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Step by Step CT Scan

Ct scan learning

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Step by Step CT Scan

Ct scan learning

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Step by Step

CT Scan
Step by Step

CT Scan
(A Practical Guide for Residents and Technologists)

D Karthikeyan DMRD DNB

Chief Radiologist
Division of Computed Tomography and Body Imaging
Department of Imaging Sciences
KG Hospital and Postgraduate Institute
Coimbatore
Programme Director, Radeducation Pvt. Ltd.
Coimbatore
Deepa Chegu
Consultant Radiologist
GEM Hospital (P) Ltd
Coimbatore

JAYPEE
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MEDICAL PUBLISHERS (P) LTD
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S tep by S tep C T S can

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or
transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise,
without the prior written permission of the authors and the publisher.
This book has been published in good faith and belief that the material provided by authors is original.
Every effort is made to ensure accuracy of material, but the
t he publisher, printer and authors will not be
held responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled
s ettled
under Delhi jurisdiction only.

First Edition : 2005

ISBN 81-8061-480-8

Typeset at JPBMP typesetting unit

Printed at Paras Offset
Preface

Since the introduction of computed tomography in the

70’s, there has been tremendous changes in the way CT
is performed resulting in a broad positive impact on
patient management. This book has been designed as a
primer which gives a practical insight into the principles
and practice of computed tomography for radiology
residents and technicians.

D Karthikeyan
Deepa Chegu
Contents

1. History and Basics ...........

......................
.......................
..............
.. 1

2. Development of Scanner Technology

Technology .......
.......41
41

3. Technical Parameters
Parameters...........
......................
...................
........59
59

4. Practical
Practical Overview of Performing
Performing a
CT Scan ...........
.....................
.....................
......................
..................
.......81
81

5. Image Aquisition Protocols .....................

.....................93
93

6. Post Processing
Processing Techniques ...........
...................
........147
147

7. Contrast Issues .....................

................................
................
.....161
161

8. Radiation Dose .......................

..................................
..............
...171
171

9. Proficiency Check ...........

......................
......................
...........179
179

10. Comp
Computed
uted Tomogr
Tomograph
aphy
y Glossary
Glossary ....
........
.......
...193
193

Index
Inde x ....................
.........................................
.........................................
.................... 20
2099
Chapter 1

History and
Basics
2 STEP BY STEP CT SCAN

GN Hounsfield, a senior research scientist in

Middlesex, England announced the invention of a
revolutionary imaging technique. In the year 1972, that
he called computed axial transverse scanning ( tomos—
meaning section, graphy—picture in Greek).
He presented a cross-sectional image of the head
that revealed the internal structures of the brain in a
manner previously only seen at surgery or autopsy
and for the first time pathologic processes such as blood
clots, tumors, and strokes could be easily seen non-
invasively.

COMMON NAMES

a. Comp
Computer
uterized
ized
(Hounsfield, 1972)axial tran
transver
sverse
se scann
scanning
ing
b. Computerized axial tomography (CAT)
c. X-ray
X-ray comp
compute
uted
d tomog
tomograp
raphy
hy (X-r
(X-ray
ay CT)
CT)
d. Computed/
Compu ted/compu
computeriz
terized
ed tomo
tomograph
graphyy (CT)
Computed tomography (CT) is currently the
preferred name.

HISTORY LEADING TO CT SCAN

• 1917—Ra
1917—Radondon devdevelop
eloped
ed the bas
basic
ic math
mathema
ematica
ticall
equations.
• 1940—Frank and Takahashi published the basic
principles of axial CT.
• 195
1956—C
6—Cormormackack dev
develo
eloped
ped the
theory
ory of imaimage
ge
reconstruction.
• 1967—
1967—Hou
Hounsfi
nsfield
eld dev
develop
eloped
ed the clin
clinical
ically
ly use
useful
ful
CT scanner.
• 197
1973—F
3—Firs
irstt clinic
clinical
al brain
brain scan
scanner
ner in
in Mayo
Mayo Clinic
Clinic..
HISTORY AND BASICS 3

Hounsfield and Cormack shared the 1979 Nobel

Prize for their development of CT.

CONVENTIONAL TOMOGRAPHY (Fig. 1.1)

Conventional radiographs provide an integrated, 2D
view of a 3D distribution of a object µ (x, y, z) with
superimposition of all structures. The disadvantage
of this method is:
1. De
Dept
pth
h info
inform
rmatatio
ion n is los
lost.
t.
2. Ove
Overla
rlappin
pping g structu
structuresres may
may interf
interfere
ere with
with diag-
diag-
nosis, and subtle differences in contrast is lost.
3. Not ququan
anti
tita
tati
tive
ve..

Tomo (=“cut or section”) + graph (=”something

written or drawn”) = tomograph.
X-ray tomography an analog technique suggested
in 1914 by Mayer, Bocage, Grossman, and Vallebona
all developed the idea further and built their own
equipment.

Method
a. X-ray
X-ray sourc
sourcee on one
one side
side of subj
subject
ect and
and film
film on
another, diagonally opposed.
b.. Sour
b So urce
ce an
andd de
dete
tect
ctor
or mo
move
ve at co
cons
nsta
tant
nt ra
rate
tess in
opposite directions.
c. Sour
Source
ce and
and detec
detector
tor dist
distance
ancess from
from the
the imaging
imaging
plane and rate of motion determined such that
objects in the imaging plane always project to the
same relative locations on the film.
d. Obje
Objects
cts out
out of the
the plane proj
project
ect to severa
severall locations
locations
and are thus blurred.
4 STEP BY STEP CT SCAN

Three basic goals of computed tomography were

based
bas ed to rec
recti
tify
fy the pi
pitf
tfal
alls
ls of co
conv
nven
entio
tiona
nall tom
tomo-
o-
graphy, they are:
• To over
overcom
comee super
superimp
imposi
ositio
tion
n of str
struc
uctur
tures.
es.
• To iimp
mpro
rove
ve the
the con
contr
tras
astt of the
the ima
image
ge..
• To measu
measurere smal
smalll differ
differenc
ences
es in tiss
tissue
ue cont
contras
rast.
t.
These three goals were accomplished by:
• Tra
Transm
nsmitt
itting
ing a coll
collima
imated
ted X-r
X-ray
ay beam
beam throthrough
ugh a
specific cross-section of the body.
• Det
Detect
ectors
ors that
that can
can meas
measureure sma
smallll diff
differe
erence
ncess in
tissue contrast.
• A compu
computer
ter tha
thatt allows
allows dat
dataa to be
be manip
manipulaulated
ted and
enhanced.

Fig. 1.1: Conventional tomography

INTRODUCTION—EQUIPMENT
The basic principle behind CT is that the internal
structure of an object can be reconstructed from
multiple projections of the object. The patient lies on
the table within the CT gantry, which is shaped like a
HISTORY AND BASICS 5

giant donut. During each slice acquisition, an X-ray

tube circling the patient produces an X-ray beam that
passes through the patient and is absorbed by a ring
of detectors surrounding the patient (Fig. 1.2). The
intensity of the X-ray beam that reaches the detectors
is dependent on the absorption characteristics of the
tissues it passes through. Since the beam is moving
around the patient, each tissue will be exposed from
multiple directions. Using a process called Fourier
analysis, the computer uses the information obtained
from the different amounts of X-ray absorption to
reconstruct the density and position of the different
structures contained within each slice.
A thin cross-section of the human body, or a
tomographic slice, can be reconstructed from images,
or projections, taken from multiple angles around the
human body.
CT images show a radiographic difference in the
various soft tissues and structures forming the human
body. Proje
Projection
ctionss are obtai
obtained
ned by passi
passingng an X-ray
beam
be am th
thro
roug
ugh h th
thee ob
obje
ject
ct at di
diff
ffer
eren
entt an
angl
gles
es an
andd
measuring the transmitted radiation.
Then, the internal structure of an object can be
reconstructed by adding multiple projections of the
object: X-rays passing through a body section are
attenuated at different rates by different tissues (Figs
1.3 and 1.4).

System Components of CT Scanner

Three main components are—gantry assembly,
computer, operating console.
6 STEP BY STEP CT SCAN

Figs 1.2A and B: Tomographic images are produced from a large

number of X-ray transmission measurements called rays, a group of rays
acquired in a certain geometry is called a projection or view. Two different
geometries are used in CT, parallel beam and fan beam projection
HISTORY AND BASICS 7

Fig. 1.3: Axial CT section of lungs

Fig. 1.4: Schematic diagram depicting tube rotation

8 STEP BY STEP CT SCAN

Figs 1.5A and B: The X-ray tube and the detector or set of detectors,
and the mechanism for rotation around the patient are included into the
data acquisition system (DAS)
HISTORY AND BASICS 9

Fig. 1.6: Schematic diagram showing the data acquisition system (DAS)

Hardware Consideration
A. X-ra
X-rayy tub
tubee
B. Col
olllim
imat
ator
orss
C. Det
Detecto
ectors—
rs—Sci
Scintil
ntillati
lation
on crystals
crystals
Xenon gas ionisation chambers.

Fig. 1.7: Schematic diagram showing the CT scan gantry assembly

10 STEP BY STEP CT SCAN

GANTRY ASSEMBLY
General Gantry Specifications for a Helical Scanner

•
• A plt—
Tilt
Ti e—rtu+/-
+r/-
e—2065 dcem. ee.
gre
gr
• Tilt
Ti ltsp
spee
eed—
d—11 deg
degreree/
e/se
seco
cond
nd..
• Heig
He ightht to is
isoc
ocet
etre
re—9
—900 cm
cm.
• Rotati
Rot ation
on spee
speed—3
d—360°60° in 1.5,
1.5, 2, 3,
3, 5 seco
seconds
nds..

Table Specification for a Single Slice Helical

Scanner
• Vertic
Vertical
al ra
rang
nge—e—4040 to 90 cm.
cm.
• Vertic
Vertical
al ele
elevat
vation
ion spe
speed
ed—17
—17 mmmm/se
/sec.
c.
• Maxi
Ma ximu
mum m cra
cradl
dlee tra
trave
vel—
l—151522 cm.
cm.
• Cradle
Cradle tra
travel
vel spe
speeded—20
—20 to 100 mmmm/se
/sec.
c.
• Tabl
Tablee load
load cap
capac
acit
ity—
y—20
2055 kg.
kg.

CT Gantry
The first major component of a CT system is referred
to as the scan or imaging system. The imaging system
primarily includes the gantry and patient table or
couch. The gantry is a moveable frame that contains
the X-ray tube including collimators and filters,
detectors, data acquisition system (DAS), rotational
components including slip ring systems and all
HISTORY AND BASICS 11

associated electronics such as gantry angulation motors

and positioning laser lights.
In older CT systems a small generator supplied
power to the X-ray tube and the rotational components
via cables for operation. This type of generator was
mounted on the rotational component of the CT system
and rotated with the X-ray tube. Some generators
remain mounted inside the gantry wall.
Some newer scanner designs utilize a generator that
is located outside the gantry. Slip ring technology
eliminated the need for cables and allows continuous
rotation of the gantry components. The inclusion of
slip ring technology into a CT system allows for
continuous scanning without interference of cables. A
CT gantry can be angled up to 30° toward a forward
or backward position. Gantry angulation is determined
by the manufacturer and varies among CT systems.
Gantry angulation allows the operator to align per-
tinent anatomy with the scanning plane. The opening
through which a patient passes is referred to as the
gantry aperture.
Gantry aperture diameters generally range from 50
to 85 cm. Generally, larger gantry aperture diameters,
70 to 85 cm, are necessary for CT departments that do
a large volume of biopsy procedures. The larger gantry
aperture allows for easier manipulation of biopsy
equipment and reduces the risk of injury when scanning
the patient and the placement of the biopsy needle
simultaneously. The diameter of the gantry aperture is
different for the diameter of the scanning circle or scan
field of view. If a CT system has a gantry aperture of
70 cm diameter it does not mean that you can acquire
patient data utilizing a 70 cm diameter.
12 STEP BY STEP CT SCAN

Generally, the scanning diameter in which patient

or projection data is acquired is less than the size of
the gantry aperture. Lasers or high intensity lights are
included within or mounted on the gantry. The lasers
or high intensity lights serve as anatomical positioning
guides that reference the center of the axial, coronal,
and sagittal planes.

X-RAY TUBE, COLLIMATION, FILTRATION

X-ray Sources
X-ray is produced by an X-ray tube. The three main
parts of any X-ray tube are the anode, cathode and
the filament. When the filament is heated, electrons
are ejected from its surface. A large voltage between
the cathode and the anode force electrons to accelerate
towards the anode. The electrons hitting the anode
(tungsten) produce Bremstrahlung radiation at an
efficiency of only 1 percent. The other 99 percent of
the electrons energy is converted into heat.
Most modern system use tubes with two focal spots
small spot is used for high resolution examination.
And large spot is used for larger anatomic coverage.
Stationary anode—Used in eary scanners, oil cooled,
large focal spot giving rise to higher potential radiation.
Rotating anode—Aircooled, small focal spot requires
large heat capacity and fast cooling rates.
Mechanical stresses due to tube rotation—Up to 13 G for
0.5 second rotation.
CT procedures facilitate the use of large exposure
factors, (high mA and kVp values) and short
short exposure
HISTORY AND BASICS 13

B
Figs 1.8A and B: (A) Rotating anode; (B) Conventional tube
14 STEP BY STEP CT SCAN

times. The development of spiral/helical CT allows

continuous scanning while the patient table or couch
moves through the gantry aperture. A typical spiral/
helical CT scan of the abdomen may require the
continuous production of X-rays for a 30 to 40 second
period. The stress caused by the constant build up of
heat can lead to a rapid decrease of tube life. When an
X-ray tube reaches a maximum heat value it simply will
not operate until it cools down to an acceptable level.
CT systems produce X-radiation continuously or in
short millisecond bursts or pulses at high mA and kVp
values. CT X-ray tubes must possess a high heat capacity
which is the amount of heat that a tube can store without
operational damage to the tube. The X-ray tube must
be designed to absorb high heat levels
levels generated from
the high speed rotation of the anode and the
bombardment
bombardme nt of electrons upon the anode surface.
An X-ray tubes heat capacity is expressed in heat
units. Modern CT systems utilize X-ray tubes that have
a heat capacity of approximately 3.5 to 5 million heat
unit (MHU). A CT X-ray tube must possess a high heat
dissipation rate. Many CT X-ray tubes utilize a
combination of oil and air cooling systems to eliminate
heat and maintain continuous operational capabilities.
A CT X-ray tube anode has a large diameter with a
graphite backing. The large diameter backed with
graphite allows the anode to absorb and dissipate large
amounts of heat. The focal spot size of an X-ray tube
is determined by the size of the filament and cathode
which is determined by the manufacture
manufacturer. r. Most X-ray
tubes have more than one focal spot size. The use of a
small focal spot increases detail but it concentrates heat
onto a smaller portion of the anode, therefore, more
HISTORY AND BASICS 15

heat is generated. As previously described, when heat

is building up faster than the tube can dissipate it the
X-ray tube will not produce X-rays until it has suffi-
ciently cooled. CT tubes utilize a bigger filament than
conventional radiography X-ray tubes. The use of a
bigger filament increases the size of the effective focal
spot.
Decreasing the anode or target angle decreases the
size of the effective focal spot. Generally, the anode
angle of a conventional radiography tube is between
12 and 17 degrees. CT tubes employ a target angle
approximately between 7 and 10 degrees. The
decreased anode or target angle also helps aleviate
some of the effects caused by the heel effect.
CT can compensate any loss of resolution due the
use of larger focal spot sizes by employing resolution
enhancement algorithms such as bone or sharp
algorithms, targeting techniques, and decreasing
section thickness.

Collimation
Important Component for Reducing Patient Dose
and Improving Image Quality by Reducing Scatter
Radiation
In CT collimation of the X-ray beam includes tube
collimators, a set of pre-patient collimators and post-
patient or pre-detector collimators. Some CT systems
utilize this type of collimation system while other do
not. The tube or source collimators are located in the
X-ray tube and determine the section thickness that
will be utilized for a particular CT scanning procedure.
When the CT technologist selects a section thickness
16 STEP BY STEP CT SCAN

The X-ray field is filtered to reduce the low energy

X-rays which are not useful for imaging but that
increase the radiation dose received by the patient.
This process is called collimation.
The beam undergoes two-levels of collimation:
(1) source collimation, and (2) detector collimation.
The source collimator controls the thickness of the
tomographic slice (most common thickness are 1, 2,
5 or 10 mm).
HISTORY AND BASICS 17

Figs 1.9A and B: Schematic diagram showing the

relationship between detectors and collimators
18 STEP BY STEP CT SCAN

Filtration
There are two types of filtration utilized in CT.
Mathematical filters such as bone or soft tissue
algorithms are included into the CT reconstruction
process to enhance resolution of a particular anatomical
region of interest. Inherent tube filtration and filters
made of aluminium or Teflon are utilized in CT to
shape the beam intensity by filtering out low energy
photons that contribute to the production of scatter.
Special filters called “bow-tie” filters absorb low
energy photons before reaching the patient. X-ray
beams are polychromatic in nature which means an X-
ray beam contains photons of many different energies.
Ideally, the X-ray beam should be monochromatic or
composed of photons having the same energy. Heavy
filtration of the X-ray beam results in a more uniform
beam. The more uniform the beam, the more accurate
the attenuation values or CT numbers are for the
scanned anatomical region.

Provides for a equal photon distribution across the

X-ray beam.
Allows equal beam hardening were the X-ray passes
through the filter and object.
Lessens overall patient dose by removing softer
radiation.
Made of aluminium, grafite can be curved, wedge
or flat in shape.
HISTORY AND BASICS 19

Detectors
Detectors gather information by measuring the X-ray
attenuation through objects.
The most important properties of X-ray detectors
used in CT are:
a. Efficiency
b.. Response time (after glow)
b
c. L in e ar ity
Efficiency is related to the number of X-rays
reaching the detector that are detected.
Response time is related to how fast the detected
X-ray is converted into an electrical pulse or current.
Linearity is related to the proportionality between
the output of the detector and the number of incident
X-rays.
The two types of detector that have been used for
CT are:
• ScScin
inti
till
llat
atio
ion
n det
detec
ectors:: Use solid materials in which
tors
the energy of X-rays is converted to light photons.
Then, the emitted light is converted into an
electrical current by using a photomultiplier tube
or a silicon photodiode. The material which
produces light when the X-ray energy is absorbed
is named scintillator and the combination of a
scintillator and thescintillation
current, is named device converting
detector.light into a
• Ga
Gass io
ioni
niza
zati
tion
on de
dete
tect
ctors: These are based on the
ors:
ionization of a gas inside a closed chamber when
the X-ray energy is absorbed into a gas. The main
disadvantage is the low efficiency of gas detectors.
20 STEP BY STEP CT SCAN

Favourable Detector Characters

• High
High absorp
abso rpti
tion
on efeffi
fici
cien
encycy..
• High
High conv
conver
ersi
sion
on ef
effi
fici
cien
ency
cy..
• High
High captu
capture
re ef
effi
fici
cien
encycy..
• High
High reprod
reproduc
ucibibil
ilit
ity
y and sta stabi
bili
lity
ty..

Scintillation Detectors
• Uses a scintilla
scintillation
tion crystal
crystal coupled
coupled to a photo-
multiplier tube to convert light to electrons.
• Amou
Amountnt of light produc
produced
ed is proporti
proportional
onal to the
energy of the absorbed X-rays.

•
• Used in older
in olde
Disadvanta
Disadvantageger is
generatio
gene ration
that
that of nafter
ofrmachines
afte mac hines.
glow
glow.. .
Examples—Sodium iodide, cadmium tungstate,
caesium iodide.

Gas Detectors
• Ionization chamber that uses
uses xenon or krypton
krypton gas.
• Ionize
Ionized
d gas cause
causess electrons
electrons to attach
attach to tungsten
tungsten
plates creating electronic signals.
• Gas that is ionized
ionized is proport
proportional
ional to the incide
incident
nt

• radiation.
100% effect
effective
ive utilizati
utilization
on of energy.
energy.
Ionization chamber—xenon (underpressure).
HISTORY AND BASICS 21

Fig. 1.10: Schematic diagram showing the

mechanism of xenon and solid state detector

Operator Console

Scan Console
• Techni
Technical
cal fact
factors
ors,, slice
slice thick
thicknes
ness,
s, no of scan
scans,
s, angle
angle
of gantry.
• Ini
Initia
tiates
tes sca
scan,
n, reco
recordrd pati
patient
ent dat
data,
a, sets
sets FOV
FOV..

Display Console
• Used
Used to
to man
manipipul
ulat
atee post
post sca
scan
n data
data,,
• Pos
Postt proce
processi
ssing
ng work
work—me
—measuasurem
rement
ents,
s, MIPS
MIPS,, 3D
formations.
• Wi
Wind
ndow
ow le
leve
vell and
and wiwidt
dth.
h.

Computer
The computer processes convert the signal from analog
to digital by using a analog to digital convertor. It
stores the digital signal during the scan and recons-
tructs the images after the scan is complete. This
reconstruction can be done immediately or later. Data
can be manipulated to reconstruct into various planes.
22 STEP BY STEP CT SCAN

Summary of Processes
The formation of a CT image is a distinct three phase
process.
• The rec
recons
onstru
tructio
ction
n phase
phase pro
proces
cesses
ses the acq
acquir
uired
ed
data and forms a digital image.
• The scascanni
nning
ng phase
phase pro
produ
duce
cess data,
data, bu
butt not an
an
image.
• The visi
visible
ble and
and disp
display
layed
ed anal
analog
og image
image (sha
(shade
dess of
grey) is produced by the digital-to analog con-
version phase.

Fig. 1.11: Summary of CT image formation

IMAGE RECONSTRUCTION
The computer receives a signal in analog form and
converts it to a binary digit by using a analog to digital
convertor. The digital signal is stored and the image
is reconstructed after the scan is over.
Each picture is displayed on a matrix, each square
in a matrix is called a pixel, its assigned a number based
on the amount of energy reaching the detector. This
number is called as Hounsfield unit.
HISTORY AND BASICS 23

Fig. 1.12: Schematic diagrams demonstrating the

concept of pixel and voxel

The reconstructed anatomy of an object is in the

digital format composed of a large number of Tiny
elongated blocks. Representing a volume of tissue
called voxel (Figs 1.12 and 1.13).
Voxel—3D tissue element that has a width, height
and depth. Depth of a voxel is a important parameter which
depends on the slice thickness and each unit is assigned a
shade of grey.
Pixel is the 2D projection of a voxel on the computer
screen and it has only height and width.

CT NUMBERS
CT Numbers and Hounsfield Units
The digital value ascribed to each pixel is called the
Hounsfield units or HU, which lies on a scale were
water has a value of 0 and air has a value of –1000.
Bone has a value in order of +1000. HU values reflect
24 STEP BY STEP CT SCAN

Fig. 1.13: Schematic diagram showing contents in an axial CT slice

the electron density and thus the physical composition

of the voxel of tissue that the pixel represents.
Reconstruction yields linear attenuation coefficients,
usually relative to that of water and scaled to a large
number, the CT number.
µtissue – µwater
CT number = K ———————
µwater

Pixel values for some biological tissues are:

Tissue CT number range in HU

A ir –1000
Lun gs – 90 0 t o – 3 00
Fat –1 20 t o –8 0
Water 0
M u s cl e 10 t o 30
S oft t i s s ue 1 0 t o 30
Cortical bone 5 0 t o 1 00
Trabecular bone 50 0 t o 100 0
HISTORY AND BASICS 25

Fig. 1.14: Schematic diagram showing the Hounsfield unit

Algorithms for Image Reconstruction

The fundamental problem in CT is to calculate the
linear attenuation coefficient of the pixels using a large
number of X-ray transmission measurements and to
use the results to build up an image of the object by
means of computer processing algorithm.
An algorithm is a mathematical method for solving
a problem. Various methods are used for reforming
the image.
1. Ba
Back
ck pr
proj
ojec
ecti
tion
on me
meth thod
od
2 . It
Iter
erat
ativ
ivee me
meth
thod
od
3 . An
Analalyt
ytic
ical
al me
meth
thod
od..
26 STEP BY STEP CT SCAN

Back Projection Method

• Simple
Simplest
st meth
method
od also
also kno
known
wn as
as linear
linear or sum
summat
mation
ion
method.
• Inv
Involv
olves
es obta
obtaini
ining
ng profi
profiles
les of an obj
object
ect and the
then
n
combining them.
• Do
Does
es no
nott pro
produ
duce
ce sh
shar
arp
p ima
image
ges.
s.

Analytical Reconstruction Algorithm

• Common
Commonly ly used
used now bec
becaus
ausee of the
their
ir spee
speed.
d.
• It is a filter
filtered
ed back
back proj
project
ection
ion meth
methodod –no
–no stai
stairr
artifacts.
• Dat
Dataa is reco
reconst
nstru
ructe
cted
d using
using a four
fourier
ier tran
transfo
sform
rm..

Windowing and Grey Scale

Technique of windowing is a electronic manipulation
of the data to enable the shades of grey to be used to
represent a limited range of HU values so that different
structures can be imaged.
CT scans are displayed as a monochrome image on
a TV screen. The value of the pixel at a specific point
in the image is converted to a grey level. However,
the range of pixel values is approximately
–1000 (air) to +800 (dense bone) and the eye can only
distinguish 32 grey levels at best. The majority of the
soft tissues range from -100 to +100 so a system know
as windowing has been developed to allow
Radiologists to dynamically view images.
• Dec
Decreareasin
singg the
the window
window wid width
th incre
increase
asess the
the
contrast in the image so is good for looking at
differences in soft tissues.
HISTORY AND BASICS 27

• Increasi
Increasing
ng the wind
windowow widt
width h allow
allowss stru
structu
ctures
res
with a large pixel range (i.e. bones and lungs) to be
viewed.
• DeDecre
creasi
asing
ng the
the wind
windowow leve
levell allow
allowss the
the lungs
lungs and
other airways to be viewed.
• Inc
Increa
reasin
sing
g the
the windo
window w level
level all
allows
ows the dedense
nserr
bones to be viewed.
Windowing allows you to dynamically alter the
image. Film hard copies are taken at specific (user
defined) window settings so are just a representative
copy of the original image. Good diagnostic practice
is to have access to the images on a diagnostic console
to allow windowing to be performed as required.

Image Quality
• Spa
patitial
al res resololu
uti
tion
on..
• Cont
Co ntra
rast st rereso
solu
lutition
on..
• Nois
No isee and
and sp spat
atia
iall uni
unifo
form
rmit
ity.
y.
• Li n e a r i t y .
• Imag
agee ar arttifacactts.
Image noise and artifacts are the two biggest
enemies of CT image quality. CT parameters can be
manipulated to either decrease or eliminate the adverse
effects of these image.

