Journal of the Korean Physical Society, Vol. 60, No. 7, April 2012, pp.

1150∼1156

Estimates of the Image Quality and the Radiation Dose for Head and
Abdomen Phantom Image Acquisition by Using Dual-energy CT

Dae-Hong Kim, Hee-Joung Kim∗ and Chang-Lae Lee

Department of Radiological Science and Institute of Health Science,
College of Health Science, Yonsei University, Wonju 220-710, Korea

Pil-Hyun Jeon
Department of Radiological Science and Institute of Health Science,
College of Health Science, Yonsei University, Wonju 220-710, Korea and
Department of Radiology, Yonsei University Wonju Christian Hospital, Wonju 220-701, Korea

Won-Hyung Lee and Sung-Soo Jeon

Department of Radiology, Yonsei University Wonju Christian Hospital, Wonju 220-701, Korea

(Received 21 November 2011, in final form 9 February 2012)

Using dual-energy computed tomography (CT) scans, we obtained images from a raw data set
by using low- and high-energy scans (usually 80 and 140 kV, respectively). Generally, the head and
the abdomen examinations were performed using single-energy (120 kV) scanning with a routine
exposure protocol, and the images were used for diagnostic interpretation. The dual-energy CT
scans can also be used for diagnosis by using the linearly-mixed method with low- and high-energy
images. In the current study, we evaluated mixed images in dual-energy and single-energy scans for
image quality and radiation dose. The CT scan protocol for single energy was adopted from IEC
protocols, and the recommended dose from the EC. The dual-energy scan protocol was based on the
Siemens dual-energy CT scan protocol. The CT scan protocols were extended further in the mA
range for both scans to estimate the image quality corresponding to these dose alternations. The
results demonstrate that the Contrast-to-noise ratio (CNR) value of a dual-energy mixed image
is higher than that of a single-energy image in similar dose regions for both the head and the
abdomen phantoms. We observed that the dual-energy images could reduce the dose compared to
single-energy images. In the abdomen phantom study, the CNR of dual-energy images was even
higher than that of single-energy images with half the radiation dose of the single-energy scan.
Therefore, the dual-energy CT scan can accomplish a remarkable dose reduction while preserving
image quality for head and abdomen imaging.

PACS numbers: 87.59.Fm

Keywords: Linearly-mixed image, CTDIw, Contrast-to-noise ratios (CNR), Dual-energy CT
DOI: 10.3938/jkps.60.1150

