ct protocols
TRANSCRIPT
CT Protocol Development and Adaptation
for the Head and NeckNeuroradiologist
eEdE-99
Greg Avey, MDTabassum Kennedy, MD
Lindell Gentry, MD
Disclosures
The authors have no relevant financial relationships to disclose.
No off label or investigational uses will be discussed.
Objective
After completing this module, the reader will be more knowledgeable about and comfortable with generating, evaluating, implementing, and troubleshooting head and neck CT protocols.
Organization
This tutorial consists of 3 separate modules: A brief, practical physics review
A discussion on dose reduction strategies and sources for normative dose information
Discussion of acquisition challenges and tips for commonly performed head and neck sites – Head, Cervical Spine, Neck, Temporal Bone, and Paranasal Sinuses
Physics Dose Reduction Site Specific Tips
Links to Modules
Physics Topics
kV mA Rotation Time Pitch Effective mA Table Speed Reconstruction Kernel
Physics Dose Reduction Site Specific Tips
kV kV measures the peak energy level of the
photons emitted from the x-ray tube. For CT, typical kV values range from 80 kV
to 140 kV. Most adult body parts have traditionally
been imaged at 120 kV.
80
120
Low energy photon
High energy photon
Physics Dose Reduction Site Specific Tips
As kV increases, the probability of a photon passing through without being absorbed increases. More photons make it to the detector. The decrease in differential absorption causes soft tissue contrast to be
decreased.
kV
80
120
Physics Dose Reduction Site Specific Tips
The CT density of contrast increases with lower kV, as the k edge of iodine is approached.
80
120
kV
Physics Dose Reduction Site Specific Tips
Iodinated Contrast
The CT density of contrast increases with lower kV, as the k edge of iodine is approached.
At a lower kV, more photons are absorbed, yielding a higher CT density.
80
kV
Physics Dose Reduction Site Specific Tips
80
808080
Iodinated Contrast
The CT density of contrast increases with lower kV, as the k edge of iodine is approached.
At a high kV, less photons are absorbed, yielding a lower CT density.
120
kV
Physics Dose Reduction Site Specific Tips
120
120120120
Iodinated Contrast
This results in a significant increase in the CT density of contrast – from 341 HU @ 140 kV to 635 HU @ 80 kV.
Kalva SP1, Sahani DV, Hahn PF, Saini S. Using the K-edge to improve contrast conspicuity and to lower radiation dose with a 16-MDCT: a phantom and human study. J Comput Assist Tomogr. 2006 May-Jun;30(3):391-7.
For a 5% solution of contrast in saline, density change with kV.
kV
80 kVp 100 kVp 120 kVp 140kVpHounsfield Units 654.6 494.4 407.1 341.5% increase from 140 kVp 90% 40% 20%
Physics Dose Reduction Site Specific Tips
kV The relationship between dose and kV is nonlinear and
dependent on the size and composition of the object being scanned.
There is a significant increase in dose with increased kV, ~ 40% dose increase at 140kV compared to 120 kV, and ~ 90% increase at 100 kV compared to 80 kV.
Physics Dose Reduction Site Specific Tips
80 kVp 100 kVp 120 kVp 140 kVp0
10
20
30
40
50
60 kV vs Dose (CTDI-vol, mGy)
CTDI-vol Head CT CTDI-vol Body CT
McNitt-Gray MF. Radiation dose in CT. Radiographics. 2002 Nov-Dec;22(6):1541-53.
* mA=300, 1 sec rotation, pitch=1
McNitt-Gray MF. Radiation dose in CT. Radiographics. 2002 Nov-Dec;22(6):1541-53.
CTDI-vol Head CT
(mGy)
CTDI-vol Body CT (mGy)
% change from lower kV - head
% change from lower kV - body
80 kV 14 5.8 100 kV 26 11 86% 90%120 kV 40 18 54% 64%140 kV 55 25 38% 39%
kV
Physics Dose Reduction Site Specific Tips
The relationship between dose and kV is nonlinear and dependent on the size and composition of the object being scanned.
