RESEARCH ARTICLE CT Pulmonary Angiography at Reduced Radiation Exposure and Contrast Material Volume Using Iterative Model Reconstruction and iDose4 Technique in Comparison to FBP Azien Laqmani1*, Maximillian Kurfürst1, Sebastian Butscheidt1, Susanne Sehner2, Jakob Schmidt-Holtz1, Cyrus Behzadi1, Hans Dieter Nagel3, Gerhard Adam1, Marc Regier1 1 Department for Interventional and Diagnostic Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 2 Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 3 Science & Technology for Radiology, Buchholz, Germany a11111 * [email protected] Abstract Purpose To assess image quality of CT pulmonary angiography (CTPA) at reduced radiation expo- OPEN ACCESS sure (RD-CTPA) and contrast medium (CM) volume using two different iterative reconstruc- Citation: Laqmani A, Kurfürst M, Butscheidt S, tion (IR) algorithms (iDose4 and iterative model reconstruction (IMR)) in comparison to Sehner S, Schmidt-Holtz J, Behzadi C, et al. (2016) CT Pulmonary Angiography at Reduced Radiation filtered back projection (FBP). Exposure and Contrast Material Volume Using Iterative Model Reconstruction and iDose4 Technique Materials and Methods in Comparison to FBP. PLoS ONE 11(9): e0162429. < doi:10.1371/journal.pone.0162429 52 patients (body weight 100 kg, mean BMI: 23.9) with suspected pulmonary embolism (PE) underwent RD-CTPA (tube voltage: 80 kV; mean CTDIvol: 1.9 mGy) using 40 ml CM. Editor: Gayle E. Woloschak, Northwestern University 4 Feinberg School of Medicine, UNITED STATES Data were reconstructed using FBP and two different IR algorithms (iDose and IMR). Sub- jective and objective image quality and conspicuity of PE were assessed in central, seg- Received: May 25, 2016 mental, and subsegmental arteries. Accepted: July 28, 2016 Published: September 9, 2016 Results 4 Copyright: © 2016 Laqmani et al. This is an open Noise reduction of 55% was achieved with iDose and of 85% with IMR compared to FBP. access article distributed under the terms of the Contrast-to-noise ratio significantly increased with iDose4 and IMR compared to FBP Creative Commons Attribution License, which permits (p<0.05). Subjective image quality was rated significantly higher at IMR reconstructions in unrestricted use, distribution, and reproduction in any 4 medium, provided the original author and source are comparison to iDose and FBP. Conspicuity of central and segmental PE significantly credited. improved with the use of IMR. In subsegmental arteries, iDose4 was superior to IMR. Data Availability Statement: All relevant data are within the paper. Conclusions Funding: The author(s) received no specific funding CTPA at reduced radiation exposure and contrast medium volume is feasible with the use for this work. of IMR, which provides improved image quality and conspicuity of pulmonary embolism in Competing Interests: The authors have declared central and segmental arteries. that no competing interests exist. PLOS ONE | DOI:10.1371/journal.pone.0162429 September 9, 2016 1/15 CT Pulmonary Angiography at Reduced Dose and Contrast Material with Iterative Reconstruction Introduction With advances in CT technology offering high temporal and spatial resolution, the diagnostic accuracy of CT pulmonary angiography (CTPA) has increased with reported sensitivities and specificities of 83–100% and 89–97%, respectively [1–3]. However, the utilization of CTPA increased dramatically, raising concerns with respect to radiation exposure [4–6]. As the high diagnostic value of CTPA has been outlined in numerous studies, the focus has been shifted to the optimization of CTPA protocols in order to comply to “as low as reasonably achievable” (ALARA) principles. Moreover, the use of iodinated contrast medium (CM) for CTPA exami- nations also remains a concern since it may contribute to contrast-induced nephropathy (CIN), especially in patients with pre-existing renal impairment [7, 8]. The risk of developing CIN is increased with higher volumes of iodinated CM [8]. Therefore an optimized CTPA pro- tocol with a combination of both reduced radiation dose and reduced CM volume would be desirable. Low tube voltage CTPA protocols have shown the ability to reduce radiation dose and, by shifting the average x-ray photon energy closer to the k-absorption edge of iodine, to reduce CM volume in non-obese patients [9–12]. A drawback of low tube voltage is the increased image noise, which can impair image quality [13]. The increased image noise can be compensated by iterative reconstruction (IR). Previous studies have shown the feasibility of low KV CTPA examinations combined with IR, facilitating good image quality [14]. Recently, iterative model reconstruction (IMR) has been introduced, which offers a higher