I. INTRODUCTION be divided for projection-based and image-based ap-

Dual-energy computed tomography (CT) is commonly
used to obtain information such as tissue segmenta-
tion [1], plaque segmentation [2], angiography [3], and
lung perfusion [4]. Prior studies using dual-energy CT
involved measurements of both the effective atomic
numbers and electron densities [5–7], and synthesized
monochromatic imaging [8]. In dual-energy CT imag-
ing, the projection data require two different data sets
having both low- and high-energy. These data sets can
∗ E-mail: hjk1@yonsei.ac.kr; Tel:+82-33-760-2475; Fax: +82-33-
760-2562
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proaches. A synthesized monochromatic image is used in
the projection-based approach, which can reduce beam-
hardening artifacts in the CT image. The projection-
based approach is also able to produce a material se-
lective image. The image-based approach is involved in
bone removal, effective atomic number and electron den-
sity imaging, and linearly-mixed imaging for diagnos-
tic interpretations. Thus, dual-energy CT is widely used
for a variety of purposes. Additionally, dual-energy CT
images are also used in diagnostic interpretation with
equations to generate linearly-mixed images. Yu et al.
described the optimized dose fraction for dual-energy
CT scans when the total dose was the same as that
Estimates of the Image Quality and the Radiation Dose for Head · · · – Dae-Hong Kim et al.
in single-energy CT scans [9]. Generally, head and ab-
domen examinations have been performed with single-
energy CT scans by using routine scan protocols. There-
fore, both single-energy and dual-energy mixed images
have been used for diagnostic interpretations. As the
dual-energy scan includes low- and high-energy images,
the image quality and the dose dependence of the phan-
tom size need to be compared to those in single-energy
images. Furthermore, dual-energy images must optimize
the image quality within recommended dose limitations.
Hence, the purpose of the current study was to estimate
the image quality of head and abdomen phantoms with
single-energy and dual-energy mixed methods. The re-
sults from single- and dual-energy CT scans were com-
pared under routine clinical exposure conditions. The
scan protocol for tube current such as mA was alter-
nated within the recommended limited dose levels while
the other scan protocols were fixed in the single- and
the dual-energy scans. The dose ranges were extended
within the recommended dose levels for the head and the
abdomen.
II. MATERIAL AND METHODS
1. Data Acquisition
The image quality and the radiation dose of single-
energy and dual-energy scans were evaluated for head
and abdomen phantoms. We utilized the X-ray computed
tomography (CT) modality (Philips, Brilliance CT 64,
Eindhoven, Netherlands), which was originally designed
to perform single-energy scans with exposure modes at
80, 120, and 140 kV. Typically, single-energy scans (usu-
ally at 120 kV) are performed for patient diagnostic in-
terpretations. Dual-energy scans (generally at 80 and
140 kV) can also generate a single set of images for diag-
nostic interpretation with linearly-mixed equations from
two different energy images, termed the linearly-mixed
image. The equation reported by Yu et al. for obtaining
the linearly-mixed image is as follows [9]:
I = wL IL + wH IH , (1)
where IL and IH denote the low- and high-energy scan
images intensity,respectively, wL and wH are the weight-
ing factors for the low- and high-energy scan images, and
wL + wH = 1. wL is given by
2 2
CL (σH,s + σH,b )
wL = 2 2 ) + C (σ 2 + σ 2 ) , (2)
CL (σH,s + σH,b H L,s L,b
where CL and CH are the contrasts between the sig-
nal and the noise for low- and high-energy scans, σL,s
and σL,b are the noises expressed as standard deviations
at the signal and the background images in low-energy
scans, and σH,s and σH,b are the noises at the signal and
the background in high-energy scans, respectively.
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Table 1. Diagnostic reference levels for CT examination of
adults (European Commission, 1999).
Diagnostic reference level
Examination
CTDIw (mGy) DLP (mGy cm)
Head 60 1050
Sinuses 35 360
Chest 30 650
Abdomen 35 780
Pelvis 25 520
Fig. 1. A PMMA phantom for CTDIw . The diameters
of the PMMA phantoms are 16 cm for the head and 32 cm
for the abdomen. The ion chamber was inserted into the
hole at the center, 3, 6, 9, and 12 o’clock positions, and the
CTDI100 was calculated from the measured charges on the
ion chamber. CTDIw was obtained with weighting from the
equation for CTDI100 .
The single-energy scan image was used as a refer-
ence for image quality and radiation dose for compar-
ison to dual-energy scans. We used X-ray tube voltages
of 80 and 140 kV to obtain results similar to those of
dual-energy CT scans. The single-energy scans for the
head and the abdomen phantoms were performed with
scan protocols based on the International Electrotech-
nical Commission (IEC). The X-ray tube voltage was
120 kV with a rotation time of 1 s. The current was only
varied up to the levels recommended for CT radiation
doses for both head and abdomen imaging. The diag-
nostic reference levels for the CT radiation doses for the
head and the abdomen were 60 and 35 mGy, respectively,
given as CTDIw in Table 1, referring to the European
Commission (EC) [10]. The image quality was estimated
using the Philips system phantom (Philips, Sys. phan-
tom kit, Eindhoven, Netherlands). Dual-energy scans
were also performed to assess the radiation dose and im-
age quality.
2. CTDIw
Prior to radiation exposure to image the quality phan-
tom, the CTDIw values of a single-energy scan and a
dual-energy scan were measured for a head (16 cm di-
-1152- Journal of the Korean Physical Society, Vol. 60, No. 7, April 2012

