See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/327562204

Digital Tomosynthesis artifacts resulting from medical devices and respiratory

conditions in ICU patients

Poster · October 2016

DOI: 10.1594/esti2016/P-0018

CITATIONS READS

0 28

7 authors, including:

Shailaja Sajja Fatima Ursani

Sunnybrook Health Sciences Centre Trinity College Dublin
10 PUBLICATIONS   0 CITATIONS    6 PUBLICATIONS   0 CITATIONS   

SEE PROFILE SEE PROFILE

Narinder S Paul
University Health Network
62 PUBLICATIONS   115 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Lung transplantation View project

Dual energy and digital tomosynthesis View project

All content following this page was uploaded by Shailaja Sajja on 10 September 2018.

The user has requested enhancement of the downloaded file.

Digital Tomosynthesis artifacts resulting from medical
devices and respiratory conditions in ICU patients

Award: Cum Laude

Poster No.: P-0018
Congress: ESTI 2016
Type: Educational Poster
Authors: 1 2 2 1 2
S. Sajja , S. Richard , M. Heath , F. Ursani , X. Wang , L.
2 1 1 2
Vogelsang , N. Paul ; Toronto, ON/CA, Rochester/US
Keywords: Outcomes, Physics, Instrumentation, Education, Digital
radiography, Thorax, Lung
DOI: 10.1594/esti2016/P-0018

Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to third-
party sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org

Page 1 of 32
Learning objectives

• To characterize the nature and severity of artifacts in thoracic Digital

Tomosynthesis (DT) generated from implanted medical devices
• To evaluate the influence from respiratory motion on these artifacts during
thoracic DT
• To understand the implications of these DT artifacts in ICU patients.

Background

Cardio-respiratory disease is the most significant cause of death in ICU patients. Patient
assessment is challenging with portable CXR due to superimposition of anatomical
structures, and imaging in the CT suite may be impractical or difficult.

Digital Tomosynthesis (DT) is an advanced x-ray technique which addresses anatomical

superimposition using spatial discrimination by using multiple small angle and low dose x-
ray projections to create a series of stacking planar images through the target of interest
(Figure 1). However, the x-ray tube scan motion trajectory and total time duration of
these image acquisitions create challenges for DT even in the out-patient situation. These
issues may become critical in ICU patients who most likely have difficulty in holding their
breath during a DT exam, and who may have a multitude of implanted devices [1]. In this
study the average image acquisition time for DT is 6.8 s, which can result in significant
respiratory motion artifact that causes obscuration of anatomical structures. We conduct
a survey of 100 consecutive CXR of ICU patients that demonstrates the distribution and
complexity of implanted multiple devices. We present examples of implanted devices in
an anthropomorphic chest phantom and evaluate the pattern of artifacts on DT images.
Also two examples of patient images with a port-a-cath and pacemaker are presented.

Common cardiorespiratory diseases in ICU patients.

· Identification of emergencies (pneumothorax),

· Early detection of new problems (ventilator associated pneumonia or atelectasis),

Page 2 of 32
· Assessment of volume status.

· Possible complications of placement - pneumothorax, pneumomediastinum,

pneumopericardium or free air beneath the diaphragm.

DT - principles, background

Digital Tomosynthesis involves the acquisition of images through the motion of the x-ray
tube along a scan path, such as the vertical axis (for standing patients) and horizontal axis
(for supine patients). This is illustrated in Figure 1. A total of 10 to 60 projection images
are acquired over 15 to 45 degrees. The projections are reconstructed to visualize planes
(parallel to the detector) within the patient- similar to CT. Different techniques such as
shift-and-add technique, iterative reconstruction techniques and filtered backprojection
techniques are available for reconstruction of the DT images [3]

DT images provides increased spatial discrimination as compared to chest radiographs

(CXR) hence resulting in reduced overlying clutter and improved feature conspicuity. This
illustrated in Figure 2 where the nodule (circled) is visible on the DT and CT but not on
the CXR. Figure 3 illustrates another DT slice of a patient in comparison with the CT slice
at the same location.

Figure 4 is a good illustrative example of the detail which can be seen in the DT image,
in the absence of motion and metallic artifacts. This is a cadaveric image hence there
is no motion. The right side of the chest has no devices to occlude the visibility of the
structures. The left-side of the chest however has a pacemaker which obscures some of
the detail in the lung parenchyma.

DT acquisition parameters and artifacts:

Acquisition parameters which affect the artifacts are: sweep angle, sweep direction, and
number of projections.

Sweep angle: It refers to the total arc from the first to the final projection about the center
of the detector.

Sweep direction: It is the direction of x-ray tube movement relative to the object or body
part of interest during the sweep.

Page 3 of 32
Number of projections: It is the number of projection images acquired during a single
sweep.

Commonly occurring artifacts in DT are:

Blurring: The imaging of structures outside the section plane causes blurring. Particularly
high contrast structures outside the image plane and its edges being perpendicular to
the sweep direction results in blurring artifacts.

