Instructions for use - VueBox® - Quantification Toolbox
Contents
1. For the specific case of Focal Liver Lesions FLL the Dynamic Vascular Pattern DVP can be used to highlight how the contrast agent is being distributed in the lesion compared with the healthy liver tissue Therefore the hyper enhanced and hypo enhanced pixels are being displayed over the time Hyper enhanced areas are displayed using warm colors whereas hypo enhanced ones are represented with cold hues DVP signal is defined as the subtraction of a reference signal from pixel signals fovr x y t f x y t OG y frer t Ogerl Where f is the instantaneous signal and O the offset associated with x y pixel coordinates On the basis of this result the software will display a curve representing the distribution of the contrast agent a b c 15 10 Healthy parenchyma REFERENCE Healthy parenchyma REFERENCE csion 1 esjon 1 REFERENCE _ csion 2 esion 2 REFERENCE 3 ms G 10 5 NE en 7 be am m may bs 5 P ne i VA T M a j D i ES h iy F i E JE 0 t ve T Z 5 l L li li li J 0 20 40 60 80 100 120 Time s Figure 19 DVP processing In the above figure a represents a simulation of the perfusion kinetics of healthy parenchyma taken as the reference black of a fast washing lesion 1 red and of a slow washing lesion 2 green b is the DVP processed signals expressed as differences of echo power signals wit2. Select a shape in the ROI toolbar a or W Move the mouse pointer to the wanted location in the B mode image left side or the contrast image right side Click and drag to draw the ROI To draw a closed polygonal or curved ROI Select a shape in the ROI toolbar E or Move the mouse pointer to the wanted location in the B mode image left side or the contrast image right side 3 To add anchor points click repeatedly while moving the mouse pointer 4 Double click at any time to close the shape DELETING A ROI To delete a ROI 1 2 3 4 Right click in the image to set the ROI selection mode or click the IN button Move the mouse pointer to any border of the ROI Select the ROI using the left or right mouse button Press either the DELETE or BACKSPACE keys MOVING A ROI To change the location of a ROI Right click in the image to set the ROI selection mode or click the button Move the mouse pointer to any border of the ROI When the pointer shape changes to a double arrow click and drag the ROI to a new location EDITING A ROI To change the location of anchor points of a ROI Right click in the image to set the ROI selection mode or click the L5 button Move the mouse pointer to any anchor point of the ROI When the pointer shape changes to a cross click and drag the anchor point to a new location COPYING AND PASTING ROI Regions of interest can be copied into a ROI library and pasted at a late
3. previously analyzed in the start page of VueBox Click OK to save the current Result Save As Date Time 27 01 2011 10 33 49 Figure 32 Result database dialog box The result database is automatically displayed when saving a result or loading a clip for which previous analyses exist SAVING AN ANALYSIS To save the current result 1 Click the E button in the main toolbar 2 Under Save as type the result name 3 Click the OK button To overwrite a result 1 Click the button in the main toolbar 2 Select a result in the list 3 Click the OK button To remove a result 1 Click the button in the main toolbar 2 Select a result in the list 3 Click the DELETE button O A 4 15 EXPORT ANALYSIS DATA 4 15 1 PRINCIPLE VueBox offers the possibility to export numerical image and clip data to a user defined directory For example the numerical data are particularly useful for carrying out further analyses in a spreadsheet program The image data are a set of screenshot containing both the regions of interest and parametric images These images allow to perform qualitative comparisons between successive studies in the course of a therapeutic follow up on a given patient As a second example of qualitative analysis the processed clips may provide a better assessment of the contrast uptake over time Still images or processed clips may also be useful for documentation or presentation purposes Finally an analysi
4. x a opens and concatenates a clip with the current clip MOVE HB moves up the selected clip in the Clip selector list selected clip selected clip Move down EB Delete removes the selected clip from the Clip selector list C1 selected clip moves down the selected clip in the Clip selector list sets the transition delay in seconds between the beginning of the selected clip and the end of the previous one to account for this delay in the analysis Transition delay Clip selector selects a clip in the list 4 7 5 FLASH IMAGE DETECTION The selection of the perfusion model i e Bolus or replenishment can be performed in the clip editor So as to reduce the risk of selecting a wrong model e g the replenishment model for a bolus injection the replenishment button becomes active only if the software has detected flash images in the dip The flash detection is an automatic process launched every time a clip is loaded in VueBoxQ Original Clip Editor Hash image a detection Figure 8 Flash image detection The automatic flash image detection progress can be seen in the clip editor toolbar as Shown in the figure above In some cases this detection may not be accurate Therefore you may want to cancel it when the automatic detection is not accurate or fails To cancel this flash image detection or to remove unwanted flash images 1 if the detection is still being performed click on the X x Th
5. IMAGING VueBoxQ can perform spatial rendering of any perfusion parameter in the form of a color rendered parametric map This map synthesizes the time sequence of images into a single parametric image Parametric imaging may enhance the information content of the contrast examination This technique may be particularly useful for making qualitative analyses in the course of a therapeutic monitoring performed on a given small animal In the example of using the destruction replenishment technique the efficacy of a substance inhibiting angiogenesis may be assessed by observing parametric images of relative blood volume rBV in a tumor before and in the course of therapeutic treatment reflecting the state of tumor perfusion resulting from the neovasculature A second benefit of parametric images is the spatial visualization of tumor response to the treatment or its effects on healthy surrounding parenchyma Note that in order to perform qualitative analyses on the basis of parametric images certain recommendations must be made e the clips must represent the same anatomical cross section from one exam to another e acquisition of contrast ultrasound sequences must be performed using identical system settings primarily transmit power display settings gain TGC dynamic range and post processing e only parametric images of the same perfusion parameter can be compared Figure 24 Parametric images example 4 13 11 WORK
6. for determining if artifacts are present in the data to be analyzed Artifacts can severely affect the analysis outcome and require a reacquisition Examples of artifacts are e Obvious discontinuity due to a jerky motion during acquisition or because the acquisition plane changed e excess shadowing in images e poorly defined anatomy or evidence of distorted anatomical representation In the case of a poorly reconstructed image as determined by the above criteria e g artifacts or by the user s clinical experience and training measurements should not be made and must not be used for any diagnostic purposes The user must ensure the accuracy of the images and measurement results Acquisitions should be repeated if there is the slightest doubt as to the accuracy of images and measurements The user is responsible for a suitable length calibration In case of incorrect usage wrong measurement results may occur The user should always make sure to select the appropriate calibration according to the ultrasound system probe and settings used This control should be performed for each clip to be analyzed 2 INSTALLATION 2 1 SYSTEM REQUIREMENTS Minimum Proposed CPU Intel Pentium 4 520 Intel Core 2 Duo E8400 or better RAM 1 LB 2 2GBormoe or more C Card c GeForce 8500GT 512DDR Io GeForce 8800GT 1024DDR Minimum Resolution 1024x768 Resolution 1280x1024 and higher 17 SVGA
7. the interface elements in the clip editor in the replenishment mode idi Clip1 1 289 590 r Original clip editor Replenishment Repl 1 2 amp Bolus Menscturer name SIEMENS Model name Sequam 512 4C1 OPS 3098 PP Deta Figure 7 User interface in the clip editor in the replenishment mode Element Name Image display 60 286 Image number Time indicator Zoom In Out Image slider Image status bar Play Fast play Dearrn Ciliccn Ch CAEEuiarn Agente Ame Bracco Suisse SA Software Applications Function shows the order number of the currently displayed image as well as the total number of images available in the clip shows the time instant of the currently displayed image increases or decreases the image size selects the image to be displayed If the cursor points to an excluded image a red frame appears around it shows excluded and included image ranges in red and green respectively Destruction images are shown in orange runs the movie player runs the movie player in fast mode V D 4Q 44 40 VBO 8 11 LI SS OO Clip editor Exclude sets the exclusion mode Include sets the inclusion mode amp Add Flash marks the current image as flash see section 4 7 5 Replenishment selects the previous next replenishment 4 segment segment only available if the clip includes selector destruction replenishment segments 4 7 3 WORKFLOW EXCLUDING IMAGES To exc
