Comparison of low-energy virtual monoenergetic images between photon-counting CT and energy-integrating detectors CT: A phantom study.

PURPOSE: The purpose of this study was to assess image quality and dose level using a photon-counting CT (PCCT) scanner by comparison with a dual-source CT (DSCT) scanner on virtual monoenergetic images (VMIs) at low energy levels. MATERIALS AND METHODS: A phantom was scanned using a DSCT and a PCCT with a volume CT dose index of 11 mGy, and additionally at 6 mGy and 1.8 mGy for PCCT. Noise power spectrum and task-based transfer function were evaluated from 40 to 70 keV on VMIs to assess noise magnitude and noise texture (fav) and spatial resolution on two iodine inserts (f50), respectively. A detectability index (d') was computed to assess the detection of two contrast-enhanced lesions according to the energy level used. RESULTS: For all energy levels, noise magnitude values were lower with PCCT than with DSCT at 11 and 6 mGy, but greater at 1.8 mGy. fav values were higher with PCCT than with DSCT at 11 mGy (8.6 ± 1.5 [standard deviation [SD]%), similar at 6 mGy (1.6 ± 1.5 [SD]%) and lower at 1.8 mGy (-17.8 ± 2.2 [SD]%). For both inserts, f50 values were higher with PCCT than DSCT at 11- and 6 mGy for all keV levels, except at 6 mGy and 40 keV. d' values were higher with PCCT than with DSCT at 11- and 6 mGy for all keV and both simulated lesions. Similar d' values to those of the DSCT at 11 mGy, were obtained at 2.25 mGy for iodine insert at 2 mg/mL and at 0.96 mGy for iodine insert at 4 mg/mL at 40 keV. CONCLUSION: Compared to DSCT, PCCT reduces noise magnitude and improves noise texture, spatial resolution and detectability on VMIs for all low-keV levels.

Value of virtual non-contrast images to identify uncomplicated cystic renal lesions: photon-counting detector CT vs. dual-energy integrating detector CT.

PURPOSE: To investigate the value of photon-counting detector CT (PCD-CT) derived virtual non-contrast (VNC) reconstructions to identify renal cysts in comparison with conventional dual-energy integrating detector (DE EID) CT-derived VNC reconstructions. MATERIAL AND METHODS: We prospectively enrolled consecutive patients with simple renal cysts (Bosniak classification-Version 2019, density ≤ 20 HU and/or enhancement ≤ 20 HU) who underwent multiphase (non-contrast, arterial, portal venous phase) PCD-CT and for whom non-contrast and portal venous phase DE EID-CT was available. Subsequently, VNC reconstructions were calculated for all contrast phases and density as well as contrast enhancement within the cysts were measured and compared. MRI and/or ultrasound served as reference standards for lesion classification. RESULTS: 19 patients (1 cyst per patient; age 69.5 ± 10.7 years; 17 [89.5%] male) were included. Density measurements on PCD-CT non-contrast and VNC reconstructions (arterial and portal venous phase) revealed no significant effect on HU values (p = 0.301). In contrast, a significant difference between non-contrast vs. VNC images was found for DE EID-CT (p = 0.02). For PCD-CT, enhancement for VNC reconstructions was < 20 HU for all evaluated cysts. DE EID-CT measurements revealed an enhancement of > 20 HU in five lesions (26.3%) using the VNC reconstructions, which was not seen with the non-contrast images. CONCLUSION: PCD-CT-derived VNC images allow for reliable and accurate characterization of simple cystic renal lesions similar to non-contrast scans whereas VNC images calculated from DE EID-CT resulted in substantial false characterization. Thus, PCD-CT-derived VNC images may substitute for non-contrast images and reduce radiation dose and follow-up imaging.

Photon-counting CT-angiography in pre-TAVR aortic annulus assessment: effects of retrospective vs. prospective ECG-synchronization on prosthesis valve selection.

To compare the diagnostic value of ultrahigh-resolution CT-angiography (UHR-CTA) compared with high-pitch spiral CTA (HPS-CTA) using a first-generation, dual-source photon-counting CT (PCD-CT) scanner for preprocedural planning of transcatheter aortic valve replacement (TAVR). Clinically referred patients with severe aortic valve stenosis underwent both, retrospective ECG-gated cardiac UHR-CTA (collimation: 120 × 0.2 mm) and prospective ECG-triggered aortoiliac HPS-CTA (collimation: 144 × 0.4 mm, full spectral capabilities) for TAVR planning from August 2022 to March 2023. Radiation dose was extracted from the CT reports, and the effective dose was calculated. Two radiologists analyzed UHR-CTA and HPS-CTA datasets, assessing the image quality of the aortic annulus, with regard to the lumen visibility and margin delineation using a 4-point visual-grading scale (ranges: 4 = "excellent" to 1 = "poor"). Aortic annulus area (AAA) measurements were taken for valve prosthesis sizing, with retrospective UHR-CTA serving as reference standard. A total of 64 patients were included (mean age, 81 years ± 7 SD; 28 women) in this retrospective study. HPS-CTA showed a lower radiation dose, 4.1 mSv vs. 12.6 mSv (p < 0.001). UHR-CTA demonstrated higher image quality to HPS-CTA (median score, 4 [IQR, 3-4] vs. 3 [IQR, 2-3]; p < 0.001). Quantitative assessments of AAA from both CTA datasets were strongly positively correlated (mean 477.4 ± 91.1 mm2 on UHR-CTA and mean 476.5 ± 90.4 mm2 on HPS-CTA, Pearson r2 = 0.857, p < 0.001) with a mean error of 22.3 ± 24.6 mm2 and resulted in identical valve prosthesis sizing in the majority of patients (91%). Patients with lower image quality on HPS-CTA (score value 1 or 2, n = 28) were more likely to receive different sizing recommendations (82%). Both UHR-CTA and HPS-CTA acquisitions using photon-counting CT technology provided reliable aortic annular assessments for TAVR planning. While UHR-CTA offers superior image quality, HPS-CTA is associated with lower radiation exposure. However, severely impaired image quality on HPS-CTA may impact on prosthesis sizing, suggesting that immediate post-scan image evaluations may require complementary UHR-CTA scanning.

