Medical Physics

Cynthia H. McCollough,
PhD
Michael R. Bruesewitz,
RT(R)
Terri J. Vrtiska, MD
Bernard F. King, MD
Andrew J. LeRoy, MD
Jeffrey P. Quam, MD
Robert R. Hattery, MD

Index terms:
Computed tomography (CT),
technology, 80.12115
Radiography, technology, 80.1215
Screens and films, 80.1215
Urography, technology, 80.12115,
80.1215
Published online before print
10.1148/radiol.2212000784
Radiology 2001; 221:395 403
Abbreviations:
CR computed radiography
ESE entrance skin exposure
CT SPR CT scanned projection
radiography
S-F screen-film radiography
1

From the Department of Radiology,

E2-A, Mayo Clinic and Foundation, 200
First St SW, Rochester, MN 55905. Received April 7, 2000; revision requested
June 1; revision received May 2, 2001;
accepted May 15. Address correspondence to C.H.M. (e-mail: mccollough
.cynthia@mayo.edu).

RSNA, 2001

Image Quality and Dose

Comparison among
Screen-Film, Computed,
and CT Scanned Projection
Radiography: Applications
to CT Urography1
PURPOSE: To evaluate image quality and dose for abdominal imaging techniques
that could be used as part of a computed tomographic (CT) urographic examination: screen-film (S-F) radiography or computed radiography (CR), performed with
moving and stationary grids, and CT scanned projection radiography (CT SPR).
MATERIALS AND METHODS: An image quality phantom underwent imaging
with moving and stationary grids with both a clinical S-F combination and CR plate.
CT SPR was performed with six CT scanners at various milliampere second and
kilovolt peak settings. Entrance skin exposure (ESE); spatial, contrast, and temporal
resolutions; geometric accuracy; and artifacts were assessed.
RESULTS: S-F or CR images, with either grid, provided image quality equivalent to
that with the clinical standard, S-F with a moving grid. ESE values for both S-F and
CR were 435 mR (112.2 C/kg [1 mR 0.258 C/kg]) with a moving grid and 226
mR (58.3 C/kg) with a stationary grid. All CT SPR images provided inferior spatial
resolution compared with S-F or CR images. High-contrast objects generated substantial artifacts on CT SPR images. Compared with S-F, CR and CT SPR provided
improved resolution of small low-contrast objects. The contrast between iodine and
soft-tissuemimicking structures on CT SPR images acquired at 80 kVp was twice
that at 120 kVp. CT SPR images with acceptable noise levels required a midline ESE
value of approximately 300 mR (77.4 C/kg) at 80 kVp.
CONCLUSION: S-F and CR provided better spatial resolution than did CT SPR.
However, CT SPR provided improved low-contrast resolution compared with S-F, at
exposures comparable to those used for S-F or CR.

Author contributions:
Guarantors of integrity of entire study,
all authors; study concepts, C.H.M.,
A.J.L., B.F.K., T.J.V., R.R.H.; study design,
C.H.M.; literature research, C.H.M.,
T.J.V.; clinical studies, A.J.L., B.F.K.;
experimental studies, C.H.M., M.R.B.;
data acquisition and analysis, C.H.M.,
M.R.B.; statistical analysis, C.H.M.;
manuscript preparation, C.H.M.; definition of intellectual content, C.H.M.;
manuscript editing, C.H.M., B.F.K.;
manuscript review and final version approval, all authors.

Computed tomographic (CT) urography is a developing concept that combines portions of

intravenous urography and CT into one examination, hence requiring only a single dose
of intravenously administered iodinated contrast media. Intravenous urography and CT
each have strengths and weaknesses in the evaluation of the urinary tract. CT is superior
for the detection of urinary stone disease (1 4) and for the evaluation of the renal
parenchyma and adjacent structures and organs (5). Intravenous urography is better for
evaluating the pyelocalyceal collecting system and ureters, because of the superior spatial
resolution of radiography (4 line pairs per millimeter for screen-film radiography [S-F])
compared with that of CT (0.7 line pairs per millimeter for abdominal CT). Specifically,
intravenous urography is considered superior for the delineation of calyceal and papillary
anatomy, collecting ducts, mucosal detail, and small filling defects. In our experience, we
have found that 10% of urinary tract abnormalities were depicted more clearly or appreciated only on S-F urographic images when compared with CT cross-sectional images.
Hence, by combining the strengths of each study into one CT urographic examination, the
urinary tract can be evaluated more thoroughly in a single session.
395

