CT evaluation of musculoskeletal trauma: initial experience with cinematic rendering

Precomputed low-frequency lighting in cinematic volume rendering

Cinematic Rendering (CR) employs physical models such as ray tracing and global illumination to simulate real-world light phenomena, producing high-quality images with rich details. In the medical field, CR can significantly aid doctors in accurate diagnosis and preoperative planning. However, doctors require efficient real-time rendering when using CR, which presents a challenge due to the substantial computing resources demanded by CR's ray tracing and global illumination models. Precomputed lighting can enhance the efficiency of real-time rendering by freezing certain scene variables. Typically, precomputed methods freeze geometry and materials. However, since the physical rendering of medical images relies on volume data rendering of transfer functions, the CR algorithm cannot utilize precomputed methods directly. To improve the rendering efficiency of the CR algorithm, we propose a precomputed low-frequency lighting method. By simulating the lighting pattern of shadowless surgical lamps, we adopt a spherical distribution of multiple light sources, with each source capable of illuminating the entire volume of data. Under the influence of these large-area multi-light sources, the precomputed lighting adheres to physical principles, resulting in shadow-free and uniformly distributed illumination. We integrated this precomputed method into the ray-casting algorithm, creating an accelerated CR algorithm that achieves more than twice the rendering efficiency of traditional CR rendering.

The role of 3D cinematic rendering in the evaluation of upper extremity trauma

Traumatic upper extremity injuries are a common cause of emergency department visits, comprising between 10-30% of traumatic injury visits. Timely and accurate evaluation is important to prevent severe complications such as permanent deformities, ischemia, or even death. Computed tomography (CT) and CT angiography (CTA) are the favored non-invasive imaging techniques for assessing upper extremity trauma, playing a crucial role in both the treatment planning and decision-making processes for such injuries. In CT postprocessing, a novel 3D rendering method, cinematic rendering (CR), employs sophisticated lighting models that simulate the interaction of multiple photons with the volumetric dataset. This technique produces images with realistic shadows and improved surface detail, surpassing the capabilities of volume rendering (VR) or maximal intensity projection (MIP). Considering the benefits of CR, we demonstrate its use and ability to achieve photorealistic anatomic visualization in a series of 11 cases where patients presented with traumatic upper extremity injuries, including bone, vascular, and skin/soft tissue injuries, adding to diagnostic confidence and intervention planning.

No-Reference-Based and Noise Level Evaluations of Cinematic Rendering in Bone Computed Tomography

Cinematic rendering (CR) is a new 3D post-processing technology widely used to produce bone computed tomography (CT) images. This study aimed to evaluate the performance quality of CR in bone CT images using blind quality and noise level evaluations. Bone CT images of the face, shoulder, lumbar spine, and wrist were acquired. Volume rendering (VR), which is widely used in the field of diagnostic medical imaging, was additionally set along with CR. A no-reference-based blind/referenceless image spatial quality evaluator (BRISQUE) and coefficient of variation (COV) were used to evaluate the overall quality of the acquired images. The average BRISQUE values derived from the four areas were 39.87 and 46.44 in CR and VR, respectively. The difference between the two values was approximately 1.16, and the difference between the resulting values increased, particularly in the bone CT image, where metal artifacts were observed. In addition, we confirmed that the COV value improved by 2.20 times on average when using CR compared to VR. This study proved that CR is useful in reconstructing bone CT 3D images and that various applications in the diagnostic medical field will be possible.

Clinical implementation of cinematic rendering

Cinematic rendering is a recently developed photorealistic display technique for standard volumetric data sets. It has broad-reaching applications in cardiovascular, musculoskeletal, abdominopelvic, and thoracic imaging. It has been used for surgical planning and has emerging use in educational settings. We review the logistics of performing this post-processing step and its integration into existing workflow.

Cinematic rendering improves the AO/OTA classification of distal femur fractures compared to volume rendering: a retrospective single-center study

Purpose: Correctly classifying distal femur fractures is essential for surgical treatment planning and patient prognosis. This study assesses the potential of Cinematic Rendering (CR) in classifying these fractures, emphasizing its reported ability to produce more realistic images than Volume Rendering (VR). Methods: Data from 88 consecutive patients with distal femoral fractures collected between July 2013 and July 2020 were included. Two orthopedic surgeons independently evaluated the fractures using CR and VR. The inter-rater and intra-rater agreement was evaluated by using the Cicchetti-Allison weighted Kappa method. Accuracy, precision, recall, and F1 score were also calculated. Diagnostic confidence scores (DCSs) for both imaging methods were compared using chi-square or Fisher's exact tests. Results: CR reconstruction yielded excellent inter-observer (Kappa = 0.989) and intra-observer (Kappa = 0.992) agreement, outperforming VR (Kappa = 0.941 and 0.905, respectively). While metrics like accuracy, precision, recall, and F1 scores were higher for CR, the difference was not statistically significant (p > 0.05). However, DCAs significantly favored CR (p < 0.05). Conclusion: CR offers a superior visualization of distal femur fractures than VR. It enhances fracture classification accuracy and bolsters diagnostic confidence. The high inter- and intra-observer agreement underscores its reliability, suggesting its potential clinical importance.

