Colon distension and scan protocol for CT-colonography: an overview.

This article reviews two important aspects of CT-colonography, namely colonic distension and scan parameters. Adequate distension should be obtained to visualize the complete colonic lumen and optimal scan parameters should be used to prevent unnecessary radiation burden. For optimal distension, automatic carbon dioxide insufflation should be performed, preferably via a thin, flexible catheter. Hyoscine butylbromide is - when available - the preferred spasmolytic agent because of the positive effect on insufflation and pain/burden and its low costs. Scans in two positions are required for adequate distension and high polyp sensitivity and decubitus position may be used as an alternative for patients unable to lie in prone position. The great intrinsic contrast between air or tagging and polyps allows the use of low radiation dose. Low-dose protocol without intravenous contrast should be used when extracolonic findings are deemed unimportant. In patients suspected for colorectal cancer, normal abdominal CT scan protocols and intravenous contrast should be used in supine position for the evaluation of extracolonic findings. Dose reduction can be obtained by lowering the tube current and/or voltage. Tube current modulation reduces the radiation dose (except in obese patients), and should be used when available. Iterative reconstructions is a promising dose reducing tool and dual-energy CT is currently evaluated for its applications in CT-colonography. This review also provides our institution's insufflation procedure and scan parameters.

Effective radiation dose in CT colonography: is there a downward trend?

RATIONALE AND OBJECTIVES: Radiation dose is an important drawback of computed tomography (CT) colonography, especially for its use as a screening tool for colorectal cancer. It is therefore important to know the present radiation dose. Our objective is to assess the effective radiation doses used for CT colonography and its trend over time. MATERIALS AND METHODS: Institutions performing CT colonography research were asked to provide their CT colonography protocols. Median effective doses were calculated and compared with a 2007 inventory. Separate analyses were performed for protocols using intravenous contrast medium and for academic versus nonacademic institutions. Differences in effective dose were tested for significance, using Wilcoxon rank-sum or Wilcoxon signed-rank test. RESULTS: Sixty-two of 109 (57%) institutions responded, providing protocols for 58 institutions. Median effective dose for daily practice protocols was 7.6 mSv (4.3 mSv and 2.0 mSv for supine and prone, respectively) and for screening 4.4 mSv (2.6 mSv and 2.0 mSv, respectively; P = .01). For daily practice with and without contrast medium, the median effective doses were 10.5 mSv and 4.0 mSv (P < .001), respectively. Academic and nonacademic institutions used similar doses (all comparisons P > .05). For institutions also participating in the 2007 inventory, effective dose for both daily practice and screening protocols were similar (P > .05). CONCLUSION: In 2011 the median effective radiation dose for daily practice protocols was 7.6 mSv and for screening 4.4 mSv. Median effective doses have not decreased as compared to 2007. Academic and nonacademic institutions use similar radiation dose.

A history of cranial radiotherapy is associated with a higher visceral to subcutaneous fat ratio in men with pituitary insufficiency.

OBJECTIVE: Endocrine deficiencies, like GH and estrogen deficiencies, are likely candidates to explain increased visceral to subcutaneous fat ratio in patients with pituitary insufficiency. However, recent reports pointed to cranial radiotherapy (CRT) as an additional determinant of an unfavorable fat distribution. Therefore, we determined the effect of CRT on abdominal fat distribution in men with treated pituitary insufficiency. DESIGN: Cross-sectional study. METHODS: Thirty-five consecutive male subjects (16 men with and 19 men without CRT aged 62±12 and 56±14 years respectively, P=0.175) visiting our Endocrine Outpatient Clinic for pituitary insufficiency were invited to participate in this study. A standardized single-slice abdominal CT scan at the level of fourth lumbar vertebra was performed to determine visceral fat area, subcutaneous fat area, and visceral to subcutaneous fat ratio. In addition, we assessed body mass index, total fat percentage with bioelectrical impedance analysis, resting energy expenditure with indirect calorimetry, calorie intake using a diary, and serum hormone concentrations. RESULTS: Subjects with CRT had a smaller subcutaneous fat area (225.1 (71.1-480.7) vs 269.0 (133.2-59.9) cm(2), P=0.022) and a higher visceral to subcutaneous fat ratio (0.79 (0.39-1.55) vs 0.63 (0.23-0.88), P=0.001) than subjects without CRT. Both the groups were comparable for body mass index, waist-hip ratio, resting energy expenditure, and calorie intake. Importantly, serum hormone concentrations were similar. CONCLUSION: In men treated for pituitary insufficiency, previous CRT is associated with a higher visceral to subcutaneous fat ratio.

