1. IHE Profiles for Enhanced DICOM (CT and MR) Kees Verduin Philips Healthcare Chair DICOM WG16

2. IHE Webinar Series 2009 1 Introduction DICOM has standardized the ENHANCED MR IOD in 2002 followed by CT in 2004 and others Modalities have already implemented these from the start, but workstations that support these are still scarcely available. To close the radiology cycle around these IHE makes choices that reduce the diversity of solutions and herewith guarantees interoperability for specific use cases. This will improve the acceptance of Enhanced SOP Classes by industry and users.

3. IHE Webinar Series 20092 Summary IHE decided for development year 2008-2009 to work on 2 (out of 5) use cases prepared for MR and CT, to enable testing of existing and future implementations of Enhanced DICOM SOP Classes. The selection was made for: –CT/MR Perfusion: “PERF” because the timing attributes are better defined in Enhanced DICOM IODs. –MR Diffusion: “DIFF” because this can not be done with Classic DICOM. The use cases will cover 80-90% of the routine applications in their area, suited for standard display systems. Both profiles that use the DIMENSION information, will be available for Trial Testing at the 2010 Connectathon in Chicago. This will make these cases also a baseline for other profiles for other DICOM Enhanced SOP Classes.

4. IHE Webinar Series 20093 Agenda for this session Common features for both profiles –Dimension Module Concept Contrast Perfusion in CT/MR –Use case –Object Requirements Restrictions for Modalities Additional requirements –Display requirements Diffusion in MR –Use case –Object Requirements Restrictions for Modalities Additional requirements –Display requirements

5. Common features for both profiles Dimension Module: Dimension Index Sequence is mandatory for IHE profiles

6. IHE Webinar Series 20095 time Temporal Position Index (Phase-index) 6 5 4 3 2 1 6 5 4 3 2 1 123 6 5 4 3 2 1 In-stack Position Number (Slice- Index) Frame number 1-6 Frame number 7-12Frame number 13-18 Multi-phase / Multi-Slice Slice Order for phase 1 Phase order for slice 2 Image frames can be sorted/displayed independent of the frame order 4\14\24\3 Slice Order for phase 2

7. IHE Webinar Series 20096 Dimension Module There is a place where the dimension attributes are listed (these are existing attributes, that play a role in the object dimension,like : time, position, echo, phase, contrast, …….) >Dimension Index Pointer (0020,9165) There is a place where for each frame the index values for these attributes are stored: >Dimension Index Values (0020,9157) Frames shall be displayed according these indices (irrespective of the physical order of the frames in the object !!!)

8. IHE Webinar Series 20097 Contrast Perfusion in CT/MR The CT/MR Perfusion Imaging with Contrast Integration Profile facilitates the exchange of contrast enhanced images containing standard attributes for timing and position. The exchange of these attributes allows for correct and convenient display. Applications using the older single-frame DICOM image objects, depend on proprietary assumptions about timing attributes expected to be present, and are not generally interoperable.

9. IHE Webinar Series 20098 Use Case Description This use case refers to CT/MR Perfusion imaging that basically creates a stack of images at different timeslots, in order to demonstrate the (possibly selective) uptake of a contrast agent over time. The images shall be stored with indices along their position in the stack and the progress of time. The use case assumes that all these images are present as frames in one Enhanced CT object or one Enhanced MR object. Time and In-stack position are also to be stored as DIMENSION attributes

10. IHE Webinar Series 20099 Requirements for creators 1.One Enhanced SOP Instance 2.Creator provides dimension indices for: Stack ID In Stack Position Number Temporal Position Index 3.Data requirements: Image Type and Frame Type: Value 1: ORIGINAL Value 2: PRIMARY Value 3: PERFUSION

11. IHE Webinar Series 200910 time Temporal position Index (phase-index) 6 5 4 3 2 1 6 5 4 3 2 1 123 6 5 4 3 2 1 In-stack Position Number (Slice- index) Frame number 1-6 Frame number 7-12Frame number 13-18 Multi-phase / Multi-Slice Slice Order for phase 1 Phase order for slice 2 Image frames can be sorted/displayed independent of the frame order

12. IHE Webinar Series 200911 Functional Requirements for Image Display 1.Provide at least one viewport for display of frames with the same In-Stack Position Number (Slice- index). (More viewports may be used for displaying images for other In- Stack Position Numbers= simultaneous scrolling) 2.Be able to scroll the images by Temporal Position Index (phase-index = time related movie). 3.Be able to provide the time since the start (deducted from Frame Reference DateTime (0018,9151))

