Mobile C-Arm with a CMOS detector: Technical assessment of fluoroscopy and Cone-Beam CT imaging performance

Purpose: Indirect-detection CMOS flat-panel detectors (FPDs) offer fine pixel pitch, fast readout, and low electronic noise in comparison to current a-Si:H FPDs. This work investigates the extent to which these potential advantages affect imaging performance in mobile C-arm fluoroscopy and cone-beam CT (CBCT). Methods: FPDs based on CMOS (Xineos 3030HS, 0.151 mm pixel pitch) or a-Si:H (PaxScan 3030X, 0.194 mm pixel pitch) sensors were outfitted on equivalent mobile C-arms for fluoroscopy and CBCT. Technical assessment of 2D and 3D imaging performance included measurement of electronic noise, gain, lag, modulation transfer function (MTF), noise-power spectrum (NPS), detective quantum efficiency (DQE), and noise-equivalent quanta (NEQ) in fluoroscopy (with entrance air kerma ranging 5–800 nGy per frame) and cone-beam CT (with weighted CT dose index, CTDI_w, ranging 0.08–1 mGy). Image quality was evaluated by clinicians in vascular, orthopaedic, and neurological surgery in realistic interventional scenarios with cadaver subjects emulating a variety of 2D and 3D imaging tasks. Results: The CMOS FPD exhibited ~2–3× lower electronic noise and ~7× lower image lag than the a-Si:H FPD. The 2D (projection) DQE was superior for CMOS at ≤50 nGy per frame, especially at high spatial frequencies (~2% improvement at 0.5 mm⁻¹ and ≥50% improvement at 2.3 mm⁻¹) and was somewhat inferior at moderate-high doses (up to 18% lower DQE for CMOS at 0.5 mm⁻¹). For smooth CBCT reconstructions (low-frequency imaging tasks), CMOS exhibited ~10%–20% higher NEQ (at 0.1–0.5 mm⁻¹) at the lowest dose levels (CTDI_w ≤0.1 mGy), while the a-Si:H system yielded slightly (~5%) improved NEQ (at 0.1–0.5 lp/mm) at higher dose levels (CTDI_w ≥0.6 mGy). For sharp CBCT reconstructions (high-frequency imaging tasks), NEQ was ~32% higher above 1 mm⁻¹ for the CMOS system at mid-high-dose levels and ≥75% higher at the lowest dose levels (CTDI_w ≤0.1 mGy). Observer assessment of 2D and 3D cadaver images corroborated the objective metrics with respect to a variety of pertinent interventional imaging tasks. Conclusion: Measurements of image noise, spatial resolution, DQE, and NEQ indicate improved low-dose performance for the CMOS-based system, particularly at lower doses and higher spatial frequencies. Assessment in realistic imaging scenarios confirmed improved visibility of fine details in low-dose fluoroscopy and CBCT. The results quantitate the extent to which CMOS detectors improve mobile C-arm imaging performance, especially in 2D and 3D imaging scenarios involving high-resolution tasks and low-dose conditions.