International Journal of Alsafi.

Int J Radiol Imaging Technol 2016, 2:016

Volume 2 | Issue 2

Radiology and Imaging Technology

Review Article: Open Access

Radiation Protection in X-Ray Computed Tomography: Literature

Review
Khalid G Alsafi*
Department of Radiology, Medical Physics Unit, King Abdul Aziz University, Saudi Arabia

*Corresponding author: Khalid G Alsafi, Department of Radiology, Medical Physics Unit, King Abdul Aziz
University,
P.O. Box 80215, Jaddah 21589, Saudi Arabia, E-mail: [email protected]

Abstract Dose reduction in CT should be optimized by adjustment of scan

The aim of this study was to evaluate radiation protection techniques in parameters (tube current, peak tube voltage and pitch) according to
computed tomography (CT) scanning, address concerns on the increased patient weight or age, and weight-adapted CT protocols have been
population exposure during CT procedures, and provide a review on dose suggested and published. For the purpose of minimizing radiation
management and optimization procedures. Radiation protection in CT exposure, noisier images, if sufficient for radiological diagnosis,
requires regular dose surveys and optimization of CT exposure parameters, should be accepted. Optimized study quality also depends on region
establishing and/or implementing diagnostic references (DRLs),
implementation of a comprehensive quality assurance program, reference
scanned and study indication. Other dose reduction strategies
dose levels, and CT dose saving protocols. Patient dose reduction of 40-60%, include restricting multiphase examination protocols, avoiding
50%, 20-30%, 20-40%, 30-50% can be achieved using tube current overlapping of scan regions, and only scanning the area in question.
modulation, beam filters, thyroid and breast shields, low tube voltage for Guidelines to optimize the protection of patients during CT
abdominal CT, automatic pitch adaptation; respectively. CT users are procedures have been provided by various international
strongly encouraged to take advantage of these dose reduction techniques organizations [5-7]. All guidelines include reference doses that are
while maintaining diagnostic image quality. Current review provides updated
described as diagnostic reference levels (DRLs) or guidance levels
radiation protection measures for minimizing patient radiation dose in CT
without adversely affecting the quality of diagnostic information. that assist in the optimization of radiation protection of the patient
and permit comparisons of the performance of different CT scanners
and techniques. Full optimization of CT requires implementing
Keywords quality assurance program and optimization of both scanner and CT
Radiation protection, Computed tomography, Dose optimization strategies
operator factors including the use of tube current modulation and
other dose saving protocols.

Radiation health effects

Two primary detrimental health effects are associated with
ionizing radiation: stochastic effects and deterministic effects. A

Introduction stochastic effect of radiation is one in which the probability of

the effect, rather than its severity, increases with radiation dose.
Radiation protection in CT Radiation-induced cancer and genetic effects are stochastic in
Radiation protection in computed tomography (CT) deserves nature. On contrary, deterministic effects occur when radiation dose
special attention since CT is by far the largest contributor to patient exceeds certain threshold [8,9].
radiation exposure in diagnostic radiology [1]. The United Nation In CT examinations, the entrance skin doses are approximately
Scientific Committee on Effect of Atomic Radiation (UNSCEAR) 40 mGy for head examinations and approximately 20 mGy for body
reported that on average for countries in Health-care level I, CT examinations [10]. As far as deterministic effects (tissue reactions)
represents 6% of all diagnostic medical x-ray examinations but are concerned, ICRP notes that ‘in the absorbed dose range up to
accounts for 41% of the total population radiation dose [1]. In around 100 mGy (low LET or high LET) no tissues are judged to
UK, CT was reported to contribute to 47% of the collective dose express clinically relevant functional impairment [8,11]. Accordingly,
from diagnostic radiology, but representing only 9% of all X-ray deterministic effects are not expected for any patient undergoing a
examinations [2,3]. Because of the technological advancement standard diagnostic CT examination.
added to the clear benefit to the examined individuals, the frequency
of CT examinations is increasing worldwide and the types of Below the threshold for the induction of deterministic effects,
examination using CT are also becoming more numerous. As a the principal concern of any radiation exposure is the induction of
result the population radiation burden is high. Many authors mention stochastic (random) risks. In diagnostic radiology, these stochastic
growing concerns about the long-term effects of radiation exposure radiation risks are carcinogenesis and genetic effects that would
during CT examinations [2,4]. It is important that these potentially appear in the offspring of an irradiated individual.
very high doses be kept to a minimum through careful assessment of The principal concern for any patient undergoing a diagnostic
protocols, strict referral criteria for patients, use of automatic CT examination is the risk of developing a radiation-induced cancer,
exposure controls and choice of scan techniques. which may be fatal or nonfatal. The total patient risk is related to the

