Computed Tomography Procedures & Clinical Practice CT Head protocols Lecture:6 Mr. Ali AkhtarWHATIS CT SCANNING OF THE HEAD? > Computed tomography, more commonly known as a CT or CAT scan, is a diagnostic medical imaging test. Like traditional x-rays, it produces multiple images or pictures of the inside of the body. > The cross-sectional images generated during a CT scan can be reformatted in multiple planes. They can even generate three- dimensional images. These images can be viewed on a computer monitor, printed on film or by a 3D printer, or transferred to a CD or ™ hindCONTINUE... >CT images of internal organs, bones, soft tissue and blood vessels provide greater detail than traditional x- rays, particularly of soft tissues and blood vessels. > CT scanning provides more detailed information on head injuries, stroke brain tumors and other brain diseases tena than regular radiographs (x-rays).PREPARATION > You should wear comfortable, loose-fitting clothing to your exam. You may need to wear a gown during the procedure. > Metal objects, including jewelry, eyeglasses, dentures and hairpins, may affect the CT images. Leave them at home or remove them prior to your exam. You may also be asked to remove hearing aids and removable dental work. Women will be asked to remove bras containing metal underwire. You may be asked to remove any piercings, if possible. teriCONTINUE... > You will be asked not to eat or drink anything for a few hours beforehand, if contrast material will be used in your exam. You should inform your physician of all medications you are taking and if you have any allergies. If you have a known allergy to contrast material, your doctor may prescribe medications (usually a steroid) to reduce the risk of an allergic reaction. To avoid unnecessary delays, contact your doctor before the exact time of your exam. > Also inform your doctor of any recent illnesses or other medical conditions and whether you have a history of heart disease, asthma, diabetes, kidney disease or thyroid problems. Any of these conditions may increase the risk of an adverse effect. ini‘WHAT ARE SOME COMMON USES OF THE PROCEDURE? > CT scanning of the head is typically used to detect: > Bleeding, brain injury and skull fractures in patients with head injuries. > Bleeding caused by a ruptured or leaking aneurysm in a patient with a sudden severe headache. > A blood clot or bleeding within the brain shortly after a patient exhibits ena symptoms of a stroke.CONTINUE... > Astroke, especially with a technique called CT Perfusion of the Head. > Brain tumors. > Enlarged brain cavities (ventricles) in patients with hydrocephalus. > Diseases or malformations of the skull. CT scanning is also performed to: > Evaluate the extent of bone and soft tissue damage in patients with facial trauma, and planning surgical reconstruction. » Diagnose diseases of the temporal bone on the side of the skull, which may be causing hearing problems.CONTINUE... > Determine whether inflammation or other changes are present in the paranasal sinuses. > Plan radiation therapy for cancer of the brain or other tissues. > Guide the passage of a needle used to obtain a tissue sample (biopsy) from the brain. > Assess aneurysms, arteriovenous malformations, and blood vessels through a technique called CT angiography. eer #4‘WHAT ARE THE BENEFITS VS. RISKS? Benefits > CT scanning is painless, noninvasive and accurate. > A major advantage of CT is its ability to image bone, soft tissue and blood vessels all at the same time. > Unlike conventional x-rays, CT scanning provides very detailed images of many types of tissue as well as the lungs, bones, and blood vessels. > CT examinations are fast and simple; in emergency cases, they can reveal internal oni injuries and bleeding quickly enough to help save lives.CONTINUE... CT has been shown to be a cost-effective imaging tool for a wide range of clinical problems. > CTis less sensitive to patient movement than MRI. > CT can be performed if you have an implanted medical device of any kind, unlike MRI. A diagnosis determined by CT scanning may eliminate the need for exploratory surgery and surgical biopsy. > No radiation remains in a patient's body after a CT examination. > X-rays used in CT scans should have no immediate side effects. tenaCONTINUE... CT has been shown to be a cost-effecti imaging tool for a wide range of clinical problems. > CTis less sensitive to patient movement than MRI. CT can be performed if you have an implanted medical device of any kind, unlike MRI. ‘A diagnosis determined by CT scanning may eliminate the need for exploratory