LITERATUR REVIEW: PENCITRAAN GRADIEN ECHO

Studi Literatur Review

Diajukan oleh:
ANGEL LINGKAN MARTOYO
NIM: 021801003

PROGRAM STUDI SARJANA TERAPAN

TEKNOLOGI RADIOLOGI PENCITRAAN
AKADEMI TEKNIK RADIODIAGNOSTIK DAN RADIOTERAPI BALI
(ATRO BALI)
2021
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BAB I

PENDAHULUAN

1.1 Latar Belakang

Magnetic Resonance Imaging ( MRI) berbasi gradien echo

digunakan dalam berbagai teknik pencitraan dan aplikasi klinis. Gradien

echo banyak digunakan dalam praktek klinis terutama MRI jantung , dan

MRA. Namun istilah “ gradients echo Squence” tidak spesifik karena

gambaran yang diperoleh dengan squence grandien echo untuk akuisisi

data dapat berbeda, misalnya signal, kontras,artefak,dan sensitif terhadap

aliran. Hal ini disebabkan oleh penggunaan waktu dan squence dasar

seperti gradien echo spoiler atau radiofrekuensi tertentu.

Prinsip dan konsep pencitraan gema gradien (juga disebut

''gradient recalled echo'' [GRE]) merupakan dasar dari

banyak aplikasi pada sistem pencitraan resonansi magnetik

(MRI) modern. Secara teknis, perbedaan antara spin echo

dan gradien echo dan pencitraan gradient echo berkaitan

dengan elemen urutan pulsa yang digunakan untuk

menghasilkan sinyal MR. Sementra spin echo menggunakan

dua pulsa radiofrekuensi (90° dan 180°) sedangkan gradien

echo menggunaka singgle radiofrekuensi biasanya <90°.

Berdasarkan latar belakang tersebut, penulis tertarik untuk meninjau

kembali Literatur dengan judul “GRADIENS ECHO IMAGING”

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1.2 Rumusan Masalah

Bagaimana prinsip dan konsep dasar terbentuknya gradien echo ?

1.3 Tujuan Penelitian

1.4 Untuk memberikan gambaran umum mengenai sifat dasar pencitraan GRE dan
menjelaskan pengauh pemilihan parameter pencintraan pada signal, kontras, dan
tipical artefak.

pertimbangan dan masukan terutama bagi pihak-pihak yang terkait

khususnya tentang pengaruh penggunaan Automatic Tube Current

Modulation terhadap kualitas citra dan dosis radiasi pada modalitas

CT-Scan.

1.5 Sistematika Penulisan

Untuk memudahkan dalam penulisan Studi Literatur ini, maka penulis

menyusun sistematika penulisan yang terdiri dari:

BAB I: PENDAHULUAN

Bab ini berisi tentang latar berlakang penelitian, rumusan masalah,

tujuan penelitian, manfaat penelitian, dan sistematika penulisan.

BAB II: TINJAUAN PUSTAKA

Bab ini berisi hasil tinjauan kepustakaan yang dilakukan penulis

berdasarkan pada penelitian yang dilaksanakan. Isi bab ini yaitu

tinjauan teori.

BAB III: METODOLOGI PENELITIAN

Bab ini berisi tentang jenis penelitian, waktu penelitian, metode

pengambilan data, dan alur penelitian yang akan dilakukan oleh

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penulis.

BAB IV HASIL DAN PEMBAHASAN

BAB V PENUTUP

DAFTAR PUSTAKA
 BAB III

METODOLOGI PENELITIAN

3.1. Rancangan Penelitian

3.1.1 Jenis Penelitian

Penelitian ini menggunakan jenis penelitian deskriptif dengan

pendekatan Studi Literatur dengan cara mengumpulkan dan

menganalisis data yang bertujuan untuk mengetahui Pengaruh

Penggunaan Automatic Tube Current Modulation pada Modalitas

CT-Scan.

1.3.2 Waktu Penelitian

Penelitian ini dilakukan pada Bulan Januari – Februari 2021.

3.2. Metode Pengambilan Data

Metode pengambilan data yang digunakan dalam penulisan ini adalah

study literatur review dengan mengkaji jurnal yang berhubungan dengan

Pengaruh Penggunaan Automatic Tube Current Modulation terhadap

kualitas citra dan dosis radiasi pada modalitas CT-Scan. Penelitian studi

literatur ini dilakukan dengan mengumpulkan data yang bersumber dari

basis data seperti Google Scholar, PubMed, dan JimeD (Jurnal Imaging

Diagnostik). Pencarian untuk jurnal-jurnal yang diterbitkan tahun 2010-

2020 menggunakan kata kunci CT-Scan yang membahas Automatic Tube

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Current Modulation. Kata kunci yang digunakan adalah “CT-Scan” dan

“ATCM”.

Sumber utama penelitian ini adalah 3 jurnal yang ditulis oleh (1) Yurt,

Özsoykal dan Obuz yang berjudul “Effect of the Use of Automatic Tube

Current Modulation on Patient Dose and Image Quality in Computed

Tomography” , (2) Su et al yang berjudul “Automatic Tube Current

Modulation versus Fixed Tube Current in Multi-detector Row Computed

Tomography of Liver: Comparison of Image Quality and Radiation Dose”,

(3) Martin dan Sookpeng yang berjudul “Setting up computed tomography

automatic tube current modulation system”. Jurnal-Jurnal Tersebut Dipilih

oleh penulis berdasarkan beberapa pertimbangan. Pertama, relevansi jurnal

dengan rumusan masalah pada penelitian ini. Selain sumber utama, sumber

pendukung juga digunakan dalam penelitian ini. Sumber-sumber

pendukung tersebut di antaranya e-book dan jurnal yang membahas

tentang Pengaruh Penggunaan Automatic Tube Current Modulation

terhadap kualitas citra dan dosis radiasi pada modalitas CT-Scan dan buku

lain yang mempunyai relevansi dengan penelitian ini.

Langkah-langkah yang dilakukan oleh peneliti dalam mendapatkan

jurnal dengan cara sebagai berikut:

1. Jurnal awal yang didapatkan ada 9 jurnal melaluli Pubmed, Research

Gate, dan JimeD (Jurnal Imaging Diagnostic). Melakukan screening

jurnal sesuai materi yang dibutuhkan.

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2. Hasil screening tersebut kemudian di reduksi menjadi 3 jurnal yang

digunakan.

3. Enam jurnal lainnya di eksklusi.

Kriteria jurnal yang penulis ambil yaitu:

1. Kriteria Inklusi

a. Jurnal yang dapat mendukung dan sangat berkaitan dengan

penelitian penulis.

b. Jurnal dalam bentuk full text.

c. Jurnal yang digunakan membahas penggunaan tentang Pengaruh

Penggunaan Automatic Tube Current Modulation terhadap kualitas

citra dan dosis radiasi pada modalitas CT-Scan dengan Jurnal yang

digunakan original research.

2. Kriteria eksklusi

a. Jurnal yang tidak berkaitan dengan penelitian penulis.

b. Jurnal tidak dalam bentuk full text.

c. Jurnal yang tidak membahas Pengaruh Penggunaan Automatic Tube

Current Modulation terhadap kualitas citra dan dosis radiasi pada

modalitas CT-Scan.

d. Jurnal yang tidak original research.

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3.3. Alur Penelitian

Dalam penelitian Study Literatur Review ini, penulis melakukan

langkah-langkah sebagai berikut:

1. Mencari sumber atau bahan pustaka tentang Pengaruh Penggunaan

Automatic Tube Current Modulation terhadap kualitas citra dan dosis

radiasi pada modalitas CT-Scan.

2. Proses Organize, yakni mengorganisasi literatur yang akan ditinjau

atau di-review. Literatur yang di-review merupakan literatur yang

relevan/sesuai dengan permasalahan. Adapun tahap dalam

mengorganisasi literatur adalah mencari ide, tujuan umum, dan

simpulan dari literatur dengan membaca abstrak, beberapa paragraf

pendahuluan dan kesimpulannya, serta mengelompokkan literatur

berdasarkan kategori-kategori sesuai dengan topik yang penulis ambil

terkait dengan Pengaruh Penggunaan Automatic Tube Current

Modulation terhadap kualitas citra dan dosis radiasi pada modalitas

CT- Scan.

3. Proses Synthesize, yakni menyatukan hasil organisasi literatur menjadi

suatu ringkasan agar menjadi satu kesatuan yang padu, dengan

mencari keterkaitan antar literatur;

4. Proses Identify, yakni mengidentifikasi isu-isu kontroversi dalam

literatur. Isu kontroversi yang dimaksud adalah isu yang dianggap

sangat penting untuk dikupas atau dianalisis, guna mendapatkan suatu

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tulisan yang menarik untuk dibaca;

5. Proses pembahasan / melakukan analisis terkait Pengaruh Penggunaan

Automatic Tube Current Modulation terhadap kualitas citra dan dosis

radiasi pada modalitas CT-Scan.

6. Proses Formulate, yakni merumuskan pertanyaan yang membutuhkan

penelitian lebih lanjut.

Review Pengaruh Penggunaan

Automatic Tube Current
Modulation pada Modalitas CT-
Scan

Pencarian
Literatur

Pemilihan Literatur

Analisis

Pembahasan

Kesimpulan

Bagan 3.1 Alur Penelitian

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3.4. Pengolahan dan Analisa Data

Penulis mengkaji literatur terkait pengaruh penggunaan Automatic

Tube Current Modulation terhadap kualitas citra dan dosis radiasi pada

modalitas CT-Scan untuk mengambil kesimpulan dan menjawab rumusan

masalah serta memberikan saran pada akhir kajian, review dan analisa

teoritis pengolahan terkait pengaruh penggunaan Automatic Tube Current

Modulation terhadap kualitas citra dan dosis radiasi pada modalitas CT-

Scan yang menggunakan jurnal terkait.

Analisis data yang digunakan dalam penelitian ini adalah dengan

metode open coding sebagai proses untuk mem-break-down data,

mempelajari satu demi satu, membandingkan, dan mengkonseptualisasikan

data dimana penulis merangkum dan mengelompokkan informasi yang

didapatkan dari berbagai jurnal mengenai pengaruh penggunaan Automatic

Tube Current Modulation terhadap kualitas citra dan dosis radiasi pada

modalitas CT-Scan yang bersumber dari jurnal resmi ataupun website

resmi pemerintah. Tujuan tahap ini adalah untuk penamaan dan

pengkategorian melalui pencermatan data. Termasuk dalam tahap ini

adalah mengenali konsep-konsep yang merepresentasikan fenomena yang

sejenis, hal ini disebut dengan pengkategorian (categorizing).

Pengelompokkan fenomena ini didasarkan pada pola kesamaan

(similiarity), perbedaan (difference), dan sebab-akibat (causation).

 BAB IV

HASIL DAN PEMBAHASAN

4.1 Hasil

Berdasarkan studi yang dikumpulkan, berikut 3 (tiga) jurnal yang penulis

gunakan karena membahas dengan detail mengenai pengaruh penggunaan

Automatic Tube Current Modulation. Adapun rincian studi yang digunakan

dapat dilihat pada tabel di bawah ini:

Tabel 1. Penelitian-penelitian terhadap pengaruh penggunaan

Automatic Tube Current Modulation
No. Penulis Tahun Judul Metode Teknik Hasil
1. Aysegül 2019 Effects of the Use studi Penelitian ini Hasil penelitian ini
Yurt, et al of Automatic Tube retrospektif dilakukan dengan studi menunjukkan 30
Current retrospektif dengan pasien wanita dan 34
Modulation on mengklasifikasikan 64 pria yang diperiksa
Patient Dose and pasien yang dijadikan memiliki rata-rata usia
Image Quality in subjek ke dalam tiga 57,4 ± 12,7 tahun
Computed kelompok pasien dengan nilai rata-rata
Tomography sesuai dengan ukuran diameter efektif
pasien berdasarkan ditemukan menjadi
citra CT menurut 23,8 ± 2cm, 28,9 ±eff
pengukuran diameter 1,4 cm, dan 33,1 ± 1,5
efektif pasien yang cm untuk kelompok 1,
diambil dari daerah kelompok 2, dan
abdomen. kelompok 3 masing-
masing. Penggunaan
protokol ATCM
diamati lebih tinggi
31% dan 21%
pengurangan dosis
efektif (E) untuk
Arterial and Portal
Phases masing-
masing, NI
menunjukkan
peningkatan antara 9%
dan 46% untuk hati,

25
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lemak dan aorta dan

nilai CNR diamati
menurun antara 5%
dan 19%.

2. Jen-Pai 2010 Automatic Tube studi Penelitian ini Hasil penelitian ini
Su, et al Current retrospektif dilakukan dengan studi menunjukkan arus
Modulation versus retrospektif dengan tabung rata-rata dari
Fixed Tube Current mengklasifikasikan gambar fase arteri dan
in Multi-detector pasien ke empat vena yang tidak
Row Computed protokol berbeda mengalami
Tomography of berdasarkan parameter
peningkatan pada
Liver: Comparison scanning yang
kelompok ATCM
of Image Quality berbeda: (1) 100 kVp,
and Radiation Dose fixed current 350 mA; lebih rendah
(2) 100 kVp, ATCM; dibandingkan pada
(3) 120 kVp, fixed kelompok arus tabung
current 350 mA; (4) tetap, meskipun tidak
120 kVp, ATCM dan ada perbedaan yang
melakukan signifikan dalam usia,
pengukuran tinggi berat badan dan BMI
badan, berat badan, di antara empat
dan BMI pasien kelompok. Ion reduksi
dihitung untuk arus rata-rata
mengevaluasi kelompok ATCM
hubungan antara arus
dibandingkan dengan
tabung dan berat badan
atau BMI. kelompok arus tetap,
adalah 20,4% dan
24,5%, 8,6% dan
44,2% masing-masing
pada 100 kVp dan 120
kVp. Dalam aspek
dosis radiasi,
menemukan bahwa
dosis efektif dan DLP
pada kelompok ATCM
secara signifikan lebih
rendah daripada pada
kelompok arus tabung
tetap. Pada 120 kVp,
dosis efektif rata-rata
dapat dikurangi 35,9%
pada kelompok ATCM
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dibandingkan dengan
kelompok arus tetap.
3. C. J. 2016 Setting Up eksperimen Penelitian ini Sistem ATCM
Martin, S. Computed dilakukan dengan memiliki potensi
Sookpeng Tomography metode eksperimen memungkinkan
Automatic Tube yakni dengan menguji penyesuaian
Current performa dosis CT- dilakukan untuk
Modulation Scan melalui
mempertahankan
Systems pengukuran CT Dose
Index (CTDI) dengan tingkat kualitas citra
sebuah ionization yang dipilih terkait
chamber 100 mm dengan noise citra
dalam phantom atau faktor
silinder standar yang berdasarkan standar
terbuat dari polymethyl citra. Sistem ATCM
methacrylate (PMMA) menyesuaikan mA
320 mm dan 160 mm secara otomatis
yang masing-masing relatif terhadap
mewakili tubuh dan atenuasi pasien di
kepala.
bidang longitudinal
dan rotasi dengan
pemilihan faktor
eksposur agar sesuai
dengan habitus
pasien dan
menyesuaikan mA
untuk menjelaskan
variasi ukuran dan
atenuasi pasien
selama pemindaian.

4.2 Pembahasan
Dari studi yang terpilih dalam literature review ini terdapat persamaan

dan perbedaan pembahasan mengenai pengaruh penggunaan Automatic Tube

Current Modulation, yang dapat dilihat pada tabel dibawah ini:

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Tabel 2. Persamaan dan Perbedaan antar Studi

Persamaan
1. Menggunakan modalitas MSCT
2. Membahas pengaruh
penggunaan Automatic Tube
Current Modulation
3. Menggunakan CTDI dan DLP
sebagai parameter untuk
menentukan pengaruh dosis
Perbedaan
1. Objek yang digunakan.
Penelitian jurnal pertama
menggunakan objek Abdomen,
jurnal kedua menggunakan
objek Liver, dan jurnal ketiga
menggunakan sebuah
ionization chamber 100 mm
dalam phantom silinder
standar yang terbuat dari
polymethyl methacrylate
(PMMA) 320 mm dan 160
mm yang masing-masing
mewakili tubuh dan kepala

Berdasarkan penelitian-penelitian yang dilakukan sebelumnya, didapati

bahwa penggunaan ATCM memberikan pengaruh terhadap kualitas citra hal

ini dilihat dengan penggunaan parameter noise untuk ketiga jurnal terpilih.

