Cumulative radiation dose during hospitalization for aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Radiation exposure from neurointerventional procedures and diagnostic neuroimaging can be substantial, with many recommendations offered to guide the interventionalist in the conscientious use of ionizing radiation. Patients presenting with an aneurysmal subarachnoid hemorrhage can undergo multiple imaging procedures during a prolonged hospital course. Therefore, we reviewed a cohort of such patients to identify the sources and quantify the cumulative radiation exposure seen during their hospitalization. MATERIALS AND METHODS: We retrospectively reviewed a single-center experience with these patients to define the potential for short-term skin injury and long-term oncologic risk due to absorbed radiation dose and sources of ionizing radiation and their contribution to the cumulative absorbed dose to the cranial tissues. RESULTS: We demonstrated that substantial cumulative doses can be seen, with 87% of the cumulative absorbed dose occurring during neurointerventional procedures and 7% from CT. Mathematic modeling was performed identifying potential techniques to further reduce the cumulative radiation absorbed dose to these patients. CONCLUSIONS: We conclude that repetitive irradiation during the care of patients with aneurysmal subarachnoid hemorrhage can result in significant cumulative doses and a variety of techniques can be applied to reduce this absorbed dose. Use of radiation for diagnostic and therapeutic purposes during prolonged procedures of patients with subarachnoid hemorrhage demands diligence throughout the hospitalization.

Spiral CT scanning technique in the detection of aspiration of LEGO foreign bodies.

BACKGROUND: Radiolucent foreign bodies (FBs) such as plastic objects and toys remain difficult to identify on conventional radiographs of the neck and chest. Children may present with a variety of respiratory complaints, which may or may not be due to a FB. OBJECTIVE: To determine whether radiolucent FBs such as plastic LEGOs and peanuts can be seen in the tracheobronchial tree or esophagus using low-dose spiral CT, and, if visible, to determine the optimal CT imaging technique. MATERIALS AND METHODS: Multiple spiral sequences were performed while varying the CT parameters and the presence and location of FBs in either the trachea or the esophagus first on a neck phantom and then a cadaver. Sequences were rated by three radiologists blinded to the presence of a FB using a single scoring system. RESULTS: The LEGO was well visualized in the trachea by all three readers (both lung and soft-tissue windowing: combined sensitivity 89 %, combined specificity 89 %) and to a lesser extent in the esophagus (combined sensitivity 31 %, combined specificity 100 %). The peanut was not well visualized (combined sensitivity < 35 %). The optimal technique for visualizing the LEGO was 120 kV, 90 mA, 3-mm collimation, 0.75 s/revolution, and 2.0 pitch. This allowed for coverage of the cadaver tracheobronchial tree (approximately 11 cm) in about 18 s. Although statistical power was low for detecting significant differences, all three readers noted higher average confidence ratings with lung windowing among 18 LEGO-in-trachea scans. CONCLUSION: Rapid, low-dose spiral CT may be used to visualize LEGO FBs in the airway or esophagus. Peanuts were not well visualized.

Three-dimensional computed tomographic volume rendering techniques in endoscopic thoracoplasty.