Interobserver variability in the detection of cerebral venous thrombosis using CT venography with matched mask bone elimination.

OBJECTIVES: Computed tomography venography (CTV) has proven to be a reliable imaging method in the evaluation of cerebral venous thrombosis with good correlation to magnetic resonance (MR) imaging and digital subtraction angiography (DSA). It is fast and widely accessible, especially in the emergency setting. For better visualization of vascular structures bone is often removed from the images. The purpose of this study was to evaluate the quality of a fully automatic bone removal method, matched mask bone elimination (MMBE), and to assess the interobserver variability of the CTV technique. PATIENTS AND METHODS: Fifty patients with clinical suspicion of cerebral venous thrombosis underwent multislice CTV with MMBE post-processing. Axial source images and maximum intensity projections were retrospectively evaluated by two neuroradiologists for quality of bone removal and for the presence or absence of thrombosis in nine dural sinuses and five deep cerebral veins. A per sinus/vein and a per patient analysis (thrombosis in at least one sinus or vein) was performed and interobserver agreement was assessed. RESULTS: Both observers considered bone removal good in all patients (100%). Interobserver agreement per patient was excellent (kappa=0.83), with a full agreement in 47 of 50 patients (94%). The interobserver agreement per sinus or vein was good (kappa=0.76), with a full agreement in 679 of 700 sinuses or veins (97%). CONCLUSION: CTV aided with MMBE is a robust technique for visualization of the intracranial venous circulation, removing bone effectively. CTV has high interobserver agreement for presence or absence of cerebral venous thrombosis.

Influence of tagged fecal material on detectability of colorectal polyps at CT: phantom study.

OBJECTIVE: The purpose of this study was to determine the influence of tagged material on the minimal radiation dose needed to detect colorectal polyps at CT. MATERIALS AND METHODS: The study was conducted in two phases. In the first, three experienced observers determined the visibility of sessile polyps (6 mm) at five contrast levels (300, 480, 790, and 1,040 HU and air) and five tube charge levels (10, 14, 20, 28, and 40 mAs) in an anthropomorphic phantom. Each polyp was present in one of eight possible locations. The mean tube charge threshold for 90% correct responses was determined for each contrast level. Blinded observers performed independent 2D readings. In the second phase of the study, three 150-cm virtual colons were evaluated at two contrast levels (300 and 480 HU) and at five tube charge levels between 20 and 80 mAs. The three colons contained 18 randomly located polyps. The mean tube charge threshold for 90% sensitivity was determined for each contrast level. RESULTS: In the first phase of the study, the estimated tube charge thresholds for 300, 480, and 790 HU were 24.0, 16.3, and 6.2 mAs. At 1,040 HU and in air, all polyps were detected at the lowest tube charge setting (10 mAs). In the second phase, the tube charge thresholds for 90% sensitivity at 300 and 480 HU were 70 and 35 mAs, respectively. CONCLUSION: If polyps are covered by fecal material, a considerably higher tube charge setting is needed for adequate visualization than is needed for polyps in a completely cleansed colon, especially when the density of the tagged residue is low.

Digital chest radiography: an update on modern technology, dose containment and control of image quality.

The introduction of digital radiography not only has revolutionized communication between radiologists and clinicians, but also has improved image quality and allowed for further reduction of patient exposure. However, digital radiography also poses risks, such as unnoticed increases in patient dose and suboptimum image processing that may lead to suppression of diagnostic information. Advanced processing techniques, such as temporal subtraction, dual-energy subtraction and computer-aided detection (CAD) will play an increasing role in the future and are all targeted to decrease the influence of distracting anatomic background structures and to ease the detection of focal and subtle lesions. This review summarizes the most recent technical developments with regard to new detector techniques, options for dose reduction and optimized image processing. It explains the meaning of the exposure indicator or the dose reference level as tools for the radiologist to control the dose. It also provides an overview over the multitude of studies conducted in recent years to evaluate the options of these new developments to realize the principle of ALARA. The focus of the review is hereby on adult applications, the relationship between dose and image quality and the differences between the various detector systems.

