Content

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Purpose of this article . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Dual Energy vs. Single Energy Dose Comparison Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Opportunities for Further Radiation Dose Reduction with DECT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

[1] Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA

[2] Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University,
Germany
 Introduction | 2

Introduction
visualization of lung perfusion and ventilation [1316],
and the automatic removal of bone from angiographic data
sets [1719].

Dual Energy Computed Tomography (DECT) is one of the most ex-

citing and promising developments in radiology in recent history. The
ability to enhance the resolution of CT images using different X-ray
spectra was demonstrated in the 1970s, but was clinically imple-
mented only for the purpose of emission tomography. Early diagnos-
tic CT approaches exploring multiple energy applications involved
two subsequent scans at different tube voltages over the same ana-
tomical position.

However, these approaches, besides the high computational efforts,

failed to seamlessly align the imaged anatomy and to capture the
same phase of contrast enhancement. Only since the introduction of
dual-source CT (DSCT) in 2006 have multiple energy image acquisi-
tion methods achieved clinical significance and widespread applica-
tion for diagnostic CT imaging.

Since then, various methods for acquiring DECT data have been Figure 1: Adenosine stress DECT coronary CT study of a 64-year-old
proposed for use with recent generations of advanced multi detec- man shows reversible ischemia of the left lateral wall and a papillary
tor-row CT systems: simultaneously applying two X-ray tubes and muscle (A and B). The diagnosis was confirmed by stress SPECT
two corresponding detectors at different kV and mA settings, as with (C and D).
dual-source CT; ultrafast kV switching based on single-source CT;
compartmentalization of detected X-ray photons into energy bins by
double layer detectors of a single-source CT scanner operating at
constant kV and mA settings; or the principle of a counting detector
system which allows dual-energy or spectral CT imaging. The former
methods all aim at acquiring multiple energy data of a given anatomic
area simultaneously, at the same time interval during the gantry rota-
tion. DSCT and double layer technology derive their information from
one set of data, acquired at identical time points. With ultrafast kV
switching there is a small delay of a few ms between readings; how-
ever, the data is fully interlaced as full images are based on several
hundred readings during which the system switched back and forth
multiple times. Another, conceptually different, approach revisits the Figure 2: Coronal DECT images of a 51 year-old man with lung can-
above described earlier concepts of generating dual energy data, cer. (A) represents 120 kV images, (B) shows a calculated virtual non
which involved scanning patients twice, by combining image data contrast image (VNC); (C) shows the color-coded iodine distribution
from two consecutive 270 rotations across the same anatomic re- within the tumor.
gion, one at low kV followed by one at high kV. This latter method
accordingly appears less suitable for imaging organs that change However, this exciting advancement has coincided with a growing
position during scan acquisition, foremost the heart, or patients with public awareness regarding the use of ionizing radiation for medical
limited compliance (trauma, pediatric patients). Also, with such an imaging, and increasing concerns over total radiation dose received
approach, quantitative dual-energy evaluation at applications involv- by the population from imaging tests. Accordingly, successful clini-
ing contrast administration is limited, since contrast concentration cal implementation of multiple-energy imaging will require convincing
changes between two acquisitions which are 270 apart. evidence that these techniques do not come at the price of higher
patient radiation exposure. Dual-source CT and dual-energy CT both
Over the last 5 years, the use of DECT has been evaluated for a va- carry the word dual in their name; likely on this semantic back-
riety of clinical applications. Studies, overwhelmingly based on dual- ground, concern has been raised, whether this technology involves
source CT technology (> 130 peer reviewed articles), have shown increased (as in double) radiation exposure as compared to single-
substantial clinical benefits e.g. in source CT, single-energy investigations.

the identification of renal stones [14],

detection and characterization of liver and kidney neo-
plasms [5, 6],
characterization of pulmonary nodules [7],
assessment of myocardial perfusion [812],