Ultra-high-resolution photon-counting detector CT in evaluating coronary stent patency: a comparison to invasive coronary angiography.

OBJECTIVES: To determine the diagnostic accuracy of ultra-high-resolution photon-counting detector CT angiography (UHR PCD-CTA) for evaluating coronary stent patency compared to invasive coronary angiography (ICA). METHODS: Consecutive, clinically referred patients with prior coronary stent implantation were prospectively enrolled between August 2022 and March 2023 and underwent UHR PCD-CTA (collimation, 120 × 0.2 mm). Two radiologists independently analyzed image quality of the in-stent lumen using a 5-point Likert scale, ranging from 1 ("excellent") to 5 ("non-diagnostic"), and assessed all coronary stents for the presence of in-stent stenosis (≥ 50% lumen narrowing). The diagnostic accuracy of UHR PCD-CTA was determined, with ICA serving as the standard of reference. RESULTS: A total of 44 coronary stents in 18 participants (mean age, 83 years ± 6 [standard deviation]; 12 women) were included in the analysis. In 3/44 stents, both readers described image quality as non-diagnostic, whereas reader 2 noted a fourth stent to have non-diagnostic image quality. In comparison to ICA, UHR PCD-CTA demonstrated a sensitivity, specificity, and accuracy of 100% (95% CI [confidence interval] 47.8, 100), 92.3% (95% CI 79.1, 98.4), and 93.2% (95% CI 81.3, 98.6) for reader 1 and 100% (95% CI 47.8, 100), 87.2% (95% CI 72.6, 95.7), and 88.6% (95% CI 75.4, 96.2) for reader 2, respectively. Both readers observed a 100% negative predictive value (36/36 stents and 34/34 stents). Stent patency inter-reader agreement was 90.1%, corresponding to a substantial Cohen's kappa value of 0.72. CONCLUSIONS: UHR PCD-CTA enables non-invasive assessment of coronary stent patency with high image quality and diagnostic accuracy. CLINICAL RELEVANCE STATEMENT: Ultra-high-resolution photon-counting detector CT angiography represents a reliable and non-invasive method for assessing coronary stent patency. Its high negative predictive value makes it a promising alternative over invasive coronary angiography for the rule-out of in-stent stenosis. KEY POINTS: • CT-based evaluation of coronary stent patency is limited by stent-induced artifacts and spatial resolution. • Ultra-high-resolution photon-counting detector CT accurately evaluates coronary stent patency compared to invasive coronary angiography. • Photon-counting detector CT represents a promising method for the non-invasive rule-out of in-stent stenosis.

Photon-counting computed tomography - clinical application in oncological, cardiovascular, and pediatric radiology. / Photon-Counting Computertomographie ­ klinische Anwendungen in der onkologischen, kardiovaskulären und pädiatrischen Radiologie.

BACKGROUND: Photon-counting detector computed tomography (PCD-CT) is a promising new technology with the potential to fundamentally change workflows in the daily routine and provide new quantitative imaging information to improve clinical decision-making and patient management. METHOD: The contents of this review are based on an unrestricted literature search of PubMed and Google Scholar using the search terms "photon-counting CT", "photon-counting detector", "spectral CT", "computed tomography" as well as on the authors' own experience. RESULTS: The fundamental difference with respect to the currently established energy-integrating CT detectors is that PCD-CT allows for the counting of every single photon at the detector level. Based on the identified literature, PCD-CT phantom measurements and initial clinical studies have demonstrated that the new technology allows for improved spatial resolution, reduced image noise, and new possibilities for advanced quantitative image postprocessing. CONCLUSION: For clinical practice, the potential benefits include fewer beam hardening artifacts, a radiation dose reduction, and the use of new or combinations of contrast agents. In particular, critical patient groups such as oncological, cardiovascular, lung, and head & neck as well as pediatric patient collectives benefit from the clinical advantages. KEY POINTS: · Photon-counting computed tomography (PCD-CT) is being used for the first time in routine clinical practice, enabling a significant dose reduction in critical patient populations such as oncology, cardiology, and pediatrics.. · Compared to conventional CT, PCD-CT enables a reduction in electronic image noise.. · Due to the spectral data sets, PCD-CT enables fully comprehensive post-processing applications.. CITATION FORMAT: · Hagen F, Soschynski M, Weis M et al. Photon-counting computed tomography - clinical application in oncological, cardiovascular, and pediatric radiology. Fortschr Röntgenstr 2024; 196: 25 - 34.

Impact of different metal artifact reduction techniques in photon-counting computed tomography head and neck scans in patients with dental hardware.

