Review

Radiology

Mannudeep K. Kalra, MD, Techniques and Applications

DNB
Michael M. Maher, MD, FFR of Automatic Tube Current
(RCSI), FRCR
Thomas L. Toth, DSc
Bernhard Schmidt, PhD
Modulation for CT1
Bryan L. Westerman, PhD
Hugh T. Morgan, PhD Introduction of slip-ring technology with subsequent development of single– and
Sanjay Saini, MD multi– detector row helical computed tomographic (CT) scanners have expanded
the applications of CT, leading to a substantial increase in the number of CT
examinations being performed. Owing to concerns about the resultant increase in
Index terms: associated radiation dose, many technical innovations have been introduced. One
Computed tomography (CT), image such innovation is automatic tube current modulation. The purpose of automatic
quality tube current modulation is to maintain constant image quality regardless of patient
Computed tomography (CT),
attenuation characteristics, thus allowing radiation dose to patients to be reduced.
radiation exposure
Computed tomography (CT), This review discusses the principles, clinical use, and limitations of different auto-
technology matic tube current modulation techniques.
Radiations, exposure to patients and © RSNA, 2004
personnel
Review

Published online before print

Tube current (measured in milliamperes) is an important determinant of radiation dose
10.1148/radiol.2333031150
Radiology 2004; 233:649 – 657 and image quality in x-ray– based examinations. Recent advances in computed tomo-
graphic (CT) technology, including implementation of automatic tube current modula-
Abbreviations: tion (ATCM), allow reduction in radiation exposure during CT examinations (1– 6). ATCM
ACS ⫽ automatic current setting may be defined as a set of techniques that enable automatic adjustment of the tube current
ATCM ⫽ automatic tube current in the x-y plane (angular modulation) or along the z-axis (z-axis modulation) according to
modulation
the size and attenuation characteristics of the body part being scanned and achieve
constant CT image quality with lower radiation exposure. Hence, ATCM techniques are
1
From the Division of Abdominal Im- analogous to the automatic exposure-control or photograph-timing techniques used in
aging and Intervention, Department conventional radiography.
of Radiology, Massachusetts General
Hospital and Harvard Medical School,
Amid growing concerns about CT radiation exposure, the adoption of ATCM techniques
Wht-270, 32 Fruit St, Boston, MA should permit overall reduction in radiation exposure in CT examinations. Unfortunately,
02134 (M.K.K., M.M.M.); GE Medical owing to rapid technologic advances, different vendors have developed different ATCM
Systems, Waukesha, Wis (T.L.T.); Sie- techniques and use proprietary nomenclature.
mens Medical Solutions, Forchheim,
Nevertheless, the introduction of ATCM techniques in modern CT scanners represents
Germany (B.S.); Toshiba America
Medical Systems, Tustin, Calif (B.L.W.); an important step toward standardization of tube current protocols, with elimination of
Philips Medical Systems, Cleveland, arbitrary selection by radiologists and technologists. This article will describe the princi-
Ohio (H.T.M.); and Department of Ra- ples of ATCM techniques, their clinical use, and the advantages and disadvantages of
diology, Emory University School of application in diagnostic CT scanning.
Medicine, Emory University Hospital, At-
lanta, Ga (S.S.). Received July 25, 2003;
revision requested September 30; final PRINCIPLES OF ATCM TECHNIQUES
revision received and accepted Decem-
ber 9. Address correspondence to S.S.
Unlike in conventional radiography, during CT scanning the x-ray tube continuously
(e-mail: mannudeep_k_kalra@yahoo.com).
©
rotates around the patient, emitting x-rays that traverse through a cross section of the
RSNA, 2004
body to generate attenuation profiles (image raw data) at the detectors. Thus, incident
x-ray beam projections from multiple directions around the region of interest are used to
reconstruct each cross-sectional CT image. Scanning parameters such as tube current and
tube potential determine photon fluence and incident beam energy, which affect image
quality and absorbed radiation dose. With other scanning parameters held constant, a
reduction in tube current decreases radiation exposure but increases image noise or mottle,
a principle determinant of image quality. Likewise, an increase in tube current leads to an
increase in radiation exposure and a decrease in image noise. On a scale of diagnostic
acceptability, image noise and radiation exposure represent conflicting factors, and dis-
proportionate emphasis on either factor may have an adverse effect on image quality or
radiation dose. Whereas images with lower noise (increased radiation exposure) may not

