REVIEW ARTICLE
How to Incorporate Dual-Energy Computed Tomography
Into Your Neuroradiology Practice: Questions and Answers
Jeffrey R. Sachs, MD, Thomas G. West, MD, Christopher M. Lack, MD, PhD,
Brad Perry, MD, and Michael E. Zapadka, DO
Abstract: Dual-energy computed tomography (DECT) has many current
and evolving applications in neuroradiology including material decompo-
sition, improving conspicuity of iodinated contrast enhancement, and arti-
fact reduction. However, there are multiple challenges in incorporating
DECT into practice including hardware selection, postprocessing software
Downloaded from http://journals.lww.com/jcat by BhDMf5ePHKbH4TTImqenVE+K0QyTIVibQZ+BSicEnp0xNJCbW6E+SzyZfB0GwC5xXAksP3IWogg= on 11/28/2018
requirements, technologist and physician training, and numerous workflow
issues. This article reviews in a question-and-answer format common issues
that arise when incorporating DECT into a busy neuroradiology practice.
Key Words: computed tomography, dual energy, workflow
(J Comput Assist Tomogr 2018;42: 824–830)
T he decision to incorporate dual-energy computed tomography
(DECT) into practice is both exciting and daunting. There are
several established applications of this technology in neuroim-
aging, but also new and emerging functions. Some of these ap-
plications include distinguishing blood from calcium in brain
imaging,1 aging spine fractures without magnetic resonance
imaging (MRI),2 material decomposition analysis,3 increasing
conspicuity of enhancement in head and neck squamous cell
carcinoma,4 and metal artifact reduction.5 There are a number of ex-
cellent recent publications that review the spectrum of ways in
which DECT has proven useful clinically in neuroradiology.1,2,4–18
The purpose of this article is to review the opportunities
and challenges that come with incorporating DECT into a high-
volume neuroradiology practice. The article follows a question-
and-answer format spanning those issues that impact selection,
workflow, and interpretation in DECT.
SELECTION
There are several competitive dual-energy capable computed
tomography (CT) scanners on the market today. While the decision
of which scanner to choose may ultimately be influenced by current
vendor relationships, one should be aware of the different methods
available to perform DECT. These include (1) dual-source DECT
(SOMATOM Dual Source Definition Flash, Force, and Drive;
Siemens AG, Forchheim, Germany), (2) Rapid-kV Switching DECT
(RSDECT) (Discovery HD750/Revolution 750HD and Revolution;
GE Healthcare, Waukesha, Wis), and (3) layered detector DECT
(IQon; Philips Healthcare, Andover, Mass). For a thorough review
of the physical principles underlying these different methods, the
reader is referred to previously published works on this topic.19,20
It should be noted that even for specific vendors providing a
certain scanner type there may be multiple generations of the
From the Department of Radiology, Wake Forest School of Medicine, Wake
Forest Baptist Health, Winston-Salem, NC.
Received for publication August 30, 2018; accepted August 31, 2018.
Correspondence to: Jeffrey R. Sachs, MD, Wake Forest University Baptist
Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157
(e‐mail: jsachs@wakehealth.edu).
The authors declare no conflict of interest.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/RCT.0000000000000810
824 www.jcat.org J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
same scanner available for purchase, each with its own cadre
of capabilities. Always refer to vendor-provided documenta-
tion for further details. A brief review of the main differences
and pros/cons of each “method” of performing DECT follows.
What Is Dual-Source DECT?
This type of scanner uses 2 source and detector combina-
tions, which are placed at a near-perpendicular angle to each other.
