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As robotic systems are now technically mature and widely available, they also play an increasingly important role in the clinical environment. Thus, numerous robotic assistance systems for diagnosis and therapy have shown their potential for supporting patient care. After a brief review of the history, this article describes currently available robotic assistance systems for surgery, especially those originating in Germany and Europe as well as current focal topics of research. In addition, challenges in this field as well as possibilities for close active and interdisciplinary cooperation between stakeholders from hospitals, industry and science to overcome such challenges are presented.

We developed a new approach to produce individual immobilization devices for the head based on MRI data and 3D printing technologies. The purpose of this study was to determine positioning accuracy with healthy volunteers. 3D MRI data of the head were acquired for 8 volunteers. In-house developed software processed the image data to generate a surface mesh model of the immobilization mask. After adding an interface for the couch, the fixation setup was materialized using a 3D printer with acrylonitrile butadiene styrene (ABS). Repeated MRI datasets (n=10) were acquired for all volunteers wearing their masks thus simulating a setup for multiple fractions. Using automatic image-to-image registration, displacements of the head were calculated relative to the first dataset (6 degrees of freedom). The production process has been described in detail. The absolute lateral (x), vertical (y) and longitudinal (z) translations ranged between -0.7 and 0.5 mm, -1.8 and 1.4 mm, and -1.6 and 2.4 mm, respectively. The absolute rotations for pitch (x), yaw (y) and roll (z) ranged between -0.9 and 0.8°, -0.5 and 1.1°, and -0.6 and 0.8°, respectively. The mean 3D displacement was 0.9 mm with a standard deviation (SD) of the systematic and random error of 0.2 mm and 0.5 mm, respectively. In conclusion, an almost entirely automated production process of 3D printed immobilization masks for the head derived from MRI data was established. A high level of setup accuracy was demonstrated in a volunteer cohort. Future research will have to focus on workflow optimization and clinical evaluation., Competing Interests: CONFLICTS OF INTEREST FLG and JD have a patent issued to parts of the method used in this work. All other authors have no competing interests to report.

Objectives: The purpose of this study was to quantify the benefit of the incorporation of radiologic anatomy (RA), in terms of student training in RA seminars, cadaver CT scans and life-size virtual dissection tables on the learning success in general anatomy., Methods: Three groups of a total of 238 students were compared in a multiple choice general anatomy exam during first-year gross anatomy: (1) a group (year 2015, n 1  = 50) that received training in radiologic image interpretation (RA seminar) and additional access to cadaver CT scans (CT + seminar group); (2) a group (2011, n 2  = 90) that was trained in the RA seminar only (RA seminar group); (3) a group (2011, n 3  = 98) without any radiologic image interpretation training (conventional anatomy group). Furthermore, the students' perception of the new curriculum was assessed qualitatively through a survey., Results: The average test score of the CT + seminar group (21.8 ± 5.0) was significantly higher when compared to both the RA seminar group (18.3 ± 5.0) and the conventional anatomy group (17.1 ± 4.7) (p < 0.001)., Conclusions: The incorporation of cadaver CT scans and life-size virtual dissection tables significantly improved the performance of medical students in general gross anatomy. Medical imaging and virtual dissection should therefore be considered to be part of the standard curriculum of gross anatomy., Key Points: • Students provided with cadaver CT scans achieved 27 % higher scores in anatomy. • Radiological education integrated into gross anatomy is highly appreciated by medical students. • Simultaneous physical and virtual dissection provide unique conditions to study anatomy.