649
 the fact that image noise is determined tion reduction (up to 50%) with the on-
ESSENTIALS by x-ray quantum noise in the transmit- line modulation technique was docu-
ted beam projections. This technique mented (1).
● Automatic tube current modulation aims to modulate tube current on the In patients with circular cross-sectional
techniques are based on the fact that basis of regional body anatomy for ad- geometry, beam attenuation is constant
image noise is determined by x-ray justment of x-ray quantum noise to in all projections (x-ray beam projection
Radiology

quantum noise in the transmitted maintain constant image noise with im- angles). However, in a noncircular cross-
beam projections. proved dose efficiency. sectional geometry, attenuation varies
Currently, two distinct techniques are strongly in different projections, some-
● These techniques adjust tube current in available for ATCM: angular (x-y) modu- times by more than three orders of mag-
an effort to maintain constant image lation and z-axis modulation. Both tech- nitude. In these settings, image noise in
niques modulate tube current in an effort high-attenuation projection angles deter-
quality at the lowest dose.
to maintain constant image quality at mines the overall image noise content.
the lowest dose while simultaneously re- Thus, at angular projections with a small
● Automatic tube current modulation ducing tube loading (heating) and mini- patient diameter or body region being
represents an exciting recent techno- mizing streak artifacts caused by a mini- imaged (eg, greater tube current reduc-
logic innovation to enable radiation mal number of photons. tion occurs in chest than in abdomen),
dose optimization. corresponding to a relatively lower atten-
uation, the tube current can be reduced
Angular Modulation
substantially without a measurable in-
The angular-modulation technique crease in the overall noise content of the
was introduced in 1994 for a single– de- image. Without angular modulation, tube
reveal additional diagnostic information, tector row helical CT scanner (Smart- current is held constant over the 360° ro-
images with higher noise may obscure Scan; GE Medical Systems, Waukesha, tation, regardless of the patient attenua-
lesions that might have been visible in Wis) (13–15). This software-based tech- tion profile. The angular-modulation tech-
lower-noise images (7–9). nique modulated tube current on the ba- nique reduces tube current as a function of
Authors of previous clinical and exper- sis of the measured density of regional projection angles for low-attenuation
imental studies have reported that satis- structures and the absorption values of projections (anteroposterior vs lateral
factory image quality can be obtained the object of interest. This information projections). This technique calculates
with a reduction of tube current on the was obtained by measuring local x-ray the modulation function (an objective
basis of weight and cross-sectional di- beam absorption in 100 central channels image quality parameter) from the online
mensions of patients undergoing CT on two localizer radiographs (lateral and attenuation profile of the patient. The
scanning (10 –12). Results of these studies anteroposterior views). Preprogrammed modulation function data are processed
may be explained on the basis of variable sinusoidal modulation of tube current and sent to the generator control for tube
attenuation of the incident beam travers- was achieved during 360° rotation for current modulation with a delay of 180°
ing a particular cross-sectional dimen- equalization of local differences in beam from the x-ray generation angle. In re-
sion at a particular projection angle (1,2). absorption to obtain relatively constant gions with marked asymmetry, such as
The resultant attenuation determines im- noise content and reduce radiation expo- the shoulders in CT scanning of chest,
age noise and is affected by scanning pa- sure. A radiation dose reduction of up to where attenuation is substantially less in
rameters, particularly tube current. For 20%, depending on patient geometry the anteroposterior direction than in the
example, greater beam attenuation in a (asymmetry), has been reported (14). A lateral direction, a reduction in radiation
particular dimension or projection will recent refinement of the angular-modu- dose of up to 90% can be achieved in the
result in greater noise and will require lation approach is an online, real-time, anteroposterior or posteroanterior direc-
higher tube current than that needed by anatomy-adapted, attenuation-based tube tion by using the angular-modulation
a beam undergoing less attenuation in current modulation technique (CARE technique (20). In summary, the tech-
another projection. Dose; Siemens Medical Solutions, Forch- nique of angular modulation aids in im-
Manual adjustment of tube current heim, Germany) that does not need the proving dose efficiency in the x-y axis by
based on patient weight or dimensions information of radiographic localizer im- reducing radiation exposure in a particu-
can aid in establishing an appropriate ages to achieve ATCM (1–3,16 –20). lar scanning plane.
balance between image noise and radia- Angular-modulation techniques auto- The Dose-Right Dose Modulation, or
tion exposure (10,12). However, these matically adjust the tube current for each DOM, technique (Philips Medical Sys-
adjustments do not guarantee constant projection angle to the attenuation of the tems, Eindhoven, the Netherlands) of an-
image quality throughout the entire ex- patient to minimize x-rays in projection gular modulation also adjusts tube cur-
amination. For example, in CT scanning angles (eg, anteroposterior or posteroan- rent in asymmetric anatomic regions.
of chest, the choice of a fixed tube cur- terior angles are less important than are This technique is based on the premise
rent does not account for differences in lateral projections because the former that tube current should be modulated
beam attenuation between the shoulder cause less beam attenuation and hence according to the square root of the mea-
region and midchest region or between an- are associated with less noise) that are sured attenuation for that projection (1).
teroposterior and lateral cross-sectional di- less important with regard to reducing The DOM technique modulates the cur-
mensions. ATCM techniques allow main- the overall noise content (Fig 1). In phan- rent within a 360° tube rotation accord-
tenance of constant image quality at a tom studies in which an online angular- ing to the square root of the attenuation
required radiation exposure level because modulation technique was compared measured from the similar and previous
ATCM rapidly responds to large variations with the previous angular-modulation 180° or 360° views. In other words, the
in beam attenuation. ATCM is based on technique, a substantially greater radia- attenuation measured at an angular view

