European Journal of Radiology 163 (2023) 110829

Contents lists available at ScienceDirect

European Journal of Radiology

journal homepage: [Link]/locate/ejrad

Review

Photon-counting CT: Review of initial clinical results

Judith van der Bie a, Marcel van Straten a, Ronald Booij a, Daniel Bos a, b, Marcel L. Dijkshoorn a,
Alexander Hirsch a, c, Simran P. Sharma a, c, Edwin H.G. Oei a, Ricardo P.J. Budde a, *
a
Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
b
Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
c
Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: Photon-counting computed tomography (PCCT) is a new technology that enables higher spatial resolution
Computed tomography compared to conventional CT techniques, energy resolved imaging and spectral post-processing. This leads to
Photon-counting CT improved contrast-to-noise ratio, artifact and potential dose reduction as well as elimination of electronic noise.
Spectral imaging
Since the introduction of clinical PCCT in 2021, a shift has been observed from solely pre-clinical studies to
clinical research (i.e. use of PCCT imaging in humans). This review article is focused on the initial clinical results
of PCCT by explaining the current PCCT systems, the applications themselves and, the challenges of PCCT.

1. Introduction Low-energy photons are responsible for generating contrast, however,

due to integration, they contribute relatively less to the final image,
After its clinical introduction, computed tomography (CT) has resulting in lower contrast-to-noise images with conventional CT
become an integral part of contemporary medicine [1,2]. Over the years, (Fig. 1A).
the technique gradually improved in various aspects including scan Photon-counting CT (PCCT) is a new technique that has the potential
speed, dose efficiency, dual-energy acquisition methods and temporal to overcome the limitations of EIDs by using photon-counting detectors
and spatial resolution. Today, conventional CT still has limitations (PCDs) (Fig. 1B). PCDs consist of a semiconductor in which no septa are
regarding tissue contrast, image quality and spatial resolution for spe­ needed to separate individual detector elements [5]. The detector ele­
cific applications, which are mostly related to the design of current ments of PCDs are smaller, whilst remaining geometrically efficient.
energy-integrating detectors (EIDs) [3,4]. These detectors consist of This leads to an improved spatial resolution, creating new opportunities
scintillator material, such as cesium iodide or gadolinium oxysulfide, for clinical applications. PCDs convert single incoming photons directly
which absorbs X-ray photons and emits visible light in response (Fig. 1). into an electrical pulse proportional to the photon’s energy. This enables
The emitted light is then detected by a photodiode and converted into an the detector to categorize photons into energy bins based on the heights
electrical signal. Septa are integrated in the detector to prevent cross- of the incoming electric pulses, allowing for spectral imaging, filtering
talk between detector elements reducing the effective detector area. In out the electronic noise of the final image, and improved material
addition, all incoming photons are integrated to generate the signal. decomposition [5]. Several of these advanced image reconstruction

Abbreviations: CACS, Coronary artery calcium score; (C)CTA, (Coronary) computed tomography angiography; CNR, Contrast-to-noise ratio; CT, Computed to­
mography; CTDIvol, Computed tomography dose index (volume); ECV, Extracellular volume; EIDs, Energy-integrating detectors; EVAR, Endovascular aneurysm
repair; HU, Hounsfield unit; IR, Iterative reconstruction; IQR, Interquartile range; keV, Kiloelectronvolt; PC, Pure calcium; PCCT, Photon-counting computed to­
mography; PCDs, Photon-counting detectors; SNR, Signal-to-noise ratio; SPCCT, Spectral photon-counting computed tomography; TNC, True-non-contrast; UHR,
Ultra-high resolution; VNC, Virtual-non-contrast; VMI, Virtual-mono-energetic image.
Peer review under responsibility of If file “editor conflict of interest statement” is present in S0, please extract the information and add it as a footnote (star) to the
relevant author. The sentence should read (and be amended accordingly): Given his/her role as EditorinChief/Associate Editor/Section Editor <NAME of Editor>
had no involvement in the peerreview of this article and has no access to information regarding its peerreview.
* Corresponding author.
E-mail addresses: [Link]@[Link] (J. van der Bie), [Link]@[Link] (M. van Straten), [Link]@[Link] (R. Booij), [Link]@
[Link] (D. Bos), [Link]@[Link] (M.L. Dijkshoorn), [Link]@[Link] (A. Hirsch), [Link]@[Link] (S.P. Sharma), [Link]@
[Link] (E.H.G. Oei), [Link]@[Link] (R.P.J. Budde).

[Link]
Received 3 April 2023; Accepted 5 April 2023
Available online 11 April 2023
0720-048X/© 2023 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license ([Link]
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

techniques are illustrated in Fig. 2. 17) of this system (Siemens Healthineers). The clinical system contains a
PCCT is starting to be gradually employed in clinical practice and dual-source PCD setup with a maximal temporal resolution of 66 ms and
more research giving insight into this matter has become available. a cadmium-telluride detector. In high-resolution mode, the PCCT system
Therefore, this article reviews the literature on the current PCCT systems can acquire images with a z-coverage of 144x0.4 mm. In ultra-high-
and is followed by an overview of the potential clinical applications and resolution (UHR) mode a maximal coverage of 120x0.2 mm is ach­
current challenges. ieved albeit for dual-source applications without spectral information as
of yet due to the amount of data to be registered for these acquisitions
2. Data collection [6].

A literature search was performed in the following databases: 3.3. Philips

Embase, Medline, Web of Science, Cochrane and Google Scholar for
articles written in English published until September 2022 (appendix A). Three studies from the same center use the spectral photon-counting
One author (JvdB) assessed all retrieved articles based on title and ab­ CT (SPCCT) system from Philips. The system is equipped with a detector
stract. References were scanned to ensure no relevant articles were yielding a pixel pitch of 0.3 × 0.3 mm (UHR) at the isocenter and a z-
missed. Articles were included if they described clinical application of coverage 64 x 0.3 mm [7–9].
photon-counting CT in patients. Overall, 51 studies were included in this
review. From all studies the following characteristics were extracted: 3.4. Other vendors
first author, publication year, journal, clinical application, sample size,
PCCT system, EID system, acquisition mode and conclusions. All char­ Two other vendors (GE Healthcare, and Canon) are developing a
acteristics are summarized in supplementary table 1. A summary of this PCCT system, to our best knowledge, Canon has one prototype installed
table is provided in Table 1. in Japan and GE has multiple prototypes installed but none have pub­
lished results of its use in patients [10,11]. GE Healthcare uses a
3. Technical background different type of semiconductor material (silicon) whereas Canon uses
cadmium-zinc-telluride.
3.1. Available PCCT systems
4. Cardiovascular imaging
Until now, two PCCT systems by different vendors are described for
patient use. Other manufacturers are currently developing their system In cardiovascular imaging, thirteen studies were found focusing on
but there is only scant information available on system design, capa­ enhancement of contrast agent signal, depiction of coronary arteries,
bilities and, to our best knowledge, no use in humans. The different calculation of coronary artery calcium scores (CACS) on virtual-non-
PCCT systems and properties are briefly discussed below. contrast reconstructions (VNC), stent imaging and myocardial
assessment.
3.2. Siemens
4.1. Coronary computed tomography angiography (CCTA)
Most studies are conducted with the NAEOTOM Alpha (n = 29)
which is currently commercially available or a prototype version (n = Si-Mohamed et al. showed improved contrast-dependent spatial

