The invention concerns a system and method for estimating one or more haemodynamic perfusion parameters. The invention is based in particular on Perfusion Weighted Magnetic Resonance Imaging (PW-MRI) techniques or Computed Tomography (CT). These techniques make it possible to quickly obtain precious information on the haemodynamics of organs such as the brain or heart. This information is particularly crucial for a practitioner seeking to establish a diagnosis and to make a therapeutic decision in the emergency treatment of pathologies such as strokes.
In order to implement such techniques, use is made of a nuclear magnetic resonance imaging apparatus or computed tomography apparatus. This delivers a plurality of sequences of digital images of a part of the body, in particular of the brain. The said apparatus applies for this purpose a combination of electromagnetic waves at high frequency on the part of the body in question and measures the signal re-emitted by certain atoms. The apparatus thus makes it possible to determine the chemical composition and therefore the nature of the biological tissues at each point (or voxel) of the volume imaged.
Image sequences are analysed by means of a dedicated processing unit. This treatment unit in the end delivers to a practitioner an estimation of the haemodynamic parameters from the perfusion images, by means of a suitable human-machine interface. The practitioner can thus make a diagnosis and decide on the therapeutic action that he judges suitable.
Nuclear magnetic resonance perfusion or computed tomography images are obtained by injecting a contrast agent (for example a gadolinium salt for magnetic resonance imaging) intravenously and recording its bolus over the course of time at each voxel of the image. For reasons of concision, the indices x, y, z for identifying the voxels will be omitted. For example, instead of denoting as Sx,y,z(t) the signal for a voxel of coordinates x, y, z, it will be denoted simply S(t). It will be understood that the operations and calculations described hereinafter are generally performed for each voxel of interest, so as to obtain in the end images or maps representing the haemodynamic parameters that it is sought to estimate.
A standard model makes it possible to connect the intensity of the signals S(t) measured over a time t, at the concentration C(t) of the said contrast agent.
For example, in perfusion computed tomography, the signal for each voxel is directly proportional to the concentration: S(t)=α·C(t), α being a non-zero constant.
In nuclear magnetic resonance perfusion imaging, there exists an exponential relationship S(t)=S0·e−k·TE·C(t) where S0 is the mean intensity of the signal before the arrival of the contrast agent, TE the echo time and k is a constant dependent on the relationship between the paramagnetic susceptibility and the concentration of the contrast agent in the tissue. The value of the constant k for each voxel being unknown, this is fixed at an arbitrary value for all the voxels of interest. In this way relative rather than absolute estimations are obtained. The said relative information remains relevant since the concern is mainly with the variation in these relative values in space.
The concentration C(t) can then be expressed itself by the standard perfusion convolution model C(t)=BF·Ca(t)R(t) where Ca(t) is the concentration of the contrast agent in the artery supplying the tissue volume in a voxel (Arterial Input Function—AIF), BF is the blood flow in the tissue volume, R(t) is the residue function of the transit time in the tissue volume and designates the convolution product.
Starting from an experimental signal S(t), known methods consist of estimating first of all S0 by taking for example its mean before the contrast agent arrives. In this way an estimation is obtained of the concentration of the contrast agent C(t) by means of the equation
Knowing C(t) and the arterial input function Ca(t), it is then possible to obtain, by digital deconvolution, the function BF·R(t) under the standard perfusion model.
Subsequently, it is possible to obtain an estimation of the parameter BF since R(0)=1 by definition. In addition an estimation of the mean transit time in the tissue is obtained, since
It is also possible to obtain an estimation of the blood volume (BV) in the tissue by means of the equation BV=BF·MTT.
According to the prior art, it does not appear to be possible to design a processing unit able to implement a method for deconvolution of the standard perfusion model C(t)=BF·Ca(t)R(t) without needing to provide an arterial input function Ca(t). This because the said model is expressed in the form of a single equation and there exist two unknowns.
Techniques have therefore been envisaged for fixing one or more arterial input functions Ca(t) and thus make possible the deconvolution of concentration curves C(t) in order to estimate the haemodynamic parameters.
To estimate haemodynamic parameters of an organ such as the human brain, according to a first technique, a global arterial input function is chosen manually by a practitioner. The choice may relate for example to the sylvian artery contralateral to the pathological hemisphere in the case of perfusion imaging of the brain. It is possible to obtain as a variant a global arterial input function by means of supplementary measurements, for example optical.
