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Radiation Measurements 46 (2011) 2065e2068

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Dose reduction in 256-slice triple rule-out CT angiography

Chia-Jung Tsai a, Liang-Kuang Chen b, c, Greta S.P. Mok d, e, Tung-Hsin Wu a, Jason J.S. Lee a, *
Department of Biomedical Imaging and Radiological Sciences, National Yang Ming University, Taipei, Taiwan, ROC
Department of Radiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC
College of Medicine, Fu Jen Catholic University, Taipei, Taiwan, ROC
Department of Electrical and Electronics Engineering, Faculty of Science and Technology, University of Macau, Macau
Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Triple rule-out (TRO) computed tomographic angiography (CTA) is a protocol which allows
Received 22 December 2010 evaluation of coronary arteries, aorta, pulmonary arteries and adjacent intrathoracic structures for
Received in revised form patients with acute chest pain. Retrospective ECG-gated (RGH) is generally used for TRO CTA while the
21 June 2011
feasibility of using ECG-gated tube current modulation (ETCM) or prospective ECG-triggering (PGT)
Accepted 28 June 2011
protocols have not been fully investigated. The objective of this study is to investigate the potential for
dose reduction through the use of ETCM and PGT in TRO CTA examination as compared with routine RGH
Triple rule-out CTA
Retrospectively ECG-gated
Material and methods: All TRO CTA examinations were performed on a 256-slice CT scanner using an
ECG-gated tube current anthropomorphic phantom. To determine equivalent doses for different organs, thermal-luminance
Prospectively ECG-triggering dosimeters (TLDs) were placed in different positions in the organs during the scanning and effective
Radiation dose doses were calculated based on ICRP-103 guidelines. Effective doses calculated from volume CT dose
index (CTDIvol) were also compared with those obtained from TLD measurements.
Results: From the study, the mean effective dose for RGH, ETCM and PGT scanning was 21.54 mSv,
15.52 mSv and 10.75 mSv respectively. The doses for ETCM and PGT techniques were signicantly
reduced by 27% and 50% (p < 0.01) as compared to that for RGH. Effective doses calculated from CTDI
method for three protocols were no signicantly difference compared with those obtained from TLD
Conclusion: Radiation dose could be efciently reduced by applying the ETCM and PGT protocols in the
256-slice TRO CTA examinations.
2011 Elsevier Ltd. All rights reserved.

1. Introduction consistent visualization of the small arteries (Chen et al., 2010).

Also, MDCT with a non-electrocardiography (ECG)-gated, contrast-
Acute chest pain is one of the most common complaints in enhanced pulmonary angiogram is now the standard imaging
emergency departments, with more than 5 million patients annu- modality for detecting pulmonary embolism (Schoepf and Costello,
ally in the United States (McCaig and Burt, 2005). Among these 2004; Schoepf et al., 2004). However, cardiac motion artifacts
cases, pulmonary embolism or even more life-threatening condi- signicantly affect the diagnostic accuracy for the suspected culprit
tions such as acute coronary syndrome or acute aortic syndrome lesions in the coronary and aortic arteries. For this reason, triple
may present with similar complaints (Goldhaber, 2004). Thus, an rule-out (TRO) protocol with ECG-gating technology has been
enormous number of patients from emergency departments proposed to encompass the entire thorax, allowing simultaneous
receive multiple examinations for accurate diagnosis (Rogg evaluation of coronary arteries, thoracic aorta and pulmonary
et al., 2011). arteries (White and Kuo, 2007) for improving diagnosis of acute
Since multi-detector computed tomography (MDCT) has been chest pain.
rapidly developed, CT angiography (CTA) has become much more Currently radiation dose for coronary CTA examinations varies
widespread. Current 64- or 256-slice CT, for instance, with higher widely, depending on different scanning parameters. For example,
spatial and temporal resolution, permits improved and more radiation dose might be up to 40 mSv if patients are scanned with
retrospective ECG-gated technique (RGH) (Paul and Abada, 2007).
* Corresponding author. Tel.: 886 2 28267134. Several strategies can be used to minimize dose from coronary CTA
E-mail address: (J.J.S. Lee). such as ECG-gated with tube current modulation (ETCM) (Jakobs

