Iterative Metal Artifact Reduction Research Articles

Photon-counting detector computed tomography for metal artifact reduction: a comparative study of different artifact reduction techniques in patients with orthopedic implants.

Artifacts caused by metallic implants remain a challenge in computed tomography (CT). We investigated the impact of photon-counting detector computed tomography (PCD-CT) for artifact reduction in patients with orthopedic implants with respect to image quality and diagnostic confidence using different artifact reduction approaches. In this prospective study, consecutive patients with orthopedic implants underwent PCD-CT imaging of the implant area. Four series were reconstructed for each patient (clinical standard reconstruction [PCD-CTStd], monoenergetic images at 140keV [PCD-CT140keV], iterative metal artifact reduction (iMAR) corrected [PCD-CTiMAR], combination of iMAR and 140keV monoenergetic [PCD-CT140keV+iMAR]). Subsequently, three radiologists evaluated the reconstructions in a random and blinded manner for image quality, artifact severity, anatomy delineation (adjacent and distant), and diagnostic confidence using a 5-point Likert scale (5 = excellent). In addition, the coefficient of variation [CV] and the relative quantitative artifact reduction potential were obtained as objective measures. We enrolled 39 patients with a mean age of 67.3 ± 13.2years (51%; n = 20 male) and a mean BMI of 26.1 ± 4kg/m2. All image quality measures and diagnostic confidence were significantly higher for the iMAR vs. non-iMAR reconstructions (all p < 0.001). No significant effect of the different artifact reduction approaches on CV was observed (p = 0.26). The quantitative analysis indicated the most effective artifact reduction for the iMAR reconstructions, which was higher than PCD-CT140keV (p < 0.001). PCD-CT allows for effective metal artifact reduction in patients with orthopedic implants, resulting in superior image quality and diagnostic confidence with the potential to improve patient management and clinical decision making.

Potential Benefits of Photon-Counting CT in Dental Imaging: A Narrative Review.

Background/Objectives: Advancements in oral imaging technology are continually shaping the landscape of dental diagnosis and treatment planning. Among these, photon-counting computed tomography (PCCT), introduced in 2021, has emerged as a promising, high-quality oral technology. Dental imaging typically requires a resolution beyond the standard CT systems achievable with the specialized cone-beam CT. PCCT can offer up to 100 µm resolution, improve soft-tissue contrast, and provide faster scanning times, which are crucial for detailed dental diagnosis and treatment planning. Using semiconductor detectors, PCCT produces sharper images and can potentially reduce the number of scans required, thereby decreasing patient radiation exposure. This review aimed to explore the potential benefits of PCCT in dental imaging. Methods: This review analyzed the literature on PCCT in dental imaging from January 2010 to February 2024, sourced from PubMed, Scopus, and Web of Science databases, focusing on high-resolution, patient safety, and diagnostic efficiency in dental structure assessment. We included English-language articles, case studies, letters, observational studies, and randomized controlled trials while excluding duplicates and studies unrelated to PCCT's application in dental imaging. Results: Studies have highlighted the superiority of PCCT in reducing artifacts, which are often problematic, compared to conventional CBCT and traditional CT scans, due to metallic dental implants, particularly when used with virtual monoenergetic imaging and iterative metal artifact reduction, thereby improving implant imaging. This review acknowledges limitations, such as the potential for overlooking other advanced imaging technologies, a narrow study timeframe, the lack of real-world clinical application data in this field, and costs. Conclusions: PCCT represents a promising advancement in dental imaging, offering high-resolution visuals, enhanced contrast, and rapid scanning with reduced radiation exposure.

A New Iterative Metal Artifact Reduction Algorithm for Both Energy-Integrating and Photon-Counting CT Systems.

The aim of this study was to introduce and evaluate a new metal artifact reduction framework (iMARv2) that addresses the drawbacks (residual artifacts after correction and user preferences for image quality) associated with the current clinically applied iMAR. A new iMARv2 has been introduced, combining the current iMAR with new modular components to remove residual metal artifacts after image correction. The postcorrection image impression is adjustable with user-selectable strength settings. Phantom scans from an energy-integrating and a photon-counting detector CT were used to assess image quality, including a Gammex phantom and anthropomorphic phantoms. In addition, 36 clinical cases (with metallic implants such as dental fillings, hip replacements, and spinal screws) were reconstructed and evaluated in a blinded and randomized reader study. The Gammex phantom showed lower HU errors compared with the uncorrected image at almost all iMAR and iMARv2 settings evaluated, with only minor differences between iMAR and the different iMARv2 settings. In addition, the anthropomorphic phantoms showed a trend toward lower errors with higher iMARv2 strength settings. On average, the iMARv2 strength 3 performed best of all the clinical reconstructions evaluated, with a significant increase in diagnostic confidence and decrease in artifacts. All hip and dental cases showed a significant increase in diagnostic confidence and decrease in artifact strength, and the improvements from iMARv2 in the dental cases were significant compared with iMAR. There were no significant improvements in the spine. This work has introduced and evaluated a new method for metal artifact reduction and demonstrated its utility in routine clinical datasets. The greatest improvements were seen in dental fillings, where iMARv2 significantly improved image quality compared with conventional iMAR.

