ICRU REPORT No.

87

RADIATION DOSE AND IMAGE-QUALITY

ASSESSMENT IN COMPUTED
TOMOGRAPHY

THE INTERNATIONAL COMMISSION ON

RADIATION UNITS AND
MEASUREMENTS

Journal of the ICRU Volume 12 No 1 2012

Published by Oxford University Press
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT
IN COMPUTED TOMOGRAPHY

Report Committee
J. M. Boone (Chair), University of California Davis, Sacramento, California, USA
J. A. Brink, Massachusetts General Hospital, Boston, Massachusetts, USA
S. Edyvean, Public Health England, Oxfordshire, UK
W. Huda, Medical University of South Carolina, Charleston, South Carolina, USA
W. Leitz, Swedish Radiation Protection Authority, Stockholm, Sweden
C. H. McCollough, Mayo Clinic, Rochester, Minnesota, USA
M. F. McNitt-Gray, University of California Los Angeles, Los Angeles, California, USA

ICRU Sponsors
P. Dawson, UCL Hospitals, London, UK
P. L. M. DeLuca, University of Wisconsin, Madison, Wisconsin, USA
S. M. Seltzer, National Institute of Standards and Technology, Gaithersburg, Maryland, USA

Consultants to the Report Committee

J. A. Brunberg, University of California Davis, Sacramento, California, USA
G. W. Burkett, University of California Davis, Sacramento, California, USA
R. L. Dixon, Wake Forest University, South Carolina, USA
J. Geleijns, Leiden University Medical Center, Leiden, The Netherlands
J. P. McGahan, University of California Davis, Sacramento, California, USA
S. E. McKenney, University of California Davis, Sacramento, California, USA
N. J. Pelc, Stanford University, Palo Alto, California, USA
J. H. Siewerdsen, Johns Hopkins University, Baltimore, Maryland, USA
J. A. Seibert, University of California Davis, Sacramento, California, USA
H. Winer-Muram, University of Indiana, Indianapolis, Indiana, USA
S. Wootton-Gorges, University of California Davis, Sacramento, California, USA

The Commission wishes to express its appreciation to the individuals involved in the preparation of this
Report for the time and efforts that they devoted to this task and to express its appreciation to the
organizations with which they are affiliated.

All rights reserved. No part of this book may be reproduced, stored in retrieval systems or transmitted in
any form by any means, electronic, electrostatic, magnetic, mechanical photocopying, recording or
otherwise, without the permission in writing from the publishers.

British Library Cataloguing in Publication Data. A Catalogue record of this book is available at the British
Library.
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
The International Commission on Radiation Units and
Measurements
Introduction
The International Commission on Radiation Units
and Measurements (ICRU), since its inception in
1925, has had as its principal objective the develop-
ment of internationally acceptable recommendations
regarding:
(1) quantities and units of radiation and radioactivity,
(2) procedures suitable for the measurement
and application of these quantities in clinical
radiology and radiobiology, and
(3) physical data needed in the application of these
procedures, the use of which tends to assure
uniformity in reporting.
The Commission also considers and makes similar
types of recommendations for the radiation protec-
tion field. In this connection, its work is carried
out in close cooperation with the International
Commission on Radiological Protection (ICRP).
Policy
The ICRU endeavors to collect and evaluate
the latest data and information pertinent to the
problems of radiation measurement and dosimetry
and to recommend the most acceptable values and
techniques for current use.
The Commission’s recommendations are kept
under continual review in order to keep abreast of
the rapidly expanding uses of radiation.
The ICRU feels that it is the responsibility of
national organizations to introduce their own
detailed technical procedures for the development
and maintenance of standards. However, it urges
that all countries adhere as closely as possible to
the internationally recommended basic concepts of
radiation quantities and units.
The Commission feels that its responsibility lies
in developing a system of quantities and units having
the widest possible range of applicability. Situations
can arise from time to time for which an expedient
solution of a current problem might seem advisable.
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/ndt006
Generally speaking, however, the Commission feels
that action based on expediency is inadvisable
from a long-term viewpoint; it endeavors to base
its decisions on the long-range advantages to be
expected.
The ICRU invites and welcomes constructive
comments and suggestions regarding its rec-
ommendations and reports. These may be trans-
mitted to the Chairman.
Current Program
The Commission recognizes its obligation to
provide guidance and recommendations in the areas
of radiation therapy, radiation protection, and the
compilation of data important to these fields, and to
scientific research and industrial applications of
radiation. Increasingly, the Commission is focusing
on the problems of protection of the patient and
evaluation of image quality in diagnostic radiology.
These activities do not diminish the ICRU’s commit-
ment to the provision of a rigorously defined set of
quantities and units useful in a very broad range of
scientific endeavors.
The Commission is currently engaged in the
formulation of ICRU Reports treating the following
subjects:
Bioeffect Modeling and Biologically Equivalent
Dose Concepts in Radiation Therapy
Concepts and Terms for Recording and Reporting
Gynecologic Brachytherapy
Key Data for Measurement Standards in the
Dosimetry of Ionizing Radiation
Measurement and Reporting of Radon Exposure
Operational Radiation Protection Quantities for
External Radiation
Prescribing, Recording, and Reporting Ion-Beam
Therapy
Small-Field Photon Dosimetry and Applications in
Radiotherapy
The Commission continually reviews radiation
science with the aim of identifying areas in which
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
the development of guidance and recommendations
can make an important contribution.
The ICRU’s Relationship with Other
Organizations
In addition to its close relationship with the ICRP,
the ICRU has developed relationships with national
and international agencies and organizations. In
these relationships, the ICRU is looked to for
primary guidance in matters relating to quantities,
units, and measurements for ionizing radiation, and
their applications in the radiological sciences. In
1960, through a special liaison agreement, the ICRU
entered into consultative status with the
International Atomic Energy Agency (IAEA).
The Commission has a formal relationship with the
United Nations Scientific Committee on the Effects
of Atomic Radiation (UNSCEAR), whereby ICRU
observers are invited to attend annual UNSCEAR
meetings. The Commission and the International
Organization for Standardization (ISO) informally
exchange notifications of meetings, and the ICRU is
formally designated for liaison with two of the ISO
technical committees. The ICRU also enjoys a strong
relationship with its sister organization, the
National Council on Radiation Protection and
Measurements (NCRP). In essence, these organiz-
ations were founded concurrently by the same indi-
viduals. Presently, this long-standing relationship is
formally acknowledged by a special liaison agree-
ment. The ICRU also exchanges reports with the fol-
lowing organizations:
Bureau International de Métrologie Légale
Bureau International des Poids et Mesures
European Commission
Council for International Organizations of Medical
Sciences
Food and Agriculture Organization of the United
Nations
International Council for Science
International Electrotechnical Commission
International Labour Office
International Organization for Medical Physics
International Radiation Protection Association
International Union of Pure and Applied Physics
United Nations Educational, Scientific and Cultural
Organization
The Commission has found its relationship with
all of these organizations fruitful and of substantial
benefit to the ICRU program.
Operating Funds
In recent years, principal financial support has
been provided by the European Commission, the
National Cancer Institute of the US Department of
Health and Human Services, and the International
Atomic Energy Agency. In addition, during the last
10 years, financial support has been received from
the following organizations:
American Association of Physicists in Medicine
Belgian Nuclear Research Centre
Canadian Nuclear Safety Commission
Electricité de France
Helmholtz Zentrum München
Hitachi, Ltd.
International Radiation Protection Association
International Society of Radiology
Ion Beam Applications, S.A.
Japanese Society of Radiological Technology
MDS Nordion
National Institute of Standards and Technology
Nederlandse Vereniging voor Radiologie
Philips Medical Systems, Incorporated
Radiological Society of North America
Siemens Medical Solutions
US Department of Energy
Varian Medical Systems
In addition to the direct monetary support pro-
vided by these organizations, many organizations
provide indirect support for the Commission’s
program. This support is provided in many forms,
including, among others, subsidies for (1) the time
of individuals participating in ICRU activities,
(2) travel costs involved in ICRU meetings, and
(3) meeting facilities and services.
In recognition of the fact that its work is made
possible by the generous support provided by all
of the organizations supporting its program, the
Commission expresses its deep appreciation.
Hans-Georg Menzel
Chairman, ICRU
Geneva, Switzerland
Journal of the ICRU Vol 12 No 1 (2012) Report 87 doi:10.1093/jicru/ndsxxx
Oxford University Press

Radiation Dose and Image-Quality Assessment

in Computed Tomography

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.1 CT Manufacturers and Model Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2. Basics of Computed-Tomography Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.1 CT-Scanner Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2.2 Scan-Acquisition Modes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2.1 Axial CT Scanning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2.2 Helical (Spiral) Scan Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.2.3 Repeated Scanning at the Same Table Position. . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.2.4 Dual-Energy CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.2.5 Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3 Scan-Acquisition Parameters and Their Effects on Image Quality . . . . . . . . . . . . . . . . 19
2.4 Dose-Reduction Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.4.1 Fixed Tube Current (Technique Charts) and Patient Size. . . . . . . . . . . . . . . . . 20
2.4.2 Automatic Exposure Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.4.3 Angular and Longitudinal X-Ray-Tube-Current Modulation . . . . . . . . . . . . . . 21
2.4.4 Adjusting X-Ray-Tube Potential Based on Patient Size . . . . . . . . . . . . . . . . . . . 21
2.4.5 Beam-Shaping Filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.4.6 Image-Reconstruction and Noise-Reduction Algorithms. . . . . . . . . . . . . . . . . . 22
2.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

3. Computed Tomography in Clinical Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

3.1 Introduction . . . . . . . . . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 25
3.2 CT in Neuroradiology . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 25
3.3 CT in Thoracic Radiology . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 28
3.4 CT in Abdominal Imaging . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 29
3.5 CT in Pediatric Radiology. . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 31
3.6 CT in Clinical Use: Summary . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 33

4. Overview of Existing CT-Dosimetry Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

4.1 Goals of CT Dosimetry . . .. .. .. . .. ........................................... 35

4.2 CTDI-Based Metrics . . . . .. .. .. . .. ........................................... 36
4.2.1 Basic Tools . . . . . .. .. .. . .. ........................................... 36
4.2.2 CTDI1 . . . . . . . . . .. .. .. . .. ........................................... 38

# International Commission on Radiation Units and Measurements 2013

 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

4.2.3 CTDIFDA. . . . . . . . . . . . . . . . . . . ......................................... 38

4.2.4 The nT Term . . . . . . . . . . . . . . . ......................................... 39
4.2.5 CTDI100 . . . . . . . . . . . . . . . . . . . ......................................... 40
4.2.6 Weighted CTDI, CTDIw . . . . . . ......................................... 41
4.2.7 Volume CTDI, CTDIvol . . . . . . . ......................................... 41
4.2.8 Limitations of CTDIvol . . . . . . ......................................... 41
4.3 Dose – Length Product . . . . . . . . . . . . . ......................................... 42
4.3.1 Limitations of CTDI Methods ......................................... 42
4.4 Estimation of Effective Dose. . . . . . . . ......................................... 43

5. CT X-Ray-Spectrum Characterization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. . 47
5.2 Methods for HVL Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. . 48
5.2.1 Conventional HVL Assessment in CT . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. . 48
5.2.2 Aluminum-Cylinder Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. . 48
5.2.3 Real-Time Probes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. . 48
5.2.4 Aluminum Cage with Real-Time Probe Method. . . . . . . . . . . . . . . . . . .. .. . .. . 50
5.3 Spectrum Assessment Using the Tube Potential and the HVL . . . . . . . . . . . . .. .. . .. . 50
5.3.1 Off-Angle HVL Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. . 52
5.4 Typical HVL Values in CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . .. . 52

6. CT Output Characteristics Measured in Air. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.2 Theoretical Methods for Predicting fair(z) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.3 Measurement of fair(z) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
6.3.1 Optically Stimulated Luminescence Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
6.3.2 TLD Measurements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.3.3 Film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.3.4 Computed-Radiography Detectors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.3.5 Real-Time Radiation Detectors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.3.6 Summary of fair(z) Measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
6.4 Measurement of fL(x) or fA(u) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
6.4.1 Measurement of fL(x) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
6.4.2 Measurement of fA(u) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
6.5 Planar Measurements of the CT Beam Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
6.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

7. CT Dosimetry in Phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

7.1 Axial Dose Profiles in Phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

7.2 Cumulative Absorbed-Dose Distributions for Helical Scans . . . . . . . . . . . . . . . . . . . . . 72
7.3 Equilibrium Dose, Deq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
7.3.1 Dose Profile for a Single Axial Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
7.3.2 Cumulative Absorbed-Dose Distribution, DL(z), for Multiple Rotations 74
Covering a Scan Length L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.4 Phantom Design and Usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
7.5 AAPM Report 111 Recommendations for Assessment of H(L). . . . . . . . . . . . . . . . . . . . . 78
7.6 The Role of the Real-Time Radiation Meter in Measuring H(L) . . . . . . . . . . . . . . . . . . 80
7.7 Measurement of h(L) in the Clinical Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
7.8 Rise to Equilibrium in 160 mm and 320 mm PMMA phantoms. . . . . . . . . . . . . . . . . . . . 84
7.9 The Radial Dose Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
7.10 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

8. Patient Size-Specific Dose Estimation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

 Contents

8.1 Introduction . . . . . . . . . . . . . . . . . . . .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 89
8.2 Absorbed Dose versus Patient Size .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 90
8.3 Size Metrics . . . . . . . . . . . . . . . . . . . . .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 91
8.4 Size-Specific Dose Estimates . . . . . .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 95
8.5 Summary . . . . . . . . . . . . . . . . . . . . . . .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 97

9. Automatic Exposure Control in CT . . . . . . . . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 99

9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 99
9.2 Automatic Exposure Control . . . . . . . . . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 99
9.3 Angular Tube-Current Modulation . . . . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 100
9.4 Patient Dose Assessment with TCM . . . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 101
9.5 Examples of Slice-by-Slice CT Dose Calculation. .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 101
9.6 Organ-Dose Estimation . . . . . . . . . . . . . . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 104
9.7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. .. . .. .. .. . .. .. .. . .. .. .. . .. . 105

10. Spatial Resolution in CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. . 107

10.2 Basic Spatial-Resolution Metrics. . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. . 107
10.3 Assessment of Axial-Plane Resolution in CT . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. . 108
10.3.1 Limitations and Concerns in Axial-MTF Assessment .. . .. .. .. . .. .. .. . .. . 112
10.4 Resolution Along the z Axis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. . 115
10.5 Modern Resolution Metrics in CT . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. . 117
10.5.1 Axial-Plane Resolution. . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. . 117
10.5.2 z-Axis Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. . 118
10.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. . 118

11. Noise Assessment in CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

11.1 Introduction . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. ...................... 121

11.2 Basic Noise Metrics . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. ...................... 121
11.3 The Noise-Power Spectrum, NPS(f) .. . .. .. .. . .. .. .. . .. ...................... 122
11.4 Demonstration of NPS Utility. . . . . . .. . .. .. .. . .. .. .. . .. ...................... 127
11.5 Noise-Equivalent Quanta, NEQ . . . . .. . .. .. .. . .. .. .. . .. ...................... 130
11.6 Dose-Normalized NPS(f) . . . . . . . . . . .. . .. .. .. . .. .. .. . .. ...................... 133
11.7 Summary . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. .. . .. .. .. . .. ...................... 134

12. Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

12.1 Radiation-Dose Assessment in CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

12.1.1 Existing CT-Dosimetry Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
12.1.2 CT X-Ray-Spectrum Characterization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
12.1.3 CT Output-Related Parameters Measured in Air . . . . . . . . . . . . . . . . . . . . . . . 136
12.1.4 CT Dosimetry in Phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
12.1.5 Patient SSDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
12.1.6 Automatic Exposure Control in CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
12.2 Other Considerations in Patient Dosimetry in CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
12.3 Image-Quality Metrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
12.3.1 Spatial Resolution in CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
12.3.2 Noise Assessment in CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
12.4 Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
12.4.1 Real-Time Probe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
12.4.2 Rise-to-Equilibrium Curve, H(L) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
12.4.3 Incorporation of Scan-Length Corrections to the SSDE . . . . . . . . . . . . . . . . . 140

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
Preface
For nearly three decades, the ICRU has devel-
oped authoritative Reports dealing directly with
radiological imaging. These include: Report 41,
Modulation Transfer Function of Screen-Film
Systems (1986); Report 54, Medical Imaging – The
Assessment of Image Quality (1995); Report 70,
Image Quality in Chest Radiography (2003); Report
74, Patient Dosimetry of X Rays Used in Medical
Imaging (2005); Report 79, Receiver Operating
Characteristic Analysis in Medical Imaging (2008);
and Report 82, Mammography – Assessment of
Image Quality (2009). This Report on computed
tomography (CT) continues that series and is
intended to advance dosimetry and image-quality
evaluation in this important application.
Computed tomography has experienced rapid
growth in technological sophistication, and with
these advancements there has been a commensur-
ate increase in the types of clinical questions that
can be addressed. In addition to profound improve-
ments in image quality, the acquisition times for
routine CT examinations have dropped from several
minutes in the early era to a few tens of seconds
today, opening up new clinical uses, including pedi-
atric, cardiac, and thoracic imaging, for which
organ or patient motion preclude the use of other
imaging modalities. The improvement in the diag-
nostic information that CT provides has led to a
large increase in utilization, with well over 100
million studies performed worldwide annually.
CT scans involve radiation exposure, and the
radiation dose levels in most cases are higher
than with other radiographic examinations. The
higher dose levels, coupled with the very large
number of CT scans performed annually, has led
to concerns about the associated radiation risks.
The National Council on Radiation Protection and
Measurements has reported that 48 % of the
average total dose to citizens in the U.S. is from
medical-imaging procedures, and of this about
49 % is due to CT. Thus, approximately 24 % of the
radiation burden to the U.S. population is from CT
examinations.
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/ndt007
There have been a number of dosimetric quan-
tities used for CT since the early 1980s, and these
have undergone incremental changes over the past
3 decades. It has been recognized that in light of
the large population doses associated with CT, and
given the improved features of modern scanners,
that current radiation-dosimetry methods are out
of date. Therefore, there is a need to make more ac-
curate measurements of more relevant parameters,
including those that take into consideration scan-
specific parameters such as patient size and the
length of the scan.
One of the principal driving forces for the
increased use of CT for clinical diagnosis is the
phenomenal improvement in image quality that
has occurred over the past 15 years. In addition to
increased spatial resolution, improvements in
detectors, x-ray tubes, and reconstruction algo-
rithms have led to significant improvements in the
signal-to-noise properties in CT images. These
improvements challenge traditional measures of
image quality. This Report seeks to amend,
improve, and update the methods for both dosim-
etry and image-quality evaluation in CT. After
reviewing current CT-dose metrics, a number of
updated measurement procedures are recom-
mended that capitalize on faster systems and on
new phantom designs that allow more accurate as-
sessment of dose in patients. Measurement proce-
dures are introduced that allow rapid measurement
of the x-ray beam in terms of both its quality and
the spatial distribution of the air kerma. Updated
methods for characterizing image quality, including
both spatial resolution and noise performance are
recommended. Overall, this Report capitalizes on
recent developments in CT metrology combined with
new measurement technology, with the intent of
providing more accurate characterization of the dose
and image-quality from modern, high-performance
CT systems.
John M. Boone
Stephen M. Seltzer
Journal of the ICRU Vol 12 No 1 (2012) Report 87 doi:10.1093/jicru/ndt004
Oxford University Press

Glossary

Artifact the appearance in the CT image of details not present in the scanned object.
Acquisition process of acquiring raw data by measuring the transmission of the x-ray
beam through an object.
Acquisition channel one or more electronically coupled detector arrays yielding one transmission
profile.
Attenuation reduction in the number of photons in an x-ray beam upon passage through
matter.
Automatic exposure control automatic adjustment of the tube current, depending on the attenuation of
the patient, to achieve a pre-determined level of image quality.
Axial CT the standard step-and-shoot acquisition mode of CT scanners. Also called se-
quential by some manufacturers.
Axis of rotation axis about which the x-ray tube rotates, coincident with the isocenter.
Back projection a mathematical procedure for CT reconstruction, based on projecting
the detected x-ray signal back along the measurement trajectory between
detector element and focal spot.
Beam filtration material, usually metal or plastic, placed in the x-ray-tube port that filters
the x-ray beam and preferentially removes lower-energy photons, sparing
some dose to the patient.
Beam hardening the result of filtration of a polychromatic beam by the absorption of lower-
energy photons in a patient or material, with a subsequent increase in
effective energy. Beam hardening can cause artifacts in CT images, so the
x-ray spectrum is pre-hardened in CT to reduce beam-hardening artifacts.
Beam-shaping filter same as bow-tie filter.
Bow-tie filter a metal filter that is placed in the x-ray-tube assembly, which is thicker at
the periphery and tapers gradually to a thin filter at the center of the beam.
The bow-tie filter reduces x-ray intensity incident peripherally upon the
patient, and compensates for the typically round contours of the patient’s
body to deliver a more homogeneous beam intensity to the detector arrays.
Breast computed tomography a method of examining the breast utilizing a specially designed CT scanner,
where the breast hangs pendant into the field of view with the woman lying
prone on the table.
Collimation geometrical limitation of the extent of the radiation beam in the z direction.

# International Commission on Radiation Units and Measurements 2013

 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Computed-tomography dose integral along a line parallel to the axis of rotation (z) of the air-kerma
index (CTDI) profile;
ð
1 1
CTDI1 ¼ KðzÞdz;
nT 1

where K(z) is the air kerma as a function of z,

n is the number of sections,
T is the nominal section thickness.
Computed tomography (CT) a process to image anatomical information in a cross-sectional plane of the
body from a computed synthesis of x-ray transmission data.
Computed-tomography a method of examining blood vessels utilizing a CT scanner and injection of
angiography (CTA) iodine-containing contrast medium.
CT generation indicates place in the evolution of CT technology. First- and second-
generation CT geometry used rotate-translate motions, but all modern
MDCT systems use a third-generation motion: rotate-rotate, for which the
x-ray tube and detector arrays are mounted rigidly on a rotating gantry.
Fourth-generation CT uses a rotating x-ray source with a full 2p ring of
detectors.
CT number equivalent to Hounsfield Unit (HU).
Contrast the difference in HU between adjacent regions or structures within an
image, for example, HUa –HUb for regions a and b.
Contrast agent a liquid injected intravascularly prior to imaging that contains a high
atomic number compound, usually iodine, to enhance vessels and vascular
tissues.
Contrast resolution the ability to detect objects that are only subtly different in contrast from
the background. Contrast resolution is related to the signal-to-noise ratio
of the object to be detected.
CT fluoroscopy continuous real-time imaging by CT to guide a diagnostic or therapeutic
intervention, often used for CT-guided needle biopsy.
CT number see Hounsfield Unit.
CTDI abbreviation for computed-tomography dose index.
CTDI100 CTDI calculated by integrating the air-kerma profile K(z) over 100 mm:

ð þ50 mm
x 1
CTDI100 ¼ KðzÞ dz;
nT 50 mm

where x refers to either the center or peripheral position in a standard

cylindrical phantom.
CTDIair value of CTDI determined free-in-air, at the isocenter of the scanner.
CTDIw the weighted CTDI.
CTDIvol the volume CTDI.
Detector on the CT scanner, a device that responds to ionizing radiation, converting
this response to an electronic signal for subsequent digitization. More gener-
ally, a meter used to measure radiation levels.
Detector array a collection of individual detectors that are typically located in an arc along
the fan angle of a CT scanner. A single-detector array collects enough infor-
mation during an axial (sequential) CT scan to produce one CT image.

4
 Glossary

Detector efficiency
Detector element (del)
Detector row
Dose – length product (DLP)
the fraction of x-ray energy incident upon a detector that contributes to the
electronic signal.
a single element of a detector array.
a row of detector elements, including their interspace material, arranged
along an arc centered on the axis of rotation; same as detector array.
a parameter used as a surrogate measure for energy imparted to the patient
in a CT scan of length L:

DLP ¼ CTDIvol  L:

By convention, the DLP is reported in the units of mGy cm.

Dose profile representation of the absorbed dose or air kerma as a function of position,
e.g., usually along the z axis.
Effective dose risk-related quantity defined by the International Commission on
Radiological Protection in Publication 60 (ICRP, 1991) as the sum of the
weighted absorbed doses in all tissues and organs of the body:
XX
E¼ wR wT DT ;
R T

where DT is the absorbed dose in tissue T due to radiation of type R, wR is

the weighting factor for radiation type R, and wT is the weighting factor for
tissue T. For x-rays, wR is equal to unity. The tissue weighting factors have
been revised in ICRP Publication 103 (ICRP, 2007).
Field of view (FOV) the maximum diameter of the scanned area or reconstructed image (SFOV,
scanned field of view; DFOV, displayed field of view).
Filtered back projection a mathematical procedure that reconstructs the CT images from the mea-
sured profile data in a CT scanner. The profile data are convolved with a filter
function (usually performed in the spatial-frequency domain), and the entire
projected data set is then backprojected to produce the CT image.
Focal spot the effective area on the x-ray-tube anode from which x rays are emitted.
The size of the focal spot affects the spatial resolution in the CT image.
Full width at half interval parallel to the abscissa between the points on a curve with the
maximum (FWHM) value of one-half of the maximum of the curve.
Gantry part of the CT scanner that, for modern third-generation systems, supports
the x-ray tube, x-ray generator, collimators, and detector arrays.
Helical CT technique of scanning in which there is continuous rotation of the x-ray tube
coupled with continuous linear translation of the patient through the gantry
aperture in order to achieve volumetric data acquisition. Also known as
spiral or volume CT.
Hounsfield Unit the gray-scale values in a CT image, named after inventor Godfrey
Hounsfield (also called CT number). The HU of a voxel m is defined as:
mm  mw
HUm ¼ 1000 ;
mw
where mm and mw are the effective linear attenuation coefficients of the voxel
material and water, respectively.

5
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Iterative-reconstruction a reconstruction algorithm that uses a series of successive iterations, each

algorithms one becoming closer to the appearance of the object scanned. Iterative
reconstruction is usually more computer intensive than filtered-back-
projection reconstruction, and is thought to produce CT images with lower
noise levels.
Kernel see reconstruction filter.
Linear attenuation coefficient the fractional reduction in intensity per thickness of material as an x-ray
beam passes through the material.
Line-spread function (LSF) the LSF is evaluated by imaging a slit in radiography or a plane of material
parallel to the z axis in CT, both of which result in a line on the resulting
images. The LSF is then given by image intensity (HU in CT) versus pos-
ition orthogonal to the line.
Modulation-transfer function the MTF is the classical approach to characterizing the spatial resolution of
(MTF) an imaging system. It is generally computed by taking the Fourier trans-
form of the line-spread function.
Monte Carlo technique a method for computing the distribution of x-ray energy deposition (other
applications exist also) in objects, based on realistic simulations of photon
transport using known interaction probabilities. A state-of-the-art method
for estimating absorbed dose in patients or phantoms in CT procedures.
Multi-detector CT (MDCT) a CT scanner that has multiple detector arrays; also called multi-slice CT.
MDCT systems, with between 64 and 320 detector arrays, are the current
state of the art in CT systems.
Multi-slice CT (MSCT) same as multi-detector CT.
Noise variation of CT numbers from a mean value in a defined area in the image
of a uniform substance, indicated by the standard deviation of the CT
numbers in that region of interest.
Noise-power spectrum (NPS) the NPS is used to characterize the noise variance as a function of spatial
frequency in an imaging system.
Nyquist frequency the maximum frequency, fN, that can be described by a sampled system with
a sampling spacing of a, where fN ¼ (2a)21.
Over-beaming in multiple-detector-array CT scanners (MDCT), the effect whereby the
FWHM, a, of the dose profile along the z axis exceeds the active detector
width, i.e., for n detectors of width T, over-beaming is the situation for
which a . nT. Over-beaming is considered necessary in MDCT systems in
order to prevent artifacts.
Over-ranging in helical (spiral) scanning, over-ranging occurs because it is necessary to
scan beyond the edges of the reconstructed CT volume to produce the
required images. For a scanner with a nominal beam width of nT, over-
ranging of approximately 12 nT on each side of the volume is required.
Over-ranging can be reduced by the use of adaptive beam collimation.
Pitch for helical (or spiral) CT, the pitch, p, is the quotient of the table advance
per 2p rotation of the x-ray tube, b, by the product of the number of simul-
taneously acquired sections, n, and the section thickness, T, i.e.,

b
p¼ :
nT

Pixel picture element of a digital image.

6
 Glossary

Post-patient collimation geometrical limitation of the extent of the radiation beam in the z direction
by a slit device positioned between the patient and the detector.
Infrequently used for thin-section imaging.
Profile a profile is a collection of rays acquired at a specific gantry angle using the
detector array. The term profile is synonymous with projection or view.
Projection same as profile.
Quantitative computed the use of CT images and the corresponding HU values for quantitative
tomography (QCT) characterization of organs or tissues. QCT is most widely used in the deter-
mination of bone-mineral content, lung density, and treatment planning in
radiotherapy.
Ray the schematization of a narrow beam of x rays from the x-ray-tube focal spot
to a single detector element, giving rise to a detector-element reading. Each
view or projection is composed of numerous rays.
Reconstruction algorithm precisely defined computational procedure to produce CT images from
the acquired projection data. Filtered back projection has been used for most
image reconstruction in CT; however, in recent years, iterative-
reconstruction algorithms have been used as well.
Reconstruction filter for filtered back projection, the reconstruction filter is used to mathematical-
ly filter the projection data prior to back projection. Typically, the reconstruc-
tion filter is described in the frequency domain and consists of a ramp
component combined with an apodization filter to reduce the impact of
quantum noise at higher spatial frequencies. Reconstruction filters have
names that vary among CT-scanner manufacturers.
Region of interest (ROI) a region that is part of an image. The ROI is typically square or rectangular,
but can be of any arbitrary shape.
Rotation period time duration of a single 3608 rotation of the x-ray tube and detector array
(in third-generation CT geometry). Typical rotation periods for modern CT
scanners range from 0.25 s to 1.0 s.
Scan range the length of the body that is visualized, measured along the z axis for one
volume acquisition or for a series in sequential (axial) acquisition
(step-and-shoot mode).
Scan time the time interval between the beginning and the end of the acquisition of
data, i.e., time for either a complete spiral acquisition or for a single tube ro-
tation in the step-and-shoot mode.
Scattered radiation x rays whose trajectories have been redirected due to a scattering event in
the patient or CT hardware. Generally, scattered radiation can deposit
energy inside the patient but outside of the primary x-ray beam, can be
emitted into the CT scanner room, and can reach detector elements and
cause artifacts or increased noise in the reconstructed CT images.
Section in multi-slice scanning, the tomographic volume corresponding to a single
image in the reconstructed CT data set. Sections can be of different thick-
ness, usually ranging from 0.5 mm to 5 mm, and sometimes to 10 mm. CT
sections are also called CT slices.
Section thickness the thickness of a CT image, measured at the scanner isocenter.
Thicknesses range from 0.5 mm to 10 mm on most CT systems. Also called
slice thickness.
Sequential (axial) CT CT-scanning technique in which images are acquired at fixed z positions
interspersed by translation of the patient in the z direction. During transla-
tion, the x-ray beam is turned off. Sequential or axial CT imaging is the
basic step-and-shoot acquisition method of CT scanners.

7
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Shaped x-ray filter same as bow-tie filter.

Single-slice scanner CT scanner with a single row of detector elements, i.e., only one acquisition
channel.
Slice tomographic volume corresponding to the reconstructed image; a single CT
image is often called a slice. The thickness of this volume is defined by the
slice thickness.
Slice-sensitivity profile (SSP) relative response of a CT system along the z axis. The SSP is essentially the
line-spread function of the CT scanner along z.
Slice thickness same as section thickness.
Spatial resolution the ability to resolve fine detail in an image.
Spiral CT see helical CT.
Spread function spread functions are used to measure the spatial resolution of imaging
systems, and include the point-spread function (PSF), the line-spread func-
tion (LSF), and the edge-spread function (ESF).
Table feed for helical (spiral) CT scans, the distance that the patient table moves longi-
tudinally during a 2p rotation of the CT gantry.
Uniformity consistency of the CT numbers in the image of an homogeneous material
across the scan field. Synonymous with homogeneity.
View a collection of rays acquired at a specific angle by the detector array. Same
as projection or profile.
Volume CTDI (CTDIvol ) the weighted CTDI, CTDIw, normalized by the helical pitch, p, i.e.,

CTDIw
CTDIvol ¼ :
p

Voxel volume element.

Weighted CTDI (CTDIw) an estimate of the average dose over a single slice in a CT dosimetry
phantom, defined as:
1 center 2 peri
CTDIw ¼ CTDI100 þ CTDI100 ;
3 3

center peri
where CTDI100 or CTDI100 refer to measurements of CTDI100 at the center
(center) or periphery ( peri) of the head or body phantom.
z axis axis parallel to the axis of rotation.

8
 Abstract
Computed tomography has experienced a number of significant technological advances over the past
decade, and these have had pronounced impacts on the accuracy of radiation dosimetry and the assessment
of image quality. After reviewing CT technology and clinical applications, this Report describes and dis-
cusses existing dosimetry methods and then presents new methods for radiation dosimetry, including the
evaluation of beam quality, and measurement of CT-scanner output in air and in phantoms. Many of the
proposed dosemetric quantities can be measured quickly using a real-time ionization chamber, which is
introduced here. Traditional measurements of image quality for computed tomography rely upon simple and
subjective observations. A more rigorous approach is proposed, including routine use of the modulation-
transfer function for describing spatial resolution along all axes, and of the noise-power spectrum for des-
cribing the noise amplitude and texture properties of CT images. This Report focuses on new but practical
methods for the assessment of radiation dose and image quality for CT scanners.

9
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
1. Introduction
This Report centers on computed tomography
(CT) scanners, which are used widely in diagnostic
medicine around the world. The Report focuses on
dose assessment, as well as the characterization of
image quality in CT.
A description of the basic technology underlying
CT is provided in Section 2. The early systems,
which used simple acquisition geometries requiring
several seconds per slice, have evolved into modern
axial (sequential) and spiral (helical) acquisition
platforms that can acquire a large number of slices
in one-third of a second or less. A number of differ-
ent dose-reduction features have been added to CT
scanners in recent years, and these are also dis-
cussed in Section 2.
Section 3 describes the clinical utility of CT,
described by radiologists specializing in neurora-
diology, body CT, thoracic imaging, and pediatric
radiology. This Section introduces the reader to a
sampling of clinical applications of CT, demonstrat-
ing why this modality is used so widely and so fre-
quently in diagnostic medicine.
Absorbed-dose levels have been an emerging
issue in regard to CT for the past decade or more.
Sections 4 through 9 of the Report focus on various
aspects of radiation dose and dose assessment,
recognizing recent advancements in CT scanner
design, new perspectives on the radiation dose dis-
tribution in CT, and the important issue of patient
size and length of the CT scan.
Section 4 describes the conventional measure-
ments of CT-radiation dose, and is intended to fa-
miliarize the reader with traditional methods of
radiation-dose assessment in CT. This Section high-
lights the technological baseline, and provides a
context from which the many CT-dosimetry recom-
mendations contained in this Report can be
understood.
This Report also introduces the use of a real-time
dosimeter for evaluation of the air-kerma rate. The
use of a real-time dosimeter provides capabilities in
CT dosimetry that cannot be achieved using
integration-mode radiation meters, and simplifies
several of the proposed measurements. These new
dosimeters are first discussed in Section 5. Section 5
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/nds001
mainly addresses measurement of the spectral prop-
erties of CT scanners, including use of the new tech-
nology of real-time ionization-chamber systems.
Although the measurement of the half-value layer
(HVL) in CT is generally performed infrequently,
x-ray beam quality is an important property that
relates to both image quality and absorbed dose in
the patient. Proposed methods for HVL assessment
considerably streamline previous approaches.
Section 6 discusses the assessment of the x-ray
output (air kerma or air-kerma rate) of a CT
scanner as measured free-in-air in the absence of a
phantom. Although a dosimetry phantom is an im-
portant tool in the assessment of dose in CT, the
x-ray output (air kerma) is a fundamental quantity
that impacts the dose in the patient during CT. In
this Section, it is recognized that measuring the
output characteristics of the CT scanner in the
absence of a phantom can be a practical method for
routine quality assurance. This Section focuses on
the dose distributions in both the z dimension and
along the axial or x – y dimensions of the CT system.
The real-time dosimeter has an important role to
play in these measurements.
Section 7 introduces a newly designed phantom
that is long enough (600 mm) to capture the major-
ity of the absorbed dose due to x-ray scatter that
occurs in a phantom. This Section is harmonized
with AAPM Report 111 (AAPM, 2010), and the
phantom was designed in close collaboration with
AAPM Task Group 200. With a phantom and real-
time dosimeter, an asymptotic curve that represents
the air kerma or absorbed dose at the center plane
of the CT scan can be determined as a function of
the scan length in a single measurement. This
“rise-to-equilibrium” curve can be used to describe,
in general, the dose distribution in CT under the
simplified conditions of a homogeneous phantom.
In all x-ray imaging modalities, including CT, the
size of the patient plays an important role in x-ray
dosimetry. Section 8 discusses methods by which
patient size, defined as the water-equivalent diam-
eter, can be used to adjust the value of CTDIvol
reported by the CT scanner to produce a more accur-
ate dose estimate. A quantity is introduced in this
 RADIATION DOSE AND IMAGE QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Section called the size-specific dose estimate. This
Section is well aligned with AAPM Report 204
(AAPM, 2011a), which has been endorsed by the
AAPM, the ICRU, and the Image Gently campaign.
Modern CT systems dynamically adjust the x-ray-
tube current depending upon the dimensions of the
patient along the length of the scan, in a procedure
called automatic exposure control or x-ray-tube
current modulation. In order to compute dose when
x-ray-tube-current modulation is used, an image-
by-image assessment of both patient size and tube
current becomes necessary to achieve good accuracy.
Section 9 describes the algorithms necessary for
this, together with a computer program developed
to illustrate the trends in dose estimates as a func-
tion of patient size and CT technical parameters.
Image quality is an important characteristic of
any imaging system, and is related to the associated
absorbed-dose levels. In Section 10, characterization
of the spatial resolution of CT scanners is discussed.
Historical methods have utilized the point-spread
function, line-spread function, and edge-spread
function to compute the modulation transfer func-
tion (MTF). This Section also discusses the use of
the MTF to characterize the spatial resolution in
the z dimension, moving away from the historical
use of the slice-sensitivity profile.
Section 11 addresses the measurement of noise
texture and amplitude in CT images. The 3D noise-
power spectrum (NPS) is proposed to characterize
the noise properties of CT images. The dependen-
cies of the NPS on CT parameters such as x-ray-
tube potential, the product of gantry rotation time
and x-ray-tube current, the reconstruction kernel
used, and other technical parameters are discussed.
The assessment of both spatial resolution and con-
trast resolution is described in some cases using the
CT phantom recommended in Section 7. The Report
concludes with Section 12, which makes specific
recommendations with respect to the characteriza-
tion of both dose and image quality in CT.
1.1 CT Manufacturers and Model Names
There are only a few large manufacturers of CT
scanners, and there are some differences in the fun-
damental technology offered by these companies. In
some cases, the makes and models available differ,
depending on country of placement. In this Report
when discussing CT characteristics, in many cases,
the type of scanner (manufacturer and model) is
mentioned. In doing so, there is no intent for en-
dorsement, but rather to allow readers to under-
stand the type of scanner that produced a specific
set of data. In general, this knowledge will be more
useful to readers who work in the CT field, and who
are familiar with the subtle differences in the cap-
abilities of various CT-scanner types. The manufac-
turers of the CT scanners mentioned in this report
are listed here alphabetically:
General Electric Medical Systems, Waukesha,
Wisconsin.
Philips Healthcare, DA Best, The Netherlands.
Siemens Medical Systems, Erlangen, Germany.
Toshiba Medical Systems, Irvine, California, USA.

12
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
2. Basics of Computed-Tomography Technology
For the first 75 years of x-ray imaging, the detec-
tors used in diagnostic radiology, such as radio-
graphic film or image intensifiers, provided
reasonably good visualization of high-contrast
objects. However, their ability to record small dif-
ferences in transmitted x-ray signals was limited.
Several factors contributed to the inability to
resolve low-contrast signals.
First, large-area detectors record a large amount
of scattered radiation, making small differences in
x-ray transmission difficult to resolve. Second, the
superposition of the patient’s three-dimensional in-
formation onto a two-dimensional detector obscures
low-contrast information. Geometrical tomography
provided some separation of overlapping structures,
but its utility was limited to high-contrast struc-
tures such as bones, airways, and iodinated
vessels. Finally, radiographic film, intensifying
(scintillation) screens, and image intensifiers can
exhibit non-linearities and/or non-uniformities that
are large compared with the small differences in
x-ray transmission of low-contrast objects.
Introduced clinically in the early 1970s, x-ray
computed tomography (CT) overcame many of the
difficulties encountered in using large-area detec-
tors. First, the sequential irradiation of slabs of
tissues and collimation at the detector markedly
reduced the amount of scattered radiation mea-
sured. Second, the reconstruction of a tomographic
image eliminated much of the problem of overlap-
ping anatomy. X-ray CT was the first imaging mo-
dality that allowed physicians to see the internal
structure of a three-dimensional object in cross-
section (see Figure 2.1). With CT, the use of high-
efficiency, low-noise detectors that could respond
linearly over a wide range of transmission values
provided uniform sensitivity over a wide dynamic
range, producing excellent CT images across a wide
variety of clinical applications.
The Radon transform introduced the concept of
mathematically reconstructing the internal struc-
ture of an object from multiple projections through
the object (Radon, 1917). The techniques of image
reconstruction were pursued in a variety of disci-
plines including Bracewell’s work in the 1950s in
radio astronomy (Bracewell, 1956; Bracewell and
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/nds002
Riddle, 1967). In the early 1960s, several independ-
ent investigations into the medical applications
of image-reconstruction techniques were carried
out (Cormack, 1963; Kuhl and Edwards, 1968;
Oldendorf, 1961). However, it was not until the late
1960s and the work of Hounsfield that the first
clinically useful x-ray CT scanner was developed
(Hounsfield, 1973).
Despite its relatively low spatial resolution,1 CT
was rapidly accepted into clinical practice because
of its tomographic nature and superior contrast
resolution (0.5 %) when compared with existing
radiographic images (approximately 5 %). In 1979,
the Nobel Prize in Medicine was awarded to
Hounsfield and Cormack for their contributions to
the development of x-ray CT (Hounsfield, 1980).
2.1 CT-Scanner Design
CT-scanner hardware is designed to determine
effective x-ray attenuation coefficients at each point
within a volume of interest from transmission mea-
surements acquired at multiple angles through the
object. A set of transmission measurements
through the object at a given angle is known as a
projection, or view. These projection measurements
are mathematically combined to form a two-
dimensional representation of a three-dimensional
object. Figure 2.2 illustrates a single projection,
which contains multiple rays (representing line
integrals) through the patient, acquired as the
x-ray tube rotates around the patient.
The x-ray tube is used to irradiate the patient
with a diverging beam of x-rays, and transmission
measurements are acquired using a detector array
on the opposite side of the patient. At each angular
position, approximately 600 –900 transmission
measurements (rays) are acquired (with each de-
tector array), with a spacing of approximately
1 mm. The x-ray tube and detector array(s) rotate
continuously, and the data-collection process is
1
Current spatial resolution limits are 1.0 cycle/mm for CT
compared with 3.5 cycle/mm for digital radiography and 7.0
cycles/mm for digital mammography.
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 2.1. Sample CT images. High-spatial-resolution images can be generated in all the axial, coronal, and sagittal planes from a
single data acquisition.
Figure 2.2. Schematic of the transmission measurements
acquired in a single projection measurement as the tube rotates
around the patient.
repeated (usually for the complete 3608) until a
predetermined number of views of the subject are
gathered to allow mathematical reconstruction of
the object. Typically, data from about 1000 view
angles are acquired, and this is performed by re-
peatedly sampling the detector arrays as the
gantry rotates.
The CT-scanner hardware shown in Figure 2.2
acquires a large number of transmission measure-
ments, m, along the detector at position x and at a
14
gantry angle u, which can be described mathemat-
ically as
mðx; uÞ ¼ I0 emef f tðx;uÞ; ð2:1aÞ
where meff is the effective x-ray linear attenuation
coefficient for the tissues in the patient, and t is
the thickness of those tissues through a path in
the patient defined by the geometrical parameters
x and u. It is noted that the use of the variables x
and u in this Section is general, and other assign-
ments of these terms are made in later Sections of
this Report. All CT scanners also have a reference
detector, which measures the x-ray-tube output
when there is no anatomy in the beam path:
mref ¼ I0 : ð2:1bÞ
Basic signal processing in CT produces a projec-
tion value, P, from the measured detector informa-
tion:
 
mref
Pðx; uÞ ¼ ln ¼ mef f tðx; uÞ : ð2:2Þ
mðx; uÞ
The projection values P(x,u) are used in various
image-reconstruction algorithms to compute the
CT image. A key observation from Eq. (2.2) is that
the intensity of the x-ray beam, Io, has been fac-
tored out of the equation. This means that the
gray-scale value in CT images is not dependent on
the intensity settings used for acquisition;
however, the statistical noise in the CT image is
dependent upon I0.
Another important normalization is applied
to CT images after the reconstruction process.
In honor of Godfrey Hounsfield’s pioneering work,
 Basics of Computed-Tomography Technology

the Hounsfield Unit,2 HU, is the name given to now in clinical use. Some scanners rapidly toggle
the gray-scale values in CT images. The HU is the position of the x-ray source (by magnetically
defined as: deflecting the electron beam inside the tube),
forming two channels from one physical detector. It
 
mx;y;z  mw is also possible to add the signal from adjacent de-
HUx;y;z ¼ 1000 ; ð2:3Þ tector arrays together, for instance, a 64-detector
mw
array scanner with 0.625 mm detector widths can be
configured to acquire 32  1.25 mm, 16  2.50 mm,
where the HU for a voxel located at position (x,y,z),
or 8  5.00 mm channels. These systems are referred
HUx,y,z, corresponds to the measured effective linear
to as multiple-detector-row CT (MDCT) scanners.
attenuation coefficient for that voxel, mx,y,z, rescaled
Although the design details become more compli-
after being normalized to the effective linear attenu-
cated as the number of channels increases, the basic
ation coefficient of water, mw. Thus, the gray-scale
idea behind MDCT imaging remains the same.
values (CT numbers) in CT images have physical
Scanners with more data channels generally offer
meaning and are essentially rescaled linear attenu-
more coverage in the z-axis direction for each rota-
ation coefficients. With the definition given in Eq.
tion of the CT gantry, which results in even greater
(2.3), the HU of water is 0.0 and that of air is 21000.
scanning speed. However, this scanner geometry
These are the only two materials for which the
also requires more divergence of the x-rays along the
Hounsfield scale is defined and calibrated against.
z-axis direction (forming a cone angle), and allows
Since the early days of CT, a number of diffe-
more x-rays scattered within the patient to reach the
rent CT-scanner designs have been developed.
detectors, potentially creating anomalous signal in-
Currently, all commercial systems use a geometry
formation. Algorithms that take into account the
in which the x-ray tube and opposing detector
cone-beam geometry and increased scatter are
array are mounted onto a common frame (gantry)
required on these newer CT-scanner types.
that rotates on a mechanical “slip-ring” system,
In addition to the development of more numerous
which passes electrical signals across sliding metal
detector arrays with thinner detector elements,
contacts (Crawford and King, 1990; Kalender et al.,
gantry rotation periods have continued to decrease.
1990; Rigauts et al., 1990). Slip-ring designs elimi-
Current state-of-the-art systems have rotation
nated inter-scan delays that were once necessary to
periods in the range of from 0.27 s to 0.35 s per rota-
unwind cables between successive rotations of the
tion. With the use of partial-scan reconstruction tech-
gantry; this development enabled the continuous
niques (rotation of approximately 1808 plus the fan
gantry rotation and patient-table motion necessary
angle in the scan plane), this has allowed temporal
for helical (spiral) CT data acquisition. The axis of
resolutions per image in the range of from 130 ms to
rotation of the CT gantry is called the isocenter.
175 ms. Application of this technology to cardiac CT is
The rotational plane of the CT gantry is perpen-
now well established. For patients with high heart
dicular to the z axis of the system, which is typical-
rates (.70 beats/min) or irregular heart rhythms,
ly the cranial – caudal direction of the patient.
further improvements in temporal resolution are
In the late 1990s, a new CT design emerged for
required. One approach to this problem has been the
clinical use. Instead of acquiring a single ring of
development of a CT system equipped with two x-ray
transmission data with each rotation of the x-ray
tubes and two detector arrays, placed at approximate-
tube, the new CT scanners were able to acquire four
ly right angles to one another. Temporal resolutions
separate rings of data with each rotation. This was
as short as 75 ms are possible on such systems, which
made possible by the use of multiple rows of x-ray
are referred to as dual-source CT scanners.
detector arrays positioned side by side along the z
axis. The most important clinical advantage of these
scanners is the considerable decrease in routine
2.2 Scan-Acquisition Modes
scanning time while simultaneously producing
thinner image sections (higher z-axis resolution), There are two basic scan modes in CT, axial
i.e., faster scans with better spatial resolution. (sequential) scanning and helical (spiral) scanning.
Since the late 1990s, CT scanners have been Building on these are specialized modes of scan-
designed with an increasing number of detector ning for perfusion, fluoroscopy, cardiac, and dual-
channels or arrays. CT scanners with 4, 6, 8, 10, 16, energy imaging.
20, 32, 40, 64, 128, and 320 detector channels are
2.2.1 Axial CT Scanning
2
The Hounsfield Unit is not a unit in the usual sense. As it is so
basic to CT imaging, this nomenclature will be retained in this In the axial scan mode, the patient table remains
Report. stationary while the tube and detector array rotate

15
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 2.3. Illustration of the differences between axial (a) and helical (b) scan modes.
once around the patient, collecting the necessary
data for image reconstruction. After one rotation,
the patient table is moved along the z axis to the
next position, and another set of scan data are
acquired (see Figure 2.3a). This mode is also re-
ferred to as “step-and-shoot” scanning. If projec-
tions through the entire organ of interest (e.g., the
heart or brain) can be acquired in one rotation,
such as with 16 cm wide detector arrays, then no
table translation is required.
In single-detector row CT systems, the image
thickness is determined primarily by the collima-
tion of the x-ray beam along the z axis, and one
wide detector array (e.g., 13 mm) was used to
acquire different slice thicknesses such as 1 mm,
3 mm, 5 mm, 7 mm, and 10 mm thick CT slices, but
not simultaneously. In MDCT scanners, the image
thickness is determined by the detector-element
dimensions, which on modern systems are approxi-
mately from 0.50 mm to 0.625 mm along the z axis,
as measured at isocenter (the physical detectors
are about two times wider, the difference being the
geometric magnification from isocenter to the phys-
ical detectors). In MDCT, the data from adjacent
detector rows can be added together to give wider
image thicknesses. This provides the flexibility to
reconstruct narrow and/or wider image thicknesses
from the same measured projection data set, so a
range of different slice thicknesses can be acquired
simultaneously.
2.2.2 Helical (Spiral) Scan Mode
Helical (spiral) scanning involves continuous
translation of the patient table with continuous
x-ray rotation and data collection (see Figure 2.3b).
This decreases overall scan time, and can allow
scanning of the entire adult torso within a breath
hold. Helical scanning also allows for reconstruc-
tions of overlapping slices at any z-axis position.
For an MDCT scanner with n arrays that have a
thickness T (at isocenter), the beam width a as
measured at the isocenter is given by
a ¼ nT þ z;
where z is the “over-beaming” that is necessary in
MDCT systems. The z portion of the beam corre-
sponds to the width of the penumbra on both sides
of the active beam, which extends beyond the edges
of the active detector arrays (nT) to reduce artifacts
in helical scanning. With a helical CT scanner, the
ratio of the table feed b (a distance) per full gantry
rotation (i.e., 3608) to the beam width is defined as
the pitch, p, thus
b
p¼ : ð2:5Þ
nT
In helical scanning, extra rotations of data acquisi-
tion are required at the beginning and end of the
helical scan in order to provide sufficient data for
image reconstruction at the edges of the prescribed
scan range. This is referred to as “over-ranging.” For
CT scanners with wider detector arrays (40 mm to
160 mm), a significant amount of extra irradiation
beyond the prescribed scan volume can occur.
Scanner manufacturers have addressed this by
using adaptive z-axis collimators (see Figure 2.4),
which open and close at the beginning and end of
the scan to shield the patient from unnecessary ra-
diation (Christner et al., 2010; Deak et al., 2010).
With all other technique factors held constant,
the use of larger pitch values in helical scanning
will reduce patient dose; the average absorbed dose
for a given scan volume can be shown to be inverse-
ly proportional to pitch. Although the dose is
decreased, there is a penalty in terms of loss of
image quality (see Table 2.1). The penalty depends
on whether the scanner has a single detector row
or is a MDCT system.
In single-detector-row CT, as the pitch is
increased, the data sampling along z is more
sparse, and the resultant image is wider ( poorer
z-axis resolution). Image noise is not affected,
however, as the same number of projections is
always used to form an image. MDCT scanners use
spiral interpolation algorithms that are different
than those in single-detector-row CT and take ad-
vantage of the multiple rings of transmission data.
ð2:4Þ For MDCT scanners, the width of the section
16
 Basics of Computed-Tomography Technology

Figure 2.4. Adaptive collimation in helical CT. For helical CT scanning without adaptive z-axis beam collimation (left), half of the x-ray
beam width at both ends of the scan is not used because those projections do not have sufficient angular sampling for image
reconstruction, resulting in unnecessary absorbed dose in the patient. With adaptive beam collimation, collimators are used to
eliminate patient exposure at the edges of the scan, reducing the absorbed dose in the helical scan mode, especially for short scan
ranges or wide beam widths.

