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Estimation of effective doses of radiation for patients with novel Coronavirus

Disease Undergoing Chest CT scans

Article  in  Arab Journal of Nuclear Sciences and Applications · May 2021

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Shaban Alramlawy I. Maamoun

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Estimation of effective doses of radiation for patients with novel Coronavirus Disease Undergoing Chest
CT scans.
Shaban Alramlawy1 I.Maamoun1,2
1,2
Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
2
Medical Physics Department, Kundiawa General Hospital, Kundiawa, Papua New Guinea .

ABSTRACT
Evaluating the hazards and beneficiary of chest - CT imaging for patients of COVID-19 is considered of high
concern because of many patients had imaged many times. There is a lack of information about the harm
associated for patients of COVID-19.
Objective:- To estimate the effective doses for diagnosing Corona virus patients from chest CT scans .
Subjects and Methods: -
A total number of 160 suspected Covid-19 patients were classified into four groups (GP1(n=40) ,GP2(n=40)
and GP3(n=40)).
The groups undergoing CT chest examination (Toshiba, Activion 16) .The acquisition protocols for the different
groups were as follows: GP 1 ((n=40), 100 Kv , 160 ±15 mAs , GP2 ((n=40) , 120 Kv , 150 ±20 mAs) ,
GP3((n=40) , were 120 Kv Sure Exposure (SE), GP4((n=40) , 100 Kv , Sure Exposure (SE)) . and the other
parameters are (pitch=1.5; rotation time=0.75 sec; matrix size 512x512), All images were reconstructed by
Filtered Back Projection.

Results:-

The CTDI volume for the different groups were: (GP1: 7.8±0.09 mGy ; GP2: 26.4 ±0.25mGy; GP3: 16.8
±4.7mGy; GP4: 5.5±0.1mGy , P<0.05 ). The values for DLP in the different groups were (GP1: 322.4
±24.5mGy.cm ; GP2 : 907.4 ±15mGy.cm; GP3 : 512 ±20mGy.cm; GP4 : 250±10mGy.cm, P<0.05). The effective
dose for the different groups were (GP1: 4.83 ±0.36mSv; GP2 : 13.6 ±0.225mSv; GP3 :7.68 ±0.3 mSv; GP4
:3.7±0.3 mSv,P<0.05).

Contrast, CNR and SNR were insignificantly different (P>0.05) among all groups . GP1and GP4 have a highly
significant noise (P<0.05), in comparison with GP2 and GP3 .

Conclusion:
In conclusion, this study demonstrates that chest CT performed with 100 kV protocol and dose modulation
(GP4) results in a significant reduction in the radiation dose used with other groups. According to our results,
the proposed CT chest protocol Gp4 (100 Kv with mA modulation) was found to be reliable in the detection of
COVID-19 .

Introduction
Coronaviruses are a family of viruses which cause illness, such as respiratory diseases or gastrointestinal
diseases. Respiratory disorders, such as Middle East Respiratory Syndrome (MERS-CoV) and Extreme Acute
Respiratory Syndrome (SARS-CoV), can range from common colds to more serious illnesses. (1) The novel
coronavirus (CoV) is a new strain that has not been previously described in humans.
Once researchers decided exactly what the coronavirus was, they assigned a name to it (as in the case of
COVID-19, the virus that causes it is SARS-CoV-2).
There are broad uses of radiation in medicine. Nevertheless, considering the benefits of medical radiation
exposure, harmful long-term health implications are a cause for concern.
Imaging can be useful in identifying patients with COVID-19, which is particularly useful in areas where
there is a good access to imaging technology but limited access to reliable and fast laboratory testing. (2)
Chest computed tomography (CT) is known to be the primary diagnostic modality for evaluating patients with
COVID-19 (3,4,5). Many studies (6,7,8,9,10-11,12,13) have studied CT image manifestations in COVID-19 cases.
The most prevalent chest CT imaging features of COVID-19 pneumonia are peripheral ground-glass opacities
(GGOs) and consolidation in the lower and middle lung regions, typically bilaterally distributed and with
multi-lobar participation. (14,15,16)
Because of the importance of CT in the diagnosis and monitoring of patients with covid-19, they are at least
exposed three times a month to ionizing radiation.
The objective of the present work was to estimate the effective doses for patients with Corona virus from
chest CT scanning.