One detector uses high-energy spectra, and the other low-energy
spectra (Siemens AG). Having separate tubes allows for indepen-
dent adjustment of the kV and mA levels for each tube. This can
make it easier to balance the total amount of photons emitted from
each tube and also help achieve good separation of the high- and
low-energy spectra. The use of 2 separate tubes also allows for
higher total x-ray flux relative to a single tube system, a benefit
for imaging patients with large body habitus. Addition of a filter
to the high-energy spectrum can also improve the separation
between the high- and low-energy spectra. Single-energy CT
(SECT) protocols are easily utilized on this scanner type as
well. A current disadvantage of this system is that the second
tube/detector system is typically smaller due to space limitations
in the gantry. This results in a limited size of the usable field of
view (FOV) for dual-energy scans. This FOV is defined as the
volume scanned by both the higher and lower energies and is
displayed as a superimposed circle on the images (see question
below); anatomy outside this FOV is only scanned using the
larger tube/detector system and is therefore single energy. This
is typically not a problem for neuroradiology applications, but can
be problematic in obese patients for abdominal applications. There
is also a relative temporal skew of approximately 70 milliseconds
between the 2 tube/detector pairs due to the rotation time required
to cover the same area. Because of the time delay, the 2 energy
data sets are geometrically inconsistent. Subsequent material de-
composition is performed in the image domain (rather than using
the raw data), a process that ultimately can result in persistence of
beam hardening artifacts and less accuracy.21,22
What Is Single-Source DECT With Rapid
kVp Switching?
These systems use a single source and detector pair (GE
Healthcare; Canon Medical Systems, Otawara, Tochigi, Japan).
They require a proprietary and very fast, specialized detector, as
well as a generator capable of quick transitions between high
and low tube potentials. During each rotation, the tube switches
rapidly between high (140) and low (80) kVp. The main advan-
tages of this system are that the entire field of view is scanned with
both energies, and the temporal skew is lower relative to dual-
source scanners (delay between high and low energies can be as
low as 50 microseconds). This type of system allows for material
decomposition to be performed using the raw data, a process that
can minimize beam hardening in virtual monoenergetic images
(VMIs). One disadvantage of this system is that the gantry rotation
time must be ~0.5 second or longer to allow for acquisition of
J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018
projections at 2 energies, which can prolong total scan acquisition
time. Another disadvantage is that the low-energy spectrum is limited
to 80 kVp, which can make photon starvation effects worse when
scanning larger patients. Because of the tube voltage switching
several thousand times per second, filtering the higher-energy
spectrum is difficult, limiting the spectral separation of the 2 en-
ergy levels. Dose reduction features such as tube current modula-
tion are also not possible because of the speeds involved.
What Is Layered Detector DECT?
In this configuration, spectral separation is achieved at the
detector level (Philips Healthcare). A single-tube/detector combi-
nation is used, and the patient is scanned at a higher energy level
such as 140 kVp. The spectral separation is achieved by having
layered scintillator materials, with the top layer preferentially
absorbing lower-energy photons but allowing the higher-energy
photons to pass through and be absorbed by the subsequent layer.
Major advantages of this recently available commercial system
include scanning dual energy at full FOV (50 cm), excellent tem-
poral resolution, and higher total x-ray power (because it uses a
single high-energy source), which is helpful for scanning larger
patients. The rays are also inherently perfectly registered, allowing
for material decomposition to be done using the raw data. How-
ever, this system has a lower-energy separation as the scintillator
absorption properties do not sharply distinguish between low- and
high-energy photons. This means that the contrast of the spectral
information is more limited or requires a higher radiation dose.
The clinical efficacy of this design is not as well studied relative
to the dual-source or rapid kVp switching systems.
Question: Do I have to purchase a new scanner to get
dual-energy capability, or are upgrades available to my
existing equipment?
Answer: It depends. Most SECT scanners are not upgrad-
able to dual energy. However, an upgrade may be possible, such
as CT scanners from vendors that utilize fast kV switching (eg,
HD750; GE Healthcare). Upgrading an existing model may be
significantly more cost-effective than purchasing a new scanner.
Hardware requirements for dual-source DECT scanners and layered
detector scanners generally mean that an upgrade is not possible.
Question: Where should the scanner be installed?
