Reduced Radiation Exposure in Dual-Energy Computed Tomography of the Chest: Impact on Image Quality

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Reduced Radiation Exposure in Dual-Energy
Computed Tomography of the Chest: Impact on Image Quality
ABSTRACT:
Objective: This study purports to answer the question: Does a dual-energy CT
scan of the chest using reduced radiation result in images of equal or better quality
compared to those produced bythe gold standard of care?
Methods:With the agreement of the Ethical Review Committee and written
informed consent from 32 patients, who received dual-energy CT (DECT) scanof
the chest in a dual-source scanner, a second set of images was taken at a reduced
radiation dose. On virtual monochromatic images at 40 and 60 keV, three thoracic
radiologists evaluated image quality, normal thoracic structures, and pulmonary
and mediastinal aberrations. Students analyzed the data using analysis of variance,
Kappa statistics, and Wilcoxon signed-rank tests.
Results:No irregularities in the scans were missed in the virtual monochrome
photographs of all patients at a lower radiation dose, and the images were found to
be of sufficient quality. At 40 and 60 keV, standard-of-care pictures produced
equal contrast enhancement and lesion detection. Observers were entirely
consistent with one another. Among other characteristics, reduced-doseDECT had
a CTDIvol of 3.0 ±0.6 mGy, and a size specified doseestimate (SSDE) of 4.0 ±0.6
mGy, a dose-length product(DLP) of 107 ±30 mgy.cm, and an effective dose(ED)
of 1.15 ±0.4 mSv.
Conclusion: Dual-energy computed tomography of the chest allows for the
administration of lower radiation doses (CTDIvol <3 mGy).
INTRODUCTION:
Dual-energy computed tomography (DECT) was originally a potential alternative
that enabled more accurate images, but it required a high doseof radiation and had
issues with the two kV image files collected during two consecutive DECT
acquisitions not being in the same location at the same time (1). In the 1990s,
numerous studies demonstrated that DECT was superior to single-energy CT for

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detecting lung nodules (2). However, according to a study financed by the
Fleischner Society, DECT still proved to be unable to distinguish lung nodules
toward the decade's end (3).
As public awareness of the dangers of CT scan radiation has grown, additional
clinical research and technological advancements have been made to minimise CT
scan radiation levels (4). According to some experts, DECT can be performed with
doses comparable to those used in single-energy CT in multidetector CT (5). In
fact, doctors have employed both single-phase and dual-phase DECT scans to
detect benign and malignant mediastinal tumours. These tests have identified
aneurysms of the aorta, chronic pulmonary embolism, lung emboli, and pulmonary
nodules (6,7). Few persons who use chest DECT have considered reducing their
daily radiation exposure. Recent studies have demonstrated that DECT scans are
effective for examining lung parenchyma and pulmonary embolisms. This is
accomplished through the use of material separation techniques and the creation of
virtual monochrome images (8,9).
As mentioned above, the goal of this study is to determine whether chest dual-
energy CT can be administered at lower doses than the current gold standard of
care and still produceviable images.
METHODOLOGY:
The voxel standard deviation was used to assess the number of CT counts and the
amount of noise in DECT images (defined as the standard deviation of voxel
values). Chest phantoms were used in this study. Double-sided tape was applied to
the surface of test tubes containing iopamidol 370 mg/mL diluted contrast material
at 1:20 and 1:40 concentrations. Two scans of the phantom were performed using
standard-of-care and low-dose DECT procedures. Changing this has no effect on
the amount of time required to scan a file or on the size of the file scanned. CT
scans and standard deviations (SDs) were calculated for each region at ten
locations on the right upper lung and chest wall of the phantom. The diluted
contrast solution test tubes were scanned using CT scanners and their standard
deviations were recorded twice.

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Figure1: Imageof the anthropomorphicphantom'schest in the transverse plane
from a CT scan.
Participants in the Study
Our Institutional Review Board's Human Research Committee approved this study
after everyone signed an informed consent form to participate. To ensure that the
research was conducted properly, HIPPAA regulations were strictly adhered to.

