low-keV Virtual Monoenergetic Images Research Articles

Pancreatic cancer in photon-counting CT: Low keV virtual monoenergetic images improve tumor conspicuity

Purpose of the studyThe aim of the study was to identify differences in the tumor conspicuity of pancreatic adenocarcinomas in different monoenergetic or polyenergetic reconstructions and contrast phases in photon-counting CT (PCCT). Material and methods34 patients were retrospectively enrolled in this study. Quantitative image analysis was performed with region of interest (ROI) measurements in different monoenergetic levels ranging from 40 up to 70 keV (5-point steps) and polyenergetic series. Tumor-parenchyma attenuation differences and contrast-to-noise-ratio (CNR) were calculated. A qualitative image analysis was accomplished by 4 radiologists using a 5-point Likert scale (1 = “not recognizable” up to 5 = “easy recognizable”). Differences between groups were evaluated for statistical significance using the Friedman test and in case of significant differences pair-wise post-hoc testing with Bonferroni correction was applied. ResultsTumor-parenchyma attenuation difference was significantly different between the different image reconstructions for both arterial- and portal-venous-phase-images (p < 0.001). Tumor-parenchyma attenuation difference was significantly higher on arterial-phase-images at mono40keV compared to polyenergetic images (p < 0.001) and mono55keV images or higher (p < 0.001). For portal-venous-phase-images tumor-parenchyma attenuation difference was significantly higher on mono40keV images compared to polyenergetic images (p < 0.001) and mono50keV images (p = 0.03) or higher (p < 0.001). The same trend was seen for CNR. Tumor conspicuity was rated best on mono40keV images with 4.3 ± 0.9 for arterial-phase-images and 4.3 ± 1.1 for portal-venous-phase-images. In contrast, overall image quality was rated best on polyenergetic-images with 4.8 ± 0.5 for arterial-phase-images and 4.7 ± 0.6 for portal-venous-phase-images. ConclusionLow keV virtual monoenergetic images significantly improve the tumor conspicuity of pancreatic adenocarcinomas in PCCT based on quantitative and qualitative results. On the other hand, readers prefer polyenergetic images for overall image quality.

Performance of dual-layer spectrum CT virtual monoenergetic images to assess early rectal adenocarcinoma T-stage: comparison with MR.

To evaluate the image quality and utility of virtual monoenergetic images (VMI) of dual-layer spectrum computed tomography (DLSCT) in assessing preoperative T-stage for early rectal adenocarcinoma (ERA). This retrospective study included 67 ERA patients (mean age 62 ± 11.1 years) who underwent DLSCT and MR examination. VMI 40-200 keV and poly energetic image (PEI) were reconstructed. The image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and tumor contrast of different energy levels were calculated and compared, respectively. Two radiologists independently assess the image quality of the VMIs and PEI using 5-point scales. The diagnostic accuracies of DLSCT and HR-MRI for ERA T-staging were evaluated and compared. The maximum noise was observed at VMI 40 keV, and noise at VMI 40-200 keV in the arterial and venous phases showed no significant difference (all p > 0.05). The highest SNR and CNR were obtained at VMI 40 keV, significantly greater than other energy levels and PEI (all p < 0.05). Tumor contrast was more evident than PEI at 40-100 keV in the arterial phase and at 40 keV in the venous phase (all p < 0.05). When compared with PEI, VMI 40 keV yielded the highest scores for overall image quality, tumor visibility, and tumor margin delineation, especially in the venous phase (p < 0.05). The overall diagnostic accuracy of DLSCT and HR-MRI for T-stage was 65.67 and 71.64% and showed no significant difference (p > 0.05). VMI 40 keV improves image quality and accuracy in identifying lesions, providing better diagnostic information for ERA staging. Low-keV VMI from DLSCT can improve tumor staging accuracy for early rectal carcinoma, helping guide surgical intervention decisions, and has shed new light on the potential breakthroughs of assessing preoperative T-stage in RC. • Compared with PEI, low-keV VIM derived from DLSCT, particularly at the 40 keV, significantly enhanced the objective and subjective image quality of ERA. • Using VMI 40 keV helped increase lesion detectability, leading to improved diagnostic accuracy for ERA. • Low-keV VMI from DLSCT has shed new light on the potential breakthroughs of assessing preoperative T-stage in RC.

Dual-energy CT revisited: a focused review of clinical use cases.

