x-ray imaging system, the GMTF and GDQE for the II are better at low spatial frequencies, whereas the microangiographic system performs substantially better at higher spatial frequencies. This generalized approach can be used to more realistically evaluate and compare total system performance leading to improved system designs tailored to the imaging task.
MTF; NPS; GMTF; GNNPS; GDQE; Image Intensifier; generalized; microangiography; performance
A new microangiographic system (MA) integrated into a c-arm gantry has been developed allowing precise placement of a MA at the exact same angle as the standard x-ray image intensifier (II) with unchanged source and object position. The MA can also be arbitrarily moved about the object and easily moved into the field of view (FOV) in front of the lower resolution II when higher resolution angiographic sequences are needed. The benefits of this new system are illustrated in a neurovascular study, where a rabbit is injected with contrast media for varying oblique angles. Digital subtraction angiographic (DSA) images were obtained and compared using both the MA and II detectors for the same projection view. Vessels imaged with the MA appear sharper with smaller vessels visualized. Visualization of ~100 μm vessels was possible with the MA whereas not with the II. Further, the MA could better resolve vessel overlap. Contrast to noise ratios (CNR) were calculated for vessels of varying sizes for the MA versus the II and were found to be similar for large vessels, approximately double for medium vessels, and infinitely better for the smallest vessels. In addition, a 3D reconstruction of selected vessel segments was performed, using multiple (three) projections at oblique angles, for each detector. This new MA/II integrated system should lead to improved diagnosis and image guidance of neurovascular interventions by enabling initial guidance with the low resolution large FOV II combined with use of the high resolution MA during critical parts of diagnostic and interventional procedures.
x-ray detectors; x-ray tomosynthesis; detector technology; digital angiography; microangiography; image intensifier; multiview; image guided interventions; image reconstructions
Stenting may provide a new, less invasive therapeutic option for cerebral aneurysms. However, a conventional porous stent may be insufficient in modifying the blood flow for clinical aneurysms. We designed an asymmetric stent consisting of a low porosity patch welded onto a porous stent for an anterior cerebral artery aneurysm of a specific patient geometry to block the strong inflow jet. To evaluate the effect of the patch on aneurysmal flow dynamics, we “virtually” implanted it into the patient's aneurysm geometry and performed Computational Fluid Dynamics (CFD) analysis. The patch was computationally deformed to fit into the vessel lumen segmented from the patient CT reconstructions. After the flow calculations, a patch with the same design was fabricated using laser cutting techniques and welded onto a commercial porous stent, creating a patient-specific asymmetric stent. This stent was implanted into a phantom, which was imaged with X-ray angiography. The hemodynamics of untreated and stented aneurysms were compared both computationally and experimentally. It was found from CFD of the patient aneurysm that the asymmetric stent effectively blocked the strong inflow jet into the aneurysm and eliminated the flow impingement on the aneurysm wall at the dome. The impact zone with elevated wall shear stress was eliminated, the aneurysmal flow activity was substantially reduced, and the flow was considerably reduced. Experimental observations corresponded well qualitatively with the CFD results. The demonstrated asymmetric stent could lead to a new minimally invasive image guided intervention to reduce aneurysm growth and rupture.
