Dual-Energy Computed

Tom o g r a p h y
Physical Principles, Approaches to
Scanning, Usage, and Implementation:
Part 1
Reza Forghani, MD, PhDa,*, Bruno De Man, PhDb,
Rajiv Gupta, MD, PhDc

KEYWORDS
 Dual-energy CT  Spectral CT or multienergy CT  Dual-source CT  Fast kVp switching
 Gemstone spectral imaging  Layered or sandwich detectors  Photon counting
 Virtual monochromatic images

KEY POINTS
 Spectral computed tomography (CT) material differentiation relies on differences in energy-
dependency of the attenuation of different materials.
 The photoelectric effect has a strong energy dependence, and the attenuation due to the photo-
electric effect is highly dependent on the atomic number (Z) of the element.
 Elements with a high atomic number, such as iodine, that have a strong energy dependence can be
exploited for spectral CT scanning.
 Current commercially available spectral CT scanners are dual-energy CT scanners that may consist
of 1 or 2 tubes, or use specialized layered detectors for spectral separation.
 Multienergy scanning systems, such as photon counting scanners, are under development but not
yet commercially available for routine clinical use.

INTRODUCTION tissue characterization. Current commercially

available clinical systems use 2 different photon
Dual-energy computed tomography (DECT) or spectra for scanning, and therefore, the term
spectral computed tomography (CT) is an DECT is sometimes used interchangeably with
advanced form of CT that uses different X-ray spectral CT. However, it is noteworthy that the
spectra to enhance material differentiation and term spectral CT could also encompass more

Disclosures: R. Forghani has acted as a consultant for GE Healthcare and has served as a speaker at lunch and
learn sessions titled “Dual-Energy CT Applications in Neuroradiology and Head and Neck Imaging” sponsored
by GE Healthcare at the 27th and 28th Annual Meetings of the Eastern Neuroradiological Society in 2015 and
neuroimaging.theclinics.com

2016 (no personal compensation or travel support for these sessions). B. De Man is CT Business Portfolio Leader
and Manager of Image Reconstruction Laboratory, GE Global Research. R. Gupta declares no relevant conflict
of interest.
a
Department of Radiology, Segal Cancer Centre and Lady Davis Institute for Medical Research, Jewish General
Hospital, McGill University, Room C-212.1, 3755 Cote Ste-Catherine Road, Montreal, Quebec H3T 1E2, Canada;
b
GE Global Research, One Research Circle, KWC1300B, Niskayuna, NY 12309, USA; c Department of Radiology,
Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
* Corresponding author.
E-mail address: [email protected]

Neuroimag Clin N Am 27 (2017) 371–384

http://dx.doi.org/10.1016/j.nic.2017.03.002
1052-5149/17/Ó 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
372 Forghani et al

advanced systems capable of discrimination be- DECT may be used to perform tissue characteriza-
tween more than 2 spectra, such as the photon tion beyond what is possible with conventional
counting scanners currently under investigation SECT. For successful DECT scanning and material
and development. Therefore, strictly speaking, characterization, the following fundamental con-
the terms are not synonymous and DECT is a sub- siderations related to the scanner type and tissues
set of spectral CT. being characterized must be taken into account.
Applications of DECT for clinical use were
initially explored in the 1970s.1–7 However, the
Fundamentals of Dual-Energy Computed
technological and computational advances neces-
Tomography Scanning: Factors Related to the
sary for implementation of DECT and successful
Scanner
introduction into the clinical arena were not yet
made. Therefore, attempts for implementation For acquiring the projection data, the scanner
were temporarily abandoned, just to be revived must use different energy spectra and separately
later with the introduction of the first DECT system record the high- and low-energy measurements.
in the clinical arena in 2006.8,9 DECT scanning, as This has been implemented in the clinical setting
the name implies, is based on image acquisition in multiple ways. One way is through simultaneous
with 2 different energy spectra. The data obtained use of 2 different imaging chains, each with its own
are then combined in order to generate images for dedicated source and detector. Another way to
routine clinical interpretation or for more advanced accomplish this is via a single X-ray source that
material characterization. The objectives of this is capable of fast switching between 2 energy
2-part review are to provide an overview of the levels and a detector with very fast readout
(1) physical principles behind spectral CT scanning capability; technical innovations in modern X-ray
and material differentiation, (2) major spectral CT source technology—taking advantage of the
acquisition systems available clinically, and (3) high-voltage controls for X-ray generation—
basics of implementation and use of the technol- enable this capability. In yet another design, it is
ogy in clinical practice. possible to acquire high- and low-energy data
sets by use of specialized detectors that have 2
different scintillator layers, one for high energy
FUNDAMENTAL PRINCIPLES OF SPECTRAL
and the other for low energy, built into them.
COMPUTED TOMOGRAPHIC SCANNING AND
Various methods for acquiring dual-energy data
MATERIAL CHARACTERIZATION
sets are discussed in detail later in this article.
Overview
For the purposes of material differentiation, it
With conventional, single-energy computed to- would be ideal for each of the 2 different energy
mography (SECT), a polychromatic beam is X-ray beams to be composed of monochromatic
emitted by a single source (X-ray tube), passes energies. However, with current X-ray tube tech-
through the patient resulting in attenuation of the nology used in the clinical setting, it is not possible
beam, and is captured by an array of detector to generate monochromatic X-ray spectra. There-
cells. The resulting projection data, after prepro- fore, clinical DECT scanners use polychromatic
cessing and reconstruction via sophisticated X-ray sources but attempt to have as little overlap
computer algorithms, is rendered into CT slices between the different energy spectra as possible.
that are used for diagnostic interpretation. With Fig. 1 shows a typical X-ray spectrum at 80 kilovolt
DECT, on the other hand, projection data are peak (kVp) and 140 kVp, including inherent X-ray
obtained at 2 different energy spectra instead of tube filtration, generated with the XSpect simu-
one, and the information acquired is then blended lator.10 For DECT systems relying on different
to create images for routine diagnostic interpreta- tube voltages for spectral separation, the standard
tion. More advanced tissue analysis and material peak energies used for scan acquisition are typi-
characterization are also feasible with these data cally at 80 and 140 kVp. For some dual-source
sets. scanner models, 90 or 100 kVp with a filter may
The key advantage of DECT over SECT is that be used instead of 80 kVp, especially for scanning
by acquiring data at 2 different energy spectra, it heavier patients. Alternatively, energies lower than
is possible to use sophisticated computer algo- 80 kVp, for example, 70 kVp, may also be used
rithms to combine the different energy data in with some models or for specialized applications
order to evaluate tissue attenuation at different en- such as in pediatric imaging. For the high-energy
ergies rather than at a single effective energy. acquisitions, 150 kVp may be used instead of
Because different types of materials and tissues 140 kVp with some models. Protocols may also
may attenuate X-rays differently at different en- vary depending on the scanner vendor or the spe-
ergies depending on their elemental composition, cific application under consideration.
 Dual-Energy CT Principles & Technique 373

