Dual-energy and photon-counting computed tomography in critical care

Dual-energy computed tomography (DECT) acquires images at two X-ray energy levels, enabling material differentiation beyond conventional single-energy CT. DECT generates iodine maps, virtual non-contrast images, and other reconstructions that enhance diagnostic performance while reducing contrast dose and radiation exposure. These advantages are particularly relevant for critically ill patients, where accurate and rapid imaging with reduced contrast exposure can be organ or life saving. This review summarizes current evidence on DECT in critical care. In pulmonary embolism, DECT provides anatomical and functional assessment through iodine perfusion maps, improving detection of segmental and subsegmental emboli. In post-thrombectomy intracerebral hemorrhage, DECT can distinguish true hemorrhage from post-procedural contrast staining. In acute abdominal pathology, DECT can improve visualization of ischemia, inflammation, infection, and hemorrhage. In urolithiasis, DECT can identify uric acid stone composition, informing treatment selection. In aortic imaging, DECT may improve diagnostic confidence while enabling iodine dose reduction and substitution of true non-contrast scans with virtual alternatives. In musculoskeletal imaging, DECT accurately detects bone marrow edema, potentially reducing the need for magnetic resonance imaging when access is limited. DECT also has applications in tendon and ligament injury, and metal artifact reduction. Across these scenarios, DECT offers advantages over conventional CT in critical care, including material differentiation, functional assessment, and potential reductions in contrast dose and radiation exposure. It generally demonstrates high specificity and variable sensitivity, with the level of supporting evidence varying by indication, ranging from meta-analyses to small retrospective studies. Wider adoption will require standardized protocols, targeted training, and additional high-quality studies.