Material and Methods (Patient population)-:

This study was approved by the local ethical research committee, and a written informed consent was obtained
from relatives of patients where there was no chance that a patient could be identified (or could identify
themselves). Written informed consents were obtained. A total number of 160 suspected Covid-19 patients
(age range, 19-87 years, mean age 58.8 ±23 years) weighing mean70 ± 25kg were enrolled in the study. All
patients undergoing the procedure were subdivided into four groups. The mean number of days before hospital
admission was 9.0 ± 5.5. At the time of hospital admission, the nasopharyngeal swab identified 106 patients
(63,8%) who had positive PCR results for COVID-and all the tested positive again in the following 3-5 weeks
and their antero-posterior chest radiographs showed patchy ground-glass opacities. The chest CT scans
showing diffuse ground-glass opacities with a certain consolidation region were also performed three times
for all patients. The seriousness of the disease was mild to moderate overall. The mean hospital stays,
including critical care and intermediate care, was 33± 6.9 days. Table (1) illustrates different patients
characteristics and CT acquisition parameters for all participating groups.

Table 1: The patients characteristics and CT acquisition parameters for all groups

No. of N0. of Mean Mean Acquisition protocol

group patients of age of
weight kv mAs pitch R.T M.S
sec
Group 1 40 54.6 73 ± 100 160 ±15 1.5 0.75 512X512
patients ±26 y 25kg
Group 2 40 56.8 74 ± 120 150 ±20 1.5 0.75 512X512
patients ±17.7 22kg
y
Group 3 40 52.9 70 ± 120 Sure 1.5 0.75 512X512
patients ±25 y 27 kg Exposure
Group 4 40 57.5 75± 27 100 Sure 1.5 0.75 512X512
patients ±23.8 kg Exposure
y
 FILTERS All images were reconstructed by Filtered Back Projection.

Radiation dose calculations:

The patient dose indices were CTDIvol, Dose Length Product (DLP) and effective dose. CTDIvol and
DLP were collected from the summary page of patient file (16). Subsequently, the effective dose (E) was
calculated using 0.015 mSv/mGy.cm as an average conversion factor (EDLP) for chest, abdomen and pelvis
according to the following equation 1: (14):

E = DLP x f --------------------- (1)

Where f, measured in units of mSv/(mGy.cm), is a body region–specific conversion factor.

Image Quality Assessment:-

The measured parameters of image quality were Contrast, Noise (σ), Signal to noise Ratio (SNR) and
Contrast to noise Ratio (CNR).

Image quality indices were measured by drawing Region of Interests (ROIs) . The location and size of ROIs
were consistent, as shown in Figure 1 (17). The sizes of ROIs were measured at ROI (1): 240±10mm2 and
ROI (2): 255±10 mm2 for GGO (figure 1) and background equations 2, 3 and 4 respectively.

Contrast =ROI (HU) – BKG (HU) / ROI(HU) + BKG(HU) ----------------------- (2)

Noise = σ/N = 1/√N -----------------------(3)

Where N is the number of counts per unit area in the image

-----------------------(4)
SNR =

Each ROI was calculated for the CT value and the standard deviation (SD). Contrast to noise ratio (CNR)
is defined as the ratio of the difference of signal intensities of two regions of interest to the background
noise as shown in equation 5 (17)

CNR = Contrast / Noise

| 𝑀𝑜 − 𝑀𝑏 | -----------------------(5)
CNR =
𝜎𝑏
 Where Mo is the average Hounsfield unit of ROI at organs (GGO), Mb is the average Hounsfield unit
of ROI at background (Lung) and σb is the background standard deviation.

Figure 1: Computer tomography showing the dropping of 2 regions of interest at Ground Glass Opacities
(GGO) and Background.

Subjective assessment:

Four radiologists (R1, R2, R3, and R4) used a scale of 0-3 to measure the degree of image quality. Score 0
reflected inaccurate diagnostic image. Score 1 was demonstrative of a mild effect that affected the diagnosis.
Score 2 suggested a weak noise that however, it was detected. Score 3 indicated that no items exerted an
impact on the accuracy of the diagnosis.