Metal Artifact Reduction in Photon-Counting Detector CT: Quantitative Evaluation of Artifact Reduction Techniques.

With the introduction of clinical photon-counting detector computed tomography (PCD-CT) and its novel reconstruction techniques, a quantitative investigation of different acquisition and reconstruction settings is necessary to optimize clinical acquisition protocols for metal artifact reduction. A multienergy phantom was scanned on a clinical dual-source PCD-CT (NAEOTOM Alpha; Siemens Healthcare GmbH) with 4 different central inserts: water-equivalent plastic, aluminum, steel, and titanium. Acquisitions were performed at 120 kVp and 140 kVp (CTDIvol 10 mGy) and reconstructed as virtual monoenergetic images (VMIs; 110-150 keV), as T3D, and with the standard reconstruction "none" (70 keV VMI) using different reconstruction kernels (Br36, Br56) and with as well as without iterative metal artifact reduction (iMAR). Metal artifacts were quantified, calculating relative percentages of metal artifacts. Mean CT numbers of an adjacent water-equivalent insert and different tissue-equivalent inserts were evaluated, and eccentricity of metal rods was measured. Repeated-measures analysis of variance was performed for statistical analysis. Metal artifacts were most prevalent for the steel insert (12.6% average artifacts), followed by titanium (4.2%) and aluminum (1.0%). The strongest metal artifact reduction was noted for iMAR (with iMAR: 1.4%, without iMAR: 10.5%; P < 0.001) or VMI (VMI: 110 keV 2.6% to 150 keV 3.3%, T3D: 11.0%, and none: 16.0%; P < 0.001) individually, with best results when combining iMAR and VMI at 110 keV (1.2%). Changing acquisition tube potential (120 kV: 6.6%, 140 kV: 5.2%; P = 0.33) or reconstruction kernel (Br36: 5.5%, Br56: 6.4%; P = 0.17) was less effective. Mean CT numbers and standard deviations were significantly affected by iMAR (with iMAR: -3.0 ± 21.5 HU, without iMAR: -8.5 ± 24.3 HU; P < 0.001), VMI (VMI: 110 keV -3.6 ± 21.6 HU to 150 keV -1.4 ± 21.2 HU, T3D: -11.7 ± 23.8 HU, and none: -16.9 ± 29.8 HU; P < 0.001), tube potential (120 kV: -4.7 ± 22.8 HU, 140 kV: -6.8 ± 23.0 HU; P = 0.03), and reconstruction kernel (Br36: -5.5 ± 14.2 HU, Br56: -6.8 ± 23.0 HU; P < 0.001). Both iMAR and VMI improved quantitative CT number accuracy and metal rod eccentricity for the steel rod, but iMAR was of limited effectiveness for the aluminum rod. For metal artifact reduction in PCD-CT, a combination of iMAR and VMI at 110 keV demonstrated the strongest artifact reduction of the evaluated options, whereas the impact of reconstruction kernel and tube potential was limited.

Personalization of thoracoabdominal CT examinations using scanner integrated clinical decision support systems – Impact on the acquisition technique, scan range, and reconstruction type

ObjectivesThis study evaluates the impact of a scanner-integrated, customized clinical decision support system (CDSS) on the acquisition technique, scan range, and reconstruction in thoracoabdominal CT. Materials and MethodsWe applied CDSS in contrast–enhanced examinations of the trunk with various clinical indications on a recent scanner with the capability of dual-energy CT (DECT), anatomic landmark detection (ALD), and iterative metal-artifact reduction (MAR). Simple and comprehensive questions about the patient’s breath hold capability, the anatomical region of interest, and metal implants can be answered after the localizer. The acquisition technique (single energy, SECT, or dual energy), scan range (chest-abdomen-pelvis or chest-abdomen), and reconstruction technique (with or without MAR) were then automatically adapted in the examination protocols in coherence with these selections. Retrospectively, we compared the usage rates for these techniques in 624 examinations on the study scanner with 740 examinations on a comparable scanner without CDSS. Subgroup analysis of effective dose (ED), scan duration, and image quality (IQ) was performed in the study group. ResultsCDSS leads to an increased usage rate of DECT (64.4% vs. 2.8%) and MAR (75.4% vs. 44.0%). All scan range adaptations by ALD were successful. The resulting subjective IQ between single energy and DECT acquisitions was comparable (all p > 0.05). Scan duration was significantly longer in DECT than in SECT (16.9 s vs. 6.5 s; p < 0.001). However, the objective IQ was significantly higher in DECT (CNRD 2.1 vs. 1.8; p < 0.01), and the ED significantly lower (6.7 mSv vs. 7.6 mSv; p = 0.004). ConclusionCDSS for thoracoabdominal CT leads to a substantially increased usage rate of innovative techniques during acquisition and reconstruction. Patients with adapted protocols benefit from improved image quality and increased post-processing options at lower radiation doses.

