Comparison of “one-stop” coronary and head-and-neck computed tomography angiography with different scan sequences using a wide-detector system: heart-to-cranial vs. cranial-to-heart

Introduction

Atherosclerosis is the leading cause of cardiovascular and cerebrovascular diseases (1). Cardiovascular and cerebrovascular diseases are sweeping the globe and becoming the primary causes of mortality and morbidity worldwide (1). Atherosclerosis is a systemic disease, and previous studies have shown a coexisting relationship between carotid artery stenosis and coronary artery disease (2). Further, ischemic stroke is frequently suffer from asymptomatic coronary artery disease (2-4).

Computed tomography angiography (CTA) is a non-invasive examination that has proven to be a reliable method for detecting stenosis in peripheral arteries (5,6). CTA of the cerebral, carotid, and coronary arteries has high accuracy in the detection of steno-occlusive disease, and its consistency with digital subtraction angiography is as high as 97% (7-10). However, conventional computed tomography (CT) techniques require separate scans for head-and-neck computed tomography angiography (HNCTA) and coronary computed tomography angiography (CCTA), resulting in an increased iodine contrast volume and longer waiting times for patients.

With recent advancements in computed tomography (CT) techniques, such as a faster rotation time, and the introduction of the high pitch or fast switching modes, it is now possible to perform “one-stop” HNCTA and CCTA using dual-source or 16-cm wide-detector CT scanners with a single iodine contrast injection (5,11-13). In most clinical settings, the CCTA scan is completed before the HNCTA scan (the heart-cranial sequence) in one-stop CTA. However, this scanning order results in iodine contrast residual in the right atrium (RA) and the hyperdense visualization of veins of the head and neck (14,15).

We therefore established an alternative scanning sequence in which the HNCTA scan is followed by the CCTA scan (the cranial-heart sequence). This study aimed to compare the image quality of one-stop CTA scans acquired using the two different scanning sequences on a wide-detector CT system. We present this article in accordance with the STROBE reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-24-824/rc).

Methods

Study population

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This prospective study was approved by the Institutional Review Board of Xuanwu Hospital (No. 169-001), and informed consent was obtained from all the individual participants included in the study. Consecutive patients diagnosed or suspected of having atherosclerosis who attended the Department of Radiology & Nuclear Medicine of Xuanwu Hospital for HNCTA and CCTA were enrolled in the study from September 2019 to November 2020. Patients were excluded from the study if they met any of the following exclusion criteria: (I) had a history of carotid artery bypass grafting; (II) had a history of stents or pacemaker implantation; and/or (III) had significant motion artifacts in the cerebral, carotid, and coronary arteries.

The patients were randomly allocated to one of the following three groups: group A, which underwent one-stop CTA using the heart-cranial sequence (i.e., CCTA first); group B, which underwent one-stop CTA using the cranial-heart sequence (i.e., HNCTA first); and group C, which underwent HNCTA and CCTA separately within 1 month.

Scan protocols and image reconstruction

All the scans were performed using a 16-cm wide-detector CT scanner (Revolution CT, GE Healthcare, Milwaukee, USA). CTA acquisition timing was calculated based on test-bolus data. In groups A and B, the monitor level was set at the 3rd/4th cervical spine level. In group C, the monitor level was set at the 3rd/4th cervical spine level for separate HNCTA, and the monitor level was set at the aortic root (AR) level for the separate CCTA. All the CCTA scans were acquired within one cardiac cycle using the prospectively electrocardiogram-triggered mode. The motion correction algorithm (Snapshot Freeze, GE Healthcare) and smart-phase technique were employed to reduce the motion of coronary arteries. For the one-stop CTA, the transition time between the two scans was about 2 seconds. Patients were not required to hold their breath or take medicine to control their heart rate (HR) during the CCTA scans. In group C, the patients had to hold their breath to complete the separate CCTA. The scanning protocols and sequences for all three groups are shown in Figure 1 and Table 1.

Figure 1 Scanning sequences for the three groups. (A) The scanning protocol of group A: one-stop CTA using the heart-to-cranial sequence. (B) The scanning protocol of group B: one-stop CTA using the cranial-to-heart sequence. (C) The scanning protocol of group C: separate HNCTA and CCTA. Group A: one-stop CTA using the heart-to-cranial sequence. Group B: one-stop CTA using the cranial-to-heart sequence. Group C: separate HNCTA and CCTA. CTA, computed tomography angiography; HNCTA, head-and-neck computed tomography angiography; CCTA, coronary computed tomography angiography.

