D u a l - E n e r g y C T • R ev i ew

Postma et al.
Dual-Energy CT of the Brain and Intracranial Vessels

Dual-Energy CT
Review
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Dual-Energy CT of the Brain

and Intracranial Vessels
Alida A. Postma1 OBJECTIVE. The purpose of this review is to summarize the principles and applications
Paul A. M. Hofman1 of dual-energy CT in evaluation of the brain and the intracranial blood vessels.
Annika A. R. Stadler 1 CONCLUSION. One major advantage of dual-energy CT is the capability of material
Robert J. van Oostenbrugge2 differentiation. In general, this property can be applied to bone removal in CT angiography
Maud P. M. Tijssen1 for easier and faster postprocessing. In neuroradiology, material decomposition allows detec-
tion of hemorrhage on contrast-enhanced CT scans and facilitates the search for the underly-
Joachim E. Wildberger 1
ing pathologic mechanism of hematomas. The combination of low radiation dose and advan-
Postma AA, Hofman PAM, Stadler AAR, van tageous spectral information (blood vs contrast) from these datasets justifies broad clinical
Oostenbrugge RJ, Tijssen MPM, Wildberger JE implementation of dual-energy CT in neuroradiology.

Keywords: brain hemorrhage, dual-energy CT (DECT),
dual-energy CT angiography, material differentiation
DOI:10.2214/AJR.12.9115
Received April 24, 2012; accepted after revision
May 8, 2012.
Publication of this supplement to the American Journal of
Roentgenology is made possible by an unrestricted grant
from Siemens Healthcare.
J. E. Wildberger is a member of the speakers’ bureau of
Bayer Healthcare, Boston Scientific, GE Healthcare, and
Siemens Healthcare and is affiliated with an institution
that has received research grants from Bayer
Healthcare, GE Healthcare, Philips Healthcare, and
Siemens Healthcare.
1
Department of Radiology, Maastricht University Medical
Centre, PO Box 5800, 6202 AZ Maastricht, The
Netherlands. Address correspondence to A. A. Postma
(l.jacobi@mumc.nl).
2
Department of Neurology, Maastricht University
Medical Centre, Maastricht, The Netherlands.
AJR 2012; 199:S26–S33
0361–803X/12/1995–S26
© American Roentgen Ray Society
B
etween the discovery of x-rays in
1895 and the introduction of CT
in 1971, neuroradiology entailed
radiography, myelography, pneu-
moencephalography, and angiography as indi-
rect tools for imaging of the brain and spinal
cord. CT marked the beginning of a revolu-
tionary era. The internal structure of the brain
could be visualized without invasive exami-
nations [1]. Brain, blood vessels, and osseous
structures were directly evaluated. Adminis-
tration of contrast material enabled better vis-
ualization of the vessels and the breakdown of
the blood-brain barrier. In the next decades,
CT had substantial developments, including
helical acquisition and MDCT in the late
1990s, which enabled faster data acquisition
and isotropy of datasets and, last but not least,
dual-energy scanning.
MRI was introduced in the late 1970s and
to a large extent has replaced CT in neuro-
radiology in clinical routine. However, there
are still indications for CT: imaging of acute-
ly ill patients, diagnosis of acute (subarach-
noid) hemorrhage, and imaging of patients
with contraindications to MRI. These indica-
tions necessitate ongoing development of CT
as, for example, dual-energy CT (DECT).
The first publications on DECT appeared
in the late 1970s [2]. At that time, however,
owing to technical shortcomings (e.g., insuf-
ficient spatial resolution, long scan duration,
and misregistration), it did not receive broad
clinical implementation [3–5]. Since the ear-
ly 2000s, the evolution of DECT led to a re-
vival in modern MDCT scanners through the
use of two simultaneous working x-ray tubes
(Siemens Healthcare), fast peak kilovoltage
switching (GE Healthcare), and dual-layer de-
tection systems (Philips Healthcare). Since the
implementation of DECT, the number of indi-
cations has increased, especially in abdominal
and cardiac imaging [6–15]. Neuroradiologic
application lags behind the other uses, how-
ever [16]. The advantage of DECT is the abil-
ity to characterize material-specific and non–­
material-specific image fusion by combining
low and high peak voltage acquisitions [17–19].
For imaging of the brain and intracrani-
al blood vessels, material decomposition can
be applied for bone removal in CT angiogra-
phy (CTA). In addition, iodine can be virtually
subtracted from the images, resulting in cal-
culated virtual unenhanced images. The latter
can be used to identify the underlying patho-
logic mechanism in patients with brain hemor-
rhage [20, 21] and after previous delivery of
contrast medium, as after intraarterial recana-
lization in patients with stroke to differentiate
iodine and hemorrhage [22, 23]. Calculation
of single-energy images can be useful because
of the increased vascular opacification at low
kilovoltage. With higher kilovoltage, visuali-
zation of structures near the skull base is less
affected by beam-hardening artifacts than it is
at low kilovoltage [24].

