Instructions for use - VueBox® - Quantification Toolbox

Instructions for use - VueBox® - Quantification Toolbox
VueBox®
Quantification Toolbox
Instructions for use
Copyright© 2015 Bracco Suisse SA
Bracco Suisse SA – Software Applications
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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 –
Software Applications
2015/09
Bracco Suisse SA – Software Applications
BRACCO Suisse S.A.
Software Applications
31, route de la Galaise
1228 Plan-les-Ouates
Genève - Suisse
fax +41-22-884 8885
www.bracco.com
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CONTENTS
1
2
3
4
Introduction ............................................................................ 5
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
About this manual .......................................................................... 5
Interpreting symbols of the product ............................................. 5
Definitions ...................................................................................... 6
System description ........................................................................ 6
Intended use .................................................................................. 6
Product lifetime.............................................................................. 7
Safety precautions ......................................................................... 7
Installation and maintenance ........................................................ 7
Patient and user safety .................................................................. 7
Measurement ................................................................................. 8
Installation .............................................................................. 9
2.1
2.2
2.3
System Requirements .................................................................... 9
Installation of VueBox®................................................................. 9
Activation of VueBox® ................................................................. 10
General review tools.............................................................. 11
3.1
Interface elements....................................................................... 11
3.1.1
3.1.2
Main toolbar ............................................................................... 11
Side toolbar................................................................................ 12
Functional Reference ............................................................. 13
4.1
4.2
4.3
User interface............................................................................... 13
General workflow ......................................................................... 15
Specific application packages ...................................................... 15
4.3.1
4.3.2
4.3.3
4.3.4
4.3.5
Principle .................................................................................... 15
Package selection ........................................................................ 15
GI-Perfusion – General Imaging Perfusion Quantification ..................... 16
Liver DVP – Focal Liver Lesion ........................................................ 16
Plaque....................................................................................... 16
4.7.1
4.7.2
4.7.3
4.7.4
4.7.5
Principle .................................................................................... 18
Interface elements....................................................................... 18
Workflow ................................................................................... 20
Clip concatenation ....................................................................... 20
Flash image detection................................................................... 21
4.8.1
4.8.2
4.8.3
4.8.4
Principle .................................................................................... 22
Interface elements....................................................................... 22
Workflow ................................................................................... 23
Dual display mode ....................................................................... 24
4.12.1
4.12.2
Principle .................................................................................... 27
Workflow ................................................................................... 27
4.13.1
4.13.2
4.13.3
Principle .................................................................................... 28
Linearized signal ......................................................................... 28
Contrast arrival detection .............................................................. 29
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
Supported datasets ...................................................................... 16
Video settings .............................................................................. 17
Calibration files ............................................................................ 17
Clip edition ................................................................................... 18
Regions of interest ....................................................................... 22
Length calibration and measurement .......................................... 26
Anonymization of clip .................................................................. 27
Annotation.................................................................................... 27
Motion compensation ................................................................... 27
4.13 Perfusion data processing ........................................................... 28
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4.13.4
4.13.5
4.13.6
4.13.7
4.13.8
4.13.9
4.13.10
4.13.11
Skip duplicate images................................................................... 29
Perfusion models ......................................................................... 29
Dynamic Vascular Pattern.............................................................. 32
Dynamic Vascular Pattern Parametric .............................................. 32
Perfusion Segments Analysis.......................................................... 33
Measurement acceptance criteria .................................................... 36
Parametric imaging ...................................................................... 36
Workflow ................................................................................... 37
4.14.1
4.14.2
4.14.3
4.14.4
4.14.5
4.14.6
4.14.7
Interface elements....................................................................... 37
Adjustable display presets ............................................................. 38
Auto-scaled display presets ........................................................... 39
Storing / loading display preset ...................................................... 39
Parametric image overlay .............................................................. 40
Perfusion instant detection ............................................................ 40
Analysis result database................................................................ 41
4.15.1
4.15.2
4.15.3
4.15.4
Principle .................................................................................... 42
Interface elements....................................................................... 42
Workflow ................................................................................... 43
Analysis report............................................................................ 43
4.14 Result window.............................................................................. 37
4.15 Export analysis data..................................................................... 42
4.16 Import and export user settings.................................................. 45
4.17 About screen ................................................................................ 46
5
6
Quick guide ........................................................................... 47
5.1
5.2
5.3
5.4
General Imaging - Bolus analysis ................................................ 47
General Imaging – Replenishment analysis ................................ 47
Focal Liver Lesions, Dynamic Vascular Pattern Analysis ............. 48
Plaque .......................................................................................... 49
Index ..................................................................................... 50
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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
precautions, or warnings.
important
information,
safety
The stop symbol highlights important information. You should stop
and read before continuing.
The bulb symbol indicates a suggestion 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
Location
Description
REF
User Manual
Product name and version
User Manual
Manufacturer’s name
User manual
Production Year and month
User Manual
Conformity assessment procedure according
to directive 93/42/EEC Annex II.3
Classification according to directive
93/42/EEC, Ann. IX: class IIa according to
rule 10
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1.3 DEFINITIONS
ASR
DVP
DVPP
FLL
FT
MI
MIP
mTT
PA
PE
PI
PSA
QOF
rBV
ROI
rPA
RT
TSV
TTP
WiAUC
WiPI
WiR
WiWoAUC
WoAUC
WoR
Advanced System Recognition
Dynamic Vascular Pattern
Dynamic Vascular Pattern Parametric
Focal Liver Lesion
Fall Time
Molecular Imaging
Maximum Intensity Projection
Mean Transit Time
Perfused Area
Peak Enhancement
Perfusion Index
Perfusion Segments Analysis
Quality Of Fit
Regional Blood Volume
Region Of Interest
Relative Perfused Area
Rise Time
Tabulation-Separated Values
Time To Peak
Wash-in Area Under Curve
Wash-in Perfusion Index
Wash-in Rate
Wash-in and Wash-out AUC
Wash-out AUC
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
calculated, 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.
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The visualization 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.
1.8 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 safety, reliability and performance of the system, if:
• the product is not operated in accordance with the operating manual
• the product is operated outside of its operating conditions
• the product is operated outside of the specified operating
environment.
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”.
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.
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1.10 MEASUREMENT
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 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:
• obvious discontinuity due to a jerky motion during acquisition or
because the acquisition plane changed;
• excess shadowing in images;
• 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.
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2 INSTALLATION
2.1 SYSTEM REQUIREMENTS
Minimum
Proposed
CPU
Intel® Pentium 4 520
Intel® Core 2 Duo E8400 or better
RAM
1 GB
2 GB or more
Graphics Card
Nvidia GeForce 8500GT 512DDR
Minimum Resolution 1024x768
Nvidia GeForce 8800GT 1024DDR
Resolution 1280x1024 and higher
Monitor
17’’ SVGA (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
Screen text size
96 dpi
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:

