651655

research-article2016
PSH0010.1177/2010105816651655Proceedings of Singapore HealthcareYu et al.

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Original Article OF SINGAPORE HEALTHCARE

Proceedings of Singapore Healthcare

Reducing cranial computed tomography 2016, Vol. 25(4) 230­–234

© The Author(s) 2016
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effective radiation dose by 30% using sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/2010105816651655

adaptive iterative dose reduction psh.sagepub.com

Wai-Yung Yu1, Thye Sin Ho1, Henry Ko2,3,4, Wai-Yee Chan1,

Serene Ong3 and Francis Kim Hoong Hui1

Abstract
Introduction: The use of computed tomography (CT) imaging as a diagnostic modality is increasing rapidly and CT is the
dominant contributor to diagnostic medical radiation exposure. The aim of this project was to reduce the effective radiation
dose to patients undergoing cranial CT examination, while maintaining diagnostic image quality.
Methods: Data from a total of 1003, 132 and 27 patients were examined for three protocols: CT head, CT angiography
(CTA), and CT perfusion (CTP), respectively. Following installation of adaptive iterative dose reduction (AIDR) 3D software,
tube current was lowered in consecutive cycles, in a stepwise manner and effective radiation doses measured at each step.
Results: Baseline effective radiation doses for CT head, CTA and CTP were 1.80, 3.60 and 3.96 mSv, at currents of 300, 280
and 130–150 mA, respectively. Using AIDR 3D and final reduced currents of 160, 190 and 70–100 mA for CT head, CTA
and CTP gave effective doses of 1.29, 3.18 and 2.76 mSv, respectively.
Conclusion: We demonstrated that satisfactory reductions in the effective radiation dose for CT head (28.3%), CTA
(11.6%) and CTP (30.1%) can be achieved without sacrificing diagnostic image quality. We have also shown that iterative
reconstruction techniques such as AIDR 3D can be effectively used to help reduce effective radiation dose. The dose
reductions were performed within a short period and can be easily achievable, even in busy departments.

Keywords
Computed Tomography, head, CT radiation dosage, iterative reconstruction, quality improvement

Introduction
While the application of computed tomography (CT)
imaging as a diagnostic modality is increasing rapidly, CT is
also the dominant contributor to diagnostic medical radia-
tion exposure.1 In some departments, CT procedures
makes up about 15% of the total number of examinations
but accounts for some 70% of the exposure.1 Thus, there
is great interest in reducing unnecessary radiation dose
from CT examinations.
Although skin burns2 and hair loss3 have been reported
from ionising radiation has to be weighed against the useful
diagnostic information that radiological procedures pro-
vides, this damage can be mitigated by reducing the expo-
sure to ionising radiation to as low as reasonably achievable
1Department of Neuroradiology, National Neuroscience Institute,
Singapore
2SingHealth Centre for Health Services Research, SingHealth, c/o
SingHealth Office of Research, Singapore
3SingHealth & Duke-NUS Academic Medicine Research Institute, Duke-

with CT perfusion (CTP), most diagnostic radiology proce- NUS Medical School, Singapore
dures normally produce relatively low radiation doses; the 4NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia

dose from a typical CT exam (1–14 mSv) is comparable to

Corresponding author:
the annual dose received from natural sources (1–10 mSv).4 Wai-Yung Yu, National Neuroscience Institute, 11 Jalan Tan Tock Seng,
Singapore advises an annual dose limit for the general public 308433 Singapore.
of 1 mSv from medical sources.8 While the potential harm Email: wai_yung_yu@nni.com.sg