650 䡠 Radiology 䡠 December 2004 Kalra et al

Radiology

Figure 1. Angular modulation with CARE Dose (Siemens Medical Solutions) ATCM technique. (a) Online modulation of tube current is performed
at different projections in the x-y plane within each 360° x-ray tube rotation. Thin arrows indicate reduction of tube current relative to higher tube
current (thick arrows). (b) Users specify an effective tube current value in milliamperes (circled) to perform scanning with this technique.

(projection angle) is used to optimize the tion data of a single localizer radiograph tons is proportional to section thickness,
tube current later for a similar angular contain the patient’s density and size in- section acquisition time, and tube cur-
view. formation about the projection area, rent. In the currently available version of
whereas the amplitude and area of the pro- z-axis modulation of tube current, an ad-
Z-Axis Modulation jection contain the patient’s shape infor- justment factor for different helical
mation, which gives an estimate of the pa- pitches is incorporated in the calculation
The z-axis–modulation (AutomA, GE tient’s elliptic asymmetry expressed as an to account for noise differences between
Medical Systems; Real E.C., Toshiba Med- oval ratio at a given z-axis position. The helical selections and the transverse ref-
ical, Tokyo, Japan) technique functions oval ratio is the ratio of the a and b param- erence technique data. Recent data (4 – 6)
somewhat differently than does angular eters (lengths of the long and short axes) of from clinical evaluations of z-axis modu-
modulation (21). The AutomA technique
an ellipse. The ellipse parameters can be lation suggest that the radiation dose re-
adjusts the tube current automatically to
determined for the patient by using the duction with this technique is expected
maintain a user-specified quantum noise
equation for the area of an ellipse. The to be greater than that with fixed-tube-
level in the image data. It provides a
measured projection area and amplitude current methods, since the tube current
noise index to allow users to select the
from the localizer radiograph give the area is automatically reduced for smaller pa-
amount of x-ray noise that will be
and the length of one axis, a, of the ellipse, tients and specific anatomic regions.
present in the reconstructed images. Us-
allowing the length of the other axis, b, to Often, the actual noise measured on
ing a localizer radiograph, the scanner
be calculated. These characteristics of the the image by drawing a region of interest
computes the tube current needed to ob-
localizer radiograph predict the amount of will differ from the noise index selected
tain images with a selected noise level.
Hence, z-axis modulation attempts to x-rays that will reach the detector for a for scanning. This is due to the fact that
make all images have a similar noise irre- specified technique and, hence, determine noise index settings only adjust the tube
spective of patient size and anatomy. The the image standard deviation due to x-ray current, whereas the standard deviation
noise index value is approximately equal noise for a given reconstruction algorithm. is also affected by other parameters, in-
to the image noise (standard deviation) The predicted x-ray noise at a given z-axis cluding the reconstruction algorithm,
in the central region of an image of a position for the reference technique (ie, the reconstructed section thickness (if
uniform phantom. reference noise) is calculated from the pro- different from the prospective thickness),
In the z-axis–modulation technique, jection area and oval ratio from the local- the use of image space filters, variations
the system determines the tube current izer radiograph by using the polynomial in patient anatomy and patient motion,
by using the patient’s localizer radio- coefficients that were determined from the and the presence of beam-hardening ar-
graph projection data and a set of empir- noise measurements in a set of phantoms tifacts. Substantial differences between
ically determined noise prediction coeffi- representing a wide range of patient sizes the selected noise index and the standard
cients by using the reference technique and shapes. deviation can also occur in very large
(Fig 2). The reference technique com- With knowledge of the reference noise patients owing to insufficient signal
prises an arbitrary 2.5-mm-thick section and the difference between the reference strength at the detector and superimpo-
obtained at the selected peak voltage and technique and the selected technique sition of electronic noise, which can be
100 mAs for transverse reconstruction data, the tube current required to obtain minimized by using a higher peak volt-
with a standard reconstruction algorithm. a prescribed noise index is easily calcu- age. Likewise, improper centering of pa-
The projection data from a single localizer lated by using known x-ray physics equa- tients in the scan field of view can result
radiograph can be used to determine the tions, which state that noise is inversely in noisier images owing to inappropri-
density, size, and shape information of the related to the square root of the number ate beam attenuation by the bow-tie
patient (4,5). The total projection attenua- of photons and that the number of pho- filter (5). As bow-tie filter attenuation

