Stroke Evaluation in the Interventional Suite Using Dual-Layer Detector Cone-Beam CT: a First-in-human Prospective Cohort Study (the Next Generation X-ray Imaging System Trial).

PURPOSE: Cone-beam CT in the interventional suite could be an alternative to CT to shorten door-to-thrombectomy time. However, image quality in cone-beam CT is limited by artifacts and poor differentiation between gray and white matter. This study compared non-contrast brain dual-layer cone-beam CT in the interventional suite to reference standard CT in stroke patients. METHODS: A prospective single-center study enrolled consecutive participants with ischemic or hemorrhagic stroke. The hemorrhage detection accuracy, per-region ASPECTS accuracy and subjective image quality (Likert scales for gray-white matter differentiation, structure perception and artifacts) were assessed by three neuroradiologists blinded to clinical data on dual-layer cone-beam CT 75 keV monoenergetic images compared to CT. Objective image quality was assessed by region-of-interest metrics. Non-inferiority for hemorrhage detection and ASPECTS accuracy was determined by the exact binomial test with a one-sided lower performance boundary prospectively set to 80% (98.75% CI). RESULTS: 27 participants were included (74 years ± 9; 19 female) in the hyperacute or acute stroke phase. One reader missed a small bleeding, but all hemorrhages were detected in the majority analysis (100% accuracy, CI lower boundary 86%, p = 0.002). ASPECTS majority analysis showed 90% accuracy (CI lower boundary 85%, p < 0.001). Sensitivity was 66% (individual readers 67%, 69%, and 76%), specificity was 97% (97%, 96%, 89%). Subjective and objective image quality were inferior to CT. CONCLUSION: In a small single-center cohort, dual-layer cone-beam CT showed non-inferior hemorrhage detection and ASPECTS accuracy to CT. Despite inferior image quality, the technique may be useful for stroke evaluation in the interventional suite. TRIAL REGISTRATION NUMBER: NCT04571099 (clinicaltrials.gov). Prospectively registered 2020-09-04.

Correction for Mechanical Inaccuracies in a Scanning Talbot-Lau Interferometer.

Grating-based X-ray phase-contrast and in particular dark-field radiography are promising new imaging modalities for medical applications. Currently, the potential advantage of dark-field imaging in early-stage diagnosis of pulmonary diseases in humans is being investigated. These studies make use of a comparatively large scanning interferometer at short acquisition times, which comes at the expense of a significantly reduced mechanical stability as compared to tabletop laboratory setups. Vibrations create random fluctuations of the grating alignment, causing artifacts in the resulting images. Here, we describe a novel maximum likelihood method for estimating this motion, thereby preventing these artifacts. It is tailored to scanning setups and does not require any sample-free areas. Unlike any previously described method, it accounts for motion in between as well as during exposures.

Dark-field chest X-ray imaging for the assessment of COVID-19-pneumonia.

BACKGROUND: Currently, alternative medical imaging methods for the assessment of pulmonary involvement in patients infected with COVID-19 are sought that combine a higher sensitivity than conventional (attenuation-based) chest radiography with a lower radiation dose than CT imaging. METHODS: Sixty patients with COVID-19-associated lung changes in a CT scan and 40 subjects without pathologic lung changes visible in the CT scan were included (in total, 100, 59 male, mean age 58 ± 14 years). All patients gave written informed consent. We employed a clinical setup for grating-based dark-field chest radiography, obtaining both a dark-field and a conventional attenuation image in one image acquisition. Attenuation images alone, dark-field images alone, and both displayed simultaneously were assessed for the presence of COVID-19-associated lung changes on a scale from 1 to 6 (1 = surely not, 6 = surely) by four blinded radiologists. Statistical analysis was performed by evaluation of the area under the receiver-operator-characteristics curves (AUC) using Obuchowski's method with a 0.05 level of significance. RESULTS: We show that dark-field imaging has a higher sensitivity for COVID-19-pneumonia than attenuation-based imaging and that the combination of both is superior to one imaging modality alone. Furthermore, a quantitative image analysis shows a significant reduction of dark-field signals for COVID-19-patients. CONCLUSIONS: Dark-field imaging complements and improves conventional radiography for the visualisation and detection of COVID-19-pneumonia.

Computed tomography (CT) imaging uses X-rays to obtain images of the inside of the body. It is used to look at lung damage in patients with COVID-19. However, CT imaging exposes the patient to a considerable amount of radiation. As radiation exposure can lead to the development of cancer, exposure should be minimised. Conventional plain X-ray imaging uses lower amounts of radiation but lacks sensitivity. We used dark-field chest X-ray imaging, which also uses low amounts of radiation, to assess the lungs of patients with COVID-19. Radiologists identified pneumonia in patients more easily from dark-field images than from usual plain X-ray images. We anticipate dark-field X-ray imaging will be useful to follow-up patients suspected of having lung damage.

Sensitivity of photon-counting based K-edge imaging in X-ray computed tomography.

