Why is CT Dose of Interest?

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2 Why is CT Dose of Interest? CT usage has increased rapidly in the past decade Compared to other medical imaging CT produces a larger radiation dose. There is direct epidemiological evidence for a an increase in cancer risk at these doses.

3 UNSCEAR 2000

4 Volume of CT exams is growing 2006* 2003 U.S. Germany % of Exams 12% 6 % % Total Dose 49% 47% * NCRP Report No. 160, 2007

5 Radiation Doses By Modality, 2006 CT Nuclear Medicine Radiography Interventional Mammography 6.8 <1 Dental 22.8 <1

6 CT Susceptible to Undetected Radiation Over Exposures FDA Recommendations Concerning Excess Radiation Exposure during CT Perfusion Imaging: The FDA issued an initial safety notification in October 2009 after learning of 206 patients who had been exposed to excess radiation at Cedars-Sinai Medical Center in Los Angeles over an 18-month period. The FDA has also received reports of excess radiation in >50 additional patients from other states [who were] exposed to radiation of up to eight times the expected level during their CT perfusion scans. These cases involve more than one CT scanner manufacturer.

7 CT Susceptible to Undetected Radiation Over Exposures

8 Reporting CT Doses California Senate Bill 1237 CTDI vol & DLP printed on patient s medical record CT services to be accredited to qualify for reimbursement Effective Jan, 2012 Votes: 6/23/10 Senate /9/10 Assembly 17-0

9 FDA Working on Mandate

10 What Are We Reporting? 1. CTDI vol CT Dose Index (volume) 2. DLP Dose-Length Product

11 1. Radiation absorbed dose 2. Absorbed dose in CT 3. Integral dose 4. Risk Comparison

12 Current Design of MSCT 3 rd generation geometry

13 Anatomy of a CT Scanner

14 Path of X-Ray Beam

15 1. Radiation absorbed dose 2. Absorbed dose in CT 3. Integral dose 4. Risk Comparison

16

17 Daily rad, rem Publications Gray, Sievert

18 1 Gy = 100 rad 1 mgy = 100 mrad 100 mrem = 1 msv 37 MBq = 1 mci

19 Radiation absorbed dose CT Dose Index, CTDI Integral dose, DLP Effective Dose

20 CT Dose Measurement Dose profile spreads beyond imaging section

21 Multiple Scan Average Dose Dose contribution from adjacent slices

22 CT Dose Measurement Single slice dose profile MSAD SINGLE SLICE DOSE MSAD can be measured from a single dose profile MSAD of central slice = Dose integrated over a single slice profile

23 CT Dose Index, CTDI CTDI is a MSAD to 2 FDA phantoms CTDI of head MSAD to a 16-cm plastic cylinder CTDI of body MSAD to a 32-cm plastic cylinder

24 CT Dose Index, CTDI X-ray output expressed as dose to a phantom FDA head & body phantoms

25 ion chamber (10 cm length) Area under rectangle = Area under dose profile = Dose reading of ion chamber Width of rectangle = slice thickness Height of rectangle = Dose to central slice = CTDI

26 CT Dose Index CTDI = Multiple scan average dose to central slice Includes dose contributions from adjacent slices Dose to a phantom, not actual dose to patient

27 CTDI Measurement

28

29 Helical Scanning Combine x-ray rotation with table motion X-ray beam wraps around patient in a helical path

30 Multi-Slice CT

31 CT Image of Helical Scans Interpolate data from adjacent projection planes Resolution is lower than axial scans

32 4-Slice CT

33 Multi-Slice Helical Reconstruction Interpolate multiple projection data for a given axial position.

34 Definition of a Screw Pitch Distance advanced in one rotation of screw

35 Definition of CT Pitch

36 Pitch

37 Pitch Axial Scan Pitch = 0 Pitch > 1 Pitch = 1 Pitch < 1

38 Pitch and Scan Overlaps

39 Effects of Varying the Pitch

40 For Spiral Scans MSAD Changes with Pitch

41 CTDI volume CTDIvol = MSAD for helical scans Accounts for non-contiguous exposure along patient

42 Interpretation of CTDI vol Not actual dose to patient An index of x-ray output expressed in terms of dose to a phantom Dose to a standard plastic phantom Useful for comparing doses from different CT scan techniques

43 Radiation absorbed dose CT Dose Index, CTDI Integral dose, DLP Effective Dose

44 Risk of Radiation Depends on total radiation energy absorbed Dose is energy concentration Dose is energy absorbed per gram tissue 1 gray = 1 Joule/Kg tissue CTDI vol does not change with scan length Radiation risk increases with scan length

45 Risk of Radiation Depends on total radiation energy absorbed Energy absorbed = Dose x Scan volume Scan length ~ Tissue volume irradiated

46 Dose Length Product, DLP DLP = CTDI vol * scan length Scan length is proportional to volume of tissue irradiated DLP and CTDI vol are shown on CT consoles

47 Dose Length Product, DLP DLP = CTDI vol * scan length CTDI does not change with scan length DLP changes with scan length Proportional to total radiation energy absorbed Radiation risk increases with DLP Radiation energy absorbed increases with DLP

