Imaging evaluation of uterine arteries in potential living donors for uterus transplantation: a comparative study of MRA, CTA, and DSA.

OBJECTIVE: To evaluate uterine arteries (UA) of potential living donors for uterus transplantation (UTx) by comparison of CT angiography (CTA), digital subtraction angiography (DSA), and MR angiography (MRA) with care taken to minimize radiation doses. METHODS: Prospective donors for a clinical UTx trial were included. CTA, DSA, and MRA measurements in three predefined segments of the UAs were evaluated. Radiation doses were estimated and 1-year graft survival was recorded. RESULTS: Twelve potential donors (age 37-62 years) were investigated. There was no difference in visualized average UA lumen diameter when comparing CTA (mean 2.0 mm, SD 0.4), DSA (mean 2.1 mm, SD 0.6), and MRA (mean 2.0 mm, SD 0.3). MRA was not able to fully evaluate 10 (43%) out of 23 UA that proved to be patent on DSA. One UA was not identified by any of the modalities, and three MRA-absent UAs were identified by both CTA and DSA. The estimated mean effective dose was lower for DSA (5.1 mSv, SD 2.8) than CTA (7.1 mSv, SD 2.0), but not significantly (p value = 0.06). Three potential donors were excluded due to UA pathology and one due to adenomyosis. Eight donors underwent hysterectomy, with 1-year graft survival in six women. CONCLUSION: MRI including MRA should be the initial modality to examine potential UTx donors to acquire valuable details of uterine anatomy, and if UAs are fully visualized, there is no need for further angiographic methods with radiation. If UAs are not visualized by MRA, CTA may be performed and in selective cases with addition of the invasive modality DSA. KEY POINTS: • For uterine transplantation, pelvic MRI with MRA provides information of the uterine structure and of the diameters of uterine arteries in living donors. • Failure of MRA to demonstrate uterine arteries could be followed by CTA which will visualize the uterine arteries in a majority of cases. If MRA and additional CTA provide inconclusive results, the uterine arteries should be further evaluated by DSA. • Information of CTA can be used in the angio-system for DSA settings to minimize the radiation and contrast media doses.

Prediction of proton stopping power ratios using dual-energy CT basis material decomposition.

BACKGROUND: Proton radiotherapy treatment plans are currently restricted by the range uncertainties originating from the stopping power ratio (SPR) prediction based on single-energy computed tomography (SECT). Various studies have shown that multi-energy CT (MECT) can reduce the range uncertainties due to medical implant materials and age-related variations in tissue composition. None of these has directly applied the basis material density (MD) images produced by projection-based MECT systems for SPR prediction. PURPOSE: To present and evaluate a novel proton SPR prediction method based on MD images from dual-energy CT (DECT), which could reduce the range uncertainties currently associated with proton radiotherapy. METHODS: A theoretical basis material decomposition into water and iodine material densities was performed for various pediatric and adult human reference tissues, as well as other non-tissue materials, by minimizing the root-mean-square relative attenuation error in the energy interval from 40 to 140 keV. A model (here called MD-SPR) mapping predicted MDs to theoretically calculated reference SPRs was created with locally weighted scatterplot smoothing (LOWESS) data-fitting. The goodness of fit of the MD-SPR model was evaluated for the included reference tissues. MD images of two electron density phantoms, combined to form a head- and an abdomen-sized phantom setup, were acquired with a clinical projection-based fast-kV switching DECT scanner. The MD images were compared to the theoretically predicted MDs of the tissue surrogates and other non-tissue materials in the phantoms, as well as used for input to the MD-SPR model for generation of SPR images. The SPR images were subsequently compared to theoretical reference SPRs of the materials in the phantoms, as well as to SPR images from a commercial algorithm (DirectSPR, Siemens Healthineers, Forchheim, Germany) using image-based consecutive scan DECT for the same phantom setups. RESULTS: The predicted SPRs of the tissue surrogates were similar for MD-SPR and DirectSPR, where the adipose and bone tissue surrogates were within 1% difference to the reference SPRs, while other non-adipose soft tissue surrogates (breast, brain, liver, muscle) were all underestimated by between -0.7% and -1.8%. The SPRs of the non-tissue materials (polymethyl methacrylate (PMMA), polyether ether ketone (PEEK), graphite and Teflon) were within 2.8% for MD-SPR images, compared to 6.8% for DirectSPR. CONCLUSIONS: The MD-SPR model performed similar compared to other published methods for the human reference tissues. The SPR prediction for tissue surrogates was similar to DirectSPR and showed potential to improve SPR prediction for non-tissue materials.