OBJECTIVES: Metal artifacts remain a challenge in computed tomography. We investigated the potential of photon-counting computed tomography (PCD-CT) for metal artifact reduction using an iterative metal artifact reduction (iMAR) algorithm alone and in combination with high keV monoenergetic images (140 keV) in patients with dental hardware. MATERIAL AND METHODS: Consecutive patients with dental implants were prospectively included in this study and received PCD-CT imaging of the craniofacial area. Four series were reconstructed (standard [PCD-CTstd], monoenergetic at 140 keV [PCD-CT140keV], iMAR corrected [PCD-CTiMAR], combination of iMAR and 140 keV monoenergetic [PCD-CTiMAR+140keV]). All reconstructions were assessed qualitatively by four radiologists (independent and blinded reading on a 5-point Likert scale [5 = excellent; no artifact]) regarding overall image quality, artifact severity, and delineation of adjacent and distant anatomy. To assess signal homogeneity and evaluate the magnitude of artifact reduction, we performed quantitative measures of coefficient of variation (CV) and a region of interest (ROI)-based relative change in artifact reduction [PCD-CT/PCD-CTstd]. RESULTS: We enrolled 48 patients (mean age 66.5 ± 11.2 years, 50% (n = 24) males; mean BMI 25.2 ± 4.7 kg/m2; mean CTDIvol 6.2 ± 6 mGy). We found improved overall image quality, reduced artifacts and superior delineation of both adjacent and distant anatomy for the iMAR vs. non-iMAR reconstructions (all p < 0.001). No significant effect of the different artifact reduction approaches on CV was observed (p = 0.42). The ROI-based analysis indicated the most effective artifact reduction for the iMAR reconstructions, which was significantly higher compared to PCD-CT140keV (p < 0.001). CONCLUSION: PCD-CT offers highly effective approaches for metal artifact reduction with the potential to overcome current diagnostic challenges in patients with dental implants. CLINICAL RELEVANCE STATEMENT: Metallic artifacts pose a significant challenge in CT imaging, potentially leading to missed findings. Our study shows that PCD-CT with iMAR post-processing reduces artifacts, improves image quality, and can possibly reveal pathologies previously obscured by artifacts, without additional dose application. KEY POINTS: • Photon-counting detector CT (PCD-CT) offers highly effective approaches for metal artifact reduction in patients with dental fillings/implants. • Iterative metal artifact reduction (iMAR) is superior to high keV monoenergetic reconstructions at 140 keV for artifact reduction and provides higher image quality. • Signal homogeneity of the reconstructed images is not affected by the different artifact reduction techniques.

Detectability and Volumetric Accuracy of Pulmonary Nodules in Low-Dose Photon-Counting Detector Computed Tomography: An Anthropomorphic Phantom Study.

The aim of this phantom study was to assess the detectability and volumetric accuracy of pulmonary nodules on photon-counting detector CT (PCD-CT) at different low-dose levels compared to conventional energy-integrating detector CT (EID-CT). In-house fabricated artificial nodules of different shapes (spherical, lobulated, spiculated), sizes (2.5-10 mm and 5-1222 mm3), and densities (-330 HU and 100 HU) were randomly inserted into an anthropomorphic thorax phantom. The phantom was scanned with a low-dose chest protocol with PCD-CT and EID-CT, in which the dose with PCD-CT was lowered from 100% to 10% with respect to the EID-CT reference dose. Two blinded observers independently assessed the CT examinations of the nodules. A third observer measured the nodule volumes using commercial software. The influence of the scanner type, dose, observer, physical nodule volume, shape, and density on the detectability and volumetric accuracy was assessed by a multivariable regression analysis. In 120 CT examinations, 642 nodules were present. Observer 1 and 2 detected 367 (57%) and 289 nodules (45%), respectively. With PCD-CT and EID-CT, the nodule detectability was similar. The physical nodule volumes were underestimated by 20% (range 8-52%) with PCD-CT and 24% (range 9-52%) with EID-CT. With PCD-CT, no significant decrease in the detectability and volumetric accuracy was found at dose reductions down to 10% of the reference dose (p > 0.05). The detectability and volumetric accuracy were significantly influenced by the observer, nodule volume, and a spiculated nodule shape (p < 0.05), but not by dose, CT scanner type, and nodule density (p > 0.05). Low-dose PCD-CT demonstrates potential to detect and assess the volumes of pulmonary nodules, even with a radiation dose reduction of up to 90%.

Photon-counting computed tomography of coronary and peripheral artery stents: a phantom study.

Accurate small vessel stent visualization using CT remains challenging. Photon-counting CT (PCD-CT) may help to overcome this issue. We systematically investigate PCD-CT impact on small vessel stent assessment compared to energy-integrating-CT (EID). 12 water-contrast agent filled stents (3.0-8 mm) were scanned with patient-equivalent phantom using clinical PCD-CT and EID-CT. Images were reconstructed using dedicated vascular kernels. Subjective image quality was evaluated by 5 radiologists independently (5-point Likert-scale; 5 = excellent). Objective image quality was evaluated by calculating multi-row intensity profiles including edge rise slope (ERS) and coefficient-of-variation (CV). Highest overall reading scores were found for PCD-CT-Bv56 (3.6[3.3-4.3]). In pairwise comparison, differences were significant for PCD-CT-Bv56 vs. EID-CT-Bv40 (p ≤ 0.04), for sharpness and blooming respectively (all p < 0.05). Highest diagnostic confidence was found for PCD-CT-Bv56 (p ≤ 0.2). ANOVA revealed a significant effect of kernel strength on ERS (p < 0.001). CV decreased with stronger PCD-CT kernels, reaching its lowest in PCD-CT-Bv56 and highest in EID-CT reconstruction (p ≤ 0.05). We are the first study to verify, by phantom setup adapted to real patient settings, PCD-CT with a sharp vascular kernel provides the most favorable image quality for small vessel stent imaging. PCD-CT may reduce the number of invasive coronary angiograms, however, more studies needed to apply our results in clinical practice.

