Multimodal and multiscale imaging of the human placental vasculature

Minimally invasive fetal interventions, such as those used for therapy of twin-to- twin transfusion syndrome (TTTS), require accurate image guidance to optimise patient outcomes. Photoacoustic imaging can provide molecular contrast based on the optical absorption of the haemoglobin, and in this dissertation, it was proposed as a novel technique to image the human placental vasculature. Normal term and in utero TTTS treated placentas were imaged post-partum using two novel photoacoustic imaging systems. With PA imaging, vasculature was resolved to a depth of approximately 7 mm from the chorionic placental surface; the photocoagulated tissue provided a negative contrast and the ablation depth of the scar was visualised. Complementary imaging of the placental vasculature in a microscopic size scale was performed with a handheld incident dark field illumination video microscope in fresh and formalin-fixed term placentas. Real time visualisation of the villus tree down to the terminal villi level was achieved without any contrast injection or extensive tissue preparation. Additionally, the novel application of photoacoustic imaging to guide minimally invasive fetal interventions motivated the development of tissue-mimicking placental phantoms for bench-top system validation and for clinical training. Ideally, phantoms for this modality comprise materials with optical and acoustic properties that can be precisely and independently controlled, which are stable over time, and which are non-toxic and low-cost. Gel wax was proposed as a novel tissue-mimicking material (TMM) that satisfies these criteria, and that it can be used to represent various soft tissues and fabricate heterogeneous phantoms with structures based on patient-specific anatomy. This dissertation sets the stage for the development of miniaturised photoacoustic imaging probes for intraoperative guidance, and new methods of understanding the placental vascular anatomy in health and disease. Gel wax has strong potential to become a next generation TMM for evaluation, and standardisation of imaging systems, and for clinical training

Neural Network Kalman Filtering for 3-D Object Tracking From Linear Array Ultrasound Data

Many interventional surgical procedures rely on medical imaging to visualise and track instruments. Such imaging methods not only need to be real-time capable, but also provide accurate and robust positional information. In ultrasound applications, typically only two-dimensional data from a linear array are available, and as such obtaining accurate positional estimation in three dimensions is non-trivial. In this work, we first train a neural network, using realistic synthetic training data, to estimate the out-of-plane offset of an object with the associated axial aberration in the reconstructed ultrasound image. The obtained estimate is then combined with a Kalman filtering approach that utilises positioning estimates obtained in previous time-frames to improve localisation robustness and reduce the impact of measurement noise. The accuracy of the proposed method is evaluated using simulations, and its practical applicability is demonstrated on experimental data obtained using a novel optical ultrasound imaging setup. Accurate and robust positional information is provided in real-time. Axial and lateral coordinates for out-of-plane objects are estimated with a mean error of 0.1mm for simulated data and a mean error of 0.2mm for experimental data. Three-dimensional localisation is most accurate for elevational distances larger than 1mm, with a maximum distance of 6mm considered for a 25mm aperture

Enhancement of instrumented ultrasonic tracking images using deep learning

PURPOSE: Instrumented ultrasonic tracking provides needle localisation during ultrasound-guided minimally invasive percutaneous procedures. Here, a post-processing framework based on a convolutional neural network (CNN) is proposed to improve the spatial resolution of ultrasonic tracking images. METHODS: The custom ultrasonic tracking system comprised a needle with an integrated fibre-optic ultrasound (US) transmitter and a clinical US probe for receiving those transmissions and for acquiring B-mode US images. For post-processing of tracking images reconstructed from the received fibre-optic US transmissions, a recently-developed framework based on ResNet architecture, trained with a purely synthetic dataset, was employed. A preliminary evaluation of this framework was performed with data acquired from needle insertions in the heart of a fetal sheep in vivo. The axial and lateral spatial resolution of the tracking images were used as performance metrics of the trained network. RESULTS: Application of the CNN yielded improvements in the spatial resolution of the tracking images. In three needle insertions, in which the tip depth ranged from 23.9 to 38.4 mm, the lateral resolution improved from 2.11 to 1.58 mm, and the axial resolution improved from 1.29 to 0.46 mm. CONCLUSION: The results provide strong indications of the potential of CNNs to improve the spatial resolution of ultrasonic tracking images and thereby to increase the accuracy of needle tip localisation. These improvements could have broad applicability and impact across multiple clinical fields, which could lead to improvements in procedural efficiency and reductions in risk of complications