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Yu et al.
(the ‘ALARA’ principle), while maintaining sufficient diag-
nostic imaging quality of the results.
The aim of this study was to reduce effective radiation
dose to patients undergoing CT scans of the head, while
maintaining diagnostic image quality. This was achieved in a
two-pronged approach: (1) by lowering the tube current for
three types of head scans: CT head, CT angiography (CTA),
and CTP, in consecutive cycles; and (2) by optimising image
quality using adaptive iterative dose reduction (AIDR), soft-
ware provided by the scanner manufacturer Toshiba.
Methods
Investigations were carried out on an Aquilion ONE™,
320-detector row system scanner v4.74 ER004 (Toshiba,
Japan) with the X-ray tube voltage set at 120 kV (manufac-
turer’s recommended parameters). Rotation times varied
with current, as needed. The scan data, which included unen-
hanced CT head scans, CTA and CTP, was collected over a
period of 9 months from December 2011 to September
2012, from patients who had to undergo CT head scans at
our institution. Exclusion criteria include non-CT head cases,
CTA of the neck, and restless or uncooperative patients.
Including baseline determination, a total of 1003 CT head,
132 CTA and 27 CTP patients’ data were examined. This
project was approved by our institution’s Centralised
Institutional Review Board.
It was inevitable that image quality degrades with lowered
tube current, with resultant increased graininess of images,
but our threshold standard was that diagnostic image quality
was maintained throughout. Diagnostic image quality was
assessed by a panel of six consultant neuroradiologists every
time current was lowered. Preliminary CT scans performed
at the new lowered tube current were compared with a
recent CT scan performed at the higher tube current, for
diagnostic acceptability by assessing lesion conspicuity and
grey white matter differentiation.
Quantification of radiation dose
We chose the effective radiation dose as the descriptor of
radiation dose as it is commonly accepted, and it takes into
account the dose and relative radiosensitivity of all irradiated
organs.6,7 Measured in millisieverts (mSv), the effective radia-
tion dose is not actually a metric of dose but rather a concept
that reflects and best quantifies the stochastic risk from an
exposure to ionising radiation.6,8
The radiation dose measurements available on the CT con-
sole are volume CT dose index (CTDIvol) and dose length prod-
uct (DLP). CTDIvol is calculated with a pitch value where pitch is
the table distance travelled in one 3600 rotation; and DLP is
CTDIvol multiplied by scan length (slice thickness and number of
slices). In this study, each sample was calculated from the DLP
taken from the scanner after each scanand multiplied by the
conversion factor for head (0.0021) to obtain the effective radi-
ation dose in mSV. The effective radiation dose was calculated
as the mean of all samples, where samples referred to the num-
ber of scans and not patients (e.g. some patients may have one,
two, or more scans done).
231
Image optimisation using AIDR
Adaptive Iterative Dose Reduction 3D, or AIDR 3D, is soft-
ware provided by the scanner manufacturer Toshiba.9 It is an
advanced iterative reconstructive algorithm that reduces
noise both in the raw data domain and in the three-dimen-
sional reconstruction process, and improves spatial resolu-
tion. As the reconstructed image is optimised, scanning can
be then performed at lower current settings without losing
diagnostic information. Three settings, differing in the amount
of noise removal, are available: mild, standard and strong. The
standard setting was used throughout, except at PDSA Cycle
2a (elaborated below).
Human-dependent variables
We took steps to ensure that human-dependent variables
such as scan range and repeat scans were controlled for in this
study. As scan range is directly related to the effective radia-
tion dose, it is important to keep it only as large as needed; this
is the simplest way to control dose. A scout view was selected
from the CT scanner, and keeping the same scout for each
radiographer, the scan range for each radiographer was col-
lected. As the scan range for CTP was set at 16 cm, this meas-
urement step was not carried out for CTP scans.
Another factor that could possibly result in unnecessarily
high dose is repeat scans. The number of repeat scans due to
patient movement was counted over a period of 7 weeks.
There were only 34 repeat scans out of 2582 scans (1%), and
we found no factors such as patient age, medication, medical
condition or time of day that was associated with the repeat
scans. Based on this baseline count, we assumed that repeat
scans should not constitute a substantial portion in the effec-
tive radiation dose given to patients and that it would be
impractical to try to reduce the number of repeat scans fur-
ther. Repeat scans or data from restless patients were dis-
carded in this study.
Quality improvement methodology
This project was undertaken as an organisational quality
improvement initiative within the institution under the
Enhancing Performance Improving Care healthcare quality
improvement programme. Using the Accelerated Model for
Improvement (AmiTM) framework developed by C. Jane
Norman and based on The Model for Improvement by
Langley et al.,10 an AMI charter was drawn up to answer three
fundamental questions.
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in
improvement?
These questions inform the Plan-Do-Study-Act (PDSA) itera-
tive cycles that forms an efficient trial-and-learning methodol-
ogy for stepwise improvement. Built into the PDSA cycle are
the ideas of deductive and inductive learning.
The current was lowered according to the aims of the
PDSA cycles:
232
•• PDSA Cycle 1 aims to establish baselines levels of