Many different approaches are used in

CT urography (6). Perlman et al (7) advocate the acquisition of intravenous urographic images in a urography suite, followed by patient transfer to a CT suite for
the CT portion of the examination. In
other centers, the CT cross-sectional images are acquired first and then the patient walks to the urography suite to
complete the radiographic portion of the
study. Movement of the patient between
procedure rooms requires additional time,
can cause scheduling complications, and
may affect the level of pyelocalyceal distention in the second portion of the examination.
An alternative to this approach, which
was recently implemented at our center,
is the acquisition of abdominal radiographs with an overhead x-ray tube while
the patient is lying on the CT table (8).
This method allows high-spatial-resolution intravenous urography to be performed at various times during the CT
examination without the need for the
patient to move. The technique requires
the use of an auxiliary CT tabletop that
can accommodate an S-F or computed
radiography (CR) cassette under the patient without introducing artifacts on the
CT image (9). Because such a tabletop
cannot include the metal components
needed to operate a moving grid (ie, a
table bucky), a stationary grid with a high
line density must be slipped over the cassette.
As another alternative, other authors
(10) performed the entire CT urographic
study with the patient lying on the CT
table, with use of the CT scanned projection radiographic (CT SPR) image (localization image) for the abdominal radiographs. This method also optimizes
examination timing and pyelocalyceal
distention, but it may be limited by the
relatively poor limiting spatial resolution
of CT SPR images (1 line pair per millimeter). Another alternative in the literature, which was not addressed in this
study, is reconstruction of coronal maximum or minimum intensity projection
images or curved planar reformation images of the collecting system from the CT
data.
Despite the interest in these various
approaches to CT urography, to our
knowledge, few studies have been published that compare the image quality,
radiation dose, or ability to depict subtle
urothelial abnormalities of these various
alternatives. The purpose of this study
was to compare image quality and dose
among three techniques: (a) S-F or CR
performed with the patient in a separate
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November 2001

Figure 1. Photograph of image quality phantom and test objects.

The phantom contains three stacked slabs whose total attenuation
simulates a 21-cm-thick patient. The image quality test objects, embedded in the central acrylic slab of the phantom, are shown in the
foreground, leaning against the stacked phantom.

radiography room with use of a moving

grid (table bucky), (b) S-F or CR performed with the patient lying on the CT
table with use of a stationary (slip-on)
grid, and (c) CT SPR performed with the
patient lying on the CT table. Future
work, which is beyond the scope of this
article, will address the clinical performance of these methods.

MATERIALS AND METHODS

Image Quality Phantom
The image quality phantom used in
this study was designed and constructed
at our institution. The attenuation approximated that of a 21-cm-thick patient. The various test objects embedded
in the center slab of the phantom are
shown in Figure 1. The objects included
bone fragments, catheters, an aluminum
ramp, plastic and acrylic beads of assorted sizes, steel wool, wire mesh, and
0.1-mm-thick lead resolution targets. To
simulate low to medium levels of iodine
contrast (atomic number, 53; k edge, 33.2
keV), 0.5-inch (1.27 cm)-diameter disks
of 99.7% pure tin (atomic number, 50; k
edge, 29.2 keV) were added to the phantom. Varying contrast levels were obtained by stacking one to five of these
0.0125-mm-thick tin disks. Radiographs
of the test objects are shown in Figure 2.

S-F and CR Techniques

S-F and CR images were obtained
(M.R.B.) with both moving and stationary grids with use of our clinical S-F combination and film processor (Insight film,
Min R Medium front screen, Lanex Me-

dium back screen, M8 processor; Eastman Kodak, Rochester, NY) and clinical
CR system (STVA phosphor plate, IP 3
cassette, FCR AC-3CS-ID reader, FL-IMD
printer; Fuji Medical Systems, Stamford,
Conn). The grid ratio and line density of
the moving grid, which was within the
table bucky holder, were 16:1 and 85
lines per inch (33.5 lines per centimeter),
respectively. The grid ratio and line density of the stationary grid, which was
slipped over the cassette, were 8:1 and
152 lines per inch (59.8 lines per centimeter), respectively. Clinical technique
factors for a 21-cm-thick patient were
used for both S-F and CR with the table
bucky (40-inch [101.6 cm] source-to-image distance, small focal spot [0.6 mm],
69 kVp, 300 mA, 0.16-second exposure).
Images of the 21-cm-thick phantom were
acquired with use of the stationary grid
slipped over an S-F or CR cassette, as both
lay on a urography table, with use of a
lower technique factor (36-inch [91.4 cm]
source-to-image distance, small focal spot
[0.6 mm], 69 kVp, 300 mA, 0.08-second
exposure) to match the optical density
with that on images acquired with the table bucky.