Fig. 1. Schematic overview of CT detectors. A. Energy-integrating detectors convert incoming photons to visible light, which is directly followed by a conversion
to an electrical signal by photo-diodes. All measured photons in one projection are integrated to create the signal of that projection. The detector’s spatial resolution
depends on the use of reflecting septa to prevent cross-talk. B. Photon-counting detectors create an electron-hole pair when a photon strikes the semiconductor
material of the detector. The anode attracts the electrons from the electron-hole-pair resulting in an electric pulse proportional to the photon’s energy.

2
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

Fig. 2. PCCT-scan of a Patient with endovascular aortic repair. A/B. Virtual-mono-energetic images (VMIs) can be created without additional scanning from the
spectral dataset to generate images for virtual photons at a single kiloelectronvolt (keV) energy level. This can be helpful to improve differentiation between tissues,
visualization of contrast-enhanced tissues, or reducing artifacts. C. Virtual-non-contrast (VNC) reconstructions remove the signal of iodinated contrast agents from
contrast-enhanced scans, with the idea to potentially make non-enhanced scans obsolete. D. Iodine maps are useful to measure perfusion but hinge on their
quantification accuracy [2]. E. It is possible to fuse VNC and iodine maps for additional information.

to a less sharp kernel Bv40 (40%vs53%, respectively) despite lower SNR

Table 1
(2.4 ± 0.4) and CNR (3.0 ± 0.4) for Bv89 compared to Bv40 (SNR:18.7
Summary of articles included.
± 3.8, CNR:22.5 ± 3.3)[13]. UHR acquisition also allowed for sharp
Body region Number Total Clinical depiction of partially calcified plaques, discriminating between calcium
of number applications /
and non-calcified components, which might improve the identification
articles of pathologies
subjects of vulnerable plaques [13]. Considering the subjective image analysis,
Bv64/Bv72 kernels were recommended for lumen and adjacent plaques
Cardiovascular 13 340 Coronary CTA Myocardium
Calcium scoring radiomics
assessment by the authors for this specific vendor.
with VNC Extra-cellular Virtual-mono-energetic images (VMI’s) can increase luminal iodine
reconstructions volume contrast at lower keV levels (40–45 keV) [14,15]. In aortic imaging,
Stent/EVAR quantification lower keV’s also showed a significant increase in CNR (p < 0.025) and
imaging Epicardial
similar subjective overall image quality but increased image noise (p <
adipose tissue
characterization 0.001) in 40 patients compared with EID-CT [15]. The increase of iodine
Thoracic 9 448 Low-dose Lung contrast allows for reducing the administered iodine dose while pre­
imaging emphysema serving visualization of small low-contrast structures [14].
Systemic quantification
sclerosis Usual interstitial
pneumonia 4.2. Coronary artery calcium score
Abdominal 14 690 Abdominal Obese patient
malignancies population
CACS is an important predictive marker for future cardiovascular
and metastases Liver imaging
Adrenal with VNC and events. [16]. True-non-contrast (TNC) scans are made to determine
adenomas VMI CACS and represent a considerable part of the total radiation dose of a
Renal stones reconstructions clinical CCTA [17]. In addition, blooming artifacts and the presence of
characterization Bowel infarction small calcifications may lead to CACS over- or underestimation. Symons
Neuro 6 137 Temporal bone White and gray
et al. investigated low-dose PCCT (25% of the standard dose) to compute
imaging matter
Neurovascular differentiation CACS in 10 patients [17]. Low-dose PCCT had a mean difference of
imaging and − 10.8 in Agatston CACS compared to EID-CT. VMI’s at higher keV levels
plaque analysis and stronger iterative reconstruction (IR) strengths also resulted in
Musculoskeletal 4 68 Visualization of Bone metastasis
lower mean Agatston scores [18]. The lower Agatston scores could lead
bone structure
Implant imaging
to underdiagnosis of patients with coronary calcifications, incorrectly
with artifact classifying them with no calcifications or in a lower risk group.
reduction By using the spectral information of PCCT, images can be recon­
Mixed* 5 141 See above- structed without the signal of iodinated contrast, obviating the need for
mentioned
a non-enhanced scan. In 67 patients, CACS derived from two re­
applications
constructions algorithms (VNC and Pure calcium (PC)) showed under­
*
Mixed articles describe multiple clinical applications in various fields. estimation of Agatston scores compared to standard non-enhanced scans
[16]. These algorithms aim to replace TNC scans in the future, however
resolution and noise reduction in UHR-CCTA which allowed for further optimization of these algorithms seems needed to derive more
improved subjective visualization of small arteries, stents, calcifications, accurate calcium scores of CCTA scans.
and non-calcified plaques compared to EID-CT (n = 14) using the Philips
system [12]. An additional study using the Siemens system demon­
4.3. Stent imaging
strated UHR-CCTA (n = 20) with a sharp kernel (Bv89) depicted coro­
nary arteries with less blooming artifacts due to calcifications compared
On CT, metal stents appear thicker due to blooming artifacts

