Modified calcium subtraction in dual-energy CT angiography of the lower extremity runoff: impact on diagnostic accuracy for stenosis detection.

OBJECTIVES: To investigate the diagnostic accuracy of a modified three-material decomposition calcium subtraction (CS) algorithm for the detection of arterial stenosis in dual-energy CT angiography (DE-CTA) of the lower extremity runoff compared to standard image reconstruction, using digital subtraction angiography (DSA) as the reference standard. METHODS: Eighty-eight patients (53 males; mean age, 65.9 ± 11 years) with suspected peripheral arterial disease (PAD) who had undergone a DE-CTA examination of the lower extremity runoff between May 2014 and May 2015 were included in this IRB-approved, HIPAA-compliant retrospective study. Standard linearly blended and CS images were reconstructed and vascular contrast-to-noise ratios (CNR) were calculated. Two independent observers assessed subjective image quality using a 5-point Likert scale. Diagnostic accuracy for ≥ 50% stenosis detection was analyzed in a subgroup of 45 patients who had undergone additional DSA. Diagnostic accuracy parameters were estimated with a random-effects logistic regression analysis and compared using generalized estimating equations. RESULTS: CS datasets showed higher CNR (15.3 ± 7.3) compared to standard reconstructions (13.5 ± 6.5, p < 0.001). Both reconstructions showed comparable qualitative image quality scores (CS, 4.64; standard, 4.57; p = 0.220). Diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) for CS reconstructions was 96.5% (97.5%, 95.6%, 90.9%, 98.1) and 93.1% (98.8%, 90.4%, 82.3%, 99.1%) for standard images. CONCLUSIONS: A modified three-material decomposition CS algorithm provides increased vascular CNR, equivalent qualitative image quality, and greater diagnostic accuracy for the detection of significant arterial stenosis of the lower extremity runoff on DE-CTA compared with standard image reconstruction. KEY POINTS: • Calcified plaques may lead to overestimation of stenosis severity and false positive results, requiring additional invasive digital subtraction angiography (DSA). • A modified three-material decomposition algorithm for calcium subtraction provides greater diagnostic accuracy for the detection of significant arterial stenosis of the lower extremity runoff compared with standard image reconstruction. • The application of this algorithm in patients with heavily calcified vessels may be helpful to potentially reduce inconclusive CT angiography examinations and the need for subsequent invasive DSA.

Coronary CT Angiography-derived Fractional Flow Reserve: Machine Learning Algorithm versus Computational Fluid Dynamics Modeling.

Purpose To compare two technical approaches for determination of coronary computed tomography (CT) angiography-derived fractional flow reserve (FFR)-FFR derived from coronary CT angiography based on computational fluid dynamics (hereafter, FFRCFD) and FFR derived from coronary CT angiography based on machine learning algorithm (hereafter, FFRML)-against coronary CT angiography and quantitative coronary angiography (QCA). Materials and Methods A total of 85 patients (mean age, 62 years ± 11 [standard deviation]; 62% men) who had undergone coronary CT angiography followed by invasive FFR were included in this single-center retrospective study. FFR values were derived on-site from coronary CT angiography data sets by using both FFRCFD and FFRML. The performance of both techniques for detecting lesion-specific ischemia was compared against visual stenosis grading at coronary CT angiography, QCA, and invasive FFR as the reference standard. Results On a per-lesion and per-patient level, FFRML showed a sensitivity of 79% and 90% and a specificity of 94% and 95%, respectively, for detecting lesion-specific ischemia. Meanwhile, FFRCFD resulted in a sensitivity of 79% and 89% and a specificity of 93% and 93%, respectively, on a per-lesion and per-patient basis (P = .86 and P = .92). On a per-lesion level, the area under the receiver operating characteristics curve (AUC) of 0.89 for FFRML and 0.89 for FFRCFD showed significantly higher discriminatory power for detecting lesion-specific ischemia compared with that of coronary CT angiography (AUC, 0.61) and QCA (AUC, 0.69) (all P < .0001). Also, on a per-patient level, FFRML (AUC, 0.91) and FFRCFD (AUC, 0.91) performed significantly better than did coronary CT angiography (AUC, 0.65) and QCA (AUC, 0.68) (all P < .0001). Processing time for FFRML was significantly shorter compared with that of FFRCFD (40.5 minutes ± 6.3 vs 43.4 minutes ± 7.1; P = .042). Conclusion The FFRML algorithm performs equally in detecting lesion-specific ischemia when compared with the FFRCFD approach. Both methods outperform accuracy of coronary CT angiography and QCA in the detection of flow-limiting stenosis.