Impact of Photon-Counting Detector Computed Tomography on Image Quality and Radiation Dose in Patients With Multiple Myeloma.

OBJECTIVE: Computed tomography (CT) is an established method for the diagnosis, staging, and treatment of multiple myeloma. Here, we investigated the potential of photon-counting detector computed tomography (PCD-CT) in terms of image quality, diagnostic confidence, and radiation dose compared with energy-integrating detector CT (EID-CT). MATERIALS AND METHODS: In this prospective study, patients with known multiple myeloma underwent clinically indicated whole-body PCD-CT. The image quality of PCD-CT was assessed qualitatively by three independent radiologists for overall image quality, edge sharpness, image noise, lesion conspicuity, and diagnostic confidence using a 5-point Likert scale (5 = excellent), and quantitatively for signal homogeneity using the coefficient of variation (CV) of Hounsfield Units (HU) values and modulation transfer function (MTF) via the full width at half maximum (FWHM) in the frequency space. The results were compared with those of the current clinical standard EID-CT protocols as controls. Additionally, the radiation dose (CTDIvol) was determined. RESULTS: We enrolled 35 patients with multiple myeloma (mean age 69.8 ± 9.1 years; 18 [51%] males). Qualitative image analysis revealed superior scores (median [interquartile range]) for PCD-CT regarding overall image quality (4.0 [4.0-5.0] vs. 4.0 [3.0-4.0]), edge sharpness (4.0 [4.0-5.0] vs. 4.0 [3.0-4.0]), image noise (4.0 [4.0-4.0] vs. 3.0 [3.0-4.0]), lesion conspicuity (4.0 [4.0-5.0] vs. 4.0 [3.0-4.0]), and diagnostic confidence (4.0 [4.0-5.0] vs. 4.0 [3.0-4.0]) compared with EID-CT (P ≤ 0.004). In quantitative image analyses, PCD-CT compared with EID-CT revealed a substantially lower FWHM (2.89 vs. 25.68 cy/pixel) and a significantly more homogeneous signal (mean CV ± standard deviation [SD], 0.99 ± 0.65 vs. 1.66 ± 0.5; P < 0.001) at a significantly lower radiation dose (mean CTDIvol ± SD, 3.33 ± 0.82 vs. 7.19 ± 3.57 mGy; P < 0.001). CONCLUSION: Whole-body PCD-CT provides significantly higher subjective and objective image quality at significantly reduced radiation doses than the current clinical standard EID-CT protocols, along with readily available multi-spectral data, facilitating the potential for further advanced post-processing.

Accuracy of Ultrahigh-Resolution Photon-counting CT for Detecting Coronary Artery Disease in a High-Risk Population.

Background Recently introduced photon-counting CT may improve noninvasive assessment of patients with high risk for coronary artery disease (CAD). Purpose To determine the diagnostic accuracy of ultrahigh-resolution (UHR) coronary CT angiography (CCTA) in the detection of CAD compared with the reference standard of invasive coronary angiography (ICA). Materials and Methods In this prospective study, participants with severe aortic valve stenosis and clinically indicated CT for transcatheter aortic valve replacement planning were consecutively enrolled from August 2022 to February 2023. All participants were examined with a dual-source photon-counting CT scanner using a retrospective electrocardiography-gated contrast-enhanced UHR scanning protocol (tube voltage, 120 or 140 kV; collimation, 120 × 0.2 mm; 100 mL of iopromid; no spectral information). Subjects underwent ICA as part of their clinical routine. A consensus assessment of image quality (five-point Likert scale: 1 = excellent [absence of artifacts], 5 = nondiagnostic [severe artifacts]) and a blinded independent reading for the presence of CAD (stenosis ≥50%) were performed. UHR CCTA was compared with ICA using area under the receiver operating characteristic curve (AUC). Results Among 68 participants (mean age, 81 years ± 7 [SD]; 32 male, 36 female), the prevalence of CAD and prior stent placement was 35% and 22%, respectively. The overall image quality was excellent (median score, 1.5 [IQR, 1.3-2.0]). The AUC of UHR CCTA in the detection of CAD was 0.93 per participant (95% CI: 0.86, 0.99), 0.94 per vessel (95% CI: 0.91, 0.98), and 0.92 per segment (95% CI: 0.87, 0.97). Sensitivity, specificity, and accuracy, respectively, were 96%, 84%, and 88% per participant (n = 68); 89%, 91%, and 91% per vessel (n = 204); and 77%, 95%, and 95% per segment (n = 965). Conclusion UHR photon-counting CCTA provided high diagnostic accuracy in the detection of CAD in a high-risk population, including subjects with severe coronary calcification or prior stent placement. Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Williams and Newby in this issue.

