Carestream Vue PACS MR Diffusion User manual

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Clinical Collaboration Platform
Vue PACS
MR Diffusion and MR Perfusion
User Guide
Part # AE9362
2017-05-17

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Table of Contents
1. Acronym list .....................................................................................................................................6
2. Introduction ......................................................................................................................................9
3. Application Workflow......................................................................................................................11
4. Loading the Study..........................................................................................................................12
5. Initial Display..................................................................................................................................14
5.1 Basic Image Manipulation.....................................................................................................14
5.2 Tool Ribbon...........................................................................................................................14
6. Viewing Diffusion Series................................................................................................................16
6.1 DWI Images...........................................................................................................................16
6.2 DTI Images............................................................................................................................17
6.3 Using the Brain Mask Correction Tool ..................................................................................20
6.3.1 Displaying the Brain Mask.................................................................................................20
6.3.2 Adding Brain Mask............................................................................................................20
6.3.3 Erasing Brain Mask...........................................................................................................21
6.4 Adding an ROI.......................................................................................................................21
6.5 Determining the Display........................................................................................................21
7. Perfusion Series.............................................................................................................................22
7.1 Initial Layout..........................................................................................................................22
7.2 Calculating Perfusion Input Values.......................................................................................25
7.2.1 Identifying the AIF and VOF..............................................................................................25
7.2.2 Adding Arteries and Veins.................................................................................................25
7.2.3 Using the Artery and Vein Segmentation Tool..................................................................25
7.2.4 Using the Brain Mask Correction Tool ..............................................................................27
7.2.5 Correcting the Brain Centerline.........................................................................................27
7.2.6 Using Motion Correction....................................................................................................27
7.3 Working with Perfusion Maps................................................................................................28
7.3.1 Initiating Map Calculation..................................................................................................28
7.3.2 Analyzing Perfusion Calculation Results ..........................................................................28
7.4 Displaying a Fused Image.....................................................................................................32
8. Selecting a Layout .........................................................................................................................33
9. Using Settings................................................................................................................................34
10. Opening a Report.......................................................................................................................39
11. Exporting the Perfusion Analysis ...............................................................................................40
12. Accuracy and Limitations ...........................................................................................................41
13. References.................................................................................................................................42

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Preface
Trademark and Copyright Information
CARESTREAM is a trademark of Carestream Health.
This document is copyrighted with all rights reserved.
Under the copyright laws, this document may not be copied, in whole or in part, without the written
consent of Carestream Health, Inc. Under the law, copying includes translating into another language
or format.
All names or identities used in this document are fictitious.
Caution: Federal law restricts this device to sale to, by, or on order of a physician.
The information contained herein is based on the experience and knowledge relating to the subject
matter gained by Carestream Health, Inc. prior to publication. No patent license is granted by this
information.
Carestream Health, Inc. reserves the right to change this information without notice and makes no
warranty, express or implied, with respect to this information.
Carestream Health, Inc. shall not be liable for any loss or damage, including consequential or special
damages, resulting from the use of this information, even if loss or damage is caused by Carestream
Health, Inc.'s negligence or other fault.
FCC Compliance
This equipment has been tested and found to comply with the limits for a Class A digital device,
pursuant to Part 15 of the FCC Rules.
These limits are designed to provide reasonable protection against harmful interference when the
equipment is operated in a commercial environment. This equipment generates, uses, and can
radiate radio frequency energy and, if not installed and used in accordance with the instruction
manual, may cause harmful interference to radio communications.
Operation of this equipment in a residential area is likely to cause harmful interference in which case
users will be required to correct the interference at their own expense.
Regulatory Information
AUTHORIZED REPRESENTATIVE (European Union)
Carestream Health France
1 rue Galilée
93192 Noisy Le Grand cedex
France
Importer for European Union
Carestream Health Netherlands B.V.
Bramenberg 12
3755 BZ Eemnes
The Netherlands

