Utility of an automatic adaptive iterative metal artifact reduction AiMAR algorithm in improving CT imaging of patients with hip prostheses evaluated for suspected bladder malignancy.

PURPOSE: To compare the utility of a novel metal artifact reduction algorithm to standard imaging in improving visualization of key structures, diagnostic confidence, and patient-level confidence in malignancy in patients with suspected bladder cancer. METHODS: Patients with hip implants undergoing CT urography for suspected bladder malignancy were enrolled. Images were reconstructed using 3 methods: (1) Filtered Back Projection (FBP), (2) Iterative Metal Artifact Reduction (iMAR), and (3) Adaptive Iterative Metal Artifact Reduction (AiMAR) strength 4. In multiple reading sessions, three radiologists graded visualization of critical anatomic structures and artifact severity (6-point scales, lower scores desirable), and diagnostic confidence in blinded fashion. They also graded patient-level confidence in malignancy based on imaging findings in each patient. RESULTS: Thirty-two patients (8 females) with a mean age of 74.5 ± 8.5 years were included. The median (range) visualization scores for FBP, iMAR, and AiMAR were 3.6 (1.1-4.9), 1.6 (0.3-2.8), and 1.6 (0.3-2.6), respectively. Both iMAR and AiMAR had anatomic visualization and artifact scores better than FBP (P < 0.001 for both) and similar to each other (P > 0.05). Structures with the most improvement in visualization score with the use of metal artifact reduction algorithms included the obturator internus muscle, internal and external iliac nodal chains, and vagina. iMAR and AiMAR improved diagnostic confidence (P < 0.001) and patient-level confidence in malignancy (P ≤ 0.24). CONCLUSION: For patients with hip prostheses and suspected bladder malignancy, the use of iMAR or AiMAR was shown to significantly reduce metal artifacts, thus improving diagnostic confidence and patient-level confidence in malignancy.

Prior iterative reconstruction (PIR) to lower radiation dose and preserve radiologist performance for multiphase liver CT: a multi-reader pilot study.

PURPOSE: Prior iterative reconstruction (PIR) spatially registers CT image data from multiple phases of enhancement to reduce image noise. We evaluated PIR in contrast-enhanced multiphase liver CT. METHODS: Patients with archived projection CT data with proven malignant or benign liver lesions, or without lesions, by reference criteria were included. Lower-dose PIR images were reconstructed using validated noise insertion from multiphase CT exams (50% dose in 2 phases, 25% dose in 1 phase). The phase of enhancement most relevant to the diagnostic task was selected for evaluation. Four radiologists reviewed routine-dose and lower-dose PIR images, circumscribing liver lesions and rating confidence for malignancy (0 to 100) and image quality. JAFROC Figures of Merit (FOM) were calculated. RESULTS: 31 patients had 60 liver lesions (28 primary hepatic malignancies, 6 hepatic metastases, 26 benign lesions). Pooled JAFROC FOM for malignancy for routine-dose CT was 0.615 (95% CI 0.464, 0.767) compared to 0.662 for PIR (95% CI 0.527, 0.797). The estimated FOM difference between the routine-dose and lower-dose PIR images was + 0.047 (95% CI - 0.023, + 0.116). Pooled sensitivity/specificity for routine-dose images was 70%/68% compared to 73%/66% for lower-dose PIR. Lower-dose PIR had lower diagnostic image quality (mean 3.8 vs. 4.2, p = 0.0009) and sharpness (mean 2.3 vs. 2.0, p = 0.0071). CONCLUSIONS: PIR is a promising method to reduce radiation dose for multiphase abdominal CT, preserving observer performance despite small reductions in image quality. Further work is warranted.

Reducing radiation dose for multi-phase contrast-enhanced dual energy renal CT: pilot study evaluating prior iterative reconstruction.

