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All photon counting detectors have a characteristic count rate over which their performance degrades. Degradation in the clinical setting takes the form of increased noise, reduced material quantification accuracy, and image artifacts. Count rate is a function of patient attenuation, beam filtration, scanner geometry, and X-ray technique.To guide protocol and technology development in the photon counting space, knowledge of clinical count rates spanning the complete range of clinical indications and patient sizes is needed. In this paper, we use clinical data to characterize the range of computed tomography (CT) count rates.We retrospectively gathered 1980 patient exams spanning the entire body (head/neck/chest/abdomen/extremity) and sampled 36 951 axial image slices. We assigned the tissue labels air/lung/fat/soft tissue/bone to each voxel for each slice using CT number thresholds. We then modeled four different bowtie filters, 70/80/100/120/140 kV spectra, and a range of mA values. We forward-projected each slice to obtain detector-incident count rates, using the geometry of a GE Revolution Apex scanner. Our analysis divided the detector into thirds: the central one-third, one-third of the detector split into two equal regions adjacent to the central third, and the final one-third divided equally between the outer detector edges. We report the 99th percentile of counts to mimic the upper limits of count rates making passing through a patient as a function of patient water equivalent diameter. We also report the percentage of patient scans, by body region, over different count rate thresholds for all combinations of bowtie and beam energy.For routine exam types, we recorded count rates of approximately 3.5 × 10Our results are the first to use a large patient cohort spanning all body regions to characterize count rates in CT. Our results should be useful in helping researchers understand count rates as a function of body region and mA for various combinations of bowtie filter designs and beam energies. Our results indicate clinical rates1 × 10

Purpose To validate the SpekPy software toolkit that has been developed to estimate the spectra emitted from tungsten anode X-ray tubes. The model underlying the toolkit introduces improvements upon a well-known semi-empirical model of X-ray emission. Materials and methods Using the same theoretical framework as the widely-used SpekCalc software, new electron penetration data was simulated using the Monte Carlo (MC) method, alternative bremsstrahlung cross-sections were applied, L-line characteristic emissions were included, and improvements to numerical methods implemented. The SpekPy toolkit was developed with the Python programming language. The toolkit was validated against other popular X-ray spectrum models (50 to 120 kVp), X-ray spectra estimated with MC (30 to 150 kVp) as well as reference half value layers (HVL) associated with numerous radiation qualities from standard laboratories (20 to 300 kVp). Results The toolkit can be used to estimate X-ray spectra that agree with other popular X-ray spectrum models for typical configurations in diagnostic radiology as well as with MC spectra over a wider range of conditions. The improvements over SpekCalc are most evident at lower incident electron energies for lightly and moderately filtered radiation qualities. Using the toolkit, estimations of the HVL over a large range of standard radiation qualities closely match reference values. Conclusions A toolkit to estimate X-ray spectra has been developed and extensively validated for central-axis spectra. This toolkit can provide those working in Medical Physics and beyond with a powerful and user-friendly way of estimating spectra from X-ray tubes.

Introduction Increasing use of CT examinations has led to concerns of possible negative cognitive effects for children. The objective of this study is to examine if the ionizing radiation dose from a CT head scan at the age of 6–16 years affects academic performance and high school eligibility at the end of compulsory school. Materials and methods A total of 832 children, 535 boys and 297 girls, from a previous trial where CT head scan was randomized on patients presenting with mild traumatic brain injury, were followed. Age at inclusion was 6–16 years (mean of 12.1), age at follow up 15–18 years (mean of 16.0), and time between injury and follow up one week up to 10 years (mean of 3.9). Participants’ radiation exposure status was linked with the total grade score, grades in mathematics and the Swedish language, eligibility for high school at the end of compulsory school, previously measured GOSE-score, and their mothers’ education level. The Chi-Square Test, Student’s t-Test and factorial logistics were used to analyze data. Results Although estimates of school grades and high school eligibility were generally higher for the unexposed, the results showed no statistically significant differences between the exposed and unexposed participants in any of the aforementioned variables. Conclusions Any effect on high school eligibility and school grades from a CT head scan at the age of 6–16 years is too small to be detected in a study of more than 800 patients, half of whom were randomly assigned to CT head scan exposure.

Objective The purpose of this study was to assess if ultra-low-dose CT is a useful clinical alternative to digital radiographs in the evaluation of acute wrist and ankle fractures. Materials and methods An ultra-low-dose protocol was designed on a 256-slice multi-detector CT. Patients from the emergency department were evaluated prospectively. After initial digital radiographs, an ultra-low-dose CT was performed. Two readers independently analyzed the images. Also, the radiation dose, examination time, and time to preliminary report was compared between digital radiographs and CT. Results In 207 extremities, digital radiography and ultra-low-dose CT detected 73 and 109 fractures, respectively (p p = 0.002). The recommended treatment changed in 34 (16.4%) extremities. Conclusions Ultra-low-dose CT is a useful alternative to digital radiography for imaging the peripheral skeleton in the acute setting as it detects significantly more fractures and provides additional clinically important information, at a comparable radiation dose. It also provides faster combined examination and reporting times.

To investigate if the conventional localizer radiograph (LR) can be replaced by a synthetic LR (SLR), generated from a low-dose spiral CT scan, for CT scan planning with minimal changes to current clinical workflows.A dosimetric comparison of SLRs and LRs was made using Monte Carlo methods. Water equivalent diameters (WEDs) of a centered and mis-centered phantom were estimated from low-dose spiral CT scans and LRs acquired at different angles. Body sizes, in the form of two lengths and two diameters obtained from SLRs and LRs, were compared for 10 patients (4 men and 6 women with a mean age of 74.8 and 76.2 years respectively) undergoing CT of thorax and abdomen. The image quality of SLRs for CT scan planning relative to LRs was rated using a 5-grade scale by four radiologists and two CT radiographers.An SLR can be obtained at a comparable effective dose to that of traditionally acquired LRs: 0.14 mSv. WEDs from LRs were more affected by mis-centering than WEDs calculated from low-dose spiral scans. One significant discrepancy of estimated body sizes was observed, the broadest part of the patient that on lateral localizers showed a mean deviation of 17.7 mm (range: 7.3-28.7 mm, p 0.001). The anteroposterior/posteroanterior SLR image quality was assessed as better compared to an LR while the same could not be shown for lateral localizers.SLRs based on low-dose spiral scans can replace LRs for CT planning.

