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REVIEW ARTICLE

How to Incorporate Dual-Energy Computed Tomography


Into Your Neuroradiology Practice: Questions and Answers
Jeffrey R. Sachs, MD, Thomas G. West, MD, Christopher M. Lack, MD, PhD,
Brad Perry, MD, and Michael E. Zapadka, DO

same scanner available for purchase, each with its own cadre
Abstract: Dual-energy computed tomography (DECT) has many current of capabilities. Always refer to vendor-provided documenta-
and evolving applications in neuroradiology including material decompo- tion for further details. A brief review of the main differences
sition, improving conspicuity of iodinated contrast enhancement, and arti- and pros/cons of each “method” of performing DECT follows.
fact reduction. However, there are multiple challenges in incorporating
DECT into practice including hardware selection, postprocessing software
What Is Dual-Source DECT?
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requirements, technologist and physician training, and numerous workflow


issues. This article reviews in a question-and-answer format common issues This type of scanner uses 2 source and detector combina-
that arise when incorporating DECT into a busy neuroradiology practice. tions, which are placed at a near-perpendicular angle to each other.
One detector uses high-energy spectra, and the other low-energy
Key Words: computed tomography, dual energy, workflow
spectra (Siemens AG). Having separate tubes allows for indepen-
(J Comput Assist Tomogr 2018;42: 824–830) dent adjustment of the kV and mA levels for each tube. This can
make it easier to balance the total amount of photons emitted from
each tube and also help achieve good separation of the high- and
T he decision to incorporate dual-energy computed tomography
(DECT) into practice is both exciting and daunting. There are
several established applications of this technology in neuroim-
low-energy spectra. The use of 2 separate tubes also allows for
higher total x-ray flux relative to a single tube system, a benefit
aging, but also new and emerging functions. Some of these ap- for imaging patients with large body habitus. Addition of a filter
plications include distinguishing blood from calcium in brain to the high-energy spectrum can also improve the separation
imaging,1 aging spine fractures without magnetic resonance between the high- and low-energy spectra. Single-energy CT
imaging (MRI),2 material decomposition analysis,3 increasing (SECT) protocols are easily utilized on this scanner type as
conspicuity of enhancement in head and neck squamous cell well. A current disadvantage of this system is that the second
carcinoma,4 and metal artifact reduction.5 There are a number of ex- tube/detector system is typically smaller due to space limitations
cellent recent publications that review the spectrum of ways in in the gantry. This results in a limited size of the usable field of
which DECT has proven useful clinically in neuroradiology.1,2,4–18 view (FOV) for dual-energy scans. This FOV is defined as the
The purpose of this article is to review the opportunities volume scanned by both the higher and lower energies and is
and challenges that come with incorporating DECT into a high- displayed as a superimposed circle on the images (see question
volume neuroradiology practice. The article follows a question- below); anatomy outside this FOV is only scanned using the
and-answer format spanning those issues that impact selection, larger tube/detector system and is therefore single energy. This
workflow, and interpretation in DECT. is typically not a problem for neuroradiology applications, but can
be problematic in obese patients for abdominal applications. There
is also a relative temporal skew of approximately 70 milliseconds
SELECTION between the 2 tube/detector pairs due to the rotation time required
There are several competitive dual-energy capable computed to cover the same area. Because of the time delay, the 2 energy
tomography (CT) scanners on the market today. While the decision data sets are geometrically inconsistent. Subsequent material de-
of which scanner to choose may ultimately be influenced by current composition is performed in the image domain (rather than using
vendor relationships, one should be aware of the different methods the raw data), a process that ultimately can result in persistence of
available to perform DECT. These include (1) dual-source DECT beam hardening artifacts and less accuracy.21,22
(SOMATOM Dual Source Definition Flash, Force, and Drive;
Siemens AG, Forchheim, Germany), (2) Rapid-kV Switching DECT What Is Single-Source DECT With Rapid
(RSDECT) (Discovery HD750/Revolution 750HD and Revolution; kVp Switching?
GE Healthcare, Waukesha, Wis), and (3) layered detector DECT
These systems use a single source and detector pair (GE
(IQon; Philips Healthcare, Andover, Mass). For a thorough review
Healthcare; Canon Medical Systems, Otawara, Tochigi, Japan).
of the physical principles underlying these different methods, the
They require a proprietary and very fast, specialized detector, as
reader is referred to previously published works on this topic.19,20 well as a generator capable of quick transitions between high
It should be noted that even for specific vendors providing a
and low tube potentials. During each rotation, the tube switches
certain scanner type there may be multiple generations of the
rapidly between high (140) and low (80) kVp. The main advan-
tages of this system are that the entire field of view is scanned with
From the Department of Radiology, Wake Forest School of Medicine, Wake
Forest Baptist Health, Winston-Salem, NC.
both energies, and the temporal skew is lower relative to dual-
Received for publication August 30, 2018; accepted August 31, 2018. source scanners (delay between high and low energies can be as
Correspondence to: Jeffrey R. Sachs, MD, Wake Forest University Baptist low as 50 microseconds). This type of system allows for material
Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157 decomposition to be performed using the raw data, a process that
(e‐mail: jsachs@wakehealth.edu).
The authors declare no conflict of interest.
can minimize beam hardening in virtual monoenergetic images
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. (VMIs). One disadvantage of this system is that the gantry rotation
DOI: 10.1097/RCT.0000000000000810 time must be ~0.5 second or longer to allow for acquisition of

