CT-guided intervention with the SOMATOM go. platform
Case Series
Clinical value of CT-guided interventions
User experiences with the new Guide&GO interventional suite
International version. Not for distribution or use in the U.S.
Take-home message
Interventions guided by computed tomography (CT) are key to providing the full range of clinical services, including those in private practices that serve medium-sized hospitals. Innovations in workflows and CT technologies, such as spectral shaping with Tin Filter and tablet-based workflows, are also affecting how modern CT scanners are used in interventional scenarios. This enables clinicians and radiologists to improve their clinical offerings.
Introduction
About the hospital:
Dreifaltigkeits-Hospital Lippstadt is located in western Germany in the state of North Rhine-Westphalia. It serves as a local acute-care hospital for the town of Lippstadt (approximately 66,000 inhabitants) and the surrounding rural area. With 15 specialist departments and 350 beds, it offers everything required for typical 24/7 standard care, including a dedicated center for trauma surgery. It also provides a comprehensive and progressive range of medical services for clinical fields such as radiation therapy, dialysis, and geriatric medicine. The hospital additionally serves as a teaching hospital for the University of Muenster.
Set-up of small and mid-sized hospitals:
Small and mid-sized hospitals in Germany commonly organize their radiology departments as a cooperative unit. At Dreifaltigkeits-Hospital Lippstadt, the department is managed by a private practice called Radiologie am Dreifaltigkeits-Hospital. In addition to providing hospital and outpatient services, the department serves smaller hospitals in the greater Lippstadt area and must cover all clinical emergencies to support the hospital's 24/7 service.
Challenges and questions when replacing a CT scanner:
Until 2018, the radiologists' main workhorse was a six-slice CT system (SOMATOM Emotion 6-slice). The small radiology unit had a high workload and needed to extend its clinical offerings, especially with regard to lower-dose imaging (in terms of both radiation and contrast media). The chief radiologist, Henning Bovenschulte, MD, decided to replace the SOMATOM Emotion with a new SOMATOM go.Up. This system features a unique tablet-based mobile workflow for intuitive scanner operation and supports users with innovative software for planning and conducting examinations. Switching from a SOMATOM Emotion to a SOMATOM go.Up meant users had to adapt to a completely new software philosophy. Dr. Bovenschulte performs a wide range of CT-guided interventions. While the technological advances of the SOMATOM go.Up introduced new diagnostic capabilities, CT-guided interventions place specific demands on the CT system. This raised the question of whether the new scanner, particularly with its tablet-based workflow, would interfere with the user's experience or provide advantages for interventions. Introducing a new scanner also posed challenges for protocol management and total applied radiation dosage, which is a combination of scanner technology, efficiency of radiation usage, interaction with the scanner's user interface, and the user's clinical knowledge.
Concept of Guide&GO tablet-based workflow for intervention guidance
The same tablet used for patient positioning, scan control, and image review is also utilized for the Guide&GO intervention workflow. The tablet can be covered with a sterile sheet and placed on a flexible, individually positioned “gooseneck.” The tablet's interactions with the scanner's interface allow the user or interventionalist to work with the scanner more intuitively than with most conventional user interfaces. SOMATOM go.Up supports sequenced scans for guidance. After scanning, images are displayed in a logical order. Selecting the plane, manipulating images, and planning the next scan is easily done thanks to the touch-based user interface. Radiation exposure must be triggered using a remote control or an X-ray footswitch that complies with radiation-protection regulations. Pre- and post-interventional scans can be handled easily with the tablet-based workflow.
Image Description: The Guide&GO tablet interface displays axial CT slices of a patient's abdomen, showing controls for patient positioning and scan planning.
Clinical cases
The following cases demonstrate a selection of typical indications and common clinical scenarios for CT-guided interventions using the SOMATOM go.Up system.
1. Pain management
An increasing number of patients are referred to the radiology department for supportive pain-management interventions. All interventions are conducted in close collaboration with relevant pain specialists. One of the most common interventions is periradicular infiltration, which reduces nerve swelling and provides pain relief to support further treatment. Periradicular infiltration therapy (PRT) is an effective minimally invasive procedure, mainly used for degenerative conditions of the spine, often associated with vertebral disc herniations.