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Purpose of this article
The purpose of this article is to review the available literature regard-
ing the radiation dose associated with DECT imaging applications
in comparison with traditional single-energy CT techniques, keeping
in mind that dual-energy CT scans provide clinically useful material-
specific information in addition to the mere structural, anatomic infor-
mation of conventional single-energy scans.
Dual Energy vs. Single
Energy Dose Compari-
son Studies
Until recently, most studies comparing radiation doses of DECT and
single energy CT were performed using DSCT scanners, with com-
paratively sparse information available in the literature on the radia-
tion doses involved with the other above mentioned techniques for
acquiring DECT data. In general, considerable caution is in order
when interpreting comparative reports on radiation exposure with dif-
ferent techniques. A multitude of studies indiscriminately report radia-
tion doses with various routine techniques and conclude that one or
the other method results in higher or lower radiation, while no at- such as iodinated contrast material [28]. During evaluation, DECT
tention is paid to normalization of image quality, signal/noise ratio, or
DLP. In a recently published phantom study by Schenzle et al. such
normalization was indeed performed and the authors reported the
feasibility of DECT without increasing radiation dose [20]. Moreover,
they observed no significant difference in image noise, but showed
that the contrast to noise ratio (CNR) could be doubled with optimized
DECT reconstructions. Specifically, Schenzle et al. equipped an an-
thropomorphic Alderson phantom with thermoluminescent diodes
(TLDs) and scanned its chest with a 1st generation DSCT system in
dual energy mode at 140 and 80 kVp with 14 x 1.2mm collimation
as well as on a 2nd generation DSCT system at 140 kVp and 100
kVp with selective photon shielding at 128 x 0.6 mm collimation. For
dose comparison with single energy CT, the investigators obtained
reference examinations at 120 kVp with 64 x 0.6 mm collimation at
an equivalent CT dose index of 5.4 mGy*cm. In this phantom study,
the authors report effective dose measurements with TLDs, that were
equal for both DSCT systems in dual energy mode at 140/80 kV
and 140/100 kV with selective photon shielding, when compared to
the single energy 120 kV reference examination [2.61mSv (1st gen-
eration DSCT in DECT mode), 2.69 mSv (2nd generation DSCT in
DECT mode), and 2.70 mSv (2nd generation DSCT in single-energy
mode)]. Moreover, the image noise was reported similar for all three
of the different imaging techniques. The selective photon shielding
evaluated in this study is based on filtering techniques, aimed at fur-
ther spectral separation and thus higher discriminatory abilities for
tissue characterization of dual-energy CT acquisitions. Similarly, in a
phantom study performed on a DSCT system, Yu et al. showed that
images blended from low and high tube-potential data yield similar or
even better iodine CNR than that of typical 120 kV images acquired
at the same radiation dose [21].
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Practical Technical Aspects | 3
An application which currently receives especially high scrutiny vis-
-vis radiation dose issues is cardiac CT. DECT has shown distinct
advantages for comprehensively evaluating coronary artery mor-
phology and the myocardial blood supply [812, 2225]. Initially, the
use of dual-energy CT for cardiac applications required decreasing
the temporal resolution from 83 ms to 165 ms [8]. This was not in
keeping with the tenet that obtaining ancillary information on the
myocardial blood supply must not detract from the full diagnostic per-
formance of coronary CT angiography for stenosis detection. Mean-
while, however, this limitation has been successfully addressed and
the full temporal resolution of 83 ms (1st generation dual-source CT)
or 75 ms (2nd generation dual-source CT) is now available for car-
diac dual-energy CT studies [26]. Regarding radiation exposure at
cardiac DECT, a recently published study by Kerl et al. compared
dose levels at coronary CT angiography between dual-energy CT,
1st generation DSCT in single-energy mode, and 16-slice single
source CT. This investigation reports lower dose levels for DECT and
DSCT than for 16-slice CT [27]. In addition, the investigators con-
clude that DECT delivers significantly lower dose than does regular
DSCT, but still maintains comparably good diagnostic image qual-
ity. The authors report significantly higher CNR with DSCT in dual-
energy mode compared to both DSCT and 16-slice CT and attribute
this observation to the low kV data used in the DECT reconstruction
algorithm. The superior CNR found with low kV protocols is a result
of the increase in the photoelectric effect at lower tube voltages, par-
ticularly in examinations of structures with a high anatomic number,
permits alteration of the balance between images acquired at low kV
and highkV data for each study. For example, inclusion of more of
the low kV data set results in increased attenuation of contrast ma-
terial in the coronary arteries. Consequently, this ability to enhance
contrast attenuation could facilitate a reduction in the total amount
of contrast medium required for this and other contrast medium en-
hanced CT applications without incurring higher image noise levels
involved with single-energy low kV imaging.
As mentioned above, very limited information is available in the lit-
erature regarding radiation doses associated with multi-energy imag-
ing on platforms that are not based on dual-source CT technology.
Ho et al. observed two to three times higher doses for DECT [25]
using a single-source system and rapid voltage switching (22.5 to
36.4mSv for DECT vs. 9.4 to 13.8 mSv for single-source CT). This
group did not perform normalization of image noise or dose; thus
the lower energy spectrum was obtained with the same tube current
time product as the single energy scan. In another study that did per-
form normalization to equivalent low-contrast detectability, Li et al.
observed an additional dose of 14% in the body and 22% in the head
using DECT with rapid kV switching in comparison to that of single
energy CT [29]. At this point, no study has systemically evaluated the
radiation dose of multiple energy image acquisitions using a single
source dual-layer detector CT system or combining image data from
two consecutive 270 rotations. Furthermore, clinical studies specifi-
cally comparing the dose efficiency of different DECT systems are
lacking.
h Back to overview
 Head and Neck | 4

