Multi-institutional Protocol Guidance for Pediatric Photon-counting CT.

Performing CT in children comes with unique challenges such as greater degrees of patient motion, smaller and densely packed anatomy, and potential risks of radiation exposure. The technical advancements of photon-counting detector (PCD) CT enable decreased radiation dose and noise, as well as increased spatial and contrast resolution across all ages, compared with conventional energy-integrating detector CT. It is therefore valuable to review the relevant technical aspects and principles specific to protocol development on the new PCD CT platform to realize the potential benefits for this population. The purpose of this article, based on multi-institutional clinical and research experience from pediatric radiologists and medical physicists, is to provide protocol guidance for use of PCD CT in the imaging of pediatric patients.

Standardizing technical parameters and terms for abdominopelvic photon-counting CT: laying the groundwork for innovation and evidence sharing.

Photon-counting detector CT (PCD-CT) is a new technology that has multiple diagnostic benefits including increased spatial resolution, iodine signal, and radiation dose efficiency, as well as multi-energy imaging capability, but which also has unique challenges in abdominal imaging. The purpose of this work is to summarize key features, technical parameters, and terms, which are common amongst current abdominopelvic PCD-CT systems and to propose standardized terminology (where none exists). In addition, user-selectable protocol parameters are highlighted to facilitate both scientific evaluation and early clinical adoption. Unique features of PCD-CT systems include photon-counting detectors themselves, energy thresholds and bins, and tube potential considerations for preserved spectral separation. Key parameters for describing different PCD-CT systems are reviewed and explained. While PCD-CT can generate multi-energy images like dual-energy CT, there are new types of images such as threshold images, energy bin images, and special spectral images. The standardized terms and concepts herein build upon prior interdisciplinary consensus and have been endorsed by the newly created Society of Abdominal Radiology Photon-counting CT Emerging Technology Commission.

Technology Characterization Through Diverse Evaluation Methodologies: Application to Thoracic Imaging in Photon-Counting Computed Tomography.

OBJECTIVE: Different methods can be used to condition imaging systems for clinical use. The purpose of this study was to assess how these methods complement one another in evaluating a system for clinical integration of an emerging technology, photon-counting computed tomography (PCCT), for thoracic imaging. METHODS: Four methods were used to assess a clinical PCCT system (NAEOTOM Alpha; Siemens Healthineers, Forchheim, Germany) across 3 reconstruction kernels (Br40f, Br48f, and Br56f). First, a phantom evaluation was performed using a computed tomography quality control phantom to characterize noise magnitude, spatial resolution, and detectability. Second, clinical images acquired using conventional and PCCT systems were used for a multi-institutional reader study where readers from 2 institutions were asked to rank their preference of images. Third, the clinical images were assessed in terms of in vivo image quality characterization of global noise index and detectability. Fourth, a virtual imaging trial was conducted using a validated simulation platform (DukeSim) that models PCCT and a virtual patient model (XCAT) with embedded lung lesions imaged under differing conditions of respiratory phase and positional displacement. Using known ground truth of the patient model, images were evaluated for quantitative biomarkers of lung intensity histograms and lesion morphology metrics. RESULTS: For the physical phantom study, the Br56f kernel was shown to have the highest resolution despite having the highest noise and lowest detectability. Readers across both institutions preferred the Br56f kernel (71% first rank) with a high interclass correlation (0.990). In vivo assessments found superior detectability for PCCT compared with conventional computed tomography but higher noise and reduced detectability with increased kernel sharpness. For the virtual imaging trial, Br40f was shown to have the best performance for histogram measures, whereas Br56f was shown to have the most precise and accurate morphology metrics. CONCLUSION: The 4 evaluation methods each have their strengths and limitations and bring complementary insight to the evaluation of PCCT. Although no method offers a complete answer, concordant findings between methods offer affirmatory confidence in a decision, whereas discordant ones offer insight for added perspective. Aggregating our findings, we concluded the Br56f kernel best for high-resolution tasks and Br40f for contrast-dependent tasks.

First experience of evaluation of the impact of high-matrix size reconstruction in image quality in arterial CT runoff studies of the lower extremities.