The feasibility of K-edge imaging using energy-resolved, photon-counting transmission measurements in X-ray computed tomography (CT) has been demonstrated by simulations and experiments. The method is based on probing the discontinuities of the attenuation coefficient of heavy elements above and below the K-edge energy by using energy-sensitive, photon counting X-ray detectors. In this paper, we investigate the dependence of the sensitivity of K-edge imaging on the atomic number Z of the contrast material, on the object diameter D , on the spectral response of the X-ray detector and on the X-ray tube voltage. We assume a photon-counting detector equipped with six adjustable energy thresholds. Physical effects leading to a degradation of the energy resolution of the detector are taken into account using the concept of a spectral response function R(E,U) for which we assume four different models. As a validation of our analytical considerations and in order to investigate the influence of elliptically shaped phantoms, we provide CT simulations of an anthropomorphic Forbild-Abdomen phantom containing a gold-contrast agent. The dependence on the values of the energy thresholds is taken into account by optimizing the achievable signal-to-noise ratios (SNR) with respect to the threshold values. We find that for a given X-ray spectrum and object size the SNR in the heavy element's basis material image peaks for a certain atomic number Z. The dependence of the SNR in the high- Z basis-material image on the object diameter is the natural, exponential decrease with particularly deteriorating effects in the case where the attenuation from the object itself causes a total signal loss below the K-edge. The influence of the energy-response of the detector is very important. We observed that the optimal SNR values obtained with an ideal detector and with a CdTe pixel detector whose response, showing significant tailing, has been determined at a synchrotron differ by factors of about two to three. The potentially very important impact of scattered X-ray radiation and pulse pile-up occurring at high photon rates on the sensitivity of the technique is qualitatively discussed.

Performance simulation of an x-ray detector for spectral CT with combined Si and Cd[Zn]Te detection layers.

The most obvious problem in obtaining spectral information with energy-resolving photon counting detectors in clinical computed tomography (CT) is the huge x-ray flux present in conventional CT systems. At high tube voltages (e.g. 140 kVp), despite the beam shaper, this flux can be close to 109 Mcps mm⁻² in the direct beam or in regions behind the object, which are close to the direct beam. Without accepting the drawbacks of truncated reconstruction, i.e. estimating missing direct-beam projection data, a photon-counting energy-resolving detector has to be able to deal with such high count rates. Sub-structuring pixels into sub-pixels is not enough to reduce the count rate per pixel to values that today's direct converting Cd[Zn]Te material can cope with (≤ 10 Mcps in an optimistic view). Below 300 µm pixel pitch, x-ray cross-talk (Compton scatter and K-escape) and the effect of charge diffusion between pixels are problematic. By organising the detector in several different layers, the count rate can be further reduced. However this alone does not limit the count rates to the required level, since the high stopping power of the material becomes a disadvantage in the layered approach: a simple absorption calculation for 300 µm pixel pitch shows that the required layer thickness of below 10 Mcps/pixel for the top layers in the direct beam is significantly below 100 µm. In a horizontal multi-layer detector, such thin layers are very difficult to manufacture due to the brittleness of Cd[Zn]Te. In a vertical configuration (also called edge-on illumination (Ludqvist et al 2001 IEEE Trans. Nucl. Sci. 48 1530-6, Roessl et al 2008 IEEE NSS-MIC-RTSD 2008, Conf. Rec. Talk NM2-3)), bonding of the readout electronics (with pixel pitches below 100 µm) is not straightforward although it has already been done successfully (Pellegrini et al 2004 IEEE NSS MIC 2004 pp 2104-9). Obviously, for the top detector layers, materials with lower stopping power would be advantageous. The possible choices are, however, quite limited, since only 'mature' materials, which operate at room temperature and can be manufactured reliably should reasonably be considered. Since GaAs is still known to cause reliability problems, the simplest choice is Si, however with the drawback of strong Compton scatter which can cause considerable inter-pixel cross-talk. To investigate the potential and the problems of Si in a multi-layer detector, in this paper the combination of top detector layers made of Si with lower layers made of Cd[Zn]Te is studied by using Monte Carlo simulated detector responses. It is found that the inter-pixel cross-talk due to Compton scatter is indeed very high; however, with an appropriate cross-talk correction scheme, which is also described, the negative effects of cross-talk are shown to be removed to a very large extent.

X-ray imaging performance of scintillator-filled silicon pore arrays.

The need for fine detail visibility in various applications such as dental imaging, mammography, but also neurology and cardiology, is the driver for intensive efforts in the development of new x-ray detectors. The spatial resolution of current scintillator layers is limited by optical diffusion. This limitation can be overcome by a pixelation, which prevents optical photons from crossing the interface between two neighboring pixels. In this work, an array of pores was etched in a silicon wafer with a pixel pitch of 50 microm. A very high aspect ratio was achieved with wall thicknesses of 4-7 microm and pore depths of about 400 microm. Subsequently, the pores were filled with Tl-doped cesium iodide (CsI:Tl) as a scintillator in a special process, which includes powder melting and solidification of the CsI. From the sample geometry and x-ray absorption measurement the pore fill grade was determined to be 75%. The scintillator-filled samples have a circular active area of 16 mm diameter. They are coupled with an optical sensor binned to the same pixel pitch in order to measure the x-ray imaging performance. The x-ray sensitivity, i.e., the light output per absorbed x-ray dose, is found to be only 2.5%-4.5% of a commercial CsI-layer of similar thickness, thus very low. The efficiency of the pores to transport the generated light to the photodiode is estimated to be in the best case 6.5%. The modulation transfer function is 40% at 4 lp/mm and 10%-20% at 8 lp/mm. It is limited most likely by the optical gap between scintillator and sensor and by K-escape quanta. The detective quantum efficiency (DQE) is determined at different beam qualities and dose settings. The maximum DQE(0) is 0.28, while the x-ray absorption with the given thickness and fill factor is 0.57. High Swank noise is suspected to be the reason, mainly caused by optical scatter inside the CsI-filled pores. The results are compared to Monte Carlo simulations of the photon transport inside the pore array structure. In addition, some x-ray images of technical and anatomical phantoms are shown. This work shows that scintillator-filled pore arrays can provide x-ray imaging with high spatial resolution, but are not suitable in their current state for most of the applications in medical imaging, where increasing the x-ray doses cannot be tolerated.