Scientific Principles of Medical

Devices- Computerised
Tomography (CT) Imaging
RAD 5313

Terence Cesare
 Comparison of Image Quality and
Radiation Dose between Fixed Tube
Current and Combined Automatic Tube
Current Modulation in Craniocervical CT
Angiography

Lee,E.J., Lee, S.K., Agid,R.,

Howard,P., Bae, J.M., terBrugge, K.,
Oct 2009,
AJNR 30, 1754-1759
Objectives
• Original research

• To prove that the combined Automatic Tube

Current Modulation (ATCM) technique in
Craniocervical CT angiography (CCTA)
performed on a 64-slice Multidetector row
Computed Tomography (MDCT) system
substantially reduces radiation exposure,
whilst maintaining diagnostic image quality.
Background
 Problem Statement

• Optimisation of dose to:

– Maintain diagnostic image quality
– At lowest possible radiation dose
• Which is the best tube current technique to
use in CCTA when using a 64-slice
MDCT?
 Relevance
• CT has increased greatly it’s clinical
applications.
• CT increased concern on:
– Radiation dose
– Optimisation of techniques (ALARA principle)
• In CCTA, little is known on the optimal
imaging parameters for MDCT (Lee et al,
2009).
 Limitations
• Different Patients were assessed
• The ability of showing depictions of
vascular structures was only evaluated.
• Effective dose
• Body mass index
Literature Review
Automatic Tube Current Modulation
(ATCM)
• Same as the automatic exposure control
(Rizzo et al, 2006.)
• “ATCM is based on the principle that X-ray
attenuation and quantum image noise are
determined by the size of the object and
its tissue density” Kalra et al, 2004.
• Kalra also states that ATCM maintains
constant image quality and increases
radiation dose efficiency.
• Angular or xy-axes modulation techniques
• The z-axis modulation techniques
• Combined (xyz-axes) ATCM techniques,
merge the complementary techniques of
angular and z-axis modulation.
• Fixed Tube Current (FTC) gives constant
current throughout whole exposure in all
directions (x/y/z)
• CT manufactures differ in their approach
to ATCM:
– Philips: DoseRight
– Siemens: CARE Dose 4D
– GE: AutomA (z-axis) / SmartmA (x/y-axis)
– Toshiba: SureExposure3D
 Craniocervical CT Angiography
CCTA vs. MRA vs. DSA
• Ionising vs. Non-ionising
• Invasive vs. Non-invasive
• Length of procedure & Availability
• Procedure expenses
• Contrast
• Bone
• Repeats
• Diagnostic vs. Therapeutic
 CT radiation dose
• Radiation dose and mAs.
• CTDIvol (CT dose index)(mGy)
– Represents the average dose delivered to the
scan volume in a specific examination.
• DLP (dose-length product)(mGy-cm)
– Represents the integrated dose across the
scan length.
Methodology
• Toshiba Aquilion 64
• 50 consecutive adult patients
– 25 scanned using FTC (300mA)
– 25 scanned using ATCM (101-300mA)
• The other parameters were held constant:
• Scan length (from the aortic arch to the vertex)
• Voltage of 120kV
• Matrix size of 512*512
• FOV of 28–32cm
• Slice thickness of 0.5mm
• Pitch of 1.0
• Isotropic voxel size of 0.5mm
• I.V. contrast administration
• Acquisition time of 11–16s
• Image processing:
– Axial
– Coronal
– Sagittal multiplanar volume-reformatted
maximum intensity projections (MIP)
– 3D volume-rendered (VR) reconstructions
 Ethical Considerations
• The institutional review board approved the study.
 Data

Statistical Analysis
Image Analysis
Radiation Dose
 Statistical Analysis
• The Mann-Whitney U test is a non-
parametric test
• Commonly used to compare between two
populations that are related.
• Data is usually ordinal
• 5-point scale
 Image Analysis
• Comparison between patients:
– Age
– Length of scan
– Max. transverse neck diameter (level of hyoid)
• Image quality was based on objective
evaluation of image noise. The latter was
measured at 2 levels (lowest and highest
current site).
 Image Analysis (cont.)
• Image scoring was performed independently by 2
experienced neuroradiologists
• Blinded
• Axial, Coronal, MIP and 3D VR were evaluated by
the latter.
• 5-point scale was used to evaluate:
– Vascular delineation
– Visibility of small arterial detail
– Subjective image noise
– Certainty of diagnosis
• N.B. A score of 3 or more was considered as an acceptable level
 Radiation Dose
• The DLP was recorded for both
techniques
• Also CTDIvol was calculated using the
formula:
• DLP = CTDIvol × scan length (cm).
 Results
and
Conclusions
 Conclusion
• Lee et al concluded that Combined ATCM
technique for CCTA provided similarly
acceptable levels of depiction of the
craniocervical vessels and diagnostic
acceptability, as well as a reduction in
radiation dose (18%), compared with the FTC
technique.
 Critique
• “SURE Exposure 3D controls and modulates
the current in the x, y, and z directions to
achieve and maintain a uniform user
selected noise level in the images” (Lee et
al, 2009).
• Operator-selected image quality settings
play a key role in the dose efficiency of
ATCM (Schindera et al, 2008).
• What was the user selected noise level?
 Future Research
• The tube current isn’t the only parameter
that affects radiation dose.
• Other scanning parameters include:
– Pitch,
– Slice thickness,
– Scanning volume,
– Voltage.
• ASIR (Adaptive Statistical Iterative Reconstruction)
• MBIR (Model - Based Iterative Reconstruction)
 References
• Kalra, K., Maher, M.,Toth, Kamath, R., Halpern, E., Saini,S. (2004). Comparison of Z-
Axis Automatic Tube Current Modulation Technique with Fixed Tube Current CT
Scanning of Abdomen and Pelvis. Radiology, 232, 347–353. doi:
10.1148/radiol.2322031304.
• Kalra, K., Maher, M.,Toth, M.,Schmidt, B.,Westerman, B., Morgan, H., et al (2004)
Techniques and Applications of Automatic Tube Current Modulation for CT.
Radiology, 233, 649–657. doi:10.1148/radiol.2333031150.
• Lee,E.J., Lee, S.K., Agid,R., Howard,P., Bae, J.M., terBrugge, K., (2009) Comparison
of Image Quality and Radiation Dose between Fixed Tube Current and Combined
Automatic Tube Current Modulation in Craniocervical CT Angiography. AJNR, 30,
1754-1759. doi:10.3174/ajnr.A1675.
• Rizzo, S., Kalra, M., Schmidt, B., Dalal, T.,Suess, C.,Flohr, T., et al. (2006.)
Comparison of Angular and Combined Automatic Tube Current Modulation
Techniques with Constant Tube Current CT of the Abdomen and Pelvis. AJR, 186,
673–679. doi:10.2214/AJR.04.1513.
• Su, J.,Jaw, T., Chen C., Kuo, Y., Hsieh, T., Lee, S., et al. (2010) Automatic Tube
Current Modulation versus Fixed Tube Current in Multi-detector Row Computed
Tomography of Liver: Comparison of Image Quality and Radiation Dose. Chin J
Radiol, 35, 131-142.
Thank you for your attention

Any Questions?