8. Bracco recommends activating the dual display mode when available as this feature increases the robustness of the motion compensation algorithm Default values are kept in memory from one session to another e g last ultrasound system used etc Therefore it is important to make sure that these settings are correct before continuing with the analysis The user should make sure that the clip frame rate read from the DICOM file and displayed in the video settings panel is correct before pursuing the analysis An incorrect frame rate may result in a wrong time base and thus affect the computed values of perfusion parameters 4 6 CALIBRATION FILES Calibration files contain the appropriate linearization function and color map correction for a given ultrasound system and specific setting i e probe dynamic range color map etc Using calibration files the VueBox can convert video data extracted from DICOM clips into echo power data a quantity directly proportional to the instantaneous concentration of contrast agent concentration at each location in the field of view Bracco Suisse SA Software Applications VBO 8 11 i 5 5 Calibration files are distributed to users according to their ultrasound system s e g Philips Siemens Toshiba etc and can be added to VueBoxQ by a simple drag amp drop into the VueBox user interface The most common settings are available for each ultrasound system Howev
9. CRT 19 TFT Flat Screen or higher Additional Requirements Operating System Microsoft Windows VISTA SP1 32 bit 64 bit Microsoft Windows 7 32 bit 64 bit Microsoft Windows 8 32 bit 64 bit Microsoft Windows 10 32 bit 64 bit 36 dn Please make sure that your screen resolution fulfills the minimum requirement and that your DPI Dots Per Inch setting is set at 96 2 2 INSTALLATION OF VUEBOX The installation package of VueBox includes the following mandatory prerequisites e Microsoft NET Framework 4 5 1 e SAP Crystal Report Runtime Engine for NET Framework 4 0 e Visual C 2010 Runtime Libraries e Visual C 2012 Runtime Libraries During the installation procedure you will be automatically prompted if any of these prerequisites needs to be installed Please perform the following steps in order to install VueBox 1 close all applications 2 run the setup exe installation package located in VueBox installation folder 3 accept the installation of the prerequisites if not already installed 4 select the installation folder and press Next 5 follow the on screen instructions 6 atthe end of the installation press Close The installation is now complete VueBox can be started from the VueBox folder in the start menu or more directly using the desktop shortcut VueBox can be uninstalled through the Add Remove software feature from the Windows control panel SS Jo CEN
10. E 2 3 ACTIVATION OF VUEBOX At first start up VueBox launches an activation process that will validate and unlock the copy of the software application In this process you will be prompted to enter the following information e Serial number e E mail address e Hospital Company name The activation needs to communicate these information to the activation server This can be performed automatically through the online activation or manually using the e mail activation In the online activation VueBox will be activated and unlocked automatically by simply following the on screen instructions In the e mail activation an e mail including all necessary information for the activation of VueBoxQ will be generated and you will be asked to send it to the activation server e mail address will be displayed Within a few minutes you will receive an automatic reply by e mail including an unlock code This unlock code will be required at the next start up of VueBox to finalize the activation process Please note that this activation process either through the online or the e mail method needs to be performed only once 3 GENERAL REVIEW TOOLS 3 1 INTERFACE ELEMENTS 3 1 1 MAIN TOOLBAR Available in mode Item Function Clip Motion Result Comments editor comp DRE kum editor Return to the clip editor mode Length Set a known distance in the image Calibration to calibrate for length and area measurements Not av
11. FLOW To perform perfusion data processing click the button 2 in the Bolus case only accept modify or ignore the automatic contrast arrival detection 3 review the result in the result window 4 14 RESULT WINDOW 4 14 1 INTERFACE ELEMENTS Once the perfusion quantification processing is completed VueBox switches from the clip editing mode to the result mode The display layout in the result mode comprises four quadrants Q1 Q4 The four quadrant representation combines all results within one display namely e Original clip Q1 e Processed clip or parametric image Q2 e Chart displaying time intensity curves linearized and fitted signals in each ROI Q3 e Table listing the computed parameter values in each ROI Q4 Q1 displays the original clip and Q2 a processed clip or a parametric image depending on the selection in the Parametric image view menu Each parametric image has its own colormap which is rendered in the colorbar located in the lower right corner of Q2 For amplitude perfusion parameters the colormap ranges from blue to red representing low to high amplitudes respectively As regards time parameters the colormap is a reversed version of the colormap used for amplitude parameters In Q3 the colors of the traces match those of the ROI When a ROI is moved or modified its corresponding signals and computed values are automatically and immediately recalculated and displayed in Q4 The ROI label
12. L VueBox Quantification Toolbox Instructions for use Copyright 2015 Bracco Suisse SA Bracco Suisse SA Software Applications VBO 8 11 1 This publication may not be reproduced stored in a retrieval system distributed recreated displayed or transmitted in any form or by any means electronic mechanical recording or otherwise in whole or in part without prior written authorization by Bracco Suisse SA If publication of this work should occur the following notice shall apply Copyright 2015 Bracco Suisse SA ALL RIGHTS RESERVED The software described in this manual is supplied under license and may only be used or copied in accordance with the terms of such license The information in this manual is for instructional use only and is subject to change without notice REF VueBox v6 0 Bracco Suisse SA BRACCO Suisse S A O S Software Applications ud Software Applications BR ACCO 2015 09 31 route de la Galaise 1228 Plan les Ouat es Gen ve Suisse fax 41 22 884 8885 CE rw bac cen LIFE FROM INSIDE 0086 CONTENTS ETON 5 L1 ADOUC THIS VAM Al uussuucecunu uuu cuida xxu EE DNE x xxx XXXKKEXKNEXKKKEREEREKKEEREREE KNEES 5 1 2 Interpreting symbols of the product 5 L3 D LT LL AT oe dada ee rrr rrr rrr rrr rer ccc 6 L4 System description La 6 L5 Lee Eee een ee ee rrrrrrrrrreeeeeeeeeerrrrrrrrrrr rrr re 6 L5 Product ITS dende 7 1 7 Satety precautions saisis onuEEE
13. XEREERRENEEEMEEENIEIENINEREEEIIIE MINE RNRE NIU E EIE 7 1 8 Installation and maintenance nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn 7 1 9 Patient and user safety Jr 7 1 10 Measurement nan MA AD AON CN RE RERO HERE RHET ARCH CA RR 8 2 Triad E eee ee 9 21 System RequIremMments samedi 9 2 2 Installation or VUEBOXEB LL 9 2 3 Activation ON BON Lur 10 3 General review COOKS s 11 3 1 nterace elements sssrin 11 3 1 1 METODE 11 3 1 2 SIGS COON EN 12 4 Functional Reference n nnnnunnnnnnnnnnnnnnnnnnnnnnnnnnnnnunnnnunnnnnnnnnnnnnnn 13 4 1 User NENNE 13 4 2 General WOFKTIOW sssssEERRAERREKENEESESEESEEEEEEISRRRRRRRRRRRRRRRRERRRRRRRERREENE EE EE EE 15 4 3 Specific application packages eere 15 4 3 1 A ALES n 15 4 3 2 PANNA 15 4 3 3 GI Perfusion General Imaging Perfusion Quantification 16 4 3 4 Liver DVP Focal Liver Lesion eseennn mmm 16 4 3 5 DE 16 16 4 4 Supported datasets xnnnnnnnnnnnnnnnnnnnnnunnnnnnnnnnnnnvnnnnnnnnnnnvnnnnnnnnnnunvnnn 16 AS Video Settings ussssesessssstzz exVEEEREREKERAMEERERRR VR AREE RR RAVE M RR ENTRE FEEFEEEREEEE 17 46O OF ee el Tes RENE 17 4 7 CD EAN H re 18 4 7 1 aslneo cm O 18 4 7 2 Interface elements sas aaa raa aa aaa aan 18 4 7 3 OG EE di id dd Ed de eae 20 4 7 4 Clip concatenation nne hh enhn nhan 20 4 7 5 Flash im
14. age detection is hr rre 21 4 8 Regions of InteresE sag ww Rx c a E CER e EG Rl ww RR RR 22 4 8 1 Fe EE 22 4 8 2 Interface elements nennen nenas nana asses ra aa aaa nan 22 4 8 3 Woden 23 4 8 4 Dust aspis OR nana dE 24 4 9 Length calibration and measurement eere 26 4 10 Anonymization of clip annnnnnnnnnnnnnnnnnnunnnnnnnnnnnnnunnnnnnnnnnnunnnnnnnnnuuunnun 27 4 11 ADO OI ONE a rrr rrr rrr rrr rrr EE EE EIE IMMUNE 27 4 12 Motion compensatiON nnnnuunnnnnnnnnnunnnnnnnnnnnnnunnnnnnnnnnnvnnnnnnnnnunvnnnn 27 MEE ideis oo 27 M Mb ieudie T Tee 27 4 13 Perfusion data processing 1 eere e enn nnn nn nn nnn 28 MO PN ERR 28 215 2 Linearized signal EEE EEE 28 LL NLA deti eseevasveswwsdevewwwwwwsdesewnis 29 4 13 4 SKP 29 4 13 5 PANNEN FEE FYF rre PEU ERE re 29 4 13 6 Dynamic Vascular PAS cena eepa chansons 32 4 13 7 Dynamic Vascular Pattern Parametric c cece cece cece cece eee eeeeeeeeeaeenaes 32 4 13 8 Perfusion Segments Analysis 33 4 159 Measurement acceptance AMEN suco iisuiisicieis eie mkisivicioiieitieie enis om norms wii m 36 d 15 19 PETE NNN 36 4 13 11 VNR 37 4 14 Result NINA NNN 37 4 14 1 TSN 37 4 14 2 Adjustable display PpreSets cccccsccceeccnececeeeteueecercenetanesuneeurseuesags 38 4 14 3 Auto scaled display presets ccc cece cece cece cece eee tees eeeeeeeeeeeeeaeenanenaes 39 4 14 4 Storing loading