Adrenal lesions: variability in attenuation over time, between scanners, and between observers.

BACKGROUND: Measurements of attenuation (in Hounsfield units [HU]) and contrast wash-out are widely used to characterize adrenal lesions as benign or indeterminate/malignant at computed tomography (CT). Clinical experience suggests that such measurements of adrenal lesions may vary over time and between observers, making evaluation difficult. PURPOSE: To investigate the change over time of adrenal lesion size, attenuation, and contrast wash-out at CT, to determine inter-observer variability, and to analyze other factors underlying the variability. MATERIAL AND METHODS: In a cohort of patients, with or without malignant disease, undergoing CT, adrenal lesions were prospectively analyzed. Lesions with growth >20% or >5 mm over 6 months were excluded. Non-enhanced attenuation and contrast medium wash-out over 2-year follow-up were analyzed. An inter-observer analysis with five observers and a phantom study of eight different CT scanners were performed to assess measurement variability. RESULTS: Mean adrenal lesion non-enhanced attenuation values decreased by 0.5 HU/year during follow-up. Using 10 HU or 40% relative wash-out as threshold values for benign versus indeterminate lesions, 27 (20%) and 39 (29%) of 136 lesions, respectively, would be reclassified at some occasion during follow-up. In the observer analysis 37 of 40 lesions demonstrated agreement between all observers, using established threshold values. The phantom study showed an intra-scanner variability of 1-3 HU, but an inter-scanner variability of up to 8 HU for water. CONCLUSION: The clinically widespread use of specific attenuation threshold values for characterizing adrenal lesions must be used with great caution, considering that multiple factors, related to patient, equipment, scanning technique, and observer influence the outcome.

Visualization of the distortion induced by nonlinear noise reduction in computed tomography.

Purpose: We developed a method to visualize the image distortion induced by nonlinear noise reduction algorithms in computed tomography (CT) systems. Approach: Nonlinear distortion was defined as the induced residual when testing a reconstruction algorithm by the criteria for a linear system. Two types of images were developed: a nonlinear distortion of an object (NLDobject) image and a nonlinear distortion of noise (NLDnoise) image to visualize the nonlinear distortion induced by an algorithm. Calculation of the images requires access to the sinogram data, which is seldomly fully provided. Hence, an approximation of the NLDobject image was estimated. Using simulated CT acquisitions, four noise levels were added onto forward projected sinograms of a typical CT image; these were noise reduced using a median filter with the simultaneous iterative reconstruction technique or a total variation filter with the conjugate gradient least-squares algorithm. The linear reconstruction technique filtered back-projection was also analyzed for comparison. Results: Structures in the NLDobject image indicated contrast and resolution reduction of the nonlinear denoising. Although the approximated NLDobject image represented the original NLDobject image well, it had a higher random uncertainty. The NLDnoise image for the median filter indicated both stochastic variations and structures reminding of the object while for the total variation filter only stochastic variations were indicated. Conclusions: The developed images visualize nonlinear distortions of denoising algorithms. The object may be distorted by the noise and vice versa. Analyzing the distortion correlated to the object is more critical than analyzing a distortion of stochastic variations. The absence of nonlinear distortion may measure the robustness of the denoising algorithm.

FREQUENCY RESPONSE AND DISTORTION PROPERTIES OF RECONSTRUCTION ALGORITHMS IN COMPUTED TOMOGRAPHY.

Denoising reconstruction techniques can introduce nonlinear properties into computed tomography (CT) systems. These nonlinear algorithms introduce distortion which affects the assessment of the resolution of the system. The purpose of the present study was to decouple and investigate amplitude modulation and waveform distortion in reconstruction algorithms in CT. The methodology developed by Wells, J. R. and Dobbins, J. T. III [Frequency response and distortion properties of nonlinear image processing algorithms and the importance of imaging context. Med. Phys. 40, 091906 (2013)] was adapted to CT reconstruction algorithms. The CT simulating program ASTRA Toolbox© for MATLAB™ was used for the reconstruction of the sinusoidal wave functions. Filtered back projection and the simultaneous iterative reconstruction technique were investigated with simple nonlinear mechanisms: a median filter and a non-negative constraint, respectively. The native reconstruction algorithms were not free from nonlinear waveform distortion, however, none of the metrics showed any dependence on the contrast-to-noise ratio (CNR). Furthermore, the algorithms including nonlinear mechanisms showed a clear and specific CNR dependence, indicating the necessity for distortion analysis in nonlinear CT reconstruction.

