Utilization Patterns of Multidetector Computed Tomography in Elective and Emergency Conditions: Indications, Exposure Risk, and Diagnostic Gain
Utilization Patterns of Multidetector Computed Tomography in Elective and Emergency Conditions: Indications, Exposure Risk, and Diagnostic Gain
Utilization Patterns of Multidetector Computed Tomography in Elective and Emergency Conditions: Indications, Exposure Risk, and Diagnostic Gain
vations. With the new MDCT technology and the introduc- on a case-by-case basis,5 considering also the use of low dose
tion of hybrid systems, the volume of diagnostic procedures and to account the real short-term benefit for the patient.
involving the use of ionizing radiation continue to increase, Recently, virtual colonoscopy and cardiac CT angiography is
including in the pediatric population as well as screening being used as diagnostic or screening tool by physicians and
procedures in asymptomatic adults.5 In an article discussing patients. Due to the increased number of these examinations,
Alliance for Radiation Safety in Pediatric Imaging Vendor the use of low dose and further improvement in new tech-
Summit, stakeholders were invited to discuss the develop- nology CT scanners to reduce radiation dose should be aimed
ment of better estimates of pediatric patient radiation dose.6 for without loss in diagnostic effectiveness.9,10
In fact, medical physicists currently use 2 standardized phan- Frequent exposure to possibly carcinogenic levels of ionizing
toms to estimate CT patient radiation dose;6 however, the radiation from helical CT scanning is considered a potentially
adult model may underestimate displayed pediatric CT radi- large public health issue for the medical community.11 Many
ation dose on the console of current CT machines.6 These studies have shown that organ doses associated with routine
stakeholders agreed to partner to improve CT radiation dose diagnostic CT scans are similar to the low-dose range of ra-
estimates for children.6 The induced potential iatrogenic ma- diation received by atomic-bomb survivors.12 The food and
lignancy from diagnostic radiation is considered a crucial drug administration estimates that a CT examination with an
concern: according to major national and international orga- effective dose of 10 mSv may be associated with an increased
nizations responsible for evaluating radiation risks, it seems chance of developing fatal cancer for approximately 1 patient
that there is no low-radiation threshold for inducing cancer5 in 2000,12 whereas the biological effects of ionizing radiation
and, consequently, no amount of radiation should be consid- VII lifetime risk model predicts that with the same low-dose
ered “safe.”5 To reduce the overall radiation dose from CT radiation, approximately 1 in 1000 individuals will develop
procedures in the population, it is important to adjust scan- cancer.12 The general attention to problems related to radia-
ner parameters separately for each individual, to keep radia- tions is high;13,14 in April 2007, the American College of
tion dose as low as possible.5 Radiology released the “White Paper on Radiation Dose in
In a study aimed to assess patient dose and occupational Medicine”15 in which the panel concluded that the expanding
dose in established and new applications of MDCT fluoros- use of imaging modalities using ionizing radiations such as
copy, the study revealed high effective patient doses mainly CT and nuclear medicine may result in an increased inci-
for relatively new applications such as CT fluoroscopy- dence of radiation-related cancer in the exposed population.
guided radiofrequency ablations using MDCT, vertebro- As potential solution to this problem, a prevention of the
plasty, and percutaneous ethanol injections of tumors.7 Be- inappropriate use of such imaging modalities and a studies
yond complex procedures and expected benefits of the optimization was proposed to obtain the best image quality
treatments, what should be considered seems to be the gen- with the lowest radiation dose.14 Additional practical sugges-
eral health state of the patient to justify any observed high tions to minimize radiation risk were also to include educa-
effective patient doses.7 tion for all stakeholders in the principles of radiation safety
Indications for a CT examination, particularly in young and preferential use of alternative (nonionizing) imaging
and/or asymptomatic patients should be carefully consid- techniques (magnetic resonance imaging and ultrasound).15
ered.5 A critical point to consider is that the appropriateness The use of alternative diagnostic modalities to MDCT
of a diagnostic imaging tool must be kept in radiologist’s could be potentially easier to adopt in elective scenarios,
hand. The referring clinician may have to be educated by the whereas in an emergency setting, the need for precise infor-
radiologist as to the most appropriate modality for the clinical mation related to imaging findings in as short a time as pos-
question. Comprehension and knowledge of the need for sible makes alternative imaging methods less desirable, par-
imaging the patient should be a team approach. When refer- ticularly in the critical patient. In traumatized patients,
ring clinicians or surgeons seek a radiologist’s opinion, the conventional radiography and ultrasound examinations can
radiologist must be well informed to provide precise answers, represent the basic diagnostic tools;16 however, MDCT with
particularly in the context of justification of a modality that its shorter scan time and increased accuracy has become the
delivers low-dose ionizing radiation. With this aim, for ex- gold standard for many indications in trauma imaging.16 Be-
ample, a US national campaign in radiology designed to pro- cause of the higher radiation dose, the use of MDCT should
mote the need and the opportunities to decrease radiation to be carefully assessed in younger patient population,16-18 and
children when CT examination is indicated, demonstrated optimization of imaging parameters has to be performed to
that simple and direct safety messages on radiation protec- minimize exposure and maximize diagnostic safety.16 Be-
tion targeted to medical professionals throughout the radiol- yond these undoubted concerns and required attentions,
ogy community, using multiple media, seem to be able to trauma care benefits from the use of imaging technologies.19
affect awareness potentially leading to change in practice.8 However, questions and problems related to the use of the
As attested in a 2008 publication,5 the risk of radiation- MDCT examination in trauma still exist: CT scans should not
induced cancer is much smaller than the risk of cancer from replace careful clinical examination and should be used only
natural sources; however, it can become a public health con- in appropriate patients;19 by contrast, potential risk from
cern if large numbers of the population undergo increased missed important and often unsuspected findings that could
numbers of CT screening procedures that may even be of be evident at CT examination must be an additional consid-
uncertain benefit.5 In this order, CT use needs to be evaluated eration to be kept in mind.