PURPOSE: Prior iterative reconstruction (PIR) uses spatial information from one phase of enhancement to reduce image noise in other phases. We sought to determine if PIR could reduce radiation dose while preserving observer performance and CT number at multi-phase dual energy (DE) renal CT. METHODS: CT projection data from multi-phase DE renal CT examinations were collected. Images corresponding to 40% radiation dose were reconstructed using validated noise insertion and PIR. Three genitourinary radiologists examined routine and 40% dose PIR images. Probability of malignancy was assessed [from 0 to 100] with malignancy assumed at probability ≥ 75. Observer performance was compared on a per patient and per lesion level. CT number accuracy was measured. RESULTS: Twenty-three patients had 49 renal lesions (11 solid renal neoplasms). CT number was nearly identical between techniques (mean CT number difference: unenhanced 2 ± 2 HU; enhanced 4 ± 4 HU). AUC for malignancy was similar between multi-phase routine dose DE and lower dose PIR images [per patient: 0.950 vs. 0.916 (p = 0.356); per lesion: 0.931 vs. 0.884 (p = 0.304)]. Per patient sensitivity was also similar (78% routine dose vs. 82% lower dose [p ≥ 0.99]), as was specificity (91% routine dose vs. 93% lower dose PIR [p > 0.99]), with similar findings on a per lesion level. Subjective image quality was also similar (p = 0.34). CONCLUSIONS: Prior iterative reconstruction is a new reconstruction method for multi-phase CT examinations that promises to facilitate radiation dose reduction by over 50% for multi-phase DE renal CT exams without compromising CT number or observer performance.

High-Resolution Chest Computed Tomography Imaging of the Lungs: Impact of 1024 Matrix Reconstruction and Photon-Counting Detector Computed Tomography.

OBJECTIVES: The aim of this study was to evaluate if a high-resolution photon-counting detector computed tomography (PCD-CT) system with a 1024×1024 matrix reconstruction can improve the visualization of fine structures in the lungs compared with conventional high-resolution CT (HRCT). MATERIALS AND METHODS: Twenty-two adult patients referred for clinical chest HRCT (mean CTDI vol, 13.58 mGy) underwent additional dose-matched PCD-CT (mean volume CT dose index, 13.37 mGy) after written informed consent. Computed tomography images were reconstructed at a slice thickness of 1.5 mm and an image increment of 1 mm with our routine HRCT reconstruction kernels (B46 and Bv49) at 512 and 1024 matrix sizes for conventional energy-integrating detector (EID) CT scans. For PCD-CT, routine B46 kernel and an additional sharp kernel (Q65, unavailable for EID) images were reconstructed at 1024 matrix size. Two thoracic radiologists compared images from EID and PCD-CT noting the highest level bronchus clearly identified in each lobe of the right lung, and rating bronchial wall conspicuity of third- and fourth-order bronchi. Lung nodules were also compared with the B46/EID/512 images using a 5-point Likert scale. Statistical analysis was performed using a Wilcoxon signed rank test with a P < 0.05 considered significant. RESULTS: Compared with B46/EID/512, readers detected higher-order bronchi using B46/PCD/1024 and Q65/PCD/1024 images for every lung lobe (P < 0.0015), but in only the right middle lobe for B46/EID/1024 (P = 0.007). Readers were able to better identify bronchial walls of the third- and fourth-order bronchi better using the Q65/PCD/1024 images (mean Likert scores of 1.1 and 1.5), which was significantly higher compared with B46/EID/1024 or B46/PCD/1024 images (mean difference, 0.8; P < 0.0001). The Q65/PCD/1024 images had a mean nodule score of 1 ± 1.3 for reader 1, and -0.1 (0.9) for reader 2, with one reader having improved nodule evaluation scores for both PCD kernels (P < 0.001), and the other reader not identifying any increased advantage over B46/EID/1024 (P = 1.0). CONCLUSIONS: High-resolution lung PCD-CT with 1024 image matrix reconstruction increased radiologists' ability to visualize higher-order bronchi and bronchial walls without compromising nodule evaluation compared with current chest CT, creating an opportunity for radiologists to better evaluate airway pathology.

Breathe New Life Into Your Chest CT Exams: Using Advanced Acquisition and Postprocessing Techniques.

OBJECTIVE: Chest computed tomography (CT) imaging enables detailed visualization of the pulmonary structures and diseases. This article reviews how continued innovation and improvements in modern CT system hardware and software now facilitate a wider range of image acquisition options and generate unique qualitative and quantitative information that can benefit patients RESULTS: Dual energy imaging utilizes two x-ray energies to highlight differences in tissue properties and increase iodine signal to improve diagnosis or reduce metal artifacts. Ultra-low dose imaging can be performed by using additional x-ray beam filtration, such as a tin filter, combined with iterative reconstruction algorithms to benefit lung cancer screening or pediatric imaging. Ultra-fast pitch spiral acquisition improves temporal resolution and reduces motion artifacts. Higher spatial resolution acquisition and reconstruction methods permit improved visualization of small structures. Radiomic analysis of chest CT image features permits risk stratification of pulmonary nodules and masses and reliable measures of change in pulmonary architecture and disease. CONCLUSIONS: Multiple new CT acquisition and reconstruction techniques, along with advanced post processing methods permit detailed analysis of changes in pulmonary architecture and function, and an expanded ability to adapt chest CT to the unique needs of different patients.