Purpose SpekPy is a free toolkit for modeling x-ray tube spectra with the Python programming language. In this article, the advances in version 2.0 (v2) of the software are described, including additional target materials and more accurate modeling of the heel effect. Use of the toolkit is also demonstrated. Methods The predictions of SpekPy are illustrated in comparison to experimentally determined spectra: three radiation quality reference (RQR) series tungsten spectra and one mammography spectrum with a molybdenum target. The capability of the software to correctly model changes in tube output with tube potential is also assessed, using the example of a GE RevolutionTM CT scanner (GE Healthcare, Waukesha, WI, USA) and specifications in the system's Technical Reference Manual. Furthermore, we note that there are several physics models available in SpekPy. These are compared on and off the central axis, to illustrate the differences. Results SpekPy agrees closely with the experimental spectra over a wide range of tube potentials, both visually and in terms of first and second half-value layers (HVLs) (within 2% here). The CT scanner spectrum output (normalized to 120 kV tube potential) agreed within 4% over the range of 70 to 140 kV. The default physics model (casim) is adequate in most situations. The advanced option (kqp) should be used if high accuracy is desired for modeling the anode heel effect, as it fully includes the effects of bremsstrahlung anisotropy. Conclusions SpekPy v2 can reliably predict on- and off-axis spectra for tungsten and molybdenum targets. SpekPy's open-source MIT license allows users the freedom to incorporate this powerful toolkit into their own projects.

This chapter shows that information in Radiation Dose Structured Reports (RDSR) objects can be parsed, aggregated and analyzed to provide a meaningful overview of dose indices. While this chapter has mainly focused on the CT modality, the restructuring of the RDSR objects will likely work on modalities other than CT. The script that was used to parse the RDSR structs can be adapted to these other modalities after the user has become familiar with the contents in those RDSR objects.

Purpose The weighted CT dose index (CTDI w) has been extended for a nominal total collimation width (nT) greater than 40 mm and relies on measurements of CTDIfreeair. The purpose of this work was to compare three methods of measuring CTDIfreeair and subsequent calculations of CTDI w to investigate their clinical appropriateness. Methods The CTDIfreeair, for multiple nTs up to 160 mm, was calculated from (1) high‐resolution air kerma profiles from a step‐and‐shoot translation of a liquid ionization chamber (LIC) (considered to be a dosimetric reference), (2) pencil ionization chamber (PIC) measurements at multiple contiguous positions, and (3) air kerma profiles obtained through the continuous translation of a solid‐state detector. The resulting CTDIfreeair was used to calculate the CTDI w, per the extended formalism, and compared. Results The LIC indicated that a 40 mm nT should not be excluded from the extension of the CTDI w formalism. The solid‐state detector differed by as much as 8% compared to the LIC. The PIC was the most straightforward method and gave equivalent results to the LIC. Conclusions The CTDI w calculated with the latest CTDI formalism will differ most for 160 mm nTs (e.g., whole‐organ perfusion or coronary CT angiography) compared to the previous CTDI formalism. Inaccuracies in the measurement of CTDIfreeair will subsequently manifest themselves as erroneous calculations of the CTDI w, for nTs greater than 40 mm, with the latest CTDI formalism. The PIC was found to be the most clinically feasible method and was validated against the LIC.

The purpose of this study was to evaluate the dosimetric impact of including the patient table in Monte Carlo CT dose estimates for both spiral scans and scan projection radiographs (SPR). CT scan acquisitions were simulated for a Siemens SOMATOM Force scanner (Siemens Healthineers, Forchheim, Germany) with and without a patient table present. An adult male, an adult female and a pediatric female voxelized phantom were simulated. The simulated scans included tube voltages of 80 and 120 kVp. Spiral scans simulated without a patient table resulted in effective doses that were overestimated by approximately 5% compared to the same simulations performed with the patient table present. Doses in selected individual organs (breast, colon, lung, red bone marrow and stomach) were overestimated by up to 8%. Effective doses from SPR acquired with the x-ray tube stationary at 6 o'clock (posterior-anterior) were overestimated by 14-23% when the patient table was not included, with individual organ dose discrepancies (breast, colon, lung red bone marrow and stomach) all exceeding 13%. The reference entrance skin dose to the back were in this situation overestimated by 6-15%. These results highlight the importance of including the patient table in patient dose estimates for such scan situations.

Purpose To investigate the association between exposure to head computed tomography (CT) and subsequent risk of meningioma. Materials and Methods The study was approved by the local ethics committee. A cohort of 26 370 subjects was retrospectively collected from a radiology archive of CT examinations of the head performed from 1973 through 1992. For comparison, an age- and sex-matched cohort of 96 940 subjects who were not exposed to CT (unexposed cohort) was gathered. The risk of meningioma was assessed by using data from the Swedish Cancer Registry; however, one-third of patients with meningioma had to be excluded because they either had a prevalent meningioma or other brain tumor at the first CT examination or had undergone radiation treatment to the head. Hazard ratios (HRs) were calculated from time of exposure to the occurrence of meningioma or death or until December 31, 2010, with logistic regression. Results Comparison of exposed and unexposed cohorts showed that there was no statistically significant increase in the risk of meningioma after exposure to CT of the head (HR: 1.49; 95% confidence interval: 0.97, 2.30; P = .07). If incident cases at the time of the first CT examination were not excluded, the risk of meningioma would have been falsely increased (HR: 2.28; 95% confidence interval: 1.56, 3.33; P = .0001). Conclusion When prevalent cases of meningioma at first exposure to CT of the head are excluded, no statistically significant increase in risk of meningioma was found among exposed subjects compared with unexposed control subjects.

BackgroundThe use of computed tomography (CT) for image guidance during biopsies is a powerful approach. The method is, however, often associated with a significant level of radiation exposure to the patient and operator.PurposeTo investigate if a low-dose protocol for CT-guided musculoskeletal (MSK) biopsies, including a combination of different radiation dose (RD) techniques, is feasible in a clinical setting.Material and MethodsFifty-seven patients underwent CT-guided fine-needle aspiration cytology (FNAC) utilizing the low-dose protocol (group A). A similar number of patients underwent CT-guided FNAC using the reference protocol (group B). Between-group comparisons comprised radiation dose, success rate, image quality parameters, and workflow.ResultsIn group A, the mean total dose-length product (DLP) was 41.2 ± 2.9 mGy*cm, which was statistically significantly lower than of group B (257.4 ± 22.0 mGy*cm), corresponding to a mean dose reduction of 84% ( Pvolfor the control scans were 1.88 ± 0.09 mGy and 13.16 ± 0.40 mGy for groups A and B, respectively ( P ConclusionWe successfully developed a low-dose protocol for CT-guided MSK biopsies that maintains diagnostic accuracy and image quality at a fraction of the RD compared to the reference biopsy protocol at our clinic.