3
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

hampering in-stent lumen assessment. Additionally, stents have struts experimental and has yet to prove its clinical value.
that are spaced close to each other which complicates visualization of Extracellular volume (ECV) quantification is a technique to measure
stents. UHR-PCCT of eleven coronary stents showed smaller external and the expansion of myocardial tissue and usually measured on magnetic
larger internal stent diameters for PCCT than EID-CT (p < 0.05). Less resonance imaging [22]. In most pathologies involving the myocardium,
blooming artifacts were present in PCCT images, resulting in more ac­ ECV enlarges. For ECV quantification, a non-contrast and contrast-
curate stent diameter measurements[7] (Fig. 3). enhanced scan are needed. Mergen et al. studied the feasibility of
In patients after endovascular aneurysm repair (EVAR), routine iodine maps from late-enhancement PCCT scans to quantify ECV. The
follow-up is often done by CT using TNC and CTA scans for diagnosing use of iodine maps is not subjected to misregistration and might obviate
endoleaks and accurate discrimination from calcifications. In 20 EVAR the need for a TNC image like in CAC scoring. Further evidence is
patients, two contrast removing algorithms (VNC and PC) were recon­ required to establish the clinical efficacy of quantifying ECV utilizing
structed from CTA images to investigate if they can replace TNC images PCCT.
[19]. Complete iodine removal was obtained by both algorithms, but VMIs were investigated for the quantification of epicardial adipose
only the PC algorithm obtained minimal erroneous elimination of tissue attenuation [23]. Images at 70 keV were suggested for the optimal
calcification and stent struts [19]. Five-point Likert scales showed more epicardial adipose tissue attenuation assessment due to corresponding
accurate image quality for PC (4.2 ± 0.9) compared to VNC (2.5 ± 0.6). CT numbers compared to conventional CT. Lastly, one case report
Lower SNR (PC = 2.5 ± 1.3, VNC = 1.9 ± 0.9) compared to enhanced showed the feasibility of myocardial perfusion assessment through
scans (3.3 ± 1.6) was found for both algorithms. iodine mapping for myocardial infarction with obstructive coronary
artery disease in a single patient [24].
4.4. Other cardiac imaging
4.5. Thoracic imaging
Four studies investigated the advantages of PCCT to evaluate the
myocardium. First, Ayx et al. compared myocardial radiomics features In thoracic imaging, high spatial resolution is of vital importance to
between PCCT and EID-CT [20,21]. Radiomic features incorporate pixel- assess lung parenchyma and surrounding low-contrast structures espe­
based quantitative data to reveal characteristics that are not observed cially in patients with interstitial or alveolar lung diseases [25,26].
with the human eye. Both scanners showed comparable first-order fea­ Spectral properties may provide information on vessel occlusions and
tures but second-order features (textures) were more heterogeneous lung perfusion differences with the aid of blood volume maps (Fig. 4).
[21]. This heterogeneity might indicate improved spatial resolution, Nine articles investigated the possibilities of PCCT in thoracic imaging.
detection of lower-energy photons, and signal-to-noise ratio. The dif­
ferences between EID-CT and PCCT image textures indicate the images 4.6. Thoracic imaging at reduced dose
cannot always be used interchangeably for radiomics assessment.
Texture-features analysis in the assessment of myocardium is still Dose reduction is a major goal in clinical practice and is especially

Fig. 3. Dual-source ultra-high resolution PCCT scans of a 73-year-old patient suspected of obstructive coronary artery disease A. Demonstrate calcifications in
circumflex coronary artery with no significant stenosis as confirmed by angiography. B/C. Depiction of a stent in the left anterior descending with calcification
outside of the stent is compressing the lumen. Mid-LAD a suspected stenosis was observed.

4
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

Fig. 4. Imaging of pulmonary embolism by PCCT.

A/B. Patient with bilateral central pulmonary em­
bolism as seen on the axial CT images. C. Spectral
properties of PCCT allow to reconstruct perfusion
blood volume maps to determine perfusion loss of
the lung. The darker area in the left lower lung in­
dicates less perfusion. The Red/blue overlay
enhanced the differences between anatomical
structures filled with contrast (blue) and thrombi
and less perfused tissues (red). (For interpretation of
the references to colour in this figure legend, the
reader is referred to the web version of this article.)

valuable for patients with interstitial disease or lung cancer (screening/ TNC, demonstrating the feasibility of replacing TNC scans with VNC
treatment) as their radiation exposure can accumulate rapidly when reconstructions for lung emphysema quantification.
undergoing regular CT scans for treatment monitoring and follow-up
[25,26]. Four studies compared image quality of low-dose high-resolu­
tion PCCT to EID-CT [25–29]. PCCT allowed for scanning with lower 4.8. Ultra-high resolution thoracic imaging
radiation dose (43%–50% reduction) while retaining equal image
quality. One study found lower SNR in PCCT (CTDIvol = 2.5 mGy) Six feasibility studies with ultra-high-resolution acquisition (0.2
compared to EID-CT (CTDIvol = 3.0 mGy) in the evaluation of lung pa­ mm) in combination with a sharp kernel, showed excellent visibility of
thologies [28]. The higher noise levels could be explained by increased 4th and 5th-order bronchi, bronchial walls, vessels and lung paren­
spatial resolution and the use of sharper kernels in PCCT [28,30]. The chyma as well as retaining visibility of lung nodules [27,28,30,33–35].
lower SNR in PCCT did not affect subjective visual assessment. Proper kernel selection is important for optimal usage of high spatial
resolution PCCT. Two studies investigated UHR-PCCT imaging in
4.7. Lung emphysema interstitial lung disease [36,37]. In 30 patients with usual interstitial
pneumonia, low-contrast tasks like assessing absence or presence of
For the quantification of lung emphysema, a non-contrast-enhanced ground glass opacities (p = 0.019) and mosaic pattern (p = 0.013)
scan is needed. Jungblut et al. investigated the impact of different VMIs demonstrated higher readers confidence compared to EID-CT [37]. For
(n = 60) and VNC (n = 65) reconstructions to quantify lung emphysema systemic sclerosis, a dose reduction of 66% was established while
[31,32]. For VMI (40–80 keV), the smallest difference in the amount of maintaining equal diagnostic accuracy compared to EID-CT [36].
emphysema (-16 %) was found at 80 keV compared to VNC. Mono-
energetic levels at 40 keV showed improved iodine CNR (46.5 ± 10.7 5. Abdominal imaging
vs 29.1 ± 7.5) and vessel evaluation. Considering the assessment of
pulmonary vessels and emphysema simultaneously, objective and sub­ Clinical studies in abdominal PCCT focused on three main topics: the
jective analysis showed the best results for images reconstructed be­ need for anatomical detail in abdominal contrast-enhanced scans,
tween 60 and 70 keV. For VNC reconstructions, emphysema improvement of image quality in obese patients, and spectral post-
quantification was comparable for both VNC reconstructions derived processing in abdominal malignancies, liver, spleen and pancreas
from arterial (p = 0.41), and venous (p = 0.09) scan phases compared to imaging.