Statistical analysis
SPSS 19.0 software (IBM, Chicago, Ill) was used for statistical analyses. All experimental results were
expressed by mean ±s. Differences were considered statistically significant at a p value < 0.05.

Results:

The dose calculation parameters were highly significant (P<0.05) in GP2 in comparison with GP1, GP3 GP4
(Table 2 and figure 2).
GP4 had the lowest significant (P<0.05) effective dose in comparison with all groups (Table 2 and figure 2).

Table 2: Radiation dose measurements for different groups GP1 ,GP2 ,GP3 and GP4 per one
CT chest scan

Parameter GP1 GP2 GP3 GP4 P Value

CTDIvol (mGy) 7.8±0.09 26.4 ±0.25 16.8 ±4.7 5.5±0.1 <0.05

DLP (mGy × cm) 322.4 ±24.5 907.4 ±15 512 ±20 250±10 <0.05

Effective dose 4.83 ±0.36 13.6 ±0.225 7.68 ±0.3 3.7±0.3 <0.05

(mSv)

90

80

70

60
Effective Dose (mSv)

50

40 Effective dose.(mSv)

30

20

10

0
GP1 GP2 GP3 GP4
Groups

Figure 2 : The effective dose for one CT chest scan in mSv ±SD for different groups GP1 ,GP2 ,GP3 and
GP4 sure exposure ,where P<0.05.
Radiologists R1, R2, R3 and R4 graded all images of all groups by 3 (no effect on the accuracy of diagnosis),
where no significant difference P>0.05.

Patient data analysis showed an insignificant difference (P>0.05) of as regards Contrast, CNR and SNR in all
groups, as illustrated in Table 3 and Figures 3, 4. However, the noise showed a highly significant difference
(P<0.05) for GP 1, GP2 and GP4 in comparison with GP3.

Table 3 :Image quality parameters for all groups expressed in Mean±SD

Contrast noise SNR CNR

Groups Contrast SD noise SD SNR SD CNR SD
0.23 17.2 6.4
GP1 0.47 53.3 11.7 19.029 9.4
0.27 18.8 27.7
GP2 0.5 36.2 31.3 38.102 10.4
0.18 12.2 15.3
GP3 0.43 27.1 27.5 32.034 12.1
0.22 15 6.0
GP4 0.39 50.2 10.5 18.3 14.5
 60

50

40
CNR

30
CNR (GGO)
20

10

0
GP1 GP2 GP3 GP4
Groups

Figure 3 : The Contrast to noise Ratio (CNR) of Ground Glass Opacities (GGO) for different groups
GP1 ,GP2 ,GP3 and GP4 ,where P>0.05.

Figure 4 : computer tomography of axial cut is showing the image quality of Ground Glass Opacities
(GGO) for different groups GP1 ,GP2 ,GP3 and GP4

The total effective dose of covid-19 patients for the three CT chest (Follow up) is shown in table (4). As regards
the capacity to detect COVID-19 pneumonia, there was no statistically significant difference between the
different groups of CT images found. At the same time, the low dose protocol (GP4) in our analysis was
associated with a reduction of approximately 48 % in the mean effective dose value relative to GP2 (120 Kv).

Table 4: The total effective dose of three CT Chest (Follow up) for Covid-19 Patients for different
groups GP1 ,GP2 ,GP3 and GP4

Parameter GP1 GP2 GP3 GP4 The mean hospital stay PCR for
COVID 19
 Mean of Total 13.13 38.8 20.1 10.2 33± 6,9 days 3± 1
Effective Dose per 3 CT
Chest scans

