3D CT cinematic rendering of pediatric thoracic vascular anomalies

Abstract

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.

Keywords: 3D imaging; Bronchopulmonary sequestration; Cinematic rendering; Pediatric; Pulmonary slings; Thoracic; Vascular; Vascular rings.

Fig. 1

Patient 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. 2

Patient 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).

Fig. 3

Patient 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.

Fig. 4

Patient 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.

Fig. 5

Patient 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. 6

Patient 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.

Fig. 7

Patient 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. 8

Patient 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.