Cinematic rendering in the evaluation of complex vascular injury of the lower extremities: how we do it

Lower extremity trauma is one of the most common injury patterns seen in emergency medical and surgical practice. Vascular injuries occur in less than one percent of all civilian fractures. However, if not treated promptly, such injuries can lead to ischemia and death. Computed tomography angiography (CTA) is the non-invasive imaging gold standard and plays a crucial part in the decision-making process for treating lower extremity trauma. A novel, FDA-approved 3D reconstruction technique known as cinematic rendering (CR) yields photorealistic reconstructions of lower extremity vascular injuries depicting clinically important aspects of those injuries, aiding in patient workup and surgical planning, and thus improving patient outcomes. In this article, we provide clinical examples of the use of CR in evaluating lower extremity vascular injuries, including the relationship of these injuries to adjacent osseous structures and overlying soft tissues, and its role in management of lower extremity trauma.

Musculoskeletal CT Imaging: State-of-the-Art Advancements and Future Directions

CT is one of the most widely used modalities for musculoskeletal imaging. Recent advancements in the field include the introduction of four-dimensional CT, which captures a CT image during motion; cone-beam CT, which uses flat-panel detectors to capture the lower extremities in weight-bearing mode; and dual-energy CT, which operates at two different x-ray potentials to improve the contrast resolution to facilitate the assessment of tissue material compositions such as tophaceous gout deposits and bone marrow edema. Most recently, photon-counting CT (PCCT) has been introduced. PCCT is a technique that uses photon-counting detectors to produce an image with higher spatial and contrast resolution than conventional multidetector CT systems. In addition, postprocessing techniques such as three-dimensional printing and cinematic rendering have used CT data to improve the generation of both physical and digital anatomic models. Last, advancements in the application of artificial intelligence to CT imaging have enabled the automatic evaluation of musculoskeletal pathologies. In this review, the authors discuss the current state of the above CT technologies, their respective advantages and disadvantages, and their projected future directions for various musculoskeletal applications.

The Use of Virtual Reality in Teaching Three-Dimensional Anatomy and Pathology on CT

While radiological imaging is presented as two-dimensional images either on radiography or cross-sectional imaging, it is important for interpreters to understand three-dimensional anatomy and pathology. We hypothesized that virtual reality (VR) may serve as an engaging and effective way for trainees to learn to extrapolate from two-dimensional images to an understanding of these three-dimensional structures. We created a Google Cardboard Virtual Reality application that depicts intracranial vasculature and aneurysms. We then recruited 12 medical students to voluntarily participate in our study. The performance of the students in identifying intracranial aneurysms before and after the virtual reality training was evaluated and compared to a control group. While the experimental group's performance in correctly identifying aneurysms after virtual reality educational intervention was better than the control's (experimental increased by 5.3%, control decreased by 2.1%), the difference was not statistically significant (p-value of 0.06). Significantly, survey data from the medical students was very positive with students noting they preferred the immersive virtual reality training over conventional education and believed that VR would be a helpful educational tool for them in the future. We believe virtual reality can serve as an important tool to help radiology trainees better understand three-dimensional anatomy and pathology.

MR Imaging of Acute Knee Injuries: Systematic Evaluation and Reporting

Acute knee injury ranges among the most common joint injuries in professional and recreational athletes. Radiographs can detect joint effusion, fractures, deformities, and malalignment; however, MR imaging is most accurate for radiographically occult fractures, chondral injury, and soft tissue injuries. Using a structured checklist approach for systematic MR imaging evaluation and reporting, this article reviews the MR imaging appearances of the spectrum of traumatic knee injuries, including osteochondral injuries, cruciate ligament tears, meniscus tears and ramp lesions, anterolateral complex and collateral ligament injuries, patellofemoral translation, extensor mechanism tears, and nerve and vascular injuries.

3D CT cinematic rendering of pediatric thoracic vascular anomalies

Thoracic vascular anomalies in the pediatric population are a heterogeneous group of diseases, with varied clinical presentations and imaging findings. High-resolution computed tomography is widely available and has become a standard part of the workup of these patients, often with three dimensional images. Cinematic rendering is a novel 3D visualization technique that utilizes a new, complex global lighting model to create photorealistic images with enhanced anatomic detail. The purpose of this pictorial review is to highlight the advantages of cinematic rendering compared to standard 2D computed tomography and traditional volume-rendered 3D images in the evaluation of thoracic vascular anomalies. Although cinematic rendering remains a new visualization technique under continued study, the improved anatomic detail and photorealistic quality of these images may be advantageous for surgical planning in cases of complex vascular abnormalities. Cinematic rendering may also help improve communication among clinicians, trainees, and patients and their families.

