The effects of patient positioning when interpreting CT dose metrics: A phantom study

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Review of dose metrics as part of the routine evaluation of CT protocols has become commonplace and is required by the Joint Commission and the American College of Radiology for accreditation. Most CT quality assurance programs include a review of CTDIvol and/or SSDE, both of which are affected by changes in mAs and kV. mAs, and sometimes kV, are largely determined by the Tube Current Modulation (TCM) functions of the scanner. TCM, in turn, relies on localizer scans to provide an accurate estimate of patient size. When patient size estimates are inaccurate, TCM and SSDE calculations are affected, leading to errors in both. It is important that those who are involved in reviewing CT dose indices recognize these effects to properly direct quality improvement initiatives.


An anthropomophic phantom was scanned on four clinical CT scanners using AP and PA localizers and the institution's routine abdomen protocol. Scans were repeated with the phantom at various heights relative to scanner isocenter. For each height, the projected phantom width, as shown by the localizer scans, was measured and normalized by the width of the helical scan. After each localizer scan, the TCM algorithm determined the mAs to be used for the helical scan. The scanner-reported average CTDIvol was recorded for each helical scan, and the SSDE was calculated from the projected phantom size and the scanner-reported CTDIvol at each phantom height. Last, the phantom was augmented with a lipid-gel bolus material to simulate different body mass distributions and investigate the effect of differing body habitus on projected phantom size. The results were considered in the context of optimizing dose in CT imaging, with particular attention paid to the effect on dose to breast tissue.


Vertical mis-positioning of the phantom within the scanner led to errors in estimated phantom size of up to a factor of 1.5. These effects were more severe when localizers were acquired in the PA orientation compared with the AP orientation. Minification effects were more pronounced for AP localizers. As a consequence of inaccuracies in estimated phantom size, TCM resulted in changes in CTDIvol and SSDE of as much as a factor of 4.4 and 2.7, respectively. The effect was more pronounced when the TCM function used data from the PA, rather than the AP, localizer.


Proper patient positioning plays a large role in the function of TCM, and hence CTDIvol and SSDE. In addition, body mass distribution may affect how patients ought to be positioned within the scanner. Understanding these effects is critical in optimizing CT scanning practices.

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