Diagnostic accuracy and added value of dual-energy subtraction radiography compared to standard conventional radiography using computed tomography as standard of reference

PURPOSE: To retrospectively evaluate diagnostic performance of dual-energy subtraction radiography (DESR) for interpretation of chest radiographs compared to conventional radiography (CR) using computed tomography (CT) as standard of reference. MATERIAL AND METHODS: A total of 199 patients (75 female, median age 67) were included in this institutional review board (IRB)-approved clinical trial. All patients were scanned in posteroanterior and lateral direction with dual-shot DE-technique. Chest CT was performed within ±72 hours. The system provides three types of images: bone weighted-image, soft tissue weighted-image, herein termed as DESR-images, and a standard image, termed CR-image (marked as CR-image). Images were evaluated by two radiologists for presence of inserted life support lines, pneumothorax, pleural effusion, infectious consolidation, interstitial lung changes, tumor, skeletal alterations, soft tissue alterations, aortic or tracheal calcification and pleural thickening. Inter-observer agreement between readers and diagnostic performance were calculated. McNemar's test was used to test for significant differences. RESULTS: Mean inter-observer agreement throughout the investigated parameters was higher in DESR images compared to CR-images (kDESR = 0.935 vs. kCR = 0.858). DESR images provided significantly increased sensitivity compared to CR-images for the detection of infectious consolidations (42% vs. 62%), tumor (46% vs. 57%), interstitial lung changes (69% vs. 87%) and aortic or tracheal calcification (25 vs. 73%) (p<0.05). There were no significant differences in sensitivity for the detection of inserted life support lines, pneumothorax, pleural effusion, skeletal alterations, soft tissue alterations or pleural thickening (p>0.05). CONCLUSION: DESR increases significantly the sensibility without affecting the specificity evaluating chest radiographs, with emphasis on the detection of interstitial lung diseases

Maximum Diameter Measurements of Aortic Aneurysms on Axial CT Images After Endovascular Aneurysm Repair: Sufficient for Follow-up?

Purpose: To assess the accuracy of maximum diameter measurements of aortic aneurysms after endovascular aneurysm repair (EVAR) on axial computed tomographic (CT) images in comparison to maximum diameter measurements perpendicular to the intravascular centerline for follow-up by using three-dimensional (3D) volume measurements as the reference standard. Materials and Methods: Forty-nine consecutive patients (73±7.5years, range 51-88years), who underwent EVAR of an infrarenal aortic aneurysm were retrospectively included. Two blinded readers twice independently measured the maximum aneurysm diameter on axial CT images performed at discharge, and at 1 and 2years after intervention. The maximum diameter perpendicular to the centerline was automatically measured. Volumes of the aortic aneurysms were calculated by dedicated semiautomated 3D segmentation software (3surgery, 3mensio, the Netherlands). Changes in diameter of 0.5cm and in volume of 10% were considered clinically significant. Intra- and interobserver agreements were calculated by intraclass correlations (ICC) in a random effects analysis of variance. The two unidimensional measurement methods were correlated to the reference standard. Results: Intra- and interobserver agreements for maximum aneurysm diameter measurements were excellent (ICC=0.98 and ICC=0.96, respectively). There was an excellent correlation between maximum aneurysm diameters measured on axial CT images and 3D volume measurements (r=0.93, P<0.001) as well as between maximum diameter measurements perpendicular to the centerline and 3D volume measurements (r=0.93, P<0.001). Conclusion: Measurements of maximum aneurysm diameters on axial CT images are an accurate, reliable, and robust method for follow-up after EVAR and can be used in daily routin

