Iterative reconstruction in CT : optimization of image quality and dose for personalized care

Avec l’augmentation du nombre de scanner et de la dose collective, le risque potentiel d’apparition d’effets stochastiques est accentué. Pour limiter au maximum ce risque, les principes de justification et d’optimisation doivent être appliqués avec rigueur. L’optimisation des pratiques a pour but de délivrer la dose la plus faible possible tout en conservant une qualité diagnostique des images. C’est une tâche complexe qui implique de trouver en permanence un compromis entre la dose délivrée et la qualité image résultante. Pour faciliter cette démarche, des évolutions technologiques ont été développées. Les deux évolutions majeures sont la modulation du courant du tube en fonction de l’atténuation du patient et l’apparition des reconstructions itératives (IR). L’introduction des IR a modifié les habitudes puisqu’elles permettent de conserver des indices de qualité image équivalents en réduisant les doses. Cependant, leurs utilisations s’accompagnent d’une modification de la composition et de la texture de l’image nécessitant d’utiliser des métriques adaptées pour les évaluer. Le but de cette thèse est d’évaluer l’impact d’une utilisation des IR sur la réduction de la dose et sur la qualité des images afin de proposer en routine pour tous les patients, des protocoles avec la dose la plus faible possible et une qualité image adaptée au diagnostic. La première partie de cette thèse est consacrée à une mise au point sur la problématique du compromis dose/qualité image en scanographie. Les métriques de qualité image et les indicateurs dosimétriques à utiliser, ainsi que le principe et l’apport des reconstructions itératives y sont exposés. La deuxième partie est consacrée à la description des trois étapes réalisées dans cette thèse pour atteindre les objectifs. La troisième partie est constituée d’une production scientifique de 7 articles. Le 1er article présente la méthodologie d’optimisation globale permettant la mise en place de protocoles Basses Doses en routine avec utilisation de niveaux modérés des IR. Le 2ème article évalue l’impact et l’apport sur la qualité des images obtenues pour des niveaux de doses très bas. Le 3ème et le 4ème article montrent l’intérêt d’adapter ou de proposer des protocoles optimisés selon la morphologie du patient. Enfin les 3 derniers articles, illustrent la mise en place de protocoles Très Basses Doses pour des structures ayant un fort contraste spontané. Pour ces protocoles les doses sont proches des examens radiographiques avec des niveaux élevés des IR. La démarche d’optimisation mise en place a permis de réduire considérablement les doses. Malgré une modification de la texture et de la composition des images, la qualité des images obtenues pour tous les protocoles était jugée satisfaisante pour le diagnostic par les radiologues. L’utilisation des IR en routine nécessite une évaluation particulière et un temps d’apprentissage pour les radiologues.The increasing number of scanner and the cumulative dose delivered lead to potential risk of stochastic effects. To minimize this risk, optimization on CT usage should be rigorously employed. Optimization aims to deliver the lowest dose but maintaining image quality for an accurate diagnosis. This is a complex task, which requires setting up the compromise between the dose delivered and the resulting image quality. To achieve such goal, several CT technological evolutions have been developed. Two predominant developments are the Tube Current Modulation and the Iterative Reconstruction (IR). The former lays one patient's attenuation, the latter depend on advanced mathematical approaches. Using IR allows one to maintain equivalent image quality values by reducing the dose. However, it changes the composition and texture of the image and requires the use of appropriate metric to evaluate them. The aim of this thesis was to evaluate the impact of using IR on dose reduction and image quality in routine for all patients, protocols with the lowest dose delivered with an image quality suitable for diagnosis. The first part of the thesis addressed the compromise between dose delivered and image quality. Metrics of the image quality and the dosimetric indicators were applied as well the principle and the contribution of IRs were explored. The second part targets the description of the three steps performed in this thesis to achieve the objectives. The third part of the thesis consists of a scientific production of seven papers. The first paper presents the global optimization methodology for the establishment of low dose protocols in routine using moderate levels of IR. The second paper assesses the impact and contribution of IR to the image quality obtained to levels very low doses. The third and the fourth papers show the interest to adapt or propose protocols optimized according to patient's morphology. Finally the last three papers illustrate the development of Very Low Dose protocols for structures with high spontaneous contrast. For these protocols, doses are close to radiographic examinations with high levels of IR. The optimization process implementation has significantly doses reduction. Despite the change on the texture and on composition of the images, the quality of images obtained for all protocols was satisfactory for the diagnosis by radiologists. However, the use of routine IR requires special assessment and a learning time for radiologists

