This document discusses strategies for reducing radiation dose from computed tomography (CT) scans while maintaining image quality. It notes that CT use has increased dramatically in recent decades due to greater availability and replacement of other imaging modalities. While CT is a powerful diagnostic tool, radiation exposure can increase cancer risk, especially in children. The document explores techniques such as tube current modulation, prospective ECG gating, and dual energy CT which can reduce radiation dose compared to standard protocols. It emphasizes optimizing scan parameters and tracking radiation doses for individual patients.
This document discusses strategies for reducing radiation dose from computed tomography (CT) scans while maintaining image quality. It notes that CT use has increased dramatically in recent decades due to greater availability and replacement of other imaging modalities. While CT is a powerful diagnostic tool, radiation exposure can increase cancer risk, especially in children. The document explores techniques such as tube current modulation, prospective ECG gating, and dual energy CT which can reduce radiation dose compared to standard protocols. It emphasizes optimizing scan parameters and tracking radiation doses for individual patients.
This document discusses strategies for reducing radiation dose from computed tomography (CT) scans while maintaining image quality. It notes that CT use has increased dramatically in recent decades due to greater availability and replacement of other imaging modalities. While CT is a powerful diagnostic tool, radiation exposure can increase cancer risk, especially in children. The document explores techniques such as tube current modulation, prospective ECG gating, and dual energy CT which can reduce radiation dose compared to standard protocols. It emphasizes optimizing scan parameters and tracking radiation doses for individual patients.
This document discusses strategies for reducing radiation dose from computed tomography (CT) scans while maintaining image quality. It notes that CT use has increased dramatically in recent decades due to greater availability and replacement of other imaging modalities. While CT is a powerful diagnostic tool, radiation exposure can increase cancer risk, especially in children. The document explores techniques such as tube current modulation, prospective ECG gating, and dual energy CT which can reduce radiation dose compared to standard protocols. It emphasizes optimizing scan parameters and tracking radiation doses for individual patients.
Quality and Dose Martin Gunn Outline Frequency of CT Bioeffects of radiation Radiation dose in the ER Image noise and radiation dose kV and intravenous contrast Shielding Z -Overscanning Protocol design Prediction rules and utilization Special considerations USA CT Procedures / Year 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 1 9 9 3 1 9 9 4 1 9 9 5 1 9 9 6 1 9 9 7 1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6 C T
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( m i l l i o n s ) Hospital Non-Hospital Annual Growth > 10% / year. Pop growth < 1% / year NCRP Scientific Committee 6-2, 2008 CT Scanners Per Million Population CT Scanners / million (OECD) 20.6 2005 15.9 1995 10.8 1990 % of ED Evaluations involving CT Broder and Warshauer, Emergency Radiology Sept 2006 13: 25-30 CT Utilization in the ER 2000-2005 Broder and Warshauer, Emergency Radiology Sept 2006 13: 25-30 Radiation Exposure in BWH Brigham and Womens Hospital, Boston MA Longitudinal study looking retrospectively at 22 years of data. 190,712 CT exams in 31,462 patients. Mean 6.1 CTs (54 mSv), max 132 CTs (1375 mSv). 