New-Generation 0.55 T MRI of the Knee-Initial Clinical Experience and Comparison With 3 T MRI.

OBJECTIVES: The aim of this study was to compare the detection rate of and reader confidence in 0.55 T knee magnetic resonance imaging (MRI) findings with 3 T knee MRI in patients with acute trauma and knee pain. MATERIALS AND METHODS: In this prospective study, 0.55 T and 3 T knee MRI of 25 symptomatic patients (11 women; median age, 38 years) with suspected internal derangement of the knee was obtained in 1 setting. On the 0.55 T system, a commercially available deep learning image reconstruction algorithm was used (Deep Resolve Gain and Deep Resolve Sharp; Siemens Healthineers), which was not available on the 3 T system. Two board-certified radiologists reviewed all images independently and graded image quality parameters, noted MRI findings and their respective reporting confidence level for the presence or absence, as well as graded the bone, cartilage, meniscus, ligament, and tendon lesions. Image quality and reader confidence levels were compared ( P < 0.05 = significant), and clinical findings were correlated between 0.55 T and 3 T MRI by calculation of the intraclass correlation coefficient (ICC). RESULTS: Image quality was rated higher at 3 T compared with 0.55 T studies (each P ≤ 0.017). Agreement between 0.55 T and 3 T MRI for the detection and grading of bone marrow edema and fractures, ligament and tendon lesions, high-grade meniscus and cartilage lesions, Baker cysts, and joint effusions was perfect for both readers. Overall identification and grading of cartilage and meniscal lesions showed good agreement between high- and low-field MRI (each ICC > 0.76), with lower agreement for low-grade cartilage (ICC = 0.77) and meniscus lesions (ICC = 0.49). There was no difference in readers' confidence levels for reporting lesions of bone, ligaments, tendons, Baker cysts, and joint effusions between 0.55 T and 3 T (each P > 0.157). Reader reporting confidence was higher for cartilage and meniscal lesions at 3 T (each P < 0.041). CONCLUSIONS: New-generation 0.55 T knee MRI, with deep learning-aided image reconstruction, allows for reliable detection and grading of joint lesions in symptomatic patients, but it showed limited accuracy and reader confidence for low-grade cartilage and meniscal lesions in comparison with 3 T MRI.

3D-printed iodine-ink CT phantom for radiomics feature extraction - advantages and challenges.

BACKGROUND: To test and validate novel CT techniques, such as texture analysis in radiomics, repeat measurements are required. Current anthropomorphic phantoms lack fine texture and true anatomic representation. 3D-printing of iodinated ink on paper is a promising phantom manufacturing technique. Previously acquired or artificially created CT data can be used to generate realistic phantoms. PURPOSE: To present the design process of an anthropomorphic 3D-printed iodine ink phantom, highlighting the different advantages and pitfalls in its use. To analyze the phantom's X-ray attenuation properties, and the influences of the printing process on the imaging characteristics, by comparing it to the original input dataset. METHODS: Two patient CT scans and artificially generated test patterns were combined in a single dataset for phantom printing and cropped to a size of 26 × 19 × 30 cm3 . This DICOM dataset was printed on paper using iodinated ink. The phantom was CT-scanned and compared to the original image dataset used for printing the phantom. The water-equivalent diameter of the phantom was compared to that of a patient cohort (N = 104). Iodine concentrations in the phantom were measured using dual-energy CT. 86 radiomics features were extracted from 10 repeat phantom scans and the input dataset. Features were compared using a histogram analysis and a PCA individually and overall, respectively. The frequency content was compared using the normalized spectrum modulus. RESULTS: Low density structures are depicted incorrectly, while soft tissue structures show excellent visual accordance with the input dataset. Maximum deviations of around 30 HU between the original dataset and phantom HU values were observed. The phantom has X-ray attenuation properties comparable to a lightweight adult patient (∼54 kg, BMI 19 kg/m2 ). Iodine concentrations in the phantom varied between 0 and 50 mg/ml. PCA of radiomics features shows different tissue types separate in similar areas of PCA representation in the phantom scans as in the input dataset. Individual feature analysis revealed systematic shift of first order radiomics features compared to the original dataset, while some higher order radiomics features did not. The normalized frequency modulus |f(ω)| of the phantom data agrees well with the original data. However, all frequencies systematically occur more frequently in the phantom compared to the maximum of the spectrum modulus than in the original data set, especially for mid-frequencies (e.g., for ω = 0.3942 mm-1 , |f(ω)|original  = 0.09 * |fmax |original and |f(ω)|phantom  = 0.12 * |fmax |phantom ). CONCLUSIONS: 3D-iodine-ink-printing technology can be used to print anthropomorphic phantoms with a water-equivalent diameter of a lightweight adult patient. Challenges include small residual air enclosures and the fidelity of HU values. For soft tissue, there is a good agreement between the HU values of the phantom and input data set. Radiomics texture features of the phantom scans are similar to the input data set, but systematic shifts of radiomics features in first order features, due to differences in HU values, need to be considered. The paper substrate influences the spatial frequency distribution of the phantom scans. This phantom type is of very limited use for dual-energy CT analyses.