The contrast agent (Ioversol, 320 mg iodine/mL; Jiangsu Hengrui Pharmaceuticals Co., Lianyungang, China) was injected at a flow rate of 5 mL/s for all scans. Contrast agent (15 mL) followed by saline (15 mL) was used for the test-bolus scans, while contrast agent (60 mL) followed by saline (60 mL) was used for the CTA scans. The injection protocols and iodine dose were the same for all patients. All the CTA data were transferred to a workstation (Advantage Workstation 4.7, GE Healthcare) for post-processing. The curved planar reconstruction, multi-planar reformations, maximum intensity projection, and volume rendering were re-formatted.

Objective image quality evaluation

A radiologist, who was blinded to the protocols, delineated the region of interest (ROI) on the 0.625-mm axial images to measure the CT values and standard deviation (SD). The ROI was 1 cm² in the RA. The ROI was drawn as large as possible to include the entire contrast-enhanced target vascular lumen, while avoiding calcification, atherosclerotic plaques, and vessel walls, and the ROIs ranged from 0.10 to 0.15 cm².

The mean CT attenuation and SD of the aorta arch (AA), the bifurcation of the common carotid artery (CCA), the cervical spine 1–2 level of the internal carotid artery (ICA), and the bilateral M1 segment of the middle cerebral artery (MCA) were used to assess the degree of enhancement of the carotid and cerebral arteries (16). The CT attenuation of the confluence of sinuses (CS) and the internal jugular vein (IJV) at the cervical spine 1–2 level were recorded to evaluate the degree of venous visualization (17). The background noise of the cerebral and carotid vessels was defined as the SD of the sternocleidomastoid muscle at the thyroid cartilage level.

The mean CT attenuation and SD were measured for the AR, and proximal segments of the left anterior descending (LAD) artery, left circumflex (LCX) artery, and right coronary artery (RCA) to evaluate the degree of enhancement in the coronary arteries. The CT attenuation of the center of the RA was measured at the level of the aortic valve (18). The image noise in the coronary arteries was defined as the SD of the thoracic muscle at the AR level.

The single-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated using the following formulas:

SNR=CTattenuation(vessel)SD(vessel)[1]

CNR=CTattenuation(vessel)−CTattenuation(backgroud)SD(backgroud)[2]

Subjective image quality evaluation

Two radiologists, each with more than 5 years of experience and each blinded to the scan modes, independently assessed the image quality. If any discrepancies arose in the image quality evaluation, a consensus reading was performed.

For HNCTA, a 5-point scoring system was used to evaluate image quality on which 5 represented excellent (clear vessel boundary delineation without artifacts or venous visualization); 4 represented good (mostly clear boundary delineation with minimal artifacts or venous visualization); 3 represented adequate (suboptimal vessel boundary delineation with moderate artifacts or venous visualization); 2 represented poor (blurred vessel boundary with severe artifacts or venous visualization); and 1 represented non-diagnostic (no clear vessel boundary delineation with many severe artifacts or venous visualization) (16,17,19). Images with scores of 3 or higher were considered acceptable for clinical diagnosis.

The coronary artery was divided into 15 segments according to the standards of the American Heart Association (4,5). The image quality of the coronary arteries was assessed using a 4-point scoring system on which 4 represented excellent vessel definition and no streak artifacts in the RA; 3 represented standard vessel definition with mild streak artifacts in the RA; 2 represented poor vessel definition or moderate streak artifacts in RA; and 1 represented non-diagnostic vessel definition or severe streak artifacts in the RA (13,20,21). Coronary artery segments with a diameter of 1.5 mm or less were not evaluated. Images with a score of 2 or more were considered acceptable for diagnosis.

Radiation dose calculation

The calculation of the volume CT dose index and the dose-length product (DLP) included toppgrams, calcification score, test-bolus, no-contrast scan, and CTA scan (Figure 1). The radiation dose of CCTA and HNCTA was assessed separately. The effective dose (ED) was calculated using the following formula:

ED=DLP∗k[3]

where k is the conversion factor, and 0.028 mSv/(mGy·cm) was used for CCTA, and 0.0031 mSv/(mGy·cm) for HNCTA (4,12).

Statistical analysis

All the statistical analyses were performed using commercially available software (SPSS, version 20.0, SPSS, USA). The study size was calculated based on a statistical analysis. The Kolmogorov-Smirnov test was used to evaluate if the data were normally distributed. The normally distributed data were expressed as the mean ± SD; otherwise, they were expressed as the frequency or percentage. Differences in patient characteristics, contrast enhancement, the SNR, and the CNR were compared using the analysis of variance test and the Student’s t test. The inter-reader agreement in assessing image quality was calculated using weighted kappa statistics. Kappa values were interpreted as either poor (K <0.20), fair (K =0.21–0.40), moderate (K =0.41–0.60), good (K =0.61–0.80), very good (K =0.81–0.90), or excellent (K ≥0.91). The Kruskal-Wallis test was used to compare the image quality scores of the three groups. A P value less than 0.05 was considered statistically significant.