Emerging Technology in Musculoskeletal MRI and CT

This article provides a focused overview of emerging technology in musculoskeletal MRI and CT. These technological advances have primarily focused on decreasing examination times, obtaining higher quality images, providing more convenient and economical imaging alternatives, and improving patient safety through lower radiation doses. New MRI acceleration methods using deep learning and novel reconstruction algorithms can reduce scanning times while maintaining high image quality. New synthetic techniques are now available that provide multiple tissue contrasts from a limited amount of MRI and CT data. Modern low-field-strength MRI scanners can provide a more convenient and economical imaging alternative in clinical practice, while clinical 7.0-T scanners have the potential to maximize image quality. Three-dimensional MRI curved planar reformation and cinematic rendering can provide improved methods for image representation. Photon-counting detector CT can provide lower radiation doses, higher spatial resolution, greater tissue contrast, and reduced noise in comparison with currently used energy-integrating detector CT scanners. Technological advances have also been made in challenging areas of musculoskeletal imaging, including MR neurography, imaging around metal, and dual-energy CT. While the preliminary results of these emerging technologies have been encouraging, whether they result in higher diagnostic performance requires further investigation.

Multimodality imaging of a cardiac paraganglioma: A case report

Cardiac paragangliomas (PGLs) are rare extra-adrenal tumors that arise from chromaffin cells of the sympathetic ganglia. PGLs are often diagnosed incidentally, in the absence of symptoms, or with symptoms related to cardiovascular dysfunction. Cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) can be used to accurately determine the lesion morphology and position as well as providing detailed tissue characterization. A multimodal imaging approach, not yet standardized, could be useful either in diagnosis and monitoring or in treatment planning. In the case reported here, CCT and CMR were performed to define lesion anatomy, and a reconstruction was generated using cinematic rendering (CR) to characterize the PGL angioarchitecture.

Augmented Reality With Cinematic Rendered 3-Dimensional Images From Volumetric Computed Tomography Data

ABSTRACT

Recent advances in 3-dimensional visualization of volumetric computed tomography data have led to the novel technique of cinematic rendering (CR), which provides photorealistic images with enhanced surface detail and realistic shadowing effects that are generally not possible with older methods such as volume rendering. The emergence of CR coincides with the increasingly widespread availability of virtual reality (VR)/augmented reality (AR) interfaces including wearable headsets. The intersection of these technologies suggests many potential advances, including the ability of interpreting radiologists to look at photorealistic images of patient pathology in real time with surgeons and other referring providers, so long as VR/AR headsets are deployed and readily available. In this article, we will present our initial experience with viewing and manipulating CR images in the context of a VR/AR headset. We include a description of key aspects of the software and user interface, and provide relevant pictorial examples that may help potential adopters understand the initial steps of using this exciting convergence of technologies. Ultimately, trials evaluating the added value of the combination of CR with VR/AR will be necessary to understand the potential impact of these methods on medical practice.

A novel computed tomography angiography technique: guided preoperative localization and design of anterolateral thigh perforator flap

BACKGROUND

Anterolateral thigh perforator (ALTP) flap is considered a versatile flap for soft tissue reconstruction. Computed tomography angiography (CTA) is used for mapping perforator in abdominal-based reconstruction; however, it is less commonly used in ALTP due to its poor imaging efficacy. In this study, we introduced a novel CTA technique for preoperative localization and design of ALTP flap and evaluated its value in directing surgical reconstruction.

RESULTS

Thirty-five patients with soft tissue defects were consecutively enrolled. Modified CTA procedures, such as sharp convolution kernel, ADMIRE iterative reconstruction, 80 kV tube voltage, high flow contrast agent and cinematic rendering image reconstruction, were used to map ALTPs. A total of 287 perforators (including 884 sub-branches) were determined, with a mean of 5 perforators per thigh (range 2-11). The ALTPs were mainly concentrated in the "hot zone" (42%, 121/287) or the distal zone (41%, 118/287). Most perforators originated from the descending branch of the lateral circumflex femoral artery (76%, 219/287). Three perforator types, namely musculocutaneous (62%, 177/287), septocutaneous (33%, 96/287), and mixed pattern (5%, 14/287), were identified. The median pedicle length measured by two methods was 4.1 cm (range 0.7-20.3 cm) and 17.0 cm (range 4.7-33.9 cm), respectively, and the median diameter of the skin flap nourished by one perforator was 3.4 cm (IQR 2.1-5.7 cm). Twenty-eight ALTP flaps were obtained with the guidance of CTA, and 26 flaps survived after follow-up.

CONCLUSIONS

The proposed CTA mapping technique is a useful tool for preoperative localization and design of ALTP flap.

Photorealistic three-dimensional visualization of fusion datasets: cinematic rendering of PET/CT

PURPOSE

Cinematic rendering (CR) is a method of photorealistic 3D visualization of volumetric imaging data. We applied this technique to fusion PET/CT data.