Multimodality imaging and 3D-printing of a thoraco-abdominal aortic aneurysm eroding into the spine.

A rare case of a previously treated thoraco-abdominal aortic aneurysm eroding into the thoracic spine is described. Initially, several follow-up CT angiography scans showed an increasing aneurysm sack, but no endoleak could be depicted. Then, a new rapidly developing erosion into the thoracic spine was noted. MRI imaging excluded any other underlying infectious or malignant process. Additional contrast-enhanced ultrasound excluded an endoleak. A 3D-printed model of the aneurysm and spine and cinematic renderings were created to improve visualization. She underwent relining of the thoracic stent graft. Follow-up imaging showed a stable aneurysm size and no progression of the vertebral erosions.

Metal implants on abdominal CT: does split-filter dual-energy CT provide additional value over iterative metal artifact reduction?

PURPOSE: To assess image quality and metal artifact reduction in split-filter dual-energy CT (sfDECT) of the abdomen with hip or spinal implants using virtual monoenergetic images (VMI) and iterative metal artifact reduction algorithm (iMAR). METHODS: 102 portal-venous abdominal sfDECTs of patients with hip (n = 71) or spinal implants (n = 31) were included in this study. Images were reconstructed as 120kVp-equivalent images (Mixed) and VMI (40-190 keV), with and without iMAR. Quantitative artifact and image noise was measured using 12 different ROIs. Subjective image quality was rated by two readers using a five-point Likert-scale in six categories, including overall image quality and vascular contrast. RESULTS: Lowest quantitative artifact in both hip and spinal implants was measured in VMI190keV-iMAR. However, it was not significantly lower than in MixediMAR (for all ROIs, p = 1.00), which were rated best for overall image quality (hip: 1.00 [IQR: 1.00-2.00], spine: 3.00 [IQR:2.00-3.00]). VMI50keV-iMAR was rated best for vascular contrast (hip: 1.00 [IQR: 1.00-2.00], spine: 2.00 [IQR: 1.00-2.00]), which was significantly better than Mixed (both, p < 0.001). VMI50keV-iMAR provided superior overall image quality compared to Mixed for hip (1.00 vs 2.00, p < 0.001) and similar diagnostic image quality for spinal implants (2.00 vs 2.00, p = 0.51). CONCLUSION: For abdominal sfDECT with hip or spinal implants MixediMAR images should be used. High keV VMI do not further improve image quality. IMAR allows the use of low keV images (VMI50keV) to improve vascular contrast, compared to Mixed images.

Imaging standardisation in metastatic colorectal cancer: A joint EORTC-ESOI-ESGAR expert consensus recommendation.

