Interventions with AXIOM – InSpace 3D
Clinical case studies from angiography –
3D display in neuroradiology
InSpace 3D
University Hospital of Würzburg 4 Subarachnoid hemorrhage with 6 aneurysm of right terminal internal
carotid artery
Symptomatic stenosis of the left 7 internal carotid artery
Contents
Hannover Medical School 8 Aneurysm of basilar tip 10 in 12-year-old girl
Subarachnoid hemorrhage 11 InSpace 3D is the standard tool for three-dimensional
visualization in angiography.
Today, 3D display is routinely used for neuroradiological interventions. For years, the established treatment of aneurysms and arteriovenous deformities has been coils or other embolisates. High image quality and the benefits of 3D display are finding application in an increasing number of areas, ranging from carotid stenting and abdominal aorta aneurysms to non-vascular studies. InSpace 3D receives two-dimensional X-ray rotational angiography images from an angiography system and uses them to create a (three-dimensional) volume that can be visualized on the syngo® LEONARDO workstation. The images can be acquired with all the angiography systems of the AXIOM Artis family.
The volume is displayed in real time through the Volume Rendering Technique (VRT) and can be rotated and manipulated by the clinician. The in-room control function and the ability to display the image in the exam room make it all possible without leaving the sterile environment.
InSpace 3D makes it possible to view the 3D
image at the exam table during the intervention, reach a diagnosis, and determine further treatment.
The 3D display on LEONARDO and 2D display on the imaging system are linked. A simple press of a button moves the C-arm into the display position of the 3D image and vice-versa. This allows pathologies found in 3D to be relocated under fluoroscopy without having to use radiation. Finding the optimal working position during interventions is quite easy. As a result, radiation is reduced and workflow accelerated.
By generating both native and subtracted volumes, e.g. bones can either be displayed or removed. VRT also allows transparent display of structures. This view into the morphology increases the reliability of the diagnosis using the 3D image and can accelerate the intervention.
AXIOM Artis MP
University Hospital of Würzburg
The neuroradiology department of the University of Würzburg under the direction of Prof. Dr. med. László Solymosi is among the most renowned neuroradiology facilities in Germany.
The following areas are emphasized:
• Interventional neuroradiology and the treatment of vascular abnormalities (aneurysms, AVM), highly vascular tumors of the head and spine, and stenoses and occlusions in the vessels of the head and neck. • Pediatric neuroradiology with radiological examination
of diseases of the pediatric nervous system (brain and spinal cord).
• Neurooncology with neuroradiological examination of tumors of the nervous system.
Each year approx. 700 angiographies, including 350 angiographic interventions, are performed using the AXIOM Artis BA biplane system.
“3D display allows us to see anatomical structures we just couldn’t see before. It helps us reach a more accurate diagnosis“.
Department of Neuroradiology
We have found that no other method provides the resolution and precision of the angiographic images. For our purposes, there is little competition.
The advantage of MRI is that no contrast medium is required. However, mainly blood flow is displayed, not the lumen itself. The lumen does display in CT, but a lot of contrast medium is required. Neither method can come close to the resolution of angiographic images. We use 3D display in angiography for intracranial
vessel malformations, especially aneurysms. We also use it to a lesser extent for planning angioma (AVM) intervention and stent implantation for severe carotid stenoses.
A better procedure selection means fewer complications.
3D display allows us to see structures we never could before. Choosing between a subsequent intervention or a surgical procedure is much simpler. It is possible to select the intervention more reliably.
Prof. Dr. med. László Solymosi
It is so easy to operate the system and generate three-dimensional views acquired with our angiography system. Calculation and image generation are reliable.
Subarachnoid hemorrhage
with aneurysm of right terminal
internal carotid artery
Case history and diagnostics:
Hospital admission of a comatose 42-year-old male. Skull CT [1.1], DSA of the right internal carotid artery [1.2] and rotational angiography with 3D display of the right internal carotid artery [1.3].
