European Journal of Radiology 131 (2020) 109261

Contents lists available at ScienceDirect

European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Review

Technological developments of X-ray computed tomography over half a

century: User’s influence on protocol optimization
Ronald Booij *, Ricardo P.J. Budde, Marcel L. Dijkshoorn, Marcel van Straten
Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, P.O. Box 2240, 3000 CA, The Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: Since the introduction of Computed Tomography (CT), technological improvements have been impressive. At the
Computed x ray tomography (MeSH) same time, the number of adjustable acquisition and reconstruction parameters has increased substantially.
Health physics Overall, these developments led to improved image quality at a reduced radiation dose. However, many pa­
Radiation dosage
rameters are interrelated and part of automated algorithms. This makes it more complicated to adjust them
Diagnostic imaging
individually and more difficult to comprehend their influence on CT protocol adjustments. Moreover, the user’s
influence in adapting protocol parameters is sometimes limited by the manufacturer’s policy or the user’s
knowledge. As a consequence, optimization can be a challenge. A literature search in Embase, Medline,
Cochrane, and Web of Science was performed. The literature was reviewed with the objective to collect infor­
mation regarding technological developments in CT over the past five decades and the role of the associated
acquisition and reconstruction parameters in the optimization process.

1. Introduction its easy accessibility, associated technological developments and capa­

bilities. In parallel with the increase of performed CT scans, public
Computed tomography (CT) has fundamentally changed the practice awareness and concerns about medical radiation exposure increased [7,
of medicine and continues to expand our knowledge about diseases and 8]. The radiology community is aware of this fear and technological
management of major health challenges [1]. Consequently, the number developments for radiation dose optimization have always been at their
of CT scans performed worldwide is constantly increasing. The number attention. However, optimization of a scanning protocol with respect to
of CT exams obtained per year in the United States was around 3 million image quality (IQ) and radiation dose is a delicate procedure, mainly
at the early eighties, increasing with approximately a factor of 20–62 due to the interrelation of parameters. Furthermore, system properties
million performed CT exams in 2007 [2]. The rapid increase of CT use and accompanying data acquisition techniques changed and expanded
was seen in European countries as well, and where previously CT scans over the years. In this paper, we present an overview of the technological
of mainly adults were performed, there is an increase of CT’s performed developments during the evolution of CT and the accompanying user’s
in pediatric patients [3,4]. Especially the latter are believed to benefit influence for protocol optimization. Finally, a future outlook on tech­
from technological innovations such as high-speed CT scanning that nological developments is given.
improve diagnostic capabilities in these patients. But, just like in adults,
these scans should always be justified [2,5]. Without a doubt, CT 2. Search strategy
scanning is the biggest contributor of radiation exposure to the collec­
tive effective dose of medical examinations worldwide [3,6]. Dutch re­ Embase, Medline, Cochrane, and Web of Science were used for the
searchers found that the increase in CT exams was not primarily due to literature search for this narrative review by combining synonyms for
the growth and aging of the Dutch population, but can be explained by ‘image quality’, ’radiation dose’, and ‘CT’ with English language

Abbreviations: AEC, automatic exposure control; AI, artificial intelligence; ATCM, automated tube current modulation; CNR, contrast-to-noise ratio; CT, computed
tomography; DSCT, dual source computed tomography; ECG, electrocardiogram; FBP, filtered backprojection; FoV, field of view; IQ, image quality; IR, iterative
reconstruction; kVp, peak kilovolt; MDCT, multi-detector CT; PCCT, photon counting CT; TR, temporal resolution.
* Corresponding author.
E-mail addresses: [email protected] (R. Booij), [email protected] (R.P.J. Budde), [email protected] (M.L. Dijkshoorn), marcel.vanstraten@
erasmusmc.nl (M. van Straten).

https://doi.org/10.1016/j.ejrad.2020.109261
Received 16 March 2020; Received in revised form 11 August 2020; Accepted 27 August 2020
Available online 31 August 2020
0720-048X/© 2020 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
R. Booij et al. European Journal of Radiology 131 (2020) 109261