The reason for the choice of energies is that

typically, at peak energies less than approxi-
mately 80 kVp, too few photons are generated
and, in addition, a large proportion of photons
would be absorbed by the body, and therefore,
not generate any clinically useful information.1,11
For the high-energy acquisitions, voltages higher
than 140 kVp (or 150 kVp for some models) are
typically not available on all DECT scanners.
Furthermore, such high energies may result in
higher dose and too little soft tissue contrast,
limiting applications in the clinical setting,
although they could still be useful for specialized
Fig. 1. Typical X-ray spectrum for X-ray tube voltages
applications and for discriminating between low
of 80 kVp and 140 kVp, including inherent X-ray tube
Z and high Z materials (discussed in greater detail
filtration (generated with the XSpect simulator). The
peaks represent characteristic lines of a tungsten in the following section).
anode, and the continuous spectrum is the result of
bremsstrahlung. This example illustrates the polychro- Fundamentals of Dual-Energy Computed
matic nature of the X-ray beams used for DECT scan- Tomography Scanning: Factors Related to the
ning. For DECT scanning, it is desirable to achieve as Materials or Tissues Being Evaluated
much separation as possible between the low-
energy and high-energy spectra. In addition, the Beyond the specific technique used for image
tube voltage used must not be too low or too high. data acquisition, factors related to the materials
If it is too low, it will be excessively absorbed by the or tissues of interest must be taken into account
body, yielding little information; if it is too high, it for successful clinical application of DECT
will not yield useful information because of poor tis-
(Box 1). It is important to understand the basis
sue contrast. In routine DECT, 80-100 kVp (low-energy
spectrum) and 140-150 kVp (high-energy spectrum)
of DECT material characterization as well as the
are commonly used settings for this purpose, strengths and limitations of this technique. X-ray
although there may be variations depending on the attenuation is governed by 2 main processes,
scanner model, filters used, or the specific clinical with a third process only contributing a negligible
application at hand. (Courtesy of Reza Forghani, amount. At the typical tube voltages used in CT,
MD, PhD, Montreal, Quebec, Canada and Bruno De Compton scattering accounts for the greatest
Man, PhD, Niskayuna, NY.) contribution to the overall attenuation. Compton

Box 1
Physical basis of material characterization and differentiation using dual-energy computed
tomography

 DECT material differentiation relies on energy dependence of CT attenuation for different materials.
 Compton scatter and photoelectric effect are the main processes accounting for attenuation during
CT scanning.
 Whereas the Compton effect is minimally dependent on photon energy, the photoelectric effect is
strongly X-ray energy dependent.
 Because of its strong energy dependency, the photoelectric effect is key for material differentiation
based on spectral properties with DECT.
 The photoelectric effect is also highly dependent on the atomic number (Z) of the element being
imaged.
 Elements with a high atomic number, such as iodine (Z 5 53) and calcium (Z 5 20), have strong spectral
properties and can be readily differentiated from low-Z materials (such as H, C, N, and O); this prop-
erty forms the basis of multiple clinical applications for DECT scanning.
 To distinguish different materials or tissues based on their spectral properties, there must be a suffi-
cient difference in their atomic number (Z) or effective atomic number.
374 Forghani et al

scattering is a function of both the electron similar atomic numbers. As a result, these
density of the tissue and the tube voltage and materials do not have sufficient component of
spectrum. The electron density of the tissue is photoelectric interactions: their attenuation is
the dominant factor, as Compton effect is only relatively low and very similar to each other at
minimally dependent on photon energy.9 different energies, precluding reliable differentia-
The other important physical process account- tion based on their spectral properties
ing for CT attenuation is the photoelectric effect. (Fig. 2).1,13
This effect, which is strongly dependent on Elements with high atomic numbers and large
the atomic number or Z (ie, the number of pro- differences in their atomic numbers, on the other
tons within the nucleus) of the elements that hand, have a stronger energy dependence and
constitute the tissue under consideration, is can be distinguished from lower-Z materials us-
particularly important for spectral CT.12 Photo- ing DECT. Among these elements, one of the
electric interactions are strongly energy depen- prime candidates that is of clinical interest is
dent, and as a result, key for DECT material iodine (Z 5 53) (see Fig. 2). Most clinically used
characterization. The third physical process, CT contrast agents are iodine based and are
Rayleigh or coherent scatter (related to the widely used for a variety of indications that
electrons), only accounts for a very small per- include oncologic imaging and angiography. Io-
centage of interactions and attenuation and is dine’s strong energy dependence can therefore
typically considered negligible in conventional be exploited in a variety of settings in which
absorption-based CT. contrast-enhanced CT scans are obtained for
For elements or tissues to be distinguishable material characterization, iodine quantitation,
based on their spectral properties, there must and improving diagnostic evaluation using
be sufficient difference in their atomic number DECT. Among the elements that are intrinsic to
or Z. Understanding the impact of such the human body and have a relatively high atomic
elemental or tissue properties is critical when number, calcium (Z 5 20) is another prime candi-
planning applications of DECT in any research date. This element has been used in a variety of
or clinical setting. As an example, common clinical applications in body imaging and head
elements found in the human body, such as and neck imaging. These applications are
hydrogen (Z 5 1), carbon (Z 5 6), nitrogen covered in greater detail in subsequent articles
(Z 5 7), and oxygen (Z 5 8), have low, very in this series.