Dual-energy CT (DECT) has been available for more than 15 years and has undergone continuous technical development and refinement. Recently, the first photon-counting CT scanner became clinically available and has the potential to further expand the possibilities of spectral imaging. Numerous studies on DECT have been published since its creation, highlighting the clinical applications of the various reconstructions enabled by DECT. The aim of this focused review is to succinctly summarize basic principles and available technical concepts of DECT and to discuss established applications relevant to the daily clinical routine. DECT is instrumental for a broad variety of clinical use cases. While some DECT applications can enhance day-to-day clinical practice, others are still subject to broad-scale validation and should therefore be handled with restraint in the clinical routine. · Virtual monoenergetic images, virtual unenhanced images, and iodine maps are the most well-investigated and relevant dual-energy CT reconstructions for clinical application.. · Low-keV virtual monoenergetic images (VMIs) yield superior image and iodine contrast, which can be leveraged for improved vessel assessment and lesion conspicuity, or to reduce contrast media or radiation dose. VMIs at intermediate energies can serve as a replacement for conventional grey-scale images. VMIs at high keV enable efficient artifact reduction, which can be further optimized in combination with dedicated metal artifact reduction algorithms.. · Iodine maps and virtual unenhanced images can improve lesion detection in oncologic imaging and enable lesion assessment in monophasic CT examinations, which may allow a reduction of correlative and follow-up imaging..

Expanding Role of Dual-Energy CT for Genitourinary Tract Assessment in the Emergency Department, From the AJR Special Series on Emergency Radiology.

Among explored applications of dual-energy CT (DECT) in the abdomen and pelvis, the genitourinary (GU) tract represents an area where accumulated evidence has established the role of DECT to provide useful information that may change management. This review discusses established applications of DECT for GU tract assessment in the emergency department (ED) setting, including characterization of renal stones, evaluation of traumatic injuries and hemorrhage, and characterization of incidental renal and adrenal findings. Use of DECT for such applications can reduce the need for additional multiphase CT or MRI examinations and reduce follow-up imaging recommendations. Emerging applications are also highlighted, including use of low-energy virtual monoenergetic images (VMIs) to improve image quality and potentially reduce contrast media doses and use of high-energy VMIs to mitigate renal mass pseudoenhancement. Finally, implementation of DECT into busy ED radiology practices is presented, weighing the trade-off of additional image acquisition, processing time, and interpretation time against potential additional useful clinical information. Automatic generation of DECT-derived images with direct PACS transfer can facilitate radiologists' adoption of DECT in busy ED environments and minimize impact on interpretation times. Using the described approaches, radiologists can apply DECT technology to improve the quality and efficiency of care in the ED.

Screening for osteoporosis based on IQon spectral CT virtual low monoenergetic images: Comparison with conventional 120 kVp images

ObjectivesTo explore the differences between low kiloelectron volt (keV) virtual monoenergetic images (VMIs) using IQon spectral CT and conventional CT (120 kVp) in the diagnosis of osteoporosis. MethodsThis retrospective study included 317 patients who underwent IQon spectral CT and dual-energy X-ray absorptiometry (DXA) examination. Commercial deep learning–based software was used for the fully automated extraction of the CT values of the first to fourth lumbar vertebrae (L1–L4) from two different low-keV levels (including 40/70 keV) VMIs and conventional 120 kVp images. The DXA examination results served as the standard of reference (normal [T-score ≥ −1], osteopenia [-2.5 < T-score < −1], and osteoporosis [T-score < −2.5]). Osteoporosis diagnosis models were constructed using machine learning classifiers (logistic regression, support vector machine, random forest, XGBoost, and multilayer perceptron) based on the average CT values of L1–L4. The area under the receiver operating characteristic curve (AUC) and DeLong test were performed to compare differences in the performance of the osteoporosis diagnosis model between virtual low-keV VMIs and standard 120 kVp images. ResultsRandom forest-based prediction model obtained good overall performance among all classifiers, and macro/micro average AUC values of 0.820/840, 0.834/853, and 0.831/852 were obtained based on 40/70 keV and 120 kVp images, respectively. The model presented no significant difference between low-keV VMIs and standard 120 kVp images for the diagnosis of osteoporosis (p > 0.05). ConclusionsThe performance of the osteoporosis diagnosis model using IQon spectral CT simulating the low tube voltage scanning condition (less than 120 kVp) was also satisfactory. Bone density screening evaluation can be performed with a combination of low-dose lung scanning CT, greatly reducing the radiation dose without affecting the diagnosis.

Nonenhanced Photon Counting CT of the Head : Impact of the keV Level, Iterative Reconstruction and Calvaria on Image Quality in Monoenergetic Images.