CT Systems Studied
Six CT systems (A to F) were used to
perform CT SPR (localization or scout imaging) (M.R.B., C.H.M.). The following
CT scanners were used in this study: system A, multi detector row spiral CT,
model QX/i, GE Medical Systems, Milwaukee, Wis; system B, single detector
row spiral CT, model CT/i, GE Medical
Systems; system C, single detector row
McCollough et al

smooth). All CT SPR images were obtained with the phantom height centered
at scanner isocenter. The resultant digital
CT SPR images were displayed and hardcopy images printed with the appropriate
window and level settings.

Exposure Measurements
Entrance skin exposure (ESE) was measured (M.R.B., C.H.M.) for all images with
use of an ionization chamber and electrometer (model 10 5-6 chamber and
MDH model 1015 electrometer; Radcal,
Monrovia, Calif). The chamber was positioned at the upper left corner of the
image quality phantom.

Iodine-Contrast Measurements
Image brightness of the iodine-mimicking tin disks and the uniform background material, which was acrylic, were
measured (M.R.B., C.H.M.) with use of an
optical densitometer on the S-F and CR
images and by using digital region-of-interest measurements on the CT SPR images. On S-F and CR images, multiple
measurements were made over the images of the tin disks to estimate an average optical density value. On CT SPR images, the diameter of the circular region
of interest was about 0.6 of the total disk
diameter to avoid measuring the edgeenhanced region of the disks. The area
within the region of interest was 60 mm2.
Figure 2. Anteroposterior S-F and CR images of the image quality phantom. (a) S-F image
obtained with moving grid (table bucky). 1 ion chamber, 2 lead numbers, 3 bone pieces,
4 wire mesh, 5 five tin disks, 6 lead resolution targets, 7 double-looped object, 8
low-contrast beads, 9 steel wool, 10 catheters. (b) S-F image obtained with stationary grid
(slipped over the cassette). (c) CR image obtained with moving grid. (d) CR image obtained with
stationary grid. Images b d were judged to have the same image quality (based on iodine
contrast, spatial resolution, low-contrast resolution, and lack of appearance of grid lines) as our
clinical standard, image a. In ad, A anode, C cathode.

spiral CT, model HiSpeed/RP, GE Medical

Systems; system D, nonspiral CT, model
9800, GE Medical Systems; system E,
electron-beam CT, model C150-XLPHRD, Imatron, South San Francisco, Calif; system F, single detector row spiral
CT, model PQ6000, Picker International
(now Marconi Medical Systems), Highland Heights, Ohio.

CT Acquisition Techniques
To optimize iodine contrast, or visualization of calcified ureteral stones (10),
x-ray tube potential levels should range
from 60 to 90 kVp. Thus, CT SPR was
performed at both the routine and the
lowest kilovolt peak settings available on
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each system (systems A to D, 120 and 80

kVp, respectively; systems E and F, only
130 kVp available). For all the CT systems, exposure times in the CT SPR mode
cannot be selected directly; rather, they
are a function of table speed. Only system D provided a choice of table speed
(slow or fast), and the fast option was
used to allow scanning of the full z-axis
length of the phantom (430 mm). Except
for system E, in which the tube current
was fixed at 620 mA, tube currents between 10 and 400 mA were used to obtain a distribution of radiation dose and
image noise levels. None of the CT systems allowed the user to choose postprocessing image algorithms (eg, sharp or

Artifacts and Spatial, or

High-Contrast, Resolution
Spatial, or high-contrast, resolution
was determined by means of visual inspection (C.H.M., M.R.B., T.J.V., B.F.K.,
A.J.L.) of the lead resolution targets and
bone and steel wool test objects in the
phantom. The limiting spatial resolution,
or the spatial frequency of the bar pattern
at which the bars and space become
blurred, was determined by consensus. A
consensus forced-choice rating better
than, same as, or worse than the S-F image acquired with the moving grid of
the clarity of the fine structures of the
steel wool test object was also performed
(C.H.M., M.R.B., T.J.V., A.J.L.). The presence or absence of artifacts (streaks, dark
or white banding of objects, signal intensity of any type not present on the S-F
image acquired with the moving grid)
was noted for all images (C.H.M., M.R.B.,
T.J.V., B.F.K., A.J.L.).