sensitivity profile (i.e., image thickness) remains Table 2.1. Effect of increased pitch.
relatively constant as the pitch changes. However,
Scanner type Tube Dosea Image Image
with all other technique factors held constant, such
current noise thickness
as occurs using a constant value of the product of
tube current, J, and tube-on time per rotation, t, Single-detector Constant Reduced Constant Larger
corresponding to a constant “mAs”-setting,3 image row
noise will increase as pitch increases. This is Multi-detector Constant Reduced Increased Constant
because the number of projections that can be used row
Multi-detector Increased Constant Constant Constant
while still maintaining the prescribed image thick-
rowb
ness decreases as pitch increases. However, some
MDCT scanners automatically adjust the photon a
As represented by the volume CT dose index (AAPM, 2008;
fluence, that is, Jt, to compensate for changes in IEC, 2009; McNitt-Gray, 2002).
b
the pitch setting, and therefore image thickness, Tube current, J (mA setting), adjusted as pitch, p, is changed to
noise, and absorbed dose remain constant as pitch yield the same effective photon fluence, Jt (“mAs” setting),
where the effective fluence is defined as Jt/p.
is varied. This approach allows the scanner oper-
ator to adjust pitch as needed, without having to
calculate and make the compensatory changes in 2.2.3 Repeated Scanning at the Same
Jt to maintain image-noise levels. The ratio of Jt Table Position
to pitch is referred to as the effective “mAs” or
“mAs”/slice, depending on the scanner manufactur- CT fluoroscopy is used to guide interventional
er (AAPM, 2011b). procedures, such as the placement of biopsy
needles to extract tissue samples for the assess-
ment of pathology. This near-real-time procedure is
3
During the development of CT scanners, certain jargon has useful for providing visual feedback for needle
been established in which the product of the tube current, J, guidance.
and the tube-on time per rotation, t, is referred to as the “mAs.” The CT perfusion study is used with an intravas-
Although such a variable as this product should not be named
using unit symbols (which symbols, in this case, should correctly
cular injection of an iodine-based contrast agent,
be written as mA s), the use of “mAs” appears to be so and a quantitative assessment of contrast kinetics
entrenched that it will occasionally be used in this Report to is made by scanning the same region for a relative-
avoid terms that might be obscure to the practitioner. A similar ly long period of time, which depends on the organ
issue concerns using “kV” to indicate the value of the or tissue of interest. Scan times of about 40 s are
accelerating potential, V, for the x-ray tube (which is commonly
expressed in units of kV). When needed, these quantities will be
typical for brain perfusion imaging, although scans
termed “mAs” setting and “kV” setting, which correspond to up to 3 min in duration can be necessary in abdo-
displays on most scanners. minal organs. In both of these scan modes, the

17
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
table is stationary and the same region of the
patient is repeatedly scanned, resulting in the
buildup of absorbed dose in the tissues within and
around the scanned volume. In these acquisition
modes, it is typical to operate the scanner with
a lower tube current, as very high absorbed
doses can result from these repetitive scanning
procedures.
2.2.4 Dual-Energy CT
Dual-energy CT scanning more easily allows the
delineation of regions in the patient corresponding
to different densities and mean atomic number,
such as bone, iodine, or soft tissue. The acquired
dual-energy CT images are processed such that
subsequent computer-based enhancement or elim-
ination of certain tissue types is accomplished. An
example would be subtracting out the bones in a
neck CT angiogram to allow the physician to better
evaluate the vasculature without having it
obscured by overriding boney anatomy. Equation
(2.3) defines the relationship between the CT
number and the effective linear attenuation coeffi-
cient, and it is the differences in how meff decreases
for higher-energy x-ray spectra that allows discrim-
ination of materials of different atomic number.
Dual-energy scanning requires the acquisition of
two sets of projection data, each of which contain a
sufficient number of projections for image recon-
struction. One set is acquired at a high x-ray-tube
potential, V, (e.g., 140 kV) and the other at a lower
x-ray-tube potential (e.g., V ¼ 80 kV). From either
the reconstructed images or the raw projection
data, the effective atomic number of the tissue com-
position can be differentiated from the material
density. The reason for this is that the CT number
of any voxel is a rescaled measure of the linear
x-ray attenuation coefficient [Eq. (2.3)]. Thus, the
same amount of x-ray attenuation (i.e., the same
CT number) can be obtained for two different mate-
rials (e.g., iodine and bone) in typical single-energy
CT scanning, if the densities of the materials com-
pensate for the differences in atomic number. In
dual-energy CT, the projection data acquired at the
two x-ray tube potentials provide the information
needed to assess what fraction of the x-ray attenu-
ation is due to the material composition (atomic
number) and what fraction is due to mass density.
The dual-energy concept was initially described by
Godfrey Hounsfield in 1973 (Hounsfield, 1973), and
was subsequently explored by several investigators
(Alvarez and Macovski, 1976; Kalender et al., 1986)
decades ago. Widespread clinical applications of
dual-energy CT did not emerge until approximately
2007 (Johnson et al., 2007; Primak et al., 2007). Some
18
models of Siemens CT scanners have two x-ray tubes
and detector arrays, and these allow simultaneous ac-
quisition of low- and high-V data. Other manufac-
turers have developed single x-ray tube systems that
are capable of rapidly switching the tube potential in
order to acquire low- and high-V data in one rotation
of the gantry. In switched-potential systems, the
x-ray pulse duration can be adjusted to balance the
x-ray intensity levels between the low- and high-V
pulses. In the future, it is anticipated that photon-
counting detector systems will be developed for CT;
such systems will differentiate detected photon
energy into several energy channels, and thus dual-
energy scanning can be performed without switching
x-ray-tube potential.
Dual-energy CT scanning can be used also to es-
timate so-called “monoenergetic” images, which are
mathematical combinations of the high- and low-V
scans that approximate the CT image that would
be produced with a monoenergetic x-ray beam
(instead of the polyenergetic spectra that were ac-
tually used). Dual-energy CT imaging also allows
the correction for beam-hardening artifacts. Beam
hardening occurs as a polyenergetic x-ray spectrum
passes through a thick, dense structure such as the
bones in the skull (see Figure 2.5). As the x-ray
beam traverses the tissue, the overall x-ray fluence
is of course reduced, but there is also a shift in the
shape of the x-ray spectrum as lower-energy x-ray
photons are absorbed preferentially as a function of
depth relative to higher-energy photons. This
occurs because, in general, the effective linear
Figure 2.5. Beam hardening. Three x-ray spectra, all produced
at 120 kV, are shown, corresponding to the spectra at different
points along the x-ray beam path in CT. These spectra are
interpolated measured data, and the energy resolution was not
sufficient to resolve the individual characteristic x-ray peaks.
Beam-hardening artifacts occur if the reconstruction algorithm
does not take beam hardening into consideration (see inset,
arrows point to a dark region in the brain resulting from beam
hardening).
 Basics of Computed-Tomography Technology
attenuation coefficient is higher at lower x-ray en-
ergies. This process causes meff in Eq. (2.1a) to vary
as the x-ray beam passes through the patient, cre-
ating slight errors in the CT numbers on the recon-
structed CT images. Artifacts that occur in the
image, often adjacent to highly attenuating struc-
tures, are referred to as beam-hardening artifacts.
2.2.5 Cardiac CT
Initially, CT imaging of the coronary arteries
was accomplished with unique CT scanner designs,
for example, electron-beam CT. These systems
were not, however, widely available. Cardiac CT
became more feasible clinically with the advent of
four-detector-row CT scanners. The technique
required that the CT scan continuously throughout
the cardiac cycle and the table be translated slowly
along the z axis, such that every z-axis position
was imaged during every phase of the cardiac
cycle. The ECG trace was recorded simultaneously
with the CT projections. This data redundancy was
required because the reconstruction algorithm
sorted through the acquired data to determine
which projection data were appropriate to recon-
struct a CT image at a given z position at a given
phase in the cardiac cycle. This approach, referred
to as retrospective gating (see Figure 2.6a), was
very dose inefficient compared with non-cardiac
CT exams.
With 16- and 64-detector-row scanner technology,
the use of ECG-based tube-current modulation
became common, whereby the tube current was
reduced by a factor of 5 or more during those phases
of the cardiac cycle in which image reconstruction
was not anticipated (Jakobs et al., 2002). In this
manner, ventricular and valve function could still be
assessed over the entire cardiac cycle using the
Figure 2.6. In retrospective gating (a), the x-ray beam is
continuously on throughout the cardiac cycle, irradiating the
patient much longer than with prospective triggering (b), in
which the x-ray beam is turned on only for short periods of time
during the phase of interest within the cardiac cycle.
19
noisier, reduced-dose projection data, while the
quality of the coronary angiogram was maintained
during the full-dose portion of the cardiac cycle.
This strategy evolved further to eliminate the con-
stant motion of the patient (and table) through the
gantry, using axial prospectively triggered acquisi-
tions (see Figure 2.6b), in which the tube current
was shut off in synchrony with the ECG signal
during the scan, and also between table movements
(Hsieh et al., 2006; Stolzmann et al., 2008). Wider
detector coverage, up to 160 mm for some systems,
also became available, such that the entire heart
could be imaged in one beat (Einstein et al., 2010;
Goma et al., 2011; Rybicki et al., 2008).
With dual-source CT scanner technology, a high-
pitch mode (so-called “flash” scan mode, pitch of
3.4, Siemens Healthcare) was developed to image
the entire heart in one beat using approximately
40 mm detector coverage (Achenbach et al., 2010;
Flohr et al., 2009; Lell et al., 2009; McCollough
et al., 2009). For stable heart rates below approxi-
mately 65 beats/min, high-pitch scanning enabled
a reduction in the estimated effective dose from
approximately 12 mSv using 64-detector-row
technology (Hausleiter et al., 2009) to below 1 mSv
(Achenbach et al., 2010; Raff et al., 2009;
Stolzmann et al., 2008).
2.3 Scan-Acquisition Parameters and Their
Effects on Image Quality
CT image quality can be predictably affected by
several scan-acquisition parameters. These para-
meters include x-ray-tube potential, V (typically in
units of kV), tube current, J (typically in units of
mA), rotation time, t (typically in units of s), pitch,
p, reconstructed CT image thickness, beam and de-
tector collimation, and scan mode.
The typical range of x-ray-tube potentials pro-
vided in CT systems is approximately from 80 kV to
140 kV. Within this range, the effective linear at-
tenuation coefficient for many tissues changes sub-
stantially. Although the use of lower V settings to
improve soft-tissue contrast has been recommended
(Huda et al., 2000a; 2000b), this approach can lead
to fairly severe beam-hardening artifacts, even in
small children (Cody et al., 2004). Higher V
(130 kV to 140 kV) is often used in CT imaging of
the bodies of very large patients.
Contrast resolution (i.e., the ability to distinguish
lesions differing only slightly in HU values) is
strongly dependent on CT-image noise. Noise is
the pseudo-random visual pattern of CT numbers
observed in a CT image of a uniform object such as a
water-filled cylinder. The so-called root-mean-square
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
(RMS) noise can be determined on a CT image by
computing
sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
Pn 
i¼1 HUi  HU ;
s ¼
n1
where s is the RMS noise, and HUi corresponds to
the CT number in each of n voxels in a region with a
mean voxel value of HU (mean CT number). A
simple software tool to calculate RMS noise in a
user-defined region of interest is commonly available
on all current CT scanners and on image-review
workstations. Image noise cannot be measured ac-
curately in patient images (due to the presence of
tissue heterogeneity) unless regions of known homo-
geneous tissue composition are present, such as
urine in the bladder or blood in large arteries with
no contrast agent present. Noise is routinely mea-
sured on phantoms of uniform composition.
The image noise in a CT image is affected by the
reconstruction methods used for computing the CT
image from the raw projection data, and in general
the reconstruction process tends to add noise correl-
ation to the reconstructed image. The correlation
structure of CT image noise can be characterized
by computing the noise-power spectrum, and this
will be discussed in more detail in Section 11.
Despite the influences of reconstruction methods
in CT images, image noise is principally a function
of the photon counting statistics of the individual
transmission measurements, which are a function
of the photon fluence measured at the detector ele-
ments during the scan. Thus, in CT scanning, any-
thing done to increase the number of photons
reaching the detector will in general result in lower
image noise and better contrast resolution.
Another factor that directly affects image noise,
and thus affects contrast resolution, is the thick-
ness of the reconstructed CT image t. If the image
thickness is reduced by a factor of 2, (e.g., from
5 mm to 2.5 mm), then pffiffiffi the CT image noise
increases by a factor of 2 (or about 40 %), because
only half of the x-ray photons contribute to the
image in that case. In MDCT scanners, the detector
configuration implemented during the scan acquisi-
tion will define the range of CT image-thickness
values that are available for retrospective CT
image reconstruction. For example, if a CT scan
protocol on a 64-slice MDCT system calls for the ac-
quisition of 64 rings of transmission data,
0.625 mm thick, then this finely sampled data can
be used (after the scan) to retrospectively recon-
struct thicker images such as 1.25 mm, 2.5 mm, or
5.0 mm thick images. Thus, several sets of image
data can be reconstructed having different image
thicknesses with no additional scanning necessary,
and hence no additional absorbed dose in the
patient. If, however, the CT-acquisition protocol is
2 set to acquire eight 5.0 mm thick rings of transmis-
ð2:6Þ sion data, retrospective generation of thinner CT
images would not be possible. Although the thinner
1.25 mm images convey more spatial resolution
along the z axis, they are substantially noisier than
corresponding 5.0 mm thick images for the same
acquisition parameters.
2.4 Dose-Reduction Techniques
Modern dose-management strategies in CT
imaging recommend that the appropriate radiation
fluence level be used for the specific patient thick-
ness and the specific diagnostic task for which the
scan was ordered. Unlike film-based radiographic
imaging, a CT image never appears “over-exposed”
or “underexposed” in the sense of being too dark
or too light. The normalization of the acquired CT
projection data [Eq. (2.2)] factors out the incident
beam intensity used during acquisition, resulting
in uniform gray scale images for low-dose and
high-dose images alike. As a consequence, CT tech-
nologists do not receive the feedback on technique
selection that was available in radiography during
the screen-film era. Therefore, the CT operator needs
to consider patient size when selecting parameters
that affect absorbed dose and image quality, the most
basic factor being the photon fluence used to acquire
the scan, which is most commonly adapted by adjust-
ing the tube-current–time product, Jt (mA s) (FDA,
2002; Linton and Mettler, 2003).
2.4.1 Fixed Tube Current (Technique Charts)
and Patient Size
For most CT applications, it is common to stand-
ardize the tube potential and gantry rotation time:
the fastest rotation time is typically used to reduce
motion artifacts and the lowest plausible tube po-
tential is selected to maximize image contrast, pro-
vided that the tube-current limits are adequate to
provide sufficient photon fluence (Funama et al.,
2005; Huda et al., 2002a; McCollough et al., 2006;
Nakayama et al., 2005; Siegel et al., 2004). Thus,
x-ray tube current, J, is the primary parameter
used to account for patient size (see Section 8).
When all other parameters are kept constant, I has
a linear relationship with detected x-ray fluence
rate, i.e., mðx;
_ uÞ ¼ k1 J, and the product of tube
current, J, and exposure time, t has a linear rela-
tionship with detected x-ray fluence; mðx; uÞ ¼ k2 J t,
where k1 and k2 are constants of proportionality
20
 Basics of Computed-Tomography Technology
that depend on numerous scanner and technique
factors.
Tube current is typically adjusted to patient
dimensions based on the overall attenuation of the
anatomy of interest. Weight is used in some set-
tings to adjust tube current, although weight is
less useful than actual physical dimensions as a
quantity to adjust for x-ray attenuation (Boone
et al., 2003; McCollough et al., 2002; Wilting et al.,
2001). Importantly, when considering CT images
acquired across a range of patient sizes, it has been
shown that radiologists do not find the same
image-noise level acceptable for all patient sizes
(Wilting et al., 2001). Radiologists tend to require
lower image noise in children relative to larger
patients because children often lack adipose tissue
between organs and tissue planes and have smaller
anatomic dimensions (Boone et al., 2003; Kalra
et al., 2004; McCollough et al., 2002; Wilting et al.,
2001). For body CT imaging, it has been found that
a reduction in Jt by a factor of from 4 to 5 from
adult techniques is generally acceptable in infants,
although for obese patients, an increase of at least
a factor of two is required (McCollough et al.,
2002). To achieve sufficient exposure levels for
obese patients, the tube current can be increased,
the gantry rotation period can be increased, or the
pitch can be decreased (at constant Jt setting).
2.4.2 Automatic Exposure Control
Modern CT systems have the capability to adjust
the x-ray-tube current in response to variations in
patient attenuation (Gies et al., 1999; Haaga et al.,
1981; Kalender et al., 1999; McCollough, 2005).
Methods of adapting the tube current to patient at-
tenuation, known generically as automatic expos-
ure control (AEC), are analogous to AEC methods
(also called photo-timing) in general radiography,
and in CT have demonstrated substantial reductions
in absorbed dose when image quality is appropriately
specified. An exception to this trend occurs with obese
patients, in which the radiation output of the system
is increased under most AEC system scenarios to
ensure adequate image quality. In obese patients,
much of the additional x-ray energy is absorbed by
excess adipose tissue, a relatively radio-insensitive
tissue. In obese patients due to x-ray attenuation by
peripheral adipose tissues, absorbed doses in internal
organs are slightly reduced at the same tube
current–time product compared with thinner
patients (Schmidt and Kalender, 2002).
AEC is a broad term that encompasses not only
tube-current modulation (see Section 3), but also
refers to overall technique selection according to
patient size in order to achieve appropriate image
21
quality for the diagnostic task. The specific imple-
mentations of AEC differ by the manufacturer.
Practically speaking, acceptable noise levels can
change across patient-size ranges, and so size-
based technique charts are sometimes used to pre-
scribe the AEC parameters (Kalra et al., 2004;
2005; McCollough et al., 2006; Nyman et al., 2005;
Wilting et al., 2001).
2.4.3 Angular and Longitudinal X-Ray-
Tube-Current Modulation
Angular tube-current modulation addresses (see
Section 9) variation in the x-ray attenuation path
within a scan plane, for example, the differences in
the anterioposterior (AP) and lateral dimensions of
the patient at a particular location along the z axis
of the patient. The tube current is varied as the
x-ray tube rotates around to the patient, with
higher current used for thicker projections and
lower current for thinner projections through the
patient’s anatomy. Attenuation information is
determined from the previously acquired CT locali-
zer view, or on some systems the projection meas-
urement acquired 1808 before the currently
acquired projection is used to modulate the tube
current level; for a 0.30 s gantry rotation period,
that requires dynamic (150 ms) modulation hard-
ware. X-ray-tube-current modulation along the z
axis of the patient takes into account variations in
attenuation among different regions (e.g., shoulders
versus abdomen) by varying the average Jt along
the patient’s long axis. To achieve the right com-
promise between image quality and absorbed dose,
the parameters that influence tube-current modu-
lation, which are scanner-manufacturer dependent,
must be clearly communicated by the manufacturer
and properly chosen by the user. Both angular and
z-axis tube-current modulation are effective
methods of achieving CT dose reduction.
2.4.4 Adjusting X-Ray-Tube Potential Based
on Patient Size
Several investigators have studied the use of
lower-tube-potential CT imaging to improve image
quality or reduce absorbed dose. The principle
behind lower-energy imaging is that the attenu-
ation coefficient of iodine increases as photon
energy decreases toward the iodine K-edge energy
of 33 keV. In CT exams involving the use of iodi-
nated contrast media, the superior enhancement of
iodine at lower tube potentials improves the conspi-
cuity of hypervascular or hypovascular pathologies.
However, images obtained using lower tube poten-
tials tend to be much noisier, mainly due to the
higher absorption of low-energy photons by the
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
patient, unless the tube current is adequately
adjusted (FDA, 2002; Funama et al., 2005; Haaga
et al., 1981; Huda et al., 2000a; Kalender et al.,
1999; McCollough, 2005; Nakayama et al., 2005;
Siegel et al., 2004). The x-ray tube output (for in-
stance, the measured air kerma at isocenter) changes
non-linearly as a function of V, when other para-
meters are held constant (see Figure 2.7). In general,
there is a power-law function that describes x-ray
tube output as a function of x-ray-tube potential, V:
Kair ¼ aðVÞb ; ð2:7Þ
where Kair is the air kerma at isocenter, a a coeffi-
cient, and b the parameter of interest here. As seen
in Figure 2.7 for four CT scanners from different
manufacturers, the exponent b ranges from 1.8 to
2.6. As a generalization, b increases with increasing
added filtration in the x-ray beam, and that is why
the curves in Figure 2.7 have decreasing overall
output levels as the value of b increases.
The optimal and most dose-efficient tube poten-
tial is dependent on the patient size and diagnostic
task (McCollough, 2005), considering the
contrast-to-noise ratio in tissues with and without
contrast agent (Yu et al., 2010).
2.4.5 Beam-Shaping Filters
CT scanners generally use a greater amount of
beam filtration than x-ray systems used for radiog-
raphy or fluoroscopy in order to reduce the beam
hardening that occurs as the beam passes through
Figure 2.7. The x-ray tube output [expressed as the air kerma
(mGy) measured at the isocenter of the scanner per Jt (mA s) as
a function of tube potential, V (kV)] for four manufacturers.
Curve A: General Electric VCT; curve B: Siemens Definition;
curve C: Toshiba Aquilion 16; and curve D: Philips Brilliance 16.
The value of the exponent b is shown with each curve, ranging
from 1.8 to 2.6. These curves illustrate the non-linear
relationship between tube potential and x-ray tube output in CT
systems.
22
the patient. The tube assembly for modern CT
scanners usually has between 1 mm and 3 mm alu-
minum filtration with an additional flat filter of
0.1 mm copper, giving a total filtration of between
6 mm and 9 mm of aluminum equivalent. As x-ray
tube and generator technology has advanced,
allowing higher peak power levels, additional filtra-
tion can be used without limiting the ability of the
system to achieve the necessary x-ray fluence rates
for fast CT scanning protocols. MDCT scanners also
make much more efficient use of the x rays that are
produced because of the larger beam widths that are
used. Compared with a single-detector-row CT
scanner with a 5 mm beam width, an MDCT system
with a 40 mm beam width (i.e., nT ¼ 40) is eight
times more efficient in terms of usable photon
fluence rate per x-ray-tube power.
Because most body regions that are scanned in
clinical CT are approximately cylindrical, the x-ray
path length is smaller at the periphery of the
patient relative to the center. If uncompensated,
the x-ray fluence reaching the detectors corre-
sponding to the periphery of the patient would be
much greater than at the center of the patient. To
compensate for this, the x-ray beam in CT scanners
is attenuated more at the periphery and less at the
center. These bow-tie or wedge filters reduce un-
necessary patient absorbed dose by matching the
filter shape to the patient size and clinical applica-
tion. Most CT systems have two or three different
bow-tie filters, which are selected based on patient
size. In cardiac CT, the region of interest is cen-
tered within the thorax, and therefore the x-ray
fluence can be substantially reduced outside the
cardiac volume of interest using an appropriately
designed bow-tie filter, with no loss of diagnostic in-
formation. The use of beam-shaping filters on CT
scanners heightens the importance of properly cen-
tering the patient in the scan field.
2.4.6 Image-Reconstruction and
Noise-Reduction Algorithms
Iterative reconstruction and algorithms such as
projection- or image-based noise reduction are cur-
rently being introduced to help users reduce
absorbed doses in CT. In iterative reconstruction,
an initial estimate of the “truth” (i.e., the object
being imaged) is generated from the acquired pro-
jection data. This is typically done using conven-
tional filtered-back-projection reconstruction
methods, which are very fast. From this initial esti-
mate, the system performs a forward projection
mathematically from the initial estimate of truth.
This step can address scanner-specific geometrical
and x-ray properties such as detector spacing and
 Basics of Computed-Tomography Technology
focal-spot distribution. The algorithm might also
include a model of the quantum noise (i.e., Poisson
distribution). The forward projection data are com-
pared with the originally measured projections,
and the differences are used to update the estimate
of the truth. This process is repeated (iterated)
until the differences between the actual and simu-
lated projections are acceptably small. This tech-
nique can produce images that more closely
resemble the scanned object, and, in particular,
noise and artifacts can be reduced substantially
and spatial resolution improved, leading to the
potential for absorbed-dose reduction.
Iterative-reconstruction methods or other image
noise-reduction techniques do not, by themselves,
reduce absorbed dose in CT scanning. Rather, by
improving the image quality through noise reduc-
tion, the technical factors that affect absorbed dose
(tube potential and current, pitch, etc.) can be
adjusted to realize excellent image quality at
reduced dose levels.
In contrast to iterative-reconstruction methods,
which form an image from the projection data,
23
noise-reduction techniques can be used to reduce
noise levels in the projection data (Funama et al.,
2011; La Riviere, 2005; La Riviere et al., 2006; Li
et al., 2004; Manduca et al., 2009; Silva et al., 2010;
Wang et al., 2006) or on the reconstructed CT
images (Bittencourt et al., 2011; Tipnis et al.,
2010). These approaches can reduce noise, but do
not in themselves reconstruct an image and do not
reduce artifacts or improve spatial resolution.
2.5 Summary
CT technology has evolved over four decades to
the point at which CT is one of the most widely
used diagnostic imaging examinations performed.
Its rapid scan time and isotropic resolution provides
excellent anatomical detail, and - with the use of
dynamic imaging and contrast-medium injection -
functional physiological information such as regional
blood volume and tissue perfusion can be assessed.
Because CT entails more absorbed dose than radiog-
raphy, there have been a number of recent efforts to
reduce the radiation levels in clinical CT scanning.
Journal of the ICRU Vol 12 No 1 (2012) Report 87 doi:10.1093/jicru/nds003
Oxford University Press

3. Computed Tomography in Clinical Use

3.1 Introduction importantly, the imaging process could be accom-

plished in a manner that was rapid, entirely non-
Since its introduction in 1972, computed tomog-
invasive, relatively low in cost, and eventually,
raphy (CT) has become an integral diagnostic tool
widely available. The tool was also free of immedi-
of modern medicine. According to national surveys
ate risk, and was entirely pain-free.
of CT use, it is estimated that approximately 70
In the four decades since 1972, technological
million CT examinations are performed per year in
developments relating to CT-beam generation, de-
the USA (Brenner and Hall, 2007), and the use of
tector technology, image-reconstruction algorithms,
CT in Europe and Asia has experienced large
and computer-processing capabilities have dramat-
increases as well. Current scanners are capable of
ically improved image resolution and the utility of
rendering sub-millimeter-resolution images of the
brain CT imaging. These improvements have
entire body in a matter of seconds. With the in-
resulted in greater spatial resolution and improved
creasing use of picture archiving and communica-
attenuation-related differentiation of brain struc-
tion systems, teleradiology, and voice-recognition
tural components, both for normal and for abnor-
software that facilitate rapid image dissemination
mal brain tissue. In a separate manner, the
and interpretation, CT has become an especially
development of intravenously administered iodi-
vital component of patient evaluation for a large
nated contrast agents has enabled even more
number of diagnostic settings. In this Section,
precise tissue-differentiation capabilities during CT
some of the clinical applications of CT in the
imaging, based on differential contrast penetration
several sub-specialty fields of radiological imaging
through the vascular endothelial wall (see
are presented.
Figure 3.1). In the past decade, the dramatically
The development of multi-detector CT in 1998
increased speed of current CT-image acquisition, in
was a major step forward in CT technology. The
association with contrast administration, has
sub-second rotation time of the scanners, the
enabled the dynamic acquisition of image data that
slip-ring technology that enabled helical (spiral) ac-
enables the quantification of normal or abnormal
quisition, coupled with the ability to produce a set
vascular perfusion of brain tissue. The combination
of CT images in a single rotation has made it pos-
of imaging speed and contrast administration has
sible to scan large areas of the body in a single
also allowed for CT angiography, enabling a precise
breath hold. Multi-planar reconstructions and
anatomic depiction of the arterial and venous vas-
three-dimensional (3D) images of excellent quality
cular structures of the head and neck.
can be produced, which can be of great benefit in
For patients with suspected brain dysfunction re-
many clinical situations (Hu, 1999).
lating to trauma, stroke, tumors, infectious pro-
cesses, or developmental abnormality, CT imaging
is usually the first and most useful imaging tool.
3.2 CT in Neuroradiology
This same imaging technology is generally pre-
The first clinically available CT scanners were ferred for the characterization of soft tissues and
head CT scanners only. The introduction of clinical osseous structures of the facial region, and for
CT brain imaging led to an immediate and perman- imaging of osseous components of the cervical,
ent transformation of the clinician’s approach to thoracic, and lumbar spine.
adults and children with suspected neurologic dis- In an emergency-room setting, brain CT imaging
orders. With this tool, physicians could, for the first can generally be completed within from 2 min to
time, obtain an accurate structural image of the 3 min, providing the physician with critical infor-
brain, demonstrating not only its contour, but also mation regarding the presence or absence of
differentiating regions of normal and abnormal at- trauma-related intracranial hemorrhage or mass
tenuation within the brain parenchyma itself. And, effect (see Figure 3.2). Skull and facial fractures

# International Commission on Radiation Units and Measurements 2013

 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 3.1. Images from a 42-year-old with the new onset of seizures. Axial CT slices without contrast (left) could be interpreted as
normal. Following contrast administration (right), there are enhancing foci due to metastatic melanoma (arrows).
Figure 3.2. Images from a 27-year-old with head trauma. Axial
images demonstrate an epidural hematoma over the surface of
the brain (double white arrows) with mass effect manifest by a
shift of the midline septum pellucidum from right to left (single
white arrow). A hemorrhagic cerebral contusion is deep to the
hematoma (double black arrows), and scalp hematoma is present
(single black arrow) outside of the skull.
are identified immediately. In patients with sus-
pected stroke, early subarachnoid hemorrhage can
be identified. Areas of early ischemic stroke, not
26
associated with hemorrhage, might not be demon-
strable on routine axial CT images during the first
several hours, but can be identified on CT brain-
perfusion studies performed with a few extra
minutes of workstation-based processing of
dynamic brain CT images obtained following the
intravenous administration of iodinated contrast.
Magnetic resonance diffusion imaging is often cor-
related with initial CT imaging for the rapid clinic-
al characterization of potential areas of early
non-hemorrhagic stroke.
In patients with more prolonged or recurring
symptoms of abnormal neurologic function, CT
imaging can be performed both prior to and/or fol-
lowing the intravenous administration of iodinated
contrast agents. In these situations, the radiologist
and referring physician might be concerned with
the potential presence of an extremely broad
number of disorders, such as an underlying
primary or metastatic tumor (see Figure 3.1), a de-
generative disorder such as Alzheimer’s disease, or
the presence of a chronic brain alteration asso-
ciated with prior trauma or stroke.
CT imaging of the spine is useful when there has
been significant trauma, or when there are symp-
toms of suspected spinal-cord or nerve-root dys-
function. Although cross-sectional images of the
spine provide excellent anatomic detail, contiguous
thin-cut axial slices can be reformatted almost
 Computed Tomography in Clinical Use

Figure 3.3. Images from a 44-year-old with upper and lower extremity paralysis following trauma. (a) Axial CT images demonstrate a
burst fracture of the C6 vertebral body (black arrow) with spinal-canal narrowing (white arrow). (b) These findings are more clearly
demonstrated on reformatted sagittal images.

instantaneously into coronal, sagittal, oblique, or

3D images, which provide an optimal anatomic
characterization for referring physicians (see
Figure 3.3). Lumbar-spine CT imaging is often
used to demonstrate the presence or absence of disc
protrusion (see Figure 3.4), to show narrowing of
the spinal canal that can be associated with degen-
erative or congenital disorders of the spinal
column, or to characterize congenital or acquired
disorders of the spinal cord. Such imaging can be
accomplished without or with the injection of a con-
trast agent into the cerebrospinal fluid space that
normally surrounds the nerve roots and spinal cord
within the spinal canal.
In patients with suspected skull-base lesions,
and in those with suspected tumors or infections
involving the neck or facial region, CT imaging is
generally performed with intravenous contrast ad-
Figure 3.4. Images from a 35-year-old with back and left-lower
ministration. Its purpose is to characterize the site extremity pain. Axial CT image from a lumbar-spine CT study
of origin, the presence of regional extension, and shows a left paramedian disc protrusion at the L4–L5 disc
the presence or absence of regional lymphatic or space. The disc margin (double arrows) is indenting the spinal
other metastatic involvement. Thin-slice, high- canal and the originating left L5 nerve-root sleeve. The normal
resolution CT imaging allows a precise character- originating right L5 nerve-root sleeve is unaffected (single
arrow).
ization of regional anatomy, including fascial
planes. The value of coronal and sagittal reformat-
ted images is often additive. On the basis of patient differential diagnosis of the underlying pathological
age, regional soft tissue, and/or bone extension, process can generally be established. For mass
tissue attenuation, and the pattern of tissue and lesions involving the skull base, face, or neck, CT
lymph-node enhancement, a relatively narrow imaging is an indispensable complement to the

27
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 3.6. Axial chest CT scan with contrast on a 62-year-old

male following a motor-vehicle accident. The image shows
rupture of the aorta (arrow) in the most common location, at the
aortic arch. There is a substantial collection of blood in the
mediastinum.
Figure 3.5. Images from a 58-year-old with a lump in his neck.
Axial images through the lower facial region demonstrate a
poorly marginated right-sided oropharyngeal squamous-cell
carcinoma (double arrows) with extensive regional lymph-node
metastases (single black arrow).

physical examination, which is generally constrained

to an inspection or palpation of regional cutaneous
and mucosal surfaces (see Figure 3.5).

3.3 CT in Thoracic Radiology

In the emergency department, the most common
indications for obtaining a chest CT include trauma
and chest pain (Larson et al., 2011a; 2011b). In
patients with trauma, CT imaging can show signifi-
cant critical injuries such as aortic rupture, tension
pneumothorax, pulmonary laceration, hemorrhage,
and airway and esophageal injury (see Figure 3.6).
All of these findings require immediate interven-
tion. In patients with chest pain and shortness of
breath, the scope of diagnoses is vast. CT can pin-
point the cause to be pulmonary embolism, pneu-
monia, or pulmonary edema (see Figure 3.7). In
some instances, pleural or pericardial disease, for
example empyema (infected pleura) or pericarditis,
can be the cause of the chest pain. Cardiac CT for
coronary-artery disease in many medical centers is
performed on a non-emergent basis, and not in the
emergency department.
Various pulmonary fungal infections are endemic
in certain geographic regions of the world. For
example, histoplasmosis is endemic in the
mid-South and Midwest of the USA. Approximately
50 % of chest CT scans will show lung nodules, half
Figure 3.7. Images from a 62-year-old male complaining of
shortness of breath and chest pain. Axial chest CT scan with
contrast shows a massive saddle embolus (arrow) in the right
and left main pulmonary arteries.
of which are not calcified. In high-risk patients who
smoke, differentiating these nodules from lung
cancer is of utmost importance. Solid nodules that
are less than 1 cm in diameter and are not calcified
are typically followed with serial CT scans for 2 y.
Stability over a 2 y period in most cases indicates
benign nodules. Nodules that increase in size or in-
determinate nodules that are greater than 1 cm in
diameter are often imaged with a PET-CT examin-
ation or are surgically removed (Winer-Muram,
2006) (see Figure 3.8).
Patients who present with a mass on chest radi-
ography are commonly referred for CT as the next

28
 Computed Tomography in Clinical Use
Figure 3.8. Axial chest CT scan without contrast in an
asymptomatic 73-year-old man. This image shows a 1.4 cm
nodule in the left upper lobe. Comparison with a prior chest CT
performed 4 y earlier showed interval growth of the nodule.
study. CT can elucidate if a mass is present and
show the extent of disease spread (see Figure 3.9).
Enlarged hilar and mediastinal lymph nodes,
pleural masses and fluid, rib erosion, and chest-
wall invasion are very suggestive of advanced
disease.
CT is one of the best diagnostic tools to evaluate
for tumor response to chemotherapy. Protocol-
driven studies are routinely requested by oncolo-
gists to assess the efficacy of the chemotherapy or
radiation-therapy regimen they have chosen.
Recently, chest CT was determined to be useful
in screening of patients at high risk for lung
cancer, which is the leading cause of cancer-related
death in the developed world. A large multicenter
study, the National Lung Screening Trial (NLST),
compared low-dose helical CT with chest radiog-
raphy in the screening of older, current, and former
heavy smokers, for early detection of lung cancer.
Starting in August 2002, the NLST enrolled about
53 500 men and women: all had a smoking history
of at least 30 pack-years and were either current or
former smokers without signs, symptoms, or
history of lung cancer. They were randomly
assigned to receive three annual screens with
either low-dose helical CT or standard chest radiog-
raphy, and were then followed for another 5 y. At
the conclusion of the study, a total of 354 deaths
from lung cancer had occurred among participants
in the CT arm of the study, whereas a significantly
larger 442 lung-cancer deaths had occurred among
those in the chest-radiography group (Aberle et al.,
2011). How this information will be implemented in
clinical practice is not yet clear, as the cost–benefit
29
Figure 3.9. A 64-year-old male presented with chronic cough
and an abnormal chest radiograph. Chest CT without contrast
shows a heterogeneous mass-like opacity (arrow) in the right
upper lobe. Further clinical evaluation led to a diagnosis of lung
cancer.
analysis is still ongoing and the infrastructure ne-
cessary to launch such a large-scale screening
program currently does not exist in any country.
CT has been shown to be very useful in patients
with diffuse lung disease. Thin-section CT (1 mm
to 2 mm thick) reconstructed images with a bone
kernel show exquisite detail of the lung paren-
chyma. A diagnosis of pulmonary fibrosis with hon-
eycombing is so reliable with imaging that
open-lung biopsy need not be performed in most
cases. If surgery is needed, the scan can be used as
a guide for the best biopsy site.
Distinguishing emphysema, cystic lung disease,
and cavities can be difficult with chest radiography.
There are a variety of diseases that cause lucent
lung lesions, and chest CT images can delineate
“vanishing lung” from emphysema, thin-walled
cystic lung disease, and thick-walled cavities (see
Figure 3.10). In many cases, the CT findings can
provide the diagnosis, or a short list of possibilities.
It is a powerful tool that has played a crucial role
in the diagnosis and management of diseases of the
thorax.
3.4 CT in Abdominal Imaging
Worldwide, ultrasound imaging is the most com-
monly used cross-sectional imaging modality to
evaluate potential abnormalities of the abdomen
and pelvis. Advantages of ultrasound over CT
include a much lower cost, better delineation of
cystic versus solid masses, and absence of ionizing
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 3.10. Chest CT, coronal reconstruction in a 52-year-old
male smoker. The patient complained of increasing shortness of
breath. This CT image shows abnormal lung parenchyma,
especially at the apices (arrows) representing bullous
emphysema, a smoking-related lung disease.
radiation. However, in many parts of the world,
ultrasound is often used as a screening exam, and
CT is used for definitive diagnosis, particularly in
situations in which ultrasound visualization is
obscured by overlying structures in the abdomen
such as loops of air-filled bowel. With the rising
number of obese individuals in many countries, CT
is often used as the first-choice imaging modality
owing to the difficulty of obtaining diagnostic-
quality ultrasound images of internal organs in
obese individuals. CT gives a quick and comprehen-
sive view of the abdomen and pelvis, and is the
imaging method of choice in a number of clinical
situations. Situations in which CT is helpful are
described below.
There are numerous etiologies of abdominal
pain, for which CT is an ideal tool (Rao et al.,
1997). CT can evaluate inflammatory conditions in
solid organs or hollow viscous regions within the
abdomen. These can include evaluation of pancrea-
titis or diverticulitis and related complications. CT
can evaluate other inflammatory conditions such
as acute appendicitis (see Figure 3.11). With this
condition, the appendix becomes inflamed and
enlarged, usually due to a small appendicolith
(small stone-like structure) obstructing the appen-
dix. This can be seen as a fluid-filled enlarged ap-
pendix in the right lower quadrant of the abdomen
(Figure 3.11). In some situations in which appendi-
citis is suspected, there can be other etiologies of
the patient’s pain. Figure 3.12 shows CT images of
a patient with right-sided pain due to a renal
stone, which has lodged in the ureter. The stone
30
Figure 3.11. Images from a 35-year-old male with right-lower-
quadrant pain. Coronal CT reformatted image demonstrates the
liver (L) and the kidney (K). There is a tubular structure seen in
the right lower quadrant of the abdomen (arrow), which
represents an inflamed appendix in this patient.
imposes an obstruction, which causes kidney swel-
ling due to the back-up of urine, with associated
intense flank pain.
CT is well suited for the examination of the
patient with acute blunt or penetrating abdominal
trauma (Federle et al., 1981). In these situations,
the patient is often unstable, and it is essential to
rapidly diagnose any potential abnormality for im-
mediate surgery or other interventional therapy.
This can include injuries to arteries causing intern-
al bleeding, injuries to hollow viscous tissues (e.g.,
bowel), or injuries to solid organs. Figure 3.13
shows a CT image of a patient with blunt trauma
from a motor-vehicle accident. The patient has a se-
verely fractured spleen with active bleeding from
the spleen into the abdomen.
CT is the preferred imaging modality for the
detection of malignant or non-malignant abdom-
inal masses (Freeny et al., 1988). CT can also
guide biopsy or treatment of these masses.
Figure 3.14 shows images of a patient with pan-
creatic cancer; CT can detect the cancer, deter-
mine local extension, and identify liver and other
metastases, resulting in tumor staging. Tumor
staging is important because it helps to guide
oncologists as to what therapies should be consid-
ered. CT imaging can also be used to follow oncol-
ogy patients to evaluate their response to tumor
therapy.
CT is well suited to guide needle-biopsy place-
ment into abdominal masses, particularly those
that are not amenable to biopsy under ultrasound
guidance. Biopsy needles are placed in the
 Computed Tomography in Clinical Use

Figure 3.12. Coronal CT image from a 45-year-old with right-sided flank pain. (a) This coronal CT image demonstrates the liver (L),
right kidney (K), and the bladder (B). There is dilatation of the right renal pelvis and ureter (arrow). (b) Another reformatted coronal
image demonstrating the liver (L), kidney (K), and the bladder (B). Note that there is a high-attenuation spherical structure
representing a kidney stone (arrow), which is obstructing the right ureter and causing the patient’s right-sided pain.

Figure 3.14. Pancreatic cancer. The axial CT scan demonstrates

Figure 3.13. Images from a 22-year-old involved in a motor-
vehicle accident. The axial CT scan after administration of
contrast demonstrates active extravasation of contrast in the
region of the patient’s spleen (arrow). This caused hemorrhage
into the abdomen (curved arrow) surrounding the patient’s liver
(L). This patient required immediate operative intervention for
removal of his spleen.
a low-density mass identified in the body of the pancreas
(arrow). There are multiple low-density regions seen within the
patient’s liver corresponding to multiple metastases from the
patient’s pancreatic carcinoma. There is also a benign cyst noted
within the left kidney (curve arrow).
images of a patient with liver metastases treated
by placement of three radiofrequency needles.

abdomen using CT-image guidance, and small

amounts of tissue are removed and sent for histo-
pathology assessment.
Invasive techniques have been developed that
allow CT-guided treatment of abdominal tumors,
avoiding open surgery. For example, radiofrequency
ablation allows a series of small needle electrodes
to be placed into a tumor, which result in intense
tissue heating when electrified, killing the tumor
cells by tissue coagulation (McGahan and Dodd,
2001; McGahan et al., 2011). Figure 3.15 shows
3.5 CT in Pediatric Radiology
CT is a powerful tool in the diagnosis and care of
pediatric patients. The development of multi-slice
scanners and helical scanning allows for faster
scanning in less-cooperative children. Quality
imaging can now be performed without the signifi-
cant risk and cost of patient sedation. Dynamic
studies also add important information. CT has
resulted in a beneficial change in patient manage-
ment in as many as 68 % of hospitalized pediatric

31
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 3.15. Images from a 68-year-old with metastatic colon cancer. (a) The axial CT scan shows a heterogeneous mass in the right
lobe of the liver (arrow). (b) This liver lesion was treated with radiofrequency ablation (RFA), and three electrodes used to perform the
RFA are seen in the liver.
Figure 3.16. Head CT images of a 5-year-old boy. After trauma
experienced while wrestling, a large epidural hematoma (arrow)
is seen and the brain is shifted to the left from the mass effect of
the hemorrhage.
patients (Callahan et al., 2002) and has decreased
the need for exploratory surgery. As a result, CT
use in children is on the rise. As many as 7 million
CT scans are performed yearly in children in the
USA (Frush and Applegate, 2004), and CT use in
the pediatric emergency department has increased
five-fold between 1995 and 2008 (Larson et al.,
2011a; 2011b).
Concern regarding radiation exposure from CT
scans in children has been in the forefront of the
medical literature and the lay press in recent
years. Children are more radiosensitive than
adults, and have a longer lifetime to develop
radiation-induced cancer (Brenner and Hall, 2007).
32
Figure 3.17. Axial CT image from a 3-year-old boy with a Wilms
tumor. The arrows point to the tumor in the left kidney. It
enhances less (so is not as bright) with IV contrast than does
the normal kidney tissue. RK, normal right kidney; LK, normal
part of left kidney, from which the tumor arises.
Organizations such as the Alliance for Radiation
Safety in Pediatric Imaging, the Image Gently cam-
paign, and the ALARA (as low as reasonably
achievable) principle have focused on the need for
radiation protection in children. There is increased
awareness, knowledge, and communication in
the efforts to optimize CT imaging in children
(Newman and Callahan, 2011). Evidence-based
imaging research helps guide clinicians toward the
appropriate utilization of CT imaging, and when to
consider alternative imaging options.
Imaging the brain is one major use of CT in chil-
dren. CT scans give physicians a rapid “window”
through which to see the otherwise hidden region
enclosed by the skull. For example, emergent and
critical decisions for patient care are made based
upon CT imaging in trauma patients. In the image
shown in Figure 3.16, there is a large hemorrhage
between the brain and the skull (arrow), which
compresses the brain.
CT imaging of the abdomen and pelvis in chil-
dren is performed for a variety of reasons. CT is
 Computed Tomography in Clinical Use

Figure 3.18. (a) Three-dimensional reconstruction of a complex (tri-plane) ankle fracture in a 14-year-old boy (arrows show multiple
fracture lines). These 3D images can be viewed from various angles, and allow the surgeon to accurately plan the surgical reduction of
this injury. (b) A post-operative radiograph shows anatomic bony alignment after fracture reduction and internal fixation with plates
and screws.

the standard imaging modality used in the evalu-
ation of pediatric blunt abdominal trauma, usually
from motor vehicle or bicycle accidents, falls, or
sports injuries. CT can accurately define the extent
and type of intra-abdominal and intra-pelvic injury
(Wootton-Gorges, 2010). CT can also be used in the
diagnosis and management of children with ab-
dominal tumors. Figure 3.17 shows a child with
Wilms tumor, the most common kidney and
intra-abdominal malignant tumor in children.
Although ultrasound is favored in many centers for
diagnosing appendicitis in children, CT has also
been useful in the diagnosis of appendicitis in chil-
dren. In some centers, using CT to diagnose appen-
dicitis has decreased the negative appendectomy
rate (Callahan et al., 2002). One study also
describes less delay in treatment and fewer compli-
cations with the use of CT in over 2000 patients
with suspected appendicitis seen between 1997 and
2004 (Frei et al., 2008).
CT scanning of the chest in the pediatric popula-
tion is most frequently performed for trauma and
for evaluation for metastatic tumor spread to the
lungs or other tissues in the thorax. Evaluation of
serious pneumonia is another common reason phy-
sicians ask for CT scans of the chest. Less-frequent
reasons for scanning the chest include congenital
abnormalities, such as maldevelopment of the
heart or large vessels in the chest, or primary
tumors in the chest. Lung disease, such as cystic
fibrosis, can also be followed to assess its severity
and/or response to therapy.
CT scanning is very useful in evaluation of bony
abnormalities. Three-dimensional reformatted
images are particularly useful to the orthopedic
surgeon managing spinal curvature, fractures,
or bone tumors. Figure 3.18 shows a 3D reforma-
tion of a complex fracture of the ankle. Three-
dimensional images allow the surgeon to accurately
plan the operative procedure before going to the op-
erating room.
3.6 CT in Clinical Use: Summary
CT was originally utilized for examining the
head and brain only, because the head could be
immobilized for long scan periods. Through four
decades of technological advancement, CT scanners
can now acquire high-resolution images throughout
the body in a matter of a few seconds. The increased
image quality and decreased scan time has led to
the use of CT for many examinations for which radi-
ography was used in the past. This has increased
the utilization of CT imaging in most clinical disci-
plines. Although the diagnostic accuracy of CT is
generally superior to radiographic (or other)
imaging procedures, the increased use of CT has
also increased concerns about large populations
receiving higher exposures to ionizing radiation.

33
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
4. Overview of Existing CT-Dosimetry Methods
4.1 Goals of CT Dosimetry
As pointed out in Sections 2 and 3, rapid
advances in CT technology over the past decade
have led to increasing clinical demand for CT exam-
inations. Because of the increased sophistication of
modern CT scanners, performing CT on patients
has becomse easier and faster, and better image
quality has improved diagnostic accuracy. The dra-
matically shorter acquisition times of multi-
detector-row CT (MDCT) systems have opened up a
number of new clinical applications, including
cardiac CT, time-domain CT perfusion, and pediat-
ric imaging on unsedated patients. These improve-
ments have led to a huge increase in the number of
CT examinations performed around the world, and
especially in developed countries in which CT scan-
ners are more widely available. As noted in NCRP
160 (NCRP, 2009) over the last 30 y, there has been a
72 % increase in the radiation dose in the USA, aver-
aged over the entire population, and a sizeable
fraction of this increase is attributed to the more
widespread use of CT. Modern CT scanners have
more advanced capabilities, and these features affect
the patient’s radiation dose. It is therefore necessary
to identify the requirements of CT dosimetry to
better optimize dosimetry tools and metrics that are
most useful for CT dose estimation in the context of
modern medical practice and CT utilization.
CT dose-estimation methodologies and accuracy
requirements will vary depending on the specific
objective. Modern CT scanners have the capacity to
produce deterministic effects (tissue reactions) in
addition to stochastic effects. Deterministic effects
include erythema, epilation, and disruption of the
normal function of implanted devices such as pace-
makers and neurostimulators. In many instances,
the dosimetry techniques required for the evalu-
ation of stochastic effects differ from those neces-
sary for evaluation of deterministic effects. For
example, absorbed doses in internal organs are
more pertinent to stochastic influences of radiation,
and absorbed doses in the skin or eye lens are often
more important in considering deterministic effects
of radiation exposure.
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/nds004
Dosimetry in CT and other x-ray procedures is
complicated by the fact that there is a wide range
of body shape, height, and weight distributions in
the population. Adult women and men have differ-
ent characteristic body types and organ sites of
concern in regard to radiation risk. In addition to
their smaller body habitus, pediatric patients
present special concerns in terms of CT dosimetry,
given their more rapidly growing tissues and
greater longevity.
General categories of CT dosimetry methods
include (1) routine dose characterization of a CT
scanner for acceptance testing and quality control;
(2) the determination of dose for the generic
patient to compare acquisition protocols; (3) dosim-
etry for a specific patient; and (4) large-scale moni-
toring of CT dose values across hundreds or
thousands of patients to assess institutional CT
practices.
(1) For acceptance testing and quality control, radi-
ation output (air kerma), or dose indices (dis-
cussed below) might be measured for a wide
array of uses, including:
† To assure that the scanner is generating
similar air-kerma levels, for a given set of
technique factors, as other identical scanners,
and that these values are consistent with
vendor-provided specifications.
† To assure that the CT scanner is generating
similar radiation-output levels periodically
over time, after a change in the x-ray tube, or
after a CT scan of a patient that requires
follow-up dosimetry.
† To optimize technique factors using phantoms
of different size, complexity, and composition.
† To comply with applicable regulations or ac-
creditation procedures.
(2) CT dosimetry for generic patients using specific
acquisition protocols, which represent the most
common use of CT dosimetry in patients,
including:
† A general knowledge of CT doses (organ
absorbed and effective doses) for various CT
examinations (e.g., head, abdomen) for rapid,
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
routine clinical decision-making and protocol
selection.
† The computation of CT doses for a specific
examination type for a general population of
patients ( pediatric patients, women undergo-
ing CT evaluation for pulmonary embolism
during pregnancy, trauma patients, etc.) for
clinical practice or research studies.
† Estimation of peak doses in specific organs
(e.g., brain, skin) to assess the potential for
deterministic effects in generic patients for
specific CT examinations (e.g., CT head perfu-
sion, CT angiography).
† Assessment of the cumulative organ dose
from CT examinations and comparison of this
value with the exposures from other artificial-
or natural-radiation sources.
† Comparison of the estimated radiation risks
associated with different radiological methods
that are expected to provide similar medical
outcomes.
(3) Dosimetry performed on specific individual
patients that usually (but not always) occurs
after the examination has been performed, and
typically includes the following situations:
† Estimation of the absorbed dose in specific
organs associated with a particular
examination.
† Estimation of the stochastic radiation risk
associated with a specific CT examination.
† Assessment of the absorbed dose to a fetus
when a pregnant woman is undergoing or has
had a CT examination.
† Absorbed dose in exposed tissues when there
is concern about the potential for the patient
to develop deterministic effects from a high-
dose CT procedure.
(4) The assessment of CT dosimetric quantities to
evaluate large numbers of dose estimates for
characterization of an institution’s CT-dose
practices, including:
† The use of dose-reporting software to charac-
terize quantities such as the volume com-
puted tomography dose index (CTDIvol ),
dose – length product (DLP), or size-specific
dose estimates (SSDE) for classes of CT exam-
inations such as the head, chest, or abdomen/
pelvis CT scans.
† Assessment of the DICOM object (RDSR
object—radiation dose structured report) for
CT-dose registry programs.
Increasing concern over the radiation dose asso-
ciated with modern CT scanners has led to the
need for more accurate methods for CT-dose assess-
ment and for a wider range of CT-dose assessment
36
techniques. Although CTDI-based methods have
proved useful in the past when the CT function
was far more limited, it is clear that CT-dosimetry
methods need to advance to keep pace with the
technological advances of the scanners themselves.
This is discussed in detail below.
Ideally, a single radiation-dose quantity in CT
would be usable by all parties of interest. However,
different quantities might be necessary for the
needs of various stakeholders involved in CT, in-
cluding patients, radiologists and other physicians,
medical physicists, lawyers, and others. For
example, to monitor radiation output of a CT
scanner over extended periods of time, a number of
different radiation measurements could be used.
However, for the assessment of potential fetal risk
from an extensive series of CT procedures, more
specific dosimetric quantities would be required.
Section 4.2 discusses existing dosimetric quantities
that have been used for these various purposes for
the past several decades.
CT dosimetry is in a state of flux as a result of a
number of recent publications, including AAPM
Report 111 (AAPM, 2010). The purpose of this
Section is to define the state of the art for CT dose as-
sessment. It should be noted that the CTDI method-
ology is a key part of International Electrotechnical
Commission regulations, and it is therefore unlikely
that measurement protocols that are a part of many
regulations worldwide will be changed in the short
term. Therefore, a review of current methodologies
for assessing “dose” from a CT scanner will be
described below.
4.2 CTDI-Based Metrics
4.2.1 Basic Tools
Figure 4.1 illustrates the basic shape of the
100 mm “pencil chamber” used for over 30 y for CT
dose measurements. The pencil chamber has a
100 mm active length and is designed to fit within
a solid phantom with holes placed at various loca-
tions as illustrated in Figure 4.2. The design of the
chamber produces a uniform response along its
axis. A radiation meter longer than the collimated
radiation beam was required historically in CT
dose assessment because it is difficult to position a
small radiation meter precisely within the very
narrow collimated slice thicknesses, especially in
the era of single-slice scanners in which nT ranged
typically from 1 mm to 10 mm. With multi-detector
array (n) CT scanners with detector widths of T (in
mm), the parameter nT describes the nominal
beam width, and this is a very useful measure in
CT acquisition protocols and dosimetry in general.
 Overview of Existing CT Dosimetry Methods

Whereas, in a radiographic field of (for example)

Figure 4.1. A schematic diagram of the 100 mm pencil chamber.
The active length of this chamber is 100 mm, with a total
volume of 3 cm3. Inside the pencil chamber, a long graphite
electrode runs through the center of the volume.
30 cm  30 cm, placement of a 5 cm diameter radi-
ation meter in the center can be performed with
confidence that the dosimeter will not accidentally
be placed outside of the beam (also most radio-
graphic systems have a light field to help with
guidance), the same was and is not true for the
narrow beams in CT. Therefore, the approach of
using a pencil chamber significantly longer than
the width of the collimated beam was required, and
a correction for partial-volume exposures of the
chambers was also intrinsic to the measurement.
Today, however, there are CT beams that are
wide—much wider—than the 100 mm pencil-
chamber length, so alternative methods for

Figure 4.2. Schematics of the CTDI phantom. (a) CTDI phantoms are cylinders comprised of PMMA. At a minimum, there is a
through-hole at the center and at one location on the periphery of the phantom. Various manufacturers have slightly different designs,
and some phantoms have several holes around the periphery. (b) The phantom is illustrated with a pencil chamber positioned in the
central hole. All remaining holes are plugged with PMMA rods during measurements. With the phantom placed on the patient table,
the 12 o’clock and 6 o’clock positions are illustrated.