METHODS

Two recent PET/CT cases were selected, one each of prostate-specific membrane antigen (PSMA)-targeted ¹⁸F-DCFPyL, and somatostatin-receptor-targeted ⁶⁸ Ga-DOTATATE. Targeted radiotracers were selected in order to provide high-contrast images for this proof-of-principle study. Cinematic rendering was performed with an enhanced algorithm that incorporated internal lighting within the PET-avid organs and lesions to allow for a distinct visual signature.

RESULTS

The use of internal lighting for PET data provided CR of fused PET/CT scans. The interpreting radiologist must make judicious use of presets and cut planes in order to ensure important findings are not missed.

CONCLUSIONS

CR of PET/CT data provides a photorealistic means of visualizing complex fusion imaging datasets. Such visualizations may aid anatomic understanding for surgical or procedural applications, may improve teaching of trainees, and may allow improved communication with patients.

Dual-Energy CT and Cinematic Rendering to Improve Assessment of Pelvic Fracture Instability

Background Grading of pelvic fracture instability is challenging in patients with pelvic binders. Dual-energy CT (DECT) and cinematic rendering can provide ancillary information regarding osteoligamentous integrity, but the utility of these tools remains unknown. Purpose To assess the added diagnostic value of DECT and cinematic rendering, with respect to single-energy CT (SECT), for discriminating any instability and translational instability in patients with pelvic binders. Materials and Methods In this retrospective analysis, consecutive adult patients (age ≥18 years) were stabilized with pelvic binders and scanned in dual-energy mode using a 128-section CT scanner at one level I trauma center between August 2016 and January 2019. Young-Burgess grading by orthopedists served as the reference standard. Two radiologists performed blinded consensus grading with the Young-Burgess system in three reading sessions (session 1, SECT; session 2, SECT plus DECT; session 3, SECT plus DECT and cinematic rendering). Lateral compression (LC) type 1 (LC-1) and anteroposterior compression (APC) type 1 (APC-1) injuries were considered stable; LC type 2 and APC type 2, rotationally unstable; and LC type 3, APC type 3, and vertical shear, translationally unstable. Diagnostic performance for any instability and translational instability was compared between reading sessions using the McNemar and DeLong tests. Radiologist agreement with the orthopedic reference standard was calculated with the weighted κ statistic. Results Fifty-four patients (mean age, 41 years ± 16 [SD]; 41 men) were analyzed. Diagnostic performance was greater with SECT plus DECT and cinematic rendering compared with SECT alone for any instability, with an area under the receiver operating characteristic curve (AUC) of 0.67 for SECT alone and 0.82 for SECT plus DECT and cinematic rendering (P = .04); for translational instability, the AUCs were 0.80 for SECT alone and 0.95 for SECT plus DECT and cinematic rendering (P = .01). For any instability, corresponding sensitivities were 61% (22 of 36 patients) for SECT alone and 86% (31 of 36 patients) for SECT plus DECT and cinematic rendering (P < .001). The corresponding specificities were 72% (13 of 18 patients) and 78% (14 of 18 patients), respectively (P > .99). Agreement (κ value) between radiologists and orthopedist reference standard improved from 0.44 to 0.76 for SECT versus the combination of SECT, DECT, and cinematic rendering. Conclusion Combined use of single-energy CT, dual-energy CT, and cinematic rendering improved instability assessment over that with single-energy CT alone. © RSNA, 2022 Online supplemental material is available for this article.

Cinematic rendering of paediatric musculoskeletal pathologies: initial experiences with CT

Cinematic rendering (CR) is a novel post-processing technique similar to volume rendering (VR), which allows for a more photorealistic imaging reconstruction by using a complex light modelling algorithm, incorporating information from multiple light paths and predicted photon scattering patterns. Several recent publications relating to adult imaging have argued that CR gives a better "realism" and "expressiveness" experience over VR techniques. CR has also been shown to improve visualisation of musculoskeletal and vascular anatomy compared with conventional CT viewing, and may help non-radiologists to understand complex patient anatomy. In this review, we provide an overview of how CR could be used in paediatric musculoskeletal imaging, particularly in complex diagnoses, surgical planning, and patient consent processes. We present a direct comparison of VR and CR reconstructions across a range of congenital and acquired musculoskeletal pathologies, highlighting potential advantages and areas for further research.

3D MRI of the Rheumatic Diseases

Magnetic resonance imaging (MRI) is commonly used to evaluate musculoskeletal pathologies due to its high spatial resolution and excellent tissue contrast. The diagnosis of rheumatic diseases can often be challenging. Investigation with conventional two-dimensional MRI is helpful for diagnosis and monitoring treatment. In the past few years, three-dimensional (3D) MRI has been more commonly used to assess joint pathologies including inflammatory and rheumatic diseases. This review discusses the techniques and protocols of 3D MRI and its diagnostic yield in the assessment of rheumatic diseases, along with different examples.