15% > 100 mSv 4% > 250 mSv 1% > 400 mSv Sodickson et al, American Society of Emergency Radiology Annual Meeting, Oct 2008, Houston TX BWH Longitudinal CT Survey * Max 1/15 (6.7%) Max 1/8 (12.5%) Mean 1/509 (0.2%) Mean 1 / 320 (0.3%) 1% of patients > 1/62 (1.6%) 1% of patients > 1/ 38 (2.6%) 3% of patients > 1/100 7% of patients > 1 / 100 CANCER MORTALITY CANCER INCIDENCE * Sodickson A, American Society of Emergency Radiology Annual Meeting, Oct 2008, Houston TX Diagnostic Accuracy Increasing Utilization of CT Diagnostic accuracy Cx spine, appendicitis, renal colic, multi rule out. Replacement of other modalities: Volume of CT > study it replaces. Renal CT vol. > IVU vol. for renal colic Increased availability Clinicans and Staff: ? Reduced tolerance for diagnostic uncertainty or delay. More rapid patient throughput BEIR VII Report 2005 Supports Linear No Threshold (LNT) Risk Model Risk model for cancer development: 1 person / 1000 would develop cancer from 10 mSv (CT Abdomen / Pelvis) Committee to assess health risks from exposure to low levels of ionizing radiation, National Research Council (2005) Health risks from exposure to low levels of tadiation: BEIR VII phase 2, National Academies, Washington DC. Relative Biological Risk of Cancer 0 50 100 250 150 200 1.01 1.02 1.03 1.04 1.05 1.06 1.00 1.07 BIER VII Report Effective Dose (mSv) L i f e t i m e
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( L A R ) Linear No Threshold (LNT) Linear Threshold Hormesis The following organizations believe that the current evidence supports the Linear No Threshold (LNT) model of radiation induced cancer and hereditary disease. International Commission on Radiation Protection (IRCP) United National Scientific Committee on Effects of Atomic Radiation (UNSCEAR) Radiation Protection Division of the UK Health Protection Agency (formerly NRPB). National Council on Radiation Protection (NCRP) (USA) National Academy of Science (USA). Environmental Protection Agency (USA). International Organizations Supporting LNT Theory Hormesis Greek: hormaein: to excite. Low levels of radiation exposure have a beneficial effect, lowering the rate of cancer compared to no exposure. Theory is that a small radiation dose up- regulates DNA repair mechanisms, adaptive response. Supported mostly by plant, protozoal and fungal studies, a few mouse studies, and a few human observational studies. Nearly all studies have serious problems. Hormesis: Position of National Academy of Sciences (BEIR VII) BIER VII: The assumption that any stimulatory hormetic effects from low doses of ionizing radiation will have a significant health benefit to humans that exceeds potential detrimental effects from the radiation exposure is unwarranted at this time. Publicity CT scans in children linked to cancer By Steve Sternberg, USA TODAY, January 22, 2001 Each year, about 1.6 million children in the USA get CT scans to the head and abdomen and about 1,500 of those will die later in life of radiation-induced cancer, according to research out today. What's more, CT or computed tomography scans given to kids are typically calibrated for adults, so children absorb two to six times the radiation needed to produce clear images , a second study Evidence of Radiation Risks Studies of humans exposed to radiation. Mostly from Atomic bomb survivors from Hiroshima and Nagasaki. Radiation Effects Research Foundation (RERF) and the Atomic Bomb Casualty Commission (ABCC) Insufficient statistical power at low radiation doses (< 50-100 mSv). Linear response above these levels. Cellular and animal studies used for lower levels. Latency problem: some cancers take 20-30 years to develop. Brenner et al, NEJM 2007 357: 2277 Lifetime Attributable Risk of Cancer Death and Age: Abdominal CT Brenner et al, NEJM 2007 357: 2277 Lifetime Attributable Risk of Cancer (10mGy) Availability Utilization. Need for diagnostic certainty Concerns about radiation Regulation What can we do? 1.Use technology to reduce radiation exposure. 2.Image patients appropriately 3.Track per scan and per patient radiation dose. CT Dilemmas CMS PQRI Test Measures 2008: T144: COMPUTED TOMOGRAPHY (CT) RADIATION DOSE REDUCTION Percentage of final reports for CT examinations performed with documentation of use of appropriate radiation dose reduction devices OR manual techniques for appropriate moderation of exposure. CMS 2008 PQRI Test Measure Specification http://www.cms.hhs.gov/PQRI/Downloads/PQRI2008TestMeasureSpecifications.pdf New technologies. Getting more for less. ALARA Tube Current Modulation Tube Current Modulation Longitudinal Tube Current Modulation Angular tube current modulation Combined (Angular-Longitudinal) Tube Current Modulation Cardiac CT: ECG synchronized tube current modulation. Prospective cardiac gating. Longitudinal Tube Current Modulation Tube Current Varies the tube current (mA) along the z-axis Different mA / dose applied to different regions Scout series used to calculate mA along z-axis to yield a pre-determined setting for image quality (GE = Noise Index). 