Scanning and Radiation Dose Parameters in CT
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1 4 th Stanford Computed Tomography Workshop RADIATION DOSE AND CONTRAST MEDIA IN NEURO & BODY CT Lucas Learning Center, NOV 18, 2010 Scanning and Radiation Dose Parameters in CT Computed Tomography (CT) in the United States in 2007 approx. 70 million scans / year (threefold increase of CT since 1993) Dominik Fleischmann Department of Radiology Stanford University Berrington de Gonzalez et al., Arch Intern Med Estimated number of cancers from 100mSv exposure for 100,000 persons Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VI report Excess cases (including non-fatal) cases in the absence of exposure Excess deaths from exposure to 100 msv deaths in the absence of exposure Berrington de Gonzalez et al., Arch Intern Med All solid cancer Leukemia males females males females ( ) ( (30-300) (20-250) 45,500 36, ( ) 610 ( ) ~ 0.01% / msv Cancer risk 70 (20-220) 50 (10-190) Estimated Radiation Dose Associated with Cardiac CT Angiography Dose-length-pro odut (mgy*cm) n=1965 patients, at 50 study sites Range of medians: mgy*cm msv Hausleitner et al. JAMA. 2009;301: Estimated Radiation Dose Associated with Cardiac CT Angiography Dose-length-pro odut (mgy*cm) n=1965 patients, at 50 study sites Range of medians: mgy*cm msv Hausleitner et al. JAMA. 2009;301:
2 California Bill SB 1237 (signed Sept 2010) Number of CT Scans Perform med in the U.S. in 2007 Estimated using IMV,7 Medica are, and nationalcommercial insurance database. Scan Type Scans (mio) Percent Head Chest Cervical spine Thoracic spine Lumbar spine Abdomen/pelvis CTA chest CTA abdomen CTA pelvis CTA head other cardiac Whole body Colonography calcium scoring Other Total al., Arch Intern Med Berrington de Gonzalez et Radiation Dose in Computed Tomography OBJECTIVE Typical effective dose values Explain risk of radiation exposure and Radiation dose parameters: general (whole body) CT specific milli Sievert [msv] CTDIvol: milligray (mgy) DoseLength product (mgy*cm) Head CT Chest CT Abdomen CT Pelvis CT Abd-Pelv CT Chest x-ray Abdomen x-ray 1-2 msv 5-8 msv 5-10 msv 8-15 msv 0.02 msv 0.07 msv CT dose of 15mSv ~ 750 chest x-rays ~ 4 years backgr. ~ 1:600 cancer (young adult) Average U.S background radiation ~ 3.6 msv C. McCollough, MDCT Course 2003 San Francisco Typical effective dose values Typical effective dose values Head CT Chest CT Abdomen CT Pelvis CT Abd-Pelv CT 1-2 msv 5-8 msv 5-10 msv 8-15 msv Head CT Chest CT Abdomen CT Pelvis CT Abd-Pelv CT C. McCollough, MDCT Course 2003 San Francisco 1-2 msv 5-8 msv 5-10 msv 8-15 msv CT P Head Neck CTA Coronary CT 4-5 msv 5-30 msv Chest 5-8 msv ( mgy) Low-dose Chest 2-5 msv (5-12 mgy) HR-CT msv (3-5 mgy) Average U.S background radiation ~ 3.6 msv C. McCollough, MDCT Course 2003 San Francisco Average U.S background radiation ~ 3.6 msv 2
3 Calculated radiation-induced induced Risk of dying from cancer per msv. Child (0-10y) Estimates, 14 / 100 extrapolated 000 from accidental or occupatonal Adolescent (10-20y) 10 / whole-body exposure to high Adult (20-30y) doses 7.5 / and 100 dose-rates. 