Evaluation of perivascular fat attenuation with coronary CT angiography in cardiac transplantation patients: an imaging biomarker candidate for prediction of cardiac mortality and re-transplantation.

OBJECTIVES: In cardiac transplant recipients, non-invasive allograft surveillance for identifying patients at risk for graft failure remains challenging. The fat attenuation index (FAI) of the perivascular adipose tissue in coronary computed tomography angiography (CCTA) predicts outcomes in coronary artery disease in non-transplanted hearts; however, it has not been evaluated in cardiac transplant patients. METHODS: We followed 39 cardiac transplant patients with two or more CCTAs obtained between 2010 and 2021. We performed FAI measurements around the proximal 4 cm segments of the left anterior descending (LAD), right coronary artery (RCA), and left circumflex artery (LCx) using a previously validated methodology. The FAI was analyzed at a threshold of - 30 to - 190 Hounsfield units. RESULTS: FAI measurements were completed in 113 CCTAs, obtained on two same-vendor CT models. Within each CCTA, the FAI values between coronary vessels were strongly correlated (RCA and LAD R = 0.67 (p < 0.0001), RCA and LCx R = 0.58 (p < 0.0001), LAD and LCx R = 0.67 (p < 0.0001)). The FAIs of each coronary vessel between the patient's first and last CCTA completed at 120 kV were also correlated (RCA R = 0.73 (p < 0.0001), LAD R = 0.81 (p < 0.0001), LCx R = 0.55 (p = 0.0069). Finally, a high mean FAI value of all three coronary vessels at baseline (mean ≥ - 71 HU) was predictive of cardiac mortality or re-transplantation, however, not predictive of all cause-mortality. CONCLUSION: High baseline FAI values may identify a higher-risk cardiac transplant population; thus, FAI may support the implementation of CCTA in post-transplant surveillance. KEY POINT: • Perivascular fat attenuation measured with coronary CT is feasible in cardiac transplant patients and may predict cardiac mortality or need for re-transplantation.

Photon-Counting Computed Tomography - Basic Principles, Potenzial Benefits, and Initial Clinical Experience.

BACKGROUND: Photon-counting computed tomography (PCCT) is a promising new technology with the potential to fundamentally change today's workflows in the daily routine and to provide new quantitative imaging information to improve clinical decision-making and patient management. METHOD: The content of this review is based on an unrestricted literature search on PubMed and Google Scholar using the search terms "Photon-Counting CT", "Photon-Counting detector", "spectral CT", "Computed Tomography" as well as on the authors' experience. RESULTS: The fundamental difference with respect to the currently established energy-integrating CT detectors is that PCCT allows counting of every single photon at the detector level. Based on the identified literature, PCCT phantom measurements and initial clinical studies have demonstrated that the new technology allows improved spatial resolution, reduced image noise, and new possibilities for advanced quantitative image postprocessing. CONCLUSION: For clinical practice, the potential benefits include fewer beam hardening artifacts, radiation dose reduction, and the use of new contrast agents. In this review, we will discuss basic technical principles and potential clinical benefits and demonstrate first clinical use cases. KEY POINTS: · Photon-counting computed tomography (PCCT) has been implemented in the clinical routine. · Compared to energy-integrating detector CT, PCCT allows the reduction of electronic image noise. · PCCT provides increased spatial resolution and a higher contrast-to-noise ratio. · The novel detector technology allows the quantification of spectral information. CITATION FORMAT: · Stein T, Rau A, Russe MF et al. Photon-Counting Computed Tomography - Basic Principles, Potenzial Benefits, and Initial Clinical Experience. Fortschr Röntgenstr 2023; 195: 691 - 698.

Photon-Counting Computed Tomography (PC-CT) of the spine: impact on diagnostic confidence and radiation dose.

OBJECTIVES: Computed tomography (CT) is employed to evaluate surgical outcome after spinal interventions. Here, we investigate the potential of multispectral photon-counting computed tomography (PC-CT) on image quality, diagnostic confidence, and radiation dose compared to an energy-integrating CT (EID-CT). METHODS: In this prospective study, 32 patients underwent PC-CT of the spine. Data was reconstructed in two ways: (1) standard bone kernel with 65-keV (PC-CTstd) and (2) 130-keV monoenergetic images (PC-CT130 keV). Prior EID-CT was available for 17 patients; for the remaining 15, an age-, sex-, and body mass index-matched EID-CT cohort was identified. Image quality (5-point Likert scales on overall, sharpness, artifacts, noise, diagnostic confidence) of PC-CTstd and EID-CT was assessed by four radiologists independently. If metallic implants were present (n = 10), PC-CTstd and PC-CT130 keV images were again assessed by 5-point Likert scales by the same radiologists. Hounsfield units (HU) were measured within metallic artifact and compared between PC-CTstd and PC-CT130 keV. Finally, the radiation dose (CTDIvol) was evaluated. RESULTS: Sharpness was rated significantly higher (p = 0.009) and noise significantly lower (p < 0.001) in PC-CTstd vs. EID-CT. In the subset of patients with metallic implants, reading scores for PC-CT130 keV revealed superior ratings vs. PC-CTstd for image quality, artifacts, noise, and diagnostic confidence (all p < 0.001) accompanied by a significant increase of HU values within the artifact (p < 0.001). Radiation dose was significantly lower for PC-CT vs. EID-CT (mean CTDIvol: 8.83 vs. 15.7 mGy; p < 0.001). CONCLUSIONS: PC-CT of the spine with high-kiloelectronvolt reconstructions provides sharper images, higher diagnostic confidence, and lower radiation dose in patients with metallic implants. KEY POINTS: • Compared to energy-integrating CT, photon-counting CT of the spine had significantly higher sharpness and lower image noise while radiation dose was reduced by 45%. • In patients with metallic implants, virtual monochromatic photon-counting images at 130 keV were superior to standard reconstruction at 65 keV in terms of image quality, artifacts, noise, and diagnostic confidence.