Results

Patient characteristics

Overall, 150 patients were included in the study, of whom 102 were male and 48 were female. The patients had a mean age of 61±11 years, an average body mass index (BMI) of 25.04±3.35 kg/m², and an average HR of 67.74±14.47 beats/min. The patients in groups A, B, and C had an average BMI (minimum and maximum) of 25.10±3.56 (17.51, 30.00) kg/m², 25.29±3.89 (18.37, 30.45) kg/m², 24.59±2.98 (17.58, 33.46) kg/m², respectively. Of the patients, 22 (44%) in group A, 24 (48%) in group B, and 31 (62%) in group C had a HR ≤65 beat/min, but there was no statistically significant difference between the three groups in terms of the HR (P=0.28). There were no statistically significant differences among the three groups in terms of their demographic data (Table 2).

Objective image quality analysis

Cerebral and carotid arteries

In terms of CT attenuation, all the cerebral and carotid arteries in the three groups had values greater than 300 Hounsfield units (Hu). No significant differences were found between the three groups in terms of CT attenuation of the AA, CCA, and ICA. The CT attenuation of the MCA was lower in group B (381±80 Hu) than group A (401±71 Hu) (P=0.19). In terms of the SNR and CNR, there were no significant differences between the three groups for the AA and IAC. However, the SNR of the CCA (27.14±11.17) and MCA (12.32±8.39) in group B were lower than those in the other two groups, but only the difference between groups B and C was statistically significant. The CNR of the CCA of group B (30.09±11.33) was better than that of group A (28.35±14.53), and the P value was 0.63. Additionally, there was a statistically significant difference in CT attenuation at the IJV and CS among the three groups. The CT attenuation values at the IJV and CS were 115±64 and 151±51 Hu in group B, respectively, which were lower than those of the other groups (P<0.05). Group A had the highest CT attenuation values at the IJV and CS. The results of the comparison of the three groups are presented in detail in Figure 2 and Table 3.

Figure 2 Comparison of CT attenuation, the SNR and the CNR among the three scanning protocol groups. Group A: one-stop CTA using the heart-to-cranial sequence. Group B: one-stop CTA using the cranial-to-heart sequence. Group C: separate HNCTA and CCTA. * indicates a statistically significant difference between the groups (P<0.05). AA, aorta arch; AR, aorta root; CS, confluence of sinuses; CCA, common carotid artery; ICA, internal carotid artery; LAD, left anterior descending; LCX, left circumflex; MAC, middle cerebral artery; RCA, right coronary artery; RA, right heart; CT, computed tomography; SNR, single-to-noise ratio; CNR, contrast-to-noise; CTA, computed tomography angiography; HNCTA, head-and-neck computed tomography angiography; CCTA, coronary computed tomography angiography.

Coronary arteries

In terms of CT attenuation, there were no significant differences between the three groups at the AR and RCA. However, the CT values at the LAD and LCX arteries were higher in group B (251±78, 260±81 Hu) than group A (220±74, 234±87), and had P values of 0.04 and 0.12, respectively. In terms of the SNR, there were no statistically significant differences among the three groups at the RCA (P=0.76), LAD artery (P=0.59), and LCX artery (P=0.89). The highest CNR was observed in group C, followed by group B, and then group A. In relation to the LAD artery and LCX, there were statistically significant differences in the CNR between groups A and C, and groups B and C. However, no statistically significant differences were found between groups A and B in terms of the CNR (Figure 2C). The mean CT attenuation value of the RA in group B was 136±52 Hu, which was lower than that of both group A (295±139 Hu, P<0.001) and group C (220±101 Hu, P<0.001) (Figure 2 and Table 3).

Subjective image quality analysis

Cerebral and carotid arteries

For all the patients, the image quality of all cerebral and carotid arteries was acceptable for diagnosis (i.e., had scores of no less than 3 points), and there was no statistically significant difference among the three groups (P=0.24). The k statistic for inter-observer agreement for HNCTA image quality was 0.67. The percentage of subjectively rated 5-score images in groups B and C was 36%, while group A had the lowest percentage of subjectively rated 5-score images at 18%. Figure 3 shows volume rendering and maximum intensity projection images of the three groups. The visualization of the IJV at the cervical spine 1–2 level and CS in the three groups of patients is indicated by the arrows in Figure 4. The specific subjective image quality scores for the three groups are set out in Table 4.

