CT Protocol Optimisation:

Balancing Image Quality and Dose

Maria Lewis

Guy’s & St.Thomas’ NHS Foundation Trust

 Overview

•  Introduction
•  Challenges of CT protocol optimisation
•  Radiation dose optimisation features
•  Dose audit
•  Approaches to balancing image quality
and dose
 Trends in CT doses
•  Rapid technical
developments and
expanding list of
applications have led to
a dramatic increase in
the use of CT Hall & Brenner, BJR 2008

80 1997/8
2008
70

•  CT contribution to
60

% Dose contribution
50

collective dose 40

30

•  1988 ≈ 40% 20

10

•  2008 ≈ 70% 0
Conventional CT Angiography Interventional
UK data, HPA, 2008
 Trends in CT doses
•  In a well-optimised practice* doses have
been decreasing

Europe 1999

Europe 2004

UK 2003

*Data from Mayo Clinic Rochester - Routine abdomen exam

 Trends in CT doses

From Mahesh, AAPM 2010 - New Technologies for image quality improvement and dose reduction
 Trends in CT dose

The equipment… …and how it is used

 Optimising dose and image quality

•  Aim
•  achieve desired image quality
•  lowest radiation dose possible

•  Requirement
•  fully utilise the capabilities of the equipment
Optimising dose and image quality
 Imaging challenges in CT

Small Low contrast

Patient motion structures
structures

Scan time Spatial resolution Image noise

Artefacts Radiation dose

 Protocol design
Focal    
kV   spot   Recon.   mA  
Beam  
width   interval  
 
FBP/  
Slice   Itera2ve  
width   Acquired   Recon.  
  width  
Pitch   kernel  
Scan    
Rota2on   FOV   Scan  
2me   Flying  
Recon.     length  
focal    
FOV  
spot  
 Protocol design
•  Spatial detail •  Contrast resolution
 Protocol design: example
•  X-ray beam width selection
4-slice scanner
16 x 1.25 mm detector banks
Protocol for CTPA exam
 Protocol dessign example
•  How long does it take to cover 300 mm
length?

300 mm

Rot. time (s) 1 1 1

Pitch 1 1 1
Beam width (mm) 5 10 20
Z-axis resolution (mm) 1.25 2.5 5
Total scan time (s) 60 30 15
 Protocol design example
•  Is spatial resolution adequate?

300 mm

Rot. time (s) 1

Pitch 1
Beam width (mm) 20
Z-axis resolution (mm) 5
Total scan time (s) 15
 Protocol design example
•  Is spatial resolution adequate?

300 mm

Rot. time (s) 1 0.5

Pitch 1 1
Beam width (mm) 5 5
Z-axis resolution (mm) 1.25 1.25
Total scan time (s) 60 30
 Protocol design example
•  What about dose?

Beam width z-axis GE Relative

(mm) (%) dose

20 (4 x 5) 97 1.00
10 (4 x 2.5) 83 1.17
5 (4 x 1.25) 67 1.45

z-axis 4 x 5 mm 4 x 2.5 mm 4 x 1.25 mm

 Protocol design example

•  Helical scanning includes extra rotations at

either end of imaged volume:‘over-ranging’
•  Additional dose more significant for wider
beams particularly for short scan ranges

Tzedakis et al, Med. Phys. (2005) 32 (6)

 Protocol design example
•  On modern scanners dose from ‘over-ranging’
is reduced with dynamic collimators
•  Collimator blades open and close
asymetrically at start and end of scan

Scan range Scan range

Conventional technology SOMATOM Definition AS+ with

without Dose Shield Adaptive Dose Shield
Courtesy Siemens Medical Systems
 Protocol design example

•  Any other implications?

•  Cone beam artefacts with wider beams?
•  E.g. For head scans it may be better to use
20 mm beam width instead of 40 mm
 Protocol review and optimisation
Focal     mA/  
kV   mA/   Scan  
spot   Recon.  
Recon.    
kV   Beam   Pitch  
AEC  
AEC  
width   length   interval  
interval  
 
Protocol FBP/  review
  is a
Slice   complex
Slice   Acquired   FBP/  
Itera2ve   task Focal  
and   Recon.  
Acquired   Recon.  
width   should
width   width   be   undertaken
Itera2ve   spot   kernel  
Pitch   width   kernel  
with caution   and as a
Flying     team Scan    
Rota2on   Scan     Recon.     Beam  
Rota2on   focal     FOV   Scan  
2me   Flying   FOV   FOV   width  
2me   spot   Recon.     length  
focal    
FOV  
spot  
 Optimisation – Working as a team
•  Team members:
•  Medical Physicist – technical
•  CT Radiologist – clinical
•  CT Technologist - implementation