Heavily Calcified Coronary Arteries: Advanced Calcium Subtraction Improves Luminal Visualization and Diagnostic Confidence in Dual-Energy Coronary Computed Tomography Angiography.

OBJECTIVES: The aim of this study was to evaluate a prototype dual-energy computed tomography calcium subtraction algorithm and its impact on luminal visualization in patients with heavily calcified coronary arteries. MATERIALS AND METHODS: Twenty-nine patients (62% male; mean age, 64 ± 7 years) who had undergone dual-energy coronary computed tomography angiography were retrospectively included in this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study. Linearly blended (M_0.6) and calcium-subtracted images were reconstructed. Two independent observers assessed luminal visualization of the coronary arteries in a segment-based analysis, subjective image quality, and diagnostic confidence using 5-point Likert scales. Contrast-to-noise ratios for both data sets were calculated. Wilcoxon testing and Cohen's κ were used for statistical comparisons. RESULTS: Calcium-subtracted image series showed improved lumen visualization of the coronary arteries (P = 0.008), with excellent interreader agreement (mean score, 3.3; κ = 0.82), compared with M_0.6 series (mean score, 2.9; κ = 0.77). The calcium subtraction algorithm improved diagnostic confidence compared with the M_0.6 reconstructions (mean scores, 4.0 and 3.1, respectively; all P ≤ 0.002). The image quality analysis showed no significant differences between calcium-subtracted and M_0.6 data sets (subjectively: mean scores, 4.1 and 4.2, respectively, P = 0.442; objectively: mean contrast-to-noise ratio, 37.0 and 38.2, respectively, P = 0.733). CONCLUSIONS: A prototype algorithm for calcium subtraction improves coronary lumen visualization and diagnostic confidence in patients with heavy coronary calcifications without differences in conventional subjective and objective measures of image quality.

Spatial Distribution of Iron Within the Normal Human Liver Using Dual-Source Dual-Energy CT Imaging.

OBJECTIVES: Explore the potential of dual-source dual-energy (DSDE) computed tomography (CT) to retrospectively analyze the uniformity of iron distribution and establish iron concentration ranges and distribution patterns found in healthy livers. MATERIALS AND METHODS: Ten mixtures consisting of an iron nitrate solution and deionized water were prepared in test tubes and scanned using a DSDE 128-slice CT system. Iron images were derived from a 3-material decomposition algorithm (optimized for the quantification of iron). A conversion factor (mg Fe/mL per Hounsfield unit) was calculated from this phantom study as the quotient of known tube concentrations and their corresponding CT values. Retrospective analysis was performed of patients who had undergone DSDE imaging for renal stones. Thirty-seven patients with normal liver function were randomly selected (mean age, 52.5 years). The examinations were processed for iron concentration. Multiple regions of interest were analyzed, and iron concentration (mg Fe/mL) and distribution was reported. RESULTS: The mean conversion factor obtained from the phantom study was 0.15 mg Fe/mL per Hounsfield unit. Whole-liver mean iron concentrations yielded a range of 0.0 to 2.91 mg Fe/mL, with 94.6% (35/37) of the patients exhibiting mean concentrations below 1.0 mg Fe/mL. The most important finding was that iron concentration was not uniform and patients exhibited regionally high concentrations (36/37). These regions of higher concentration were observed to be dominant in the middle-to-upper part of the liver (75%), medially (72.2%), and anteriorly (83.3%). CONCLUSIONS: Dual-source dual-energy CT can be used to assess the uniformity of iron distribution in healthy subjects. Applying similar techniques to unhealthy livers, future research may focus on the impact of hepatic iron content and distribution for noninvasive assessment in diseased subjects.

The importance of spectral separation: an assessment of dual-energy spectral separation for quantitative ability and dose efficiency.