Selain itu, ATCM juga memberikan pengaruh terhadap dosis yang diterima

oleh pasien. Pada jurnal pertama dijelaskan bahwa Penggunaan protokol

ATCM diamati lebih tinggi 31% dan 21% pengurangan dosis efektif (E) untuk

Arterial and Portal Phases masing-masing, NI menunjukkan peningkatan

antara 9% dan 46% untuk hati, lemak dan aorta dan nilai CNR diamati

menurun antara 5% dan 19%. Dari evaluasi citra oleh ahli radiologi

menunjukkan tidak ditemukan kendala yang membatasi evaluasi sehingga

semua citra memenuhi tingkat kualitas diagnostik yang dapat diterima.

Pengaruh penggunaan teknik Z-DOM (ATCM) sebagai pengganti protokol

fixed current berbasis berat badan pada

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pemeriksaan Contrast-enhanced biphasic CT Abdomen diamati dapat

menurunkan dosis pasien berbanding terbalik dengan ukuran pasien dengan

tetap mempertahankan kualitas citranya.

Pada jurnal kedua dijelaskan bahwa dalam penelitian tersebut, arus tabung

rata-rata dari citra Arterial and venous phases yang tidak mengalami

peningkatan pada kelompok ATCM lebih rendah dibandingkan pada

kelompok fixed current, meskipun tidak ada perbedaan yang signifikan dalam

usia, berat badan dan BMI di antara empat kelompok pasien. Dalam aspek

dosis radiasi, ditemukan bahwa dosis efektif dan DLP pada kelompok ATCM

secara signifikan lebih rendah daripada kelompok fixed current. Pada 120

kVp, dosis efektif rata-rata dapat dikurangi 35,9% pada kelompok ATCM

dengan DLP di bawah tingkat referensi diagnostik. Oleh karena itu ATCM

dapat membantu mengurangi dosis radiasi pasien dalam pemeriksaan CT

klinis. Penggunaan ATCM dapat tetap menjaga kualitas citra dan memiliki

kelebihan dalam menghindari photon staravation artifacts dan mengurangi

beban tabung sinar-

x. Penggunaan modulasi sumbu-z (ATCM) dapat memberikan pengurangan

yang signifikan dari tube current, DLP dan perkiraan dosis efektif dengan

pemeliharaan kualitas citra yang sama untuk CT dan CTA hepatik yang dinilai

baik dengan penilaian subjektif atau analisis kuantitatif objektif. Oleh karena

itu, penggunaan rutin teknik ATCM untuk CT hepatik dan CTA diperlukan

untuk mengurangi dosis pada pasien.

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Pada jurnal ketiga dijelaskan bahwa Sistem ATCM memiliki potensi

memungkinkan penyesuaian dilakukan untuk mempertahankan tingkat

kualitas citra yang dipilih terkait dengan noise citra atau faktor berdasarkan

standar citra. Sistem ATCM menyesuaikan mA secara otomatis relatif

terhadap atenuasi pasien di bidang longitudinal dan rotasi dengan pemilihan

faktor eksposur agar sesuai dengan habitus pasien dan menyesuaikan mA

untuk menjelaskan variasi ukuran dan atenuasi pasien selama pemindaian.

Penggunaan sistem ATCM memiliki potensi mencapai pengurangan dosis

pasien yang signifikan, terutama untuk pasien yang lebih kecil, membantu

mengoptimalkan kinerja CT-Scan. Penggunaan ATCM juga sesuai untuk

sebagian besar jenis pemeriksaan, kecuali jika tidak ada perubahan atenuasi

yang signifikan atau ada sedikit pergerakan meja.

 BAB V

PENUTUP

5.1 Kesimpulan
Berdasarkan penelitian studi literatur yang telah peneliti lakukan,

ditemukan bahwa penggunaan ATCM memberikan pengaruh pengurangan

dosis yang signifikan terutama untuk pasien yang lebih kecil dengan tetap

mempertahankan tingkat kualitas citra dan memiliki kelebihan dalam

menghindari photon starvation artifacts serta mengurangi beban tabung sinar

X dibandingkan dengan penggunaan Fixed Tube Current bahkan penggunaan

rutin sistem ATCM untuk CT Liver dan CTA memungkinkan diperlukan

untuk pengurangan dosis radiasi yang wajar pada pasien juga membantu

mengoptimalkan kinerja CT-Scan.

5.2 Saran
Pada pemeriksaan CTA dan CT Liver disarankan menggunakan ATCM

untuk dapat mengurangi dosis pemeriksaan tetapi tetap mempertahankan

kualitas citra yang baik, dan mampu menegakkan diagnosa. Untuk peneliti

selanjutnya dapat melakukan penelitian pengaruh penggunaan ATCM pada

organ lainnya.

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 DAFTAR PUSTAKA

Anam, C. et al. (2014) ‘Teknik Rekonstruksi Iteratif untuk Data Proyeksi

Renggang (Sparse Projection Data) sebagai Upaya untuk Mereduksi Dosis
CT Scan’, Seminar Nasional Keselamatan, Kesehatan dan Lingkungan IX,
(June), pp. 53–63.
Badan Pengawas Tenaga Nuklir (BAPETEN) Nomor 8. (2011) Keselamatan
Radiasi Dalam Penggunaan Pesawat Sinar-X Radiologi Diagnostik dan
Intervenstional. Jakarta: BAPETEN.
Badan Pengawas Tenaga Nuklir (BAPETEN). (2016) Pedoman Teknis
Penyusunan Tingkat Panduan Paparan Medik atau Diagnostic Reference
Level (DRL) Nasional. Jakarta: BAPETEN.
Bushberg, J. T., J. A. Seibert, E. M. Boone. (2012) The Essential Physics of
Medical Imaging. Third Edition. Baltimore: Williams dan Wilkins.
Cantatore, A. and Muller, P. (2011) ‘Introduction to computed tomography’,
Introduction to Computed Tomography. doi: 10.1157/13088421.
Hiswara, E. (2015) Buku Pintar Proteksi dan Keselamatan Radiasi di Rumah
Sakit.
Kalra, M. K. et al. (2004) ‘Techniques and applications of automatic tube current
modulation for CT.’, Radiology, 233(3), pp. 649–657. doi:
10.1148/radiol.2333031150.
Lampignano, J. P. and Kendrick, L. E. (2018) Bontrager’s Textbook of
Radiographic Positioning and Related Anatomy. Ninth. St. Louis, Missouri:
Elsevier.
Martin, C. J. and Sookpeng, S. (2016) ‘Setting up computed tomography
automatic tube current modulation systems’, Journal of Radiological
Protection, 36(3), pp. R74–R95. doi: 10.1088/0952-4746/36/3/R74.
Nursianto, T.H. (2019) Perbandingan Informasi Anatomi dan Nilai Dosis Radiasi
Pada CT Stonography Kasus Urolithiasis Dengan Rekonstruksi Quantum
Denoising Software dan Adaptive Iterative Dose Reduction 3D Terintegrasi
Automatic Exposure Control. Semarang: Poltekkes Kemenkes Semarang.
Pane, D. N., Fikri, M. EL and Ritonga, H. M. (2018) Sinar-X menjawab masalah
kesehatan, Journal of Chemical Information and Modeling.
Rahadhy, S. and I.Syafitri (2014) ‘Seminar Keselamatan Nuklir 2014 Makalah
Penyaji Oral Bidang Fasilitas Radiasi dan Zat Radioaktif PROTEKSI
RADIASI PASIEN PADA PEMERIKSAAN CT-SCAN’, Prosiding
32
Seminar

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Keselamatan Nuklir 2014, pp. 21–24.

Resmana, T. A., Darmini, D. and Wijokongko, S. (2017) ‘Analisis Image Noise
dan Nilai Dosis Radiasi Penggunaan Aplikasi Care Dose 4D dan Non Care
Dose 4D pada Pesawat MSCT Siemens’, Jurnal Imejing Diagnostik
(JImeD), 3(2), pp. 258–265. doi: 10.31983/jimed.v3i2.3196.
Rozana, Budi, W. S. and Arifin, Z. (2015) ‘Perbandingan Kualitas Citra Ct Scan
Pada Protokol Dosis Dewasa Dan Anak’, 4(1).
Söderberg, M. and La, S. (2013) ‘Evaluation of adaptation strengths of CARE
Dose 4D in pediatric CT’, Medical Imaging 2013: Physics of Medical
Imaging, 8668, p. 866833. doi: 10.1117/12.2001694.
Su, J. P. et al. (2010) ‘Automatic tube current modulation versus fixed tube
current in multi-detector row computed tomography of liver: Comparison of
image quality and radiation dose’, Chinese Journal of Radiology, 35(3), pp.
131– 142.
Supanich, M. P. (2013) ‘Strategies for CT-scan parameter optimazation: Tube
Current Modulation’, Academic Radiology, (8), pp. 1–7. Available at:
http://dx.doi.org/10.1016/j.acra.2010.09.014.
Wahdiana, E. (2018) Digital Digital Repository Repository Universitas
Universitas Jember Jember PENGARUH WORD OF MOUTH Digital
Digital Repository Repository Universitas Universitas Jember Jember,
Jawa.
Yurt, A., Özsoykal, İ. and Obuz, F. (2019) ‘Effects of the use of automatic tube
current modulation on patient dose and image quality in computed
tomography’, Molecular Imaging and Radionuclide Therapy, 28(3), pp. 96–
103. doi: 10.4274/mirt.galenos.2019.83723.
 JADWAL TENTATIF KEGIATAN PENULISAN STUDI LITERATUR
REVIEW
TAHUN AJARAN 2020/2021

Bulan
No. Kegiatan Januari Februari Maret April
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
Penyusunan
1
Proposal
Pengumpulan
2
Proposal
Ujian Proposal
3

Perbaikan
4
Proposal
Pengambilan data
5
SLR

6 Penyusunan SLR

Pengumpulan
7
SLR
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 LAMPIRAN
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 Original Article
Mol Imaging Radionucl Ther 2019;28:96-103 DOI:10.4274/mirt.galenos.2019.83723

Effects of the Use of Automatic Tube Current Modulation on Patient

Dose and Image Quality in Computed Tomography
Bilgisayarlı Tomografide Otomatik Tüp Akımı Modülasyonu Kullanımının Hasta Dozu ve
Görüntü Kalitesi Üzerine Etkileri

Ayşegül Yurt1, İsmail Özsoykal1, Funda Obuz2

1Dokuz Eylül University Faculty of Medicine, Department of Medical Physics, İzmir, Turkey
2Dokuz Eylül University Faculty of Medicine, Department of Radiology, İzmir, Turkey

Abstract
Objectives: The frequency of abdominal computed tomography examinations is increasing, leading to a significant level of patient dose.
This study aims to quantify and evaluate the effects of automatic tube current modulation (ATCM) technique on patient dose and image
Address
quality for Correspondence: biphasic
in contrast-enhanced Ayşegül Yurt MD, Dokuzexaminations.
abdominal Eylül University Faculty of Medicine, Department of Medical Physics, İzmir, Turkey
Phone: +90
Methods: Two different scan537 338 86 82 based
protocols, E-mail:on
aysegul.yurt@gmail.com
constant tube currentORCID and ID: orcid.org/0000-0001-9898-2329
ATCM technique, were used on 64 patients who
Received: 21.03.2019 Accepted: 01.07.2019
visited our radiology department periodically. For three patient groups with different patient size, results from two protocols were
compared with respect to patient dose and image quality.
©Copyright Dosimetric evaluations were based on the Computed Tomography Dose Index,
2019 by Turkish Society of Nuclear Medicine
dose length product, and effective dose. For Imaging
Molecular the comparison of image
and Radionuclide qualities
Therapy between
published two protocols, Noise Index (NI) and Contrast to
by Galenos
Noise Ratio (CNR) values were determined for each image. Additionally, the quality of each image was evaluated subjectively by an
experienced radiologist, and the results were compared between the two protocols.
Results: Dose reductions of 31% and 21% were achieved by the ATCM protocol in the arterial and portal phases, respectively. On the
other hand, NI exhibited an increase between 9% and 46% for liver, fat and aorta. CNR values were observed to decrease between 5%
and 19%. All images were evaluated by a radiologist, and no obstacle limiting a reliable diagnostic evaluation was found in any image
obtained by either technique.
Conclusion: These results showed that the ATCM technique reduces patient dose significantly while maintaining a certain level of image quality.
Keywords: Tomography, radiation protection, abdomen

Öz
Amaç: Abdominal bilgisayarlı tomografi incelemelerinin sıklığı artmakta ve önemli miktarda hasta dozuna yol açmaktadır. Bu çalışma,
kontrastlı, çift fazlı abdomen incelemelerinde otomatik tüp akım modülasyon tekniğinin hasta dozu ve görüntü kalitesi üzerine
etkilerini ölçmeyi ve değerlendirmeyi amaçlamaktadır.
Yöntem: Radyoloji anabilim dalını periyodik olarak ziyaret eden 64 hastaya sabit tüp akımı ve otomatik tüp akımı modülasyonu tekniğine
dayanan iki farklı tarama protokolü uygulandı. Farklı hasta boyutlarına sahip üç hasta grubu için, iki protokolden elde edilen sonuçlar hasta
dozu ve görüntü kalitesi açısından karşılaştırıldı. Dozimetrik değerlendirmeler, Bilgisayarlı Tomografi Doz İndeksi, doz uzunluk çarpımı ve
etkin doza dayandırıldı. İki protokol arasındaki görüntü kalitesinin karşılaştırılması amacıyla her görüntü için Gürültü İndeksi (NI) ve
Kontrast Gürültü Oranı (CNR) değerleri belirlendi. Ek olarak, her görüntü deneyimli bir radyolog tarafından öznel olarak değerlendirildi ve
sonuçlar iki protokol arasında karşılaştırıldı.
Bulgular: Otomatik tüp akım modülasyon protokolü ile arteriyel ve portal fazlarda sırasıyla %31 ve %21 doz düşüşleri sağlandı. Öte
yandan, NI karaciğer, yağ ve aort için %9 ile %46 arasında bir artış gösterdi. CNR değerlerinin ise %5 ile %19 arasında azaldığı

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Mol Imaging Radionucl Ther 2019;28:96-103 Yurt et al. Automatic Tube Current Modulation in CT

bir radyolog tarafından değerlendirildi ve herhangi bir teknikle elde edilen görüntülerde güvenilir bir tanısal değerlendirmeyi sınırlayan bir
engel bulunmadı.
Sonuç: Bu sonuçlar, otomatik tüp akım modülasyon tekniğinin, belirli bir görüntü kalitesi seviyesini korurken hastanın dozunu önemli
ölçüde azalttığını göstermiştir.
Anahtar kelimeler: Tomografi, radyasyondan korunma, abdomen

Introduction Automatic Current Setting (ACS) and Automatic Tube

In the early 1990s, helical computed tomography (CT)

devices were introduced for medical imaging. Shortened
examination times, improved visibility of vascular structures
and potential reduction in the use of contrast material
enabled intensive use of this technology. However, the
clinical use of CT increased mainly after multislice helical CT
scanners became available towards the end of the decade.
Today, images from 64 to 320 slices can be acquired in
a single rotation of the X-ray tube within one-third of a
second. These advances led to a further increase in the use
of CT for cardiovascular examinations, perfusion
imaging, brain, heart, breast, colon, and whole body
studies (1).
Radiation exposure of patients having CT scans has
increased as a consequence of more frequent use of
CT. Recent studies on major medical centers in the UK
showed that only 11% of all applications in the radiology
departments are CT applications, whereas the effective
radiation dose of patients due to CT applications was
reported as 40% in 1998 and 68% in 2008 (2).
Although offering shorter image acquisition time and
higher spatial resolution, multislice CT technology has
some dosimetric handicaps to be considered. In MSCT,
over-beaming and end effect terms refer to the
necessity of beam and scan widths extending beyond
detector area and imaged region, respectively. These
conditions that arise due to image reconstruction
purposes lead to increase in radiation dose to the patient,
when compared to single slice CT scanners. On the
other hand, smaller gantry designs for MSCT devices led
to a shorter patient-tube distance which obviously affects
patient dose (3). These conditions have forced CT
manufacturers to develop dose optimization strategies
either based on image processing or the prevention of
unnecessary radiation. The most common strategy
among these is the use of Automatic Exposure Control
(AEC), where the tube current is adjusted by the
scanner according to the patient size. Since the beginning
of the 2000s, AEC systems have been developed by the
manufacturers based on different operating
mechanisms; however, offering similar opportunities on
patient dose control, image quality, and tube life (4,5).
In CT, AEC is applied based on two main techniques:
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Mol Imaging Radionucl Ther 2019;28:96-103 Yurt et al. Automatic Tube Current Modulation in CT
Current Modulation (ATCM), which can be activated
separately or combined. In ACS technique, scanner
generates an optimized constant tube current to be
applied along the scanned region for which ATCM
offers a modulated tube current. This modulation may
be achieved either for every single longitudinal slice
along the z-axis or at different angular projections of
the tube on x-y plane. These techniques are known as
longitudinal ATCM and angular ATCM, respectively.
Longitudinal ATCM, a commonly used ACS
technique, is available under different names
among different manufacturers. Z-DOM, a
longitudinal ATCM named by Philips, makes use of a
pre-scan radiograph, named as a topogram, to
compute the attenuation properties of the patient as
a function of scan length and modulate tube current
based on this information. This dose modulation
mechanism works in accordance with a reference
image quality selected and standardized by the user,
in terms of a Noise Index (NI) (6). In CT exams that
include both head&neck and abdominal regions, for
example, Z-DOM technique achieves both radiation
protection in thyroids and good image quality in
abdominal region by locally decreasing and increasing
tube current. However, scan protocols applying
constant tube current usually fail to meet these goals
at the same time. These scans end up with either
overexposure of thyroids or underexposure of
abdominal region depending on the amount of tube
current.
In the literature, studies carried on the abdominal CT
examinations of adults report commonly that the
use of AEC techniques leads to a considerable
decrease in patient dose while keeping a reasonable
image quality (6,7,8,9,10,11,12,13,14). This study
aims to focus on the use of Z-DOM in contrast-
enhanced biphasic abdominal examinations and to
make evaluations on image quality and patient dose.
The results will be examined with respect to different
patient groups in different size.