•  Cultivate good inter-profession relationships

 CT Protocol management and review
•  How team members may work together and in parallel:

AAPM Guidelines: J Applied Clin Med Phys. 2013;14(5):3-12

 Protocol review & optimisation

•  Scanner arrives with default protocols – good

starting point
•  Applications training
•  Protocols adapted to local practice (?) with
input from:
•  Lead CT technologist
•  CT radiologists (from different specialists)
•  Medical physicist
•  Use application training and acceptance to
learn about scanner capabilities
 Protocol review & optimisation

•  Once in use, review any obvious weaknesses

in image quality?
•  Too noisy, poor contrast, artefacts, high dose…
•  When making protocol changes MUST
understand your scanner
•  Consult colleagues with same scanner
•  Review literature and web resources
•  www.aapm/pubs/CTprotocols
•  AAPM CT Dose summit meetings
•  www.aapm.org/meetings/2013CTS/presentations.asp
•  Perform your own phantom studies if necessary
 Trends in CT dose

The equipment…
 CT dose optimisation features

•  Radiation dose control is now a priority for

manufacturers
•  Main dose optimisation features:
•  Automatic tube current adjustment (CT AEC)
•  Automatic kV selection
•  Adaptive collimation
•  Organ specific dose modulation
•  Iterative reconstruction
 AEC in CT
•  Removes guesswork from manual adjustment
for patient size
Patient size Longitudinally Rotationally

attenuation

high current
low current
 AEC in CT

•  In practice different levels of modulation

are usually combined
•  Patient size
•  Longitudinal
•  Rotational
Implementation of AEC in CT
 Implementations of AEC in CT
•  Reference level of image quality must be set
Manufacturer Image Quality setting For reduced dose

Philips mAs/slice Decrease mAs/slice

Siemens Quality reference mAs Decrease Qual. ref. mAs
GE Noise index Increase NI setting
Toshiba AECS.D.can increase
(standard deviation) Increase S.D. setting

as well as
400
Tube current
350 Attenuation
300 decrease N.I. = 10 the
250
dose!
tube current

200
N.I. = 15
150

100

50
 Automatic kV selection

•  Traditionally tube potential of 120 kV used

•  Decreasing tube potential
•  Increases noise
•  Increases contrast between high & low z materials

120 kV
Automatic kV selection
Automatic kV selection
 Dynamic collimation
•  Dose from ‘over-ranging’ reduced
•  Collimator blades open and close
asymetrically at start and end of scan

Scan range Scan range

Conventional technology SOMATOM Definition AS+ with

without Dose Shield Adaptive Dose Shield

Courtesy Siemens Medical Systems

 Organ-based tube current modulation
•  Siemens X-CARE: dose reduction to sensitive
anterior organs

X-rays OFF
120°

Lungren,
AJR, 2012
 In-plane bismuth shields

•  Or use bismuth shields?

•  Use controversial

Kim et al Pediatr Radiol 2010; 40:1739

 In plane bismuth shields

•  AAPM statement on use of in-plane bismuth

shields
AAPM Position Statement on the Use of Bismuth Shielding for the Purpose
of Dose Reduction in CT scanning

Policy Text: Bismuth shields are easy to use and have been shown to reduce
dose to anterior organs in CT scanning. However, there are several
disadvantages associated with the use of bismuth shields, especially when used
with automatic exposure control or tube current modulation. Other techniques
exist that can provide the same level of anterior dose reduction at equivalent or
superior image quality that do not have these disadvantages. The AAPM
recommends that these alternatives to bismuth shielding be carefully considered,
and implemented when possible.

www.aapm.org/publicgeneral/BismuthShielding.pdf
 Iterative reconstruction
• Process of repeatedly improving an image
by comparison to the measured data

From: Iterative reconstruction methods in x-ray CT

Beister, Kolditz, Kalender, Physica Medica (2012) 28
 Iterative reconstruction

•  Can offer improvements compared to FBP

methods
•  Noise reduction without degraded resolution
•  Artefact reduction
•  Improved spatial resolution
•  What’s the downside? Measured data
•  Computational cost: clinically practical?
•  Change in image texture
Compare Update