Combining virtual monoenergetic imaging and iterative metal artifact reduction in first-generation photon-counting computed tomography of patients with dental implants

ObjectivesWhile established for energy-integrating detector computed tomography (CT), the effect of virtual monoenergetic imaging (VMI) and iterative metal artifact reduction (iMAR) in photon-counting detector (PCD) CT lacks thorough investigation. This study evaluates VMI, iMAR, and combinations thereof in PCD-CT of patients with dental implants.Material and methodsIn 50 patients (25 women; mean age 62.0 ± 9.9 years), polychromatic 120 kVp imaging (T3D), VMI, T3DiMAR, and VMIiMAR were compared. VMIs were reconstructed at 40, 70, 110, 150, and 190 keV. Artifact reduction was assessed by attenuation and noise measurements in the most hyper- and hypodense artifacts, as well as in artifact-impaired soft tissue of the mouth floor. Three readers subjectively evaluated artifact extent and soft tissue interpretability. Furthermore, new artifacts through overcorrection were assessed.ResultsiMAR reduced hyper-/hypodense artifacts (T3D 1305.0/−1418.4 versus T3DiMAR 103.2/−46.9 HU), soft tissue impairment (106.7 versus 39.7 HU), and image noise (16.9 versus 5.2 HU) compared to non-iMAR datasets (p ≤ 0.001). VMIiMAR ≥ 110 keV subjectively enhanced artifact reduction over T3DiMAR (p ≤ 0.023). Without iMAR, VMI displayed no measurable artifact reduction (p ≥ 0.186) and facilitated no significant denoising over T3D (p ≥ 0.366). However, VMI ≥ 110 keV reduced soft tissue impairment (p ≤ 0.009). VMIiMAR ≥ 110 keV resulted in less overcorrection than T3DiMAR (p ≤ 0.001). Inter-reader reliability was moderate/good for hyperdense (0.707), hypodense (0.802), and soft tissue artifacts (0.804).ConclusionWhile VMI alone holds minimal metal artifact reduction potential, iMAR post-processing enabled substantial reduction of hyperdense and hypodense artifacts. The combination of VMI ≥ 110 keV and iMAR resulted in the least extensive metal artifacts.Clinical relevanceCombining iMAR with VMI represents a potent tool for maxillofacial PCD-CT with dental implants achieving substantial artifact reduction and high image quality.Key Points• Post-processing of photon-counting CT scans with an iterative metal artifact reduction algorithm substantially reduces hyperdense and hypodense artifacts arising from dental implants.• Virtual monoenergetic images presented only minimal metal artifact reduction potential.• The combination of both provided a considerable benefit in subjective analysis compared to iterative metal artifact reduction alone.

Combining iterative metal artifact reduction and virtual monoenergetic images severely reduces hip prosthesis-associated artifacts in photon-counting detector CT

Aim of this study was to assess the impact of virtual monoenergetic images (VMI) in combination and comparison with iterative metal artifact reduction (IMAR) on hip prosthesis-associated artifacts in photon-counting detector CT (PCD-CT). Retrospectively, 33 scans with hip prosthesis-associated artifacts acquired during clinical routine on a PCD-CT between 08/2022 and 09/2022 were analyzed. VMI were reconstructed for 100–190 keV with and without IMAR, and compared to polychromatic images. Qualitatively, artifact extent and assessment of adjacent soft tissue were rated by two radiologists using 5-point Likert items. Quantitative assessment was performed measuring attenuation and standard deviation in most pronounced hypodense and hyperdense artifacts, artifact-impaired bone, muscle, vessels, bladder and artifact-free corresponding tissue. To quantify artifacts, an adjusted attenuation was calculated as the difference between artifact-impaired tissue and corresponding tissue without artifacts. Qualitative assessment improved for all investigated image reconstructions compared to polychromatic images (PI). VMI100keV in combination with IMAR achieved best results (e.g. diagnostic quality of the bladder: median PI: 1.5 (range 1–4); VMI100keV+IMAR: 5 (3–5); p < 0.0001). In quantitative assessment VMI100keV with IMAR provided best artifact reduction with an adjusted attenuation closest to 0 (e.g. bone: PI: 302.78; VMI100keV+IMAR: 51.18; p < 0.0001). The combination of VMI and IMAR significantly reduces hip prosthesis-associated artifacts in PCD-CT and improves the diagnostic quality of surrounding tissue.