BACKGROUND: Treatment monitoring in metastatic colorectal cancer (mCRC) relies on imaging to evaluate the tumour burden. Response Evaluation Criteria in Solid Tumors provide a framework on reporting and interpretation of imaging findings yet offer no guidance on a standardised imaging protocol tailored to patients with mCRC. Imaging protocol heterogeneity remains a challenge for the reproducibility of conventional imaging end-points and is an obstacle for research on novel imaging end-points. PATIENTS AND METHODS: Acknowledging the recently highlighted potential of radiomics and artificial intelligence tools as decision support for patient care in mCRC, a multidisciplinary, international and expert panel of imaging specialists was formed to find consensus on mCRC imaging protocols using the Delphi method. RESULTS: Under the guidance of the European Organisation for Research and Treatment of Cancer (EORTC) Imaging and Gastrointestinal Tract Cancer Groups, the European Society of Oncologic Imaging (ESOI) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), the EORTC-ESOI-ESGAR core imaging protocol was identified. CONCLUSION: This consensus protocol attempts to promote standardisation and to diminish variations in patient preparation, scan acquisition and scan reconstruction. We anticipate that this standardisation will increase reproducibility of radiomics and artificial intelligence studies and serve as a catalyst for future research on imaging end-points. For ongoing and future mCRC trials, we encourage principal investigators to support the dissemination of these imaging standards across recruiting centres.

Reducing Visceral-Motion-Related Artifacts on the Liver with Dual-Energy CT: A Comparison of Four Different CT Scanner Techniques.

Purpose: To assess the influence of different dual-energy CT (DECT) scanner techniques on the severity of visceral-motion-related artifacts on the liver. Methods: Two independent readers retrospectively evaluated visceral-motion-related artifacts on the liver on 120-kVp(-like), monoenergetic low- and high-keV, virtual non-contrast (VNC), and iodine images acquired on a dual-source, twin-beam, fast kV-switching, and dual-layer spectral detector scanner. Quantitative assessment: Depth of artifact extension into the liver, measurements of Hounsfield Units (HU) and iodine concentrations. Qualitative assessment: Five-point Likert scale (1 = none to 5 = severe). Artifact severity between image reconstructions were compared by Wilcoxon signed-rank and paired t-tests. Results: 615 contrast-enhanced routine clinical DECT scans of the abdomen were evaluated in 458 consecutive patients (mean age: 61 ± 14 years, 331 men). For dual-source and twin-beam scanners, depth of extension of artifacts into the liver was significantly shorter and artifact severity scores significantly lower for 120-kVp-like images compared with the other image reconstructions (p < 0.001, each). For fast kV-switching and spectral detector scanner images, depth of extension of artifacts was significantly shorter and artifact severity scores significantly lower for iodine images (p < 0.001, each). Dual-source 120-kVp-like and spectral detector iodine images reduced artifacts to an extent that no significant difference in HU or iodine concentrations between artifacts (dual-source: 97 HU, spectral detector: 1.9 mg/mL) and unaffected liver parenchyma (dual-source: 108 HU, spectral detector: 2.1 mg/mL) was measurable (dual-source: p = 0.32, spectral detector: p = 0.15). Conclusion: Visceral-motion-related artifacts on the liver can be markedly reduced by viewing 120-kVp-like images for dual-source and twin-beam DECT scanners and iodine images for fast kV-switching and dual-layer spectral detector DECT scanners.

Reduction of Peristalsis-Related Streak Artifacts on the Liver with Dual-Layer Spectral CT.