37
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
measuring dose need to be addressed, as will be
discussed later in this Report.
The phantoms used for CT dosimetry over the
years were defined by the report of AAPM
Diagnostic Radiology Committee Task Force on CT
Scanner Phantoms (AAPM, 1977). The general
design of the CT dosimetry phantom is illustrated
in Figures 4.2a and 4.2b. The phantoms are fabri-
cated from polymethyl methacrylate (PMMA), or
[C5H2O8]n, which has a density of approximately
1.19 g/cm3. Although the design of the phantom
has several variations, in general there is a central
hole and one or more peripheral holes, which are
through-bored with diameters of 12 mm, large
enough to allow the placement of the pencil
chamber in any of the holes. When the pencil
chamber is placed to make a measurement in one
hole, PMMA rods are placed in all the other holes
to displace the air with solid material. There are
two phantoms in general usage for CT dosimetry, a
“body” phantom that is 320 mm in diameter, and a
“head” phantom that is 160 mm in diameter. The
head phantom also doubles as a pediatric body
phantom, with an equivalent cross-sectional area of
the typical 2-year-old. Both of the PMMA phantoms
are 150 mm in length, although some phantoms
that were 140 mm in length were manufactured and
used in some settings.
4.2.2 CTDI1
In this Section, the methods to measure or calcu-
late various traditional CT dose descriptors are
described. The CTDI is currently the primary dose
measurement concept in CT:
ð
1 1
CTDI1 ¼ KðzÞdz; ð4:1Þ
nT 1
where
K(z) is the air kerma in the phantom as a func-
tion of position on the z axis.
n is the number of tomographic sections imaged
in a single axial scan. This is equal to the number
of data channels used in a particular scan. The
value of n is less than or equal to the maximum
number of data channels available on the system.
T is the nominal width of the tomographic
section along the z axis imaged by one data
channel. In MDCT scanners, several detector ele-
ments can be grouped together to form one data
channel. In single-detector-row (single-slice) CT,
the z-axis collimation at the isocenter determines
the nominal beam width.
38
Another parameter becomes useful in this discus-
sion when considering the clinical reality of a
series of axial CT scans that cover a length of the
patient. This is the scan interval, b, defined as the
table-translation distance between rotations. An
interval of b ¼ nT produces “contiguous” scans,
leaving no gaps in the acquired image data. CTDI1
represents the average dose (i.e., air kerma) in a
defined phantom over a small interval +b/2 about
the center of the scan length that accumulates at
z ¼ 0 from a series of N contiguous (b ¼ nT) scans
covering a scan length L ¼ Nb, which is sufficient
to produce scatter equilibrium at z ¼ 0 (symbolical-
ly denoted by L ! 1) (AAPM, 1990; IEC, 2009;
COCIR, 2000; Shope et al., 1981).
The CTDI1 is in principle measured in the axial
scan mode using a single 2p rotation of the x-ray
source around a stationary phantom, and allows
one to estimate the average absorbed dose at the
center (z axis) of the scan volume resulting from
multiple gantry rotations, if the scan length is suf-
ficiently long for the central dose to approach its
asymptotic upper limit (McCrohan et al., 1987;
COCIR, 2000; Shope et al., 1981). To measure
CTDI1 in one axial scan, the measurement instru-
ment needs to be long enough to integrate the ma-
jority of the dose from scattered radiation that
propagates away from the scan plane.
4.2.3 CTDIFDA
The multiple-scan average dose (MSAD) repre-
sents the absorbed dose averaged over a small scan
interval, b, and requires multiple exposures for its
direct measurement. The CTDI approach offers a
more convenient yet nominally equivalent method
of predicting the MSAD, and requires only a single
axial CT scan acquisition. In the early days of CT,
this saved considerable time and x-ray-tube heat
loading.
Theoretically, the equivalence of the MSAD and
the CTDI requires that all contributions from the
tails of the absorbed-dose distribution be included in
the CTDI measurement. The exact integration limits
required to meet this criterion depend upon the width
of the primary beam, the scattering medium, and the
x-ray beam energy. To standardize CTDI measure-
ments, the FDA (1984) introduced the integration
limits of +7T, where T is the nominal slice width.
Interestingly, the original CT scanner, the EMI
Mark I, was a dual-detector-row system. Hence, the
nominal radiation-beam width was equal to twice the
 Overview of Existing CT Dosimetry Methods

nominal slice width (i.e., 2  T). Thus,
ð 7T
fSI
CTDIFDA ¼ KðzÞdz:
nT 7T
For an ionization chamber that is calibrated in terms
of air kerma, the measured value is converted to
absorbed dose in PMMA, using the ratio of the mass
energy-absorption coefficients:
fmen =rgmedium
fSI ¼ :
fmen =rgair
For the typical energies used in CT, the value of fSI is
0.90 mGy/mGy to convert to absorbed dose in PMMA.
Here, fSI is the value of the so-called f-factor in units
consistent with the International System of Units. A
value of fSI of 1.06 mGy/mGy would be appropriate to
convert to absorbed dose in tissue. Conversion to
absorbed dose in PMMA is unique to CTDIFDA, and
the more-recently defined CTDI quantities (discussed
below) are reported as air kerma, with no conversion
factor necessary. The original definition of CTDIFDA
was to include the f-factor such that the resultant
measure was in terms of the quantity absorbed dose;
however, the more modern CTDI100 is explicitly
defined as a measurement of air kerma. In the follow-
ing, the general term dose is kept because air kerma
is closely related to absorbed dose in air at the x-ray
energies used in CT.
For the CTDIFDA, the limits of integration were
expressed in terms of nT (such as +7nT), allowing
for the potential underestimation of the MSAD by
the CTDI. For modern MDCT scanners, such as a
16-slice scanner using nT ¼ 16  1.25 mm ¼
20 mm, the integration length of 14T ¼ 17.5 mm is
smaller than the primary-beam width and clearly
beyond the intent of the CTDIFDA model. As n ¼ 1
ð4:2Þ
for the vast majority of CT scanners in use from
1975 to the late 1980s, the integration width was
14 times wider than the primary collimated beam,
so that the measurement of all of the primary radi-
ation was intended. The limits of integration in the
CTDIFDA mean that for a 3 mm beam width (T ¼
3 mm), the integration length of 14T was 42 mm;
98 mm for a 7 mm beam width; and 140 mm for a
ð4:3Þ
10 mm beam width. However, the variation in the
integration length (42 mm to 140 mm) implies that
differing extents of x-ray-scatter-tail integration
would be measured with changes in T, even though
the propagation distances of scatter along the z
axis from the center of the primary beam (at z ¼ 0)
is related more to the x-ray spectrum, phantom
composition, and diameter than to the beam width
T (Boone, 2007). It is likely that the importance of
the role of scattered radiation in CT dosimetry was
not fully appreciated in the early years of CT
operation.
The scattering media for CTDI measurements
were also standardized by the FDA (1984). As men-
tioned previously, these consist of the two PMMA
cylinders, 160 mm and 320 mm in diameter and
150 mm in length. Figure 4.3 shows these two phan-
toms in the measurement position.
4.2.4 The nT Term
Air kerma, K, is defined (ICRU, 2011) as
dEtr
K ¼ ; ð4:4Þ
dm

Figure 4.3. Photographs of the CTDI head phantom and body phantom, with the cable from the pencil chamber visible. For CTDI
measurements, the cylindrical phantom is located concentrically in the gantry using laser lights for positioning. Along the z axis, the
phantom is positioned so the center of the axial (sequential) scan intersects the phantom at its midpoint. The pencil chamber is also
positioned so its midpoint is aligned with the center of the radiation beam (and hence with the phantom). In the photograph on the left,
the head phantom is placed on the table. This is a common geometry for an emergency-room CT scanner, in which many patients are
either unconscious or otherwise impaired. In most CT scanners outside of the emergency department, the head phantom is more
typically placed in the CT head holder, which is used preferably for head imaging with ambulatory patients.

39
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
where dEtr is the mean sum of the initial kinetic
energies of all the charged particles liberated in a
mass dm of a material by the uncharged particles
incident on dm.
Ionization chambers, including the long pencil
chamber typically used for CT, are designed to
produce accurate dosimetry readings only when
they are completely and uniformly exposed, and this
is the manner in which most ionization chambers
are used and calibrated. When partial exposure of
the pencil chamber occurs, as in CT measurements,
a partial-volume correction is necessary.
4.2.5 CTDI100
The CTDI100 protocol calls for measurements to
be made using a 2p rotation of the gantry in the
axial mode, with the PMMA cylindrical phantom
placed concentrically with its center coincident
with the isocenter of the CT scanner’s rotation, and
with the center of the phantom along the z axis
located at the CT scanning location (Figure 4.3) at
z ¼ 0. The pencil chamber is placed on the central
axis of the phantom, and subsequently at the per-
ipheral position. The measurements made under
these conditions are referred to in this document as
center peri
the CTDI100 and CTDI100 . Some head and body
phantoms include multiple (e.g., 4) holes in the
phantom at its periphery to allow assessment of
peri
CTDI100 at various angles, and these values are
center
typically averaged. Because the CTDI100 meas-
urement is only at the center of the phantom, and
also at the center of the scanner’s field of view, this
measurement is relatively insensitive to the influ-
ence of the bow-tie filter, which is relatively homo-
geneous at the center of the field of view. However,
center
the CTDI100 measurement is indirectly affected
by the bow-tie filter (see Section 2), because periph-
erally scattered photons can reach the central axis
and affect the measurement. The peripheral meas-
peri
urement, CTDI100 , however, interrogates the x-ray
fan beam at a wider fan angle and therefore is
more sensitive to the attenuation properties of the
bow-tie filter. Because some CT scanners initiate
the beam-on position at an arbitrary start angle,
peri
the peripheral measurements, CTDI100 , are typic-
ally less reproducible than those for the center
hole.
It is also noted that measurement of CTDI100
requires that the phantoms be placed on the CT
table, and the measurements therefore include at-
tenuation of the table itself. Although the table has
little effect on the central measurement, it has a
measurable influence on the peripheral CTDI100
measurement; if the peripheral hole location where
the pencil chamber is placed is in the 6 o’clock
40
position (nearest to the tabletop), then this meas-
urement will be in general lower in value than
with the pencil chamber placed in the 12 o’clock
position. Even though the measurement value is
the integral of the 2p rotation of the x-ray tube
around the phantom and chamber, the peripheral
measurement of air kerma is highly influenced by
the part of the 2p scan when the x-ray source is on
the side of the phantom at which the peripheral
measurement is made. When the CT table is
between the x-ray source and chamber as in the 6
o’clock position, it will have a greater influence on
the measured air kerma than when the table is not
between the source and pencil chamber as in the
12 o’clock position (see Figure 4.2b).
Unlike CTDIFDA, CTDI100 values are reported in
terms of air kerma, and no conversions are per-
formed to convert the air kerma to absorbed dose
in PMMA or any other medium.
CTDI100 represents the accumulated multiple-
scan air kerma at the center of a 100 mm scan and
underestimates the accumulated air kerma for
longer scan lengths. It is thus smaller than the
equilibrium air kerma or MSAD for most clinical
examinations, because most patient CT scans are
longer than 100 mm. The CTDI100, as does the
CTDIFDA, requires integration of the radiation dose
profile from a single axial scan over specific inte-
gration limits. In the case of CTDI100, the integra-
tion limits are +50 mm, which corresponds to the
100 mm length of the commercially available pencil
ionization chamber (Jucius and Kambic, 1980;
AAPM, 1990; 1993; McNitt-Gray, 2002). Pencil
chambers of lengths other than 100 mm have been
manufactured; however, the 100 mm version is
required for the CTDI100 measurement, thus
ð 50 mm
1
CTDI100 ¼ KðzÞdz: ð4:6Þ
nT 50 mm
We note that historically the integrand in Eq. (4.6)
has been written in terms of a generalized dosimet-
ric quantity, such as D(z), but current protocols are
specified in terms of air kerma, K(z). The use of a
single, constant set of integration limits avoids the
problem of overestimation for narrow slice widths
(e.g., ,3 mm) (AAPM, 1990) compared with
CTDIFDA. It also resolves the problem of measure-
ments for a number of different scan lengths; the
+7T limits for CTDIFDA were defined when mul-
tiple thermoluminescent dosimeters (TLDs) were
more commonly used, and the length of the TLD
array could be varied. CTDI100 is typically mea-
sured using a 100 mm long, 3 cm3 active volume
CT pencil ionization chamber in conjunction with
the two standard CTDI PMMA phantoms (AAPM,
 Overview of Existing CT Dosimetry Methods
1990; FDA, 1984), using a single rotation about a
stationary patient table and phantom, i.e., in axial
(or sequential) acquisition mode.
4.2.6 Weighted CTDI, CTDIw
The dose in CT varies across the axial
field-of-view, that is, across the plane of an individ-
ual axial CT scan. For example, for the 320 mm
diameter PMMA body phantom, the CTDI100 is
typically a factor of two higher at the periphery
than at the center of the field-of-view (average for
120 kV from four major manufacturers ¼ 1.99; coef-
ficient of variation ¼ 6 %); whereas for the head
phantom (160 mm diameter), the CTDI100 is quite
similar at the center and peripheral locations
(average ratio 1.08; COV ¼ 2 %). The average
CTDI100 across the field-of-view at the central scan
plane is estimated by the weighted CTDI (CTDIw)
(IEC, 1999; 2002; Leitz et al., 1995), where
1 center 2 peri
CTDIw ¼ CTDI100 þ CTDI100 : ð4:7Þ
3 3
CTDIw is intended as an average value, calculated
from the CTDI100 center and peripheral measure-
ments. The weights of 1/3 and 2/3 are from the as-
sumption of a linear increase in CTDI100 with radial
distance from the phantom central axis, and approx-
imates the relative areas represented by the center
and edge values (Leitz et al., 1995). CTDIw is a
useful indicator of a CT scanner’s radiation output
(air-kerma levels measured in a specific phantom)
for a specific “kV” and “mAs” setting. According to
IEC requirements, CTDIw must use CTDI100 as
described above (IEC, 2009).
4.2.7 Volume CTDI, CTDIvol
To represent the radiation levels (air kerma) in a
phantom for a specific scan protocol, which almost
always involves a series of scans, it is essential to
take into account any gaps or overlaps between the
x-ray beams from consecutive rotations of the x-ray
source. This is accomplished with the use of a dose
descriptor known as the volume CTDI, or CTDIvol.
As CTDIw is the central plane (along the z axis) air
kerma for contiguous scans (b ¼ nT), CTDIvol con-
verts CTDIw to the central plane for an arbitrary
scan interval, b, as
nT 1 Although CTDIvol is not an ideal direct measure-
CTDIvol ¼  CTDIw ¼ CTDIw ; ð4:8Þ
b p
where b is the table translation increment per axial
scan (IEC, 2009), and p is the pitch. The smaller
the scan spacing relative to nT, the greater the
41
overlap of the dose profiles, and the larger the
CTDIvol value. Because no averaging over the scan
length L has been performed, CTDIvol (and also
CTDIw) is essentially an average over the area of
the central scan plane at z ¼ 0, with no appreciable
z extent, namely over only a relatively small dis-
tance +b/2 about z ¼ 0 for axial scans, and is a pure
planar average at z ¼ 0 for helical scanning (Dixon,
2003). Thus, its name is somewhat of a misnomer.
Likewise, MSAD is a central-plane average about
z ¼ 0. Pitch is defined as the ratio of the table travel
per rotation, b, to the total active detector length
(nT) (IEC, 2009; McCollough and Zink, 1999), as in
Eq. (2.5).
The CTDIvol provides a single CT dose quantity
based on a directly and easily measured quantity,
which approximates the average absorbed dose (in
air) across the central scan plane for a 100 mm
scan length in a standardized (CTDI) phantom
(IEC, 2009). CTDIvol is a useful dose metric for a
standardized phantom for a specific examination
protocol, because it takes into account the import-
ant parameter of pitch. Its value is displayed pro-
spectively on the console of newer CT scanners,
although it might be mislabeled as CTDIw on some
older systems. The IEC consensus agreement on
these definitions is used on most modern scanners
(IEC, 2009).
4.2.8 Limitations of CTDIvol
Although CTDIvol is an attempt, given previous
CTDI quantities, to better estimate the average
absorbed dose (in air) in the central CT slice for an
object of attenuation similar to that of the CTDI
phantom, it does not represent the average dose for
most patients, which differ from the phantom in
size, shape, and attenuation; moreover, the 100 mm
integration limits omit a considerable fraction of
the scatter tails (Boone, 2007) and underestimates
the absorbed dose for typical body-scan lengths of
250 mm or more. This is discussed at length in
Section 7. The CTDIvol as indicated on the scanner
console remains unchanged whether the scan
length is 10 mm, 100 mm, or 1000 mm. CTDIvol
estimates the dose for a 100 mm scan length only,
as it is derived from the CTDI100, even though the
actual central dose will increase as a function of
scan length, up to an asymptotically approached
equilibrium dose value (AAPM, 2010).
ment of patient dose for the reasons discussed
above, it is considered to be a useful measurement
of the pitch-corrected x-ray output properties (inte-
grated air kerma for specific technique factors) of
each make and model of CT scanner. As will be
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
seen later in Sections 7 and 8, CTDIvol has shown
value in normalizing a number of quantities to the
output characteristics of different CT scanners.
The usefulness of CTDIvol is further supported by
the widespread availability of tools ( phantoms and
pencil chambers) for measuring it, and on more
recent scanners, the IEC requires display of the
CTDIvol after a CT scan technique is set up, but
before it is initiated. CTDIvol is also commonly
reported after the CT scan, and more recently the
CTDIvol is often stored as a secondary capture
image (a bitmap image) in the patient’s CT image
files in the Picture Archiving and Communication
System (PACS) or in the DICOM (digital image
communication) standard.
4.3 Dose – Length Product
The total energy 1 deposited in the phantom by a
given scan protocol can be estimated by multiplying
CTDIvol by the directly irradiated mass of the
phantom pr 2rL, where L is the scan length and r
is the mass density. Thus
1 ¼ rpr2 L  CTDIvol : ð4:9Þ
Therefore, a surrogate measure of the total energy
absorbed in the phantom is the dose –length
product (DLP) (IEC, 1999), where
DLP ¼ CTDIvol  L; ð4:10Þ
and where typically the units of CTDIvol are mGy,
of length L are cm, and of DLP are mGy cm.
The DLP is a surrogate for the total energy
absorbed [formerly called the integral dose (Johns
and Cunningham, 1974)] attributable to the com-
plete scan acquisition. For example, an abdomen-
only CT exam might have the same CTDIvol as an
abdomen/pelvis CT exam, but the latter study
would have a greater DLP, proportional to the
greater z extent of the scan volume.
In helical CT, the scan length L is defined as
total table travel during the beam-on time (couch
velocity  total beam-on time), which is longer
than the programmed, reconstructed image length
because images at the beginning and end of a
helical scan require data from z-axis projections
beyond the programmed “scan” boundaries. The in-
crease in dose-length product due to the additional
gantry rotation(s) and table travel required for the
helical interpolation algorithm is often referred to
as over-ranging. For MDCT scanners, the number
of additional rotations is pitch-dependent, with a
typical additive increase in scan length of 1.5 times
42
the total nominal beam width. The overall dose
implications of over-ranging with regard to the
dose –length product, DLP, depends on the scan
length. For helical scans that are relatively short
(e.g., 100 mm), a scanner using a 40 mm collimated
beam width can have up to 40 % of the DLP in the
over-ranging region. For a scan length of 300 mm
with a 20 mm collimated beam, about 7 % of the
DLP is contributed by the over-ranging region.
Newer models of CT scanners have independent
collimator systems (adaptive dose collimation, see
Section 2.2.2) that are designed to substantially
reduce the over-ranging dose, and these systems
perform well in terms of reducing unnecessary dose
at the edges of the CT scan.
Table 4.1 shows the CTDIvol and DLP for typical
CT exams. The values are meant to be illustrative
only; they can vary by scanner model, vendor, insti-
tution, and image-quality requirements. Because
the DLP is related to the total energy absorbed, it
depends only on the total number of rotations, and
is indifferent as to how these rotations are distribu-
ted along z, i.e., DLP remains the same even if
the table does not move (L ¼ 0). For a given tube-
potential setting and bow-tie filter, the DLP
depends on the product of the primary beam width,
a, and the total tube-current–time product used
for the entire scan series. If scan length is changed
by changing pitch without increasing the total
“mAs” setting, DLP remains unchanged.
4.3.1 Limitations of CTDI Methods
For body scan lengths of 400 mm or more, the
accumulated dose approaches the limiting equilib-
rium dose (see Section 7). However, CTDI100 under-
estimates the equilibrium dose CTDI1 (or the
MSAD for a pitch of unity) by a factor of approxi-
mately 0.6 on the central axis and by about 0.8 on
the periphery (Mori et al., 2005; Boone, 2007).
In order to measure the equilibrium dose (i.e., air
kerma), a phantom of almost 450 mm in length is
required (Boone, 2009). This length of phantom is
required in order to capture the extent of the x-ray
scatter tails in both directions. Because a pencil
chamber of this length is not practical, direct meas-
urement of the MSAD using a short ion chamber
(Dixon, 2003) is possible. Such a method can be uti-
lized to emulate a “virtual” pencil chamber of arbi-
trary length up to the available phantom length
using helical acquisition modes. The issue of dose
estimation in longer phantoms is discussed in
Section 7 of this Report.
 Overview of Existing CT Dosimetry Methods

Table 4.1. Illustrative values for CTDIvol and DLP for common CT exams for 4- and 16-channel MDCT.

Exam Beam Pitch Tube current  time per Scan CTDIvol (mGy) DLP
collimation rotation (mA s) length (cm) (mGy cm)

Four-channel MDCT (120 kV)

Head 4  2.5 mm Axial 250 15 55.0 825
Chest 4  5 mm 0.75 100 40 12.0 480
Abdomen 4  5 mm 0.75 150 20 19.1 382
Abdomen and pelvis 4  5 mm 0.75 150 40 19.1 764
16-channel MDCT (120 kV)
Chest 16  1.25 mm 0.938 150 35 13.3 466
Abdomen 16  1.25 mm 0.938 212 28 18.8 526
Pelvis 16  1.25 mm 0.938 212 25 18.8 470

Table 4.2. Effective-dose weighting factors from ICRP Table 4.3. DLP-to-E conversion coefficients, k, for various types
Publication 103 (ICRP, 2007), combined with the example of a of CT examinations. Conversion coefficients for head-and-neck
thoracic CT scan. Column 1 identifies the organ site of interest, assume the use of the 16 cm diameter CT head phantom. All
and column 2 gives the tissue-weighting factors (wT) defined in other conversion coefficients assume the use of the 32 cm
ICRP Publication 103. Column 3 represents the various organ diameter CT body phantom (Bongartz et al., 2004; Shrimpton
absorbed doses from a thoracic CT examination, determined et al., 2006).
using Monte Carlo methods. Column 4 is the product of wT and
the organ absorbed doses, resulting in the contribution to Region of body k/[mSv/(mGy cm)]
effective dose from that organ. Summing column 4 represents
the total effective dose of 9.3 mSv for this hypothetical CT Head and neck 0.0031
examination. Head 0.0021
Neck 0.0059
Organ site WT Organ dose E Chest 0.014
(mSv/mGy) (mGy) (mSv) Abdomen and pelvis 0.015
Trunk 0.015
Gonads 0.08 0.03 0.00
Bone marrow 0.12 6.70 0.80
Colon 0.12 0.24 0.03
Lung 0.12 24.00 2.88 considerations. Effective dose was never intended
Stomach 0.12 5.90 0.71 to be used for the assessment of an individual
Bladder 0.04 0.02 0.00 patient’s radiation dose, because the radiobiologic-
Breast 0.12 18.00 2.16
al weighting factors are not pertinent to a specific
Liver 0.04 9.00 0.36
Esophagus (thymus) 0.04 27.00 1.08 patient.
Thyroid 0.04 4.50 0.18 To minimize controversy over differences in
Skin 0.01 4.60 0.05 effective-dose values that are purely the result of
Bone surface 0.01 13.00 0.13 calculation methodology and data sources, a
Brain 0.01 0.20 0.00
Salivary glands (brain) 0.01 0.20 0.00
generic estimation method was proposed by the
Remainder 0.12 7.50 0.90 European Working Group for Guidelines on
Total 9.28 Quality Criteria in CT (IEC, 2009). In this method,
effective-dose values are calculated from the NRPB
dose-conversion coefficients derived from Monte
Carlo calculations of organ absorbed doses (Jones
4.4 Estimation of Effective Dose
and Shrimpton, 1991), using the ImPACT spread-
When comparing different CT scan protocols, or sheet (ImPACT, 2011). The effective doses were
when comparing absorbed-dose levels between compared with DLP values for the corresponding
x-ray radiography and CT, methods are required clinical exams to determine a set of coefficients, k,
that allow prorating the absorbed dose levels for a that are dependent only on the region of the body
generic patient. The effective dose, E, defined in being scanned (head, neck, thorax, abdomen, or
ICRP 60 (ICRP, 1991) and subsequently redefined pelvis) (see Table 4.3). Using this methodology, E
(ICRP, 2007), can be a useful tool in such compari- can be estimated from the DLP, which is reported
sons (see Table 4.2). Effective dose is not a physic- on most CT systems, according to
al dose, as its computation includes weighting
factors that are derived from radiobiological E  k  DLP; ð4:11Þ

43
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 4.4. The relationship between dose– length product, DLP,
and the effective dose, E. The individual data points were
gathered from 46 different CT scanners. With the line
intersecting the y axis at zero, the inverse slope of the line
shown is the k coefficient for abdominal CT (k ¼ 0.017 mSv/
(mGy cm)).
Figure 4.5. The DLP versus E for thoracic CT. The inverse slope
of the line (i.e., the k coefficient) is 0.018 mSv/(mGy cm).
where E is the effective dose in mSv if DLP has
units of mGy cm and k has units of mSv/(mGy cm).
To illustrate the utility of Eq. (4.11), Figure 4.4
illustrates the relationship between DLP and E for
abdominal CT scans; these data were derived from
46 different CT scanners in the European Union,
with the observation that the relationship is rela-
tively robust across this large number of scanners.
Figure 4.5 shows the relationship between DLP
and E for thoracic CT scans, and Figure 4.6 shows
this relationship for head CT scans.
The values of E predicted by DLP and the values
of E estimated using more rigorous calculations
methods are remarkably consistent, with a
maximum relative deviation from the mean of ap-
proximately 10 % to 15 % (McCollough, 2003). Lam
et al. (2011) have also demonstrated a good rela-
tionship between DLP and E (see Figure 4.7) based
on observations from a single pediatric patient
receiving 50 CT scans as a part of a cancer-
surveillance protocol. Hence, the use of DLP to esti-
mate E is a reasonably robust method for estimating
effective dose. In addition, Huda et al. (1997) have
44
Figure 4.6. The DLP versus E for head CT scans. The fit shows
a k coefficient of 0.0023 mSv/(mGy cm).
Figure 4.7. The effective dose as a function of the DLP. These
data were specific to a single pediatric patient who had
repetitive CT scans as a result of a cancer-screening protocol.
For this one individual, the slope for these predominantly
abdominal CT scans was 0.0147 mSv/(mGy cm), with excellent
correlation.
compared effective dose, as calculated from the
NRPB data of Jones and Shrimpton (1991), to esti-
mates of total energy deposited in order to develop
conversion coefficients with which to later estimate
effective dose.
The use of routinely displayed scan parameters
such as “mAs” and “kV” settings is marginally suc-
cessful in predicting dose (Herlihy et al., 2006).
Rather than relying on parameters such as the
tube-current–time product, the tube potential, and
pitch, the use of CTDIvol provides a single dose
metric by which users can benchmark the pre-
scribed output for a given exam against national
averages, having factored in the effects of pitch, de-
tector collimation, x-ray-tube-to-isocenter distance,
and other technical parameters (McCollough,
2006). The values of CTDIvol displayed on the user
console prior to scan initiation can be compared
with published values, such as reference values
provided by the ACR and AAPM (McCollough,
 Overview of Existing CT Dosimetry Methods

2006; Gray et al., 2005), and results of national Radiological Health. Users prescribing CT protocols
surveys, such as the NEXT study (Conway that result in doses above references values
et al., 1992) conducted by the Food and Drug should have an appropriate justification (Hart
Administration’s Center for Devices and et al., 1996).

45
Journal of the ICRU Vol 12 No 1 (2012) Report 87 doi:10.1093/jicru/nds005
Oxford University Press

5. CT X-Ray-Spectrum Characterization

5.1 Introduction the stationary x-ray source. In the context of CT,

the traditional method for HVL measurement
The vast majority of x-ray tubes used in diagnos-
requires that the service mode of the scanner be
tic radiology make use of tungsten anodes, and CT
used in order to stop gantry rotation. Aluminum is
is no exception. Tungsten (alloyed with 5 % to 10 %
the predominant material for characterizing the
rhenium) has excellent heat conductivity, a high
HVL in diagnostic-radiology applications, including
melting point, and its relatively high atomic
CT.1 For an aluminum thickness t, the measure-
number (Z ¼ 74) makes for efficient bremsstrahl-
ment is approximated by the polyenergetic form of
ung x-ray production. Although bremsstrahlung
the Lambert–Beers law:
represents the majority of the photons produced by
CT x-ray tubes, the characteristic-radiation produc-  
Ð m
tion from tungsten produces two peaks, at 59 keV
m ðEÞt  m
Kair ðtÞ ¼ E f ðEÞ e F add e Al ðEÞt E en dE;
r air
and 68 keV (each is a doublet) when tube poten-
tial is above tungsten’s K edge of 70 keV. ð5:1Þ
The x-ray spectra used in CT imaging are some
where Kair(t) is the air kerma for an aluminum
of the hardest used in medical radiological x-ray
thickness t, f(E) is the x-ray fluence as a function
imaging, generally because of the typically higher
of energy, E, at the isocenter in the absence of the
tube potentials used and the greater amount of
added filtration, and mAl(E) is the linear attenu-
added filtration for the central ray. Toward the per-
ation coefficient as a function of energy of the alu-
iphery of the fan beam, the beam-shaping filter
minum filters used for HVL assessment. The
provides even more x-ray-beam filtration, and this
thickness tadd of a permanent filter (F) material
hardens the x-ray spectrum further. A harder
with an attenuation coefficient mF(E) is the
beam is necessary in CT to reduce beam-hardening
(inherent þ added filtration) in the x-ray beam at
artifacts, which arise from differing magnitudes of
the center of the field of view. Inherent filtration
spectrum hardening for different projections
refers to the attenuation properties of the x-ray-tube
around a patient. Adding metallic (and sometimes
housing itself that the x-ray beam has to penetrate
plastic) filtration to the x-ray beam pre-hardens
in exiting the x-ray-tube port. Added filtration refers
the x-ray beam and thus reduces beam-hardening
to additional filtration that is permanently and in-
artifacts, as discussed in Section 2.4.5. The higher
tentionally added to the x-ray tube assembly to
filtration levels also lead to relatively lower
harden the x-ray beam, i.e., to reduce the fluence of
absorbed-dose levels in the patient.
low-energy x rays relative to higher-energy x rays; it
Although spectroscopy methods have been used
might or might not be aluminum in composition.
to accurately measure x-ray spectra, the experi-
Added filtration does not refer to the aluminum
mental setup for x-ray spectroscopy is complicated,
filters that are inserted in the x-ray beam only to
the equipment is expensive, and the procedure is
make the HVL measurement. From the HVL meas-
time-consuming and requires significant expertise
urement procedure, using additional Al filters, a
to produce accurate results. Consequently, x-ray
relative transmission curve is produced according to
spectra have been characterized using the concept
of the half-value layer (HVL) for nearly a century. Kair ðtÞ
The HVL of an x-ray beam is measured using an AðtÞ ¼ : ð5:2Þ
Kair ð0Þ
air-kerma meter, or other dosimeters calibrated to
produce air-equivalent readings. The measurement The HVL is the thickness, t, of aluminum such that
of the HVL generally requires that the measure- A(t) ¼ 1/2 (for a given tube potential), which can be
ment instrument remain fixed in location, as a
number (including zero) of different thicknesses of 1
Type 1100 Al alloy is often used, but high-purity Type 1145 is
an absorber are placed between the dosimeter and also available.

# International Commission on Radiation Units and Measurements 2013

 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
evaluated graphically, interpolated among adjacent
data, or estimated by curve fitting of A(t). The HVL
increases as the x-ray-tube potential increases, with
constant inherent þ added filtration. It is noted that
by convention, the HVL is defined in terms of air
kerma, and therefore its accurate measurement
requires that a properly calibrated air-ionization
chamber be used. If solid-state detectors are used,
then corrections are necessary to convert the mea-
sured values to air kerma.
Modern CT dosimetry is substantially informed
by data produced using Monte Carlo radiation-
transport techniques. In order to achieve desired
levels of accuracy, methods require a good model of
the x-ray spectrum used. It has been shown that
x-ray spectrum modeling can produce adequate
spectra if both the tube potential and the HVL of
the x-ray beam are known (Boone, 1986; 1988;
Duan et al., 2011; Turner et al., 2009). Therefore,
for accurate CT dosimetry, characterization of the
HVL of the CT scanner is necessary. HVL measure-
ment is useful for research studies of CT beam
spectra, but can be a quality-control tool as well.
5.2 Methods for HVL Measurement
5.2.1 Conventional HVL Assessment in CT
The conventional assessment of the HVL in com-
puted tomography requires that the service mode
of the CT scanner be used in order to stop the rota-
tion of the x-ray tube. In this mode, the HVL meas-
urement is performed as it would be for any
radiographic system; measurements are made in a
fixed geometry as increasing thicknesses of filter
material are added incrementally to determine
Kair(t) over a range of t [see Eq. (5.2)]. Figure 5.1
illustrates the experimental set-up for conventional
HVL assessment. Although a number of different
measurement configurations are possible, in
Figure 5.1 the aluminum filters are placed directly
on the gantry cowling, the x-ray tube is centered at
the 6 o’clock position, and the ionization chamber
is placed in the center of the field. The patient
table is retracted out of the gantry so as not to
interfere with the measurements. A series of mea-
surements are then made with different thick-
nesses of Al placed in the beam.
Few medical physicists have the passwords ne-
cessary to enter the service mode of most CT scan-
ners, let alone the ability to use the system in
service mode in a safe and time-efficient manner.
Therefore, the conventional measurement of the
HVL using the service mode typically requires the
presence of the service engineer during the proced-
ure. Because of this difficulty, the characterization
48
of a CT scanner HVL is typically performed infre-
quently or not at all in most settings.
5.2.2 Aluminum-Cylinder Method
Kruger et al. (2000) described a method by which
the HVL of a CT x-ray beam can be measured
without the need for using the service mode of the
system. This “ring” method uses a series of alumi-
num cylinders of slightly different diameters that
can be nested in a concentric fashion to create a
number of different filtration thicknesses. The
100 mm pencil chamber is aligned at the isocenter
of the scanner with the aid of laser positioning,
and a series of repeated axial CT scans is per-
formed, with additional cylindrical filtration added
between measurements (see Figure 5.2a). The
table is positioned out of the gantry for this meas-
urement. The ionization chamber is read out in the
integration mode, and an axial CT scan with the
same technique settings is repeated until all of the
measurements are made. The investigators used a
number of cylinders, each with 2.0 mm thickness.
This approach was demonstrated to produce HVL
measurements of acceptable accuracy. The HVL
values for 120 kV measured with the ring method
and the conventional service-mode method were
not significantly different. The investigators also
studied the influence of mispositioning the ioniza-
tion chamber away from isocenter, and found that
the ring technique was relatively insensitive to
realistic positioning uncertainties in the field.
Although the manual placement of the alumi-
num cylinders between measurements can be time-
consuming, by obviating the need for the presence
of the service engineer during the measurements,
this approach has clear advantages over the con-
ventional HVL-measurement method when service
engineers are not routinely available.
5.2.3 Real-Time Probes
X-ray source rotation in a CT scanner creates a
dynamic situation in which the radiation beam is
directed toward the center from a circular trajec-
tory. Combined with table translation along z, and
depending upon the experimental setup and if a
phantom is involved, the air-kerma rate can vary
rapidly and appreciably. The use of a conventional
thimble chamber with integration periods of 0.1 s
precludes the measurement of the dynamic charac-
teristics of the CT x-ray beam. Therefore, the use of
a rapid-readout, real-time radiation meter is recom-
mended for several classes of measurement in CT.
For the purposes of characterizing the dynamically
changing x-ray beam in a CT scanner, a rate of
 CT X-Ray Spectrum Characterization

Figure 5.1. The traditional measurement of the HVL for a CT scanner. (a) Serial measurements are made with the x-ray gantry held
stationary, a process typically requiring access to the service mode of the system. (b) A photograph showing a 0.6 cm3 ionization
chamber used for HVL measurements. A sheet of aluminum is positioned directly below the ionization chamber on the plastic cowling
of the scanner.

Figure 5.2. Measuring the HVL using a series of Al rings. (a) Schematic illustration of the method. (b) The concentric Al rings used for
this method.

1000 samples per second or higher is considered
necessary.
There are different types of technologies that can
be brought to bear to achieve a high temporal
bandwidth x-ray meter: (1) solid-state x-ray meters,
and (2) air-ionization chambers with real-time
readout capabilities. Solid-state x-ray meters can
be fabricated from a number of different detector
materials. A simple approach is to couple a scintil-
lating material to a photodiode using a fiberoptic
cable, assuring that the photodiode is outside of
the x-ray beam or is well shielded. A key require-
ment for solid-state x-ray meters is that the x-ray
scintillator material has a short decay constant.
Most solid-state x-ray meters demonstrate excellent
linearity as a function of air-kerma rate. One of the
biggest limitations of solid-state x-ray meters is
that in general they have a different response than
air and therefore energy-dependent corrections are
necessary to provide a signal measurement that is
similar or identical to air ionization chambers.
Although energy corrections are plausible in a
free-in-air geometry for which x-ray scatter levels
are small, much of the utility of a real-time x-ray
dosimeter is in phantom measurements, in which
scatter levels can be quite high. A large scattered-
radiation component introduces uncertainty with
respect to the effective energy of the x-ray beam,
confounding accurate energy-correction algorithms.
Nevertheless, it seems that real-time solid-state
x-ray detectors can be designed and calibrated for
use in real-time CT dosimetry.
A real-time thimble chamber that uses air as the
x-ray detector presents a technological challenge if a
small detector volume is desired. The density of air is
three orders of magnitude smaller than many solid-
state detectors, and therefore the electronic-signal
levels generated in air-based detectors are much

49
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
smaller, leading to noisy signals. Nevertheless, the
use of air as the detection medium is appealing due
to the long history of air-ionization chambers in diag-
nostic radiology applications.
5.2.4 Aluminum Cage with Real-Time Probe
Method
Most ionization chambers read out in the inte-
gration mode, in which they integrate the charge
produced over a time interval that is typically from
sub-seconds to several seconds. Real-time radiation
meters are only now becoming available, and these
systems are capable of accurately measuring a radi-
ation beam of varying intensity over short periods
of time ranging from 100 ms to 1000 ms. Thus, 1000
or more measurements per second can be made
using real-time x-ray detector systems.
When a real-time radiation meter is available, an
aluminum-cage method for measuring the HVL is
feasible. Similar to the ring setup (see Section
5.2.2), the real-time probe is positioned at the
Figure 5.3. The aluminum cage for HVL measurement using a
real-time probe. The system presents a number of different
thicknesses of aluminum, interspersed with air gaps, into the
x-ray beam. As the x-ray tube rotates during the scan, the
central ray passes through each of the Al filters in the cage
assembly, resulting in eight (or more) measurements with each
rotation of the gantry.
Figure 5.4. The HVL cage illustrated in the context of a rotating CT gantry. (a) Schematic illustrating use of the cage. (b) Photograph
of a prototype HVL cage.
50
isocenter of the CT scanner using laser positioning,
with the patient table retracted out of the beam.
An aluminum cage (see Figure 5.3) has been
designed to have a number of aluminum filters
(eight in the configuration shown) of different
thicknesses placed around the center of the cage in
which the real-time probe is positioned. One or
more axial CT scans are acquired, and the data
derived from the real-time probe can then be used
to compute the HVL. The measurement geometry
is shown in Figure 5.4. Data generated from the
real-time probe (in this case, Radcal Chamber
Model 10X6-0.6) using this technique are illu-
strated in Figure 5.5a. This signal trace is used to
produce the attenuation measurements described
in Eq. (5.2), and is plotted in Figure 5.5b.
There are a number of commercially available
real-time radiation meters available, including air-
ionization chambers and solid-state systems. Solid-
state, real-time radiation meters include silicon-
based systems as well as scintillator-based probes.
For the solid-state radiation meters used to deter-
mine the HVL, in general, energy-dependent correc-
tions are required.
5.3 Spectrum Assessment using the Tube
Potential and the HVL
There are a number of x-ray-spectrum models
that can be used to generate relatively accurate
x-ray spectra using empirical or semi-empirical
methods (Boone and Seibert, 1997; Duan et al.,
2011; Tucker et al., 1991a; 1991b; Turner et al.,
2010). Common to all the models is the selection of
the x-ray tube potential. With knowledge of the
tube potential and the measured HVL, the model
can be used to estimate the x-ray spectrum in an it-
erative manner.
 CT X-Ray Spectrum Characterization

Figure 5.5. Results from an Al-cage measurement. (a) The signal trace generated by the real-time probe in the cage geometry for HVL
assessment. This trace illustrates attenuated regions labeled a–h, with the interspersed unattenuated measurements. These data were
acquired on a General Electric VCT scanner for a tube potential of 120 kV, and with the medium bow-tie filter, using a prototype air-
ionization chamber (Radcal, Monrovia, CA, USA). (b) The attenuation curve computed from the data shown in (a). The attenuation
values corresponding to the specific signal components a–h are labeled. The dashed line corresponds to the conventional measurement
of HVL, and the solid line is that measured using the real-time air-ionization chamber and the Al cage.

In a computer program that starts with an unfil-

tered x-ray spectrum, f (E), from tabulations, incre-
mental thicknesses, tadd, of absorber with linear
attenuation coefficient mF(E) are added. The ab-
sorber material can be aluminum, or other materi-
als that are known to be used by CT manufacturers
to harden the beam. Other materials might include
PMMA, copper, tantalum, or combinations of these.
The x-ray spectrum is thus hardened by adding the
thickness tadd of a material with attenuation coeffi-
cient mF(E), and the computer program then iter-
ates using the necessary added Al thicknesses to
compute the HVL. This process of adding absorbers
and then computing the HVL, is repeated until the
thickness of added filtration tadd results in a com-
puted HVL that matches the measured HVL. Figure 5.6. Illustrative results of the iterative procedure used to
Figure 5.6 illustrates the results of a least-squares estimate the inherent-plus-added filtration. As the amount of
approach for determining the modeled spectrum inherent-plus-added aluminum thickness is added, the calculated
HVL using a spectrum model (Boone and Seibert, 1997) computed
that most closely matches a measured spectrum of for a tube potential of 120 kV increases as shown by the curve with
known tube potential and measured HVL. The diamond symbols (left vertical axis). The squared differences
value of tadd at which the minimum squared differ- between the calculated and measured HVLs are shown as the
ence between the measured and modeled HVL dashed curve (right vertical axis). The minimum in that curve
occurs is accepted, and the estimated x-ray spec- corresponds to the best-fit spectrum parameters, in this example
having a total of 9.5 mm Al of inherent-plus-added filtration, giving
trum f0 (E) is defined as the measured HVL of 8.0 mm Al.

f0 ðEÞ ¼ f ðEÞemF ðEÞtadd : ð5:3Þ

also a 120 kV spectrum but with 15 mm of added

Figure 5.7 illustrates two different spectra, both
generated with a tube potential of 120 kV but with
substantially different inherent-plus-added filtra-
tion and hence different HVLs; Figure 5.7a shows a
120 kV spectrum with 2 mm of added Al filtration
intrinsic to the beam, whereas Figure 5.7b shows
Al filtration. Figure 5.7 underscores the importance
of knowing the HVL in addition to the x-ray tube
potential.
It is noted that if the spectrum model used to
produce f 0 (E) was capable of exactly matching the
actual x-ray spectrum emitted by the x-ray tube

51
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

anode, then the mF(E)tadd term should be the same 5.4 Typical HVL Values in CT
at all x-ray tube potentials because the inherent fil-
The HVLs typical in conventional radiography are
tration does not change within the x-ray tube as-
compared with those typical in CT in Figure 5.8;
sembly when the x-ray tube potential is changed.
measured HVLs from two scanner types are shown.
However, due to inherent inaccuracies of the spec-
Measured HVLs as a function of tube potentials for
trum model, the optimal estimated spectra f0 (E)
several CT models are provided in Table 5.1. It is
will have slightly different thicknesses tadd for dif-
clear from Figure 5.8 that the typical HVL in CT is
ferent tube potentials. Differences between actual
considerably larger than that generally used in con-
and estimated inherent þ added filtration also will
ventional radiographic imaging. The primary
occur when the precise elemental composition of
purpose for the harder beam (i.e., higher HVL) in
the filtration is not known.
CT is to reduce the absorbed dose in the patient,
and to reduce the impact of beam-hardening arti-
facts in CT images (see Section 2.4.5).
5.3.1 Off-Angle HVL Assessment HVL measurement in the clinical CT environment
can be useful as a quality-assurance tool, and is
The HVL described so far corresponds only to the
HVL along the central ray of the scanner, i.e.,
where the fan angle is zero (u ¼ 0). Thus, the influ-
ence of the bow-tie filter is not included in the HVL
assessment, as the bow-tie filter is conventionally
defined as having zero thickness at u ¼ 0. Because
the bow-tie filter adds additional x-ray absorber
material gradually toward the periphery of the fan
angle, the beam will be increasingly hardened by
this additional filter, and the HVL will increase. If
there were interest in measuring the off-angle
HVL, then the only direct method would be the
conventional method outlined earlier. Both the
Al-ring and the Al-cage methods outlined above are
designed to measure the HVL along the central ray
of the scanner, and they cannot measure the
off-angle HVL. An indirect method for estimating
the off-angle HVL is to perform the assessment at
the center of the field as described above, to use the
known bow-tie filter-thickness distribution to Figure 5.8. Typical values of the HVLs used in CT and
radiography. Measured HVL values for two commercial CT
further harden the beam using appropriate attenu-
scanners are shown. For the radiography curve, the HVLs were
ation coefficients, and then to compute the HVL. modeled (Boone and Seibert, 1997) using a total of 2.0 mm of
Estimation of the bow-tie thickness as a function of added filtration (lower solid line), and for the CT curve a total
angle will be described in Section 6. added filtration of 10.0 mm (upper solid line).

Figure 5.7. X-ray spectra generated using a spectrum model, the known tube potential, and the measured HVL. (a) A 120 kV spectrum,
which has a small amount of inherent filtration, resulting in a measured HVL of 5.1 mm of Al. (b) A 120 kV spectrum for an x-ray
system with more inherent filtration, resulting in a harder x-ray spectrum with a measured HVL of 9.0 mm of Al.

52
 CT X-Ray Spectrum Characterization

Table 5.1 Typical values of the HVL in mm AL for several measured in a relatively easy and rapid manner, it
commercially available CT scanners (Mathieu et al., 2010). can and should become a useful parameter for moni-
These were measured at the isocenter for the “large” or “body”
toring beam quality as a part of a quality-assurance
bow-tie filter
program in CT, just as it is in radiography, fluoros-
X-ray GE VCT GE Siemens Toshiba copy, and mammography settings.
tube Lightspeed-16 Sensation 64 Aquilliona In a research setting, the estimated spectrum
potential f0 (E) determined for a given tube potential and
measured HVL can be used in Monte Carlo simu-
80 kV 5.4 5.9 6.2 4.6 lations to estimate organ dose or other dosimetric
100 kV 6.6 7.2 7.6 5.8
120 kV 7.7 8.3 8.7 6.7
quantities. For CT dosimetry, and in particular in
135 kV — — — 7.4 Monte Carlo based dosimetry studies, the use of
140 kV 8.6 9.2 9.7 — accurate x-ray-beam spectra is an important con-
sideration in the assessment of absorbed dose in
a
Premier One models. patients, phantoms, and in air. Moreover, as the
number of scanner models, typical tube poten-
likely to be of value as a parameter during scanner tials, and acquisition protocols continue to in-
acceptance-testing. The value of the HVL for a crease, it might become necessary to generate
given tube potential is an indicator of beam quality dosimetry tables based on generic beam-quality
(often used a surrogate for effective energy), which parameters, e.g., tube potential and HVL. This
should remain relatively stable over time and after approach is common in mammography but not
x-ray-tube changes. Thus, if the HVL can be yet in CT.

53
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
6. CT-Output Characteristics Measured in Air
6.1 Introduction
Section 5 discussed methods to evaluate the x-ray
spectrum at the isocenter of the scanner. In this
Section, the distribution of air kerma in both the
lateral (x, y) and z dimensions is discussed in detail.
Although the use of a physical phantom is con-
sidered necessary for the measurement of absorbed
dose in objects approximating patients, in most
cases such measurements reveal more about the
phantom’s attenuation and scattering properties
than about a specific CT scanner’s x-ray-tube air-
kerma (output) characteristics. Therefore, charac-
terizing the air-kerma distribution as a function of
both the fan angle u and longitudinal spatial vari-
able z is a valid, useful, and rigorous method for
quality assurance and reproducibility assessment.
Additionally, given the important reliance of CT
dosimetry on Monte Carlo simulations, the distri-
butions fair(z) and fA(u) are key inputs for accurate
Monte Carlo modeling of energy deposition. The
function fair(z) is defined as the air-kerma distribu-
tion along the z axis at the isocenter of the scanner,
in air. The function fA(u) is defined as the angular
measurement of air kerma along the center of the
fan beam as a function of fan angle, u.
Most commercial x-ray CT scanners use the
same basic components in the tube assembly,
which include: (a) an x-ray tube that is operated
between 70 kV and 140 kV, (b) inherent filtration
as part of the x-ray tube port and related struc-
tures, (c) permanently installed added filtration to
harden the entire x-ray beam, (d) a compensating
bow-tie filter that partially equalizes air kerma to
the patient and detectors, and (e) collimators to
control the longitudinal (z-axis) extent of the
beam. This is illustrated schematically in
Figure 6.1b. Additional collimators to reduce over-
ranging (Section 2.2.2) during helical acquisitions
are a part of newer CT scanners. Each CT-
scanner manufacturer will have different imple-
mentations of these components, and therefore in-
dividual one-dimensional measurements in both
directions, or simultaneous two-dimensional mea-
surements, made free-in-air, are necessary to
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/nds006
characterize each CT scanner’s specific output
distribution.
6.2 Theoretical Methods for Predicting fair(z)
The air-kerma distribution along the z axis of a
CT scanner, fair(z), is fundamentally related to the
geometry of the scanner and the intensity distribu-
tion of x-ray emission from the x-ray-tube focal
spot. The x-ray tube rotates around the CT gantry
at very high rotation speeds. For scanners with a
rotation period of 0.33 s, assuming a 1.4 m gantry
diameter, components at the outer edge of the
gantry experience a speed of 48 km/h, and a centri-
petal acceleration of almost 26 g. The x-ray-tube
anode rotates in the same plane as the rotating
gantry (see Figure 6.2a), which is necessary to
reduce gyroscopic effects, and this orientation is
also desirable from a beam-coverage consideration.
Hence, the anode – cathode dimension is parallel to
the z axis of the scanner, and thus the heel effect
runs along the z axis. A simplified geometry
showing some of the critical geometrical para-
meters in the x-ray source assembly is illustrated
in Figure 6.2. Dixon et al. (2005) used a geometric-
al construct similar to that shown in Figure 6.2b,
and derived the profile of the x-ray beam in the z
direction from first principles. A comparison of the
analytical result to the measured air-kerma distri-
bution from a General Electric Lightspeed-8 system
is shown in Figure 6.3. The air-kerma profile was
measured using film (Kodak EDR2), correcting for
the characteristic curve. In the derivation, Dixon
and colleagues assumed a Gaussian focal-spot in-
tensity distribution, and thus the penumbra on
either side of the x-ray beam was modeled as a cu-
mulative normal distribution. Due to parallax dif-
ferences on either side of the beam resulting from
the anode angle, slightly different focal-spot dimen-
sions were used to optimize the analytical fit to the
measured curve. The Dixon derivation extends
earlier work (Gagne, 1989) and demonstrates that
the relative air-kerma profile of the x-ray beam
along the z axis of CT scanners can be accurately
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

explained by straightforward physical and geomet-
rical principles.
6.3 Measurement of fair(z)
6.3.1 Optically Stimulated Luminescence
Systems
Arrays of optically stimulated luminescence
(OSL) dosimeters were developed by a commercial
manufacturer (CT Dosimeter, Landauer, Inc.,
Figure 6.1. The components of a modern CT scanner tube
assembly. X rays emanating from the tungsten anode pass
through inherent þ added filtration, and are then attenuated by
the beam-shaping filter. Finally, collimator blades truncate the
beam in the – z and þ z directions.
Glenwood, IL, USA) to provide for the measure-
ment of fair(z) in CT. These OSL systems have ex-
cellent spatial resolution and are well-suited for
qualitative measurement of air-kerma profiles
free-in-air along the z axis. The system uses a long
strip of AlO2 film inside a light-tight plastic cylin-
der that is 150 mm long and 10 mm in diameter. To
measure fair(z) directly, the dosimeter is placed in
air at isocenter; it is also designed to fit within a
phantom. The OSL dosimeter is exposed under
typical CT operating conditions in the axial mode,
and is then sent back to the manufacturer to be
analyzed. The manufacturer’s reader uses a
0.2 mm slit width that samples every 0.05 mm and
uses a 20-point smoothing average to generate
output values. From the resulting profiles (see
Figure 6.4), one can obtain the raw values for
fair(z). In addition, derived parameters such as the
full-width at half-maximum can be calculated,
which can be compared with the nominal x-ray-
beam collimation to determine the extent of over-
beaming (see, e.g., Liu et al., 2005). Although the
energy response of the OSL dosimeter is reason-
ably constant over the x-ray energies involved, it is
not the same as that of ionization chambers.
However, for OSL measurements made free-in-air
at the isocenter of the CT scanner, the relative in-
tensity of the x-ray-beam profile is of primary inter-
est and not the absolute values; in this case, a

Figure 6.2. X-ray-tube geometry in a CT scanner. (a) The x-ray tube in a modern CT scanner rotates in an orientation such that the
plane of the anode is parallel to the plane of gantry rotation. (b) The geometry of the electron beam striking the anode. As the x-ray-
tube potential increases, the kinetic energy of the electrons incident on the anode increases, and so does the average depth of
penetration (DoP). As x rays are produced within the anode, they are attenuated by different thicknesses of anode material along the z
axis of the beam, with greater thickness on the anode side of the field (giving rise to the heel effect). This basic geometry can be used to
derive the theoretical shape of the air-kerma profile along the z axis.