Purpose To investigate two methods of approximating the Modulation Transfer Function (MTF) and Noise Power Spectrum (NPS) in computed tomography (CT) for a range of scan parameters, from limited image acquisitions. Methods The two methods consist of 1) using a linear systems approach to approximate the NPS for different filtered backprojection (FBP) kernels with a filter function derived from the kernel ratio of determined MTFs and 2) using an empirical fitted model to approximate the MTF and NPS. In both cases a scaling function accounts for variations in mAs and kV. The two methods of approximating the MTF/NPS are further investigated by comparing image quality figure of merits (FOM) d′ and AUC calculated using approximations of the MTF/NPS and MTF/NPS that have been determined for different mAs/kV levels and reconstruction kernels. Results The greatest RMSE for NPS approximated for a range of mAs/kVp/convolution kernels using both methods and compared to determined NPS was 0.05 of the peak value. The RMSE for FOM with the kernel ratio method were at most 0.1 for d′ and 0.01 for the AUC. Using the empirical model method, the RMSE for FOM were at most 0.02 for d′ and 0.001 for the AUC. Conclusions The two methods proposed in this paper can provide a convenient way of approximating the MTF and NPS for use in, among other things, mathematical observer studies. Both methods require a relatively small number of direct determinations of NPS from scan acquisitions to model the NPS/MTF for arbitrary mAs and kV.

Purpose: The highest photon fluence rate that a computed tomography (CT) detector must be able to measure is an important parameter. The authors calculate the maximum transmitted fluence rate in a commercial CT scanner as a function of patient size for standard head, chest, and abdomen protocols. Methods: The authors scanned an anthropomorphic phantom (Kyoto Kagaku PBU-60) with the reference CT protocols provided by AAPM on a GE LightSpeed VCT scanner and noted the tube current applied with the tube current modulation (TCM) system. By rescaling this tube current using published measurements on the tube current modulation of a GE scanner [N. Keat, “CT scanner automatic exposure control systems,” MHRA Evaluation Report 05016, ImPACT, London, UK, 2005], the authors could estimate the tube current that these protocols would have resulted in for other patient sizes. An ECG gated chest protocol was also simulated. Using measured dose rate profiles along the bowtie filters, the authors simulated imaging of anonymized patient images with a range of sizes on a GE VCT scanner and calculated the maximum transmitted fluence rate. In addition, the 99th and the 95th percentiles of the transmitted fluence rate distribution behind the patient are calculated and the effect of omitting projection lines passing just below the skin line is investigated. Results: The highest transmitted fluence rates on the detector for the AAPM reference protocols with centered patients are found for head images and for intermediate-sized chest images, both with a maximum of 3.4 ⋅ 108 mm−2 s−1, at 949 mm distance from the source. Miscentering the head by 50 mm downward increases the maximum transmitted fluence rate to 5.7 ⋅ 108 mm−2 s−1. The ECG gated chest protocol gives fluence rates up to 2.3 ⋅ 108 − 3.6 ⋅ 108 mm−2 s−1 depending on miscentering. Conclusions: The fluence rate on a CT detector reaches 3 ⋅ 108 − 6 ⋅ 108 mm−2 s−1 in standard imaging protocols, with the highest rates occurring for ECG gated chest and miscentered head scans. These results will be useful to developers of CT detectors, in particular photon counting detectors.

Photon-counting detectors are expected to bring a range of improvements to patient imaging with x-ray computed tomography (CT). One is higher spatial resolution. We demonstrate the resolution obtained using a commercial CT scanner where the original energy-integrating detector has been replaced by a single-slice, silicon-based, photon-counting detector. This prototype constitutes the first full-field-of-view silicon-based CT scanner capable of patient scanning. First, the pixel response function and focal spot profile are measured and, combining the two, the system modulation transfer function is calculated. Second, the prototype is used to scan a resolution phantom and a skull phantom. The resolution images are compared to images from a state-of-the-art CT scanner. The comparison shows that for the prototype 19 lp∕cm are detectable with the same clarity as 14 lp∕cm on the reference scanner at equal dose and reconstruction grid, with more line pairs visible with increasing dose and decreasing image pixel size. The high spatial resolution remains evident in the anatomy of the skull phantom and is comparable to that of other photon-counting CT prototypes present in the literature. We conclude that the deep silicon-based detector used in our study could provide improved spatial resolution in patient imaging without increasing the x-ray dose. QC 20191022 EXCITING-CT, European Union’s Horizon 2020 Grant Agreement No. 750564

Purpose: The quantitative effects of assumptions made in the calculation of stopping-power ratios (SPRs) are investigated, for stoichiometric CT calibration in proton therapy. The assumptions inves ...

The purpose of this study was to develop a method of performing routine periodical quality controls (QC) of CT systems by automatically analyzing key performance indicators (KPIs), obtainable from images of manufacturers' quality assurance (QA) phantoms. A KPI pertains to a measurable or determinable QC parameter that is influenced by other underlying fundamental QC parameters. The established KPIs are based on relationships between existing QC parameters used in the annual testing program of CT scanners at the Karolinska University Hospital in Stockholm, Sweden. The KPIs include positioning, image noise, uniformity, homogeneity, the CT number of water, and the CT number of air. An application (MonitorCT) was developed to automatically evaluate phantom images in terms of the established KPIs. The developed methodology has been used for two years in clinical routine, where CT technologists perform daily scans of the manufacturer's QA phantom and automatically send the images to MonitorCT for KPI evaluation. In the cases where results were out of tolerance, actions could be initiated in less than 10 min. 900 QC scans from two CT scanners have been collected and analyzed over the two‐year period that MonitorCT has been active. Two types of errors have been registered in this period: a ring artifact was discovered with the image noise test, and a calibration error was detected multiple times with the CT number test. In both cases, results were outside the tolerances defined for MonitorCT, as well as by the vendor. Automated monitoring of KPIs is a powerful tool that can be used to supplement established QC methodologies. Medical physicists and other professionals concerned with the performance of a CT system will, using such methods, have access to comprehensive data on the current and historical (trend) status of the system such that swift actions can be taken in order to ensure the quality of the CT examinations, patient safety, and minimal disruption of service PACS numbers: 87.57.C‐, 87.57.N‐, 87.57.Q‐

