Radiation from "extra" images acquired with abdominal and/or pelvic CT: effect of automatic tube current modulation

Reduced dose helical CT scout imaging on next generation wide volume CT system decreases scan length and overall radiation exposure

Purpose

Traditional CT acquisition planning is based on scout projection images from planar anterior-posterior and lateral projections where the radiographer estimates organ locations. Alternatively, a new scout method utilizing ultra-low dose helical CT (3D Landmark Scan) offers cross-sectional imaging to identify anatomic structures in conjunction with artificial intelligence based Anatomic Landmark Detection (ALD) for automatic CT acquisition planning. The purpose of this study is to quantify changes in scan length and radiation dose of CT examinations planned using 3D Landmark Scan and ALD and performed on next generation wide volume CT versus examinations planned using traditional scout methods. We additionally aim to quantify changes in radiation dose reduction of scans planned with 3D Landmark Scan and performed on next generation wide volume CT.

Methods

Single-center retrospective analysis of consecutive patients with prior CT scan of the same organ who underwent clinical CT using 3D Landmark Scan and automatic scan planning. Acquisition length and dose-length-product (DLP) were collected. Data was analyzed by paired t-tests.

Results

104 total CT examinations (48.1 % chest, 15.4 % abdomen, 36.5 % chest/abdomen/pelvis) on 61 individual consecutive patients at a single center were retrospectively analyzed. 79.8 % of scans using 3D Landmark Scan had reduction in acquisition length compared to the respective prior acquisition. Median acquisition length using 3D Landmark Scan was 26.7 mm shorter than that using traditional scout methods (p < 0.001) with a 23.3 % median total radiation dose reduction (245.6 (IQR 150.0-400.8) mGy cm vs 320.3 (IQR 184.1-547.9) mGy cm). CT dose index similarly was overall decreased for scans planned with 3D Landmark and ALD and performed on next generation CT versus traditional methods (4.85 (IQR 3.8-7) mGy vs. 6.70 (IQR 4.43-9.18) mGy, respectively, p < 0.001).

Conclusion

Scout imaging using reduced dose 3D Landmark Scan images and Anatomic Landmark Detection reduces acquisition range in chest, abdomen, and chest/abdomen/pelvis CT scans. This technology, in combination with next generation wide volume CT reduces total radiation dose.

Excessive z-axis scan coverage in body CT: frequency and causes

OBJECTIVES

The aim of this study was to determine the frequency and causing factors of excessive z-axis coverage in body CT examinations.

METHODS

A total of 2032 body CT examinations performed between 1 March and 1 April 2018 in 1531 patients were included in this study. The over-scanned length values in the z-axis for each CT examination on each patient were determined by calculating the difference between the actual scanned length and optimal scan length in the z-axis. Over-scanning and over-scanning ratios were interrogated in terms of potential underlying factors that can be affected by patient demography, time, the throughput of CT, and the experience of technologists.

RESULTS

Over-scanned CTs in z-axis were 66% of all CTs performed. CT scans were over-scanned in the cranial side in 18.4% and caudal side in 48.5% of patients. Over-scanning was found to be more frequent in 55-64-year-old age group (74%), thorax CTs (89.2%), patients with consciousness change (88.9%), patients with misleading findings related to lung apex or diaphragm on the scout images (76.6%), CTs performed in day shift (66.8 %), in CT with low daily scan (72.4%), and CT scans performed by less-experienced technologists (75.9%).

CONCLUSIONS

Over-scanning in z-axis in body CT examinations is not infrequently encountered in routine practice. Awareness of causes of over-scanning in z-axis can be helpful to prevent over-scanning in CT and unnecessary ionizing radiation exposure in patients.

KEY POINTS

• Over-scanning in z-axis frequently occurs in body CT. • The frequency of over-scanning in caudal side is higher than cranial side. • Chest CT and any CT performed in following situation were more prone to over-scanning: older patients, patients with consciousness change, presence of misleading findings on the scout images related to lung apex or diaphragm, day shift, CT with low daily scan, less-experienced technologist.

Determination of a suitable low-dose abdominopelvic CT protocol using model-based iterative reconstruction through cadaveric study

INTRODUCTION

Cadaveric studies provide a means of safely assessing new technologies and optimizing scanning prior to clinical validation. Reducing radiation exposure in a clinical setting can entail incremental dose reductions to avoid missing important clinical findings. The use of cadavers allows assessment of the impact of more substantial dose reductions on image quality. Our aim was to identify a suitable low-dose abdominopelvic CT protocol for subsequent clinical validation.

METHODS

Five human cadavers were scanned at one conventional dose and three low-dose settings. All scans were reconstructed using three different reconstruction algorithms: filtered back projection (FBP), hybrid iterative reconstruction (60% FBP and 40% adaptive statistical iterative reconstruction (ASIR40)), and model-based iterative reconstruction (MBIR). Two readers rated the image quality both quantitatively and qualitatively.

