Using the Mouse

Working with images and series in iSite depends heavily on the mouse. A link to the Mouse Control Reference Sheet has been provided for your convenience in the navigation bar above. A recommended, short tutorial on using the mouse is also provided via the link above.

iSite was designed to be most effective using a standard three-button mouse with a wheel. If you currently work with a two-button mouse, a list of shortcut keys has also been included in the tutorial and in the reference sheet. It is recommended that you keep a copy of this sheet handy until you have familiarized yourself with the various mouse controls.

Image Adjustment Controls

iSite allows you to adjust many important factors in images and series for optimum viewing. For detailed instructions, please see both the iSite Features Reference Sheet and the following section on the Pop-Up Menu. You can manipulate images and series in the following ways:

• Window Width and Window Level:
  
  You can adjust the window width and window level in an image for optimal viewing or to highlight certain details for better visibility. Click the left mouse button and drag the cursor horizontally, in one fluid motion, across the image to increase or decrease the Window Width. Click the left mouse button and drag the cursor vertically, in one fluid motion, across the image to increase or decrease the Window Level. Please note that the cursor will not be visible while you are dragging. 
  
  Other Window Width and Window Level features, such as WW/WL presets, are available from the right-click pop-up menus. For information on these features, please click here. 
  

• Zooming & Panning:
  
  You can zoom in and out of the image or series, and can pan around zoomed  images, viewing detailed portions in smaller windows. To zoom into or out of plain film images, scroll the mouse-wheel. To pan, hold down the mouse-wheel and drag the mouse. Multi-slice images such as MR, CT, XA and US can be zoomed to a factor or 400%. CR's and other plain-film images can be zoomed to 1600%. 
  
  Other zooming features, such as preset zoom factors and interpolation preferences, are available from the right-click pop-up menus. For more information on these features, please click here.
  

• Viewing Slices in Multi-slice Series:
  
  Multi-slice series from MR, CT, XA, US or other multi-slice modalities can be cined and looped. You can scroll through the slices in a series either one-by-one (Cine mode) or rapidly (Fast Cine). For a frame-by-frame review, slowly scroll the mouse-wheel. For rapid review, hold down the mouse-wheel and drag the mouse forward or backward. You can also cine through series by using the Up Arrow and Down Arrow buttons. For fast cine, hold the buttons down. For more information on Cine and Fast Cine with CT's and MR's, see the iSite Features Reference Sheet.
  
  Other cine features, such as global stacking of all series in an exam and playing sliced in a loop, are available from the right-click pop-up menus. For more information on these features, please click here.

Expanding Images and Series

You can expand images and series into larger floating views by double-clicking the desired image or series, as shown below. You may use the same mouse and keyboard controls with floating windows as you can with normal views in exam rows.

Expanded Image Overlay Information

All expanded image windows have text overlay with the following default fields: Lossy Compression Indicator, Current FPS (frames per second, multi-slice series only), Desired FPS (multi-slice series only), Zoom Factor, Key Image Indicator and Link Indicator. All other overlay content is set by your iSite System Administrator. A complete list of screen overlay information options is seen below:

• Patient: Name, MRN, Birth Date, Sex, Age
  
  

• Exam: Accession, Referring Physician Name, Procedure Code, Procedure Description
  
  

• Study: Date, Time, Description
  
  

• Series: Modality, Description, Body Part, Series Number, Institution Name, Patient Position
  
  

• Images: Image Type, Acquisition Date, Acquisition Time, Instance Number, Images in Acquisition, Acquisition Number, Spacing Between Slices, Slice Thickness, Slice Location.
  
  

• CT: KVP, Scan Options, Exposure Time, X-ray Tube Current, Gantry/Detector Tilt, Generator Power
  
  

• MR: Scanning Sequence, Sequence Variant, Scan Options, Repetition Time, Echo Time, Echo Train Length
  
  

• Calculated: Window Width, Window Level, Number of Images in Window, Page Number (Printing), Total Pages (Printing), Image Number (in Window), Link Status, Key Image, Zoom Factor, Positioner Primary Angle, Positioner Secondary Angle, Current Frame Rate, Desired Frame Rate, Number of Bits.