surgery and surgical biopsy. No radiation remains in a patient's body after a CT examination. X-rays used in CT scans should have no immediate side effects. , fnRISKS > There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. > The effective radiation dose for this procedure varies. See the Radiation Dose in X-Ray and CT Exams page for more information about radiation dose. > Women should always tell their doctor and x-ray or CT technologist if there is any chance they are pregnant. See the Safety in X-ray, Interventional Radiology and Nuclear Medicine Procedures page for more information about pregnancy and x-rays. : teatCONTINUE... > CT scanning is, in general, not recommended for pregnant women unless medically necessary because of potential risk to the baby. This risk is, however, minimal with head CT scanning. > IV contrast manufacturers indicate mothers should not breastfeed their babies for 24- 48 hours after contrast material is given. However, the most recent American College of Radiology (ACR) Manual on Contrast Media reports that studies show the amount of contrast absorbed by the infant during breastfeeding is extremely low. For further information please consult the ACR Manual on Contrast Media and its references. hierCONTINUE... > The risk of serious allergic reaction to contrast materials that contain iodine is extremely rare, and radiology departments are well-equipped to deal with them. > Because children are more sensitive to radiation, they should have a CT exam only if it is essential for making a diagnosis and should not have repeated CT exams unless absolutely necessary. CT scans in children titi should always be done with low-dose technique.CT ROUTINE ADULT HEAD (NCCT BRAIN) PROTOCOL Indications: v Epilepsy v Acute head trauma Neoplasms: Pre or v Stroke postoperative v Intracranial bleed evaluation v Headache ¥ Hydrocephalus v Abscess +} yp riCONTRAINDICATIONS v Pregnancy v Hypersensitivity to iodinated contrast media. v Renal impairment (Creatinine >1.5mg/dl ) tenaPOSITION Y Patient Position: Spine with head first arms bilaterally downwards, with the head in the head holder. Center the table height such that external auditory meatus (EAM) is at center of the gantry. To decrease the ocular lens exposure, the scan angle should be parallel to a line created by the supraorbital ridge and the inner table of the posterior margin of the foramen magnum. Y Topogram Direction: Craniocaudal v Scan Type: Axial ¥ Position/Landmark: 2-3cm (20-30mm) above the vertex. v Start Location: Skull base. v End Location: Skull vertex. Y Gantry Tilt: 15 to 20 degrees angulation of the gantry to the canthomeatal line or tilting the patient’s chin toward the chest (‘tucked” position). v¥ DFOV: 22cmCONTINUE... ¥ Contrast: Nil ¥ Slice Thickness: 2-5 mm Y¥ Algorithm: standard, bone v Respiratory Phase: None ¥ Tube Voltage (Kv): 120 ¥ Tube Current (mAs): 300- 450 ¥ Rotation Time (s): 1 ¥ Pitch: 10.65 mm ¥ Contrast: Nil v Image Format: DICOM tenCONTRAST ENHANCED CT HEAD PROTOCOL i i . v Patient Position: Spine with head Indications: first arms bilaterally downwards, with v ici the head in the head holder. Center Suspicion of mass the table height such that external ¥ Known primary auditory meatus (EAM) is at center of the gantry. To decrease the ocular tumour lens exposure, the scan angle should be parallel to a line created by the v Metastases ‘supraorbital ridge and the inner table v of the posterior margin of the foramen Aneurysm magnum ”¥ Abscesses ¥ Topogram Direction: Craniocaudal Y Meningitis ey #CONTINUE.... v Scan Type: Helical Y Position/Landmark: 2-3 cm (20-30 mm) above the vertex. Y Start Location: 1 cm inferior to Skull base. v End Location: 1 cm superior to Skull vertex. v Gantry Tilt: 15 to 20 degrees angulation of the gantry to the canthomeatal line or tilting the patient's chin toward the chest (‘tucked” position). ¥ DFOV: 25cm Y Contrast: Nonionic low osmolar lodinated Contrast media ¥ Contrast Administration: IV ¥ Volume: 60-100 ml v Rate of Injection: 2-3 ml Is ¥ Slice Thickness: 2-5 mm hierCONTINUE.... v Scan Delay: 30-50sec v Algorithm: Standard, Soft tissue v Recons and Reformations: MPR, MIP v Respiratory Phase: Any ¥ Tube Voltage (Kv): 135-240 ¥ Tube Current (mAs): 150-220 ¥ Rotation Time (s): 0.5- 0.7 v Image Format: DICOM hitCT TEMPORAL BONES PROTOCOL Indications: > Inflammatory middle ear diseases >Cholesteatoma > Hearing Loss > Trauma fieryCONTINUE.... > Mastoiditis > Neoplastic lesions > Congenital anomalies tenaAXIAL PROJECTION Y Patient Position: Spine with head first, head in head rest. ¥ Topogram Direction: Craniocaudal