Low-dose CT of the lung: potential value of iterative reconstructions

Objectives: To prospectively assess the impact of sinogram-affirmed iterative reconstruction (SAFIRE) on image quality of nonenhanced low-dose lung CT as compared to filtered back projection (FBP). Methods: Nonenhanced low-dose chest CT (tube current-time product: 30mAs) was performed on 30 patients at 100kVp and on 30 patients at 80kVp. Images were reconstructed with FBP and SAFIRE. Two blinded, independent readers measured image noise; two readers assessed image quality of normal anatomic lung structures on a five-point scale. Radiation dose parameters were recorded. Results: Image noise in datasets reconstructed with FBP (57.4 ± 15.9) was significantly higher than with SAFIRE (31.7 ± 9.8, P < 0.001). Image quality was significantly superior with SAFIRE than with FBP (P < 0.01), without significant difference between FBP at 100kVp and SAFIRE at 80kVp (P = 0.68). Diagnostic image quality was present with FBP in 96% of images at 100kVp and 88% at 80kVp, and with SAFIRE in 100% at 100kVp and 98% at 80kVp. There were significantly more datasets with diagnostic image quality with SAFIRE than with FBP (P < 0.01). Mean CTDIvol and effective doses were 1.5 ± 0.7mGy·cm and 0.7 ± 0.2mSv at 100kVp, and 1.4 ± 2.8mGy·cm and 0.5 ± 0.2mSv at 80kVp (P < 0.001, both). Conclusions: Use of SAFIRE in low-dose lung CT reduces noise, improves image quality, and renders more studies diagnostic as compared to FBP. Key Points : • Low-dose computed tomography is an important thoracic investigation tool. • Radiation dose can be less than 1mSv with iterative reconstructions. • Iterative reconstructions render more low-dose lung CTs diagnostic compared to conventional reconstruction

Maximum diameter measurements of aortic aneurysms on axial CT images after endovascular aneurysm repair: sufficient for follow-up?

PURPOSE: To assess the accuracy of maximum diameter measurements of aortic aneurysms after endovascular aneurysm repair (EVAR) on axial computed tomographic (CT) images in comparison to maximum diameter measurements perpendicular to the intravascular centerline for follow-up by using three-dimensional (3D) volume measurements as the reference standard. MATERIALS AND METHODS: Forty-nine consecutive patients (73 ± 7.5 years, range 51-88 years), who underwent EVAR of an infrarenal aortic aneurysm were retrospectively included. Two blinded readers twice independently measured the maximum aneurysm diameter on axial CT images performed at discharge, and at 1 and 2 years after intervention. The maximum diameter perpendicular to the centerline was automatically measured. Volumes of the aortic aneurysms were calculated by dedicated semiautomated 3D segmentation software (3surgery, 3mensio, the Netherlands). Changes in diameter of 0.5 cm and in volume of 10% were considered clinically significant. Intra- and interobserver agreements were calculated by intraclass correlations (ICC) in a random effects analysis of variance. The two unidimensional measurement methods were correlated to the reference standard. RESULTS: Intra- and interobserver agreements for maximum aneurysm diameter measurements were excellent (ICC = 0.98 and ICC = 0.96, respectively). There was an excellent correlation between maximum aneurysm diameters measured on axial CT images and 3D volume measurements (r = 0.93, P < 0.001) as well as between maximum diameter measurements perpendicular to the centerline and 3D volume measurements (r = 0.93, P < 0.001). CONCLUSION: Measurements of maximum aneurysm diameters on axial CT images are an accurate, reliable, and robust method for follow-up after EVAR and can be used in daily routine

Image fusion of coronary CT angiography and cardiac perfusion MRI: a pilot study

Objective: To develop a tool for the image fusion of computed tomography coronary angiography (CTCA) and cardiac magnetic resonance imaging (CMR). Methods: Surface representations and volume-rendered images from fused CTCA/CMR data of five patients with significant coronary artery disease (CAD) on CTCA and perfusion deficits on CMR were generated using a newly developed software prototype. The spatial relationship of significant coronary artery stenosis at CTCA and myocardial defects at CMR was evaluated. Results: Registration of CTCA and CMR images was possible in all patients. The comprehensive three-dimensional visualisation of fused CTCA and CMR data accurately demonstrated the relationship between coronary artery stenoses and myocardial defects in all patients. Conclusion: The introduced tool enables image fusion of CTCA and CMR data sets and allows for correct superposition of the coronary arteries derived from CTCA onto the corresponding myocardial segments derived from CMR. The method facilitates the comprehensive assessment of the functionally relevant CAD by the exact allocation of culprit coronary stenoses to corresponding myocardial defects at a low radiation dos