There is a significant increase in dose with increased kV, ~ 40% dose increase at 140kV compared to 120 kV, and ~ 90% increase at 100 kV compared to 80 kV.
kV Note: This chart shows the same CT technique, with use of different size
phantoms for the head and body data. Use of the large phantom cuts reported dose by 50%.
This is particularly important for neck CT dose – reported doses can differ by a factor of two depending on which size phantom is reported.
80 kVp 100 kVp 120 kVp 140 kVp0
10
20
30
40
50
60 kV vs Dose (CTDI-vol, mGy)
CTDI-vol Head CT CTDI-vol Body CT
McNitt-Gray MF. Radiation dose in CT. Radiographics. 2002 Nov-Dec;22(6):1541-53.
* mA=300, 1 sec rotation, pitch=1
Physics Dose Reduction Site Specific Tips
mA mA describes the number of photons
generated.
Low MAHigh MA
Physics Dose Reduction Site Specific Tips
Rotation Time Another method to expose a region to more photons
is to lengthen the time the x-ray tube spends over each location.
Rotation times for current scanners are as fast as 0.25 seconds.
Faster rotation times can allow for less patient motion and faster exams, at the expense of requiring greater mA output to maintain similar image quality.
Physics Dose Reduction Site Specific Tips
Pitch The ratio of the table travel per rotation to x-ray
beam width (collimation). At a pitch of 1.0 there is a match between the beam width and the
distance traveled for each rotation. At a pitch of 0.5 each segment gets covered by the beam twice. At a pitch greater than 1.0 some segments have only been covered
by part of the beam rotation (e.g. only in the AP or PA projections).
Most protocols use a pitch between 0.5 and 2.5.
Physics Dose Reduction Site Specific Tips
LowPitch
HighPitch
Effective mA Three parameters (mA, rotation time, pitch) change
the overall number of photons which interact with a given slice of tissue. 1. mA – the greater the mA, the larger the number of total
photons generated during a given time. 2. Rotation Time – the shorter the rotation time, the smaller the
number of photons interact with each slice. 3. Pitch – greater pitch => less overlapping coverage => fewer
photons in each slice.
Effective mA =
Physics Dose Reduction Site Specific Tips
Table Speed Table speed increases with detector width and pitch, and with
faster rotation times. Can be calculated from: With high pitch, fast rotation times, and larger detectors, table
speeds can approach 50 cm/sec. However, most non-angiographic neuroradiology protocols will
have a table speed of ~5 cm/sec. This yields a scan time of 4 to 5 seconds for a head CT and 8 to
10 seconds for a head and neck CT.
Physics Dose Reduction Site Specific Tips
Reconstruction Kernel The algorithm used to reconstruct CT images from
raw CT data. The kernel is selected to balance the need for high
resolution and the accompanying increase in high frequency image noise.
Less high frequency noise
More high frequency noise
Most high frequency noise
Blurring of septae Crisp septae Edge Enhanced
Physics Dose Reduction Site Specific Tips
Dose Reduction Topics
Physics Dose Reduction Site Specific Tips
Dose Measures Diagnostic Reference Levels Achievable Dose Levels Effective Dose Dose Reduction – kV Dose Reduction – mA Dose Reduction – pitch Dose Reduction – Collimation Dose Reduction – Image Reconstruction
Dose Measures CTDIvol
CTDIvol is a proxy for absorbed dose for a single slice at the center of the scan. (mGy)
This is how the ACR sets Diagnostic Reference Levels. (DRL => 75th percentile of reported doses)
DLP– Accounts for length of scan – CTDI x length (mGy*cm)– This is how most European countries set DRLs.
