Adjusting kv to Reduce Dose or Improve Image Quality - How to Do it Right. J. G. Fletcher, MD
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1 Adjusting kv to Reduce Dose or Improve Image Quality - How to Do it Right J. G. Fletcher, MD Associate Professor of Radiology CT Clinical Innovation Center Department of Radiology Mayo Clinic, Rochester MN
2 DISCLOSURES Research Support: Siemens Healthcare Off Label Usage None
3 Background Majority of abdominal CT scans: 120 kv It is possible to reduce to kv* Benefits of low-kv CT: Radiation dose reduction** Increased contrast provides increased conspicuity to enhancing lesions and structures *** 80 kv 120 kv *Funama, et al., Radiology 2005 *Nakayama, et al., Radiology 2005 **Ende, et al., Invest Radiol 1999 **Huda, et al., Med Phys 2004 ***Nakayama, et al. AJR 2006 *** Macari, et al. AJR 2010
4 Lower-kV Benefits Increased Iodine Contrast
5 80 kv 140 kv Lower-kV Benefits Increased Iodine Contrast
6 120 kv, CTDI vol =5.18 mgy 100 kv, CTDI vol =3.98 mgy Lower-kV Benefits Reduced Radiation Dose
7 140kV 80kV Lower-kV Risks Increased Noise or Artifacts
8 The appropriateness of using lower-kv is highly dependent on patient size and diagnostic task
9 Overview How does kv affect iodine enhancement and noise? How does patient size affect this relationship? How can I safely pick lower kv imaging without sacrificing diagnostic image quality? Who is going to benefit from low kv imaging? How can I integrate lower kv imaging into my practice? How do lower kv images look different? Future of lower kv imaging
10 Contrast (CT Number) Technology Assessment Institute: Summit on CT Dose How does kv affect iodine enhancement? Iodine Contrast vs. kvp kvp Patient Small size Medium Large From Bodily et al. RSNA 2008 Iodine att n at 80 kv twice that of 140 kv Relative to iodine att n at 120 kv 70% higher at 80 kv 25% higher at 100 kv
11 linear attenuation coefficient (1/cm) How does kv affect water enhancement? kv 140 kv x-ray energy (kev) Water Cortical Bone Pure Iodine Relative contrast changes only hold for high atomic number substances Iodine, barium NOT water, soft tissue, calcium Courtesy Dr. Lifeng Yu Bruesewitz et al. RSNA 2009
12 How does kv affect iodine enhancement? 80 kv 1193 HU 120 kv 695 HU
13 140 kv 80 kv
14 Relative Contrast Differences due to Iodine Also Increase at Low kv 120 kv 100 kv
15 Relative Contrast Differences due to Iodine Also Increase at Low kv 140 kv 80 kv Macari M et al. AJR 2010
16 Noise (HU) Technology Assessment Institute: Summit on CT Dose How does kv affect iodine noise? Noise vs. kvp (CTDIvol=23mGy) kvp Patient sizesmall Medium Large For large patients, lower kv imaging can result in excessive beam hardening and other artifacts
17 F G 80 kv imaging with excessive artifacts limiting diagnostic quality
18 10 cm 25 cm 40 cm Technology 80 kv Assessment Institute: 100 kvsummit on CT Dose 120 kv 140 kv Figure 5 Courtesy Dr. Lifeng Yu
19 Low kv Imaging: Maintaining Image Quality Issue is noise (patient size) Organ of interest Measurements of size Guimaraes et al. RSNA pts undergoing 80 kv CT 2 3 mm slices IQ, artifact, confidence Multiple pt size measures
20 Association of Patient Size with Unacceptability Odds Ratio p-value 14 x 1.2 mm Liver Pancreas Kidneys Ileum x 0.6 mm Liver Pancreas Kidneys Ileum
21 Association of Patient Size with Unacceptability cm 14 x 1.2 mm 64 x 0.6 mm 90% Sensitivity 90% Sensitivity Liver Pancreas Kidney 36* 37 Ileum 35* 35 Dimension cut-offs (cm) that would achieve 90% sensitivity and 80% sensitivity for prediction of an unacceptable exam * Likely underestimated due to small # of unacceptable cases (n=2 or 3)
22 Association of Patient Size with Unacceptability Lateral width the best predictor of acceptable image quality < 36 cm => 80 kv imaging acceptable < 41 cm => 100 kv imaging acceptable Larger patients may not be able to undergo low kv imaging Patient size selection only insures good quality Dose reduction is considered separately (later)