S26 AJR:199, November 2012

 Dual-Energy CT of the Brain and Intracranial Vessels
Background Physics
X-ray attenuation of materials is based on
the photoelectric effect and Compton scat-
tering. The photoelectric effect is responsi-
ble for the largest part of the attenuation and
depends on the energy of the x-ray beam and
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on the atomic number (Z) of the material. In
materials with a higher atomic number, the
photoelectric effect prevails, whereas in ma-
terials with a lower atomic number, Comp-
ton scatter occurs most. Thus the higher the
atomic number, the greater is the photoelec-
tric effect and the greater is the attenuation
of the x-ray beam [25]. When the photon en-
ergy exceeds the binding energy of the K-
shell electron of the material, the attenuation
coefficient suddenly increases in an effect
called K edge.
The closer the energy level of the x-ray
beam is to the K edge of a substance such as
iodine, the more the beam attenuates. Thus
the energy dependency of the photoelectric
effect and the variability of K edges form
the basis of DECT and can be used to detect
substances such as iodine and calcium [26].
DECT can be used for material differentia-
tion based on atomic number. Differences be-
tween the K edge of iodine and that of calci-
um are used in the bone removal algorithm in
CTA. In comparison with calcium (Z = 20),
iodine has a higher atomic number (Z = 53)
and therefore a greater K edge.
Material quantification allows reconstruc-
tion of virtual unenhanced images in which
the iodine content is subtracted from the con-
trast-enhanced images [27]. In three-material
decomposition, concentrations of the ele-
ments in the brain can be determined. Iodine
has a high atomic number, whereas most
other tissues in the brain consist of elements
with a low atomic number. When two ma-
terials with low atomic numbers (e.g., brain
parenchyma and blood) and different attenu-
ation in a single energy spectrum are placed
in a diagram with one material with a high
atomic number (iodine), the algorithm can
decompose a single voxel in a mixture of
these three elements, and it becomes possible
to calculate the contributions of iodine and
the tissue to the attenuation of the voxel (Fig.
1). This algorithm thus allows identification
and its quantification of the element with the
higher atomic number (iodine) [20, 28].
Applications in Intracranial Vessels
The standard of reference for the evaluation
of intracranial and transcranial blood vessels
is digital subtraction angiography (DSA), 3D
AJR:199, November 2012 S27
DSA being the actual reference standard. Over
the last decade, CTA has gained its place in
evaluation of stenosis and aneurysm detection
[29, 30]. Improvements in MDCT, including
shorter scanning times, led to improved arterial
phase imaging without interfering with venous
contrast enhancement. Moreover, bone sub-
traction techniques such as matched mask bone
elimination were developed to improve delin-
eation of vasculature adjacent to bony struc-
tures, such as the skull base [31–33]. The lim-
itations of these bone removal techniques are
possible misregistration due to patient motion
between and during the enhanced and the un-
enhanced acquisitions. In addition, the require-
ment for double scanning increases the radia-
