Communication and technique at the service of Body Geriatric … · Geriatric Radiology 1st to be dedicated to geriatric p. Département diagnostique Service de radiologie Background

Département diagnostique

Service de radiologie

Communication and technique at the service ofBody Geriatric Imaging: approach with CT

A Technical tool serving Clinique



Les Trois-Chêne, HUG; Unique context in Europe

Site presentation :▪ Geriatric Hospital

▪ Mean AGE 84 Y

▪ 300 beds

In Geriatric

Geriatric emergency (11.2015)▪ 7/7 ▪ From 75 year▪ Non-vital emergecies & no trauma

Geriatric Radiology1st to be dedicated to geriatric p.



Background – Overview

▪ Geriatric epidemiological transition

▪ Age increase, senses decrease

▪ Concept of fragility or vulnerability

In Geriatric



Care Specifies Overview

▪ Failing Cognition

▪ The pain, one way or another

▪ A full “CUMULUS” pathology card

▪ The death in the background , but still alive !

In Geriatric

Global Dimension

Physical Dimension

Psychological Dimension

Spiritual Dimension

Social or Cultural

Dimension



Welcome to the CT….

▪ « I warn you, I am claustrophobic! »

▪ Common fear of falling

▪ “Nobody warned me, what the hell am I doing here?”

▪ “What does it mean doing all these exams?”

▪ Veins in very bad condition

▪ « Good morning, I need to pee! »

▪ « There is a beast up to the ceiling! »

In Geriatric



The CT-scan: Siemens Somatom Definition AS

UFC DETECTOR 128x0.6mm 64 barrettes

STRATON TUBE



Historical Context

1972the first

HOUNSFIELD’s CT

1989Helical CT

1998 CT

Multislice

2018Siemens Force

19301895



Problem : sometimes one of ours exams can give that….





Even if our machine can do this…





Principel : fight against the kinetic blur of patient breathing

Rotation-tube

Aceleration

Per a CT for

Image more

Diagnostic

Evidently

No trace of inspiration and

apnea befor images.

0.3s

0.5s

PITCH 1.0

PITCH 0.6



User Interface

Main Idea: fight against the kinetic blur of patient breathing

List of « Protocoles Rapides » :

• LOWDOSE_THORAX_Rapide• THORAX_SPC_Rapide• THORAX_IV_Rapide• TAP_SPC_Rapide• TAP_IV_Rapide• Thorax_EP_Abdo_IV_Rapide

• --------------------------------------------------------• Abdo_LowDose_Rapide• Abdo_SPC_Rapide• Abdo_iv_Rapide• Abdo_4_phases_Rapide• Abdo_4_Phases_et_Thorax_IV_Rapide• Abdo_4_Phases_et_Thorax_artériel_Rapide• Uro_CT_SPLITBOLUS_Sans_Lasix_Rapide



Image quality: Usual Protocol Protocole Rapide

QUALITEIMAGE GLOBALE

CONTRASTE DENSITY

RESOLUTION

SPACERESOLUTION

TEMPORALRESOLUTION

S/NRATIO

ARTEFACTS



Temporal Resolution

Problematic of Kinetic Blur in Imaging

Definition: organ movement during acquisition= several positions on the same image

ConclusionProtocole Rapide = Acquisition time can be almost divided by 2.

D = S . tD – Kinetic blur in imageS – speed of patient organs t – acquisition time

U R



Abdo IV T rot :0.5 sPitch :0.9Collimation 64x0.6mmTable speed: 6,9 cm/s

Abdo IV RapideT rot :0.3 sPitch :1.0Collimation 64x0.6mmTable speed: 12,8cm/s

Abdo IV RapideT Rot : 0.3sPitch :1.5Collimation: 64x0.6mmTable speed: 19,2cm/s

Temporal Resolution : Aeolian experience

Angular speed of the displacement23.5 Rot/min, otherwise 140°/s

U R



Temporal resolution, water challenge

4.93s

13.21s

9.05s

TAP IVU R

U

S

U

A

L

R

A

P

I

D

E

M

A

X

I

M

A

L

NEW RECORD

4.93 s



0

0.5

1

1.5

0

0.5

1

1.5

15

.2

18

.2

18

.6

21

.5

24

.1

25

.2

29

.1 30

31

Temps Acquisition Qualité Image Maximale(Préconisation SIEMENS)

Temps Acquisition Usuel CT-3C

Temps Acquisition Rapide 2 Bras en haut

Curves gain of temporal resolution in function of patient BMI

Temporal Resolution and X-ray tube dose rate constraint

0

0.5

1

14

.9

16

.25

19

.4

23

.1

23

.9

26

.7

28

.2

28

.7

U R

Temps

Temps

Temps



Temporal resolution, case report: Protocol Thorax SPC , February 2018, CT-3C

U R



Temporal resolution, case report:

CT Thorax SPC,Mai 2018:

CT Thorax Low-dose , Mai 2018:

Usual Rapide

U R



Temporal resolution, case report:Protocol Abdo IV, April 2018, CT-3C.

U R



Temporal resolution, case report : Protocol Abdo IV, April 2018, CT-3C.

Usual Rapide

U R



Space Resolution

Go into « rapide » mode (Trot 0.3s et Pitch 1) lead to moderate loss of sampling

➢ Numbre of slice profile / Rotation decrease➢ Pitch increase➢ Sinogramme less riche➢ Identical matrix of image reconstruction in axials views ( 10242 )

However the quality of resolution sufficient and adequate for a diagnostic analysis (Siemens Healthcare)

Aliasing Artifacts and Noise in CT Images

U R

Usual Rapide

Z

YX



S/N Ratio

Go into a « Rapide » mode leads to a light decrease of SNR with the equivalent dose

The beam hardening : Moiré pattern Case report: streaks and noise

U RR

apid

e

U

sual



Contrast density Resolution

Light loss intrinsic contrast,usually due to the KV stepped up.

