Dual energy digital radiography is an imaging technique that ray exposure and a second at a relatively higher energy, it is takes advantage of the differential, energy-dependent possible to mathematically derive a soft tissue-only image with absorption properties of bone and soft tissue structures in bone structures removed, and a corresponding bone-only human anatomy. By capturing two radiographic images of a image [1] (Figure 1). patient in rapid succession, one at a relatively lower energy X-
Capture Display Image Processing
70 kVp Soft Tissue Image
120 kVp Bone Image
Figure 1: High and low energy images captured of a patient in rapid succession (on left) are transformed using image processing to create a soft tissue-only image and a corresponding bone-only image (on right) White Paper Numerous studies have been reported in the scientific bone-only images, which is usually indicative that the lesion is literature regarding the diagnostic benefits of dual energy benign. Other published scientific papers have reported that imaging, in particular for chest radiography. For example, the dual energy soft-tissue images provide overall increased detection sensitivity for abnormalities in the lung is improved sensitivity for the detection of infectious consolidations, because features that are often difficult to visualize in standard interstitial lung changes, and aortic or tracheal calcification. chest radiographs become more conspicuous when overlying Dual energy further allows for the assessment of bone rib structures are subtracted [2,3]. Dual energy imaging abnormalities that can simulate disease, such as a bone islands, additionally enables a degree of quantification for certain costochondral osteophytes, or healing rib fractures, each of material properties which can help to improve specificity. For which may mimic a solitary pulmonary nodule. example, calcified lung nodules appear more pronounced in
Figure 2: Two sets of image examples comparing between standard radiography (on left), and the soft tissue (in middle) and bone (on right) images from dual energy subtraction.
2 White Paper There are two important limitations with dual energy imaging systems that offer dual energy employ a fixed filtration that have historically limited its widespread adoption: approach. This means that the X-ray beam filtration remains 1) concerns about increased radiation dose because two constant for the exam, and that only the kilovoltage setting exposures are required and 2) artifacts resulting from patient- (kV) is changed between the high energy and low energy motion induced misregistration (due to heartbeat and exposures. The Carestream dual energy technology utilizes an breathing) between the capture of the high and low energy approach whereby different materials (filters) are placed in the image pair. Carestream’s dual energy implementation X-ray beam paths respectively for the high and low energy addresses both of these limitations. exposures to optimally (differentially) shape the X-ray spectrums [4]. The net result is that the Carestream dual Exposure Dose Efficiency energy method delivers excellent image quality at the equivalent patient exposure as a standard (single exposure) PA The key to achieve optimal dose efficiency is to maximize the or AP chest radiograph. Figure 3 illustrates the increased separation of the energy spectrums between the high and low separation achieved for the high and low energy spectrums for energy image captures. Dose efficiency is a measure of the the dual energy image pair when employing the differential image quality, which is defined here as signal difference to filtration approach versus the fixed filtration approach. Figure 3 noise ratio (SDNR), realized given the radiation dose that is also shows that the soft tissue image quality, measured in delivered, i.e., for a given dose to the patient, greater dose terms of the signal difference to noise ratio (SDNR), is efficiency translates to better the image quality. Currently, all approximately doubled for the same exposure to the patient. (except Carestream) commercially available digital radiography
Figure 3: Comparison of dual energy imaging with fixed and differential filtration in term of beam energy separation (top) and the signal difference to noise ratio for soft tissue (bottom left) and bone (bottom right) at the same patient exposure.
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Figure 4: Comparison of soft tissue images captured of anthropomorphic chest phantom. Images were captured at the same exposure level using a fixed filtration approach (on left) and a differential filtration method (on right).
Figure 4 shows a comparison of soft tissue images of an caused by heartbeat and involuntary respiration occurring anthropologic phantom captured at the same dose level using between the capture of high and low energy images may be the fixed filtration method (on left) versus using the differential introduced. To alleviate this concern, Carestream developed a filtration method (on right). By inspection, the appearance of motion compensation algorithm. This algorithm analyzes the noise is visually less for the image captured using the relative motion inside localized regions between the high and differential filtration approach, consistent with the quantitative low energy images, then corrects the motion in the high analysis illustrated in Figure 3. energy image by warp transform so the anatomical features in the high and low energy images are registered before the Patient Motion Compensation energy subtraction processing. Figure 5 shows a comparison of the soft tissue and bone images, with and without the motion The time interval between the successive captures of the high compensation applied. Clinical studies were conducted that and low energy image pair is rapid (about ¼ of a second). indicate the algorithm is effective in reducing patient Although the time interval is short, residual misregistration respiration-induced motion artifacts.
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Figure 5: Soft tissue and bone images without (on left) and with (on right) patient motion correction applied. Note the appearance of residual rib edges in the uncorrected soft tissue image, and the appearance of vascular (soft tissue) structures in the uncorrected bone-only image.
Summary 2. “Dual-energy subtraction chest radiography: what to look
for beyond calcified nodules,” Kuhlman JE1, Collins J, The Carestream dual energy subtraction method utilizes Brooks GN, Yandow DR, Broderick LS, Radiographics, differential filtration which enables high quality dual energy 2006, 26(1). images to be captured at the same patient exposure level as a standard PA or AP digital chest radiograph. Further, the 3. “Dual-energy chest radiography with a flat-panel digital Carestream patient motion compensation software has been detector: revealing calcified chest abnormalities,” demonstrated in clinical studies to be effective in reducing Fischbach F, Freund T, Röttgen R, Engert U, Felix R, Ricke J, patient respiration-induced motion artifacts. American Journal of Roentgenology, 2003, 181(6).
References 4. “Optimization of image acquisition techniques for dual-
1. “Development and characterization of a dual-energy energy imaging of the chest,” Shkumat NA, Siewerdsen subtraction imaging system for chest radiography based JH, Dhanantwari AC, Williams DB, Richard S, Paul NS, on CsI:Tl amorphous silicon flat-panel technology, “ John Yorkston J, Van Metter R, Med Phys. 2007, 34(10). M. Sabol; Gopal B. Avinash; Francois Nicolas; Bernhard E. H. Claus; Jianguo Zhao; James T. Dobbins III, Proceedings Medical Imaging 2001: Physics of Medical Imaging, vol 4320.
