Emergency Radiology (2005) 11: 127–128
DOI 10.1007/s10140-004-0396-6
E D I T ORI AL
Mannudeep K. Kalra Æ Stefania M. R. Rizzo
Robert A. Novelline
Technologic innovations in computer tomography dose reduction:
implications in emergency settings
Published online: 5 March 2005
Ó ASER 2005
Introduction of multi-detector-row computer tomogra-
phy (CT) scanners has revolutionized imaging of acutely
ill patients. However, CT scanning with multi-detector-
row scanners now accounts for about 15% of proce-
dures and 75% of the diagnostic radiation dose received
by patients, which are substantially higher than in the
mid-1990s, when CT scanning constituted 4% of radi-
ology procedures and contributed about 40% of the
collective radiation dose in diagnostic radiology. In the
United States, the Nationwide Evaluation of X-ray
Trends (NEXT) survey of patient radiation exposure
from CT has reported that about 60 million CT exam-
inations are performed annually. Continuing evolution
of multi-detector-row CT technology and introduction
of 16-, 32-, 40-, and 64-slice scanners have led to
remarkable improvement in temporal resolution and
z-axis spatial resolution (isotropic scanning). Radiolo-
gists, including those practicing emergency radiology,
are exploring new and promising applications for these
state-of-the-art multi-detector-row scanners. Paradoxi-
cally, some investigators have claimed that cumulative
doses from multiple CT studies can reach the dose levels
associated with risk of cancer. Although individual risk
of radiation-induced cancer with CT scanning may not
be substantial compared with the background cancer
incidence in the population, the staggering number of
CT examinations performed annually raises concerns.
Almost 43 million road-traffic accidents occur annu-
ally in the United States, most commonly involving the
young population. CT scanning is often recommended
for evaluation of accidental injuries. As younger patients
M. K. Kalra Æ S. M. R. Rizzo Æ R. A. Novelline (&)
Division of Emergency Radiology,
Department of Radiology,
Massachusetts General Hospital
and Harvard Medical School,
Founders 215, 55 Fruit Street, Boston,
MA 02114, USA
E-mail: rnovelline@partners.org
Tel.: +1-617-726-8796
Fax: +1-617-724-7140
have a greater cancer risk with radiation exposure
compared with that of the elderly, increasing use of CT
scanning and associated radiation dose in these young
patients for evaluation of trauma demands special
attention. Therefore, radiation concerns associated with
increasing use of CT scanning in emergency radiology
and acute settings may rank second only to CT scanning
in children. Low-dose CT scanning protocols in children
and young patients have been proposed for acute indi-
cations such as trauma, appendicitis, renal calculi, and
abdominal colic. These protocols primarily focus on
reducing tube current, increasing pitch, and restricting
scan coverage to the area of interest. Patient weight and
cross-sectional regional dimensions have also been used
to adjust scanning parameters for radiation dose
reduction. However, use of low-dose scanning protocols
can result in greater image noise and can affect inter-
pretation.
Recently, CT vendors have introduced several tech-
niques to aid radiation dose reduction by improving
scanner efficiency and image quality in order to allow
acquisition of image information at low radiation dose.
These techniques include pre-patient collimation of X-ray
beams, use of better filters (bow-tie filters) and image
processing algorithms, noise reduction filters, automatic
exposure control (AEC), and efficient detector configu-
ration. Although certain multi-detector-row CT scanners
(4- and 8-slice multi-detector-row scanners) were associ-
ated with inferior radiation dose efficiency due to ‘‘over-
beaming’’ of X-rays beyond active detector rows,
development of improved collimation of X-ray beam and
better detector array configurations have helped to im-
prove radiation dose efficiency of more advanced scanners
(16-slice and above).
Automatic tube current modulation or AEC tech-
niques represent the most promising development in view
of concerns that many CT centers do not adjust scanning
parameters for different body regions (chest vs abdo-
men), patient size (large vs small), and age (children vs
adults). AEC techniques offer several advantages over
manual selection of fixed tube current, including
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selection of required image quality instead of tube cur-
rent and standardization of protocols for different
scanners and institutions. These techniques are compa-
rable to photo timing or automatic brightness control
technique used in conventional radiography and fluo-
roscopy. AEC is based on the premise that CT image
noise is attributable to the quantum noise in the projec-
tions, and alteration of the tube current to follow the
changing patient anatomy can adjust the quantum noise
in the projections to maintain a constant image noise and
improve dose efficiency. Three AEC techniques are
available in multi-detector-row CT scanners, namely,
angular (x, y axes), z-axis, and combined modulation.
Within each slice position or tube rotation, the angular
modulation technique adapts the tube current to reduce
X-rays in projection angles that cause less beam attenu-
ation and are less important in minimizing the overall
image noise. In asymmetric body regions (such as the
shoulders), where X-ray beam is substantially less
attenuated in the anterior–posterior direction than in the
lateral direction, abundance of X-rays in the anterior–
posterior projection is reduced without a substantial
increase in image noise. After the user specifies a tube
current value, the angular modulation may either deter-
mine tube current adjustment from real-time projection
data (CARE Dose, Siemens Medical Solution, Forch-
heim, Germany; Dose-Right Dose Modulation or DOM,
Philips Medical Systems, Eindhoven, The Netherlands),
or from attenuation data of a single localizer radiograph
(Smart scan, GE Medical Systems, Waukesha, WI,
USA). The z-axis modulation techniques (AutomA, GE
Medical Systems; ZEC or z-axis exposure control,
Siemens Medical Solutions; Real E.C. or Real Exposure
Control, Toshiba Medical Corporation, Tokyo, Japan)
adapt the tube current to maintain a user-selected
quantum noise level in reconstructed CT images. These
AEC techniques attempt to generate images with a sim-
ilar user-specified image quality independent of patient
size and anatomy. With z-axis modulation, the tube
current is automatically reduced for smaller patients and
anatomic regions, which causes less beam attenuation. In
these techniques, the tube current adaptation in the
scanning direction is determined from the attenuation
and shape information of the patient from a single lo-
calizer radiograph prior to the acquisition of transverse
images.
The combined modulation techniques (AutomA 3D,
GE Medical Systems; CARE Dose 4D, Siemens Medical
Solutions) combine angular modulation with z-axis
modulation to maximize the scanner efficacy and reduce
radiation dose. With this technique, the user specifies
desired image quality, and the system adapts tube cur-
rent for each slice position (z-axis modulation) and then
adjusts tube current within each slice position (angular
modulation). Although several studies have reported a
10–66% reduction in CT radiation dose with use of the
AEC techniques in different regions of the body, its use
in emergency settings has not been fully investigated.
However, lack of consensus regarding the AEC
nomenclature as well as manner of tube current adap-
tation may hamper the search for ‘‘ideal’’ and ‘‘stan-
dard’’ image quality.
Radiation dose reduction is limited by an increase in
image noise, which can potentially obscure lesions
otherwise visible on standard higher dose CT protocols.
To decrease image noise in low-dose CT studies, noise
reduction filters have been assessed with variable success.
Although these nonlinear, two-dimensional noise reduc-
tion filters decrease image noise in low-dose CT images,
they adversely affect the image contrast and sharpness.
Currently, three-dimensional nonlinear optimized
reconstruction algorithms (filters) are being assessed for
reduction in image noise while preserving image contrast.
In summary, radiologists must initiate steps for
radiation dose reduction, particularly for CT scanning
of young patients, with the help of preestablished scan-
ning protocols and newer techniques of AEC. Most
existing single-detector-row and multi-detector-row CT
systems can be upgraded with appropriate, vendor-spe-
cific software for these AEC techniques.