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Lens Dose in Routine Head CT: Comparison of

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Article in American Journal of Roentgenology · January 2015

DOI: 10.2214/AJR.14.12763 · Source: PubMed

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 M e d i c a l P hy s i c s a n d I n f o r m a t i c s • O r i g i n a l R e s e a r c h

Nikupaavo et al.
Lens Dose in Head CT

Medical Physics and Informatics

Original Research
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Lens Dose in Routine Head CT:

Comparison of Different
Optimization Methods With
Anthropomorphic Phantoms
Ulla Nikupaavo1,2 OBJECTIVE. The purpose of this study was to study different optimization methods for
Touko Kaasalainen1,3 reducing eye lens dose in head CT.
Vappu Reijonen1 MATERIALS AND METHODS. Two anthropomorphic phantoms were scanned with
Sanna-Mari Ahonen2 a routine head CT protocol for evaluation of the brain that included bismuth shielding, gan-
Mika Kortesniemi1,3 try tilting, organ-based tube current modulation, or combinations of these techniques. High-
sensitivity metal oxide semiconductor field effect transistor dosimeters were used to measure
Nikupaavo U, Kaasalainen T, Reijonen V, local equivalent doses in the head region. The relative changes in image noise and contrast
Ahonen SM, Kortesniemi M were determined by ROI analysis.
RESULTS. The mean absorbed lens doses varied from 4.9 to 19.7 mGy and from 10.8 to
16.9 mGy in the two phantoms. The most efficient method for reducing lens dose was gantry
tilting, which left the lenses outside the primary radiation beam, resulting in an approximately
75% decrease in lens dose. Image noise decreased, especially in the anterior part of the brain.
The use of organ-based tube current modulation resulted in an approximately 30% decrease in
lens dose. However, image noise increased as much as 30% in the posterior and central parts of
the brain. With bismuth shields, it was possible to reduce lens dose as much as 25%.
CONCLUSION. Our results indicate that gantry tilt, when possible, is an effective
method for reducing exposure of the eye lenses in CT of the brain without compromising im-
age quality. Measurements in two different phantoms showed how patient geometry affects
the optimization. When lenses can only partially be cropped outside the primary beam, or-
gan-based tube current modulation or bismuth shields can be useful in lens dose reduction.

I
n CT of the head, the eye lens is
always exposed to scattered radi-
ation and, depending on the scan
Keywords: anthropomorphic phantom, CT optimization, geometry, often to the direct
image quality, lens dose, MOSFET beam. Results of epidemiologic studies of
populations with low-dose radiation expo-
DOI:10.2214/AJR.14.12763
sure have suggested that the lens is more sen-
Received February 24, 2014; accepted after revision sitive to ionizing radiation than has previous-
March 31, 2014. ly been assumed and that the process of
1
radiation-induced cataract formation may
HUS Medical Imaging Center, Helsinki University Central
even be stochastic without a threshold dose
Hospital, POB 340 (Haartmaninkatu 4), 00290 Helsinki,
Finland. Address correspondence to U. Nikupaavo [1–3]. Therefore, the International Commis-
(ulla.nikupaavo@hus.fi). sion on Radiological Protection has reevalu-
ated the equivalent dose limit of the eye lens to
2
University of Oulu, Institute of Health Sciences, ionizing radiation by lowering the recom-
Oulu, Finland.
mended acute dose threshold for lens effects
3
Department of Physics, University of Helsinki, (cataracts and opacities) from 2–8 Gy to
Helsinki, Finland. 0.50 Gy [4, 5]. Measurements in phantoms
and patients have varied considerably in ab-
AJR 2015; 204:117–123 sorbed dose of the lens. The variation, ranging
0361–803X/15/2041–117
from a few to approximately 100 mGy per
scan, depends on the scanner, imaging tech-
© American Roentgen Ray Society nique, and optimization methods used [6–16].
Analysis of data on occupational exposure
and on patients undergoing diagnostic scan-
ning of the head has had mixed results. Klein
et al. [17] reported a significant correlation
between CT scanning and increased risk of
nuclear sclerosis and posterior subcapsular
opacity. Hourihan et al. [18], however, found
no evidence of the prevalence of any type of
cataract in people with a history of head CT.
However, a 2013 study by Yuan et al. [19]
corroborated the connection between in-
creased risk of cataract formation and CT of
the head and neck region. The risk seems to
increase gradually with repeated CT studies.
The radiation exposure of the lens and
of other selective radiation-sensitive tissues
can be reduced by use of technical solutions
such as organ-based tube current modula-
tion (OBTCM) [6–8], local exterior shield-
ing (bismuth shields) [7, 9, 10, 15, 16], and
optimization of the gantry tilt angle [10, 11,
15, 20]. Users can also reduce radiation ex-
posure and improve image quality by taking