13. IHE Webinar Series 2009 12 Position = 1Position = 2Position =..Position = n Time = 1 Time = 2 Time =.. Time = n Suggested display layout for use case support scroll

14. IHE Webinar Series 200913 Time = 1Time = 2Time =..Time = n Position = 1 Position = 2 Position =.. Position = n Suggested display layout for alternative use case support scroll

15. IHE Webinar Series 200914 Data Requirements for Display Display the values of the dimension attributes and contrast attributes. Display Frame annotations for Frame Number, Slice offset, relative time.

16. IHE Webinar Series 200915 Diffusion in Brain This use case refers the MR procedure of standard Diffusion Weighted Imaging (DWI) or Diffusion Tensor Imaging (DTI), in which stacks of images (slices) are generated with different meaning and derived contrast. The use case supports the presence of images created with post-processing The exchange of the selected attributes allows for correct and convenient display. Applications using the older single-frame DICOM image objects depended on proprietary attributes only, because diffusion parameters were not standardized.

17. IHE Webinar Series 200916 Functional Requirements for Creators The images are stored in different Enhanced MR SOP Instances: 1.a series of original images with different Diffusion b- values. There shall be a stack of images for b=0. For other b-values there may be images for different diffusion gradient directions, but these are not to be displayed (see note). 2.a series with resulting ISOTROPIC images (at least for b=max). 3.a series with ADC images for each slice (at least for b=max). The isotropic images and ADC images for b = max shall be presented in conjunction with the b=0 images for each slice. Note: This use case defines that non-isotropic images (which only differ by Gradient Direction) may be present, but are not of interest for standard viewing applications (these images may be specific for Diffusion postprocessing like FiberTracking).

18. IHE Webinar Series 200917 SOP Instance Content b=0 b x >0, direction 1, slice y b x >0, direction.., slice y b x >0, direction n…………. …………………………… ISOTROPIC ADC SOP 1 ORIGINAL x b-values, y slices + n directionals SOP 2 DERIVED x-1 b-values, y slices SOP 3 DERIVED x-1 b-values, y slices

19. IHE Webinar Series 200918 Image Type (and Frame Type) Values for the images in this use case content b=0 series Isotropic series ADC series Value 1 ORIGINALDERIVED Value 3 DIFFUSION Value 4 -ISOTROPICADC

20. IHE Webinar Series 200919 Data Requirements for Creators Creator provides dimension indices for: 1.Stack ID 2.In Stack Position Number 3.Diffusion b-value ( new IHE Use Case Requirement: to sort on increasing value Therefore index values are to be given according increasing b- value) Correct relationship between the different SOP instances.

21. IHE Webinar Series 200920 Object Relations Derivation Image Sequence –Refers to the method used for derivation. Codes to be used for Image Derivation: CID 7203 –Isotropic: Diffusion weighted : 113043 –ADC: Apparent Diffusion Coefficient: 113041 Source Image Sequence –Refers to the SOP Instance of the source images SOP Instance UID of the source

22. IHE Webinar Series 200921 Functional Requirements for Display 1.Support by the display according the Image Dimensions. 2.Provide (at least) one row of three viewports for the display of frames for the same InStackPositionNumber (= slice number). Minimally the frames with b=0 and an Isotropic for b=max and the ADC image for b=max should be displayed. 3.The frames for one InStackPositionNumber must be presented in one row. Additional rows can be used for other InStackPositionNumber- s. 4.Be able to filter (select) frames based on Diffusion Directionality attribute as described in the profile. 5.Be able to scroll the images (vertically) by InStackPositionNumber-Index.

23. IHE Webinar Series 200922 b=0 ISO ADC Display Example Series navigation scroll b=0 Slice 1 b=0, Slice 3 b=0 Slice 2 b=max ISO Slice 1 b=max ISO Slice 3 b=max ISO Slice 2 ADC for b=max Slice 1 ADC for b=max Slice 3 ADC for b=max Slice 2 Linked by position

24. IHE Webinar Series 2009 23 How to recognize the use case? SOP CLASS UID : Enhanced MR Image  ======== Image Type and Frame Type according slide 18 of this presentation. The “Per Frame Functional Groups Sequence” contains the “MR Diffusion Sequence”.  ============

25. Thank You Any Questions?