Utilization Patterns of Multidetector Computed

Tomography in Elective and Emergency Conditions:

Indications, Exposure Risk, and Diagnostic Gain
Stefania Romano, MD, and Luigia Romano, MD

Computed tomography (CT) seems to be a favorable method in diagnostic workup of

patients. Multidetector (MD) CT technology has allowed joining of a rapid time examination
to dynamic study after intravenous contrast medium administration; wide information
regarding the status of the vessels as well as of the parenchymal organs could be received
from the image analysis. Is the destiny of the MDCT same as that of conventional plain
radiograph in the past: a relatively “simple and rapid” method to make diagnosis? This
review will focus on the use of MDCT considering questions related to radiation dose and
diagnostic gain.
Semin Ultrasound CT MRI 31:53-56 © 2010 Elsevier Inc. All rights reserved.

C omputed tomography (CT) has now become a first line

of imaging modality for radiologists in the diagnostic
workup of patients. Multidetector (MD) CT technology al-
lows rapid examination and dynamic study after intravenous
contrast medium administration; wide-ranging information
regarding the status of the vessels as well as of the parenchy-
mal organs can be obtained from image analysis. In this elec-
tronic era, postprocessing at a dedicated workstation allows
us to make use of image reformations in a simple and direct
way. From detection of a small nodule in the lung paren-
chyma or a small polyp of the colon to an active bleeding
source or tiny lesion of the trachea, the “real” and the “virtual”
but evident findings represent the daily routine for radiolo-
gists. In this background, the destiny (in some institutions
probably the actual rule?) of the MDCT seems to be what in
the past the conventional plain radiography was: a relatively
“simple and rapid” method to make a clinical diagnosis.
When the “easy and fast” becomes the “standard,” it seems
that the risks of overuse are often ignored. As attested by
Brenner and Hall in 2007,1 the increasing exposure to radia-
tion in the population could represent a public health issue in
the future, although the risk for any 1 person is not large. The
critical point related to CT is related to the “dose”: the absorbed
dose represents the energy absorbed per unit of mass (measured
Section of General and Emergency Radiology, Department of Diagnostic
Imaging, “A. Cardarelli” Hospital, Naples, Italy.
Address reprint requests to Stefania Romano, MD, Section of General and
Emergency Radiology, Department of Diagnostic Imaging, “A. Car-
darelli” Hospital, Viale Cardarelli 9, 80131 Naples, Italy. E-mail:
stefromano@libero.it
in Grays); the organ dose majorly determines the level of risk
to organ from radiation; and the effective dose (measured in
Sievert) is proportional to a generic estimate the overall dam-
age to the patient from radiation exposure.1 The organ dose is
the preferred quantity to estimate the radiation risk.1 Radia-
tion doses to organs from CT examination depends on several
factors1 such as the number of scans, the tube current and
scanning time, the size of patient, the axial scan range, the
scan pitch, the tube voltage, and the type of scanner used.1,2
Advances in MDCT technology have made isotropic data
acquisition feasible for nearly every application,3 and the
benefits of routine use of isotropic data for image display and
interpretation are known.3 However, the parameters that af-
fect the radiation dose vary considerably in accordance with
the CT scanner design, and those variations determine the
cost in dose increase relative to the voxel size.3 Image acqui-
sition using narrow or wide detector configuration and beam
collimation can also affect the voxel size and the relationship
between spatial resolution and the radiation dose.3 Image
quality is proportional to radiation dose,4 and improvement
in image quality implies an increased radiation dose.4 Com-
parison of the quality of MDCT images obtained with differ-
ent detector configurations on scanners with 4, 16, 40, and
64 channels and the estimated radiation exposure incurred
with each option, may allow radiologists to better understand
the relationship between radiation dose and voxel size,3 to
help balance the need for diagnostic image quality against the
concern for patient safety.3
The problem of safety in radiation dose related to CT ex-
amination has been considered in various studies and obser-