Nonenhanced computed tomography (CT) of the head is among the most commonly performed CT examinations. The spectral information acquired by photon counting CT (PCCT) allows generation of virtual monoenergetic images (VMI). At the same time, image noise can be reduced using quantum iterative reconstruction (QIR). In this study, the image quality of VMI was evaluated depending on the keV level and the QIR level. Furthermore, the influence of the cranial calvaria was investigated to determine the optimal reconstruction for clinical application. Atotal of 51PCCT (NAEOTOM Alpha, Siemens Healthineers, Erlangen, Germany) of the head were retrospectively analyzed. In aquantitative analysis, gray and white matter ROIs were evaluated in different brain areas at all available keV levels and QIR levels with respect to signal, noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). The distance to the cranial calvaria of the ROIs was included in the analysis. This was followed by aqualitative reading by five radiologists including experienced neuroradiologists. In most ROIs, signal and noise varied significantly between keV levels (p < 0.0001). The CNR had afocal maximum at 66 keV and an absolute maximum at higher keV, slightly differently located depending on ROI and QIR level. With increasing QIR level, asignificant reduction in noise was achieved (p < 0.0001) except just beneath the cranial calvaria. The cranial calvaria had astrong effect on the signal (p < 0.0001) but not on gray and white matter noise. In the qualitative reading, the 60 keV VMI was rated best. In nonenhanced PCCT of the head the selected keV level of the VMI and the QIR level have acrucial influence on image quality in VMI. The 60 keV and 66 keV VMI with high QIR level provided optimal subjective and objective image quality for clinical use. The cranial calvaria has asignificant influence on the visualization of the adjacent brain matter; currently, this substantially limits the use of low keV VMIs (< 60 keV).

Photon-counting detector CT improves quality of arterial phase abdominal scans: A head-to-head comparison with energy-integrating CT

PurposePhoton-counting detector (PCD)-CT is expected to have a substantial impact on oncologic abdominal imaging. We compared subjective and objective image quality between PCD-CT and conventional energy-integrating detector (EID-)CT arterial phase abdominal scans. MethodsThis study included 84 patients undergoing both types of abdominal CT. EID-CT scans were acquired with a tube voltage of 100 kVp. With PCD-CT, acquired with 120-kVp, we reconstructed polychromatic T3D images and virtual monoenergetic images (VMIs) in 10-keV intervals from 40 to 90 keV. Quantitative image analysis included noise and contrast-to-noise ratio (CNR) of hepatic vessels, kidney cortex, and hypervascular liver lesions to liver parenchyma. Three raters used a 5-point Likert scale for qualitative image analysis of image noise and contrast, lesion conspicuity, and overall image quality. Radiation dose exposure (CT dose index) was compared between the two CT types. ResultsMean CT dose index and effective dose were respectively 18 % and 26 % lower with PCD-CT versus EID-CT. Compared with EID-CT, CNRs of kidney cortex and vessel to liver parenchyma were significantly higher in PCD-CT VMIs at energies ≤ 60 keV and in polychromatic T3D images (p < 0.004). Overall image quality of PCD-CT VMIs at 50 and 60 keV was rated as significantly better (p < 0.01) than the EID-CT images (inter-reader agreement alpha = 0.80). Lesion conspicuity was significantly better in low-keV VMIs (p < 0.03) and worse in > 70-keV VMIs. ConclusionsWith low-keV VMI, PCD-CT yields significantly improved objective and subjective quality of arterial phase oncological imaging compared with EID-CT. This advantage may translate into higher diagnostic confidence and lower radiation dose protocols.

Diagnostic performance of dual-energy CT in nonspecific terminal ileitis.

To investigate the value of dual-energy CT (DECT) imaging in the diagnosis of nonspecific terminal ileitis (NTI). This is a retrospective study, enrolling patients with symptomatic terminal ileitis that underwent conventional multidetector CT (MDCT) enterography or DECT enterography. The sensitivity of the diagnosis of NTI between MDCT images and different kinds of DECT images (40-70 kev virtual monoenergetic images (VMIs) and iodine density images) was compared. The iodine concentrations of lesion bowel wall among NTI, Crohn's disease (CD) and intestinal tuberculosis (ITB) in DECT group and the value of lesion-to-non-lesion contrast ratios of all patients were measured. Receiver operator characteristic (ROC) curves for normalized iodine concentration (NIC) for differentiating among the three kinds of disease were drawn. The sensitivity for the diagnosis of NTI in DECT group (including 40 kev, 50keV VMIs, and iodine density images) were all 89.7%, significantly higher than that in MDCT group (65.1%) (P = 0.026). Statistical analysis did not reveal marked differences between 60 kev, 70 kev VMIs (86.2%) and MDCT images (65.1%) (P = 0.059). The NIC of NTI was (0.15 ± 0.04)100µg/cm3 and (0.45 ± 0.08)100µg/cm3, significantly lower than that of CD (0.34 ± 0.09) 100µg/cm3, (0.85 ± 0.06) 100µg/cm3 and that of ITB (0.29 ± 0.07) 100µg/cm3, (0.88 ± 0.07) 100µg/cm3 at the enteric phase (EP) and portal venous phase (PVP) (P < 0.001, wholly). The area under the ROC curves (AUROCs) of NICEP and NICPVP were 0.910 and 0.980, respectively, for differentiating between NTI and CD. The value of lesion-to-non-lesion contrast ratios is maximum on the 40keV VMI both EP and PVP. The value of lesion-to-non-lesion contrast ratios of NTI was lower than that of CD and ITB on each image. The AUROCs of NICEP and NICPVP were 0.875 and 0.940, respectively, for differentiating between NTI and ITB. DECT has higher sensitivity in the diagnosis of NTI than MDCT. Low-keV VMI and iodine density images of DECT can clearly show the NTI. DECT imaging can help to differentiate NTI from CD or ITB by comparing the NIC.

