Noise reduction and motion elimination in low-dose 4D myocardial computed tomography perfusion (CTP): preliminary clinical evaluation of the ASTRA4D algorithm

To propose and evaluate a four-dimensional (4D) algorithm for joint motion elimination and spatiotemporal noise reduction in low-dose dynamic myocardial computed tomography perfusion (CTP). Thirty patients with suspected or confirmed coronary artery disease were prospectively included and underwent dynamic contrast-enhanced 320-row CTP. A novel deformable image registration method based on the principal component analysis (PCA) of the ante hoc temporally smoothed voxel-wise time-attenuation curves (ASTRA4D) is presented. Quantitative (standard deviation, signal-to-noise ratio (SNR), temporal variation, volumetric deformation) and qualitative (motion, contrast, contour sharpness [1, poor; 5, excellent]) measures of CTP quality were assessed for the original and motion-compensated sequences (without and with temporal filtering, PCA/ASTRA4D). Following myocardial perfusion deficit detection by two readers, diagnostic accuracy was evaluated using magnetic resonance myocardial perfusion imaging (MR-MPI) as the reference standard in 15 patients. Registration using ASTRA4D was successful in all 30 patients and resulted in comparison with the benchmark PCA in significantly (p < 0.001) reduced noise over time (− 83%, 178.5 vs 29.9) and spatially (− 34%, 21.4 vs 14.1) as well as improved SNR (+ 47%, 3.6 vs 5.3) and subjective image quality (motion, contrast, contour sharpness [+ 1.0, + 1.0, + 0.5]). ASTRA4D had significantly improved per-segment sensitivity of 91% (58/64) and similar specificity of 96% (429/446) compared with PCA (52%, 33/64; 98%, 435/446; p = 0.011) in the visual detection of perfusion deficits. The ASTRA4D registration algorithm improved the spatiotemporal noise profile and CTP sequence image quality, resulting in significantly improved sensitivity of 4D CTP in the detection of myocardial ischemia. • ASTRA4D combines local temporal regression and deformable image registration. • Quantitative and qualitative measures of CTP quality are improved compared to PCA. • Improved spatiotemporal differentiation of ischemic regions leads to an excellent perfusion deficit concordance of ASTRA4D with MRI.