RESULTS

Model-based iterative reconstruction images had significantly better objective image noise and higher qualitative scores compared with both FBP and ASIR40 images at all dose levels. The greatest absolute noise reduction, between MBIR and FBP, of 34.3 HU (equating to a 68% reduction) was at the lowest dose level. MBIR reduced image noise and improved image quality even in CT images acquired with a mean radiation dose reduction of 62% compared with conventional dose studies reconstructed with ASIR40, with lower levels of objective image noise, superior diagnostic acceptability and contrast resolution, and comparable subjective image noise and streak artefact scores.

CONCLUSION

This cadaveric study demonstrates that MBIR reduces image noise and improves image quality in abdominopelvic CT images acquired with dose reductions of up to 62%.

Effect of reduced z-axis scan coverage on diagnostic performance and radiation dose of neck computed tomography in patients with suspected cervical abscess

Purpose

To evaluate the effect of reduced z-axis scan coverage on diagnostic performance and radiation dose of neck CT in patients with suspected cervical abscess.

Methods

Fifty-one patients with suspected cervical abscess were included and underwent contrast-enhanced neck CT on a 2^nd or 3^rd generation dual-source CT system. Image acquisition ranged from the aortic arch to the upper roof of the frontal sinuses (CT_std). Subsequently, series with reduced z-axis coverage (CT_red) were reconstructed starting at the aortic arch up to the orbital floor. CT_std and CT_red were independently assessed by two radiologists for the presence/absence of cervical abscesses and for incidental and alternative findings. In addition, diagnostic accuracy for the depiction of the cervical abscesses was calculated for both readers. Furthermore, DLP (dose-length-product), effective dose (ED) and organ doses were calculated and compared for CT_red and CT_std, using a commercially available dose management platform.

Results

A total of 41 abscesses and 3 incidental/alternative findings were identified in CT_std. All abscesses and incidental/alternative findings could also be detected on CT_red resulting in a sensitivity and specificity of 1.0 for both readers. DLP, ED and organ doses of the brain, the eye lenses, the red bone marrow and the salivary glands of CT_red were significantly lower than for CT_std (p<0.001).

Conclusions

Reducing z-axis coverage of neck CT allows for a significant reduction of effective dose and organ doses at similar diagnostic performance as compared to CT_std.

Computed tomography and patient risk: Facts, perceptions and uncertainties

Since its introduction in the 1970s, computed tomography (CT) has revolutionized diagnostic decision-making. One of the major concerns associated with the widespread use of CT is the associated increased radiation exposure incurred by patients. The link between ionizing radiation and the subsequent development of neoplasia has been largely based on extrapolating data from studies of survivors of the atomic bombs dropped in Japan in 1945 and on assessments of the increased relative risk of neoplasia in those occupationally exposed to radiation within the nuclear industry. However, the association between exposure to low-dose radiation from diagnostic imaging examinations and oncogenesis remains unclear. With improved technology, significant advances have already been achieved with regards to radiation dose reduction. There are several dose optimization strategies available that may be readily employed including omitting unnecessary images at the ends of acquired series, minimizing the number of phases acquired, and the use of automated exposure control as opposed to fixed tube current techniques. In addition, new image reconstruction techniques that reduce radiation dose have been developed in recent years with promising results. These techniques use iterative reconstruction algorithms to attain diagnostic quality images with reduced image noise at lower radiation doses.

Low-Dose Carotid Computed Tomography Angiography Using Pure Iterative Reconstruction

The aim of this study was to assess if a low-dose carotid computed tomography angiography (CTA) performed with pure iterative reconstruction (IR) is comparable to a conventional dose CTA protocol.

METHODS

Twenty patients were included. Radiation dose was divided into a low-dose acquisition reconstructed with pure IR and a conventional dose acquisition reconstructed with 40% hybrid IR. Dose, image noise, contrast resolution, spatial resolution, and carotid artery stenosis were measured.

RESULTS

Mean effective dose was significantly lower for low-dose than conventional dose studies (1.84 versus 3.71 mSv; P < 0.001). Subjective image noise, contrast resolution, and spatial resolution were significantly higher for the low-dose studies. There was excellent agreement for stenosis grading accuracy between low- and conventional dose studies (Cohen κ = 0.806).

CONCLUSIONS

A low-dose carotid CTA protocol reconstructed with pure IR is comparable to a conventional dose CTA protocol in terms of image quality and diagnostic accuracy while enabling a dose reduction of 49.6%.

Cumulative radiation exposure from diagnostic imaging in intensive care unit patients

AIM: To quantify cumulative effective dose of intensive care unit (ICU) patients attributable to diagnostic imaging.

METHODS: This was a prospective, interdisciplinary study conducted in the ICU of a large tertiary referral and level 1 trauma center. Demographic and clinical data including age, gender, date of ICU admission, primary reason for ICU admission, APACHE II score, length of stay, number of days intubated, date of death or discharge, and re-admission data was collected on all patients admitted over a 1-year period. The overall radiation exposure was quantified by the cumulative effective radiation dose (CED) in millisieverts (mSv) and calculated using reference effective doses published by the United Kingdom National Radiation Protection Board. Pediatric patients were selected for subgroup-analysis.