Spatial Resolution
It is the CT system’s ability to differentiate small
objects that are adjacent to one another. The CT
scanner’s resolving power relies on how well small
objects that are close together but have very different
attenuation values or CT numbers are imaged.
28 STEP BY STEP CT SCAN

Fig. 1.15: Relationship between window level and width

There are parameters that a CT technologist can

manipulate to increase the spatial resolution when
scanning high frequency regions. Utilizing a bone,
sharp, high frequency or high pass algorithm during
reconstruction can improve the spatial resolution.
Other factors that influence spatial resolution
include pixel size, which is influenced by the chosen,
scanned field of view and matrix size, width of the
detector, spacing between detectors, number of
projections or views obtained and focal spot size.

Field of View (FOV)

• Diamet
Diameter
er of
of FOV
FOV has
has a prov
proved
ed eff
effect
ect on the
the imag
imagee
quality.
HISTORY AND BASICS 29

• FOV sho
should
uld be adju
adjuste
sted
d to the
the size
size of
of the ana
anatom
tomic
ic
areas to be examined.
• Ide
Ideall
ally
y pixels
pixels sho
should
uld be sma
smalle
llerr than
than the
the minim
minimum
um
distance resoluble by the scanner.

Contrast Resolution
It is the ability of a CT scanner to differentiate small
attenuation differences on the CT image. Contrast
Resolution is also known as Low Contrast Resolution
and Tissue Resolution. Contrast resolution is limited
by nonois
ise,
e, as no
nois
isee in an im
imag
agee in
incr
crea
ease
ses,
s, co
cont
ntra
rast
st
resolution decreases thereby, inhibiting the ability of
the CT scanner to image slight differences in tissue
density.
A soft tissue, standard or smooth algorithm is used
during the reconstruction process to enhance
enhan ce soft tissue
and contrast resolution.

Image Noise
Noise is considered to be the number one limiting
factor of CT image quality. Noise is the portion of a
signal that contains no information. Noise is
characterized by a grainy appearance of the image.
The major types of noise include quantum noise,
electronic noise and computational noise. Quantum
noise is a result of too few photons reaching a detector
after being attenuated by the body. Any factor that
limits the number of attenuated photons at the detector
will increase image noise. Anatomical structure size,
reduction of slice thickness without increasing technical
factors, decreasing pixel size and scatter radiation are
all factors that contribute to image noise.
30 STEP BY STEP CT SCAN

Electronic noise is noise contained within the image

that can be caused by vibrations of any of the physical
components, especially the rotational components or
power fluctuations. Computational noise is primarily
caused by all the statistical fluctuations that occur from
the reconstruction mathematics that are essential to
produce a CT image. The following factors influence
image noise:
• Vox
Voxel el size
size,, slic
slicee thic
thickne
kness,
ss, mat
matrix
rix,, FOV.
FOV.
• Fi
Filt
lter
er al
algo
gori
rith
thm,
m, mAmAs.s.

Image Artifacts
“An artifact is any distortion or error in the image
thatArtifacts
is unrelated to the as
can appear subject being studied.”
geometrical inconsistencies,
blurring
blur ring,, stre
streaks
aks or inac
inaccura
curate
te CT numb
numbers.
ers. Stre
Streak
ak
artifacts are the most common distortions or errors
that affect the quality of CT images. Motion, metallic
objects, out-of-field, edge gradient effects, high-low
frequency interfaces, equipment malfunctions and
sampling errors are all causes of streak artifacts.
Equipment malfunctions such as tube arching,
electrical malfunctions and detector malfunctions
produce streak artifacts on a CT image.

Source of Artifacts
• Data formation
• Patient motion.
• Po
Poly
lych
chro
roma
mati ticc ef
effe
fect
cts.s.
• Eq
Equi
uipm
pmenentt misal
misalig ignm
nmen ent.
t.
• Fa
Fauult
lty
y X-
X-ra
ray y sou
sourrce
ce..
HISTORY AND BASICS 31

CT Image Parameters—Definitions and Ranges

Noise A l l C T i m a ge s c on t a i n no i s e or p i x e l t o p i x el
variations in the pixel value in the image of an
object of uniform linear attenuation coefficient. It
is measured as the standard deviation (σ) of the
pixel values within an area of the image. The
units are HU and it typically ranges from 3 to 30
HU

S pat ial Th is is quote d either as the full width at half

ressol
re olu
uti
tion
on in max
axim
imum
um (F
(FWH
WHM M) of th
thee poi
oinnt sp
spre
read
ad fun
unct
ctio
ion
n
the imag
imagee plane
plane (PSF
(PSF)) me
meas
asur
ured
ed in mm or as the spatial frequency
of the 50% modulation transfer function (MTF)
measured in cycles/cm. (Note percentages other
than the 50% can be quoted. A simple method of
converting is:
5
FWHM of PSF in mm =50% ———————————
of MTF in cycles/cm
The typical range of the fwhm of the PSF is from
0.75 to 2.0 mm.

Spatial resolution This is

is the slice
slice width.
width. The image
image is the
the “average”
“average”
in th
thee lon
long
g ax
axis
is acr
acros
osss the slic
slicee width
width so in
in genera
generall the spat
spatial
ial
resolution is up to an order of magnitude poorer
in this direction. This also gives rise to the partial
volume effect (see later).

Dose CT doses ar e me asured in mGy and range

upwards from about 50 mGy. CT has one of the
highest dose consequences to the patient.

• Data ac
acquisition
• Slic
icee geometry.
• Pr
Prof
ofil
ilee sa
sammplplin
ing.
g.
• An
Angugula larr sa
sam
mpl
plin
ing.
g.
32 STEP BY STEP CT SCAN

• Dat ataa measasu

urem
emen entt
• Det etec
ecto
torr im
imbabala
lanc
nce.e.
• Sc
Scaatt
tter
er col
colli
lim
matatio
ion.
n.
• Data processing
• Alg lgor
orit
ithm
hm effeffeect
ctss.
Because the patient moves continuously through
the Gantry for a 360° rotation, the reconstructed
image will be blurred with only the same filtered
backprojection algorithm as conventional CT. That’s
why we should interpolate our image data before the
filtered back-projection is used. This process leads to
a higher noise level and artifacts such as stair-step
artifact.

Patient Motion Artifacts (Fig. 1.16)

Motion can be voluntary or involuntary. No matter
which kind of motion we are dealing with, the most
efficient way to reduce motion artifact is to reduce
our scanning time. Methods to reduce patient motion
artifacts include patient immobilization, ECG gated
CT, and some correction algorithms.

Metal Artifacts (Fig. 1.17)

Metallic materials such as prothetic devices, dental
fillings, surgical clips, and electrodes produce streak
artifacts on the image. Several methods have been
provided to remove the artifacts coming from metal.

Beam Hardening Artifacts (Fig. 1.18)

Beam hardening is a phenomenon results from the
increase of mean energy of the X-ray beam when it
HISTORY AND BASICS 33

Fig. 1.16: Axial CT brain showing motion artifacts

Fig. 1.17: Axial CT brain showing metal artifacts

34 STEP BY STEP CT SCAN

Fig. 1.18: Axial CT brain showing beam hardening artifact

passes through object. Therefore, the CT numbers of

certain structures change and induce some artifacts.
This kind of artifact can be reduced or eliminated with
a filter that ensures the uniformity of the beam at the
detectors.

Partial Volume Artifacts

Partial volume artifacts arise when a voxel contains

many types of tissue. It will produce a CT number as
an average of all types of tissue. This is the source of
partial volume effect and will appear as bands and
streaks. Using thinner slice and some computer
algorithms can reduce partial volume artifacts.
HISTORY AND BASICS 35

Fig. 1.19: Axial CT brain showing partial volume of clivus

Stair Step Artifacts

Apart from the well-recognized effects on the section-
sensitivity profile and average image noise, the
particular geometry helical CT causes complex periodic
asymmetries and inconsistencies
inconsistenc ies in the volumetric data
sets that give rise to less-recognized effects such as
variable noise distribution and section thickness.
Ring artifacts appear on a CT image as a ring or a
number of rings superimposed on the structures being
scanned. The artifact is commonly associated with third
generation or rotate-rotate CT systems. This artifact
occurs due to one or several misaligned or miscali-
brated
brate d detect
detectors
ors in the detect
detector
or array of the rotat
rotate-
e-
rotate CT system.
CT image quality is dependent upon the balancing
of parameters relative to image resolution. Balancing
image quality by manipulating and altering CT para-
meters depends upon the region or the condition being
scanned with respect for patient dose. Image quality
36 STEP BY STEP CT SCAN

is also dependent upon limiting or eliminating the

image degrading effects of noise and artifacts.

Fig. 1.20: Axial CT brain showing ring artifacts

Image Archiving
The sheer explosion of data with the advent of modern
scanners. Result in a load of images which necessitates
manipulation of data in the Giga byte range along with
increasing need for image processing, and graphics at
interactive speeds facilitating a high throughput.
Modal
Mod ality
ity Matrixx
Matri No imag
images
es File size
D i g i t a l ma m m o g r a m 4092 × 51 2 0 × 12 4 16 0 M B
D i g i t a l r a d i o gr a p h 20 48 × 20 4 8 × 12 4 3 2 MB
CT 512 × 512 × 12 30 1 5 MB
MRI 2 56 × 25 6 × 8 50 6. 5 M B
U l t ra s ound 2 56 × 256 × 8 24 1.5 M B
Nuclear medicine 1 28 × 12 8 × 8 24 0. 4 M B
HISTORY AND BASICS 37

Storage Devices
Medium
Medi um Data access for
f or processing

F ilm No
M a g ne t i c t a p e Yes
F l o ppy d i sc Yes
M a g ne t i c d i s c Yes
O ptica l disc Yes
Server Yes

FILM PROCESSING AND FILMING

Film Processing
Processing film is a strict science governed by rigid
rules of chemical concentration, temperature,
temperature, time, and
physical movement. Whether processing is done by
hand or automatically by machine, excellent
radiographs require the highest possible degree of
consistency and quality control.

Manual Processing and Darkrooms

Manual processing begins with the darkroom. The
darkroom should be located in a central location,
adjacent to the reading room and a reasonable distance
from the exposure area. For portability darkrooms are

often mounted
Film onlocated
should be pickupsinor trailers.
a light tight compartment,
which is most often a metal bin that is used to store
and protect the film. An area next to the film bin that
is dry and free of dust and dirt should be used to load
and unload the film. While another area, the wet side,
will be used to process the film. Thus, protecting the
film from any water or chemicals that may be located
on the surface of the wet-side.
38 STEP BY STEP CT SCAN

Each of step in film processing must be done

properly to develop the image, wash out residual
processing chemicals, and to provide adequate shelf-
life of the radiograph. The objective of processing is
two-fold. First to produce a radiograph adequate for
viewing, and secondly to prepare the radiograph for
archival storage. A radiograph may be retrieved after
5 or even 20 years in storage.

Automatic Processor Evaluation

The automatic processor is the essential piece of
equipment in every X-ray department. The automatic
processor will reduce film processing time when
compared to manual development by a factor of four.
To monitor the performance of a processor, apart from
optimum temperature and mechanical checks, chemical
and sensitometric checks should be performed for
developer and fixer. Chemical checks involve measure-
ment of pH values for developer and replenisher, fixer
and replenisher, measurement of specific gravity and
fixer silver levels. Ideally pH should be measured daily
and it is important to record these measurements, as
regular logging provides very useful information. The
daily measurements of pH values for developer and
fixer can then be plotted to observe the trend of
variations in these values compared to normal pH
operating levels to identify problems.
Sensitometric checks may be carried out to evaluate
if the performance of films in the automatic processors
is being maximized. These checks involve measure-
ment of basic fog level, speed and average gradient
made at 1° C intervals of temperature. The range of
HISTORY AND BASICS 39

temperature measurement depends on the type of

chemistry in use, whether cold or hot developer. These
three measurements: fog level, speed, and average
gradient, should then be plotted against temperature
and compared with the manufacturer’s supplied
figures.

FILM DISPATCH
• Check
Check moda
modalit
lity
y if there
there is comm
commonon print
printing
ing for
for all
all
modalities.
• Pat
Patien
ientt data,
data, stu
study
dy data
data—pl
—plain
ain or
or contr
contrast
ast..
• Exam dadate/time.
• Number of films.
• Veri
Verifi
fica
cati
tion
on of pa
paym
ymen
ent.
t.
• Sig
Signat
natur
uree from
from the rec
recipi
ipient
ent of the
the fil
film.
m.
Chapter 2

Development of
Scanner Technology
42 STEP BY STEP CT SCAN

ALL X-RAY CT SYSTEMS USE

• Thinly
Thin ly co
coll
llim
imatated
ed X-X-ra
ray
y bea
beamm
• Multiple views
• Dete
De tect
ctor
orss to col
colle
lect
ct X-r
X-ray
ay pho
photo
tons
ns
• Data
Da ta ac
acqu
quis
isit
itio
ionn sys
syste
tem
m
• Imag
Im agee rec
recon
onst
stru
ruct
ctio
ion
n algo
algori
rith
thm
m
• Film/
Film/monmonito
itors
rs to dis
displa
playy axia
axiall slic
slices
es

BASIC DIFFERENCE BETWEEN CONVENTIONA

CONVENTIONAL
L
AND HELICAL SCANNERS
Conventional
Tube rotates around stationary patient
(Table is incremented between acquisitions)
• All vie
views
ws in
in a slic
slicee are
are at sam
samee table
table pos
positi
ition
on
• Po
Powe
werr to
to X-r
X-ray
ay tutube
be vi
viaa cor
cord
d
• Sc
Scan
an CWCW and
and CCW
CCW to to wind
wind/u/unw
nwin
ind
d cor
cord
d
• In
Inte
terrscan de
delay
ayss:
3.5 seconds between slices

Helical Scan
Continuous tube rotation—No interscan delays
(Power to X-ray tube via slip ring)
• Continuous table motion as tube rotates
• Eac
Eachh view
view is at a dif
differ
ferent
ent tab
table
le pos
positi
ition
on
Form images by synthesizing projection data via
interpolation
DEVELOPMENT OF SCANNER TECHNOLOGY 43

First Generation (Fig. 2.1)

• Single de
detector
• Tr
Tran
ansl
slat
ate-
e-ro
rota
tate
te acqui
acquisisiti
tion
on
— Tra
Transl
nslate
atess across
across pati
patient
ent
— Rot
Rotate
atess arou
aroundnd pati
patient
ent
• Very slow
— Mi
Minu
nute
tess per
per slic
slicee

Fig. 2.1: First generation CT scanner

Second Generation (Fig. 2.2)

• Mult
ltip
iplele det
etec
ecto
tors
rs
• Tra
rans
nsla
latition
on-r
-rot
otat
atio
ionn
• Small fan beam
• Shor
Shorte
terr sca
scann
nnin
ingg tim
times
es (3
(300 s)
s)
44 STEP BY STEP CT SCAN

Fig. 2.2: Second generation

Third Generation (Fig. 2.3)

• Mul
ulti
tipl
plee de
dete
tect
ctor
orss
• Rota
Ro tati
tion
onal
al mov
moveemen entt
• Larger fan beam
• Shor
Shorteterr sca
scann
nnin
ingg tim
times
es (1 to 3 s)
s)

Fig. 2.3: Third generation

Fourth Generation (Fig. 2.4)

• Circul
Circularar arra
array
y of fixe
fixed
d detec
detector
torss (600
(600 to
to 4800)
4800)
• Ro
Rota
tati
tion
onal
al mov
moveemenentt
DEVELOPMENT OF SCANNER TECHNOLOGY 45

• Larger fa
fan be
beam
• Sh
Shor
orte
terr sca
scann
nnin
ing
g tim
times
es (1 to 3 s)
s)

Fig. 2.4: Fourth generation

Spiral/Helical CT
Simultaneous source rotation, table translation and
data acquisition. Projection data for multiple slices
covering a volume of the patient, can be aquired at 1 s
per slice.

Spiral CT (Fig. 2.5)

The most significant advance in CT technology in the
past few years has been the developments of spiral
(or helical) CT. During spiral CT, the X-ray tube rotates
continuously as the patient is smoothly moved through
the X-ray scan field. Unlike the separate data sets
produces for each individual slice in standard CT,
spiral CT produces one continuous volume set of data
for the entire region scanned.
46 STEP BY STEP CT SCAN

Fig. 2.5: Diagram showing a spiral scan

Spiral CT has Several Advantages

Over Standard CT
• Speed: Since the patient is moving continuously
through the scanner, the duration of the exam is
markedly shortened. The entire chest or abdomen
can be scanned in 30 seconds, usually during a single
breath-h
brea th-hold.
old.
• Improved detection of small lesions: In standard CT,
the patient holds their breath for a slice acquisition,
then breathes, than holds their breath again for the
next slice. If they hold their breath slightly
differently for each slice, small lesions may fall out
of the plane of each contiguous slice and therefore
may be missed. Since spiral CT can be performed
during a single breath-hold, contiguous slices are
truly contiguous. Also, since a volume of data is
obtained, the spacing of the acquired slices can be
DEVELOPMENT OF SCANNER TECHNOLOGY 47

manipulated after the scan is completed. This allows

detected lesions to be placed in the middle of the
slice, which creates a more accurate image of the
lesion.
• Improved contrast enhancement: Intravenous contrast
is often injected during the CT scan. Since spiral
CT can image a region of interest in such a short
period of time, the injection of intravenous contrast
can be timed to ensure optimal contrast
enhancement and improved evaluation of various
organs and blood vessels.
• Image reconstruction and manipulation: The volume
of data obtained through spiral CT can be mani-
pulated in many fascinating ways by powerful
computers connected to the scanner. The transverse
images can be reconstructed in any plane. Three
dimensional images be formed and moved into any
position. A surface view of the body can be created,
and then skin, muscles, and overlying organs can
be stripped away. Contrast enhanced vessels can
be isolated and converted into CT angiograms.

Technical Data for Helical Scans

The fundamental step in helical CT technology is the
introduction of slip ring technology. Pioneering work
in this field was done by Kalendar in 1989.

Advantages
Advantag es
• Continuou
Contin uouss table
table move
movemement—
nt—no
no inter
intersca
scan
n delay
delay..
• Image
Image reco
reconst
nstru
ructi
ction
on at any
any posit
position
ion or
or inter
interval
val..
• Large
Large volu
volume
me cov
covera
erage
ge in
in singl
singlee breat
breathe
he hold
hold..
• No int
inter
ersc
scan
an dela
lay.
y.
48 STEP BY STEP CT SCAN

• Form
Form image
imagess by synt
synthes
hesisi
ising
ng proje
projecti
ction
on data
data via
via
interpolation.

Spiral Slip Ring

• Also
Also called
called volu
volumet
metric
ric,, helica
helical,
l, or spir
spiral
al scann
scanning
ing..
• Allo
Allows
ws for the tub
tubee and
and dete
detector
ctor com
compon
ponent
entss to
spin continuously in a non-stop rotation sequence,
can scan whole body segments in one breathe hold.

Fig. 2.6: Slip ring

Reconstruction Principles
Data in spiral CT can be obtained in two ways :
DEVELOPMENT OF SCANNER TECHNOLOGY 49

Fig. 2.7: Schematic diagram of tube motion

The major difference in data acquisition in spiral

CT is that
stream, thatit can
displays data from a continuous
be computationally manipulated data
to
represent varying amount of projections from adjacent
slices thus its possible to reconstruct slices at intervals
smaller than the prescribed slice thickness.
This is a major advantage as it helps us to find the
best slice through a focal abnormality. It also helps to
produce better 3D data sets.
When the acquisition pitch is large and if the
reconstruction interval is small not much additional
data can be got.
As a thumb rule with a pitch of one—3-5 slices can
be reconstructed and with a pitch of 2, two slices can
be got.

Effective slice thickness is determined by acquisition

parameters (Collimation, pitch) and interpolation
50 STEP BY STEP CT SCAN

Fig. 2.8

Fig. 2.9: Schematic diagram of helical data interpolation

DEVELOPMENT OF SCANNER TECHNOLOGY 51

Pitch
In conventional study the patient is stationary relative
to the detector array, while the entire set of projection
are needed to reconstruct an image.
In helical scans it is a combination of circular
rotation of detectors and simultaneous translation of
the patient. Geometrically this combination of
rotational and translational movements result in a
helecoidal pathway of data projection this raw data
has to be first manipulated prior to reconstruction via
a process called interpolation among the adjacent
projection so that the entire planar data can be
reconstructed.

vedThis
in can
twobeways:
achie-
360—interpolation
and 180 interpola-
tion, currently the
latter is used as it
causes least amount
of translational dis-
tortion and blurring.
SUMMARY
52 STEP BY STEP CT SCAN

MULTISLICE SCANNING
As discussed above conventional single slice CT has
one X-ray tube and a single row of detectors. The
detector row contains 500 to 900 detector elements. In
contrast multisection CT has one X-ray tube and
multiple rows of detectors. Along the longitudinal axis
of the patient. Each row has 500 to 900 detector
elements. And many rows together create a two
dimensional curved array containing thousands of
detector elements. Which are connected to separate
data acquisition systems generating multiple channels
of separate data.
The use of N detector rows enables us to divide
the total row
detector X-ray beam into
aperture N subdivided
is 1/N beamsbeam
of the total X-ray (the
collimation). In a multislice CT system, while the total
X-ray collimation still indicates the volume coverage
speed, the detector row collimation, rather than the
total X-ray collimation, determines the z-axis
resolution, i.e. the slice thickness. In general, the larger
the number of detector rows N, the better the volume
coverage speed performance. In the multi-slice CT the
ray bundles not only fan out within the gantry plane
but also diverge from the gantry plane. This imaging
geometry is called the cone-beam imaging geometry,
which calls for special cone-beam reconstruction
algorithms. Because the scanner discussed has a
relatively small number of detector rows and therefore,
relatively small cone-beam divergence, parallel fan-
beam based reconstruction algorithms can be used to
approximate the cone-beam geometry.
DEVELOPMENT OF SCANNER TECHNOLOGY 53

Fig. 2.10: Schematic diagram of multiple detector-geometry

Selection of Section Thickness

Selection of thickness by the operator causes:
1. Move
Movement
ment of pre- and post-
post-patie
patient
nt collim
collimation
ation..
2. Sele
Selection
ction of detect
detector
or rows
rows that
that are
are combi
combined
ned with
the DAS to obtain specified section thickness.
Scanning Speed
Single section CT have a 360° gantry rotation speed of
1 second, multisection scanners can generate 4-16,32
sections per rotation depending upon the speed of the
gantry rotation and the number of detectors.
54 STEP BY STEP CT SCAN

Fig. 2.11: Schematic diagram of detector array configuration

Interpolation algorithms for multislice CT are

different from single slice, new type of image distor-
tion which can happen is cone-beam artifact because
the beam diverges slightly along the z-axis.
• Imp
Improv
roved
ed tempor
temporalal resolu
resolutio
tion—f
n—fast
aster
er scanni
scanning
ng
time results in fewer motion artifacts breathe hold
times are reduced.
DEVELOPMENT OF SCANNER TECHNOLOGY 55

Fig. 2.17: Schematic diagram showing the concept of dual pitch

• Im
Impro
proved
ved spat
spatial
ial reso
resolut
lution
ion—th
—thinn
inner
er setio
setions
ns
improve resolution in the z-axis, reducing partial
volume artifacts and increase the diagnostic
accuracy.
• De
Decre
crease
ased d image
image nois
noise—m
e—more
ore pati
patient
ent leng
length
th is
scanned per rotation, thus for extended length
study the X-ray tube current can be higher than for
single slice. This reduces image noise and improves
image resolution.
56 STEP BY STEP CT SCAN

• Longer
Longer anat
anatomi
omicc covera
coverage—
ge—isis due
due to simu
simulta
ltaneo
neous
us
registration of multiple sections and increased
gantry rotation speed, the coverage in the z-axis is
dependent on the number of data channels, pitch,
section thickness, scanning time, and the gantry
rotation time.
C=n×p×s×t/r
N = No.
No. of da
data
ta ch
chan
anne
nels
ls..
P = Pitch.
S = Se
Sect
ctio
ionn th
thic
ickn
knesess.
s.
T = Tim
Timee of
of ent
entir
iree sca
scann in
in sec
secononds
ds..
R = Rot
Rotat
atio
ion
n tim
timee in
in sec
secon
ondsds..

Pitch
Pitch is the parameter without units that provide
information about table travel relative to beam
collimation. It is defined as table travel per gantry
rotation to beam collimation.
In multisection CT two definition of pitch exist
because of the
th e confusion caused by some vendors
v endors the
orginal definition of pitch is preferred because it can be
applied to both single and multisection CT without
confusion.

Fig. 2.13
DEVELOPMENT OF SCANNER TECHNOLOGY 57

Fig. 2.14: Schematic diagram describing the difference in pitch

between single and multislice CT

Isotropic Scanning
Isotropic scanning refers to a situation were mpr images
can be created in any plane with the same spatial
resolution as the orginal sections for small body parts
is resolution is achieved using a small focal spot and
scanning with ultra thin sections.

Applications of Multislice CT
Musculoskeletal: with isotropic acquisitions (narrow
collimation, lowpitch, high mAs), the quality of
multiplanar reformations (MPRS) obtained is very high.
• CT angi
angiogr
ograph
aphy—l
y—long
ong cove
coverag
ragee possib
possible,
le, wit
withou
houtt
sacrificing spatial resolution,
• Card
Cardiac
iac scor
scoring,
ing, brai
brain
n perfu
perfusion
sion,, virtu
virtual
al endos
endoscopy,
copy,
coronary angiography.
Chapter 3

Technical
Parameters:
In General for All

Scanner Types
60 STEP BY STEP CT SCAN

TECHNICAL PARAMETERS
The quality of the image relates to the fidelity of the

CT numbersinand
differences to the accurate
attenuation reproduction
(low contrast of small
resolution) and
fine detail (spatial resolution). Good imaging
performance demands that image quality should be
sufficient to meet the clinical requirement for the
examination, whilst maintaining the dose to the patient
at the lowest level that is reasonably practicable.
In order to achieve this, there must be careful
selection of technical parameters that control exposure
of the patient and the display of the images, and also
regular checking of scanner performance with
measurement of physical image parameters as part of
a programme of quality assurance.

Display and Exposure Parameters with an

Influence on Image Quality and Dose
Nominal Slice Thickness
The slice thickness in CT is a value selected by the
operator according to the clinical requirement and
generally lies in the range between 1 and 10 mm. In
general, the larger the slice thickness, the greater the
low contrast resolution in the image; the smaller the
slice thickness, the greater the spatial resolution. If
the slice thickness is large, the images can be affected
by artifact, due to partial volume effects; if the slice
thickness is small (e.g. 1-2 mm), the images may be
significantly affected by noise.
TECHNICAL PARAMETERS 61

Inter-slice Distance/Pitch Factor

Inter-slice distance is defined as the couch increment

(distance) between
factor is the ratio oftwo
the slices.
couch In helical CT
increment perthe pitch
rotation
to the slice thickness at the axis of rotation. In clinical
practice the inter-slice distance generally lies in the
range between 2 and 10 mm, and the pitch factor
between 1 and 2. In general, for a constant volume of
investigation, the smaller the inter-slice distance or
pitch factor, the higher both the local dose and the
integral dose to the patient. The increase in the local
dose is due to superimposition of the dose profiles of
the adjacent slices. The increase in the integral dose is
due to an increase in the volume of tissue undergoing
direct irradiation as indicated by a packing factor.