Ripple: Ripple occurs due to similar mechanism as blurring artifact. This is illustrated
in Figure 7. When the high contrast structure is far outside the imaging plane, ripple
occurs. In fact the blurring artifact changes to ripple as the distance of the high contrast
structure from the imaging plane increases above a certain threshold. As the ripple artifact
is caused by the fact DT projection images are captured in pulsed exposure mode, by
increasing the projection density, i.e. the number of projections per unit sweep angle, the
ripple can be reduced significantly or eliminated.

Ghost artifact: When high contrast structures exist outside the section plane and its long
axis is parallel to the sweep direction. This artifact is caused by the DT reconstruction
algorithm.

Metallic artifacts: Due to the presence of various metal objects in the body - medical
devices such as pacemakers, ICD's as well as screws, metallic implants, various artifacts
arise. Depending on which slice is in focus and the orientation of the metal object with
respect to the DT scan direction, the artifacts can occur as aforementioned blurring
artifacts, ripple or ghost artifacts.

Motion artifacts: Due to the breathing motion of the patient, often blurring can occur in
the reconstructed images. This is illustrated in Figure 9.

Artifacts in ICU Patients

The artifacts observed in the regular patients are also observed in the ICU patients.
However in ICU patients, due to patient breathing motion and increased incidence of
medical devices, the artifacts will be exacerbated.

Page 4 of 32
Images for this section:

Fig. 1: The working of the Digital Tomosynthesis (DT) system in the table top position
and wall stand position to accomodate both the supine patient and standing patient

© Radiology, Toronto General Hospital - Toronto/CA

Page 5 of 32
Fig. 2: An increased spatial discrimination is achieved on moving from DR (digital
radiography) to DT (digital tomosynthesis) and CT (computed tomography). The overlying
clutter is reduced and feature conspicuity is improved.

© Richard S, Paul N.S. (March 2015) Evaluating Noise in images. Diagnostic Imaging
Europe pp. 82-85

Page 6 of 32
Fig. 3: Comparison of the DT image versus the CT image

© Radiology, Toronto General Hospital - Toronto/CA

Fig. 4: Digital Tomosynthesis of the thorax - pulmonary vasculature: Cadaveric Digital

Tomosynthesis images reconstructed posterior to the pulmonary hila demonstrating high
resolution images of the branch pulmonary arteries and veins in the right lung (inset)
using a slice thickness of 5 mm, a slice interval of 3 mm, full dose and 1x1 binning.

© Radiology, Toronto General Hospital - Toronto/CA

Page 7 of 32
Fig. 5: Blurring of the screws caused by (a) DT imaging with a vertical sweep direction
(b) with a horizontal sweep direction

© Machida H et al. (2010) Optimizing Parameters for Flat-Panel Detector Digital

Tomosynthesis, Radiographics, 2010, Vol 30, Issue 2, pp 549-563

Fig. 6: Illustration of the ripple artifacts due to the dorsal ribs which are located far outside
the imaging plane but are oriented perpendicular to the sweep direction.

© Machida H et al. (2010) Optimizing Parameters for Flat-Panel Detector Digital

Tomosynthesis, Radiographics, 2010, Vol 30, Issue 2, pp 549-563

Page 8 of 32
Fig. 7: Illustration of ghost artifact

© Machida H et al. (2010) Optimizing Parameters for Flat-Panel Detector Digital

Tomosynthesis, Radiographics, 2010, Vol 30, Issue 2, pp 549-563

Page 9 of 32
Fig. 8: Illustration of the artifacts caused by High-contrast wire on the various planes
along the sweep direction

© Machida H et al. (2010) Optimizing Parameters for Flat-Panel Detector Digital

Tomosynthesis, Radiographics, 2010, Vol 30, Issue 2, pp 549-563

Page 10 of 32
Fig. 9: Anthropomorphic lung phantom modified to simulate breathing motion

© Radiology, Toronto General Hospital - Toronto/CA

Page 11 of 32
Imaging findings OR Procedure details

The systematic survey of 100 ICU CXR demonstrated that 90% of patients had implanted
devices and 74% had more than 2 devices. The 4 most common devices were ECG
leads, cerclage wires, chest drains and nasogastric tubes. The bar graph summarizing
the types and number of devices is presented in Figure 10.

Some example cases of the CXRs of ICU patients are presented to provide an
understanding of the typical cases in terms of the device encountered occurring in the
ICU patients.

Phantom imaging

We present the artifact patterns observed on using two example devices 1) LVAD - left
ventricular assist devices 2) ICD - Implantable cardioverter-defibrillator.

LVAD imaging

The HeartMate II® left ventricular assist device (LVAD) was connected to the
anthropomorphic heart (Figure 15). DT images were acquired of the combination in
isolation and also inside the anthropomorphic phantom (LUNGMAN, Kyoto Kagaku)
- Figure 16. LVAD is battery operated mechanical pump which serves as assistive
devices for end-stage heart failure patients. It helps the left ventricle pump blood into the
remaining part of the body. From the survey of the ICU patients, the presence of LVAD in
patients is ~4%. However given the bulky nature of the device, the artifacts are expected
to be significant and it will be worthwhile to investigate artifact mitigation strategies.

Also the DT images were acquired at different dosages (30%, 50% and 100%) with fixed
KVp. The difference in the reconstructed images at different dosages is quite subtle.