OBJECTIVES: To determine whether image reconstruction with a higher matrix size improves image quality for lower extremity CTA studies. METHODS: Raw data from 50 consecutive lower extremity CTA studies acquired on two MDCT scanners (SOMATOM Flash, Force) in patients evaluated for peripheral arterial disease (PAD) were retrospectively collected and reconstructed with standard (512 × 512) and higher resolution (768 × 768, 1024 × 1024) matrix sizes. Five blinded readers reviewed representative transverse images in randomized order (150 total). Readers graded image quality (0 (worst)-100 (best)) for vascular wall definition, image noise, and confidence in stenosis grading. Ten patients' stenosis scores on CTA images were compared to invasive angiography. Scores were compared using mixed effects linear regression. RESULTS: Reconstructions with 1024 × 1024 matrix were ranked significantly better for wall definition (mean score 72, 95% CI = 61-84), noise (74, CI = 59-88), and confidence (70, CI = 59-80) compared to 512 × 512 (wall = 65, CI = 53 × 77; noise = 67, CI = 52 × 81; confidence = 62, CI = 52 × 73; p = 0.003, p = 0.01, and p = 0.004, respectively). Compared to 512 × 512, the 768 × 768 and 1024 × 1024 matrix improved image quality in the tibial arteries (wall = 51 vs 57 and 59, p < 0.05; noise = 65 vs 69 and 68, p = 0.06; confidence = 48 vs 57 and 55, p < 0.05) to a greater degree than the femoral-popliteal arteries (wall = 78 vs 78 and 85; noise = 81 vs 81 and 84; confidence = 76 vs 77 and 81, all p > 0.05), though for the 10 patients with angiography accuracy of stenosis grading was not significantly different. Inter-reader agreement was moderate (rho = 0.5). CONCLUSION: Higher matrix reconstructions of 768 × 768 and 1024 × 1024 improved image quality and may enable more confident assessment of PAD. CLINICAL RELEVANCE STATEMENT: Higher matrix reconstructions of the vessels in the lower extremities can improve perceived image quality and reader confidence in making diagnostic decisions based on CTA imaging. KEY POINTS: • Higher than standard matrix sizes improve perceived image quality of the arteries in the lower extremities. • Image noise is not perceived as increased even at a matrix size of 1024 × 1024 pixels. • Gains from higher matrix reconstructions are higher in smaller, more distal tibial and peroneal vessels than in femoropopliteal vessels.

Flat-panel dual-energy head computed tomography in the angiography suite after thrombectomy for acute stroke: A clinical feasibility study.

BACKGROUND: Management of large vessel occlusion (LVO) patients after thrombectomy is affected by the presence of intracranial hemorrhage (ICH) on post-procedure imaging. Differentiating contrast staining from hemorrhage on post-procedural imaging has been facilitated by dual-energy computed tomography (DECT), traditionally performed in dedicated computed tomography (CT) scanners with subsequent delays in treatment. We employed a novel method of DECT using the Siemens cone beam CT (DE-CBCT) in the angiography suite to evaluate for post-procedure ICH and contrast extravasation. METHODS: After endovascular treatment for LVO was performed and before the patient was removed from the operating table, DE-CBCT was performed using the Siemens Q-biplane system, with two separate 20-second CBCT scans at two energy levels: 70 keV (standard) and 125 keV with tin filtration (nonstandard). Post-procedurally, patients also underwent a standard DECT using Siemens SOMATOM Force CT scanner. Two independent reviewers blindly evaluated the DE-CBCT and DECT for hemorrhage and contrast extravasation. RESULTS: We successfully performed intra-procedural DE-CBCT in 10 subjects with no technical failure. The images were high-quality and subjectively useful to differentiate contrast from hemorrhage. The one hemorrhage seen on standard DECT was very small and clinically silent. The interrater reliability was 100% for both contrast and hemorrhage detection. CONCLUSION: We demonstrate that intra-procedural DE-CBCT after thrombectomy is feasible and provides clinically meaningful images. There was close agreement between findings on DE-CBCT and standard DECT. Our findings suggest that DE-CBCT could be used in the future to improve stroke thrombectomy patient workflow and to more efficiently guide the postoperative management of these patients.

Liver fat quantification in photon counting CT in head to head comparison with clinical MRI - First experience.