effective radiation dose;
•• PDSA Cycle 2 installs AIDR and aims to lower the
tube current until the image quality was comparable to
pre-AIDR installation; and
•• PDSA Cycle 3, with AIDR still in place, aims to lower
the current further.
We wanted to test (1) the effect of AIDR installation, and (2)
the effect of reduced current, on effective radiation dose.
Changes are measured by (1) reduction in radiation dose,
and (2) radiologist satisfaction.
Statistical Analysis
Statistical analysis was conducted in MiniTab (Version 16)
software. Data collected from the PDSA cycles were entered
into MiniTab and control and run charts were created. Using
standard quality improvement analyses rules used by the
Accelerated Model for Improvement (AmiTM) framework
and MiniTab software, different control charts were created
depending on the sampling size. “Experiments” with large
samples (e.g. CT head) had calculated mean and standard
deviation values, and small “experiments” (e.g. CT angiograph
and CT perfusion) had calculated mean and range or moving
range values. As with any control chart analysis, the key
parameter other than the mean (or more accurately, the
“Central Line”) is the Upper Control Limit (UCL) and the
Lower Control Limit (LCL). We have provided the
mean/”Central Line” and UCL and LCL values in this paper.
Results
Human-dependent variables
Scan ranges for CT head for the radiographers involved in the
study varied from 125 to 150 mm, with a mean of 135 mm,
resulting in a variability range of 25 mm. For CTA, the scan
ranges varied from 135 to 150 mm, with a mean of 142 mm
leading to a range of only 15 mm. In both cases, we decided
that the variability ranges for and between each radiographer
were acceptable on a practical process level.
PDSA cycles
At the start of the study, the tube current was 300 mA for CT
head, 280 mA for CTA, and 130–150 mA for CTP. These val-
ues were taken from the scanner manufacturer’s guidelines.
PDSA Cycle 1 established the baseline values. Calculated
from scan data in the scanner database, the mean doses
(UCL, LCL) were found to be 1.80 (1.88, 1.73), 3.60 (4.00,
3.19) and 3.95 (4.02, 3.89) mSv for CT head, CTA and CTP,
respectively.
In PDSA Cycle 2, current was lowered from 300 to 240
mA for CT head; current was lowered from 280 to 270 mA
for CTA; and current was lowered from 130–150 to 130–
140 mA for CTP. In the cases of CT head and CTA, rotation
time was increased in order to compensate for increased
image noise with reduced tube current. Effective radiation
dose fell from 1.80 to 1.59 (1.67, 1.50) mSv for CT head, 3.60
Proceedings of Singapore Healthcare 25(4)
to 3.20 (3.56, 2.57) mSv for CTA, and 3.95 to 3.76 (no varia-
tion) mSv for CTP, resulting in 11.7%, 11.1% and 4.8% reduc-
tions, respectively.
In PDSA Cycle 3, current was further reduced from 240 to
160 mA for CT head; from 270 to 190 mA for CTA and from
130–140 to 70–100 mA for CTP. For CT head, effective radia-
tion dose following current reduction fell from 1.59 to 1.29
(1.32, 1.27) mSv (18.9% reduction), and the cumulative reduc-
tion from baseline was 28.3%. For CTA, the final effective
radiation dose only fell from 3.2 to 3.18 (3.57, 2.74) mSv (0.6%
reduction), with a cumulative reduction of 11.6% from base-
line. For CTP, effective radiation dose was reduced from 3.76
to 2.76 (3.03, 2.44) mSv (26.6% reduction), with a cumulative
reduction of 30% from baseline.
The results of the PDSA cycles are summarised in Table 1,
and a representative control chart showing the effective radi-
ation doses pre- and post-AIDR installation for CT head is
shown in Figure 1.
From Table 1, we can see that a 46.7% drop in current
(300 to 160 mA) for CT head resulted in a 28.3% (1.80 (1.88,
1.73) to 1.29 (1.32, 1.27) mSv) reduction in effective radia-
tion dose, while a 32.1% drop in current (280 to 190 mA) for
CTA resulted in a 11.6% (3.60 (4.00, 3.19) to 3.18 (3.57, 2.74)
mSv) reduction in effective radiation dose. The current varies
over a range for the CTP procedure, but an approximate
reduction by a third of the current resulted in a 30.1% reduc-
tion (3.95 (4.02, 3.89) to 2.76 (3.03, 2.44) mSv) in effective
radiation dose.
There were situations where scanning time had to be
increased to offset for the lowered current; in such cases, the
eventual reduction in effective radiation dose was less than ini-
tially expected. In particular, although the current for CTA in
PDSA cycle 3 was reduced by 29.6% (from 270 to 190 mA), the
drop in effective radiation dose was only 0.6% because of the
increase in rotation time, from 0.50 to 0.60 s. In contrast, while
the current for CTA in cycle 2 was only reduced by 3% (from
280 to 270 mA), the drop in effective radiation dose was 11%;
there was no change in rotation time from baseline parameters.
Discussion
We have satisfactorily reduced effective radiation dose to
patients undergoing CT scans of the head, while maintaining
diagnostic image quality. The reductions were 28.3% for CT
head, 11.6% for CTA, and 30.1% for CTP, arriving at final
effective radiation doses of 1.29 mSv, 3.18 mSv, and 2.76
mSV, respectively.
Radiation dose is largely determined by the tube current
and X-ray voltage, and is a main determinant of CT image
quality and therefore diagnostic accuracy.1,11 In addition to
current and voltage, other machine specifications that affect
radiation dose include scanning rotation time, slice thickness,
scan length and the type of scanner.11,12 While only current
was varied in this study, other studies have shown that dose
reduction can be satisfactorily achieved by lowering tube
potentials, especially for CT examinations using iodinated
contrast media.13–15
One of the simplest ways to reduce radiation dose is to
match the diagnostic aim and not requiring lower noise or higher
spatial resolution than necessary; the type of diagnostic
Yu et al. 233

