Optimization of carotid CT angiography image quality with deep learning image reconstruction with high setting (DLIR-H) algorithm under ultra-low radiation and contrast agent conditions.

Introduction: Carotid artery disease is a major cause of stroke and is frequently evaluated using Carotid CT Angiography (CTA). However, the associated radiation exposure and contrast agent use raise concerns, particularly for high-risk patients. Recent advances in Deep Learning Image Reconstruction (DLIR) offer new potential to enhance image quality under low-dose conditions. This study aimed to evaluate the effectiveness of the DLIR-H algorithm in improving image quality of 40 keV Virtual Monoenergetic Images (VMI) in dual-energy CTA (DE-CTA) while minimizing radiation dose and contrast agent usage.

Methods: A total of 120 patients undergoing DE-CTA were prospectively divided into four groups: one control group using ASIR-V and three experimental groups using DLIR-L, DLIR-M, and DLIR-H algorithms. All scans employed a "triple-low" protocol-low radiation, low contrast volume, and low injection rate. Objective image quality was assessed via CT values, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). Subjective image quality was evaluated using a 5-point Likert scale.

Results: The DLIR-H group showed the greatest improvements in image quality, with significantly reduced noise and increased SNR and CNR, particularly at complex vascular sites such as the carotid bifurcation and internal carotid artery. Radiation dose and contrast volume were reduced by 15.6 % and 17.5 %, respectively. DLIR-H also received the highest subjective image quality scores.

Conclusion: DLIR-H significantly enhances DE-CTA image quality under ultra-low-dose conditions, preserving diagnostic detail while reducing patient risk.

Implications For Practitioners: DLIR-H supports safer and more effective carotid imaging, especially for high-risk groups like renal-impaired patients and those needing repeated scans, enabling wider clinical use of ultra-low-dose protocols.