Physics Dose Reduction Site Specific Tips
Diagnostic Reference Level DRL – “Is this dose greater than is typical?” Set at the 75th percentile of reported exams. Not a target level – Protocols consistently at or
above the regional DRL should be evaluated for dose reduction.
Physics Dose Reduction Site Specific Tips
Achievable Dose AD – “What is the median dose for this exam.” Set at the 50th percentile of reported exams. Must be interpreted with respect to patient
population and clinical context.
CTDI Phantom Diameter (cm)
DRL (mGy) AD (mGy)
Adult Head 16 75 57
Pediatric 5 year old head CT 16 40 31
Physics Dose Reduction Site Specific Tips
Effective Dose Effective Dose
An approximate effective dose can be estimated by multiplying the DLP by a conversion factor for the anatomy being imaged.
Note that the head and cervical spine are much less radiosensitive than other body sites.
Huda et al. Radiology. Sep 2008; 248(3): 995–1003.
ED/DLP ratio @120 kV, µSv per mGy*cm
Head Cervical Spine
Chest Abdominal Pelvic
ED / DLP Ratio 2.2 5.4 17 16 19
Physics Dose Reduction Site Specific Tips
Effective Dose Common Neuro Exams
From these conversion factors and reported achievable doses, it is possible to estimate effective dose for common neuro exams.
Head CT DLP ~1000 mGy*cm x 2.2 => 2.2 mSv
CT Neck / C-spine DLP ~600 mGy*cm x 5.4 => 3.2 mSv
CT T-bone DLP ~500 mGy*cm x 2.2 => 1.1 mSv
Annual exposure due to environmental factors ~ 3 mSv
Physics Dose Reduction Site Specific Tips
Dose Reduction Strategies - kV
Dose decreases significantly with a decrease in Kv A decrease in kV improves low contrast detection by
increasing the density difference between similar appearing tissues.
A decrease in kV also causes an increase in the conspicuity of contrast enhancement.
This can be a particularly helpful strategy for pediatric patients who don’t require the increased tissue penetration of higher kV exams.
This strategy is less successful when imaging small high contrast structures (i.e. CT temporal bone).
CTDI-vol Head CT
(mGy)
CTDI-vol Body CT (mGy)
% change from lower kV - head
% change from lower kV - body
80 kV 14 5.8 100 kV 26 11 86% 90%120 kV 40 18 54% 64%140 kV 55 25 38% 39%
Physics Dose Reduction Site Specific Tips
Dose Reduction Strategies - mA Dose is proportional to mA. Automatic adjustment of mA during the exam compensates for change
in the diameter of the imaged tissue (e.g. head vs shoulders), keeping noise approximately constant through the exam.
Many vendors now adjust mA both along the long axis of the patient and also within a rotation to compensate for the differences in tissue width in the AP and lateral planes. This can result in a 60% dose reduction over manual mA techniques.
Z axis only X, Y, and Z axes
mA mA
Physics Dose Reduction Site Specific Tips
Dose Reduction Strategies - Pitch
Dose is inversely proportional to pitch – i.e. a pitch of 0.5 will have twice the dose of an exam with a pitch of 1.0.
An increased pitch will also decrease the amount of time required for the exam.
These benefits are often offset by the need to change mA to keep image noise constant.
Physics Dose Reduction Site Specific Tips
Dose Reduction Strategies - Collimation
Collimation has a limited direct influence on dose. However, a larger collimation does limit the potential for mA change during transitions between areas of different diameters (i.e. neck and shoulders).
A larger collimation also increases the potential for over ranging – tissue at the start or end of an exam which is partially radiated, but not included in the image data set.
Physics Dose Reduction Site Specific Tips
Dose Reduction Strategies Image Reconstruction
Noise increases with thin reconstructions – with a noise increase proportional to the .
Changing from a 5mm thick reconstruction to a 2.5mm reconstruction increases noise by 44%) and a change from 5mm to 1.25mm images would double image noise ().