Volume 233 䡠 Number 3 Automatic Tube Current Modulation 䡠 651

Radiology

Figure 2. Z-axis modulation with AutomA (GE Medical Systems) ACTM technique. (a) Auto-
matic modulation of tube current from one section location to others in the scanning direction
is performed. (b) User selects noise index or enters value for desired noise index and sets
minimum and maximum current values. (c) Tube current values (in milliamperes) can be
previewed prior to scanning.

increases with distance from isocenter,

the thickest part of the patient should
be approximately centered in the scan
field of view to prevent inappropriate
attenuation compensation by the bow-
tie filter due to incorrect patient posi-
tioning.
The Real E.C. technique implemented
on Toshiba CT scanners is a z-axis–mod-
ulation technique that is also based on
patient attenuation measurements ac-
quired from a single localizer radio-
graph. Evolving from its original form,
which provided operators with several
options in the choice of nominal tube
current to modulate on the basis of pa-
tient attenuation data, Real E.C. now Figure 3. Z-axis modulation with Real E.C. technique (Toshiba Medical). (a) Attenuation is
offers four levels of image noise to match measured on a digital radiograph (left) and is converted to water-equivalent thickness (right),
the diagnostic needs of the examination. allowing user to specify image quality by choosing different noise levels. (b) After user selects tube
The scanner software enables this by calcu- current or, more appropriately, desired noise level for the examination (left), the software displays
the automatic modulation of tube current that will be used to achieve selected image quality.
lating the “water-equivalent” thickness of
each section from the localizer radiograph
(Figs 3, 4). The appropriate tube current is
applied at the thickest section in the z- standard deviation (noise level). Tube the selected noise level throughout the
axis direction to achieve the selected current is then modulated to maintain entire scan.

652 䡠 Radiology 䡠 December 2004 Kalra et al

Radiology

Figure 4. Transverse CT scans obtained with AutomA technique (noise index, 15 HU; 75–380 mA; 140 kVp; gantry rotation time, 0.5 second) in
a 32-year-old woman with treated lymphoma. (a) Chest image obtained at 136 mA shows satisfactory image quality with soft-tissue algorithm.
(b) Pelvic image obtained at 295 mA shows that noise in soft tissue is similar to that in a.