Purpose One of the major applications of Dual-Energy Computed Tomography (DECT) technology is virtual monochromatic imaging, which are representations of an object as if the source of a CT used single energy photons (keV). The advantages with virtual monochromatic imaging is that the user can manipulate image quality by freely selecting the monochromatic energy. The aim of this work was to study the image quality of virtual monochromatic images generated by two different algorithms, one of which includes a noise-reduction feature (Mono and Mono+). Methods A modified commercial image quality phantom was scanned using a dual-source CT scanner (80/140 Sn kVp). Virtual monochromatic images were generated over a range of 40–170 keV in 10 keV increments using both algorithms. Uniformity, noise, the CT number of water, the CT number of iodine, the contrast-to-noise ratio (CNR) and linearity were evaluated in both image stacks using open-source image processing software. Results In general, the Mono+ images resulted in better image quality. A significant noise reduction was found at low keV using this technique, with a maximum reduction of 50% at 40 keV, compared to the Mono images. The Mono+ images also provided an increased iodine CNR at lower keVs, moving the optimum CNR from 60 keV to 40 keV. Conclusions The Mono+ algorithm for creation of virtual monoenergetic images was shown to be superior to the Mono algorithm, especially for low keVs.

The highest photon fluence rate that a computed tomography (CT) detector must be able to measure is an important parameter. The authors calculate the maximum transmitted fluence rate in a commercial CT scanner as a function of patient size for standard head, chest, and abdomen protocols.The authors scanned an anthropomorphic phantom (Kyoto Kagaku PBU-60) with the reference CT protocols provided by AAPM on a GE LightSpeed VCT scanner and noted the tube current applied with the tube current modulation (TCM) system. By rescaling this tube current using published measurements on the tube current modulation of a GE scanner [N. Keat, "CT scanner automatic exposure control systems," MHRA Evaluation Report 05016, ImPACT, London, UK, 2005], the authors could estimate the tube current that these protocols would have resulted in for other patient sizes. An ECG gated chest protocol was also simulated. Using measured dose rate profiles along the bowtie filters, the authors simulated imaging of anonymized patient images with a range of sizes on a GE VCT scanner and calculated the maximum transmitted fluence rate. In addition, the 99th and the 95th percentiles of the transmitted fluence rate distribution behind the patient are calculated and the effect of omitting projection lines passing just below the skin line is investigated.The highest transmitted fluence rates on the detector for the AAPM reference protocols with centered patients are found for head images and for intermediate-sized chest images, both with a maximum of 3.4 ⋅ 10(8) mm(-2) s(-1), at 949 mm distance from the source. Miscentering the head by 50 mm downward increases the maximum transmitted fluence rate to 5.7 ⋅ 10(8) mm(-2) s(-1). The ECG gated chest protocol gives fluence rates up to 2.3 ⋅ 10(8) - 3.6 ⋅ 10(8) mm(-2) s(-1) depending on miscentering.The fluence rate on a CT detector reaches 3 ⋅ 10(8) - 6 ⋅ 10(8) mm(-2) s(-1) in standard imaging protocols, with the highest rates occurring for ECG gated chest and miscentered head scans. These results will be useful to developers of CT detectors, in particular photon counting detectors.

Purpose Automatic Tube Current Modulation (ATCM) adapts the tube current during a CT scan to provide a target image quality throughout the scan as well as for patients of varying sizes. However, the misapplication of ATCM can result in excessive radiation doses or images of non-diagnostic quality. Furthermore, it is not always intuitive to know which scan settings can affect the resulting ATCM and the ATCM functionality between vendors differs. The purpose of this work was to investigate which variable scan settings can impact the ATCM on CT scanners from the four major vendors. Methods The investigation was categorized into scan setting variations in CT localizer radiographs, exposure parameters, reconstruction parameters, and miscentering. A phantom dedicated to ATCM testing was designed and manufactured. A baseline scan was first made by scanning the ATCM phantom using reference scan settings. The ATCM phantom was subsequently scanned by systematically varying the settings in the four categories of setting variations. The scans with varied settings were compared to baseline and evaluated in terms of differences in applied tube current and image noise. The evaluation included both quantitative and qualitive metrics. Results The impact of scan settings on the applied ATCM will differ greatly between vendors, as each vendor has their own unique ATCM implementation. The impact on ATCM can either be apparent or subtle, depending on which scan setting has been varied. Comprehensive tables, corresponding to the different categories of setting variations, has been compiled highlighting the results. 1 . Conclusions A method (including the design of a phantom) has been developed to systematically evaluate how the choice of scan settings can affect the applied ATCM. The methodology was used to investigate the ATCM from four major CT vendors, highlighting similarities and differences among them.

Purpose A new healthcare reform centered around Value-based healthcare has recently been implemented in our region. To pursue this reform, drastic changes have been made to our hospital’s organizational structure and our hospital will serve as a tertiary and quaternary healthcare provider. The Unit of X-ray Physics is therefore in the process of implementing a new operational model to provide relevant Medical Physics support to the new clinical organization at our hospital. Methods To better understand the clinical demand for Medical Physicists, interviews were conducted with Lead Section Radiologists. These interviews indicated that there was a demand for highly specialized Medical Physics support, however the integration between Medical Physicists and the clinic was in many cases unsatisfactory. The operational model at the Unit of X-ray Physics has therefore been structured around Quality-Optimization-Methodology (QOM) groups, providing more continuous and specialized Medical Physics support to the clinic. The QOM groups are multidisciplinary (consisting of Lead Radiologists, Lead Radiographers and Medical Physicists) and they are placed at the intersection of an imaging modality and a clinical sub-specialization to best match with our hospital’s new structure (e.g., Pediatric Computed Tomography). Results The QOM group based operational model, where implemented in the still emerging new clinical structure, enables members of the Unit of X-ray Physics to become highly specialized in one or more combinations of modality and clinical sub-specialization. The new operational model also provides the Unit of X-ray Physics a clear understanding of how resources should be allocated among the identified QOM groups to best meet clinical demands. Conclusions A new operational model centered around QOM groups has been implemented at the Unit of X-ray Physics to provide continuous and specialized Medical Physics support in the new clinical structure at our hospital. In this structure, Medical Physicists become highly specialized on both a modality and clinical sub-specialty level. Furthermore, the new QOM group based operational model provides an important tool when allocating Medical Physics resources in the clinic. The model is planned to be evaluated after being fully implemented and tested.