Materials and Methods

Patient Profile and Scan Protocol
This retrospective study was conducted in accordance
with ethical standards under the responsibility of
the

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Yurt et al. Automatic Tube Current Modulation in CT Mol Imaging Radionucl Ther 2019;28:96-103

Institutional Review Board that approved the study
(decision no: 2015/05-19). Sixty four patients
undergoing contrast-enhanced biphasic abdominal CT
examination were involved in the study. The scans were
performed with a 64-slice CT scanner (Brilliance, Philips
medical systems, Netherlands) which is located in the
radiology department of our university hospital. All data
regarding both image quality and dosimetric quantities
were classified under three patient groups with respect
to patient size for a better evaluation of the results.
This classification was carried out based on CT images,
according to the effective diameter measurements of the
patients taken from the abdominal region. Effective
diameter, Deff, was determined using lateral and
anterioposterior sizes of the patient as shown in
Equation 1.
D = (D + D )/2 (1)
eff LAT AP
quantities reported by the scanner following each
exam. CTDIvol refers to the dose output of the CT
scanner measured in a cylindrical PMMA phantom
with an ionization chamber. It represents absorbed
dose, in mGy, in the central slice of the scan range.
Therefore, it is not a direct measure of patient dose,
however, it offers the opportunity for dosimetric
comparison between different scanning protocols and it is
commonly used for quality control purposes. DLP, on
the other hand, represents the total radiation output of
a scanner along the axis of scan and it is determined by
multiplying CTDIvol with the scan length. These two
quantities were obtained from examination specific
dose reports given by the scanner which has been
objected to a dosimetric quality control test prior to
the collection of data. Besides CTDIvol and
DLP, effective dose (E) was calculated for each scan using

Patients with effective diameters in the range of 21-26 cm E per DLP (E/DLP) value recommended by the European
were included in the first group, patients with effective Commission’s Guidelines, as shown in Equation 2.
diameters in the range of 26-31 cm were included in the E = EDLP x DLP (2)
second group, and patients with effective diameters in the
range of 31-36 cm were included in the third group.
Cohort of the study involved the patients who underwent
biphasic abdominal examinations periodically. In these
examinations, the arterial phase scan involved thorax and
abdomen while portal phase scan involved abdominopelvic
region (Figure 1). Scan parameters regarding weight based
routine protocol and ATCM protocol are given in Table 1.
All parameters were kept constant except effective tube
current.
Patient Dosimetry
Computed Tomography Dose Index (CTDIvol) and Dose Figure 1. Scan regions for arterial phase (A) and portal phase (B)
Length Product (DLP) values are two main dosimetric

Table 1. Contrast-enhanced biphasic abdominal scan protocols

Routine scan protocol Z-DOM scan protocol
Effective tube current Patient weight (kg) Arterial phase Portal phase Arterial phase Portal phase
(mAs/ slice)
40-80 200 200 Z-DOM Z-DOM
80< 250 250 Z-DOM Z-DOM
Tube voltage (kVp) 120 120 120 120
Slice thickness (mm) 0.9 2 0.9 2
Pitch 1.172 1.172 1.172 1.172
Increment (mm) 0.45 1 0.45 1
Scan length (mm) 500 500 500 500
Collimation (mm) 64 x 0.625 64 x 0.625 64 x 0.625 64 x 0.625
Field of view (mm) 350 350 350 350
Gantry rotation time (s) 0.75 0.75 0.75 0.75

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Yurt et al. Automatic Tube Current Modulation in CT Mol Imaging Radionucl Ther 2019;28:96-103
Image matrix size 512 x 512 512 x 512 512 x 512 512 x 512
Reconstruction filter Standard (B) Standard (B) Standard (B) Standard (B)

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Mol Imaging Radionucl Ther 2019;28:96-103 Yurt et al. Automatic Tube Current Modulation in CT

Here, E stands for the E (mSv) to the patient due to CT
scan. EDLP represents the E per DLP, and it is given as 0.015
mSv/mGy.cm specific to abdominal scans (15). Two
scan protocols were compared based on CTDIvol, DLP and
E.
Image Quality
In this part of the study, following the dosimetric
comparison, NI and Contrast to Noise Ratio (CNR) of the
images obtained via both protocols were compared, and
the image quality was examined objectively based on
these parameters as recommended by the international
authorities. In addition to this, subjective evaluation made
by a clinician was another method in which image
quality was considered.
Objective Approach
Objective analysis of the image quality was based on NI
which is defined as the standard deviation in the pixel
values (i.e., Hounsfield Units, HU) for a homogeneous
object being scanned. Circular region of ınterest (ROI) was
drawn to measure NI in three regions: The subcutaneous
fat in the anterior region of the abdomen, liver, and aorta.
Figure 2 shows three ROIs with identical areas that were
cared to be located at the same regions for each
patient. For each image, an average NI calculation was
made based on the NI measurements taken in three
consecutive slices. Apart from NI, average CNR values
were determined to compare the images by means of
contrast resolution. CNR value of two tissues A and B was
determined as shown in Equation 3 (16):
CNR = (S -S ) / [(SD )2 + (SD )2]1/2 (3)
A B A B
different patient groups (1, 2 and 3) as well as all patients
(overall). Besides, data obtained for dosimetric and
objective image quality purposes were analyzed
statistically using Mann-Whitney U and t-test,
respectively.
Results
In this study, 30 female and 34 male patients were
examined. The mean age of the patients was 57.4±12.7
years. On the other hand, mean Deff values were found
to be 23.8±2 cm, 28.9±1.4 cm, and 33.1±1.5 cm for
group 1, group 2 and group 3, respectively. In Table 3 and
Table 4 are given the dosimetric results obtained for each
biphasic scan protocol for different patient sizes. ATCM
protocol was observed to lead 31% and 21% reductions
in E for arterial and portal phases, respectively,
according to the
results obtained from all patient groups, as given in Table
5 which also represents the results based on different
patient groups.
Statistical Analysis
Statistical analysis on dosimetric data mostly gave
significantly different (p<0.05) results across patient

Where SA and SB denote mean HU values within the ROIs quality, arithmetic mean values were calculated and
while SDA and SDB denote the standard deviation, or NI, presented for
measured for tissues A and B, respectively. CNR values
were obtained for liver-fat and aorta-fat and compared
between two scan protocols (Figure 2).
Subjective Approach
In addition to the objective analysis of image quality,
subjective evaluations were made on images by a
radiologist who rated the overall image quality and the
visibility of anatomic details. This evaluation was done
by grading the diagnostic quality of the image examined
without any information known about the scan protocol.
The grading scale is given in Table 2. Minimum grade
required for an image to be regarded as acceptable in
terms of diagnostic quality was determined as 2,
referring to a study carried out by Mulkens et al. (14).
Presentation and Statistical Analysis of Data
Among all data obtained for patient dose and image

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Mol Imaging Radionucl Ther 2019;28:96-103 Yurt et al. Automatic Tube Current Modulation in CT

Figure 2. Objective analysis of image quality

Table 2. Grading scale for subjective evaluation

4 There is no handicap due to noise, and the image
quality is very high.
3 A low level of noise is observed in the image, but a reliable
diagnostic quality has been maintained.
2 The noise observed in the image is moderate but
suitable for a successful diagnostic evaluation.
1 High level of noise observed in the image prevents
a reliable diagnostic evaluation.
0 Noise level totally prevents any diagnostic evaluation.

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Yurt et al. Automatic Tube Current Modulation in CT Mol Imaging Radionucl Ther 2019;28:96-103

groups for routine and Z-DOM scanning protocols. The only scan protocol that used Z-DOM was evaluated against
exception was the portal phase examination of patients in routinely used constant tube current protocol for biphasic
group 3 for which the dosimetric results were not observed abdominal CT exams. The two quantities of evaluation
to be significantly different for two scan protocols
were patient dose and image quality.
(p>0.05).
Z-DOM protocol was observed to lead significant
Findings based on NI and CNR obtained for the objective
reductions in CTDIvol, DLP and E values across all patient
image quality comparison of two protocols are given in
groups (Table 3 and Table 4). The percentage
Table 6. As observed, images obtained from the ATCM
reductions are presented in Table 5 indicating that the use
protocol had higher NI and lower CNR values compared to
the routine protocol. However, statistical analysis showed of Z-DOM decreased the radiation exposure of the patients
that, for patients in group 3, there was no significant between 19% and 37% for the arterial phase and
difference between two protocols based on NI and CNR between 2% and 34% for the portal phase. The reason for
values (p>0.05), unlike the findings obtained from group 1 difference in dose reduction rates observed for the two
and group 2 (p<0.05). phases is based on the differences in the anatomic
Results from subjective image quality evaluations made by regions scanned. In the arterial phase, the scan area
a radiologist are given in Table 7. Findings indicated involves thorax and abdomen, while the portal phase
that all images met an acceptable level of diagnostic includes abdominal and pelvic regions. Since the pelvic
quality, regardless of which scan protocol was used. region with a bony structure has a higher radiation
attenuation compared to the thoracic region filled with
Discussion air, higher amounts of tube current are needed in this
region. This explains why a lower dose reduction rate
Patient size, institution-specific scan protocols and the use was observed in the portal phase compared to the arterial
of multiphase scanning are three main factors that
phase, especially for patients in group 2 and group 3.
affect patient dose in CT examinations (17). In this
study, a new
Table 3. CTDIvol, DLP and E values of scan protocols for arterial phase
Routine scan protocol Z-DOM scan protocol
1 (n=16) 2 (n=36) 3 (n=12) Overall (n=64) 1 (n=16) 2 (n=36) 3 (n=12) Overall (n=64)
CTDIvol (mGy) 13.2 13.9 14.4 13.8 8.2 9.6 11.3 9.6
DLP (mGy.cm) 660 697 722 692 413 475 585 480
E (mSv) 9.9 10.5 10.8 10.4 6.2 7.2 8.8 7.3
DLP: Dose Length Product, CTDIvol: Computed Tomography Dose Index, E: Effective dose

Table 4. CTDIvol, DLP and E values of scan protocols for portal phase
Routine scan protocol Z-DOM scan protocol
1 (n=16) 2 (n=36) 3 (n=12) Overall (n=64) 1 (n=16) 2 (n=36) 3 (n=12) Overall (n=64)
CTDIvol (mGy) 12.8 13.9 15.5 13.9 8.5 10.9 14.3 10.9
DLP (mGy.cm) 639 694 773 695 422 543 758 553
E (mSv) 9.6 10.4 11.6 10.4 6.3 8.1 11.4 8.3
DLP: Dose Length Product, CTDIvol: Computed Tomography Dose Index, E: Effective dose

Table 5. Dose reductions for patients in group 3

Dose reduction Arterial phase Portal phase
1 (n=16) 2 (n=36) 3 (n=12) Overall (n=64) 1 (n=16) 2 (n=36) 3 (n=12) Overall (n=64)
CTDIvol (%) 38 31 21 31 33 21 7 21
DLP (%) 37 32 19 31 34 22 2 21
E (%) 37 32 19 31 34 22 2 21

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DLP: Dose Length Product, CTDIvol: Computed Tomography Dose Index, E: Effective dose

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Mol Imaging Radionucl Ther 2019;28:96-103
On the other hand, Table 5 shows different rates of
decreases observed in CTDIvol, DLP and E values across 3
groups of patients. Based on Table 5, it could be concluded
that the rate of dose reduction was inversely proportional
with the patient size. Dosimetric differences between
the scan protocols were supported by statistical
analysis, where all group based and phase based
comparisons yielded significantly different results, except
for the portal phase scan of patients in group 3. This
was due to the high radiation attenuation property of the
pelvic region in patients in group 3, so that, the tube
current applied by Z-DOM was not much different from
the routine protocol.
In a study that Lee et al. (18) conducted on abdominal
CT scans, dose reduction up to 45% was reported and it
was shown that higher dose reduction rates were achieved
with lower body mass index. These results were parallel
to the results obtained from our study. In another study
carried out by S. Livingstone et al. (7) on contrast-
enhanced biphasic abdominal examinations, dose
reductions between 16% and 28% were achieved with
the protocol using ATCM compared to fixed current
protocols based on patient weight. According to the results
of our study, dose reduction rates were observed
approximately between 10% (group 3) and 35% (group
1) among the 3 groups when both phases were
considered together (Table 5). The results of a
comprehensive study in which dosimetric data from 12
centers in the USA were collected showed that the third
quartile of the biphasic abdominal CT doses was 32 mSv
(19). This value represented the exam specific reference
dose level for these medical centers. In this study, the total
E due to biphasic abdominal examination was reported
as 20.8 mSv and 15.6 mSv, for routine protocol and
ATCM protocol, respectively. These values showed that
using ATCM techniques, Z-DOM in this case, provided CT
scans with lower radiation doses.
Table 6. Group-specific and overall changing in Noise Index and Contrast to Noise Ratio due to the use of automatic tube
current modulation protocol
Arterial phase
1 (n=16) 2 (n=36) 3 (n=12)
NI Increase in tissues
LIVER (%) 28 21 18
FAT (%) 26 25 20
AORTA (%) 46 28 18
Decrease in CNR for tissues
LIVER/FAT(%) 17 15 13
Yurt et al. Automatic Tube Current Modulation in CT
In the second part of the study, the diagnostic quality
of the images obtained by both protocols was compared
using objective and subjective approaches. NI and CNR
measurements and calculations were conducted as part
of the objective image quality assessment. Table 6 shows
the increase in NI values across all patient groups for
the protocol using the Z-DOM technique. This increase
was observed to become lower as the patient size
increased. This is because the Z-DOM technique uses
higher tube currents in overweight patients to maintain
image quality at a certain level. Comparison of two
protocols based on CNR values is given in Table 6.
According to this table, CNR values regarding liver-fat and
aorta-fat decreased between 5% and 19% in all patient
groups for both arterial and portal phases. The
conclusion reached with these two tables was that the
use of Z-DOM technique leaded to lower objective
image quality when compared to routine examination
protocol. However, increased noise in the image and
therefore decreased contrast between the tissues do
not always mean that the image does not meet
diagnostic standards required for a successful evaluation.
Subjective image quality assessment performed in the last
part of the study had an important role in this context.
According to the results obtained from the subjective
assessment which was made by a radiologist based on
the scale given in Table 2, all images were concluded to
have the criterion of acceptable diagnostic quality (Table
7).
It is of great importance that the patient dose is
brought to the lowest possible level so as to present
adequate diagnostic information to the clinician. In order
to achieve this goal, it is necessary for the clinical staff
to review all parameters of the examination protocols.
On the other hand, further advances should follow in
the present techniques of image reconstruction
developed by the manufacturers which recently play a
very important role in
Portal phase
Overall (n=64) 1 (n=16) 2 (n=36) 3 (n=12) Overall (n=64)
22 32 22 14 23
24 15 14 9 13
31 41 26 21 29
15 16 12 5 12
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Mol Imaging Radionucl Ther 2019;28:96-103 Yurt et al. Automatic Tube Current Modulation in CT
AORTA/FAT (%) 18 16 10 15 19 15 8 15
CNR: Contrast to Noise Ratio, NI: Noise Index