48 Example Neuroradiology Diagnostic Reference Levels*!"#$%&#'%(&) *+,-.)/$012),34)/$01)5$2)!"#$%&'()'*+(,-((./0-(1'2(34!5( 6-7-( 8*9'(*&+(:%&#:':( ;7( ;,-( A-( B,-( *European Guidelines on Quality Criteria for Computed Tomography, EUR 162, May

49 Why Not Report DLP Alone? Redundancy in dose reporting? DLP = CTDI vol x Scan Length No, loosely speaking DLP ~ Stochastic risk CTDI vol ~ Deterministic risk Can have small DLP, large CTDI vol If scan length is short Example: Brain Perfusion Scans

50 Loosely Speaking CTDI vol Estimates deterministic risk DLP Estimate stochastic risk

51 Types of Risk Deterministic Risk Injury occurs definitely above threshold dose 2-3 Gy cataract Stochastic Risk Probability to develop cancer Linear no threshold model

52 Radiation Effects: Stochastic and Deterministic Detrimental Effects Threshold Patrick Colletti, MD Radiation Dose

53 Linear Extrapolation Cancer risk = % chance for 1 msv

54 Radiation absorbed dose CT Dose Index, CTDI Integral dose, DLP Effective Dose

55 Effective Dose Not a physically measurable quantity A calculated equivalent wholebody dose For partial body exposure Mathematically derived from the DLP

56 Effective Dose An equivalent wholebody dose to compare stochastic risk from radiation Knowledge of stochastic risk was derived from wholebody exposures Accounts for Different organ sensitivities to radiation Different types of radiation

57 CT Effective Dose 1. Measure CTDI 2. Calculate CTDI vol = CTDI / pitch 3. Calculate DLP = CTDI vol x scan length 4. Calculate Effective dose = DLP x CF

58 Some Effective Doses, msv Chest, PA 0.02 Pelvis, AP 0.70 CT, head 2 CT, chest 8 CT, abdomen 10 CT, pelvis 8 CT, Pulmon Angio 15 CPTA, stent, etc. 15 Mammogram (4-view) 0.2 FDG 10 mci 7.0 MDP MIBI Ga Tl V/Q 10/3 1.5 Renal Background radiation 3.0 msv/yr Nuclear medicine technologists 2.0 Flight Crew, 700 hrs between LA-DC 3.0 New York Grand Central Station 3.0 Radiologists 0.7 Interventional Radiologists 17.0

59 Methods for CT Dose Reduction Reduce mas Dose increases linearly with mas Reduce KV X-ray output ~ (KVp) 2 Reduces KV 30%, reduces dose by 50%

60 Methods for CT Dose Reduction Reduce scan length Decreases DLP Decreases effective Dose Increase pitch Decreases CTDI Use Automatic Exposure Control (AEC) Understand how dose modulation works Caveat: Improper use with certain types of studies can drastically increase dose (i.e. CT Brain Perfusion)

61 CT Brain Perfusion: Automatic Exposure Control Know the ma and kvp being used! Recommend: kvp = 80 ma = 100 Make sure Automatic Exposure Control is OFF! SureExposure (Toshiba) Care Dose (Siemens) Auto ma (GE) DoseRight (Phillips) Check cine scan time: ~ 50 seconds with 25 phases/acquisitions Verify estimated CTDI and DLP on consoles prior to initiating scan

62 CT Stroke Protocol: Expected Radiation Dose Standard non-enhanced CT ~ msv 4 slice CT Perfusion ~ msv Though deposited in a smaller region of the brain CT Angiogram ~ 4.5 msv Total CT Stroke Protocol ~ 9 msv ~ 4 noncontrast CT head doses

63 CT Brain Perfusion: Radiation Report on Console/PACs Expected Values for CTP: CTDIvol (mgy) ~ DLP (mgy-cm) ~ Scanner Console displayed as CTDIvol and DLP per phase (25 phases) CTDIvol ~ 7-8 mgy DLP ~ mgy-cm Total Exam (NeCT, CTP, CTA): DLP (mgy-cm) < 3500

64 What Can Technologists do to Reduce Patient Dose in CT? Limit the scan length Adjust mas according to patient size! One size does not fit all Use automatic exposure control when appropriate! Understand how dose modulation works Do not overly rely on the manufacturer! Mfg suggested techniques tend to be high

65 What Can Manufacturers Do? Utilization of low dose techniques Improve AEC algorithms GE Auto ma Siemens Care Dose Philips DoseRight ToshibaSureExposure Prompt user attention to: High CTDI and DLP Alarm or scanner disable feature for doses above certain threshold

66 What Can Physicians do? Reduce unnecessary scans Provide written CT protocols to technologists Use ALARA principles when establishing protocols Approval by Radiation Safety Committee When possible actively participate in the CT scan procedure Monitor and report dose on all CT scans during time of study interpretation to detect and correct errors

67 Dose Limits NCRP is working on acceptable range of CTDI vol and DLP Europeans have a reference guideline Use in-house dose references Inform radiation safety officer of unusual values

68

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