Advanced Visualization: A Do-it-yourself Approach

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With three-dimensional and other advanced visualization tools being used for a greater share of CT and other imaging studies, it is more important than ever for radiologists to have access to postprocessing software and equipment at the point of interpretation.

It is equally important for radiologists to develop and keep up their skills in using these tools. This means that hospitals and radiology practices must decide which kinds of advanced visualization tools they will put in place and where and how they will deploy them. Will they opt for enterprise-wide, single-vendor solutions, or will they choose best-of-breed approaches that might limit image distribution in favor of the ability of one vendor’s tool to perform a task particularly well?

At Albert Einstein Medical Center (AEMC) in Philadelphia, both approaches are used. Radiologists have access to advanced visualization tools embedded in their PACS software (Synapse from FUJIFILM) as well as a thin-client advanced visualization tool that has been interfaced with the PACS, tools powerful enough to handle the majority of the radiologist’s post processing needs. For other studies, like virtual colonoscopies, the hospital uses specialized post-processing tools.

Terence A.S. Matalon, MD, FACR, FSIR, is chair of the hospital’s department of radiology. He has been at AEMC for five years and has seen the hospital progress, he says, from largely film-based imaging to the PACS-based operation of today. Matalon says that about half of his time is spent administratively. During the other half, he’s a clinician who splits his time equally between interventional and diagnostic radiology, with the bulk of the diagnostic work involving CT. He recently shared his approach to volumetric imaging with

AEMC is a tertiary-care teaching hospital affiliated with Philadelphia’s Jefferson Health System and Thomas Jefferson University. AEMC has about 20 radiologists on its faculty, and each year, it admits 24 radiology residents. The radiology department performs about 250,000 diagnostic examinations annually, according to the hospital’s Web site.

Start Thin
Because advanced visualization is used more and more in CT imaging and, to a lesser extent, in MRI and ultrasound, Matalon says that it’s mandatory for radiologists who are going to be looking at multislice examinations to have access to postprocessing tools. He is also a stickler about radiologists doing—or at least being able to do—their own reconstructions.

Matalon says that one core concept at AEMC is to start with thin CT slices and build from there. A second is to have ubiquitous access to post-processing tools that can be accessed through PACS. This is the foundation that broadens to more specialized postprocessing when needed.

“We take the approach where we acquire the thinnest slices available on every patient that we image using CT,” Matalon says. “We send those images both to PACS (Synapse from Fujifilm) and to our 3D solution, which happens to be TeraRecon, as a default for every patient. That allows us, with a single click, to bring up 3D applications with that particular patient’s images already loaded right from the PACS, so the threshold associated with manipulating those studies is very low. Anyone interested in using a 2D or a 3D multiplanar reconstruction has very, very low work to be able to do that,” Matalon says.

“The technologists will not only send thick and thin slices to the PACS, but will also routinely send coronal and sagittal reconstructions to the PACS,” he adds. “Whenever we bring up a patient, the axial, coronal, and sagittal reformats are immediately available to us as part of that patient’s default presentation.”

For any off-axis views or 3D work, the radiologists can bring up the third-party application and produce added images that can be sent to PACS.

Matalon makes the point that a big part of the value that radiologists add to the diagnostic process is their ability to create reconstructions themselves. “For CT angiography—for example, of the aorta and the lower extremities—the technologist will typically obtain routine 3D reconstructions and send those to PACS. My personal opinion is that, in general, these are not adequate for my purposes, and I will routinely produce my own. In the process of interpreting exams, I will use the 3D tool to evaluate the patient’s dataset. I will create what I call a movie for the clinicians and for anyone else who follows me. That