Automatic current setting (ACS) is a a standardized index of the average dose on the basis of his or her judgment or
component of the Dose-Right technique delivered from the scan series. Thus, the departmental guidelines. With this z-
(Philips Medical Systems). ACS suggests user can select the suggested tube cur- axis–modulation technique, instead of
a tube current–time product level for in- rent–time product or individual settings selecting a fixed tube current the tech-
dividual patient examinations to achieve at his or her discretion. nologist selects a noise index and a range
a preselected quantitative image noise of acceptable tube current (minimum
level measured in the central region of a CLINICAL USE OF ATCM and maximum milliampere) settings. As
stored reference image from a prior ex- TECHNIQUES described in the preceding section, the
amination performed to generate this im- noise index determines image quality.
age with a desired noise content for a From a practical standpoint, bringing No unit of measure has been assigned to
specific protocol. ACS is calibrated on a ATCM techniques into everyday CT scan- the noise index, but because it approxi-
protocol-by-protocol basis at the clinical ning means that most currently used mates the standard deviation (in Houns-
site by storing reference images that scanning protocols, which involve man- field units) on CT images of a phantom,
achieve the clinical site’s desired image ual selection of tube current for radiation the noise index can be expressed in
quality (ie, signal-to-noise ratio) for that dose optimization and image quality, Hounsfield units. From a practical stand-
protocol. In practice, a protocol is se- need to be modified. Basic differences in point, the technologist selects the noise
lected, the ACS is chosen, the localizer ATCM techniques necessitate separate index and the acceptable range of tube
radiograph associated with the protocol protocols for each technique. In this sec- current settings for the scan (Fig 2b). A
is obtained, and the system host com- tion, we shall discuss the protocols for 5% decrease in noise index (in Houns-
puter compares the localizer radiograph routine CT scanning with individual field units) typically increases radiation
data with the protocol’s reference local- ATCM techniques. exposure by 10% and vice versa.
izer radiograph data and calculates pa- Determination of the range of tube
tient-specific calibration factor and tube current values can sometimes be influ-
Z-Axis Modulation
current–time product for the CT scan. enced by patient habitus. Because noise
The suggested tube current–time product The AutomA z-axis–modulation tech- index and tube current range affect im-
for the study will produce CT images nique is offered with recently available age quality and radiation exposure to the
with image noise (image quality) similar multi– detector row CT scanners (Light- patient, these two parameters must be
to that in the site’s prestored reference Speed; GE Medical Systems). Although judiciously selected. A very low noise in-
CT images. The system displays the vol- angular modulation has been compared dex may provide higher image quality
ume CT dose index (radiation dose re- with fixed-tube-current techniques, to but will also result in higher than neces-
duction with ACS prior to scanning) by date there are no studies of which we are sary radiation exposure to the patient.
calculating the dose difference between aware in which angular modulation has Conversely, a higher noise index will re-
scans obtained with and scans obtained been compared with z-axis modulation sult in radiation dose reduction at the
without the ACS technique. The volume in terms of image quality or radiation price of noisier images. Thus, with the
CT dose index represents the average dose efficiency (18 –20). AutomA technique, radiation exposure
dose within a scan volume (relative to In scanners with the AutomA feature, depends on the selected noise index and
that of a standardized CT phantom) and the operator can use either a fixed-tube- patient size. Higher radiation exposure
is now required to be displayed on the current technique or a z-axis–modulation can be avoided by selecting a higher
user interface of the CT scanner. The CT technique. In fixed-tube-current scan- noise index or by setting the maximum
dose index is given in milligrays. While it ning protocols, the technologist selects a tube current parameter to the same level
is not the dose to any specific patient, it is suitable tube current for all examinations used with fixed-tube-current protocols.

Volume 233 䡠 Number 3 Automatic Tube Current Modulation 䡠 653

 Although image noise will increase in re-
gions where the required tube current is TABLE 1
Protocol for AutomA Technique of Z-Axis Modulation for Routine Chest,
limited by the maximum tube current, Abdominal, and Pelvic CT
overall image quality would be similar to
that with fixed-tube-current scanning. Parameter Value
The vendor prescribes a noise index of
Radiology