tion dose. Postprocessing is not automatic and
is user dependent, making it time-consuming
and difficult to standardize. These problems ne-
cessitate multiplanar reformation and addition-
al postprocessing to avoid misdiagnosis.
With the development of DECT, material
differentiation becomes feasible, and the two
consecutive scans can be replaced by one
scan. Use of this technique reduces the radi-
ation dose, eliminates possible misregistra-
tion artifacts, and saves postprocessing time.
There have been few studies evaluating
DECT angiography of cranial and transcra-
nial vessels. To the best of our knowledge, all
have been based on first-generation DECT.
Ma et al. [34] assessed the feasibility of du-
al-energy bone subtraction in cranial CTA in
a phantom model and in imaging of 36 pa-
tients. They focused on image quality, time
consumption, and radiation dose. Conven-
tional CTA was used as the standard of ref-
erence. The investigators concluded that the
postprocessing time and reading time with
Fig. 1—Diagram shows
that when two materials
with low atomic
numbers, such as brain
parenchyma and blood
from hemorrhage, and
Tube A Low Kilovoltage
different attenuation in
single energy spectrum
are placed in diagram
with one material with
high atomic number, for
example, iodine, algorithm
can decompose single
voxel (mixed) in mixture
of these three elements.
It then becomes possible
to calculate contribution
of iodine and tissue to
attenuation of this mixed
voxel. (Modified with
permission from Kim et
al. [21])
dual-energy bone removal were shorter.
They noticed better vessel delineation at the
skull base but similar vessel visualization of
the intracranial vessels. They found that cal-
cified plaques could be differentiated from
the lumen and were automatically removed
in dual-energy bone removal.
Mühlenbruch et al. [35] investigated the
carotid and intracranial vessels in 16 patients
with symptomatic carotid artery stenosis.
They concluded that dual-energy CTA for
extracranial vessels was as good as MR angi-
ography (MRA) but yielded additional mor-
phologic information, for example, on calci-
fications. The investigators found, however,
that smaller intracranial arteries were better
depicted with 3-T MRA.
Hegde et al. [36] found that DECT angi-
ography was a robust and efficient technique
in their clinical practice. They found 30–50%
radiation dose reduction compared with sin-
gle-energy CTA on the same scanner while
still generating images of diagnostic qual-
ity. Maximum-intensity-projection images
obtained with dual-energy software allowed
a quick overview for detection of stenosis
and aneurysms. However, the techniques
were prone to pitfalls in false-positive an-
eurysm detection due to infundibuli and ve-
nous enhancement, as is in digital subtrac-
tion CTA. Stenoses tended to be overrated in
DECT angiography. Hegde et al. concluded
that the source images (mixed 140/80 kV)
and triplanar reconstructions should be used
to confirm pathologic findings. With DECT
angiography, misregistration artifacts due to
patient motion between the unenhanced and
enhanced phases of CTA cannot happen. The
investigators noticed that most surgical clips
Iodine
Mixed
el
ox
tv
en
nt
co
Hemorrhage
ne
di
Io
Hemorrhage content voxel
Parenchyma content voxel
Brain parenchyma
Tube B High Kilovoltage