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J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018 Incorporating DECT Into Neuroradiology Practice

projections at 2 energies, which can prolong total scan acquisition postscanning clinic and laboratory appointments is crucial for
time. Another disadvantage is that the low-energy spectrum is limited proper utilization. Otherwise, the full capabilities of the DECT
to 80 kVp, which can make photon starvation effects worse when are likely to go underappreciated. Convenience and patient satis-
scanning larger patients. Because of the tube voltage switching faction often go hand in hand. It also cannot be underestimated
several thousand times per second, filtering the higher-energy the importance of referring clinician satisfaction when attempting
spectrum is difficult, limiting the spectral separation of the 2 en- to incorporate DECT into a practice.
ergy levels. Dose reduction features such as tube current modula- Question: Are there specific infrastructure requirements for
tion are also not possible because of the speeds involved. dual energy that would require major renovations to a hospital or
imaging center?
What Is Layered Detector DECT? Answer: In general, no. Every time a new piece of radiog-
raphy or CT scanner is installed, a new shielding plan must be
In this configuration, spectral separation is achieved at the submitted to state regulators (varying according to applicable state
detector level (Philips Healthcare). A single-tube/detector combi- laws). This requires the input from a medical physicist to ensure
nation is used, and the patient is scanned at a higher energy level that the proper perimeter shielding is in place for the safety of
such as 140 kVp. The spectral separation is achieved by having patients, health care personnel, and the public. This requirement
layered scintillator materials, with the top layer preferentially is not unique to DECT, however.
absorbing lower-energy photons but allowing the higher-energy There are variations in size between make/model of DECT
photons to pass through and be absorbed by the subsequent layer. scanner. However, in general one could expect a room within a
Major advantages of this recently available commercial system facility that previously housed an SECT scanner should be able
include scanning dual energy at full FOV (50 cm), excellent tem- to fit a DECT with minimal modification.
poral resolution, and higher total x-ray power (because it uses a
single high-energy source), which is helpful for scanning larger
patients. The rays are also inherently perfectly registered, allowing WORKFLOW
for material decomposition to be done using the raw data. How- The integration of DECT into practice requires new training
ever, this system has a lower-energy separation as the scintillator of technologists and radiologists as to the indications and capa-
absorption properties do not sharply distinguish between low- and bility of this technology. There are potential impacts upon sched-
high-energy photons. This means that the contrast of the spectral uling patients, image acquisition times, and concerns regarding
information is more limited or requires a higher radiation dose. postprocessing software and the potential impact on the workflow
The clinical efficacy of this design is not as well studied relative and productivity of the entire imaging team. This section explores
to the dual-source or rapid kVp switching systems. workflow issues that have arisen at the authors' practice.
Question: What resources are available for training technol-
Question: Do I have to purchase a new scanner to get ogists to use DECT?
dual-energy capability, or are upgrades available to my Answer: Vendors will provide an initial period of on-site
existing equipment? hands-on applications training for both technologists and physi-
Answer: It depends. Most SECT scanners are not upgrad- cians. The specific amount of applications time is negotiable at
able to dual energy. However, an upgrade may be possible, such time of contracting for the scanner(s) being purchased. If the tech-
as CT scanners from vendors that utilize fast kV switching (eg, nologists are familiar with a certain vendor's platform, changing to
HD750; GE Healthcare). Upgrading an existing model may be a new vendor means that the technologists will have to learn an
significantly more cost-effective than purchasing a new scanner. entirely new imaging platform in addition to the DECT-specific
Hardware requirements for dual-source DECT scanners and layered features. This may negatively impact adoption of DECT in unan-
detector scanners generally mean that an upgrade is not possible. ticipated ways. Considering pressure placed upon technologists for
Question: Where should the scanner be installed? expedient throughput, it may be tempting to preferentially divert
The answer to this question depends heavily on factors cases to a much more familiar, but older and less capable single-
unique to the individual practice. In making the decision, one must energy scanner. Investing more heavily in technologist training
take into account the age and level of disrepair of all scanners in up-front may mitigate the impact of introducing a new scanner
the fleet. Ideally, one would prefer to replace the oldest scanner and lead to less disturbances in the workflow. Although vendor
with the most current and feature-rich DECT. However, replacing specific, there are some DECT-specific workshops for physicians
an older scanner that is not heavily utilized may lessen the positive and technologists that one can explore to learn the physical
impact of this new technology on patients. Consider the clinical concepts of dual energy and how the data are acquired and
questions potentially impacted by DECT and in which practice en- postprocessed. Such workshops include dose and protocol optimi-
vironment they are likely to arise. For example, in our practice, it zation as well as hands-on sessions with the vendor-specific dual-
has been helpful to have the DECT scanner in a physical location energy viewing software for advanced postprocessing applications.
optimal for scanning patients with ischemic stroke who are The authors' institution primarily uses Siemens for DECT, which
postthrombectomy to differentiate contrast staining from intracra- offers a hotline where application specialists are standing by for
nial hemorrhage. Our DECT in the emergency department (ED) near-immediate assistance when help is needed (even when ac-
on numerous occasions has helped us to distinguish calcifications tively scanning a patient).
from acute intracranial hemorrhage. By adding confidence in Question: Is the dual-energy postprocessing software avail-
ruling out intracranial hemorrhage, DECT helps to improve ED able as a thin client or on a separate workstation?
throughput as well as avoid unnecessary admissions and follow- Answer: Both solutions are available. However, a single in-
up scans. dependent workstation is impractical for real-time utilization by
Streamlining patient convenience also needs to be consid- the radiologist in a busy practice. Issues would arise when several
ered when making this decision. For example, if an imaging prac- radiologists may wish to perform dual-energy postprocessing
tice currently serves a comprehensive oncology group that wishes simultaneously, and it would also require the radiologist to
to take advantage of dual-energy oncology protocols, placing a leave his/her PACS (picture archiving and communication sys-
DECT scanner in a convenient location to facilitate immediate tem) station to process images. Having a single postprocessing

