Clinical Application of Dark-blood Imaging in Head and Neck CT Angiography: Effect on Image Quality and Plaque Visibility

Abstract

The aim of this study was to explore the potential of a newly developed dark-blood imaging technique to improve image quality and plaque visibility in head and neck computed tomography (CT) angiography. Patients who underwent triphasic head and neck CT angiography scans from August 2021 to March 2023 were retrospectively enrolled (mean age 67.23±10.81 [SD] years, range 43-85 years, 64.7% male). The CT protocol consists of pre-contrast, arterial and delayed phases. Dark-blood images were postprocessed with the contrast-enhancement boost (CE-boost) technique. The quantitative assessment involved evaluating the CT value, image noise, contrast-to-noise ratio (CNR), and signal-to-noise ratio (SNR) of calcified plaque and non-calcified plaque. The plaque CNR relative to the vessel lumen (CNRplaque-lumen), vessel wall (CNRplaque-wall), and adjacent muscle (CNRplaque-muscle) was respectively calculated. Two experienced radiologists independently evaluated the CT images (5, best; 1, worst) by four characteristics including calcified plaque visibility, non-calcified plaque visibility, diagnostic confidence, and overall image quality. Inter-rater variability was also evaluated. The artery stenosis rate and plaque burden on dark-blood images were measured and compared with arterial phases. The intraclass correlation coefficient (ICC) was used for consistency analysis. The diagnostic accuracy of dark-blood images for the stenosis rate was evaluated by the area under the curve (AUC). A total of 43 patients with 54 calcified plaques and 34 non-calcified plaques were assessed in this study. When compared with pre-contrast and delayed phase, dark-blood images yielded significantly higher CNRplaque-lumen and CNRplaque-muscle of calcified (219.79±159.20 and 181.23±112.12, respectively) and non-calcified (30.30±29.11 and 6.28±4.75, respectively) plaques (all p<0.001). Calcified plaque SNR of dark-blood showed equal or slightly lower than other phases (p>0.05 or p=0.02). A major increase was observed in the non-calcified plaque SNR of dark-blood compared to the arterial phase (5.56±3.71 vs. 4.23±3.56, p=0.02), although there were no apparent differences compared to pre-contrast and delayed phases (p>0.05). In subjective analyzes, the calcified plaque visibility (4.99±0.07), non-calcified plaque visibility (4.62±0.48), overall image quality (4.81±0.34), and diagnostic confidence (4.74±0.36) in dark-blood images dominated the highest scores (p<0.001). The subjective scores of radiologists exhibited good consistency (all kappa value>0.7). The dark-blood image and the arterial phase image exhibited good consistency in identifying the stenosis rate (p<0.001). In the evaluation of plaque burden, the interobserver agreement for dark-blood images was higher compared to arterial phase images (ICC = 0.870 vs. 0.729). Compared to conventional triphasic head and neck CT angiography, the CE-boost derived dark-blood imaging demonstrated a significant improvement in image quality and visibility for both calcified and non-calcified plaque assessment.