The answer to this question depends heavily on factors
unique to the individual practice. In making the decision, one must
take into account the age and level of disrepair of all scanners in
the fleet. Ideally, one would prefer to replace the oldest scanner
with the most current and feature-rich DECT. However, replacing
an older scanner that is not heavily utilized may lessen the positive
impact of this new technology on patients. Consider the clinical
questions potentially impacted by DECT and in which practice en-
vironment they are likely to arise. For example, in our practice, it
has been helpful to have the DECT scanner in a physical location
optimal for scanning patients with ischemic stroke who are
postthrombectomy to differentiate contrast staining from intracra-
nial hemorrhage. Our DECT in the emergency department (ED)
on numerous occasions has helped us to distinguish calcifications
from acute intracranial hemorrhage. By adding confidence in
ruling out intracranial hemorrhage, DECT helps to improve ED
throughput as well as avoid unnecessary admissions and follow-
up scans.
Streamlining patient convenience also needs to be consid-
ered when making this decision. For example, if an imaging prac-
tice currently serves a comprehensive oncology group that wishes
to take advantage of dual-energy oncology protocols, placing a
DECT scanner in a convenient location to facilitate immediate
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Incorporating DECT Into Neuroradiology Practice
postscanning clinic and laboratory appointments is crucial for
proper utilization. Otherwise, the full capabilities of the DECT
are likely to go underappreciated. Convenience and patient satis-
faction often go hand in hand. It also cannot be underestimated
the importance of referring clinician satisfaction when attempting
to incorporate DECT into a practice.
Question: Are there specific infrastructure requirements for
dual energy that would require major renovations to a hospital or
imaging center?
Answer: In general, no. Every time a new piece of radiog-
raphy or CT scanner is installed, a new shielding plan must be
submitted to state regulators (varying according to applicable state
laws). This requires the input from a medical physicist to ensure
that the proper perimeter shielding is in place for the safety of
patients, health care personnel, and the public. This requirement
is not unique to DECT, however.
There are variations in size between make/model of DECT
scanner. However, in general one could expect a room within a
facility that previously housed an SECT scanner should be able
to fit a DECT with minimal modification.
WORKFLOW
The integration of DECT into practice requires new training
of technologists and radiologists as to the indications and capa-
bility of this technology. There are potential impacts upon sched-
uling patients, image acquisition times, and concerns regarding
postprocessing software and the potential impact on the workflow
and productivity of the entire imaging team. This section explores
workflow issues that have arisen at the authors' practice.
Question: What resources are available for training technol-
ogists to use DECT?
Answer: Vendors will provide an initial period of on-site
hands-on applications training for both technologists and physi-
cians. The specific amount of applications time is negotiable at
time of contracting for the scanner(s) being purchased. If the tech-
nologists are familiar with a certain vendor's platform, changing to
a new vendor means that the technologists will have to learn an
entirely new imaging platform in addition to the DECT-specific
features. This may negatively impact adoption of DECT in unan-
ticipated ways. Considering pressure placed upon technologists for
expedient throughput, it may be tempting to preferentially divert
cases to a much more familiar, but older and less capable single-
energy scanner. Investing more heavily in technologist training
up-front may mitigate the impact of introducing a new scanner
and lead to less disturbances in the workflow. Although vendor
specific, there are some DECT-specific workshops for physicians
and technologists that one can explore to learn the physical
concepts of dual energy and how the data are acquired and
postprocessed. Such workshops include dose and protocol optimi-
zation as well as hands-on sessions with the vendor-specific dual-
energy viewing software for advanced postprocessing applications.
The authors' institution primarily uses Siemens for DECT, which
offers a hotline where application specialists are standing by for
near-immediate assistance when help is needed (even when ac-
tively scanning a patient).
Question: Is the dual-energy postprocessing software avail-
able as a thin client or on a separate workstation?
Answer: Both solutions are available. However, a single in-
dependent workstation is impractical for real-time utilization by
the radiologist in a busy practice. Issues would arise when several
radiologists may wish to perform dual-energy postprocessing
simultaneously, and it would also require the radiologist to
leave his/her PACS (picture archiving and communication sys-
tem) station to process images. Having a single postprocessing
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Sachs et al J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018
workstation essentially dooms the successful widespread adop-
tion of DECT in a larger practice. By implementing a vendor-
specific thin client that can be accessed at the PACS station, a
practice is far more likely to realize widespread utilization of
DECT postprocessing. One additional step to consider when
implementing the thin client is the number of licenses needed.
