energy subtraction

a radiographic technique in which two different x-

ray beams are used alternately to provide a subtraction image resultingfrom differences
in photoelectric interaction.

digital radiography using higher- and lower

energy exposures, either by double exposure at 2-
kV levels or byinterposing a copper filter that absorbs the lower-
energy photons between two phosphor plates, with computercalculation of high-
Z and low-
Z images (bone and soft tissues, respectively); makes use of the fact that lower-
energyx-rays are absorbed by more high-
Z substances, such as calcium and copper, because of the photoelectric effect.
See also: Z, photoelectric effect, phosphor plate.

Introduction
Knowing how a substance behaves at two different energies can provide information
about tissue composition beyond that obtainable with single-energy techniques (1–5).
Early work in the 1970s and 1980s demonstrated that dual-energy technology improved
tissue characterization; however, its utility was limited because of noise in the low-
kilovoltage images and the amount of time required for data acquisition, which led to
misregistration

Newer CT technologies that allow for more rapid data acquisition have sparked
renewed interest in dual-energy applications. Manufacturers continue to improve dual-
energy CT scanners, and those that are currently available differ in terms of the number
of x-ray tubes, the number and arrangement of detector arrays, the energy of fan
beams, and the rotation of x-ray tubes and detector arrays. Relatively recent advances
in CT technology allow for rapid and essentially simultaneous acquisition of datasets at
two different energies, depending on the manufacturer. In addition, current dual-source
CT scanners offer improved temporal resolution, which is helpful for cardiac CT
angiography, and increased photon flux, which may be helpful when imaging large or
obese patients (8–12). The ability of current dual-energy CT systems to simultaneously
(or near-simultaneously) acquire images at two different energies is the focus of this
article, which discusses how dual-energy CT works, the kinds of information it provides,
and scenarios in which it may be helpful for abdominopelvic imaging, particularly in the
liver, kidneys, adrenal glands, and pancreas.
Unknown substance 1 does not attenuate the x-ray beam at either energy and therefore
contains neither element A nor element B. Unknown substance 2 has higher attenuation
at 200 kVp than at 100 kVp; therefore, it must contain a relatively large amount of
element B, because 200 kVp is close to 190 keV, the K edge of element B. Similarly,
unknown substance 3 has higher attenuation at 100 kVp; therefore, it must contain a
relatively large amount of element A, because 100 kVp is close to 90 keV, the K edge of
element A. Unknown substance 4 has similar attenuation at both energy levels, so it
must contain similar amounts of element A and element B. The study by Rutherford et
al (3) is a good source of equations used to compute effective atomic number and
electron density with dual-energy techniques.
Translating the schematic in Figure 1 to human tissues introduces many confounding
variables. Unlike the previous scenario, which only has two elements, the human body
is made up of many different elements—primarily carbon, oxygen, hydrogen, nitrogen,
phosphorous, and calcium—which are arranged in many different combinations.
Hydrogen, carbon, nitrogen, and oxygen have similar K edges, ranging from 0.01 to
0.53 keV. These values are well below the energies currently used in most dual-energy
CT applications (most use 80 kVp and 140 kVp), and thus these elements are not well
appreciated at dual-energy imaging.
the K edges of calcium (4.0 keV) and iodine (33.2 keV) are higher than those of soft
tissues, and although they are lower than those of most inorganic elements, they are
sufficiently different from those of soft tissues that they may be distinguished from soft
tissues at dual-energy imaging.

What Can Dual-Energy CT Tell Us?

Knowing how a substance behaves at two different energies can provide information
about tissue composition beyond that obtainable with single-energy techniques (1–5).
Early work in the 1970s and 1980s demonstrated that dual-energy technology improved
tissue characterization; however, its utility was limited because of noise in the low-
kilovoltage images and the amount of time required for data acquisition, which led to
misregistration (3–7).

Newer CT technologies that allow for more rapid data acquisition have sparked
renewed interest in dual-energy applications. Manufacturers continue to improve dual-
energy CT scanners, and those that are currently available differ in terms of the number
of x-ray tubes, the number and arrangement of detector arrays, the energy of fan
beams, and the rotation of x-ray tubes and detector arrays. Relatively recent advances
in CT technology allow for rapid and essentially simultaneous acquisition of datasets at
two different energies, depending on the manufacturer. In addition, current dual-source
CT scanners offer improved temporal resolution, which is helpful for cardiac CT
angiography, and increased photon flux, which may be helpful when imaging large or
obese patients (8–12). The ability of current dual-energy CT systems to simultaneously
(or near-simultaneously) acquire images at two different energies is the focus of this
article, which discusses how dual-energy CT works, the kinds of information it provides,
and scenarios in which it may be helpful for abdominopelvic imaging, particularly in the
liver, kidneys, adrenal glands, and pancreas.