Microsoft .NET Framework 4.5.1

SAP Crystal Report Runtime Engine for .NET Framework 4.0

Visual C++ 2010 Runtime Libraries

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. at the 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.
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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:

Serial number

E-mail address

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 email 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 VueBox® 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.
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3 GENERAL REVIEW TOOLS
3.1 INTERFACE ELEMENTS
3.1.1
MAIN TOOLBAR
1
2
3
4
5
6
7
8
9
10
Available in mode
Item
Function
Clip
editor
Motion
comp.
Result
Comments
X
X
Return to the clip editor mode.
1
Clip editor
2
Length
Calibration
X
X
X
Set a known distance in the image
to calibrate for length and area
measurements.
(Not available in the segmentation
packages)
3
Copy ROI
X
X
X
Copy all ROI of the current active
window into the ROI database.
4
Paste ROI
X
X
X
Paste selected ROI set from the ROI
database.
5
Motion
compensation
X
X
Apply spatial realignments on all
images using a specific reference
image.
(Not available in the segmentation
packages)
6
Perfusion data
processing
X
X
Perform perfusion quantification or
calculate DVP according to selected
package
7
Save result
X
Store a result file (analysis result
context) into the result database.
(Not available in the segmentation
packages)
8
Validate
segmentation
X
Save the segmentation results
(Only available in the segmentation
packages)
9
Export data
X
Export selected data (e.g.
quantification data, screenshots,
movies).
(Not available in the segmentation
packages)
10
About
X
Display the about screen.
X
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3.1.2
Exit
X
X
X
Close all clips opened and exit the
software.
SIDE TOOLBAR
11
12
13
14
Available in mode
Item
Function
Clip
editor
Motion
comp.
Result
Comments
11
Import /
Export user
settings
X
X
X
Import / export user settings (i.e.
ROI, result and display preset
databases).
12
Length
Measurement
X
X
X
Measure distances in the image.
13
Annotations
X
X
X
Add text labels on images.
14
Anonymize
X
X
X
Hide patient’s name and
identification.
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4 FUNCTIONAL REFERENCE
To get instant help on working with VueBox®, click the
toolbar and click the help button.
button in the main
You will need Adobe Acrobat 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
VueBox® 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.
Figure 1 – VueBox® start page
When VueBox® is launched from TomTec’s Image-Arena platform, the start
page cannot be accessed. The data selection must be performed from ImageArena™.
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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.).
Patient
ID
Main toolbar
Side
toolbar
ROI
toolbar
Video
settings
Clip
Editor
Figure 2 - One-quadrant view
Finally, when the perfusion data processing is completed, results are presented in a fourquadrant view, where time-intensity curves, parametric images, time intensity curves
and perfusion parameter values are displayed.
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Display settings
Parametric
image
Perfusion
parameter
selection
TimeIntensity
curves
Parameter
table
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:
1. Choose an application package
2. Load a dataset
3. Adjust video settings
4. Select perfusion model, if applicable
5. Remove unwanted images with the clip editor
6. Draw several ROI
7. Apply motion compensation if needed
8. Perform quantification
9. 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.
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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 General 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:

Liver-dedicated Bolus perfusion model (i.e. Bolus Liver)

Dynamic Vascular Pattern (see section 4.13.6)

Dynamic Vascular Pattern Parametric (see section 4.13.7)

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:

Perfused Area (see section 4.13.8)

Relative Perfused Area (rPA)

Mean MIP Opacification (MIP)

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-mode clips and contrast/B-mode overlay displays are not supported.
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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:
Figure 5 - Video settings panel

define the desired sub-sampling rate if
needed, so as to reduce the number of
frames to be processed (optional),

select
the
appropriate
ultrasound
system and settings used for the
acquisition so as to apply the correct
linearization function to the image data
(mandatory),

activate the dual display mode if the clip
was recorded with both contrast and
fundamental B-mode images side-by-side
(or
above
each-other)
on
screen
(optional),