Reconstruction itérative en scanographie : optimisation de la qualité image et de la dose pour une prise en charge personnalisée

The increasing number of scanner and the cumulative dose delivered lead to potential risk of stochastic effects. To minimize this risk, optimization on CT usage should be rigorously employed. Optimization aims to deliver the lowest dose but maintaining image quality for an accurate diagnosis. This is a complex task, which requires setting up the compromise between the dose delivered and the resulting image quality. To achieve such goal, several CT technological evolutions have been developed. Two predominant developments are the Tube Current Modulation and the Iterative Reconstruction (IR). The former lays one patient's attenuation, the latter depend on advanced mathematical approaches. Using IR allows one to maintain equivalent image quality values by reducing the dose. However, it changes the composition and texture of the image and requires the use of appropriate metric to evaluate them. The aim of this thesis was to evaluate the impact of using IR on dose reduction and image quality in routine for all patients, protocols with the lowest dose delivered with an image quality suitable for diagnosis. The first part of the thesis addressed the compromise between dose delivered and image quality. Metrics of the image quality and the dosimetric indicators were applied as well the principle and the contribution of IRs were explored. The second part targets the description of the three steps performed in this thesis to achieve the objectives. The third part of the thesis consists of a scientific production of seven papers. The first paper presents the global optimization methodology for the establishment of low dose protocols in routine using moderate levels of IR. The second paper assesses the impact and contribution of IR to the image quality obtained to levels very low doses. The third and the fourth papers show the interest to adapt or propose protocols optimized according to patient's morphology. Finally the last three papers illustrate the development of Very Low Dose protocols for structures with high spontaneous contrast. For these protocols, doses are close to radiographic examinations with high levels of IR. The optimization process implementation has significantly doses reduction. Despite the change on the texture and on composition of the images, the quality of images obtained for all protocols was satisfactory for the diagnosis by radiologists. However, the use of routine IR requires special assessment and a learning time for radiologists.Avec l’augmentation du nombre de scanner et de la dose collective, le risque potentiel d’apparition d’effets stochastiques est accentué. Pour limiter au maximum ce risque, les principes de justification et d’optimisation doivent être appliqués avec rigueur. L’optimisation des pratiques a pour but de délivrer la dose la plus faible possible tout en conservant une qualité diagnostique des images. C’est une tâche complexe qui implique de trouver en permanence un compromis entre la dose délivrée et la qualité image résultante. Pour faciliter cette démarche, des évolutions technologiques ont été développées. Les deux évolutions majeures sont la modulation du courant du tube en fonction de l’atténuation du patient et l’apparition des reconstructions itératives (IR). L’introduction des IR a modifié les habitudes puisqu’elles permettent de conserver des indices de qualité image équivalents en réduisant les doses. Cependant, leurs utilisations s’accompagnent d’une modification de la composition et de la texture de l’image nécessitant d’utiliser des métriques adaptées pour les évaluer. Le but de cette thèse est d’évaluer l’impact d’une utilisation des IR sur la réduction de la dose et sur la qualité des images afin de proposer en routine pour tous les patients, des protocoles avec la dose la plus faible possible et une qualité image adaptée au diagnostic. La première partie de cette thèse est consacrée à une mise au point sur la problématique du compromis dose/qualité image en scanographie. Les métriques de qualité image et les indicateurs dosimétriques à utiliser, ainsi que le principe et l’apport des reconstructions itératives y sont exposés. La deuxième partie est consacrée à la description des trois étapes réalisées dans cette thèse pour atteindre les objectifs. La troisième partie est constituée d’une production scientifique de 7 articles. Le 1er article présente la méthodologie d’optimisation globale permettant la mise en place de protocoles Basses Doses en routine avec utilisation de niveaux modérés des IR. Le 2ème article évalue l’impact et l’apport sur la qualité des images obtenues pour des niveaux de doses très bas. Le 3ème et le 4ème article montrent l’intérêt d’adapter ou de proposer des protocoles optimisés selon la morphologie du patient. Enfin les 3 derniers articles, illustrent la mise en place de protocoles Très Basses Doses pour des structures ayant un fort contraste spontané. Pour ces protocoles les doses sont proches des examens radiographiques avec des niveaux élevés des IR. La démarche d’optimisation mise en place a permis de réduire considérablement les doses. Malgré une modification de la texture et de la composition des images, la qualité des images obtenues pour tous les protocoles était jugée satisfaisante pour le diagnostic par les radiologues. L’utilisation des IR en routine nécessite une évaluation particulière et un temps d’apprentissage pour les radiologues