0 380 Angular Tube Current Modulation Radiation output (mA) is adjusted to minimize dose in lower density profiles of the patients. Occurs during each tube rotation. m A z axis of scan T u b e
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( m A ) Combined Dose Modulation Fixed mA D o s e
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m A Dose too low with fixed mA Dose Savings: 1. McCullough CH Radiographics 2006; 26: 503-512 2. Hausleiter et al, Circulation. 2006;113:1305-1310 3. Shuman et al, Radiology 2008;248:431-437 Retrospective < 77% 3 Prospective Triggering Fixed mA < 40% 2 Retrospective Gating Fixed mA 0-45% 1 Combined modulation Compared to: Saving Technique ECG Gated Tube Current Modulation High Tube Current Low Tube Current Tube current reduced during parts of the cardiac cycle when data not used for coronary CTA is obtained. Beam is on during the whole acquisition. ECG Gated Current Modulation m A Prospective ECG Triggering Tube on Tube off X-ray beam is on about 25% of the R-R interval. Step and shoot technique. Predicts timing of next R-wave. Mean dose 6.2 mSv (2.3-11.9 mSv) 1 Shuman et al, Radiology 2008;248:431-437 Table movement Prospective ECG Triggering Prospective Gated CCTA Partial Scan Tube is turned off for part of the rotation to avoid exposure to radiosensitive organs. Occurs during each tube rotation. Tube on for about 232 degrees. Fig C: Vollmer and Kalender, Eur Radiol. 2008 Aug;18(8):1674-82 Dose Distribution Bismuth Shielding Z Over-scanning Bismuth Shielding Noise Distribution with Bismuth Shielding Adapted from Vollmar and Kalender, Eur Radiol. 2008 Aug;18(8):1674-82 Primary beam exposure in areas above and below the scan range. Ends of the helix. Wider detector arrays and higher pitches. Overscan Top axial slice Bottom axial slice Z- Over-scanning Adaptive Collimation Top axial slice Bottom axial slice Collimator Collimator Adjusting the Scan Parameters: kVp / Dual Energy CT mA, Effective mAs or Noise Index Reconstruction kernel. Display window. Reconstruction thickness Changing the kVp and DECT kVp: Iodine k Edge and Contrast Attenuation of x-ray by contrast is affected by the mean energy (keV) of the photon. This is lower than the kVp of the beam With increasing kVp, photon energy increases and attenuation decreases. At lower kVp, there is greater attenuation due to iodine, as more photons are close to the k-edge of I (33.2 keV) Studies have shown an increase in contrast enhancement of vessels (CNR) with decreasing kVp (140 120 100 80.) kV: Polychromatic X-ray beam 140 Photon energy (keV) kVp P h o t o n
n u m b e rk-edge of I 33.2 100 kVp 120 kVp CTDI vol = 419 CTDI vol = 362 Same Patient, Different kVp kVp and Dose: Exponential 80 100 120 140 0 20 40 60 80 100 R e l a t i v e
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( % ) 120 kVp 140 kVp = 1.4 x in CTDI 120 kVp 80 kVp = 2.2 x in CTDI Dual Energy CT Dual energy scanning (typically 80 and 140kVp): Dual source (two tubes at different kV) Single source with rapid kV switching. Sandwich Detector. Single helical acquisition. Can generate 80kVp, 140 kVp and virtual 120kVp, and non- enhanced images. Graser et al Eur Radiol. 2008 Aug 2 Epub 80 80 kVp kVp / 400 / 400 mAs mAs 140 140 kVp kVp / 96 / 96 mAs mAs Sim Sim Un Un- -enh enh Sim Sim 120 120 kVp kVp Iodine Iodine Iodine + Iodine + Unenh Unenh Radiation Dose and DE CT No silver bullet Dose from single DE CT ~ multiple phase single energy (SE) CT 1,2 Single phase DECT acquisition is higher dose than single phase SECT. Need studies comparing image noise, number of phases, and diagnostic accuracy. 1.Chandarana et al, Radiology. 2008 Sep 23. Epub ahead of print. 2.Chae EJ et al, Radiology. 