Fig. 3.1: Schematic diagram of pitch

62 STEP BY STEP CT SCAN

In those cases where 3D reconstruction or

reformatting of the images in coronal, sagittal or
oblique planes is required, it is necessary to reduce
the inter-slice distance to zero or perform a helical
scan. In screening or examinations performed with
regard to control of disease it can be diagnostically
justifiable to have an inter-slice distance corresponding
to half the slice thickness or a pitch factor of 1.5 to 2.0.

Volume of Investigation
Volume of investigation, or imaging volume, is the
whole volume of the region under examination. It is
defined by the outermost margins of the first and last
examined slices or helical exposure. The extent of the
volume of investigation depends on the clinical needs;
in general the greater its value the higher the integral
dose to the patient, unless an increased inter-slice
distance or pitch factor is used.

Exposure Factors
Exposure factors are defined as the settings of X-ray
tube voltage (kV), tube current (mA) and exposure
time (s). In general, one to three values of tube voltage
(in the range
A high tubebetween
voltage80isand 140 kV) can befor
recommended selected.
high
resolution CT (HRCT) of the lungs and may be used
for examination of osseous structures such as the spine,
pelvis and shoulder. Soft tissue structures are usually
best visu
visualis
alised
ed usin
usingg the stan
standard
dard tube volt
voltage
age for
the given equipment. In some cases of quantitative
computed tomography (QCT), the same slice is
TECHNICAL PARAMETERS 63

examined with two different values of tube voltage,

in order to subtract corresponding images and derive
information about the composition of particular tissues.
At given values of tube voltage and slice thickness,
the image quality depends on the product of X-ray
tube current (mA) and exposure time (s), expressed in
mAs. Absolute values of mAs necessary for an imaging
task will depend on the type of scanner and the patient
size and composition. For a particular CT model, an
increase in radiographic exposure setting (mAs) is
accompanied by a proportional increase in the dose to
the patient. Relatively high values of radiographic
exposure setting (mAs) should, therefore, be selected

only in those cases where a high signal to noise ratio

is indispensable.
• TuTube
be po
pote
tent
ntia
ial—
l—8080 to 14
1400 kV
kV
• Vol
Voltag
tagee betwe
between en the
the fila
filame
ments
nts and anoanode
de .
• Hig
Higher
her pot
potent
ential
ial acc
accele
elerat
rates
es elec
electro
tronsns more
more..
• Tu
Tube
be cu
curr
rren
ent—
t—2020 to 50
5000 mA.
mA.
• CuCurre
rrent
nt flo
flowin
wing g thro
through
ugh the filfilam
ament
ent..
• Lar
Larger
ger cur
curren
rentt produ
produce cess more
more electr
electrons
ons and
and
greater X-ray beam intensity
Auto mAs option
Some manufacturers have provided this option were
the machine automatically selects the optimum mA for
a given slice without compromising the image quality
resulting in reduced dose.
Principle: This feature requires an ap/lateral scan to
obtain information on the X-ray attenuation, so that
the mA is increased automatically in areas of high
X-ray attenuation.
64 STEP BY STEP CT SCAN

Field of View
Field of view (FOV) is defined as the maximum

diameter
selected byofthe
theoperator
reconstructed image. Its
and generally liesvalue
in thecan be
range
between
betw een 12 and 50 cm. The cho choice
ice of a smal
smalll FOV
allows increased spatial resolution in the image,
because the whole reconstruction matrix is used for a
smaller region than is the case with a larger FOV; this
results in reduction of the pixel size. In any case, the
selection of the FOV must take into account not only
the opportunity for increasing the spatial resolution
but also the need for examining all the areas of possible
disease. If the FOV is too small, relevant areas may be
excluded from the visible image. If raw data are
available the FOV can be changed by post-processing.

Gantry Tilt
Gantry tilt is defined as the angle between the vertical
plane and the plane containing the X-ray tube, the
X-ray beam and the detector array. Its value normally
lies in the range between -25° and +25°. The degree of
gantry tilt is chosen in each case according to the clinical
objective. It may also be used to reduce the radiation
TECHNICAL PARAMETERS 65

dose to sensitive organs or tissues and/or to reduce

or eliminate artifacts.

Reconstruction Matrix
Reconstruction matrix is the array of rows and columns
of pixels in the reconstructed
reconstructed image,
image, typically 512 × 512.

Reconstruction Algorithm
Reconstruction algorithm (filter, or kernel) is defined
as the mathematical procedure used for the
convolution of the attenuation profiles and the
consequent reconstruction of the CT image. In most
CT scanners, several reconstruction algorithms are
available. The appearance and the characteristics of
the CT image depend strongly on the algorithm
selected. Most CT scanners have special soft tissue or
standard algorithms for examination of the head,
abdomen, etc. Depending on clinical requirements, it
may be necessary to select a high resolution algorithm
which provides greater spatial resolution, for detailed
representation of bone and other regions of high
natural contrast such as pulmonary parenchyma.

Reconstructional Interval
Spiral slice displays data from a continuous data
stream, that can be computationally manipulated to
represent varying amounts of projections from adjacent
slices. Thus, it is possible to reconstruct slices at
intervals smaller than the prescribed slice thickness.
If reconstruction interval is small with a large
acquisition pitch not much additional data can be
obtained.
66 STEP BY STEP CT SCAN

As a thumb rule 3 to 5 slices can be reconstructed

for a pitch of one 2 slices for a pitch of 2.
Finer reconstruction intervals may not prove
additional information, even though they may enhance
the visual effect of 3D images.

Window Width
Window width is defined as the range of CT numbers
converted into grey levels and displayed on the image
monitor. It is expressed in HU. The window width can
be selected by the operator according to the clinical
requirements,
requiremen ts, in order to produce an image from which
the clinical information may be easily extracted. In
general, a large for
a good choice window (for instance
acceptable 400 HU) represents
representation of a wide
range of tissues. Narrower window widths adjusted
to diagnostic requirements are necessary to display
details of specific tissues with acceptable accuracy.

Window Level
Window level is expressed in HU and is defined as
the central value of the window used for the display
of the reconstructed CT image. It should be selected
by
b y the viewer according to the attenuation
characteristics of the structure under examination.

Clinical and Associated Performance Parameters

A series of clinical factors play a special part in the
optimal use of ionising radiation in CT. They are
described here in order to ensure that an appropriate
CT examination is carried out, providing diagnostic
quality with a reasonable radiation dose for the patient.
TECHNICAL PARAMETERS 67

Figs 3.2A and B: Same image set in lung and mediastinal window

A CT examination should, therefore, only be carried

out on the basis of a justifiable clinical indication, and
exposure of the patient should always be limited to
the minimum necessary to meet clinical objectives.
68 STEP BY STEP CT SCAN

Adequate clinical information, including the records

of previous imaging investigations, must be available
to the person approving requests for CT.
In certain applications, in order to practice CT
effectively, prior investigation of the patient by other
forms of imaging might be required.

Supervision
CT examinations should be performed under the
clinical responsibility of a radiologist/practitioner
according to the regulations and standard examination
protocols should be available.
Effective supervision may support radiation pro-
tection of the patient by terminating the examination
when the clinical requirement has been satisfied, or
when problems occurring during the examination (for
example, unexpected uncooperation by the patient or
the discovery of contrast media residue from previous
examinations) cannot be overcome.
Problems and pitfalls: The responsible radiologist/
practitioner should be aware of clinical or technical
problems which may interfere with image quality. Many
of these are particular to specific organs or tissues and
may lead to modification of technique. The radiologist/
practitioner
manoeuvresand the may
which radiographer must
be used to be aware
overcome of
such
diagnostic or technical problems in order to provide a
clinically relevant examination.

Patient Preparation
The following patient-related operational parameters
play an important role for the quality of the CT
examination:
TECHNICAL PARAMETERS 69

Cooperation: Patient cooperation should be ensured as

far as possible prior to the examination. An explanation
of the procedure should be given to each patient. Good
communication with and control of the patient is
equally necessary during the whole examination.
Protective shielding: Relevant protection for sensitive
organs outside the imaging field is a lead-purse for the
male gonads, if the edge of the volume of investigation
is less than 10-15 cm away. The protection of female
gonads by wrap-around lead has not yet been
demonstrated.. Appropriate protection measures must
demonstrated
be applied to persons who, for clinical reasons or to
ensure cooperation, may need to accompany patients
in the examination room during the examination.
Clothing: The area of examination should be free of
external metal or other radio-dense items where
possible. Special attention must be given to eliminating
any X-ray dense material in the patient’s clothes or
hair.
Fasting: Fasting prior to the examination is not essential.
Restraint from food, but not fluid, is recommended if
intravenous contrast media are to be given.

Intravenous
examinationscontrast media:be
and must These are needed
employed in some
in a manner
appropriate to the clinical indication, taking into
consideration the risk factors.
Oral or cavitatory contrast media: Oral contrast medium
may be required in abdomino-pelvic examinations and
must be administered at times and in doses appropriate
to the indication. Administration of contrast medium
70 STEP BY STEP CT SCAN

per rectum may be required in some examinations of

the pelvis and a vaginal tampon should be used in
some examinations for gynaecological applications.
Positioning and motion : Most CT examinations are
carried out with the patient supine. In this position
the patient is most comfortable with the knees flexed.
Alternate positioning may be required to aid comfort
and cooperation, for appropriate display of anatomy,
to reduce absorbed radiation to particular organs, or
to minimise artifact. Motion should be kept to a
minimum to reduce artifacts; typical sources of arti-
facts are involuntary patient movement, respiration,
cardiovascular action, peristalsis and swallowing.

Examination Technique

Scanogram
A scanogram permits the examination to be planned
and controlled accurately, and provides a record of
the location of images. It is recommended that this is
performed in all cases. In general such imaging
provides only a small fraction of the total patient dose
during a complete CT procedure.

Clinical aspects of setting

These parameters mustthebe
appropriate technical
set according parameters.
to the area of
examination and clinical indication, as follows:
• Nom
Nomina inall slice
slice thic
thickne
knessss is
is chosen
chosen acc
accord
ording
ing to
to the
size of the anatomical structure or lesion that needs
to be visualised. Staff should be aware of the
implications of choice of slice thickness in relation
to the image quality and radiation dose to the
patient.
TECHNICAL PARAMETERS 71

• Inter-
Inter-sli
slice
ce dist
distanc
ancee is chose
chosenn accord
according
ing to
to the area
area
under examination and the clinical indication. Staff
should be aware of the risk of overlooking lesions
which fall in the inter-slice interval during serial
CT. In general, the interval should not exceed one
half of the diameter of suspected lesions. This
problem is absent in helical scanning, when an
appropriate reconstruction index is used.
• Fie
Field
ld of vie
view
w (FOV).
(FOV). Sel
Select
ection
ion of
of FOV
FOV must
must resp
respect
ect
image resolution and the need to examine all areas
of possible disease. If the FOV is too small, disease
may be excluded from the visible image.
• Exposure factors: Tube voltage (kV), tube current
(mA) and exposure time (s) affect image quality
and patient dose. Increasing exposure increases low
contrast resolution by reducing noise but also
increases patient dose. Patient size is an important
factor in determining the image noise. Image quality
consistent with the clinical indications should be
achieved with the lowest possible dose to the
patient. In certain examinations image noise is a
critical issue and higher doses might be required.
• The vol
volum
umee of inve
investi
stigat
gation
ion is
is the
the imagi
imaging
ng volum
volume,
e,
defined by the beginning and end of the region
imaged. It should cover all regions of possible
disease for the particular indication.
• Reconstruction algorithm: This is set according to the
indication and area under examination. For most
examinations, images are displayed utilising
algorithms suitable for soft tissues; other algorithms
available include those providing greater spatial
resolution for detailed display of bone and other
areas of high natural contrast.
72 STEP BY STEP CT SCAN

Helical or Spiral CT
• The rep
repeat
eating
ing of
of single
single scan
scans,
s, whic
which
h someti
sometime
mess
results from lack
CT, is reduced of patient
in spiral cooperation
CT because of theinshorter
serial
examination times involved.
• For pit
pitch
ch >1>1 the
the dose
dose will
will be
be reduc
reduced
ed comp
comparearedd
with contiguous serial scanning; there are no data
missing as may be the case with the use of an inter-
slice interval in serial CT.
• The prac
practic
ticee of usi
using
ng overl
overlappi
apping
ng scans
scans or thin
thin slice
slicess
in serial CT for high quality 3D display or multi-
planar reconstructions is replaced by the possibility
of reconstructing overlapping images from one
helical scan volume data set.
• Extrem
Extremelyely sho
shorte
rtened
ned exa
examin
minatiation
on tim
time:
e:
• Mak
Makeses it
it possib
possiblele to
to acqui
acquirere cont
continu
inuous
ous pat
patien
ientt
data during a single breath-hold; problems with
inconsistent respiration can thereby be avoided.
• Dis
Distur
turban
bances
ces due to invo involun
luntar
taryy move
movemen
mentsts
such as peristalsis and cardiovascular action are
reduced.
• May opt optimi
imize ze scan
scannin
ningg with
with the
the use
use of
of intra
intra--
venous contrast media.
• Ima
Images
ges can
can be rec
recons
onstru
tructe
ctedd for
for any
any couch
couch posit
position
ion
in the volume of investigation:
• Ana
Anatom
tomica
icall misr
misregi
egistr
strati
ation
on is avo
avoide
ided.
d.
• EqEquiv
uivoca
ocall lesion
lesionss can be be furthe
furtherr evalua
evaluated
ted
without additional patient exposure.
• The pospossib
sibili
ility
ty of
of displ
displayi
aying
ng the
the data
data vol
volum
umee in
transverse slices reconstructed at intervals
smaller than the X-ray beam collimation results
in overlapping slices which, in combination with
TECHNICAL PARAMETERS 73

reduced or eliminated movement artifacts,

makes it possible to perform high quality three-
dimensional (3D) and multi-planar reconstruc-
tions with smooth tissue contours. This is used
especially in skeletal and vascular imaging (CT
angiography).
Helical CT, however, has drawbacks such as:
• Ea
Ease
se of per
perfor
forma
mance
nce may
may temp
temptt the ope
operat
rator
or to
to
extend the examination unjustifiably, either by
increasing the imaging volume, or by repeated
exposure of a region.
• Alt
Althou
hough gh most
most ima
image
ge quali
qualityty para
paramet
meters
ers are
equivalent for contiguous serial CT and helical CT
performed with a pitch = 1, the performance of
helical CT with a pitch greater than 1.5 may imply
lower and possibly insufficient diagnostic image
quality due to reduced low contrast resolution
• Spa
Spatia
tiall resol
resoluti
ution
on in the z-d
z-dire
irecti
ction
on is low
lower
er than
than
indicated by the nominal slice width unless special
interpolation is performed.
• The tec
techni
hniqu
quee has
has inh
inher
erent
ent art
artifa
ifact.
ct.
When using helical CT in conjunction with intra-
venous injection of contrast media to provide optimally

enhanced images,
to intravenous carefulis timing
injection of exposure relative
mandatory.

Image Viewing Conditions

It is recommended that initial reading of CT images is
carried out from the TV monitor. Display of images
and post-processing image reconstruction should be
at a display matrix of at least 512 × 512.
74 STEP BY STEP CT SCAN

Brightness and contrast control on the viewing

monitor should be set to give a uniform progression
of the grey-scale from black to white. A calibrated
grey-scale would be preferable.
Settings of window width and window level dictate
the visible contrast between tissues and should
generally be chosen to give optimum contrast between
normal structures and lesions.

Film Processing
Optimal processing of the film has important implica-
tions for the diagnostic quality of the image stored on
film. Film processors should be maintained at their
optimum operating conditions as determined by the
manufacturer and by regular and frequent quality
control procedures.

Physical Parameters: Physical Measures of

Scanner Performance
The quality of the CT image may be expressed in terms
of physical parameters such as uniformity, linearity,
spatial resolution, low contrast resolution and absence
of artifacts according to IEC recommendations. It
depends on the
scanner, the technological
exposure characteristics
factors used and imageofviewing
the CT
conditions. Quality may be assessed by quantitative
measurement of the parameters listed above, using
suitable test phantoms, and by the appearance of
artifacts. These measurements should be conducted
regularly, in order to guarantee the maintenance of
performance of the CT scanner during its whole period
TECHNICAL PARAMETERS 75

of use. It is essential that such technical quality control

has been performed when using the criteria presented

in these guidelines.
Test Phantoms
Test phantoms (phantom of a standardised human
shape or test objects of a particular shape, size and
structure) are used for the purposes of calibration and
evaluation of the performance of CT scanners.
Performance is checked by acceptance tests after
installation and important repairs, and by periodic
quality control tests, as established in standardised
protocols. A number of test phantoms are commercially
available and most manufacturers provide one or more
test objects.
The test phantoms should allow for the following
parameters to be checked: mean CT number, unifor-
mity, noise, spatial resolution, slice thickness, dose and
positioning of couch.

CT Number
The accuracy of CT number is verified by scanning a
test object utilising the usual operating parameters and
reconstruction algorithms. The CT number is affected
by the X-ray tube voltage, beam filtration and object
thickness. The CT number of water is by definition
equal to 0 HU and the mean CT number measured
over the central region of interest (ROI) should be in
the range +/- 4 HU.
76 STEP BY STEP CT SCAN

Linearity
Linearity concerns the linear relationship between the
calculated
coefficient ofCT number
each and
element the object.
of the linear Itattenuation
is essential
for the correct evaluation of a CT image and, in
particular, for the accuracy of QCT. Deviations from
linearity should not exceed +/- 5 HU over specific
ranges (soft tissue or bone).

Uniformity
Uniformity relates to the requirement for the CT
number of each pixel in the image of a homogeneous
object to be the same within narrow limits over various
regions of the object such as a cylindrical 20 cm
diameter phantom of water-equivalent plastic. The
difference in the mean CT number between a
peripheral and a central region of a homogeneous test
object should be < 8 HU. Such differences are largely
due to the physical phenomenon of beam hardening.

Noise
Picture element (pixel) or image noise is the local
statistical fluctuation in the CT numbers of individual
picture elements of a homogeneous ROI. Noise is
dependent on the radiation dose and has a marked
effect on low contrast resolution. The magnitude of
the noise is indicated by the standard deviation of the
CT numbers over a ROI in a homogeneous substance.
It should be measured over an area of about 10% of
the cross-sectional area of the test object. Image noise
diminishes with the use of a slightly flattened
TECHNICAL PARAMETERS 77

convolution kernel, with simultaneous reduction of

spatial resolution and an increase in low contrast
resolution. Image noise is inversely proportional to
the square root of the dose and to the slice thickness.
For example, if the dose is halved then the noise will
only increase by about 40 percent. Conversely, a
reduction in slice thickness requires a proportionate
increase in dose in order to avoid an increase in noise.
The medical problem under study and the corres-
ponding image quality required should determine
what level of image noise and what patient dose are
reasonably practicable.

Spatial Resolution
Spatial resolution at high and low contrast are
interdependentt and critical to image quality and good
interdependen
imaging of diagnostically important structures.
The spatial resolution at high contrast (high contrast
resolution) determines the minimum size of detail
visualised in the plane of the slice with a contrast >10
percent. It is affected by the reconstruction algorithm,
the detector width, the slice thickness, the object to
detector distance, the X-ray tube focal spot size, and
the matrix size.
The spatial resolution at low contrast (low contrast
resolution) determines the size of detail that can be
visibly reproduced when there is only a small
difference in density relative to the surrounding area.
Low contrast resolution is considerably limited by
noise. The perception threshold in relation to contrast
and detail size can be determined, for example, by
means of a contrast-detail curve. In such determi-
78 STEP BY STEP CT SCAN

nations, the effects of the reconstruction algorithm and

of the other scanning parameters have to be known.
Dose and the corresponding image noise greatly affect
low contrast resolution.

Slice Thickness
The slice thickness is determined in the centre of the
field of view as the distance between the two points
on the sensitivity profile along the axis of rotation at
which response has fallen to 50 percent. Certain
deviations in thickness should not be exceeded because
of the effect of slice thickness on image detail; for
example, with a nominal slice thickness > 8 mm, a
maximum deviation of ± 10 percent is acceptable;
tolerable deviations for smaller slice thickness of 2 to
8 mm and < 2 mm are ± 25 percent and ± 50 percent,
respectively.
The use of post-patient collimation, which is
inherent in some CT equipment to reduce the slice
sensitivity profile, leads to significant increases in the
patient dose for a series of contiguous slices.

Stability of CT Numbers

Stability
constancyisofdefined as the
CT number maintenance
and overtime
of uniformity. of
It can be
checked by means of a suitable test object, containing
at least three specimens of different materials, e.g.
water, Polymethyl-methacrylate (PMMA) and Teflon.
Deviations should not exceed +/- 5 CT numbers with
respect to initial mean values. A similar tolerance
should be applied in the verification of uniformity, as
measured in three ROIs, each containing approximately
TECHNICAL PARAMETERS 79

100 pixels and placed respectively at the centre, at the

periphery, and in a position intermediate between the
centre and the periphery of the reconstructed image.

Positioning of Couch
The accuracy of positioning of the patient couch is
evaluated by moving the loaded couch a defined
distance relative to the gantry and subsequently
moving it back to the start position. Positional accuracy
includes both deviation in longitudinal positioning and
also backlash. Maximum tolerances of ±2 mm apply to
both criteria. These also apply to mobile CT equipment
equipment..

Image Quality Modification Based on the

Clinical Requirement
High Signal to Noise
• Useful in lung nodule characterization.
• COPD.
• Co
Coro
ronar
naryy ar
arter
tery
y cal
calcif
cifica
icatio
tion.
n.

Low Signal to Noise Task

• Abdominal scscans.
• Di
Diff
ffus
usee lu
lung
ng di
dise
seas
ase.
e.

Medium Signal to Noise Task

• Br a i n .
• Pae
aed diaiatr
tric
ic sc
scaans
ns..
Chapter 4

Practical Overview
of Performing
a CT Scan
82 STEP BY STEP CT SCAN

PATIENT POSITIONING 1
The scan procedure start with patient positioning
within thethe
although gantry,
designtheofparts of the vary
machines gantrybetween
is showed,
the
manufacturers the basic principles remain the same.
• Ima
Image
ge qual
quality
ity sta
starts
rts wit
with
h prope
properr posit
position
ioning
ing..
• Poo
Poorr pati
patient
ent pos
positi
itioni
oning
ng caus
causee arti
artifac
facts.
ts.

MAIN COMPONENTS
Gantry
Function
The gantry incorporates the X-ray tube unit, the high-
light detector and DAS (Data acquisition system)
inside. It also provides the following functions.
• Display panel: The display shows the reading of the
gentry tilt, table height, position of landmark, latch
status, scannable range and tilt range.

Fig. 4.1: Diagram of CT scan gantry

PRACTICAL OVERVIEW OF PERFORMING A CT SCAN 83

• Emergency button: Pressing the emergency button

stops every mechanical movement and the X-ray

• emission.
Control panel: The control panel incorporates the
several buttons to mainly control the movements
of the gantry and table. Each front and rear cover
has two control panels.
• Positioning light and breath navi: The Halogen
will be emitted through here that will be used to
position a patient breath navi gives the visual
breathin
brea thing
g ins
instruc
tructio
tions
ns to a pat
patien
ientt wit
withh hea
hearing
ring
problem.

Table
Function
The table is used to load a patient for scanning.
• Cradle: The cradle moves into or out of the gantry
aperture.
• Latch button: The latch button is used to latch or
unlatch the cradle. The unlatched cradle can be
manually slid. The display panel shows whether
the cradle is latched.
• Speaker: The speaker is used to deliver oral instruc-
tions to a patient.
• Mat switch: The mat switch is placed at the foot of
the table. When the operator steps on it, the switch
turns on and activates functional buttons on the
gantry panel.
84 STEP BY STEP CT SCAN

Fig. 4.2: Diagram of a CT scan couch

Operator Console (OC)

Function
The operator console (OC) is mainly used for the
operator to set up the scan procedures and process
the resultant image data.
• Scan/display monitor: The 17 inch monitor (21 inch
optional) on the OC can be mainly used for two
purposes, scanning patients and displaying images.
• Keyboard/Mouse: Please refer to the User Interface

on page
• Main 1-10Please refer to the System power On/
switch:
Off on page 1-22
• CD-ROM drive: This drive is dedicated to service
of application software installation.
• MOD (Magnetic Optical Disk) drive (optional): Image
data can be stored in 5 inch MOD.
PRACTICAL OVERVIEW OF PERFORMING A CT SCAN 85

Fig. 4.3: Diagram of CT scan console

Caution: It is highly recommended to always take back-

up image data because of a possibility of medium
breakdow
brea kdown. n.

PATIENT POSITIONING 2
1. In order
order to safely
safely lay a patie
patient
nt on the cradl
cradle,
e, make
make
sure first that the cradle is locked.

Fig. 4.4: Diagram of gantry display panel

86 STEP BY STEP CT SCAN

2. Press
Press a posit
positioning
ioning light butt
button
on on the gantry
gantry
control panel to light a halogen marker (Refer to

chapter
3. Match
Matc 1 forhalog
h the the function
halogen of gantry
en marker
marker to ancontrol panel).
anatomica
anato micall
landmark of the patient by using control buttons
on the gantry control panel.

Fig. 4.5: Diagram depicting tomographic planes

Patient positioning ends when the table location

figure is displayed on the display panel.

PATIENT POSITIONING 3

Main Landmarks for CT Examination

The following landmarks are usually in CT examina-
tions (Fig. 4.6).