Stent; Aneurysm; Computational Fluid Dynamics; Image guided interventions; Angiography; Asymmetric stent
For treatment of cerebral aneurysms, the low porosity patch-like region of a new asymmetric stent must be accurately aligned both longitudinally and rotationally to cover the aneurysm orifice. Image guided interventions (IGI) for this task using either a high spatial resolution microangiographic detector (MA) or a standard x-ray image intensifier (XII) are compared. MA is a custom built phosphor-fiberoptic-CCD x-ray detector; the MA array is 1024X1024 with 43 microns pixels. We designed an experimental simulation of the IGI which involved localization using a combination of a computer-controlled rotational stage supported on a linear traverse. A catheter containing the asymmetric stent with special gold markers was positioned near the aneurysm of a vessel phantom which is contained in a flow loop to enable contrast injection for creation of roadmap images. We used four different configurations for the markers consisting of dots and lines. The true stent alignment, obtained by direct visual viewing, was determined to better than one degree rotational accuracy. The resultant IGI localization accuracy under radiographic control with the microangiographic detector was 4° compared to 12° for the XII. In general the line markers performed better than the dot markers. Experimental data show that high resolution detectors such as MA can vastly improve the accuracy of localization and tracking of devices such as asymmetric stents. This should enable development of more effective treatment devices and interventions. (Partial support from NIH grants NS38746, NS43294, and EB002873; UB STOR, Toshiba MSC, and Guidant Corp.)
The new Multi-View Reconstruction (MVR) method for generating 3D vascular images was evaluated experimentally. The MVR method requires only a few digital subtraction angiographic (DSA) projections to reconstruct the 3D model of the vessel object compared to 180 or more projections for standard CBCT. Full micro-CBCT datasets of a contrast filled carotid vessel phantom were obtained using a Microangiography (MA) detector. From these datasets, a few projections were selected for use in the MVR technique. Similar projection views were also obtained using a standard x-ray image intensifier (II) system. A comparison of the 2D views of the MVRs (MA and II derived) with reference micro-CBCT data, demonstrated best agreement with the MA MVRs, especially at the curved part of the phantom. Additionally, the full 3D MVRs were compared with the full micro-CBCT 3D reconstruction resulting for the phantom with the smallest diameter (0.75 mm) vessel, in a mean centerline deviation from the micro-CBCT derived reconstructions of 29 μm for the MA MVR and 48 μm for the II MVR. The comparison implies that an MVR may be substituted for a full micro-CBCT scan for evaluating vessel segments with consequent substantial savings in patient exposure and contrast media injection yet without substantial loss in 3D image content. If a high resolution system with MA detector is used, the improved resolution could be well suited for endovascular image guided interventions where visualization of only a small field of view (FOV) is required.
Micro CT; x-ray detectors; diagnostic imaging; x-ray tomosynthesis; algorithms; image reconstruction; microangiography; multi-view reconstruction
New cone-beam computed tomographic (CBCT) mammography system designs are presented where the detectors provide high spatial resolution, high sensitivity, low noise, wide dynamic range, negligible lag and high frame rates similar to features required for high performance fluoroscopy detectors. The x-ray detectors consist of a phosphor coupled by a fiber-optic taper to either a high gain image light amplifier (LA) then CCD camera or to an electron multiplying CCD. When a square-array of such detectors is used, a field-of-view (FOV) to 20 × 20 cm can be obtained where the images have pixel-resolution of 100 µm or better. To achieve practical CBCT mammography scan-times, 30 fps may be acquired with quantum limited (noise free) performance below 0.2 µR detector exposure per frame. Because of the flexible voltage controlled gain of the LA’s and EMCCDs, large detector dynamic range is also achievable. Features of such detector systems with arrays of either generation 2 (Gen 2) or 3 (Gen 3) LAs optically coupled to CCD cameras or arrays of EMCCDs coupled directly are compared. Quantum accounting analysis is done for a variety of such designs where either the lowest number of information carriers off the LA photo-cathode or electrons released in the EMCCDs per x-ray absorbed in the phosphor are large enough to imply no quantum sink for the design. These new LA- or EMCCD-based systems could lead to vastly improved CBCT mammography, ROI-CT, or fluoroscopy performance compared to systems using flat panels.
x-ray detectors; detector arrays; cone beam computed tomography; mammography; fluoroscopy; CT; electron multiplying CCD; light amplifiers; quantum accounting; detector mosaic
Background and Purpose
Development of hemodynamic modifying devices to treat intracranial aneurysms (IAs) is an active area of research. The asymmetric vascular stent (AVS), a stent containing a low porosity patch, is such device. We evaluate AVS efficacy in an in vivo IA model.