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The researchers searched the Radiology Information System (RIS) for patients who
needed a conventional chest CT with contrast enhancement. They discovered that
there were individuals. To participate in the study, participants needed to be alert,
have stable blood pressure, and be at least 56 years old. A CT scan was not
performed if the patient could not hold their breath for more than 10 seconds orif
the patient was allergic to the contrast used. Certain individuals were unable to
participate in the study due to their BMI being greater than 32 kg/m2. Individuals
who had previously undergone two CT scans at our clinic — one in the prone
position and another in the supine position — were also denied participation due to
a history of interstitial lung disease. Forty-five individuals participated in the study.
Eight patients stated that they did not wish to be treated after signing an informed
consent form. Five persons were forced to abandon the experiment for health
reasons after an accident involving a single-energy CT scanner. As a result, there
were finally 32 adults participating: 12 men and 20 women. The average age was
71 ±6 years in general. On average, the men were 70 ±5 years old, and the women
were 72 ±7 years old, with a range of 56 to 87 years. The 32 individuals who
underwent clinical CT scans included those with lung cancer, pneumonia, and
other non-pulmonary ailments.
For each CT scan performed, the patient received 65mL of IV contrast material.
This was achievable in this circumstance because the CT scanner was a
multidetector CT scanner with a zooming focus point. It took 35 seconds for the
individual to be scanned in preparation for the contrastmedia injection. They were
scanned at a rate of 2.5 mL per second. Each scan lasted nearly the same length of
time (approximately 3 s).
Patients could see how much of their bodywas covered by both standard-of-care
and low-dose imaging because they would eventually get a chest CT scan. CT
scans with a standard dosetook longer than scans with a low dose. The decreased-
dosage technique reduced the quality reference mAs to approximately half that of
the standard of care (10). Between the two scans, all other scanning parameters
remained constant. It was not included in the set of low-dose images. Each photo
set's CTDIvol and dose-length products (DLP) were determined. We were able to
determine the water-equivalent diameter (WED) and size-specific dose estimate
(SSDE) for each person by utilising software called the Radmetrics Enterprise

5
Platform (11). This meant that each chest CT image was estimated because it took
0.14 of a second to convert each image to an EDT. This was the DLP's operation. It
resembled a map (12).
Images of normal and lower doses were created using Healthcare's proprietary
technology. The images were created with the industry-standard medium-smooth
soft-tissue reconstruction kernel, a proprietary iterative reconstruction technique
(I30f). There were no patients with interstitial lung disease in this research. As a
result, we used a soft-tissue kernel for all of the images in order to improve spatial
resolution and the ability to see edges (which provides optimal image contrast at
the costof spatial resolution).
This is how transversely orientated pictures (80/Sn140 kV) were created. Each
slice was separated by a 2mm gap. Virtual monochromatic images at 40 and 60
keV, as well as images of blood flow and images with no contrast, were created
using dedicated computers. Because virtual monochromatic low-energy images
had the same or less noise and additionally might aid in making iodine more
visible, they were the best choice (13–16). The images taken at 40 keV were
chosen for the investigation becausethey best fit the K-edge of iodine (33 keV). A
60 keV resolution image has better contrastthan a 65-70 keV resolution image due
to the absenceof noise. This is why they were chosen for investigation (8, 17).
Before the investigators examined the photographs, no scan settings nor patient
information were associated with individual participants.
Board-certified thoracic radiologists viewed and analyzed the chest CT images
using a DICOM-compliant image viewer. Radiologists were unaware of how much
radiation was emitted during each imaging series, since they did not administer the
tests. Each radiologist examined standard-of-care and low-dose images privately
without collaboration. A side-by-side comparison was required to determine
whether the image quality was the same for both treatments and whether noise
obscured the lesions. Radiologists graded the appearance of images of mediastinal
and lung lesions, as well as normal bodycomponents, using a two-point scale. The
lesions included lung fissures and the sub-segmental bronchial wall, the
pericardium, and sub-centimeter mediastinal lymph nodes. This study examined a
variety of factors that influence the appearance of an image (18).

