A theoretical comparison of x-ray angiographic image quality using energy-dependent and conventional subtraction methods.

PURPOSE X-ray digital subtraction angiography (DSA) is widely used for vascular imaging. However, the need to subtract a mask image can result in motion artifacts and compromised image quality. The current interest in energy-resolving photon-counting (EPC) detectors offers the promise of eliminating motion artifacts and other advanced applications using a single exposure. The authors describe a method of assessing the iodine signal-to-noise ratio (SNR) that may be achieved with energy-resolved angiography (ERA) to enable a direct comparison with other approaches including DSA and dual-energy angiography for the same patient exposure. METHODS A linearized noise-propagation approach, combined with linear expressions of dual-energy and energy-resolved imaging, is used to describe the iodine SNR. The results were validated by a Monte Carlo calculation for all three approaches and compared visually for dual-energy and DSA imaging using a simple angiographic phantom with a CsI-based flat-panel detector. RESULTS The linearized SNR calculations show excellent agreement with Monte Carlo results. While dual-energy methods require an increased tube heat load of 2× to 4× compared to DSA, and photon-counting detectors are not yet ready for angiographic imaging, the available iodine SNR for both methods as tested is within 10% of that of conventional DSA for the same patient exposure over a wide range of patient thicknesses and iodine concentrations. CONCLUSIONS While the energy-based methods are not necessarily optimized and further improvements are likely, the linearized noise-propagation analysis provides the theoretical framework of a level playing field for optimization studies and comparison with conventional DSA. It is concluded that both dual-energy and photon-counting approaches have the potential to provide similar angiographic image quality to DSA.