Patient Positioning & It's

Impact On Dose & CT

Number Accuracy

Timothy P. Szczykutowicz
Ph.D., DABR
University of Wisconsin Madison
Departments of Radiology1, Medical
Physics2 and Biomedical Engineering3
 Disclosures/COI

• TPS Equipment Grant and Consultant GE

HealthCare; supplies CT protocols to GE
HealthCare under a licensing agreement; the
founder of protocolshare.org
 CT Scanner Basics

•  All modern CT scanners employ bowAe filters and

applicaAons specialists stress proper paAent
posiAoning during training
•  CT measurement noise is affected by how many photons
make it through the paAent
•  CT measurement value (à CT #) is affected by how much
beam hardening is present
•  Any pracAce that increases detector signal uniformity will
make our detector noise (à image noise) more uniform
•  Any pracAce that reduces the amount of beam hardening
will reduce beam hardening induced arAfacts
 CT scanner basics

• What you see is what you get…

•  When a paAent is not posiAoned in the center of
the gantry, the CT localizer radiograph suffers
from either geometric magnificaAon or
minificaAon
PaAent high in PaAent low in
the gantry à the gantry à
AEC system AEC system
thinks the thinks the
paAent is paAent is
smaller than smaller than
they really are they really are

American Association of Physicists in Medicine (AAPM). "Use of water equivalent

diameter for calculating patient size and size-specific dose estimates (SSDE) in CT:
the report of AAPM Task Group 220. AAPM website." (2016).
 CT Scanner Basics

Almost all human body parts can

be positioned to take advantage
of the bowtie filter delivering more
fluence in the center of the FOV
relative to the edges

J. Hsieh
“Computed
Tomography”
 Effects of Poor Positioning

Poor positioning makes noise

non uniformity/streaks

Poor positioning makes the

CT number change

Beam hardening
induced signal
decrease
 Controlled conditions: CT number and noise changes

•  Lets look at a phantom experiment to see how changing

posiAon can change CT number and noise under controlled
condiAons
•  ROI measurements were used to quanAfy noise uniformity and
CT number change
•  Anterior and posterior ROI locaAons were chosen (averaged over 5
adjacent slices)
•  ROIs contain only uniform plasAc material
•  Noise would ideally be zero, CT # would ideally be constant

Szczykutowicz, Timothy P., Andrew DuPlissis, and Perry J. Pickhardt. "Variation in CT Number and Image
Noise Uniformity According to Patient Positioning in MDCT." American Journal of Roentgenology 208.5
(2017): 1064-1072.
Results
 Results

High-Thorax Mid-Thorax Abdomen

Anterior Posterior Anterior Posterior Anterior Posterior

Key:
Position* Mean Nois Mean Nois Mean Nois Mean Nois Mean Nois Mean Nois
e e e e e e
Yellow = CT #
deviaAon of 5-9 HU
-10 cm 10±13 17±2 23±9 28±3 -2±1 9±1 0±9 25±2 -8±1 9±1 20±2 23±1
-6 cm 12±6 15±4 13±7 21±1 -2±2 8±1 -16±3 15±1 -6±1 9±1 5±3 16±1 Orange = CT #
deviaAon of 10-19
-4 cm 0±12 13±3 6±4 15±1 -2±2 9±1 -8±5 14±2 -4±1 9±1 1±4 13±1
HU
0 cm 8±9 13±3 -9±8 12±1 1±1 9±1 -10±6 12±2 -1±1 9±1 -3±2 12±1
4 cm 12±9 12±1 -7±3 12±2 1±2 11±1 -15±5 12±3 2±2 11±1 -8±2 11±1 Red = CT # deviaAon
>20 HU
6 cm 13±4 13±2 -13±3 12±2 2±2 12±1 -20±5 12±3 7±2 13±1 -9±4 11±1

10 cm 19±12 20±2 -15±6 11±1 5±1 15±1 -23±2 13±2 9±2 16±2 -10±4 12±1

The CT number changed by over 20 HU

in some cases!
The noise changed by more than a
factor of 2 in some cases!
Mis-positioning and dose

The tube is
on different
sides of the
paAent for
the gray and
black curves
 Mis-positioning and dose

Matsubara, Kosuke, et al. "Misoperation of CT automatic tube current modulation systems with inappropriate
patient centering: phantom studies." American Journal of Roentgenology 192.4 (2009): 862-865.
 Know your AEC system!

•  Depending on how your AEC system works and how you perform your
scans, the effects seen in the last slides can differ
•  For example, in the study I reported CT # changes from, a lateral scout was
performed last which miAgated the dose change with posiAoning
Posi*on (cm) Last localizer was Last localizer was
a lateral view an AP view
(mGy) (pa*ent supine)
-10 3.14 n/a
-6 3.22 5.15
-4 3.27 4.35
0 3.32 3.32
4 3.29 2.76
6 3.23 2.21
10 3.15 n/a

All basically the same More than a 2x

difference!
 Current methods for determining patient position

• Clinically, CT technologists rely on the lasers to

help posiAon paAents within the gantry
•  The table “dips” in the center à table “dip”
causes systemaAc mis-posiAoning of paAent too
low within the gantry in our experience

Perceived middle of
Actual middle of patient
patient
 Conclusions

•  So gross mis-posiAoning causes CT number, dose, and noise

variaAons
•  Noise non-uniformity can translate into dose increase demands by
radiologist to make protocols “robust” against this kind of scan Ame
error
•  CT number differences can affect clinical decisions
•  Undesired dose variaAons make acAng on dose monitoring data more
difficult

Mis posiAoning happens at the

UW
1.9% of paAents >4 cm off, 0.3%
of paAents > 6 cm off…this is
happening every day

 Discussion

Berland, Lincoln L., et al. "Managing incidental findings on abdominal CT: white paper of
the ACR incidental findings committee." Journal of the American College of Radiology 7.10
(2010): 754-773.