Noise index 15*

11–12 HU for routine abdominal and pel- Tube current (mA) 75–380
vic examinations and 10 –11 HU for chest Gantry rotation time (sec) 0.5†
examinations, with a minimum tube cur- Voltage (kVp) 140
Beam pitch 0.94
rent of 60 – 80 mA. Table speed (mm per rotation) 18.75
The protocol used at our institution for Detector configuration 16 rows, 1.25-mm-thick sections‡
routine chest, abdominal, and pelvic CT Reconstructed section thickness (mm) 5
examinations with a 16 – detector row CT * Noise index of 20 used for unenhanced phase of CT and for assessment of kidney stones; index
scanner and the AutomA technique of of 55, for CT colonography; and index of 12, for liver transplants.
z-axis modulation is summarized in Ta- † Time increased in 0.1-second steps to prevent maximum tube current limit.
‡ LightSpeed 4.X; GE Medical Systems.
ble 1. Once the user has determined the
desired parameter adjustments (includ-
ing noise index), the parameters can be
stored in the computer memory and re-
called without need for modification in TABLE 2
similar clinical cases. Protocol for CARE Dose Technique of Angular Modulation for Routine
Abdominal and Pelvic CT
Although the scanner automatically
modulates tube current for a selected Parameter Value
noise index, the user should be aware of
Tube current (effective mA) 200
some important implications of the tech- Gantry rotation time (sec) 0.5
nique. In patients with large cross-sec- Voltage (kVp) 140
tional dimensions, the scanner may not CT pitch factor 1
provide images with the selected noise Table speed (mm per rotation) 24
Detector configuration 16 rows, 1.25-mm-thick sections*
index because the maximum tube cur- Reconstructed section thickness (mm) 5
rent parameter may be less than the tube
current required to generate images with * Senstation 16; Siemens Medical Solutions.
that noise index. In this situation, the
user should prospectively preview the
amperage table on the console monitor
before initiating scanning to determine manual selection of a fixed tube current, thus relieving the operator of any need to
whether the maximum tube current limit CT examinations of abdomen and pelvis apply the technique to individual exam-
has been reached (Fig 2). If the maximum performed with the z-axis–modulation inations. Should any protocol need ad-
tube current limit is reached with a 0.5- technique provided images with similar justment to suit the needs of individual
second rotation, the user can increase the noise, diagnostic acceptability, and le- patients, the Real E.C. technique auto-
gantry rotation time or use higher peak sion detectability. In a study of 153 pa- matically evaluates the effects on the
kilovoltage (140 instead of 120 kVp). tients who underwent abdominal-pelvic noise level of parameters such as peak
Conversely, with small patients, partic- CT with the AutomA technique (5), a voltage, section thickness, helical pitch,
ularly when not correctly positioned, greater reduction in mean radiation dose and reconstruction algorithm and selects
ATCM techniques can result in excessive was noted in smaller patients (mean the required tube current to deliver the
reduction in tube current and very noisy weight ⫽ 72 kg ⫾ 17 [standard devia- desired standard deviation.
images. Instructions to technologists about tion], mean anteroposterior abdominal The availability of multiple choices of
the necessity of proper centering of pa- diameter ⫽ 23.2 cm ⫾ 3.5, mean trans- image noise is consistent with recent at-
tients in the gantry isocenter and increas- verse diameter ⫽ 30.9 cm ⫾ 3.8) than in tempts to reduce patient dose by careful
ing the limit for the minimum tube cur- larger patients (weight ⫽ 82 kg ⫾ 16, matching of technique not only to pa-
rent parameter usually help limit the anteroposterior diameter ⫽ 26.9 cm ⫾ tient habitus but also to diagnostic needs.
probability that noisy images will be ob- 3.9, transverse diameter ⫽ 34 cm ⫾ 3.4). By incorporating the choices of image
tained in small patients. Selecting a lower Findings from a recent phantom study quality and dose within the stored proto-
noise index for small patients while cap- (6) showed that kidney stones smaller col, the operator can make modifications
ping the maximum tube current parameter than 5 mm can be adequately evaluated at the time of scanning to ensure that
to avoid higher than necessary radiation by using AutomA technique, with 56%– radiation dose reduction is achieved
exposure can also help improve image 77% reduction in radiation dose relative while a specific image quality is gener-
quality (5). to the dose from a fixed-tube-current ated.
Authors of a recent study (4) found technique. In addition, the authors of
that the AutomA technique for pelvic that study reported that patients with
Angular Modulation
and abdominal CT resulted in a mean kidney stones can be adequately scanned
reduction in tube current–time product with a noise index of 20 HU. In many studies, angular modulation
of 33% (range, 1%–91%), compared with With the Real E.C. technique of z-axis (eg, CARE Dose) has been reported to
manual selection of tube current, in 87% modulation, the noise level can be incor- help reduce radiation exposure in phan-
(54 of 62) of patients. Compared with porated into the examination protocol, tom experiments and clinical studies in-

