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OBJECTIVE The aim of this study was to investigate if Hounsfield unit (HU) values from virtual noncontrast (VNC) images derived from portal venous phase spectral-detector computed tomography can help to differentiate adrenal adenomas and metastases. METHODS Spectral-detector computed tomography datasets of 33 patients with presence of adrenal lesions and standard of reference for lesion origin by follow-up/prior examinations or dedicated magnetic resonance imaging were included. Conventional and VNC images were reconstructed from the same scan. Region of interest-based image analysis was performed in adrenal lesions and contralateral healthy adrenal tissue. RESULTS The 33 lesions consisted of 23 adenomas and 10 metastases. Hounsfield unit values of all lesions in VNC images were significantly lower compared with conventional images (18.2 ± 12.6 HU vs 59.6 ± 21.7 HU, P < 0.001). Hounsfield unit values in adenomas were significantly lower in VNC images (11.3 ± 6.5 HU vs 34.1 ± 9.1 HU, P < 0.001). CONCLUSIONS Virtual noncontrast HU values differed significantly between adrenal adenomas and metastases and can therefore be used for improved characterization of incidental adrenal lesions and definition of adrenal adenomas.

Objective This study aimed to identify the energy level of virtual monoenergetic images (VMI) that closest represents conventional images (CI) in order to demonstrate that these images provide improved image quality in terms of noise and Signal-to-noise ratio (SD/SNR) while attenuation values (HU) remain unaltered as compared to CI. Methods 60 and 30 patients with contrast-enhanced (CE) and non-enhanced (NCE) spectral detector CT (SDCT) of the abdomen were included in this retrospective, IRB-approved study. CI and VMI of 66–74 keV as well as quantitative iodine maps were reconstructed (Q-IodMap). Two regions of interest were placed in each: pulmonary trunk, abdominal aorta, portal vein, liver, pancreas, renal cortex left/right, psoas muscle, (filled) bladder and subcutaneous fat. For each reconstruction, HU and SD were averaged. ΔHU and SNR (SNR = HU/SD) were calculated. Q-IodMap were considered as confounder for ΔHU. In addition, two radiologists compared VMI of 72 keV and CI in a forced-choice approach regarding image quality. Results In NCE studies, no significant differences for any region was found. In CE studies, VMI72keV images showed lowest ΔHU (HUliver CI/VMI72keV: 104 ± 18/103 ± 17, p ≥ 0.05). Iodine containing voxels as indicated by Q-IodMap resulted in an over- and underestimation of attenuation in lower and higher VMI energies, respectively. Image noise was lower in VMI images (e.g. muscle: CI/ VMI72keV: 15.3 ± 3.3/12.3 ± 2.9 HU, p ≤ 0.05). Hence, SNR was significantly higher in VMI72keV compared to CI (e.g. liver 3.8 ± 0.6 vs 3.0 ± 0.8, p ≤ 0.05). In visual analysis, VMI72keV were preferred over CI at all times. Conclusions VMI72keV show improved SD/SNR characteristics while the attenuation remains unaltered as compared to CI.

Neck fat distribution plays an important role in aging, yet how fat distribution changes with age is largely unknown. This study used volumetric computed tomography in live patients to characterize neck fat volume and distribution in young and elderly women.A retrospective analysis was conducted of head and neck computed tomographic angiographs of 20 young (aged 20 to 35 years) and 20 old (aged 65 to 89 years) women. Fat volume in the supraplatysmal and subplatysmal planes was quantified. Distribution of fat volume was assessed by dividing each supraplatysmal and subplatysmal compartment into upper, middle, and lower thirds.Total supraplatysmal fat volume was greater than subplatysmal in all patients. Young patients had more total supraplatysmal fat than old patients (p0.0001). No difference was found between age groups in subplatysmal fat (p0.05). No difference was found between upper/middle/lower third supraplatysmal fat volumes in young patients. When comparing supraplatysmal thirds within the elderly population, the middle third fat volume (28.58 ± 20.01 cm3) was greater than both upper (18.93 ± 10.35 cm3) and lower thirds (15.46 ± 11.57 cm3) (p0.01).This study suggests that total supraplatysmal fat volume decreases with age. Older patients had more fat volume in the upper and middle thirds compared with the lower third of the supraplatysmal fat compartment, whereas young patients had more evenly distributed fat. These results suggest that fat deposition and redistribution in the neck occur with age and may be a contributing factor to the obtuse cervicomandibular angle of the elderly.