These licenses allow users to not only view but also manipulate
the dual-energy spectral data to obtain virtual noncontrast
(VNC), virtual noncalcium (VNCa), and VMI reconstructed im-
ages, among others. These licenses may be a rate-limiting step
in day-to-day clinical use if only a small number are available
and multiple physicians are attempting to use the software at once.
Question: Can the dual-energy postprocessing software be
integrated with PACS? Are there any drawbacks to doing so?
Answer: Siemens dual-energy postprocessing software
Syngo.Via can successfully be integrated with Philips IntelliSpace
4.4 PACS via an API Plugin within the Philips PACS software.
While this integration is a fairly simple process, there are various
configuration issues that need to be weighed. This integration is
on a per-machine basis, and one would need to consider compat-
ibility with the operating system, system memory, network band-
width, and internet explorer security settings along with user
security in general. It is also prudent to consider how many other
third-party plug-ins are currently configured within Philips 4.4
PACS as the addition of another plug-in could cause system in-
stability for the PACS. Aside from these usual considerations, in-
tegrating Syngo.Via with Philips IntelliSpace 4.4 provides a
focused and efficient tool with few drawbacks. When integrated
it can be quickly accessed from within a patient's study via 1 or 2
clicks without having to access the software outside of PACS, log
in, and then spend precious time finding the patient's study.
While the above answer is specific for the Siemens software
and PACS system at the authors' institution, similar information
technology security and hardware concerns would apply when
attempting to integrate third-party applications with other PACS.
Question: What type of training do radiologists need to get
comfortable with using dual-energy postprocessing?
Answer: Initial hands-on training by the vendor will famil-
iarize the radiologist with the functionality of the software. Pro-
ducing the various maps and utilizing other postprocessing
features (eg, VMI ROI curves) on known entities help to develop
confidence in diagnoses. For example, one can do postprocessing
on posttraumatic hemorrhage that does not present a diagnostic di-
lemma, choroid plexus calcifications, or contrast in vessels on
postcontrast examination/CT angiography (CTA). As previously
mentioned, vendor-specific workshops may be available in your
region for more focused hands-on training.
Question: Do all scans performed on a dual-energy scanner
utilize dual energy?
Answer: Not necessarily. A dual-source DECT scanner can
also perform SECT, necessitating creation of DECT-specific pro-
tocols if desired. A rapid kVp switching DECT scanner has a
dual-energy mode that must be preselected if DECT is desired.
If using a layered detector-based scanner for DECT, all patients
scanned will have spectral data available for postprocessing,
which eliminates the need for DECT-specific protocols. As
previously mentioned, the authors' institution currently utilizes
dual-source DECT, and it has been difficult to predict when
dual energy will be useful in postprocessing. It is helpful to route
patients with examinations or indications that have a higher like-
lihood of having a finding that would benefit from DECT directly
to the DECT scanners.
Question: If a practice has only 1 dual-energy scanner amid
a larger fleet, which patients would benefit the most from this
new scanner?
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Answer: One of the most common indications for utilizing
DECT at the authors' institution is to differentiate iodine contrast
staining from hemorrhage in patients following thrombectomy
for acute ischemic stroke. Another common indication typically
seen through the ED (but encountered in all practice settings) is
differentiating acute intracranial hemorrhage from calcification
or potential mimickers such as a cavernous malformation. Dual-
energy CT can reduce unnecessary consultations and hospital ad-
missions, prevent patient anxiety, and eliminate wasteful repeat
imaging. Virtual noncontrast images obtained via postprocessing
are particularly helpful in patients status post recent intravenous
contrast material administration or post recent myelography or in
patients with contraindication to MRI where a single contrast-
enhanced acquisition can provide true postcontrast and virtual
precontrast series. Dual-energy CT is also potentially useful to
assess for bone marrow edema in vertebral bodies if patients with
age-indeterminant compression deformities cannot undergo MRI.2,23
Question: Can dual-energy sequences be automatically sent
to PACS?