Table 1. Actions and results of PDSA Cycles 1–3.

CT head CTA CTP

PDSA 1: Baseline establishment
Baseline current (mA) 300 280 130–150
Mean baseline dose (mSv) (UCL, LCL) 1.80 (1.88, 1.73) 3.60 (4.00, 3.19) 3.95 (4.02, 3.89)
Rotation time (s) 0.50 0.50 0.75
No. of scans 314 48 15
PDSA 2: Effect of AIDR and current reduction
Reduction in current (mA) 300  240 280  270 130–150  130–140
Reduction in mean dose (mSv) (UCL, LCL) 1.80  1.59 (1.67, 1.50) 3.60  3.20 (3.56, 2.87) 3.95  3.76 (No variation)
Amount of reduction (mSv) 0.21 (11.7%) 0.40 (11.1%) 0.19 (4.8%)
Rotation time (s) 0.60 0.50 0.75
No. of scans 331 49 7
PDSA 3: Effect of AIDR and further current reduction
Reduction in current (mA) 240  160 270  190 130–140  70–100
Reduction in mean dose (mSv) (UCL, LCL) 1.59  1.29 (1.32, 1.27) 3.20  3.18 (3.57, 2.74) 3.76  2.76 (3.03, 2.44)
Amount of reduction (mSv) 0.30 (18.9%) 0.02 (0.6%) 1 (26.6%)
Rotation time (s) 0.75 0.60 0.75
No. of scans 358 35 5
Cumulative drop in dose (mSv) 0.51 (28.3%) 0.42 (11.6%) 1.19 (30.1%)

AIDR: adaptive iterative dose reduction; CT: computed tomography; CTA: computed tomography angiography; CTP: computed tomography perfusion;
PDSA: Plan-Do-Study-Act.