15. ailable in the segmentation Copy ROI Paste ROI packages Motion Copy all ROI of the current active window into the ROI database compensation Paste selected ROI set from the ROI database Apply spatial realignments on all images using a specific reference image Not available in the segmentation packages Perform perfusion quantification or calculate DVP according to selected package Store a result file analysis result context into the result database Not available in the segmentation packages Validate segmentation Save the segmentation results Only available in the segmentation packages Export data Export selected data e g quantification data screenshots movies Not available in the segmentation packages Perfusion data processing Display the about screen O 11 Exit X X X Close all clips opened and exit the software 3 1 2 SIDE TOOLBAR Available in mode Item Function Clip Motion Result Comments editor comp Import Import export user settings i e Export user ROI result and display preset settings databases Length t quem distances in the image Measurement PO nn mr ere Pk text labels on images EB MEM patient s name and identification 7 Do 4 FUNCTIONAL REFERENCE p To get instant help on working with VueBox click the eo button in the main toolbar and click the help button You will need Adobe Acroba
16. al Imaging Perfusion Quantification package contains generic perfusion quantification tools including both Bolus and Replenishment perfusion models see section 4 13 5 allowing to extract quantitative perfusion estimates through perfusion parameters in general radiology applications cardiology excluded 4 3 4 LIVER DVP FOCAL LIVER LESION The Focal Liver Lesion dedicated package contains the following specific tools for the analysis of FLLs e Liver dedicated Bolus perfusion model i e Bolus Liver e Dynamic Vascular Pattern see section 4 13 6 e Dynamic Vascular Pattern Parametric see section 4 13 7 e Customized analysis report see section 4 15 4 These tools allow the enhancement of blood perfusion differences between liver lesions and parenchyma This package does not include any perfusion quantification tools aS Opposed to the General Imaging Perfusion Quantification Package 4 3 5 PLAQUE The plaque package contains tools dedicated to the quantification of atherosclerotic plaques To identify vulnerable plaques specific tools are available such as e Perfused Area see section 4 13 8 e Relative Perfused Area rPA e Mean MIP Opacification MIP e Mean MIP Opacification Perfused Pixel only MIP th 4 4 SUPPORTED DATASETS VueBox supports contrast ultrasound 2D DICOM clips of systems for which linearization tables are available also called calibration files Other datasets such as Color Doppler clips B mo
17. angular shape to where the information to be hidden is located in the image 5 Figure 15 Anonymization mask 4 11 ANNOTATION The Annotation Tool is used for labeling important parts of the image for instance the lesion type After selecting the tool click at a desired location for the annotation in the image Then the software displays a dialog box in which you may enter text Annotations can be moved or deleted exactly like ROIs using either the DELETE or BACKSPACE key 4 12 MOTION COMPENSATION 4 12 1 PRINCIPLE Motion compensation is a key tool for allowing reliable perfusion assessments Motion in a cip can be due to internal organ movements such as breathing or to slight probe movements Manual alignment of individual images is extremely time consuming and thus not proposed in VueBox VueBox provides an automatic motion correction tool to correct in plane breathing motion and probe movements by spatially realigning anatomical structures with respect to a user selected reference image Lateral Motion breathing Automatically Compensated Motion Time Figure 16 Motion compensation example 4 12 2 WORKFLOW To apply motion compensation 1 Move the Image slider to choose a reference image 2 Click the A button in the main toolbar 5 5 e 3 Once motion compensation is applied the native clip editor is replaced by a motion corrected clip editor where the clip resulting from the m
18. ated such as wash in rate WiR peak enhancement PE rise time RT or area under curve during wash in WiAUC Time parameters e g RT can be interpreted in absolute terms and amplitude parameters e g WiR PE and WiAUC in relative terms vs values in a reference region VueBox can display the spatial distribution of any of these and other parameters synthesizing time sequences of contrast images into single parametric images Models are provided for the two most common modes of administration bolus wash in wash out kinetics and infusion replenishment kinetics after destruction For the specific case of Focal Liver Lesions FLL the Dynamic Vascular Pattern DVP of a lesion in comparison with its surrounding healthy parenchyma is displayed Moreover the DVP information over time is summarized in a single parametric image defined as Dynamic Vascular Pattern Parameter DVPP For the quantification of atherosclerotic plaques as a way to identify vulnerable plaques specific tools are necessary These tools include a multi scale graph specific perfusion quantification methods and specific quantification parameters such as Perfused Area PA relative Perfused Area rPA 1 5 INTENDED USE VueBox is intended to assess relative perfusion parameters in radiology applications cardiology excluded based on 2D DICOM datasets acquired in Dynamic Contrast Enhanced Ultrasound examinations SS 5 5n EROOOO The visual
19. de clips and contrast B mode overlay displays are not supported 5 9 For ASR compatible Advanced System Recognition ultrasound systems linearization is performed automatically and manual selection of a calibration file is not required More information can be found on http vuebox bracco com In general bolus clips longer than 90 seconds are recommended so as to include wash in and wash out phases Replenishment clips can be substantially shorter 4 5 VIDEO SETTINGS The video settings panel is shown when a clip is loaded in the software In this panel you need to Sub sampling rate e define the desired sub sampling rate if needed so as to reduce the number of Pr EE frames to be processed optional e select the appropriate ultrasound system and settings used for the acquisition so as to apply the correct Model name Sequoia 512 linearization function to the image data Settings 4C1 CPS 80dB PP1 Detta2 mandatory Manufacturer name SIEMENS e activate the dual display mode if the clip was recorded with both contrast and Dual display fundamental B mode images side by side 2 Of or above each other on screen optional Gain compensation e select the gain compensation so as to Overal 0 22 compensate for gain variations across different exams in order to be able to compare results of a given patient at Figure 5 Video settings panel different visits optional
20. display preset mH mmn 39 4 14 5 Parametric image OV ra Vi ss addu a EROR BADEN A Re CR GR IER OCC COR be 40 4 14 6 Perfusion instant detection nnn nnne nnne 40 RE ME Analysis result dataDa vidas ane aba a ee se istius 41 4 15 Export analysis Gate ssssss ss RA NM M DX RD NIORT uses cesser 42 2m MEE Plura 42 4 15 2 Interface elements eene mh hhnmhhh ehh rana rara 42 ON T mM 43 AAS Analysis FENG 43 4 16 Import and export user settinNngS xxxnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn 45 4 17 ADOUE STEEN avvise 46 S QUICK OUE eer 47 5 1 General Imaging Bolus analysis nnnnnnnunnnnnnnnnnnnnnnnnnnnnnnnuunnnnnn 47 5 2 General Imaging Replenishment analysis 47 5 3 Focal Liver Lesions Dynamic Vascular Pattern Analysis 48 54 PlagUE ne ee re errr rrr rr VA NN UA NEA MEDIE SAN RM MEM IE MR ARN DR NOR RUM UE 49 D Ihd8X 2 2252223 92235 E MEME E NENE SENE NN NE CM NE NER 50 SS 1 INTRODUCTION 1 1 ABOUT THIS MANUAL In this manual examples suggestions and warnings are included to help you to start using the VueBox software application and to advise you on important items This information is indicated using the following symbols The caution symbol indicates important information safety precautions or warnings The stop symbol highlights important information You should stop and read before continuing The bulb symbol indicates a sugg
21. display presets from the library Load 1 Click the Load button in the preset mem toolbar 30 112012 12 02 29 2 Select the item in the list and press the OK button Figure 29 Loading display presets from library 4 14 5 PARAMETRIC IMAGE OVERLAY In Q2 the B Mode side can also displayed the parametric image by overlay The opacity of this overlay can be increased or decreased using the opacity slider of the display settings 16 32 15 Puis 323dB nere 2045 00 20 27 PE dB Gain 23 Sortir D sactiver Horloge DR 20 PE Peak Enhancement Figure 30 An overlay is displayed on the B Mode side in Q2 4 14 6 PERFUSION INSTANT DETECTION This feature is only available in the Liver DVP package see section 4 3 4 Most representative perfusion instants initial mid and last of the DVP clip are provided by VueBoxQ as a suggestion of DVP images to be added to the patient report Once the DVP processing is performed perfusion instants are displayed as three red vertical bars in the difference graph Q4 as illustrated below These instants can be easily modified by dragging the bars to the desired instants Echo power a u Figure 31 DVP perfusion instants 4 14 7 ANALYSIS RESULT DATABASE Each clip associates a result database in which the whole context of each analysis result can be stored This enables restoration of the result at a later time by selecting the corresponding clip