Though it makes it possible to obtain signals with high signal to noise ratios, this technique nevertheless causes numerous drawbacks. First of all, it requires human intervention and/or additional measurements. This may be highly detrimental in an emergency clinical situation. In addition, the procedures and the final results are difficult to reproduce. Next and especially, the global arterial input function does not correspond to the local arterial input functions for the tissues of interest. It differs in terms of delay since the local arterial input functions are usually late compared with the global arterial input function taken upstream. It also differs in terms of dispersion since the propagation of the contrast agent is slower downstream than upstream. However, it is known that such phenomena have a considerable influence on the estimations of the haemodynamic parameters. In particular, according to this first technique, an estimation of the true mean transit time MTT between the local arterial input function and the venous output function is not obtained. There is obtained only a mean transit time between the global arterial input function and venous output function. In order to attempt to quantify these clashes with respect to the standard perfusion model, some have introduced new description parameters, such as a parameter TMAX=argmaxR(t), even though the said parameters do not intervene in the standard perfusion model. Other methods tend to minimise the influence of these clashes on the estimation of the haemodynamic parameters but introduce new unknowns in the global problem.
According to a second technique a global arterial input function is obtained automatically from perfusion images by means of signal processing techniques such as data partitioning (clustering) or independent component analysis (ICA). This second technique dispenses with human intervention. However, this approach does not solve the problems of delay and dispersion inherent in global arterial input functions.
According to a third approach, local arterial input functions are produced automatically from perfusion images by means of signal processing techniques and selection criteria. For example, the “best” function in the immediate vicinity of the current voxel for which it is wished to estimate the haemodynamic parameters is sought. The purpose of this third technique is to obtain in the end estimations that are less biased and more precise. Problems of delay and dispersion are, at least partly, dispensed with. However, nothing guarantees a priori and a posteriori that the local arterial input functions thus obtained are relevant approximations of the “true local function” for the voxel of interest. For example, this “true” function might not be situated in the vicinity in question if the latter is too small. The said “true” function could also be confused with another arterial input function if the vicinity in question is too large. Consequently, even if the results can be better than with a global arterial input function, the uncertainties weighing on the local arterial input functions (and consequently on the haemodynamic parameters) remain to major extent.
Whatever the technique employed up until then the deconvolution of the concentration curve by the arterial input function, whether this be global or local (and consequently the estimation of the haemodynamic parameters) is performed using, for example, non-parametric deconvolution methods such as singular value decomposition, Hunt deconvolution in the frequency domain, Tikhonov regularisation, etc.
Methods using parametric and semiparametric physiological models Cα(t,Θα) for the arterial input function and R(t,ΘR) for the complementary cumulative distribution function of the transit time in the tissue, have however been proposed in the literatures. The purpose of the known use of such models is not to supplant the deconvolution operation but to attempt to improve certain results obtained by the non-parametric methods as described previously.
For example, a parametric physiological model Cα(t,Θα) of the local arterial input function, a “mono-Gamma” model, has one component and four parameters
This kind of model was introduced in order to:
Likewise, parametric or semiparametric models R(t,ΘR) of the complementary cumulative distribution function of the transit time in the tissue, have been proposed, among which can be cited:
These models were introduced in order to:
where δ(t) is Dirac generalised function.
The use of such models has made it possible to improve more or less certain estimations of parameters. However, the drawbacks inherent in the fact of fixing the arterial input function, whether this be global or local, remain present.
The invention makes it possible to respond to all the drawbacks raised by the known solutions. It offers rapid, objective and reproducible procedures. The invention does not relate to a diagnosis method as such since a method according to the invention does not encompass all the steps allowing such a diagnosis. In particular, the invention does not concern investigation phases allowing collection of data performed for example by means of a nuclear magnetic resonance imaging apparatus. The invention also does not concern steps of interaction with a human or animal body enabling a practitioner to perform a diagnosis.
However, the advantages afforded by the invention are numerous and significant. The invention may prove to be particularly appreciated in an emergency clinical situation, thus offering to a practitioner an aid for perfecting a diagnosis and making an appropriate therapeutic decision.
Implementation of the invention also enables a researcher to progress in the physical understanding of an organ of a human or animal.