654 䡠 Radiology 䡠 December 2004 Kalra et al

 lected effective tube current–time prod-
uct represents the maximum effective
value that will be used for scanning. The
angular-modulation technique reduces
the effective tube current–time product
Radiology

to a value less than that selected for pro-

jection angles with a lower attenuation
profile. The final displayed effective tube
current–time product represents an aver-
age of various effective values used in
different projections (Fig 5).
Real-time online selection of the effec-
tive tube current–time product with an-
gular modulation enhances the radiation
dose efficiency of the CT scanner. The
user must remember that, like z-axis
modulation, accurate centering of pa-
tients in the scanning field of view is
critical with angular modulation, since
shifts from the center can lead to errone-
ous estimation of the projection angle
area and tube current modulation, result-
ing in noisier images. The scanning pro-
tocol used at our institution for routine
abdominal and pelvic CT with angular
modulation is summarized in Table 2.
In initial investigations in patients in
which online angular modulation was
used (3), authors have reported an aver-
age reduction in tube current–time prod-
uct of up to 38%, with less image noise in
75% of CT studies, better low-contrast
detectability in 51%, and superior overall
image quality in 71%, compared with im-
ages obtained with fixed-tube-current
protocols. Authors of a subsequent study
(17) in which angular modulation was
used for scanning six anatomic regions,
including head, shoulder, thorax, abdo-
men, pelvis, and extremities (knee), re-
ported a 15%–50%-mAs reduction. Mas-
tora et al (19) used an angular-modulation
Figure 5. Transverse CT images obtained with CARE Dose technique technique and reported dose reduction
(140 kVp, 0.5-second rotation time, 1:1 pitch) in a 65-year-old
with improved image quality for CT angio-
woman evaluated for metastases from colon cancer. (a) Chest image
obtained at 177 mAs (effective) and (b) abdominal image obtained at grams of the thoracic outlet (which is often
188 mAs (effective) show satisfactory image quality. affected by noise and artifacts when a
fixed-tube-current protocol is used). A
10%– 60% reduction in the tube current–
time product, depending on patient ge-
volving both adults and children (18 – the gantry rotation time (in seconds), ometry and anatomic region, has been
20). With angular modulation, the and PF is the CT pitch factor. reported in children scanned with angu-
effective tube current–time product is the The scanner maintains a constant ef- lar modulation with a mean effective
key difference. Scanners with the angular fective tube current–time product irre- tube current–time product reduction of
modulation technique offer users the op- spective of pitch value so that radiation 22.3% (20% for neck, 23% for thorax,
tion of scanning with angular modula- dose does not vary as pitch is changed. 23% for abdomen) (20).
tion or fixed tube current (Fig 1b). After This helps to maintain a constant image The Dose-Right Dose Modulation tech-
selecting other scanning parameters such quality as the pitch factor (table feed) nique of ATCM uses the milliampere
as peak voltage, table feed, and detector changes. Consequently, an increase in value of the default protocol as a near-
configuration, the user enters a value for pitch leads to an increase in tube current, upper (within 10%) bound and modu-
the effective tube current–time product and a decrease in pitch leads to a reduc- lates the tube current during gantry rota-
for the scan. The effective tube current– tion in tube current. After selection of the tion on the basis of the system’s prior
time product (mAseff) is defined as fol- effective tube current–time product, the attenuation measurements in cross-sec-
lows: mAseff ⫽ (TC 䡠 GR)/PF, where TC is scanner performs real-time modulation tional anatomy. The Dose-Right Dose
the tube current (in milliamperes), GR is of tube current in the x-y plane. The se- Modulation technique produces an im-

Volume 233 䡠 Number 3 Automatic Tube Current Modulation 䡠 655

 age signal-to-noise ratio and image qual- mended noise indexes, however, users that is necessary for individual patient
ity that are very close to those of the full can restrict the range of tube currents body habitus to achieve similar image
nonmodulated milliampere image qual- that can be used for scanning in order to quality. For the examination, the user en-
ity of the system but with marked reduc- cap the maximum dose to ensure a min- ters an effective milliampere-seconds set-
tion in radiation dose. Within a particu- imum image quality. However, use of an ting for a “normal-sized” patient to ob-
lar protocol, the user can select both ACS arbitrary range of tube currents intro- tain a specific expected image quality.
Radiology