restriction. The full search syntax is provided in the Appendix A of the width, but detector size decreased rapidly to 2–8 mm [11,12]. With the
supplementary material. Duplicates were removed and reference lists of introduction of spiral multi-detector CT (MDCT) in 1998 (also known as
included articles and review articles were searched for additional arti­ multi-slice CT), the individual detector elements became even smaller,
cles. First, articles were screened on title and abstract. Non-original down to 0.25 mm per detector element nowadays [13], resulting in
research articles, e.g. case-reports, and original research articles not improved spatial resolution. Moreover, it provided more and fast lon­
containing information on image quality and radiation dose regarding gitudinal coverage since multiple detector elements were combined
CT were excluded. Inclusion, exclusion, and screening of all articles was (Fig. 1) [14]. Currently, for several CT manufacturers the total beam
performed by one author (RBo). Selection criteria were articles con­ collimation is up to 160 mm with multiple detectors in the z-direction,
taining information regarding key technological developments in CT allowing dynamic data acquisition of e.g. the entire brain or heart
and the accompanied influence of those developments on image quality without table movement [15,16]. Another positive outcome of an
and/or radiation dose. After the search, we continued to prospectively increased total collimation, is the decrease of the overbeaming effect:
add recent articles of which we thought that they supported the text. The collimated x-ray beam is always wider than the total detector width
because of the penumbra, which does not contribute to the image
3. System properties reconstruction, but does increase radiation dose. Although the impact of
overbeaming on radiation dose was reduced with increased total colli­
The user’s influence and choices in protocol optimization depend on mation, overranging dose increases with increasing collimation and
the CT scanner’s technological capabilities and system properties. Main pitch values [17]. Therefore, a dynamic collimator was introduced in
technological developments of system properties, acquisition, and 2009 to reduce the amount of pre- and post-spiral dose which are
reconstruction parameters are presented in Table 1 and are discussed irrelevant for image reconstruction and is automatically applied [18].
below. An overview of the evolution of CT scanners and the technical Another approach to detector developments were improved detector
advances in CT, is illustrated in Fig. 1. efficiency to increase radiation dose efficacy, and the introduction of
dual layer detectors. These detectors can measure x-ray attenuation for
3.1. Translation-rotation and slip ring technology low and high energy photons separately in two different detector layers,
enabling material identification and quantification [19].
Initially, CT images were acquired by the translation-rotation
method in the "first and second" generation CT scanners. Within this 3.3. X-ray tube
method, data was acquired by the x-ray tube and detector moving in a
linear translatory pathway and was repeated with small rotational in­ With the introduction of spiral CT, the x-ray tubes had to be rede­
crements [9]. The third generation CT scanners have a wide fan beam signed again to cope with overheating problems because of the need for
and detectors that rotated slowly around the patient, requiring multiple increased tube output [20]. The introduction of a periodic motion of the
breath holds to complete an axial CT exam. There was a high chance in focal spot in the z-direction resulted in doubling measurement positions
missing abnormalities due to the multiple breath holds (Fig. 1a). Slip in the longitudinal direction per rotation; thereby increasing spatial
ring technology introduced in 1987 allowed continuous rotation of the resolution and eliminating aliasing artifacts [21]. This multifan mea­
tube and detectors by transferring electrical energy to the rotating surement technique is commonly known as z-flying focal spot and
gantry part and transmission of measured data to the computer system “double-dynamic” focus and applied by several vendors
[10]. As the fourth generation scanners, with a stationary detector ring, Recent developments also include an additional tin filtration within
did not get widely accepted, all currently available CT scanners are third the x-ray tube, which is of particular use in e.g. unenhanced CT high
generation scanners by design. Therefore, we will only briefly comment contrast studies of the chest and sinus [22,23] and is currently applied
on special scanner concepts like electron beam CT and dynamic spatial by one vendor.
reconstructor.
3.4. Dual source CT (DSCT)
3.2. Detectors
CT scanners with multiple x-ray sources can provide fast imaging and
The total beam collimation in the longitudinal, or z-direction, in the improved temporal resolution (TR). The dynamic spatial reconstructor
first-generation CT scanners was limited to one detector of 8–13 mm in was one of the first attempts to introduce such a CT system but was never

Table 1
Timeline Main Technological Developments of System Properties, Acquisition, and Reconstruction Parameters over the Course of Half a Century of Computed
Tomography.
Decades `70 s - `80s `90s `00s `10s

Solid state Detector Dynamic Additional tin

Gas detectors Fan beam Dual source CT Electronic noise
detectors collimation collimation filtration
System properties
Translation-
Slip ring Wide area CT
rotation
Rapid tube voltage Automated tube
Constant tube Temporal
switching dual ECG-pulsing current Dual energy Automatic tube voltage selection
voltage resolution
energy modulation
Acquisition ECG-guided
Constant tube
properties dose 4DCT Routinely low tube voltage
current
modulation
Sequential Multi-detector
ECG-gating Spiral scanning
scanning spiral
Noise &
Algebraic 180- and 360-de­ Reconstruction Temporal Increased Artificial
Slice thickness motion
reconstruction gree reconstruction speed resolution matrix size intelligence
Reconstruction reduction
properties Advanced beam
Filtered back- Iterative
hardening
projection reconstruction
correction

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Fig. 1. (a-g) Graphical representation of the evolution of third-generation CT scanner technology from a single detector row design to expected future technology.
The coronal multiplanar reconstructions (MPR) of the thorax-abdomen that illustrate the improvements of MPR quality over time, are based on a dataset of one
patient (at one moment in time). (a) Single-detector (row) 10 mm axial scan. (b) Spiral single-detector scan needed at least two breath holds for a full thorax-
abdomen scan. (c) Multi-detector CT. (d) Spiral CT with 16 detector rows allowed for volume scanning with isotropic datasets. (e) Faster rotation times and 64-de­
tector CT allowed for robust cardiac CT exams. (f) Free-breathing and dual energy possibilities with dual source CT. (g) Future technologies. The color scale is used
for illustrative purposes only and does not reflect true photon counting (PCCT) or spectral CT.
See text for more details.

used in clinical routine [24]. In 2005, the first DSCT with two tubes and patient sizes and anatomical regions.
two corresponding detectors was introduced, demonstrating improved A high level of awareness by the users for optimal positioning of the
TR and dual energy imaging capabilities in clinical practice which was patient in the CT scanners is of utmost importance [30,31]. Both radi­
widely accepted [25]. ation dose and IQ may be affected when the CT localizer radiograph,
which is used by the AEC, is made with the patient positioned off-center
4. Acquisition parameters [30,31].