How Does Dual-Energy CT Work?

The photoelectric effect and Compton scatter are the primary ways in which x-ray
photons interact with matter at the energy levels used in diagnostic imaging. The term
photoelectric effect refers to the ejection of an electron from the K shell (the innermost
shell) of an atom by an incident photon. An electron from an adjacent shell fills the void,
and energy is released in the form of a photoelectron (13). The photoelectric effect
occurs when an incident photon has sufficient energy to overcome the K-shell binding
energy of an electron (13). Organic substances with a low atomic number are affected
by Compton scatter, whereas those with a higher atomic number are affected by the
photoelectric effect.
The photoelectric effect is energy dependent, and its likelihood increases as the energy
of the incident photon approximates the K-shell binding energy of an electron (13). The
K-shell binding energy varies for each element, and it increases as the atomic number
increases. The term K edge refers to the spike in attenuation that occurs at energy
levels just greater than that of the K-shell binding because of the increased
photoelectric absorption at these energy levels. K-edge values vary for each element,
and they increase as the atomic number increases (Table).
he energy dependence of the photoelectric effect and the variability of K edges form the
basis of dual-energy techniques.

To understand the principles underlying dual-energy techniques, imagine hypothetical

elements A and B, with K edges of 90 keV and 190 keV, respectively (Fig 1). Next,
imagine four unknown substances, each of which contains unknown quantities of
hypothetical elements A and B. To determine the relative amounts of
elements A and B in each unknown substance, the substances are imaged at two
different energies: 100 kVp and 200 kVp. The results are illustrated in Figure 1. A
simplified schematic is assumed, in which there is minimal spread of energies around
the stated kilovolt peak.
Dual-energy CT techniques may be used to distinguish substances such as iodine,
calcium, and uric acid crystals from soft tissues. The closer the energy level is to the K
edge of a substance such as iodine, the more the substance attenuates.

With current dual-energy CT technology, the two energies most frequently employed
are 80 kVp and 140 kVp.
Because the K edge of iodine (33.2 keV) is closer to 80 kVp than it is to 140 kVp, the
attenuation of iodine-containing substances is substantially higher at 80 kVp. There is a
bell curve of energies for a set of photons at a certain kilovolt peak. Therefore, at 80
kVp, some photons have an energy that is close to 33.2 keV, the K edge of iodine. For
example, the main portal vein, aorta, and kidneys have higher attenuation at 80 kVp
than at 140 kVp, and in this case, the attenuation values of these structures are
approximately 95%, 93%, and 101% greater at 80 kVp than at 140 kVp, respectively
(Fig 2).
Increased attenuation of iodine-containing structures on lower-energy images. (a) Axial
contrast-enhanced portal venous phase CT image obtained at 80 kVp with a 26-cm field
of view shows that iodine-containing structures, such as the main portal vein and
kidneys, have high attenuation at 80 kVp, which is close to 33.2 keV, the K edge of
iodine. (b) Axial contrast-enhanced portal venous phase CT image obtained at 140 kVp
shows that iodine-containing structures have lower attenuation as the beam energy
moves farther away from the K edge of iodine.
TEMPORAL SUBTRACTION TECHNIQUE

temporal subtraction. the subtraction of two or more digitized x-ray images that were
acquired at different times. The subtraction process eliminates information in the
image that was static.

the method, which consists of subtracting dynamic digital fluoroscopic images of the
breathing chest in the time interval difference (TID) mode, applies to the study of the
lucency variations during the respiratory cycle and provides dynamic functional
information about ventilation and/or perfusion and diaphragmatic

Radiologist are commonly required to compare a sequence of two or more

chest radiographs of a given patient obtained over a period of time, which may
range from a few hours to many years. In such cases, the task is one of
detecting interval change. In the case of patients who have had a previous
chest radiograph, an opportunity exists to enhance selectively areas of
interval change, including regions with new or altered pathology, by using the
previous radiographs as a subtraction mask. With temporal subtraction, the
previous image is superimposed and registered with the current image, using
automated two-dimensional warping to compensate for any differences in
positioning. A “difference image” is then created, by subtracting the previous
from the current radiograph. In this temporal subtraction image, areas that are
unchanged appear as uniform gray, while regions of new opacity, such as due
to pneumonia or cancer, appear as prominent dark foci on a lighter
background. By cancelling out the complex anatomical background, temporal
subtraction can provide dramatically enhanced visibility of new areas of
disease.

The temporal subtraction (TS) technique is one of the CAD techniques in which a
previous image is subtracted from a current image so that interval changes are
enhanced (5). TS on plain radiographs has been commercially available, and several
previous studies have shown that TS can improve the diagnostic accuracy of lung
nodules on plain radiographs (6–9). However, to our knowledge, computed tomographic
(CT) TS has not been commercially available, and the effectiveness of TS at thoracic
CT with a soft-copy display has never been assessed.