0887-2171/10/$-see front matter © 2010 Elsevier Inc. All rights reserved. 53

doi:10.1053/j.sult.2009.10.002
54
vations. With the new MDCT technology and the introduc-
tion of hybrid systems, the volume of diagnostic procedures
involving the use of ionizing radiation continue to increase,
including in the pediatric population as well as screening
procedures in asymptomatic adults.5 In an article discussing
Alliance for Radiation Safety in Pediatric Imaging Vendor
Summit, stakeholders were invited to discuss the develop-
ment of better estimates of pediatric patient radiation dose.6
In fact, medical physicists currently use 2 standardized phan-
toms to estimate CT patient radiation dose;6 however, the
adult model may underestimate displayed pediatric CT radi-
ation dose on the console of current CT machines.6 These
stakeholders agreed to partner to improve CT radiation dose
estimates for children.6 The induced potential iatrogenic ma-
lignancy from diagnostic radiation is considered a crucial
concern: according to major national and international orga-
nizations responsible for evaluating radiation risks, it seems
that there is no low-radiation threshold for inducing cancer5
and, consequently, no amount of radiation should be consid-
ered “safe.”5 To reduce the overall radiation dose from CT
procedures in the population, it is important to adjust scan-
ner parameters separately for each individual, to keep radia-
tion dose as low as possible.5
In a study aimed to assess patient dose and occupational
dose in established and new applications of MDCT fluoros-
copy, the study revealed high effective patient doses mainly
for relatively new applications such as CT fluoroscopy-
guided radiofrequency ablations using MDCT, vertebro-
plasty, and percutaneous ethanol injections of tumors.7 Be-
yond complex procedures and expected benefits of the
treatments, what should be considered seems to be the gen-
eral health state of the patient to justify any observed high
effective patient doses.7
Indications for a CT examination, particularly in young
and/or asymptomatic patients should be carefully consid-
ered.5 A critical point to consider is that the appropriateness
of a diagnostic imaging tool must be kept in radiologist’s
hand. The referring clinician may have to be educated by the
radiologist as to the most appropriate modality for the clinical
question. Comprehension and knowledge of the need for
imaging the patient should be a team approach. When refer-
ring clinicians or surgeons seek a radiologist’s opinion, the
radiologist must be well informed to provide precise answers,
particularly in the context of justification of a modality that
delivers low-dose ionizing radiation. With this aim, for ex-
ample, a US national campaign in radiology designed to pro-
mote the need and the opportunities to decrease radiation to
children when CT examination is indicated, demonstrated
that simple and direct safety messages on radiation protec-
tion targeted to medical professionals throughout the radiol-
ogy community, using multiple media, seem to be able to
affect awareness potentially leading to change in practice.8
As attested in a 2008 publication,5 the risk of radiation-
induced cancer is much smaller than the risk of cancer from
natural sources; however, it can become a public health con-
cern if large numbers of the population undergo increased
numbers of CT screening procedures that may even be of
uncertain benefit.5 In this order, CT use needs to be evaluated
S. Romano and L. Romano
on a case-by-case basis,5 considering also the use of low dose
and to account the real short-term benefit for the patient.
Recently, virtual colonoscopy and cardiac CT angiography is
being used as diagnostic or screening tool by physicians and
patients. Due to the increased number of these examinations,
the use of low dose and further improvement in new tech-
nology CT scanners to reduce radiation dose should be aimed
for without loss in diagnostic effectiveness.9,10
Frequent exposure to possibly carcinogenic levels of ionizing
radiation from helical CT scanning is considered a potentially
large public health issue for the medical community.11 Many
studies have shown that organ doses associated with routine
diagnostic CT scans are similar to the low-dose range of ra-
diation received by atomic-bomb survivors.12 The food and
drug administration estimates that a CT examination with an
effective dose of 10 mSv may be associated with an increased
chance of developing fatal cancer for approximately 1 patient
in 2000,12 whereas the biological effects of ionizing radiation
VII lifetime risk model predicts that with the same low-dose
radiation, approximately 1 in 1000 individuals will develop
cancer.12 The general attention to problems related to radia-
tions is high;13,14 in April 2007, the American College of
Radiology released the “White Paper on Radiation Dose in
Medicine”15 in which the panel concluded that the expanding
use of imaging modalities using ionizing radiations such as