Purpose Due to the lack of a sufficient CT Protocol Management System (CT-PMS) at our facility, adverse incidents directly affecting patient safety have occurred. The aim of this work is to mitigate adverse incidents in the future and to ensure the quality of our facility’s CT examinations by developing a CT-PMS. Methods A multidisciplinary optimization team (Lead Radiologists, Lead Radiographers, a Medical Physicist specialized in CT and vendor representatives) in direct need of a sufficient CT-PMS to support their clinical efforts initiated this project. Components of a CT-PMS were identified through a literature study as well as a site visit at a facility employing a comprehensive CT-PMS [1] . Sixteen components of a CT-PMS relevant to our facility were identified including team member roles and responsibilities, implementation and review of CT protocols, protocol naming conventions, requirements for documentation as well as dose and image quality management procedures. Where applicable, it is our goal to implement processes and methods in accordance with applicable ISO 9001:2015 clauses [2] . A project manager was recruited to organize the development of the different CT-PMS components. Results Since this is an ongoing project, only a subset of the CT-PMS components has been fully developed. These developed components include team member roles and a process for updating CT scanners with approved protocol changes. However, the completed components of the CT-PMS have been implemented and have already had a positive clinical impact. When fully completed, the CT-PMS is scheduled to be tested and evaluated in a controlled environment (one CT optimization group) before wider roll-out and adoption. Conclusions A comprehensive CT-PMS is needed to manage the quality and safety of CT examinations. As no sufficient CT-PMS existed at our institution, we are in the process of developing one. Although not yet fully developed, we have already started to see a positive clinical impact.

Although interventional x-ray angiography (XA) procedures involve relatively high radiation doses that can lead to deterministic tissue reactions in addition to stochastic effects, convenient and accurate estimation of absorbed organ doses has traditionally been out of reach. This has mainly been due to the absence of practical means to access dose-related data that describe the physical context of the numerous exposures during an XA procedure. The present work provides a comprehensive and general framework for the determination of absorbed organ dose, based on non-proprietary access to dose-related data by utilizing widely available DICOM radiation dose structured reports. The framework comprises a straightforward calculation workflow to determine the incident kerma and reconstruction of the geometrical relation between the projected x-ray beam and the patient's anatomy. The latter is difficult in practice, as the position of the patient on the table top is unknown. A novel patient-specific approach for reconstruction of the patient position on the table is presented. The proposed approach was evaluated for 150 patients by comparing the estimated position of the primary irradiated organs (the target organs) with their position in clinical DICOM images. The approach is shown to locate the target organ position with a mean (max) deviation of 1.3 (4.3), 1.8 (3.6) and 1.4 (2.9) cm for neurovascular, adult and paediatric cardiovascular procedures, respectively. To illustrate the utility of the framework for systematic and automated organ dose estimation in routine clinical practice, a prototype implementation of the framework with Monte Carlo simulations is included.

The quantitative effects of assumptions made in the calculation of stopping-power ratios (SPRs) are investigated, for stoichiometric CT calibration in proton therapy. The assumptions investigated include the use of the Bethe formula without correction terms, Bragg additivity, the choice of I-value for water, and the data source for elemental I-values.The predictions of the Bethe formula for SPR (no correction terms) were validated against more sophisticated calculations using the SRIM software package for 72 human tissues. A stoichiometric calibration was then performed at our hospital. SPR was calculated for the human tissues using either the assumption of simple Bragg additivity or the Seltzer-Berger rule (as used in ICRU Reports 37 and 49). In each case, the calculation was performed twice: First, by assuming the I-value of water was an experimentally based value of 78 eV (value proposed in Errata and Addenda for ICRU Report 73) and second, by recalculating the I-value theoretically. The discrepancy between predictions using ICRU elemental I-values and the commonly used tables of Janni was also investigated.Errors due to neglecting the correction terms to the Bethe formula were calculated at less than 0.1% for biological tissues. Discrepancies greater than 1%, however, were estimated due to departures from simple Bragg additivity when a fixed I-value for water was imposed. When the I-value for water was calculated in a consistent manner to that for tissue, this disagreement was substantially reduced. The difference between SPR predictions when using Janni's or ICRU tables for I-values was up to 1.6%. Experimental data used for materials of relevance to proton therapy suggest that the ICRU-derived values provide somewhat more accurate results (root-mean-square-error: 0.8% versus 1.6%).The conclusions from this study are that (1) the Bethe formula can be safely used for SPR calculations without correction terms; (2) simple Bragg additivity can be reasonably assumed for compound materials; (3) if simple Bragg additivity is assumed, then the I-value for water should be calculated in a consistent manner to that of the tissue of interest (rather than using an experimentally derived value); (4) the ICRU Report 37 I-values may provide a better agreement with experiment than Janni's tables.

Complex interventional and diagnostic x-ray angiographic (XA) procedures may yield patient skin doses exceeding the threshold for radiation induced skin injuries. Skin dose is conventionally determined by converting the incident air kerma free-in-air into entrance surface air kerma, a process that requires the use of backscatter factors. Subsequently, the entrance surface air kerma is converted into skin kerma using mass energy-absorption coefficient ratios tissue-to-air, which for the photon energies used in XA is identical to the skin dose. The purpose of this work was to investigate how the cranial bone affects backscatter factors for the dosimetry of interventional neuroradiology procedures. The PENELOPE Monte Carlo system was used to calculate backscatter factors at the entrance surface of a spherical and a cubic water phantom that includes a cranial bone layer. The simulations were performed for different clinical x-ray spectra, field sizes, and thicknesses of the bone layer. The results show a reduction of up to 15% when a cranial bone layer is included in the simulations, compared with conventional backscatter factors calculated for a homogeneous water phantom. The reduction increases for thicker bone layers, softer incident beam qualities, and larger field sizes, indicating that, due to the increased photoelectric crosssection of cranial bone compared to water, the bone layer acts primarily as an absorber of low-energy photons. For neurointerventional radiology procedures, backscatter factors calculated at the entrance surface of a water phantom containing a cranial bone layer increase the accuracy of the skin dose determination.