Background: Peristalsis-related streak artifacts on the liver compromise image quality and diagnostic accuracy. Purpose: To assess dual-layer spectral-detector computed tomography (CT) image reconstructions for reducing intestinal peristalsis-related streak artifacts on the liver. Methods: We retrospectively evaluated 220 contrast-enhanced abdominal dual-energy CT scans in 131 consecutive patients (mean age: 68 ± 10 years, 120 men) who underwent routine clinical dual-layer spectral-detector CT imaging (120 kVp, 40 keV, 200 keV, virtual non-contrast (VNC), iodine images). Two independent readers evaluated bowel peristalsis streak artifacts on the liver qualitatively on a five-point Likert scale (1 = none to 5 = severe) and quantitatively by depth of streak artifact extension into the liver and measurements of Hounsfield Unit and iodine concentration differences from normal liver. Artifact severity between image reconstructions were compared by Wilcoxon signed-rank and paired t-tests. Results: 12 scans were excluded due to missing spectral data, artifacts on the liver originating from metallic foreign materials, or oral contrast material. Streak artifacts on the liver were seen in 51/208 (25%) scans and involved the left lobe only in 49/51 (96%), the right lobe only in 0/51 (0%), and both lobes in 2/51 (4%) scans. Artifact frequency was lower in iodine than in 120 kVp images (scans 18/208 vs. 51/208, p < 0.001). Artifact severity was less in iodine than in 120 kVp images (median score 1 vs. 3, p < 0.001). Streak artifact extension into the liver was shorter in iodine than 120 kVp images (mean length 2 ± 4 vs. 12 ± 5 mm, p < 0.001). Hounsfield Unit and iodine concentration differed significantly between bright streak artifacts and normal liver in 120 kVp, 40 keV, 200 keV, and VNC images (p < 0.001, each), but not in iodine images (p = 0.23). Conclusion: Intestinal peristalsis-related streak artifacts commonly affect the left liver lobe at CT and can be substantially reduced by viewing iodine dual-energy CT image reconstructions.

Comparison of the performance of conventional and spectral-based tagged stool cleansing algorithms at CT colonography.

OBJECTIVES: To compare the performance of conventional versus spectral-based electronic stool cleansing for iodine-tagged CT colonography (CTC) using a dual-layer spectral detector scanner. METHODS: We retrospectively evaluated iodine contrast stool-tagged CTC scans of 30 consecutive patients (mean age: 69 ± 8 years) undergoing colorectal cancer screening obtained on a dual-layer spectral detector CT scanner. One reader identified locations of electronic cleansing artifacts (n = 229) on conventional and spectral cleansed images. Three additional independent readers evaluated these locations using a conventional cleansing algorithm (Intellispace Portal) and two experimental spectral cleansing algorithms (i.e., fully transparent and translucent tagged stool). For each cleansed image set, readers recorded the severity of over- and under-cleansing artifacts on a 5-point Likert scale (0 = none to 4 = severe) and readability compared to uncleansed images. Wilcoxon's signed-rank tests were used to assess artifact severity, type, and readability (worse, unchanged, or better). RESULTS: Compared with conventional cleansing (66% score ≥ 2), the severity of overall cleansing artifacts was lower in transparent (60% score ≥ 2, p = 0.011) and translucent (50% score ≥ 2, p < 0.001) spectral cleansing. Under-cleansing artifact severity was lower in transparent (49% score ≥ 2, p < 0.001) and translucent (39% score ≥ 2, p < 0.001) spectral cleansing compared with conventional cleansing (60% score ≥ 2). Over-cleansing artifact severity was worse in transparent (17% score ≥ 2, p < 0.001) and translucent (14% score ≥ 2, p = 0.023) spectral cleansing compared with conventional cleansing (9% score ≥ 2). Overall readability was significantly improved in transparent (p < 0.001) and translucent (p < 0.001) spectral cleansing compared with conventional cleansing. CONCLUSIONS: Spectral cleansing provided more robust electronic stool cleansing of iodine-tagged stool at CTC than conventional cleansing. KEY POINTS: • Spectral-based electronic cleansing of tagged stool at CT colonography provides higher quality images with less perception of artifacts than does conventional cleansing. • Spectral-based electronic cleansing could potentially advance minimally cathartic approach for CT colonography. Further clinical trials are warranted.

Positive Versus Neutral Oral Contrast Material for Detection of Malignant Deposits in Intraabdominal Nonsolid Organs on CT.