Fig. 2. Example of tissues with weak and strong spectral characteristics based on their elemental composition.
Axial non-contrast-enhanced CT image of the neck acquired in dual-energy mode using a fast kVp switching scan-
ner is shown (A). Region of interest analysis was performed comparing the spectral Hounsfield unit attenuation
curves of muscle (green) to that of the thyroid gland (blue) (B). Most of the soft tissue in the human body,
including muscle, is composed of low-Z materials such as oxygen (Z 5 8), carbon (Z 5 6), and hydrogen
(Z 5 1). As a result, there is little energy dependency of measured attenuation of muscle on an uninfused study
(B; green curves). The thyroid gland, on the other hand, contains iodine (Z 5 53) with strong energy dependence
due to photoelectric effect. Note the marked energy-dependent increase in its attenuation at low energies ap-
proaching the K-edge of iodine (33.2 keV) (B; blue curves). Because most clinically used CT contrast agents are
iodine based, iodine’s strong energy dependence can be exploited in a variety of clinical settings.
 Dual-Energy CT Principles & Technique 375

OVERVIEW OF CURRENT AND EMERGING

DUAL-ENERGY COMPUTED TOMOGRAPHIC
SYSTEMS
The first DECT scanner approved for clinical use,
a dual-source CT scanner, was introduced into
the market in 2006. This scanner was followed a
few years later by a CT scanner with fast kVp
switching and fast detector technology. Since
then, multiple scanners based on different dual-
energy technologies have become available for
clinical use from different vendors. There has
also been refinement of different scanner types
for optimizing image quality, postprocessing ca-
pabilities, radiation exposure, and ease of use.
Fig. 3. Dual-source DECT (Siemens AG). Schematic
As is the case with any type of high-end technol-
illustration of dual-source detector combination scan-
ogy, this is an evolving area with continued refine- ners with the 2 imaging chains in a nearly orthogonal
ments and iterations being introduced. In this configuration, allowing the same slice to be scanned
section, an up-to-date overview of the major simultaneously at the 2 energies. Yellow is used
DECT scanner types currently available is pro- to illustrate the low-energy spectrum, and blue,
vided. The focus is on the fundamentals, such the high-energy spectrum. Typically, 80-100 kVp (low
as mode of acquisition, as well as the advantages energy spectrum) and 140-150 kVp (high energy spec-
and disadvantages of each system. Additional trum) are used depending on the model, but other
information that is specific and pertinent to each combinations may be used for specific applications.
Because there are 2 separate source-detector pairs, a
scanner type is also provided as needed. It should
filter can be placed to harden the high-energy spec-
be noted that for commercially available scan-
trum. For some higher generation dual-source scan-
ners, depending on the vendor, more than one ners, it is possible to use a higher kVp for the lower
model or generation of that scanner type may be spectrum (90 or 100 instead of 80 kVp) in conjunction
available. Therefore, even for the same overall with a filter. Because of the limited space in the CT
design, there may be important variations in gantry, there is only sufficient space for a smaller sec-
the capabilities offered. This article focuses ond detector, which in turns places restrictions on
on the fundamentals of each design. A complete the usable field of view of the dual-energy CT mode,
description of the variations in different models as shown in the illustration. (Courtesy of Reza For-
of the same scanner type is beyond the scope of ghani, MD, PhD, Montreal, Quebec, Canada and Bruno
De Man, PhD, Niskayuna, NY.)
this article, and interested readers are referred
to vendor-provided documentation and literature.
This section concludes with a discussion of Because of the use of 2 X-ray tubes, a filter
emerging spectral CT platforms such as photon may be applied to the tube emitting the higher
counting scanners. energy spectrum in order to harden the spectrum
(ie, reduce associated low-energy quanta from
Dual-Source Dual-Energy Computed
the polychromatic emission). For some scanner
Tomography
models, an additional filter may be available for
As the name implies, a dual-source scanner use with the tube emitting the lower energy
consists of 2 source and detector combina- spectrum as well. If the second filter is used, ac-
tions1,2,9,11,14,15 (Siemens AG, Forchheim, Ger- quisitions will typically be performed at 100/140
many) (Fig. 3). The source-detector combinations kVp instead of 80/140 kVp. This enables acquisi-
are at a near perpendicular angle, allowing the tion of scans with lower image noise for larger
same volume to be scanned simultaneously with patients, whereby 80 kVp may not yield optimal
high- and low-energy spectra. The obvious advan- results. An additional advantage of 2 separate
tage of this system is that separate tubes are used tubes is that the combined tubes can provide a
for generating the high- and low-energy spectra. higher total X-ray flux in a given amount of
The use of separate tubes enables independent time, which is also beneficial for larger patients.
adjustment of the tube voltage and current and The use of separate tubes also allows the appli-
helps optimize separation of the low- and high- cation of established SECT technology and
energy spectra. Furthermore, the use of separate algorithms.
tubes facilitates balancing the total amounts of Among the disadvantages, one pertains to chal-
quanta emitted from the 2 tubes. lenges posed by the limited space in the CT
376 Forghani et al

