1. EBT CLINICAL UPDATE November 2000

2. EBT Clinical Applications CARDIAC IMAGING Coronary Artery Calcium Scanning Coronary Electron Beam Angiography (EBA) Functional Cardiac Imaging BODY IMAGING Pulmonary Embolism Low-Dose Lung Scanning Abdominal Scanning Colonography Peripheral EBA (Carotid, Aorta, Renal, Femoral) Head Scan

3. EBT Radiation Dose EBT Coronary calcium scan 50 to 63 mrem0.5 to 0.63 mSv EBT Coronary EBA scan 70 to 90 mrem0.7 to 0.9 mSv EBT Low-dose Lung scan 100 to 150 mrem1.0 to 1.5 mSv Background radiation in 1year 300 mrem3.0 mSv Cross country airplane trip 2 mrem0.02 mSv Chest X-ray 8 to 10 mrem0.08 to 0.1 mSv Abdominal X-ray 48 mrem4.8 mSv Lumbar Spine X-ray series 300 mrem3.o mSv Coronary Angiogram 500 to 600 mrem5.0 to 6.0 mSv Lower G.I. X-ray series 600 mrem6.0 mSv Radiation dose from EBT scans compared to other sources of radiation MilliremsMillisieverts The advantage of the EBT over conventional scanners is that, instead of exposing the entire circumference of the body to the X-ray beam, the EBT X-ray beam enters from the back. Thus, anterior structures such as the breast and thyroid are subjected to a lesser dose of radiation (17% of the entrance skin dose). Radiation Source

4. Functional Cardiac Imaging Multi-Slice Mode Cine and Flow Acquisitions

5. Cine Mode – Functional Cardiac Imaging Prospective ECG-Triggering 80% RR 1 40% RR 2 Flow Mode – Perfusion Imaging Volume Mode – Coronary Imaging (Calcium & EBA) Cardiac Imaging

6. Myocardial Perfusion Scanning Protocol Flow Mode Table is slewed for Long Axis ECG Triggered to 40% of the R to R interval MSM 8 mm 15 to 20 images per level Injection of 35ml IV contrast @ 4ml per second. Repeat scan post stress Pre Dobutamine Stress Post Dobutamine Stress Functional Cardiac Imaging

7. SystoleDiastole Pre Dobutamine Stress Post Dobutamine Stress Pre Dobutamine Stress Ejection Fraction Scanning Protocol Cine Mode Table is slewed for Short Axis ECG Triggered to 0% of the R to R interval MSM CINE mode 8 mm 15 to 20 images per level Injection of 35ml IV contrast @ 4ml per second Repeat scan post stress Functional Cardiac Imaging

8. Coronary Artery Calcium Scanning Step Volume Mode ECG Triggered Acquisitions

9. Coronary Calcium Scanning Coronary Artery Scanning Protocol Patient Preparation: None ECG Triggered to 60-70% of the R to R interval 3mm contiguous scans From carina to the apex

10. Calcium Report Generation Coronary Artery Calcium Report Agatston Calcium Score Volume Calcium Score Example Images Clinical Findings Clinical Recommendations Further Cardiac testing

11. Coronary Calcium Progression Calcium Score: 56 Calcium Score: 90 Calcium Score: 128 Volume Score: 45 Volume Score: 78 Volume Score: 113 1993 1995 1997 Progression of Right coronary artery calcium score over 5 years

12. LAD LCX LM LAD Soft Plaque Coronary Calcium Scanning G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Visualization of Non-obstructive Plaque Formation - EBT

13. Coronary EBA Step Volume Mode ECG Triggered Acquisition

14. Coronary EBA CLINICAL INDICATIONS Follow-up PTCA and Stents Follow-up Bypass grafts Equivocal results following stress testing (or stress imaging) Congenital anomalies Symptomatic patients with Coronary Calcium score Asymptomatic patients with Coronary Calcium score greater than 400 or in the 75 percentile Pre and post operative Heart transplant patients People who are not willing to have an elective conventional angiogram