Structure delineation in the presence of metal - A comparative phantom study using single and dual-energy computed tomography with and without metal artefact reduction.

BACKGROUND AND PURPOSE: Metal artefacts in computed tomography (CT) images impairs structure delineation. These artefacts can potentially be reduced with dual-energy CT (DECT) with or without using metal artefact reduction (MAR). The purpose was to investigate how structure delineation in DECT with or without MAR and single-energy CT (SECT) images were affected by metals. MATERIALS AND METHODS: A phantom with known irregular structures was developed. Reference structures were determined from a low-noise scan without metal. Bilateral hip prostheses were simulated with steel or titanium inserts. The phantom was scanned with SECT and fast-kV switching DECT with optional MAR. Four radiation oncologists delineated the structures in two phantom set-ups. Delineated structures were evaluated with Dice similarity coefficient (DSC) and Hausdorff distance relative to the reference structures. RESULTS: With titanium inserts, more structures were detected for non-MAR DECT compared to SECT while the same or less were detected with steel inserts. MAR improved delineation in DECT images. For steel inserts, three structures in the region of artefacts, were delineated by at least two oncologists with MAR-DECT compared to none with non-MAR DECT or SECT. The highest values of DSC for MAR-DECT were 0.69, 0.81 and 0.77 for those structures. CONCLUSIONS: Delineation was improved with non-MAR DECT compared to SECT, especially for titanium inserts. A larger improvement was seen with the use of MAR for both steel and titanium inserts. The improvement was dependent on the location of the structure relative to the inserts, and the structure contrast relative to the background.

COMPARISON OF ADAPTIVE STATISTICAL ITERATIVE RECONSTRUCTION (ASIR™) AND MODEL-BASED ITERATIVE RECONSTRUCTION (VEO™) FOR PAEDIATRIC ABDOMINAL CT EXAMINATIONS: AN OBSERVER PERFORMANCE STUDY OF DIAGNOSTIC IMAGE QUALITY.

The diagnostic image quality of 75 paediatric abdominal computed tomography (CT) examinations reconstructed with two different iterative reconstruction (IR) algorithms-adaptive statistical IR (ASiR™) and model-based IR (Veo™)-was compared. Axial and coronal images were reconstructed with 70 % ASiR with the Soft™ convolution kernel and with the Veo algorithm. The thickness of the reconstructed images was 2.5 or 5 mm depending on the scanning protocol used. Four radiologists graded the delineation of six abdominal structures and the diagnostic usefulness of the image quality. The Veo reconstruction significantly improved the visibility of most of the structures compared with ASiR in all subgroups of images. For coronal images, the Veo reconstruction resulted in significantly improved ratings of the diagnostic use of the image quality compared with the ASiR reconstruction. This was not seen for the axial images. The greatest improvement using Veo reconstruction was observed for the 2.5 mm coronal slices.

THE EFFECT OF ADAPTIVE STATISTICAL ITERATIVE RECONSTRUCTION ON THE ASSESSMENT OF DIAGNOSTIC IMAGE QUALITY AND VISUALISATION OF ANATOMICAL STRUCTURES IN PAEDIATRIC CEREBRAL CT EXAMINATIONS.

The purpose of this study was to investigate the effect of adaptive statistical iterative reconstruction (ASiR) on the visualisation of anatomical structures and diagnostic image quality in paediatric cerebral computed tomography (CT) examinations. Forty paediatric patients undergoing routine cerebral CT were included in the study. The raw data from CT scans were reconstructed into stacks of 5 mm thick axial images at various levels of ASiR. Three paediatric radiologists rated six questions related to the visualisation of anatomical structures and one question on diagnostic image quality, in a blinded randomised visual grading study. The evaluated anatomical structures demonstrated enhanced visibility with increasing level of ASiR, apart from the cerebrospinal fluid space around the brain. In this study, 60 % ASiR was found to be the optimal level of ASiR for paediatric cerebral CT examinations. This shows that the commonly used 30 % ASiR may not always be the optimal level.

