Combining iterative metal artifact reduction and virtual monoenergetic images severely reduces hip prosthesis-associated artifacts in photon-counting detector CT

Aim of this study was to assess the impact of virtual monoenergetic images (VMI) in combination and comparison with iterative metal artifact reduction (IMAR) on hip prosthesis-associated artifacts in photon-counting detector CT (PCD-CT). Retrospectively, 33 scans with hip prosthesis-associated artifacts acquired during clinical routine on a PCD-CT between 08/2022 and 09/2022 were analyzed. VMI were reconstructed for 100–190 keV with and without IMAR, and compared to polychromatic images. Qualitatively, artifact extent and assessment of adjacent soft tissue were rated by two radiologists using 5-point Likert items. Quantitative assessment was performed measuring attenuation and standard deviation in most pronounced hypodense and hyperdense artifacts, artifact-impaired bone, muscle, vessels, bladder and artifact-free corresponding tissue. To quantify artifacts, an adjusted attenuation was calculated as the difference between artifact-impaired tissue and corresponding tissue without artifacts. Qualitative assessment improved for all investigated image reconstructions compared to polychromatic images (PI). VMI(100keV) in combination with IMAR achieved best results (e.g. diagnostic quality of the bladder: median PI: 1.5 (range 1–4); VMI(100keV+IMAR): 5 (3–5); p < 0.0001). In quantitative assessment VMI(100keV) with IMAR provided best artifact reduction with an adjusted attenuation closest to 0 (e.g. bone: PI: 302.78; VMI(100keV+IMAR): 51.18; p < 0.0001). The combination of VMI and IMAR significantly reduces hip prosthesis-associated artifacts in PCD-CT and improves the diagnostic quality of surrounding tissue.