The main developments in acquisition parameters and how they 4.3. Tube voltage
influence image acquisition are discussed next.
Within the first and second generation CT scanners, the user was able
4.1. Tube current to set the peak tube voltage in the range of 100–140 kilovolt peak (kVp)
[27,32,33]. These high voltages are much appreciated when imaging
Within the first-generation CT scanners, the user could set tube thick patients, or to reduce metal implant artifacts, however radiation
current (mA value) depending on the accompanying tube voltage [26, dose is likely to be increased. Lowering the tube voltage requires tube
27]. Tube current was constant during a scan and this remained so for current to be increased, and this was often limited by tube power early
almost twenty years. on.

4.2. Automated tube current modulation (ATCM) 4.4. Automatic tube voltage selection

ATCM was introduced end ’90 s as part of the automatic exposure Changing the tube voltage in predefined scan protocols, requires
control (AEC) [28]. Early strategies consisted of online angular tube understanding of its influence on signal-to-noise ratio and contrast-to-
current modulation only, where nowadays it is often applied in combi­ noise ratio (CNR). Therefore, it could be challenging for users to un­
nation with tube current adaptation in longitudinal directions. Some derstand how to perceive an improved IQ, or even the same IQ while
strategies enabled users to set customizable quality levels to achieve a reducing radiation dose, when changing the tube voltage. It was until
constant noise level, whereby tube current is adjusted for the chosen the ’10 s that integrated automatic tube voltage selection and accom­
scan and reconstruction parameters. Algorithms within the latest sys­ panying tube current adjustment became fully integrated into the AEC.
tems may suggest adjustments to average tube current and image noise Currently, it is available in most CT systems [34]. The main goal of
based on a user defined dose index and patient diameter, accounting for automated tube voltage selection is to control the CNR and thereby
the use of iterative reconstructions (IR) and used tube voltage. Another minimize radiation dose. The user can define settings for the anatomical
strategy was to have the ATCM system measure the attenuation from region and exam type with or without contrast.
patients in a specific protocol, using this as a standard protocol body
attenuation. The user can determine a noise reference or set the tube 4.5. Dual energy imaging
current to individual patient habitus. A different approach of fully ATCM
is adaptation to different anatomical regions and patient sizes by setting Dual energy, or so-called spectral imaging, can add tissue informa­
a target tube current level for a standard-size reference patient [29]. The tion to the CT image (e.g. discriminate bone from iodine-enhanced tis­
user may set different tube current modulation schemes for different sue). The possibility of determining the atomic number of the materials