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Yurt et al. Automatic Tube Current Modulation in CT Mol Imaging Radionucl Ther 2019;28:96-103

A.Y., İ.Ö., F.O., Analysis or Interpretation: A.Y., İ.Ö., F.O.,

Table 7. Mean values of subjective grading scores
Literature Search: A.Y., İ.Ö., Writing: A.Y., İ.Ö., F.O.
Arterial phase Portal phase
Conflict of Interest: No conflict of interest was
Routine Z-DOM Routine Z-DOM
protocol protocol protocol protocol declared by the authors.
1 (n=16) 4 3.3 4 3.5 Financial Disclosure: The authors declared that this study
2 (n=36) 4 3.1 4 3.2 received no financial support.
3 (n=12) 3.6 2.6 3.6 2.9
Overall (n=64) 3.9 3.1 3.9 3.2 References
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Acknowledgements
The authors would like to offer their special thanks to
Handan Güleryüz, head of Dokuz Eylül University
Hospital Radiology Department, who made this study
possible. The authors also would like to thank to Gizem
Şişman, Rukiye Çakır Haliloğlu and the department staff
for their assistance with the collection of data.
Ethics
Ethics Committee Approval: This retrospective study
was conducted in accordance with ethical standards under
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Informed Consent: Retrospective study.
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中華放射醫誌 Chin J Radiol 2010; 35: 131-142
Automatic Tube Current Modulation versus
Fixed Tube Current in Multi-detector Row
Computed Tomography of Liver: Comparison
of Image Quality and Radiation Dose
JEN-PAI SU1,2 TwEI-SHIUN JAw1,3 CHIAO-YUN CHEN1,3 YU-TING KUO1,3 TSYH-JYI HSIEH1,3
SHU-HUEI LEE1 C HIEN -C HUNG LIN1
Department of Medical Imaging1, Kaohsiung Medical University Chung-Ho Memorial Hospital
Department of Medical Imaging2 and Radiological Sciences, College of Health Sciences, Kaohsiung Medical University
Department of Radiology3, School of Medicine, College of Medicine, Kaohsiung Medical University
The purpose of this study was to compare
the image quality, diagnostic acceptability, and
radiation exposure between z-axis automatic
tube current modulation (ATCM) and f ixed
tube current techniques in multi- detector row
computed tomography (CT) of liver. One hundred
and eighty-two patients referred for performing
dual-phase contrast-enhanced CT examination to
assess liver tumors were divided, according to the
study periods, into four groups based on different
scanning parameters: (1) 100 kVp, fixed current
(350 mA); (2) 100 kVp, ATCM; (3) 120 kVp, fixed
current (350 mA); (4) 120 kVp, ATCM. Patient
medical records of body height, body weight and
body mass index (BMI) were obtained. We used
signal-to-noise ratio (SNR) and contrast-to-noise
ratio (CNR) to quantitatively evaluate the quality
of hepatic CT images and CT angiography.
Radiation dose measurements were generated
Reprint requests to: Dr. Twei-Shiun Jaw
Department of Medical Imaging, Kaohsiung Medical
University Chung-Ho Memorial Hospital.
No. 100, Tz You 1st Road, Kaohsiung 80714,
Taiwan, R.O.C.
131
automatically by the CT unit with calculation
of dose-length products ( DLP). The axial CT
images and post-processing 3D CT angiographic
images were reviewed by two subspecialist radi-
ologists who were blinded to the CT parameters.
They ranked subjective image quality using a
four-point quality rating independently. Data
were analyzed with statistical tests. The results
showed that the averaged tube current of unen-
hanced images in the ATCM groups was 22.7%
lower than in the fixed tube current groups. As
compared with f ixed tube current groups, the
ATCM groups decreased 8.6% and 8.7% at 100
kVp, and 44.2% at 120 kVp on arterial and venous
phases respectively. The mean effective dose of
the ATCM group was lower than in the fixed tube
current group by 6.2% and 35.9% at 100 kVp
and 120 kVp respectively. There was basically no
significant difference in the quantitatively assess-
ment of CT and CTA image quality between the
ATCM and fixed tube current groups. Both 100
kVp and 120 kVp ATCM groups showed positive
correlation coefficients between the tube current
and BMI or body weight (100 kVp, r = 0.663,
0.724; and 120 kVp, r= 0.792, 0.789 respectively).
In the image quality indices of hepatic CT and
CTA, no significant difference existed among the
four groups or between the two radiologists. In
conclusion, by using ATCM, the radiation expo-
sure and effective radiation dose of dynamic
contrast-enhanced multi-detector row CT of the
liver could be effectively reduced with mainte-
nance of the image quality.
132 Automatic Tube Current Modulation MDCT of
Liver
Recent advancement of computed tomography
(CT) has markedly enhanced its clinical applica-
tions, and during the last few decades, there has
been a remarkable increase in use of CT [1-4]. The
United Nations Scientific Committee on the Effect of
Atomic Radiation 2000 reported that CT constitutes
5% of radiologic examinations and contributes 34%
of the collective dose [4]. Hepatocellular carcinoma
( HCC) was the second most common of the ten
major causes of death due to cancers in Taiwan [5].
Multi-detector row CT plays an important role in
the diagnosis of liver tumors. For diagnosis and
follow-up of HCC, two or three phases of dynamic
contrast-enhanced computed tomography are often
required. The broadened use of CT for liver imaging
in clinical practice has raised concerns about its
radiation exposure, thus emphasizing the need for
appropriate strategies to optimize and reduce radia-
tion doses of CT examination.
Clinical and experimental studies have reported
that satisfactory CT image quality can be maintained
with a reduction of the tube current adjusted on the
bases of body weight and cross-sectional dimension
of patients [6-8]. In helical CT, as variable attenu-
ation of the incident beam traversing a particular
cross-sectional dimension at a particular projection
angle, the resultant attenuation determines image
noise [6-8]. Image noise is inversely proportional to
the square of the tube current. Although we can use
manual adjustment of tube current based on patient
body weight or dimension to reduce the radiation
dose, these adjustments do not guarantee constant
image quality throughout the entire examination [8,
9]. Recent advances in CT technology, providing
various systems of automatic tube current modula-
t ion (ATCM), allow better control in radiation
exposure and maintenance of constant image quality
Table 1. Scanning parameters and data of the patients in each protocol group
Protocol Patient Number
Group
Voltage Current/mode (male/female)
1 100 kVp 350 mA/fixed 27 ( 18/ 9 )
2 100 kVp ATCM 47 ( 32/15 )
3 120 kVp 350 mA/fixed 62 ( 44/18 )
4 120 kVp ATCM 46 ( 27/19 )
p value
* ANOVA
during CT examinations [8, 10-14]. However, to
our knowledge, there is limited information on the
quality outcomes of ATCM on hepatic CT images
and CTA [11].
Thus, the purpose of our study was to assess the
effect of ACTM on image quality, diagnostic accept-
ability and radiation dose of liver CT examinations.
We compared patient-effective doses of dynamic
enhanced CT for the liver between automatic tube
current modulation (ATCM) and fixed tube current
modes. We also evaluated their impacts on the
quality of hepatic CT images as well as CTA. The
relationship between tube current and BMI or body
weight of the patients was also analyzed.
MATERIALS AND METHODS
This study was approved by the institutional
rev iew boa rd of ou r med ical center. Wr i t t en
informed consent was obtained from all participating
patients before CT scan.
Patients
From July 2006 to March 2007, 182 patients
(61 woman, 121 men; mean age, 62.6 years) were
referred to a dynamic contrast- enhanced CT by
their physicians for assessment of hepatic tumors.
According to the study periods, the patients were
assigned to four protocol groups based on different
scanning parameters: (1) 100 kVp, f ixed current
350 m A; (2) 100 kVp, ATCM; (3) 120 kVp, f
ixed
current 350 mA; and (4) 120 kVp, ATCM (Table 1).
The body height and body weight of the patients
were measured, and BMIs (body mass index: body
weight (kg)/body length (m)2) were calculated for
evaluating the relationship between tube current and
body weight or BMI. The data of age, gender, body
Age Weight (kg) Height (cm) BMI
61.2 ± 9.9 62.7 ± 8.6 163.3 ± 8.1 23.5 ± 3.8
60.7 ± 12.2 66.0 ± 12.1 164.1 ± 7.1 24.5 ± 4.1
61.1 ± 12.6 64.7 ± 10.3 163.6 ± 6.8 24.2 ± 3.6
56.7 ± 14.4 63.0 ± 11.4 162.2 ± 7.8 23.9 ± 3.7
0.260* 0.482* 0.212* 0.484*
 Automatic Tube Current Modulation MDCT of Liver 133

weight, body height, and BMI of the patients in each
group are shown in Table 1.
CT Examination
The hepatic dynamical CT examination was
performed in all patients using a multi-detector row
CT scanner (LightSpeed 16; GE Medical System,
Waukesha, Wis) with 16 channels. The ATCM was
applied using z-axis modulation (Auto m A; GE
Medical Systems). The common protocol included
a pitch of 1.35, a detector configuration of 16x1.25
mm, a table feed per gantry rotation of 27 mm and
a rotation speed of 800 ms. The noise index of the
ATCM protocol was 9.1 HU, and the tube current
ranges were 10 – 380 mA. The reconstructed slice
thickness and intervals were 10 mm/10 mm for
hepatic CT images and 1.25 mm/0.9 mm for hepatic
CT angiography respectively.
The patients drank 500 mL of water 15 minutes
before CT scanning. The patients were instructed
to obtain a similar degree of inspiration with each
breath hold for the series of scanning. The scanning
region of non-enhanced images was from above the
diaphragm to the lower liver margin. The arterial
phase of post-enhanced image scanned from the
diaphragm to the lower liver margin, and the portal-
venous phase scanned from the diaphragm to the
lower renal pole with intravenous injection of 100
ml non-ionic contrast medium (300 mg/ml Iodine,
Ultravist-300, Shering) via an antecubital vein using a
power injector (Autoenhance A-50; Nemotokyorindou,
Tokyo, Japan) with an injection rate of 3-4 ml/sec.
The scan delay time was 30s and 70s for arterial phase
and portal venous phase respectively.
Image analysis
The l iver and CTA images were analyzed
separately and independently by two experienced
radiologists (JTS and CCY) with more than 10 years
of experience in reading CT scans of the abdomen.
The readers were blinded to the technical parameters
used, and independently performed qualitative
analyses of the randomized CT images acquired by 4
protocols on a digital picture archiving and commu-
nication system (PACS) workstation. The four-point
quality rating systems for qualitative assessment of
hepatic CT images and CTA were modified from
the rating system developed by Kalra et al [7] and
Tanikake et al [9] respectively (Table 2)(Fig.1).
The measurements of CT number (HU)(Fig.2)
were performed for the aorta at the celiac trunk
levels exuding areas of calcific and non- calcific
plaques and for the erector spine muscles. The
background noise (standard deviation) within the
surrounding air was also measured to calculate
signal-to-noise ratio (SNR) and contrast-to-noise
ratio (CNR). These values were calculated using the
following equations:
SNR = aortic HU/background noise
CNR = (aortic HU - muscle HU)/background
noise
The SNR and CNR analyes were performed to
evaluate the impacts on the quality of hepatic CT
images and CTA.
Measurement of Radiation Exposure
Radiation dose measurements were generated
automatically by the CT unit with calculation of
dose-length products (DLP). The effective dose

Table 2. Scoring of four-point quality rating for hepatic CT images and CTA.
(A) Criteria of Quality Assessment for hepatic CT images
Excellent (grade 4): if image quality provided optimal information for a radiological diagnosis.
Good (grade 3): if image quality was satisfactory enough to provide the information necessary to make an adequate radiological diagnosis.
Adequate or Fair (grade 2): if the examination provided acceptable information but unsatisfactory image quality.
Poor (grade 1): if graininess or streak artefacts did not provide acceptable information for the diagnosis.

(B) Criteria of Quality Assessment for CTA images

Excellent (grade 4): the peripheral branches of the hepatic artery were visualized to the subsegmental level, providing very useful information of angiography.
Good (grade 3): all of the segmental hepatic artery branches were clearly visualized, providing sufficient useful information of angiography.
Fair (grade 2): insufficient angiographic information was obtained because some of the segmental hepatic artery branches were indistinct.
Poor (grade 1): no angiographic information could be obtained because none of the segmental hepatic artery branches were visualized.
134 Automatic Tube Current Modulation MDCT of Liver

1a 1b

1c 1d
Figure 1. 3D hepatic CT angiography. a. Grade 4. The peripheral branches of the hepatic artery were visualized to the
subsegmental level. b. Grade 3. The segmental hepatic artery branches were visualized. c. Grade 2. Some of the seg-
mental hepatic branches were indistinct. d. Grade 1. None of the segmental hepatic artery branches were visualized.

was converted from the DLP using a standardized
conversion factor of 0.015 mSv/mGy • cm [15].
Effective dose = DLP x 0.015 mSv/mGy • cm
Statistical Analysis
We used software SPSS (12.0) and EXCELE
(2003) to calculate statistics. To assay the differ-
ences between the age and sex distributions among
each group, Chi-square tests were applied; for the
differences in age, body weight, effective dose, HU,
SNR, CNR and SD among each group, ANOVA were
used; for the differences in height and BMI between
100 kVp and 120 kVp groups, we used Student t-test.
The paired t-test was used to evaluate the difference
in image quality scored by the two radiologists.
ANOVA was applied for the difference in scoring
 Automatic Tube Current Modulation MDCT of Liver 135

Table 3. Comparison of the tube current (mA) between ATCM and fixed current groups

100 kVp 120 kVp

p value p value
Group 1 (n=27) Group 2 (n=47) Group 3 (n=62) Group 4 (n=46)
Unenhanced 300 238.7±83.2 <0.01 300 226.5±91.7 <0.01
Arterial phase 350 319.9±72.5 <0.05 350 195.3±87.8 <0.01

Venous phase 350 319.5±72.7 <0.05 350 195.4±87.3 <0.01

in ATCM groups than in fixed tube current groups

Figure 2. Measurement of CT number (HU): circle 1:
aorta, circle 2: muscles, circle 3: background.
for image quality among groups. Linear correla-
tion between the tube current in ATCM groups and
the BMI or body weight of the patients was also
obtained.
RESULTS
There was no statistically significant difference
in age, weight, height and BMI existing among the
4 groups of patients (Table 1). The average tube
current of unenhanced images in ATCM groups
2 and 4 were 238.7±83.2 m A and 226.5±91.7 m A
respectively, which were 20.4% and 24.5% lower
than in fixed tube current groups (1 and 3) respec-
tively. On arterial and venous phases, at 100 kVp,
there were also 8.6% and 8.7% lower tube current
respectively. At 120 kVp, similar results were
observed with an average tube current reduction of
44.2% in ATCM groups on both arterial and venous
phases (Table 3).
In quantitative measurements of CT images
and CTA, at 100 kVp, there was no statistically
significant difference between the ATCM (group
1) and fixed tube current (group 2) in mean CT HU
of hepatic artery, muscle and background, SNR of
hepatic artery, and CNR of hepatic artery ( p=0.423,
0.695, 0.059, 0.293, 0.499 respectively). At 120 kVp,
there was also no significant difference in hepatic
artery, muscle, and hepatic artery CNR (0.523,
0.428, 0.054 respectively) between groups 3 and 4.
However, there was significantly higher background
noise and lower SNR of the hepatic artery ( p=0.029
and 0.032 respectively) in ATCM group than in fixed
current group. The 100 kVp groups had significantly
higher mean hepatic artery HU than the 120 kVp
groups either in fixed tube current or ATCM modes
( p<0.001)(Table 4).
CT diagnoses of these patients were: hepatocel-
lular carcinomas (HCC) 135 (74.2%), hemangiomas
15 (8.2%), dysplastic/regenerative nodules 8 (4.4%),
pseudotumors (fatty liver with focal sparing) 6
(3.3%), cysts 6 (3.3%), focal nodular hyperplasia
3 (1.6%), metastases 3 (1.6%), abscesses 2 (1.1%),
adenoma 1 (0.5%), unclassified nodules 2 (1.1%),
and no detectable nodules 1 (0.5%). Presence of
hypertocellular carcinomas was noted in 74.1%
(20/27) of group 1, 76.6% (36/47) of group 2, 75.8%
(47/62) of group 3 and 69.6% (32/46) of group 4
patients. The diagnostic acceptability scores of
hepatic CT images and CTA by the two radiologists
are summarized in Table 5, Table 6, and Figure 3.
In qualitative assessment of the hepatic CT images,
both readers graded scores of 3 or 4, except for two
cases with score 2. The ranges of mean scores were
3.42 to 3.67 for reader 1, and 3.23 to 3.63 for reader
136 Automatic Tube Current Modulation MDCT of Liver