Low kV versus dual-energy virtual monoenergetic CT imaging for proven liver lesions: what are the advantages and trade-offs in conspicuity and image quality? A pilot study.

PURPOSE: Single-energy low tube potential (SE-LTP) and dual-energy virtual monoenergetic (DE-VM) CT images both increase the conspicuity of hepatic lesions by increasing iodine signal. Our purpose was to compare the conspicuity of proven liver lesions, artifacts, and radiologist preferences in dose-matched SE-LTP and DE-VM images. METHODS: Thirty-one patients with 72 proven liver lesions (21 benign, 51 malignant) underwent full-dose contrast-enhanced dual-energy CT (DECT). Half-dose images were obtained using single tube reconstruction of the dual-source SE-LTP projection data (80 or 100 kV), and by inserting noise into dual-energy projection data, with DE-VM images reconstructed from 40 to 70 keV. Three blinded gastrointestinal radiologists evaluated half-dose SE-LTP and DE-VM images, ranking and grading liver lesion conspicuity and diagnostic confidence (4-point scale) on a per-lesion basis. Image quality (noise, artifacts, sharpness) was evaluated, and overall image preference was ranked on per-patient basis. Lesion-to-liver contrast-to-noise ratio (CNR) was compared between techniques. RESULTS: Mean lesion size was 1.5 ± 1.2 cm. Across the readers, the mean conspicuity ratings for 40, 45, and 50 keV half-dose DE-VM images were superior compared to other half-dose image sets (p < 0.0001). Per-lesion diagnostic confidence was similar between half-dose SE-LTP compared to half-dose DE-VM images (p ≥ 0.05; 1.19 vs. 1.24-1.32). However, SE-LTP images had less noise and artifacts and were sharper compared to DE-VM images less than 70 keV (p < 0.05). On a per-patient basis, radiologists preferred SE-LTP images the most and preferred 40-50 keV the least (p < 0.0001). Lesion CNR was also higher in SE-LTP images than DE-VM images (p < 0.01). CONCLUSION: For the same applied dose level, liver lesions were more conspicuous using DE-VM compared to SE-LTP; however, SE-LTP images were preferred more than any single DE-VM energy level, likely due to lower noise and artifacts.

How Low Can We Go in Radiation Dose for the Data-Completion Scan on a Research Whole-Body Photon-Counting Computed Tomography System.

PURPOSE: A research photon-counting computed tomography (CT) system that consists of an energy-integrating detector (EID) and a photon-counting detector (PCD) was installed in our laboratory. The scanning fields of view of the EID and PCD at the isocenter are 500 and 275 mm, respectively. When objects are larger than the PCD scanning field of view, a data-completion scan (DCS) using the EID subsystem is needed to avoid truncation artifacts in PCD images. The goals of this work were to (1) find the impact of a DCS on noise of PCD images and (2) determine the lowest possible dose for a DCS such that truncation artifacts are negligible in PCD images. METHODS: First, 2 semianthropomorphic abdomen phantoms were scanned on the PCD subsystem. For each PCD scan, we acquired 1 DCS with the maximum effective mAs and 5 with lower effective mAs values. The PCD image reconstructed using the maximum effective mAs was considered as the reference image, and those using the lower effective mAs as the test images. The PCD image reconstructed without a DCS was considered the baseline image. Each PCD image was assessed in terms of noise and CT number uniformity; the results were compared among the baseline, test, and reference images. Finally, the impact of a DCS on PCD image quality was qualitatively assessed for other body regions using an anthropomorphic torso phantom. RESULTS: The DCS had a negligible impact on the noise magnitude in the PCD images. The PCD images with the minimum available dose (CTDIvol < 2 mGy) showed greatly enhanced CT number uniformity compared with the baseline images without noticeable truncation artifacts. Further increasing the effective mAs of a DCS did not yield noticeable improvement in CT number uniformity. CONCLUSIONS: A DCS using the minimum available dose had negligible effect on image noise and was sufficient to maintain satisfactory CT number uniformity for the PCD scans.

Physiorack: an integrated MRI safe/conditional, gas delivery, respiratory gating, and subject monitoring solution for structural and functional assessments of pulmonary function.