ameter) and an abdomen (32 cm diameter) Polymethyl

methacrylate (PMMA) phantom. The CTDIw can be
obtained from the CDTI100 . The CTDI100 was measured
using both head and abdomen phantoms with nine holes
and a pencil ion chamber for the CT (Radical Corpora-
tion, 20X6-3CT, CA, USA). The values of CTDI100 were
calculated with the following equation:
M × Chamberlength (cm) × F × tp × cf
CTDI100 = , (3)
n×T
where M is the measured value in Roentgen, F is
the exposure-to-dose conversion factor (0.78 cGy/R in
acryl), tp is the correction factor for both temperature Fig. 2. The image quality phantoms used in this study.
and pressure, cf is the chamber calibration factor, n is The diameters of the head and the abdomen phantoms are
the number of slices, and T is the slice thickness (cm). 20 cm and 30 cm, respectively. The circles on both phantoms
The dose measurements were estimated at the center and represent the signal, and the rectangles are noise.
four peripheral locations (3 o’clock, 6 o’clock, 9 o’clock,
and 12 o’clock), as shown in Fig. 1. The CTDIw can
be obtained by using a weighted CTDI100 from the cen-
ter and the peripheral locations and the following the
equation:
1 2
CTDIw = CTDIC + CTDIP , (4)
3 3
where CTDIC is the CTDI100 measured in the center,
and CTDIP is the mean of the CTDI100 values measured
at the 3 o’clock, 6 o’clock, 9 o’clock, and 12 o’clock po-
sitions.

