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Jurnal Radiologi CT Scan
Jurnal Radiologi CT Scan
Although there has been increasing recognition of the importance of reducing radiation dose when performing
multidetector CT examinations, the increasing complexity of CT scanner technology, as well as confusion
about the importance of many different CT scan parameters, has served as an impediment to radiologists
seeking to create lower dose protocols. The authors seek to guide radiologists through the manipulation of 8
fundamental CT scan parameters that can be altered or optimized to reduce patient radiation dose, including
detector configuration, tube current, tube potential, reconstruction algorithm, patient positioning, scan range,
reconstructed slice thickness, and pitch. Although there is always an inherent trade-off between image quality
or noise and patient radiation dose, in many cases, a reasoned manipulation of these 8 parameters can allow the
safer imaging of patients (with lower dose) while preserving diagnostic image quality.
Key Words: Radiation dose, automated tube current modulation, low kVp, pitch, iterative reconstruction
J Am Coll Radiol 2013;10:840-846. Copyright © 2013 American College of Radiology
INTRODUCTION can affect radiation dose and image quality and examine
Over the past several years, there has been increasing how these can be altered to reduce dose.
recognition of the importance of reducing radiation dose In this review, we seek to provide radiologists with a
in radiologic studies, particularly with regard to multide- simple approach to the manipulation of 8 CT parameters
tector CT. The growth in the volume of multidetector that can be changed by the radiologist, while designing or
CT studies performed in the United States, the increas- altering scan protocols, to reduce patient radiation dose:
ing use of CT in susceptible populations (including chil- (1) detector configuration, (2) tube current, (3) tube
dren), and growing concerns on the part of the general potential (kVp), (4) reconstruction algorithm, (5) pa-
public with regard to radiation exposure have provided tient positioning, (6) scan range, (7) reconstructed slice
an impetus for performing these studies with the least thickness, and (8) pitch.
possible radiation dose [1]. It is now believed that as
many as 0.4% of all malignancies in the United States
can be traced back to radiation from CT studies per- DETECTOR CONFIGURATION
formed between 1991 and 1996 and that radiation from Detector configuration is a term encompassing the num-
CT studies currently being performed may ultimately ber of data channels being used in the z axis and the
account for 1.5% to 2% of all cancers in the future [2]. “effective detector thickness” of each data channel. For
Unfortunately, despite this growing awareness among example, a detector configuration of 64 ⫻ 0.5 mm would
radiologists, the introduction of each new generation of suggest the use of 64 data channels in the z-axis, each of
CT scanners has resulted in scanning protocols that are
which has an effective thickness of 0.5 mm. Notably, the
increasingly complex and difficult to manipulate for a
effective detector thickness represents the smallest possi-
radiologist whose primary expertise lies in clinical imag-
ble reconstructed slice thickness: if a study is acquired
ing rather than medical physics. When facing increasing
criticism regarding CT dose, the best way to tackle the with an effective detector thickness of 0.5 mm, images
issue is to understand all the factors and parameters that cannot be reconstructed to any smaller interval (such as
0.25 mm). Both the number of channels used and the
effective detector thickness can be varied depending on
Department of Radiology, Johns Hopkins University, Baltimore, Maryland.
how many channels in a detector array are used, which
Corresponding author and reprints: Siva P. Raman, MD, Johns Hopkins
channels in a detector array are used, and the manner in
University, Department of Radiology, JHOC 3251, 601 N Caroline Street, which different channels are combined [3]. Different scan-
Baltimore, MD 21287; e-mail: srsraman3@gmail.com. ners from different manufacturers have different included
detector channels, and the detector configurations available most applications. This computer software, which has
on different equipment can vary widely [4]. various names depending on the specific vendor (ie,
The product of the detector configuration (the num- CARE Dose 4D on Siemens, Dose-Right on Phillips,
ber of data channels multiplied by the effective detector Auto mA/Smart mA on GE, and SUREExposure 3D on
row thickness) is equivalent to the beam collimation. The Toshiba), automatically increases the mAs in those parts
physical manifestation of the beam collimation is the of the body with the greatest attenuation and decreases
x-ray beam size as defined at the gantry isocenter [5]. In the mAs in those parts of the body with lower attenua-
the example given previously, with a detector configura- tion. As a result, the software usually increases the mAs in
tion of 64 ⫻ 0.5 mm, the beam collimation would be 32 the shoulder and hips (which have relatively more atten-
mm. This has a critical impact on patient dose because uation) and decreases the mAs in the abdomen and tho-
the x-ray beam is actually slightly wider than the beam rax (which have relatively less attenuation) [1,7]. In most
collimation as a result of a penumbra effect (also referred cases, automated tube current modulation reduces pa-
to as “overbeaming”), resulting in a small amount of tient dose and minimizes photon starvation artifacts.