RESULTS: A total of 2737 studies were performed in 421 patients. The total CED was 1704 mSv with a median CED of 1.5 mSv (IQR 0.04-6.6 mSv). Total CED in pediatric patients was 74.6 mSv with a median CED of 0.07 mSv (IQR 0.01-4.7 mSv). Chest radiography was the most commonly performed examination accounting for 83% of all studies but only 2.7% of total CED. Computed tomography (CT) accounted for 16% of all studies performed and contributed 97% of total CED. Trauma patients received a statistically significant higher dose [median CED 7.7 mSv (IQR 3.5-13.8 mSv)] than medical [median CED 1.4 mSv (IQR 0.05-5.4 mSv)] and surgical [median CED 1.6 mSv (IQR 0.04-7.5 mSv)] patients. Length of stay in ICU [OR = 1.12 (95%CI: 1.079-1.157)] was identified as an independent predictor of receiving a CED greater than 15 mSv.

CONCLUSION: Trauma patients and patients with extended ICU admission times are at increased risk of higher CEDs. CED should be minimized where feasible, especially in young patients.

Automated detection of z-axis coverage with abdomen-pelvis computed tomography examinations

Excessive cephalocaudal anatomic (Z-axis) coverage can lead to unnecessary radiation exposure to a patient. In this study, an automated computing model was developed for identifying instances of potentially excessive Z-axis coverage with abdomen-pelvis examinations. Eight patient and imaging attributes including patient gender, age, height, weight, volume CT dose index (CTDIvol), dose length product (DLP), maximum abdomen width, and maximum abdomen thickness were used to build a feedforward neural network model to predict a target Z-axis coverage whether it is an excessive or non-excessive Z-axis coverage scans. 264 CT abdomen-pelvis exams were used to develop the model which is validated using 10-fold cross validation. The result showed that 244 out of 264 exams (92.4%) correctly predicted Z-axis excessive coverage. The promising results indicate that this tool has the potential to be used for CT exams of the chest and colon, urography, and other site-specified CT studies having defined limited length.

Successful Dose Reduction Using Reduced Tube Voltage With Hybrid Iterative Reconstruction in Pediatric Abdominal CT

OBJECTIVE

The purpose of this article is to assess radiation dose reduction, image quality, and diagnostic confidence using low tube voltage in combination with hybrid iterative reconstruction in contrast-enhanced pediatric abdominal CT.

MATERIALS AND METHODS

CT examinations of 133 patients (median age, 10 years) were performed at sequentially reduced doses. The first group (group 1) was scanned using dimension-based protocols at 120 kV for all patient sizes. The optimized group (group 5) was scanned at 80 kV for less than 18 cm in the lateral dimension and 100 kV in the 19-30 cm lateral dimension. CT examinations reconstructed with filtered back projection (FBP) and four levels of hybrid iterative reconstruction were reviewed by four blinded readers for subjective image quality and diagnostic confidence. Objective noise, volume CT dose index (CTDIvol), and size-specific dose estimate (SSDE) were recorded. Data were analyzed using t tests, one and two-way ANOVA, and the intraclass correlation coefficient.

RESULTS

Compared with group 1, the radiation dose was reduced for group 5 by 63% measured by SSDE (4.69 vs 10.00 mGy; p < 0.001). Subjective image noise was increased for FBP images (p < 0.001) but not was statistically significantly different for all levels of hybrid iterative reconstruction; artifacts were reduced and visibility of small structures was improved (both p < 0.001). Diagnostic confidence was improved for solid organ injury and metastatic disease (both p < 0.001) and was not statistically significantly different for appendicitis (p = 0.306).

CONCLUSION

Use of hybrid iterative reconstruction with low-tube-voltage protocols enables substantial radiation dose reduction for pediatric abdominal CT with equivalent to improved subjective image quality and diagnostic confidence.

Computed tomography: revolutionizing the practice of medicine for 40 years

Computed tomography (CT) has had a profound effect on the practice of medicine. Both the spectrum of clinical applications and the role that CT has played in enhancing the depth of our understanding of disease have been profound. Although almost 90 000 articles on CT have been published in peer-reviewed journals over the past 40 years, fewer than 5% of these have been published in Radiology. Nevertheless, these almost 4000 articles have provided a basis for many important medical advances. By enabling a deepened understanding of anatomy, physiology, and pathology, CT has facilitated key advances in the detection and management of disease. This article celebrates this breadth of scientific discovery and development by examining the impact that CT has had on the diagnosis, characterization, and management of a sampling of major health challenges, including stroke, vascular diseases, cancer, trauma, acute abdominal pain, and diffuse lung diseases, as related to key technical advances in CT and manifested in Radiology.

Radiation exposure from diagnostic imaging in young patients with testicular cancer

OBJECTIVES

Risks associated with high cumulative effective dose (CED) from radiation are greater when imaging is performed on younger patients. Testicular cancer affects young patients and has a good prognosis. Regular imaging is standard for follow-up. This study quantifies CED from diagnostic imaging in these patients.

METHODS

Radiological imaging of patients aged 18-39 years, diagnosed with testicular cancer between 2001 and 2011 in two tertiary care centres was examined. Age at diagnosis, cancer type, dose-length product (DLP), imaging type, and frequency were recorded. CED was calculated from DLP using conversion factors. Statistical analysis was performed with SPSS.