Thumb Injuries and Instabilities. Part 1: Anatomy, Kinesiology, and Imaging Techniques of the Thumb

The unique anatomical characteristics of the thumb offer a broad range of motion and the ability to oppose thumb and finger, an essential function for grasping. The motor function of the thumb and its orientation make it particularly vulnerable to trauma. Pathologic lesions encountered in this joint are varied, and imaging techniques play a crucial role in injury detection and characterization. Despite advances in diagnostic accuracy, acute thumb injuries pose a challenge for the radiologist. The complex and delicate anatomy requires meticulous and technically flawless image acquisition. Standard radiography and ultrasonography are currently the most frequently used imaging techniques. Computed tomography is most often indicated for complex fractures and dislocations, and magnetic resonance imaging may be useful in equivocal cases. In this article, we present the relevant anatomy and imaging techniques of the thumb.

Cone-beam computed tomography cinematic rendering: clinical, teaching and research applications

Cone-beam computed tomography (CBCT) is an essential imaging method that increases the accuracy of diagnoses, planning and follow-up of endodontic complex cases. Image postprocessing and subsequent visualization relies on software for three-dimensional navigation, and application of indexation tools to provide clinically useful information according to a set of volumetric data. Image postprocessing has a crucial impact on diagnostic quality and various techniques have been employed on computed tomography (CT) and magnetic resonance imaging (MRI) data sets. These include: multiplanar reformations (MPR), maximum intensity projection (MIP) and volume rendering (VR). A recent advance in 3D data visualization is the new cinematic rendering reconstruction method, a technique that generates photorealistic 3D images from conventional CT and MRI data. This review discusses the importance of CBCT cinematic rendering for clinical decision-making, teaching, and research in Endodontics, and a presents series of cases that illustrate the diagnostic value of 3D cinematic rendering in clinical care.

Evaluation of the urinary bladder using three-dimensional CT cinematic rendering

Three-dimensional (3D) visualizations of volumetric data from computed tomography (CT) acquisitions can be important adjuncts to interpretation of two-dimensional (2D) reconstructions. Recently, the 3D technique known as cinematic rendering (CR) was introduced, allowing photorealistic images to be created from standard CT acquisitions. CR methodology is under increasing investigation for use in the display of regions of complex anatomy and as a tool for education and preoperative planning. In this article, we will illustrate the potential utility of CR for evaluating the urinary bladder and associated pathology. The urinary bladder is susceptible to a multitude of neoplastic and inflammatory conditions and their sequelae. The intrinsic properties of CR may prove useful for the display of subtle mucosal/luminal irregularities, the simultaneous display of soft tissue detail with high-resolution maps of associated tumor neovasculature, and the improved display of spatial relationships to aid pre-procedural planning. Further refinement of presets for CR image creation and prospective evaluation of urinary bladder CR in real-world settings will be important for widespread clinical adoption.

Postoperative Spinal CT: What the Radiologist Needs to Know

During the past 2 decades, the number of spinal surgeries performed annually has been steadily increasing, and these procedures are being accompanied by a growing number of postoperative imaging studies to interpret. CT is accurate for identifying the location and integrity of implants, assessing the success of decompression and intervertebral arthrodesis procedures, and detecting and characterizing related complications. Although postoperative spinal CT is often limited owing to artifacts caused by metallic implants, parameter optimization and advanced metal artifact reduction techniques, including iterative reconstruction and monoenergetic extrapolation methods, can be used to reduce metal artifact severity and improve image quality substantially. Commonly used and recently available spinal implants and prostheses include screws and wires, static and extendable rods, bone grafts and biologic materials, interbody cages, and intervertebral disk prostheses. CT assessment and the spectrum of complications that can occur after spinal surgery and intervertebral arthroplasty include those related to the position and integrity of implants and prostheses, adjacent segment degeneration, collections, fistulas, pseudomeningoceles, cerebrospinal fluid leaks, and surgical site infections. Knowledge of the numerous spinal surgery techniques and devices aids in differentiating expected postoperative findings from complications. The various types of spinal surgery instrumentation and commonly used spinal implants are reviewed. The authors also describe and illustrate normal postoperative spine findings, signs of successful surgery, and the broad spectrum of postoperative complications that can aid radiologists in generating reports that address issues that the surgeon needs to know for optimal patient management.^©RSNA, 2019.

Comparison of Cinematic Rendering and Computed Tomography for Speed and Comprehension of Surgical Anatomy

Question

Does the use of cinematic rendering improve the comprehension of the surgical anatomy?

Findings

In this German preclinical randomized crossover study, visualization with cinematic rendering allowed a more correct and faster comprehension of the surgical anatomy compared with conventional computed tomography independent of the level of surgical experience.

Meaning

Cinematic rendering is a tool that may assist general surgeons with preoperative preparation and intraoperative guidance through an improved interpretation of computed tomography imaging data.

Importance

Three-dimensional (3-D) volume rendering has been shown to improve visualization in general surgery. Cinematic rendering (CR), a novel 3-D visualization technology for postprocessing of computed tomographaphy (CT) images, provides photorealistic images with the potential to improve visualization of anatomic details.

Objective

To determine the value of CR for the comprehension of the surgical anatomy.