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Sachs et al J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018

workstation essentially dooms the successful widespread adop- Answer: One of the most common indications for utilizing
tion of DECT in a larger practice. By implementing a vendor- DECT at the authors' institution is to differentiate iodine contrast
specific thin client that can be accessed at the PACS station, a staining from hemorrhage in patients following thrombectomy
practice is far more likely to realize widespread utilization of for acute ischemic stroke. Another common indication typically
DECT postprocessing. One additional step to consider when seen through the ED (but encountered in all practice settings) is
implementing the thin client is the number of licenses needed. differentiating acute intracranial hemorrhage from calcification
These licenses allow users to not only view but also manipulate or potential mimickers such as a cavernous malformation. Dual-
the dual-energy spectral data to obtain virtual noncontrast energy CT can reduce unnecessary consultations and hospital ad-
(VNC), virtual noncalcium (VNCa), and VMI reconstructed im- missions, prevent patient anxiety, and eliminate wasteful repeat
ages, among others. These licenses may be a rate-limiting step imaging. Virtual noncontrast images obtained via postprocessing
in day-to-day clinical use if only a small number are available are particularly helpful in patients status post recent intravenous
and multiple physicians are attempting to use the software at once. contrast material administration or post recent myelography or in
Question: Can the dual-energy postprocessing software be patients with contraindication to MRI where a single contrast-
integrated with PACS? Are there any drawbacks to doing so? enhanced acquisition can provide true postcontrast and virtual
Answer: Siemens dual-energy postprocessing software precontrast series. Dual-energy CT is also potentially useful to
Syngo.Via can successfully be integrated with Philips IntelliSpace assess for bone marrow edema in vertebral bodies if patients with
4.4 PACS via an API Plugin within the Philips PACS software. age-indeterminant compression deformities cannot undergo MRI.2,23
While this integration is a fairly simple process, there are various Question: Can dual-energy sequences be automatically sent
configuration issues that need to be weighed. This integration is to PACS?
on a per-machine basis, and one would need to consider compat- Answer: Yes. The authors' practice currently has the weighted
ibility with the operating system, system memory, network band- average images, a bone subtraction image, and a 190-keV VMI sent
width, and internet explorer security settings along with user to PACS for routine noncontrast head CT. This requires no specific
security in general. It is also prudent to consider how many other effort by the technologist and is fully automated. The 80- and
third-party plug-ins are currently configured within Philips 4.4 140-kVp acquisitions are utilized to produce the above series but
PACS as the addition of another plug-in could cause system in- are first sent to the vendor-specific postprocessing server and then
stability for the PACS. Aside from these usual considerations, in- to PACS. Although vendor specific, there is typically a limit to
tegrating Syngo.Via with Philips IntelliSpace 4.4 provides a the number of series that can be automatically sent to PACS. Net-
focused and efficient tool with few drawbacks. When integrated work speed can impact the time to availability on PACS, and this
it can be quickly accessed from within a patient's study via 1 or 2 may negatively impact both technologist and radiologist workflow.
clicks without having to access the software outside of PACS, log Question: What series are useful to automatically send
in, and then spend precious time finding the patient's study. to PACS?
While the above answer is specific for the Siemens software Answer: The VMI 190 keV is quite useful as it allows for