gantry. Because of this, there is only sufficient

space for a smaller second detector, which in
turns places restrictions on the usable field of
view of the DECT mode (eg, 27, 33, or 35 cm,
depending on the model) as compared with
50 cm for single-energy mode acquisitions. There
is also the problem of cross-scatter from the pri-
mary course of one source-detector combination
hitting that of the detector from the second
source-detector combination at a perpendicular
angle, contaminating its data with additional bias
and noise. Therefore, technical modifications and
optimizations are performed to reduce cross-
scatter and corrections applied during image
reconstruction (using different methods depend- Fig. 4. Single-source DECT with rapid kVp switching:
ing on the scanner model) to mitigate, at least in GSI (GE Healthcare). Schematic illustration of this
part, these effects. type of a single source-detector combination system.
This design also results in challenges for post- Yellow is used to illustrate the low-energy spectrum,
processing of the projection data. Because the and blue, the high energy spectrum, typically
projection data are acquired at different angles, 80/140 kVp. DECT projection data are acquired by
very fast switching between low- and high-energy
for a given z-axis position, there is an offset of
spectra combined with fast sampling capabilities of
90 . As a result, there is at least 70 milliseconds a proprietary, garnet-based scintillator detector with
(ie, one-quarter rotation time) delay or “temporal low afterglow for spectral separation at each succes-
skew” between the high and the corresponding sive axial or spiral view. (Courtesy of Reza Forghani,
low projection measurements. This temporal MD, PhD, Montreal, Quebec, Canada and Bruno De
skew makes it hard to perform material decompo- Man, PhD, Niskayuna, NY.)
sition in the projection domain, especially if there is
any patient motion. Hence, the high- and low-
energy datasets are separately reconstructed by high kVp. Since the temporal skew or the delay be-
filtered back projection, and material decomposi- tween the high and low projections is as low as 50
tion is performed afterward in the image domain, microseconds, there is excellent spatiotemporal
which may lead to imperfect elimination of beam registration, and material decomposition is per-
hardening and reduced material decomposition formed directly in the projection domain, making
accuracy. Last, there are considerable additional it quantitatively accurate and robust against any
hardware requirements for this system compared possible patient motion. With current Gemstone
with the single-source scanners, posing techno- spectral imaging (GSI) scanners, axial or helical
logical challenges and imposing certain limitations acquisitions are obtained for the full field of view
on the longitudinal or detector z-coverage of the of 50 cm.
system because the detector cost could become On the source side, the generator and tube used
prohibitive. for these scanners are capable of reliably switch-
ing between the 80 and 140 kVp voltages, with
sampling periods as fast as 50 microseconds.
Single-Source Dual-Energy Computed
For this approach to be successful, a highly
Tomography with Rapid kVp Switching:
specialized generator capable of very rapid transi-
Gemstone Spectral Imaging
tions in tube potential as well as very fast elec-
This scanner consists of a single source and detec- tronics and detector materials are required.
tor combination1,16–18 (GE Healthcare, Waukesha, Overall, the advantages of rapid kVp switching
WI, USA) (Fig. 4). With this scanner, the tube or GSI DECT systems are excellent temporal
voltage follows a square wave form, and projection registration and a cost-efficient design offering
data are collected for twice the number of view an- an opportunity to increase the longitudinal detec-
gles, half at high- and the other half at low-tube tor coverage up to 160 mm. These systems also
voltage. This approach is made possible by the enable scanning over the entire full field of view
fast sampling capabilities of a proprietary, garnet- of 50 cm. In addition, material decomposition
based scintillator detector with very low afterglow, can be performed in the projection space, which
referred to as Gemstone. During a single rotation, helps to reduce beam-hardening artifacts in virtual
the image acquisition using this scanner is on a monochromatic images (VMIs) generated in this
view-by-view basis, alternating between low and manner (VMIs and other DECT reconstructions
 Dual-Energy CT Principles & Technique 377

are discussed in part 2 of this review). If needed,

with these systems, additional spectral analysis
or reconstruction of different VMIs or maps can
also be performed retrospectively in the image
space based on the data generated from the orig-
inal material decomposition and reconstruction
from the projection data.
One challenge in the design and implementation
of such a system is the issues related to the rela-
tive photon flux between the 2 energies. In order
to address this challenge, the scanners are
designed to balance the flux, with allocation of
additional time for the low kVp relative to the
high kVp acquisition. Not only does this approach
serve to reduce photon starvation conditions, but Fig. 5. Layered or sandwich detector DECT (Philips
when complemented by the appropriate choice Healthcare). Schematic illustration of this type of a
of rotation speed, it also achieves a more balanced single source-detector combination system in which
flux state between the 2 energies and neutralizes spectral separation is achieved at the level of the
patient radiation exposure. detector. This system takes advantage of the polychro-
Disadvantages of this system include those matic nature of the beam produced at the source and
related to adaptation of the current that can result highly specialized detectors that consist of 2 layers
having maximal sensitivity for different energies. The
in a relative reduction of signal from the low-
first layer (yellow) preferentially absorbs the low-
energy spectrum, but this is partly compensated energy photons, by design approximately 50% of the
for by the additional time allocated for the low total incident photon flux. The second layer (blue)
kVp acquisition, as described earlier. Last, in prac- absorbs the remaining high-energy photons. (Courtesy
tice, the time profile of the tube voltage has a of Reza Forghani, MD, PhD, Montreal, Quebec, Canada
slightly trapezoidal shape rather than a purely rect- and Bruno De Man, PhD, Niskayuna, NY.)
angular shape. As a result, the spectral difference
is slightly lower than the nominal tube voltages,
and this has to be accounted for during image absorbs the remaining photons, which are primar-
reconstruction. ily higher-energy photons. Naturally, this scheme
works only because of the polychromatic nature
of the X-ray beam generated by a conventional
Layered Detector Dual-Energy Computed
bremsstrahlung tube.
Tomography
One advantage of this system is its excellent
In the systems discussed so far, spectral energy temporal registration. Because energy separation
separation is mainly dependent on design or alter- is at the level of the detector and does not rely
ations at the X-ray source and generator level that on different energy spectra generated at the
result in generation of the 2 different energy source, there is no time lag between acquisitions
spectra. With layered detector or “sandwich” de- of the different energy spectra. Therefore, this sys-
tector DECT,1,2,19,20 on the other hand, spectral tem is well suited for material decomposition in the
separation is achieved at the level of the detector projection domain, which would make it quantita-
(Philips Healthcare, Andover, MA, USA) (Fig. 5). tively accurate and robust for possible patient mo-
These systems consist of a single source and de- tion. Along similar lines, there is also perfect spatial
tector combination. However, they use highly registration of the acquired data to create the
specialized detectors that consist of 2 scintillator complete spectral dataset, without the need to
layers that have maximal sensitivity for different compensate for shifting or interpolation that may
X-ray photon energies. When seen in a cross- be seen with systems relying on energy separation
sectional view, the detectors consist of 2 layers at the X-ray source.
of scintillators directly on top of one another, The fact that the tube always operates at high
with an optional interlayer filter. The system takes kVp results in a high total X-ray power, which is ad-
advantage of the polychromatic nature of the X- vantageous for larger patients. Because of the de-
ray beam, and a single scan is performed at a tector design with most low-energy photons being
high energy (120 or 140 kVp). The first or top (inner) absorbed by the first layer, there is in effect “filtra-
layer preferentially absorbs lower-energy photons, tion” of those photons and hardening of the spec-
by design approximately 50% of the total incident trum absorbed by the second layer. Similar to the
photon flux. The second, bottom (or outer) layer fast kVp switching systems, scanning is performed
378 Forghani et al