Table 4. Comparison of the quantitative measurements of hepatic CT images between ATCM and fixed current groups.
100 kVp 120kVp
p value p value
Group 1 (n=27) Group 2 (n=47) Group 3 (n=62) Group 4 (n=46)

Hepatic artery HU 277.7 ± 46.8 286.1 ± 41.2 0.423 245.4 ± 38.7 239.0 ± 65.5 0.523
※
Muscle HU 57.5 ± 6.0 55.7 ± 6.6 0.695 ※ 55.8 ± 6.7 56.7 ± 5.8 0.428

Background (SD) 5.81 ± 1.2 6.4 ± 1.1 0.059 5.4 ± 0.9 5.8 ± 0.8 0.029
Hepatic artery SNR 48.7 ± 13.1 45.7 ± 10.3 0.293 46.4 ± 9.9 41.8 ± 11.9 0.032

Hepatic artery CNR 38.3 ± 11.6 36.6 ± 9.7 0.499 35.7 ± 8.6 31.8 ± 11.9 0.054
Student t-test
※ p < 0.001

3a 3b

3c 3d
Figure 3. Assessment of Image Quality by two Radiologists. a. Reader 1 for hepatic CT images. b. Reader 2 for hepat-
ic CT images. c. Reader 1 for CTA images. d. Reader 2 for CTA images.
 Automatic Tube Current Modulation MDCT of Liver 137

2. In subjective assessment of CTA, the majority of
cases were scored as grade 2 or 3 by the two readers.
The percentage of grade 3 or 4 ranged from 36.7%
- 48.1% for reader 1, and 40.3% - 50% for reader 2.
There was no significant difference existing among
the four groups in the image quality scores of hepatic
CT images and CTA assessed by the two radiologists
(ANOVA, p values all > 0.05).
As for the interobserver agreement, there was
no significant difference between the two readers
in each group for the hepatic CT images and CTA
(paired t-test, p values all > 0.05). In ATCM groups
( groups 2 and 4), positive cor relation existed
between the tube current and body weight or BMI.
At 100 kVp, the correlation coefficients between
tube current and body weight or BMI were 0.724 and
0.663 respectively (Figs. 4(a), (b)). At 120 kVp, the
correlation coefficients between tube current and
body weight or BMI were 0.789 and 0.792 respec-
tively (Figs. 4(c), (d)).
The DLP and effective dose in the ATCM
groups (2,4) and fixed current groups (1,3) are listed
in Table 7. There was no significant difference
between group 1 and group 2 either in DLP or effec-
tive dose. At 120 kVp, however, the DLP and effec-
tive dose of ATCM group were significantly lower
than that of the fixed tube current group ( p <0.01).
The mean effective dose reduction of ATCM groups
compared with fixed current groups was 35.9% at
120 kVp and 6.2% at 100 kVp (Table 7).
DISCUSSION
With advances in helical CT technology, images
can be obtained rapidly during different phases of
liver parenchymal enhancement. Previous studies
have reported the value of dual-phase- or triple-
phase- enhanced CT in diagnosis of the various
focal hepatic lesions based on their appearances
during different phases of enhancement [16,17].
Multi- detector row helical CT angiography of
hepatic vessels depicting during arterial phase of
contrast study could demonstrate hepatic vascular
structures, which may be helpful in road-mapping

Table 5. Qualitative assessment of hepatic CT images scored by two radiologists.

Group 1 Group 2 Group 3 Group 4 p value**
Reader 1 3.42 ± 0.50 3.55 ± 0.50 3.51 ± 0.50 3.67 ± 0.47 0.229
Reader 2 3.23 ± 0.42 3.51 ± 0.54 3.37 ± 0.49 3.63 ± 0.48 0.085
p value* 0.203 0.66 0.072 0.598
* paired t-test; ** ANOVA

Table 6. Qualitative assessment of hepatic CTA scored by two radiologists.

Group 1 Group 2 Group 3 Group 4 p value**
Reader 1 2.64 ± 0.70 2.54 ± 0.58 2.43 ± 0.59 2.54 ± 0.72 0.567
Reader 2 2.64 ± 0.75 2.43 ± 0.50 2.37 ± 0.57 2.36 ± 0.48 0.359
p value* 1 0.168 0.419 0.103
* paired t-test; ** ANOVA

Table 7. Comparison of DLP and Effective dose between ATCM and fixed current groups
100 kVp 120 kVp
p value p value
Group 1 (n=27) Group 2 (n=47) Group 3 (n=62) Group 4 (n=46)
DLP (mGy•cm) 928.7 ± 137.9 868.0 ± 201.6 >0.05 1295.9 ± 185.3 829.4 ± 383.5 <0.001

Effective dose (mSv) 13.9 ± 2.2 13.0 ± 3.0 >0.05 19.4 ± 2.8 12.4 ± 5.8 <0.001
* Student t-test
138 Automatic Tube Current Modulation MDCT of Liver

100 kVp ATCM y = 4.3368x + 33.664 100 kVp ATCM y = 11.719x + 33.006
600 2 500
R = 0.5243 R2 = 0.4394
500
400
400
Tube current

Tube current
r = 0.724 r = 0.663
300
300
200
200
100 100

0 0
0 20 40 60 80 100 120 0 10 20 30 40

4a Body weight (kg) 4b BMI (kg/m2)

120 kVp ATCM y = 18.872x - 256.14

120 kVp ATCM y = 6.058x - 186.62
500 500 R2 = 0.6267
R2 = 0.6321
400 400
Tube current

Tube current
r = 0.792
300 r = 0.789 300

200 200

100 100
0
0 20 40 60 80 100 0
0 5 10 15 20 25 30 35 40
4c Body weight (kg)
4d BMI (kg/m2)

Figure 4. The correlations between tube current and body weight or BMI in ATCM groups. a. Correlation between
tube current and body weight at 100kVp. b. Correlation between tube current and BMI at 100kVp. c. Correlation
between tube current and body weight at 120 kVp. d. Correlation between tube current and BMI at 120 kVp.

for surgical resection or transarterial embolization
[18]. However, multiphase contrast-enhanced CT
produced more radiation dose to the patient. The
estimated risk of cancer death for those undergoing
CT examination is 12.5/100,000 population for
each pass of the CT scan through the abdomen [19].
Therefore, the effective reduction of CT radiation
dose to patients is a very important issue in radio-
logical daily practice.
For years, efforts have been made to reduce the
radiation exposure associated with CT. The radia-
tion dose reduction in CT can be modulated by scan-
ning parameters such as tube current and voltage,
scanning modes, and scan length. The scanning
parameters determine photon f luence and incident
beam energy, which affects both image quality and
radiation dose. If other scanning parameters are held
constant, a reduction in tube current decreases radia-
tion dose, however, it increases image noise, which
is one of the major determinants of image quality.
When the tube current increases, it does decrease
image noise, however, it leads to an increase in
radiation dose [20]. To minimize subjective esti-
mation and selection of tube current required to
obtain desired image quality at reasonable radiation
exposure levels, techniques of automatic tube current
modulation (ATCM) have been developed [14, 15, 21,
22]. ATCM allows automatic adjustment in radiation
exposure and maintenance of constant image quality
during CT examinations. The ATCM systems make
use of different types of control, including patient
size, z-axis and rotational (or angular), or a combina-
tion of two or more of these types [14]. The ATCM
rapidly responds to large variations in beam attenua-
tion. It is based on the fact that image noise is deter-
mined by x-ray quantum noise in the transmitted
beam projections. The ATCM controls modulate
tube current on the basis of regional body anatomy
for adjustments of x-ray quantum noise to maintain
constant image noise with improved dose efficiency
[14, 15, 21, 22].
In this study, we found that by using ATCM,
the radiation exposure of CT could be reduced with
maintenance of the image quality of hepatic CT
and CTA compared with fixed tube current groups.
These findings are in agreement with reports using
the angular modulation technique [23 -25]. We
used z-axis modulation technique to adjust the tube
current automatically and maintain a user-specified
quantum noise level in the image data. At the first
localized radiograph, the scanner computes the tube
current needed to obtain images with a selected
noise level, and it attempts to make all images
have a similar noise irrespective of patient size and
anatomy. The noise index value is approximately
equal to the image noise (standard deviation) in the
 Automatic Tube Current Modulation MDCT of Liver
central region of a uniform phantom. In our series,
compared with fixed current groups, ATCM groups
had a significant reduction in tube current while
maintaining similar image noise. Our results are
basically consistent with a previous study using z-
axis modulation technique by Kalra et al [11].
However, Israel et al found that when tube modula-
tion is combined with fast tube rotation time, tube
saturation (t ube cur rent reaching its maximal
capacity) occurs with weaker x-ray tube resulting in
deterioration of image noise [26].
In our study, the mean tube currents of unen-
hanced, arterial and venous phase images in ATCM
groups were lower than those in fixed tube current
groups, even though there was no significant differ-
ence in age, weight and BMI among the four groups
of patients. The average current reductions of
ATCM groups compared with fixed current groups,
were 20.4% and 24.5%, 8.6% and 44.2% at 100 kVp
and 120 kVp respectively. These results were quite
similar to previous report by Kalra et al, which
found an average current reduction of 35.6% for the
abdomen at the level of porta hepatis with z-axis
ATCM compared with 140 kVp/380 mA fixed tube
current group [11]. In the aspect of radiation dose,
we found that the effective doses and DLPs in ATCM
groups were significantly lower than those in fixed
tube current groups. At 120 kVp, the mean effec-
tive dose can be reduced 35.9% in ACTM groups
comparing with fixed current groups. These find-
ings are in agreement with previous reports [11, 23],
therefore, ATCM can be helpful to reduce radiation
dose of patients in clinical CT examination. The
DLPs of ATCM of groups are below the diagnostic
reference level of European guidelines, while those
in f ixed tube current groups are higher than the
reference level (900 mGy for liver and spleen) [27].
Although ATCM systems generally reduced
radiation dose, image noise inevitably increased,
particularly in the region of contrast material related
artifacts [14]. In quantitative analysis of hepatic
CT image and CTA quality, there was generally
no significant difference in artery and muscle HU,
background noise, SNR and CNR between ATCM
and fixed current groups. This indicates that ATCM
could basically maintain the image quality of the
liver. Nevertheless, there were a few exceptions, that
at 120 kVp, the ATCM group showed significantly
higher background noise and lower SNR of the
hepatic artery than the fixed current group. This
is probably because the actual noise measured in a
region of interest on an image often differs from the
139
selected noise index. The noise index setting only
adjusts the tube current, whereas the image noise
can be also affected by other parameters such as
the reconstruction algorithm, reconstructed section
thickness, variations in patient anatomy, and beam-
hardening artifacts [11]. It is reasonable that the
marked tube current reduction may also contribute to
the increase in noise.
Basically, there was no significant difference
of hepatic artery HU, SNR and CNR between the
ATCM and f ixed current groups in quantitative
analysis. It could, therefore, be expected that
there would be no significant difference in hepatic
CTA quality between the ATCM and fixed current
groups. We found that the 100 kVp groups had
significantly higher mean hepatic artery HU than the
120 kVp groups. This is consistent with studies by Erl-
Wagner et al in brain CTA [28], Wintersperger et al
in aorta-iliac CTA [12] and Heyer et al in
pulmonary CTA [29]. The absorption value of the
blood vessels containing iodine contrast medium
will be influenced by the amount of photon energy
[28]. The K edge of the iodinated contrast medium
is about 33.2 keV [30]. In the MDCT, the voltage
is usually 120-140 kVp (66-72 keV) which exceeds
the energy of the best absorption value of the iodine
[10]. With the low voltage CT techniques, it will be
relatively close to the best absorption energy value
of the iodinated contrast medium in the blood vessel.
In the study of Hude et al, the absorption value of
iodine in 100 kVp was 27% more than that of 120
kVp [10]. Although lower voltage will increase
absorption value of iodine in the contrast medium,
it can reduce f lux of photons and lead to increased
noise. As a result, the SNR and CNR may remain
with no significant difference between 100 kVp and
120 kVp groups.
In qualitative assessment of hepatic CT images,
the majority of our cases were graded as good (grade
3) or excellent (grade 4) in each group, providing
satisfactory images for radiological diagnosis. There
was no significant difference in the quality assess-
ment of hepatic CT images among the four groups.
No significant interobserver disagreement existed
between the two readers in each group. As to the
qualitative assessment of hepatic CTA, most cases
were categorized as grades 2 and 3. Only about 40-
50% of hepatic CTA provided sufficient clinically useful
information. The causes of image degrading of
hepatic CTA in our series could be due to a rela-
tively slower injection speed (3-4 ml/sec) and the use
of fixed scan delays which did not take in account
140 Automatic Tube Current Modulation MDCT of Liver
individual patient variations in circulation time [9].
There was no significant difference in the quality
assessment of hepatic CTA among each group. No
significant interobserver discrepancy was noted.
From the data of ATCM groups, we found that
there were good correlations between tube current
and body weight or BMI at either 100 kVp or 120
kVp. Our findings are consistent with a previous
report by Huda et al [10]. The current practice for
CT scanning at many institutions is to use the fixed
technique factors regardless of patient weight [10,
30, 31]. This could cause either increased radiation
dose to the patient if higher current is being used or
degraded image quality by increasing noise if lower
current is being used. Kalra et al in their study
concluded that z-axis ATCM resulted in reduced
tube current-time product with similar image noise
and diagnostic acceptability at CT of abdomen and
pelvis compared with manually selected fixed tube
current [11]. Our results demonstrated good corre-
lations between tube current and body weight or
BMI, further supporting the reliability of ATCM in
providing appropriate tube current for abdominal CT
scanning.
ATCM can sig nif icantly reduce radiation
dose of CT examination while maintaining image
quality as we have shown in this study. ACTM also
has advantages in avoidance of photon starvation
artifacts and reducing load to the x-ray tube [21, 22].
On the contrary, Althen found that photon starva-
tion artifacts remain when using z-axis ATCM [32].
However, there are still problems in clinical applica-
tion of ATCM: (1) Standardization: Differences in
types of ATCM introduced by different vendors
make universal standardization for different scan-
ning protocols difficult [14, 15, 33]; (2) Optimum
image quality: Inappropriate selection of noise index
or reference mA for ATCM may result in unaccept-
able image quality, and image noise may increase
in the regions adjacent to contrast material- or
prosthesis-related artifacts [15, 33]; (3) Higher dose
in heavier patients: ATCM increases radiation dose
for heavier patients, and this may be encountered
especially if selected image quality must be main-
tained [15, 33]; and (4) Quality in smaller patients:
ATCM requires modification in small patients to
avoid excessive tube current reduction, which can
occasionally result in noisy images [15, 33].
There are several limitations in this study. We
evaluated the hepatic CT and CTA image quality
by comparing 4 protocols in 4 different groups of
patients. We did not compare the different protocols
in the same patients. Because the presence of
enhanced portal veins may interfere with the hepatic
artery at 3D CTA, the timing of scanning might
not be optimized in patients with various clinical
situations. This could be improved by changing the
manual scan delay time to aortic tracking techniques
with an automatic detection system. We evaluated
examinations performed with z-axis modulation by
using the noise index suggested by the vendor. We
did not assess the image quality by altering different
levels of the noise index. Although our study
demonstrated a significant reduction in tube current
and DLP by ATCM with maintenance of image
quality, a larger study cohort and greater range of
noise index values would be necessary to validate
our findings.
In conclusion, compared with the f ixed tube
current techniques, z-axis modulation could provide
significant reduction of tube current, DLP and
estimated effective dose with maintenance of similar
image quality for hepatic CT and CTA assessed
either by subjective grading score or objective
quantitative analysis. Therefore, routine usage of the
ATCM techniques for hepatic CT and CTA may be
warranted for reasonable reduction of radiation dose
to the patients. 
ACKNOWLEDGEMENT
We thank Hui-Min Chu for assembling clinical
data and typing the manuscript.
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 Society for Radiological Protection Journal of Radiological Protection
J. Radiol. Prot. 36 (2016) R74–R95 doi:10.1088/0952-4746/36/3/R74

Review

Setting up computed tomography

automatic tube current modulation
systems
C J Martin1 and S Sookpeng2
1
Health Physics, Department of Clinical Physics, University of Glasgow,
Gartnavel Royal Hospital, Glasgow, G12 0XH, UK
2
Department of Radiological Technology, Faculty of Allied Health Sciences,
Naresuan University, Phitsanulok 65000, Thailand

E-mail: colin.j.martin@ntlworld.com

Received 13 February 2016, revised 9 April 2016

Accepted for publication 8 July 2016
Published 3 August 2016

Abstract
Automatic tube current modulation (ATCM) on CT scanners can yield
significant reductions in patient doses. Modulation is based on x-ray beam
attenuation in body tissues obtained from scan projection radiographs
(SPRs) and aims to maintain the same level of image quality throughout a
scan. Noise level is important in judging image quality, but tissues in larger
patients exhibit higher contrast resulting from the presence of fat. CT scanner
manufacturers use different metrics to assess image quality. Some employ
a simple measure of image noise, while others adopt a measure related to
a reference image that accepts higher noise levels in more attenuating parts
with higher contrast. At the present time there is no standard method for
testing ATCM. This paper reviews the operation of different ATCM systems,
considers options for testing, and sets out a framework that could be used for
optimizing clinical protocols. If dose and image quality can be established
for a reference phantom, the modulation performed by ATCM systems
can be characterised using anatomical phantoms or geometrical elliptical
phantoms which may be conical or include sections of varying dimension.
For scanners using a reference image or mAs, selection of the image quality
reference determines other factors. However, for scanners using a noise
reference, a higher noise level should be selected for larger patients to avoid
high doses, and the operator should ensure that appropriate limits are set for
mA modulation. Other factors that need to be considered include the SPRs
used to plan the ATCM and image thickness. Users should be aware of the
mode of operation of the ATCM system on their CT scanner, and be familiar
with the effects of changing different protocol parameters. The behaviour of
ATCM systems should be established through testing of each CT scanner
with suitable phantoms during commissioning.