High-pitch dual-source CT coronary angiography: systolic data acquisition at high heart rates

Objective: To assess the effect of systolic data acquisition for electrocardiography (ECG)-triggered high-pitch computed tomography (CT) on motion artefacts of coronary arteries in patients with high heart rates (HRs). Methods: Eighty consecutive patients (15 women, age 67 ± 14years) with HR ≥70bpm underwent CT angiography of the thoracic aorta (CTA) on 128-slice dual-source CT in ECG-triggered high-pitch acquisition mode (pitch = 3.2) set at 60% (group A, n = 40) or 30% (group B, n = 40) of the RR interval. Two blinded readers graded coronary artery image quality on a three-point scale. Radiation doses were calculated. Results: Inter-observer agreement in grading image quality of the 1,154 coronary segments was good (κ = 0.62). HRs were similar in groups A and B (85 ± 13bpm vs 85 ± 14bpm, p not significant). Significantly fewer coronary segments with non-diagnostic image quality occurred (i.e. score 3) in group B than in group A [2.8% (16/579) vs 8.3% (48/575), p < 0.001]. Seventeen patients (42.5%) of group A and 12 patients (30.0%) of group B had at least one non-diagnostic segment. Effective radiation doses were 2.3 ± 0.3mSv for chest CTA. Conclusion: A systolic acquisition window for high-pitch dual-source CTA in patients with high HRs (≥70bpm) significantly improves coronary artery image quality at a low radiation dos

Dual-step prospective ECG-triggered 128-slice dual-source CT for evaluation of coronary arteries and cardiac function without heart rate control: a technical note

Purpose: To describe prospective ECG-triggered dual-source CT dual-step pulsing (pECGdual_step) for evaluation of coronary arteries and cardiac function. Methods: Fifty-one consecutive patients pre- or post-cardiovascular surgery were examined with adaptive sequential tube current modulated (pECGdual-step) 128-slice dual-source CT without heart rate control (main padding window: 40% RR interval >65bpm/70% RR interval <65bpm). Image quality of coronary arteries was graded (4-point scale), and cardiac function was evaluated. Results: Mean HR was 68bpm. Thirty-seven patients were in stable sinus rhythm (SR); 14 had arrhythmia. Image quality of coronary arteries was diagnostic in 804/816 (98%) of segments. The number of non-diagnostic segments was higher in patients with arrhythmia as compared to those in SR (4% vs. 0.5%; p = 0.01), and there were fewer segments with excellent image quality (79% vs. 94%; p < 0.001) and more segments with impaired image quality (p < 0.001 and p = 0.002). Global and regional LV function could be evaluated in 41 (80%) and 47 (92%) patients, and valvular function in 48 (94%). In 11/14 of patients with arrhythmia, the second step switched to full mAs, increasing radiation exposure to 8.6mAs (p < 0.001). The average radiation dose was 3.8mSv (range, 1.7-7.9) in patients in SR. Conclusion: pECGdual-step128-slice DSCT is feasible for the evaluation of coronary arteries and cardiac function without heart rate control in patients in stable sinus rhythm at a low radiation dos

Diagnostic accuracy of high-pitch dual-source CT for the assessment of coronary stenoses: first experience