at the full field of view of 50 cm. Last, because prefiltered using 2 different materials and split into
spectral separation is at the level of the detector, high- and low-energy beams. A split filter consist-
these systems always acquire scans in DECT ing of gold and tin is placed at the output of the
mode, allowing retrospective spectral evaluation tube, resulting in separation of the beam into a
for all scan acquisitions. Because there is perfect side with a lower-energy spectrum and a side
alignment of acquired spectral data, material with a higher-energy spectrum. The corresponding
decomposition can be performed in the projection halves of the detector are then used for detection of
and image domains. Noise correlation in the pro- the low- and high-energy spectra (see Fig. 6).
jection domain can be used to improve material Advantages of this system include the ability to
separation and reduce noise on low-energy VMIs. image the full field of view, and lesser hardware
The main disadvantage of this system is its complexity and lower cost compared with all above
lower energy separation, because the scintillator systems. TwinBeam may even be incorporated as
absorption properties do not offer a sharp distinc- an upgrade to some scanner models. The main
tion between lower- and higher-energy photons. disadvantage is that a different portion of the pa-
As a result, the material differentiation contrast is tient is irradiated by the low- and high-energy
decreased unless a higher radiation dose is spectra. Hence, a helical scan is needed so that
used. An earlier design choice to mitigate this each voxel scanned at one energy is eventually
challenge is to use an interlayer filter between also scanned with the other energy. The resulting
the 2 scintillator layers. The use of an interlayer fil- temporal skew, however, is very high, and there is
ter improves the energy separation but also re- relatively poor temporal registration between high-
duces the dose efficiency. The noise level can be and low-energy scans of any given voxel. Another
balanced between low- and high-energy acquisi- important challenge is that a central 2- to 3-mm
tions by designing individual-layer thicknesses in portion of the beam will have a mixed energy spec-
order to try and achieve comparable noise levels trum due to the finite focal spot size. As a result, that
at the 2 different energies. Because spectral sep- portion of the data cannot be used for material
aration is exclusively at the level of the detector, discrimination. There is also potential for cross-
this system does not permit alterations at the scatter originating from one side of the beam
source that may optimize the balance between contaminating data at the other side of the beam.
low- and high-energy spectra emitted, unlike the There are in addition limited ways of balancing the
fast kVp switching or dual-source systems. This photon flux of the low- and high-energy spectra
system does not have the problems of cross- for optimal spectral differentiation beyond what
scatter discussed earlier for dual-source scan- the X-ray beam filters provide. These systems
ners, but is susceptible to a different type of have become commercially available only recently,
cross-scatter between the 2 detector layers. The and therefore, at this time, there are relatively few
technical challenges and expense for these sys- clinical studies using this system design. This will
tems are related to their specialized detector hard- undoubtedly change over time and more data on
ware requirements. Because of the relatively the performance of these systems is likely to
recent introduction of this system in the market, emerge with an increase in their availability and use.
at this time there are fewer studies available that
use this DECT technique. As a result, the clinical
Dual-Energy Computed Tomographic
efficacy of this design when compared with dual-
Scanning Using Sequential Acquisitions
source or fast kVp switching systems is largely un-
known. However, this is likely to change with time One of the earliest and technologically most
with more widespread availability and use of this straightforward ways to obtain DECT scans, at
type of scanner. least from a hardware standpoint, is by acquiring
2 different scans sequentially.1,2,6,12 With this
approach, the spectral data at 2 different energies
Single-Source Dual-Energy Computed
are acquired sequentially at the same table posi-
Tomography with Beam Filtration at the
tion or a range of table positions using different
Source: TwinBeam Dual-Energy Computed
tube voltages (Fig. 7). The basic scheme can be
Tomography
optionally enhanced with the use of an additional
A relatively recent addition to clinically available reconfigurable filter similar to the dual-source or
DECT systems is the TwinBeam DECT scanner21,22 TwinBeam scanners.
(Siemens AG) (Fig. 6). This system consists of a The obvious advantage with this approach is
single source and detector combination, and spec- that there is little to no significant hardware modi-
tral separation is achieved at the level of the source. fication required for scanning, and an established
However, unlike the fast kVp approach, the beam is technology can be used for the acquisitions. The
 Dual-Energy CT Principles & Technique 379

Fig. 6. Single-source DECT with beam filtration at the source: TwinBeam DECT (Siemens AG). Schematic illustra-
tion of this type of a single source-detector combination system in which a split filter consisting of gold and tin is
placed at the output of the tube, resulting in separation of the beam into low- and high-energy spectra. The cor-
responding halves of the detector are then used for detection of the low- and high-energy spectra. (Courtesy of
Reza Forghani, MD, PhD, Montreal, Quebec, Canada and Bruno De Man, PhD, Niskayuna, NY.)