Hepatic insulin resistance in antipsychotic naive schizophrenic patients: stable isotope studies of glucose metabolism.

OBJECTIVE: Our objective was to measure insulin sensitivity and body composition in antipsychotic-naive patients with DSM IV schizophrenia and/or schizoaffective disorder compared with matched controls. DESIGN: Seven antipsychotic medication-naive patients fulfilling the DSM IV A criteria for schizophrenia/schizoaffective disorder were matched for body mass index, age, and sex with seven control subjects. We measured endogenous glucose production and peripheral glucose disposal using a hyperinsulinemic euglycemic clamp (plasma insulin concentration approximately 200 pmol/liter) in combination with stable isotopes. Fat content and fat distribution were determined with a standardized single-slice computed tomography scan and whole body dual-energy x-ray absorptiometry. RESULTS: Endogenous glucose production during the clamp was 6.7 micromol/kg x min (sd 2.7) in patients vs. 4.1 micromol/kg x min (sd 1.6) in controls (P = 0.02) (95% confidence interval -5.2 to 0.006). Insulin-mediated peripheral glucose uptake was not different between patients and controls. The amount of sc abdominal fat in patients was 104.6 +/- 28.6 cm(3) and 63.7 +/- 28.0 cm(3) in controls (P = 0.04) (95% confidence interval 4.4-77.2). Intraabdominal fat and total fat mass were not significantly different. CONCLUSIONS: Antipsychotic medication-naive patients with schizophrenia or schizoaffective disorder display hepatic insulin resistance compared with matched controls. This finding cannot be attributed to differences in intraabdominal fat mass or other known factors associated with hepatic insulin resistance and suggests a direct link between schizophrenia and hepatic insulin resistance.

Feasibility study of computed tomography colonography using limited bowel preparation at normal and low-dose levels study.

The purpose was to evaluate low-dose CT colonography without cathartic cleansing in terms of image quality, polyp visualization and patient acceptance. Sixty-one patients scheduled for colonoscopy started a low-fiber diet, lactulose and amidotrizoic-acid for fecal tagging 2 days prior to the CT scan (standard dose, 5.8-8.2 mSv). The original raw data of 51 patients were modified and reconstructed at simulated 2.3 and 0.7 mSv levels. Two observers evaluated the standard dose scan regarding image quality and polyps. A third evaluated the presence of polyps at all three mSv levels in a blinded prospective way. All observers were blinded to the reference standard: colonoscopy. At three times patients were given questionnaires relating to their experiences and preference. Image quality was sufficient in all patients, but significantly lower in the cecum, sigmoid and rectum. The two observers correctly identified respectively 10/15 (67%) and 9/15 (60%) polyps > or =10 mm, with 5 and 8 false-positive lesions (standard dose scan). Dose reduction down to 0.7 mSv was not associated with significant changes in diagnostic value (polyps > or =10 mm). Eighty percent of patients preferred CT colonography and 13% preferred colonoscopy (P<0.001). CT colonography without cleansing is preferred to colonoscopy and shows sufficient image quality and moderate sensitivity, without impaired diagnostic value at dose-levels as low as 0.7 mSv.

Perfusion CT to evaluate the effect of transluminal angioplasty on cerebral perfusion in the treatment of vasospasm after subarachnoid hemorrhage.

INTRODUCTION: Delayed ischemic neurologic deficits secondary to vasospasm are a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Treatment of vasospasm after SAH is associated with complications, and reliable techniques for evaluating effects of treatment of vasospasm in such patients are warranted. We present the use of perfusion computed tomography (PTC) to evaluate the effect of transluminal percutaneous angioplasty in a with SAH and vasospasm-induced ischemia. METHODS: Dynamic PCT with deconvolution produced maps of time-to-peak, mean transit time, regional cerebral blood flow, and regional cerebral blood volume, with a computerized automated map of the infarct and penumbra. CT scanners with quadruple detector array were used before and after angioplasty. RESULTS: Before angioplasty and intraarterial papaverine, PCT showed normal to decreased cerebral blood flow and increased cerebral blood volume and mean transit time in the middle cerebral artery territory of the left hemisphere. After angioplasty and intraarterial papaverine, PCT showed normalization of perfusion parameters. CONCLUSION: PCT can be a useful technique in monitoring angioplasty treatment effects in patients with vasospasm after SAH.