Diagnosis:
Subarachnoid hemorrhage, Grade IV per Hunt and Hess, with fusiform aneurysm of the right terminal internal carotid artery below the carotid T, with very wide neck. Treatment:
Endovascular coil repair to the right internal carotid artery above the ophthalmic artery and caudal placement of safety balloon.
Comments:
The 3D display [1.3] shows, in contrast to the DSA images [1.2], that the anterior choroidal artery is receiving its supply medially out of the aneurysm. Coiling the aneurysm would inevitably lead to an infarct of the posterior limb of the internal capsule and hemiplegia. The only option was to occlude the internal carotid artery above the ophthalmic artery. A test occlusion of the right internal carotid artery was first performed, which produced good collateralization of the right carotid flow area through the anterior ramus communicans. Occluding the right internal carotid artery blocked most of the blood flow to the aneurysm. Four weeks after the intervention, the patient showed only mild left-side hemiparesis.
[1.2] DSA right internal carotid artery,
anterior (A) and lateral (B): Display of the aneurysm of terminal internal carotid artery ( ). Unclear course of anterior choroidal artery ( ) [1.3 A+B] 3D-display of right internal carotid artery: Display of anterior choroidal artery, being supplied medially out of the aneurysm of the terminal internal carotid artery ( ) [1.1] CCT: Subarachnoid hemorrhage post-ruptured aneurysm of right terminal internal carotid artery ( )
Example 1
B A B ASymptomatic stenosis
of the left internal carotid artery
Case history and diagnostics:
Hospital admission of 63-year-old male with symptoms of right-side hemiparesis. Skull CT [2.1], DSA of the left internal carotid artery [2.2] and rotational angiography with 3D display of the left internal carotid artery, before and after stent implantation [2.3].
Diagnosis:
Subacute embolic infarct with symptomatic stenosis of the left internal carotid artery.
Treatment:
Endovascular stent implantation in the left internal carotid artery.
Comments:
Duplex sonography indicated probable 70% stenosis of left internal carotid artery. DSA revealed a severe stenosis in the outflow area of the left internal carotid artery with an ulcerated atheroma [2. 2]. An adherent thrombus, surrounded by contrast medium, posed
[2.1] CCT: Infarct in the supply area of the left middle cerebral artery ( )
Example 2
[2.3 A+B] 3D display of left internal carotid artery:
At right, before ( ) and at left, after stent implantation ( ) in left internal carotid artery [2.2] DSA of left internal
carotid: stenosis with free-floating thrombus ( ) in the left internal carotid artery
B A
The illustrated C-arm plays back the 3D projection angle to the C-arm. The cube on the lower right shows the orientation of the displayed volume.
The department of neuroradiology at the Hannover Medical School under the direction of Prof. Dr. med. Hartmut Becker has three main objectives: Research, teaching, and providing healthcare.
In 2002, they performed 2,880 DSA series,
105 myelographies, and 145 interventional procedures on two angiography systems. The AXIOM Artis MP universal angiography and fluoroscopy system was used to generate the 3D images.
“Without rotational angiography and 3D display, we need to acquire additional oblique or axial series to assess an aneurysm. Fewer series means reduced risk for the patient and lower costs“.
Hannover Medical School
Neuroradiology department of the Radiology Center
Rotational angiography produces much greater resolution than the competition.
This is significant for smaller aneurysms that cannot be identified with 100% certainty through CT angiography until they reach 4-5 mm.
We use 3D display in angiography primarily for precise localization and to assess the condition of intracranial aneurysms.
The acquisition of 3D views from rotational angiography contributes greatly to the choice between endovascular or surgical treatment of the aneurysm.
One benefit is the ability to evaluate the aneurysm from so many different views. Fewer image series and less contrast medium are needed, in particular with aneurysms that are difficult to pinpoint anatomically.