Figure 3 Representative HNCTA reconstruction images from three groups. (A1,A2) The volume rendering and maximum intensity projection images of a 61-year-old woman in group A (BMI: 22.78 kg/m²). (B1,B2) The volume rendering and maximum intensity projection images of a 57-year-old woman in group B (BMI: 21.88 kg/m²). (C1,C2) The volume rendering and maximum intensity projection images of a 69-year-old man in group C (BMI: 21.87 kg/m²). The image quality of all cerebral and carotid arteries was satisfactory for diagnosis, scoring no less than 3 points across the three groups. Group A: one-stop CTA using the heart-to-cranial sequence. Group B: one-stop CTA using the cranial-to-heart sequence. Group C, separate HNCTA and CCTA. HNCTA, head-and-neck computed tomography angiography; CTA, computed tomography angiography; CCTA, coronary computed tomography angiography; BMI, body mass index.

Figure 4 Representative axial images of the IJV and transverse sinus from three groups. The arrows shown the IJV at the cervical spine 1–2 level (A1/B1/C1) and transverse sinus (A2/B2/C2) in the three groups of patients. (A1,A2) Images of a 57-year-old female patient in group A (BMI: 27.39 kg/m²). (B1,B2) Images of a 50-year-old male patient in group B (BMI: 27.92 kg/m²). (C1,C2) Images of a 47-year-old male patient in group C (BMI: 27.78 kg/m²). Group A had the highest computed tomography attenuation at the IJV and transverse sinus, followed by group C and then group B. Group A: one-stop CTA using the heart-to-cranial sequence. Group B: one-stop CTA using the cranial-to-heart sequence. Group C: separate HNCTA and CCTA. IJV, internal jugular vein; CTA, computed tomography angiography; HNCTA, head-and-neck computed tomography angiography; CCTA, coronary computed tomography angiography; BMI, body mass index.

Coronary artery

On a per-patient basis, the mean image scores for one-stop CTA were similar (group A vs. group B, 2.86±0.76 vs. 3.00±0.73), and the difference was not statistically significant (χ²=1.53, P=0.67). Group C had a higher mean score (3.50±0.58) than the other groups A and B (P<0.001). Additionally, nearly 100% of patients had images of an assessable quality on a per-patient basis. The overall inter-observer agreement on a per-patient-based was 0.65. There were 601 coronary artery segments available for interpretation in group A, 599 in group B, and 616 in group C. In total, 99.168% (596/601) and 97.495% (584/599) of the coronary arterial segments were of assessable image quality for groups A and group B, respectively (Table 5). The images included in Figure 5 were obtained from patients in the three groups. As indicated by the arrow, the RA contrast was more clearly visible in group A than group B.

Figure 5 Reconstruction coronary images obtained from the three groups. (A1,A2) Volume rendering and the axial images of a 78-year-old male patient (HR: 65 bpm, BMI: 27.76 kg/m²) in group A. (B1,B2) Volume rendering and axial images of a 75-year-old male patient (HR: 65 bpm, BMI: 28.58 kg/m²) in group B. (C1,C2) Volume rendering and the axial images of the RA of a 68-year-old male patient (HR: 59 bpm, BMI: 27.81 kg/m²) in group C. The coronary arteries were clearly displayed in the three groups. As the arrows show, Group A exhibited the highest computed tomography attenuation at the RA, followed by group B, and group C. Group A: one-stop CTA using the heart-to-cranial sequence. Group B: one-stop CTA using the cranial-to-heart sequence. Group C: separate HNCTA and CCTA. CTA, computed tomography angiography; HNCTA, head-and-neck computed tomography angiography; CCTA, coronary computed tomography angiography; HR, heart rate; BMI, body mass index; RA, right atrium.

Radiation dose

The radiation dose of the one-stop of CCTA and HNCTA was lower than that of the separate CCTA and HNCTA. The total ED was 9.0±1.4 mSv for group A and 8.3±1.5 mSv for group B, and the difference was statistically significant (P<0.001). Detailed radiation dose information for each group is provided in Table 6.

Discussion

Most previous studies on combined CTA for the evaluation of coronary, cerebral, and carotid arteries have used a protocol in which CCTA is performed first, which is also known as the heart-cranial sequence (12,14,18). In the present study, we proposed a cranial-heart scanning sequence to complete one-stop CTA and sought to compare the differences between the two different scanning sequences. Our study showed that one-stop CTA, which uses a low dose of contrast media, provided good-quality images and had a reduced radiation dose compared to that of separate CCTA and HNCTA. Most importantly, this cranial-heart sequence protocol for one-stop CTA addressed the issue of visualization in the RA and venous arteries.