23 Who is going to benefit from lower kv imaging?
24 Who is going to benefit from lower kv imaging? Limited IV access Limited contrast dose Subtle attenuation differences Young patients Small and medium-sized adult patients
25 Limited IV access 80 kv < 1 cc injection over 3 minutes
26 Limited IV access 2 cc/s with pedal access Imaged at 85 sec
27 Who is going to benefit from lower kv imaging? Limited IV access Limited contrast dose Subtle attenuation differences Young patients Small and medium-sized adult patients
28 Limited Contrast Dose 80 cc Omnipaque due to solitary kidney
29 Who is going to benefit from lower kv imaging? Limited IV access Limited contrast dose Subtle attenuation differences Young patients Small and medium-sized adult patients
30 Subtle Attenuation Differences 80 kv 45 HU diff lesion-liver 120 kv 21 HU diff lesion-liver
31 Who is going to benefit from lower kv imaging? Limited IV access Limited contrast dose Subtle attenuation differences Young patients Small and medium-sized adult patients
32 Low kv to Lower Radiation Dose 120 kv 17.3 mgy 100 kv 7.71 mgy
33 Who is going to benefit from lower kv imaging? Limited IV access Limited contrast dose Subtle attenuation differences Young patients Small and medium-sized adult patients Maintain Radiation Dose (CTDI vol ) Radiation Dose (CTDI vol )
34 Who is going to benefit from lower kv imaging? Limited IV access Limited contrast dose Subtle attenuation differences Young patients Small and mediumsized adult patients Maintain Radiation Dose (CTDI vol ) Radiation Dose (CTDI vol ) Dose-match Look-up table Later
35 Low kv Imaging While Maintaining Dose Limited IV access Limited contrast dose Subtle attenuation differences Size < 36 cm => 80 kv Size 41 cm => 100 kv Plug protocol from 120 kv scan and record CTDI vol Change tube energy Adjust mas upwards until CTDI vol is achieved Make sure you are operating within tube limits Use a look up table with your technique charts
36
37
38 Low kv Imaging While Reducing Dose More complicated Need to consider both patient size and diagnostic task into kv selection process Greater the iodine contrast differences, the greater ability to reduce dose for smaller pts kv selection combined with lowering of dose-matched mas Creates a new technique chart for each diagnostic task L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
39 General Strategy for kv selection Iodine CNR is a not a sufficient image quality index Must also constrain image noise We already know what noise levels we can tolerate CNR CNR ref, and σ α σ ref Relative dose factor (RD) Determine relative dose at each tube potential needed to achieve the same CNR as at the reference kv Within the noise constraint patient size, diagnostic task) L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
40 Here s the idea Consider 80 kv imaging Contrast by 70% L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
41 Here s the idea Consider 80 kv imaging Contrast by 70% Noise by 70% L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
42 Here s the idea Consider 80 kv imaging Contrast by 70% Noise by 70% Contrast 120 Noise 120 L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
43 Here s the idea Consider 80 kv imaging Contrast by 70% Noise by 70% Contrast 120 Noise 120 Improved contrast permits the noise level to increase L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
44 Here s the idea Consider 80 kv imaging Contrast by 70% Noise by 70% Contrast 120 Noise 120 Increased noise permits the dose reduction L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
45 Here s the idea Consider 80 kv imaging Contrast by 70% Noise by 60% Contrast 120 Noise 120 As patients get larger (or task requires less noise), the acceptable increase noise (σ) becomes smaller L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
46 Here s the idea Consider 80 kv imaging Contrast by 70% Noise by 50% Contrast 120 Noise 120 As patients get larger (or task requires less noise), the acceptable increase noise (σ) becomes smaller L. Yu, H. Li, J. Fletcher, C. McCollough, Medical Physics, 37(1), 2010.