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Safety Guidelines
This product was designed and manufactured to ensure maximum safety of operation. It must be
operated and maintained in strict compliance with the safety precautions and operating instructions
described.
•This product must be installed, maintained and serviced according to Carestream Health
Inc.'s maintenance procedures by Carestream Health, Inc. personnel, or other qualified
maintenance personnel approved in writing by Carestream Health, Inc.
•The system, in whole or in any part, may not be modified in any way without prior written
approval from Carestream Health.
•Unauthorized personnel must be prevented from accessing the system.
•If the system does not operate properly, or if it fails to respond to the controls described in this
manual, contact the nearest Carestream Health, Inc. field service office to report the incident
and await further instructions.
•The images and tools provided by this system are intended as tools for the competent user
only. They are explicitly not to be regarded as a sole incontrovertible basis for clinical
diagnoses. Operators are encouraged to study the literature and reach their own professional
conclusions regarding the utility of the system.
•The operator must be aware of the product specifications and of the system accuracy and
limitations. These limitations must be considered before making a decision based on
quantitative values. When in doubt, consult the nearest Carestream Health, Inc. field service
office.
Hazard Warnings
CAUTION: To prevent serious personal injury and damage to the system, strictly follow the
instructions provided in these hazard warnings. Always remain alert when operating this
equipment. If a malfunction occurs, do not use the equipment until qualified personnel correct
the problem.
ELECTRICAL SHOCK HAZARD
Do not remove or open system panels, covers or plugs. The internal system circuits use high voltages
that can cause serious injury or death from electrical shock.
EXPLOSION HAZARD
Do not operate the equipment in the presence of flammable or explosive liquids, vapors or gases. Do
not plug in or turn on the system if hazardous substances are detected in the environment.
If flammable substances are detected after the system has been turned on, do not attempt to turn off
the system or unplug it. Evacuate and ventilate the area before turning off the system.
OVERHEATING
Do not block the ventilation ports of the electronic equipment. Always maintain at least 6 inches (15
cm) clearance around the ventilation ports to prevent overheating and damage to the electronic
hardware.
EMERGENCIES
Do not use the system if unsafe conditions are known to exist. In the event of hardware failure that
could cause hazardous conditions (smoke, fire, and so on), turn the power OFF and unplug the power
cords for both the monitor and the desktop unit.
ELECTRICAL FIRES
Conductive fluids that seep into the active circuit components of the system may cause short circuits
that can result in an electrical fire. Therefore, do not place fluids or food on any part of the system.
To avoid electrical shocks and burns caused by the use of the wrong type of fire extinguisher, ensure
that the fire extinguisher at the site has been approved for use on electrical fires.

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POTENTIAL PACEMAKER HAZARD
Although the possibility of interference with pacemakers is slight, the operator should be alert to such
a potential hazard from any equipment using high-frequency electrical signals.
INDICATIONS FOR USE
The CARESTREAM Vue PACS is an image management system whose intended use is to provide
completely scalable local and wide area PACS solutions for hospital and related institutions/sites,
which will archive, distribute, retrieve and display images and data from all hospital modalities and
information systems. The system is to be used by trained professionals including, but not limited to,
physicians and medical technicians.
The system contains interactive tools in order to ease the process of analyzing and comparing three
dimensional (3D) images. It is a single system that integrates review, dictation and reporting tools to
create a productive work environment for the radiologists and physicians.
The system contains a Perfusion module with interactive tools to analyze and compare Computed
Tomography Perfusion (CTP) and MR Perfusion (MRP) images of adult patients. Blood perfusion
parameters are automatically calculated and displayed as a set of perfusion maps and perfusion
tables. The perfusion tables include the calculation of parameters related to tissue flow (perfusion)
and tissue blood volume.
The system contains a Diffusion Module with interactive tools to ease the process of analyzing and
comparing MR Diffusion Weighted images (DWI) and MR Diffusion Tensor Imaging (DTI) of adult
patients. This module is used to visualize local water diffusion properties from the analysis of
diffusion- weighted MRI data.
The system supports Subtraction with interactive tools to aid with the analysis of Digital Subtraction
Angiography (DSA) images in both interventional radiology and cardiology. Subtraction automatically
subtracts a mask from contrast frames of an X-Ray Angiography study for visualization of vascular
anatomy and pathology of adult patients.