A comparison of primary two- and three-dimensional methods to review CT colonography.

The aim of our study was to compare primary three-dimensional (3D) and primary two-dimensional (2D) review methods for CT colonography with regard to polyp detection and perceptive errors. CT colonography studies of 77 patients were read twice by three reviewers, first with a primary 3D method and then with a primary 2D method. Mean numbers of true and false positives, patient sensitivity and specificity and perceptive errors were calculated with colonoscopy as a reference standard. A perceptive error was made if a polyp was not detected by all reviewers. Mean sensitivity for large (> or = 10 mm) polyps for primary 3D and 2D review was 81% (14.7/18) and 70%(12.7/18), respectively (p-values > or = 0.25). Mean numbers of large false positives for primary 3D and 2D were 8.3 and 5.3, respectively. With primary 3D and 2D review 1 and 6 perceptive errors, respectively, were made in 18 large polyps (p = 0.06). For medium-sized (6-9 mm) polyps these values were for primary 3D and 2D, respectively: mean sensitivity: 67%(11.3/17) and 61%(10.3/17; p-values > or = 0.45), number of false positives: 33.3 and 15.6, and perceptive errors : 4 and 6 (p = 0.53). No significant differences were found in the detection of large and medium-sized polyps between primary 3D and 2D review.

Reduced corneal swelling and deswelling response in the iridocorneal endothelial syndrome.

PURPOSE: Despite severe abnormalities of the corneal endothelium in the iridocorneal endothelial (ICE) syndrome, the cornea can remain clear and maintain its normal thickness for years before corneal decompensation occurs. The aim of this study is to analyze this discrepancy by studying corneal hydration control in the ICE syndrome. METHODS: In four subjects with unilateral ICE syndrome, without signs of corneal decompensation, a "corneal stress test" was performed in both the affected and the unaffected eye. The stress test measures the recovery of corneal thickness after swelling induced by wearing a soft contact lens with the eyes closed. Corneal thickness was measured by noncontact pachymetry. RESULTS: Mean baseline corneal thickness of affected eyes (535+/-56 microm) was not different from unaffected eyes (526+/-39 microm). On the other hand, the corneal stress test showed a smaller induced swelling in affected eyes (33+/-15 microm) compared with unaffected eyes (67+/-11 microm) and a slower recovery of corneal thickness in affected eyes. In one of four subjects, the cornea of the affected eye was calculated not yet to have recovered its original thickness before midnight. After this finding, although the cornea of this subject did not show any signs of clinical decompensation, the study was discontinued. CONCLUSIONS: Corneal hydration control is altered in the ICE syndrome. The ICE cornea can maintain its normal thickness despite severe morphologic abnormalities of the endothelium. Because we found that recovery of corneal thickness can be extremely slow, it cannot be guaranteed that such corneal "stress tests" are completely safe for subjects with the ICE syndrome, and we therefore feel that they should no longer be performed in these subjects.

Effective radiation doses in CT colonography: results of an inventory among research institutions.

The purpose of this study was to estimate the effective dose that is currently used in CT colonography using scan parameters that were collected for this purpose, and to investigate trends in time. PubMed was systematically searched from 1996 until January 2004 for studies investigating CT colonography. Research institutions were contacted and asked for their current scan protocol. Thirty-six institutions published 74 studies. Twenty-eight of the 36 institutions provided their current protocol. The median effective dose in 2004 was 5.1 mSv (range 1.2-11.7 mSv) per position. Most institutions (93%) scan in both the supine and prone positions. The median mAs value was 67 mAs (range 20-200), median collimation was 2.5 mm (range 0.75-5). From 1996 until 2004 a significant decrease in mAs and collimation (P=0.006, P<0.0001, respectively) was observed, while institutions that used a multislice scanner increased (P<0.0001). The effective dose remained constant (P=0.76). In 2004 the median effective dose for a complete CT colonography was 10.2 mSv. Despite the increasing use of multislice scanners, which are slightly less dose-efficient, the median effective dose remained approximately constant between 1996 and 2004. This is mainly caused by the use of lower mAs settings.