INTRODUCTION: One method to acquire dual-energy (DE) computed tomography (CT) data is to perform CT scans at 2 different x-ray tube voltages, typically 80 and 140 kV, either as 2 separate scans, by means of rapid kV switching, or with the use of 2 x-ray sources as in dual-source CT (DSCT) systems. In DSCT, it is possible to improve spectral separation with tin prefiltration (Sn) of the high-kV beam. Recently, x-ray tube voltages beyond the established range of 80 to 140 kV were commercially introduced, which enable additional voltage combinations for DE acquisitions, such as 80/150 Sn or 90/150 Sn kV. Here, we investigate the DE performance of several x-ray tube voltages and prefilter combinations on 2 DSCT scanners and the impact of the spectra on quantitative analysis and dose efficiency. MATERIALS AND METHODS: Circular phantoms of different sizes (10-40 cm in diameter) equipped with cylindrical inserts containing water and diluted iodine contrast agent (14.5 mg/cm) were scanned using 2 different DSCT systems (SOMATOM Definition Flash and SOMATOM Force; Siemens AG, Forchheim, Germany). Five x-ray tube voltage combinations (80/140 Sn, 100/140 Sn, 80/150 Sn, 90/150 Sn, and 100/150 Sn kV) were investigated, and the results were compared with the previous standard acquisition technique (80/140 kV). As an example, 80/140 Sn kV means that 1 x-ray tube of the DSCT system was operated at 80 kV, whereas the other was operated at 140 kV with additional tin prefiltration (Sn). Dose values in terms of computed tomography dose index (CTDIvol) were kept constant between the different voltage combinations but adjusted with regard to object size according to automatic exposure control recommendations. Reconstructed images were processed using linear blending of the low- and high-kV CT images to combined images, as well as 3-material decomposition techniques to generate virtual noncontrast (VNC) images and iodine images. Contrast and pixel noise were evaluated, as well as DE ratios, which are defined as the CT value at low kV divided by the CT value at high kV. RESULTS: For the 10-, 20-, 30-, and 40-cm phantom, dose values in terms of CTDIvol were 1.2, 2.6, 7.3, and 21.6 mGy, respectively. In the combined images, those obtained with tin filtration showed lower noise values at similar iodine enhancement levels than did images obtained without tin filtration. The largest differences in noise were observed for the larger phantoms, in particular the 40-cm phantom. Dual-energy ratios for iodine increased with decreasing voltages of the low-kV beam and with increasing voltages of the high-kV beam, and they increased when tin prefiltration was added. In case of the 20-cm phantom, DE ratios ranged from 2.0 at 80/140 kV to 3.4 at 80/150 Sn kV. The noise level of the VNC images was strongly correlated with the inverse of the DE ratio. Irrespective of the phantom size, the lowest noise values were measured for 80/150 Sn kV. DISCUSSION: Dual-source CT systems enable DE data to be acquired using a variety of voltage combinations. Combined (or mixed) DE images provide an image impression similar to standard 120 kV images, yet the noise level depends on the DE voltage combination that is selected. Noise in decomposed VNC images is strongly influenced by the DE ratio, and it improves substantially with tin filtration of the high-voltage beam.

Feasibility of discriminating uric acid from non-uric acid renal stones using consecutive spatially registered low- and high-energy scans obtained on a conventional CT scanner.

OBJECTIVE: The objective of our study was to show the feasibility of distinguishing between uric acid (UA) and non-UA renal stones using two consecutive spatially registered low- and high-energy scans acquired on a conventional CT system. SUBJECTS AND METHODS: A total of 33 patients undergoing clinically indicated dual-source dual-energy CT examinations to differentiate UA from non-UA renal stones were enrolled in this study. Immediately after patients underwent clinically indicated dual-source dual-energy CT, two consecutive scans (one at 80 kV and one at 140 kV) were obtained on a conventional CT scanner over the region limited to the stones identified on the dual-source scans. After 3D deformable registration of the 80- and 140-kV images, UA and non-UA stones were identified using commercial software. The sensitivity, specificity, and accuracy of stone classification were calculated using the dual-source results as the reference standard. RESULTS: A total of 469 stones were identified in the dual-source examinations (26 UA and 443 non-UA stones). The average in-plane stone diameter was 4.4 ± 2.5 (SD) mm (range, 2.0-18.9 mm). The overall sensitivity, specificity, and accuracy for identifying UA stones were 73.1%, 90.1%, and 89.1%, respectively. The sensitivity, specificity, and accuracy were 94.7%, 96.9%, and 96.8% for stones 3 mm or larger (n = 341 [19 UA and 322 non-UA]). CONCLUSION: Accurate differentiation of UA from non-UA renal stones is feasible using two consecutively acquired and spatially registered conventional CT scans.