PURPOSE: To compare liver fat quantification between MRI and photon-counting CT (PCCT). METHOD: A cylindrical phantom with inserts containing six concentrations of oil (0, 10, 20, 30, 50 and 100%) and oil-iodine mixtures (0, 10, 20, 30 and 50% fat +3 mg/mL iodine) was imaged with a PCCT (NAEOTOM Alpha) and a 1.5 T MRI system (MR 450w, IDEAL-IQ sequence), using clinical parameters. An IRB-approved prospective clinical evaluation included 12 obese adult patients with known fatty liver disease (seven women, mean age: 61.5 ± 13 years, mean BMI: 30.3 ± 4.7 kg/m2). Patients underwent a same-day clinical MRI and PCCT of the abdomen. Liver fat fractions were calculated for four segments (I, II, IVa and VII) using in- and opposed-phase on MRI ((Meanin - Meanopp)/2*Meanin) and iodine-fat, tissue decomposition analysis in PCCT (Syngo.Via VB60A). CT and MRI Fat fractions were compared using two-sample t-tests with equal variance. Statistical analysis was performed using RStudio (Version1.4.1717). RESULTS: Phantom results showed no significant differences between the known fat fractions (P = 0.32) or iodine (P = 0.6) in comparison to PCCT-measured concentrations, and no statistically significant difference between known and MRI-measured fat fractions (P = 0.363). In patients, the mean fat signal fraction measured on MRI and PCCT was 13.1 ± 9.9% and 12.0 ± 9.0%, respectively, with an average difference of 1.1 ± 1.9% between the modalities (P = 0.138). CONCLUSION: First experience shows promising accuracy of liver fat fraction quantification for PCCT in obese patients. This method may improve opportunistic screening for CT in the future.

Comparison of 100-Kilovoltage Tin Filtration With Advanced Modeled Iterative Reconstruction Protocol to an Automated Kilovoltage Selection With Filtered Back Projection Protocol on Radiation Dose and Image Quality in Pediatric Noncontrast-Enhanced Chest Computed Tomography.

OBJECTIVE: The aim of the study was to compare effects of a 100-kilovoltage (kVp) tin filtration (Sn100kVp) with Advanced Modeled Iterative Reconstruction (ADMIRE) protocol to an automated kVp selection and filtered back projection (FBP) protocol on radiation dose and image quality of in noncontrast-enhanced pediatric chest computed tomography (CT). METHODS: This retrospective study included 55 children (12 ± 6 years) undergoing baseline imaging using automated kVp selection with FBP on a second-generation dual-source CT scanner and follow-up CT using Sn100kVp with ADMIRE on a third-generation dual-source CT scanner. The volume CT dose index, dose length product, size-specific dose estimate, and milliamperage were compared. Image quality was calculated using signal-to-noise ratio and subjectively evaluated by 2 radiologists. RESULTS: Mean volume CT dose index, dose length product, and size-specific dose estimate were lower for the Sn100kVp protocol with ADMIRE (0.83 ± 0.18 mGy, 21.9 ± 7.5 mGy × cm, 1.28 ± 0.24 mGy) compared with the automated kVp protocol with FBP (2.17 ± 1.10 mGy, 65.1 ± 41.1 mGy × cm, 3.25 ± 1.44 mGy, P < 0.001), whereas milliamperage was and subjective image quality were higher for Sn100kVp (P < 0.001). CONCLUSIONS: A Sn100kVp protocol with ADMIRE lowers dose while maintaining image quality in noncontrast-enhanced pediatric chest CT.

Can radiomic analysis of a single-phase dual-energy CT improve the diagnostic accuracy of differentiating enhancing from non-enhancing small renal lesions?

BACKGROUND: The value of dual-energy computed tomography (DECT)-based radiomics in renal lesions is unknown. PURPOSE: To develop DECT-based radiomic models and assess their incremental values in comparison to conventional measurements for differentiating enhancing from non-enhancing small renal lesions. MATERIAL AND METHODS: A total of 349 patients with 519 small renal lesions (390 non-enhancing, 129 enhancing) who underwent contrast-enhanced nephrographic phase DECT examinations between June 2013 and January 2020 on multiple DECT platforms were retrospectively recruited. Cohort A included all lesions, while cohort B included Bosniak II-IV and solid enhancing renal lesions. Radiomic models were built with features selected by the least absolute shrinkage and selection operator regression (LASSO). ROC analyses were performed to compare the diagnostic accuracy among conventional and radiomic models for predicting enhancing renal lesions. RESULTS: The individual iodine concentration (IC), normalized IC, mean attenuation on 75-keV images, radiomic model of iodine images, 75-keV images and a combined model integrating all the above-mentioned features all demonstrated high AUCs for predicting renal lesion enhancement in cohort A (AUCs = 0.934-0.979) as well as in the test dataset (AUCs = 0.892-0.962) of cohort B (P values with Bonferroni correction >0.003). The AUC (0.864) of mean attenuation on 75-keV images was significantly lower than those of other models (all P values ≤0.001) except the radiomic model of 75-keV images (P = 0.038) in the training dataset of cohort B. CONCLUSION: No incremental value was found by adding radiomic and machine learning analyses to iodine images for differentiating enhancing from non-enhancing renal lesions.