ClinMed International Library

Citation: Alsafi KG (2016)
Radiation Protection in X-Ray
Computed Tomography: Literature
Review. Int J Radiol Imaging
Technol 2:016
Received: March 30, 2016:
Accepted: July 15, 2016:
Published: July 18, 2016
Copyright: © 2016 Alsafi KG.
This is an open-access article
distributed under the terms of the
Creative Commons Attribution
License, which permits unrestricted
use, distribution, and reproduction
in any medium, provided the
original author and source are
credited.
effective dose, which depends on the dose to each organ, organ take into account any gaps or overlaps between the X-ray beams
radio sensitivity as well as patient age [12]. Children are more from consecutive rotation of X-ray source. This is accomplished
sensitive to radiation than adults and have a longer life expectancy. with of volume CTDI100,c , quantity that takes into account the helical
As a result, the risk for developing a radiation related cancer can
pitch or axial scan spacing, thus:
be several
times higher for a young child compared with an adult exposed to an
CTDIvol  (NxT / I )xCTDIw (4)
identical CT scan.
At the (low) doses associated with diagnostic radiologic Where N is a number of simultaneously acquired tomographic
examinations, the radiation risk is generally taken to be proportional slices, T is the nominal slice thickness, I is the distance moved by
to the cumulative organ dose. The radiation risk from two CT scans, the patient couch per helical rotation or between consecutive scans
for
for example, would be approximately twice the risk of a single scan, a series of axial scans. The quantity p  I / (NxT ) is known as the CT
irrespective of the time interval between the two CT scans [12]. pitch factor (or pitch) for helical scanning, CTDI vol represents the
average absorbed radiation dose over the x, y, and z directions. The
Justification and Optimization of Protection in CT CTDIvol provides a single CT dose parameter, based on a directly and
The principles of radiation protection as stated by ICRP are easily measured quantity, which represents the average dose within
justification, optimizations of protection and dose limitation [8]. the scan volume for a standardized (CTDI) phantom.
Justification for examinations involving ionizing radiation, such as Dose-length product (DLP)
CT, is an important way of avoiding unnecessary exposure and thus
a powerful radiation protection tool. It is widely believed that many To better represent the overall energy delivered by a given scan
unjustified exposures are made both in developing and industrialized protocol, the absorbed dose can be integrated along the scan length
countries [3,4]. Therefore, the referring physician has responsibility to compute the Dose-Length Product (DLP) where
for the justification of an examination in individual cases and
DLP (mGycm) = CTDIvol (mGy) × scan length (cm) (4)
obtaining the advice of a radiologist for any alternative examination
that would provide the desired information. The principle of dose The DLP reflects the total energy absorbed (and thus the
potential biological effect) attributable to the complete scan
acquisition. Thus,
limitation applies to occupational and public exposure but not an abdomen-only CT exam might have the same CTDI vol as an
for patients. On the other hand, both quality assurance (QA) and
diagnostic reference dose levels (DRLs) have been recommended abdomen/pelvis CT exam, but the latter exam would have a greater
for implementation of the principle of optimizations of protection DLP, proportional to the greater z-extent of the scan volume.
[8,9].
Effective dose
Radiation Dose Measurements in CT In diagnostic radiology, the patient effective dose, expressed in
In X-ray computed tomography, two quantities are proposed for sieverts, is determined by multiplying the DLP value by a
expressing patient radiation dose [5,6]: weighted CTDI (CTDIw) per appropriate normalized coefficients which takes in to account the
slice (serial scanning) or per rotation (helical scanning), and dose- patient’s age and specific anatomical region being imaged:
length product (DLP) per complete examination.
Effective dose = Conversion factor. DLP (5)
CT dose index is defined as the quotient of the integral of
absorbed dose to air along a line parallel to the axis of rotation of the CT Parameters Affecting Patient Dose
scanner over a length of 100 mm and the nominal slice thickness, T Dose and image quality in CT generally depend on the choice
[5-7]. For multi-slice
50 scanner with Ni slices of thicknessTi , of technique factors that are used to perform CT examination. The
D(z)dz (1) most important of the parameters that are under the control of the
CTDI100,c  
50
NiTi CT operator are as follows:
In practice the integration range is ± 50 mm as defined by the Tube voltage (kVp) determines the energy distribution of the
International Electrotechnical commission (IEC) and the European incident x-ray beam. Variation in the tube voltage causes a
guidelines in CT [5-7]. substantial change in CT dose, as well as image noise and contrast.
In practice CTDI100,c is derived from the expression: The choice of X-ray tube voltage (kVp) in CT scanning ranges from
80 to 140 kV. Increasing the X-ray tube voltage will increase the
amount of
CK ,PMMA,100DL [mGy] radiation used in the exam, and will also increase the average photon
(2)
 T energy. As a result, high voltages reduce image contrast, as well as
where D is the dose measured with the chamber and L is the
reducing the amount of noise (mottle). In addition, use of high kV
sensitive length of the chamber (100 mm for this case). CTDI100 is values may also reduce artifacts, such as beam hardening. Most of
the abdominal CT examinations can be done using 120 kVp and
earn
expressed in terms of absorbed dose to air. It can be measured in air 20% to 40% reduction in radiation dose compared to a value of 140
(CTDI100, air) or in phantom (CTDI100, phantom). kVp. Furthermore, pediatrics CT examinations can be successfully
Weighted CT dose index, CTDIw performed using 80 kVp resulting in sufficient image quality
[12,13].
CTDIw represents the average absorbed radiation dose over the x
and y directions at the center of the scan from a series of axial scans Tube current/exposure time
where the scatter tails are negligible beyond the 100 mm integration The product of the X-ray tube current (mA) and scan time (s) is
limit. The CTDIw is defined by the relation [5,6]: known as the mAs, which is a measure of the amount of radiation
that is used to generate any radiographic or CT image. Because
pediatric
CTDIw  1/ 3CTDI100,c  2 / 3CTDI100, p (3) patients are smaller, and therefore easier to penetrate, the CT mAs