Utilisation of virtual non-contrast images and virtual mono-energetic images acquired from dual-layer spectral CT for renal cell carcinoma: image quality and radiation dose

BackgroundRenal cell carcinoma (RCC) is the most common renal malignant tumour. We evaluated the potential value and dose reduction of virtual non-contrast (VNC) images and virtual monoenergetic images (VMIs) from dual-layer spectral CT (DL-CT) in the diagnosis of RCC.ResultsSixty-two patients with pathologically confirmed RCC who underwent contrast-enhanced DL-CT were retrospectively analysed. For the comparison between true non-contrast (TNC) and VNC images of the excretory phase, the attenuation, image noise, signal-to-noise ratio (SNR) and subjective image quality of tumours and different abdominal organs and tissues were evaluated. To compare corticomedullary phase images and low keV VMIs (40 to 100 keV) from the nephrographic phase, the attenuation, image noise, SNR and subjective lesion visibility of the tumours and renal arteries were evaluated. For the tumours, significant differences were not observed in attenuation, noise or SNR between TNC and VNC images (p > 0.05). For the abdominal organs and tissues, except for fat, the difference in attenuation was 100% within 15 HU and 96.78% within 10 HU. The subjective image quality of TNC and VNC images was equivalent (p > 0.05). The attenuation of lesions in 40 keV VMIs and renal arteries in 60 keV VMIs were similar to those in the corticomedullary images (p > 0.05). The subjective lesion visibility in low keV VMIs is slightly lower than that in the corticomedullary images (p < 0.05). Using VNC and VMIs instead of TNC and corticomedullary phase images could decrease the radiation dose by 50.5%.ConclusionVNC images and VMIs acquired from DL-CT can maintain good image quality and decrease the radiation dose for diagnosis of RCC.

Dual-Layer Spectral CTA for TAVI Planning Using a Split-Phase Protocol and Low-keV Virtual Monoenergetic Images: Improved Image Quality in Comparison with Single-Phase Conventional CTA.

Adaptation of computed tomography protocols for transcatheter aortic valve implantation (TAVI) planning is required when a first-generation dual-layer spectral CT scanner (DLCT) is used. The purpose of this study was to evaluate the objective image quality of aortic CT angiography (CTA) for TAVI planning using a split-phase technique with reconstruction of 40 keV virtual monoenergetic images (40 keV-VMI) obtained with a DLCT scanner. CT angiography obtained with a single-phase protocol of a conventional single-detector CT (SLCT) was used for comparison. 75 CTA scans from DLCT were retrospectively compared to 75 CTA scans from SLCT. For DLCT, spiral CTA without ECG-synchronization was performed immediately after a retrospectively ECG-gated acquisition covering the heart and aortic arch. For SLCT, spiral CTA with retrospective ECG-gating was performed to capture the heart and the access route simultaneously in one scan. Objective image quality was compared at different levels of the arterial access route. 40 keV virtual monoenergetic images of DLCT showed a significantly higher mean vessel attenuation, SNR, and CNR at all levels of the arterial access route. With 40 keV-VMI of DLCT, the overall mean aortic attenuation of all six measured regions was 589.6 ± 243 HU compared to 492.7 ± 209 HU of SLCT (p < 0.01). A similar trend could be observed for SNR (23.6 ± 18 vs. 18.6 ± 9; p < 0.01) and CNR (21.1 ± 18 vs. 16.4 ± 8; p < 0.01). No deterioration was observed for vascular noise (27.8 ± 9 HU vs. 28.1 ± 8 HU; p = 0.599). Using a DLCT scanner with a split-phase protocol and 40 keV-VMI for TAVI planning, higher objective image quality can be obtained compared to a single-phase protocol of a conventional CT scanner. · Adaption of TAVI planning CT protocols may be required when using a first-generation dual-layer CT scanner.. · Reconstruction of virtual monoenergetic images at 40 keV improves image quality.. · With a split-phase protocol, the radiation dose is lower compared to a single-phase ECG-gated CT acquisition.. · Mangold D, Salatzki J, Riffel J et al. Dual-Layer Spectral CTA for TAVI Planning Using a Split-Phase Protocol and Low-keV Virtual Monoenergetic Images: Improved Image Quality in Comparison with Single-Phase Conventional CTA. Fortschr Röntgenstr 2022; 194: 652 - 659.

Virtual Monoenergetic Spectral Detector CT for Preoperative CT Angiography in Liver Donors

ObjectiveThe purpose of this study was to evaluate the use of virtual monoenergetic images (VMI) in pre-operative CT angiography of potential donors for living donor adult liver transplantation (LDALT), and to determine the optimal energy level to maximize vascular signal-to-noise and contrast-to-noise ratios (SNR and CNR, respectively). Materials and methodsWe retrospectively evaluated 29 CT angiography studies performed preoperatively in potential liver donors on a spectral detector CT scanner. All studies included arterial, early venous, and delayed venous phase imaging. Conventional polyenergetic images were generated for each patient, as well as virtual monoenergetic images in 10 keV increments from 40 –100 keV. Arteries (aorta and celiac, superior mesenteric, common hepatic, right and left hepatic arteries) were assessed on arterial phase images; portal venous system branches (splenic, superior mesenteric, main, right, and left portal veins) on early venous phase images; and hepatic veins on late venous phase images. Vascular attenuation, background parenchymal attenuation, and noise were measured on each set of virtual monoenergetic and conventional images. ResultsBackground hepatic and vascular noise decreased with increasing keV, with the lowest noise at 100 keV. Vascular SNR and CNR increased with decreasing keV and were highest at 40 keV, with statistical significance compared with conventional ( P < 0.05). ConclusionsIn preoperative CT angiography for potential liver donors, the optimal keV for assessing the vasculature to improve SNR and CNR is 40 keV. Use of low keV VMI in LDALT CT protocols may facilitate detection of vascular anatomical variants that can impact surgical planning.

Generally applicable window settings of low-keV virtual monoenergetic reconstructions in dual-layer CT-angiography of the head and neck.

Increased vessel contrast in low-keV virtual monoenergetic images (VMI) in spectral detector CT angiography of the head and neck requires adaption of window settings. Aim of this study was to define generally applicable window settings of low-keV VMI. Two radiologists determined ideal subjective window settings for VMI40-70 keV in 54 patients. To obtain generally applicable window settings, center and width values were modeled against the attenuation of the internal carotid artery (HUICA). This modeling was performed with and without respect to keV. Subsequently, image quality of VMI40-70 keV was assessed using the model-based determined window settings. With decreasing keV values, HUICA increased significantly in comparison to conventional images (CI) (P<0.05 for 40-60 keV). No significant differences between modelled and individually recorded window settings were found confirming validity of the obtained models (P values: 0.2-1.0). However, modelling with respect to keV was marginally less precise. Window settings of low-keV VMI can be semi-automatically determined in dependency of the ICA attenuation in spectral detector CTA of the head and neck. The reported models are a promising tool to leverage the improved image quality of these images in clinical routine.

Acute cholecystitis: diagnostic value of dual-energy CT-derived iodine map and low-keV virtual monoenergetic images.

To compare conventional and dual-energy CT (DECT) for the diagnosis of acute cholecystitis and gangrene. Fifty-seven consecutive adult patients with abdominal pain who underwent IV contrast-enhanced abdominal DECT on a dual-layer (dlDECT) or rapid-switching (rsDECT) scanner from September, 2018 to April, 2021 with cholecystectomy and pathology-confirmed cholecystitis were retrospectively reviewed, and compared with 57 consecutive adult patients without cholecystitis from the same interval scanned with DECT. Images were reviewed independently by two abdominal radiologists with 12 and 16years of experience in two sessions 4weeks apart, blinded to clinical data. Initially, only blended reconstructions (simulating conventional single-energy CT images) were reviewed (CT). Subsequently, CT and DECT reconstructions including low-keV virtual monoenergetic images and iodine maps were reviewed. Gallbladder fossa hyperemia, pericholecystic fluid, subjective presence of gangrene, heterogeneous wall enhancement, sloughed membranes, intramural air, abscess, overall impression of the presence of acute cholecystitis, and intramural iodine density were assessed. Gallbladder fossa hyperemia was detected with increased sensitivity on DECT (R1, 61.4%; R2, 75.4%) vs. CT (R1, 22.8%; R2, 15.8%). DECT showed increased sensitivity for gangrene (R1, 24.6%; R2, 38.6%) vs. CT (R1, 5.3%; R2, 14%), heterogeneous wall enhancement (DECT: R1, 33.3%; R2, 63.2% vs. CT: R1, 7%; R2, 31.6%), and cholecystitis (DECT: R1, 86%; R2, 89.5% vs. CT: R1, 77.2%; R2, 70.2%). In addition, DECT was more sensitive for the detection of acute cholecystitis (R1, 86%; R2, 89.5%) vs. CT (R1, 77.2%; R2, 70.2%). Iodine density threshold of 1.2mg/ml, 0.8mg/mL, and 0.5mg/mL showed specificity for gangrenous cholecystitis of 78.26%, 86.96%, and 95.65%, respectively, using the rsDECT platform. DECT showed improved sensitivity compared to conventional CT for detection of acute cholecystitis. Iodine density measurements may be helpful to diagnose gangrene.