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within a slice was already discussed by Sir Hounsfield in the seventies practice. Especially from the 64-row MDCT on, robust low heart rate
[12]. First attempts were done by a double scan: once with a high tube (HR) cardiac CT was possible (Fig. 1e). [48,49]. At first, only a retro­
voltage and once with a low tube voltage and in parallel by a rapid kV spective spiral scan mode with full dose, during the whole R-R interval at
switching technique. However, clinical use was rather limited due to low pitch values was provided [50]. Later on, by introducing adaptive
needed technological improvements and high costs. The introduction of algorithms which can react to heart rate variability and simple
DSCT in 2005 allowed the acquisition of nearly simultaneous arrhythmia, a dose reduction was achieved [51]. When the heart rhythm
dual-energy data by using two tubes (Fig. 1f) [35]. A few years later, this has complex arrhythmia, often a retrospective protocol is preferred for
was also made possible with the introduction of an improved rapid tube ECG gated data editing possibilities. However, such a protocol requires a
voltage switching technique [36]. TwinBeam CT and Dual layer spectral low pitch for oversampling to ensure enough data for reconstruction is
CT are the latest technologies to acquire dual energy datasets [19,37]. available at the expense of a high(er) radiation dose. While a prospective
sequential scanning technique might have stack artifacts, a single heart
4.6. Scan mode beat scan mode such as a high-pitch prospective scan or a scan with a
wide area detector does not. However, both single heart beat techniques
4.6.1. Sequential scanning require a low and stable heart rate [52].
Sequential CT imaging represents scanning with a stationary scanner
table while the x-ray tube is rotated around the patient. After the scan, 5. Reconstruction parameters
the patient is transported with a predefined incremental step. Then the
next acquisition is performed and the process is repeated to the end of Some of the steps in the reconstruction process are not, or to a less
the scan range. degree, adjustable by the user. All of the choices made within the
reconstruction process directly influence IQ. We will highlight the main
4.6.2. Spiral scanning technological developments in reconstruction techniques.
CT entered a new era with spiral CT (also known as helical scanning)
in the late 1980s [38,39]. The scanner table was able to travel at a 5.1. Image reconstruction technique
constant speed through the gantry, i.e. the table feed, with the tube
rotating, allowing the acquisition of volumetric data. It also introduced Within the first CT systems, images were reconstructed with a simple
the concept of pitch (the ratio between the table feed per full rotation iterative reconstruction method known as algebraic reconstruction [53].
and total beam collimation) which can be adjusted by the user. With However, due to the lack of computing power, this technique was soon
single-detector spiral CT and a reduced rotation time, scan time was replaced by filtered backprojection (FBP) [54]. FBP images are recon­
reduced. However, scans were restricted to single organs. A complete structed by a convolution method or a direct Fourier algorithm. This
thorax-abdomen scan required at least two breath holds (Fig. 1b). The second group incorporated interpolation in the Fourier plane, followed
introduction of MDCT (Fig. 1c) gave the user the choice to scan with a by inverse Fourier transformation. Convoluting the attenuation profiles
small detector row width (e.g. 4 × 1 mm) to increase spatial resolution with a so-called kernel and the backprojection of the modified profiles
(=detail) or to scan with a large detector size, e.g. 4 × 2.5 mm, to reduce into the image plane to create the final image, is the method known as
scan time (=volume). Spiral scanning with a 16-row MDCT allowed filtered backprojection. It is an analytical solution of the reconstruction
isotropic datasets of large volumes and an increase in quality of the problem. Where FBP was the most widely used CT image reconstruction
post-processing images, as demonstrated in Fig. 1b-f. DSCT made scan­ technique for decades, nowadays mainly IR techniques are applied [55].
ning at a pitch >2 possible by filling the sampling gaps of one detector
with data of the second detector, providing clinical advantages in (car­ 5.1.1. Iterative reconstruction technique
dio)vascular, trauma and pediatric patients due to increased scan speed Computing power by the late ’00 made IR techniques feasible in
(Fig. 1f) [40,41]. clinical routine [55]. IR techniques developed rapidly in three steps:
Firstly, IR reconstruction was mainly done in the image domain on an
4.7. Rotation time and temporal resolution initial image reconstructed from the raw data, secondly it went to
sinogram-based or so-called hybrid reconstructions. Thirdly, recon­
Gantry rotation time directly affects TR as data from at least a 180- struction algorithms developed to full model-based IR techniques [56].
degree rotation are needed to reconstruct an image. Faster gantry However, most algorithms remain a “black-box” lacking specific details.
rotation times result in improved TR with less motion artifacts and
improved clarity of lung and cardiac imaging [42,43]. Gantry rotation 5.2. Matrix and FoV
times have decreased from 5 to 40 seconds in rotation-translation sys­
tems in the seventies to 0.24− 0.30 seconds for the current CT systems Within the first-generation CT scanners, the image matrix size was
[26]. Until today, most single source scanners still cannot reach the limited to 80 × 80 pixels and one could only adjust the window level and
50–100 ms TR of electron beam CT scanners. Those scanners were width. Nowadays 512 × 512 is the most commonly used image matrix
especially proposed for cardiac CT because they were able to reach good size but CT scanners with sizes up to 2048 × 2048 are available [57].
TR thanks to its scanning without mechanical motion [44]. It was until Extended field of view (FoV) reconstructions allow visualization of
the introduction of DSCT to achieve similar TR with up to 66 ms with 3rd skin and tissue outside the primary FoV. This is of importance for PET-
generation CT systems [45]. CT attenuation correction and radiotherapy CT dose calculations [58].

4.8. Electrocardiogram (ECG) synchronization and ECG-guided dose 5.3. Cardiac reconstructions
modulation
The multiple ECG cycles acquired for cardiac CT in the late seventies
Cardiac motion limited imaging of the heart in the early years of CT. were needed for acceptable effective TR with the aid of multi-segment
However, in 1977 there were considerable achievements in technology reconstruction. Despite long acquisition time and extensive motion ar­
reducing cardiac motion by ECG-gated reconstruction and provided tifacts, the cardiac outline and fat grooves could be sharply visualized.
"stop-action" cardiac CT scans [46,47]. However, acquiring data for a Nowadays, mono-segment reconstruction is often used, but bi- or multi-
single slice took up to 12 s. Multi-detector spiral CT reduced exam time, segment reconstruction techniques are still available to make scanning
enabled reducing contrast volume, improved spatial resolution and of coronaries at higher heartrates feasible. These methods could improve
ECG-gated coronary CT angiography became feasible in clinical the TR by a factor of 2 by combining two or more heart beats for one