0952-4746/16/030R74+22$33.00 © 2016 IOP Publishing Ltd Printed in the UK R74

J. Radiol. Prot. 36 (2016) R74 Review

Keywords: computed tomography, CT, automatic tube current modulation,

CT AEC, CT optimization, diagnostic radiology

1. Introduction

The importance of computed tomography (CT) scanning has increased steadily as the
sophis- tication and flexibility of scanners has evolved over the last 30 years. When the last
UK review of doses to patients was undertaken, CT scans made up 60% of the collective
dose to patients from medical diagnostic exposures (Hart et al 2010). The key role that
optimization of radiation protection plays in keeping CT doses to an acceptable level has
been high- lighted by the International Commission on Radiological Protection (ICRP)
(2007). The UK Committee on Medical Aspects of Radiation in the Environment
(COMARE) recommends that a full range of dose reduction features are included on CT
scanners (COMARE 2014). A major technological development to aid in optimization in the
last decade has been the inclu- sion of facilities to modulate the tube current to compensate
for variations in the attenuation of patients’ body tissues (Kalra et al 2004, McCollough et al
2006). These facilities perform adjustments which allow both for differences in patient size
and for variation in tissue attenu- ation during scans of individual patients. Automatic tube
current modulation (ATCM) was highlighted by the ICRP as one of the improvements that
could reduce the doses from CT examinations (ICRP 2007), and when used effectively
ATCM can reduce doses to individual patients by 40%–60% (Mulkens et al 2005, Rizzo et
al 2006, Lee et al 2008, Söderberg and Gunnarsson 2010).
Thus ATCM systems offer considerable potential for the reduction of doses to patients.
This coupled with the availability of iterative reconstruction of CT images and optimizing of
tube potential should allow much lower dose CT scanning in the future. The modulation of
tube current (mA) is based on assessment of the attenuation of the x-ray beam and is
designed to maintain a similar level of image quality throughout a scan. Adjustments are
made as the x-ray tube rotates around the patient with the smaller diameter antero-posterior
(AP) direction receiving a lower exposure than the lateral. Adjustments are also made as the
scan progresses along the patient with a higher mA used for the thicker lateral shoulder and
hip regions, and a reduced current used where the soft tissue attenuation is lower in the
thorax and abdomen. The ATCM systems also change exposure levels according to patient
size to give a more uniform level of image quality for every patient, in a similar manner to
the automatic exposure control on radiographic systems.
There have been a variety of studies showing the variation in patient dose with patient
size under ATCM operation (Schindera et al 2008, Israel et al 2010, Meeson et al 2010,
Zarb et al 2010, Sookpeng et al 2014) and on the optimization of image noise and dose as
a function of patient size (Siegel et al 2004, Verdun et al 2004, Li et al 2012). These studies
show that potential reductions are dependent on the appropriate selection of the scanning
parameters and image quality reference. The operator can adjust some scan acquisition
parameters in order to obtain the desired image quality, but increases in the exposure factors
that result in higher quality images will go undetected, unless dose levels are monitored
closely, so there is considerable scope for the operator to perform CT examinations at higher
dose levels than necessary. Wide variations are observed in large dose surveys even among
facilities using the same CT scanners (Mettler et al 2008, Martin and Huda 2013, Shrimpton
et al 2014). There are many factors that affect ATCM performance and the manner in which
they interact varies between CT manufacturers (Gutierrez et al 2007, Söderberg and
Gunnarsson 2010, Sookpeng et al 2013), so ensuring that systems are set up correctly is
not straight forward. Moreover,

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J. Radiol. Prot. 36 (2016) R74 Review

there are as yet no standard methods for testing ATCM systems, as this requires assessment
of performance under a range of conditions. This paper reviews methods of ATCM opera-
tion on different scanners, considers the options for carrying out tests of ATCM systems,
and goes through the factors that influence ATCM performance with which operators should
be familiar. Results presented in the figures are derived from analyses of experimental data
from an earlier study (Sookpeng et al 2013) and patient doses data from surveys in the West
of Scotland.

2. Operation of ATCM systems

The first requirement for the operation of ATCM is the determination of patient attenuation.
This is done primarily from scan projection radiographs (SPRs), called variously scout,
topo- gram, surview or scanogram by different manufacturers, which include information on
both patient tissue sizes and attenuations. The adjustments may be based on a single SPR
using predictive calculations of the difference in AP/lateral dimensions or two SPRs.
Siemens can use either two SPRs or a single SPR and adjust the angular mA based on online
feedback measurements during each tube rotation. The attenuation profile measurements
made from the previous 180° view are used to calculate the angular modulation of the mA.
For all CT scanners, the average attenuation values for each rotation from the SPR are
converted into water equivalent thicknesses (WETs), and the mA is set automatically at each
Z-position to achieve a selected image quality reference based on the WET using proprietary
algorithms. The variation may be in the form of step changes in mA for every AP and lateral
quadrant, or a sinusoidal interpolation between AP and lateral values. Thus the exposure,
which is deter- mined by the product of tube current (mA) and exposure time (s) or mAs, is
varied along and around the body to match the tissue attenuation for each patient, and the
current modulation will follow different patterns, depending on body shape.
The parameter that is used as the image quality reference has an important bearing on the
operation of ATCM, but different approaches are used by CT scanner manufacturers. Noise
is the obvious parameter when making adjustments as different regions of the body are
imaged, but the situation is more complicated when dealing with patients of different size.
The ability to detect structures in an image depends on the signal to noise ratio, and more
particularly for x-ray imaging, the contrast to noise ratio. A factor that needs to be taken into
account is that organs in larger patients are separated by a layer of fat and the images have a
higher contrast resulting from the presence of fat (Wilting et al 2001). This allows
anatomical structures in larger patients to be visualized with a higher noise level, whereas a
lower noise level is required for smaller patients and children in whom the contrast is poorer
and the anatomical detail to be visualized may be finer. There are important differences
between manufacturers in the image quality references used, the way in which acceptable
image quality is defined, and the algorithms that govern the modulation, and all these affect
the way that ATCM is imple- mented (Söderberg and Gunnarsson 2010, Sookpeng et al
2014).
Siemens and Philips use measures that increase the acceptable noise level as attenuation
increases to allow for the higher contrast in larger patients. For the Siemens CARE Dose 4D
system the operator chooses an image quality reference mAs relating to a standard patient
(Stratis et al 2013, Söderberg 2016). An algorithm determines how the dimensions meas-
ured from the SPRs compare with those for the standard patient and the operator chooses the
strength of the mA modulations (very weak, weak, average, strong or very strong). Choice
of a strong modulation will give a larger increase in mAs for larger patients and a greater
reduction for smaller ones. For the Philips system, DoseRight, automatic current selection
(ACS) determines the operation of the ATCM, and can vary the current either along the
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scan direction (Z-DOM) or with angle around the patient (D-DOM) (Wood et al 2015). The
system uses a reference image concept and the mA is adjusted to achieve a similar level
of image quality for the patient being imaged. An automatic patient size averaging facility
learns from the scanning of patients based on intervention by the operator, so that the patient
reference can evolve during clinical use, and adjusting the mAs per slice when planning a
scan may result in a drift in settings over time. There is an alternative manual mode which
uses a reference image from a selected patient, and use of this option avoids the changes
once optimized settings have been established. In both the Siemens and Philips systems, the
noise level increases with attenuation of the patient section being imaged and the limits on
mA are derived from the SPR, the upper limit being based on the most attenuating section of
the patient.
In contrast, General Electric (GE) and Toshiba use a measure of noise based on the
standard deviation (SD) in a standard phantom directly as the image quality reference. GE
AutomA 3D has z-axis (AutomA) and angular modulation (SmartmA), with the mA being
changed for each quadrant during every rotation (Moro et al 2013). The image quality ref-
erence is a noise index selected by the operator that is approximately the SD in a 200 mm
water phantom. The Toshiba SureExposure 3D system uses a similar approach with a target
noise level relating to the SD in the first axial image reconstruction set by the user and
varying through high quality, quality, standard, low dose and very low dose (Sookpeng et al
2015). The ATCM for both GE and Toshiba aims to maintain the same noise level through-
out a scan. Since this does not take account of differences in contrast between patients,
systems require the operator to select a higher noise reference level for larger patients,
and if this is neglected it can lead to high doses for large patients (Sookpeng et al 2014).
Adaptive software is included in current models to adjust the reference image quality with
patient attenuation, decreasing the target SD for small patients and increasing it for larger
ones. Standard settings are recommended for all models, but the user can choose alterna-
tives to achieve the required image quality for particular clinical tasks. It would be difficult
to achieve a constant noise level throughout every patient because of the wide range in size
and the technical requirements. Minimum and maximum limits are set for the mA modula-
tion, which can be selected by the operator.
Most companies now also offer the facility to use information from the SPR to optimize
both tube potential (kV) and mAs to achieve the chosen contrast-to-noise ratio. Image con-
trast increases as the kV is reduced, and this is especially useful for iodine contrast studies.
Patient-specific mAs curves are calculated for different kV levels based on the scan range,
patient anatomy, and the contrast required. An optimized kV is then selected for the patient
protocol and only the mA is modulated during the scan. Clinical studies have demonstrated
that scanning at a lower kV using a higher noise reference can provide images with
improved contrast at reduced patient doses and with systems having automated kV
selection, 100 kV is the setting adopted most frequently (Rampado et al 2009, Lee et al
2012, Vardhanabhuti et al 2013, Mayer et al 2014). In principle kV can be selected
manually depending on size for each patient, in a similar manner to radiography
examinations, with 100 kV for an aver- age 70 kg–80 kg patient, 120 kV or even 140 kV for
larger patients, and 80 kV for smaller ones. Another facility incorporated into new CT
scanners is a reduction in mA to the anterior aspect of the body by up to 60% in order to
minimize doses to radiosensitive organs such as the breasts and eye lenses. These facilities
coupled with iterative reconstruction techniques can pave the way to substantially lower
dose CT. However, the availability of more sophis- ticated techniques for reducing doses,
has made the process of optimization more complex, and an understanding of the interplay
of the many different factors involved is necessary if their potential is to be realized.

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3. Assessment and optimization of ATCM systems

3.1. Assessment of CT dose and image quality

The dose performance of CT scanners is tested through measurement of the CT dose index
(CTDI) with a 100 mm ionization chamber in standard cylindrical phantoms made from
poly- methyl methacrylate (PMMA) 320 mm and 160 mm in diameter representing the body
and head respectively (IEC 2003). Measurements are made with a CTDI chamber at the
centre (CTDIc) and four peripheral (CTDI p) positions, for which results are averaged, in a
phantom, and the weighted CTDI (CTDIw) derived using the equation:
CTDIw = 1/3CTDIc + 2/3CTDIp
The volume averaged CTDI (CTDIvol), is derived by dividing the CTDIw by the pitch of the
tube rotation (table movement/ beam width). It is displayed on CT scanner consoles and used
in evalu- ation of patient doses. For dosimetry purposes, the CTDIvol values for the two
phantoms are very different, so in any study of ATCM performance it is important to ensure
that it is clear which CTDIvol is being used. The CTDIvol was designed to provide a measure
related to the average dose within a CT slice, but the actual dose will be dependent on the
patient or phantom dimensions. In order to take account of changes with patient size, an
adjustment can be made to the CTDIvol to give a size specific dose estimate that approximates
to the average tissue doses for patients of different size (AAPM 2014). In this study although
phantoms with elliptical cross sections of different sizes are used, it will be the CTDIvol for the
standard 320 mm PMMA phantom that is displayed on the CT console which will be
employed for the analyses of ATCM performance.
Image quality is assessed using other cylindrical phantoms containing contrast detail
tests. It is difficult to incorporate ATCM system performance into these tests, since the
phantoms have fixed dimensions. An option that provides a good test of ATCM is to scan an
anatomi- cal phantom representing a standard adult, but a set of phantoms of different sizes
would be required to fully evaluate ATCM performance and data from phantoms of this type
cannot be quantified readily. A geometrical phantom with sections having a range of dimensions
can be used to assess the modulation for patients of different sizes, but performance
quantities that might be measured will vary along the phantom. Dose levels at different
positions inside a phantom will be determined by the incident air kerma and the phantom
dimensions which affect the attenuation and scattering, and will vary with position both
within the phantom and in the scan field. Therefore the measure of mA provided by the CT
scanner is an easier quantity through which to assess the relative variation in exposure. The
relationship between dose in terms of the CTDI vol measured in a phantom and the mA will
vary with the CT scan- ner, as it depends on the attenuation and shape of the bow-tie filter,
but the mA provides a useful indicator of relative changes in dose for individual CT
scanners. There are ranges of attenuations along the lengths of anatomical phantoms and
these data can be used to provide an indication of the variation in mA with attenuation.
Quantification of attenuation data along the lengths of such phantoms might also allow
changes in mA with attenuation to be quanti- fied. Image quality can most readily be
assessed through changes in noise along the phantom. Data acquired as part of the study
described in Sookpeng et al (2013) are included in the first two figures, and additional
analyses of data from this study are included in later figures.