Time-resolved, Cardiac-gated Computed Tomography After Endovascular Ascending Aortic and Arch Repair.

PURPOSE: Better time-resolved imaging of stent grafts in the ascending aorta and arch accounting for cardiac motion is necessary to understand device-related complications and endoleaks. This report describes dynamic time-resolved computed tomographic angiography (d-CTA) and its combination with electrocardiography gating (d-gated CTA) to image stent grafts in the ascending aorta and to characterize endoleaks more clearly. DESCRIPTION: d-CTA involves multiple scans acquired at different time points along the contrast enhancement curve. d-Gated CTA involves concomitant electrocardiography gating in a predefined cardiac phase minimizing motion-induced artifacts. EVALUATION: This report illustrates the utility of d-CTA and d-gated CTA in 2 clinical cases. d-CTA demonstrated a type 1A endoleak in a patient with an aortic arch aneurysm treated with total arch debranching and a thoracic stent graft. d-gated CTA demonstrated a type 1A endoleak in a patient with an ascending aortic pseudoaneurysm treated with aortic cuff placement. CONCLUSIONS: Dynamic, cardiac-gated CTA enables time-resolved angiographic imaging of the ascending aorta and arch without any cardiac motion-related artifacts. Such advanced imaging techniques help with better characterization of endoleaks after stent graft deployment in the ascending aorta and arch.

Comparison of radiation dose and image quality between contrast-enhanced single- and dual-energy abdominopelvic computed tomography in children as a function of patient size.

BACKGROUND: Widespread adoption of dual-energy computed tomography (DECT) requires evidence it does not cause higher radiation dose than conventional single-energy CT (SECT). While a few publications involving pediatric patients exist, most have focused on small cohorts. Hence, there is still a need for studies that ascertain what radiation doses are expected in larger populations that include representative ranges of patient sizes and ages. OBJECTIVE: To compare radiation dose and image quality of DECT and SECT abdominopelvic examinations in children as a function of patient size. MATERIALS AND METHODS: This retrospective study included 860 children (age range: 12.3±5.3 years) who underwent contrast-enhanced abdominopelvic exams on second-generation dual-source CT in a five-year period. Two groups, SECT and DECT, consisting of 430 children each, were matched by 5 effective diameters. Volume CT dose index (CTDIvol) and size-specific dose estimate (SSDE) were analyzed as a function of effective diameter. Objective image quality was compared between the groups. RESULTS: DECT SSDEs were lower across all effective patient diameters compared with SECT (mean: 8.5±1.8 mGv vs. 9.3±2.0 mGv, respectively, P≤0.001). DECT CTDIvol was lower compared to SECT (mean: 5.6±2.4 mGv vs. 6.1±2.7 mGv, respectively, P≤0.001) except in the smallest diameter group (<15 cm) where it was comparable to SECT (P=0.065). Objective image quality versus effective diameter between the two CT groups was comparable (P>0.05). CONCLUSION: In children, regardless of effective diameter, contrast-enhanced abdominopelvic DECT can be performed with a similar or lower dose and similar image quality compared with SECT examinations.

A Clinically Driven Task-Based Comparison of Photon Counting and Conventional Energy Integrating CT for Soft Tissue, Vascular, and High-Resolution Tasks.

