Willi A. Kalender

Detection of Coronary Artery Stenoses by Contrast-Enhanced, Retrospectively Electrocardiographically-Gated, Multislice Spiral Computed Tomography

Background—Multislice spiral computed tomography (MSCT) with retrospectively ECG-gated image reconstruction permits coronary artery visualization. We investigated the method’s ability to identify high-grade coronary artery stenoses and occlusions. Methods and Results—A total of 64 consecutive patients were studied by MSCT (4×1 mm cross-sections, 500-ms rotation, table feed 1.5 mm/rotation, intravenous contrast agent, retrospectively ECG-gated image reconstruction). All coronary arteries and side branches with a luminal diameter ≥2.0 mm were assessed concerning evaluability and the presence of high-grade stenoses (>70% diameter stenosis) or occlusions. Results were compared with quantitative coronary angiography. Of 256 coronary arteries (left main, left anterior descending, left circumflex and right coronary artery, including their respective side branches), 174 could be evaluated (68%). In 19 patients (30%), all arteries were evaluable. Artifacts caused by coronary motion were the most frequent reason for unevaluable arteries. Overall, 32 of 58 high-grade stenoses and occlusions were detected by MSCT (58%). In evaluable arteries, 32 of 35 lesions were detected, and the absence of stenosis was correctly identified in 117 of 139 arteries (sensitivity, 91%; specificity, 84%). If analysis was extended to all stenoses with >50% diameter reduction, sensitivity was 85% (40 of 47) and specificity was 76% (96 of 127). Conclusions—MSCT with retrospective ECG gating permits the detection of coronary artery stenoses with high accuracy if image quality is sufficient, but its clinical use may presently be limited due to degraded image quality in a substantial number of cases, mainly due to rapid coronary motion.

Multisection CT Protocols: Sex- and Age-specific Conversion Factors Used to Determine Effective Dose from Dose-Length Product

PURPOSE To determine conversion factors for the new International Commission on Radiological Protection (ICRP) publication 103 recommendations for adult and pediatric patients and to compare the effective doses derived from Monte Carlo calculations with those derived from dose-length product (DLP) for different body regions and computed tomographic (CT) scanning protocols. MATERIALS AND METHODS Effective dose values for the Oak Ridge National Laboratory phantom series, including phantoms for newborns; 1-, 5-, and 10-year-old children; and adults were determined by using Monte Carlo methods for a 64-section multidetector CT scanner. For each phantom, five anatomic regions (head, neck, chest, abdomen, and pelvis) were considered. Monte Carlo simulations were performed for spiral scanning protocols with different voltages. Effective dose was computed by using ICRP publication 60 and publication 103 recommendations. The calculated effective doses were compared with those derived from the DLP by using previously published conversion factors. RESULTS In general, conversion factors determined on the basis of Monte Carlo calculations led to lower values for adults with both ICRP publications. Values up to 33% and 32% lower than previously published data were found for ICRP publication 60 and ICRP publication 103, respectively. For pediatric individuals, effective doses based on the Monte Carlo calculations were higher than those obtained from DLP and previously published conversion factors (eg, for chest CT scanning in 5-year-old children, an increase of about 76% would be expected). For children, a variation in conversion factors of up to 15% was observed when the tube voltage was varied. For adult individuals, no dependence on voltage was observed. CONCLUSION Conversion factors from DLP to effective dose should be specified separately for both sexes and should reflect the new ICRP recommendations. For pediatric patients, new conversion factors specific for the spectrum used should be established.

X-ray computed tomography

X-ray computed tomography (CT), introduced into clinical practice in 1972, was the first of the modern slice-imaging modalities. To reconstruct images mathematically from measured data and to display and to archive them in digital form was a novelty then and is commonplace today. CT has shown a steady upward trend with respect to technology, performance and clinical use independent of predictions and expert assessments which forecast in the 1980s that it would be completely replaced by magnetic resonance imaging. CT not only survived but exhibited a true renaissance due to the introduction of spiral scanning which meant the transition from slice-by-slice imaging to true volume imaging. Complemented by the introduction of array detector technology in the 1990s, CT today allows imaging of whole organs or the whole body in 5 to 20 s with sub-millimetre isotropic resolution. This review of CT will proceed in chronological order focussing on technology, image quality and clinical applications. In its final part it will also briefly allude to novel uses of CT such as dual-source CT, C-arm flat-panel-detector CT and micro-CT. At present CT possibly exhibits a higher innovation rate than ever before. In consequence the topical and most recent developments will receive the greatest attention.