RESULTS

In total, 120 patients with a mean age of 30.7 ± 5.2 years at diagnosis had 1,410 radiological investigations. Median (IQR) surveillance was 4.37 years (2.0-5.5). Median (IQR) CED was 125.1 mSv (81.3-177.5). Computed tomography accounted for 65.3 % of imaging studies and 98.3 % of CED. We found that 77.5 % (93/120) of patients received high CED (>75 mSv). Surveillance time was associated with high CED (OR 2.1, CI 1.5-2.8).

CONCLUSIONS

Survivors of testicular cancer frequently receive high CED from diagnostic imaging, mainly CT. Dose management software for accurate real-time monitoring of CED and low-dose CT protocols with maintained image quality should be used by specialist centres for surveillance imaging.

KEY POINTS

• CT accounted for 98.3 % of CED in patients with testicular cancer. • Median CED in patients with testicular cancer was 125.1 mSv • High CED (>75 mSv) was observed in 77.5 % (93/120) of patients. • Dose tracking and development of low-dose CT protocols are recommended.

Variability of MDCT dose due to technologist performance: impact of posteroanterior versus anteroposterior localizer image and table height with use of automated tube current modulation

OBJECTIVE

The purpose of this study was to determine MDCT dose variability due to technologist variability in performing CT studies.

MATERIALS AND METHODS

Fifty consecutive adult patients who underwent two portal venous phase CT examinations of the abdomen and pelvis on the same 64-MDCT scanner between January and December 2011 were retrospectively identified. Tube voltage (kVp), tube current (mA), use of automated tube current modulation (ATCM), dose-length product (DLP), volume CT dose index (CTDIvol), table height, whether the localizer image was obtained using the posteroanterior or the anteroposterior technique, arm position, and number of overscanned slices were recorded.

RESULTS

For a given patient, the total examination DLP difference comparing the two MDCT studies ranged from 0.1% to 238.0%. For the same patient, total examination DLP was always higher when the localizer image was obtained with the posteroanterior compared with the anteroposterior technique. When table position was closer to the x-ray source, patients appeared magnified in the posteroanterior localizer image (8-29%; average, 14%) and higher tube currents were selected with ATCM. Localizer technique, table height, arm position, number of overscanned slices, and technologist were all significant predictors of dose.

CONCLUSION

Patient off-centering closer to the x-ray source resulted in patient magnification in the posteroanterior localizer image, leading to higher tube currents with ATCM and increased DLP. Differences in technologist, arm position, and overscanning also resulted in dose variability.

Radiation exposure in gastroenterology: improving patient and staff protection

Medical imaging involving the use of ionizing radiation has brought enormous benefits to society and patients. In the past several decades, exposure to medical radiation has increased markedly, driven primarily by the use of computed tomography. Ionizing radiation has been linked to carcinogenesis. Whether low-dose medical radiation exposure will result in the development of malignancy is uncertain. This paper reviews the current evidence for such risk, and aims to inform the gastroenterologist of dosages of radiation associated with commonly ordered procedures and diagnostic tests in clinical practice. The use of medical radiation must always be justified and must enable patients to be exposed at the lowest reasonable dose. Recommendations provided herein for minimizing radiation exposure are based on currently available evidence and Working Party expert consensus.

Combining automatic tube current modulation with adaptive statistical iterative reconstruction for low-dose chest CT screening

Objective

To reduce radiation dose while maintaining image quality in low-dose chest computed tomography (CT) by combining adaptive statistical iterative reconstruction (ASIR) and automatic tube current modulation (ATCM).

Methods

Patients undergoing cancer screening (n = 200) were subjected to 64-slice multidetector chest CT scanning with ASIR and ATCM. Patients were divided into groups 1, 2, 3, and 4 (n = 50 each), with a noise index (NI) of 15, 20, 30, and 40, respectively. Each image set was reconstructed with 4 ASIR levels (0% ASIR, 30% ASIR, 50% ASIR, and 80% ASIR) in each group. Two radiologists assessed subjective image noise, image artifacts, and visibility of the anatomical structures. Objective image noise and signal-to-noise ratio (SNR) were measured, and effective dose (ED) was recorded.

Results

Increased NI was associated with increased subjective and objective image noise results (P<0.001), and SNR decreased with increasing NI (P<0.001). These values improved with increased ASIR levels (P<0.001). Images from all 4 groups were clinically diagnosable. Images with NI = 30 and 50% ASIR had average subjective image noise scores and nearly average anatomical structure visibility scores, with a mean objective image noise of 23.42 HU. The EDs for groups 1, 2, 3 and 4 were 2.79±1.17, 1.69±0.59, 0.74±0.29, and 0.37±0.22 mSv, respectively. Compared to group 1 (NI = 15), the ED reductions were 39.43%, 73.48%, and 86.74% for groups 2, 3, and 4, respectively.

Conclusions

Using NI = 30 with 50% ASIR in the chest CT protocol, we obtained average or above-average image quality but a reduced ED.