Patient-Specific 3D Printed Models for Education, Research and Surgical Simulation

3D printing techniques are increasingly used in engineering science, allowing the use of computer aided design (CAD) to rapidly and inexpensively create prototypes and components. There is also growing interest in the application of these techniques in a clinical context for the creation of anatomically accurate 3D printed models from medical images for therapy planning, research, training and teaching applications. However, the techniques and tools available to create 3D models of anatomical structures typically require specialist knowledge in image processing and mesh manipulation to achieve. In this book chapter we describe the advantages of 3D printing for patient education, healthcare professional education, interventional planning and implant development. We also describe how to use medical image data to segment volumes of interest, refine and prepare for 3D printing. We will use a lung as an example. The information in this section will allow anyone to create own 3D printed models from medical image data. This knowledge will be of use to anyone with little or no previous experience in medical image processing who have identified a potential application for 3D printing in a medical context, or those with a more general interest in the techniques

A patient-specific multi-modality abdominal aortic aneurysm imaging phantom

PURPOSE: Multimodality imaging of the vascular system is a rapidly growing area of innovation and research, which is increasing with awareness of the dangers of ionizing radiation. Phantom models that are applicable across multiple imaging modalities facilitate testing and comparisons in pre-clinical studies of new devices. Additionally, phantom models are of benefit to surgical trainees for gaining experience with new techniques. We propose a temperature-stable, high-fidelity method for creating complex abdominal aortic aneurysm phantoms that are compatible with both radiation-based, and ultrasound-based imaging modalities, using low cost materials. METHODS: Volumetric CT data of an abdominal aortic aneurysm were acquired. Regions of interest were segmented to form a model compatible with 3D printing. The novel phantom fabrication method comprised a hybrid approach of using 3D printing of water-soluble materials to create wall-less, patient-derived vascular structures embedded within tailored tissue-mimicking materials to create realistic surrounding tissues. A non-soluble 3-D printed spine was included to provide a radiological landmark. RESULTS: The phantom was found to provide realistic appearances with intravascular ultrasound, computed tomography and transcutaneous ultrasound. Furthermore, the utility of this phantom as a training model was demonstrated during a simulated endovascular aneurysm repair procedure with image fusion. CONCLUSION: With the hybrid fabrication method demonstrated here, complex multimodality imaging patient-derived vascular phantoms can be successfully fabricated. These have potential roles in the benchtop development of emerging imaging technologies, refinement of novel minimally invasive surgical techniques and as clinical training tools

Photoacoustic imaging of the human placental vasculature

Minimally invasive fetal interventions require accurate imaging from inside the uterine cavity. Twin‐to‐twin transfusion syndrome (TTTS), a condition considered in this study, occurs from abnormal vascular anastomoses in the placenta that allow blood to flow unevenly between the fetuses. Currently, TTTS is treated fetoscopically by identifying the anastomosing vessels, and then performing laser photocoagulation. However, white light fetoscopy provides limited visibility of placental vasculature, which can lead to missed anastomoses or incomplete photocoagulation. Photoacoustic (PA) imaging is an alternative imaging method that provides contrast for hemoglobin, and in this study, two PA systems were used to visualize chorionic (fetal) superficial and subsurface vasculature in human placentas. The first system comprised an optical parametric oscillator for PA excitation and a 2D Fabry‐Pérot cavity ultrasound sensor; the second, light emitting diode arrays and a 1D clinical linear‐array ultrasound imaging probe. Volumetric photoacoustic images were acquired from ex vivo normal term and TTTS‐treated placentas. It was shown that superficial and subsurface branching blood vessels could be visualized to depths of approximately 7 mm, and that ablated tissue yielded negative image contrast. This study demonstrated the strong potential of PA imaging to guide minimally invasive fetal therapies. [Image: see text

EFEKTIFITAS PROGRAM REHABILTASI POST OPERATIF CEDERA LUTUT DALAM MENINGKATKAN RANGE OF MOTION PASIEN DI JOGJA SPORTS CLINIC