We created twenty-four elastase rabbit model aneurysms: thirteen treated with the AVS, five treated with standard coronary stents, and six untreated controls. Four weeks following treatment, aneurysms underwent follow-up angiography, cone-beam micro-CT, histologic evaluation, and selective electron microscopy scanning.
Four rabbits died early in the study: three during AVS treatment and one control (secondary to intra-procedural vessel injury and an unrelated tumor, respectively). AVS-treated aneurysms exhibited very weak or no aneurysm flow immediately after treatment and no flow in all aneurysms at follow-up. Stent-treated aneurysms showed flow both after treatment (5/5) and at follow-up (3/5). All control aneurysms remained patent during the study. Micro-CT scans showed: 9/9 of scanned AVS aneurysms were occluded, (6/9) AVSs were ideally placed and (3/9) the low porosity region partially covered the aneurysm neck; stent-treated aneurysms were 1/5 occluded, 2/5 patent, and 2/5 partially-patent. Histology results demonstrated: for AVS-treated aneurysms, advanced thrombus organization in the (9/9); for stent-treated aneurysms (1/4) no thrombus, (2/4) partially-thrombosed and (1/4) fully-thrombosed; for control aneurysms (4/4) no thrombus.
The use of AVSs shows promise as a viable new therapeutic in intracranial aneurysm treatment. These data encourage further investigation and provide substantial support to the AVS concept.
Asymmetric Vascular Stent; elastase aneurysm model; hemodynamics modification
This paper proposes a new discrete optimization framework for tomographic reconstruction and segmentation of CT volumes when only a few projection views are available. The problem has important clinical applications in coronary angiographic imaging. We first show that the limited view reconstruction and segmentation problem can be formulated as a “constrained” version of the metric labeling problem. This lays the groundwork for a linear programming framework that brings metric labeling classification and classical algebraic tomographic reconstruction (ART) together in a unified model. If the imaged volume is known to be comprised of a finite set of attenuation coefficients (a realistic assumption), given a regular limited view reconstruction, we view it as a task of voxels reassignment subject to maximally maintaining consistency with the input reconstruction and the objective of ART simultaneously. The approach can reliably reconstruct (or segment) volumes with several multiple contrast objects. We present evaluations using experiments on cone beam computed tomography.
Minimally invasive interventions are rapidly replacing invasive surgical procedures for the most prevalent human disease conditions. X-ray image-guided interventions carried out using the insertion and navigation of catheters through the vasculature are increasing in number and sophistication. In this article, we offer our vision for the future of this dynamic field of endovascular image-guided interventions in the form of predictions about (1) improvements in high-resolution detectors for more accurate guidance, (2) the implementation of high-resolution region of interest computed tomography for evaluation and planning, (3) the implementation of dose tracking systems to control patient radiation risk, (4) the development of increasingly sophisticated interventional devices, (5) the use of quantitative treatment planning with patient-specific computer fluid dynamic simulations, and (6) the new expanding role of the medical physicist. We discuss how we envision our predictions will come to fruition and result in the universal goal of improved patient care.
endovascular; image-guided intervention; detectors; cone beam CT; computer fluid dynamics (CFD)
Currently, a large number of endovascular interventions are performed for treatment of intracranial aneurysms. For these treatments, correct positioning of microcatheter tips, microguide wire tips, or coils is essential. Techniques to detect such devices may facilitate endovascular interventions. In this paper, we describe an algorithm for tracking of microcatheter tips during fluoroscopically guided neuroendovascular interventions. A sequence of fluoroscopic images (1,024 × 1,024 × 12 bits) was acquired using a C-arm angiography system as a microcatheter was passed through a carotid phantom which was on top of a head phantom. The carotid phantom was a silicone cylinder containing a simulated vessel with the shape and curvatures of the internal carotid artery. The head phantom consisted of a human skull and tissue-equivalent material. To detect the microcatheter in a given fluoroscopic frame, a background image consisting of an average of the four previous frames is subtracted from the current frame, the resulting image is filtered using a matched filter, and the position of maximum intensity in the filtered image is taken as the catheter tip position in the current frame. The distance between the tracked position and the correct position (error distance) was measured in each of the fluoroscopic images. The mean and standard deviation of the error distance values were 0.277 mm (1.59 pixels) and 0.26 mm (1.5 pixels), respectively. The error distance was less than 3 pixels in the 93.0% frames. Although the algorithm intermittently failed to correctly detect the catheter, the algorithm recovered the catheter in subsequent frames.