and PACS system at the authors' institution, similar information quick confirmation of suspected calcium versus hemorrhage
technology security and hardware concerns would apply when (calcium will be less conspicuous, whereas hemorrhage will ap-
attempting to integrate third-party applications with other PACS. pear similar to the weighted average image) and also increases
Question: What type of training do radiologists need to get conspicuity of subtle extra-axial hemorrhage due to reducing beam
comfortable with using dual-energy postprocessing? hardening artifact at the brain-bone interface. Bone subtraction
Answer: Initial hands-on training by the vendor will famil- sequences are also useful to increase conspicuity of extra-axial
iarize the radiologist with the functionality of the software. Pro- hemorrhage, and bone subtracted CTA examinations allow for
ducing the various maps and utilizing other postprocessing rapid evaluation of the vasculature as 3-dimensional (3D) recon-
features (eg, VMI ROI curves) on known entities help to develop structions can be made where the vessels are visible at the skull
confidence in diagnoses. For example, one can do postprocessing base. See below for additional information on useful sequences
on posttraumatic hemorrhage that does not present a diagnostic di- unique to spine and neck imaging.
lemma, choroid plexus calcifications, or contrast in vessels on Question: How can patients who would benefit from a dual-
postcontrast examination/CT angiography (CTA). As previously energy scan be routed to the new dual-energy scanner?
mentioned, vendor-specific workshops may be available in your Answer: In a practice with multiple CT scanners serving ED,
region for more focused hands-on training. inpatient, and outpatient settings, the scanners may be some dis-
Question: Do all scans performed on a dual-energy scanner tance apart. It is preferable to select DECT as the mode of scan-
utilize dual energy? ning at the time of scheduling. The authors have experimented
Answer: Not necessarily. A dual-source DECT scanner can with having referring clinicians request dual energy by specifying
also perform SECT, necessitating creation of DECT-specific pro- as such in the comments section in the electronic medical record,
tocols if desired. A rapid kVp switching DECT scanner has a but this approach is not 100% consistent as it relies on the technol-
dual-energy mode that must be preselected if DECT is desired. ogist to recognize the comment and route the patient to a DECT-
If using a layered detector-based scanner for DECT, all patients capable scanner. A more effective systems-based solution is to
scanned will have spectral data available for postprocessing, create dual-energy–specific orders in the electronic medical record,
which eliminates the need for DECT-specific protocols. As which should improve the workflow by seamlessly routing these
previously mentioned, the authors' institution currently utilizes patients directly to a DECT scanner. However, this requires con-
dual-source DECT, and it has been difficult to predict when tinued education of referring clinicians as to how and when to or-
dual energy will be useful in postprocessing. It is helpful to route der DECT. Likewise, investing time in technologists' education is
patients with examinations or indications that have a higher like- crucial in this process as they will often be the first to recognize
lihood of having a finding that would benefit from DECT directly and appropriately triage patients to different scanners.
to the DECT scanners. Question: What is the importance of isocentering the patient?
Question: If a practice has only 1 dual-energy scanner amid Answer: Isocentering the patient is critical to image quality
a larger fleet, which patients would benefit the most from this and dose reduction efforts. One advantage of dual-source dual-
new scanner? energy scanners is the ability to use automated tube current