Our result showed that the different scanning sequences may result in some variations in the image details for one-stop CTA. However, regardless of whether HNCTA or CCTA was performed first, this combined approach achieved a 100% diagnostic rate in HNCTA. In relation to HNCTA, our subjective evaluation results revealed that more images were scored 5 points in group B (36%) than group A (18%). We observed that the images obtained from group B (using the cranial-to-heart sequence) had significantly lower venous visualization in the head and neck compared to the other two groups [Figure 4A (A1 and A2)]. This finding is consistent with that of Wang et al. (15). In their study, patients underwent one-stop CTA using a prospective electrocardiogram-triggered high-speed spiral scan in a caudocranial direction. They found that the average attenuation values of the left and right IJVs at the level of the carotid bifurcation were 156±84 and 129±84 Hu, respectively. In our study, the CT attenuation value of the IJV at the level of the CCA in group B was 115±51 Hu, which was lower than that reported by Wang et al. (15). The result can be attributed to the CTA scan sequence. In group A, there was a 2-second delay to switch to a spiral mode before the HNCTA scan, which increased the visibility of the IJV and CS. In terms of the objective results, the CT attenuation, SNR, and CNR of the HNCTA in group B were sufficient to ensure the display of the carotid and cerebral arteries, and did not differ significantly compared to those obtained using the separate HNCTA protocol.

The one-stop CTA with cranial-heart sequencing not only ensured the image quality of the coronary arteries, but also effectively reduced the contrast residual in the RA. In Figure 5, B1 and B2, show CCTA images of an obese patient (BMI: 28.58 kg/m²) from group B; the CT value of the RCA was 292±39 Hu, and no obvious contrast agent residue in the RA was observed. This is because the CCTA scan was performed after HNCTA in group B, which allowed more saline to enter the circulation and reduced the iodine contrast residual in the RA. By way of comparison, the CT values of the RA of group A (295±139 Hu) were similar to the those of Kerl et al.’s (18) monophasic protocol group (302±25 Hu), and the CT values of the RA in group B (136±52 Hu) were similar to those of Kerl et al.’s (18) biphasic protocol group (143±17 Hu). Similarly, in the present study, group B was significantly less affected by streak artifacts for the high-attenuation contrast medium. Additionally, we also found that the image quality of CCTA from one-stop CTA was slightly worse than that of the separate CCTA (group C). There are two possible reasons for these results. First, there were differences in the test-bolus monitoring level between the groups. In group C, the test-bolus level was placed at the root of the AC, resulting in better timing for the CCTA scan compared to the one-stop CTA. Second, the difference in the patients’ position could have affected the results. In groups A and B, the patients placed their arms at the sides of their body, which could have potentially increased the noise and decreased the SNR and CNR of the coronary arteries. Conversely, in the separate CCTA scan, the patients raised their arms, which helps avoid this issue. These viewpoints have also been discussed in previous research studies (22,23).

In terms of the radiation dose, no significant difference was observed between the different scanning sequences of the one-stop CTA, which had a lower ED than the total of ED of the separate HNCTA and CCTA. The radiation dose for our study incorporated all the scanning sequences, including the localization image, monitoring phase, no-contrast, and the CTA phase, to provide a comprehensive evaluation of the ED generated by the different scanning protocols. The one-stop CTA not only improved the efficiency of CTA scanning, but also reduced the radiation dose and iodine contrast agent dose.

Our study had some limitations. First, the present study was a feasibility study conducted with a small sample size, which might limit its statistical effectiveness. Second, this study did not adjust the contrast fluxes based on the patients’ weight. There were no statistically significant differences in weight among the groups; however, this could still have caused bias in the CT values. Third, the patients did not take nitroglycerin, which would have affected the evolution of coronary arteries. Finally, while the data were collected prospectively between 2019 and 2020, the long duration between the data collection and the publication of this article is a limitation of this study.

Conclusions

“One-stop” CTA provides images of acceptable quality for both CCTA and HNCTA, while reducing the contrast agent dose and radiation dose compared to separate CCTA and HNCTA scans. One-stop CTA in which the HNCTA scan is performed first not only provides a good evaluation of the carotid, cerebral, and coronary arteries, but also effectively reduces the visualization of the RA and veins.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-24-824/rc

Funding: This study received funding from Huizhi Ascent Project of Xuanwu Hospital (No. HZ2021ZCLJ005).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-824/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This prospective study was approved by the Institutional Review Board of Xuanwu Hospital (No. 169-001), and informed consent was obtained from all individual participants included in the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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