56
 CT Output Characteristics Measured in Air
Figure 6.3. X-ray-beam profiles, fair(z), along the z axis.
Theoretical (curve) and measured ( points) profiles are compared.
The heel effect is readily seen.
slight energy dependence should not be a limiting
factor.
6.3.2 TLD Measurements
Another type of dosimeter that provides good
spatial resolution in one dimension is the thermo-
luminescence dosimeter (TLD). Although its spatial
resolution is not as good as that for the OSL dosim-
eter, its lower atomic number gives a smaller over-
response at low photon energies. An array of TLDs
allows for measurement of absolute absorbed-dose
profiles with a spatial resolution of about from
1 mm to 5 mm. Figure 6.5 shows the fair(z) mea-
sured using TLDs at 3 mm intervals. These data
were measured on a General Electric Lightspeed 4
CT scanner with a nominal beam width of 20 mm.
Because TLDs need to be read out individually,
there is a practical limit on the spatial sampling
that can be achieved using these dosimeters
(McNitt-Gray, 2002; Ogden and Huda, 2008).
6.3.3 Film
Figure 6.6 shows the fair(z) measured using XV
film (Eastman Kodak, Rochester, NY, USA) placed
in the CT field of view. After exposure and develop-
ment, the film was digitized, and the measured
sensitometric curve was used to convert the optical
density to relative exposure (i.e., air kerma) (Liu
et al., 2005). Film has perhaps the best spatial
57
resolution available but exhibits non-linearity at
higher optical density and has some over-response
due to its higher average atomic number than air.
In order to produce quantitative results, the devel-
oped film needs to be digitized and then corrected
for non-linearities, if accurate dose profiles are
desired. The absolute accuracy of film dosimetry is
very much related to the consistency of the film
processing conditions, including developer concen-
tration and temperature.
6.3.4 Computed-Radiography Detectors
The fair(z) measured using a computed radiog-
raphy (CR) plate is shown in Figure 6.7. CR plates
typically comprise a BaFBr compound and thus
exhibit an energy sensitivity different from air-
ionization chambers. Nevertheless, as a relative
measurement of the beam profile with excellent
spatial resolution, CR represents a modern solution
compared to film, as film and the necessary film
processors are becoming increasingly rare in the
modern clinical environment. Although CR systems
are used at many facilities, they are not ubiquitous,
so availability will be an issue in some settings.
Furthermore, one needs to use the raw CR image
read-out in the high-dynamic-range mode, and no
processing should be applied (other than basic
corrections for inactive detector elements and for
differential collection efficiency of the read-out
optics and electronics). The so-called “for display”
images should not be used because they have
been subjected to processing that alters the quanti-
tative integrity of the gray scale in the image.
Therefore, experience with CR readers and their
modes of operation is required to use these systems
successfully for assessment of the dose distribution
in CT.
6.3.5 Real-Time Radiation Detectors
A radiation probe with real-time (1 kHz)
readout (see Section 5.2.3) can be translated
through the x-ray beam at isocenter, and the tem-
poral readout will give a trace as a function of z
in the beam. Assuming constant velocity, the
relationship between time and position is given by
z ¼ zstart þ vt, where zstart is the (arbitrary) start-
ing position of the x-ray detector. A real-time x-ray
probe (Radcal Accugold, Monrovia, CA, USA) was
used to demonstrate the potential of this approach.
Figure 6.8 illustrates the measurement geometry
using the real-time probe, and Figure 6.9 shows
measured beam profiles, fair(z), for a commercially
available CT system (General Electric VCT). These
data were acquired using the CT table for transla-
tion of the probe through the beam. The probe was
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 6.4. Relative profiles, fair(z), measured for a Toshiba CT scanner operating at 120 kV using OSL detectors. The one-dimensional
view of the x-ray beam intensity distribution along the z axis is shown for: (a) a 32 mm nominal collimation setting, and (b) a 128 mm
nominal collimation setting.

Figure 6.6. Relative profiles, fair(z), measured using x-ray film.

Figure 6.5. Relative profiles, fair(z), measured using TLDs. The optical density is shown as solid circles. The characteristic
Profiles are for both the head and body bow-tie filters on a curve of the film was measured and used to correct the optical
General Electric Lightspeed-16 scanner. density to air-kerma units (right axis).

extended out in front of the table, so the table pro- where FT is the Fourier transform, FT21 is the
vided mechanical translation but was not in the inverse Fourier transform, sinc(lprobe/n) is the
x-ray beam. The fair(z) measured with the real-time Fourier transform of a rect function of length lprobe,
probe relies on stable table velocity. The raw meas- and n is the frequency. Here the length, lprobe, is
urement of fair(z) using this approach also includes the active length of the chamber. When the same
the influence of the length (and sensitivity profile) real-time instrument is used, e.g., in annual x-ray
of the real-time probe. Let the true profile be fair(z) beam comparisons, serial comparisons among the
m
and the response function of the real-time probe be uncorrected profiles, fair ðzÞ, would be adequate for
m consistency checking.
q(z), then the measured profile fair ðzÞis given by
Ð1
m
fair ðzÞ ¼ 1 fair ðz0 Þ qðz  z0 Þ dz0 : ð6:1Þ 6.3.6 Summary of fair(z) Measurements
The fair(z) in CT can be measured using a
number of different technologies with adequate-to-
If q(z) is small in z extent in comparison to fair(z),
m excellent results. There are tradeoffs with each
then fair ðzÞ ffi fair ðzÞ. In the special but realistic case
method, and it is ultimately up to the CT scientist
that q(z) is a rect function, the influence of the
or medical physicist to determine which approach
probe length, lprobe, can be removed by deconvolu-
is most appropriate for their specific application
tion in the frequency domain:
and institution. It is observed that with film proces-
m
sors rapidly becoming less available in the hospital
1 FT½ fair ðzÞ setting, the film-sensitometric approach will be
fair ðzÞ ¼ FT ; ð6:2Þ
sincðlprobe =nÞ more difficult to implement in coming years. CR is

58
 CT Output Characteristics Measured in Air

Figure 6.7. Relative profile, fair(z), measured for a General Electric VCT scanner at 120 kV using a CR detector system. An image of the
profile is shown in the left panel, and the profile taken through this is plotted in the right panel. These data were not corrected for the
response of the CR plate.

Figure 6.9. Probe output from fair(z) measurements for the

20 mm and the 40 mm beam collimation in a GE VCT scanner.
The probe sensitivity function has not been deconvolved.

accurate results. The TLD approach is appealing,

Figure 6.8. The geometry for measuring fair(z) along the z axis
using a small ionization chamber. The ionization chamber is
mounted in front of the CT table and translated through the
x-ray beam at the isocenter by table translation with the
scanner in the helical acquisition mode. The resulting profile is
the convolution of the beam profile and the ionization chamber
response function in the z direction.
a viable approach only if the institution has CR
plates and reader systems available, and even then
special processing modes are required and non-
linear correction methods are necessary to produce
but is time-consuming and requires a large number
of TLD readings to make high-resolution measure-
ments of fair(z). The OSL approach is nearly ideal if
one is willing to wait for the physical transporta-
tion of the OSL dosimeter (usually by mail) to a
commercial laboratory to obtain the results. The
translated thimble chamber (or other radiation de-
tector) requires a real-time readout system, and
some subsequent processing is required to decon-
volve the detector response function. This latter ap-
proach is appealing because it provides prompt
results, is performed with portable instrumentation,

59
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
and the necessary signal processing can be imple-
mented using pre-programmed spreadsheet soft-
ware. Although real-time radiation detectors are not
widely available at this time, it is anticipated that
as CT dosimetry progresses the use of real-time
dosimeters will become commonplace.
6.4 Measurement of fL(x) or fA(u)
6.4.1 Measurement of fL(x)
The function fL(x) represents a linear measure-
ment of air kerma across the field of view, and the
function fA(u) represents an angular measurement
of air kerma. The angle u is defined here as the
angle from the central ray of the beam in the trans-
verse x –y plane, such that at the center of the field
u ¼ 0. This angle is called the fan angle.
Evaluation of the beam profile as a function of the
fan angle essentially characterizes the angle-
dependent attenuation of the bow-tie filter that the
scanner employs. This can also be called the bow-
tie filter function. Beam-profile data are useful for
two primary reasons: (1) accurate CT dosimetry is
increasingly dependent upon Monte Carlo compu-
tations of dose-conversation coefficients, and the
characterization of the bow-tie-filter function is es-
sential for accurate computer modeling in CT. For
users of CT Monte Carlo approaches, the data
derived from a measurement of the air kerma as a
function of fan angle for a variety of CT scanners
are extremely useful. (2) For the clinical practition-
er, the fL(x) and fA(u) provide characterization of
one of the two dimensions of the air-kerma distri-
bution from x rays incident upon the patient.
Combined with fair(z), characterization of fA(u) (or
fL(x)) provides a two-dimensional understanding of
the x-ray output properties.
Because at least two bow-tie filters (body and
head) are used on most CT scanners and because of
the different beam spectra that are possible, the
measurement of all combinations can require 8, 12,
or more measurements for each CT scanner. Thus,
a simple method for performing the beam profile
measurement is desirable. The profile fA(u) requires
that the air kerma (or air-kerma rate) be measured
on a radius of curvature centered at the x-ray
source, such that beam divergence due to the
inverse-square law and solid-angle effects are fac-
tored out. That is, fA(u) should represent the
angular dependence of the air-kerma profile; fA(u)
profiles measured at different radii from the x-ray
source should vary only by a scalar constant, and
thus fA(u) profiles normalized to unity at u ¼ 0 will
be independent of the distance from the x-ray
source. Note that at the center of the fan beam
60
(where u ¼ 0) the bow-tie filter has no effect on
fA(u), but there is still considerable x-ray beam fil-
tration material in the tube assembly.
Measuring fA(u) can be difficult, however,
because the location of the x-ray source is not
obvious due to the CT-scanner cowling and because
physical positioning of the detector along a radius
of curvature is challenging. For most experimental
settings, therefore, a measurement of the air-
kerma profile along a line running through the iso-
center is more convenient. The results of such mea-
surements are related to fA(u), and are referred to
here as fL(x), where the (horizontal) x axis is or-
thogonal to the central ray (where u ¼ 0) and gen-
erally runs through isocenter. Due to the rotational
symmetry in CT, it is recognized that measure-
ments along the (vertical) y axis are the same as
those made along the (horizontal) x axis, as long as
the measurement is made orthogonal to the central
ray. In all cases, however, this profile will be re-
ferred to here as fL(x).
Turner et al. (2009) described a method for using
the vertical adjustment capabilities of the CT couch
(with an additional vertical stand) to make mea-
surements along a line running through the isocen-
ter of the CT system, and this technique is
illustrated in Figure 6.10. Ideally, this measure-
ment of fL(x) would be performed with a relatively
small device (such as a small-diameter thimble
chamber). In practice, Turner et al. (2009) used a
100 mm pencil ionization chamber placed in air
and positioned perpendicular to the scan plane so
that only a portion of the chamber’s length was
irradiated. This method also requires that the CT
gantry be in a fixed, non-rotating position; a
3 o’clock position was used with the central ray of
Figure 6.10. The experimental geometry used to characterize
the beam profile in the x direction. The position of the ionization
chamber is moved vertically using the CT tabletop, with the
stationary x-ray source positioned in the 3 o’clock position.
 CT Output Characteristics Measured in Air

Figure 6.11. Linear profiles for small and large bow-tie filters.
These results for fL(x) indicate the shape of the bow-tie filter
function as a function of linear distance across the field of view,
and these data include the 1/r fall-off as discussed in the text.
Figure 6.12. The x-ray-beam profile, fL(x), for a General Electric
Lightspeed 16 scanner measured with a pencil chamber. The
bow-tie filter function for both the head and body filters is
shown, along with no filter (Huda, personal communication).
The use of the pencil chamber results in a 1/r fall-off.

the x-ray beam aligned horizontally across the top

of the CT couch. Measurements were made at a
series of positions starting from the central ray and
extending to the edge of the fan beam. This allowed
the entire extent of the bow-tie filter to be charac-
terized. These measurements were obtained using
vertical table motion, with a test stand of known
height to extend the range of measurements
beyond the range of table movement. The use of
the table-height adjustment simplified the meas-
urement procedure as this was controlled electron-
ically and the table height position is accurately
reported by the CT-scanner hardware. Air kerma
was recorded as a function of table height.
Figure 6.11 shows the measured fL(x) values and
illustrates the differences in attenuation between
the head and body bow-tie filters.
Ogden and Huda (2008) also made use of a
100 mm pencil chamber to measure fL(x), although
their experimental setup was performed with the
x-ray tube parked at the 12 o’clock position, and Figure 6.13. Uncorrected linear profiles, fL(x), from
repositioning of the ionization chamber was per- measurements with a CR plate of a 40 mm wide beam from a
formed manually. Figure 6.12 shows the measured General Electric VCT scanner. An example image is shown at
data, including measurements for the head and the top of the figure. Results are shown for the body, medium,
and head bow-tie filters. These profiles were not corrected for
body bow-tie filters, as well as the case when the the response of the CR plate.
bow-tie filters were retracted. For the geometries
used in both the Turner et al. (2009) and the Ogden
and Huda data, the source-to-probe distance distance is 1/r, as will be discussed in Section 6.4.2.
increased for the more peripheral measurements, The curvature that is visible in the Ogden and
resulting in intensity reductions at the periphery. Huda measurements in the case of no bow-tie filter
If a small detector (fully contained within the (see Figure 6.12) demonstrates this influence,
beam) is used, then the dependence on distance which affects the other measurements (those with
would be 1/r 2, i.e., the familiar inverse-square law. bow-tie filters) as well.
However, a 100 mm long pencil chamber extending Seibert ( personal communication) used CR
beyond the limits of the x-ray beam was used to plates to characterize fL(x). Figure 6.13 shows such
collect both the Ogden and Huda and the Turner et results for fL(x) associated with three different
al. data. In this geometry, the dependence on bow-tie filters on a General Electric VCT scanner.

61
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
This approach uses CR plates that are commonly
available at many medical centers. The gray scale
produced by CR systems is not a linear function of
the air kerma, and therefore a calibration proced-
ure is necessary if absolute values are required.
Evaluation of the characteristic curve of the CR
plate is a straightforward process (Lui et al., 2005).
6.4.2 Measurement of fA(u)
McKenney et al. (2011) report a method that uses
a single radiation detector with real-time readout
to measure fA(u) directly. The real-time detector
was placed in air, near the periphery of the CT
field of view, as shown in Figure 6.14. No other
object was placed in the x-ray beam, and the table
was retracted. The air-kerma rates were recorded
in real time (1 kHz) during CT acquisitions at
specified technique factors (tube potential, tube-
current – time product, etc.) over several gantry
rotations; the results are shown in Figure 6.15. In
this method, as the gantry rotates, the air-kerma
rate is recorded at the location of the probe. The
air-kerma rate changes due to the varying angle u
through the bow-tie filter, and also because the dis-
tance between the probe and the x-ray tube
changes, resulting in a change of intensity due to
the inverse-square law. Referring to the geometry
shown in Figure 6.14, there are two points in the
2p rotation of the gantry at which the bow-tie filter
has no effect (i.e., at a fan angle, u ¼ 0), and in
both cases this occurs when the x-ray tube, the iso-
center, and the x-ray probe are co-linear. The first
point corresponds to the maxima in the signal
Figure 6.14. The measurement geometry for the characterization-of-beam-relative-attenuation (COBRA) method (McKenney et al.,
2011). Angles are defined in (a), and dimensions are defined in (b). A small ionization probe is placed completely within the x-ray beam
on the z axis, toward the periphery of the scanner’s field of view. The table is retracted from the field of view for this measurement.
62
train, at u ¼ 0, 2p, 4p, . . ., at which the x-ray tube
is closest to the probe, maximizing the intensity in
regard to the inverse-square law and minimizing
the influence of the bow-tie filter. The other point
in the rotation of the gantry at which the bow-tie
filter has no effect is when u ¼ p, 3p, 5p, . . ., at
which the x-ray tube is on the opposite side of iso-
center from the x-ray probe.
Image-processing techniques are used
(McKenney et al., 2011) to identify the peaks at
even multiples of p in the signal trace (gray line in
Figure 6.15), and the odd multiples of p are identi-
fied as they are midway between adjacent maxima.
From these two values of the signal amplitude
(averaged over several gantry rotations), the effect
of the inverse-square law in the absence of the
bow-tie filter’s influence can be deduced, and this is
shown as the black line in Figure 6.15. The align-
ment of the odd-p and even-p locations along the
time-domain signal train allows the gantry angle
and the fan angle to be deduced as a function of
time as well. Using the data given in Figure 6.15
along with a well-defined mathematical construct
(McKenney et al., 2011), the bow-tie filter function
can be determined. The resultant bow-tie filter
function, fA(u), is shown in Figure 6.16 for four
x-ray-tube potentials. This procedure does not
require precise probe positioning because the dis-
tance between the x-ray probe and the isocenter
can be determined mathematically from the mea-
sured data. Thus, probe positioning does not
require careful physical alignment; the probe can
simply be placed at a convenient location near the
edge of the scanner’s field of view. The probe,
 CT Output Characteristics Measured in Air

Figure 6.17. Theoretically derived thickness of a bow-tie filter

Figure 6.15. The output of a real-time probe for the COBRA as a function of fan angle. Using dual-energy decomposition
method (McKenney et al., 2011). The gray trace indicates the techniques and the data shown in Fig. 6.16, the thicknesses of
raw output of the real-time probe. The minima and maxima of bow-tie filters were computed assuming a PMMA filter (solid
that trace are analyzed, and from that the inverse-square law circles) and an Al filter (open circles).
(shown as the black trace) is used to compute the x-ray beam
intensity in the absence of the bow-tie filter. The ratio of these
two curves allows one to calculate the bow-tie filter function.

Figure 6.18. The fan-beam geometry of a CT scanner,

illustrating the fundamental differences between fA(u) and fL(x).
Here dsic is the source-to-isocenter distance, and x ¼ 0 at the
central ray of the fan beam.

Figure 6.16. Illustrative bow-tie filter functions from the

COBRA method. Results for a Siemens ASþ CT scanner
source-to-isocenter distance, dsic, the angular func-
operated at four different x-ray tube potentials. The effect of the tion fA(u) is given by:
bow-tie filter is greater at lower tube potentials, as expected
(McKenney et al., 2011).
d2sic
fA ðuÞ ¼ g fL ðxÞ ; ð6:3Þ
d2sicþ x2
however, does need to be fully contained within the
x-ray field of the scanner such that there is no where the relationship between the angle u and
partial-volume irradiation. If the bow-tie filter distance x is given by
function is determined at two or more x-ray beam  
energies, dual-energy decomposition techniques x
u ¼ tan1 : ð6:4Þ
(Lehmann et al., 1981) can be used to estimate the dsic
actual filter thickness. Figure 6.17 shows derived
thicknesses of the bow-tie filter assuming a com-
position of either PMMA or Al. The value of g to be used in Eq. (6.3) depends on
There is a straightforward difference between the type of measurement device that is used. For
fL(x) and fA(u), as illustrated in Figure 6.18. As measurement systems that are spherical or cylin-
described previously, conventional measurements drical (such as a cylindrical chamber or TLD rods),
of bow-tie-filter effects typically rely on the transla- the cross section of the radiation sensor is generally
tion of the measurement device laterally across the not angular dependent, and g ¼ 1. For a linear or
field, or on the use of a linear or planar detector planar measurement system such as film or a CR
system, with which fL(x) is measured. For a given imaging plate, there is a slight change in the

63
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
sensitivity given by
1 Gorny et al. (2005) used Gafchromic XR-QA
g¼ : ð6:5Þ
cosðuÞ
For a measurement made in the plane of the iso-
center, the maximum angle at the periphery of the
field is about 0.45 radians (268), corresponding to
a maximum value of g of about 1.11.
For measurements made along a line using a
pencil chamber placed orthogonal to the CT fan
beam, the relationship between fA(u) and fL(x)
becomes a 1/r function instead of 1/r 2, due to the
one-dimensional nature of the pencil chamber:
dsic
fA ðuÞ ¼ gqffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi fL ðxÞ:
d2sic þ x2
For Monte Carlo calculations, the function fA(u) is
generally more useful than fL(x) in most code
systems. Therefore, linear measurements should be
converted to angular functions. For example, the
data shown in Figures 6.11 and 6.12 should be cor-
rected using Eqs. (6.6) and (6.4), where g ¼ 1 due
to the cylindrical shape of the ionization chamber
used. The curves shown in Figure 6.13, in addition
to correction for the response of the CR system,
should be converted to fA(u) using Eqs. (6.3 –6.5).
Equation 6.3 is used instead of Eq. (6.6) in this
case because the detector elements are fully con-
tained within the x-ray field and therefore have a
1/r 2 dependence with distance. Because the CR
plate is planar, geometrical foreshortening occurs
away from the central axis and therefore the cor-
rection factor described in Eq. (6.5) is necessary.
Note that the COBRA method measures fA(u) dir-
ectly (see Figure 6.16), and therefore no correction
factors are necessary when this approach is used.
6.5 Planar Measurements of the CT Beam
Profile
Dosimetry techniques that permit either qualita-
tive or quantitative assessment of a two-
dimensional air-kerma profile can characterize the
entire x-ray field produced by the CT-scanner
source assembly. In addition to spatial changes in
the air kerma (e.g., due to heel effect, penumbrae,
etc.), a two-dimensional measurement will charac-
terize the impact of the inherent and beam-shaping
filters and of the collimator subsystems. The two-
dimensional intensity distribution can be measured
using a planar detector system such as film, CR, or
a solid-state system. A planar detector placed at
the plane of the isocenter of the scanner will
measure a field defined as fP(z,x).
Dosimetry Film (International Specialty Products
Inc., Wayne, NJ, USA), in a General Electric CT/i
scanner operated at 120 kV to record the two-
dimensional radiation intensity pattern orthogonal
to the central beam and through the isocenter of
the scanner. After exposure, this self-developing
film develops over time; a photograph of the devel-
oped film is shown in Figure 6.19a. The film was
digitized using a commercial color, flatbed scanner,
and the so-called red-channel component was iso-
lated digitally and mapped into a pseudo-colored
image, giving the two-dimensional distribution
ð6:6Þ shown in Figure 6.19b. Using data from a calibra-
tion study, the signal was properly scaled, and the
resultant two-dimensional air-kerma distribution is
shown in Figure 6.19c.
CR can also be used to characterize the two-
dimensional distribution of radiation emerging
from the x-ray tube assembly of a CT system.
Figure 6.20 illustrates the two-dimensional inten-
sity distribution for a General Electric VCT system.
CR has a low-amplitude, long-range glare function,
as reported by Liu (2005) and observed by Seibert
( personal communication). This glare is a result of
the long-range (over centimeters) propagation of
optical light in the collection optics of the CR
system. If not corrected for, this glare can lead to
artifacts. Figure 6.7 illustrates such an artifact in a
one-dimensional plot. Due to this concern, CT rela-
tive intensity distributions measured using CR
should be considered as qualitative estimates and
not as accurate measurements.
6.6 Summary
The characterization of the two-dimensional
x-ray beam emerging from a CT-scanner tube as-
sembly, using either fP(z,x) or fair(z) combined with
either fL(x) or fA(u) might in some cases supplant
the need for in-phantom measurements. In particu-
lar, such measurements will be extremely useful
for assessment of CT air-kerma reproducibility over
time, or after an x-ray tube is changed. It is unlike-
ly that changes in the absorbed-dose distribution in
the patient or in a phantom will occur if the x-ray
beam emerging from the x-ray tube head is consist-
ent both spatially and in terms of intensity over
time. Although a number of different detector
systems have been discussed for such measure-
ments, including film, CR, optically stimulated lu-
minescence, TLDs, and real-time detectors, it is
expected that the radiation measurement tools that
64
 CT Output Characteristics Measured in Air

Figure 6.19. Use of radiochromic self-developing film to determine the relative two-dimensional distribution. A photograph of the
self-developing film exposed at the isocenter of the CT scanner is shown in (a). The analog film was digitized, and the red channel was
used with appropriate characteristic-curve normalization to determine the relative two-dimensional radiation-intensity distribution,
shown in (b). An isometric plot of the distribution is shown in (c).

Figure 6.21. An illustration of a fair(z) profile, with thimble-

chamber profiles aligned in different locations in the x-ray beam,
illustrating that slight changes in the positioning of the thimble
chamber can result in appreciable imprecision in the
measurement. A 100 mm pencil chamber cannot make accurate
air-kerma measurements in this geometry, due to the
inhomogeneous air-kerma distribution incident upon it.
Figure 6.20. The fP(z,x) profile measured using a CR plate.

set-up for fair(z). Figure 6.21 illustrates an ioniza-

are most accessible will be the most useful at a
given institution.
The selection of detectors is large and the avail-
ability of solid-state devices is growing; however,
the air-ionization chamber is still preferred when
accurate, air-kerma measurements are the goal.
Solid-state detectors can provide excellent relative
measurements, and in many cases are accurate if
conventional x-ray-beam spectra are used and
energy correction factors are employed appropriate-
ly. Some caution is necessary even when using air-
ionization chambers in terms of the measurement
tion chamber positioned parallel to the z axis of the
x-ray beam. When a short thimble chamber is
used, its position along z is critical in making ac-
curate and reproducible measurements because the
x-ray beam in many scanners has significant inho-
mogeneities along the cathode –anode axis due to
the heel effect. Small placement errors along z can
therefore lead to slightly different output results
among measurements. Long ionization chambers,
such as the 100 mm pencil chamber, can interrogate
the entire beam width, but the partial-volume correc-
tion factor used to convert the meter reading to an

65
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
accurate air-kerma value is ambiguous because the
edges of the beam are ill-defined, and also because
the x-ray beam is inhomogeneous along z. Both of
these effects make the 100 mm pencil chamber an
ill-suited tool for characterizing the absolute air
kerma for a CT x-ray tube head.
Given the above considerations, long-term
recommendations assume that real-time air-
ionization chambers will eventually become
routine measurement instruments in the CT envir-
onment. Using a small ionization chamber that is
translated through the beam, as illustrated in
66
Figure 6.8, both the spatial profile and the abso-
lute air kerma can be determined using a
minimum of hardware: just a laptop computer,
electrometer, and the real-time ionization
chamber. The fair(z) measurement using this hard-
ware is a robust characterization of the x-ray-tube
output, and is likely to be all that is required for
CT-scanner output consistency measurements over
time. Of course, complete measurement would
include evaluation at all tube potentials, for all
bow-tie filters, and for all clinically useful beam-
collimation settings.
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
7. CT Dosimetry in Phantoms
The standard 160 mm and 320 mm diameter,
150 mm long PMMA phantoms have been used for
40 y in CT dosimetry, and serve as the basis of CT
dosimetric quantities such as CTDIvol, as discussed
in Section 4. With the increasing sophistication of
CT acquisition modes, as well as an interest in
better characterizing the absorbed dose arising from
the long scatter paths in CT, there is a need for a
longer phantom. In the previous Section, character-
ization of the x-ray beam in air was discussed.
When a phantom is introduced into the x-ray beam
in CT, it becomes a major source of scattered radi-
ation that is responsible for absorbed dose in parts
of the phantom (and patient) away from the colli-
mated primary beam. Hence, phantoms are an es-
sential tool in understanding the distribution of
absorbed dose in CT.
7.1 Axial Dose Profiles in Phantoms
The axial or sequential CT scan involves the rota-
tion of the x-ray-tube head around the patient or
phantom with no table motion during rotation. In
this basic mode of operation, it is instructive to
understand the extent and shape of the absorbed-
dose profile along the z axis. It is realized that for
axial scanning, the absorbed dose in the patient is es-
sentially a summation of the absorbed-dose distribu-
tions from individual axial scans spaced at equal
intervals along z. Those profiles, which can be mea-
sured as air kerma or absorbed dose, can be com-
puted using Monte Carlo techniques or can be
measured in physical phantoms using a number of
different detector systems. In many cases, only the
relative shape of the absorbed-dose profile is of inter-
est, and the amplitude is arbitrarily normalized. In
such cases, the quantity used to describe the profile
shape can be either air kerma or absorbed dose, and
the generic term profile is used. For the purpose of
absolute dose assessment, either the quantities of air
kerma or absorbed dose are reported.
The shape, size, and anatomical complexity of the
patient tend to complicate an understanding of the
absorbed-dose distribution; therefore, it is routine to
use simpler phantom shapes for this assessment. In
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/nds007
most circumstances, a cylindrical phantom is used
because it has rotational symmetry and is easier to
fabricate than more complicated shapes. Figure 7.1
illustrates the basic geometry of a cylindrical
phantom with a diameter dphantom and a length
Lphantom. Different investigators have studied CT
scanners with a large number of beam widths in the
z dimension, and the parameter L in Figure 7.1
represents the length of the phantom irradiated dir-
ectly by the primary beam (scan length for axial or
helical scans). Even though a number of custom CT
phantoms have been described in the literature, it is
a common to incorporate holes that allow the inser-
tion of a radiation meter at the center or the periph-
ery of the phantom.
Figure 7.2 illustrates a single x-ray projection
through a 300 mm diameter cylindrical water
phantom, involving no x-ray-tube rotation around
the phantom. In this numerical simulation, the
x-ray beam from the General Electric VCT scanner
was modeled mathematically. The inset in
Figure 7.2 shows the primary x-ray beam in the
axial plane, and the individual profiles run along
the z axis at the points marked a through e in the
figure. These data are useful to better understand
what happens to the primary x-ray beam as it is
attenuated by the phantom. The simulation involves
primary radiation only; the entrance-beam profile
(curve a) is narrow because it strikes the phantom
at a position between the isocenter and the x-ray
source where there is less beam divergence. As the
x-ray beam penetrates the phantom, it is both atte-
nuated and diverging, hence the subsequent profiles
are lower in amplitude and wider. These data are
from a single projection, but the x-ray beam profile
along the z dimension in an axial CT scan repre-
sents the rotational summation of the data illu-
strated in Figure 7.2. At the isocenter (curve c), the
dose distribution integrated over a 2p rotation of
the gantry will have a shape identical to curve c, but
away from isocenter the dose profiles will be the in-
tegral over angle (and hence depth of interaction) of
the different x-ray-beam profiles.
Monte Carlo simulations were performed using
a number of cylindrical phantoms with different
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 7.1. A cylindrical phantom typically used in CT
dosimetry. The generic cylindrical phantom has a length
Lphantom, a diameter dphantom, and can be scanned over a scan
length of L. Two holes are illustrated, indicating locations where
radiation detectors can be positioned.
Figure 7.2. Absorbed-dose profile along the z axis for a single
CT stationary projection (inset picture) from the 12 o’clock
position. The asymmetry in the curves is a result of the heel
effect (see Section 6.2), in which the cathode– anode direction
runs left to right in the figure. These data were computed for a
40 mm wide CT beam modeled for a General Electric VCT
scanner, and the truncation of the beam intensity (shown as
gray to white) at the edges of the inset photograph is due to the
body bow-tie filter.
diameters, composition, and beam spectra (Boone,
2009). For these simulations, a very narrow
(0.01 mm) primary x-ray beam was assumed inci-
dent upon the phantom, approximating a delta-
function input. Therefore, the dose distributions in
the z dimension are considered dose-spread func-
tions (DSF), similar to the concept of the line-spread
function in imaging. Figure 7.3a shows the DSF at
three different depths within a 300 mm diameter cy-
lindrical water phantom for a 120 kV beam. The
central region (R1) has the same area as the other
regions, R2 and R3. Figure 7.3b illustrates the DSF
for a 400 mm diameter cylinder using a Siemens
body bow-tie filter, for three different phantom
materials: polyethylene, PMMA, and water. As seen
on these semi-log arithmic plots, after some initial
curvature near z ¼ 0 the DSFs are approximately
68
exponential along distances away from the center,
which is not surprising. Figure 7.3c illustrates the
DSF at the center of the phantom (R1) for different
phantom diameters. The DSFs fall off more rapidly
for smaller-diameter phantoms. This is understand-
able given solid-angle considerations of scattered
radiation: smaller-diameter phantoms lose more
scatter due to escape from the edges than do larger-
diameter phantoms. Figure 7.3d illustrates DSFs
at two different x-ray-tube potentials. Here, the
higher-energy spectrum (140 kV) produces a
broader DSF than does the lower-energy spectrum
(80 kV). It is evident from these DSFs that the
shape of the long-range exponential tails is related
to the x-ray attenuation of scattered radiation, away
from the very narrow central x-ray beam. This is
why the DSF for low-density and lower effective-
atomic-number polyethylene is broader than those
for water or PMMA in Figure 7.3b, and also why the
higher-tube-potential DSF is broader (see
Figure 7.3d). In both cases, the effective linear at-
tenuation coefficient is smaller, leading to a larger
tail in the DSF. It is observed from Figure 7.3a that
the DSF in the center region (R1) of the 300 mm
diameter phantom reaches a 10 % value at an axial
distance of approximately 80 mm, for a full width at
10 % of the maximum of about 160 mm.
Nakonechny et al. (2005) used a Phillips PQ-5000
system running at a tube potential of 130 kV, as well
as a Phillips MX-8000 Quad system at 120 kV, both
with bow-tie filters, to study the axial absorbed-dose
profiles in a water-equivalent plastic phantom and in
the standard CTDI body phantom. These investiga-
tors used a small-volume air-ionization chamber as
well as TLDs, but their primary tool was a diamond-
detector array for measuring the absorbed dose along
the z axis in the phantom. The water-equivalent
phantom was elliptical, 200 mm  300 mm in cross-
section, with a length of 300 mm. The absorbed-dose
profiles for the PQ 5000 are shown in Figure 7.4a.
The PQ-5000 single-detector-array scanner was used
in the measurement, with primary beams ranging
from 3 mm to 10 mm in width. The MX 8000 scanner
is a four-slice system, and the absorbed-dose profiles
are shown in Figure 7.4b for nominal slice widths
ranging from 4 mm to 20 mm. It is observed from
these profiles that the full width at 10 % of
maximum is approximately 140 mm for the 10 mm
nominal beam widths, and thus the scatter tails
extend a total of 140 mm – 10 mm ¼ 130 mm. For
the MX8000 scanner, the tails reached a total width
of about 180 mm for the nominal 20 mm beam width.
Subtracting the primary-beam width as a crude cor-
rection for the width of the primary beam, the
scatter tails reach a full width at 10 % amplitude of
about 160 mm.
 CT Dosimetry in Phantoms

Figure 7.3. The DSF for infinitely long phantoms and a very narrow primary incident x-ray beam (0.01 mm). (a) DSFs for three regions
in the phantom, R1, R2, and R3, illustrated in the inset. These data are for a tube potential of 120 kV and a 30 cm diameter water
phantom using a General Electric body bow-tie filter. (b) The influence on DSF of phantom composition is illustrated for a 120 kV scan
in a 40 cm diameter phantom with a Siemens body bow-tie filter. The profile data are for region R1. (c) DSF profiles are illustrated for
phantoms of different diameter, for a 120 kV scan in a water phantom using a General Electric body bow-tie filter. The data show the
profiles for region R1. (d) DSFs are shown for two different beam spectra, showing greater scattering for higher-energy spectra. These
data are for region R1, using a General Electric body bow-tie filter, and a 30 cm diameter water phantom.

Figure 7.4. Axial absorbed-dose profiles measured by Nakonechny et al. (2005). Profiles at various primary-beam scan widths are
shown for (a) a Philips PQ5000 system, a single-detector array fourth-generation scanner, and (b) a Philips MX8000 Quad system, a
four-detector-array, third-generation CT scanner. The profiles were measured using a diamond-detector system (PTW, Freiberg,
Germany).

A Siemens Sensation 64 CT scanner was used to head phantom (160 mm diameter) are shown in
produce the absorbed-dose profiles given in Figure 7.5a for both the central and peripheral
Figure 7.5. Absorbed-dose profiles for the PMMA regions. Absorbed-dose profiles for the PMMA body

69
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 7.5. Absorbed-dose profiles for a Siemens Sensation 64 scanner. (a) for the 160 mm head, and (b) the 320 mm body PMMA
phantoms. The center and peripheral profiles are shown in both cases. These measurements were performed using a commercially
available array of optically stimulated luminescence detectors (McNitt-Gray et al., 2008). The curves were normalized to a maximum of
unity for the periphery measurement.

phantom (320 mm diameter) are shown in

Figure 7.5b. These investigators used OSL dosi-
meters for the evaluation of the profile. The nominal
beam width of 19.2 mm (32  0.6 mm) was used for
these measurements. For the body phantom in the
central region, it is observed that the full width at
10 % corresponds to about 150 mm, and—subtracting
the 20 mm primary-beam width—the scatter tails
extend to a full width at 10 % of about 130 mm.
Gorny et al. (2005) used strips of self-developing
GafChromic film to measure the absorbed-dose pro-
files from a Siemens scanner, and their results are
shown in Figure 7.6. For this experiment, the stand-
ard 320 mm diameter PMMA phantom was used. In
this case, the limited horizontal extent of the pro-
files does not allow the estimation of the full width
at 10 % maximum. Although the use of the self-
Figure 7.6. Absorbed-dose profiles measured using commercially
developing film and the necessary correction for its available self-developing film (GafChromic film) strips, placed at
characteristic curve can be tedious, the profile itself the center and edge of the phantom. After development, the film
has extremely high spatial resolution. Nevertheless, was digitized using the red channel of a color document scanner,
in general, self-developing film has low dosimetric and corrected for dose–response using a calibration procedure
accuracy even when corrected for its non-linear (Gorny et al., 2005).
response.
Mori et al. (2005) investigated the absorbed-dose 220 mm, after correction for the primary-beam
profiles for a CT scanner with a very wide axial width. The profiles measured at the periphery of the
beam, the Toshiba Extech CT scanner, using PIN phantom are shown in Figure 7.7b for the same
photodiodes. These investigators corrected for the range of beam widths. The widths of the peripheral
x-ray-energy response and the directional depend- profiles are markedly smaller than those at the
ence of the PIN photodiodes. Measurements were center of the phantom, and this is consistent with
made in 320 mm diameter, 900 mm long PMMA the notion that scatter does not propagate as far
phantoms, at from 1 mm to 10 mm intervals along z. along z near the periphery of a phantom because it
Figure 7.7a shows absorbed-dose profiles at the has a higher probability of exiting the phantom,
center of the phantom for nominal beam widths fundamentally a solid-angle effect. Figure 7.7c
ranging from 20 mm to 138 mm. The full width of shows a logarithmic plot of the same central-axis
the scatter tails at 10 % maximum for the 20 mm profiles as in Figure 7.7a, which are well matched
nominal beam is approximately 125 mm, and that by the theoretically derived analytical functions of
for the 138 mm nominal beam is approximately Dixon and Boone (2011).

70
 CT Dosimetry in Phantoms

Figure 7.7. Absorbed-dose profiles for a number of different CT beam widths for a Toshiba 256-channel CT scanner. These profiles were
measured in the axial (cone-beam) scanning mode, using PIN-photodiode sensors. (a) Profiles for a 320 mm PMMA body phantom at
the center, and (b) on the peripheral axis of the phantom (Mori et al., 2005), using a 900 mm long phantom. (c) The Mori et al. data
were fit using analytical methods (Dixon and Boone, 2011) with good results shown here.

Geleijns et al. (2009) evaluated the absorbed-dose
profiles in a wide-cone-beam CT system. Figure 7.8
gives the normalized absorbed-dose profile in a
320 mm diameter PMMA phantom for a Toshiba
320 cone-beam CT scanner, which has a nominal
beam width of 160 mm. In this study, both
measurements and Monte Carlo calculations were
used to estimate the profile. The data shown in
Figure 7.8 are from Monte Carlo simulations for the
x-ray dose profiles at the center and periphery of the
phantom. In the center, scatter tails at 10 %
maximum approach +140 mm, for a full width of

71
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 7.8. Absorbed dose from Monte Carlo computations for a
Toshiba 320-detector CT scanner with a body bow-tie filter.
These profiles were computed (Geleijns et al., 2009) using a
nominal 160 mm beam width. The periphery and center profiles
are illustrated for a 320 mm diameter, 350 mm long PMMA
phantom at 120 kV.
280 mm. Subtracting the primary-beam width of ap-
proximately 150 mm, the scatter tails are seen to
have a full width of about 130 mm at the 10 % level.
Figures 7.3 through 7.8 illustrate CT absorbed-dose
profiles for a simple axial rotation from a number of
different CT scanners and measurement conditions,
performed by a number of different investigators.
These include both measured and Monte Carlo
derived profiles, using a number of different phan-
toms. The x-ray-primary-beam width ranged from a
0.01 mm nominal beam width (in a simulation) to a
3 mm nominal width for a single-detector-array CT
system, and up to a 180 mm beam width for a full-
cone-beam CT system. Despite the wide range of para-
meters studied in these examples, the absorbed-dose
profile from scattered radiation at the center along the
z axis of the phantom averaged 154 mm in width at
10 % amplitude (standard deviation of 33 mm). The
primary-beam width influences the scatter-tail width
in a complicated fashion (i.e., a mathematical convolu-
tion, as discussed below), and simple subtraction of
the beam width does not take these influences fully
into account. This approach is nevertheless useful to
illustrate the significant absorbed-dose profiles that
result from scattered radiation in a phantom. These
observations also point to the need for a phantom
longer than 150 mm if the scattered radiation dose is
to be characterized accurately.
7.2 Cumulative Absorbed-Dose Distributions
for Helical Scans
For the typical whole-body CT scanner, helical
(spiral) acquisition techniques are commonly used to
scan the patient, especially in the chest, abdomen,
and pelvic regions. For a helical CT scan, the accumu-
lated absorbed-dose distribution at the center of the
scan length (from –L/2 to þL/2), smoothed as
72
Figure 7.9. Normalized absorbed dose as a function of z for a
number of different scan lengths: 10 mm, 50 mm, 100 mm,
150 mm, 200 mm, 300 mm, 400 mm, 500 mm, and 600 mm (from
center to edge on the graph). These data were derived by
convolving the DSF computed from Monte Carlo simulations
with rect functions characterizing the length of the scan (i.e., L
in Figure 7.1), for a 320 mm diameter PMMA phantom at
120 kV, assuming a General Electric Lightspeed-16 body bow-tie
filter.
necessary (Dixon, 2003), is represented by a convolu-
tion
Q  z of the axial dose profile with a rect function,
L . When tube-current-modulation schemes are
used, the convolution is invalid and a superposition
of profiles of varying amplitude is required.
Figure 7.9 shows normalized cumulative absorbed-
dose distributions for a series of helical CT scans of
different scan length, produced by Monte Carlo simu-
lation (Boone et al., 2009). These data were calculated
for a General Electric Lightspeed-16 system with a
tube potential of 120 kV and an infinitely long
320 mm diameter PMMA phantom. The scan lengths
range from 100 mm to 600 mm in Figure 7.9. Note
that the amplitude of the cumulative absorbed-dose
distribution increases as the scan length increases,
even though the primary-beam contribution is the
same for all curves. The increase in the absorbed-
dose amplitude at the center of the scan length (z ¼
0) as a function of scan length, L, is due to the incre-
mental contributions of the long-range, low-
amplitude scatter tails that were seen in Figures 7.3
through 7.8, accumulating at z ¼ 0.
The cumulative absorbed-dose distributions from
Nakonechny et al. (2005) are shown for a number
of different scan lengths, L, in Figure 7.10. These
profiles were produced using a computer-modeled
single-scan absorbed-dose profile measured on a
Picker PQ5000 CT system, in an elliptical water-
equivalent phantom. The profiles were computed
by convolving the axial absorbed-dose
Q z distributions,
f(z), with rect functions L for different scan
lengths L. The mathematical description of this
process is discussed in Section 7.3.2. Nakonechny
et al. note that the asymptote to the equilibrium
dose, Deq, is reached in this phantom for a scan
length .370 mm.
 CT Dosimetry in Phantoms
Figure 7.10. Absorbed-dose distributions along the central axis
of a 300 mm long, elliptical (200 mm  300 mm in cross-section)
water-equivalent phantom for a tube potential of 120 kV. These
profiles were calculated using measured f(z) axial profiles,
assuming helical CT ( pitch, p ¼ 1.0) scans, and convolving with
the rect function for scan length L. A range of scan lengths are
indicated in the figure (Nakonechny et al., 2005).
Figure 7.11. Absorbed-dose profiles in a 320 mm PMMA
phantom. (a) A Monte Carlo derived profile calculated for the
center position in a helical scan ( pitch, p ¼ 1) with a beam
width of 34.1 mm. (b) Monte Carlo derived dose profiles for
several different pitch values, at the peripheral position (Zhang
et al., 2009).
Zhang et al. (2009) evaluated the cumulative
absorbed-dose distribution along the z axis of the
scanner at both the center and the peripheral loca-
tions using Monte Carlo techniques. For a helical
scan, the profile of the center of the beam is rela-
tively smooth (see Figure 7.11a), as seen previously
73
Figure 7.12. A comparison between film-measured and
simulated dose profiles at the periphery of a 320 mm diameter
PMMA phantom (Dixon et al., 2005), for a 21-rotation helical
scan with pitch, p ¼ 0.625. Excellent agreement between the
measured and computed profiles is observed.
in Figures 7.9 and 7.10. At the periphery of the
beam, the cumulative absorbed-dose distribution
exhibits a pattern of oscillations that are pitch-
dependent, e.g., for p , 1 there are peaks in the
dose distribution, and for p . 1 there are valleys in
the dose distribution when multiple rotations of
the gantry are considered.
Dixon et al. (2005) measured the cumulative
absorbed-dose distribution at the surface of a
320 mm PMMA phantom for a helical scan using
film densitometry, and also used an analytical
model to compute the absorbed-dose profile for a
nominal 10 mm beam width at a small pitch, p ¼
0.625. The absorbed-dose profiles, measured and
modeled, for a 120 mm scan length were compared
at the periphery of the phantom. These results
were determined for a General Electric Lightspeed-
8 CT system, and are shown in Figure 7.12.
Excellent correspondence between the measured
profile and the analytically simulated profile is
seen. This approach leads to a better understand-
ing of the small ripples in the absorbed-dose
profile, which are clearly the result of the summa-
tion of primary-beam profiles of adjacent scans,
which overlap for a pitch 1.
7.3 Equilibrium Dose, Deq
The equilibrium dose has been discussed exten-
sively in AAPM Report 111 (AAPM, 2010). With a
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

given DSF and a relatively narrow collimated states that the absorbed-dose profile at the center of
primary beam (as in helical CT scanners), the the phantom for a single gantry rotation and no
absorbed dose at the center of the field of view table motion is the convolution of the DSF(z) and
along z increases as the scan length increases. the collimated beam width a.
Absorbed-dose profiles along the z axis for a number
of different scan lengths are shown in Figure 7.9. As
can be seen, the absorbed dose, DL(0), at z ¼0 along 7.3.2 Cumulative Absorbed-Dose
the dashed vertical line increases as the scan length Distribution, DL(z), for Multiple
L increases. As L increases, however, the absorbed Rotations Covering a Scan Length L
dose at the center of the scan will at some point The cumulative absorbed-dose distribution, DL(z),
reach an asymptotic limit, and this is the so-called from a helical scan of length L with a table advance
equilibrium dose, Deq. per gantry rotation of b, as illustrated in Figures 7.9
and 7.10, is described by the convolution
ð  
7.3.1 Dose Profile for a Single Axial Rotation 1 þ1 Y z0
DL ðzÞ ¼ f ðz  z0 Þ dz0
Consider a DSF generated using a very thin b 1 L
(0.010 mm) primary-beam impulse [approximating 1 Q z
¼ f ðzÞ : ð7:3Þ
a Dirac delta function, d(z)] projected through the z b L
collimator to the central axis giving a width a for
the primary beam full width at half maximum Equation 7.3 applies only in the absence of tube-
(FWHM). Then an analytical function describing current modulation during the scan (i.e., is valid for
the complete absorbed-dose profile, f(z), resulting constant x-ray-tube output). The convolution given
from a single axial rotation can be obtained by con- in Eq. (7.3) can be reduced to a simple integration:
volving the dose-spread function DSF ¼ d(z) þ h ð þL=2
dsf(z) obtained from Monte Carlo simulation with 1
DL ðzÞ ¼ f ðz  z0 Þ dz0 : ð7:4Þ
the primary-beam intensity profile (Dixon and b L=2
Boone, 2010; 2011). Note that the upper case dose-
spread function, DSF(z), includes both the primary Evaluating this function at z ¼ 0, Eq. (7.4) further
component, d(z), and the scattered component, simplifies to
dsf(z), of the dose-spread function. The axial scan ð þL=2
profile is the convolution of the DSF and a rect func- 1
DL ð0Þ ¼ f ðz0 Þ dz0 ¼ p CTDIL ; ð7:5aÞ
tion of width a: b L=2

z
f ðzÞ ¼ DSFðzÞ A0 P where we recall that pitch is defined as p ¼ b/nT.
a This equation reduces further to CTDIL for a
z
¼ ½dðzÞ þ h dsf ð zÞ A0 P ; ð7:1Þ table advance of b ¼ nT (where p ¼ b/nT¼1). The
a dashed vertical line at z ¼ 0 in Figure 7.9 corre-
sponds to DL(0); this maximum absorbed-dose
where, assuming a point focal spot, d(z) replicates
value as a function of scan length L is shown in
the rectangular primary-beam profile
Figure 7.13. The gradual increase in absorbed dose
z as a function of scan length becomes asymptotic at
A0 P ;
a the larger scan lengths. This trend has been re-
ferred to as the rise-to-dose-equilibrium curve
with A0 the primary-beam amplitude, and h the (Dixon and Boone, 2010). To express the explicit de-
scatter-to-primary ratio (SPR) on that axis. pendence of DL(0) on L, the function h(L) is defined
Replacing d(z) by the focal-spot-intensity distribu- as h(L) ¼ DL(0); thus, these functions are mathem-
tion projected through the collimators produces a atical synonyms. Recognizing this, Eq. (7.5a) can be
more realistic primary-beam function (Dixon et al., written as
2005) without affecting the scatter component in
ð þL=2
Eq. (7.1). Equation 7.1 can be simplified to 1
hðLÞ ¼ f ðz0 Þ dz0 : ð7:5bÞ
Ð þa=2 0 0
b L=2
f ðzÞ ¼ a=2 DSFðz  z Þ dz : ð7:2Þ

This formalism includes also the simplification that These and related curves have been reported by
the primary beam in air
Q can
 z  be described by a rect a number of different investigators. If the cumula-
function of width a, a . Equation 7.2 simply tive absorbed dose at z ¼ 0 is normalized to Deq, it

74
 CT Dosimetry in Phantoms

Figure 7.13. A number of h(L) curves computed from Monte
Carlo derived DSFs (Boone, 2009), for different phantom
diameters (as indicated). These curves were computed for water
phantoms at a tube potential of 120 kV for a Siemens body
bow-tie filter.
becomes the function H(L), defined (Dixon and
Boone, 2010) as
hðLÞ DL ð0Þ
HðLÞ ¼ ¼ : ð7:6Þ
Deq Deq
Figure 7.14 gives H(L) curves derived by
Nakonechny et al. (2005) for the center of a water-
equivalent phantom. Figure 7.14a is for a single-
detector-array scanner (Phillips PQ 5000), and
Figure 7.14b is for a four-slice scanner (Phillips MX
8000). Figure 7.15 gives H(L) curves as measured by
Mori et al. (2005), both at the center (Figure 7.15a)
and the periphery (Figure 7.15b) of a 320 mm diam-
eter PMMA phantom.
As described in detail in Dixon and Boone (2010),
the scatter component of the Monte Carlo derived
DSFs shown in Figure 7.3 is well characterized by a
double-exponential function such as
1 1
dsf ðzÞ ¼ ð1  lÞ expð2j zj=d1 Þþ l exp ð2j zj=d2 Þ:
d1 d2
ð7:7Þ
This function has a short-range (transient) term
that is weighted by l, and a longer-range term
weighted by (1 2 l ). The fall-off of dsf(z) with z
depends on the d1 and d2 coefficients.
The profile, f(z), can be separated into primary
and scatter terms:
f ðzÞ¼ fp ðzÞ þ fs ðzÞ ; ð7:8Þ
where fp is the primary component, and fs is the
scatter component of absorbed dose obtained by
convolving dsf(z) with a rect function of width a
terms of absorbed dose) be h, it has been
shown (Dixon and Boone, 2010) that for conven-
tional helical or axial scans covering scan length
L, the rise-to-equilibrium curve H(L) can be
described as
1 h
HðLÞ ¼ þ ð1  lÞð1  eL=d1 Þ þ lð1  eL=d2 Þ :
1þh 1þh
ð7:9Þ
It has also been demonstrated that the same
equation applies to stationary phantom, cone-
beam CT, with L replaced by the cone-beam
width a (all other parameters remaining the
same). In Eq. (7.9), the 1=ð 1 þ h Þ term is the
primary fraction and the h=ð 1 þ h Þ term is the
scatter fraction, and these terms sum to unity. It
can be seen that with this normalization, H(L) ¼
1.0 for L !1 .
Figure 7.16 shows a comparison between the
rise-to-equilibrium data points measured by Mori
et al. (as shown in Figure 7.15) and the results of
Eq. (7.9), where the values of h, d1, and d2 were
determined independently by Monte Carlo simula-
tion (Boone, 2009). The H(L) curves shown in
Figure 7.16 were not fit to the measured data
points, they simply match the data well. It is noted
that the value of l in Eq. (7.9) for the central axis is
small (0.015), and therefore the second exponential
growth term in Eq. (7.9) becomes negligible at small
distances away from z ¼ 0. This leads to the simpli-
fied expression
h
1
HðLÞ ¼ þ ð1  eL=d1 Þ: ð7:10Þ
1þh 1 þ h
For the central axis of the PMMA 320 mm body
phantom (see Figure 7.16a), the parameter values
were determined to be h ¼ 13, and d1 ¼ 117 mm.
Equation (7.10) shows that H(L) intersects the
vertical axis (where L ¼ 0) at a value correspond-
ing to the primary fraction [the first term in
Eq. (7.10)], and the vertical extent of the actual
equilibrium curve, i.e., [H(1) – H(0)], has a value
equal to the scatter fraction, h / (1 þ h). These
observations are consistent with physical
interpretation.
A modified H(L) equation that accounts for the
small dependence of H(L) on a (Dixon and
Boone, 2011) can address the variation with a
shown in the Mori et al. (2005) data
(Figure 7.15). Earlier Monte Carlo simulations
Q z (Boone, 2007) focused on the efficiency of the
representing the primary beam, , as CTDI100 value, which is defined as CTDI100/
a
expressed in Eq. (7.1). Letting the SPR (in CTDI1. This work showed that for the center

75
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 7.14. H(L) curves computed by convolution with measured dose profiles (Nakonechny et al., 2005). These curves show the trend
for (a) the single-detector array Philips PQ5000, and for (b) the four-detector array Philips MX8000. A 300 mm long, water-equivalent
elliptical (200 mm  300 mm) phantom was used in these measurements for a tube potential of 120 kV.