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J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018 Incorporating DECT Into Neuroradiology Practice

FIGURE 1. The importance of isocentering the patient. Imperfect isocentering will lead to inaccuracies in the calculated attenuation and
imperfect tube current modulation. For example, in the middle image, the patient is positioned too high, resulting in the patient appearing
artificially large on the topogram. The tube current will be inappropriately increased in this situation, using more radiation dose than necessary.
Conversely, in the scenario on the far right image, the patient is positioned too low and appears artificially small on the topogram. Tube
current will be inappropriately low in this situation, and image noise will increase. Figure 1 can be viewed online in color at www.jcat.org.

modulation. Isocentering is important with these scanners so Answer: Yes. Dual-energy CT has several advantages over
that the appropriate geometry is available for calculations of ap- SECT. Single-energy CT is often compromised by beam-hardening
propriate tube current at any given position (Fig. 1). This allows artifacts in patients with spinal hardware as the metallic implants
for similar reference mAs to be utilized for a DECT as one would absorb the lower-energy portion of the polychromatic x-ray beam.
use for a conventional SECT scan. Radiation doses similar to The resulting higher-energy beam results in lower contrast adjacent
conventional SECT can be obtained using DECT at the same to the metal implant that manifests as dark bands on the image.
quality reference mAs.24 If the patient is out of isocenter, the High-energy VMI created via DECT can significantly reduce beam
tube current may be inappropriately high or low, which would hardening artifacts. Virtual monoenergetic image is an image that
lead to inappropriately high radiation dose or suboptimal image simulates what the scan would look like if scanned using only that
quality. Artifacts may become apparent when the patient is not specific energy level.5,25 If higher-energy monochromatic energies
isocentered (for example, see Fig. 2). Isocentering can be done are selected (greater than ~95 keV) it can virtually eliminate beam
by a variety of approaches including at the scanner workstation hardening artifact adjacent to postoperative implants.3,26–28 Bone
(scout image crosshairs) or laser guides at the gantry.
Question: If manual postprocessing of DECT images is
required, who can/should do this?
Answer: There is no question that the postprocessing of DECT
images can be time consuming. For radiologists, postprocessing the
examination by themselves can be useful as they are familiar with
the case and know what postprocessing is needed for interpretation.
“Super-user” technologists may be trained to do this postprocessing
as well, or it may be beneficial to create a “3D” laboratory if resources
are available. Many conundrums that present on noncontrast head CT
can be confidently answered with the weighted average images and
VMI 190-keV images. Vendors are constantly working to improve
the automaticity of the DECT workflows. There is no question that
a seamless, efficient workflow is very important for successful adop-
tion and growth of DECT in a busy, high-volume neuroradiology
practice. Given that not all physicians in a practice may be up-to-date
on DECT and its capabilities, let alone the postprocessing functions,
automating the process of sending spectral-based reconstructions
to PACS (especially early on implementation) would be helpful.
Question: Is the DECT spectral data available for
postprocessing indefinitely?
Answer: Not necessarily. In order to postprocess the spectral
data and create unique reconstructions such as VMI data in the
future, the spectral data must be preserved. For example, with
Siemens, the dual-source data are preserved on Syngo.Via, but
only for a set period of time before eventually the data are over-
written by new scan data because of storage limits. Therefore, it
is recommended that the most commonly utilized dual-energy
FIGURE 2. Occipital lobe artifact. Arrows point to areas of
reconstruction data sets are sent to PACS for long-term storage hypoattenuation in the occipital lobes, which can lead to an
and future use as a comparison study. However, the spectral data inappropriate diagnosis of posterior reversible encephalopathy
would not be available to permit region-of-interest analysis or syndrome or infarct. This artifact was resolved by more careful
generation of spectral HU attenuation curves. attention to isocentering the patient. Figure 2 can be viewed online
Question: Is dual-energy CT useful for spine imaging? in color at www.jcat.org.