Among the many advantages, the following can be mentioned:
To this end, a method is provided for estimating one or more haemodynamic perfusion parameters of an elementary volume—referred to as a voxel—of an organ, the said method being implemented by a processing unit of a perfusion imaging analysis system, and comprising a step for estimating one or more haemodynamic parameters from perfusion signals S(t), characterised in that the step for estimating the haemodynamic parameter or parameters consists of a joint estimation of the parameters Θ of a global perfusion model comprising:
According to a first example of an application of the invention, such a method may relate to:
According to a second example of an application of the invention, such a method may relate to:
According to a first embodiment, a method according to the invention can be implemented by successive iterations for a plurality of voxels in question.
By way of example, the joint estimation of the parameters Θ of the global perfusion model implemented by the processing unit may be performed by means of the Bayes method or the method of maximum likelihood or the method of non-linear least squares.
According to a preferred embodiment, the method can comprise a step for quantifying the goodness-of-fit of the global perfusion model to experimental perfusion data D=[S(t1), . . . , S(tN)] by a calculation of a probability
of these data given the said model.
Provision may also be made for the method according to the invention to be able to comprise a prior step for choosing a global perfusion model from a plurality.
Thus it is possible for such a method to be able to be implemented iteratively by the processing unit for each global perfusion model known from the said processing unit.
According to the preferred embodiment previously described, provision may then be made for the estimated parameters according to the perfusion model to be delivered, the probability of which, given the data, is the greatest.
Apart from an estimation of one or more haemodynamic parameters, the invention provides for the method to be able to comprise a step for calculating supplementary information in the form of:
The invention provides an embodiment of the method so that it can comprise a step for delivering estimated haemodynamic parameters, or even all other supplementary information that would be associated therewith, to a human-machine interface able to restore the said estimated parameters to a user.
The invention also provides a variant according to which the global perfusion model comprises a third relationship Ψ(Θα)=0 between the parameters Θa of the model of the arterial input function Ca(t,Θa).
The invention also concerns a processing unit comprising storage means, means for communicating with the outside world and processing means, so that:
The invention concerns a variant of a processing unit the means for communicating of which are able to receive from the outside world digital perfusion images from which the processing means determine a perfusion signal S(t) and implement a method for estimating one or more haemodynamic perfusion methods according to the invention.
The invention also provides for the communication means of a processing unit according to the invention to be able to deliver an estimated parameter according to an appropriate format to a human-machine interface able to restore the said estimated parameter to a user.
The invention also concerns any perfusion imaging analysis system comprising a processing unit as described above and a human-machine interface able to restore to a user one or more estimated parameters according to a method in accordance with the invention and implemented by the said processing unit.
Other features and advantages will emerge more clearly from a reading of the following description and an examination of the figures that accompany it, among which:
a and 5b present a typical nuclear magnetic resonance perfusion signal S(t) relating to a voxel of a human brain;
The image sequences 12 could optionally be stored in a server 3 and constitute a medical case 13 of a patient. Such a case 13 can comprises images of different types, such as perfusion or diffusion images. The image sequences 12 are analysed by means of a dedicated processing unit 4. The said processing unit comprises means for communicating with the outside world in order to collect the images. The said means for communicating also enable the processing unit to in the end deliver to a practitioner 6 or to a researcher an estimation of the haemodynamic parameters from the perfusion images 12, by means of an adapted human-machine interface 5. The user 6 of the analysis system can then confirm or invalidate a diagnosis, decide on a therapeutic action that he deems appropriate, go deeper into research work, etc. Optionally, this user can parameterise the functioning of the processing unit 4 by means of parameters 16. For example, he may thus define display thresholds or choose the estimated parameters that he wishes to display.
b illustrates an example of a nuclear magnetic resonance perfusion signal S(t) such as the signals 15 delivered by the pre-processing unit 7 described in relation to
As for
To implement the invention, a parametric or semi-parametric physiological model Ca(t,Θa) of an arterial input function is introduced. Such a model is stored by storage means or programmed in the processing unit 4 of an analysis system as described in relation to
According to a preferred embodiment of the invention, this model is a so-called “tri-gamma” model with twelve parameters, defined by:
In addition, a parametric or semi-parametric physiological model R(t,ΘR) of the complementary cumulative distribution function of the transit time in the tissue is introduced.