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reconstruction, but at the cost of a very low pitch value and conse­ and IQ are dictated by the ALARA (As Low as Reasonably Achievable)
quently an increased radiation dose [50]. A disadvantage of principle. With the introduction of diagnostic reference levels for CT in
multi-segment reconstruction is a possible creation of blurry images 1996, a practical tool came available to promote radiation dose opti­
[59]. Even though vendors developed motion reduction algorithms, mization for specific diagnostic tasks [67]. With that, reference levels for
motion free imaging primarily depends on heart rate and gantry rotation CT exams were introduced around the globe [68–71]. Together with the
time [60,61]. technological developments it contributed to the decrease of effective
dose for a CT exam [72]. However, the diagnostic reference levels are
5.4. Image enhancement tools general guidelines and do not apply to optimization for an individual
patient. In the meantime, the user is one of the “protocol optimization
Several tools to improve IQ are developed and can be manually factors” or may be even the most important factor in the optimization
selected or are integrated into the reconstruction process. The most process. The user’s contribution to the optimization process depends on
often used tools are noise and artifact reduction algorithms. the user himself and on the technological developments. All stake­
holders, e.g. radiologist, medical physicist, and radiographer should
work together and consider the whole optimization process as a team
5.5. Noise reduction
effort. In the next paragraph we will discuss the optimization process.
Some optimization steps are highlighted by a single case study (Fig. 2),
Recently, noise reduction algorithms are implemented in several
which covers a wide area of technological developments over more than
reconstruction processes, mostly running in the background e.g. in
a decade. Note: As there are several CT manufacturers, so are (subtle)
repeated low dose imaging during dynamic CT perfusion, in order to
differences in their approaches in the technological developments in
improve spatial resolution and CNR [62]. Sometimes it can be manually
system, acquisition, and reconstruction parameters. Generalizations
applied by the user e.g. to improve CNR in monoenergetic image
should come in only if features are significantly similar in all or most
reconstruction of dual energy data [63].
common vendors.
The whole scan protocol optimization process strives for optimiza­
5.6. Artifact reduction tion for an individual patient, taking the specific organ region and the
referral question into account. Some technological developments have a
Artifacts are defined as artificial structures, which deviate from re­ direct effect on radiation dose applied to a patient (e.g. tube current).
ality. Examples are artifacts occurring from voluntary and involuntary Other developments, like iterative reconstructions or automatic adap­
patient motion or beamhardening. Nowadays, motion correction algo­ tation of tube voltage, are dependent on the user’s motivation, accep­
rithms are often used in CT perfusion of the head and body to correct for tation and awareness. Benefits of the increased and evolved technologies
subtle head displacement or the breathing state during the acquisition are known, but the technological developments were and could be
times. The corrections are applied on already reconstructed image data misunderstood or misused, leading to excessive radiation dose to the
and mainly done in post-processing software. Whereas most of the al­ patient [73,74]. Thereby, awareness of radiation dose and the possible
gorithms for beam hardening correction or metal artifact reduction use risks are not always known [75].
iterative algorithms and therefore have to be applied on raw data [64]. Within the optimization process, the user’s influence has increased,
while automated tools were integrated to assist in the optimization
6. Scanning protocol optimization process. This does not mean that changing a parameter will lead to an
automatic compensation in other features/parameters, for example to
Technological developments generally resulted in a reduction of maintain image quality. Many of the acquisition and reconstruction
radiation dose per exam and improved IQ [65,66]. Both radiation dose

Fig. 2. (a-c) Case presentation of a female child in the follow-up of cystic fibrosis. (a) Scan length and the chest diameter are shown as vertical bars on the left y-axis.
The size-specific dose estimates (SSDE) are illustrated as diamonds on the secondary, right y-axis. At first, the patient was scanned with anesthesia on a 6-slice CT
scanner with a slice width of 2.5 mm within the period 2005 – 2008. Tube voltage was fixed in this period and the scans in 2006 and 2008 were performed with a
technician controlled breath hold. (b). From 2010 – 2018, the patient was scanned with spirometry controlled breath hold on dual source CT, equipped with faster
rotation time and thinner detector collimation. Within this period, scan protocol was optimized with iterative reconstruction technique, automatic tube voltage
selection, and additional tin filtration. (c) CT scan (axial view) of the chest (2018) diameter increased from 18 cm to 29 cm and the scan length increased accordingly
from 13 cm to 31 cm. SSDE dropped with almost 80 %. Image noise was increased between (b) and (c) while increasing image quality due to improved temporal
resolution and spatial resolution: White arrows in (b) show motion artifacts and the grey arrows in (c) show sharp delineation of the lung vessels and the airway wall.