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1. Acronym list
Acronym Meaning
AD
Axial Diffusivity
ADC
Apparent Diffusion Coefficient
eADC
Exponential Apparent Diffusion Coefficient
AE
Application Entity
AIF
Arterial Input Function
ANOVA
Analysis of variance
AVG
Average
AVG_SUB
Average Subtraction
CA
Certificate Authority
CAD
Computer-aided design
CAS
Content-addressable storage
CBF
Cerebral Blood Flow
CBV
Cerebral Blood Volume
CD
Compact disc
CDA
Clinical Document Architecture
CFN
Contrast Frame Number
CORBA
Common Object Request Broker Architecture
COTS
Commercial Off the Shelf Software
CS
Carestream
CSH
Carestream Health
cSVD
Circular Singular Value Decomposition
CVA
Cerebrovascular accident
DBMS
Database Management System
DER
Distinguished Encoding Rules
DICOM
Digital Imaging and Communications in Medicine
DSC
Dynamic Susceptibility Contrast
DTI
MR Diffusion Tensor Imaging
DVD
Digital Versatile Disk
DWI
MR Diffusion Weighted Imaging
ECG
Electrocardiography
FA
Fractional Anisotropy
FCFN
First Contrast Frame Number
FFT
Fast Fourier Transform
FMEA
Failure Modes and Effects Analysis
FSC
File Set Creator
FSR
File Set Reader
FTA
Fault Tree Analysis
GDA
Group Display Area
GSDF
Grayscale Standard Display Function
HIPAA
Health Insurance Portability and Accountability Act

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Acronym Meaning
HL7
Health Level Seven International
HTTP
Hypertext Transfer Protocol
HTTPS
Hypertext Transfer Protocol over TLS
IHE
Integrating the Healthcare Enterprise
IIS
Internet Information Services
IP
Image Processing
IPS
Intrusion Prevention System
K2
MR Leakage Map
KO
Key Object
KOS
Key Object Selection
LDAP
Lightweight Directory Access Protocol
LUT
Lookup Table
MCA
Middle Cerebral Artery
MD
Mean Diffusivity
MFN
Mask Frame Number
MPPS
Modality Performed Procedure Step
MR
Magnetic Resonance
MRI
Magnetic Resonance Imaging
MTT
Mean Transit Time
NAS
Network Attached Storage
NFS
Network File System
OI
Oscillating Index
OS
Operating System
oSVD
Oscillating Value Singular Value Decomposition
OTS
Off the Shelf Software
PACS
Picture Archiving and Communication System
PD
Processed Data
PDU
Protocol Data Unit
PEM
Private Enhanced Mail
PET-CT
Positron emission tomography–computed tomography
PHI
Protected Health Information
PMA
Patient Mini Archive
QA
Quality Assurance
RA
Relative Anisotropy
RAID
Redundant Array of Independent Disk
RAM
Random-Access Memory
rBF
relative Blood Flow
rBV
relative blood Volume
rCBF
relative Cerebral Blood Flow
rCBV
relative Cerebral Blood Volume
RD
Radial Diffusivity
REVTID
Reverse Time Interval Difference
RIS
Radiology Information System

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Acronym Meaning
RMS
Remote Management Services
ROI
Region of Interest
SCP
Service Class Provider
SCU
Service Class User
SOP
Service Object Pair
SQL
Structured Query Language
SR
Structured Report
SRSA
Secure Remote Service Access
SSL
Secure Sockets Layer
sSVD
Standard Singular Value Decomposition
SUV
Standard Uptake Value
SVD
Singular Value Decomposition
TCP/IP
Transmission Control Protocol/Internet Protocol
TID
Time Interval Difference
TLS
Transport Layer Security
TMAX
Time to maximum impulse response function
TMIP
Temporal Maximum Intensity Projection
TTP
Time to Peak
TW
Trace Weighted
UI
User Interface
UID
Unique Identifier
USB
Universal Serial Bus
Vi
Vein
VM
Value Multiplicity
VOF
Venous Output Function
VOI
Volume of Interest
VR
Volume Ratio
WC
Window Center
WS
Web Server
WW
Window Width