The aim of this study was to make a comprehensive evaluation of how variable scan settings can affect the performance of automatic tube current modulation (ATCM) in recent CT scanners from the four major manufacturers.A phantom was designed and manufactured for the purpose of evaluating ATCM. The phantom was scanned with four categories of systematically varied settings (scan projection radiograph, technique and reconstruction parameters and phantom miscentring). The performance of ATCM, in terms of applied tube current and noise uniformity, for the scans with varied settings was compared with a reference scan using subjective and quantitative approaches.The ATCM implemented by each manufacturer is based on different principles and any affect to the performance of the ATCM, when varying scan settings, will manifest differently among the vendors. The results are summarized in four tables corresponding to the categories of varied settings.The developed phantom proved useful for evaluating the ATCM. It is important to understand how different implementations (vendor specific) of ATCM perform in order to make informed decisions about the selection of scan settings when designing protocols. The resulting tables can serve as a reference for understanding the different implementations of ATCM and highlight settings that should be taken into consideration when adjusting an imaging protocol. Advances in knowledge: The results from this work can serve as a reference for how changes in geometry or scan settings can affect the performance of ATCM, in terms of tube current and noise.

Due to the relatively high occupational doses associated with interventional and diagnostic fluoroscopy procedures it is important to create awareness about and to quantify the radiation environment that medical staff are exposed to. A computer program was developed to analyze dose data collected from a dosimetry system that uses active personal dosimeters to monitor staff dose in real-time, to obtain an expanded analysis of the radiation environment that clinical staff are exposed to, on a procedural basis. The analyses that are made per procedure and staff member include: accumulated dose μSv, maximum and median dose rate mSv/h, the amount of time a staff member has been exposed to radiation compared to the total fluoroscopy time and the percentage of accumulated dose from 3 different dose rate intervals, including < 0.3 mSv/h, 0.3 - 2.6 mSv/h, and < 2.6 mSv/h. The developed computer program was used to analyze dose data collected from the dosimetry system at the Karolinska University Hospital to study the radiation environment that different categories of staff are exposed to during interventional aorta aneurysm treatment procedures. The analyses have provided the ability to know where to concentrate radiation safety training in interventional and diagnostic fluoroscopy and to ensure that operating rooms are equipped with adequate radiation protection (e.g., radiation protection barriers etc.). The developed computer program and dose data collected from the dosimetry system can be appropriated for other radiation environmental studies in diagnostic x-ray imaging.

Purpose: Advanced dosimetry in CT (e.g. the Monte Carlo method) requires an accurate characterization of the shaped filter and radiation quality used during a scan. The purpose of this work was to develop a method where half value layer (HVL) profiles along shaped filters could be made. From the HVL profiles the beam shaping properties and effective photon spectrum for a particular scan can be inferred. Methods: A measurement rig was developed to allow determinations of the HVL under a scatter-free narrow-beam geometry and constant focal spot to ionization chamber distance for different fan angles. For each fan angle the HVL is obtained by fitting the transmission of radiation through different thicknesses of an Al absorber (type 1100) using an appropriate model. The effective Al thickness of shaped filters and effective photon spectra are estimated using a model of photon emission from a Tungsten anode. This method is used to obtain the effective photon spectra and effective Al thickness of shaped filters for a CT scanner recently introduced to the market. Results: This study resulted in a set of effective photon spectra (central ray) for each kVp along with effective Al thicknesses of the different shaped filters. The effective photon spectra and effective Al thicknesses of shaped filters were used to obtain numerically approximated HVL profiles and compared to measured HVL profiles (mean absolute percentage error = 0.02). The central axis HVL found in the vendor's technical documentation were compared to approximated HVL values (mean absolute percentage error = 0.03). Conclusion: This work has resulted in a unique method of measuring HVL profiles along shaped filters in CT. Further the effective photon spectra and the effective Al thicknesses of shaped filters that were obtained can be incorporated into Monte Carlo simulations.

Purpose: To investigate the feasibility of deploying a novel method for the daily monitoring of x-ray Angiography (XA) equipment performance as a cloud-based service. Methods: From previous work, we have developed a novel image based method of testing the performance of XA equipment on a daily basis. A pre-programmed protocol on an XA system is used and images are automatically analyzed using software developed in-house, resulting in a set of Key Performance Indicators (KPI's) that can be tracked over time. The analysis software was deployed in the cloud and a routing rule was set up to automatically transfer images from the XA systems to the cloud. A web based user interface was developed with access to the KPI's for studying auto generated reports, trends and anomalies. Technologists were instructed on how to perform the daily scans with a remotely hosted instructional video and have actively participated in this endeavor for the last 7 months. Results: Quantitative performance tests have been automated including data aggregation, management, analysis and visualization which enables sampling of KPI's on a daily basis and the developed solution has been migrated to the cloud. The daily performance check routine takes ∼6 minutes per XA system in total including the transfer of images, analysis and reporting. In one instance a significant artifact and a defective pixel has been identified. A generally stable system performance has otherwise been observed as indicated by the process control charts. Conclusion: A cloud based solution for monitoring the performance of XA equipment has been developed. The solution facilitates efficient data collection, enabling useful trend analysis on large data sets. This project was funded by Vinnova (Swedish Innovation Agency), grant number 2012-03693, and was carried out in collaboration with Image Owl, Inc. (Reykjavik, Iceland).

Background Quality assurance (QA) of computed tomography (CT) systems is one of the routine tasks for medical physicists in the Nordic countries. However, standardized QA protocols do not yet exist and the QA methods, as well as the applied tolerance levels, vary in scope and extent at different hospitals. Purpose To propose a standardized protocol for acceptance and constancy testing of CT scanners in the Nordic Region. Material and Methods Following a Nordic Association for Clinical Physics (NACP) initiative, a group of medical physicists, with representatives from four Nordic countries, was formed. Based on international literature and practical experience within the group, a comprehensive standardized test protocol was developed. Results The proposed protocol includes tests related to the mechanical functionality, X-ray tube, detector, and image quality for CT scanners. For each test, recommendations regarding the purpose, equipment needed, an outline of the test method, the measured parameter, tolerance levels, and the testing frequency are stated. In addition, a number of optional tests are briefly discussed that may provide further information about the CT system. Conclusion Based on international references and medical physicists’ practical experiences, a comprehensive QA protocol for CT systems is proposed, including both acceptance and constancy tests. The protocol may serve as a reference for medical physicists in the Nordic countries.