BACKGROUND. Data are limited regarding utility of positive oral contrast material for peritoneal tumor detection on CT. OBJECTIVE. The purpose of this article is to compare positive versus neutral oral contrast material for detection of malignant deposits in nonsolid intraabdominal organs on CT. METHODS. This retrospective study included 265 patients (133 men, 132 women; median age, 61 years) who underwent an abdominopelvic CT examination in which the report did not suggest presence of malignant deposits and a subsequent CT examination within 6 months in which the report indicated at least one unequivocal malignant deposit. Examinations used positive (iohexol; n = 100) or neutral (water; n = 165) oral agents. A radiologist reviewed images to assess whether the deposits were visible (despite clinical reports indicating no deposits) on unblinded comparison with the follow-up examinations; identified deposits were assigned to one of seven intraabdominal compartments. The radiologist also assessed adequacy of bowel filling with oral contrast material. Two additional radiologists independently reviewed examinations in blinded fashion for malignant deposits. NPV was assessed of clinical CT reports and blinded retrospective readings for detection of malignant deposits visible on unblinded comparison with follow-up examinations. RESULTS. Unblinded review identified malignant deposits in 58.1% (154/265) of examinations. In per-patient analysis of clinical reports, NPV for malignant deposits was higher for examinations with adequate bowel filling with positive oral contrast material (65.8% [25/38]) than for examinations with inadequate bowel filling with positive oral contrast material (45.2% [28/62], p = .07) or with neutral oral contrast material regardless of bowel filling adequacy (35.2% [58/165], p = .002). In per-compartment analysis of blinded interpretations, NPV was higher for examinations with adequate and inadequate bowel filling with positive oral contrast material than for examinations with neutral oral contrast regardless of bowel filling adequacy (reader 1: 94.7% [234/247] and 92.5% [382/413] vs 88.3% [947/1072], both p = .045; reader 2: 93.1% [228/245] and 91.6% [361/394] vs 85.9% [939/1093], both p = .01). CONCLUSION. CT has suboptimal NPV for malignant deposits in intraabdominal nonsolid organs. Compared with neutral material, positive oral contrast material improves detection, particularly with adequate bowel filling. CLINICAL IMPACT. Optimization of bowel preparation for oncologic CT may help avoid potentially severe clinical consequences of missed malignant deposits.

Assessing radiomics feature stability with simulated CT acquisitions.

Medical imaging quantitative features had once disputable usefulness in clinical studies. Nowadays, advancements in analysis techniques, for instance through machine learning, have enabled quantitative features to be progressively useful in diagnosis and research. Tissue characterisation is improved via the "radiomics" features, whose extraction can be automated. Despite the advances, stability of quantitative features remains an important open problem. As features can be highly sensitive to variations of acquisition details, it is not trivial to quantify stability and efficiently select stable features. In this work, we develop and validate a Computed Tomography (CT) simulator environment based on the publicly available ASTRA toolbox ( www.astra-toolbox.com ). We show that the variability, stability and discriminative power of the radiomics features extracted from the virtual phantom images generated by the simulator are similar to those observed in a tandem phantom study. Additionally, we show that the variability is matched between a multi-center phantom study and simulated results. Consequently, we demonstrate that the simulator can be utilised to assess radiomics features' stability and discriminative power.

Dual-energy CT of acute bowel ischemia.

Acute bowel ischemia is a condition with high mortality and requires rapid intervention to avoid catastrophic outcomes. Swift and accurate imaging diagnosis is essential because clinical findings are commonly nonspecific. Conventional contrast enhanced CT of the abdomen has been the imaging modality of choice to evaluate suspected acute bowel ischemia. However, subtlety of image findings and lack of non-contrast or arterial phase images can make correct diagnosis challenging. Dual-energy CT provides valuable information toward assessing bowel ischemia. Dual-energy CT exploits the differential X-ray attenuation at two different photon energy levels to characterize the composition of tissues and reveal the presence or absence of faint intravenous iodinated contrast to improve reader confidence in detecting subtle bowel wall enhancement. With the same underlying technique, virtual non-contrast images can help to show non-enhancing hyperdense hemorrhage of the bowel wall in intravenous contrast-enhanced scans without the need to acquire actual non-contrast scans. Dual-energy CT derived low photon energy (keV) virtual monoenergetic images emphasize iodine contrast and provide CT angiography-like images from portal venous phase scans to better evaluate abdominal arterial patency. In Summary, dual-energy CT aids diagnosing acute bowel ischemia in multiple ways, including improving visualization of the bowel wall and mesenteric vasculature, revealing intramural hemorrhage in contrast enhanced scans, or possibly reducing intravenous contrast dose.