Case
A patient suffered from severe pain and movement limitations caused by degenerative damage and pain radiating from the L5/S1 nerve root. Conventional therapy had been unsuccessful, so PRT was performed to reduce pain and swelling of the right sacroiliac nerve root. The patient was placed in a prone position and asked to breathe shallowly for the infiltration. A low-dose i-Sequence scan was performed for precise needle-path planning using the tablet-based Guide&GO solution. After skin disinfection and local anesthesia, a needle was placed close to the nerve root. Attaining the target position was aided by administering a small amount of contrast medium and performing an i-Sequence scan. The total intervention time was approximately five minutes, and the applied radiation was 40mGy cm DLP. The patient left radiology without complications and showed clear improvement in his clinical symptoms on follow-up.
Image 1.0 Description: Axial CT scan of the lumbar spine, acquired in i-Sequence mode with 130 kVp, a CTDIvol of 23.8 mGy, and a scan length of 15 mm, showing the target area for needle placement.
Image 1.1 (a-c) Description: Three axial CT slices showing the progression of a needle towards the L5/S1 nerve root, with the needle tip clearly visible prior to medication administration.
Image 1.2 Description: Final axial CT scan documenting correct placement of steroids near the nerve root, visualized by contrast medium added to the medication.
2. Biopsies
CT-guided biopsies are performed when suspicious findings cannot be accessed by ultrasound or other means. Examples include lung lesions via bronchoscopy and pancreatic lesions via ERCP.
Case
A patient with extensive stenosis of the gastroesophageal passage underwent stenting and a further whole-body evaluation. The scan displayed multiple lymph node glomerates at the peritoneal lymph node stages, in addition to the known pathology. The location and size of the nodes meant that safe access for a representative biopsy was not possible by ultrasound. Therefore, CT-guided sampling was decided upon in close collaboration with the referring ward. With a rotation time of 0.8 seconds, the SOMATOM go.Up allows clinicians to perform multiple scans quickly, visualizing even challenging cases where the biopsy needle must be placed directly alongside the aorta. The biopsy was successfully performed, and pathology verified the diagnosis of extensive stage 4 gastric cancer.
Image 2.1 Description: Diagnostic single-phase CT scan (axial a-c, coronal d) acquired with 130 kVp, a CTDIvol of 8.37 mGY, and a scan length of 490 mm, showing thickening of the stomach wall, a stent in the gastroesophageal passage, and multiple suspicious lymph nodes.
Image 2.2 (a-d) Description: Four axial CT slices acquired in sequential mode with 130 kVp, a CTDIvol of 46.5 mGy, and a scan length of 9 x 15 mm, demonstrating the needle progression and location of the tip before acquiring biopsy tissue. The upper and lower rows are in different windowing for improved visualization of soft tissue and bony structures.
3. Management of complications, and supportive interventions
Complex surgical procedures, severe traumata, and final-stage patients are scenarios where CT-guided interventions are required to manage complications or support therapy. One of the most frequently performed procedures is drainage placement using the Seldinger technique, which is crucial for patient management and requires close collaboration with the treating department.
Case
A patient was hospitalized with severe symptoms of infection. Diagnostic workup revealed a large pleural fluid collection and subcapsular fluid in the liver, leading to a diagnosis of pleuropneumonia with subdiaphragmatic secondary abscess and subcapsular liver abscess. Working closely with the surgical department, the decision was made to support systemic antibiotic therapy via minimally invasive drains. Initially, ultrasound guidance was used for the subdiaphragmatic abscess. However, the location and extent of the subcapsular abscess favored CT image-guided intervention. The best access path was achieved by left-side patient positioning. CT Guide&GO supports flexible positioning, including z-axis compensation, for optimal patient access and a better workflow, reducing in-room time. As demonstrated in the images, a flexible drainage tube was successfully placed via a hollow needle. The CT scan confirmed that the drainage fully covered the abscess and relieved the purulent fluid. The patient recovered quickly and was soon discharged.
Image 3.1 Description: Pre-diagnostic spiral CT scan with oral contrast medium acquired with 130 kVp, a CTDIvol of 6.95 mGy, and a scan length of 664 mm. Axial views (a-b) show extensive subpleural/subcapsular fluid collections.
Image 3.2 Description: Coronal (a) and sagittal (b) CT views from a planning CT, indicating the extent of initial findings that required a whole-body CT.
Image 3.3 Description: Axial CT slices acquired in i-Sequence mode with 130 kVp, a CTDIvol of 25.82 mGy, and a scan length of 5 x 15 mm. (a) shows the location of the hollow needle before placing the guidewire, and (b) shows the advancement of the guidewire.