To assess spatial and temporal pressure characteristics in patients with repaired aortic coarctation compared to young healthy volunteers using time-resolved velocity-encoded three-dimensional phase-contrast magnetic resonance imaging (4D flow MRI) and derived 4D pressure difference maps. After in vitro validation against invasive catheterization as gold standard, 4D flow MRI of the thoracic aorta was performed at 1.5T in 13 consecutive patients after aortic coarctation repair without recoarctation and 13 healthy volunteers. Using in-house developed processing software, 4D pressure difference maps were computed based on the Navier-Stokes equation. Pressure difference amplitudes, maximum slope of pressure amplitudes and spatial pressure range at mid systole were retrospectively measured by three readers, and twice by one reader to assess inter- and intraobserver agreement. In vitro, pressure differences derived from 4D flow MRI showed excellent agreement to invasive catheter measurements. In vivo, pressure difference amplitudes, maximum slope of pressure difference amplitudes and spatial pressure range at mid systole were significantly increased in patients compared to volunteers in the aortic arch, the proximal descending and the distal descending thoracic aorta (p < 0.05). Greatest differences occurred in the proximal descending aorta with values of the three parameters for patients versus volunteers being 19.7 ± 7.5 versus 10.0 ± 2.0 (p < 0.001), 10.9 ± 10.4 versus 1.9 ± 0.4 (p = 0.002), and 8.7 ± 6.3 versus 1.6 ± 0.9 (p < 0.001). Inter- and intraobserver agreements were excellent (p < 0.001). Noninvasive 4D pressure difference mapping derived from 4D flow MRI enables detection of altered intraluminal aortic pressures and showed significant spatial and temporal changes in patients with repaired aortic coarctation.

Purpose: To develop a method for computing and visualizing pressure differences derived from time-resolved velocity-encoded three-dimensional phase-contrast magnetic resonance imaging (4D flow MRI) and to compare pressure difference maps of patients with unrepaired and repaired aortic coarctation to young healthy volunteers., Methods: 4D flow MRI data of four patients with aortic coarctation either before or after repair (mean age 17 years, age range 3-28, one female, three males) and four young healthy volunteers without history of cardiovascular disease (mean age 24 years, age range 20-27, one female, three males) was acquired using a 1.5-T clinical MR scanner. Image analysis was performed with in-house developed image processing software. Relative pressures were computed based on the Navier-Stokes equation., Results: A standardized method for intuitive visualization of pressure difference maps was developed and successfully applied to all included patients and volunteers. Young healthy volunteers exhibited smooth and regular distribution of relative pressures in the thoracic aorta at mid systole with very similar distribution in all analyzed volunteers. Patients demonstrated disturbed pressures compared to volunteers. Changes included a pressure drop at the aortic isthmus in all patients, increased relative pressures in the aortic arch in patients with residual narrowing after repair, and increased relative pressures in the descending aorta in a patient after patch aortoplasty., Conclusions: Pressure difference maps derived from 4D flow MRI can depict alterations of spatial pressure distribution in patients with repaired and unrepaired aortic coarctation. The technique might allow identifying pathophysiological conditions underlying complications after aortic coarctation repair.

Purpose: Integrating interactive three-dimensional post-processing software into undergraduate radiology teaching might be a promising approach to synergistically improve both visual-spatial ability and radiological skills, thereby reducing students' deficiencies in image interpretation. The purpose of this study was to test our hypothesis that a hands-on radiology course for medical students using interactive three-dimensional image post-processing software improves radiological knowledge, diagnostic skills and visual-spatial ability., Materials and Methods: A hands-on radiology course was developed using interactive three-dimensional image post-processing software. The course consisted of seven seminars held on a weekly basis. The 25 participating fourth- and fifth-year medical students learnt to systematically analyse cross-sectional imaging data and correlated the two-dimensional images with three-dimensional reconstructions. They were instructed by experienced radiologists and collegiate tutors. The improvement in radiological knowledge, diagnostic skills and visual-spatial ability was assessed immediately before and after the course by multiple-choice tests comprising 64 questions each. Wilcoxon signed rank test for paired samples was applied., Results: The total number of correctly answered questions improved from 36.9±4.8 to 49.5±5.4 (p<0.001) which corresponded to a mean improvement of 12.6 (95% confidence interval 9.9-15.3) or 19.8%. Radiological knowledge improved by 36.0% (p<0.001), diagnostic skills for cross-sectional imaging by 38.7% (p<0.001), diagnostic skills for other imaging modalities - which were not included in the course - by 14.0% (p=0.001), and visual-spatial ability by 11.3% (p<0.001)., Conclusion: The integration of interactive three-dimensional image post-processing software into undergraduate radiology education effectively improves radiological reasoning, diagnostic skills and visual-spatial ability, and thereby even diagnostic skills for imaging modalities not included in the course., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Several approaches for the non-invasive MRI-based measurement of the aortic pressure waveform over the heart cycle have been proposed in the last years. These methods are normally based on time-resolved, two-dimensional phase-contrast sequences with uni-directionally encoded velocities (2D PC-MRI). In contrast, three-dimensional acquisitions with tridirectional velocity encoding (4D PC-MRI) have been shown to be a suitable data source for detailed investigations of blood flow and spatial blood pressure maps. In order to avoid additional MR acquisitions, it would be advantageous if the aortic pressure waveform could also be computed from this particular form of MRI. Therefore, we propose an approach for the computation of the aortic pressure waveform which can be completely performed using 4D PC-MRI. After the application of a segmentation algorithm, the approach automatically computes the aortic pressure waveform without any manual steps. We show that our method agrees well with catheter measurements in an experimental phantom setup and produces physiologically realistic results in three healthy volunteers.