AJR:204, January 2015 117


steps such as centering patients properly in
the scan isocenter [21, 22]. Iterative recon-
struction techniques have enabled major re-
ductions in total dose, 20–30% in the case of
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head CT, while diagnostic image quality is
maintained [23–25].
Our aim was to compare a group of meth-
ods developed to reduce the dose to the eye
lens in head CT. We quantitatively assessed
their effect on dose distribution and image
quality in different anatomic locations by
performing measurements in two anthropo-
morphic phantoms.
Materials and Methods
Dose Measurements and Calculations
We imaged two tissue-equivalent anthropo-
morphic phantoms—ATOM model 702-D (CIRS)
and RANDO (The Phantom Laboratory)—in
the head-first supine position (Fig. 1) with a 128-
MDCT scanner (Somatom Definition AS+, Sie-
mens Healthcare). We performed CT head scan-
ning in helical mode with eight settings: reference
scan without an optimization method; gantry tilted
according to clinical practice (baseline from skull
base to radix nasi); gantry tilted at an angle one
half of that used in clinical practice; 0.06-mm lead
equivalent bismuth shield (AttenuRad Radiation
Protection, F&L Medical Products) on the eyes;
both a bismuth shield and gantry tilted according
to clinical practice; OBTCM (X-CARE, Siemens
Healthcare); both OBTCM and gantry tilted ac-
Fig. 2—Scan settings used for head CT and geometric profiles of phantoms. Top row, gantry tilting angles and
reference scan setting in two phantoms (left, ATOM, CIRS; right, RANDO, Phantom Laboratory). Bottom row,
scan settings with bismuth shields.
118 AJR:204, January 2015
Nikupaavo et al.
A B
Fig. 1—Photographs show anthropomorphic phantoms used in study.
A, ATOM model 702-D (CIRS).
B, RANDO (Phantom Laboratory).
cording to the clinical practice; and bismuth shield
already set on the eyes in scout imaging (Fig. 2).
The following scan parameters were identical for
all studied scan settings and defined as applied in
clinical practice: 120 kV, tube current modulation
with quality reference tube current–time product
of 410 mAs, 1-second rotation time, pitch of 0.6,
and detector configuration of 128 × 0.6 mm (with
double z-sampling corresponding to a total detec-
tor width of 38.4 mm). Scan range was set for a rou-
tine head CT examination (from skull base to ver-
tex). Volume CT dose index varied from 46.06 to
47.02 mGy for the ATOM phantom and from 44.38
to 45.35 mGy for the RANDO phantom.
We measured local organ doses with high-sen-
sitivity TN-1002RD metal oxide semiconduc-
tor field effect transistor (MOSFET) dosimeters
(TN-1002RD, Best Medical) with high bias set-
tings. Before the measurements were made, the
dosimeters were calibrated in the CT beam on an
axial scan obtained with 120-kVp tube voltage.
In calibration, the reference air kerma was mea-
sured with a CT pencil ionization chamber (Ray-
Safe Xi, Unfors RaySafe), and the calibration
factor was defined separately for each MOSFET
dosimeter. One of the dosimeters was discarded
because of observed high instability. Thus a total
of nine MOSFET dosimeters were inserted in the
phantom head in different locations: left mandi-
ble, both lenses, skull base, posterior right and left
hemispheres, occipital bone, anterior right hemi-
sphere, and anterior aspect of the central part of
the brain. The active part and epoxy bulb of the
MOSFET dosimeters were located slightly be-
low the midpoint of each phantom layer, the tips
pointing toward the anterior part of the phantom.
We read the MOSFETs after each acquisition, and
scanning was performed five times for each set-
ting. Average absorbed doses (in milligrays) were
calculated for each organ in each scanning setting.
Image Analysis
Because the MOSFET dosimeter lead wires
produce metal artifacts and interfere with image
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TABLE 1: Absorbed Organ Doses in Milligrays and Relative Change Compared With Reference Scanning of ATOM (CIRS) Phantom
Lens
Posterior Right Anterior Part of Posterior Left Anterior Right
Scan Setting Left Mandible Skull Base Hemisphere Central Brain Occipital Bone Hemisphere Hemisphere Right Left
Reference 3.1 ± 0.2 (0.0) 18.1 ± 0.3 (0.0) 20.1 ± 0.9 (0.0) 15.4 ± 0.3 (0.0) 16.9 ± 1.0 (0.0) 18.9 ± 0.4 (0.0) 17.5 ± 0.7 (0.0) 20.1 ± 1.3 (0.0) 19.2 ± 1.5 (0.0)
Bismuth shield after scout imaging 3.1 ± 0.2 (0.0) 18.0 ± 0.5 (–0.8) 20.3 ± 0.5 (1.1) 15.2 ± 0.6 (–1.3) 16.7 ± 0.8 (–0.8) 19.2 ± 1.3 (1.6) 17.0 ± 0.5 (–3.0) 14.9 ± 0.1 (–26.1) 15.2 ± 1.5 (–21.2)
Bismuth shield before scout imaging 3.5 ± 0.4 (13.8) 18.1 ± 0.5 (–0.1) 19.7 ± 1.0 (–2.2) 15.0 ± 0.5 (–2.5) 15.8 ± 0.8 (–6.2) 18.7 ± 0.7 (–1.1) 17.0 ± 0.8 (–3.0) 15.1 ± 1.2 (–24.8) 14.5 ± 1.2 (–24.4)
Bismuth shield with gantry tilt 2.2 ± 0.2 (–29.5) 18.3 ± 0.4 (1.2) 19.2 ± 0.5 (–4.5) 15.8 ± 0.8 (3.0) 15.5 ± 0.9 (–8.3) 18.9 ± 0.8 (0.4) 17.4 ± 0.8 (–0.5) 5.0 ± 0.4 (–74.9) 4.8 ± 0.6 (–74.9)
Gantry tilt 2.1 ± 0.2 (–31.1) 17.6 ± 0.7 (–2.7) 19.7 ± 1.1 (–2.2) 15.8 ± 0.5 (2.7) 15.5 ± 1.0 (–8.4) 19.2 ± 0.9 (1.6) 17.1 ± 0.5 (–2.0) 5.1 ± 0.2 (–74.5) 4.7 ± 0.2 (–75.6)
Gantry tilt with one-half angle 2.4 ± 0.2 (–20.9) 17.8 ± 0.6 (–1.6) 20.0 ± 0.8 (–0.8) 15.5 ± 0.3 (1.0) 15.3 ± 0.7 (–9.6) 18.3 ± 0.5 (–2.9) 17.3 ± 0.5 (–1.0) 16.0 ± 2.0 (–20.6) 15.3 ± 2.3 (–20.3)
OBTCM 3.5 ± 0.3 (14.5) 21.2 ± 0.4 (16.9) 22.8 ± 0.6 (13.5) 14.7 ± 0.2 (–4.2) 18.8 ± 1.2 (11.5) 20.2 ± 1.3 (7.2) 15.7 ± 0.5 (–10.3) 13.8 ± 0.4 (–31.3) 13.1 ± 1.1 (–32.1)
OBTCM with gantry tilt 2.4 ± 0.2 (–23.8) 20.4 ± 0.8 (12.8) 21.6 ± 0.7 (7.4) 14.1 ± 0.6 (–8.3) 17.7 ± 0.8 (5.1) 19.9 ± 0.6 (5.6) 14.9 ± 0.9 (–14.9) 6.2 ± 0.6 (–69.1) 5.4 ± 0.4 (–71.9)
Note—Values are mean ± SD. Values in parentheses are relative change as percentage. Negative relative change value indicates dose reduction compared with reference scan setting. OBTCM = organ-based
tube current modulation.

