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www.totoku.eu The new CCL650i2 When size matters - 6 Megapixel - 30inch - 800cd/m² brightness LEDBACKLIGHT C M Y CM MY CY CMY K EUROPEAN HOSPITAL Vol 23 Issue 5/14 RADIOLOGY Virtual assistance during procedures Delivering on dose reduction promises Neurosurgery aided by flight simulation technology Radiology and imaging Report: Cynthia E Keen The adage ‘practice makes perfect’ is applicable to every profession – but even more so for pilots and sur- geons. Flight simulation technology has been used for decades to hone aviators’ skills, and this technology is now being used by neurosur- geons to plan as well as practise surgical procedures and for real- time virtual assistance in operating theatre. Interestingly, products from Surgical Theater of Cleveland, Ohio, are the brainchild of a career Israeli Air Force flight simulation designer, Moty Avisar. Working with Dr Warren Selman, neurosurgeon-in-chief at the UH Case Medical Centre in Cleveland, Surgical Theater first developed a Surgical Rehearsal Platform (SRP) that received the USA’s Food and Drug Administration 510(k) clear- ance in 2013. The SRP uses CR or MRI images to create 3-D models. The model ena- bles surgeons to plan and practise a surgery, such as clipping an aneu- rysm. It enables users to make rec- ommendations on what size, shape, and placement of a clip would be best for a given patient, thus elimi- nating wastage of expensive clips that may be tried and rejected dur- ing surgery because they do not With more than 60 years in radiol- ogy, Zwanger-Pesiri is one of the largest non-hospital-based radiology practices in the USA. Among its 60 radiologists the number of special- ties include interventional, neuro, abdominal and cardiovascular radi- ology as well as musculoskeletal, breast and vascular imaging. With such a diverse, large patient base, and many radiologists to man- age, workflow is a key consid- eration, which is why the DX-D 300 DR system, with its Cesium Iodide detector technology and immediate image availability, was chosen. Workflow was the initial driver ‘We installed our first Agfa HealthCare DR solution, the DX-D 300, in our Elmont site in August 2013. We chose it primarily because the workflow was so efficient, it was easy for the technolgists to set up and images were quickly available. At the time, Agfa HealthCare was telling me about its dose reduction capabilities but, to be frank, I didn’t really believe them. They kept on about it, so we set up a study to compare results. ‘We had two competitive units from other suppliers on the same site, so that provided the ideal opportunity to test what they said.’ Study parameters The aim was to determine if the DX-D 300 needed less exposure and patient dose than two other systems used at Zwanger-Pesiri Radiology. It also compared doses used to those used for similar exams in other facil- ities, based on available published studies*. It comprised PA Chest, Lateral Skull and AP Hand expo- sures taken on phantoms used to simulate patient exposures.In each case the phantom was positioned just as a patient would be and the standard exposure made. 41 percent average dose reductions Results showed that, while the amount varied depending on the type of exam, the average dose on most was 41% lower with the Agfa HealthCare system versus the other systems – an admittedly unexpected result for Zwanger-Pesiri. ‘Much to my surprise, the DX-D 300 was able to provide high image quality at a lower dose,’ Dr Mendelsohn said. ‘For me, that’s great in one way and possibly bad in another. It’s good because we can promote our commitment to dose reduction to our patients and now have the figures to prove it, but,’ he adds laughingly, ‘it could possibly be bad, because the company will want to raise the price we pay! Although, to be honest, I would be prepared to pay a little more for the level of dose reduction we achieved. Agfa HealthCare has done a really won- derful job with it.’ A compelling story ‘Dose reduction has become a very compelling story; all radiologists need to be cognitive of is patient dose and aware that patients are becoming better informed and will increasingly ask questions,’ Dr Mendelsohn said. ‘Change will ulti- mately be driven from the grass roots rather than by radiologists because our financial model does not currently place a premium on it.’ Dr Mendelsohn acknowledges that, with the advent of Cesium Iodide phosphor detectors and Musica imaging processing software used with the DX-D 300 solution, the firm can now achieve the best of both worlds – significant dose reduction while radiologists still gain high quality images with which to work. ‘With so many sites, and such a large population to serve, our big- gest challenge is one of workflow,’ says Jeanine Sartorelli, Zwanger- Pesiri’s Chief Technical Officer. ‘To meet demand, we have a lot of teams that rotate across our sites, so ease of use when switching between solutions is paramount.’ A happy patient is the ultimate aim. ‘With the advent of Google and other information sites, patients are more knowledgeable and more prepared to question their dose exposure,’ Janine explains. ‘It’s great to be able to say that we are using the lowest possible dose for their images. With the automation and accuracy offered by the DX-D 300 with Cesium Iodide detectors and Musica, we can speed them through the process and make it easier for referrers to access their information.’ * Ernest K. Osei and Johnson Darko ‘A Survey of Organ Equivalent and Effective Doses from Diagnostic Radiology Procedures’ ISRN Radiology Volume 2013, Article ID 204346, 9 pages http://dx.doi. org/10.5402/2013/204346 provide the best fit. Alternatively, a surgeon could virtually position a patient and plan the point of entry that provides the best access to the surgical target. The Surgical Navigation Advanced Platform (SNAP) is an extension of SRP. It connects to a navigation sys- tem (such as the Brainlab Curve or the Medtronic Stealth), which allows a surgeon to view a 3-D representa- tion of the patient’s cranial anatomy in the operating theatre and navi- gate off it. SNAP provides the ability to rotate an image or make it semi- transparent to see behind arteries and other critical structures, some- thing not previously possible to do. Dr Selman, who is also chief medi- cal officer of Surgical Theater, has used SNAP’s automated reality and simulation capabilities to pause the navigation scene during surgeries to rotate a 3-D image to verify that he had completely removed a tumour. The neurosurgery department of Mount Sinai Hospital in New York City started using SNAP in July 2014, immediately following FDA clear- ance on 30 June 2014. Department chair Dr Joshua B Bederson advised European Hospital that he has been using SNAP in the operating room for a rapidly growing number of surgeries. He compared the technol- ogy with that of watching football on television, where multiple cam- eras positioned in a stadium can show different angles of an image, or freeze it, zoom in, and enable the viewer to think about other ‘what if’ scenarios. ‘I currently use the SNAP to pause navigation during surgery, allowing me to rotate, expand, or cut away parts of the image. This allows me to confirm that vital structures are safe- ly protected, that I removed a spe- cific portion of the tumour, and that I am not threatening critical brain arteries,’ explained Dr Bederson. ‘I’ve also found that connecting Snap to an intraoperative naviga- tion platform enhances coordination among team members.’ Steven Philemond, a clinical research coordinator in the hospi- tal’s neurosurgery department, said that Mount Sinai has not compiled any quantifiable data to determine whether SNAP use has minimised the length of a surgical procedure. ‘However,’ he said, ‘it does reinforce a neurosurgeon’s confidence in the approaches to cases. Failing to pick the proper trajectory may also add on time to the case. The 3-D render- ing that the SNAP provides allows both neurosurgeons and residents to have the ability to re-orient them- selves during the case.’ Other valued uses: Mt. Sinai uses the SNAP as a rehearsal and training platform for neurosurgeons and residents. Philemond said that residents use the system to review cases where surgery has already taken place, plan their approach and rehearse the procedure. They then view the intraoperative video to see how the actual procedure compares to the approach they out- lined. The SNAP system also can interface with videoconferencing and video streaming systems, offer- ing residents and neurosurgeons throughout the world the chance to view the surgical procedures in which it is used. Dr Bederson presented the tech- nology in a scientific session at the annual meeting of the European Association of Neurosurgical Societies this October in Prague. Surgical Theater also will be an exhibitor at EANS 2014. The company anticipates receiv- ing a CE Mark approval for both SRP and SNAP within six months. SNAP is used as a rehearsal and training platform for neurosurgeons and residents System shows 41% lower dosage than others Dr Bederson using the SNAP in the operating theatre The DX-D 300 DR system in use at Zwanger-Pesiri Radiology CourtesyofMountSinaiHospital,DepartmentofNeurosurgery Committed to dose reduction, Steven L Mendelsohn MD, CEO and Medical Director of Zwanger-Pesiri Radiology, New York, believes a change in attitudes will be driven by patients rather than radiology professionals 14

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