Three-dimensional velocity-encoded cine magnetic resonance imaging (3D VEC MRI) allows for calculation of secondary flow parameters that may be used to estimate prognosis of individual cardiovascular diseases. However, its accuracy has not been fully investigated yet. The purpose of this study was to validate aortic flow quantification by 3D VEC MRI in vitro and in vivo using stacked two-dimensional acquisitions. Time-resolved stacks of two-dimensional planes with three-directional velocity-encoding (stacked-2D-3dir-MRI) were acquired in an elastic tube phantom with pulsatile flow simulating aortic flow as well as in 11 healthy volunteers (23 ± 2 years). Previously validated two-dimensional through-plane VEC MRI at six equidistant levels in vitro and three locations in vivo (ascending aorta/aortic arch/descending aorta) was used as reference standard. The percentage difference of the stacked-2D-3dir-MRI measurement to the reference standard was defined as the parameter for accuracy. For in vitro aortic flow, stacked-2D-3dir-MRI underestimated average velocity by -6.8% (p < 0.001), overestimated average area by 13.6% (p < 0.001), and underestimated average flow by -7.4% (p < 0.001). Accuracy was significantly higher in the field of view centre compared to off-centre (p = 0.001). In vivo, stacked-2D-3dir-MRI underestimated average velocity (all three locations p < 0.001) and overestimated average area at all three locations (p = n.s./<0.001/<0.001). Average flow was significantly underestimated in the ascending aorta (p = 0.035), but tended to be overestimated in the aortic arch and descending aorta. In conclusion, stacked-2D-3dir-MRI tends to overestimate average aortic area and to underestimate average aortic velocity, resulting in significant underestimation of average flow in the ascending aorta.

This report describes flow patterns derived by three-dimensional (3D) three-directional velocity-encoded cine (VEC) magnetic resonance imaging (MRI), in a patient with chronic Stanford type B aortic dissection. Acquired 3D VEC MRI data illustrated an acceleration of blood flow through the primary entry toward the vessel wall of the false lumen, leading to disturbed intraluminal flow. Furthermore, accelerated blood flow was observed in the partially compressed true lumen. 3D VEC MRI data may be helpful to guide physicians for a more comprehensive preoperative and postoperative assessment of complex aortic pathologies., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

In cardiovascular diagnostics, phase-contrast MRI is a valuable technique for measuring blood flow velocities and computing blood pressure values. Unfortunately, both velocity and pressure data typically suffer from the strong image noise of velocity-encoded MRI. In the past, separate approaches of regularization with physical a-priori knowledge and data representation with continuous functions have been proposed to overcome these drawbacks. In this article, we investigate polynomial regularization as an exemplary specification of combining these two techniques. We perform time-resolved three-dimensional velocity measurements and pressure gradient computations on MRI acquisitions of steady flow in a physical phantom. Results based on the higher quality temporal mean data are used as a reference. Thereby, we investigate the performance of our approach of polynomial regularization, which reduces the root mean squared errors to the reference data by 45% for velocities and 60% for pressure gradients.