“wasted” radiation dose with each rotation [6]. As a re- Automated tube current modulation works on differ-
sult, if a smaller beam collimation (4 ⫻ 0.5 mm) is used, ent principles depending on the specific vendor, al-
the relative wasted dose is relatively high compared with though a combination of 4 different strategies is generally
the primary beam size. On the other hand, with a larger used: Patient size modulation varies the mAs on the basis
64 ⫻ 0.5 mm collimation, the wasted dose is relatively of a global evaluation of the overall size of the patient as
low compared with the primary beam size. However, it seen on the scout radiograph. Z-axis modulation changes
should be noted that with the newest CT scanners, the the mAs constantly along the z-axis of the patient de-
penumbra effect is much less apparent compared with pending on the patient attenuation at each point, as
earlier generations of spiral CT technology because the determined using the scout image. Angular (x, y) modu-
extent of the overbeaming or penumbra effect is less lation changes the mAs as the x-ray tube rotates 360°
pronounced (relative to the beam width). Therefore, the around the patient to account for different attenuations
need to obtain a smaller effective detector thickness to in different projections of the x-ray beam [1]. Combined
improve spatial resolution in the z-axis must be balanced x, y, and z modulation adjusts the mAs in all 3 axes on the
against the increased radiation dose associated with such basis of the patient’s attenuation [8]. The user must de-
a detector configuration, as well as longer scan times fine a minimum acceptable image quality, the definition
[3,5]. of which will vary depending on the specific vendor and
The detector configuration should be determined on system. For example, GE users must specify a noise index
the basis of the type of study performed, the necessary value that is maintained as a constant on every image in a
slice thickness for multiplanar reformations (MPRs), and series, while Siemens users must specify an image quality
the need for 3-D images. For routine acquisitions, with- reference mAs, the mAs that would be used for an aver-
out the need for thin-section MPR images or 3-D imag- age-sized patient [1].
ing, an extremely thin effective detector thickness is In almost all cases, automated tube current modulation
unnecessary. In such cases, if thick-section 5-mm images should be enabled and used by all users, although some
in the axial, coronal, and sagittal planes are sufficient for significant caveats and exceptions must be kept in mind:
radiologist review, the effective detector thickness can be
● Small or pediatric patients, when incorrectly positioned
widened to 1.25 or 1.5 mm (rather than 0.75 or 0.5
or improperly centered within the CT gantry, can result
mm), without a marked impact on image quality (either
in excessively noisy images with artificially low mAs. Not
for the axial images or MPR images). However, if thin-
only must technologists be properly taught to correctly
section MPRs or high-resolution 3-D images (with in-
position patients, but it may also be helpful to modify the
creased spatial resolution in the z-axis) are required, a
noise index or increase the reference mAs for smaller
thin effective detector thickness (0.5-0.75 mm) may be
patients (while still capping the maximum mAs to avoid
necessary, although there is an associated dose penalty.
inadvertently high radiation doses) [8,9].
● Many institutions do not use automated tube current
TUBE CURRENT modulation when performing scans of the head, particu-
Increases in tube current or the product of tube current larly in pediatric patients, because of the difficulty in
and scan time (mAs) result in improved image quality, correctly placing the head in the isocenter of the gantry. A
decreased image noise, and increased patient dose. In small deviation of the head from the isocenter can result
general, the relationship between tube current and pa- in a significant increase in image noise.