With the TS method, it is important to use an image-warping technique to accurately

deform the previous image to match the current image. Although many image-warping
techniques for two-dimensional images have been developed with the TS technique
(10,11), it is necessary to use a more complex three-dimensional registration technique
with multidetector CT volume images. We have been developing a new TS method by
using a voxel-matching technique with generalized gradient vector flow algorithms. Our
purpose in this observer study was to assess the effects of a new CT TS method on
radiologist performance in lung nodule detection on thin-section CT images.

hybrid subtraction. a method for producing digitized radiographic images that requires
at least four images. It uses both energy and temporal subtraction steps to mitigate
patient motion artifacts.

Hybrid digital subtraction angiography was performed after modification of a

DSA system. Alternate high voltage (110–120 kV) and low voltage (65–70 kV)
were obtained within short time intervals of 60–70 ms with a high voltage
switching generator. Experimental phantom studies revealed the exposure
dose per single image of hybrid subtraction was approximately 30% of that of
conventional DSA. The SNR (Signal to Noise Ratio)of hybrid subtraction was
improved by increasing the exposure dose and application of post processing
programs. Clinical application of intra-arterial and intravenous DSA revealed
that soft tissue artifacts were removed surprisingly well, but image quality
decreased because of lowered SNR. Frame integration and matched filtering
improved image quality of hybrid subtraction.

Dual energy subtraction (DES) radiography is a powerful but underutilized technique

which aims to improve the diagnostic value of an X-ray by separating soft tissue from
bones, producing two different images.

Dual-energy CT is becoming increasing more common in clinical practice due to the rapid rise in computer
technology and expanding literature exhibiting vast advantages over conventional single energy CT.

Virtual non-contrast
There is a potential to eliminate the need for pre-contrast imaging, using complex subtraction algorithms based
on the two datasets known as virtual unenhanced imaging 1.

The acquired images are automatically reconstructed to three separate image sets: 80 kVp, 140 kVp and mixed
80:140 kVp image with the weighting factor of 0.4 (40% image information from the 80 kVp image and 60%
information from the 140 kVp image). The weighting factors can be adjusted, to achieve the desirable effect.
The 80 kvP images have higher contrast attenuation but intrinsically lower signal to noise ratio and smaller field
of view. The 140 kVp images have less contrast attenuation better signal to noise ratio and full field of view.

Material decomposition can be further performed on a dedicated workstation to create different image setting
including iodine map (virtual contrast image), iodine subtraction (virtual non-contrast image) and bone mask
(bone and calcium subtraction). A further perfusion blood volume colour coded images can be created by using
a grey or colour scale. This perfusion blood volume images reflect the lung perfusion at a single time point.
Thus they are only a surrogate perfusion images.
Vascular
High kVp CT scans have a lower contrast than that of lower kVp due to the K-edge of iodine, giving the lower
energy of the dual energy scan an advantage over conventional CT. In fact, the attenuation values of large
vessels enhanced with iodine are 70% higher at 80 kVp than at 140 kVp 7.

It isn't unreasonable to assume that you can use single energy scanners at a lower kVp in arterial studies, yet
isolated lower kVp scans have a greater noise, while dual-energy CT can be fused with the higher energy
scans to compensate.

As mentioned above it is possible to create virtual non-contrast images to delineate dense hematoma from
active extravasation of contrast 13.

Bone subtraction techniques in dual-energy CT utilise the same dual attenuation method to remove bony
structures more accurately at a set threshold, rather than manual selection in post processing, this has
exceptional advantages when asses vessels that lay close to skeletal structures 7.

Dual energy aortogram in surveillance of endovascular aneurysm repair improves detection of endoleaks in
fewer acquisitions as seen in the case study 7; low kVp scanning can detect subtle leaks, while the virtual non-
contrast images replace the unenhanced scan holding a notable radiation saving in patients that require life-
long check ups 14,15.

Suboptimal contrast injection

In the event of suboptimal contrast injection and or timing, the lower energy set (closer to the K-edge of iodine)
can be favoured to improve the contrast resolution in various studies from pulmonary angiograms to
aortagrams 8.

Contrast sparing
Using lower energy data sets are proven to increase the arterial enhancement of pulmonary angiograms and
other contrast studies due to the K-edge of iodine being closer to the lower energy tube of a dual energy
scanner 9-11.

Pulmonary angiography
The 80 kVp image has the potential to improve subsegmental pulmonary artery perfusion and distal pulmonary
embolus detection 8.

Perfusion blood volume map can be used to identified the segmental or subsegmental areas of lung affected by
a pulmonary embolus. Review of lung window is paramount as other lung pathology - atelectasis, cardiac
motion or streak artefact can all cause perfusion defects 9.

