The Gamma Knife is a non-invasive stereotactic radiosurgery system used for treatments of deep targets in the brain. Accurate patient positioning is needed for precise radiation delivery to the target. The two latest versions of the Gamma Knife allow fractionated treatment by co-registering Cone-beam computed tomography (CBCT) images of the patient's position in the Gamma Knife with a diagnostic magnetic resonance (MR) image used for treatment planning. However, CBCT images often suffer from artifacts that degrade image quality, which may result in less accurate co-registration. This thesis project investigates the potential of a new reconstruction framework developed by Elekta, which incorporates scattering correction and noise filters, for the reconstruction of Gamma Knife CBCT images. The performance of the new reconstruction framework, along with its noise filter and scatter correction, is quantified using image quality metrics of phantoms, including contrast, uniformity, spatial resolution, and CT-number accuracy. Additionally, brain CBCT images of five patients are co-registered with their diagnostic MR images, and the mean target registration error is measured. The results indicate that the new reconstruction framework, without using scatter correction and noise filtering, performs equally well as the current framework in reconstructing Gamma Knife CBCT images, as it achieved similar image quality and co-registration accuracy. However, when the scatter correction was used, there were improvements in image uniformity and CT-number accuracy without compromising spatial resolution. Additionally, the introduction of a noise filter resulted in an improved contrast-to-noise ratio and low contrast visibility with minimal compromise of spatial resolution. Despite these image quality enhancements, there were no consistent improvements in co-registration accuracy, indicating that the co-registration is not sensitive to scatter or noise artefacts. / Gammakniven är en medicinteknisk apparat som används för icke-invasiv stereotaktisk strålkirurgi vid behandling av djupa mål i hjärnan. För att uppnå precision i strålbehandlingen krävs noggrann patientpositionering. De två senaste versionerna av Gammakniven tillåter fraktionerad behandling genom att co-registrera cone-beam computed tomography (CBCT)-bilder av patientens position i Gammakniven med en diagnostisk magnetresonans (MR)-bild som används för behandlingsplanering. Tyvärr lider CBCT-bilder ofta av artefakter som kan försämra bildkvaliteten och därmed minska precisionen i co-registreringen. Detta examensarbete undersöker ett nytt rekonstruktionsramverk som utvecklats av Elekta. Det nya rekonstruktionsramverket och dess tillhörande brusfilter och spridningskorrigering utvärderas för rekonstruktion av Gammaknivens CBCT bilder med hjälp av bildkvalitetsmått för fantomer, såsom kontrast, uniformitet, spatial upplösning och noggrannhet i CT-nummer. Dessutom co-registreras CBCT-bilder från fem patienter med deras diagnostiska MR-bilder, och det genomsnittliga registreringsfelet mäts. Resultaten visar att det nya rekonstruktionsramverket, utan användning av spridningskorrigering och brusfiltrering, presterar lika bra som det nuvarande ramverket för rekonstruktion av CBCT-bilder från Gammakniven. Båda ramverken ger liknande bildkvalitet och noggrannhet i co-registreringen av bilderna. Vid användning av spridningskorrigering observerades förbättringar i uniformiteten och noggrannheten i CT-nummer utan att den spatiala upplösningen försämrades. Införandet av brusfilter resulterade i ett förbättrat kontrast-brus-förhållande och synlighet av svaga kontrastskillnader med endast lite avkall på den spatiala upplösningen. Trots dessa förbättringar i bildkvaliteten observerades ingen konsekvent förbättring av noggrannheten i co-registreringen av bilderna, vilket tyder på att co-registreringen inte påverkas av spridnings- eller brusartefakter i stor utsträckning.

BACKGROUND: Magnetic resonance imaging and echo color Doppler (ECD) scan techniques do not accurately assess the cerebral venous return. This generated considerable scientific controversy linked with the diagnosis of a vascular syndrome known as chronic cerebrospinal venous insufficiency (CCSVI) characterized by restricted venous outflow from the brain. The purpose of this study was to assess the cerebral venous return in relation to the change in position by means of a novel cervical plethysmography method. METHODS: This was a single-center, cross-sectional, blinded case-control study conducted at the Vascular Diseases Center, University of Ferrara, Italy. The study involved 40 healthy controls (HCs; 18 women and 22 men) with a mean age of 41.5 +/- 14.4 years, and 44 patients with multiple sclerosis (MS; 25 women and 19 men) with a mean age of 41.0 +/- 12.1 years. All participants were previously scanned using ECD sonography, and further subset in HC (CCSVI negative at ECD) and CCSVI groups. Subjects blindly underwent cervical plethysmography, tipping them from the upright (90 degrees ) to supine position (0 degrees ) in a chair. Once the blood volume stabilized, they were returned to the upright position, allowing blood to drain from the neck. We measured venous volume (VV), filling time (FT), filling gradient (FG) required to achieve 90% of VV, residual volume (RV), emptying time (ET), and emptying gradient (EG) required to achieve 90% of emptying volume (EV) where EV = VV - RV, also analyzing the considered parameters by receiver operating characteristic (ROC) curves and principal component mathematical analysis. RESULTS: The rate at which venous blood discharged in the vertical position (EG) was significantly faster in the controls (2.73 mL/second +/- 1.63) compared with the patients with CCSVI (1.73 mL/second +/- 0.94; P = .001). In addition, respectively, in controls and in patients with CCSVI, the following parameters were highly significantly different: FT 5.81 +/- 1.99 seconds vs 4.45 +/- 2.16 seconds (P = .003); FG 0.92 +/- 0.45 mL/second vs 1.50 +/- 0.85 mL/second (P < .001); RV 0.54 +/- 1.31 mL vs 1.37 +/- 1.34 mL (P = .005); ET 1.84 +/- 0.54 seconds vs 2.66 +/- 0.95 seconds (P < .001). Mathematical analysis demonstrated a higher variability of the dynamic process of cerebral venous return in CCSVI. Finally, ROC analysis demonstrated a good sensitivity of the proposed test with a percent concordant 83.8, discordant 16.0, tied 0.2 (C = 0.839). CONCLUSIONS: Cerebral venous return characteristics of the patients with CCSVI were markedly different from those of the controls. In addition, our results suggest that cervical plethysmography has great potential as an inexpensive screening device and as a postoperative monitoring tool.