BACKGROUND CONTEXT: Thoracoplasty is occasionally necessary to achieve an acceptable cosmetic result in the presence of a rib hump, especially in previously fused young adults with scoliosis. This usually requires the resection of four to five rib segments, and the morbidity associated with open posterior resection or of open anterior resection by means of thoracotomy is often considerable, apart from leaving an unsightly scar. We thought the use of an endoscopic internal rib resection technique would achieve the desired result with less morbidity. Our experience with using the technique of three-dimensional (3-D) computed tomographic (CT) volume rendering to plan our portals and releases for endoscopic scoliosis correction led us to believe the same techniques could be adapted to plan and endoscopically carry out the thoracoplasty. PURPOSE: To define the utility of 3-D CT volume rendering of the spine and thorax in the preoperative planning of endoscopic rib resection. STUDY DESIGN: A prospective evaluation of the utility of 3-D CT volume rendering for preoperative planning in patients with scoliosis undergoing endoscopic thoracoplasty for correction of rib humps. PATIENT SAMPLE: Four consecutive patients with previously fused scoliotic spines and pronounced right-sided rib humps requiring operative correction were selected. OUTCOME MEASURES: Outcome was assessed at a minimum follow-up of 6 months by clinical examination, patient satisfaction with the clinical result, and repeat helical CT scanning with 3-D reconstruction. METHODS: Four patients with previously fused scoliotic spines and pronounced rib humps underwent helical CT scanning with 3-D volume rendering, prior to endoscopic corrective surgery. All four patients had right-sided rib humps requiring corrective rib resection for cosmetic reasons. Using the technique of 3-D volume rendering, a vector plane was created to mirror the left scapula, and its intersections on the right chest wall were noted. The ribs to be resected were marked, and the length of rib resection was measured from the vector plane's intersection points with the ribs. In this way an estimate of the resection required to achieve the desired final position of the right elevated scapula could be determined. Entry portals were also estimated with vector lines to achieve optimal access to each rib. During surgery, the portal sites were assessed for access to the selected ribs. Also, the extent of rib resections was compared with the estimates. The final clinical outcome was assessed by clinical examination, patient satisfaction with the cosmetic result, and repeat helical CT scanning with 3-D reconstruction. RESULTS: The male to female ratio was 1:3, and the average age was 21 years. Our average estimated blood loss was 307 ml and average hospital stay was 4.75 days. The estimated portal sites were accurate and did provide for direct access to each selected rib involved in the deformity. We were able to resect the ribs at the points suggested by 3-D CT volume rendering, with the lengths of our resected segments matching our preoperative estimates. In all cases the elevated right scapula did descend into the rib resection bed, thus balancing the shoulder heights. An excellent cosmetic result was achieved in all cases as evaluated by clinical examination, patient's perception, and repeat helical CT scanning. CONCLUSION: The technique of 3-D CT volume rendering with vector plane estimates provides a reliable estimate of the rib resection required to achieve a cosmetically acceptable correction of the rib hump through minimally invasive techniques.

Preoperative use of 3D volume rendering to demonstrate renal tumors and renal anatomy.

With increased use of computed tomography (CT) and abdominal ultrasonography, the indications for nephron-sparing surgery are also increasing. Triphasic helical CT and three-dimensional (3D) volume rendering can be combined into a single noninvasive test to delineate renal tumors and normal and complex renal anatomy prior to nephron-sparing surgery. This combination technique has proved accurate and very useful for both preoperative and intraoperative planning by demonstrating renal position, tumor location and depth of tumor extension into the kidney, relationship of the tumor to the collecting system, and renal vascular anatomy. Knowledge of the position of the kidney relative to the lower rib cage, iliac crest, and spine helps in planning the initial surgical incision. By depicting tumor location and depth of extension, helical CT with 3D volume rendering helps ensure complete tumor excision and conservation of adjacent normal renal parenchyma. Depiction of the relationship of the tumor to the collecting system helps anticipate further tumor extension and minimize postoperative complications. Identification of normal renal vasculature and anatomic variants can help minimize ischemic injury and intraoperative bleeding. Radiologists should be familiar with current indications for nephron-sparing surgery and understand what information is required prior to surgery.

3-dimensional volume rendered computerized tomography for preoperative evaluation and intraoperative treatment of patients undergoing nephron sparing surgery.