select the gain compensation so as to
compensate for gain variations across
different exams in order to be able to
compare results of a given patient at
different visits (optional).
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.
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Calibration files are distributed to users according to their ultrasound system(s) (e.g.
Philips, Siemens, Toshiba, etc.) and can be added to VueBox® by a simple drag & drop
into the VueBox® user interface.
The most common settings are available for each ultrasound system. However, 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 washin 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
Replenishment segments:
1st
2nd
Relevant time interval
Destruction event
Time
Image status bar:
Exclusion
Inclusion
Time
Image status bar:
Exclusion
Inclusion (selected segment)
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 the interface elements in the clip editor in the
replenishment mode.
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Figure 7 – User interface in the clip editor in the replenishment mode.
Element
Name
Function
Image display
Image number
shows the order number of the currently
displayed image as well as the total number of
images available in the clip.
Time indicator
shows the time instant of the currently
displayed image.
Zoom In / Out
increases or decreases the image size.
Image slider
selects the image to be displayed. If the cursor
points to an excluded image, a red frame
appears around it.
Image status
bar
shows excluded and included image ranges in
red and green, respectively. Destruction images
are shown in orange.
Play
runs the movie player.
Fast play
runs the movie player in fast mode.
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Clip editor
4.7.3
Exclude
sets the exclusion mode.
Include
sets the inclusion mode.
Add Flash
marks the current image as flash (see section
4.7.5).
Replenishment
segment
selector
selects the previous/next replenishment
segment (only available if the clip includes
destruction-replenishment segments).
WORKFLOW
EXCLUDING IMAGES
To exclude 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 ( )
2. When the pointer's shape changes to a vertical split
the range of excluded images.
, drag the border to change
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 ( )
2. When the pointer's shape changes to a vertical split
, 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.
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Bracco recommends concatenating clips with a clip-transition delay ≤ 15
seconds.
4.7.5
Concatenate
clip
opens and concatenates a clip with the current clip.
Move up
selected clip
moves up the selected clip in the Clip selector list.
Delete
selected clip
removes the selected clip from the Clip selector list.
Move down
selected clip
moves down the selected clip in the Clip selector list.
Transition
delay
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.
Clip selector
selects a clip in the list.
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 clip. The flash detection is an
automatic process launched every time a clip is loaded in VueBox®.
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"
button to stop it.
2. If the detection is completed, click on the destruction
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
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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 additional two ROI
are available to user’s discretion.
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
toolbar identifies the current region to be drawn,
and may be edited by clicking on it.
Button
Figure 10 – ROI toolbar
Name
Function
Select
allows to select / modify a region of interest.
Rectangle
draws a rectangular shape.
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4.8.3
Ellipse
draws an elliptical shape.
Polygon
draws a closed polygonal shape.
Closed curve
draws a closed curvilinear shape.
WORKFLOW
DRAWING A ROI
To draw a rectangular or elliptical ROI:
1. Select a shape in the ROI toolbar (
or
)
2. Move the mouse pointer to the wanted location in the B-mode image (left
side) or the contrast image (right side)
3. Click and drag to draw the ROI.
To draw a closed polygonal or curved ROI,
1. Select a shape in the ROI toolbar (
or
)
2. 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. Right click in the image to set the ROI selection mode or click the
button
2. Move the mouse pointer to any border of the ROI
3. Select the ROI using the left or right mouse button
4. Press either the DELETE or BACKSPACE keys.
MOVING A ROI
To change the location of a ROI:
1. Right click in the image to set the ROI selection mode or click the
button
2. Move the mouse pointer to any border of the ROI
3. 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:
1. Right click in the image to set the ROI selection mode or click the
button
2. Move the mouse pointer to any anchor point of the ROI
3. When the pointer shape changes to a cross, click and drag the anchor point
to a new location.
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COPYING AND PASTING ROI