Figure 7.15. Graphs adapted from Mori et al. (2005) showing measured H(L) curves. These data are for a 900 mm long, 320 mm
diameter PMMA phantom, for a tube potential of 120 kV. Three different beam-collimation widths are shown in each plot, for (a) the
center, and (b) the periphery positions.

position in the 320 mm diameter PMMA 7.4 Phantom Design and Usage
phantom, the efficiency of measuring dose over a
Mori et al. (2005) studied the dependence of the
length of 100 mm (i.e., the CTDI100 methodology)
absorbed-dose profile on phantom length, in which
was approximately 62 % (see Figure 7.17) com-
he compared the absorbed-dose profiles in a
pared with an infinitely long measurement (or
phantom of length 140 mm with that in a 900 mm
CTDI1). Evaluating this in the context of the
long phantom. These results are shown in
analytical development above, the ordinate value
Figure 7.18 for the central axis. Near the center of
at a beam width of 100 mm is approximately 62
the scans, close to the primary beam, there is little
% in Figure 7.16a (see the dashed line with
difference between the two profiles; however,
arrow), in excellent agreement with the 62 %
farther from the center, the relative dose profiles
value determined independently.
diverge. These data suggest that a 140 mm long

76
 CT Dosimetry in Phantoms

Figure 7.16. H(a) curves for wide-cone-beam CT. The solid circles are the data from Mori et al. (2005), as seen in Figure 7.15. The solid
line was derived using Eq. (7.9) (Dixon and Boone, 2010), with shape parameters from Monte Carlo determined DSFs similar to those
shown in Figure 7.3. (a) The H(a) curve for the center of an essentially infinitely long phantom, and (b) the corresponding curve at the
periphery. There was no curve fitting per se in these comparisons; the fit parameters for the center profile correspond to a 1/e scatter
length of 117 mm (d1), and a scatter-to-primary ratio of 13.

Figure 7.18. The role that phantom length plays in the

Figure 7.17. Plots of the efficiency of CTDI100, relative to CTDI1
(Boone, 2007). These data are for a 320 mm diameter PMMA
phantom and a tube potential of 120 kV; curves for the center,
periphery, and an intermediate “middle” position are shown. The
62 % efficiency for a 40 mm beam width at the center position
in this figure is consistent with the data shown in Figure 7.16a.
phantom is too short to measure the entire
absorbed-dose distribution that includes the scatter
tails.
Figure 7.3 also sheds light on the potential accur-
acy of CT dosimetry for different phantom lengths.
For a clinically relevant setting and a 300 mm
diameter water phantom (e.g., see Figure 7.3d), the
exponential tails decrease to a relative level of 1 %
at a distance of 200 mm from the center of the
phantom (where z ¼ 0). Because 1 % of the cumula-
tive absorbed dose is lost on each side, this corre-
sponds to a 2 % loss. Therefore, it would appear
that a 400 mm long, 300 mm diameter water
measurement of the dose profile (Mori et al., 2005). The longer
phantom (900 mm) contributes more absorbed dose from distant
scattered radiation than does the shorter phantom (140 mm).
phantom is necessary in order to measure about
98 % of the equilibrium dose. Equation (7.10)
depicts an analytic approach to equilibrium with
d1 ¼ 117 mm, so to reach the 98 % of Deq, a length
of 425 mm would be needed for the 320 mm diam-
eter PMMA phantom to reach 98 % of dose equilib-
rium on the central axis, in good agreement with
the data of Figure 7.3.
Recognizing the need to establish a standard
phantom capable of capturing the majority of the
scattered radiation in order to measure H(L) accur-
ately, this ICRU Report Committee collaborated
with Task Group 200 of the AAPM to design such a
phantom. The results of this collaborative effort led
to the ICRU/AAPM phantom design shown in
Figure 7.19. Figure 7.19a illustrates the general
design of the phantom, and Figure 7.19b shows a

77
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 7.19. The ICRU/AAPM phantom design. The ICRU, in collaboration with AAPM Task Group 200, defined a polyethylene
phantom for the purposes of measuring the rise-to-dose-equilibrium function, h(L) or H(L). (a) The phantom design, and (b) a
photograph of the phantom. Due to the large mass of this large phantom, it was designed to be modular, with three different sections.

picture of an actual phantom. The phantom com-
prises high-density polyethylene (mass density of
 0.97 g/cm3) and is 300 mm in diameter. The total
length of the phantom is 600 mm. Due to the large
mass of the phantom (41 kg), it was necessary to
manufacture it in three separate sections. Because
a radiation detector is to be located at the center of
the phantom along the z dimension, it was neces-
sary to design the phantom without a seam at the
center (z ¼ 0) to avoid the potential streaming of
primary radiation that could give erroneously high
readings. In order to keep the three sections
aligned, alignment pegs were included in the
design. The three sections of the phantom are re-
ferred to as section A, B, and C. Sections A and B
are bored through with holes necessary for place-
ment of dosimeters (e.g., small thimble chambers)
at the center, periphery, and at an intermediate pos-
ition between the center and edge of the phantom.
Figure 7.20 shows a more complete technical
drawing of the phantom.
It is recognized that this phantom is too large
and heavy to be practical for routine dosimetry
measurements on CT scanners in the clinical envir-
onment. However, for research in CT dosimetry,
and potentially for dose assessment in the testing
facilities of CT-scanner manufacturers, this
phantom is practical. The phantom design repre-
sents a reasonable compromise between utility and
cost; it is long enough that accurate measurements
of the equilibrium dose can be made, and—because
the stock material comes from extruded polyethyl-
ene boules—it is relatively inexpensive. Several of
these phantoms have been manufactured and dis-
tributed internationally, and some results mea-
sured with the phantom are reported below.
7.5 AAPM Report 111 Recommendations
for Assessment of H(L)
The measurement of the rise-to-dose-equilibrium
curve, H(L), is discussed at length in AAPM Report
111 (AAPM, 2010) with the methodology described
in that report for estimating H(L) as indicated sche-
matically in Figure 7.21. A short thimble chamber,
connected to an integrating electrometer, is placed
near the center of a long cylindrical phantom on the
CT couch. A series of helical CT scans of different
lengths are acquired, each scan centered on the
thimble chamber. In Figure 7.21, three different
scan lengths are shown, La, Lb, and Lc. The

78
 CT Dosimetry in Phantoms

Figure 7.20. Technical drawings of the ICRU/AAPM CT phantom.

Figure 7.21. The measurement procedure described in AAPM Report 111 (AAPM, 2010). An integrating thimble chamber is placed in
the center hole (or periphery, not shown) of a long cylindrical phantom. A series of helical CT scans are performed, with the center
(along z) of the scan located at the center of the phantom. Each chamber reading (in scans a, b, and c) is plotted as a function of the
scan length, L. The three different scan lengths La, Lb, and Lc are shown on the left, and the measured air-kerma values are plotted on
the right. These data are obtained for a given scanner, tube potential, “mAs” setting, and phantom, resulting in the h(L) profiles. When
the asymptotic value Deq [or equivalently h(1)] is used for normalization, the H(L) profiles are produced.

measurements for each of these scan lengths corres- by Deq and therefore asymptotically approaches
pond to a specific point on the H(L) curve, indicated unity whereas the unnormalized function h(L),
in the graph. The rise-to-dose-equilibrium curve, asymptotically approaches Deq. Hence, h(L) depends
H(L), defined by Eqs. (7.6) and (7.10), is normalized on CT acquisition parameters and has the utility

79
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

that it retains quantitative CT-scanner air-kerma

information that is lost in H(L) due to the normal-
ization procedure.
The methods of AAPM Report 111 described
above and in Figure 7.21 are robust and are capable
of producing accurate h(L) curves using widely
available integrating radiation meters. The disad-
vantage of this approach is that it requires quite a
few long, helical CT scans in order to fully charac-
terize h(L). Therefore, the procedure is relatively
time-consuming and can result in considerable heat
loading of the x-ray tube if many points are mea-
sured. Another important observation regarding
this point-by-point measurement is that the desig-
nated scan interval (at the CT console) for a given
helical acquisition might not be the exact length
used for the acquisition. For helical scans, the IEC
definition of scan length is L ¼ v t0, where v is the
table velocity and t0 is the total beam-on time. Thus,
the length of the physical scan is slightly longer
than the region in which images are prescribed on
the localizer view during scan set-up. For a pre-
scribed length for CT image acquisition of Li, the
physical scan length is approximately L ¼ Li þ nT.
Therefore, for helical scans on modern MDCT
systems (where nT  40 mm), the integral dose effi-
ciency (Li/L) for a 100 mm scan is 71 %, for a
200 mm scan it is 83 %, and for a 300 mm scan, it is
88 %. In state-of-the-art CT scanners, the presence
of adaptive collimation (see Section 2.2.2) can
substantially reduce the amount of helical over-
ranging. An accurate method to determine the
physical scan length, L, from the recorded CTDIvol
and DLP values reported by the scanner is to
compute L ¼ DLP/CTDIvol.
AAPM Report 111 did not anticipate the exist-
ence of a real-time radiation meter (introduced in
Section 5.2.3), which provides a more efficient
method for measuring the h(L) and H(L) curves.
These methods are discussed in the next Section.
Figure 7.22. Measurement of h(L) using a real-time meter. (a)
With the real-time probe positioned as shown, measurements
using the ICRU/AAPM phantom or some other suitable (long)
phantom are performed. The x-ray beam of width a is positioned
7.6 The Role of the Real-Time Radiation at the end of the phantom, and, using a helical-scan acquisition,
Meter in Measuring H(L) the x-ray beam is translated through the phantom and the
thimble chamber contained within. (b) An idealized real-time
A real-time radiation meter, capable of .1 kHz signal from the thimble chamber is illustrated. (c) The time axis
readout rates, can be used in combination with a is converted to position, and the signal is integrated numerically
long phantom to determine h(L) in one long helical over increasing scan length, L. (d) Plot of the integrated data
CT scan. Figure 7.22a illustrates the scan geom- derived from the procedure shown in (c), with the point
etry, in which the real-time radiation detector is corresponding to the measurement at length L1 shown. As the
integration in (c) proceeds beyond the value of L2, the curve
positioned near the center (along z) of the long shown in (d) extends further. The raw measurement shown in
phantom. A helical scan is performed covering the (d) using the real-time thimble chamber results in the function
entire length of the phantom, and in this procedure h(L).

80
 CT Dosimetry in Phantoms

the x-ray beam approaches and then passes
through the real-time detector (a small thimble ion-
ization chamber), and continues toward the other
edge of the phantom. An idealized real-time air-
kerma rate of the radiation meter is shown in
Figure 7.22b. As the primary beam enters the CT
phantom on the left, the x-ray probe measures the
signal produced by distant x-ray scatter. As the
x-ray beam approaches the detector, the measured-
scatter intensity increases, due both to solid-angle
effects and the shorter attenuation path length
between the x-ray beam and the real-time probe.
As the primary beam passes over the probe, it
records not only scattered radiation but the
primary radiation as well. The x-ray beam then
continues toward the right edge of the phantom,
producing an approximately symmetrical profile.
The real-time results, measured as air kerma per
time, can be converted to air kerma as a function of
position using the known sampling period Dt (i.e.,
Kair ¼ K_ air  Dt) and the known velocity v of the
table transport, where position ¼ t/v. After this
transformation, the profile as illustrated in
Figure 7.22c represents the air-kerma profile, f(z).
Using Eq. (7.5b), the cumulative air kerma at the
center of the phantom for scan length L can be
obtained by integrating f(z) from 2L/2 to þL/2, as
shown graphically in Figure 7.22c. These data are
then compiled to compute h(L) as a function of L, as
shown in Figure 7.22d. Despite the convenience of
this method for the assessment of h(L), it is not pos-
sible to accurately assess the SPR, h, in Eq. (7.10),
and therefore, there is some imprecision in the exact
shape of the curve near the y axis (for L , nT),
where the primary term becomes more prominent.
This is more apparent in peripheral dose profiles
than in center profiles.
7.7 Measurement of h(L) in the Clinical
Environment
Using the real-time probe located near the center
(along the z axis) of the ICRU/AAPM, 600 mm
long, 300 mm diameter polyethylene phantom
shown in Figure 7.19, the measurement of f(z) can
be determined directly. Such a measurement for a
Siemens ASþ CT scanner is illustrated in
Figure 7.23a. This is similar to the idealized dose
profile shown in Figure 7.22c; however, there is an
obvious notched pattern in this measured profile
that is due to CT-couch attenuation. Although the
modern CT couch is made from low-attenuation
carbon-fiber components, there is still some attenu-
ation by the patient table evident in Figure 7.23a.
Although the notches in the f(z) profile appear as a
distraction, the integration of this curve from 2 L/2
to þL/2 according to Eq. (7.5b) produces a mono-
tonic function h(L) in which the influence of
the table attenuation is largely eliminated (see
Figure 7.23b). Thus, depending on the alignment of
the notched pattern (i.e., its position relative to z ¼
0), the integration of f(z) can result in the apparent
cancellation of the notches. That is, notches on one
side of z ¼ 0 will cancel out the absence of a notch
on the other side. Another interesting observation
in regard to Figure 7.23a is how sharp each of the
notches appears, given that for most of the curve

Figure 7.23. Air-kerma rate from a Siemens spiral-CT scan through a phantom. (a) The signal trace from the real-time probe for a
helical scan performed along the entire length of the ICRU/AAPM phantom is shown for a Siemens ASþ scanner operating at 120 kV.
The thimble chamber was positioned at the center of the 300 mm diameter polyethylene phantom. (b) The rise-to-dose-equilibrium
curve, h(L), is computed from the profile shown in (a) by integrating from the center out. The h(L) from the real-time trace (solid line)
compares well with individual measurements using AAPM Report 111 methods (solid circles).

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 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 7.24. Air-kerma rate from a General Electric helical CT-scan through the ICRU/AAPM phantom. (a) The real-time trace is
shown for a General Electric VCT scanner operating at 120 kV. Although the notches from the table produce a trace with substantial
inhomogeneities, integration from the center outwards of this profile tends to reduce the impact of the table notches. (b) The h(L) curve
for the General Electric VCT scanner, determined by center-to-edge integration of the profile shown in (a). As before, the individual
data points represent serial measurements using AAPM Report 111 methodology.

Figure 7.25. Air-kerma rate from a Philips Brilliance 16 helical-CT scan through the ICRU/AAPM phantom. These data were
measured for a tube potential of 120 kV. (a) The output of the real-time x-ray meter. (b) The h(L) curve computed from the trace in (a).
Individual data points using AAPM Report 111 serial measurement methods are shown.

the real-time radiation meter is measuring scat-
tered radiation only. As the x-ray tube rotates and
the x-ray beam intercepts the table, the primary
x-ray intensity striking the phantom is rapidly
reduced, also reducing the scatter signal even at
considerable distances away from the primary
x-ray beam.
A particularly important observation from
Figure 7.23b is that the solid circles plotted are h(L)
values measured using an integrating ionization
chamber according to the methodology of AAPM
Report 111. The agreement between these points
and the solid curve measured using the real-time
probe is excellent.
Figure 7.24a shows a measured f(z) using the
0.6 cm3 real-time probe through the center of the
ICRU/AAPM phantom for a General Electric VCT
scanner, and the corresponding h(L) curve is shown
in Figure 7.24b. Again, the notches from the
CT-table attenuation seen in Figure 7.24a do not
appear in the h(L) curve in Figure 7.24b. The solid
points measured using the AAPM Report 111
methods are shown as well, with excellent agree-
ment between the two measurement approaches.
Analogous results for a Philips Brilliance 16 CT
scanner are shown in Figure 7.25a and 7.25b. The
very good agreement between the two measurement
methods for three different scanners as shown in

82
 CT Dosimetry in Phantoms

Figures 7.23 – 7.25 demonstrates concordance
between the AAPM Report 111 measurement
methods and those using the real-time probe
described here.
There is a sentiment in the CT community that
CTDIw can be considered as a loose measure per-
taining to the relative output of the CT scanner;
CTDIw is measured as air kerma in a PMMA
phantom (160 mm or 320 mm in diameter) and
increases with x-ray tube potential, tube current,
and exposure time, and has only a slight depend-
ence on collimation at clinically realistic settings
on MDCT scanners. Because CTDIvol is
Figure 7.26. Three G(L) curves from three different CT
scanners, normalized by CTDIvol. This figure illustrates the
three central-position h(L) curves illustrated in Figs. 7.23, 7.24,
and 7.25, normalized by CTDIvol corresponding to the CT
scanner used.
dependent on table speed, it is not an ideal
measure of CT scanner output per se, as x-ray
output should be independent of table speed. For
measurements involving helical-CT scanning,
however, CTDIvol can be considered to be a
measure of pitch-normalized output (e.g., air
kerma per effective “mAs” setting, where effective
“mAs” is the tube-current–time product divided
by the pitch). Embracing this concept, the h(L)
curves shown for three different CT models and
manufacturers in Figures 7.23 – 7.25 are normal-
ized by the corresponding CTDIvol at the appro-
priate tube potential and for each machine type,
and subsequently corrected to the appropriate
tube-current–time product, and pitch for each
scan. These results are shown in Figure 7.26.
Given that these curves are from measurements
on three different CT scanners, the normalized
curves are remarkably similar.
Figure 7.27a shows f(z) curves for a Siemens
ASþ CT scanner measured for a number of x-ray
tube potentials using the real-time probe
method. As expected, at the same tube-current –
time value, the air kerma for the system at
higher x-ray-tube potentials (and hence the area
of the curves) increases. Integration of these
curves leads to the h(L) curves given in
Figure 7.27b. The h(L) curves can also be nor-
malized by the tube-potential-dependent values
of CTDIvol, and these results are shown in
Figure 7.27c. It is evident that this normaliza-
tion essentially eliminates the effects of the
x-ray-tube potential, resulting in very similar
normalized curves for all four x-ray-tube poten-
tials evaluated.

Figure 7.27. Real-time probe data versus x-tube potential for a Siemens’ ASþ CT scanner using the ICRU/AAPM phantom. (a) The
traces of the real-time x-ray detector for four different tube potentials. All traces were corrected to a current–time product of 100 mA s.
The amplitude for the higher tube potentials is greater, as anticipated. The different location of the notches in the four traces indicates
that the start angle changed between measurements. (b) The resulting h(L) curves from the traces for the four tube potentials shown in
(a). The asymptotic value reached at the right end of the curves corresponds to the total area of the f(z) traces shown in (a). (c) The
individual h(L) curves for the x-ray tube potentials shown in (b), normalized by the measured CTDIvol, and thus are Gc(L) curves per
Eq. (7.13). As seen before with the different CT scanners, these normalized G(L) curves essentially fall on one another.

83
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Thus, it is seen that normalization by CTDIvol is

an effective method for correcting for the character-
istics of different CT scanners operating at different
x-ray tube potentials, providing a nearly universal
h(L)/CTDIvol curve. These results suggest that the
parameter h(L)/CTDIvol is a useful quantitative de-
scription of the dose-distribution characteristics in
CT for a cylindrical phantom of a given diameter.
Although there are differences among the different
manufacturer’s CT scanners in terms of x-ray spec-
trum, beam-shaping filters, collimated-beam width,
table composition, the x-ray-source-to-isocenter
distance, etc., normalization by CTDIvol appears to
correct for these differences. Given the likely utility
of this normalized function, a function G(L) can be Figure 7.28. The Gc(L) curves for polyethylene phantoms of
defined: different diameters acquired at 120 kV. The 300 mm diameter
phantom approximates an average-sized adult, whereas the
hx ðLÞ DL ð0Þ 180 mm phantom corresponds to a pediatric patient of
Gx ðLÞ ¼ ¼ ; ð7:11Þ approximately 5 y old. Both curves were produced by
CTDIvol CTDIvol
normalizing hc(L) curves by the measured CTDIvol, which was
measured using a 100 mm pencil chamber and a 140 mm long,
where the CTDIvol is specific to the 320 mm diam- 320 mm diameter PMMA phantom for the Siemens ASþ CT
eter, 150 mm long PMMA phantom (or the 160 mm scanner.
diameter phantom for head CT applications), and
where L ¼ 100 mm, whereas hx(L) can be measured
in phantoms of different diameter, length, and com-
position. The subscript x is meant to designate h(L)
at a peripheral (x ¼ p) or center (x ¼ c) location, or
the weighted average (x ¼ a) of these. It is recog-
nized that the asymptotic value of Gx(L) is Deq/
CTDIvol, on a given phantom axis (central or periph-
eral). It is also evident that Ga ð1Þ is equal to
CTDI1/CTDIvol, the inverse of the efficiency intro-
duced in Section 7.3 regarding Figure 7.17. For the
300 mm diameter polyethylene ICRU/AAPM
phantom, the measured data show that for the
center position, the asymptote (Deq/CTDIvol )
reaches a value of approximately 2.08 (see
Figure 7.28). Figure 7.28 gives Gc(L), at the center
Figure 7.29. H(L) curves for the center and peripheral positions
of the phantom, for two polyethylene phantoms:
in the 320 mm PMMA phantom for a tube potential of 120 kV.
180 mm and 300 mm in diameter. These data were The solid triangles correspond to measurements (Dixon and
obtained with the real-time radiation meter by inte- Ballard, 2007), and the closed circles represent Monte Carlo
grating f(z). These Gc(L) curves have both been nor- data (Zhou and Boone, 2008). The dashed lines correspond to
malized to the CTDIvol value for the scanner the analytical fits [Eq. (7.10)] to these data.
operating at the same tube potential and tube-
current – time product, which explains why the several phantoms, in order to evaluate the
180 mm diameter phantom curve is higher than rise-to-dose-equilibrium characteristics in PMMA.
that of the 300 mm diameter phantom. Monte Carlo data (Zhou and Boone, 2008) are com-
pared with measured data (Dixon and Ballard,
2007) for the 320 mm diameter PMMA phantom,
both for a tube potential of 120 kV, in Figure 7.29.
7.8 Rise to Equilibrium in 160 mm
The calculated and measured data are shown as
and 320 mm PMMA phantoms
points and the analytical curves from Eq. (7.10) are
In this Section, the focus is on the rise-to- plotted as dashed lines for both the center and per-
dose-equilibrium functions in the 160 mm and ipheral axes. For the analytical curve on the center
320 mm diameter PMMA dosimetry phantoms. The axis, the dashed line was computed with h ¼ 13
phantoms have been extended in length by using and d1 ¼ 117 mm, as described previously for

84
 CT Dosimetry in Phantoms
Figure 7.16a. Figure 7.29 shows the excellent
agreement among measured, simulated, and ana-
lytical results.
The function h(L) represents the raw measure-
ment (using either the integrating-probe method of
AAPM Report 111 or the real-time probe measure-
ment approach) of absorbed dose as a function of
scan length in a phantom, at either the center
[hc(L)] or peripheral [hp(L)] locations. The h(L)
curves are dependent on output-related parameters
such as tube potential, tube current, acquisition
time, pitch, etc. Combining the center and periph-
eral measurements, the CTDIvol(L) can be derived:
1 2
CTDIvol ðLÞ¼ ha ðLÞ ¼ hc ðLÞ þ hp ðLÞ:
3 3
Following Eq. (7.11), Eq. (7.12) can be divided by
the conventional (L ¼ 100 mm) CTDIvol value, mea-
sured at (or scaled to) the same technique factors
(tube potential, tube current, pitch, etc.) that were
used to measure the h(L) data, to yield:
CTDIvol ðLÞ 1 2
¼ Ga ðLÞ ¼ Gc ðLÞ þ Gp ðLÞ:
CTDIvol ð100 mmÞ 3 3
Figure 7.30a shows three 320 mm diameter PMMA
phantoms placed end-to-end on the table of a CT
scanner (Siemens ASþ). The G(L) curves acquired
at 120 kV for both the center [Gc(L)] and the per-
ipheral profiles [Gp(L)] were evaluated using the
real-time-probe method for both the 160 mm and
320 mm diameter phantoms. The 320 mm diameter
results are shown in Figure 7.30b and those for a
160 mm diameter phantom in Figure 7.30c. At the
peripheral location [i.e., Gp(L)], some waviness in
the profile is seen (Figures 7.30b and 7.30c), which
Figure 7.30. Data from a long PMMA phantom acquired at 120 kV. (a) A photograph of three 320 mm diameter PMMA phantoms,
placed end-to-end on a CT couch. (b) The center, Gc(L), and peripheral, Gp(L), curves are shown for the 320 mm diameter PMMA
phantom. The Ga(L) was computed as well, seen as the dashed line. Due to the normalization, the Ga(L) curve passes through a value
of 1.0 at L ¼ 100 mm. (c) The Gc(L), Gp(L), and Ga(L) curves are shown for the 160 mm diameter head phantom.
is due to the influence of both phantom attenuation
and the inverse-square law.
As noted previously, although the Gx(L) curves
are plotted starting at L ¼ 0 in Figure 7.30b and
7.30d, the data are unreliable for L , nT, which is
about 40 mm for this scanner. For the 320 mm
diameter phantom (see Figure 7.30b), the center
measurement is nearly always lower than that of
the peripheral value, as would be expected for a
large-diameter phantom. For the 160 mm diameter
phantom (see Figure 7.30c), however, the center
and peripheral profiles intersect at a scan length of
about 135 mm, with the center exceeding the per-
ipheral beyond this scan length. This demonstrates
the increasing build-up of scattered radiation at
ð7:12Þ
the center of the phantom as a function of scan
length.
Although the numerator, CTDIvol(L), in Eq. (7.13)
is from a measurement using a long phantom and
the denominator, CTDIvol(L ¼ 100 mm), is from a
measurement in the standard 150 mm diameter
PMMA phantoms, the value of Ga(L) at L ¼ 100 mm
is approximately 1.0 for both the 320 mm diameter
(see Figure 7.30b) and the 160 mm diameter (see
Figure 7.30c) phantoms. The implications of Eqs.
ð7:13Þ 7.11–7.12 and Figures 7.23–7.30 will be discussed
in the Summary section.
7.9 The Radial Dose Profile
Much of the focus so far has been on the air-
kerma or absorbed-dose distribution as a function of
z in a phantom. In this Section, the radial distribu-
tion is discussed. A Monte Carlo evaluation of an in-
finitely long, 320 mm diameter water phantom has
been performed, and the x-ray energy deposited ra-
dially at 10 mm annular thicknesses was evaluated.
85
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 7.31. Radial dose profiles. (a) Monte Carlo generated profiles as a function of radial position (from center to edge) for a 320 mm
diameter water phantom in a beam generated at 120 kV. The energy deposited increases from center to edge, which is consistent with
basic principles of radiation attenuation. Because absorbed dose is energy deposited per mass, and the mass of an annulus of smaller
radius is smaller than that of an annulus toward the periphery of the phantom, the absorbed-dose profile is different. (b) The radial
absorbed-dose profiles for four different x-ray tube potentials, for a 320 mm diameter water phantom. In all cases, the absorbed dose at
the center of the phantom is about from 20 % to 25 % less than the maximum absorbed doses that occur near the periphery of the
phantom.

The deposited energy is shown as the lower curve in
Figure 7.31a. Although less energy is deposited
centrally in the phantom due to attenuation, the
volumes (and hence masses) of the inner annuli
(and central cylinder) are also much smaller, so that
the radial distribution of the equilibrium absorbed
dose (top profile in Figure 7.31a) is much more
uniform than the distribution of total energy depos-
ited. Figure 7.31b illustrates the equilibrium
absorbed dose as a function of radial position for
four x-ray tube potentials. There is some variation
in the absorbed dose as a function of radial position
in CT. However, compared with x-ray projection
imaging such as radiography and fluoroscopy, the
radial equilibrium absorbed-dose distribution in CT
is relatively uniform, the peripheral-to-central-axis
ratio being about 1.4 for a tube potential of 120 kV
in this 320 mm diameter phantom.
7.10 Summary
In this Section, the body of knowledge produced
by many scientists working in the field of CT dos-
imetry has been presented and compared. Many
common themes have emerged. Collectively, this
work demonstrates that CT dosimetry in phantoms
has moved well beyond the traditional parameter of
CTDIvol, and it also follows the developments pre-
sented in AAPM Report 111 (AAPM, 2010).
The function hx(L) was defined as a raw (unnor-
malized) measurement of the rise-to-equilibrium
curve for either the center (x ¼ c) or peripheral (x ¼
p) phantom positions, or the 13 and 23 weighted
average value [x ¼ a; see Eq. (7.12)]; this is consist-
ent with the definition h(L) ; DL(0). The amplitude
of h(L) scales with the CT technique factors
used, and therefore this function reflects the specific
set of acquisition parameters (tube potential, tube
current, acquisition time, pitch, etc.) used for the
scan. In the limit of L ! 1, h(L)! Deq, and the
function H(L), defined as h(L)/Deq, approaches
unity. The normalized value of H(L) is useful in
many applications (AAPM, 2010) and is also import-
ant to the understanding of the energy deposited
by scattered radiation (i.e., Eqs. 7.9 and 7.10), and
the normalization process eliminates most of the
dependencies on technique factors.
It is recognized that the function h(L) is useful
because it retains the CT scanner output character-
istics that are dependent upon technique factors;
however, this means that there would be a different
h(L) curve for each combination of technique
factors. To address this, the Gx(L) was defined in Eq.
(7.13), which is simply hx(L)/CTDIvol, where the
definitions for x were defined previously. The utility
of Gx(L) is that it retains the output characteristics
unique to the CT technique factors, but is normal-
ized by a quantity that is available on the CT
console (or in the DICOM header), the conventional
CTDIvol. Therefore, given the Ga(L) curve for a
given phantom diameter and composition, the
planar dose average at z ¼ 0 can be computed
knowing the CTDIvol as well as the scan length L.

86
 CT Dosimetry in Phantoms

Because the CTDIvol and the dose – length product
(DLP) are reported on all modern CT scanners for
each CT scan, the value of L can be computed as
L ¼ DLP/CTDIvol [see Eq. (4.11)]; this means that
the length-adjusted planar-dose average (at z ¼ 0)
can be computed in a clinical setting when G(L) is
known for the average diameter of the patient’s
anatomy being scanned. This would suggest that a
family of Ga(L) functions for different phantom dia-
meters, Gdia
a ðLÞ, could be useful for the clinical as-
sessment of patient dose.

87
Journal of the ICRU Vol 12 No 1 (2012) Report 87 doi:10.1093/jicru/nds008
Oxford University Press

8. Patient Size-Specific Dose Estimation

8.1 Introduction should not be considered as the patient dose per se

(McCollough et al., 2011). For the same x-ray-tube
As concerns about the absorbed dose from CT
potential, time –current product, and primary-
examinations have grown, stakeholders, including
beam collimation width, the absorbed dose at the
patients, referring physicians, radiologists, medical
center of a cylindrical object in CT increases as the
physicists, and others, have sought to improve the
diameter of that object is reduced (see Figure 8.1)
accuracy of dose assessment. Nowhere has this
because of the reduction in self-attenuation. This
effort been more emphasized than in pediatric CT,
was seen in Figure 7.28, which compares the
and indeed the well-known Image Gently campaign
absorbed dose in a 180 mm diameter cylinder with
of the Alliance for Radiation Safety in Pediatric
that in a 300 mm diameter cylinder for the same
Imaging (Image Gently, 2011) has been a driving
CT technique factors. For a large reduction in
force calling for improved dosimetry for pediatric
patient or phantom diameter, the absorbed dose in-
radiology.
crease can be substantial. Another way to under-
Two standard PMMA phantoms have been used
stand this dependence on patient size is to recognize
for CT dosimetry for almost 40 y, the 160 mm diam-
the larger mass of bigger patients. The vast major-
eter head phantom and the 320 mm diameter body
ity of an x-ray beam incident upon a patient is atte-
phantom. Air kerma is measured at points both in
nuated by, and its energy absorbed in, the patient.
the center and the periphery of these two phan-
Because the average absorbed dose is deposited
toms, and are combined together as described in
energy divided by mass, a patient with smaller
Section 4.2.6 to form the weighted CT dose index,
mass receives a higher average absorbed dose than
CTDIw. The CTDIw captures useful x-ray output in-
a larger patient for the same x-ray beam fluence in-
formation for a given CT scanner, and is dependent
cident on the patient.
on a number of CT technical factors including x-ray
The IEC (2009) requires that all modern CT
tube potential and current, rotation time, bow-tie
scanners be capable of displaying the CTDIvol
filter, total collimation width, as well as
both prior to and after a CT scan, and efforts are
source-to-isocenter distance. Because CTDIw is
underway to use this displayed CTDIvol as a prac-
defined only in the axial-acquisition mode; it has
tical parameter in estimating absorbed dose for
no dependence on pitch. The CTDIvol is the pitch-
different-sized patients. The displayed CTDIvol is
corrected CTDIw, and therefore CTDIvol is an im-
available after the technique factors have been set,
portant dosimetric quantity that pertains to helical
but prior to the actual CT scan, which enables the
or spiral CT scanning. The CTDIvol cannot be con-
CT operator to use the CTDIvol to estimate patient
sidered as solely an x-ray-tube-output measure
absorbed dose prior to the exposure of the patient.
because it depends upon table-feed velocity.
However, the CTDIvol value is not by itself suffi-
Nevertheless, the CTDIvol has been demonstrated
cient as it does not address the size of the patient.
to be a useful parameter in normalizing for the
With appropriate compensation for patient size as
pitch-corrected x-ray-tube output on a CT system
described below, CTDIvol can be used to estimate
(see Section 7.7). The CTDIvol is reported on the
more accurately the absorbed dose prior to the CT
console of most CT scanners and is also recorded as
scan. This same quantity can be used after the CT
part of the CT dose report1 on many systems as
scan is performed as well.
well. The ubiquitous availability of CTDIvol makes
A document published by the American
it a useful parameter in dose assessment, but it
Association of Physicists in Medicine, AAPM
Report 204 (AAPM, 2011), directly addresses the
1 issue of the size-specific dose estimate (SSDE) and
The Digital Imaging Communication in Medicine (DICOM)
Radiation Dose Structured Report (RDSR) records a number of
has been endorsed by both the Image Gently cam-
parameters in the CT image header that are pertinent for CT paign and the ICRU. This Section includes much of
dosimetry. the information described in AAPM Report 204.

# International Commission on Radiation Units and Measurements 2013

 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 8.1. The relative absorbed dose as a function of the
effective diameter of the patient. If the patient were 320 mm in
diameter and composed of PMMA, CTDIvol or CTDIw would be
an accurate dosimetric quantity. However, at the same technique
settings (tube potential a current, time, pitch, etc.), the absorbed
dose increases for patients smaller than this (i.e., most).
8.2 Absorbed Dose versus Patient Size
A number of investigators have independently
studied the absorbed dose in different-sized objects
or patients scanned in CT. These efforts will be
briefly reviewed here, and the combined data from
these studies will be analyzed in Section 8.4.
Nickoloff et al. (2003) reported on the influence
of patient diameter for different x-ray-tube poten-
tials and scan modes. These investigators studied a
total of six different CT systems, including four
single-slice and two early MDCT scanners. Given
that the cylindrical PMMA phantoms are placed
concentrically at the isocenter of the CT system, it
was recognized that the attenuation path-length
through the PMMA to the center of the phantom is
constant with x-ray gantry rotation. This led
Nickoloff and colleagues to assess the effective
linear attenuation coefficient, meff, for a number of
CT scanners over a range of different tube poten-
tials. Characterization of meff allows the computa-
tion of a size-adjusted CTDIvol, and Nickoloff et al.
include tables of these parameters and formulae
for estimation.
Huda et al. (2010) evaluated the organ doses for
thoracic CT for commercial CT scanners from two
different manufacturers and for different patient
sizes. These investigators studied effects of the CT
scan length, as well as the dependence of absorbed
dose on body mass. They observed that the thoracic
dimensions of most adult patients are likely to be
modeled by cylinders of water with diameters that
range from 200 mm to 280 mm, and they provided
a polynomial relationship for relative absorbed
dose in water cylinders of different diameters.
A group of investigators reported on a multi-
institutional collaboration (Turner et al., 2010) that
involved the Monte Carlo characterization of organ
90
absorbed-dose estimates as a function of patient
size, over a range of patient sizes, including pediat-
ric patients, females, and males. The Monte Carlo
patient models (see Figure 8.2) were developed
from CT scans of actual individuals (Petoussi-
Henss et al., 2002). The Monte Carlo studies evalu-
ated the absorbed dose in a number of abdominal
organs, including the liver, stomach, adrenal
glands, kidneys, pancreas, spleen, and gallbladder.
The investigators normalized the organ absorbed
doses to the CTDIvol; the simulations included the
parameters from four major CT manufacturers,
and were based on a 120 kV x-ray spectrum.
A collaboration of Strauss and Toth ( personal
communication) performed measurements on CT
scanners from four different manufacturers using
PMMA phantoms of 100 mm, 160 mm, and 320 mm
diameters. The measurements were made as a
function of x-ray-tube potential, and the investiga-
tors normalized the average measured air kerma to
CTDIvol for the 320 mm diameter PMMA phantom.
McCollough and colleagues at the Mayo Clinic
( personal communication) made dosimetry mea-
surements in a family of commercially available
phantoms, shown in Figure 8.3, that spanned a
range from 100 mm to 400 mm in diameter. By
adding an additional layer of simulated fat, a total
of 11 different patient sizes were evaluated in these
measurements. This study included CT scanners
from two different manufacturers.
A group of investigators at the University of
California Davis used a series of six PMMA cylin-
drical phantoms to make image-quality assess-
ments, including contrast and image noise (Boone
et al., 2003). In this investigation, the CTDI100 was
also measured at the center and periphery of each
phantom; these measurements were made for tube
potentials from 80 kV to 140 kV.
Monte Carlo simulations were performed for a
series of mathematical cylindrical phantoms that
ranged from 10 mm to 500 mm in diameter (Zhou
and Boone, 2008). Several different phantom com-
positions were studied, including water, polyethyl-
ene, and PMMA. In these simulations, the
phantoms were considered to be infinitely long,
thereby including the contributions of multiply
scattered x rays. These investigators also developed
a spreadsheet-based tool that incorporated mono-
energetic Monte Carlo data spanning 22 different
phantom diameters. The spreadsheet allows the
x-ray spectrum to be generated using a spectrum
model, permitting flexibility in terms of x-ray-tube
potential. A polynomial fit was used for interpol-
ation of the absorbed dose across the entire range
of phantom diameters from 20 mm to 500 mm.
Dose estimates using this tool are provided at the
 Patient Size-Specific Dose Estimation
Figure 8.2. Examples of three-dimensional voxel phantoms (Turner et al., 2010). Organ boundaries were hand segmented in most
cases.
Figure 8.3. The eight phantoms used by McCollough and
colleagues for the measurement of absorbed dose as a function
of patient size.
center and peripheral positions in the phantom, as
well as for a planar average.
8.3 Size Metrics
Figure 8.4 illustrates the concept of effective
diameter, deff. In most cases, the lateral and anter-
ior– posterior (AP) dimensions of a patient are dif-
ferent. When the transverse area of a patient’s
body in the plane of the CT image is considered,
the effective diameter is defined as the diameter
of a circle of equal area. Investigators have also
defined a patient’s water-equivalent diameter,
dw. The water-equivalent diameter includes a
91
Figure 8.4. The concept of effective diameter. For a CT scan of
the cross-sectional area A, the effective diameter is defined as
the diameter of a circle with equal area. Here, the AP and
lateral dimensions are also illustrated.
correction for the density of the patient’s tissues in
the CT plane of interest, as will be defined below in
more detail.
Kleinman et al. (2010) made comprehensive mea-
surements of the dimensions of pediatric patients
using CT images. These data characterized the AP
and lateral dimensions as a function of age, from
newborn to 20 y. Analysis was performed for the
head, thorax, abdomen, and pelvis. The abdominal
dimensions from this work are illustrated in
Figure 8.5. These data can be combined to deter-
mine the AP dimension as a function of lateral
dimension as well. In Boone et al. (2003), the
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 8.5. Patient sizes. (a) The anterioposterior dimension as a function of patient age. (b) The transverse or lateral dimension as a
function of age (Kleinman et al., 2010).
Figure 8.6. The lateral dimension (L) and AP dimension (A) as a
function of effective diameter, for 87 patients (Boone et al.,
2003).
investigators characterized the AP and lateral
dimensions for a cohort of 87 adult patients, as a
function of effective diameter. The data shown in
Figure 8.6 illustrate the relationships for the
lateral and AP dimensions as a function of the ef-
fective diameter. For adult patients, it was found
that both of the linear measurements scaled pro-
portionately to the effective diameter, with just a
scalar offset. For example, for these data, the
lateral dimension, LAT ¼ deff þ 3.8 cm, and for the
AP dimension, AP ¼ deff – 4.5 cm. These investiga-
tors also found that the mean aspect ratio of the
torso, that is, the ratio of the AP dimension to the
lateral dimension, was 0.745 (standard deviation ¼
0.061). The investigators also evaluated the mean
aspect ratio for 35 pediatric patients and found it
to be 0.718 (standard deviation ¼ 0.054).
The data from Kleinman et al. (2010) and Boone
et al. were combined, along with information
92
provided in ICRU Report 74 (ICRU, 2005), to esti-
mate the relationship between effective diameter
and the linear dimensions (AP and lateral) of the
torso. Figure 8.7a shows the relationship between ef-
fective diameter and the AP dimension; a
second-order polynomial function was used to fit the
relationship. Figure 8.7b illustrates the effective
diameter as a function of the lateral dimension. For
these data, the shape of the torso in cross-section
was assumed to be elliptical, and the area was com-
puted from the major and minor radii, which in turn
are related to the AP and lateral dimensions of the
patient. Figures 8.7a and 8.7b are taken from AAPM
report 204 (AAPM, 2011), and these curves (with
associated equations) allow the estimation of effect-
ive diameter when either the AP dimension or
lateral dimension of the patient is known.
Lateral and AP dimensions can be obtained
from a projection image of the patient, which is
routinely acquired prior to the actual CT scan. This
image is used to set up the subsequent CT scan;
for instance, the technologist can mark the super-
ior and inferior edges of the CT acquisition using
the patient’s anatomy as a landmark. The projec-
tion image is acquired using the CT hardware,
but without gantry rotation as the patient is
translated through the x-ray beam on the CT
couch. This projection image has many trade-
marked names, such as the scout view, the scano-
gram, or the topogram; however, generically this
image is referred to as the localizer or the digital
projection radiograph.
The primary utility of the relationships illu-
strated in Figures 8.7a and 8.7b in the clinical CT
setting occurs when the localizer view has been
acquired, but the CT scan has not yet been
 Patient Size-Specific Dose Estimation

Figure 8.7. Effective diameter as a function of linear dimensions of the torso. The points represent data reported in Boone et al. (2003),
Kleinman et al. (2010), and ICRU Report 74 (ICRU, 2005). A second-order polynomial provides an approximate fit (solid line). (a) The
effective diameter as a function of the AP dimension. (b) The effective diameter as a function of the lateral dimension (fit is solid line).

initiated. For the localizer view, the AP dimension
can be measured from a lateral localizer scan, and
the lateral patient dimensions can be evaluated in
a PA view. By determining the AP or lateral dimen-
sion of the patient on the localizer view, the effect-
ive diameter of the patient can be estimated. As
will be shown below, these values can then be used
to estimate a conversion factor that in turn can be
used to compute the SSDE (AAPM, 2011) for the
patient prior to the commencement of the CT scan.
In principle, this method would allow the technolo-
gist to predict inappropriately high patient doses
prior to the CT scan, and make technique adjust-
ments to reduce the absorbed dose.
It is recognized that the localizer view on the CT
scanner is a projection image produced in fan-beam
geometry, and therefore some magnification in the
image is present. If the patient is not properly cen-
tered in the gantry, the linear dimensions mea-
sured on the image will be less accurate because of
the magnification. CT manufacturers have access
to the attenuation data measured during a localizer
view, and these data could also be used to compute
a more accurate estimate of patient size. However,
this information is proprietary to each vendor, and
achieving a common metric across vendors using
attenuation measurements is not likely.
In most clinical settings when dose estimates are
required (after the CT scan), the CT image itself
should be used for the determination of patient
size. Unlike the localizer images, the CT image
dimensions are accurate in all three dimensions.
Although the lateral and the AP linear dimensions
can be measured on an axial CT image using soft-
ware tools available on all modern CT scanners,
the preferred approach for estimating size is to
measure the area of the patient’s body directly
from the cross-section of the CT image. A relatively
simple approach for estimating the area of a
patient’s cross-section is described below.
The automated assessment of the effective diam-
eter from an axial CT image is relatively straight-
forward. The dimensions of a given pixel (Dx, Dy)
are found in the DICOM header, and the pixel area
is computed: Ap ¼ Dx  Dy. In the CT image, the
HU of water is approximately 0, and the range of
HUs in most soft tissues ranges from about 2200
to þ200; however, the HU for lung tissues can be
much lower, and the HU of bone is much higher.
Air surrounds the body and is also present in the
lung and in some body cavities. To calculate the ef-
fective diameter from a single CT image, an algo-
rithm can be used to evaluate each HU value in
the image, and tally only those pixels that exceed a
certain threshold value, G. Although for air, HU
; 2 1000, the HU of air in some regions of the
image internal to the body can be higher than
21000 due to x-ray scatter and other artifacts, sug-
gesting that a threshold value slightly higher than
21000 should be used to segment tissues from air.
A computer algorithm that counts the number of
pixels in the image exceeding a threshold value G
(such as G ¼ 2800) can be used to segment body
tissues from air. In this algorithm, N is first set to

93
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
zero, and then:
yP
max xP
max
if ðimageðx; yÞ . GÞ; N ¼ N þ 1;
y¼0 x¼0
where G is the threshold value, image(x,y) is the
HU value for pixel (x,y), and the summation is per-
formed over the entire CT image. It is understood
that N ¼ N þ 1 refers to indexing the counter vari-
able N when the if condition is true. The number of
pixels, N, exceeding the threshold value in the CT
image is then multiplied by the area per pixel, Ap,
to compute the total cross-sectional area, A, of the
segmented body region in that CT image,
A ¼ N  Ap :
The effective diameter is then computed from the
segmented body area:
rffiffiffiffiffiffiffi
4A :
def f ¼ shape for the human torso. The use of dw is pre-
p ferred over deff, in general, especially for the thorax.
This procedure is relatively robust, but it tends to
include the CT table as part of the body area; in
practice, this results in a small positive bias in the
estimate of the effective diameter. One of the lim-
itations of this procedure is that in some cases the
body area in the CT images is truncated, that is,
part of the patient’s anatomy is outside of the
reconstructed CT image. In such cases, the method
described above will underestimate the effective
diameter. However, it might still be possible to
evaluate either the lateral or AP dimension of the
patient, which then can be used in the estimation
of body size.
In some CT images (e.g., chest), an appreciable
amount of internal air is contained within the body
dimensions; however, air does not attenuate x rays
appreciably, and therefore the external dimensions
of the body will overestimate the attenuation of
that axial section of the body. To compensate for
this, the water-equivalent patient diameter can be
used.
The assessment of the water-equivalent patient
diameter, dw, requires an additional step in the al-
gorithm described above for deff. Essentially, the
average density of the pixels in the image that are
flagged as being tissue (when HU . G) is also
tallied:
8 corrections that are global and are not performed
yP
max xP
max < N ¼ N þ 1;
if ½imageðx; yÞ . G; HU þ 1000 :
y¼0 x¼0 :X ¼ X þ
1000
In this case, for pixels other than for air, the
average pixel density relative to water is
ð8:1Þ X
Pave ¼ : ð8:5Þ
N
Note that if in Eq. (8.4), HU ¼ 0 for all pixels (cor-
responding to water), then the average density Pave
would be unity. The water-equivalent patient diam-
eter, dw, is given by
rffiffiffiffiffiffiffi
4A
dw ¼ Pave : ð8:6Þ
p
Figure 8.8 illustrates this case for cylindrical
ð8:2Þ PMMA (r ¼ 1.19 g/cm3) phantoms with diameters
ranging from 100 mm to 320 mm. The estimation of
deff or dw for the patient from area measurements
made from the CT image is a direct measurement;
however, the estimation of deff from the lateral or
AP dimensions assumes a characteristic (elliptical)
ð8:3Þ
Another consideration regarding patient dimen-
sions relates to where along z should the effective
diameter be measured. To study this, data from a
cohort of patients were evaluated, and the average
diameter of the patient [using Eq. (8.3)] for each
CT image over the entire length of the scan was
compared against the diameter of one CT image at
the midpoint of an abdominal-pelvis CT scan.
Figure 8.9a illustrates this relationship for the
most prevalent CT examination, the abdomen –
pelvis scan. Although good correlation exists
between these two dimensions of body size, there is
concern about the 4.7 cm offset seen in the data.
Assuming that the average diameter is the superior
quantity as it takes into consideration all of the CT
images in the scan, these data suggest that the
midpoint diameter for an abdomen –pelvis CT scan
is not the best value to use for the SSDE.
Figure 8.9b illustrates the average-diameter versus
midpoint-diameter relationship for the abdomen-
only component of the CT scan, and here better
agreement is seen, with no offset and an insignifi-
cant 2.6 % difference in slope. Figure 8.9c illus-
trates this relationship for the pelvis component of
the CT scan, and an even better agreement is seen
with no offset and a slope of essentially 1.0.
The data shown in Figure 8.9a indicate that
there should be some concern when using SSDE
on a CT slice-by-slice basis in the abdomen –pelvis
exam. This bias is considered significant, and
further research is necessary to evaluate if the
ð8:4Þ midpoint diameter of the patient is sufficiently
94
 Patient Size-Specific Dose Estimation
Figure 8.8. The assessment of the water-equivalent diameter. (a) An axial CT image of a small PMMA phantom. (b) The
water-equivalent diameter as a function of actual PMMA diameter. The higher density of PMMA relative to water accounts for the
slight upward bias of the data relative to the line of identity.
robust for SSDE assessment in abdomen –
pelvis CT.
8.4 Size-Specific Dose Estimates
The combined data from the numerous studies
described in Section 8.2 have been evaluated to
develop a relationship between a dose-conversion
factor and the effective diameter of the patient. As
described by Turner et al. (2010), when size-
dependent scaling factors were normalized by the
CTDIvol, many of the dependencies on scanner
type, bow-tie filter, and x-ray-tube potential were
effectively factored out. Therefore, the data used as
input to this analysis were individually normalized
by CTDIvol, and then combined. If the CTDIvol was
specifically reported, it was used for the normaliza-
tion. For the data illustrated in Figure 8.10 (for a
tube potential of 120 kV), if CTDIvol data were not
available, the individual curves were normalized to
a value of 1.09 for a 320 mm diameter patient. This
factor of 1.09 [see Eq. (4.3)] converts from air
kerma to absorbed dose in water, recognizing that
CTDIvol is measured in air, whereas the desired
dose information is for a water-equivalent patient.
The data points in Figure 8.10 show very similar
trends; however, there is greater dispersion in the
data at smaller effective diameters. This is in part
due to the fact that the normalization point is at
320 mm. The best-fit curve of the points is the solid
black line. The dashed line also plotted represents
the results of AAPM Report 204 (AAPM, 2011),
which was derived from 8 of the 12 data sets shown
95
here (specifically, the top eight data sets as indi-
cated in the key in Figure 8.10). The difference
between the AAPM Report 204 trend line and that
developed from this more inclusive database is very
small, and—given the dispersion in the data—the
differences are clearly insignificant. Therefore, the
use of the curve as published in AAPM Report 204
is recommended.
The data illustrated in Figure 8.10 are for a tube
potential of 120 kV. The data shown in Figure 8.11a
correspond to the average absorbed dose as a func-
tion of effective diameter for x-ray-tube potentials
ranging from 80 kV to 140 kV, with each curve nor-
malized to a setting of 100 mA s (Zhou and Boone,
2008). As expected, for the same “mAs” setting,
higher tube potential leads to higher air-kerma and
absorbed-dose levels. The average absorbed dose
for smaller patients is higher than for larger
patients, consistent with the results of Figure 8.10.
Figure 8.11b shows the curves for 80 kV to 140 kV,
but normalized to 1 mGy of air kerma at the iso-
center of the scanner. This normalization causes
the four curves to essentially collapse on one
another. Figure 8.11c shows the average absorbed
dose as a function of the effective diameter, but
here each curve is normalized by the CTDIvol
assessed for the 320 mm diameter phantom. The
curves in Figure 8.11c also show significant
overlap, with better overlap at larger effective dia-
meters and more dispersion at smaller effective
diameters. Based upon the plots shown in
Figures 8.11b and 8.11c, normalization to the air
kerma at isocenter results in the best agreement
among these four curves. However, such air-kerma
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 8.9. Diameter at the midpoint versus average diameter.
(a) The midpoint diameter of patients from the abdomen–pelvis
CT scan, as a function of the average patient diameter computed
from the diameter measured for each CT slice in the scan. The
solid line represents the fit, Dmidpoint ¼ 1.1631 Dave – 4.7437. (b)
The diameter at midpoint as a function of average diameter for
the abdomen component of the CT scan. The solid line
represents the fit Dmidpoint ¼ 1.0255  Dave. (c) The diameter at
midpoint versus average diameter for the pelvic component of
the CT scan. The solid line represents the fit Dmidpoint ¼
0.9996  Dave.
96
Figure 8.10. The conversion coefficient as a function of effective
diameter for a 32 cm diameter phantom. The points are from 12
different studies, as described in Section 8.2: Mc-Si, McCollough/
Siemens; Mc-GE, McCollough/General Electric; MG-Si,
McNitt-Gray/Siemens; MG-Ph, McNitt-Gray/Philips; MG-GE,
McNitt-Gray/General Electric; MG-To, McNitt-Gray/Toshiba;
TS-Mx, Toth-Strauss/mixed scanner manufacturers; ZB-GE,
Zhou-Boone/General Electric; B-G-S-G, Boone et al./General
Electric; HD-cxr, Huda, General Electric Chest CT; N-GE,
Nickoloff/General Electric; N-Si, Nickoloff/Siemens. The solid
line represents the best fit to the data points; the dashed line is
the curve reported in AAPM Report 204 (AAPM, 2011).
data are typically not available to the operators of
CT scanners, except from a physicist’s report. The
normalization procedure using CTDIvol (Figure 8.10)
is considered adequate, and the CTDIvol is more
widely available. The trends shown in Figure 8.11a
and 8.11c illustrate that when normalized by
CTDIvol, the dose dependence on x-ray-tube poten-
tial is well accounted for. This means that one
general curve corresponding to conversion coeffi-
cients as a function of deff (or dw) can be used for dif-
ferent types of CT scanners (e.g., see Figure 8.10),
operating at different tube potentials (e.g., see
Figure 8.11).
Figure 8.12, taken from AAPM Report 204, shows
dose-conversion coefficients as a function of effective
diameter for the situation in which the 160 mm
PMMA phantom was used for the assessment of
CTDIvol. Because the small phantom is often used to
assess pediatric body imaging, the ages correspond-
ing to different effective diameters are illustrated on
this figure as well. As mentioned in AAPM Report
204, deff or preferably dw should be used to compute
the dose-conversion coefficient when this value is
known. In the absence of knowledge of deff or dw, age
can be used as a secondary parameter for absorbed-
 Patient Size-Specific Dose Estimation

Figure 8.11. Average absorbed dose as a function of the effective diameter. (a) For four different tube potentials and 100 mA s on the
General Electric VCT scanner (Zhou and Boone, 2008). (b) Data of Fig. 8.11a normalized by the air kerma at isocenter of the scanner.
(c) Data of Fig. 8.11a normalized by the CTDIvol for the 320 mm PMMA phantom.

dose estimates. The diameter-versus-age information
used in Figure 8.12 was described in ICRU Report 74
(ICRU, 2005).
8.5 Summary
The data from a number of investigators have
been combined and show that for the same CT
technique factors, the average absorbed dose is
higher for smaller patients. The curves shown in
Figures 8.10 and 8.12 clearly demonstrate these
trends. The CTDIvol is reported for air; however,
the dose-conversion coefficients to obtain SSDE
include the f-factor, fSI, from air to water absorbed
dose. The SSDE dose-conversion coefficients also
include the fact that abdomen scans are longer
(200 mm to 300 mm) than the 100 mm scan length
that is the basis for CTDIvol (i.e., taking into con-
sideration the discussion of H(L) in Section 7), at
least for the eight studies that contributed to the
AAPM Report 204 data that are recommended for
use in this Report. The SSDE values were computed
for the center of the scan field along the z axis, and
the absorbed doses at the edges of the field will be
slightly lower (see Figures 7.9 and 7.10). The SSDE is
considered to be more accurate than CTDIvol, and
allows a relatively straightforward assessment of
absorbed dose in patients. The coefficients provided in
Table 8.1 describe the equations to convert CTDIvol to
SSDE when the deff or dw of the patient is known. A
more complete discussion of the SSDE concept is
available in AAPM Report 204 (AAPM, 2011).