Image 2
n
3

Iterative Reconstruction Techniques, UKRC 2012

Adapted from: Keat, Iterative Reconstruction Techniques, UKRC 2012

 Iterative reconstruction

•  Change in image texture can have

significant effect on visualisation of
structures (low contrast detectability)
•  Clinical acceptability of images must be
considered

S Singh, AAPM 3rd CT Dose Summit, 2013. Iterative Reconstruction: Dose it work to reduce noise...
 Iterative Reconstruction

•  Vendor specific implementations

Vendor System Approach
GE ASIR – Adaptive Statistical Statistical method
Image Reconstruction
Veo (MBIR) Statistical + Geometric
Philips iDose4 Statistical
IMR – Iterative Model Statistical + Geometric
Reconstruction (WIP)
Siemens IRIS – Iterative Image based
Reconstruction in Image
Space
SAFIRE – Sinogram AFfirmed Statistical
Iterative Reconstruction
Toshiba AIDR – Adaptive Iterative Statistical
Dose Reduction
 Dose audit
The equipment… …and how it’s used
 Dose audit

•  Collect, for common scans

•  patient weight, sex
•  CTDIvol & DLP for each series
•  Select standard patients
•  60 - 80 kg adults
•  3.5, 9, 19, 32, 35 ± 15% for children
•  Compare to
CT TAP CTDIvol DLP
•  National DRLs (mGy) (mGy)
•  Local DRLs Hospital A 12 840
NDRL 12, 14 940
•  Scientific literature
Courtesy Elly Castellano, RMH
 Dose audit example

•  District General Hospital with 2 CT scanners

•  GE LightSpeed 32
•  Siemens Somatom Sensation 64
 Background

•  Initial review of doses by radiologist

•  Small numbers (8 patients per scanner)
•  No info on patient size
The  use  of  this  scanner  
must  be  suspended  

Scan type DLP (mGy.cm) National DRL

GE Siemens (mGy.cm)
Routine Abdo-Pelvis 1707 753 560
 Method

•  Protocols
•  Routine abdo-pelvis: helical, contrast-enhanced

Scan AEC Beam Recon Pitch kV Rotation Noise index/ Max/min Recon
type width slice time Qual. ref. mAs mA filter
(mm) (mm) (s)
GE Helical Smart mA 32 x 1.25 5 0.969 120 0.8 24.6 750/100 Standar
(40 mm) d
Siemens Helical CAREDose 4D 24 x 1.2 5 1.4 120 0.5 200 - B31f
(28.8 mm)
 Dose review methodology

•  From RIS system ~50 consecutive

patients selected from each scanner
•  Patient images reviewed on PACS
•  Measurements of patient size
•  Noise values in ROIs
•  CTDIvol and DLP from dose report
 Dose review methodology
•  Patient dimensions – effective diameter
•  Geometric mean (GM) of AP and lat dimensions
•  GM = √36.2*28.2 = 32 cm

36.2 cm

28.2 cm
 Dose review methodology

•  Measurement of noise: ROI Level 1

•  Liver and aorta
 Dose review results

Scanner Patient CT no: Noise: CTDIvol DLP

dimension Liver ROI Liver ROI (mGy) (mGy.cm)
(cm) Mean values ± S.D
GE 28.9 ± 3.7 97± 20 13.8 ± 2.9 14.4 ± 11.0 689 ± 554
Siemens 28.1 ± 3.0 91 ± 15 12.3 ± 2.3 11.5 ± 2.7 552 ± 141

•  National DRL = 560 mGy.cm

•  Mean GE doses ~ 25% higher than Siemens
doses
Results:Doses
CTDI vol versus patient size
for Siemens routine abdo-pelvis protocol
y = 0.7487x - 9.2314
R2 = 0.7606

Siemens
70.0
60.0
50.0
CTDIvol (mGy)
40.0
30.0
20.0
10.0
0.0
20.0 25.0 30.0 35.0 40.0
Doses for GE routine abdo-pelvis protocol
Mean water-equivalent patient diameter (cm)

y = 0.2468e0.1354x
2
R = 0.8419

GE
70.0
60.0
CTDIvol (mGy)

50.0
40.0
30.0
20.0
10.0
0.0
20.0 25.0 30.0 35.0 40.0

Mean water-equivalent patient diameter (cm)

 Results

•  Dose variation with patient size sub-group

GE Siemens
3000
DLP (mGy.cm)