Bowel Peristalsis Artifact on Dual-Energy CT: In Vitro Study on the Influence of Different Dual-Energy CT Platforms and Enteric Contrast Agents.

BACKGROUND. The value of dual-energy CT (DECT) for bowel wall assessment is increasingly recognized. Although technical improvements reduce peristalsis artifact in conventional CT, the effects of peristalsis on DECT image reconstructions remain poorly studied. OBJECTIVE. The purpose of this study was to evaluate the influence of different DECT scanners and enteric contrast agents on the severity of bowel peristalsis artifact in vitro. METHODS. To simulate bowel peristalsis, a 3-cm-diameter corrugated hollow tube representing the bowel was oscillated constantly in the z-axis within a larger water-filled cylinder. The bowel was serially filled with air, water, and iodinated or experimental dark contrast material and scanned on four different DECT platforms (spectral detector, rapid peak kilovoltage switching, split filter, and dual source) to reconstruct 120-kVp-like and iodine images. Two readers rated each image reconstruction for artifact severity from 0 (none) to 3 (severe) and recorded the degree to which iodine images depicted bowel wall hyperattenuation on 120-kVp-like images as artifactual. Artifact severity scores were compared by ANOVA with Bonferroni correction. RESULTS. Interrater agreement on artifact scores was excellent (intraclass correlation coefficient, 0.82 [95% CI, 0.79-0.84]). For 120-kVp-like images, mean peristalsis artifact scores were lower (all p < .001) for split-filter (1.47) and dual-source (1.86) scanners than for spectral-detector (2.58) and rapid-kilovoltage-switching (2.74) scanners. Compared with those on 120-kVp images, peristalsis artifacts on iodine images were less severe for spectral-detector (score, 1.03; p < .001) and rapid-kilovoltage-switching (2.09; p < .001) systems but more severe for dual-source (2.77; p < .001) and split-filter (2.62; p < .001) systems. Peristalsis artifact was rated less severe with experimental dark bowel contrast medium (score, 1.79) than with other bowel contrast agents (all p < .001). Iodine images helped identify bowel wall hyperattenuation as artifactual in 94.7% of reviewed cases for spectral-detector and 40.7% of cases for rapid-kilovoltage-switching scanners. CONCLUSION. For spectral-detector and rapid-kilovoltage-switching DECT, iodine images minimize peristalsis artifact, but for dual-source and split-filter DECT, mixed 120-kVp-like images are preferred. Compared with iodinated contrast material and water, experimental dark bowel contrast material reduces peristalsis artifact. CLINICAL IMPACT. Knowledge of the preferred images for reducing peristalsis artifact can lessen the effect of peristalsis on clinical DECT interpretation. Dark enteric contrast agents, when they become clinically available, may further reduce the effects of peristalsis.

The Discriminative Power and Stability of Radiomics Features With Computed Tomography Variations: Task-Based Analysis in an Anthropomorphic 3D-Printed CT Phantom.

OBJECTIVES: The aims of this study were to determine the stability of radiomics features against computed tomography (CT) parameter variations and to study their discriminative power concerning tissue classification using a 3D-printed CT phantom based on real patient data. MATERIALS AND METHODS: A radiopaque 3D phantom was developed using real patient data and a potassium iodide solution paper-printing technique. Normal liver tissue and 3 lesion types (benign cyst, hemangioma, and metastasis) were manually annotated in the phantom. The stability and discriminative power of 86 radiomics features were assessed in measurements taken from 240 CT series with 8 parameter variations of reconstruction algorithms, reconstruction kernels, slice thickness, and slice spacing. Pairwise parameter group and pairwise tissue class comparisons were performed using Wilcoxon signed rank tests. RESULTS: In total, 19,264 feature stability tests and 8256 discriminative power tests were performed. The 8 CT parameter variation pairwise group comparisons had statistically significant differences on average in 78/86 radiomics features. On the other hand, 84% of the univariate radiomics feature tests had a successful and statistically significant differentiation of the 4 classes of liver tissue. The 86 radiomics features were ranked according to the cumulative sum of successful stability and discriminative power tests. CONCLUSIONS: The differences in radiomics feature values obtained from different types of liver tissue are generally greater than the intraclass differences resulting from CT parameter variations.