000 Risk Adult (30-40y) cannot 3.5 / yet 100 be 000 statistically Adult (60) proven 2.0 / for 100 an 000 effective dose Adult (80) below 1.0 / 20mSv Average 5.0 / % / msv Natural risk / ~ 0.01% / msv Cancer risk (incl. non-fatal) IRCP publication 60 Estimated Risks of Fatal Malignancy of Death from Radiation Exposure and Lifetime Odds of Dying as a Result of Selected Activities of Everyday Life (per msv (calcium score) mSv (coronary CT, cath,..) Individuals) 50mSv (yr radiation worker allowance) mSv (definition of 'low exposure') 0.5 NATURAL fatal cancer 21.2 passive smoking radon in home (US average) 0.3 Motor vehicle accident 1.9 Gerber et al. Circulation 2009 Radiation Dose in Computed Tomography OBJECTIVE Explain risk of radiation exposure and Radiation dose parameters: general (whole body) CT specific milli Sievert [msv] CTDIvol: milligray (mgy) DoseLength product (mgy*cm) Scan Protocol / Dose Optimization? Attempt that scanning and exposure parameters best balance Image quality Other factors, e.g. total scan time Adjustable parameters kv mas Collimation / slice thickness Pitch / table feed per rotation Dose Quantities in CT Instrumentation for measurement of radiation exposure in computed tomography CTDI vol (mgy) CT dose index local dose measured in head or body phantom DLP (mgy cm) dose length product total scan dose displayed on the scanner console E (msv) effective dose biological risk CTDI: local dose (mgy mgy) DLP: local dose length (mgy cm) Morin, R. L. et al. Circulation 2003;107:
4 How to estimate Risk from Exposure How to get E (msv) from CTDI VOL & DLP (mgy cm) Normalized values of effective dose per dose- length product (DLP) over various body regions For whole body exposure, 1mGy = 1mSv For non-uniform and partial irradiation Monte Carlo simulations model dose distributions within the body of calculated x-ray spectra in mathematical phantom Region of Body E / CTDI vol Normalised effective dose, E DLP (msv mgy - 1 cm - 1 ) Neck (20cm) 20% Chest (30cm) 42% Liver (20cm) 32% Sum of the organ doses is the effective dose 0-10 Abd.+Pelv. (40cm) 73% Pelvis (20cm) 41% ImPACT CT Patient Dosimetry Calculator Version 0.99u, 12/12/ European guidelines on quality criteria for Computed Tomography - EUR Conversion Factors for Children (for CT abdomen/pelvis) Age Conversion factor (msv mgy -1 cm -1 ) Neonate year year year year Adult / Practical Example: CTA of the Abdominal Aorta 60 y o man with AAA Using the preset protocol for routine abdom. CTA Siemens Sensation 16 - Topogram -Non-con series 3mm (16 1.5) 1.5) - Monitoring series (bolus) 4.5mm - CTA 1.5mm (16( mm) 1.5mm) PatientProtocol (single DICOM image) Scan kv mas CTDIvol DLP Topogram NON-CON PreMonitoring Monitoring ABD ANGIO Calculated radiation-induced induced Risk of dying from cancer per msv. Child (0-10y) 14 / Adolescent (10-20y) 10 / Adult (20-30y) 7.5 / mSv f 60yo man Adult (30-40y) 3.5 / / Adult (60) 2.0 / :3300 Adult (80) 1.0 / Average 5.0 / Natural risk Natural risk ~1:3 20 mgy ( 75%) ~ 15 msv 1040 mgy cm ( 0.015) ~ 15 msv ~ 0.01% / msv Cancer risk (incl. non-fatal): 0.15% IRCP publication 60 4
5 .. Keep in Mind The amount of information in a CT exam is far greater than an equivalent x-ray huge amount of diagnostic information available Diagnostic image quality is overriding concern Non-diagnostic exam is 100% wasted dose Some dose savings can be achieved without loss of image quality The remainder comes down to dose and image- quality optimization Scan Protocol Optimization start with Review scanning protocols scanning range, patient positioning number of phases appropriate use of automated exposure control new dose reduction techniques (e.g. ASIR) cardiac: gating technique, low heart rate % max. ma 100% - 100% - 20% - 100% - 4% - Retrospectively gated cardiac CT EKG Modulation of Tube Current end syst. diastole diastole 30-70% 70% 'Pulsing Window (%RR)' No Modulation max.ma: full RR min.ma: 100% EKG Modulation max.ma: ma: 30-70%RR max.ma: 70%RR min.ma: 20% 'Min.