Iterative Metal Artifact Reduction in Head and Neck CT Facilitates Tumor Visualization of Oral and Oropharyngeal Cancer Obscured by Artifacts From Dental Hardware

The purpose of this study was to evaluate the diagnostic utility of iterative metal artifact reduction (iMAR) in computed tomography (CT)-imaging of oral and oropharyngeal cancers when obscured by dental hardware artifacts and to determine the most appropriate iMAR settings for this purpose. The study retrospectively enrolled 27 patients (8 female, 19 male; mean age 64±12.7years) with histologically confirmed oral or oropharyngeal cancer obscured by dental artifacts in contrast-enhanced CT. Raw CT data were reconstructed with ascending iMAR strengths (levels 1/2/3/4/5) and one reconstruction without iMAR (level 0). For subjective analysis, two blinded radiologists rated tumor visualization and artifact severity on a five-point Likert scale. For objective analysis, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and artifact index (AI) were determined. iMAR reconstructions improved the subjective image quality of tumor edge and contrast, and the objective parameters of tumor SNR and CNR, reaching their optimum at iMAR levels 4 and 5 (P<.001). AI decreased with iMAR reconstructions reaching its minimum at iMAR level 5 (P<.001). Tumor detection rates increased 2.4-fold with iMAR 5, 2.1-fold with iMAR 4, and 1.9-fold with iMAR 3 compared to reconstructions without iMAR. Disadvantages such as algorithm-induced artifacts increased significantly with higher iMAR strengths (P<.05), reaching a maximum with iMAR 5. iMAR significantly improves CT imaging of oral and oropharyngeal cancers, as confirmed by both subjective and objective measures, with best results at highest iMAR strengths.

Semi-automatic artifact quantification in thermal ablation probe and algorithms for the evaluation of metal artifact reduction

Objectives To compare metal artifacts and evaluation of metal artifact reduction algorithms during probe positioning in computed tomography (CT)-guided microwave ablation (MWA), cryoablation (CRYO), and radiofrequency ablation (RFA). Materials and methods Using CT guidance, individual MWA, CRYO, and RFA ablation probes were placed into the livers of 15 pigs. CT imaging was then performed to determine the probe’s position within the test subject’s liver. Filtered back projection (B30f) and iterative reconstructions (I30-1) were both used with and without dedicated iterative metal artifact reduction (iMAR) to generate images from the initial data sets. Semi-automatic segmentation-based quantitative evaluation was conducted to estimate artifact percentage within the liver, while qualitative evaluation of metal artifact extent and overall image quality was performed by two observers using a 5-point Likert scale: 1-none, 2-mild, 3-moderate, 4-severe, 5-non-diagnostic. Results Among MWA, RFA, and CRYO, compared with non-iMAR in B30f reconstruction, the largest extent of artifact volume percentages were observed for CRYO (11.5–17.9%), followed by MWA (4.7–6.6%) and lastly in RFA (5.5–6.2%). iMAR significantly reduces metal artifacts for CRYO and MWA quantitatively (p = 0.0020; p = 0.0036, respectively) and qualitatively (p = 0.0001, p = 0.0005), but not for RFA. No significant reduction in metal artifact percentage was seen after applying iterative reconstructions (p > 0.05). Noise, contrast-to-noise-ratio, or overall image quality did not differ between probe types, irrespective of the application of iterative reconstruction and iMAR. Conclusion A dedicated metal artifact algorithm may decrease metal artifacts and improves image quality significantly for MWA and CRYO probes. Their application alongside with dedicated metal artifact algorithm should be considered during CT-guided positioning.

Artifact Reduction From Dental Material in Photon-Counting Detector Computed Tomography Data Sets Based on High-keV Monoenergetic Imaging and Iterative Metal Artifact Reduction Reconstructions-Can We Combine the Best of Two Worlds?

The aim of this study was to compare the effectiveness of common strategies for artifact reduction of dental material in photon-counting detector computed tomography data sets. Patients with dental material who underwent clinically indicated CT of the neck were enrolled. Image series were reconstructed using a standard and sharp kernel, with and without iterative metal artifact reduction (IMAR) (Qr40, Qr40 IMAR , Qr60, Qr60 IMAR ) at different virtual monoenergetic imaging (VMI) levels (40-190 keV). On representative slice positions with and without dental artifacts, mean and standard deviation of CT values were measured in all series at identical locations. The mean absolute error of CT values ( ) and the artifact index (AIX) were calculated and analyzed focusing on 3 main comparisons: ( a ) different VMI levels versus 70 keV, ( b ) standard versus sharp kernel, and ( c ) nonuse or use of IMAR reconstruction. The Wilcoxon test was used to assess differences for nonparametric data. The final cohort comprised 50 patients. Artifact measures decreased for VMI levels >70 keV, yet only significantly so for reconstructions using IMAR (maximum reduction, 25%). The higher image noise of the sharp versus standard kernel is reflected in higher AIX values and is more pronounced in IMAR series (maximum increase, 38%). The most profound artifact reduction was observed for IMAR reconstructions (maximum reduction : 84%; AIX: 90%). Metal artifacts caused by large amounts of dental material can be substantially reduced by IMAR, regardless of kernel choice or VMI settings. Increasing the keV level of VMI series, on the other hand, only slightly reduces dental artifacts; this effect, however, is additive to the benefit conferred by IMAR reconstructions.