Answer: Yes. The authors' practice currently has the weighted
average images, a bone subtraction image, and a 190-keV VMI sent
to PACS for routine noncontrast head CT. This requires no specific
effort by the technologist and is fully automated. The 80- and
140-kVp acquisitions are utilized to produce the above series but
are first sent to the vendor-specific postprocessing server and then
to PACS. Although vendor specific, there is typically a limit to
the number of series that can be automatically sent to PACS. Net-
work speed can impact the time to availability on PACS, and this
may negatively impact both technologist and radiologist workflow.
Question: What series are useful to automatically send
to PACS?
Answer: The VMI 190 keV is quite useful as it allows for
quick confirmation of suspected calcium versus hemorrhage
(calcium will be less conspicuous, whereas hemorrhage will ap-
pear similar to the weighted average image) and also increases
conspicuity of subtle extra-axial hemorrhage due to reducing beam
hardening artifact at the brain-bone interface. Bone subtraction
sequences are also useful to increase conspicuity of extra-axial
hemorrhage, and bone subtracted CTA examinations allow for
rapid evaluation of the vasculature as 3-dimensional (3D) recon-
structions can be made where the vessels are visible at the skull
base. See below for additional information on useful sequences
unique to spine and neck imaging.
Question: How can patients who would benefit from a dual-
energy scan be routed to the new dual-energy scanner?
Answer: In a practice with multiple CT scanners serving ED,
inpatient, and outpatient settings, the scanners may be some dis-
tance apart. It is preferable to select DECT as the mode of scan-
ning at the time of scheduling. The authors have experimented
with having referring clinicians request dual energy by specifying
as such in the comments section in the electronic medical record,
but this approach is not 100% consistent as it relies on the technol-
ogist to recognize the comment and route the patient to a DECT-
capable scanner. A more effective systems-based solution is to
create dual-energy–specific orders in the electronic medical record,
which should improve the workflow by seamlessly routing these
patients directly to a DECT scanner. However, this requires con-
tinued education of referring clinicians as to how and when to or-
der DECT. Likewise, investing time in technologists' education is
crucial in this process as they will often be the first to recognize
and appropriately triage patients to different scanners.
Question: What is the importance of isocentering the patient?
Answer: Isocentering the patient is critical to image quality
and dose reduction efforts. One advantage of dual-source dual-
energy scanners is the ability to use automated tube current
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018 Incorporating DECT Into Neuroradiology Practice

FIGURE 1. The importance of isocentering the patient. Imperfect isocentering will lead to inaccuracies in the calculated attenuation and
imperfect tube current modulation. For example, in the middle image, the patient is positioned too high, resulting in the patient appearing
artificially large on the topogram. The tube current will be inappropriately increased in this situation, using more radiation dose than necessary.
Conversely, in the scenario on the far right image, the patient is positioned too low and appears artificially small on the topogram. Tube
current will be inappropriately low in this situation, and image noise will increase. Figure 1 can be viewed online in color at www.jcat.org.

modulation. Isocentering is important with these scanners so Answer: Yes. Dual-energy CT has several advantages over
that the appropriate geometry is available for calculations of ap- SECT. Single-energy CT is often compromised by beam-hardening
propriate tube current at any given position (Fig. 1). This allows artifacts in patients with spinal hardware as the metallic implants
for similar reference mAs to be utilized for a DECT as one would absorb the lower-energy portion of the polychromatic x-ray beam.
use for a conventional SECT scan. Radiation doses similar to The resulting higher-energy beam results in lower contrast adjacent
conventional SECT can be obtained using DECT at the same to the metal implant that manifests as dark bands on the image.
quality reference mAs.24 If the patient is out of isocenter, the High-energy VMI created via DECT can significantly reduce beam
tube current may be inappropriately high or low, which would hardening artifacts. Virtual monoenergetic image is an image that
lead to inappropriately high radiation dose or suboptimal image simulates what the scan would look like if scanned using only that
quality. Artifacts may become apparent when the patient is not specific energy level.5,25 If higher-energy monochromatic energies
isocentered (for example, see Fig. 2). Isocentering can be done are selected (greater than ~95 keV) it can virtually eliminate beam
by a variety of approaches including at the scanner workstation hardening artifact adjacent to postoperative implants.3,26–28 Bone
(scout image crosshairs) or laser guides at the gantry.