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Sachs et al J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018

subtraction for myelography can produce a virtual myelographic differences. Bone subtraction can be helpful when interpreting head
image (similar to magnetic resonance myelography).11 Specific al- and neck CTAs, especially arterial structures in the region of the
gorithms for detection of monosodium urate in gout are available as skull base. It can also be used for calcific plaque removal, mak-
well, although the “normal” distribution of monosodium urate ing it easier to evaluate for vascular stenosis. Bone-subtracted
needs further study. A recent study has reported monosodium urate images can also be displayed as 3D and maximum intensity
crystals within the intervertebral disks of older men as a possible projection images.
physiologic finding rather than gout related.29 In theory, creation Question: Are VMI useful for routine imaging of the brain?
of VNCa images can allow detection of marrow edema that is Answer: Yes. Lower-energy VMIs maintain superior tissue
obscured by trabecular bone on conventional SECT, although contrast that can be beneficial in regions that are traditionally
the authors' initial experience with this has been disappointing. difficult to evaluate using SECT, such as the posterior fossa. The
However, several studies have evaluated the performance of DECT authors suggest VMIs with energies in the range of 65 to 75 keV
relative to MRI in evaluation of bone marrow edema.2,23,30–32 to accomplish both improved signal-to-noise and contrast-to-noise
Question: Is dual energy beneficial for CT neck examinations? ratios and acceptable beam hardening artifacts.17,40
Answer: Yes. The VMI 40 keV can be sent to PACS auto- Question: Are there any artifacts unique to DECT?
matically. Utilizing a lower keV (closer to the 33.2-keV K-edge Answer: When the authors' practice first started performing
of iodine) results in increased contrast between iodine and back- DECT head scans, we encountered an artifact in the occipital lobes
ground soft tissues. The result is that enhancing head and neck tu- where there was apparent symmetric hypoattenuation with loss of
mors may be more conspicuous on this series.4 In addition, higher gray-white differentiation, an appearance that mimicked posterior
VMI keV can reduce artifact related to dental amalgam (useful for reversible encephalopathy syndrome or infarct (Fig. 2). This artifact
evaluation of oral cavity or oropharyngeal tumors) or spine hard- was resolved by ensuring that the patient is well isocentered for
ware, but comes at the cost of decreasing visualization of enhance- the scan.
ment. Recent studies have shown that high-energy VMIs and One potential artifact that may arise in performing DECT
iodine maps/VNC images have utility in evaluating for laryngeal using dual-source technology is a detector miscalibration artifact.
cartilage invasion in the setting of laryngeal squamous cell carci- If the scanner has been used only for single-energy scans for an
noma.4,8,15,18,33,34 A nice review on incorporating DECT of the extended period prior to performing a DECT, it is possible that
neck into clinical practice was recently published.16 the second tube/detector system is “cold,” and this may result in
Question: Is dual energy beneficial for CTA examinations of a ringlike artifact (Fig. 3). This ring artifact mimics a broken de-
the head and neck? tector, but is not present on all images (does not propagate through
Answer: Yes. Metal artifact reduction techniques may im- the entire imaging volume in the Z axis). Note that photon star-
prove visualization of the vessels around the coil mass in patients vation artifact can also cause a similar appearance. To avoid
who have undergone endovascular coiling of aneurysms.27 Dual- miscalibration artifacts, performing a “checkup” is recommended
energy CT can also be useful to subtract the bones, which can if a DECT has not been performed in the past 12 hours. This will
impede interpretation of maximum intensity projection or volume- allow the second tube/detector system to both warm and become
rendered CTA images. There are several publications that investi- calibrated. This checkup should also be performed when prompted
gated the use of DECT for bone removal in CTA.35–39 at the scanner console, or when the system is rebooted.
Although technically not an artifact, the reader of DECT
should be aware if he/she is using a dual-source scanner that there
INTERPRETATION
Question: How is it apparent that one is looking at a
DECT scan?
Answer: Dual-energy CT images used for standard diagnos-
tic interpretation are very similar to those acquired with SECT.
They are created as a “weighted average,” which is a blend of
CT images acquired at the 2 energies, that is, 80 and 140 kVp.
This combines the advantages of low-energy contrast-to-noise ra-
tio and high-energy signal-to-noise ratio. At the authors' practice,
standard diagnostic DECT weighted average images contain 40%
of the 80-kVp image and 60% of the 140-kVp image. When in
doubt (especially the case when initially instituting DECT proto-
cols with dual-source systems), the dual-energy scans will have
the “DE” label on images in PACS. One can also check the dose
report that will confirm a scan was done dual energy by
documenting the CT dose index from the low- and high-energy
portions of the scan.
With DECT, there are several other commonly generated
maps that are available, typically used for problem solving. These
include VMIs, which are a simulated acquisition at a single-
energy level. Low-energy VMIs will have better soft tissue con-
trast, whereas high-energy VMIs will have better artifact reduction.
Additional maps include VNC, VNCa, and overlay maps, which
FIGURE 3. Ringlike artifact in the aortic arch on CTA (arrows).
are based on the principle of material decomposition (discussed be- Upon first impression, this may imply that a detector is broken;
low) and can effectively remove contrast or iodine from the images. however, this artifact does not propagate entirely through the Z axis
These maps can differentiate iodine from blood and blood from cal- of the scan. Such an artifact may be due to detector miscalibration
cium. Finally, bone-subtracted images are available, which are able in dual-source DECT systems or photon starvation effects. Figure 3
to differentiate calcium (bone) from iodine based on atomic number can be viewed online in color at www.jcat.org.