Design, Setting, and Participants

This preclinical, randomized, 2-sequence crossover study was conducted from February to November 1, 2018, at University Hospital of Erlangen, Germany. The 40 patient cases were evaluated by 18 resident and attending surgeons using a prepared set of CT and CR images. The patient cases were randomized to 2 assessment sequences (CR-CT and CT-CR). During each assessment period, participants answered 1 question per case that addressed crucial issues of anatomic understanding, preoperative planning, and intraoperative strategies. After a washout period of 2 weeks, case evaluations were crossed over to the respective second image modality.

Main Outcomes and Measures

The primary outcome measure was the correctness of answers. Secondary outcome was the time needed to answer.

Results

The mean (SD) interperiod differences for the percentage of correct answers in the CR-CT sequence (8.5% [7.0%]) differed significantly from those in the CT-CR sequence (−13.1% [6.3%]) (P < .001). The mean (SD) interperiod differences for the time spent to answer the questions in the CR-CT sequence (−18.3 [76.9] seconds) also differed significantly from those in the CT-CR sequence (52.4 [88.5] seconds) (P < .001). Subgroup analysis revealed that residents as well as attending physicians benefitted from CR visualization. Analysis of the case assessment questionnaire showed that CR added significant value to the comprehension of the surgical anatomy (overall mean [SD] score, 4.53 [0.75]). No carryover or period effects were observed.

Conclusions and Relevance

The visualization with CR allowed a more correct and faster comprehension of the surgical anatomy compared with conventional CT imaging, independent of level of surgeon experience. Therefore, CR may assist general surgeons with preoperative preparation and intraoperative guidance.

Initial experience with 3D CT cinematic rendering of acute pancreatitis and associated complications

Inflammation of the pancreas can present with a wide range of imaging findings from mild enlargement of the gland and surrounding infiltrative fat stranding through extensive glandular necrosis. Complications of pancreatitis are varied and include infected fluid collections, pseudocysts, and vascular findings such as pseudoaneurysms and thromboses. Cross-sectional imaging with computed tomography (CT) is one of the mainstays of evaluating patients with pancreatitis. New methods that allow novel visualization volumetric CT data may improve diagnostic yield for the detection of findings that provide prognostic information in pancreatitis patients or can drive new avenues of research such as machine learning. Cinematic rendering (CR) is a photorealistic visualization method for volumetric imaging data that are being investigated for a variety of potential applications including the life-like display of complex anatomy and visual characterization of mass lesions. In this review, we describe the CR appearance of different types of pancreatitis and complications of pancreatitis. We also note possible future directions for research into the utility of CR for pancreatitis.

Is CT-based cinematic rendering superior to volume rendering technique in the preoperative evaluation of multifragmentary intraarticular lower extremity fractures?

PURPOSE

Cinematic rendering (CR), a recently launched, FDA-approved rendering technique converts CT image datasets into nearly photorealistic 3D reconstructions by using a unique lighting model. The purpose of this study was to compare CR to volume rendering technique (VRT) images in the preoperative visualization of multifragmentary intraarticular lower extremity fractures.

METHOD

In this retrospective study, CT datasets of 41 consecutive patients (female: n = 13; male: n = 28; mean age: 52.3 ± 17.9y) with multifragmentary intraarticular lower extremity fractures (calcaneus: n = 16; tibial pilon: n = 19; acetabulum: n = 6) were included. All datasets were acquired using a 128-row dual-source CT. A dedicated workstation was used to reconstruct CR and VRT images which were reviewed independently by two experienced board-certified traumatologists trained in special trauma surgery. Image quality, anatomical accuracy and fracture visualization were assessed on a 6-point-Likert-scale (1 = non-diagnostic; 6=excellent). The regular CT image reconstructions served as reverence standard. For each score, median values between both readers were calculated. Scores of both reconstruction methods were compared using a Wilcoxon-Ranksum test with p < 0.05 indicating statistical significance. Inter-reader agreement was calculated using Spearman's rank correlation coefficient.

RESULTS

Compared to VRT, CR demonstrated a higher image quality (VRT:2.5; CR:6.0; p < 0.001), a higher anatomical accuracy (VRT:3.5; CR:5.5; p < 0.001) and provided a more detailed visualization of the fracture (VRT:2.5; CR:6.0; p < 0.001). An additional benefit of CR reconstructions compared to VRT reconstructions was reported by both readers in 65.9 % (27/41) of all patients.

CONCLUSIONS

CR reconstructions are superior to VRT due to higher image quality and higher anatomical accuracy. Traumatologists find CR reconstructions to improve visualization of lower extremity fractures which should thus be used for fracture demonstration during interdisciplinary conferences.

Initial experience with cinematic rendering for the visualization of extracardiac anatomy in complex congenital heart defects†

OBJECTIVES

Detailed anatomical information is essential for planning of surgical therapy in patients with congenital heart disease. We wanted to determine whether cinematic rendering, the novel 3-dimensional visualization technique, could help paediatric cardiac surgeons achieve better preoperative visualization of the extracardiac anatomy in patients with complex congenital heart defects. Therefore, cinematic rendering was compared to the traditional volume rendering technique by means of a questionnaire with predefined criteria.