Influence of Scan Parameters of Single and Dual-Energy CT Protocols in Combination with Metal Artifact Suppression Algorithms for THA: An ex Vivo Study.

Metal artifacts caused by hip arthroplasty stems limit the diagnostic value of computed tomography (CT) in the evaluation of periprosthetic fractures or implant loosening. The aim of this ex vivo study was to evaluate the influence of different scan parameters and metal artifact algorithms on image quality in the presence of hip stems. Nine femoral stems, 6 uncemented and 3 cemented, that had been implanted in subjects during their lifetimes were exarticulated and investigated after death and anatomical body donation. Twelve CT protocols consisting of single-energy (SE) and single-source consecutive dual-energy (DE) scans with and without an iterative metal artifact reduction algorithm (iMAR; Siemens Healthineers) and/or monoenergetic reconstructions were compared. Streak and blooming artifacts as well as subjective image quality were evaluated for each protocol. Metal artifact reduction with iMAR significantly reduced the streak artifacts in all investigated protocols (p = 0.001 to 0.01). The best subjective image quality was observed for the SE protocol with a tin filter and iMAR. The least streak artifacts were observed for monoenergetic reconstructions of 110, 160, and 190 keV with iMAR (standard deviation of the Hounsfield units: 151.1, 143.7, 144.4) as well as the SE protocol with a tin filter and iMAR (163.5). The smallest virtual growth was seen for the SE with a tin filter and without iMAR (4.40 mm) and the monoenergetic reconstruction of 190 keV without iMAR (4.67 mm). This study strongly suggests that metal artifact reduction algorithms (e.g., iMAR) should be used in clinical practice for imaging of the bone-implant interface of prostheses with either an uncemented or cemented femoral stem. Among the iMAR protocols, the SE protocol with 140 kV and a tin filter produced the best subjective image quality. Furthermore, this protocol and DE monoenergetic reconstructions of 160 and 190 keV with iMAR achieved the lowest levels of streak and blooming artifacts. Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Metal implants on abdominal CT: does split-filter dual-energy CT provide additional value over iterative metal artifact reduction?

PurposeTo assess image quality and metal artifact reduction in split-filter dual-energy CT (sfDECT) of the abdomen with hip or spinal implants using virtual monoenergetic images (VMI) and iterative metal artifact reduction algorithm (iMAR).Methods102 portal-venous abdominal sfDECTs of patients with hip (n = 71) or spinal implants (n = 31) were included in this study. Images were reconstructed as 120kVp-equivalent images (Mixed) and VMI (40–190 keV), with and without iMAR. Quantitative artifact and image noise was measured using 12 different ROIs. Subjective image quality was rated by two readers using a five-point Likert-scale in six categories, including overall image quality and vascular contrast.ResultsLowest quantitative artifact in both hip and spinal implants was measured in VMI190keV-iMAR. However, it was not significantly lower than in MixediMAR (for all ROIs, p = 1.00), which were rated best for overall image quality (hip: 1.00 [IQR: 1.00–2.00], spine: 3.00 [IQR:2.00–3.00]). VMI50keV-iMAR was rated best for vascular contrast (hip: 1.00 [IQR: 1.00–2.00], spine: 2.00 [IQR: 1.00–2.00]), which was significantly better than Mixed (both, p < 0.001). VMI50keV-iMAR provided superior overall image quality compared to Mixed for hip (1.00 vs 2.00, p < 0.001) and similar diagnostic image quality for spinal implants (2.00 vs 2.00, p = 0.51).ConclusionFor abdominal sfDECT with hip or spinal implants MixediMAR images should be used. High keV VMI do not further improve image quality. IMAR allows the use of low keV images (VMI50keV) to improve vascular contrast, compared to Mixed images.Graphical abstract

Metal artifact reduction in ultra-high-resolution cone-beam CT imaging with a twin robotic X-ray system