were eliminated during DECT angiography
subtraction, as in subtraction CTA. However,
a few clips remained intact during bone re-
moval subtraction. As in conventional CTA,
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S28 AJR:199, November 2012
Postma et al.
beam-hardening artifacts around metallic ob-
jects can hinder depiction of nearby vessels.
Buerke et al. [37] performed DECT angi-
ography with a DSCT scanner for 50 patients
with suspected cerebrovascular disease and
compared the degree of stenosis found with
DECT angiography and that found with time-
of-flight MRA and conventional CTA in trans­
cranial arteries. They found that the conven-
tional CTA and time-of-flight MRA findings
were similar. However, with bone removal
DECT angiography, stenosis in close relation
to the skull base was overestimated, specif-
ically in the carotid canal (C2 segment), as
was calcified stenosis. This finding is partly
explained by the generation of blooming ar-
tifacts from the calcified plaques. These ar-
tifacts cause ill-defined borders, the conse-
quence of which is overestimation of stenosis.
Buerke et al. concluded that in DECT angiog-
raphy there is a risk of a false-positive finding
of stenosis in cases of close relation to bone or
calcification. They suggested that optimization
Fig. 2—55-year-old previously healthy woman with
confusion and drowsiness, left-sided hemorrhagic
lesion at brainstem, and obstructive hydrocephalus.
(All dual-source CT [DSCT] scans in this review
obtained with second-generation scanner [Somatom
Definition Flash, Siemens Healthcare]: tube A,
80 kV and 310 mAs; tube B, 140 kV and 155 mAs;
acquisition, 32 × 0.6 mm; collimation, 0.6 mm; pitch,
0.7; reconstruction slice thickness, 1 mm; increment,
0.7; D26 kernel; contrast administration of 110 mL
iopromide 300 [Ultravist, Bayer Schering Pharma]
with dual-head injector [Stellant, Medrad] at flow
rate of 7 mL/s followed by 50-mL saline flush at
same rate.) Lesion at mesencephalon at thinner
reconstructions is less pronounced compared with
true native image (B), having increased noise, but
is still of diagnostic quality at lower dose. Virtual
unenhanced image (F) shows residual attenuation in
veins, whereas enhancement from arterial vessels is
removed. With half dose of true native scan (effective
dose, 2.48 mSv), single dual-energy CT (DECT)
angiography (effective dose 0.97 mSv) provides
information about brain parenchyma, lesion, and
vessels with possibility of bone removal.
A, Single-energy reconstructions from circle of Willis
show that at lower reconstructed kilovoltage, there
is increased attenuation of vessels accompanied
by increase in noise. At higher reconstructed
kilovoltage, vessels nearly disappear. Conspicuity
of hemorrhagic lesion does not change in range of
60–150 kV. At lowest kilovoltage, decreased visibility
is probably due to noise.
B, True native CT image from referring hospital with
6-mm slice thickness shows high-attenuation lesion
at posterior left mesencephalon with obstructive
hydrocephalus. DECT angiography was performed to
identify underlying vascular pathologic mechanism.
C, DECT angiographic reconstruction of mixed image
with head kernel, 3-mm slice.
D, DECT angiographic reconstruction of mixed image
with soft head kernel, 3-mm slice.
E, Bone removal DECT angiographic reconstruction.
F, Virtual unenhanced DECT angiographic
reconstruction, 3-mm slice.
G, T2-weighted MR image shows hypointense
blooming at mesencephalon. Lesion was suspected
of being cavernoma.
 Dual-Energy CT of the Brain and Intracranial Vessels
of demarcation algorithms and reconstruction
kernels could resolve this problem.
Watanabe et al. [38] compared DECT an-
giography and DSA of 12 patients with intra-
cranial aneurysms or internal carotid artery
stenosis. They concluded that DECT angi-
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ography was successful for evaluation of an-