Purpose: To manufacture a phantom specifically designed for the purpose of evaluating the performance of the longitudinal and angular automatic tube current modulation (ATCM) on modern CT scanners. Methods: In order to evaluate angular ATCM, the phantom has an elliptical cross section (aspect ratio 3:2). To evaluate longitudinal ATCM, the phantom consists of 3 sections, with different major axes (25 cm, 30 cm and 35 cm). Each section is 15 cm long in the longitudinal direction. Between each section is a smooth transition. The phantom was milled from a solid block of PMMA. ATCM performance is evaluated by 1) analyzing the applied tube current for each slice of the phantom and 2) analyzing the distribution of image noise (σ) along the scan direction at different positions in the phantom. A demonstration of the ATCM performance evaluation is given by investigating the effects of miscentering during a CT scan. Results: The developed phantom has proven useful for evaluating both the longitudinal and angular ATCM on modern CT scanners (spiral collimations ≥ 4 cm). Further benefits are the smooth transitions between the sections that prevent abnormal responses in the ATCM and the invariant sections that provide a means for investigating the stability of image noise. The homogeneity of the phantom makes image noise at different positions along the scan direction easy to quantify, which is crucial to understand how well the applied ATCM can produce a desired image quality. Conclusion: It is important to understand how the ATCM functions on CT scanners as it can directly affect dose and image quality. The phantom that has been developed is a most valuable tool to understand how different variables during a scan can affect the outcome of the longitudinal and angular ATCM.

Purpose: Stationary table acquisitions (Bolus tracking) in X-ray Computed Tomography (CT) can Result in dose length products (DLP) comparable to spiral scans. It is today unclear whether or not the effective dose (E) for Bolus Tracking can be approximated using target region specific conversion factors (E/DLP). The purpose of this study was to investigate how E depends on the anatomical location of the Bolus Tracking in relation to Chest CT scans with the same DLP. Methods: Effective doses were approximated for the ICRP 110 adult Reference Male (AM) and adult Reference Female (FM) computational voxel phantoms using software for CT dose approximations (pre-simulated MC data). The effective dose was first approximated for a Chest CT scan using spiral technique and a CTDIvol (32 cm) of 6 mGy. The effective dose from the spiral scan was then compared to E approximated for contiguous Bolus Tracking acquisitions (1 cm separation), with a total collimation of 1 cm, over different locations of the chest of the voxel phantoms. The number of rotations used for the Bolus Tracking acquisitions was adjusted to yield the same DLP (32 cm) as the spiral scan. Results: Depending on the anatomical location of the Bolus Tracking, E ranged by factors of 1.3 to 6.8 for the AM phantom and 1.4 to 3.3 for the AF phantom, compared to the effective dose of the spiral scans. The greatest E for the Bolus Tracking acquisitions was observed for anatomical locations coinciding with breast tissue. This can be expected as breast tissue has a high tissue weighting factor in the calculation of E. Conclusion: For Chest CT scans, the effective dose from Bolus Tracking is highly dependent on the anatomical location where the scan is administered and will not always accurately be represented using target region specific conversion factors.

Purpose: The purpose of this work was to develop a method so that the noise power spectrum (NPS) can be approximated for arbitrary levels of mAs, from a single determination in CT. Methods: The NPS is factorized into 2 components, 1) a parameterized function representing the 1D normalized spatial frequency distribution and 2) a function to scale the magnitude of 1) for arbitrary values of mAs. The 1D NPS, normalized by image variance (NNPS), was determined for 2 FBP reconstruction kernels (smoothing and edge enhancing) for 400 mAs. The NNPS were fit to the parameterized function and a scaling function was established to approximate the image variance at arbitrary values of mAs. Using the root mean square error normalized by the maximum value (NRMSE), the NPS approximated with the factorization method was compared to the NPS determined at 5 different mAs levels. Results: The factorization resulted in a set of 7 coefficients that can be used to approximate the 1D NPS, for arbitrary levels of mAs, for the convolution kernels studied in this work. The approximated NPS (factorization) agreed well with the determined NPS for all mAs levels. The greatest NRMSE was 0.02 and was observed for the edge enhancing kernel. Conclusion: The proposed factorization method has been demonstrated as applicable for FBP reconstruction. It can be used to approximate the 1D NPS for arbitrary levels of mAs, from a single NPS determination. Furthermore, approximations of the 1D NPS can conveniently be distributed since the factorization method only used 7 coefficients in the approximation.

Purpose: To measure and compare the performance of X-ray imaging detectors in a clinical setting using a dedicated instrument for the quantitative determination of detector performance. Methods: The DQEPro (DQE Instruments Inc., London, Ontario Canada) was used to determine the MTF, NPS and DQE using an IEC compliant methodology for three different imaging modalities: conventional radiography (CsI-based detector), general-purpose radioscopy (CsI-based detector), and mammography (a-Se based detector). The radiation qualities (IEC) RQA-5 and RQA-M-2 were used for the CsI-based and a-Se-based detectors, respectively. The DQEPro alleviates some of the difficulties associated with DQE measurements by automatically positioning test devices over the detector, guiding the user through the image acquisition process and providing software for calculations. Results: A comparison of the NPS showed that the image noise of the a-Se detector was less correlated than the CsI detectors. A consistently higher performance was observed for the a-Se detector at all spatial frequencies (MTF: 0.97@0.25 cy/mm, DQE: 0.72@0.25 cy/mm) and the DQE drops off slower than for the CsI detectors. The CsI detector used for conventional radiography displayed a higher performance at low spatial frequencies compared to the CsI detector used for radioscopy (DQE: 0.65 vs 0.60@0.25 cy/mm). However, at spatial frequencies above 1.3 cy/mm, the radioscopy detector displayed better performance than the conventional radiography detector (DQE: 0.35 vs 0.24@2.00 cy/mm). Conclusion: The difference in the MTF, NPS and DQE that was observed for the two different CsI detectors and the a-Se detector reflect the imaging tasks that the different detector types are intended for. The DQEPro has made the determination and calculation of quantitative metrics of X-ray imaging detector performance substantially more convenient and accessible to undertake in a clinical setting.