in axial plane or in spine position. ¥ Scan type: Helical Y Position /landmark: Midforehead in axial plane. ¥ Start Location: Skull base ¥ End Location: Superior margin of petrous temporal bone HopiCONTINUE... v Gantry Tilt: No tilt in axial plane. v DFOV: 20 cm Y Scan field of view: 25 cm ¥ Contrast Administration: IV v Volume: 80-100 ml v Rate of Injection: 2-3 ml /s v Scan Delay: 30-40 sec Y Algorithm: Bone ¥ Slice Thickness: 1-2mm v Tube Voltage (Kv): 140 v Tube Current (mAs): 350 Y Rotation Time (s): 0.5 v Image Format: DICOM » tHMt LyCORONAL PROJECTION > Patient Position: Prone with head first, with extended neck and chin on chin rest. > Topogram Direction: Posterior to anterior in coronal plane or in prone position > Scan Type: Helical > Position/Landmark: 2-3 cm (20-30 mm) anterior to the forehead in coronal plane. v Start Location: Anterior margin of petrous temporal bone ¥ End Location: Posterior margin of petrous temporal bone v Gantry Tilt: 17-23 degrees to make the scanning plane perpendicular to bony palate in coronal plane. v DFOV: 18 cm Y Scan field of view: 25 cm ttnCONTINUE... Y Contrast: Nonionic low osmolar lodinated Contrast v Scan Delay: 30-40 sec media Y Contrast Administration: IV v Volume: 80-100 ml v Rate of Injection: 2-3 ml /s ¥ Algorithm: Standard, Bone 350 . . v Recons and Reformations: ¥ Rotation Time (s): 0.5 MPR, MIP ¥ Image Format: DICOM Nitra Y¥ Slice Thickness: 1-3mm ¥ Tube Voltage (Kv): 140 ¥ Tube Current (mAs): 150-Topogram of temporal bone showing scan range Coronal section of temporal boneCT PITUITARY GLAND PROTOCOL Indications: ¥ Pituitary adenoma v Suspected/ known pituitary mass ¥ Inflammation Y Pituitary tumor ¥ Contraindications to MRI tenaPROTOCOL Y Patient/Position: Spine with IOML perpendicular to table and head in a symmetrical position. ¥ Topogram Direction: Caudocranial v Scan Type: Helical Y Position/Landmark: Y Start Location: Bottom of sella Y End Location: Hypothalamus Y Breath hold: None v DFOV: 22 cm ¥ Scan field of view: 25 cm ¥ Contrast: Nonionic low osmolar lodinated Contrast media Y Contrast Admini ge #4CONTINUE... ¥ Volume: 80-100 ml ¥ Slice Thickness: 1-3 mm v Rate of Injection: 3-3.5 ml ~ Tube Voltage (Kv): 130- Is 150 Y Algorithm: Standard, soft ~ Tube Current (mAs): 220- tissue, bone, 250 v Recons and ¥ Rotation Time (s): 0.5 Reformations: MPR, MIP v Image Format: DICOM ¥ Scan Delay: 30 sec : tenCT CEREBRAL PERFUSION PROTOCOL, Indications: ¥ Brain tumor Y Acute stroke Y Transient ischemic attack v Evaluate vasospasm Y Follow up after ischemic stroke v Suspected cerebral v Assessment of reperfusion infarction after treatment of acute Y Vasculitis strokePROTOCOL Patient/Position: Spine with head first arms bilaterally downwards, with the head in the head holder. Center the table height such that external auditory meatus (EAM) is at center of the gantry. Topogram Direction: Caudocranial Scan Type: Helical Position/Landmark: At the level of the canthomeatal line Start Location: 1cm inferior to skull base v v *% HK & End Location: Skull vertex Gantry Tilt: 15 to 20 degrees angulation of the gantry to the canthomeatal line is advisable if possible or tilting the patient's chin toward the chest (“tucked” position). Breath hold: None DFOV: 20 cm ‘Scan field of view: 25 cm Contrast: Nonionic low osmolar lodinated Contrast media eriCONTINUE... v inistration: . | Contrast Administration: IV Y Slice Thickness: 3-5 mm v Tube Voltage (Kv): 80-100 Y Tube Current (mAs): 120- ¥ Volume: 80-100 ml ¥ Rate of Injection: 2-3 ml /s Y Algorithm: Standard, soft tissue 150 v Recons and Reformations: Y Rotation Time (s): 0.8 MPR, MIF, SSD v Image Format: DICOM Y Scan Delay: 30-40 sec ftCT CEREBRAL VENOGRAM PROTOCOL i i . ¥ Patient/Position: Spine with head Indications: first arms bilaterally downwards, with v the head in the head holder. Center Cerebral venous: the table height such that external thrombosis auditory meatus (EAM) is at center of the gantry. v Topogram Direction: Caudocranial v Scan Type: Helical ¥ Position/Landmark: 2-3 cm (20-30 mm) above the vertex.CONTINUE... Y Start Location: 1cm inferior to skull base ¥ End Location: skull vertex ¥ Breath hold: Any ¥ DFOV: 18 cm ¥ Scan field of view: 25 cm ¥ Contrast: Nonionic low osmolar lodinated Contrast media Y Contrast Administration: IV ¥ Volume: 80-100 ml ¥ Rate of Injection: 5.00 ml Is ¥ Algorithm: Standard, soft tissue v Recons and Reformations: MPR, MIP, VRT, SSD niCONTINUE... ¥ Scan Delay: 45 sec Y¥ Slice Thickness: 1-1.5 mm ¥ Tube Voltage (Kv): 130-150 ¥ Tube Current (mAs): 220-450 ¥ Rotation Time (s): 0.5 v Image Format: DICOM ftMtn