Reproducibility of multi-slice spiral computed tomography scans: an experimental study.

In multi-slice spiral computed tomography (CT) images interpolation artifacts are present. The relationship between the x-ray tube rotation angle and these artifacts is demonstrated. A head phantom was repeatedly scanned with a four-slice CT scanner at different pitch values. Two scans, made with identical scan parameters, nearly always have different x-ray tube starting angles. Consequently, artifacts appeared differently and residual artifacts appeared when subtractions were made. We conclude that only if the x-ray tube starting angle is equal for both scans or if a very low pitch is used, images are highly reproducible.

Removal of bone in CT angiography of the cervical arteries by piecewise matched mask bone elimination.

In maximum intensity projection (MIP) images of CT angiography (CTA) scans, the arteries are often obscured by bone. A bone removal method is presented that uses an additional, nonenhanced scan to create a mask of the bone by thresholding and dilation. After registration of the CTA scan and the additional scan, the bone in the CTA scan is masked. As the cervical area contains bones that can move with respect to each other, these bones are separated first using a watershed algorithm, and then registered individually. A phantom study was performed to evaluate and quantify the tradeoff between the removal of the bone and the preservation of the arteries contiguous to the bone. The influence of algorithm parameters and scan parameters was studied. The method was clinically evaluated with data sets of 35 patients. Best results were obtained with a threshold of 150 HU and a dilation of 8 in-plane voxels and two out-of-plane voxels. The mean width of the soft tissue layer, which is also masked, was approximately 1 mm. The mAs value of the nonenhanced scan could be reduced from 250 mAs to 65 mAs without a loss of quality. In 32 cases the bones were registered correctly and removed completely. In three cases the bone separation was not completely successful, and consequently the bone was not completely removed. The piecewise matched mask bone elimination method proved to be able to obtain MIP images of the cervical arteries free from overprojecting bone in a fully automatic way and with only a slight increase of radiation dose.

CT colonography: feasibility of substantial dose reduction--comparison of medium to very low doses in identical patients.

In a feasibility study, the authors compared polyp detection and interobserver variability at computed tomographic (CT) colonography in 15 patients with doses ranging from medium to very low (12.00-0.05 mSv). At levels down to 2% of the medium dose, the mean detection of polyps 5 mm or larger remained at least 74%, while the number of false-positive results decreased and the interobserver agreement remained constant. Initial observations indicate that it is feasible to reduce the radiation dose required for CT colonography. Further studies are needed, however, to investigate the clinical value of very low-dose CT colonography.

Multisection CT venography of the dural sinuses and cerebral veins by using matched mask bone elimination.

Matched mask bone elimination (MMBE) is a technique for the automatic removal of bone pixels from CT angiography data sets. We describe the use of this technique in two patients with the clinical suspicion of dural sinus thrombosis. We conclude that multisection CT venography with MMBE is a useful adjunct for the visualization of the intracranial venous circulation by removing bone from the image. In contrast to techniques described previously, MMBE is fully automated and operator independent.

Removal of arterial wall calcifications in CT angiography by local subtraction.

CT Angiography (CTA) is an established technique for the minimally invasive imaging of arteries. The technique of maximum intensity projection (MIP) is often used to get a comprehensive overview of the vascular anatomy. On a MIP, however, arterial wall calcifications may hinder the visualization of the arterial lumen. These calcifications are in direct contact with the contrast-enhanced blood, which makes removal difficult. We present a local subtraction method for the automatic removal of these calcifications. In our approach a second CT scan has to be made, prior to contrast injection. The calcifications in both scans are registered prior to subtraction to compensate for displacements in between the two scans. Local subtraction results are compared with results obtained by thresholding. The method was tested in a phantom and with data from four patients. The phantom represented an artery with different types of stenosis. Data were used from patients for which CTA of the renal arteries was performed. For two patients the electrocardiogram (ECG) was recorded during the CTA examination, making retrospective cardiac gated reconstructions possible. Both the phantom and the patient study showed that the local subtraction method is capable of removing calcifications and visualizing the residual lumen. In the patient study it appeared that some artifacts remained for higher pitch values. We conclude that the local subtraction method is less subjective and more accurate than thresholding. Best results are obtained by use of a small pitch, at the expense of the volume covered during a single breath hold.