22. e ROI must be defined in the lumen further to the plaque ROI s Also for this specific package no curve fitting is applied on linearized data However a Maximum Intensity Projection is performed on a small portion of the linearized data Indeed only 3 time segments 1 baseline segment and 2 perfusion segments will be analyzed As shown in Figure 21 the baseline segment is a 1 second interval selected before the contrast arrival time in the lumen And the perfusion segment is the concatenation of 2 segments of 2 seconds interval the first one starts 2 seconds after the peak in the lumen and the second one 7 seconds after the peak NN OO Then the MIP processing for each individual pixel in the plaque ROI is performed in two steps e A noise level detection based on the last MIP image in the baseline time segment e The filtering of pixels based on the last MIP image in the perfused segment and on the threshold defined after the noise level Echo power Perfusions Baseline Contrast arrival Time to Time time Lumen Peak Lumen Figure 21 Baseline and Perfused segments detection The time segments baseline and perfusions are automatically detected by VueBox and displayed in the Frame segments detection dialog box cf Figure 22 The signal of each ROI is displayed in a multi scale time intensity graph The left scale in white is dedicated to the plaque ROI s whereas the right one yellow is the sca
23. e Video Settings panel Choose the Bolus perfusion model in the perfusion models tab Define the images to be excluded using the Clip editor Draw Delimitation ROI delimiting the processing area Draw multiple ROI successively as desired Move the Image slider to choose a reference image for motion compensation Click the 4 button to launch the motion compensation Review the motion compensated clip using the Image slider If the Motion compensation is unsuccessful try one of the following Select another reference image and click the A gt button again to re apply Motion compensation Click the button to return to the Clip editor and exclude any images thought to be degrading the result of motion correction such as out of plane movements and then re apply Motion compensation Once satisfied with motion compensation click the button to launch the Perfusion Data Processing Accept or select another instant in the Contrast arrival detection dialog box If needed adjust the Gain and Dynamic range sliders for each parametric image or check Apply preset to apply the user preferences Click the _ button to export data Click the button to store the context 5 2 GENERAL IMAGING REPLENISHMENT ANALYSIS Open a Replenishment clip in GI Perfusion package Adjust the linearization settings in the Video Settings panel Wait for the flash detection to be completed If necessary set flash images manually by using t
24. e linked image cannot be displayed butto n to sto p it The file may have been moved renamed or deleted Verify that the link points to the correct file and 2 If the detection is completed click on the destruction iun orange square located in the clip editor caption with a X letter inserted However the Replenishment model will not be accessible anymore Therefore if you want to process destruction replenishment clips with the replenishment model you will 5 need to identify flash images manually by placing the image slider at the desired location and clicking the button or pressing the F keyboard key on each destruction frame Flash image detection and or manual definition is not available in all packages e g Liver DVP and Plaque which are compatible for bolus kinetics only 4 8 REGIONS OF INTEREST 4 8 1 PRINCIPLE With the help of the ROI toolbar you can define up to five Regions of Interest on images of the clip using the mouse a mandatory ROI named Delimitation and up to four generic ROI The Delimitation ROI is used to delimit the processing area It must thus exclude any non echographic data such as text colorbars or image borders A first generic ROI e g ROI 1 usually includes lesion if applicable and a second generic ROI e g ROI 2 may include healthy tissue to serve as reference for relative measurements Note that ROI names are arbitrary and can be entered by the user An additio
25. er new calibration files can be generated with specific settings upon users request Please contact your local Bracco representative for more information on how to obtain additional calibration files 4 7 CLIP EDITION 4 7 1 PRINCIPLE The clip editor module allows you to limit the analysis to a specified time window and also to exclude unwanted images from processing either isolated or in ranges As illustrated on the figure below the clip editor may be used to retain within the wash in and wash out phases of a bolus only the images within a relevant time interval If the destruction replenishment technique is applied during the experiment the clip editor automatically defines selectable replenishment segments by including images between two destruction events only a BOLUS b REPLENISHMENT Relevant time interval Replenishment segnes lt _ st n Destruction event Time Time Image status bar Image status bar M Exclusion E Exclusion E Inclusion Inclusion selected segment MN Destruction Figure 6 Typical examples of clip edition Using the bolus perfusion model the user should make sure to include both wash in and wash out phases Not doing so may affect the outcome of the perfusion data processing For the specific case of the Molecular Imaging package the number of frames used for analysis should never be lower than 31 4 7 2 INTERFACE ELEMENTS Figure 7 shows a screenshot of
26. er amplitudes at a given instant in two ROI one in a tumor and one in surrounding parenchyma If the echo power amplitude is twice as high in the tumor than in the parenchyma this means that the concentration of ultrasound contrast agent in the lesion is close to double that present in the parenchyma The same is true at the pixel level NN ee 5 4 13 3 CONTRAST ARRIVAL DETECTION At the beginning of the perfusion quantification process when the Bolus model is selected the arrival of contrast is detected within the ROIs The time of contrast arrival is automatically determined as the instant when the echo power amplitude rises above the background wash in phase and is represented by a red line As shown in the Contrast arrival detection dialog box this instant remains a suggestion which may be modified by dragging the red cursor line After pressing the OK button all images preceding the selected instant will be excluded from the analysis and the clip time origin will be updated accordingly This instant should be shortly before contrast arrival in any region Automatic estimate of contrast amival is 3 7 s Origin will be set at red cursor may be adjusted by dragging it with the mouse Echo power a u Time S u Figure 17 Contrast arrival detection dialog box um The automatic contrast arrival detection is to be considered as a suggestion only The user should make sure to review this suggestion before pr
27. erted into echo power data a quantity directly proportional to the instantaneous concentration of contrast agent concentration at each location in the field of view This conversion process called linearization takes into account color or greyscale rendering the dynamic range of log compression used during the clip acquisition and compensates for contrast gain as long as pixel intensity is not truncated or saturated The echo power data as a function of time or Linearized signals are then processed to assess blood perfusion using a curve fitting approach with a parametric Perfusion model The parameters derived from such a model are called Perfusion parameters and are useful for relative estimates of local perfusion e g in terms of relative blood volume or relative blood flow For instance theses parameters may be particularly useful for assessing the efficacy of given therapeutic agents at different times In the next sections the concepts of linearized signal perfusion modeling and parametric imaging are explained further 4 13 2 LINEARIZED SIGNAL A linearized or echo power signal represents echo power data as a function of time at either the pixel level or in a region of interest The linearized signal results from a linearization process of the video data and is proportional to the local ultrasound agent concentration As it is expressed in arbitrary units only relative measurements are possible For instance let s consider echo pow
28. essing OK 4 13 4 SKIP DUPLICATE IMAGES Duplicate images i e two or more consecutive similar images may be found when a clip was exported from the ultrasound scanner at a frame rate higher than the acquisition frame rate e g 25 Hz instead of 8 or 15 Hz In this case duplicate images are found in the clip In order to insure a correct analysis as well as reliable time related parameters the duplicate images have to be discarded To do so when the clip is being loaded in memory the software compares each frame with the previous one and discards any duplicate ones This operation is automatic and requires no user intervention 4 13 5 PERFUSION MODELS Perfusion estimates in VueBox are made by a curve fitting process that adjusts the parameters of a mathematical model function to fit the experimental linearized signal in an optimal way In the context of ultrasound contrast imaging the mathematical function is called Perfusion model and is chosen to represent either bolus kinetics or replenishment kinetics following bubble destruction Such models serve to estimate sets of Perfusion parameters for quantification purposes These parameters can be divided into three categories those representing an amplitude a time and a combination of amplitude and time Firstly amplitude related parameters are expressed as echo power in a relative way arbitrary units Typical amplitude parameters are the peak enhancement in a bolus kinetics or the pla