Window Shades

Expanded windows can be minimized to window shades by double-clicking on the window's top margin. To re-enlarge the window, double-click the image margin.

Resizing Image Windows

     
Expanded images, with the exception of full-screen windows, can be resized to fit your viewing needs. To resize a window horizontally or vertically, place your mouse pointer on the margin you wish to resize. To diagonally resize the window, place the mouse pointer in one of the image window's corners. The pointer will change to a resize cursor. Click and drag the mouse until you have resized the window to your liking.

Using the CT Scout View

When available, CTs are displayed with a Scout View. As seen in the images above, the horizontal CT slices of the  series are cross referenced to the first image, the CT Scout View. The horizontal line, an interactive navigation bar, running across the Scout Views indicates the transverse or axial views of the CT slices. All of the images above are linked and, by clicking and dragging the Scout Views' navigation bars, the two series of slices will move in synch. Conversely, when the slices are cined, the interactive navigation bar will move in synch. Please note that, if several corresponding series are present in the exam, the CT Scout View will display more than one navigation bar, as seen in the second CT series (Acc#4135625). 

CT Scout Views may or may not be initially displayed when you first use iSite Enterprise. This setting is in your Preferences section. To learn more about setting this preference, please click here. 

To toggle between showing CT Scout Views and not showing them, right-click a CT exam's margin and choose the "Show/Hide CT Scouts" option from the pop-up menu.

Using the MR Scout View Function

Selecting a Scout Image

Like the CT Scout View Function, the MR Scout View uses one image as a navigational tool for one or more series in an exam row. As there are no pre-set scout images, you will have to select the one that you wish to use as a scout image. Right click on that image and select the "Show Scout Lines" option from the pop-up menu.

Navigating Through MR Slices

The image you have selected will be will be outfitted with interactive navigation bars in the form of horizontal and vertical navigational coordinates. As with the CT Scout View, the horizontal MR slices in the first and third series are cross referenced to the selected scout view. The horizontal bar running across the scout view indicates the transverse or axial views of the MR slices and the vertical bar indicates their frontal or coronal views. All of the images above are linked and, by clicking and dragging the scout view's navigation bars, the related series of MR slices will move in synch. Please note that, if several corresponding series are present in the exam, the MR Scout View will display multiple navigation bars. 

To remove the scout lines, right-click the Scout View and deselect the "Show Scout Lines" option from the pop-up menu.

Image Pop-Up Menus

Right-clicking an image or series opens a modality and exam specific pop-up menu, such as the MR pop-up menu seen below.

 

The image pop-up menus provide access to many important image analysis tools, a detailed list of which can be found below. Please note, because menus are modality-specific, certain features are only available with certain types of images.

The menu items are:

• Window Width/Level: iSite will use the optimal  Window Width/Level setting as the initial value. The submenus of this item include Default Window/Level, Modality Default and Histogram Calculation and may contain other custom Window Width/Level values if your iSite System Administrator has created them. 
  
  If you are viewing a CT, you will see the CT Window Level presets, as seen below.
  
  
  
    This function allows you to choose from one of several preset window width and window level settings that have been found to be effective for viewing various types of exams. The preset options are configured on a site-specific basis and can  include: Abdominal, Chest, Liver, Brain, Bone, and Lung.
  
  Please note that you can quickly select one of these preset CT WW/WL settings by placing your mouse over the CT in question and clicking the corresponding number. For example, clicking "3" would display the CT with the "Brain" WW/WL setting. Up to ten options can be selected if present (ie. 1, 2, 3, 4, 5, 6, 7, 8, 9, 0).
  
