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Department of Radiology, Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 800, Chicago, IL 60611, United States of America
Johns Hopkins University School of Medicine, The Russell H. Morgan Department of Radiology and Radiological Science, 601 North Caroline Street, Baltimore, MD 21287, United States of America
Johns Hopkins University School of Medicine, The Russell H. Morgan Department of Radiology and Radiological Science, 601 North Caroline Street, Baltimore, MD 21287, United States of America
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.
Approved by the U.S. Food and Drug Administration and introduced in 2016, cinematic rendering (CR) is a novel 3D visualization technique that creates photorealistic images from volumetric computed tomography (CT) and magnetic resonance imaging (MRI) datasets [
]. CR is similar to traditional volume rendering (VR), as images are created from passing light through reconstructed stacked axial thin-slice isotropic voxel data. However, CR utilizes a global illumination model, using complex path tracing of the projected light rays, as opposed to the local illumination model created by the traditional ray casting method of VR [
]. This global illumination model allows for the creation of photorealistic 3D images. At our institutions, the images are created by a radiologist using commercial postprocessing software (Siemens Syngo Via VB-40, Siemens Healthineers, Erlangen, Germany). In an interactive process, the radiologist can alter the window width and level and cut planes, assign colors to different tissue types, as well as determine other parameters to highlight the relevant structures of interest. Presets can be created and saved, which can subsequently be adjusted by the radiologist during CR image formation, streamlining the process and obviating the need for long post-processing times. At our institutions, an experienced radiologist can create CR images for most cases in under five minutes, allowing for integration into clinical workflow, including in the acute setting.
While its clinical and diagnostic roles remain under study, several reports have cited improved visualization of a wide variety of pathologies in the adult population, including in the abdominal [
MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury.
Evaluation of CR in the pediatric population has not been as well-assessed. While there has been one study demonstrating the potential benefit of CR in patients with complex congenital heart defects [
], the extent to which CR may have applicability in the pediatric population is unknown.
Congenital intrathoracic vascular anomalies are a heterogeneous group of diseases with varied clinical presentations, ranging from asymptomatic to life-threatening. Cross-sectional imaging with 3D visualization has been the standard of care in diagnosis of aortic arch anomalies [
Multidetector computed tomography and 3-dimensional imaging: preoperative evaluation of thoracic vascular and tracheobronchial anomalies and abnormalities in pediatric patients.
In this case series, we have included various examples of non-cardiac congenital intrathoracic vascular anomalies. The purpose of this article is to demonstrate the unique benefits of CR, and how the application of this novel technique can improve visualization of complex anatomy.
1.1 Clinical scenarios
1.1.1 Patient # 1
A 4-year-old boy with a history of speech delay presented with episodes of eye rolling and was incidentally found to have elevated blood pressure during a neurology workup. A subsequent echocardiogram found severe coarctation and a bicuspid aortic valve. A contrast-enhanced CT angiogram of the chest was then ordered for surgical planning.
The 2D contrast-enhanced sagittal image in Fig. 1a shows the coarctation in the classic location just distal to the left subclavian artery with focal, severe narrowing. The CR image in Fig. 1c provides an unobstructed view of the entire course of the aortic arch, as the patient’s persistent left-sided superior vena cava (as seen in the VR image in Fig. 1b) was excluded in this image by utilizing cut planes. Fig. 2 demonstrates two coronal CR images from the same patient. Fig. 2a highlights the entire course of both the right and left internal mammary arteries, dilated due to collateral circulation, and their relationship to surrounding structures. This perspective is unavailable by standard multi-planar reformations and demonstrates anatomic structure textures with decreased noise and clearer spatial relationships compared to VR. The coronal CR image in Fig. 2b provides a global assessment of the aorta as well as adjacent structures and shows the persistent left-sided superior vena cava.