29. estion or an idea that simplifies the use of VueBox It can also refer to information available in other chapters 1 2 INTERPRETING SYMBOLS OF THE PRODUCT Symbol bl p CE Location Description User Manual Product name and version User Manual Manufacturer s name User manual Production Year and month Conformity assessment procedure according to directive 93 42 EEC Annex II 3 User Manual Classification according to directive 93 42 EEC Ann IX class IIa according to rule 10 1 3 DEFINITIONS ASR Advanced System Recognition DVP Dynamic Vascular Pattern DVPP Dynamic Vascular Pattern Parametric FLL Focal Liver Lesion FT Fall Time MI Molecular Imaging MIP Maximum Intensity Projection mIT Mean Transit Time PA Perfused Area PE Peak Enhancement PI Perfusion Index PSA Perfusion Segments Analysis QOF Quality Of Fit rBV Regional Blood Volume ROI Region Of Interest rPA Relative Perfused Area RT Rise Time TSV Tabulation Separated Values TTP Time To Peak WiAUC Wash in Area Under Curve WiPI Wash in Perfusion Index WiR Wash in Rate WiWoAUC Wash in and Wash out AUC WoAUC Wash out AUC WoR Wash out Rate 1 4 SYSTEM DESCRIPTION VueBox is a software package useful for the quantification of blood perfusion based on clips acquired in Dynamic Contrast Enhanced Ultrasound in radiology applications cardiology excluded From the analysis of a time sequence of 2D contrast images perfusion parameters are calcul
30. h respect to the reference and c the bipolar color map coding in warm and cold colors the positive and negative amplitudes respectively resulting from subtraction 4 13 7 DYNAMIC VASCULAR PATTERN PARAMETRIC This feature is available in the Liver DVP application package see section 4 3 4 In addition to the DVP feature see section 4 13 6 the Dynamic Vascular Pattern Parametric DVPP maps difference signals signatures into a single image called DVP parametric image SS 5 s J Using DVP signals a classification is performed at the pixel level where each pixel is categorized into four classes according to the polarity of its difference signal over time namely e unipolar positive hyper enhanced signature W PH e unipolar negative hypo enhanced signature e bipolar positive a hyper enhancement followed by a hypo enhancement and conversely e bipolar negative DVP parametric image is then built as a color coded map where pixels with red blue green and yellow hue colors correspond to and classes respectively with a luminance proportional to the difference signal energy Image at peak DVP parametric enhancement image Za WwW i i J Figure 20 Example of DVPP images 4 13 8 PERFUSION SEGMENTS ANALYSIS This feature is available in the Plaque application package see section 4 3 5 For the plaque application package a referenc
31. he E button or the F keyboard key Choose the Replenishment perfusion model in the perfusion models tab If multiple segments are present select the replenishment segment to be analyzed with arrow buttons Draw Delimitation ROI delimiting the processing area Draw multiple ROI successively as desired Move the Image slider to choose a reference image for motion correction 10 11 12 13 14 15 16 17 SS 55 M Click the A button Review the motion compensated clip using the Image slider If the Motion compensation is unsuccessful try one of the following Select another reference image and click the A gt button again to re apply Motion compensation Click the button to return to the Clip editor and exclude any images thought to be degrading the result of motion correction such as out of plane movements and then re apply Motion compensation Once satisfied with motion compensation click the button to launch the Perfusion Data Processing If needed adjust the Gain and Dynamic range sliders for each parametric image or check Apply preset to apply the user preferences Click the _ button to export data Click the button to store the context 5 3 FOCAL LIVER LESIONS DYNAMIC VASCULAR PATTERN ANALYSIS 2 eS YS Nx 10 11 12 13 14 15 16 17 Open a Bolus clip in Liver DVP package Adjust the linearization settings in the Video Setting
32. he perfused pixel after filtering The Mean parameter corresponds to the mean value of the linearized signal inside a ROI the Median parameter corresponds to the median value of the linearized signal inside a ROI and the Integral parameter corresponds to the integral value of the linearized signal inside a ROI Figure 23 Parametric image of the perfused area Figure 23 shows the parametric image of the perfused area In the plaque ROI the pixels highlighted correspond to area considered as perfused Time segments baseline or perfusion must contain images from the same plane out of plane frames must not be included It could lead to wrong perfusion area results A plaque ROI must not be contaminated by enhancement coming from the lumen It could lead to wrong perfusion area results OO During the baseline time segment which aim is to compute the noise level in each plaque ROI a plaque ROI should not be contaminated by artefacts specular reflectors to avoid perfusion area underestimation Additionally the baseline segment must be located before the contrast arrival time Distal plaques cannot be analyzed correctly Indeed distal artefact creates an artificially high enhancement in the plaque 4 13 9 MEASUREMENT ACCEPTANCE CRITERIA The accuracy of the calculated and measured parameters was verified and the following error should be taken into account Calculated amp Measured parameters 4 13 10 PARAMETRIC
33. if present and TO is the instant at which the minimum slope tangent intersects the x axis or offset value if present For Replenishment kinetics VueBox provides the following parameters illustrated in the figure hereafter 7 Linearized signal Perfusion model Echo power ee a O gt mTT Time rBV relative Blood Volume A a u WiR Wash in Rate maximum slope a u mTT mean Transit Time s PI Perfusion Index rBV mTT a u QOF Quality Of Fit between the echo power signal and f t 96 where a u and s are arbitrary unit and second respectively The selection of the perfusion model e g Bolus Replenishment can be performed in the Perfusion Models tab BOLUS REPLENISH Figure 18 Perfusion model selection Note the availability of perfusion models depends on the selected application package see section 4 3 The user must ensure that the right perfusion model was selected before performing the perfusion data processing otherwise analysis results may be OE incorrect The user must ensure that perfusion kinetics are not affected by any vessel or artifact Bracco Suisse SA Software Applications VBO 8 11 31 SS In the replenishment perfusion case the user must ensure that the plateau value is reached before considering analysis results 4 13 6 DYNAMIC VASCULAR PATTERN This feature is available in the Liver DVP application package see section 4 3 4
34. igure 14 Orientation marker detection in dual display mode In some cases similar orientation markers on both contrast and B mode images may not be available Thus the automatic detection cannot be performed and the manual selection of landmarks within both images should be chosen To activate dual display with automatic detection i e both probe orientation markers are available Set the EX toggle button to On in the dual display section of the video settings panel Make sure that the Click on the probe orientation marker of the contrast image d toggle button is set to Auto Control that the corresponding orientation marker located on the B mode image is correctly detected To activate dual display with manual landmarks selection i e no or different probe orientation markers present 1 re 2 qe Set the EX toggle button to On in the dual display section of the video settings panel Manual Set the kA toggle button to Manual Click on an image landmark of the contrast image Click on a corresponding image landmark of the B mode image Note By pressing the left mouse button in the vicinity of each landmark a magnifying tool is activated to help the user position a cursor in a very precise way The user should make sure to select the correct orientation marker i e on the contrast image side Otherwise all ROI may be inverted and all analysis results will be invalid In the ma
35. inearization 31 linearization function 19 Main toolbar 13 Motion compensation 30 motion correction 56 57 58 Move down selected clip 23 Move up selected clip 23 Moving a ROI 25 mTT 33 34 37 orientation marker 26 Parametric imaging 41 PE 33 Perfusion data processing 31 Perfusion model 31 32 Plaque 16 33 SS Play 22 prerequisites 11 preset 44 45 56 57 58 PSA 33 Preset 44 QOF 33 34 quantification 31 32 44 Quick guide 56 rBF 34 37 rBV 34 37 41 reconstruction 47 50 59 Regions of interest 24 relative measurements 31 43 replenishment 20 22 32 41 56 Replenishment 22 33 56 result database 46 Result window 42 ROI 43 ROI label 25 ROI toolbar 24 RT 33 Safety precautions 9 Save 47 53 screen resolution 11 segmentation 47 59 Skip duplicate images 32 start page 15 Study Browser 56 57 58 sub sampling rate 19 Supported datasets 19 time intensity curves 52 Transition delay 23 TSV 52 TTP 33 User settings 55 video settings 19 WiAUC 33 WiPI 33 WiR 33 34 37 Zoom 21 REF iE CC VueBox v6 0 Bracco Suisse SA Software Applications 2015 09 BRACCO Suisse S A Software Applications 31 route de la Galaise 1228 Plan les Ouates Gen ve Suisse fax 41 22 884 8885 www bracco com cS BRACCO N LIFE FROM INSIDE