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parameters are interrelated, making them more complicated to adjust determine the tolerance level of noise in the CT images as Sir Hounsfield
individually and more difficult to comprehend, especially when they are already stated in 1976 [79]. An increase in noise is not problematic in
part of automated algorithms and, likely, in the near future with artifi­ objects with high intrinsic contrast, e.g. bone and air ways. [57,79].
cial intelligence. Nevertheless, technological improvements and auto­ Adaptation of the tube voltage will have different effects and de­
mated tools, combined with attention to the human side by the pends on whether or not iodinated contrast material is used (Table 2,
radiographer, will lead to the optimal scanning procedure. For example, “acquisition parameters”, “image quality”, “radiation dose”) and on the
automatization might speed up the scanning and reconstruction process, general strategy for using automatic tube voltage selection [80]. X-ray
while the main focus of the radiographer is on the patient itself. In the attenuation by objects such as bone and iodine contrast strongly de­
meantime, adjusting parameters is like slotted dials: On the road to pends on the photon energy due to their high atomic number. Therefore,
optimization, regardless of whether the adjustments have been made by when iodine material is used, an improved CNR is possible, e.g. to better
humans or artificial intelligence, an adjustment of an acquisition or depict enhancing masses, at a low tube voltage with a dose similar to a
reconstruction parameter will have a direct influence on image quality high tube voltage scan (Fig. 4AB) [81]. On the other hand, for scanning
and, directly or indirectly, on radiation dose as well due to their inter­ protocol optimization in e.g. young patients, the user may consider a
relation (Fig. 3). Within this light, it is mandatory to focus first on reduction of radiation dose while maintaining CNR (Fig. 4C) [82]. While
diagnostic optimization, which can be defined, and achieved, by the the main goal of automatic tube voltage selection is to control the CNR
determination of the minimally acceptable IQ for diagnosis and thus of and thereby minimize radiation dose, sometimes the user should adjust
the lower limit of the diagnostic reference level. Minimally acceptable the proposed parameters by the scanner software for an individual pa­
IQ is set by the desired image contrast, spatial resolution, and the tient, instead of following the general strategy for automatic tube
amount of artifacts accepted [76,77]. The second step will be techno­ voltage selection. Thus, in some cases the referral question or individual
logical optimization, defined as parameter selection to achieve this patient demands for a higher radiation dose. For example, the user may
preferred lower limit IQ at the lowest reasonable dose. Fig. 2 shows an also want to apply a higher contrast volume or flow since a high tube
example how a thoracic scanning protocol was technologically opti­ voltage decreases iodine contrast enhancement (Fig. 5AB).
mized. Users should be aware that diagnostic and technological opti­ The presence of high attenuating materials such as a hip prosthesis
mization outcomes may vary between different CT scanners and (Fig. 5CD), warrants an increased tube voltage to decrease artifacts
institutions with different IQ preferences [71,78]. The impact of a when no metal artifact reduction techniques are available (Table 2, “risk
change in acquisition and reconstruction parameters on IQ and radiation of artifacts”).
dose, together with considerations for protocol optimization is illus­ Continuing with the parameter adaptation shown in Table 2: In
trated in Table 2. This table is used as a guidance for the next paragraphs general, tube current adaptation is not dependent on the use of iodine
to discuss the impact of adaptation of a single parameter on IQ and ra­ material, but rather on the noise tolerated in the images. Modulation of
diation dose. the tube current is used throughout most of the CT scanning protocols.
Its use changes the relative dependencies in individual exposure pa­
6.1. Acquisition parameters rameters. For example, changing the pitch or rotation time often does
not affect the patient’s dose, as a change in tube current compensates for
Protocol optimization for every individual patient can be obtained by the change in other parameters [83]. However, when using ATCM, one
adaptation of a single or multiple acquisition parameters. Every should be aware that specific parameters, like slice thickness, kernel,
parameter demands its own consideration for optimization (Table 2, and tube voltage, may affect the behavior of ATCM and that this differs
“considerations for CT protocol optimization”). For instance, when ob­ between vendors [84].
jects have slight attenuation differences such as in soft tissue studies, Considerations to increase TR and the pitch mostly depend on the
image noise impairs contrast resolution. So again, it is essential to need of decreasing motion artifacts (Fig. 2B and 2C), mainly when

Fig. 3. Graphical illustration by slotted dials, demonstrating the balance between optimization of a scanning protocol with respect to image quality and radiation
dose. Changing system properties or parameters, input of human or artificial intelligence will influence both radiation dose and image quality.

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Table 2
Overview of general impact when adapting acquisition and reconstruction parameters currently used.
Acquisition Parameters Image Quality Radiation Considerations for CT Protocol Optimization
Dose
Contrast Spatial Risk of Direct
Resolution Resolution Artifacts Absolute
Effect