Cone-beam computed tomography (CBCT) has been shown to be a powerful tool for 3D imaging of the appendicular skeleton, allowing for detailed visualization of bone microarchitecture. This study was designed to compare artifacts in the presence of osteosynthetic implants between CBCT and multidetector computed tomography (MDCT) in cadaveric wrist scans. A total of 32 scan protocols with varying tube potential and current were employed: both conventional CBCT and MDCT studies were included with tube voltage ranging from 60 to 140 kVp as well as additional MDCT protocols with dedicated spectral shaping via tin prefiltration. Irrespective of scanner type, all examinations were conducted in ultra-high-resolution (UHR) scan mode. For reconstruction of UHR-CBCT scans an additional iterative metal artifact reduction algorithm was employed, an image correction tool which cannot be used in combination with UHR-MDCT. To compare applied radiation doses between both scanners, the volume computed tomography dose index for a 16 cm phantom (CTDIvol) was evaluated. Images were assessed regarding subjective and objective image quality. Without automatic tube current modulation or tube potential control, radiation doses ranged between 1.3 mGy (with 70 kVp and 50.0 effective mAs) and 75.2 mGy (with 140 kVp and 383.0 effective mAs) in UHR-MDCT. Using the pulsed image acquisition method of the CBCT scanner, CTDIvol ranged between 2.3 mGy (with 60 kVp and 0.6 mean mAs per pulse) and 61.0 mGy (with 133 kVp and 2.5 mean mAs per pulse). In essence, all UHR-CBCT protocols employing a tube potential of 80 kVp or more were found to provide superior overall image quality and artifact reduction compared to UHR-MDCT (all p < .050). Interrater reliability of seven radiologists regarding image quality was substantial for tissue assessment and moderate for artifact assessment with Fleiss kappa of 0.652 (95% confidence interval 0.618–0.686; p < 0.001) and 0.570 (95% confidence interval 0.535–0.606; p < 0.001), respectively. Our results demonstrate that the UHR-CBCT scan mode of a twin robotic X-ray system facilitates excellent visualization of the appendicular skeleton in the presence of metal implants. Achievable image quality and artifact reduction are superior to dose-comparable UHR-MDCT and even MDCT protocols employing spectral shaping with tin prefiltration do not achieve the same level of artifact reduction in adjacent soft tissue.

Combining gantry-free cone-beam computed tomography with iterative metal artefact reduction for surgical follow-up imaging of the appendicular skeleton

PurposePost-surgical evaluation of osteosynthesis material and adjacent tissue can be challenging in both radiography and cross-sectional imaging. This study investigates the performance of a multi-purpose X-ray scanner with cone-beam CT (CBCT) function and iterative metal artefact reduction capabilities in patients after osteoplasty of the appendicular skeleton. MethodEighty individuals who underwent both conventional X-ray imaging and CBCT after osteoplasty of the hand/wrist (48), elbow (14), or ankle/foot (18) with the gantry-free twin robotic system were retrospectively enrolled. Radiological reports from clinical routine for both imaging modalities were retrospectively analyzed and compared with consensus expert reading by two musculoskeletal specialists serving as the standard of reference. Findings of screw dislocation or implant loosening, fragment displacement, and delayed healing were compared between X-ray and CBCT reports using the McNemar test. ResultsThe median dose-area-product of CBCT and X-ray scans amounted to 27.98 and 0.2 dGy*cm2, respectively. Diagnostic accuracy for screw dislocation was superior in CBCT compared to standard radiograms (98.8 % vs 83.8 %; p = 0.002). Implant loosening (98.8 % vs 86.3 %; p = 0.006), fragment displacement (98.8 % vs 85.0 %; p < 0.001), and delayed healing (97.5 % vs 88.8 %; p = 0.016) were also more reliably detected in CBCT. Employing CBCT, postoperative complications were detected with a sensitivity and specificity of at least 95.8 % and 98.1 %, compared to 33.3 % and 92.86 % in radiography. ConclusionsWith superior accuracy for various osteoplasty-related complications, the CBCT scan mode of a gantry-free twin robotic X-ray system with iterative metal artefact reduction aids post-surgical assessment in the appendicular skeleton.

Influence of CT metal artifact reduction on SPECT/CT quantification of bone scintigraphy – Retrospective study for selected types of metal implants

Implanted metal prostheses can cause severe artifacts in reconstructed computed tomography (CT) images. To reduce the diagnostic impact of these artifacts and improve attenuation correction in single photon emission computed tomography (SPECT), an algorithm of iterative metal artifact reduction (iMAR) for SPECT/CT systems was developed. The aims of this study were (a) to assess the difference in visual image quality by comparing CT and SPECT images reconstructed with and without iMAR and (b) to determine the influence of iMAR on quantitative 99mTc-uptake in SPECT/CT. This retrospective study includes 21 patients with implanted metal prostheses who underwent SPECT/CT bone scintigraphy. CT data were reconstructed with iMAR and without (noMAR) and were used for attenuation correction of SPECT data for xSPECT Quant and xSPECT Bone reconstruction. The effect of iMAR on image quality was evaluated by visual analysis and the effect on quantitative SPECT/CT was assessed by measuring HU values and absolute uptake values (kBq/mL) in volumes of interest (VOIs). There was a significant reduction of visible metal artifacts with iMAR (p<0.01) in the CT images, but visual differences in the SPECT images were minor. The values of quantitative tracer uptake in VOIs near metal implants were lower for iMAR vs. noMAR xSPECT Quant (p<0.01). Only VOIs near metal showed significant differences in HU values, which were 14.6% lower for iMAR CT (p<0.01). The use of iMAR reduces metal artifacts in CT and improves the perceived image quality. Although in some cases a significant difference in the quantitative evaluation of SPECT/CT was observed, the influence of iMAR can be considered small in relation to other factors in the clinical setting.