and Dose-Right Dose Modulation inde- duces subjective constraints to the tech- The CARE Dose 4D protocol adapts the
pendently or together. As described in a nique. A lower minimum tube current tube current to the patient’s individual
previous section, the ACS icon on the may result in reduced patient exposure, anatomy and modulates the tube current
user interface automatically suggests a which occasionally results in noisier im- in the section and the z-axis to obtain the
patient-tailored tube current–time prod- ages in small patients who are scanned at desired image quality for all images at
uct setting; Dose-Right Dose Modulation a substantially reduced tube current. the lowest dose levels. Initial results
then modulates this setting downward Conversely, large patients occasionally (22,23) have shown a 20%– 60% dose re-
during rotation to reduce dose without receive higher tube current with z-axis duction, depending on the anatomic re-
affecting the desired image quality. The modulation than they would receive if a gion and patient habitus, with improved
volume CT dose index and dose length fixed-tube-current technique was used in image quality.
product are displayed according to the order to maintain the selected image Authors of another study (24) in which
protocol tube current–time product and noise. While ATCM results in better im- combined angular and z-axis modulation
the selected protocol parameters. Radia- age quality in this setting, it can result in (3D Auto mA; GE Yokogowa Medical Sys-
tion dose reduction with Dose-Right greater radiation exposure than would a tems, Tokyo, Japan) was used have also
Dose Modulation ranges between 15% fixed-tube-current protocol in large pa- reported dose reductions of 60% in ab-
and 40%, depending on the patient’s size tients. dominal-pelvic CT examinations. This
and the anatomy being scanned. If Dose- The foremost limitation of ATCM is technique uses a single localizer radio-
Right Dose Modulation is selected, the the lack of uniformity between tech- graph to determine patient asymmetry
actual volume CT dose index and dose niques developed by different vendors. and appropriate angular and z-axis mod-
length product are displayed after the With the addition of ATCM techniques ulation for the patient. The investigators
scan on the basis of the actual average to the technologic revolution in CT scan- added noise (computer modification of
tube current–time product used for the ners, user comprehension is confounded original raw scan data to simulate lower
scan, which aids the operator in monitor- by the separate protocols for systems tube current noise levels) to patients’
ing reductions in the volume CT dose from different vendors. Industry stan- scan data to produce images and calcu-
index and dose length product by com- dards organizations need to build a con- late the radiation dose reduction.
paring the prescan (programmed) and sensus so that a more uniform ATCM
postscan (actual) dose values. technique is offered to the user in order
CONCLUSION
to minimize confusion and ensure appro-
priate use of the technique. Further expe-
LIMITATIONS OF AVAILABLE Currently available ATCM techniques
rience and research with ATCM tech-
ATCM TECHNIQUES can be used to maintain acceptable image
niques, regardless of type, will aid in
quality while reducing radiation expo-
optimization these techniques. In addi-
sure on the basis of patient geometry and
At our institution, both angular- and z- tion, the introduction of ATCM to an
clinical indications. ATCM techniques
axis–modulation techniques have been institution requires close communica-
represent an exciting recent technologic
in use for over 18 months for routine tion between radiologists, medical phys-
innovation toward radiation dose opti-
scanning of patients. While each tech- icists, and technologists, because a defi-
mization. Further research is needed to
nique has strengths, there are some lim- nite learning curve exists.
standardize these techniques and define
itations with each technique. With angu- Presently, no vendor offers a combined
appropriate protocols for different pa-
lar modulation, the user has to prescribe ATCM technique that uses both angular
tient sizes and indications.
a specific tube current value, which intro- and z-axis modulation as complementary
duces subjectivity in the selection of an approaches for maximum radiation ben-
effective tube current–time product. On efits, although industry expects to release References
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occasion in scanners with an angular- a combination technique by the end of
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modulation technique, selection of higher 2003. A work-in-progress installation (Care adapted tube current modulation. I. Sim-
effective tube current–time product values Dose 4D; Siemens Medical Solutions), ulation studies. Med Phys 1999; 26:2235–
for scanning of larger patients may require which combines the angular- and z-axis– 2247.
an increase in the scanning time (espe- modulation techniques, has been re- 2. Kalender WA, Wolf H, Suess C. Dose re-
duction in CT by anatomically adapted
cially if the operator believes that selected ported (22,23). This technique modulates tube current modulation. II. Phantom
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Bautz W. Dosage reduction in computed
Because z-axis modulation is a recent tomic regions (z-axis modulation). To tomography by anatomy-oriented atten-
innovation, there is a noticeable lack of adapt the tube current in the z-axis, this uation-based tube-current modulation:
scientific documentation in the medical technique uses a database that correlates the first clinical results. Rofo Fortschr Geb
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and specific clinical indications. In addi- tomic regions and a “standard” body with RS, Halpern EF, Saini S. Comparison of
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656 䡠 Radiology 䡠 December 2004 Kalra et al

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scanning of abdomen and pelvis. Radiol- Strategies for CT radiation dose optimiza- nary coin lesions with and without ana-
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