major and significant disadvantage is the temporal energy data. This can be achieved by alternating
skew between the high- and low-energy acquisi- scanning of high and low kVp data for each gantry
tions. The inherent delay or temporal skew can rotation, instead of scanning the entire volume
pose a limitation on evaluation of any process with multiple rotations at one energy followed by
requiring a high temporal resolution, such as mov- the other (see Fig. 7). Partial scanning techniques
ing organs as may be seen in cardiac imaging. It may also help with temporal resolution for scan-
would also pose a limitation on processes in which ning of relatively static organs, but the delays are
there is a change in contrast opacification, such as still too long, and motion misregistration of low-
angiographic acquisitions or even routine studies and high-energy data remains a significant prob-
evaluating tissue enhancement. Furthermore, any lem. The alternating acquisition of different energy
patient motion between the different energy acqui- data at each gantry position is the approach used
sitions can result in significant distortion of spec- by some scanners with DECT capabilities, such as
tral data. In its simplest form, sequential scans some Aquilion ONE models (Toshiba, Tochigi,
may be obtained with any CT scanner, and the ac- Japan) and Revolution EVO (GE Healthcare). Other
quired data combined afterward for spectral commercially available CT scanners may also
analysis. have the option of sequential DECT acquisitions,
One way to partially mitigate the most significant some limited to that of the entire scanned volume
disadvantage of this system is by minimizing the at one energy followed by the other for very limited
delay between the acquisition of low- and high- DECT applications. However, even with the more
380 Forghani et al

Fig. 7. Sequential scanning approaches to DECT Fig. 8. Schematic illustration of a photon counting
scanning. This is one of the earliest and technologi- scanner, one of the most advanced spectral CT systems
cally most straightforward ways to obtain DECT currently under development. These scanners use
scans. With this approach, the spectral data at 2 photon counting detectors to resolve the energy of
different energies are acquired sequentially at the individual photons or photon bins. Theoretically,
same table position, or a range of table positions us- these highly specialized and efficient detectors would
ing different tube voltages. Although simpler to count each individual incident X-ray photon and
implement, this approach has significant limitations measure its energy. Narrow selectable subranges
because of the delay between the acquisition of (or bins) of the spectrum can then be used to
low- and high-energy data, as discussed in the text. detect and classify materials based on their spectral
One way to minimize the delay between the acquisi- response, enabling robust multienergy material
tion of low- and high-energy data is by alternating characterization. (Courtesy of Reza Forghani, MD,
scanning of high and low kVp data for each gantry PhD, Montreal, Quebec, Canada and Bruno De Man,
rotation, instead of scanning the entire volume PhD, Niskayuna, NY.)
with multiple rotations at one energy followed by
the other. (Courtesy of Reza Forghani, MD, PhD, integrating detectors. However, this cannot fully
Montreal, Quebec, Canada and Bruno De Man, be exploited in whole-body CT scanners because
PhD, Niskayuna, NY.)
the geometric efficiency is limited by the antiscatter
collimator. Furthermore, with these detectors, an
refined approaches, major limitations regarding ef- energy threshold may be applied to enable the
fects of motion and temporal misregistration rejection of false counts that are solely due to
remain. These factors may limit successful appli- measured electronic noise. Hence, the impact of
cation and use of this technology to certain niche detector electronic noise can be entirely elimi-
areas. nated, or at least significantly reduced. Although
electronic noise will still affect the measured
energy of true individual photons, it will not alter
Emerging Spectral Computed Tomographic
photon counts.
Systems
These systems are conceptually interesting
One of the most advanced spectral CT systems because they provide energy information for each
currently under investigation and development is individual photon, and they may have the potential
the photon counting scanner (Figs. 8 and 9).2,23–34 to perform K-edge imaging and detect and classify
The principle behind these scanners is the use of materials of potential interest at very low concentra-
photon counting detectors that are used to resolve tions. As such, photon counting has the potential
the energy of individual photons or photon bins. to provide improved spectral material characteriza-
Theoretically, these highly specialized and efficient tion compared with current clinically available
detectors would count each individual incident X- approaches. The potential advantages of photon
ray photon and measure its energy range. Narrow counting systems include improvements in charac-
selectable subranges (or bins) of the spectrum terization of energy dependency of material attenu-
can then be used to detect and classify materials ation and improved distinction of a material based
based on their spectral response, enabling robust on its specific K-edge, also referred to as K-edge
multienergy material characterization. imaging.
There are multiple potential advantages of such In practice, however, there are challenges that
a system. Photon-counting detectors have a higher need to be overcome. There is still a substantial
geometric efficiency than conventional energy- overlap between the different energy bins, and it
 Dual-Energy CT Principles & Technique 381

Fig. 9. Examples of abdominal images obtained with a full field-of-view photon-counting CT scanner prototype
developed by GE Healthcare and installed at Rabin Medical Center, Israel in 2008. Two different slices are shown
in 2 different representations: (A, C) monochromatic images at 70 keV and (B, D) effective Z images. Different Z
numbers are mapped to different colors. The images were obtained with a 32-slice helical scan, 1-second gantry
rotation, 140 kVp and 140 mA. (Courtesy of Dr Ofer Benjaminov, Rabin Medical Center, Israel; with permission.)