Question: If manual postprocessing of DECT images is
required, who can/should do this?
Answer: There is no question that the postprocessing of DECT
images can be time consuming. For radiologists, postprocessing the
examination by themselves can be useful as they are familiar with
the case and know what postprocessing is needed for interpretation.
“Super-user” technologists may be trained to do this postprocessing
as well, or it may be beneficial to create a “3D” laboratory if resources
are available. Many conundrums that present on noncontrast head CT
can be confidently answered with the weighted average images and
VMI 190-keV images. Vendors are constantly working to improve
the automaticity of the DECT workflows. There is no question that
a seamless, efficient workflow is very important for successful adop-
tion and growth of DECT in a busy, high-volume neuroradiology
practice. Given that not all physicians in a practice may be up-to-date
on DECT and its capabilities, let alone the postprocessing functions,
automating the process of sending spectral-based reconstructions
to PACS (especially early on implementation) would be helpful.
Question: Is the DECT spectral data available for
postprocessing indefinitely?
Answer: Not necessarily. In order to postprocess the spectral
data and create unique reconstructions such as VMI data in the
future, the spectral data must be preserved. For example, with
Siemens, the dual-source data are preserved on Syngo.Via, but
only for a set period of time before eventually the data are over-
written by new scan data because of storage limits. Therefore, it
is recommended that the most commonly utilized dual-energy
FIGURE 2. Occipital lobe artifact. Arrows point to areas of
reconstruction data sets are sent to PACS for long-term storage hypoattenuation in the occipital lobes, which can lead to an
and future use as a comparison study. However, the spectral data inappropriate diagnosis of posterior reversible encephalopathy
would not be available to permit region-of-interest analysis or syndrome or infarct. This artifact was resolved by more careful
generation of spectral HU attenuation curves. attention to isocentering the patient. Figure 2 can be viewed online
Question: Is dual-energy CT useful for spine imaging? in color at www.jcat.org.

© 2018 Wolters Kluwer Health, Inc. All rights reserved. www.jcat.org 827

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Sachs et al J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018
subtraction for myelography can produce a virtual myelographic
image (similar to magnetic resonance myelography).11 Specific al-
gorithms for detection of monosodium urate in gout are available as
well, although the “normal” distribution of monosodium urate
needs further study. A recent study has reported monosodium urate
crystals within the intervertebral disks of older men as a possible
physiologic finding rather than gout related.29 In theory, creation
of VNCa images can allow detection of marrow edema that is
obscured by trabecular bone on conventional SECT, although
the authors' initial experience with this has been disappointing.
However, several studies have evaluated the performance of DECT
relative to MRI in evaluation of bone marrow edema.2,23,30–32
Question: Is dual energy beneficial for CT neck examinations?
Answer: Yes. The VMI 40 keV can be sent to PACS auto-
matically. Utilizing a lower keV (closer to the 33.2-keV K-edge
of iodine) results in increased contrast between iodine and back-
ground soft tissues. The result is that enhancing head and neck tu-
mors may be more conspicuous on this series.4 In addition, higher
VMI keV can reduce artifact related to dental amalgam (useful for
evaluation of oral cavity or oropharyngeal tumors) or spine hard-
ware, but comes at the cost of decreasing visualization of enhance-
ment. Recent studies have shown that high-energy VMIs and
iodine maps/VNC images have utility in evaluating for laryngeal
cartilage invasion in the setting of laryngeal squamous cell carci-
noma.4,8,15,18,33,34 A nice review on incorporating DECT of the
neck into clinical practice was recently published.16
Question: Is dual energy beneficial for CTA examinations of
the head and neck?