5
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

5.1. Image detail advancement 4.7HU) and the spleen (mean difference; 5.5 ± 4.7HU) resulting in more
false positives when only liver HU values were included for diagnosis
In contrast-enhanced abdominal imaging, three studies observed [46]. Considering the mean CT numbers for both liver and spleen were
equal objective and subjective image quality compared to EID-CT with a lower on VNC compared to TNC, the ratio between the two with an
low or reduced dose up to 57% for PCCT [27,38–40]. Sartoretti et al. adjusted cut-off value was considered useful for diagnosis. Sartoretti
examined the effect of increased IR strength on noise magnitude and et al. found stable HU values for hypodense liver lesions in VNC and TNC
texture in patients with a contrast-enhanced abdominal scan [41]. images with a mean error of 3.7 ± 2.2HU [47]. Mergen et al. found an
Increasing IR strength did not affect the noise texture. However, the area absolute error (VNC/TNC) < 10 HU in 95 % of 100 patients [48].
of the noise power spectrum decreased with an increase in IR strength Furthermore, attenuation values remained stable when IR strength
corresponding with less noise (45%) and a better subjective/objective increased for both conventional and 60 keV images [41]. In another
(p < 0.001) image quality. Higher diagnostic accuracy for abdominal study in 29 patients with adrenal adenomas, VNC reconstructions
pathologies could be achieved due to this image quality improvement. showed over- and underestimation of the HU values compared to TNC
For example, Marcus et al. found the number of detected uric acid and resulting in a non-significant mean difference of 9.2 ± 8.6HU vs 7.3 ±
non-uric acid containing normal and small size renal stones (<3mm) 8.4HU respectively [49]. But, despite the small absolute difference in
was higher for PCCT compared to DECT (70% vs 54.4%)[42]. HU values this lead to seven misclassified adrenal lesions.
In 30 patients with liver lesions, iodine quantification of the liver
5.2. Obese patient population parenchyma and lesions was investigated. Iodine concentration in PCCT
was measured and compared to values of EID-CT found in literature. For
To achieve high image quality in obese patients, an increase in kV is the liver parenchyma (1.7 ± 0.4 vs 2.1 ± 0.8 mgIodine/mL) and cysts
required leading to a more substantial reduction of iodine image (0.2 ± 0.1 vs 0.2 ± 0.3 mgIodine/mL) concentrations were comparable,
contrast compared to other tissues. Using spectral information, PCCT opening opportunities for iodine mapping with PCCT [50]. The use of
offers the potential to compute low-keV VMI. Decker et al. investigated VNC/iodine mapping can reveal the perfusion status of tissue and might
the feasibility of low-dose non-contrast abdominal PCCT compared to play a role in detection of bowel infarction. Improvement in CNR can
EID-CT in 20 dose-matched patients [43]. They concluded that an in­ detect subtle density differences in bowel wall enhancement [51].
crease in BMI had a greater impact on noise in EID-CT (+39 %) than
PCCT (+2%). Abdominal structures such as mesenteric vessels, ureters 6. Neuro-imaging
and the renal pelvis were better delineated by PCCT compared to EID-CT
(overall image quality: p < 0.001). Low-dose non-contrast abdominal For the initial assessment of the brain with conventional CT, soft-
PCCT enables a more reliable diagnosis of abdominal pathologies with tissue contrast remains low, beam-hardening arises from the skull and
higher SNR at equal low-dose EID-CT. Another strategy is to keep image small anatomic structures are difficult to visualize. Reconstructions with
quality constant to conventional EID-CT but decrease the radiation dose high mono-energetic levels can reduce beam hardening artefacts
for the patient [38]. Hagen et al. confirmed this strategy with a cohort of without additional scanning. A total of nine studies assessed opportu­
obese patients scanned for oncological reasons (n = 51) with a dose nities of PCCT head imaging.
reduction of 25% [44].
6.1. Gray matter – White matter differentiation
5.3. Spectral post-processing
Differentiation between white and gray matter is troublesome with
Virtual-mono-energetic images were effective for the detection of conventional CT considering tissue attenuations only differ by approx­
liver and pancreas tumors and peritoneal lesions [43,45] (Fig. 5). In 100 imately 10HU [52]. Subjectively, neuroradiologists could make more
patients with liver lesions, images at 40 keV had the highest CNR (6.88 accurate distinction between gray matter and white matter with PCCT
IQR[4.79–10.19]) of all VMIs (120 kV) and compared to EID-CT (100/ compared to EID-CT in 21 patients [53]. Objectively, in 49 patients,
120 kV; 4.31 IQR[3.11–5.17]). Images at higher mono-energetic levels conventional PCCT images had higher white–gray matter CNR (2.90 ±
(>70 keV) had significantly less noise compared to 40 keV (13.4HU IQR 0.92, p < 0.001) compared to mono-energetic reconstructions (40 keV
[12.1–15.2] vs 20.4HU IQR[17.0–24.2], respectively, p < 0.001), and [2.26 ± 0.96] − 120 keV [0.71 ± 0.54]) [52]. The CT numbers of white
resulted in improved subjective analysis [45]. and gray matter still only differed by ≈10HU (WM = 33HU, GM =
Niehoff et al. investigated diagnostic accuracy of VNC re­ 42HU) for conventional images. Images at 40 keV depicted a more
constructions compared to TNC images for hepatic steatosis. VNC im­ prominent differentiation with a mean signal difference of ≈20HU but
ages showed lower HU values for both the liver (mean difference; 8.7 ± with larger image noise. Low keV images are also prone to more noise

Fig. 5. Spectral advantages in abdominal imaging. A/B by lowering the virtual-mono-energetic level, hyperdense liver lesions with iodine uptake stand out more
clearly compared to 70 keV images.

