Virtual Monoenergetic Imaging and Iodine Perfusion Maps Improve Diagnostic Accuracy of Dual-Energy Computed Tomography Pulmonary Angiography With Suboptimal Contrast Attenuation

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The aim of this study was to investigate the impact of virtual monoenergetic imaging (VMI+) and dual-energy computed tomography perfusion maps (DECT-PMs) on reader confidence and diagnostic accuracy in dual-energy computed tomography pulmonary angiography (DE-CTPA) studies with suboptimal contrast attenuation, compared with standard linearly blended reconstruction series.

Materials and Methods

Dual-energy computed tomography pulmonary angiography examinations with suboptimal contrast attenuation of 68 patients with suspected pulmonary embolism (PE) were included in this institutional review board–approved retrospective study. Virtual monoenergetic imaging series at 40 keV, DECT-PM, and linearly blended images (M_0.6, 60% 90-kV spectrum) were reconstructed. Contrast-to-noise ratio and signal-to-noise ratio within the pulmonary trunk were calculated. Four independent radiologists assessed the presence of PE and their diagnostic confidence using 3 DE-CTPA reconstruction protocols: protocol 1, M_0.6 images; protocol 2, M_0.6 series and DECT-PM; and protocol 3, M_0.6, DECT-PM, and VMI+ series. Receiver operating characteristic (ROC) analysis was performed.


Fourteen patients showed central and 29 segmental PE. Greater contrast-to-noise ratio and signal-to-noise ratio values were measured in VMI+ series at 40 keV in comparison to M_0.6 images (P < 0.001). Diagnostic accuracy for segmental PE detection was as follows: protocol 1 (69.1%); protocol 2 (86.8%); and protocol 3 (92.6%). Protocol 3 resulted in a significantly greater area under the curve for diagnosing segmental PE (0.991, P ≤ 0.033), compared with protocol 1 and 2 (0.897 and 0.951, respectively), and provided the highest diagnostic confidence (P < 0.001).


A reconstruction protocol including 40-keV VMI+ series and DECT-PM improves reader confidence and diagnostic accuracy for segmental PE detection compared with standard M_0.6 images in DE-CTPA with suboptimal contrast attenuation.

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