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Iterative Reconstruction May Improve Diagnosis of Gout

An Ex Vivo (Bio)Phantom Dual-Energy Computed Tomography Study

Diekhoff, Torsten MD*; Kotlyarov, Maximilian*; Mews, Jürgen; Hamm, Bernd MD*; Hermann, Kay-Geert Armin MD*

doi: 10.1097/RLI.0000000000000402
Original Articles

Objectives We hypothesize that, compared with filtered back projection (FBP), iterative reconstruction (IR) increases the detected volume of uric acid, which serves as a measure of the sensitivity of the method, and therefore allows examinations with lower radiation exposure. Thus, the aim of our study was to evaluate the role of IR in dual-energy computed tomography (DECT) for gout assessment and volumetry in an ex vivo gout model using an epoxy phantom and a biophantom.

Materials and Methods We prepared specimens with different concentrations of monosodium uric acid in ultrasound gel (30%–50%) and inserted them into an epoxy-based phantom and a porcine foreleg. Computed tomography scanning was performed on a 320-row single-source DECT scanner in volume mode with an ascending order of tube currents. Image data sets were reconstructed using FBP and IR with 2 iteration levels (IR1 and IR2). Measurements in regions of interest (ROIs) and volumetric measurements were performed using either fixed parameters for the analysis software (epoxy phantom) or parameters specifically adapted for each data set (porcine phantom). Seven retrospectively identified clinical data sets were used for validation in patients. Rm-ANOVA was used for statistical analysis. No institutional review board approval was required.

Results We found no differences in Hounsfield units between the different reconstruction algorithms (P = 0.09 and 0.05 for 80 and 135 kVp, respectively) and the calculated dual-energy gradient (P = 0.27). Filtered back projection detected less uric acid compared with IR (with fixed parameters: 6.0 ± 0.3 cm3 for FBP and 6.1 ± 0.2 for IR1 and IR2; with adapted thresholds: 1.2 ± 0.3 cm3 for FBP and 1.8 ± 0.1 and 2.0 ± 0.1 for IR1 and IR2, respectively). The differences were significant for all measurements (P = 0.0003). Also in the test cases, FBP detected significantly fewer tophi (mean volume, 1.38 ± 2.1 cm3) compared with IR1 (1.86 ± 2.9) and IR2 (2.07 ± 3.1) (P = 0.04).

Conclusions Iterative reconstruction has the potential to improve the sensitivity of a DECT scan for gouty tophi, to decrease radiation exposure, or to combine both options.

From the *Department of Radiology, Charité–Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin, Germany; and †Toshiba Medical Systems Europe BV, Center for Medical Research & Development Europe, Zoetermeer, the Netherlands.

Received for publication April 28, 2017; and accepted for publication, after revision, June 29, 2017.

Conflicts of interest and sources of funding: The Department of Radiology of Charité–Universitätsmedizin Berlin has received a research grant from Toshiba Medical Systems. J.M. is an employee of Toshiba Medical Systems. For the remaining authors, none were declared.

Correspondence to: Torsten Diekhoff, MD, Department of Radiology, Charité–Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität Berlin, Berlin, Germany, Charitéplatz 1, 10117 Berlin, Germany. E-mail:

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