New Patient 1
Select (new patient) to initiate a new examination.
1 . Selec
Selectt (New
(New patien
patient)t) to
to open
open the follow
following
ing patien
patientt
information/protocol selection screen.
PRACTICAL OVERVIEW OF PERFORMING A CT SCAN 87

Fig. 4.6: Diagram showing normal landmarks for positioning

GB: Glabella OM: Orbital meatal line

EM: External auditory meatus SN: Sternal notch
XY: Xyphoid CM: Costal margin
IC: Iliac crest UB: Umbilicus
SP: Symphysis pubis

2. Enter
Enter the pat
patien
ientt demog
demograp
raphic
hic dat
data.
a.
Note: As a minimum, the patient ID must be entered
– Exam number: (within 12 characters)
– Accession number: (within 16 characters)
– Patient ID: (within 16 characters)
– Patient’s name: (within 64 characters)
88 STEP BY STEP CT SCAN

Fig. 4.7: Sample scout of CT/ e GE scanner

SCOUT PRESCRIPTION SCREEN

Axial/Helical Scan Prescription 1
Axial/Helical Prescription (View/Edit)
(View/Edit) Screen
After scout scan, you may proceed to the following
axial/helical prescription screen to perform axial, helical
or cine scans.
• I mage area: Images will be displayed here. This
image area can be enlarged to full screen by clicking
on the small square icon located in the upper right
corner.
• Prior/Next: Prior or next key appears on the screen
only when more than three groups are prescribed.
PRACTICAL OVERVIEW OF PERFORMING A CT SCAN 89

Fig. 4.8: Sample page for planning act study from CT/e GE scanner

SCAN RECONSTRUCTION PARAMETERS

Prospective Multiple Reconstruction
• Recon
Recon type:
type: Soft
Soft,, STND
STND,, STD+
STD+,, DETL
DETL,, chest,
chest, bon
bonee
edge or PERM
• Ima
Image
ge filte
filters:
rs: Smoo
Smooth th (S1,
(S1, S11, S2, S21, S3), Edg
Edgee
(E1, E2, E21, E22, E23), Lung (L1, L2, L3)
• Ma
Matri
trix
x size:
size: 256 × 256,
256, 320
320 × 320 or 512
512 × 512
• Mo
Moti
tion
on cor
corre
rect:
ct: Mo
Motition
on cor
corre
rect
ctio
ion
n
90 STEP BY STEP CT SCAN

• Special
Special filt
filter:
er: ANR (Ad
(Advanc
vanced
ed nois
noisee redu
reductio
ction)
n)
(1 or 2) AAR (Arm artifact reduction) (1 or 2)

ANR filter allows

compromising spatial you to reduce
resolution. noise without
It contributes to a
decrease in standard deviation by approximately 10
percent which may be equivalent to one-step decrease
in mA.
AAR filter allows you to reduce artifacts shown
around arms.
When you click on the (Special filter) button or the
each special filter field, the following menu appears.

N o ne ANR 1 ANR 2 AAR 1 AAR 2 Cancel

(ANR 2) has a stronger effect than (ANR 1). Also,

(AAR 2) has a stronger effect than (AAR 1). Select
either of them or select (none) not to use this filter.
When you need to return to the parameters of recon
1, simply select (show recon 1),
1. If you need to perform
perform the third
third reco
reconstr
nstruct
uction,
ion,
select (show recon 3), then take the same steps as
recon 2.
2. Sel
Select
ect (Co
(Confi
nfirm
rm)) to int
intiat
iatee a scan
scan..
Note: During the scan, only the set of recon 1 will be
reconstructed. In order to activate recon 2 or 3, select
any of the following buttons (end exam), (create new
series), (next series), (select new protocol) or (repeat
series).

Technique
Generation of scout images: Patient lies supine on scanning
couch and is advanced towards the scanning field in
PRACTICAL OVERVIEW OF PERFORMING A CT SCAN 91

the gantry. A scout film is generated by generating

the X-ray beam and passing the relevant part of the

patient
Thisincontinuous
one movement through
exposure the gantry.
as the patient moves
through the beam generates a topogram resembling
an X-ray from the scout the position number and
angulation of the subsequent slices are chosen.

Imaging Planes
• Axial—advantage of direct right-left comparison.
Ease of performance.
• Coronal—geometric advantage of offering scans at
right angles to major bone structures. Helps to
clarify the relationship of a lesion seen in axial
sections.
• Sagittal—useful for assessing midline structures.
Usually a reformatted projection as direct sagittal
aquisition is anatomically difficult to obtain .
Chapter 5

Image Acquisition
Protocols
94 STEP BY STEP CT SCAN

Protocols are guidelines used to scan a particular area

of interests, they are flexible and should be adapted

to
cansuit
be the patient.
changed Parameters
when used Used
appropriate. are not
asrigid
a tooland
to
reduce radiation dose.

FACTORS TO BE CONSIDERED FOR SCAN

PLANNING
• Positi
Posi tion
onin
ing
g and
and scscou
out.t.
• Type
Ty pe of sc
scan
an—a
—axixial
al or he
heli
lica
cal.
l.
• Slice th
thickness.
• Incr
Increm
emenentt of
of gan
gantrtry
y mov
movememenent.
t.
• Expo
Ex posu
sure
re fa
fact
ctor
ors—
s—kVkVp,p, mA
mAs.s.
• Field of view.
• Pitch.
• Cont
Co ntra
rast
st cons
considider
erat
atio
ion.
n.

Slice Thickness
• Slice
Slice thick
thicknes
nesss is deter
determin
mineded by beam
beam coll
collim
imati
ation,
on,
size thickness is dependent on the size of the
detectors and is usually about 10 mm.
• Thi
Thinn slices
slices pro
produ
duce
ce bette
betterr spatia
spatiall resolu
resolutio
tion.
n.
• Rad
Radiat
iation
ion dose
dose in CT is inve
inverse
rsely
ly propo
proporti
rtiona
onall to
slice thickness.

Incrementation
• Increm
Increment
entati
ation
on is defi
defined
ned as
as the dist
distanc
ancee betwee
between
n
scans.
• The sta
starti
rting
ng poin
pointt of the sca
scann is def
define
inedd as 0,
distance is measured from this location as S or I
(superior or inferior).
IMAGE ACQUISITION PROTOCOLS 95

• In helic
helical
al scans
scans the
the image
image incr
increm
ement
entss may
may be
changed after the scan has been completed.

• Overla
Overlappi
small pping
ng scans
lesions scanstocan
are can
be be used for 3D
used
displayed. 3D refor
reformat
mation
ions,
s,

Field of View
• Deter
Determin
mines
es the
the size
size of the
the ima
image
ge on the scrscreen
een..
• Fro
Fromm a giv
given
en FOV,
FOV, FOV may be chan changed
ged sma
smalle
llerr
after completion of scan, but cannot be changed to
larger.
• Te
Techn
chnolo
ologis
gistt should
should sel
select
ect FOV
FOV to suit
suit the
the patie
patient
nt
and anatomy.
• Sm
Small
all FOV enh
enhanc
ances
es the
the spa
spatia
tiall resol
resoluti
ution.
on.

Exposures
• kVp
kVp defi
define
ness the
the qual
qualit
ity
y of ththee beam
beam..
• Hi
Highe
gherr kVp
kVp is neeneededed d for
for penet
penetratration
ion of
of thick
thick
anatomy.
• Thi
Thin
n secti
sections
ons req
requir
uiree highe
higherr kVp
kVp so as as to impr
improve
ove
the signal to noise ratio.
• mA
mAss defi
define
ness the
the quan
quanti tity
ty of
of the
the beam
beam..
• Lo
Loww mAs
mAs wiwill
ll de
degr
grad
adee the
the im
imagage.
e.
• Hig
Highh mAs
mAs will
will incr
increas
easee the
the heat
heat gene
generat
ration
ion and
decrease the life of the scan.
• Patien
Patientt dose
dose is
is increa
increased
sed wit
withh increa
increased
sed mA
mAs.
s.

Pitch
• It is
is defin
defined
ed as
as the
the ratio
ratio of the
the speed
speed of table
table to the
the
slice thickness.
• Hi
Highgher
er pit
pitch
ch red
reduc
uces
es the
the sca
scan
n time
time..
96 STEP BY STEP CT SCAN

• If the
the table
table move
movess exactl
exactly
y the sam
samee as slic
slicee thickn
thickness
ess
through one tube rotation, the pitch is said to be

• one.
Pitch
Pitch ooff 2 mean
meanss the
the table
table mo
moves
ves a total
total of 2x
2x the
the
slice thickness which results in a faster scan.

CRANIUM
• Brain, general
• Skull base
• CT ang
ngiiography.

FACE AND NECK

•
• F
Paectreoaunsdbsoinneuses
• Orb i ts
• Sell
Se llaa and
and hyp ypopophy
hyssis
• Saliva
Sal ivaryry gland
glandss (Paro
(Parotid
tid and
and subm
submand
andibu
ibular
lar))
• Pharynx
• L ar y nx .

SPINE
• Ve
Vert
rteb
ebra
rall and para
paraver
verte
tebr
bral
al stru
structu
cture
ress
• Lu
Lumb
mbar
ar spi
spine
ne,, disc
discal
al her
herni
niat
atio
ion.
n.

CHEST
• Chest, general
• Chest, mediastinal vessels
• Che
Chest,
st, HR
HRCT
CT (Hig
(High
h Resol
Resoluti
ution
on Comp
Compute
uted
d Tomo
Tomo--
graphy).
IMAGE ACQUISITION PROTOCOLS 97

ABDOMEN AND PELVIS

• Abdom
omeen, gene
nerral
• Liver and spleen
• Kidneys
• Pancreas
• Adrenal glglands
• Pelvis
is,, ge
general.

BONES
BONES AN
AND
D JOI
JOINT
NTS
S
• Osseous pe pelvis
• Shoulder jo joint
• Elbow joints
• Wr i s t
• Hip
• Knee
• An k l e .

CT Brain
Indication: Trauma, cerebrovascular accidents, seizures,
congenital lesions, meningitis.
Patient preparation: Information about the procedure;
restraint from food, but not fluid, is recommended, if

intravenous contrast media are to be given.

Scanogram: Lateral scano from vertex to maxilla.
Image criteria: Visualization of all brain structures, skull
base and sinus if needed.
FOV: Head dimension (about 24 cm).
98 STEP BY STEP CT SCAN

Fig. 5.1: Digital scanogram showing slice planning for brain

Gantry tilt: 0 to –10° from OM for axial scanning.

• X-ray tube voltage (kV): Standard
• Tube current and exposure time product (mAs): Should
be as low as consistent with required
required image quality
• Reconstruction algorithm: Standard
• Window width: 1500-3000 HU (bones)140-1000 HU
(soft tissue)
• Window level: 200-400 HU (bones)30-100 HU (soft
tissue).
IV contrast: 40 ml of ionic/nonionic contrast.

Circle of Willis: R/O Aneurysm

Specific anatomic region: Circle of Willis.
Application: R/O aneurysm.
Injection rate: 3 ml/sec
IMAGE ACQUISITION PROTOCOLS 99

Contrast volume and type: 90 ml of nonionic contrast.

Area scanned: Entire brain (with a single box over the
circle of Willis area s5- s40 table position).
Scan delay: Usually 15-20 sec.
Length of spiral (time): 40 sec.
Slice thickness: 1 mm.
Table speed/pitch: 1.
Reconstruction Interval: 0.5 mm.
3D technique used: Mip/volume rendering .

FACE AND SINUSES

Indications: Trauma, malformations, malignancies and
inflammation.

Fig. 5.2: Digital scanogram showing slice planning for face

100 STEP BY STEP CT SCAN

Preliminary investigations: Appropriate X-ray exami-

nation of the face except for isolated evaluation of the

sinuses.
Patient preparation: Information about the procedure;
restraint from food, but not fluid, is recommended, if
intravenous contrast media are to be given.
Scan projection radiograph: Lateral from jaw to vertex.

Image Criteria
• Visualization of entire face from palate to the top
of the frontal sinus.
• Vessels after intravenous contrast media.
FOV: Head dimension (about 24 cm).
Gantry tilt: 0 to –10° from OM for axial scanning of the
face; according to the patient position for coronal
scanning.
X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: High resolution or standard.

Window width: 1500-3000 HU (bones), 140-1000 HU (soft

tissue).
Window level: 200-400 HU (bones), 30-100 HU (soft
tissue).
Pitfalls : Artifacts from teeth or dental prothesis/
fillings.
Modification to technique: Change of gantry angulation
or patient position to avoid artifact.
IMAGE ACQUISITION PROTOCOLS 101

Examination of the sinuses in a prone position to

keep inflammatory secretion away from the osteo-

meatal complex.of the sinuses for functional endoscopic

Examination
sinus surgery is best performed directly in the coronal
plane.
IV contrast— 60–120 ml of ionic/nonionic contrast
based on the indication.

Figs 5.3A and B: Axial and coronal digital scanograms showing slice
pan for temporal lobe
102 STEP BY STEP CT SCAN

PETROUS TEMPORAL BONE

Indications: Hearing deficits, inflammation, vertigo,
facial or acoustic nerve diseases, malformations, bone
diseases and trauma.
Preliminary investigations: Examination of acoustic and
labyrinth function, evoked potentials; appropriate
X-ray examination of skull, base and petrous bone may
only occasionally be necessary.
Patient preparation: Information about the procedure;
restraint from food, but not fluid, is recommended, if
intravenous contrast media are to be given.
Scan projection radiograph:
above skull base. Lateral from mastoid to

Image Criteria
• Visualization of entire petrous bone.
• Vessels after intravenous contrast media.
Patient position: Supine, for axial scans; supine or prone
for coronal scans.
Volume of investigation: From 0.5 cm below to 0.5 cm
above the petrous bone.
Nominal slice thickness: 1-3 mm.
Inter-slice distance/pitch: Contiguous or a pitch = 1.0.
FOV: Head dimension (about 24 cm); secondary
reduction of FOV is necessary for evaluation of subtle
pathology.
Gantry tilt: OM line or tilted above OM line for axial
scanning; according to the patient position for coronal
scanning.
IMAGE ACQUISITION PROTOCOLS 103

ORBITS

Indications: Structural diseases of the orbits and orbital

content, trauma, foreign body.
Advisable preliminary investigations: Evaluation of visual
function; evoked potentials; appropriate X-ray exa-
mination of the orbits may occasionally be necessary.
104 STEP BY STEP CT SCAN

Patient preparation: Information about the procedure;

restraint from food, but not fluid, is recommended, if

intravenous contrast media are to be given.

Scan projection radiograph: Lateral from jaw to vertex.
Image criteria:
Visualization of
• Entire orbits
• Osseous walls
• Ves
Vessel
selss after
after int
intrav
raveno
enous
us con
contra
trast
st med
media
ia
Patient position: Supine for axial scans; supine or prone
for coronal scans.

Volume orbital cavity.From 0.5 cm below to 0.5 cm

of investigation:
above the
Nominal slice thickness: 2-5 mm.
Inter-slice distance/pitch: Contiguous or a pitch = 1.0.
FOV: Head dimension (about 24 cm); secondary
reduction of FOV is necessary for evaluation of subtle
pathology.
Gantry tilt: -6 to -10° from OM or parallel to the optic
nerve for axial scanning; according to the patient
position for coronal scanning.
X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: High resolution or standard
Window width: 140-300 HU (soft tissue), 2000-3000 HU
(bones), about 4000 HU (special orbit window).
IMAGE ACQUISITION PROTOCOLS 105

Window level: 30-40 HU (soft tissue), 200-400 HU

(bones), about 0 HU (special orbit window).

Motion: Movement artifact deteriorates image quality

(prevented by head fixation or sedation of non-
cooperative patients).
Intravenous contrast media: Useful to identify vascular
structures and enhancing lesions.
Pitfalls
• Cal
Calcif
cifica
icatio
tions
ns vers
versus
us cont
contras
rastt enhan
enhancem
cement
ent
• For
Foreig
eignn bodi
bodies
es (be
(beam
am har
harden
dening
ing art
artifa
ifacts
cts))
• ArArtif
tifact
actss from orbi
orbital
tal or denta
dentall prothes
prothesis/
is/fil
fillin
lings.
gs.
Modification to technique: Change of gantry angulation
or patient position to avoid artifact.
IV contrast: 40-60 ml based on indication.

SELLA
Indications: Suspicion of sellar or hypophyseal altera-
tions (endocrinological diseases, visual defects,
alterations of ocular motility).
Scan projection radiograph: Lateral from C2 to above skull
base.
bas e.
Image criteria:
Visualization of:
• Ent
Entire
ire hypo
hypophy
physea
seall region
region incl
includ
uding
ing osse
osseous
ous wall
wallss
• Ve
Vesse
ssels
ls afte
afterr intra
intraven
venous
ous con
contra
trast
st medi
media.
a.
Patient position: Supine for axial scans; supine or prone
for coronal scans.
Volume of investigation: From 0.5 cm below to 0.5 cm
above the hypophyseal region.
106 STEP BY STEP CT SCAN

Nominal slice thickness: 2-3 mm.

Inter-slice distance/pitch: Contiguous or a pitch = 1.0.
FOV: Head dimension (about 24 cm); secondary
reduction of FOV is necessary for evaluation of subtle
pathology.
Gantry tilt: OM line for axial scanning; according to
the patient position for coronal scanning.
X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.

Reconstruction algorithm: Soft tissue or high resolution.

Window width: 140-300 HU (soft tissue), 2000-3000 HU
(bones).
Window level: 30-40 HU (soft tissue), 200-400 HU (bones)
Pitfalls:
• For
Foreig
eign
n bodi
bodies
es (be
(beam
am har
harden
dening
ing art
artifa
ifacts
cts))
• Art
Artifa
ifacts
cts fro
from
m dent
dental
al pro
prothe
thesis
sis/fi
/filli
llings
ngs..
Modification to technique: Change of gantry angulation
or patient position to avoid artifact.

IV contrast: 50-80 ml based on indication.

PHARYNX

Indications: Diagnosis of parapharyngeal masses; T/N

staging of pharyngeal neoplasms.
Advisable preliminary investigations: Endoscopy may be
performed.
IMAGE ACQUISITION PROTOCOLS 107

FIGURE 5.4: Digital scanogram showing slice plane for pharynx

Patient preparation: Information about the procedure;

restraint from food, but not fluid, is recommended, if
intravenous contrast media are to be given.
Scan projection radiograph: Lateral from orbital roof to
root of neck.
Image criteria:
Visualization of:
• Entire ph pharynx
• Re
Regio
gional
nal lymp
lymph h node
node areas
areas and
and associ
associate
ated
d muscl
muscles
es
• Base of the skull
• Es
Esop
ophahago
goph
phararyn
ynge
geal
al ju
junc
ncti
tion
on
• Ve
Vesse
ssels
ls afte
afterr intra
intraven
venous
ous con
contra
trast
st medi
media.
a.
Patient position: Supine.
Volume of investigation: Nasopharynx: from sphenoid
bone to hyoid bone and continue to root of the neck
108 STEP BY STEP CT SCAN

for N-staging of neoplasms; oropharynx/hypopharynx:

from palate to root of the neck.
Nominal slice thickness: 3-5 mm serial or preferably
helical.
Inter-slice distance/pitch: Contiguous, but for large
lesions distances
distances of < 3-5 mm or a pitch up to 1.5-2.0
may be used.
FOV: Adjusted to the minimum required to demon-
strate complete cross-section of the face. Reduction of
FOV may be necessary for the evaluation of subtle
pathologies.

Gantry tilt: None.

X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with image quality.
Reconstruction algorithm: Soft tissue/standard or if
necessary high resolution.
Window width: 300-500 HU.
Window level: 0-30 HU (unenhanced examination),
30-60 HU (enhanced examination).
Pitfalls:
• Art
Artifa
ifact
ct fro
fromm dent
dental
al pro
prothe
thesis
sis/fi
/filli
llings
ngs
• Appo
Appositi
sition
on of the phar
pharynge
yngeal
al muc
mucosaosall folds
folds may
obscure pathology
• PoPool
olin
ingg of sal
saliv
ivaa may
may mimi
mimicc path
pathol
olog
ogyy
• Sup
Superf
erfici
icial
al muco
mucosalsal ext
extent
ent of neop
neoplasm
lasmss may
may not
not
be identified
• Sec
Secret
retion
ion fro
fromm orop
orophar
haryng
yngeal
eal neo
neopla
plasms
sms..
IMAGE ACQUISITION PROTOCOLS 109

Modification to technique:
• Cor
Corona
onall section
sectionss for demon
demonstr
strati
ating
ng the rela
relatio
tionsh
nship
ip

• of disease
Exposu
Exp osure to the
re wit
with opskull
h open mbase
en mout
outhh or wit
withh oral
oral Vals
Valsalv
alvaa
to open nasopharyngeal folds
• Cha
Change
nge of
of gantry
gantry ang
angula
ulatio
tion
n or pati
patient
ent pos
positi
ition
on to
avoid artifact.
IV contrast: 60-80 ml based on indication.

LARYNX
Indications: T/N staging of neoplasm; evaluation of
congenital or post-traumatic abnormalities of airway.
Advisable preliminary investigations: Larnygoscopy, MRI
may be alternative examinations.
Patient preparation: Information about the procedure;
restraint from food, but not fluid, is recommended, if
intravenous contrast media are to be given.
Scan projection radiograph: Lateral from floor of mouth
to thoracic inlet.
Image criteria:
Visualization of:
• Entire larynx
• Par
Paralar
alarynge
yngeal al tissu
tissues,
es, incl
includi
uding
ng muscl
muscles,
es, bloo
blood
d
vessels and the thyroid gland
• Re
Regi
gion
onal
al ly
lymp
mph h nod
nodee are
areasas
• Sp
Spin
inee and
and para
paravevert
rteb
ebra
rall musc
muscleless
• Ve
Vesse
ssels
ls afte
afterr intra
intraven
venous
ous con
contra
trastst medi
media.
a.
Patient position: Supine.
110 STEP BY STEP CT SCAN

Volume of investigation: From base of tongue to root of

neck.
Nominal slice thickness: 3-5 mm serial or preferably
helical CT, especially in patients having difficulties with
salivary pooling.
Inter-slice distance/pitch: Contiguous, but for large
lesions distances
distances of < 3-5 mm or a pitch up to 1.5-2.0
may be used.
FOV: Adjusted to the minimum required to demon-
strate complete cross-section of the neck. Reduction
of FOV may be necessary for the evaluation of subtle
pathologies.
Gantry tilt: None or modified parallel to the line of
vocal folds on scan projection radiograph.
X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: Soft tissue/standard or if
necessary high resolution.
Window width: 250-500 HU.
Window level: 0-30 HU (unenhanced examination)
30-60 HU (enhanced examination).
Pitfalls:
• Mov
Movem ement
ent art
artifa
ifact
ct due to res
respir
pirati
ation
on
• Sta
Stagin
gingg errors
errors due
due to
to poor
poor discr
discrim
imina
inatio
tion
n betwee
between
n
normal and abnormal tissues
• SaSali
liva
vary
ry poo
pooli
ling
ng may
may mim
mimicic pat
patho
holo
logy
gy
IMAGE ACQUISITION PROTOCOLS 111

• Displ
Displace
aceme
ment
nt of voc
vocal
al fold
fold by
by adjac
adjacent
ent mas
masss may
may
mimic glottal involvement.
Modification to technique:
• Re
Refor
format
matted
ted ima
images
ges may
may requi
require
re thin
thin seria
seriall slices
slices
if helical CT is not available
• Sec
Sectio
tions
ns throu
throughgh glott
glottis
is may
may be obt
obtain
ained
ed dur
duringing
phonation.
IV contrast: 60-80 ml based on indication.

LUMBAR SPINE

Indications: Radiculopathy (sciatica), back pain, failure

of conservative
especially whentreatment and postoperative back pain,
MRI is contraindicated.
Advisable preliminary
preliminary investigations: Radiography of the
spine.
Patient preparation: Information about the procedure;
restraint from food, but not fluid, is recommended, if
intravenous contrast media are to be given.
Scan projection radiograph: Lateral of the suspected
diseased disks.

Image criteria:
Visualization of:
• The entire region of suspected pathology
• Ve
Vesse
ssels
ls afte
afterr intra
intraven
venous
ous con
contra
trast
st med
media
ia
• Spi
Spinal
nal cord
cord andand nerve
nerve root
rootss after
after intra
intrathe
thecal
cal
injection of contrast media (CT myelography).
ADDITIONAL IMAGING TECHNIQUE
Patient position: Supine, legs in flexion.
112 STEP BY STEP CT SCAN

Volume of investigation: From pedicle to pedicle with

targeting of a slice at the centre of the suspected
diseased disks.
Nominal slice thickness: 2-5 mm.
Inter-slice distance/pitch: Contiguous or a pitch = 1.0.
FOV: Supine dimension.
Gantry tilt: As parallel as possible to the intervertebral
disc planes; a different gantry tilt may be required for
each intervertebral space.
X-ray tube voltage (kV): Standard or high kV in large
persons to avoid noise.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: Soft tissue/standard or high
resolution.
Window width: 140-400 HU (soft tissue), 2000-3000 HU
(bones), 250-300 HU (lumbar spine).
Window level: 30-40 HU (soft tissue) 200-400 HU (bones)
25-35 HU (lumbar spine).

Motion: Movement artifact deteriorates image quality

(prevented by sedation of non-cooperative patients).
Intravenous contrast media: Useful to identify vascular
structures and enhancing lesions.
Pitfalls:
• For
Foreig
eignn bodi
bodies
es (be
(beam
am har
harden
dening
ing art
artifa
ifacts
cts))
• Cal
Calcif
cifica
icatio
tions
ns vers
versus
us cont
contras
rastt enhan
enhancem
cement
ent..
IMAGE ACQUISITION PROTOCOLS 113

Modification to technique
Modification technique:: Intrathecal injection of contrast
medium (CT myelography) to delineate the spinal cord
and nerve roots (nonionic contrast 8-10 ml).
CHEST, MEDIASTINAL VESSELS

Indications: Suspected or known major vessel aneurysm,

dissection or congenital anomaly.
investigations: Chest radiography,
Advisable preliminary investigations:
including lateral projection.
Patient preparation: Information about the procedure;
restraint from food, but not fluid, is recommended, if
intravenous contrast media are to be given.

Fig. 5.5: Digiral scanogram showing slice plane for thorax

114 STEP BY STEP CT SCAN

Scan projection radiograph: Frontal from neck to upper

abdomen.
Image criteria:
Visualization of:
• En
Enti
tirre tho
thorrac
acic
ic ao
aort
rtaa
• Entire vena cava
• Entire he heart
• Ves
Vessel
selss after
after int
intrav
raveno
enous
us con
contra
trast
st med
media
ia
• Pat
Patien
ientt positi
position:
on: sup
supine
ine,, arms
arms abov
abovee the
the head.
head.
Volume of investigation: May be limited to area of
radiographic abnormality or clinically suspected lesion.
Nominal slice thickness: 4-5 mm serial or preferably
helical.
Inter-slice distance/pit
distance/pitch:
ch: Contiguous or a pitch = 1.0;
2-4 mm or a pitch up to 1.2 - 1.5 for
for large lesions.
lesions.
FOV: Limited to area of the heart and major vessels.
Gantry tilt: None.
X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm:
Soft tissue/standard.
Window width: 100-400 HU (soft tissue, unenhanced
examination) 150-500 HU (soft tissue, enhanced
examination).
Window level: 0-50 HU (soft tissue, unenhanced
examination) 20-150 HU (soft tissue, enhanced
examination, depends on dose and method of contrast
administration).
IMAGE ACQUISITION PROTOCOLS 115

Problems and pitfalls:

• Ar
Artif
tifact
act from
from the card
cardiac
iac out
outlin
linee may cros
crosss the aort
aortaa

• and mimic
Inhomo
Inh omogen dissection
geneit
eities
ies in flapinall opacifi
in lumina
lum opacificat
cation
ion due
due to
inconstant blood flow
• Inap
Inapprop
propria
riate
te admi
adminis
nistrat
tration
ion of cont
contras
rastt medi
mediaa may
may
mimic thrombus.
Modification to technique: Plain study can be obtained
as a HRCT.
IV contrast: 60-100 ml based on indication.