ICD imaging

The ICD (was connected to the anthropomorphic heart. DT images were acquired of
the combination in isolation (Figure 21) and also inside the anthropomorphic phantom
(LUNGMAN, Kyoto Kagaku) - Figure 22. ICD (Implantable cardioverter defibrillator)
are battery operated devices to keep track of the heart rate. It helps in restoring and
maintaining normal heart rhythm by delivering an electric shock whenever an abnormal
rhythm is detected.

Page 12 of 32
Also a combination of the LVAD and ICD was placed into the anthropomorphic phantom
maintaining the clinical placement of these devices. Since the devices often occur in
combinations (74% of the ICU patients have 2 or more devices), this scenario provided
an insight into the degree of artifacts and if and how the artifacts from each of the devices
would combine with each other. This is illustrated in Figure 23.

Patient imaging

Figure 24 and 25 include the images of patient images with devices - port-a-cath and
pacemaker respectively. It is evident that accurate diagnosis would be difficult if the
particular features occured at the same regions as the medical devices.

Images for this section:

Fig. 10: Number of devices counted by type in 100 consecutive chest radiographs

© Radiology, Toronto General Hospital - Toronto/CA

Page 13 of 32
Fig. 11: Case 1: ICU patient with a tracheostomy tube, PICC catheters, NG tube, ECG
leads and surgical sutures

© Radiology, Toronto General Hospital - Toronto/CA

Page 14 of 32
Fig. 12: Case 2: ICU patient with NG tubes, chest wires, LVAD, pacemaker, ECG leads
and PICC line

© Radiology, Toronto General Hospital - Toronto/CA

Page 15 of 32
Fig. 13: Case 3: ICU patient with spinal instrumentation

© Radiology, Toronto General Hospital - Toronto/CA

Page 16 of 32
Fig. 14: Case 4: ICU patient with ECG leads, ECMO, Endotracheal tubes, Nasogastric
tubes and Central line

© Radiology, Toronto General Hospital - Toronto/CA

Page 17 of 32
Fig. 15: Anthropomorphic heart connected to LVAD

Page 18 of 32
© Radiology, Toronto General Hospital - Toronto/CA

Fig. 16: Experimental setup demonstrating the anthropomorphic heart connected to a

LVAD placed inside the cage of the anthropomorphic LUNGMAN

© Radiology, Toronto General Hospital - Toronto/CA

Page 19 of 32
Fig. 17: Comparison of the artifacts at different dosages (fixed KVp is maintained hence
at different mAs)

© Radiology, Toronto General Hospital - Toronto/CA

Page 20 of 32
Fig. 18: Illustration of ripple and blurring artifact depending on the slice (plane) in focus.
This relates to the illustration provided in Figure 8 where it is shown that the appearance
of the artifact changes based on the distance between the slice in focus and the object
location.

© Radiology, Toronto General Hospital - Toronto/CA

Page 21 of 32
Page 22 of 32
Fig. 19: Reconstructed images at different slice locations demonstrating the combination
of the anthropomorphic heart + LVAD

© Radiology, Toronto General Hospital - Toronto/CA

Fig. 20: Reconstructed images at different slice locations demonstrating the combination
of the anthropomorphic heart + LVAD + cage of the LUNGMAN

© Radiology, Toronto General Hospital - Toronto/CA

Page 23 of 32
Page 24 of 32
Fig. 21: Reconstructed images at different slice locations of the anthropomorphic heart
and Implantable cardioverter defibrillator (ICD)

© Radiology, Toronto General Hospital - Toronto/CA

Page 25 of 32
Fig. 22: Reconstructed images at different slice locations demonstrating the combination
of the anthropomorphic heart + ICD + cage of the LUNGMAN

Page 26 of 32
© Radiology, Toronto General Hospital - Toronto/CA

Page 27 of 32
Page 28 of 32
Fig. 23: Reconstructed images at different slices locations of cage of the LUNGMAN
(anthropomorphic phantom) + LVAD + ICD + anthropomorphic heart

© Radiology, Toronto General Hospital - Toronto/CA

Page 29 of 32
Fig. 24: Reconstructed images at different slice locations of a patient with a Port-a-Cath

© Radiology, Toronto General Hospital - Toronto/CA

Page 30 of 32
Fig. 25: Reconstructed images at different slice locations of a patient with a pacemaker

© Radiology, Toronto General Hospital - Toronto/CA

Page 31 of 32
View publication stats

Conclusion

It is essential to minimize or eliminate DT related artifacts in order to develop a robust

chest x-ray device for critically ill patients. Further research on techniques for reduction
of the DT related artifacts would be valuable.

References

[1] Hunter T.B. et al, Medical Devices in the Chest, Radiographics, 2004, Vol 24, Issue
6, pp 1725 -1744.

[2] Machida H. et al, Optimizing Parameters for Flat-Panel Detector Digital

Tomosynthesis, Radiographics, 2010, Vol 30, Issue 2, pp 549-563.

Personal Information

I hope you find the exhibit useful.

Please feel free to contact me at: shailaja.sajja@uhn.ca in case of any questions.

Page 32 of 32