1350-4487/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
2066 C.-J. Tsai et al. / Radiation Measurements 46 (2011) 2065e2068

et al., 2002) and prospective ECG-triggering (PGT) (Scheffel et al., of heart, with an average length of 22.7 cm. Three scanning
2008) techniques. Nowadays, RGH technique is typically used for protocols, including RGH, ETCM and PGT, were applied on the
TRO CTA examination; however, the feasibility of using ETCM or phantom (Table 2). The RGH scan mode with full exposure within
especially PGT techniques has not been fully investigated for TRO so the whole cardiac interval (0e100%) was performed as the standard
far. Therefore, the objective of this study is to investigate the protocol (Fig. 1a); while ETCM with full dose exposure within
potential for dose saving through the use of ETCM and PGT in TRO 30e80% cardiac phases, and 20% of the nominal tube current in the
CTA examination as compared with the routine RGH protocols. outside phases (Fig. 1b). PGT with data acquired only in 75  5%
cardiac phases at a step-and-shoot mode were also conducted for
reducing radiation doses (Fig. 1c). Additional 5% padding of the
2. Materials and methods
tube-on time allows the reconstruction to adapt to minor heart rate
variations and produce consistent image quality. Based on theo-
2.1. Phantom and dose measurement
retical foundation, minimum acquisition time of 135 ms
(i.e. 270 ms/2) and indispensably time to ramp up and down the
The experiments were performed using an anthropomorphic
tube current (McCollough et al., 2007) needs to be required. As the
Alderson-Rando phantom (Radiology Support Devices, Long Beach,
cone beam geometry of the large coverage, system requires overlap
CA) and LiF-TLDs (TLD 100, Harshaw, Cleveland, Ohio) for dose
between adjacent axial slices, craniocaudal coverage of 22.7 cm can
measurement. We have calibrated the TLDs according to the tube
be covered with four axial acquisitions each with X-ray exposure
potential: 120 kV, 6.58-mm Al ltering. The TLDs were also readout
during a rest phase of four heart beats and three beat between used
after heating and annealing (TLD oven; Furnaces-Mufe, Type
for translating the patient couch (Fig. 2). Overall, the acquisition
47900, Thermolyne) in a TLD reader (UL-320, TLD Systems &
time for both RGH and ETCM mode was 6.3 s, and that for PGT mode
Components, Inc.) within 24 h for dose measurement. Using the
was about 8.2 s, respectively.
TLD batch calibration factor, absorbed doses were determined at
each TLD location. In this study, a total of 76 TLDs were divided and
placed in 19 measurement positions in the phantom. Following the 2.3. Effective dose determination
ICRP 103 recommendations, we placed the TLDs in the relevant
organs and tissues for calculation of effective dose. The measure- Effective dose (ED) was computed by using TLD measurement
ment sites included relevant organs in the scanning area (red bone and CT dose index (CTDI) method, respectively. Effective dose for
marrow, thoracic surface, breast, lung, heart) and sensitive organs TLD method was calculated as the summation of the measured
outside the scanning area (brain, thyroid, skin, colon, gonads, absorbed organ doses, multiplied by individual tissue weighting
bladder, liver, esophagus, and kidney). Dose values of the skin factors published by the ICRP-103. Effective dose estimates for CTDI
measured at the thoracic region were used to estimate doses of the method was determined using the volume CT dose index (CTDIvol)
breast. Four TLDs were placed at each site. The measurement sites in Gy, as provided on the scanner console. The dose-length product
are summarized in Table 1. is dened as the volume CT dose index multiplied by scan length,
and is an indicator of the integrated radiation dose of an entire CT
examination. An approximation of the effective dose was obtained
2.2. CT protocol by multiplying the dose-length product by a conversion factor, k
(equal to 0.017 mSv mGy1 cm1) (Schoepf & Costello, 2004).
All TRO CTA examinations were performed on a 256-slice CT Statistical analysis was performed between the effective doses
scanner (Brilliance iCT; Philips Medical Systems, Eindhoven, obtained from TLD and CTDI method using Students t-test, and a p
Netherlands) using the phantoms. This novel scanner with value of less than 0.05 was considered there was a statistically
a detector z-coverage of 80 mm allows a fast z-coverage. The signicant difference. Radiation doses among different dose
acquisition parameters include 256  0.625 mm slice collimation reduction techniques were also compared.
by means of a dynamic z-focal spot (ZFS) for double sampling, and
270 ms gantry rotation time. In this study, scan length of all TRO
3. Results
CTA examinations was from the clavicle through the lower border