Photon-counting CT detectors are the next step in advancing CT system development and will replace the current energy integrating detectors (EID) in CT systems in the near future. In this context, the performance of PCCT was compared to EID CT for three clinically relevant tasks: abdominal soft tissue imaging, where differentiating low contrast features is important; vascular imaging, where iodine detectability is critical; and, high-resolution skeletal and lung imaging. A multi-tiered phantom was imaged on an investigational clinical PCCT system (Siemens Healthineers) across different doses using three imaging modes: macro and ultra-high resolution (UHR) PCCT modes and EID CT. Images were reconstructed using filtered backprojection and soft tissue (B30f), vascular (B46f), or high-resolution (B70f; U70f for UHR) kernels. Noise power spectra, task transfer functions, and detectability index were evaluated. For a soft tissue task, PCCT modes showed comparable noise and resolution with improved contrast-to-noise ratio. For a vascular task, PCCT modes showed lower noise and improved iodine detectability. For a high resolution task, macro mode showed lower noise and comparable resolution while UHR mode showed higher noise but improved spatial resolution for both air and bone. PCCT offers competitive advantages to EID CT for clinical tasks.

Evaluating renal lesions using deep-learning based extension of dual-energy FoV in dual-source CT-A retrospective pilot study.

PURPOSE: Dual-source (DS) CT, dual-energy (DE) field of view (FoV) is limited to the size of the smaller detector array. The purpose was to establish a deep learning-based approach to DE extrapolation by estimating missing image data using data from both tubes to evaluate renal lesions. METHOD: A DE extrapolation deep-learning (DEEDL) algorithm had been trained on DECT data of 50 patients using a DSCT with DE-FoV = 33 cm (Somatom Flash). Data from 128 patients with known renal lesions falling within DE-FoV was retrospectively collected (100/140 kVp; reference dataset 1). A smaller DE-FoV = 20 cm was simulated excluding the renal lesion of interest (dataset 2) and the DEEDL was applied to this dataset. Output from the DEEDL algorithm was evaluated using ReconCT v14.1 and Syngo.via. Mean attenuation values in lesions on mixed images (HU) were compared calculating the root-mean-squared-error (RMSE) between the datasets using MATLAB R2019a. RESULTS: The DEEDL algorithm performed well reproducing the image data of the kidney lesions (Bosniak 1 and 2: 125, Bosniak 2F: 6, Bosniak 3: 1 and Bosniak 4/(partially) solid: 32) with RSME values of 10.59 HU, 15.7 HU for attenuation, virtual non-contrast, respectively. The measurements performed in dataset 1 and 2 showed strong correlation with linear regression (r2: attenuation = 0.89, VNC = 0.63, iodine = 0.75), lesions were classified as enhancing with an accuracy of 0.91. CONCLUSION: This DEEDL algorithm can be used to reconstruct a full dual-energy FoV from restricted data, enabling reliable HU value measurements in areas not covered by the smaller FoV and evaluation of renal lesions.

Variability of quantitative measurements of metastatic liver lesions: a multi-radiation-dose-level and multi-reader comparison.

PURPOSE: To evaluate the variability of quantitative measurements of metastatic liver lesions by using a multi-radiation-dose-level and multi-reader comparison. METHODS: Twenty-three study subjects (mean age, 60 years) with 39 liver lesions who underwent a single-energy dual-source contrast-enhanced staging CT between June 2015 and December 2015 were included. CT data were reconstructed with seven different radiation dose levels (ranging from 25 to 100%) on the basis of a single CT acquisition. Four radiologists independently performed manual tumor measurements and two radiologists performed semi-automated tumor measurements. Interobserver, intraobserver, and interdose sources of variability for longest diameter and volumetric measurements were estimated and compared using Wilcoxon rank-sum tests and intraclass correlation coefficients. RESULTS: Inter- and intraobserver variabilities for manual measurements of the longest diameter were higher compared to semi-automated measurements (p < 0.001 for overall). Inter- and intraobserver variabilities of volume measurements were higher compared to the longest diameter measurement (p < 0.001 for overall). Quantitative measurements were statistically different at < 50% radiation dose levels for semi-automated measurements of the longest diameter, and at 25% radiation dose level for volumetric measurements. The variability related to radiation dose was not significantly different from the inter- and intraobserver variability for the measurements of the longest diameter. CONCLUSION: The variability related to radiation dose is comparable to the inter- and intraobserver variability for measurements of the longest diameter. Caution should be warranted in reducing radiation dose level below 50% of a conventional CT protocol due to the potentially detrimental impact on the assessment of lesion response in the liver.

Impact of dual energy cardiac CT for metal artefact reduction post aortic valve replacement.

