Visual grading evaluation of reconstruction methods and dose optimisation in abdominal Computed Tomography

Abstract: Since its introduction in the 1970’s CT has emerged as a modality of choice because of its high sensitivity in producing accurate diagnostic images. A third of all Computed Tomography (CT) examinations are abdominal CTs which deliver one of the highest doses among common examinations. An increase in the number of CT examinations has raised concerns about the negative effects of ionising radiation as the dose is cumulative over the life span of the individual. Image quality in CT is closely related to the radiation dose, so that a certain dose with an associated small, but not negligible, risk is a prerequisite for high image quality. Typically, dose reduction in CT results in higher noise and a decrease in low contrast resolution which can be detrimental to the image quality produced. New technology presents a wide range of dose reduction strategies, the latest being iterative reconstruction (IR).The aim of this thesis was to evaluate two different classes of iterative reconstruction algorithms: statistical (SAFIRE) and model-based (ADMIRE) as well as to explore the diagnostic value of a low-dose abdominal CT for optimisation purposes.This thesis included a total of 140 human subjects in four image quality evaluation studies, three of which were prospective studies (Papers I, II and IV) and one retrospective study (Paper III). Visual grading experiments to determine the potential dose reductions, were performed with pairwise comparison of image quality in the same patient at different tube loads (dose) and reconstructed with Filtered back projection (FBP) and SAFIRE strength 1 in a low-dose abdominal CT (Paper I) and FBP and ADMIRE strengths 3 and 5 in a standard dose abdominal CT (Paper II). Paper IV evaluated the impact of slice thicknesses in CT images reconstructed with ADMIRE strengths 3 and 5 when comparing multiplanar reconstruction (MPR) formatted images in a standard dose abdominal CT. Paper III, on the other hand, was an absolute assessment of image quality and pathology between the three phases of a CT Urography (CTU) protocol to explore the diagnostic value of low-dose abdominal CT. The anonymised images were displayed in random order and image quality was assessed by a group of radiologists using image quality criteria from the “European guidelines of quality criteria for CT”. The responses from the reviewer assessment were analysed statistically with ordinal logistic regression i.e. Visual Grading Regression (VGR).Results in Paper I show that a small dose reduction (5-9 %) was possible using SAFIRE strength 1and indicated the need for further research to evaluate the dose reduction potential of higher strengths of the algorithm. In Paper II a 30% dose reduction was possible without change in ADMIRE algorithm strength as no improvement in image quality was observed between tube loads 98- and 140 mAs. When comparing tube loads 42 and 98 mAs, further dose reduction was possible with ADMIRE strength 3 (22-47%). However, for images reconstructed with ADMIRE strength 5, a dose reduction of 34-74% was possible for some, but not all image criteria. Image quality in low-contrast objects such as the liver parenchyma, was affected and a decline in diagnostic confidence was observed. Paper IV showed potential dose reductions are possible with increasing slice thickness from 1 mm to 2 mm (24-35%) and 1 mm to 3mm (25-41%). ADMIRE strength 3 continued to provide diagnostically acceptable images with possible dose reductions for all image criteria assessed. Despite objective evaluations showing a decrease in noise and an increase in contrast to noise ratio, ADMIRE strength 5 had diverse effects on the five image criteria, depending on slice thickness and further dose reductions were limited to certain image criteria. The findings do not support a general recommendation to replace ADMIRE3 with ADMIRE5 in clinical abdominal CT protocols.Paper III studied another aspect of optimisation and results show that visualisation of renal anatomy was as expected in favour of the post-contrast phases when compared to the native phase. Assessment of pathology showed no significant differences between the three phases. Significantly higher diagnostic certainty for renal anatomy was observed for the post-contrast phases when compared to the native phase. Significantly high certainty scores were also seen for the nephrographic phase for incidental findings. The conclusion is that a low-dose series seems to be sufficient as a first-line modality in certain patient groups.This thesis clinically evaluated the effect of IR in abdominal CT imaging and estimated potential dose reductions. The important conclusion from papers I, II and IV is that IR improves image quality in abdominal CT allowing for some dose reductions. However, the clinical utility of the highest strength of the algorithm is limited to certain criteria. The results can be used to optimise the clinical abdominal CT protocol. The conclusion from paper III may increase clinical awareness of the value of the low-dose abdominal protocol when choosing an imaging method for certain patient groups who are more sensitive to radiation.