In x-ray computed tomography (CT), materials with different elemental compositions can have identical CT number values, depending on the mass density of each material and the energy of the detected x-ray beam. Differentiating and classifying different tissue types and contrast agents can thus be extremely challenging. In multienergy CT, one or more additional attenuation measurements are obtained at a second, third or more energy. This allows the differentiation of at least two materials. Commercial dual-energy CT systems (only two energy measurements) are now available either using sequential acquisitions of low- and high-tube potential scans, fast tube-potential switching, beam filtration combined with spiral scanning, dual-source, or dual-layer detector approaches. The use of energy-resolving, photon-counting detectors is now being evaluated on research systems. Irrespective of the technological approach to data acquisition, all commercial multienergy CT systems circa 2020 provide dual-energy data. Material decomposition algorithms are then used to identify specific materials according to their effective atomic number and/or to quantitate mass density. These algorithms are applied to either projection or image data. Since 2006, a number of clinical applications have been developed for commercial release, including those that automatically (a) remove the calcium signal from bony anatomy and/or calcified plaque; (b) create iodine concentration maps from contrast-enhanced CT data and/or quantify absolute iodine concentration; (c) create virtual non-contrast-enhanced images from contrast-enhanced scans; (d) identify perfused blood volume in lung parenchyma or the myocardium; and (e) characterize materials according to their elemental compositions, which can allow in vivo differentiation between uric acid and non-uric acid urinary stones or uric acid (gout) or non-uric acid (calcium pyrophosphate) deposits in articulating joints and surrounding tissues. In this report, the underlying physical principles of multienergy CT are reviewed and each of the current technical approaches are described. In addition, current and evolving clinical applications are introduced. Finally, the impact of multienergy CT technology on patient radiation dose is summarized.

Non-linear iterative reconstruction (IR) algorithms have been increasingly incorporated into clinical cardiac CT protocols at institutions around the world. Multiple IR algorithms are available commercially from various vendors. IR algorithms decrease image noise and are primarily used to enable lower radiation dose protocols. IR can also be used to improve image quality for imaging of obese patients, coronary atherosclerotic plaques, coronary stents, and myocardial perfusion. In this article, we will review the various applications of IR algorithms in cardiac imaging and evaluate how they have changed practice.

Spectral detector computed tomography (SDCT) is a novel technology that uses two layers of detectors to simultaneously collect low and high energy data. Spectral data is used to generate conventional polyenergetic images as well as dedicated spectral images including virtual monoenergetic and material composition (iodine-only, virtual unenhanced, effective atomic number) images. This paper provides an overview of SDCT technology and a description of some spectral image types. The potential utility of SDCT for cardiovascular imaging and the impact of this new technology on radiation and contrast dose are discussed through presentation of initial patient studies performed on a SDCT scanner. The value of SDCT for salvaging suboptimal studies including those with poor contrast-enhancement or beam hardening artifacts through retrospective reconstruction of spectral data is discussed. Additionally, examples of specific benefits for the evaluation of aortic disease, imaging before transcatheter aortic valve implantation, evaluation of pulmonary veins pre- and post-pulmonary radiofrequency ablation, evaluation of coronary artery lumen, assessment of myocardial perfusion, detection of pulmonary embolism, and characterization of incidental findings are presented.

Computed tomography is vulnerable to a wide variety of artifacts, including patient- and technique-specific artifacts, some of which are unique to imaging of the heart. Motion is the most common source of artifacts and can be caused by patient, cardiac, or respiratory motion. Cardiac motion artifacts can be reduced by decreasing the heart rate and variability and the duration of data acquisition; adjusting the placement of the data window within a cardiac cycle; performing single-heartbeat scanning; and using multisegment reconstruction, motion-correction algorithms, and electrocardiographic editing. Respiratory motion artifacts can be minimized with proper breath holding and shortened scan duration. Partial volume averaging is caused by the averaging of attenuation values from all tissue contained within a voxel and can be reduced by improving the spatial resolution, using a higher x-ray energy, or displaying images with a wider window width. Beam-hardening artifacts are caused by the polyenergetic nature of the x-ray beam and can be reduced by using x-ray filtration, applying higher-energy x-rays, altering patient position, modifying contrast material protocols, and applying certain reconstruction algorithms. Metal artifacts are complex and have multiple causes, including x-ray scatter, underpenetration, motion, and attenuation values that exceed the typical dynamic range of Hounsfield units. Quantum mottle or noise is caused by insufficient penetration of tissue and can be improved by increasing the tube current or peak tube potential, reconstructing thicker sections, increasing the rotation time, using appropriate patient positioning, and applying iterative reconstruction algorithms.