tient dose is essentially linear, with increases in mAs ● Patients’ arms should be out of the field of view for
resulting in a comparable percentage increase in patient both scout-image and axial-image acquisition. Any
dose [3]. Although tube current can be manually con- discrepancy in the position of the arms between the
trolled, most operators use automated tube current mod- scout and axial images can adversely affect the algo-
ulation (also known as automated exposure control) for rithm’s function and theoretically increase dose. If
842 Journal of the American College of Radiology/ Vol. 10 No. 11 November 2013
general, the larger the reconstructed slice thickness used, true dose savings in nonvascular studies in the chest or
the lower the patient dose. It is worth repeating, however, abdomen. In particular, in such cases, some systems will
that the reconstructed slice thickness cannot be smaller attempt to maintain a constant effective mAs (Siemens)
than the acquired slice thickness. or mAs per slice (GE) (tube current ⫻ rotation time/
pitch) and will consequently increase the tube current to
compensate for the increased pitch. In addition, in pa-
PITCH
tients who are large, the system may attempt to increase
Pitch in the multidetector, spiral CT era is defined as
the tube current but may be precluded from doing so as a
table travel per rotation divided by beam collimation.
result of a capped or limited mAs, and image noise may
Pitch ⬍1 suggests overlap between adjacent acquisi-
actually rise. Accordingly, in nonvascular studies in
tions, pitch ⬎1 implies gaps between adjacent acquisi-
which scan speed is not as important, using a high-pitch
tions, and pitch of 1 suggests that acquisitions are
technique may offer little dose savings and potentially
contiguous, with neither overlap nor gaps [7]. A smaller
worse image quality. That said, high-pitch techniques on
pitch, with increased overlap of anatomy and increased
these scanners still offer significant value in nonvascular
sampling at each location, results in an increased radia-
studies in children, in whom scan speed is critical.
tion dose. Alternatively, a larger pitch implies gaps in the
anatomy and hence lower radiation dose. As a result, if all
other parameters are unchanged, increasing pitch reduces CONCLUSIONS
radiation dose in a linear fashion [7,33]. Low-pitch tech- As both the general public and clinicians have become
nique is associated with less image noise, fewer artifacts, increasingly aware of the concerns associated with mul-
and improved signal-to-noise and contrast-to-noise ra- tidetector CT–related radiation dose, it has become crit-
tios [34]. For routine body CT protocols, pitch ⬎1 is ical for radiologists to better understand the CT scanner
generally acceptable with no compromise to image qual- technology they work with. In particular, a detailed under-
ity. However, using higher pitches (pitch ⬎1.5) can re- standing of a few basic CT scan parameters is essential, and
sult in interpolation artifacts and image noise that is knowledge of how to manipulate these parameters to pro-
typically unacceptable. For most cardiac CT applica- duce diagnostic images at lower doses is critical for safe
tions, pitch values ⬍0.5 are routinely used, resulting in imaging.
higher doses in such studies. These lower pitch values are
used to overcome motion artifacts and are also stipulated TAKE-HOME POINTS
by the reconstruction algorithms in use. As mentioned
earlier, one major caveat to this discussion of the normal ● Several multidetector CT parameters can be changed
relationship between pitch and radiation dose is the fact to reduce radiation dose, including detector configu-
that certain scanners use the concept of effective mAs or ration, tube current, kVp, reconstruction algorithm,
mAs per slice [33]. In these cases, the effect of pitch on patient positioning, scan range, reconstructed slice
dose is negated by proportional increases in tube current thickness, and pitch.
to maintain similar image noise. ● Although all users should generally use automated
Although higher pitch values have traditionally been tube current modulation, users must be careful about
thought to be associated with poor image quality, this is using this software in obese patients, children, and
no longer true with the latest dual-source CT technology. patients with metallic hardware.
A study by Apfaltrer et al [35] using pitch values ⬎3 on a ● Low-kVp protocols may be most useful in thin, non-
dual-source scanner for vascular studies suggested that obese patients, particularly in vascular or angiographic
image quality was more than acceptable, with radiation studies.
dose savings as high as 45% to 50%. The newest dual- ● Iterative reconstruction techniques allow the recon-
source scanners offer high-pitch or FLASH mode acqui- struction of images with improved image quality, even
sitions with pitch values ⬎3, consequently decreasing in cases in which the imparted radiation dose and
scan times precipitously and potentially reducing radia- contrast-to-noise ratios are low.
tion doses significantly. These high-pitch modes mark- ● The scan range should be reduced to the needed min-
edly reduce scan times and eliminate many motion- imum for any examination.
related artifacts, particularly those previously seen with ● Incorrect positioning of patients in the scanner gantry can
cardiac imaging [36]. However, it should be noted that be associated with significant radiation dose penalties.
there are significant caveats that should induce some
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