Low-Contrast Resolution
Visual assessment of low-contrast resolution was performed by five experienced
Image Quality and Dose Comparison

397

radiologists (T.J.V., B.F.K., A.J.L., J.P.Q.,

R.R.H.), who were blinded to the data
acquisition system. Because the edge-enhanced appearance of high-contrast
structures immediately identified which
images were CT SPR images, all portions
of the images were covered except for a
triangular section that contained the
small low-contrast plastic beads. A consensus forced-choice rating of the appearance of the beads and double-looped object was selected from the following
options: better than, same as, or worse
than the S-F image acquired with the
moving grid.

Temporal Resolution
Temporal resolution for S-F and CR
was determined on the basis of the exposure time used. For CT SPR, the total exposure time was measured with a stopwatch (M.R.B.). The total time was the
time required to sequentially scan a
length of 430 mm. The actual time required to image one region of the phantom object (eg, a 10-mm-long object
along the z axis) was the total scanning
time multiplied by the region length (in
millimeters) divided by 430 mm. This
time to scan a small section of the phantom, which was arbitrarily chosen to be
10 mm, was computed as an indicator of
the amount of motion blur that might be
expected over a small region of the CT
SPR image.

Geometric Accuracy
Geometric accuracy was determined by
measuring (M.R.B.) the vertical (z axis,
craniocaudal), horizontal (left to right),
and diagonal dimensions of the three targets. Measurements were made with rulers on S-F and CR images, and the values
were corrected for image magnification.
Digital calipers were used to measure
these same distances on CT SPR images.

Clinical CT SPR Abdominal

Imaging
Institutional review board approval
was obtained for the comparison between CT SPR and S-F images acquired in
patients who were lying on the CT table
as part of the clinical CT urographic examination at our center. The study was
deemed minimal risk, as the lower-dose
CT SPR images were substituted for the
higher dose tomographic images from
the preempted intravenous urographic
examination; hence, informed consent
was not required. CT SPR images were
acquired at various times after intrave398

Radiology

November 2001

TABLE 1
S-F and CR Contrast Resolution
S-F
Optical Density
Background
Difference between
disks 1 and 5*

CR

Moving Grid
(table bucky)

Stationary Grid
(slip on)

Moving Grid
(table bucky)

Stationary Grid
(slip on)

1.33 0.01

1.55 0.02

1.11 0.01

1.10 0.03

0.30

0.31

0.32

0.32

* Higher values indicate better contrast resolution.

nous injection of contrast media (Isovue300; Bracco Diagnostics, Princeton, NJ).

CT SPR acquisitions were intermixed
with either CT cross-sectional imaging or
S-F radiography.

RESULTS
S-F versus CR and Moving versus
Stationary Grids
Image quality.S-F and CR images obtained with the use of a moving grid in
the table bucky and a slip-on stationary
grid on the tabletop are shown in Figure
2. On the basis of the parameters of iodine contrast, spatial resolution, lowcontrast resolution, and lack of appearance of grid lines, all the images were
judged, by consensus, to have the same
image quality as the clinical standard, the
S-F image obtained with a moving grid.
Images obtained when the motion of the
table bucky grid was stopped were completely unacceptable owing to the visibility of grid lines throughout the image
and are not shown in this article.
Radiation exposure.The use of identical imaging technique factors ensured
that the ESE levels for S-F and CR were
identical for a given grid choice (435 mR
[112.2 C/kg] with the moving grid and
226 mR [58.3 C/kg] with the stationary
grid). Although CR images with acceptable optical density could have been produced with many different technique
factors, we found that optimal image
quality, or no increase in image noise,
required the use of essentially the same
factors as were used for conventional radiographs. A lower ESE value (226 mR
[58.3 C/kg]) was measured for acquisitions with the slip-on grid because of two
factors: a shorter source-to-image distance and a lower grid ratio.
Iodine contrast.As shown in Table 1,
the background optical densities were
well matched between the two grid types,
although there was a very small (0.3
optical density units) decrease in optical
density on the CR images compared with

the S-F images. The iodine contrast values for each acquisition mode, based on
the optical density difference between
disks 1 and 5, were essentially identical.

