Optimization of Posterior Fossa Image Quality Using Virtual Monoenergetic Reconstructions from Dual-Layer Spectral CT

Background/Objectives: Beam-hardening artifacts from the skull base reduce image quality in routine non-contrast head CT, particularly in the posterior fossa. Virtual monoenergetic images (VMIs) reconstructed from dual-layer spectral CT have been shown to reduce these artifacts, but previous studies have generally been limited by small cohorts or evaluation of only a limited range of monoenergetic reconstructions. The aim of this study was to comprehensively evaluate image quality and posterior fossa artifact reduction across the monoenergetic spectrum in a large cohort of normal head CT examinations. Methods: Consecutive adult patients undergoing non-contrast head CT on a dual-layer spectral CT system were retrospectively included if no intracranial pathology was identified on clinical interpretation. Regions of interest were placed in predefined posterior fossa and supratentorial locations in conventional images and automatically propagated to VMIs reconstructed from 40 to 200 keV. Image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), attenuation, and a posterior fossa artifact index were quantified. Two neuroradiologists independently performed qualitative image quality assessment. Results: A total of 188 examinations were included in the quantitative analysis and 40 in the qualitative assessment. Compared with conventional images, VMIs reconstructed at ≥50 keV demonstrated significantly reduced image noise in the posterior fossa together with a higher SNR, while the CNR was improved between 40 and 80 keV. Qualitative assessment likewise demonstrated superior overall image quality and reduced artifact severity, with the highest ratings generally obtained for reconstructions around 60 keV. Improvements became marginal above approximately 80 keV. Conclusions: Virtual monoenergetic reconstructions from dual-layer spectral CT improve posterior fossa image quality by reducing beam-hardening artifacts while maintaining favorable image noise and tissue contrast. Intermediate-energy reconstructions (approximately 50–70 keV) provide the most favorable balance between beam-hardening artifact reduction, image noise, and tissue contrast, supporting their use as an image optimization strategy for non-contrast head CT. Whether these technical improvements translate into improved diagnostic performance should be evaluated in future studies including patients with posterior fossa pathology.