Dixon or DWI - Comparing the utility of fat fraction and apparent diffusion coefficient to distinguish between malignant and acute osteoporotic vertebral fractures.

PURPOSE: To compare fat fraction (FF) and apparent diffusion coefficient (ADC) as discriminators distinguishing malignant from acute/subacute osteoporotic vertebral fractures. METHOD: 1.5 T MRIs of 42 malignant and 27 acute/subacute osteoporotic vertebral fractures (38 patients) were retrospectively reviewed. Two readers independently classified fractures as malignant or osteoporotic based on conventional imaging morphology. Diagnostic reader confidence was rated as confident or not confident. FF was derived from axial T1 gradient-echo 2-point Dixon MRI. ADC maps were calculated from axial b50 and b900 images. Both readers independently performed ROI measurements of mean FF and ADC of the same fractured vertebrae. FF and ADC values, corresponding ROC curves and optimized cut-off value performance were compared. Inter-reader agreement was analysed by calculation of intraclass correlation coefficients (ICCs). A p-value < 0.05 was deemed significant. RESULTS: Mean FF and ADC were significantly lower in malignant (9.5 % and 1.05 × 10-3 mm²/s) compared to osteoporotic fractures (32 % and 1.34 × 10-3 mm²/s, all p < 0.001). The optimal cut-off FF was 11.5 %, detecting malignant fractures with 86 %/89 % sensitivity/specificity. The optimal ADC cut-off of 1.04 × 10-3 mm/s² yielded 62 %/96 % sensitivity/specificity. FF AUC (0.93) was significantly larger than ADC AUC (0.82, p = 0.03). In the subgroup of nine cases reported with low expert reader confidence, the optimized cut-off specificities of FF (83 %) and ADC (83 %) exceeded reader specificity (50 %). There was excellent inter-reader agreement for mean FF (ICC = 0.99) and good agreement for mean ADC (ICC = 0.86) measurements. CONCLUSION: FF and ADC can improve reader specificity to distinguish between malignant and acute or subacute osteoporotic vertebral fractures. As single discriminator, FF was superior to ADC.

Improved Sensitivity and Reader Confidence in CT Colonography Using Dual-Layer Spectral CT: A Phantom Study.

Background Limited cathartic preparations for CT colonography with fecal tagging can improve patient comfort but may result in nondiagnostic examinations from poorly tagged stool. Dual-energy CT may overcome this limitation by improving the conspicuity of the contrast agent, but more data are needed. Purpose To investigate whether dual-energy CT improves polyp detection in CT colonography compared with conventional CT at different fecal tagging levels in vitro. Materials and Methods In this HIPAA-compliant study, between December 2017 and August 2019, a colon phantom 30 cm in diameter containing 60 polyps of different shapes (spherical, ellipsoid, flat) and size groups (5-9 mm, 11-15 mm) was constructed and serially filled with simulated feces tagged with four different iodine concentrations (1.26, 2.45, 4.88, and 21.00 mg of iodine per milliliter), then it was scanned with dual-energy CT with and without an outer fat ring to simulate large body size (total diameter, 42 cm). Two readers independently reviewed conventional 120-kVp CT and 40-keV monoenergetic dual-energy CT images to record the presence of polyps and confidence (three-point scale.) Generalized estimating equations were used for sensitivity comparisons between conventional CT and dual-energy CT, and a Wilcoxon signed-rank test was used for reader confidence. Results Dual-energy CT had higher overall sensitivity for polyp detection than conventional CT (58.8%; 95% confidence interval [CI]: 49.7%, 67.3%; 564 of 960 polyps vs 42.1%; 95% CI: 32.1%, 52.8%; 404 of 960 polyps; P < .001), including with the fat ring (48% and 31%, P < .001). Reader confidence improved with dual-energy CT compared with conventional images on all tagging levels (P < .001). Interrater agreement was substantial (κ = 0.74; 95% CI: 0.70, 0.77). Conclusion Compared with conventional 120-kVp CT, dual-energy CT improved polyp detection and reader confidence in a dedicated dual-energy CT colonography phantom, especially with suboptimal fecal tagging. © RSNA, 2020.