Task-Based Image Quality Assessment Comparing Classical and Iterative Cone Beam CT Images on Halcyon^®

Background: Despite the development of iterative reconstruction (IR) in diagnostic imaging, CBCT are generally reconstructed with filtered back projection (FBP) in radiotherapy. Varian medical systems, recently released with their latest Halcyon® V2.0 accelerator, a new IR algorithm for CBCT reconstruction. Purpose: To assess the image quality of radiotherapy CBCT images reconstructed with FBP and an IR algorithm. Methods: Three CBCT acquisition modes (head, thorax and pelvis large) available on a Halcyon® were assessed. Five acquisitions were performed for all modes on an image quality phantom and reconstructed with FBP and IR. Task-based image quality assessment was performed with noise power spectrum (NPS), task-based transfer function (TTF) and detectability index (d’). To illustrate the image quality obtained with both reconstruction types, CBCT acquisitions were made on 6 patients. Results: The noise magnitude and the spatial frequency of the NPS peak was lower with IR than with FBP for all modes. For all low and high-contrast inserts, the values for TTF at 50% were higher with IR than with FBP. For all inserts and all modes, the contrast values were similar with FBP and IR. For all low and high-contrast simulated lesions, d’ values were higher with IR than with FBP for all modes. These results were also found on the 6 patients where the images were less noisy but smoother with IR-CBCT. Conclusions: Using the IR algorithm for CBCT images in radiotherapy improve image quality and thus could increase the accuracy of online registration and limit positioning errors during processing

Spectral CT imaging: technical principles of dual-energy CT and multi-energy photon-counting CT

International audienceSpectral computed tomography (CT) imaging encompasses a unique generation of CT systems based on a simple principle that makes use of the energy-dependent information present in CT images. Over the past two decades this principle has been expanded with the introduction of dual-energy CT systems. The first generation of spectral CT systems, represented either by dual-source or dual-layer technology, opened up a new imaging approach in the radiology community with their ability to overcome the limitations of tissue characterization encountered with conventional CT. Its expansion worldwide can also be considered as an important leverage for the recent groundbreaking technology based on a new chain of detection available on photon counting CT systems, which holds great promise for extending CT towards multi-energy CT imaging. The purpose of this article was to detail the basic principles and techniques of spectral CT with a particular emphasis on the newest technical developments of dual-energy and multi-energy CT systems

Patient dose in interventional radiology: a multicentre study of the most frequent procedures in France

International audienceOBJECTIVES:A national retrospective survey on patient doses was performed by the French Society of Medical physicists to assess reference levels (RLs) in interventional radiology as required by the European Directive 2013/59/Euratom.METHODS:Fifteen interventional procedures in neuroradiology, vascular radiology and osteoarticular procedures were analysed. Kerma area product (KAP), fluoroscopy time (FT), reference air kerma and number of images were recorded for 10 to 30 patients per procedure. RLs were calculated as the 3rd quartiles of the distributions.RESULTS:Results on 4600 procedures from 36 departments confirmed the large variability in patient dose for the same procedure. RLs were proposed for the four dosimetric estimators and the 15 procedures. RLs in terms of KAP and FT were 90 Gm.cm2 and 11 mins for cerebral angiography, 35 Gy.cm2 and 16 mins for biliary drainage, 75 Gy.cm2 and 6 mins for lower limbs arteriography and 70 Gy.cm2 and 11 mins for vertebroplasty. For these four procedures, RLs were defined according to the complexity of the procedure. For all the procedures, the results were lower than most of those already published.CONCLUSIONS:This study reports RLs in interventional radiology based on a national survey. Continual evolution of practices and technologies requires regular updates of RLs.KEY POINTS:• Delivered dose in interventional radiology depends on procedure, practice and patient. • National RLs are proposed for 15 interventional procedures. • Reference levels (RLs) are useful to benchmark practices and optimize protocols. • RLs are proposed for kerma area product, air kerma, fluoroscopy time and number of images. • RLs should be adapted to the procedure complexity and updated regularly