2008 Sep 16. Epub ahead of print. Changing the mA or Tube Current Modulation Parameters. Increased Noise Index / Reduced Effective mAs DLP 853 mA 439 2.5mm Recon DLP 325 mA 244 5mm Recon Stab wound to left flank NI = 15.4 NI = 22.0 Reducing the mAs Radiology 2003; 229:575580 140 kVp, 170mA, 136mAs 140 kVp, 100mA, 80mAs CT KUB for Renal Calculi, single and 4 channel CT scanners with fixed mA Are Lower Dose Techniques Accurate? AJR 2008; 191:396-401 Dose of IVU = 2.6 mSv Low dose CT 0.7-2.1 mSv Routinely used CT Abd Pelv = 8-16 mSv Sensitivity = 0.966 Specificity = 0.949 Ultra-Low Dose CT Colonography 3D Colonoscopy Optical Colonoscopy Surgical Spec 140 kVp; and 10 mAs Total radiation exp. (prone + supine) 1.7 mSv (M) and 2.3 mSv (F). Optical colonoscopy: 9 Ca 2 polyps in 15 pts Remaining 12 patients normal Ultra-low-dose CT: Detected all carcinomas 10 / 12 polyps (sens 83.3%). Missed 2/6 < 5mm polyps. Eur Rad 2003 Jun;13(6):1297-302 Noise and Windowing WW 3000 WL550 WW 340 WL60 Bone Plus Algorithm Reconstruction Kernel Standard Bone Plus Slice Reconstruction Thickness 2.5 mm 0.625 mm Double Image Noise Reduce Phases. Reduce phase overlap. Reduce scan range. Center the patient. Reduce Follow-up Exams. Protocol Design Which phases are really necessary for multi-phase CT? Post-contrast CT for adrenal adenomas Non-contrast CT for HCC screening CTs Separate dual phase vs. single phase split bolus technique for CT IVU. Reducing overlap between phases. How can we position the patient to reduce dose? Reduce Phases: Adrenal Washout AJR 2000;175:14111415 OR DO MRI!! Segmented approach Segmented approach Pan Pan- -Scan Approach Scan Approach Overlap regions: Overlap regions: Wasted radiation Wasted radiation Reducing the Scan Range Positioning: Body / Profile Size and Symmetry Noise increases with increasing phantom diameter. Also increases in humans, but slightly differently, due to a number of factors (asymmetry, tissue type, intrinsic contrast of fat. X-ray attenuation increases exponentially with body diameter Noise level doubles every 4-8 cm increase in effective body diameter. Asymmetric Profile Arms at side Arms up Arms at side Standard approach Standard approach Total Body Approach Total Body Approach mA Patient Size Iterative Reconstruction Original way to reconstruct CT data. Replaced by Filtered Back Projection Latest statistical iterative reconstruction techniques produce: Less noisy images with significantly lower radiation dose. Less beam hardening artifact. Currently limited by computer power. 2.5 mm Images courtesy of GE Healthcare Iterative Reconstruction Quality Improvement How to Approximate Effective Dose eDLP Factor Region 0.019 Pelvis 0.015 Abdomen 0.017 Chest 0.0054 Neck 0.0023 Head EUR 16262 EN-European Guidelines on Quality Criteria for Computed Tomography May 1999). = DLP x k = 0.017 x 547.37 = 9.3 mSv http://faculty.washington.edu/aalessio/doserisk/index.html Repeat CT for Renal Colic 5,564 examinations performed on 4,562 patients. 61% women (mean age, 45.5 y) 38% men (mean age, 44.7 y) 3% (44) patients of pediatric age (<18 y). Mean Eff Dose = 6.5 mSv (SDCT) & 8.5 mSv (MDCT) 176 patients (4%) had 3 examinations. Estimated Eff Doses of 19.5 to 153.7 mSv. All patients with multiple examinations had a known history of nephrolithiasis. AJR 2006; 186:1120-1124 Repeat CTs for Renal Colic* * Does not include examinations performed at other sites AJR 2006; 186:1120-1124 Other examinations have a proven efficacy Quality Control Collect Dose Data on All Scans Effective Dose (mSV) = 0.016 x DLP 0.017 x 1710.95 = 29.08 mSv Head 0.0023, Neck 0.0054, Chest 0.017, Abdomen 0.015, Pelvis 0.019 Other ways to reduce dose Not doing a CT! Ultrasound, MRI, x-ray, or no imaging. Using prediction rules to determine the need for imaging. Wells criteria for CT PA for PE, New Orleans criteria for minor head injury, Mann-Wilson C Spine CT rules. Summary Increasing CT use. Low dose CT believed to cause cancer. New technologies can reduce dose. Need to be vigilant in protocol design and utilization of protocols. Always use the dose that is reasonably achievable. Use prediction rules Track dose. Perform QA