Clinical evaluation of a novel multibolus contrast agent injection protocol for thoraco-abdominal CT angiography: Assessment of homogeneity of arterial contrast enhancement.

PURPOSE: To evaluate the in vivo feasibility of a multibolus contrast agent (CA) injection protocol with a reduced CA volume for thoraco-abdominal CT angiography (CTA) and to compare it to a single-bolus CA injection protocol. METHOD: 63 patients who underwent CTA with the multibolus protocol (60 ml CA) were divided in two groups either without (group 1, n = 48) or with (group 2, n = 15) aortic dissection. The aortic contrast enhancement was measured in group 1 using manual ROI analysis (10 segments), as well as semi-automated linear attenuation profiles. A subgroup (n = 18) of group 1, who also underwent imaging with the single-bolus protocol (94 ml CA), was used to compare both protocols. In group 2, differences in attenuation of the true and the false lumen for both the single- and the multibolus protocol were assessed with ROI attenuation measurements in both lumina. Comparisons were made using Wilcoxon test. RESULTS: Average attenuation was above 200 HU for 98 % of cases using the multibolus protocol. There was superior contrast homogeneity for the multibolus protocol with a lower standard deviation of attenuation values along the length of the scan (p = 0.003), while average attenuation was higher for the single-bolus protocol (p = 0.002). Prolonged enhancement plateau lead to a more uniform opacification of the true and the false lumen in patients with aortic dissection using the multibolus protocol (p = 0.012). CONCLUSIONS: The multibolus protocol in thoraco-abdominal CTA is feasible in patients. It shows consistently high arterial enhancement with superior contrast homogeneity compared to a single-bolus protocol in patients with and without aortic dissection.

Quantitative enhancement thresholds and machine learning algorithms for the evaluation of renal lesions using single-phase split-filter dual-energy CT.

PURPOSE: To establish thresholds for contrast enhancement-based attenuation (CM) and iodine concentration (IOD) for the quantitative evaluation of enhancement in renal lesions on single-phase split-filter dual-energy CT (tbDECT) and combine measurements in a machine learning algorithm to potentially improve performance. MATERIAL: 126 patients with incidental renal cysts (both hypo- and hyperdense cysts) or high suspicion for renal cell carcinoma (312 total lesions) undergoing abdominal, portal venous phase tbDECT were initially included in this retrospective study. Gold standard was pathological confirmation or follow-up imaging (MRI or multiphasic CT). CM, IOD, and ROI size were recorded. Thresholds for CM and IOD were identified using Youden-Index of the empirical ROC curves. Decision tree (DTC) and random forest classifier (RFC) were trained. Sensitivities, specificities, and AUCs were compared using McNemar and DeLong test. RESULTS: The final study cohort comprised 40 enhancing and 113 non-enhancing renal lesions. Optimal thresholds for quantitative iodine measurements and contrast enhancement-based attenuation were 1.0 ± 0.0 mg/ml and 23.6 ± 0.3 HU, respectively. Single DECT parameters (IOD, CM) showed similar overall performance with an AUC of 0.894 and 0.858 (p = 0.541) (sensitivity 90 and 80%, specificity 88 and 92%, respectively). While overall performance for the DTC (AUC 0.944) was higher than RFC (AUC 0.886), this difference (p = 0.409) and comparison to CM (p = 0.243) and IOD (p = 0.353) was not statistically significant. CONCLUSIONS: Enhancement in incidental renal lesions on single-phase tbDECT can be classified with up to 87.5% sensitivity and 94.6% specificity. Algorithms combining DECT parameters did not increase overall performance.