Advances in scanner technology enabling shorter scan times, improvements in spatial and temporal resolution, and more dose-efficient data reconstruction coupled with rapidly growing evidence from clinical trials have established computed tomography (CT) as an important imaging modality in the evaluation of cardiovascular disorders. Multienergy (or spectral or dual-energy) CT is a relatively recent advance in which attenuation data from different energies are used to characterize materials beyond what is possible at conventional CT. Current technologies for multienergy CT are either source based (ie, dual source, rapid kilovoltage switching, dual spin, and split beam) or detector based (ie, dual layer and photon counting), and material-based decomposition occurs in either image or projection space. In addition to conventional diagnostic images, multienergy CT provides image sets such as iodine maps, virtual nonenhanced, effective atomic number, and virtual monoenergy (VM) images as well as data at the elemental level (CT fingerprinting), which can complement and in some areas overcome the limitations posed by conventional CT methods. In myocardial perfusion imaging, iodine maps improve the sensitivity of perfusion defects, and VM images improve the specificity by decreasing artifacts. Iodine maps are also useful in improving the performance of CT in delayed-enhancement imaging. In pulmonary perfusion imaging, iodine maps enhance the sensitivity of detection of both acute and chronic pulmonary emboli. Low-energy (as measured in kiloelectron volts) VM images allow enhancement of vascular contrast, which can either be used to lower contrast dose or salvage a suboptimal contrast-enhanced study. High-energy VM images can be used to decrease or eliminate artifacts such as beam-hardening and metallic artifacts. Virtual nonenhanced images have similar attenuation as true nonenhanced images and help in reducing radiation dose by eliminating the need for the latter in multiphasic vascular studies. Other potential applications of multienergy CT include calcium scoring from virtual nonenhanced images created from coronary CT angiograms and myocardial iron quantification. Online supplemental material is available for this article. ©RSNA, 2017.

Transcatheter aortic valve replacement (TAVR) is performed frequently in patients with severe, symptomatic aortic stenosis who are at high risk or inoperable for open surgical aortic valve replacement. Computed tomography angiography (CTA) has become the gold standard imaging modality for pre-TAVR cardiac anatomic and vascular access assessment. Traditionally, cardiac CTA has been most frequently used for assessment of coronary artery stenosis, and scanning protocols have generally been tailored for this purpose. Pre-TAVR CTA has different goals than coronary CTA and the high prevalence of chronic kidney disease in the TAVR patient population creates a particular need to optimize protocols for a reduction in iodinated contrast volume. This document reviews details which allow the physician to tailor CTA examinations to maximize image quality and minimize harm, while factoring in multiple patient and scanner variables which must be considered in customizing a pre-TAVR protocol.

Technical specifications for multi-detector row computed tomography (CT) scanners from different manufacturers were very similar until the introduction of 64-slice scanners but then began to diverge with fundamental differences in the number of X-ray sources, detector geometry, gantry rotation time, and reconstruction algorithms. These hardware and software advancements were largely driven by clinical requirements for cardiac CT. This article provides an overview of technologies available on state-of-the-art CT systems and the clinical needs they seek to address.

Physician certification is critical in all areas of cardiovascular imaging to assure optimal performance and interpretation of quality studies for patient diagnosis and management. This is especially important in the field of cardiovascular computed tomography where practitioners have varied training and expertise that may not cover the full range of skills in the technical, image interpretative and clinical application of the results for patient management. The Certification Board of Cardiovascular Computed Tomography was developed to test the minimal level of competence of physicians performing cardiovascular computed tomography. In this article, the process of defining the content areas, determining candidate eligibility and the process of examination development and testing will be defined.

This work evaluated the performance of a detector-based spectral CT system by obtaining objective reference data, evaluating attenuation response of iodine and accuracy of iodine quantification, and comparing conventional CT and virtual monoenergetic images in three common phantoms. Scanning was performed using the hospital's clinical adult body protocol. Modulation transfer function (MTF) was calculated for a tungsten wire and visual line pair targets were evaluated. Image noise power spectrum (NPS) and pixel standard deviation were calculated. MTF for monoenergetic images agreed with conventional images within 0.05 lp cm−1. NPS curves indicated that noise texture of 70 keV monoenergetic images is similar to conventional images. Standard deviation measurements showed monoenergetic images have lower noise except at 40 keV. Mean CT number and CNR agreed with conventional images at 75 keV. Measured iodine concentration agreed with true concentration within 6% for inserts at the center of the phantom. Performance of monoenergetic images at detector based spectral CT is the same as, or better than, that of conventional images. Spectral acquisition and reconstruction with a detector based platform represents the physical behaviour of iodine as expected and accurately quantifies the material concentration.