In less than 2 minutes, the data was transmitted to the LEONARDO workstation and the 3D view was reconstructed.
Aneurysm of basilar tip
in 12-year-old girl
Case history and diagnostics:
12-year-old girl with headaches and vision problems. Severe arterial hypertonia, probably nephrogenous, with generalized vasculitis. DSA of left vertebral artery [3.1], selective display of a basilar tip aneurysm [3.2] and rotational angiography with 3D display of left vertebral artery [3.3].
Diagnosis:
Aneurysm of the basilar tip involving the posterior cerebral arteries and the superior cerebellar arteries. Treatment:
Initial conservative treatment with medication because of generalized vasculitis.
[3.2] Selective DSA: Display of basilar tip
aneurysm ( )
Example 3
[3.3] 3D views of left vertebral artery: anterior (A), translucent anterior (B) and lateral (C): Display of basilar tip aneurysm ( )
Comments:
After DSA of left vertebral artery [3.1], selective display of the basilar tip aneurysm with microcatheter [3.2]. Subsequent rotational angiography with 3D display of left vertebral artery [3.3].
The rotational angiography was performed using a total of 9 ml of contrast medium (240 mg iodine/ml) at a flow rate of 2 ml/sec. This view into the morphology increases the reliability of the diagnosis using the 3D image [3.3].
C B
A
[3.1] DSA left vertebral artery lateral:
Display of basilar tip aneurysm ( )
Subarachnoid hemorrhage
with aneurysm of anterior
communicating artery
Case history and diagnostics:
47-year-old female with long history of alcohol abuse. The subarachnoid hemorrhage was first diagnosed and treated in the hospital ten days after rupture. Initial generalized severe vasospasms with subsequent development of prolonged cerebral ischemia. DSA of the left internal carotid artery [4.1], rotational
angiography with 3D display of the left internal carotid artery [4.2], and DSA of the left internal carotid artery after coiling [4.3] of the aneurysm of the anterior communicating artery.
Diagnosis:
Severe subarachnoid hemorrhage with symptomatic aneurysm of anterior communicating artery. Additionally, two infraclinoid aneurysms of the left internal carotid artery.
Treatment:
Coiling of the aneurysm of the anterior communicating artery.
[4.1] DSA left internal carotid artery: aneurysm of anterior
communicating artery ( ) and infraclinoid aneurysms of the left internal carotid artery ( )
Example 4
[4.3] DSA left internal carotid artery: Post-coiling of aneurysm of the anterior communicating artery ( ) A B
[4.2 A+B] 3D views of left internal carotid artery:
aneurysm of anterior communicating artery ( ) and infraclinoid aneurysms of the left internal carotid artery ( )
The illustrated C-arm plays back the 3D projection angle to the C-arm. The cube on the lower right shows the orientation of the displayed volume.
On account of certain regional limitations of sales rights and service availability, we unfortunately cannot guarantee that all products included in this brochure are available through Siemens sales organisation worldwide.
The information in this document contains general technical descriptions of specifications and options which do not always have to be present in individual cases. Availability and packaging may vary by country. The required specifications and options should therefore be specified in each individual case at the time of closing the contract.
Siemens reserves the right to modify the design, packaging, specifications and options described herein without prior notice. Please contact your local Siemens sales representative for the most current information.
Some options and functionality will not be available immediately on product release. Where certain options and functionality are not available on delivery, these will be delivered as part of subsequent software or hardware releases. Please confirm availability and timing with your Siemens representative.
In the event that upgrades require FDA approval, Siemens cannot predict whether or when the FDA will issue its approval. Therefore, if regulatory clearance is obtained and is applicable to this package, it will be made available according to the terms of this offer.
Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.
Please find fitting accessories: www.SiemensMedical.com/accessories
Siemens AG, Medical Solutions Henkestr. 127, D-91052 Erlangen
Siemens AG, Medical Solutions Angiography, Fluoroscopy and Radiography Systems