CHEST, GENERAL

Indications: Suspected or known pulmonary, pleural

or lymph node disease, including metastatic neoplasms,
infection, traumatic lesions and focal diseases.
Advisable preliminary investigations:
investigations: Chest radiography.
Patient preparation: Information about the procedure;
restraint from food, but not fluid, is recommended, if
intravenous contrast media are to be given.
Scan projection radiograph: Frontal from neck to upper
abdomen.

Image criteria:
Visualization of:
• Entitirre th
thor
oraaci
cicc wal
walll
• En
Enti
tire
re tho
thora
raci
cicc aort
aortaa and
and vena
vena cav
cavaa
• Entire he heart
• En
Enti
tire
re lu
lungng pa
parerenc
nchy
hymama
• Ve
Vesse
sselsls afte
afterr intra
intraven
venous
ous con
contra
trast
st medi
media.
a.
Patient position: Supine, arms above the head.
116 STEP BY STEP CT SCAN

Volume of investigation: From lung apex to the base of

the lungs.
Nominal slice thickness: 7-10 mm serial or preferably
helical.
Inter-slice distance/pitch: Contiguous or a pitch = 1.0; or
pitch up to 1.5 may be used for large lesions or
detection of lymphadenopathy alone; even larger inter-
slice distance/pitch may be applied in critically ill
patients.
FOV: Adjusted to the largest thoracic diameter within
the volume of investigation.

Gantry tilt: None.

X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: Soft tissue/standard.
Window width: 300-600 HU (soft tissue), 800-1.600 HU
(lung parenchyma).
Window level: 0-30 HU (soft tissue, unenhanced exami-
nation), 30-60 HU (soft tissue, enhanced examination),
500 to 700 HU (lung parenchyma).
on:: Movement artifact deteriorates the image
Mo tion
Moti
quality. This is prevented by a standard breath-hold
technique; alternatively if this is not possible scan
during quiet respiration.
Intravenous contrast media: May be used to characterize
lesions or to distinguish them from vessels.
IMAGE ACQUISITION PROTOCOLS 117

Pitfalls:
• Ana
Anatomtomica
icall misreg
misregist
istrat
ration
ion due
due to vari
variati
ation
on in the
the

• phase
Focal
Foc of lectas
respiration
al atelec
ate tasis
is may obs
obscu
cure
re pat
pathol
hology
ogy
• Mot
Motion
ion artif
artifact
act due to card
cardiac
iac puls
pulsatio
ation
n or res
respi-
pi-
ration.
Modification to technique:
• Pro
Pronene posit
position
ion may be used
used to eluc
elucida
idate
te pleu
pleural
ral
lesions or focal spaces
• The exa
exami
minat
nation
ion may
may be con
confin
fined
ed to
to a speci
specific
fic area
area
of interest
• 2 mm sli slices
ces ma
mayy be
be use
used
d for spe
specif
cific
ic exa
examin
minati
ation
on
of hilar pathology and subtle pulmonary lesions.

CHEST, HRCT (HIGH RESOLUTION CT)

Indications: Detection and characterization of diffuse
parenchymal lung disease including emphysema or
bronchiectasis.
bronchiecta sis.
Advisable preliminary investigations: Chest radiography
and respiratory function tests.
Patient preparation: Information about the procedure.
Scan projection radiograph: Frontal from neck to upper
abdomen.
Image criteria:
Visualization of:
• En
Enti
tire
re fie
field
ld of lun
lung
g pare
parenc
nchy
hyma
ma..
Patient position: Supine, arms above the head.
Volume of investigation: From lung apex to the base of
the lungs (survey) or corresponding to radiographically
defined abnormality (localized disease).
118 STEP BY STEP CT SCAN

Nominal slice thickness: 1-2 mm.

Inter-slice distance/pitch: 10-20 mm.
FOV: Adjusted to the minimum which will demonstrate
the whole lung field.
Gantry tilt: None.
X-ray tube voltage (kV): High kV or standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: High resolution.
Window width: 1000-1600 HU.
Window level: -400 to -700 HU.
Problems and pitfalls:
• Mo
Motition
on ar
arti
tifa
fact
ct du
duee to
to dys
dyspn
pnea
ea
• At
Atel
elec
ecta
tasi
siss may
may obscu
obscurere path
pathol
olog
ogy.
y.

Fig. 5.6: Scan plan for HRCT chest

IMAGE ACQUISITION PROTOCOLS 119

Modification to technique: Prone position may be used

to elucidate dependent changes, especially small areas
of
• atelectasis
Exami
Ex aminat
nation
ion in
in suspen
suspende
ded
d expira
expiratio
tion
n to detec
detectt air
trapping
• Sec
Sectio
tions
ns with
with small
smaller
er inter
inter-sl
-slice
ice dist
distanc
ancee for
evaluation of very small areas of disease
• Sec
Section
tionss with
with a cra
cranio-
nio-cau
caudal
dal –25 to –30°
–30° gant
gantryry
tilt for detection of bronchiectasis.

ABDOMEN, GENERAL
Indications: Inflammatory lesions, abscess, suspected
or known structural alteration or space-occupying
lesions of the abdomen and retroperitoneum, lesions
of major vessels such as aneurysms and traumatic
lesions, and as a guide to biopsy.
Advisable preliminary investigations: Ultrasonography.
Patient preparation: Information about the procedure;
exclude high density contrast media from previous
investigations; oral application of contrast media for
the intestine; restraint from food, but not fluid, is
recommended, if intravenous contrast media are to
be given.
Scan projection radiograph: Frontal from lower chest to
pelvis.
Image criteria:
Visualization of:
• Diaphragm
• En
Enti
tire
re li
live
verr and
and sp
sple
leen
en
• Re
Retro
troper
perito
itonea
neall parenc
parenchym
hymal
al organ
organss (pancr
(pancreas
eas,,
kidneys).
120 STEP BY STEP CT SCAN

• Abdom
Abdomina
inall aorta
aorta and the pr
proxi
oxima
mall part
part of
of the
the
common iliac arteries
•
• Abdomi
Abd ominal
Vessel
Vessels nal
terwal
s after
af wall
lraveno
includ
incl
intrav
int uding
ingcont
enous
us call hernia
her
rasttniatio
ontras metions
medians.
dia.
Patient position: Supine with arms at chest or head level.
Volume of investigation: From dome of the liver to the
aortic bifurcation.
Nominal slice thickness: 7-10 mm; 4-5 mm for dedicated
indications only (suspected small lesions), serial or
preferably helical.
Inter-slice distance/pitch: Contiguous or a pitch = 1.0; in
screening investigations, e.g. for traumatic lesions
< 10 mm or a pitch up to 1.2-2.0.

Fig. 5.7: Scan plan for abdomen

IMAGE ACQUISITION PROTOCOLS 121

FOV: Adjusted to the largest abdominal diameter.

Gantry tilt: None.
X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: Standard or soft tissue.
Window width: 150-600 HU, 2000-3000 HU (bone, if
required).
Window level: 30-60 HU (enhanced examination), 0-30
HU (unenhanced examination), 400-600 HU (bone, if
required).
Moti
Mo tion
on:: Movement artifact deteriorates the image
quality. This is prevented by a standard breath-hold
technique; alternatively, if this is not possible scan
during quiet respiration.
Intravenous contrast media: Useful for differentiating
vessels and organ tissues from adjacent structures and
to detect parenchymal lesions in solid organs.
Problems and pitfalls

• Non-c
No n-cont
ontras
tumours rasted
ted part
partss of the
the intest
intestine
ine may
may mimic
mimic
• Th
Thee del
deline
ineati
ation
on of orga
organs
ns and
and struc
structur
tures
es may
may be
poor in cachectic patients with reduced intra-
abdominal and retroperitoneal fat.
Modification to technique:
technique: Helical CT which is beneficial
for elimination of motion artifact can be used for
demonstrating vascular pathologies may be combined
122 STEP BY STEP CT SCAN

with examination of the pelvis. CT colonograpy can

be done were indicated.
IV contrast: 80-120 ml based on patient size and
indication.

PELVIS
General Preparatory Steps
Indications: Disorders of the prostate, uterus or female
gonads and suspected or known focal or diffuse
structural disease of the pelvis, e.g. lymphomas.
Advisable preliminary investigation
investigations:
s: Ultrasonography;

endoscopy (for intraluminal pathology).

Patient preparation: Information about the procedure;
exclude high density contrast media from previous
investigations; administration
administration of oral or rectal contrast
media for bowel demarcation; vaginal contrast tampon
in gynecological indications. Urinary bladder should
not be empty; restraint from food, but not fluid, is
recommended, if intravenous contrast media are to
be given.
Scan projection radiograph: Frontal from iliac crest to

proximal femur.
Image criteria:
Visualization of:
• Entire iliac bones
• Ent
ntiriree is
isch
chia
iall bon
bonees
• En
Enti
tire
re pu
pubi
bicc sym
symphphysysis
is
• En
Enti
tire
re ur
urin
inar
aryy bl
blad
addederr
• Al
Alll pe
periripe
pelv
lvic
ic mususcl
cles
es
• Ves
Vessel
selss after
after int
intrav
raveno
enous us cont
contras
rastt media
media..
IMAGE ACQUISITION PROTOCOLS 123

Patient position: Supine with arms at chest or head level.

Volume of investigation: From iliac crest to pelvic floor.
Nominal slice thickness: 7-10 mm; 4-5 mm if small lesions
are suspected, serial or preferably helical CT.
Inter-slice distance/pitch: Contiguous or a pitch = 1.0; 4-
5 mm or a pitch up up to 1.2-1.5 may be used
used in screening
examinations.
FOV: Adjusted to the maximum diameter of the pelvis.
Gantry tilt: None.
X-ray tube voltage (kV): Standard.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: Soft tissue/standard or high
resolution if bone evaluation is required.
Window width: 200-600 HU (soft tissues), 2000-3000 HU
(bones).
Window level: 30-60 HU (enhanced examination), 0-30
HU (unenhanced examination), 400-600 HU (bones).
Protective shielding: Lead-shielding for the gonads.
Pitfalls:
• DeDelin
lineat
eation
ion ofof organs
organs andand stru
structu
cture
ress may bebe
difficult in cachectic patients with reduced intra-
abdominal and retroperitoneal fatty tissue
• Fol
Folds
ds of
of the
the bowel
bowel wal
walll or stoo
stooll may
may mimic
mimic tum
tumor
or
• EmEmptptyy ur
urininar
ary
y bl
blad
adde
derr
• Cont
Contrast
rast med
mediaia “jets
“jets”” from
from the ure
ureter
terss into
into the
the
urinary bladder.
124 STEP BY STEP CT SCAN

Modification to technique : Additional thinner slices to

delineate small alterations
• Additi
Add itiona
onall entera
to visualize ent
theeral
l contra
contrast
bowel st med
media
ia may
may be need
neededed
• Add
Additi
itiona
onal,
l, iv
iv contra
contrast
st medi
mediaa with
with regar
regard
d to the
the
urinary bladder
• Fil
Fillin
ling
g of the
the urina
urinaryry blad
bladder
der by oral
oral water
water int
intake
ake..

OSSEOUS PELVIS
Indications: Evaluation or verification of pelvic ring and
acetabular fractures, hip dislocation, bone tumours,
degenerative, infectious, arthritic and osteonecrotic
changes.
Advisable prel
Advisable prelimin
iminary
ary inves
investigat
tigations:
ions: Always conventional
radiography; MRI or ultrasonography may be alter-
native examinations without exposure to ionising
radiation in non-traumatic disorders.
Patient preparation: Information about the procedure;
restraint from food, but not fluid, is recommended, if
intravenous contrast media are to be given.
Scan projection radiograph: Frontal from iliac crest to
ischial tuberosity.
Image criteria:
Visualization of:
• Whole pelvic ring
• Hip
Hip(s)
(s) inc
includ
luding
ing the tro
trocha
chante
nterr reg
region
ion
• Sa
Saccro
roil
ilia
iacc jo
join
ints
ts
• Pubic sy symphysis.
Patient position: Supine with arms at chest or head level.
IMAGE ACQUISITION PROTOCOLS 125

Fig. 5.8: Scanogram of pelvis

Volume of investigation: Tumour/fracture: from 1 cm

above to 1 cm below; the diseased area; joint disorders:
1 cm above to 1 cm below the joint region.
Nominal slice thickness: 3-5 mm in the hip region; 3-10
mm outside the hip, serial or preferably helical.
Inter-slice distance/pitch: Contiguous or pitch = 1.0 in
the hip region, < 5 mm or a pitch up to 1.2-1.5 outside
outside
the hip region.
FOV: Pelvis, hip or sacroiliac joint dimension (usually
15-40 cm).
Gantry tilt: Usually none, but cranial tilting should be
used for examination of the sacroiliac joints to reduce
radiation to the female gonads.
126 STEP BY STEP CT SCAN

X-ray tube voltage (kV): Standard or high kV in large

persons to avoid noise.
Tube current and exposure time product (mAs): Should be
as low as consistent with required image quality.
Reconstruction algorithm: Soft tissue/standard or high
resolution.
Window width: 1000-1500 HU (joints/bones), 200-600
HU (soft tissue).
Window level: 150-200 HU (joints/bones), 30-50 HU (soft
tissue).
Protective shielding: Lead-shield for the gonads.
Problems and pitfalls: Artifact due to metallic objects such
as prothesis.
Modification to technique: IV contrast media to delineate
traumatic lesion of pelvic organs.

PROTOCOLS FOR COMMON CLINICAL

INDICATION
Acute Abdomen

ICo
njentra
Contctrast
iost
n vo
ratlum
volue me and
and ty
type
pe 380c-100
c/00
80-1 seio
c nic/
ionic/no
noni
nion
onic
ic
Area scanned From diaphragm to
symphysis pubis
Scan delay 25 sec
Length of spiral (time) 30-40 sec
Slice thickness 7 mm
Table speed/pitch 7 mm/sec
IMAGE ACQUISITION PROTOCOLS 127

Reconstruction interval As decided by the

radiologist
Comment: 750 cc of oral contrast (3% gastroscan) is
given in divided doses beginning approximately one
hour prior to the study. Delayed scans may be useful
in select cases. In cases of suspected pelvic abscess,
rectal contrast may prove useful to define the position
of the rectum and sigmoid colon.

Abdomen—Trauma
Injection rate 3 ml/sec
Contrast volume and type 135 ml of 60%
Area scanned
1. Hig
Highes
hestt hemidi
hemidiaph
aphrag
ragm
m throug
through h kidney
kidneyss
2. Bel
Below
ow kidn
kidneys
eys thr
throug
oughh ischi
ischial
al rami
rami..
Scan delay 70 sec/additional
70 sec
Length of spiral (time) 30-40 sec/nonspiral
Slice thickness 5 mm
Table speed/pitch 1.5 pitch/5 mm
increments
Reconstruction interval 5 mm
3D technique used None
Comment:
• Ora
Orall contra
contrast
st is
is routi
routinely
nely give
given
n (wate
(water-s
r-solu
oluble
ble
agent).
• Re
Rect
ctal
al contr
contras
astt is given
given whe
whenn colon
colon inju
injury
ry is
suspected.
128 STEP BY STEP CT SCAN

Abdomen—Livermass
Specific anatomic region Li v er
Application Differential diagnosis
of liver masses
Injection rate 2.5-3 ml/sec
Cont
Co ntrras
astt vol
volum
umee and
and ty
type
pe 80-1
80 -120
20 ml of io
ion
nic
ic/
/
nonionic contrast
Area scanned Entire liver
Scan delay 25 sec arterial/60 sec
venous
Length of spiral (time) Approx 30 sec
Slice thickness 5 mm
Table speed/pitch Pitch 1-1.5
Reconstruction interval 3 mm intervals
3D technique used None

Suspected Hemangioma
Specific anatomic region Li v er
Application Suspected hemangioma
Injection rate 2-3 ml/sec
Contrast vo
volume an
and type 100 ml of non ionic
Area scanned Sequential images over
suspected lesion
Scan delay 25 sec to initial scan
Length of spiral (time) N o t n e ed ed
Slice thickness 5 mm
Table speed/pitch N/A
Reconstruction interval N/A
3D technique used N/A
Comment: Scans are obtained at 30 sec intervals until
5 min, then at 10 min to note the classic peripheral
enhancement and fill in for these tumors.
IMAGE ACQUISITION PROTOCOLS 129

PANCREAS
Pancreatitis
Injection rate 2-3 ml/sec
Contrast vo
volume an
and ty
type 80-100 nonionic
Area scanned From diaphragm to
iliac crest
Scan delay 25 sec
Length of spiral (time) 30-40 sec
Slice thickness 5 mm
Table speed/pitch 5-7 mm/sec
Reconstruction in
interval 2-3 mm as needed
3D technique used Volume rendering

Pancreatic Mass
Injection rate 3.5 ml/sec
Cont
Co ntra
rast
st vo
volu
lum
me and
and ty
type
pe 75–1
75 –100
00 cc of no
non
nio
ioni
nicc
contrast
Area scanned Diaphragm to iliac crest
Liver and pancreas in
arterial-phase study.
Scan delay 20 sec for arterial
phase/60 sec for
venous phase
Length of spiral (time) 25 sec
Slice thickness 3 mm
Table speed/pitch 4.5 mm/sec or a pitch
of 1.5
Reconstruction interval 1.3 mm
3D technique used MIP to denote the
vascular relationship.
Volume rendering can
also be used
130 STEP BY STEP CT SCAN

Endocrine Tumours of Pancreas

Injection rate 3-4 ml/sec
Con
ontr
tras
astt vol
volu
ume and
and ty
typ
pe 100-
10 0-12
1200 ml of no
noni
nion
onic
ic
contrast
Area scanned Area of pancreas first
defined on contrast
scan
Scan delay Arterial phase deter-
mined by test bolus
injection
Length of spiral (time) 20 sec
Slice thickness 5 mm
Table speed/pitch 5 mm/sec or a pitch
of 1
Reconstruction interval 2 mm
3D technique used None
Comment: The arterial phase is classically best for
vascular tumors like an islet cell tumor. It is best to
opacify c loop with water so that the enhancement is
not obscured.

R/O Renal or Ureteral Calculus

Application R/O renal or ureteral
calculus
Injection rate No contrast used
Contrast volume and type N/A
Area scanned From midportion T-12
to midportion of
symphysis
Scan delay None
Length of spiral (time) Up to 40 sec
IMAGE ACQUISITION PROTOCOLS 131

Slice thickness 3 mm
Table speed/pitch 6 mm/sec
Reconstruction interval 3 mm
3D technique used None usually
Comment: Reformatting of data into oblique planes
plan es may
better define the location of a stone in difficult cases.

Staging Renal Mass

Injection rate 3 ml/sec
Cont
Co ntra
rast
st vo
volu
lum
me and
and typ
ypee 1200 ml of Omni
12 nip
paq
aqu
ue-
350
Area scanned
Arterial phase (AP) 2 cm above
and below kidney.
Delayed phase (DP) From diaphragm to
symphysis
Scan delay 30 sec, 70 sec (dual
spiral)
Length of spiral (time) Usually 30 sec for
arterial and 40 sec for
delayed phase
Slice thickness 3 mm (AP) 5 mm (DP)
Table sp
speed/pitch 5 mm/ sec (AP), 8 mm/
sec (DP)
Reconstruction in
interval 3 mm (AP), 5 mm (DP)
3D technique used Volume rendering on
arteriall pha
arteria phase.
se.

Evaluate Suspected Renal Artery Stenosis

Injection rate 3 cc/sec
Contrast vo
volume an
and ty
type 100-120 cc
132 STEP BY STEP CT SCAN

Area scanned Through regions of

renal arteries
Scan delay 25-30 sec
Length of spiral (time) 20-30 sec each
Slice thickness 2-3 mm
Table speed/pitch 4-6 mm/sec
Reconstruction interval 1 mm
3D technique used Volume rendering
and MIP
Comment : Non-contrast CTs are first obtained to
localize the renal arteries for the CT angiogram. This
allows a smaller scan volume which is critical with

SDCT and the

is accurate use of 1-2stenosis.
to quantify mm collimation. 3D with VRT

Renal Donor Evaluation

Injection rate 3.5 ml/sec (mean)
Con
ontr
tras
astt vol
volu
ume an
and typ
typee 80--10
80 1000 ml no
noni
nion
onic
ic
contrast
Area scanned Entire kidneys
Scan delay 20 sec
Length of spiral (time) Approx 30 sec
Slice thickness 3 mm
Table speed/pitch 3-5 mm
Reconstruction interval 2 mm
3D technique used MIP
Comment: 15 minutes after contrast injection, conven-
tional radiographs (AP, obliques) can be obtained if
the urologists desires so.
IMAGE ACQUISITION PROTOCOLS 133

Stomach: Gastric Mass

Injection rate 2-3 ml/sec
Cont
Co ntra
rasst vol
volu
ume and
and ry
rype
pe 80-
0-10
1000 ml of no
noni
nion
onic
ic
contrast
Area scanned From diaphragm to top
of iliac crest
Scan delay 24 sec
Length of spiral (time) Up to 30-40 sec
Slice thickness 3 mm
Table speed/pitch 5 mm/sec
Reconstruction interval 2-3 mm
Comment: Distension of the stomach with 750 cc of 3%
gastrograffin or 750-1000 cc of water. This allows better
evaluation of the gastric wall and definition of tumors,
etc.

Colon: Suspected Diverticulitis

Injection rate 3 cc/sec
Contrast vo
volume and type 80-100
Area scanned From diaphragm to
symphysis
Scan delay 50 sec
Length of spiral (time) 32-40 sec
Slice thickness 5 mm
Table speed/pitch 8 mm/sec
Reconstruction interval 5 mm
3D technique used No n e
Comment: A focused exam of the colon requires P.O.
contrast 90-120 minutes before the study. If necessary,
rectal contrast may be given.
134 STEP BY STEP CT SCAN

Appendix, Cecum: R/O Appendicitis

Injection rate 80-100 ml nonionic
IV contrast.
Cont
Contrras
astt vo
volu
lum
me an
and ty
type
pe 7500 ml
75 ml or
oral co
cont
ntra
rast
st;;
300-800 ml rectal
contrast
Area scanned From L2 level
Scan delay 40 min delay between
oral contrast and CT
scan. 25 seconds delay
for IV contrast
Length of spiral (time) 30 sec
Slice thickness 5 mm
Table speed/pitch 5 mm/sec or a pitch
of 1
Reconstruction interval 5 mm
3D technique used If needed VR may be
used

Pelvic
Application Cervical cancer,
bladder cancer
Injection rate 3 ml/sec
Contrras
Cont astt volu
volum
me and
and type
type 110-12
110- 1200 ml of non
non io
ioni
nicc
Area scanned From symphysis pubis
through iliac crest
followed by scans
through the diaphragm
Scan delay 25 sec
Length of spiral (time) 30 sec followed by a
second spiral to screen
the abdomen
IMAGE ACQUISITION PROTOCOLS 135

Slice thickness 3-5 mm for pelvis, 7 mm

for the abdominal
screening.
Table speed/pitch 3-5 mm/sec
Reconstruction interval 3-5 mm
3D technique used None routinely needed

Ovarian Mass/Cancer
Injection rate 2 cc/sec
Cont
Co ntra
rast
st vo
volu
lum
me and typ
ypee 80--10
80 1000 of non
onio
ioni
nicc
Area scanned Diaphragm through
symphysis pubis

S
Lceanngtdheloafyspiral (time) 5300-s4e0csec
Slice thickness 5 mm
Table speed/pitch 7 mm
Reconstruction interval 3 mm
Comment:
• De
Delay
layed
ed sca
scans
ns thr
throug
ough
h the
the pelvi
pelviss at 5 minu
minutes
tes pos
post-
t-
injection allow adequate bladder opacification
• Rec
Rectal
tal cont
contras
rastt may
may be helpf
helpful
ul for
for defi
definin
ning
g spread
spread
of tumor in the pelvis.

Fistula to Bladder
Injection rate None used
Contrast volume and type None usused
Area scanned From iliac crest to
symphysis pubis
Scan delay No n e
Length of spiral (time) 30 sec
Slice thickness 5 mm
136 STEP BY STEP CT SCAN

Table speed/pitch 5 mm/sec

Reconstruction interval 5 mm
3D technique used MPR
Comment: Contrast is given via rectum and reflux in
to urinary bladder.

Musculoskeletal Shoulder: Trauma to

Shoulder Joint
Injection rate N/A
Contrast volume and type N/A
Area scanned From just above
acromioclavicular joint
through scapular tip
Scan delay None
Length of spiral (time) 40 sec
Slice thickness 3 mm
Table speed/pitch 3-5 mm/sec

Fig. 5.9: Scan plan for shoulder

IMAGE ACQUISITION PROTOCOLS 137

Reconstruction interval 2 mm
3D technique used Volume rendering and
multiplanar obliques
Comment: The technique can be modified if only the
humeral head is injured. In cases with complex trauma
IV contrast may be used to exclude a vascular injury to
the mediastinum. The protocol used would use 120 ml
of contrast injected at 3 ml/sec with a 30 sec delay.

Specific Anatomic Region Wrist

Application 1.R/O fracture,
R/O Fx/dislocation
Injection rate N/A
Contrast vo
volume and type N/A
Area scanned Entire wrist
Scan delay None
Length of spiral (time) 15-25 sec
Slice thickness 2 mm
Table speed/pitch 2-3 mm
Reconstruction interval 1-2 mm
3D technique used Volume rendering
Comment: The best plane to scan is with the patient’s
arm in the scanner parallel to the X-ray beam.
Specific Anatomic Region Acetabulum/Pelvis
Application Evaluate suspected
fracture
Injection rate N/A
Contrast vo
volume and type N/A
Area scanned From iliac crest through
ischium
138 STEP BY STEP CT SCAN

Scan delay None

Length of spiral (time) 40 sec
Slice thickness 3 mm
Table speed/pitch 1.6 pitch
Reconstruction interval 2 mm
3D technique used Volume rendering
Comment: IV contrast can be used to create vascular
maps to exclude vascular injury. In these cases a delay
of 30 sec till scanning is ideal. A CT cystogram may
also be useful in these cases.

Knee: Trauma

ICnojencttriaosnt vraotleume and type N

Noon
nee
Area scanned Tibial plateau
Scan delay None
Length of spiral (time) 30-40 sec
Slice thickness 2 mm
Table speed/pitch 2 mm/sec
Reconstruction interval 1 mm
3D technique used Vr, mpvr.