  

• Measurement:  The measurement tools "Ruler," "Angle," "Region of Interest," and "Freehand ROI" allow you to indicate and measure specific areas of an image. The Point Value tool is used for measuring the Window Width and Level value of a single pixel 
  
  

Ruler


To initiate a Ruler Measurement, choose the ruler option from the pop-up menu. Click on a point from which you want to measure and then drag the cursor to the second point, as in figure 1. A box next to the ruler will indicate the measurement of the span in millimeters or pixels, depending on the DICOM information available. The ruler measurement tool has the unique feature of displaying a letter next to each measurement. This feature allows you to place the measurement display anywhere in the image, as seen in figure 4. This naming convention is image-specific, meaning that you can have an "A", "B" or "C" in different images. These letters will be preserved in If you want to move the entire ruler without repositioning either end, click anywhere on the ruler and drag it to the new location, as in figure 2. If you want to reposition either end of the ruler, click on that end and drag it to the new location, as in figure 3. You can reposition the end-points of the ruler at any time, as in figure 4.  

          

        

Angle


To initiate an Angle Measurement, choose the angle option from the pop-up menu. Click on the point that you want to serve as the angle's endpoint, move the cursor to a second point (the angle's apex) and click again. To complete the angle, move the cursor to the second endpoint and click again. The resulting, complete angle is shown in figure 1. A box in the angle will indicate the measurement of the angle  in degrees. If you want to move the entire angle without repositioning either end-point, click on the center box and drag it to the new location, as in figure 2. If you want to reposition either end of the angle tool, click on that end and drag it to the new location, as in figure 3. The arms of the angle can be fully articulated by clicking anywhere on them and dragging them to a new location as seen in figure 4.

 

          

Region of Interest


To initiate the measurement of a Region of Interest, select "Region of Interest" from the pop-up menu. Click on a point from which you want to measure and then drag the cursor so as to include the region you are interested in, as in figure 1. A circle will delineate the region and a box next to the region will indicate its area in centimeters squared or in Hounsfield units and centimeters squared, if the image you are viewing is a CT. To move the entire region without altering its size, click on the central box and drag the region to the desired location, as in figure 2. The region can be resized by clicking and dragging the box on the circle's perimeter so as to increase or decrease the area of the region, as in figure 3.  PLEASE NOTE: If iSite compression is engaged, the Hounsfield unit measurements will not be accurate unless the image is being viewed at full fidelity. Furthermore, if the image is not being viewed at the highest available resolution, the value displayed by the ROI tool will include the tilde (~) symbol to indicate that the value is an approximation. 

        

Freehand ROI


The Freehand ROI tool is similar to the Region of Interest tool. To initiate the Freehand Region of Interest tool, right-click on an image or series and select the "Freehand Region of Interest" option "Measurement" section of the pop-up menu. Using your cursor, left-click and drag the cursor to enclose the desired area, as seen in Figure 1. The shape your outline can be as complex as necessary with the only restriction that your lines must not intersect. Release the left mouse button when you have finished the outline. iSite will display the enclosed area of the outline in centimeters squared or Hounsfield units for CTs. Any portion of the outline can be selected and dragged to adjust the outline's contours as seen in figure 2. The outline can also be dragged to any part of the image by clicking on the box next to the end-points of the outline, clicking and dragging to the desired location, as seen in Figure 3. 

Point Value 

This feature gives the luminance value for single pixels of the original DICOM image. In other words, the value given is not related to what is being displayed on your screen. Rather, it is the value for a reference point which is mapped to the original DICOM image. Point values for CT's are displayed in Hounsfield units. All other values are displayed in mean units with standard deviations. 

To use this feature, select the "Point Value" option from the Measurements sub-menu, as seen below.

When you select this option, screen overlay text will appear at the bottom of the image. This text will read "Point Value:" followed by a number that will change as you move your cursor over the image. Clicking the image will disable the "Point Value" display.

Measurement Palette

If you will be making numerous measurements of an image, iSite Radiology provides a floating Measurement Palette that will streamline your work. To use the Tool Palette, select the Measurement Palette option from the Measurement submenu in the pop-up menu, as seen below.

 The floating Measurement Palette, shown below, will appear. 

From left to right, the tools are the ruler, angle, region of interest and the freehand region of interest. To use a tool, click the corresponding button and then place your cursor over the image you wish to measure. Only one tool can be selected at a time.