PURPOSE: Computerized tomography (CT) is the diagnostic and staging modality of choice for renal neoplasms. Existing imaging modalities are limited by a 2-dimensional (D) format. Recent advances in computer technology now allow the production of high quality 3-D images from helical CT. Nephron sparing surgery requires a detailed understanding of renal anatomy. Preoperative evaluation must delineate the relationship of the tumor to adjacent normal structures and demonstrate the vascular supply to the tumor for the surgeon to conserve as much normal parenchyma as possible. We propose that helical CT combined with 3-D volume rendering provides all of the information required for preoperative evaluation and intraoperative management of nephron sparing surgery cases. We prospectively evaluated the role of 3-D volume rendering CT in 60 patients undergoing nephron sparing surgery for renal cell carcinoma at the Cleveland Clinic Foundation. MATERIALS AND METHODS: Triphasic spiral CT was performed preoperatively in 60 consecutive patients undergoing nephron sparing surgery for renal neoplasms. A 3 to 5-minute videotape was prepared using volume rendering software which demonstrated the position of the kidney, location and depth of extension of the tumor(s), renal artery(ies) and vein(s), and relationship of the tumor to the collecting system. These videotapes were viewed by a radiologist and urologist in the operating room at surgery, and immediately correlated with surgical findings. Corresponding renal arteriograms of 19 patients were retrospectively compared to 3-D volume rendering CT and operative findings. RESULTS: A total of 97 renal masses were identified in 60 cases evaluated with 3-D volume rendering CT before nephron sparing surgery. There were no complications related to the 3-D protocol and 3-D rendering was successful in all patients. The number and location of lesions identified by 3-D volume rendering CT were accurate in all cases, while enhancement and diagnostic characteristics were consistent with pathological findings in 95 of 97 tumors (98%). Of 77 renal arteries identified at surgery 74 were detected by 3-D volume rendering CT (96%). Helical CT missed 3 small accessory arteries, including 1 in a cross fused ectopic kidney. All major venous branches and anomalies were identified, including 3 circumaortic left renal veins. Of 69 renal veins identified at surgery 64 were detected by 3-D volume rendering CT (93%). All 5 renal veins missed by CT were small, short, duplicated right branches of the main renal vein. Renal fusion and malrotation anomalies were correctly identified in all 4 patients. CONCLUSIONS: The 3-D volume rendering CT accurately depicts the renal parenchymal and vascular anatomy in a format familiar to most surgeons. The data integrate essential information from angiography, venography, excretory urography and conventional 2-D CT into a single imaging modality, and can obviate the need for more invasive imaging. Additionally, the use of videotape in an intraoperative setting provides concise, accurate and immediate 3-D information to the surgeon, and it has become the preferred means of data display for these procedures at our center.

Selenium-based digital radiography versus conventional film-screen radiography of the hands and feet: a subjective comparison.

OBJECTIVE: The purpose of this study was to subjectively compare the visibility of normal anatomy of the hands and feet using selenium-based digital radiography versus conventional film-screen (100-speed) radiography. SUBJECTS AND METHODS: Digital and film-screen images of the hands and feet of 24 patients were obtained without an antiscatter grid using identical X-ray exposure. Each pair of images was evaluated independently by five experienced radiologists for visibility of normal anatomy using a six-point rating scale. Soft tissues, cortical bone, and trabeculae were evaluated. For each observer, "equivalence" was defined as a mean difference in image quality of less than 1 unit on the 0-5 scale used in the study. Paired t tests were also performed to determine whether the average visibility rating of one technique was statistically superior to that of the other at a .05 level of significance for each observer and at each anatomic landmark. RESULTS: In all categories, selenium-based digital images were rated equivalent to film-screen images by the five observers. Using the sum of the nine landmarks, four of the five observers rated the quality of selenium-based digital images superior to that of film-screen images. CONCLUSION: Subjective visibility of normal anatomy of the hands and feet using selenium-based digital radiography was similar to that achieved using conventional film-screen radiography.

Quantitative analysis of breast parenchymal density: correlation with women's age.

RATIONALE AND OBJECTIVES: The authors evaluated the relationship between a woman's breast parenchymal density and her age by means of a quantitative method for measuring density from digitized mammograms. MATERIALS AND METHODS: The percentage of the breast considered to be dense was evaluated from mammograms of 50 women stratified by age. Quantitative analysis based on the computer segmentation of tissue in digitized mammograms was performed by three expert mammographers. The results of this analysis were compared with results from a review of the film mammograms by three expert mammographers. RESULTS: A slight decrease in the percentage of breast considered to be dense with increased age was observed. The average difference in the percentage of dense breast tissue between the youngest and the oldest age groups was 6.4% based on the digital review and 14.6% based on the film review. Within each age group, the total variability was on the order of 75%. CONCLUSION: The difference in mean magnitude between the youngest and oldest age groups was small and may not be clinically important. The variability within an age group was large, which suggests that age is not a reliable indicator of percentage of dense breast tissue.

Comparison of examination times between CT scanners: are the newer scanners faster?