Ankle: Evaluate Suspected Fracture

Application Evaluate suspected
fracture
Injection rate N/A
Contrast volume and type N/A
Area scanned Several cm above the
talotibial joint through
the midfoot
Scan delay None
Length of spiral (time) 30-40 sec
IMAGE ACQUISITION PROTOCOLS 139

Fig. 5.10: Scan plan for knee

Fig. 5.11: Scan plan for ankle

140 STEP BY STEP CT SCAN

Slice thickness 3 mm
Table speed/pitch Usually 3 mm/sec or a
pitch of 1
Reconstruction in
interval 1 or 3 mm
3D technique used Volume rendering and
MPR
Comment: This technique relies on a single CT acqui-
sition in a plane parallel to the foot with MPR and 3D
reconstructions done to provide all views.

Cervical Spine: Trauma—Extent of Injury

Application Trauma—extent of
injury
Injection rate N/A
Contrast volume and type None usused
Area Scanned From craniocervical
junction to the top of
T-1
Scan delay None
Length of spiral (time) No t d ef i n ed
Slice thickness 3 mm
Table speed/pitch 1.5 pitch
Reconstruction interval 1 mm
3D technique used ? shaded surface ? MPR
Comments: IV contrast is given if vascular injury is also
suspected.

Orbit: Trauma
Injection rate N/A
Contrast volume and type None us
used
IMAGE ACQUISITION PROTOCOLS 141

Area scanned Coronal—from front of

eyelids to behind the
optic canals.
Axial—through orbits.
Scan delay No n e
Length of spiral (time) No t d e f i n e d
Slice thickness Coronal: 1 mm
Axial: 1 mm
Table speed/pitch Coronal: 1.5 mm/sec
Axial: 1 mm
Reconstruction in
interval Coronal: 1 mm
Axial: 1 mm
3D technique used Shaded surface
rendering
Comments:
1. This proto
protocol
col is
is also
also used
used for
for foreig
foreign
n body
body
localization.
2. Image
Imagess are
are filmed
filmed at both
both soft
soft tissu
tissuee and bone
windows.

Facial Region: Trauma

Injection rate N/A
Contrast volume and type None us
used

Area scanned C oronbone

nasal al—frto ombehind
front of
sphenoid sinuses.
Axial—from below
maxillae to above
frontal sinuses.
Scan delay No n e
Length of spiral (time) No t d e f i n e d
Slice thickness Coronal: 3 mm
Axial: 3 mm
142 STEP BY STEP CT SCAN

Table speed/pitch Coronal: 4.5 mm/sec

Axial: 4.5 mm/sec
Reconstruction in
interval Coronal: 3 mm or 1
Axial: 3 mm or 1
3D technique used Shaded surface (SSD)
Comments:
1. Sca
Scanni
nning
ng is done
done in
in both
both corona
coronall and axia
axiall plane.
plane.
2. Data is recons
reconstruc
tructed
ted at 1 mm inter
interval
val when
when MPR
or 3D is done.

Neck—Adenopathy
Injection rate 1 ml/sec
Cont
Contrras
astt vol
volum
umee and
and ty
type
pe 100 ml of Omnip
ipaq
aque
ue--
300
Area scanned Cervical region
Scan delay 30 sec
Length of spiral (time) 40 sec

Fig. 5.12: Scan plan for neck

IMAGE ACQUISITION PROTOCOLS 143

Slice thickness 5 mm
Table speed/pitch 5 mm/sec
Reconstruction interval 5 mm
3D technique used None used
Comment:
1. With spira
spirall CT this can easil
easily
y be comb
combined
ined with an
examination of the chest.
2. I think
think this
this flow
flow rate
rate is just
just too low
low for
for a good
good
study. A flow rate of 2-2.5 ml/sec is ideal.

Anatomic Region: Pulmonary Artery

Application R/O pulmonary

Injection rate 3embolism

ml/sec
Contrast vo
volume an
and type 80-120 ml
Area scanned Level of just above
aortic arch through
lung bases
Scan delay 25 sec
Length of spiral (time) 30-35 sec
Slice thickness 3 mm
Table speed/pitch 5 mm/ sec
Reconstruction interval 2 mm
3D technique used V olumMPR.
MIP/ e rendThis
ering /
protocol is followed by
screening of leg and
pelvic veins.

Thoracic Aorta: R/O Dissection

Specific anatomic region Thoracic ao
aorta
Application R/O dissection
144 STEP BY STEP CT SCAN

Injection rate 3 ml/sec

Con
ontr
tras
astt vo
volu
lum
me an
and
d ty
typ
pe 1200 ml of 60
12 60%
% io
iod
din
inat
ateed
contrast
Area scanned From apex of lung
through approx L-1
Scan delay 30 sec
Length of spiral (time) 40 sec
Slice thickness 3 mm
Table speed/pitch 5 mm/ sec with a
pitch of 1:6
Reconstruction interval 3 mm
3D technique used MIP and shaded-
surface

Aorta: Suspected Aneurysm or Dissection

Specific anatomic region Abdominal aorta
Application Suspected aneurysm or
dissection
Injection rate 3cc/sec
Contrast volume and type 80-120
Area scanned From diaphragm to
symphysis
Scan delay 30 sec
Length of spiral (time) 35-40 sec
Slice thickness 3 mm
Table speed/pitch 6 mm/ sec or pitch of 2
Reconstruction interval 3 mm
3D Technique used Volume rendering

Lung Parenchyma: R/O Lung Metastasis

Specific anatomic region Lung parenchyma
Application R/O lung metastases
IMAGE ACQUISITION PROTOCOLS 145

Injection rate 2cc/sec

Contrast volume and type 100-110cc of
Omnipaque 350
Area scanned Entire lung fields
Scan delay 20 sec
Length of spiral (time) Up to 40 sec
Slice thickness 5 mm
Table speed/pitch 8 mm/ sec or a pitch
of 1.6
Reconstruction interval 5 mm
3D technique used Rarely needed
Although for detection of lung nodules CT without
contrast is enough,
stinum and IVassess
hilum to helps
contrastfor to stage the media-
lymphadenopathy.

Summary of Scan Parameters

P a r a m e t er U nit Ra n ge T ypica l
Scan parameters
kV kV 80-140 120
mA mA 60-200 100-120
Scan time - t s ec 1-9 2
Slice width - w mm 1 - 10 5/10
Ap ertu re mm 600 - 700
Tilt angle degree ± 20° - 25°

Processing
Reconstruction or origin
Field of view—FOV mm 5 - 500
Ma trix pixels 3 20 - 1 024 512
Convolution filter - CF
I m age
Pixel value HU ± 1000
N o is e HU 3 - 30
S p a t i a l r e s o l ut i o n mm 0.75 - 2.0
Dose m Gy 50 - 150
Chapter 6

Post Processing
Techniques
148 STEP BY STEP CT SCAN

MULTIPLANAR RECONSTRUCTION (MPR)

The 3D nature of volume images acquired using helical
CT allows for simple and efficient computation of
images that lie along the non-acquired orthogonal
orientations of the volume. It is a very fast and inter-
active algorithm, suitable to represent several arbitrary
planes at once. Implementations of multiplanar
reconstruction techniques (MPR) on modern computers
allow interactive generation and display of these
images in real-time on multipanal displays. From the
early days of CT, MPR is being used as a tool to provide
arbitrary planes from transaxial slices. MPR, however,
is not considered to be a true 3D representation and
the image quality is limited by the z-resolution of the
CT data set. Therefore, MPR have not been used much
in conventional CT since spatial resolution along the
z-axis used to be poor and stair step artifacts were
common. With the advent of MDCT with the possi-
bility of isotropic data sets, artifacts can be eliminated
but image quality still depends on acquisition para-
meters. Using thin collimation, excellent results are
obtained.
Generally, MPR are helpful whenever pathology
cannot be accurately
Most situations involveassessed on axial
pathologic imagesthat
interfaces alone.
are
oriented parallel to the axial plane or structures that
cannot be displayed in their entirety since they run
through a number of slices. In these cases, problem-
oriented imaging planes can be generated using MPR.
MPR is the fastest reconstruction method and almost
everywhere available.
POST PROCESSING TECHNIQUES 149

MPR also serve as an important communication tool

with the referring physicians and play a major role in
orthopedic and trauma therapy planning.

B
A
Figs 6.1A and B: Diagram showing the basis of MPR

SURFACE RENDERING [SHADED SURFACE

DISPLAY (SSD)]
The “Marching Cubes” algorithm must be considered
the hallmark of surface rendering. Prior to applying
the algorithm, the user specifies a threshold value and
by doing so selects the objects to be rendered.
This specification has vast ramifications regarding
the quality and accuracy of the object depiction. The
threshold needs to be adapted to the individual
application under consideration, e.g. bone, soft tissue.
Once the threshold has been determined, the
surface rendering algorithm loops on each successive
group of four adjacent data slices. The slices are read
into memory and each cell is scanned to determine
whether its corner values straddle the threshold value.
Non-straddling cells are discarded. Cells that do
straddle the threshold are examined more closely. The
150 STEP BY STEP CT SCAN

eight corners of the cube are valued “1” if their signal

exceeds the threshold and “0” if it does not. They form
an eight bitbyte,
Surface rendering, also called shades surface
displays (SSD), was mainly used to communicate
findings to the referring physicians during the last
decade. Using larger data sets performing MDCT, this
visualization role will be overtaken by newer volume
rendering techniques. While surface rendering images
are very intuitive, they are also prone to artifacts since
image quality is strongly dependent on the chosen
threshold range for the definition of the displayed 3D
object. However, there are many applications in which
radiology truly benefits from SSD. These include all
procedures for surgical planning and 3D renderings
of complex acetabular fractures, facial fractures,
orthopedic deformities,
deformities, CT angiography of the thoracic
aorta and preoperative planning for interventional
endovascular procedures. The classification of

A B
Figs 6.2A and B: Diagram showing SSD
POST PROCESSING TECHNIQUES 151

acetabular fractures is markedly simplified with 3D

reconstructions
Complex procedures in craniofacial surgery also
benefit from surface rendering

VOLUME RENDERING (VR)

Volume rendering is the representation, visualization,
and manipulation of objects represented as sampled
data in three or more dimensions. Volume rendering
displays visual images directly from volume data,
enabling the viewer to fully reveal the internal structure
of 3D data. Rather than editing a single scan, volume
rendering
image postinterpolates
processing, the entirerendering
volume data set. is
Speaking of
one of the
most important software techniques
With standard orthographic imaging, such as
shaded surface display or MIP, changing position can
cause distortions in the image. With perspective

A B
Figs 6.3A and B: Diagrams showing the basis of volume rendering
152 STEP BY STEP CT SCAN

volume rendering, there is no distortion. Perspective

volume rendering requires a data set that permits
3D imaging, which basically means one with thin
collimation.
The rendering is performed by a software technique
that assigns both opacity and color to each voxel in
the data set.
Once the volume rendering display has been
compiled, the opacity can be suppressed in order to
examine different tissues.

VIRTUAL ENDOSCOPY (VE)

Virtual endoscopy
diagnosis, (VE) describes
using computer proces singa of
processing new3D method of
image data
sets (such as from spiral or multidetector CT scans) to
provide simulated visualizations of patient—specific
organs similar or equivalent to those produced by
standard endoscopic procedures, such as colonoscopy,
bronchoscopy.
bronchosco py.
VE can be performed using surface rendering or
volume rendering based either on volumetric CT.

VIRTUAL COLONOSCOPY
Virtual colonoscopy techniques have been introduced
as potential methods for colorectal screening and
preoperative staging, and combine volumetric imaging
based on CT with sophisticated image processing.
This technique is particularly attractive due to the
increased potential for patient compliance.
Screening for colorectal cancer with virtual
colonoscopy is well tolerated by patients, although it
POST PROCESSING TECHNIQUES 153

does involve a cleansing preparation for the colon. The

procedure is safe, and the 3D images are quite
compelling and allow for a number of unique abilities,
such as separating out polyps from nodular folds by
virtually splitting the colon open.
The data sets for virtual colonoscopy are acquired
using 4 × 1 mm slice collimation, slice thickness
1.25 mm, data reconstruction interval 1 mm and a pitch
of 6.
Radiologists using this technology must also look
carefully to see whether there is any air within a filling
defect of the colon. Even on the endoscopic views,
fecal residue can look relatively rounded, and so
endoscopic views alone will not suffice: radiologists
must refer back to the axial source images.

VIRTUAL BRONCHOSCOPY
Virtual bronchoscopy is emerging as a useful approach
for assessment of three dimensional reconstructed
airways.
1. Pre
Preproc
processi
essing
ng of image
image data
data,, which
which involves
involves
extracting objects of interest, defining paths through
major airways, and preparing the extracted objects
for 3D rendering; and interactive image.
2. Assessme
Assessment,
nt, which involv
involves
es use of graphi
graphics-ba
cs-based
sed
software tools such as surface-rendered views,
projection images, virtual endoscopic views, oblique
section images, measurement data and cross-
sectional views. Although a virtual bronchoscope
offers a unique opportunity for exploration and
quantitation, it cannot replace a real bronchoscope.
154 STEP BY STEP CT SCAN

Virtual endoscopy reproduces real endoscopic

images but cannot provide information on the aspect
of the mucosa or biopsy specimens. It offers possible
applications for preparing, guiding and controlling
interventional fibroscopy procedures.
However, virtual bronchoscopy based on MSCT
data permits to investigate peripheral bronchi far
beyon
bey ond d th
thos
osee th
that
at ca
cann be ex
exami
amine
nedd by a ph
phys
ysic
ical
al
bronchosco
bronc hoscope.
pe. Indic
Indicatio
ations
ns for virtu
virtual
al bronc
bronchosco
hoscopy
py
include evaluation of bronchial anastomosis following
lung transplantation, evaluation of abnormalities of
the central airways after intubation, tracheotomy or
irradiation of the neck, bronchial stenosis in Wegener
granulomatosis, and airway reconstruction after tumor
resection functional imaging of the tracheobronchial
tree is also possible by acquiring a scan in inspiration
as well as in expiration. Furthermore, the MDCT data
can be used to generate an interactive 3D virtual
bronchoscopic approach for preoperative endotracheal
stent planning.

Biopsy Planning
In the past, if a patient had a tumor in the chest,
abdomen, or pelvis, surgery was required in order to
make a definite diagnosis and determine the specific
type of tumor before appropriate therapy could be
implemented. This approach is certainly acceptable if
the patient would require surgery anyway in order to
treat the tumor. However, many patients have types
of tumors in which surgery is not indicated (frequently
patients with metastatic disease), and other patients
are not surgical candidates because of additional
POST PROCESSING TECHNIQUES 155

medical conditions. CT guided, percutaneous (i.e.

through the skin) needle biopsy has developed into
the frequently used alternative to open surgical
exploration and biopsy.

Indications and Contraindications

Almost any organ or structure in the body can be
biops
bi opsied
ied per
percut
cutan
aneou
eously
sly und
under
er CT gui
guidan
dance.
ce. Thi
Thiss
includes the lungs, mediastinum, liver, kidneys,
adrenal glands, pancreas, retroperitoneum, and pelvis.
The spleen is seldom biopsied because it is a highly
vascular organ and the risk of severe post-biopsy
hemorrhage is significant.
to confirm that significant
a mass is .malignant,
Most biopsies
andare
to performed
determine
the specific type of tumor so that appropriate therapy
can be started. Some biopsies are performed to evaluate
the type and severity of benign disease (e.g. liver
biop
bi opsy
sy fo
forr he
hepa
pati
titi
tis,
s, re
rena
nall bi
biop
opsy
sy fo
forr gl
glom
omer
erul
ulo-
o-
nephritis).
Relative contraindications to CT guided biopsy
include:
• Pat
Patien
ients
ts with
with uncorr
uncorrect
ectabl
ablee bleedin
bleedingg disord
disorders
ers.. The
risk of post-biopsy hemorrhage is too high.
• Les
Lesions
ions in which
which a safe
safe biops
biopsyy path
path canno
cannott be fou
found.
nd.
This includes deep tumors which the needle could
only reach by traversing large blood vessels (in the
chest, abdomen, or pelvis), bowel (in the abdomen
or pelvis), or other vital organs (e.g. the spleen,
heart, aorta).
• Le
Lesio
sions
ns which
which will
will be surg
surgica
ically
lly resec
resected
ted rega
regardl
rdless
ess
of the biopsy result. This applies to many solitary
lung and kidney masses.
156 STEP BY STEP CT SCAN

• Suspec
Suspected
ted typ
types
es of les
lesion
ionss in whic
which
h the ris
risk
k of life
life--
threatening post-biopsy complications is high. This
includes pulmonary arteriovenous malformation,
cavernous hemangioma or echinococcal cyst of the
liver.
• Pat
Patien
ients
ts who
who cann
cannot
ot coop
coopera
erate
te with
with the exa
exam.
m.

Risks
CT guided biopsy is a relatively safe procedure. The
risks are almost always less than surgical biopsy, which
would be the most common alternative. The recovery
time is considerably less than surgery.

theRisks of CTbiopsied.
site being guided biopsy depend
These risks somewhat on
include:
• Ble
Bleedi
eding:
ng: Mos
Mostt patien
patientsts have
have eval
evaluat
uation
ion of their
their
blood clotting status prior to biopsy. Although rare,
bleeding
bleed ing can be life-
life-threa
threatenin
teningg and can requir
requiree
surgery to correct.
• Inf
Infect
ection
ion:: Infec
Infectio
tionn can dev
develo
elop
p anytim
anytimee a need
needle
le
pierces the skin. However, sterile technique is used
during the biopsy and this is a very rare complication.
• Pne
Pneumo
umotho
thorax:
rax: A repor
reported
ted com
complic
plicatio
ation
n in up to
to
25% of lung biopsies (although only a few of these
patients require a chest tube). Also a risk during
biopsies in the upper abdomen (usually liver and
adrenal).
• Da
Dama
magege to adj
adjace
acent
nt orga
organs:
ns: Alt
Althou
hough
gh CT can
accurately locate the lesion, the biopsy is not
performed under real time imaging. Patient
movement and variation in breathing can alter the
relationship of the lesion and adjacent organs,
including bowel and vascular structures.
POST PROCESSING TECHNIQUES 157

Technique
The technique will vary based on the lesion being
bii o p s i e d a n d a n y l i m i t a t i o n s o f t h e p a t i e n t . A
b
generalized sequence is as follows:
• The pat patien
ientt can
can lie
lie on the CT tabl tablee on the
theirir back
back,,
on their stomach, or on either side, depending on
the needle path planned. Although systemic
anesthesia is usually not required, some patients
will receive intravenous sedation and/or pain relief.
• LimLimite ited
d CT scan
scannin
ning g is perfo
performe rmed,
d, and
and the
the lesio
lesionn
is located. The safest and easiest path for the needle
is planned.

• manner.
The ove
overly
rlying
ing skin
The skin is cleane
is
skin cleaned
and dunderlying
and drape
and drapedd in a ster
sterile
tissue ile
is
anesthetized. Once the depth and angulation of the
needle is determined from the CT images, the
needle is placed through the skin into the body.
• Ad
Addit
dition
ional
al CT im
image
agess are
are obtai
obtained
ned to conf
confirm
irm tha
thatt
the tip of the needle lies in the lesion. Adjustments
to the needle position are made as necessary.
• Whe
When n the
the tip
tip of the nee
needle
dle is show
shownn to lie in the
the
proper position, the biopsy is obtained. Different
types of needles are available. Some are for
aspiration
and others (obtains scattered
are cutting needlescells
whichfrom the lesion),
obtain a small
core of tissue.
• A prel
prelimi
iminar
nary y evalu
evaluatio
ation
n of the spespecim
cimen
en is
is
frequently performed by the pathologist. If there
is sufficient tissue for diagnosis, the procedure is
terminated. If not, additional biopsies will be
obtained.
158 STEP BY STEP CT SCAN

• The pati
patient
ent is
is observ
observed
ed eith
either
er in
in the depa
departm
rtment
ent
or in a short-stay nursing unit for 2 to 4 hours, and
then sent home. If there are no complications,
admission to the hospital is seldom required.

BIOPSY SCAN
Biopsy Scan 1
Function
The biopsy Rx feature allows you to easily repeat the
scan location during the biopsy procedures. Example
given below is from a CT/E scanner from Ge.

Biopsy Rx Prescription
1. Biopsy
Biopsy Rx can be accesse
accessedd throug
through
h the (Biop
(Biopsy
sy Rx)
Rx)
icon on the righ side of axial/helical prescription
screen.
2. The follo
following
wing scree
screen
n appears
appears upon the select
selection
ion of
(biopsy Rx).

Fig. 6.4: Schematic representation of planning biopsy

POST PROCESSING TECHNIQUES 159

Biopsy Scan 2
1. In order
order to deter
determine
mine the refer referenceence cente
centeringring in a
bii o p s y s c a n , s e l e c t ( s u p e r i o r ) , ( c e n t e r e d ) o r
b
(inferior) at biopsy reference field.
• SupSuperierior
or mean
meanss scannscanning ing fr from
om the the land
landmar mark k
toward patient’s head
• CenCentertered
ed mean
meanss scann
scanning ing arou
around nd the
the land
landma mark.
rk.
• InfInferi
erior
or mea
means ns scascanni
nningng from
from the land landmar mark k
toward patient’s feet
2. When the inter internal
nal light
light is is used,
used, selec
selectt (interna
(internal) l) or
when the external light is used select (external) at
Get Alignment Light Location Field.

3. Enter
Ent
• N eruthe
mbefol
follow
r olowing
iming
f im agepar
parame
s ameter
ters:
s:
• Gantry tilt
• Thickness
• Helical pitch
• Image in interval
4. Cli
Click
ck on the (co
(confi
nfirm
rm biop
biopsy
sy Rx)
Rx) butt
button.
on.
5. Pres
Presss (move
(move to
to scan)
scan) button
button when
when itit lights
lights up.
up. Then,
Then,
press (start scan) to start the biopsy scans.
Chapter 7

Contrast Issues
162 STEP BY STEP CT SCAN

CT contrast agents, sometimes referred to as “dyes”

are used to highlight specific areas so that the organs,
blood vessels, or tissues are more visible. By increasing
the visibility of all surfaces of the organ or tissue being
studied, they can help the radiologist determine the
presence and extent of disease or injury.
Contrast agents are available in several different
forms, but in general a CT contrast agent is a pharma-
ceutical substance. Some of the more common contrast
agents used are:
• I o di n e
• Barium
• Barium sulfate
• G as t r og r a f in
Contrast agents for CT examinations are adminis-
tered in four different ways:
• In
Intr
trav
avenenou
ouss ininje
ject
ctio
ion
n
• Or
Oralal ad
admin inisistr
trat
atio
ionn
• Re
Rectctal
al ad
admi
mini nist
stra
rati
tion
on
• Inh
Inhala
alatio
tion—T
n—This his is
is a relat
relative
ively
ly uncom
uncommon
mon proc
proce-
e-
dure in which xenon gas is inhaled for a highly
specialized form of lung or brain imaging. The
technique, xenon CT, is only available at a small

number of locations worldwide and is used only

for rare cases.

INTRAVENOUS CONTRAST
Intravenous contrast is used to highlight blood vessels
and to enhance the structure of organs like the brain,
spine, liver, and kidney. The contrast agent (usually
an iodine compound) is clear, with a water-like
consistency. Typically the contrast is contained in a
CONTRAST ISSUES 163

special injector, which injects the contrast through a

small needle taped in place (usually on the back of the
hand) during a specific period in the CT exam.
Once the contrast is injected into the bloodstream,
it circulates throughout the body. The CT’s X-ray beam
is weakened as it passes through the blood vessels
and organs that have “taken up” the contrast. These
structures are enhanced by this process and show up
as white areas on the CT images. When the test is
finished, the kidneys and liver quickly eliminate the
contrast from the body.

Iodinated Contrast Agents

Is Iodine a Safe Contrast Agent?
Iodine is considered to be a safe contrast agent. It has
been used for many years
years without serious side
side effects.
Because iodine contrast increases the visibility of target
tissues on the images, the benefits are considered to
outweigh the risks. The most common side effect of
iodine is a warm or “flushed” sensation during the
actual injection of the iodine, followed sometimes by
a metallic taste in the mouth that usually lasts for less
than a minute. No treatment is necessary for this
sensation, if experienced.
Another mild reaction is itching over various parts
of the body. This reaction lasts from several minutes
to a few hours after the injection. When this reaction
occurs, medication is usually administered to
counteract the itching.
More serious allergic reactions, while uncommon,
include difficulty breathing and swelling of the throat
164 STEP BY STEP CT SCAN

or other parts of the body. These reactions, if

experienced, are treated immediately.
Newer forms of contrast help to reduce the risk of
an allergic reaction. If you have had an allergic reaction
to iodine or a contrast agent in the past, the physician
may recommend on of these newer agents.
In some cases, CT can still provide valuable
diagnostic information without the administration of
a contrast agent, so the radiologist or a trained
technologist may decide this is the best course of action.

ORAL CT CONTRAST

Oral contrast
organs is used toand
in the abdomen highlight
pelvis.gastrointestinal
If oral contrast (GI)
will
be used during an exami
examinatio
nation,
n, the pati
patient
ent will be
asked to fast for several hours before administration.

Fig. 7.1: Oral contrast agent

CONTRAST ISSUES 165

Two types of oral contrast are used:

Barium sulfate, the most common oral contrast
agent, resembles a milkshake in appearance and
consistency. The compound, available in various
flavors, is prepared by mixing with water.
Gastrografin is a yellowish, water-based drink
mixed with iodine. It can have a bitter taste.
When oral contrast has been requested by the
doctor, patients usually drink about 1,000 to 1,500 cc
over a one hour period.
After the contrast is swallowed, it travels to the
stomach and gastrointestinal tract. Like intravenous
iodine, barium and gastrografin weaken X-rays. On
CT images, the organs that have “taken up” the
contrast appear as highlighted white areas.

Is Oral Contrast Safe?

In general, both barium and gastrografin contrast are
safe and pass uneventfully through the gastrointestinal
tract. Minor and temporary side effects, such as
constipation, may occur.

RECTAL CT CONTRAST
Rectal contrast is used when enhanced images of the
large intestine and other lower GI organs are required.
The same types of contrast used for oral contrast are
used for rectal contrast, but in different concentrations.
Rectal CT contrast is usually administered by
enema. When the contrast is administered
administered,, the patient
may experience mild discomfort, coolness, and a sense
of fullness. After the CT is complete, the contrast is
drained and the patient may go to the bathroom.
166 STEP BY STEP CT SCAN

The preparation for rectal contrast is similar to oral

contrast, in that the patient should be fasting for
several hours before the test. In addition, the patient
will be required to use a Fleets Enema to cleanse the
colon; it is usually used the night before the exami-
nation.

Is Rectal Contrast Safe?

Rectal contrast is considered to be safe and passes
through the gastrointestinal tract uneventfully. Minor
and temporary side effects, such as constipation, can
occur.