CT and nuclear medicine may result in an increased inci-
dence of radiation-related cancer in the exposed population.
As potential solution to this problem, a prevention of the
inappropriate use of such imaging modalities and a studies
optimization was proposed to obtain the best image quality
with the lowest radiation dose.14 Additional practical sugges-
tions to minimize radiation risk were also to include educa-
tion for all stakeholders in the principles of radiation safety
and preferential use of alternative (nonionizing) imaging
techniques (magnetic resonance imaging and ultrasound).15
The use of alternative diagnostic modalities to MDCT
could be potentially easier to adopt in elective scenarios,
whereas in an emergency setting, the need for precise infor-
mation related to imaging findings in as short a time as pos-
sible makes alternative imaging methods less desirable, par-
ticularly in the critical patient. In traumatized patients,
conventional radiography and ultrasound examinations can
represent the basic diagnostic tools;16 however, MDCT with
its shorter scan time and increased accuracy has become the
gold standard for many indications in trauma imaging.16 Be-
cause of the higher radiation dose, the use of MDCT should
be carefully assessed in younger patient population,16-18 and
optimization of imaging parameters has to be performed to
minimize exposure and maximize diagnostic safety.16 Be-
yond these undoubted concerns and required attentions,
trauma care benefits from the use of imaging technologies.19
However, questions and problems related to the use of the
MDCT examination in trauma still exist: CT scans should not
replace careful clinical examination and should be used only
in appropriate patients;19 by contrast, potential risk from
missed important and often unsuspected findings that could
be evident at CT examination must be an additional consid-
eration to be kept in mind.
Utilization patterns of MDCT
A recent study estimated cumulative radiation exposure
and lifetime attributable risk (LAR) of radiation-induced can-
cer from CT scanning of adult patients at a tertiary care aca-
demic medical center.20 The study comprised 31,462 pa-
tients who underwent diagnostic CT in 2007 and had
undergone 190,712 CT examinations over the previous 22
years.20 Thirty-three percent of patients underwent 5 or more
lifetime CT examinations, and 5% underwent between 22
and 132 examinations.20 Fifteen percent received estimated
cumulative effective doses of more than 100 mSv, and 4%
received between 250 and 1375 mSv.20 CT exposures were
estimated to produce 0.7% of total expected baseline cancer
incidence and 1% of total cancer mortality.20 Seven percent
of the patient population had estimated LAR greater than 1%,
of which 40% had either no malignancy history or a cancer
history without evidence of residual disease.20 Cumulative
CT radiation exposure added incrementally to baseline can-
cer risk in the cohort:21 most patients accrue low radiation-
induced cancer risks, but a subgroup seems to be potentially
at higher risk due to recurrent CT imaging.20
The widespread use of MDCT in emergency seems to be
gaining interest all round the world. Another recent study
evaluated the justification and radiation risk of patients who
undergo multiple CT scans during their hospital stay for
emergency condition,22 where Griffey and Sodickson23
(2009) defined a conservative estimate of the number of pa-
tients undergoing repeat or multiple emergency department
CT studies, quantifying their cumulative CT radiation doses
and LAR of developing cancer. In this study, all patients at a
tertiary care adult academic medical center with at least 3
emergency department visits within a 1-year period that in-
cluded CT of the neck, chest, abdomen, or pelvis were con-
sidered,23 identifying all diagnostic CT studies over the pre-
vious 7.7 years.23 The authors calculated cumulative
radiation doses by summing typical effective doses of the
anatomic regions scanned, and LAR using the population-
averaged dose-to-risk conversion factor of 1 cancer per 1000
patients receiving a 10 mSv dose, in accordance with the
seventh biological effects of ionizing radiation VII report.23
Repeat imaging of the same study type represented at least
half of the imaging for 72% of the patient population and all
the imaging for 12%.23 A small proportion (1.9%) of emer-
gency department patients undergoing CT of the neck, chest,
abdomen, or pelvis have high cumulative rates of multiple or
repeat imaging24; this patient subgroup was considered to
have a heightened risk of developing cancer from cumulative
CT radiation exposure.23 In an Emergency situation the
health benefit of CT-related diagnostic information is imme-
diate24 and not rarely life-saving, whereas the risk of induced
cancer is decades away,24 with conservative estimates of the
benefit-to-risk ratio for CT equal to 100:1 and higher.24 As
assessed by Boone24 (2006) that CT examination should not