3.2. Designs of geometrical phantom design

A phantom for testing ATCM systems needs to be elliptical to take account of changes in
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cur- rent as the x-ray tube rotates around the body. An axis ratio of 3:2 provides a realistic
cross

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800 40

700 NI 20.83
600 30 NI 16.20
NI_11.57 NI 11.57
500 Fixed mAs
NI_16.20
Tube Current

Measured SD
400 NI_20.83 20

300

200 10

100

0 0
40 80 120 160 200 240 280 40 80 120 160 200 240 280
Distance from end of phantom (mm) Distance from end of phantom (mm)

a b
450 50
400 Z DOM 405mAs/Slice 188 mAs/slice
350 Z DOM 300mAs/Slice 40
Z DOM 250mAs/Slice 250 mAs/slice
300 Z DOM 188mAs/Slice 300 mAs/slice
Measured SD 30 405 mAs/slice
250
Fixed mAs
mAs/

200
20
150
100 10
50
0 0
40 80 120 160 200 240 280 40 80 120 160 200 240 280
Distance from end of phantom (mm) Distance from end of phantom (mm)
c d

Figure 1. Plots of mA (a) and (c) and image noise (b) and (d) recorded from scans
along the length of a PMMA conical ImPACT phantom from dimensions of 110 mm
× 55 mm at 40 mm, to 411 mm × 206 mm at 280 mm (Sookpeng et al 2013). The
results are for a GE scanner with smart mA and different noise index settings (a) and
(b) and a Philips scanner with ACS Z-DOM ATCM and a range of setting for the mAs
per slice (c) and (d). Plots of the variation in noise resulting from use of fixed mAs
values are also given in (b) and (d).

section for much of the trunk, but a wider section (e.g. ratio 2:1) would be required to mimic
the shoulder region. ATCM phantoms should cover a substantial portion of the useful range
of patient attenuation encountered routinely in clinical practice, with a steady progression
from the smallest to the largest diameter. The majority of phantoms go from diameters less
than that of the neck up to diameters larger than an average patient, typically over 400 mm in
order to allow trends in dose level for larger patients to be assessed. However, the
implications of size on manual handling must be considered if a phantom is to be transported
between different hospitals for routine testing. There must also be a facility to suspend the
phantom horizontally in the x-ray beam, without the interference of support material.
A number of phantoms have been based on cones with diameters varying continuously
along the length. An elliptical conical phantom made from PMMA with axis ratio 3:2 and a
largest diameter of 424 mm has been used by ImPACT (Keat et al 2005, Sookpeng et al
2013) and others have used related designs (Gutierrez et al 2007, Muramatsu et al 2007,
Field 2010, McKenney et al 2014). The differences in performance between different modes
of scanner operation can be seen clearly in results from scans of this design of phantom for
Philips and GE CT scanners (figure 1). The mA increases with phantom diameter for both
scanners over
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Figure 2. Plots showing the variation in mA along a phantom from a GE Lightspeed

CT scanner using a 32 mm wide beam showing the variations triggered by the sharp
discontinuities in attenuation for each tube rotation. The phantom is made from
elliptical polyethylene sections representing the dimensions of the human torso
(Sookpeng et al 2013) is sketched in diagrammatic form below the plot (not to scale).
The mA is varied in quadrants corresponding to the AP/PA and lateral tube
orientations around the phantom and the two values are shown for each rotation. The
resulting mAs per image along the phantom is plotted beneath.

the range of cross-sectional areas from about 250 cm2 to 700 cm2, but starts to level off
towards the upper end, with that for the GE scanner reaching the maximum mA value
(figure 1(a)). The noise level in the GE scanner remains fairly constant over most of the
phantom, in line with the use of the noise reference comparator, but begins to increase at the
point where the mA reaches the maximum value (figure 1(b)). Whereas the noise in images
from the Philips scanner, for which the comparator is a reference image, starts at a lower
level in the narrower end of the phantom, but rises steadily as the diameter increases (figures
1(c) and (d)). The mA does not reach a maximum at a particular value, and the relative
increases in current with size are similar for the different mAs settings. The mA for the GE
scanner rises more steeply under ATCM control as the phantom diameter increases than that
for the Philips one in order to maintain a constant noise level and this translates into a
proportionately more rapid increase in patient dose with body size. Thus conical phantoms
provide a good indication of perfor- mance in terms of the variation in mA modulation and
image noise with phantom diameter. They do not provide positions where factors are
constant or ones that can readily be identified for measurement of dose.
An alternative design is a stepped phantom made up of a series of polyethylene or
PMMA sections of different diameter (Sookpeng et al 2013, McKenney et al 2014).
However, the sharp steps in attenuation between sections do not mimic the smooth
variations encountered
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Figure 3. Plots of the mAs per slice recorded from scans of a sectional PMMA
phantom shown in diagrammatic form (not to scale) with a Toshiba Aquilion scanner
using SureExposure 3D. The plots show the variations triggered by the sharp
discontinuities in attenuation by version 6 of the Toshiba software and the reduced
oscillation achieved in version 7.

in the body, and there may be small air gaps between sections that can give large
discrepancies in x-ray penetration. These sharp variations in attenuation affect the way in
which the ATCM operates on some CT scanners, particularly those using image quality
references based on noise level, as the algorithms are designed to be more responsive to
small changes in attenu- ation, and over-compensate for step changes that do not normally
occur in the human body. Figure 2 shows an example of the sharp changes in mA that may
occur every quadrant with GE and Toshiba scanners. Large increases and decreases in mA
occur on the next rotation following respective increases and decreases in phantom
attenuation as the phantom moves through the CT gantry. Thus although this design of
phantom is easier to construct it is not suitable for testing all CT scanners in use at the
present time and this is discussed in more depth by Sookpeng et al (2013). The problems
relating to the scanning of stepped phan- toms are being addressed by manufacturers in
more recent scanners. For example whereas the Toshiba SureExposure 3D version 6 based
the changes in mA on the actual SPR of the phantom and gave sharp variations in mA when
step changes were encountered, that in ver- sion 7 uses an internal SPR with substantially
improved mA calculation at such step changes (figure 3). Phantoms with limited numbers of
elliptical sections can potentially be used for dosimetry and noise measurement, but in order
for them to perform satisfactorily with some CT scanners currently in service, sharp
discontinuities in attenuation may need to be limited to less than 6% and air gaps between
sections excluded to minimize the effects described above (Sookpeng et al 2013). The
flexibility of such phantoms may be improved by incorporating annular wedges between
adjacent sections to eliminate sharp discontinuities. In order to accu- rately characterise dose
performance within sections of fixed diameter, lengths of individual sections should ideally
be three times the beam width used for testing. Another option is to
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Table 1. Properties of phantom materials and

water.
Mass energy
Effective
Energy atomic Density Mass attenuation absorption
Materials (keV) number (g cm−3) coefficient (cm2 g−1) coefficients
Water 60 7.42 1.00 0.2059 0.031 90
80 0.1837 0.025 97
100 0.1707 0.025 46
120 0.1615 0.026 25
PMMA 60 6.48 1.17 0.1924 0.025 30
80 0.1751 0.023 02
100 0.1641 0.023 68
120 0.1558 0.024 83
Polyethylene 60 5.44 0.92 0.1974 0.022 36
80 0.1826 0.022 65
100 0.1722 0.024 23
120 0.1638 0.026 28
Cast nylon 6 60 6.85 1.14 0.2058 0.032 87
80 0.1831 0.026 32
100 0.1701 0.025 58
120 0.1617 0.025 73
Note. Coefficients taken from Hubbell and Seltzer (1995), with values for 120 keV derived from fits of data which
did not include values between 100 and 150 keV.

use a series of shorter elliptical sections with small changes in diameter between sections to
create a conical phantom. This approach has been adopted in the production of the Leeds CT
AEC phantom, which comprises eleven PMMA ellipses, each 25 mm thick, for which the
steps in attenuation between adjacent sections are smaller (www.leedstestobjects.com/index.
php/phantom/ct-aec-phantom/) (Wood et al 2015).
The phantoms described so far have been made from PMMA or polyethylene, but other
materials such as nylon, which has an effective atomic number and attenuation coefficient
simi- lar to water, could be used, and properties are compared in table 1. When scanning any
of these phantoms it is recommended that the SPR used to plan the scan is set within the
boundaries of the phantom, as the large changes in attenuation at the start and end of the
phantom can lead to unrealistic tube currents that affect the performance of some ATCM
systems. In addition, it is better to carry out the tests using smaller beam widths, so that the
response is averaged over a smaller range of diameters in conical phantoms and the response
in the centre of a section can be quantified more reliably for sectional ones. Some phantoms
also have facilities for measure- ment of dose in the centre with an ionization chamber either
a 100 mm CTDI pencil chamber or a smaller one to give the dose at a central position. If a
dedicated ATCM phantom is not avail- able, some information on ATCM performance could
be obtained using a nested PMMA CTDI phantom, that is one in which the 160 mm diameter
standard head phantom fits within a larger annulus to form the 320 mm body one (Tsalafoutas
et al 2013). Offsetting the head and body sections will allow three regions of differing
attenuation to be created, although such a phantom will have a circular rather than an
elliptical cross-section and contains sharp discontinuities.

3.3. Patient dose audit

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Having a phantom with a range of diameters allows the performance of a scanner ATCM
system to be assessed qualitatively, but gives little information about dose performance in

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Figure 4. Data for groups of 500 patients undergoing chest-abdomen-pelvis

examinations ordered in terms of increasing DLP on each of five Toshiba Aquilion
64 CT scanners for. All the scanners use sure exposure 3D ATCM in which the image
quality is selected in terms of a noise reference, and in all the target noise was set by
the operators. Each curve represents values for CAP examinations performed on a
different scanner (A)–(E). The median values for unit A are 40% higher than those for
unit E and the 3rd quartile values are 70% higher.

clinical practice. The dose performance of CT scanners is described in terms of two measur-
able quantities, the CTDIvol (IEC 2003), which relates to the dose per unit length of a patient
taking account of the pitch of the x-ray tube rotation, and the dose length product (DLP),
which gives a measure related to the total dose received by a patient from an examination.
The dose performance of CT scanners in clinical practice is assessed through audit of dose
quantities for patient examinations (IPSM 1992, Martin 2011). It is now possible to
download large amounts of DLP and CTDI vol data from Radiology Information Systems on
all patients scanned within particular periods (Wood et al 2012, Martin 2016). In the past
when data were only available for a limited number of patients, it was necessary to restrict
the range of patient weights for each examination studied, but with larger numbers of results
this is unnecessary. The median value of the distribution of dose quantities for all patients is
recommended for these assessments of larger numbers of patients (Martin 2016).
Comparison of median patient doses for examinations performed on CT scanners with
diagnostic reference levels (DRLs) enables their performance to be assessed. If the median
dose exceeds or is close to the DRL, then the scanner protocol should be reviewed and
factors optimized. Valuable information on optimizing scanning protocols can be obtained
by comparing results for different scanners. But judgements on the optimal dose levels must
take account of the image quality and users must be assured that it is adequate for the types
of examination to be performed. Figure 4 shows patient doses for chest abdomen pelvis CT
examinations listed in order of increasing DLP for five Toshiba Aquilion CT scanners in
which the target noise values were selected by the operators. The DLPs rise more steeply
towards the end of the distribution for scanners A, B and C linked to higher dose levels for
larger patients, whereas the rise is lower for scanners D and E. The median DLPs for all
scanners are within 40%, but those with ATCMs using the
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Figure 5. Plots of the relative x-ray tube current against diameter of the lateral axis
of the conical elliptical PMMA phantom as selected by the ATCM systems on the
CT scanners of four CT scanner manufacturers operating at 120 kV. A curve is also
shown relating to the reciprocal of the air kerma transmission for 120 kV with 8 mm
of aluminium filtration excluding scatter. The results are normalized with respect to
the performance for an ellipse with lateral diameter 300 mm. Two curves are shown
for Toshiba, representing the modulation of the ‘low dose’ and ‘standard’ image
quality reference options.

same reference noise level for all patients gave higher doses to heavier patients. Differences
between CT scanners in patient dose distributions can be identified by comparing the 3rd
quartile values of the DLPs as well as the medians (figure 4) (Martin 2016). If the image
qual- ity given by scanners using a lower dose protocol is judged to be acceptable, then this
can be used as a guide in setting up protocols on other scanners. The distribution of doses
for groups of patients on different scanners will depend on the relative weight distributions.
However, as a rough guide to whether protocols are optimized for larger patients, the user
could take scan- ners where the third quartile is more than about 50% higher than the median
of the dose distri- bution as the starting point for carrying out an investigation. Changes
made to protocols may involve setting a higher noise reference for larger patients. In current
models of CT scanner, such large increases in dose for Toshiba and GE scanners should be
avoided by the automatic setting of higher reference noise levels for larger patients, but in
many models in use currently, this will not be the case.

3.4. Investigating ATCM performance

If the dose performances of different CT scanners for a standard sized patient are adjusted
so that they are similar, then the mA modulations produced by their ATCM systems along a
conical or sectional phantom can be compared. The relative values for the mA for different
parts of the phantom can be obtained from mA versus phantom position curves, such as
those shown in figures 1(a) and (c). Results of this type are plotted as a function of the larger
axis diameter for the elliptical conical phantom for CT scanners from the four manufacturers
in figure 5. Tube current data have been normalized with respect to the requirement for a
PMMA phantom of diameter 300 mm, which equates to an attenuation similar to that for
320 mm
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Figure 6. Plots of image noise in terms of SD in Hounsfield number against diameter

of the lateral axis of the conical elliptical PMMA phantom as selected by the ATCM
systems using the standard option at 120 kV for CT scanners of four CT scanner
manufacturers. A curve is also shown representing the variation in image noise with
a fixed tube current. The settings used are given in the key after the manufacturer. The
dotted line represents values for a fixed tube current with no ATCM.

of water. A curve equating to the mA required to maintain the same level of transmitted air
kerma is also included for comparison. The forms of the normalized curve for different
image quality reference values on each individual scanner were generally similar. The
scanners that apply a reference image or mAs (Philips and Siemens) use a higher mA for
smaller patients, whereas those based on a noise reference (GE and Toshiba) increase the
mA more for larger patients. The form of the latter group is similar to the curve representing
the reciprocal of the transmitted air kerma (figure 5). There is some levelling off in mA at larger
diameters for these scanners, when the mA reaches the maximum value. Two curves are
included for the Toshiba scanner showing that with the ‘low dose’ option that starts at a
lower mA, a wider mA range can be achieved, whereas with the ‘standard’ range the
modulation is curtailed when the mA reaches its maximum value. In practice the actual mA
selected for the standard option would be substantially greater than that for the low dose one,
but when normalized the programmes follow similar trajectories at low and medium
phantom diameters, while at large diameters the actual mA values for the two options both
approach the maximum value.
Plots comparing the variation in noise in terms of the measured SD in the image along the
conical phantom for different CT scanners are shown in figure 6 for the settings regarded as
the standard options. The GE and Toshiba scanners maintained a fairly constant noise level
through the middle part of the phantom, whereas the noise level in the Philips scanner rose
steadily, although much less than the noise when a fixed mA was used with no ATCM. The
noise level for all options tended to rise towards the thicker end of the phantom as the mA
approached the limiting value. Each CT scanner offered a range in the choice of image qual-
ity level from low dose and to high image quality and plots of the measured noise for the
upper and lower levels along the length of the phantom for three of the scanners are shown
in figure 7. The SDs of the lowest dose (LD) options were 2–3 times those for the highest
image quality (HQ) in each case. There is considerable overlap between the ranges for the
different scanners, with the main difference being that the noise varied less with phantom
diameter for the GE and Toshiba scanners that used a noise based reference, compared to
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the Philips

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scanner. If the main factor contributing to improved contrast in larger patients is the
presence of fat, then it might be argued that maintaining the same level of noise throughout
the scan of an individual patient is a better approach, provided the appropriate noise
reference is selected. However, if ATCM operation is based on a reference image or mAs, as
practised by Philips and Siemens, it can be adapted more readily to scanning patients of
differing size, as a similar image quality reference can be chosen for all patients. Thus
there are arguments in favour of both approaches to the choice of image quality reference,
but the important thing for the operator is to understand how the ATCM system on each CT
scanner performs and adapt the settings to suit all groups of patients.

3.5. Strategies for optimizing ATCM performance (section revised)

Wood et al (2015) describe how, following a dose audit on Philips CT scanners, they were
able to optimize examinations based on what was considered to be the optimum protocol.
They chose the third and fourth sections of a Leeds CT AEC phantom, made from short sec-
tions of PMMA with a diameter close to the standard for Philips scanners of 320 mm WET
to compare performance, but another elliptical phantom with a similar diameter could be
used as an alternative. They scanned the phantom using the clinical protocol with ATCM to
check performance, and using the clinical protocol from the LD scanner as a guide, having
checked the image quality was acceptable, they matched settings on other scanners to the
protocol cho- sen. Finally Wood et al confirmed the performance of each scanner by
rescanning the conical phantom and measuring CT number and noise along the phantom.
A similar methodology could be used for comparing performances of CT scanners from
the same manufacturer, for which the image quality references are similar. For models from
Philips and Siemens, scan parameters such as the maximum and minimum limits on tube
currents are adjusted automatically for each patient based on the SPR and the modulations in
tube current with patient size are similar in form (figure 5). For GE and Toshiba scanners
that use an image quality reference based on the noise level, a similar approach based on a
phan- tom of standard dimensions could be used for setting up the clinical protocol, but
additional factors would need to be checked to ensure that the adjustments made for patient
size were optimized. The various peripheral factors that influence ATCM performance are
discussed in more detail in section 4, but the framework for optimization will be set out first.
Establishing the CTDIvol and noise levels required for scanning a phantom of standard size
and then checking how they change with ATCM for a geometrical phantom with a range of
diam- eters (section 3.2) provides a method for comparing performance of scan protocols.
Relative values of the CTDIvol for different diameters can then be inferred directly from the
changes in tube current relative to the value for the standard phantom as depicted in figure 5.
The translation of protocols between scanners from different manufacturers, particularly
between ones using ATCM based on a reference image or mAs and those using a noise
reference is a more difficult task, because the forms of the variations in tube current and
image noise with attenuation are substantially different (figures 5–7). Nevertheless this can
be tackled in a similar manner by determining values for CTDI vol relative to those for a
standard phantom from the variation in tube current with phantom diameter (figure 5). Once
values of CTDIvol for different sizes of phantom required for an optimized protocol have
been determined, then values for the image quality references that will give similar CTDI vol
values for different sizes of phantom with the scanner to be optimized need to be
determined. If the forms of the relationship between CTDIvol or mA and phantom diameter
are substantially different on the two CT scanners (figure 5), then scans of the geometrical
phantom using different values of the image quality reference will be required to provide
information on the possible settings
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Figure 7. Plots of image noise in terms of SD against diameter of the lateral axis of
the conical elliptical PMMA phantom as selected by the ATCM systems using the LD
and HQ image references for three CT scanners operating at 120 kV. The image
quality options are: for GE noise indices 20.83 (LD) and 6.94 (HQ); Toshiba low
dose++(LD) and High quality (HQ); Philips 124 mAs/slice (LD) and 405 mAs/slice
(HQ).

that might be appropriate. The steps that can be followed in the optimization of clinical
protocols are set out in table 2.

