Sven Prevrhal

Clinical use of quantitative computed tomography and peripheral quantitative computed tomography in the management of osteoporosis in adults: the 2007 ISCD Official Positions.

The International Society for Clinical Densitometry (ISCD) has developed Official Positions for the clinical use of dual-energy X-ray absorptiometry (DXA) and non-DXA technologies. While only DXA can be used for diagnostic classification according to criteria established by the World Health Organization, DXA and some other technologies may predict fracture risk and be used to monitor skeletal changes over time. ISCD task forces reviewed the evidence for clinical applications of non-DXA techniques and presented reports with recommendations at the 2007 ISCD Position Development Conference. Here we present the ISCD Official Positions for quantitative computed tomography (QCT) and peripheral QCT (pQCT), with supporting medical evidence, rationale, controversy, and suggestions for further study. QCT is available for bone mineral density measurements at the spine, hip, forearm, and tibia. The ISCD Official Positions presented here focus on QCT of the spine and pQCT of the forearm. Measurements at the hip may have clinical relevance, as this is an important fracture site; however, due to limited medical evidence, definitive advice on its use in clinical practice cannot be provided until more data emerge.

Accuracy limits for the determination of cortical width and density: the influence of object size and CT imaging parameters

In this study we analysed the accuracy of computed tomography (CT) measurements in assessing cortical bone. We determined the dependency of thickness and density measurements on the true width and density of the cortex and on the spatial resolution in the CT images using two optimized segmentation methods. As a secondary goal, we assessed the ability of CT to reflect small changes in cortical thickness. Two different bone-mimicking phantoms with varying cortical thickness were scanned with single-slice CT on a Somatom Plus 4 scanner. Images were reconstructed with both a standard and a high-resolution convolution kernel. Two special operator-independent segmentation methods were used to automatically detect the edges of the cortical shell. We measured cortical thickness and density and compared the phantom measurements with theoretical computations by simulating a cross-sectional shape of the cortical shell. Based on the simulations, we calculated CTs power to detect small changes in cortical thickness. Simulations and phantom measurements were in very good agreement. Cortical thickness could be measured with an error of less than 10% if the true thickness was larger than 0.9 (0.7) mm for the standard (high-resolution) kernel which is close to the full width at half maximum (FWHM) of the point spread functions for these kernels and our scanner. Density measurements yielded errors of less than 10% for true cortical thickness values above two to three times the FWHM corresponding to 2.5 (2) mm in our case. The simulations showed that a 10% change in cortical width would not be detected with satisfying probability in bones with a cortical shell thinner than 1.2 mm. An accurate determination of the cortical thickness is limited to bones with a thickness higher than the FWHM of the scanners point spread function. Therefore, the use of a high-resolution reconstruction kernel is crucial. Cortical bone mineral density can only be measured accurately in bones two to three times thicker than this number. In thinner bones, the measured density becomes dependent on the thickness. Changes in cortical thickness can only be assessed if the change is rather large or if the measured bone has sufficient thickness. Therefore, assessing density or thickness of the vertebral shell by CT should be treated with caution.

Dual-Energy and Low-kVp CT in the Abdomen

OBJECTIVE The purpose of this article is to discuss the influence of tube potential on CT images and explore the potential impact of dual-energy CT on imaging of the abdomen and pelvis. CONCLUSION Low peak tube voltage (kVp) settings provide high conspicuity of contrast materials at CT but may result in high image noise, particularly in larger patients. Material decomposition at dual-energy CT can differentiate renal stones by their composition, quantify tissue iron stores, improve the detection of pathologic hyperenhancement, and reduce contrast material and radiation dose compared with conventional CT. Further clinical research and technique refinement will be needed as the usage of these exciting technologies spreads.

Advanced CT bone imaging in osteoporosis

Non-invasive and/or non-destructive techniques can provide structural information about bone, beyond simple bone densitometry. While the latter provides important information about osteoporotic fracture risk, many studies indicate that BMD only partly explains bone strength. Quantitative assessment of macro- and microstructural features may improve our ability to estimate bone strength. Methods for quantitatively assessing macrostructure include (besides conventional radiographs) DXA and CT, particularly volumetric quantitative CT (vQCT). Methods for assessing microstructure of trabecular bone non-invasively and/or non-destructively include high-resolution CT (hrCT), microCT (μCT), high-resolution magnetic resonance (hrMR) and microMR (μMR). vQCT, hrCT and hrMR are generally applicable in vivo; μCT and μMR are principally applicable in vitro. Despite recent progress made with these advanced imaging techniques, certain issues remain. The important balances between spatial resolution and sampling size, or between signal-to-noise and radiation dose or acquisition time, need further consideration, as do the complexity and expense of the methods vs their availability and accessibility. Clinically, the challenges for bone imaging include balancing the advantages of simple bone densitometry vs the more complex architectural features of bone or the deeper research requirements vs the broader clinical needs. The biological differences between the peripheral appendicular skeleton and the central axial skeleton must be further addressed. Finally, the relative merits of these sophisticated imaging techniques must be weighed with respect to their applications as diagnostic procedures, requiring high accuracy or reliability, compared with their monitoring applications, requiring high precision or reproducibility.