Objectives: The objective was to prospectively investigate the diagnostic accuracy of high-pitch (HP) dual-source computed tomography coronary angiography (CTCA) compared with catheter coronary angiography (CCA) for the diagnosis of significant coronary stenoses. Methods: Thirty-five patients (seven women; mean age 62 ± 8years) underwent both CTCA and CCA. CTCA was performed with a second-generation dual-source CT system permitting data acquisition at an HP of 3.4. Patients with heart rates >60bpm were excluded from study enrolment. All coronary segments were evaluated by two blinded and independent observers with regard to image quality on a four-point scale (1: excellent to 4: non-diagnostic) and for the presence of significant coronary stenoses (defined as diameter narrowing exceeding 50%). CCA served as the standard of reference. Radiation dose values were calculated using the dose-length product. Results: Diagnostic image quality was found in 99% of all segments (455/459). Non-diagnostic image quality occurred in a single patient with a sudden increase in heart rate immediately before and during CTCA. Taking segments with non-evaluative image quality as positive for disease, the sensitivity, specificity and positive and negative predictive values were 94, 96, 80 and 99% per segment and 100, 91, 88 and 100% per patient. The effective radiation dose was on average 0.9 ± 0.1mSv. Conclusion: In patients with heart rates ≤60bpm, CTCA using the HP mode of the dual-source CT system is associated with high diagnostic accuracy for the assessment of coronary artery stenoses at sub-milliSievert dose

Low-dose CT coronary angiography for the prediction of myocardial ischaemia

The purpose of this study was to prospectively determine the accuracy of low-dose computed tomography coronary angiography (CTCA) for the diagnosis of functionally relevant coronary artery disease (CAD) using cardiac magnetic resonance (CMR) as a standard of reference. Forty-one consecutive patients (age 64 ± 10years) underwent k-space and time broad-use linear acquisition speed-up technique accelerated CMR (1.5T) and dual-source CTCA using prospective electrocardiography gating within 1day. CTCA lesions were analysed and diameter stenoses of more than 50% and more than 75% were compared with CMR findings taken as the reference standard for assessing the functional relevance of CAD. CMR revealed perfusion defects in 21/41 patients (51%). A total of 569 coronary segments were analysed with low-dose CTCA. The image quality of low-dose CTCA was diagnostic in 566/569 segments (99.5%) in 39/41 patients (95%). Low-dose CTCA revealed stenoses of more than 50% in 58/123 coronary arteries (47.2%) in 24/41 patients (59%) and more than 75% stenoses in 46/123 coronary arteries (37.4%) in 23/41 patients (56%). Using a greater than 50% diameter stenosis, low-dose CTCA yielded the following per artery sensitivity, specificity, positive and negative predictive values, and accuracy for the detection of perfusion defects: 89%, 79%, 72%, 92% and 83%, respectively. Low-dose CTCA is reliable for ruling out functionally relevant CAD, but is a poor predictor of myocardial ischaemi

Low-dose CT and cardiac MR for the diagnosis of coronary artery disease: accuracy of single and combined approaches

To prospectively compare the diagnostic performance of low-dose computed tomography coronary angiography (CTCA) and cardiac magnetic resonance imaging (CMR) and combinations thereof for the diagnosis of significant coronary stenoses. Forty-three consecutive patients with known or suspected coronary artery disease underwent catheter coronary angiography (CA), dual-source CTCA with prospective electrocardiography-gating, and cardiac CMR (1.5Tesla). The following tests were analyzed: (1) low-dose CTCA, (2) adenosine stress-rest perfusion-CMR, (3) late gadolinium enhancement (LGE), (4) perfusion-CMR and LGE, (5) low-dose CTCA combined with perfusion-CMR, (5) low-dose CTCA combined with late gadolinium-enhancement, (6) low-dose CTCA combined with perfusion-CMR and LGE. CA served as the standard of reference. CA revealed >50% diameter stenoses in 68/129 (57.7%) coronary arteries in 29/43 (70%) patients. In the patient-based analysis, sensitivity, specificity, NPV and PPV of low-dose CTCA for the detection of significant stenoses were 100, 92.9, 100 and 96.7%, respectively. For perfusion-CMR and LGE, sensitivity, specificity, NPV, PPV, and accuracy were 89.7, 100, 82.4, and 100%, respectively. In the artery-based analysis, sensitivity and NPV of low-dose CTCA was significantly (P<0.05) higher than that of perfusion-CMR and LGE. All combinations of low-dose CTCA and perfusion-CMR and/or LGE did not improve the diagnostic performance when compared to low-dose CTCA alone. Taking CA as standard of reference, low-dose CTCA outperforms CMR with regard to sensitivity and NPV, whereas CMR is more specific and has a higher PPV than low-dose CTC