eurysms and internal carotid artery stenosis
with a short calculation time and was com-
parable to DSA. They found that three aneu-
rysms near the skull base were fully visible
with DECT angiography but that only partial
visualization was achieved with convention-
al CTA. The stenoses tended to be overesti-
mated with bone removal DECT angiogra-
phy compared with DSA, partially because
of the aforementioned blooming effect of
calcifications. Watanabe et al. concluded that
dual-energy bone removal CTA eliminated
bone and calcifications from CTA images
with only a single contrast-enhanced acqui-
sition and was a useful tool for evaluating in-
tracranial aneurysms and stenosis.
Zhang et al. [39, 40] published two articles
concentrating on detection of aneurysms in a
group of 80 patients. They compared DECT
angiography and digital subtraction CTA with
3D DSA and evaluated image quality, ra-
diation dose, and the diagnostic accuracy of
DECT angiography in the detection of intra-
cranial aneurysms. The image quality of the
AJR:199, November 2012 S29
Fig. 3—80-year-old man with dysarthria and right-sided paralysis but no stenosis or occlusion of middle
cerebral artery. Example of bone removal dual-energy CT (DECT) angiography without removal of calcified
plaques.
A, DECT angiographic source image shows carotid arteries at cavernous sinus and calcified plaque at left
carotid artery.
B, Bone removal CT image shows that although bone has been removed, calcified plaque is still visible.
C, Volume-rendered bone removal DECT angiogram shows calcifications along carotid artery. Irregularities at
right-sided carotid artery suggest overestimation of bone of skull base.
DECT angiography was not statistically dif- tivity, 95.7%; specificity, 95%; positive pre-
ferent from that of digital subtraction CTA, dictive value, 97.8%; negative predictive val-
although the quality of vessel depiction near ue, 90.5%; accuracy, 95.5%) compared with
the skull base seemed to decrease. This simi- the results for 3D DSA and not statistically
lar quality was conceived at a lower radiation different from those for conventional CTA.
dose with DECT angiography, being reduced As expected, these numbers increased in the
60% compared with the quality of digital sub- detection of aneurysms larger than 5 mm (all
traction CTA. These investigators found high values, 100%). The authors concluded that
sensitivity and specificity in the detection of DECT angiography is comparable to conven-
intracranial aneurysms (per-aneurysm sensi- tional CTA in the detection of intracranial an-
eurysms but at lower radiation cost.
With postprocessing of DECT angiogra-
phy, next to bone removal, single-energy im-
ages can be generated for better delineation
of the iodine content in a vessel because at
lower kilovoltage, iodine attenuation is high-
er than at higher kilovoltage (Fig. 2A). This
feature can be useful in CTA with lower dos-
es of contrast material [24]. To our knowl-
edge, no results concerning these applica-
tions have been published.
Fig. 4—72-year-old man with subarachnoid
hemorrhage due to ruptured aneurysm of anterior
communicating artery (ACoA). Surgical treatment
with clipping of aneurysm was performed. Dual-
energy CT (DECT) angiography was performed for
evaluation of treated aneurysm.
A, Source images at level of skull base show calcified
plaque at left-sided carotid artery.
B, Bone removal DECT angiogram, including plaque
removal, shows overestimation of calcified plaques at
both carotid arteries due to blooming of calcification.
C, Volume-rendered non–bone removal CT angiogram
shows presence of clip at ACoA.
D, Volume-rendered bone removal CT angiogram
clearly shows position of aneurysm clip at ACoA and
allows 360° inspection of region. Irregular borders of
carotid arteries are signs of excess removal of bone.
 Postma et al.