Accuracy of CT-based thickness measurement of thin structures: modeling of limited spatial resolution in all three dimensions.

Measurement of the width of thin structures such as the cortical shell of the vertebral body or femoral neck with computed tomography (CT) is limited by the spatial resolution of the CT system. Limited spatial resolution exists both within the CT image plane and perpendicular to it and can be described by the in-plane point spread function (PSF) and the across-plane slice sensitivity profile (SSP), respectively. The goal of this study was to confirm that errors of thickness measurement of thin structures critically depend on the spatial positioning of the object and the spatial resolution limitations of CT in all three dimensions, and to assess the size of the errors themselves. We compared computer models that incorporated both effects to experimentally assessed cortical thicknesses of the European Spine Phantom. Analysis included varying CT slice width, the orientation of measurement and angle beta of misalignment of longitudinal scanner and phantom axes. Agreement of models with measurements was good in all configurations with an overall error of 0.17 mm. This showed that PSF and SSP are adequate system characteristics to predict deviation of measured values from true widths. Errors between measurements and true cortical thickness values delta(true) averaged to 1.5 mm were strongly positively correlated with slice width d and beta. When the across-plane partial volume effect was eliminated, limited in-plane resolution still accounted for overestimation of delta(true) by 0.68 (137%), 0.27 (27%), and 0.06 mm (4%) for delta(true)=0.5, 1.0, and 1.5 mm, respectively. For delta(true) of 1.0 mm and above, it was shown that although the absolute cortical thickness values might not be accurately measurable, relative differences between two values are reflected in measurement. Implications for cortical thickness measurement are that the spinal cortical shell is too thin, whereas accurate assessment at locations of the femoral neck exhibiting a thicker cortical shell of both difference and absolute values should be possible with CT even for larger misalignment angles, especially when a smaller CT slice width is chosen.

Fully 3D list-mode time-of-flight PET image reconstruction on GPUs using CUDA.

PURPOSE List-mode processing is an efficient way of dealing with the sparse nature of positron emission tomography (PET) data sets and is the processing method of choice for time-of-flight (ToF) PET image reconstruction. However, the massive amount of computation involved in forward projection and backprojection limits the application of list-mode reconstruction in practice, and makes it challenging to incorporate accurate system modeling. METHODS The authors present a novel formulation for computing line projection operations on graphics processing units (GPUs) using the compute unified device architecture (CUDA) framework, and apply the formulation to list-mode ordered-subsets expectation maximization (OSEM) image reconstruction. Our method overcomes well-known GPU challenges such as divergence of compute threads, limited bandwidth of global memory, and limited size of shared memory, while exploiting GPU capabilities such as fast access to shared memory and efficient linear interpolation of texture memory. Execution time comparison and image quality analysis of the GPU-CUDA method and the central processing unit (CPU) method are performed on several data sets acquired on a preclinical scanner and a clinical ToF scanner. RESULTS When applied to line projection operations for non-ToF list-mode PET, this new GPU-CUDA method is >200 times faster than a single-threaded reference CPU implementation. For ToF reconstruction, we exploit a ToF-specific optimization to improve the efficiency of our parallel processing method, resulting in GPU reconstruction >300 times faster than the CPU counterpart. For a typical whole-body scan with 75 × 75 × 26 image matrix, 40.7 million LORs, 33 subsets, and 3 iterations, the overall processing time is 7.7 s for GPU and 42 min for a single-threaded CPU. Image quality and accuracy are preserved for multiple imaging configurations and reconstruction parameters, with normalized root mean squared (RMS) deviation less than 1% between CPU and GPU-generated images for all cases. CONCLUSIONS A list-mode ToF OSEM library was developed on the GPU-CUDA platform. Our studies show that the GPU reformulation is considerably faster than a single-threaded reference CPU method especially for ToF processing, while producing virtually identical images. This new method can be easily adapted to enable more advanced algorithms for high resolution PET reconstruction based on additional information such as depth of interaction (DoI), photon energy, and point spread functions (PSFs).

Computed tomographic metal artifact reduction for the detection and quantitation of small features near large metallic implants: a comparison of published methods.

Computed tomographic imaging of tissue surrounding metallic implants is often limited by metal artifacts. This paper compares 3 existing metal artifact reduction techniques that are based on segmentation of metal-affected regions in native images, followed by reprojection of segmented areas into original Radon space, removal of metal trace(s), and renewed reconstruction: Detector row-wise linear interpolation, 2-dimensional interpolation, and combination of row-wise linear interpolation and adaptive filtering. For each method, improvements of CT number accuracy and signal-noise as well as contrast-noise ratios near the prosthesis and in the image periphery over the values found for native images were evaluated in a phantom experiment simulating osteolytic bone lesions of different size and density around a Chrome-Cobalt hip prosthesis stem. Improvement in diagnostic usability was evaluated as lesion detectability by size. Quantitative and qualitative results showed that the linear interpolation and the combination method removed the artifacts most effectively. The mean accuracy error over different regions of interest placed in the direct vicinity of the metal and in the periphery of the object decreased 10-fold with linear interpolation. These methods increased contrast-noise ratio up to 68% of that measured on artifact-free images for the least dense lesion. Qualitatively, the linear interpolation and the combination method improved the lesion detectability and enabled differentiation of different lesion densities. However, in proximity to the stem, some artifacts remained for all methods. We conclude that published algorithms for metal artifact reduction substantially improve image quality for CT imaging of a metallic object and may be adequate for quantitative measurements except for the direct vicinity of the metallic object.