OBJECTIVE: The purpose of this study was to determine if a newer technology helical CT scanner can reduce CT examination times. MATERIALS AND METHODS: Data from 1049 CT examinations were recorded prospectively during a 5-week period. "Room time" was defined as the time each patient spent in the CT room (time patient exited minus time patient entered) and "scanner time" was defined as the time a scanner was dedicated to a specific patient (longer of either time that image processing was complete minus time patient entered room, or total time that patient spent in the scanner room). Data to calculate the room and scanner times were recorded along with the scanner type, examination protocol, and five other covariates. Both times were calculated for the 10 most common examination protocols (n = 769 patients) and compared between the older and newer model CT scanner using analysis of covariance models. The most common protocols were abdomen and pelvis (n = 211); head (n = 146); chest (n = 99); simple sinus (n = 99); and chest, abdomen, and pelvis (n = 68). RESULTS: The mean room and scanner times, adjusted for covariates, were both significantly shorter for the newer scanner (p = .0001). The results for room time were statistically significant for six of the 10 examination protocols (84% of examinations). Likewise, the results for scanner time were statistically significant for four examination protocols (68% of examinations). Examination times were longer for inpatients (p = .0001) and when problems occurred during the examination (p = .0001). Sex and age did not significantly affect examination times (p > .08). CONCLUSION: The newer helical CT scanner we studied significantly reduced the time for many types of examinations.

A phantom study: evaluation of renal artery stenosis using helical CT and 3D reconstructions.

PURPOSE: We studied which set of CT parameters and modeling parameters yielded accurate measurements of three graded artificial renal artery stenoses. METHOD: An acrylic phantom resembling the abdominal aorta and renal arteries was constructed. Stenotic segments had diameters of 1.8, 3.2, and 4.8 mm; nonstenotic segment diameter was 6.3 mm. Helical scans were done using 1 and 3 mm collimation at pitches of 1, 1.5, and 2. 3D renderings were produced and measured. Multifactorial and regression tree analysis were used to determine the accuracy of the 3D renderings. Mean squared error (MSE) was used to compare true diameter with measured diameter. RESULTS: Collimation of 1 mm produced an MSE of 0.55 versus an MSE of 1.35 for 3 mm collimation. Stenosis grade was the next most important parameter in the 1 mm subgroup and viewing direction in the 3 mm collimation subgroup. In the 1 mm subgroup, high and mid grade stenoses had an MSE of 0.52 versus low grade stenosis that had an MSE of 0.61. Pitch was a fourth-order effect. CONCLUSION: Collimation of 1 mm combined with a pitch ratio as high as 2:1 is superior to 3 mm collimation. Shaded surface modeling was the single best choice for rendering 3D data. Stenosis grade interacted strongly with user-controllable parameters.

Optimization of Cd1-xZnxTe Detectors for Digital Radiography.

In this study, measurements of the electrical and detection parameters of the Cd1-xZnxTe detectors, within the x-ray diagnostic energy range, have been performed with the aim of optimizing the image quality parameters of these solid-state-ionization detectors. Namely, the leakage current and system capacitance of the x-ray imaging system have been measured as they relate to signal parameters. Similarly, the detected signal and noise contributions were measured and related to the radiation exposure and tube current setting. Furthermore, the detector contrast has been experimentally determined. The experimental results indicate that Cd1-xZnxTe detectors have low leakage current, high resistivity, and high detector contrast resolution. Therefore, they appear to be very attractive for imaging applications with applications in x-ray digital radiography.

Contrast Study of CdZnTe Detectors for Digital Mammography.

Experiments have been performed with the aim of optimizing the image quality parameters of CdZnTe detectors for digital mammography. A geometrical breast phantom has been designed, and the dependence of the contrast resolution of a planar CdZnTe detector on the phantom thickness has been experimentally determined. Specifically, the detected signal and noise contributions were measured and related to phantom thickness. The results of this study indicate that the CdZnTe detectors exhibit a high contrast resolution. On the other hand, the dynamic range of this detector can be improved significantly by further implementation of the data acquisition electronics.

Power injection of intravenous contrast material through central venous catheters for CT: in vitro evaluation.