PURPOSE: To evaluate the use of a modular MRI conditional respiratory monitoring and gating solution, designed to facilitate proper monitoring of subjects' vital signals and their respiratory efforts, during free-breathing and breathheld 19F, oxygen-enhanced, and Fourier-decomposition MRI-based acquisitions. MATERIALS AND METHODS: All Imaging was performed on a Siemens TIM Trio 3 Tesla MRI scanner, following Institutional Review Board approval. Gas delivery is accomplished through the use of an MR compatible pneumotachometer, in conjunction with two three-way pneumatically controlled Hans Rudolph Valves. The pneumatic valves are connected to Douglas bags used as the gas source. A mouthpiece (+nose clip) or an oro-nasal Hans Rudolph disposable mask is connected following the pneumatic valve to minimize dead-space and provide an airtight seal. Continuous monitoring/sampling of inspiratory and expiratory oxygen and carbon dioxide levels at the mouthpiece/mask is achieved through the use of an Oxigraf gas analyzer. RESULTS: Forty-four imaging sessions were successfully monitored, during Fourier-decomposition (n=3), fluorine-enhanced (n=29), oxygen-enhanced, and ultra short echo (n=12) acquisitions. The collected waveforms, facilitated proper monitoring and coaching of the subjects. CONCLUSION: We demonstrate an inexpensive, off-the-shelf solution for monitoring these signals, facilitating assessments of lung function. Monitoring of respiratory efforts and exhaled gas concentrations assists in understanding the heterogeneity of lung function visualized by gas imaging.

Quantification of ventilation distribution in regional lung injury by electrical impedance tomography and xenon computed tomography.

Validation studies of electrical impedance tomography (EIT) based assessment of regional ventilation under pathological conditions are required to prove that EIT can reliably quantify heterogeneous ventilation distribution with sufficient accuracy. The objective of our study was to validate EIT measurements of regional ventilation through a comparison with xenon-multidetector-row computed tomography (XeCT) in an animal model of sub-lobar lung injury. Nine anesthetized mechanically ventilated supine pigs were examined before and after the induction of lung injury in two adjacent sub-lobar segments of the right lung by saline lavage or endotoxin instillation. Regional ventilation was determined in 32 anteroposterior regions of interest in the right and left lungs and the ventilation change quantified by difference images between injury and control. Six animals were included in the final analysis. Measurements of regional ventilation by EIT and XeCT correlated well before (rs = 0.89 right, rs = 0.90 left lung) and after local injury (rs = 0.79 and 0.92, respectively). No bias and narrow limits of agreement were found during both conditions. The ventilation decrease in the right injured lung was correspondingly measured by both modalities (5.5%±1.1% by EIT and 5.4%±1.9% by XeCT, p = 0.94). EIT was inferior to clearly separate the exact anatomical location of the regional injuries. Regional ventilation was overestimated (<2%) in the most ventral and dorsal regions and underestimated (2%) in the middle regions by EIT compared to XeCT. This study shows that EIT is able to reliably discern even small ventilation changes on sub-lobar level.

Perfluoropropane gas as a magnetic resonance lung imaging contrast agent in humans.

BACKGROUND: Fluorine-enhanced MRI is a relatively inexpensive and straightforward technique that facilitates regional assessments of pulmonary ventilation. In this report, we assess its suitability through the use of perfluoropropane (PFP) in a cohort of human subjects with normal lungs and subjects with lung disease. METHODS: Twenty-eight subjects between the ages of 18 and 71 years were recruited for imaging and were classified based on spirometry findings and medical history. Imaging was carried out on a Siemens TIM Trio 3T MRI scanner using two-dimensional, gradient echo, fast low-angle shot and three-dimensional gradient echo, volumetric, interpolated, breath-hold examination sequences for proton localizers and PFP functional scans, respectively. Respiratory waveforms and physiologic signals of interest were monitored throughout the imaging sessions. A region-growing algorithm was applied to the proton localizers to define the lung field of view for analysis of the PFP scans. RESULTS: All subjects tolerated the gas mixture well with no adverse side effects. Images of healthy lungs demonstrated a homogeneous distribution of the gas with sufficient signal-to-noise ratios, while lung images from asthmatic and emphysematous lungs demonstrated increased heterogeneity and ventilation defects. CONCLUSIONS: Fluorine-enhanced MRI using a normoxic PFP gas mixture is a well-tolerated, radiation-free technique for regionally assessing pulmonary ventilation. The inherent physical characteristics and applicability of the gaseous agent within a magnetic resonance setting facilitated a clear differentiation between normal and diseased lungs.