Iterative metal artifact reduction on a clinical photon counting system—technical possibilities and reconstruction selection for optimal results dependent on the metal scenario

Objective. To give an overview about technical possibilities for metal artifact reduction of the first clinical photon-counting CT system and assess optimal reconstruction settings in a phantom study, assessing monoenergetic imaging (VMI) and iterative metal artifact reduction (iMAR). Approach. Scans were performed with 120 kV and Sn140 kV on the first clinical photon-counting detector CT scanner. To quantify artifact reduction, anthropomorphic phantoms (hip, dental, spine, neuro) were assessed, in addition to a tissue characterization phantom (Gammex) to quantify the HU restoration accuracy, all with removable metal inserts. Each setup was reconstructed with and without dedicated iMAR, and VMIs were computed in 10 keV steps from 40 keV (60 keV at Sn140 kV) to 190 keV for all setups (ground truth and metal with and without iMAR). To find the optimal energy, pixel-wise errors were computed in relevant ROIs in water-equivalent tissue around the metal in each phantom setup. To assess HU restoration potential, measurements were performed in the Gammex phantom’s inserts. Main results. Large metal objects (hip head) or metal with high atomic numbers (dental and neuro) do not benefit from higher-energetic reconstructions. The hip shaft (large, low atomic number) comprises a lower base artifact level than the head, still without an energetic optimum. Within the spine (short penetration length, low atomic number) an energy optimum could be identified for both spectra (100 keV for 120 kV and 120 keV for Sn140 kV). The Gammex showed best HU restoration at 100 keV for 120 kV and at 110 keV for Sn140 kV. In all cases, additional iMAR reduced the base artifact level. Significance. This study shows that a novel photon-counting CT system has the capability to reduce metal artifacts in metal types with low atomic number and low penetration length by applying VMI. For all other metal types, additional iMAR is required to reduce artifacts.

Accuracy of the doses computed by the Eclipse treatment planning system near and inside metal elements

Metal artefacts degrade clinical image quality which decreases the confidence of using computed tomography (CT) for the delineation of key structures for treatment planning and leads to dose errors in affected areas. In this work, we investigated accuracy of doses computed by the Eclipse treatment planning system near and inside metallic elements for two different computation algorithms. An impact of CT metal artefact reduction methods on the resulting calculated doses has also been assessed. A water phantom including Gafchromic film and metal inserts was irradiated (max dose 5 Gy) using a 6 MV photon beam. Three materials were tested: titanium, alloy 600, and tungsten. The phantom CT images were obtained with the pseudo-monoenergetic reconstruction (PMR) and the iterative metal artefact reduction (iMAR). Image sets were used for dose calculation using an Eclipse treatment planning station (TPS). Monte Carlo (MC) simulations were used to predict the true dose distribution in the phantom allowing for comparison with doses measured by film and calculated by TPS. Measured and simulated percentage depth doses (PDDs) were not statistically different (p > 0.618). Regional differences were observed at edges of metallic objects (max 8% difference). However, PDDs simulated with and without film were statistically different (p < 0.002). PDDs calculated by the Acuros XB algorithm based on the dose-to-medium approach best matched the MC reference regardless of the CT reconstruction methods and inserts used (p > 0.078). PDDs obtained using other algorithms significantly differ from the MC values (p < 0.011). The Acuros XB algorithm with a dose-to-medium approach provides reliable dose calculation in all metal regions when using the Varian system. The inability of the AAA algorithm to model backscatter dose significantly limits its clinical application in the presence of metal. No significant impact on the dose calculation was found for a range of metal artefact reduction strategies.

3D Printing of Tooth Impressions Based on Multi-Detector Computed Tomography Images Combined with Beam Hardening Artifact Reduction in Metal Structures

We investigated the role of metal artifact reduction by taking 3D print impressions using 3D data of Computed Tomography (CT) images based on the algorithm applied. We manufactured a phantom of a human mandible tooth made of gypsum and nickel alloy to measure the metal artifacts. CT images were obtained by changing the phantom tube voltage and tube current. The signal intensity of the image generated by the metal artifacts before and after the iterative metal artifact reduction algorithm (iMAR) was measured. A 3D printing process was performed after converting the images, before and after iMAR application, into STL files using InVesalius version 3.1.1 by selecting the conditions that minimized the effect of the artifact. Regarding metal artifacts, the Hounsfield unit (HU) value showed low as the tube voltage increased. The iMAR-applied images acquired under the same conditions showed a significantly lower HU. The artifacts, in the form of flashes, persisted in the 3D-printed product of the image not subjected to iMAR, but were largely removed in the 3D-printed product following iMAR application. In this study, the application of iMAR and data acquired using high tube voltage eliminated a significant portion of the metal artifacts, resulting in an impression shape that was consistent with the human body.