47 Here s the idea Consider 80 kv imaging Contrast by 70% Noise by 40% Contrast 120 Noise 120 As patients get larger (or task requires less noise), the acceptable increase noise (σ) becomes smaller The dose reduction will also decline
48 Optimal kv Settings Optimal kv based on RD for different phantom sizes with different noise constraints Noise Constraint Extra Small Small Medium Large Extra Large = 1.0: Routine non-contrast exams = 1.25: Routine contrast-enhanced exams = 1.5: CTA with minimal noise constraint = 2.0: CT exams no noise constraint
49 Dose Reduction Technology Assessment Institute: Summit on CT Dose Dose Reduction vs Phantom Size 80% 70% 60% 50% 40% 30% 20% 10% 0% Extra small Small Medium Large Extra Large Phantom Size
50 Workflow for kv Selection with Dose Reduction Acquire a CT radiograph (e.g., topogram, scout) Select a scanning protocol (mas, pitch) at 120 kv Select the noise constraint parameter CT angiogram: minimal noise constraint ( = ) Routine contrast enhanced chest: moderate noise constraint ( = ) Routine non-contrast enhanced chest: maximum noise constraint ( = 1.0) Routine contrast-enhanced CT enterography: moderate noise constraint ( = 1.25) PhD s - choose the most dose-efficient kv (with the smallest Relative Dose), and adjust the mas, rotation time, and/or pitch MD s use the look-up table for your diagnostic task
51 patient lateral width RD at each kv Image quality index Final output
52 How does this work in clinical practice? Two GI radiologists recently evaluated experience with two automatic kv selection tools based on this paradigm Evaluated image quality, noise level, diagnostic confidence Dose savings ranged from 0 55%, mean of ~ 20% No non-diagnostic studies
53 How do low kv images look different? More contrast, more noise Require modified window-level settings, based on radiologist preference 120 kv 17.3 CTDI vol 100 kv 11.9 CTDI vol
54 Future of Low kv Imaging 100 kv can be practically implemented already in most patients Task-specific technique charts will include kv and mas selection to perform most dose-efficient exam 140 kv imaging may be most dose-efficient for large pts Manufacturers will integrate automatic kv selection tools into the CT system Based on similar principles, but also take automatic exposure control and tube current limits into account Provide a new level of individualization for CT imaging (task + patient-specific) Combine low kv + noise reduction to reduce dose while increasing conspicuity
55 full dose mixed image
56 sig2 B45 ASA
57
58 Lesion Characterization 20 patients 56 lesions 15 with HCC 3 with metastases 1 cyst 1 indeterminate Average size = 1.54 cm 80% (45/56) hypervascular 20% (11/56) hypodense
59 Lesion Conspicuity B43 PSD 80kV B40 PSD 80kV B40 PSD Mixed kv B40 No PSD 80kV Reader 1 Reader 2 Reader 3 Average
60 B43 Denoised 80kV B40 Mixed kv B40 Denoised 80kV B40 Denoised Mixed kv
61 Conclusions Tube energy (kv) selection can benefit your patients Limited IV access, renal insufficiency, iodine-sensitive pathology Dose reduction kv selection is dependent upon patient size and diagnostic task (which affect the acceptable noise in the image) Several pathways to begin kv modulation in your practice Look-up tables for dose-matched exams Technique charts for specific diagnostic tasks that include patient size and kv New automatic kv selection tools available by manufacturers
62 Mayo CT Clinic Innovation Center and Dept. of Radiology
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