Value of spectral detector computed tomography for the early assessment of technique efficacy after microwave ablation of hepatocellular carcinoma.

ObjectivesTo investigate whether virtual monoenergetic images (VMI) and iodine maps derived from spectral detector computed tomography (SDCT) improve early assessment of technique efficacy in patients who underwent microwave ablation (MWA) for hepatocellular carcinoma (HCC) in liver cirrhosis.MethodsThis retrospective study comprised 39 patients with 49 HCC lesions treated with MWA. Biphasic SDCT was performed 7.7±4.0 days after ablation. Conventional images (CI), VMI and IM were reconstructed. Signal- and contrast-to-noise ratio (SNR, CNR) in the ablation zone (AZ), hyperemic rim (HR) and liver parenchyma were calculated using regions-of-interest analysis and compared between CI and VMI between 40–100 keV. Iodine concentration and perfusion ratio of HR and residual tumor (RT) were measured. Two readers evaluated subjective contrast of AZ and HR, technique efficacy (complete vs. incomplete ablation) and diagnostic confidence at determining technique efficacy.ResultsAttenuation of liver parenchyma, HR and RT, SNR of liver parenchyma and HR, CNR of AZ and HR were significantly higher in low-keV VMI compared to CI (all p<0.05). Iodine concentration and perfusion ratio differed significantly between HR and RT (all p<0.05; e.g. iodine concentration, 1.6±0.5 vs. 2.7±1.3 mg/ml). VMI50keV improved subjective AZ-to-liver contrast, HR-to-liver contrast, visualization of AZ margin and vessels adjacent to AZ compared to CI (all p<0.05). Diagnostic accuracy for detection of incomplete ablation was slightly higher in VMI50keV compared to CI (0.92 vs. 0.89), while diagnostic confidence was significantly higher in VMI50keV (p<0.05).ConclusionsSpectral detector computed tomography derived low-keV virtual monoenergetic images and iodine maps provide superior early assessment of technique efficacy of MWA in HCC compared to CI.

Value of spectral detector CT for pretherapeutic, locoregional assessment of esophageal cancer

PurposeTo investigate the diagnostic value of spectral detector dual-energy CT-derived low-keV virtual monoenergetic images (VMI) and iodine overlays (IO) for locoregional, pretherapeutic assessment of esophageal cancer. Method74 patients with biopsy-proven esophageal cancer who underwent pre-therapeutic, portal-venous-phase staging examinations of the chest and abdomen were retrospectively included. Quantitative image analysis was performed ROI-based within the tumor, healthy esophageal wall, peri-esophageal lymph nodes, azygos vein, aorta, liver, diaphragm, and mediastinal fat. Two radiologists evaluated delineation of the primary tumor and locoregional lymph nodes, assessment of the celiac trunk and diagnostic certainty regarding tumor infiltration in conventional images (CI), VMI from 40 to 70 keV and IO. Moreover, presence/absence of advanced tumor infiltration (T3/T4) was determined binary using all available images. ResultsVMI40−60keV showed significantly higher attenuation and signal-to-noise ratio compared to CI for all assessed ROIs, peaking at VMI40keV (p < 0.05). Contrast-to-noise ratio of tumor/esophagus (VMI40keV/CI: 7.7 ± 4.7 vs. 2.3 ± 1.5), tumor/diaphragm (VMI40keV/CI: 9.0 ± 5.5 vs. 2.2 ± 1.7) and tumor/liver (4.3 ± 5.5 vs. 1.9 ± 2.1) were all significantly higher compared to CI (p < 0.05). Qualitatively, lymph node delineation and diagnostic certainty regarding tumor infiltration received highest ratings both in IO and VMI40keV, whereas vascular assessment was rated highest in VMI40keV and primary tumor delineation in IO. Sensitivity/Specificity/Accuracy for detecting advanced tumor infiltration using the combination of CI, VMI40−70keV and IO was 42.4 %/82.0 %/56.3 %. ConclusionsIO and VMI40−60keV improve qualitative assessment of the primary tumor and depiction of lymph nodes and vessels at pretherapeutic SDCT of esophageal cancer patients yet do not mitigate the limitations of CT in determining tumor infiltration.

Virtual monoenergetic images preserve diagnostic assessability in contrast media reduced abdominal spectral detector CT.