Regions of interest can be copied into a ROI library and pasted at a later time point, in
any clip analysis. To copy all the ROI currently drawn:
1.
Click the
toolbar
button in the main
2.
Set a name or accept the default
generated one and press the OK button
Figure 11 - Copying ROI into library
To paste ROI from the library:
1.
Click the
toolbar
button in the main
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.
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.
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1st
Time
Figure 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):
1. Set the
toggle button to “On” in the dual display section of the
video settings panel
2. Make sure that the
toggle button is set to “Auto”
3. Click on the probe orientation marker of the contrast image
4. 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. Set the
toggle button to “On” in the dual display section of the
video settings panel
2. Set the
toggle button to “Manual”
3. Click on an image landmark of the contrast image
4. Click on a corresponding image landmark of the B-mode image
5. 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 manual 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 Bmode image areas.
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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.
Once the Length calibration has been defined, areas of regions of interest will be listed in
cm2, in the quantitative parameter table.
The lengths within the images can be measured with the Length measurement tool .
The first Measurement tool
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:
1. click the length measurement
button,
2. select the type of ruler in the ROI toolbar (line or cross),
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)
< 1%
Error on Area
< 1%
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4.10 ANONYMIZATION OF CLIP
The Anonymize Clip Tool
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.
The general workflow is as follows:
1. Click the Anonymize
button.
2. Adjust and move the Anonymize mask (rectangular shape) to where the
information to be hidden is located in the image.
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 clip 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
button in the main toolbar
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3. Once motion compensation is applied, the native clip editor is replaced by a
motion-corrected clip editor, where the clip resulting from the motion
compensation process can be further edited. At this stage, colors of the
Image status bar ( ) 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
again to re-apply Motion compensation.
button
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 reapply 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 converted 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-power 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.
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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.
Figure 17 - Contrast arrival detection dialog box
The automatic contrast arrival detection is to be considered as a suggestion
only. The user should make sure to review this suggestion before pressing
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 plateau 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
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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, VueBox® provides the following parameters, illustrated in the figure
hereafter:
PE
WiAUC
Peak Enhancement
[a.u]
Wash-in Area Under the Curve ( AUC (TI:TTP) )
[a.u]
Rise Time ( TTP – TI )
[s]
mTTl
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]
Wash-out AUC ( AUC (TTP:TO) )
[a.u]
Wash-in and Wash-out AUC ( WiAUC + WoAUC )
[a.u]
RT
WoAUC
WiWoAUC
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)
[%]
Where TI is the instant at which the maximum slope tangent intersects the x-axis (or
offset value 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:
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rBV
relative Blood Volume ( A )
[a.u]
WiR
Wash-in Rate ( maximum slope )
[a.u]
mTT
mean Transit Time
PI
QOF
[s]
Perfusion Index ( rBV / mTT )
[a.u]
Quality Of Fit between the echo-power signal and f(t)
[%]
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.
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
incorrect.
The user must ensure that perfusion kinetics are not affected by any vessel
or artifact.
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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).
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:
𝑓𝐷𝑉𝑃(𝑥, 𝑦, 𝑡) = [𝑓(𝑥, 𝑦, 𝑡) − 𝑂(𝑥, 𝑦)] − [𝑓𝑅𝐸𝐹 (𝑡) − 𝑂𝑅𝐸𝐹 ]
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)
Echo power [a.u.]
15
Healthy parenchyma (REFERENCE)
Lesion 1
Lesion 2
(c)
10
10
5
5
0
Healthy parenchyma - REFERENCE
Lesion 1 - REFERENCE
Lesion 2 - REFERENCE
+
+
-
0
0
20
40
60
80
100
120
-5
0
20
40
Time [s]
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 with 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.
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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

