Ultra-low dose chest CT with silver filter and deep learning reconstruction significantly reduces radiation dose and retains quantitative information in the investigation and monitoring of lymphangioleiomyomatosis (LAM).

PURPOSE: Frequent CT scans to quantify lung involvement in cystic lung disease increases radiation exposure. Beam shaping energy filters can optimize imaging properties at lower radiation dosages. The aim of this study is to investigate whether use of SilverBeam filter and deep learning reconstruction algorithm allows for reduced radiation dose chest CT scanning in patients with lymphangioleiomyomatosis (LAM). MATERIAL AND METHODS: In a single-center prospective study, 60 consecutive patients with LAM underwent chest CT at standard and ultra-low radiation doses. Standard dose scan was performed with standard copper filter and ultra-low dose scan was performed with SilverBeam filter. Scans were reconstructed using a soft tissue kernel with deep learning reconstruction (AiCE) technique and using a soft tissue kernel with hybrid iterative reconstruction (AIDR3D). Cyst scores were quantified by semi-automated software. Signal-to-noise ratio (SNR) was calculated for each reconstruction. Data were analyzed by linear correlation, paired t-test, and Bland-Altman plots. RESULTS: Patients averaged 49.4 years and 100% were female with mean BMI 26.6 ± 6.1 kg/m2. Cyst score measured by AiCE reconstruction with SilverBeam filter correlated well with that of AIDR3D reconstruction with standard filter, with a 1.5% difference, and allowed for an 85.5% median radiation dosage reduction (0.33 mSv vs. 2.27 mSv, respectively, p < 0.001). Compared to standard filter with AIDR3D, SNR for SilverBeam AiCE images was slightly lower (3.2 vs. 3.1, respectively, p = 0.005). CONCLUSION: SilverBeam filter with deep learning reconstruction reduces radiation dosage of chest CT, while maintaining accuracy of cyst quantification as well as image quality in cystic lung disease. CLINICAL RELEVANCE STATEMENT: Radiation dosage from chest CT can be significantly reduced without sacrificing image quality by using silver filter in combination with a deep learning reconstructive algorithm. KEY POINTS: • Deep learning reconstruction in chest CT had no significant effect on cyst quantification when compared to conventional hybrid iterative reconstruction. • SilverBeam filter reduced radiation dosage by 85.5% compared to standard dose chest CT. • SilverBeam filter in coordination with deep learning reconstruction maintained image quality and diagnostic accuracy for cyst quantification when compared to standard dose CT with hybrid iterative reconstruction.

A Noninvasive Assessment of Flow Based on Contrast Dispersion in Computed Tomography Angiography: A Computational and Experimental Phantom Study.

Transluminal attenuation gradient (TAG), defined as the gradient of the contrast agent attenuation drop along the vessel, is an imaging biomarker that indicates stenosis in the coronary arteries. The transluminal attenuation flow encoding (TAFE) equation is a theoretical platform that quantifies blood flow in each coronary artery based on computed tomography angiography (CTA) imaging. This formulation couples TAG (i.e., contrast dispersion along the vessel) with fluid dynamics. However, this theoretical concept has never been validated experimentally. The aim of this proof-of-principle phantom study is to validate TAFE based on CTA imaging. Dynamic CTA images were acquired every 0.5 s. The average TAFE estimated flow rates were compared against four predefined pump values in a straight (20, 25, 30, 35, and 40 ml/min) and a tapered phantom (25, 35, 45, and 55 ml/min). Using the TAFE formulation with no correction, the flow rates were underestimated by 33% and 81% in the straight and tapered phantoms, respectively. The TAFE formulation was corrected for imaging artifacts focusing on partial volume averaging and radial variation of contrast enhancement. After corrections, the flow rates estimated in the straight and tapered phantoms had an excellent Pearson correlation of r = 0.99 and 0.87 (p < 0.001), respectively, with only a 0.6%±0.2 mL/min difference in estimation of the flow rate. In this proof-of-concept phantom study, we corrected the TAFE formulation and showed a good agreement with the actual pump values. Future clinical validations are needed for feasibility of TAFE in clinical use.

Ultra-Small Lung Cysts Impair Diffusion Without Obstructing Air Flow in Lymphangioleiomyomatosis.