ASSESSMENT OF CLINICAL IMAGE QUALITY IN PAEDIATRIC ABDOMINAL CT EXAMINATIONS: DEPENDENCY ON THE LEVEL OF ADAPTIVE STATISTICAL ITERATIVE RECONSTRUCTION (ASiR) AND THE TYPE OF CONVOLUTION KERNEL.

The purpose of this study was to investigate the effect of different combinations of convolution kernel and the level of Adaptive Statistical iterative Reconstruction (ASiR™) on diagnostic image quality as well as visualisation of anatomical structures in paediatric abdominal computed tomography (CT) examinations. Thirty-five paediatric patients with abdominal pain with non-specified pathology undergoing abdominal CT were included in the study. Transaxial stacks of 5-mm-thick images were retrospectively reconstructed at various ASiR levels, in combination with three convolution kernels. Four paediatric radiologists rated the diagnostic image quality and the delineation of six anatomical structures in a blinded randomised visual grading study. Image quality at a given ASiR level was found to be dependent on the kernel, and a more edge-enhancing kernel benefitted from a higher ASiR level. An ASiR level of 70 % together with the Soft™ or Standard™ kernel was suggested to be the optimal combination for paediatric abdominal CT examinations.

Absorbed organ and effective doses from digital intra-oral and panoramic radiography applying the ICRP 103 recommendations for effective dose estimations.

OBJECTIVE: During dental radiography, the salivary and thyroid glands are at radiation risk. In 2007, the International Commission on Radiological Protection (ICRP) updated the methodology for determining the effective dose, and the salivary glands were assigned tissue-specific weighting factors for the first time. The aims of this study were to determine the absorbed dose to the organs and to calculate, applying the ICRP publication 103 tissue-weighting factors, the effective doses delivered during digital intraoral and panoramic radiography. METHODS: Thermoluminescent dosemeter measurements were performed on an anthropomorphic head and neck phantom. The organ-absorbed doses were measured at 30 locations, representing different radiosensitive organs in the head and neck, and the effective dose was calculated according to the ICRP recommendations. RESULTS: The salivary glands and the oral mucosa received the highest absorbed doses from both intraoral and panoramic radiography. The effective dose from a full-mouth intraoral examination was 15 µSv and for panoramic radiography, the effective dose was in the range of 19-75 µSv, depending on the panoramic equipment used. CONCLUSION: The effective dose from a full-mouth intraoral examination is lower and that from panoramic radiography is higher than previously reported. Clinicians should be aware of the higher effective dose delivered during panoramic radiography and the risk-benefit profile of this technique must be assessed for the individual patient. ADVANCES IN KNOWLEDGE: The effective dose of radiation from panoramic radiography is higher than previously reported and there is large variability in the delivered radiation dosage among the different types of equipment used.

Evaluation of subjective image quality in relation to diagnostic task for cone beam computed tomography with different fields of view.

AIMS: To evaluate subjective image quality for two diagnostic tasks, periapical diagnosis and implant planning, for cone beam computed tomography (CBCT) using different exposure parameters and fields of view (FOVs). MATERIALS AND METHODS: Examinations were performed in posterior part of the jaws on a skull phantom with 3D Accuitomo (FOV 3 cm×4 cm) and 3D Accuitomo FPD (FOVs 4 cm×4 cm and 6 cm×6 cm). All combinations of 60, 65, 70, 75, 80 kV and 2, 4, 6, 8, 10 mA with a rotation of 180° and 360° were used. Dose-area product (DAP) value was determined for each combination. The images were presented, displaying the object in axial, cross-sectional and sagittal views, without scanning data in a random order for each FOV and jaw. Seven observers assessed image quality on a six-point rating scale. RESULTS: Intra-observer agreement was good (κw=0.76) and inter-observer agreement moderate (κw=0.52). Stepwise logistic regression showed kV, mA and diagnostic task to be the most important variables. Periapical diagnosis, regardless jaw, required higher exposure parameters compared to implant planning. Implant planning in the lower jaw required higher exposure parameters compared to upper jaw. Overall ranking of FOVs gave 4 cm×4 cm, 6 cm×6 cm followed by 3 cm×4 cm. CONCLUSIONS: This study has shown that exposure parameters should be adjusted according to diagnostic task. For this particular CBCT brand a rotation of 180° gave good subjective image quality, hence a substantial dose reduction can be achieved without loss of diagnostic information.