Fig. 1Patient 1: A 4-year-old male with aortic coarctation. (a) Sagittal contrast-enhanced 2D CT and (b) VR images demonstrate the coarctation (red arrow) distal to the left subclavian artery. (c) Sagittal contrast-enhanced CR image demonstrates improved 3D visualization of the coarctation (red arrow), as well as highlights the prominent left subclavian artery. The persistent left-sided SVC seen on the VR image could also be subtracted using the CR technique, emphasizing the entire course of the aortic arch without obscuration.
Fig. 2Patient 1: (a) Coronal CR post-contrast image of the same patient with aortic coarctation highlights the prominent internal mammary arteries (red arrowheads), as well as their relationship to the surrounding structures. (b) Coronal CR post-contrast image set deeper within the thorax provides additional 3D global assessment, demonstrating the entire course of the ascending thoracic aorta (red arrowhead), as well as the persistent left-sided SVC (red arrow).
The patient subsequently underwent repair of the coarctation and aortic arch using a pulmonary artery homograft patch. During the procedure, the patient also had atrial septal defect closure. At the most recent follow-up visit, the patient had normal upper and lower extremity pulses, without an arch gradient, and required no anti-hypertensive medications.
1.1.2 Patient # 2
An 8-year-old boy presented to a cardiologist prior to starting stimulant medication reporting difficulty swallowing solids. He had a history of a cardiac murmur noted during infancy prompting an echocardiogram, which reported non-visualization of the left main pulmonary artery. Further workup at the time was electively deferred. At the time of more recent presentation, an echocardiogram revealed a possible left pulmonary artery sling, and a chest CT angiogram was ordered for further evaluation.
The 2D axial image in Fig. 3a demonstrates the classic appearance of a pulmonary sling, with the aberrant left main pulmonary artery arising from the distal right main pulmonary artery, coursing between the trachea and the esophagus and anterior to the descending thoracic aorta. The axial and axial oblique CR images (Fig. 3b and c) provide full 3D visualization of the pulmonary sling and distal intraparenchymal vessels, a more complete assessment of the surrounding organs, and further information about the location of the sling relative to the other intrathoracic structures. The oblique coronal CR image in Fig. 3d provides a unique view of the course of the left pulmonary artery, in a tight, anatomically complex region, which could not be visualized on standard MDCT imaging. The additional, non-standard views provided by CR could be advantageous in planning a surgical approach.
Fig. 3Patient 2: An 8-year-old male with a pulmonary sling. (a) Axial contrast-enhanced 2D image demonstrates the pulmonary sling, with the left pulmonary artery (red arrowhead) arising from the right pulmonary artery, coursing posterior to the trachea (red arrow) and anterior to the descending thoracic aorta (white arrowhead). (b, c) Axial and axial oblique contrast-enhanced CR images provide improved 3D visualization of the course of the left pulmonary artery (red arrowhead), and its relative position to the expected location of the adjacent airway and descending thoracic aorta (red arrowhead). (d) Coronal oblique contrast-enhanced CR image provides a unique view of the pulmonary sling, highlighting the sharp turn of the left pulmonary artery (red arrowhead), which is not as well appreciated in the standard 2D images.
Given the lack of significant clinical symptoms, the patient was treated conservatively without plans for surgical intervention, and a two-year follow-up was planned.
1.1.3 Patient # 3
A 3-month-old male twin born at 29 weeks presented with concern for vascular ring and esophageal compression. A prior modified barium swallow demonstrated aspiration and a posterior indentation on the thoracic esophagus, as seen in Fig. 4a. A contrast-enhanced CT angiogram of the chest was ordered for evaluation of a possible vascular ring.