15. Coronary EBA Coronary EBA Scanning Protocol Patient Preparation: Start IV ECG Triggered to 40% of the R to R interval 3mm x 2mm scans Injection of 150ml IV contrast @ 4ml per second Normal algorithm, 18 cm FOV

16. Coronary EBA Report Generation Coronary Artery EBA Report Clinical Indication Procedure Example Images Clinical Findings Clinical Recommendations Further Cardiac testing

17. Coronary EBA Posterior Descending Coronary artery This 3 Dimensional Volume Rendered image demonstrates normal coronary arterial flow in the Posterior Descending Coronary artery to the apex of the heart as well as the coronary sinus and cardiac vein. This ECG triggered acquisition consisted of sixty, 3 mm images, each taken at 100 milliseconds. The total acquisition time was 45 seconds with an intravenous injection of 150 ml of contrast media.

18. G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Follow Up PTCA This 3 Dimensional Volume Rendered image demonstrates a re-stenosis in the mid LAD coronary artery in a patient post PTCA This ECG triggered acquisition consisted of sixty, 3 mm images, each taken at 100 milliseconds. The total acquisition time was 45 seconds with an intravenous injection of 150 ml of contrast media. Coronary EBA

19. Coronary Artery Stent Scanning Protocol This 3 Dimensional Volume Rendered image demonstrates a 50% stenosis just proximal to the stent in the left anterior descending coronary artery. This ECG triggered acquisition consisted of sixty, 1.5 mm images, each taken at 100 milliseconds. The total acquisition time was 45 seconds with an intravenous injection of 150 ml of contrast media.

20. Maximum intensity projection MIP Volume rendering technique VRT Coronary Stent Virtual Angioscopy FLY THROUGH Courtesy of Milwaukee Heart Scan, Milwaukee, WI Coronary EBA

21. Stent - Ave gfx TM 3,0/30mm G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Coronary EBA Right Coronary Artery Stent

22. G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Coronary EBA Right Coronary Artery Bypass Graft – Distal anastomoisis

23. G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Coronary EBA Right Coronary Artery Bypass Graft

24. Central occluded Right Coronary Artery Graft Coronary EBA G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000)

25. Coronary EBA Congenital Anomalies This 3 Dimensional Volume Rendered image demonstrates an aberrant circumflex coronary artery that arises from the Right coronary artery. This ECG triggered acquisition consisted of fifty, 3 mm images, each taken at 100 milliseconds. The total acquisition time was 35 seconds with an intravenous injection of 120 ml of contrast media.

26. Coronary EBA Sensitivity & Specificity

27. 77.99mm 76.94mm Large Thoracic Aneurysm G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Coronary and Thoracic EBA

28. True Lumen False Lumen G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Thoracic aortic stent (Talent Medtronic TM ) in dissection of the aorta Coronary and Thoracic EBA

29. Lung Scanning Continuous Volume Scan

30. Lung Scanning Lung Scan Protocol Patient Preparation: None This Continuous Volume acquisition consisted of forty seven, 6 mm images, each taken at 300 milliseconds. The total acquisition time was 18 seconds. Findings: Asbestosis

31. Lung Scanning Lung Scan Protocol Patient Preparation: None This Continuous Volume acquisition consisted of forty seven, 6 mm images, each taken at 300 milliseconds. The total acquisition time was 18 seconds. Findings: Lung Nodule Right Upper Lobe

32. Pulmonary Embolism Pulmonary Embolism Acute Scan Protocol Patient Preparation: None This Continuous Volume acquisition consisted of 42, 6 mm images, each taken at 100 milliseconds. The total acquisition time was 5 seconds with an intravenous injection of 50 ml of contrast media @ 3 ml per second. Findings: Large embolism in right and left main pulmonary arteries.

33. Pulmonary Embolism Pulmonary Embolism Chronic Scan Protocol Patient Preparation: NPO 4 hour prior to scanning. This Continuous Volume acquisition consisted of 120, 3 mm images, each taken at 100 milliseconds. The total acquisition time was 5 seconds with an intravenous injection of 50 ml of contrast media @ 3 ml per second. Maximum Intensity Projections

34. Abdominal Scanning Continuous Volume Scan

35. Abdominal Scan Abdomen screen Protocol Patient Preparation: Optional NPO after midnight the night prior to the exam. Drink 24 oz of gastrographin and H2o mix 2 hour prior and 12 oz before scanning. This Continuous Volume acquisition consisted of, 6mm images, each taken at 400 milliseconds. The total acquisition time was 24 seconds.