In the same way as the arterial input function model, such a model is stored or programmed in the processing unit 4 of an analysis system as described in relation to
By way of example, this complementary cumulative distribution function of the transit time may be a so-called “corrected integral gamma” model with two parameters:
By introducing only parametric or semi-parametric models for the arterial input function and for the complementary cumulative distribution function, the invention makes it possible to obtain very satisfactory results. However, the invention provides a variant for which the precision of the estimation obtained is particularly improved. This is because a standard perfusion model, for example in nuclear magnetic resonance imaging, may be expressed in the following equivalent manner:
λ being a non-zero constant.
Thus, if and are two estimations fitting the theoretical perfusion model to the experimental data, then and
are two other estimations fitting the model just as well to the experimental data for any λ≠0.
In other words, BF and Ca(t,Θa) are determined only to within a multiplicative constant under a standard perfusion model. The Bayes method in particular does however make it possible to obtain satisfactory results since it makes it possible to take account of information where a priori there are available the manipulative quantities that make certain values of said quantities, in particular BF and Ca(t,Θa), more probable. Consequently some values of the multiplying constant λ are themselves more probable, which has the effect of making the problem of estimating the quantities better determined.
However, to make this problem perfectly determined and thus to improve the precision of the estimation of parameters such as BF or Θa, the invention makes provision for introducing an additional constraint Ψ(Θa) on the model of the arterial input function Ca(t,Θa). This third relationship can express for example the preservation of a physical quantity on all of the arterial input functions of interest, such as the total mass of contrast agent circulating in an arterial voxel over time. Particularly advantageously, this constraint is independent of the model Ca(t,Θa) in question.
This constraint may be expressed, in general terms, by a relationship between the parameters Θa of the model of the arterial input function such as Ψ(Θa)=0.
This additional relationship in the form of a constraint on the model of the arterial input function Ca(tΘa) makes it possible to fix, once and for all and for all the voxels in question, the constant λ. This third relationship is stored or programmed in the processing unit 4 of an analysis system as described in relation to
The problem of the joint estimation of the parameters Θ of the constrained global model, in particular BF and Θa, then becomes entirely well determined and posed.
According to a first embodiment of the invention, this constrain Ψ(Θa)=0 can be expressed as:
where C0 is an non-zero arbitrary constant identical for all the voxels of interest.
In the case of the “tri-gamma” model for an arterial input function of parameters Θa=(a, b, c, α0, β0, t0, α1, t1, α2, β2, t2), this constraint on the parameters can be expressed as a+b+c=C0.
This therefore gives the equation: Ψ(Θa)=a+b+c−C0.
Under this constraint, it is thus possible to eliminate one of the three parameters, for example c by posing c=C0−a−b, and come down to a constrained model Ca(t,Θa) with eleven free parameters such that:
According to a second embodiment, the constraint can be expressed as
where Cca(t,Θca) is a component of the model Ca(t,Θa) modelling the concentration of the contrast agent during its first pass and C0 is a non-zero arbitrary constant identical for all the voxels of interest.
In the case of the “tri-gamma” model, this component is simply the first of its three components:
so that the constraint becomes a=C0 that is to say Ψ(Θa)=a−C0.
This can therefore once again amount to a constrained model Ca(t,Θa) with eleven free Parameters such that:
The invention thus makes it possible to amount to a problem of joint estimation of the parameters Θ=(Θa, ΘR, BF, S0, ΘB) in magnetic resonance imaging or Θ=(Θa, ΘR,BF, ΘB) in computed tomography, where ΘB is a parameter vector characterising the measurement noise on the perfusion signal S(t), without having to previously supply or estimate any arterial input function.
The invention is thus based on a constrained model, possibly constrained, comprising:
It will be possible to consider the models respectively of an arterial input function Ca(t,Θa) and of a complementary cumulative distribution function of the transit time R(t,ΘR) to be sub-models of a global perfusion model optionally constrained by the said third relationship Ψ(Θa)=0 between the parameters Θa of the said model of the arterial input function Ca(t,Θa).
By way of example in nuclear magnetic resonance imagining, such a global constrained perfusion model M can be expressed in a form such that:
where designates the convolution product, η is an arbitrarily fixed non-zero constant and BF is the blood flow circulating in the voxel in question.