Answer: Yes. Metal artifact reduction techniques may im-
prove visualization of the vessels around the coil mass in patients
who have undergone endovascular coiling of aneurysms.27 Dual-
energy CT can also be useful to subtract the bones, which can
impede interpretation of maximum intensity projection or volume-
rendered CTA images. There are several publications that investi-
gated the use of DECT for bone removal in CTA.35–39
INTERPRETATION
Question: How is it apparent that one is looking at a
DECT scan?
Answer: Dual-energy CT images used for standard diagnos-
tic interpretation are very similar to those acquired with SECT.
They are created as a “weighted average,” which is a blend of
CT images acquired at the 2 energies, that is, 80 and 140 kVp.
This combines the advantages of low-energy contrast-to-noise ra-
tio and high-energy signal-to-noise ratio. At the authors' practice,
standard diagnostic DECT weighted average images contain 40%
of the 80-kVp image and 60% of the 140-kVp image. When in
doubt (especially the case when initially instituting DECT proto-
cols with dual-source systems), the dual-energy scans will have
the “DE” label on images in PACS. One can also check the dose
report that will confirm a scan was done dual energy by
documenting the CT dose index from the low- and high-energy
portions of the scan.
With DECT, there are several other commonly generated
maps that are available, typically used for problem solving. These
include VMIs, which are a simulated acquisition at a single-
energy level. Low-energy VMIs will have better soft tissue con-
trast, whereas high-energy VMIs will have better artifact reduction.
Additional maps include VNC, VNCa, and overlay maps, which
are based on the principle of material decomposition (discussed be-
low) and can effectively remove contrast or iodine from the images.
These maps can differentiate iodine from blood and blood from cal-
cium. Finally, bone-subtracted images are available, which are able
to differentiate calcium (bone) from iodine based on atomic number
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differences. Bone subtraction can be helpful when interpreting head
and neck CTAs, especially arterial structures in the region of the
skull base. It can also be used for calcific plaque removal, mak-
ing it easier to evaluate for vascular stenosis. Bone-subtracted
images can also be displayed as 3D and maximum intensity
projection images.
Question: Are VMI useful for routine imaging of the brain?
Answer: Yes. Lower-energy VMIs maintain superior tissue
contrast that can be beneficial in regions that are traditionally
difficult to evaluate using SECT, such as the posterior fossa. The
authors suggest VMIs with energies in the range of 65 to 75 keV
to accomplish both improved signal-to-noise and contrast-to-noise
ratios and acceptable beam hardening artifacts.17,40
Question: Are there any artifacts unique to DECT?
Answer: When the authors' practice first started performing
DECT head scans, we encountered an artifact in the occipital lobes
where there was apparent symmetric hypoattenuation with loss of
gray-white differentiation, an appearance that mimicked posterior
reversible encephalopathy syndrome or infarct (Fig. 2). This artifact
was resolved by ensuring that the patient is well isocentered for
the scan.
One potential artifact that may arise in performing DECT
using dual-source technology is a detector miscalibration artifact.
If the scanner has been used only for single-energy scans for an
extended period prior to performing a DECT, it is possible that
the second tube/detector system is “cold,” and this may result in
a ringlike artifact (Fig. 3). This ring artifact mimics a broken de-
tector, but is not present on all images (does not propagate through
the entire imaging volume in the Z axis). Note that photon star-
vation artifact can also cause a similar appearance. To avoid
miscalibration artifacts, performing a “checkup” is recommended
if a DECT has not been performed in the past 12 hours. This will
allow the second tube/detector system to both warm and become
calibrated. This checkup should also be performed when prompted
at the scanner console, or when the system is rebooted.
Although technically not an artifact, the reader of DECT
should be aware if he/she is using a dual-source scanner that there
FIGURE 3. Ringlike artifact in the aortic arch on CTA (arrows).
Upon first impression, this may imply that a detector is broken;
however, this artifact does not propagate entirely through the Z axis
of the scan. Such an artifact may be due to detector miscalibration
in dual-source DECT systems or photon starvation effects. Figure 3
can be viewed online in color at www.jcat.org.