The use of appropriate reconstruction kernels can decrease the high frequency noise in an image, making soft tissue images more clinically useful.
Physics Dose Reduction Site Specific Tips
Dose Reduction Strategies Image Reconstruction
Iterative reconstruction (ASIR, IRIS, iDose) improves reconstruction of images with higher noise levels, and can decrease artifacts associated with low photon counts.
This can allow for substantial dose reduction. However
the resulting images have a different noise texture than conventional filtered back projection (FBP) images. Most centers using this technology combine the traditional FBP and iterative reconstruction images to obtain clinically acceptable exams.
Physics Dose Reduction Site Specific Tips
Site Specific Tips
CT Head CT C-Spine CT Neck CT Paranasal Sinuses CT Temporal Bone
Physics Dose Reduction Parameters Site Specific Tips
CT Head
The typical limiting factor for head CT dose is maintaining good gray-white matter contrast.
The CT density difference between gray and white matter is approximately 10 HU at 120 kV, and 15 HU at 80kV.
As shown on the perfusion image set, the gray-white matter contrast also increases following administration of intravenous contrast.
Physics Dose Reduction Site Specific Tips
CT Head With the use of gantry angulation or a chin tuck
maneuver, the lens can often be kept out of the radiation beam.
The utility of this maneuver depends on the amount of over-ranging on the CT system. A lens carefully just excluded on the scout image may be within the exposed zone due to over ranging!
Physics Dose Reduction Site Specific Tips
Lens inclusive prescriptionLens excluding prescription
CT Cervical Spine Cervical Spine CTs range from the skull base through the
thoracic inlet and shoulders. This anatomy has a large range in diameter and tissue density,
requiring a large variation in dose to achieve a similar noise level throughout the exam.
Larger patients may require imaging at 140 kV to provide diagnostic images through the shoulders. Smaller adults and pediatric patients should be imaged at lower kV values.
Physics Dose Reduction Site Specific Tips
CT Cervical Spine Lowering the position of the shoulders is important in both
allowing adequate visualization of the cervicothoracic junction and in lowering the dose required for the exam.
Fastening the CT table strap around the torso only, as compared to around the torso and arms, decreases the level of the shoulders by one vertebral body level.
Simply encouraging appropriate patients to “pull” their shoulders down has also been found to be effective.
Physics Dose Reduction Site Specific Tips
CT Neck The neck has similar challenges as the cervical spine CT – a wide
variation in circumference and a need to appropriately select the kV for patient size.
Contrast enhanced neck CTs also require appropriate contrast timing. Squamous cell cancer can be isodense or minimally less dense than
muscle on noncontrast images. Contrast enhancement plateaus 50 to 60 seconds after injection. Imaging too soon after contrast injection can result in the tumor being isodense to adjacent muscle.
HU
Squamous Cell Carcinoma Enhancement
Time1
2
3 1. Start of enhancement ~16 sec2. Isodense to muscle ~25 sec3. Plateau ~52 sec
* from start of injection
Keberle M, Tschammler A, Hahn D. Single-bolus technique for spiral CT of laryngopharyngeal squamous cell carcinoma: comparison of different contrast material volumes, flow rates, and start delays. Radiology. 2002 Jul;224(1):171-6.
Physics Dose Reduction Site Specific Tips
CT Neck Beam hardening and streak artifact from dental
amalgam can obscure the oral cavity and oropharynx on CT.
Angled axial images performed with gantry tilt can allow visualization of the oropharynx in these cases.
Physics Dose Reduction Site Specific Tips
CT Paranasal Sinus There is a wide range in reported dose for paranasal sinus CTs.
One survey reported an 18 fold variation in CTDIvol, from 5 mGy to 80mGy.
Studies have found that low dose exams, while less aesthetically pleasing, provide good delineation of mucosal drainage pathways and are adequate for surgical planning and intraoperative guidance.
In general, a protocol at 120 kV and with an effective mA between 20 and 50 mAs is considered sufficient to provide the necessary anatomic detail.