Likewise, in computed tomography imaging a global constrained perfusion model M can be expressed in a form such that:
where designates the convolution product, η is an arbitrarily fixed non-zero constant, BF is the blood flow circulating in the voxel in question and a non-zero constant.
In relation to
By way of examples, such a processing unit 4 is able to use the method of maximum likelihood methods, the method of non-linear least squares methods or Bayes method.
In order to illustrate a preferred embodiment of the invention, we will consider that:
For a nuclear magnetic resonance perfusion imaging application, the constrained model Ca(t,Θa) is therefore written:
Let ti,i=1,N be the sampling instants and S(ti),i=1,N the intensity of the perfusion signal measured at these instants. The experimental data are therefore D=[S(t1), . . . , S(tN)].
If a white, stationary, additive Gaussian noise of standard deviation σ−=ΘB is assumed and, then the likelihood function or direct probability distribution of the perfusion data D, given all the parameters, is written:
C(t)=η·BF·Ca(t,Θa)R(t,ΘR) is calculated numerically after temporal discretisation or preferably analytically using an approximation for the convolution product of two probability distributions Γ.
Given a prior joint probability distribution of all the parameters given the model p(Θ|M) representing the information available before the experiment on these parameters, an a posteriori joint distribution is obtained by means of the Bayes rule:
From this joint distribution, the method according to the invention makes it possible to obtain 52 the marginal a posteriori distribution of each of the haemodynamic parameters of interest θ such as the blood flow BF−, the blood volume BV or the mean transit time MTT, marginalising all the others. From this marginal distribution, it is finally possible to obtain an estimator of the parameter, for example the Bayes estimator under the quadratic loss function taking the mathematical expectation of this distribution or the most probable value of the parameter (the maximum a posteriori estimator). Thus the invention makes it possible for example to be able to estimate, for any voxel of interest, the blood flow in an organ, an estimation of the blood volume and an estimation of the mean transit time
Optionally, a method according to the invention makes it possible to obtain 52a supplementary information in the form of confidence intervals on estimated parameters and even bets 52b on the said confidence intervals. This supplementary information may be particularly useful, for a user such as a practitioner, and prove to be an additional aid in developing a diagnosis. Using techniques of the art prior to the invention, a practitioner has no idea of the precision of the estimations available to him for each voxel of interest.
For example, for a particular haemodynamic parameter θ, such as the cerebral blood flow θ=CBF, the invention makes it possible to obtain an a posteriori marginal distribution:
and then a Bayes estimator {circumflex over (θ)} of θ under the quadratic loss function L(θ−{circumflex over (θ)}Q)=(θ−{circumflex over (θ)}Q)2:
or the most probable value of the parameter:
The unit 4 can also optionally deduce:
[{circumflex over (θ)}−{circumflex over (σ)}θ,{circumflex over (θ)}+{circumflex over (σ)}θ]
According to one embodiment, the processing unit 4 using a method according to the invention makes it possible to calculate 52b a probability or bet that the parameter is in the confidence interval, for example:
In a variant, the invention provides for the method to make it possible to obtain 53 supplementary information corresponding to the a posteriori joint marginal distribution of the parameters of the local arterial input function for a tissue volume in question, such that:
The invention thus makes it possible to obtain for example a “mean” arterial input function Cα(t,) under the quadratic loss function L(Θα−)=∥Θα−∥2 of joint parameters:
or “the most probable” arterial input function of parameters:
In the same way, the invention provides a variant embodiment for which a method according to the invention comprises a step 54 for calculating a “mean” or “the most probable” complementary cumulative distribution function R(t,).
It is thus also possible to obtain supplementary information in the form of estimations of the theoretical concentration of the contrast agent by C(t,{circumflex over (Θ)}).
According to one embodiment, the invention provides for these arterial input functions or estimated complementary cumulative distribution functions, “mean” or “most probable”, to be able to be compared with the one or those obtained by the approaches prior to the invention or to those obtained from distinct arterial input function or complementary cumulative distribution function models for the purpose of enabling the most relevant models to be selected.
This because it may be advantageous to compare the estimated arterial input functions with the true arterial input function when the latter is known and attempt to minimise the difference between them by introducing more appropriate models if necessary.