6
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

and beam-hardening artifacts caused by the skull leading to a decrease incudostapedial articulation at a reduced radiation dose (-31%)
in SNR and CNR. PCCT showed less beam-hardening artifacts compared compared to EID-CT [57] (Fig. 6D/E).
to EID-CT even at low keV’s, but optimization is needed. Currently,
images at high resolution (0.4/0.2 mm) are more favorable to assess 6.4. Musculoskeletal imaging
brain matter but not optimal [53,54].
The ability to visualize trabecular bone and the reduction of metal
6.2. Neurovascular imaging artifacts near orthopedic implants has created interest for musculo­
skeletal imaging with PCCT. Until now, four studies with a small study
Beam-hardening artifacts attributable to the skull base and cervical population described a clinical evaluation in this field.
vertebrae greatly impact the assessment of vascular disease (i.e.,
atherosclerotic lesions) in the carotid and intracranial vessels. Three 6.5. Bone structure
studies investigated CTA of the brain with PCCT. Conventional images
had comparable results in terms of SNR/CNR compared to VMI’s but Four patients with bone lesions of metastasized breast cancer were
subjectively, were more favorable for the assessment of brain arteries scanned with UHR-PCCT [58]. Fine structures such as single trabeculae
with CTA (p < 0.001) [54]. In two studies describing a total of seventeen could be visualized. In conventional CT, the partial volume effect affects
patients, higher iodine contrast attenuation (20.8%) with VMI re­ the differentiation between small metastases and benign bone focal
constructions and less beam-hardening in regions with extensive bone changes. PCCT allows for an accurate depiction of tumor margins and
involvement (C2 segment of the carotid artery) compared to EID-CT spiculae resulting in a more definite evaluation of bone metastasis [58].
were found [55,56] (Fig. 6A/B/C). Three studies investigated the image quality of bone in patients under­
going UHR-PCCT for shoulder/pelvic/wrist assessment [33,59,60]. Fine
6.3. Temporal bone cortical and trabecular bone together with bridging callus and sequalae
of hypertrophic degenerative arthritis had greater subjective reader
Temporal bone imaging seems to benefit from UHR-PCCT because of confidence at 31%-49% lower radiation dose compared to EID-CT.
the submillimeter size of the anatomical structures [33–35,57]. UHR-
PCCT in thirteen patients showed subjectively sharp anatomic details 6.6. Orthopedic implants
because of the reduced partial volume effect. This resulted in improved
visualization of abnormalities of the ossicular chain, postoperative Zhou et al. demonstrated imaging with 0.4 mm of spectral shaping
changes related to ossicular prostheses, and the integrity of the with the aid of tin filtration substantially improved the diagnostic

Fig. 6. Applications of PCCT for neuro-imaging. A/B/C. A patient with an occluded flow diverter. Thanks to the increased spatial resolution of PCCT, the lumen of
the flow diverter is clearly depicted, allowing for assessment of the lumen. D/E. Labyrinthitis ossificans in a 63-year-old patient. Again, the high spatial resolution of
PCCT, enables differentiation between intracochlear calcification and partial volume effect of the surrounding otic capsular bone, which could be differentiated less
reliably before with conventional CT.

7
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

confidence (65%) of periprothestic fractures, implant loosening, and Challenges of abdominal imaging, like imaging obese patients, can be
enhanced delineation of cortical bone, bone trabeculae, and implant- mitigated by PCCT. Additional spectral post-processing has the potential
bone interface compared to EID-CT. UHR-PCCT also demonstrated less to improve visualization of liver and renal pathologies but further
metal artifacts (p < 0.001) compared to EID-CT. This effect was most research is needed to identify more advantages of abdominal PCCT. For
evident in patients with spinal implants. The noise level was ≈12% neuro-imaging, the sharp depiction of temporal bone can improve di­
lower in PCCT, yielding a 23% improvement in dose efficiency [61]. agnostics in this small and complex anatomic region, differentiation of
Fig. 7 demonstrates a clinical case example of metal artifact reduction. white and gray matter, however, remains challenging. Lastly, a detailed
assessment of bone structure and osseointegration of orthopedic im­
6.7. Current challenges of photon-counting CT plants in musculoskeletal imaging can be achieved with PCCT. The
number of studies describing the clinical applications of PCCT is still
Besides the benefits of PCCT, there are also some limitations. In limited and most studies include small sample size and scan acquisition
PCCT, achievable image quality is now limited by the X-ray tube that has protocols vary widely. A vast increase in the number of publications on
a maximum filament current, maximum power and an inadequate focal PCCT is expected in the (near future). There is a need for studies
spot size. Second, many studies mentioned potential dose reduction of assessing the capabilities of PCCT in larger patient cohorts, using stan­
PCCT. The aims of these studies are often to demonstrate non-inferior dardized acquisition settings to investigate the influence of photon-
image quality compared to conventional CT. To profit from the spec­ counting CT on the sensitivity and classification of various diseases.
tral properties of PCCT, a relatively wide energy spectrum is needed. To
create such a wide spectrum, a relatively high tube voltage is needed Declaration of Competing Interest
which is often correlated with a higher dose and lower contrast,
depending on the clinical task. The question remains whether this leads The authors declare institutional support by Siemens Healthineers to
to an increased dose and if this is justified by the advantages of spectral Erasmus MC.
image analysis [62]. In addition, the large amount of data generated by
PCCT requires significant computational resources or prior to scanning Appendix A. Search terms
accurate selection of the acquisition protocol and reconstructions to
limit the data, especially in UHR mode. Lastly, and not insignificantly, [Link].
PCCT undoubtedly enables high-quality images and allows physicians to ((((photon*-count* OR spectra* OR multi-energ*) NEAR/3 (com­
post-process images to their preferences to increase diagnostics confi­ put*-tomo* OR CT))):ab,ti,kw) NOT ((animal/exp OR animal*:de OR
dence. However. the impact of PCCT on clinical decision-making is still nonhuman/de) NOT (’human’/exp)) NOT ([conference abstract]/lim
unanswered and the question remains if PCCT will lead to for example AND [1800–2019]/py).
earlier diagnosis or make invasive interventions obsolete. Medline (ovid).
((((photon*-count* OR spectra* OR multi-energ*) ADJ3 (comput*-
7. Conclusion tomo* OR CT))).ab,ti,kf.) NOT (exp animals/ NOT humans/).
Web of science.
PCCT is a promising technique to overcome the shortcomings of TS=(((((photon*-count* OR spectra* OR multi-energ*) NEAR/2
energy-integrating CT detectors currently used in clinical practice. In (comput*-tomo* OR CT)))) NOT ((animal* OR rat OR rats OR mouse OR
cardiovascular imaging, PCCT improves image quality of small arteries, mice OR murine OR dog OR dogs OR canine OR cat OR cats OR feline OR
stent visualization and allows for deriving CAC scores from the contrast- rabbit OR cow OR cows OR bovine OR rodent* OR sheep OR ovine OR
enhanced CCTA’s. In thoracic imaging, PCCT can play a role in radiation pig OR swine OR porcine OR veterinar* OR chick* OR zebrafish* OR
dose reduction for patients who frequently undergo CT scans. baboon* OR nonhuman* OR primate* OR cattle* OR goose OR geese OR