Guidelines for IV Contrast Agent Reactions

Q. Radio
Radiograph
graphic
ic contrast
contrast media adverse
adverse reactions?
reactions?
Iodinated contrast media is routinely administered for
many radiological procedures like CT, IVP or angio-
graphy. Due to the higher absorption of X-ray beams
by the iodinated contrast, both normal and abnormal
structures are better seen. However, because of the
risks of adverse reaction to contrast administration in
some patients, judicious use of these agents is required.
The following are frequently asked questions about
contrast media and contrast reactions.
Q. How frequently
frequently do allergic
allergic contrast
contrast reactions
reactions
occur?
It is estimated that the overall frequency of adverse
reactions is 5 to 10 percent. Most of these are very
mild and may consist of only a few hives. However,
in one of every 1,000 to 2,000 examinations, a moderate
or severe reaction can occur. The risk of death from a
CONTRAST ISSUES 167

contrast agent is estimated to be 0.3 to 2.6 per 100,000

uses (comparable in magnitude to the risk of death
from receiving a dose of penicillin).
Q. What types
types of allergic
allergic contrast
contrast reactions
reactions are seen?
seen?
Contrast reactions are classified as mild, moderate, or
severe. Mild reactions include mild nausea and
vomiting, mild urticaria and pruritus, and mild
diaphoresis. Moderate reactions would include more
severe presentations of the above symptoms, facial and
laryngeal edema or mild bronchospasm. Severe
reactions may include hypotensive shock, cardiac or
respiratory arrest, pulmonary edema, loss of conscious-
ness, convulsions, and severe laryngeal or bronchial
spasm.
Q. How are these
these contras
contrastt reactions
reactions treated?
treated?
All contrast examinations are performed in the
presence of a physician, usually a radiologist, the
technician must be ready to initiate treatment of any
reaction (Keep a guidelines for the treatment of these
reactions in the CT gantry room). Most reactions are
mild and require no treatment; outpatients are usually
observed for 30 minutes for worsening of symptoms.

In
andmost
will cases, these
resolve mild
within symptoms
this time withare self-limiting
minimal or no
treatment.
Q. What can be done if a patient with a history
history of
of
contrast reaction needs another contrast exam?
This depends on the nature and severity of the prior
reaction. If the prior reaction was mild, selection of a
low-osmolar contrast agent (“non-ionic”) and/or
pretreatment with 25 to 50 mg of diphenhydramine
168 STEP BY STEP CT SCAN

(avil) prior to the examination may be all that is

needed. If the prior reaction was moderate or severe,
a radiologist should be consulted to see if there is an
alternative diagnostic imaging strategy (e.g. ultra-
sound or MRI) that avoids iodinated contrast exposure.
Of note, gadolinium based MRI contrast agents have
a different formulation from iodinated radiographic
contrast media, and there is no known cross sensitivity
between these two types of contrast.
If a contrast examination is still felt necessary,
premedication with corticosteroids should be perfor-
med and low osmolar contrast selected. Two accepted
protocols for corticosteroid administration in this
setting include 50 mg of prednisone peroral. 12, 6, and
1 hour prior to the examination, or 32 mg of peroral
solumedrol 12 and 2 hours prior to the exam. Fifty mg
of diphenhydramine at bedtime the evening prior and
1 hour prior to the procedure is usually also
administered. The equivalent IV dose of solumedrol
can be substituted if the patient is unable to tolerate
peroral administration.
Q. Are low-osmo
low-osmolar
lar contrast
contrast media
media safer?
safer?
Low-osmolar contrast media (LOCM) are associated
with less patient discomfort during administration.
However, the risk of death from contrast reaction is
felt to be mostly unchanged from that of high-osmolar
contrast media (HOCM). The risk of very severe
reactions is decreased with low osmolality contrast
but the amoun
amountt of risk reduct
reduction
ion in pati
patients
ents not at
high-risk for a reaction is very low. For the patient
with no known risk factors for contrast reaction,
HOCM are felt to be relatively safe.
CONTRAST ISSUES 169

Q. Why are LOCM

LOCM not used
used routinely
routinely on all
all contrast
contrast
examinations?
Low osmolality contrast agents
ag ents are about 10 times more
expensive than high osmolality agents. All outpatients
who will undergo a contrast examination are screened
by the
the radiologic
radiologic technologist for risk factors including
prior reaction, history of severe allergy to any
medication, active asthma, current severe cardiac
disease, history of sickle cell disease or multiple
myeloma, and increased risk of aspiration. The
radiologist then selects the dose and type of contrast
media after reviewing this information. Formalize a
protocol for the use of LOCM, patients can also be
offered the choice by providing them with pamphlets
detailing the contrast study.
Q. Do low osmolalit
osmolalityy contrast
contrast media have a lower
lower
incidence of associated nephrotoxicity?
Patients with insulin-dependent diabetes, volume
depletion, and baseline renal dysfunction are a higher
risk for contrast induced acute tubular necrosis or
transient renal dysfunction. A few studies have
suggested a slight benefit to use of LOCM in this
setting. Contrast administration in patients with rising
creatinine or stable creatine greater than 2.5 mg/dl is
not recommended. LOCM is also often used in the
patients with end-stage renal disease, not because of
concerns of nephrotoxicity but due to the possible
hemodynamic effects of an osmotic load in these
patients that may also commonly have cardiac disease.
With the availability of new iso-osmolar contrast
more at risk patients can be taken up for contrast
studies in consultation with the nephrologist.
170 STEP BY STEP CT SCAN

Algorithm for Treating Contrast Reactions

Mild to Moderate Anaphylaxis
First symptom—perioral numbness.
Inj. Decadron— 8 mg (2cc) IV
Inj. Efcorlin — 300 mg, IV
Inj. Avil 2 cc IV
Inj. Emiset 2 cc IV

Severe Anaphylaxis
• Tongue
Tongue edeedema,
ma, no
no pulse,
pulse, call
call for
for assis
assistan
tance,
ce, init
initiat
iatee
CPR protocol.
• Ad
Adre
rena
nali
line
ne 1/2
1/2 cc
cc subc
subcut
utan
aneo
eous
us..
• Non
Non-re
-respo
sponse
nse adr
adrena
enalin
linee 1 cc—di
cc—dilutlutee to 10
10 cc give
give
1 cc IV.
• In cente
centersrs wher
wheree intens
intensive
ive care
care is
is availa
available
ble pati
patient
ent
has to be shifted as soon as possible.
Chapter 8

Radiation Dose
172 STEP BY STEP CT SCAN

We have always been concerned with the radiation

dose to our patients from various imaging studies, as
all of us know CT is a high dose examination. Dose in
CT is measured by the effective dose, i.e. dose received
by critical organs.
The majority of dose in CT scanning is delivered
to the thin volume of tissue (1-10 mm) exposed to the
primary beam. Tissues outside this will also receive
some dose from scatter radiation.
Radiation dose from CT procedures varies from
patient. A particular radiation dose will depend on
the size of the body part examined, the type of
procedure, and the type of CT equipment and its
operation. Typical values cited for radiation dose
should be considered as estimates that cannot be
precisely associated with any individual patient,
examination, or type of CT system. The actual dose
from a procedure could be two or three times larger
or smaller than the estimates. Facilities performing
“screening” procedures may adjust the radiation dose
used to levels less (by factors such as 1/2 to 1/5 for so
called “low doses CT scans) than those typically used
for diagnostic CT procedures.

The quantity
of cancer most from
detriment relevant forprocedures
a CT assessing theis risk
the
effective dose. Effective dose is evaluated in units of
millisieverts (abbreviated mSv; 1 mSv = 1 mGv in the
case of X-rays). Using the concept of effective dose
allows comparison of the risk estimates associated with
partial or whole-body radiation exposures. This
quantity also incorporates the different rdiation
sensitivities of the various organs in the body. Estimates
RADIATION DOSE 173

of the effective dose from a diagnostic CT procedure

can vary by a factor of 10 or more depending on the
type of CT procedure patient size and the CT system
and its operating technique. A list of representative
diagnostic procedures and associated doses are given
in Table 8.1 that is from a report of the European
commission.

Table 8.1: Radiation dose comparison

D i a gno s t i c T ypica l Number of chest Time period for

procedure effective X-rays (PA film) equivalent effective
do s e for equivalent dose from natural
(mSv)1 effective dose2 background radiation3

Chest X-ray 0.02 1 2 .4 days

(PA film)
S k u l l X - r ay 0.07 4 8 .5 days
L um b a r s p i n e 1.3 65 1 58 da y s
I V u r o gr a m 2.5 125 3 04 da y s
Up pe r G I e x a m 3.0 150 1 . 0 ye a r
B a ri u m en em a 7.0 350 2 . 3 y ea r s
C T he a d 2.0 100 2 43 da y s
C T a b do m e n 10.0 500 3.3 ye ar s

The primary dose comes from the acquisition of

data for slice recon. Scout scans have a lower radiation
dose than their conventional counterparts.

FACTORS AFFECTING RADIATION DOSE

• Scan
Scannenerr ge
gene
nerarati
tion
on..
• Rot
Rotati
ation
on ang
angle—
le—360
360°° prod
produce
uce mor
moree dose
dose..
• Fil
Filtra
tratio
tion—d
n—decr ecreas
eases
es the
the patien
patientt dose
dose from
from
removal of low energy X-rays.
• Det
etec
ecto
torr ef
effi
fici
cien
ency
cy..
174 STEP BY STEP CT SCAN

• Tube
Tube curren
current—d t—direirect
ct linea
linearr relati
relations
onship
hip betw
between
een
mAs and radiation dose.
• Sli
Slice
ce thic
thickne
kness—ss—thi
thinn slice
slice mor
moree radia
radiatio
tion.
n.
• PaPati
tien
entt th
thiick
ckne
nesss.
• Foc
Focal
al spo
spott siz
size—d
e—dire irectl
ctlyy pro
propor
portio
tional
nal..
Two main variables used to describe doses received
from CT scanning includes.
1. CTDI (computed tomography dose index): Measures
the radiation dose within the slice width, measured
using a ionization chamber, or TLD chips.
2 . MSA
MSAD D (mult
(multipl
iplee scan
scan aver
average
age dos e): Represents dose
dose):
to a specific section location resulting from the scan
at that location as well as from adjacent location.
MSAD equals the CTDI from seven contiguous
sections above and below the section of interests if
the interval between sections is equal to the section
thickness.

FACTORS AFFECTING THE DOSE IN

CONVENTIONAL CT
Beam energy and filtration: Higher the beam energy for
an otherwise constant exposure higher the dose. Use
of most appropriate peak dose for a given patient
keeps the dose reasonable. The type of filter used by
the manufacturer also plays a major role in beam
modulation.
Collimation: Both pre- and post-patient collimation plays
a significant role in modulating patient dose.
Number and spacing of adjacent sections: When more
sections are scanned more total volume of tissue is
irradiated.
RADIATION DOSE 175

Image quality and noise: Statistical noise and loss of image

contrast as a result of scattered radiation, to maintain
acceptable level of noise the peak kilovoltage and tube
current used to acquire the image may need to be
increased.

TRADE OFFS BETWEEN RADIATION DOSE AND

IMAGE QUALITY
As we change the parameters to reduce radiation
dose, the impact on image quality must be considered
as there is direct link between the two:
• Reducin
Reducing g mAs
mAs reduc
reduceses radia
radiation
tion dose
dose,, but
but increa
increases
ses
image noise.
• Increase in pitch or table speed—decreases the
dose but may increase the slice profile creating
a larger slice thickness reducing the z axis
resolution.
Radiation dose
• For pit
pitch
ch of
of 1—Sam
1—Samee as comcompar
parabl
ablee conti
contiguo
guous
us
conventional scans
• For pitc
pitch
h 1.5—A
1.5—Apprpproxi
oxima
matel
tely
y 2/3 that
that of conti
contiguo
guous
us
scans
• For pit
pitch
ch 2—Ap
2—Appro proxim
ximate
ately
ly 1/2
1/2 of
of conti
contiguo
guous
us
scans
• Rad
Radiat
iation
ion dos
dosee is
is prop
proport
ortion
ional
al to
to 1/pit
1/pitch
ch
• Reducing kVp—reduces radiation dose, may
increase signal contrast for some tissues.
176 STEP BY STEP CT SCAN

NATIONAL COUNCIL ON RADIATION

PROTECTION (NCRP) AND MEASUREMENTS
Occupational Dose Limits
• 50 mSv (5 rem)—annual effective dose limit
and
• 10 mSv (1 rem) × age (y)—cumulative effective dose
limit
• 150 mSv (15 rem)—annual equivalent dose limit to
lens of eye
• 500 mSv (50 rem)—annual equivalent dose limit to
skin, hands, and feet

Public Dose Limits

• 1 mSv (0.1 rem)—annual effective dose limit for
continuous exposure
• 5 mSv (0.5 rem)—annual effective dose limit for
infrequent exposure
• 50 mSv (5 rem)—annual effective dose limit to lens
of eye, skin, and extremities

Embryo Fetus
• 0.5 mSv (0.05-50 m rem)—equivalent dose limit in a
month once pregnancy is known..

ESTIMATED RADIATION RISKS POTENTIALLY

ASSOCIATED WITH FULL-BODY CT SCREENING
Full-body CT screening of healthy adults is intended
to be an early detection device for a variety of diseases
including lung cancer, coronary artery disease, and
colon cancer.
RADIATION DOSE 177

While the potential benefits and risk have been

debated in terms of disease detection vs. false
positives, less attention has been paid to the potential
radiation risks associated with full-body CT scanning.
The radiation issue is pertinent because CT scans by
their nature result in much larger organ doses
compared with conventional single-film X-rays.
Typical doses from a single full-body scan are about
9 mGy to the lung, 8 mGy to the digestive organs, and
6 mGy to the bone marrow. The effective dose, which
is a weighted average of doses to all organs, is about
7 mSv.

In Utero Exposure
Whenever a patient with clinical suspicion of pregnancy
needs a scan the potential benefits and risks have to
be weighed before a decicion is made for scannin
scanning.
g.
Following precautions can be taken if the need is very
great: (1) shielding of abdomen if the study permits,
(2) no of slices can be reduced to a minimum.
Report 54 of the NCRP (National Council for
Radiation Protection) is particularly useful for
calculating fetal dose. These data include dose received
from both direct and indirect exposures.
NCRP reports state that the risk for pregnancy is
less at 5 rad (50 mGy) or less when compared to other
risks of pregnancy. The risk for malformation is sub-
stantially increased at doses above 15 rad (150 mGy).
Chapter 9

Proficiency Check
180 STEP BY STEP CT SCAN

The complex
complex nature of processes involves multiple
imaging modalities. Requires an interdisciplinary team
of medical and paramedical personnel and techno-
logists.
In case of computed tomography, it is the CT
technologist who performs the computed tomography
examination that creates the images needed for
diagnosis. Computed tomography technologists need
to integrate scientific knowledge and technical skills
with effective patient interaction to provide quality
patient care and useful diagnostic information for the
radiologist.

NEEDS OF A GOOD
GOOD COMPUTED TOMOGRAPHY
TOMOGRAPHY
TECHNOLOGIST
The computed tomography technologist must demon-
strate an understanding of human cross-sectional
anatomy, and medical terminology.
Computed tomography technologists must maintain
a high degree of accuracy in positioning and exposure
technique. He or she must maintain knowledge about
radiation protection and safety.
Computed tomography technologists prepare for
and assist the radiologist in the completion
completion of compu-
ted tomography examinations including a range of
tissue biopsies and fluid drainages. They should
supervise or be able to administer contrast media
media and
medications.
Computed tomography technologists are the
primary liaison between patients and radiologists and
other members of the support team. They must remain
sensitive to the physical and emotional needs of the
PROFICIENCY CHECK 181

patient through good communication, patient assess-

ment, patient monitoring and patient care skills.
The practice standards define the practice and
establish general criteria to determine compliance.
They include desired and achievable levels of
performance against which actual performance can be
measured.

COMPUTED TOMOGRAPHY CLINICAL

PERFORMANCE STANDARDS: SUMMARY

Standard one—Assessment: Collect pertinent data

about the patient and the procedure.
Standard two—Analysis/Determination: Analyzes the
information obtained plan for completing the scan.
Standard three—Patient Education: Provide infor-
mation about the procedure to the patient.
Standard four—Imple mentation: Implements the scan
four—Implementation:
and Archives images to data storage devices
devices according
to established guidelines.
1 . Pe
Perf
rfor
orms
ms ve
veni
nipu
punc
nctu
ture
re,,
2. Adm
Adminis
inisters
ters contr
contrast
ast agents
agents accor
accordin
dingg to esta-
esta-

3. blished
torsguidelines.
Monitors
Moni the patien
patientt for reac
reactions
tions to contras
contrastt agent.
agent.
4. Use
Usess appropr
appropriatiatee radiat
radiation
ion safet
safetyy devices
devices..
5. Moni
Monitors
tors the patie
patient’s
nt’s physic
physical al condi
condition
tion duri
during
ng
the procedure.
6. Appl
Applies
ies appro
appropriat
priatee patient
patient imm
immobili
obilizatio
zation
n devices
devices
when necessary.
7. Com
Complet
pleteses routine
routine camera
camera operat
operations
ions—fo
—formarmats,
ts,
ensures an adequate film supply for the procedure
and verifies image location.
182 STEP BY STEP CT SCAN

The candidate is expected to have acquired detailed

knowledge of all aspects of:

Foundations of CT and Computers

• Definition of CT
• Evolut
Evo lutionion of the
the term
term ‘co
‘compu
mputedted tom
tomogr
ograph
aphy’
y’
• Pioneers
• Basic process
• High
Hi ghliligh
ghts
ts of
of deve
develo
lopm
pmen
entt tren
trends
ds
• Defi
De fini
nitition
on of co
comp
mpututer
er
• Dig
igit
itaal pr
proc
oces
essi
sin
ng
• Data st storage
• Dat
ataa com
comm
munic
icat
atio
ion
n
System Design and Components
• G e n e ra t i o n s
• Helical de design
• Multlti-
i-sl
slic
icee dedesi
sign
gn
• Acqu
Ac quis isit
itio
ion n com
compo
pone
nent
ntss

Image Reconstruction
• Li
Line
near
ar at
atte
tenu
nuat
atio
ion
n coe
coeff
ffici
icien
entt
• Pixels anand vo
voxels
• Projections
• CT numbers
• Array pr processor
• Back projection
• Filt
Filter
ered
ed baback
ck pr
proj
ojec
ecti
tion
on
• Digi
Di gita
tall ana
analo
log
g con
conve
vert
rtor
or
PROFICIENCY CHECK 183

Parameter Options
• Exposure fafactors
• Scan se
set-up
• Contrast me
media
• Reco
Re cons
nstr
truc
ucti
tion
on op
opti
tion
onss
• Display fo
format
• Scan
Scan pr
proj
ojec
ecti
tion
on ra
radi
diog
ogra
raph
phy
y

Image Display and Manipulation

• Cons ol e
• Windowing
• Display options
• Analysis opoptions
• Mult
Mu ltip
ipla
lana
narr re
reco
cons
nstr
truc
ucti
tion
on
• Maxi
Ma ximu
mum m int
inten
ensi
sity
ty pr
proj
ojec
ecti
tion
on
• 3-Di
3-Dim
menensi
sion
onal
al im
imag
agin
ing
g
• Dental planning
• Work station

Image Quality
• Spa
pattia
iall res
resol
olu
uti
tio
on
• Co
Cont
ntrarast
st re
reso
solu
luti
tion
on
•
• N
Unoiifsoermity
• Li n e a r i t y
• Phantom
• Prev
Pr even entitiveve ma
main
inte
tena
nanc
ncee
• Ar t i f a c t s
184 STEP BY STEP CT SCAN

m
r
o
f
A
T
A
D
e
c
n
a
r
u
s
s
a
y
ti
l
a
u
Q
:
.1
9
.
gi
F
PROFICIENCY CHECK 185

Radiation Dose
• Factor
Factorss aff
affec
ecti
ting
ng pa
patitien
entt dos
dosee
• Dos
osee mea easu
surrem
emeent
• Typ
ypic
icaal dos
dosee va
valu
luees
• Rad
adia
iati
tion
on pro
prote
tect
ctio
ion.
n.

Quality Check-up
In order to maintain consistent image quality users
must establish and actively maintain
• A qua
quali
lity
ty as
assu
sura
ranc
ncee pro
progrgramammeme
• Quaup phantom
• Hi
High
gh cocont
ntra
rast
st re
reso
solu
lutition
on
• Contrast sc scale
• Slice thickness
• Po
Posi
siti
tion
onin
ingg loca
locali
lize
zerr accu
accura racy
cy
• Lo
Loww con
contr
tras
astt det
detec
ecta
tabi
bili
lity
ty
• No
Nois
isee an
and
d un
unif
ifor
ormi
mityty..

PROTOCOLS TO BE KNOWN
Head
• Brain routine
• Brai
Br ain-
n-ax
axia
iall and
and co coro
rona
nall
• Posterior fo fossa
• Trauma
• Circle of Willis
• Pitu
Pi tuit
itar
aryy gland
gland—a —axi xial
al and
and corcoron
onal
al
• Orbi
Or bits
ts—a
—axixialal and
and corcoron
onalal
• Faci
Fa cial
al bo
bone
nes—s—ax axia
iall and
and cocoro
rona
nall
• Sinu
Sinuseses—
s—axaxiaiall and
and coro
coronanall
• Inte
In tern
rnal
al au
audidito
toryry ca
cananals
ls
• Tempo
Te mporom
romandandibu ibular
lar joi
joints
nts—ax
—axial
ial and
and coro
coronal
nal
186 STEP BY STEP CT SCAN

Neck
• Neck—Routine
• Carotid ar arteries
• Nasopharynx
• Oral ca cavity
• T hyroi d
• G l o tt i s

Chest
• Chest—Routine
• Hilum
• Aortic dis
isssectio
ion
n
• Aortic aneurysm
• Pulm
Pu lmon
onar
aryy em
embololis
ism
m
• High
High res
esol
oluuti
tion
on lu
lung
ng

Abdomen and Pelvis

• Abdomen—Routin inee
• Abdomen—Trauma
• Abdo
Ab dome
men
n an
and
d pe
pelv
lvis
is—R
—Rou
outi
tine
ne
• Aortic An
Aneurysm
• Live
verr—Triphase
• A d r en a l s
• Pan
anccreaeas—
s—U Uni
nip
pha
hasse
• Kid
idn neys
ys— —Routine
• Kidn
Kidney eys—
s—St Ston
onee se
sear
arch
ch
• Kid
idneneys
ys— —Bipiph
has
asee
• Kid
Kidneys ys— —Trip
ipha
hasse
• Pelvis—Routine
• Pelvis—Biphase
• Pelvis—Trauma
PROFICIENCY CHECK 187

• End
ndom
omet etri
rium
um/C
/Cer
ervi
vix
x
• Ov a r y

Spine
• Cervic
icaal—Routin
inee
• Cervi
viccal—
l—T
Trauma
• Thor
oraacic
ic—
—Routine
• Lumbar—Routin inee
• Lumbar—Disks

Extremities
• Shoulder
• El b ow
• Wr i s t
• Hip
• Knee
• Ankle
• Calcaneus

Interventional
• CT guided biopsy

CT SECTIONAL ANATOMY
Head
• Bra i n
• Or bi ts
• Sinuses
• Temporal bo bones
• Max
axililllof
ofac
acia
iall bone
boness
• Posterior fo fossa
188 STEP BY STEP CT SCAN

• TM joints
• Circle of Willis

Neck
• Nasopharynx
• Esophagus
• La r yn x
• Musculature
• Vasculature

Spine
• Cervical
• Thoracic
• Lumbar
• Sacrum

Chest
• Mediastinum
• Heart
• Lung
• Pleural space
• Vasculature

Abdomen
• Liverr and
Live and ga gall
llbl
blad
add
der
• GI tract
• Pancreas
• Spleen
• A d r en a l s
• Kidneys
PROFICIENCY CHECK 189

• Retr
Retrop
oper
erit
iton
onea
eall sp
spac
acee
• Vasculature

Pelvis
• Uret ers
• Urinary bl bladder
• U t e r us
• Ov a r i e s
• P r os t a t e
• Vasculature

Musculoskeletal
• Upper extremity
• L o w er e x t r e m i t y
• Pelvis
• Hips
• Vasculature

STEP BY STEP GUIDE TO A TYPICAL CT

EXAMINATION
Request Form
• Check
Check form
form is full
fully
y compl
complete etedd and
and sign
signed
ed..
• Check pregnancy question if required.
• Che
Check
ck exami
examinatnation
ion requ
requestest corr
correla
elates
tes to
to clinic
clinical
al
history.
• Re
Regi
gist
ster
er on co
comp
mput
uter
er..
• Tak
Takee specia
speciall care
care with
with detail
detailss from,
from, elde
elderly
rly,, handi-
handi-
capped, deaf, blind, very young, individuals with
poor English etc.
• Rev
Review
iew any preprevio
vious
us rep
report
ortss and
and or
or film
films.
s.
190 STEP BY STEP CT SCAN

Request Form + Patient

• Confir
Con firm
Check
Che ck m deils
detai
tails
details
deta ls
of of
oany
afny
paspec
patie
stient
ntial
and
and
pecial ejectio
exam
xamina
projec
pro inatio
tion tion.
n. .
n asked
asked.
• Ide
Identi
ntity,
ty, us
usee a posit
positive
ive ID chec
check,
k, use
use DOB
DOB and
and or
or
address.
• Pr
Prev
evio
ious
us ex
exam
amininat
atio
ions
ns..
• Che
Check
ck and
and have
have pat
patien
ientt sign
sign for
for preg
pregnan
nancy
cy risk
risk if
appropriate.

Escort Patient to Changing Cubicles

• Give
Give changi
changing ng instr
instruct
uction
ion rele
relevan
vantt to exami
examinat
nation
ion..
• Use starch
starch fre
freee exami
examinat
nation
ion gown
gown and and dres
dressin
singg
gown.
• Ens
Ensur
uree patien
patient’s
t’s mod
modest
estyy is protec
protected
ted and
and they
they are
are
warm enough.
• Ins
Instru
truct
ct patie
patients
nts in
in the remo
removalval of
of artifa
artifacts
cts rele
relevan
vantt
to the examination, i.e. jewellery and prostheses.

Whilst Patient is Changing

Pre-examination Preparation
*** Collect patient and escort to examination room***

The Examination
• Greet
Greet patie
patient
nt and
and make
make posi
positiv
tivee ident
identity
ity chec
check.
k.
State your name and grade.
• Check request details match patients’ symptoms ,
i.e. right/left limbs.
• InInfo
form
rm pat
patie
ient
nt of
of basi
basicc proc
procededur
ure.
e.
• Position pat patient.
• PoPosisiti
tion
on gona
gonadd prot
protec
ectt if req
requi
uire
red.
d.
PROFICIENCY CHECK 191

• FiFina
nali
lisse exp
expososuure
re..
• Reh
Rehear
earse
se any
any brea
breathithing/
ng/mo movin
vingg proce
procedudures
res..
• Instr
Ins truct
uct pati
patient
ent and visu visuallally
y check
check them them in in
respiratory manoeuvres or required movements.
• Visual
Vis ually
ly check
check allall round
round to ensuensurere it is
is safe
safe to make
make
exposure.
• Expose
• Inform
Inform pat
patien
ientt to rel
relax
ax and
and brea
breath
th norm
normallally
y
• Remo
Re move
ve cacass
sset
ette
te to a safsafee pla
place
ce
• Proc
Procee
eed
d with
with the
the nex
nextt posi
positition
on etc
etc..
• When
Whe n finish
finished
ed escor
escortt patien
patientt to waiti
waiting ng cubic
cubiclele and
and
instruct to wait and or to redress if required.