BACKGROUND: Lymphangioleiomyomatosis (LAM) is a rare lung disease found primarily in women of childbearing age, characterized by the formation of air-filled cysts, which may be associated with reductions in lung function. An experimental, regional ultra-high resolution CT scan identified an additional volume of cysts relative to standard chest CT imaging, which consisted primarily of ultra-small cysts. RESEARCH QUESTION: What is the impact of these ultra-small cysts on the pulmonary function of patients with LAM? STUDY DESIGN AND METHODS: A group of 103 patients with LAM received pulmonary function tests and a CT examination in the same visit. Cyst score, the percentage lung volume occupied by cysts, was measured by using commercial software approved by the US Food and Drug Administration. The association between cyst scores and pulmonary function tests of diffusing capacity of the lungs for carbon monoxide (Dlco) (% predicted), FEV1 (% predicted), and FEV1/FVC (% predicted) was assessed with statistical analysis adjusted for demographic variables. The distributions of average cyst size and ultra-small cyst fraction among the patients were evaluated. RESULTS: The additional cyst volume identified by the experimental, higher resolution scan consisted of cysts of 2.2 ± 0.8 mm diameter on average and are thus labeled the "ultra-small cyst fraction." It accounted for 27.9 ± 19.0% of the total cyst volume among the patients. The resulting adjusted, whole-lung cyst scores better explained the variance of Dlco (P < .001 adjusted for multiple comparisons) but not FEV1 and FEV1/FVC (P = 1.00). The ultra-small cyst fraction contributed to the reduction in Dlco (P < .001) but not to FEV1 and FEV1/FVC (P = .760 and .575, respectively). The ultra-small cyst fraction and average cyst size were correlated with cyst burden, FEV1, and FEV1/FVC but less with Dlco. INTERPRETATION: The ultra-small cysts primarily contributed to the reduction in Dlco, with minimal effects on FEV1 and FEV1/FVC. Patients with lower cyst burden and better FEV1 and FEV1/FVC tended to have smaller average cyst size and higher ultra-small cyst fraction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT00001465; URL: www.clinicaltrials.gov.

Morphology and chemical identity of periarticular and vascular calcification in a patient with the rare genetic disease of arterial calcification due to deficiency of CD73 (ACDC).

A 54-year old female patient with the genetic disease of arterial calcification due to deficiency of CD73 was studied under the Undiagnosed Disease Program of the National Institutes of Health. She presented with symptoms of claudication in her 40s and later developed arthritic symptoms, ectopic calcification in her left hand and severe arterial calcifications of the lower extremities. Since little was known about the composition of the calcifications in arterial calcification due to deficiency of CD73, we investigated their chemical identity and microscopic morphology in this patient with imaging and x-ray diffraction analysis. We found that, microscopically, the bulk calcifications consisted of fragments of either solid or porous internal structure. Both periarticular and arterial calcifications were primarily hydroxyapatite crystals of the same crystalline anisotropy, but different crystalline grain sizes. This was consistent with the presence of hydroxyapatite crystals along with birefringent calcium pyrophosphate dihydrate crystals in the synovial fluid of the patients by polarized light microscopy. The result suggests that tissue calcification in both locations follow a similar biochemical mechanism caused by an increase in extracellular tissue-nonspecific alkaline phosphatase activity.

Performance of single-energy metal artifact reduction in cardiac computed tomography: A clinical and phantom study.

BACKGROUND: To investigate the performance of a reconstruction algorithm, single-energy metal artifact reduction (SEMAR), against standard reconstruction in cardiac computed tomography (CT) studies of patients with implanted metal and in a defibrillator lead phantom. METHODS: From a retrospective, cross-sectional clinical study with institutional review board approval of 118 patients with implanted metal, 122 cardiac CT studies from November 2009 to August 2016 performed on a 320-detector row scanner with standard and SEMAR reconstructions were included. The maximum beam hardening artifact radius, artifact attenuation variation surrounding the implanted metal, and image quality on a 4-point scale (1-no/minimal artifact to 4-severe artifact) were assessed for each reconstruction. A defibrillator lead phantom study was performed at different tube potentials and currents with both reconstruction methods. Maximum beam hardening artifact radius and average artifact attenuation variation were measured. RESULTS: In the clinical study, SEMAR markedly reduced the maximum beam hardening artifact radius by 77% (standard: 14.8 mm [IQR 9.7-22.2] vs. SEMAR: 3.4 mm [IQR 2.2-7.1], p < 0.0001) and artifact attenuation variation by 51% (standard: 130.0 HU [IQR 75.9-184.4] vs. SEMAR: 64.3 HU [IQR 48.2-89.2], p < 0.0001). Image quality improved with SEMAR (standard: 3 [IQR 2-3.5] vs. SEMAR: 2 [IQR 1-2.5], p < 0.0001). The defibrillator lead phantom study confirmed these results across varying tube potentials and currents. CONCLUSIONS: SEMAR reconstruction achieved superior image quality and markedly reduced maximum beam hardening artifact radius and artifact attenuation variation compared to standard reconstruction in 122 clinical cardiac CT studies of patients with implanted metal and in a defibrillator lead phantom study.

