DICOM and NMDICOM and NM

• Jerold Wallis, MDJerold Wallis, MD– Head of SNM DICOM Working GroupHead of SNM DICOM Working Group

– Past President of SNM Computer and Past President of SNM Computer and Instrumentation CouncilInstrumentation Council

• IHE 4-10-02IHE 4-10-02

DICOM in Nuclear MedicineDICOM in Nuclear Medicine

SNM DICOM Working Group

SNM DICOM Demo 2001

SNM DICOM Demo 2002

SNM & IHE Cooperation

ASNC DICOM Demo 2002

SNM & IHE CooperationSNM & IHE Cooperation

• Learn about IHE effortsLearn about IHE efforts

• Integrate NM into IHE demosIntegrate NM into IHE demos

• Use established IHE “network” to Use established IHE “network” to help distribute and get support for help distribute and get support for upcoming changes in NM DICOM upcoming changes in NM DICOM standardstandard

• Work with PACS vendors on Work with PACS vendors on display issues unique to NMdisplay issues unique to NM

Cardiac is KeyCardiac is Key

• Support for cardiac NM images is Support for cardiac NM images is currently lackingcurrently lacking

• Standards need to be definedStandards need to be defined

3rd party cardiac software authors

Camera vendors systems and databases

PACS systems and databases

Low cost generic viewers

Other NM systems

These (and a few subsequent images) are from the Autoquant cardiac package. Raw projections images from the spect cardiac acquisitions (rest and stress), each shown cineing simultaneously and synchronously .with controls below it for stepping or cineing at various rates and for separately adjusting the gray level of each.

Comments: These are static. PACS systems would receive this as a secondary capture. If viewed in an NM cardiac package, the 3rd column can be moved by the viewer to other orientations using the mouse as a 3D object. The white lines (edges) seen in the left two columns can be toggled on and off, possibly beyond the scope of a PACS system. Numeric quantitative data is shown in the lower right. Currently, this program only saves this as a single secondary capture object.

Comments: Same as prior slide. Numeric data now in alternate table format, with green region overly on top of images, and with application of a CLUT (palette) commonly used for interpretation. Currently, this program only saves this as a single secondary capture object.

Comments: PACS systems would receive this as a secondary capture object.

If viewed in an NM cardiac package, images are not cined, but there are controls to slide the rows back and forth. The row sliding is somewhat complex. The first slider controls the 1st and 3 rows, which slide as a single unit. The second slider controls the 2nd and 4th rows, which slide as a single unit. The 3rd slider controls the 5th row, the 4th slider controls the 6th row, the 5th slider controls the 7th row, and the 6th slider controls the last row.

Initial image scaling is somewhat complex as well. The stress (odd number rows) and rest (even number rows) images are scaled separately, each to the maximal pixel in the myocardium. Note that if intense bowel activity is present in the image but outside of the myocardium, the program does NOT scale to that. This requires detection of myocardial boundaries (or at least, the myocardial region), and saving such state for later use.

Image scaling can then be further adjusted as a whole (both stress and rest) or the rest and stress images can be fine-tuned individually as two units: the stress images are the odd numbered rows, and the rest image are the even numbered rows. Color palettes can be also be applied to the screen as a whole.

Comments: The second column in the red box is a (gated) cine. Detected myocardial boundaries are shown in this column as white lines. The white lines can be toggled off (possibly beyond the scope of a PACS display).

The two bottom right images with mesh-work on this page are gated 3D volumes, which move in realtime as the user rotates the 3-d volume to arbitrary angles using the mouse. This is likely outside the scope of a PACS display program.

Comments: Same dataset, with some (rarely used) overlays turned on, and with the white myocardial boundaries turned off.

Comments: Upper images are (gated) cines. Optionally, they can be moved to arbitrary angles using a mouse, likely beyond the scope of a PACS system. These are not currently saved to disk, except perhaps as AVI files.

Cardiac CinesCardiac Cines

• Multi-frame Secondary Capture?Multi-frame Secondary Capture?– Do you support it?Do you support it?

– If not, will you support it within 1 year?If not, will you support it within 1 year?