• Mark
Ma rkplete
name
na
Complet
Com me on fi
e docufilm
lmsstation
documen
mentatiand
andonpr
proc
oces
on
on ess.
re s. st form
reque
quest form and in
computer.

Assessing the CT Film

• Place
Place the
the radio
radiogra
graph
ph corr
correct
ectly
ly on the
the viewi
viewingng box.
box.
• Chec
Check,k, iden
identific
tification
ation,, name,
name, date
date,, hospi
hospital,
tal, regi
regis-
s-
tration number.
• Che
Checkck anato
anatomi
mical
cal mark
marker/
er/leg
legend
end cor
correc
rectt R/L
R/L and
AP/PA area under examination, limits of exami-
nation.

Departure of the Patient

• Inform
Inform pat
patien
ientt exam
examina
inatio
tion
n is com
comple
pleted
ted..
• Ret
Return
urn any jew
jewell
eller
ery
y or art
artifa
ifacts
cts rem
remove
oved.
d.
• Inf
Inform
orm patient
patient that any diet
dietary
ary pre
prepar
paratio
ations
ns are
are
finished and any side/after effects of any drugs or
medication e.g. white stools after Barium exami-
nations.
Chapter 10

Computed
Tomography
Glossary
194 STEP BY STEP CT SCAN

Artifact (structured noise): The appearance in the CT

image of details not present in the scanned object. The
main components of structured noise are due to a form
of partial volume effect and to beam hardening. Both
effects usually result in streaking artifacts, which are
observed in regions of high contrast when there is a
sharp discontinuity in object density, such as at air-
tissue, air-bone and metal-tissue boundaries.
boundaries. Streaking
will also arise from mechanical misalignment within
the scanner and, in clinical practice, from patient motion
and the use of high-density contrast media.
Attenuation: Reduction of the radiation intensity ,
upon passage through matter, resulting from all types
of interaction.
Back projection: Mathematical procedure for the
reconstruction of the CT image, based on the smearing
of the individual rays within a view (projection) back
along the direction in which they were measured.
Spatial filtration (convolution ) of the raw data is
necessary before back projection in order to reduce
artifacts.
Beam hardening: The process of filtration of a
polychromatic beam by the preferential absorption of
lower energy photons in tissue, with a subsequent
increase in effective energy. The associated artifacts
are of particular significance in quantitative computed
tomography (QCT).
Calibration of a CT scanner: Correction procedures
used to take account of variations in beam intensity or
detector efficiency in order to achieve homogeneity
COMPUTED TOMOGRAPHY GLOSSARY 195

within the field of view and accuracy of CT number.

Calibration procedures include scanning air or an
appropriate test phantom.
Collimation: Geometrical limitation of the extent of
the radiation beam in the z-direction.
Computed tomography dose index (CTDI): Integral
along a line parallel to the axis of rotation (z) of the
dose profile (D(z)), measured free-in-air or in a CT
dosimetry phantom for a single slice, divided by the
nominal slice thickness (T):

(mGy)

In practice, it is convenient to use a pencil ionisation

chamber with an active length of 100 mm so as to
provide a measurement of CTDI100 (mGy to air).
Computed tomography number (CT number):
Number used to represent the mean X-ray attenuation
associated with each elemental area of the CT image.
Numbers are normally expressed in terms of Houns-
field unit (HU). Measured values of attenuation are
transformed into CT numbers using the international
Hounsfield scale:

(HU)

Where μ is the effective linear attenuation

coefficient for the X-ray beam. The CT number scale
196 STEP BY STEP CT SCAN

is defined so that water has a value of 0 HU and air a

value of -1000 HU.
Contrast: In relation to the radiation emerging from
an irradiated object, if the photon fluence at some
reference point is Ø0, and at an adjacent point is Ø1,
the contrast can be defined as (Ø 1 - Ø0) / Ø0. Contrast
can also be expressed in terms of energy fluence or
exposure.
Contrast enhancement: Administration of intravenous
or intra-arterial contrast increase the visibility of low
contrast structures due to increased density of vessels
and organs/tissue containing contrast media.
Contrast resolution: See low contrast resolution.
Convolution: The mathematical process by which raw
data undergo spatial filtration prior to back projection.
Couch increment: Distance by which position of
patient couch (table) is changed between individual
slices in serial scanning or the distance the couch
position is changed during one 360 o rotation of the
tube during helical scanning.

CT dosimetry(PMMA
methacrylate phantoms: Cylinders
) used of polymethyl-
for standard measure-
ments of dose in CT, having a diameter of 16 cm (head
phantom) or 32 cm (body phantom) and a length of at
least 14 cm. The phantoms are constructed with
removable inserts parallel to the axis to allow the
positioning of a dosimeter at the centre and 1 cm from
the outer surface (periphery).
COMPUTED TOMOGRAPHY GLOSSARY 197

CT number: Abbreviation for computed tomography

number.
CTDI: Abbreviation for computed tomography dose
index.
CTDIair: Value of CTDI determined free-in-air.
CTDIw: See weighted CTDI.
Detector: A single element of a detector array, which
produces an electrical or light signal in response to
stimulation by X-rays.
Detector array: The entire assembly of detectors,
including their interspace material, arranged along an
arc or circumference (depending on scanner
technology) of a circle centred on the axis of rotation.
Detector efficiency: For each detector contained in a
detector array, the ratio between the number of pulses
recorded and the number of X-ray photons incident
on the detector.
Detector width: In a detector array, the distance
between the two opposite faces of any single detector.

Diagnostic
by pro
profes
fessioreference
siona
nall bod
bodielevel:
ies Advisory
s to pro
prompt
mpt lo dose
loca
cal levels
l rev
revie ws set
iews of
practice if consistently exceeded.
Display matrix: The array of rows and columns of
pixels in the displayed image, typically between 512 ×
512 and 1024 × 1024. It may be equal to or larger than
the size of the reconstruction matrix due to
interpolation procedures.
198 STEP BY STEP CT SCAN

Dose descriptor: Measurable parameter, such as

CTDIair, CTDIw or DLP, from which the effective dose
or the organ dose delivered to a patient in a CT
examination can be estimated, or the performances of
different CT scanners can be compared.
Dose-length product (DLP): Dose descriptor used as
an indicator of overall exposure for a complete CT
examination in order to allow comparison of
performance against a reference dose value set for the
purpose of promoting optimisation of patient
protection.

(mGy cm)
Where i represents each scan sequence forming part
of an examination, and CTDIw is the weighted CTDI
for each of the N slices of thickness T (cm) in the
sequence.
Dose profile: Representation of the dose as a function
of position along a line perpendicular to the
tomographic plane.
Dosimetry phantom: See CT dosimetry phantom.
Dynamic scanning: A method of obtaining CT scans
in rapid sequence so as, for example, to follow the
passage of contrast material through vessels or tissue,
or to decrease examination time.
Effective dose: Risk-related quantity used as indicator
of overall patient dose. It is defined by the Inter-
national Commission on Radiological Protection (ICRP)
COMPUTED TOMOGRAPHY GLOSSARY 199

in Publication 60 (1991) as the sum of the weighted

absorbed doses in all tissues and organs of the body:
(mSv)

where DT is the absorbed dose (mGy) in tissue T due

to radiation R, wR is the weighting factor for radiation
R and wT is the weighting factor for tissue T. For X-
rays, wR is equal to unity.
Exposure factors: The settings of X-ray tube voltage
(kV), tube current (mA) and exposure time (s).
Exposure time: Duration of emission of radiation by
the X-ray tube (seconds) for an individual slice in axial
scanning or total acquisition time for helical scanning.
Field of view (FOV): The maximum diameter of the
reconstructed image.
Filter: Mathematical procedure used for the convo-
lution of the attenuation profiles and the consequent
reconstruction of the CT image.
Focal spot: The effective area on the X-ray tube anode
from which X-rays are emitted. The size of the focal
spot has influence on spatial resolution.
Full width at half maximum (FWHM): Interval parallel
to the abscissa between the points on a curve with the
value of one-half of the maximum of the symmetrical
curve.
Gantry: Scanner structure containing the X-ray tube,
collimators and the detector array.
200 STEP BY STEP CT SCAN

Gantry aperture: Diameter of the physical opening of

the gantry through which the patient is moved for the
examination.
Gantry tilt: The angle between the vertical plane, and
the plane containing the X-ray fan beam and the
detector array.
Helical CT: A particular technique of scanning in which
there is continuous rotation of the X-ray tube coupled
with continuous linear translation of the patient
through the gantry aperture in order to achieve
volumetric data acquisition. Also known as spiral or
volume CT
.
High contrast resolution: See spatial resolution.
HU (Hounsfield unit): See CT number.
Imaging volume: See volume of investigation.
Intensity: The quantity of radiation energy flowing
through unit area in unit time.
Interpolation: A mathematical method of averaging
or smoothing images that are being displayed on a
larger number of pixels than that for which they were
originally reconstructed.
Inter-slice distance: The distance between the adjacent
nominal margins of consecutive slices in serial CT
scanning. It is dependent upon the couch increment
between slices.
Linearity: In CT, the extent to which the CT number
of a given material is exactly proportional to its density
(in HU unit).
COMPUTED TOMOGRAPHY GLOSSARY 201

Linear attenuation coefficient: The fractional

reduction in intensity per unit thickness of material as
an X-ray beam passes through an absorber. For a
polychromatic beam, the effective linear attenuation
coefficient depends on the effective energy of the
beam, and the density and atomic number (compo-
sition) of the material.
Kernel: See filter.
Low contrast resolution: A measure of the ability to
discriminate between structures with slightly differing
attenuation properties (CT number). It depends on
noise
the stochastic
minimum detectable and
size isofusually expressed as
detail discernable in the
image, for a fixed percentage difference in contrast
relative to the adjacent background.
Monte Carlo Technique: A technique for obtaining
an approximate solution to certain mathematical and
physical problems, characteristically involving the
replacement of a probability distribution by sample
values, usually performed using a computer.
Multiple scan average dose (MSAD): The MSAD is
the
of Naverage doseofacross
slices (each the T)
thickness central
whenslice
therefrom a series
is a constant
increment I between successive slices:

(mGy)

Where DN,I(z) is the multiple scan dose profile along a

line parallel to the axis of rotation (z). For a sufficient
202 STEP BY STEP CT SCAN

number of slices such that the first and the last in the
series do not contribute any significant dose over the
width of the central slice:
(mGy)

Noise: Noise is the point-to-point variation in image

density that does not contain useful information. The
magnitude of noise is indicated by the percentage
standard deviation of the CT numbers within a region
of interest in the image of a uniform substance
(generally water), relative to the difference in CT
numbers between water and air.
Nominal (tomographic) slice thickness: The slice
thickness selected and indicated at the control panel
of the CT scanner.
Number of measurements: The total number of
attenuation values measured during the acquisition of
the raw data for a single slice.
Packing factor: In relation to dosimetry for serial CT,
the packing factor (p) is used to spread the radiation
density evenly over the volume of investigation when
the
eachslices are not T,
of thickness contiguous.
and with a For a series
couch of N slices,
increment I such
that the total scan length is L:

P = 1 for contiguous slices

p > 1 for overlapping slices
p < 1 for gaps between slices.
COMPUTED TOMOGRAPHY GLOSSARY 203

Partial volume effect: The inaccuracy in CT number

caused by the presence of a structure within only part
of a slice. Such effects become less important as the
slice thickness is reduced.
Pitch factor: In relation to helical CT, ratio of the patient
couch travel in horizontal direction per rotation of the
X-ray tube divided by the product of the number of
tomographic sections produced by a single rotation of
the X-ray tube N times the nominal tomographic slice
thickness T:

Where:
Delta d is the pat
patien
ientt couc
couchh trav
travel
el in hor
horizo
izonta
ntall dire
directi
ction
on
N is the
the number
number ofof tomogra
tomographic
phic sectio
sections
ns produ
produced
ced
by a single rotation of the X-ray tube
T is the nominal tomographic slice thickness.
Pixel: Individual square picture element of a digital
image display, being the two-dimensional
representation in HU of a voxel within the scanned
slice. Pixel
field of viewsize
andisthe
determined
number ofby the diameter
elements of the
in the display
matrix.
Polymethylmethacrylate (PMMA): Polymethylmetha-
Polymethylmethacrylate
crylate, a polymer plastic commercially available for
example as Perspex or Lucite.
Profile of CT numbers: Representation of the CT
numbers of the pixels along a specified direction in a
CT image.
204 STEP BY STEP CT SCAN

Quantitative computed tomography (QCT): The use

of CT images and the corresponding CT numbers for
quantitative characterization of organs or tissues. QCT
is most-widely used in relation to the determination
of bone mineral content and treatment planning in
radiotherapy.
Radiographic exposure: Product of tube current and
exposure time.
Raw data: The values of X-ray detector response from
all views and rays within a scan. These data are
convolved with the convolution filter and undergo

back projection to produce a CT image.

Ray: The narrow beam of X-rays from the tube focal
spot to a single detector within a detector array, giving
rise to a detector reading. Each view or projection is
composed of numerous rays.
Reconstruction algorithm: Mathematical procedure
used to convert raw data into an image. Different
algorithms are used to emphasize, enhance, or improve
certain aspects of the data.
Reconstruction matrix: The array of rows and columns
of pixels in the reconstructed image.
Region of interest (ROI): Localised part of an image
defined by the operator which is of particular interest
at a given time.
Ring artifacts: Circular artifacts, usually found in third-
generation scanners, caused by faulty calibration or a
defect in detector function.
COMPUTED TOMOGRAPHY GLOSSARY 205

Scanning: The process of recording X-ray attenuation

data through a slice of an object, from which images
are reconstructed.
Scan projection radiograph (SPR): Generic name for
the digital image obtained by linearly translating the
patient through the gantry aperture during an X-ray
exposure while the X-ray tube remains stationary. The
SPR has a similar appearance to a plain radiograph
and is used primarily for localizing the required region
of scanning. Synonymous terms include radiographic
mode and localizer image, together with the
proprietary names Pilot scan, Scanogram, Scanoscope,
Scoutview, Surview and Topogram.
Scan time: The time interval between the beginning
and the end of the acquisition of attenuation data for
a single exposure. For some CT scanners, this may be
longer than the exposure time due to the pulsing of X-
ray emission.
Scattered radiation: Secondary radiation belonging to
the same radiation type as the original radiation,
produced in the interaction of the original radiation
with a material medium. The interaction can be
characterized by a reduction in radiation energy and/
or by a change in the direction of the radiation.
Sensitivity profile: Relative response of a system for
CT as a function of position along a line perpendicular
to the tomographic plane.
Signal to noise ratio: The ratio of the strength of the
signal for information content in the image to the noise
level (the standard deviation of the signal).
206 STEP BY STEP CT SCAN

Slice: Tomographic section (defined by position and

thickness) of a test phantom or patient under
investigation during a single CT exposure in serial
scanning.
Slice thickness: Effective thickness of the tomographic
section, as measured by the full width at half
maximum of the sensitivity profile in the centre of
the scan field.
Spatial resolution (or high contrast resolution): The
ability to resolve different objects in the displayed CT
image, when the difference in attenuation between

the objects
noise and the
; normally background
a difference is large compared
corresponding to
to at least
one hundred HU is considered adequate.
Spiral CT: See helical CT.
Stability: The maintenance over time of constancy of
CT numbers and uniformity.
Standard examination: Outline of scanning procedure
for a particular clinical indication that is generally
accepted as being able to provide adequate clinical
information in most of the patients examined.
Test phantom: Object of particular shape, size and
structure (including standardised representations of
human form), used for the purposes of calibration and
evaluation of performance of CT scanners.
Uniformity: Consistency of the CT numbers in the
image of a homogeneous material across the scan field.
Volume CT: See helical CT.
COMPUTED TOMOGRAPHY GLOSSARY 207

Volume of investigation (imaging volume): Entire

volume of the region under investigation by scanning.
Voxel: Elementary volume element (expressed in units
of mm3) within the scanned slice of the object, with
which CT numbers are associated.
Weighted CTDI (CTDIw): An estimate of the average
dose over a single slice in a CT dosimetry phantom
that is used to allow comparison of performance
against a reference dose value set for the purpose of
promoting optimisation of patient protection.

(mGy)
Where CTDI100,c or p refer to measurements of CTDI100
at the centre (c) or periphery (p) of the head or body
phantom for the settings used in clinical practice.
Window level: The central value of the window (in
HU) used for the display of the reconstructed image
on the image monitor of the CT scanner.
Window setting: The setting of the window level and
the window width, selected for optimization of the
grey scale levels in the displayed CT-image.
Window width: The range of CT numbers within
which the entire grey scale is displayed on the image
monitor of the CT scanner.
Index

A Collimation 15
pre-detector collimation 16
AAR filter 90 pre-patient collimation 16
Algorithm for treating contrast Computed/computerized
reactions 170 tomography (CT) 2
Algorithms for image Computed axial transverse
reconstruction 25 scanning 2
Allergic contrast reactions 166 Computed tomography clinical
Analytical reconstruction performance
algorithm 26 standards 181
Applications of multislice CT 57 Computed tomography
Auto mAs option 63 geometry 6
Computed tomography
B glossary 193
Back projection method 26 Computer 21
Beam projection 6 Computerized axial
Biopsy Rx 158 tomography (CAT) 2
Biopsy scan 158 Computerized axial transverse
biopsy scan 1 158 scanning 2
biopsy scan 2 159 Contrast agents 162
Blood clots 2 barium 162
Bow-tie filters 18 barium
bariu m sulfa
sulfate
te 162
Brain 2 gastrografin 162
iodine 162
C Conventional and helical
scanners 42
Changing cubicles 190 Conventional tomography 3
Circle of Willis 98 equipment 4
Clinical and associated perfor- method 3
mance parameters 66 CT angiography 57
examination technique 70 CT brain 97
film processing 74 FOV 97
helical or spiral CT 72 image criteria 97
image viewing conditions 73 indication 97
patient preparation 68 patient preparation 97
supervision 68 scanogram 97
210 STEP BY STEP CT SCAN

CT gantry 10 Filtration 18
CT guided biopsy 156 Foundations of CT and
CT
CT number
sectional 195
anatomy 187 computers 182

G
D Gantry assembly 10
Data acquisition system 10 Gastrografin 165
Detectors 19 Generation of scout images 90
gas ionization detectors 19 Grey scale 26
scintillation detectors 19 Guidelines for IV contrast agent
Display and exposure reactions 166
parameters 60 Guide to a typical CT
exposure factors 62 examination 189
field of view 64
gantry tilt 64 H
inter-slice distance/pitch Head 2
factor 61
Helical scan 42
nominal slice thickness 60
reconstruction algorithm 65 High signal to noise 79
History leading to CT scan 2
reconstruction matrix 65
Hounsfield unit 22
reconstructional interval 65
volume of investigation 62
window level 66 I
window width 66 Image acquisition protocols 93
abdomen, general 119
F chest mediastinal vessels
113
Factors to be considered for scan chest, general 115
planning 94
chest, HRCT 117
exposures 95 face and sinuses 99
field of view 95
gantry tilt 98
incrementation 94
pitch 95 IV contrast 98
slice thickness 94 larynx 109
Film dispatch 39 lumbar spine 111
Film processing and filming 37 orbits 103
automatic processor osseous pelvis 124
evaluation 38 pelvis 122
film processing 37 petrous temporal bone 102
manual processing and pharynx 106
darkrooms 37 sella 105
INDEX 211

Image archiving 36 O
Image quality 27
Operator console 21
contrast resolution
image artifacts 30 29 display console 21
beam hardening artifacts 32 scan console 21
metal artifacts 32 Oral contrast agent 164
partial volume artifacts 34 Oral CT contrast 164
patient motion artifacts 32 Osmolality 169
source of artifacts 30 Overview of performing a CT
stair step artifacts 35 scan 81
image noise 29 main components 82
spatial resolution 27 gantry 82
Image reconstructi
reconstruction
on 22 operator console (OC) 84
Imaging planes 91 table 83
axial 91 new patient 1 86
coronal 91 patient positioning 1 82
patient positioning 2 85
sagittal
Imaging 91 10
system patient positioning 3 86
Intravenous contrast 162
Iodinated contrast agents 163 P
Isotropic scanning 57
Parallel beam projection 6
Photons 18
L Physical parameters 74
Localized disease 117 CT number 75
LOCM 169 linearity 76
Low signal to noise task 79 noise 76
Low-osmolar contrast 168 positioning of couch 79
slice thickness 78
spatial resolution 77
M
stability of CT numbers
test phantoms 75 78
Marching cubes 149
mAs 63 uniformity 76
Medium signal to noise task 79 Pitch 56
Monochrome image 26 Pixel 23
Monte Carlo technique 201 Pixel values 24
Multislice scanning 52 Pneumothorax 156
Polymethylmethacrylate 203
Post processing techniques 147
N biopsy planning 154
National Council on Radiation indications and
Protection 176 contraindications 155
212 STEP BY STEP CT SCAN

risks 156 stomach gastric mass 133

technique 157 suspected hemangioma 128
multiplanar
(MRP)reconstruction
148 thoracic
trauma toaorta 143 joint 136
shoulder
surface rendering 149
virtual bronchoscopy 153
virtual colonoscopy 152 Q
virtual endoscopy 152 Quantitative computed
volume rendering 151 tomography (QCT) 62
Principle behind CT 4
Protocols for common clinical
indication 126 R
abdomen-trauma 127 Radiation dose 171
acute abdomen 126 factors affecting radiation
anatomic region 143 dose 173
ankel: evaluate suspected factors affecting the dose in
aorta fracture
144 138 conventional CT 174
beam energy and filtration
cecum 134 174
cervical spine 140
collimation 174
evaluate suspected renal
image quality
quality and noise 175
artery stenosis 131
number and spacing of
facial region 141
adjacent sections 174
fistula to bladder 135
lung parenchyma 144 Radiation dose comparison 173
musculoskeletal shoulder 136 Radiation risks 176
neck 142 Reconstruction principles 48
ovarian mass/cancer 135 Rectal CT contrast 165
pancreas 129 Representation of planning
endocrine tumours of biopsy 158
Revolutionary imaging technique
pancreasmass
pancreatic 130 129 2
pancreatitis 129 Ring artifacts 35
pelvic 134
pulmonary artery 143
renal donor evaluation 132 S
renal or ureteral calculus 130 Scan parameters 145
specific anatomic region Scan plan for ankle 139
acetabulum/pelvis 137 Scan reconstruction parameters 89
specific anatomic region wrist prospective multiple
137 reconstruction 89
staging renal mass 131 Scanning speed 53
INDEX 213

Scout prescription screen 88 V

axial/helical scan prescription
2D view 3
1 88 Voxel-3D tissue element 23
Scout scans 173
Selection of section thickness 53
Single slice helical scanner 10 W
Spiral CT 45
Spiral slip ring 48 Windowing 26
Spiral/helical
Spiral/helic al CT 45
Storage devices 37
Strokes 2 X
System components of CT X-ray computed tomography
scanner 5 (X-ray CT) 2
X-ray CT system 22
X-ray sources 12
T X-ray tomography 3
Technical data for helical scans 47 X-ray tube 12
Technical parameters 60
Tomograph 3
Tomographic images 6 Z
Tomographic slice 16 Z-resolution 148
Tumors 2

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Step by Step CT Scan

Uploaded by

Step by Step CT Scan

Uploaded by

Step by Step

D Karthikeyan DMRD DNB

S tep by S tep C T S can

First Edition : 2005

Typeset at JPBMP typesetting unit

Since the introduction of computed tomography in the

1. History and Basics ...........

2. Development of Scanner Technology

5. Image Aquisition Protocols .....................

7. Contrast Issues .....................

8. Radiation Dose .......................

9. Proficiency Check ...........

GN Hounsfield, a senior research scientist in

HISTORY LEADING TO CT SCAN

Hounsfield and Cormack shared the 1979 Nobel

CONVENTIONAL TOMOGRAPHY (Fig. 1.1)

Tomo (=“cut or section”) + graph (=”something

Three basic goals of computed tomography were

Fig. 1.1: Conventional tomography

giant donut. During each slice acquisition, an X-ray

System Components of CT Scanner

Figs 1.2A and B: Tomographic images are produced from a large

Fig. 1.3: Axial CT section of lungs

Fig. 1.4: Schematic diagram depicting tube rotation

Fig. 1.7: Schematic diagram showing the CT scan gantry assembly

Tube Specification for a Single Slice Helical

Table Specification for a Single Slice Helical

associated electronics such as gantry angulation motors

Generally, the scanning diameter in which patient

X-RAY TUBE, COLLIMATION, FILTRATION

times. The development of spiral/helical CT allows

heat is generated. As previously described, when heat

he or she is determining tube collimation by narrowing

The X-ray field is filtered to reduce the low energy

Figs 1.9A and B: Schematic diagram showing the

Provides for a equal photon distribution across the

Favourable Detector Characters

Fig. 1.10: Schematic diagram showing the

Fig. 1.11: Summary of CT image formation

Fig. 1.12: Schematic diagrams demonstrating the

The reconstructed anatomy of an object is in the

Fig. 1.13: Schematic diagram showing contents in an axial CT slice

the electron density and thus the physical composition

Pixel values for some biological tissues are:

Fig. 1.14: Schematic diagram showing the Hounsfield unit

Algorithms for Image Reconstruction

Back Projection Method

Analytical Reconstruction Algorithm

Windowing and Grey Scale

Fig. 1.15: Relationship between window level and width

There are parameters that a CT technologist can

Field of View (FOV)

Electronic noise is noise contained within the image

CT Image Parameters—Definitions and Ranges

S pat ial Th is is quote d either as the full width at half

Spatial resolution This is

Dose CT doses ar e me asured in mGy and range

• Dat ataa measasu

Patient Motion Artifacts (Fig. 1.16)

Metal Artifacts (Fig. 1.17)

Beam Hardening Artifacts (Fig. 1.18)

Fig. 1.16: Axial CT brain showing motion artifacts

Fig. 1.17: Axial CT brain showing metal artifacts

Fig. 1.18: Axial CT brain showing beam hardening artifact

passes through object. Therefore, the CT numbers of

Partial Volume Artifacts

Partial volume artifacts arise when a voxel contains

Fig. 1.19: Axial CT brain showing partial volume of clivus

Stair Step Artifacts

is also dependent upon limiting or eliminating the

Fig. 1.20: Axial CT brain showing ring artifacts

FILM PROCESSING AND FILMING

Manual Processing and Darkrooms

Each of step in film processing must be done

Automatic Processor Evaluation

temperature measurement depends on the type of