In this paper we present a web-based remote visualization system. The system makes use of video stream based techniques to reduce the network bandwidth requirements and is capable of performing interactive volume rendering on computed tomography data in real-time. The technique allows embedding interactive volume rendering into a website. The concrete contribution of this paper is twofold. First, we outline a Microsoft Silverlight based implementation of the prototype and describe the applied video encoding techniques. Furthermore we present experimental results that allow evaluating the system in terms of latency and image quality. In particular, we show that the additional delay of stream based remote visualization is very small if compared to picture based techniques.

Tablet computers, netbooks, and other mobile devices find their way into medical applications. However, advanced visualization such as volume rendering of tomographic data is too demanding for these devices. Hence the concept of remote visualization gains attention again. Using powerful servers views are rendered and transmitted as video-stream to the mobile devices in real-time. In this article we present a new extension to our software framework Mediframe allowing easy setup of remote visualization in the medical imaging domain. We give an overview of the general visualization architecture and explain the remoting component in detail. Tests from different cities in Europe revealed good latency and rendering times as well as a surprisingly smooth user experience. We conclude that our remote visualization framework is a handy, functional extension to medical visualization applications.

Objectives: Phase-contrast flow magnetic resonance imaging (pc-MRI) measurements are an established technique for noninvasive assessment of hemodynamics. However, in vivo validation data on the accuracy of pc-flow especially for nonphysiologic hemodynamic conditions are missing. The goal of our work was 1) to validate pc-flow with perivascular ultrasound in different hemodynamic conditions in the main pulmonary artery (MPA) and ascending aorta (AO) and 2) to investigate the relation between pc-MRI and invasive pressure measurements., Materials and Methods: Five healthy pigs with opened chest were investigated. Ultrasound measurements were performed outside the MRI unit using a detachable MR-table. Parallel to ultrasound flow measurements, invasive pressure measurements were performed. PC-MRI (1.5 T MRI) measurements were done using a FLASH 2-dimensional sequence. First the animals were examined in normotonia, followed by hypertension (infusion of Arterenol) and hypotension (infusion of Sodiumnitropussid)., Results: Flow measurements acquired in normotonia were 2.7 +/- 0.6 L/min (ultrasound) and 2.8 +/- 0.6 L/min for pc-MRI (not significantly different, P = 0.17). During hypertonia, the blood flow increased to 3.1 +/- 0.7 and 2.7 +/- 0.8 L/min, respectively (P = 0.01). During hypotension, the blood flow decreased to 1.7 +/- 0.5 and 1.7 +/- 0.5 L/min, respectively (P = 0.7). An excellent linear correlation (taking all measurements together) between the ultrasound and pc-MRI measurements was found (r = 0.89). 95% Limits of intraindividual agreement correspond to relative differences of -36 to 44%. Systolic pressure measurements in the AO were 91 mm Hg (normotonic), 111 mm Hg (hypertonic), and 64 mm Hg (hypotonic) and in the MPA 23 mm Hg (normotonic), 29 mm Hg (hypertonic), and 20 mm Hg (hypotonic). Systolic pressure measurements showed good linear correlation with pc-MRI average flow per minute and peak velocity (AO: r = 0.79, MPA: r = 0.66)., Conclusion: MRI pc-flow measurements are a reliable tool for noninvasive assessment of blood flow. Hemodynamic parameters derived by MRI demonstrate good linear correlations with the pressure in the systemic and pulmonary arterial circulation.