TABLE 2: Absorbed Organ Doses in Milligrays and Relative Change Compared With Reference Scan in RANDO Phantom (Phantom Laboratory)
Lens
Posterior Right Anterior Part of Posterior Left Anterior Right
Scan Setting Left Mandible Skull Base Hemisphere Central Brain Occipital Bone Hemisphere Hemisphere Right Left
Reference 3.8 ± 0.2 (0.0) 16.4 ± 0.7 (0.0) 17.6 ± 0.6 (0.0) 18.1 ± 0.7 (0.0) 15.0 ± 1.4 (0.0) 17.1 ± 0.9 (0.0) 18.0 ± 0.6 (0.0) 17.7 ± 1.8 (0.0) 16.1 ± 1.2 (0.0)
Bismuth shield after scout imaging 3.9 ± 0.5 (3.5) 16.9 ± 0.5 (2.9) 18.5 ± 0.4 (5.2) 17.9 ± 0.5 (–1.2) 14.8 ± 1.6 (–1.5) 17.1 ± 0.7 (0.0) 17.6 ± 0.6 (–2.6) 16.3 ± 1.3 (–7.6) 14.1 ± 1.1 (–12.3)
Bismuth shield before scout imaging 4.4 ± 0.4 (15.1) 16.8 ± 0.4 (2.8) 17.5 ± 1.0 (–0.3) 17.6 ± 0.5 (–2.8) 15.0 ± 1.0 (–0.4) 17.2 ± 0.9 (0.4) 17.4 ± 0.4 (–3.7) 14.5 ± 1.2 (–17.9) 15.2 ± 1.2 (–15.5)
Bismuth shield with gantry tilt 3.1 ± 0.3 (–18.9) 17.8 ± 0.4 (8.9) 18.3 ± 0.4 (4.2) 17.7 ± 0.5 (–2.4) 14.4 ± 1.2 (–4.5) 17.5 ± 0.6 (2.2) 18.3 ± 0.5 (1.4) 12.9 ± 0.7 (–27.2) 10.4 ± 0.7 (–35.3)
Gantry tilt 2.9 ± 0.1 (–22.0) 18.4 ± 0.3 (12.3) 18.0 ± 1.2 (2.5) 17.7 ± 0.7 (–2.2) 13.7 ± 1.2 (–8.9) 17.0 ± 1.0 (–0.9) 18.3 ± 0.7 (1.7) 14.8 ± 1.7 (–16.1) 12.9 ± 1.5 (–19.7)
Lens Dose in Head CT