Utilization patterns of MDCT 55
A recent study estimated cumulative radiation exposure patients who were considered underwent whole-body CT
and lifetime attributable risk (LAR) of radiation-induced can- scan and the relative reduction in mortality based on trauma
cer from CT scanning of adult patients at a tertiary care aca- and injury severity score was 25%, whereas that based on
demic medical center.20 The study comprised 31,462 pa- revised injury severity classification was 13%.21 This result
tients who underwent diagnostic CT in 2007 and had seems to attest that whole-body CT examination in poly-
undergone 190,712 CT examinations over the previous 22 trauma patient can reduce the probability of death.21 Al-
years.20 Thirty-three percent of patients underwent 5 or more though the greater radiation exposure of a whole-body CT
lifetime CT examinations, and 5% underwent between 22 examination and the potential dangerous effects, the better
and 132 examinations.20 Fifteen percent received estimated diagnostic accuracy has to be considered: the early recogni-
cumulative effective doses of more than 100 mSv, and 4% tion of findings implies a prompt therapeutic plan.21
received between 250 and 1375 mSv.20 CT exposures were The usefulness of a prompt diagnosis and the risk from
estimated to produce 0.7% of total expected baseline cancer
radiation due to CT examination have to be evaluated case-
incidence and 1% of total cancer mortality.20 Seven percent
by-case, particularly but not exclusively, in emergency,
of the patient population had estimated LAR greater than 1%,
where the time has a very high cost in terms of life-saving for
of which 40% had either no malignancy history or a cancer
patients care and treatment.
history without evidence of residual disease.20 Cumulative
CT radiation exposure added incrementally to baseline can-
cer risk in the cohort:21 most patients accrue low radiation-
induced cancer risks, but a subgroup seems to be potentially References
1. Brenner DJ, Hall EJ: Computed tomography—an increasing source of
at higher risk due to recurrent CT imaging.20
radiation exposure. N Engl J Med 357:2277-2284, 2007
The widespread use of MDCT in emergency seems to be 2. McNitt-Gray MF: AAPM/RSNA Physics tutorial for residents—topics in
gaining interest all round the world. Another recent study CT: radiation dose in CT. Radiographics 22:1541-1553, 2002
evaluated the justification and radiation risk of patients who 3. Dalrymple NC, Prasad SR, El-Merhi FM, et al: Price of isotropy in
undergo multiple CT scans during their hospital stay for multidetector CT. Radiographics 27:49-62, 2007
emergency condition,22 where Griffey and Sodickson23 4. Payne JT: CT radiation dose and image quality. Radiol Clin North Am
(2009) defined a conservative estimate of the number of pa- 43:953-962, 2005
5. Iakovou I, Karavida N, Kotzassarlidou M: The computerized tomogra-
tients undergoing repeat or multiple emergency department
phy scans and their dosimetric safety. Hell J Nucl Med 11:82-85, 2008
CT studies, quantifying their cumulative CT radiation doses 6. Strauss KJ, Goske MJ, Frush DP, et al: Image Gently Vendor Summit:
and LAR of developing cancer. In this study, all patients at a Working together for better estimates of pediatric radiation dose from
tertiary care adult academic medical center with at least 3 CT. AJR Am J Roentgenol 192:1169-1175, 2009
emergency department visits within a 1-year period that in- 7. Joemai RM, Zweers D, Obermann WR, et al: Assessment of patient and
cluded CT of the neck, chest, abdomen, or pelvis were con- occupational dose in established and new applications of MDCT fluo-
sidered,23 identifying all diagnostic CT studies over the pre- roscopy. AJR Am J Roentgenol 192:881-886, 2009
8. Goske MJ, Applegate KE, Boylan J, et al: Image Gently(SM): A national
vious 7.7 years.23 The authors calculated cumulative
education and communication campaign in radiology using the science
radiation doses by summing typical effective doses of the of social marketing. J Am Coll Radiol 5:1200-1205, 2008