CT SPR Images
Image quality.The CT SPR image with
the highest image quality obtained from
each CT system is shown in Figure 3.
Image quality was assessed qualitatively,
by consensus rating of low- and highcontrast resolution and the absence or
presence of artifacts, and quantitatively,
on the basis of iodine contrast and limiting spatial resolution. For all scanners,
the best CT SPR image was obtained with
the lowest kilovolt peak setting and highest milliampere setting, as these conditions maximize iodine contrast and minimize image noise.
The pixel values on a CT SPR image are
not reported in CT numbers (Hounsfield
units) but rather represent relative
brightness. Unlike CT numbers, CT SPR
brightness does not have a defined absolute scale, so the window and level values
required for optimal visualization of a
given material thickness varied substantially. This is indicated by the range of
optimal window and level settings used
for the different systems (Fig 3). The window and level settings were different for
scanners from different manufacturers,
but they were comparable for systems
AD, which were made by the same manufacturer.
Radiation exposure.On the basis of the
ESE values measured on images obtained
with various kilovolt peak and milliampere settings, the average ratio of ESE to
tube current (in milliroentgen per milliampere [to convert from milliroentgen to
microcoulombs per kilogram, multiply
by 0.258]) was determined for CT systems AF (Table 2). The ratios of ESE to
tube current for scanner A (multi detector row CT scanner) were found to be
approximately eight times higher than
those for scanners BD (single detector
McCollough et al

Figure 3. CT SPR image with the best quality

(anteroposterior orientation except for posteroanterior with system F) obtained with CT systems
AF. (a) System A, 80 kVp, 400 mA; window width,
400; window level, 40; 888 788 matrix. (b) System B: 80 kVp, 400 mA; window width, 400; window level, 40; 512 424 matrix. (c) System C: 80
kVp, 400 mA; window width, 400; window level,
20; 512 424 matrix. (d) System D: 120 kVp, 200
mA; window width, 400; window level, 20; 75
mm/sec table speed. (e) System E: 130 kVp, 620
mA; window width, 914; window level, 610.
(f) System F: 130 kVp, 150 mA; window width,
800; window level, 500. Window width and level
settings were individually adjusted for optimal image display. Only system A was judged to have
sufficient exposure levels at 80 kVp (which provided optimal iodine contrast), although the general appearance was similar to that with systems
BD. Numerous artifacts are apparent with system
D owing to tape, spilled contrast material, and
other debris on the CT tabletop. System E showed
horizontal banding and was particularly grainy.
System F had vertical and horizontal ringing from
high-contrast objects, as opposed to the circular
banding artifact common to systems AE.

row scanners), which were all from the

same manufacturer. This is because CT
SPR images have optimal z-axis resolution if they are acquired with the narrowest beam collimation, which is approximately 1.0 1.5 mm for single detector
row scanners and approximately 8 mm
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for multi detector row scanners (11).

The wider x-ray beam causes the ratio of
ESE to tube current to be approximately
eight times higher for the multi detector
row CT scanner. Despite the wider beam
collimation with the multi detector row
scanners, the z-axis resolution is not

compromised because the detector width

of each of the four z-axis detectors is 1.25
mm (11).
The ESE values were determined at the
upper left corner of the image quality
phantom, near the bone test object. With
conventional CT systems, however, the
use of a bow-tie filter between the x-ray
tube and the patient causes the radiation
exposure to increase strongly from the
edge to center positions (along the leftto-right axis) (12). This is not true with
electron-beam CT systems, which do not
use a bow-tie filter. Depending on the
bow-tie filter, the exposure at the edge of
the phantom can be as much as six times
lower than that at the center.
Maximum and suggested ESE values.
Table 2 also lists the maximum tube current available for the acquisition of CT
SPR images, which, when used in conjunction with the ratio of ESE to tube
current, determines the maximum patient ESE values at a given kilovolt peak
setting. Evaluation of the phantom images obtained with various milliampere
values showed that ESE values greater
than 150 mR (38.7 C/kg) at the phantom edge were preferred to avoid a CT
SPR image with a grainy appearance. Images acquired with ESE values of approximately 100 mR (25.8 C/kg) at the
phantom edge showed acceptable lowcontrast resolution but were noticeably
grainy. Images acquired with ESE values
less than 70 mR (18.1 C/kg) at the phantom edge were deemed unacceptable.
Thus, only system A provided sufficient
ESE levels at 80 kVp. Systems BD and F
Image Quality and Dose Comparison

