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Effect of CT modality in patient doses and image quality in pediatric CT

Prepared by: Assmaa Elkabbashi Hamed Ahmad Bsc in medical physics, Alneelan University

The use of CT has increased rapidly in the past two decades, since its introduction in 1973(3); the computed tomography has established itself as primary diagnostic imaging modality. Subsequent to the introduction of helical scanning in late 1980s and appears of multi row detector in the late 1990s (1). Multi-slice or multi-detector row CT scanners, capable of imaging four simultaneous, parallel slices in a single rotation, since then, scanners With 6, 8, 10 and 16 slice capabilities have become available. Most recently 32, 40, 64, 128 and 256 slice scanners have been announced and the trend for increased capabilities and hence extended applications of CT is certain to continue. (2). CT scanning has been introduced as a high radiation dose modality, when compared to other diagnostic X-ray techniques as scanner technology has developed and its use has become more widespread, concerns over patient radiation doses from CT have grown. The amount of radiation dose a patient receives from a CT scan depends upon two factors, the design of the scanner and also on the way that the scanner is used (2). The designs of single slice and multi-slice scanners are similar in most aspects that affect radiation dose, but multi-slice scanning can potentially result in higher radiation risk to the patient due to increased capabilities allowing long scan lengths at high tube currents. Many studies suggested that because of increasing of population that undergoing CT scan, the implications of ct radiation doses on public health effect can be s significant. Causing cancer because of highly radiation dose ((4) Radiation dose is particularly important in children because of the relatively increased lifetime cancer risk of children compared with that of adult. The organ radio-sensitivity and the effective radiation dose from an individual CT examination were higher in children than in adults. The thyroid gland, breast tissue, and gonads are structures that have an increased sensitivity to radiation in growing children.

This means that a similar radiation dose per gram weight of tissue has a greater potential for developing fatal cancer The aim of this study to evaluate the differences between different types of multislice modality will impact on radiation doses and image quality.

Factors affecting radiation dose:

First: the design of CT scanner factors; there's no difference in features that affect dose and dose efficiency between single slice and multislice, the only exception is that the single bank of detectors of a single slice scanner is replaced by multiple detector banks along the z-axis It is this factor This primarily causes differences in dose efficiency between single and multislice scanners. The factor that can effect on dose and dose efficiency are x-ray tube filtration and x-ray beam shaping filter, collimator design, axis to focus distance, detector material and Number, width and spacing of detectors. Second: the scanner use User selected scanning parameters, such as kV, mAs and scan length, will largely determine the radiation dose to the patient. The increased capabilities of multi-slice scanners, which allow higher mAs values, longer scan lengths and multi-phase contrast studies, have the potential of directly increasing patient doses. Another indirect but significant effect on dose can result from the imaged slice width. Scanning is usually performed with narrower slices than on single slice scanners, so for the same noise, higher mAs values would need to be used. Third factor is Geometric efficiency which means is the proportion of the total beam that is utilized in the imaging process. If the geometric efficiency decreases from 100% to 50% whilst all other factors are kept equal, then, to maintain the same image quality, the dose would need to be doubled. The overall geometric efficiency is sub-divided into two aspects. The first is the z-axis geometric efficiency, where the proportion of the overall X-ray beam width (dose profile) utilized along the long axis of the patient is considered. The second aspect is the detector array geometric efficiency. This defines the proportion of the overall detector area that contains active detector material.

The forth is helical pitch which On multi-slice scanners, as on single slice systems, the absorbed radiation dose is inversely proportional to pitch if the tube current time product (mAs) and tube potential (kV) are kept constant Due to the nature of the reconstruction method used. The fifth is dose optimization as it knows that the patient dose is highly dependent on scan parameter (kV, mAs, focal spot size, scan field of view, slice width and pitch and additional variable as reconstruction parameters such as the reconstruction matrix, reconstruction field of view and reconstruction algorithm). The final factor is Automatic tube current control (AECs) which is critical factor control the exposure, it operate by adjusting the length of exposure to produce X-ray films with a consistent level of optical density, regardless of the patient size. This avoids over- and under-exposures of the radiographic film and the necessity for repeat examinations. Manufacturers generally recommend tube current and time settings for different examinations for a standard sized patient (recommended to pediatric) The final point is that it has to achieve ALARA principle; as low as reasonably achievable, consistent with the diagnostic task and the practice must to justify.

Image quality parameters in multislice ct: noise, resolution etc:

The radiation dose is one of the most significant factors determining ct image quality and thereby diagnostic accuracy and the outcome of examination. The radiation dose must be reduced without scarified the image quality. Therefore is important to be familiar with relationship between radiation dose and image quality. Noise describes variation of ct number in physically uniform region. High contrast spatial resolution both in plane and cross plane quantifies the minimum size of high contrast object that can be resolved. Low contrast spatial resolution quantifies the minimum size of low contrast object that can be differentiated from the background which related both to the contract of the material and noise-resolution properties system.