Tube current increase + ≈ ≈ + (linear) Increase of contrast resolution and decrease of noise at the cost of
increased radiation dose
Tube current decrease − ≈ ≈ − (linear) Decrease of radiation dose at the cost of decrease of contrast resolution
and increase of noise
Tube voltage increase (no soft tissue ≈ / − ≈ − (1,2) + (non- Decrease of artifacts and noise at the cost of increased radiation dose
iodinated contrast material bone/fat linear) and decreased contrast of bone/fat
applied)
Tube voltage decrease (no soft tissue ≈ / + ≈ + (1,2) − (non- Increase of contrast bone/fat and decreased radiation dose at the cost
iodinated contrast material bone/fat linear) of increase of artifacts and noise
applied)
Tube voltage increase (iodinated soft tissue – / − ≈ − (1,2) + (non- Decrease of artifacts and noise at the cost of increased radiation dose
tissue) bone/fat linear) and decreased contrast of bone/fat, especially soft tissue (iodine)
Tube voltage decrease (iodinated soft tissue ++ / ≈ + (1,2) − (non- Increase of contrast in soft tissue (iodine) and bone/fat with decreased
tissue) + bone/fat linear) radiation dose at the cost of increase of artifacts and noise
Sequential/ Axial (relative to ≈ − − (3) / + (4) − (non- No windmill/spiral artifacts and no overranging dose at the cost of
spiral) linear) increased stair-step artifacts and impaired scan speed
Multi-detector spiral (relative to ≈ + + (3) / − (4) + (linear) Increased spatial resolution and scan speed at the cost of overranging
sequential) dose and possible windmill/spiral artifacts
Pitch increase − − + (3) / − (5) − Decrease of motion artifacts, increase windmill/ spiral artifacts.
Increase of noise when keeping tube current constant (strategies vary
between vendors): Absorbed dose decrease. Overranging dose increase,
but depends on the beam collimation, scanning range and the presence
of dynamic collimation
Pitch decrease + + - (3) / + (5) + Increase of motion artifacts, but decrease of noise and windmill/spiral
artifacts and increase of contrast and spatial resolution. Increase of
absorbed dose due to constant tube current (strategies may vary
between vendors) and a decrease of overranging dose. Overranging
depends on beam collimation and the presence of dynamic collimation
as well.
Longer rotation time + + / ++ (a) − (3,6) / + (linear) Increase of contrast and spatial resolution with decrease of windmill/
++ (5) spiral artifacts with active flying focal spot and decrease of blooming at
the cost of increased motion artifacts and radiation dose
Shorter rotation time − − / ≈ (a) + (3,6) / - (linear) Decrease of motion artifacts and reduced radiation dose at the cost of
− − (5) increased windmill/spiral artifacts when no active flying focal spot is
used, increase of blooming and noise with decreased contrast and
spatial resolution
Radiation
Image Quality
Dose
Reconstruction Parameters Direct Considerations for CT Protocol Optimization
Contrast Spatial Risk of
Absolute
Resolution Resolution Artifacts
Effect
Iterative reconstruction ≈/− Increase of contrast and spatial resolution with ability to reduce
≈ / + (model
technique (relative to filtered + (model ≈ radiation dose and artifacts; probably user adaptation to different
based)
back-projection) based) image impression
Increase of spatial resolution; necessity to increase radiation dose to
Matrix increase − + − (6) ≈
preserve the same SNR
Increase of contrast resolution but increase of partial volume effect;
Matrix decrease + − + (6) ≈
ability to reduce radiation dose
Increase of contrast resolution but increase of partial volume effect;
dFoV increase + − + (6) ≈
ability to reduce radiation dose
Increase of spatial resolution; necessity to increase radiation dose to
dFoV decrease − + − (6) ≈
preserve the same SNR
Increase of contrast resolution but increase of partial volume effect;
Slice thickness increase + − − (3) / + (6) ≈
ability to reduce radiation dose and windmill/spiral artifacts
Increase of spatial resolution with decrease of partial volume effect;
Slice thickness decrease − + − (6) ≈
necessity to increase radiation dose to preserve the same SNR

Note. : Increase is demonstrated with the "+", decrease with the "− ", and (almost) equal effect with the "≈". dFoV = display field of view. Data in paranthesis
1=beamhardening; 2=streak; 3=windmill/spiral; 4=stair-step; 5=motion/breathing/pulsation; 6=partial volume effect/ blooming; a=active flying focal spot.

imaging the heart or scanning non-cooperative patients. However, a 6.2. Reconstruction parameters
higher pitch value often demands a higher tube current, especially in
scanners that keep the noise and dose level constant. Faster rotation CT protocol optimization is also obtained by adaptation of single, or
times may increase artifacts. Therefore, in cases of cooperative patients, multiple, reconstruction parameters (Table 2). In image reconstruction,
the user may decrease the pitch to decrease the overranging effect. when selecting the level of smoothing (minimal, moderate, or
Moreover, this will also lead to increased IQ in e.g. bone exams, espe­ maximum), the user can improve low contrast detectability by reducing
cially when the structures are angulated relative to scan plane [18,85]. the amount of noise. The other way around, edge-enhancement filters
improve spatial resolution, by "sharpening up" the CT image and are
especially useful in bone or lung exams [86]. Other filters may increase

7
R. Booij et al. European Journal of Radiology 131 (2020) 109261

Fig. 4. (a-c) Axial CT images of the same human abdomen acquired with equal CTDIvol and contrast injection protocol. Window width and level were 300/30.
Images made with two days in between. (a) Demonstrating an increased contrast to noise ratio (CNR) when applying a lower tube voltage of 80 kVp compared to the
CNR observed in (b) with 120 kVp. (c) CT image (maximum intensity projection, coronal view) of the heart of a thirteen-year-old boy. Reduced radiation dose in
coronary CT angiography when applying low tube voltage (70 kV, a total dose length product of 8.2 mGy*cm, and a SSDE of 0.77 mGy).