Renal stone composition

Renal calculi are composed of different substances such: uric acid, calcium phosphate, calcium oxalate,
cystine, and brushite. Each of which changes the clinical management of the patient. Dual-Energy CT uses
advanced post processing techniques to determine the composition of the calculi accurately, allowing for
precise treatment pathways, based on a non-invasive diagnostic test 16.

For example, if a stone is predominantly made up of uric acid, patients can undergo standard urinary
alkalinization rather than have an interventional procedure 17.

Used to obtain the composition of urinary tract stones preoperatively accurately, to see if stones are comprised
of uric acid, calcium or cystine 4,5.
Bone bruising
The bone mineral can be retrospectively subtracted revealing areas of increased fluid attenuation, providing a
notable step forward in the detection of occult fractures 1-5.

PERCUTANEOUS ANGIOGRAPHY

Angioplasty, also known as

balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally
invasive, endovascular procedure to widen narrowed or obstructed arteries or veins,
typically to treat arterial atherosclerosis.

Percutaneous Coronary Intervention (PCI, formerly known as angioplasty with stent) is

a non-surgical procedure that uses a catheter (a thin flexible tube) to place a small
structure called a stent to open up blood vessels in the heart that have been narrowed
by plaque buildup, a condition known as atherosclerosis.

INTRA CRANIAL ANGIOGRAPHY

Cerebral angiography uses a catheter, x-ray imaging guidance and an injection of

contrast material to examine blood vessels in the brain for abnormalities such as
aneurysms and disease such as atherosclerosis (plaque). The use of a catheter makes
it possible to combine diagnosis and treatment in a single procedure.
A pulmonary angiogram is an angiogram of the blood vessels of the lungs. The
procedure is done with a special contrast dye injected into the body's blood vessels.
This is done in the groin or arm. The dye shows up on X-rays. Fluoroscopy is often used
during this test.

Treatment for:
Pulmonary AVMs (arteriovenous malformations)
Why it’s done:
Pulmonary AVMs act as direct conduits between the pulmonary artery and the
pulmonary vein, which reduces blood oxygen levels, and also allows clots and bacteria
to bypass the normal filtration process of the lung capillaries. Pulmonary AVMs can also
rupture, causing serious bleeding. Embolization of pulmonary AVMs greatly reduce
these risks.

How it’s done:

An interventional radiologist uses X-rays to guide a small catheter from the femoral vein
at the groin and into the pulmonary arteries. Contrast injection is performed to locate the
pulmonary AVMs. Each AVM is then accessed using a catheter or microcatheter, and
blocked with small fibered coils or plugs.
Level of anesthesia:
Conscious sedation.
Risks:
Small risks of bleeding, infection, stroke, and coil dislodgment. Contrast dye and X-rays
are used.

Post-procedure:

Four hours of lying flat in recovery; then discharge home the same day. Some pain with
coughing or deep breathing is normal and should resolve in several days.

Follow-up:

A follow-up CT is usually performed 1-3 months after embolization to confirm complete

blockage of the pulmonary AVMs. CT is then repeated approximately every 5 years to
check for re-opening of the AVMs or growth of new AVMs.
Thoracic Angiogram (AAA assessment) This is an arterial study to look at the major
blood vessels that arise from the aorta to look for any abnormalities, i.e. aneurysms.
Local anaesthetic is injected into the skin to numb the area.

Computed tomography angiography (also called CT angiography or CTA) is a

computed tomography technique used to visualize arterial and venous vessels
throughout the body. This ranges from arteries serving the brain to those bringing blood
to the lungs, kidneys, arms and legs.

An abdominal angiogram looks at the blood vessels in your belly (abdomen). It may
be used to check blood flow to the organs of the abdomen, such as the liver and
spleen. It may also be used to guide in the placement of medicine or other materials to
treat cancer or bleeding in the abdomen.
Angiogram of the limb

A peripheral angiogram is a test that uses X-rays and dye to help your doctor find
narrowed or blocked areas in one or more of the arteries that supply blood to your legs.
The test is also called a peripheral arteriogram.
Lower limb 3D contrast-enhanced magnetic resonance angiography (CE-MRA). Early (a) and late
dynamic (b), and steady state (c). A 61-year-old man had a painful varicosity along the lateral aspect
of his left thigh. Following duplex studies, CE-MRA was undertaken to assess suitability for
percutaneous sclerotherapy. mean intensity projections (MIPs) showed filling of an arteriovenous
fistula in the lateral thigh (arrowhead), communicating with multiple superficial varicosities on
delayed images. First pass imaging shows high flow and early venous filling (a, arrowhead). Late
dynamic and delayed high resolution MIPs show communications with the superficial varicosities
(b,c).