3. Image Evaluation cmcm

The image quality metric for medical images is di-
vided into quantitative methods and qualitative meth-
ods. We chose the image metric as the contrast-to-noise
ratio (CNR) for the quantitative method for the head
and the abdomen phantoms. The CNR is calculated as
|Ss − Sb |
CNR =
, (5)
σs2 + σb2
where Ss and Sb are the signal intensities of the signal
and background, respectively, and σs and σb are the noise
values for the signal and background in Region of interest
(ROI).
The head and abdomen phantom kits were provided by
the Philips CT system. The phantom was constructed in
two sections: one with a diameter of 20 cm for the head
section consisting of water, polyethylene, Nylon, Lexan,
acrylic, and Teflon materials, and one with a diameter
of 30 cm for the abdomen section composed of water,
Nylon, and Teflon materials. The phantom was used to
carry out a quality-control analysis of the Philips CT
modality. In head phantom imaging, the signal and the
noise are set as Teflon and water, respectively, as shown
in Fig. 2, while the signal and the noise for abdomen
phantom imaging are Teflon and Nylon, respectively.
Fig. 3. The CNR evaluations of single-energy (SE) and
dual-energy (DE) scans were performed using the head phan-
tom in similar dose regions. The DE scan outperformed at
CNR values in similar CTDIw regions.
III. RESULTS
1. Estimates of CNR and CTDIw in Single- and
Dual-energy Scans
In single scans for the head phantom, the CTDIw
ranged from 29.75 to 58.75 mGy. The CTDIw of 58.75
mGy was within the EC recommendation for the head
region. The maximum CNR value for the head phantom
was 142.28, and the minimum was 107.53. In abdomen
phantom imaging, the CTDIw ranged from 15.55 to
31.94 mGy, the maximum CNR was 49.34, and the mini-
mum was 39.73. An evaluation of image quality and radi-
ation dose between single-energy and dual-energy imag-
ing was performed for both head and abdomen phantom
imaging.
Figures 3 and 4 give the CNR values for single- and
dual-energy imaging of the head and the abdomen phan-
toms for similar dose regions. The maximum values of
Estimates of the Image Quality and the Radiation Dose for Head · · · – Dae-Hong Kim et al.
cmcm
Fig. 4. The CNR values of dual-energy scans were higher
than those of single-energy scans in similar dose regions when
using abdomen phantoms.
cmcm
Fig. 5. Comparisons of CNR values in head phantoms
between single-energy (SE) and dual-energy (DE) scans at
one-half the radiation dose of SE scans. The CNR values
were 16.27, 13.69, and 8.18% higher for head phantoms when
using single-energy scans. As a point of comparison between
the 32.85- (single-energy) and the 16.05-mGy (dual-energy)
scans, the CNR of the single-energy scan was 11.89% higher
whereas the CNR values for dual-energy scans were 2.45, 4.29,
and 11.84% higher.
the CNR for single-energy and dual-energy scans were
115.50 and 133.45 in similar dose regions for the head
phantom, respectively. The minimum values of CNR
for single-energy and dual-energy scans were 107.53 and
119.49, respectively. In the abdomen phantom analy-
sis, the maximum values of the CNR single-energy and
dual-energy scans were 41.83 and 54.58 in similar dose
regions, respectively. The minimum values of the CNR
values for single-energy and dual-energy scans were 39.73
and 50.44, respectively.
One-half of the doses for single-energy scans were cho-
sen for dual-energy scans to validate dose reduction, as
described in Figs. 5 and 6. In the single-energy scans for
the head phantom, the CNR values were 107.53, 123.58,
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cmcm
Fig. 6. The CNR values for single-energy (SE) scans using
abdomen phantoms were 10.62% higher than those of dual-
energy (DE) scans at 17.32 vs. 8.36 at one-half the radiation
dose of the SE scans. With increasing radiation dose, the
CNR values of the DE scan increased from 2.51% to 13.42%.
cmcm
Fig. 7. The dose evaluations at similar dose points for
single-energy (SE) and dual-energy (DE) scans in head phan-
toms. The radiation dose was higher for the SE scans at every
point. The point of 126.82 vs. 127.42 was chosen to estimate
the effects in clinical radiation exposure conditions. The dose
was reduced up to 40.86% when the DE scan was performed
at that point.
and 129.26 at 32.85 mGy, 47.98 mGy, and 56.25 mGy, re-
spectively, and the CNR values for the dual-energy scans
were 92.48, 108.70, and 119.49 at 16.05 mGy, 23.92 mGy,
and 27.80 mGy, respectively. In the abdomen image eval-
uation, the CNR values for the single-energy scans were
41.32, 41.78, 44.80, and 44.47 at 17.32 mGy, 20.65 mGy,
25.67 mGy, and 28.85 mGy, respectively. The CNR val-
ues for the dual-energy scans were 36.93, 42.83, 46.81,
and 50.44 at 8.36 mGy, 10.48 mGy, 12.67 mGy, and 14.41
mGy, respectively.
Figures 7 and 8 show the dose evaluations between
single- and dual-energy scans at similar CNRs. The doses