The Measurement Palette can be dragged to any location on your screen. Click the close button to close the Palette. You can also toggle the measurement tool off and on by hitting Control-key+M on your keyboard.

Calibrate Image

This feature allows you to calibrate the image on your screen for certain known measurements. Select the Calibrate Image option from the Measurements sub-menu as seen below.

After selecting "Calibrate Image" place your cursor at the end-point of a known distance and then drag to the end of the known distance. When you release your mouse button, iSite Enterprise will display the following dialog:

Enter the length of the known distance in millimeters and click the "OK" button. From now on, all measurements or distance and area will be based on the newly defined scale. In addition, the interactive, scaled rulers will be resized.

Ultrasound Measurements

There are two types of ultrasound image, B-mode and B/F-mode. B-mode is a typical grayscale ultrasound while B/F includes superimposed Doppler or other color-coded information. Both of these types of ultrasound are measured in the exact same way, using the grayscale information as a guide. 

Default units of measurement depend on what is received from the scanner itself. To set up your own measurement units, you can use the calibration tool with the calibration overlay from your scanner, if present. For more information on using the "Calibrate Image" tool, please click here.

There are a few instances when ultrasound measurement may not be possible. iSite 3.2 supports length measurements on ultrasounds for most cases. Ultrasound is a complex modality and frequently contains more than just image data such as EKG, etc. For a technical explanation of specific instances when US cannot be measured using iSite Enterprise, please see below.

In some types of ultrasound, the DICOM data actually defines different regions on the image and defines the type of measurement in the X and Y direction. To perform measurements in 3.2, the image must meet the following criteria:

1. Only one region that has measurement of type "centimeter" in both the x and y directions. We need at least one region of this type, otherwise we don't know the calibration information to perform the measurement with. Also, we don't support images that have multiple cm x cm regions because the product doesn't support images with different calibration regions.
   
   

2. No spectral regions. Length measurements on spectral images is not a common use case, so we do not permit it.
   
   

3. No M-mode regions. Length measurements on M-mode images is not a common use case, so we do not permit it

To see if we support length measurements for a particular US exam, open the metadata for that exam and look for the following:

• US Calibration Sequence tag "0018,6011" - if this isn't present, the US equipment isn't sending us the necessary information required for measurements.
  
  

• Under that tag, look at all the items. The tag "0018,6012" identifies the type of region. For the last digit, a value of "2" equals M Mode and a value of "3" equals Spectral Mode. If the last digit of the tag is either "2" or "3", you will not get measurements.
  
  

• Under that tag, one of the items must have the tag "0018,6014" with values 1 (tissue) or 2(color flow). If you don't find one, you can't do measurements
  
  

• Under that tag, look for tag "00186024" and "00186026", they must both be present with value "3" (CM measurement) and there can only be one
  
  

• Under that tag, look for tag "0018602c" and "0018602e", they must both be present and that is what we use to calibrate length measurement

 

• Annotations:
  
  
  The Annotation feature is a quick and useful tool for annotating images. There are several annotation styles that can be applied including line, circle, arrow, triangle, text and freehand as well as custom annotation styles.
  
   
  
  To apply the line, arrow, triangle or freehand tools select the option from the pop-up menu, click the image where you wish to initiate the annotation and drag your mouse cursor as desired. When you release the mouse button, the annotation will be complete. To use the text annotation, select the "text" option from the pop-up menu and click the image at the point where you wish to place the text annotation. A dialog box will appear. Type your annotation into the textbox and click the "OK" button. Your text will be place on the image. All annotations can be moved by clicking anywhere on the annotation and dragging it to the desired location. 
  
  The style of annotations can be changed by right-clicking any annotation. If you are configuring any type of annotation except for text annotations, you'll see the Edit Line Style dialog, as below. Otherwise, you will see the "Edit Font" dialog, also pictured below.
  