image noise reduction strength, thus a greater increase in CNR can be achieved, which can be potentially advantageous for reduction of CM volume. A combination of both, low kilo voltage CTPA pro- tocol and IR may facilitate the reduction of both, radiation dose and CM volume, while main- taining image quality. Therefore, the aim of this study was to assess image quality of CTPA at reduced radiation exposure (RD-CTPA) and CM volume using the two different IR algorithms iDose4 and IMR in comparison to filtered back projection (FBP). Materials and Methods Patient population Between November 2014 and January 2015, a total of 52 patients with a body weight less than 100 kg who were referred to our emergency department for a clinically indicated CTPA for sus- pected PE were included. Demographic patient data including sex, age, height, and weight were noticed. Body-Mass-Index (BMI) was calculated using the formula (patient weight (kg)/ [patient height (m)]2). The retrospective study was approved by the local Clinical Institutional Review Board (Ethic committee of the medical chamber of Hamburg) with a waiver of informed consent. CT pulmonary angiography acquisition protocol All CTPA examinations were performed on a 256-slice MSCT scanner (Brilliance iCT, Philips, Best, The Netherlands) using the following parameters: tube voltage: 80 kV; detector collima- tion: 128 x 0.625 mm; pitch 0.915; tube rotation time: 0.4 s. The automatic exposure control system (automatic current selection (ACS)) combined with z-axis dose-modulation (Z-DOM)) were used with a quality reference tube charge setting of 130 effective mAs, resulting in a CTDIvol setting of 2.6 mGy (without considering the additional dose saving effect of Z-DOM). The CTPA scan was performed in a craniocaudal direction from the top of the aortic arch to the level of the bottom of the heart within a single breath hold at mid inspiration in order to PLOS ONE | DOI:10.1371/journal.pone.0162429 September 9, 2016 2/15 CT Pulmonary Angiography at Reduced Dose and Contrast Material with Iterative Reconstruction avoid valsalva maneuvers. In cases of additionally suspected pneumonia, the scan area was extended. The injection protocol consisted of intravenous administration of 40 mL contrast medium with an iodine concentration of 300 mg/ml (Imeron 300, Bracco Altana Pharma, Milan, Italy) at a flow rate of 4 mL/sec followed by a 20-ml saline flush at the same flow rate via a commer- cially available injector (Medrad1, Stellant1 D, Bayer HealthCare, USA). The CT acquisition was triggered using a bolus tracking technique (Bolus Pro Ultra, Philips Healthcare) with the region of interest (ROI) placed in the pulmonary trunk. Data acquisition started with a delay of 4 seconds after exceeding a threshold level of 130 Hounsfield units (HU). iDose4 and IMR technique iDose4 (Philips Healthcare, Cleveland, OH, US) represents a hybrid IR algorithm with 2 denoising components: an iterative maximum likelihood-type sinogram restoration based on Poisson noise distribution and a local structure model fitting on image data that iteratively decreases the noise [15, 16]. The iDose4 levels (1–7) define the increasing strength of noise reduction [14]. IMR is the latest IR approach introduced by Philips Healthcare and is an advanced, model and knowledge based IR technique that states to overcome the trade-off between image noise and spatial resolution that is typical for traditional FBP [17]. Noise reduction by up to factor 10 (17), which is even larger compared to other hybrid algorithms (factor up to 3 (10, 11, 13, 21)), provides virtually noise free images. But IMR aims at accounting for not only the noise behav- ior of the image but also the data statistics, image statistics, and system models during its itera- tive cycle. Hence, different aspects of image quality can be targeted, such as image smoothness, spatial resolution and artifacts. The vendor offers different “IMR definitions” (i.e. filter set- tings) for reconstruction of the images, whereby “BodyRoutine” (BR) is the recommended set- ting for CT angiography examinations. The IMR levels (1–3) define the increasing strength of noise reduction [16–18]. Image reconstruction All raw data were reconstructed with FBP, the HIR iDose4 and with a prototype implementa- tion of the new knowledge-based IR algorithm IMR (Philips Healthcare, Cleveland, OH, US). Axial source images were reconstructed with a slice thickness of 1 mm and an increment of 0.5 mm using a standard body filter (B) for FBP and iDose4. For IMR, the recommended setting “BodyRoutine” (BR) was used. In order to compare different reconstruction levels of the two IR algorithms, two increasing iDose4 levels 4 (iDose4 L4) and 6 (iDose4