Alsafi. Int J Radiol Imaging Technol 2016, 2:016  Page 2 of 5

 where CTDI used to scan pediatric patients is generally reduced relative to those
represents the CTDI 100 measured at the center
100,c used for adults [12-14].
of the dosimetry phantom, and CTDI100,p represents an average of
measurements of CTDI100 at four different positions 10 mm below Beam collimation and slice width
the surface of the phantom. CTDIw values can vary with nominal
Beam collimation and slice width are related to the detector
slice thickness, especially for the narrowest thicknesses.
configuration used for MDCT scanning. Generally, wider x-ray
Volume CT dose index, CTDIvol beam widths result in more dose-efficient examinations, as over-
beaming constitutes a smaller proportion of the detected X-ray
To represent dose for a specific scan protocol, it is essential to beam. However, a wider beam width can limit the thinnest
reconstructed sections for

Alsafi. Int J Radiol Imaging Technol 2016, 2:016  Page 3 of 5

MDCT systems with less than 16 data channels. On such systems,
and longitudinal (x, y, z) mA modulation varies the mA during both
narrow beam widths decrease dose efficiency owing to over-
rotation and longitudinal movement of the patient through the x-ray
beaming, but are needed to allow reconstruction of thinner slice
beam (i.e., anterior/posterior versus lateral and shoulders versus
widths. Hence, beam width must be carefully selected to address the
abdomen). CVOL reductions of up to 40-60%, depending on the type
specific clinical requirements [15]. of examination and the default settings [15].
Over-beaming: is when the X-ray beam incident on the patient
Pitch ratio
extends beyond the active detector area and hence part of the beam
is not used for imaging purposes. Pre-patient control of x-ray tube In helical CT, the pitch ratio (P) is given by the table increment
focal spot motion and beam collimation improves scanner dose distance per 360 rotation of the X-ray tube divided by the X-ray
efficiency and thus reduces radiation dose. This technique reduces beam width. Radiation dose is inversely proportional to pitch, such
over-beaming by measuring the position of the beam every few that a 2-fold increase in pitch results in a 50% reduction in dose
milliseconds and repositioning the collimating aperture as necessary. (assuming all other parameters are held constant). Increasing pitch
This allows a narrower dose profile compared to systems with no focal will decrease the amount of radiation needed to cover the region
spot tracking [15]. indicated, usually without compromising the diagnostic quality of
the scan. Increasing pitch from 1.0 to 1.375:1 decreases dose by a
Over-hanging factor of about 27% [12- 14].
Is the increase in dose-length product due to the additional
Scan coverage and indication
rotation (s) required for the spiral interpolation algorithm. For
MDCT scanners, the number of additional rotations is strongly The scan length determines the extent of the irradiated portion
dependent on pitch, and the increase in irradiation length is typically of the body in the z-direction and is therefore directly proportional
1.5 times the total beam width. The implications of over-ranging to patient radiation exposure. The scan length should be set at the
with regard to the air kerma-length product PKL,CT depend on the lowest value possible that will still allow for the clinical question to
length of the imaged body region. For spiral scans that are short be answered.
relative to the
With the short scan acquisition times of MDCT, there is a
total beam width, the dose efficiency (with regard to over-ranging)
tendency to increase the scan length to include multiple body