36. ity curves Parameter table Ref dB Figure 3 Four quadrant view 4 2 GENERAL WORKFLOW The application workflow is easy and intuitive for a routine clinical use It consists of the following steps Choose an application package Load a dataset Adjust video settings Select perfusion model if applicable Remove unwanted images with the clip editor Draw several ROI Apply motion compensation if needed SS ew eS d Perform quantification Visualize save and export results 4 3 SPECIFIC APPLICATION PACKAGES 4 3 1 PRINCIPLE While VueBox is a general quantification toolbox dedicated features have been developed to address specific needs e g DVP for focal liver lesions see section 4 3 4 These dedicated features are placed into packages which can be selected according to user needs In most cases the core features of VueBox e g video data linearization clip edition ROI drawing motion compensation analysis context saving result exporting etc are Similar in all packages 4 3 2 PACKAGE SELECTION Specific application packages can be selected in the start page see section 4 1 by clicking on the appropriate button Liver DVP Figure 4 Specific application package selection The user should make sure to select the appropriate package in order to perform its analysis e g Liver DVP for focal liver lesions 4 3 3 GI PERFUSION GENERAL IMAGING PERFUSION QUANTIFICATION The Gener
37. ization of DVP through a contrast ultrasound examination after a bolus administration shall help clinicians characterize suspicious lesions and better differentiate benign from malignant lesion types The plaque package assesses pathologies of carotid arteries during a contrast ultrasound examination after a bolus administration 1 6 PRODUCT LIFETIME For a given version of the product the software and its documentation are supported for five years after the release date 1 7 SAFETY PRECAUTIONS Please read the information in this section carefully before using the program This section contains important information on safe operation and handling of the program as well as information on service and support Only trained and licensed medical practitioners are authorized to use the system Any diagnosis based on the usage of this product must be confirmed by a differential diagnosis prior any treatment according to common medical sense Only 2D DICOM datasets of Dynamic Contrast Enhanced Ultrasound examinations for which a calibration file is available should be processed OG Oo z 00 INSTALLATION AND MAINTENANCE Bracco Suisse SA assumes no liability for problems attributable to unauthorized modifications additions or deletions to Bracco Suisse SA software or hardware or unauthorized installation of third party software As manufacturer and distributor of this product Bracco Suisse SA is not responsible for safet
38. le associated to the lumen ROI In this graph the user can modified the location of each time segment independently by a drag and drop operation Frame segments detection fx O The Baseline and Perfusion segments may be adjusted by dragging them with the mouse Parfusion m on Echo power a u Time s Figure 22 Frame segments detection dialog box Finally the following parameters are computed e Perfused Area PA PA1 PA2 e relative Perfused Area rPA rPA1 rPA2 e Mean MIP Opacification MIP e Mean MIP Opacification Perfused Pixel only MIP th e Mean e Median e Integral PA represents the total number of pixels retained in the plaque after the processing or the area in mm of these pixels if the length calibration has been defined Additionally the rPA is expressed in 96 and corresponds to percentage of retained pixels with respect to the total pixels in the plaque ROI For the parameters PA and rPA the images considered during the processing are the concatenation of the two perfusion segments For the parameters PA1 and rPA1 only the first perfusion segment is taken into account during the processing For PA2 and rPA2 only the second perfusion segment is taken into account during the processing The Mean MIP Opacification computes the mean value of the MIP in the ROI It is also calculated in the lumen ROI which can serve as a reference ROI The MIP th only takes into account t
39. lude a range of images 1 Move the Image slider to the first image to be excluded 2 Click the Exclude button 3 Move the Image slider to the last image to be excluded INCLUDING IMAGES To include a range of images 1 Move the Image slider to the first image to be included 2 Click the Include button 3 Move the Image slider to the last image to be included CHANGING THE RANGE OF EXCLUDED IMAGES To change the range of excluded images 1 Move the mouse pointer over the Image status bar to any border of a range of excluded images EM 2 When the pointer s shape changes to a vertical split qu drag the border to change the range of excluded images MOVING THE RANGE OF EXCLUDED IMAGES To move the range of excluded images 1 Move the mouse pointer over the Image status bar to any border of a range of excluded images E 2 When the pointer s shape changes to a vertical split T press the Shift key and drag the range of excluded images to the desired position 4 7 4 CLIP CONCATENATION The clip concatenation or combination is the process of pooling clips together to build up a single sequence of images Using this feature a set of clips recorded in chronological order by an ultrasound scanner can be processed The concatenation function is useful when the ultrasound system has a limited clip recording time per DICOM file 7 Bracco recommends concatenating clips with a clip transition delay lt 15 seconds
40. m Figure 1 VueBox start page When VueBoxQ is launched from TomTec s Image Arena platform the start page cannot be accessed The data selection must be performed from Image Arena Bracco Suisse SA Software Applications VBO 8 11 13 7 Do Once a package is selected clips can be opened recent clips and recent analyses if applicable can be quickly reopened Moreover when a recent clip is selected its associated analyses i e previously saved analysis contexts are accessible and can be restored Once a clip is opened a one quadrant view is displayed including the video settings toolbar the clip editor as well as the remaining functionalities useful prior to launching the analysis process e g ROI drawing toolbar etc Main toolbar Patient ID Side toolb ROT oolbar toolbar Video settings Clip Editor Figure 2 One quadrant view Finally when the perfusion data processing is completed results are presented in a four quadrant view where time intensity curves parametric images time intensity curves and perfusion parameter values are displayed Bracco Suisse SA Software Applications VBO 8 11 14 Display settings FT x z m Cip1 1 191 580 240sfy por i Opao E Pa ra metri C ROI4 Mo dyn Range 20 dB a 614 285 4 0 I mage o j 6 32 18 cy co 6 32 18 Puis 22208 M mang Mi ET D 15345 NA pw lt a P a A 2 EUM Perfusion A ST 2A ea parameter selection Time Intens
41. nal two ROI are available to user s discretion 425 337 zE Figure 9 Example of Regions of interest For the specific case of the Liver DVP package see section 4 3 4 ROI are not generic anymore and have a specific use Beside the Delimitation ROI the following 4 ROI are available Lesion 1 Reference Lesion 2 Lesion 3 Note that Lesion 1 and Reference ROI are mandatory For the specific application package Plaque ROI are not generic anymore and have a specific use Beside the Delimitation ROI the following 4 ROI are available Plaque 1 Lumen Plaque 2 Plaque 3 Note that Plaque 1 and Lumen ROI are mandatory The plaque ROI s must delineate all the plaque s whereas the Lumen ROI must contain a part of the lumen cf Figure 23 for an example 4 8 2 INTERFACE ELEMENTS The ROI toolbar located in the upper left corner of the image viewer offers tools to draw four different shapes The ROI label on the right of the 5 amp ROI Label toolbar identifies the current region to be drawn j w fes ng and may be edited by clicking on it Figure 10 ROI toolbar Button Name Function Select allows to select modify a region of interest Inl Rectangle draws a rectangular shape Ellipse draws an elliptical shape Polygon draws a closed polygonal shape Closed curve draws a closed curvilinear shape 4 8 3 WORKFLOW DRAWING A ROI To draw a rectangular or elliptical ROT 1 2 23
42. nual landmarks selection mode the user should carefully select a pair of image landmarks spaced in exactly the same way as the B mode and contrast images Otherwise ROI positioning may be incorrect and this may degrade both image registration and analysis results When processing an ASR compatible DICOM clip the dual display mode is automatically enabled if the clip contains both contrast and fundamental B mode image areas SS TT 4 9 LENGTH CALIBRATION AND MEASUREMENT The Length Calibration tool is required for performing length and area measurements of anatomical objects in the images It consists in identifying a known distance in any image of the clip Once the line is drawn the effective corresponding distance in mm needs to be entered To calibrate 1 click the length calibration button 2 draw a line on a known distance in the image e g along a calibrated depth scale 3 in the Length calibration dialog box type the known corresponding distance in mm 08 42 50 122 6C2 p2 0M Hz 110mmi CPS Abdomen CPS General V Pwr 21dB MIFz 12 MI 22 Manuel length i 80 S1 0 3 4 Length calibration editor CPSGain 14 a 4 m 1 M2 11d mm C31 OK Once the Length calibration has been defined areas of regions of interest will be listed in cm in the quantitative parameter table The lengths within the images can be measured with the Length measurement tool The first Measurement to
