Ultra-Low-Dose Photon-counting Detector CT for Emphysema Assessment: A Head-to-Head Comparative Study with Low-Dose...

Background Reducing the radiation dose without compromising image quality or diagnostic accuracy is essential for repeat CT monitoring in emphysema. Purpose To evaluate the accuracy of ultra-low-dose (ULD) photon-counting CT (PCCT) for both visually and quantitatively assessing emphysema, and to compare this accuracy with that of low-dose (LD) PCCT. Materials and Methods Participants with emphysema who underwent same-day LD and ULD PCCT between November 2024 and February 2025 were prospectively included. Two radiologists independently evaluated the image quality parameters (overall image quality, sharpness, artifacts, and noise) and visually assessed emphysema (subtype and severity). Automated emphysema quantification was performed using low-attenuation volume (LAV) analysis. For centrilobular emphysema (CLE), automated LAV measurements were converted to severity grades and compared with visual severity grades. Paired t tests, Cohen κ analysis, and intraclass correlation coefficients were used to evaluate differences and agreement in findings at LD and ULD PCCT. Results In 152 participants (median age, 68 years [IQR, 60-72 years]; 139 male participants), the ULD protocol reduced radiation exposure by 87% compared with the LD protocol (mean effective dose, 0.20 mSv ± 0.03 [SD] vs 1.58 mSv ± 0.39; P < .001). There was no evidence of a difference between the two protocols in overall image quality (median score, 4 [IQR, 4-5] for both; P = .16), sharpness (median score, 4 [IQR, 4-5] for both; P = .08), or artifacts (median score, 4 [IQR, 3-4] for both; P = .39), but ULD images had lower noise scores (ie, more noise) than LD images (median score, 3 [IQR, 3-3] vs 4 [IQR, 4-4]; P < .001). There was excellent agreement between the two protocols for grading of visual CLE severity (weighted κ = 0.98) and paraseptal emphysema severity (κ = 0.96). The two protocols exhibited excellent agreement in LAV measurements across the lungs and for individual lung lobes (intraclass correlation coefficient range, 0.96-0.98). Visual CLE severity grades demonstrated good agreement with LAV measurements for both the LD (weighted κ = 0.73) and ULD (weighted κ = 0.75) protocols. Conclusion PCCT enables accurate visual and automated assessments of emphysema at a radiation dose equivalent to that of two chest radiographs without compromising image quality. © RSNA, 2026 Supplemental material is available for this article.