Gantry tilt with one-half angle 3.1 ± 0.2 (–18.7) 17.7 ± 1.1 (7.8) 17.7 ± 0.5 (1.0) 17.9 ± 0.4 (–1.0) 13.9 ± 1.6 (–7.7) 17.0 ± 0.7 (–0.8) 17.9 ± 0.5 (–0.9) 16.5 ± 1.8 (–6.7) 14.9 ± 1.3 (–7.6)
OBTCM 4.6 ± 0.3 (21.4) 19.0 ± 0.7 (16.0) 19.3 ± 0.5 (9.9) 17.3 ± 0.3 (–4.5) 18.1 ± 1.6 (20.1) 19.6 ± 0.5 (14.5) 16.5 ± 0.4 (–8.5) 14.4 ± 0.4 (–18.6) 11.3 ± 0.5 (–30.0)
OBTCM with gantry tilt 3.5 ± 0.3 (–9.6) 20.9 ± 0.8 (27.6) 20.6 ± 0.6 (17.1) 17.7 ± 0.5 (–2.3) 15.9 ± 1.8 (5.6) 18.9 ± 1.0 (10.4) 17.3 ± 0.6 (–4.0) 11.3 ± 0.7 (–36.3) 10.4 ± 1.2 (–35.4)
Note—Values are mean ± SD. Values in parentheses are relative change as percentage. Negative relative change value indicates dose reduction compared with reference scan setting. OBTCM = organ-based
tube current modulation.

Results
Dosimetric Results
quality measurements.

National Institutes of Health).

to 22.8 mGy in the case of the ATOM

phantom and from 10.8 to 16.9 mGy

relative changes compared with the
from the ATOM phantom scans for image

interval. We performed the image analysis

el 2 (Siemens Healthcare), which is used at
ed the relative changes. We studied image
curacy of placement of the phantom for

AJR:204, January 2015 119

Depending on the scanning setting
absorbed organ doses varied from 2.2
reference scanning performed without
The size of ROI 1 was approximately 450
lobes, and ROIs 4 and 5 in the expected po-
right cerebellum, ROIs 2 and 3 in the ex-
particular clinical significance for ROIs:
of air gaps between the phantom layers,
the RANDO phantom was poor because
try scans was ± 2 mm in the x, y, and z di-

used, the mean lens dose varied

phantom and from 3.1 to 20.9 mGy
mm2. We compared image noise and con-
mm2, and the size of ROIs 2–5 was 300
sitions of the basal ganglia nuclei (Fig. 3).
pected positions of the anterior temporal
ROI 1 was located in the region of the
measuring 1 SD of the CT number in five
suring the mean CT number and noise by
We determined image contrast by mea-
the image quality as opposed to dosime-
the dosimeters. We estimated that the ac-
plugs. Each time, the scan parameters
quality analysis (noise, contrast), we re-

for the RANDO phantom. In the case

any optimization methods. The mean
in each scanning setting and their
results of the dose measurements
In Tables 1 and 2, we present the
with ImageJ software (version 1.48, U.S.
with 4-mm thickness and a 4-mm interslice
our clinic. Axial slices were reconstructed
and iterative reconstruction with Safire lev-
quality using both filtered back projection
trast of the reference images and calculat-
trast at each setting with the noise and con-
different ROIs. We selected locations of
and we decided to use only image data
rections. The image quality in the case of
simeter holes filled with tissue-equivalent
without the dosimeters and with the do-
peated all scans with different settings

from 4.9 to 19.7 mGy for the ATOM

in the case of the RANDO phantom.
were identical to the scans obtained with
 Nikupaavo et al.