unipolar positive “+”(hyper-enhanced signature),

unipolar negative “-” (hypo-enhanced signature),

bipolar positive “+/-” (a hyper-enhancement
enhancement) and, conversely,

bipolar negative “-/+”.
followed
by
a
hypo-
A 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.
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 reference 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).
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Then, the MIP processing (for each individual pixel in the plaque ROI) is performed in two
steps:

A noise level detection, based on the last MIP image in the baseline time
segment.

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
Baseline
Perfusions
2s
3s
1s
2s
2s
Lumen
Plaque
Contrast arrival
time (Lumen)
Time to
Peak (Lumen)
Time
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 scale 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.
Figure 22 - Frame segments detection dialog box
Finally the following parameters are computed:
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
Perfused Area (PA, PA1, PA2)

relative Perfused Area (rPA, rPA1, rPA2)

Mean MIP Opacification (MIP)

Mean MIP Opacification – Perfused Pixel only (MIP –th)

Mean

Median

Integral
PA represents the total number of pixels retained in the plaque after the processing or
the area in [mm2] of these pixels if the length calibration has been defined. Additionally,
the rPA is expressed in [%] 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 the 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.
A plaque ROI must not be contaminated by enhancement coming from the
lumen. It could lead to wrong perfusion area results.
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.
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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 & Measured
parameters
f t 
4.13.10
Tolerance
± 15%
DVP  t 
± 15%
WiAUC
RT
mTTl
TTP
WiR (Bolus)
WiR (Replenishment)
WiPI
WoAUC
WiWoAUC
FT
WoR
rBV
mTT
rBF
QOF
PA
rPA
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
±
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
15%
PARAMETRIC IMAGING
VueBox® 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:
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
the clips must represent the same
anatomical cross-section from one
exam to another;