Assessment of an advanced image-based technique to calculate virtual monoenergetic computed tomographic images from a dual-energy examination to improve contrast-to-noise ratio in examinations using iodinated contrast media.

INTRODUCTION: Following the trend of low-radiation dose computed tomographic (CT) imaging, concerns regarding the detectability of low-contrast lesions have been growing. The goal of this research was to evaluate whether a new image-based algorithm (Mono+) for virtual monoenergetic imaging with a dual-energy CT scanner can improve the contrast-to-noise ratio (CNR) and conspicuity of these low-contrast objects when using iodinated contrast media. MATERIALS AND METHODS: Four circular phantoms of different diameter (10-40 cm) with an iodine insert at the center were scanned at a fixed radiation dose with different single- (80, 100, 120 kV) and dual-energy protocols (80/140 kV, 80/140 Sn kV, 100/140 Sn kV) using a dual-source CT system. In addition, an anthropomorphic abdominal phantom with different low-contrast lesions was scanned with the settings previously mentioned but also at only a half and a quarter of the initial dose. Dual-energy data were processed, and virtual monoenergetic images (range, 40-190 keV) were generated. Beside the established technique, a newly developed prototype algorithm to calculate monoenergetic images (Mono+) was used. To avoid noise increase at lower calculated energies, which is a known drawback of virtual monoenergetic images at low kilo electron-volt, a regional spatial frequency-based recombination of the high signal at lower energies and the superior noise properties at medium energies is performed to optimize CNR in case of Mono+ images. The CNR and low-contrast detectability were evaluated. RESULTS: For all phantom sizes, the Mono+ technique provided increasing iodine CNR with decreasing kilo electron-volt, with the optimum CNR obtained at the lowest energy level of 40 keV. For all investigated phantom sizes, CNR of Mono+ images at low kilo electron-volt was superior to the CNR in single-energy images at an equivalent radiation dose and even higher than the CNR obtained with 80-kV protocols. In case of the anthropomorphic phantom, low-contrast detectability in monoenergetic images was, for all settings, similar to the circular phantoms, best for the voltage combination 80/140 Sn kV, irrespective of the dose level. For all dual-energy voltage combinations, the Mono+ algorithm led to superior results compared with single-energy imaging. DISCUSSION: With regard to optimized iodine CNR, it is more efficient to perform dual-energy scans and compute virtual monoenergetic images at 40 keV using the Mono+ technique than to perform low kilovolt scans. Given the improved CNR, the Mono+ algorithm could be very useful in improving both detection and differential diagnosis of abdominal lesions, specifically low-contrast lesions, as well as in other anatomical regions where improved iodine CNR is beneficial.

Subtraction color map of contrast-enhanced and unenhanced CT for the prediction of pancreatic necrosis in early stage of acute pancreatitis.