Fig. 7. Spectral shaping in combination with high

energy (keV) provides artifact-free imaging of bone
with a metal elbow implant. High X-ray attenuation
of orthopedic implants causes metal artifacts
expressed by streaks and dark/bright regions in the
image. Elimination of these artifacts is crucial to
assess the position, osteointegration and infection
of orthopedic implants. A. Using the spectral
dataset, low-energy photons can be excluded from
the final image, which might improve the perfor­
mance of metal artifact reduction thanks to less
beam-hardening and photon starvation compared
to conventional dual-energy CT. B cinematic
rendering of CT scan.

8
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

duck OR macaque* OR avian* OR bird* OR fish*) NOT (human* OR [20] I. Ayx, H. Tharmaseelan, A. Hertel, D. Nörenberg, D. Overhoff, L.T. Rotkopf, et al.,
Myocardial radiomics texture features associated with increased coronary calcium
patient* OR women OR woman OR men OR man))) AND DT=(Article
score-first results of a photon-counting CT, Diagnostics (Basel) 12 (7) (2022).
OR Review OR Letter OR Early Access). [21] I. Ayx, H. Tharmaseelan, A. Hertel, D. Nörenberg, D. Overhoff, L.T. Rotkopf, et al.,
Cochrane central. Comparison study of myocardial radiomics feature properties on energy-
((((photon* NEXT count* OR spectra* OR multi NEXT energ*) integrating and photon-counting detector CT, Diagnostics (Basel) 12 (5) (2022).
[22] V. Mergen, T. Sartoretti, E. Klotz, B. Schmidt, L. Jungblut, K. Higashigaito, et al.,
NEAR/3 (comput* NEXT tomo* OR CT))):ab,ti,kw). Extracellular volume quantification with cardiac late enhancement scanning using
Google scholar. dual-source photon-counting detector CT, Invest. Radiol. (2022).
“photon-counting CT”|“photon-counting Computed Tomography”. [23] V. Mergen, E. Ried, T. Allmendinger, T. Sartoretti, K. Higashigaito, R. Manka, et al.,
Epicardial adipose tissue attenuation and fat attenuation index: phantom study and
in-vivo measurements with photon-counting CT, AJR Am. J. Roentgenol. (2021).
Appendix B. Supplementary material [24] M. Polacin, C. Templin, R. Manka, H. Alkadhi, Photon-counting computed
tomography for the diagnosis of myocardial infarction with non-obstructive
coronary artery disease, Eur Heart J Case Rep. 6 (2) (2022) ytac028.
Supplementary data to this article can be found online at [Link] [25] D. Graafen, T. Emrich, M.C. Halfmann, P. Mildenberger, C. Düber, Y. Yang, et al.,
org/10.1016/[Link].2023.110829. Dose reduction and image quality in photon-counting detector high-resolution
computed tomography of the chest: routine clinical data, J. Thorac. Imaging
(2022).
References [26] Hagen F, Walder L, Fritz J, Gutjahr R, Schmidt B, Faby S, et al. Image Quality and
Radiation Dose of Contrast-Enhanced Chest-CT Acquired on a Clinical Photon-
[1] H. Bornefalk, M. Danielsson, Photon-counting spectral computed tomography Counting Detector CT vs. Second-Generation Dual-Source CT in an Oncologic
using silicon strip detectors: a feasibility study, Phys. Med. Biol. 55 (7) (2010) Cohort: Preliminary Results. Tomography. 2022;8(3):1466-76.
1999–2022. [27] J. Ferda, T. Vendiš, T. Flohr, B. Schmidt, A. Henning, S. Ulzheimer, et al.,
[2] M.J. Willemink, M. Persson, A. Pourmorteza, N.J. Pelc, D. Fleischmann, Photon- Computed tomography with a full FOV photon-counting detector in a clinical
counting CT: technical principles and clinical prospects, Radiology 289 (2) (2018) setting, the first experience, Eur. J. Radiol. 137 (2021).
293–312. [28] M.M. Woeltjen, J.H. Niehoff, A.E. Michael, S. Horstmeier, C. Moenninghoff,
[3] R. Booij, R.P.J. Budde, M.L. Dijkshoorn, M. van Straten, Technological J. Borggrefe, et al., Low-dose high-resolution photon-counting CT of the Lung:
developments of X-ray computed tomography over half a century: User’s influence radiation dose and image quality in the clinical routine, Diagnostics (Basel) 12 (6)
on protocol optimization, Eur. J. Radiol. 131 (2020), 109261. (2022).
[4] T. Flohr, M. Petersilka, A. Henning, S. Ulzheimer, J. Ferda, B. Schmidt, Photon- [29] R. Symons, A. Pourmorteza, V. Sandfort, M.A. Ahlman, T. Cropper, M. Mallek, et
counting CT review, Phys. Med. 79 (2020) 126–136. al., Feasibility of dose-reduced chest CT with photon-counting detectors: Initial
[5] M. Danielsson, M. Persson, M. Sjolin, Photon-counting x-ray detectors for CT, Phys. results in humans, Radiology 285 (3) (2017) 980–989.
Med. Biol. 66 (3) (2021) 03TR1. [30] D.J. Bartlett, C.W. Koo, B.J. Bartholmai, K. Rajendran, J.M. Weaver, A.
[6] E Shanblatt, J O’Doherty, M Petersilka, P Wolber, G Fung, J.C Ramirez-Giraldo. F. Halaweish, et al., High-Resolution Chest Computed Tomography Imaging of the
NAEOTOM Alpha with Quantum Technology. How photon-counting CT works and Lungs: Impact of 1024 matrix reconstruction and photon-counting detector
the benefits it provides, 2022. computed tomography, Invest. Radiol. 54 (3) (2019) 129–137.
[7] S. Boccalini, S.A. Si-Mohamed, H. Lacombe, A. Diaw, M. Varasteh, P.A. Rodesch, et [31] L. Jungblut, T. Sartoretti, D. Kronenberg, V. Mergen, A. Euler, B. Schmidt, et al.,
al., First in-human results of computed tomography angiography for coronary stent Performance of virtual non-contrast images generated on clinical photon-counting
assessment with a spectral photon counting computed tomography, Invest. Radiol. detector CT for emphysema quantification: proof of concept, Br. J. Radiol. 95
(2021). (1135) (2022) 20211367.
[8] D.C. Rotzinger, D. Racine, F. Becce, E. Lahoud, K. Erhard, S.A. Si-Mohamed, et al., [32] L. Jungblut, D. Kronenberg, V. Mergen, K. Higashigaito, B. Schmidt, A. Euler, et al.,
Performance of spectral photon-counting coronary CT angiography and Impact of contrast enhancement and virtual monoenergetic image energy levels on
