State of the art in abdominal CT: The limits of iterative reconstruction algorithms

The development and widespread adoption of iterative reconstruction (IR) algorithms for CT have greatly facilitated the contemporary practice of radiation dose reduction during abdominal CT examinations. IR mitigates the increased image noise typically associated with reduced radiation dose levels, thereby maintaining subjective image quality and diagnostic confidence for a variety of clinical tasks. Mounting evidence, however, points to important limitations of this method involving radiologists' ability to perform low-contrast diagnostic tasks, such as the detection of liver metastases or pancreatic masses. Radiologists need to be aware that use of IR can result in a decline of spatial resolution for low-contrast structures and degradation of low-contrast detectability when radiation dose reductions exceed approximately 25%. This article will review the principles of IR algorithm technology, describe the various commercial implementations of IR in CT, and review published studies that have evaluated the ability of IR to preserve diagnostic performance for low-contrast diagnostic tasks. In addition, future developments in CT noise reduction techniques and methods to rigorously evaluate their diagnostic performance will be discussed.