  Configurable options include font size (for text annotations), text color, line color, line size and line style. When you have finished customizing the annotation styles, click the "OK" button to save your changes and return to reading. Annotation styles can also be created and personalized by the iSite System Administrator. If you have any questions regarding custom annotation styles, please ask your iSite System Administrator.
  
                    
  
  Spine Labeling: The spine labeling tool allows you to place markers at each vertebra or vertebral disc. The spinal tool is only available on MR series.  To engage the tool, select "Spine Labeling" from the "Measurement" section of the pop-up menu, as shown in figure one. A dialog will appear, as shown below in figure two. 

  

  

  There are two ways to label the image. The first is by  clicking on the desired label from the dialog and then click the location in the image where you wish the label to be placed. The label will be placed, as shown in figure three. The second, faster way of using the spinal labeling tool is to highlight the label that you wish to begin with and begin clicking on the image. At every click iSite Radiology will place a label from the list. The order of the automatic labeling can be changed from ascending to descending by clicking the check box at top. Labels can by hidden or deleted by clicking the buttons at the bottom of the dialog. To delete an individual label, click that label with your mouse and hit the "delete" key on your keyboard. The end result will look like the example below.

  

  Labels, as well as any other annotation you might use for the image, will be saved when mark an exam "read' or upon saving a particular configuration as a presentation state.

• Image Processing
  
          Invert Image: This function reverses the black and white coloration of the highlighted image.

Interpolation Schemes: Located in the Image Processing sub-menu, iSite Enterprise provides three types of interpolation schemes for you two choose from:  Pixel Replication, Bilinear Interpolation and Bicubic Interpolation. A checkbox, as seen above, shows which scheme is in use for interpolation. 

Of the three schemes, Pixel Replication is the fastest while Bicubic is the most accurate. 

When you use the pop-up menu to select an interpolation scheme, the scheme is selected only for that image or series. 
        

• Global Stack Mode (only in expanded floating windows): This feature allows you to compile all images and series into one single series, available for viewing in a single floating window. Cine through all images and series as if you were cineing through a singe stack.

• Play Cine Loop (series only): This feature allows you to play a continuous loop of a image series. For example, if a series has 30 slices, they will be played sequentially from 1 to 30 and will repeat endlessly. The loop can be stopped by clicking on the series. You can change the direction of the loops (from ascending to descending or vice versa) by scrolling your mouse wheel towards and away from you or by clicking the arrow keys. 
  
  The FPS (Frames per Second) rate is displayed in the lower right-hand corner. To increase or decrease the FPS rate, hold down the wheel button and drag the mouse towards or away from you. The maximum FPS rate is 30 and the minimum is 1. 
  
  For modalities such as XA, US, PET and NucMed, iSite Enterprise will detect multi-frame series and will automatically engage the "Play Cine Loop" when the series is displayed in an expanded window. XA images will have additional screen overlays added to them consisting of the primary and secondary positioner angles. These will be displayed as "LAO: __, CAUD: __"
  
  There are several key-commands that can be initiated while a cine loop is playing. Cine Loop can also be initiated by hitting the "C" key. Hitting the "C" key will toggle the feature on and off. F7 will allow you to view the previous series in the exam while continuing to Cine Loop. F8 will show you the next series. Right-clicking the image will stop the Cine Loop.

• Flip: This function allows you to flip the selected image horizontally (around the y-axis) or vertically (around the x-axis).

• Rotate: This function allows you to rotate the selected image or series in 90-degree clockwise or counter-clockwise increments.

• Sort (Series only):
  
  The feature has four options, Table Position Ascending, Table Position Descending, Image Number Ascending and Image Number Descending, which allow you to change the sort order of the series you're reviewing from ascending to descending according to your sorting preferences.

• Linking:
  
  
  This function allows you to link two or more images and zoom, pan or view slices simultaneously. To initiate a  link, right-click the desired image and then select "New Link." Then right-click the second image and select "Join Link."  The link symbol ( ) will appear in the upper left-hand corner of each image as it is linked. When you link two series from the same exam, iSite will order the slices so that both series windows are displaying the same slice. Please note that the slice location that will take precedence is that of the first series.
  
