Patient positioning and centering in CT

Etienne Grech CT Unit, Mater Dei Hospital.

Aim of presentation
To differentiate between the term positioning and centering. To determine the effects on patient dose and image quality of improper centering and positioning.

Radiation dose & reduction techniques

Radiation doses in CT range between 124mSv for adults and 2 to 6.5mSv. Heightened concerns and awareness of radiation induced cancer from CT prompted to the development of strategies and techniques for dose reduction. In order to obtain appropriate benefits from these techniques, it is important to appropriately centre/position patients to the isocenter of the gantry.

Positioning and centering

Positioning: the proper placement of the patient on the CT table in the zaxis or along the length of patient for scanning an anatomical region. Centering: the appropriate placement of the patient with respect to the gantry isocenter in the x-y plane.

Patient positioning
Improper positioning: may result in the acquisition of a reference radiograph beyond the ROI and/or require a repeat of the latter.

Positioning

cont.

Proper positioning in head examinations is important so as to adequately ensure the reproduction of any asymmetry due to any pathological process. Avoiding the eyes by depressing the patients chin may reduce lens dose.

Improper positioning cont.

Navasivayam et al., (2006) have reported that up to 13cm are sometimes exposed unintentionally in reference radiographs due to inadequate positioning. Increase in radiation dose due to improper placement of the upper limb in systems using tube current modulation (up to 45% higher). Degradation in image quality usually occurs.

What is tube current modulation??????????

Automatic tube current adjustment along the x-y axis (angular) and z-axis (or both) according to patient thickness. Philips uses DoseRight-consists of two types of modulations ACS and DOM. ACS uses a reference radiograph to asses the patients attenuation. It suggests the lowest mA to maintain adequate image quality. mA is set so that 90% of images will have noise levels equal to or higher than that of a reference image.

Tube current modulation

cont.

D-DOM provides angular modulation. Z-DOM modulates mA in the z-axis

Reasons for off centering

Awareness/attention: lack of education, increase in workload etc. Kalra et al., (2008) demonstrated that in 240 patients, mean mis-positioning averaged 33mm in 95% of patients (range 5.1-97mm). Adjustment of DFOV: acquisition of reference radiographs at different planes. Patient related factors: physical abnormalities, obese individuals etc.

Off centering: effect on scout data

Inappropriate centering effects size of reference radiographs. Magnification or reduction of the latter accompanies mis-operation of DOM. The latter leads to erroneous calculations for mA settings

Magnification and off centering

Effects of off centering

CT uses a bow tie filter to shape Xray beam to the body, i.e. restrict photons at the periphery (areas with less attenuation) and allow more photons to pass trough the central portions i.e. those with greater attenuation and contribution to image noise.

Off centering and bow tie filters

Shaping the radiation beam allows for: 1)A reduction in scattered radiation from peripheral object zones. 2)Reduce patient dose. 3) Improve image quality.

Effects of off centering cont.

BF presumes that the centre of the body is at the isocenter. If the patient is off centre, portions of the body other than the peripheral portions receive fewer photon. Increase in image noise and radiation dose to peripheries.

 With correct centering, more photons (X+++) traverse the thicker central parts, resulting in adequate image noise and radiation dose.

 More photon (X+++) passing through peripheral parts, increase noise centrally and dose peripherally.

Effects of off centering cont.

Phantom studies have shown a 50% increase in surface and peripheral doses (12%-18%@30mm.41%-50%@60mm). Actual patients: 2%-30% (older study). Organs mostly at risk: breast, eye lens, thyroid. Such phenomena are more common when using lower mA, for example when imaging children. Such phenomena are more common when using lower mA, for example when imaging children.

Off centering and image quality

Difference in image noise @30mm (left) and 60mm (right).

Effect on image quality

Conclusion
Radiographers must pay attention whilst position/centering. Patients arms should elevated on top of the head. When not possible improvised arrangements should be made. Radiographers are directly responsible for patient doseso think before you act!