Figure 1. A representative control chart showing the effective radiation doses pre- and post-AIDR (adaptive iterative dose reduction)
installation for CT head. PDSA (Plan-Do-Study-Act) Cycle 3 was done in a two-step manner (3a, from 240 to 180 mA; and 3b, from 180
to 160 mA).

examination sets the image quality required. The challenge with
head CT is that the tissues scanned are relatively low contrast,
compared with high-contrast areas such as the lung or bones,
where a dose reduction of more than 50% can be
tolerated.16,17
Another way to reduce radiation dose is to improve radi-
ographers’ skill and experience. Training for new staff as well
as refresher courses for existing staff is important, especially
whenever a new machine, software or update is installed.
Other strategies on the operator’s side include regular cali-
bration of CT scanners, and keeping abreast and installing
manufacturers’ updates.
Since the extent to which current can be lowered is lim-
ited by diagnostic image quality, optimisation of image quality
is an important problem. Image quality can be optimised
through hardware and software means. When image quality
234
is improved, the current can be further lowered before diag-
nostic quality is lost. One of the main challenges to dose
reduction is image noise, which results from two main
sources: photon noise and electronic noise. In a low-dose
scan, when the number of X-ray photons drops to the extent
that the electronic noise in the data acquisition system
becomes dominant, image quality degrades. The AIDR soft-
ware used in this study addresses this problem, by reducing
both photon and electronic noise, and therefore increases
the signal-to-noise ratio, improves spatial resolution and pro-
duces a more natural-looking image.9 It has a smoothing
effect on the images, although higher strength can lead to
over smoothing or waxiness of images.18
Iterative reconstruction, also known as adaptive statisti-
cal iterative reconstruction (ASIR), algorithms have been
available for some years, and have been shown to signifi-
cantly improve image quality.18,19 Though computationally
more intensive than the alternative filtered back projec-
tion (FBP) algorithms, they are more accurate and perform
better, especially when dealing with noisy data.5 Vendors
will often have their proprietary iterative methods to opti-
mise image quality: while Toshiba has AIDR, Siemens offers
Iterative Reconstruction in Image Space (IRIS), and Phillips,
iDose.
Our final effective dose of 1.29 mSv for CT head compares
well with other image optimisation work on head CT. Rapalino
et al.18 used a blended ASIR and FBP algorithm on cranial CT,
and reduced the routine effective dose of 2.66 mSv (at 175
mAs) to 1.95 mSv (at 140 mAs), a reduction of 26.2%. Kilic
et al.19 used ASIR to lower the effective dose from 2.3 to 1.6
mSv, a reduction of 31%. As mentioned earlier, the low-con-
trast tissue in the head presents a challenge; using ASIR, Flicek
et al.20 studied were able to achieve a dose reduction of 50%
for CT colonoscopy examination.
Conclusions
Satisfactory reductions in effective radiation dose for CT
head (28.3%), CTA (11.6%) and CTP (30.1%) can be obtained
without sacrificing diagnostic image quality. The final effective
radiation doses were 1.29 mSv for CT head, 3.18 mSv for
CTA and 2.76 mSV for CTP. Moreover, image optimisation
protocols such as AIDR 3D are an effective aid to current
reduction in reducing the effective radiation dose. Finally,
using a quality improvement methodology, we demonstrated
that dose reductions can be tested in a stepwise manner,
measured through assessment of image quality, and imple-
mented within a short timeframe in a busy department.
Declaration of Conflicting Interest
None declared.
Funding
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
Proceedings of Singapore Healthcare 25(4)
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