will decrease. It is generally more dose efficient to use a single
regions either in part or completely. This increases radiation dose to
spiral scan than multiple spiral scans for the same anatomical
the patient. It is necessary to be aware about the dose consequences
coverage [15].
of repetitive studies, requesting examinations of inappropriate
Image thickness anatomy, or requesting examinations for non-medically-necessary
indications [15].
MDCT technology allows for the reconstruction of relatively
narrow image widths in total scan times that are comparable with, Optimization of Protection in X-Ray Computed
or shorter than, in single-detector CT. The detector collimation, Tomography
however, must not necessarily be identical to the thickness of the
reconstructed images. Thicker images, which are less noisy, can be As the medical use of X-ray imaging is clearly justified because the
generated from the thinner projection data. When reformations or clear benefit that weight radiation, optimization is certainly the most
partial volume averaging are not of concern, thicker images should important parameters to consider. In medical imaging optimization
be reconstructed in order to reduce noise [15]. include regular dose surveys for audits, applications of DRLs and
QA.
Filtration
Diagnostic reference levels
X-ray filters are used in radiology for cutting off the X-rays that
have lower energy and do not contribute to the image but only to the In order to optimize the radiation dose delivered to patients in
patient dose. There are studies in the literature that have investigated the course of diagnostic and/or therapeutic procedures, measured
the use of various filters and their effect on dose reduction. radiation dose should be compared against establishment diagnostic
According to these studies, bow-tie or beam shaping filters reduce reference levels (DRLs). These are defined by the council of the
radiation dose by 50% compared with the conventional flat filters. European Union as; “dose levels in medical radio diagnostic
Software noise reduction filters is an alternative, especially in high practices for typical examinations for groups of standard-sized
contrast examinations such as chest CT. patients or standard phantoms for broadly defined types of
equipment [16]. These levels are expected not to be exceeded for
CT Optimization Strategies standard procedures when good and normal practice regarding
diagnostic and technical performance is applied.
Tube current modulations (TCM)
Radiation dose in CT can be reduced as well as in other X-
The main dose saving technique is certainly the automatic tube ray procedures using reference dose levels. When these levels
current modulation (TCM). It adjust the mAs to compensate for are routinely exceeded, sites should initiate investigation of the
different levels of attenuation of the CT scanner’s x-ray beam and appropriateness of their examination protocol to more appropriate
thus accounts for the varying attenuation of the human body along optimize examination quality and safety. Established International
the body axis (‘longitudinal’) and in the transverse plane (‘angular’). DRLs are presented in table 1 (for adults) and table 2 (for children).
Angular (x, and y-axis) tube current modulation involves variation
of the tube current to equalize the photon flux to the detector as the Quality assurance
x-ray tube rotates about the patient. In longitudinal (z) modulation, QA is powerful tool for optimizations of equipment
the mA is modulated to provide the desired level of image quality as performance. The World Health Organization (WHO) [23]
the attenuation between anatomic regions varies. Combined angular definition of QA