is not yet clear whether the energy separation will scanning faces significant technological hurdles
be a significant advantage. Another advantage of because of the high exposure rates and photon
photon-counting detectors is their smaller cell flux required for CT. These hurdles include pulse
size, which could offer a substantial increase in pileup effects that can result in loss of counts, or
spatial resolution. However, this would have to potentially, even “paralyze” the detector. Pulse
be coupled to a smaller focal spot size and a major sharing across multiple detector pixels or K-
X-ray flux, and a dose increase would be required escape (reemission of a characteristic X-ray) can
to maintain acceptable image noise at the higher also occur and result in degradation of the accu-
spatial resolution. For example, if all other factors racy of the recorded energy. To be effective,
are kept unchanged, a 2-fold improvement in photon counting detectors would have to be
spatial resolution may require a 16-fold increase much faster than currently used CT detectors
in radiation dose in order to maintain the same and avoid prohibitively long scan times. Currently,
image noise. there are no commercially available photon-
The main limitations and challenges of photon counting scanners for clinical use, but different
counting spectral CT are currently technical in prototypes are available that may one day enable
nature. Although photon counting detectors clinical implementation of this exciting technology
are used in other disciplines such as nuclear and open a new era of spectral CT imaging,
medicine, application of this technology for CT potentially at a molecular level.
382 Forghani et al

In addition to active investigations and develop- is the use of multi-kVp imaging, switching the
ment of photon counting scanners, alternative X-ray tube between multiple voltages. These are
methods aimed at expanding multienergy evalua- other examples of exciting opportunities and areas
tion capabilities of spectral CT are also being of active research aimed at producing more robust
explored. One example is the adaptation and spectral CT platforms in the future. The different
combination of dual-source and TwinBeam tech- types of clinical DECT scanners and spectral CT
nologies described earlier to perform triple or scanners under investigation or development are
quadruple beam acquisitions.35 Another example summarized in Table 1.

Table 1
Different types of spectral computed tomography in clinical use or under development

Commercially available clinical DECT approaches and scanners

Tube voltage-based DECT scanners
Dual-source DECT  Two-source detector combinations at nearly 90 angles
 Allow the same volume to be scanned simultaneously at the 2
energies
Single-source DECT with  Single source and detector combination
rapid kVp switching  Very fast (submillisecond) switching between low- and high-
(GSI) energy spectra using a single source at each successive axial or
spiral view enables DECT acquisition
Detector-based DECT scanners
Layered or sandwich  Single source and detector combination
detector DECT  Highly specialized dual-layer detectors, each layer having
maximal sensitivity for different energies, used for DECT
acquisition
Filtration-based DECT scanners
Single-source DECT with  Single source and detector combination
beam filtration at the  A split filter at the output of the tube results in separation of the
source (TwinBeam beam into low- and high-energy spectra, that in turn are
DECT) detected by their respective halves of the detector enabling DECT
acquisition
Temporally sequential scanning
Sequential scanning of  Scan the volumes sequentially at the 2 different energies
entire scan volume  In theory possible with any scanner with the use of appropriate
software for merging of different energy data
Sequential scanning of  Alternating scanning of high and low kVp data for each gantry
each gantry rotation rotation instead the entire volume
 Reduces temporal and spatial misregistration compared with
sequential scanning of the entire volume at each energy
Spectral CT approaches and scanners under development
Dual-source and filtration-  Combination of dual-source DECT and split filter placed at the
based combinations output of one or both tubes
 Each source with split filter results in separation of the beam into
low- and high-energy spectra detected by their respective halves
of the detector
 Could potentially enable the acquisition of triple or quadruple
energy acquisitions
Photon counting  Detector-based material differentiation
 Narrow selectable subranges (or bins) of the spectrum can
potentially be used to detect and classify materials based on their
spectral “K-edge” patterns
 If successfully implemented, it could represent the most advanced
spectral CT system to date, enabling robust multienergy material
characterization
 Dual-Energy CT Principles & Technique 383