Radiation Dose Reduction in Contrast-Enhanced Abdominal CT: Comparison of Photon-Counting Detector CT with 2nd Generation Dual-Source Dual-Energy CT in an oncologic cohort.

RATIONAL AND OBJECTIVES: Comparison of radiation dose and image quality in routine abdominal and pelvic contrast-enhanced computed tomography (CECT) between a photon-counting detector CT (PCD-CT) and a dual energy dual source CT (DSCT). MATERIALS AND METHODS: 70 oncologic patients (mean age 66 ± 12 years, 29 females) were prospectively enrolled between November 2021 and February 2022. Abdominal CECT were clinically indicated and performed first on a 2nd-generation DSCT and at follow-up on a 1st-generation dual-source PCD-CT. The same contrast media (Imeron 350, Bracco imaging) and pump protocol was used for both scans. For both scanners, polychromatic images were reconstructed with 3mm slice thickness and comparable kernel (I30f[DSCT] and Br40f[PCD-CT]); for PCD-CT data from all counted events above the lowest energy threshold at 20 keV ("T3D") were used. Results were compared in terms of radiation dose metrics of CT dose index (CTDIvol), dose length product (DLP) and size-specific dose estimation (SSDE), objective and subjective measurements of image quality were scored by two emergency radiologists including lesion conspicuity. RESULTS: Median time interval between the scans was 4 months (IQR: 3-6). CNRvessel and SNRvessel of T3D reconstructions from PCD-CT were significantly higher than those of DSCT (all, p < 0.05). Qualitative image noise analysis from PCD-CT and DSCT yielded a mean of 4 each. Lesion conspicuity was rated significantly higher in PCD-CT (Q3 strength) compared to DSCT images. CTDI, DLP and SSDE mean values for PCD-CT and DSCT were 7.98 ± 2.56 mGy vs. 14.11 ± 2.92 mGy, 393.13 ± 153.55 mGy*cm vs. 693.61 ± 185.76 mGy*cm and 9.98 ± 2.41 vs. 14.63 ± 1.63, respectively, translating to a dose reduction of around 32% (SSDE). CONCLUSION: PCD-CT enables oncologic abdominal CT with a significantly reduced dose while keeping image quality similar to 2nd-generation DSCT.

Myeloma bone disease imaging on a 1st-generation clinical photon-counting detector CT vs. 2nd-generation dual-source dual-energy CT.

OBJECTIVE: Subjective and objective image quality comparison of bone microstructure and disease-related abnormalities in multiple myeloma patients using a 1st-generation dual-source photon-counting detector CT(DS-PCD-CT) and a 2nd-generation dual-source dual-energy (energy-integrating detector) CT (DS-EID-CT). METHODS: Fifty multiple myeloma patients (mean age 67.7 ± 10.9 years,16 females) were prospectively enrolled. Unenhanced whole-body CTs were clinically indicated and performed on DS-EID-CT and DS-PCD-CT (median time difference: 12 months). DS-PCD-CT was performed in Quantumplus UHR mode and DS-EID-CT was performed using dual-energy mode. DS-PCD-CT kernel was set at Br64 with Quantum iterative reconstruction strength Q1; for DS-EID-CT a comparable I70f kernel with SAFIRE iterative reconstruction strength 1 was used. Two independent radiologists assessed image quality subjectively using a 5-point Likert scale considering delineation and sharpness of trabecular bone and lytic bone lesions in the spine and pelvic bones. Additionally, ImageJ was used for quantification of bony septa inside the cancellous bone and through or the edges of osteolysis. RESULTS: Overall quality as well as detectability and sharpness in the delineation of lytic bone lesions were superior for DS-PCD-CT compared with DS-EID-CT (p < 0.0001). The inter-reader agreement for subjective image quality readings showed excellent consistency(α = 94.2-98.8). CTDI and DLP mean values for DS-PCD-CT and DS-EID-CT were 1107.4 ± 247.6 mGy*cm and 8.2 ± 1.8 mGy vs. 1344.3 ± 204.6 mGy*cm and 10.1 ± 1.9 mGy. The quantitative metric for bone microstructure in the femoral head showed significantly better visualization of trabeculae in DS-PCD-CT compared with DS-EID-CT (p < 0.0001). Quantitative analyses of edge sharpness of osteolysis showed significant steeper edges for DS-PCD-CT (p < 0.0001). CONCLUSION: DS-PCD-CT significantly improves spatial resolution of bony microstructure and lytic bone lesions compared to DS-EID-CT. KEY POINTS: • Application of photon-counting detector CT is superior to dual-source dual-energy integrating detector in clinical workup of multiple myeloma patients. • Compared to energy integrating detectors, photon-counting detectors significantly increase the spatial resolution of bone microstructure including disease-related lytic bone lesions in patients with multiple myeloma.