➢Compton effect increase therefore the diffuse radiation increase as well➢Incident radiation has higher energetic value, ➢The µ absorption of the: air; water, bone decrease and get closer

90

100

110

120

16

.62

17

.15

18

.11

9.5

19

.71

9.7

21

.42

1.7

22

.68

22

.92

3.4

26

.62

8.1 29

29

.12

9.3

32

.05

36

.6

KV Abdo IV Usuel

KV Abdo IV Rapide

90

100

110

120

15.2 17.1 18.5 20.9 22.5 25.2 26.1 30.2 31.7 34.4KV TAP IV Usuel

KV TAP IV Rapide

Abdo IV Usual, 100KV Abdo IV Rapide: 120KV

194 UH

270 UH

206 UH

143 UH

173 UH136 UH

113 UH

136 UH

Exam of the same patient, in 2 days apart, September 2017

U R

80ml Acc 350 78ml Acc 350

KV

KV



90

100

110

120

15

.4

16

.3

19

.8 22

23

.1

23

.1

23

.2

25

.3

27

.4

28

.2

28

.3

33

.6

36

.2

KV Thorax SPC Usuel

KV Thorax SPC Rapide

Contrast Density Resolution

70

80

90

100

110

120

KV Thorax IV Usuel

KV Thorax IV Rapide

Rapport Contraste sur bruit

Rapport Signal sur bruit

U R

KV

KV



Quality Image Conclusion

Maximal Image vs Optimal Image

U R

https://www.google.fr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwihlYOS4tjeAhUDJ1AKHRPdADAQjRx6BAgBEAU&url=https://anzetsewere.wordpress.com/page/27/?page=success&forum_id=38&psig=AOvVaw1rBJUaW0h5xCL7yJZ_daOt&ust=1542452667196648



Day by day: the Radiographer’s choice of the right technic

✓ The smelling of the radiographer

✓ Communication Channels:“On a tous quelque chose en nous de…” « De la Garanderie »



Et au Quotidien: Le choix de la technique par le TRM (suite)

✓ Le cognitif, mais aussi l’émotionnel :L’empathie, une approche décisive

✓ Cela fait écho sur notre émotionnel.



OUI

NON

How Does the Radiographer CT-3C decide between Usual or Rapide

OUI

NON

OUI

NON

OUI

NON

OUI

NON

ACCUEIL✓ Présentations réciproques✓ Prise de contact✓ Evaluation du TRM✓ Radiologue averti

Contact possible ? Le patient ne semble pas

comprendre ce qu’on lui dit.Il peut être opposant

L’examen est

réalisable ?

Le Patient accepte ?

EVALUATION DU BLOQUAGEInformer le prescripteur,Discussion multilatérale,dans le respect du droit du patient

Le patient accepte

au final ?

PHASE PREPARATOIRE✓ Explication du déroulement

d’examen, ✓ Transmission des consignes d’apnée,✓ Test de restitution active des

consignes

Le patient tient

l’apnée ?

PROTOCOLE RAPIDE

PROTOCOLE USUEL

PAS D’EXAMEN



Analyse for the 1° semester 2018

68%

32%

Distribution 1° semester 2018 (493 exams)

Normal

Rapide

5457

66

4649

63

2825

28

24

29

24

Janvier 2018 Février 2018 Mars 2018 Avril 2018 Mai 2018 Juin 2018

Normal Rapide



Analyse for the 1° semester 2018, 2nd reading

0

10

20

30

40

50

60

70

80

90

100

Jan.18 Feb.18 Mrz.18 Apr.18 Mai.18 Jun.18

Protocole Rapide

On a dû recommencer en modeRapide

Le patient a respiré

Protocole Standard réussi



Protocol Rapide : Centering,Always in sight




1. The Centring and the dose

Reference Dose

+ 13.5%*

+ 33.3%*

+ 51.1%*

* : Fantôme CTDI 32 cm



Protocol Rapide : Centering,Always in sightCentering et dose gradient +

+

-

-




2. Dose Gradient dose and posterior noise

bruit de référence

+ 1.8%*

+ 5.4%*

+ 13.4%*

*: Fantôme W23



Protocol Rapide : Arms, Centering, Dose, Time

+ +

8

7

6

5

4

3

2

1

0

-1

-2

-3

-4

-5

-6

-7

-8

BMI PATIENT CENTRAGE BRASPERCEPTION

INFORMATIQUE DOSERESOLUTIONTEMPORELLE



Any question?



A last call?



Thanks for your attention

Remerciements particuliers: DR. Max Scheffler, Méd Adjoint, Service de radiologie, HUG Professeur ZAIDI, Physicien, HUG.Mme JEHL, Siemens HealthCareL’équipe TRM , Hôpital des Trois –Chênes, HUG.Mr et Mme HENNEQUIN, Montreuil,France,informatique.Mr S.RICHARD, Manipulateur radio, CHBM, France

Auteurs:David Delarbre, TRMAitor Bonneau, TRMEnrique Maturana, Chef TRM adjoint,

Documents

Communication and technique at the service of Body Geriatric … · Geriatric Radiology 1st to be dedicated to geriatric p. Département diagnostique Service de radiologie Background