PURPOSE: Assess image quality of dual-energy (DE) and single-energy (SE) cardiac multi-detector computed tomographic (MDCT) post aortic valve replacement (AVR) on a dual source MDCT scanner. METHODS: Eighty patients with cardiac MDCT acquisitions (ECG gated, dual-source) post-surgical and transcatheter AVR were retrospectively identified. Forty DE (cohort 1) and 40 SE acquisitions (cohort 2; 100 or 120 kVp) were reviewed. Metal artefact at valve coaptation (VC) and valve insertion site (VIS), and contrast enhancement were assessed. Valve leaflet edge definition was graded on a 4-point scale by three radiologists. RESULTS: The mean percentage valve area obscured by metal artifact differed between the cohorts; cohort 1 DE blended, high keV and low keV: 14.8 %, 11.1 % and 17.8 % at VC and 16.4 %, 13 %, 20.4 % at VIS respectively. Cohort 2: 25.8 % and 33.6 % (VC and VIS); each DE reconstruction vs SE: P < 0.0001. Average contrast opacification and coefficient of variance for cohort 1: 562.9 ± 144.7, 281.1 ± 60.3 and 1132.7 ± 300.8 Hounsfield Units (HU) and 9.6 %, 10 % and 8.9 %. For cohort 2: 437.2 ± 119.2 HU and 10.8 % (P < 0.01). Average leaflet edge definition cohort 1: 2.3 ± 0.4, 2.7 ± 0.2 and 2.3 ± 0.2, and cohort 2: 2.9 ± 0.2. CONCLUSION: DE high keV renderings can result in up to 17.2 % less metal artefact compared to standard SE acquisition for cardiac CT. Contrast opacification and homogeneity is higher for DE blended and low keV renderings compared to SE acquisition with leaflet visibility preferred for low keV and blended DE renderings.

Reproducibility of CT Radiomic Features within the Same Patient: Influence of Radiation Dose and CT Reconstruction Settings.

Background Results of recent phantom studies show that variation in CT acquisition parameters and reconstruction techniques may make radiomic features largely nonreproduceable and of limited use for prognostic clinical studies. Purpose To investigate the effect of CT radiation dose and reconstruction settings on the reproducibility of radiomic features, as well as to identify correction factors for mitigating these sources of variability. Materials and Methods This was a secondary analysis of a prospective study of metastatic liver lesions in patients who underwent staging with single-energy dual-source contrast material-enhanced staging CT between September 2011 and April 2012. Technique parameters were altered, resulting in 28 CT data sets per patient that included different dose levels, section thicknesses, kernels, and reconstruction algorithm settings. By using a training data set (n = 76), reproducible intensity, shape, and texture radiomic features (reproducibility threshold, R2 ≥ 0.95) were selected and correction factors were calculated by using a linear model to convert each radiomic feature to its estimated value in a reference technique. By using a test data set (n = 75), the reproducibility of hierarchical clustering based on 106 radiomic features measured with different CT techniques was assessed. Results Data in 78 patients (mean age, 60 years ± 10; 33 women) with 151 liver lesions were included. The percentage of radiomic features deemed reproducible for any variation of the different technical parameters was 11% (12 of 106). Of all technical parameters, reconstructed section thickness had the largest impact on the reproducibility of radiomic features (12.3% [13 of 106]) if only one technical parameter was changed while all other technical parameters were kept constant. The results of the hierarchical cluster analysis showed improved clustering reproducibility when reproducible radiomic features with dedicated correction factors were used (ρ = 0.39-0.71 vs ρ = 0.14-0.47). Conclusion Most radiomic features are highly affected by CT acquisition and reconstruction settings, to the point of being nonreproducible. Selecting reproducible radiomic features along with study-specific correction factors offers improved clustering reproducibility. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Sosna in this issue.

Performance evaluation of computed tomography systems: Summary of AAPM Task Group 233.