Purpose: This feasibility study in healthy animals should prove the concept that it is possible to quantitatively assess the effects of different ventilatory settings on the lung parenchyma during ongoing ventilation in respiratory gated 4-dimensional (D)-computed tomography (CT). For this purpose, the influence of different tidal volumes and positive end-expiratory pressure (PEEP) on quantitative assessment of lung volumes (LVs) and lung compartments was analyzed., Methods: Five anesthetized and ventilated (20 breaths/min, inspiratory/expiratory ratio of 1:2) healthy pigs underwent 16-row multidetector CT with retrospective respiratory gating using a noncontact charge-coupled device camera as a gating device. The device was connected to the scanner instead of the electrocardiogram gating unit. Parameters for retrospective scans were collimation 1 mm, 120 kV, 300 mA, gantry rotation time 0.5 seconds, helical pitch 2.4. Two tidal volumes (300 mL and 450 mL) and 3 PEEP levels (0, 5, and 10 cm H(2)O) were applied resulting in 6 scans per animal. Images were reconstructed throughout the respiratory cycle in increments of 10%. Semiautomatic segmentation provided LV, mean lung density (MLD), and different lung compartments (atelectasis, hypoventilated, normal ventilated, hyperventilated)., Results: At tidal volume 300 mL the inspiratory LV were 1.05, 1.26, and 1.5 L and expiratory LV 0.75, 0.99, and 1.24 L (PEEP 0, 5, 10 cm H(2)O, respectively). Differences of MLD between inspiration and expiration were 86, 65, and 46 HU. At tidal volume 450 mL, the inspiratory LV were 1.21, 1.43, and 1.72 L, and expiratory LV were 0.78, 1.01, and 1.34 L (for PEEP 0, 5, 10 cm H(2)O). Differences of MLD between inspiration and expiration were 109, 86, and 59 HU. A clear oscillatory wave of the normal and hypoventilated volumes was found at PEEP 0, with increase in PEEP the hypoventilated areas became increasingly normal ventilated, the amplitude of the curves decreased, and hyperventilated areas increased., Conclusion: Using a new 4D-CT technique we were able to demonstrate the effect of different ventilation settings on the whole lung during the whole respiratory cycle. The disadvantages of static lung imaging or dynamic 2D-CT can be overcome. The possibility of quantitative evaluation of the whole lung and direct visualization and measurement of recruitment during different ventilation settings might be a great benefit for patients suffering from inhomogeneous lung injury and failure.

Rationale and Objectives: Multidirectional phase-contrast magnetic resonance imaging allows the acquisition of time-resolved velocity fields (vectors) of cardiac and vascular blood flow. Its unique ability to provide vectorial flow information promises to give new insights into hemodynamic physiology. However, up to now appropriate and standardized procedures and software tools are missing to take advantage of all the information contained in the data. The objective of this work is to present a new versatile software tool and to demonstrate its practical value for the examination of multidirectional blood flow., Materials and Methods: An exemplary selection of data sets from healthy volunteers, patients with cardiovascular pathologies, and healthy domestic pigs has been acquired using a phase-contrast magnetic resonance imaging sequence based on FLASH (fast low angle shot) that encodes velocity as field of three-dimensional vectors. For data processing, we have developed a software tool that integrates the whole workflow, including noise filtering, interactive visualization, and flow quantification., Results: Using the software tool visualization of complex flow data is easily generated within 5 minutes; interactive exploration of the data is possible in real-time. Exemplary physiologic and pathologic flow patterns were visualized in an intuitive manner. The visual results suggest valuable diagnostic information; its significance, however, must be further evaluated together with the development of more specific data processing., Conclusions: Multidirectional phase-contrast magnetic resonance imaging is a valuable tool for assessment of cardiac and vascular hemodynamics. With the development of tools that offer standardized and thus comparable visualizations it may be integrated into the clinical routine in the near future.