TABLE 3: Mean Image Noise (1 SD HU) and Relative Change Compared With Reference Setting in Five ROIs in
­Clinically Significant Areas
ROI 1 ROI 2 ROI 3 ROI 4 ROI 5
Scan Setting FBP Safire 2 FBP Safire 2 FBP Safire 2 FBP Safire 2 FBP Safire 2
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Reference 5.0 (0.0) 4.1 (0.0) 5.8 (0.0) 4.9 (0.0) 5.8 (0.0) 4.9 (0.0) 4.7 (0.0) 3.9 (0.0) 4.5 (0.0) 3.7 (0.0)
Bismuth shield after scout imaging 5.0 (0.0) 4.1 (0.0) 5.4 (–7.4) 4.5 (–8.6) 6.0 (4.0) 5.1 (4.9) 4.9 (4.3) 4.0 (3.6) 5.1 (14.5) 4.3 (17.4)
Bismuth shield before scout imaging 5.4 (8.5) 4.6 (8.3) 5.5 (–5.8) 4.6 (–5.1) 5.4 (–7.4) 4.5 (–8.4) 4.9 (4.7) 4.1 (6.2) 4.7 (4.0) 3.8 (4.6)
Bismuth shield with gantry tilt 5.1 (3.2) 4.2 (2.9) 4.4 (–24.5) 3.6 (–26.0) 4.6 (–20.5) 3.8 (–22.2) 4.4 (–5.8) 3.7 (–6.2) 4.4 (–2.5) 3.6 (–2.7)
Gantry tilt 5.1 (2.4) 4.0 (–2.4) 4.5 (–22.6) 3.8 (–22.8) 4.7 (–19.8) 3.7 (–23.9) 4.8 (2.4) 3.9 (0.0) 4.7 (5.6) 3.9 (5.2)
Gantry tilt with half an angle 4.8 (–3.6) 3.9 (–6.1) 4.9 (–17.0) 4.0 (–18.7) 5.4 (–6.7) 4.5 (–9.0) 4.8 (2.2) 4.1 (4.1) 4.7 (5.4) 3.9 (5.7)
OBTCM 6.3 (27.9) 5.3 (29.7) 6.2 (5.8) 4.8 (–0.8) 6.5 (12.4) 5.2 (5.3) 5.7 (22.8) 4.7 (20.3) 5.8 (29.2) 4.7 (28.1)
OBTCM with gantry tilt 6.4 (30.1) 5.1 (24.8) 5.6 (–4.1) 4.8 (–0.8) 6.3 (7.9) 4.9 (0.0) 5.7 (22.8) 4.3 (9.7) 5.5 (22.0) 4.0 (7.1)
Note—Values in parentheses are relative change as percentage. Negative relative change value indicates noise reduction compared with reference scan setting. ROI 1 =
region of the right cerebellum, ROIs 2 and 3 = expected positions of the anterior temporal lobes, ROIs 4 and 5 = expected positions of the basal ganglia nuclei, FBP =
filtered back projection, Safire 2 = Safire level 2 iterative reconstruction (Siemens Healthcare). OBTCM = organ-based tube current modulation.

TABLE 4: Mean CT Numbers (HU) and Relative Change Compared With Reference Setting in Five ROIs in Clinically
Significant Areas
ROI 1 ROI 2 ROI 3 ROI 4 ROI 5
Scan Setting FBP Safire 2 FBP Safire 2 FBP Safire 2 FBP Safire 2 FBP Safire 2
Reference 51.0 (0.0) 50.8 (0.0) 51.9 (0.0) 51.7 (0.0) 53.2 (0.0) 53.3 (0.0) 49.4 (0.0) 49.2 (0.0) 49.7 (0.0) 49.7 (0.0)
Bismuth after scout imaging 51.6 (1.2) 51.3 (1.0) 51.8 (–0.2) 51.6 (–0.3) 53.9 (1.2) 53.8 (0.9) 49.6 (0.4) 49.5 (0.6) 50.1 (0.9) 50.2 (1.1)
Bismuth shield before scout imaging 51.7 (1.5) 51.8 (2.0) 53.8 (3.5) 53.4 (3.2) 55.4 (3.9) 54.4 (2.1) 49.3 (–0.2) 49.4 (0.4) 49.8 (0.3) 49.9 (0.6)
Bismuth shield with gantry tilt 48.3 (–5.3) 48.3 (–4.9) 52.3 (0.8) 52.3 (1.2) 53.2 (–0.2) 53.1 (–0.5) 49.4 (0.1) 49.3 (0.1) 49.7 (–0.1) 49.7 (0.1)
Gantry tilt 47.9 (–6.0) 48.0 (–5.5) 51.9 (–0.2) 52.1 (0.7) 53.0 (–0.5) 52.9 (–0.7) 49.3 (–0.2) 49.4 (0.3) 49.8 (0.2) 50.0 (0.7)
Gantry tilt with one-half angle 48.2 (–5.4) 47.9 (–5.7) 49.0 (–5.8) 49.9 (–3.4) 53.5 (0.5) 53.5 (0.4) 49.0 (–0.8) 48.8 (–0.9) 49.8 (0.2) 49.6 (–0.1)
OBTCM 50.5 (–1.0) 50.2 (–1.2) 53.4 (2.8) 53.7 (3.9) 51.5 (–3.3) 51.7 (–3.1) 48.7 (–1.4) 49.1 (–0.3) 50.2 (1.1) 50.2 (1.2)
OBTCM with gantry tilt 52.3 (2.7) 50.4 (–0.9) 51.4 (–1.1) 50.5 (–2.3) 55.2 (3.7) 55.9 (4.8) 48.2 (–2.5) 48.8 (–1.0) 49.9 (0.3) 49.0 (–1.3)
Note—Values in parentheses are relative change as percentage. Negative relative change value indicates noise reduction compared with reference scan setting. ROI 1 =
region of the right cerebellum, ROIs 2 and 3 = expected positions of the anterior temporal lobes, ROIs 4 and 5 = expected positions of the basal ganglia nuclei, FBP =
filtered back projection, Safire 2 = Safire level 2 iterative reconstruction (Siemens Healthcare). OBTCM = organ-based tube current modulation.