between the single- and the dual-energy scans were eval-
uated when the image qualities were similar. With the
-1154-
cmcm
Fig. 8. The radiation dose required to obtain similar CNRs
is increased for single-energy (SE) scans at every data point.
The point of 41.83 vs. 42.83 was used to evaluate the dose and
the image quality for clinical exposure conditions. The dose
was reduced up to 45.90% when a dual-energy (DE) scan was
used at that point.
head phantom, the doses in the single-energy scans were
32.85, 38.70, and 54.19 mGy at CNR values of 107.53,
120.98, and 126.82, respectively. The doses in the dual-
energy scans were 23.92, 27.80, and 32.05 mGy at CNR
values of 108.70, 119.49, and 127.42, respectively. For
the abdomen phantoms, the doses were 19.37, 29.39, and
31.94 mGy at CNR values of 41.83, 47.59, and 49.34 for
single-energy scans, and the dose for dual-energy scans
were 10.48, 12.67, and 14.41 mGy at CNR values of
42.83, 46.81, and 50.44, respectively.
2. Estimates of CNR and CTDIw in Clinical
Radiation Exposure Conditions
In single-energy scans, the routine radiation exposure
condition for the current on the head ranged from ap-
proximately 300 to 360 mAs at Yonsei University Wonju
Christian Hospital. The CNR value was 126.82 for this
range of currents for single-energy scans. The CNR of
127.42 in dual-energy CT scans is comparable to the
CNR value for the single-energy scans for head phan-
toms; the associated doses for single- and dual-energy
scans were 54.19 and 32.05 mGy, respectively. The cur-
rent for the abdomen imaging ranged from 250 to 300
mAs. The CNR values for single- and dual-energy scans
within this range were 41.83 and 42.83, and the radiation
doses were 19.37 and 10.48 mGy, respectively.
IV. DISCUSSION
The effects of single- and dual-energy scans were eval-
uated for head and abdomen phantoms. In a prior study,
Journal of the Korean Physical Society, Vol. 60, No. 7, April 2012
Yu et al. evaluated the image quality of linearly-mixed
images when the total radiation dose was constant and
the dose fraction was varied in dual-energy CT imaging
[9]. This study evaluated the optimal weighting factors
for generating linearly mixed images. In this study, CNR
values heavily depended on the phantom size. However,
the CNR values and the noise levels were altered accord-
ing to changes in weighting factors for the linear combi-
nation at the same phantom size, except for 70% of dose
partitioning at 80 kV. Therefore, we did not consider op-
timal weighting factors when the maximum CNRs were
calculated, and the mixed images were produced by us-
ing the weighting factors in Eqs. (1) and (2).
As seen in Figs. 3 and 4, the CNR values for the
dual-energy scans were higher than these for the single-
energy scans for both head and abdomen phantoms in
similar dose regions. The CNR improvement of dual-
energy images was remarkable, with maxima of 18.50
and 30.48% for the head and the abdomen phantoms,
respectively, relative to single-energy images. These re-
sults contributed to the dose reduction observed using
dual-energy CT.
When comparing the dose reduction effect, Figs. 5
and 6 demonstrate that about one-half the dose could
be used for the head and the abdomen regions when
dual-energy scans. The single-energy scan was outper-
formed in terms of CNR values for head phantoms at ev-
ery dose comparison. The CNR values were 16.27, 13.69,
and 8.18% higher for head phantoms when using single-
energy scans. The CNR results for the head phantom in-
dicate that the dose reduction effect was approximately
50% for similar CNR values. The CNR difference be-
tween single- and dual-energy scans decreased when the
current was increased. Relative to the single-energy scan,
the dual-energy scan demonstrated higher CNR values
than the single-energy scans, except for one point for
the abdomen phantoms at one-half the dose. As a point
of comparison between the 32.85- (single-energy) and the
16.05-mGy (dual-energy) scans, the CNR of the single-
energy scan was 11.89% higher whereas the CNR values
for dual-energy scans were 2.45, 4.29, and 11.84% higher.
For the abdomen study, the CNR values for single-energy
(SE) scans using abdomen phantoms were 10.62 % higher
than those of dual-energy (DE) scans at 17.32 vs. 8.36
at one-half the radiation dose of the SE scans. With in-
creasing radiation dose, the CNR values of the DE scan
increased from 2.51% to 13.42%. Thus, a dual-energy
scan of the abdomen can be used with one-half of the
radiation dose for a similar single-energy scan.
In Figs. 7 and 8, the dose evaluations at similar CNR
points are presented using single- and dual-energies for
head and abdomen phantoms. Greater dose increases
were required for single energy CTs to obtain CNRs sim-
ilar to the dual-energy CTs for both head and abdomen
phantoms. These results also included the dose reduction
aspect of dual-energy CT.