Tujuan penelitian ini adalah untuk mengetahui seberapa tingkat efektifitas pemberian program rehabilitasi post operatif cedera lutut terhadap peningkatan range of motion pasien cedera lutut di Jogja Sports Clinic. Desain penelitian ini adalah penelitian survey dari data medical record pasien JSC. Menggunakan teknik dokumentasi karena penelitian ini menggunakan data sekunder tentang program rehab dan Range Of Motion (ROM) pasien sebagai hasil rehabilitasi. Sedangkan subyek penelitian ini adalah data medical record dari 11 pasien cedera lutut post operatif JSC pada bulan September 2016 s/d februari 2017 yang sudah melakukan rehab 5sesi di JSC. Instrument yang digunakan adalah goniometer, sedangkan teknik analisis data yang digunakan adalah data rasio dengan uji normalitas menggunakan ujji-t berpasangan karena hanya dua kelompok yang diuji. Uji-t menggunakan taraf signifikansi 5%, sehingga jika nilai p < 0,05 maka ada perbedaan signifikan, selanjutnya jika p > 0,05 maka tidak ada perbedaan signifikan. Hasil uji-t data fleksi pada perlakuan program rehabilitasi cedera lutut diperoleh nilai sebesar -6,629 dengan nilai signifikansi sebesar 0,000, ekstensi pada perlakuan stretching dan terapi latihan pembebanan diperoleh nilai sebesar 3,331 dengan nilai signifikansi sebesar 0,008, maka dapat disimpulkan terdapat perbedaan yang signifikan antara pretest dan posttest ROM fleksi dan ekstensi pada program rehabilitasi cedera lutut, dan terdapat perubahan yang signifikan dilihat dari prosentase perubahan pretest dan posttest pada fleksi 8,26% dan P = 0,00 nilai P ˂ 0,05, sedangkan pada gerakan ekstensi prosentase perubahan pretest dan posttest -19,15% dan P = 0,008 dengan nilai P ˂ 0,05 sehingga diketahui terdapat peningkatan pada ROM pasien dan program rehabilitasi post operatif cedera lutut dapat dinyatakan efektif untuk meningkatkan ROM

Anatomically realistic ultrasound phantoms using gel wax with 3D printed moulds

Here we describe methods for creating tissue-mimicking ultrasound phantoms based on patient anatomy using a soft material called gel wax. To recreate acoustically realistic tissue properties, two additives to gel wax were considered: paraffin wax to increase acoustic attenuation, and solid glass spheres to increase backscattering. The frequency dependence of ultrasound attenuation was well described with a power law over the measured range of 3 to 10 MHz. With the addition of paraffin wax in concentrations of 0 to 8 w/w%, attenuation varied from 0.72 to 2.91 dB/cm at 3 MHz and from 6.84 to 26.63 dB/cm at 10 MHz. With solid glass sphere concentrations in the range of 0.025 to 0.9 w/w%, acoustic backscattering consistent with a wide range of ultrasonic appearances was achieved. Native gel wax maintained its integrity during compressive deformations up to 60%; its Young's modulus was 17.4 ± 1.4 kPa. The gel wax with additives was shaped by melting and pouring it into 3D printed moulds. Three different phantoms were constructed: a nerve and vessel phantom for peripheral nerve blocks, a heart atrium phantom, and a placental phantom for minimally-invasive fetal interventions. In the first, nerves and vessels were represented as hyperechoic and hypoechoic tubular structures, respectively, in a homogeneous background. The second phantom comprised atria derived from an MRI scan of a patient with an intervening septum and adjoining vena cavae. The third comprised the chorionic surface of a placenta with superficial fetal vessels derived from an image of a post-partum human placenta. Gel wax is a material with widely tuneable ultrasound properties and mechanical characteristics that are well suited for creating patient-specific ultrasound phantoms in several clinical disciplines

Placenta Imaging Workshop 2018 report:Multiscale and multimodal approaches

The Centre for Medical Image Computing (CMIC) at University College London (UCL) hosted a two-day workshop on placenta imaging on April 12th and 13th 2018. The workshop consisted of 10 invited talks, 3 contributed talks, a poster session, a public interaction session and a panel discussion about the future direction of placental imaging. With approximately 50 placental researchers in attendance, the workshop was a platform for engineers, clinicians and medical experts in the field to network and exchange ideas. Attendees had the chance to explore over 20 posters with subjects ranging from the movement of blood within the placenta to the efficient segmentation of fetal MRI using deep learning tools. UCL public engagement specialists also presented a poster, encouraging attendees to learn more about how to engage patients and the public with their research, creating spaces for mutual learning and dialogue

Visualisation.mp4

Video showing manual compressions of a heterogeneous gel wax-based tissue-mimicking phantom