be performed for inappropriate indications.
In a recently published article by Huber-Wagner et al21 in
2009, a retrospective multicenter study was made to com-
pare the probability of survival in patients with blunt trauma
who did or did not undergo a whole-body CT examination
during resuscitation. The authors found that 32% of 4621
55
patients who were considered underwent whole-body CT
scan and the relative reduction in mortality based on trauma
and injury severity score was 25%, whereas that based on
revised injury severity classification was 13%.21 This result
seems to attest that whole-body CT examination in poly-
trauma patient can reduce the probability of death.21 Al-
though the greater radiation exposure of a whole-body CT
examination and the potential dangerous effects, the better
diagnostic accuracy has to be considered: the early recogni-
tion of findings implies a prompt therapeutic plan.21
The usefulness of a prompt diagnosis and the risk from
radiation due to CT examination have to be evaluated case-
by-case, particularly but not exclusively, in emergency,
where the time has a very high cost in terms of life-saving for
patients care and treatment.
References
1. Brenner DJ, Hall EJ: Computed tomography—an increasing source of
radiation exposure. N Engl J Med 357:2277-2284, 2007
2. McNitt-Gray MF: AAPM/RSNA Physics tutorial for residents—topics in
CT: radiation dose in CT. Radiographics 22:1541-1553, 2002
3. Dalrymple NC, Prasad SR, El-Merhi FM, et al: Price of isotropy in
multidetector CT. Radiographics 27:49-62, 2007
4. Payne JT: CT radiation dose and image quality. Radiol Clin North Am
43:953-962, 2005
5. Iakovou I, Karavida N, Kotzassarlidou M: The computerized tomogra-
phy scans and their dosimetric safety. Hell J Nucl Med 11:82-85, 2008
6. Strauss KJ, Goske MJ, Frush DP, et al: Image Gently Vendor Summit:
Working together for better estimates of pediatric radiation dose from
CT. AJR Am J Roentgenol 192:1169-1175, 2009
7. Joemai RM, Zweers D, Obermann WR, et al: Assessment of patient and
occupational dose in established and new applications of MDCT fluo-
roscopy. AJR Am J Roentgenol 192:881-886, 2009
8. Goske MJ, Applegate KE, Boylan J, et al: Image Gently(SM): A national
education and communication campaign in radiology using the science
of social marketing. J Am Coll Radiol 5:1200-1205, 2008
9. Wang J, Wang S, Li L, et al: Virtual colonoscopy screening with ultra
low-dose CT and less-stressful bowel preparation: A computer simula-
tion study. IEEE Trans Nucl Sci 55:2566-2575, 2008
10. Chinnaiyan KM, McCullough PA: Optimizing outcomes in coronary
CT imaging. Rev Cardiovasc Med 9:215-224, 2008
11. Birnbaum S: Radiation safety in the era of helical CT: A patient-based
protection program currently in place in two community hospitals in
New Hampshire. J Am Coll Radiol 5:714-718, 2008
12. Semelka RC, Armao DM, Elias J Jr, et al: Imaging strategies to reduce the
risk of radiation in CT studies, including selective substitution with
MRI. J Magn Reson Imaging 25:900-909, 2007
13. Chen MM, Coakley FV, Kaimal A, et al: Guidelines for computed to-
mography and magnetic resonance imaging use during pregnancy and
lactation. Obstet Gynecol 112:333-340, 2008
14. Ament L: Patient safety. In the wake of safety concerns, hospitals revise
CT scan protocols. Hosp Health Netw 82:14, 2008
15. Picano E, Vano E, Semelka R, et al: The American College of Radiology
white paper on radiation dose in medicine: Deep impact on the practice
of cardiovascular imaging. Cardiovasc Ultrasound 5:37, 2007
16. Körner M, Reiser M, Linsenmaier U: Imaging of trauma with multi-
detector computed tomography. Radiologe 49:510-515, 2009
17. Broder JS: CT utilization: The emergency department perspective. Pe-
diatr Radiol 38:S664-S669, 2008 (suppl 4)
18. Markel TA, Kumar R, Koontz NA, et al: The utility of computed tomog-
raphy as a screening tool for the evaluation of pediatric blunt chest
trauma. J Trauma 67:23-28, 2009
56
19. Hui CM, MacGregor JH, Tien HC, et al: Radiation dose from initial
trauma assessment and resuscitation: Review of the literature. Can
J Surg 52:147-152, 2009
20. Sodickson A, Baeyens PF, Andriole KP, et al: Recurrent CT, cumulative
radiation exposure, and associated radiation-induced cancer risks from
CT of adults. Radiology 251:175-184, 2009
21. Huber-Wagner S, Lefering R, Qvick LM, et al: Effect of whole-body CT
during trauma resuscitation on survival: A retrospective, multicenter
study. Lancet 373:1455-1461, 2009
S. Romano and L. Romano
22. Thomson KR, Street M, Van Every B, et al: Radiation exposure and the
justification of CT scanning in an Australian hospital Emergency De-
partment. Intern Med J (in press)
23. Griffey RT, Sodickson A: Cumulative radiation exposure and cancer
risk estimates in emergency department patients undergoing repeat or
multiple CT. AJR Am J Roentgenol 192:887-892, 2009
24. Boone JM: Multidetector CT: Opportunities, challenges, and concerns
associated with scanners with 64 or more detector rows. Radiology
241:334-337, 2006