P - value 0.04 0.05 0.03 0.04 0.05 0.05

Discussion

With the high rate of infection with the emerging corona virus ( Covid-19), and the diversity of treatment and
diagnosis protocols, the frequency of the use of a chest CT scan has increased in addition to assessing the
diagnostic value of low dose protocol CT images, the current study shed light on the radiation exposure of Covid-
19 patients undergoing CT Chest examination.
The cancer risk increases with 0.01% / mSv exposure, so the hazard associated with radiation exposure of Covid-
19 patients must be reduced during CT chest scan (reference required).
Reducing kv from 120 (GP2 and Gp3) to 100(GP1 and Gp4) in the current study caused a reduction in the
intensity of x ray photons produced by power 3 and the average energy. Subsequently all dose parameters were
decreased by greater than 50 % significantly (P<0.05) (figure 2 and Table 2).
The diagnostic value should be maintained with Kv reduction as much as possible by mA modulation
(SureExposure). The mAs modulation in x,y and z direction causes a variation of intensity of X Ray beam
according to the patient density . The mAs modulation of 120 KV (GP3) with patient size is significantly reduced
the patient dose while maintaining the same noise level compared to 120 KV(GP2) Figure 2 ,Table 1).

These results agree with Leschka et al.(18) who obtained a 25 percent reduction in radiation dose while reducing
tube voltage from 120 kV to 100 kV using the same tube current-time product (330 mAs). Also, the results are
in line with Tobias Pflederer et al (19) who showed that their research achieved a nearly 39 percent reduction in
radiation dose. Huda W et al concluded that based on theoretical considerations, a dose reduction of
approximately 40 percent could be predicted since the dose is related to the square voltage of the tube(20).
Tube current-time product (mAs) is another aspect that affects the efficient dose (mSv). Although the relationship
between the current-time product of the tube and the effective dose is linear, lowering the current-time product
of the tube results in higher image noise and may therefore adversely affect the quality of the image.(21)

Four radiologists assessed all images and found no significant difference in image quality and the diagnostic
value of GGO for all groups of COVID-19 patients.

The qualitative assessment was supported by the quantitative measurements of image quality indices that
revealed reduction in the mean value of Contrast, noise, SNR and CNR with low Kv groups against high Kv .
Reducing Kv in GP1 and GP4 caused a reduction in the number of photons produced and transmitted through
the patient to reach the detectors. The smaller number of photons (high noise) would not be enough to form the
full image data for reconstruction. Using mA modulation maintains the noise level with different body contours
that produces more homogenous images (as in GP4). However, the statistical analysis revealed that no significant
difference in Contrast, SNR and CNR(P>0.05) ,while a significant difference (P<0.05) in noise of GP3 was noted
against all groups .
Tube current-time product (mAs) is another aspect that affects efficient dose (mSv). Although the relationship
between the current-time product of the tube and the effective dose is linear, lowering the current-time product
of the tube results in higher image noise and may therefore adversely affect the quality of the image.(21).
Georgios Kareliotis stated that although both tube potential and current-time product affect image quality and
radiation dose, the former does it in a more drastic way. For low-contrast protocols, tube potential reduction
down to the 90 kVp region affects image quality, in contrast to transition from 140 to 120 kVp. For high-contrast
protocols the low kVp – high mAs combination seems to be the best choice (22).

Gill MK(2015 ) found that reducing the tube voltage from 120 to 100 kV in CTPA allows a significant
reduction of radiation dose without significant loss of diagnostic image quality where the effective radiation
dose for the 100 and 120 kV scans was 3.2 and 6.8 mSv, respectively(23).

The repetition of CT chest for Covid-19 Patients enforce using low dose CT acquisition parameters that reduce
the exposure to radiation. By using a tube voltage of 100 kV instead of 120 kV (the most suggested value), nearly
31% mean image quality ratings were well maintained, with no major variations in the quality of the image
whether subjectively measured or in objective parameters such as the CNR and SNR. Therefore, when
performing contrast-enhanced chest scan in non-obese patients, we actually support the use of lower tube
voltages with dose modulation techniques.