To establish current radiation dose levels with contemporary scanners capable of prospectively triggered or high-pitch spiral scan modes to previous generation scanners among patients evaluated for coronary artery disease, pulmonary embolism, aortic disease, and "triple rule out" in a large population of patients at multiple centers.Previous small-scale studies with carefully controlled scan protocols report that CT scanners that facilitate prospectively triggered scanning and provide high-pitch spiral CT scan modes drastically lower radiation doses. However, diagnostic reference levels should be selected by medical bodies on the basis of large surveys of representative sites and reviewed at appropriate time intervals.Scan data including dose and image quality parameters were collected retrospectively from 64 slice scanners (control) and prospectively after sites installed 128-slice dual-source scanners with high-pitch capability (study). Protocol selection was purposely not specified to survey "real world" results. Blinded quantitative image analysis was performed on every fifth scan.From April 2011 to March 2012, 2085 patients at 9 sites completed the study: 1051 coronary artery disease (509 control, 542 study), 528 pulmonary embolism (267 control, 261 study), 419 aortic disease (268 control, 151 study), and 87 triple rule out (53 control, 34 study). There was a significant reduction in median dose-length product (DLP) from 669 mGy ∙ cm (interquartile range [IQR]: 419-1026 mGy ∙ cm) in the control group to 260 mGy ∙ cm (IQR: 159-441 mGy ∙ cm) in the study group, a reduction by 61% (P.0001) and was lower in all categories. No significant differences were noted in image quality.Use of advanced scanners facilitating prospectively triggered or high-pitch spiral scan modes results in marked dose reduction across a variety of cardiovascular studies, with no compromise in image quality. These findings may contribute to new target dose recommendations in societal guidelines.

Purpose: To evaluate the attenuation response of iodine and the accuracy of iodine quantification on a detector-based spectral CT scanner. Methods: A Gammex 461A phantom was scanned using a dual-layer detector (IQon, Philips) at 120 kVp using helical acquisition with a CDTIvol of 15 mGy to approximate the hospital's clinical body protocol. No modifications to the standard protocol were necessary to enable spectral imaging. Iodine inserts at 6 concentrations (2, 5, 7.5, 10, 15, 20 mg/ml) were scanned individually at the center of the phantom and the 20 mg/ml insert was additionally scanned at the 3, 6, and 12 o'clock positions. Scans were repeated 10 times. Conventional, virtual monoenergetic (40–200 keV) and iodine-no-water images (with pixel values equal to iodine concentration of corresponding tissue) were reconstructed from acquired data. A circular ROI (diameter=30 pixels) was used in each conventional and monoenergetic image to measure the mean and standard deviation of the CT number in HU and in each iodine-no-water image to measure iodine concentration in mg/ml. Results: Mean CT number and contrast-to-noise ratio (CNR) measured from monoenergetic images increased with decreasing keV for all iodine concentrations and matched measurements from conventional images at 75 keV. Measurements from the 20 ml insert showed the CT number is independent of location and CNR is a function only of noise, which was higher in the center. Measured concentration from iodine-no-water images matched phantom manufacturer suggested concentration to within 6% on average for inserts at the center of the phantom. Measured concentrations were systematically higher due to optimization of iodine quantification parameters for clinical mixtures of iodine and blood/tissue. Conclusion: Spectral acquisition and reconstruction with a dual-layer detector represents the physical behavior of iodine as expected and accurately quantifies the material concentration. This should permit a variety of clinical applications including lesion characterization, vessel patency, and myocardial perfusion. This study was performed as part of a research agreement among Philips Healthcare, University Hospitals of Cleveland, and Case Western Reserve University.

Purpose: To obtain objective reference data for the spectral performance on a dual-layer detector CT platform (IQon, Philips) and compare virtual monoenergetic to conventional CT images. Methods: Scanning was performed using the hospital's clinical adult body protocol: helical acquisition at 120kVp, with CTDIvol=15mGy. Multiple modules (591, 515, 528) of a CATPHAN 600 phantom and a 20 cm diameter cylindrical water phantom were scanned. No modifications to the standard protocol were necessary to enable spectral imaging. Both conventional and virtual monoenergetic images were generated from acquired data. Noise characteristics were assessed through Noise Power Spectra (NPS) and pixel standard deviation from water phantom images. Spatial resolution was evaluated using Modulation Transfer Functions (MTF) of a tungsten wire as well as resolution bars. Low-contrast detectability was studied using contrast-to-noise ratio (CNR) of a low contrast object. Results: MTF curves of monoenergetic and conventional images were almost identical. MTF 50%, 10%, and 5% levels for monoenergetic images agreed with conventional images within 0.05lp/cm. These observations were verified by the resolution bars, which were clearly resolved at 7lp/cm but started blurring at 8lp/cm for this protocol in both conventional and 70 keV images. NPS curves indicated that, compared to conventional images, the noise power distribution of 70 keV monoenergetic images is similar (i.e. noise texture is similar) but exhibit a low frequency peak at keVs higher and lower than 70 keV. Standard deviation measurements show monoenergetic images have lower noise except at 40 keV where it is slightly higher. CNR of monoenergetic images is mostly flat across keV values and is superior to that of conventional images. Conclusion: Values for standard image quality metrics are the same or better for monoenergetic images compared to conventional images. Results indicate virtual monoenergetic images can be used without any loss in image quality or noise penalties relative to conventional images. This study was performed as part of a research agreement among Philips Healthcare, University Hospitals of Cleveland, and Case Western Reserve University.