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2. Introduction
The MR Diffusion and MR Perfusion modules are clinical tools for evaluating water diffusion and blood
perfusion parameters in the brain.
The applications use as input a collection of images produced by a Magnetic Resonance (MR)
scanner. Diffusion Weighted Imaging (DWI) MR and Diffusion Tensor Imaging (DTI) MR series are
used for calculating the rate and direction of water diffusion in the brain, while DSC series serve to
calculate blood flow, blood volume, and permeability.
Based on the input data and on the calculation of water and blood supply parameters, the application
produces maps that help diagnose the clinical question at hand.
The diffusion module provides1:
•Automatic calculation of a brain mask
•Ability to add or subtract mask areas manually
•Automatic calculation of DWI maps based on input data, including:
•ADC
•eADC
•Automatic calculation of DTI maps based on input data, including:
•ADC
•eADC
•DWI iso
•Axial diff
•Rad diff
•FA
•VR
•FA dir
•Ability to add ROIs
•Show calculated information in tabular form
The perfusion module provides2,3,4,5,6:
•Automatic calculation of a brain mask
•Ability to add or subtract mask areas manually
•Ability to add or subtract segmented arteries
•Ability to add or subtract segmented veins
•Automatic calculation of the average of all potential AIF points
•Automatic calculation of the average of all potential VOF points
•Automatic calculation of the brain symmetry plane
•Automatic motion correction
•Automatic calculation of DSC perfusion maps based on input data, including:
•rCBV
•rCBF
•TTP
•MTT

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•TMAX
•Calculation of a k2 permeability map
•Corrected maps based on the k2 maps
For further details on the diffusion and perfusion maps, see Section 5 Viewing Diffusion
Series and Section 6.3 Working with Perfusion Maps.
•Ability to add ROIs
•Automatic selection of the affected hemisphere of the brain
•Segmentation of two ischemic regions marked as Lesion and Hypoperfusion. The
segmentation of each region is based on thresholds and parameters configurable by the user.
•Show calculated information in tabular form
NOTE: The values for blood volume and blood flow are shown in relative units up to an arbitrary
multiplicative constant. Relative units are used because partial volume effects and other
measurement limitations prevent absolute quantification.

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3. Application Workflow
An MR study may include diffusion series, perfusion series, or both diffusion and perfusion series.
For the diffusion series, the following steps are performed:
1. Automatic calculation of the brain mask—Executed automatically by the application while
allowing manual corrections by the user.
2. Displaying of the original image data and calculated maps—executed automatically by the
application.
For DWI series—ADC and eADC maps + the original data
For DTI series—ADC, eADC, DWI, Ax diff, Rad diff, FA, VR, and FA dir maps + the original
data
NOTE: The specific maps that appear are configurable. Contact your system administrator to
specify which maps will be displayed.
3. Calculation of diffusion parameters for ROIs drawn manually by the operator. These
measurements are displayed in a table.
For the perfusion series, the application segments the arteries and veins in order to calculate AIF and
VOF signals, identifies the brain centerline, and marks the results on a standard Temporal Minimum
Intensity Projection (TMIN) series.
Based on this data, the user can initiate the perfusion calculations, the results of which are displayed
in a set of maps. Measurements of parameters for specific Regions of Interest (ROIs) are presented in
tables.
Finally, a segmentation of the Lesion and Hypoperfusion areas is marked on the TMIN image.
A typical workflow includes the following automatic and manual steps:
1. Loading of the study to the MR Perfusion application—executed by the user.
2. AIF Indication—Executed automatically by the application while allowing manual corrections
by the user.
3. VOF Indication—Executed automatically by the application while allowing manual corrections
by the user.
4. Identification of the brain center line—Executed automatically by the application while
allowing manual corrections by the user (calculated and shown already for the diffusion
series).
5. Automatic calculation of a brain mask (calculated and shown already for the diffusion series).
6. Automatic calculation of a TMIN series.
7. Motion correction.
8. Calculation of the perfusion parameters—rCBV, rCBF, TTP, MTT, TMAX and k2.
The parameters are calculated automatically by the application and displayed as a set of
perfusion maps.
9. Measurement of the above parameters for ROIs drawn manually by the operator. These
measurements are displayed in a table.
10. Segmentation of two ischemic regions marked as Lesion and Hypoperfusion. The
segmentation of each region is based on thresholds and parameters configurable by the user
(see Section 8 Using Settings).