Radiation exposure in a chest CT scan is influenced by several factors: First, tube voltage and the scanning
length. Second, the speed of table movement (pitch) affects the duration of exposure and therefore radiation
dose.
The diagnostic importance is maintained by the need for suitable methodologies to improve and decrease
exposure of coronavirus patients to radiation.
A covid 19 patient usually undergoes between one and three CT scans and sometimes more than that. In this
research paper our goal was to measure and determine the effective radiation doses for these tests, by using the
following- :
We examined four groups of patients and the results were as follows:
In the Gp1 and Gp4 imaging technique, usinga lowered tube voltage resulted in a significant decrease in contr
ast mean, SNR mean and CNR mean, and some markedly increased image noise compared to GP2 and GP3 im
age quality specifications, that hadenhanced contrast mean, SNR mean and CNR mean, and reduced significant
ly image noise quality parameters . Reducing KV from 120 to 100 kv had a great effect on the reduction of the
intensity of radiation and the average energy of the X Ray beam. Thus, a patient dose of 100 Kv( GP1 and GP4
) was decreased by 50 % in comparison with 120 Kv (GP3 and GP4) )Figure 2 ,Table 4) .
These results agree with Leschka et al.(18) who obtained a 25 percent reduction in radiation dose while reducing
tube voltage from 120 kV to 100 kV using the same tube current-time product (330 mAs) and in agreement with
Tobias Pflederer et al (19) who showed that their research achieved a nearly 39 percent reduction in radiation
dose. Huda W et al concluded that based on theoretical considerations, a dose reduction of approximately 40
percent could be predicted since the dose is related to the square voltage of the tube(20).
The mAs modulation in x,y and z direction causes a variation of intensity of x Ray beam according to the patient’s
density . The mAs modulation of 120 KV (GP3) with patient size is significantly reduces the patient’s dose while
maintaining the same noise level compared to 120 KV(GP2) Figure 2 ,Table 1). Tube current-time product (mAs)
is another aspect that affects the efficient dose (mSv). Although the relationship between the current-time product
of the tube and the effective dose is linear, lowering the current-time product of the tube results in higher image
noise and may therefore adversely affect the quality of the image.(21)

Georgios Kareliotis concluded that although both tube potential and current-time product affected image quality
and radiation dose, the former did it in a more drastic way. For low-contrast protocols, tube potential reduction
down to the 90 kVp region affects image quality, in contrary to transition from 140 to 120 kVp. For high-contrast
protocols the low kVp – high mAs combination seems to be the best choice (22).

In the current study, four radiologists assessed all images and did not observe any significant difference in image
quality and the diagnostic value of GGO for all groups of COVID-19 patients.

The reduction in CNR among all groups was not significant to assess the changes of lung in covid-19 patients
(Figure 3 and 4).

The quantitative assessment of image quality revealed that the use of a lower tube voltage in the Gp1 and Gp4
scanning protocol resulted in a substantial decrease in contrast mean, SNR mean and CNR mean, as well as
significantly higher image noise compared to GP2 and GP3 image quality parameters. The latter improved
contrast mean, SNR mean and CNR mean, and significantly lowered image noise and this is illustrated in table
3. Our results agreed with Mannudeep K. Kalra who recommended against routine use of diagnostic imaging for
the diagnosis of COVID-19 pneumonia unless there was a lack of availability to RT-PCR or immunoassays in
patients with moderate to severe disease, worsening respiratory status, or a suspicion of cardiopulmonary
complications. They recommended that a chest CT when indicated, should be performed with a low-dose, single-
phase protocol using fast scanning techniques to minimize motion artifacts.( 24)

Conclusion:

According to our results, the proposed CT chest protocol Gp4(100 Kv with mA modulation) was found to be
reliable in the detection of COVID-19 pneumonia in daily practice with a substantial reduction in radiation
dose modulation. Also, we recommend that no chest CT scan be conducted unless the Corona virus analysis
is positive, and that the procedure should not be repeated unless it is appropriate to prevent exposure to high
doses of radiation.
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 Table 5 of abbreviated words

CT computed tomography

R0I Region Of Interests

SNR Signal to noise Ratio
FDG fluorodeoxyglucose
GGO ground-glass opacity
MERS Middle East respiratory syndrome
MERS-CoV Middle East respiratory syndrome
coronavirus
NCP novel coronavirus pneumonia
PET/CT positron emission
topography/computed tomography
RT-PCR reverse transcription–polymerase
chain reaction
SARS severe acute respiratory syndrome
SARS-CoV severe acute respiratory syndrome
coronavirus
COVID-19 Coronavirus disease 2019
CNR Contrast to Noise Ratio
R Radiologists
GP Group
CTDI CT dose index
kV Kilovolt

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