Definitely not something to be forgotten if you're expecting to compress lossless RGB, although this is pretty rare outside of niche-ish use cases (afaik game capture is basically the only place where people are likely to be using RGB and not YCbCr? could be wrong!)
Is it similar to lossless audio were there's not a ton of optimization you can do?
They are still using directories of tiff, though.
I’m not sure if lossless h.264 is I only or not, but if it uses inter-frame compression then it’s difficult to randomly access arbitrary frames. For any arbitrary frame you’d have to find the nearest key frame, then interpolate from there based on the inter-frame compression metadata.
The real problem is that you'd have to rewrite the entire app stack to use H.264 or AV1 for storing the image stack generated by CT.
CT images are 16-bit monochrome, and the pixel values have real physical meaning (Hounsfield Units). So you'd have to prove that your compression tool can reproduce the original images 1:1. The H.264 encoder would also need to be modified to support 16-bit pixels.
And you'd need to modify the post-processing tools to accept your new file format. Otherwise users will still have to convert it back to DICOM or some other commonly accepted format before they can use their post-processing software.
So unless you're a CT vendor, you'll have a hard time pushing this into a hospital.
the days where the OS matters for video playback are long gone