2500
2000
1500
1000
500 DRL
0
20.1 - 25.0 25.1 - 30.0 30.1 - 35.0 35.1 - 40.0
Mean patient dimension (cm)
 Tube current modulation approach
2.0
Relative tube current
1.8

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1.6 se
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tan cu
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stro ge increa

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reference tube current

co Tub
1.4 avera ak increase

Ob
we

Image Quality
es
1.2

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1.0

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Sl
im

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0.2
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ag

0.0
on
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0.5 1.0 1.5 2.0 2.5 3.0

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Reference Relative attenuation

attenuation
 Dose audit example: Outcome

•  We suggested setting higher Noise Index

values for large patients (‘Large’ protocol)
•  problems if patient size not assessed
correctly
•  GE recommend controlling dose to large
patients by reducing ‘Max’ mA setting
•  non-uniform IQ along patient
•  Hospital decided that all large patients
scanned on Siemens scanner
 Balancing image quality and dose
•  CT dose – how low can we go?
•  What is diagnostic threshold?
•  Dependent on diagnostic task

Karmazyn B et al, AJR Jan 2009

 Balancing image quality and dose
Various approaches to determining
diagnostic threshold
•  Gold standard: Blinded human observer
studies at different dose levels
•  Progressive reduction of mAs in small
increments
•  Useful tool: simulation of reduced dose
scans by addition of noise
 Balancing image quality and dose
Aquilion 16
120 kV, 200 mAs, 5 mm

Scanned dose: 1 0.8

0.3
0.9
0.7
0.4
0.15
0.1
Simulated dose: 0.2
0.5
0.6
Noise = 7.6 HU Noise = 24 HU
Images courtesy Y. Muramatsu, NCC Tokyo
 Conclusions
•  Modern scanners are complex
•  Every scanner is different – essential to
understand operation of your scanner
•  A team approach is essential in CT
protocol review
•  Make use of information resources
•  Consult: user manuals, manufacturers,
websites, scientific literature and colleagues
•  Dose audit is important and is a good first
step in highlighting optimisation issues
 Thank  you  for  listening

 
 
 
 
 
www.maria.lewis@gs8.nhs.uk  
 Developments in technology
CT scanner ~1971 … …40 years later

•  4 min rotation time •  < 0.3 s rotation

•  Recon overnight •  Real time recon
•  2 slices/rot (8 mm) •  up to 320 slices (0.5 mm)
•  80 x 80 matrix •  512 x 512 matrix
 Implementation of AEC in CT

•  Implementation manufacturer specific

Patient size Longitudinal Rotational

GE Auto mA Smart mA
Philips DoseRight ACS DoseRight DoseRight
Z-DOM D-DOM
Siemens CARE Dose 4D
Toshiba SUREExposure 3D
 Iterative loops
•  Steps 5 6
1.  Acquire raw data-> sinogram
2.  Generate initial image (FBP)
3.  Forward project 4 7
1
4.  Compare 2
5.  FBP for correction image
(to aid convergence)
6.  Apply image regularization
3
7.  Update image
8.  Repeat 3-7 as necessary

•  Iterate until suitable convergence reached

Iterative Reconstruction Techniques, UKRC 2012

N Keat, Iterative Reconstruction Techniques, UKRC 2012

 Highlighting radiation risk
•  CT – An increasing source of radiation
exposure. Brenner & Hall, NEJM, Nov 2007
28th November 2007

Overuse of diagnostic CT scans

may cause as many as 3 million excess
cancers in the USA over the next two
decades, doctors report today...
 “normal”  dose  →  hair  loss,  skin  burns,  
cataractogenesis?
•
CT over-exposure
Mad River Incident: repeated scans in
incidents
single location on baby
••  Class
2008 Mad
action River
lawsuits incident
against multiple
hospitals and vendors
•  repeated head scans on child
• Media attention & requests for CT
•  Skin dose > 7 Gy
experts/ opinions
•  2009 – 2010 brain perfusion
overdose incidents Cagnon, CT Protocols, AAPM 2012 8

•  multiple hospitals and vendors

•  ~ x 8 expected dose (3 – 4 Gy)
•  Lack of standardisation and/or
poor understanding of protocol
and equipment capabilities
 Scan & reconstruction parameters
Focal     mA/  
kV   mA/   Scan  
spot   Recon.  
Recon.    
kV   Beam   Pitch  
AEC  
AEC  
width   length   interval  
interval  
 