To investigate if low-keV virtual monoenergetic images (VMI40keV) from abdominal spectral detector CT (SDCT) with reduced intravenous contrast media application (RCM) provide abdominal assessment similar to conventional images with standard contrast media (SCM) dose. 78 patients with abdominal SDCT were retrospectively included: 41 patients at risk for adverse reactions who received 44 RCM examinations with 50 ml and 37 patients who underwent 44 SCM examinations with 100 ml of contrast media (CM) and who were matched for effective body diameters. RCM, SCM images and RCM-VMI40keV were reconstructed. Attenuation and signal-to-noise ratio (SNR) of liver, pancreas, kidneys, lymph nodes, psoas muscle, aorta and portal vein were assessed ROIs-based. Contrast-to-noise ratios (CNR) of lymph nodes vs aorta/portal vein were calculated. Two readers evaluated organ/vessel contrast, lymph node delineation, image noise and overall assessability using 4-point Likert scales. RCM were inferior to SCM images in all quantitative/qualitative criteria. RCM-VMI40keV and SCM images showed similar lymph node and muscle attenuation (p = 0.83,0.17), while for all other ROIs, RCM-VMI40keV showed higher attenuation (p ≤ 0.05). SNR was comparable between RCM-VMI40keV and SCM images (p range: 0.23-0.99). CNR of lymph nodes was highest in RCM-VMI40keV (p ≤ 0.05). RCM-VMI40keV received equivalent or higher scores than SCM in all criteria except for organ contrast, overall assessability and image noise, where SCM were superior (p ≤ 0.05). However, RCM-VMI40keV received proper or excellent scores in 88.6/94.2/95.4% of the referring cases. VMI40keV counteract contrast deterioration in CM reduced abdominal SDCT, facilitating diagnostic assessment. SDCT-derived VMI40keV provide adequate depiction of vessels, organs and lymph nodes even at notable CM reduction.

Salvage of Suboptimal Enhancement of Pulmonary Artery in Pulmonary CT Angiography Studies: Rapid kVp Switch Dual Energy CT Experience

Background: Multidetector computed tomography (MDCT) angiography is considered as the gold standard imaging modality in the evaluation of acute pulmonary embolism. Optimum vascular enhancement is critical for MDCT studies. The suboptimal opacification in pulmonary artery could be salvaged using low-energy virtual monoenergetic images (VMI) at rapid kVp switch dual energy CT. Objectives: To explore the potential improvement in pulmonary artery opacification and to assess the change in image quality parameters in VMI using fast switch kVp dual energy CT. Patients and Methods: The CT images of 877 patients who were referred with a preliminary diagnosis of pulmonary embolism were reviewed. Sixty patients with suboptimal enhancement (&lt; 200 Hounsfeld Unit [HU]) were involved. Standard images (140 kVp) and VMI from 40 to 120 keV were generated. Attenuation, noise, signal to noise ratio (SNR) and contrast to noise ratio (CNR) were measured in the pulmonary artery. Using VMIs, the best image was determined as the image with the main pulmonary artery opacification greater than 200 HU and image quality ≥ 3. Fifty six studies that met these criteria were considered as salvaged. At this best energy level, quantitative parameters were compared with standard images. Results: The mean attenuation of pulmonary arteries was 169.80 HU in standard images in patients with suboptimal enhancement. The attenuations of VMIs at 40, 45, 50, 55, 60, 65, and 70 keV were significantly higher than standard images (P &lt; 0.001). Similar findings were observed with SNR and CNR. In the salvaged patients, the average increase in mean pulmonary artery attenuation was 62% (from 172.61 ± 23.4 to 280.55 ± 40.7), the average increase in SNR was 38% (from 12.1 ± 5.3 to 16.7 ± 7.1) and the average increase in CNR was 48% (9.2 ± 4.3 to 13.7 ± 6) (P &lt; 0.001). Conclusions: Low keV VMI reconstructions significantly increase pulmonary artery attenuation, CNR and SNR compared to standard image reconstructions. Suboptimal CT studies could be salvaged using low keV VMIs.

Measurement Reliability and Diagnostic Accuracy of Virtual Monoenergetic Dual-Energy CT in Patients with Colorectal Liver Metastases

To compare dual-energy CT virtual monoenergetic images (VMI) and standard reconstructions for reliability of quantitative size measurements and diagnostic accuracy for the detection of colorectal liver metastases (CRLM). We retrospectively included 98 patients (mean age, 61.1±11.5 years) with colorectal cancer, of whom 49 subjects had CRLM. All patients underwent a portal-venous phase dual-energy CT examination. Standard linearly-blended reformats and 40-keV VMI were reconstructed. For both reconstruction techniques, two blinded readers performed measurements of CRLM twice in a preset sequence. Three additional radiologists independently assessed all liver lesions in terms of dignity (benign vs. malignant). Sensitivity, specificity and diagnostic accuracy were calculated on a per-patient basis using MRI as reference standard. Readers scored the suitability for metric measurements and their diagnostic confidence using 5-point Likert scales. Inter-rater agreement was evaluated using intraclass correlation coefficient (ICC). Inter-rater agreement for lesion size measurements was higher for 40-keV VMI (ICC, 0.88) compared to standard linearly-blended series (ICC, 0.80). Sensitivity and diagnostic accuracy for the detection of CRLM were significantly higher for VMI at 40-keV compared to standard reconstructions (90.6% vs. 80.6%, and 89.1% vs. 81.3%; p < 0.001). Reader scores indicated that 40-keV VMI were more suitable for metric lesion measurements and provided greater diagnostic confidence compared to standard reformats (median, 5 vs. 3, and 5 vs. 4; both p < 0.001). Low-keV VMI reconstructions improve reliability of quantitative size measurements and diagnostic accuracy for the assessment of CRLM compared to standard linearly-blended images.