OBJECTIVE: The objective of our study was to evaluate the accuracy of subtraction color-map images created from contrast-enhanced CT (CECT) and unenhanced CT for the diagnosis of pancreatic necrosis in the early stage of acute pancreatitis. MATERIALS AND METHODS: Forty-eight patients underwent unenhanced CT and CECT within 72 hours from the onset of acute pancreatitis. Subtraction color-map images were created from unenhanced CT and CECT using a 3D nonrigid registration method. Three radiologists reviewed two image sets: CECT alone and subtraction color-map images in conjunction with CECT. Readers evaluated each image set for the presence of pancreatic necrosis. The reference standard for pancreatic necrosis was CT or MRI 1 week or more after the onset of acute pancreatitis. The performance of each image set for the prediction of pancreatic necrosis was calculated and compared using the McNemar test. RESULTS: Eleven of the 48 patients developed pancreatic necrosis. There were no technical failures creating the subtraction images. The sensitivity, specificity, and accuracy for predicting pancreatic necrosis with CECT were 64%, 97%, and 90%, respectively, for reader 1; 73%, 87%, and 83% for reader 2; and 73%, 87%, and 83% for reader 3. The sensitivity, specificity, and accuracy for predicting pancreatic necrosis with the subtraction color maps were 100%, 100%, and 100%, respectively, for reader 1; 100%, 95%, and 96% for reader 2; and 82%, 92%, and 90% for reader 3. Accuracy significantly improved with the addition of subtraction color maps compared with CECT alone for reader 1 (p = 0.03) and reader 2 (p = 0.02) but not for reader 3 (p = 0.37). CONCLUSION: A subtraction color map is accurate in the diagnosis of pancreatic necrosis in the early stage of acute pancreatitis.

Automatic selection of tube potential for radiation dose reduction in vascular and contrast-enhanced abdominopelvic CT.

OBJECTIVE: The purpose of this study is to assess the ability of a novel automatic tube potential selection tool to reduce radiation dose while maintaining diagnostic quality in CT angiography (CTA) and contrast-enhanced abdominopelvic CT. MATERIALS AND METHODS: One hundred one CTA examinations and 90 contrastenhanced abdominopelvic examinations were performed using an automatic tube potential selection tool on a 128-MDCT scanner. Two vascular radiologists and two abdominal radiologists evaluated the image quality for sharpness, noise, artifact, and diagnostic confidence. In a subset of patients who had undergone prior studies (CTA, 28 patients; abdominopelvic CT, 25 patients), a side-by-side comparison was performed by a separate radiologist. Dose reduction and iodine contrast-to-noise ratio resulting from use of the tool were calculated. RESULTS: For CTA, 80 or 100 kV was selected for 73% of the scans, with a mean dose reduction of 36% relative to the reference 120-kV protocol. For abdominopelvic CT examinations, 80 or 100 kV was used for 55% of the scans, with a mean dose reduction of 25%. Overall dose reduction relative to the reference 120-kV protocol was 25% and 13% for CTA and abdominopelvic CT scans, respectively. Over 98% of scans had acceptable sharpness, noise texture, artifact, and diagnostic confidence for both readers and diagnostic tasks; 94-100% of scans had acceptable noise. Iodine contrast-to-noise ratio was significantly higher than (p < 0.001) or similar to (p = 0.11) that of prior scans, and equivalent quality was achieved despite the dose reduction. CONCLUSION: Automatic tube potential selection provides an efficient and quantitativeway to guide the selection of the optimal tube potential for CTA and abdominopelvic CT examinations.

Pilot study of detection, radiologist confidence and image quality with sinogram-affirmed iterative reconstruction at half-routine dose level.

OBJECTIVE: The objective of this study was to determine the effect of Sinogram-Affirmed Iterative Reconstruction (SAFIRE) on radiological detection, diagnostic confidence, and image quality at half-dose, contrast-enhanced abdominopelvic computed tomography. METHODS: Forty dual-source examinations were reconstructed using routine-dose with filtered back projection, half-dose filtered back projection, and half-dose SAFIRE. Three radiologists detected lesions in abdominopelvic organs, reporting findings of potential medical significance, diagnostic confidence, and image quality. RESULTS: There was greater than 78% concordance between full- and half-dose images ± SAFIRE, and no difference in the detection of lesions within organs between half-dose images ± SAFIRE (P = 0.22 - 1.0). Detection of potentially important findings varied by reader, but not between dose/reconstruction methods. Diagnostic confidence varied widely (P < 0.001 to P > 0.91). Sinogram-Affirmed Iterative Reconstruction significantly improved image quality in the pelvis (P ≤ 0.04). CONCLUSIONS: Half-dose images ± SAFIRE had organ-specific detections similar to routine-dose images. Sinogram-Affirmed Iterative Reconstruction improved image quality in the pelvis, but diagnostic confidence and image quality scores in the abdomen depended on the reader.