Dual energy CT in acute appendicitis: value of low mono-energy

Objectives: To assess the potential role of low monoenergetic images in the evaluation of acute appendicitis. Methods: A retrospective study of 42 patients with pathology proven acute appendicitis underwent contrast-enhanced-CT conducted on a single-source-DECT before surgery. Attenuation, SNR, and CNR were calculated on both monoenergetic and conventional images and compared to 24 abdominal CT-scans with normal appendix. Representative conventional and monoenergetic images were randomized and presented side-by-side to three abdominal radiologists to determine preferred images for detecting inflammation. Additionally, six individual acute inflammatory characteristics were graded on a 1–5 scale to determine factors contributing to differences between conventional and monoenergetic images by 2 abdominal radiologists. Paired t-tests, Wilcoxon and McNemar tests, and intra-observer error statistics were performed. Results: For the inflamed appendixes monoenergetic images had overall increased attenuation (average ratio 1.7; P < 0.05), signal-to-noise-ratio (6.7 ± 3.1 vs 4.2 ± 1.6; P < 0.001) and contrast-to-noise-ratio (12.1 ± 3 vs 9 ± 2.1; P < 0.001). Moreover, this increase was not found in normal appendixes (P < 0.001 vs p = 0.28–0.44). Subjectively, radiologists showed significant preferences towards monoenergetic images (P < 0.001), with inter-reader agreement of 0.84. Two parameters, diffuse bowel wall and mucosal enhancement, received significantly higher scores on monoenergetic images (average 4.3 vs. 3.0; P < 0.001 and 2.8 vs. 2.3 P < 0.03 respectively, with interobserver agreements of 62% and 52%). Conclusion: Increased bowel wall conspicuity from enhanced attenuation, SNR, and CNR on low monenergetic CT images results in a significant preference by radiologists for these images when assessing acute inflamed appendixes. Thus, close inspection of low monoenergetic images may improve the visualization of acute inflammatory bowel processes.