of the ATOM phantom, the most efficient
way to reduce eye lens dose appeared to be
gantry tilt according to our clinical practice
(baseline set from skull base to radix nasi),
with or without bismuth shields, with an
approximately 75% decrease in the absorbed
dose compared with the reference setting. In
addition, using the combination of OBTCM
and gantry tilt produced a dose savings of
70%, whereas OBTCM alone was associated
with a dose reduction of 32%. With the
6-mm lead equivalent bismuth shield, it was
possible to reduce lens dose as much as 25%,
whereas gantry tilted at an angle one half of
that used in clinical practice produced 20%
dose savings for the lens compared with the
reference setting. In the case of the RANDO
phantom, the dose reduction was less and
occurred in different order than in the
ATOM phantom owing to different phantom
geometry. The highest lens dose reduction
(36%) was achieved with the RANDO
phantom with the combination of OBTCM
and gantry tilt. The other methods produced
dose reductions of 31% (bismuth shield
together with gantry tilt), 24% (OBTCM
alone), 18% (gantry tilt), 12% (bismuth shield
already set on eyes in scout imaging), and
10% (bismuth shield alone). Using gantry tilt
at an angle one half of that used in clinical
practice produced only approximately 7%
dose savings for the lens compared with the
results with the reference scan setting.
When OBTCM was used, the dose distri-
bution differed substantially from the dis-
tributions observed with the other settings:
The absorbed dose increased in the pos-
terior parts of the phantoms (up to 17% in
the case of the ATOM phantom and 27% in
the case of the RANDO phantom) owing to
boosting of radiation output in the posteri-
or angles (covering approximately 240°) and
decreased in the anterior tissues owing to re-
duced radiation output in the anterior angles
(covering approximately 120°).
By tilting the gantry, we were able to re-
duce scan length by a few slices. Thus the
dose-length product and therefore the effec-
tive dose calculated with International Com-
mission on Radiological Protection publi-
cation 103 conversion factors was reduced
approximately 6% compared with the refer-
ence scan with no gantry tilt.
Image Analysis Results
Mean image noise and CT numbers are
shown in Tables 3 and 4. Image noise varied
in the range of 4.8–6.4 HU in ROI 1, 4.4–6.5
HU in ROIs 2 and 3, and 4.4–5.7 HU in ROIs
4 and 5 when iterative reconstruction was not
used. When OBTCM was used with or with-
out gantry tilt, the image noise increased as
much as 30% in the bottom and posterior part