For example: Slice Width dose can be reduced by increasing slice width; although SNR is improved, axial resolution /detail is reduced. While Matrix Size and FOV any increase in these results in improved contrast and spatial resolution, at the expense of dose. Window and Level a narrower window enhances contrast resolution.

There are several kinds of artifacts that can occur in multislice ct. Some affect the quality of the ct exam; others may be confused with pathology. Also there are much type of artifacts such as beam Harding , motion , ring artifact ,metal artifact , partial volume and streak artifact .The influence of presences of artifact is that is may obscure anatomy and pathology or be confused with pathology which will have direct impact on image quality.

Literature Review:
the first study is CT doses in children: a multicentre study conducted by Pages, PhD1, N Buls, MSc2 and M Osteaux, MD, PhD2 The evaluated examination protocols used for common CT procedures of pediatric patients at different hospitals in Belgium in order to determine whether adjustments related to patient size are made in scanning parameters, and to compare patient doses with proposed reference levels. Three pediatric hospitals and one non-pediatric hospital participated in the study. Weighted CT dose-index (CTDIw), doselength product (DLP) and effective dose (E) were evaluated for three patient ages (1year, 5years and 10years) and three common procedures (brain, thorax and abdomen). CTDIw and DLP values higher than the reference levels were found for all types of evaluated examination. E ranged from 0.4 mSv to 2.3mSv, 1.1mSv to 6.6mSv, and 2.3mSv to 19.9mSv for brain, thorax and abdomen examinations, respectively. All centre's but one adapted their protocols as a function of patient size. However, no common trend in the selection of protocols was observed. Some centre's divided the whole range of J

patient size into only two/three groups by age, while others classified the patients into six groups by weight. It was also observed that some centres used the same mAs for the total range of patient sizes and decreased the pitch factor for small children, which resulted in higher doses. This indicates the importance of careful selection of technical scan parameters. If CT parameters used for paediatric patients are not adjusted on the basis of examination type, age and/or size of the child, then some patients will be exposed to an unnecessarily high radiation dose during CT examinations. The another study called Survey of practice in pediatric computed tomography carried by D. Kostova-Lefterova National Centre of Radiobiology and Radiation Protection, Sofia, Bulgaria and J. Vassileva, The purpose of this study was to explore the frequency of pediatric computed tomography (CT) examinations in several hospitals in Bulgaria and to assess the current practice. The standard forms provided by the International Atomic Emergency Agency for survey of the pediatric CT practice were used. Six hospitals provided data on frequency of pediatric CT examinations performed in 2009. Large variations in dose, up to a factor of 4, were found among the centres within the same age group for a given procedure, and in one of the hospitals the paediatric dose was twice higher than the adult dose. Seven departments use dedicated CT protocols for children. Only 4 in 12 departments keep records of patient dose. Dose information for previous examinations is not required by the radiologists. The collected detailed data provided preliminary information how the patient doses in pediatric CT can be reduced. Recommendations were given based on the findings.

Problem of study:
The multislice ct technique has been considered to be the advanced technique in nowadays and have made a marked impact on the role of ct in diagnostic radiology department. Ct scanning has been recognized as high radiation dose modality when compared with other diagnostic x-ray.

The urgent need to have accurate diagnosis with minimum radiation doses is critical, dependent strongly on good image quality and efficient reduction methods.


Evaluate the radiation dose among the different type of multislice


Evaluate the image quality.

Material and method:

Data source of patient. Quality control tools. Data source of protocol.

The method:
The method based on collecting to data of patient (dose that use) from different multislice ct modality 8, 16, 32, 64 and 128. Compare between the results with put in consider the changing of image quality.

CT machine shielding:
To design room for multislice, the shielding requirements dose not differs from single slice room. Isodose curve patterns should be similar, but absolute scattered dose rate values may be higher due to the wider collimated widths available. Changes in protocols in terms of kV, mAs and scan length, as well as a possible increase in patient throughput, need to be considered, and shielding requirements calculated on the basis of typical usage patterns.

Place of study:
Al-Amal hospital.

6 months.


Time frame:

Tim fram e

2. Result and conclusion 1. Introduction, literature review, study problemsand objective

s d o h t e m

Analyze result Chick equipm ent, testing and get result Collect data 0 2 4 6 8 10


week s

Expected outcome:

Increase of awareness of worker and public for the risks that can

may get of using such technique.

Improve the skills of the worker in the field by providing the

adequate training to staff to deal with pediatric patient.

Improve the general performance.

By focusing on this area, help to develop technology, improve the skills of pediatricians and radiological technologists.

Accurate diagnosis depends on image quality which will drain on benefit of patient, hospital and country. The ultimate advantage is improving the general health to pediatric and avoids the expected risk.

The References citation (author, Year). ImPACT publication ( Maria Lewis , 2005 ) (lifeng yu , xin liu, James M kofler,

Juan C Ramirez-Giraldo, Mingliang Qu, Jodie Christner, Joel G Fletcher and Cynthin H McCollough , 2009)

From national cancer instute (Posted: 08/20/2002, Updated: