The buzzwords for 2017, when it comes to CT, are dual energy and spectral imaging. It is all about getting functional information out of the same CT without additional expense or radiation to the patient, while providing valuable functional information.

Computed tomography (CT) has evolved significantly since its debut in the 1970s. While the basic principles have stayed the same, manufacturers have been able to expand on these principles to offer enhanced performance and image quality. The makers of CT equipment are stepping off the trodden path and taking the medical community with them. Ahead is a world of changing workflows, decreasing times from diagnosis to treatment, and improving patient care.

Indian Market Dynamics

The Indian CT scanners market was valued at Rs. 900 crore in 2015, a 13 percent increase in value terms over 2014. The smaller machines, <16-slice category, continue to gain popularity, and account for 40 percent of the market in value terms. The 16-slice machines, giving value for money contribute 25 percent to the market. The discerning customer continues to prefer the 64- and larger-slice machines. The three brands, GE, Philips, and Siemens, dominate the market, albeit the Revolution ACT by GE has gained ground.

The pre-owned (refurbished) CT scanners are primarily sold in the <16-slice category, with Siemens being the most popular brand. Some GE systems are also sold. About 30 units were also sold in the 16-slice category, at an average unit price of Rs. 1 crore and a couple of systems in the 16- to 28-slice category, at an average unit price of Rs. 2.5 crore. The leading vendors in this category are Cura, Sanrad, Ives Medical, Soma Technology, and some regional freelancers.

{mosimage}The recently announced AERP regulation that systems older than seven years cannot be refurbished and sold has changed the dynamics of this market. At the outset, freelancers who currently sell about 100 systems annually will perhaps get marginalized over this year, after which the pre-owned segment market is expected to shrink.

Global Market

The global market for CT scanners is forecast to reach USD 5.7 billion by 2020, driven by the growing prominence of image-guided interventions against the backdrop of rising need for early and accurate diagnosis.

CT scan, being a non-invasive, painless, and comparatively safe procedure that does not require any recovery time, is being increasingly used to assess shape/structure of the body parts; to diagnose various health conditions; to aid planning of surgeries and radiotherapy; in the administration of radiation therapy; as a visual aid in interventional procedures, such as biopsy; in bone strength determination; and as an alternative to select exploratory and diagnostic surgeries. Superior attributes of CT scanners over other imaging technologies that are driving its steady adoption include high image quality, outstanding flexibility, clinical excellence, dynamic acquisition and reconstruction speeds, task automation, improved spatial resolution, low contrast detectability, excellent reliability, high patient throughput, and advanced patient care. The growing need for effective and early diagnosis is driving the demand for superior data images offered by CT systems, particularly in the field of oncology and cardiovascular and other chronic diseases.

The global CT scanners market is expected to witness healthy growth in the coming years, primarily driven by rising incidences of cardiovascular diseases (CVDs), circulatory system diseases, spinal conditions, inflammatory diseases, kidney and bladder stones, and injuries to the head, skeletal system, and internal organs. Other important growth drivers include expanding geriatric population in need of medical imaging, ever-improving image processing capabilities of CT scanners in delivering enhanced image quality with more contrast, and increasing shift of medical care toward image-guided interventions and minimally/non-invasive procedures for diagnosis and treatment of various common and life-threatening diseases. Rising popularity of automated workflows in emergency clinical settings, increasing investments from public-private partnerships in medical imaging equipment, and adoption of micro-computed tomography in endodontic procedures, are also expected to benefit market prospects in the near term.

Growth Drivers

  • Aging population in need of medical imaging drives market growth.
  • Technology improvements in image processing and resolution fuel adoption of CT scanners.
  • Increasing shift of medical care toward image-guided interventions spurs market expansion.
  • Emphasis on less invasive procedures for diagnosis and treatment of diseases provides market opportunities.
  • Rising popularity of automated workflows in emergency clinical settings fuels market demand.
  • Growing adoption of micro-CT in endodontic procedures shall benefit market prospects.

CT Technology - What Is Next?

Today's CT scanners include technological developments that enable users to better manage patient care, including lung cancer screening, dose guidance and regulation, spectral and multi-energy imaging, and expansion of cardiac and brain imaging. These scanners and solutions also provide new levels of information to help clinicians make a more confident diagnosis at low dose, without increasing complexity in their routines.

Global CT trends continue to focus on addressing the increasing burden for diagnosing complex patients while ensuring optimal dose management, efficient system utilization, and standardization of protocol practice. Health systems are seeking CT systems that can improve the efficiency of handling complex workflows and broad case mixes for settings like outpatient or emergency, from polytrauma to light headaches, or improving clinical excellence in specialties such as detecting small liver lesions or establishing lung screening practices. Optimizing dose as well as greater standardization of protocols also continues as health systems improve operational efficiency and ensure patient satisfaction as well. Traditional installed CT systems are unable to address these dynamic challenges.