anatomic regions scanned, and LAR using the population- 9. Wang J, Wang S, Li L, et al: Virtual colonoscopy screening with ultra
averaged dose-to-risk conversion factor of 1 cancer per 1000 low-dose CT and less-stressful bowel preparation: A computer simula-
patients receiving a 10 mSv dose, in accordance with the tion study. IEEE Trans Nucl Sci 55:2566-2575, 2008
seventh biological effects of ionizing radiation VII report.23 10. Chinnaiyan KM, McCullough PA: Optimizing outcomes in coronary
Repeat imaging of the same study type represented at least CT imaging. Rev Cardiovasc Med 9:215-224, 2008
11. Birnbaum S: Radiation safety in the era of helical CT: A patient-based
half of the imaging for 72% of the patient population and all
protection program currently in place in two community hospitals in
the imaging for 12%.23 A small proportion (1.9%) of emer- New Hampshire. J Am Coll Radiol 5:714-718, 2008
gency department patients undergoing CT of the neck, chest, 12. Semelka RC, Armao DM, Elias J Jr, et al: Imaging strategies to reduce the
abdomen, or pelvis have high cumulative rates of multiple or risk of radiation in CT studies, including selective substitution with
repeat imaging24; this patient subgroup was considered to MRI. J Magn Reson Imaging 25:900-909, 2007
have a heightened risk of developing cancer from cumulative 13. Chen MM, Coakley FV, Kaimal A, et al: Guidelines for computed to-
mography and magnetic resonance imaging use during pregnancy and
CT radiation exposure.23 In an Emergency situation the
lactation. Obstet Gynecol 112:333-340, 2008
health benefit of CT-related diagnostic information is imme- 14. Ament L: Patient safety. In the wake of safety concerns, hospitals revise
diate24 and not rarely life-saving, whereas the risk of induced CT scan protocols. Hosp Health Netw 82:14, 2008
cancer is decades away,24 with conservative estimates of the 15. Picano E, Vano E, Semelka R, et al: The American College of Radiology
benefit-to-risk ratio for CT equal to 100:1 and higher.24 As white paper on radiation dose in medicine: Deep impact on the practice
assessed by Boone24 (2006) that CT examination should not of cardiovascular imaging. Cardiovasc Ultrasound 5:37, 2007
be performed for inappropriate indications. 16. Körner M, Reiser M, Linsenmaier U: Imaging of trauma with multi-
detector computed tomography. Radiologe 49:510-515, 2009
In a recently published article by Huber-Wagner et al21 in
17. Broder JS: CT utilization: The emergency department perspective. Pe-
2009, a retrospective multicenter study was made to com- diatr Radiol 38:S664-S669, 2008 (suppl 4)
pare the probability of survival in patients with blunt trauma 18. Markel TA, Kumar R, Koontz NA, et al: The utility of computed tomog-
who did or did not undergo a whole-body CT examination raphy as a screening tool for the evaluation of pediatric blunt chest
during resuscitation. The authors found that 32% of 4621 trauma. J Trauma 67:23-28, 2009
56 S. Romano and L. Romano
19. Hui CM, MacGregor JH, Tien HC, et al: Radiation dose from initial 22. Thomson KR, Street M, Van Every B, et al: Radiation exposure and the
trauma assessment and resuscitation: Review of the literature. Can justification of CT scanning in an Australian hospital Emergency De-
J Surg 52:147-152, 2009 partment. Intern Med J (in press)
20. Sodickson A, Baeyens PF, Andriole KP, et al: Recurrent CT, cumulative 23. Griffey RT, Sodickson A: Cumulative radiation exposure and cancer
radiation exposure, and associated radiation-induced cancer risks from risk estimates in emergency department patients undergoing repeat or
CT of adults. Radiology 251:175-184, 2009 multiple CT. AJR Am J Roentgenol 192:887-892, 2009
21. Huber-Wagner S, Lefering R, Qvick LM, et al: Effect of whole-body CT 24. Boone JM: Multidetector CT: Opportunities, challenges, and concerns
during trauma resuscitation on survival: A retrospective, multicenter associated with scanners with 64 or more detector rows. Radiology
study. Lancet 373:1455-1461, 2009 241:334-337, 2006