120 AJR:204, January 2015


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A B
Fig. 3—CT images show selected ROIs for measurement of image noise and contrast.
A, ROI 1 is in region of right cerebellum.
B, ROIs 2 and 3 are in expected positions of anterior temporal lobes.
C, ROIs 4 and 5 are in expected positions of basal ganglia nuclei.
of the brain (ROI 1) of the ATOM phantom.
Similarly, OBTCM increased image noise ap-
proximately 12% in the anterior part of the
brain (ROIs 2 and 3) and 29% in the central
part of the brain (ROIs 4 and 5). The use of
gantry tilt decreased image noise approxi-
mately a quarter in the anterior part of the
brain compared with the reference scan set-
ting. In other ROIs, the change was more mod-
erate. The use of a bismuth shield increased
image noise approximately 17% in the central
part of the brain when the shield was set on
the eyes after scout imaging. Image noise in-
creased less when the bismuth shield was set,
incorrectly, before scout imaging, because the
tube current modulation compensated the in-
creased x-ray attenuation of the scan object by
increasing the tube current–time product. The
use of iterative reconstruction (Safire level 2)
decreased image noise approximately 20% in
each ROI and for all scan settings.
Image contrast was maintained for each
scan setting when Safire level 2 was used for
image reconstruction. The mean CT num-
ber, and thus the image contrast, in the brain
tissue of the ATOM phantom was approxi-
mately 50 HU (minimum and maximum, 48
and 56 HU). The greatest variation (5–6%)
in image contrast was observed in the bot-
tom posterior part of the brain when gantry
tilting was used.
Discussion
CT scanner manufacturers and users
have made an effort to minimize the dose to
AJR:204, January 2015 121
Lens Dose in Head CT
the eye lenses since results of several stud-
ies have indicated that the lens is more sen-
sitive to ionizing radiation than previously
believed. The aim of our study was to ex-
plore the lens dose reduction capability of
different optimization methods in head CT
of the brain by use of two tissue-equiva-
lent anthropomorphic phantoms, MOSFET
dosimeters, and quantitative image quali-
ty analysis. In all, we used eight different
scanning settings.
In this study, we followed the gantry tilt
practice at our hospital, aligning the scan
plane along the skull base to the radix nasi.
The European guidelines call for a 10–12°
gantry tilt above the orbitomeatal line to re-
duce exposure of the eye lenses [26]. Be-
cause of different geometric profiles of the
phantoms, tilting in the case of the ATOM
phantom was mainly comparable to the su-
praorbital baseline, whereas in the case of
the RANDO phantom, the gantry tilt fol-
lowed closely the orbitomeatal baseline, al-
though the tilting angles (13° and 11.5°) were
about the same. Thus the lens dosimeter
points were left outside of the primary radi-
ation beam in the ATOM phantom, where-
as in the case of the RANDO phantom, the
lenses were partly inside the primary beam.
According to results of previous studies, the
use of supraorbital gantry tilt reduces expo-
sure of the eye lenses by 78–88%, depending
on the CT scanner and technique used [10,
12, 13, 15]. Our results for the ATOM phan-
tom were similar, the lens dose reduction be-
C
ing up to 75%. In the case of the ­R ANDO
phantom, however, the lens dose was re-
duced only up to 18%.
We studied the effect of tilting the gantry
at an angle one half of that used in clinical
practice (6.5° and 7°) for lens doses, because
tilting angles also vary remarkably in routine
work owing to patient-specific physiologic
limitations [20]. Although the lens dose re-
duction was considerably smaller (20% for
the ATOM phantom, 7% for the RANDO
phantom) than in the case of the original
gantry tilt, using even a small tilting angle
appears useful—because the scanning range
may be shortened—with a corresponding de-
crease in total radiation dose.
Bismuth shields are used in CT exami-
nations to protect radiosensitive superficial
tissues and organs such as the lens, thy-
roid, and mammary tissue from primary
radiation within the scanning range. In our
study, the reduction of lens dose due to bis-
muth shielding was approximately 10% in
the case of the RANDO phantom and ap-
proximately 25% in the case of the ATOM
phantom, which is moderate compared with
earlier published results [7, 9, 10, 16, 27].
OBTCM can also be used for reduction
of dose to superficial radiosensitive tissues.
In this study, we found that the lens doses
were reduced as much as one third in the
case of the ATOM phantom and one fourth
for the RANDO phantom when we used the
OBTCM method. The results were similar
to those in other studies of OBTCM tech-