dual-energy scan, as when a patient presents

with subarachnoid hemorrhage, unenhanced
CT can be omitted because of the possibility
of calculating a virtual unenhanced image. A
third application is identification of iodine in
an area of hemorrhage because it can be a clue
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to an underlying pathologic condition in pa-

tients with intracranial hemorrhage.
Hemorrhagic transformation is one of the
major complications after intraarterial re-
canalization in stroke patients. Identification
of hemorrhage after intraarterial recanaliza-
tion therefore is important, but it is difficult
with conventional CT, as found by Kim et al.
[41]. Some authors [42, 43] have advocated
measuring attenuation to predict hemorrhag-
ic transformation. The higher the attenuation
of lesions at conventional CT immediately
after intraarterial recanalization, the great-
er is the probability of hemorrhagic transfor-
mation at follow-up. Yoon et al. [43] found
that areas with attenuation greater than 90
HU may be associated with parenchymal
hemorrhage. However, predicting hemor-
rhagic foci or hemorrhagic transformation
Fig. 5—53-year-old woman with sudden onset of headache due to subarachnoid hemorrhage.
A, True native CT image shows subarachnoid hemorrhage in basal cisterns. Mild hydrocephalus with dilated solely based on attenuation is nearly impos-
temporal horns is evident. sible [41]. DECT has been introduced for dif-
B, Bone removal dual-energy CT (DECT) angiogram shows small aneurysm of anterior communicating artery ferentiation of contrast material and blood in
(ACoA).
C, Volume-rendered bone removal DECT angiogram shows small aneurysm of ACoA and irregularity of carotid the brain [20, 22, 23].
arteries at segments at level of skull base suggestive of overestimation of surrounding bone. Gupta et al. [22] analyzed 28 intraparen-
D, Virtual unenhanced image reconstructed from DECT angiogram shows subarachnoid hemorrhage in basal chymal areas of high attenuation at CT af-
cisterns at slightly increased noise level compared with A.
E, Iodine overlay image shows enhancing vessels without density of surrounding hemorrhage.
ter administration of an iodinated contrast
F, Volume-rendered 3D digital subtraction angiogram shows ACoA aneurysm with exact outlines and agent to 15 patients. Twelve of these pa-
relationship to parent vessel. tients received the contrast agent soon after
they underwent intraarterial recanalization,
In summary, studies have shown good im- there being some benefit for DECT angiog- one patient after carotid stent placement,
age quality for DECT angiography of intra- raphy in the detection of aneurysms adjacent and two for further evaluation of intracra-
cranial vessels, but imaging of arteries at the to the skull base (Fig. 5). A major advantage nial hemorrhage. Twenty lesions were clas-
level of the skull base remains problemat- of DECT angiography is the substantial radi- sified at DECT as contrast material, five as
ic for selective visualization and is prone to ation dose reduction compared with the dose blood, and three as both contrast material
overestimation of the grade of stenosis. Cal- for conventional (subtraction) CTA. This fac- and blood. The sensitivity for identification
cified plaques can also cause problems in tor is especially important with the increasing of hemorrhage, compared with 24-hour fol-
grading of stenosis. Dual-energy software, awareness of radiation burden. low-up CT, was 100%, the specificity was
however, has the advantage of allowing op- 91%, and the accuracy was 93%.
tional subtraction of calcified plaques and Applications in the Brain Phan et al. [23] reported on the use of
thus optimal assessment of the vascular lu- Next to bone removal algorithms, differ- DECT in a group of 40 patients. Eighteen of
men (Figs. 3 and 4). entiation between blood present from hemor- the patients had undergone intraarterial recan-
The dual-energy software allows fast pro- rhage and iodine is a potential application of alization, and the others were evaluated for
cessing in the way that maximum-intensity- DECT (Figs. 2B–2G, 6, and 7). Whereas in carotid stenosis, trauma, or tumors. The in-
projection reconstructions of the vessels allow conventional CT, iodine and blood typically vestigators evaluated a total of 148 foci of in-
quick overview and identification of segments have similar attenuation, these substances can tracranial high attenuation. Of these, 142 foci
with possible stenosis. As in conventional be differentiated with dual-energy algorithms. were correctly classified as hemorrhage with
(subtraction) CTA, the source images should This capability can be useful for imaging of DECT and confirmed with follow-up CT or
by all means be taken into account with mul- patients who have received iodinated contrast MRI. The sensitivity, specificity, and accura-
tiplanar reformation and volume-rendered re- material before admission for CT, such as pa- cy in identification of hemorrhage, depending
construction as additional options. tients who have undergone coronary angiog- on the parenchymal, intraventricular, or sub-
Detection of aneurysms with DECT angi- raphy or intraarterial recanalization. For im- arachnoid compartment, were 100%, 84.4–
ography is as good as with conventional CTA, mediate acquisition of a contrast-enhanced 100%, and 87.2–100%.