Imaging the small bowel

PURPOSE OF REVIEW

Radiologic investigations continue to play a pivotal role in the diagnosis of pathologic conditions of the small intestine despite enhancement of capsule endoscopy and double-balloon endoscopy. Imaging techniques continue to evolve and new techniques in MRI in particular, are being developed.

RECENT FINDINGS

Continued advances in computed tomography (CT) and MRI techniques have reinforced the importance of these imaging modalities in small bowel assessment. The more invasive enteroclysis technique yields better small bowel distension for both CT and MRI when compared with peroral enterography, but no clinically significant difference is seen in terms of diagnostic accuracy. Recent concern regarding radiation exposure means that MRI is gaining in popularity. Fluoroscopic studies such as barium follow through and small bowel enteroclysis are being replaced by the cross-sectional alternatives. Contrast-enhanced ultrasound is showing results comparable with CT and MRI, but concern remains regarding reproducibility, especially outside centres that specialize in advanced sonographic techniques.

SUMMARY

CT and MRI enterography are comparable first-line modalities for patients with suspected small bowel disease, but magnetic resonance enterography is favoured given the absence of ionizing radiation. Capsule endoscopy is a reasonable alternative investigation in exploration of chronic gastrointestinal blood loss, but is best kept as a second-line test in patients with other symptoms.

Cardiac computed tomography angiography with automatic tube potential selection: effects on radiation dose and image quality

PURPOSE

Automatic exposure control (AEC) algorithms are widely available in coronary computed tomography angiography (CTA) and have been shown to reduce radiation doses by adjusting tube current to patient size. However, the effects of anthropometry-based automatic potential selection (APS) on image quality and radiation dose are unknown. We sought to investigate the effect of an APS algorithm on coronary CTA radiation dose and image quality.

MATERIALS AND METHODS

For this retrospective case-control study we selected 38 patients who had undergone coronary CTA for coronary artery assessment in whom tube potential and tube current were selected automatically by a combined automatic tube potential and tube current selection algorithm (APS-AEC) and compared them with 38 controls for whom tube voltage was selected according to standard body mass index (BMI) cutoffs and tube current was selected using automatic exposure control (BMI-AEC). Controls were matched for BMI, heart rate, heart rhythm, sex, acquisition mode, and indication for cardiac CTA. Image quality was assessed as contrast-to-noise ratio and signal-to-noise ratio in the proximal coronary arteries. Subjective reader assessment was also made. Total radiation dose (volume-weighted computed tomography dose index) was measured and compared between the 2 groups. In the study group, comparison was made with conventional BMI-guided prior protocols (site protocols and Society of Cardiovascular Computed Tomography recommendations) through disagreement analysis.

RESULTS

The APS-AEC cases received 29.8% lower overall radiation dose compared with controls (P=not significant). APS-AEC resulted in a significantly higher signal-to-noise ratio of the proximal coronary arteries (P<0.01) and contrast-to-noise ratio of the left main (P=0.01). In the study cases, the APS resulted in a change in tube potential versus site protocols and Society of Cardiovascular Computed Tomography recommendations in 45% (n=17) and 50% (n=19) of patients, respectively.

CONCLUSION

Automated tube potential selection software resulted in significantly improved objective image quality versus standard BMI-based methods of tube potential selection, without increased radiation doses.

Optimised z-axis coverage at multidetector-row CT in adults suspected of acute appendicitis

OBJECTIVE

To compare diagnostic performances of two reduced z-axis coverages to full coverage of the abdomen and pelvis for the diagnosis of acute appendicitis and alternative diseases at unenhanced CT.

METHODS

This study included 152 adults suspected of appendicitis who were enrolled in two ethical committee-approved previous prospective trials. Based on scans covering the entire abdomen and pelvis (set L), two additional sets of images were generated, each with reduced z-axis coverages: (1) from the top of the iliac crests to the pubis (set S) and (2) from the diaphragmatic crus to the pubis (set M). Two readers independently coded the visualisation of the appendix, measured its diameter and proposed a diagnosis (appendicitis or alternative). Final diagnosis was based on surgical findings or clinical follow-up. Fisher exact and McNemar tests and logistic regression were used.

RESULTS

46 patients had a definite diagnosis of appendicitis and 53 of alternative diseases. The frequency of appendix visualisation was lower for set S than set L for both readers (89% and 84% vs 95% and 91% by Readers A and B, respectively; p=0.021 and 0.022). The probability of giving a correct diagnosis was lower for set S (68%) than set L (78%; odds ratio, 0.611; p=0.008) for both readers, without significant difference between sets L and M (77%, p=0.771); z-axis coverage being reduced by 25% for set M.

CONCLUSION

Coverage from diaphragmatic crus to pubis, but not focused on pelvis only, can be recommended in adults suspected of appendicitis.

ADVANCES IN KNOWLEDGE

In suspected appendicitis, CT-coverage can be reduced from diaphragmatic crus to pubis.

Radiation dose reduction with hybrid iterative reconstruction for pediatric CT

PURPOSE

To assess image quality and radiation dose reduction with hybrid iterative reconstruction of pediatric chest and abdominal computed tomographic (CT) data compared with conventional filtered back projection (FBP).