The CT scanners market has shown consistent growth over the last three years, driven by a number of factors. The conversion to a value-based payment healthcare system has changed what hospitals look for in return on investment, cost-effectiveness, efficiency, and increasing patient safety. Hospitals need to operate more efficiently and productively, meaning a shift toward more value-oriented products. Similarly, a quality shift has occurred with patients, who are now more proactively involved in their care.

Trends from this shift to value-based care include data integration (big data) and population health management. An influx of data combined with advancements in imaging helps leverage this data to not only bring further value but also apply it to broader populations.

The buzzwords for 2017, when it comes to CT, are dual energy and spectral imaging. It is all about getting functional information out of the same CT without additional expense or radiation to the patient, while providing valuable functional information. Examples include detecting lesions earlier in the disease process and customizing future treatments. Structural heart imaging is also on the rise, a trend believed to continue.

The latest advancements in CT technology focus on the information derived from CT solutions, looking at how else this information can be used and integrated to bring further value. Some of the notable advancements include:

  • The ability to extract clinical information from CT studies, which enables a more confident diagnosis - potentially resulting in reduced follow-up testing and improved disease management;
  • The ability to extract clinical information at lower radiation doses, which allows a broader use of CT for high-risk populations and earlier disease detection (lung cancer screening); and
  • The ability to integrate information across different diagnostic tools, creating opportunities to optimize information across the continuum of patient care.

Spectral CT is a relatively new concept in diagnostic imaging, allowing physicians to use CT scanning to assess the material composition of the target area. This makes CT more definitive and cost effective, by reducing the need for downstream tests, especially in cancer, vascular diseases, and kidney stones. Another trend that is likely to continue to gain prominence is the transition of 3-D printing from toy to tool.

Next-Generation Scanners

Researchers from the National Institute of Health (NIH) have successfully tested new photon-counting detector (PCD) CT technology on human patients for the first time, potentially giving radiologists and clinicians an enhanced look inside the body using multi-energy imaging.

Currently available CT scanners utilize energy-integrating detectors (EIDs) to create an electrical signal using X-ray photon energy. Conversely, PCDs calculate individual photon interactions through high-speed semiconductors, eliminating reliance on resolution-limiting scintillator crystals.

This advancement in CT scanner technology has several advantages, said lead author Amir Pourmorteza and his colleagues from NIH.

Pourmorteza and his team recently performed the first test of the new CT technology on human patients. They conducted radiation dose-matched delayed contrast agent-enhanced spiral and axial abdominal scans on 15 volunteer participants using both EID and PCD CT scanners, evaluating both methods using image quality, noise, artifact, and spatial resolution scores. Scans using PCD were also used to investigate iodine concentration. Their results showed that both systems displayed similar performance in all the categories studied, with PCD improving iodine mapping capabilities as compared to EID scans.

At the current stage of development, the qualitative and quantitative image quality analyses showed similar performance in EID and PCD. In addition, the current PCD system with two to four adjustable energy thresholds can acquire dual- and multi-energy projections from a single scan, which could be used in multi-material decomposition.

The NIH has plans to continue testing the new CT technology over the next five years, focusing on the development of scan protocols and processing algorithms to improve screening, imaging, and treatment planning for a variety of health conditions.

The Road Ahead

Looking forward to the future of CT, radiologists should expect to see faster, more automated, and easier-to-use scanners. The technology will transition from a good interpretation tool to a machine with more quantification and a speedy and direct diagnosis.

There will be growing interest and demand for analytics solutions that can help medical imaging professionals deliver more value by reducing length of stay, improving compliance, increasing revenue, decreasing medical errors and medical legal risk, and evaluating outcomes and quality. CT will not only be able to routinely deliver anatomical information but also feature the ability to characterize structures based on their material makeup within a single scan. This will change and improve clinical pathways to personalized medicine.

Many aspects, including equipment, will continue to evolve, but none more so than applications and cloud computing. Considering the enormous amounts of data generated by a CT scan, there is a tremendous amount of data to capture and optimize. The health cloud offers tremendous potential to turn volumes of data from a CT scan and enable greater insight and analytics for clinicians to further enable better outcomes. Massive data sets can be managed in areas such as processing speed of 3-D visualization or bringing together patient case planning through multidisciplinary care teams with virtual viewing and planning.

Ease-of-use, simplicity, automation, and functional imaging are all advancements expected from the modality in the years ahead.