METHODS

Picture sets from 20 infant patients (mean age = 17 days) were generated from computed tomography data with both the cinematic rendering and the volume rendering techniques. These were presented side by side in a digital high-resolution portfolio without labelling them. Three experienced paediatric cardiac surgeons were provided with these portfolios and a questionnaire. They were asked to evaluate the images individually in predefined categories on a 4-point Likert scale from 1 = 'fully acceptable' to 4 = 'unacceptable'.

RESULTS

Cinematic rendering scored significantly better values on the Likert scale in 7 of 9 categories, namely 'spatial impression in general', 'depth perception', 'delineation of the atrial appendages/pulmonary veins/peripheral pulmonary arteries', 'assessability of the anterior interventricular sulcus' and 'assessability of the aortic arch branches'.

CONCLUSIONS

Cinematic rendering is a valuable software tool, and our data suggest that it provides significantly better visualization than volume rendering. The surgeons appraised improved depth perception and delineation of structures adjacent to the heart as the most significant advantages.

The role of cinematic rendering in pre-operative planning of a thoracodorsal artery perforator flap (TDAP) phalloplasty: a case study

The thoracodorsal artery perforator (TDAP) flap is a muscle-sparing skin and fat flap that requires precise intramuscular dissection of the thoracodorsal artery perforators in the axillary region. Pre-operative image-based treatment planning is a crucial part of flap design. In this article, we discuss the first-ever reported use of the cinematic volume rendering technique (CVRT) to evaluate the thoracodorsal artery for a TDAP flap phalloplasty in a 49-year-old transgender patient. Cinematic volume rendering technique uses light maps to generate photo-realistic three-dimensional images of the thoracodorsal artery and its perforators. These images aid the surgeon in evaluating optimal perforators and latissimus dorsi muscle involvement for more efficient flap design.

3D-cinematic rendering for dental and maxillofacial imaging

OBJECTIVES

Aim of this technical note is to show the applicability of cinematic rendering (CR) for a photorealistic 3-dimensional (3D) visualization of maxillofacial structures. The focus is on maxillofacial hard tissue pathologies.

METHODS

High density maxillofacial pathologies were selected in which CR is applicable. Data from both, CT and cone beam CT (CBCT) were postprocessed using a prototype CR software.

RESULTS

CR 3D postprocessing of CT and CBCT imaging data is applicable on high density structures and pathologies such as bones, teeth, and tissue calcifications. Image reconstruction allows for a detailed visualization of surface structures, their plasticity, and 3D configuration.

CONCLUSIONS

CR allows for the generation of photorealistic 3D reconstructions of high density structures and pathologies. Potential applications for maxillofacial bone and tooth imaging are given and examples for CT and CBCT images are displayed.

Value of the Cinematic Rendering From Volumetric Computed Tomography Data in Evaluating the Relationship Between Deep Soft Tissue Sarcomas of the Extremities and Adjacent Major Vessels: A Preliminary Study

Supplemental digital content is available in the text.

Objective

The aim of the study was to assess the value of cinematic rendering (CR) from volumetric computed tomography data in evaluating the relationship between deep soft tissue sarcomas (STSs) of the extremities and the adjacent major vessels.

Methods

Preoperative contrast-enhanced axial imaging (CEAI) in the arterial phase with three-dimensional volume rendering (VR) and CR of contrast-enhanced computed tomography were used to assess adjacent vascular invasion in 43 cases of deep STSs of the extremities. The imaging assessments were compared with surgical findings and interpreted as negative (no vascular invasion) or positive (vascular invasion was present). Intrareader and interreader agreement were assessed using Cohen κ statistics. The diagnostic performance of CEAI, VR, and CR was evaluated by receiver operating curve analysis and compared using the DeLong test.

Results

Thirty-four and nine cases were classified as negative and positive, respectively, in surgery. Intrareader agreement values for the CEAI, VR, and CR assessments were all excellent (0.984, 0.934, and 0.914, respectively), whereas the interreader agreement for CEAI assessments was greater than that for VR and CR (0.969 vs 0.804 and 0.761). Cinematic rendering showed lower accuracy (0.698), sensitivity (0.778), specificity (0.676), positive predictive values (0.389), and negative predictive values (0.920) for vascular invasion diagnosis than CEAI or VR; the accuracy, sensitivity, specificity, positive predictive values, and negative predictive values increased to 0.767, 0.889, 0.735, 0.471, and 0.962 for both CEAI and VR. The results were not statistically significant (all P > 0.05).

Conclusions

Cinematic rendering has the potential to be used to evaluate vascular invasion in cases of deep STSs of the extremities, but it should be used alongside the traditional methods such as CEAI.