Fig. 4Patient 3: An 8-week-old male with a history of a left-sided aortic arch and aberrant right subclavian artery. (a) Fluoroscopic image from a modified barium swallow examination demonstrates an impression on the posterior esophagus in its mid to upper portion (red arrow). (b) Axial contrast-enhanced CT demonstrates the left-sided arch (red arrow), with the aberrant right subclavian artery (red arrowhead) coursing posterior to the trachea and enteric tube. (c) Oblique coronal contrast-enhanced CR image provides markedly improved 3D visualization of the surrounding structures, particularly the trachea (red arrowhead) and lung (red arrow). CR can reveal the textural differences between the distinct tissues and provides a global evaluation not attainable via the standard 2D CT images as shown by the movie depicting the aberrant right subclavian artery. (d) Coronal, posterior approach contrast-enhanced CR image provides an additional view of the course of the aberrant artery (red arrowhead), and its relationship to the surrounding structures.
The 2D axial image in soft tissue windows in Fig. 4b reveals a normal left-sided arch with an aberrant right subclavian artery with a retroesophageal course, the etiology of the posterior indentation seen on fluoroscopy. No vascular ring or tracheal compression was present. The oblique CR image in Fig. 4c provides a more global visualization of the aberrant subclavian artery (see Fig. 4c movie). The CR display enhances tissue contrast among pulmonary, cardiovascular, and musculoskeletal structures, and improves visualization compared to standard 2D images. It also provides improved detail of the course of the artery in cross-section, highlighting the relative position of the artery with respect to the enteric tube anteriorly and the vertebral bodies posteriorly. This feature can be essential when assessing for disorders that can affect multiple organ systems. The coronal CR image (Fig. 4d) presents a unique view of the origin and course of the aberrant subclavian artery from a posterior approach, providing further 3D information.
The patient underwent a Nissen fundoplication procedure and gastrostomy tube placement. No cardiovascular surgery was necessary for the vascular variant.
1.1.4 Patient # 4
This patient was a 22-month-old female with a history of resolved laryngomalacia, with recurrent respiratory tract infections requiring hospitalization and intubation. The patient underwent combined bronchoscopy, laryngoscopy, and endoscopy for further evaluation, which demonstrated pulsing of the posterior wall of the lower trachea with associated narrowing. A contrast-enhanced CT angiogram of the chest was ordered for evaluation.
Coronal VR images seen in Fig. 5a and b demonstrate a double aortic arch, with a larger and more superiorly located right arch. The same view of the double arch is seen in the CR image in Fig. 5c; however, the CR provides improved visualization of the location of the double aortic arch within the thorax, as well as increased photorealism. The axial and axial oblique CR images seen in Fig. 6a and b, respectively, demonstrate an excellent view of the complete vascular ring, providing a unique 3D view of the trachea encircled and confined by the double aortic arch (see movie depicting the CR view of the double arch of patient 4 associated with Fig. 5, Fig. 6).
Fig. 5Patient 4: A 22-month-old female with a double aortic arch. (a, b) Coronal contrast-enhanced maximum intensity projection (MIP) images demonstrate the double aortic arch, with the slightly larger and higher right arch (red arrowhead) compared to the left (red arrow). (c) Coronal contrast-enhanced CR image at the same level provides improved photorealistic detail, and with better visualization of the relationship of the right arch (red arrowhead) and left arch (red arrow) to the surrounding structures (see movie).
Fig. 6Patient 4: (a, b) Axial and coronal oblique contrast-enhanced CR images from the same patient give a clear view of the complete ring (red arrowheads) that is formed by the double arch. The coronal oblique contrast-enhanced CR image (b) clearly delineates the encircling of the trachea (red arrow) by the vascular ring (red arrowheads). (c) The coronal contrast-enhanced CR image provides improved textural differences between the airways, lungs, and cardiovascular structures. The anterior aspect of the vascular ring was subtracted, providing a clear view of the entire course of the trachea (red arrowhead) and proximal mainstem bronchi. See movie illustration of enhanced views provided by CR.
This 3-month-old male had a history of prenatally diagnosed congenital pulmonary airway malformation (CPAM). The patient had been doing well clinically following delivery without respiratory symptoms. A CT angiogram was ordered for further workup.