Iterative reconstruction methods in X-ray CT

Iterative reconstruction (IR) methods have recently re-emerged in transmission x-ray computed tomography (CT). They were successfully used in the early years of CT, but given up when the amount of measured data increased because of the higher computational demands of IR compared to analytical methods. The availability of large computational capacities in normal workstations and the ongoing efforts towards lower doses in CT have changed the situation; IR has become a hot topic for all major vendors of clinical CT systems in the past 5 years. This review strives to provide information on IR methods and aims at interested physicists and physicians already active in the field of CT. We give an overview on the terminology used and an introduction to the most important algorithmic concepts including references for further reading. As a practical example, details on a model-based iterative reconstruction algorithm implemented on a modern graphics adapter (GPU) are presented, followed by application examples for several dedicated CT scanners in order to demonstrate the performance and potential of iterative reconstruction methods. Finally, some general thoughts regarding the advantages and disadvantages of IR methods as well as open points for research in this field are discussed.

Dose reduction in CT by anatomically adapted tube current modulation. II. Phantom measurements

Theoretical considerations and simulation studies have led to the expectation that patient dose in CT (computed tomography) can be reduced significantly without a concomitant loss in image quality if tube current is modulated according to rotation angle-dependent x-ray attenuation. In this study, the simulation results presented in Part I were validated with phantoms. We used one cylindrical, two oval, and one elliptical phantom, available both as mathematical descriptions and in physical form, to mimic different parts of the human anatomy. Prototype hardware was available to control tube current on a commercial clinical CT scanner. The potential for dose reduction was evaluated for sinusoidal and attenuation-based current modulation for variable modulation amplitudes. Agreement between simulations and measured results was better than within 10%. Dose reduction values of 8%-56% were found depending on the phantom geometry and tube current modulation function. Attenuation-based tube current modulation consistently yielded higher reduction than fixed-shape sinusoidal modulation functions. For the shoulder phantom and 70% modulation amplitude, 44.6% dose reduction was measured as compared to 34.1% for sinusoidal modulation. A maximum of 56% was measured for the shoulder phantom including inserts. Specifying mAs reduction as an estimate for dose reduction proved to be a valid and conservative estimate; measured dose is reduced more strongly than the total mAs product both centrally and on average. First patient studies confirm the results of simulation and phantom studies. We conclude that attenuation-based online tube current control has great potential for reducing patient dose in CT and that it should be made generally available for clinical use.

Evaluation of a prototype dual-energy computed tomographic apparatus. I. Phantom studies.

We report the evaluation of a prototype dual-energy implementation using rapid kVp switching on a clinical computed tomographic scanner. The method employs prereconstruction basis material decomposition of the dual-energy projection data. Each dual-energy scan can be processed into conventional single-kVp images, basis material density images, and monoenergetic images. Phantom studies were carried out to qualitatively and quantitatively evaluate and validate the approach.

Dose reduction in CT by anatomically adapted tube current modulation. I. Simulation studies

Tube current modulation governed by x-ray attenuation during CT (computed tomography) acquisition can lead to noise reduction which in turn can be used to achieve patient dose reduction without loss in image quality. The potential of this technique was investigated in simulation studies calculating both noise amplitude levels and noise distribution in CT images. The dependence of noise on the inodulation function, amplitude of modulation, shape and size of the object, and possible phase shift between attenuation and modulation function were examined. Both sinusoidal and attenuation-based control functions were used to modulate tube current. Noise reduction was calculated for both ideal systems and for real systems with limited modulation amplitude. Dose reductions up to 50% can be achieved depending on the phantom geometry and tube current modulation function. Attenuation-based tube current modulation yields substantially higher reduction than fixed-shape modulation functions. Optimal results are obtained when the current is modulated as a function of the square root of attenuation. A modulation amplitude of at least 90% should be available to exploit the potential of these techniques.

Generalized multi-dimensional adaptive filtering for conventional and spiral single-slice, multi-slice, and cone-beam CT.