Clinical CT underestimation of the percentage volume occupied by cysts in patients with lymphangioleiomyomatosis.

PURPOSE: To evaluate the accuracy of cyst score measurements by standard high-resolution helical volume chest CT (HRCT) in patients with lymphangioleiomyomatosis (LAM), using a short z-length ultra-high resolution re-scan (UH re-scan) as the reference. In cystic lung diseases, cyst score is derived from CT scans and defined as the percentage of the total lung parenchymal volume occupied by cysts, a biomarker which measures the severity of the disease. METHODS: In a prospective study of 73 LAM patients, each patient received the standard HRCT chest scan and a short z-length UH re-scan. Cyst scores were acquired from both scans using a standard FDA-approved scoring software on the CT scanner. RESULTS: The limited UH re-scan resolved small cysts that were not resolved in the HRCT. The HRCT-derived cyst scores were on average 59.6% of the reference values from the UH re-scan (p = 4.7e-25). The amount of under-estimation by HRCT varied from patient to patient, with an inter-quartile range of 29.8% and standard deviation of 20.7%. The overall trend was more pronounced underestimation for patients with lower cyst scores. For patients whose reference cyst scores were below 15 (n = 29), the HRCT cyst scores were 46.9 ± 21.6% of reference values (p = 7.4e-12), while for the rest of the patients (n = 44) the HRCT cyst scores were 68.0 ± 15.3% of reference values (p = 1.2E-19). Reconstructing the HRCT images to the resolution of the UH re-scan further widened the spread of the discrepancy between HRCT and reference values due to increased image noise, and did not provide accurate cyst scores. CONCLUSION: Cyst scores derived from standard high-resolution helical volume chest CT significantly underestimates the percentage lung volume occupied by cysts. This inaccuracy needs to be taken into consideration when cyst score is used as part of the CT assessment of the patient's condition.

Prototype Ultrahigh-Resolution Computed Tomography for Chest Imaging: Initial Human Experience.

OBJECTIVE: The objective of this study was to evaluate a prototype, ultrahigh-resolution computed tomography offering higher reconstruction matrix (1024 × 1024) and spatial resolution (0.15 mm) for chest imaging. METHODS: Higher (1024) matrix reconstruction enabled by ultrahigh-resolution computed tomography scanner (128-detector rows; detector width, 0.25 mm; spatial resolution, 0.15 mm) was compared with conventional (512) reconstruction with image quality grading on a Likert scale (1, excellent; 5, nondiagnostic) for image noise, artifacts, contrast, small detail, lesion conspicuity, image sharpness, and diagnostic confidence. Image noise and signal-to-noise ratio were quantified. RESULTS: Diagnostic image quality was achieved for all scans on 101 patients. The 1024 reconstruction demonstrated increased image noise (20.2 ± 4.0 vs 17.2 ± 3.8, P < 0.001) and a worse noise rating (1.98 ± 0.63 vs 1.75 ± 0.61, P < 0.001) but performed significantly better than conventional 512 matrix with fewer artifacts (1.37 ± 0.43 vs 1.50 ± 0.48, P < 0.001), better contrast (1.50 ± 0.56 vs 1.62 ± 0.57, P < 0.001), small detail detection (1.06 ± 0.19 vs 2.02 ± 0.22, P < 0.001), lesion conspicuity (1.08 ± 0.23 vs 2.02 ± 0.24, P < 0.001), sharpness (1.09 ± 0.24 vs 2.02 ± 0.28, P < 0.001), and overall diagnostic confidence (1.09 ± 0.25 vs 1.18 ± 0.34, P < 0.001). CONCLUSIONS: Ultrahigh-resolution computed tomography enabled a higher reconstruction matrix and improved image quality compared with conventional matrix reconstruction, with a minor increase in noise.

Reduced radiation dose with model based iterative reconstruction coronary artery calcium scoring.