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4. Loading the Study
To load an MR perfusion study –
1. In the Vue PACS client, highlight the study in the Archive Explorer.
2. Select one of the following from the right-click menu:
•Load To > Perfusion Stroke:
The “Perfusion Stroke” application is the main Perfusion application, which calculates
the Core & Penumbra, and compares the two brain sides.
This application is applicable for Perfusion studies of any modality (CT or MR).
•Load To > Perfusion Lesion (only applicable for MR Perfusion studies):
The “Perfusion Lesion” application is intended to measure brain lesions. It does not
calculate the Core/Penumbra and the brain center-line is not shown.
This application is applicable only for MR Perfusion studies.

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•Load To > Perfusion Lesion (applicable for any study containing Diffusion groups):
The “Diffusion” application is intended for any study that contains a Diffusion group,
and it loads that group only. Furthermore, only Diffusion maps will be calculated.

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5. Initial Display
When the study loads, the screen displays the perfusion and/or diffusion data (depending on whether
the study contains perfusion series only, diffusion series only, or diffusion and perfusion series) as
well as a ribbon with tools to help you control the workflow and add manual calculations.
5.1 Basic Image Manipulation
Right-click anywhere in the image display area to select image manipulation activities, such as
windowing, zooming, panning, and others. For a description of all image manipulation tools available
in the Vue PACS application, see the CARESTREAM Vue PACS help.
Use the mouse wheel to scroll through the series images.
5.2 Tool Ribbon
# Description
1 Next Step—Click to progress to the next step.
2 Select Step—Select the next step.
Steps include display of perfusion input data and display
of perfusion maps.
3 Calculate Perfusion Maps—Click to initiate the calculation of perfusion maps (perfusion
series only).
4 Add New Artery—Click to manually add an artery (perfusion series, in seed mode only).
5 Add New Vein—Click to manually add a vein (perfusion series, in seed mode only).
6 Motion Correction—Click to correct the effect of patient movement (perfusion series only).
7 Select Damaged Brain Side—Specify the damaged brain side to indicate the side on which
the hypoperfusion is assessed and segmented by the application (perfusion series only).
8 Symmetric Operation Toggle—Click to have the application automatically draw an ROI on
the contralateral side when you draw an ROI.
9 Show/Hide graphics—Use the drop-down menu to hide the ischemic regions or to hide all
graphics (perfusion series only).
10 Add ROI—Click to manually draw an ROI.
11 Reset All Calculations—Delete all ROIs, tissues, maps, AIF and VOF corrections.

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# Description
12 Settings—Adjust settings related to the algorithm, maps, clinical parameters, input state,
ischemic regions, and tables.
13 Open a Report—
Opens an automatically generated report containing all the measurements
and graphs performed by the user.
14 Show/Hide Brain Mask—Show/hide brain mask. You can also add brain mask manually as
well as erase added brain mask coloring.
15 Show/Hide AIF Segmentation—Show/hide automatically segmented arteries
. You can also
add segmentations manually as well as erase the added segmentations (perfusion series
only).
Show/Hide VOF Segmentation— Show/hide automatically segmented veins. You can also
add segmentations manually as well as erase the added segmentations (perfusion series
only).
17 Export Perfusion Analysis—Export the calculated maps and TMIN images to the study.

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6. Viewing Diffusion Series
The system calculates water diffusivity and displays a set of maps summarizing the calculated values.
The windowing menu, displayed by right-clicking the windowing annotation, allows you to apply
various maps and change the windowing scale to minimum and maximum values.
Use the windowing menu to display values that are beyond the values of the bar. In such cases, the
value displayed on the color bar is marked with an asterisk.
6.1 DWI Images
The DWI scan is isotropic and measures the diffusivity in different magnetic field gradients
(characterized by different b values). The layout includes:
•The data of the original series with a b-value slider
•Calculated maps
The following illustrations show the initial layout on landscape and portrait monitors.