S30 AJR:199, November 2012

 Dual-Energy CT of the Brain and Intracranial Vessels

Ferda et al. [20] assessed the use of DECT
angiography in the detection of intracranial
hemorrhage on the virtual unenhanced images
of 25 patients with subarachnoid hemorrhage
diagnosed on the basis of the finding of intra-
cranial bleeding on unenhanced CT images.
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includes virtual unenhanced reconstruction,
radiation burden to the patient can be reduced
and diagnostic efficacy retained.
Analysis of the underlying pathologic mech-
anism in patients with intracranial hemor-
rhage is performed with contrast-­enhanced
nial hemorrhage without a definite underlying
cause. They calculated virtual unenhanced im-
ages, iodine overlay images, and fusion imag-
es (Fig. 8). The sensitivity and specificity for
the detection of underlying brain tumor were
94.4% and 97.4%. These values are signifi-

They rated the quality of the virtual unenhanced
images as excellent for 13 patients and suffi-
cient for 12 patients. Although the image qual-
ity was slightly lower than that of conventional
CT, all images were of diagnostic quality. The
agreement between virtual unenhanced images
and conventional CT images in the detection of
intracranial hemorrhage was 96% in per-lesion
and 100% in per-patient analysis. The investi-
gators concluded that by replacing convention-
al CT and CTA with DECT angiography that
CT or MRI. Both techniques have limita-
tions. The high signal intensity of areas of
hemorrhage on T1-weighted MR images
makes it difficult to differentiate blood from
gadolinium contrast material. On CT imag-
es, hematomas and areas of iodine enhance-
ment have high attenuation.
Kim et al. [21] used DECT in the evaluation
of intracerebral hemorrhage of unknown origin.
They used arterial and venous phase DECT to
analyze the cases of 56 patients with intracra-
cantly higher than for conventional unenhanced
imaging (66.7%, 89.7%) and combined con-
trast-enhanced and conventional unenhanced
imaging (61.1%, 92.3%). The areas under the
receiver operating characteristic curves were
0.964, 0.786, and 0.842. Image noise was high-
er on virtual unenhanced images than on true
unenhanced images, with lower attenuation of
the hematomas, but was not rated differently at
visual assessment. All hematomas were identi-
fied on virtual unenhanced images.

Fig. 6—44-year-old man with right-sided paralysis due to occlusion of left middle
cerebral artery. Dual-energy CT was performed immediately after successful
intraarterial thrombectomy of left middle cerebral artery.
A, Mixed image (comparable to conventional CT image) shows area of high
attenuation in lentiform nucleus.
B, Iodine overlay image suggests high attenuation is caused by iodinated contrast
material. Calcifications, in this case calcification of choroid plexus, are visible on
iodine overlay images.
C, Virtual unenhanced image shows absence of attenuation, with lower
attenuation in lentiform nucleus, suggestive of ischemia without hemorrhagic
focus.
D, Follow-up conventional CT image 24 hours after A–C confirms absence of
hemorrhage and presence of small infarct.
Fig. 7—63-year-old man found unresponsive with dilated pupils and referred
to hospital. CT angiography showed basilar artery occlusion, and patient was
transferred to intervention unit. Immediately after successful recanalization, dual-
energy CT was performed.
A, Mixed image (comparable to conventional CT) shows bilateral areas of high
attenuation in medial thalami corresponding to distribution area of artery of
Percheron.
B, Iodine overlay image suggests area of high attenuation is iodinated contrast
material. Pineal gland calcification also is evident.
C, Virtual unenhanced image suggests absence of hemorrhage.
D, Follow-up conventional CT image 24 hours after A–C shows small left-
sided hemorrhagic focus in bilateral thalamic infarcts just lateral to area of
enhancement on first scan, suggestive of hemorrhagic transformation.