Assessing coronary artery calcium (CAC) is a valuable tool for individualizing cardiac risk assessment. In CAC scanning, this technical report assesses the use of a true model-based iterative reconstruction algorithm using forward projected model-based iterative reconstruction ("FIRST") and assess whether FIRST allows for reduced radiation dose CAC scanning on 320-detector row computed tomography (320-CT). Here, 100 consecutive patients prospectively underwent reduced and standard dose scans. For the patients (59 ± 9 years, 61% male) stratified by Agatston categories 0, 1-10, 11-100, 101-400,> 400, agreement between reduced dose with FIRST versus standard dose with FBP was excellent at 81% (95% CI: 73-88%) with kappa 0.74 (95% CI: 0.64-0.85). Median radiation exposure was 75% lower for reduced (0.35 mSv) versus standard dose (1.37 mSv) scans. In conclusion, agreement was excellent for reduced dose with FIRST and standard dose with FBP in 320-detector row CT CAC imaging in well-established categories of cardiovascular risk. These methods make it possible to reduce radiation exposure by 75%.

Chest CT Scan at Radiation Dose of a Posteroanterior and Lateral Chest Radiograph Series: A Proof of Principle in Lymphangioleiomyomatosis.

BACKGROUND: Given the rising utilization of medical imaging and the risks of radiation, there is increased interest in reducing radiation exposure. The objective of this study was to evaluate, as a proof of principle, CT scans performed at radiation doses equivalent to that of a posteroanterior and lateral chest radiograph series in the cystic lung disease lymphangioleiomyomatosis (LAM). METHODS: From November 2016 to May 2018, 105 consecutive subjects with LAM received chest CT scans at standard and ultra-low radiation doses. Standard and ultra-low-dose images, respectively, were reconstructed with routine iterative and newer model-based iterative reconstruction. LAM severity can be quantified as cyst score (percentage of lung occupied by cysts), an ideal benchmark for validating CT scans performed at a reduced dose compared with a standard dose. Cyst scores were quantified using semi-automated software and evaluated by linear correlation and Bland-Altman analysis. RESULTS: Overall, ultra-low-dose CT scans represented a 96% dose reduction, with a median dose equivalent to 1 vs 22 posteroanterior and lateral chest radiograph series (0.14 mSv; 5th-95th percentile, 0.10-0.20 vs standard dose 3.4 mSv; 5th-95th percentile, 1.5-7.4; P < .0001). The mean difference in cyst scores between ultra-low- and standard-dose CT scans was 1.1% ± 2.0%, with a relative difference in cyst score of 11%. Linear correlation coefficient was excellent at 0.97 (P < .0001). CONCLUSIONS: In LAM chest CT scan at substantial radiation reduction to doses equivalent to that of a posteroanterior and lateral chest radiograph series provides cyst score quantification similar to that of standard-dose CT scan. TRIAL REGISTRY: ClinicalTrials.gov; Nos.: NCT00001465 and NCT00001532; URL: www.clinicaltrials.gov.

Feasibility of low radiation dose retrospectively-gated cardiac CT for functional analysis in adult congenital heart disease.

BACKGROUND: The use of cardiac computed tomography (CT) in the evaluation of adult congenital heart disease patients is limited due to concerns of high radiation doses. The purpose of this study was to prospectively assess whether low radiation dose cardiac CT is feasible to evaluate ventricular systolic function in adults with congenital heart disease. METHODS: The study group included 30 consecutive patients with significant congenital heart disease who underwent a total of 35 ECG-gated cardiac CT scans utilizing a 320-detector row CT scanner. Each study included a non-contrast scan and subsequent contrast-enhanced retrospectively-gated acquisition. Effective radiation dose was estimated by multiplying the dose length product by a k-factor of 0.014mSv/mGycm. RESULTS: The mean age of the patients was 34.4±8.9years, 60% were men, and mean body mass index was 24.2±4.3kg/m2. A majority of patients (n=28, 93.3%) had contraindications to cardiac MRI. A tube potential of 80kV was used in 27 (77.1%) of the contrast-enhanced scans. The mean signal-to-noise and contrast-to-noise ratios were 11.5±3.9 and 10.3±3.7, respectively. The median radiation dose for non-contrast and contrast-enhanced images were 0.1mSv (0.07-0.2mSv) and 0.94mSv (0.5-2.1mSv), respectively. All 35 CT scans were successfully analyzed for ventricular systolic function. CONCLUSIONS: A low radiation contrast-enhanced, retrospectively-gated cardiac CT with a median radiation dose of less than 1mSv was successful in evaluating ventricular systolic function in 30 consecutive adult congenital heart disease patients who underwent a total of 35 scans.