43. ol M is called ruler and is used for drawing straight lines The second one is called cross ruler and is able to draw a cross 2 lines perpendicular to each other To make a length measurement click the length measurement button 2 select the type of ruler in the ROI toolbar line or cross 5 Length measurement ESC key to cancel 3 draw the ruler on the image by holding down the left mouse button and drag the line to change its length The ruler direction location and size can be modified with the same procedure 4 the cross ruler follows the same principle The user must know that the perpendicular line may be shifted by moving the mouse in the direction opposite to the first line The accuracy of the measurement tools was verified and the following error should be taken into account Error on Length horizontal and vertical lt 1 Error on Area lt 1 7 Do The Anonymize Clip Tool amp is useful for presentations lectures or any occasions in which the patient information must be removed to comply with privacy protection This tool is available at any processing stage of VueBox The user can move or resize the anonymization mask to hide the patient name This mask is automatically filled with the most prominent color from the portion of the image covered 4 10 ANONYMIZATION OF CLIP The general workflow is as follows 1 Click the Anonymize amp button 2 Adjust and move the Anonymize mask rect
44. on stores restores and auto scales Preset display preset gain and dynamic range of all parametric images controls the gain applied to the Gain m Ps Gain current processed image Q2 60dB to 60dB controls the dynamic range of log compressed applied to the current Dyn Range 20 dB Dynamic range a ma Q2 OdB to 60dB controls the opacity of the overlay displayed on the B Mode side Q2 Opacity B AQ Overlay opacity 4 14 3 AUTO SCALED DISPLAY PRESETS Display presets i e gain amp dynamic range for each parametric image are automatically adjusted once the perfusion quantification processing is completed using the built in auto scaling function However this adjustment is to be seen as a suggestion and may need further manual fine tuning Below an example of a parametric image prior and after auto scaling is applied Figure 27 Parametric image prior and after display presets auto scaling 4 14 4 STORING LOADING DISPLAY PRESET Display preset can be stored into a dedicated library and loaded at a later time point To store the preset for all parametric images Click OK to save the current display preset Save As 1 Click the button in the preset I n toolbar 30112012 12 02 29 2 Set a name or accept the one generated by default and press the OK button Figure 28 Storing display presets into library Bracco Suisse SA Software Applications VBO 8 11 39 To load
45. otion compensation process can be further edited At this stage colors of the Image status bar I representing excluded and included image ranges are set to violet and blue respectively 4 Check the accuracy of the motion compensation by scrolling through the clip using the Image slider motion compensation is considered a success if the images are spatially realigned and any residual motion is deemed acceptable 5 If the motion compensation is unsuccessful try one of the following 6 Use the scissors and select another reference image and click the gt button again to re apply Motion compensation 7 Use the Clip editor to exclude any images thought to be degrading the result of motion compensation such as out of plane movements and then re apply Motion compensation The user is responsible for checking the accuracy of the motion compensation before pursuing the clip analysis In case of failure incorrect results may occur The user should exclude any out of plane images using the clip editor before performing a motion compensation The user should avoid performing motion compensation when the clip does not contain any motion as this may degrade slightly the analysis results 4 13 PERFUSION DATA PROCESSING 4 13 1 PRINCIPLE The Perfusion data processing or perfusion quantification feature represents the core of the VueBox functionality and performs quantification in two steps Video data are first conv
46. r time point in any clip analysis To copy all the ROI currently drawn Click OK to save the current ROL Save As m m IF F 1 Click the toolbar button in the main 2 Set a name or accept the default generated one and press the OK button To paste ROI from the library SE Select one item to paste a ROL 1 Click the O button in the main 15 31 15 toolbar 2 Select the item in the list and press the OK button Figure 12 Pasting ROI from library 4 8 4 DUAL DISPLAY MODE The dual mode is active when a clip is split into two image areas contrast and fundamental B mode Each image area may be identified by its orientation marker usually the logo of the ultrasound scanner manufacture showing the scan orientation of the probe Dual display Dual display On a Figure 13 Dual display mode with automatic or manual detection options In this mode ROI can be drawn on any side i e contrast or B mode provided that that the contrast side is manually determined by the user This operation is performed by first enabling the dual display mode in the video settings panel and then by left clicking on the orientation marker of the contrast image VueBox delineates the orientation marker using a white rectangle and detects the corresponding marker on the B mode side automatically Bracco Suisse SA Software Applications VBO 8 11 24 11 30 49 am Pot 22d8 e t EL E Miz 18 tu 2 10008 F
47. s may be changed by editing the data in the left column cells Q4 For the specific case of the Plaque package in Q3 the signal of each ROI is displayed in a multi scale time intensity graph cf Figure 22 The left scale in white is dedicated to the plaque ROI s whereas the right one yellow is the scale associated to the lumen ROI Settings Opacity Gain m diis Dyn Range 20dB 614 205 iy 2239 bd rs I n o he DP Ee Z IU WIR Wash in Rate Ref Ref dB Figure 25 User interface in result mode Control Name Function allows the selection of WIR Wash in Rate Parametric image view parameter to be displayed Finally relative measurements can be displayed in the Q4 table by checking one of the ROI as a reference in the Ref column Relative values are displayed in and dB for amplitude related parameters and in 96 for time related parameters WIR Wash in Rate M Figure 26 Quantitative parameter table When selecting DVP or DVPP parameters i e in Liver DVP package from the Parametric image view menu the quantitative parameter table is replaced by a chart showing the DVP difference signals 4 14 2 ADJUSTABLE DISPLAY PRESETS Above Q2 sliders are provided to adjust the gain and the dynamic range log compression of the processed image displayed in Q2 in a way similar to a standard ultrasound scanner o Slider control Name Functi
48. s panel Define the images to be excluded using the Clip editor Draw Delimitation ROI delimiting the processing area Draw Lesion 1 and Reference ROI successively As desired additional Lesion 2 and Lesion 3 ROI can be drawn see section 4 8 Move the Image slider to choose a reference image for motion compensation Click the button to launch the motion compensation Review the motion compensated clip using the Image slider If the Motion compensation is unsuccessful try one of the following Select another reference image and click the gt button again to re apply Motion compensation Click the button to return to the Clip editor and exclude any images thought to be degrading the result of motion correction such as out of plane movements and then re apply Motion compensation Once satisfied with motion compensation click the D button to launch the Perfusion Data Processing Accept or select another instant in the Contrast arrival detection dialog box If needed adjust the Gain and Dynamic range sliders for each parametric image or check Apply preset to apply the user preferences Click the _ button to export data Click the button to store the context 5 4 PLAQUE aS mm qw dq en 10 11 12 13 Open a Plaque clip in Plaque package Adjust the linearization settings in the Video Settings panel Draw Delimitation ROI delimiting the processing area Draw Plaque ROI delimiting the plaq
49. s report summarizing qualitative i e still images and quantitative i e numerical data information can be generated Mul The user should always review the consistency of the exported results i e images numerical data etc 4 15 2 INTERFACE ELEMENTS Some export options may not be available in all application packages EE Desktop b 3 Libraries D B Mercier Laurent 47 Computer p gt WINDOWS7 C D xa VISTA64 D File Type BMP TIFF JPEG bg DATA E ao ta RECOVERY F Fullscreen i 4 4 SEAGATE G M Ultrasound Image current gt BACKUP i b J Bin b drivers M Time Intensity Curve M Parametric Images p dd EULA aJ Export js New Folder WMV None Original Registered Parametric Video Quality Frame rate M M Generate Report Figure 33 User interface in export mode Name Function Data TSV exports a tabulated text file XLS extension including time intensity curves and perfusion estimates Images Full screen exports a screenshot of the front panel All 4 quadrants Bracco Suisse SA Software Applications VBO 8 11 42 SS OO Ultrasound image exports the current ultrasound image with its ROIs Quadrant 1 current Parametric m images exports all parametric images Quadrant 2 Time Intensity exports an image of the chart Quadrant 3 Curve Clip Original exports the original clip Parametric exports the processed clip Nati