comparison with energy-integrating-detector CT: objective assessment with model emphysema quantification: experience with photon-counting detector computed
observer, Diagn. 11 (12) (2021). tomography, Invest. Radiol. (2022).
[9] S.A. Si-Mohamed, J. Greffier, J. Miailhes, S. Boccalini, P.A. Rodesch, A. Vuillod, et [33] S. Leng, K. Rajendran, H. Gong, W. Zhou, A.F. Halaweish, A. Henning, et al., 150-
al., Comparison of image quality between spectral photon-counting CT and dual- μm spatial resolution using photon-counting detector computed tomography
layer CT for the evaluation of lung nodules: a phantom study, Eur. Radiol. (2021). technology: technical performance and first patient images, Invest. Radiol. 53 (11)
[10] Canon. Commencement of Research Collaboration into Japan’s first Photon (2018) 655–662.
Counting Computed Tomography with National Cancer Center Japan 2021 [34] A. Pourmorteza, R. Symons, A. Henning, S. Ulzheimer, D.A. Bluemke, Dose
[Available from: [Link] efficiency of quarter-millimeter photon-counting computed tomography: first-in-
5-834. human results, Invest. Radiol. 53 (6) (2018) 365–372.
[11] Healthcare G. Silicon Dreams: A Technological Breakthrough To Let Doctors Peer [35] Rajendran K, Petersilka M, Henning A, Shanblatt E, Marsh J, Jr., Thorne J, et al.
Inside The Body With Startling Clarity 2022 [Available from: [Link] Full field-of-view, high-resolution, photon-counting detector CT: technical
[Link]/insights/article/silicon-dreams-a-technological-breakthrough-to assessment and initial patient experience. 2021.
-let-doctors-peer-inside-the-body-with-startling-clarity. [36] L. Jungblut, A. Euler, J. von Spiczak, T. Sartoretti, V. Mergen, V. Englmaier, et al.,
[12] S.A. Si-Mohamed, S. Boccalini, H. Lacombe, A. Diaw, M. Varasteh, P.A. Rodesch, et Potential of Photon-Counting Detector CT for Radiation dose reduction for the
al., Coronary CT Angiography with Photon-counting CT: first-In-Human Results, assessment of interstitial lung disease in patients with systemic sclerosis, Invest.
Radiology 303 (2) (2022) 303–313. Radiol. (2022).
[13] V. Mergen, T. Sartoretti, M. Baer-Beck, B. Schmidt, M. Petersilka, J.E. Wildberger, [37] A. Inoue, T.F. Johnson, D. White, C.W. Cox, T.E. Hartman, J.E. Thorne, et al.,
et al., Ultra-high-resolution coronary CT Angiography With Photon-Counting Estimating the clinical impact of photon-counting-detector CT in diagnosing usual
Detector CT: feasibility and image characterization, Invest. Radiol. (2022). interstitial pneumonia, Invest. Radiol. (2022).
[14] K. Rajendran, M. Petersilka, A. Henning, E.R. Shanblatt, B. Schmidt, T.G. Flohr, et [38] J.A. Decker, S. Bette, N. Lubina, K. Rippel, F. Braun, F. Risch, et al., Low-dose CT of
al., First clinical photon-counting detector CT System: technical evaluation, the abdomen: Initial experience on a novel photon-counting detector CT and
Radiology (2021), 212579. comparison with energy-integrating detector CT, Eur. J. Radiol. 148 (2022).
[15] A. Euler, K. Higashigaito, V. Mergen, T. Sartoretti, B. Zanini, B. Schmidt, et al., [39] R. Wrazidlo, L. Walder, A. Estler, R. Gutjahr, B. Schmidt, S. Faby, et al., Radiation
High-pitch photon-counting detector computed tomography angiography of the dose reduction in contrast-enhanced abdominal CT: comparison of Photon-
aorta: intraindividual comparison to energy-integrating detector computed Counting Detector CT with 2nd Generation Dual-Source Dual-Energy CT in an
tomography at equal radiation dose, Invest. Radiol. 57 (2) (2022) 115–121. oncologic cohort, Acad. Radiol. (2022).
[16] Emrich T, Aquino G, Schoepf UJ, Braun FM, Risch F, Bette SJ, et al. Coronary [40] A. Pourmorteza, R. Symons, V. Sandfort, M. Mallek, M.K. Fuld, G. Henderson, et
Computed Tomography Angiography-Based Calcium Scoring: In Vitro and In Vivo al., Abdominal imaging with contrast-enhanced photon-counting CT: first human
Validation of a Novel Virtual Noniodine Reconstruction Algorithm on a Clinical, experience, Radiology 279 (1) (2016) 239–245.
First-Generation Dual-Source Photon Counting-Detector System. Invest Radiol. [41] T. Sartoretti, A. Landsmann, D. Nakhostin, M. Eberhard, C. Röeren, V. Mergen, et
2022;57(8):536-43. al., Quantum iterative reconstruction for abdominal photon-counting detector CT
[17] R. Symons, V. Sandfort, M. Mallek, S. Ulzheimer, A. Pourmorteza, Coronary artery improves image quality, Radiology (2022), 211931.
calcium scoring with photon-counting CT: first in vivo human experience, Int. J. [42] R.P. Marcus, J.G. Fletcher, A. Ferrero, S. Leng, A.F. Halaweish, R. Gutjahr, et al.,
Card. Imaging 35 (4) (2019) 733–739. Detection and characterization of renal stones by using photon-counting-based CT,
[18] M. Eberhard, V. Mergen, K. Higashigaito, T. Allmendinger, R. Manka, T. Flohr, et Radiology 289 (2) (2018) 436–442.
al., Coronary calcium scoring with first generation dual-source photon-counting [43] K. Higashigaito, A. Euler, M. Eberhard, T.G. Flohr, B. Schmidt, H. Alkadhi,
ct—first evidence from phantom and in-vivo scans, Diagn. 11 (9) (2021). Contrast-Enhanced Abdominal CT with Clinical Photon-Counting Detector CT:
[19] J.A. Decker, S. Bette, C. Scheurig-Muenkler, B. Jehs, F. Risch, P. Woźnicki, et al., assessment of image quality and comparison with energy-integrating detector CT,
Virtual non-contrast reconstructions of photon-counting detector CT angiography Acad. Radiol. (2021).
datasets as substitutes for true non-contrast acquisitions in patients after EVAR- [44] F. Hagen, J. Hofmann, R. Wrazidlo, R. Gutjahr, B. Schmidt, S. Faby, et al., Image
performance of a novel calcium-preserving reconstruction algorithm, Diagnostics quality and dose exposure of contrast-enhanced abdominal CT on a 1st generation
(Basel) 12 (3) (2022). clinical dual-source photon-counting detector CT in obese patients vs. a 2nd