Opportunities for Further

after aortic stent grafting consists of acquisition of unenhanced, ar-
terial and venous phase images. This protocol exposes the patient

Radiation Dose Reduc-

to a high radiation burden because it is repeated every six months.
Several studies have demonstrated that virtual non-contrast DECT

tion with DECT

The existing literature suggests that there is no increase in radiation
exposure when DECT protocols, based on dual-source CT technology,
are used instead of single-energy techniques. However, the higher in-
formational content and post-processing flexibility of DECT data opens
up additional avenues for substantial radiation dose savings over rou-
tine protocols. One example is virtual non-contrast imaging, which is
another promising method for dose reduction enabled by DECT. Many
CT exams involve both non-contrast and contrast-enhanced scans.
DECT allows the creation of virtual non-contrast images from a post-
contrast DECT dataset, thus obviating the need for prior non-contrast
scanning with substantial beneficial impact on the overall radiation
dose associated with the exam.
images can obviate the need for prior unenhanced CT acquisition,
and iodine map images may facilitate the recognition of endoleaks
[3438].
In addition to avoiding unnecessary traditional non-contrast scan-
ning, further substantial reductions in radiation exposure can and
should be aimed for by applying the full spectrum of radiation pro-
tection strategies during DECT scanning. By now most radiation
saving algorithms have been made available for use with DSCT in
dual energy mode: Iterative reconstruction techniques suppress im-
age noise and hold the potential for maintained image quality despite
lower X-ray tube settings [39]. Adaptive dose shielding blocks unnec-
essary pre- and post-spiral X-ray emission which otherwise increas-
es radiation exposure but does not contribute to image generation.
Automated anatomical tube current modulation along the patient axis
adjusts X-ray tube settings in an online fashion to the attenuation
characteristics of different body parts within the scan range [40].

Figure 3: 120 kV image in sagittal orientation demonstrates a small
isolated segmental pulmonary embolism of the right lower lobe (A).
DECT iodine map demonstrates the corresponding wedge shaped
perfusion defect (B).
Conclusion
Of the various methods that have been proposed for acquiring DECT
data, image acquisition based on dual-source CT is the most in-
tensely evaluated approach in the literature. The available literature
suggests that there is indeed no radiation dose penalty with the use
of dual-source CT based DECT over single-energy protocols. Re-
ports on radiation dose with other approaches for DECT data acqui-
sition are scarce or non-existent, so that a conclusive evaluation of
the radiation dose associated with these techniques remains elusive
to date. Finally, judicious use of DECT techniques holds the potential
of drastically reducing radiation exposure, e.g. via the elimination of
unnecessary non-contrast CT scans.

Graser et al. published two studies using 1st and 2nd generation
DSCT systems to assess the performance of DECT in renal mass
characterization [6, 30]. In these studies, the replacement of a real
non-contrast CT scan with a virtual non-contrast scan resulted in a
35% (1st generation DSCT) and a 50% (2nd generation DSCT) re-
duction of the radiation dose. Similar findings of potential decreases
in radiation dose via virtual non-contrast DECT scans have been re-
ported by Leschka et al. and Brown et al. in phantom models [31,
32]. Furthermore, Zhang et al. compared virtual non-contrast scans
of the liver based on DECT with true non-contrast liver CT examina-
tions. Based on their results, they concluded that virtual non-con-
trast DECT could replace true non-contrast CT scans as part of a
multi-phase liver imaging protocol. In this study, the use of a bipha-
sic DECT examination with virtual non-contrast images instead of a
triphasic single energy CT study of the liver resulted in a 33% reduc-
tion of CTDIvol and a 34% reduction of DLP [33].

Virtual non-contrast images obtained from DECT data are of particu-

lar interest in patients who require frequent follow-up CT examina-
tions. For instance, the recommended imaging protocol for patients

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