In modern computed tomography (CT) there is a strong desire to reduce patient dose and/or to improve image quality by increasing spatial resolution and decreasing image noise. These are conflicting demands since increasing resolution at a constant noise level or decreasing noise at a constant resolution level implies a higher demand on x-ray power and an increase of patient dose. X-ray tube power is limited due to technical reasons. We therefore developed a generalized multi-dimensional adaptive filtering approach that applies nonlinear filters in up to three dimensions in the raw data domain. This new method differs from approaches in the literature since our nonlinear filters are applied not only in the detector row direction but also in the view and in the z-direction. This true three-dimensional filtering improves the quantum statistics of a measured projection value proportional to the third power of the filter size. Resolution tradeoffs are shared among these three dimensions and thus are considerably smaller as compared to one-dimensional smoothing approaches. Patient data of spiral and sequential single- and multi-slice CT scans as well as simulated spiral cone-beam data were processed to evaluate these new approaches. Image quality was assessed by evaluation of difference images, by measuring the image noise and the noise reduction, and by calculating the image resolution using point spread functions. The use of generalized adaptive filters helps to reduce image noise or, alternatively, patient dose. Image noise structures, typically along the direction of the highest attenuation, are effectively reduced. Noise reduction values of typically 30%-60% can be achieved in noncylindrical body regions like the shoulder. The loss in image resolution remains below 5% for all cases. In addition, the new method has a great potential to reduce metal artifacts, e.g., in the hip region.

A new accurate and precise 3-D segmentation method for skeletal structures in volumetric CT data

We developed a highly automated three-dimensionally based method for the segmentation of bone in volumetric computed tomography (CT) datasets. The multistep approach starts with three-dimensional (3-D) region-growing using local adaptive thresholds followed by procedures to correct for remaining boundary discontinuities and a subsequent anatomically oriented boundary adjustment using local values of cortical bone density. We describe the details of our approach and show applications in the proximal femur, the knee, and the skull. The accuracy of the determination of geometrical parameters was analyzed using CT scans of the semi-anthropomorphic European spine phantom. Depending on the settings of the segmentation parameters cortical thickness could be determined with an accuracy corresponding to the side length of 1 to 2.5 voxels. The impact of noise on the segmentation was investigated by artificially adding noise to the CT data. An increase in noise by factors of two and five changed cortical thickness corresponding to the side length of one voxel. Intraoperator and interoperator precision was analyzed by repeated analysis of nine pelvic CT scans. Precision errors were smaller than 1% for trabecular and total volumes and smaller than 2% for cortical thickness. Intraoperator and interoperator precision errors were not significantly different. Our segmentation approach shows: 1) high accuracy and precision and is 2) robust to noise, 3) insensitive to user-defined thresholds, 4) highly automated and fast, and 5) easy to initialize.

Dose reduction in CT by on-line tube current control: principles and validation on phantoms and cadavers.

Abstract. We investigated approaches to reducing the dose in CT without impairing image quality. Dose can be reduced for non-circular object cross-sections without a significant increase in noise if X-ray tube current is reduced at angular tube positions where the X-ray attenuation by the patients is small. We investigated different schemes of current modulation during tube rotation by simulation and phantom measurements. Both pre-programmed sinusoidal modulation functions and attenuation-based on-line control of the tube current were evaluated. All relevant scan parameters were varied, including constraints such as the maximum modulation amplitude. A circular, an elliptical and two oval water phantoms were used. Results were validated on six cadavers. Dose reduction of 10–45 % was obtained both in simulations and in measurements for the different non-circular phantom geometries and current modulation algorithms without an increase in pixel noise values. On-line attenuation-based control yielded higher reductions than modulation by a sinusoidal curve. The maximal dose reduction predicted by simulations could not be achieved due to limits in the modulation amplitude. In cadaver studies, a reduction of typically 20–40 % was achieved for the body and about 10 % for the head. Variations of our technique are possible; a slight increase in nominal tube current for high-attenuation projections combined with attenuation-based current modulation still yields significant dose reduction, but also a reduction in the structured noise that may obscure diagnostic details. We conclude that a significant reduction in dose can be achieved by tube current modulation without compromising image quality. Attenuation-based on-line control and a modulation amplitude of at least 90 % should be employed.