9
J. van der Bie et al. European Journal of Radiology 163 (2023) 110829

generation dual-source dual energy integrating detector CT, Eur. J. Radiol. 151 [54] A.E. Michael, J. Boriesosdick, D. Schoenbeck, I. Lopez-Schmidt, J.R. Kroeger,
(2022), 110325. C. Moenninghoff, et al., Photon Counting CT angiography of the head and neck:
[45] S. Bette, J.A. Decker, F.M. Braun, J. Becker, M. Haerting, T. Haeckel, et al., Optimal image quality assessment of polyenergetic and virtual monoenergetic
conspicuity of liver metastases in virtual monochromatic imaging reconstructions reconstructions, Diagnostics (Basel) 12 (6) (2022).
on a novel photon-counting detector CT-Effect of keV Settings and BMI, Diagnostics [55] S. Boccalini, S. Si-Mohamed, R. Dessouky, M. Sigovan, L. Boussel, P. Douek,
(Basel) 12 (5) (2022). Feasibility of human vascular imaging of the neck with a large field-of-view
[46] J.H. Niehoff, M.M. Woeltjen, S. Saeed, A.E. Michael, J. Boriesosdick, J. Borggrefe, spectral photon-counting CT system, Daign Intervent Imaging. 102 (5) (2021)
et al., Assessment of hepatic steatosis based on virtual non-contrast computed 329–332.
tomography: initial experiences with a photon counting scanner approved for [56] Symons R, Reich DS, Bagheri M, Cork TE. Photon-counting CT for vascular imaging
clinical use, Eur. J. Radiol. 149 (2022), 110185. of the head and neck: First in vivo human results: [Link]; 2018.
[47] Sartoretti T, Mergen V, Higashigaito K, Eberhard M, Alkadhi H, Euler A. Virtual [57] J.C. Benson, K. Rajendran, J.I. Lane, F.E. Diehn, N.M. Weber, J.E. Thorne, et al.,
Noncontrast Imaging of the Liver Using Photon-Counting Detector Computed A new frontier in temporal bone imaging: photon-counting detector CT
Tomography: A Systematic Phantom and Patient Study. 2022. demonstrates superior visualization of critical anatomic structures at reduced
[48] V. Mergen, D. Racine, L. Jungblut, T. Sartoretti, S. Bickel, P. Monnin, et al., Virtual radiation dose, AJNR Am. J. Neuroradiol. 43 (4) (2022) 579–584.
noncontrast abdominal imaging with photon-counting detector CT, Radiology [58] E. Wehrse, S. Sawall, L. Klein, P. Glemser, S. Delorme, H.P. Schlemmer, et al.,
(2022), 213260. Potential of ultra-high-resolution photon-counting CT of bone metastases: initial
[49] S. Lennartz, D. Schoenbeck, J.R. Kröger, J. Borggrefe, Henning Niehoff J, Initial experiences in breast cancer patients, npj Breast Cancer 7 (1) (2021) 3.
Experience in Assessing Adrenal Adenoma. Radiology, Photon-counting CT [59] F.I. Baffour, K. Rajendran, K.N. Glazebrook, J.E. Thorne, N.B. Larson, S. Leng, et
Material Decomposition, 2022, p. 220919. al., Ultra-high-resolution imaging of the shoulder and pelvis using photon-
[50] T. Sartoretti, V. Mergen, L. Jungblut, H. Alkadhi, A. Euler, Liver iodine counting-detector CT: a feasibility study in patients, Eur. Radiol. (2022).
quantification with photon-counting detector CT: accuracy in an abdominal [60] K. Rajendran, F. Baffour, G. Powell, K. Glazebrook, J. Thorne, N. Larson, et al.,
phantom and feasibility in patients, Acad. Radiol. (2022). Improved visualization of the wrist at lower radiation dose with photon-counting-
[51] N.H. Shaheen, M. Stroebel, C. Welsh, B. Gibney, A.D. Hardie, Use of novel photon - detector CT, Skeletal Radiol. (2022).
counting detector CT for diagnosis of bowel infarction, Radiol Case Rep. 17 (5) [61] W. Zhou, D.J. Bartlett, F.E. Diehn, K.N. Glazebrook, A.L. Kotsenas, R.E. Carter, et
(2022) 1674–1677. al., Reduction of metal artifacts and improvement in dose efficiency using photon-
[52] A.E. Michael, J. Boriesosdick, D. Schoenbeck, M.M. Woeltjen, S. Saeed, J. counting detector computed tomography and tin filtration, Invest. Radiol. 54 (4)
R. Kroeger, et al., Image-quality assessment of polyenergetic and virtual (2019) 204–211.
monoenergetic reconstructions of unenhanced CT scans of the head: initial [62] J. van der Bie, D. Bos, M. Dijkshoorn, N.R. van der Werf, R. Booij, R.P.J. Budde, et
experiences with the first photon-counting CT approved for clinical use, al., Image quality and radiation dose of dual-source photon-counting CT coronary
Diagnostics (Basel) 12 (2) (2022). angiography compared to conventional CT: a phantom study, ECR (2022) C-21793.
[53] Pourmorteza A, Symons R, Reich DS, Bagheri M, Cork TE, Kappler S, et al. Photon-
Counting CT of the Brain: In Vivo Human Results and Image-Quality Assessment.
AJNR Am J Neuroradiol. 2017;38 12 2257-63.

10