Reduced versus standard dose contrast volume for contrast-enhanced abdominal CT in overweight and obese patients using photon counting detector technology vs. second-generation dual-source energy integrating detector CT.

PURPOSE: To compare image quality of contrast-enhanced abdominal-CT using 1st-generation Dual Source Photon-Counting Detector CT (DS-PCD-CT) versus 2nd-generation Dual-Source Energy Integrating-Detector CT (DS-EID-CT) in patients with BMI ≥ 25, applying two different contrast agent volumes, vendor proposed protocols and different virtual monoenergetic images (VMI). METHOD: 68 overweight (BMI ≥ 25 kgm2) patients (median age: 65 years; median BMI 33.3 kgm2) who underwent clinically indicated, portal-venous contrast-enhanced abdominal-CT on a commercially available 1st-generation DS-PCD-CT were prospectively included if they already have had a pre-exam on 2nd-generation DS-EID-CT using a standardized exam protocol. Obesity were defined by BMI-calculation (overweight: 25-29.9, obesity grade I: 30-34.9; obesity grade II: 35-39.9; obesity grade III: > 40) and by the absolute weight value. Body weight adapted contrast volume (targeted volume of 1.2 mL/kg for the 1st study and 0.8 mL/kg for the 2nd study) was applied in both groups. Dual Energy mode was used for both the DS-PCD-CT and the DS-EID-CT. Polychromatic images and VMI (40 keV and 70 keV) were reconstructed for both the DS-EID-CT and the DS-PCD-CT data (termed T3D). Two radiologists assessed subjective image quality using a 5-point Likert-scale. Each reader drew ROIs within parenchymatous organs and vascular structures to analyze image noise, contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR). RESULTS: Median time interval between scans was 12 months (Min: 6 months; Max: 36 months). BMI classification included overweight (n = 10, 14.7 %), obesity grade I (n = 38, 55.9 %), grade II (n = 13, 19.1 %) and grade III (n = 7, 10.3 %). The SNR achieved with DS-PCD-CT at QIR level 3was 12.61 vs. 11.47 (QIR 2) vs. 10.53 (DS-EID-CT), irrespective of parenchymatous organs. For vessels, the SNR were 16.73 vs. 14.20 (QIR 2) vs. 12.07 (DS-EID-CT). Moreover, the obtained median noise at QIR level 3 was as low as that of the DS-EID-CT (8.65 vs. 8.65). Both radiologists rated the image quality higher for DS-PCD-CT data sets (p < 0.05). The highest CNR was achieved at 40 keV for both scanners. T3D demonstrated significantly higher SNR and lower noise level compared to 40 keV and 70 keV. Median CTDIvol and DLP values for DS-PCD-CT and DS-EID-CT were 10.90 mGy (IQR: 9.31 - 12.50 mGy) vs. 16.55 mGy (IQR: 15.45 - 18.17 mGy) and 589.50 mGy * cm (IQR: 498.50 - 708.25 mGy * cm) vs. 848.75 mGy * cm (IQR: 753.43 - 969.58 mGy * cm) (p < 0.001). CONCLUSION: Image quality can be maintained while significantly reducing the contrast volume and the radiation dose (27% and 34% lower DLP and 31% lower CDTIvol) for abdominal contrast-enhanced CT using a 1st-generation DS-PCD-CT. Moreover, polychromatic reconstruction T3D on a DS-PCD-CT enables sufficient diagnostic image quality for oncological imaging.

High Temporal Resolution Dual-Source Photon-Counting CT for Coronary Artery Disease: Initial Multicenter Clinical Experience.

The aim of this paper is to evaluate the diagnostic image quality of spectral dual-source photon-counting detector coronary computed tomography angiography (PCD-CCTA) for coronary artery disease in a multicenter study. The image quality (IQ), assessability, contrast-to-noise ratio (CNR), Agatston score, and radiation exposure were measured. Stenoses were quantified and compared with invasive coronary angiography, if available. A total of 92 subjects (65% male, age 58 ± 14 years) were analyzed. The prevalence of significant coronary artery disease (CAD) (stenosis ≥ 50%) was 17% of all patients, the range of the Agatston score was 0−2965 (interquartile range (IQR) 0−135). The IQ was very good (one, IQR one−two), the CNR was very high (20 ± 10), and 5% of the segments were rated non-diagnostic. The IQ and assessability were higher in proximal coronary segments (p < 0.001). Agatston scores up to 600 did not significantly affect the assessability of the coronary segments (p = 0.3). Heart rate influenced assessability only at a high-pitch mode (p = 0.009). For the invasive coronary angiography (ICA) subgroup (n = nine), the diagnostic performance for CAD per segment was high (sensitivity 92%, specificity 96%), although the limited number of patients who underwent both diagnostic modalities limits the generalization of this finding at this stage. PCD-CCTA provides good image quality for low and moderate levels of coronary calcifications.

Assessing the Accuracy of an Artificial Intelligence-Based Segmentation Algorithm for the Thoracic Aorta in Computed Tomography Applications.