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Two radiologists conducted this research examining the effect of low-dose DECT
images on diagnostic information, but they were unable to view what was
occurring in the lung parenchyma or mediastinum due to their “blindness.” At 40
and 60 keV, two monochromatic pictures were created (images illustrating
standard-of-care methods). An outstanding grade indicated that anomalous
structures could be observed clearly in this example due to excellent delineation. If
images received a high score, they were perceived as having some blurriness or
ambiguity over how to assess them. If they received a low grade, they were
considered invisible. Monochromatic 40 keV images were superior to standard-of-
care images due to the reduced doseof DECT utilized to increase contrast.
The image noise and signal data for the tracheal lumen, mid-thoracic vertebral
body, and paraspinal muscle ROIs were gathered concurrently, with CT numbers
expressed in HUs. Additionally, CT scans of the right pulmonary artery were
performed to determine its appearance on the CT. One researcher created circular
ROIs on virtual monochromatic images at 60 and 40 keV using standard-of-care
datasets. These took up a lot of space. They occupied an area of between 0.5 and
0.8 cm2 , respectively. The signal to noise ratio (SNR) and contrast to noise ratio
(CNR) were also calculated (20). The CNR was determined using tracheal ROIs.
Due to the ten-second delay between the standard-of-care and reduced-dose
photographs, it was difficult to determine the amount of iodine in blood flow
photographs.
StatisticalAnalysis:
SPSS Statistics, version 25.0, was used to examine the data and determine an
appropriate method of analysis. Students employed a t-test to assess the quantity of
image noise and the number of CT scans performed in the right pulmonary artery
between two groups of individuals. The study used the Wilcoxon signed-rank test
to evaluate the subjective image quality of standard of care with low-dose DECT.
Cohen's kappa statistic was used to determine the degree to which two radiologists
might agree. According to Cohen, those with a scoreof less than 0.20 could claim
only “slight agreement,” whereas those individuals with a scoreof more than 0.60
could claim "substantial agreement." As illustrated in the image, a one-way
analysis of variance was used to compare HU values between persons who

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received standard of care and those who received less care in a phantom study. We
considered this to be significant because our p value was 0.05.
RESULTS:
The demographics of our patients are summarized in the table below (Table 1).
Between standard-of-care and reduced-doseDECT scans, soft tissue and lung
parenchyma CT values did not differ substantially (p >0.05, respectively).
According to our findings, there was no significant difference in picture noise
between standard-of-care and reduced-dosetreatments (p >0.05). (Table 2)
Table 1:
Characteristics Males Females
No. of participants 12 20
Age (years)(Mean ±SD) 70 ± 5 72 ± 7
Weight (kilogram) 80 ± 12 66 ± 10
BMI (Mean ±SD) 25.5 ± 3.7 24.7 ± 3.5
BMI (According to sub categories)
≤ 20 kilogram/meter2
1 2

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20-25 kilogram/meter2
6 9
4 8
1 1
Table 2:
Standard-of-Care Dual-
Energy CT Scan
Reduced-Dose Dual-
Energy CT Scan
Region (HU ±SD) (HU ±SD)
Soft tissue (60
keV)
31.4 ±14.6 32.1 ± 4.1
Soft tissue (40
keV)
32.4 ±26.1 30.2 ±28.3
Lung parenchyma
(60 keV)
-795.8 ±10.7 -792.4 ±12.6