BACKGROUND: The rapid development and complexity of new x-ray computed tomography (CT) technologies and the need for evidence-based optimization of image quality with respect to radiation and contrast media dose call for an updated approach towards CT performance evaluation. AIMS: This report offers updated testing guidelines for testing CT systems with an enhanced focus on the operational performance including iterative reconstructions and automatic exposure control (AEC) techniques. MATERIALS AND METHODS: The report was developed based on a comprehensive review of best methods and practices in the scientific literature. The detailed methods include the assessment of 1) CT noise (magnitude, texture, nonuniformity, inhomogeneity), 2) resolution (task transfer function under varying conditions and its scalar reflections), 3) task-based performance (detectability, estimability), and 4) AEC performance (spatial, noise, and mA concordance of attenuation and exposure modulation). The methods include varying reconstruction and tube current modulation conditions, standardized testing protocols, and standardized quantities and metrology to facilitate tracking, benchmarking, and quantitative comparisons. RESULTS: The methods, implemented in cited publications, are robust to provide a representative reflection of CT system performance as used operationally in a clinical facility. The methods include recommendations for phantoms and phantom image analysis. DISCUSSION: In line with the current professional trajectory of the field toward quantitation and operational engagement, the stated methods offer quantitation that is more predictive of clinical performance than specification-based approaches. They can pave the way to approach performance testing of new CT systems not only in terms of acceptance testing (i.e., verifying a device meets predefined specifications), but also system commissioning (i.e., determining how the system can be used most effectively in clinical practice). CONCLUSION: We offer a set of common testing procedures that can be utilized towards the optimal clinical utilization of CT imaging devices, benchmarking across varying systems and times, and a basis to develop future performance-based criteria for CT imaging.

Dual-Energy CT in Children: Imaging Algorithms and Clinical Applications.

Dual-energy CT enables the simultaneous acquisition of CT images at two different x-ray energy spectra. By acquiring high- and low-energy spectral data, dual-energy CT can provide unique qualitative and quantitative information about tissue composition, allowing differentiation of multiple materials including iodinated contrast agents. The two dual-energy CT postprocessing techniques that best exploit the advantages of dual-energy CT in children are the material-decomposition images (which include virtual nonenhanced, iodine, perfused lung blood volume, lung vessel, automated bone removal, and renal stone characterization images) and virtual monoenergetic images. Clinical applications include assessment of the arterial system, lung perfusion, neoplasm, bowel diseases, renal calculi, tumor response to treatment, and metal implants. Of importance, the radiation exposure level of dual-energy CT is equivalent to or less than that of conventional single-energy CT. In this review, the authors discuss the basic principles of the dual-energy CT technologies and postprocessing techniques and review current clinical applications in the pediatric chest and abdomen.

Dual-Energy CT Material Density Iodine Quantification for Distinguishing Vascular From Nonvascular Renal Lesions: Normalization Reduces Intermanufacturer Threshold Variability.

OBJECTIVE: The purpose of this study was to determine whether a single, uniform normalized iodine threshold reduces variability and enables reliable differentiation between vascular and nonvascular renal lesions independent of the dual-energy CT (DECT) platform used. MATERIALS AND METHODS: In this retrospective, HIPAA-compliant, institutional review board-approved study, 247 patients (156 men, 91 women; mean age ± SD, 67 ± 12 years old) with 263 renal lesions (193 nonvascular, 70 vascular) underwent unenhanced single-energy and contrast-enhanced DECT scans. One hundred and six nonvascular and 38 vascular lesions were scanned on two dual-source DECT (dsDECT) scanners, and 87 nonvascular and 32 vascular lesions were scanned on two rapid-kilovoltage-switching single-source DECT (rsDECT) scanners. Optimal absolute and normalized (to aorta) lesion iodine thresholds were determined for each platform type and for the entire cohort combined. RESULTS: Mean optimal absolute discriminant thresholds were 1.3 mg I/mL (95% CI, 1.2-1.9 mg I/mL), 1.6 mg I/mL (95% CI, 0.9-1.5 mg I/mL), and 1.5 mg I/mL (95% CI, 1.4-1.7 mg I/mL) for dsDECT, rsDECT, and combined cohorts, respectively. Optimal normalized discriminant thresholds were 0.3 mg I/mL (95% CI, 0.2-0.4 mg I/mL) for both the dsDECT and rsDECT cohorts, and 0.3 mg I/mL (0.3-0.4 mg I/mL) for the combined cohort. The AUC, sensitivity, and specificity for the combined optimal normalized discriminant threshold of 0.3 mg I/mL was 0.96 (95% CI, 0.92-1.00), 0.93 (0.84-0.97), and 0.95 (0.91-0.98), respectively. Normalization resulted in decreased variability and better lesion separation (effect size, 1.77 vs 1.69, p < 0.0001). CONCLUSION: The optimal absolute discriminant threshold for evaluating renal lesions varies depending on the type of DECT platform, though this difference is not statistically significant. Variation can be reduced with a better separation of vascular and nonvascular lesions by normalizing iodine quantification to the aorta.