Microwave Ablation of Liver, Kidney and Lung Lesions: One-Month Response and Manufacturer’s Charts’ Reliability in Clinical Practice

Microwave ablation systems allow for performing tumoral destruction in oncology. The objective of this study was to assess the early response and reliability of the microwave ablation zone size at one month for liver, kidney and lung lesions, as compared to the manufacturer’s charts. Patients who underwent microwave ablation with the EmprintTM ablation system for liver, kidney and lung lesions between June 2016 and June 2018 were retrospectively reviewed. Local response and ablation zone size (major, L, and minor, l, axes) were evaluated on the one-month follow-up imaging. Results were compared to the manufacturers’ charts using the Bland–Altman analysis. Fifty-five patients (mean age 68 ± 11 years; 95 lesions) were included. The one-month complete response was 94%. Liver ablations showed a good agreement with subtle, smaller ablation zones (L: −2 ± 5.7 mm; l: −5.2 ± 5.6 mm). Kidney ablations showed a moderate agreement with larger ablations for L (L: 8.69 ± 7.94 mm; l: 0.36 ± 4.77 mm). Lung ablations showed a moderate agreement, with smaller ablations for l (L: −5.45 ± 4.5 mm; l: −9.32 ± 4.72 mm). With 94% of early complete responses, the system showed reliable ablations for liver lesions, but larger ablations for kidney lesions, and smaller for lung lesions

Determining the Optimal Energy Level of Virtual Monoenergetic Images in Dual-Source CT for Diagnosis of Bowel Obstruction and Colitis

Images from 64 patients undergoing an enhanced abdominal-pelvis scan at portal phase in dual-energy CT mode for the diagnosis of colitis or bowel obstruction were retrospectively analyzed. Acquisitions were performed on a third-generation dual-source CT (DSCT) 100/Sn150 kVp. Mixed images were generated, as well as virtual monoenergetic images (VMIs) at 40/50/60/70 keV. Objective image quality was assessed on VMIs and mixed images by measuring contrast, noise and contrast-to-noise ratio (CNR). Noise, smoothing and overall image quality were subjectively analyzed by two radiologists using Likert scales. For both patient groups, the noise decreased significantly according to the energy level from 40 to 60 keV by −47.2 ± 24.0% for bowel obstruction and −50.4 ± 18.2% for colitis. It was similar between 60 and 70 keV (p = 0.475 and 0.059, respectively). Noise values were significantly higher in VMIs than in mixed images, except for 70 keV (p = 0.53 and 0.071, respectively). Similar results were observed for contrast values, with a decrease between 40 and 70 keV of −56.3 ± 7.9% for bowel obstruction −56.2 ± 10.9% for colitis. The maximum CNR value was found at 60 keV compared to other energy levels and mixed images, but there was no significant difference with the other energy levels apart from 70 keV (−9.7 ± 9.8%) for bowel obstruction and 40 keV (−6.6 ± 8.2%) and 70 keV (−5.8 ± 9.2%) for colitis. The VMIs at 60 keV presented higher scores for all criteria for bowel obstruction and colitis, with no significant difference in smoothing score compared to mixed images (p = 0.119 and p = 0.888, respectively)

Impact of an artificial intelligence deep‐learning reconstruction algorithm for CT on image quality and potential dose reduction: A phantom study