Table 1: Published adult DRLs for CTDIvol (mGy) and DLP (mGy· cm).
Head Abdomen Pelvis Abdomen and Pelvis
CTDIvol DLP CTDIvol DLP CTDIvol DLP CTDIvol DLP
EC ( 2004) [16] 60 - - - - - 15-25 -
Sweden (2002) [17] 75 1200 25 - - - - -
UK (2003) [2] 65-100 930 14 470 - - 14 650
ACR (2008) [18] 75 - 25 - - - - -

Alsafi. Int J Radiol Imaging Technol 2016, 2:016  Page 4 of 5

Switzerland (2010) [19] 65 1000 15 400 20 500 15 650

Alsafi. Int J Radiol Imaging Technol 2016, 2:016  Page 5 of 5

 Table 2: Published pediatrics DRLs in Belgium, Canada and Australia [20-22].
Brain CT Abdominal CT
• Significant decreases in dose can be achieved with lower kVp
selections e.g. decreasing the kilovoltage to 80 or 100 kVp for
Age group Belgium Canada Australia Belgium Canada Australia
smaller patients while using tube current modulation
CTDIvol (mGy)
0-1 20.5 ** 30 16.4 ** 12 • The small size of a child may require thinner CT slices
1-5 26.5 ** 45 17.7 ** 13 compared with adults in order to improve spatial resolution.
5-10 ** 50 20.8 ** 20
DLP (mGy· cm) Shielding considerations
0-1 168.8 543 270 324 371 200
In addition to the shielding that the X-ray unit assembly itself
1-5 225.2 610 470 387 420 230
provides to the parts of the body which are not to be imaged, some
5-10 592 639 620 714 595 370
patient organs like gonads, breast, thyroid and eyes within or
adjacent to the primary X-ray beam can be shielded with leaded-
Table 3: Annual QC tests and tolerances levels for X-ray CT.
impregnated materials placed over them and whenever possible,
Test quantity Acceptable Achievable surrounding them. The use of thyroid and breast shields was report
CT alignment lights ± 5 mm ± 1 mm to decrease surface dose to the breast and thyroid by approximately
SPR accuracy ± 2 mm ± 1 mm 20% to 30% [27].
CT number ± 5 from baseline valuea ±4
Image Noise ± 25% from baseline valuea ±10 % of the baseline Conclusions
Uniformity ± 10 ±4
In radiology, it is normal practice to modify radiographic
Artefact No artefacts to affect No visible artefacts
diagnostic confidence techniques to take into account patient characteristics, as well as the
CTDIvol < ± 20% manufacturer’s diagnostic task at hand. With increasing contributions from CT to
recommendations and console the collective dose from medical exposure, it is important for each
displayed dose values centre to employ certain dose reduction techniques for optimisation
of radiation protection. Table 4 summarizes the dose reduction
Table 4: Selected dose optimization strategies with their expected Percentage of dose techniques used in computed tomography. We strongly encourage
reduction. users to take advantage of these technical mechanisms for reducing
CT dose reduction technique Percentage of dose reduction radiation dose while maintaining diagnostic image quality.
Tube current modulation 16 [28] 40-60 %
Bow-tie /beam shaping filters up to 50 % References
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