Characterization of Small Incidental Indeterminate Hypoattenuating Hepatic Lesions: Added Value of Single-Phase Contrast-Enhanced Dual-Energy CT Material Attenuation Analysis.

OBJECTIVE: The objective of this study is to determine whether single-phase contrast-enhanced dual-energy CT (DECT) material attenuation analysis improves the characterization of small (< 2.0 cm) incidental indeterminate hypoattenuating hepatic lesions, compared with conventional single-energy CT evaluation. MATERIALS AND METHODS: This retrospective study involved 55 patients (24 men and 31 women; mean [± SD] age, 63.9 ± 15.3 years) with 77 incidental hypoattenuating hepatic lesions (59 benign and 18 malignant lesions) measuring 0.5-2.0 cm who underwent single-phase contrast-enhanced DECT of the abdomen for pain. For each lesion, attenuation measurements were obtained using blended 120-kVp-equivalent images and contrast map images. DECT material attenuation images were used for iodine quantification. Optimal lesion attenuation and iodine concentration threshold values that best distinguished benign lesions from malignant lesions were generated using smooth bootstrapping. The diagnostic accuracy of the optimized thresholds was compared using the Wilcox rank sum test. RESULTS: The optimal mean (± standard error) attenuation threshold values that best differentiated benign and malignant lesions were 50.2 ± 5.2 HU and 11.5 ± 2.0 HU when blended 120-kVp and contrast map images, respectively, were used. The iodine concentration (expressed as milligrams of iodine per milliliter) differed significantly (p < 0.0001) between benign lesions (0.6 ± 0.4 mg I/mL) and malignant lesions (1.7 ± 0.4 mg I/mL). The optimal iodine concentration that best distinguished between benign and malignant lesions was 1.2 ± 0.1 mg I/mL. The sensitivity, specificity, and AUC value were highest for iodine concentration (0.94, 0.93, and 0.97, respectively), compared with blended images (0.89, 0.70, and 0.81, respectively) and contrast map images (0.94, 0.64, 0.77, respectively). CONCLUSION: Iodine quantification performed using single-phase contrast-enhanced DECT material attenuation images improves the characterization of small (< 2 cm) incidental indeterminate hypoattenuating hepatic lesions, compared with conventional attenuation measurements.

Evaluating Lens Dose Reduction in Pediatric Neuroradiology Examinations Using Automated Kilovoltage Selection Software.

OBJECTIVE: The purpose of this study is to evaluate the potential of an automated kilo-voltage selection software for the reduction of lens dose in pediatric CT scans. MATERIALS AND METHODS: Two metal oxide semiconductor field effect transistor (MOSFET) detectors measured the lens dose in two anthropomorphic 1- and 5-year-old phantoms. These phantoms were scanned using a clinical pediatric brain protocol at 120 kVp as a control with the MDCT scanner. Scans were then repeated using automated kilovoltage software. The automated kilovoltage was set to operate at tube potentials of 120, 110, and 100 kVp. Dose savings were compared with the average lens dose of both eyes between automated kilovoltage and the control setting. Image quality was studied by contrast-to-noise ratios (CNRs) for each setting. RESULTS: The mean (± SD) lens dose from the routine brain scan without automated kilovoltage was 0.92 ± 0.03 cGy and 0.81 ± 0.03 cGy for the 1- and 5-year-old phantoms, respectively. Use of the automated kilovoltage software at 120 kVp, 110 kVp, and 100 kVp resulted in dose reductions of 9.8%, 17.4%, and 19.6%, respectively, for the 1-year-old phantom and 1.2%, 8.6%, and 17.3%, respectively, for the 5-year-old phantom. The CNR for all automated kilovoltage scans was within 11% of the control scans for the 1-year-old and within 6% for the 5-year-old phantom. CONCLUSION: Our results show that automated kilovoltage software is effective for reducing the radiation dose to the lens of the eye in pediatric patients. Furthermore, the image quality by CNR remained acceptable within 11% of the baseline for all kilovoltage settings used.