The equivalent doses for each of the whole body organs and
Table 1 calculated effective dose (EDTLD) over the three different scan
Measurement positions and their associated number of TLD placed in the anthro- protocols were shown in Table 3. In this study, thoracic organs such
pomorphic phantom. as esophagus, thyroid, lung, breast/thorax surface, heart, rib and
Organ/tissue Position (transverse section) TLD number T-spine have higher dose compared with other organs. Our results
Red bone marrow Rib (14), T-spine (15), L-spine (25), 16 showed that equivalent doses in the cranial and abdominal regions
Pelvis (30)
Colon (31) 4
Lung (15) 4 Table 2
Stomach (22) 4 Imaging parameters for RGH, ETCM and PGT modes.
Gonads (34) 4
Bladder (32) 4 Scan technique RGH ETCM PGT
Liver (20) 4 Tube voltage (kV) 120 120 120
Esophagus (12, 13) 4 Current-time product (mA s) 800 800 300
Thyroid (9, 10) 4 Pulsing window 0e100% 30e80% 70e80%
Skin Eye (3, 4), Thorax (15, 16), 12 Pitch 0.18 0.18 1
Abdomen (24, 25) Scan length (cm) 22.7 22.7 22.7
Brain (2) 4 CTDIvol (mGy) 51 37.8 24.5
Heart (17) 4 DLP (mGy  cm) 1315 946 612
Small intestines (24) 4 EDCTDI (mSv) 22.42 16.09 10.40
Kidney (25) 4
Note: RGH, retrospective ECG-gated; ETCM retrospective ECG-gated with tube
Note: Each position in parentheses indicates number of transverse section started current modulation; PGT, prospective ECG-triggering; CTDIvol, Volume CTDI; DLP,
from skull to symphysis pubis. dose-length product; EDCTDI, effective dose calculated from CTDI method.
C.-J. Tsai et al. / Radiation Measurements 46 (2011) 2065e2068 2067

Fig. 1. Demonstrations of beam-on time in 256-slice CT for (a) RGH; (b) ETCM; and (c) PGT scan mode, encompassing individual pulsing window width (spot area), minimum
acquisition window, i.e. 135 ms (dark gray) and time required to ramp up and down the tube current (oblique line).

such as brain, small intestine, colon, kidney, bladder and gonads entire thorax. Our results showed that effective dose is
obtained from scattering radiation were lower than 0.5 mSv. On the 21.54  0.98 mSv in TRO protocol with RGH mode, which is
other hand, relative higher radiation doses were received (primary approximately 10% higher than that in conventional coronary CTA
and scattering) in the thoracic region, especially in lung, breast and with RGH mode (Rahmani et al., 2009). In order to reduce radiation
bone marrow (Fig. 3). For both TLD and CTDI methods, there were dose, ETCM and PGT protocols were attempted to exam for TRO
signicant dose reductions by factors of about 27e50% (p < 0.01) CTA. The effective dose for RGH and ETCM in this study was close or
when using ETCM and PGT protocols as compared to RGH protocol even lower than that in the 64-slice TRO CT studies (Rahmani et al.,
(RGH, 21.54 mSv; ETCM, 15.52 mSv; and PGT, 10.75 mSv). In addi- 2009; Takakuwa et al., 2009). Currently there are no studies that
tion, the differences of effective doses calculated from CTDI and TLD have investigated the role of PGT mode in 256-slice TRO CTA. Thus
methods for these three protocols were lower than 5% (Fig. 4). our data provides the rst PGT dose information for TRO CTA. In this
study, we obtained dose reduction on effective dose for PGT by
4. Discussion a factor of 50%, as comparing to that for RGH protocol. For dose
reduction, researches have indicated that effective dose for PGT
TRO coronary CT angiography can provide similar image quality protocols were demonstrated more than 80% reduction as
on coronary artery evaluation as compared with coronary CT compared with that for RGH during coronary CTA examinations
angiography (Rahmani et al., 2009). In addition, it has the advan- (Shuman et al., 2008; Earls et al., 2008). There are possibly two
tages of evaluating pulmonary arteries and aorta for possible reasons, one is the requirement of pulsing window with only single
diagnosis of acute chest pain because of a larger eld of view (FOV) shot, 75%; the other is tube voltage setting of 100 kV for slim
including the entire thorax. However, one disadvantage of this patients to reduce radiation dose.
technique is that patients have to practice breath-hold for as long as In this study, we found the relationship with estimated radiation
possible to eliminate motion artifact. The recently introduced 256- dose for RGH, ETCM and PGT protocols was not directly associated
slice CT provides superior spatial and temporal resolutions with with pulsing window width. The extra radiation dose was poten-
around 270-ms gantry rotation, and has a larger z-coverage of tially introduced from the minimum acquisition window and
80 mm, allowing scan time for the whole thorax to be as low as 10 s indispensably time to ramp up and down the tube current shown in
for a 220 mm z-axial coverage using RGH technique. This scanner Fig. 1. In this study, we simulated a patient with heart rate of
thus is very suitable for TRO CTA examinations (Mok et al., 2010). 60 bpm, representing 100 ms for each phase when one beat
Another important limitation of TRO CT angiography is the (i.e. cardiac cycle) was segmented into 100 phases. Hence, it could
increase in radiation dose in comparison to the conventional be rough calculated the beam-on time of RGH and PGT was about
coronary CT angiography due to the larger longitudinal coverage of 1135 ms and 235, respectively. There was an ideal situation that