PURPOSE: To determine the feasibility of use of a power injector to deliver contrast material through central venous catheters for computed tomographic (CT) examinations. MATERIALS AND METHODS: Ioversol 240 and iothalamate meglumine 43% were separately injected through three 9.6-F Hickman catheters and three 10.0-F Leonard catheters with a power injector in an in vitro study. Flow rates of 1.0, 1.5, 2.0, and 2.5 mL/sec were tested. Peak pressures were mechanically recorded from two sites. A 95% prediction interval was calculated for each peak pressure, and the upper limits at the prediction interval were evaluated to determine if it was less than the recommended limit of 25 psi (175 kPa). RESULTS: Contrast medium, flow rate, and catheter type each statistically significantly affected the measured peak pressures (P = .0001). For each flow rate tested, the upper limits of the prediction interval for the peak pressure at the connection between the coiled tubing and the catheter were below the manufacturer's specified peak pressure. CONCLUSION: In vitro analysis demonstrates that power injection of intravenous contrast medium through central venous catheters does not exceed the pressure limits of these catheters at the flow rates tested. In vivo testing to evaluate the safety and efficacy of power injection through central venous catheters is necessary.

Helical (spiral) CT of the upper airway with three-dimensional imaging: technique and clinical assessment.

OBJECTIVE: The purpose of this study was to evaluate the application of helical CT-generated three-dimensional images of the upper airway. MATERIALS AND METHODS: Thirty patients, 10 healthy and 20 with upper-airway disease, were studied with helical CT (5-mm collimation). Overlapping images at 2-mm intervals were retrospectively generated. In the group of healthy patients, two radiologists in independently compared overlapping with nonoverlapping images, ranked confidence in identifying small airway structures on a scale of 1-5, and tabulated the number of images demonstrating these structures. In the 20 patients with disease, three-dimensional (3D) surface models were rendered on an independent workstation and were reviewed by two radiologists and one otolaryngologist for image quality, appreciation of lesion morphology, and ability to judge lesion extent, using a similar scale. A phantom was used to optimize parameters for the 3D reconstructions. RESULTS: Viewing of the retrospectively generated overlapping images increased by 122% the number of images in which laryngeal and hypopharyngeal structures could be identified (p < .01). Image confidence scores for the radiologists averaged 3.3 for nonoverlapping and 4.0 for overlapping (p < .05). Radiologists and otolaryngologist rated the quality of the 3D images equally. The otolaryngologist's assessment of the value of the models for understanding the lesion morphology was 3.5 compared with the radiologists assessment of 2.5; and for judging the lesion extent, the otolaryngologist's assessment was 3.8 compared with 2.7 for the radiologist, a statistical significance of p < .01. CONCLUSION: Helical CT with the application of overlapping images and 3D reconstructions significantly assists the understanding of upper-airway disease.

Determination of spiral CT slice sensitivity profiles using a point response phantom.

OBJECTIVE: This study was done to compare the slice sensitivity profiles (SSP) for combinations of collimation, pitch, and table speed for spiral CT using a point response phantom. The goal was to determine the optimal combination of parameters to reduce partial volume averaging without compromising z-axis coverage. MATERIALS AND METHODS: A copper ball bearing measuring 0.4 mm was embedded in a closed-cell air-foam background to create a point response input phantom. The phantom was scanned at pitches from 0.1 to 2.0 for collimations of 5, 8, and 10 mm. The full width half maximums (FWHMs) and full width tenth maximums (FWTMs) were estimated from SSP curves generated by plotting the maximum pixel value in HU for each reconstructed image against table position. FWHMs and FWTMs were compared separately for constant collimation and increasing table speed and for constant table speed and decreasing collimation using either a two-tailed z-test or chi-square test. RESULTS: Differences between FWHMs and between FWTMs for comparisons made between different collimations at constant table speeds of 8 and 10 mm/s were significantly different (p < or = 0.0001). Differences between FWHMs and between FWTMs showed a linear trend, increasing with increasing pitch for constant collimation (p < or = 0.0013). CONCLUSION: Scanning at narrower collimation but higher pitch provides a narrower SSP when scanning at equivalent table speeds without compromising z-axis coverage.

Helical CT of the upper airway: normal and abnormal findings on three-dimensional reconstructed images.