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J Comput Assist Tomogr • Volume 42, Number 6, November/December 2018 Incorporating DECT Into Neuroradiology Practice

FIGURE 4. An example of the ring demarcating the boundary between single- and dual-energy scanned zones. The ring in the abdominal
CT on the left image (arrow) encompasses the anatomy scanned at both high- and low-energy spectra. On the right image, notice the
difference in noise in the liver parenchyma between the area scanned with dual energy (arrow within the circle) versus single energy
(arrow outside the circle). Figure 4 can be viewed online in color at www.jcat.org.

will be a circle superimposed on the diagnostic images. Because
of space limitations in the gantry, the second tube/detector system
will have a smaller FOV. The central portion of the circle de-
marcates the anatomy scanned with both high- and low-energy
photons, and the volume outside the circle is the anatomy that
was scanned only with single, low-energy photons. As expected,
this results in an increase in image noise outside the circle. See
the liver parenchyma in Figure 4. This is generally not a prob-
lem in neuroimaging because the FOV is limited but can be an
issue in abdominal applications especially when imaging
obese patients.
Question: Is the entire patient scanned with dual-energy
photons on every DECT scan?
Answer: It depends on the DECT scanner being used. If uti-
lizing dual-source DECT, as stated above space constraints require
the detectors be of different sizes, so dual energy is achieved
only in the region of overlap. On the Siemens FLASH model,
for instance, tube A is 50 cm but tube B is 33 cm. That means that
dual-energy data are available only within the smaller 33-cm radius.
If using a rapid kV switching system, there is a mode (such as
“GSI” on GE systems) that if activated implies the entire FOV
was scanned with dual-energy photons. If using a layered detector
system, the dual-energy information is extracted at the detector
level and is thus available for the entire FOV scanned.
Question: What is a material decomposition curve?
Answer: Material decomposition is the basis by which mate-
rials can be differentiated given their variable attenuation at differ-
ent energy spectra. The attenuation of a material at a given energy
is based on its atomic number. Materials with high atomic num-
bers (eg, iodine and calcium) have significantly higher attenuation
at lower energies (ie, 80 kVp) due to the photoelectric effect
compared with materials with low atomic numbers (ex. soft tis-
sue, blood, and water). If a voxel contains iodine and soft tissue,
its attenuation will increase across all energy spectra, but will in-
crease even more so at low kV because of its iodine content.
Therefore, by scanning at multiple energies, this would allow us
to see the difference between an iodine/soft tissue–containing
voxel and a blood/soft tissue–containing voxel. This same exercise
can be performed with calcium in place of iodine. Through
material decomposition, one can generate overlay maps (cal-
cium, iodine) and VNC/noncalcium images. In neuroradiology,
this allows for clinically useful interrogations. It allows differenti-
ating hemorrhage from calcium and hemorrhage from iodine.
However, the applications extend outside the neuroaxis. For example,
VNC images can be used to evaluate the kidneys for renal lesions/
stones in patients undergoing a contrast-enhanced examination.
Question: If dense material is still evident on the VNC/VNCa,
does that mean it is hemorrhage?
Answer: Not necessarily. While one can be confident that
hyperdense material evident on a VNCa is not calcium and if seen
on the VNC that it is not iodine, etiologies other than hemorrhage
can account for hyperdensity on these maps. This would include
hypercellular tumor, nonhemorrhagic proteinaceous material, fungus,
tuberculoma, cavernous malformation, and so on. Also, persistent
hyperdensity on a VNCa map could represent iodinated contrast.1,9,41
CONCLUSIONS
The incorporation of DECT into a busy neuroradiology
practice can be challenging. Success requires thoughtfulness
in scanner selection, technologist and radiologist training, and
workflow integration. There is no one-size-fits-all approach.
Simplicity in ordering dual-energy scans and automated processes
for sending dual-energy postprocessed series to PACS are helpful
in achieving efficiency and clinician satisfaction. This automation
also has the added benefit of minimizing the time and effort
needed to utilize a vendor-specific “thin client” software.
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