Purpose: To investigate the potential benefits of automatic monitoring of accumulated patient and staff dose indicators, i.e., CAK and KAP, from DICOM Radiation Dose Structured Reports (RDSR) in x-ray angiography (XA). Methods: Recently RDSR has enabled the convenient aggregation of dose indices and technique parameters for XA procedures. The information contained in RDSR objects for three XA systems, dedicated to different types of clinical procedures, has been collected and aggregated in a database for over one year using a system developed with open-source software at the Karolinska University Hospital. Patient weight was complemented to the RDSR data via an interface with the Hospital Information System (HIS). Results: The linearly approximated trend in KAP over a time period of a year for cerebrovascular, pelvic/peripheral vascular, and cardiovascular procedures showed a decrease of 12%, 20%, and 14%, respectively. The decrease was mainly due to hardware/software upgrades and new low-dose imaging protocols, and partially due to ongoing systematic radiation safety education of the clinical staff. The CAK was in excess of 3 Gy for 15 procedures, and exceeded 5 Gy for 3 procedures. The dose indices have also shown a significant dependence on patient weight for cardiovascular and pelvic/peripheral vascular procedures; a 10 kg shift in mean patient weight can result in a dose index increase of 25%. Conclusion: Automatic monitoring of accumulated dose indices can be utilized to notify the clinical staff and medical physicists when the dose index has exceeded a predetermined action level. This allows for convenient and systematic follow-up of patients in risk of developing deterministic skin injuries. Furthermore, trend analyses of dose indices over time is a valuable resource for the identification of potential positive or negative effects (dose increase/decrease) from changes in hardware, software, and clinical work habits.

Purpose: ImpactMC (CT Imaging, Erlangen, Germany) is a Monte Carlo (MC) software package that offers a GPU enabled, user definable and validated method for 3D dose distribution calculations for radiography and Computed Tomography (CT). ImpactMC, in and of itself, offers limited capabilities to perform batch simulations. The aim of this work was to develop a framework for the batch simulation of absorbed organ dose distributions from CT scans of computational voxel phantoms. Methods: The ICRP 110 adult Reference Male and Reference Female computational voxel phantoms were formatted into compatible input volumes for MC simulations. A Matlab (The MathWorks Inc., Natick, MA) script was written to loop through a user defined set of simulation parameters and 1) generate input files required for the simulation, 2) start the MC simulation, 3) segment the absorbed dose for organs in the simulated dose volume and 4) transfer the organ doses to a database. A demonstration of the framework is made where the glandular breast dose to the adult Reference Female phantom, for a typical Chest CT examination, is investigated. Results: A batch of 48 contiguous simulations was performed with variations in the total collimation and spiral pitch. The demonstration of the framework showed that the glandular dose to the right and left breast will vary depending on the start angle of rotation, total collimation and spiral pitch. Conclusion: The developed framework provides a robust and efficient approach to performing a large number of user defined MC simulations with computational voxel phantoms in CT (minimal user interaction). The resulting organ doses from each simulation can be accessed through a database which greatly increases the ease of analyzing the resulting organ doses. The framework developed in this work provides a valuable resource when investigating different dose optimization strategies in CT.

Purpose: To develop a method of performing routine periodical QC of CT systems by automatically analyzing key performance indicators (KPI) obtainable from scanning manufacturers' QC phantoms making it possible to follow a CT scanners performance between annual tests (e.g., on a daily basis). Methods: A KPI pertains to a measurable or determinable parameter that is influenced by other underlying parameters, where a stable KPI implies that the underlying parameters are stable as well. KPIs were identified and verified by studying and mapping out the relationship between established QC parameters used in annual testing. The KPIs include positioning, noise, uniformity, homogeneity, CT number of water and CT number of air. An application that automatically analyzes phantom images sent to a DICOM receiver was developed (MonitorCT). CT technologists send scans of a QC phantom to the developed application on a daily basis. Results: 290 daily QC scans, from two CT scanners, have been collected and analyzed during ten months. A systematic offset of circa 3mm from the scanner isocenter has been observed in the positioning test, which is under investigation. Noise, uniformity and homogeneity tests have been within specified tolerances during the data collection period. The CT numbers have trended outside of both MonitorCT and vendor tolerances which was caught using the developed method, which would not have been noticed otherwise until annual tests were performed. Consequently, actions could be taken promptly (water calibration). Conclusion: Automated monitoring of KPIs is a powerful tool that can, with little effort, be used to supplement established QC methodologies. Medical physicists, or other concerned parties, are able to obtain an indication of the current and historical (trends) status of a CT system so that actions can be taken directly to ensure the quality of CT examinations and patient safety.

Rationale and objectives The purpose of this study was to evaluate the feasibility of unconstrained three-material decomposition in a human tissue specimen containing iodinated contrast agent, using an experimental multi-bin photon-counting silicon detector. It was further to evaluate potential added clinical value compared to a 1st-generation state-of-the-art dual-energy computed tomography system. Materials and methods A prototype photon-counting silicon detector in a bench-top setup for x-ray tomographic imaging was calibrated using a multi-material calibration phantom. A heart with calcified plaque was obtained from a deceased patient, and the coronary arteries were injected with an iodinated contrast agent mixed with gelatin. The heart was imaged in the experimental setup and on a 1st-generation state-of-the-art dual-energy computed tomography system. Projection-based three-material decomposition without any constraints was performed with the photon-counting detector data, and the resulting images were compared with those obtained from the dual-energy system. Results The photon-counting detector images show better separation of iodine and calcium compared to the dual-energy images. Additional experiments confirmed that unbiased estimates of soft tissue, calcium, and iodine could be achieved without any constraints. Conclusion The proposed experimental system could provide added clinical value compared to current dual-energy systems for imaging tasks where mix-up of iodine and calcium is an issue, and the anatomy is sufficiently small to allow iodine to be differentiated from calcium. Considering its previously shown count rate capability, these results show promise for future integration of this detector in a clinical CT scanner. Key Points • Spectral photon-counting detectors can solve some of the fundamental problems with conventional single-energy CT. • Dual-energy methods can be used to differentiate iodine and calcium, but to do so must rely on constraints, since solving for three unknowns with only two measurements is not possible. Photon-counting detectors can improve upon these methods by allowing unconstrained three-material decomposition. • A prototype photon-counting silicon detector with high count rate capability allows performing unconstrained three-material decomposition and qualitatively shows better differentiation of iodine and calcium than dual-energy CT.