MATERIALS AND METHODS

A total of 234 patients (median age, 12 years; age range, 6 weeks to 18 years) underwent chest and abdominal CT in this institutional review board-approved HIPAA-compliant retrospective study. CT was performed with a hybrid adaptive statistical iterative reconstruction (ASIR)-enabled 64-detector row CT scanner. Scanning protocols were adjusted for clinical indication and patient weight to enable acquisition of reduced-dose CT images in all patients, and tube current was further lowered for ASIR protocols. Weight, age, and sex were recorded, and objective noise was measured in the descending thoracic aorta for chest CT and in the liver for abdominal CT. Of the 234 consecutive patients who underwent ASIR-enabled CT (115 chest and 119 abdominal examinations), 70 patients had undergone prior FBP CT. ASIR and FBP CT studies (29 chest and 41 abdominal studies) in these 70 patients were reviewed for image quality, artifacts, and diagnostic confidence by two pediatric radiologists working independently. Data were analyzed with multiple paired t tests.

RESULTS

Compared with FBP, ASIR enabled dose reduction of 46.4% (3.7 vs 6.9 mGy) for chest CT and 38.2% (5.0 vs 8.1 mGy) for abdominal CT (P < .0001). Both radiologists deemed image quality of and diagnostic confidence with ASIR and FBP CT images as acceptable, without any artifacts. Despite the lower radiation dose used, ASIR images (chest, 10.7 ± 2.5 [mean ± standard deviation]; abdomen, 11.8 ± 3.4) had substantially less objective noise than did FBP images (chest, 13.3 ± 3.8; abdomen, 13.8 ± 5.2) (P = .001, P =.006, respectively).

CONCLUSION

Use of a hybrid iterative reconstruction technique, such as ASIR, enables substantial radiation dose reduction for pediatric CT when compared with FBP and maintains image quality and diagnostic confidence.

Evaluation of dose reduction and image quality in chest CT using adaptive statistical iterative reconstruction with the same group of patients

OBJECTIVES

The objective of this study was to compare the image quality and radiation dose of chest CT images reconstructed with a blend of adaptive statistical iterative reconstruction (ASIR) and filtered back-projection (FBP) with images generated using conventional FBP.

METHODS

Patients with chest CT re-examinations were alternately assigned to two scanners with different reconstruction techniques. The study groups included noise index (NI) 11 with 30% ASIR (A30), NI 13 with 40% ASIR (A40), NI 15 with 50% ASIR (A50) and NI 17 with 60% ASIR (A60), sequentially changed every 2 months. The control images were obtained using FBP and NI 11. All acquisitions were performed with automatic dose modulation. Paired t-test and non-parameter test were applied to compare the difference.

RESULTS

The radiation doses were significantly lower in the examinations that used ASIR (p<0.001). The mean dose reduction rate was 27.7%, 45.2%, 57.1% and 71.8% for Groups A30, A40, A50 and A60, respectively. The image quality of Groups A30-A50 was not inferior to that of the control examinations. The image noise of Group A60 was greater and subjective image quality was inferior to that of the control.

CONCLUSIONS

ASIR enabled the use of a higher NI with automatic dose modulation. With 50% ASIR and a NI of 15, the effective radiation dose was reduced by 57%, without compromising image quality.

Minimization of Radiation Exposure due to Computed Tomography in Inflammatory Bowel Disease

Patient awareness and concern regarding the potential health risks from ionizing radiation have peaked recently (Coakley et al., 2011) following widespread press and media coverage of the projected cancer risks from the increasing use of computed tomography (CT) (Berrington et al., 2007). The typical young and educated patient with inflammatory bowel disease (IBD) may in particular be conscious of his/her exposure to ionising radiation as a result of diagnostic imaging. Cumulative effective doses (CEDs) in patients with IBD have been reported as being high and are rising, primarily due to the more widespread and repeated use of CT (Desmond et al., 2008). Radiologists, technologists, and referring physicians have a responsibility to firstly counsel their patients accurately regarding the actual risks of ionizing radiation exposure; secondly to limit the use of those imaging modalities which involve ionising radiation to clinical situations where they are likely to change management; thirdly to ensure that a diagnostic quality imaging examination is acquired with lowest possible radiation exposure. In this paper, we synopsize available evidence related to radiation exposure and risk and we report advances in low-dose CT technology and examine the role for alternative imaging modalities such as ultrasonography or magnetic resonance imaging which avoid radiation exposure.

Extra Z-axis coverage at CT imaging resulting in excess radiation dose: frequency, degree, and contributory factors

OBJECTIVE

To assess the degree of extra scanning beyond the prescribed anatomic boundaries for thoracic and body computed tomographic (CT) scans and to identify associated factors.

METHODS

For 442 consecutive chest, abdomen, and/or pelvis CT examinations, the length of extra scanning beyond the prescribed anatomic boundaries was determined. Examinations were grouped according to the locations/types of the prescribed boundaries and compared with regard to length of extra scanning.