The aim was to evaluate the accuracy of a prototypical artificial intelligence-based algorithm for automated segmentation and diameter measurement of the thoracic aorta (TA) using CT. One hundred twenty-two patients who underwent dual-source CT were retrospectively included. Ninety-three of these patients had been administered intravenous iodinated contrast. Images were evaluated using the prototypical algorithm, which segments the TA and determines the corresponding diameters at predefined anatomical locations based on the American Heart Association guidelines. The reference standard was established by two radiologists individually in a blinded, randomized fashion. Equivalency was tested and inter-reader agreement was assessed using intra-class correlation (ICC). In total, 99.2% of the parameters measured by the prototype were assessable. In nine patients, the prototype failed to determine one diameter along the vessel. Measurements along the TA did not differ between the algorithm and readers (p > 0.05), establishing equivalence. Inter-reader agreement between the algorithm and readers (ICC ≥ 0.961; 95% CI: 0.940−0.974), and between the readers was excellent (ICC ≥ 0.879; 95% CI: 0.818−0.92). The evaluated prototypical AI-based algorithm accurately measured TA diameters at each region of interest independent of the use of either contrast utilization or pathology. This indicates that the prototypical algorithm has substantial potential as a valuable tool in the rapid clinical evaluation of aortic pathology.

Image Quality and Radiation Dose of Contrast-Enhanced Chest-CT Acquired on a Clinical Photon-Counting Detector CT vs. Second-Generation Dual-Source CT in an Oncologic Cohort: Preliminary Results.

Our aim was to compare the image quality and patient dose of contrast-enhanced oncologic chest-CT of a first-generation photon-counting detector (PCD-CT) and a second-generation dual-source dual-energy CT (DSCT). For this reason, one hundred consecutive oncologic patients (63 male, 65 ± 11 years, BMI: 16−42 kg/m2) were prospectively enrolled and evaluated. Clinically indicated contrast-enhanced chest-CT were obtained with PCD-CT and compared to previously obtained chest-DSCT in the same individuals. The median time interval between the scans was three months. The same contrast media protocol was used for both scans. PCD-CT was performed in QuantumPlus mode (obtaining full spectral information) at 120 kVp. DSCT was performed using 100 kV for Tube A and 140 kV for Tube B. "T3D" PCD-CT images were evaluated, which emulate conventional 120 keV polychromatic images. For DSCT, the convolution algorithm was set at I31f with class 1 iterative reconstruction, whereas comparable Br40 kernel and iterative reconstruction strengths (Q1 and Q3) were applied for PCD-CT. Two radiologists assessed image quality using a five-point Likert scale and performed measurements of vessels and lung parenchyma for signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and in the case of pulmonary metastases tumor-to-lung parenchyma contrast ratio. PCD-CT CNRvessel was significantly higher than DSCT CNRvessel (all, p < 0.05). Readers rated image contrast of mediastinum, vessels, and lung parenchyma significantly higher in PCD-CT than DSCT images (p < 0.001). Q3 PCD-CT CNRlung_parenchyma was significantly higher than DSCT CNRlung_parenchyma and Q1 PCD-CT CNRlung_parenchyma (p < 0.01). The tumor-to-lung parenchyma contrast ratio was significantly higher on PCD-CT than DSCT images (0.08 ± 0.04 vs. 0.03 ± 0.02, p < 0.001). CTDI, DLP, SSDE mean values for PCD-CT and DSCT were 4.17 ± 1.29 mGy vs. 7.21 ± 0.49 mGy, 151.01 ± 48.56 mGy * cm vs. 288.64 ± 31.17 mGy * cm and 4.23 ± 0.97 vs. 7.48 ± 1.09, respectively. PCD-CT enables oncologic chest-CT with a significantly reduced dose while maintaining image quality similar to a second-generation DSCT for comparable protocol settings.

Differentiation of adrenal adenomas from adrenal metastases in single-phased staging dual-energy CT and radiomics.

PURPOSE Differentiation of incidental adrenal lesions remains a challenge in diagnostic imaging, especially on single-phase portal venous computed tomography (CT) in the oncological setting. The aim of the study was to explore the ability of dual-energy CT (DECT)-based iodine quantification and virtual non-contrast (VNC) imaging and advanced radiomic analysis of DECT for differentiation of adrenal adenomas from metastases. METHODS A total of 46 patients with 49 adrenal lesions underwent clinically indicated staging DECT and magnetic resonance imaging. Median values of quantitative parameters such as VNC, fat frac- tion, and iodine density in DECT images were collected and compared between adenomas and metastases using non-parametric tests. Magnetic resonance imaging, washout CT, and clinical follow-up were used as a reference standard. Diagnostic accuracy was assessed by calculat- ing receiver operating characteristics. A DECT tumor analysis prototype software was used for semiautomatic segmentation of adrenal lesions and extraction of radiomic features. A radiomics prototype was used to analyze the data with multiple logistic regression and random forest clas- sification to determine the area under the curve (AUC). RESULTS The study cohort (60.87% women; mean age: 66.91 ± 12.93 years) consisted of 32 adenomas and 17 metastases. DECT-based VNC imaging (AUC=0.89) and fat quantification (AUC=0.86) differentiate between adrenal adenomas and metastases with high diagnostic accuracy (P < .001). Analysis of radiomic features revealed that DECT features such as VNC imaging and fat fraction (AUC = 0.87-0.89; < .001) and radiomic features such as 90th percentile and total energy (AUC = 0.88-0.93; P < .001) differentiate with high diagnostic accuracy between adrenal adeno- mas and metastases. Random forest classification revealed an AUC of 0.83 for separating adrenal adenomas from metastases. CONCLUSION Virtual non-contrast imaging and fat quantification as well as extraction of radiomic features accurately differentiate between adrenal adenomas and metastases on single-phase oncologic staging DECT.