acquisition of contrast-ultrasound
sequences must be performed using
identical system settings (primarily
transmit power, display settings,
gain, TGC, dynamic range and postprocessing);

only parametric images of the same
perfusion
parameter
can
be
compared.
Figure 24 - Parametric images example
4.13.11
WORKFLOW
To perform perfusion data processing:
1. 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
•
Original clip (Q1);
•
Processed clip or parametric image (Q2);
•
Chart displaying time intensity curves (linearized and fitted signals) in each
ROI (Q3);
•
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 labels 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.
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Q1
Q2
Q3
Q4
Figure 25 - User interface in result mode
Control
Name
Function
Parametric image view
allows the selection of
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 [%] for time-related parameters.
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 (logcompression) of the processed image displayed in Q2, in a way similar to a standard
ultrasound scanner.
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Slider / control
Name
Function
Preset
stores, restores and auto scales
display preset (gain and dynamic
range of all parametric images).
Gain
controls the gain applied to the
current processed image (Q2).
(-60dB to +60dB)
Dynamic range
controls the dynamic range of logcompressed applied to the current
processed image (Q2).
(0dB to +60dB)
Overlay opacity
controls the opacity of the overlay
displayed on the B-Mode side (Q2)
4.14.3 AUTO-SCALED DISPLAY PRESETS
Display presets (i.e. gain & 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:
1.
Click the
toolbar
button in the preset
2.
Set a name or accept the one
generated by default and press the OK
button
Figure 28 : Storing display presets into
library
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To load display presets from the library:
1.
Click the
toolbar
button in the preset
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.
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 VueBox® 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.
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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 (previously analyzed) in the start page of VueBox®.
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
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.
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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 followup 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 analysis report summarizing qualitative (i.e. still images) and quantitative (i.e.
numerical data) information can be generated.
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.
The figure below shows a screenshot of the interface elements in export mode.
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).
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Ultrasound
image
(current)
exports the current ultrasound image with its ROIs (Quadrant 1).
Parametric
images
exports all parametric images (Quadrant 2).
Time
Intensity
Curve
exports an image of the chart (Quadrant 3).
Clip
Original
exports the original clip.
Parametric
exports the processed clip.
Native &
Parametric
exports both the original and processed clips in a side-by-side view
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
report
generates the analysis report and display the report generator dialog
box.
Folder name
Save as
indicates the folder name where the result files will be saved.
4.15.3 WORKFLOW
To export data:
1. Click the
button
2. Select a target directory in the left panel
3. Under Data, Images and Clip in the right panel, choose the type of results
to export
4. Under Option, type a folder result name
5. 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
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Patient- and exam-related information
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
Hospital name

Patient ID

Department name

Patient name

Professor name

Physician name

Phone & 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 extracted 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:

an image of the analyzed clip including ROI,

a DVPP image,

three images at different DVP instants,

a chart representing the average signal within available ROI,

a chart representing the average difference signal within available ROI (i.e. DVP
signal),

an editable comment field.
Otherwise, in all other cases:
The body of the report contains the following information:

an image of the analyzed clip including ROI,

a chart representing the average signal within available ROI,

the perfusion model selected,

a parametric image and quantitative values, in absolute and relative terms, for
each perfusion parameters,