Imaging of the hypopharynx, larynx, and upper airway are effectively achieved with CT and MR imaging. These techniques have proved their diagnostic usefulness in assessing the deep soft tissues not visible with laryngoscopy [1]. However, with axial imaging, large numbers of images often need to be mentally stacked to envision the appearance of the airway. With helical CT, we can create high-quality three-dimensional (3D) reconstructions [2, 3]. Advantages of helical technology include rapid scanning, decreased motion artifact, and minimization of misregistration artifacts. Recent work has suggested a role for multiplanar and 3D reconstructions of helical data for assessing the tracheobronchial tree [3]. The helically derived 3D models illustrate the normal and abnormal findings affecting the airway.

Diagnosis of aortic dissection: value of helical CT with multiplanar reformation and three-dimensional rendering.

OBJECTIVE: Twenty-three patients with suspected aortic dissection were evaluated in this preliminary study of helical CT to determine the usefulness of axial sections, multiplanar reformation, and three-dimensional (3D) rendering in assessing the presence of dissection and the extent of intimal flap. MATERIALS AND METHODS: Patients were referred for helical CT scanning because of chest pain or an abnormal chest radiograph. Scans were performed during bolus injection of nonionic contrast material at 2.0-2.5 ml/sec using a mean scan delay of 47 sec. Axial scans with 5-mm collimation were obtained in all patients. They extended from the great vessels to the distal thoracic aorta just above the hiatus. Delayed nonhelical sections were obtained through the upper abdomen. Multiplanar reformations and 3D models were reconstructed from the helical data in 13 patients and were compared to axial sections in 7 patients who proved to have documented dissection. The efficacy of CT was determined using surgery, angiography, or clinical outcome to establish the diagnosis. RESULTS: Of the 23 patients studied, axial sections resulted in 15 true-negative, 7 true-positive, and 1 false-positive interpretation. In three of seven patients with dissection, it was difficult to determine the extent of the intimal flap on axial sections; multiplanar reformation or 3D views clarified the relevant anatomy in all 3 cases. Among the 3D display methods, ray-sum projection views were superior to surface model or maximum-intensity-projection views. CONCLUSION: If studies of larger numbers of patients confirm our preliminary findings, multiplanar reformation and 3D rendering of helical CT scans will be a valuable addition to axial display of CT studies used to detect aortic dissection and to determine the extent of the intimal flap.

Abdominal aortic aneurysms: findings on three-dimensional display of helical CT data.

Excellent vascular opacification, reduction in misregistration artifacts, and the option of reconstructing overlapping scans from which three-dimensional (3D) models of the abdominal vessels may be rendered are among the benefits of helical CT [1-4]. The purpose of this essay is to illustrate the findings of 3D rendering of helical CT data in patients with abdominal aortic aneurysms.

The optimal temporal window for CT of the liver using a time-density analysis: implications for helical (spiral) CT.

OBJECTIVE: Scanning protocols for conventional CT of the liver have been proposed. Current availability of helical CT with a four- to sixfold decrease in scan time requires significant adjustments in these protocols. The present study assesses the implications of time-density curves on the performance of helical liver CT. MATERIALS AND METHODS: Twenty patients without liver lesions were studied for time-density analysis of the aorta, inferior vena cava (ICV), portal vein, and liver. Scans were performed at the level of the portal vein at baseline and every 15 s for 3 min following uniphasic administration of 150 ml (300 mg I/ml) nonionic contrast agent. Regions of interest were used to measure three areas in each anatomic structure over time. Median and mean peak enhancement times were calculated for all 20 patients. Cubic spline interpretation was employed to determine the point of equilibrium. RESULTS: Results demonstrated the following average maximum enhancement values and times for peak enhancement: aorta: 227 HU (75 s); liver: 123 HU (105 s); portal vein: 187 HU (90 s); IVC: 142 HU (90 s). Hepatic enhancement achieved 67 HU over baseline. Peak portal enhancement occurred 15 s prior to liver enhancement (p = 0.001). Aortic and hepatic curves became parallel (onset of equilibrium) at a median time of 120 s. CONCLUSION: Helical scanning requires a longer delay (70-80 s) than used for conventional CT. Upon application of these principles, scan initiation occurs higher on the liver enhancement curve, improving liver enhancement without impinging on equilibrium.