Another area that will continue to grow is CT's role in chest pain management.

The biggest change will be driven by artificial intelligence/computer-aided design and expanded analytics. Healthcare is in a place where there is an influx of data, but its power has yet to be harnessed. CT technology will continue to see advancements that quantify and make sense of this data - using it to bring value back to the radiologist, the provider, and the patient.

Dr Anurag Yadav, Consultant Radiologist, Sir Ganga Ram Hospital, New Delhi
Second Opinion
Horizon Boundaries Further Enhanced!

The future of CT Imaging has undergone a paradigm shift from the intense race of multiple rows of detectors to a completely different era of polychromatic energies. The single-energy CT has transitioned to spectral CT with de-differentiation of images into individual components for better understanding of pathologies in human beings. Major vendors have introduced different CT technologies ranging from dual-source twin-beam CT; to single-source dual-energy system, with fast kilovolt - peak switching; and the most recent single-source 
dual-layer detector spectral CT.

The low-energy scans improve the vessel contrast and hence, 
very-good-quality angiographies can be obtained with less volume of iodinated contrast. The high-energy scans decrease the blooming and beam-hardening metallic artifacts from dental fillings, neuro coils, spinal implants, vascular stents, and brachytherapy needles, resulting in better-quality images. Blended or composite images of multiple energies can summate these advantages.

Material decomposition images obtained by spectral CT can significantly reduce the radiation dose and eliminate respiratory misregistration by constructing virtual non-contrast images, differentiate between types of renal calculi, non-invasive diagnosis of urate crystals in gout, and predict histopathological severity of hepatic fibrosis. The iodine images map myocardial perfusion defects in conjunction with significant coronary artery stenosis; pulmonary perfusion defects even in small emboli in subsegmental branches; and organ perfusion imaging to accurately predict the response to anti-angiogenetic drugs. The elimination of calcium from vessels with better visualization of the lumen, and from trabecular bone for diagnosis of marrow edema in subtle fractures can easily rival the advantages only inherent to MRI till now. Attenuation of fat decreases at lower energies, so lipid-rich plaques can be differentiated from fibrous plaques.

Low-dose scans, with iterative reconstructions, are being extensively used for lung cancer screening, for detecting and characterizing lung nodules, and can be used concomitantly for coronary calcium scoring and lung emphysema distribution in heavy smokers for a more comprehensive counseling.

The upcoming FFR-CT using complex mathematical calculations of myocardial mass for estimation of coronary blood flow gradient across a stenotic segment, and 3-D printing of the volume-rendered images will revolutionize the world of CT dramatically. The optimum utilization of such high-end expensive scanners (approximately Rs. 7-10 crore) can at present be justified only in tertiary care hospitals.

Dr Anurag Yadav
Consultant Radiologist,
Sir Ganga Ram Hospital, New Delhi

Sudip Bagchi, Vice President-Radiology, Schiller Healthcare India Private Limited
Industry Speak
Mobile Stroke Unit - An Innovation in Pre-Hospital Stroke Treatment

Indian Council for Medical Research (ICMR) states that a person suffers from a brain stroke every three seconds in India and a death is reported every 3 minutes. This is a rather alarming statistic and a very important one. This statistic reiterates how crucial it is for such patients to have access to timely treatment, failing which it leads to loss of life or disability.

Brain stroke patients need to be taken to the hospital in the first hour - golden hour - of getting the stroke. During this time, there is a four-and-a-half hour window for treatment, which needs to be administered to the patient on an urgent basis.

In cases where treatment is delayed, millions of neurons are damaged and higher functions of the brain are affected resulting in brain damage. This is where a mobile stroke unit (MSU) provides pre-hospital stroke treatment to the patient. The MSU is a specialized ambulance that consists of a CT scanner and laboratory equipment essential for the diagnosis of stroke. It needs a dedicated nurse, a physiotherapist and an interested physician, and a CT scan unit. With the help of telemedicine, the medical staff present in the unit can send the CT images and videos of the patient to the hospital where experts can support in diagnosis and treatment management. Patients lose no time during transport to the hospital, as a spot diagnosis and thereafter an immediate treatment can be initiated because of the MSU.

Neurologists have often pointed out that stroke is a medical emergency where time is critical for saving the patients' brain and lives. Using specialized mobile stroke units to assess and treat suspected stroke patients during emergency has considerably reduced the time taken by doctors to decide on the appropriate treatment. In most cases of stroke, the earlier the thrombolytic treatment is given, better is the outcome.

Sudip Bagchi
Vice President-Radiology,
Schiller Healthcare India Private Limited

10 Diagnostic Imaging Trends for 2018



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