3D CT cinematic rendering of the spleen: Potential role in problem solving

Cinematic rendering (CR) is a new 3D visualization methodology for volumetric diagnostic imaging including computed tomography (CT) datasets composed of isotropic voxels. CR produces photorealistic images with enhanced detail relative to other 3D visualization methods and realistic shadowing. In this review, we provide a number of examples of splenic pathology visualized with CR including conditions affecting the splenic vasculature, neoplasms, and accessory spleens. These examples are compared to 2D CT and traditional 3D CT techniques and the potential advantages of CR are highlighted. CR displays textural changes in the splenic parenchyma to particular advantage, and a portion of this review will be devoted to examples of how textural features can help distinguish intrapancreatic accessory spleens from neuroendocrine tumors.

Cinematic rendering of small bowel pathology: preliminary observations from this novel 3D CT visualization method

3D visualization methods for volumetric CT data have played an important role in diagnostic imaging of the small bowel, a structure which intrinsically crosses numerous slices in any 2D imaging plane. Recently, a new approach to 3D CT image creation has become available-cinematic rendering (CR). CR differs from other 3D methods in making use of a global lighting model that produces high surface detail and realistic shadowing effects that lead to 3D visualizations with photorealistic quality. Although the utility of these images for improving diagnostic accuracy has not yet been established, our group's early experience in regions of complex anatomy and pathology has been encouraging. In this pictorial review, we review the established role of 3D CT in many of the most common small bowel pathologies, provide examples of those pathologies visualized with CR, and suggest future directions for researchers to pursue.

Cinematic rendering of pancreatic neoplasms: preliminary observations and opportunities

Pancreatic cancer is the third most common cause of cancer death and CT is the most commonly used modality for the initial evaluation of suspected pancreatic cancer. Post-processing of CT data into 2D multiplanar and 3D reconstructions has been shown to improve tumor visualization and assessment of tumor resectability compared to axial slices, and is considered the standard of care. Cinematic rendering is a new 3D-rendering technique that produces photorealistic images, and it has the potential to more accurately depict anatomic detail compared to traditional 3D reconstruction techniques. The purpose of this article is to describe the potential application of CR to imaging of pancreatic neoplasms. CR has the potential to improve visualization of subtle pancreatic neoplasms, differentiation of solid and cystic pancreatic neoplasms, assessment of local tumor extension and vascular invasion, and visualization of metastatic disease.

CT cinematic rendering for pelvic primary tumor photorealistic visualization

Pelvic tumors can be both complicated and challenging, and computed tomography (CT) has played an important role in the diagnosis and treatment planning of these conditions. Cinematic rendering (CR) is a new method of 3D imaging using CT volumetric data. Unlike traditional 3D methods, CR uses the global illumination model to produce high-definition surface details and shadow effects to generate photorealistic images. In this pictorial review, a series of primary pelvic tumor cases are presented to demonstrate the potential value of CR relative to conventional volume rendering (VR). This technique holds great potential in disease diagnosis, preoperative planning, medical education and patient communication.

A review of existing and potential computer user interfaces for modern radiology

Abstract

The digitalization of modern imaging has led radiologists to become very familiar with computers and their user interfaces (UI). New options for display and command offer expanded possibilities, but the mouse and keyboard remain the most commonly utilized, for usability reasons. In this work, we review and discuss different UI and their possible application in radiology. We consider two-dimensional and three-dimensional imaging displays in the context of interventional radiology, and discuss interest in touchscreens, kinetic sensors, eye detection, and augmented or virtual reality. We show that UI design specifically for radiologists is key for future use and adoption of such new interfaces. Next-generation UI must fulfil professional needs, while considering contextual constraints.

Teaching Points

• The mouse and keyboard remain the most utilized user interfaces for radiologists.

• Touchscreen, holographic, kinetic sensors and eye tracking offer new possibilities for interaction.

• 3D and 2D imaging require specific user interfaces.

• Holographic display and augmented reality provide a third dimension to volume imaging.

• Good usability is essential for adoption of new user interfaces by radiologists.

3D cinematic rendering of the calvarium, maxillofacial structures, and skull base: preliminary observations

Three-dimensional (3D) visualizations of volumetric data from CT have gained widespread clinical acceptance and are an important method for evaluating complex anatomy and pathology. Recently, cinematic rendering (CR), a new 3D visualization methodology, has become available. CR utilizes a lighting model that allows for the production of photorealistic images from isotropic voxel data. Given how new this technique is, studies to evaluate its clinical utility and any potential advantages or disadvantages relative to other 3D methods such as volume rendering have yet to be published. In this pictorial review, we provide examples of normal calvarial, maxillofacial, and skull base anatomy and pathological conditions that highlight the potential for CR images to aid in patient evaluation and treatment planning. The highly detailed images and nuanced shadowing that are intrinsic to CR are well suited to the display of the complex anatomy in this region of the body. We look forward to studies with CR that will ascertain the ultimate value of this methodology to evaluate calvarium, maxillofacial, and skull base morphology as well as other complex anatomic structures.