399

provided barely sufficient ESE levels at

120 or 130 kVp for the 21-cm-thick patient-equivalent phantom; thus, the
maximum exposure values would likely
be insufficient for larger patients. Furthermore, the use of higher kilovolt peak
settings decreases the contrast between
iodine or calcium and soft tissue.
Iodine contrast at 120 versus 80 kVp.The
difference in iodine, or tin, contrast on CT
SPR images obtained with typical tube potential values (120 or 130 kVp) compared
with a lower tube potential value (80 kVp,
which was available on only systems AD)
is given in Table 3. At 80 kVp, the contrast
for the tin disks was twice that at 120 kVp,
although background noise at 80 kVp was
also about twice that at 120 kVp for the
same milliampere setting. Although the
data shown in Table 3 are from only system B, the same results were observed for
systems A and C. The 80-kVp setting was
not tested on system D, because that setting was not calibrated at the time of data
acquisition (80 kVp is not used clinically
on that system).
CT tabletop artifacts.Because CT SPR
images are formed by transmitting x rays
through the patient and CT tabletop, care
must be taken to ensure tabletop cleanliness. As in radiography, artifacts can be
created by debris or spilled contrast media
or by gouges or cracks in the tabletop or
tabletop padding. Examples of such artifacts are shown in Figure 3, D. Because
system D was used for only CT of the head,
these undesirable artifacts were not detected during routine use of the scanner.
Edge-enhancement artifacts.The edgeenhancement image processing used by
the manufacturers for CT SPR images is
apparent in Figure 3. The processing created the dark banding apparent around
high-contrast (white) structures, such as
the lead letters that identify the mesh
patterns. This ringing of areas with high
contrast completely obscured the lead
septa in the resolution test patterns,
which apparently severely limited spatial
resolution. The algorithms used with systems AE produced similar results, but
the algorithm used with system F produced more horizontal and vertical,
rather than concentric, artifacts. The images obtained with system F also appeared substantially blurrier than those
obtained with systems AE.

S-F, CR, and CT SPR Findings

Spatial resolution.Because the conventional test objects for spatial resolution
(lead resolution targets) were overly attenuating with the CT systems and created
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November 2001

TABLE 2
Ratio of ESE to Tube Current for CT SPR Images Acquired at Various Settings
Kilovolt Peak Setting (kVp)
CT System

80

120

130

Maximum Tube
Current (mA)

A
B
C
D
E
F

0.48
0.06
0.05
NA*
NA
NA

1.74
0.22
0.19
0.12
NA
NA

NA
NA
NA
NA
0.13
0.56

440
400
400
200
620
150

Note.Data are in milliroentgen per milliampere. NA not available.

* An 80 kVp setting is available on system D but was not calibrated for use.

TABLE 3
Contrast Resolution at 120 versus 80 kVp for CT System B
Pixel Data

120 kVp, 400 mA

80 kVp, 400 mA

Background brightness
Background noise
Digital brightness difference
between disks 1 and 5*

32.48 1.79
1.78

88.70 0.90
3.59

16.13

32.20

Note.Data are in pixel brightness values.

* Higher values indicate better contrast resolution.

substantial artifacts, we imaged acrylic resolution targets to allow quantification of

the spatial resolution of the CT SPR images.
Also, the steel wool and bone test objects
were used as indicators of the spatial resolution of the CT SPR images. By looking at
the bone and steel wool, we could see that
the CT SPR images had substantially inferior spatial resolution compared with the
S-F or CR images. This subjective finding is
in agreement with the quantitative assessment (Table 4). However, the relatively
good image quality of the clinical CT SPR
abdominal images (Fig 4) demonstrated
that this loss of spatial resolution did not
necessarily make the CT SPR images unacceptable for clinical use.
Low-contrast resolution.Figure 5 shows
only the low-contrast portion of the phantom images shown in Figures 2 and 3.
Without the distraction of the artifacts
from high-contrast test objects, it is difficult to differentiate the CT SPR images
from the S-F and CR images. When only
these portions were compared, the consensus judgement of five radiologists was that
the low-contrast resolution of the best CT
SPR image (system A, 80 kVp, ESE of 150
mR [38.7 C/kg]) was better than that of
the S-F and CR images. In addition, the CR
images were judged by consensus to be superior to the S-F images, with improved
visual perception of small low-contrast objects. This improvement was likely due to
the edge-enhancement algorithms used on
the digital CT SPR and CR images.

Temporal resolution.The exposure

time for the S-F and CR images made
with the table bucky was 0.16 second.
The exposure time for the S-F and CR
images made with the slip-on grid was
0.08 second. The total CT SPR acquisition
times were 4.4 seconds for system A, 5.8
seconds for systems B and C, 6.3 seconds
for system D, 16.1 seconds for system E,
and 4.3 seconds for system F. Thus, the
temporal resolution of S-F or CR images
appeared substantially better. However,
because CT SPR images are formed with
temporal scanning of a 1 8-mm-wide
(along the z axis) x-ray beam, any given
portion of the phantom or patient is exposed for a time substantially shorter
than the total CT SPR acquisition time.
The scanning times of 4.3 6.3 seconds
were used to scan a length of 430 mm.
Thus, for a 10-mm-long object, the temporal resolution would be approximately
0.01 0.15 second, which is comparable
to that with S-F and CR.
Geometric accuracy.Distance measurements along three orientations (z axis,
left to right, and diagonal) were within
0.2 mm of the expected values for the S-F,
CR, and CT SPR images when the S-F and
CR magnification levels were determined
at the plane of the test objects and the CT
SPR images were acquired with the test
objects at isocenter. Because of the divergence of the x-ray beam, all radiographic
images are subject to some level of geometric distortion, which is caused by the
McCollough et al