In relation to
The dimensions of the typical parametric and semi-parametric modes for the arterial input functions Ca(t,Θa) and the complementary cumulative distribution functions R(t,ΘR) are sufficiently small to be able to be applied to methods of sampling or approximating the a posteriori joint distribution p(Θ|D,M) and a marginal posteriori distribution such as Markov Chain Monte-Carlo methods or the variational Bayes methods.
The invention consequently makes it possible to obtain approximations of the required estimations for the parameters of interest.
According to a particular embodiment, the invention provides for the method described in relation to
with Θ={Θa, ΘR, θ, S0, ΘB} in magnetic resonance imagining or Θ=(Θa, ΘR, BF, ΘB) in computed tomography.
The calculation 55 of this quantity was not conceivable with the techniques of the art prior to the invention since, according to the latter, clearly determined global signal models are not available.
The invention provides for this quantity to make it possible to compare objectively several global perfusion models, possibly constrained, obtained from different sub-models for the arterial input function Ca(t, Θa) and/or different sub-models for the complementary cumulative distribution function R(t, ΘR) and/or different supplementary constraints Ψ(Θa)=0 as described previously.
Thus the invention provides for the method to be able to be implemented by the processing unit by successive iterations using distinct constrained global perfusion models. The processing unit can keep the result of the calculation 55 for each model used. The invention makes it possible to select in the end the best global perfusion model. This model is the one for Which the probability of the perfusion signals, given the model, is the greatest on average over all the voxels of interest.
In a variant, the invention provides for the method to be able to comprise steps 56a, 56b and 56c in order to choose, during an iteration, respectively a sub-model Ca(t,Θa), a sub-model R(t,ΘR), or even a constraint Ψ(Θa)=0 from a plurality and thus adjust 57 a global perfusion model. This selection can be carried out manually by a user 6 by means of parameters 16 or automatically by the method itself. Through an iterative process and successive tests, it becomes possible by virtue of the invention to progress in the modelling and the understanding of the perfusion phenomena and in the end to identify and validate the best models according to the patient, the pathologies, types of tissues, etc.
By way of example of application of the invention, we can cite the main steps of implementation of the invention by means of an adapted perfusion imaging analysis system such as the one described in
Thus, for a human brain analysed by means of nuclear magnetic resonance imaging,
By means of the maps presented above, the invention makes available to a user a whole range of useful information, information that could not be available by means of the techniques known from the prior art. This making available is made possible by an adaptation of the processing unit 4 according to
We can also remark that the invention makes it possible to eliminate steps necessary according to the techniques of the art prior to the invention. Among various steps we can cite the elimination of:
We can also remark that, according to the invention, the processing unit is adapted to implement a joint estimation algorithm for the parameters of the global perfusion model instead of a deconvolution algorithm in accordance with the prior techniques.
By virtue of the invention, the items of information delivered are more numerous and accurate. The information available to a researcher or practitioner are thus of such a nature as to increase their confidence in the determination of a diagnosis and a therapeutic decision.
In order to improve the performance of the system according to the invention, the latter provides for the processing unit 4 to be able to provide it with means for putting in parallel calculations on the voxels of the image for which the estimation of the parameters is required. Such a processing unit may comprise means such as graphical microprocessors (graphical processor units (GPUs)) or use calculation clusters. In a variant such a processing unit may use programmed means such as parallel Monte-Carlo methods. In a variant, the processing unit according to the invention can rely on remote computing means. The computing times can thus be considerably reduced. In addition, a processing unit according to the invention can comprise means for storing one or more global perfusion models or a plurality of arterial input function sub-models or complementary cumulative distribution function sub-models of the transit time or a plurality of constraints based on the parameters of the said arterial input function sub-models. In a variant such a processing unit may allow loading of such global perfusion models, possibly constrained, or sub-models or even constraints by means of its means for communicating with the outside world. The latter may be able to implement a cabled or remote communication according to techniques known from the prior art.
The invention has been described and illustrated in the field of dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI). The invention should not be limited solely to this example application but can also apply to other medical technologies such as perfusion imaging by computed tomography in particular.
Number | Date | Country | Kind |
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09/05759 | Nov 2009 | FR | national |
Filing Document | Filing Date | Country | Kind | 371c Date |
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PCT/FR10/51068 | 6/1/2010 | WO | 00 | 2/21/2012 |
Number | Date | Country | |
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61213417 | Jun 2009 | US | |
61259268 | Nov 2009 | US |