RESULTS

Of 442 CT examinations, 438 (99%) included extraneous imaging, showing a mean excess scanning length of 43.2 mm per examination (range, 0-180 mm). Significantly more extraneous imaging was performed when soft tissue or vascular structures defined anatomic boundaries compared to when osseous (P < 0.001) or air/soft tissue interfaces (P < 0.0001) defined the boundaries. The average percent of total scan dose attributable to extra imaging was 8.64% to 10.38%.

CONCLUSIONS

Computed tomographic scanning beyond the prescribed anatomic boundaries occurs commonly, resulting in moderate extra radiation dose.

Minimization of radiation exposure due to computed tomography in inflammatory bowel disease

Exposure to ionising radiation as a result of diagnostic imaging is increasing among patients with inflammatory bowel disease (IBD), primarily due to the more widespread use of computed tomography (CT). The potentially harmful effects of ionising radiation are a major cause for concern and radiologists, technologists and referring physicians who have a responsibility to the patient to ensure judicious use of those imaging modalities which result in exposure to ionising radiation and, when imaging is necessary, to ensure that a diagnostic quality imaging examination is acquired with lowest possible radiation exposure. This can be achieved by limiting the use of those imaging studies which involve ionising radiation to clinical situations where they are likely to change management, by implementing advances in low-dose CT technology, and, where feasible, by using alternative imaging modalities, such as ultrasonography or magnetic resonance imaging, which avoid radiation exposure.

Iterative reconstruction technique for reducing body radiation dose at CT: feasibility study

OBJECTIVE

The purpose of this study was to evaluate the image noise, low-contrast resolution, image quality, and spatial resolution of adaptive statistical iterative reconstruction in low-dose body CT.

MATERIALS AND METHODS

Adaptive statistical iterative reconstruction was used to scan the American College of Radiology phantom at the American College of Radiology reference value and at one-half that value (12.5 mGy). Test objects in low- and high-contrast and uniformity modules were evaluated. Low-dose CT with adaptive statistical iterative reconstruction was then tested on 12 patients (seven men, five women; average age, 67.5 years) who had previously undergone routine-dose CT. Two radiologists blinded to scanning technique evaluated images of the same patients obtained with routine-dose CT and low-dose CT with and without adaptive statistical iterative reconstruction. Image noise, low-contrast resolution, image quality, and spatial resolution were graded on a scale of 1 (best) to 4 (worst). Quantitative noise measurements were made on clinical images.

RESULTS

In the phantom, low- and high-contrast and uniformity assessments showed no significant difference between routine-dose imaging and low-dose CT with adaptive statistical iterative reconstruction. In patients, low-dose CT with adaptive statistical iterative reconstruction was associated with CT dose index reductions of 32-65% compared with routine imaging and had the least noise both quantitatively and qualitatively (p < 0.05). Low-dose CT with adaptive statistical iterative reconstruction and routine-dose CT had identical results for low-contrast resolution and nearly identical results for overall image quality (grade 2.1-2.2). Spatial resolution was better with routine-dose CT (p = 0.004).

CONCLUSION

These preliminary results support body CT dose index reductions of 32-65% when adaptive statistical iterative reconstruction is used. Studies with larger statistical samples are needed to confirm these findings.

Automatic exposure control in multichannel CT with tube current modulation to achieve a constant level of image noise: Experimental assessment on pediatric phantoms

Automatic exposure control (AEC) systems have been developed by computed tomography (CT) manufacturers to improve the consistency of image quality among patients and to control the absorbed dose. Since a multichannel helical CT scan may easily increase individual radiation doses, this technical improvement is of special interest in children who are particularly sensitive to ionizing radiation, but little information is currently available regarding the precise performance of these systems on small patients. Our objective was to assess an AEC system on pediatric dose phantoms by studying the impact of phantom transmission and acquisition parameters on tube current modulation, on the resulting absorbed dose and on image quality. We used a four-channel CT scan working with a patient-size and z-axis-based AEC system designed to achieve a constant noise within the reconstructed images by automatically adjusting the tube current during acquisition. The study was performed with six cylindrical poly(methylmethacrylate) (PMMA) phantoms of variable diameters (10-32 cm) and one 5 years of age equivalent pediatric anthropomorphic phantom. After a single scan projection radiograph (SPR), helical acquisitions were performed and images were reconstructed with a standard convolution kernel. Tube current modulation was studied with variable SPR settings (tube angle, mA, kVp) and helical parameters (6-20 HU noise indices, 80-140 kVp tube potential, 0.8-4 s. tube rotation time, 5-20 mm x-ray beam thickness, 0.75-1.5 pitch, 1.25-10 mm image thickness, variable acquisition, and reconstruction fields of view). CT dose indices (CTDIvol) were measured, and the image quality criterion used was the standard deviation of the CT number measured in reconstructed images of PMMA material. Observed tube current levels were compared to the expected values from Brooks and Di Chiro's [R.A. Brooks and G.D. Chiro, Med. Phys. 3, 237-240 (1976)] model and calculated values (product of a reference value multiplied by a dose ratio measured with thermoluminescent dosimeters). Our study demonstrates that this AEC system accurately modulates the tube current according to phantom size and transmission to achieve a stable image noise. The system accurately controls the tube current when changing tube rotation time, tube potential, or image thickness, with minimal variations of the resulting noise. Nevertheless, CT users should be aware of possible changes of tube current and resulting dose and quality according to several parameters: the tube angle and tube potential used for SPR, the x-ray beam thickness (tube current decreases and image noise increases when doubling x-ray beam thickness), the pitch value (a pitch decrease leads to a higher dose but also to a higher noise), and the acquisition field of view (FOV) (tube current is lower when using the small acquisition FOV compared to the large one, but the use of small acquisition FOV at 120 kVp leads to a peculiar increase of tube current and CTDIvol).