97
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 8.12. The conversion factor as a function of effective
diameter for a 160 mm PMMA phantom. These data are useful
when the CTDIvol is reported for a clinical study for the 160 mm
phantom. The relationship between age and effective diameter
is indicated by the vertical lines, with the age information data
taken from ICRU Report 74 (ICRU, 2005).
In some CT-scanning modes, there are limita-
tions in the application of the SSDE using a single
image for estimating patient size for a given
98
Table 8.1. The mathematical relationships between the effective
diameter (deff ) and the lateral dimension (LAT) or the AP
dimension of a CT image. The linear fit relating deff to the sum
of the LAT and AP dimensions is also provided
deff ¼ 2 3.744858 þ 1.671734  (AP)} 2 0.01338955  (AP)2
deff ¼ 5.899298 þ 0.3270494  (LAT) þ 0.00978896  (LAT)2
deff ¼ 2 0.203128 þ 0.4958912  (AP þ LAT)
Note: The coefficients are given to from six to eight decimal
places to maintain computational accuracy in the evaluation of
these polynomials.
protocol (such as chest, abdomen, or pelvis). When
x-ray-tube-current modulation is used, the tube
current and hence the absorbed dose in the patient
can vary appreciably along the z axis of the
patient, depending upon how the patient diameter
varies along the z axis. In patients with large longi-
tudinal variations in girth, a single, global estimate
of effective diameter will be insufficient to compen-
sate for the range of diameters interrogated by the
x-ray beam and thus the different absorbed-dose
levels that will be realized. In this case, a
CT-image-by-image approach to size estimation is
necessary. This will be discussed in Section 9.
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
9. Automatic Exposure Control in CT
9.1 Introduction
Up until the early 2000s, whole-body CT scan-
ners required manual selection of technique factors
such as the tube potential, tube current, time, and
pitch. Recognizing that the automatic-exposure
control (AEC) features used so successfully in radi-
ography could play an important role in CT, manu-
facturers developed a number of vendor-specific
AEC techniques. AEC systems not only adjust tech-
nique factors to accommodate to the overall physic-
al size of the patient being scanned, they also can
dynamically accommodate for differences in the
x-ray beam path-length through the patient during
gantry rotation and while scanning along the
z axis. Although the use of manually selected tech-
nique factors is still common in some circum-
stances, AEC with tube-current modulation (TCM)
has become standard practice in CT imaging.
Helical (spiral) CT, combined with the use of dy-
namically adjusted technique factors, adds to the
complexity of dose assessment, the topic of this
Section. The overall function of automatic exposure
control in CT was described in Section 2.4.2. Here,
the operation is described in the context of absorbed
dose in the patient. Automatic exposure control
applies to two general aspects of CT technique selec-
tion: overall exposure control and tube-current modu-
lation. These features will be discussed sequentially.
9.2 Automatic Exposure Control
The basic AEC feature has the effect to increase
the overall dose levels for large patients and de-
crease the dose levels for smaller patients, in order
to deliver comparable image quality for both. As
with all x-ray imaging, it is the x-ray intensity
striking the detector that governs the statistics in
the image. To penetrate larger patients and thicker
body parts, the incident x-ray beam intensity needs
to be increased for an appropriate x-ray intensity to
reach the detector. For smaller patients, the x-ray
beam intensity can be reduced, and for small pedi-
atric patients, the dose levels thus can be reduced
considerably.
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/nds009
Figure 9.1a is a schematic of a phantom with five
different object diameters, ranging from 10 cm to
32 cm in diameter. This phantom was used to
examine the automatic adjustment of overall dose
levels for two different CT scanners, a Siemens AS þ
system and a General Electric VCT system. These
two scanners were selected because they utilize fun-
damentally different concepts in TCM. Figure 9.1b
illustrates the automatically selected “mAs” levels for
the Siemens system, over the range of phantom dia-
meters. This system uses the concept of reference
“mAs” as its primary AEC control parameter. The
reference “mAs” is selected by the CT operator to
deliver an expected image quality (essentially noise
levels) to a standard-sized patient. For a given refer-
ence “mAs,” if the patient diameter is larger or
smaller than the reference patient diameter, the
system will increase or decrease radiation levels, re-
spectively. In both cases, the goal is to provide the
same image quality (signal-to-noise ratio) over a
range of different patient sizes. In Figure 9.1b, it is
seen that for a given reference “mAs,” the actual
tube current selected in the AEC mode is adjusted
depending upon the diameter of the phantom. The
relative adjustment as a function of phantom diam-
eter is constant across the reference “mAs” settings.
Figure 9.1c illustrates the control scheme used by
General Electric scanners that make use of the
noise index as their primary AEC parameter. The
noise index is related to the standard deviation of
CT numbers in the CT image, and therefore is a
control parameter that focuses more on the noise in
the image than on a technique factor per se. It is
observed that the slope of the curves in Figure 9.1c
is negative, and that the slope of the curves for the
Siemens scanner in Figure 9.1b is positive, as a
function of their respective AEC parameters. The
ramifications of this are clear: for Siemens scanners,
the reference “mAs” parameter is turned up with
the result to increase the absorbed dose, and for
General Electric scanners, the noise index param-
eter is turned down with the result also to increase
the absorbed dose.
The trends illustrated in Figures 9.1b and 9.1c
represent the overall AEC control of the CT
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 9.1. Illustration of tube-current modulation. (a) The so-called “wedding-cake” phantom. The individual section diameters are
10 cm, 13 cm, 16 cm, 20 cm, and 32 cm. (b) The x-ray-tube-current–time product resulting from the automatic exposure control on a
Siemens scanner, as a function of the reference “mAs”. (c) The x-ray-tube-current –time product resulting from the automatic exposure
control used by General Electric as a function of the noise index.

scanner, as the phantoms used were cylindrical

and homogeneous along the z axis, except for the
discontinuities between sections of the phantom.
The overall AEC control is essentially a one-
parameter approach (either reference “mAs” or
noise index) for the overall dose levels from a given
CT scanner; however, the x-ray-tube potential is an
independent parameter that also plays a role in
dose and image quality.

9.3 Angular Tube-Current Modulation

The second component of automatic exposure
control in CT is x-ray TCM. X-ray TCM changes
the air-kerma rate by modulating the tube current
to accommodate for the varying thickness of the
body part being scanned. There are two compo-
nents to tube-current modulation, an angular com-
ponent that is active as the gantry rotates and
affects the image-noise distribution in the x – y
plane, and a longitudinal component that adapts to
the changing body dimensions as the patient is
translated through the field of view along the z
axis. Figure 9.2 illustrates both the angular and
longitudinal components of tube-current modula-
tion (see also Section 2.4.3). The cross-sectional
shape of patients tends to be more elliptical than
circular, and the angular TCM adjusts the x-ray-
tube current to accommodate for the differences in
x-ray path-length. Typically, the lateral dimension
of the patient is greater than the anterior–posterior
distance, and the tube-current modulation would
increase the tube current as the beam is penetrat-
ing the lateral dimension and reduce it in the AP
dimension. This is a very rapid process, as the
Figure 9.2. Angular TCM levels and the cumulative impact on
the tube-current –time product as a function of the position for a
specific patient. Angular modulation of the x-ray-tube current
occurs as the x-ray tube rotates around the patient, producing a
high-frequency, approximately sinusoidal variation in air-kerma
rate. TCM also has a lower-frequency component as the patient
is translated through the x-ray beam.
entire gantry rotation period is typically 0.50 s,
so TCM is performed at approximately kilohertz
frequencies. The modulation process leads to a rela-
tively homogeneous distribution of x-ray photon
fluence striking the detector during gantry rota-
tion, which in turn reduces unnecessarily high
absorbed-dose levels (for smaller projection path-
lengths) and is an important component of dose op-
timization. The approximately sinusoidal modula-
tion seen in Figure 9.2 represents the angular (i.e.,
x – y) modulation of tube current. Along the length
of the patient, the patient dimensions change de-
pending upon the body habitus. In Figure 9.2, the
patient has a relatively thin abdomen with larger

100
 Automatic Exposure Control in CT
hips, so the x-ray-tube current was increased over
the hips and was slightly decreased through the
torso. The x-ray-tube current was also reduced
through the thoracic region due to the low density
of the lungs, and increased near the patient’s
shoulders.
Tube current is modulated to account for the
average tissue path in the entire CT beam width
(in z), and for scanners with wide x-ray beams this
means that modulation of the tube current will be
performed over wider swaths of tissue (in z). The
temporal response of TCM along the z dimension of
the patient will therefore be slower for wider x-ray
beams (e.g., 80 mm), compared with narrower beam
collimation (e.g., 20 mm). For situations in which
the z-axis coverage is easily addressed (e.g., ample
x-ray-tube power exists and patient motion is un-
likely), CT operators might in some cases choose to
reduce the x-ray-beam thickness (e.g., use 20 mm
collimation on a 40 mm scanner) through protocol
selection to allow tube-current modulation to be
more adaptive to body contours.
9.4 Patient Dose Assessment with TCM
The assessment of the size-specific dose estimate
(SSDE) is straightforward when TCM is not uti-
lized and when the patient diameter is relatively
uniform over the scan length. In such case, the
CTDIvol can be used with the known water-
equivalent diameter of the patient to compute the
SSDE. In the following, data from abdomen –pelvis
CT scans performed on 227 patients on a single CT
scanner (Siemens ASþ) will be used to illustrate
the challenges of CT dosimetry when TCM is used.
When constant tube current, J, is used throughout
the entire CT scan and for a constant water-
equivalent patient diameter, dw, the SSDE can be
computed as
SSDE ¼ fd32D
w
32
 CTDIvol ; ð9:1Þ
where fd32D
w
is the coefficient from AAPM Report 204
(AAPM, 2011) for a water-equivalent diameter of dw,
derived from the tables in Report 204 (hence the “D”
in the superscript nomenclature) for the 32 cm diam-
eter phantom. The CTDI32 vol is the CTDIvol reported
by the CT scanner; for this adult-abdomen applica-
tion, all scanner manufacturers use the 32 cm diam-
eter phantom as reference, and that is indicated
explicitly here in the superscript.
For a situation in which the x-ray-tube current is
constant, but the body region of the patient has
variable diameter along the scan length, the SSDE
101
is estimated according to
SSDE ¼ fd32D
w
32
 CTDIvol : ð9:2Þ
Here, the average water-equivalent diameter, dw , is
assessed along the length of the scan. Alternatively,
the water-equivalent diameter of a representative
CT slice along the scan length can be used (see
Section 8.3). Equation (9.2) should be sufficiently
accurate for SSDE when TCM is not used; however,
it is recognized that there is a non-linear relation-
ship between the fdw coefficient and diameter that
can lead to a reduction in accuracy when significant
fluctuations in diameter occur along the scan length
of the patient.
The use of TCM is common in CT imaging of the
torso, as well as in the head and neck regions.
When TCM is used, a more accurate estimate of
the SSDE can be made if a slice-by-slice evaluation
of dw is made and the tube-current–time product
for each CT image is known. In this case, the
SSDE is determined using
PN
i¼1
fd32w ½i C32 Ji Dt
SSDE ¼ : ð9:3Þ
pN
Here, the summation over i includes the total
number of CT slices in the scan, N; the coefficient
fd32D
w[i]
is determined from the water-equivalent
diameter of the patient for each CT image i; the
average tube current for slice i is Ji, the
gantry-rotation period is Dt, and the helical pitch is
p. The product Ji Dt is the “mAs,” and the product
Ji Dt p21 is the effective “mAs.” The factor C 32 is
the conversion coefficient that the specific CT
scanner uses to compute CTDI32 vol from the effective
“mAs,” and depends on CT manufacturer, pitch,
collimation settings, x-ray-tube potential, bow-tie
and other filters, and other more subtle factors.
Figure 9.3 shows the linear relationship between
CTDIvol and effective “mAs”, and the slope of this
curve (0.0674 in this case) is essentially the param-
eter C 32 in Eq. (9.3).
9.5 Examples of Slice-by-Slice CT Dose
Calculation
When TCM is used, and when the patient has a
relatively non-uniform distribution of diameters
along the scan length, Eq. (9.3) will yield a more
accurate SSDE than using the simpler assumption
of constant or average tube current for a scan. For
implementation of Eq. (9.3) to be practical, auto-
mated software is needed to extract the pertinent
information from the DICOM header on each CT
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

image, and an automatic determination of the dw is
necessary for each CT image (see Section 8.3). To
realize the potential of this approach, software was
Figure 9.3. The CTDIvol as a function of effective “mAs” (J 
Dt  p 21) for one scanner (Siemens Definition ASþ), from 227
data sets. The slope of this curve (0.0674) determines the
relationship between the CTDIvol and effective “mAs” for this
scanner, for a particular tube potential and bow-tie filter.
developed to perform the SSDE calculation when
current-tube modulation is used.
Figure 9.4 illustrates such software. The entire
series of CT images in a patient scan is read into
computer memory, and the pertinent DICOM
header information is extracted. The CT data itself
are used to generate the PA (box 1 in Figure 9.4)
and lateral data (box 2) projections, illustrated in
the upper right of Figure 9.4. The effective “mAs”
is displayed in the lower left plot (box 3), and it is
observed that large variations in the effective
“mAs” were used in this CT scan. The lower middle
panel (box 4) illustrates the equivalent diameter
assessed from CT images along the length of the
scan. From this, the fdw conversion factor for the
SSDE estimate was computed from the average
diameter of each CT slice. Once the effective diam-
eter is known, the fdw conversion factor is computed
analytically from equations given in AAPM Report
204, which expedites this calculation. The com-
puted SSDE is shown plotted as a function of z on
the lower right panel (box 5).
This software was used to evaluate parameters on
227 patients, and a number of trends can be

Figure 9.4. The output of a program written to evaluate the slice-by-slice characteristics of an abdominal-pelvic CT scan. The CT
images were used to generate the AP (box 1) and lateral (box 2) projection images shown. The three plots illustrate (box 3) the effective
“mAs,” (box 4) the water-equivalent patient diameter, and (box 5) the SSDE as a function of CT-slice position along the z axis. For each
of the four sections A, B, C, and D on each plot, summary statistics are provided in the data box in the upper left of the display.

102
 Automatic Exposure Control in CT
identified as illustrated in Figures 9.5 through 9.9.
The study involved the use of one CT scanner for
one CT protocol (abdominal-pelvis examination),
with automatic exposure control (including tube-
current modulation). Figure 9.5 illustrates, as is to
be expected, that the effective “mAs” of the scan
tracks reasonably well with the average patient
diameter. The CTDIvol also tracks quite well with
patient diameter, as shown in Figure 9.6a. This
figure illustrates that under the simplified condi-
tions of this one-scanner/one-protocol study,
changes in the CTDIvol can be largely attributed to
patient diameter coupled with automatic exposure
control. The R 2 value of 0.77 in Figure 9.6a suggests
Figure 9.5. The effective “mAs” as a function of average patient
diameter. These data were acquired using tube-current
modulation. The effective “mAs” increases non-linearly as a
function of average patient diameter, typical of TCM techniques
on any modern CT scanner.
Figure 9.6. (a) The CTDIvol as a function of average patient diameter. Tracking with the effective “mAs” (as shown in Fig. 9.5), the
CTDIvol increases as a function of patient diameter. (b) The residual differences between the actual values and the curve fit (in
Fig. 9.6a). The mean residual value is 0.0 mGy, and the standard deviation is 4.88 mGy.
103
that 77 % of the variance can be attributed to
patient diameter; the residuals between the mea-
sured data and best-fit line are illustrated in
Figure 9.6b. The variance of the CTDIvol in
Figure 9.6a is 55.2 mGy2, and the variance in
Figure 9.6b is 12.96 mGy2, confirming the 77 % re-
duction in variance ([55.2 2 12.96]/55.2 ¼ 0.77).
Relative to the CTDIvol, the SSDE tends to be
larger for smaller patients, and smaller for larger
patients. Figure 9.7 shows the SSDE as a function
of CTDIvol; lower values of CTDIvol correspond to
smaller patient diameters (as seen in Figure 9.6a),
and the lower CTDIvol values for smaller diameter
patients are associated with higher SSDE conver-
sion coefficients. The increase in SSDE relative to
CTDIvol is shown as a function of average patient
diameter in Figure 9.8. For patients whose diameter
is smaller than 25 cm, the relative dose increase
(i.e., SSDE/CTDIvol ) is from 50 % to 60 % on
average, and for patients whose diameter is about
30 cm, the relative dose increase is about 20 %.
Patients in the 35 cm to 45 cm range in diameter
have a small dose reduction.
The data were further evaluated as shown in
Figure 9.9, where the ratio of the average pelvis
diameter to the average abdomen diameter was
assessed for male and females in the cohort of CT
patients. A significant difference in the ratio is
seen; women tend to have lower abdomen/pelvis
diameter ratios, and men have characteristically
larger ratios. These trends substantiate the very
general observation that men tend to gain weight
in their abdomen whereas women tend to carry
weight in their hips. These trends have gender-
dependent ramifications on dose assessment when
tube-current modulation is used.
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 9.7. The SSDE as a function of CTDIvol. The dashed line
of identity is shown. As expected, the SSDE is higher than the
CTDIvol (i.e., is above the line of identity) for smaller patients,
and it is only slightly lower for larger patients.
Figure 9.8. The variation of the SSDE relative to CTDIvol as a
function of patient average diameter.
9.6 Organ-Dose Estimation
Organ-by-organ dose assessment is considered by
many to be the ultimate dose assessment; a com-
plete description of organ doses is necessary for the
actual computation of effective dose, using (for
example) the tissue-weighting coefficients from
ICRP Publication 103 (ICRP, 2007). Although over
the years, there have been many efforts using
Monte Carlo calculations in three-dimensional
phantoms to determine organ dose, the methods for
computing SSDE on a slice-by-slice basis described
above demonstrate that a practical tool for the esti-
mation of absorbed dose on a slice-by-slice basis is
presently available. It is further suggested that al-
though Monte Carlo dose assessment is essential in
104
Figure 9.9. The ratio of the average abdomen diameter to the
average pelvis diameter for two populations, males and females.
A significant difference ( p , 0.05) is observed, demonstrating
that men and women tend to have different body-shape
characteristics.
CT in general, it is impractical and unnecessary to
use Monte Carlo techniques on a patient-by-patient
basis, especially when x-ray-tube modulation tech-
niques have been used. It is, however, possible to
extend the slice-by-slice dose-assessment approach
described above (see Figure 9.4) to the estimation of
organ absorbed doses, with the assumption that the
relative organ position along the z axis of the
patient can be characterized by a parameter Yorgan.
The organ positions can be scaled relative to boney
anatomy, and thus the organ distributions along z
would be based on a geometric rescaling of a specific
patient’s CT-based anatomy to a standard organ
template produced by assessing organ positions
over a large cohort of patients. With the assumption
that such a rescaling has been performed, organ
dose can be estimated using
P
N organ
Dorgan ¼ fD32w ½i Yz½i C32 Ji Dt p1 ; ð9:4Þ
i¼1
where Yorgan
z is a dose-weighting function describing
the contribution of organ dose at position z for each
organ of interest (liver, kidney, bladder, etc.) from
the average absorbed dose in the plane at the z pos-
ition corresponding to the index value i. Figure 9.10
illustrates this concept. Note that z[i] need not be a
linear function of i. Examples of realistic boney
landmarks in the torso include the superior edge of
the clavicle, the sternum, the pelvic crest, or any
vertebral body. All other terms in Eq. (9.4) have
been described previously.
Using center and peripheral CTDI100 values
averaged over tube potential (from 100 kV to
 Automatic Exposure Control in CT
Figure 9.10. A torso with boney landmarks, and with associated
representative organ positions. Using an organ-weighting
system (Yorgan
z ), determined from a large patient cohort but
scaled to each individual patient, estimation of individual organ
doses would be possible even when AEC is used for a patient
with a non-uniform diameter distribution along z.
140 kV) and across four manufacturers’ systems1
(ImPACT, 2004), the periphery-to-center CTDI100
ratio in the 160 mm diameter head phantom is 1.08
(COV ¼ 2.8 %), and for the 320 mm diameter body
phantom the ratio is 1.98 (COV ¼ 7.5 %). Thus, the
weighting functions, Yorgan
z , would have to take into
consideration the average in-plane position of the
organ, from center to edge; however, this is likely
to be a second-order effect relative to the organ’s
position along the z axis. Furthermore, most
organs are positioned neither at the center nor at
the extreme periphery, and so radial ( periphery-
to-center) averaging is already included in the com-
putation of CTDIw from CTDIcenter100 and CTDIperi100 .
These observations suggest that there might be
little dependence on organ position in the (x – y)
1
General Electric VCT, Philips Brilliance, Siemens’ Definition
AS, and Toshiba Aquilion Multi.
105
plane, and that the z-dependent Yorgan
z is sufficient-
ly robust to provide a good estimate of each organ’s
dose when the average planar dose to each individ-
ual CT section is known. Further research is
needed to evaluate if one-dimensional (i.e., along z)
organ-distribution functions can produce accurate
estimates of organ dose in CT.
9.7 Summary
CT dosimetry has had to adapt rapidly to
changes in CT-scanner capabilities. Although con-
stant-tube-current protocols are still used for
some applications, AEC techniques in CT lead to
dynamically adjusted x-ray-fluence rates during
the entire procedure in the majority of CT proto-
cols. Dosimetry under these conditions is most ac-
curate when the effective “mAs” for each CT slice
generated in the image series is considered separ-
ately, and size corrections using the SSDE can
then address both the specific x-ray-tube output
for each CT image, as well as the water-
equivalent diameter of the patient at that z pos-
ition. Although simpler methods such as using
one CT image at the middle of the CT scan to es-
timate patient size can deliver reasonable esti-
mates for some scan protocols, or assuming that
an average tube current was used over the entire
scan, a slice-by-slice approach to individual
patient dosimetry will likely yield the most accur-
ate dose estimate possible at this time. Such an
approach requires software that evaluates each
CT image in the CT scan. If such software is not
available, other methods for dose assessment
when AEC modes are employed will be adequate
to determine SSDE in most clinical settings.
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
10. Spatial Resolution in CT
10.1 Introduction
Spatial resolution is an important attribute
of any radiological imaging system. In CT,
spatial resolution depends not only upon physical
parameters such as the focal-spot size and detector-
element dimensions similar to projection radiog-
raphy, but—because all CT images are reconstructed
mathematically—the resolving power of a CT image is
fundamentally linked to the image-reconstruction
methods as well. In addition to traditional filtered-
back-projection-reconstruction algorithms, which
utilize a variety of reconstruction kernels that have
a profound impact on spatial resolution, iterative
CT image-reconstruction techniques using statistic-
al or model-based constructs are also used clinically.
These non-linear, adaptive algorithms create a chal-
lenging mathematical environment for objectively
characterizing spatial resolution.
10.2 Basic Spatial-Resolution Metrics
Spatial resolution refers to the ability of an
image to convey detail; medical imaging systems
produce images that are usually degraded in detail
compared with the actual object being imaged.
With respect to a volumetric CT data set, the
imaging process can be described mathematically
by the three-dimensional (3D) spatial convolution
ð1 ð1 ð1
Iðx; y; zÞ ¼ Vðx0 ; y0 ; z0 Þ
z0 ¼1 y0 ¼1 x0 ¼1
 PSF3D ðx  x0 ; y  y0 ; z  z0 Þdx0 dy0 dz0 :
ð10:1Þ
Here, the input object, V (x, y, z), is defined in
three spatial coordinates, and the CT data set
resulting from the imaging procedure is given here
by I(x, y, z). The 3D point-spread function PSF3D(x,
y, z) describes the 3D-resolution properties of the
imaging system. Because CT images are mathemat-
ically reconstructed, the spatial resolution is
enhanced in some cases by the use of specific
kernels used for CT-image reconstruction, which
operate over a finite range of spatial frequencies.
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/ndt001
An ideal stationary imaging system is the one in
which the PSF3D is constant over the entire
imaging field of view, and most medical imaging
systems approximate this ideal. However, due to
the acquisition geometry of whole-body CT systems,
the attributes of the PSF3D vary in the axial (x – y)
plane compared with the longitudinal (z) axis. To
characterize the 3D PSF, consider a phantom con-
struct of a very small metal sphere surrounded by
a homogeneous material (such as water) as shown
in Figure 10.1. If the metal sphere has dimensions
that are much smaller than the voxel dimensions,
then it approximates a 3D delta function, d(x, y, z).
For an image acquired of this phantom, the PSF3D
can be assessed simply as
ð1 ð1 ð1
PSF3D ðx; y; zÞ ¼ dðx0 ; y0 ; z0 Þ
z0 ¼1 y0 ¼1 x0 ¼1
 PSF3D ðx  x0 ; y  y0 ; z  z0 Þdx0 dy0 dz0 :
ð10:2Þ
Equation 10.2 states that if a delta function
(i.e., the small sphere) characterizes the object to
be imaged, the image produced after acquisition
represents the PSF3D. Although a fully 3D charac-
terization of the PSF3D is a desirable goal for
most tomographic imaging technologies, the acqui-
sition geometry of CT suggests that separating the
axial (x – y) and longitudinal (z) components of
spatial resolution should be useful from a practical
standpoint.
Figure 10.2a illustrates ideal input functions to a
two-dimensional imaging system, and Figure 10.2b
illustrates the degraded (blurred) output images. In
addition to the point-spread function, other spatial-
domain spread functions (Bushberg et al., 2012;
Dainty and Shaw, 1974; Hsieh, 2003; Kalender,
2011) can be used to quantify the spatial resolution
in computed tomography. Figure 10.2c illustrates
the point-spread function (PSF), the line-spread
function (LSF), and the edge-spread function
(ESF). All of these spread functions have been used
to measure spatial resolution in computed
tomography.
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 10.1. Measurement of the 3D MTF. A small
high-contrast sphere placed in the center of a homogeneous
phantom provides a 3D delta function, d(x, y, z), as a stimulus to
a CT system for characterization of the PSF3D(x, y, z).
There is a relationship between the point-spread
function and the line-spread function. Let the x
and y axes define the axial plane, and z the longitu-
dinal or long-axis of the scan (or patient’s body).
The axial-plane line-spread function can be deter-
mined by integration of the point-spread function:
ð1 ð1
LSFaxial ðxÞ ¼ PSF3D ðx; y; zÞdydz: ð10:3Þ
z¼1 y¼1
Because the axial (x – y) plane is rotationally sym-
metric, LSF(x) ¼ LSF(y), in general. However, in
some cases (including CT imaging), the two dimen-
sional PSF(x, y) can be anisotropic, and in such a
case the LSF will be dependent upon the angular
orientation of the two-dimensional PSF(x, y) with
respect to the x – y coordinate system.
The edge-spread function can be determined by
the integration of the axial line-spread function:
ðx
ESFaxial ðxÞ ¼ LSFaxial ðx0 Þdx0 ; ð10:4aÞ
x0 ¼1
and conversely,
d functions
LSFaxial ðxÞ ¼ ESFaxial ðxÞ:
dx
Equations (10.3), (10.4a), and (10.4b) illustrate that
the family of spread functions, the point-spread
function, the line-spread function, and the edge-
spread function, are related and that any one of
them can be used to assess the resolution of a CT
system in the axial plane.
The PSF, LSF, and ESF are functions that de-
scribe resolution in the spatial domain. However, it
is common to transform these functions into the
spatial-frequency domain, to obtain the
modulation-transfer function, MTF. The MTF is
typically computed from the line-spread function
(axial or longitudinal) using the Fourier transform:
Ð 1 
 2pifx x
dx
1 LSFðxÞe
MTFð fx Þ ¼ Ð1 ; ð10:5Þ
1 LSFðxÞ dx
where here fx represents spatial frequency. The in-
tegral in the denominator of Eq. (10.5) normalizes
the MTF to unity at fx ¼ 0. If the PSF or ESF is
measured directly in CT, these functions can be
transformed into the LSF using Eqs. (10.3) or
(10.4b), respectively, for subsequent assessment of
the MTF. Although analytical computation of the
MTF from the LSF is possible in some cases, Eq.
(10.5) is evaluated in most cases by a computer
subroutine.
10.3 Assessment of Axial-Plane Resolution
in CT
In the earliest days of computed tomography,
Judy (1976) used a slanted-edge approach to deter-
mine the edge-spread function (Figure 10.3). The
slanted edge provided the ability to oversample the
edge-spread function, and overcome the Nyquist1
limitations imposed by the CT-image pixel dimen-
sions. In Report 1 of the American Association of
Physicists in Medicine Report series (AAPM, 1976),
it was noted that a number of established techni-
ques for characterizing spatial resolution could be
adapted to CT scanners. These approaches included
(a) wedge or spoke-type modulation-transfer func-
tion phantoms, (b) edge-response functions, and (c)
the impulse response (i.e., PSF) from a small wire.
Although direct measurement of the line-spread func-
tion using slit images was not mentioned, this tech-
nique is a straightforward extrapolation of methods
used in radiography, and will be discussed below.
Point-response functions were studied (Bicshof
and Ehrhardt, 1976) by scanning 0.15 mm diam-
eter stainless-steel wires, to produce point-spread
in reconstructed CT images.
ð10:4bÞ
Two-dimensional-Fourier-transform techniques were
used to compute the two-dimensional MTF(fx, fy)
from these point-spread functions. These investiga-
tors also studied the dependence of the MTF on the
position in the field, and found virtually no depend-
ence (see Figure 10.4a) on the parallel-beam CT
scanner studied. The inverse Fourier transform of
the two-dimensional MTF was computed to produce
a point-spread function, and the profile through
that PSF is shown in Figure 10.4b. The negative-
1
The Nyquist frequency (fN) is the highest frequency that can be
described in an image with linear pixel dimension s, and is
given by fN ¼ 1/(2 s).
108
 Spatial Resolution in CT

Figure 10.2. Illustration of the spread functions used in imaging. (a) Input images (left to right) defining the point-spread function
(PSF), the line-spread function (LSF), and the edge-spread function (ESF). (b) Simulated degraded-output images showing raw image
data used for the measurement of the PSF, LSF, and ESF. The blurring seen in these functions is due to the imperfect resolution
properties of the imaging system being characterized. (c) Graphs showing the actual PSF, LSF, and ESF. The PSF(x,y) is a 2D function,
and the LSF(x) and ESF(x) are 1D functions.

side lobes seen in Figure 10.4b are the result of
the edge-enhancement features of the convolution
kernel used for filtered-back-projection reconstruc-
tion (Bushberg et al., 2012).
In the early work of Schneiders and Bushong
1=2
(1980), the technique of Judy was used with a
custom computer program to compute the edge-
spread function from an image. The ESF was dif-
ferentiated numerically, producing the line-spread
function. Fourier transform of the LSF resulted in
the (complex) optical-transform function, whose
modulus is the modulation-transfer function. This
study was an early demonstration of computer-
based numerical methods for the calculation of
spatial-resolution in CT.
Other investigators (Nickoloff and Riley, 1985)
developed an interesting approach toward charac-
terizing the spatial resolution of CT. They assumed
that the point-spread function could be approxi-
mated by the Gaussian distribution:
2
ðrrc Þ2
PSFðrÞ ¼ ea ; ð10:6Þ
where rc is the center position of the PSF.
Rearrangement of the above equation and substi-
tuting b ¼ 2arc gives

1
a r þ b ¼ ln : ð10:7Þ
PSFðrÞ
Using this approach, point-spread-function data
were plotted as shown in Figure 10.5a. Data points
along a straight line describe a point-spread func-
tion that is strictly Gaussian, whereas deviation
from the straight line suggests non-Gaussian be-
havior. The slope of the line shown in Figure 10.5a
is the value of a in Eq. (10.7), determined by linear
regression. By inserting the value of a into
Eq. (10.6), the point-spread function is obtained
(see Figure 10.5b).
Before the existence of modern-day picture
archiving and communication systems (PACS),
access to the digital-image data from a CT scanner
or any other digital-imaging modality was limited,
and the CT-image-file format was often proprietary.

109
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 10.3. Early MTF characterization in CT by Judy (1976). (a). By angling an edge of PMMA in water by a small angle (u) relative
to the image pixel array, the sampling interval D was decreased geometrically, producing a smaller sampling interval cD. For this work,
u ¼ 1.28 and c ¼ 0.02. (b) The ESF computed from the oversampled edge. (c) The MTF computed from the LSF (determined by
numerically differentiating the ESF). This scanner had a cut-off frequency of about 0.30 mm21 at 5 % MTF.

In many cases, the only output was a film image. is computed as

However, many CT scanners had basic image-
processing tools available at the console, such as
the ability to measure the mean and standard devi-
ation of the HU in a user-placed region of interest.
Droege and Morin (1982) capitalized on the avail-
ability of these tools for the estimation of the MTF.
Figure 10.6a illustrates a CT image of a line-pair
phantom designed for use in CT. The modulation
M0 is determined by the expression
jHU1  HU2 j
M0 ¼ ; ð10:8Þ
2
where HU1 and HU2 correspond to the mean CT
numbers of the bars and of the background mater-
ial, respectively. The frequency-dependent MTF(f )
pffiffiffi
p 2 Mð f Þ
MTFð f Þ ¼ ; ð10:8Þ
4 M0
corresponding to the discrete frequency f of each
bar pattern, where f ¼ (2B)21 for bars of width B.
Note that four different bar patterns are seen in
Figure 10.6a. Figure 10.6b illustrates the excellent
agreement between the Droege –Morin MTF
method and that using a conventional method
(using the PSF from stainless-steel wires). The
Droege –Morin approach allowed the practical esti-
mation of the MTF in CT in the pre-PACS era.
Although the use of wires to generate PSF and
edges to generate ESF profiles have been used ex-
tensively, planar layers of metallic foil can be used
to measure the LSF directly (Boone, 2001). In this

110
 Spatial Resolution in CT

Figure 10.4. Resolution measurements on an early CT scanner. (a) Bischof and Ehrhardt (1977) characterized the PSF in the CT field
of view, and the MTFs were computed at several locations. (b) An assumed symmetrical PSF was computed from the two-dimensional
MTF measurements.

Figure 10.5. Resolution assessment using a Gaussian model. (a) The analysis concept devised by Nickoloff and Riley (1985), as
described in the text. When the PSF data plotted in this manner fall on a straight line, the CT system demonstrates a PSF that can be
characterized by a Gaussian function. (b) The Gaussian PSF derived from the slope of the line in (a).

procedure, a sheet of metallic foil sandwiched General Electric Lightspeed 16 scanner.

between two tissue-equivalent slabs for rigidity
(see Figure 10.7a) was imaged at a slight angle
with respect to the pixel array in the CT image.
Imaging a plane on-edge produces an axial image
with a line or slit running through it (see
Figure 10.7b). From these slit images, a pre-
sampled line-spread function (see Figure 10.7c) can
be synthesized (Boone, 2001; Bushberg et al., 2012),
and the pre-sampled MTF can be computed from it.
The measured LSF and MTF plots in Figures 10.7c
and 10.7d are for three different kernels for a
Considerable edge enhancement is apparent for the
lung kernel, where the MTF values substantially
exceed unity at mid-frequencies.
An alternative approach to generating a slit
image is to use an air gap instead of a metallic foil,
creating a negative-polarity line-spread function
instead of a positive-polarity line-spread function
(Uto et al., 2012). The phantom is illustrated in
Figure 10.8a, and consists of two tissue-equivalent
slabs separated at the edges by a thin layer of
paper. The CT image of this is inverted

111
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 10.6. MTF analysis using a bar phantom. (a) The method described by Droege and Morin (1982) made use of the basic image
analysis tools available on CT scanners in the early 1980s, with regions of interest located on a bar phantom as shown. The mean and
standard deviation of the HU in each region of interest were used to compute the MTF. (b) The MTF measured using the Droege–
Morin method compares well with the more conventionally (i.e., wire PSF) measured MTF curve.

mathematically, creating the line-spread functions,
illustrated in Figures 10.8b and 10.8c, for two dif-
ferent reconstruction kernels. The MTFs from this
method are compared with those using the alumi-
num foil in Figure 10.8d (standard kernel) and in
Figure 10.8e (bone kernel). Although some system-
atic bias is apparent, the MTFs from these two
phantoms are quite similar.
For routine quality control in the clinical envir-
onment, bar patterns designed specifically for CT
are commonly used (see Figures 10.9a and 10.9b).
This technique allows the user to determine the
limiting spatial resolution subjectively, by visual in-
spection. Although this technique is adequate for
spot checking the resolution properties of a CT
scanner in the field, the evaluation of the
modulation-transfer function is considered to be a
more rigorous assessment of the resolution proper-
ties of the CT scanner.
10.3.1 Limitations and Concerns in
Axial-MTF Assessment
As mentioned in Section 10.2, a stationary
imaging system is one in which the point-spread
function is constant over the field of view. Modern
fan-beam and cone-beam CT systems are only ap-
proximately stationary, as there are differences in
the PSF from the center to edge in the recon-
structed image, and there is a slight angular de-
pendence as well. Therefore, the location of the
measurement of spread functions (and the
subsequent calculation of the MTF) needs to be
referenced and/or made in a consistent manner
using similar regions in the image.
All modern CT scanners make use of filtered
back projection (FBP), and many also utilize itera-
tive reconstruction techniques. There are a number
of iterative algorithms in common use among the
commercial CT vendors, but most of the details of
these algorithms are proprietary. Nevertheless, in
general, iterative algorithms can exhibit non-linear
behavior that violates the measurement paradigm
(i.e., a linear, stationary system) for the MTF.
Specifically, iterative reconstruction methods can
produce images in which the MTF exhibits a greater
or lesser dependence on spatial location (in compari-
son to FBP) as well as a dependence on the contrast
(difference in HU) of the material forming the edge.
Commercial CT scanners for medical applications
are designed to optimally image tissue, which
spans a range in Hounsfield units from about 2200
to þ200. Tissues and non-tissue materials encoun-
tered outside this range can produce unwanted
effects on image quality, chiefly high-density
objects of high atomic number (Z) that produce
artifacts and non-linear responses. Therefore, reso-
lution templates and phantoms that make use of
either high-Z or very dense materials can drive the
scanner into non-linear regions of operation. The
effect of dense or high-Z materials can also cause
beam hardening, another source of non-linearity in
the reconstructed image. These observations
suggest that phantoms for the measurement of

112
 Spatial Resolution in CT

Figure 10.7. MTF analysis using an aluminum slit. (a) A thin Al foil is compressed between two tissue-equivalent blocks, and is aligned
parallel to the z axis, with a slight angle with respect to the x– y plane. (b) The image from which the LSF is deduced. (c) The LSF
synthesized using the angled-slit method, for three reconstruction kernels. (d) The corresponding MTF curves for the three kernels.

spatial resolution should employ relatively low-Z
materials or foils thin enough to not exceed the
linear operating range of the scanner. A contrary
observation, however, is that high-Z or dense mate-
rials produce edges or lines with a high signal-to-
noise ratio, which helps to produce high-precision
MTF measurements. At the very minimum, HU
saturation should be avoided by not exceeding the
12-bit HU range between 21024 and þ3095. A
histogram plot of Hounsfield units for the image
where spatial resolution is to be measured can
verify that HU saturation has not occurred.
Quantum noise tends to degrade the precision
and accuracy of measurements of spatial resolution.

113
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 10.8. An inverse-contrast slit method employing an air slit. Some results are compared with those from an aluminum slit as
described in Figure 10.7 (from Boone, 2000). (a) An air gap created between two pieces of solid phantom using paper spacers. (b) The
LSF determined from the air slit (AS) and the aluminum slit (Al), for the standard kernel. (c) The LSF determined from the air slit
(AS) and the aluminum (Al) slit for the bone kernel. (d) The MTFs assessed for the standard kernel. (e) The MTFs assessed for the
bone kernel.

Figure 10.9. Resolution assessment using the American College of Radiology CT phantom. (a) An image from the resolution section of
the ACR Phantom, reconstructed with the standard kernel on a General Electric VCT system. (b) The same raw data as in (a) but
reconstructed with the bone kernel, which has higher spatial resolution compared with that using the standard kernel.

To reduce the influence of quantum noise, tube- images are recommended, but with the following
current and exposure-time settings that give the considerations. The x-ray-tube focal spot can experi-
flexibility to use the small and large focal spots of ence blooming effects (an increase in apparent size)
the x-ray tube and yet provide high-precision at very high tube-current settings, and thus the use

114
 Spatial Resolution in CT
of the highest tube-current settings is not recom-
mended unless these settings are used clinically.
Large-diameter phantoms tend to increase the noise
levels in the reconstructed image due to their
greater attenuation. Therefore, it is desirable to
characterize spatial resolution using a relatively
small-diameter phantom. When the ESF is used to
measure spatial resolution, differentiation [Eq.
(10.4b)] to produce the LSF (which leads to the
MTF) adds considerable noise to the LSF profile,
whereas integration of the PSF to produce the LSF
[Eq. (10.3)] acts to reduce noise. These considera-
tions also have an impact on the choice of method-
ology used for MTF characterization in CT.
Historically, spatial resolution in CT has been
described in units of cycles per centimeter or line
pairs per centimeter (i.e., cm21); however, with the
improved spatial-resolution capabilities of modern
scanners, it is recommended that cycles per milli-
meter (i.e. mm21) be used instead in all forums of
discussion, including the scientific literature and
commercial, technical, and sales documents.
10.4 Resolution Along the z Axis
The z-axis resolution in CT has improved signifi-
cantly with the introduction of MDCT scanners. In
the era of single-slice CT scanners, slice thicknesses
used for clinical imaging were typically 5 mm,
7 mm, or 10 mm, depending upon the clinical appli-
cation. On occasion, thinner slices, such as 1 mm or
2 mm, were used for specialty applications. As the
voxel thickness dimension was on the order of from
10 to 20 times that of the in-plane pixel dimensions,
the slice-sensitivity profile was used to characterize
spatial resolution (essentially the line-spread
function).
Gagne (1989) studied the shape of the slice-
sensitivity profile and the air-kerma profile, both ex-
perimentally and mathematically. Samples of these
Figure 10.10. Slice-sensitivity profiles. A comparison is made between a geometric model (solid line) and the measured sensitivity
profile (symbols) for the z axis (see Gagne, 1989), for nominal CT slices between 8 mm and 10 mm. (a) For the General Electric 9800
scanner. (b) For the Siemens DR/H CT system. (c) For a stationary-detector CT system, the Picker 1200.
115
profiles are shown in Figure 10.10 for representative
single-slice CT scanners of the late 1980s, for colli-
mated slice thicknesses ranging from 8 mm to
10 mm. A mathematical model of the slice-sensitivity
profile was also developed (solid lines in
Figure 10.10a–10.10c; see also Section 6.2).
With the advent of helical (spiral) CT, Hu and Fox
(1996) developed analytical equations corroborated
by physical experiments to describe the slice-
sensitivity profiles in single-slice helical scanners
(see Figure 10.11a). Profiles with different colli-
mated slice thickness are shown in Figure 10.11b.
These investigators also computed the modulation-
transfer function for the z-axis resolution, calling it
the longitudinal MTF (see Figure 10.11c).
Figure 10.12a shows a diagram of a common geo-
metric strategy used to estimate slice thickness. A
number of evenly spaced small attenuating rods are
aligned diagonally in a phantom, and a CT scan is
acquired of this array. Visual inspection of the CT
image allows the number of rods in the image to be
counted (see the drawing in Figure 10.12b). For
the American College of Radiology (ACR) CT-
accreditation phantom, each rod corresponds to
0.5 mm of slice thickness. For example, counting 10
rods in the image then results in an estimate of a
5.0 mm slice thickness. Figure 10.13a through
10.13d illustrates CT images from the actual ACR
phantom, for different thicknesses. This determin-
ation of slice thickness allows rapid subjective as-
sessment of slice thickness for routine quality
assurance or for spot checking CT systems in the
clinical environment. Although adequate for these
purposes, the determination of the line-spread func-
tion along the z axis with subsequent conversion to
the longitudinal MTF is considered to be a more
rigorous quantitative evaluation of the longitudinal
spatial resolution.
Thin-section single-detector-array axial-CT acquisi-
tion provides well-sampled data for CT-image
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 10.11. Measurements of slice-sensitivity profiles and the longitudinal MTF. (a) A comparison between measured data (symbols)
and model predictions (lines) for different collimations (from Hu and Fox, 1996). (b) The impact of x-ray-beam collimation on the
slice-sensitivity profile, for a helical acquisition on a single-detector-row CT scanner. (c) The z-axis (or longitudinal) MTF from the
slice-sensitivity profiles.

Figure 10.12. Phantom-based determination of CT slice

thickness. (a) A standard geometry using an angled wire or series
of beads or rods to estimate the effective slice (section) thickness.
(b) The slice thickness is estimated by counting the number of
objects seen. For example, the ACR Phantom has rods placed
0.5 mm apart (in z), and thus for M visible markers, the slice
thickness Ts is assessed as Ts ¼ 0.5 mm  M.

Figure 10.13. Images of the ACR phantom for CT scans

reconstruction with a negligible cone angle (see
Section 2.1 and Figure 10.14a). With the advent of
multiple-detector-array CT (MDCT) scanners, the
cone angle is larger for the peripheral detector
arrays, and this leads to under-sampling in z, which
violates the so-called Tuy data-sufficiency condition
(Tuy, 1983). For example, for a 64-detector-array CT
system with 0.625 mm detector-array widths, a
40 mm collimated slice thickness is used. The periph-
eral detector arrays in this configuration (using the
General Electric VCT scanner geometry as an
example) are 20 mm away from the center of the
reconstructed at several nominal slice thicknesses. Slice
thickness of (a) 2.5 mm, (b) 3.75 mm, (c) 5.0 mm, and (d) 7.5 mm.
detector array, and with the source-to-isocenter dis-
tance of 541 mm the cone angle for the edge detector
arrays is 2.168 or 37.6 milliradian (see Figure 10.14b).
With contiguous axial scanning, the data in the
central array are well sampled in z (i.e., meets Tuy’s
data-sufficiency condition), but the edge arrays do not
fully meet this condition. This can give rise to cone-
beam artifacts that can distort the LSF(z).

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 Spatial Resolution in CT

Figure 10.14. CT-acquisition geometry in the z dimension. (a) A single-detector-array, axial-scan geometry has a negligible cone angle,
and therefore there is complete sampling along the z dimension for contiguous SDCT scanning. (b) An MDCT system has a small
half-cone angle of approximately from 18 to 48, depending on the scanner configuration, which results in a slight under-sampling in the
z dimension for both axial and helical scans. (c) Full-cone-beam scanners, such as the Toshiba Aquilion 320, or flat-panel-based CT
systems make use of large cone angles; the severe under-sampling in the z dimension can give rise to cone-beam artifacts.

Full-cone-beam CT scanners are available that
use very wide cone angles for axial acquisition; for
example, the Toshiba Aquilion 320 makes use of a
160 mm wide array of detectors along z, such that
the edge detectors (see Figure 10.14c) have a cone
angle approaching 88. Flat-panel-based CT scanners
used in dental, orthopedic, and breast-imaging appli-
cations also have very large cone angles, in some
cases exceeding 208. With both MDCT and
full-cone-beam CT systems, the resolution along the z
axis has increased dramatically compared with what
was practical with single-detector-array CT systems,
and this has been accompanied by much shorter
scan times as well. Nevertheless, the increased z-axis
resolution has also given rise to the potential for
cone-beam and other artifacts stemming from under-
sampling in z. Due to these considerations, CT reso-
lution along the z axis for MDCT and cone-beam CT
scanners can have substantial spatial dependence
(non-stationarity).
10.5 Modern Resolution Metrics in CT
The voxel dimensions of a CT image are no
longer measured in fractions of a centimeter, but
rather in fractions of a millimeter. With this in
mind, it is reasonable to use methods in CT that
have been used to characterize spatial resolution in
digital radiography systems, with the need to also
address the 3D nature of the CT volume data set.
As mentioned in Section 10.1, a fully 3D character-
ization of the spatial resolution of a CT scanner is
possible, yielding the PSF3D(x,y,z). One approach
would be to use a large high-contrast sphere em-
bedded in a homogeneous material as shown in
Figure 10.15a. Such a phantom provides edges in
all three orthogonal dimensions, which can be used
to characterize the resolution in each dimension.
Although there is potential utility in the computa-
tion of the 3D MTF, the parameters that influence
the axial (x – y) resolution in CT tend to be quite
different from those that influence the longitudinal
(z) resolution. For this reason, separate resolution
measurements of the axial and longitudinal compo-
nents are typically performed. In both cases, the
line-spread function serves as a basis from which
to calculate the MTF.
10.5.1 Axial-Plane Resolution
It is straightforward to generate a line image in
CT by scanning a high-contrast (thin foil) plane of
material encompassed in a cylindrical phantom;
this is illustrated in Figure 10.15b and is pictured
in Figure 10.15c. This phantom comprises 100 mm
diameter PMMA, and has two sections: on top, the
cylinder was cut down the center and machined
flat, and a thin metal foil was placed between the
two halves. The bottom section is homogeneous
PMMA, but placed vertically between the two
cylinders is another metal foil. The upper section of
the phantom is used to measure the LSF in the
axial (x – y) plane, and the foil separating the two
cylinders vertically is used to measure the LSF in
the coronal (x –z) plane (effectively the same as the
sagittal plane).

117
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 10.15. Phantom for measuring MTF in both axial and azimuthal planes. (a) A high-contrast sphere embedded in a homogeneous
phantom allows the edge-spread function to be evaluated in any plane: the axial (x–y), the coronal (x–z), and the sagittal (y–z). (b) A
phantom composed of a flat, thin metal foil embedded in a 100 mm PMMA cylinder has orthogonal planes of foil for measuring the
MTFxy and the MTFz. (c) A photograph of the phantom schematized in (b), with a half-cylinder removed for demonstration.