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.
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Figure 34 - Analysis report, header modification interface
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:
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1. Click the
button from the side toolbar
2. Select export location
3. Click the
button.
To import user settings:
1. Click the
button from the side toolbar
2. Choose Copy from… option by clicking the
button
3. Select user settings file location and choose user settings file from the list
4. 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.
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5 QUICK GUIDE
This section describes the two typical workflows to perform an analysis with VueBox®.
5.1 GENERAL IMAGING - BOLUS ANALYSIS
1. Open a Bolus clip in GI-Perfusion package.
2. Adjust the linearization settings in the Video Settings panel.
3. Choose the Bolus perfusion model in the perfusion models tab.
4. Define the images to be excluded using the Clip editor.
5. Draw Delimitation ROI delimiting the processing area
6. Draw multiple ROI successively as desired.
7. Move the Image
compensation.
8. Click the
slider to
choose a
reference
image
for
motion
button to launch the motion compensation.
9. Review the motion compensated clip using the Image slider.
10. If the Motion compensation is unsuccessful, try one of the following:
11. Select another reference image and click the
Motion compensation.
button again to re-apply
12. 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.
13. Once satisfied with motion compensation, click the
Perfusion Data Processing.
button to launch the
14. Accept or select another instant in the Contrast arrival detection dialog
box.
15. If needed, adjust the Gain and Dynamic range sliders for each parametric
image or check Apply preset to apply the user preferences.
16. Click the
button to export data
17. Click the
button to store the context.
5.2 GENERAL IMAGING – REPLENISHMENT ANALYSIS
1. Open a Replenishment clip in GI-Perfusion package.
2. Adjust the linearization settings in the Video Settings panel.
3. Wait for the flash detection to be completed. If necessary, set flash images
manually by using the
button or the “F” keyboard key.
4. Choose the Replenishment perfusion model in the perfusion models tab.
5. If multiple segments are present, select the replenishment segment to be
analyzed with arrow buttons (
).
6. Draw Delimitation ROI delimiting the processing area
7. Draw multiple ROI successively as desired.
8. Move the Image slider to choose a reference image for motion correction.
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9. Click the
button.
10. Review the motion compensated clip using the Image slider.
11. If the Motion compensation is unsuccessful, try one of the following:
12. Select another reference image and click the
Motion compensation.
button again to re-apply
13. 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.
14. Once satisfied with motion compensation, click the
Perfusion Data Processing.
button to launch the
15. If needed, adjust the Gain and Dynamic range sliders for each parametric
image or check Apply preset to apply the user preferences.
16. Click the
button to export data.
17. Click the
button to store the context.
5.3 FOCAL LIVER LESIONS, DYNAMIC VASCULAR PATTERN ANALYSIS
1. Open a Bolus clip in Liver DVP package.
2. Adjust the linearization settings in the Video Settings panel.
3. Define the images to be excluded using the Clip editor.
4. Draw Delimitation ROI delimiting the processing area
5. Draw Lesion 1 and Reference ROI successively.
6. As desired, additional Lesion 2 and Lesion 3 ROI can be drawn (see section
4.8).
7. Move the Image
compensation.
8. Click the
slider to
choose a
reference
image
for
motion
button to launch the motion compensation.
9. Review the motion compensated clip using the Image slider.
10. If the Motion compensation is unsuccessful, try one of the following:
11. Select another reference image and click the
Motion compensation.
button again to re-apply
12. 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.
13. Once satisfied with motion compensation, click the
Perfusion Data Processing.
button to launch the
14. Accept or select another instant in the Contrast arrival detection dialog
box.
15. If needed, adjust the Gain and Dynamic range sliders for each parametric
image or check Apply preset to apply the user preferences.
16. Click the
button to export data
17. Click the
button to store the context.
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5.4 PLAQUE
1. Open a Plaque clip in Plaque package.
2. Adjust the linearization settings in the Video Settings panel.
3. Draw Delimitation ROI delimiting the processing area
4. Draw Plaque ROI delimiting the plaque area
5. Draw Lumen ROI (this reference ROI should be drawn to identify a small
reference area of the lumen)
6. As desired, optional Plaque ROI can be drawn
7. Move the Image
compensation.
8. Click the
slider to
choose a
reference
image
for
motion
button to launch the motion compensation.
9. Review the motion compensated clip using the Image slider.
10. click the
button to launch the Data Processing.
11. Adjust the baseline and perfusion segments location in the Frame
Segments Detection dialog box if needed.
12. Click the
button to export data
13. Click the
button to store the context.
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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
linearization, 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
Bracco Suisse SA – Software Applications
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
VBO.8.11
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REF
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
Genève - Suisse
fax +41-22-884 8885
www.bracco.com
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