50. t Reader to display the software manual If Adobe Acrobat Reader is not installed on your system please download the latest version from www adobe com 4 1 USER INTERFACE VueBoxQ is a multiple window interface software application The possibility to process several clips in separate child windows comes in handy for the user who for example wants to analyze different cross sections of a given lesion at the same time Another example is the case of a user who is interested to compare a given lesion imaged at different dates Each analysis is performed in an individual independent child window VueBox is also multitasking as each child window can execute processing at the same time while keeping the parent interface responsive Furthermore calculations that are demanding in terms of computing power such as computing the perfusion quantification have been optimized to benefit from multicore processors when available a technology called parallelization When VueBox is launched a start page is shown indicating the software name and version number From this start page packages e g GI Perfusion Liver DVP Plaque containing a set of dedicated features to be used in a specific context can be selected Start Page 5 x Packages E GI Perfusi Welcome to VueBox v6 0 erfusion We Box Liver DVP elect a file MC Users BRG Desktop PlaqueiHighty perfused IMA Jesktop Plaque Highly perfused ADesktopyLiver DVPAHCCAHCC do
51. teau value in a replenishment kinetics which may be associated with relative blood volume Secondly time related parameters are expressed in seconds and refer to the timing of the contrast uptake kinetics As an example of time parameter in a bolus the rise time RT measures the time that a contrast echo signal takes to go from baseline level to peak enhancement a quantity SS O related to bloodflow velocity in a portion of tissue Finally amplitude and time parameters may be combined so as to produce quantities related to the blood flow blood volume mean transit time for replenishment kinetics or the wash in rate peak enhancement rise time for bolus kinetics For Bolus kinetics VueBoxQ provides the following parameters illustrated in the figure hereafter Linearized signal m Perfusion model Echo power a u Time s PE Peak Enhancement a u WiAUC Wash in Area Under the Curve AUC TI TTP a u RT Rise Time TTP TI s mTTI mean Transit Time local MTT TI s TTP Time To Peak s WiR Wash in Rate maximum slope a u WiPI Wash in Perfusion Index WiAUC RT a u WoAUC Wash out AUC AUC TTP TO a u WiWoAUC Wash in and Wash out AUC WiAUC WoAUC a u FT Fall Time TO TTP s WoR Wash out Rate minimum slope a u QOF Quality Of Fit between the echo power signal and f t 96 Where TI is the instant at which the maximum slope tangent intersects the x axis or offset value
52. ted from the DICOM dataset header if present and may be edited if not present For the specific case of the Liver DVP package see section 4 3 4 The body of the report contains the following information e an image of the analyzed clip including ROI e a DVPP image e three images at different DVP instants e achartrepresenting the average signal within available ROI e a chart representing the average difference signal within available ROI i e DVP signal e an editable comment field Otherwise in all other cases The body of the report contains the following information e animage of the analyzed clip including ROI e achart representing the average signal within available ROI e the perfusion model selected e a parametric image and quantitative values in absolute and relative terms for each perfusion parameters e an editable comment field Perfusion parameters can be dynamically added or removed from the analysis report thus reducing or increasing the number of pages The user selection is saved from one session to another Far 555 5556 2 amp Hospital Bracco Suisse 5 Departm Physcs 5 2 Profess est 3 33 es E d g at ID a H Name 2 Physician Ej Cr Exam date h date Pertusion Model BalusBILOFI Nombre total de pages 1 Facteur de zoom Toute la page Figure 34 Analysis report header modification interface IS N
53. ue area Draw Lumen ROI this reference ROI should be drawn to identify a small reference area of the lumen As desired optional Plaque ROI can be drawn Move the Image slider to choose a reference image for motion compensation Click the 4 button to launch the motion compensation Review the motion compensated clip using the Image slider click the button to launch the Data Processing Adjust the baseline and perfusion segments location in the Frame Segments Detection dialog box if needed Click the _ button to export data Click the button to store the context 6 INDEX about screen 55 activation process 12 analysis report 52 53 Annotation Tool 29 Anonymization of clip 29 artifacts 10 auto scaling 44 bolus 20 32 56 Calibration files 20 clip concatenation 23 clip editor 20 Clip selector 23 colorbar 42 colormap 42 Contrast arrival detection 31 56 57 Copying and pasting ROI 26 Delete selected clip 23 Deleting a ROI 25 display presets 43 documentation 51 Drawing a ROI 25 dual display mode 19 Dual display mode 26 Dynamic range 44 56 57 Editing a ROI 26 Exclude 22 Export analysis data 51 Fast play 22 FBI 38 58 Flash image detection 23 Gain 44 56 57 58 gain compensation 19 General workflow 16 help 15 Image slider 21 22 56 57 58 Image status bar 21 22 Include 22 installation 11 length calibration 28 length measurement 28 l
54. um ro de la page actuelle 1 Nombre total de pages 2 Facteur de zoom Toute la page Figure 35 Analysis report quantitative parameter selection Finally the report can be saved into a finalized PDF file by pressing 4 16 IMPORT AND EXPORT USER SETTINGS User settings such as ROI result and display preset databases can be exported into a single file with 1 sharp extension and reimported at a later time This function may be useful for sharing results between users or when transferring the software to another computer To export user settings 1 2 3 NN Click the Ss button from the side toolbar Select export location Click the button To import user settings 1 2 3 4 Click the es button from the side toolbar Choose Copy from option by clicking the button Select user settings file location and choose user settings file from the list Click the button 4 17 ABOUT SCREEN Information about the software such as version number and software manufacturer can be found in the about screen To display the about screen 1 Click the button in the main toolbar SS 5 QUICK GUIDE This section describes the two typical workflows to perform an analysis with VueBox 5 1 GENERAL IMAGING BOLUS ANALYSIS ID DM E E E Ew pn 10 11 12 13 14 15 16 17 Open a Bolus clip in GI Perfusion package Adjust the linearization settings in th
55. ve amp exports both the original and processed clips in a side by side view Parametric mode Video Quality quality of the exported clip in percent Frame rate video frame rate of the exported clip sub sample factor Analysis Report Generate generates the analysis report and display the report generator dialog report box Folder name Save as indicates the folder name where the result files will be saved 4 15 3 WORKFLOW To export data Click the gt button 2 Select a target directory in the left panel Under Data Images and Clip in the right panel choose the type of results to export 4 Under Option type a folder result name Click the OK button in the main toolbar to export the results in the specified folder result name 4 15 4 ANALYSIS REPORT The analysis report summarizes both qualitative i e still images and quantitative i e numerical data information in a single customizable easy to read report The report is divided into two parts a header and a body The header contains the following information Hospital related information Patient and exam related information Hospital name Patient ID Department name Patient name Professor name Physician name Phone amp fax numbers Exam date Patient birth date Contrast agent used Indication for exam Hospital related information are editable and are saved from one session to another Patient and exam related information are automatically extrac
56. y reliability and performance of the system if e the product is not operated in accordance with the operating manual e the product is operated outside of its operating conditions e the product is operated outside of the specified operating environment i 1 9 PATIENT AND USER SAFETY The user must be satisfied with the suitability and completeness of clips acquired in a study prior to analysis with VueBox If not acquisitions have to be repeated For information about performing contrast acquisitions for reliable perfusion quantification please refer to the operating instructions provided by the manufacturer of your ultrasound equipment as well as to Bracco s Application note Protocol for performing reliable perfusion quantification e The information contained in this manual is intended only for the operation of Bracco Suisse SA application software It does not include information on echocardiograms or general ultrasound acquisition Please refer to the operating instructions of your ultrasound equipment for further information SS 1 10 MEASUREMENT au e The user is responsible for a suitable choice of ROI Region of interest in order to include contrast ultrasound data only ROI should not include any overlays such as texts labels or measurements and should be drawn on ultrasound data acquired with a contrast specific mode only i e no Fundamental B Mode or Color Doppler overlays The user is responsible
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