Figure 10.16a illustrates a CT image of the top
section of the MTF phantom, showing a bright line
where the metal foil was placed between the two
half-cylinders. The oversampled LSF (Boone, 2000;
Bushberg et al., 2012) was computed from the ROI
shown in Figure 10.16a, with the result illustrated
in Figure 10.16b. The Fourier transform is taken of
the LSF data, and after normalization the MTFs
were computed for three different reconstruction
kernels, with the resultant MTFs shown in
Figure 10.16c.
10.5.2 z-Axis Resolution
Resolution assessment along the z axis requires
a point, line, or edge running nearly perpendicular
to the z axis. Figure 10.15a illustrates a sphere
embedded in a homogeneous phantom, and—as
mentioned above—this approach provides edges in
all dimensions. However, for MDCT or cone-beam
CT systems with large cone angles used during ac-
quisition, evaluation of the LSF(z) can be fraught
with artifacts. The alternative method demon-
strated in Figure 10.15b makes use of a thin metal
foil placed between two cylinders of PMMA. A
coronal image showing this foil as a bright line is
shown in Figure 10.17a. The cylindrical phantom is
slightly angled with respect to the axis of rotation
in order to produce a slight angle in the vertical
line of Figure 10.17a relative to the (x, z) pixel
array in this coronal image. This angulation allows
for the synthesis of the oversampled LSF, and
these data allow the computation of the pre-
sampled MTF as shown in Figure 10.17b for three
different reconstructed slice thicknesses.
10.6 Summary
Spatial resolution is a very important component
of image quality, requiring thorough and robust
processes to characterize and quantify the
performance of CT scanners. Although the assess-
ment of spatial resolution in the clinical environ-
ment is qualitatively managed by visual inspection
of images of bar or wedge phantoms (see
Figure 10.9), scientific characterization of the
spatial resolution in CT should make use of the
MTF. The MTF can be determined in a number of
different ways, through the measurement of the
point-spread function, the line-spread function, or
the edge-spread function, with appropriate manipu-
lation of the data as discussed in this Section. The
in-plane (axial) MTF, or MTFxy, for a reconstructed
image in a CT volume data set has similar reso-
lution in the x and y dimensions, allowing for radial
averaging. The longitudinal MTF, or MTFz, is com-
puted and interpreted separately from the MTFxy.
For simplicity and consistency, the oversampled
line-spread function approach is preferred, as
described in Sections 10.5.1 and 10.5.2, and shown
in Figures 10.7b, 10.16a, and 10.17a. In most
cases, spatial resolution should be measured using
high-dose-technique settings to achieve low-noise
images. Due to the high attenuation in large
diameter phantoms, small-diameter phantoms
(such as the 100 mm diameter phantom pictured in
Figure 10.15c) are useful to achieve higher-preci-
sion measurements of the MTF at a given tech-
nique setting. The CT-acquisition parameters
described in Table 10.1 provide guidance in these
respects. If the MTF with the small x-ray-tube
focal spot is to be measured, the tube current
should be reduced and the scan time increased to
enable small-focal-spot acquisition.
Most clinical CT-scanner systems now have avail-
able iterative-reconstruction techniques using stat-
istical or model-based reconstruction algorithms.
Images reconstructed using these methods, as
opposed to FBP, will demonstrate adaptive smooth-
ing in a manner that is dependent upon the specific
reconstruction algorithm. The adaptive behavior of
these algorithms implies that the LSF (and MTF)

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 Spatial Resolution in CT

Figure 10.16. MTFs measured in the axial plane for an MDCT system. (a) A CT image of the top section of the phantom (see
Figure 10.15b) showing a line corresponding to the metal foil in the phantom. The box indicates the region of interest in which the data
points for the LSF were measured. (b) An oversampled LSF synthesized from the data in the box shown in (a). (c) MTFs shown for
different kernels on a General Electric 16-slice Lightspeed system.

Figure 10.17. Longitudinal MTFs measured on a modern MDCT system. (a) A coronal image of the phantom pictured in Figure 10.15c.
The longitudinal MTF is computed from vertical profiles sampled in the box shown. (b) The longitudinal MTFz shown for three slice
thicknesses. Smaller reconstruction thicknesses increase the spatial resolution in the z dimension.

will change depending on the local anatomy in the
patient, depending on both position (x, y, z) and
contrast (signal difference) in the reconstruction.
For iterative reconstruction, the spatial dependence
of the MTF can be greater or less than in FBP;
some iterative methods have been developed specif-
ically to yield a PSF that does not vary in space
and others allow the PSF to vary. In the latter
case, the spatial variation violates basic assump-
tions of stationary behavior, reducing the meaning-
fulness of the MTF as a “global” metric. Similarly,
iterative-reconstruction methods often involve
adaptive, signal-dependent smoothing and regular-
ization that impart a dependence of the MTF on
the contrast (difference in attenuation coefficient)
of the material forming a given edge. For example,

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 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Table 10.1 Recommended parameters for the measurement of Recognizing these complexities in the spatial-
the MTF in CT. resolution characteristics of non-linear iterative re-
construction and the lack of a single “global” reso-
Parameter Value Tolerance or
note
lution metric, the MTF should be characterized in
a manner that is explicitly “local,” i.e., local in both
Tube potential 120 kV (typical) 80 kV to 140 kV location and contrast level.
Tube current 500 mAa +100 mA Given these constraints, it is recognized that
Time 1 sa +0.25 s characterizing the MTF of a CT scanner using the
Display field of view 200 mm +20 mm filtered-back-projection-reconstruction mode repre-
Phantom diameter 100 mm +5 mm
Phantom composition PMMA or other plastic
sents a reasonable estimate of the spatial resolution
materials of that scanner, but the local nature of the MTF
Number of lines in LSF 20-50 (about Zero padded to should be recognized. Furthermore, in most clinical
50 mm long) N ¼ 256 CT applications that employ iterative-reconstruc-
Angle of line to pixel 18 to 58 tion techniques, the iterative-reconstruction images
matrix
are combined with filtered-back-projection images
a
If the MTF for the small focal spot is being measured, the tube in a weighted manner (20 % iterative/80 % FBP,
current will need to be decreased to allow small-focal-spot 30 %/70 %, etc.), which can further complicate spe-
operation, and the rotation time can be increased to compensate. cification and emphasizes the need for rigorous
reporting of measurement conditions, reconstruc-
high-contrast edges can result in an evidently tion methods, and analysis techniques (including
higher MTF than that with low-contrast edges. dependence on location and contrast).

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Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
11. Noise Assessment in CT
11.1 Introduction
Image noise comes from a number of sources, in-
cluding structure noise due to slight pixel-to-pixel
response variations in electronic-detector systems,
additive electronic or “shot noise” from detectors
and other electronic components, grain noise in
film, and quantum noise that generally decreases
as the x-ray fluence (and consequent patient
dose) in the imaging procedure is increased.
Although all noise is undesirable, some noise can
be corrected for. For example, structure (or
so-called fixed-pattern) noise can be easily cor-
rected in digital-detector systems by using flat-field
image-correction techniques (Bushberg et al.,
2012). Grain noise in film is not an issue for digital-
detector systems, including CT. Electronic noise is
usually addressed by advanced detector and circuit
design, or by using detector-cooling techniques.
Quantum noise is fundamentally a statistical prop-
erty associated with the limited number of detected
quanta that are used to form an image.
11.2 Basic Noise Metrics
Figure 11.1 illustrates the basic concepts of
signal, noise, and the signal-to-noise ratio (SNR). It
has been known for many decades (Rose, 1973;
Brooks and Chiro, 1976; Burgess, 1999) that the
SNR plays a fundamental role in the detectability
of an object on a noisy background. In Figure 11.1a,
a circular signal is positioned in the center of a
noisy image. Idealized distributions of the signal
and background regions are illustrated in
Figure 11.1b. The noise distributions within the
object and in the background are characterized by
normal distributions defined by their standard
deviations, s, with the lateral shift between the
two distributions corresponding to the signal amp-
litude, js1  s2 j. The “Rose Criterion” (Rose, 1973)
states that when SNR  5 for an object, it will be
reliably detected. This SNR concept can be
extended to the frequency domain as well (see
Wagner and Brown, 1982), which expands the
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/ndt002
analysis to include the noise texture (described
below) and the shape of the object to be detected.
The contrast-detail (CD) image (see Figure 11.2a)
is a construct that allows for the subjective evalu-
ation of contrast resolution of an imaging system,
and CD diagrams have been used extensively in CT
(Cohen and DiBianca, 1979). Figure 11.2b illus-
trates an early example of a CD diagram that
shows differences in the performance of two differ-
ent models of General Electric CT scanners. The
CD test object presents disks that in the image
vary in diameter horizontally, and vary in contrast
vertically; the disk in the lower left is the smallest
size and with the lowest contrast, and the upper-
right disk is the largest size and with the highest
contrast. The SNR is maximal in the upper right
and decreases to the left and downward on the
diagram. The CD diagram (Figure 11.2b) shows
several curves that define the line of demarcation
between disks that can be seen from those that
cannot. Curves that extend further to the left in
the CD diagram demonstrate imaging systems that
have better spatial resolution (e.g., the General
Electric CT/T 8800 versus the earlier General
Electric CT/T 7800 model), and lines that extend
further down on this CD diagram demonstrate
imaging systems that have better contrast reso-
lution. For example, the higher dose (50 mGy)
curve in Figure 11.2b extends further down than
does the 12.5 mGy curve, because increasing the x-
ray-fluence levels decreases the quantum noise and
improves the ability to see objects that have
smaller contrast levels.
Although the signal-to-noise ratio is an important
parameter in determining the detectability of an
object, the SNR does not completely characterize
noise. Figure 11.3 shows two images with exactly
the same noise level as measured by the standard
deviation, s; however, these two images have dra-
matically different appearances to the observer. The
differences between Figure 11.3a and 11.3b are due
to the noise texture; that is, the spatial-frequency
distribution of the noise is different in these two
images. In direct analogy with sound from a piano,
although the volume is the same in these two
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 11.1. Basic concepts of signal and noise. (a) A circular signal region located in the center of a noisy image. The detectability of
this disk is related to its signal-to-noise ratio. (b) The concepts relevant to the signal (s2 – s1) to noise (s) are illustrated. These idealized
curves (measured curves would be noisier) are computed from histograms of the gray-scale values in the signal and background regions
shown in (a).

Figure 11.2. Contrast-detail curves. (a) Image of a traditional CD phantom, for which the diameter of each disk decreases from right to
left and the contrast of the disks decreases from top to bottom. (b) An early depiction of the CD diagram for two different General
Electric CT scanners, the CT/T 7800 and the CT/T 8800. Adapted from Wagner et al. (1979).

images, Figure 11.3a typifies noise produced by keys
on the left side of the piano (low-frequency sound),
and Figure 11.3b typifies noise produced by keys
further to the right on the piano (higher-frequency
sound). With audible sound, the frequencies are
temporal frequencies measured, say, in units of s21,
whereas in images, the frequencies are spatial fre-
quencies, in mm21.
11.3 The Noise-Power Spectrum, NPS(f )
The noise-power spectrum (NPS) is a useful
measure that provides a more complete description
of noise than the simple standard deviation; it
describes the noise variance as a function of spatial
frequency and therefore characterizes noise
texture. When combined with dosimetric quan-
tities, it can be used for comparisons among scan-
ners and among protocols, and has been shown to
be useful in translating protocols from one CT plat-
form to another (Soloman et al., 2012). The
primary source of noise correlation in CT is essen-
tially the point-spread function, PSF3D, discussed
in Section 10. In MDCT imaging, the 3D point-
spread function induces noise correlation in all
three spatial dimensions. Because CT images are
produced by mathematical reconstruction (e.g.,

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 Noise Assessment in CT

Figure 11.3. Noise texture: the spatial-frequency distribution of the noise. Both images are from a Siemens CT scanner and have the
same standard deviation (s ¼ 21.5 HU); hence, the noise is equal in the two images. The different appearance of the two images is due
to the different reconstruction kernels used (Boedeker et al., 2007). (a) An image reconstructed using a B10 kernel, a low-pass kernel,
producing noise texture with lower-spatial-frequency noise. (b) An image reconstructed using a B50 kernel. The B50 kernel is a
high-pass kernel, producing CT images with greater spatial resolution but also with higher-frequency noise.

Figure 11.4. The noise-power spectrum, NPS. The solid curves represent an analytical prediction, and the open circles represent the
corresponding computer simulation. Adapted from Riederer et al. (1978). (a) The noise-power spectrum for a Hanning filter, where fN is
the Nyquist frequency. (b) The noise-power spectrum for a ramp filter.

filtered back projection), the PSF depends not only
on acquisition parameters such as focal-spot size
and detector dimensions, but also on the selection
of reconstruction parameters, principally the recon-
struction kernel and the CT-slice thickness.
The autocorrelation function describes noise cor-
relation in the spatial domain. The Fourier trans-
form of the autocorrelation function is the so-called
Wiener spectrum (Dainty and Shaw, 1974; Faulkner
and Morres, 1984), also known as the noise-power
spectrum, NPS. In the context of a two-dimensional
(2D) region of interest (ROI), let Ii (x,y) be the signal
in the i th ROI with I being the mean of Ii (x, y).
Then, the 2D NPS is computed as
1X N   and computer-simulated NPSs for the Hanning
NPSð fx ; fy Þ ¼ DFT2D ½Ii ðx; yÞ  Ii 2 Dx Dy
N i¼1 Nx Ny ;
ð11:1Þ
where the summation over i (and multiplication by
N 21) refers to averaging the NPS values over N
ROIs. The values of D correspond to the pixel spacing
(i.e., spacing between pixel centers in x or y) in a
given plane. Nx and Ny are the number of voxels in
each dimension of the ROI used in the computation.
The terms fx and fy are here the spatial frequencies
in the x and y dimensions, respectively, and the
DFT2D is the discrete Fourier transform in 2D.
Seminal work by early researchers studying noise
properties in CT (Riederer et al., 1978) demon-
strated that the NPS characterizes the noise texture
of the CT image, and that in the axial plane the
NPS largely reflects the CT reconstruction kernel
used. Figure 11.4 illustrates analytically derived
filter (see Figure 11.4a) and the ramp filter (see
Figure 11.4b). For an early single-detector-array CT
scanner, these investigators used the 2D NPS

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 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

because the scanner could acquire only one CT
image per axial scan; thus, no noise correlation
occurred in the z dimension. More recent work has
extended 2D NPS concepts to cone-beam CT
systems (Baek and Pelc, 2010; 2011a; 2011b).
An example of how the 2D NPS is measured is
illustrated in Figure 11.5. A homogenous phantom
(e.g., water or plastic) is scanned using the desired
technique factors (tube potential, tube current, ro-
tation time, etc.), producing a relatively homoge-
neous image as seen in Figure 11.5a. ROIs are
sampled from the homogeneous image. Typically
that sampling is performed at a constant radius as
shown in the figure. Each 2D ROI is extracted from
the image and, after (optional) detrending (dis-
cussed below) is used (see Figure 11.5b), the 2D
Fourier transform is computed [see Eq. (11.1)] for
each ROI. After the considerable averaging of the
N NPS data sets in the frequency domain, the
mean 2D NPS is produced, and this is shown in
Figure 11.5c. The fx and fy frequencies in the 2D
NPS can be collapsed to a 1D radial frequency, fr,
by radially averaging using
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
fx2 þ fy2 :
fr ¼ ð11:2Þ

Figure 11.5. The NPS computation in CT. (a) ROIs sampled at a constant radius around the center of the phantom image. (b) An example
of detrending is shown. Here the raw ROI extracted from the image is fit with a low-order polynomial, which defines the background
trend in the data. Only the very low frequencies in the image can be addressed by the polynomial fit, due to its low order. The background
trend is subtracted from the raw ROI, resulting in the corrected ROI. (c) The two-dimensional Fourier transform is computed for the
corrected regions of interest (seen in b). In the axial plane as shown here, the NPS is approximately rotationally symmetric, and typically
has a shape resembling a torus. (d) The 1D NPS curve from radially averaging the 2D NPS. The initial positive slope of this curve results
from the ramp filtering that is used in filtered-back-projection reconstruction, and the negative slope at higher spatial frequencies occurs
due to the roll-off properties of the reconstruction kernel used to dampen high-frequency noise in the images.

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 Noise Assessment in CT
The typical appearance of the (axial) 2D NPS is
that of a torus, as shown in Figure 11.5c. Radial
averaging of this 2D surface using Eq. (11.2)
results in a 1D NPS (see Figure 11.5d). The
positive-slope region of the NPS in Figure 11.5d is
due to the ramp filtering, and the subsequent
fall-off at higher frequencies is due to the (mathem-
atical) reconstruction kernel that is used. Different
kernels are used that represent different trade-offs
between spatial resolution and image noise, but all
clinical kernels produce some roll-off in response at
high frequencies, similar to that shown in
Figure 11.5d. Roll-off refers to the progressive re-
duction in the filter function at higher spatial fre-
quencies, to reduce the impact of quantum noise on
the image. The 2D NPS can be displayed using 3D
plotting techniques, and a 2D NPS is shown in iso-
metric format in Figure 11.6.
With modern MDCT and cone-beam CT systems,
there are many detector arrays in the z dimension
that acquire the raw data simultaneously, and
these give rise to noise correlation in z. Thus, for
these modern CT systems, the 3D NPS is necessary
for fully characterizing the noise correlation in the
image data. The 3D NPS is a straightforward ex-
tension of the 2D function (Tward and Siewerdsen,
2008), and is defined as
1P N  
NPSðfx ;fy ;fz Þ ¼ DFT3D ½Ii ðx;y; zÞ  I 2 Dx Dy Dz ;
N i¼1 i
Nx Ny Nz
ð11:3Þ
where fz, Dz, and Nz refer to the frequency, voxel
spacing, and number of voxels used in the
z dimension, and DFT3D is the discrete Fourier
transform in 3D. The 3D NPS is measured as
described in Figure 11.5; however, the ROIs become
volumes of interest (VOIs), and the computations
are performed for all three dimensions.
Figure 11.7 illustrates different views of a fully
3D NPS computed from CT images acquired on an
Figure 11.6. An early example of the NPS as a function of
spatial frequencies fx and fy. Adapted from Hansen (1979).
125
experimental cone-beam CT scanner (Siewerdsen
et al., 2002). Figure 11.7a shows the 3D NPS in the
axial plane, and Figure 11.7b shows the 3D NPS in
the coronal or sagittal plane. Due to rotational
symmetry, the sagittal and coronal 3D NPS projec-
tions are essentially identical. Figure 11.7c illus-
trates a 3D rendering of the 3D noise-power
spectrum, with a cutout view for clarity.
Figure 11.8 illustrates a 2D NPS obtained from a
Siemens clinical CT system. The NPS values for
four different reconstruction kernels (B10, B20,
B30, and B40) are illustrated. When the NPS is
computed directly from the CT scan of a homoge-
neous (usually cylindrical) object, some degree of
“cupping” is usually present, and this manifests as
a spike in the curve at low frequencies in the NPS
(see Figure 11.8a). The cupping artifact is well
known in CT, and can be from beam hardening,
scattered radiation, or other phenomena. Cupping
refers to a low-frequency trend in the CT image in
which HU values near the center of a homogeneous
object are lower than those near the periphery. To
reduce the impact of cupping on the low-frequency
portion of the NPS, a number of techniques can be
used. The so-called detrending methods (Dobbins
et al., 2006; Yang et al., 2008) can be used to sub-
tract out low-frequency trends in the spatial
domain. Figure 11.5b illustrates one type of
detrending, for example, in which a low-order poly-
nomial fit to the data is subtracted out, reducing
some of the low-frequency components. Other
researchers (e.g., Yang et al., 2008) have used
image subtraction to reduce the impact of cupping
on the NPS calculation. With this method, two sep-
arate acquisitions are made of a homogeneous (typ-
ically cylindrical) test object, and these two data
sets are subtracted from one another. With this ap-
proach, inhomogeneities in the phantom are sub-
tracted away also, and only noise remains. In 2D,
the image subtraction is represented as
Kðx; yÞ ¼ IA ðx; yÞ  IB ðx; yÞ ; ð11:4Þ
where IA(x, y) and IB(x, y) are independently
acquired images of the same object. In this case,
the 2D NPS is then computed using
PN  2
 Dx Dy
NPSðfx ;fy Þ ¼ 1 i¼1 DFT2D ½Ki ðx;yÞ  K i  ;
N 2 Nx Ny
ð11:5Þ
where Ki is the mean HU value in the ROI Ki (x,y).
The image-subtraction process results in an in-
crease in the subtracted-image variance by a factor
of 2, and therefore division by a factor of 2 in Eq.
(11.5) is used to correct for this. Figure 11.8b
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 11.7. A 3D NPS computed for a cone-beam CT scanner. (a) The axial plane (fx – fy) of the 3D NPS shown for fz ¼ 0. (b) The
sagittal plane of the 3D NPS, shown for fy ¼ 0. (c) Three-dimensional rendering of the 3D NPS.

Figure 11.8. Two-dimensional NPS for a Siemens Somatom 64-slice CT scanner, adapted from Boedeker et al. (2007). (a) The 2D NPS
for four reconstruction kernels indicated in the inset. The low-frequency spike is indicated by the arrow. (b) The 2D NPS for the same
four reconstruction kernels, but using 2D image-subtraction methods [see Eq. (11.4)] to suppress the low-frequency spike.

illustrates a significant reduction in the low-
frequency spike that is seen in Figure 11.8a, and
this was achieved using the 2D image-subtraction
method of Eqs. (11.4 and 11.5).
For full 3D data sets, image subtraction is per-
formed using
Kðx; y; zÞ ¼ IA ðx; y; zÞ  IB ðx; y; zÞ ;
where the A and B subscripts refer to independent-
ly acquired measurements of the same volume (x, y,
z). The 3D NPS is then computed using
N 
P 2
 DFT3D ½Ki ðx;y;zÞK i 
NPSðfx ;fy ;fz Þ ¼ 1 i¼1
N 2
It is usually true for commercial CT scanners that
Dx ¼ Dy, and hence for a square ROI Nx ¼ Ny.
However, the voxel spacing in the z dimension (Dz)
is usually not equal to that in the x or y dimension.
Consequently, the value of Nz can be different from
Nx or Ny, depending upon the size of the cylinder
scanned and the length (along z) of the scan itself.
ð11:6Þ Figure 11.9 illustrates the influence of phantom
diameter on the NPS. These NPS curves were com-
puted using 3D data-set subtraction techniques
[Eqs. (11.6 and 11.7)] to reduce artifacts in the low-
frequency regions of the NPS. For the curves
shown in Figure 11.9a, the same technique factors
(80 kV, 7 mA, 16.6 s) were used for polyethylene
phantoms of four different diameters. In this case,
Dx Dy Dz :
the largest-diameter phantom attenuates the most
Nx Ny Nz x-ray photons, and hence fewer photons reach the
ð11:7Þ detector compared to the smaller phantoms.

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 Noise Assessment in CT

Figure 11.9. NPS curves computed from images of four polyethylene cylinders of different diameters acquired on a prototype
cone-beam breast CT scanner. Three-dimensional image-subtraction methods [see Eqs. (11.6 and 11.7)] were used to suppress
low-frequency artifacts. (a) Images were acquired with constant technique settings, so that the air kerma at isocenter (in the absence of
a phantom) was the same for each of the four cylinders imaged. Due to the increased attenuation of the larger-diameter cylinders, the
NPS is greatest with the larger-diameter cylinder, and decreases with smaller phantom diameters. (b) For images acquired in this case,
the absorbed dose at the center of the phantoms was kept approximately constant, i.e., the incident air kerma used for the
larger-diameter cylinder was greater than for the smaller cylinder. With these acquisition parameters, the smallest-diameter cylinder
has the largest-amplitude NPS curve, and the noise level decreases with increasing phantom diameter.

Therefore, the noise variance (area of the NPS
curve in this display format) is greatest for the
largest-diameter phantom. In Figure 11.9b,
however, the absorbed dose in each phantom was
designed to be approximately equal, requiring a
higher x-ray-tube current for the larger phantoms.
In this case, the smallest phantom was scanned
using the lowest tube current and had the highest
noise levels. The integrated volume of the 3D NPS
curve is equal to the overall noise variance, s2, in
the image:
ððð
s2 ¼ NPSð fx ; fy ; fz Þdfx dfy dfz : ð11:8Þ
11.4 Demonstration of NPS Utility
In this Section, a number of trends that are
evident from NPS analysis are discussed.
The ICRU/AAPM polyethylene phantom (see
Figure 7.19) was used in this work. Figure 11.10
illustrates the axial (fx – fy), sagittal (fz –fy), and
coronal (fx – fz) views of the 3D NPS for two differ-
ent reconstruction kernels on a Siemens ASþ
scanner. In the axial displays, zero frequency is at
the center of the torus, and higher frequencies
advance radially (see axes in Figure 11.5c). The
images in Figure 11.10a correspond to a reconstruc-
tion kernel (B10s) that provides considerable smooth-
ing, thereby reducing much of the high-frequency
noise in the image data sets. The images in
Figure 11.10b correspond to a high-resolution recon-
struction kernel (B80s), and the NPS demonstrates
noticeable higher-frequency noise characteristics,
i.e., the torus has a larger diameter.
The sagittal and coronal NPS curves in
Figure 11.10a and 11.10b show virtually identical
trends, due to the approximate radial symmetry of
the NPS in these planes. These 3D functions can
be condensed by radially averaging the 3D NPS in
the axial plane, through the use of Eq. (11.2). After
performing the radial averaging, which collapses
the fx and fy axes to a single fr axis, the information
illustrated in Figure 11.10 can be condensed as
seen in Figure 11.11. This figure illustrates the
(still 3D) NPS topography (fz and fr) for two differ-
ent reconstruction kernels on the Siemens CT plat-
form. The B10s kernel (see Figure 11.11a) is a
“soft” kernel and produces “smoother” images, with
an NPS that has more lower-frequency content,
and the B80s kernel (see Figure 11.11b) is a
“sharper” kernel that passes more higher-frequency
noise. Compared with B10s, images reconstructed
with the sharper B80s kernel will have better
spatial resolution (MTF) but will also have more
noise at higher frequencies.
The NPS plots shown in Figure 11.11 contain sig-
nificant amounts of information, which can be dis-
played more concisely as shown in Figure 11.12.
Figure 11.12a illustrates the radially averaged NPS
for the B10s kernel; the three plots in
Figure 11.12a correspond to the data regions high-
lighted with the horizontal bars in Figure 11.11a.
The 1D NPS profiles for kernel B80s are shown in
Figure 11.12b. These plots illustrate curves of the
3D NPS at fz ¼ 0, fz ¼ 12 fN, and fz ¼ fN, where fN is
the Nyquist frequency (see Section 10.3). It is

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 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 11.10. Full displays of the 3D NPS. (a) The 3D NPS for a B10s kernel on a Siemens scanner. These data were acquired using
the ICRU/AAPM phantom. The B10s kernel produces relatively smooth images by attenuating the higher-frequency content in the
images. This manifests in the 3D NPS as a small-diameter torus in the axial (fx – fy) display. The center of the torus corresponds to fx ¼
fy ¼ 0, with higher frequencies advancing away from the center. The coronal and sagittal NPS displays show the elongation of the basic
torus in the orthogonal dimensions. (b) The 3D NPS for a high-pass kernel (B80s). The diameter of the torus is greater than that in (a),
corresponding to the shift to higher spatial frequencies of the NPS with this kernel.

recognized that the full family of curves produced
from the data illustrated in Figure 11.11a would
span the spaces between the curves illustrated
in Figure 11.12a. It is important to note that
the ordinate of Figure 11.12b is scaled differently
from that in Figure 11.12a, which is necessary
because the B80s kernel not only produces higher-
frequency image noise than does the B10s filter (it
is shifted to the right), but it also has higher noise
(the variance is larger) for the same acquisition
parameters.
Figure 11.13 gives NPS plots for the (Siemens)
kernels B10s and B80s, and two others, for which
the data illustrated in Figure 11.11a and 11.11b
were integrated over fz, i.e.,
ð fN
NPSð fr Þ ¼ NPSð fr ; fz Þdfz ;
fN
the NPS of the B80s kernel is seen to have signifi-
cantly more area compared with that with the B10s
kernel, and the area of these curves is proportional
to s2 [Eq. (11.8) applies here as well, except that
the integration over z has already been performed].
Figure 11.14 illustrates the 3D NPS data,
showing the frequency fz as a function of the radial-
ly averaged frequency fr, for three different recon-
structed slice thicknesses (1 mm, 2 mm, and
5 mm). The maximum frequency computed (fN)
along the fz axis in these plots corresponds to
(2t)21, where t is the slice thickness. Figure 11.15a
shows the NPS amplitude as a function of the
radial frequency fr, integrated over fz. Similarly, the
3D NPS data can be integrated horizontally (see
Figure 11.14) over the radial frequency fr, as
ð fN
ð11:9Þ
NPSð fz Þ ¼ NPSð fr ; fz Þdfr : ð11:10Þ
fN

which converts the volumes of the 3D NPS (shown

in Figure 11.11) to areas of the curves of the NPS
plots shown in Figure 11.13. Note that fN in
Eq. (11.9) refers to the Nyquist frequency in z. A
change in NPS units occurs with this integration;
whereas the 3D NPS (Figures 11.10 – 11.12) are in
units of HU2  volume (i.e., HU2 mm3), the integra-
tion of Eq. (11.9) converts these into units of HU2 
area (i.e., HU2 mm2) in Figure 11.13. In this figure,
These results are illustrated in Figure 11.15b.
Figure 11.16 gives the 3D NPS integrated over fz,
and radially averaged over fx and fy, resulting in
the NPS versus spatial frequency, fr. When the 3D
NPS is integrated and then displayed in this
fashion, the relative noise variance is proportional
to the area under each curve. In the illustrated
case, the lower x-ray-tube-current–time product

128
 Noise Assessment in CT

Figure 11.11. Radially averaged 3D NPS plots, obtained from the symmetrical (in fx and fy) 3D NPS in Fig. 11.10. Here the NPS
amplitude is shown using a color scale. The plots extend from f ¼ 0 to the Nyquist frequency for each axis. (a) NPS data from the
low-pass B10s kernel. (b) NPS of the high-pass B80s kernel.

Figure 11.12. NPS(fr) for three locations along the fz axis: fz ¼ 0, fz ¼ 12 fN, and fz ¼ fN, where fN is the Nyquist frequency. NPS(fr) for (a)
the B10s kernel and (b) the B80s kernel.

(126 mA s) produces about 25 % of the x-ray
fluence compared with the higher current –time
product (500 mA s), and the noise variance scales
inversely, as is apparent in this figure, i.e., the area
under the 126 mA s curve is about four times
greater than that of the 500 mA s curve.
Figure 11.17 compares NPS curves for axial (se-
quential) and helical (spiral) acquisition with the
Siemens ASþ platform, using the ICRU/AAPM
polyethylene phantom. Figure 11.17 shows the
NPS resulting from the integration of the 3D NPS
over fz. These scans used the same set of technique
factors [tube potential, tube current, slice thick-
ness, etc., and with unit pitch ( p ¼ 1)]; however,
the noise variance in the helical scan is slightly
greater than that of the axial scan.
Figure 11.18 shows NPS curves calculated at
four different radii. These are 3D NPS data inte-
grated over fz [Eq. (11.9)] for the four different
radii. As mentioned previously, the areas under
these curves are proportional to s2. The trends in
this figure show that the NPS computed from VOIs

129
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
near the center of the field (e.g., r ¼ 30 mm) have
slightly higher noise variance than measurements
at larger radii (e.g., r ¼ 97 mm). Although the
radial dependence of the amplitude of the NPS is
small, these results do suggest that the use of a
standard radius for NPS evaluation would be more
consistent for comparisons across other parameters
(kernel, scanner type, tube current, etc.).
As there is a need to develop more uniform inter-
pretation of performance among CT-scanner plat-
forms, the NPS can also serve an important role in
Figure 11.13. The 2D NPS(fr) from the integral of the 3D NPS
over fz. The four curves show the NPS obtained with different
kernels (as labeled), and the increased noise amplitudes (areas
under the curves) of the sharper kernels (e.g., B80s and B70s)
are apparent.
Figure 11.14. Examples of the radially averaged 3D NPS for slice thicknesses of (a) 1 mm, (b) 2 mm, and (c) 5 mm. The plots extend
from f ¼ 0 to the Nyquist frequency for each axis.
130
comparing protocols (including reconstruction-
kernel selection) among CT scanners from different
vendors. Figure 11.19 gives an important compari-
son of NPS curves between two different vendors:
General Electric shown on the top row and
Siemens on the bottom row. The low-pass (softer)
kernels are illustrated in the left column of plots,
and the high-pass (sharper) kernels are illustrated
in the right column of plots. Using the NPS,
Solomon et al. (2012) performed a numerical com-
parison among the performances of the different re-
construction kernels of these two vendors. These
data provide important information with respect to
matching protocols across these two specific CT
scanner platforms. Matching the reconstruction
kernels between vendors as done by Solomon et al.
(2012) is a practical example of the utility of the
NPS(f ) in the clinical environment, over and above
the straightforward assessment of noise.
11.5 Noise-Equivalent Quanta, NEQ
As pointed out in Section 11.2, the signal-to-noise
ratio, SNR, is a key attribute of any imaging
system’s performance, and the SNR provides a
first-order prediction of observer performance.
Section 10 described the modulation transfer func-
tion MTF(f ), which essentially describes how an
 Noise Assessment in CT

Figure 11.15. The 2D NPS from the integral of the 3D NPS. (a) The 2D NPS computed from the 3D NPS by integration over fz. In this
display, as a function of fr, the area of the NPS area is proportional to the noise variance. The results for the 1 mm slice thickness show
approximately twice the noise variance compared with that for the 2 mm slice, as would be expected based upon the relative number of
x-ray quanta that contribute. These curves were produced by vertically summing the data shown in Fig. 11.14 and then multiplying the
sum by Dfz. (b) The 2D NPS computed from the 3D NPS by integration over fr, as a function of fz. Curves for four different slice
thicknesses are shown. Smaller slice thicknesses are capable of displaying higher spatial frequencies in the fz dimension.

Figure 11.16. The NPS for two products of tube current and scan
time. Here, the area of the lower-dose curve (126 mA s) is
approximately four times that of the higher-dose curve (500 mA s).
Figure 11.18. Dependence of the NPS on the radius of
measurement. Four curves are given for the radii of
measurement indicated. Although the differences are small,
these data suggest that a consistent radius of measurement
should be used to preserve NPS measurement precision.

is realized that the NPS(f ) relates to the noise-

squared (i.e., the variance s2), and the MTF(f ) is
not related to the signal-squared. To address this, it
is customary to use the SNR2out ð f Þ (Dainty and
Shaw, 1974; Hanson, 1979; Wagner and Brown,
1982). This quantity is conventionally referred to
as the noise-equivalent quanta, NEQ(f ), and is
defined as

Figure 11.17. Comparison of the 2D NPSs for axial and helical
CT. NPSs were integrated over fz. For the same technique
factors as with the axial scan (and with pitch, p ¼ 1), the helical
(spiral) NPS has slightly greater noise variance as seen by the
larger area under the curve.
imaging system passes signal. The NPS(f ) has
been discussed at length in Section 11, and it
describes how an imaging system passes noise (or,
more specifically, noise variance). The concepts of
MTF(f ) and NPS(f ) can be brought together to de-
scribe the frequency-dependent SNR(f ); however, it
g2 MTF 2 ð f Þ
NEQð f Þ ¼ SNR2out ð f Þ ¼ ; ð11:11Þ
NPSð f Þ
where g is used to normalize units, and is typically
equal to the mean gray scale (HU in CT) of the ROIs
used to compute the noise-power in the image.
Equation (11.11) is general and has been used ex-
tensively in the analysis of planar radiographic
and mammography systems. Investigators in CT
(Wagner and Brown, 1982) measured the frequency-
dependent NEQ(f) for a second-generation CT
system, and their result is illustrated in Figure 11.20.

131
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY

Figure 11.19. Comparisons of the 2D NPS from General Electric and Siemens CT systems. These measured NPS curves have utility in
clinical protocol development across vendor platforms. Adapted from Soloman et al. (2012). (a) The NPS for the low-pass General
Electric reconstruction kernels. (b) The NPS for the high-pass General Electric kernels. (c) The NPS for the low-pass Siemens kernels.
(d) The NPS for the high-pass Siemens kernels.

Figure 11.20. The NEQ is shown for a (head-only) second-

generation CT scanner (adapted from Wagner and Brown, 1982).
This figure gives the SNR2out for the early head-only
CT scanner studied. Later, researchers (Boedeker
et al., 2007) evaluated the NEQ(f) for a whole-body
Siemens CT scanner for numerous reconstruction
kernels, with results shown in Figure 11.21. Despite
the substantial differences in band-pass among the
various reconstruction kernels, as shown in the
NPS(f) curves in Figure 11.13, the NEQ(f) is shown
Figure 11.21. NEQ results for an MDCT system. The NEQ is
shown for a whole-body CT scanner (Siemens Somatom) for six
reconstruction kernels.
in Figure 11.21 to be nearly independent of the band-
pass differences among kernels (except for the B80
kernel). This is because the differences in the recon-
struction kernel not only change the NPS as illu-
strated in Figure 11.13, but similar trends in
band-pass occur in the MTF2 as well (not shown).

132
 Noise Assessment in CT
The ratio, therefore, between the MTF 2 and NPS
greatly mitigates the influence of the kernel, and
demonstrates the fundamental NEQ(f) [i.e., SNR2out ]
performance of the CT scanner.
11.6 Dose-Normalized NPS(f )
Large differences are seen in the values of
NPS(f ) as a function of the tube-current– time
product; see Figure 11.16, where results for a factor
of 4 difference in tube-current – time product (and
radiation dose) are illustrated. This observation sug-
gests that the NPS(f), if measured at a standard
dose value, might provide an excellent approach for
comparing noise versus dose among CT scanner
models. In radiography and other planar-imaging
modalities, the detective quantum efficiency, DQE(f),
is a quantity that essentially describes the dose effi-
ciency of the detector system. That is, for a given
dose, what SNR2out ð f Þ does the imaging system
produce? The DQE(f) is simply the NEQ divided by
the incident fluence (Dainty and Shaw, 1974):
SNR2out ð f Þ g2 MTF 2 ð f Þ
¼ DQEð f Þ ¼ ;
SNR2in ð f Þ qNPSð f Þ
ð11:12Þ
where q is here the x-ray-photon fluence incident on
the detector used to produce the image for which
NPS(f) was measured. For Poisson noise, SNRin
pffiffiffi
¼ q, and hence SNR2in ð f Þ ¼ q. The incident photon
fluence in CT has little spatial correlation, and
hence its frequency distribution is “white,” meaning
that the input SNRin(f) has constant amplitude as a
function of spatial frequency. That is why the q term
on the right side of Eq. (11.12) has no explicit fre-
quency dependence.
Despite the utility of the DQE(f ) in planar x-ray
imaging systems, the meaning of q is difficult to in-
terpret for CT systems (Tapiovaara and Wagner,
1985) due to the presence of the bow-tie filter,
which spatially modulates the value of q in the
field of view. In addition, unlike the simple digital-
image corrections (e.g., flat-field) performed with
digital radiography systems, the reconstruction
algorithms used in CT include corrections for
beam-hardening, x-ray scatter, and other effects
that consider the presence of an object in the
scanner. CT scanners are simply not designed to
produce optimal images when no object is present,
and therefore it would be impractical to use scans
in air to characterize CT scanner performance.
Given these observations, the use of the DQE(f ) for
CT appears to be limited at this time.
133
An alternative to the use of the DQE(f ) for the
study of noise versus dose in CT is possible,
however, and the phantom described in Section 7
(see Figures 7.19a and 7.19b) is an important tool
for this. The phantom was designed as both a dos-
imetry phantom and a tool for measuring the
NPS(f ). For a specific set of acquisition parameters
(tube potential, tube current, rotation time, pitch,
field of view, bow-tie filter, reconstruction kernel,
etc.), the NPS(f ) is characterized at a standard air
kerma at the center of the phantom. The proposed
measurement procedure is as follows:
(1) The center section of the ICRU/AAPM
phantom, a cylinder of polyethylene 200 mm long
and 300 mm in diameter, is positioned on the CT
table with a thimble chamber located in the center
hole of the phantom, and also at the center along
the z axis of the phantom as shown in
Figure 7.22a.
(2) Air-kerma measurements are made for an
axial or helical scan acquired throughout the entire
length of the phantom, using either an integrating
electrometer or an electrometer with real-time read
out as described in Section 5.2.3. The scan is per-
formed at the desired technique factors (tube po-
tential, rotation time, pitch, and x-ray-tube current
of J1, etc.), and the air kerma, K1, measured at the
center of the phantom during the scan is recorded.
The x-ray-tube current is adjusted to a new value
J2, with the intention of producing a specific mea-
sured air kerma, Kset, at the center of the phantom.
Because air kerma is linearly proportional to tube
current when all other technique parameters are
fixed, the selected tube current J2 can be deter-
mined using
Kset
J2 ¼ J1 ; ð11:13Þ
K1
where Kset could be a typical value of air kerma
used in body CT, such as 10 mGy.
(3) After J2 is selected, a second CT scan of the
entire length of the phantom is acquired as before,
and the measured air kerma, K2, is recorded. The
value of K2 should be very close (within from 2 % to
5 %) to the desired air kerma, Kset. Using this ac-
quisition, images are then reconstructed using the
desired reconstruction parameters (slice thickness,
kernel, display field of view, etc.).
(4) The CT images produced in step 3 above are
used to evaluate the 3D NPS(f), and—after radially
averaging using Eq. (11.2) and integration over fz
using (Eq. 11.9)—NPS curves similar to those shown
in Figures 11.13, 11.15a, and 11.16 are produced and
used for comparative analysis.
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
With the above procedure performed on any CT
manufacturer’s platform, NPS(f ) curves can be
compared at essentially the same air-kerma levels
at the center of a standard phantom. This approach
allows for a direct comparison of the noise perform-
ance among two or more whole-body CT scanners.
11.7 Summary
Contrast resolution in CT has traditionally been
measured using so-called low-contrast test objects,
which are widely available in commercial phantoms
(see Bushberg et al., 2012). This method requires
specialized phantoms and relies on subjective
(human-observer) interpretation of patterns similar
to the CD phantom illustrated in Figure 11.2a.
Moreover, in addition to the somewhat qualitative
observation used as a measure, vendors can report
the measurement made under differing conditions,
obscuring the ability to make meaningful compari-
sons among different scanners. This situation
clearly needs to be updated to more modern, quan-
titative, and objective metrics.
Thus, it is recommended that quantitative meas-
urement of the NPS, using the middle section
of the 300 mm diameter polyethylene ICRU/AAPM
phantom evaluated at a radius of approximately
100 mm, be used to quantify noise in CT systems.
134
The NPS(fr) curves, measured from the full 3D
NPS with subsequent radial averaging [Eq. (11.2)]
and integration over fz [Eq. (11.9)] should be
adopted for the evaluation of the noise performance
of CT scanners. NPS curves, similar to those shown
in Figures 11.13 and 11.15 –11.17, are considered to
be most useful in the evaluation of the noise prop-
erties of MDCT systems. This is because, in this
display format, the area under each curve is pro-
portional to s2. The methods described in Section
11.6 provide guidance in this manner. The 300 mm
diameter polyethylene ICRU/AAPM phantom,
scanned to produce an air kerma of 10 mGy at the
center, is appropriate for body-imaging-protocol as-
sessment. A 200 mm long, 180 mm diameter poly-
ethylene phantom would be appropriate for head
CT protocols, with 50 mGy air kerma as the target
level.
These recommendations apply not only to the
clinical evaluation of CT-scanner noise-versus-dose
performance, but also extend to data provided by
CT manufacturers in commercial, technical, and
marketing documents. It is anticipated that the
measurement of NPS(f ) as outlined above will sup-
plant the use of visual assessment of low-contrast
test phantoms in acceptance-testing and quality-
assurance procedures for CT.
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
12. Summary of Recommendations
This Section summarizes the most significant
recommendations discussed in this Report. Sections
2–4 are introductory in nature, and were provided
to acquaint those less familiar with current CT
technology, clinical usage, and conventional CT
dosimetry associated with this modality.
12.1 Radiation-Dose Assessment in CT
Sections 4 – 9 discuss matters pertaining to radi-
ation dosimetry, and recommendations associated
with each of these Sections will be provided here in
order. In the discussion below, the term acceptance
testing refers to the initial measurements per-
formed on a newly installed CT scanner, usually
prior to clinical use. Quality assurance is the
process of periodic evaluation of a CT scanner, and
is often performed annually or after a major service
event (such as an x-ray-tube change).
For dosimetry in CT, many Monte Carlo and
other studies describe the absorbed dose in a par-
ticular organ or site (e.g., liver, bladder, fetus) as a
function of air kerma at the isocenter of the
scanner. When cast in this manner, the dose coeffi-
cients take on the units of absorbed dose per air
kerma, typically in units of mGy/mGy.
12.1.1 Existing CT-Dosimetry Methods
Historical acceptance testing and quality-control
procedures for CT systems typically involve the
assessment of the CTDIvol for several standard pro-
tocols. The set of ACR quality-control recommenda-
tions is one example. In addition, based on IEC
(2009) recommendations, CTDIvol is displayed on
the console of all modern CT scanners. Due to its
broad utility and ubiquitous availability, it is
strongly recommended that the CTDIvol be mea-
sured at acceptance testing using both the 160 mm
diameter and 320 mm diameter PMMA phantoms,
at a clinically relevant tube-current – time product
(e.g., 100 mA s) over the range of tube potentials
used by the CT scanner. Measurement of the
CTDIvol in air CTDIair is also strongly recom-
mended, and this measurement is made at the
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/ndt003
isocenter only. Characterization of CTDIvol on
newly installed CT platforms provides continuity
with measurements from previous CT scanners,
even as new CT dosimetry measures are introduced
and used with more frequency. The rationale for
this recommendation is also found in Sections 7
and 8 of this Report, in which the CTDIvol is used
to scale the size-specific dose estimate, SSDE, and
to normalize rise-to-equilibrium curves. If the
recommendations of Section 12.1.3 below are fol-
lowed, CTDIvol measurements performed after the
initial acceptance testing become unnecessary;
however, if the procedures in Section 12.1.3 are not
followed, then continued periodic evaluation of
CTDIvol during quality assurance is recommended.
12.1.2 CT X-Ray-Spectrum Characterization
The CT x-ray spectrum is dependent on the tube
potential and its waveform, and the amount of
total filtration in the x-ray beam at the center of
the fan beam. All modern CT systems make use of
high-frequency generators that produce very little
voltage ripple in the tube potential, so this is a
minor factor in today’s systems. Non-invasive
x-ray-tube-potential meters can be used to deter-
mine the accuracy of the tube-potential reading on
the console. The total filtration can be evaluated
with knowledge of both the tube potential and the
measured half-value layer, HVL.
In general, the current literature tends to report
dose coefficients (e.g., absorbed dose in an organ or
phantom location as a function of CTDIair, the air
kerma at isocenter) for the specific manufacturer
and model of the CT scanner (Boone et al., 2004;
Zhou and Boone, 2008). However, the numbers of
manufacturers and models of CT scanners are
growing, and scientific reports in the future will
have more impact if, in addition to reporting dosim-
etry values, they report dose-conversion values as a
function of x-ray-tube potential and HVL of the
x-ray beam for the central ray. Although different
CT-scanner vendors use slightly different source-
to-isocenter distances and bow-tie filter designs, in
general these influences will likely have a small
impact on the dose-conversion factors. Therefore,
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
tabulation of dose-conversion coefficients based
upon tube potential and HVL (at isocenter) will po-
tentially be useful across a variety of CT-scanner
vendors and models. This is the situation in mam-
mography, for which the normalized glandular-dose
values are not specific to a manufacturer or model.
When dose-conversion coefficients are more widely
available as a function of x-ray-tube potential and
HVL, knowledge of the HVL for each tube potential
for a CT scanner will be vital for accurate dosim-
etry. Hence, it is recommended for acceptance
testing of a newly installed CT scanner that the
HVL be measured for each tube potential that will
to be used and for each of the bow-tie filters avail-
able on the scanner.
Section 5 described several methods for measure-
ment of the x-ray-beam HVL. The simplest proced-
ure uses the real-time-probe method discussed in
Section 5.2.4, but—if the necessary tools are not
available—the conventional (manual) method
described in Section 5.2.1 is recommended.
12.1.3 CT Output-Related Parameters
Measured in Air
The x-ray output of the CT scanner, character-
ized in terms of CTDIair, is a fundamental measure-
ment that should be performed on each CT scanner
at acceptance testing and on a periodic basis, e.g.,
annually, and after any change or maintenance
performed on the x-ray-tube head or collimators
and x-ray generators. Two general approaches to
measuring the x-ray-tube output as a function of
spatial position are recommended below. In each
case, the 2D output distribution should be mea-
sured for at least four x-ray-tube potentials (span-
ning the entire range of “kV settings”). It is
strongly recommended that at one tube potential
(e.g., 120 kV), the 2D output distribution should be
characterized for the three most commonly used
collimation settings. For example, for a CT scanner
with a maximum nominal collimation of 40 mm,
collimation settings of 10 mm, 20 mm, and 40 mm
should be assessed at one x-ray-tube potential. Two
specific suggestions for these measurements are:
(1) A two-dimensional detector system such as a
computed-radiography (CR) imaging plate or a
portable thin-film-transistor (TFT) system can
be used to characterize the 2D distribution of x
rays emanating from the x-ray-tube assembly.
The measurement should be performed at the
isocenter of the scanner with the gantry station-
ary, and therefore requires using the scanner
service mode. Because CR and TFT detectors
are not air-equivalent in terms of atomic
136
number, careful calibration is required to
achieve absolute air-kerma measurements.
Measurements of CTDIair at isocenter (which
does not require a phantom) will serve to nor-
malize these relative measurements to mea-
sured air kerma. The 2D output distributions
(or other quantities derived from the raw data,
such as the collimated beam’s full width at half
maximum) should be compared with previous
measurements performed on the same CT
scanner as a consistency check. The measure-
ment of output using a planar detector produces
the function fL(x) described in Figure 6.18,
which optionally could be converted to fA(u)
using Eq. (6.3).
(2) If a real-time probe is available, the measure-
ment of the f(z) profile as described in Section
6.3.5 and illustrated in Figure 6.9 is recom-
mended. The experimental setup is relatively
simple (see Figure 6.8). Optionally, for compari-
sons among CT scanners, the response function
of the real-time probe could be deconvolved
using Eq. (6.2). However, the uncorrected mea-
sured data remain useful in annual compari-
sons as long as the same type of real-time
dosimeter is used. If the real-time probe
method is used to assess f(z), then it should also
be used to measure the x-ray-beam profile as a
function of the fan angle, u, of the scanner,
which characterizes the attenuation properties
of the bow-tie filters on the system. The tech-
nique illustrated in Figures 6.15 and 6.16 for
assessing the x-ray distribution as a function of
u also utilizes the real-time probe (McKenney
et al., 2011).
12.1.4 CT Dosimetry in Phantoms
In Section 12.1.1, the assessment of CTDIvol
using the 160 mm diameter and 320 mm diameter
PMMA phantoms combined with CTDIair and other
air-kerma measurements discussed in Section
12.1.3 was recommended for acceptance testing of a
new CT scanner. It is envisioned that the CTDIvol
phantoms (160 mm and 320 mm diameter PMMA)
would not be necessary for subsequent routine
quality assurance, as long as the air-kerma mea-
surements performed without a phantom
(i.e., CTDIair) were consistent with those made at
acceptance testing.
This ICRU Report Committee worked with the
AAPM Task Group 200 to develop a 600 mm long,
300 mm diameter polyethylene phantom (see
Figure 7.19). This phantom was tested under real-
istic conditions in a clinical environment and, as
anticipated, was found to be too large to be
 Summary of Recommendations
practical for routine testing of CT systems in the
field. However, this phantom does have two import-
ant roles to play:
(1) It is strongly recommended that the full
600 mm long phantom be available at manufac-
turer’s CT-testing facilities, and that thorough mea-
surements (at both the center and the peripheral
locations) be performed using the phantom, such
that H(L) and related functions [h(L), G(L), etc.]
can be provided for each CT-scanner model.
Comprehensive measurements should be measured
at all tube-potential settings, with all appropriate
bow-tie filters, and over a realistic range of collima-
tion settings. The use of the real-time-probe meas-
urement procedure as outlined in Section 7 will
expedite these measurements. Normalization of the
acquired h(L) curves by CTDIvol leads to G(L)
curves that would be useful for the assessment of
patient dose in the clinical setting. The large mass
of the full phantom should not be an impediment
for use in a factory environment.
A subset of the tests with the 600 mm long
phantom are strongly recommended to be made by
CT manufacturers for each CT model using only
the 200 mm long center section of the ICRU/AAPM
phantom. For example, with a thimble chamber
placed in the center hole of the phantom at the
center of the hole along z, the air kerma should
be measured for a helical acquisition (with pitch
p  1) performed over the entire length of the
phantom. This measurement should be performed
for all x-ray-tube potentials at a standard tube-
current – time product (e.g., 100 mA s). In addition,
at a standard tube potential (e.g., 120 kV), this
measurement should be repeated for the three
most commonly used collimation settings (e.g., at
Cmax, 12 Cmax, and 14 Cmax, for a scanner with a
maximum collimation of Cmax). The data generated
by this measurement protocol will allow for direct
comparison in the field, using the same 200 mm
long phantom and measurement protocol. These
data also provide a means to relate the partial-
phantom measurements to the G(L) curves
acquired in the 600 mm long phantom [e.g.,
G600(L)/G200(L)].
(2) For the evaluation of CT scanners in the clin-
ical environment, it is strongly recommended that
only the middle section of the ICRU/AAPM
phantom be used. This phantom is 200 mm long
and 300 mm in diameter, and is slightly lighter
than the ubiquitous 320 mm diameter PMMA
phantom. The principal function of the phantom is
to measure image noise: the noise-power spectrum,
NPS, at a constant air kerma at the center hole of
the phantom, as described in Section 11.6. This will
be discussed in greater detail in Section 12.2.2
137
below. An additional function of the phantom meas-
urement is to evaluate the constancy of the tube-
current–time product required to produce a stand-
ard air-kerma value at the center of the phantom,
which would serve as an additional quality-control
parameter. For example, if an effective “mAs” of Jt
is required for an air kerma of 10 mGy at the
center of the phantom at one time, and 0.80 Jt is
required for the same air kerma at a later time,
then this is cause for concern and suggests that the
x-ray-tube output be further investigated.
12.1.5 Patient SSDE
Section 8 describes methods that can be used to
compute conversion coefficients that can be used
with the known CTDIvol to estimate the average
absorbed dose to patients for a scan of standard
length. The SSDE provides a more accurate esti-
mate of patient absorbed dose, and utilizes data
that are available in the CT-image data set; specif-
ically, the recorded CTDIvol and the water-
equivalent diameter of the patient that can be
estimated directly from the CT images. The math-
ematical methods pertinent to the conversion
process are described in Section 9.
The effective diameter of the patient was defined
for quantifying patient “size,” when an axial CT
image or set of CT images is available. The effect-
ive diameter, deff, is appropriate for abdomen and
pelvis imaging, for which only a small amount of
internal air exists in body cavities. For thoracic CT
scans, however, the large amount of air in the
lungs needs to be accounted for, and therefore the
water-equivalent diameter, dw, should be used for
the thorax. Given the similarity between the calcu-
lations for deff and dw, it is highly recommended
that the water-equivalent diameter be used for
computing the SSDE, for the head, neck, thorax,
abdomen, and pelvis.
The SSDE can also be used for estimating dose
after the localizer view is acquired, but prior to the
CT scan. In this case, the lateral and/or AP dimen-
sion of the patient needs to be used to compute dw.
Even after the CT images become available, one or
more edges of the patient in axial CT images might
be cut-off (i.e., a portion of the patient’s anatomy is
outside of the field of view) due either to clinically
appropriate use of small-display fields of view or
when a very large patient is scanned. This situ-
ation prevents the accurate assessment of the area
of the patient in the CT image, and hence compro-
mises the ability to estimate of dw from the CT
image. In this case, the localizer view provides the
necessary data for estimating patient size using the
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
PA or lateral dimension of the patient, one of which
is generally visible on the localizer image.
To overcome the problem of determining dw when
a small reconstructed CT field of view prevents as-
sessment of the patient’s complete anatomy, it is
strongly recommended that CT manufacturers
provide pre-calculated dw values for each CT-
section image during the reconstruction process.
The CT-scanner hardware would compute the full
field-of-view (FOV) CT images, determine the dw
for each axial image, and report this in the DICOM
header. The full-FOV images need not be stored
unless this is desired by the user. This dw computa-
tion includes many elements of the standard recon-
struction process for smaller-FOV images, and so
the additional computational burden would be
light. Proprietary or vendor-specific algorithms for
computation of dw are discouraged, because all
aspects of patient dosimetry should be transparent
and verifiable by individuals responsible for CT
dose assessment at a given institution. If dw were
available for each axial CT image in the DICOM
header, then image cut-off due to the use of a small
FOV would not be an issue, and subsequent dose
assessment would be expedited considerably.
12.1.6 Automatic Exposure Control in CT
The protocol for computing the SSDE is
described in Section 8, and the most basic computa-
tion of SSDE is given by Eq. (9.1). This equation
assumes a patient of constant diameter and a CT
scan with constant tube current. Although this ap-
proach is adequate for constant-tube-current oper-
ation and for general prospective-patient dose
calculations (i.e., for research or clinical CT proto-
cols for which patient size can only be assumed),
the complexities of size dependence in CT dosim-
etry combined with the increasing use of tube-
current-modulation-acquisition modes require a
more sophisticated approach. Furthermore,
Figure 8.9a shows that for the abdomen –pelvis
scan, a significant difference can occur when a
single value of dw is computed from a single CT
image near the center of the scan (in z), when com-
pared with the slice-by-slice determination of the
average dw. Therefore, for comprehensive patient-
dose estimation, it is highly recommended that the
average dose be computed as the average SSDE
value across all images in the CT scan using the
CT-image specific value of dw and the
CT-image-specific effective “mAs” or the CTDIvol
[see Eq. (9.3)]. Thus, when computational capabil-
ities are available, the SSDE should be computed
on a CT-image-specific basis for a given region in
the body (e.g., abdomen, pelvis, thorax, head) and
138
an average SSDE (and standard deviation) for each
region should be reported. It is recognized that the
absorbed dose associated with a given CT slice
along z is not only dependent on the dw and effect-
ive “mAs” for that slice, but that the scatter tails
from adjacent CT slices contribute a significant
fraction of dose as well. However, dw and effective
“mAs” do not change dramatically from slice to
slice along the z axis. Section 9.5 demonstrates a
software-based approach for the computation of
SSDE on a CT image-specific basis.
12.2 Other Considerations in Patient
Dosimetry in CT
The current state of science does not allow the
estimation of the radiation risk for a specific
patient, but it is known generally that the higher
the absorbed dose the higher the risk of adverse
health effects. The effective dose, E, defined by the
ICRP (ICRP, 2007) for the purpose of radiation pro-
tection and discussed in Section 4, is based on the
absorbed dose in sensitive organs and tissues.
When the DLP is known, so-called k-factors can be
used to estimate E [see Eq. (4.11)]. However, such
information cannot be used to evaluate individual
risk because effective dose applies only to a popula-
tion of adults, averaged for males and females, and
is intended to provide a tool for risk management
(limitation and optimization) for regulatory
purpose. Organ and tissue absorbed doses for indi-
viduals undergoing a radiological procedure such
as CT are no doubt fundamental, but the relation-
ships that govern the radiation response of a specif-
ic patient (depending on age, sex, size, health
history, genetic nature, etc.) are still largely
unknown.
Although effective dose is not suitable for the as-
sessment of the risk for individual patients, it can
be useful when comparing different diagnostic mo-
dalities and techniques. The assessment of organ
doses does allow, however, the use of organ-, sex-,
and age-specific coefficients provided in the BEIR
VII report (NAS/NRC, 2013) for the estimation of
the putative risk to a smaller population and thus
not all adults, but not an individual. Although
Monte Carlo calculations of organ absorbed dose
are useful in developing CT-dose coefficients for
generic populations (Zhang et al., 2012), they are
not necessary for the individual patient. A soft-
ware-based approach to assessing the absorbed
dose for a specific CT procedure is described in
Section 9.6 and is illustrated in Figure 9.4. It is
expected that the image-by-image computation of
the SSDE would be useful in organ-dose estimation
 Summary of Recommendations
using probability-density functions (see Figure
9.10) that describe the fraction of an organ’s
volume that resides in each CT section. The prob-
ability-density-function concept can be developed
using gender-specific organ templates ( probability
of a specific organ being located along the z axis),
which can be aligned (in z) with a specific patient’s
anatomy in the CT image using boney landmarks
(e.g., vertebral bodies).
12.3 Image-Quality Metrics
Image quality in CT is a complex topic; in this
Report the emphasis is on the development and use
of more quantitative metrics for image-quality as-
sessment rather than historical, qualitative
methods. For both spatial resolution and noise as-
sessment, proposed methods require access to the
CT-image digital data as well as the ability to ma-
nipulate them with custom software. Although
some of the mathematical details of these algo-
rithms have been outlined in this Report, it is
anticipated that both open-source and commercial
software will eventually be available for the recom-
mended analyses discussed here.
12.3.1 Spatial Resolution in CT
A reasonable goal in characterizing spatial reso-
lution in CT is to perform the assessment in 3D.
However, there are considerable differences in the
resolution properties between the in-plane MTFxy
and the longitudinal MTFz, and the factors respon-
sible for these differences are well understood.
Therefore, the independent characterization of the
MTFxy and MTFz is currently recommended;
however, the full 3D MTF in CT can be of value in
certain settings.
The in-plane CT image is (in general) rotational-
ly symmetric, in the sense that the x and y dimen-
sions are subject to identical factors that influence
spatial resolution when filtered-back-projection
methods are used for image reconstruction. Therefore,
the modulation-transfer function (MTFxy) can be com-
puted for the axial plane, and the frequency-domain
variables (fx and fy) can be described using a single
variable fr. The measurement of the in-plane MTFxy is
fundamentally influenced by the reconstruction
kernel used, whereas the longitudinal MTFz is almost
independent of the kernel and is more dependent on
CT-section thickness.
It is highly recommended that during acceptance
testing of a newly installed CT scanner, both the
in-plane and longitudinal MTFs be measured as
outlined in Section 10. The in-plane MTFxy should
be characterized using a few of the most commonly
139
used reconstruction kernels for that scanner.
Measurement of the in-plane MTFxy as a function
of the display field of view is also strongly recom-
mended. The longitudinal MTFz should be mea-
sured instead of the slice-sensitivity profile; in most
applications the slice-sensitivity profile should be
retired as a CT-resolution assessment along the
z axis.
To increase precision, the MTF should be mea-
sured in images produced with low noise levels.
Therefore, in addition to using a high tube-current–
time setting for the scan, a small-diameter phantom
is useful because of its lower attenuation. A small-
diameter prototype phantom is illustrated in
Figure10.15b and is pictured in Figure 10.15c.
The measurement of the MTFxy in CT images
that are reconstructed using non-linear iterative
methods needs to be performed with caution, as the
MTF construct assumes a linear, stationary
system. Therefore, it is highly recommended for
general quality assurance that the MTF be charac-
terized using images that are reconstructed by fil-
tered back projection. In such cases, it is
understood that these MTFs represent an upper
bound on the spatial resolution of the scanner.
Iterative-reconstruction techniques generally trade-
off spatial resolution to reduce noise in an adaptive
(local) manner, and any attempt to quantify the
MTFs when iterative-reconstruction methods are
used should be considered to be valid only within a
small (local) region in the image.
12.3.2 Noise Assessment in CT
The noise texture in CT is well characterized by
the 3D NPS. The measurement of MTF requires
points, lines, or edges in the phantom for resolution
measurement, but the evaluation of the NPS is
performed using a homogeneous phantom with no
specific structures. This makes phantom fabrica-
tion much easier than for the case of the MTF.
However, the phantom for NPS assessment should
approximate the size of patients because noise (and
noise texture) is directly related to the size of the
phantom. To address this, the ICRU Report
Committee and AAPM Task Group 200 developed a
300 mm diameter, polyethylene phantom that
serves as both a dosimetry phantom and a
phantom for the measurement of the 3D NPS (see
Figures 7.19 and 7.20). It is highly recommended
that the fully 3D NPS be measured using volumes
of interest [see Eq. (11.3)]; methods for radially
averaging [Eq. (11.2)] and integration over fz [see
Eq. (11.9)] should be used for the presentation of
the axial-image NPS. Given the slight dependence
of the NPS on the radius of measurement (see
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Figure 11.18), it is highly recommended that a
radius of approximately 100 mm be employed when
the 300 mm diameter ICRU/AAPM polyethylene
phantom is used.
Noise and absorbed dose are intrinsically linked
because they are fundamentally related to the x-
ray fluence used during image acquisition; conse-
quently, measuring the NPS in the absence of
absorbed-dose information is of little value. To
address this, the protocol specified in Section 11.6
is highly recommended. In that protocol, the center
section of the ICRU/AAPM phantom is scanned
over its entire length using helical (spiral) or axial
(sequential) scanning at a fixed air-kerma level at
the center of the phantom. The measurement of
the NPS at standardized air-kerma levels in the
phantom is meant to provide practitioners with the
means to compare the NPS among different CT
scanners, and to monitor a specific scanners’ per-
formance periodically. For consistency testing, NPS
curves similar to those shown in Figure 11.16
provide a more quantitative approach for noise
assessment in CT, compared with subjective
visual assessment of a low-contrast test object.
Comparison of NPS curves among CT scanners (see
Figure 11.19) is also an important aspect in proto-
col development in an environment in which mul-
tiple models (and manufacturers) of CT scanners
are used.
12.4 Future Directions
12.4.1 Real-Time Probe
The modern CT system is a dynamic platform:
not only is the beam direction changing rapidly, but
the beam intensity also can change rapidly. Given
this dynamic environment, it is unrealistic to con-
tinue to use radiation meters that operate only in
an integration mode. The dynamic nature of CT
requires dynamic, real-time-measurement technol-
ogy. The real-time probe, discussed in Section 5.2.3,
is a necessary tool for the evaluation of CT dose in
the modern era. A number of measurement proto-
cols have been described in this Report that rely
upon the use of a real-time radiation dosimeter.
Such probes are certain to become an essential tool
for the efficient and comprehensive characteriza-
tion of CT scanners.
12.4.2 Rise-to-Equilibrium Curve, H(L)
AAPM Report 111 (AAPM, 2010) describes a
method for characterizing the rise-to-equilibrium
curve, H(L). Section 7 of this Report extends the
approach of AAPM Report 111 by introducing the
140
use of the real-time probe for rapid single-
acquisition characterization of H(L). A series of dif-
ferent normalizations leading to h(L) and G(L)
were also discussed. What is still needed is for
these metrics to be included in a practical CT-dos-
imetry methodology. Although characterization of
H(L) is the first step toward understanding the im-
portant dosimetric consequence of scan length, a
straightforward recipe for how the calculation of an
individual’s dose should be computed is the subject
of future research. A likely correction factor, V(L),
is envisioned:
HðLÞ
VðLÞ ¼ : ð12:1Þ
Hð100 mmÞ
It is recognized that H(L) describes the dose (at the
periphery or center) at the center slice (i.e., at z ¼
0) of a CT scan of length L. Future studies should
develop methods that lead to accurate estimates of
the dose along the entire length of the CT scan.
The convolution method described in Eq. (7.4) gives
guidance in this manner, and other investigators
are studying numerical approaches to this as well
(Li et al., 2012).
12.4.3 Incorporation of Scan-Length
Corrections to the SSDE
The SSDE methods described in Section 8 and in
AAPM Report 204 (AAPM, 2011) allow the estima-
tion of SSDE based upon the known CTDIvol and a
conversion coefficient. The conversion coefficients
[see Figure 8.10 and Eq. (9.1)] were developed by
combining the work of a number of investigators,
and include the effect of scan length for standard
studies and the conversion from air kerma to
absorbed dose in tissue. Although the method is
considered sufficiently accurate for current pur-
poses, it is not robust in the case of large deviations
in scan length because of the implicit assumptions.
It should be recognized that both the SSDE and
the H(L) provide tools that address the size of the
patient over the length of their CT scan;
the SSDE addresses the diameter of the patient,
and the H(L) curve suggests a process [e.g., poten-
tially using Eq. (12.1)] for adjusting patient dose
based upon the length of the CT scan. Because the
conversion coefficients associated with SSDE in-
corporate the assumption of a “standard” scan
length, it is questionable whether or not the appli-
cation of an additional scan-length correction
factor would improve the accuracy of the existing
SSDE methods. Furthermore, the shape of the
H(L) curve is diameter-dependent [see Figure 7.28
for related G(L) curves], and the curve shape is
 Summary of Recommendations