36. Abdominal Scan Abdomen Diagnostic Protocol Patient Preparation: NPO after Midnight the night prior to the exam. Drink 24 oz of gastrographin and H2o mix 2 hour prior and 12 oz before scanning. This Continuous Volume acquisition consisted of sixty one, 10 mm images, each taken at 600 milliseconds. The total acquisition time was 22 seconds with an intravenous injection of 90 ml of contrast media @ 2.0 ml per second.

37. EBT Colonography Patient Preparation: 24 to 48 hour colon preparation. NPO after midnight the night prior to the exam. This Continuous Volume acquisition consisted of 140, 3mm images, each taken at 200 milliseconds. The total acquisition time was 28 seconds with and air contrast enema.

38. Peripheral EBA Continuous Volume Scan

39. Renal EBA Renal Arteries This coronal Maximum Intensity Projection image demonstrates normal renal arterial flow. This Continuous Volume acquisition consisted of seventy, 3 mm images, each taken at 400 milliseconds. The total acquisition time was 28 seconds with an intravenous injection of 100 ml of contrast media.

40. Abdominal Aortic EBA Abdominal Aortic EBA Scan Protocol This 3D Volume Rendered image loop demonstrates arterial flow through a post operative abdominal aortic graft. This Continuous Volume acquisition consisted of one hundred and forty, 3 mm images, each taken at 200 milliseconds. The total acquisition time was 28 seconds with an intravenous injection of 120 ml of contrast media.

41. Maximum intensity projection MIP Shaded surface display SSD Volume rendering technique VRT G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Abdominal Aortic EBA Post operative Abdominal Aortic Graft

42. Femoral and Iliac EBA G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000) Femoral and iliac EBA Scanning Protocol This coronal Maximum Intensity Projection image demonstrates arterial flow through a post operative abdomenoiliac graft. This Continuous Volume acquisition consisted of one hundred and forty, 3 mm images, each taken at 200 milliseconds. The total acquisition time was 28 seconds with an intravenous injection of 120 ml of contrast media.

43. Carotid EBA Carotid Arteries This 3 Dimensional Volume Rendered image demonstrate the the carotid arteries (RED) and venous circulation (BLUE). This Continuous Volume acquisition consisted of forty, 3 mm images, each taken at 300 milliseconds. The total acquisition time was 12 seconds with an intravenous injection of 60 ml of contrast media.

44. Head Scanning Continuous Volume Scan

45. Cerebral EBA Internal Carotid This axial Maximum Intensity Projection image demonstrates the Left internal carotid artery with limited flow to the Right. This Continuous Volume acquisition consisted of forty, 3 mm images, each taken at 600 milliseconds. The total acquisition time was 24 seconds with an intravenous injection of 80 ml of contrast media. G.O. Kerkhoff, Alfried Krupp Hospital Essen (2000)

46. Cerebral EBA Cerebral AVM This 3 Dimensional Volume Rendered image demonstrate the Circle of Willis with an Arterial Vascular Malformation (AVM). This Continuous Volume acquisition consisted of forty, 3 mm images, each taken at 600 milliseconds. The total acquisition time was 24 seconds with an intravenous injection of 100 ml of contrast media.

47. Cerebral EBA This axial Maximum Intensity Projection image demonstrates cerebral arterial flow. This Continuous Volume acquisition consisted of forty-five, 6 mm images, each taken at 600 milliseconds. The total acquisition time was 27 seconds with an intravenous injection of 100 ml of contrast media.

48. Head Scan Head Scanning Protocol Patient Preparation: NPO 4 hours before the scan. This Continuous Volume acquisition consisted of forty one, 6 mm images, each taken at 600 milliseconds. The total acquisition time was 25 seconds with an intravenous injection of 90 ml of contrast media @ 2.0 ml per second.