  To unlink an image, highlight that image and select "Leave Link." To unlink all linked images, select "Unlink All" from the pop-up menu. Functions such as flip, invert, rotate and WW/WL adjustment remain independent. Also, images can be temporarily disconnected from any links and manipulated independently by pressing the Shift Key while performing mouse or keyboard actions except when the images are from the same point of reference and from the same exam. Please note that CT Scout Views can only be linked to plain film images such as CRs.
  
  If more than one series in the same exam has the same orientation and the same frame of reference, you will be able to link them all simultaneously using the Link All Axial, Link All Sagital, Link All Coronal or Link All Oblique option, depending on the orientation.
  
  Along with selecting the "New Link" function from the pop-up menu, cloned or expanded windows of CTs and MRs with the same frame of reference and the same orientation can be linked by juxtaposing their lateral margins (see the Clone Pop-up View section below).
  

• Show Scout Lines (Series only):
  
  
  Use this toggle function to designate the highlighted MR image as a MR Scout View. Please see the section on MR Scout Views for more information.

• Multi-Image Mode  (for Image Series)

Image series that have been double-clicked into expanded windows can be configured using the multi-image mode. This feature allows you to reconfigure the expanded window in one of  nine different column/row configurations. These configurations include, in column/row notation, 1:1, 1:2, 1:3, 2:2, 2:3, 1:3, 3:3 (equal to the previously available nine-on-one option), 3:4 and 4:5. A graphic illustration of the various layouts can be seen below. 

 

One image slice would be presented in each section. To access Multi-Image Mode, right-click on the desired series and then select the "Multi-Image Mode" option from the resulting pop-up menu, as shown below.

• Create Popup:
  
  
  This function duplicates the contents of  the selected  image or  series in a new, expanded window. Cloned windows of CTs or MRs can be automatically linked by juxtaposing their lateral margins. Please see the Linking section above for further information.  

• Save:
  
  
  The Save option allows you to save and copy the current image or image window in two different ways, either as an image file or to the Windows Clipboard, as seen below.
  
  
  
  If you choose either the "Window to Clipboard" or "Window to File" options, the image will be saves with all of it's accompanying screen overlay information and any measurements or annotations that may be present. Selecting the "Image to Clipboard" or "Image to File" options will only copy the image itself. 
  
  Images that are saved can be preserved in JPG, GIF, TIFF, BMP and PNG formats. 

• Print to paper
  
  
  This function prints the selected image to your default printer. The following dialog will appear
  
  
  
  Select the desired printer from the drop-down menu. Configure your settings as desired, selecting the number of copies you wish to print, any image skip pattern (every other image, etc.), the print configuration, the print annotations option and the print key images options. For example, the "Print unstacked images on separate sheets" option allows you to print different plain film series on separate sheets, regardless of how much space is available. If you are printing CT or MR series, as seen above, you can include the Reference Frame by checking the "Print Reference Frame" box. Next, select the desired print-range, whether the entire exam or the selected window. You can decide to trim images from the front, back or both if desired. The dialog will display the number of pages that are necessary to print the configuration you've selected. Click "OK" when you've finished and the exam or image that you've chosen will be printed.
  
  Please note, if you wish to print only one image in a series (one slice of an MR exam), navigate to that slice and click the space bar to mark that image as a "key image." Right-click the series and select "Print to paper" from the pop-up menu. The dialog seen above will appear. Check the "Print key images only" checkbox (grayed out in the image above) and then click "OK". Only the key images will be printed.

• Zoom Presets:
  
  These options, shown in the menu below, allow you to view the image or series at a preset magnification.

• 3D (series only)
  
  iSite Enterprise's 3D imaging allows you to see the 2 alternate views of a series by compiling the information form the present series. For example, if the 3D feature is engaged for an axial view, as seen below, the resulting compilation will be of the sagital and coronal views.
  
  Please note that this is not a fully supported feature. It has been included in iSite Enterprise 3.2 for purposes of testing and receiving user feedback.