International audienceBackground: Recently, computed tomography (CT) manufacturers have developed deep-learning-based reconstruction algorithms to compensate for the limitations of iterative reconstruction (IR) algorithms, such as image smoothing and the spatial resolution's dependence on contrast and dose levels.Purpose: To assess the impact of an artificial intelligence deep-learning reconstruction (AI-DLR) algorithm on image quality and dose reduction compared with a hybrid IR algorithm in chest CT for different clinical indications.Methods: Acquisitions on the CT American College of Radiology (ACR) 464 and CT Torso CTU-41 phantoms were performed at five dose levels (CTDIvol : 9.5/7.5/6/2.5/0.4 mGy) used for chest CT conditions. Raw data were reconstructed using filtered backprojection, two levels of IR (iDose4 levels 4 (i4) and 7 (i7)), and five levels of AI-DLR (Precise Image; Smoother, Smooth, Standard, Sharp, Sharper). Noise power spectrum (NPS), task-based transfer function, and detectability index (d') were computed: d'-modeled detection of a soft tissue mediastinal nodule (low-contrast soft tissue chest nodule within the mediastinum [LCN]), ground-glass opacity (GGO), or high-contrast pulmonary (HCP) lesion. The subjective image quality of chest anthropomorphic phantom images was independently evaluated by two radiologists. They assessed image noise, image smoothing, contrast between vessels and fat in the mediastinum for mediastinal images, visual border detection between bronchus and lung parenchyma for parenchymal images, and overall image quality using a commonly used four- or five-point scale.Results: From Standard to Smoother levels, on average, the noise magnitude decreased (for all dose levels: -66.3% ± 0.5% for mediastinal images and -63.1% ± 0.1% for parenchymal images), the average NPS spatial frequency decreased (for all dose levels: -35.3% ± 2.2% for mediastinal images and -13.3% ± 2.2% for parenchymal images), and the detectability (d') of the three lesions increased. The opposite pattern was found from Standard to Sharper levels. From Smoother to Sharper levels, the spatial resolution increased for the low-contrast polyethylene insert and the opposite for the high-contrast air insert. Compared to the i4 used in clinical practice, d' values were higher using Smoother (mean for all dose levels: 338.7% ± 29.4%), Smooth (103.4% ± 11.2%), and Standard (34.1% ± 6.6%) levels for the LCN on mediastinal images and Smoother (169.5% ± 53.2% for GGO and 136.9% ± 1.6% for HCP) and Smooth (36.4% ± 22.1% and 24.1% ± 0.9%, respectively) levels for parenchymal images. Radiologists considered the images satisfactory for clinical use at these levels, but adaptation to the dose level of the protocol is required.Conclusion: With AI-DLR, the smoothest levels reduced the noise and improved the detectability of chest lesions but increased the image smoothing. The opposite was found with the sharpest levels. The choice of level depends on the dose level and type of image: mediastinal or parenchymal

Retrospective Analysis of Doses Delivered during Embolization Procedures over the Last 10 Years

Background: This study aimed to retrospectively analyze dosimetric indicators recorded since 2012 for thoracic, abdominal or pelvic embolizations to evaluate the contribution of new tools and technologies in dose reduction. Methods: Dosimetric indicators (dose area product (DAP) and air kerma (AK)) from 1449 embolizations were retrospectively reviewed from August 2012 to March 2022. A total of 1089 embolizations were performed in an older fixed C-Arm system (A1), 222 in a newer fixed C-Arm system (A2) and 138 in a 4DCT system (A3). The embolization procedures were gathered to compare A1, A2 and A3. Results: DAP were significantly lower with A2 compared to A1 for all procedures (median −50% ± 5%, p p < 0.001). CT scan was used for guidance in 90% of embolization procedures. Conclusions: The last C-Arm technology allowed a median reduction of 50% of the X-ray dose. The implementation of a CT scan inside the IR room allowed for more precise 3D-guidance with no increase of the dose delivered

Assessment of the Radiation Exposure of Surgeons and Patients During a Lumbar Microdiskectomy and a Cervical Microdiskectomy: A French Prospective Multicenter Study

International audienceOBJECTIVE:Cervical and lumbar disk herniations are the most frequently carried out procedures in spinal surgery. Often, a few snapshots during the procedure are necessary to validate the level or to position the implant. The objective of this study is to quantitatively estimate the radiation received by a spine surgeon and patient during a low-dose radiation procedure.METHODS:We conducted a prospective multicenter study in France from November 2014 to April 2015. Four spine centers were monitored for radiation received by surgeons during interventions for lumbar disk herniation and cervical disk herniation.RESULTS:A total of 134 patients were included. For lumbar disk herniation, the average exposure for the surgeon was 0.584 μSv on the chest, 5.291 μSv on the lens, and 9.295 μSv on the hands per procedure. For these procedures, the dose area product (DAP) was 94.2 ± 198.4 cGy·cm(2), and the fluoroscopic time was 10.2 ± 16.9 seconds. For a herniated cervical disk, the average exposure for the surgeon was 0.122 μSv on the chest, 3.106 μSv on the lens, and 7.143 μSv on the hands per procedure. For these procedures, the DAP was 35.7 ± 72.1 cGy·cm(2), and the fluoroscopic time was 19.7 ± 13.7 seconds.CONCLUSIONS:Exposure to x-rays for surgeons and patients during surgery for lumbar disk herniation is higher than during surgery for cervical herniation disk. Our results show that radiation exposure to the spine surgeon is still far below the annual dose limits