Utility of an automatic adaptive iterative metal artifact reduction AiMAR algorithm in improving CT imaging of patients with hip prostheses evaluated for suspected bladder malignancy.

To compare the utility of a novel metal artifact reduction algorithm to standard imaging in improving visualization of key structures, diagnostic confidence, and patient-level confidence in malignancy in patients with suspected bladder cancer. Patients with hip implants undergoing CT urography for suspected bladder malignancy were enrolled. Images were reconstructed using 3 methods: (1) Filtered Back Projection (FBP), (2) Iterative Metal Artifact Reduction (iMAR), and (3) Adaptive Iterative Metal Artifact Reduction (AiMAR) strength 4. In multiple reading sessions, three radiologists graded visualization of critical anatomic structures and artifact severity (6-point scales, lower scores desirable), and diagnostic confidence in blinded fashion. They also graded patient-level confidence in malignancy based on imaging findings in each patient. Thirty-two patients (8 females) with a mean age of 74.5 ± 8.5years were included. The median (range) visualization scores for FBP, iMAR, and AiMAR were 3.6 (1.1-4.9), 1.6 (0.3-2.8), and 1.6 (0.3-2.6), respectively. Both iMAR and AiMAR had anatomicvisualization and artifact scores better than FBP (P < 0.001 for both) and similar to each other (P > 0.05). Structures with the most improvement in visualization score with the use of metal artifact reduction algorithms included theobturator internus muscle, internal and external iliac nodal chains, and vagina. iMAR and AiMAR improved diagnostic confidence (P < 0.001) and patient-level confidence in malignancy (P ≤ 0.24). For patients with hip prostheses and suspected bladder malignancy, the use of iMAR or AiMAR was shown to significantly reduce metal artifacts, thus improving diagnostic confidence and patient-level confidence in malignancy.

Combination of Iterative Metal Artifact Reduction and Virtual Monoenergetic Reconstruction Using Split-Filter Dual-Energy CT in Patients With Dental Artifact on Head and Neck CT

BACKGROUND. Head and neck CT can be limited by dental hardware artifact. Both postprocessing-based iterative metal artifact reduction (IMAR) and virtual monoenergetic imaging (VMI) reconstruction in dual-energy CT (DECT) can reduce metal artifact. Their combination is poorly described for single-source DECT systems. OBJECTIVE. The purpose of this study was to compare metal artifact reduction between VMI, IMAR, and their combination (VMIIMAR) in split-filter single-source DECT of patients with severe dental hardware artifact. METHODS. This retrospective study included 44 patients (nine woman, 35 men; mean age, 66.0 ± 10.4 years) who underwent head and neck CT and had severe dental hardware artifact. Standard, VMI, IMAR, and VMIIMAR images were generated; VMI and VMIIMAR were performed at 40, 70, 100, 120, 150, and 190 keV. ROIs were placed to measure corrected attenuation in pronounced hyperattenuating and hypoattenuating artifacts and artifact-impaired soft tissue and to measure corrected artifact-impaired soft-tissue noise. Two radiologists independently assessed soft-tissue interpretability (1-5 scale), and pooled ratings were analyzed. Readers selected the preferred reconstruction for each patient. RESULTS. Mean hyperattenuating artifact-corrected attenuation was 521.0 HU for standard imaging, 496.4-892.2 HU for VMI, 48.2 HU for IMAR, and 32.8-91.0 HU for VMIIMAR. Mean hypoattenuating artifact-corrected attenuation was -455.1 HU for standard imaging, -408.5 to -679.9 HU for VMI, -37.3 for IMAR, and -17.8 to -36.9 HU for VMIIMAR. Mean artifact-impaired soft tissue-corrected attenuation was 10.8 HU for standard imaging, -0.6 to 24.9 HU for VMI, 4.3 HU for IMAR, and -2.0 to 7.8 HU for VMIIMAR. Mean artifact-impaired soft tissue-corrected noise was 58.7 HU for standard imaging, 38.2 to 129.7 HU for VMI, 11.0 HU for IMAR, and 5.8 to 45.6 HU for VMIIMAR. Median soft-tissue interpretability was 1.2 for standard imaging, 1.1-1.2 for VMI, 3.7 for IMAR, and 2.0-3.8 for VMIIMAR. Artifact-impaired soft tissue-corrected attenuation and soft-tissue interpretability significantly improved (p < .05) for VMIIMAR versus IMAR only at 100 keV. The two readers preferred VMIIMAR at 100 keV in 56.8% and 59.1% of examinations. CONCLUSION. For reducing severe artifact due to dental material, IMAR has greater effect than VMI. Though the results for IMAR and VMIIMAR were similar overall, VMIIMAR had a small benefit at 100 keV. CLINICAL IMPACT. VMI and IMAR techniques in split-filter DECT may be combined for clinical head and neck imaging to reduce artifact from dental hardware and improve image quality.