TABLE 4
Spatial Resolution
Measure of
Spatial Resolution
Limiting spatial
resolution (line
pairs per
millimeter)*
Clarity of steel wool
test object

S-F

CR

CT SPR by System

Moving Grid

Stationary Grid

Moving Grid

Stationary Grid

4.6

4.6

3.1

3.1

0.7

0.7

0.7

0.8

0.5

0.5

Same

Same

Same

Same

Worse

Worse

Worse

Worse

Worse

Worse

* Higher values indicate better spatial resolution.

Compared with S-F radiograph acquired with the moving grid.

center because the craniocaudal and leftto-right dimensions of the objects have
different magnification levels.

Clinical CT SPR Abdominal Images

and Patient Dose

Figure 4. Anteroposterior abdominal CT SPR images acquired with CT system A (80 kVp and
300 mA) after intravenous administration of contrast material. Window width and level settings
were determined by the radiologist for optimal viewing. Good visualization of the urinary tract
is achieved (a) with ureteral compression and (b) after release of ureteral compression. Edgeenhancement processing of the CT SPR images accentuates borders and edges.

different magnifications between structures at the anterior versus the posterior

aspect of the patient. For CT SPR images,
magnification effects were seen for only
left-to-right distance measurements. As
the object was raised above isocenter, the
left-to-right distance measured on the CT
SPR image underestimated the true distance. The effect was greater for CT SPR
images than for conventional radiographs because of the relatively larger distance between the patient and the CT
detectors. However, the height above or
below the isocenter did not affect disVolume 221

Number 2

tance accuracy along the z axis because

the thin x-ray beam did not diverge substantially along the z axis. Diagonal measurements were affected by the height
above or below the isocenter because
they contained both a left-to-right and a
craniocaudal distance component. Because this magnification of objects affects
both dimensions of a radiograph equally,
the dimensions measured on a radiograph may be incorrect, but the shape
may be represented accurately. On CT
SPR images, some degree of geometric
distortion may occur away from the iso-

Figure 4 demonstrates the clinical potential of CT SPR for imaging of the urinary tract. The objectionable artifacts
created by highly attenuating structures
in the phantom (eg, the lead numbers
and resolution targets and the steel
mesh) are not present on the clinical images, which do not include such highcontrast structures. Although the spatial
resolution was inferior to that with S-F
and CR, the contrast resolution of iodinated structures on the CT SPR images was
good. Evaluation of the phantom images
obtained with various milliampere settings showed that edge ESE values greater
than 150 mR (38.7 C/kg) were preferred
to avoid a grainy appearance on the CT
SPR images. The CT SPR images acquired
at 300 mA delivered a maximum ESE
level and effective dose of 330 mR (85.1
C/kg) and 54 mrem (0.54 mSv [1
mrem 0.01 mSv]), respectively. In comparison, one abdominal radiograph obtained in a 21-cm-thick patient delivered
an ESE level of 412 mR (106.3 C/kg) and
an effective dose of 50 mrem (0.5 mSv),
and one abdominopelvic CT scan delivered an ESE level of approximately 2,500
mR (645 C/kg) and an effective dose of
approximately 1,100 mrem (11 mSv)
(13).

DISCUSSION
CT urography is a developing concept
with substantial clinical potential; however, the best mechanism for obtaining
projection abdominal images has not
been defined. Spatial, contrast, and temporal resolutions; geometric accuracy; radiation dose; and the ability to depict
Image Quality and Dose Comparison

401

Figure 5. Low-contrast-resolution portion of images in Figures 2 and 3. A, System A. B,

System B. C, System C. D, System D. E, System E. F, System F. G, S-F and moving grid. H, S-F
with stationary grid. I, CR with moving grid. J, CR with stationary grid. Despite decreased
spatial resolution compared with S-F or CR images, the small low-contrast beads are better
resolved on CT SPR images obtained with CT systems AD compared with the S-F or CR
images (GJ). D contains artifact due to contrast material spilled on the CT tabletop. E and F
exhibit poor resolution of the low-contrast beads.