Methods for monitoring patient dose in dental radiology.

Different types of X-ray equipment are used in dental radiology, such as intra-oral, panoramic, cephalometric, cone-beam computed tomography (CBCT) and multi-slice computed tomography (MSCT) units. Digital receptors have replaced film and screen-film systems and other technical developments have been made. The radiation doses arising from different types of examination are sparsely documented and often expressed in different radiation quantities. In order to allow the comparison of radiation doses using conventional techniques, i.e. intra-oral, panoramic and cephalometric units, with those obtained using, CBCT or MSCT techniques, the same quantities and units of dose must be used. Dose determination should be straightforward and reproducible, and data should be stored for each image and clinical examination. It is shown here that air kerma-area product (P(KA)) values can be used to monitor the radiation doses used in all types of dental examinations including CBCT and MSCT. However, for the CBCT and MSCT techniques, the methods for the estimation of dose must be more thoroughly investigated. The values recorded can be used to determine the diagnostic standard doses and to set diagnostic reference levels for each type of clinical examination and equipment used. It should also be possible to use these values for the estimation and documentation of organ or effective doses.

Methods of determining the effective dose in dental radiology.

A wide variety of X-ray equipment is used today in dental radiology, including intra-oral, orthopantomographic, cephalometric, cone-beam computed tomography (CBCT) and computed tomography (CT). This raises the question of how the radiation risks resulting from different kinds of examinations should be compared. The risk to the patient is usually expressed in terms of effective dose. However, it is difficult to determine its reliability, and it is difficult to make comparisons, especially when different modalities are used. The classification of the new CBCT units is also problematic as they are sometimes classified as CT units. This will lead to problems in choosing the best dosimetric method, especially when the examination geometry resembles more on an ordinary orthopantomographic examination, as the axis of rotation is not at the centre of the patient, and small radiation field sizes are used. The purpose of this study was to present different methods for the estimation of the effective dose from the equipment currently used in dental radiology, and to discuss their limitations. The methods are compared based on commonly used measurable and computable dose quantities, and their reliability in the estimation of the effective dose.

Comparison of three methods for determining CT dose profile: presenting the tritium method.

The purpose of the present work was to describe a method of using an imaging plate from a computed radiography system to determine the computed tomography (CT) dose profile (the tritium method) and to compare this method with point-dose measurements using a solid-state detector (CT Dose Profiler; RTI Electronics, Mölndal, Sweden) and the indirect method of comparing the air kerma-length product (P(KL)) at different beam collimations. The three methods were used to determine the full width at half maximum (FWHM) of the dose profile of a multi-slice CT at different nominal beam collimations. For all beam collimations, the obtained deviation between the tritium method and the CT Dose Profiler was smaller than 0.1 mm. The maximum relative error was 2 %. For the P(KL) method, the deviation from the CT Dose Profiler was between 0.2 and 0.4 mm, resulting in a relative error larger than 10 % for the smallest beam collimation even after normalisation to a known FWHM. In conclusion, the proposed method of using an imaging plate to determine the FWHM of the CT dose profile has a high accuracy and shows good agreement with the more advanced method of point-dose measurements using a solid-state detector.

Evaluation of subjective assessment of the low-contrast visibility in constancy control of computed tomography.

The purpose of the present work was to investigate the reliability of subjective assessments of the low-contrast visibility in constancy control of computed tomography (CT). Axial CT images of a low-contrast phantom were acquired on an 8-slice multi-detector CT scanner at nine tube current settings ranging from 75 to 440 mA. Five medical physicists assessed the visibility of the low-contrast details in two sessions. In the first session, containing 54 images, the visibility was rated on an absolute scale by determining the number of visible details in each contrast group in each image. In the second session, 180 image pairs were presented to the observers with the task of determining if the two images had been acquired under identical conditions or not. In the absolute session, both the intra- and inter-observer variabilities were high. In the relative session, the variability was smaller, but an exposure difference of 50 % was needed for all observers to correctly identify a change in all cases. In conclusion, the present study indicates that subjective assessments of the low-contrast visibility in constancy control of CT are not reliable.