SUMMARY 8. Flohr TG, McCollough CH, Bruder H, et al. First per-

formance evaluation of a dual-source CT (DSCT)
Spectral CT is an exciting and evolving technology system. Eur Radiol 2006;16(2):256–68.
that has the potential to change the traditional 9. Johnson TR, Krauss B, Sedlmair M, et al. Material
SECT approach currently used in most clinical differentiation by dual energy CT: initial experience.
settings. DECT provides a new layer of informa- Eur Radiol 2007;17(6):1510–7.
tion, previously unavailable using SECT. This new 10. Dodge CW. A rapid method for the simulation of filtered
information has the potential to be expanded x-ray spectra in diagnostic imaging systems. Wayne
to elemental or molecular composition analysis State University; 2008. Available at: http://gateway.
far beyond conventional SECT scanning. In this proquest.com/openurl?url_ver=Z39.88-2004&res_dat
article, the first part of a 2-part review, the funda- =xri:pqdiss&rft_val_fmt=info:ofi/fmt:kev:mtx:disserta
mental principles underlying spectral CT scanning tion&rft_dat=xri:pqdiss:3315609.
and different spectral CT systems, both com- 11. Johnson TR. Dual-energy CT: general principles.
mercially available or under investigation, were AJR Am J Roentgenol 2012;199(5 Suppl):S3–8.
reviewed. Such familiarity is essential for those 12. Alvarez RE, Macovski A. Energy-selective recon-
using or planning to use this technology optimally. structions in X-ray computerized tomography. Phys
Since the advent of DECT systems, there has Med Biol 1976;21(5):733–44.
been a steady increase in the applications of this 13. Michael GJ. Tissue analysis using dual energy CT.
technology for the evaluation of brain or head Australas Phys Eng Sci Med 1992;15(2):75–87.
and neck abnormality. Concomitantly, there has 14. Petersilka M, Bruder H, Krauss B, et al. Technical
been a steady increase in the number of commer- principles of dual source CT. Eur J Radiol 2008;
cially available systems. Multiple workflow optimi- 68(3):362–8.
zations are also being implemented to efficiently 15. Krauss B, Schmidt B, Flohr TG. Dual source CT.
incorporate this technology into the clinical In: Johnson T, Fink C, Schönberg SO, et al, edi-
routine. Various articles in this issue review tors. Dual energy CT in clinical practice. Berlin:
different applications of DECT and how they are Springer-Verlag Berlin Heidelberg; 2011. p.
being incorporated into the clinical workflow. 10–20.
Even at this early stage in the development of 16. Chandra N, Langan DA. Gemstone detector: dual en-
this technology, it is clear that DECT will play an ergy imaging via fast kVp switching. In: Johnson T,
increasingly important role in neuroradiology and Fink C, Schönberg SO, et al, editors. Dual energy
head and neck imaging and further improve the CT in clinical practice. Berlin: Springer-Verlag Berlin
diagnostic evaluation of our patients. Heidelberg; 2011. p. 35–41.
17. Kalender WA, Perman WH, Vetter JR, et al. Evalua-
tion of a prototype dual-energy computed tomo-
REFERENCES
graphic apparatus. I. Phantom studies. Med Phys
1. Johnson TRC, Kalender WA. Physical background. 1986;13(3):334–9.
In: Johnson T, Fink C, Schönberg SO, et al, editors. 18. Xu D, Langan DA, Wu X, et al. Dual energy CT via
Dual energy CT in clinical practice. Berlin: Springer- fast kVp switching spectrum estimation. Paper pre-
Verlag Berlin Heidelberg; 2011. p. 3–9. sented at: Medical Imaging 2009: Physics of Medi-
2. McCollough CH, Leng S, Yu L, et al. Dual- and multi- cal Imaging. Lake Buena Vista (FL), March 14, 2009.
energy CT: principles, technical approaches, and 19. Vlassenbroek A. Dual layer CT. In: Johnson T, Fink C,
clinical applications. Radiology 2015;276(3):637–53. Schönberg SO, et al, editors. Dual energy CT in clin-
3. Chiro GD, Brooks RA, Kessler RM, et al. Tissue sig- ical practice. Berlin: Springer-Verlag Berlin Heidel-
natures with dual-energy computed tomography. berg; 2011. p. 21–34.
Radiology 1979;131(2):521–3. 20. Alvarez RE, Seibert JA, Thompson SK. Comparison
4. Genant HK, Boyd D. Quantitative bone mineral anal- of dual energy detector system performance. Med
ysis using dual energy computed tomography. Phys 2004;31(3):556–65.
Invest Radiol 1977;12(6):545–51. 21. Euler A, Parakh A, Falkowski AL, et al. Initial results
5. Kelcz F, Joseph PM, Hilal SK. Noise considerations of a single-source dual-energy computed tomogra-
in dual energy CT scanning. Med Phys 1979;6(5): phy technique using a split-filter: assessment of
418–25. image quality, radiation dose, and accuracy of
6. Millner MR, McDavid WD, Waggener RG, et al. dual-energy applications in an in vitro and in vivo
Extraction of information from CT scans at different study. Invest Radiol 2016;51(8):491–8.
energies. Med Phys 1979;6(1):70–1. 22. Kaemmerer N, Brand M, Hammon M, et al. Dual-
7. Macovski A, Alvarez RE, Chan JL, et al. Energy energy computed tomography angiography of the
dependent reconstruction in X-ray computerized to- head and neck with single-source computed to-
mography. Comput Biol Med 1976;6(4):325–36. mography: a new technical (Split Filter) approach
384 Forghani et al

for bone removal. Invest Radiol 2016;51(10): at clinical dose levels: contrast-to-noise ratio and
618–23. cadaver studies. Invest Radiol 2016;51(7):421–9.
23. Schlomka JP, Roessl E, Dorscheid R, et al. Experi- 31. Yu Z, Leng S, Jorgensen SM, et al. Evaluation of
mental feasibility of multi-energy photon-counting conventional imaging performance in a research
K-edge imaging in pre-clinical computed tomogra- whole-body CT system with a photon-counting
phy. Phys Med Biol 2008;53(15):4031–47. detector array. Phys Med Biol 2016;61(4):
24. Shikhaliev PM. Tilted angle CZT detector for photon 1572–95.
counting/energy weighting x-ray and CT imaging. 32. Iwanczyk JS, Nygard E, Meirav O, et al. Photon
Phys Med Biol 2006;51(17):4267–87. counting energy dispersive detector arrays for x-
25. Wang X, Meier D, Taguchi K, et al. Material separa- ray imaging. Paper presented at: 2007 IEEE Nuclear
tion in x-ray CT with energy resolved photon- Science Symposium Conference Record. Honolulu
counting detectors. Med Phys 2011;38(3):1534–46. (HI), October 26, 2007–November 3, 2007.
26. Taguchi K, Iwanczyk JS. Vision 20/20: single photon 33. Romman Z, Benjaminov O, Levinson R, et al. Virtual
counting x-ray detectors in medical imaging. Med non-contrast ct of the abdomen using a dual
Phys 2013;40(10):100901. energy photon-counting CT scanner: assessment
27. Herrmann C, Engel KJ, Wiegert J. Performance of performance. Paper presented at: Radiological
simulation of an x-ray detector for spectral CT with Society of North America 2009 Scientific Assembly
combined Si and Cd[Zn]Te detection layers. Phys and Annual Meeting. Chicago (IL), November
Med Biol 2010;55(24):7697–713. 29-December 4, 2009.
28. Leng S, Yu Z, Halaweish A, et al. A high-resolution 34. Benjaminov O, Perlow E, Romman Z, et al. Novel,
imaging technique using a whole-body, research energy-discriminating photon counting CT system
photon counting detector CT system. Proc SPIE Int (EDCT): first clinical evaluation—CT angiography:
Soc Opt Eng 2016;9783. Carotid Artery Stenosis. Paper presented at: Radio-
29. Yu Z, Leng S, Jorgensen SM, et al. Initial results from logical Society of North America 2008 Scientific
a prototype whole-body photon-counting computed Assembly and Annual Meeting. Chicago (IL),
tomography system. Proc SPIE Int Soc Opt Eng November 30-December 5, 2008.
2015;9412. 35. Yu L, Leng S, McCollough CH. Dual-source multi-
30. Gutjahr R, Halaweish AF, Yu Z, et al. Human imaging energy CT with triple or quadruple X-ray beams.
with photon counting-based computed tomography Proc SPIE Int Soc Opt Eng 2016;9783.