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If you are working with two monitors side by side, you can use a dual-monitor layout. Click Toggle
Dual Monitor in the Layout ribbon. The display is adapted to the dual-monitor environment.
The slider at the bottom of the original series represents values of gradient factor b (sec/mm2). Use
the slider to show the data at the different b-values.
Maps
The following maps are shown:
•ADC—Displays the apparent diffusion coefficient of water molecules calculated based on the
different gradient images.
•eADC—Reverses the colors of the ADC map. Because the contrast in the ADC map is the
reverse of regular T2 images, the system generates the eADC map based on the formula
exp(-b*ADC), b being a configurable constant (1000 by default). This map has a similar
contrast to that of regular T2 scans, and reflects the diffusion coefficient ADC.
•DWI iso—Isotropic map that multiplies the eADC by the T2 image (b=0).
Table
If you add an ROI, a table presenting the calculated values in the ROI is displayed on screen.
6.2 DTI Images
The DTI scan is performed in multiple directions as well as in several gradients (b values). The scan
serves to measure the diffusivity in the various directions and to help draw anatomic conclusion based
on these measurements1.
The layout presents the calculated maps.
The following illustrations show the initial layout on landscape and portrait monitors.

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If you are working with two monitors side by side, you can use a dual-monitor layout. Click Toggle
Dual Monitor in the Layout ribbon. The display is adapted to the dual-monitor environment. Note
that the dual-monitor display shows more maps than the single-monitor display. The following
illustrations show the dual-monitor layout on landscape and portrait monitors.
To change the maps that are displayed by default, right-click the map name and change the display
(see Section 5.5 Determining the display).The values annotated on the slider at the bottom of the
original series signify b values (sec /mm2).
By default, the data of the original series and the slider are not displayed in the single-monitor display.
To display this series, right-click the map name and change the display (see Section 5.5 Determining
the display).

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Maps
Based on the various diffusivity measures, the system generates a diffusion tensor and calculates the
tensor’s eigenvalues λ1, λ2, λ3 (λ1 > λ2 > λ3) and eigenvectors V1, V2, V3 respectively.
The following maps are shown:
Maps reflecting isotropic diffusivity1
•ADC—Simulates the isotropic scan and is equal to the average of the eigenvalues
(λ1+λ2+λ3)/3.
•eADC—Calculated by exp(-b*ADC) for a prefixed b value.
•DWI—Isotropic map that multiplies the eADC by the T2 image (b=0) or by a T2 extrapolation
(in cases when there is no b=0 image or when there are several such images).
Maps reflecting anisotropic diffusivity1
•Ax diff—The largest eigenvalue (λ1)
•Rad diff—The average of the two smaller eigenvalues (λ2+λ3))/2
•FA—Measures the difference between the isotropic diffusion measurement and the
directional measurement.
•RA—Measures the ratio of the isotropic diffusion measurement to the directional
measurement.
•FA dir—A color map, showing the color coding of the main direction of diffusivity (V1) relative
to the main axes X, Y, Z. Red indicates the main direction X, green indicates the main
direction Y, and blue indicates the main direction Z. At each point, the displayed color may be
either a mixture of red, green, and blue, based on the diffusion component, or only red, only
green, or only blue, based on the component of the maximal value. The system may be
configured to display the colors by one of these coloring options. See your system
administrator to change the coloring option.
Table
•If you add an ROI, a table presenting the calculated values in the ROI is displayed on screen.
6.3 Using the Brain Mask Correction Tool
You can display and hide the brain mask in the displayed input images.
6.3.1 Displaying the Brain Mask
To display the brain mask, click the brain mask icon in the Correction Tools section of the
Perfusion ribbon. The brain mask is displayed both on the TMIP and the dynamic images.
6.3.2 Adding Brain Mask
To manually add brain mask on the displayed image –
1. Click Add Brain Mask in the drop-down menu of the Show/Hide Brain Mask icon.
2. Click the left mouse button at the point where you wish to start adding brain mask to the
image.
3. Drag the mouse to add brain mask.
4. Left-click the mouse again to end the brain mask addition.