also dependent upon location in the axial plane studies might prospectively develop conversion
(i.e., center or peripheral positions; see coefficients that address differences both in diam-
Figure 7.29). Despite these complexities, future eter and scan length within the same construct.

141
Journal of the ICRU Vol 12 No 1 (2012) Report 87
Oxford University Press
References
AAPM (1977). American Association of Physicists in
Medicine. Phantoms for Performance Evaluation and
Quality Assurance of CT Scanners. AAPM Report No.
1 (American Association of Physicists in Medicine,
College Park, MD).
AAPM (1990). American Association of Physicists in
Medicine. Standardized Methods for Measuring
Diagnostic X-ray Exposures, AAPM Report No. 31
(American Association of Physicists in Medicine,
College Park, MD).
AAPM (1993). American Association of Physicists in
Medicine. Specification and Acceptance Testing of
Computed Tomography Scanners, AAPM Report No.
39 (American Association of Physicists in Medicine,
College Park, MD).
AAPM (2008). American Association of Physicists in
Medicine. The Measurement, Reporting and
Management of Radiation Dose in CT, AAPM Report
No. 96 (American Association of Physicists in
Medicine, College Park, MD).
AAPM (2010). American Association of Physicists in
Medicine. Comprehensive Methodology for the
Evaluation of Radiation Dose in X-Ray Computed
Tomography, AAPM Report No. 111 (American
Association of Physicists in Medicine, College Park, MD).
AAPM (2011). American Association of Physicists in
Medicine. Size-Specific Dose Estimates (SSDE) in
Pediatric and Adult Body CT Examinations, AAPM
Report No. 204 (American Association of Physicists in
Medicine, College Park, MD).
Aberle, D. R., Adams, A. M., Berg, C. D., Black, W. C.,
Clapp, J. D., Fagerstrom, R. M., Gareen, I. F.,
Gatsonis, C., Marcus, P. M., and Sicks, J. D. (2011).
“Reduced lung-cancer mortality with low-dose com-
puted tomographic screening,” N. Engl. J. Med. 365,
395– 409.
Achenbach, S., Marwan, M., Ropers, D., Schepis, T.,
Pflederer, T., Anders, K., Kuettner, A., Daniel, W. G.,
Uder, M., and Lell, M. M. (2010). “Coronary computed
tomography angiography with a consistent dose below
1 mSv using prospectively electrocardiogram-triggered
high-pitch spiral acquisition,” Eur. Heart. J. 31,
340– 346.
Alvarez, R. E., and Macovski, A. (1976).
“Energy-selective reconstructions in X-ray computer-
ized tomography,” Phys. Med. Biol. 21, 733 –744.
Baek, J., and Pelc, N. J. (2010). “The noise power spec-
trum in CT with direct fan beam reconstruction,” Med.
Phys. 37, 2074 –2081.
# International Commission on Radiation Units and Measurements 2013
doi:10.1093/jicru/ndt005
Baek, J., and Pelc, N. J. (2011a). “Effect of detector lag
on CT noise power spectra,” Med. Phys. 38,
2995–3005.
Baek, J., and Pelc, N. J. (2011b). “Local and global 3D
noise power spectrum in cone-beam CT system with
FDK reconstruction,” Med. Phys. 38, 2122 –2131.
Bischof, C. J., and Ehrhardt, J. C. (1977). “Modulation
transfer function of the EMI CT head scanner,” Med.
Phys. 4, 163 – 167.
Bittencourt, M., Schmidt, B., Seltmann, M., Muschiol, G.,
Ropers, D., Daniel, W., and Achenbach, S. (2011).
“Iterative reconstruction in image space (IRIS) in
cardiac computed tomography: initial experience,”
Int. J. Cardiovasc. Imaging 27, 1081–1087.
Boedeker, K. L., Cooper, V. N., and McNitt-Gray, M. F.
(2007a). “Application of the noise power spectrum in
modern diagnostic MDCT: Part I. Measurement of
noise power spectra and noise equivalent quanta,”
Phys. Med. Biol. 52, 4027–4046.
Boedeker, K. L., and McNitt-Gray, M. F. (2007b).
“Application of the noise power spectrum in modern
diagnostic MDCT: Part II. Noise power spectra and
signal to noise,” Phys. Med. Biol. 52, 4047– 4061.
Bongartz, G., Golding, S., Jurik, A., Leonardi, M., van
Persijn van Meerten, E., Rodrı́guez, R., Schneider, K.,
Calzado, A., Geleijns, J., Jessen, K., Panzer, W.,
Shrimpton, P., and Tosi, G. (2004). European
Guidelines for Multislice Computed Tomography
(European Commission).
Boone, J. M. (1986). “Equivalent spectra as a measure of
beam quality,” Med. Phys. 13, 861 –868.
Boone, J. M. (1988). “The three parameter equivalent
spectra as an index of beam quality,” Med. Phys. 15,
304– 310.
Boone, J. M. (2007). “The trouble with CTDI100,” Med.
Phys. 34, 1364 –1371.
Boone, J. M. (2009). “Dose spread functions in computed
tomography: A Monte Carlo study,” Med. Phys. 36,
4547–4554.
Boone, J. M. (2010). “Method for evaluating bow tie filter
angle-dependent attenuation in CT: Theory and simu-
lation results,” Med. Phys. 37, 40– 48.
Boone, J. M., and Seibert, J. A. (1997). “An accurate
method for computer-generating tungsten anode x-ray
spectra from 30 to 140 kV,” Med. Phys. 24, 1661–1670.
Boone, J. M., Geraghty, E. M., Seibert, J. A., and
Wootton-Gorges, S. L. (2003). “Dose reduction in pedi-
atric CT: A rational approach,” Radiology 228,
352– 360.
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
Bracewell, R. N. (1956). “Strip integration in radio
astronomy,” Aust. J. Physc. 9, 198.
Bracewell, R. N., and Riddle, A. C. (1967). “Inversion of
fan-beam scans in radioastronomy,” Astrophys. J. 150.
Brenner, D. J., and Hall, E. J. (2007). “Computed tomog-
raphy—an increasing source of radiation exposure,”
N. Engl. J. Med. 357, 2277– 2284.
Brooks, R. A., and Chiro, G. D. (1976). “Statistical limita-
tions in x-ray reconstructive tomography,” Med. Phys.
3, 237 –240.
Burgess, A. E. (1999). “The Rose model, revisited,”
J. Opt. Soc. Am. A, 16, 633– 646.
Callahan, M. J., Rodriguez, D. P., and Taylor, G. A.
(2002). “CT of appendicitis in children,” Radiology 224,
325– 332.
Christner, J. A., Kofler, J. M., and McCollough, C. H.
(2010a). “Estimating effective dose for CT using dose-
length product compared with using organ doses:
Consequences of adopting International Commission
on Radiological Protection publication 103 or dual-
energy scanning,” Am. J. Roentgenol. 194, 881 –889.
Christner, J. A., Stierstorfer, K., Primak, A. N.,
Eusemann, C. D., Flohr, T. G., and McCollough, C. H.
(2010b). “Evaluation of z-axis resolution and image
noise for nonconstant velocity spiral CT data recon-
structed using a weighted 3D filtered backprojection
(WFBP) reconstruction algorithm,” Med. Phys. 37,
897– 906.
Christner, J. A., Zavaletta, V. A., Eusemann, C. D.,
Walz-Flannigan, A. I., and McCollough, C. H. (2010c).
“Dose reduction in helical CT: Dynamically adjustable
z-axis X-ray beam collimation,” Am. J. Roentgenol. 194,
W49– W55.
COCIR (2000). European Coordination Committee of the
Radiological Electromedical and Healthcare IT
Industry. Radiation Exposure in Computed
Tomography, 2nd ed., Nagel, H. D., Ed. (COCIR,
Frankfurt).
Cody, D. D., Moxley, D. M., Krugh, K. T., O”Daniel, J. C.,
Wagner, L. K., and Eftekhari, F. (2004). “Strategies for
formulating appropriate MDCT techniques when
imaging the chest, abdomen, and pelvis in pediatric
patients,” Am. J. Roentgenol. 182, 849 –859.
Cohen, G., and DiBianca, F. A. (1979). “The use of
contrast-detail—dose evaluation of image quality in a
computed tomographic scanner,” J. Comput. Assist.
Tomogr. 3, 189– 195.
Conway, B. J., McCrohan, J. L., Antonsen, R. G., Rueter,
F. G., Slayton, R. J., and Suleiman, O. H. (1992).
“Average radiation dose in standard CT examinations
of the head: Results of the 1990 NEXT survey,”
Radiology 184, 135– 140.
Cormack, A. M. (1963). “Representation of a function by
its line integrals, with some radiological applications,”
J. Appl. Phys. 34, 2722– 2727.
Crawford, C. R., and King, K. F. (1990). “Computed tom-
ography scanning with simultaneous patient transla-
tion,” Med. Phys. 17, 967 –982.
Dainty, J. C., and Shaw, R. (1974). Image Science,
Principles, Analysis, and Evaluation of Photographic-
Type Imaging Processes (Academic Press, London).
144
Deak, P. D., Smal, Y., and Kalender, W. A. (2010).
“Multisection CT protocols: Sex- and age-specific con-
version factors used to determine effective dose from
dose–length product,” Radiology 257, 158 –166.
Dixon, R. L. (2003). “A new look at CT dose measure-
ment: beyond CTDI,” Med. Phys. 30, 1272– 1280.
Dixon, R. L., and Ballard, A. C. (2007). “Experimental
validation of a versatile system of CT dosimetry using
a conventional ion chamber: Beyond CTDI100,” Med.
Phys. 34, 3399– 3413.
Dixon, R. L., and Boone, J. M. (2010). “Cone beam CT
dosimetry: a unified and self-consistent approach in-
cluding all scan modalities—with or without phantom
motion,” Med. Phys. 37, 2703– 2718.
Dixon, R. L., and Boone, J. M. (2011). “Analytical equa-
tions for CT dose profiles derived using a scatter kernel
of Monte Carlo parentage with broad applicability to CT
dosimetry problems,” Med. Phys. 38, 4251–4264.
Dixon, R. L., Munley, M. T., and Bayram, E. (2005). “An
improved analytical model for CT dose simulation with
a new look at the theory of CT dose,” Med. Phys. 32,
3712–3728.
Droege, R. T., and Morin, R. L. (1982). “A practical
method to measure the MTF of CT scanners,” Med.
Phys. 9, 758 –760.
Duan, X., Wang, J., Yu, L., Leng, S., and McCollough,
C. H. (2011). “CT scanner x-ray spectrum estimation
from transmission measurements,” Med. Phys. 38,
993– 997.
EC (1999). European Commission. 1999 European
Guidelines on Quality Criteria for Computed
Tomography, Report EUR 16262 (European
Commission, Luxembourg).
Einstein, A. J., Elliston, C. D., Arai, A. E., Chen, M. Y.,
Mather, R., Pearson, G. D. N., DeLaPaz, R. L.,
Nickoloff, E., Dutta, A., and Brenner, D. J. (2010).
“Radiation dose from single-heartbeat coronary CT
angiography performed with a 320 –detector row
volume scanner,” Radiology 254, 698 –706.
Faulkner, K., and Moores, B. M. (1984). “Analysis of
x-ray computed tomography images using the noise
power spectrum and autocorrelation function,” Phys.
Med. Biol. 29, 1343– 1352.
FDA (1984). United States FDA Code of Federal
Regulations. 21 CFR 1020.33 - Computed tomography
(CT) equipment, US Government Printing Office,
Washington, DC.
FDA (2002). Food and Drug Administration. “FDA public
health notification: Reducing radiation risk from com-
puted tomography for pediatric and small adult
patients,” Pediatr. Radiol. 32, 314– 316.
Federle, M. P., Goldberg, H. I., Kaiser, J. A., Moss, A. A.,
Jeffrey, R. B., Jr., and Mall, J. C. (1981). “Evaluation
of abdominal trauma by computed tomography,”
Radiology 138, 637– 644.
Flohr, T. G., Leng, S., Yu, L., Aiimendinger, T., Bruder,
H., Petersilka, M., Eusemann, C. D., Stierstorfer, K.,
Schmidt, B., and McCollough, C. H. (2009).
“Dual-source spiral CT with pitch up to 3.2 and 75 ms
temporal resolution: Image reconstruction and assess-
ment of image quality,” Med. Phys. 36, 5641– 5653.
 References
Freeny, P. C., Marks, W. M., Ryan, J. A., and Traverso, L.
W. (1988). “Pancreatic ductal adenocarcinoma: Diagnosis
and staging with dynamic CT,” Radiology 166, 125–133.
Frei, S. P., Bond, W. F., Bazuro, R. K., Richardson, D. M.,
Sierzega, G. M., and Reed, J. F. (2008). “Appendicitis
outcomes with increasing computed tomographic
scanning,” Am. J. Emerg. Med. 26, 39–44.
Frush, D. P., and Applegate, K. (2004). “Computed tom-
ography and radiation: Understanding the issues,”
J. Am. Coll. Radiol. 1, 113–119.
Funama, Y., Awai, K., Nakayama, Y., Kakei, K., Nagasue,
N., Shimamura, M., Sato, N., Sultana, S., Morishita,
S., and Yamashita, Y. (2005). “Radiation dose
reduction without degradation of low-contrast detect-
ability at abdominal multisection CT with a low-tube
voltage technique: Phantom study,” Radiology 237,
905– 910.
Funama, Y., Taguchi, K., Utsunomiya, D., Oda, S.,
Yanaga, Y., Yamashita, Y., and Awai, K. (2011).
“Combination of a low-tube-voltage technique with
hybrid iterative reconstruction (iDose) algorithm at
coronary computed tomographic angiography,”
J. Comput. Assist. Tomogr. 35, 480.
Gagne, R. M. (1989). “Geometrical aspects of computed
tomography: sensitivity profile and exposure profile,”
Med. Phys. 16, 29– 37.
Geleijns, J., Salvado Artells, M., de Bruin, P. W., Matter,
R., Muramatsu, Y., and McNitt-Gray, M. F. (2009).
“Computed tomography dose assessment for a 160 mm
wide, 320 detector row, cone beam CT scanner,” Phys.
Med. Biol. 54, 3141– 3159.
Gies, M., Kalender, W. A., Wolf, H., and Suess, C. (1999).
“Dose reduction in CT by anatomically adapted tube
current modulation. I. Simulation studies,” Med. Phys.
26, 2235–2247.
Goma, C., Ruiz, A., Jornet, N., Latorre, A., Pallerol,
R. M., Carrasco, P., Eudaldo, T., and Ribas, M. (2011).
“Radiation dose assessment in a 320-detector-row CT
scanner used in cardiac imaging,” Med. Phys. 38,
1473–1480.
Gorny, K. R., Leitzen, S. L., Bruesewitz, M. R., Kofler, J. M.,
Hangiandreou, N. J., and McCollough, C. H. (2005).
“The calibration of experimental self-developing
Gafchromic HXR film for the measurement of radi-
ation dose in computed tomography,” Med. Phys. 32,
1010–1016.
Gray, J. E., Archer, B. R., Butler, P. F., Hobbs, B. B.,
Mettler, F. A., Jr., Pizzutiello, R. J., Jr., Schueler,
B. A., Strauss, K. J., Suleiman, O. H., and Yaffe, M. J.
(2005). “Reference values for diagnostic radiology:
Application and impact,” Radiology 235, 354 –358.
Haaga, J. R., Miraldi, F., MacIntyre, W., LiPuma, J. P.,
Bryan, P. J., and Wiesen, E. (1981). “The effect of mAs
variation upon computed tomography image quality as
evaluated by in vivo and in vitro studies,” Radiology
138, 449– 454.
Hanson, K. M. (1979). “Detectability in computed tomo-
graphic images,” Med. Phys. 6, 441 –451.
Hart, D., Hillier, M. C., Wall, B. F., Shrimpton, P. C., and
Bungay, D. (1996). Doses to Patients from Medical
X-ray Examinations in the UK: 1995 Review, Report
145
NRPB-R289 (National Radiological Protection Board,
Chilton, Didcot, Oxon, England).
Hausleiter, J., Meyer, T., Hermann, F., Hadamitzky, M.,
Krebs, M., Gerber, T., McCollough, C. H., Martinoff, S.,
Kastrati, A., Schomig, A., and Achenbach, S. J. (2009).
“Estimated radiation dose associated with cardiac CT
angiography,” JAMA 301, 500– 507.
Hounsfield, G. N. (1973). “Computerized transverse axial
scanning (tomography): Part 1. Description of system,”
Br. J. Radiol. 46, 1016– 1022.
Hounsfield, G. N. (1980). “Nobel Award address.
Computed medical imaging,” Med. Phys. 7, 283 –290.
Hsieh, J. (2003). Computed Tomography: Principles,
Design, Artifacts and Recent Advances, SPIE Press
Monograph PM114 (Society of Photo-Optical
Instrumentation Engineers, Bellingham, WA).
Hsieh, J., Londt, J., Vass, M., Li, J., Tang, X., and
Okerlund, D. (2006). “Step-and-shoot data acquisition
and reconstruction for cardiac x-ray computed tomog-
raphy,” Med. Phys. 33, 4236–4248.
Hu, H. (1999). “Multi-slice helical CT: scan and recon-
struction,” Med. Phys. 26, 5 –18.
Hu, H., and Fox, S. H. (1996). “The effect of helical pitch
and beam collimation on the lesion contrast and slice
profile in helical CT imaging,” Med. Phys. 23,
1943–1954.
Huda, W. (2002a). “Dose and image quality in CT,”
Pediatr. Radiol. 32, 709– 713; discussion 751– 754.
Huda, W. (2002b). “Effective doses to adult and pediatric
patients,” Pediatr. Radiol. 32, 272– 279.
Huda, W., Atherton, J. V., Ware, D. E., and Cumming,
W. A. (1997). “An approach for the estimation of effect-
ive radiation dose at CT in pediatric patients,”
Radiology 203, 417– 422.
Huda, W., Scalzetti, E. M., and Levin, G. (2000a).
“Technique factors and image quality as functions of
patient weight at abdominal CT,” Radiology 217,
430– 435.
Huda, W., Scalzetti, E. M., and Roskopf, M. (2000b).
“Effective doses to patients undergoing thoracic com-
puted tomography examinations,” Med. Phys. 27,
838– 844.
Huda, W., Ravenel, J. G., and Scalzetti, E. M. (2002a).
“How do radiographic techniques affect image quality
and patient doses in CT?,” Semin Ultrasound CT MR
23, 411– 422.
Huda, W., Sajewicz, A. M., Ogden, K. M., Scalzetti,
E. M., and Dance, D. R. (2002b). “How good is the ACR
accreditation phantom for assessing image quality
in digital mammography?,” Acad. Radiol. 9, 764 –
772.
Huda, W., Lieberman, K. A., Chang, J., and Roskopf, M.
L. (2004). “Patient size and x-ray technique factors in
head computed tomography examinations. II. Image
quality,” Med. Phys. 31, 595– 601.
Huda, W., Sterzik, A., Tipnis, S., and Schoepf, U. J.
(2010). “Organ doses to adult patients for chest CT,”
Med. Phys. 37, 842 –847.
ICRP (2007). International Commission on Radiological
Protection. The 2007 Recommendations of the
International Commission on Radiological Protection,
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
ICRP Publication 103. Ann. ICRP 37(2– 4). (Elsevier
Health Science, Oxford, UK).
ICRU (2011). International Commission on Radiation
Units and Measurements. Fundamental Quantities
and Units for Ionizing Radiation, ICRU Report 85a.
J. ICRU 11. (Oxford University Press, Oxford).
Image Gently (2011). “Image Gently and CT Scans,” http
://www.pedrad.org/associations/5364/ig/?page=614
ImPACT (2004). ImPACT Organization. “ImPACT ctdi
tables,” http://www.impactscan.org/ctditables.htm
ImPACT (2011). ImPACT Organization. “ImPACT’s ct
dosimetry tool” http://www.impactscan.org/ctdosimetry
.htm
IEC (2009). International Electrotechnical Commission.
Medical Electrical Equipment. Part 2-44: Particular
Requirements for the Basic Safety and Essential
Performance of X-Ray Equipment for Computed
Tomography. IEC publication No. 60601-2-44. ed. 3.1
(International Electrotechnical Commission Central
Office, Geneva, Switzerland).
Jakobs, T. F., Becker, C. R., Ohnesorge, B., Flohr, T.,
Suess, C., Schoepf, U. J., and Reiser, M. F. (2002).
“Multislice helical CT of the heart with retrospective
ECG gating: Reduction of radiation exposure by
ECG-controlled tube current modulation,” Eur. Radiol.
12, 1081–1086.
Johns, H. E., and Cunningham, J. R. (1974). The Physics of
Radiology, 3rd ed. (Charles C. Thomas, Springfield, IL).
Johnson, T. R., Krauss, B., Sedlmair, M., Grasruck, M.,
Bruder, H., Morhard, D., Fink, C., Weckbach, S.,
Lenhard, M., Schmidt, B., Flohr, T., Reiser, M. F., and
Becker, C. R. (2007). “Material differentiation by dual
energy CT: Initial experience,” Eur. Radiol. 17,
1510–1517.
Jones, D. G., and Shrimpton, P. C. (1991). Survey of CT
Practice in the UK. Part 3: Normalised Organ Doses
Calculated using Monte Carlo Techniques, Report
NRPB-SR250 (National Radiological Protection Board,
Chilton, UK).
Jucius, R. A., and Kambic, G. X. (1980). “Measurements
of computed tomography x-ray fields utilizing the
partial volume effect,” Med. Phys. 7, 379– 382.
Judy, P. F. (1976). “The line spread function and modula-
tion transfer function of a computed tomographic
scanner,” Med. Phys. 3, 233 –236.
Kalender, W. A. (2011). Computed Tomography:
Fundamentals, System Technology, Image Quality,
Applications, 3rd ed. (Publicis Publishing, Erlangen,
Germany).
Kalender, W. A., Perman, W. H., Vetter, J. R., and Klotz,
E. (1986). “Evaluation of a prototype dual-energy com-
puted tomographic apparatus. I. Phantom studies,”
Med. Phys. 13, 334 –339.
Kalender, W. A., Seissler, W., Klotz, E., and Vock, P.
(1990). “Spiral volumetric CT with single-breath-hold
technique, continuous transport, and continuous
scanner rotation,” Radiology 176, 181 –183.
Kalender, W. A., Wolf, H., and Suess, C. (1999). “Dose re-
duction in CT by anatomically adapted tube current
modulation. II. Phantom measurements,” Med. Phys.
26, 2248–2253.
146
Kalra, M. K., Maher, M. M., Toth, T. L., Schmidt, B.,
Westerman, B. L., Morgan, H. T., and Saini, S. (2004).
“Techniques and applications of automatic tube
current modulation for CT,” Radiology 233, 649– 657.
Kalra, M. K., Rizzo, S., Maher, M. M., Halpern, E. F.,
Toth, T. L., Shepard, J. A., and Aquino, S. L. (2005).
“Chest CT performed with z-axis modulation:
Scanning protocol and radiation dose,” Radiology 237,
303– 308.
Kleinman, P. L., Strauss, K. J., Zurakowski, D., Buckley,
K. S., and Taylor, G. A. (2010). “Patient size measured on
CT images as a function of age at a tertiary care chil-
dren”s hospital,” Am. J. Roentgenol. 194, 1611–1619.
Kruger, R. L., McCollough, C. H., and Zink, F. E. (2000).
“Measurement of half-value layer in x-ray CT: A com-
parison of two noninvasive techniques,” Med. Phys. 27,
1915–1919.
Kuhl, D. E., and Edwards, R. Q. (1968). “Rapid brain
scanner with self contained computer and CRT display
for both rectilinear and transverse section viewing,”
J. Nucl. Med. 9, 332.
La Riviere, P. J. (2005). “Penalized-likelihood sinogram
smoothing for low-dose CT,” Med. Phys. 32,
1676–1683.
La Riviere, P. J., Bian, J., and Vargas, P. A. (2006).
“Penalized-likelihood sinogram restoration for com-
puted tomography,” IEEE Trans. Med. Imaging 25,
1022–1036.
Larson, D. B., Johnson, L. W., Schnell, B. M., Goske, M.
J., Salisbury, S. R., and Forman, H. P. (2011a). “Rising
use of CT in child visits to the emergency department
in the United States, 1995– 2008,” Radiology 259,
793– 801.
Larson, D. B., Johnson, L. W., Schnell, B. M., Salisbury,
S. R., and Forman, H. P. (2011b). “National trends in
CT use in the emergency department: 1995–2007,”
Radiology 258, 164– 173.
Lehmann, L. A., Alvarez, R. E., Macovski, A., Brody,
W. R., Pelc, N. J., Riederer, S. J., and Hall, A. L.
(1981). “Generalized image combinations in dual KVP
digital radiography,” Med. Phys. 8, 659 –667.
Leitz, W., Axelsson, B., and Szendro, G. (1995).
“Computed tomography dose assessment: A practical
approach,” Radiat. Prot. Dosim. 57, 377– 380.
Lell, M., Marwan, M., Schepis, T., Pflederer, T., Anders,
K., Flohr, T., Allmendinger, T., Kalender, W., Ertel, D.,
Thierfelder, C., Kuettner, A., Ropers, D., Daniel, W. G.,
and Achenbach, S. (2009). “Prospectively ECG-triggered
high-pitch spiral acquisition for coronary CT angiog-
raphy using dual source CT: Technique and initial ex-
perience,” Eur Radiol, 19, 2576–2583.
Li, T., Li, X., Wang, J., Wen, J., Lu, H., Hsieh, J., and
Liang, Z. (2004). “Nonlinear approach to sinogram
smoothing for low-dose x-ray CT, ” IEEE Trans. Nucl.
Sci. 51, 2505–2513.
Linton, O. W., and Mettler, F. A., Jr. (2003). “National
conference on dose reduction in CT, with an emphasis
on pediatric patients,” Am. J. Roentgenol. 181,
321– 329.
Liu, H. L., Liu, R. R., Reeve, D. M., Shepard, S. J., and
Willis, C. E. (2005). “Measurement of CT radiation
 References
profile width using CR imaging plates,” Med. Phys. 32,
2881–2887.
Manduca, A., Yu, L., Trzasko, J. D., Khaylova, N., Kofler,
J. M., McCollough, C. M., and Fletcher, J. G. (2009).
“Projection space denoising with bilateral filtering and
CT noise modeling for dose reduction in CT,” Med.
Phys. 36, 4911– 4919.
Mathieu, K. B., McNitt-Gray, M. F., Zhang, D., Kim, H.
J., and Cody, D. D. (2010). “Precision of dosimetry-
related measurements obtained on current multidetec-
tor computed tomography scanners,” Med. Phys. 37,
4102–4109.
McCollough, C. H. (2003). “Patient dose in cardiac com-
puted tomography,” Herz 28, 1– 6.
McCollough, C. H. (2005). “Automatic exposure control in
CT: Are we done yet?,” Radiology 237, 755 –756.
McCollough, C. H. (2006). “It is time to retire the com-
puted tomography dose index (CTDI) for CT quality
assurance and dose optimization,” Med. Phys. 33,
1189 –1191.
McCollough, C. H. (2006). “Standardization in CT ter-
minology: A physicist’s perspective,” Radiology 241,
661– 662.
McCollough, C. H. (2009). “Re: Maximizing dose reductions
with cardiac CT,” Int. J. Cardiovasc. Imaging 25, 647.
McCollough, C. H., and Zink, F. E. (1999). “Performance
evaluation of a multi-slice CT system,” Med. Phys. 26,
2223–2230.
McCollough, C. H., Zink, F. E., Kofler, J., Matsumoto,
J. S., Thomas, K. B., and Hoffman, A. D. (2002). “Dose
optimization in CT: Creation, implementation and clin-
ical acceptance of size-based technique charts,”
Radiology 225(P), 591.
McCollough, C. H., Bruesewitz, M. R., and Kofler, J. M.,
Jr. (2006). “CT dose reduction and dose management
tools: Overview of available options,” Radiographics
26, 503– 512.
McCollough, C., Leng, S., Schmidt, B., Allmendinger, T.,
Eusemann, C., and Flohr, T. (2009). “Use of a pitch
value of 3.2 in dual source, cardiac CT angiography:
Dose performance relative to existing scan modes,”
(Annual Meeting of the Radiological Society of North
America, Chicago, IL) (abstract).
McCollough, C. H., Leng, S., Yu, L., Cody, D. D., Boone,
J. M., and McNitt-Gray, M. F. (2011). “CT dose index
and patient dose: They are not the same thing,”
Radiology 259, 311 –316.
McCrohan, J. L., Patterson, J. F., Gagne, R. M., and
Goldstein, H. A. (1987). “Average radiation doses in a
standard head examination for 250 CT systems,”
Radiology 163, 263– 268.
McGahan, J. P., and Dodd, G. D. (2001). “Radiofrequency
ablation of the liver,” Am. J. Roentgenol. 176, 3–16.
McGahan, J. P., Loh, S., Fitzgerald, E., Koppie, T.,
Evans, C. P., Dall’Era, M., and Li, C. S. (2011).
“Pretreatment imaging can be used to select imaging
guidance, ultrasound alone versus CT plus ultrasound,
for percutaneous renal radiofrequency ablation,”
Am. J. Roentgenol. 197, 1244– 1250.
McKenney, S. E., Nosratieh, A., Gelskey, D., Yang, K.,
Huang, S. Y., Chen, L., and Boone, J. M. (2011).
147
“Experimental validation of a method characterizing
bow tie filters in CT scanners using a real-time dose
probe,” Med. Phys. 38, 1406–1415.
McNitt-Gray, M. F. (2002). “AAPM/RSNA Physics
Tutorial for Residents: Topics in CT. Radiation dose in
CT,” RadioGraphics 22, 1541–1553.
McNitt-Gray, M., Angel, E., Turner, A., Stevens, D.,
Primak, A., and Cagnon, C. (2008). “CTDI normalized
to measured beam width as an accurate predictor of
dose variations for multidetector row CT (MDCT) scan-
ners across all manufacturers,” Meeting of the
Radiological Society of North America (RSNA),
Chicago, IL, (abstract).
Mori, S., Endo, M., Nishizawa, K., Tsunoo, T., Aoyama,
T., Fujiwara, H., and Murase, K. (2005). “Enlarged lon-
gitudinal dose profiles in cone-beam CT and the need
for modified dosimetry,” Med. Phys. 32, 1061–1069.
Nakayama, Y., Awai, K., Funama, Y., Hatemura, M.,
Imuta, M., Nakaura, T., Ryu, D., Morishita, S.,
Sultana, S., Sato, N., and Yamashita, Y. (2005).
“Abdominal CT with low tube voltage: Preliminary
observations about radiation dose, contrast enhance-
ment, image quality, and noise,” Radiology 237,
945–951.
Nakonechny, K. D., Fallone, B. G., and Rathee, S. (2005).
“Novel methods of measuring single scan dose profiles
and cumulative dose in CT,” Med. Phys. 32, 98–109.
NAS/NRC (2006). National Academies/National Research
Council. Health Effects from Exposure to Low Levels of
Ionizing Radiation, BEIR VII Phase 2 (National
Academy Press, Washington, DC).
NCRP (2009). National Council on Radiation Protection
and Measurements. Ionizing Radiation Exposure of
the Population of the United States, NCRP Report No.
160 (National Council on Radiation Protection and
Measurements, Bethesda, Maryland).
Newman, B., and Callahan, M. J. (2011). “ALARA (as
low as reasonably achievable) CT 2011—executive
summary,” Pediatr. Radiol. 41 Suppl 2, 453– 455.
Nickoloff, E. L., and Riley, R. (1985). “A simplified ap-
proach for modulation transfer function determina-
tions in computed tomography,” Med. Phys. 12,
437– 442.
Nickoloff, E. L., Dutta, A. K., and Lu, Z. F. (2003).
“Influence of phantom diameter, kVp and scan mode
upon computed tomography dose index,” Med. Phys.
30, 395– 402.
Nyman, U., Ahl, T. L., Kristiansson, M., Nilsson, L., and
Wettemark, S. (2005). “Patient-circumference-adapted
dose regulation in body computed tomography. A prac-
tical and flexible formula,” Acta Radiol. 46, 396– 406.
Ogden, K. M., and Huda, W. (2008). “The effect of meas-
urement location on in-air CTDI values,” Med. Phys.
35, 2657.
Oldendorf, W. H. (1961). “Isolated flying spot detection of
radio-density discontinuities displaying the internal
structural pattern of a complex object,” IRE Trans
Bio-Med Elect BME 8, 68– 72.
Primak, A. N., Fletcher, J. G., Vrtiska, T. J., Dzyubak, O.
P., Lieske, J. C., Jackson, M. E., Williams, J. C., Jr.,
and McCollough, C. H. (2007). “Noninvasive
 RADIATION DOSE AND IMAGE-QUALITY ASSESSMENT IN COMPUTED TOMOGRAPHY
differentiation of uric acid versus non-uric acid kidney
stones using dual-energy CT,” Acad. Radiol. 14,
1441–1447.
Radon, J. (1917). “Über die Bestimmung von Funktionen
durch ihre Integralwerte längs gewisser
Mannigfaltigkeiten,” Ber. Verh. Sächs. Akad. Wiss.
Leipzig, Math.-Nat. kl. 69, 262– 277.
Raff, G. L., Chinnaiyan, K. M., Share, D. A., Goraya, T.
Y., Kazerooni, E. A., Moscucci, M., Gentry, R. E., and
Abidov, A. (2009). “Radiation dose from cardiac computed
tomography before and after implementation of radiation
dose-reduction techniques,” JAMA 301, 2340–2348.
Rao, P. M., Rhea, J. T., Novelline, R. A., McCabe, C. J.,
Lawrason, J. N., Berger, D. L., and Sacknoff, R.
(1997). “Helical CT technique for the diagnosis of ap-
pendicitis: Prospective evaluation of a focused appen-
dix CT examination,” Radiology 202, 139 –144.
Riederer, S. J., Pelc, N. J., and Chesler, D. A. (1978).
“The noise power spectrum in computed x-ray tomog-
raphy,” Phys. Med. Biol. 23, 446– 454.
Rigauts, H., Marchal, G., Baert, A. L., and Hupke, R.
(1990). “Initial experience with volume CT scanning,”
J. Comput. Assist. Tomogr. 14, 675 –682.
Rose, A. (1973). Vision: Human and Electronic (Plenum
Press, New York).
Rybicki, F. J., Otero, H. J., Steigner, M. L., Vorobiof, G.,
Nallamshetty, L., Mitsouras, D., Ersoy, H., Mather, R.
T., Judy, P. F., Cai, T., Coyner, K., Schultz, K.,
Whitmore, A. G., and Di Carli, M. F. (2008). “Initial
evaluation of coronary images from 320-detector row
computed tomography,” Int. J. Cardiovasc. Imaging
24, 535– 546.
Schmidt, B., and Kalender, W. A. (2002). “A fast voxel-
based Monte Carlo method for scanner- and patient-
specific dose calculations in computed tomography,”
Physica Medica 18, 43–53.
Schneiders, N. J., and Bushong, S. C. (1980). “Computer
assisted MTF determination in CT,” Med. Phys. 7,
76–78.
Shope, T. B., Gagne, R. M., and Johnson, G. C. (1981). “A
method for describing the doses delivered by transmis-
sion x-ray computed tomography,” Med. Phys. 8,
488– 495.
Shrimpton, P. C., Hillier, M. C., Lewis, M. A., and Dunn,
M. (2006). “National survey of doses from CT in the
UK: 2003,” Br. J. Radiol. 79, 968– 980.
Siegel, M. J., Schmidt, B., Bradley, D., Suess, C., and
Hildebolt, C. (2004). “Radiation dose and image
quality in pediatric CT: Effect of technical factors and
phantom size and shape,” Radiology 233, 515 –522.
Siewerdsen, J. H., Cunningham, I. A., and Jaffray, D. A.
(2002). “A framework for noise-power spectrum analysis
of multidimensional images,” Med. Phys. 29, 2655–2671.
Silva, A. C., Lawder, H. J., Hara, A., Kujak, J., and
Pavlicek, W. (2010). “Innovations in CT dose reduction
strategy: Application of the adaptive statistical itera-
tive reconstruction algorithm,” Am. J. Roentgenol. 194,
191– 199.
Solomon, J. B., Christianson, O., and Samei, E. (2012).
“Quantitative comparison of noise texture across CT
148
scanners from different manufacturers,” Med. Phys.
39, 6048–6055.
Stolzmann, P., Leschka, S., Scheffel, H., Krauss, T.,
Desbiolles, L., Plass, A., Genoni, M., Flohr, T. G.,
Wildermuth, S., Marincek, B., and Alkadhi, H. (2008).
“Dual-source CT in step-and-shoot mode: Noninvasive
coronary angiography with low radiation dose,”
Radiology 249, 71–80.
Tapiovaara, M. J., and Wagner, R. F. (1985). “SNR and
DQE analysis of broad spectrum X-ray imaging,” Phys.
Med. Biol. 30, 519 –529.
Tipnis, S., Ramachandra, A., Huda, W., Hardie, A.,
Schoepf, J., Costello, P., Flohr, T., and Sedlmair, M.
(2010). “Iterative reconstruction in image space (IRIS)
and lesion detection in abdominal CT,” Proc. SPIE
7622, 76222K-1–76222K-12.
Tucker, D. M., Barnes, G. T., and Chakraborty, D. P.
(1991a). “Semiempirical model for generating tungsten
target x-ray spectra,” Med. Phys. 18, 211– 218.
Tucker, D. M., Barnes, G. T., and Wu, X. Z. (1991b).
“Molybdenum target x-ray spectra: A semiempirical
model,” Med. Phys. 18, 402 –407.
Turner, A. C., Zhang, D., Kim, H. J., DeMarco, J. J.,
Cagnon, C. H., Angel, E., Cody, D. D., Stevens, D. M.,
Primak, A. N., McCollough, C. H., and McNitt-Gray,
M. F. (2009). “A method to generate equivalent energy
spectra and filtration models based on measurement
for multidetector CT Monte Carlo dosimetry simula-
tions,” Med. Phys. 36, 2154– 2164.
Turner, A. C., Zankl, M., DeMarco, J. J., Cagnon, C. H.,
Zhang, D., Angel, E., Cody, D. D., Stevens, D. M.,
McCollough, C. H., and McNitt-Gray, M. F. (2010).
“The feasibility of a scanner-independent technique to
estimate organ dose from MDCT scans: Using CTDIvol
to account for differences between scanners,” Med.
Phys. 37, 1816– 1825.
Tward, D. J., and Siewerdsen, J. H. (2008). “Cascaded
systems analysis of the 3D noise transfer characteristics
of flat-panel cone-beam CT,” Med. Phys. 35, 5510–5529.
Wagner, R. F., and Brown, D. G. (1982). “Overview of a
unified SNR analysis of medical imaging systems,”
IEEE Trans. Med. Imaging 1, 210– 213.
Wagner, R. F., Brown, D. G., and Pastel, M. S. (1979).
“Application of information theory to the assessment of
computed tomography,” Med. Phys. 6, 83–94.
Wang, J., Li, T., Lu, H., and Liang, Z. (2006). “Penalized
weighted least-squares approach to sinogram noise reduc-
tion and image reconstruction for low-dose x-ray computed
tomography,” IEEE Trans. Med. Imaging 25, 1272–1283.
Wilting, J. E., Zwartkruis, A., van Leeuwen, M. S.,
Timmer, J., Kamphuis, A. G., and Feldberg, M. (2001).
“A rational approach to dose reduction in CT:
Individualized scan protocols,” Eur. Radiol. 11,
2627–2632.
Winer-Muram, H. T. (2006). “The solitary pulmonary
nodule,” Radiology 239, 34–49.
Wootton-Gorges, S. L. (2010). “Pediatric trauma,” pp 75–
97 in Essentials of Pediatric Radiology—A
Multimodality Approach (Cambridge University Press,
New York).
 References
Yang, K., Kwan, A. L. C., Huang, S.-Y., Packard, N. J.,
and Boone, J. M. (2008). “Noise power properties of a
cone-beam CT system for breast cancer detection,”
Med. Phys. 35, 5317 –5327.
Yu, L., Li, H., Fletcher, J. G., and McCollough, C. H.
(2010). “Automatic selection of tube potential for radi-
ation dose reduction in CT: A general strategy,” Med.
Phys. 37, 234 –243.
Zeman, R. K., Herlihy, V., Branham, T. A., Bhargavan,
M., Bush, K. M., and McCollough, C. H. (2011). “Can
experienced CT radiologists use technique parameters
to predict excessive patient dose? An analysis of the
ACR CT accreditation database,” J. Am. Coll. Radiol.
8, 275 –280.
Zhang, D., Savandi, A. S., Demarco, J. J., Cagnon, C. H.,
Angel, E., Turner, A. C., Cody, D. D., Stevens, D. M.,
149
Primak, A. N., McCollough, C. H., and McNitt-Gray,
M. F. (2009). “Variability of surface and center position
radiation dose in MDCT: Monte Carlo simulations
using CTDI and anthropomorphic phantoms,” Med.
Phys. 36, 1025 –1038.
Zhang, D., Cagnon, C. H., Villablanca, J. P., McCollough,
C. H., Cody, D. D., Stevens, D. M., Zankl, M.,
Demarco, J. J., Turner, A. C., Khatonabadi, M., and
McNitt-Gray, M. F. (2012). “Peak skin and eye lens
radiation dose from brain perfusion CT based on
Monte Carlo simulation,” Am. J. Roentgenol. 198,
412– 417.
Zhou, H., and Boone, J. M. (2008). “Monte Carlo evalu-
ation of CTDI1 in infinitely long cylinders of water,
polyethylene and PMMA with diameters from 10 mm
to 500 mm,” Med. Phys. 35, 2424– 2431.
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