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Lung parenchyma
(40 keV)
-780.2 ±18.1 -777.8 ±21.5
Contrastmedia
1:20 (40 keV)
1495.1 ±49.2 1487.6 ±53.4
Contrastmedia
1:20 (60 keV)
673.5 ±20.7 667.3 ±23.6
Contrastmedia
1:40 (40 keV)
780.6 ±35.6 767.4 ±34.3
Contrastmedia
1:40 (60 keV)
346.5 ±13.3 339.3 ±19.4
The scans were carried out at an energy level of 60 keV in order to comparetwo
monochromatic pictures side by side. DECT images taken at standard and
decreased doses indicated normal lung fissures, small lymph nodes, and the
pericardium. There were no visible distinctions between these two sorts of
photographs. All 39 lesions were identified on virtual monochromatic images in
the standard-of-care DECT, but were also visible in the reduced-doseDECT.
Non-calcified solid nodules with a diameter of less than one centimeter were found
in 27 of the participants. Only one patient had solid nodules that were non-calcified
and measured more than one centimetre in diameter. The overall subjective image
quality was assessed to be satisfactory in all 32 cases (kappa = 1) when
monochromatic 60 keV monochrome images were used in the reduced-doseDECT
approach. The detection of lesions can be aided by monochromatic monochrome

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images with a resolution of 40 keV. Despite the dosage reduction, the number and
kind of mediastinal lesions were identical in the standard-of-care (60 keV) and
reduced-dose(40 keV) pictures. Because of the perfect interobserver agreement
(kappa = 1), the reduced-dosepicture sequence inspired a lot of trust.
Lung nodules as small as 2 mm in diameter can be detected using this approach.
Both intraobserver (kappa = 0.73) and interobserver (kappa = 0.66) agreement
were rated as acceptable. There was a considerable improvement in interobserver
agreement when noncalcified lung nodules less than 5 mm in diameter were
omitted from the analysis. Three patients received four points for having a high
level of diagnostic confidence. There were 28 patients who had a high level of
diagnostic certainty.
Table 3 summarizes the results of the objective image quality evaluation. Noise in
the tracheal lumen was significantly reduced (12%) in the reduced-doseimaging
series, whereas noise in muscle and bone tissues increased up to 44 percent.
Regardless, the CNR increased as a result to 20 percent.
Table 3:
Standard-of-Care
DECT
Reduced-Dose
DECT
%
Difference
Variable 60 keV 40 keV 60 keV 40 keV 60
keV
40
keV
Image Noise (mean ±SD)
Trachea 8.2 ±2.5 8.7 ±3.2 7.0 ±3.0 8.0±5.7 -11% -7%

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Muscle 13.6 ±3.1 23.5 ±5.1 18.3±3.4 34.1±6.3 34% 43%
Bone 24.7 ±8.2 39.7 ±14.9 28.7±6.3 48.7±13.3 17% 21%
Signal-to-NoiseRatio (mean ±SD)
Trachea 131.5 ±7.1 125.2
±40.3
157.4 ±
51.2
151.6 ±
53.4
18% 20%
Muscle 3.8 ± 1.1 2.2 ± 0.8 3.2 ± 0.8 1.9 ± 0.9 -20% -21%
Bone 8.2 ± 4.1 8.7 ± 4.1 6.7 ± 2.6 7.4 ± 3.3 -18% -16%
Contrast-to-NoiseRatio (mean±SD)
Muscle 124.9
±38
118.6
±38.7
148.7
±48.9
142.6 ±
51.2
18% 19%
Bone 108.3
±33
86.7 ± 27.2 128.3
±41.4
101.6
±35.6
18% 16%
Reducing the dosageto 60 keV for virtual monochrome photographs resulted in an
average attenuation of 228 ±72 Hu for images of the right pulmonary artery taken
concurrently with standard-of-care images. Attenuation values of virtual