FBP/    
Slice   FBP/  
Slice   Acquired  Itera2ve   Focal     Recon.  
width   Acquired   Recon.  
kernel  
width   width   Itera2ve  
  spot  
width  
Pitch     kernel  
Flying     Scan    
Rota2on   Scan     Recon.     Beam  
Rota2on   focal     FOV   Scan  
2me   Flying   FOV   FOV   width  
2me   spot   Recon.     length  
focal    
FOV  
spot  
 Defining imaging task
•  Spatial detail •  Contrast resolution
 Defining imaging task

•  Standard-sized patients
•  Non-standard patients
 Case study 2: CT screening clinics

•  Dose audit at CT screening provider

•  13 clinics
•  4 scanner models: GE, Siemens, Toshiba
•  Screening examinations
•  abdo/pelvis
•  calcium scoring
•  lung
•  virtual colonoscopy
•  + combinations of the above
 Case study 2: CT screening clinics

•  Protocols
•  Weight-based mAs tables used on GE &
Toshiba scanners
•  CARE Dose 4D used on Siemens scanners
 Case study 2: CT screening clinics

•  Dose audit
•  Only total DLP values for whole exam
available
•  e.g. calcium sore + virtual colonoscopy
•  Patient weight also documented
 Case study 2: CT screening clinics

•  DLPs for virtual colonoscopy + calcium score

Mean DLPALL = 689 Mean DLPALL = 513
Mean DLPSTD = 523 Mean DLPSTD = 502

Mean DLPALL = 624 Mean DLPALL = 668

Mean DLPSTD = 593 Mean DLPSTD = 558
 Case study 2: CT screening clinics

•  All sites should adopt automatic exposure

control (AEC).
•  Sites should document the CTDIvol value
as well as the DLP.
•  Sites should document CTDIvol and DLP
for each exam series.
•  CT technologists should receive further
training on CT dose issues and in
particular on operation of AEC systems.
 Implementations of AEC in CT

•  Using AEC ≠ Dose reduction

•  dose can increase or decrease depending
on patient size
•  dose can increase or decrease depending
on reference ‘image quality setting’
 AEC in CT
•  Tips
•  Centre patient in FOV
•  Consider order of SPRs
- final one usually used
in AEC

Elliptical phantom 16 x 30 cm
SPR AEC CTDIvol
mode (mGy)

Lat then AP Auto mA 5.7

AP then lat Auto mA 10.1
Courtesy Elly Castellano, RMH

Courtesy Siemens
 AEC in CT

•  Removes guesswork from manual

adjustment for patient size
 Automatic kV selection

Nelson, Optimal kV selection. AAPM 3rd CT Dose Summit 2013

 Organ-based tube current modulation

•  May not always be effective

•  Another approach: in-plane bismuth shields

 Iterative reconstruction
•  Clinicians initially reported
‘waxy’nature to images
•  Change in noise structure

From: Iterative reconstruction methods in x-ray CT

Beister, Kolditz, Kalender, Physica Medica (2012) 28, 94-108
Iterative Reconstruction Techniques, UKRC 2012
used suggest that the CNR be no less than and the noise be no
Automatic kV selection
higher than those obtained at the reference tube potential.
With this very tight constraint on image noise, the RDFs at
tential
80 kV were 0.780, 1.005, 1.230, 1.897, and 2.905 for XS, S,
straint
M, L, and XL phantoms, respectively. For the requirement of
•  Relative dose factor (RDF)
straint
equal noise, there is a dose reduction at 80 kV for only the
–5!d",
XS phantom size and there is a big dose increase at 80 kV
•  mA at each kV adjusted to give same CNR
for L and XL phantom sizes. When ! = 1.25, the desired im-
all
•  agefor some
quality applications
at other tube potentials images
satisfies twoat low kV too
conditions: noisy
RDF with no noise constraint (for iodine contrast)
2.5
ge Extra Small Phantom
Small dimensions (mm):
2 XS = 150 x 150
Medium
S = 300 x 200
Large M = 350 x 250
1.5
Extra Large
RDF

L = 400 x 300
XL = 480 x 380
1

0.5

140 0
80 100 120 140
kV
Yu et al. Med Phys. 2010;37(1)
 Protocol design example
•  Choice of settings is scanner dependent
•  On a 16 - slice scanner can achieve 1.25 mm
slices with 20 mm beam width

z-axis 16 x 1.25 mm