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J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018 Incorporating DECT Into Neuroradiology Practice

FIGURE 4. An example of the ring demarcating the boundary between single- and dual-energy scanned zones. The ring in the abdominal
CT on the left image (arrow) encompasses the anatomy scanned at both high- and low-energy spectra. On the right image, notice the
difference in noise in the liver parenchyma between the area scanned with dual energy (arrow within the circle) versus single energy
(arrow outside the circle). Figure 4 can be viewed online in color at www.jcat.org.

will be a circle superimposed on the diagnostic images. Because material decomposition, one can generate overlay maps (cal-
of space limitations in the gantry, the second tube/detector system cium, iodine) and VNC/noncalcium images. In neuroradiology,
will have a smaller FOV. The central portion of the circle de- this allows for clinically useful interrogations. It allows differenti-
marcates the anatomy scanned with both high- and low-energy ating hemorrhage from calcium and hemorrhage from iodine.
photons, and the volume outside the circle is the anatomy that However, the applications extend outside the neuroaxis. For example,
was scanned only with single, low-energy photons. As expected, VNC images can be used to evaluate the kidneys for renal lesions/
this results in an increase in image noise outside the circle. See stones in patients undergoing a contrast-enhanced examination.
the liver parenchyma in Figure 4. This is generally not a prob- Question: If dense material is still evident on the VNC/VNCa,
lem in neuroimaging because the FOV is limited but can be an does that mean it is hemorrhage?
issue in abdominal applications especially when imaging Answer: Not necessarily. While one can be confident that
obese patients. hyperdense material evident on a VNCa is not calcium and if seen
Question: Is the entire patient scanned with dual-energy on the VNC that it is not iodine, etiologies other than hemorrhage
photons on every DECT scan? can account for hyperdensity on these maps. This would include
Answer: It depends on the DECT scanner being used. If uti- hypercellular tumor, nonhemorrhagic proteinaceous material, fungus,
lizing dual-source DECT, as stated above space constraints require tuberculoma, cavernous malformation, and so on. Also, persistent
the detectors be of different sizes, so dual energy is achieved hyperdensity on a VNCa map could represent iodinated contrast.1,9,41
only in the region of overlap. On the Siemens FLASH model,
for instance, tube A is 50 cm but tube B is 33 cm. That means that CONCLUSIONS
dual-energy data are available only within the smaller 33-cm radius. The incorporation of DECT into a busy neuroradiology
If using a rapid kV switching system, there is a mode (such as practice can be challenging. Success requires thoughtfulness
“GSI” on GE systems) that if activated implies the entire FOV in scanner selection, technologist and radiologist training, and
was scanned with dual-energy photons. If using a layered detector workflow integration. There is no one-size-fits-all approach.
system, the dual-energy information is extracted at the detector Simplicity in ordering dual-energy scans and automated processes
level and is thus available for the entire FOV scanned. for sending dual-energy postprocessed series to PACS are helpful
Question: What is a material decomposition curve? in achieving efficiency and clinician satisfaction. This automation
Answer: Material decomposition is the basis by which mate- also has the added benefit of minimizing the time and effort
rials can be differentiated given their variable attenuation at differ- needed to utilize a vendor-specific “thin client” software.
ent energy spectra. The attenuation of a material at a given energy
is based on its atomic number. Materials with high atomic num-
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Sachs et al J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018

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