Physics Dose Reduction Site Specific Tips
CT Temporal Bone The limiting factor for temporal bone CT dose is achieving
adequate visualization of the stapes, interscalar septum and cochlear aperture.
This is a high contrast resolution challenge: small structures which differ greatly in the CT density. Dose reduction strategies optimized for low contrast resolution (soft tissues) may not be as effective.
Given the small area to be imaged, careful prescription and a moderate collimation can limit the dose, as over ranging with a large collimation can substantially increase the overall dose given the small area imaged.
Physics Dose Reduction Site Specific Tips
Conclusion Developing and maintaining neuroradiology CT
protocols requires both an understanding of CT physics and a clinical awareness of key anatomic structures.
National and international normative dose data is available to help radiologists identify protocols which might need to be modified.
New, more dose efficient CT scanners and reconstruction algorithms allow radiologists to do more with lower overall dose.
Physics Dose Reduction Site Specific Tips
References1) ARPANSA - Australian Radiation Protection and Nuclear Safety Agency. (n.d.). Retrieved March 26, 2015, from
http://www.arpansa.gov.au/services/ndrl/adult.cfm2) Kalva, S., Sahani, D., Hahn, P., & Saini, S. (n.d.). Using the K-edge to Improve Contrast Conspicuity and to Lower
Radiation Dose With a 16-MDCT. Journal of Computer Assisted Tomography, 391-397.3) Keberle, M., Tschammler, A., & Hahn, D. (2002). Single-Bolus Technique for Spiral CT of Laryngopharyngeal
Squamous Cell Carcinoma: Comparison of Different Contrast Material Volumes, Flow Rates, and Start Delays. Radiology, 171-176.
4) Kranz PG, Wylie JD, Hoang JK, Kosinski AS. Effect of the CT table strap on radiation exposure and image quality during cervical spine CT. AJNR Am J Neuroradiol. 2014;35(10):1870-6.
5) Mccollough C, Branham T, Herlihy V, et al. Diagnostic reference levels from the ACR CT Accreditation Program. J Am Coll Radiol. 2011;8(11):795-803.
6) McNitt-Gray, M. (n.d.). AAPM/RSNA Physics Tutorial For Residents: Topics In CT: Radiation Dose In CT. Radiographics, 1541-1553.
7) Mukherji, S., Faerber, E., & Gujar, S. (2014, January 1). ACR–ASNR–SPR PRACTICE PARAMETER FOR THE PERFORMANCE OF COMPUTED TOMOGRAPHY (CT) OF THE EXTRACRANIAL HEAD AND NECK. Retrieved March 22, 2015.
8) Nauer CB, Rieke A, Zubler C, Candreia C, Arnold A, Senn P. Low-dose temporal bone CT in infants and young children: effective dose and image quality. AJNR Am J Neuroradiol. 2011;32(8):1375-80.
9) Niu YT, Olszewski ME, Zhang YX, Liu YF, Xian JF, Wang ZC. Experimental study and optimization of scan parameters that influence radiation dose in temporal bone high-resolution multidetector row CT. AJNR Am J Neuroradiol. 2011;32(10):1783-8.
10) Smith AB, Dillon WP, Lau BC, et al. Radiation dose reduction strategy for CT protocols: successful implementation in neuroradiology section. Radiology. 2008;247(2):499-506
11) Tack D, Widelec J, De Maertelaer V, Bailly JM, Delcour C, Gevenois PA. Comparison between low-dose and standard-dose multidetector CT in patients with suspected chronic sinusitis. AJR 2003;181:939-944.
12) Wintermark M, Maeder P, Verdun FR, et al. Using 80 kVp versus 120 kVp in perfusion CT measurement of regional cerebral blood flow. AJNR Am J Neuroradiol. 2000;21(10):1881-4.
Physics Dose Reduction Site Specific Tips