Catheter motion tracking; vascular intervention; fluorography; cerebral artery; image subtraction; microcatheter; navigation system
We compared three techniques for enhancement of microcatheter tips in fluoroscopic images: conventional subtraction technique (CST); averaged image subtraction technique (AIST), which we have developed; and double average filtering (DAF) technique, which uses nonlinear background estimates. A pulsed fluoroscopic image sequence was obtained as a microcatheter was passed through a carotid phantom that was on top of a head phantom. The carotid phantom was a silicone cylinder containing a simulated vessel with the shape and curvatures of the internal carotid artery. The three techniques were applied to the images of the sequence, then the catheter tip was manually identified in each image, and 100 x 100 pixel images, centered at the indicated microcatheter tip positions, were extracted for the evaluations. The signal-to-noise ratio (SNR) was calculated in each of the extracted images from which the mean value of the SNR and its standard deviation (SD) were calculated for each technique. The mean values and the standard deviations were 4.36 (SD 3.40) for CST, 6.34 (SD 3.62) for AIST, and 3.55 (SD 1.27) for DAF. AIST had a higher SNR compared to CST in almost all frames. Although DAF yielded the smallest mean SNR value, it yielded the best SNR in those frames in which the microcatheter tip did not move between frames. We conclude that AIST provides the best SNR for a moving microcatheter tip and that DAF is optimal for a temporarily stationary microcatheter tip.
Microcatheter tracking; enhancement technique; subtraction technique; signal-to-noise ratio; comparison of techniques; fluorography; endovascular intervention
Background and Purpose
Intracranial aneurysm (IA) treatment through hemodynamic modification with novel stent designs is a burgeoning area of research. We present a feasibility study for a new low-porosity patch-containing stent designed to treat intracranial aneurysms. The device is deployed so the patch covers the aneurysm neck ensuring strong flow diversion away from the aneurysm while keeping a low probability of occlusion of perforating vessels.
We created 17 side-wall aneurysms in 6 dogs, 2 per carotid artery if animal size permitted. Twelve proximal aneurysms were treated with AVSs: 5 distal aneurysms were untreated, serving as controls against self-thrombosis; 7 treated aneurysms were fully-covered; and 5 were partially-covered. After 4 weeks, a final angiogram was performed and aneurysms were explanted. Angiograms acquired pre- and posttreatment and at 4-week follow-up were analyzed quantitatively using normalized time-density curves (NTDC). Cone-beam micro-CT and histological specimen analysis were then performed.
Posttreatment, NTDC average peaks dropped to 45% of initial values for the partially-covered aneurysms and 78% for the fully-covered aneurysms. Cone-beam micro-CT imaging performed at 4 weeks posttreatment showed partial thrombosis in 4 of 5 partially-covered aneurysms and complete thrombosis in all fully-covered aneurysms. Histology revealed neointimal coverage of all asymmetrical patch regions and thrombus formation in both fully- and partially-covered aneurysms. Four-week follow-up was not done for 1 animal (2 controls, 2 treated) that expired because of groin hemorrhage and for another animal (1 aneurysm) with an occluded carotid.
