Virtual monoenergetic images by spectral detector computed tomography may improve image quality and diagnostic ability for ischemic lesions in acute ischemic stroke.

BACKGROUND: Acute ischemic lesions are challenging to detect by conventional computed tomography (CT). Virtual monoenergetic images may improve detection rates by increased tissue contrast. PURPOSE: To compare the ability to detect ischemic lesions of virtual monoenergetic with conventional images in patients with acute stroke. MATERIAL AND METHODS: We included consecutive patients at our center that underwent brain CT in a spectral scanner for suspicion of acute stroke, onset <12 h, with or without (negative controls) a confirmed cortical ischemic lesion in the initial scan or a follow-up CT or magnetic resonance imaging. Attenuation was measured in predefined areas in ischemic gray (guided by follow-up exams), normal gray, and white matter in conventional images and retrieved in spectral diagrams for the same locations in monoenergetic series at 40-200 keV. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Visual assessment of diagnostic measures was performed by independent review by two neuroradiologists blinded to reconstruction details. RESULTS: In total, 29 patients were included (January 2018 to July 2019). SNR was higher in virtual monoenergetic compared to conventional images, significantly at 60-150 keV. CNR between ischemic gray and normal white matter was higher in monoenergetic images at 40-70 keV compared to conventional images. Virtual monoenergetic images received higher scores in overall image quality. The sensitivity for diagnosing acute ischemia was 93% and 97%, respectively, for the reviewers, compared to 55% of the original report based on conventional images. CONCLUSION: Virtual monoenergetic reconstructions of spectral CIs may improve image quality and diagnostic ability in stroke assessment.