3.6. Detailed comparison of ATCM performance in clinical protocols

McKenney et al (2014) describe protocol translation between CT scanners of different

type based on more detailed comparisons of displayed CTDI vol. They employ a phantom
comprising five PMMA cylinders of varying diameter each 150 mm long and determine
the dependence of CTDIvol on the image quality reference from scans of each cylinder over
the full range of image quality reference settings. From these results values of the image
quality references for different scanners that give similar values for the CTDI vol can be
plotted against each other and relationships between them determined. McKenney et al
found that the relationships between noise index values for two GE CT scanners could be
described by a linear function of the form (y = ax + b) and differences in relationships
between the GE scanners were relatively small. They found the equivalent relationship
between noise index for a GE scanner and the quality reference mAs for a Siemens scanner
was more complex, but could be described by a power function of the form (y = axb + c).
Such equations could then be used in translation of image quality reference values that
should be selected for different protocols between CT scanners. A similar approach could
be used based on achieving similar levels of image noise instead of CTDIvol. This method
of translation requires substantial numbers of experimental measurements and analysis.
The simpler comparison of the principal image quality settings described in the previous
section may be sufficient in many cases, but whatever approach is taken, phantoms with
dimensions to represent the range of body sizes and attenuations encountered in clinical
practice are required. In addition there are a number of factors that influence the perfor-
mance of ATCM systems that complicate comparisons and these will be discussed indi-
vidually in the following section.
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Table 2. Framework setting out steps for translating ATCM settings in clinical
protocols between CT scanners
(1) Review results of patient dose audits of CT scanners (e.g. figure 4).
(2) Select CT scanners with protocols which are acceptable in terms of dose and noise level
for patients of varying size, as a reference for performance comparisons.
(3) Choose a standard phantom within the mid-range (e.g. PMMA phantom with diameters of
300 mm × 200 mm) and scan on CT scanners for which protocols are considered
acceptable.
(4) Establish acceptable CTDIvol (and noise) values from the scan of the standard phantom.
(5) Follow either (a) or (b) depending on availability of phantoms:
(a) Scan phantom with a range of dimensions and use mA values to determine the change in
CTDIvol required for different phantom sizes.
(b) Scan a series of phantoms of different sizes and record values for dsiplayed CTDIvol.
(6) Repeat the scans (a) or (b) above on the CT scanner for which performance is to be optimized
using the standard image quality reference value.
(7) Compare variation in CT scanner CTDI vol values with phantom size for CT scanner to be
optimized with those for the reference CT scanner (figure 5). Determine whether different
im- age quality reference values should be used for phantom/patients of different sizes to give
the required values of CTDIvol.
(8) If the pattern of CTDIvol or mA increase with phantom diameter is substantially different
from that required, repeat the scans (a) or (b) above on the CT scanner for which
performance is to be optimized for a range of image quality reference values to determine
new values that are required. Such changes are more likely when comparing CT scanners
with mAs and noise based references (section 3.3).
N.B. This may be a simple comparison of approximate values, or a detailed analysis as
described in section 3.6 in which the relationships between CTDIvol and the image quality
reference are analysed for phantoms of varying size, and functions determined to describe the
link between image quality references values giving similar CTDIvol values for each scanner
(McKenney et al 2014).
(9) For CT scanners using an image quality reference based on noise,
(a) Consider whether mA limits affect the degree of modulation (section 4.2).
(b) Consider whether other factors discussed in section 4 influence ATCM performance
(c) Make adjustments to scanner protocol settings as appropriate
(10) Rescan phantom with revised settings to confirm performance.
(11) Adjustments to kVs for patients of different size might be made to protocols. When
optimum kV values have been established, similar changes could be applied to all CT
scanners proto- cols (section 2).

4. Factors and settings that influence ATCM performance

4.1. SPRs used to plan scans

Higher tube currents give proportionately lower noise levels in the images and the CT scan-
ner operator must judge the appropriate balance. These choices are affected by factors that
influence the mA selection by the ATCM. CT scanner manufacturers use the SPR to plan the
ATCM to be employed in a scan. There have been a number of reports about the effect of

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SPR on the dose and noise levels. For example, when a single postero-anterior (PA) SPR is
used instead of an AP one, dose levels 30%–60% higher have been reported for GE scanners
(McNitt-Gray 2011) and 13% higher for Siemens (Söderberg 2016). These differences may
be due predominantly to geometrical factors. For example the projected sizes of the
vertebrae and ribs are greater in the PA projection as the spine is closer to the x-ray tube.
Since the ATCM uses information about the density, size and shape of the patient tissues, the
ATCM will tend to select a higher mA, because the higher density structures appear to be
larger in SPRs acquired with the PA projection. Moro et al (2013) observed that for the GE
scanner the overall body dimensions were also larger in PA SPRs than in AP ones, and this
may be the reason for the proportionately larger increases in mA planned on PA SPRs
reported for some GE scanners.
When one SPR is used for planning the ATCM, effective mAs values about 15% higher
have been reported for lateral SPRs as opposed to AP ones with Philips scanners (Sookpeng
et al 2015) and GE ones (McNitt-Gray 2011). However Papadakis (2007) reported the
reverse, so factors may vary for individual patients and scanners and assessments should be
carried out for each CT scanner. Söderberg (2016) reported a 20% decrease in CTDI vol with
a Siemens Sensation 16 scanner when performing two SPRs, the lateral and either AP or PA.
For GE scanners the SPR performed last is the one used in planning the ATCM (Moro et al
2013) and performing the AP view last is recommended. For Toshiba CT scanners, mA
modulation along the body is planned on the first SPR and the second one is used to derive the
AP lateral current ratio. If the second SPR is not performed, a standard ratio will be used. But
if a second scan is performed it must use the same exposure settings to allow a direct
AP/Lateral comparison and failure to do this will change the operation of the ATCM. Using
two SPRs is probably better in general for most CT scanners, if the scanner is designed to
utilize both. The changes in ATCM performance have been referred to in terms of the
change in dose level, but decreasing dose will lead to an increase in noise and so poorer
image quality and all factors must be borne in mind when selecting the optimal settings. As
iterative reconstruction and new techniques offer the potential for sub-mSv CT imaging, the
SPR will become a more significant proportion of the dose for a scan, so use of a single SPR
may become more appropriate.
Another factor related to the SPR that influences ATCM performance is the height of the
patient couch, as this will also change the apparent patient dimension recorded on the SPR,
which will be larger if the patient is closer to the x-ray tube (figure 8) (Matsubara et al 2009,
Supanich 2013). Scanning with the couch off-centre will also result in misalignment with
respect to the bow-tie filter and this will affect the dose distribution (Habibzadeh et al 2012,
Kataria et al 2016). Therefore ensuring that the patient is centred within the scan field is
important for optimizing performance. This issue has been appreciated by the manufacturers
and the latest versions of Philips DoseRight and Toshiba SureExposure 3D will compensate
for incorrect vertical positioning of the patient (Zhang and Ayala 2014).
Generally scans will be performed within the bounds of the planning SPR, but if a region
beyond the boundary is scanned, the behaviour of CT scanners varies. For the Philips 64
sys- tem the mA goes to the maximum, for Siemens it goes to that for the last known
location used, for GE scanners the mA goes to the minimum for the protocol, and for
Toshiba it goes to a default manual setting (Supanich 2013).

4.2. Limits set on tube currents

ATCM systems modulate mA according to the attenuation of the patient. Those using a
reference image or mAs set the upper limit to that required for the most attenuating part of
the patient based on the SPR, and scanners modulate the current within the chosen range, so
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there is no requirement to set mA limits. For scanners that employ an image noise reference,

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Figure 8. Plots showing the effect of adjustments in table height on CTDI vol values
recorded for scans based on AP SPRs on an anatomical phantom for two CT scanner
manufacturers.

the maximum and minimum currents can be set by the operator, although values are rec-
ommended. Inappropriate choice of current limits can curtail modulation, for example set-
ting of a minimum current of 100 mA was found to prevent any modulation for small
patients on a GE Lightspeed scanner (Sookpeng et al 2014). Since contrast in images of
small patients tends to be poorer, the minimum mA should be set to ensure that the image
quality will always be adequate. The maximum mA limit can restrict current modulation for
some patients, but the doses for larger patients have sometimes been found to be higher than
necessary to achieve adequate image quality on scanners using a noise reference (Sookpeng
et al 2014), so an appropriate choice of the maximum mA can provide a way in which
higher dose levels can be avoided. The maximum mA limit can also be set to allow scans to
be performed with a fine rather than a broad focus to achieve better resolution. The maxi-
mum achievable mA available on a CT scanner will be determined by tube performance
characteristics, but if a larger mAs is required for a particular patient, then it may be neces-
sary to increase the tube rotation time.

4.3. Image thickness and pitch

The image slice thickness changes the number of photons contributing to an image. The
ATCM systems based on a reference mAs or reference image (Siemens and Philips) use
the same mAs and will give a different noise level when the image thickness is changed
(Sookpeng et al 2015). For scanners using an image noise reference (GE and Toshiba), a
reduction in the image thickness used for acquisition by a factor of n will be accompanied by
an increase in mAs by a factor of the order of √n in order to maintain the same noise level
(Gutierrez et al 2007, Sookpeng et al 2015). Note that this is the slice thickness that is used
for the first axial reconstruction, not values chosen subsequently for the volume reconstruc-
tion images viewed by the radiologist. Use of a standard thickness recommended by the
manufacturer is generally appropriate, but if the slice thickness is reduced, the reference
noise would need to be increased by about √n times if it was desired to maintain the same
mAs. Modified values for the noise index have been recommended by GE for different slice
thicknesses (Kanal et al 2007, McNitt-Gray 2011). The factors involved in changing the
slice thickness for acquisition of scan data are large, and it is important to understand how
adjust- ments will change the behaviour of the ATCM on each scanner. Another factor that
could potentially alter mA selection by the ATCM is the pitch. Generally when pitch is
lowered the
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mA is reduced to achieve the specified image quality reference, and the relationship between
dose and image quality remains the same (Papadakis et al 2007). However, Rampado et al
(2009) reported that the CTDI vol increased as the pitch was reduced on a GE Lightspeed
scanner with ATCM.

4.4. Image reconstruction filter

Numerical filters are applied to each pixel within digital images either to smooth the images
to reduce the noisy appearance or to sharpen them to accentuate tissue boundaries. The filters are
based on weighted averaging of signals from pixels surrounding each pixel in the image.
The filters utilize kernels containing the weighting factors for surrounding pixels, which
depend on their relative position. Smoothing filters give a positive weighting to nearby
pixels to give an averaging effect, whereas sharpening filters give a high weighting to the
value of the pixel itself and a negative weighting to surrounding pixels, which preserves
higher spatial frequen- cies in order to enhance edges. This type of filter sharpens
boundaries, but creates a noisier image. The type of filter selected will in most cased not affect
the mAs selected by the ATCM, but alter the appearance of the image. However, in Toshiba
scanners that use a target noise reference, changes in the mAs for the scan occur when
different filters are selected for the first axial reconstruction (Sookpeng et al 2015).

4.5. Important things to check

For setting up ATCM systems, the first thing to establish is that dose and image quality per-
formance on a standard phantom are satisfactory and decide the appropriate image quality
references to be used. This should be carried out preferably using a phantom with an
elliptical cross section similar to that of the standard reference phantom that might be used
for the scan- ner, or an appropriate position in a conical or sectional phantom designed for
assessment of ATCM systems. A framework for the whole process is set out in table 2, but it
is important to ensure that other factors are considered. Appropriate SPRs should be used to
plan scans and to check whether the order in which they are performed affects current
modulation. Ensure that radiographers understand the importance of centring the patient
within the CT gantry for the SPR. For scanners using an image noise reference as the basis for
ATCM adjustment, first assess the optimum maximum and minimum mA settings to ensure
that mA is modulated over the desired ranges, and consider whether the maximum should be
set to limit the dose level for larger patients. Secondly check that the recommended settings
for the slice thickness used for acquisition are selected and if these are changed then
appropriate settings of the noise reference are used. Another factor for some scanners is the
direction in which the scan is per- formed and the influence this has on the starting mA and
overall dose performance should be considered (Gutierrez et al 2007, Sookpeng et al 2013).
A likely outcome of optimization for scanners using a noise level reference is that a higher
reference noise level is used for larger patients, if this is not selected automatically.
The measurements described in this paper are ones that should ideally be performed in
the first six months after installation. The aim is to understand how different factors
influence the performance of the ATCM, and feed information into setting up clinical
protocols for a range of examinations. This should ideally be a collaborative project
involving medical physicists, radiologists and radiographers, as recommended in COMARE
(2014). Once protocols have been established, then simpler tests, which might be scanning a
geometrical or anthropomor- phic phantom with standard settings, should be performed
periodically and results compared with those established following the early testing phase.

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5. Influence of ATCM on accuracy of recorded patient doses

Making comparisons between the dose performance of different CT scanners for patients
can readily be achieved in terms of the CTDI vol and DLP. Surveys of these quantities based
on downloads from Radiology Information Systems are recommended. Since ATCM
systems change the mA throughout the scans, the CTDIvol varies for each tube rotation. Most
manu- facturers compute an average mAs, which they call the effective mAs, and use this to
calculate values for the CTDIvol and DLP for a whole examination. Software available on the
internet can be used to calculate organ and effective doses from the CTDI vol and examination
settings for different scanners by various groups including ImPACT (2011) and CT-Expo
(Stamm and Nagel 2002, Brix et al 2004). In addition estimates of patient doses can be
obtained from con- version coefficients between DLP and effective dose (Shrimpton et al
2016). These methods use coefficients that have been derived from Monte Carlo simulations
of CT examinations with fixed tube currents, and so do not take account of ATCM. Studies
have shown that doses to some individual organs under ATCM can differ by 20%–40% from
the values calculated using a fixed current, so if a detailed dose assessment was required,
account would need to be taken of the ATCM (Khatonabadi et al 2013, Kawaguchi et al
2015, Sookpeng et al 2016). However, differences in values calculated for effective dose are
only of the order of ±10%, as doses to some organs are increased and others reduced, so this
is sufficient for the majority of assessments and allows surveys of DLP values still to be
used for evaluation of scanner dose performance.

6. Conclusions

ATCM systems adjust mA automatically relative to patient attenuation in both the longi-
tudinal and rotational planes. They select exposure factors to fit patient habitus, and adjust
mA to account for variations in patient size and attenuation throughout a scan. Thus they
have the potential to achieve significant reductions in patient dose, particularly for smaller
patients, helping to optimize CT scanner performance. Their use is appropriate for most
types of examination, except where there is no significant change in attenuation or there is
little table movement.
ATCM systems allow adjustments to be made to maintain a chosen level of image qual-
ity linked to either image noise or factors based on a standard image. This paper sets out a
framework to assist in optimization of ATCM systems. Once dose and image quality have
been established for a phantom representing an average patient, the modulation performed
by an ATCM system can be characterised using an elliptical phantom or phantoms with a
range of dimensions, which may be conical or include a series of sections of varying size.
There are many factors that need to be considered when optimizing patient protocols. For
scan- ners using mAs or another image as a reference, selection of the appropriate reference
will determine most of the other factors. However, for scanners operating on a reference
system based on image noise, a higher noise level should be selected for larger patients to
avoid high doses, and the operator should ensure that appropriate limits are set to allow mA
modulation. ATCM performance is planned using SPRs and the order in which these are
performed and the settings used are important. Generally these should be carried out as
recommended by the manufacturer with the patient centred correctly within the CT gantry. It
is essential that users of each scanner are aware of how the ATCM system on their specific
scanner operates, and are familiar with the effects from changing different protocol
parameters. Only through individual testing of each scanner with suitable phantoms coupled
with audits of patient doses can the true behaviour of ATCM systems be fully established.

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