We demonstrate aneurysmal blood flow diversion using a new low-porosity patch-containing asymmetrical vascular stent in a canine side-wall aneurysm model. Overall results are encouraging and support continued AVS development.
aneurysm; stent; canine model; time-density curve
We report on the technology of imaging corrections for a new solid state x-ray image intensifier (SSXII) with enhanced resolution and fluoroscopic imaging capabilities, made of a mosaic of modules (tiled-array) each consisting of CsI(Tl) phosphor coupled using a fiber-optic taper or minifier to an electron multiplier charge coupled device (EMCCD). Generating high quality images using this EMCCD tiled-array system requires the determination and correction of the individual EMCCD sub-images with respect to relative rotations and translations as well as optical distortions due to the fiber optic tapers. The image corrections procedure is based on comparison of resulting (distorted) images with the known square pattern of a wire mesh phantom. The mesh crossing point positions in each sub-image are automatically identified. With the crossing points identified, the mapping between distorted and an undistorted array is determined. For each pixel in a distorted sub-image, the corresponding location in the corrected sub-image is calculated using bilinear interpolation. For the rotation corrections between sub-images, the orientation of the vectors between respective mesh crossing points in the various sub-images are determined and each sub-image is appropriately rotated with the pixel values again determined using bilinear interpolation. Image translation corrections are performed using reference structures at known locations. According to our estimations, the distortion corrections are accurate to within 1%; the rotations are determined to within 0.1 degree, and translation corrections are accurate to well within 1 pixel. This technology will provide the basis for generating single composite images from tiled-image configurations of the SSXII regardless of how many modules are used to form the images.
Detector Imaging; Imaging correction algorithms; Digital X-ray imaging; Radiography; Fluoroscopy; Angiography
Two or more angiograms are being used frequently in medical imaging to reconstruct locations in three-dimensional (3D) space, e.g., for reconstruction of 3D vascular trees, implanted electrodes, or patient positioning. A number of techniques have been proposed for this task. In this simulation study, we investigate the effect of the shape of the configuration of the points in 3D (the “cloud” of points) on reconstruction errors for one of these techniques developed in our laboratory. Five types of configurations (a ball, an elongated ellipsoid (cigar), flattened ball (pancake), flattened cigar, and a flattened ball with a single distant point) are used in the evaluations. For each shape, 100 random configurations were generated, with point coordinates chosen from Gaussian distributions having a covariance matrix corresponding to the desired shape. The 3D data were projected into the image planes using a known imaging geometry. Gaussian distributed errors were introduced in the x and y coordinates of these projected points. Gaussian distributed errors were also introduced into the gantry information used to calculate the initial imaging geometry. The imaging geometries and 3D positions were iteratively refined using the enhanced-Metz-Fencil (EMF) technique. The image data were also used to evaluate the feasible R-t solution volume. The 3D errors between the calculated and true positions were determined. The effects of the shape of the configuration, the number of points, the initial geometry error, and the input image error were evaluated. The results for the number of points, initial geometry error, and image error are in agreement with previously reported results, i.e., increasing the number of points and reducing initial geometry and/or image error, improves the accuracy of the reconstructed data. The shape of the 3D configuration of points also affects the error of reconstructed 3D configuration; specifically, errors decrease as the “volume” of the 3D configuration increases, as would be intuitively expected, and shapes with larger spread, such as spherical shapes, yield more accurate reconstructions. These results are in agreement with an analysis of the solution volume of feasible geometries and could be used to guide selection of points for reconstruction of 3D configurations from two views.
Biplane projection imaging is one of the primary methods for imaging and visualizing the cardiovascular system in medicine. A key problem in such a technique is to determine the imaging geometry (i.e., the relative rotation and translation) of two projections so that the interested 3-D structures can be accurately reconstructed. Based on interesting observations and efficient geometric techniques, we present in this paper new algorithmic solutions for this problem. Comparing with existing optimization-based approaches, our techniques yield better accuracy, have bounded execution time, and thus are more suitable for on-line applications. Our techniques can easily detect outliers to further improve the accuracy.