Dual-Energy Low-keV or Single-Energy Low-kV CT for Endoleak Detection?: A 6-Reader Study in an Aortic Aneurysm Phantom.

The aim of this study was to compare image quality, conspicuity, and endoleak detection between single-energy low-kV images (SEIs) and dual-energy low-keV virtual monoenergetic images (VMIs+) in computed tomography angiography of the aorta after endovascular repair. An abdominal aortic aneurysm phantom simulating 36 endoleaks (2 densities; diameters: 2, 4, and 6 mm) in a medium- and large-sized patient was used. Each size was scanned using single-energy at 80 kVp (A) and 100 kVp (B), and dual-energy at 80/Sn150kVp for the medium (C) and 90/Sn150kVp for the large size (D). VMIs+ at 40 keV and 50 keV were reconstructed from protocols C and D. Radiation dose was 3 mGy for the medium and 6 mGy for the large size. Objective image quality and normalized noise power spectrum were determined. Subjective image quality, conspicuity, and sensitivity for endoleaks were independently assessed by 6 radiologists. Sensitivity was compared using Marascuilo procedure and Fisher exact test. Conspicuities were compared using Wilcoxon-matched pairs test, analysis of variance, and Tukey test. The contrast-to-noise-ratio of the aorta was significantly higher for VMI+ compared with SEI (P < 0.001). Noise power spectrum showed a higher noise magnitude and coarser texture in VMI+. Subjective image quality and overall conspicuity was lower for VMI+ compared with SEI (P < 0.05). Sensitivity for endoleaks was overall higher in the medium phantom for SEI (60.9% for A, 62.2% for B) compared with VMI+ (54.2% for C, 49.3% for D) with significant differences between protocols B and D (P < 0.05). In the large phantom, there was no significant difference in sensitivity among protocols (P = 0.79), with highest rates for protocols B (31.4%) and C (31.7%). Our study indicates that low-keV VMI+ results in improved contrast-to-noise-ratio of the aorta, whereas noise properties, subjective image quality, conspicuity, and sensitivity for endoleaks were overall superior for SEI.

Dual-layer spectral CT improves image quality of multiphasic pancreas CT in patients with pancreatic ductal adenocarcinoma.

To evaluate the image quality and optimal energies of virtual monoenergetic images (VMIs) from dual-layer spectral detector computed tomography (DLCT) in multiphasic pancreatic CT and investigate whether low-keV VMI at the portal venous phase (PVP) provides sufficient tumor conspicuity and arterial depiction relative to conventional pancreatic parenchymal phase (PPP) images. Forty-eight patients with pancreatic ductal adenocarcinoma (PDAC) underwent contrast-enhanced DLCT during PPP and PVP. Conventional polyenergetic images (PEIs) and VMI at 40-100keV (VMI40-100, 10-keV increments) were reconstructed at each enhancement phase. Image noise and the contrast-to-noise ratio (CNR) of the pancreas, tumors, arteries, and veins were quantified. Two radiologists independently assessed tumor conspicuity, margin delineation, image noise, sharpness of pancreatic duct, and depiction of arteries and veins on a five-point scale. Size-specific dose estimate (SSDE) was calculated. Image noise for VMI40-100 was significantly lower than that for PEI (p < 0.01). The CNR in VMI increased gradually with decreasing energy; CNRs for VMI40-60 were significantly greater than that for PEI (p < 0.01). All subjective VMI scores were maximized at VMI40, followed by VMI50-60, all of which were significantly better than of PEI (p < 0.01). Objective and subjective image qualities of VMI40-50 at the PVP were equivalent to or even better compared with conventional PPP images. No significant difference in SSDE was observed between phases (p = 0.10). DLCT-VMI improved the subjective and objective image quality in multiphasic pancreatic CT for patients with PDAC. Low-keV PVP imaging may yield diagnostically adequate tumor conspicuity and arterial assessment compared with polyenergetic PPP images. • Low-keV VMI from DLCT yields better subjective and objective image quality of multiphasic pancreas CT in comparison with conventional PEI for the assessment of pancreatic ductal adenocarcinoma. • Tumor conspicuity and depiction of peripancreatic vasculature were maximized at VMI 40without an increase in the image noise. • Low-keV VMI of the portal venous phase provides sufficient tumor conspicuity and arterial depiction, potentially allowing the early detection and local staging of PDAC on routine abdominal CT performed for various clinical indications.