We estimated the image quality and dose between
single- and dual-energy scans in routine exposure condi-
Estimates of the Image Quality and the Radiation Dose for Head · · · – Dae-Hong Kim et al.
Fig. 9. (Color online) The X-ray spectra for single- and
dual-energy scans used in this study. The total X-ray pho-
ton fluences were 84,252,513 and 35,767,322 for single- and
dual-energy scans, respectively. The X-ray photons of the
single-energy scan are approximately 2.35 times higher than
those of the dual-energy scans. This implies that relative to
the typical single-energy method, the dual-energy method is
efficient for producing mixed CT images without increasing
the dose.
tions seen in clinical practice. Figures 7 and 8 show the
evaluation for two scans in which the dose was reduced
up to 40.86 and 45.90% for the head and the abdomen
phantoms, respectively.
The trends of dual-energy CT scans for the current
study demonstrate that the dual-energy technique can
reduce the radiation dose and maintain the image quality
compared to single-energy scans because the dual-energy
scans (80 and 140 kV) used suitable energy spectra for
generating dual-energy images characterized by the at-
tenuation coefficients of the relevant materials. Dual-
energy methods acquire their separated spectra while the
tube voltage of 120 kV generates X-ray spectra across
the energy band according to the attenuation coefficient
of a material. The mean energy of a spectrum was de-
fined as 1/3 of the maximum energy. Figure 9 describes
the X-ray spectra for single-energy scans used in clini-
cal exposure conditions for abdomen phantoms, and the
spectra for dual-energy scans were added to analyze the
mean energy and photon numbers. The mean energies of
the dual-energy spectra were 64.0 and 97.6 keV at 80 and
140 kV, respectively, and the mean energy for 120 kV was
87.6 keV as measured with a SRS-78 spectrum measure-
ment program. As seen in Fig. 9, the spectra at 140 kV
exhibited a higher mean energy than that at 120 kV.
This phenomenon could be differentiated from the low-
kV energy. The total numbers of X-ray photons were
84,252,513 and 35,767,322 for single- and dual-energy
scans, respectively. The number of X-ray photons for
a single-energy scan is approximately 2.35 times greater
than those for a dual-energy scan. From these data, the
dual-energy method is efficient for producing mixed CT
images without increased dose compared to the typical
single-energy method. Consequently, the energy separa-
tion for dual-energy scans is more effective than it is for
-1155-
single-energy scans. We performed image quality analy-
sis using quantitative methods, taking into account the
contrasts and noise levels in the signal and the back-
ground images. The quantitative method, expressed as
the CNR, has a value for both single- and dual-energy
scans. However, it is necessary to carry out qualitative
evaluations, such as Receiver Operating Characteristic
(ROC), to determine the correlation between the quanti-
tative and the qualitative method, as the CNR values are
a relative metric in single-energy and dual-energy scans.
In the current study, the CNR values for the head phan-
tom were twice those for the abdomen for both single-
and dual-energy scans. A study by Siegel et al. improved
the correlations of the radiation dose and image quality
to the effects of phantom size [11]. In the study, noise
increased at tube voltages of 80, 100, 120, and 140 kV
when the phantom size was increased and iodine con-
trast decreased with increasing phantom size. The iodine
contrast/noise function rapidly decreased with increas-
ing phantom size. In the current study, the CNR of the
head was considerably higher than that of the abdomen
phantom due to our use of Eq. (2) to obtain a linearly-
mixed image. The dose measurements were performed
using CTDI in this work because the measurements of
organ dose were difficult for actual patient dose. There-
fore, previous studies included Monte-Carlo simulation
method for the organ dose [12,13]. Especially, Christner
et al. estimated the organ dose between single- and dual-
energy CT imaging using Dose-Length Product (DLP)
with both experimental and estimating methods. The
results showed that contained the effective dose using
dual-energy CT were reduced or similar to that using
single-energy CT technique [14].
The current study suggests that dual-energy scans can
contribute to a reduced radiation dose while maintain-
ing image quality by using the only current alternation.
The dual-energy scan achieved a higher CNR with one-
half the radiation dose of a single-energy scan of the ab-
domen.
ACKNOWLEDGMENTS
This work was supported by the Basic Atomic Energy
Research Institute (BAERI) of the National Research
Foundation of Korea (KRF) funded by the Ministry of
Education, Science & Technology (MEST, grand code:
2011-0006368).
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