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monochromatic images at 40 keV were greater than those at 60 keV. Despite the
10-second delay between treatments, reduced-doseprotocolphotos revealed
somewhat greater attenuation in the right pulmonary vein (452-102 HU) than 60-
keV images collected with conventional treatment (403-118 HU).
Medicine that is considered to be standard-of-care CTDIvol had a higher
concentration of CTDIvol, SSDE, DLP, and ED than the reduced-dosage
medication's lower dose. The following table summarizes these figures (p <0.001).
The p-value is <0.0001 in this situation. Other participants who underwent DECT
of the chest did not report any abnormal CT results. The average doseadministered
in the emergency department (ED) for chest CT scans was less than seven
millisieverts (mSv) for each patient in our analysis (21).
DISCUSSION:
Doctors can do DECT on the chest at lower doses without sacrificing diagnostic
information in patients with BMIs less than 32 kg/m2. For the lower dosages, a
CTDIvol of no more than 3.0 and a DLP of no more than 30 mGy.cm may be
employed down to a CTDIvol of 3.0 ±0.7 mGy and a DLP of 107 ±30 mGy.cm.
Despite the reduction in radiation exposure, small nodules, bronchial fissures,
pulmonary arteries, and bronchial walls could still be detected in the photographs.
As a result, we proved the feasibility of using low-dose virtual monochromatic
images to detect mediastinal and pulmonary abnormalities.
Our findings contradict previous research on DECT treatments, which concludes
that the scanning device exposes patients to high radiation doses during use (22,
23). CT angiography and urography are two clinical scenarios in which recent
research have considered low-radiation-dose protocols and the possibility of
eliminating one or more scanning steps (24, 25). DECT scanners may be able to
drastically reduce the amount of radiation they create compared to other scanners.
Our DECT study used a lower radiation dosethan previous studies (8). According
to the researchers, chest DECT was performed in the lab with a CTDIvol of 5.44
milliGy and 2.26 milliSv. This means that they were able to obtain the required
results with extremely low doses. Additionally, this study establishes that DECT
has a higher CNR at 120 kV than single-energy CT. A CT angiography

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examination was performed with the assistance of a dual-source DECT scanner.
They determined the average DLP to be 403.4 mGy.cm. According to Hwang et al.
(26), the ED was 1.78mSv when a dual-source DECT scanner with single-energy
collection was used for low-dose chest CT (120 kV).
For this purpose, virtual monochromatic pictures of the pulmonary artery with a
lower energy level, namely 40 keV rather than 60 keV, are preferable. In most of
the patients we evaluated, attenuation in the lung was more obvious on 40 keV
(reduced-doseprotocol) images than on 60 keV images, even after a 10-second
delay. This is because iodine's K-edge (33 keV) is closer to 40 keV than to 60 keV.
Due to DECT's ability to boostcontrast, it may be able to lower the amount of
contrast medium injected during CT scans. This may be beneficial for people who
are at risk of contrast-induced nephropathy
Patients who had previously gotten standard-of-care DECT were exposed to very
little radiation when we photographed them using low-dose DECT. This resulted in
a reduction in the size of our study sample. We were able to mitigate the risks
associated with the higher radiation exposure, however, by including only
individuals above the age of 56. Due to the fact that the rapid kV-switching
technology on our other DECT scanners did not allow us to reduce the radiation
doseby 50%, we used a single DECT scanner from a single vendor. We
recommend utilizing the lowest feasible doseof DECT chest treatment when
delivering it. This is because the rapid kV-switching approachis only effective
with pre-set doses and tube currents. However, because the SAFIRE S3 iterative
reconstruction setting has been shown to be beneficial for all patients and is
regularly used in our practice, it was chosen. Even so, we do not know how
reduced-doseDECT of the chest will effect individuals with a bodymass index
greater than 32 kg/m2 or who have interstitial lung disease. When low-dose DECT
is applied on the chest and other areas of the body, it is necessary to verify
quantitative iodine levels detected in material degradation images. Our clinical
standard of care demands us to examine all images of the lungs and mediastinum
with a single kernel (I30f). As a result, we made no attempt to determine if
reduced-doseDECT made it more difficult to understand data with a high spatial
frequency or with small kernels in the lung.

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With a patient’s BMI of less than 32 kg/m2, chest DECT can be used at a lower
dose, i.e., down to 3.0 mGy. By using low-dose monochromatic images at 40 keV
and 60 keV, radiologists can analyze normal as well as diseased thoracic findings.
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Reduced Radiation Exposure in Dual-Energy Computed Tomography of the Chest: Impact on Image Quality