niques, which have indicated dose reductions
of 26–59% to the lenses [6–8].
We also studied whether combining bis-
muth shields or OBTCM with simultaneous
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gantry tilt brings any benefit. When the lens-
es were located completely outside the pri-
mary beam owing to tilting, neither bismuth
shielding nor OBTCM resulted in extra dose
reduction. In fact, adding OBTCM result-
ed in a slight increase in the lens dose, most
probably due to higher scatter intensity origi-
nating from the elevated primary beam dose
distribution on the occipital side of the skull.
On the other hand, with more gradual tilting,
we observed that both the bismuth shield and
OBTCM resulted in clear dose reduction to
the lenses. The primary beam dose contribu-
tion and close range scatter would otherwise
become more prominent for the lenses. Wang
et al. [7] studied the simultaneous use of bis-
muth shielding and OBTCM and reported
considerable dose reduction (almost 50%)
for the eye lenses. However, this combination
should be used carefully because OBTCM
boosts radiation output in the posterior part
of the brain, and the bismuth shielding scat-
ters this back to the patient [28].
Gantry tilting is not possible with all
available CT scanner models. In such cas-
es, the patient’s head can be set on a head
support with the chin turned to the chest to
mimic gantry tilt. In practice, however, tilt-
ing the patient’s head is not always conceiv-
able because of anatomic properties and the
physiologic condition of the patient. In these
cases, the use of bismuth shields or OBTCM
together with ordinary tube current modula-
tion can be considered the primary means of
reducing the dose to the eye lenses.
The benefit of different dose reduction
methods must be evaluated against the re-
quirements for clinically adequate image
quality. Gantry tilting has been reported to
cause beam-hardening and partial volume
artifacts in the base of the skull and to cause
problems in visualization of the temporal
lobes [15, 29]. However, in other reports [20,
30] it has been claimed that no substantial
differences in clinical image quality of head
CT can be observed with different gantry tilt
angles. The use of bismuth shielding has also
been questioned, because it can degrade im-
age quality and accuracy by causing streak
and beam-hardening artifacts and waste of
image data by absorbing photons transmit-
ted through the patient before they would
appear on the detector [28, 31]. In addition,
if the shields are placed erroneously before
122 AJR:204, January 2015
Nikupaavo et al.
scout imaging in the case of automatic ex-
posure control, the patient dose will be in-
creased. These disadvantages have been ob-
served in the case of bismuth shielding of the
breast [32] and thyroid [33]. Authors of sev-
eral studies [34–37] have recommended the
use of tube current modulation with lowered
tube current–time values instead of bismuth
breast shields. This method will not cause
image quality impairments due to streak ar-
tifacts while resulting in a similar dose re-
duction. Nevertheless, in the use of bismuth
shields on the eyes, artifacts seem to fall out-
side of the diagnostic area of interest when-
ever visualization of the orbits and sinuses is
not important [16, 38]. In earlier studies, use
of OBTCM techniques did not appear to af-
fect image noise or CT numbers, or their in-
fluence was scant [6–8].
In this study, we assessed image quality
by using five ROIs located in the posterior,
anterior, and central parts of the brain. The
RANDO phantom was not suitable for image
quality evaluation because the air between
its slices caused strong artifacts. Gantry tilt
and partial gantry tilt reduced the noise level
in the anterior parts of the brain (the former
by almost one fourth), whereas in the case of
the posterior and central ROIs, the changes in
noise level were minor. The use of iterative re-
construction (Safire level 2) resulted system-
atically in an approximately 20% decrease in
noise level. However, in this study we did not
consider other image quality aspects related
to the use of iterative reconstruction.
According to our results, using bismuth
shielding of the eyes appears advantageous
with only little effect on image quality in the
case of brain scans. No artifacts were ob-
served, and the differences in noise level in
the case of the reference scan and the scan
with a bismuth shield were measured to be
minor in all brain regions. Placing the bis-
muth shield before scout imaging decreased
the exposure in all measuring points except
for the mandible, where the increase in dose
was 14% (resulting in a total increase in dose
of 2.5% for the whole scan), whereas the
change in the image quality was small com-
pared with the reference scan. However, this
feature is due to the real-time angular tube
current modulation technique and cannot be
generalized to automatic exposure control
techniques in which the angular modulation
profile is based on the scout image.
In this study, we found that OBTCM in-
creased the noise level in the posterior and
central (right and left) regions of the brain
both without (28%, 23%, and 29%) and with
combined gantry tilt (30%, 23%, and 22%).
However, the absolute change in measured
noise level compared with the reference level
was less than 1.5 HU in all of our study con-
ditions. All the different imaging methods
studied had only little effect on the measured
contrast values (mean attenuation in HU
measured in the ROIs). The mean attenua-
tion changed the most in the posterior fossa
when gantry tilt was used. The decrease was
5–6% from the reference image, correspond-
ing to an absolute difference of approximate-
ly 3 HU. However, even such small changes
in attenuation levels can be crucial in CT of
the brain, in which, for example, the contrast
between white and gray matter is approxi-
mately only 4–5 HU.
Our study had limitations. First, we used
only one CT scanner from a single vendor. Be-
cause focus-detector and focus-isocenter dis-
tances, tube current modulation techniques,
and bowtie filters vary between scanners, the
effects of different dose reduction methods on
radiation dose distribution and image noise
may vary between scanners. In addition, the
OBTCM technique is not available with most
of the scanners used today. Second, we used
only two anthropomorphic phantoms for dose
measurements and only a single phantom for
image quality assessment; the geometry and
size of real patients vary substantially. The
potential effect of this variation is seen in our
dosimetry results with different dose savings
between the two phantoms.
Conclusion
According to our study results, the most ef-
ficient way to reduce radiation exposure to the
lens appears to be gantry tilt. Compared with
the reference scan, using gantry tilt resulted in
a substantial decrease in the dose to the lens
while preserving image contrast and reducing
image noise, especially in the anterior part of
the brain. If gantry tilting is not possible, or if
the eye lenses cannot be fully excluded from
the exposed scan range, OBTCM or bismuth
shields can also be used, with some caution, to
decrease the lens exposure.
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