Renal cyst pseudoenhancement at multidetector CT: What are the effects of number of detectors and peak tube voltage?

PURPOSE To determine the effect of the number of detectors and peak tube voltage on renal cyst pseudoenhancement in a phantom model. MATERIALS AND METHODS This study on computed tomographic (CT) phantoms did not require institutional review board approval. The renal compartments of a CT phantom were filled with iodinated contrast material diluted to attain attenuations of 40, 140, and 240 HU. Saline-filled cylinders simulating cysts of varying diameters (range, 0.7-3.0 cm) were serially suspended in the renal compartments and scanned at 80, 90, 100, 120, and 140 kVp in 16-detector (n = 3) and 64-detector (n = 2) CT scanners. Generalized estimating equations were used to determine predictors of cyst pseudoenhancement (defined as a >10 HU increase in cyst attenuation when the background renal attenuation increased from 40 to 140 or 240 HU). RESULTS Pseudoenhancement was seen with higher frequency (59 [61%] of 96 cysts vs 52 [39%] of 132 cysts, P < .05) and magnitude (17 vs 13 HU, P < .005) with 64- rather than with 16-detector scanners. Pseudoenhancement was also seen with higher frequency (25 [42%] of 60 cysts vs 11 [18%] of 60 cysts, P < .005) and magnitude (18 vs 13 HU, P < .05) at 140 kVp than at 80 or 90 kVp. Cyst pseudoenhancement increased with higher background renal enhancement (P < .005) and smaller cyst diameter (P < .05). The number of detectors, peak tube voltage, renal parenchymal enhancement level, and cyst diameter were independent predictors of cyst pseudoenhancement. CONCLUSION Lower tube voltage settings may be useful when accurate differentiation between small renal cysts and solid masses is critical, particularly for 64-detector CT scanners.

Teriparatide vertebral fracture risk reduction determined by quantitative and qualitative radiographic assessment.

ABSTRACT Objective: Most registration studies for new osteoporosis drugs have used a combination of quantitative morphometry (QM) and visual semiquantitative reading (SQ) to define vertebral fractures. However, in the pivotal teriparatide Fracture Prevention Trial (ClinicalTrials.gov Identifier: NCT00670501), vertebral fractures were previously defined only by the SQ methodology. The objective of this study was to define the effect of teriparatide on the incidence of vertebral fractures defined by QM plus SQ assessment. Research design and methods: Radiographs from the Fracture Prevention Trial placebo- and teriparatide 20 μg/day groups were re-assessed in blinded fashion, defining incident vertebral fractures for vertebrae meeting all of the following requirements: (a) 20% decrease in height by QM, (b) a corresponding 4 mm decrease in height (c) an increase of at least one grade by visual SQ assessment by a radiologist. Results: By this methodology, vertebral fracture risk was reduced in the teriparatide versus placebo group by 84% (RR = 0.16, p < 0.001). The risk of two or more vertebral fractures was also significantly reduced by 94% (RR = 0.06, p < 0.001). The fractures in the teriparatide group were of lesser severity than the fractures in the placebo group. The absolute benefit of teriparatide was greatest in those patients with the highest number and severity of prevalent vertebral fractures. Conclusions: As assessed by QM plus SQ, teriparatide reduced the incidence of vertebral fractures. Trial registration: ClinicalTrials.gov identifier: NCT00670501.

Comparison of DXA Hip Structural Analysis with Volumetric QCT

Hip structural analysis (HSA) estimates geometrical and mechanical properties from hip dual-energy X-ray absorptiometry (DXA) images and is widely used in osteoporosis trials. This study compares HSA to volumetric quantitative computed tomography (QCT) measurements in the same population. A total of 121 women (mean age 58 yr, mean body mass index 27 kg/m2) participated. Each woman received a volumetric QCT scan and DXA scan of the left hip. QCT scans were analyzed with in-house software that directly computed geometric and mechanical parameters at the neck and trochanteric regions. DXA HSA was performed with an implementation by GE/Lunar. Pair-wise linear regression of HSA variables was conducted by method to site matched QCT variables for bone density, cross-sectional area, and cross-sectional moment of inertia (CSMI) of the femur neck. HSA correlated well with QCT (r2=0.67 for neck bone mineral density [BMD] and 0.5 for CSMI) and standard DXA at the neck (r2=0.82 for BMD). HSA and volumetric QCT compared favorably, which supports the validity of a projective technique such as DXA to derive geometrical properties of the proximal hip.