Fig. 5. (a-d) Axial CT images demon­

strating the influence of adjusting the
tube voltage on metal artifacts and
image quality in contrast enhanced CT
scans. (a-b) Dual energy CT angiog­
raphy of a clipped brain aneurysm with
metal clip artifacts (a) 140 kV scan with
low contrast HU, but with less beam
hardening artifacts than in (b) 80 kV
scan with high contrast HU. (c-d) CT of
the abdomen of two different patients
with hip prosthesis (c) Hip prosthesis
with cobalt head causing disturbing
beam hardening artifacts in the pelvic
area. Not all metal type will cause dis­
turbing beam hardening: (d) Hip pros­
thesis with a head made of titanium and
a clear visualization of the pelvic area.

metal to tissue transition such as stent lumen by reducing blooming a decrease of the voxel size. In general this will be accompanied by an
effects [87]. An improved spatial resolution comes with an increased increase of noise (Table 2). Moreover, users should also be aware that
noise level and reduced soft tissue contrast. image data size increases with increased matrix size.
Within iterative reconstruction techniques, careful considerations in Adaptation of the FoV is also related to the voxel size: Increasing or
iterative strength, also known as level or scale, and accompanied dose decreasing the FoV will directly influence voxel size. Thereby, it may
adjustments are mandatory [88,89]. For instance, higher iterative affect IQ: a smaller FoV may increase spatial resolution, but decrease
strength can have an effect on contrast and spatial resolution, but also on contrast resolution due to increase of noise. Balancing between opti­
image appearance [90]. The image texture might be blurred and a high mization of a protocol with respect to IQ and radiation dose, e.g. the
iterative strength can give rise to a noiseless image appearance. These increase of spatial resolution, at the cost of image noise, the user may
kind of images are often evaluated as too smooth or artificial, neither are also want to adjust the slice thickness to restore the signal-to-noise ratio.
often desired by users [91]. Reliable diagnostic quality and statistically For example, when an increase in contrast resolution is required, noise
significant dose reductions can be achieved in adult and pediatric pa­ levels can be lowered by increasing slice thickness (Fig. 6AB). Simul­
tients using IR [92,93]. However, negative effects as low contrast taneously, spatial resolution will decrease due to the partial-volume
detectability are reported as well [94]. effect (Fig. 6CD).
Spatial resolution may increase with increased matrix size thanks to

8
R. Booij et al. European Journal of Radiology 131 (2020) 109261

Fig. 6. (a-d) CT images illustrating the

influence of adjusting a reconstruction
parameter (slice thickness) and its in­
fluence on contrast and spatial resolu­
tion. (a-b) CT images (axial view) of an
adult brain (soft tissue) (a) 1.0 mm and
b 5.0 mm. (c-d) CT images (multiplanar
reconstruction, coronal view) of a wrist
(bone). Contrast resolution is increased
with thicker slices due to decrease of
noise. (c) 0.75 mm and (d) 5.0 mm.
Spatial resolution is increased with
thinner slices due to decrease of the
partial volume effect.

7. Future outlook and conclusion Statistics and biometry

CT is still evolving, even in its middle age, and bringing new tech­ One of the authors has significant statistical expertise.
nological developments and new diagnostic strategies for healthcare.
Users should not only be at the forefront in embracing latest technolo­ Informed consent
gies, but also be proactive on the road to highly optimized protocols.
Currently, photon counting CT (PCCT) and artificial intelligence (AI) Written informed consent was not required for this study because
promise to bring a new revolution in CT [55,72] (Fig. 1g). PCCT is ex­ this concerns a narrative review paper.
pected to provide intrinsic spectral sensitivity, high spatial resolution,
less noise and artifacts with better low-signal performance, and less Ethical approval
characteristic energy-weighting [55,95]. PCCT opens the possibility of
achieving multi-energy imaging in every scan, similar to dual energy CT, Institutional Review Board approval was not required because this
but using a single tube voltage. Where dual layer CT uses a single tube concerns a narrative review paper.
voltage too, PCCT is able to count the number of all incoming photons
and measure its energy. Improved iodine contrast visibility may even Methodology
require less radiation dose, or lower iodine contrast material injection
[96,97]. Narrative review paper
AI is already applied within clinical protocols for instance in artifact
reduction and image reconstruction [95]. As such the application of AI Funding
resembles IR: its application can be used to reduce radiation dose while
maintaining IQ or increase IQ without increasing radiation exposure The authors state that this work has not received any funding.
[55]. Both PCCT and AI are one of the latest technological developments
in almost five decades of CT, but certainly will not be the last to be Declaration of Competing Interest
introduced and demanding an adjustment of the optimization process.
In conclusion, technological developments in CT have led to an R. Booij: Research collaboration, Siemens Healthineers
increased number of processes for protocol optimization. Consequently, R.P.J. Budde: None
it is necessary that users are aware of those developments, their opera­ M.L. Dijkshoorn: Clinical training consultant: Siemens Healthineers
tion, and how they are interrelated with respect to image quality and M. van Straten: Research collaboration, Siemens Healthineers
radiation dose. Our department has a Master Research Agreement with Siemens
Healthineers. No funding or financial support was received for prepa­
Guarantor ration of this article.

The scientific guarantor of this publication is Marcel van Straten Acknowledgements

We would like to thank Dr. Wichor Bramer of the medical library

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