Table 3
Equivalent dose and effective dose in RGH, ETCM and PGT scan mode.

Equivalent dose (mGy) RGH ETCM PGT

Brain 0.82  0.06 0.68  0.03 0.36  0.02
Eye 1.47  0.03 0.97  0.01 0.59  0.05
Esophagus 45.77  3.27 37.17  1.96 21.98  3.82
Thyroid 31.56  0.67 24.77  0.40 10.80  0.53
Lung 47.08  1.44 37.55  0.86 25.12  2.58
Breast 44.26  2.60 36.52  1.56 22.31  5.04
Heart 48.48  5.99 39.11  3.59 22.87  1.59
Thorax surface 44.26  2.60 36.52  1.56 22.31  5.04
Stomach 10.16  0.31 7.01  0.18 4.55  0.22
Rib 35.48  0.85 28.02  0.51 15.23  0.68
Liver 15.46  2.07 10.07  1.24 7.04  0.50
T-spine 44.38  4.24 32.39  2.54 24.76  2.44
Small intestines 3.77  0.21 2.53  0.13 1.65  0.08
Abdomen surface 1.84  0.32 1.21  0.19 0.89  0.34
Colon 0.22  0.01 0.15  0.01 0.10  0.01
Kidney 2.11  0.23 1.56  0.14 1.05  0.09
Bladder 0.15  0.01 0.11  0.01 0.07  0.01
Pelvis 0.29  0.03 0.21  0.02 0.15  0.01
L-spine 2.16  0.13 1.48  0.08 1.05  0.09
Fig 2. Demonstrations of RGH and PGT techniques covered the necessary TRO CTA Gonads 0.16  0.02 0.12  0.01 0.07  0.01
scanning region. Left, continuous data in helical mode were obtained by using RGH.
EDTLD (mSv) 21.54  0.98 15.52  0.59 10.75  0.16
Right, the number of axial shots required with PGT protocol using the 256-slice CT with
80 mm detector coverage. Note: EDTLD indicates effective dose calculated from TLD method.
2068 C.-J. Tsai et al. / Radiation Measurements 46 (2011) 2065e2068

compare the radiation doses for different scan modes. However,

this study still has a limitation: our study had just used one type of
body phantom. Obese patients may have lower organ dose due to
the absorption of the photons in the subcutaneous tissue even the
tube current settings are maximized (Schindera et al., 2007). Since
it was a phantom study, our results just provide estimated organ
doses and effective doses for TRO CTA on a 256-slice CT. The actual
doses for any individual will vary, depending on the scanning
modes, tube current, heart rate, heart rate variability, z-coverage
and patient body habitus.

5. Conclusion

The widespread availability of more advance CT technology has

led to the rapid integration of ECG-synchronized CT into diagnostic
algorithm for acute chest pain. Currently available evidence
suggests that CT-based approaches, including TRO protocols, are
Fig. 3. Effective dose for each organ from RGH, ETCM and PGT modes in TRO CT safe, accurate and cost effective. In this study, compare to the
angiography. effective dose for TRO CTA with RGH technique, ETCM and PGT
techniques showed 27% and 50% dose reduction, respectively. We
concluded that radiation dose could be efciently reduced by
radiation dose for RGH was 4.8 times than that for PGT; however, applying the ETCM and PGT protocols in TRO CTA examinations.
indispensably time to ramp up and down the tube current was
needed to consider. Also, some possible factors have to be incor-
porated into consultations; for example, overlapped scan region in Acknowledgment
the step-and-shoot mode was supplemented to increase radiation
dose when larger scan length for TRO CTA than that for coronary This study was nancially supported by the National Science
CTA was used (Fig. 2). Therefore, in realistic dose measurement this Council of Taiwan (NSC99-2314-B-010-043-MY3).
study was obtained radiation dose for RGH mode was higher than
that for PGT mode by a factor of 2. Also, we know the use of
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