The axial 2D image in lung window (Fig. 7a) demonstrates the cystic component of the lesion, while the axial 2D image in soft tissue window (Fig. 7b) reveals the vascular component. The axial CR image (Fig. 7c) provides improved photorealistic detail of the lesion as well as textural information. In Fig. 8, the serpiginous feeding vessel arising from the celiac trunk is seen in both sagittal and coronal maximum intensity projection views as well as CR views. The CR views show increased information about relative depth of the vessel, and its 3D relationship to the surrounding organs.
Fig. 7Patient 5: A 3-month-old male with a hybrid pulmonary lesion. (a, b) Axial contrast-enhanced 2D CT images at the level of the hybrid lesion. The 2D image in lung windows (a) highlights the cystic nature (red arrowhead) of the hybrid lesion. The 2D image in soft tissue window (b) demonstrates the abnormal vascular supply (red arrowhead); however, there is limited evaluation of the adjacent lung parenchyma. (c) The axial CR image demonstrates the contrasting textures between the liver (red arrow), heart (white arrowhead), and vasculature (red arrowhead). The CR image also provides an excellent 3D perspective of the lesion and relationship to adjacent structures, which could be advantageous in surgical planning.
Fig. 8Patient 5: (a, b) Sagittal and coronal contrast-enhanced MIP images from the same patient show the infradiaphragmatic feeding artery (red arrowhead) arising from the celiac trunk (red arrow) off the abdominal aorta. (c, d) Sagittal and coronal contrast-enhanced CR images provide improved 3D visualization of the feeding artery (red arrowhead), celiac trunk (red arrow), and their relationship to the surrounding structures. The CR images also provide increased textural information about the surrounding organs.
The patient subsequently underwent video-assisted thoracoscopic right lower lobectomy, which revealed large cysts in the right lower lobe, with two large systemic feeding vessels arising from the aorta. Pathology demonstrated fragments of lung with bronchopulmonary foregut malformation, most likely CPAM (Stocker I), as well as features of intralobar sequestration, findings compatible with a hybrid lesion.
2. Conclusion
The examples in this case series highlight the advantages of CR over standard VR reconstructions. The ability of CR to extract additional data from standard CT datasets may obviate the need for additional testing and radiation exposure, which is particularly advantageous in the pediatric population, for whom minimizing radiation is of foremost concern [
]. The 3D visualization and textural contrast provided by CR can improve visualization of complex vascular anatomy, as shown in the above cases, which is essential for preoperative evaluation. One small study assessing the value of CR for extracardiac anatomy in patients with congenital heart defects indicated that pediatric cardiac surgeons preferred the CR images to VR images due to improved “spatial impression in general” and “depth perception” [
Beyond potential diagnostic and treatment benefits, CR offers photorealistic representation of complex anatomy and pathology that can be more intuitively understood by those without a medical background, potentially improving communication between clinicians and patients and/or their families. For the same reasons, CR also may have a role in trainee education, as virtual anatomy becomes increasingly relevant. Although CR remains a relatively new technique under much study, it brings new possibilities for improving diagnosis and treatment in the pediatric population.
Funding Information
Hannah S. Recht, MD – None. Edmund M. Weisberg, MS, MBE – None. Elliot K. Fishman, MD None.
Ethical Statement
All authors contributed equally to this work and have no pertinent conflicts of interest.
Declarations of Interest
Hannah S. Recht, MD – None. Edmund M. Weisberg – None. Elliot K. Fishman, MD receives grant funding from GE Healthcare and Siemens, and is a founder and stockholder, HipGraphics.
MDCT of ductus diverticulum: 3D cinematic rendering to enhance understanding of anatomic configuration and avoid misinterpretation as traumatic aortic injury.
Multidetector computed tomography and 3-dimensional imaging: preoperative evaluation of thoracic vascular and tracheobronchial anomalies and abnormalities in pediatric patients.
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