– Are overlays supported in definition?Are overlays supported in definition?

• Gated PlanarGated Planar– Less good alternativeLess good alternative

– Imperfect, but supported nowImperfect, but supported now

Non-Cardiac IssuesNon-Cardiac Issues

• FormattingFormatting

• ReslicingReslicing

• Palette color supportPalette color support

1024x1024 matrix whole body image, with body occupying only a small fraction of the image (the rest being zero or near zero background). Poor use of screen space. Can’t see knees, and posterior image (not shown) does not fit at all.

1024x1024, same data set, now shown with both anterior and posterior images after intelligent trimming to better use the screen real estate.

512x1024, 2 frame data set, also shown with both anterior and posterior images after intelligent trimming to better use the screen real estate. Slider at right controls image upper level, and slider at bottom controls lower level.

512x1024, same data set, now shown with assorted 256x256 spot images in addition to both anterior and posterior images. Image grayscale of spot images and whole body images can be adjusted separately.

Non-Cardiac IssuesNon-Cardiac Issues

• FormattingFormatting

• ReslicingReslicing

• Palette color supportPalette color support

A SPECT study. Note the manual controls to step through slices in the images . Also, the images themselves are "live", such that (for example) if you click on any spot on the coronal image, the transaxial and sagittal images will shift to the plane that includes the voxel clicked on. Only the transaxial dataset was supplied - the coronal and sagittal images were created on the fly.The lower right image (marked in red) is a cine of the 3D display of the same volume (supplied as a separate image file in the same series), with controls above it for stepping or cineing at various rates.

A screen of coronal images from same study as on prior screen, generated on-the-fly from the supplied transaxial dataset. It has manual controls to step through slices in the images, either one image at a time, or one screen at a time. There are also controls (not shown) to determine slice thickness, by combining adjacent slices.

A PET study. Note the manual controls to step through slices in the images . Also, the images themselves are "live", such that (for example) if you click on any spot on the coronal image, the transaxial and sagittal images will shift to the plane that includes the voxel clicked on. Only the transaxial dataset was supplied - the coronal and sagittal images were created on the fly. Cursors cross-hairs are shown,indicating relative position of images.The left-most image (marked in red) is a cine of the 3D display of the same volume (supplied as a separate image file in the same series), with controls below it for stepping or cineing at various rates.

Non-Cardiac IssuesNon-Cardiac Issues

• FormattingFormatting

• ReslicingReslicing

• Palette color supportPalette color support– Ability to switch to different color tablesAbility to switch to different color tables

– Ability to change upper and lower levels, Ability to change upper and lower levels, (not just window and width or brightness (not just window and width or brightness and contrast)and contrast)

Comments: More images from this cardiac package, currently saved as JPEGs . Stress and rest short axis images are gated on this screen.

Action ItemsAction Items

• Get support for cardiac cines from Get support for cardiac cines from PACS vendors in a specific formatPACS vendors in a specific format

• Convince cardiac software authors Convince cardiac software authors and camera vendors to support this and camera vendors to support this formatformat

• Decide on how NM can participate Decide on how NM can participate in upcoming IHE demosin upcoming IHE demos

• Get support for other NM display Get support for other NM display issues from PACS vendorsissues from PACS vendors

Other Examples of Cardiac Other Examples of Cardiac Screens from Different Cardiac Screens from Different Cardiac

PackagesPackages

Comments: Images are from another cardiac program (Wackers Lui), currently saved as JPEGs

Comments: More images from this cardiac package, currently saved as JPEGs

Comments: Standard stress and rest images from two short axis files, with generation of the vertical long and horizontal long axis images on-the-fly.

Comments: 3D renderings of the perfusion.

Comments: Emory Cardiac toolbox program, yet another cardiac package. Standard stress and rest images from two short axis files, with generation of the vertical long and horizontal long axis images on-the-fly. Lower right larger images are the stress and rest projection files, which are shown as cine files. Controls on right are used to scroll each pair of rows, either one-at-a-time or in pairs.

Comments: Bulleye processed screens (static)

Comments: More processed screens. I suspect the lower left images are gated, but have never used this system