Image 3.4 Description: Axial CT scan acquired with 130 kVp, a CTDIvol of 6.98 mGy, and a scan length of 262 mm, confirming the placement of a flexible drainage tube deployed using the Seldinger technique.
4. Palliative therapies
CT-guided lumbar sympathicolysis
Sympathicolysis for extensive peripheral vessel disease is an important supportive therapy for managing affected patients, particularly when primary treatment is not feasible or effective. This procedure has proven its clinical value in such cases.
Case
An elderly man with extended stenosis of the right popliteal artery and multiple risks due to poor general health benefited from sympathicolysis, which improved his quality of life. The SOMATOM go. platform's flexible patient positioning is crucial for patients with poor general health. Flexible table adjustment and the use of the full bore size are necessary for a convenient and successful intervention. The flexible table concept supports an easy workflow for patient positioning. After planning CT, the flexible movement concept in Guide&GO enabled easy access for needle placement and sympathicolysis. Contrast medium was added to the medication to visualize the applied alcohol. Shortly after the intervention, the patient's vascularization improved, and follow-up visits confirmed the success of the treatment and improved quality of life.
Image 4.1 Description: Peripheral MR angiography performed with a 1.5-Tesla MAGNETOM Aera, indicating the extended occlusion of the right popliteal artery.
Image 4.2 Description: Axial, oblique coronal, and oblique sagittal CT slices used for intervention planning, acquired with a spiral scan at 130 kVp, a CTDIvol of 10.2 mGy, and a scan length of 178 mm.
Image 4.3 Description: Axial CT slices acquired in i-Sequence mode with 130 kVp, a CTDIvol of 41.3 mGy, and a scan length of 7 x 15 mm, used to monitor incremental needle advancement and drug administration.
SOMATOM go. platform featuring Guide&GO
Guide&GO is the first tablet-based solution on the market for CT-guided interventions. Built on a new mobile workflow, it is both familiar and easy to use. The entire intervention can be controlled with the tablet and the remote control, which are also used for routine CT operations. There is no need for dedicated ceiling-mounted displays or joysticks. With a cover, the tablet can be used even in sterile environments. This tablet-based, easy-to-use interventional solution represents a unique and cost-effective way to transform daily patient care.
Simple and familiar tablet operation
Experience the simplicity of the only tablet-based CT-guided intervention solution. Benefit from easy and fast image-based definition of the target position, combined with the flexible patient table move concept. Leverage the straightforward workflow controlled by the remote control for patient table movements and X-ray. For an optimized and fast workflow during needle placement, Guide&GO provides an Autorepeat scan functionality, enabling the fast repetition of several i-Sequence scans.
Intuitive CT workflow solution
Needle guidance is supported by intuitive image manipulation functions familiar from smartphones, such as zoom or pan. A dedicated toolkit for performing accurate measurements and planning a secure needle path is easily accessible via the tablet and supported by a convenient “smartphone-like” zoom-glass functionality.
Safe and accurate at low dose
Protect patients and staff by introducing high-end, low-dose technologies and improved ergonomics. In terms of safety, Tin Filter technology reduces dose. The tablet interface displays a dose thermometer, allowing real-time monitoring. The flexible tablet holder can be adjusted for individual needs, ensuring a safe and comfortable working environment.
Accuracy and precision
For precision, intuitive touchscreen functions help users quickly find the right position for the needle and measure relevant distances with magnifying glass functionality. Fast toggling between predefined image windowing or between the i-Sequence and spiral planning scans facilitates anatomy cross-checking. Laser crosshairs offer additional accuracy and confidence.
Artifact reduction with iMAR
Artifacts due to metal implants or tools used in interventional procedures (e.g., RF ablation) can hamper image quality and make accurate targeting impossible. iMAR*, smoothly integrated into the tablet workflow, reduces these artifacts and improves confidence even in areas adjacent to metal implants.
* Requires iMAR or High Performance Package
On account of certain regional limitations of sales rights and service availability, Siemens Healthineers cannot guarantee that all products included in this brochure are available through its sales organization worldwide. Availability and packaging may vary by country and are subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States. The information in this document contains general technical descriptions of specifications and options as well as standard and optional features that do not always have to be present in individual cases. Siemens Healthineers reserves the right to modify the design, packaging, specifications, and options described herein without prior notice. Please contact your local Siemens Healthineers sales representative for the most current information. Note: Any technical data contained in this document may vary within defined tolerances. Original images always lose a certain amount of detail when reproduced.
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