AJR:199, November 2012 S31

 Postma et al.

Fig. 8—42-year-old previously healthy man who had

transient dysphasia at referring hospital.
A, True native CT scan shows high-attenuation lesion
with small surrounding border of low attenuation.
B, T2-weighted MR image shows susceptibility
artifacts in and around lesion.
C and D, T1-weighted images without (C) and with
(D) gadolinium enhancement do not show underlying
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enhancing pathologic features. Cavernoma was

suspected because of demographic features and
absence of visible lesion. DECT angiography was
offered when patient arrived at our hospital.
E–H, Reconstructed mixed (E), virtual unenhanced
(F), iodine overlay (G), and volume-rendered bone
removal (H) CT angiograms 2 weeks after initial
presentation show increasing surrounding edema
and partially resolving hematoma in E and F. Small
focus of enhancement is evident at lateral side of
lesion without obvious vessel abnormality.
I–L, Reconstructed mixed (I), virtual unenhanced
(J), iodine overlay (K), and fusion images (virtual
unenhanced and iodine overlay) (L) DECT images
obtained at 90 seconds show ring-enhancing lesion
with signet ring appearance. Underlying malignancy
was expected. At workup, melanoma of foot was
found and was considered primary tumor. Arterial
and late phase virtual unenhanced images show
comparable density of resorbing blood. Dose for
dual-energy CT (DECT) angiography and late DECT
together was estimated to be 2.27 mSv, slightly
higher than for conventional CT (2.2 mSv) but with
increased amount of information. DECT in venous
phase with single-energy reconstruction of arterial
vessels might have eliminated need for DECT
angiography, further reducing dose.

Kim et al. [21] concluded that DECT with
CTA seems an ideal tool in the evaluation
of patients with intracranial hemorrhage in
the acute stage. Through DECT angiograph-
ic bone removal evaluation of the vessels and
calculation of virtual unenhanced images, io-
dine overlay and fusion images for tumor eval-
uation can be obtained from the same source
images. Kim et al. suggest replacing true un-
enhanced CT of patients with known intracra-
nial hemorrhage with virtual unenhanced CT
to reduce the radiation dose. In their patient
group, the dose for DECT was 1 mSv, compa-
rable to that of conventional CTA.
The results of these studies suggest a useful
contribution of DECT for both the detection
of hemorrhage with contrast-enhanced CT and
for the detection of the underlying pathologic
condition. Use of DECT may resolve impor-
tant diagnostic problems in neuroradiology.
Conclusion
Although DECT of the brain and intracra-
nial vessels has not been widely implemented
and studied, it has great potential in neurora-
diology. Bone removal in DECT angiography
allows easier and faster acquisition and post-
processing compared with conventional (sub-
traction) CTA. Removal of bone at the skull
base remains a matter of concern, but the de-
velopment of better reconstruction algorithms
and dedicated dual-energy kernels may offer a
solution. Detection and follow-up of treated
aneurysms are reliable. The role of DECT in
detection of hemorrhage on contrast-enhanced
CT scans and analysis of the underlying patho-
logic mechanism of hematomas is promising.
Instead of waiting for resolution of the hemato-
ma, early diagnosis of the underlying patholog-
ic changes may be possible, and treatment can
be started earlier. In stroke patients, early dif-
ferentiation between iodine and blood allows
identification of the risk of hemorrhagic trans-
formation and gives further insight into this
phenomenon. The low radiation dose in DECT
and the large range of possible reconstructions
from one dataset justify further investigation of
DECT in neuroradiology and the development
of dedicated algorithms. If DECT is available
at a hospital, the use of this technique should
be expanded, not only for cardiac, skeletal, ab-
dominal, and thoracic applications but also for
neuroradiologic practice, because it may play
an important role in solving diagnostic chal-
lenges in neuroradiology.
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