Purpose: To compare different unenhanced magnetic resonance angiography (MRA) techniques for quantitative evaluation of vessel lumen in an experimental setting in young pigs whose dimensions allow for a comparison with a pediatric population., Material and Methods: Magnetic resonance imaging was performed in 5 healthy ventilated pigs at 1.5 T. Three different electrocardiogram (ECG)-triggered sequences were applied for MRA: [TSE-Db] T2-weighted dark-blood TurboSpinEcho (2.0 x 1.1 x 4 mm3); [trueFISP] 2D-steady-state-free-precession (2.2 x 1.8 x 2 mm3); [NAV] respiratory-gated, T2-prepared 3D-trueFISP (1.3 x 1.3 x 1.3 mm3). ECG-gated-CT angiography (CTA) (16-row CT, 1 mm collimation) served as the standard of reference. The vessel lumen was measured at 7 positions perpendicularly angulated to the vessel wall on multiplanar reformations: ascending aorta (P1), the aortic arch before (P2) and after (P3) the origin of the first supraaortic branch, the aortic arch after the origin of the second supraaortic branch (P4), the descending aorta at the level of the diaphragm (P5), and the first and second supraaortic branches (P6, P7)., Results: Percentage differences in the vessel area determined by MRA reformation compared with CTA-reformation were 10% +/- 20% and 35% +/- 27% (TSE-Db), -4% +/- 13% and 20% +/- 24% (trueFISP), and -3% +/- 13% and -10% +/- 19% (NAV), for positions P1 to P5 and P6 to P7, respectively. A significant difference from CTA was found for TSE-Db at all positions, and for trueFISP only at positions P6 and P7., Conclusions: Unenhanced MRA techniques allow for a reliable assessment of the dimensions of the thoracic aorta compared with CTA as the standard of reference. Using ECG-gating and navigator techniques, the free-breathing approach showed the best agreement with CTA. This technique may therefore be the most useful in the pediatric age group allowing for true 3D data acquisition with its inherent postprocessing possibilities.

We present a particle-based smoke simulation and a particle-based fluid simulation in an interactive environment with rigid and deformable objects. Many smoke and fluid simulations offer high physical and visual accuracy, but the underlaying models are to complex to run in real-time while performing soft-tissue simulation, collision detection, and haptic device support at the same time. Our algorithms are based on simple models that allow the surgery simulation to run in real-time.

Respiratory gated 3D-MDCT acquisition of the whole chest over time (4D-MDCT) allow retrospective reconstruction of raw data at any point of the respiratory cycle might be beneficial in severely ill or sedated patients. Aim of this feasibility study was to investigate 2 prototype devices as input for retrospective respiratory gating in order to calculate lung volumes (LVs) and mean lung densities (MLDs) over time. Sixteen-row MDCT data were acquired in 5 ventilated pigs using a laser sensor and charge-coupled devine (CCD) camera and retrospectively reconstructed at every 10% of the respiratory cycle. Semiautomatic segmentation of the 3D data sets was performed, and LV and MLD were calculated. Data acquisition was successful in all cases. The mean difference of LV between maximum inspiration and expiration was 246 and 240 mL (laser and CCD, respectively). The mean difference of MLD between inspiration and expiration was 70 (laser) and 67 (CCD) HU. The lowest MLD was found at the beginning of the respiratory cycle (0%) for laser, and at 90% for CCD. Both gating devices allowed for reliable 4D-MDCT image acquisition. No differences were found for calculated LV and MLD, whereas the respiratory cycle was more precisely detected using the laser based gating device.

Purpose: The aim was to investigate the feasibility and image quality of prospective respiratory gating for 3-D computed tomography (CT) of the lung., Material and Methods: Eight anesthetized pigs underwent prospectively gated multidetector computed tomography using 2 devices: a charge-coupled device (CCD) camera and a laser sensor. The output signal of both gating devices was connected to the scanner instead of ECG unit. Inspiratory and expiratory images were obtained during "free-breathing" and analyzed in MPR mode for sharpness of bronchi, diaphragm and lung using a 4-point-score (1, excellent to 4, severe artifacts)., Results: The CCD camera worked in all animals. Using the laser sensor, only 50% of expiratory scans could be acquired. All acquired images showed excellent sharpness (CCD camera vs. laser sensor) for trachea (1.1 +/- 0.3 vs. 1.3 +/- 0.5), bronchi (1.4 +/- 0.7 vs. 1.8 +/- 0.6), lung fissures (1.0 vs. 1.1 +/- 0.3), and lung parenchyma (1.0 +/- 0.2 vs. 1.4 +/- 0.6), and minor to major artifacts for diaphragm (1.5 +/- 0.8 vs. 2.0 +/- 1.0, P < 0.05) and pericardial lung structures (1.9 +/- 0.7 vs. 2.3 +/- 0.5)., Conclusion: High image quality for inspiratory and expiratory scans was achieved by free-breathing 3-D CT of the lung using noncontact prospective respiratory gating.