clinical disease states need to be better

understood before a standardized CT urographic examination is finalized.
With traditional S-F images acquired
with a reciprocating (bucky) grid as the
reference standard, we concluded that
image quality was essentially equivalent
with CR or with use of a stationary highline-density grid. Hence, these techniques appear to be acceptable options
for abdominal imaging at the time of CT.
However, the use of S-F or CR techniques
with a moving grid (ie, table bucky) requires that the patient move from a CT
suite to a radiography suite, or vice versa,
during the examination.
Modifications made to the CT urography suite at our institution (8,9) eliminated this requirement by allowing the
402

Radiology

November 2001

acquisition of S-F or CR images (with a

high-line-density stationary slip-on grid)
while the patient was lying on the CT
table. This approach required the installation of a ceiling-mounted x-ray tube
above the CT table and the attachment of
an auxiliary CT tabletop, which had a
hollow bay under the patient surface in
which to place the radiographic cassette,
to the manufactured tabletop (9). The
clinical advantages of performing radiography at the time of CT may extend beyond CT urography to other CT applications, including trauma, skeletal, chest,
and pediatric CT examinations.
CT SPR images acquired with the six
different CT scanners at our institution
provided spatial resolution inferior to
that on S-F or CR images. Additionally,

high-contrast objects generated substantial artifacts on the CT SPR images. Compared with S-F images, however, CR and
CT SPR images provided improved resolution of small low-contrast objects.
Hence, despite the decreased spatial resolution and objectionable artifacts, we
believe CT SPR has considerable potential
for urographic applications, primarily because of the improved low-contrast resolution.
Radiation doses are also important in
the establishment of the optimal type
and number of abdominal radiographs to
be acquired at CT urography. Our results
indicated that CT SPR images with acceptable levels of image contrast and
noise required a midline ESE level of
about 300 mR (77.4 C/kg) and a tube
voltage of 80 kVp. This exposure was
slightly less than that required for S-F or
CR with a table bucky grid (435 mR
[112.2 C/kg]) and slightly higher than
that required for S-F or CR with a stationary tabletop grid (226 mR [58.3 C/kg]).
On the basis of findings in our phantom
study, which evaluated ESE versus acceptable noise levels for six CT systems,
we recommend use of a tube potential of
80 kVp and midline exposure levels of
about 300 mR (77.4 C/kg), which could
be obtained with only system A and a
tube current of approximately 300 mA.
McCollough et al

These settings delivered a maximal ESE

level of 330 mR (85.1 C/kg) and an effective dose of 54 mrem (0.54 mSv) for a
phantom thickness equivalent to a
21-cm thick patient, which represents a
relatively thin patient. As with S-F or CR
for comparable image noise, the ESE and
effective dose values must increase with
patient thickness, approximately doubling for each additional 4 5 cm of patient thickness. The image quality parameters reported herein would not vary
much with increasing patient thickness,
providing the ESE level was appropriately
increased to keep the image noise constant.
In summary, S-F and CR abdominal
imaging techniques provided better spatial resolution than did CT SPR; however,
CT SPR images provided improved lowcontrast resolution compared with S-F
images, at exposure levels comparable to
those with S-F or CR techniques. We believe that improvements in spatial resolution and artifact reduction for highcontrast objects would substantially
increase the clinical usefulness of CT SPR,
for both CT urography and other CT imaging applications. Toward that goal, we
are working to optimize CT SPR postprocessing algorithms (14).
These technical considerations demonstrate some potential advantages and
disadvantages with CT SPR as compared
with S-F or CR for CT urographic examinations. However, further work is re-

Volume 221

Number 2

quired to determine the diagnostic accuracy of CT SPR images compared with the
reference standard S-F images. Ongoing
work at our institution has been designed
to help determine the clinical ability of
CT SPR images to depict clinical disease
states, as our modified CT suite allows
closely spaced (in time) acquisition of
both CT SPR and S-F images.
Acknowledgments: The authors acknowledge the expert assistance of Shirley Stuve and
B. J. James with regard to manuscript and figure preparation, respectively. We also acknowledge the technical expertise of Garth Kenyon
and Steve Savoie from Vermont Composites
(Bennington, Vt) with regard to the fabrication
of our auxiliary CT tabletop. Finally, we thank
Tim Daly, RT(R), for his many contributions
with regard to the auxiliary tabletop design,
overhead tube installation, and radiographic
technique chart optimization.

5.

6.

7.

8.

9.
10.

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