Dose reduction in paediatric MDCT: general principles

The number of multi-detector array computed tomography (MDCT) examinations performed per annum continues to increase in both the adult and paediatric populations. Estimates from 2003 suggested that CT contributed 17% of a radiology department's workload, yet was responsible for up to 75% of the collective population dose from medical radiation. The effective doses for some CT examinations today overlap with those argued to have an increased risk of cancer. This is especially pertinent for paediatric CT, as children are more radiosensitive than adults (and girls more radiosensitive than boys). In addition, children have a longer life ahead of them, in which radiation induced cancers may become manifest. Radiologists must be aware of these facts and practise the ALARA (as low as is reasonably achievable) principle, when it comes to deciding CT protocols and parameters.

Computed tomography radiation dose optimization: scanning protocols and clinical applications of automatic exposure control

As multi-detector-row computed tomography (CT) technology evolves, manifold applications of CT scanning have been adopted in clinical practice and optimization of scanning protocols to comply with an "as low as reasonably achievable" radiation dose have become more complex. Automatic exposure control techniques, which have been recently introduced on most state-of-the-art CT equipment, aid in radiation dose optimization at a selected image quality. The present article reviews the fundamentals of automatic exposure control techniques in CT, along with the scanning protocols and associated radiation dose reduction.

Overranging in multisection CT: quantification and relative contribution to dose--comparison of four 16-section CT scanners

PURPOSE

To quantify the number of overrange rotations and to assess their relative contribution to organ and effective doses at 16-section body computed tomography (CT).

MATERIALS AND METHODS

Overranging was quantified for four 16-section scanners by means of free-in-air dose measurements at different scan lengths. Overrange rotations and lengths at a certain section width were derived for all collimations and clinically used pitches by extrapolation. The effect of reconstructed section width on overranging was analyzed separately. Results were applied to clinical protocols for the chest and abdomen. Thyroid and testicular dose and effective dose were established, and relative dose contributions from overranging were calculated. Statistical analysis was performed by using Pearson correlation and paired t tests. P<.05 indicated a significant difference.

RESULTS

The number of overrange rotations showed considerable differences between scanners, with a range of 1.99-4.04 at the lowest and 0.93-2.59 at the highest pitch. Number of rotations correlated negatively with pitch, while overrange length correlated positively with collimation and pitch. The effect of section width was variable. In the protocols, overrange length ranged from 3.2 to 5.8 cm for chest and from 3.2 to 5.2 cm for abdominal CT. When the contribution of overranging was not taken into account, significantly lower values for thyroid (P=.012) and testicular (P=.025) doses and effective doses for chest (P=.005) and abdominal (P=.011) CT resulted.

CONCLUSION

Overranging is reconstruction-algorithm specific, and its length generally increases with collimation and pitch, while the effect of section width is variable. Overranging may lead to substantial but unnoticed exposure to radiosensitive organs.

Reducing radiation dose in emergency computed tomography with automatic exposure control techniques

Computed tomography (CT) scanning is being increasingly used for evaluation of trauma, which most commonly involves younger individuals. As younger patients are at higher risk for radiation-induced cancer compared to older patients, radiation dose reduction is an important issue in emergency CT scanning. With automatic exposure control techniques, users select a desired image quality and the system adapts tube current to obtain the desired image quality with greater radiation dose efficiency. These techniques can help in reducing radiation dose by 10-60% in most instances. This review article presents a comprehensive description of fundamentals, clinical applications and radiation dose benefits of automatic exposure control in emergency CT scanning.

Dose Reduction in Multislice Computed Tomography

OBJECTIVE

Evaluation of the attenuation-based on-line modulation of tube current on multislice computed tomography (CT) to explore the potential of this dose-saving technique.

METHODS

Fifty-five patients with follow-up CT examinations were scanned without and with a CARE Dose (Siemens Medical Solutions, Erlangen, Germany). The applied dose, image noise, and subjective image quality were evaluated. The reduction in patient exposure was determined by obtaining the effective milliamperes per second for each reconstructed scan and the absolute dosage requirement for the whole scan.

RESULTS

The dose reduction achieved by applying the attenuation-based on-line modulation of tube current was 29.4% +/- 3.1% (P=0.002) for all scans, 30.5% +/- 3.2% (P=0.002) for the thorax scans, 29.7% +/- 2.9% (P=0.002) for the abdomen scans, and 28.7% +/- 2.7% (P=0.003) for the thorax and abdomen scans together. No significant restrictions in image quality were observed.

CONCLUSIONS

Remarkable dose reduction can be obtained using the attenuation-based on-line modulation of tube current on multislice CT without compromising image quality.