-Dose' Modulation max.ma: 30-70%RR max.ma: 70%RR min.ma: 4% Radiation Exposure Reduction in Cardiac CT Retrospective Gating no EKG dose modulation 100 % EKG mod. 20% ma: 30-70% RR ~ 70 % EKG mod. 20% ma: 70% RR ~ 50 % EKG mod. 4% ma: 30-70% RR ~ 50 % EKG mod. 4% ma: 70% RR ~ 25 % Prospective Gating prospective std. padding ~ 25 % 100kV dose proportional to square of kv; iodine signal incr.; noise increases too; subtract kV: 100kV: -30% dose (at same ma) - 30% 25mSv 3-5m msv 3mSv retrosp., mindose 70-70, 70, 100kV: mgy, 192 mgy*cm [3.26 msv] retrosp., mindose 70-70, 70, 100kV: mgy, 192 mgy*cm [3.26 msv] 56 yo physician 5'6" (168cm) 133 lbs (60kg) 1.68 BSA HR: 48 bpm 5
6 Scan Protocol Optimization start with Review scanning protocols scanning range, patient positioning number of phases appropriate use of automated exposure control new dose reduction techniques (e.g. ASIR) cardiac: gating technique, low heart rate COMPARE TO REFERENCE VALUES European guidelines on quality criteria for Computed Tomography EUR Table 3: Proposed reference dose values for routine CT examinations on the basis of absorbed dose to air Examination Reference dose value CTDI w (mgy) DLP (mgy cm) Routine head a Face and sinuses a Vertebral trauma b Routine chest b HRCT of lung b Routine abdomen b Liver and spleen b Routine pelvis b Osseous pelvis b Notes: a.data relate to head phantom (PMMA, 16 cm diameter) b.data relate to body phantom (PMMA, 32 cm diameter) European guidelines on quality criteria for Computed Tomography EUR Table 3: Proposed reference dose values for routine CT examinations on the basis of absorbed dose to air Examination Reference dose value CTDI w (mgy) DLP (mgy cm) upper limits (ACR) Routine head a Face and sinuses a Vertebral Head trauma ~ b mgy 460 Routine chest b HRCT of Body lung ~ b mgy 280 Routine abdomen b Liver neuro and spleen perfusion b Routine pelvis b Osseous pelvis b <500mGy Notes: a.data relate to head phantom (PMMA, 16 cm diameter) b.data relate to body phantom (PMMA, 32 cm diameter) Radiation Dose in Computed Tomography OBJECTIVE Explain risk of radiation exposure and Radiation dose parameters: general (whole body) CT specific milli Sievert [msv] CTDIvol: milligray (mgy) DoseLength product (mgy*cm) 2 nd Stanford Computed Tomography Workshop RADIATION DOSE IN ACUTE CARDIOVASCULAR AND NEURO CT Lucas Learning Center, Dec 17, 2009 Thank you 6
7 QUIZ CASE CTA of the Abdominal Aorta 60 y o man with AAA - Topogram - Non-con series 3mm (16 1.5) - Monitoring series (bolus) - CTA 1.5mm (16 1.5mm) PatientProtocol (single DICOM image) What is the effective Dose in msv? Scan kv mas CTDIvol DLP (mgy) (mgy cm) Topogram NON-CON PreMonitoring Monitoring ABD ANGIO Estimate eff. radiation dose! B. mgy % msv A. mgy cm 0. msv Normalized values of effective dose per dose- length product (DLP) over various body regions Region of Body E / CTDI vol dose, E DLP (msv Normalised effective mgy -1 cm -1 ) Neck (20cm) 20% Chest (30cm) 42% Liver (20cm) 32% Abd.+Pelv. (40cm) 73% Pelvis (20cm) 41% Conversion Factors for Children (for CT abdomen/pelvis) Age Conversion factor (msv mgy -1 cm -1 ) Neonate year year year year Adult / European guidelines on quality criteria for Computed Tomography - EUR
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